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Please help me understand how one can have a fatal heart attack missed by doctors?
My husband, 45 years old, thin, active (smoker though) recently passed away from a fatal heart attack. He had no previous history except in the early 90's was told that he had a heart murmur during a pre-employment physical. (His late mother had heart attacks) He NEVER went to the doctor......until the last couple of months before his demise. He had been complaing of back & left shoulder pain (but his shoulder had bothered him for years so I thought it was the same) as for the back pain I told him he should go to the doctor. He did not have medical insurance due to layoffs, was unemployed, so for him to feel the pain was bad enough to go to the Urgent Care/Emergency Room Hospital & pay out of pocket speaks for itself. They told him he had strained his back and gave him a perscription for Ultram. He went back several times because it was not improving. They just kept taking his money, wrote the prescriptions, and sent him on his way. The Sunday after Thanksgiving he had mentioned that he felt "funny" but couldn't elaborate, and that his left arm ached and thought he had slept on it wrong, but I don't know if he told them when he went to the Urgent Care that afternoon (I wish I had went with him-but I didn't). They just wrote him a refill. He left the facility on foot and headed to the drug store (which is just across the parking lot about 50 yards) and just after entering the store he stumbled, sat on floor short of breath and collapsed. By the time the paramedics got there he was already gone. They were unable to revive him. The autopsy revealed that the heart attack ("Cardiac Insufficiency") was due to Aortic Stenosis and Cardiomegaly, and that they have been present for years. I have been doing some research trying to make sense of it all and have found that the stenosis can be detected by hearing a murmur. I obtained the Urgen Care's records and they marked the box that indicated no murmer present. I would really like to know how the stenosis can be so bad that it causes a fatal heart attack yet be missed by the doctor who saw him literally just minutes before the fatal event? It just doesn't seem right. Am I wrong in believing they should have caught it?
In case there is anyone reading this thread who thinks I am calling the urgent care doctor incompetent or stupid, no. I'm not. I'm saying that if the doctor had been incompetent or stupid, then that would be a simple answer to what happened to terileefun's husband, but I don't think it was that simple.
With the cardiomegaly, he could have had a sudden arrythmia, as kenkeith and erijon stated. A healthy heart has its normal conduction pathways that carry the electrical impulses through the heart muscle, and those pathways activate with every beat. Doctors have the conduction pathways mapped out, as there is normally a pattern that goes through the heart muscle in a similar way in all people. It's part of the natural design of the heart.
But when the heart gets enlarged, as your husband's evidently did from straining against the occluded valve for years and years, the conduction pathways get stretched out and distorted. The electrical impulse that activates each heartbeat is no longer able to travel through the heart muscle in a predictable way. One day the electrical impulse just "shorts out," so to speak. With cardiomegaly, it's predictable that something like that will happen someday, but you don't know what day. It's like the tipping of an iceberg. The ice melts, and melts, and melts, and the iceberg is changing shape under the water, and one day it flips. It seems like a sudden event, and on one level it is, but on another level, it isn't. The flipping is the culmination of a long series of minute changes. A catastrophic arrythmia in response to cardiomegaly is like that.
If it wasn't an arrythmia that killed your husband, it could have been one of a couple of other things I can think of that don't happen until they happen, and there's no obvious outward sign until they do happen. Whatever it was, if it had happened while your husband was still in the ER and was on a monitor, the doctors would have tried to shock his heart back into a normal rhythm with the defibrillator paddles, and maybe that would have worked, and maybe it wouldn't have. Unbeknownst to anyone, his heart was already severely damaged by then. Even if the shock had worked, he still would have been very critically ill, and he would still have needed open-heart surgery to replace the valve, and he would not have been a good surgical candidate at that point. He might not have survived the surgery, if he had lived long enough to have it.
It is really weird and scary that someone can get that ill without even knowing it. It is sad that he didn't get a thorough enough exam to show that there was something wrong with his heart. Do you know if he even got a chest x-ray or EKG that day? Either one of those things would have shown that his heart was enlarged, and what (if anything) the doctor chose to do about it would have been up to his or her medical judgment. It would have been within the normal operations of an urgent care center to simply advise your husband to obtain primary care or cardiology care for that. Regarding shortness of breath, if your husband was not short of breath when he left the house, then he probably wasn't short of breath when he got to the urgent care center. It sounds like he didn't get short of breath until he walked into the pharmacy. Or maybe he was a bit short of breath all the time, and he had gotten used to it. He probably told himself that he needed to quit smoking.
More about heart murmers. When I saw a cardiologist for the first time, I had already been working with my PCP on my blood pressure for about a year, and I had already been to the ER one night. No one had ever heard a murmer in my chest, never in my life. That cardiologist put me up on an exam table, and she did the most thorough chest auscultation I have ever had, before or since. She put the stethoscope on about five different positions on the front of my chest, same on the back, and she did that with me in three different body postures: sitting upright, front and back; sitting forward at a 45 degree angle, front and back; and lying flat on my back, front of my chest. She heard a faint murmer in one stethoscope position, with me lying flat on my back -- only. She said it was faint enough that anyone who did not have very acute hearing (which includes a lot of middle-aged or older doctors) would not have been able to hear it at all. Maybe if your husband had had that kind of physical exam at the urgent care center, a murmur would have been detected -- but again, it wouldn't necessarily have signified an emergency. It would have been a reason for the urgent care doctor to tell him to seek primary care or cardiology care. Maybe an urgent care or primary care doctor considers that kind of chest auscultation to be a specialty procedure that is normally only done by a cardiologist or pulmonologist; I don't know.
I appreciate that you are able to take my input in the spirit in which it is given. I believe you are really seeking the truth, and I respect that. In my opinion, you are responding to this terrible event in exactly the right way. First of all, you are trying to understand it, and second of all, you are trying to make sure that the same thing doesn't happen to other people. I think that's all you can do, at this point. Your husband's death wasn't a good thing, but you can try to make something good come from it. That is a positive response to a terrible loss.
But when the heart gets enlarged, as your husband's evidently did from straining against the occluded valve for years and years, the conduction pathways get stretched out and distorted. The electrical impulse that activates each heartbeat is no longer able to travel through the heart muscle in a predictable way. One day the electrical impulse just "shorts out," so to speak. With cardiomegaly, it's predictable that something like that will happen someday, but you don't know what day. It's like the tipping of an iceberg. The ice melts, and melts, and melts, and the iceberg is changing shape under the water, and one day it flips. It seems like a sudden event, and on one level it is, but on another level, it isn't. The flipping is the culmination of a long series of minute changes. A catastrophic arrythmia in response to cardiomegaly is like that.
If it wasn't an arrythmia that killed your husband, it could have been one of a couple of other things I can think of that don't happen until they happen, and there's no obvious outward sign until they do happen. Whatever it was, if it had happened while your husband was still in the ER and was on a monitor, the doctors would have tried to shock his heart back into a normal rhythm with the defibrillator paddles, and maybe that would have worked, and maybe it wouldn't have. Unbeknownst to anyone, his heart was already severely damaged by then. Even if the shock had worked, he still would have been very critically ill, and he would still have needed open-heart surgery to replace the valve, and he would not have been a good surgical candidate at that point. He might not have survived the surgery, if he had lived long enough to have it.
It is really weird and scary that someone can get that ill without even knowing it. It is sad that he didn't get a thorough enough exam to show that there was something wrong with his heart. Do you know if he even got a chest x-ray or EKG that day? Either one of those things would have shown that his heart was enlarged, and what (if anything) the doctor chose to do about it would have been up to his or her medical judgment. It would have been within the normal operations of an urgent care center to simply advise your husband to obtain primary care or cardiology care for that. Regarding shortness of breath, if your husband was not short of breath when he left the house, then he probably wasn't short of breath when he got to the urgent care center. It sounds like he didn't get short of breath until he walked into the pharmacy. Or maybe he was a bit short of breath all the time, and he had gotten used to it. He probably told himself that he needed to quit smoking.
More about heart murmers. When I saw a cardiologist for the first time, I had already been working with my PCP on my blood pressure for about a year, and I had already been to the ER one night. No one had ever heard a murmer in my chest, never in my life. That cardiologist put me up on an exam table, and she did the most thorough chest auscultation I have ever had, before or since. She put the stethoscope on about five different positions on the front of my chest, same on the back, and she did that with me in three different body postures: sitting upright, front and back; sitting forward at a 45 degree angle, front and back; and lying flat on my back, front of my chest. She heard a faint murmer in one stethoscope position, with me lying flat on my back -- only. She said it was faint enough that anyone who did not have very acute hearing (which includes a lot of middle-aged or older doctors) would not have been able to hear it at all. Maybe if your husband had had that kind of physical exam at the urgent care center, a murmur would have been detected -- but again, it wouldn't necessarily have signified an emergency. It would have been a reason for the urgent care doctor to tell him to seek primary care or cardiology care. Maybe an urgent care or primary care doctor considers that kind of chest auscultation to be a specialty procedure that is normally only done by a cardiologist or pulmonologist; I don't know.
I appreciate that you are able to take my input in the spirit in which it is given. I believe you are really seeking the truth, and I respect that. In my opinion, you are responding to this terrible event in exactly the right way. First of all, you are trying to understand it, and second of all, you are trying to make sure that the same thing doesn't happen to other people. I think that's all you can do, at this point. Your husband's death wasn't a good thing, but you can try to make something good come from it. That is a positive response to a terrible loss.
Thank you for your dedication in trying to help me understand. You both seem so knowledgable and passionate on th subject that you sound like cardiologists. If so, then I'm grateful that you take the time to visit these forums and help people. If not, then I applaud your efforts to gain the knowledge that you have.
Looking back over the years there were a few times that he would just be sitting on the couch or at the table and grab at his chest and say he had pain, but it was over in less than 30 seconds. When I questioned him more he would say "it felt like my heart had a cramp for a few seconds" I told him "that's NOT supposed to happen!", and he just brushed it off as a muscle spasm or something. I told him he should see a doctor about it but he just said he was ok. These were very quick episodes without any other symptoms whatsoever, and again in the 22 years we were married it only happened a few times. He was always getting weird cramps like in his big toe or a finger or hand or elbow, and he was always very, very dramatic about them in a waythat it always made me laugh....so when he said it was just a muscle spasm I really didn't worry too much, especially without other symptoms. But as for being short of breath, I never witnessed it unless it was warranted, like lugging camping equipment, etc. He was always doing something, fixing things, yard work, etc. and he never complained of being short of breath or heart pounding or anything. He also did not have high blood pressure. He was diagnosed in the early 90's with a heart murmur, but the recent records indicate none.
In my original post it was not my intent to claim the doctor incompenent. Please remember I have very little knowledge or experience with heart issues and had no clue that there were so many different causes of a "heart attack". My mindset was if his stenosis was so bad that it caused my husbands death, well it's still just hard for me to fathom that this would not have been heard when listening to his heart. I don't necessarily "blame" the doctor as much as I think he might have rushed through the motions of an exam because they just thought he was back for a refill on meds, period. He told me that they never even checked him on one visit, just asked if he needed a refill, told him to take a seat in the back and the triage nurse brought him the script. He never even saw a doctor during that visit. Yet, none of the records they gave me reflect this, they all show he was seen by a doctor and was checked. As for the day that he passed away - I do know this - if my husband had the slightest thought that he was having a heart attack, he would have said something to the doctor. But even if a person doesn't know or recognize symptoms of a heart issue the medical professionals do. His age, family history of heart disease, and lack of physicals just add more reason a doctor should be more thorough, especially knowing that he didn't have a primary care doctor to tun to.
And again, it would seem to me that if it were severe enough to kill him, that he have been short of breath walking in, or a murmur or some kind of sound would be heard through a stethoscope. I just find it hard to believe that there could be no indication of some kind of problem when it's severe enough to cause death in minutes.
My husbands death has been incredibly, incredibly painful, I just don't ever want another family to suffer such a loss. If I can build awareness to patients, doctors, nurses, ER's or Urgent Care's then just maybe we can prevent future loss and pain.
I'm agreeing with you. There does not seem to be any obvious fault that can be attributed to anyone. Sorry if I wasn't clear on that. That is what I think, also.
We really don't know all the facts of what terileefun's husband told the doctor or what the doctor told her husband. But from what terileefun has shared, it seems that yes, her husband could have died of a sudden cardiac event that was unforseeable even minutes before. Even so, you still have to call it a mistake that the doctor let him walk out. It was a mistake, given the outcome. To say that it was not a mistake would be to say that the doctor meant to let him walk over to the pharmacy and die. It was a mistake, by definition. It was a wrong decision. But not all mistakes constitute negligence, which is what terileefun basically started out asking.
What if terileefun's husband had died while he was still in the exam room with a monitor on him? It could have happened that way. What if he had sat around and thought about it at home for an hour or so longer, before he decided to go to the urgent care center that day. So that when he got there, he was an hour closer to the fatal event, and when it happened, he was still lying on a gurney in the hospital or urgent care center or whatever it was. Same outcome, ultimately, but the doctor would have called up terileefun and said, "he had massive heart attack while he was in here, and we worked hard on him, but we just couldn't pull him back. It was too massive, and there was just too much damage. Some people we can't save, even if they have a heart attack while they are in the ER. He had every medical advantage, and we did everything we could, but there was nothing anyone could have do to save him, given the catastropic nature of what happened inside his chest." Somehow that has a whole different feeling to it. But that's not the way it happened. And as to why it happened the way it did, I don't think there's an answer. It's one of those things you can ponder over, like why did someone not go to work at the World Trade Center on 9-11-01, or why did someone take someone else's place at work at the World Trade Center that day. But why things happen the way they do, I don't know.
We really don't know all the facts of what terileefun's husband told the doctor or what the doctor told her husband. But from what terileefun has shared, it seems that yes, her husband could have died of a sudden cardiac event that was unforseeable even minutes before. Even so, you still have to call it a mistake that the doctor let him walk out. It was a mistake, given the outcome. To say that it was not a mistake would be to say that the doctor meant to let him walk over to the pharmacy and die. It was a mistake, by definition. It was a wrong decision. But not all mistakes constitute negligence, which is what terileefun basically started out asking.
What if terileefun's husband had died while he was still in the exam room with a monitor on him? It could have happened that way. What if he had sat around and thought about it at home for an hour or so longer, before he decided to go to the urgent care center that day. So that when he got there, he was an hour closer to the fatal event, and when it happened, he was still lying on a gurney in the hospital or urgent care center or whatever it was. Same outcome, ultimately, but the doctor would have called up terileefun and said, "he had massive heart attack while he was in here, and we worked hard on him, but we just couldn't pull him back. It was too massive, and there was just too much damage. Some people we can't save, even if they have a heart attack while they are in the ER. He had every medical advantage, and we did everything we could, but there was nothing anyone could have do to save him, given the catastropic nature of what happened inside his chest." Somehow that has a whole different feeling to it. But that's not the way it happened. And as to why it happened the way it did, I don't think there's an answer. It's one of those things you can ponder over, like why did someone not go to work at the World Trade Center on 9-11-01, or why did someone take someone else's place at work at the World Trade Center that day. But why things happen the way they do, I don't know.
"Aortic stenosis can be part of the picure of HCM. If the septal walls thicken they can block part of the aorta. This is known as Hypertrophic Obstructive Cardiomyopathy (HOCM)"
>>>Obviously, HOCM didn't cause aorta stenosis...there was some calcification of the aorta valve according to the autopsy. There wasn't an enlargement of the heart's septum that skewed and obstructed blood flow through aorta orifice.
Unfortunately, people of all ages have a fatal cardiac arrest. There isn't any signs and symptoms that forewarn many cardiac arrests, and husband's back ache doesn't suggest a heart problem! Having a family history of a heart disorder and smoking should place husband on a short list to have periodic physical exams, but from what I have read, I don't see any fault that can be directly attributed to anyone. My experience with doctors has not been totally positive, but I don't see it here...maybe if you can be more specific.
>>>Obviously, HOCM didn't cause aorta stenosis...there was some calcification of the aorta valve according to the autopsy. There wasn't an enlargement of the heart's septum that skewed and obstructed blood flow through aorta orifice.
Unfortunately, people of all ages have a fatal cardiac arrest. There isn't any signs and symptoms that forewarn many cardiac arrests, and husband's back ache doesn't suggest a heart problem! Having a family history of a heart disorder and smoking should place husband on a short list to have periodic physical exams, but from what I have read, I don't see any fault that can be directly attributed to anyone. My experience with doctors has not been totally positive, but I don't see it here...maybe if you can be more specific.
The autopsy states calification of aorta valve causing stenosis (narrowing). As a consequence of stenosis, pressure within the left ventrical chamber will increase to overcome the gradient pressure of the valve stenosis to pass blood through the narrow valve into circulation. There will be a reduction of the cardiac output!. Regardless of the underlying cause, a severe reduction of cardiac output will produce shortness of breath, possibly chest pain, fatigue, etc. Husband never stated any low cardiac output symptoms.
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