A 62 year old man presented to his cardiologist for a routine cardiac examination with complaints of fatigue and insomnia on October 6, 2018. The cardiologist ordered a blood pressure medication, an echocardiogram and a nuclear stress test. On Oct 16 the patient underwent a stress test at the same facility. After the stress test the patient began to feel more tired than previously and his right hand began to swell. Over the following few days he became extremely fatigued and the swelling in his right hand extended up to the elbow. On Oct 22, because of those worsening symptoms, the patient went back to his cardiologist. At this time he did not complain of chest pain or shortness of breath. The cardiologist told him that his fatigue was probably due to the significant drop in his blood pressure caused by the medication prescribed on Oct 6, and gave him samples of new blood pressure medication, and a script for additional labs. At about 12:30 a.m. on Oct 23, the patient got out of bed and collapsed almost immediately after standing up. He was transported, unconscious, to the Emergency Department. He never regained consciousness and was pronounced dead at 1:00 AM on Oct 23. The official cause of death was pulmonary embolism but no autopsy was done.
The plaintiff’s estate is claiming that the IV placed on Sep 15 triggered a thrombosis that then extended more proximally to the vein of the upper extremity over the next six days.
I have the following questions: 1. Would it be possible for a small IV catheter in the arm to cause a fatal PE event? 2. Should have the cardiologist ordered a work up for PE on Oct 22?
Files:
Q: What was patient's vital signs on the October 6th visit? Specifically, what was the heart rate and O2 saturation? Also, what labs were ordered on that date and what was the results?
A: T 36.5; HR 85: BP 150/85; RR 18; 97% on room air
Q: Did the patient complain about the arm swelling to the cardiologist on the Oct 6th visit?
A: No
Q: How did they diagnose the PE if there was no autopsy?
A: When he went back to the cardiologist on Oct 22, he was told he likely had a thrombophlebitis. The records from the ED list DVT/PE as the likely diagnosis based on the worsening swelling of the right upper extremity
Q: Was there a doppler of the arm ordered at any time?
A: No
Do you believe there might have been medical error?
There was no sign or symptom to make the cardiologist suspicious of PE. If patient would've told the cardiologist about the arm swelling, them a doppler of the extremity would've been necessary to evaluate for possible DVT. However, if patient did not inform the cardiologist about the swelling in the arm, and that is very common to be missed on a routine exam.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The small peripheral IV for a short period of time for the purpose of stress test does not cause large PE to cause such outcome. Small peripheral IVs can cause superficial thrombosis which does not need treatment because they don't cause PE. Also, if there was no doppler, no CT angio, one cannot presume the cause of death was a PE. Patient may have had a myocardial infarction or a ventricular tachycardia as the cause of death.
What makes you a good expert for this case?
I'm an ICU physician and manage many patients with PE. From mild to most severe form of PE that causes sudden death.
How often do you encounter cases similar to this one in your practice?
As an ICU physician, I see multiple patients with PE every week in the hospital setting.
Do you believe there might have been medical error?
The new are swelling should have been further investigate.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Given the patient’s prior history of PE, fatigue, and new arm swelling there is plausible causation. I will of course need more information regarding this case.
What makes you a good expert for this case?
I am board certified in cardiology and vascular medicine. I was trained at Johns Hopkins in Vascular Medicine, which include thromboembolic disease (eg PE)
How often do you encounter cases similar to this one in your practice?
Rarely, but it can be missed if not included the differential diagnosis.
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