65 year old male with hx of COVID and pneumonia in 2 preceding years was following with lung and sleep clinic for chronic respiratory hypoxia. Use of supplemental oxygen had been ongoing for two years.
On 8/5/2025 patient presents with O2 sats of 75% despite 5L (improved during visit to 90) and reporting that could not walk more than 5 ft without his O2 sats dropping.
History included bilateral acute DVTs in 1/2024, no anticoagulation due to prior GI bleed, documented pulmonary hypertension on 10/2024 CT.
Seen by PA at pulmonary clinic on 8/6/2025 for Simple Pulmonary Stress Test which demonstrated severe hyposia and new need for 4L/min at rest and 10L/min with exertion.
Ordered STAT CTA to rule out PE but did not send to hospital or coordinate beyond order/referral. scheduled office follow up in 1 week.
Patient died morning of 8/7/2025.
Files:
Q: Where was he seen on 8/5/25?
A: at the lung and sleep clinic
Do you believe there might have been medical error?
1)Hx of DVT, not on anticoagulation 2) increased O2 demand 3) CTA indicated. But, could also be cardiac. Pt belonged in a monitored setting. Follow-up in one week indicates that the PA didn't understand the gravity of the case
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
1)Hx of DVT, not on anticoagulation 2) increased O2 demand 3) CTA indicated. But, could also be cardiac. Pt belonged in a monitored setting. Follow-up in one week indicates that the PA didn't understand the gravity of the case
What makes you a good expert for this case?
I have worked Emed for 25+ years. In my previous role, I was responsible for the oversight of APP Practice for a health system.
How often do you encounter cases similar to this one in your practice?
I often see patients with SOB, hx of DVT, new O2 demand (yesterday)
Do you believe there might have been medical error?
Based on the given information, I believe there was reason to send the patient for a more emergent workup than an outpatient CTA. It's a little unclear what happened on 8/5/25 as it says he presented but doesn't say to where, who saw him or what the plan was. This may have been the first missed opportunity. There is also some information missing (baseline O2 sat, baseline O2 requirements, other VS, other symptoms, physical exam, etc). I'd also like to know more about the ordered CTA, such as where/when it was to be performed and who was scheduling it. This could point to more of a systems error than a provider error. What were the timing requirements for obtaining a STAT CTA? Bottomline, though, if there is a high suspicion for a PE and a CTA can not be obtained immediately in the outpatient setting then it would be standard to send them to the ED. This would also allow for the initiation of anticoagulants. In this case, if this was a significant change from his baseline then further workup would have been warranted, even in the absence of a PE.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
This does not say the cause of death. Was an autopsy performed or is PE assumed? Regardless, it seems more likely than not that had the patient been further evaluated there would likely have been intervention to mitigate the consequences.
What makes you a good expert for this case?
I have been a PA for over 20 years and have experience in evaluating, diagnosing and treating PE as well as other causes of hypoxia. My experience spans both emergency medicine and outpatient surgical subspecialties. I also have extensive experience in medical legal review.
How often do you encounter cases similar to this one in your practice?
SOB/hypoxia is a common complaint to the ED and UC, and something that I've seen daily in practice. When I worked in ortho, DVT and PE were something I assessed patients for on a regular basis.
Do you believe there might have been medical error?
If someone is profoundly hypoxic with exertion, especially with history of PE and not anticoagulated, they should likely be evaluated in the emergency department.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
PE would require emergent treatment including anti coagulation, respiratory support, and possible thrombectomy.
What makes you a good expert for this case?
I frequently treat patients with chronic respiratory conditions and pulmonary embolism in the emergency department.
How often do you encounter cases similar to this one in your practice?
I don’t treat these as an outpatient but in the ED I encounter these patients several times per week.
Do you believe there might have been medical error?
A patient with that extensive of a medical history (especially pertaining to cardiopulmonary disease) with vital signs that are clearly abnormal (I do not know what his baseline oxygen saturation was, be he was having symptoms at a critical oxygen level--not good), documentation should have AT LEAST mentioned notification with supervising physician, but the PA should have referred this patient to the ER or called transport from their office. PE's are being treated on an outpatient nowadays, but this patient had enough going on to warrant an emergent workup. PA could have called the intake ER to present this patient and suggested CTA stat in that setting.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
This patient presenting in an ER setting may have saved their life. A CTA is appropriate, but given the details, this patient was having an actively critical problem. This is exactly what the ER is designed to handle.
What makes you a good expert for this case?
I have over 15 years of clinical practice as a Physician Assistant in a variety of settings--including surgical settings and Urgent Care--where I have diagnosed and triaged patients like this in the past.
How often do you encounter cases similar to this one in your practice?
Fortunately, not often. But I've seen enough of them. More importantly, I understand my role as a PA and when to notify my supervising physician of critical circumstances. This is more of a case of the PA not involving the supervising MD in a case that required it.
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