Double Jeopardy: Risk in Pulmonology

Peter M. DeBlieux, MD, FACEP

Daniel J. Sullivan, MD, JD,FACEP

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Objectives

Explore high-risk pulmonology complaints Review malpractice cases Discuss medical management Apply preventive documentation strategies

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Case 1

43 y/o M CC: Syncope, DIB, palpitations, weakness,

incontinence PMHx DM, CAD, HTN, obesity Meds: Metformin, ASA, Lisinopril Sx Hx: None Soc Hx: Former smoker, no illicits

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Case 1

VS: HR 115, RR 22, BP 96/56, T 98.9, SpO2 98% Exam:

Pale, appears ill RRR, no murmur, gallop, or rub Lungs clear Abd soft, nontender, no masses, obese Extremities with trace symmetric peripheral edema

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Case 1

ECG: Sinus tachycardia CXR: Borderline cardiomegaly, lung field clear Lab abnormalities:

CBC: WBC 15.1, no left shift Chem 21: Glu 440, Na 130, K 2.9, CO216 UA: Ketones, glucose

Significant NL labs: Trop, CKMB

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Case 1: Timeline

0702 EMS arrival at pt’s home Treatment: IVF, O2

0742 EMS arrival to ED 0800 Seen by resident 1145 Pre-auth for facility transfer 1305 Dx DKA

Treatment: IVF, insulin, KCL, O2 1433 Transfer

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Case 1: Timeline

1500 Arrival VS HR 104, BP 98/50, RR 20, T 98.8, SpO2 97% on 2L

1509 Found unresponsive 1510 Respiratory arrest code 1610 Time of death

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Case 1

Autopsy report:

“Pulmonary thromboembolism emanating from a deep venous

thrombosis of the left leg.”

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Pulmonary Embolus

Widely varied presentation BID: 73% Pleuritic CP: 44% Unilateral LE symptoms: 41-44% Feeling vaguely unwell: 40% Cough: 34% Non-lateralizing lower extremity edema: 24% Syncope: 10% Singultus: <1%

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Tachypnea (respiratory rate > 16/min): 96%

Rales: 58% Accentuated second

heart sound: 53% Tachycardia (heart rate

> 100/min): 44% Fever (temperature

> 37.8oC): 43%

Diaphoresis: 36% S3 or S4 gallop: 34% Evidence of

thrombophlebitis: 32% Lower extremity

edema: 24% Cardiac murmur: 23% Cyanosis: 19%

Pulmonary Embolus

Physical Findings also widely varied:

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Abn CXR Findings

Atelectasis: up to 68% Pleural effusion: 35-48% Elevated hemidiaphragm: 24% Hampton’s Hump: 20% Fleishner’s Sign: 15-20% Westermark’s Sign: 7-10% Pulmonary edema: 5%

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Pulmonary Arterial Tree

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Hampton’s Hump

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Hampton’s and Palla’s

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Westermark’s and Palla’s

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Westermark’s Sign

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To Scan or Not to Scan?

PERC Revised Geneva Wells Age-adjusted D-dimer

ADJUST-PE Pt’s age (>50) x 10 as adjusted cut-off

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Pearls

High index of suspicion Validated pre-test probability tools Subtle CXR findings Documentation

Tools used Pertinent positives/negatives MDM

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Case 2 - To Err is Human

23-year-old in MVA. Fx L fibula and laceration anterior L leg.

Laceration sutured. Dispo home with a return in 3 days for a wound

check. Returned in 4 days. She c/o leg pain and was

triaged to the Fast Track for a wound check.

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Case 2 - To Err is Human

In FT, the physician removed the immobilization device, and examined the wound. Documented “Healing well.”

He never looked at the triage complaint, did not visualize the leg beyond the laceration.

In fact it was swollen and tender. She was discharged, but was transported back

to the ED within 12 hours dead on arrival from a saddle embolus.

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Case 2

Lawsuit resulted in a $1M settlement for the family.

Key in the litigation was the family testimony about informing the physician regarding increasing leg pain.

Issues: Geography is destiny Anchoring and premature closure

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PE Litigation Overview

Failure to recognize, consider or document predisposition to PE.

Failure to explain tachycardia. Pulse temperature disparity. PE masquerading as pneumonia (CXR density

and mild WBC evaluation). Failure to rule out PE in appropriate cases with

a ‘documented’ EB diagnostic approach.

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Recreational Reading

Emergency Department Crowding and Loss of Medical Licensure; A New Risk of Patient Care in Hallways, Western J Emerg Med, Mar 2014. Derlet, McNamara et al.

http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC3966445/

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Case 3

26 yo male unrestrained driver in MVC complaining of chest pain and neck pain

VS P 110, BP 145/90, RR 20, SAO2 98% RA AOXC3: C-collar in place Lungs CTA Bilat; Heart RRR Left sided rib tenderness ant axillary line #6 & 7 Radiology: C-spine and supine CXR

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Case 3

CXR and C-spine radiographs read as no acute cardiopulmonary disease and no evidence of fracture with normal C-spine alignment.

Patient given Ibuprofen 600 mg and Robaxin 1,000 mg po

Patient ambulatory to bathroom with clear urine specimen

Patient discharged with NSAIDS and muscle relaxants with follow up with PCP and return to ED for any problems

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Case 3

CXR and C-spine radiographs read as no acute cardiopulmonary disease and no evidence of fracture with normal Cervical spine alignment

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Case 3

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Case 3, Visit 2

Patient returns 12 hours later with progressive shortness of breath and chest pain after smoking a cigarette

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Case 3, Visit 2

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Pneumothorax

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Pneumothorax

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Pneumothorax

Deep sulcus sign Manifested by free air subtly tracking anteriorly

without a clear lung edge finding Seen with supine CXRs after blunt or penetrating

trauma, central line placement, and after thoracentesis

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Pneumothorax

Occult pneumothorax Negative CXR findings associated with

presence of pneumothorax on CT scan of ABD or Chest

Increased diagnosis linked to liberal CT ordering practice

Overall prevalence is 2-15% Recent multicentered trial comparing

observation vs drainage in mechanically ventilated patients revealed no significant difference in mortality

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Pneumothorax

Ultrasound use for suspected pneumothorax Meta-analysis comparing supine Chest x-ray to

bedside point of care Ultrasound: 21 articles; 1,048 patients; CT scan or release of

air on chest tube placement viewed as gold standard for pneumothorax

Chest x-ray was 50.2% sensitive (95% CI, 43.5-57.0) and 99.4% specific (95% CI, 97.0-99.0)

Ultrasound was 90.9% sensitive (95 CI, 86.5-93.0) and 98.2% specific (95% CI, 97.0-99.0)

This study supports the routine use of Ultrasound for the detection of pneumothorax

Chest 2012 Mar:141(3):703-8.

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Pneumothorax Pearls

Occult Pneumothorax Consider the diagnosis in supine films that

sharply demarcate the hemidiaphragm Obtain erect Chest x-rays Consider Ultrasound use focusing on “slide

sign” Encourage return for worsening dyspnea or

chest pain

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Case 4

Sept 2007: ED visit for chest pain XR: “No significant osseous or soft tissue

densities” Dx: Angina, HTN

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Case 4

Oct 2008: ED visit for L rib pain EP interp of XR: L Rib fx and “a scar… at the apex” Overread: No fx and a “spiculated lesion”

Nov 2008: PCP visit for rib and back pain CT scheduled for Jan 2009 No show

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Case 4

July 2010: ED visit for dizziness, HA, vision change

Dx: Malignant lesions of lung and brain

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Documentation Pearls:Discharge Instructions Abnormal findings, incidental or not

Specific Plain language

Recommendations for follow up With whom In what time frame For what reason

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Case 5

48 y/o male presents with fever, cough and sputum production for past three days.

CAP protocol in triage dictates a Chest x-ray

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Solitary Pulmonary Nodule

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Solitary Pulmonary Nodule

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Solitary Pulmonary Nodule

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Solitary Pulmonary Nodules Ignored

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Solitary Pulmonary Nodules in ED

Defines as: Discrete, well-marginated, rounded opacity Less than or equal to 3 cm in diameter Completely surrounded by lung parenchyma Does not touch the hilum or mediastinum Not associated with adenopathy, atelectasis, or

pleural effusion Lesions larger than 3 cm are considered

masses and are treated as malignancies until proven otherwise.

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Solitary Pulmonary Nodules in ED

Upon discharge patient should be referred to PCP for PET scan or CT scan for further work up

The differential diagnosis of a solitary pulmonary nodule is broad and management depends on whether the lesion is benign or malignant.

Increased risks for malignancy include smoking history, size (larger than riskier), spiculated calcification, upper lobe presence

J Thoracic Disease Vol 6. No 3 (March 2014)

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Case 6

Patient presents with 1 month history of left sided chest pain, non-exertional radiating to left arm.

History of tobacco use. No DM, HTN, or associated CAD risks.

EKG NSR with no acute ST or T wave changes. ASA administered. Chest x-ray is obtained.

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Subtle Mass LUL

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Subtle Chest Masses

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L Shoulder Pain and Weight Loss

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Cough and Chest Pain

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Settlements & Verdicts

47 y/o F, Boston: $16.7M Adult M, Philadelphia: $3.57M 42 y/o M, Bristol City, MA: $1.25M 27 y/o M, VA: $1.25M 73 y/o F, MD: $700K

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Solitary Nodule Litigation Overview

In most cases, the radiologist sees the nodule and mentions it, the report goes to the PMD who never sees the imaging report from the ED visit.

The solitary nodule is overlooked by radiology, the ED doc gets named, but gets usually gets out of the case.

The nodule is picked up by radiology and mentioned in the report, no f/u arranged by the ED doc and it falls through the cracks.

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Solitary Nodule Litigation Overview

On wet read the solitary nodule is not relevant to the presentation, the radiologist mentions it in the report the next AM, the ED doc never sees the reading.

Not picked up on wet read, picked up next AM, and the ED over-read F/U system does not work.

The ED doc sees it on wet read, but does not address it on disposition. There is no PM, the on-call doc never looks at the interpretation.

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In Conclusion

PE High index of suspicion Validated decision-marking tools

Pneumothorax Deep sulcus sign Bedside ultrasound

Nodule and masses Documentation in record and D/C instructions Include findings, follow up, and rationale