Brief Summary of Case Review:
A 46-year-old woman called her primary care office with complaint of a cough and shortness of breath. She came in for an appointment and was seen by the physician’s assistant (PA). There were two physicians and a physician’s assistant on duty at that time. Her vital signs were normal. Her initial oxygen saturation was 94% and on re-check was at 97%. The PA documented a differential including upper respiratory infection and pulmonary embolism. She ordered a chest xray (CXR) and an ultrasound (US) for the bilateral lower extremities. The patient was given an albuterol inhaler and steroids.
The results of the CXR and the ultrasounds of the lower extremities were both negative for any acute process. Three days later the patient called and reported that she had worsening phlegm production. A z-pak was prescribed. Within 24 hours, the patient had collapsed and was taken to an academic medical center. She was diagnosed with a saddle pulmonary embolus (PE), a basilar artery occlusion and right carotid artery occlusion. She had a long hospital course and slowly declined despite numerous aggressive interventions including a craniectomy. She died 3 weeks after her initial visit. During the patient’s hospital stay, the doctors discovered that she had an underlying condition that increased the likelihood of thromboembolic disease. The husband in deposition stated that he first noticed that “one leg was thicker than the other when I first started dating her. That was from birth, from what I understand.” After her death the family contacted a law firm.
The lawsuit was filed in February 2016 (more than 2 years after the patient’s death).
The defense never submitted any of their own expert opinions.
The case dragged on for 5 years and reached a confidential settlement in July 2021.
MD Reviewer Analysis #1:
This case is a slam dunk for the plaintiff. The PA documented that she was concerned for a PE and then failed to test the patient for a PE. This failure cost the patient her life and (likely) her employer’s insurance millions of dollars.
The expert’s claim that an oxygen saturation of 94% is hypoxic is objectively incorrect. This is another example of an expert overreaching on their criticism. There are numerous valid criticisms in this case, there was no need for the expert to ruin their credibility by making the hypoxia claim.
The two physicians who had previously seen the patient were also named as defendants in the lawsuit, despite not being involved in the patient’s care at her final visit. They never made any attempt to directly review the PA’s care. They were sued for inappropriate supervision and not having diagnosed the patient’s underlying medical condition that increased likelihood of thromboembolic disease.
The plaintiff argued that if the doctors and PA had appropriately made the diagnosis of KTS, they would have known that she was at risk for PE and would have been more aggressive with the workup.
To make things worse for the defense, they found evidence that the patient had already been diagnosed with KTS years earlier. During a pregnancy she was found to have unusual vascular malformations in her uterine wall and was diagnosed by 2 MFM physicians.
MD Reviewer Analysis #2:
I honestly do not think that knowing she had KTS would have changed the outcome. The presentation was atypical for PE, even if they had known the patient had a predisposition to thromboembolic disease. This is an extremely rare disease, and many physicians have little knowledge about it or the potential complications.
The PA’s documentation made this case very hard to defend. If she had simply documented the reason why she felt it wasn’t a PE, it could have been defended (even though it was an incorrect assessment). We are not responsible for making a correct diagnosis every time, but we are expected to make logical and rational decisions. Documenting a logical and rational explanation about why she did not suspect PE (even though incorrect) could have provided grounds for a vigorous defense.
Aside from thromboembolic disease such as stroke, DVT, and PE, patients can also have bleeding complications from AVMs. These can include GI or intracranial bleeding.
Legal Nurse Consultant Analysis:
For all the mismanagement and lack of appropriate care of this patient on the part of the primary care office especially with the failed initial outpatient treatment, this patient should have been transported directly to the emergency department during her first presentation to the PCP office for a full work up of the shortness of breath. ED physicians would have applied the PERC Rule (see definition of this rule below) which she screens positive for with the <95% oxygen saturation and unilateral leg swelling (one met criteria is a screen-in). The patient would have had the gold standard of care applied which starts in the EC, a V-Q scan (ventilation and perfusion) and pulmonary angiography, and a D-Dimer blood test all to rule out a Pulmonary embolus. The diagnosis would have been swiftly made, and this patient would have been admitted to the ICU for further care.
This patient was referred to a maternal-fetal-medicine (MFM) specialist, (a doctor who helps take care of women having complicated or high-risk pregnancies) while pregnant at 30 years old, due to a suspicious ultrasound documented in her medical records at the time. These doctors are obstetricians who also completed 3 extra years of training in high-risk pregnancy. They are also called perinatologists and high-risk pregnancy doctors.
The Ultrasound performed in 1998 was suspicious of vascular malformations involving the right side of the body (port-wine stain) and newly found vascular malformations in the uterine wall. The MFM clearly states that the presence of cutaneous hemangiomas, varicose veins, and ipsilateral (belonging to or occurring on the same side of the body) hypertrophy of extremity suggest that she might have Klippel-Trenaunay-Weber (KTW) syndrome as a possible diagnosis.
Their care of this patient during pregnancy included a preparedness for bleeding complications during the peripartum period of her pregnancy as they had noted uterine angioma on prenatal ultrasound. They also documented that an MRI of the uterus at that time could delineate further about vascular involvement of the myometrium. For some reason the OB/GYN did not pass this consult on to the primary care physician for the recommended follow up for further investigation.
As a Legal Nurse Consultant, I would have requested that the plaintiff or defense attorney (depending on the attorney client I was representing) request the OB/GYN records as a part of a woman’s complete health care records. The reason this is important is that women with chronic conditions/diseases can often become complicated high-risk OB/GYN patients when pregnant and these conditions need to be known as part of her complete health care history.
As a Legal Nurse Consultant reviewing the medical record from the OB/GYN, this information would have been noted and would have been brought to the attention of the attorney client. The MFM specialist records would have been requested. Had this possible diagnosis been known about early-on in the case, and the research presented to the attorney as a possible cause, I would have suggested an MD expert review this case and it likely would have been settled as the defense would have found it difficult to defend. An interesting note is that the patient was employed by her insurance company who ended up paying for their employee’s untimely death what was sure to be an astronomical settlement.
The Perc Rule
The PERC rule (Pulmonary Embolism Rule Out Criteria) is used to rule out pulmonary embolism in those patients where the clinical gestalt is that they are low risk (i.e., <15% risk of pulmonary embolism).
Pulmonary embolism can be ruled out if none of the following features are identified:
- Age ≥50 years
- Heart rate ≥100 bpm
- Oxygen saturation <95%
- Hemoptysis
- Estrogen use
- Prior DVT or PE
- Unilateral leg swelling
- Surgery/trauma within the previous four weeks
In patients with a low pre-test probability of PE who meet any of these criteria, further testing could be considered to rule out pulmonary embolism more definitively.