PERC negative PE death leads to $10M verdict

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Order trops, ddimers and CTAs liberally, or at least at the minimum document established decision rules. MDMs rehashing history and exam, or even test results if documented elsewhere in the note, isn’t overly helpful and just redundant. Document why it’s not the life threatening disease. You can do everything reasonable though and this is your reward. Hematologists and Cardiologists have no clue what it’s like working in the ED with a million undifferentiated patients and a full waiting room, but people love to MMQB.
 
Emapp20177 said:
expertwitness.substack.com

Death After ED Visit for COVID

Case #271
expertwitness.substack.com expertwitness.substack.com
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Not totally done reading this all but.... Wait ... A healthy appearing kid with normal vital signs has new symptoms A WEEK LATER and then has massive PE 5 additionally days after that, and it's the fault of the ED from 11 days ago? I saw a wonky EKG for sure, but it doesn't seem material to the case beyond "maybe that should be investigated more" but CTPE likely isn't that investigation.

Is the hematologist going to argue that the kid was hemodynamically stable for 7 days with a massive PE and "except for that one syncope" still hemodynamically for another 5 days before sudden cardiovascular collapse? That the saddle embolism was just sitting *juuuuuust* right for 264 consecutive hours before it shifted a little and killed him?

Edit: I see the hematologist was in the good guys' side . It's the jury that just decided the rules of the law don't matter and they just want to reward a sad family for being sad because God/fate isn't always fair or kind. Also that description of "changes that could suggest PE" is nonsense. They keep talking about TWI for v1... But that would be t wave up, which this guy doesn't have. V1 is flat or negative deflection if you put the lead correctly. I get that the kid has a ton of T wave inversions, but the one they are drilling on (v1) ain't one of them.
 
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This was not a cut and dry case. I would never call this gross negligence, but there is a legitimate case for simple negligence.

This was a patient who had a prothrombotic disease (at least initial strains) who then developed new onset pleuritic chest pain. He had a wonky EKG that was ignored and never had any lab testing done.

I’m hesitant to use the PERC score on Covid patients. This patient at the very least warranted a d-dimer and a troponin.

I would have tried to settle this case if the plaintiff would accept a reasonable offer.


Btw this is why I hated dealing with Covid back in 2020-2022. It caused pleurisy because of its predilection to affect the peripheral lungs, but it also caused thrombotic events. And it was never clear how to accurately the decision rules applied.

For anyone learning from this case, optimal care was not met, I’m 50/50 on whether SOC was met.
 
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Rendar5 said:
This was not a cut and dry case. I would never call this gross negligence, but there is a legitimate case for simple negligence.

This was a patient who had a prothrombotic disease (at least initial strains) who then developed new onset pleuritic chest pain. He had a wonky EKG that was ignored and never had any lab testing done.
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Ehhh... Patient didn't have a prothombotic disease. Patient's relative did. Unless I missed something, this was a family history. I know its famously called "hereditary antithrombin deficiency", but there wasnt any actual confirmation that he had it (either knowingly or unknowingly).
Rendar5 said:
I’m hesitant to use the PERC score on Covid patients. This patient at the very least warranted a d-dimer and a troponin.
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would it have mattered? Every specialist, even the ones for the plaintiff, basically agreed that he wouldn't have found the blood clot because it almost certainly didn't exist 11 days before his death. I get the argument for "they should have done a work up on that EKG" because they should have - in isolation. But then the next question becomes "to what end." Because it wasn't going to find a PE that wasn't there yet but eventually killed him. Is the goal just to show that you take abnormal EKGs seriously in people where their abnormal EKG is (likely) not related to their cause of death? It would really only serve to retrospectively make your defense in court look better, but not change the patient outcome I would think. Its just MMQBing knowing a bad outcome happened and working backwards from there. If we knew that we would be the last person to see x patient before they died of y disease, we would run z test (even if z test would have been negative given the specifics of how y did them in). As my post said, the kid died of a massive PE that was minimally symptomatic for (i forget how many) days.... then still minimally symptomatic for 7 more days. Then maybe finally made itself known. Then was asymptomatic again for 5 more days before making itself known one last time for the CV collapse. Massive PEs dont do that and both the defense and prosecution agreed on that.

Now do I see some weird logic that maybe he had small PEs that could have been stabilized by anticoagulation beforehand and then if stabilized he could have avoided the next clot (or two)? Perhaps, but I think I'm working really hard to try to make a case against myself because it honestly seems more like an act of god x1 clot rather than some series of clots that swap rapidly between symptomatic and asymptomatic.
Rendar5 said:
I would have tried to settle this case if the plaintiff would accept a reasonable offer.
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I think they did and the plaintiff rejected. IIRC at least.
Rendar5 said:
Btw this is why I hated dealing with Covid back in 2020-2022. It caused pleurisy because of its predilection to affect the peripheral lungs, but it also caused thrombotic events. And it was never clear how to accurately the decision rules applied.
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I mean. Yeah. I agree here.
Rendar5 said:
For anyone learning from this case, optimal care was not met, I’m 50/50 on whether SOC was met.
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8KTtscB.png
 
Rendar5 said:
caused thrombotic events. And it was never clear how to accurately the decision rules applied.

For anyone learning from this case, optimal care was not met, I’m 50/50 on whether SOC was met.
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Did we know this 09/14/2020? I forget. I am not sure we knew what SOC was for COVID on 09/14/2020.
 
If a d-dimer cannot be relied upon it should be banned from the ed entirely

Then just subsequently and exclusively used by ob/gyn who per my experience would order dimers liberally and never once address a positive result
 
Porfirio said:
Did we know this 09/14/2020? I forget. I am not sure we knew what SOC was for COVID on 09/14/2020.
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Part of the hematologist’s testimony is that Covid was not recognized as an independent prothrombotic risk factor at that time.
 
I actually published a case series of PE in “low risk” eg PERC negative patients in August of 2020… because that was novel / breaking information at the time.

Regardless, if they CTA’d at initial visit they wouldn’t have seen a PE. What is being suggested, that the Ed Md should have started lovenox? What a ****ty verdict.
 
Porfirio said:
Did we know this 09/14/2020? I forget. I am not sure we knew what SOC was for COVID on 09/14/2020.
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CDC did come out with very regular updates on SOC guidelines and recommendations as information was evolving (last time I reviewed these was 2 years ago for a case, hopefully they're still all accessible if needed). The guidelines mostly involved determining universal definitions such as what defined severe covid, the role of various medications and treatments, etc. At this point, the prothrombotic nature of the disease was known but iirc the guidelines only really addressed inpatient care, when to empirically treat, and what appropriate VTE ppx was. There was not a consensus and just a lot of suggestions with acknowledgment of the limits of our knowledge. Brief search of ACEP did turn up the following regarding the understanding in September 2020:
On the Question of Venous Thromboembolism in COVID-19: Some Answers, More Questions and Our Experience.


Keep in mind, my analysis of this case is both where optimal care was lacking, and where SOC may have been lacking. Only SOC departures ideally should lead to malpractice. The only probable SOC issue in this case was recognizing but then moving past a clearly abnormal EKG. What the physician didn't recognize was that the EKG screwed up his low pre-test probability of badness. I think this case falls clearly into the grey zone where you can make a reasonable argument for or against malpractice. This isn't a ridiculously bad case like some of the ones I've seen.
 
Regardless of the varying opinions on what a person would do with that EKG, the fact that this somehow met a gross negligence standard is insane.

That they were able to find an expert witness in Emergency Medicine who testified that this was GROSS negligence (to not obtain a D-Dimer or CT scan in a PERC negative adult) is why this result occurred. There's no case without that witness.
 
My greatest frustration with the pulmonary embolism rule out criteria is that it cannot rule out pulmonary embolism.

www.aliem.com

When the PERC Rule Fails

When the PERC Rule Fails: Pitfalls and caveats on the application of the Pulmonary Embolism Rule-out Criteria (PERC) to assess whether a patient has a PE.
www.aliem.com www.aliem.com
 
So hindsight 20/20 obviously - guess this may change my practice in a sense of maybe if I am going to order blood work and wells low risk you could just order the D-dimer rather than use perc. At end of day PTP has to be less than 15% whichever that means lol.
 
deuist said:
My greatest frustration with the pulmonary embolism rule out criteria is that it cannot rule out pulmonary embolism.

www.aliem.com

When the PERC Rule Fails

When the PERC Rule Fails: Pitfalls and caveats on the application of the Pulmonary Embolism Rule-out Criteria (PERC) to assess whether a patient has a PE.
www.aliem.com www.aliem.com
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2020 i probably would have done a very similar work up and discharged this patient. He is perc negative after all. I’m not super impressed by the ekg, v1-v4 t wave inversions can be from right heart strain, but kids and young adults can just normally have those as well.

Today, i probably would have done a D dimer and troponin - seen too much myocarditis or Perc negative PEs in the last 5 years in the post covid era. I do labs on most of my chest pain patients now. 98% sensitivity unfortunately is NOT good enough in America. Especially since we probably see 100 chest pains every month. Missing 2 a month is likely not acceptable.
 
This is why I have sympathy for rising healthcare costs.

Even though this is a large verdict it’s highly unlikely that they will be on the hook for the entire amount and if they are they can just declare bankruptcy
 
Ridiculous verdict

However, that ECG in the context of pleuritic chest pain is pretty worrying, even for a 21 year old.
 
watermanMD said:
That’s a reasonable ass note. **** this game.
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agree the note was great.
That ekg was abnormal.
Why order ekg if you are t going to act on it?

That being said, this was not negligence.
Also, is there no responsibility for patient to come back in for reassessment if increasing sob and syncope. Seems like there was plenty of time for patient to catch this and death was not proximate to initial visit
 
johhnybgood said:
agree the note was great.
That ekg was abnormal.
Why order ekg if you are t going to act on it?

That being said, this was not negligence.
Also, is there no responsibility for patient to come back in for reassessment if increasing sob and syncope. Seems like there was plenty of time for patient to catch this and death was not proximate to initial visit
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Yeah the partial workup did not help the doc. Note was pretty good though, even included time specific follow up & return precautions.

Gross negligence though? "a high degree of carelessness or reckless disregard for the safety of others, demonstrating a conscious and voluntary disregard for the need to use reasonable care."

Yeah, seems like a stretch.

This case also brings up how AMAs/shared decision making does not help you in a court. Patient didn't follow the docs documented advice (return if something changes).
 
Emapp20177 said:
Yeah the partial workup did not help the doc. Note was pretty good though, even included time specific follow up & return precautions.

Gross negligence though? "a high degree of carelessness or reckless disregard for the safety of others, demonstrating a conscious and voluntary disregard for the need to use reasonable care."

Yeah, seems like a stretch.

This case also brings up how AMAs/shared decision making does not help you in a court. Patient didn't follow the docs documented advice (return if something changes).
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At the end of the day - bad outcome in medicine requires some unfortunate person to take the blame.
 
A few important things. 1) crazy you can find an expert to testify against a doc here. But some docs are money ****** and are just puppets of the plaintiffs attorneys no matter how dumb the “science” is 2) this is the difference between a good attorney and not. to 99.9% of EM docs this is clear. To the 0.1% money ****** with no functional neurons it isnt. The jury doesnt know better.. now a $10m judgement (which will settle for less).
 
It would be pretty easy to find an expert to say that this is an abnormal EKG and, in the setting of chest pain and shortness of breath, is concerning for a PE and they'd be right. In order to use PERC, they've got to be low risk. You can't have this EKG and be low risk. Nonetheless, tough case.

If you sent the EKG to Dr. Smith's EKG blog with just the chief complaint, I bet a PE would be incredibly high on his differential.
 
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It's just obnoxious the entire thread here is like: "oh, yeah, I've never heard of this specific EKG association with PE, but obviously *something* is going on" where the legal standard is supposed to be "average physician" (say 15th to 85th percentile).

So tired of seeing a "perfect care" standard.
 
xaelia said:
It's just obnoxious the entire thread here is like: "oh, yeah, I've never heard of this specific EKG association with PE, but obviously *something* is going on" where the legal standard is supposed to be "average physician" (say 15th to 85th percentile).

So tired of seeing a "perfect care" standard.
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Also they just reference some websites but no text books.
 
JacobMcCandles said:
It would be pretty easy to find an expert to say that this is an abnormal EKG and, in the setting of chest pain and shortness of breath, is concerning for a PE and they'd be right. In order to use PERC, they've got to be low risk. You can't have this EKG and be low risk. Nonetheless, tough case.

If you sent the EKG to Dr. Smith's EKG blog with just the chief complaint, I bet a PE would be incredibly high on his differential.
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EKG not in PERC. Could argue gestalt and/or Wells wasn’t low risk…but also EKG not included in those either, right?
Ultimately not an egregiously wrong or subpar practice demonstrated by the doc in this case. Certainly not a slam dunk case. Reasoning wasn’t unsound. An unfortunate miss. Very scary that this is the outcome for imperfection.
 
watermanMD said:
EKG not in PERC. Could argue gestalt and/or Wells wasn’t low risk…but also EKG not included in those either, right?
Ultimately not an egregiously wrong or subpar practice demonstrated by the doc in this case. Certainly not a slam dunk case. Reasoning wasn’t unsound. An unfortunate miss. Very scary that this is the outcome for imperfection.
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As you mentioned, it needs to be low risk (<15% pre-test probability). If someone has chest pain, shortness of breath, and an EKG that could be indicative of right heart strain, I’m not sure I’d call that low risk and PERC wouldn’t even be applicable. I agree this is tough case and not gross malpractice and, as with most bad cases, it’s easy to look in hindsight.
 
xaelia said:
It's just obnoxious the entire thread here is like: "oh, yeah, I've never heard of this specific EKG association with PE, but obviously *something* is going on" where the legal standard is supposed to be "average physician" (say 15th to 85th percentile).

So tired of seeing a "perfect care" standard.
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I don’t think anyone is arguing that this is true malpractice, but come on. There are major teaching points here that need to be recognized to provide better care, not perfect care.

That ekg does not need to be specific to PE to not be recognized as completely abnormal and inappropriate to a male in their 20’s. Maximum V1,V2, and III should be inverted in that group to be normal (V3!is a stretch but maybe). The doc in this case committed the same fallacy that lots of doctors do—completely ignored a blatantly weird EKG because the patient seemed fine and didn’t fit a demographic. the patient needed at least some lab testing.

I will still say that at least 50% of doctors would have made this mistake (and even if they hadn’t there’s no guarantee they would have found a PE or had a different ultimate outcome), but please realize for teaching purposes this was still a true mistake and fallacy within the realm of standard of care.
 
This is why I order labs/troponins on basically any chest pain these days. Patients like it, parents like it, hsTrop q1h x2 doesn't take that long if active chest pain, and if I'm even considering ordering a dimer I just tell patients up front, "we're going to get some labs to make sure cardiac and lung function are looking good, then we'll either get a CXR or CT scan depending on what we're looking for structurally" so nobody is surprised. Even in the barely positive d dimer cohort there are a LOT of pneumonias that are picked up on CT not seen on CXR. I order what lets me sleep at night.

Funky-a** EKG that was called out in the note but wasn't actually addressed, oof. I agree it wasn't ultimately this doc's fault because wtf EMS, and not coming back despite return precautions and worsening symptoms, but this was the time for CYA medicine. Sad truth is I'm more likely to get sued than to give a patient cancer with the CT I order. And even if that isn't true, well, sorry but that's the price for this ridiculously litigious society.
 
Also, while I agree that there was no standard of care breach, who the hell is documenting “short of breath with exertion” and then discharging a patient with just an EKG?

If I’m already planning to discharge that patient, that phrase is not getting anywhere near my chart regardless of whether it came out of the patient’s mouth. That’s like documenting “tearing chest pain radiating to my back” and discharging with just an EKG”, or discharging “rebound abdominal tenderness” with just a KUB, or “worst headache of my life” with just a migraine cocktail.

Either ignore the comment, or work it up, but your charts shouldn’t be court transcriptions of what patients complain of.
 
Zebra Hunter said:
Also, while I agree that there was no standard of care breach, who the hell is documenting “short of breath with exertion” and then discharging a patient with just an EKG?

If I’m already planning to discharge that patient, that phrase is not getting anywhere near my chart regardless of whether it came out of the patient’s mouth. That’s like documenting “tearing chest pain radiating to my back” and discharging with just an EKG”, or discharging “rebound abdominal tenderness” with just a KUB, or “worst headache of my life” with just a migraine cocktail.

Either ignore the comment, or work it up, but your charts shouldn’t be court transcriptions of what patients complain of.
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You can document that if there are other clinical findings to suggest the cause. If somebody has wheezing, productive cough suggestive of bronchitis, etc., then yeah, it's ok to document that if you document the other findings.

More importantly, someone with dyspnea on exertion that doesn't have other clinical findings should get a workup. I agree with @gruemd. It may not be cool with the nurses to just cavalier it with a chest x-ray and EKG without labs, but I order what lets me sleep at night. For nearly all chest pains it's at least a single hsTroponin. D-dimers get ordered when they aren't PERC negative/Wells 0. Of course, chest pain after getting hit in the chest doesn't get the full workup, but the case in discussion was not that case.
 
...the sad thing is when you show up for jury duty on this case or similar medmal cases... ANY medical professional would be dismissed from the jury pool. A plaintiff attorney would boot you ASAP, knowing full and well that you are educated and a "peer". Totally contradictory to what we all envision as a "jury of our peers".

Also, gross negligence... AYFKM?
 
What would be the downside to every healthcare system having sovereign immunity? Patients can still sue and get reparations, just not drag down doc with the suit. Medical boards or other entity of peers can reprimand doc if deemed egregious or dangerous on case-by-case basis. This place (USA) is ****ed.
 
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watermanMD said:
What would be the downside to every healthcare system having sovereign immunity? Patients can still sue and get reparations. Medical boards or other entity of peers can reprimand doc if deemed egregious or dangerous on case-by-case basis. This place (USA) is ****ed.
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I think the majority of us would be fine. But there are a handful of power hungry or sociopathic dirt bags that would still make a bad name for docs. In all specialties. I think it's just a function of the human condition, but most of us can control and suppress it.
 
Rendar5 said:
I will still say that at least 50% of doctors would have made this mistake (and even if they hadn’t there’s no guarantee they would have found a PE or had a different ultimate outcome), but please realize for teaching purposes this was still a true mistake and fallacy within the realm of standard of care.
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The argument here isn't whether it's a case worth review – though we still only have a limited set of information – but that ol' "standard of care" issue. There are a lotta very average docs out there who wouldn't be keeping up on the web, podcasts, etc., just getting their CME at ski conferences and LLSAs and plowing through the minimum. The more we sit here and claim this doc made a bonehead mistake, the less protected we all are, and the more absurd the overtesting culture and expectations will become.
 
Very easy to say “yeah, I would get a work up.” Harder to live in the moment.

So many unknowns. Sept 2020 was fu*king hell. Hospitals were overwhelmed, we all were beat down, the medical system was failing (no PPE, etc), there were plenty of other patients that were more sick than this patient at the time the doc was seeing him, this could have been a new grad or young attending (not sure the lawsuit said anything about that).

I don’t think this doc did anything wrong in the moment. So many of these patients during this time did not have an EKG/chest X-ray. So many of these patients did not have 2 weeks to be sick with COVID before dying. So many of these patients did not have as many chances for help as this patient had. So many missed opportunities on the patient’s part.

We cannot guarantee 2 weeks of immortality.
 
watermanMD said:
What would be the downside to every healthcare system having sovereign immunity? Patients can still sue and get reparations, just not drag down doc with the suit. Medical boards or other entity of peers can reprimand doc if deemed egregious or dangerous on case-by-case basis. This place (USA) is ****ed.
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People still want their pound of flesh when they're pi$$ed. If they can't get anything via the civil route, they may go after you with criminal charges. That's much worse as far as I am concerned.
 
This case and the ER note and subsequent lawsuit is why I don't spend 2 paragraphs writing what many believe to be protective medmal language in the chart. It's a waste of time. It doesn't protect you against aggressive lawyers.

If you have someone with chest pain and say "I considered dissection" or even sent a d-dimer and it was negative, and the pt dies of a dissection in the next few days, nobody is going to care about whether you considered dissection, or used a d-dimer, or used EBM, or did any of that crap.

I probably would have run some labs, troponin, and maybe a d-dimer (I don't know though) with that EKG. It's not normal for a 20 year old guy. Sad case. Absolutely no gross negligence at all.
 
thegenius said:
This case and the ER note and subsequent lawsuit is why I don't spend 2 paragraphs writing what many believe to be protective medmal language in the chart. It's a waste of time. It doesn't protect you against aggressive lawyers.

If you have someone with chest pain and say "I considered dissection" or even sent a d-dimer and it was negative, and the pt dies of a dissection in the next few days, nobody is going to care about whether you considered dissection, or used a d-dimer, or used EBM, or did any of that crap.

I probably would have run some labs, troponin, and maybe a d-dimer (I don't know though) with that EKG. It's not normal for a 20 year old guy. Sad case. Absolutely no gross negligence at all.
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It won't help what test you do is all that matters but there was a case where a EM doctor was dropped from pending litigation on a subarachnoid case for saying they considered it but didn't order a CT head. It was on the expert witness substack website the plaintiff though didnt really want to pursue it
 
Brigade4Radiant said:
It won't help what test you do is all that matters but there was a case where a EM doctor was dropped from pending litigation on a subarachnoid case for saying they considered it but didn't order a CT head. It was on the expert witness substack website the plaintiff though didnt really want to pursue it
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Anyone claiming to know definitively what is and isn’t protective is FoS. We have no data and only limited examples of cases that never made it past the medical record review stage due to certain case factors. All we have to go on is cases that made it to the point of a claim being filed, which is going to be a minority of cases, and is going to be a biased sample. There are way too many things that go into a single case to pinpoint one specific thing that prevented a claim from being filed.

There are a million different ways people have burned themselves in their note or workup. There are people that did nothing wrong and still had to pay out. There are people that have wrote beautiful, defensible notes and still lost. The only thing that definitively prevents claims is not having bad outcomes which are unfortunately inevitable.

Nevertheless, I believe it is a third of EM docs that will never be named in their career, and the majority of EM physicians will have no more than 1 paid malpractice claim in the entirety of their career. This is why I spend little mental energy on writing perfectly defensible notes, and just focus instead on finishing them efficiently in a way that maximizes billing and prevents headaches from difficult patient encounters that I know will turn into complaints, which is going to be way more common than a lawsuit. Its why I have no problem roasting ridiculous patients in notes so I never have to get a phone call from hospital admin or my medical director about a patient claiming I’m Satan when my note gives no indication of an unpleasant encounter. I’ll take the 1 in 100,000 chance (chance of losing a malpractice claim/number of patients seen in a career) this patient ends up successfully suing me.
 
Zebra Hunter said:
Anyone claiming to know definitively what is and isn’t protective is FoS. We have no data and only limited examples of cases that never made it past the medical record review stage due to certain case factors. All we have to go on is cases that made it to the point of a claim being filed, which is going to be a minority of cases, and is going to be a biased sample. There are way too many things that go into a single case to pinpoint one specific thing that prevented a claim from being filed.

There are a million different ways people have burned themselves in their note or workup. There are people that did nothing wrong and still had to pay out. There are people that have wrote beautiful, defensible notes and still lost. The only thing that definitively prevents claims is not having bad outcomes which are unfortunately inevitable.

Nevertheless, I believe it is a third of EM docs that will never be named in their career, and the majority of EM physicians will have no more than 1 paid malpractice claim in the entirety of their career. This is why I spend little mental energy on writing perfectly defensible notes, and just focus instead on finishing them efficiently in a way that maximizes billing and prevents headaches from difficult patient encounters that I know will turn into complaints, which is going to be way more common than a lawsuit. Its why I have no problem roasting ridiculous patients in notes so I never have to get a phone call from hospital admin or my medical director about a patient claiming I’m Satan when my note gives no indication of an unpleasant encounter. I’ll take the 1 in 100,000 chance (chance of losing a malpractice claim/number of patients seen in a career) this patient ends up successfully suing me.
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This is what I would have approximately written, had I wrote three paragraphs.

Most ER notes are poorly composed—they’re often either defensive, offering little valuable information, or written primarily to maximize billing, which is similarly unhelpful. I wish there was one section in the note where physicians could freely document their genuine clinical impressions about the patient encounter, without concern about repercussions.
 
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