The patient, a 45 year-old male, married with two minor children, experienced an episode of chest pain while at work in Manhattan. He characterized the pain as a tight, heavy feeling in his chest which was radiating to his jaw. On October 29th, he was taken to the Emergency Department of a major teaching hospital where he was evaluated. He is described in the record as being anxious and diaphoretic, with blood pressures of 170/120 and 162/102. An EKG was interpreted as displaying RSR with some suggestion of ST depression in the V leads. The patient was admitted and, the next day, October 30th, he was seen by a cardiologist. By this time, the patient’s pain had diminished somewhat, and laboratory studies, as well as an electrocardiogram, were viewed as essentially normal. A treadmill stress test was done and was interpreted as normal, suggesting that coronary artery disease was unlikely. A chest film taken on admission was suggestive of a prominent opacity in the aortopulmonary window. Since the radiologist felt this might be vascular in origin, he suggested a CT scan for clarification. Apparently, the attending cardiologist did not see this report, and the patient was discharged with a diagnosis of acid reflux disease without the scan having been performed.
On the following day, October 31st, at approximately 7:30 in the morning, the patient experienced a sudden onset of jaw pain and went to the Emergency Department of a local hospital near his home. The Emergency Department record reflects a complaint of severe bilateral jaw pain, with an onset at approximately 4:00 that morning. The Emergency Department physician noted that the patient described the pain as a 9 on a scale of 1 to 10 and complained that the pain radiated to his head and right shoulder. However, the patient reported a family history of TMJ syndrome and told the Emergency Department physician that he had a negative work-up for a myocardial infarction a day earlier. The patient’s physical examination was essentially within normal limits, and his electrocardiogram was considered normal. The patient was given prescriptions for Demerol, Vistaril, and Vicodan and, feeling better, he was discharged at approximately 11:00 A.M. without any communication between the ED physicians at the two hospitals. The diagnosis was TMJ syndrome, for which he was referred to a local dentist who specialized in this condition.
The patient, a seemingly very compliant individual, went to see the dentist the following day, November 1st, with a complaint of bilateral jaw and neck pain. Dental x-rays were within normal limits, and some “clicking” was noted on the right side of the patient’s jaw. A diagnosis of TMJ was made. The patient was given a prescription for Xanax for anxiety, and the Vicodan was discontinued. The patient was instructed to take Aleve for pain and to return in two weeks.
When the patient’s complaints persisted, upon recommendation of a family member, he went to a local physician who specialized in acupuncture. The visit took place on November 2nd, and acupuncture was performed for the suspected TMJ. The patient also apparently complained of some lumbar back pain which was treated with electrical stimulation.
On November 4th, the patient was experiencing low back pain that became progressively worse, prompting his wife to take him to the Emergency Department of his local hospital (the same hospital where he was treated on October 31st). He arrived at about 3:00 P.M. and was examined shortly after 5:00 P.M., complaining of severe mid to low back pain and right flank pain. The patient was medicated with Demerol, and a CT scan was ordered to rule out kidney stones. Urine was dipped and found positive for blood, but the patient had no costovertebral angle tenderness and no pain on straight leg raising. A CT scan of the pelvis and abdomen was done at 9:00 P.M., and a radiograph was taken of the lumbar spine.
At approximately 10:00 P.M., the patient’s wife notified the nursing staff that her husband had become unresponsive. The patient was attended to immediately and initially resuscitated. A sonogram at the bedside revealed pericardial effusion, but, despite thoracotomy, the patient expired. An autopsy attributed the patient’s death to a free rupture of a Type A dissecting thoracic aneurysm with dissection into the pericardial space. There was also an incidental finding of an 80% LAD obstruction.
Reviewers identified a number of areas of care that would be difficult to defend, despite the fact that there is a significant mortality rate (50%) even when a diagnosis is made quickly and surgical intervention is prompt. The original x-ray studies of October 29th showed evidence of a “prominent opacity” in the aortal pulmonary window, and a CT scan was recommended. This was not noted by the attending physician, and, consequently, the study was not completed. As well, when the patient began to complain on October 31st of jaw pain that radiated to his head and right shoulder, the possibility of an aortic dissection should have been considered. It appears the decision not to pursue additional studies was influenced by the fact that, one day earlier, the patient had been evaluated from a cardiology standpoint by physicians at a prestigious institution. However, there was no evidence of any communication between the physicians at the two institutions. Further, the work-up that the patient received on October 31st included an electrocardiogram, but, curiously, no enzyme studies were performed. Although the attending physicians had essentially ruled out a cardiac disease, other potential intra-thoracic problems were never considered.
Medical Viewpoints
All of MLMIC’s cases involving aortic dissections are extensively reviewed by medical experts. Throughout the years, these experts have gained considerable insight into the pitfalls associated with these claims. The following observations represent a unique perspective from the viewpoint of several medical specialists. While MLMIC does not seek to establish any guidelines for medical practice, we believe it is beneficial to alert our policyholders to the issues these experts have identified. It is our hope that this may result in improved patient care and, consequently, reduce losses associated with this disease process.