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flyingsquirrel

Pneumonia v PE

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The fact that it depends on the patient, and depends on the situation goes without saying. D dimer isn't perfect alone, obviously, but taken into consideration with the other issues, it's a helpful tool. There wasn't mention of it here, so I thought id chime in. Now that my two main haters are here....

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You see your elevated d dimers in elderly folks quite a bit, and just like bigdogs citation, it shows up in malignancy and bedridden. It's really up to the clinician to decide on whether the patient fits the bill. In a conversation about limiting extensive use of cts, I thought it would be a part of the thought process.

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The provider has MUCH to gain by not ordering a test....or another way of saying it, greater risk to avoid.

 

No, the *patient* avoids risk by not having an unneeded test run. The provider's risk for being "prudent" and "ordering a gold standard test" is going to be far, far less than the provider's risk for *not* ordering such a test. Don't confuse the patient's best interest with the provider's--they're not the same.

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The fact that it depends on the patient, and depends on the situation goes without saying.

 

Uhhh, no, it doesn't "go without saying"

 

"d-dimer, baby. thats the ticket. the research is pretty powerful."

 

and no baby it ain't the ticket, perhaps you can read the research.

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Cuz that's what you seem to be saying as part of the path in your quest to dis me. You had nothing to say until you decided to attack me and insist that I thought just running a dimer and sending her on her way would do the job. So taken in context of the situation, where the clinician is struggling as to whether to send a young, relatively vibrant (I'm assuming), non inpatient student for further testing, no previous occursnces, no renal issues, no chest pain beyond the point where the results would be diminished....I'd think a dimer could shed some light and give you some confidence as to which way to go.... Bigdog.

Edited by PAMAC

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So dimer wouldn't have been at all helpful in this case?

 

(Im speculating without benefit of seeing the patient...)

 

Short answer would be "no". While you at correct that the D-dimer is used in low-risk patients, it should be done in situations that are more equivocal than this specific picture. In an 18 year old who is otherwise healthy, with two obvious explanations for their tachycardia, it isn't so equivocal- the D dimer will be far more likely to hurt this patient. Here's how:

 

If its negative, then you rolled a 7 on the medical craps table and got lucky and you can stop your workup, except it wasn't needed in the first place.

 

If its positive- you just crapped out. Now good luck trying to explain that positive test result- and the only logical next step, particularly from a medico legal standpoint, is some sort of imaging study that's even more expensive. So now they're not only on the hook for a trip to the ED for a lab test they didn't need, now they need an additional imaging test with radiation exposure and IV contrast that can cause kidney damage. And guess what? It won't be positive....because the pretest probability was so low in the first place.

 

Look at it this way- think about the patient in front of you, and decide if you would commit to the CT scan (or V/Q). If you would do it, THEN order the D dimer. If its positive, you're gonna do the test anyway- because believe me, with a positive D dimer in the ED, you better do the follow up test or you truly open Pandora's box of medico legal liability.

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I am really curious to know that if the urgent care practitioner would've simply been happy with the ED just doing an evaluation on the patient, then getting a phone call saying that "In our opinion, this just isn't a PE"- without any lab or imaging workup whatsoever. In other words, just having another set of eyes on the patient

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Alright. I'll take my lumps.

 

Dude, no big deal. It's all a part of learning how to practice medicine. We all go through it in the early stages- and hopefully folks take their experience, couple it with keeping up with the research, and apply it clinically to do what's right.

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So do you think they decided to forgo the dimer? I mean, they went ahead and did the ct, right (I thought they said that)? So they went ahead and pulled the trigger. I mean, they didn't seem to need to be worried about having a false positive since the trip to ct was in the plan.

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No, the *patient* avoids risk by not having an unneeded test run. The provider's risk for being "prudent" and "ordering a gold standard test" is going to be far, far less than the provider's risk for *not* ordering such a test. Don't confuse the patient's best interest with the provider's--they're not the same.

 

MY interest as a clinician is the patient's best interest. In my thinking they are one and the same. When I keep that at the forefront then my personal liability is not at stake. I have served the patient.

 

So I see your efforts to make me seem like I'm prioritizing self interest- but you're wrong.

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(Im speculating without benefit of seeing the patient...)

 

Short answer would be "no". While you at correct that the D-dimer is used in low-risk patients, it should be done in situations that are more equivocal than this specific picture. In an 18 year old who is otherwise healthy, with two obvious explanations for their tachycardia, it isn't so equivocal- the D dimer will be far more likely to hurt this patient. Here's how:

 

If its negative, then you rolled a 7 on the medical craps table and got lucky and you can stop your workup, except it wasn't needed in the first place.

 

If its positive- you just crapped out. Now good luck trying to explain that positive test result- and the only logical next step, particularly from a medico legal standpoint, is some sort of imaging study that's even more expensive. So now they're not only on the hook for a trip to the ED for a lab test they didn't need, now they need an additional imaging test with radiation exposure and IV contrast that can cause kidney damage. And guess what? It won't be positive....because the pretest probability was so low in the first place.

 

Look at it this way- think about the patient in front of you, and decide if you would commit to the CT scan (or V/Q). If you would do it, THEN order the D dimer. If its positive, you're gonna do the test anyway- because believe me, with a positive D dimer in the ED, you better do the follow up test or you truly open Pandora's box of medico legal liability.

 

Ordering a test is like picking your nose in public.

You better know what to do if you get positive results.

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MY interest as a clinician is the patient's best interest. In my thinking they are one and the same.

 

Then your priorities are naive and possibly dangerously so. The first rule of helping other people, at least in my paraphrase, is that you cannot help people if you are dead or incapacitated. The clinician's first priority is the continuation of his practice, which includes minimizing avoidable legal risk, which can make it economically infeasible for a provider to continue to practice. Within that constraint, one will obviously try to minimize harm to the patient... but they're not my first priority. "First, do no harm" is unrealistic. "First, allow no harm to come to yourself. Second, do no harm to the patient" is a much more appropriate interpretation of the rule for our litigious age.

 

If, when it comes down to doing the best thing for a patient and the best thing for your practice, you decide to do the best thing for the patient, I wish you the best of fortune, and hope that your risking your economic future works out best for you and the patient. I am willing to accept less-than-the-best for my patients if it means ensuring that I minimize the economic risk to myself, and thus enable me to do MORE good in the long run.

 

Medicine is not just about medicine. It's just as much about the business of medicine as the science and art, and I'm not entering into the profession with an expectation that I will always be able to do the right thing. But I will persevere, and do the things that do the most good and least harm for the most people.

 

But then, if you don't accept that there can be situations where a clinician's best interest and a patient's best interest differ, this probably seems like pointless semantic nitpicking.

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Then your priorities are naive and possibly dangerously so. The first rule of helping other people, at least in my paraphrase, is that you cannot help people if you are dead or incapacitated. The clinician's first priority is the continuation of his practice, which includes minimizing avoidable legal risk, which can make it economically infeasible for a provider to continue to practice. Within that constraint, one will obviously try to minimize harm to the patient... but they're not my first priority. "First, do no harm" is unrealistic. "First, allow no harm to come to yourself. Second, do no harm to the patient" is a much more appropriate interpretation of the rule for our litigious age.

 

If, when it comes down to doing the best thing for a patient and the best thing for your practice, you decide to do the best thing for the patient, I wish you the best of fortune, and hope that your risking your economic future works out best for you and the patient. I am willing to accept less-than-the-best for my patients if it means ensuring that I minimize the economic risk to myself, and thus enable me to do MORE good in the long run.

 

Medicine is not just about medicine. It's just as much about the business of medicine as the science and art, and I'm not entering into the profession with an expectation that I will always be able to do the right thing. But I will persevere, and do the things that do the most good and least harm for the most people.

 

But then, if you don't accept that there can be situations where a clinician's best interest and a patient's best interest differ, this probably seems like pointless semantic nitpicking.

 

I gotta say that the first words that popped into my head were "this is one of the most self serving posts I have ever read"

 

I believe it is your priorities that are askew if you value your bank account more than you value your patients. Working in medicine is an advocation to serve, not an avenue to gather riches. Granted, a person needs to provide for their family and I do believe a fair wage for good work is in order but when I start looking at my patients as + or - signs, or view them as risks, then it's time to change professions.

 

Taking care of patients IS the first order of business. If you take care of the patients properly, the rest will fall into place just fine. Legality issues and the threat of losing one's ability to practice stems from gross negligence, both in under and over treatment of patients. A skillful, successful provider will do what is right for their patient, not what is right for the business office.

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Guest hubbardtim48

I agree with Just Steve...Rev you got something coming to you...if you can't get patients in the door due to your attitude then you might as well close your doors. I can't believe you even stated the words that YOU come first then the patient...I would TRULY HATE to be in the same town as you because I would be scared if I needed medical attention that I would have to drive a different direction to get medical care because I sure as he!! would not step in your office. I agree that we need fair wages and blah blah blah, but look at the salaries PA make and tell me that those aren't fair...I think people like you need/want more money because you don't know how to manage your money well...You would die a new death trying to crunch numbers on how I am in PA school working PRN for the next few months (until I start rotations then I won't work at all) and my wife works 1 day a week (making minimum wage) and going to nursing school (5 days a week, its a 1 1/2 accelerated BSN). We don't live off student loans, we own a home, two cars, drive 40 mins to work/school daily, have a dog, etc...and we are still able to live for the next 9 months without even working due to our savings!!!! Any ways, back to the stupid comment you made REV, how can you sit there and say that you are more important than the person you are treating? You are suppose to help them as best as you can and if you need help call your SP or send to a specialist. You must live your life looking at ways to cover your butt because you aren't confident in your decisions or don't know what the he!! you are doing. If YOU know what you are doing, treat as best as you can then if you do get in a situation were you are at court then YOU should be able to back up EVERY single thing you did and why. If you can do that from a medical/literature stand point then what the he!! do you have to worry about? Your way of thinking blows my mind...WE, healthcare providers, are here to help/serve our patients and not worry about the $ or taking our lunch break at 1200 or going to smoke etc... good lord, you are here for the way to improve and helps changes peoples lives for the better!!!!! I hope you understand my points and at least give it a chance to look from the patients point of view and not YOUR point of view...

P.S. would you want your family members (mom, dad, brothers, sisters, children, grandma/pa, etc..) treated in the same manner you say you will treat people? Would YOU want to be treated in that same manner.......? God Bless you and the best of luck!

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It was stated in the OP that this patient has a low pre-test probability for PE (ie: no risk factors). But it crossed the clinicians mind that she might have a PE. Anytime PE crosses your mind, you should either rule it out convincingly by history or rule it out with an adequate test or exam. In this case, a D-dimer is low cost, low risk, and sensitive enough to rule PE out in this patient. In our UC, this is a UC test and not one that I have to send the patient to the ER for. In some places, that's not the case. I agree the the dimer is patient specific and wouldn't think of getting one if I thought the results would be equivocal - but when a patient c/o pleuritic chest pain, has low pre-test probability and I want to show their lawyers that I did my due diligence to make sure they weren't going to die, I'm going to order the dimer and I feel comfortable hanging my hat on it. That's my method of practice with my understanding of the dimer in the patient population given. It would change with a different type of patient. Your style of practice may be different. To each his own.

 

Andrew

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Hubbardtim - check yourself. Rev's statements are defensively practicing medicine, making sure his doors are open to his patients and not closed because he got sued by some shmoe who wanted to make a buck off of him (and there are millions of people like this out there). You are quite correct in your convictions about why we practice medicine, and good on ya'. But until you've walked in the shoes of a PA (not a PA student) who is making actual life-and-death decisions out there on the line, you need to keep your persepective and realize that there is more to the practice of medicine than just the art and science. I agree with you - if you let this "more" aspect of medicine run your life, you are hurting and need to refocus, but I didn't get that from Rev's post. You jumped on him without knowing what you are talking about where the rubber meets the road. Keep your gung-ho spirit, but make sure you're understanding the full picture before you ram it down someone's throat.

 

Andrew

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Guest hubbardtim48

I understand the fact of being sued by some money hungry person or when the need is there, but if you practice medicine by factual data and have reasons to back up what you did and why, then the suit has no where to go. That was my point, not looking at the patient stating good lord I need to run this and this because they might have XYZ...I just don't see the point in running test after test to cover your A$$ when you can rule it out by different measures. I guess you can say that ALL people are at risk for a PE so lets CT the he!! out of them and expose them to Sh!t tons of radiation because I am scared I might get sued. Give me a break...even though I am a "student" doesn't mean I have zero HCE or have common knowledge about litigation. Who knows if I will change my ways when I am a PA-C, but for now I see my ways of practicing to be different than being scared of being sued by every one that walks in the door.

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<meta charset="utf-8">Here's a typical long-winded response from me as a huge fan of teaching cases:

 

What were her O2 stats? Her vitals concern me a bit more than r/o PE, I'd recheck them and if they were still looking tachy and hypotensive, I would be curious to know what her lactate is and start running some fluids. But I agree in our current medico-legal climate (unless she had slam-dunk CXR findings and elevated CBC) to at least send a D-dimer (since she's tachycardic and low pre-test probability) and a lactate.

 

There was a recent excellent podcast about using PERC and Wells criteria to r/o PE and the pre-test probability values:

http://blog.ercast.org/2012/01/decision-tools-perc-nexus-and-curb-65/

Great discussion on some of the germane issues to this conversation.

 

 

Here's some odd cases (to give something to think about) that I saw just as a student:

 

Case #1: young and reasonably healthy guy presenting nearly identically after 1-week of flu-like illness to UC with a probable PNA.

He was sent over to the ED and it was quite good that he was, he decompensated significantly in the ED and by the time he came upstairs he had a signicant hypercapnea on his ABG and got intubated. Was up walking to the clinic that morning and on a vent by evening.

Nasy bug, ended up being post-H1N1 S. pneumoniae. We took care of him in the ICU, had a ton of complications, got pericardial tamponade, bilateral pleural effusions (fun times tapping them!), terrible renal failure, CNS complications. Plus he was a Jehovah's witness so no blood transfusions. Made an amazing recovery though.

 

Case #2: Same ICU. Pt presents very similarly to the ED, young healthy male, some shortness of breath, mildly tachypnic, thinks he has bronchitis or PNA. Has mild bibasilar crackles on exam. Labs look like this: Na: 135 K: 6.5 Cl: 104 CO2: 22 BUN: 225 Cr 24.5 Glucose: 125.

Needless to say ED provider nearly has a stroke looking at those labs, kid gets more tachypnic, comes upstairs, gets tubed and dialyzed. Had unknown CKD his whole life, now went into renal failure with uremic pleural effusions.

 

Case #3: 7-bed rural ED. I'm down there admitting a septic lady to our 3-bed ICU, dumping fluids into her when a respiratory code comes through the door.

Pt was a young adult male, seen earlier that day in the ED. Presented with a several-day hx of URI/bronchitis symptoms, clear CXR, pt was a smoker. Had some bilateral leg swelling, but had been riding his bike, has been out of shape. No meds except new anti-psychotics (had bipolar disorder, no other medical hx) Pt had some mild tachycardia, but he was coughing in fits. No fever. Was sent out with doxycycline for bronchitis and an albuterol inhaler.

On the way to the pharmacy he seizes, turns blue, his girlfriend brings him through the door. He's on his was to the CT scan when he codes.

They work on him for almost 45 minutes. D-dimer sent pre-code comes back at 6,000. ABG was 6.9/80/50/18 or so (I hear this read aloud during the code).

Was a bit of a s#$T-show since my septic lady started to circle the drain during the code, I was running to the pharmacy for Levophed since the pharmacist was participating in the code (heck the whole rural hospital staff was hovering over the kid). Was tough to find anyone to supervise me to put in the Central and A-line she needed! Rough night all around..

 

I think there was an interesting thread a while back about some of the newer anti-psychotics increasing the risk for DVT/PE.

 

 

Edited by VictoriaO
Clarity's sake

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Guest hubbardtim48

Not trying to be rude, but I can't stand when people say, "What were her O2 stats?" I am referring to O2 STATS. The correct terminology is "O2 sat" because oxygen is measured as a % of saturation and not staturation.

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Good pick-up. Must be a bad habit I picked up during case presentations at our institution. "Statting at "x"L" for some reason seems to roll better than "satting"

*shrug*

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Guest hubbardtim48

Case number 1: Lactate was 3.5, gas was 7.14/60/70/22. And this guy was walking with a pH of 7.14 and CO2 60 with zero compensation from the kidneys? Can you elaborate on this case please? I just don't see someone in acute respiratory acidosis and failure to be walking into an UC without falling flat on his face or being dragged into the UC.

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He had a pretty quick respiratory decompensation, I don't recall the Bicarb being that depressed (was on the low end of normal), but by the time he got up to the unit that's about what his gas looked like. I should have clarified sequence of events, it's hard to say what came first neuro or respiratory decompensation (that was in the ED). I think he was initially compensating but he quickly burnt up his reserve once he got the pleural effusions. I'm not sure what it is about the post-H1N1 S. Pneumo strain that makes it so nasty, he went from walking around that morning to intubated that evening. Scary stuff!

Edited by VictoriaO
Clarity!

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Guest hubbardtim48

"I think he was initially compensating well for his metabolic acidosis." What metabolic acidosis? His ABG shows a uncompensated acute respiratory acidosis with mild hypoxemia. That is what I was questioning that your brain doesn't allow your CO2 to reach above 60 unless there is a severe neurological deficit so he acutely went into this respiratory failure because his PaO2 should be higher than that if his minute ventilation increased to try to blow off some of that CO2. So, his metabolic metabolism was not working (pH < 7.2 cellular metabolism is not functioning) and 7.14 is a coma state, unless his HCO3- was 35-40 (which I rare for someone to be able to live in this manner, but I have seen it and it is usually the pink puffers).

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