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
80
u/Xeron- Jul 24 '25 edited Jul 24 '25
The T wave inversions could be problematic. In residency we had an expert witness attending who specializes in PE cases. Especially if there's V1-V3 inversions that are new, they should always make you think PE as it's a sign of right heart strain and as I recall his lecture much more sensitive and specific that S1Q3T3. Hard to say how it would go if it goes go to court, cause they were Perc 0, but remember that doesn't mean it's 0% PE probability, especially if there's signs pointing at PE in a patient with unexplained dyspnea.
That said, this is a missed diagnosis we can all make and probably many of us would. This is the case we have nightmares about. I may not know you but I can tell you care, and that means something. Learn from this, but do not let this define you. You have saved hundreds if not thousands of lives. You have made hundreds of hard to make diagnosis and made a huge difference in their lives. This is what we do. We are not perfect, all we can do is our best and move on to the next patient. Keep trucking, and keep you head up