Pulmonary embolism (or "PE") is the blockage of the main artery of the lung. It is often a result of a blockage in the leg (deep vein thrombosis, DVT) which travels through the blood to the lung.
Pulmonary embolism and DVT are two manifestations of venous thromboembolism which has a reported annual incidence of 100-300 per 100,000 in Western countries. It is ranked as the third most prevalent cardiovascular disorder. Incidence is equal between men and women. Incidence is higher in women of child-bearing age due to the associated risk of pulmonary embolism with pregnancy and with some birth control medications, but it is higher in older men compared to older women. Incidence increases with age, from a rate of 5 per 100,000 in childhood to 500-600 per 100,000 in individuals 75> years of age.
Pulmonary embolism may result in irreversible damage to the affected lung, reduced oxygen in the blood, organ damage due to lack of oxygen, or in the case of a large clot, death may occur. It is estimated that only 1 in 5 individuals suspected to have pulmonary embolism have the diagnosis confirmed.
Diagnosis is complicated as the presentation of pulmonary embolism varies from no symptoms to cardiogenic shock. If symptoms do occur they may include chest pain, shortness of breath or coughing up blood. Blood clot symptoms in the leg include swelling, pain, tenderness or redness of the affected location.
Diagnosis is based on clinical symptoms and laboratory tests (e.g. D-dimer test) and imaging (e.g. Computed tomographic pulmonary angiography (CTPA)). CTPA is becoming the standard of care to evaluate subjects with suspected pulmonary embolism. Treatment usually includes anticoagulant medication.
In a study published in May of 2011, researchers analyzed the Nationwide Inpatient Sample and Multiple Cause-of-Death databases and compared incidence, mortality and complications of pulmonary embolism in the United States. Data was analyzed prior to (1993-1998) and after CTPA introduction (1998 to 2006). After the introduction of CTPA, the incidence of pulmonary embolism increased from 62.1 per 100,000 to 112.3 per 100,000. Mortality from pulmonary embolism has been steadily decreasing in recent years. From 1993 to 1998, mortality rates dropped from 13.4 to 12.3 per 100,000 and reduced to 11.9 per 100,000 after the introduction of CTPA. CTPA has led to the identification of more emboli, however, this has also led to over diagnosis of pulmonary embolism and unnecessary treatment. Further, complication rates due to the use of anticoagulants increased by 71% after introduction of CTPA. However, if left untreated, pulmonary embolism can have a mortality rate as high as 25%.Misdiagnosis of a Pulmonary Embolism
The sobering truth of PE cases is that the majority of patients who die from pulmonary embolism are patients who are never treated for pulmonary embolism.
There is no question that a pulmonary embolism can sometimes be tough to diagnose. Doctors have a lot of sometimes confounding variables to consider in figuring out the cause of the patient's difficulties. In some cases, a doctor can miss a pulmonary embolism and still render reasonable treatment consistent with the standard of care.
But, too often, patients with shortness of breath and obvious risk factors for PE that read like a billboard end up with a diagnosis of panic attack, anxiety, or something else less serious.
That seems to be the problem, really, with many misdiagnosis cases. Doctors fail to rule out the more serious of the potential problems and then arrive at the less serious diagnosis. It is easier. It takes time and energy to take the appropriate steps to rule out more serious life threatening problems. A chest x-ray might help a doctor rule out pulmonary embolism because there are no changes in the blood vessel patterns after embolism and signs of pulmonary infarction. So might a blood test, an electrocardiogram, d-dimer, and ultrasound, pulmonary angiography, lung perfusion scan, or a CT angiogram. Sometimes the easy answer, "Oh, she's anxious and hyperventilating, there is no need to look any further" leads to medical malpractice failure to properly diagnose lawsuits.
A study published in the Archives of Internal Medicine (2000), explored physicians' attitudes toward the misdiagnosis of pulmonary embolism and treatment of patients. The results of the study indicated that physicians may provide treatment for pulmonary embolism without confirmation of an embolus rather than take a chance in missing a case of pulmonary embolism.
Sometimes doctors don't appreciate the significance of the risk factor they ignore. The main reasons for misdiagnosis of pulmonary embolism include low awareness of risk factors by physicians, variability in patient symptoms, misinterpretation of tests, and atypical clinical manifestations. Radiologists must ensure the quality of the CTPA study and if pulmonary embolism is actually present. Any uncertainty should be stated as such and additional imaging should be requested if appropriate.
Another study published in 2009 evaluated the use of diagnostic flow-charts used in the management of pulmonary embolism, pointing to its potential in misdiagnosis. The authors commented on the complexity of the algorithm which includes several consecutive tests. The algorithm states that chest X-rays found to be normal are generally followed by ventilation perfusion (V/Q). Where non-high V/Q is reported, patients should receive a CTPA. The study found that this algorithm was only used properly in 74% of patients studied. Misuse of the algorithm may lead to delay in establishing or excluding pulmonary embolism, delays in treatment or unnecessary treatment.
Here is a simpler statistics that puts the PE misdiagnosis problem in even better context. Approximately 21 percent of otherwise healthy young people with pleuritic chest pain -- sudden sharp, stabbing, burning or dull pain -- without no known risk factors for pulmonary embolism that present to an emergency department just with onlythat type of pain in fact have a pulmonary embolism. With a greater than 1 in 5 chance, you really want to rule out a PE, right?Standard of Care in Pulmonary Embolism Cases
What exactly do doctors have to do? The standard of care for patients who presenting to the hospital or doctor with signs and symptoms that indicate a pulmonary embolism requires proper selection of therapies that can be administered. This typically involves heparin. It is incumbent upon the treating doctor to order proper diagnostic tests in order to diagnose the patient's condition and rule out a pulmonary embolism. This may include:
- Immediate recognition of the potential diagnosis of pulmonary embolism in the first place which is usually what leads to malpractice cases;
- Administration of anti-coagulation;
- Obtaining imaging studies to ascertain the diagnosis (i.e., spiral chest CT scan, V/Q scan, Doppler ultrasound of lower extremities);
- Closely monitoring of the patient in a telemetry setting.
Below is a number of example case results in PE malpractice claims. These are educational and, in some cases, illustrative of the value of cases with similar fact patterns. But keep in mind there are not two cases that are perfectly alike and that someone getting a verdict that sounds similar to yours does not mean - for better or worse - that you will get the same outcome.
- June 2013, Illinois: $800,000 Settlement: A sixteen year-old girl is 39 weeks pregnant and arrives at the hospital to deliver her child. Although the girl is not in active labor, the treating obstetrician chooses to give her an epidural. The epidural is monitored by an anesthesiologist. After 36 hours of monitoring, she begins labor. Unfortunately, as soon as labor begins she starts to code. The baby is delivered – a healthy child, thankfully – but the young mother dies from a pulmonary embolism due to a blood clot in her left leg. The young girl’s family sues on her behalf against the hospital and the treating physicians for medical malpractice. Plaintiff’s counsel claims the young girl had a high risk factor for developing blood clots as she was immobilized for 36 hours, overweight, and displayed signs of her legs swelling. Accordingly, the obstetrician improperly ordered the epidural and should have given her compression boots to prevent her from developing a blood clot. Plaintiff’s counsel also alleges that the anesthesiologist failed to communicate with the obstetrician about the risk of administering an epidural for an extended period of time. The defendants argue that the standard of care did not require the doctors to reduce the epidural over a 36 hour time frame. They also claim an issue of disputed fact: they were following the request of the girl, who wished to have a vaginal birth, and immediately began an emergency C-section the moment she began to seize. The parties resolve this claim prior to trial for $800,000.
- November 2012, Pennsylvania: $310,000 Settlement: A 50 year-old man begins to experience slurred speech and collapses while at work. He is rushed to a hospital emergency room via ambulance where the defendant physician performs an exam and EKG. The man is diagnosed with chest pains likely secondary to pleurisy or costochondritis and is discharged after a few days in the hospital. Six days pass and the man begins to feel similar symptoms and hastily dials 911 from his home. The paramedics arrived but diagnose the man with a panic attack and inform him that his condition does not warrant medical transportation and leave. The distressed man then calls his friend to inform him of the transportation refusal. The friend arrives shortly thereafter to take him to the ER, only to find him without a pulse and unconscious. The man is pronounced dead at the emergency room from a pulmonary embolism. A wrongful death and survival action ensues. This is a classic differential diagnosis case. Plaintiff argues the doctor and hospital should have ruled out a pulmonary embolism and failed to do a proper work up evaluation. They also brought suit to the ambulance company for negligence in concluding the decedent’s symptoms were caused by anxiety without consulting a doctor. The doctor and hospital deny liability and claim that all care provided to the decedent followed medical standards. The ambulance company also denies liability and claim that it was the decedent who refused transportation to the hospital. The parties choose to settle their dispute for $310,000, underscoring some of the weaknesses in the family’s claim.
- June 2012, Virginia: $1,700,000 Settlement: A 49 year-old man receives arthroscopic surgery that includes reconstruction of the ACL. He has a history of deep vein thrombosis from a previous knee surgery. He was placed on anticoagulants after his first surgery, but is not placed on the medication following the second surgery. Six days after the second surgery, the recovering man collapses after experiencing chest pains and difficulty breathing and is quickly transported to the hospital. Unfortunately, the man is declared dead shortly after arrival. Plaintiff alleges the defendant was negligent in failing to prescribe an anticoagulant medication following his second surgery. Plaintiff’s medical experts believe the decedent died from a pulmonary embolism, using cardiac monitoring strips and physical presentation to support their claim. The defendant contends the man died from a heart attack and that the standard of care did not require the decedent be placed on anticoagulation medication. The parties reach a resolution prior to trial for $1,700,000.
- May 2012, New Jersey: $1,045,000 Verdict: A 44 year-old father of three (with a fourth on the way) arrives in the emergency room with shortness of breath and intermittent chest pains that have been occurring for the past several days. Prior to his arrival, the man had used a walking boot for several weeks and informs the emergency room nurse of such. He is discharged with a diagnosis of a virus. Unfortunately, the father-to-be dies the following morning of pulmonary embolism. Plaintiff’s counsel establish the nurse had recorded the history of the decedent’s boot, and had the defendant read the entry, he would have known the patient was at a higher risk of a pulmonary embolism. They contend that a differential diagnosis of a pulmonary embolism should have been considered and the patient should have been admitted and tested. Plaintiff’s expert present studies have shown that 90% of individuals who receive treatment for pulmonary embolism recover – indicating that had the defendant considered a pulmonary embolism; the man’s children would have been able to grow up with a father. The defendant denies the decedent had a pulmonary embolism when he arrived at the emergency room and that the embolism developed the next morning shortly before his death. The defense also argues that a patient suffering from a pulmonary embolism only has a 10% chance of surviving. The jury found in favor for the plaintiff and awarded $1,045,000.
- June 2011, Maryland: $6,116,000 Verdict: A young man arrives in the emergency room with a low-grade temperature, cough and dizziness. He is treated by the defendant where he is given a differential diagnosis that includes pneumonia, congestive heart failure and pulmonary embolism. The defendant conducts and EKG, chest X-ray and labs, and concludes the man is suffering from pneumonia and has him transferred to a second hospital. Although the hospital is alerted of the plaintiff’s arrival, he is neither evaluated by a house physician nor is he seen by the admitting physician. While left unattended with his wife by his side, the young man attempts to get out of bed only to collapse in front of her. He never regains consciousness and is pronounced dead. The cause of death is noted as a pulmonary embolism and confirmed by an autopsy. Plaintiffs allege the defendants were negligent in failing to timely diagnose and treat a pulmonary embolism. They claim that had the defendants treated the pulmonary embolism with anticoagulation therapy, his chances of survival would have been at almost 95%. The jury finds in favor of the plaintiffs and award $6,116,000.
If you believe you have been a victim of medical negligence in Maryland as the result of a doctor's failure to properly diagnose you real injury, call 800-553-8082 or get a free online medical malpractice consultation.