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/leemteam1 Jul 24 '25

Sucks but also have zero reason to suspect PE in this one. Not fucked at all legally, not sure how anyone could argue in a PERC negative pt that you committed malpractice

69

u/enunymous ED Attending Jul 24 '25

I agree with you, but did you see this?

https://www.reddit.com/r/whitecoatinvestor/s/DxRoIZzkKJ

Seems like we're on the hook no matter what we consider or document. The problem is that almost every clinical decision rule has some element of subjectivity to it... The plaintiff's expert will just say, PERC doesn't apply bc the pretest probability wasn't low. Or some such BS

48

u/GreatMalbenego Jul 24 '25

Take a listen to the podcast “Doctors and Litigation: The L Word”. One of my big takeaways is that if it’s gonna happen, it’s gonna happen and has literally nothing to do with whether you did the right thing or not. You can have been overly cautious, followed standard of care as in your case, or not even been the proximate cause (or missed dx) of the harm. So be nice, laugh with your patients, document tactically, and know first steps if served.

OP, Did you give it a second thought when you clicked discharge? If not, then it sounds like in your heart of hearts you did what you thought was right for the pt with the info you had. PERC is designed with an “acceptable” miss rate of 1-2%. Most of us have probably used/documented it at least one or a few hundred times. We’ve all inevitably sent home badness. 100% catch rate is an admirable goal, but not possible. I’m trying to learn this myself. But fuck it’s a bitch of a lesson.

OP I’m sorry to hear about the bad outcome. Death after discharge is heart wrenching. It makes us feel worthless as docs. It’s virtually impossible not to beat ourselves up about it. I’m really sorry. Please don’t drink too much these nest few days/weeks. You aren’t worthless. You have helped, healed, and caught way more than you’ve missed.

6

u/Nearby_Maize_913 ED Attending Jul 25 '25

Every NOI should start with "you were unlucky enough to be working on the day..."