Hey everyone, Dr. Lavranos here – Emergency Physician and Medical Malpractice Attorney. Welcome to this week’s episode of the Acuity Podcast. As always, Acuity is best savored over an indulgent and stimulating caffeinated drink. So grab your favorite fix — a steaming cup of coffee, a refreshing diet coke, a soothing tea, or prepare to get sweaty with a pre-workout and
Let’s. Get. Started.
On the agenda this week we’ll be discussing:
A bit of an introduction of who I am, and the breakdown on education between Medical School vs Law school, and then I’ll do a deeper dive on
Heart Attacks – the medical and legal pitfalls.
To begin with, a little bit about myself. I currently serve as the CEO and Chief Litigator at Acuity Medical Law, a role I’ve held for the last year, where I tackle the intricate issues of medical malpractice and healthcare advocacy more broadly, including political advocacy and administrative law. Alongside this, I’ve been the CEO and Chief Physician at Lavranos Medical Services Inc. since 2017.
My journey in medicine started at Dalhousie University in 2008 where I completed my MD. I went on to my top choice of residency at McMaster University to do my family residency and fellowship in Emergency Medicine. I locumed in Ontario for about a year and a half before returning to Nova Scotia where I have practiced ever since.
In 2020 I retured to Dalhousie Univeristy for my JD, graduating in the class of 2023. During this time, I focussed on civil litigation, negligence and health-care law. I graduated with a Certificate from the Health-Law Institute and articled at a large personal injury law firm, where I helped develop their Medical Malpractice division, before striking out on my own creating Acuity Medical Law. At Acuity, I represent clients from birth injuries, to surgical mistakes, delayed diagnoses of cancer, and mistreatment in primary care.
Everyone always wants to know, why would I change careers after almost a decade of practicing medicine? Well, let me start by saying I love medicine which is why I still practice. Everywhere I’ve worked, I have always been one of the most efficient and respected ER physicians. I’ve worked alongside, and learned from, amazing physicians and nurses.
Initially, I had planned on using a law degree to enter into the healthcare policy world, or advancing into a political role. Maybe doing something in regulation work like at the College. But COVID changed all that. I started to see cowardice and negligence from a lot of physicians, and I became very disillusioned by the lack of expertise and beneficence of the professsion. I started to see the elitism and entitlement of the profession as profoundly negative force in society, and thought that the best corrective mechanism was to hold them accountable, while advocating for patients to have greater individual knowledge and autonomy.
To that end, my commitment extends beyond professional roles into community service. I am a founding member and board member of the Nova Scotia Civil Liberties Association, committed to advocating for civil rights within both medical and legal contexts. I’ve also served on various boards, including those involved in medical admissions, certification, and most recently the foundation of my hospital, with work for national Law Firms and consulting for political candidates.
I don’t want to hoard information, quite the opposite, I feel it is my obligation to teach. I was blessede to receive a prestigious teaching award at Dalhousie University, and lecture about medical malpractice and informed consent. My advocacy for free speech in medicine has been particularly notable, where I’ve addressed the challenges posed by the administrative state. That’s what has led me now, to creating this Podcast.
On that note, let’s move to the next topic today, heart-attacks.
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Part of what I want to do is educate the populace to advocate for themselves about their own healthcare. Today we turn our attention to one of the most critical emergencies known to modern medicine: the myocardial infarction, commonly referred to as a heart attack. As both a physician and an attorney, I’ll discuss not only the pathophysiology and management of this condition but also where medical errors might lurk, potentially leading to malpractice.
A heart attack, or myocardial infarction, occurs when atherosclerotic plaque within the coronary arteries occludes blood flow, leading to ischemia and cardiac cell death. This can compromise both the electrical conductivity and mechanical contractility of the heart, precipitating acute coronary syndromes, which are notoriously deadly due to their potential to cause arrhythmias, valve issues, pump failure, etc.
Let’s delve into the pathophysiology. The underlying mechanism involves plaque rupture or erosion, which cascades into thrombus formation, which further obstructs coronary blood flow. So basically, gunk from a lifetime of blood-vessel debris and damage ruptures, but then your blood cells block up against it forming clot. This cascade of events can lead to either ST-elevation myocardial infarction (STEMI) or non-ST-elevation myocardial infarction (NSTEMI), each with its own therapeutic implications. The difference between these two types is critical because they are managed so differently. The resultant ischemia and cell death then triggers a complex inflammatory and neurohumoral response – that is, inflammation and your own hormones can work against you in these conditions.
What sort of investigations should you expect? Firstly, electrocardiography (ECG) is paramount. The timing and frequency of ECGs are critical; a delay or misinterpretation can be catastrophic. Serial ECGs might reveal evolving changes, indicative of ongoing ischemia, infarction or arrhythmias. Alongside ECGs, cardiac biomarkers like troponin are indispensable. However, the interpretation of these markers requires clinical correlation; an elevated troponin in the absence of a heart attack syndrome might not necessarily indicate an acute coronary event but could reflect other myocardial stressors or even renal insufficiency. The timing of the markers is also critical, because it can take a while for them to rise and to fall, so understanding when you are collecting that data relative to the clinical picture is integral for proper management.
Next, comes treatment – it must be swift and tailored. For STEMI, percutaneous coronary intervention (PCI) or thrombolytic therapy is the gold standard to restore perfusion. NSTEMI management often involves a more conservative approach, stabilizing with antiplatelet agents, anticoagulants, and possibly beta-blockers or statins, with potential for delayed invasive strategy. Herein lies the rub for the discerning practitioner: the judicious use of medications. Beta-blockers, for instance, while generally beneficial, could precipitate heart failure in certain clinical contexts, like significant left ventricular dysfunction or ongoing bronchospasm.
Given all this information, let’s focus on where errors can occur.
Variable Presentation: The clinical presentation of a heart attack can be atypical, particularly in women, the elderly, or diabetic patients. Misdiagnosis as gastrointestinal, musculoskeletal, or even psychiatric conditions is not uncommon. An attorney would scrutinize whether the physician adequately considered less typical symptoms in their differential diagnosis.
ECG and Biomarker Interpretation: Errors can stem from not performing serial ECGs, misreading subtle changes, or interpreting biomarkers out of clinical context. A malpractice case might hinge on whether there was a reasonable standard of care in the timing and interpretation of these investigations and how thorough a history and physical were done to provide necessary context for the investigations.
Medication Management: The inappropriate administration of medications, such as giving beta-blockers to a patient with acute decompensated heart failure or using anticoagulants without considering bleeding risks, can be litigious. An attorney would look for evidence of a thorough risk-benefit analysis before medication decisions were made.
There are no short-cuts to good medicine. Heart attacks are no joke, and their management is fraught with potential pitfalls where medical errors could occur. From diagnostics to therapeutics, each step requires meticulous attention to detail, patient history, and clinical judgment. As both a physician and an attorney, my role is not only to heal but also to ensure that the practice of medicine adheres to the proper standards of care, safeguarding patient outcomes and advancing trust in our medical system.