70 y/o male presents for laparoscopic appendectomy on 7/2/20. Pathology positive for adenocarcinoma. DVT prophylaxis in place with Lovenox and SCDs. Hemicolectomy performed on 7/10/20. Early morning hours 7/11/20, pt c/o SOB. Inf Disease at 8:13am orders CXR and documents SOB. Urology at 9:41 documents SOB. ARNP for Int Medicine documents SOB at 11:09 and in consult with DO, orders Mucinex. At 1:30PM. surgery documents pt "feels dyspneic." Throughout the day, O2 sats normal but pt remained tachycardic. Pt suffered PEA at 2115. Autopsy confirmed bilateral pulmonary thromboemboli due to a deep vein thrombosis.
1. No negative D-Dimer since PE was never considered or r/o
2. RR normal on 7/11
3. HR elevated 110-118 but pt had sinus tach on 7/5 and given beta blocker which was not administered on 7/11 since NPO and thereafter normal
4. No prior HX of DVT or PE
5. No evidence extremities were ever examined during hospital stay
6. O2 sats normal on 2L n/c
7. CXR positive for atelectasis at lung bases
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Q: Thanks for the information. When you indicate normal sats, I assume > 95-96% as anything lower on 2L/NC would be quite low.
A: —
Do you believe there might have been medical error?
If the patient was on appropriately dosed prophylactic Lovenox and SCDs, then the standard of care was met. If the patient missed a dose of Lovenox or was not dosed properly, then he would be at increased risk of developing thromboembolic disease.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
As above, until a medical error is established, causation is speculative. It remains unclear why PE was not suspected in light of the new onset of shortness of breath and unexplained tachycardia, both of which are classic signs and symptoms of PE. Even if no medical error was done in terms of Lovenox prescribing, there was a clear delay in diagnosis which did lead ultimately to the untimely death.
What makes you a good expert for this case?
20+ years experience as a hospitalist Interim Associate Medical Director of Quality Prior case reviews of missed PE
How often do you encounter cases similar to this one in your practice?
Thankfully not often at all but that is because the diagnosis is suspected, evaluated, and managed in a timely fashion.
Do you believe there might have been medical error?
Regarding peri op care - they did provide excellent DVT/PE prophylaxis. But this was a high risk patient based on history of surgery and cancer. Therefore despite Lovenox/SCDs, PE still can occur. If the CXR was normal, than I think the pre test probability of a + CTA would be higher than if it showed abnormalities such as PNA or significant atelectasis. D-dimer useless here if + (post op), If it was negative - that would tend to rule out PE. My questions are: 1) was there a negative D-dimer, 2) what were the resp. rates that day (was tachypnea documented), 3) did patient have a prior hx of DVT/PE, 4) did anybody examine extremities for signs of DVT and 5) was the patient on O2 which would mask hypoxia - would like to know the sats and amount of O2 if used. My answer below at this state is closer to unsure.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
If there was failure to diagnose PE/DVT (see above), then there was an opportunity to start anticoag or if severe findings on CTA, direct intra pulmonary arterial thrombolysis (not systemic post op).
What makes you a good expert for this case?
Clinician since 1982 - critical care training and 15+ years experience in addition to 22 years as a hospitalist. Experience practicing in both large AMCs and mid size community hospitals working with and without housestaff. Extensive research background in medical errors, patient safety, addressing a variety of solutions to prevent errors/harm. Over 20 years of medical legal consulting experience for both plaintiffs and defendants (~ 45/55 split). I am usually able to review cases within 1-2 weeks. Happy to provide my CV.
How often do you encounter cases similar to this one in your practice?
We do medical consults on post operative patients including pre op clearance as well. DVT/PE is a common hospital acquired complication that we dx and tx.
Do you believe there might have been medical error?
Patient was appropriately on DVT prophylaxis with both lovenox and SCDs.. While his SOB may have indeed been due to pulmonary embolism, there is no medical error here as patients are often tachycardic postoperatively and there is no suspicion for PE given appropriate prophylaxis and normal oxygen saturation
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
There is no negligence to have caused any medical error in this case for above
What makes you a good expert for this case?
As a hospital based cardiologist, I am the first person called when a patient is short of breath post operatively
How often do you encounter cases similar to this one in your practice?
I have encountered this multiple times (Although patients do not die) dual Prophylaxis should be effective over 99% of the time
Do you believe there might have been medical error?
Patient with pathology proven adenocarcinoma of the appendix-at risk for hypercoagulable state due to carcinoma. Undergoes a hemicolectomy and complains of new onset shortness of breath. One must immediately rule out pulmonary embolus secondary to DVT. None of this was done.Multiple consults documented shortness of breath but take no action to rule out pulmonary embolus. Patient remains tachycardic which is another indicator of possible pulmonary embolus,despite the "normal"O2 sat. Patient continues to report "feels dyspneic" but again no one considers pulmonary embolus as a cause of his acute onset of shortness of breath post prolonged surgery.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Due to the failure to rule out a pulmonary embolus in a patient that had undergone a prolonged surgical procedure and complains of new onset shortness of breath,the patient did not receive appropriate anticoagulation therapy and therefore died of bilateral pulmonary thromboemboli.secondary to deep vein thrombosis.
What makes you a good expert for this case?
I have reviewed over 60 medical records over the past seven-to -eight years ,including several cases in which pulmonary embolism was not diagnosed in a timely manner,resulting in the death of the patients.
How often do you encounter cases similar to this one in your practice?
In my practice,never,but in the review of many other outside cases,unfortunately too many.
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