Sick of PE

[Proton Dense]

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I don't know where else to post this... move it if you want

I am a radiology resident at a decent sized hospital and must I say I am sick of PE. Just got off of another night of long call where half of the CT's were for PE
"I am concerned this patient has a PE"
"I am still concerned this patient has a PE"
"Are you sure this patient doesn't have a PE"
"What about the subsegmental arteries, huh, really, no PE. Weird"
"We might half to do a V/Q as well"

Every night it is the same thing. Multiple throng of white coats tracking me down... In a sincere hushed tone "We are going to have to rule out PE"

We are all taught it is under diagnosed, maybe it is. But holy S, it is all I hear about all night! Anyway, rant over

 

[3dtp]

I don't know where else to post this... move it if you want

I am a radiology resident at a decent sized hospital and must I say I am sick of PE. Just got off of another night of long call where half of the CT's were for PE
"I am concerned this patient has a PE"
"I am still concerned this patient has a PE"
"Are you sure this patient doesn't have a PE"
"What about the subsegmental arteries, huh, really, no PE. Weird"
"We might half to do a V/Q as well"

Every night it is the same thing. Multiple throng of white coats tracking me down... In a sincere hushed tone "We are going to have to rule out PE"

We are all taught it is under diagnosed, maybe it is. But holy S, it is all I hear about all night! Anyway, rant over

These days, anyone who has any change in O2 sat "obviously has a PE and you missed it!"

I had a case intern year where the pt desatted. Pt. was admitted for pain management and was on every brand of narc known to man, by every route available. IV/PCA, PO, etc. Stat pCXR showed a white lung c/w aspiration pneumonitis. Spiral CT didn't exist at this institution then, and I did not order a V/Q scan, the reason being, I had a pt if not o/d on narcotics, then had aspirated and as we all should know, absent a normal CXR, a V/Q scan will be inconclusive. Was crucified for not starting anti-coags on a severely malnourished pt (BMI <12) with approximately zero body fat on enough narcotics to snow an elephant. In AM, anticoags were started, causing bleeding in the malnourished and presumably Vit-K deficient patient and the angiogram turned out to be "completely normal."

I can understand the paranoia. The new real problem is what is the committed dose of radiation from the spiral ct's used to r/o PE with low clinical suspicion and does the latent risk of neoplasia outweigh the probability of discovering a PE?

 

[kamehame]

I thought you were talking about Phys Ed. I'm pretty sick of that class, myself.

 

[Tired]

Desats are PEs until proven otherwise? Hell, I could live with that. But on some of our surgical services (*cough* . . . neurosurg) tachycardia, even in the absence of respiratory symptoms, is a PE until proven otherwise.

For the OP, sorry you get saddled with that crap over and over. But believe me, I feel like a fricking ***** every time I call you for a spiral in the middle of the night. I only do it because they make me.

 

[Sanchik]

i am at a small community hospital where v/q scans and spiral ct's are not available at night. ok, theoretically they are available but a whole team has to come in, etc, it's just not really done. when i am on call, every time i have a copder with low sats which is like evbery other pt i am scared that i am missing a pe. what to do? especially now that i am on nightfloat and sometimes i see the same pts doing this every night.

 

[danielmd06]

Yeah. The problem is that if one is ever missed...there is hell to pay. Frankly they often don't read the book, either. Last one I saw intern year was a massive saddle embolus in a pt with O2 sat 98% (mine is 97% at baseleine!) and a heart rate of 63. Ri-i-ight.

The IM team was actually checking for pneumonia on CT.

 

[Geri_Gal]

i am at a small community hospital where v/q scans and spiral ct's are not available at night. ok, theoretically they are available but a whole team has to come in, etc, it's just not really done. when i am on call, every time i have a copder with low sats which is like evbery other pt i am scared that i am missing a pe. what to do? especially now that i am on nightfloat and sometimes i see the same pts doing this every night.

Most COPDers with low sats will not have a PE.

Can you order a lower extremity U/S? If the patient has a great story for PE (or hx of thromboembolism) and you *really* suspect PE at night in your small community hospital, you could give 1mg/kg lovenox and scan the pt in the morning. What do the others think -- is this too cavalier?

 

[3dtp]

Most COPDers with low sats will not have a PE.

Can you order a lower extremity U/S? If the patient has a great story for PE (or hx of thromboembolism) and you *really* suspect PE at night in your small community hospital, you could give 1mg/kg lovenox and scan the pt in the morning. What do the others think -- is this too cavalier?

If you can definitely rule out coagulopathies. Give someone lovenox or unfractionated heparins (most likely much more available because it's cheaper), they don't have a PE or there's no evidence, but they've had a chronically leaking and undiagnosed AVM and you've created a stroke. This is not good. But, you have identified a case with a highly clinically suspicious situation. Most are not that clear. And, anticoag therapy is not necessarily benign. My case required transfusion and Vit-K to reverse anticoagulation.

Danielmd noted that a saddle embolis patient was asymptomatic. This is the problem with PE. They are life threatening, hard to diagnose in a clinical setting, and can be treated. But, the treatment itself can, in the wrong patient be life threatening, hard to diagnose, and difficult to reverse.

Damned if you do, damned if you don't. The advent of spiral/helical multidetector CT has eased this dilema somethat, and provides employment for additional radiologists, so the OP is actually going to profit by the paranoia. And just try to get a rapid LE D/US at most academic hospitals in the middle of the night. They're hard enough to get during the day.

 

[Faebinder]

Desats are PEs until proven otherwise? Hell, I could live with that. But on some of our surgical services (*cough* . . . neurosurg) tachycardia, even in the absence of respiratory symptoms, is a PE until proven otherwise.

For the OP, sorry you get saddled with that crap over and over. But believe me, I feel like a fricking ***** every time I call you for a spiral in the middle of the night. I only do it because they make me.

PE is on every differential I have for my patients. That's how paranoid the wards have become.

Tachcardic? Could be PE.
Fever? Sure why not, it might be PE.
High WBC? PE with superimposed infection maybe.
Pt fell on their way to the bathroom? Did the PE happen and caused the fall or did they fall and break a bone and get the PE?
Acute Abdomen? Don't you know that might also be PE?
Ulcer in the foot? (Okay that's not a PE but still if they dont get up and use the foot they might get PE)

I have a very low resistance (if any) for putting all the surgical patients on Levonox 40 mg SQ q daily.

I think we have reached a point in medicine where someone dying from a PE is an easy lawsuit and everyone thinks you are incompetent for getting one in your patients.

 

[kamehame]

In general, people who say that everything could be something are very poor clinicians. That includes your attendings who are spouting that garbage. People like to say that about MIs, too. Vague nausea? MI. SOB? MI. Hand pain? MI. RIGHT-sided chest pain? MI. Back pain? Anginal equivalent, think MI. Neck pain? MI. Not feeling right? That's the ol' "feeling of doom." MI. No symptoms? Could be an MI, if it's a woman or diabetic. The advantage is that you don't have to think. The disadvantage is that you're not thinking.

 

[f_w]

Wait for the sh%%storm hitting your department once the 'triple rule out' becomes the norm: PE, dissection and major coronary disease in one scan.

I have been humbled a many times when I wondered about the at times oddball histories provided to justify a CT pulmonary angio. Fact is that PE is underdiagnosed, fact is also that many patients get and resolve PEs without us ever knowing about it (it is not that uncommon to see PEs on chest CTs done for other purposes).

Doesn't relieve us from the dilemma of occams razor (or the more popular version: 'walks like a duck, quacks like a duck, chances are it is a duck). If you have a febrile patient with a segmental or lobar infiltrate on CXR and WBCs with left shift, chances are he has pneumonia, not a superinfected pulmonary infarct.

We get paid to make decisions, at some point you have to make one (back in the dark days of my budding neurology career, we had some senior residents who put everyone presenting with weird central neurologic symptoms on 'triple therapy': Rocephin, dexamethasone and acyclovir. The day shift, after getting further imaging and initical cultures could still stop 2/3 or all of them.)

 

[lowbudget]

We're trained to run Well's & Wicki's pretest probability. CT, V/Q, and dopplers aren't great screening tests and so ordering it on anyone results in exactly what you're talking about: improper use of resources and over-anticoagulation.

 

[Proton Dense]

Thanks for your replies.
Actually, I have a sincere question for my clinician buddies. Discounting any use of TPA, is there a difference in treatment of a patient with DVT and PE? Say for example a patient with DVT no PE, PE and no DVT, DVT and PE. Differences such as dose of Lovenox etc?
The techs are always trying to get out of doing a study if the other study is positive. I always do it and offer no resistance. Personally I would want to know if I had one or both- I can see value in this- such has degree of clot burden for example.

 

[RTrain]

Nope, no difference. 3-6 months of anticoagulation either way with the same LMWH dose and same INR range, unless it's a recurrent VTE or no-risk patient, which buys them a work-up for hypercoagulable disorders and perhaps life-long treatment. I've got attendings who will lean more toward 3 months or more toward 6 months based on clot burden, but usually that decision is based more on clinical scenario (i.e. how time-limited is the condition that predisposed the patient to VTE in the first place).

In the ICU when there are patients we think have a PE but they aren't stable enough to transport to the CT scanner, we'll get a bedside LE doppler to see if we can't find the DVT to justify therapeutic dose lovenox.

 

[Pir8DeacDoc]

In my internship last year we gave all of our GS patients 20mg of IV Nexium and Sub-Q Heparin 5k Units BID. If people were absolutely tortured by the pain of the SubQ injection then we'd given the Lovenox (much less pain with injection but much more expensive).

 

[NEMC]

In my internship last year we gave all of our GS patients 20mg of IV Nexium and Sub-Q Heparin 5k Units BID. If people were absolutely tortured by the pain of the SubQ injection then we'd given the Lovenox (much less pain with injection but much more expensive).

I saw a 85 y.o. patient with PHX of Afib admitted for endocarditis(actually ID pretty sure it is Rocky Mountain Spot fever and ECHO showed vegetation), pt on ABX, so onenight pt had tachycardia and EKG showed Afib, resident given B-B and watched. Pt was not even desatturated... 3 hours later in AM the resident reported to attending about this episode and suggested do V/Q. attending was angry at roof that resident didn't do V/Q at night to r/o P.E!!! cardiology started iv heparin right away!!!

Pt died of huge intracranial hemahhrage next day!!

resident was fired because of this although we all think this resident didn't do anything wrong. Yeah, P.Ephobia everywhere

 

[f_w]

cardiology started iv heparin right away!!!

Pt died of huge intracranial hemahhrage next day!!

With every report I sign that contains PE or DVT, I wonder whether I have signed this patients death warrant.

It is called the 'spiral of doom', it usually starts with a medically questionable procedure --> complications --> admission --> in-hospital DVT -->
A. PE leading to death of patient
B. ICH leading to permanent disability of death.

 

[Sanchik]

Gerri Gal,
US not available at night. at least ince a night i get the shortness of breath call. most improve with med/neb or lasix but i am always thinking that i am missing a PE and tha's a scarry thought for an intern. and which one of these pts who are really old don't have risk factors for thromboembolism. the only thing that makes me worry less is that most attendings put their pts on lovenox 40 SQ daily.

 

[Geri_Gal]

I saw a 85 y.o. patient with PHX of Afib admitted for endocarditis(actually ID pretty sure it is Rocky Mountain Spot fever and ECHO showed vegetation), pt on ABX, so onenight pt had tachycardia and EKG showed Afib, resident given B-B and watched. Pt was not even desatturated... 3 hours later in AM the resident reported to attending about this episode and suggested do V/Q. attending was angry at roof that resident didn't do V/Q at night to r/o P.E!!! cardiology started iv heparin right away!!!

Pt died of huge intracranial hemahhrage next day!!

resident was fired because of this although we all think this resident didn't do anything wrong. Yeah, P.Ephobia everywhere

😱 Gah...no response. That is disturbing if the resident was fired simply for treating an 85y/o a-fib w/ RVR presumed to be secondary to endocarditis/infection. ...and called the attending...and...gah. Words fail me. That is just wrong. Are you trolling?

Wish there was a way to better identify PE w/o subjecting my patients to the nephrotoxic dye load in CT angio.

 

[deleted109597]

In my internship last year we gave all of our GS patients 20mg of IV Nexium and Sub-Q Heparin 5k Units BID. If people were absolutely tortured by the pain of the SubQ injection then we'd given the Lovenox (much less pain with injection but much more expensive).

TID heparin dosing has a better anticoagulation profile. We also use 40 mg of Nexium, or, if costs are a factor, 250mg Zantac in 150mL saline at 11mL/hour.

 

[Caffiend_79]

Thanks for your replies.
Actually, I have a sincere question for my clinician buddies. Discounting any use of TPA, is there a difference in treatment of a patient with DVT and PE? Say for example a patient with DVT no PE, PE and no DVT, DVT and PE. Differences such as dose of Lovenox etc?
The techs are always trying to get out of doing a study if the other study is positive. I always do it and offer no resistance. Personally I would want to know if I had one or both- I can see value in this- such has degree of clot burden for example.

I think it makes a difference, more so at some hospitals than others. At the institution where I did my internship, DVTs were anticoagulated for 3 months while PEs were treated for 6 months. It's also good to have a baseline evaluation of the extent of PE. If the patient presents with increasing SOB and demonstrates new areas of PE or progression of the previously identified PEs, this may mean the patient would benifit from an IVC filter or more aggressive anticoagulation.

 

[Pir8DeacDoc]

TID heparin dosing has a better anticoagulation profile. We also use 40 mg of Nexium, or, if costs are a factor, 250mg Zantac in 150mL saline at 11mL/hour.

Maybe it was 40mg of Nexium 🙂

As for the Heparin, we tended to only use the TID dosing for larger patients.

 

[3dtp]

😱 Gah...no response. That is disturbing if the resident was fired simply for treating an 85y/o a-fib w/ RVR presumed to be secondary to endocarditis/infection. ...and called the attending...and...gah. Words fail me. That is just wrong. Are you trolling?

I don't think he's trolling. Not all malignancies are in cancer patients.

In protecting themselves, hospitals will seek the path of least resistance, and act where they can with impunity. Residents are not protected by anything and can be quickly replaced. Attendings, however, generate revenue, generate referrals, have, in most cases developed collegialities.

 

[GoodMonkey]

For the OP, sorry you get saddled with that crap over and over. But believe me, I feel like a fricking ***** every time I call you for a spiral in the middle of the night. I only do it because they make me.

seconded.

 

[NEMC]

I don't think he's trolling. Not all malignancies are in cancer patients.

In protecting themselves, hospitals will seek the path of least resistance, and act where they can with impunity. Residents are not protected by anything and can be quickly replaced. Attendings, however, generate revenue, generate referrals, have, in most cases developed collegialities.

Actuully you are right. No body speaks for residency in this country. I took back, that resident was not fired. Later on he jumped to another good university hospital, People who has ability will not be killed once

 

[Faebinder]

Actuully you are right. No body speaks for residency in this country. I took back, that resident was not fired. Later on he jumped to another good university hospital, People who has ability will not be killed once

Not all residents have the ability to jump hospitals unfortunately.

 

[NEMC]

Not all residents have the ability to jump hospitals unfortunately.

That is true, considering this resident was from community hospital to university hospital, I can only admire that guy. Anyways..

I don't know what I will be when I am an attending one day. maybe I will jump to CTangio again and again...

 

[Tired]

Almost all our Ortho patients end up on DVT prophylaxis (we prefer Lovenox 40mg qd, or 30 bid in trauma patients).

Of course, while the evidence is compelling that it prevents DVTs, I have yet to see a paper showing that it prevents clinically significant PEs. Or reduces morbidity/mortality. Or a comparison of PEs prevented vs significant bleeding complications. We have a spine surgeon who calls the whole thing bullsh*t and only puts people on Lovenox because his colleagues told him he has to.

Personally, I think this whole subject is crap. 90% of the PEs I diagnose end up to not be the cause of the symptom that I scanned them for in the first place.