Author: Chuck Pilcher, MD FACEP (Editor, Med Mal Insights) // Reviewers: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)
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Chuck Pilcher, MD, FACEP
Editor, Med Mal Insights
How to miss a pulmonary embolus
Chest pain + SOB + cough = (name your poison)
Facts: A 48-year-old female smoker with a history of occasional asthma presents to a hospital’s walk-in clinic with new onset cough, SOB, and pleuritic chest pain. The triage MA checks her pulse ox (normal), and because there is a 2 hour wait she is told to go home until called. She is called as promised and returns, only to wait another hour before being taken to an exam room. She tells the PA-C that her chest pain is under her right breast and made worse by deep breathing. ROS includes SOB, wheezing, coughing, and night sweats. BCP/hormones and recent travel are not documented. VS are normal except for a pulse of 102. There is wheezing in both lungs. An EKG is normal. The PA-C tells her that she is “fine” and her problem could be related to smoking or asthma. He prescribes an albuterol inhaler and ibuprofen. She asks the discharge nurse about the chest pain and is told it might be a muscle strain. There is no evidence in the record to suggest that a supervising physician was consulted. Thirteen days later her husband finds her semi-conscious sprawled out on the bed and calls 911. She arrives in the ED in extremis and is diagnosed with a massive saddle embolus. She survives for 7 hours, suffers a cardiac arrest, and cannot be resuscitated. An attorney is consulted and a lawsuit filed against the clinic’s hospital and the PA-C.
Plaintiff: You didn’t document a differential diagnosis to rule out any serious cause or other common causes of chest pain and SOB. You did no lab work or imaging. You should have considered PE based on my symptoms alone. Had you done so, you should have sent me to the ER. Why? Because your own hospital’s policy states that my presentation was beyond the scope of both a walk-in clinic and a PA-C. While “minor asthma attack” is OK, chest pain with SOB is not. Why? Because the walk-in clinic isn’t equipped to do appropriate tests even if you ordered them. Plus, your hospital’s policies require discharge instructions with a working diagnosis and a follow-up plan. You provided neither. Our PA-C, EM, and radiology experts all support that if I had seen a doctor, I’d still be alive today.
Defense: You smoked, had a history of asthma, and told the PA that your brother’s inhaler helped, so prescribing albuterol was within the standard of care. You should not have waited 13 days to follow up with your PCP. That alone caused your death. It’s pure conjecture that a CTA done on the first encounter would have shown a PE. That’s guessing, not fact. We’re sorry this happened and agree that it should not have, but you have not proven your allegations.
Result: Settlement in the 7 figures pre-trial.
Takeaways:
- If your institution has policies that affect your practice, know what they are and follow them. Failure to do so – more than the clinical negligence – doomed the case.
- If you choose not to follow them, document your rationale.
- Chest pain + SOB = PE until ruled out. Always include it in your differential. Once you include it in your differential, document the tests you did to rule it out using your favorite PE algorithm.
- Pleuritic chest pain rarely accompanies an asthma attack.
- Diaphoresis, even “night sweats” by history is a red flag. Stop and think.
- Giving a bronchodilator in the clinic could have provided support for a diagnosis of asthma – or led to the correct diagnosis.
- Discharging a patient with chest pain and no diagnosis is risky. Another diagnosis was not more likely than a PE, so exclude PE before sending someone home.
- Be sure patients leave your care with a follow-up plan, especially for chest pain or breathing problems.
- If chest pain makes you get an ECG, a chest x-ray should be next. If not done, document why.
- Avoid any unconscious bias against smokers.
- A PE (or aortic dissection) is missed at least 10 times more often than an MI.
References:
Excerpt: The challenge in dealing with pulmonary embolism (PE) is that patients rarely display the classic presentation of this problem, that is, the abrupt onset of pleuritic chest pain, shortness of breath, and hypoxia. Studies of patients who died unexpectedly from PE have revealed that often these individuals complained of nagging symptoms for weeks before death. Forty percent of these patients had been seen by a physician in the weeks prior to their death.
It’s not the patient’s job to prove that they are sick. It’s our job to prove that they are not.
Yaron Ivan MD in EPMonthly, April 6, 2022
