For the question regarding methods of risk stratification to determine pretest probability, however, there was no Level A recommendation. Clinical gestalt is as good as clinical scores. So, D-dimer is useful if pretest probability is low, but determining pretest probability is less than perfect.

I have let this case and this published information run around my brain for a few weeks as I try to take measure of it. I’ve concluded that PE remains an elusive diagnosis that is frequently investigated, much less frequently found, and yet still often missed. Other than doling out a lot of radiation now, it seems our station is no different than it was when I graduated medical school in 1986.

While cases are missed by established screening criteria, we also have thoughtful physicians suggesting that we scan too much, not too little.

Additionally, the federal government is examining our use of CT scans. There is a current proposed measure, the wisdom of which is highly suspect, for head scans. This is from our friends and countrymen at the CMS (stands for Can’t Make it Simple). Chest scans can’t be far behind.

I’m all in favor of reducing the use of radiation, but there needs to be some bona fide contemplation and real science injected into the process. The eggheads in Washington are clueless about the clinical complexity of our work environment and our legal exposure. They sit on the beach reading cheap novels with sunblock on their noses while we swim with the sharks. “Look, Thurston, dolphins!”

All the “quality” measures and policies won’t change the fact that we are at risk of attack every day. We are asked to be more discriminating in testing, while at the same time we receive no relief from the sharks snapping at our feet. A missed PE has a reasonable chance of going to litigation, and even if the patient did not meet established criteria, there will be no shortage of medical miscreants who will testify that you are the dumbest doctor to ever sling a stethoscope around your neck.

The ethical considerations of this conundrum are striking. Is it acceptable to order a test that has a real chance of doing both near-term and delayed harm to a patient in hopes of avoiding litigation? In a sane world with only a tenth of the litigators currently populating the back cover of telephone directories, we might tell the patient the following without breaking into a sweat: “My suspicion of a clot in your lung is low, and I feel the risk of testing now outweighs any benefit. If you are having worsening symptoms, come back right away and we will recheck you.”