16 June 2010

A Scary Story

The man I was seeing was very young and completely healthy. 38 year old software engineer at a Major Operating System Manufacturer.  Nice guy. He had come in with complaint of a swollen leg and it didn't take a genius to see that there was a blood clot in it. We got the ultrasound and confirmed that he had actually a fairly large clot.

After that diagnosis was made, I had to determine the course of treatment.  For a simple clot in the leg, you get a shot of blood thinners and you go home on blood thinners.  However, if the clot has gone to the lungs, the consequences can be lethal, so you stay in the hospital for more intensive blood thinners and close monitoring. I asked him is he had any shortness of breath or chest pain, and he said no.  I asked if he had had any at all over the last few days and he clearly denied. He said he had just climbed three flights of stairs before coming in and had no problems.  I asked if he had any dizziness or fainting and again he said no.  When I pushed him, he though that maybe about three or four days ago he had a short time when he was dizzy and nauseated but it was mild and self-limited. I looked at his vitals: normal heart rate, respiratory rate, blood pressure, oxygen level.  All very reassuring, and he looked like the proverbial rose.  The likelihood of him having a blood clot in the lungs, I decided, was very low.  It would probably be OK to send him out.

But still, he had that dizzy spell.  And it is kind of a big clot.  OK fine, I'll get the CT scan of his chest to rule it out.  It's a waste of money, stupid CYA medicine, but I'll just do it.

About an hour later I got a call from the radiologist. As I have said, the radiologists don't call you to tell you that a test was normal. They call for Bad Things only, things they want you to know right away and things that they want to document on their report "Dr Shadowfax personally informed at 1835hrs."  And this was a Bad Thing. Not only did this guy have blood clots (plural) in his lungs, there was as much clot burden as you can have without a saddle embolus.  It was described as "Large bilateral PEs from the distal pulmonary veins into the segmental veins of all five lobes of both lungs."  Holy Crap!  And I was thinking of sending him home!  I rechecked him, and he still looked and felt great. He was a little annoyed that I insisted on admitting him.  The resilience of youth, I guess.

I suspect that he may not do well. He's fine now, but with this much clot he's likely to develop right heart failure, pulmonary hypertension and long-term problems as a result of this. He didn't qualify for t-PA or thrombectomy, not with normal vital signs.  I wondered to the hospitalist whether he might benefit from some interventional radiology procedure where they break up the clots with ultrasound or catheter-directed t-PA.  I hope he does.  Here are the scary pictures:

pe1
pe2
pe3

Red arrows show clot in the pulmonary arteries.  And as always, when I make a scary diagnosis by good fortune:



12 comments:

  1. So no obvious reason for his clots. Is he another of your series of cancer diagnoses patients? Poor guy.

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  2. Very scary indeed. Hits home too.

    I developed a DVT while abroad (for an extended period of time) and sought care towards the end of my stay but it was missed. Luckily it was near the end, because 10 days after my return I was in the ICU with a Saddle PE (nice pic, btw) and right-sided heart damage.

    Three days in the ICU and 1 year of anti-coagulation therapy later, I live to tell the tale but I've been told that but for my age (I was 21) and the grace of God I would've been dead.

    He was lucky to have someone who followed through on their hunch. Here's hoping the rest of the luck he needs is on his side.

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  3. I'm finding this more and more. unfortunately. I'm more inclined than not to CT anybody presenting with DVT who a) has a heart rate over 100; b) has no obvious risk factors; c) is otherwise young and healthy; d) has a big clot. right now my chest CTs are 75-80% + for PE.

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  4. In emergency medicine, I'd rather be lucky than good. (But best to be good.)

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  5. tPA has not been shown to be better than anticoagulation and catheter given tPA has not been shown to be better than peripheral IV given. More data may change that but until it does, more therapy is not better therapy.

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  6. Doc.... I just make donuts for a living, I'm married to a RNP and our daughter is a PA, but I don't get to hear about stuff like that at dinnertime discussions.

    Honestly, stuff like that scares the crap out of me.

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  7. Scary case. But good that you decided to do a CT. Good for both you and the radiologist.

    PS. I'm sure the radiology report must've mentioned Pulmonary arteries, not veins.

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  8. yikes! I remember a PE request came across "26F used to be able to run 20 miles now can only run 10". almost tried to fight that one... glad I didn't because it was a saddle embolus.

    later,
    radinc

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  9. Oh crap. That is a sphincter tightener.

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  10. My sister at 36 had a blood clot. She's a nurse and no symptoms till boom out of the blue her lips turned blue!

    3.5 weeks in ICU trying to treat it/break it up, kidney failure after they broke up the clot with ultrasound, and a heart attack later - although if you are going to have one what better place than the ICU, she's okay.

    Come to find out she had a form of lupus that's in the blood? She's still on blood thinners and still has issues. At this point, they don't think she'll get "over it" like most people do.

    Good catch!!

    Amy in Seatle

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  11. um...so now i'm curious. did the rad report really say veins?

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  12. Wow, that is a scary story! Blood clots are no joke, we are glad you are thorough and did a CT Scan. You saved his life and ee celebrate the gift of life and our mission is to try to help others enjoy it as much as possible. Learn more about what we do here: http://bit.ly/LkrEzP

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