Missed PE, patient died

[u/Repulsive_Knee1304]

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

[u/Xeron-]

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

[u/the_silent_redditor → u/Xeron-]

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.

[u/Xeron- → u/the_silent_redditor]

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

[u/No-Football-8824 → u/Xeron-]

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.

[u/Xeron- → u/No-Football-8824]

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

[u/Queasy-Reason → u/Xeron-]

https://expertwitness.substack.com/p/death-after-ed-visit-for-covid

Similar case went to court and the plaintiff won. 

[u/cosmin_c → u/Queasy-Reason]

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".

[u/BrobaFett → u/Queasy-Reason]

That's because malpractice cases have nothing to do with whether or not medicine was practiced correctly.

[u/shookwell → u/Xeron-]

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.

[u/BrobaFett → u/Xeron-]

>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.