Failure to monitor patient during stress test

Presentation

A woman in her early 60s was referred to a cardiologist for chest pain and dyspnea on exertion. The patient reported a history of hypertension, high cholesterol, and diabetes. She had also been a smoker for 40 years.
 

Physician action

Upon physical examination, the cardiologist noted bilateral carotid bruits, a 2/6 systolic murmur suggesting mild to moderate aortic stenosis, and decreased dorsalis pedis and posterior tibialis pulses in both lower extremities. An EKG performed in the office showed sinus bradycardia with nonspecific ST-T wave changes.

The cardiologist ordered lab work, a chest x-ray, a treadmill nuclear stress test, a carotid Doppler study, cardiac ultrasound, and a CTA of the abdominal aorta and lower extremities.  

The patient completed her lab work and chest x-ray the same day as the initial visit. The lab work showed she had high cholesterol and the chest x-ray revealed COPD.   

The patient began the treadmill nuclear stress test at the cardiologist’s office four days later. She completed two stages of the Bruce Protocol and developed significant ST-T wave changes. The test was stopped and the patient sat in a chair to rest. While resting, the patient went into ventricular tachycardia and ventricular fibrillation. She tried to stand, but collapsed to the floor and struck her head on the ground. The patient was resuscitated with a defibrillator and EMS was called.

The patient was transported to the hospital with fixed, dilated pupils. A CT-scan showed a linear skull fracture with acute right subdural and epidural hematomas with midline shift. The patient underwent an emergent decompressive craniectomy and evacuation of the hematoma. The patient arrested and died on the operating table.

Allegations

A lawsuit was filed against the cardiologist and the cardiology group. The allegations were:

• negligence in administering the treadmill stress test;
• failure to properly advise the patient regarding the increase in treadmill speed;
• failure to properly supervise the treadmill to prevent the patient from falling off; and
• failure to carefully monitor the patient.

Legal implications

The lawsuit stated that the patient fell off of the treadmill during the test and that the cardiologist was not present during the exam “as required by medical standards.” The plaintiff alleged that the patient was not warned of possible dangers associated with the test. The plaintiff also alleged that a stress test was contraindicated in a patient with severe aortic stenosis. The patient should have undergone cardiac catheterization instead.

The cardiologist and the nuclear medicine technologist who administered the stress test did not document anything in the chart about the fall, leading the plaintiff to incorrectly state the facts of the incident in the lawsuit.

Two cardiologists reviewed this case for the defense. The reviewing physicians were not supportive of the care given. One stated that based on the patient’s symptoms and EKG results, a stress test was contraindicated. Both felt that the patient should have been more closely monitored to prevent the fall. There was not adequate documentation in the medical record about the incident.
 

Disposition

Due to the nature of the incident and negative consultant reviews, this case was settled on behalf of the cardiologist.
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