Vascular Thromboembolism Case Review
By John D. Bibb, MD - Lead Author
Case Number Two
The purpose of the Standard of Care Review Panel is to identify testimony that does not accurately reflect the standard of care and to educate emergency physicians about the actual standard of care. The information for this case was obtained from depositions and medical records submitted to the Panel for review.
A 43-year-old, mildly hypertensive man presented to an emergency department complaining of a bluish discoloration of the volar pads of three fingers of the left hand and some intermittent discoloration of the left palm. These symptoms came on suddenly. Some weeks to months prior, the patient had transient, partial loss of vision while playing hockey. The patient has a history of a coronary artery bypass graft and DVT in years past. He smokes one to two packs of cigarettes daily. His only medication is aspirin. He denies chest pain, shortness of breath, current headache, nausea, vomiting, fever, and chills. There are no neurological complaints. On physical exam, the heart and lungs are normal. There is the bluish discoloration on the left hand, which is slightly tender to touch. The exam is otherwise normal. CBC, BMP, PT, and PTT are all normal. Pulse ox is 97%. An EKG from about the time of this emergency department visit shows sinus rhythm at 74, first degree AV block, and inverted T waves in V3, V4, & V5. A color flow duplex of the left arm shows no large vessel occlusion. Monophasic flow is noted in the palmar arch. Venous Doppler of the left arm is normal. Carotid Doppler’s are normal. The patient is stable in the emergency department. He is uninsured but a successful entrepreneur, and he wants to go home. He has physician follow-up.
The attending emergency physician discussed the case with a vascular surgeon who did not come in and see the patient. The patient was discharged home on Plavix and aspirin, against the emergency physician’s wishes but not AMA. The patient had no further medical care until six and a half days later when he presented to the same emergency department with a basilar artery embolus and profound neurological deficits. An echocardiogram showed a 2 by 3 cm clot in the hypokinetic apex the left ventricle. The patient's recovery was only partial with intra-arterial thrombolysis and he has significant disability. As a result of this deficit, the patient and his lawyer claim he lost his business and his wife.
The case went to court and there was a deposition by the plaintiff's expert, as well as court testimony for the Panel's review. Several hundred pages of testimony were submitted; however, the panel’s review and comments focus entirely on the expert witness’ testimony regarding the standard of care.
The expert indicated that it was the standard of care for the emergency physician to compile a list of risk factors that might suggest this patient was going to suffer a stroke. This list of risk factors should then be evaluated to assess the risk for stroke and that decisions should be made based on the risk stratification, particularly about admission and the administration of heparin.
The Panel unanimously agreed that risk stratification for prediction of imminent CVA is not the standard of care for the emergency physician.
The expert witness asserted that certain tests should be ordered by the emergency physician to assess the risk for embolic stroke as part of the standard of care. The tests listed by the expert are homocysteine level, PT, PTT, Sed. Rate and CRP. The expert felt that a "stroke panel" should have been ordered by the emergency physician, as the involved institution was a stroke center.
The Panel felt that it was not the job of the emergency physician to work up a patient for risk factors for thromboembolism, and further believed that some of the tests listed are of little or no value in the evaluation of risk factors for thromboembolism. The list further left out many of the appropriate tests such as evaluations for antiphospholipids, antithrombin III, Factor V Leiden, and factor S and C deficiencies. While consulting physicians may request such testing be ordered while the patient is in the emergency department with the results sent to them, the Panel agreed there was no standard of care indicating such tests should be ordered by the emergency physician.
The Panel discussed the issue of whether documenting the risks and patient's refusal of admission is adequate vs. completing a separate AMA form. In this case, the emergency physician clearly attempted to provide the risks to the patient and offered hospital admission but he refused. This was clearly documented in the medical record, but no AMA form was used. In general, the Panel believes this should be adequate documentation but believe that emergency physicians using AMA forms may be better protected if questions arise about why a patient was not admitted. In some hospitals and states, policies and state law may require the use of an AMA form. We felt physicians should be encouraged to clearly document AMA's and should not be reluctant to use the appropriate forms. In regard to the above, we again disagreed with the expert as to the necessity of using an AMA form to meet the standard of care.
The Panel agreed that the signs and symptoms of arterial embolism can be subtle and the sources of embolism are several. However, in this case there was no indication that the standard of care had not been met by the emergency physician.