Chris came to the emergency department with complaints of cough and shortness of breath. She initially became ill after returning from a trip to Hawaii with her family and figured she had caught a cold on her trip home.
She tested herself for COVID-19 several times and each test had been negative. She went to an urgent care after several days when her symptoms were not getting better despite her taking over-the-counter cough and cold medications. She had another negative COVID test at urgent care, and they did a chest X-ray that showed probable pneumonia, so she was placed on an antibiotic and stronger cough medication.
In addition to her cough and fatigue, she had started noticing that she was very short of breath when walking her dog and doing housework. She was also having a crampy pain in her right leg that was especially bothersome at night when she was trying to sleep. She waited it out for a few more days but because her symptoms worsened, she decided to come to the emergency department (ED).
Chris’s heart rate was elevated when she arrived in the triage area of the ED, and her oxygen level was low. The nurse immediately put her on oxygen through tubing in her nose. She felt very short of breath from walking in from the parking garage and the oxygen had really helped her shortness of breath. The nurse placed an IV in her arm and brought her back to a room by wheelchair.
When I went in to see Chris, I first noticed that she looked anxious and uncomfortable. Her heart rate was elevated, and her breathing was fast and shallow. She was under several blankets because she was feeling chilled. As I examined her, I noticed that her right leg was swollen, tender and larger than her left leg. Her lungs were clear, but it was hard for her to take a deep breath even for me to listen to her breathing because it caused her so much discomfort.
I asked Chris’s nurse to get an EKG and give her pain medications through her IV. I ordered lab testing, an ultrasound of her right leg, and a CT scan of her chest. At this point, I was worried that Chris’s cough and difficulty breathing could have been due to a blood clot in her leg and in her lungs.
I went back to check on Chris after she had received pain medications and she looked much better and was having an easier time breathing. I got a call from the vascular technician that her leg ultrasound found blood clot in the veins in her right lower leg. With this information, I was quite confident that Chris’s symptoms were due to a blood clot in her lung, which is called a pulmonary embolism (PE).
I let Chris know that she had a blood clot in her leg and ordered a blood thinning medication for Chris while we awaited her CT scan. A short time later the radiologist called to let me know that Chris did have blood clots in both of her lungs. There was a large amount of clot in Chris’s lungs and there were findings indicating that these clots were causing strain on Chris’s heart.
I spoke with our cardiologist who evaluated Chris to see if they could take her for a procedure where they remove the clots. He thought Chris was a good candidate for this procedure and Chris went from the ED to the catheterization lab for clot removal. In this procedure, they fed a catheter through the veins in Chris’s groin to the arteries in her lung where the clot was lodged and pulled it out.
The clot retrieval went well, and they were able to remove the large clots that were causing Chris’s shortness of breath. She was admitted to the hospital after the procedure and continued to receive blood thinning medication to prevent her from forming any more clots. Chris said her shortness of breath went away immediately after the clots were removed from her lungs. She underwent additional lab testing to help determine why she developed this blood clot in the first place and, ultimately, she was told her clot was likely the result of her long flight home from Hawaii.
Pulmonary emboli are relatively common, affecting more than 900,000 Americans each year. Blood clots can develop in the legs or pelvis and if untreated can break loose and travel through the circulatory system to the lung. When in the lung, the clot lodges in the arteries and blocks normal blood flow to the lung tissue. If there is a large burden of clots, these clots cause stress on the heart and can lead to heart failure or even cardiac arrest.
There are numerous factors for pulmonary embolism, which include a previous history as 33% of people with previous clot will experience another within 10 years. Inactivity such as when on bed rest or during air travel, after surgery or an injury predisposes to clot formation. Pregnancy can also increase the risk due to the fetus pressing on the veins in the pelvis causing slowed blood flow from the legs back to the lungs. Use of birth control and other estrogen-containing medications can increase blood clotting factors, leading to increased risk of clot formation.
Chris was able to be discharged home from the hospital after a few days. She was started on an oral blood thinning medication that she would take for the next several months. She had an appointment to see her family physician a few weeks after discharge from the hospital and they would decide how long she needed to take the blood thinning medications.
Dr. Erika Kube is an emergency physician who works for Mid-Ohio Emergency Services and OhioHealth.