1. "She seemed hysterical."
Of course she was hysterical?she was dying. Hypoxia, myocardial ischemia, and pulmonary hypertension all produce anxiety. Assume dyspnea has an organic cause until history, physical examination, and necessary testing demonstrate otherwise. Elderly patients with multiple medical problems do not develop new-onset anxiety disorders just before coming to the ED.2. "But the pulse ox was normal!"
Patients with dyspnea secondary to myocardial ischemia and pulmonary embolism may have normal oxygen saturations. Evaluate such patients for cardiac and embolic risk factors and consider additional testing such as ECG and D-dimer as indicated.3. "But he had CHF the last time he came to the ED."
Patients with a history of congestive heart failure are at risk for many serious diseases, including pulmonary embolism and myocardial infarction. Patients with a history of failure who present with recurrent failure usually complain of a gradual onset of symptoms and should have an abnormal chest x-ray. Sudden onset of severe dyspnea may be due to ischemia, infarction, pulmonary emboli, papillary muscle rupture, or other catastrophic event.4. "Here it is right in the chart??No chest pain'!"
Dyspnea may remain painless until the final gasp. Absence of pain does not rule out myocardial ischemia or pulmonary embolism. In ED patients, unlike the hospitalized population, thromboembolic disease often presents without pain.5. "I knew he was pulled out of a burning building?that's why I got the pulse ox."
This physician missed the diagnosis of carbon monoxide poisoning. Know the limitations of pulse oximetry.6. "Even the radiologist said the chest film showed pneumonia."
No radiologist can distinguish the infiltrate due to pulmonary embolism from that of pneumonia. Only the clinician can make this distinction through history and physical examination (and with a little help from a D-dimer and helical CT).7. "The radiologist said the chest x-ray was normal."
Forget the radiologist?it was probably the same guy who read the PE as pneumonia. The chest film can be normal with many serious causes of dyspnea. Patients with ARDS frequently have chest films that lag hours behind the clinical examination. If a patient with a normal chest x-ray had a toxic inhalation, near drowning, or other risk factor for noncardiogenic pulmonary edema, obtain a delayed film 4-6 hours later.8. "After I gave him the high-flow oxygen, he calmed down a lot?he even went to sleep. So I turned out the lights and let him rest."
This doctor did not realize the patient would never awaken from his CO2 narcosis. Patients with COPD who are dyspneic need oxygen. If lower levels of nasal oxygen or a Venturi mask will bring the pulse ox to 90%, this may be adequate. However, in a severely dyspneic patient, high-flow oxygen via a non-rebreather mask may be necessary to treat hypoxia. However, such patients must be closely monitored and may require serial blood gases, as they may retain CO2 and become obtunded.9. "I didn't get the V/Q scan because her obstetrician said she didn't need it."
Your co-defendant is wrong. Pulmonary embolism is a major cause of death during pregnancy. A pregnant woman with unexplained, severe dyspnea needs an evaluation for pulmonary embolism. This will require a chest x-ray with shielding of the abdomen and a V/Q scan. A half-dose perfusion scan may be adequate. There is not a single report in the literature regarding a bad fetal outcome from a V/Q scan. Do not allow a consultant to talk you out of an indicated test.10. "I should have ordered the chest x-ray and a pulse ox."
Most patients with dyspnea require a history, physical examination, and simple diagnostic tests?usually a chest x-ray and pulse oximetry. The chest x-ray may be unnecessary if the patient has a known history of asthma or COPD and improves rapidly with ED treatment. Both the chest film and pulse oximetry may affect management of patients with pneumonia.