Download PDF: Clinical Communiqué March 2017 Edition
In this edition
Case #1 NOT GOING TO PLAN
Case #2 WHEN IT’S NOT IN THE DIFFERENTIAL
Case #3 EXCLUDING A LIFE-THREATENING DIAGNOSIS
Expert Commentary LESSONS FROM CORONIAL CASES ON VENOUS THROMBOEMBOLISM
Venous thromboembolism (VTE), in the form of pulmonary embolus (PE) or deep vein thrombosis (DVT), is a disease entity that from the time it was first described in the 19th century by Virchow, has generated a substantial amount of deliberation and debate, and is likely to continue to do so well into the future.
In this issue of the Clinical Communiqué, we focus on PE as the single, specific cause of death. As featured in the three cases presented, PE is a diagnosis that can occur in any healthcare setting, from general practice, to the emergency department, to the postoperative ward. It is a diagnosis that every healthcare practitioner needs to be familiar with to adequately detect and treat it in their patients, every time.
So, why do so many of us continue to grapple with the concepts surrounding diagnosis and management? Decision tools have been created, the reliability of clinical gestalt has been explored, and yet clinically significant cases of PE continue to be missed. Is there an acceptable miss rate? What are the risks of over-investigation? There are too many conundrums and differing scholarly views to adequately explore in this editorial, however, one important point that deserves mentioning is that if you do not think of a PE, you are going to miss it.
A striking feature of the cases in this issue is the persistence of the warning signs and symptoms – hypoxia, tachycardia, calf pain, and breathlessness. The signs and symptoms were not the same in each case, and could result from many other conditions, but they persisted. Pulmonary embolus was not considered, and was subsequently missed with fatal consequences.
Associate Professor David Mountain is an Emergency Physician who includes thromboembolic research amongst his prolific clinical and academic endeavours in emergency medicine. He has also provided expert opinions on this issue’s topic to assist in coronial investigations. In his commentary, David addresses some of the complexities around diagnosis, and offers a practical outline to approaching the patient with a possible PE.
Finally, the coronial investigations applied in the three cases are worth noting. The first two cases were closed after an initial investigation without proceeding to inquest. The third case differed in that the coroner ran a joint inquest into the deaths of two patients from pulmonary embolus. These serve as a reminder of the prevention role of a coronial inquiry, whereby the aim is to reduce the number of preventable deaths through the findings of an investigation. If a coroner considers that a court hearing will not add to the information already gleaned from a hospital review or expert statements, and will not contribute to a broader understanding of patient safety measures, then an inquest will not be required. Similarly, if a coroner identifies a number of cases where there is commonality in the issues around patient safety that need exploring, then a joint inquest may be held.