PE: Pain, Puzzles and PERC
Judging by the flurry of comments on two recent EMCrit posts (OK, about half of them are mine…) Scott ‘20 inches‘ Weingart has cracked open a can of pulmonary embolus-shaped worms.
First he featured a fascinating intellectual slugfest between himself and the cerebrally top-heavy David Newman — who you will know as the brilliant ER doc (with help from his friends) behind SMARTEM, TheNNT and even the Annals of Emergency Medicine podcast
Check out all 15 rounds of this ‘clash of the titans’
A Debate on PE Rules.
One things for sure, when it comes to PE, there is no winner. The diagnosis, for many, reasons is a constant thorn in side of emergency physicians the world over. Perhaps the best comment came from Broome Docs’ Dr Casey Parker who shows that being in a remote location forces one to consider the threshold for investigation more carefully. Indeed, perhaps we should all ask ourselves:
“Would you still want to investigate the patient for PE if it involved flying them 1000 km?”
However, emerging from the blood spattered PE arena, Scott posted a nifty flowchart summarising a reasonable approach to using Wells, the PERC rule and clinical judgement to decide when you can safely rule out PE, and when you need to go on to further imaging.
So far, in a couple of days, this post has clocked up over 26 comments. The first is a classic — and exemplifies why blogs and podcasts beat journals hands down every-time. Thank you Mike J! You’ll never see a comment in a journal start with:
“Ok Weingart, i’ll bite. Fueled by the fact that i am post shift, it is 3 am and the dogs woke me up and i have had a beer. This algorithm is completely nuts! Maybe i am an ignorant slut but……..”
To Mike’s credit he revisits the post after paying off his sleep debt and blowing a zero on the alcometer.
The other spin off from all of this are the threats I’ve received from our budgie-smuggling friend Rob Orman regarding an upcoming ERCast PE feast — that’s one to look out for. But, on a side note, what is it with these podcast guys? It seems both Orman and Weingart have horribly mishapen cortical homunculi… the mouth and ears are all out of proportion. You send them an email and they send you back an mp3 audio recording with a background of laboured breathing while they multitask riding a bicycle, placing a central line and firing off responses to their latest podcasts… To me, that’s not normal.
Anyway, if you can stomach anymore on the damnation that is D-dimer or the puzzle of the PERC rule, you might want to check out these Case-based Q&A’s from the LITFL archives:
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.
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