The eggheads in Washington sit on the beach reading cheap novels while we swim with the sharks. “Look, Thurston, dolphins!”
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ACEP News: Vol 30 – No 08 – August 2011
I reviewed a disturbing case recently – disturbing not because of outcome, but because the circumstances challenge conventional wisdom. Such cases are interesting from an academic viewpoint but quite vexing otherwise. I hate to even hear about cases such as this and, worse yet, I get an overwhelming feeling of malaise and inadequacy if I am directly involved.
A man in his mid-20s presented with 3 days of cough and malaise without dyspnea. There was mild pleuritic chest pain and one episode of hemoptysis on the day of the visit. His medical and travel history were unremarkable. Vitals, including pulse oxymetry on room air, were normal. Chest radiography showed a right lower lobe infiltrate. He was placed on azithromycin and sent on his way.
He returned the next day with more hemoptysis. A chest CT scan showed a large right-sided pulmonary embolus (PE) and a suggestion of pulmonary infarction. He was placed on anticoagulation and did well. He proved to have no hypercoagulation.
By several clinical scores and by clinical gestalt, there was no indication to do a chest CT scan. If I had seen this patient, I would not have done a D-dimer or a chest scan. If the clinician had been very thorough, he or she might have looked quite clever by finding this on the first visit.
Here is the question, though. How many patients with a similar story (and no PE) would have to be scanned in order to find this one? I suspect that there would be many.
Soon after reviewing this case, I read a well-written and thoughtful editorial in the Annals of Emergency Medicine this June. Dr. Newman and Dr. Schriger make a very good case that we are doing too much testing to diagnose PE in people who have no physiologic abnormality. Autopsy studies show that small pulmonary emboli are common in those who die suddenly in accidents. This suggests that the minor ones we find on CT may not be pathologic.
They also make the case that we may be doing more harm than good by doing so many chest scans. Cancer from radiation and renal injury from contrast media are significant problems.
The June issue of ACEP News published a summary of the ACEP clinical policy on suspected pulmonary embolism (ACEP Clinical Policy Review: Suspected Pulmonary Embolism, p. 28). The policy is 100 pages. Read the summary. I found it interesting that of the six questions, only one had a Level A recommendation. The question that had a Level A recommendation involved using the D-dimer in patients with low pretest probability.
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