The patient (AC) was complaining of chest pain with mild cough in the long-term setting, however it was easily explained by over exertion in physical therapy. Chart notes reflected minor complaints of chest pain relieved with Tylenol (thought to be from increased work in PT after his recent orthopedic surgery), mild shortness of breath and cough. His mild shortness of breath was thought to be related to his prior level of poor health and increased work with physical therapy. Fortunately for this patient, he had an appointment the next day with his orthopedic surgeon. Imaging studies were done that showed multiple pulmonary embolism. Did the nurses then 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[1]. 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 elevated BMI[2].
Surgery, especially orthopedic surgery (as in hip and knee replacements) are 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[3]. In addition, after surgery one is often confined to bed for an extended period of time; increased horizontal position with increased 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 as well the usage of compression stockings during and after general surgery[4]. While AC had recent orthopedic surgery (few weeks prior) with anticoagulants, his dose had recently been decreased and he remained active with the physical therapy in hopes to regain his strength and independence.
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[5].
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 symptoms are related to potential pulmonary distress.
Treatment:
The first course of treatment for pulmonary embolism is typically anticoagulants and oxygen; anticoagulants decreasing the mortality to less than 5% as compared to the statistics of 10% of patients dying within the first hour and 30% subsequent from recurrent embolism[6]. Most patients treated with anticoagulants do not develop long term sequelae; however, the mortality of patients with undiagnosed pulmonary embolism is 30%[7] Depending on the patient’s condition, the next step might be clot busters or thrombolytic drugs[8]. In addition, the patient will likely need to wear elastic stockings to increase circulation, exercise and weight loss.
Complications:
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[9]. Patients with pulmonary embolism have no higher risk of recurrence, but recurrence is likely to be a new pulmonary embolism rather than deep vein thrombosis.[10]
A recent study determined that nearly half of the patients with pulmonary embolism experience long term limitation to their capacity for physical activity with negative impact on their quality of life-with shortness of breath and chronic fatigue long after the PE treated and resolved[11]. Lastly, the study revealed that men with three times more likely to have adverse effects, younger patients fared worse, as well as patient who were overweight and smokers.
Possible negligence?
AC’s family was indignant for the delay in diagnosis and potential for problems; upon review of the chart notes there did appear to be negligence. The chart notes reflected that the nurses did pick up the potential for pulmonary embolism (recent surgery) and the related symptoms of shortness of breath, cough and chest pain. In addition, they did not communicate with the MD regarding the concerning symptoms and physical exam findings. Thankfully, AC was successfully treated with anticoagulants, however there is concern for the negative impact in his quality of life (as in limitation of physical activity) and lingering shortness of breath.
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 put all the pieces together for either deep vein thrombosis or pulmonary embolism. The attorney then needs a legal nurse to review and analyze the medical records and determine negligence in provided care. In addition, the legal nurses can provide pertinent information regarding potential for long term damages and issues related to the pulmonary embolism. The written reports can include case strength and weaknesses as well information for writing complaint. The attorney then is provided with the necessary information to understand the necessary case components and determine their next step; always a welcome addition when working with a potential medical negligence case.
We are adept at reviewing and analyzing medical chart notes to determine any negligence or deviance from reported standards of care.
[1] https://www.mayoclinic.org/diseases-conditions/pulmonary-embolism/symptoms-causes/syc-20354647
[2] https://www.emedicinehealth.com/pulmonary_embolism/article_em.htm
[3] https://www.medicinenet.com/pulmonary_embolism/article.htm#pulmonary_embolism_facts
[4] https://www.mayoclinic.org/diseases-conditions/pulmonary-embolism/symptoms-causes/syc-20354647
[5] https://www.emedicinehealth.com/pulmonary_embolism/article_em.htm
[6] https://emedicine.medscape.com/article/300901-overview#a7
[7] https://emedicine.medscape.com/article/300901-overview#a7
[8] http://www.healthsearchonline.com/long-term-effects-of-pulmonary-embolism/
[9] https://emedicine.medscape.com/article/300901-overview#a7
[10] https://www.ncbi.nlm.nih.gov/pubmed/18695374
[11] https://www.sciencedaily.com/releases/2017/03/170320143820.htm