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ERcast Lite

Welcome to ERCast, a focused discussion on the questions, quagmires and known unknowns we face everyday in the emergency department.

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Feb 26, 2018

Amal Mattu gives his thoughts on why we actually get sued for missed MI. Is it the patient who has an impeccable workup with shared decision making? Or are there other factors/patient characteristics that commonly show up in lawsuits? 

In part 2, we talk with Mike Weinstock about criticism of his paper How Do We Balance the Long-Term Health of a Patient With the Short-Term Risk to the Physician? 


Episode contents



Part one. Amal Mattu on lawsuits for missed myocardial infarction

  • Do we mitigate medico-legal risk if we use a validated decision instrument or pathway? Amal feels that we do. You are applying validated literature to your practice.
  • Problems arise when the score, HEART for example, is miscalculated or guessed at. If you're going to use a protocol or score, be sure you're using it correctly
  • What are the things that Amal sees as common factors that lead to 'missed MI' lawsuits?
    • Misread EKGs
    • Young women presenting with atypical symptoms (atypical chest pain, shortness of breath, fatigue)
    • Young patients
    • Upper abdominal pain, especially without abdominal tenderness
    • Diagnosing a patent with 'reflux' when the patient was actually having an acute coronary syndrome. Inferior MIs in particular may masquerade as reflux symptoms or the patient with ischemia may have concomitant (true) reflux.
  • In 2015, Amal discussed his pathway for evaluating ED chest pain patients. Here is the protocol

Part two. Mike Weinstock on risk of CRACE (Clinically Relevant Adverse Cardiac Event), criticism of How Do We Balance the Long-Term Health of a Patient With the Short-Term Risk to the Physician? 

  • Original Episode air date October 30, 2017
  • We think we protect patients by admitting them to the hospital, but looking at the numbers, that might not be the case. The criticism of Mike’s paper that teased out the risk of CRACE in patients with non-ischemic interpretable EKGs and negative troponins, was that all patients were evaluated in the hospital. Did hospitalization confer some unmeasured benefit? Can we extrapolate that risk of CRACE in patients who have been hospitalized applies to discharged patients with the same profile? This is an ongoing debate, but the data is some of the best we have and can still inform discussions with patients.
  • We don't sent patients home and tell them they have no disease, we send them home with a plan for continued evaluation.

How does Mike use this information?

  • If the ED workup shows a non-ischemic EKG and there are two negative serial troponins, he presents the option of an outpatient workup. A caveat to this is that access to rapid outpatient evaluation must be readily available.
  • He advises the patient that the possibility of a CRACE is one in several thousand and, while being hospitalized may seem like the safest course of action, hospitalization itself is not without risk.
  • The Weinstock Credo: Don’t practice defensive medicine. Document “defensibly”



Singh, Swarnjit, et al. "The contribution of gastroesophageal reflux to chest pain in patients with coronary artery disease." Annals of internal medicine 117.10 (1992): 824-830. PMID: 1416557

Dobrzycki, Slawomir, et al. "Does gastro-esophageal reflux provoke the myocardial ischemia in patients with CAD?." International journal of cardiology 104.1 (2005): 67-72. PMID: 16137512

Pope, J. Hector, et al. "Missed diagnoses of acute cardiac ischemia in the emergency department." New England Journal of Medicine 342.16 (2000): 1163-1170. PMID: 10770981