A patient presenting with a possible pulmonary embolism can be considered an emergency. Often the clinical picture may not be clear for a definitive diagnosis. There are standard clinical guidelines which are followed when a DVT or pulmonary embolism is suspected.
Recently, I was asked to review a case where a patient presenting with lower left leg pain and edema to the emergency room was sent home after evaluation and treatment for a DVT. Following discharge the patient returned several hours later in respiratory arrest from a pulmonary embolism, subsequently resulting in death. The question posed; was the treating hospital at fault? Was there a breach in the Standard of Care?
Venous thromboembolism (VTE) is a blood clotting condition that has two major manifestations:
Pulmonary embolism is usually a consequence of DVT. About 40 percent of patients with proximal DVT are found to have an associated pulmonary embolism by lung scan; about 70 percent of patients presenting with pulmonary embolism are found to have DVT in the legs.
Acute pulmonary embolism (PE) is a common and sometimes fatal disease with a highly variable clinical presentation. It is critical that therapy be administered in a timely fashion so that recurrent thromboembolism and death can be prevented. To provide prompt and accurate diagnosis, clinical prediction rules and diagnostic algorithms have been developed for VTE by The American Academy of Family Physicians and The American College of Physicians.
Three standards of practice when a DVT is suspected are:
1. Perform an initial assessment:
What is the clinical presentation? Is the patient symptomatic?
For the treating physician and nurse, it is imperative to complete a thorough head to toe assessment which will help to guide the clinical pathway for treatment.
As in the case presented, the patient presented to the emergency room with pain and edema to the lower left extremity ( indicative of a possible DVT). Vital signs were within normal limits with only the heart rate slightly elevated resolving after the patient had been monitored for several hours. Normal oxygen levels were observed.
2. Assessment of risk factors:
Risk factors should be assessed and pinpointed to further lead the treating clinician on the pathway to possible diagnosis of a VTE. VTE is the result of at least one of three etiolgic factors: hypercoagulability ( the ability/inability of blood to clot), alterations in blood flow ( how the blood flows or is pumped), and endothelial injury or dysfunction ( when the inner lining of blood vessels fail to function normally as in hypertension, coronary artery disease and cardiovascular conditions.)
Some factors suggest greater risk of VTE than others as listed in table below
In the case referenced, the patient had 2 risk factors that were categorized in the "weak risk factor" category. Increasing age and varicose veins.
The physician felt that with these risk factors, that further testing could be warranted, but that the patient did not present with the clinical picture of a pulmonary embolism. Therefore lab work , EKG and lower extremity ultrasound was ordered. A lung scan was not performed.
3. Perform the appropriate tests:
Performance of the appropriate test is based on the presenting clinical picture and the treating physician's discretion.
Initial testing can include:
Further testing may include:
As in the case referenced, a D-Dimer and CBC were performed with the D-Dimer being positive indicating a strong possibility of a DVT. A lower extremity ultrasound was then ordered as well as a chest x-ray. A blood clot was noted in the right lower extremity and the chest x-ray was noted to be clear. The treating physician did not feel any further testing was needed due to the patients' vital signs stabilizing and the absence of any respiratory distress. The patient was given a prescription for Lovenox and to follow-up with their family physician the following day. Instructions were given to return to the emergency room if the patient encountered any shortness of breath,chest pain or change in condition.
In many cases, the clinical picture is not indicative of further testing. Had the patient displayed any respiratory distress, chest pain, and/or increased heart rate which did not stabilize, further testing would have been warranted. A CT scan would have been likely ordered and the pulmonary embolis would have been noted with the patient being admitted and IV blood thinners given.
Many times what may seem to be a failure to treat or deviation of the Standard of Care by a clinician may in fact be what is indicated by current standards and guidelines. Having a Legal Nurse Consultant on your team who is able to utilize their experience, research and analytical skills to aid in the review of your case can help to enhance your understanding of the strengths and weaknesses , preparing you for litigation.
The American Academy of Family Physicians; www.aafp.org
The American College of Physicians; https://www.acponline.org
Image: by designer491; Book with diagnosis Pulmonary embolism (PE). Medic concept.