Liable for not doing a heart cath on a 49 year-old

Interesting case with an unfortunate outcome:

Daniel Bettencourt was 49 when he suffered a fatal heart attack while working as a manual laborer at E.&J. Gallo Winery on Jan. 15, 2003.

An autopsy determined that the Modesto man had more than 90 percent blockage in an artery that supplies blood to the left side of the heart.

Last week, a jury found that Gould Medical Group doctors had failed to diagnose Bettencourt’s heart condition.

A 49 year-old male has recurrent chest pain. He was referred to a cardiologist and had two negative stress tests. That sounds like reasonable standard of care to me, although I probably would have done a more detailed second stress test – such as a stress-echo or MIBI. As the defense stated, you can’t cath everybody with chest pain (although if they had, this lawsuit would have been avoided – score another point for defensive medicine).

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  • jb

    To carry this just a little further, we are now obligated to do colonoscopies on everyone, even with no bleeding and no symptoms. Maybe even do colon resections on folks without polyps, because there might be a premalignant lesion in there somewhere. Remove appendixes in every case of RLQ pain, even with normal WBC and CT, because a few out of a thousand may go on to appendicitis. Next will be random breast biopsies after normal breast exams and mammograms, and maybe even radiate every woman’s breasts in the absence of a diagnosis, because, well, ya never know what you might be missing.

    Why bother to do the test at all? Just treat for whatever you think he might have.

    It’s not like they had a normal treadmill and then prescribed valium and told him it’s all in his head. They repeated the standard of care test (normal again), then tested for other less lethal causes of his symptoms. No allegation that the treadmill was not interpreted correctly.

    If we do invasive tests on everyone, there will be more complications. And there will be “experts” who will testify that the cath should not have been done in the fiirst place because he had 2 normal treadmills, so it was malpractice to do the cath that caused the arterial dissection that led to loss of the leg, or the hematoma that got infected and caused the sepsis that led to the stroke, or this or that or ad nauseam.

    As cynical as I try to be, it’s hard to keep up.

  • Gasman

    But cardiac cath has an indisputable rate of complcations that cannot be made zero. Large tubes must traverse the femoral artery, which if any atherosclerosis is present increases the risk to the leg and foot from embolisation or damage to the vascular supply. Aortic damage, coronary dissection, contrast reactions are infrequent but can cause havoc for the 0.1% or so who experience them.

    The decision to perform a more invasive and potentially injurious test must be balanced against the possible gains of doing so. There are going to be many patients who appear to be at the stage of clinical equipoise; before the ultimate results are known by waiting to see the outcome weeks, months or years later it is difficult to rationally choose one course over the other. Hindsite bias of course can clarify things immensely but only too late.
    Hindsite bias is best exemplified by the practice of pathology; the pathologist always know the correct diagnosis, but too late to matter.

  • Anonymous

    So was this gentleman given the option of the heart cath? Since there had been repeated episodes of the same symptoms, and nothing had shown up, would taking the next step to the more accurate procedure not be the reasonable course?

  • Anonymous

    So what if they did run a cardiac cath and it didnt show any blockages, yet he still had a blockage?

    Is there some super duper test beyond cardiac cath thats supposed to be even BETTER at picking up coronary blockages?

    Say for example, cardiac magnetic resonance angiography?

    If cardiac cath came back normal, and the guy still died from a blockage, these same lawyers would still be sueing the docs, claming that a cardiac MRA should have been done.

    In other words, keep testing until you find something wrong.

  • Anonymous

    So you are saying that the reasonable standard is exactly what the defendant physician did?

  • Anonymous

    Bottom line is…someone, anyone could show up at the er having chest pains and say, “you know I’ve had them before and this time I was a heart cath.” You refuse and the guy dies from a massive MI. The next day there will be 47,000 of you (medical doctors) saying that you did nothing wrong.

    How can you ever hope for good reform when you refuse to police your own?

  • Anonymous

    The catheterization should have been performed…why would the cardiologist NOT do it? When the patient went to the GI, he was scoped, right? Did the GI say he has gerd without doing the scope? No…he gets corroborration of the diagnosis, excludes gi cancer, etc, and gets paid $$$ for the test…so what if there is a small risk of harm to the patient, there is more risk to omitting tests as showcased with this narrative…

    the lesson is when you see a patientm, think about how you can get sued and then do everything possible to cover your ass, fuck the patient, think about yourself…

    look at the above lay posters, they think you can diagnose everything and cath everyone with absolute 100% certitude, this is what is expected by a jury as well, test away and then retire…

  • Anonymous

    So would you or would you not consider it reasonable, absent all your claimed lawsuit fears, to act as this physician did? Would you have ordered, or at least informed him of, the procedure?

  • jb

    anon 742,

    IMO care was very reasonable. Patient could seek a second opinion. There is never 100% certainty, only that death will at sometime happen. I have seen a bonofide MI a couple weeks after a bonofide normal cath.

  • Anonymous

    Does anyone else get concerned over the Drs, here who make comments over and over relating that “Death will happen sooner or later” Of course it will, I think we all realize that, but some of these guys seem way to accepting of it and seem not to be bothered if it happens sooner than it should. Is that now the accepted excuse for when mistakes happen…”Oh well the poor guy was going to die at some point anyway?”

  • Anonymous

    The first stress test was a thallium stress test; the second was a stress echo. He also had a holter moniter.

    He felt somewhat better on proton pump inhibitors. He had guaic positive stool.
    He died the day after his EGD.

    Jury awarded 850K to the widow. They deliberated less than 2 hours.

  • hlebushek

    I am not medic, but have few friend who are. I am coming from the position that patient is entirely responsible for their own health. Doctors’ responsibility is to think hard and offer known tests and treatments, and explain known consequences of each.
    From that position, the doctors in the case should have offered to patient the option of doing cath test, with explanations of all risks. Explain to the point where patient could make informed choice whether to take this test or not, give known percentages of risk. And so on to more elaborate tests if cath test results were not definitive. Would this work in current system?

    E.g. “You have risk of heart failure, [such-and-such] big based on [such-and-such] factors and symptoms. Previous tests are negative, but are only 75% reliable. This cath test could make it 99% reliable, but it can ccost you a leg or arm in 0.1% of cases. This is best we can do. Shall we do it?” (I made up all percentages above. Real doctors would do better.)

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