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/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

160

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.

31

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

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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.

11

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.

4

u/Emotional_Resolve764 Jul 25 '25

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