Tech Talk
A patient claims that doctors failed to anticoagulate her quickly enough.
Smart Practice
Tech Talk
Antony Scholefield
Case history A 60-YEAR-old woman attended a medical centre for management of her obesity, borderline hypertension and episodes of palpitations.
Over the years, she had been investigated fully but no cardiac abnormalities were observed. However, she presented this time with more frequent episodes of palpitations that were occasionally associated with light-headedness.
The GP found frequent symptomatic premature ventricular beats on the ECG. He discussed this with a cardiologist and prescribed a beta blocker( metoprolol), restricted her caffeine intake and recommended a referral to the cardiologist.
The patient presented a few days later with similar symptoms. On this occasion, ECG revealed atrial fibrillation with a ventricular rate of 90-120bpm. The GP consulted the cardiologist again, who recommended a change to sotalol for rhythm control instead of the metoprolol, and arranged for the patient to see him and have an echocardiogram. This was the first occasion AF had been documented.
Four days later while waiting for her cardiology consult, the patient developed a left-sided hemiparesis with mild speech disturbance. She was admitted to hospital where a CT confirmed a right cerebrovascular accident. An echocardiogram showed left ventricular hypertrophy consistent with hypertension but no thrombus. ECGs throughout her hospital admission did not demonstrate AF.
Her stroke was presumed to be thromboembolic in origin and she was prescribed warfarin. She recovered from her stroke but was left with residual weakness in her left arm.
Claim The patient started a medical negligence claim against her GP and the cardiologist, alleging they failed to anticoagulate her when she presented with paroxysmal AF. The nine-day delay in starting anticoagulants resulted in her having a stroke and sustaining permanent disabilities.
A cardiac anomaly
EXPERT OPINION
A patient claims that doctors failed to anticoagulate her quickly enough.
DR CRAIG LILIENTHAL
QUESTIONS FOR OUR EXPERT
Dr Sheena Wilmot is a GP in Sydney, NSW 1. With our ageing population and the related increased incidence of AF, what should GPs do to avoid missing this important diagnosis? Opportunistically, at every consultation we should check patients’ pulse rates, especially if they are over 60. With the widespread uptake of automated BP monitoring, we don’ t often hear and feel our patients’ cardiac rhythms.
2. What can GPs do to minimise the risk of stroke in patients we diagnose or suspect have AF? As was done in this case, assess the patient’ s risk with CHADS / CHA2 DS2 VASc scores. I would suggest that even if the risk is considered low, the pros and cons of anticoagulation should still be discussed with each patient to allow them to have input into their management.
3. What do current guidelines say about the urgency of referrals and starting anticoagulants? The Therapeutic Guidelines state that AF in all its forms carries the same thromboembolic risk. The guidelines also state that with a CHA2 DS2-VASc score of 1 or more, the recommendation is either aspirin or oral anticoagulation with a stated preference for the latter. Obviously seek review by a cardiologist as soon as possible. As in this case, immediate discussion over the phone is a good idea.
4. In a negligence claim in April this year, the judge found against the defending doctor, even though he followed the clinical guidelines. The judge even chastised him for“ slavishly” following antibiotic guidelines. How does a GP know what to do? As a GP, I would hope the finding of this judge would be contested. Following clinical guidelines is generally regarded as best practice in medicine. It is discouraging when this is not upheld by the courts and this is likely to have a negative impact on general practice.
Expert opinion Contrasting statements from each party’ s respective experts can be summarised as follows:
• The patient complained of symptoms of an intermittent arrhythmia for 12 months. An earlier referral to a cardiologist may have established the diagnosis of AF, and starting an anticoagulant may have prevented the stroke.
• When the cardiologist was first contacted, he should have anticipated the diagnosis and recommended anticoagulants.
• The patient’ s CHAD score was 1; CHAD Vascular score was 2 and the annual risk of a cerebrovascular accident was 2.2 %. This is low risk for a cerebrovascular accident.
• The ECG showing premature ventricular beats was correctly interpreted and would have explained the patient’ s symptoms. The plan to arrange an elective referral was reasonable.
• The patient was at low risk of stroke even when the diagnosis of AF was first established. For this reason, hospital admission and anticoagulation was not warranted.
Outcome The respective medical defence organisations supported the management of both the GP and the cardiologist, and agreed the claim should be defended. After the exchange of expert opinions, the plaintiff discontinued the legal action. Each party was left to pay their own legal fees. ●
Dr Lilienthal is a GP in Sydney and medicolegal adviserr.
Can iPhones help in diabetic foot ulcer care?
WHAT is the world’ s most popular camera? If you say Nikon or Canon, you clearly know a little bit about photography. But you’ re also wrong. It is in fact the iPhone. Smartphones are shaking up the photography world by providing millions of people with access to inbuilt cameras, which are, for their size, of surprisingly high quality.
For the same reason, smartphones are shaking up healthcare.
People can now photograph their symptoms and send a picture to their doctor or upload them to health discussion forums.
Many studies have reviewed their use in fields such as dermatology, where patients can photograph a suspicious lesion, send it to a distant dermatologist and find out whether it’ s worth visiting a doctor to have it checked out or not. Now researchers from the Queensland University of Technology and Queensland Health have looked at smartphone cameras and their role in the remote assessment of diabetic foot ulcers.
Writing in Scientific Reports, they claim smartphone cameras are“ already widely used in daily clinical practice” to look at diabetic foot ulcers as well as general wounds.“ For example, by home care nurses or by patients for unofficial telemedicine consultations with an interdisciplinary foot clinic.”
Unfortunately, however, the research warns against their use.
The study saw 50 patients with diabetic foot ulcers assessed in person by a clinician during which four images of their ulcer were taken using an iPhone 4. These images were sent to another clinician, with some baseline clinical information about the patient, who also assessed the ulcer.
The researchers looked at how the two assessments matched up on answers to 12 important clinical questions, such as‘ Does the wound bed contain slough?’ or‘ Is there presence of wet or dry gangrene?’.
The positive likelihood ratio was 1.3-4.2, the negative likelihood ratio was 0.13-0.88, the sensitivity was 32- 97 % and specificity was 20-87 %. All in all, poor results.
“ This indicates that mobile phone images should not be used as a stand-alone diagnostic instrument for remote assessment of diabetic foot ulcers,” the authors conclude.
“ Clinicians who use mobile phone images in daily clinical practice should obtain as much additional information as possible when making treatment decisions based on these images, and be cautious of the low diagnostic accuracy.”
This is a shame because, as the authors point out, these patients often have to make weekly visits to diabetic foot clinics that can be expensive and time-consuming. Scientific Reports 2017; online.
www. australiandoctor. com. au 15 September 2017 | Australian Doctor | 17