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/triDO16]

Sorry you're dealing with this, OP. As others have said, would take it with a grain of salt unless an autopsy had been done as you can't be certain it was a PE that you missed. I also don't think you strayed from standard of care, either, based on the info provided.

Two points of suggestion that I have routinely added to my dyspneic patients, especially young ones: bedside echo and ambulatory pulse ox. I have caught a legitimately non-zero number of new diagnosis HFrEF with massively reduced EFs (like <20%) in these cases and they're not that hard to do. Ambulatory pulse ox also helps me catch people who look great and are satting fine who all of a sudden don't look great and aren't satting fine while walking.

Lastly, hopefully as a point of comfort, let's say you did diagnose this patient with a PE. It clearly wasn't hemodynamically significant so I doubt their clot burden would have been huge. He's someone that could probably have been started on apixaban and discharged, at most obs overnight for formal echo +/- lower extremity US. He still may have died 2 days later even in that case. I have also had a non-zero number of patients diagnosed with PE, admitted on heparin, discharged on apixaban and bounced back 2-3 days later in cardiac arrest. PEs are horrible. And sometimes even when you do all of the things perfectly (not saying you even didn't in this case) people still die.

Medicine is imperfect. Learn what you can from this case, but don't beat yourself up about it.