Pulmonary Emboli, clot on the lung - learning points

This picture shows a pulmonary embolism or clot blocking off an artery in the lungs. It causes a sudden shock or collapse, where the patient has sudden severe pain in the chest, rapid breathing and a rapid pulse. He or she feels extremely anxious, sweaty and as though they might die.

You need to call a doctor or ambulance urgently


Pulmonary embolus (embolism or embolis) is a clot

The case outlined in the previous post has a number of learning points

This is a fit individual, apart from his chronic chest complaint. He has been in hospital once only, there is no history of diabetes or other illness, and he is not thin, indeed the notes say he had put on three stone in weight prior to his admission.

BJ "collapses" several times. Both in the October before his operation and after his operation. After a couple of days, he is back on his feet as though nothing had happened.

There are not many causes for this type of collapse. We are looking for something that comes on suddenly and gets better quickly. Sudden disturbances are always due to either a problem with
1 - the nervous system - the brain or spinal cord, such as epilepsy

or
2 - the heart and circulation, such as an abnormal rythm or a clot on the lung which blocks off a large part of the blood vessels to the lungs, which is another name for pulmonary emboli. Over time this damages the lungs, you get high blood pressure in the lungs, and the lungs do not work so well.

Clots in the lungs comes usually from a DVT. BR had had DVTs in the past. He did not move around a lot, and during surgery he would have been at extra risk. He was given white stockings to reduce the risk but this does not prevent a DVT especially in someone at high risk

One notable feature of a pulmonary embolus (the different endings are latin ;-)
is the anxiety and feelings of panic that come with the damage to the lungs. The person feels like they are going to die.

Pulmonary emboli are hard to diagnose, unless you keep your eyes open

There is no direct test - although changes in the concentration of oxygen and carbon dioxide in the blood indicate there is likely to have been a clot.

Chest Xrays usually look normal as do ECGs, although the pulse rate is usually fast.

Ventilation perfusion scans need to be done almost immediately - these show the blood flow in the lungs. These scans show large pulmonary emboli but miss small ones


The single most important point in diagnosing a pulmonary emboli is the history - short, often repeated collapses from which the person recovers quickly over the next two days


Why was this not diagnosed in BR's case? Because different doctors saw him. No one works 108 hours on the trot, so they do not see the condition emerge and they do not see the pattern of pulmonary embolus over time. Each doctor comes into the hospital or clinic and only sees a snap shot of the patient in time. This is like trying to understand a film like Slum Dog Millionaire from a series of photographs. You need to watch the film to know what is going on. You need to watch the patient over time to understand what is happening

If you have any questions, please email me at liz@lizmiller.co.uk, I am happy to take questions








Copyright (c) Dr. Liz Miller
www.lizmiller.info

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Why we all need to know a little medicine

The following story might be told a hundred times across the country, in different ways about different people.

It is a story of ordinary people with common medical conditions. In people without the knowledge or resources to get a second opinion.

Once I might have said, this means the NHS is bad and we must all get private medical care. However this story might as easily have happened in a private hospital, because you see the same doctors and are treated by the same nurses.

Knowledge is the only defence against charlatans and ignorance. This blog teaches you medicine.


Medical Summary of BR dob 13.07.44 of Huntleypool, Cumberland


Preoperative history
BR was admitted for a biopsy of the lump approximately 2” diameter, in the left side of his neck. An earlier needle biopsy had failed to show tumour tissue.

BR was unable to walk beyond the confines of his house but his quality of life was good, he was able to climb stairs and his partner looked after him at home. BR was a long term smoker, had a single admission to hospital following a collapse twelve months previously. He had recently gained weight

Prior to the biopsy BR was identified as a high risk case. He was at risk of heart disease but his chest pains were not thought to be typical of cardiac disease, and further investigations was said to be impossible because he was not fit to do the necessary tests.

Past medical history
He had been diagnosed as asthmatic following a single admision with a collapse thought to be a chest infection, but there was no record of any further investigations. Other diagnoses included chronic lung disease, osteoarthritis, DVR, angina treated with GTN spray, but not investigated further

Medications:
Bendrofluazide 5mg day, fenbrufen, aspirin, verapamil, GTN, isosorbide

BR's first hospital admission was a year prior to his admission for a biopsy of a mass in the neck. He had had severe chest pains, become short of breath and had been treated with antibiotics for a chest infection.


On the day of his admission BR was operated on and the mass in his neck biopsied from inside the throat as well as externally. It was difficult to put down an ET tube because the tumour mass was partially blocking his throat. After the operation, his breathing was obstructed, it was impossible to put down another ET tube and an emergency tracheostomy was done.

BR was on a ventilator overnight but recovered sufficiently the following day to be well enough to go back to the ward. A sedative was started because of his anxiety.

Six days later as BR was preparing to be discharged home, he collapsed with shortness of breath, a rapid heart beat, anxiety and chest pain. This was thought to be a chest infection, he was treated with antibiotics and seen by a MacMillan (cancer) nurse.

A CT Scan of his head, neck and mediastinum was arranged.

A week after surgery, the CT scan of the neck showed a large tumour, the CT scan of the chest, some curious "nodules" but no large primary tumour.

An cancer specialist saw BR and wanted further analysis of the tumour specimens before starting chemotherapy. The tumour appears not to have spread and is limited to the neck and is thought to have arisen from the tonsil.

2 days later, BR has a further episode where he becomes short of breath, with a rapid heart rate, chest pain - a number of different diagnoses are considered, including C Difficile, a bowel infection, a further chest infection or possibly tumour spread.

The Liverpool Palliative care pathway is started. High doses of sedatives and pain killers are begun, including tramadol, Midazolam, MST, and morphine. Doctors and nurses are concerned only to keep BR comfortable.

2 days BR has another episode of shortness of breath, rapid heart rate and chest pains. Again no diagnosis is made, BR's chest problem has not been diagnosed, nonetheless his sedation and painkillers are steadily increased. Plans are made for BR to go to a hospice. However two days later he has a further episode of shortness of breath, rapid heart rate and chest pains. His doses of sedative and painkillers are increased further. Medazolam is given by a syringe pump. Later the same day, BR dies

A death certificate is issued, which say BR died from secondary spread of cancer from a lung malignant tumour

Looking back

Was it necessary to biopsy BR's tumour under a general anaesthetic?
What other investigations might have been done first both to investigate the tumour and to assess BR's health?
What was the cause of BR's lung disease? Could it have been pulmonary emboli, or clots on the lung given his rapid deteriorations and almost equal rapid recoveries?
What caused the collapses following his operation? Was it further clots on the lung?
What happened to allow a 63 year man to walk into hospital and within three weeks he was dead, following the introduction of the Liverpool Palliative care pathway?

The management and medical staff at the hospital involved in BR's care lied to his partner, and at no stage has anyone sought to understand or answer the questions posed above.

This is why everyone in the country, both here and abroad needs to know enough medicine to keep themselves safe. It is not enough to know a doctor, you need to know what they are doing.


Copyright (c) Dr. Liz Miller
www.lizmiller.info

Find out more!
Buy the book!

www.lizmiller.co.uk
www.moodmapping.com