Santa Claus Isn’t Coming to Town: A Cardiac Cautionary Tale

Introduction: Now that Christmas has come, it is that time where people come together, share stories old and new, and enjoy food and drink together. It is, however, a time where hospitals come under increasing pressure due to many a familiar festive illness and injury. It is now well accepted that there is an increase in death rates the colder it gets. Respiratory diseases flare up and, for the purposes of this blog, cardiovascular admission rates increase over the festive period.

To outline the issues around this time of year is with a tale. A cardiac cautionary tale. A story of the big man in red himself, Mr Santa Claus.

The facts

On 24 December, Mr Claus was travelling on his sleigh, making stops at every single house to drop gifts for all and to fill up on his pre-requisites of milk, cookies, and brandy. By 3am, he has visited many houses and gorged on many a festive treat. After stopping off at the next house on the list, this time to leave a lump of coal, he starts to fall ill. Not wanting to risk it, he decides to take a detour to the local hospital, Winter Wonderland Hospital. On admission to the hospital, Mr Claus is taken to Accident & Emergency. A past medical history notes the following:

1. A high BMI and poorly controlled diet characterised by copious amounts of milk, brandy, and cookies,
2. Profuse sweating,
3. Long periods of remaining stationary as a result of extended travelling on his sleigh,
4. A previous resolving chest pain in the last 12 hours.

The decision is made that his symptoms are just aches and pains. No urgent follow up or investigations are required. This was a fatal error. Mr Claus is triaged back to Accident & Emergency. He does not receive an ECG or blood tests. Three hours later, another patient notices Mr Claus slumped to the side. He has suffered a totally avoidable heart attack.

What is a myocardial infarction?

A myocardial infarction (MI) is more commonly known as a heart attack. This is where plaque inside one of the coronary arteries builds up which can lead to the cessation of blood flow to the myocardium. This can have grave, and often fatal, consequences if left untreated.

What are the guidelines?

The NICE Guidelines (GC95) make clear that in the presence of previous chest pain, initial assessment should include considering the following points:

1. Whether there was current or previous chest pain in the last 12 hours,
2. The history of that chest pain,
3. The presence of cardiovascular risk factors,
4. Any history of heart disease,
5. Previous investigations.

In particular, pain in the chest and or other areas lasting longer than 15 minutes is considered to be a concern. There may also be nausea, vomiting, sweating, and breathlessness. If, following such an examination, an MI is expected then this must be treated as an emergency. Pain relief should be offered as soon as possible, particularly if a MI is suspected. A single loading does of 300mg of aspirin should be given as soon as possible unless there is clear evidence to the contrary.

The usual diagnostic pathway for a suspected MI or other acute coronary conditions is to take a 12-lead ECG and a blood test. The ECG will look for features that indicate an MI including changes to particular waves on the ECG. The blood test is intended to indicate any biochemical markers that are suggestive of an MI such as a raised troponin level. Troponin is one of the regulatory proteins that is released into the blood stream in the event of an MI.

If an MI is expected, there are two options for treating the symptoms. First, medical management by providing either aspirin and/or clopidogrel. Second, reperfusion therapy which is where the blood flow is restored through a combination of drugs, thrombolytics, and/or surgery. The most common procedure is called a percutaneous coronary intervention (PCI) where a catheter is used to place a stent to open up the vessel narrowed by the plaque.

What makes Mr Claus’ cardiology treatment negligent?

A common failure is the failure to diagnose an MI in spite of clear warning signs. In Mr Claus’ case, the poor diet and BMI are considered to be risk factors that increase the possibility of plaque build-up in the arteries pumping blood to the heart. Chest pain is the classic sign of an MI as well as profuse sweating. Even if an ECG was performed, there are still risks of a failure to correctly interpret the ECG.

In law, the test for determining whether there has been failure is whether the actions of the hospital when triaging a patient fell below the standard considered by a reasonable body of medical opinion. If the failure on triage was considered to be a breach of duty, the next step is to consider whether the mistake caused the injury sustained. For example, if Mr Claus had received either the medical treatment or the surgical treatment, such as the PCI, the outcome would have been prevented. Only with both the breach of duty and the thereafter flowing causation can there be a case. Whilst of course, the tragedy of Mr Claus is fictitious in this scenario, it is crucial for anyone who suspects their cardiology treatment was wrong to contact a medical negligence specialist for advice.