FAMILY PRACTITIONERS AND EKGs

Family practitioners know that good specialty back-up is essential for the health of their patients. They also believe that because over-referral to specialists can sometimes be harmful to patients, they should do their best to treat within their skills.

The limits of those skills may be reached in the interpretation of complex diagnostics. And sometimes after a bad result, the only error committed by a family practitioner turns out to be trying to do too much without a specialist’s assistance.

Dr. F is a family practitioner with a busy practice that includes urgent care patients. Mr. E, a 45-year-old executive, saw Dr. F many times over the years for routine medical needs. Despite Dr. F’s suggestion early on that Mr. E schedule a full physical exam, Mr. E chose instead to continue to visit Dr. F on an urgent-care basis for such complaints as sinusitis and upper respiratory infections.

A month after a visit for allergic sinusitis, Mr. E presented with complaints of tightness in his chest and burning sensation in the anterior chest for about two days. Mr. E said the pain came and went, at times felt like indigestion, and diminished with relaxation. He told Dr. F that he worried that he might have a heart problem. A chest X-ray was normal and Dr. F read the EKG to be “100 percent normal.” Further evaluation revealed that Mr. E had engaged in vigorous gardening and that his anterior chest wall was very tender to compression.

Upon further discussion with the patient, Dr. F concluded that Mr. E had costochondritis, for which he prescribed Cataflam and Toradol. On a return visit one week later, Mr. E told Dr. F that his symptoms had completely resolved. Lab results for Mr. E, who was mildly overweight, showed cholesterol of 212, triglycerides of 154, hdl of 31 and ldl of 150. Mr. E’s cardiac risk was 6.9 — the upper end of normal. Dr. F counseled Mr. E on diet and exercise and advised him to return in four to six months for a repeat panel.

Instead, the patient returned the next day stating that he had chest pain similar to that he experienced a week earlier.

This time, an EKG showed evidence of an acute anterior septal infarct. After a repeat EKG showed the same finding, Dr. F told Mr. E that he had had a heart attack and that he must get to the emergency room immediately. Because Mr. E told Dr. F that he would refuse an ambulance transport and Mrs. E could not be reached, Dr. F arranged for a member of his own family to drive Mr. E to the hospital.

Mr. E required a bypass surgery and claimed a shortened life expectancy in his lawsuit against Dr. F for failing to properly diagnose his condition prior to the injury.

Expert review of the case focused on Dr. F’s chart entry of an EKG being “100 percent normal.” The consensus was that though it was not necessarily abnormal, there was enough of a question that combined with the patient’s complaints of pain, Dr. F should have referred Mr. E to a cardiologist.

According to statistics on medical malpractice lawsuits, misdiagnosis of cardiac conditions resulting in myocardial infractions is a leading cause of claims against family practitioners. With family doctors on the firing line for cardiac screening, it is increasingly important for them to know when to call in the expert reinforcements.