Failure to diagnose pulmonary embolism

by Laura Hale Brockway, ELS, Vice President, Marketing

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Presentation

A 17-year-old boy came to his pediatrician’s office on February 7 with a two-week history of fever, cough, and congestion. The fever resolved two days before the visit. The patient was seen by the family nurse practitioner (FNP), who prescribed amoxicillin for 10 days and an inhaler. 

The patient returned February 11 and reported that he used the inhaler 3-4 times per day without improvement. He experienced wheezing and shortness of breath in the mornings and late evenings. The patient said he initially felt better, but after visiting his grandparent’s house and being exposed to cigarette smoke, his symptoms worsened. The FNP diagnosed acute exacerbation of asthma and administered dexamethasone. 

The boy had been a patient at the pediatric clinic for five years. His history included obesity, but no history of respiratory complaints. He had a family history of asthma, and some family members were smokers. 

Physician action

On February 18, the patient returned reporting that his cough was improving. He was seen by Pediatrician A. The patient had mild tachycardia and mild hypoxemia, but no wheezing. Pediatrician A diagnosed uncomplicated, mild intermittent asthma. 

The patient returned on February 25 with dyspnea on exertion for three days. Pediatrician A admitted him to a local hospital. The admission notes described unspecified chest pain and coarse breath sounds with a prolonged expiratory phase. He was placed on 3 L/min oxygen to achieve a saturation of peripheral oxygen (SpO2) of 96 percent. There was no mention of leg swelling by Pediatrician A or the nursing staff. 

On February 26, a hospital nurse noted that there were “no risk factors identified” on the patient’s venous thromboembolism (VTE) screen. The nurse advised Pediatrician A that the patient was unable to tolerate walking in the hallway. Pediatrician A evaluated the patient and noted persistent cough, dyspnea, tachycardia, and hypoxemia. His impression was exacerbation of asthma and no therapeutic changes were made. 

Pediatrician A returned that day and the patient reported left anterior chest pain. Bilevel positive airway pressure (BIPAP) was started; breathing and breath sounds were described as improved with this modality. An EKG was interpreted by Pediatrician A as showing sinus tachycardia. The machine interpretation printed at the top of the tracing commented on right axis deviation. 

Pediatrician A initiated a patient transfer to a medical center in another city. Emergency Medicine (EM) Physician A, who agreed to accept the patient, requested that a spiral computed tomographic angiogram (CTA) of the chest be performed before the transfer to evaluate for possible pulmonary embolism. Pediatrician A ordered the CTA and a basic metabolic panel, which revealed hyperglycemia and mildly elevated serum creatinine. 

The CTA was performed at 9:32 p.m. It revealed extensive pulmonary emboli (PE) with flattening of the interventricular septum, suggestive of right heart strain. At 11:05 p.m., the radiologist notified EM Physician A of the results. There was no record that EM Physician A notified Pediatrician A of the CTA results. At 11:30 p.m., a hospital nurse documented that the EMS transport had arrived. 

The EMS transport team documented that the patient’s condition deteriorated during transport. His heart stopped several times and the ambulance diverted to another hospital. When he arrived at the hospital, he was in asystole. After prolonged attempts to resuscitate him, he died at 1:47 a.m.

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Allegations

A lawsuit was filed against Pediatrician A and EM Physician A. The allegations were failure to properly diagnose and treat the patient’s pulmonary embolus, which led to his death.

Legal implications

Physicians who reviewed this case for the defense all agreed that diagnosing a PE in a pediatric patient is difficult, as symptoms of PE can also be seen with asthma. They were supportive of Pediatrician A’s initial evaluation, diagnosis, and decision to hospitalize the patient. 

Those reviewing the case were less supportive of Pediatrician A once the patient was admitted. Specifically, that he did not consider an alternative diagnosis when the patient’s symptoms worsened and did not order a CTA until the receiving physician (EM Physician A) told him to before transferring the patient. EM Physician A made this request based on the information Pediatrician A gave over the phone. 

Pediatrician A was also criticized for failing to recognize the EKG report showing a right axis deviation, which would be unusual in an uncomplicated case of asthma in an adolescent. 

The results of the CTA revealed the PE, and it was stated by physicians reviewing this case that if the patient had been treated immediately he may have survived. 

Of great concern in this case was the failure to communicate or act on the results of the CTA (EM Physician A) before the patient’s transfer. Reviewers pointed out that the CTA images were available to view two hours before the transfer and there was no record that the results were shared with Pediatrician A or the transport team. It was also noted that Pediatrician A did not follow up on the CTA before the patient was transferred. 
 

Disposition

This case settled on behalf of Pediatrician A. The result of the case against EM Physician A is unknown. 
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More about diagnostic errors.
Risk management for pediatricians.
 

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