pulmonary embolus

Monday, February 23, 2015

If only patients would read the textbook and always have the same complaints and physical findings for an illness or disease. That would make diagnosis much easier. But real life is never easy when it comes to diagnosis and treatment. Consider the sad stories of Chris Bosh and Jerome Kersey.

Mr. Bosh, in the prime of his career as an NBA superstar notices some pain in his chest and for a few days doesn’t feel quite right. He sees his doctor and after a few tests, the diagnosis is made of pulmonary embolus, blood clots in his lungs. Mr. Kersey, at age 52 a retired basketball star, has one of the common presenting complaints for pulmonary embolus (PE). He dies suddenly with no warning and the diagnosis is made by the coroner. Mr. Kersey is not alone. Pulmonary embolus is the second only to cardiac arrest as the most common cause of sudden death.

There may be close to a million people each year in the US who suffer from PE, but it’s a hard diagnosis to make and the frequency may be even higher. Consider that autopsy studies of people who die in the hospital found that up to 60% had PEs and the diagnosis was missed 70% of the time. And for that reasons, doctors have a high worry factor when it comes to making the diagnosis. Patients show up complaining to their doctor about chest pain, worrying about their hearts, but as it turns out, lots more things cause chest pain that just heart disease.

Modern medicine hasn’t yet figured out how to help patients like Mr. Kersey who die without warning, but Mr. Bosh is a different story. His diagnosis is made and his doctors can high five themselves for not missing the potentially lethal disease. Now comes the tough decisions about treatment options. They all have to do with anticoagulation or thinning the blood. The blood clots in the lung, and there may be one or many, are actually located in the pulmonary arteries. Those are the large blood vessels where blood is pumped from the heart to the lungs, so that oxygen can be attached to red blood cells and then circulated to the rest of the body. Clots in the artery act like a dam and it makes it tough for the heart to pump against resistance. This can strain the heart muscle. If that isn’t enough of a problem, if enough clot is present, blood can’t get into the lung tissue and get loaded with oxygen. The potential exists for shock, hypotension (low blood pressure) and death.

pulmonary artery

The diagnosis is often made by CT and the amount of blood clot can be seen. The patient’s vital signs are monitored and their stability is assessed. The treatment for pulmonary embolus is anticoagulation or thinning the blood with medications. The first questions is whether the patient is so unstable that clotting busting drugs need to be used to dissolve the emboli that are already there. Usually, the answer is no and routine anticoagulation medication can be used. The second question to be answered is whether the patient can be treated at home. Many patients with PEs are stable and will need to be on blood thinning medication for a prolonged period of time. There are different medications available to use as an outpatient and the decision needs to be made whether to use a combination of enoxaparin (Lovenox) and warfarin (Coumadin) or the newer anticoagulants like apixaban (Eliquis) or rivaroxiban (Xarelto).

So how does one decide stability? It’s all about the vital signs. If the patient is tachycardic (rapid heart rate), tachypneic (rapid respiratory rate) and/or hypoxic (low blood oxygen), hospitalization and observation may be appropriate, even if the patient would get the same medications as they would if they were an outpatient. Abnormal vital signs presume that the heart and lungs are not working as well as they should and cannot deliver an adequate oxygen load to the body. Blood tests may be able to quantify how sick. Arterial blood gasses can measure how much oxygen is getting loaded into the blood stream and whether, the lungs are able to remove waste products from the blood. Troponin levels, normally a marker used to check for heart attack, can also help decide whether the heart muscle is being strained because it has to squeeze harder to push blood past the pulmonary artery clots. An echocardiogram, or ultrasound of the heart can also help assess heart strain.

Medications are also evolving and treatment strategies depend upon patient situation and physician comfort in using the newer anticoagulation medications like Eliquis and Xarelto. Classically, warfarin is used and blood levels have to be measured routinely to make certain the blood is adequately thinned. Warfarin dosing is adjusted based on those blood test results. That means patients have to go to the lab routinely, the doctors and nurses have to follow up on the tests and adjust medications. Studies suggest that patient blood is inadequately thinned more that 30% of the time. The new drugs do not need adjustment, blood tests or much follow up. Their downside: price is much more expensive than warfarin (but there is no need for blood tests or office visits) and…the anticoagulation cannot be emergently reversed in a bleeding emergency or if emergency surgery is required. Warfarin can be.

Finally, the question most basketball fans were asking: how long does a patient have to be anticoagulated, because on blood thinners, contact sports are out of the question because of the risk of fatal bleeding from trauma, especially to the head. The easy answer is at least three months. The real answer is…it depends. Questions that need to be asked have to do with the reason for the clot, the patients’ underlying risk of bleeding, if it is a recurrent clot and what other medical issues are present. The American College of Chest Physicians publishes guidelines for the diagnosis and treatment of blood clots and the summary is 47 pages long.

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decision making

Monday, February 9, 2015

The press release was very black and white. Blake Griffin, star of the LA Clippers, requires surgery for an infected elbow. If only medicine was so cut and dry and just one option was proven to be effective. But in the real world of caring for patients, this short story does not do justice to the sometimes complex treatment alternatives that might be appropriate when caring for an injury or illness. Alternative treatment approaches mean that the physician and patient may have to come to a consensus about care, even when the medical literature and research cannot give much guidance. This may be the lesson to be learned from Griffin’s elbow short story.

elbow-bursa

The olecranon is the point of the elbow and there is a small bursa or sac that protects the skin from rubbing across that pointy bone edge with every bend of the elbow. On occasion, the bursa can become inflamed, either because of one acute blow or because repeated falls, resulting in bursitis (itis=inflammation). There is pain and swelling and the diagnosis is pretty easy because the swollen sac appears as a small knob overlying the elbow. Usually, it resolves with PRICE (protection, rest, ice, compression and elevation). Competitive athletes may not be allowed the time to rest and injecting the bursa with steroid may help with healing.

Sometimes the bursa becomes infected. Most commonly, the skin overlying the injury is damaged due to a laceration or abrasion, but the infection may arrive in the elbow after traveling through the blood stream from another site. The infection may also be a complication of aspiration, when a needle is used to inject steroid. And this is where the Blake Griffin treatment discussion begins.

The research is confusing and does not come to a consensus. Some studies suggest that the best outcome for infected olecranon bursitis occurs with a prolonged course of antibiotics. Other studies suggest that immediate surgery is appropriate. Yet others recommend surgery only after antibiotics have been started or have failed to produce a cure. depending upon the researcher, those antibiotics might be recommended to be administered intravenously or by mouth, depending upon the severity of the infection.

The treatment successes are confusing. In mild infection, antibiotic therapy can fail from 10-30% of the time while sever bursitis has a failure rate up to 50%. When it comes to the research though, the definition of mild versus severe is not set in stone. The severity of an infected olecranon bursa is in the eye of the beholder; mild to moderate infection is described as having local, significant inflammation while severe infection will show intense bursitis. There are other associated symptoms to look for, but it’s tough to know how significant “significant” is and how intense “intense” might be.

Those who advocate surgery as the first treatment option point to the statistics that show recurrent infection that happens “only” 15% of the time when the infected bursa is removed. If surgery is considered, the use antibiotics don’t decrease the re-infection rate. The type of surgery is also open to debate, including whether to leave the skin open and allow healing to occur over time, or whether the skin should be closed immediately. There are some surgeons who advocate operating with an arthroscope to make the smallest cuts possible, while others suggest a wide incision as better choice.There are a variety of other combination treatment approaches using antibiotics by mouth or intravenously, in association with surgery that are touted, depending upon the individual situation and that is the crux of the matter.

Once upon a time, the practice of medicine was all about diagnosis and there were few options available when it came to treatment. Modern medicine now has many more tools to help establish a diagnosis and offer different ways to approach treatment. It is the physician’s responsibility to teach the patient and family about different options, their benefits and risk, and to come to consensus about which plan best fiuts a particular patient’s situation. That does not mean that the physician needs to take a back seat in the decision making and agree to do something that is harmful, but it does mean that the patient has some responsibility in what happens to their body.

Much goes into the decision that cannot be summarized by a story that proclaims that Blake Griffin needs surgery. The decision may rest on the facts of the case: there is the history of repeated needle aspirations of chronic bursitis, there is an infection that occurred after the most recent injection and there is the importance that he and his team are in the midst of a playoff race with his return to play vital for his team’s success.

Those same considerations exist for those who are not famous and don’t live their lives in the public eye.  The same discussion issues exist in treating a kid’s ear infection with or without antibiotics, choosing a cast or operation for a fracture or deciding to admit or send a chest pain patient home. Decisions happen every day in medicine and it’s up to the doctor to remember to educate and up to the patient to ask to be taught.

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