The Incident
Physician's Notes from Emergency Dept
The Natural History of a Lawsuit
On February 13, 1999, A.K. Hart was at work when he felt pressure and a fluttering in in his chest and began sweating. Co-workers called an ambulance, and the ambulance picked Hart up. he was brought to Saint Jennifer's Medical Center and was seen first by an emergency room doctor, Dr. E. Mergent, and then by his regular primary care doctor, Dr. Croaker, who is a family physician.
Hart was 56 years old, was obese and by the patient's own admission "out of shape." He gave a history to the nurse of having had flu and bronchitis during the previous three to four days, with occasional feelings of shortness of breath. he was a smoker and had been diagnosed as having early COPD several months earlier. On this particular day, the 13th of February, he had tightness in his upper chest without radiation of the pain. When describing his pain he made a fist at the sternum and said he was feeling tightness. He did not have nausea, but was dizzy and lightheaded and shaky and perspiring. He described feeling "heart palpitations." He gave a history of diabetes and a perforated colon several years before and kidney stones during the past year.
Hart gave no history and had no history of any previous heart failure or heart attacks or malignancy or stroke. Hart had been reasonably healthy during the past year except for the COPD and kidney stones 11 months earlier, resolved by ultrasound. Hart was a somewhat anxious person and had been on anti anxiety meds several times for brief periods during the previous ten years. Physical exam was not particularly helpful.
Dr. Mergent and Dr Croaker were concerned about the possibility that Hart was having a heart attack or angina. At Smallville Medical Center they promptly did an electrocardiogram to try to get some better evidence.
Hart had a somewhat fast heartbeat with some nonspecific T wave changes. A previous EKG done at the time of the patient's last admission was felt to have very similar T wave changes. After discussing it Dr Mergent and Dr. Croaker felt it was appropriate to admit Mr. Hart to the hospital to try to make sure that he was not then having a heart attack.
There were appropriate lab tests and orders for observation entered by Dr. Croaker on a diagnosis of R/O myocardial infarction. The patient was put on oxygen and medications were given -- standard medications used in the case of suspected heart attack.
Hart was in the hospital overnight and was repeatedly observed by the nurses. Earlier on he had some more symptoms, including some mid-chest tightness and some more irregular heartbeats, and some more shortness of breath. Then, later in the evening, his shortness of breath and chest tightness seemed to go away.
In the morning, the patient had no more chest pain. A repeat EKG was felt to be unremarkable. At 7:30 in the morning, he was still saying that there was some shortness of breath with exertion, but, at 8:30, the patient was up to bathe and, in the nurse's words, took his time with no dyspnea or pain.
Later that morning, Dr. Croaker decided to make an order allowing Hart to go home. He was given nitroglycerine, and was told to call 911 if his pain recurred. The patient was given a printed handout for angina patients. Then he was sent home mid-morning with instructions to return early during the week so that they could get a stress test and try to determine if, in fact, the pain in his chest was cardiac in origin or whether it was really something else.
Tragically, later that morning, Hart called for an ambulance but experienced sudden death due to a massive saddle type pulmonary embolus. Hart's heirs and next of kin have now sued the two physicians who cared for Hart.
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