Episode 075: Out of Breath and Time

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Brian: Hello. Thank you for joining us on today's episode of our podcast. My name is Brian Fortenberry. Previously we have spoken with our guest today. Eric Funk joined us. He is the editor and the founder of the website MedMalReviewer.com. He's back with us today on this episode to be able to discuss information about a particular medical malpractice case. If you have yet to hear our previous podcast regarding his website and all of the information, I would highly recommend you go back and check that podcast out as well. But for those who have not been able to do that yet, first let me introduce you to Eric Funk. Eric, thanks for being here again today.

Eric: Thanks for having me, Brian. It's good to be here.

Brian: Tell us a little bit about your background and your experience before we jump into the case we're going to discuss today.

Eric: Sure, no problem. I am an emergency medicine doctor and I am currently practicing at a level one trauma center in Missouri. I did my training in emergency medicine at the Mayo Clinic and did a year as the chief resident there as well, and I am also the founder and editor of MedMalReviewer.com.

Brian: Once again, thank you for taking the time to be here to discuss this. Today, we're going to really going to get into the particulars of a case that you have reviewed. So before we get into discussing a lot, why don't you go ahead and intro the case and tell us what we're going to be talking about?

Eric: Sure. So the case that we're going to be discussing today is case number one from my website. If listeners want to follow along, they can just navigate to MedMalReviewer.com and then up at the top on the left-hand side, you'll see the link to case one. And all the information that we're going to be talking about is there as well. So, if you want to follow along at home, that's fine. Or look at things later, that's great as well. To give kind of the basic rundown of what happened with the case, this was a 31-year-old gentleman and he presented to the emergency department with a chief complaint of shortness of breath and we have been able to collect the information about his history from a couple different sources.

So the first thing that happened when he hit the door of the emergency department was a triage nurse saw him and the triage nurse was able to document kind of some basics, that he had been having a cough for two days, he had had a fever. He felt short of breath, which was ultimately his chief complaint. And then he also had some pain in his back that he described as restricting his breathing. So after the basic triage history was completed, some vital signs were obtained, the patient was found to be febrile with a fever of 102.8 degrees Fahrenheit. He was noted to have a fast heart rate at 136 beats per minute. He was also breathing fairly rapidly at 26 breaths per minute. He did have a normal oxygen level at 97% and just the slightly high blood pressure at 157/107. So after the triage nurse had gotten the basic history and we had an initial set of vital signs, and he was taken back to a room in the emergency department, and shortly thereafter the physician came in to see him.

The physician's note is documented there on the site, but basically the physician didn't notice anything that was too different from the triage nurse assessment. The physician initially noted that the symptoms were worsening over the past couple days. The physician also noticed that there was some chest pain along with this, so now we have some pain in the back as well as some chest pain in the front, and that the patient had also vomited earlier. But the patient was a 31 year old, and so he was relatively healthy otherwise.

The physician then went ahead and did a physical exam of the patient. Just looking at him, it didn't look like he was in any noticeable respiratory distress. The physician did document that he had a regular rate and rhythm, which would generally suggest that the patient had a heart rate somewhere between 60 beats per minute and 100 beats per minute, although we know from the triage note that his heart rate was measured at 136 beats per minute, so it would generally be considered to be outside of that regular rate and rhythm that was documented. And then the other thing that was noted on examination was that he had some redness on his right foot.

So after the physician had taken the time to take a history and do a physical exam, a differential was essentially included that kind of had some information about what the physician thought could be happening, and some of the differential was taken that we can basically pull from the orders that the physician put in, we can kind of assume basically what he was thinking. The things that it looks like this physician were thinking about would be a pneumonia, could certainly be explaining these symptoms. A heart attack or heart failure, or potentially a blood clot in the gentleman's lungs could be the main things that could be explaining his symptoms. The doctor never explicitly said what they were thinking about, but we've essentially deduced that from the tests that were ordered.

Brian: Gotcha.

Eric: In particular, the tests that were ordered were a complete blood count, a complete metabolic panel looking at essentially the kidney function, the liver function, and the electrolytes. A D-dimer test was ordered, and for the listeners who are non medical, this is essentially a test that shows if there's any sign that there could be a blood clot anywhere in the body, and it's a test that isn't very accurate, but if it comes back negative, then you're essentially fairly confident that the patient does not have a blood clot, but if it comes back positive, then you have to do a little bit more looking to see if that blood clot may actually be in the lungs. And then the other blood test that was ordered were blood cultures, and that's essentially looking for bacterial or fungal infection within the patient's bloodstream. The other tests that the physician ordered were a chest x-ray, so that's obviously going to show if there are signs of pneumonia or a few other abnormalities can be seen there. A DVT ultrasound was ordered, and essentially what that is is an ultrasound will be done on the patient's legs to look and see if there's any sign of a blood clot in the legs themselves. And then the final test that was ordered was a CT scan of the chest. The rationale or the thinking behind ordering the CT scan of the chest is going to be to show the physician if there could potentially be any blood clot within the lungs. Those were the tests that were ordered.

The patient was given some treatment while they were waiting for the results of the tests. They were given Toradol, which is a pain reliever. They were given some muscle relaxant, Tylenol, and then they were also given some antibiotics and some antifungal as well. The physician's note mentioned that he was suspicious that the redness on the foot may be related to a fungal infection. So that was the treatment that was given. And after a time period in the emergency department, the results came back and they found that on the ultrasound of the legs, there were not any blood clots in his legs at all. The x-ray of the chest didn't show anything abnormal or unusual. The lab test came back, overall not anything too concerning with the exception of the D-dimer that was fairly elevated, and you'll remember that that's something that tells us if there is the potential to have a blood clot in the lungs.

The final thing and the thing that ultimately caused a lot of the trouble, in this case, was that the final test that was ordered was the CT scan of this patient's lungs, and unfortunately, the physician hit a little bit of an issue when trying to get the study completed, and the issue was that the patient, unfortunately, weighed too much to fit on the CT scanner. The equipment in this emergency department wasn't large enough to handle the patient, and so it would've been unsafe to put the patient on the CT scanner to get the study done. And so at this point, the physician had kind of a couple different options and they essentially elected to go ahead and discharge the patient home with treatment for bronchitis and a foot infection. And so, the physician felt that even though they had ordered the study and that they initially felt that it should be done, because it was going to be too much of a challenge to get this study done, that it just wasn't worth doing and went ahead and diagnosed him with an alternative diagnosis being bronchitis, which could certainly explain some of his symptoms and the foot infection itself. So that was essentially the first visit to the emergency department and the patient was discharged and went along his way.

Brian: You obviously see from this history that is documented there, for the most part a relatively healthy guy, but something is going on here and obviously we wouldn't be discussing this if something bad had not happened. So, what was the ultimate outcome of the case?

Eric: The patient was discharged home and he had actually been given some instructions to follow up with the physician if he wasn't feeling better in a couple days, but the patient was feeling better after a few days and he was actually in the process of that time getting ready to move across the country. And so, over the next about two weeks or so, got all his stuff packed up and moved to a completely different state all the way across the country. And then, unfortunately, about 18 days after the initial ER visit, he again started to develop the same shortness of breath. So he had improved a little bit, but now was worsening. And this time in addition to having the shortness of breath, he started to have some episodes of passing out.

And so, the family was understandably concerned by this and ended up calling 911 given that he kept passing out, and he was taken to a different hospital to an emergency department. And on the ambulance ride in, his shortness of breath really became quite severe and unfortunately just as they were arriving to the emergency department, the patient lost pulses and went into cardiac arrest. So the ER doctor who was working has this patient come in who has CPR in progress and they're doing chest compressions, and they made heroic attempts to save his life, but unfortunately were not successful and the patient passed away while he was in the emergency department.

Brian: So, a tragic outcome unfortunately for this young man. What was the ultimate final cause of death here?

Eric: Yeah, given the patient was relatively young and healthy otherwise, an autopsy was done to see if they could figure out what exactly it was that resulted in this patient's death, and the autopsy did, in fact, show large blood clots in this patient's lungs. The death certificate lists pulmonary artery thromboembolism as the cause of death. You know, it's one of those things that it's impossible to tell what exactly caused the patient's first presentation to the original ER, but it's fairly suspicious given the autopsy that shows a pulmonary embolism and the fact that the original treating doctor at the first ER thought about a blood clot and even tried to order the test to assess it. It's pretty suspicious that this was a blood clot that ultimately caused the patient's death.

Brian: That's so unfortunate, because like you said earlier, the crux of everything seems to really have come down to not being able to do the CT on the patient. So obviously, this probably ended up being filed as a lawsuit, correct?

Eric: Yes, that's correct. So the patient's family talked to an attorney and a lawsuit was filed against the original doctor who had seen him in the emergency department and discharged him without completing the CT scan. In this circumstance, the case wasn't settled before the trial, so it did go all the way to a jury trial. And after hearing the circumstances and hearing the expert witnesses, and going through the whole trial process, the verdict was for the plaintiff and the award that was given was $2.75 million.

Brian: Just a tragic incident and a case that ended up in the death of this young man. Hopefully, one of the reasons, as we stated in a previous podcast, for doing these types of reviews on your site was to learn from it. That being said, what can we learn from this particular case?

Eric: So one of the main things that we can learn from this case is in regards to the documentation. Now I'll say before I talk about the documentation that no matter what the physician had written, the bad outcome that we see here was going to end up in all likelihood in a lawsuit. There wasn't anything that could be documented to avoid a lawsuit. I think there were a couple of things that the physician could have done better to help better explain his reasoning or rationale. 

The main thing that should've been explained was the rationale for foregoing the CT scan. Within the physician's note itself, it never actually explained why the patient couldn't undergo a CT scan. And so, having even documented why the patient couldn't undergo a CT scan would've been something that would've been wise to include. The physician would've been also wise to document any other attempts that they made to obtain the CT scan or explain why they didn't make any other attempts.

Brian: Right.

Eric: Oftentimes physicians in this circumstance will call around to surrounding hospitals or try to refer the patient to a large academic medical center who oftentimes is well equipped with the equipment that they need to obtain CT scans on obese patients. So that would've been something that would've been useful to include and just as a general rule, any time a physician is doing something that is a little bit atypical or unusual, even if it seems obvious to them at the time, you need to explain any of those atypical decisions that are made. In this circumstance, the other atypical decision is the decision to discharge this patient even after you've considered life-threatening diagnoses such as a pulmonary embolism.

Brian: Sure.

Eric: So, taking a little extra time, even taking 20 or 30 seconds extra to explain what happened and what your thinking was and why you thought that it was okay to discharge this patient would've been a wise idea. Now, the other thing that we can learn from this case is in regards to the medical learning points. So we mentioned earlier about the options to transfer a patient to a different hospital that has a CT scanner that could handle this patient's weight. So that is one of the very first things that we can learn is that there are always other hospitals out there that can help handle a patient that may have some extenuating circumstances that need to be arranged.

Another learning point would be that this patient certainly could've been admitted to the hospital if the physician couldn't find any referring center to take them. He could've admitted the patient to the hospital and started blood thinners, which would've been the treatment for the potential blood clot. And then during the next day or two with a little bit more time on your side, you could've figured out where this patient could go to ultimately have the scan done or to figure out an alternative way of diagnosing the blood clot.

Another one of the important learning points is in regard to this patient's vital signs at the time of discharge. When this patient was discharged, they still had a heart rate that was really quite elevated and for any board-certified emergency medicine doctor, sending a patient home while their heart rate is still very elevated is a huge red flag. I'm not going to say that it's something you absolutely can't do, but any time your patient has an elevated heart rate, you need to really think twice about sending that patient home and think about if there's something that you could be missing or if the patient actually needs further treatment in the hospital.

And then the third point to make is actually a point about the second physician who saw the patient, and this was the physician who was working when the patient came in already in cardiac arrest, and that physician wasn't named in the lawsuit, but looking through the notes of the code and what happened while they were trying to save this patient's life. There is one thing, in particular, that could be improved upon, and that's that any time a patient is coding from a pulmonary embolism, a blood clot in the lungs, you can make some last ditch efforts to try to break up that clot by giving them a particular medicine that breaks up blood clots. 

And the patient was coding in the emergency department and this physician even mentioned in his note that he thought it was probably this blood clot that was causing it, but that medication was never given. To be honest, would've been a long shot and may not have changed the outcome in the end, but I think most emergency medicine physicians would agree that if you have a patient who has recently coded and you suspect a blood clot, that this medication to break up the blood clot is worth at least trying. So those are essentially the basic learning points from the case.

Brian: It is a very tragic case, but fortunately it is something that can be learned from, not only in the medical care, but the documentation and how to handle that as well. This is just one example of these types of reviews that you have on your site, MedMalReviewer.com. Is that correct?

Eric: Yes, that's correct. We have several other cases up right now and we are adding one every month.

Brian: We can link to your website in our show notes below the podcast, and I really want to thank you again, Eric, for being here, taking the time to discuss this particular case. Thanks for being here today.

Eric: It's been great talking with you, Brian

Speaker 1: Thank you for listening to this episode of Your Practice Made Perfect with your host, Brian Fortenberry. Listen to more episodes, subscribe to the podcast, and find show notes at SVMIC.com/podcast.

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