# pulmonary embolism



## JCEMTB (Oct 9, 2010)

Recent call I've had..want to get some input because it's bothering me for some reason.

Dispatched to GI bleed, turns out pt. had coughed up a "glob" of blood earlier in the day, about 2 hours before they called us. Assessment was fine, pt. was negative for any SOB,  no pain on inspiration, no chest pain, lung sounds clear, vitals as follows:
BP 108/44 P: 74 R:18 Cap Refil: <2 sec PWD skin

While there he coughed a few times, but did not produce any blood.  So, the assessment was fine, pt. was in no apparent distress, vitals are good. Whats bothering me is he had a hx of having a DVT about 1 month ago, and was put on coumadin. Pulmonary embolism wasn't on our minds very long because he was negative for all the symptoms, minus the small amount of blood but that can be attributed to a lot of things. Can one be occuring without any real signs/symptoms?? I feel confident we were correct with our assessment, its just a little nag in the back of my head.


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## Akulahawk (Oct 9, 2010)

Given that little bit of info, it doesn't sound like that patient had a PE. That's pretty low on my list of things to worry about, given what I know. I'd want to know more of this patient's history, in particular respiratory.


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## Shishkabob (Oct 9, 2010)

Pulse ox?   Cyanosis? 


Doesn't really sound like a PE to me.


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## Veneficus (Oct 9, 2010)

JCEMTB said:


> Recent call I've had..want to get some input because it's bothering me for some reason.
> 
> Dispatched to GI bleed, turns out pt. had coughed up a "glob" of blood earlier in the day, about 2 hours before they called us. Assessment was fine, pt. was negative for any SOB,  no pain on inspiration, no chest pain, lung sounds clear, vitals as follows:
> BP 108/44 P: 74 R:18 Cap Refil: <2 sec PWD skin
> ...



Yes.

I doubt it was without sign or symptom since you described one, but embolism is rather complex. Some people develop saddle embolus, which partially occludes the pulmonary vasculature over time. A smaller embolis can trigger an acute event by being the straw that breaks the camel's back.

Also when breaking up clots, the is no way to determine what parts break up first or how big they are. I have even seen large clots under fluoroscope break off or bypass vascular filters.

In many cases people with PE have no prior history.

Not judging, but one time hemoptysis with recent DVT and coumadin all but screams PE.

If it was an upper GI bleed, the emergent differentials include severe peptic ulcer and espohageal varicy. If they started bleeding, why would they stop? Partial lung infarct looks best with the description you gave.

If it makes you feel any better, it is unlikely anything would have been different if you had discovered it was a DVT in the field.


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## MrBrown (Oct 9, 2010)

He's fine, leave him at home.

Get the Thomas Pack, come on Oz let's go back and watch telly.

Ambulance, Medivac airborne .....


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## JCEMTB (Oct 9, 2010)

so what you're saying is it very well may of been a PE but just a partial occlusion? I'm relatively new to working the road. I was suspicious given the hx of recent dvt and coumadin....but I felt confident in my assessment since he lacked the low O2 sat, pain on inspiration, SOB that I was taught to look for. I realise even if I do find a DVT or PE in the field there is little I can do, but I still want to be the best clinician I can be.


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## JCEMTB (Oct 9, 2010)

the oxygen sat was 97%, no cyanosis. Pt. had a history of GERD(can cause bleeding), COPD, Pacemaker, CHF, PAD.


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## Akulahawk (Oct 9, 2010)

This is one reason why getting a good history of your patient is one of the best things you can do. PE may not be this guy's problem, but the potential is there, and PE can present like that. Most of the PE patients I've had did have some signs/symptoms like OP described.

Having additional history that you just posted would have been nice to know. Cough in the setting of COPD might also cause the hemoptysis... 

To the OP: I'm glad you want to be the best clinician you can be. Keep learning.


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## mycrofft (Oct 9, 2010)

*Second Akulahawk, good on you for looking for more.*

Did you check nares and oropharynx? #1 cause of "coughing up blood" without progressing to, say, sudden death is a "retronasal haemorrhage" (nosebleed). Also, deep vigorous coughing alone can sometimes cause a faint tint of blood in mucus...which concerned parties will describe as "a glob".

Also, tuberculosis.


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## Veneficus (Oct 10, 2010)

or cancer...

I don't think you did anything wrong, it is often not possible to come up with the precise dx without considerable data. 

Even sometimes with it, a potential dx can only be narrowed down to a handful of things.

If I can offer, one of the biggest mistakes in clinical diagnosis I see new people make is they think that each disease presents with a distinct set of symptoms.

In order to be more proficent, you must know what could be wrong, performing a detailed physical exam and history, and trying to correlate what you find. 

It is also sometimes more important to figure out which of the patient's many pathologies is being exacerbated, not everything they have.


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## JPINFV (Oct 10, 2010)

Veneficus said:


> If I can offer, one of the biggest mistakes in clinical diagnosis I see new people make is they think that each disease presents with a distinct set of symptoms.



I think another problem, especially with EMS providers, is the feeling that they have to come up with a single overall diagnosis instead of a list of differentials. I recently got into a back and forth in the comments section of a story on an EMS website about whether paramedics diagnosis. What was hilarious was the other provider was arguing that paramedics don't diagnose, but treat field diagnoses. He wasn't too happy when I pointed out the hypocrisy of claiming you don't diagnosis while in the same post saying that you do.


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## Veneficus (Oct 10, 2010)

JPINFV said:


> I think another problem, especially with EMS providers, is the feeling that they have to come up with a single overall diagnosis instead of a list of differentials.



I think this is probably from the idea of "protocol" driven medicine. If you are going to use the CHF protocol, then you patient must logically have CHF? 

It is the ultimate reason why paramedics don't simply treat signs and symptoms. In a multi pathology patient liek CHF, COPD, ACS, DM, you will literally dump the sink into those people following all the protocols.

I think this is especially true of systems with strict protocol adherence. They defy all logic in the attempt to follow the list perfectly.

Some of it also goes back to education though. The way paramedcs are taught to think in school is definitive dx, definitive treatment for such. Drilled over and over.


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## MrBrown (Oct 10, 2010)

Given the limited scope of paramedic education and opportunity for dexterious application of the treatment modalities avaliable to them I think its fair to say you have to fit people into certian squares or theres not much you will be able to do, which defies what seems to be growingly accepted logic in the rest of the medical community yet remains almost universally unacceptable in EMS.

Logic dictates that if blood pressure is low maybe give a little fluid, if short of breath maybe give some oxygen and if nothing seems to be wrong take patient to hospital and don't do anything yet so much of the education and culture [in the US] seems to be focused on diving in, ripping open the bag of tricks and using all those flash skills that you got at 12 week Paramedic school for Medicfighters and Parathinktheyare's.

I mean let's face it, to a greater or lesser extent it seems we are teaching people how to manage the early critical period of cardiac chest pain, seizures, CHF, asthma/COPD, diabetic emergencies and a few broad generic traumatic injuries with childbirth thrown in for good measure. Oh and lets not forget how to zap people.

Now in my part of the world I like to think we are teaching Ambulance Officers to become confident and autonomous practitioners of Paramedicine including thrombolysis and rapid sequence intubation.

Brown is somewhat convinced but not totally.

Oh and did you know in Los Angeles it is possible for paramedics to cure leg pain with lasix coz leg pain is now a sign of CHF?


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## Melclin (Oct 10, 2010)

MrBrown said:


> I mean let's face it, to a greater or lesser extent it seems we are teaching people how to manage the early critical period of cardiac chest pain, seizures, CHF, asthma/COPD, diabetic emergencies and a few broad generic traumatic injuries with childbirth thrown in for good measure. Oh and lets not forget how to zap people.
> 
> Now in my part of the world I like to think we are teaching Ambulance Officers to become confident and autonomous practitioners of Paramedicine including thrombolysis and rapid sequence intubation.
> 
> Brown is somewhat convinced but not totally.



There is a real battle between the "into which box does this patient fit, if none nothing + transport" types and the "Whats going on with my patient and how do bring about the best outcome" types here. A lot of students have trouble with the gray involved in how illnesses present and retreat to the black and white of guidelines. 

Early on they taught "the boxes" stuff to try and make it easier for us in first year, but I think it ended up being more detrimental because it got people into the decision tree mindset. 

I always figured they'd fix us, but we're finished our degrees now and some people still have difficulty with some pretty simple ideas like ACS not always presenting with chest pain. I was running a scenario for a class mate practicing for our final scenario exams and I gave him a dead set PE and he got mad after he failed miserably at identifying it because we don't have a guideline for PE and it "wouldn't be on the exam". Another classmate failed her exam because her "patient" had a simple pneumo which confused her because as far as she was concerned pneumos had to deteriorate after you arrived and have absent breath sounds on one side, so she treated for ACS despite having elicited a hx of right sided chest trauma and observing swelling and redness on the pts chest with pain on palpation...the mind boggles.   

One does wonder about our degree system sometimes.


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## Veneficus (Oct 10, 2010)

I think medicine in general is moving towards these decision trees. I had more than my fill of it this summer in the US.

It is true when protocols are in place the statistics of people helped gets better. That whole performing the best treatment that works for the most idea. 

Having said that I ha an interesting disscussion with  a neonatologist who seems to think that more and more patients who don'tfir into the protocol are considered "acceptable losses" rather than trying to use knowledge and skill to deviate from the protocol. 

It seems at the very least, protocols have become the endpoint, not the starting point for all types and practicioners of healthcare and medicine.


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## MrBrown (Oct 11, 2010)

I like to think our ambos apply thier cognitive knowledge more dexteriously than elsewhere (same for most other commonwealth nations) but you know I am not so sure.

Perhaps we could say the same of our Doctors too but I am not sure either.

Is protocol driven medicine as big in (your location here) as it seems to be in the US?


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## EMSNicky24 (Oct 14, 2010)

*Don't think so*

Does not sound like a PE to me either. But it is always good to look at all the possiblities!


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## Charmeck (Oct 15, 2010)

Doesnt scream PE to me.  It would be lower on my list of differentials given the info you have.


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## emtchick171 (Oct 28, 2010)

From the explanation/scenario given, PE is not the first thing that comes in my mind. The major concern I would have is the blood pressure being a little on the Hypotensive side...you can always give fluids via IV to assist with the B/P. 

It is not our job as EMS providers to diagnose a PT with a condition, it is our job to treat their signs and symptoms and try to get our PT in a condition of comfort, *if possible with normal vitals. 

I don't think you did anything wrong with this PT...PE show up differently in different PTs. Not ever PT you pick up with a PT will represent the signs & symptoms in the same manner, just be open minded and think of different possibilities.


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## clibb (Oct 28, 2010)

PE can show a bunch of different symptoms. I've had patients where it shows flu like symptoms, regular chest pain, SOB, and almost no symptoms at all.
The no symptoms at all was the saddle back that I had. He just said that he's not feeling right and within 5 minutes we had to intubate him.


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