The disease is AMI ( Acute Myocardial Infarct ) or in lay terms, a heart attack, and the background facts in this situation are not in dispute.

Every year some eight million people rush to a nearby Emergency Room ( ED ) believing they are experiencing life threatening chest pain. About 8 % of all ED visits every year are for this reason.

Five million of this total are deemed to demonstrate possible cardiac etiology and are treated accordingly.

However, three million are deemed to be having non-cardiac pain and they are discharged without treatment.

And then at least 40,000 of those so released, subsequently die, often in an embarrassingly short period of time, of a heat attack.

We say that at least 40,000 die because these are the ones everyone is sure of. No doubt there are more. But for 40,000, their deaths occur very close in time to the visit to the Emergency Room and their relatives raise a fuss, ask for records, file malpractice suits etc etc.

It’s another story for another time but misdiagnosed AMI is in fact the leading cause of malpractice suits in the US. Currently, however, almost none of these is ever successful.

The question for the reader though is a simple one. Why didn’t these 40,000, ( who after the fact, we now know, were literally dying in the emergency room ) get properly diagnosed.

I can’t speak for all of them but this is what happened to one of them, and based on what I am told by experts, it is not at all uncommon.

RLT are the initials of a 42 year old woman whose husband rushed her to an emergency room in a mid size city in upstate New York exactly a year ago tomorrow complaining of crushing chest pain.

She lived less than two minutes away from the ED and she was convinced that she was having a heart attack. According to the hospital records her chest pain at time of admission was 10 on a scale of 1 to 10.

Heart attacks in 42 year old women are not common. But RLT was seriously overweight ( a BMI of 36 ), was a long time smoker and drinker, was forced by a 20 year old industrial back injury into a sedentary life style and was post menopausal, and all of these things are factors that increase the risk of coronary heart disease despite her relatively young age.

The hospital records show that-

RLT was signed in at 8 04 PM

Was triaged very promptly at 8 06,

The ED Doctor was notified at 8 28

A 12 lead EKG was taken at 8 40 PM -- Result was " normal"

Blood for cardiac enzyme analysis was drawn at 8 51 – Results are shown below

And an X Ray of her chest was read at 9 46.-- Heart was normal and was "not enlarged".

She was discharged at 10 04 PM with a diagnosis of bronchitis. Her doctor’s final words to her were "See, I told you there was nothing wrong".

And with those words to ring in her ears throughout all eternity, she died in her sleep five hours later of a heart attack.

The autopsy the next day, which fixed the cause of death as a heart attack, curiously noted that that the heart was found, in fact, to be enlarged ( weight 420 grams ).

She was right. The doctor was wrong.

How did this happen ?

And more importantly could it have been prevented? Should it have been prevented? What do you call the fact that it was not prevented ? Unfortunate Medical Error ? Or is it something worse?

Should it be something worse ?

You be the Jury. This is the part that can save your life.

It can save 40,000 lives every year.

Recommended Emergency Room practice ( Joint European Society of Cardiology/American College of Cardiology Committee ) for people who come to the Emergency Room complaining of chest pain is to -

Run a 12 lead EKG at admission and at least once again before discharge

Take a Chest X Ray, and examine it for fluid in the lungs and determine if the heart is enlarged or shows any other evidence of damage.

Draw blood at several intervals and test this for three enzymes that are known to be released into the blood stream, when part of the heart muscle has died due to a lack of oxygen.

The primary reason for running the EKG at least twice is because

In more than 40% of the instances, where it is known ( after the fact ), that an AMI has occurred, the initial EKG shows no abnormalities.

There is no other face that you can put on this piece of information. A 12 lead EKG is run virtually every time someone complains of chest pain. It is undoubtedly the most widely used diagnostic test for cardiac damage that there is.

Nonetheless, it only means something some 45% of the time. If the test is abnormal, the patient has a serious problem. If the test is not abnormal, however, the information means nothing at all.

To be blunt, if you are actually experiencing an AMI, a single EKG is essentially a coin flip. Half the time the test will show damage and be right. The other half of the time it will show no damage and be wrong.

So life saving lesson number 1 is this – If you, or a loved one, are rushed to an ED with severe chest pain, by all means be sure an EKG is run. But draw no comfort whatever from a normal result, and always inquire as to why, if there is not more than one such test made before discharge.

The reason for running the cardiac enzyme tests at various intervals is because each of them shows up in the blood at different times after the heart has been damaged and then the concentration of each of them rises at different rates before finally reaching the level called the "Reference Range".

The Reference Range is that particular concentration, specific for each enzyme and sometimes for each hospital testing lab, at which the level is considered to be so far above the normal range for that enzyme, that it is considered to be strong evidence that an AMI has actually occurred and that prompt medical response is required.

The recommended enzymes to be tested for and their concentrations at various times after AMI damage has occurred are shown in the table below.

The column labeled "Begin" shows the number of hours after the onset of the AMI that the enzyme first becomes detectable in the blood. For example it shows up essentially immediately after the AMI for Myoglobin, but does not begin to show up in the blood for CK-MB until 3 hours after the AMI and even then, the concentration is too low to be meaningful.

The Column labeled ULR ( Upper Level of Reference Range ) shows the number of hours after the onset of AMI that it takes for the enzyme to reach the Reference Range. The words "Mild" and "Lge" after the enzyme Troponin I, refer, respectively, to a Mild AMI and a much larger, more serious AMI event. Both are life threatening.

Note, Myoglobin will indicate a life threatening situation after only 3 hours, but CK-MB and Troponin I take at least twice as long. For a mild AMI ( still life threatening ) Troponin I will not reach the required reference range level for 16 hours.

Learn these names. Memorize this table.

Enzyme Begin ULR

Myoglobin 0 3

CK-MB 3 6

Troponin I Mild 8 16

Troponin I Lge 3 6

Life Saving Lesson number 2 is this. If the hospital you are in does not measure all three of these enzymes and/or does not run them all more than once each several hours apart, you are at very grave risk of being discharged with an undiagnosed AMI, and you could very easily be dead in a few hours.

The smartest thing you can do if you find yourself in this situation is let the doctor know that you know how the enzymes work and that you know how unreliable a normal EKG reading is and that you think more testing is in order.

With the above information on enzymes in mind, we should now go back to RLT.

We know right off there is a problem.

RLT arrived at the hospital within minutes of developing symptoms and was in and out of the hospital in exactly 2 hours – one full hour before the most sensitive of the enzymes ( Myoglobin ) would have reached the reference Range ( if it had even been run ), In addition, the blood that was tested was drawn just 47 minutes after arrival making the likelihood of this test producing any meaningful results absolutely nil.

But there is even more wrong.

Myoglobin, the earliest indicator of myocardial damage, wasn’t even run. Troponin I was run, which is good, and something else called CPK ( Creatine Phopho Kinase ) was run.

CPK is probably still the most commonly measured of all the cardiac enzymes, but by now it should be a relic of the past. It is widely present in the blood at all times, and if it does rise to the Reference Level, it is still highly non-specific for cardiac damage, and then another test ( CK – MB ), has to be run to determine if the source of the rise is in fact cardiac-related. In short CPK tells you nothing and delays the diagnosis, if in fact there is a problem.

In the case of RLT, the actual concentrations of the two enzymes that were tested for and the reference range for each are shown in the table below. The critical time for CPK to reach the Reference Range is about 6 hours, the same as shown earlier for its cardiac cousin, CK – MB, but it is always present in the blood at a substantial concentration, whether there is heart injury or not.

Enzyme Actual Conc. Reference Range

CPK 119 35 – 180

Troponin I 0.24 0.40

On the face of it both results indicate no problem. But then, of course, at less than an hour after onset, they would not be expected to be anything but normal. If the testing stops at this point, and it did, the results actually mean nothing at all. Expense has simply been incurred with there being no chance that the tests could provide diagnostically useful information.

This is damning on its face. Anyone who knows anything at all about the cardiac enzymes should know that they take a while after onset of AMI to show up, and even longer to become diagnostically useful.

To run only one set of tests very early after admission and not do any more has to mean that the Doctor simply did not believe that an AMI was the cause of the person’s chest pain. Why he didn’t is not clear. Bush may not be the only one who talks directly with God. But since he was sure there was no AMI, why did he incur the expense of running the initial tests at all. Just to raise the billing to the insurance company?

In order for one single test to show a problem, the onset of the pain would have had to have been several hours in the past which generally speaking would have meant that the patient would have died at home, died in the ambulance or died in the ED waiting room.

"Time is muscle" is the cry that the American Heart Association uses to try and convince its members to take all chest pain seriously and to go immediately to the ED. The meaning of the phrase is that, if you are having an AMI, more and more of the heart muscle is dying every second you delay.

So we have quite an interesting dilemma here.

The best thing you can do to prevent death if you experience chest pain is to go to the ED quickly after the onset of the pain, but this has the adverse effect of increasing the likelihood that early testing will show no problem.

If the doctor is not going to do serial testing you might as well save the cab fare. You are still going to die at home.

But we aren’t done. There are also two other things wrong with the RLT example –

RLT is a woman and the reference range listed for CPK in the table above, is for the joint male / female population. The correct reference range for women is 96 to 140. If subsequent testing had been done, it should have raised suspicion at 140 and not require waiting until it reached 180.

The other thing that is wrong is that the reference level for the Troponin I enzyme as shown in the table is 0.40.

Troponin I, is often called the "cardiac gold standard". It is uniquely specific evidence of cardiac damage. Essentially, any measurable level at all means the heart has been damaged. The Reference Range of 0.40 only means that the test method being used cannot reliably detect Troponin I at levels below 0.40.

However, since 2001 there has been a Troponin I test available on the market for which the Reference Range is 0.04. This test is 10 times more sensitive than the test that was actually used. Why would a hospital testing lab near the end of 2005 still be using a vastly inferior test method to detect the single most important compound that can diagnose the presence of heart damage? I can’t imagine an appropriate answer.

Although I had no legal standing to do so, I took the information detailed above to three large medical malpractice firms and asked each of them for their opinion as to whether or not filing a malpractice suit against the people involved in RLT’s death would be likely to be successful.

I was simply stunned to find that all three agreed that such a suit had no chance of success. I was told that if the judge even let the case go to trial, which was unlikely, he would shoot the theory down when he charged the jury.

Why ?

Because doctors, within wide bounds, are allowed to use something called "Medical Judgment" in making clinical diagnoses. Medical Judgment is not the so called evidence-based medicine you have been hearing about. Rather this is the doctor looking at the big picture, analyzing the evidence in a very special way that he has learned in some mystical way over the years and making a diagnosis that sometimes, unfortunately, simply fails to be correct. It matters not one wit, that he might have made a better decision if he had done more testing. The decision as to how much testing to do at all, is also his decision to make – again using "Medical Judgment".

All three firms said that in essence, the limited testing performed by the ED doctor, even though it had essentially zero chance of detecting an AMI early after its onset, was still "Bullet Proof" protection against a successful law suit.

And then everything was clear.

It was not really medical judgment, it was business judgment.

You can run three tests and be legally immunized against a malpractice suit or you can run eleven tests and be sure you are making a correct diagnosis.

The deal clincher is that the extra eight tests have to be run on an extra 3,000,000 patients. So if each test costs about $ 20 dollars, the extra cost to the insurance underwriter is $ 480 million.

From a straight forward business point of view, it’s a no-brainer.

The legal hurdle to protect ones self against a malpractice suit is very low. If the medical institution provides the legally minimum level of care, it is safe from suit and profit has been maximized.

"God’s in his heaven and all’s right with the world".

And if the patient is dead - no big deal, I guess.

So what’s your verdict – murder, criminal negligence, depraved indifference to human life, or unfortunate, unavoidable medical error

Keep in mind, this can happen to you – or someone you love.

A few weeks after RLT died there was a story in our local paper about a body being found in a local park swimming pool. Autopsy showed the dead person had suffered a heart attack while swimming. This was an older male in his early 70’s who had had a history of heart problems and he had gone to his doctor earlier in the same day because he had been " feeling tired". He was told he was fine.

Is RLT’s case an isolated event? I don’t think so. I think she is one of 40,000.

And I think something has to be done about it.

The Civil Court System is obviously not interested in imposing a penalty to discourage this type of medical practice, so that leaves only the Criminal Justice System, and this what I think we should do, and I don’t think it is at all extreme, So listen just a little while longer.

There are some 200 million drivers in America and 51% of them drink. Altogether those 100 million or so drinking drivers, exercising "poor judgment", get into their automobiles, after they have had "one too many" and in aggregate they kill about 17,000 people every year.

The Criminal Justice System thinks this is a big deal – and it is. And they police this problem and they prosecute this problem relentlessly and with vigor. At the very least, every driver who is involved in a fatal accident, loses his license and often his freedom as well. Quite often he/she is also sued in Civil Court for monetary damages.

On the other hand, there are less than a million doctors in the US who collectively are killing minimally 40,000 persons per year using "poor medical judgment", and there is no penalty, civil or criminal or even administrative for this.

There is definitely something wrong with this picture and I would suggest the following as a potential way to rectify it.

There are approximately 5,000 hospitals in the US, so on average, some one is dying of poor medical judgment in each one these hospitals about every 6 or 7 weeks during the year. Ponder that statement for a moment or two. When will one of them be you?

Every one of these hospitals is located in a district where there is a publicly-elected District Attorney – charged with protecting the public against criminal acts.

If enough people in enough districts start pushing their local DA’s into conducting criminal investigations into every one of these 40,000 deaths, sooner or later "Medical Judgment" is going to get a whole lot better.

If a minimum of 40,000 people a year are dying because of being misdiagnosed for the most serious, and most common, of all medical ailments, while there are procedures in existence for dropping this number to essentially zero, then any time a doctor has a patient die because this procedure wasn’t followed, there should be some kind of investigation to determine just what was the overwhelming medical evidence that caused that doctor to be so sure that the patient’s complaint was not heart related, when after the fact it is so clear that it was.

If this determination is actually being made on an economic basis rather than a medical one, and I have no doubt many of them are, then the situation is really no different than the drunk who gets in his car and drives home, and kills some one on the way, because driving drunk will save him two cab fares, and the penalties for killing heart patients to save testing money, should be the same as it is for the drunk.

Post Script

What the courts call "Medical Judgment" should really be called "Witch Doctoring". If the initial EKG does not show a problem, which is the case about 45% of the time, then the doctor, at that point, really has no idea whether or not the patient is experiencing heart pain.

The proof of this statement is the simple fact that at least 13 times out of every 1000, the patient dies of a heart attack after having been told his pain is not heart related. If you think that’s a pretty good record, ask your self if you would fly an airline with the same record.

Ten years ago, there was no choice but to trust the Doctor’s judgment and pray that he was right. But for the last five years it has been possible to run a series of tests that will tell unequivocally if chest pain in any given instance is heart related, and not to run those tests cannot be brushed off as Medical Judgment. It is some degree of homicide and it’s time we started treating it as such. Doctors are not above the Law.

If there are any DA’s in the readership, I would love to hear your thoughts on this. Doctors too.

For those of you who aren’t DA’s, or doctors, but who think that simply learning what has been written here can save lives, please don’t hesitate to recommend this Diary.

The more it is read, the more lives will be saved, and the sooner the underlying problem will disappear.

Fiat Justitia Ruat Coelum

Lucius Calpurnius Piso Caesoninus