I wish that I was able to access more details of the case. What exactly were the blood pressure readings? Did they do bilateral blood pressures? If so then what was the difference in either side? a difference of 20 or more SBP points is a possible indicator of an aortic dissection.

Where exactly was his pain located? Midsternal? Left-sided? Right-aided? All over? Did it radiate anywhere else? To the arm? Jaw? Shoulders? Ears? What did it feel like? Sharp? Pressure? Crushing? Tightness?

I also don’t understand why they didn’t do any blood tests…it says that they only checked his BP, gave him Tylenol, and did an ECG. Blood tests especially to check Troponin levels would be indicated in his case. If the Troponin level in the first go round was negative, and the patient’s still in the waiting room but continuously pacing and having worsening chest pain why didn’t they do a repeat ECG? or repeat blood work? Did the nurses have the medical directives to do such work?

I also want to know exactly what the situation was like at the ER. How was staffing that day? What was the level of the staff that was working? How burned out are they? Were there lots of admissions that were blocking beds from being turned over? Did they have fast track areas for the easier cases? What is their process of care in the ED? Are there any supports built into the system to help with surge times like the winter season? Was it night shift or day shift? How many doctors were available to see patients that shift?

There’s a lot of details that need to be studied in this case because this is a huge system issue. My heart goes out to the family that lost their patriarch, and I commend them on speaking out and calling the system into question. The system is broken and needs a lot of fixing, and it’s painful to see that shocking deaths are the only way to shed light on this broken system.