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Triple rule out protocol: Safely evaluating chest pain, shortness of breath, and passing out

Patient safety requires ruling out three life-threatening conditions

There’s an important patient safety rule called the triple rule out protocol that hospitals should have in place, train on, and enforce.

When a patient presents to a hospital with symptoms including chest pain, shortness of breath, and severe syncope (fainting), the triple rule out protocol comes into play. This constellation of symptoms requires a physical exam and testing, including a CT angiogram, to rule out or exclude three dangerous medical conditions:

• Acute coronary syndrome

• Pulmonary embolus

• Aortic dissection

If a physician skips the triple rule out protocol, or a hospital doesn’t have the correct policies, procedures, training, and supervision in place, it can lead to a needless patient death.

According to a lawsuit involving an Arlington, Texas hospital, that’s what happened to a 35-year old woman. The Fort Worth Court of Appeals recently entered an opinion in the medical malpractice wrongful death lawsuit dealing with the issues of what hospitals are supposed to do when a patient presents to the emergency room with cardiac abnormalities.

The woman in her 30s arrived at the hospital emergency room after fainting. She had serious symptoms that were consistent with pulmonary embolism, including chest pain, shortness of breath, and, of course, fainting (severe syncope).

Pulmonary embolism is a potentially deadly condition. It typically starts with the blood clot forming the deep veins of the legs (deep vein thrombosis, or DVT), and then breaking off and traveling to the lungs. Once there, it can cause intense chest pain, shortness of breath, and fainting.

According to the appellate opinion, a cardiologist performed a heart catheterization on the patient, which revealed some plaque on one of her coronary arteries. The cardiologist diagnosed her with atherosclerotic artery disease and instructions discharged her the next day, with instructions to follow-up in two weeks with a cardiologist.

Unfortunately, the lawsuit alleges, the cardiologist stopped there without following the triple rule out protocol. As a result, the patient was never worked up for pulmonary embolism before being discharged.

The patient did survive long enough to see a cardiologist for an outpatient appointment. Just three days after she was discharged home from the hospital, she was discovered struggling to breathe while lying in bed. By the time an ambulance got to the hospital, she was already in respiratory distress. Despite efforts to save her life, she died.

An autopsy showed that she had massive bilateral pulmonary thromboemboli. In this condition, lots of dislodged clots traveled to both of her lungs, where they obstructed over half of the pulmonary arterial tree. That caused her right ventricle to overload and fatal heart failure.

The wrongful death plaintiffs and their medical expert concluded that the patient’s death could have been avoided if the cardiologist and the hospital had followed the triple rule out protocol.

If you’ve been seriously injured because of poor hospital or cardiology/cardiac care in Texas, then contact a top-rated experienced Texas medical malpractice lawyer for free consultation about your potential case.

Robert Painter is an award-winning medical malpractice attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits all over Texas. Contact him by calling 281-580-8800 or emailing him right now.


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