Pulmonary embolism diagnosis often requires a combination of due diligence and independent thought and luck. I can't tell you how many times I've had massive pulmonary emoboli diagnosed in patients without any risk factors or unstable vital signs. But I've also had patients with every sign and symptom conceivable and a high pretest probability who's workup was negative.
I recently had a 96 year old male that was admitted through the emergency room with pneumonia. The hand off was straight forward. My night doc partner took the call for the day docs to come evaluate in the emergency room after morning report was complete.
ED Doc: I've got an elderly man in room six that needs to be admitted for pneumonia.
Night Hospitalist: OK, we'll send someone down there in a bit.
So Happy went to admit this 96 year old man with pneumonia. I took a look at all the data. The nursing home transfer sheet said his oxygen saturation was 78%, improved to 88% on three liters. He had dementia. His history was unreliable.
I took a look at the chest xray and noted the patient to have a basilar effusion on both sides. He also had possible infiltrates associated perhaps with the compressive atelectasis. He had no evidence of jugular venous distension.
At the point of my evaluation he had an oxygen saturation of 100% on a nonrebreather, which is the over compensated oxygen delivery of choice for any ED patient who even looks short of breath from the door way. He appeared to be a pleasantly demented man in no distress.
He was afebrile with a white blood cell count of 13K. He had already received his dose of antibiotic in the emergency room, beating the CMS quality indicator time period by a good four hours. But something just wasn't right.
Why did the guy suddently decompensate so quickly? Why was his infection count basically normal? Why was he afebrile? And why did he have effusions present? I wasn't convinced he had pneumonia , sepsis or any other infectious process going on.
So I ordered the d dimer level. I ordered a BNP blood test and a procalcitonin. Why you ask? These are three excellent blood tests who's negative values help to exclude, with high probability, the likelihood of having disease (great negative predictive value). A normal d dimer level would dramatically reduce the clinical probability of pulmonary embolism. A normal BNP would dramatically reduce, if not eliminate the probability of acute heart failure. And a normal procalcitonin assay would all but exclude a bacterial infection as the source of respiratory failure.
I could have admitted her as a pneumonia. She certainly could have it. I could have left it at that. I could have accepted the diagnosis of another excellent physician and proceeded with the management of the patient as one of pneumonia. But I didn't.
I used my clinical experience to tell me that all the data wasn't adding up. When the d dimer level and bnp assay both came back very high and the procalcitonin level normal, I knew that the diagnosis was originally missed. It happens to all of us. Pneumonia was a very plausible explanation. It just wasn't the right explanation, this time. Lawyers would say that a bad outcome from a delayed diagnosis should be compensatory negligence in our current tort system. This is just one common example of why the medical legal process is flawed. Part of the differential diagnosis process requires a failed or delayed diagnosis.
Subsequent studies confirmed the pulmonary embolism diagnosis. A massive saddle embolism.. It also showed evidence of a failing heart pump. I could have been pigeon holed into the diagnosis of pneumonia. This is a major diagnostic error that physicians battle all the time. The herd mentality can pigeon hole doctors into accepting the most popular diagnosis. But taking the time to independently evaluate the data requires an extra step of diligence, every time.
Is it negligence that the diagnosis was missed by the emergency room doctor? Of course not. Missed diagnosis is part of the differential diagnosis process. And no matter how diligent we as physicians are, we are never going to get it right every time. I just happened to get it right this time. Next time, the patient may not be so lucky. Thus is the nature of clinical medicine.
365 Days of Discharge Episode 6
365 Days of Discharge Episode 6
