PE Prognostication: Weingart Weighs In

OK friends – it has been an interesting week for me on the blog – lots of discussion about the part 2 of the PE Prognostication podcast. If you haven’t listened to the last 2 podcasts then this episode will sound like an American man who has totally lost his mind, but if you go back and listen to part 1 and 2 of the PE Prognostication podcast then it will sound like pure genius  [the two are easily confused I find!]

Don’t worry – I am not going to do a whole PE month – nobody deserves that!  I will be releasing a few non-PE posts and cases this week for those of you with a more diverse taste.

Fair to say there was a bit of a twitter shit-storm going on there for a few days and the dust is still settling.  I think Minh might have RSI of the thumbs from all his tweeting!

So a little bit of editorial orientation before we get onto today’s podcast.  I would like to take a few lines to explain what is going on so that you all have some context for this discussion and the podcast below:

  1. Dr Anand Senthi is a smart guy who has looked deeply into the PE literature
  2. There is not much evidence at all to support the “status quo” for low-risk PE work-ups in ED patients.  Largely the standard of care is based on expert consensus and the relatively poor volume of quality data available.
  3. We all know that there is a real risk of over investigation when it comes to PE work-up – especially in the patients that would be described as “low risk” by whatever system you prefer… Wells, PERC, Geneva, Gestalt.
  4. It is likley that a really conservative approach that attempts to identify every PE that presents to ED will in fact harm more patients than it helps
  5. Anand is worried about this and would like to change the way we approach these patients.
  6. Anand has generated an algorithm – a new approach to this group which is based in the evidence that is currently available
  7. Anand’s approach is at this stage a hypothesis.  It is an idea that needs to be tested in a rigorous, randomised trial in order to determine if his approach results in better patient outcomes than the current “standard of care”.
  8. We are not suggesting that you take this approach and apply it to your patients tomorrow.   It is a great idea –  but do not lose your job over it!
    1. Actually that goes for anything you read on this blog!  You are a doctor – read widely and make up your own mind.
  9. This is an idea that is evolving – this is what I love about the FOAM community – through debate and constructive feedback we can refine rough and raw ideas into actual practical and testable hypotheses.

So now that you know what is happening.

In case you don’t know Dr Weingart is an ED Critical Care guy from New York who runs the Emcrit blog / podcast.  He is also a man who has written a book about evidence-based medicine, one of the more readable guides to biostatistics that I have encountered!  So he is a clinician who understands numbers and decision-making.  This makes him a great “devil’s Advocate”, and I really appreciate the time he has taken to point out the logical and clinical problems with the Prognostication algorithm.

Scott [ @emcrit – as if I need to tell you. ] sent me this response to the PE Prognostication podcast.   He covers a lot of ideas in rapid fire.  So have a listen.

THe blog post review that Scott refers to of contrast-induced nephropathy is here at EDTCC.

I will be having Dr Anand Senthi back on the podcast soon to offer some counterpoint and we will see if the algorithm has evolved in the last few weeks!  Let me know what you think on the comments below.

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