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

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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

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u/Movinmeat ED Attending Jul 25 '25

Eh. I’ve defended and won a lot more cases like this. Runaway juries happen but we win these (and worse cases) a lot more than we lose.