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?
Part one. Amal Mattu on lawsuits for missed myocardial
- 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
- 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
- The Weinstock Credo: Don’t practice defensive medicine.
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