Low risk PE dc from ED

[Erek94]

Is your shop doing this yet? What is the protocol you use?

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[d2305]

Low PESI Score with PE....to the hizzouse??

 

[GeneralVeers]

Of course LOGICALLY low-risk PE can be discharged home. In fact PE is probably a normal part of physiology, and most people in their lives get PEs that are either asymptomatic or with barely any symptoms.

That being said, lawyers will see it different. If anything happens to that PE patient you send home, and you have documented PE, there is nothing that will save you.

 

[RustedFox]

Of course LOGICALLY low-risk PE can be discharged home. In fact PE is probably a normal part of physiology, and most people in their lives get PEs that are either asymptomatic or with barely any symptoms.

That being said, lawyers will see it different. If anything happens to that PE patient you send home, and you have documented PE, there is nothing that will save you.

Yep. PE gets admitted. I don't care if the hospitalists start them on Xarelto and send them home same-day and then call me names.

 

[migm]

i send hestia criteria negative PE home unless I have any concerns whatsoever. I think it's a defensible practice. If you wanna be more conservative, then use PESI.

 

[WilcoWorld]

This is a totally reasonable practice when you have the right patient. I do it, but usually it's during daytime hours when there's a pharmacist around to help out. If the ducks aren't all in a row I'll admit.

I disagree that "nothing will save you" if something goes wrong. An institutional policy on the books or well-documented shared decision making would both make me very comfortable defending this practice.

 

[xaelia]

Technically, patients always* should be offered the choice to be admitted or discharged based on their diagnosis, and PE is no different. For some PEs, the recommendation is very obviously for admission. For patients at low risk for adverse outcomes, using PESI or Hestia or a local institution protocol to offer patients discharge as part of shared decision-making ought not be terribly controversial.

* not always

 

[GeneralVeers]

The difficulty comes with prescribing an anti-coagulant. I have almost no way of making sure a patient's insurance will cover/approve the medication. Usually admission, especially for Medicare patients is so that the case manager can get on board and ensure they will get prescriptions prior to discharge from the hospital.

 

[bravotwozero]

If the patient has a PCP that I am able to contact, can see the patient in his office the next day, and agrees with my plan to DC on xarelto, that is the only scenario where I can see myself discharging them. Otherwise they get admitted.

 

[fahimaz7]

Low risk by pesi and no right heart strain =dc
We do riskier things daily.

 

[Erek94]

I’m working on a institutional protocol proposal for this. Curious if others work at places where this is in place. Sounds like most would use Hestia or PESI and some form of shared decision making.

 

[bigtuna]

....In fact PE is probably a normal part of physiology, and most people in their lives get PEs that are either asymptomatic or with barely any symptoms.

never heard that one. Got any sources?

 

[GeneralVeers]

never heard that one. Got any sources?

No. It's a theory but it makes sense. You probably develop small venous clots all the time in your body which get "trapped" by the lungs before they can cause damage to your brain. I don't think any evidence exists, because you would have to subject normal, asymptomatic patients to radiation to find them, and then to not treat would be considered unethical. We just assume that every sub-segmental PE we find on CT is pathologic.

 

[Apollyon]

There was a study that I don't have at my fingertips this moment that showed 25% of people had a clinically significant PE on autopsy, but the PE isn't what killed them.

I tell the young women with chest pain that the lungs filter the clots. I say we can check the d-dimer, it's positive, we CT the chest, and find a subsegmental PE, and, now, you're on anticoagulants, for something that is physiologic. I reassure with a normal EKG, and totally normal vital signs. I tell them, if it gets worse, then we go further. Painting the picture of how ****ty it is to be on anticoagulants is what sells it.

 

[GeneralVeers]

There was a study that I don't have at my fingertips this moment that showed 25% of people had a clinically significant PE on autopsy, but the PE isn't what killed them.

I tell the young women with chest pain that the lungs filter the clots. I say we can check the d-dimer, it's positive, we CT the chest, and find a subsegmental PE, and, now, you're on anticoagulants, for something that is physiologic. I reassure with a normal EKG, and totally normal vital signs. I tell them, if it gets worse, then we go further. Painting the picture of how ****ty it is to be on anticoagulants is what sells it.

Mortality for PE hasn't improved much in 30 years despite the new anticoagulant treatments. I would agree that logically every stable patient with good vital signs could be discharged with outpatient follow up. Logic doesn't typically figure into most malpractice cases.

 

[gutonc]

Mortality for PE hasn't improved much in 30 years despite the new anticoagulant treatments. I would agree that logically every stable patient with good vital signs could be discharged with outpatient follow up. Logic doesn't typically figure into most malpractice cases.

True dat.

But all you have to do is call me, get my name in the chart, document that Mr Jones will follow up with me to discuss anticoagulation and you’re pretty much off the hook.

 

[Siggy]

Here's a bigger question. Does anyone follow the most recent Chest guidelines that calls for not anticoagulating single subsegmental PEs?

 

[GeneralVeers]

True dat.

But all you have to do is call me, get my name in the chart, document that Mr Jones will follow up with me to discuss anticoagulation and you’re pretty much off the hook.

At 3AM? I work nights BTW

 

[goodoldalky]

We discharge hestia negative clots with normal cardiac enzymes and no right heart strain. They do get a visit from social work and get manufacturer 30 day starter packs of riva or apix. No point in keeping these people in the hospital and there’s good data to support that.

But, I do work in Texas, so that allows me to do logical things.

 

[gutonc]

At 3AM? I work nights BTW

I get called at 3am for much dumber s*** than that on the regular.

 

[southerndoc]

We discharge hestia negative clots with normal cardiac enzymes and no right heart strain. They do get a visit from social work and get manufacturer 30 day starter packs of riva or apix. No point in keeping these people in the hospital and there’s good data to support that.

But, I do work in Texas, so that allows me to do logical things.

How do you arrange for echos to assess for right heart strain? Maybe I'm wrong, but didn't these studies utilize echos? Right heart strain isn't always identified on a CT. Granted, they usually have high clot burden and maybe you just choose not to apply the rule with high clot burden.

 

[Angry Birds]

Yeah, here is who I am not discharging ever: someone with a PE. Heh, good one, guys!

 

[goodoldalky]

How do you arrange for echos to assess for right heart strain? Maybe I'm wrong, but didn't these studies utilize echos? Right heart strain isn't always identified on a CT. Granted, they usually have high clot burden and maybe you just choose not to apply the rule with high clot burden.

Hestia and we use RV to LV ratio on CT. Greater than 1 positive less than 1 negative. Non-normal TnI or BNP admit. We do not echo the hestia negative patients.

 

[deleted109597]

Yeah, here is who I am not discharging ever: someone with a PE. Heh, good one, guys!

You probably do every day. You just don't diagnose or find them.
PEs are like disk bulges. They're ubiquitous. Some are pathologic, others clearly aren't. And then there's middle ground. It used to be that any PE you could diagnose was clinically significant. Now imaging technology allows us to diagnose PEs that probably are just physiologic.

 

[Apollyon]

You probably do every day. You just don't diagnose or find them.
PEs are like disk bulges. They're ubiquitous. Some are pathologic, others clearly aren't. And then there's middle ground. It used to be that any PE you could diagnose was clinically significant. Now imaging technology allows us to diagnose PEs that probably are just physiologic.

That's what I said!

 

[gro2001]

True dat.

But all you have to do is call me, get my name in the chart, document that Mr Jones will follow up with me to discuss anticoagulation and you’re pretty much off the hook.

There is absolutely nothing that could ever be counted on to get an ED doc, or anyone else for that matter, off the hook, in this or any other situation that leads to a bad outcome. Not discussion with PCP, not shared decision making, not a clear recommendation from a national board, not expert witness testimony, not a decision to admit, not a negative test for the condition, nor any clinical decision rule. Nor any combination of the above.

If there is a bad outcome, most PMDs you've had a discussion with will immediately say "These were not the details of the case as they were presented to me. I was not in front of the computer at 3 AM in the morning, so I trusted Dr Veers to convey the information accurately to me, which I realize now he did not. Of course, if I knew X, I would have recommended admission". They will point out, correctly, that responsibility for this decision rest entirely with the MD actually seeing the patient at the time. Even if you are the rare exception that wants to go down fighting with the ED doc, the opposing lawyers will point out the same: you were not in a position to see the patient and examine all the details of the case, and therefore the ED doc should not have taken comfort in your reassurance. Also, they could argue, it's the ED doc that is an expert on managing acute presentations of PEs, not you (unless you are a pulmonologist), so why should contacting you let him or the hospital off the hook?

Having said that, I do everything I can to avoid testing them for PE if I do not think the answer is clinically relevant and would be happy to discharge them if reasonable follow up and access to NOACs are available. If something goes wrong, however, I don't for a second consider that my documented phone calls to PCPs will do significantly mitigate my risk.

 

[Groove]

Glad to see everyone is still on the fence about this one! That's why I started the original thread. In training, we admitted all PEs and in the majority of my professional practice, I admit all PEs. That being said, I think we are starting to have have really good EBM data to support d/c with NOACs in our low risk pt population. Everyone is right though about theoretical vs practical and that's really a personal shop sort of thing. I've d/c n=1 since that thread, and admitted all the rest. I use PESI. That risk stratification tool is much more widely quoted and used. The problem I run into oftentimes is that our patient population is horrible about compliance and there's little way for me to make sure they can fill their meds or that they will be covered with insurance. Luckily, our medicine team doesn't mind admitting to get all this figured out and d/c the pt within 24h. I think this is the way of the future though and unlike others, I think you'd have more than a single leg to stand on if you documented well, used a tool such as PESI and let the pt make an informed decision. I try to include their PCP for buy in and to assure close f/u.

I've been really surprised to find how all over the place people are with their practice patterns. My colleagues at work are no different.

For myself, after reading much of the newer studies, I've begun to be persuaded that this is indeed the future and there is pretty good evidence for it. I've started to make a conscious decision to change my practice pattern, within reason. I only consider d/c for Class I (PESI scores < 65) though. I'll readily agree that malpractice environment along with regional standard in practice CAN and SHOULD affect how you manage these cases. There's no shame in that.

 

[goodoldalky]

Let me point out one other thing here too - in my mind (at least from a medicolegal standpoint), this isn't like sending someone home with a HEART score of 2 in which you have not made a "life-threatening diagnosis", but rather just made an assessment of risk. You are sending someone home with a DIAGNOSED PATHOLOGY which still carries real 30 day mortality. The equivalent to this would be, say, sending someone home with a "low risk NSTEMI"..

First, real 30 day mortality? This multicenter validation study shows a 0% 30 day mortality in these low risk patients. Immediate Discharge and Home Treatment With Rivaroxaban of Low-risk Venous Thromboembolism Diagnosed in Two U.S. Emergency Departments: A One-year Pr... - PubMed - NCBI Your heart score of 2 that you’re so comfortable sending home has a higher mace rate than these patients.

Second, it’s not the same as sending home an NSTEMI. There is no guideline or evidence suggesting you do that. That’s not shown to be safe and that would run contrarian to the evidence we have today. It’s fundamentally different from what we are talking about doing here.

Listen, if you work in New York or some other forsaken place and want to admit everyone because it’s litigious, go ahead. Or if you want to do something just because you feel a certain way, that’s your prerogative. But just realize you’re not basing your decision on any kind of science.

To gro2001’s last paragraph (he is correct regarding phone calls btw), if your concern is medicolegal liability, you aren’t better off “not testing” and missing something. You’re better off diagnosing it, practicing evidence based medicine, using the appropriate treatment which is described in the literature, and documenting exactly that.

 

[gro2001]

To gro2001’s last paragraph (he is correct regarding phone calls btw), if your concern is medicolegal liability, you aren’t better off “not testing” and missing something. You’re better off diagnosing it, practicing evidence based medicine, using the appropriate treatment which is described in the literature, and documenting exactly that.

My main concern is not so much the medicolegal (although I'd be lying if I said that never crosses my mind). I spend far more energy worrying about doing harm. I've found that the most consistent way to avoid doing harm is to do as little testing as possible. However, I am not simply not testing. When I don't think I will find anything clinically significant, I put in quite a bit of effort to document why I think the route of testing is not indicated. Details of history, PERC when applicable, mentioning that risk of testing outweighs benefit at very low probabilities, etc. Obviously, when I suspect I could find something pathological, I test.

 

[WilcoWorld]

In residency I sent home plenty of low-risk PE's (when my attending wanted it and their name was on the chart). And now I don't.

I will agree that from a practice standpoint sending them home, if they are agreeable with outpatient management, is probably the right thing to do. But from a medicolegal standpoint? Nah. Look, my first responsibility in life is to take care of my family, which means having stable employment and avoiding the stress of having malpractice suits dropped in my lap as much as possible. Sure maybe I'm not "saving the system money" or "saving the patient money". And in this case I don't really give a d***. You think the system gives a flying crap about you or me? You think your patients give a flying crap about you or me? You think they won't try to empty your wallet if they get the chance? If we ever have a system where I can make reasonable medical decisions without fear of lawsuit I'll change my practice. Until then, no way.

Let me point out one other thing here too - in my mind (at least from a medicolegal standpoint), this isn't like sending someone home with a HEART score of 2 in which you have not made a "life-threatening diagnosis", but rather just made an assessment of risk. You are sending someone home with a DIAGNOSED PATHOLOGY which still carries real 30 day mortality. The equivalent to this would be, say, sending someone home with a "low risk NSTEMI". Look, I get that 30 day mortality for low-risk PE is low and probably the same whether they got admitted or not.... And I'll bet you this is also true for say an NSTEMI with a stable patient with resolved chest pain, reasonably normal EKG, and a trop of say 0.2 that on repeat 3 hours later hasn't increased. But are you discharging that NSTEMI patient with outpatient management and close PCP f/u? Yeah I didn't think so. Some things in our system just aren't defensible, and a patient found dead in their bed from a PE 2 days after you discharged them on Xarelto is one of them.

Just to be clear - you can have a moderately suspicious story + a positive troponin and still get a HEART score = 2.

 

[goodoldalky]

You do realize that this study you quoted to me only had 35 patients in the PE group right? (71 were DVT only). And you do realize 3 patients were totally lost to follow-up, right? Which means they could have been dead for all your know. Do you think this study is adequately powered to detect mortality in low-risk PE patients, especially considering that this was not one of their outcome measures? (Although you could argue recurrent VTE rate is kind of a surrogate for mortality). Are you going to use a single study where only 35 patients with PE were included to determine mortality risk? This is a huge problem in medicine. We get these studies published and immediately people say LOOK LOOK LOOK! This study says I can do XYZ, it's PROOF!! But they don't take the time to really consider what the study is saying, what it is designed and powered to detect and not detect, what the potential limitations are, whether the results can be reproduced, and what else is in the literature.

This metaanalysis from 2017: (PMID: 28525830) looking at literature from 1950-2016 demonstrates an overall 2.83% 90 day mortality rate in patients with PE treated outpatient. And, take a look at Table 1. There are several studies in which HESTIA, PESI, or sPESI were used for inclusion criteria with mortality (of varying length) being a primary outcome, and in several of these studies (including Aujesky, Zondag, Ozsu, Vali, and Den Exeter) there was in fact mortality with a rate between 0.6-3.2%.

So I've showed you a metaanalysis with several studies which clearly show there is mortality risk including in patients in whom HESTIA, PESI, and sPESI criteria are used (whether they go home or not).

Did you read the conclusion on the study you cited? Here it is.

“Outpatient management appears to be feasible and safe for many patients with PE.”

Admitting any patient with “a risk of mortality” must lead you to a lot of admissions.

 

[Janders]

Just to be clear - you can have a moderately suspicious story + a positive troponin and still get a HEART score = 2.

You sure can. But good luck finding these in the real world. Especially the cohort of "I thought this was low risk chest pain, i ran a heart score, they have a positive troponin, but I don't think its an unstable angina, NSTEMI, PE, myocarditis or other worrisome admission-worthy pathology, I still think its low-risk chest pain and I'm still going to apply HEART and discharge them" patients. I haven't met many of those. Just because a theoretical patient wrecks the decision rule, doesn't make it a useless decision rule. And chart buff.

Personally, I have sent some small PE home. I quote PESI in my MDM. I prescribe a NOAC. But I do this in patients with insurance, with clear understanding of what we are doing, who volunteer they WANT this and not to be admitted overnight which I offer them. They also tend not to have many comorbidities, and an obvious reason for their PE. They are a minority of the PE I see.

If I knew which freaking NOAC they could get for <$800 it would be way easier...

 

[WilcoWorld]

Yes I’m aware. That wasn’t my point.

You sure can. But good luck finding these in the real world. Especially the cohort of "I thought this was low risk chest pain, i ran a heart score, they have a positive troponin, but I don't think its an unstable angina, NSTEMI, PE, myocarditis or other worrisome admission-worthy pathology, I still think its low-risk chest pain and I'm still going to apply HEART and discharge them" patients. I haven't met many of those. Just because a theoretical patient wrecks the decision rule, doesn't make it a useless decision rule. And chart buff.

Personally, I have sent some small PE home. I quote PESI in my MDM. I prescribe a NOAC. But I do this in patients with insurance, with clear understanding of what we are doing, who volunteer they WANT this and not to be admitted overnight which I offer them. They also tend not to have many comorbidities, and an obvious reason for their PE. They are a minority of the PE I see.

If I knew which freaking NOAC they could get for <$800 it would be way easier...

It appears that the point of my (admittedly snarky) post was missed. I suppose I welcomed that by being snarky.

I work in an academic ED. Arguably, part of my job is to advance the standard of care in accordance with the literature. So, I do consider outpatient PE therapy. But please note that earlier I recommended that this be done with the protection of an institutional protocol & some shared decision making. I also said I do it during the day, with the help of a pharmacist, and that if I don't have "all my ducks in a row", I'll admit the patient.

It's funny that so many of us are arguing about this, because it seems like we mostly agree that; In the right patient, under the right circumstances (including medicolegal considerations), this is a reasonable practice. We also seem to agree that it is often (usually?) hard to meet all the necessary criteria, so in order for this practice to become widespread it will require the efforts of more than just EPs' reading articles.

 

[xaelia]

That's what I said!

Yeah, but he mansplained it for you.

 

[Angry Birds]

It appears that the point of my (admittedly snarky) post was missed. I suppose I welcomed that by being snarky.

I work in an academic ED. Arguably, part of my job is to advance the standard of care in accordance with the literature. So, I do consider outpatient PE therapy. But please note that earlier I recommended that this be done with the protection of an institutional protocol & some shared decision making. I also said I do it during the day, with the help of a pharmacist, and that if I don't have "all my ducks in a row", I'll admit the patient.

It's funny that so many of us are arguing about this, because it seems like we mostly agree that; In the right patient, under the right circumstances (including medicolegal considerations), this is a reasonable practice. We also seem to agree that it is often (usually?) hard to meet all the necessary criteria, so in order for this practice to become widespread it will require the efforts of more than just EPs' reading articles.

I think this is reasonable. Those in academia can and should lead the way. But it will take time before such a practice could become mainstream out in the community. Which is probably something you agree with, based on what you said above.

 

[Old Grunt]

Of course LOGICALLY low-risk PE can be discharged home. In fact PE is probably a normal part of physiology, and most people in their lives get PEs that are either asymptomatic or with barely any symptoms.

That being said, lawyers will see it different. If anything happens to that PE patient you send home, and you have documented PE, there is nothing that will save you.

Yep. Not doing it. Don't care what the hospitalist says. It doesn't pay to be an early adaptor on this one.

 

[Old Grunt]

No. It's a theory but it makes sense. You probably develop small venous clots all the time in your body which get "trapped" by the lungs before they can cause damage to your brain. I don't think any evidence exists, because you would have to subject normal, asymptomatic patients to radiation to find them, and then to not treat would be considered unethical. We just assume that every sub-segmental PE we find on CT is pathologic.

One of my attendings in residency was always referencing this as something he had heard from one of his attendings many moons ago in his residency but no one could ever find and documentation. I agree it makes sense that the lungs wash out small clots the body naturally makes.

 

[WilcoWorld]

Yep. Not doing it. Don't care what the hospitalist says. It doesn't pay to be an early adaptor on this one.

What's that old saying about advances in medicine? Something like, "You don't want to be the first one to change, but you also don't want to be the last."

One of my attendings in residency was always referencing this as something he had heard from one of his attendings many moons ago in his residency but no one could ever find and documentation. I agree it makes sense that the lungs wash out small clots the body naturally makes.

It would seem pretty reasonable to infer this claim from the fact that, while the rates of diagnosing have gone up & up & up, the mortality rates have stayed pretty steady.

 

[Old Grunt]

What's that old saying about advances in medicine? Something like, "You don't want to be the first one to change, but you also don't want to be the last."



It would seem pretty reasonable to infer this claim from the fact that, while the rates of diagnosing have gone up & up & up, the mortality rates have stayed pretty steady.

The best advice I got before going to Ranger School was from a guy who had been a Company Commander at Ripcord in Viet Nam with the 101st. "Be the gray man. Don't stand out for the right or wrong reasons."

I think it's reasonable that our new CT scanners are catching benign PEs, but until that is the wide consensus, I am admitting them.

 

[Angry Birds]

The best advice I got before going to Ranger School was from a guy who had been a Company Commander at Ripcord in Viet Nam with the 101st. "Be the gray man. Don't stand out for the right or wrong reasons."

I think it's reasonable that our new CT scanners are catching benign PEs, but until that is the wide consensus, I am admitting them.

What I don’t get is that our patient is coming in with chest pain worrying enough that we get a CTA. How is that ever a benign insignifant PE if the patient is symptomatic?

 

[CanadianEM]

You guys are nuts. Put them on a DOAC, discharge them, and call it a day. At worst, if our patients can't afford a DOAC, I'll put them on LMWH, start Warfarin, bring them back in the next few days till their Warfarin is therapeutic, and D/C them to their GP for followup care. I've never heard of a patient in the EDs where I work, coming back in arrest as a result of this. To admit a stable patient with PE who doesn't require O2 or have submassive/massive PE is silly.

 

[TooMuchResearch]

What I don’t get is that our patient is coming in with chest pain worrying enough that we get a CTA. How is that ever a benign insignifant PE if the patient is symptomatic?

Right lateral chest pain, left subsegmental PE?

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[TooMuchResearch]

You guys are nuts. Put them on a DOAC, discharge them, and call it a day. At worst, if our patients can't afford a DOAC, I'll put them on LMWH, start Warfarin, bring them back in the next few days till their Warfarin is therapeutic, and D/C them to their GP for followup care. I've never heard of a patient in the EDs where I work, coming back in arrest as a result of this. To admit a stable patient with PE who doesn't require O2 or have submassive/massive PE is silly.

Welcome to the United States!

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[RustedFox]

You guys are nuts. Put them on a DOAC, discharge them, and call it a day. At worst, if our patients can't afford a DOAC, I'll put them on LMWH, start Warfarin, bring them back in the next few days till their Warfarin is therapeutic, and D/C them to their GP for followup care. I've never heard of a patient in the EDs where I work, coming back in arrest as a result of this. To admit a stable patient with PE who doesn't require O2 or have submassive/massive PE is silly.

Welcome to America, where the med.mal system is not about good or bad medicine - its about good or bad outcomes and the hot potato. I thought you guys up there just prescribed "don't eat the yellow snow" for your PEs, anyways. (I kid, I kid).

Classmate of mine from residency had this case in his first year out: 30-something female with chest pain and an already diagnosed PE. She's on warfarin already, but comes in because "the pain is worse". What is he to do; re-scan her? No. Start another drug? No. (This was before DOACs were a thing). Supportive care and discharge, which is what any doc with good sense would do.

Gal is dead several days later from.... more PEs.

First year out. First lawsuit.

Settled.

I don't kid.

 

[CanadianEM]

I would argue that he made a poor non-defensible medical decision NOT to re-scan. We know that Warfarin is a reasonable option for PE but there will still be patients who have worsening clot burden despite that, or who are not ALWAYS in the therapeutic INR range for whatever compliance or dietary reasons... I just had a patient like this yesterday. But that just means that they are a warfarin failure and need to be started on a DOAC or LMWH or whatever else. Especially so if its malignancy related PE. And despite this, there will be patients who need 1.25 or 1.5x that dose of LMWH... Doesnt necessarily mean that they need admission.

 

[RustedFox]

I would argue that he made a poor non-defensible medical decision NOT to re-scan. We know that Warfarin is a reasonable option for PE but there will still be patients who have worsening clot burden despite that, or who are not ALWAYS in the therapeutic INR range for whatever compliance or dietary reasons... I just had a patient like this yesterday. But that just means that they are a warfarin failure and need to be started on a DOAC or LMWH or whatever else. Especially so if its malignancy related PE. And despite this, there will be patients who need 1.25 or 1.5x that dose of LMWH... Doesnt necessarily mean that they need admission.

1. I had that thought, too - but now we can go down the risk rabbithole either way. If he did scan her.... were the "new" PEs even there at the time? If no; what's to be gained by admission? She still would have died.
2. The DOACs didn't exist back then.
3. Lovenox as an outpatient requires a degree of education and resource arrangement (its not cheap) that is not gonna happen in the ER. Thus; admit. Also; LWMH isn't a magic spell; the clot is still there for quite some time - thus, admit for observation. Hot potato.

 

[Apollyon]

Someone is on the "bleeding edge" (pun intended) of anticoagulative verbology. As I am guessing from the lurkers who would never post, the term "DOAC" is, possibly-to-likely supplanting the term "NOAC" in the future. What I just found out from my laborious (one-click Google) search was that NOAC has been maintained, but, instead of the N being "novel", it is now "Non Vitamin K". However, the safety concern of people thinking NOAC means "No anticoagulation" is why "DOAC" (for Direct Oral AntiCoagulation) was suggested.

 

[Old Grunt]

You guys are nuts. Put them on a DOAC, discharge them, and call it a day. At worst, if our patients can't afford a DOAC, I'll put them on LMWH, start Warfarin, bring them back in the next few days till their Warfarin is therapeutic, and D/C them to their GP for followup care. I've never heard of a patient in the EDs where I work, coming back in arrest as a result of this. To admit a stable patient with PE who doesn't require O2 or have submassive/massive PE is silly.

Don't care. Still not going to be an early adaptor on this.

 

[TooMuchResearch]

Welcome to America, where the med.mal system is not about good or bad medicine - its about good or bad outcomes and the hot potato. I thought you guys up there just prescribed "don't eat the yellow snow" for your PEs, anyways. (I kid, I kid).

Classmate of mine from residency had this case in his first year out: 30-something female with chest pain and an already diagnosed PE. She's on warfarin already, but comes in because "the pain is worse". What is he to do; re-scan her? No. Start another drug? No. (This was before DOACs were a thing). Supportive care and discharge, which is what any doc with good sense would do.

Gal is dead several days later from.... more PEs.

First year out. First lawsuit.

Settled.

I don't kid.

I've rescanned these folks. You really really want to know if someone is having more PEs while already being treated.

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[CanadianEM]

Don't care. Still not going to be an early adaptor on this.

Early adopter?? The rest of the world manages PE this way. Same with low risk chest pain. And atrial fib (in the sense that they get discharged and not admitted). But as was previously suggested, management plans that are well supported by the literature and supported by guidelines might not work in the med mal environment of the US