Expert Witness Blog
In Chest Pain & Medical Malpractice, medical malpractice expert witness Barry Gustin, M.D. writes:
The quality and quantity of pain itself is highly variable and in some situations may be totally absent and yet an AMI be in progress. Blunted pain responses commonly seen with underlying chronic disease in elderly patients frequently mask AMI and can stear a complacent physician away from the true diagnosis. These patients may present with other symptoms and signs indicative of serious disease such as sweating at rest, increasing fatigue with less activity and shortness of breath. Physicians must maintain a high index of suspicion and entertain a full range of differential diagnosis when evaluating patients.
Other factors can complicate the decision making process such as the stoic patient with chest pain who wishes to leave the ER before receiving a complete evaluation. In this setting, it is important that the family be included in the evaluation so that all clinically relevant information is obtained. Enlisting the family’s participation may also ensure that the patient does not leave the ER prematurely. But even if such a patient refuses admission and the physician is concerned about the possibility of serious disease, a compromise can be struck and the patient can be convinced to stay temporarily in the ER while repeated exams are performed and serial ECGs and cardiac enzymes are obtained thereby increasing the likelihood of detecting acute myocardial disease.