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American Wrongful Death
Law Report
MEDICAL MALPRACTICE IN THE
DIAGNOSIS AND TREATMENT OF
PULMONARY EMBOLISM
The Need for Prompt Diagnosis
The failure of doctors to properly
diagnose and treat pulmonary embolism is a leading cause of unnecessary
death in the United States.1
Scientists estimate that as many as 60,000 Americans die annually
as a result of the failure to properly diagnose pulmonary embolism.
More Americans presently die of pulmonary embolism than die of
breast cancer. Because it is a common and lethal condition, the
established 'standard of medical care' requires doctors to rule
out a pulmonary embolism whenever a patient has symptoms and risk
factors that raise a reasonable suspicion that the patient may
be suffering from this condition. Untreated pulmonary embolism
often leads quickly to death. When a patient has symptoms that
raise a high level of suspicion for pulmonary embolism, doctors
must respond to the situation as a medical emergency. A 'wait
and see' approach subjects the patient to unacceptable risk.
Doctors
must respond to the suspicion of pulmonary embolism as a medical
emergency.
Where doctors are unsure if a patient
suffers from deep vein thrombosis (DVT), the underlying cause
of pulmonary embolism, they usually need to perform a ventilation/perfusion
scan (V/Q scan), CT angiogram or a pulmonary angiogram to definitively
diagnose the condition.2
When pulmonary embolism is not properly diagnosed, the mortality
rate rises dramatically, largely as a result of recurrent emboli.
Nearly a third of patients suffering from pulmonary embolism will
die without treatment. Many patients die less than an hour after
the onset of symptoms. All too often, doctors fail to perform
essential tests and miss this diagnosis.
Doctors often
fail to perform essential tests and miss the diagnosis of pulmonary
embolism.
Claims based on failure to properly
diagnose pulmonary embolism fall within well established principles
of medical malpractice law.3
Many cases are based on the doctor's negligent failure to order
appropriate diagnostic tests, negligent failure to follow proper
diagnostic protocols, and negligent failure to recognize the possibility
of pulmonary embolism based on the patient's symptoms and risk
factors. Where a physician should have a reasonable suspicion
of pulmonary embolism, the standard of medical care requires that
the physician promptly order appropriate diagnostic tests.4
A variety of risk factors and symptoms
should give rise to a suspicion of pulmonary embolism. Risk factors
include recent surgery, a history of venous thromboembolism (DVT),
prolonged imobilization, congestive heart failure, cancer, fracture
of the pelvis, femur or tibia, obesity, pregnancy or recent delivery,
estrogen therapy (including the use of birth control pills), and
inflammatory bowel disease.5
Over 95% of patients suffering from massive pulmonary embolism
show signs of rapid breathing (tachypnea). Where massive pulmonary
embolism leads to death, shortness of breath (dyspnea) is present
in 60% of all cases . The failure of a physician to rule out pulmonary
embolism when confronted with breathing abnormalities such as
tachypnea and dyspnea in combination with other risk factors and
symptoms may well amount to malpractice. Many patients have an
elevated heart rate (tachycardia) or experience a loss of consciousness
(syncope). 6
In cases where physicians confuse syncope with a seizure, they
will likely fail to diagnose pulmonary embolism . Patients often
experience chest or back pain, have abnormal breathing sounds
(rales), have abnormal EKGs, or are sweaty (diaphoretic) . 7
The Importance of
Proper Treatment
When pulmonary embolism is properly
diagnosed, physicians have several treatment options which include:
anti-coagulant drugs, clot busting drugs and surgical embolectomy.
Prompt treatment with anti-coagulant (blood thinning) drugs such
as heparin can reduce the mortality rate of the condition by about
90%.8
Because existing forms of treatment are so effective, the vast
majority of preventable deaths from pulmonary embolism are the
result of diagnostic failures. Once pulmonary embolism or DVT
is diagnosed, patients are most often treated with high doses
of heparin, which acts immediately to prevent creation of new
blood clots and emboli. Most physicians would agree that the medical
standard of care usually requires that a physician start full-dose
heparin if he or she has a strong suspicion of pulmonary embolism,
even before the V/Q scan can be obtained. This is because the
risks of harming the patient from heparin treatment are far outweighed
by the life threatening risk associated with pulmonary embolism.
When the patient's condition is stabilized with heparin, patients
can normally be given the oral anticoagulant drug warfarin (Coumadin),
a less powerful blood thinner, within two to five days. Treatment
with warfarin will normally continue for weeks or months. To ensure
that the blood is adequately thinned so as to prevent further
thrombosis, physicians must perform blood tests to monitor the
patient's 'activated partial thromboplastin time' (aPTT). If physicians
fail to properly monitor the patient's aPTT and adjust the medication
accordingly, the patient will sometimes die or suffer injury from
recurrent pulmonary embolism or DVT.
Prompt treatment
can reduce the mortality of pulmonary embolism by 90 percent.
In cases involving massive pulmonary
embolism, more aggressive treatment with 'clot busting' drugs
or surgery may be required. 'Clot busting' drugs are known as
'fibrinolytic enzymes' and include streptokinase, urokinase, and
tPA. While they accelerate the rate at which clots dissolve, they
also increase the risk of stroke significantly. Because massive
pulmonary embolism is an emergent life threatening condition,
physicians who fail to give fibrinolytic therapy immediately when
a patient with pulmonary embolism shows signs of impaired circulation
or 'hemodynamic instability' may be committing medical malpractice.
In some cases, surgical removal of
an embolism, known as an embolectomy, may be the appropriate course
of treatment. Some patients suffering from massive pulmonary embolism
cannot safely be treated with clot busting thrombolytic drugs.
These drugs may not be suitable for patients who have suffered
from stroke, recent surgery or cancer. In contrast to the recent
past, advances in surgical technique make it possible for skilled
surgeons to perform embolectomies with relatively low risk and
high survival rates.9
Working Toward Solutions
Preventing future tragedies from occurring
can be achieved through education, action in the medical community,
and litigation. Substantially reducing the number of preventable
deaths caused by pulmonary embolism is a goal championed by many
heroes in the medical community. Although this goal is attainable,
progress in reducing the number of preventable deaths has been
elusive. Standards of care from doctor to doctor and hospital
to hospital vary greatly. Improvements in primary medical education
and continuing medical education are of course essential. Hospital
wide initiatives to improve clinical practice through the use
of diagnostic protocols can significantly reduce the number of
needless deaths. Litigation can serve a variety of functions that
lead to solutions. First, it can uncover problems which otherwise
might be covered up or ignored. It can punish providers of poor
care for their negligence, serve as a deterrent to careless behavior
and can provide incentives for improvement. Finally, part of the
solution must include providing a measure of justice to victims
of bad medical practices and their families.
FOOTNOTES:
1. Fedullo, P.F., Tapson, V. F., The
Evaluation of Suspected Pulmonary Embolism, New England Journal
of Medicine, Vol. 349, pp 1247-56 (2003).
2. The PIOPED Investigators, Value
of the ventilation/perfusion scan in acute pulmonary embolism:
results of the Prospective Investigation of Pulmonary Embolism
Diagnosis (PIOPED). Journal of the American Medical Association
(JAMA), Vol. 263, pp. 2753-59 (1990).
3. Dinozzi v. Lovejoy, 20 Mass.
App. Ct. 973 (1985); Kopycinski v. Aserkoff, 410 Mass.
410 (1991); Nickerson v. Lee, 42 Mass. App. Ct. 106 (1997).
4. Mcgrath v. Carson, ___ S.W.3d
___ (2002).
5. Fedullo, P.F., Tapson, V. F., The
Evaluation of Suspected Pulmonary Embolism, New England Journal
of Medicine, supra at 1248.
6. Feied, C.F., Pulmonary embolism.
In: Rosen and Barkin, eds, Emergency Medicine Principles and
Practice, 4th ed. 1998; 3: Chapter 111.
7. Feied, C.F., Pulmonary embolism.
In: Rosen and Barkin, eds, Emergency Medicine Principles and
Practice, 4th ed. 1998; 3: Chapter 111.
8. Carson, JL, et al., The Clinical
Clinical Course of Pulmonary Embolism, New England Journal
of Medicine, Vol 326, pp. 1240-1245 (1992); Goldhaber SZ, Morpurgo
M. Diagnosis, Treatment, and Prevention of Pulmonary Embolism.
Report of the WHO/International Society and Federation of Cardiology
Task Force. Journal of the American Medical Association (JAMA)
1992;268:1727-1733.
9. Aklog, L., et al., Acute Pulmonary
Embolectomy: A Contemporary Approach, Circulation,
Vol. 105, p. 1416 (2002).
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