The importance of pre-surgery cardiac clearance
Do not allow your doctors go through the motions when it comes to cardiac clearnace
Any time a patient is taken to surgery, there are risks involved. Some risks are avoidable and some are unavoidable.
One foreseeable complication is that the stress of surgery can trigger cardiac, or heart, complications, such as a heart attack (myocardial infarction), arrhythmia (an irregular heart rhythm), and acute coronary conditions.
This is a particular concern considering the multiplication of surgical procedures being done on patients in their 50s, 60s, and older, where the risk of cardiac complications is higher.
Pre-operative cardiac evaluation/clearance
As a result of the increased awareness of heart risks as a result of operations, surgeons frequently require a pre-operative cardiac evaluation before they will even schedule surgery.
Cardiologists (heart doctors) who perform these types of evaluations should consider patient-related factors that increase risk, including: age, chronic diseases (coronary artery disease, diabetes mellitus, and hypertension), functional status, medications the patient is taking, implanted devices, and the history of previous surgeries. In particular, a history of a heart attack within the previous six weeks, unstable angina, and aortic or peripheral vascular surgery place a patient into a high-risk category for heart complications during a surgery.
Additionally, cardiologists should also consider surgery-related factors, like the type of surgery (vascular, endoscopic, abdominal), how urgent the operation is, how long the operation will last, the potential for blood loss and fluid shifts.
In my experience as a Texas medical malpractice lawyer, many cardiac evaluations/clearances consist of an evaluation by a cardiologist with testing limited to a chest x-ray and electrocardiogram (ECG).
Computer-read & cardiologist-read ECGs
In almost all instances, an ECG is printed out on paper, with the text of a machine-read (computer) interpretation printed on the page. The machine-read interpretation is referred to as an unconfirmed reading. After a cardiologist reviews the ECG, he or she may modify the machine-read interpretation or leave it the same. At the conclusion of the cardiologist’s review, it is referred to as a confirmed interpretation.
Sometimes the computer will identify a concerning finding on an ECG, which the cardiologist discounts in the confirmed interpretation. This may be done because the finding is insignificant to the cardiologist, in terms of the patient’s overall heart health for surgery. In some situations, though, this can be dangerous to a patient.
A particular case comes to mind where I represented the family of a lady in her 40s who died at a Memorial Hermann hospital in the Houston area after a routine endoscopy. Prior to the endoscopy, a surgeon had referred the patient to a cardiologist for pre-surgical clearance.
As part of the cardiologist’s evaluation, there was an ECG, which the computer interpreted as showing a prolonged QT interval. When the cardiologist read the ECG, he deleted the finding of a prolonged QT interval in the confirmed interpretation.
When the patient was taken to the procedure suite at the hospital for the routine outpatient endoscopy, an anesthesiologist gave her an anti-nausea medication called Zofran. Zofran should not be given to a patient with a prolonged QT interval. The patient went into cardiac arrest during the procedure and ultimately died from the permanent injuries she sustained.
Long QT syndrome (LQTS)
Long QT syndrome is a disorder that affects the heart’s electrical conduction system, causing fast and chaotic heartbeats. Some people with this condition have no symptoms, but others experience sudden fainting spells or seizures.
The syndrome is named after two parts of the waveform on an ECG, the Q and T components. The length of time between the Q and T parts of the ECG waveform—called the QT interval—shows how long it takes the electrical signal to go on and off in the heart’s ventricles.
If the QT interval is too long, it may indicate a long QT syndrome. This disorder increases a patient’s chance for a specific type of arrhythmia called torsade de pointes. With torsade de pointes, the heart cannot pump enough oxygen-rich blood to the rest of the body, and can also lead to ventricular fibrillation, a dangerous arrhythmia that causes rapid, uncoordinated contractions in the ventricle muscles. Ventricular fibrillation can deprive the rest of the body of oxygen-rich blood, which can lead to death.
Some people are born with long QT syndrome, in which case it is called congenital. Other people can develop a long QT syndrome as a result of medications they are taking or even some medical conditions.
While many people live with long QT syndrome without treatment, there are available interventions, including taking medications or even have surgery to place an implantable device to control the heart rhythm.
Significantly, people with long QT syndrome should avoid medications that are known to further increase the QT interval. In the case I referenced earlier, our medical expert felt that the anesthesiologist improperly administered Zofran to a patient who had pre-existing prolonged QT syndrome, which further increased the QT interval, put her into torsade de points, and cardiac arrest.
Improving safety in the cardiac evaluation/clearance process
Based on my experience in handling medical negligence cases, cardiologists, anesthesiologists or certified registered nurse anesthetists (CRNAs), and surgeons sometimes put little thought into the unique needs or challenges of each patient. Instead of treating the patient in front of them, they treat what they consider to be a “typical” patient. I call this auto-pilot healthcare.
You can get your health care providers off auto-pilot by asking specific questions. In the context of a surgery that requires cardiac clearance, ask for a copy of the unconfirmed and confirmed ECG printouts. If either the machine-read or cardiologist-read ECG printouts reflect any abnormalities, be sure to ask your anesthesia provider (anesthesiologist or CRNA) about how these findings will impact their selection of anesthesia or other medications that they will administer. Ask your surgeon or doctor performing the procedure the same question with regard to medications that they will choose.
We are here to help
If you or someone you care for has been seriously injured as a result of a cardiology clearance mishap or surgical error, call 281-580-8800 for a free consultation with an experienced medical malpractice lawyer at Painter Law Firm.
Robert Painter is a medical malpractice lawyer at Painter Law Firm PLLC.
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A physician has to supervise the care and prescriptions of nurse practitioners and physician assistants under written, signed agreements
On 4/1/2018, the new law will end the current practice where doctors can secretly enter a DNR order against patient and family wishes
This article was originally published in the September/October 2017 edition of "The Houston Lawyer" magazine
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