Legal Pearls: Delay in Aortic Dissection Diagnosis Leads to Paralysis

Ms W, a 51-year-old woman, visited the emergency department reporting sudden onset of left-sided chest pain that radiated to her left arm and jaw. Her blood pressure was elevated, and her electrocardiogram (ECG) was abnormal.

Dr P ordered chest radiography scan and a troponin test but did not order a chest computed tomography (CT) scan despite aortic dissection being one of the possible diagnoses.

Three hours after she arrived in the ED, Ms W suddenly began crying out in pain and sweating profusely. Dr P ordered a CT angiogram to evaluate for aortic dissection, but it took almost 45 minutes for the patient to be taken for imaging. The CT showed a complete dissection of the thoracic aorta. At 6:15 pm, arrangements were made for an emergency flight to another facility where Ms W’s aorta could be surgically repaired.

Was Dr P Negligent?

(Discussion on next page)

Ann W. Latner, JD, is a freelance writer and attorney based in New York. She was formerly the director of periodicals at the American Pharmacists Association and editor of Pharmacy Times.

Coming up with differential diagnoses is one of the most important things that needs to be done in emergent situations. But coming up with a potential diagnosis is only useful if it is acted on or ruled out. Today, we look at a case where the differential diagnoses included the correct one, but it was not acted upon in time.

Clinical Scenario

It was a busy day in the emergency department of the hospital where Dr P worked as a physician. This was not surprising or unusual–the emergency department was always a place of controlled chaos as streams of new patients were brought in by ambulance or car.

At about 2 pm, Ms W, a 51-year-old elementary school teacher, walked into the hospital emergency department. She reported experiencing sudden onset of left-sided chest pain that radiated to her left arm and jaw.

“I know I’m too young for a heart attack,” she told the triage nurse, worriedly, “but I’ve heard that it’s important to get to the hospital immediately if you have chest pain.” She reported leaving the elementary school where she worked as soon as the pain began.

At 2:12 pm, Dr P examined the patient. Her blood pressure was elevated, and her EKG was abnormal. After the physician evaluated Ms W, he noted that the differential diagnosis included acute myocardial infarction, anxiety, coronary artery disease, chest wall pain, costochondritis, mitral valve prolapse, myocarditis, pneumonia, pneumothorax, pulmonary embolus, stable angina, and aortic dissection. Dr P ordered a chest radiolography scan and a troponin test but did not order a chest CT despite aortic dissection being one of the possible diagnoses.

“I’ve ordered some tests to rule out a heart attack,” the physician told the patient. “Hopefully we’ll have you back to your students in no time.”

The results of the chest radiography and troponin test both came back negative, but the patient’s blood pressure remained elevated, and her chest pain did not improve.

At 5 pm, 3 hours after she arrived in the ED, Ms W suddenly began crying out in pain and sweating profusely. She reported severe chest, back and abdominal pain.

“My legs are burning!” she told the medical staff, “I can’t feel my feet!”

Dr P ordered a CT angiogram to evaluate for aortic dissection, but it took almost 45 minutes for the patient to be taken for imaging. The CT showed a complete dissection of the thoracic aorta. At 6:15 pm, arrangements were made for an emergency flight to another facility where Ms W’s aorta could be surgically repaired.

Despite the repair, Ms W continued to exhibit signs of right lower extremity ischemia and compartment syndrome. She required 4 compartment fasciotomies. Following the extensive surgeries, Ms W was found to have paraplegia from spinal cord ischemia. She became confined to a wheelchair with only limited use of her arms, and she required help for all aspects of daily living.

Ms W consulted with a plaintiff’s attorney who agreed to take the case.

NEXT: The Lawsuit

The Lawsuit

Ms W’s attorney filed a lawsuit against the hospital, Dr P, and the other medical staff that had treated Ms W. Her attorney hired experts to look at the medical record and to testify at trial. The experts were prepared to testify that once aortic dissection is a differential diagnosis, imaging must be ordered right away, or the patient must be immediately transferred to a facility that can handle the situation.

“I think we have a strong case,” the attorney told Ms W.

Meanwhile, Dr P met with the defense attorney who was representing the hospital and its staff.

“Why didn’t you order a CT scan right away?” asked the attorney.

“We ordered a chest x-ray,” said Dr P.

“Yes, but that wouldn’t reveal an aortic dissection, would it?” asked the attorney.

“No,” the physician had to admit. “But it didn’t seem very likely that it was an aortic dissection when she came in. I mean, we did list it as a differential diagnosis, but in a 51-year old woman it is much more likely that chest pain is caused by anxiety or angina or something else. As soon as she reported lower extremity involvement, we immediately ordered the CT.”

“Yes,” said the attorney, “but apparently that didn’t happen for another 45 minutes in a ‘time is of the essence’ situation.”

“The imaging department must have been busy,” replied the doctor.

“We don’t have a great defense here,” the attorney told the physician. “If we go to trial, I’m going to have to argue that the failure to order a CT earlier wasn’t the cause of Ms W’s permanent disability–it would have happened regardless even if she had been sent to the other facility an hour or 2 earlier. But it’s not the best defense, and I think we should explore settling the case.”

Dr P and the hospital administration agreed that settling the case was probably the best course of action.

Settlement talks between the parties began, and eventually the case was settled out of court for a total sum of $4 million.

The Takeaway

In this particular case, Dr P’s facility was not able to handle an emergency aortic dissection repair and the patient had to be transferred to another facility. This made it even more urgent to confirm or rule out an aortic dissection diagnosis, since treatment would have to take place elsewhere. Dr P failed to handle the situation like the true emergency that it was.

Bottom Line— In an emergency, ruling out the most dangerous diagnosis (or the one that needs to be acted on most immediately) is vital. Simply making a list of the possibilities is not enough–tests must be run to rule out or confirm the diagnosis.