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Recent Cases Where NPs Missed Pulmonary Emboli
JNP
Recent Cases Where NPs Missed Pulmonary Emboli LEGAL LIMITS Carolyn Buppert Like all conscientious clinicians, nurse practitioners (NPs) are always concerned that we make the correct diagnosis. Missing subtle symptoms or a challenging case that doesn’t look like the textbook still would dismay us. One of those very tricky diagnoses is that of pulmonary emboli. Consider these cases.
Case 1 A 45-year-old man fell off a horse trailer and arrived at a clinic short of breath, dizzy, tachycardic, and with low oxygen saturation. A nurse practitioner (NP) at the clinic allegedly did not refer the man for emergency care and failed to diagnose possible pulmonary embolism (PE). The man died 2 days later of PE. The NP said she advised the man to seek emergency care, but he did not follow the advice. The parties reached a settlement. This case and the next were reported in the May 2009 issue of Malpractice Verdicts, Settlements and Experts.
Case 2 A 48-year-old man burned his leg and foot while cooking French fries. His family physician and a hand surgeon evaluated him. During rehabilitation, he became disoriented, hyperventilated, was short of breath, and reported seeing aliens. He was depressed. His wife called both the family physician and the hand surgeon 4 times over 2 days. She never spoke with the physicians. Two days later, an NP who worked for the family physician returned her call and prescribed Prozac for depression. Shortly thereafter, the patient suffered a massive pulmonary embolus and died. The plaintiff claimed the defendants were negligent in failing to properly respond to 646
The Journal for Nurse Practitioners - JNP
the phone calls and that prompt intervention would have avoided the pulmonary embolus. The defendants claimed that the only information relayed to their offices was that the patient was depressed and “talking funny.” A jury found for the defense. The problem with PE is that symptoms and signs can be vague. “A good clinician should consider the diagnosis if any suspicion of PE exists, because prompt diagnosis and treatment can dramatically reduce the morbidity and mortality of the disease. Unfortunately, the diagnosis is often missed, because PE frequently causes only vague and nonspecific symptoms. PE is so common and so lethal that the diagnosis should be sought actively in every patient who presents with any chest symptoms that cannot be proven to have another cause.”1 A brief summary of foundational information about PE suggests the following. • PE is traditionally diagnosed by the classic triad of signs and symptoms (hemoptysis, dyspnea, chest pain), which are all neither sensitive nor specific and may occur in less than 20% of patients with PE. Most patients who have those symptoms are also found to have another etiology for them. For patients who die from massive PE, dyspnea is present in 60%, chest pain is present in 17%, and hemoptysis occurs in 3%. At the same time, respiratory complaints are most common in patients who are seen alive in the ED and later die unexpectedly.1 The reality is that the presence of any of these classic signs and symptoms should warrant a complete diagnostic evaluation. • The incidence of physical signs in patients with PE has been reported1,2 as follows: o 96% have tachypnea (respiratory rate > 16/min) o 58% develop rales o 53% have an accentuated second heart sound o 44% have tachycardia (heart rate > 100/min) Volume 5, Issue 9, October 2009
o o o o
43% have fever (temperature > 37.8°C) 36% have diaphoresis 34% have an S 3 or S 4 gallop 32% have clinical signs and symptoms suggesting thrombophlebitis o 24% have lower extremity edema o 23% have a cardiac murmur o 19% have cyanosis Some scales have been developed to score the likelihood of a patient developing PE. For example, the Wells Criteria for Pulmonary Emboli assigns a numerical score to such clinical findings as previous pulmonary embolus or deep venous thrombosis, heart rate greater than 100 beats per minute, recent surgery or immobilization, clinical signs of deep venous thrombosis, an alternative diagnosis less likely than pulmonary embolus, hemoptysis, and cancer.3,4 According to Sutherland, these scoring algorithms are more subjective and less powerful than desired. For example, writes Sutherland, the objective components of the Wells (Canadian Pulmonary Embolism Score) criteria, have shown to have little effect on the stratification power of the criteria with virtually all of the classification power associated with subjective prejudgment of physician as to the likelihood of PE being present.5 • Because PE is both common and difficult to diagnose, many patients seen in the ED die later from undiagnosed PE that is only revealed at autopsy.6 • PE can arise from anywhere in the body; most commonly it originates in the calf veins. • “Pulmonary thromboembolism is not a disease in and of itself. Rather, it is a complication of underlying venous thrombosis.”1 • “A small number of often repeated mistakes in diagnosis and treatment are responsible for a large proportion of the bad outcomes with serious legal repercussions.1 The most common and most serious of these errors are as follows. o Dismissing complaints of unexplained shortness of breath as anxiety or hyperventilation without an adequate workup or unexplained chest pain as musculoskeletal pain without an adequate workup o Failing to:
www.npjournal.org
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Properly diagnose and treat symptomatic deep vein thrombosis (DVT) Recognize that DVT below the knee is just as serious as more proximal DVT Order a CTPA or V/Q scan when a patient has symptoms consistent with PE Start full-dose heparin at the first real suspicion of PE, before the V/Q scan Give fibrinolytic therapy immediately when a patient with PE becomes hemodynamically unstable
Comments on the Cases Consider PE whenever a patient presents with chest symptoms that cannot be proven to have another cause. In Case 1, the NP should have arranged for emergency transportation to an emergency department and, if the patient refused, should have documented that the patient was informed of the need for emergency evaluation and treatment and the urgency and the possible consequences of failing to get such evaluation. In Case 2, there was a lack of appropriate triage by telephone. The physician offices should have returned the wife’s phone call sooner, and the NP should have performed a thorough telephone evaluation and then advised emergency department evaluation. References 1. Sutherland F. Pulmonary embolism. Available at: http://emedicine. medscape.com/article/759765 overview. Accessed July 6, 2009. 2. Tapson VF. Acute pulmonary embolism. N Engl J Med. 2008;358(10):1037-1052. 3. Wells PS, Anderson DR, Rodger M, et al. Derivation of a simple clinical model to categorize patients’ probability of pulmonary embolism: increasing the models utility with the SimpliRED d-dimer. Thromb Haemost. 2000;83:416-420. 4. Online Wells score calculators. Available at: www.uptodate.com Accessed on August 26, 2009. 5. Wells PS. Advances in the diagnosis of venous thromboembolism. J Thromb. 2006;21(1):31-40. 6. Sandler DA, Martin JF. Autopsy proven pulmonary embolism in hospital patients: are we detecting enough deep vein thrombosis? J R Soc Med. 1989;82(4):203-205.
Carolyn Buppert, CRNP, JD, practices law in Bethesda, MD. She can be reached at [email protected]. 1555-4155/$ see front matter © 2009 American College of Nurse Practitioners doi: 10.1016/j.nurpra.2009.08.006
The Journal for Nurse Practitioners - JNP
647
Recent Cases Where NPs Missed Pulmonary Emboli LEGAL LIMITS Carolyn Buppert Like all conscientious clinicians, nurse practitioners (NPs) are always concerned that we make the correct diagnosis. Missing subtle symptoms or a challenging case that doesn’t look like the textbook still would dismay us. One of those very tricky diagnoses is that of pulmonary emboli. Consider these cases.
Case 1 A 45-year-old man fell off a horse trailer and arrived at a clinic short of breath, dizzy, tachycardic, and with low oxygen saturation. A nurse practitioner (NP) at the clinic allegedly did not refer the man for emergency care and failed to diagnose possible pulmonary embolism (PE). The man died 2 days later of PE. The NP said she advised the man to seek emergency care, but he did not follow the advice. The parties reached a settlement. This case and the next were reported in the May 2009 issue of Malpractice Verdicts, Settlements and Experts.
Case 2 A 48-year-old man burned his leg and foot while cooking French fries. His family physician and a hand surgeon evaluated him. During rehabilitation, he became disoriented, hyperventilated, was short of breath, and reported seeing aliens. He was depressed. His wife called both the family physician and the hand surgeon 4 times over 2 days. She never spoke with the physicians. Two days later, an NP who worked for the family physician returned her call and prescribed Prozac for depression. Shortly thereafter, the patient suffered a massive pulmonary embolus and died. The plaintiff claimed the defendants were negligent in failing to properly respond to 646
The Journal for Nurse Practitioners - JNP
the phone calls and that prompt intervention would have avoided the pulmonary embolus. The defendants claimed that the only information relayed to their offices was that the patient was depressed and “talking funny.” A jury found for the defense. The problem with PE is that symptoms and signs can be vague. “A good clinician should consider the diagnosis if any suspicion of PE exists, because prompt diagnosis and treatment can dramatically reduce the morbidity and mortality of the disease. Unfortunately, the diagnosis is often missed, because PE frequently causes only vague and nonspecific symptoms. PE is so common and so lethal that the diagnosis should be sought actively in every patient who presents with any chest symptoms that cannot be proven to have another cause.”1 A brief summary of foundational information about PE suggests the following. • PE is traditionally diagnosed by the classic triad of signs and symptoms (hemoptysis, dyspnea, chest pain), which are all neither sensitive nor specific and may occur in less than 20% of patients with PE. Most patients who have those symptoms are also found to have another etiology for them. For patients who die from massive PE, dyspnea is present in 60%, chest pain is present in 17%, and hemoptysis occurs in 3%. At the same time, respiratory complaints are most common in patients who are seen alive in the ED and later die unexpectedly.1 The reality is that the presence of any of these classic signs and symptoms should warrant a complete diagnostic evaluation. • The incidence of physical signs in patients with PE has been reported1,2 as follows: o 96% have tachypnea (respiratory rate > 16/min) o 58% develop rales o 53% have an accentuated second heart sound o 44% have tachycardia (heart rate > 100/min) Volume 5, Issue 9, October 2009
o o o o
43% have fever (temperature > 37.8°C) 36% have diaphoresis 34% have an S 3 or S 4 gallop 32% have clinical signs and symptoms suggesting thrombophlebitis o 24% have lower extremity edema o 23% have a cardiac murmur o 19% have cyanosis Some scales have been developed to score the likelihood of a patient developing PE. For example, the Wells Criteria for Pulmonary Emboli assigns a numerical score to such clinical findings as previous pulmonary embolus or deep venous thrombosis, heart rate greater than 100 beats per minute, recent surgery or immobilization, clinical signs of deep venous thrombosis, an alternative diagnosis less likely than pulmonary embolus, hemoptysis, and cancer.3,4 According to Sutherland, these scoring algorithms are more subjective and less powerful than desired. For example, writes Sutherland, the objective components of the Wells (Canadian Pulmonary Embolism Score) criteria, have shown to have little effect on the stratification power of the criteria with virtually all of the classification power associated with subjective prejudgment of physician as to the likelihood of PE being present.5 • Because PE is both common and difficult to diagnose, many patients seen in the ED die later from undiagnosed PE that is only revealed at autopsy.6 • PE can arise from anywhere in the body; most commonly it originates in the calf veins. • “Pulmonary thromboembolism is not a disease in and of itself. Rather, it is a complication of underlying venous thrombosis.”1 • “A small number of often repeated mistakes in diagnosis and treatment are responsible for a large proportion of the bad outcomes with serious legal repercussions.1 The most common and most serious of these errors are as follows. o Dismissing complaints of unexplained shortness of breath as anxiety or hyperventilation without an adequate workup or unexplained chest pain as musculoskeletal pain without an adequate workup o Failing to:
www.npjournal.org
■
■
■
■
■
Properly diagnose and treat symptomatic deep vein thrombosis (DVT) Recognize that DVT below the knee is just as serious as more proximal DVT Order a CTPA or V/Q scan when a patient has symptoms consistent with PE Start full-dose heparin at the first real suspicion of PE, before the V/Q scan Give fibrinolytic therapy immediately when a patient with PE becomes hemodynamically unstable
Comments on the Cases Consider PE whenever a patient presents with chest symptoms that cannot be proven to have another cause. In Case 1, the NP should have arranged for emergency transportation to an emergency department and, if the patient refused, should have documented that the patient was informed of the need for emergency evaluation and treatment and the urgency and the possible consequences of failing to get such evaluation. In Case 2, there was a lack of appropriate triage by telephone. The physician offices should have returned the wife’s phone call sooner, and the NP should have performed a thorough telephone evaluation and then advised emergency department evaluation. References 1. Sutherland F. Pulmonary embolism. Available at: http://emedicine. medscape.com/article/759765 overview. Accessed July 6, 2009. 2. Tapson VF. Acute pulmonary embolism. N Engl J Med. 2008;358(10):1037-1052. 3. Wells PS, Anderson DR, Rodger M, et al. Derivation of a simple clinical model to categorize patients’ probability of pulmonary embolism: increasing the models utility with the SimpliRED d-dimer. Thromb Haemost. 2000;83:416-420. 4. Online Wells score calculators. Available at: www.uptodate.com Accessed on August 26, 2009. 5. Wells PS. Advances in the diagnosis of venous thromboembolism. J Thromb. 2006;21(1):31-40. 6. Sandler DA, Martin JF. Autopsy proven pulmonary embolism in hospital patients: are we detecting enough deep vein thrombosis? J R Soc Med. 1989;82(4):203-205.
Carolyn Buppert, CRNP, JD, practices law in Bethesda, MD. She can be reached at [email protected]. 1555-4155/$ see front matter © 2009 American College of Nurse Practitioners doi: 10.1016/j.nurpra.2009.08.006
The Journal for Nurse Practitioners - JNP
647