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

367 Upvotes

96% Upvoted

170 comments sorted by

View all comments

Show parent comments

21

u/Baba-Yaga-X Jul 24 '25

How did you find them? Do you scan or d-dimer PERC negative patients? PERC negative, no alarm signs: I’m done.

16

u/Ok-Bother-8215 ED Attending Jul 24 '25

Just so you know, PERC is for those whose pretest probability is less than 15%. Which means you ought to risk stratify with say Wells BEFORE you apply PERC rule.

People always miss this part. It’s not just PERC neg then no PE.

6

u/Baba-Yaga-X Jul 24 '25

Look, with PERC you have a 2% false negative rate, so you will miss some PE’s. Therefor, only in low risk patients should the PERC rule be used. Wells is heavily dependant on gestalt, and needs a d-dimer. My practice is a combination of PERC and gestalt.

1

u/Ok-Bother-8215 ED Attending Jul 25 '25

Using Wells does not need a dimer. Wells is a stratification rule that gives pretest probability. You don’t need a dimer to use wells and PERC.