Episode 076: Back to the Heart of the Matter

Speaker 1: You are listening to Your Practice Made Perfect: Support, Protection and Advice for Practicing Medical Professionals, brought to you by SVMIC.

Brian: Thank you for joining us today. My name is Brian Fortenberry. And on today's episode of our podcast, once again we're going to look at a closed claim, gain some information that hopefully will be beneficial as you continue to practice, and some areas, maybe, that you can learn to avoid as you practice medicine. And joining me today to discuss this, I have Katy Smith and J. Baugh. Welcome. 

Katy: Thanks. 

J. Baugh: Thanks, Brian.

Brian: Katy, tell us a little bit about yourself.

Katy: I'm a claims attorney. I've been with SVMIC for over 12 years now. I'm a licensed attorney, licensed to practice law in state and federal courts in Tennessee. Used to practice privately before I joined State Volunteer, and had the honor and privilege of helping defend our insureds when they were sued.

Brian: And J, tell us a little bit about yourself. You're one of these crazy people likes school a lot, apparently.

J. Baugh: Yeah, no. I didn't want to admit that, but thank you for asking. 

Brian: Sure.

J. Baugh: My undergraduate degree is in Accounting, and I became a CPA after that. And then, being a glutton for punishment, I decided to go to law school after getting my CPA, and passed the bar after that. So, I am now both a licensed attorney and a licensed CPA in the state of Tennessee. And I have been in the Claims Department at State Volunteer for 18 years.

Brian: Thanks for being with us, and I really appreciate both of you taking the time to be here today. And we're going to talk about this case that involves a 73-year-old lady who presented to the doctor with complaints of back pain, and she, unfortunately, ultimately passed away two days later from presumably an acute myocardial infarction. A heart attack, right? So, let's get started with the initial appointment there. How did the initial appointment go with this patient?

Katy: Well, the patient, whom we are calling Mrs. White, developed back pain. So, she went to go see her primary care physician, Dr. Steele. She went on a Friday, which happened to be Good Friday. So, the Friday before the Easter holiday weekend. She described her pain as pain that was in her back. Did not radiate to her chest. But activities such as bending over and reaching exacerbated the back pain.

Brian: It's not uncommon for women to have back pain issues when it comes to heart attacks, right? Is that correct?

J. Baugh: I think that's right.

Brian: Often, it radiates around. So, it sounds like Dr. Steele did an examination, and the fact that it sounds like she could bend over, the first thing comes to mind, maybe, is, "Well, this is just... It can be repeated... It's muscular issues," is what I would think. So, what did he document after he did his examination there? 

J. Baugh: Dr. Steele did a careful examination, and he documented that the patient complained of upper thoracic chest pain for the past four days, and it was described as both sharp and aching, and that it radiated into her arms. And so, Dr. Steele felt that the patient's symptoms were probably related to an exacerbation of chronic back pain that she had. But just to be safe, he decided to order an EKG out of an abundance of caution.

Brian: Okay, so he did go ahead and go through that process of, "Hey, we'd better check the heart issue, potentially."

J. Baugh: That's right. This patient actually had a history of heart issues.

Katy: As well as back pain.

J. Baugh: That's right. She had both. She had been seeing a cardiologist for the past six or seven years prior to this incident, so it could have been either back pain or it could've been a heart issue. And so, he was trying to rule both of those out.

Brian: I got you. So, Katy, and you were saying there is an issue of back pain as well. 

Katy: Correct.

Brian: So, we're looking at a female patient that is dealing with past back issues and past heart issues, so-

Katy: Cardiac concerns, mm-hmm (affirmative).

Brian: This could go a lot of different ways. So, an EKG was ordered by Dr. Steele. So, you were talking about it being around Easter, right?

Katy: Right.

J. Baugh: That's correct.

Brian: So, this is on Good Friday, is that what we said?

Katy: That's right.

J. Baugh: Mm-hmm (affirmative).

Brian: So, you got the holiday weekend coming up. When did he see the results of this EKG? Did he get them back immediately? Was there a lag time? Was there an overread? How soon did he know the results of the EKG?

Katy: Well, he actually did not see the results of the EKG, Brian, until Monday. But they were returned. I don't know how promptly. They were not returned urgently, which we'll, I know, discuss in a little bit. But they were returned back to his office that Friday. Though again, because it was a holiday weekend, I believe Dr. Steele and his nurse both left early for the day.

J. Baugh: That's right.

Katy: So, though the results were returned, he didn't actually see them until Monday.

Brian: So, were the results abnormal? 

Katy: They were markedly abnormal. 

J. Baugh: That's right. The chest x-ray and the spine film, so forth, those were interpreted as being negative.

Brian: Okay.

J. Baugh: Or non-revealing. 

Brian: Sure.

J. Baugh: So, that ruled out that problem. But the EKG was definitely a problem. The defense counsel described it as being sort of a classic sign of an acute myocardial infarction.

Brian: So, we've got an abnormal result of a test, we have physicians and healthcare providers leaving the office early... I'm assuming the ball was dropped here and the patient was not notified, correct? 

Katy: That's right. I mean, you have the patient basically presenting in a crisis, and the crisis was revealed with the testing, and unfortunately, the healthcare provider wasn't aware of the results of the testing until, as it turned out, it was too late. The end for this patient is, unfortunately, that she died of a heart attack-

Brian: She did. 

Katy: ... over the weekend.

Brian: Over the weekend.

J. Baugh: That's right. She died on Sunday. When Dr. Steele got the results of the EKG on Monday, he called to let her know what the results were, but he found out in his phone call on Monday morning that her pain had increased over the weekend and she died of a myocardial infarction on Sunday.

Brian: Wow. So, this is about as bad of an outcome as you could potentially have here-

J. Baugh: Right.

Katy: Yeah.

Brian: ... in this case. So, in my mind, I'm now going, "Uh oh. We've got abnormal EKG results on Friday. We've missed calling the patient to let them know. It's Monday and we're getting around to it now, and we have a patient that has passed over the week..." Did she go back to the ER? Do you know? Because this was in a primary care setting, correct?

Katy: That's right. It was in the office setting. That's an interesting point, I think, to make on the defense side of the case. The patient... Apparently her symptoms, not only did they continue, but they worsened. They progressed. She experienced an increase in her chest pain, increase in nausea and vomiting. She apparently did not make any efforts to contact her primary care physician, nor did she go to the ER. There were many opportunities that were missed in this situation to try to avoid what was, unfortunately, coming for the patient.

J. Baugh: And what might have happened, to look at it from the patient's side, is when the patient was not notified-

Brian: I was about to say.

J. Baugh: ... on Friday afternoon what the results of the EKG were, she probably assumed that everything was normal. I think that's pretty typical for a patient. If they don't hear from the physician, they assume that everything is okay.

Katy: No news is good news.

J. Baugh: That's right. "Because if something bad had happened, somebody would've called me." And so, she probably assumed that that was okay. And then we had the ultimate outcome because her problems got worse.

Brian: And we hear, on these case reviews that we do, time and time again, you go back and a lot of the situation is, "Well, the patient just assumed that everything was okay because if it had been bad enough, they would've called me back. I didn't need to follow up. I missed that appointment and didn't follow up, but if it was really important, the doctor's office would've called me back. And then it would've been an issue." And I think that is a trap that happens so often is the population, the consumer, the patient, believes that, "If I don't get word that it's really bad, then it's just okay and I have to 'suck it up.'" Right?

J. Baugh: I see that in a lot of cases. How about you, Katy? Do you see that a lot?

Katy: I agree, I agree.

J. Baugh: Yeah.

Katy: I think this case also presents kind of a twist on that same idea, Brian, because not only do you have a patient who is expecting her doctor to call if something was wrong with the test, you have a doctor who was probably expecting the lab who performed the EKG to call him if the test was abnormal. And it was clearly markedly abnormal, and there's no indication in the chart that the lab informed the physician's practice other than just sending the test result over.

J. Baugh: That's right. I don't think there was any dispute that there were classic signs of a heart attack on the EKG. So, the question becomes, “Where was the breakdown in communication?” Was it-

Katy: Yeah, why was this handled normally? 

J. Baugh: Exactly. Why didn't someone flag this and tell the doctor, "You've got a problem here." Call the doctor, somehow notify the doc this is going on. It was just left on his desk and he didn't get to see it until Monday morning. So, somehow there was a breakdown in communication because somebody should've notified the doctor what was happening. 

Brian: And you hate to even say this, but do you think it might have been due to the holiday?

Katy: I mean, I think so.

J. Baugh: You have to think that may have played some part in it, yes.

Katy: I mean, it certainly is the time that it occurred, so at least that's a fact. I think it would give me pause.

J. Baugh: Yeah.

Brian: That makes me think if I have a practice... If I'm listening to this podcast and I have a practice, I'd better double-check and triple-check and make sure we have the proper protocols, the proper rules in place whenever we're on a weekend or a holiday or something like that-

Katy: Or a vacation.

J. Baugh: Yes.

Brian: So things don't get missed like this and you end up with a terrible outcome.

J. Baugh: That's a big takeaway from this case, is when there's something that's out of the ordinary that's happening, you've got to make sure that you have the proper procedures in place to take care of those unusual situations. An office closing early on a Friday, like Katy said, the doctor going on a vacation.

J. Baugh: Any time that it's not normal business hours, how are you going to handle those types of situations? And you need to review those procedures and protocols occasionally to make sure that they're up to date and that everyone understands what's going on. 

Brian: So, Katy, what was the outcome of this case?

Katy: There was a suit, obviously, that was filed and proceeded through litigation. Ultimately, after some work was done, the decision was made to try and compromise the case. And it was ultimately, I think, mediated and a settlement was reached. This case was a little unusual, and we see this in our files occasionally, when you have two defendants. Here, you have not only the physician but the EKG lab. There was some infighting between those two factions- 

Brian: Okay.

J. Baugh: Yes.

Katy: ... as to who should have more responsibility, thus pay more, in a settlement. But ultimately that was worked out and a settlement was reached for this family.

Brian: Something I haven't even mentioned in this. I'm backtracking just a bit. The EKG was ordered by the physician in the primary care office. Correct?

Katy: That's right. 

J. Baugh: Yes.

Brian: Where was the EKG performed? Was it out of the office, offsite, then?

Katy: It was. I believe it was at a hospital which may have been close in proximity. So, it was an outside facility to whom the doctor regularly referred patients. So it had a good working relationship with him. But it was an outside facility, so the doctor had to wait for the report to come in, and then take action.

J. Baugh: Yes.

Brian: We had already said it's a holiday weekend. It's Good Friday. People are going to be leaving early. Everybody's already making plans. So, now you're sending a patient to a different facility that they may have people leaving early.

Katy: Right. 

Brian: I mean, you've got this perfect storm here- 

Katy: Right.

Brian: ... is what it sounds like to me. 

J. Baugh: That's right.

Katy: Right. But as J was talking earlier, this is the perfect opportunity to review your internal processes when you've got a holiday weekend, when you have... even something as simple as just a patient going to an outside lab for a test. What is your tickler system? How are you going to receive the result? When do you expect it to be received? Are you going to follow up on it?

J. Baugh: And that's a good point. To not only look at your internal processes in terms of how you're going to communicate with people within your clinic, but how are you going to communicate with people who are outside the clinic-

Katy: Right.

J. Baugh: ... with a hospital, a specialist, whoever that might be. You don't want those lines of communication to break down either.

Brian: You can find yourself in a bad situation when you personally even did everything right. But then on the other end, they maybe did the right test, but the process of communication had broken down. 

Katy: Right.

Brian: Or that tickler system, or how you get notified of abnormal results broke down. Then you find yourself at the mercy of, "It was a breakdown in the system, and now I have a bad outcome."

Katy: I mean, we've got such a technologically advanced society, and certainly medicine is very advanced, but man, the simple phone call, just to reach out and... Place a call. And for the lab, call over. "This is a really scary EKG result. Is your patient still in the office?" Or for the nurse or the doctor to make the same call.

J. Baugh: Right.

Brian: The other thing, too, is, Katy, as you were saying, you look back at it and you go, "Man, what a phone call could have made." 

Katy: Right.

Brian: What the difference in a phone call. And the thing is, you think about that in hindsight. It's once you had this bad outcome, you look back and you go, "These simple things could've taken care of it." Well, the next thing you have to think about when you're a practicing physician or an attorney or anybody involved in this process is, that's what the jury is thinking about. "If they had just done this, then we wouldn't be here today."

J. Baugh: Right.

Brian: And so, hindsight is going to put a magnifying glass on things that may not have seemed that significant on the front end. Is that a fair statement?

Katy: Sure.

J. Baugh: Mm-hmm (affirmative). I think so.

Katy: But you know, and here, the doctor's obviously worried about the thing that the patient ultimately was suffering from, which was a cardiac situation. But the argument is, man, the terrible outcome... Could it have been avoided? Maybe it could've been avoided. Her death wasn't until the Sunday, and she was in the office on Friday, and so it certainly makes it a more difficult case to defend, which is probably one of the main reasons that the case was settled.

J. Baugh: Yeah, I think so, because the patient died two days later. It's difficult to argue that, "If I had known-"

Katy: Wouldn't have made a difference.

J. Baugh: That's right. If I had known the EKG was made on Friday afternoon, you could've gotten the patient into the hospital. And so, a jury's going to look at a case like this and say, "Somebody had to be at fault. I don't know if it's the EKG lab or if it's the doctor, but it had to be somebody."

Brian: So, as we look at this retrospectively, the beauty of having these podcasts and having these opportunities is to retrospectively look at these situations and then hopefully give information that will help people from making the same mistake again. What advice would you give either physicians, office managers, nurses, all the people that could potentially be involved in this, labs, whatever, that we can avoid a situation like this in the future?

Katy: I think number one, make sure your office has a game plan for handling absences, whether it's a holiday, whether it's planned or unplanned.

J. Baugh: Right. 

Katy: Physicians get sick too.

J. Baugh: That's true, yup.

Katy: Just make sure you have a game plan and that that has been activated when it's necessary.

J. Baugh: Mm-hmm (affirmative). And one saying that we hear sometimes in cases like this is, if it was important enough for you to order it, then it was important enough for you to have followed up to see what the results are.

Brian: That's a great point.

J. Baugh: If you don't do that, you might be able to explain why, but it's very difficult for a jury to buy that. 

Brian: Yeah. To me, that's an easy argument. From a plaintiff attorney is if you thought it was important enough to run the EKG, why didn't you stick around to see what the result was?

J. Baugh: That's right.

Katy: So, make sure you've got a tickler system to follow up on everything that you order, and make sure your staff knows how to use it, they do use it, they follow through with it.

J. Baugh: That's right. And you also need to make sure that you're teaching new employees about that. I can see a situation where you've got a staff that's been in place for a number of years and they know everything that's going on, and you get someone new that comes in and they may not have been properly trained on what's going on because you just assume everything's been working so well for so long that we can just continue to go forward with the way we've been doing things. And you've got to really pay attention to the new employees that come in. 

Brian: That could be detrimental at any point, but often, we know in the healthcare industry, as in other industries, when it comes to holidays or something like that, the low person on the totem pole is often the one that's there on holidays, right? 

J. Baugh: That's right. Yes, absolutely.

Brian: So if you haven't updated that training and you haven't gotten the people with the least experience in your particular area, your particular practice, up to par, that could be a recipe for disaster.

J. Baugh: Absolutely.

Brian: Katy, J, thank you so much for coming in. I think this was an incredibly interesting case with an unfortunate outcome, but hopefully, something that we can learn from and that our physicians can use to better protect the patient and better protect themselves.

Katy: Thanks, Brian.

J. Baugh: It's good to be here. Thank you.

Speaker 1: Thank you for listening to this episode of Your Practice Made Perfect, with your host, Brian Fortenberry. Listen to more episodes, subscribe to the podcast, and find show notes at svmic.com/podcast.

The contents of this podcast are intended for informational purposes only and do not constitute legal advice. Policyholders are urged to consult with their personal attorney for legal advice, as specific legal requirements may vary from state to state and change over time. All names in the case have been changed to protect privacy.