The patient (AC) was complaining of chest pain, however it was easily explained by over exertion in physical therapy. His lung exam was entirely normal, except for the minor complaints of chest pain relieved with Tylenol and thought to be from pushing himself in PT after his recent orthopedic surgery. Fortunately for this patient, he had an appointment the next day with his orthopedic surgeon. Imaging studies were done that showed multiple pulmonary embolism. So what happened and did the nurses miss important information?
What is Pulmonary Embolism?
A pulmonary embolism is a blood clot that travels to the lung, usually from a thrombi or blood clot that originates in the lower extremities. A pulmonary embolism or PE can block circulation to the lung, depending on where it lodges. Because pulmonary embolism almost always occurs along with deep vein thrombosis, the two conditions together are known as venous thromboembolism.
Risk Factors?
Although anyone can develop a deep vein thrombosis and resultant pulmonary embolism, there are factors that can increase one’s risk. The main risk factors include immobility, recent surgery, history of smoking and overweight. The patient had recent orthopedic surgery (knee replacement one month prior) and had been immobile except for working with physical therapy with the use of walker and/ or wheelchair. AC was also neither a smoker nor obese.
Surgery, especially orthopedic surgery (as in hip and knee replacements) is one of the leading contributing factors of blood clots. During the bone preparation, tissue debris can enter the blood stream and contribute to a clot. In addition, after surgery one is often confined to bed for an extended period of time; increased horizontal position withincreased risk of blood stasis to the lower extremities, which can contribute to clot formation. The risk also is increased with the length of time under anesthesia. For these reasons, many individuals undergoing a surgery with increased risk of deep vein thrombosis (DVT) will receive medications after surgery to prevent clot formation. While AC had orthopedic surgery with anticoagulants, his dose had recently been decreased and he remained active with the physical therapy to regain his strength.
Symptoms
Symptoms of pulmonary embolism can vary, depending on overall health, size of clot and amount of lung involved. Common signs and symptoms can include shortness of breath, chest pain worsened with exertion and possible blood tinged sputum and cough.
Additional symptoms can include leg pain or swelling, cyanosis, fever, excessive swelling or dizziness. The leg pain is related to deep vein thrombosis and other symptomsare related to potential pulmonary distress.
Complications
AC was fortunate in that he did not have any complications that might be associated with a pulmonary embolism. A pulmonary embolism can be life threatening, and approximately one third individuals with undiagnosed and untreated pulmonary embolism don’t survive. In addition, some individuals can develop pulmonary hypertension or increased pressure in the lungs, related to the obstruction in arteries in the lungs. AC was incredibly fortunate in that he did not have any problems related to delay in diagnosis of his pulmonary embolism; not everyone is so fortunate however.
Possible negligence?
While AC’s family was indignant for the delay in diagnosis and potential for problems, upon review of the chart notes there did not appear to be any negligence. The nursing staff did not fail to communicate to providers and diagnose pulmonary embolism.
While AC recently had orthopedic surgery (one month prior), his vital signs remained stable without shortness of breath. In addition, his chest pain remained mild ( a 2-3 out of 10) that was relieved with Tylenol and no need for narcotics. AC also did not have any shortness of breath nor any possible symptoms of deep vein thrombosis (normal leg exam). Lastly, AC did not have any long term damages associated with the deep vein thrombosis and pulmonary embolism except for a more aggressive treatment with anticoagulants.
As a legal nurse, chart reviews of undiagnosed pulmonary embolism can at times detect negligence- as in failure to appropriately assess patients with chest pain after recent orthopedic surgery. While the nursing staff may provide the basic care for their patient, they might not tap into their critical thinking skills and put all the pieces together for either deep vein thrombosis or pulmonary embolism. The attorney then needs a legal nurse to read and analyze the medical records and determine negligence in provided care.
We are adept at reviewing and analyzing medical chart notes to determine any negligence or deviance from reported standards of care.
Sources:
http://www.mayoclinic.org/diseases-conditions/pulmonary-embolism/basics/definition/con-20022849