I missed a PE once on a woman who was just “anxious”. Wasn’t short of breath. Her o2 Sat. was 100%. I referred her to a psychiatrist, her PCP saw her the next day started her on Wellbutrin. 10 Days later she showed up dead in the ER. Massive PE. I didn’t get a D-Dimer. The D-Dimer is the Lawyer’s best friend. If a patient shows up totally vague, like this woman, and you don’t get a D-Dimer, they can use it against you in court. Now I get D-Dimers all the time. And if they’re positive, I needlessly Chest CT many patients.

Anon 11:56,

I don’t blame you. I’m a radiologist and hate having to read medically unnecessary CT’s like this in the middle of the night but, like you say, the ambulance chasers have forced you into it. You gotta play the game.

“No one wants to miss a PE, duh.”

Really. I guess the idiot who posted that thinks that eveyone who sees their doctor should get a $700 CT scan, irregardless of symptoms or lack thereof. I hope he or she gets plenty of defensive tests ordered next time they visit their poor unsuspecting doc.

Anon 9:32

Do you have ANY statistics for the sensitivity of an MRI vs a CT scan for detecting a PE? Apparently not, under your suggestion, about 9/10 PE’s will be missed.

You can’t do MRI for the heart? Actually MRI is far superior to CT for the heart (the coronary arteries excepted)

You clearly have very very little understanding of the appropriate use of imaging technology, yet apparently it’s enough to threaten litigation. Rarely are CT and MRI interchangable. If your Dr. ordered a CT over an MRI, that was likely the most appropriate test. Quite frankly, your arrogance may have put your own health at risk.

“Is it belaboring the obvious that if you had CT’d the woman with a PE she might not have died?”

I am the poster of the original blurb about the young woman with “anxiety” I sent home who nded up having a PE. No, I’m guessing if I had done a CT scan of the chest it would probably have been negative. Remember from my posting she died 10 days later. She may have had a small subsegmental PE on the day I saw her. CT would have missed this. The only person this CT would have helped, in all likelihood, was me. I could have used it as a defense in court. At least I have a normal EKG (she wasn’t even tachycardic)

Hey Anon 9.32,

No, doctor, it is your arrogance that is putting patients at risk, or at least rendering you indifferent to patient (your customer’s) preference.

you say: “If your Dr. ordered a CT over an MRI, that was likely the most appropriate test. Quite frankly, your arrogance may have put your own health at risk.”

The fact is that in many situations CTs and MRIs can be used interchangeably or (as in my situation)there was debate in the literature as to which mode was most effective. Given the lack of empirical certitude, I chose what I felt comfortable with–not my doctor–whose justification for using a CT after discussion was simply that he was “used to it.”

Many radiologists (but apparently not you) see the value of replacing CTs with MRI. http://bjr.birjournals.org/cgi/content/full/74/886/926#T1

But, what we get from you Anon 9.32 is more of the same: doctors protecting each other and protecting their professional prerogatives.

Loathsome or pathetic>

Did you read the article you posted a link to???

You advocate MRI over CT for pulmonary embolus (a chest exam)

From your article:

Preferred modality, Chest:
CT 85
CT or MRI 3
MRI 6

Next time post data that backs up your claim.

Love the nonphysician experts on d-dimers here. It is not simple and I won’t even begin a discourse on numbers. There is reams of new and often conflicting literature every month. There are many different d-dimer tests with different purported sensitivities and specificities for different scenarios. There is danger in putting faith in both the positive and negetive test.

The insanity won’t stop.

Just yesterday a woman at 41 weeks gestation presents to ER triage complaining of contractions, and by the way had two brief episodes of shortness of breath. The physician assistant sees her at triage because all 50 beds in the ER are full and 20 are waiting. The PA stupidly orders a d-dimer which comes back positive. Some brilliant nurse in Labor and Delivery tells the PA that the shortness of breath must be evaluated first in the ER before going to L&D for evaluation. I subsequently get involved with the patient. HR is 80. RR is 18. Pulse Ox is 99% and is not currently short of breath. I say go to L&D and moniter the baby, deliver it if you need to and evaluate with CT or V/Q if there is still concern of PE and delivery of a 41 weeker has not resolved the so-called shortness of breath. I am just so glad the patient didn’t demand an MRI!!!

“Doctors, in my view, should not be in the business of saying, oh, it’s probably nothing”

This is not the business of doctors. Believe me, no one wants to miss a fatal diagnosis. It is absurd to think that they do.

Depending on your source, PE is the third leading cause of death. CT is not even perfect. A pulmonary angiogram (with a fairly high complication rate) is the gold standard or an autopsy!! The medical community is very, very interested in finding better screening methods for this. There are reams of new studies every month from all over the world on this very topic. Hindsight is 20/20. Some cases will get missed and I am skeptical that perfection will be reache. I am aware of it constantly in daily practice and must make reasonable judgements based upon varied presentations and nonideal tests available. I hope I never miss a fatal case balanced by causing a serious complication by unneededly (is that a word?) pursuing false positive tests.

Also what do you do with someone 500lbs who doesn’t fit into a scanner or V/Q?

Any ideas for better screening of patients with PE, especially young women? If CT is the only way to know for sure, then it’s the best you’ve got. A negative CT is not “uneccessary” if the only alternative is to miss the cases that are positive.

If the whole issue was simple and easy it wouldn’t take 4 years of medical school and 3+ years of indentured servitude residency training to practice medicine.

I love it! A D-Dimer in a woman who’s 41 weeks pregnant! (All Pregnant woman will have positive D-Dimers) And yes, there apparently was an extenuating circumstance in the woman I sent home who died of a PE. She was on Birth Control Pills (It is controversial whether it’s a risk factor for PE’s) But the patient never told anyone she was on birth control pills. And to the patient above, who threatened to sue his/her doctor if he didn’t do an MRI. If I was your doctor, and you threatened me like that, I’d punch you in the mouth. Man or woman. No human being deserves to be threatened like that. Remember, your doctor is a human being.

“And to the patient above, who threatened to sue his/her doctor if he didn’t do an MRI. If I was your doctor, and you threatened me like that, I’d punch you in the mouth. Man or woman. No human being deserves to be threatened like that. Remember, your doctor is a human being.”

well, anon 11.16, I am the “patient” above and take your best shot–but I am a black belt in tae kwon do.

your reaction–and virtually all the other reactions to my post–are bizarre and really demonstrate the near pathological self-absorption of doctors.

Hit me because I threaten to sue?! Doctor, you are providing a service, just like a builder or accountant or prostitute. We have a contractual relationship. If I have to use all the leverage at my disposal to obtain what I want, why is that evil or impinge upon your personhood. It’s called the market.

As for all the other doctors who stated I recommend MRI for PE–I did nothing of the sort. Only asked why MRI could not be used in PE–an idea that occurred to me given my own experience in which both modalities were acceptable (which as the article I cite is true for numerous conditions). Well, I suppose any health care customer who threatens physicians’ fragile little egos must face their mob-like wrath.

“Well, I suppose any health care customer who threatens physicians’ fragile little egos must face their mob-like wrath.”

It’s not that. It’s the know-it-all arrogance you display, all the while making an idiot out yourself trying to teach us about something you are ignorant about. Why can’t you just admit that you know nothing about CT, MRI, and the diagnosis of PE and just move on?

I just read Anon 932 posting. What an idiot! Does this guy know how stupid he is?

Thanks to everyone for the great discussion about PE and troublesome diagnosis (it degenerated a bit at the end with the face punching bit; somewhat insensitive!)

Anyway, no one mentioned VQ lung scans in nuclear medicine in the CT vs MRI controversy. In the data I’ve seen, nuclear has a slight edge in terms of sensitivity for finding PE over CT (the new 64 slice spiral CT might have improved on the sensitivity). Also, the radiation dose is much lower with nuclear medicine (xrays vs gamma rays, at lower numbers of millirads).

I was interested in the discussion on D-Dimers, and the inaccuracy. Isn’t the d-dimer test a 98% accurate negative predictor of PE, i.e. if your d-dimers aren’t elevated, there’s a less than 2% chance of PE?