How in the world does this happen?

I read about this and wonder:

Untreated ER patient dies at Olive View

The 33-year-old man, reporting pain in his chest and left arm, waited more than three hours, then stepped outside and collapsed.

latimes.comBy Jack Leonard and Charles Ornstein
Los Angeles Times Staff Writers
October 31, 2007
Christopher Jones arrived at Olive View-UCLA Medical Center in Sylmar on Sunday complaining of chest pains.
Jones, 33, was told to sit in the waiting room until it was his turn. He didn’t receive a simple test to determine whether his heart was functioning properly, a measure that is standard practice nationally in cases of chest pain, Los Angeles County officials said.
After more than three hours, Jones got up, walked outside, collapsed face down on the pavement and died within minutes.

That’s horrible.  I cannot fathom how this happens, though I wonder if their EKG at triage for chest pain has an age limit he didn’t meet, through no fault of his own.  If it did then, I’ll bet it doesn’t now.

I hear this from nurses, doctors, Paramedics: “30 year olds don’t have heart attacks”, and I tell them politely that yes, they do.  In our ED last year we had a 16 year old with an MI.  Consultants like to tell us we overtest in the ED (‘why get a troponin on a 25 year old with chest pain?’ they ask, with a condescending tone and a ‘you’re another dumb ER doc’ look;) they never seem to remember the positive ones.

Chest pain is usually not life threatening, and we make that determination after the workup is complete, not before. 

 

How far is Olive View from the recently closed King-Drew?

The incident, which is being investigated by state regulators, is the latest case of questionable patient care delivered at Olive View, a public hospital run by the county. The California Department of Public Health has cited Olive View for medical and other problems five times this year.

Sounds a little too familiar… 


Comments

  1. Missing an MI does not make it wise use of resources to investigate every low-probability case.

    This is tragic, but do you really want to culture every furuncle for MRSA? Do you really scan every patient with a headache. Do you do a chest X-ray for every cough. The laws of probability will lead you to discover something when you do enough testing. It doesn’t make it the right thing to do.

    Let the newspapers do their screaming; it sells newspapers. It’s entertainment. It’s not health policy, good management or good medicine.

  2. That’s spurious logic, and there are guidelines for the life threats there; there are also some reasonable things that can be done in patients who present to the ED with chest pain, and a screening EKG is a Good Idea.

    While we don’t know this patient’s death was a heart attack, where’s the downside of getting an EKG at triage? Best case, the patient has an MI, it’s seen and acted upon, and you’re done. Worst case the EKG is normal, the patient still dies, but at least you can show that acute MI wasn’t happening, and it was documented that it was considered.

    Missing an MI is nothing to address cavalierly. It happens. That doesn’t mean you shouldn’t look.

  3. Goatwhacker says:

    The downside to getting an EKG in triage is it does not rule out an MI and can be falsely reassuring, as ER docs have reminded me many times when asking me to admit atypical chest pain. Obviously I am majorly second-guessing here but a 33 year old with CP radiating to the left arm needs to be taken seriously.

    Having said that, too many EKGs are ordered for weak indications and Zagreus Ammon has a point.

  4. Weak indication? A male with chest pain radiating to the left arm?

    The indication is dead on the sidewalk. EKG’s cost virtually nothing (as opposed to the charge). There’s virtually no downside to getting an EKG in triage.

  5. The two hospitals are quite far apart physically.

    Both are public hospitals, and both have reputations for extremely long waiting times in the ER.

    I don’t know what went wrong at Olive View in this instance. I’ve been there once with a family member in the ER and once for lab tests, and there does seem to be a problem with “overbooking,” which suggests to me a shortage of qualified people, with those people trying to cover an ever-growing number of uninsured patients. One person did mention to me a shortage of beds as a reason for the long waiting time in the ER.

    To put it simply, there is not enough to go around.

    However, let’s say you are leaving the world of uninsured care and visiting the privileged world of the insured. You might visit a local urgent care facility or private emergency room, where you might be amazed to find people greeting you at the front desk who are actually relaxed, even bored with inactivity, and eager to treat your problem with the microscopic attention it deserves.

    So… how do we get back to some middle ground where we can all hope for humane and kind treatment when we are in trouble?

  6. Goatwhacker says:

    Naaah I’m not talking about this guy being a weak indication, I’m talking about EKGs ordered on every Tom, Dick and Harry that comes through the door. Unfortunately I see a lot of that, along with troponins, D-Dimers and BNPs. They are too often applied to a low risk population which drops the specificity considerably.

    I don’t know who you have in triage but they’d better be pretty damn good if they’re doing EKGs and then sending people back to the waiting room on the basis of a normal EKG. That’s a disaster waiting to happen. If they’re worried enough to get an EKG they should be worried enough to get him back to a doc.

  7. Our hospital has nowhere to do EKGs in the lobby (unless you want to do it in plain view of the rest of the lobby or in the restroom, which is real classy); we must bring them all back. Our protocol says we can send the patients back to the lobby if the doctor says the EKG shows no MI (you walk the EKG back to the doctor in the ER, goatwhacker), but all the doctors essentially forbid us from moving a patient back to the lobby, so it’s one of those things where we “bring them back” for an EKG then have nowhere to put them afterwards but maybe an exam table in the fasttrack/urgent care (which is for colds, minor lacs, minor headaches, etc) or a hall bed off all monitors. It’s really fun and embarrassing doing a chest pain workup with treatments in the fasttrack or on an unmonitored hall bed (this is assuming all the monitors are already attached to patients who need to be monitored).

    We also have the added fun of if you move a patient to a different room to make room for your unmonitored chest pain patient, you have to find the nurse who has that room and report off on the patient you moved out (since our rooms are assigned and moving a patient to a new room usually means you switch nurses for the patient too) then you have to report on your patient with chest pain who you move in. Meanwhile, you can’t find that nurse and your boss yells at you for just keeping your patient when it’s in another nurse’s “room” so no one ever wants to move patients out because it’s silly to change nurses if you move a patient to a different room. The simple act of trading rooms is a big fight and a process.

    and on and on and on

    It would be nice to, ya know, let us just do the EKGs in some room that doesn’t exist in the lobby.

  8. Triage nurses usually are pretty damn good.

  9. A big mistake was made and the lawsuits will soon follow. I don’t care how old you are! A pt with chest pn that radiates down the arm shouldn’t sit for 3 hours without a single test to rule out an MI. If you don’t rule out an MI, how can you possibly triage this person? You rule out MI after the workup, not before!

  10. Re: “Triage nurses usually are pretty damn good.”

    So are ours. CP = EKG. A 33 y/o with CP radiating to the left arm would have gotten an EKG and since there was a long wait, labs would have been sent from triage.
    I wonder what their side of the story is. I can’t imagine what they had back there which made a CP w/ radiation wait for 3 hours. Surely it wasn’t full of more critical cases. But, you know how you can have those shifts where you can’t discharge anyone, you’ve got a plethora of admit holds cutting your ED in half, etc.

  11. “I can’t imagine what they had back there which made a CP w/ radiation wait for 3 hours. Surely it wasn’t full of more critical cases.”

    Surely you jest. We’ve all had a couple of 33 year olds with MIs out of the thousands who have nothing serious, and they do make quite an impression on us, precisely because they are so unusual. But we aren’t just seeing sprained ankles and stuffy noses back there. Take a handful of patients waiting for ICU/tele beds, add a few 70 year olds with ______ (almost any complaint at all), a couple of backboarded trauma patients, a few 20 year olds with abdominal pain, and you’ve got a 3 hour wait.

    Those patients are statistically much more likely to have serious conditions than a 33 year old with chest pain. And I’m not discounting the guy with chest pain, because he needs a workup too.

    Definitely an ECG should have been done promptly; no reasonable person would argue otherwise. But a normal ECG (reviewed by a physician) buys the triage nurse some time to triage the other 3 patients who also just presented with chest pain. The ones that are older/higher risk and the ones with abnormal ECGs will get the first available rooms, and the low risk 33 year old may have blood drawn and wait (yes, occasionally up to three hours or more) until a room becomes available.

    But the ECG is a critical part of triaging chest pain patients, despite its imperfections.

  12. A 33 yr old guy presumably has a long time to live, possibly a family to support, parents to take care of ( I know, he might not do any of those things..) but, IMHO this is the guy who will benefit the most from a workup rather than the 85 yr old with the chest pain who will get another cath and 10th stent to open on some tiny vessel..

    I agree with gruntdoc-get that damn EKG its better than nothing!

  13. Re: “Surely you jest.”

    Yes.

    Nothing is more infuriating than an ED cut in half for admits with a quarter of remaining space filled with those patients (I’m convinced they fly in together in groups) that are nearly impossible to get rid of. “But why does my back hurt? Can’t I get an MRI? I want a cat scan!”

  14. Time cannot expand. At my ED anyone who complains of pain anywhere between their ear and groin get an EKG at triage because the hsopital promotes us as a “chest pain” center.

    Other medical problems get ignored at the expense of getting the EKG on the 18 year old with bronchitis.

  15. Zagreus Ammon –
    They’re “worthless” tests until one of two things happens:
    1. You or your family member go to the ED. Sorry Johnny, you’re my son and all, but the chances of you having MRSA are only about 2%, so we’ll just stick it out and hope you don’t become all septic on us.
    2. One of the tests turns up positive. When this happens, everyone with a retrospectoscope jumps in and says how they could have predicted the test to be positive before the test was even ordered. And who’s the dummy that keeps ordering all those negative tests, anyway?
    As soon as you find someone with chest pain willing to reject an EKG because they only have a 1% chance of having a heart attack, let me know.
    And when you find a lawyer who won’t sue because the “laws of probability” weren’t in the doc’s (or patient’s) favor that night, I’d like to meet him.
    Medicine is a little different when you’re the one responsible for someone’s life.

  16. The only downside of doing the EKG in Triage is when the ED is not staffed with a back-up Triage Nurse and doing an EKG extends the wait of patients in line waiting to be Triaged, many who are very sick. In ED’s with the luxury of having open beds its simple, once the complaint is determined to be Chest Pain the patient goes straight back. Those that run full all the time, including their Hall Space, need to have 2 Triage Nurses or a Nurse / Midlevel / MD combo (provided the midlevel or MD is willing to do hands on triage and ekg’s) to not only handle the lines that form at Triage but do EKG’s and recheck those who are waiting. Some big urban ED’s try to do all this with one Nurse which results in a lot of things that should be done not getting done. Others throw in a greeter to help manage the line but they dont to EKG’s. And then there is the space issue as Nurse K pointed out.

    # posted by ERMurse : 11:37 AM

  17. I have a vested interest in these comments, and the patient as well. I have known the pt since he was 5 years old. His mother is my best friend. I am also a nurse (not ER, but county jail). I have pt’s (inmates) c/o CP everyday of the week. Mostly its drug seeking. I’ve NEVER ONCE told them to go wait. I’m not willing to risk my job, or their lives on a reckless decision. We get a lot of MRSA too. We test them all.

    This pt worked for the studios in Hollywood and had terrific insurance. He went to that hospital because he was scared and it was the nearest facility. The EKG would have been paid for.

    Zagreus Ammon, you appear to think like a machine. Are you, perhaps an administrator? Bottom line and all, right? In the mean time, I fly to LA tomorrow to help my friend bury her youngest child. He had everything in the world to live for. He had a good job and his mother was so proud of him. I’m ashamed that there are things like this happening in ER’s.

    Here’s to all you good (and overworked) ER nurses and doctors.

  18. This is a great discussion. My response to some of the comments on this post is too long for the comments section, so please see http://executivephysician.blogspot.com/2007/11/missing-heart-attack-in-la-how-much-to.html at my blog. There are bigger picture resource allocations that many commenters rightly bring up. There is also the concern that the sensitivity and specificity of an EKG may not be the answer to preventing this death, which was my original point (and Goatwhacker highlights).

    I only take issue with Clara, who suggests that administrators are perhaps a lesser form of human. I am a physician first and administrator second. There is insight there and a bridge, but one must be prepared to consider and hear with an open mind. Grief is not the right context to take on a policy and management issues.

  19. Ed Bearden says:

    This is a good example of why a local 24 hr stand alone emergency care facility not connected to a hospital would have been the best solution for him to receive immediate triage. I used to think I would never use one until a fried of mine went to one and was immediately given an evaluation that made a difference.

  20. You can’t blame the hospitals, they have to set some form of policy and live by it.

    You can’t blame the doctors, chances are they are working as fast as they can. Doubt anyone wants to be rushed when they get in front of a doc.

    You can’t blame the nurses even the grumpy ones, emergency rooms are swamped because people without money can’t be turned down.

    That being said, I smell lawsuits coming.

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