Failure to Diagnose Unstable Angina in ER Resulting in Death

The Fleantice Case

BRIEF SYNOPSIS

A 44-year old married, mother of four and full-time worker for the Unites States Post Office, went to a hospital emergency room with continuous chest pain radiating down her right arm, shortness of breath, and nausea (persistent for 10 hours but intermittent over past few days). After ordering a chest x-ray, a CT angiogram, and lab work, none of which offered any explanation for the patient’s symptoms, and after forgetting to give the patient aspirin, the Defendant ER doctor told the patient and her husband that everything was “very reassuring” and that the pain was not coming from her heart. The doctor then discharged the patient, who was still in pain, with a “diagnosis” of chest pain of uncertain cause and hypokalemia (low potassium) and instructed her to call her PCP in 3-5 days. Less than 12 hours later, the patient suffered a massive cardiac arrest. Shortly thereafter, she was declared brain dead and subsequently died.

FACTUAL NARRATIVE

Mrs. Andrea Fleantice, age 44, an African-American female, was married with 4 children and in relatively good health. She was a nonsmoker and did not drink alcohol. She worked for the United States Postal Service full-time in a warehouse. Mrs. Fleantice had a history of spinal stenosis so she was on light duty at work. She was prescribed pain medication as well as muscle relaxants for the back pain as needed. She also had a history of migraine headaches.

On September 4, Mrs. Fleantice felt ill when she came home from work with shortness of breath and chest pain. Her husband (who is an asthmatic) suggested that she try a breathing treatment. When she tried the breathing treatment and it didn’t help, and since the pain had been intermittent for a few days and persistent since 2:00 pm, they decided to go to the local emergency department around 11:00 p. m.

Immediately in the ER, per protocol, a 12 lead EKG was performed at 11:23 pm which was read by the ER physician as normal. Notably, the cardiologist that read the EKG the next morning noted “Poor R-wave progression in anterior leads III, could be due to lead positioning, otherwise normal EKG.”

A nurse documented a chief complaint of: “upper chest pain since 2:00 pm, intermittent, some shortness of breath and nausea.” Admission vitals, taken at 11:31 pm, were: 36.7°, pulse 79, RR 18, 100%RA, and 146/84. Height and weight were both estimated at 165 cm (5’4”) and 85 kg (187 lbs). Nursing assessment was within normal limits except for upper chest pain, and “states SOB but appears in no distress”, and nausea. The pain score was 7.5/10, and noted that the patient was in acute chest pain in the ER. It was also noted that the patient was receptive and willing to learn. A chest x-ray was normal/negative. A CT angiography chest with contrast had a noted impression: “No pulmonary embolism or acute abnormality identified. ” Blood was collected at 11:37 pm. Abnormal results were: red blood cell low at 3.35, hemoglobin low at 108, hematocrit low at 31.1, MPV low at 6.6. The d-dimer result was positive at 0.42. A basic metabolic panel revealed a low potassium level of 2.8, sodium low at 132, and calcium low at 8.2. The initial troponin was 0.06.

Later that night, now on September 5, at 1:43 am, Mrs. Fleantice was discharged with a “diagnosis” of chest pain of uncertain cause and hypokalemia (low potassium). She was given a prescription for potassium pills and muscle relaxers and was instructed to call her PCP in 3-5 days. Discharge vitals included: pulse 91, RR 18, 100RA, and 130/71. No temperature was taken. It was also noted that the patient was still in pain on discharge, even though given pain medication throughout the ER visit, with a 7/10 pain.

On September 5, Mrs. Fleantice was scheduled for work a 3:30 pm to 12:00 am shift. In the morning, she spoke on the phone to her husband who was working the day shift, and told him that she was still experiencing chest pain and pain in her arms with shortness of breath. Her husband suggested that she call off work, but since it was the day after Labor Day, she thought that it would be very busy and didn’t want to leave her coworkers short. At about 11:30 am, one of their daughters called Mr. Fleantice at work to let him know that Mrs. Fleantice felt really sick. Mr. Fleantice instructed his daughter to call 911. As Mrs. Fleantice was getting dressed to go to the hospital, she vomited and fell back on her bed in cardiac arrest. The EMS instructed the daughter to perform CPR until the ambulance arrived.

EMS provided ambulance transport to a different local hospital (the closest facility). There, a heart catheterization was performed and it was determined that Mrs. Fleantice’s left anterior descending artery (“LAD”) was completely blocked. A stent was inserted as well as an intra-aortic balloon pump.

Mrs. Fleantice was then air-lifted to a tertiary hospital in Pittsburgh where she was determined to be brain dead. Mr. Fleantice did not consent to withdraw life support until five days later. The death certificate listed the cause of death as anoxic encephalopathy (within hours), cardiopulmonary arrest (within hours), and acute myocardial infarction (within days).

THE LAWSUIT/RESULT

First, we opened up an Estate naming Mr. Fleantice as the “Administrator. ” Then, on behalf of the Estate and the wrongful death beneficiaries, we filed suit against the ER doctor, her employer (a practice group owned by the hospital system), and the hospital. We took extensive written discovery and also took the videotaped depositions of the ER doctor and the ER nurse. The Defendants took the depositions of Mr. Fleantice and the daughter who was present the next morning.

An interesting twist in this case involved a significant discrepancy between what the ER doctor said occurred and what Mr. Fleantice said occurred. In her deposition, the ER doctor claimed that she wanted to admit the patient because she was concerned that the patient may be suffering a cardiac event, and that Mrs. Fleantice refused to be admitted. This was flatly contradicted by Mr. Fleantice who unequivocally testified that he and his wife were repeatedly told that everything was okay, that it was likely a muscle strain related to her work in a warehouse, and that they could go home. Importantly, the records supported Mr. Fleantice’s versions of the events. First, the discharge instructions stated that the patient’s condition “does not seem serious” and the “pain does not appear to be coming from your heart”. Second, hospital policy requires the healthcare providers to fill out paperwork if a patient leaves “against medical advice” (“AMA”). No AMA paperwork was filled out. Third, no cardiac medications (such as aspirin or nitroglycerin) were ever given (per hospital policy for cardiac related concerns). Fourth, the ER doctor’s dictated notes repeatedly state that she told the patient that everything was “very reassuring”.

We had the records and deposition testimony reviewed by an extremely qualified ER doctor who is the regional director of emergency medicine of an internationally respected health system and by an extremely qualified cardiologist who is also a faculty member at a Big Ten institution. The experts both provided opinions that the ER doctor was negligent, that she should have admitted the patient, obtained a cardiac consult, and obtained serial troponin testing; and had appropriate care been provided, Mrs. Fleantice would still be alive today. Conversely, the Defendants hired an ER expert and cardiologist that provided opinions that the care was appropriate and, as is a common theme in our cases, that this was all the patient’s fault for refusing to be admitted.

Shortly before the scheduled jury trial, the case settled for a substantial amount.