Missed heart attacks - how can it happen?

Specialties Emergency

Published

Recently there was a case where a man in his early 40s with no history of cardiac issues died of a MI. He was seen in the ER of hospital A and released. Later that day, he suffered cardiac arrest and was pronounced dead on arrival at hospital B. His death was attributed to MI. How is it that the first hospital missed this diagnosis? Is it possible that all tests (i.e. markers, EKG, CXR, etc) can be negative yet there is still an MI in process? I ask because I will be starting an ER position soon and I don't want to contribute to something like this happening. Basically, how can something like this happen?

Sorry, I don't have more details regarding the care he received at the first hospital but perhaps you ER nurses may have seen or heard of cases in your dept and have some insight to share.

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Thanks for the response. Your case sounds very different from the case I posted. I think a lot of people would miss that because the complaints were so vague and it was going on for a while.

Also, I'm not an articulate person and I don't know how to say this but I feel like people are starting to attack me on this thread. I already said I'm here to learn. I will be starting a new job soon and wanted to learn from other people's experiences, especially when it comes to missed diagnoses. I don't need people being condescending towards me when I'm trying to learn here. This is why I have become hesitant to post for help in understanding nursing-related things here on allnurses.com and will probably refrain from posting for help in the future. This site used to be a great resource when I was applying to nursing school and going through nursing school, but now as a RN I have found that people are not as nice here as when I was a student. The majority of you have been helpful but there's always a few that think it's ok to be rude and condescending towards the newer nurses who have questions.

I don't think anyone was being rude or condescending. In the life of an ED nurse we see many things.

Without the particulars it is impossible to say what was missed if anything. You can only d your best and listen to you inner voice that "something isn't right here".

Things get "missed" ALL the time. If this patient was vague in symptoms it is not uncommon that things can be "missed" IN reality it isn't "missed" it just wasn't the path taken with the patient's presentation to the ED.

Lets say...a 41 year old patient came into the ED complaining of indigestion and shoulder pain. They stated that they had spicy food or have a history of GB disease...and no family history of young cardiac disease in the family. They deny radiation, diapohesis and report that in the past it has been relieved by Maalox. They state they were working on the deck this weekend for the fourth of July. Many MD's I work with would get an EKG, basic enzymes and a amalayse...and Order a GI cocktail. If the EKG was normal and the symptoms resolved they would be discharged and told to follow up with the PCP for a stress test to be sure.

Nowif this same patient has the same complaint and has had 3 family members die from sudden cardiac arrest at age 45 the work up might be different with admission in the list for a stress test.

IN emergency medicine we are not there to work up every possible scenario. We are there for an emergent focused assessment and helping immediate issues. Pain gone with a GI cocktail and a negative enzyme/EKG is a discharge. One would have to see the whole chart and see what was done...but yes...someone can get a clean bill of health and drop dead in the parking lot....and it isn't anyone's fault.

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Looking at the article...

A staff sergeant at Camp Roberts in San Luis Obispo County died after suffering a heart attack during a training exercise on Wednesday, shortly after a local hospital released him back to duty. Raul Escobedo, 41, first complained of chest pains during the early evening hours and was taken to Twin Cities Community Hospital in Templeton. Medical staff examined Escobedo and released him back to duty. [KCBX]

Escobedo continued participating in the training exercise and had a heart attack at about 10:30 p.m. His fellow soldiers attempted unsuccessfully to revive him.

I am willing to bet they did the usual...EKG, enzymes and probably electrolytes. All negative and was pain free. He was released and He later died. Sometimes you get a "feeling" about patients that something isn't right...but you can't prove it. The ED will not keep patients for serial enzymes without good evidence that it is necessary.

This can be from a multitude of reasons...one being electrolyte imbalance...another... arrythmia. I KNOW that the facility will be doing a follow up on this and they will find out more on a post mortem. But is is very possible that no one in particular is to "blame" it was just his time.

I hope this helps.

Specializes in ER.

It was not my intention to be rude or condescending.

Specializes in ED.

I can only echo a lot of the comments already posted. Sometimes things get missed. Sometimes you also have to go with your gut feeling and push for more follow up or another test / labs.

About 18 months ago one of my best work friends just did not feel well. He was 34 and a very healthy kind of guy - marathoner, triathlete, not med hx whatsoever. He was scheduled to work 3p-3 am one day and said he just couldn't get comfortable all day and go very little sleep before his shift.

He woke up at 1pm and said he felt just really irritated but blamed it on lack of sleep. Went to work anyway and was very SOB while walking from the parking garage to the hospital and then got really, REALLY sweaty and nauseated.

Called our boss and said he needed to check in. He got an EKG and it was not reading normal but saw nothing acute. Took it to one doc who signed off on the EKG with no real concern. The nurse that triaged him took that EKG to another doc who said, "Get this man on a bed now." He also ordered a posterior EKG. We don't do that too often but that posterior EKG showed "the big one."

The doc shared with all of us how he picked up on one teeny, tiny little blip on the regular EKG triggered him to perform the posterior one. It was pretty cool to see the difference and get some education on EKGs.

I also had a pt that got to me about 1 hr before shift change with what appeared to be COPD exacerbation. Did the EKG, labs, x-ray, etc. All signs pointed to a breathing issue. I passed the pt on but later learned that this pt refused to be admitted to our Obs unit for the night and stress test. The nurse did repeat EKGs and labs...nothing. Pt refused all night long and found a ride home. Came back 2hr later in cardiac arrest.

I replayed that pt over and over again in my head. I beat myself up quite a bit about it too but I really didn't do anything wrong. Maybe I could have done more. Maybe not. That's the hardest part of our job sometimes!!!

m

Specializes in Emergency/ICU.

OP: I have a 59 year-old neighbor (now deceased) who went to the ER with chest pain twice within a week. Both times, cardiac workup was negative (evidently) because he wasn't admitted for obs/further testing. Approximately 10 days after the pain started, the pain persisted, so the patient went to his PCP. The PCP diagnosed him with a muscle pull to the chest and gave him pain meds and muscle relaxers. The next day, my neighbor died at home alone while his significant other was out.

In autopsy, it was discovered that he died of cardiac tamponade: 750mLs of blood was in the pericardial sac. I often wonder how this could have been avoided. Was a larger cardiac silhouette evident on the second chest xray, if so, was it compared to the 1st? Did the patient have Beck's triad symptoms: JVD, hypotenion, muffled heart sounds? Or, were there no discernible symptoms while the bleeding was a painful small trickle until it suddenly became a deadly gush?

I appreciate the OP's question because it causes us to think about situations in which things might have been missed and what we can look for the next time - just in case. It helps us become better nurses. That being said, we can't drive ourselves nuts with the "what ifs" either, especially if due diligence has been done. Most nurses can probably relate to a reluctance to let certain patients go home with troubling (MD is aware) symptoms.

I once had a teen Sickle Cell patient who came to the ED for a painful crisis. We drew labs, chest xray, gave her pain meds, hydrated her, warmed her, treated her for a UTI, and sent her home that night. She was sleepy, but appeared stable. Her labs showed a WBC count of 17,000. She died the next day. I'm not sure why she died, but when I asked my charge nurse, she said it was just "one of those things" and that we did nothing wrong. I expected an inquiry, but there was none. I wish there had been. I want to know why she died. I know "stuff happens," but I'm not sure: did we do everything right? Ugh. Now, I'm really hesitant to let my Sickle Cell patients go home, especially if their white count is high. But often they do go home, and they are OK. And this is just part of being an acute care nurse.

Keep asking questions, OP, many of us are seeking answers.

Specializes in Cardiac, ER.

It happens,....I like to remind my fellow coworkers and patients that even when everything is done "correctly" sometimes bad things happen! I ended up in court over a similar situation, 40"s M, "heartburn", chronic back and shoulder pain from an old college football injury,....this pt was kept overnight, had Q 4hour troponins, EKG Q 6hours X 3 and a negative stress test, was dc'd and died 24 hours later,.....very sad, but short of sending every chest pain to the cath lab I'm not sure what else we can do. We all felt horrible about the situation and I at least, really thought that by looking back we could discover something we missed,...but we didn't. The idea was tossed around that this man didn't actually have CAD, but a rhythm problem that just didn't show itself during his 28 hour stay in the hospital,...again a horrible situation but we are educated professionals, not magicians,......sometimes bad things happen.

Specializes in CCU, SICU, CVSICU, Precepting & Teaching.

Sometimes bad things happen even if everyone involved does everything right. It's good that you (the OP) are looking for ways to keep the bad things from happening on your watch. But I would agree with the person who said you also need to do some self examination and figure out ways to deal with it when bad things DO inevitably happen. They will happen. Sometimes it will be on your watch. Understand and accept that no matter how much you do to try to prevent it, bad things happen, and you'll need to figure out how to go forward despite that. Good luck!

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