By William Sullivan, DO, JD - Lead author

The patient's emergency department records were not provided for this review, so the patient's symptoms, physical examination, and emergency department course were gleaned from the depositions of two plaintiff's experts in the case.

A postmenopausal African-American female patient presented to the emergency department with a chief complaint of fairly persistent pain "inside her back" for two days prior to her evaluation. While the patient did not verbally describe the location of her pain, nurses noted that the patient pointed to her low back as she described the pain. The patient attributed her pain to "overexerting" herself doing yard work two days prior to evaluation. She also reported a history of nausea of unknown duration.

Upon her presentation, the patient's pulse was 104 and her blood pressure was 157/110. Her height was 5' 0" and her weight was 270 pounds. She had no SOB or diaphoresis.

The patient's medical history included hypertension and obesity. She had a positive family history for atherosclerotic heart disease.

The physician's examination of the back showed no abnormalities. The pain was unable to be reproduced with bedside maneuvers. The remainder of the physical examination was not discussed in the depositions. A urinalysis showed 1+ bacteria.

The patient's pain resolved without intervention. She was apparently discharged home with Lortab and Motrin.

On discharge, the patient's BP was 140/90 and her pulse was 80.

The following day, the patient's husband found her poorly responsive. She was brought back to ER and later died from unknown causes.

An autopsy was performed and showed that the patient's heart was hypertrophied and there was narrowing of coronary vessels. There was no evidence of clot or plaque ruptures found in any of the coronary arteries.

Prior to the experts reviewing the case, the plaintiff's attorney discussed the case with each physician and sent the experts articles relating to the subject matter of the case.

Expert Number One
The first plaintiff's expert believed that the patient's symptoms were manifestation of undiagnosed heart disease. It was this expert's opinion that the patient's sore back, elevated blood pressure, elevated heart rate, and nausea signaled that the patient was having unstable angina. The expert stated that isolated nausea, cough, and other GI symptoms can all be manifestations of unstable angina.

This expert stated that in this case, the standard of care required that the patient be given aspirin and put on a heart monitor. It also required that the physician obtain cardiac enzymes and a chest x-ray. Finally, the standard of care required that this patient be given heparin, beta blockers, and morphine.

In explaining why the emergency physician fell below the standard of care in this case, the expert stated that "there were risks that . . . were not explored," including the patient's history of hypertension, African American race, and abnormal vital signs. The expert stated that if the risks had been explored, the physicians "could have intervened" and presumably could have prevented the patient's death.

It was this expert's opinion that the patient died from an acute coronary event. The defense attorney noted that the patient's autopsy showed no clot or plaque ruptures in any of the coronary arteries. The expert believed that "severe spasm" of a coronary artery could also cause an acute coronary event that would also have resulted in the patient's death.

The defense attorney demonstrated the expert's retrospective approach at reviewing this case when he saw a note the expert had apparently written to himself that stated "Did [physician] have any reason to suspect [heart disease]?"

Expert Number Two
The second expert did not believe that the patient was actually having low back pain. While the nurse's notes show that the patient pointed to her low back, due to the patient's body habitus, this expert questioned whether the patient could have been pointing to the upper back.

This expert believed that back pain was the patient's anginal equivalent. Given the patient's history of hypertension, her race, her family history of cardiac disease, and her symptoms at presentation, this expert stated that a reasonable doctor should have evaluated the patient for heart disease.

This expert faulted the physician for failing to ask historical questions such as, "What does your blood pressure normally run?" and, "Does your blood pressure normally elevate when you have pain?" The expert also stated that there was a reasonable degree of medical certainty that patient was having ischemia at the time she presented to the emergency department and that to a reasonable degree of medical certainty, the EKG may have shown ischemic changes had it been performed.

The expert stated low back pain that lasted for 2 days, brought the patient to the ED in the middle of night, caused abnormal vital signs, and went away without treatment is not consistent with musculoskeletal pain.

"The physician deviated from standard of care because the physician failed "[to do what the expert] would do and [what the expert] would expect to be done for that presentation," the expert stated.

Conclusion
When evaluating patients for acute low back pain, medical literature focuses upon determining the presence of "red flags." These red flags include major trauma, age>50, persistent fever, history of cancer, metabolic disorders, major muscle weakness, bowel or bladder dysfunction, saddle anesthesia, decreased sphincter tone, and unrelenting night pain. Presence of these red flags is used to suggest the possibility of malignancy, fractures, infections, abdominal aneurysms, disk herniations, and epidural compression syndromes. Although "back pain" can be one of the symptoms of an acute coronary syndrome, neither the Standard of Care Committee nor the experts in this case were able to find any references describing "low back pain" as a presenting complaint of patients with any form of myocardial ischemia.

It was the opinion of the Standard of Care Committee that the experts in this case presented opinions that did not represent the standard of care for several reasons:

1. The experts assumed facts that were not in evidence. For example, when the patient complained of pain inside her back while pointing to her lumbar region, the experts, knowing the outcome of the case, stated that they believed the patient was instead referring to pain in her upper back as a manifestation of cardiac disease. The only basis for these opinions was speculation that the patient may not have been able to point to her low back due to her body habitus. In addition, contrary to one expert's assertions, there was no evidence that the patient experienced "spasm" of the coronary arteries, or that she died from an acute coronary event.

2. One expert stated that the standard of care required physicians to perform in-depth history and physical examinations. Instead, it was the consensus of the Standard of Care Committee that focused physical examinations are the standard of care in emergency medicine and that in-depth and detailed history and physical examinations are more appropriately left to the primary care physicians. The expert's statements that physicians who encounter patients with high blood pressure should be required to ask patients questions such as "how high their blood pressure usually runs" and "whether their blood pressure elevates with pain" are unrealistic and do not represent the standard of care in emergency medicine.

3. Both experts placed an inordinate amount of weight on the patient's risk factors for cardiac disease, even when the patient presented with complaints that did not suggest a cardiac etiology. The Standard of Care Committee believed that while risk factors may contribute to a patient's overall history, patient management cannot be based solely on risk factors unrelated to a patient's complaints.

4. The Standard of Care Committee believed that the expert opinions in this case were influenced by retrospective analysis. The plaintiff's attorney discussed the case and outcome with both experts prior to their review. This appears to have biased the experts as demonstrated by the notations one expert made to himself about whether the physician had "any reason to suspect [heart disease]." While low back pain has not been described in medical literature as a manifestation of heart disease, at least one of the experts apparently began with the diagnosis of heart disease and worked backwards to determine whether the patient exhibited any symptoms that could have remotely suggested heart disease. It was the opinion of The Standard of Care Committee that prospective analysis is of utmost importance when determining the standard of care in a given situation.

5. Finally, at least one of the experts stated that the standard of care was represented by what the expert would have done or would have expected to be done in a similar situation. The standard of care in medical practice is what a prudent and reasonably well trained physician would do in the same or similar circumstances. Using oneself as a yardstick for determining the standard of care may not be appropriate since some experts may practice above the standard of care and others may utilize only one of several acceptable medical practices in given circumstances.