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/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.