Whirlwind

First day back in the ED in 2 months felt a little like my very first day in the ED. I forgot how to order lab tests, get x-rays, do a focused H&P, smooth talk consultants…

But I did “fix” at least one person today. An unfortunate man with an infected knee and a “Peripherally Inserted Central Venous Catheter” for 6 weeks of home antibiotics. He came in because the arm that had the catheter in it was red & swollen. I sent him up to the vascular lab and sure enough, he had a clot in his subclavian artery. I called the coagulation clinic since I was working during the day shift, called the PICC team to put in a new catheter and got all of his followup arranged. He was a little bummed about the whole situation, but I was glad I found out what was wrong with him.

Later in the day, I argued with one of the medicine attendings about the use of the d-dimer test in patients with greater than a low pre-test probability for a pulmonary embolism. Then we argued about the definition of Low pre-test probability. He wanted to to add up points for the Well’s criteria. I wanted to use my clinical judgement. Niether has been proven to be a better method, but he insisted I order the d-dimer anway when I already had an intermediate VQ scan. We then proceded to duplex his legs which were negative. So does he have a PE? Well, 30% of people with PEs have negative venous duplex exams. I’m anxious to find out what happened to him.

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