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.
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.”
For many conditions, I already do this. I’m not big on doing a lot of tests. I completely appreciate, however, that many emergency physicians feel uncomfortable sending people home without flipping over a few more stones. So, here we are with a slim allowable margin of error to diagnose a condition that is easy to miss, with tests that may do more harm than good.
On the bright side, at least PE is not contagious.
I can only hope that we will look back on these days 5 or 10 years from now and talk about the bad old days when we did not have an easy way to find a pulmonary embolus.
Be happy.
Dr. Baehren lives in Ottawa Hills, Ohio. He practices emergency medicine and is an assistant professor at the University of Toledo (Ohio) Medical Center. Your feedback is welcome at David.Baehren@utoledo.edu.
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