A 15 year old patient, who was one week post-arthroscopic knee surgery, went to the ED with complaints of left chest pain. The pain was worse when he laid flat. He had no fever or dyspnea and denied other complaints. In the ED, the patient had normal vital signs and pulse oximetry. The physician performed a physical exam and ordered an EKG and a chest x-ray, both interpreted as normal. The patient’s pain resolved after receiving Toradol and was sent home with a diagnosis of pleurisy and Rx for Naprosyn. Two weeks later, the patient again developed chest pain and dyspnea. He was transported by ambulance back to the ED where he died from bilateral pulmonary emboli.

A medical malpractice lawsuit was filed against the treating emergency physician and the emergency physician’s group. Plaintiff experts testified: The EKG showed Q3T3 abnormalities and the chest x-ray demonstrated cardiomegaly – which were allegedly both suggestive of a pulmonary embolism; Symptoms presented a classic case of pulmonary embolism and the diagnostic measures that the emergency physician took in response to those symptoms did nothing to prove or disprove the presence of a pulmonary embolism. The treating physician testified that relief of pain from a pulmonary embolism would not occur with administration of Toradol – experts called that reasoning ridiculous. Plaintiff experts concluded that the standard of care required the treating physician to obtain a CT scan in order to rule out a postoperative pulmonary embolism, and failure to do so was grossly improper, egregious, and contrary to fundamental medical principles.

STANDARD OF CARE ARGUMENTS

PLAINTIFF

• Failure of duty to the patient was in failing to practice with a high clinical index of suspicion for postoperative Pulmonary Emboli.
• The omission of not ordering a CT scan as a PERC (pulmonary emboli rule-out criteria) was a breach in standard of care and the core of the medical malpractice suit.
• Given the patient’s history of new onset of post-operative pleuritic chest pain, it was the duty of the ED physician to consider PE as a differential diagnosis and ruling it out with CT scan would have been safe practice. Unsafe practice led to a bad outcome.
• A suggestive clinical presentation of acute postoperative pleuritic chest pain, a suggestive EKG, and the duty to rule out a life-threatening emergency, should have prompted a thorough PE rule-out that included a CT scan.
• [D-dimer was clinically mandated – if low, it would have supported no CT scan. D-Dimer is a rule-out blood test for DVT & PE as it suggests presence of a blood clot.
• [PERC, definitively yes, given the patient’s recent surgery. Ordering a d-dimer practice would have been safe practice & the omission is below standard of care.
• A normal chest X-ray does not support a diagnosis of pleurisy.
• None of the tests ordered were reliable to rule-out PE. Defense is not based on number of tests ordered, but what tests were appropriate.
• The clinical presentation without tachypnea or tachycardia may suggest an early onset of PE, that of a younger patient with intact compensatory mechanisms of which early intervention would have been lifesaving.
• Cardiomegaly is an abnormal clinical presentation/clinical indicator especially in a 15 y/o. Q3T3 can be a common EKG finding & a normal variant, however an EKG with a new S1Q3T3 indicates right heart strain and PE– Cardiomegaly supports heart strain.
• Ultrasound (lung and venous) would have been a safe noninvasive diagnostic process for PE that can yield improved sensitivity and specificity obviating the need for pulmonary CT scan in many cases according to the March 2017 issue of Academic Emergency Medicine
• Blindly treating symptoms without knowing the cause supports gross failure to protect the patient from the worst possible outcome.
• Failure to order medical follow-up post-ED discharge (for at least 2 weeks) was failure of duty to the patient.
• The patient was in the subpediatric population of an adolescent (12-21), not pediatric (2-12).
• Regardless of age, any postoperative patient can form a clot and embolize it.

DEFENSE

• Arthroscopic knee surgery is not a long bone and patients ambulate immediately post-op thus not at high risk for DVT and PE.
• Patient’s vital signs and oxygenation were normal, clinical exam was normal, the alleged abnormalities found on x-ray and EKG were not predictive of pulmonary embolism, and the patient had a low pre-test probability for pulmonary embolism. Reasonable standard of care was provided.
• [Practice with a low clinical index of suspicion for PE: Pediatric PE are exceedingly rare 1 in 100,000 (50% related to indwelling CVP’s) & two thirds of pediatric PE originate in the UE, not LE.
• [Generally speaking, 15 year olds have a very low risk of thromboembolic disorder.
• [Risk is so low in the pediatric population that PE diagnosis would have been unlikely.
• The diagnosis of PE was not known until 2 weeks post-ED discharge – the chest pain may have been from post-operative crutch-walking, thus the PE hypothetically may not have been present at the time of the initial ED exam.
• CT scanning all pleuritic patients is not good practice.
• Chest pain is less associated with PE than is dyspnea.
• D-dimer would have been positive secondary to recent surgery.
• The utilization of d-dimer has not been well-studied in children.
• The risk of harm from CT scan (radiation & contrast) was greater than the risk of the diagnosis. (Whatever the percentage risk the patient is 100% dead).
• Often, the thought process of the physician is entirely absent from the record, despite the fact it was subtle, deep & considered.

Kathleen A. Mary, RNC, Legal Nurse Consultant Certified is an honored medical expert and lifetime clinical scholar valued immeasurably by her plaintiff and defense attorney-clients as a time/cost-efficient asset to medical malpractice, personal injury and product liability claims. Kathleen provides flawless investigative navigation of meritorious complexities, meticulous comprehensive medical record reviews, locates trusted preeminent experts, is a recognized medical researcher and lifetime standard of care clinical consultant. For over 25 years, 100% of Kathleen’s cases (hundreds) have been positively settled without trial. Please contact Kathleen for your next medical-legal case.