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Failure to Communicate Severity of Heart Attack; Expert


A patient presented to the emergency room (ER) complaining of shortness of breath and chest pain. An ER physician concluded that the patient had suffered a heart attack. The ER physician discussed the patient’s condition with the cardiologist on call and the hospital’s internist/hospitalist. The ER physician admitted the patient to the hospital.

 

Upon admission to the hospital, the patient’s blood pressure was low, troponin levels were elevated, and heart rate was elevated. The patient had fluid in the lungs and crackles in the bases of the lungs, which may indicate pneumonia. An electrocardiogram, echocardiogram, and other tests indicated that the patient had experienced a non-ST elevation heart attack. A non-ST elevation heart attack requires close monitoring, but not necessarily immediate invasive care. In contrast, an ST elevation heart attack is more serious and requires immediate treatment.

 

Based on the echocardiogram, the internist/hospitalist believed that the patient was in cardiogenic shock, meaning the heart was unable to pump enough blood to meet the body’s needs. The internist/hospitalist believed an emergency heart catheterization was necessary, which would have revealed the reason for the cardiogenic shock, such as a blocked blood vessel. The internist/hospitalist could not perform that invasive procedure.

 

The internist/hospitalist consulted the cardiologist on call. The internist/hospitalist told the cardiologist that the patient had low blood pressure, an elevated heart rate, elevated troponin levels, and fluid in the lungs. Additionally, the internist/hospitalist told the cardiologist that the patient was probably in cardiogenic shock, the patient probably needed a heart catheterization, and the cardiologist should see the patient before going home for the night. After this conversation, the cardiologist went home for the night without seeing the patient. The cardiologist ordered the patient be monitored by a registered nurse (RN) who monitored the cardiologist’s patients and relayed information to the cardiologist regarding those patients.

 

The next morning, the internist/hospitalist learned that the patient’s condition had worsened and that the cardiologist had not yet seen the patient. The cardiologist’s RN told the internist/hospitalist that the patient was being transferred to the hospital’s intensive care unit and that the cardiologist was en route to the hospital.

 

At approximately 12:50 p.m., an emergency code was relayed over the hospital’s public address system indicating that the patient had suffered cardiac arrest. The cardiologist still had not personally seen the patient at that point.

 

A heart catheterization performed after the patient had suffered cardiac arrest indicated that the patient had heart blockages that might have been bypassed through surgery had they been discovered earlier. The patient later died from insufficient oxygen to the brain.

 

The patient’s estate sued the cardiologist and internist/hospitalist for medical malpractice. The estate settled the claims against the cardiologist.

 

The internist/hospitalist filed a motion to strike the standard-of-care testimony of the estate’s designated expert witness because the expert was a board-certified cardiologist, not a board-certified internist or hospitalist. The internist/hospitalist filed a motion for summary judgment.

 

The estate argued that, if the motion to strike the expert witness’s testimony was granted, summary judgment was not appropriate because the internist/hospitalist’s want of skill or lack of care was so apparent it could be understood by a lay person and required only common knowledge and experience to understand it. Specifically, the estate asserted that the internist/hospitalist simply failed to inform the cardiologist that an emergency existed and that a lay person was capable, without the aid of expert testimony, of concluding that that failure constituted a breach of the applicable standard of care.

 

The Calhoun Circuit Court granted the motion to strike the standard-of-care testimony of the estate’s designated expert witness and summary judgment in favor of the internist/hospitalist.

 

The Supreme Court of Alabama affirmed. The court held that the trial court did not err in concluding that the estate was required to present expert testimony.

 

The trial court did not err in concluding that the estate was required to present expert testimony. The court found that the testimony established that the internist/hospitalist provided the cardiologist with substantial diagnostic information regarding the patient’s condition. The court reasoned that, given the technical nature of the dialogue between the physicians, it would be difficult, if not impossible, for a layperson, in considering the roles, responsibilities, relationship, and communications of and between the internist/hospitalist and the cardiologist to determine the applicable standard of care, much less whether that standard was breached. The court concluded that the estate was required to present the expert testimony of a similarly situated health-care provider to identify the applicable standard of care and to specify how that standard was breached. Consequently, the court concluded that the trial court did not err in concluding that the estate was required to present expert testimony showing that the internist/hospitalist’s alleged failures in consulting with the cardiologist the evening the patient was admitted to the hospital fell below the applicable standard of care.

 

The Supreme Court of Alabama affirmed the trial court’s grant of summary judgment in favor of the internist/hospitalist.

 

See: Shadrick v. Grana, 2018 WL 5306883 (Ala., October 26, 2018) (not designated for publication).

 

See also Medical Law Perspectives Report: Diagnosis and Treatment of Heart Attacks: Liability Issues

 

See also Medical Law Perspectives Report: Unnecessary Cardiac Procedures: Getting to the Heart of the Risks

 

See also Medical Law Perspectives Report: Mending a Broken Heart: Malpractice Risks in Diagnosing and Treating Heart Disease

 

See also Medical Law Perspectives Report: Congenital Heart Conditions: How Infants, Adults, and Healthcare Providers Handle the Risks

 

 

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