Pneumonia v PE

[ajnelson]

Couple of points here:

 

First off, if you don't think it's a PE, don't order a D-dimer, it is non-specific, and many times can come back elevated even in simple pneumonia. We have a few local urgent cares who run D-dimers on EVERYONE that complains of CP or dyspnea....which, unfortunately send many, many patients to the ED for PE work up (that obviously don't need it, though, I'm now obliged).

Secondly, though I'm sure this is rare, I had a 7 day post-partum woman who came in with fever, tachycardia, chest pain and dyspnea. I had gone ahead and ordered the CTA as PE was high on my list, (despite the fever). When I got her 1V CXR back, she had a huge infiltrate. I had gone to cancel the CTA, but she was already getting the test done. CTA - large PE with infarcted lung (hence the 'infiltrate' on CXR). So, again, must use clinical judgement in determining differential and most likely diagnosis. Unfortunately, much of our practice is dictated by malpractice and CYA, but until the culture changes, we will have to continue practicing this way.

[rev ronin]

This is just about the most heinous thing I've read on this forum....and I've been a member for 10 yrs...and survived the Political Thread Fiasco of '07-'08.

I really don't know where to start- or how to.

 

Really? I find that odd that actually speaking the truth to you causes outrage. I think you've got goals and priorities confused. The patient's best interest is a goal, but there are other priorities that trump that goal when the two conflict. Again, I don't think you're really understanding what I'm saying, rather than that you're actually horrified I would embrace and defend defensive medicine.

 

Your first obligation is to your patient, not the survivability of your practice.

 

Actually, I did a quick tally in my head, and my obligation to any individual patient is about 5th, behind God, family, self, and the practice of medicine. But only in extremely rare cases would those other obligations NOT already compel my best efforts on the behalf of that patient. In our litigious world, however, defensive medicine is probably the one that will compel me to look after my own best interests ahead of my patients'. You see, entering medicine with a mature ethical and moral system in place, I don't have any room for nonsense like "always do what's best for the patient!" in it. I will take vacations, when the "best thing for the patient" would be to work 80+ hour weeks and see more patients--I don't risk my family to help patients; I use my time with my family as the support system which allows me to recharge my batteries and invest in my patients.

 

Every time I pull shift at a fire department, I tell myself "I will not knowingly risk my life to save anyone else's" I've long been resigned to the fact that one day, I might be wrong in my risk assessment and die trying to help someone despite my intent to not place my life in jeopardy, but if I approached firefighting with the "I will die of something someday, and I want to die a hero. I will strive to find situations where I can risk my life for other people" mentality, I would be a mentally unstable hazard to myself, the rest of my crew, and the public. My first obligation as a firefighter is to go home at the end of my shift and hug my family, so I can come back again and do it next shift. Likewise, my first obligation as a PA is to go home at the end of my day and hug my family, so I can come back and do it again the next day.

 

One of the things I love about being a PA is that there is going to be a physician to whom I can turf the truly sticky and above-my-paygrade issues, and, in doing so (after presenting the case to the best of my ability, of course) let the physician decide what s/he believes the best course of action to be. After all, I did knowingly enter a position that says "assistant" right in the title.

 

Perhaps you need to be cut some slack because you are a student

 

Only for a matter of days. My, how time flies.

[Guest hubbardtim48]

I doubt you will die working in a clinic...anyways I thought firefighters were the one's willing to risk their life for others in harm...? If it was me I would risk my life to try to make someones life go on and/or better. God is number ONE then my wife and family, but I would go the extra mile for anyone that truly needed help even if it meant risking my life or staying 2 hours to educate a patient. If you believe in God then I would think you should know that he would want you to help others out without thinking of yourself.

[flyingsquirrel]

There is a difference between increased risk (firefighting/EMS/law enforcement in general) and reckless disregard for personal safety. Doing the latter shows a lack of maturity and selfishness (because you are diverting resources to your rescue and away from the people who originally needed it).

 

Your priorities are as follows:

1. Your own personal safety.

2. The safety of your partner/team.

3. The safety of the public at large. (think the dangers posed by speeding emergency vehicles or inappropriate abx usage)

4. The safety and needs of your patient.

 

The ONLY time is is appropriate to deviate from this (in a public safety setting) is when you are charged with caring for "high value targets" ie presidents, members of congress, judges, etc. In this case, stabilizing them and evacuating them to a secure location fits in between #1 and #2. Only members of the secret service are expected to take a bullet for someone else.

[rev ronin]

Thank you, Flyingsquirrel. That's almost certainly a more apt way of putting it than I did.

[Guest hubbardtim48]

That maybe your thinking, but I would never take a bullet for Obama over a kid. Any public official is a HUMAN and has not more reason to live than any other person on this planet. Again, we will not see eye to eye because you care about YOURSELF more than others and then you think because you are elected into a position your status of dying is greater than someone that is not an elected offical....crazy talk man.

[jen0508]

yall are twisting eachothers words to attack eachother....

[greenmood]

This is getting kind of stupid.

 

I get what rev is trying to say, I think, although I disagree with the fundamental idea that one's ability to practice medicine is more valuable than the wellbeing of a single patient simply because preserving the ability to practice might save more people in the future. However, I also don't think rev is a demon out to kill patients for profit, nor do I believe it's productive for people to imply that he's a selfish *** for stating he cares more about himself than other people. I care more about myself than other people, too, but it doesn't make me a sociopath.

 

Also, the comment about the secret service was clearly meant to illustrate the dangers of placing oneself too low on the totem pole of safety priority. I think you're taking it too far, hubbardtim. It was a decent analogy, but one's life is not the same as one's medical practice, even though it may seem that way sometimes.

[flyingsquirrel]

Everyone is entitled to their opinions, but you seem to have a skewed view of the role of PUBLIC safety. Before I went back to school, I taught EMT and Paramedics classes and I spent a good deal of my time systematically dismanteling the "cowboy attitude" that so many of them came in with...that come hell or high water (or medical directors) they were going to save the day. It took a while for most of them, but eventually they learned, got fired, or decided that EMS was not for them.

 

Public safety (and medicine) is a team sport. If we don't take care of ourselves first, how can we provide excellent care for our patients? I'm not talking about demanding exorbinant wages or making it all about us as providers (ie ordering CT scans on everyone so we NEVER miss a PE), but we need to make sure we have the training and resources we need to do our jobs, we need to be able to say no to ANOTHER overtime EMS call at the end of a busy 48 hour shift because we know we are not mentally up to the task, and we need to be able to hold our team back from rushing into the burning building that is about to collapse because four dead firefighters can't help ANYONE whose house catches on fire next week or the week after that (and the rest of the department will be busy mourning the loss and taking care of the families they left behind).

 

Call it selfisness if you want. I call it personal and professional responsibility...and THAT'S what allows me to give my patients the best care possible.

[LT_Oneal_PAC]

Six out of 10 physicians 55 and older have been sued, according to a new American Medical Association study.

 

[brevit edit...]

 

The majority of lawsuits never made it to the courtroom, according to 2008 data from the Physician Insurers Assn. of America, a trade group representing liability insurance companies owned or operated by physicians, hospitals and other health care professionals.

Sixty-five percent were dropped, dismissed or withdrawn. About one in four claims was settled, and 4.5% were decided by alternative dispute mechanism. Of the 5% that went to trial, defendants won in 90% of cases, the PIAA said.

 

So 5% of 60% had to go to trial, that's 3% of physicians will have to go to trial. We'll ignore settlements since it implies you either are guilty, or the cost of trial is more than the settlement. Either way, ordering more tests here wouldn't help. They were either suing for a quick buck with a settlement or you were in the wrong.

 

Back to the 3%. Of the 3%, only 10% lost. So the odds of getting sued and losing (for the argument we'll say all of these were lost because lack of testing) is .03%. This is not even to say they lost their right to practice, just a lawsuit that malpractice should pay for up to a certain amount. Even including settlement, that's 15.03%, and let's be honest, the majority of those would not have been thrown out just by ordering more tests.

 

I'll take those odds and order less tests. Not exactly being a "cowboy" with those statistics.

 

Being cost minded doesn't mean you have to throw yourself under the bus.

[Guest hubbardtim48]

Don't have a cowboy attitude, just a real attitude on my outlook on life. I wouldn't wrongfully give exposure to radiation unless truly necessary, there are better ways of ruling out a PE instead of always doing a CT. I just see this every day at work and I think modern (Western) medicine over uses there tools. Just because you have a fancy machine, doesn't mean you need to use it. I understand your comments flyingsquirrel, but I was not stating I would stay up for 3 days to help my patients or go into a situation that I knew I couldn't handle. I guess my point was that my attitude about being sued was different than rev's and that people in need is more important than my 30 minute lunch break or being home exactly at 5:00. Yes, we need our time to relax at work, but I just think in one is at work they should put fourth all their effort to do as much good as possible. If it means taking a 15 minute lunch break or going home at 5:30 sure I will still be married and not die because I didn't eat a little slower. I guess I saw rev's comments more as, "see as many patients as possible to make the most money" attitude. I highly doubt that is his attitude, but the comments rev made SHOCKED me and others on this forum.

[andersenpa]

Really? I find that odd that actually speaking the truth to you causes outrage. I think you've got goals and priorities confused. The patient's best interest is a goal, but there are other priorities that trump that goal when the two conflict. Again, I don't think you're really understanding what I'm saying, rather than that you're actually horrified I would embrace and defend defensive medicine.

 

 

 

Actually, I did a quick tally in my head, and my obligation to any individual patient is about 5th, behind God, family, self, and the practice of medicine. But only in extremely rare cases would those other obligations NOT already compel my best efforts on the behalf of that patient. In our litigious world, however, defensive medicine is probably the one that will compel me to look after my own best interests ahead of my patients'. You see, entering medicine with a mature ethical and moral system in place, I don't have any room for nonsense like "always do what's best for the patient!" in it. I will take vacations, when the "best thing for the patient" would be to work 80+ hour weeks and see more patients--I don't risk my family to help patients; I use my time with my family as the support system which allows me to recharge my batteries and invest in my patients.

 

Every time I pull shift at a fire department, I tell myself "I will not knowingly risk my life to save anyone else's" I've long been resigned to the fact that one day, I might be wrong in my risk assessment and die trying to help someone despite my intent to not place my life in jeopardy, but if I approached firefighting with the "I will die of something someday, and I want to die a hero. I will strive to find situations where I can risk my life for other people" mentality, I would be a mentally unstable hazard to myself, the rest of my crew, and the public. My first obligation as a firefighter is to go home at the end of my shift and hug my family, so I can come back again and do it next shift. Likewise, my first obligation as a PA is to go home at the end of my day and hug my family, so I can come back and do it again the next day.

 

One of the things I love about being a PA is that there is going to be a physician to whom I can turf the truly sticky and above-my-paygrade issues, and, in doing so (after presenting the case to the best of my ability, of course) let the physician decide what s/he believes the best course of action to be. After all, I did knowingly enter a position that says "assistant" right in the title.

 

 

 

Only for a matter of days. My, how time flies.

 

You have an interesting way of playing with ideas here.

The topic of this thread was our clinical priorities. The first clinical priority for a clinician is do no harm. Any way you slice it, if you are not prioritizing the best interest of the patient in your clinical decision making (again, the topic of this thread), then you are not practicing good medicine.

 

It's absurd (and obfuscating) to draw in outside, nonclinical priorities (family, etc) into the discussion. That is not the focus. The topic was the best workup for this patient.

 

Re: "defensive medicine", as a provider you can always draw the line too far in the name of self preservation. The question is where does that line negatively impact the patient? Insuring your own self worth as a provider does not take precedence over patient risk, whether the risk is mild (unecessary antibiotics), moderate (excessive CT scans), or severe (dubious interventional procedures/surgery).

 

 

All this talk about risk to the provider's family/etc, or oddball analogies to firefighters, are not applicable. Thanks to EBM there are plenty of standards of practice to follow which support the clinician in the event that their judgement is questioned. You will encounter this regularly when you start practicing.

 

You haven't ever participated in a malpractice trial as a PA, and I'm guessing not ever in your prePA life. I've done expert witness work. The "reasonable and prudent" standard, if you follow recommended guidelines, is hard to fall below unless you are 1) particularly maleficent or 2) willfully stupid. As I mentioned before, when you order an unecessary contract CT and the patient goes into ARF, gets hospitalized, etc....is that "defensive medicine" CT scan as easy to defend?

 

Clearly, not doing what's best for the patient.

And no, working 80+ hrs is not what's best for the patient (familiarize yourself with the reasons behind the Bell Commission...or the simple fact that there are partner coverage systems in place so that isn't necessary).

 

I don't like to make such pointed attacks but I want other young PAs and PA students to take something away from this. Don't let perceived notions about risk to your practice force you to make unfounded decisions which, by definition, can put patients at risk. When you are their provider, your obligation is to them. There's nothing nonsensical about "always do what's best for the patient".

 

Your notions above about patient care are misguided and, sorry to say, selfish. I hope whatever time you have in school puts you under the guidance of some good preceptors, and hopefully a strong mentorship in your early years of practice. Good luck.

[rev ronin]

Andersen,

 

I'm far from a young PA--EMED has met me, and can attest that I am both graying and balding... subtly, I would hope, but still. In my prior life, I have helmed risk reduction programs with an internally assessed value of $20 billion--yes, with a B--and think I have a pretty good handle on risk assessment.

 

Your point is well taken that one can go TOO far into defensive medicine, and order indefensible tests. From my perspective, that would be a completely bonheaded move, that doesn't benefit the patient or protect the practitioner from accusations of negligence. No, I have never had to testify at a malpractice trial. Chatted with investigating attorneys twice as a witness to others' misdeeds, but never in a medical context and neither case went to trial. At any rate...

 

I still think you're exaggerating the difference between our positions. I don't disagree with "doing the right thing for the patient", but include "staying in practice" and "economic survival" as higher considerations than "perfectly optimized diagnostic testing". My point with the "80+ hours" statement is that many things people claim to be in the patients' best interests are, in fact, not.

 

Still, I get the feeling we're going to continue talking past each other here, so allow me to close with an on-topic example from a recent clinical rotation:

 

I overheard an attending cardiologist complain to an attending EM doc about the number of spiral CTs that were being ordered by the EM residents on low-probability chest pain patients. Most of these low-probability patients wound up with the cardiology service for obs and rule out or for cath. The cardiologist's complaint wasn't that the contrast wasn't directly about the effect of CT contrast on the patient's kidneys, but rather on the effect the prior insult had on his ability to use a sufficient amount of dye during catheterization to do a detailed study. I did, in fact, get to observe this cardiologist in the lab both when he was "economizing" on dye use, vs. doing a complete study unhindered by considerations of prior CT contrast use, and even as an essentially untrained observer, I could see how many more and better pictures he was getting of the coronary arteries in the latter case.

 

Was this cardiologist somehow less than ethical because he wasn't doing the best left heart study he could? After all, the kidneys are far easier to live without than, oh, the LAD. I would say not--he did a less-than-perfect job based on other clinical priorities, and settled for a "good enough" standard for an articulable reason, even though the failure to do as comprehensive a study as he would have in other circumstances could clearly have cause a bad outcome for the patient.

[andersenpa]

Andersen,

 

I'm far from a young PA--EMED has met me, and can attest that I am both graying and balding... subtly, I would hope, but still. In my prior life, I have helmed risk reduction programs with an internally assessed value of $20 billion--yes, with a B--and think I have a pretty good handle on risk assessment.

 

Age and previous experience (particularly nonclinical experience) have little to do with this. A 24 yr old and a 44 yr old PA student are the same in many ways, especialy in how it applies to in the trenches clinical practice.

 

Your point is well taken that one can go TOO far into defensive medicine, and order indefensible tests. From my perspective, that would be a completely bonheaded move, that doesn't benefit the patient or protect the practitioner from accusations of negligence. No, I have never had to testify at a malpractice trial. Chatted with investigating attorneys twice as a witness to others' misdeeds, but never in a medical context and neither case went to trial. At any rate...

 

I still think you're exaggerating the difference between our positions. I don't disagree with "doing the right thing for the patient", but include "staying in practice" and "economic survival" as higher considerations than "perfectly optimized diagnostic testing".

 

Well I can't follow you going back and forth. I am basing on this comment:

I don't have any room for nonsense like "always do what's best for the patient!" in it.

 

So you either agree or disagree, it's up to you to choose.

 

My point with the "80+ hours" statement is that many things people claim to be in the patients' best interests are, in fact, not.

 

I don't know anyone who claims that is good for patients.

 

Still, I get the feeling we're going to continue talking past each other here, so allow me to close with an on-topic example from a recent clinical rotation:

 

I overheard an attending cardiologist complain to an attending EM doc about the number of spiral CTs that were being ordered by the EM residents on low-probability chest pain patients. Most of these low-probability patients wound up with the cardiology service for obs and rule out or for cath. The cardiologist's complaint wasn't that the contrast wasn't directly about the effect of CT contrast on the patient's kidneys, but rather on the effect the prior insult had on his ability to use a sufficient amount of dye during catheterization to do a detailed study. I did, in fact, get to observe this cardiologist in the lab both when he was "economizing" on dye use, vs. doing a complete study unhindered by considerations of prior CT contrast use, and even as an essentially untrained observer, I could see how many more and better pictures he was getting of the coronary arteries in the latter case.

 

Was this cardiologist somehow less than ethical because he wasn't doing the best left heart study he could? After all, the kidneys are far easier to live without than, oh, the LAD. I would say not--he did a less-than-perfect job based on other clinical priorities, and settled for a "good enough" standard for an articulable reason, even though the failure to do as comprehensive a study as he would have in other circumstances could clearly have cause a bad outcome for the patient.

 

No he was doing what I am advocating- appropriately weighing risk and looking out for the patient's best interest.

If he followed the rules you suggest, he should perform a full dyeload angio in order to avoid missing any coronary lesions that he could later get sued over missing.

[andersenpa]

Interesting article I just got in email, relevant to this discussion:

 

http://www.startribune.com/opinion/commentaries/164577846.html?page=1&c=y&refer=y

 

"...... But a reasonable estimate is that medical mistakes now kill around 200,000 Americans every year. That would make them one of the leading causes of death in the United States.Why have these mistakes been so hard to prevent? Here's one theory. It is a given that American doctors perform a staggering number of tests and procedures, far more than in other industrialized nations, and far more than we used to. Since 1996, the percentage of doctor visits leading to at least five drugs' being prescribed has nearly tripled, and the number of M.R.I. scans quadrupled.

Certainly many procedures, tests and prescriptions are based on legitimate need. But many are not. In a recent anonymous survey, orthopedic surgeons said 24 percent of the tests they ordered were medically unnecessary. This kind of treatment is a form of defensive medicine, meant less to protect the patient than to protect the doctor or hospital against potential lawsuits.

Herein lies a stunning irony. Defensive medicine is rooted in the goal of avoiding mistakes. But each additional procedure or test, no matter how cautiously performed, injects a fresh possibility of error. CT and M.R.I. scans can lead to false positives and unnecessary operations, which carry the risk of complications like infections and bleeding. The more medications patients are prescribed, the more likely they are to accidentally overdose or suffer an allergic reaction. Even routine operations like gallbladder removals require anesthesia, which can increase the risk of heart attack and stroke....."

[Sajedr]

I have to agree with Emed that an infiltrate and leukocytosis would be enough to call PNA. But we are playing armchair quarterback here - there was something in the H&P that made the clinician think PE strongly enough that he/she couldn't write it off and be done with it. There is a lot to be said for being able to live with yourself based on how you care for your patients, and I don't fault the clinician for wanting to r/o PE. However, have we forgotten about the d-dimer? If your clinical suspicion is low and you order the dimer with it coming out negative, then you can rest easily knowing you have made a good, inexpensive, effort to r/o the scary thing, the life-threatening thing. And, if it comes back positive, then you can go down the road to CTA of the chest. D-dimer is something that, at least in our UC, is a stat lab and done within an hour. Some places, maybe not an option. At any rate, that's my $.02.

 

Andrew

 

I was thinking the same thing as EMED and you - incl the d-dimer (although remembering the limitations of d-dimer) BUT at the UC where I work part time a "stat lab" actually comes back in about 4-5 hours. SO. I could get the xray - but if there were no infiltrates, I couldn't get the CBC or d-dimer. so, off to the ER this patient would go. Because that is the SAFE thing for the patient. and.... I depending on which hospital she wanted to go to, I wouldn't do the full workup at the UC either - because the hospital that is in the same health system as the UC I work for can see my charting, and the Xrays etc. But, if she wanted to go to a different systems hospital - I wouldn't want her to be charged twice for xrays etc that were just going to be re-ordered.

[CAdamsPAC]

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

 

Ditto! We are all second guessing the decisions of another PA, while we are not privy to the actual HPI & complete PE. I have worked in UC w/o complete lab services or anything beyond basic x-ray capability and sent pts to the ED for a definative w/u when I felt it was in order. I practice doing what I believe is good medicine meeting the "standard of care" for the complaint/dx which won't stop some malcontent pt from filing a lawsuit, but it's the best I can do and I accept it. I do believe that most PEs are dx'ed on post mortem exam, if it's in your ddx you need to address it appropriately.

[OpSite]

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!!!!

 

In this economy I'm more apt to say that you and your wife have been blessed. I'm not saying you haven't worked hard to build savings, but I am saying that you might want to be careful saying others are reckless with their finances if they aren't able to do it like you do. Some of us have been belted pretty hard by the recession even with care spending and planning.

 

As for the salary of a PA, it'd be hard to justify not being able to make a living off of that ;-)