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| Chest Pain and Plaintiff Attorneys |
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by Donald Correll, M.D., FACEP - May 4, 2011
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Perfection is a wonderful state of being. For every other “state of being” we have plaintiff attorneys to remind us of our imperfect existence. Plaintiff attorneys attend seminars on how to better sue us on pulmonary embolism patients. I was amazed when I first heard this. They are perfecting their existence, and here are some pointers on how to protect our existence.
Homan’s sign
Homan’s sign has no value medically in determining whether a deep vein thrombosis (DVT) is present in the leg. It has tremendous value in deterring a malpractice suit for missed pulmonary embolism. Attorneys place much importance on this sign. As we know, a patient with a positive Homan’s sign has a 50/50 chance of having or not having a DVT in the leg. If you record a negative Homan’s sign and a negative D-dimer, then the odds of getting sued on a missed pulmonary embolism are very low. I recommend on adult patients recording a Homan’s sign for chest pain and/or shortness of breath, especially if negative, for this reason. The D-dimer is very useful also if negative, and it even has clinically utility.
Here are some excerpts on chest pain from my books on Physician Assistant and/or Nurse Practitioner Acute Care Protocols and Practice Guides to improve outcomes and decrease medical liability. More information about the books can be found at www.acutecarehorizons.com:
Evaluation with D-dimer
D-dimer (LIA method) — some methods currently in use not reliable
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Useful if negative at cutoff value to rule out DVT or PE
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Negative D-dimer with low to moderate probability Well’s DVT or PE score largely excludes venous thromboembolic disease
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Well’s DVT criteria high probability: order ultrasound scan regardless of D-dimer result
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If positive — not as useful as a negative result which usually rules out VTE (venous thromboembolic) disease
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Frequently positive with
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Hospitalization in past month
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Chronic bedridden or low activity state
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Increasingly positive with age without significant acute disease process
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CHF
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Chronic disease processes
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Edematous states
Well’s DVT criteria
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Active cancer
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Paralysis/recent cast immobilization
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Recently bedridden > 3 days or surgery < 4 weeks
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Deep vein tenderness
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Entire leg edema
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Calf swelling > 3 cm over other leg
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Pitting edema > other calf
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Collateral superficial veins
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Two points — alternative diagnosis less likely
High probability: ≥ 3 points
Moderate probability: 1–2 points
Low probability: 0 points
Well’s PE criteria score 3 or greater consider D-dimer and CT chest PE protocol
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Suspected DVT = 3
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Alternative diagnosis less likely than PE = 3
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Heart rate > 100 = 1.5
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Immobilization/surgery past 4 wks = 1.5
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Previous DVT/PE = 1.5
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Hemoptysis = 1
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Cancer past 6 months = 1
Well’s score ≥ 6: order CTA chest PE protocol
Document positive or negative Homan’s sign or calf tenderness regardless of Well’s scores
Document PERC and/or Well’s scores when appropriate
Pulmonary Embolism Rule-out Criteria (PERC Rule)
(Reportedly decreases significantly the likelihood of pulmonary embolism if all 8 criteria met)
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Age < 50
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Pulse oximetry > 94%
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Heart rate < 100
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No history of DVT or VTE
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No hemoptysis
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No estrogen use
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No unilateral leg swelling
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No recent surgery or trauma hospitalization past 4 weeks
Best regards,
Donald Correll, M.D., FACEP
Jackson-Madison County General Hospital
Emergency Department Medical Director
www.acutecarehorizons.com
The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.
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