Failure to diagnose pulmonary embolism
by Olga Maystruk, Designer and Brand Strategist, and
Jennifer Templin, Risk Management Representative
Presentation
On January 5, a 51-year-old woman came to the emergency department (ED) of a large hospital with excessive vaginal bleeding, progressive diarrhea, and dizziness over the past three days. The patient was obese with a BMI of 30.9 and had a history of smoking. She reported that the onset of her bleeding was consistent with her menstrual cycle but heavier than usual.
The patient had visited an urgent care center the day before with the same symptoms. At the center, she received a prescription for losartan and multivitamin with iron.
Physician action
The emergency physician ordered a chest x-ray and pelvic ultrasound. The x-ray showed mildly enlarged cardio mediastinal silhouette with no acute abnormalities. The ultrasound revealed an enlarged uterus and numerous fibroid tumors, the largest measuring 6.5 x 5.5 x 3.5 cm.
Additional lab tests were also performed. Partial thromboplastin time was 14.4, within the normal range of 12.0-15.0. The patient’s heart rate was slightly elevated, and her respirations (R) and oxygen saturation range (O2 sats) were recorded at 20 (normal adult respiration is 12-18 breaths per minute) and 94% (normal O2 sats are between 95-100%). Her heart rate and O2 sats were consistent with severe anemia and significant blood loss. The patient was given oxygen via nasal cannula.
The emergency physician's differential included anemia, dysfunctional uterine bleeding, elevated troponin levels, tachycardia, dysmenorrhea, endometriosis, uterine fibroids, malignancy, menorrhea, and a possible non-ST elevation myocardial infarction. The patient was admitted to the hospital under the care of an internal medicine physician. Ob-gyn and cardiology consults were ordered.
On January 6, the internal medicine physician consulted with a hematologist, cardiologist, and ob-gyn. The internal medicine physician noted raised troponin levels and hemoglobin at 7.2. The cardiologist reviewed the electrocardiogram (EKG) that revealed sinus tachycardia, voltage criteria for left ventricular hypertrophy, and inferior MI of an undetermined age.
The EKG also showed T-wave abnormalities with both inferior and anterolateral T-wave changes which may have been ischemic or due to repolarization abnormality. The patient’s troponin levels were out of range at 0.33 and 0.24 (normal range 0.00 – 0.10), and an ultrasound showed multiple fibroids.
Upon his examination of the patient, the cardiologist documented a minimal troponin leak and abnormal EKG. His differential diagnosis was myocardial infarction, severe anemia, hypertension, cardiovascular disease with left ventricular hypertrophy 2° hypertension, and congestive heart failure. He noted that the patient could be managed on an outpatient basis with a 2-D echocardiogram (echo) and nuclear stress test.
The cardiologist stopped the losartan and hydrochlorothiazide treatments and switched the patient to metoprolol SR 25 mg a day. The ob-gyn ordered estrogen 25 mg IV every four hours x 3 doses to control the bleeding in addition to six units of platelets. The patient’s O2 sat was at 93%.
On January 7, the ob-gyn signed off on the patient’s care due to vaginal bleeding subsiding to normal levels. He planned to follow the patient on an outpatient basis. The internal medicine physician wrote an order for discharge at 8 a.m. with instructions to follow up within two weeks. The cardiologist signed off on an oral order for the discharge at 9 a.m. The patient left the hospital at 11:53 a.m.
At 10:30 p.m. that night, EMS was called to the patient’s home where they found the patient lying supine in her driveway. A family member reported that she stopped breathing in the car and that he attempted to revive her with CPR. EMS continued CPR and attempted to place an IV and obtain a blood pressure reading, but were unsuccessful. The patient was given 2 mg epinephrine, intubated, and transported to the ED.
Upon arrival, the patient was hypotensive and in shock. Following resuscitative efforts, the on-call surgeon pronounced the patient dead. The autopsy stated the cause of death to be pulmonary embolism (PE) due to deep vein thrombosis associated with obesity and uterine enlargement caused by uterine fibroids and adenomyosis.
Allegations
The patient’s family filed a lawsuit against the cardiologist, internal medicine physician, and hospital. Allegations included:
- failure to administer appropriate testing for PE;
- failure to follow up on echo results; and
- prematurely discharging the patient.
Legal implications
The case presented several documentation issues for the defense. First, there was a nursing note from January 6 about a message on the cardiologist’s answering service regarding the patient's brain natriuretic peptide (BNP) level of 936 pg/ml (normal is less than 100 pg/ml) and that the patient desaturated when walking without oxygen. The cardiologist did not recall receiving this message.
Another nursing note from January 7 indicated that the cardiologist was notified of the patient’s BNP test results before the patient’s discharge. The cardiologist did not recall discharging the patient and mentioned calling the hospital to follow up on the echo. The hospital, however, did not have a record of that call.
Aside from documentation inconsistencies, two of three cardiology experts who reviewed the case for TMLT were supportive of the cardiologist’s treatment methods. They observed that the patient presented several health issues that made it hard to diagnose PE, especially since the most common PE symptoms such as shortness of breath and chest pain were not present.
However, the third cardiology expert felt that the standard of care was not met in this case. This consultant was critical of the cardiologist not following up on echo results and not considering PE based on the patient’s x-ray and test results.
An emergency medicine expert assessing the case argued that the cardiologist did indeed meet the standard of care and instead put responsibility of the outcome on the internal medicine physician and ob-gyn.
A cardiologist consultant for the plaintiff was critical of the cardiologist for failing to consider a diagnosis of PE based on the patient’s clinical presentation. This consultant felt the cardiologist could have ruled out PE with testing, such as D-dimer, venous Doppler, chest CTA, and echo. Had the cardiologist taken these measures, the consultant argued that the patient’s condition could have been improved through anticoagulation therapy, thrombectomy, or placing an inferior vena cava filter.
Plaintiff consultants were also critical of the nurses for not being more persistent about reaching the cardiologist with the patient’s abnormal test results.
Disposition
The case was settled on behalf of the cardiologist and the hospital. The outcome of the case against the internal medicine physician is unknown.
Risk management considerations
Proper and timely patient charting and documentation is vital for quality patient care, and can be a physician’s best defense in the event of a claim. In the hospital setting, when each provider adequately documents their evaluation, treatment, and management of conditions, it also helps to ensure a continuity of care. Documentation becomes even more important, as some patients require more consulting physicians. Ensuring that each consulting physician is advised of any testing and treatment can help with ruling out differentials and developing appropriate treatment plans.
Effective communication between physicians and hospital staff is also key for providing optimal patient care. In this case, the lack of communication and appropriate follow up on test results, may have led to the patient being discharged too early. According to the Agency for Healthcare Research and Quality, “communication issues are the most common root cause of sentinel events (serious and preventable patient harm incidents).” 1
Given that the patient’s BNP level was outside the normal range and that the patient desaturated while walking without the use of oxygen, additional attempts to ensure that the cardiologist received this information might have been beneficial.
Additionally, if the cardiologist did not receive the results of the ordered tests, it would have been prudent for the cardiologist to follow up. Had the cardiologist been aware of the BNP test results, further testing and treatment may have been warranted and the patient’s discharge delayed.
Ensuring a patient is appropriately discharged can lead to better outcomes and lessen the chance that a patient will return to the emergency department. While there are several key elements noted to be essential in discharge planning, physicians and patients alike must be aware of any pending test results before discharge.
In this case, there were test results that had been communicated to the hospital staff but not to the cardiologist, or the cardiologist could not recall receiving the test results. Either way, it is recommended that the discharging physician make sure that pending and treatment-determining test results are received in the patient record and read before the patient is discharged. 2
Sources
1.Communication between clinicians. Agency for Healthcare Research and Quality. September 2019. Available at https://psnet.ahrq.gov/primer/communication-between-clinicians. Accessed March 12, 2021.
2.Alper. Hospital Discharge and Readmission. UpToDate website. Updated March 10, 2021. Available at https://www.uptodate.com/contents/hospital-discharge-and-readmission. Accessed March 17, 2021.