I was supervising the inpatient service when I received a call from another supervisor regarding a patient of ours who was going to be transferred to us from an outside hospital.  This hospital from which the patient was coming is an Orthopedic hospital and given Nebraska law, it is required to have an emergency room since it has “hospital” in its name.  However, no medical patients are admitted at this orthopedic facility and thus we receive a lot of medical transfers, some more serious than others.

This particular patient had presented to the emergency room with chest tightness and was reporting that it was his asthma.  The physician in the ER that night was concerned and wanted him observed overnight so was calling to transfer him to the University Hospital.  In the past there was a lot of difficulty contacting the right service to receive the transfer, so a centralized system was created so that all calls are received by one of the medicine services who then decides where they belong.

It was late into the evening when I got the call from the IM resident telling me that we had a patient coming from this particular hospital.  They relayed to me their chief complaint and the relevant labs.  They had said they were being transferred for asthma, reported the basic labs and then mentioned that the patient had some cardiac risk factors so they had obtained and EKG which showed a left bundle branch block and an initial cardiac panel that was negative.  Nonchalantly, this information was relayed on to me as though it was a basic transfer and the nurse would call when they got to the floor.  As residents do, we growled about getting another patient, but paged our attending to let them know we had another admission and we would call them when he got to the hospital.

Several hours had passed, and it was almost time to handoff by the time the patient arrived.  The intern and I both went to see the patient to discuss a plan before calling the attending.  We went through the standard asthma treatment, but agreed that we should trend his cardiac enzymes since he had some risk factors, and his asthma picture didn’t quite fit.  By the time we were finished we made our way back to the work room just in time to meet the staff who was coming on.  We did the typical patient presentation and went through all the labs, radiographs, and EKG when our attending asked about the left bundle on the EKG.  Does he have a previous one to compare?  It only took that question to realize that this patient was having a STEMI.  We called cardiology immediately and he was taken to the cath lab emergently and found to have diffuse multi vessel disease.  A intra-aortic balloon pump was placed and he was taken directly to the OR where he underwent a 4 vessel CABG.  Prior to all of this, he had his second troponin drawn which was around 40.

I realized we and the system had let this patient down on multiple levels.  The diagnosis had been overlooked by the ED staff at the outside hospital, missed by the IM staff, the IM supervisor, myself, and the intern with whom I was working.   My perception after receiving the call was that this was a non-emergent asthma patient coming to the floor.  I assumed, as well as the others, that this EKG finding and cardiac workup was nothing to worry and more side information since it was presented to me outside the initial diagnosis.  Communication amongst providers was insufficient as this patient presentation was coming from the supervising resident who heard about it from their staff who heard it from the emergency physician at the outside hospital.

Today, John Nance discussed the principles of perception, assumption, and communication as three possible routes to failure in medicine.  As he mentioned these, I realized the trifecta of failure we had achieved.  While the patient is alive, he did not receive the immediate care he required .  We had failed as humans often do, but the system had magnified our failure.