Patient Suffers Fatal Cardiac Arrest Following Delayed Aneurysm Diagnosis

This case involves a 70-year-old woman with a history of heart bypass graft surgery and several coronary stent procedures who developed a sudden onset of chest pain. She presented to the emergency room pale, sweating heavily, and had high blood pressure. An IV was started along with supplemental oxygen. The patient’s blood pressure began to drop shortly after arriving and 4 liters of IV fluid were ordered. A portable chest x-ray revealed a widened mediastinum. CT scans of the chest, abdomen, and pelvis were also performed. Following the imaging, Radiology erroneously reported that the patient’s aorta was of normal caliber without dissection or an aneurysm. It was later discovered the imaging taken actually revealed a slow leaking aneurysm and large right upper lobe mass. The patient was then discharged to the medical/surgical floor with a diagnosis of mediastinal mass and chest pain. Under the care of the hospitalist and PA-C, the patient was assessed and noted to have coronary artery disease with possible congestive failure. Furthermore, it was noted the patient may have not tolerated the 4 liters of IV fluid. The patient was given an anticoagulant. The following morning, radiologist correctly read the chest CT angiogram reporting that there was an aneurysm extending off the superior aspect of the ascending aorta at the beginning of the arch. The patient then required a transfer to another facility. Even though there was a cardiac unit within 30 minutes of the hospital, the patient was transferred to another facility approximately 2 hours away. At the other facility, the patient was thought to have an anastomotic rupture at the site of an old vein graft. In the catheterization lab, studies revealed three-vessel coronary disease and an occluded LAD, 60 to 70% mid-right coronary lesions and diffuse narrowing of the left main circumflex artery. The patient was taken to surgery immediately. A transesophageal echocardiogram probe was introduced and revealed that the left ventricle of the heart was empty. The patient eventually went into ventricular fibrillation and could not be revived.

Question(s) For Expert Witness

1. Do you routinely treat patients like the one described above?

2. Have you ever had a patient develop the outcome or complications noted above?

3. Given the delay in diagnosis, should the patient have been transferred urgently to a closer facility?

Expert Witness Response E-007034

I have been a full-time hospitalist since 2004. I am also a full professor of medicine with extensive experience training residents and thus very familiar with the scope of practice of and responsibilities of hospitalists and excellence at all stages of training and career. Evaluating chest pain and considering aortic aneurysms are basic skills for hospitalists, including myself. However, at my facility, someone with obvious cardiac complications or cardiothoracic surgery issues would be managed on cardiology or CT surgery as soon as they were recognized, not general medicine. It is not the delay in diagnosis, but the patient's condition (test results, vital signs, exam, medications received, overall urgency) that dictates the urgency of care at another facility and thus the location of transfer. It would not have been acceptable to wait longer, should the same condition have been present on admission and recognized at that time, just because there had been no delay. I have seen a similar presentation before. During my residency, a patient, who was admitted with an aortic aneurysm, went into cardiac arrest because it progressed and ruptured into the pleural space. I was part of a group that attempted to revive him. Again, these issues are managed on other services at most teaching institutions, including mine, but may also be co-managed with hospitalists at community hospitals.