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Proper diagnostic tests can save life and undue disasters


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A number of years ago I lost a close friend who died of a pulmonary embolism secondary to a DVT that he was seen for by a PA and two physicians. It is so important to look beyond erythema, tenderness and a negative Homan's sign when trying to rule out a DVT. Homan's sign is as antique as your grandfathers model T Ford. Today as clinicians we have a responsibility to either order better and gold standard tests or know how to perform them ourselves. Here is a very important summer course for Rural Health Personnel to learn to perform Ultrasound Diagnostic Exams. If you are a cutting edge PA or NP than this is for you. PracticalPOCUS.com/CriticalAccess2019

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I just looked at it and it seemed to post OK. did you get this?  A number of years ago I lost a close friend who died of a pulmonary embolism secondary to a DVT that he was seen for by a PA and two physicians. It is so important to look beyond erythema, tenderness and a negative Homan's sign when trying to rule out a DVT. Homan's sign is as antique as your grandfathers model T Ford. Today as clinicians we have a responsibility to either order better and gold standard tests or know how to perform them ourselves. Here is a very important summer course for Rural Health Personnel to learn to perform Ultrasound Diagnostic Exams. If you are a cutting edge PA or NP than this is for you. PracticalPOCUS.com/CriticalAcess2019

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So, how does the fact that a PA and two physicians neglected to consider DVT in their differentials on your friend, compel the rest of us to take an ultrasound course?

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Ral- this happened thirty years ago prior to the advent of POCUS. There was an intelligent response on Huddle to this post from a PA who was expertly aware of POCUS and our need to have this course in PA programs, nationwide.  &5% of the profession has been taught what is now archaic medicine in terms of the diagnostic approach to this problem as well as others. Thanks for your question.

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Homan is a tool, just as every other tool in the bag...it should still be taught in my opinion, but in addition should be taught that it does NOT rule out a DVT (i.e. sensitivity vs. specificity).  Honestly, I use Homan's sign as a way to get patients to follow through with the ultrasound.  In my first month of FM I had a patient with uncontrolled DMII present with unilateral edema and pain.  Ordered US + D-Dimer.  Skipped US appointment we set up for her and never had lab drawn.  Died from PE 2 days later IIRC.  While I did EVERYTHING right, that still haunts me...could I have educated her better on the risks, reinforced better the importance of getting the US, etc., etc...probably.  But, bottom line, I did what I could do and she made a choice.  Could having an US machine available and I being certified to complete a POCUS have saved this lady?  Maybe.  But US machines are not cheap, and at that job it would not have been cost effective to have an US machine in the office.  So, even with a certification, unless I paid for the US machine myself it wouldn't have been available in the office.

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Diagnosis of Deep Venous Thrombosis

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About 30% of patients with PE are not found to have a lower extremity DVT.  What do you do with those folks?

I am not arguing the benefit of ultrasound.  I just don't feel it is a necessary skill for everyone to have.  

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I use DVT POCUS nearly everyday in the ED. It’s highly sensitive, incredibly easy to perform, and can be taught in probably in less than 30 minutes. It takes longer to learn the US machine than it does this. Honestly, a nonprofit should be started to go and teach this for free to whoever wants to learn basic US....maybe I should start something after residency...

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I would say POCUS can be useful but I still look at as a tool at the lower end to my toolbox. These studies should be rule in exams (and even after rule in for DVT would likely still get a confirmatory study by radiology) and are often limited evaluations. Your H&P is more useful. The issue is some people are very large and those are tough DVTs to spot. I’m sure not writing on my chart I did ultrasound and it was negative and letting them go. I would get the study or if study not available give them a shot of lovenox and get the study next morning. So if I was in a clinic no matter what I would be getting the Radiology study so POCUS would really not change the final disposition. Another issue with POCUS is I don’t think any studies are “easy.” It takes continual development and practice for these studies. Hundreds of hours no a weekend course. The radiologist and ultrasound techs have amazing skills honed over years. I have put in a fair amount of time with ultrasound and still have hard times getting views and see thing that I don’t know what it is. Just my opinion.

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Homan is a tool, just as every other tool in the bag...it should still be taught in my opinion, but in addition, should be taught that it does NOT rule out a DVT (i.e. sensitivity vs. specificity).  I agree wholeheartedly with your assessment and would place emphasis on the fact that it does NOT Rule Out a DVT. DVT is ominous, it is like a Ninja warrior, stealth and unseen until it strikes, and we have the embolism. I cannot speak to all of the comments separately but can say that a good history that includes cramping and pain, as well as congestion, cough and difficulty in breathing, will lead you to follow the algorithm that Rai sent as we have the D-Dimmer as well as radiographs and even an EKG. We become detectives in medicine and we cannot afford to have "cold cases'" I like what Lt. Ryan stated as he is a PA and a Resident with experience and his comment diffuses the difficulty. I argue that this course can teach you on a three day weekend and offers much more assistance later. check out the link as it is one of the best I have seen and if Rev Ronnin is going that puts more gas into its efficacy. Maybe he can report on this after August.

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28 minutes ago, Overtired said:

I would say POCUS can be useful but I still look at as a tool at the lower end to my toolbox. These studies should be rule in exams (and even after rule in for DVT would likely still get a confirmatory study by radiology) and are often limited evaluations. Your H&P is more useful. The issue is some people are very large and those are tough DVTs to spot. I’m sure not writing on my chart I did ultrasound and it was negative and letting them go. I would get the study or if study not available give them a shot of lovenox and get the study next morning. So if I was in a clinic no matter what I would be getting the Radiology study so POCUS would really not change the final disposition. Another issue with POCUS is I don’t think any studies are “easy.” It takes continual development and practice for these studies. Hundreds of hours no a weekend course. The radiologist and ultrasound techs have amazing skills honed over years. I have put in a fair amount of time with ultrasound and still have hard times getting views and see thing that I don’t know what it is. Just my opinion.

While I’m a big proponent of clinical gestalt, saying US should be low end of your tool box is not supported by literature. Meta analysis suggests that experienced EM provider can be equal to radiology interpretation and POCUS US for DVT is equal to duplex. Specific to this discussion is it’s use in rural sites that may not have US overnight, or at all, so developing this skill by performing it often would decrease missed VTE. Like all tests, it’s important to consider pretest probability.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3211105/#!po=2.17391

https://www.thennt.com/lr/pocus-atlas-dvt-2/

https://www.ncbi.nlm.nih.gov/m/pubmed/29306580/

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What I mentioned was it is the low end of MY toolbox. This is from a perspective of being credentialed, doing hundreds of these studies, working and training at institutions with US fellowships. I realize this is focused at rural which I have moderate experience but not far far rural. I just am offering an alternative perspective. I think US is cool. I think it’s great to take a course. Those studies are you listed are fine.  I’m glad to hear you are so proficient. I still believe these exams take a lot of practice. So it’s more of a perspective from someone who feels more than competent doing these but ultimately has not ended up changing my personal practice. This is a N of 1 though.

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2 hours ago, Overtired said:

What I mentioned was it is the low end of MY toolbox. This is from a perspective of being credentialed, doing hundreds of these studies, working and training at institutions with US fellowships. I realize this is focused at rural which I have moderate experience but not far far rural. I just am offering an alternative perspective. I think US is cool. I think it’s great to take a course. Those studies are you listed are fine.  I’m glad to hear you are so proficient. I still believe these exams take a lot of practice. So it’s more of a perspective from someone who feels more than competent doing these but ultimately has not ended up changing my personal practice. This is a N of 1 though.

That's plenty fair! I read it as you citing low sensitivity and specificity as you state "your H&P is more useful," implying others beside yourself and wanted to relay the evidence and not discourage people from attempting to become proficient. Once proficient, it should be one of the first skills you pull out. I certainly ordered plenty of confirmatory duplexs in the beginning.

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It's extremely important to remember that DVT (whether ruled in or  out) does NOT equal PE.  You can have PE without DVT and DVT without PE.  I do POCUS US for DVT at my FT rural critical access EM job.  It's just a preliminary data point.  If the clinical picture makes PE sound likely (because PE is what I really care about as it's the real immediate threat to my patient) I go straight to the CTA chest which I can get 24x7.  Based on clinical picture, I may give lovenox or a NOAC and have the patient return when full duplex US is available if there's less immediate indication of PE.  Either confirmed DVT or confirmed PE means they start on a NOAC.

However, just because a person with a confirmed DVT (or afib, or other clot source) is anti-coagulated doesn't mean that the PE risk is gone once they're at therapeutic anti-coagulation.  There are other things to think about: Greenfield filters, clot size and location(s), whether the patient should be hospitalized, etc.

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42 minutes ago, ohiovolffemtp said:

It's extremely important to remember that DVT (whether ruled in or  out) does NOT equal PE.  You can have PE without DVT and DVT without PE.  I do POCUS US for DVT at my FT rural critical access EM job.  It's just a preliminary data point.  If the clinical picture makes PE sound likely (because PE is what I really care about as it's the real immediate threat to my patient) I go straight to the CTA chest which I can get 24x7.  Based on clinical picture, I may give lovenox or a NOAC and have the patient return when full duplex US is available if there's less immediate indication of PE.  Either confirmed DVT or confirmed PE means they start on a NOAC.

However, just because a person with a confirmed DVT (or afib, or other clot source) is anti-coagulated doesn't mean that the PE risk is gone once they're at therapeutic anti-coagulation.  There are other things to think about: Greenfield filters, clot size and location(s), whether the patient should be hospitalized, etc.

Excellent and valid point. Though I feel it goes beyond the scope of the original topic of missed proximal DVT. We are using POCUS to prevent PE and not diagnose it using DVT US. If DVT is allowed to propagate, up to 50% of proximal DVT with result in a PE. 70% of PEs have a proximal DVT present. That all may be exactly what you’re trying to point out, though I feel your alluding to something that requires a much larger discussion of wells, PERC, HESTIA and sPESI criteria, patient affordability of a NOAC, thrombolysis, undiagnosed coagulation disorders. Then we need to talk about the importance of cardiac POCUS to observe for RV strain! Certainly takes a lot more practice than DVT POCUS!

 I don’t think anyone is suggesting that we should do an US and if it’s negative send that chest painer with tachycardia, who just got back from Japan, home. US has limited use when your primary suspicion is a PE. Now where DVT does have a role in PE is when a patient cannot have chest imaging. I’ve had plenty of people have a CT chest with contrast at the rural OSH, but not a CTA. If it’s after 5pm, not even my fancy level one hospital will get a VQ until the morning. Sometimes the readily department puts up a real hissy fit when we try to perform an a accelerated contrast allergy prtoocol. So, in the low-medium risk patient, we’ll perform a DVT US and treat presumptively if positive or monitor if negative.

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