For PE victim, would Wells’ have been enough?

Dr. Hospitalist defended himself by arguing that CR suffered a sudden fatal PE on the day of his death despite appropriate prophylaxis and that the “dizziness” the prior day was unrelated. The defense explained that the day prior to his death, CR was simply orthostatic from his postanesthesia state, combined with opiate analgesics, and any hypoxia was from CR’s preexisting COPD.

Plaintiff experts replied that CR had virtually no symptoms for a COPD exacerbation (i.e., no cough, no sputum production), and there was no explanation for the elevated troponin other than PE. Plaintiff experts further alleged that Dr. Hospitalist failed to incorporate an algorithm, such as the modified Wells’ Criteria, into his diagnostic approach for PE. Had he done so, Dr. Hospitalist would have recognized that CR had a high enough clinical probability for PE to warrant empiric treatment and confirmatory testing. The defense responded that the use of the modified Wells’ Criteria was nothing but an arcane “academic” exercise that did not match real clinical practice.

Conclusion:

Acute pulmonary embolism is a well-known postoperative pulmonary complication. The diagnosis must be considered in any surgical patient that has postoperative shortness of breath or unexplained hypoxia. The importance of using an algorithm to determine the need for testing and treatment cannot be understated. In this case, the PE diagnosis was considered but no algorithm was used. The jury in this case deliberated for more than a day, but ultimately returned a full defense verdict.

Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He has been involved in peer review both within and outside the legal system. Read past columns at eHospitalist news.com/Lessons.