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/golemsheppard2 → u/WobblyWidget]

They did a follow up actually interviewing the jury foreman. Sounds like the suit was against the healthcare institution and not the attending themselves. That case has been a hot topic at my shop because the jury foreman said they overrode the fact that the patient was PERC negative because patient had TWIs in lead III and V1 and apparently everyone who is a dental hygienist or above knows that means likely PE (none of my three questioned attendings knew this, nor did I until reading medmal reviewers breakdown). Oddly there was no discussion about him being PERC negative but COVID positive which Id argue cant exist in our MDM. I mean, we know that COVID is associated with higher thromboembolic events and show me a single PERC trial validated in COVID positive patients. But that never even came up. At this point, juries are so non evidence based that even if you are low risk wells and PERC negative, they are still going to rule against you. That verdict shifted the goalposts for me and Im much more inclined now to offer them a PE workup even if PERC negative than before and document that patient declined. PERC missed 2% of PEs, just like CTAs. But the eye opening take away from that case was that if your patient is part of the 2%, uneducated juries are going to crucify your MDM even if thats the recommended pathway and thats the standard of care.

Edit: Also they dude was told to go to the emergency department if any new or worsening symptoms in discharge instructions. He then went home and days later, got worse, and passed out while walking up the stairs, refused medical attention when EMS was on scene trying to take him back to that emergency department for his worsening symptoms. They still ruled against the ED for $10M for sending a PERC negative patient home. Why am I gonna continue bending over backwards to limit iatrogenic radiation exposure in patients whose families are gonna sue me when I follow the recommendations and send low risk patients home and the patients refuse my strict return precautions and Im held liable for their refusal of care days later when they have worsening DOE and syncopize? Fuck it man, CT scanner go BRRR at this point.