Spotting bacterial endocarditis in the ED: The Result

Continue Next for the result from Dr. Sullivan’s

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The result:
EP loses big for not spotting diagnosis that was not related to the chief complaint. After a trial, the jury entered an $18.5 million judgment against the emergency physician and the hospital.Another look at the facts:
In this case, the facts were taken from the appellate court’s opinion, so they may be incomplete in some regards. The plaintiff alleged that the emergency physician was negligent because he failed to detect the plaintiff’s endocarditis and alleged that the emergency physician’s negligence was a direct cause of the patient’s stroke.

The patient’s presenting complaints included tongue swelling, difficulty breathing, and difficulty speaking which were presumably a reaction to the antibiotic that the patient had already been taking. The court opinion did not state why the patient was taking an antibiotic. Although the symptoms for which the patient sought care had resolved without treatment by the time that the physician evaluated the patient, the question remained as to whether the patient had endocarditis during his emergency department visit.The issue:
How should a reasonably well qualified emergency physician treat a patient who was already taking oral antibiotics and who had transient swelling of the tongue, transient difficulty breathing, and transient difficulty speaking with a fever of 102 degrees and no source?

How the case was decided:
The plaintiff’s expert testified that endocarditis often presents as a fever and a heart murmur and that an appropriate history and physical examination would have led to appropriate testing and would have averted the patient’s stroke.

There was one piece of the puzzle missing, though. The physician did not hear a heart murmur and the expert did not state whether a heart murmur likely existed or whether the physician would have been negligent for failing to hear the heart murmur. Unfortunately, this is where the physician hurt himself. During his testimony, the physician admitted that the patient probably did have a heart murmur during his ED visit, that he failed to hear the patient’s murmur, that endocarditis should have been considered given the patient’s symptoms and that he might have diagnosed the patient’s endocarditis if he had heard the patient’s heart murmur.

When viewed as a whole, the physician’s testimony amounted to an admission of his own negligence.  The appellate court used the physician’s testimony against him, holding that “while plaintiff’s expert did not specifically say that the appropriate standard of care required [the ED physician to hear the]murmur, it is inconceivable that the correct standard of care would not have required him to hear plaintiff’s ‘quite noticeable’ defect once he had determined it important to listen to the plaintiff’s heart.”  Had the physician instead testified that he uses a stethoscope every day, that it is sometimes difficult to hear heart murmurs in the noisy emergency department, and that the patient’s presenting symptoms of tongue swelling, dyspnea and difficulty speaking are not symptoms of endocarditis, and that the standard of care does not require emergency physicians to diagnose every possible disorder a patient might have, perhaps the case may have been decided differently.

Aside from the standard of care, this case also presented an issue as to whether the physician’s alleged negligence caused the patient’s stroke. Recall that there was a 7 week time delay between the patient’s emergency department visit and the patient’s stroke. Also recall that the patient visited more than one physician after his emergency department visit and was receiving intravenous antibiotics for three weeks before the stroke occurred. Another way of assessing causation is the “but for” test: But for the physician’s negligence would the patient have incurred damages? In other words, to a reasonable degree of medical certainty, if the physician had successfully diagnosed subacute endocarditis, would the patient still have had a stroke? I believe that there are too many other intervening factors for a direct causal link to be drawn between the patient’s stroke and the emergency physician’s care. Negligence by the patient’s other treating physicians and the patient’s own contributory negligence, if present, need to be considered. Did the stroke actually result from the patient’s vegetation or was there another source for the emboli? In addition, it is difficult quantify how much the patient’s risk of stroke increased due to a delay in diagnosis. If there was little or no increased risk, then the physician’s alleged negligence did not cause any additional damages to the patient. The appellate court even noted that the defense attorneys failed to elicit a basis for the plaintiffs expert’s opinion that “had it not been for the negligence of [the ED physician]the stroke would not have occurred.”My opinion:
My verdict is that the physician may have needed better legal representation. Even though I believe the physician’s actions met the standard of care, his apparent lack of trial preparation caused him to admit negligence during court testimony.  The issues in this case underscore the importance of finding a knowledgeable and experienced defense attorney when you have been accused of medical malpractice.