In my practice, I review a lot of medical records. If you review enough records, you will see some patterns that repeat over and over. One is the patient who goes to the emergency department or to the primary care physician with some shortness of breath, a cough, and some chest pain. The patient gets treated for the symptoms and sent home, where they proceed to die. The name of the killer? Pulmonary embolism.
The term pulmonary embolism (PE) describes emboli (in this case blood clots) that formed somewhere in the veins of the body, most often in the legs, traveled to the heart and then been sent by the heart into the lungs. In the lungs, the emboli get caught in the small vessels there. Once they are trapped in a vessel, that part of the vessel downstream from a trapped embolus can no longer provide oxygen to the body. The larger the embolus, the sooner it gets trapped and the greater the amount of vessel which is no longer able to provide oxygen to the body. A single very large embolus can kill instantly. Usually, however, there are many smaller emboli. The greater the number of emboli, the more the ability of the lungs to supply oxygen is compromised.
The creation of clots in the body causing pulmonary embolism is not usually a one-time occurrence. The mechanism that created the clots in the first place will usually continue to produce them, unless there is some form of medical intervention. If the process of clot formation continues, more and more emboli will travel to the lungs and the ability of the lungs to supply oxygen will be more and more compromised. Eventually, there may be so many emboli that the lungs cannot provide enough oxygen to support life and the patient dies.
The patient at the emergency department or at the doctor’s office with pulmonary embolism is obviously not dead yet. However, if the doctor fails to recognize that the problem is pulmonary embolism and sends the patient home, clot will continue to be produced by the body and sent to the lungs. Death is often the result.
The root of the problem is that this constellation of symptoms produced by pulmonary embolism can be produced by a wide variety of common conditions that doctors see every day and which have almost no potential to be fatal. Of course, doctors are supposed to be able to differentiate common, non-fatal conditions from those which can cause death. That is why they went to medical school. That is why we go see them. That is why they get paid.
In medicine there are many conditions that have symptoms in common. Doctors are trained to create a list of conditions which may explain the symptoms with which the patient is presenting. This list is called a differential diagnosis. It takes into account the patient’s symptoms, history, physical examination, and the results of any tests.
Once the doctor has created a list of all of the possible explanations for the patient’s presentation, the doctor should rank them in order of likelihood. The doctor should also know which of the potential explanations, if any, has the potential to be fatal. The doctor needs to assure himself/herself that the patient does not have a potentially fatal condition before deciding whether to send the patient home or not. This is called “ruling out” potentially fatal conditions. There are a number of tests which can establish a diagnosis of pulmonary embolism or rule it out. Those tests are only effective, however, if the doctor thinks to order them.
I have had a number of pulmonary embolism cases over the years. Each of them involved a preventable death. In each of them, I was able to make a recovery for the surviving family members. In each of them, the doctor was forced to admit that pulmonary embolism was either on the differential diagnosis or should have been. In each of them, the doctor was forced to admit that pulmonary embolism should have been ruled out before the patient was sent home.
Patients have very little power to protect themselves from a missed diagnosis of pulmonary embolism. We have to rely on the doctor to know what she or he is doing. The best advice I can give is that if you have shortness of breath, chest pain and a cough and are sent home with reassurance that it is only a cold or some other benign condition, go/return to the emergency department IMMEDIATELY if your condition worsens after you arrive home. Failure to return immediately may cost you your life.
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