Failure to Initiate Thrombolytic Therapy for Bilateral PE Claimed in Patient Death

Commentary: 

Medical expert testimony established that the defendant provided the appropriate standard of care and acceptable forms of treatment, despite a poor outcome for the patient. 

The Case: 

An 18 YOBF (5’10”, 142 lbs.) presented to the ER with complaints of dizziness, SOB, and fever for the past two days. Her past medical history consisted of a tonsillectomy and an umbilical hernia repair.  

Examination findings were mild anemia, fever, and a possible viral infection. She was released with instructions to take Ferinsol®, Tylenol®, and Advil®. Four days later, the patient returned to the ER at 2:00 a.m. with pleuritic chest pain. A chest x-ray revealed mild infiltrates at the left lung base. She was diagnosed with pneumonia and was discharged to go home with a Zithromax Z-Pak (Azithromycin), and instructed to follow up with her PCP. That afternoon, the patient presented to a physician assistant at an urgent care, who noted the pneumonia diagnosis. An EKG showed sinus tachycardia with a heart rate of 129. The patient was discharged and told to continue her medications. 

Several days later, the patient presented to a different ER with complaints of her heart racing, chills, fever, bloody sputum, and anxiety. She was admitted to the hospital. An EKG revealed atrial flutter. She was diagnosed with pneumonia and anemia. Blood cultures and a ferritin level were ordered. Lab work revealed HGB 7.8 (12-16), HCT 25.8 (36-46), and WBC 16.74 (4.5-13). Upon examination, it was noted the patient’s medical record had no history of sickle cell disease or sickle cell trait. It was also observed that the patient had chills and a temperature of 102.2° F. She was diagnosed with pneumonia and anemia and treated with the broad-spectrum antibiotics Vancomycin® and Zosyn®.    

The physician at the admitting hospital reviewed the results of a positive D-dimer assay and chest x-rays with the patient and her mother. The chest x-rays showed worsening of the extensive left lower lobar consolidation and some developing right lower lobe alveolar opacity. The physician ordered a CTA. 

Staff took the patient for a CTA at 12:57 p.m. but the procedure was delayed because the patient refused to have a larger IV started. At 1:20 p.m., nursing notes indicated the patient complained of chest pain that was rated 8/10 and worsened with deep breathing. By 2:15 p.m., her heart rate was 153 and her O2 sat 95%. Nursing documentation indicated more anxious hyperventilating at 2:17 p.m. 

At 6:12 p.m., CTA results showed large bilateral pulmonary emboli, and atelectasis versus consolidation that could be either infection or secondary to pulmonary infarctions. Per protocol, the staff started a heparin drip, and the patient was moved to the ICU. Consultation with a pulmonologist indicated the need to transfer the patient to a higher level of care at another facility.  

At 3:06 a.m. the next morning, the defendant pulmonologist examined the patient. His consultation indicated the patient had a similar episode approximately one year before that involved two ER visits due to fever, SOB, and dizziness. The pulmonologist’s impression was massive bilateral emboli with subsequent tachycardia, pulmonary infarction, and hemoptysis. Hematology was consulted and an anemia work-up was initiated. He ordered an echocardiogram to evaluate any right ventricular strain. He noted that the patient was at an increased risk of complications from thrombolytics. 

Later that day at 9:45 a.m., the echocardiogram demonstrated moderate tricuspid regurgitation and right ventricular systolic pressure elevation. A lower extremity exam was negative. At 6:30 p.m., a hematologist examined the patient for bilateral pulmonary embolus. A hypercoagulable work-up and CT imaging of the abdomen and pelvis were ordered for when the patient’s heart rate stabilized to exclude any occult malignancy. 

A respiratory therapist was in the patient’s room adjusting the O2 sensor at approximately 8:40 p.m. and reported that the patient said something was wrong with her heart. She then lost consciousness and bladder control. At 8:55 p.m., a Code Blue was initiated. The patient could not be resuscitated and was pronounced dead at 9:18 p.m. 

The deceased patient’s mother brought suit against the pulmonologist. She alleged failure by the pulmonologist to recognize the indications for thrombolytic therapy for the patient’s PE in a timely manner, leading to the patient’s death. 

A plaintiff’s expert testified the pulmonologist breached the standard of care when he failed to recognize the patient needed thrombolytic therapy. He further testified that the patient would have survived if the thrombolytic therapy had been started immediately after the echocardiogram. 

Defense experts testified that the two accepted forms of treatment for pulmonary embolism is either blood thinners and/or thrombolytic therapy. A board-certified pulmonologist was adamant that the decision not to administer thrombolytics was correct in light of the way the patient medically presented. A board-certified hematologist testified she believed the patient was hemodynamically stable and not a candidate for thrombolytic therapy. A board-certified cardiologist who read the echocardiogram did not think the patient was a candidate for thrombolytic therapy because she did not have right ventricular dysfunction. 

The jury returned a verdict in favor of the defense.   

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