The EKG: 25-40% of malpractice and ACS misdiagnosis in the ED involves EKG interpretation. 

• Over-reliance on computer interpretation; the machine will read 0.999 of ST elevation or depression as "non-specific EKG changes". 
• Get an old EKG for comparison. 
• One EKG begets another EKG - 10% of STEMI's are diagnosed on the second or third EKG. 

Misdiagnosis of GERD: Single most common misdiagnosis in cardiac malpractice lawsuits involving missed MI/ACS. 

• 20% used the word burning or indigestion to describe their MI. 
• Maalox is the most dangerous drug in the Emergency Department - 15% with improvement after Maalox. 

Atypical Presentations are Typical Med-Mal Cases:

• Elderly, Females, Diabetics. 
• Women tend to present with more symptoms than men and often get an influenza-like illness diagnosis, especially in the winter time. 
• Women are more likely to have a false negtive stress test than men, possibly because more likely to have single vessel disease. 
• Anginal equivalents: Shortness of breath, neck pain, shoulder pain, jaw pain, arm pain or numbness. 
• Know the elements that increase liklihood ratio of ACS:
• Chest pain radiating to bilateral arms or right arm
• Chest pain with exertion
• Chest pain with diaphoresis.
• Chest pain with vomiting. 
• Atypical Risk Factors: CKD + HIV + Connective Tissue Disease like RA or Lupus
• Young Patients: Teenagers and young adults can true atherosclerotic myocardial infarctions with the increase in obesity. 
• Upper Abdominal Pain: The diaphragm is not a concrete barrier and anything in the upper abdomen can cause chest pain and anything in the chest can cause upper abdominal pain. Have a low threshold to perform an EKG. 

Failure to Emergently Consult a Cardiologist or Active the CATH lab for NSTEMI Condtions:

• ACC/AHA Guidelines:
• NSTEMI with intractable ischemic pain not resolving with medications within the first two hours. 
• NSTEMI with ischemic EKG who develops acute heart failure. 
• NSTEMI with persistent symptoms who develop ventricular arrhythmia. 
• Make sure to document consultant's name  + time of conversation + conversation + if the consultant will see the patient. 

Discharge Issues

• Validated scoring systems (HEART, ADAPT) have been used to successfully defend med-mal cases. 
• Document shared decision making - the patient needs to be aware that there risk is not 0. 
• Give the patient time and action specific instructions.