Mr A was a 45-year-old physician assistant (PA) who had been working in a midsized practice with several physicians, PAs, and nurse practitioners for the past 6 years. He liked working with Dr S, his supervising physician, and appreciated having the autonomy to see his own patients.

One of Mr A’s patients was Mr P, a married security guard with 2 daughters in their 20s. The patient’s medical history included hypertension, dyslipidemia, situational anxiety, and seasonal allergies. One day, Mr P called the office to make an appointment, complaining of shortness of breath. Four days later, Mr P came in for his appointment with Mr A.

Mr P noted that for the past 3 months he has been getting winded very easily. “It’s worse if I try to exercise — then I huff and puff and can’t catch my breath,” noted Mr P. He also said he has heartburn and that when he exercises, his jaw hurts.

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When questioned about the frequency of his symptoms, Mr P described the issues as intermittent but said he felt heartburn or “pressure” during light exercise. “I know I could stand to lose some weight or get in better shape,“ noted Mr P, “but when I try to push myself, I [get] out of breath and [feel] pressure in my ribs, so I stop.”

Mr P’s complaints of dyspnea on exertion, jaw pain, and epigastric pain are noted in his medical record. Mr A also recorded the patient’s vital signs: height, 5’6”; weight, 189 lb; BMI, 28.84. His sitting blood pressure was measured twice (150/88 mm Hg and 138/90 mm Hg). Oxygen saturation rate was 96% on room air.

Mr A noted in the record a normal physical examination and regular heart rate and rhythm, with normal S1 and S2 without murmurs, rubs, gallops, or clicks. An electrocardiogram was performed and showed a normal sinus rhythm.

Given the new onset of dyspnea on exertion associated with jaw and epigastric discomfort, Mr A planned to order stress echocardiography and have Mr P return in 2 to 4 weeks for a follow-up consultation. The plan was electronically signed by both Mr A and his supervising physician, Dr S.

Mr A told the patient that he had scheduled the cardiopulmonary stress test (in 3 weeks), after which they would meet again for a follow-up visit. The day before the stress test was scheduled, Mr P suffered a cardiac arrest and died in his home.

Mr P’s widow sought the advice of a plaintiff’s attorney. After reviewing Mr P’s medical records with medical experts, the attorney called Mrs P back and said she had a case. The lawsuit was filed against the medical practice.

The medical practice, including Mr A and Dr S, received notice of the lawsuit and consulted their defense attorney. The defense attorney, like the plaintiff’s attorney, sent the medical records out to be reviewed by experts.

The plaintiff’s experts alleged that Mr A, his supervising physician, and the practice had failed to meet the standard of care required in this case by failing to recognize and appreciate Mr P’s risk for sudden cardiac arrest. They noted that the PA had failed to recognize or understand that a single electrocardiogram is not reassuring for the lack of significant cardiac disease and risk for heart attack.

The defense experts also were critical after reviewing the medical records. They criticized the PA (and by extension his supervising physician and the practice) for not immediately referring Mr P to a cardiologist and/or the emergency department for further monitoring, evaluation, and treatment. They noted that the patient should have had immediate stress echocardiography, serial cardiac enzyme tests, and serial electrocardiograms, considering his presenting symptoms.

Mr A admitted that he was concerned it was a cardiac issue, which is why he ordered a stress test and a follow-up visit, but that he didn’t appreciate the urgent nature of the complaint.

After numerous discussions, the parties settled the case before trial for $3.5 million.

Protecting Yourself

One of the most challenging jobs of a clinician is recognizing when something should be treated as an emergency. Sometimes it is obvious — trauma, loss of consciousness, broken bones, or a heart attack in progress. Sometimes, however, it is less obvious.

When it comes to cardiac issues, it is better to err on the side of caution. In the case of an overweight, middle-aged man with a history of hypertension and dyslipidemia who is complaining of shortness of breath, epigastric pain, and jaw pain, it would have been appropriate to refer the patient to a cardiologist or hospital for further testing and monitoring; however, Mr A relied solely on a single office electrocardiogram and auscultation. Had Mr A referred his patient immediately to a cardiologist or to the emergency department for further screening, the patient may have experienced a different outcome.

It is far better to be overly cautious in the case of possible cardiac issues and order further testing immediately than to take a wait-and-see attitude and risk something happening before the next appointment.

Ann W. Latner, JD, a former criminal defense attorney, is a freelance medical writer in Port Washington, New York.