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

375 Upvotes

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659

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

159

u/WobblyWidget ED Attending Jul 24 '25

there was a recent medmal review on perc/wells negative but ekg changes of RHS and the doc is appealing a 10mil decision for missing PE. this is why I threw out that . the jury doesn’t care. I’d rather have a negative ddimer at this point.

206

u/yurbanastripe ED Attending Jul 24 '25

My plan is to install a CTA chest scanner at the door that everyone entering has to walk through, kinda like a metal detector. Call it the PE detector

54

u/indigorabbit_ Radiology Tech Jul 24 '25

I've said so many times that I need a walk-thru cxr in triage (like a u-arm) because everyone gets one eventually anyway...would save me so much time

40

u/Recent-Honey5564 Jul 24 '25

Everyone gets a urine cup when they check in. I dont care if it’s toe pain, pee in this cup. Always the rate limiter.

13

u/indigorabbit_ Radiology Tech Jul 25 '25

Exactly, I don't ever let my pts sneak off to the bathroom after their xr without a cup in hand

17

u/CertifiedSheep ED Tech Jul 25 '25

You can also hand out oral contrast to everyone who has abdominal pain and asks for something to drink.

1

u/Razz_mattaz Jul 27 '25

radiation is low enough. How are hospital admin/er/efficiency lady not jumping on this.

22

u/yrgrlfriday Physician Jul 24 '25

Lawyers hate this one weird trick!

24

u/pshaffer Jul 25 '25

I am a radiologist who has covered a large ER - 100 beds.
we would do about 100 scans per weekend.
few positive

and very few unexpectedly positive, like your patient.

I don't think scanning every patient who is SOB is a good idea, but I could be convinced otherwise.

Incidentally, I had a friend who died of PE with a similar history to your patient, except, by report from his wife, he was profoundly SOB for some days (also quite overweight) he was early 40s.

18

u/adoradear Jul 25 '25

This is the problem. Most are negative, but sometimes they are unexpectedly and significantly positive. In the ED we’re expected to be sensitive, which by def means a drop in specificity. Which sucks, but it’s the name of the game unfortunately.

6

u/Emotional_Resolve764 Jul 25 '25

Had a patient (not mine) came in for very mild chest pain that already resolved and exertional breathlessness. No ecg changes. Normal HR and sats on RA. Incidentally raised D-dimer so proceeded with CTPA - freaking saddle PE completely occluding R) bronchus.

3

u/Broguest_Squadron ED Attending Jul 25 '25

Agree with you. Very few ED docs seem to understand that the risks of radiation, contrast and false positives greatly outweigh the risk of the missed PE, (when using other appropriate evidence based screening tools such as EKG, D Dimer, Wells/PERC). Greatly over ordered test. Not nearly as specific as many docs think - have seen inter rater reliability numbers as low as 60%.

2

u/pshaffer Jul 25 '25

60% surprises me. I trained in the era prior to CT so when we got it, it was a godsend. No more “low probability for pe” nuc scans. Maybe I trust I too much.

1

u/pshaffer Jul 27 '25

I have had to educate more than a few physicians that the radiation risk of a CT for PE is largely theoretical, where as death from PE is quite real.

Especially true in pregnant patients. dead moms are bad for babies. Scatter radiation to the baby is almost unmeasureable.

17

u/Superb_Preference368 Jul 24 '25

The donut of YES!

14

u/[deleted] Jul 25 '25

[deleted]

12

u/twisteddv8 Jul 25 '25

Come to Australia where we have CT machines in ambulances!

8

u/Doxie_Chick Jul 25 '25

One of our ED docs is planning a move to Australia. He will think he has died and gone to radiology heaven!

3

u/twisteddv8 Jul 25 '25

Ha there's only a couple and they're utilised when crews call a code stroke.

13

u/k3liix Jul 24 '25

As your friendly radiologist, please god no. We can’t take any more CT PEs.

9

u/MrPBH ED Attending Jul 25 '25

u/eFunkEM is singlehandedly ensuring that your children's' college (and medical school!) is going to be 100% paid for by the 4000% increase in CTA PA studies that will be ordered around the nation for the clinical indication of "TWI V1/III."

7

u/efunkEM Jul 25 '25

My evil plan is to scare everyone into ordering CTAs then sell an AI to read them all automatically. hides from angry radiology mob

1

u/DonkeyKong694NE1 Physician Jul 25 '25

Just like the TSA

1

u/Stlswv Jul 25 '25

Everything detector

0

u/MATTAYELE Jul 25 '25

With that attitude i would hate to be your paitent.

33

u/surfdoc29 ED Attending Jul 24 '25

I just looked at the review of that case… there were some pretty significant ekg changes. Given the history of recent Covid infection it would have been reasonable to at least send some cardiac enzymes and maybe a dimer. Myocarditis should have probably been on the differential as well. These days it’s pretty rare at most shops I work at to not at least single Hs trop most chest pain patients, especially those with ekg changes

24

u/AnalOgre Jul 24 '25 edited Jul 24 '25

Yea this is my thoughts too. Soooo many things get dimer or trops that are completely unjustified.

Coming in with dyspnea particularly with exertion, ekg not being stone cold normal plus obesity equals you getting a trop and dimer IMO because yes, I’m seeing absolutely wild jury awards and this is going to be hard to defend to non medical people why they don’t get a cheap dimer and trop to better explain DOE…

Granted I’m inpatient so obviously my opinion is not going to be as good as the EM docs here but this was my thought as well.

10

u/MrPBH ED Attending Jul 25 '25

Yeah, hs troponin is so good nowadays that your chest pain story has to be pretty stupid for me not to order it on you (like "I punched myself in the chest and now it hurts").

If the hs troponin is normal, then you're discharged. If the hs troponin is elevated, we recheck and if no change, then you're discharged.

If it's rising, then I guess you get admitted. But I'm going to be upset about it.

5

u/Emotional_Resolve764 Jul 25 '25

Nah, would still order a troponin if punched in the chest, what about cardiac contusions! 😂😂

6

u/tarheels1010 ED Attending Jul 25 '25

Yup ever since I read it, I’ve gotten more liberal with the dimer game at this point. The system isn’t supportive of us, so fuck it, we order more tests.

6

u/golemsheppard2 Jul 27 '25 edited Jul 27 '25

They did a follow up actually interviewing the jury foreman. Sounds like the suit was against the healthcare institution and not the attending themselves. That case has been a hot topic at my shop because the jury foreman said they overrode the fact that the patient was PERC negative because patient had TWIs in lead III and V1 and apparently everyone who is a dental hygienist or above knows that means likely PE (none of my three questioned attendings knew this, nor did I until reading medmal reviewers breakdown). Oddly there was no discussion about him being PERC negative but COVID positive which Id argue cant exist in our MDM. I mean, we know that COVID is associated with higher thromboembolic events and show me a single PERC trial validated in COVID positive patients. But that never even came up. At this point, juries are so non evidence based that even if you are low risk wells and PERC negative, they are still going to rule against you. That verdict shifted the goalposts for me and Im much more inclined now to offer them a PE workup even if PERC negative than before and document that patient declined. PERC missed 2% of PEs, just like CTAs. But the eye opening take away from that case was that if your patient is part of the 2%, uneducated juries are going to crucify your MDM even if thats the recommended pathway and thats the standard of care.

Edit: Also they dude was told to go to the emergency department if any new or worsening symptoms in discharge instructions. He then went home and days later, got worse, and passed out while walking up the stairs, refused medical attention when EMS was on scene trying to take him back to that emergency department for his worsening symptoms. They still ruled against the ED for $10M for sending a PERC negative patient home. Why am I gonna continue bending over backwards to limit iatrogenic radiation exposure in patients whose families are gonna sue me when I follow the recommendations and send low risk patients home and the patients refuse my strict return precautions and Im held liable for their refusal of care days later when they have worsening DOE and syncopize? Fuck it man, CT scanner go BRRR at this point.

1

u/whskeyt4ngofox RN Jul 25 '25

THIS. Who said?