Cardiologist Fails To Refer Child For Additional Testing

This case involves an 8-year-old boy who experienced recurring palpitations and dizziness for several months. The child was taken to a cardiologist who thought the symptoms to be heart-related. The child’s Holter monitor tests were normal. However, no neurosurgical consult or brain MRI were ever ordered. The child subsequently suffered a serious seizure one day at school and was rushed to the hospital. An MRI revealed a tangle of abnormal blood vessels in the brain. While the patient was in the hospital, the child suffered a massive bleed rendering him unconscious. He died several days later, never regaining consciousness. It was alleged that the treating cardiologist failed to refer the child to the proper specialist for further testing.

Question(s) For Expert Witness

1. How often do you evaluate pediatric patients with palpitations and dizziness?

2. If a cardiac cause is not found, what is the responsibility of the cardiologist, if anything, to refer the patient to another physician for further testing?

Expert Witness Response E-008699

I have treated hundreds of patients with dizziness, palpitations, and syncope in the last few years, and perhaps 10 patients with cerebral AV malformations in the last 20 years. The duty of the cardiologist will depend upon the specifics of the case. Often the diagnostic evaluation for patients with these symptoms is being managed and coordinated by a primary care doctor or a neurologist. In this case, the cardiologist is asked only to rule out a cardiac cause so the diagnostic process can proceed down other paths. In other cases, the cardiologist directs the work up and coordinates evaluations for non-cardiac causes. In my experience, the former arrangement is far more likely if the presenting symptom is dizziness/syncope, and the latter is more common if the presenting symptom is palpitations. In the former case, once I indicate that a cardiac cause is not identified, the primary care doctor or neurologist usually determines subsequent referrals and evaluations. This is an area of medicine in which one would historically find considerable practice variability, so different experts often make different recommendations and patients flow through the system differently, depending upon patient factors, region of the country, insurance guidelines, etc. Clinical practice guidelines specific to syncope were just published (in the Journal of the American College of Cardiology), in part to reduce practice variability in the field. I believe my strengths as an expert derive from both my clinical background and my background as an epidemiologist. The latter has provided me with insights into the validity, or lack thereof, of the medical and scientific arguments made to support a particular case. In addition, I understand practice guidelines, evidence-based medicine, and standards of care in the clinical domains in which I practice medicine.