Pulmonary Embolism Ruled Out in Error

OUTCOME
According to a published account, a $6.1 million verdict was returned.

COMMENT
This is a substantial verdict, reflecting the jury’s revulsion at the loss of a 28-year-old patient. His initial presentation of low-grade fever, nonproductive cough, and dizziness with tachycardia and hypoxia could be consistent with either pneumonia or PE. The facts as presented render the chest x-ray findings and the magnitude of hypoxia unclear. We also are not told whether any specific risk factors existed to make PE more likely, nor whether there was evidence of deep vein thrombosis (DVT) during presentation or at autopsy.

Diagnosing PE can be difficult. However, jurors confronted with a case involving a fatal PE may be led to believe that the diagnosis is straightforward and should never be missed. Plaintiff’s counsel will argue that the patient “would be standing here today” in a fully functional status if the diagnosis had been made.

Here, presumptively, the chest films and chest auscultation were suggestive of pneumonia and led the clinician, who actively considered PE, to ultimately exclude the possibility. It is not clear why the patient was transferred and not formally evaluated upon arrival at the second hospital, but the facts indicate that the patient was “significantly hypoxic.” This should have entailed close monitoring by the receiving clinician, irrespective of the diagnosis.

The pathophysiology of PE is straightforward—but the presentation is often variable and nonspecific and the diagnosis tricky. Thus, for the clinician confronted with a hypoxic patient, it is important to consider this diagnosis early and thoroughly. Evaluate for risk factors: hypercoagulability, as in cases of malignancy, estrogen use, pregnancy, antiphospholipid syndrome (Hughes syndrome), or genomic mutations (eg, factor V Leiden mutation, prothrombin mutation, factor VIII mutations, protein C and protein S deficiency); venous stasis; and vascular endothelial damage, as possibly occasioned by hypertension or atherosclerotic disease.

In addition, it is important to confirm the presence or absence of a DVT. Follow evidence-based rules, such as the Wells score, to guide decision making. In Wells scoring, points are assigned for each of seven criteria, allowing the patient to be categorized by high, moderate, or low probability for PE. The Wells scoring criteria comprise
• Suspected DVT (3 points)
• PE the most likely diagnosis, or equally likely as a second diagnosis (3 points)
• Tachycardia (heart rate > 100 beats/min; 1.5 points)
• Immobilization for at least three days or surgery within the previous four weeks (1.5 points)
• History of DVT or PE (1.5 points)
• Hemoptysis (1 point)
• Malignancy with treatment within previous six months (1 point)

Patients with a total score exceeding 6 points are considered high-probability for PE and should undergo multidetector CT. Those with a score of 2 to 6 have moderate probability and should undergo high-sensitivity d-dimer testing; negative d-dimer results exclude PE and positive results warrant multidetector CT and lower-extremity ultrasound. In low-probability patients (Wells score below 2) with negative d-dimer results, PE is excluded; if d-dimer results are positive, multidetector CT should be ordered.

IN SUM
Extensive discussion of clinical predictive rules, diagnostic modalities, and treatment is beyond the scope of this comment. But clinicians should apply evidence-based decision-making rules to establish a diagnosis. And it should be apparent that hypoxic patients warrant close monitoring—particularly when a change of provider, service, or institution occurs. —DML