Pulmonary Embolism in the Emergency Department: Legal Cases and Clinical Caveats
By Gregory Pittman, MD, Emergency Medicine Residency, Madigan Army Medical Center, Tacoma, WA, Gregory Moore, MD, JD, Emergency Medicine Residency, Madigan Army Medical Center, Tacoma, WA, Marilyn R. Geninatti, MD, FAAEM, FACC, CWS, Paradise Valley, AZ
Pulmonary embolism (PE) is not an uncommon disease, and is easily misdiagnosed, resulting in litigation against emergency department (ED) physicians. This article will use legal cases to illustrate medical caveats regarding PE.
The Presentation of Thrombotic Pulmonary Embolism
In the Estate of Chambers v. Quinones, a 41-year-old New Jersey man presented to the ED after two episodes of fainting. Upon arrival, he was noted to have hypoxia, tachypnea, and signs of heart strain. He had a history of hypertension and had recently taken two four-hour plane flights. The patient was initially evaluated by the ED physician, and then 12 hours later by the family practice attending. The man died of PE, and his decedents sued claiming prompt PE testing was needed. The defendant claimed that fainting is not a common presentation for PE and that two plane rides of four hours is usually not long enough to cause a PE. A settlement was reached for $975,000, of which $400,000 was contributed by the ED physician and $500,000 by the admitting physician.1
The classic presentation of PE is pleuritic chest pain, shortness of breath, and hypoxia, but may also include tachypnea, tachycardia, hypotension, syncope, hemoptysis, right heart strain, or, in the worst case, cardiovascular collapse. Not all patients will present with all of these symptoms, and many are nonspecific, as there is no reliable single symptom. It is imperative, however, for the ED physician to investigate further when one or more of these factors are present. The following cases emphasize the challenging and vague presentation of this disease and why it is often referred to as the great masquerader.
In the Estate of Jabari Rhodes v. Dr. Khalid Malik, Dr. Ahmed Raziuddin, and Weiss Memorial Hospital, a 29-year-old man presented to the emergency department lightheaded and dizzy after collapsing briefly prior to arrival. He was responsive when paramedics arrived and transported him to the ED. The first physician to see the patient ordered a head CT, chest X-ray, drug screen, and an EKG. The first physician’s shift ended 30 minutes after the patient’s arrival and his care was signed out to the oncoming physician. The CT of the head was negative, along with an unremarkable chest X-ray, drug screen, and EKG. The oncoming physician ordered no further testing, and the patient was discharged home with a diagnosis of possible seizure and advised to follow-up with his doctor for an outpatient EEG. Later that same day, the patient collapsed again at home, and paramedics were called. An hour later, he was pronounced dead. The autopsy revealed a PE to be the cause of death from a deep vein thrombosis (DVT) behind his right knee.
The decedent’s family claimed a D-dimer and CT-PA should have been performed. The defense stated that the symptoms did not indicate PE and that the patient would have died even with a correct diagnosis. A jury verdict was returned for $2,757,209 for the plaintiff against the oncoming physician, while the off-going physician, who was originally caring for the patient, was found not to be at fault. The hospital settled pre-trial for $185,000.2
Another case of missed diagnosis is reported from Maryland in the Estate of Derek Pastor v. Patrick Daly, MD, and Rointan Farahifar, MD, in which a 28-year-old man with fever, non-productive cough, and dizziness presented to the ED. Upon arrival, he was noted to be tachycardic, hypoxic, and weak, with noted shortness of breath. The differential included PE, congestive heart failure, and pneumonia. After initial work-up with EKG, chest X-ray, and labs, however, the patient was diagnosed with pneumonia and renal insufficiency and admitted before being transferred to another hospital. Upon arrival to the receiving hospital, no physician evaluation was performed, and five hours later, he collapsed. The decedent died 1.5 hours later. An autopsy confirmed PE as the cause of death.
The decedent’s survivors alleged negligence in failing to diagnose or treat PE. The defendants claimed there was no negligence and that heparin would not have prevented the patient’s death. A verdict was returned for $6.1 million.3
ED physicians should have PE high on their differential diagnosis because mortality without treatment is as high as 30%. This significantly high mortality results in large settlements and judgments when undiagnosed. While common symptoms in PE are dyspnea (73%), pleuritic pain (44%), cough (34%), or calf or thigh pain or swelling (44/41%),4 syncope can be the presenting symptom in 14% of patients.5 Fever may be present in up to 43% of patients and, when present with pulmonary consolidation, can be misdiagnosed as pneumonia. Beware of atypical presentations.
Risk Factors in the Evaluation for Pulmonary Embolism
A recent case from Massachusetts exhibiting multiple PE risk factors demonstrates the importance of recognizing common PE associations. In the Estate of Anonymous 32-year-old Woman v. Anonymous Emergency Room Physician and Anonymous Nurse Practitioner, a 32-year-old woman was seen in the ED for shortness of breath and calf pain soon after having recent gynecological surgery and using Provera. The ED physician ordered ultrasounds of both legs, chest X-ray, lung scan, and D-dimer. The results showed a normal chest X-ray, a low-probability lung perfusion study, and negative ultrasounds of the lower extremities; however, the D-dimer was elevated. The patient was discharged with a diagnosis of leg edema and dyspnea, and she was advised to follow-up with her primary provider.
Two weeks later, after having multiple episodes of collapsing without loss of consciousness, increasing shortness of breath, and lethargy, the patient saw her nurse practitioner (NP). At that visit, she was noted to be diaphoretic, pale, and tachycardic. After basic laboratory tests and a chest X-ray were negative, the patient was discharged from the clinic and advised to follow-up four days later.
Two days later, she was taken to the hospital by ambulance after collapsing at home. A CT scan of the chest was ordered, but the woman died about 90 minutes later. An autopsy confirmed saddle PE as the cause of death. The decedents claimed CT angiography should have been performed at the initial visit and that she had classic signs and symptoms of PE at her clinic visit. A $2 million settlement was reached with all defendants but the nurse practitioner.6
Many risk factors increase the likelihood of developing PE and should prompt further inquiry into the cause of even vague or nonspecific symptoms. By far, the most common association with PE is the presence of DVT, which occurs in more than 50% of cases. Other common risk factors include immobilization, surgery in the last three months, malignancy, pregnancy, exogenous hormone usage, trauma, and heavy cigarette smoking.4 Failure to recognize these risk factors exposes the ED physician to liability.
Two cases further illustrate the importance of early diagnosis in PE. In the Estate of Kenneth Mathiasen v. Albany Medical Center and Donald Jeanmonod, MD, a 53-year-old man with a history of atrial fibrillation fell, fractured his leg, and was transported to the hospital, where he received a cast. He was discharged and advised to stay immobile.
Two days later, he had an episode of syncope, atrial fibrillation, shortness of breath, seizure-like activity, and profuse sweating, which prompted transfer to the hospital by ambulance. His symptoms and atrial fibrillation resolved at the time of hospital admission. An EKG showed no signs of ischemia; however, soon after, his oxygen saturation dropped into the low 90s and he was placed on supplemental oxygen. A chest X-ray was originally read as negative, but later over-read by the radiologist as being suggestive of PE; however, this was not conveyed to the ED staff. The ED physician ordered a CT-PA based on symptoms, but it was not performed until three hours later. The CT scan showed PEs of the bilateral pulmonary arteries. The radiology read was not performed until one hour later, which coincided with the time the patient suffered a fatal cardiac arrest.
The plaintiff claimed that prompt testing should have been performed to diagnose PE and heparin should have been started before confirmation of the diagnosis. The defendants claimed that the actions taken were proper and that the size of the PE left no chance for survival. A $1 million settlement was reached.7
In the Estate of Anonymous 40-year-old Man v. Anonymous Physicians in Virginia demonstrated a similar presentation and outcome. A 40-year-old man fractured his tibia in an accident involving a tree. He was seen in the ED and referred to an orthopedist. Over the next several days, he developed chest pain and shortness of breath. His primary care physician diagnosed him with pneumonia and admitted him to the hospital for observation. On the second day of admission, a duplex ultrasound revealed a deep venous thrombosis, and anticoagulation was started. Laboratory tests revealed worsening renal function; therefore, CT of the chest could not be performed. The patient continued to worsen and a lung biopsy was ordered. In anticipation, anticoagulation was stopped. Due to worsening renal function, the decision was made to start dialysis, and surgery was postponed; however, heparin was not restarted. The patient suffered a PE prior to surgery and died.
The plaintiffs claimed there was an inadequate diagnostic evaluation. Also, they claimed that a lung biopsy was not indicated and heparin should have been promptly restarted. The defendants claimed there was no evidence of premonitory PE, even at autopsy, and that the decedent was suffering from pneumonia and multiorgan system failure, which would have resulted in his death regardless of the PE. They also claimed that the PE came from the site of the dialysis catheter insertion, not the previously diagnosed DVT. A $1.7 million settlement was ultimately reached.8
Risk factors should be acknowledged in assessing the likelihood of PE. When suspicion is raised for PE, many different approaches exist for further evaluation. For low-risk patients, the PERC criteria is a validated tool for excluding PE and includes many of the common risk factors to exclude higher-risk patients. If a patient fulfills the PERC criteria, there is less than a 1% chance of the patient having a PE9; however, if a patient does not meet the PERC criteria, the modified Wells criteria may be used to further stratify patients based on PE risk and guide further work-up.
The modified Wells criteria are a scoring system that can stratify patients into high and low risk based on historical factors. Patients deemed to be low risk may undergo D-dimer testing. If the D-dimer is negative in a low-risk patient, no further evaluation is required; however, if the D-dimer is elevated or the patient is considered high risk, further evaluation is required using either CT-PA or ventilation-perfusion (V/Q) scan.10 A negative CT-PA effectively excludes PE; however, a low probability or intermediate probability V/Q scan is not sufficient to exclude a PE and will require a CT-PA to confidently diagnose or exclude PE.
EKG in Pulmonary Embolus
A 35-year-old man was seen in an emergency department about 10 days after being hospitalized for diverticulitis and two months after knee surgery. He had complaints of shortness of breath, chest pain, and palpitations. The emergency physician ordered an EKG and interpreted it as normal. The patient was sent out with a diagnosis of a panic attack. He was prescribed Ativan and given a referral to a psychiatrist to see in consult. The psychiatrist believed the patient had a medical condition and advised him to seek medical attention promptly with his own doctor or to go to another emergency room. The patient saw his family doctor, who sent him to a nearby hospital as a direct admit, suspecting angina as a diagnosis. There, the patient waited 12 hours to be seen by the admitting physician. He had increased pain and leg swelling during that time. The admitting physician then consulted a cardiologist, who made the diagnosis of a PE and evacuated the patient to another hospital. The patient died eight hours later.
A lawsuit was filed by the decedent’s wife claiming that the EKG was misread, the patient was incorrectly diagnosed as having a panic attack, and that a diagnosis of PE should have been entertained and excluded. The plaintiff pointed out that the symptom complex of tachycardia, shortness of breath, and an abnormal EKG (along with a post-operative status) should have led to an evaluation for PE. The defendants argued that the diagnosis of a panic attack was within the standard of care. At trial, the jury found for the plaintiff and awarded her $1.264 million. The original ED physician was responsible for 35% of the award.11
The abnormal findings on the EKG in acute PE are neither sensitive nor specific for this diagnosis. Rather, the EKG is used most commonly to exclude other causes of chest pain such as myocardial ischemia, myocardial infarct, or pericarditis.12 The EKG may be normal in up to 20% of cases, although sinus tachycardia and nonspecific ST-T wave changes are two of the most commonly cited findings.13 A rightward shift of the frontal plane axis along with T-wave inversions (the classic S1 Q3 T3 pattern), new right ventricular conduction delay (incomplete or complete right bundle branch block), asymmetric T-wave inversions in the precordial leads, and a late transition of the R to S ratio in the precordial leads (signifying clockwise or rightward shift in the horizontal plane) all suggest right heart strain with volume and/or pressure overload. These acute cor pulmonale EKG findings may occur in many disease states in which the right heart is stressed. Likewise, atrial arrhythmias (atrial fibrillation and flutter) may occur due to hypoxia and stretch on the right atrium.14 Recently, the finding of simultaneous T-wave inversions in both the inferior and the anterior leads has been shown to be specific for pulmonary embolism; yet, the incidence of this finding is rare at 4-11%.15
Pulmonary Embolism Treatment
Once the diagnosis of PE is made, initiation of prompt and adequate anticoagulation should be administered to care for the patient and avoid litigation. The initiation of treatment decreases the mortality from 30% to 3-8%.16 The case of Curry v. Jewish Hospital demonstrates anticoagulation as the standard of care in PE. A morbidly obese Kentucky man with a history of PE three years prior was diagnosed with a new PE in the ED. He was started on heparin in consultation with his primary care physician, which is the same treatment he had undergone previously. The following day, the man died of a cardiac event. His decedents sued the hospital claiming the dosage of heparin administered was not therapeutic. The hospital claimed that the dosage was proper and that a higher dosage would have carried a higher risk due to the decedent’s recent vasectomy. In addition, they claimed the decedent had a week of symptoms prior to seeking care. A defense trial verdict was returned.17
New data are showing that not all patients require hospital admission after diagnosis of acute PE; however, all patients do require a period of observation, education on the usage of outpatient medications, and very close follow-up.18
By increasing awareness of atypical presentations, risk factor assessment, diagnostic modalities, and prompt treatment, liability in PE cases may be decreased.
1. Estate of Chambers v. Dr. Ariel Quinones, Union county (NJ) Superior Court. No. V26N10 Oct. 2010.
2. Estate of Jabari Rhodes, deceased v. Dr. Khalid Malik, Dr. Ahmed Raziuddin, Weiss Memorial Hospital. Cook County (IL) Circuit Court, Case No. 06l-5467.
3. Aubrey Pastor, indiv. and as PR of the Estate of Derek Pastor and Cesar Pastor v. Patrick Daly, MD and Rointan Farahifar, MD Prince George’s County (MD) Circuit Court, Case No. CAL0-39966.
4. Stein PD, et al. Clinical characteristics of patients with acute pulmonary embolism: Data from PIOPED II. Am J Med 2007;120(10):871.
5. Blinder RA, Coleman RE. Evaluations of pulmonary embolism. Radiol Clin North Am 1985;23:392.
6. Estate of Anonymous Thirty-two-year-old Woman v. Anonymous Emergency Room Physician and Anonymous Nurse Practitioner, unknown Massachusetts venue, No. V27N4. April 2011.
7. Maryann Mathiasen, as Executor of the Estate of Kenneth Mathiasen, etc. v. Albany Medical Center and Donal Jeanmonod, MD. Nassau County (NY) Supreme Court, Case No. 10235/06.
8. Estate of Anonymous Forty-year-old Man v. Anonymous Physicians. Unknown Virginia venue. V27N11.
9. Kline JA, Et al. Prospective multicenter evaluations of the pulmonary embolism rule-out criteria. J Thromb Haemost 2008;6(5):772.
10. Van Belle A, et al. Effectiveness of managing suspected pulmonary embolism using and algorithm combining clinical probability, D-dimer testing, and computed tomography. JAMA 2006;295(2):1721.
11. Patricia Kilburn v. Aliquippa Community Hospital, Ganapathi Moka, MD, James Tatum, MD, et al. Beaver County (PA) Court of Common Pleas, Case No. 12340-2005.
12. Goldhaber S. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 2008:1868.
13. Stein PD, et al. Clinical characteristics of patients with acute pulmonary embolism. Am J Cardiol 1991; 68:1723.
14. Todd K, Simpson CS, Redfearn DP, et al. ECG diagnosis of pulmonary embolism when conventional imaging cannot be used: A case report and review of the literature. Indian Pacing Electrophysiol J 2009;5:268-275.
15. Wittig MD, Mattu A, Rogers R, Halvorson C. Simultaneous T-wave inversions in the anterior and inferior leads: An uncommon sign of pulmonary embolism. J Emerg Med 2011;7:228-235.
16. Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: Clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet 1999;353(9162):1386.
17. Curry v. Jewish Hospital Shelbyville. Shelby County (KY) Circuit Court, Case No. 07-0481.
18. Erkens PM, et al. Safety of outpatient treatment in acute pulmonary embolism. J Thromb Haemost 2010; 8(11):2412.