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Cardiovascular disease is the leading cause of death in men and women in the United States. The rate of death has declined dramatically since the 1970s, however, primarily due to earlier diagnosis and the use of life-saving medical interventions like “clot-busters” for ischemic strokes and angioplasty for heart attacks. But these treatments are of no use if doctors don’t promptly recognize the signs and symptoms of the disease and then treat the patient properly.
Unfortunately, as medical malpractice lawyers, we’ve become accustomed to seeing these cases often. A patient goes to their doctor or to the emergency room with chest pain and the doctors tell them it’s probably nothing. Or, a patient comes in with weakness in their limbs, vision problems, or a headache, and the doctor dismisses it without checking their arterial blood pressure, monitoring their breathing, or sending them for a CT Scan or MRI.
Let’s talk first about heart attack (myocardial infarction). Every year, over 700,000 people have a heart attack, and so hospital emergency departments are supposed to be well-equipped and well-trained to handle them. The first step is an immediate electrocardiogram (ECG), which should be performed within 10 minutes of the patient’s arrival. The ECG should then be reviewed immediately to determine if the patient has an “ST elevation” or not, which helps the doctors figure out what kind of acute coronary syndrome the patient is experiencing. Aspirin and nitroglycerin are given and the patient’s blood is drawn to look for markers of myocardial infarction, like elevated levels of troponin or CK-MB.
If the patient has a “STEMI” heart attack, then the next step is reperfusion to restore the flow of blood. That typically takes the form of angioplasty (technically, percutaneous coronary intervention) performed by an interventional cardiologist or the use of fibrinolytics (like Alteplase, or tPA), which break up plaque that has lodged in or near the heart. If the patient has a “non-STEMI,” then antiplatelet and anticoagulant therapies are given, and the patient is sent for a coronary arteriography (to see how the blood is flowing in the arteries) and revascularization.
This sounds like a lot to manage, and there are a lot of moving parts, but decades of research have boiled down the essentials to a universal definition of myocardial infarction and algorithms for treatment that hospitals, doctors, and nurses are expected to follow. The heart attack malpractice we see often involves one of the following:
- The patient has chest pain (“angina”) at rest that has lasted for more than twenty minutes, or chest pain that limits their physical activity, as well as factors indicating they are at risk (such as age, hypertension, diabetes, dyslipidemia, or a family history of heart attack), but they are sent home without further testing.
- The ECG is either misread by emergency physician or cardiologist, and is classified as either harmless or as the wrong type of acute coronary syndrome.
- The initial ECG comes back okay (“nondiagnostic”), and so the patient is sent home. This is wrong: the ECG should be repeated at least every 30 minutes for any patient where there’s a suspicion of a heart attack, and sometimes more frequently.
- The initial troponin levels are not elevated, and so the patient is sent home. This is wrong: troponin levels, which indicate the death of heart muscle, often take hours to rise, and so the troponin levels should be measured again six to nine hours later.
- The hospital staff recognizes the heart attack, but is too slow in getting the patient to an angioplasty or administering medications.
The consequences are devastating: the patient’s heart attack goes without proper treatment, resulting in the loss of heart muscle, hypoxia, and, sometimes, death.
Next, stroke (brain ischemia and intracerebral hemorrhage). Stroke is the leading cause of permanent disability in America. The American Stroke Association has done a lot to help patients identify when they might be at risk for a stroke with its “F.A.S.T.” campaign, which tells patients to look for Face drooping, Arm weakness, Speech difficulty, any one of which means it’s Time to call 9-1-1. But what happens when they get to the hospital?
The first order of business is, perhaps surprisingly, the patient’s breathing. Abnormally slow breathing (hypoventilation) can lead to a buildup of carbon dioxide, which in turn can lead to dilation of the blood vessels in the head, increasing intracranial pressure. Additionally, stroke patients have a far higher risk of having problems swallowing and potentially aspirating. After that, a careful but quick patient history is performed to find out exactly when the symptoms began, to see if the patient is a candidate for thrombolysis, the clot-busting drugs that have to be given within 4.5 hours of the initial stroke symptoms. Additionally, the presence of certain symptoms can help establish what kind of stroke the patient is having. For example, the onset of a headache or vomiting point more towards bleeding in the brain than towards a clot.
The physical examination requires close look at blood pressure and temperature, both of which can give clues, as well as several more subtle features, like pressing on the neck, arms, and legs to “palpate” for the presence or absence of a pulse in particular places. Once the patient is evaluated and stabilized, the next step is a trip to the CT or MRI as soon as possible. There’s simply no better way to see what’s going on inside a patient’s brain than to take a picture. Recent research has indicated that MRIs are better than CTs, but, if an MRI isn’t immediately available, it’s better to get a CT scan than to wait.
Once the type of stroke is identified, then the treatment begins. For an acute ischemic stroke, the idea treatment is tPA (alteplase), if started within 4.5 hours of symptoms, and antithrombotics, like aspirin, if after 4.5 hours but less than 48 hours. For an intracerebral hemorrhage (which can be caused by anticoagulants like heparin or warfarin), the initial focus is on carefully stabilizing the patient’s cardiovascular system, including by reversing any anticoagulants, normalizing glucose levels, preventing seizures, reducing intracranial pressure, and considering surgical options.
The treatment of stroke requires good coordination between primary physicians, emergency rooms, neurologists, neuroradiologists, and neurosurgeons — but those systems are supposed to be in place at every major hospital. The stroke malpractice we see often involves:
- A patient telling a primary care physician that they have difficulty walking, talking, seeing, using the phone, using their hands, or that they have a serious migraine or numbness, and the doctor tells them it’s not an emergency.
- A family doctor or emergency room nurse failing to recognize that abrupt neurological symptoms that disappear once the patient is at the hospital represent a transient brain ischemia, and that the patient is still at risk.
- An emergency room dismissing the possibility of stroke, and not using a CT or MRI to rule it out.
- An emergency room putting a potential stroke victim too low in the “triage,” so that their symptoms aren’t recognized in time to use tPA or other immediate measures.
As with an untreated heart attack, the consequences are devastating: the patient’s heart attack goes without proper treatment, resulting in further stroke attacks, brain damage, and permanent disabilities.