r/emergencymedicine • u/Repulsive_Knee1304 • Jul 24 '25
Advice Missed PE, patient died
Throwaway account as to be expected.
I had a younger obese smoker male patient come in recently for shortness of breath that was exertional in nature, he said it started after he recently started working out. Patient was a smoker, 1/2 pack a day. SOB Resolved upon rest. patient states that he was carrying some heavy containers at work today, and noticed the shortness of breath again. No chest pain. No diaphoreses . No fever. No lower extremity swelling. No recent uri. Perc negative. Low pretest probability. Physical exam was significant for an expiratory wheeze, diminished sounds at bases. Patient got Breathing treatments, steroids and felt better. Reexamination showed improved aerations. Patient was discharged on steroids, albuterol. EKG NSR rate of 74, t wave inversions in v1-v3. No inversion in lead 3. No st changes. Cxr portable showed poor inspiratory effort, cardiomegaly( rotational?) but read as normal by radiologist and myself. Completely stable vitals. O2 sat of 95%, no tachy. No chest pain. Sob got better. Perc negative. Patient died at home 2 days later. Someone said PE. My guilt is consuming me. How fucked am i
EKG- S1,small q3. No t wave inversions in III. So no t3. Sinus rythym rate of 74 Qrs 88. Upright axis V1-v3 t wave inversions. No previous to compare to
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u/leemteam1 Jul 24 '25
Sucks but also have zero reason to suspect PE in this one. Not fucked at all legally, not sure how anyone could argue in a PERC negative pt that you committed malpractice
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u/enunymous ED Attending Jul 24 '25
I agree with you, but did you see this?
https://www.reddit.com/r/whitecoatinvestor/s/DxRoIZzkKJ
Seems like we're on the hook no matter what we consider or document. The problem is that almost every clinical decision rule has some element of subjectivity to it... The plaintiff's expert will just say, PERC doesn't apply bc the pretest probability wasn't low. Or some such BS
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u/Plumbus_DoorSalesman Physician Jul 24 '25
Basically medicine sucks in America for everyone involved except lawyers
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u/GreatMalbenego Jul 24 '25
Take a listen to the podcast “Doctors and Litigation: The L Word”. One of my big takeaways is that if it’s gonna happen, it’s gonna happen and has literally nothing to do with whether you did the right thing or not. You can have been overly cautious, followed standard of care as in your case, or not even been the proximate cause (or missed dx) of the harm. So be nice, laugh with your patients, document tactically, and know first steps if served.
OP, Did you give it a second thought when you clicked discharge? If not, then it sounds like in your heart of hearts you did what you thought was right for the pt with the info you had. PERC is designed with an “acceptable” miss rate of 1-2%. Most of us have probably used/documented it at least one or a few hundred times. We’ve all inevitably sent home badness. 100% catch rate is an admirable goal, but not possible. I’m trying to learn this myself. But fuck it’s a bitch of a lesson.
OP I’m sorry to hear about the bad outcome. Death after discharge is heart wrenching. It makes us feel worthless as docs. It’s virtually impossible not to beat ourselves up about it. I’m really sorry. Please don’t drink too much these nest few days/weeks. You aren’t worthless. You have helped, healed, and caught way more than you’ve missed.
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u/MrPBH ED Attending Jul 25 '25
1-2% miss rate for all PEs. So a lot of those 1-2% of PEs missed by PERC will be small and inconsequential. Those are the PEs where the patient will probably have time to return if they get worse.
The miss rate for large, hemodynamically significant PEs is rather low. Partially because the incidence of large, hemodynamically significant PEs is low to begin with.
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u/Nearby_Maize_913 ED Attending Jul 25 '25
Every NOI should start with "you were unlucky enough to be working on the day..."
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u/Nightshift_emt ED Tech Jul 24 '25
Absolutely agree with you! I went down this rabbit hole in PA school and realized there are just situations where whatever you do, they may get you anyway.
Everyone seems to think getting the patient to sign a cute hospital refusal form or putting their words in quotations in the chart is some sure way to avoid being involved in a lawsuit.
I have read about many cases where the physician was absolutely in the right but lost the lawsuit anyway. Welcome to America where a jury with 0 medical expertise will decide your fate. I even know EM physicians who got dragged into a lawsuit for a patient they transferred to another hospital…
Note: Im not a lawyer or an expert on this by any means. Feel free to correct me if I said anything incorrect here.
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u/skywayz ED Attending Jul 25 '25
I think it’s all bs, and this case should be thrown out because this patient has his outcome 13 days after his ER visit.
That being said, I read his MDM it just is kinda contradictory, you can’t say it was reproducible with palpation, and then in the same sentence say it sounds more pleuretic and is worse when he coughs and breaths, but I doubt PE. That should raise your pretest probability a little bit… like I said though, complete nonsense as the timing does not line up at all.
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u/Movinmeat ED Attending Jul 25 '25
Eh. I’ve defended and won a lot more cases like this. Runaway juries happen but we win these (and worse cases) a lot more than we lose.
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u/ProtectionPolitics4 Jul 25 '25
PERC negative won't save you unfortunately. A negative d-dimer will though.
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u/Successful-Tone-548 Jul 24 '25
PGY 32 here. I've come to have great respect for isolated SOB that isn't clearly decompensated asthma or COPD. The dd for SOB has a greater breadth than for chest pain. I go on fishing expeditions when I encounter that, especially in young adults. One case that comes to mind was a pudgy 32 year old man who started feeling mildly SOB sitting at his desk. Nothing else. No risks for anything. Normal vitals and exam. I ordered a CT because it didn't add up. He had a large aortic aneurysm. Air shipped him to a university medical center that successfully grafted it. Saved a life. Four months later when I was working the ambulance brought in a man in full arrest. He was DOA. I recognized him. It was the guy with the aneurysm.
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u/Historical_Box9654 Jul 24 '25
I agree with your take that unexplained dyspnea is a red flag- but how is an unruptured aneurysm related? Unless causing mass effect or something…
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u/cosmin_c Physician Jul 25 '25
It was probably either mass effect or an actual incidental finding and his initial SOB was caused by something else (?random arrythmia) which eventually killed him, hell knows at this point.
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u/circular159 Jul 25 '25
100% agree. Isolated SOB can be super deceptive and the ddx is way broader than we usually think. Sometimes you just gotta trust your gut when things feel off, even if the workup doesn’t scream red flags.
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u/Xeron- Jul 24 '25 edited Jul 24 '25
The T wave inversions could be problematic. In residency we had an expert witness attending who specializes in PE cases. Especially if there's V1-V3 inversions that are new, they should always make you think PE as it's a sign of right heart strain and as I recall his lecture much more sensitive and specific that S1Q3T3. Hard to say how it would go if it goes go to court, cause they were Perc 0, but remember that doesn't mean it's 0% PE probability, especially if there's signs pointing at PE in a patient with unexplained dyspnea.
That said, this is a missed diagnosis we can all make and probably many of us would. This is the case we have nightmares about. I may not know you but I can tell you care, and that means something. Learn from this, but do not let this define you. You have saved hundreds if not thousands of lives. You have made hundreds of hard to make diagnosis and made a huge difference in their lives. This is what we do. We are not perfect, all we can do is our best and move on to the next patient. Keep trucking, and keep you head up
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u/the_silent_redditor Jul 24 '25
PERC 0 and alternate diagnosis that responded to therapy.
No way I would have done anything differently, and I think that’s reasonable.
I think if this goes to court, unfortunately there will probably be some BS blame attribution as PERC isn’t 0% probability (which leads us to as why we even use it if it’s going to end up biting you in court..) and due to ECG changes.
I’ve seen a PERC 0 PE, but he had a tiny wedge opacity that could be seen on plain film, so it was picked up by that. He could have easily presented before infarcting and I woulda sent him home.
I use PERC every day in work; I will continue to do so, as should you. It sounds like this is still not confirmed anyway, I’d wait till you hear more.
What you did is reasonable and folk investigating beyond this would be over-investigating.
It’s shitty, but you lose some. Part of the job.
Also, this guy could have gone home, felt very lethargic and shitty from his viral illness and lay in bed for 48hrs+, developing a PE.
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u/Xeron- Jul 24 '25
100% agree that it shouldn't dissuade PERC. Honestly I would have made the same choice and disposition OP did. You're right though, I somehow missed the wheezing on initial exam, so not unexplained dyspnea
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u/No-Football-8824 Jul 26 '25
This case itself might not dissuade perc but that medmal case certainly does. Perc negative discharged died of a pe, family awarded 10 mil, 4 mil owed by the ER physician. Things have to look perfect for me to use perc now. Abnormal labs of any kind, CTA chest.
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u/Xeron- Jul 26 '25 edited Jul 26 '25
One of my attendings was the main author behind PERC. It's important to remember that PERC is used in conjunction with gestalt. If you read the article and follow up interview with the jury foreman that was what was lacking. The patient had a pleuritic chest pain and clear right sided heart strain on EKG. There's no mention of it in his note and the foreman makes it clear that they found it striking that the ER physician failed to explain the EKG changes in any way, even after the fact in court. Having had lectures from Kline and worked with him on shift, the gist of what I learned from him is that you can't use PERC in a silo and ignore evidence that should push you to consider a PE. One of the biggest things he stressed in his lectures was that he doesn't want any resident that trains under him to ever not be able to recognize right heart strain patterns on EKG. I use PERC, Wells, and YEARS all the time on my shifts. But the second I see something of right heart strain that I can't explain as chronic or otherwise explained then I do not use PERC and move to Wells, YEARS, and Age Adjusted. Imho these cases are a reminder that we're physicians, and that using any decision tool comes after first being a physician. So in essence, I 100% agree with you. If something is off and could point towards a PE, don't ignore it!
OP if you're reading this, I want to stress that I don't want you to freak out from this other case. Yes, I would imagine this will get brought up if your case goes to court, but your case has asthma and asthmatic changes on exam, obesity (OSA) and as a result a foot to stand on for right heart strain on the EKG
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u/Queasy-Reason Jul 24 '25
https://expertwitness.substack.com/p/death-after-ed-visit-for-covid
Similar case went to court and the plaintiff won.
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u/cosmin_c Physician Jul 25 '25
These are sad cases that I don't think doctors could realistically catch following the regular procedures.
Then again, I may be a complete idiot, but for me personally TWI V1-V3 as well as DIII & 97% SpO2 in a 21 year old for me personally is absolutely grounds for CTA, albeit I'd have to sell it to Radiology. I have had patients with normal DDimers which had proper DVT demonstrated on Doppler.
Then again OP said TWI were only V1-V3, with normal DIII. Then again, his patient had sats of 95% in the context of being a smoker and obese - and whilst it isn't uncommon to have slightly lower SpO2 in this case (my own sats went from 97% to 99% when I quit smoking and lost a little weight), 95% is a bit low for a younger person who only smokes half a pack a day and would warrant further fishing - but this is a flag that I personally made for myself going through experiences like "why tf is this attending ordering all these tests" -> "oh, shit".
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u/BrobaFett Jul 25 '25
That's because malpractice cases have nothing to do with whether or not medicine was practiced correctly.
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u/shookwell Jul 25 '25
Agree - TWI in lead v1-v3 always make me think right heart strain and possible PE if the clinical scenario fits. Although the argument can be made that this finding is more sensitive and specific than S1Q3T3, the numbers are pretty similar. In this case there are other reasons for right heart strain so the findings are probably even less specific.
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u/BrobaFett Jul 25 '25
>Especially if there's V1-V3 inversions that are new
Can we assume they are new? Also, aren't V1-V3 inversions a variant of normal in young individuals?
Perc is 98% NPV, IIRC.
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u/DrS7ayer Jul 24 '25
I almost wonder if the perc rule needs to be re-validated in the post-covid, obesity epidemic world we live in. I too have found some “perc negative” PEs
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u/thehomiemoth Physician Jul 24 '25
I mean doesn’t PERC just mean <2% chance? We should all run into a couple PERC negative PEs in our career
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Jul 24 '25
[deleted]
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u/No-Football-8824 Jul 26 '25
Right but we are incentivized to order additional testing because it's unlikely you will get blamed for lung cancer down the road 2/2 a CTA as apposed to blamed formissing that one PE and patient dying within a week of you seeing them in their Ed.
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u/Baba-Yaga-X Jul 24 '25
How did you find them? Do you scan or d-dimer PERC negative patients? PERC negative, no alarm signs: I’m done.
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u/Crunchygranolabro ED Attending Jul 24 '25
I like to think of decisions rules more of guidelines than some iron set of laws that must be obeyed.
For PE, the biggest issue that to use PERC requires patients to be low risk, and low risk by wells, Geneva, etc, relies at least in part on gestalt. If some part of my brain is saying that something seems off, it’s worth listening.
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u/mjjacks Resident Jul 24 '25
Could you clarify that for me? I (and the bulk of my coresidents) use Geneva explicitly because it does not include gestalt like Wells does. Do you mean using the tool in the first place would be predicated on your gestalt that the patient needs to be risk stratified in the first place?
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u/Crunchygranolabro ED Attending Jul 25 '25
Good point on Geneva. I take issue with it because in the lowest risk group incidence is <7-9% which isn’t adequate.
Adding PERC to that is partly redundant as there’s multiple aspects (HR, hemoptysis, surgery/immobilization, prior VTE, unilateral leg swelling) which overlap. You really only get a slightly more granular stratification by age (50 vs 65) and hormone use. If there are robust studies suggesting that those 2 aspects +geneva is adequate to bring incidence to <2% I’d love to see them, but it doesn’t pass the sniff test
So at the end of the day we’re still relying on something that isn’t explicitly defined by any one scoring rule.
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u/Ok-Bother-8215 ED Attending Jul 24 '25
Just so you know, PERC is for those whose pretest probability is less than 15%. Which means you ought to risk stratify with say Wells BEFORE you apply PERC rule.
People always miss this part. It’s not just PERC neg then no PE.
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u/Baba-Yaga-X Jul 24 '25
Look, with PERC you have a 2% false negative rate, so you will miss some PE’s. Therefor, only in low risk patients should the PERC rule be used. Wells is heavily dependant on gestalt, and needs a d-dimer. My practice is a combination of PERC and gestalt.
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u/Ok-Bother-8215 ED Attending Jul 25 '25
Using Wells does not need a dimer. Wells is a stratification rule that gives pretest probability. You don’t need a dimer to use wells and PERC.
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u/the_silent_redditor Jul 24 '25
I use PERC every day.
The one PERC 0 PE (that I’ve picked up) had a tiny wedge opacity on CXR.
Dimer was super high and the CT showed bilateral PE with radiological strain.
Had that dude presented prior to infarcting, I’d probably be making this post myself as I would have 100% sent him home without Dimer/CTPA.
Can’t win them all.
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u/StupidSexyFlagella Jul 24 '25
I don’t disagree with your overall point, but of course there are perc misses. Just like there are heart score misses. It’s the nature of these things.
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u/KingNobit Jul 24 '25
Perc will put it at less than 2%. Maybe you've just had enough volume to see it?
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u/MocoMojo Radiologist Jul 24 '25
Was the somebody who said it’s a PE a pathologist who did an autopsy?
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u/Repulsive_Knee1304 Jul 24 '25
I was told by an ED staff member who remembered the patient and pulled up the obituary. No confirmation. Patient died at home 2 days after discharge. Patient most likely had an autopsy
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u/Comprehensive_Elk773 Jul 24 '25
It is not yet time to be worried legally. I’m sorry you are going through this. It sounds like you gave the patient all the attention that was indicated by their presentation. You can’t catch every problem every time.
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u/20thsieclefox Jul 24 '25
I work at a medical examiner's office. They would have done an autopsy on someone young and probably pulled toxicology. The results of that could take a while to get back. If the pathologists saw a PE or anything natural during autopsy they may have ruled/signed the death certificate out already. Depends on the pathologist.
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u/thomasblomquist Jul 25 '25
Am a Forensic Pathologist lurking here. Yes, death shortly after hospital discharge for what is otherwise stable disease in a young person <50-60 is automatic autopsy. Also, PE at autopsy, if impressive enough (e.g. saddle with ramifying branches) will be easy to sign final DC with pending Tox (but usually the results won’t change the top line of part1). My guess is ME office gave feedback.
Now! Some words of advice. Thrombi propagate at ridiculous speeds. It’s very probable he had mini PEs with no major impact on heart strain during initial visit but enough to be periodically symptomatic. And later threw the big one. Clinical Interpretation is Even harder because of the lungs collateral circulation which can make interpretation of vitals fraught with pitfalls.
Now for the legal advice. IANAL but I deal with lawyers regularly. It always comes down to a battle of experts. It’s harrowing the first time going through the experience. Vast majority of cases are never litigated. This is what malpractice insurance is for. Let the lawyers deal with the machinations of these things while OP focus on doing a deep literature dive so we can catch it in the next patient.
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u/Fun_Budget4463 Jul 24 '25
Keep going. Keep practicing medicine. Tidal forces. The ebb and flow. It’s a long career and not the only or worst miss you’ll have.
Emergency Medicine is like being a rail yard switch operator. 20,000 ton freight trains barrel through at top speed. They are loaded with car upon car of saturated fats, nicotine, sedentary lifestyles, and genetics. Your job is to try to switch those trains onto slightly longer tracks. But they will all, ultimately, end up at their final destination. Do your job. Do your best to help them. But mostly, don’t stand on the tracks.
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u/EbagI Jul 24 '25
If you've never missed a PE, one of two things is true, maybe both.
You haven't been in the ED long enough.
You're too shit of a clinician to realize that you've missed a PE
It's the name of the game. It happens.
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u/karleksbarn Jul 24 '25
Swedish attending. I've had worse misses, as have most of us.
T-wave inversions in v1-v3 is pathognomic for acute rv strain and should raise suspicion for PE, along with other common ecg changes.
Take it with you, learn and spread your experience.
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u/ExtremeCloseUp Jul 25 '25
Not pathognomonic, what about Wellen’s? Or apical HCM?
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u/karleksbarn Jul 25 '25
Of course you are correct that that both Wellen's, HCM, a past MI as well as several other clinical conditions can produce similar ecg findings.
I should have amended it to very pathognomic in the clinical setting of dyspnea.
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u/Wahrnehmung ED Attending Jul 25 '25
V1-V3 inversion is nonspecific and absolutely not pathognomonic
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u/karleksbarn Jul 25 '25
Yes you are correct that anterior T-wave inversion by itself is non-specific. As noted in a follow up post it is highly pathognomic for rv strain and PE in the clinical setting of new onset dyspnea.
Would you argue with this?
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u/code_blu1 Jul 26 '25
I can argue that no ekg finding is pathognomic for any acute heart disease. To me it’s a misnomer lol
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u/Throwawayyawaworth9 Jul 24 '25
I’m sorry you’re feeling so much guilt over this— it’s a very hard emotion to work through.
This patient does not read as a PE— I suspect this would have been very difficult to catch.
You did an appropriate workup. You did the best you could. Sometimes things will be missed. We are human after all.
However, I doubt that anything we could say here can completely alleviate your negative thoughts. Do you have a therapist or anything you can talk this through with to help cope with your feelings of guilt?
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u/hungryhungryHIPAA Jul 24 '25
I always do an ambulatory pO2 on these patients and if they do well then no more work up. I’ve had people surprise me with their ambulatory sats when they look so good on a stretcher. That would be my only change but it’s so easy to Monday morning quarterback. We all have our stories like this. Try not to guilt trip yourself.
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Jul 25 '25
[deleted]
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u/efunkEM Jul 25 '25
The plaintiffs bar is really good at advertising their side of med mal cases, showing how they won trials, etc… Defense needs to step up their game and start getting PR out about all their victories.
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u/Ineffaboble Jul 24 '25
It sounds like they would be wells 0 perc negative. I understand your devastation, no one ever ever ever wants a bad outcome for a patient, but I don’t see any deviation from standard of care and I can’t imagine you catching heat for it.
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u/ImmediateYam9792 Jul 25 '25
Did you miss it? Yes. Did you practice reasonable medicine? Also yes. The human body is not a car, biology is complex. You are clearly an empathetic person because you feel bad. However you must find a way to adjust your expectations for yourself. The goal in this field is not to miss a diagnosis, it is to practice reasonable, empathetic medicine in an unreasonable system with a society that (occasionally) has unreasonable expectations.
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u/dajoemanED Jul 24 '25
PERC and Wells scores of zero, normal vital signs, low pretest probability, and everything you did was according to standard of care. Plus, you don’t know that it was a confirmed PE. What you did here is what pretty much any of us would have done to the letter in the same situation.
Remember, a bad outcome does not necessarily mean bad medical care. If indeed this was a PE, there doesn’t seem like there was a thing you could have done about it.
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u/Haldol4UrTroubles Jul 24 '25
Seems like you didn't deviate from the standard of care. Imagine if you CT scanned every single patient who presented the way this one did. You would be accused of being too liberal with your radiation and causing cancers down the line. There has to be an acceptable miss rate, otherwise we would be CT scanning or admitting every single patient that presents to the hospital.
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u/Haldol4UrTroubles Jul 24 '25
This is also why we are liberal with our return precautions listed on the patient's discharge instructions, whether or not they are willing or able to follow those instructions is out of our control.
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u/SpicyMarmots Paramedic Jul 24 '25
Two days later? It's entirely possible that the patient was in fact just wheezy from smoking+manual labor when you saw him, went home, and then had a PE.
I'm not a doc so I'd be happy to be corrected if this is wrong, but my instinct is that it seems super unlikely that he'd see you, feel better from your treatment plan, and then walk around for two more days with a PE large enough to ultimately kill him. Surely he would have come back (or decided to seek care at another facility) the next day if he started feeling worse again?
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u/Alternative_Ebb8980 Jul 24 '25
They just had a case about this on r/hospitalist:
https://expertwitness.substack.com/p/death-after-ed-visit-for-covid
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u/VertigoDoc Jul 24 '25
https://www.reddit.com/r/medicine/comments/1luvcgf/pe_death_after_covid_visit_med_mal_case/n21zn7s/
I made a comment about a missed PE on r/medicine on the above link about two weeks ago. I think this comment still stands. SOB on exertion, his sat is 95% (lower than this now elderly doc has ever had) and he wasn't walked around to see what happens to his sat when he exerts himself.
Not saying that it wouldn't be easy to miss OP's case, but it might be something to think about in future patients.
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u/memedoc314 Jul 24 '25
Can you share more about your thoughts on EKG findings?
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u/Repulsive_Knee1304 Jul 24 '25
S1, small q3. No t wave inversions in III. So no t3. Sinus rythym rate of 74 Qrs 88. V1-v3 t wave inversions.
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u/MedicTech Paramedic Jul 24 '25
S1Q3T3 is neither sensitive nor specific and is the wrong thing to be looking for. This has been removed from common teaching tropes on PE for years now because it was leading people down an unhelpful path with that one mnemonic being what everyone remembers.
Sinus tach, RV strain pattern via t-wave inversions on right sided leads, RAD, RBBB (complete or incomplete), terminal R in aVR, etc. all more pertinent findings. Essentially all indicators of right sided dilation or strain. LITFL post here.
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u/KimPossibleDO Jul 24 '25
V1-V3 inversions with no baseline to compare to I would’ve considered abnormal. If NOT new from baseline I would’ve done the same workup. If it’s new or no known baseline- probably playing the dimer game on this patient.
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u/MedicTech Paramedic Jul 24 '25
I agree with that assessment. From what OP described the ECG isn't a smoking gun here, I'll let the docs discuss the rest of the workup because that's outside my wheelhouse.
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u/tablesplease Physician Jul 24 '25
I read a recent medmal case of a kid dx with covid who died of a pe a few weeks after ama? The selling point was t wave inversions in the anterior leads. Something I need to read more about.
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u/NeisAEL Jul 24 '25
Now I'm just a medic, bear with me.
AFAIK Precordial t wave inversions, esp v1-v4, can be signs of right ventricular strain associated with high pulmonary artery pressures, according to LITFL.
Ive never had a prehospital PE patient with abnormal ECG findings so I don't know how sensitive/specific these findings are. If I see patients with SOB and precordial t wave abnormalities I always try to rule out PE as best as I can. Maybe someone with a higher degree can clarify how sensible that sounds
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u/thatlooksinfected_ Jul 24 '25
Yes agreed. As a Paramedic every confirmed PE patient I’ve seen had none of the noted EKG changes apart from sinus tachycardia
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u/B52fortheCrazies ED Attending Jul 24 '25
Agreed. In residency they would always remind us the most common EKG in PE is NSR (> 50%). The second most common is sinus tach and/or non-specific S-T changes (40% - 50%). The s1q3t3 and the precordial TWI are only ~30%.
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u/drjhustle ED Attending Jul 24 '25
Sounds like you did nothing wrong and provided perfectly reasonable medical care. It’s ok to feel bad for the patient and their family but that doesn’t equate to the need to feel guilty that you made a ‘mistake’. You didn’t.
PERC negative means <2% risk of PE. It may be counterintuitive but it’s ok and GOOD MEDICAL CARE to miss up to 1 in 50 PEs, as you will do more harm to more patients in terms of overinvestigation and overdiagnosis trying to chase down the elusive final 2%.
T wave inversion in V3, especially <1mm as in your patient, wouldn’t have triggered me to go PE hunting. Depending how young the patient was it could be a persistent juvenile pattern. Or given he was obese and a smoker it could be pulmonary hypertension secondary to lung disease or OHS/OSA. I wouldn’t have done anything more than mention it to him and have him follow up with his primary care doctor for further investigation if his symptoms persisted.
Those replies saying you could have or should have done anything differently are heavily influenced by hindsight bias and should be taken with a grain of salt.
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u/BrobaFett Jul 25 '25
PERC negative- already <2% pre-test probability
Wheezing- not a feature in most PE (~5-9% at most) and the pathogenesis of wheeze in PE is not clearly understood (very likely secondary to other concomitant causes of wheeze)
Diminished breath sounds- the most non-specific exam finding in the history of exam findings. I care about "diminished" breath sounds, as a pulmonologist, as much as a general surgeon cares about bowel auscultation
Got better with albuterol and steroids- PE doesn't get better with albuterol (steroids take longer)
ECG findings- Eh... maybe? Still, in a patient with so few symptoms that's an outpatient Echo in every shop I've worked at.
Died but we don't know why- OP, please.
Being 98% certain means you are still wrong 2% of the time. This is why you give return precautions. This is why you say things like, "It could be this, this or this but the tests aren't suggesting this". Let me put it this way, OP, unless there is something utterly incongruent with what you are reporting and what happened; I wouldn't hold this against you if it were my family member as the patient. We cannot expect perfection, especially when it's unreasonable to assert that perfection would have changed this patient's outcome.
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u/NOCnurse58 RN Jul 24 '25
First, unless that someone was a coroner take it with a chunk of salt. It could easily be conjecture. Plus two days later there are any number of other factors that could have come into play.
You treated the patient for his presentation and his symptoms improved. If symptoms returned or new ones developed it’s on the patient to seek care. It’s normal to wonder if you missed something but I think you’re fine.
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u/esophagusintubater Jul 24 '25
I wouldn’t have even ordered labs. Probably got a PE after he was discharged based on what u described
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u/RoughTerrain21 Jul 24 '25
Most concerning thing you said was exertional SOB and O2 of 95%. Exertional SOB gets admission for CAD, ambulatory pulse ox for asthma/COPD exacerbation and then admission based on that. With O2 of 95% ambo pulse ox would've probably allowed the pt to get admission for acute hypoxic respiratory failure. You live and you learn.
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u/phattyh Jul 24 '25
No tachy. Perc negative. “Someone said PE”. Gtfo. I’ve done studies on PE and risk scores. I’m so perplexed why people do this to themselves. Don’t think how “f-ed am I”. There are so many other things to be worried about in general and it seems like you did a good work up. I will say everyone gets so jazzed about the old school PE ecg findings - but in reality, the most SPECIFIC sign for PE on ECG are flipped T waves in anterior and inferior leads.
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u/Specific_Macaroon921 Jul 24 '25
"Someone said PE."
More like "someone said maybe he had a PE?" How can you know until an autopsy is done? Dead bodies don't have signs floating over them saying "PE" or "STEMI".
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u/Fit_Bodybuilder2295 Jul 24 '25
No judgement. Just for my learning. I’m curious as to why you ordered an EKG on someone who you thought had asthma for this particular patient. I feel like you had a feeling something was off with his presentation? Also, I think someone with a sat of 95%, it’s borderline for PERC rule out? There’s definitely no right answer and that’s a tough case!!!
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u/triDO16 ED Attending Jul 25 '25
Sorry you're dealing with this, OP. As others have said, would take it with a grain of salt unless an autopsy had been done as you can't be certain it was a PE that you missed. I also don't think you strayed from standard of care, either, based on the info provided.
Two points of suggestion that I have routinely added to my dyspneic patients, especially young ones: bedside echo and ambulatory pulse ox. I have caught a legitimately non-zero number of new diagnosis HFrEF with massively reduced EFs (like <20%) in these cases and they're not that hard to do. Ambulatory pulse ox also helps me catch people who look great and are satting fine who all of a sudden don't look great and aren't satting fine while walking.
Lastly, hopefully as a point of comfort, let's say you did diagnose this patient with a PE. It clearly wasn't hemodynamically significant so I doubt their clot burden would have been huge. He's someone that could probably have been started on apixaban and discharged, at most obs overnight for formal echo +/- lower extremity US. He still may have died 2 days later even in that case. I have also had a non-zero number of patients diagnosed with PE, admitted on heparin, discharged on apixaban and bounced back 2-3 days later in cardiac arrest. PEs are horrible. And sometimes even when you do all of the things perfectly (not saying you even didn't in this case) people still die.
Medicine is imperfect. Learn what you can from this case, but don't beat yourself up about it.
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u/Broguest_Squadron ED Attending Jul 25 '25
Only thing concerning in this history are the TWI in V2-V3, really. Otherwise no issues with care from my viewpoint. Not sure the TWI alone would have prompted me to do anything different with the perc negative and good vitals.
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u/InquisitiveCrane ED Resident Jul 24 '25
I think this is just an example of how following criteria can fail you and should just follow your gut. Not your fault, you did your job, you can never know for sure.
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Jul 24 '25
[deleted]
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u/No-Zookeepergame-301 ED Attending Jul 24 '25
This EKG is not worrisome for PE.. it's pretty normal
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u/violentsushi ED Attending Jul 24 '25
It’s ok to feel bad. I argue it’s a good thing. We learn best from our mistakes and it makes us better. More importantly it means you empathize for and take responsibility for your patients. Don’t lose that core.
My advice is to stay grounded not on what you could have done but what you might do next time. Are you going to CTA everyone despite a negative perc? Are you going to admit every HEART 0 TIMI 0 patient? Probabaly not.
Might you take a second before dismissing an otherwise well appearing nonspecific chest pain? Sure. But don’t collapse into a black hole of self doubt and risk avoidance. It does no one, not you or the patient, any good. Treating future patients as liabilities is part of the rot in modern medicine.
You’ll remember the misses and they will haunt you but you’ll do immeasurable good in countless small ways that no one will thank you for between those cases.
Ground yourself in the good and the mission. Take some time for yourself. Tell someone about how you feel. The get your head back in the game we need you on the front lines… they’re starting to stack up in the waiting room again.
Cheers.
Edited for typos. Sorry on the pooper between patients.
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u/InitialMajor ED Attending Jul 24 '25
I’m pretty sure obese patients were excluded in the PERC patient cohort. Going from memory here.
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u/InitialMajor ED Attending Jul 24 '25
To clarify - no issues with the work up in general - would be low risk for PE regardless.
Also “someone said PE” - unless there was an autopsy that’s just someone else guessing.
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u/Commotio-Cordis ED Attending Jul 24 '25
You didn’t do anything wrong. You can’t work up PE in everyone, and by the sounds of this case you had a good alternative explanation for their symptoms. To be liable they need to prove negligence - and there was nothing negligent in your care here.
These cases are though. You’re going to feel bad and that’s normal. In ER we see so many people that occasionally bad things will happen to people we discharge.
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u/Ketamine_Cartel Ground Critical Care Jul 24 '25
I won’t be as up to speed as you and others in here on some of the diagnostics and current practices. That being said I’ve had a few misses over the years. Try as I might to do a good job I am only human. At the most basic level I’ve always been told that the first symptom of PE is resting tachycardia then SOB. You already described confounding factors. That’s never a great feeling when you see someone and they die later but the mathematical probability of it happening to you just increases with every year that goes by. I’m not in the least a Monday morning quarterback, just know that it does suck, but it unfortunately does happen. Sometimes there’s no reason or rational for it and no fault to assign. Don’t beat yourself up too bad.
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u/Johndowboy Jul 24 '25
D-dimer ?
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u/MisChef Jul 25 '25
shows up in blood after a clot
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u/Johndowboy Jul 25 '25
You are correct it’s a cheaper option we ordered them with any SOB upon exertion
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u/Maveric1984 Jul 24 '25
As a coroner, rumors run rampant. I have been involved with major homicides and it's interesting to read the direction that people start to pull. Until there is a PM and a coroner to call you, I would not assume.
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u/Yololvling Jul 24 '25
Insane case, don’t blame yourself too much. Hopefully documentation holds up here. I will say to harp/expand on some of the other comments t wave inversions in V1-V3 esp in v1 with no prior should raise an eyebrow slightly in the right clinical context. Super scary though, makes getting the dimer seem more useful just for legal purposes
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u/No-Football-8824 Jul 24 '25
I've been reading medmal cases and yes I read the one about the negative perc (not documented in the chart though) and the family died and won 10 million. Now imagine you only have malpractice for 1 mil. Technically they can go after your personal assets.
We absolutely need tort reform because it's pretty obscure and we use the clinical rules we were given and still can be wrong.
Sadly it seems like best practice is to CTA a hell of a lot more SOB patients. One could even argue a negative d dimer wouldn't protect you in a lawsuit. Sadly it just means more radiation.
A lot harder to prove that you caused their cancer 20 years down the road when they got scanned 10 times than it is if you miss that one PE because you didn't scan when you could have.
I wish you the best and hope this doesn't result in a lawsuit. Sometimes that just depends on the family and if they have the economic support to continue to pursue a case with lawyers and whatnot.
Hopefully it doesn't end in a lawsuit but if it does settle within your limits imo at all costs. Nothing worse than them going after personal assets.
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u/Gratekontentmint Jul 25 '25
You had me at PERC negative. As one colleague said, if you play the game you run the risk of getting hit by the ball. These cases happen. You didn’t make him sick. You did the appropriate work up. Try not to ruminate. Talk with your work buds. Get outside.
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u/Silent_Law6552 Jul 24 '25
People die everyday. ER nurse for 26 years. If it’s their day to die, nothing we do is going stop it. If it’s not their day to die, can’t really kill them. Motor on. Save lives
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u/4QuarantineMeMes Paramedic Jul 24 '25
Always a good chance he threw the clot after discharge. Can’t miss it when it wasn’t there when you treated them.
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u/Simonmoine Jul 24 '25
If it’s a EP, it’s not your fault. Could have happen to anyone here. Only a bad doc would have Done more. Overinvestigation is a serious problem too. It’s easy to Say (your chief doc) that you miss something the truth is : it happen sometimes you had bad Luck; your patient is an anomaly
My advise; try not to think about it for at least one week; watch tv, do sport etc you’ll see it’ll be less painful in a week
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u/spcmiller Jul 25 '25
Thank you all for your discussion. I have learned some here. Sorry for the loss, but maybe it wasn't you at all, OP.
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u/NotAnAltSmurf Jul 25 '25
Is the take away to order dimer on every sob patient despite perc negative
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u/code_blu1 Jul 26 '25
Wells and PERC rules are not perfect and will miss some PEs. I don’t know why, but smoking and obesity were not included in the the criteria. Don’t rely on these on every patient. I will list every risk factor in a patient with dyspnea in my differentials to rule out PE or ACS
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u/No-Football-8824 Jul 26 '25
Can't rule out a PE without the CTA. You can argue it's extremely unlikely but that's not enough in a court battle when the pitch forks come out
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u/Patient-Rope-4053 Jul 27 '25
This happen to my daughter . All new nurses on the flour & no crash cart . I had to orient her while I was working & told her to find another job . I told her the next time how to make sure a crash cart is on that floor start of shift & get order for BNP next time if patient is complaining of those symptoms what cardiac labs and tests she needed & include a BNP . Happened her next shift , patient was saved went to ICU . She said they wanted to “ how did you know to order BNP “. She didn’t tell them . She did resign & found a hospital that gave her 8 weeks of orientation, they were glad to have her . This was during the time we switch from paper charting . She also had a computer technology degree , they hired her in with a nice hourly wage .
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u/Sv747 Jul 28 '25
In all practicality, has anyone ever seen a PE with a HR < 100? Especially if the patient isn't on any rate limiting drugs. Also, the lack of POCUS/2D ECHO in a SOB patient isn't sitting well with me.
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u/DrBusyMind Jul 28 '25
Recently, I had a patient in their 30s with epigastric a/p and vomiting. CT ap showed possible vascular defects in lower lobes. CTA confirmed bilateral PE. Strangest PE find ever. Even stranger is that when I was explaining my flabbergastedness to the admitting doc, they told me a personal story of a relative with the exact same presentation who unfortunately died after being diagnosed with gastritis. The point is that we're meant to be really good at pattern recognition so we can maximize the amount of badness we catch. We can't possibly reinvent the wheel with every patient, especially when they're so far outside the imaginable pattern of presentation, or even the atypical variants of presentation. As a fairly young attending, cases like this definitely rattle my risk tolerance, but they also add to the database of weirdness to be aware of so I can consider it in other patients in the future.
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u/Livid-Ad-4678 Jul 29 '25
Listen my old man died at work the next day after a stress test he passed. It happens. You can't document a life time of bad food and life choices.
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u/annacooperbooper 8d ago
Not a doctor but literally just went to Urgent Care who kicked me out and said go to ER with back pain, doc gave me all the tests, felt like a guinea pig, ended up with DVT and PE from my recent ankle fracture. Happy they took it serious. I literally thought I just had muscular issues. PE is scary!
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u/jasilucy Paramedic Jul 24 '25
What was their D-dimer levels?
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u/robije Physician Assistant Jul 25 '25
Didn’t order one because he was excluded via the PERC criteria.
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u/Creative_Flow2497 Jul 25 '25
Hey- I agree with all of the previous replies but the information written in this post is very specific so I’d recommend removing it just in case.
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u/ihearttroponin ED Attending Jul 24 '25
"Someone said PE" so you don't even know that it was a PE for sure and you're guilting yourself? If the patient is truly Wells low risk, PERC negative, there was no reason to proceed with further PE testing. Sounds like it could have been asthma/COPD that maybe worsened after discharge