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/MocoMojo Radiologist Jul 24 '25

Was the somebody who said it’s a PE a pathologist who did an autopsy?

12

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

13

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.

7

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.