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A malpractice case from the Massachusetts Medical Law Report:

A 38-year old patient presented to the emergency room with complaints of chest pain and diaphoresis.
He was hyperventilating and complained that his arm was feeling numb. An EKG revealed ST elevations. Cardiac enzymes were within normal limits.
The emergency room doctor administered 1 mg of Ativan. Several minutes later, the patient was found to be unresponsive, cyanotic and foaming at the mouth. CPR was initiated and the patient was defibrillated without success . . .
. . . The expert planned to testify that standards of care required the emergency room physician to have immediately started thrombolytic therapy after the EKG to help abort the myocardial infarction.

The case was settled for over half a million dollars.

Comments

Gasman
Fault is supposed to be causative.
Thrombolytic therapy would not have made a difference because it takes more than a few minutes to prepare, and then it takes some time, typically more than 30 minutes, to work, this patient would have checked out pretty much regardless of speed of administration.
When your gene’s and lifestyle are a bad enough combination to have an MI at age 38 not much is going to save the patient. Let’s blame the primary doc for not screening him prior to his first MI.
Anonymous
When your gene’s and lifestyle are a bad enough combination to have an MI at age 38 not much is going to save the patient.
Regardless of the merits of the case, why do doctors always have to blame the lifestyle? Grinkov (as in Gordeeva & Grinkov – olympic champions) had a heart attack when he was very young, but you could hardly blame his lifestyle…
Anonymous
“Regardless of the merits of the case, why do doctors always have to blame the lifestyle?”
We don’t, but sometimes shit happens and if you walk around it a lot you are more likely to step into it.
Anonymous
We don’t, but sometimes shit happens and if you walk around it a lot you are more likely to step into it.
There is nowhere in the original article where they mention if the guy was thin or fat or smoker or not. He could’ve had bad genes, though.
In case you don’t remember Grinkov
Anonymous
In the “The Textbook of Defensive Medicine” which is yet to be published and yet to be written, a patient 20 years old or over with chest pain and shortness of breath has either P.E., Acute M.I., Pnemothorax, Aortic Dissection, Pericarditis with pericardial effusion with tamponade, Pneumomediastinum, superior vena caval syndrome, or Atrial Myxoma and should be approached as such,so that the public or the plaintiff’s attorney or the family will not misconstrue that these diagnoses were not entertained during the first 5 minutes of the encounter. Do not give any medication such as Ativan or a device such as paper sack to suggest a diagnosis of trivial significance.
Anonymous
How long is “a few minutes” ?
Anonymous
Was a cardiologist called at anytime during this?
Anonymous
Was PCI available?
Frankly I see patient’s going to cath much more so than thrombolytics given. I also agree with gasman. Anybody who thinks that the “several minutes” inbetween seeing the ST elevations and the code would have given time for the thrombolytics to be prepared let alone administered clearly has never given thrombolytics before (I have). Don’t forget the “extra time” calling the cardiologist. A sad outcome but was it malpractice?
Anonymous
Again, this is retrospective, and I’m a doctor not a sodomite so I don’t practice medicine retrospectively, but if the DOc gave a 38 year old Ativan, had the patient told him he had just used Cocaine? Ativan is the treatment for cocaine chest pain. When I was a resident I had a great attending who used to ask “How much cocaine did the patient use?” whenever I presented him a young person with chest pain. When I said “patient denies cocaine” he would say again, “OK, so how much cocaine did he use?” At my hospital any young person admitted for chest pain is tested for cocaine, even if they deny it. Approximately 25% test positive.
Anonymous
Thanks for explaining the ativan usage…I didn’t understand why it was given. The only thing I remember is you are not supposed to give beta-blocker to cocaine chest pain because the universe will explode or something.
By the way, I thought a more telling article in that Mass. law Journal was the article about the neurologist being responsible for a patient having a car accident while taking meds…that is nuts! Does that mean I am responsible for every joker who has a car accident while taking Ambien that I prescribed? I have to get out of this goddam* business!
Anonymous
Sorry, I put the * in the wrong place.
Anonymous
“I thought a more telling article in that Mass. law Journal was the article about the neurologist being responsible for a patient having a car accident while taking meds…that is nuts!”
He hasn’t been held responsible yet. Read it again.
Anonymous
“Cocaine differs from other local anesthetics in that it also binds to monoamine transporters and blocks the reuptake of catecholamines into the presynaptic nerve terminals. This results in a high degree of adrenergic activity and widespread toxicity. Alpha-adrenergic stimulation, which is largely due to norepinephrine, induces hypertension, whereas beta-receptor stimulation, which is largely due to epinephrine, commonly results in tachycardia (beta1 effect) and hypotension (beta2 vasodilation). Other factors, such as the generation of CNS-excitatory amino acids (glutamate and aspartate), may play a role in CNS hyperactivity and cardiovascular pathology.
Beta-blockers, in general, are best avoided in the setting of cocaine toxicity because they may result in unopposed alpha effects of cocaine.
“Beta-blockers have been reported to increase the blood pressure, reduce coronary blood flow, reduce left ventricular function, and reduce the cardiac output and tissue perfusion in patients with cocaine toxicity. Furthermore, in animal models of cocaine toxicity, beta-blockers have been associated with an increased risk of seizures and an increased mortality.
“Benzodiazepines have been shown to be effective in the treatment of cocaine-induced hypertension, with or without chest pain or tachycardia.
“When benzodiazepines fail to control hypertension, vasodilators, such as nitroprusside and nitroglycerin, are effective in controlling the blood pressure. If a contraindication to nitrate therapy exists, alpha-blockers, such as phentolamine, which block the vasomotor effect of norepinephrine, may be used.from emedicine.com
-Your friendly neighborhood med student
Anonymous
If I’m having an MI, please give me some Ativan, especially if my Seinfeld-like parents are hovering over me in the room! And no I’ve never done cocaine!
Anonymous
To the med student: EKG’s can be remarkably unhelpful in Cocaine chest pain. Patients can come in with obvious ST elevation MI’s and if they’ve been using cocaine it can be just vasospasm. That’s why its important to get a tox screen in these patients, since they are known to lie about their cocaine use (this has been studied, it’s not a patient insult)
Anonymous
38 is not THAT young. Plenty of people have CAD by their late 30s. I have seen MIs in several people that age.
Fine give him ativan but also give him stand MI drugs too — ASA, Morphine, Nitroglycerine, Heparin. Call cardiology to let them know they might have an emergency cath coming up.
That isn’t defensive medicine, it is careful medicine. These steps might not have made a difference in the patient’s outcome but they would have persuaded a jury that the physician was willing to consider the worst-case scenario and do something about it.
Mark
Anonymous
When you say thrombolytic therapy, are you talking about tPA? As far as I know, tPA is the only thrombolytic thats FDA approved. Or does that include clopidogrel, or the experimental drugs like desmoteplase?
tPA has a freaking huge laundry list of inclusion and exclusion criteria. Its NOT a routine drug to administer and few people, evne if they are having an MI, qualify for it.
If this case is about failure to deliver tPA, there’s no way it should have ever gotten past initial review. Just to go thru the inclusion/exclusion criteria requires more than “several minutes”
Anonymous
“That isn’t defensive medicine, it is careful medicine. These steps might not have made a difference in the patient’s outcome but they would have persuaded a jury that the physician was willing to consider the worst-case scenario and do something about it.”
We have no idea based on the facts what happened. Maybe this doc had 20 other patients at the same time and he was “getting to” this patient when he coded. Maybe there was a trauma keeping this doc busy. Maybe the patient sat in the waiting room from 10 am to 2 pm, was brought back, and was sitting there when this doc came in for his 4 pm shift. ALl these things have happened to me, when I read the brief passage above, all I could think is “this could happen to me” or “this has happened to me”. But again, we have very limited information.
Anonymous
I think we all agree that the lawsuit is ludicrous (except the sodomites and their concubines, diora and cathy and sarah w)but the question is how do we protect ourselves from this type of thing until we can save enough money to retire and take care of our families…I think the answer is cardiology should be called immediately and the call documented, and treat chest pain aggressively (beta-blocker, ntg, asa) and document all of it…chest pain should be triaged to the acute area and dealt with immediately…
it would take a few minutes to arrange this, write orders and then you can return to giving lidocaine, amio, ambu-bagging the code and take over from the residents or nurses…
Anonymous
“I think we all agree that the lawsuit is ludicrous”
No it is not ludicrous. There is a problem when a 38 year old male with acute MI was given Ativan instead of the usual acute MI meds. There is a problem in a system that allowed it to happen and more likely this is a system problem and it can happen in any ER. Each ER has to look into their processes so that this does not happen in their ER’s. We cannot accept this as just part of doing business. I am actually more interested on the details of how this happened which can probably help some ER’s change a few things to prevent this from happening. In some ER’s, I know that the situation is hopeless. -AMD
Cathy
anon 11:07,
“A concubine of the sodomites” Is that what you just called me? I have not posted even one response to this post. I know NOTHING about this topic. I have just been reading it. Are you so angry that I sign my posts that now I must be siding with the Lawyers? I guess you missed my post where I told him he wouldn’t want me in his malpractice lawsuit.
Does it now mean if someone actually owns their work (by signing in) it gives cause to attack? BTW, are you VS?
DBR
Cathy asks: “Does it now mean if someone actually owns their work (by signing in) it gives cause to attack?”
I can attest to that….
I suggest that everyone ignore the most insulting, caustic and clearly out-of-control comments of anyone who refers to anyone else as “sodomites.”
Eventually, he or she will get tired of being ignored and might go bother folks on another blog….nothing beneficial is added to the discussion on either side by such blatant bitterness and anger…
Anonymous
As one of the alleged “sodomites”, I’m curious – how does one maintain a concubine?
CJD
Anonymous
after taking cocaine everyday for the last month, I’ve taken ativan a couple of times to come down in the evenings, is this safe?
Anonymous
after taking cocaine on a daily basis for the last month, I’ve used ativan a couple of times to come down in the evenings, is this safe?
Anonymous
after taking cocaine every day for the past month, I’ve used ativan to come down in the evenings a couple of times, how safe is this

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