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/ihearttroponin]

"Someone said PE" so you don't even know that it was a PE for sure and you're guilting yourself? If the patient is truly Wells low risk, PERC negative, there was no reason to proceed with further PE testing. Sounds like it could have been asthma/COPD that maybe worsened after discharge

[u/WobblyWidget → u/ihearttroponin]

there was a recent medmal review on perc/wells negative but ekg changes of RHS and the doc is appealing a 10mil decision for missing PE. this is why I threw out that . the jury doesn’t care. I’d rather have a negative ddimer at this point.

[u/yurbanastripe → u/WobblyWidget]

My plan is to install a CTA chest scanner at the door that everyone entering has to walk through, kinda like a metal detector. Call it the PE detector

[u/pshaffer → u/yurbanastripe]

I am a radiologist who has covered a large ER - 100 beds.
we would do about 100 scans per weekend.
few positive

and very few unexpectedly positive, like your patient.

I don't think scanning every patient who is SOB is a good idea, but I could be convinced otherwise.

Incidentally, I had a friend who died of PE with a similar history to your patient, except, by report from his wife, he was profoundly SOB for some days (also quite overweight) he was early 40s.

[u/Broguest_Squadron → u/pshaffer]

Agree with you. Very few ED docs seem to understand that the risks of radiation, contrast and false positives greatly outweigh the risk of the missed PE, (when using other appropriate evidence based screening tools such as EKG, D Dimer, Wells/PERC). Greatly over ordered test. Not nearly as specific as many docs think - have seen inter rater reliability numbers as low as 60%.

[u/pshaffer → u/Broguest_Squadron]

60% surprises me. I trained in the era prior to CT so when we got it, it was a godsend. No more “low probability for pe” nuc scans. Maybe I trust I too much.

[u/pshaffer → u/Broguest_Squadron]

I have had to educate more than a few physicians that the radiation risk of a CT for PE is largely theoretical, where as death from PE is quite real.

Especially true in pregnant patients. dead moms are bad for babies. Scatter radiation to the baby is almost unmeasureable.