Medicolegal Briefs: Sepsis + PE
Mike Weinstock, MD, and Matt DeLaney, MD
- A 54-year-old woman had a past medical history of abdominal surgeries complicated by adhesions which resulted in chronic pain. She was taken for elective surgery. One week later, she developed fatigue. Over the following week, she noticed gradual onset of shortness of breath. During that time, she had developed an obvious wound infection leading her presentation to the ED. After arrival in the ED, the patient had a work-up and treatment initiated with lab tests, IV fluids, and antibiotics. One hour after arrival, her shortness of breath worsened and she was placed on supplemental oxygen—initially with nasal cannula and then with non-rebreather. She didn’t require BiPAP or intubation. An hour later, she suddenly coded. Despite ACLS, she did not regain spontaneous circulation. Autopsy showed she had died not of sepsis, but from a saddle pulmonary embolism.
- The plaintiffs contended that pulmonary embolism (PE) should have been at the top of the diagnosis due to the shortness of the breath and that there were significant delays in care (delays in getting a chest x-ray, lab results, ordering the CT angiogram and delays in initiating heparin or tPA).
- The defense said sepsis and septic shock were appropriate initial diagnoses to work-up and treat first. It wasn’t until an hour into presentation when she had worsening shortness of breath that PE would have entered the differential diagnosis. Things progressed quickly and once the patient started to decompensate, she was never hemodynamically stable enough to allow additional work-up. Had they given her heparin immediately, it would have been unlikely to help her massive saddle pulmonary embolism. She never achieved return of spontaneous circulation despite an hour of interventions and the yield of giving thrombolytics in this setting is very low and is not standard practice. In addition, for true septic shock, the mortality is almost 30%.
- The verdict was for the defense.
- Teaching Points
- Patients may have more than one life-threatening diagnosis at the same time.
- In sick patients, the incidence of other complications is higher. Pause and make sure you consider all probable diagnoses. Be aware of anchoring bias.
- Consider pulmonary embolism with unexplained breathlessness.
- Patients may be too unstable for additional work-up. Make sure you document this well.
- Sometimes patients die, even if you provide good care.