Risk Aversion Trumps Risk Tolerance

It's better for EPs to be cautious and wrong than optimistic and rightFigureFigureA male adult in a rural community said he felt bad and was experiencing chest pain after breakfast. The feeling recurred after a spicy lunch, so he went to see his doctor that afternoon. He was given four chewable baby aspirin and a GI cocktail during that visit, and he experienced “mild relief.” He was diagnosed with “unspecified chest pain,” given a prescription for hydrocodone and omeprazole, and told to return in one week and do “physical activity to tolerance.” He was sent as an apparent precaution to a small local hospital for outpatient lab work, a chest x-ray, and an ECG. The lab called the doctor to tell him that the patient's troponin level was borderline at 0.4. The doctor called the patient at home, and his son said he was in the shower. The doctor called a second time about an hour later. The son went to check on his father and found him unresponsive in the shower. He was unable to be revived by EMS. The family filed a lawsuit. The Plaintiff's Case The family said the patient reported that he had chest pain and that the doctor knew the cause could be cardiac because he gave him aspirin and ordered an ECG, chest x-ray, and cardiac enzymes. The lawsuit said the doctor should have given him nitroglycerin, called EMS to his office, and sent him to a higher level of care immediately. Instead, the doctor relied on the patient's slight improvement from a GI cocktail and hoped that the tests he ordered would prove him right. The family said a GI cocktail was useless in this case, and that the doctor delayed having his son check on him when he called the first time. The doctor, the suit said, assumed he was having a simple problem, not one that could kill him, and that that was careless. The Verdict The case was reviewed by cardiology and emergency medicine experts. All were supportive of the plaintiff's claims, and the case settled pretrial for an undisclosed amount. Takeaways Never rely on a GI cocktail to influence decision-making. If ever used, a simple antacid is equally effective. Chest pain that is benign should never require an opioid. There are times when risk tolerance is acceptable, such as when using the Ottawa Ankle Rules or the Canadian C-Spine Rule to avoid imaging. When the choices are benign or potentially life-threatening, always rule out the latter before assuming the former. It's better to be cautious and wrong than to be optimistic and right. We become too risk-tolerant over time if we're repeatedly optimistic and right and too risk-averse over time if we're repeatedly optimistic and wrong. Find the happy medium. This case was not even close to that. References: Ann Emerg Med. 2005;46[6]:525. The Sullivan Group Blog. January 2017; https://bit.ly/431lXSZ. DR. PILCHER is a retired emergency physician and the former medical director of the ED at EvergreenHealth and Evergreen Medic One in Kirkland, WA. He has reviewed hundreds of medical malpractice cases for plaintiff and defense attorneys throughout his career, and is also the editor of Medical Malpractice Insights-Learning from Lawsuits (https://bit.ly/MedMalInsights), a monthly newsletter focused primarily on diagnostic errors in the ED. Send stories you would like him to review to [email protected]. Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website: www.EM-News.com. Comments? Write to us at [email protected].

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