I learned from my radiologist a few weeks ago that "some nuclear reactor in Canada" that makes "most of the nuclear medicine" tracers went off line, causing a nation wide shortage in nuclear isotope compounds necessary to do common medical nuclear imaging. Those imaging studies include something called the ventilation/perfusion(V/Q) scan used to look for pulmonary emboli. This test looks for mismatches in the lung between ventilation (breathing) and perfusion (blood flow). And can be highly sensitive for pulmonary emboli in patients with normal underlying lung tissue.
Now I learned the rest of the story from the WSJ Health Blog. And it's not pretty. In fact, it sounds like this shortage is going to get worse. A nuclear reactor in the Netherlands went off line for maintenance.
This shortage has personally affected my practice. Here is a clinical scenario I was just presented with at Happy's Hospital:
Just the other day I had a post op day 5 spine patient on 4 liters of oxygen, a clear chest xray and no indication of parenchymal pathology. I couldn't do a CT angiogram (CKD IV) to look for pulmonary emboli. I couldn't do the V/Q scan due to the nationwide shortage. We have no tracers available to run them. I ordered venous dopplers. They were normal.
Now I'm stuck. Unexplained post operative hypoxemia in a surgical spine patient with negative leg dopplers. Could this patient have had a DVT that broke loose? I see it all the time. Pulmonary emboli with negative leg dopplers. I wasn't going to empirically treat a spine patient with full dose anticoagulation without compelling evidence of a pulmonary embolism. That could potentially paralyze them for life.
So I made the medical judgement to just wait. And wait. And wait. And HOPE that they didn't die of a pulmonary embolism. He didn't. But what if he did? What if this guy really had a clot? I found myself in the midst of an internal conflict.
Would I be negligent for not making the diagnosis because I couldn't test for it? Then I found myself disturbed at even having to think about the legal implications of my medical actions in this clinical scenario. In fact, I found myself pissed off that I even had to consider the legal implications of my actions in this clinical scenario. Why should I have to worry about being sued for managing a condition that may end with a bad outcome? Why would I be blamed? How could I possible be considered negligent for a missed diagnosis in this clinical scenario?
I could have punted the duties of management and spread the risk down hill and asked for a pulmonary consult (which would be ridiculous). I could have punted and asked for a hematology consult (which is even more laughable in this clinical scenario). But I didn't. I knew their opinions on this matter would be of limited value, just as mine would be.
I found trying to understand what the standard of care would be in this situation. I came to the conclusion that there isn't one. In so many situations I practice medicine, there is no standard to guide me, just education and sound clinical practice experience.
There is no standard for diagnosing a pulmonary embolism in a post operative patient where radiographic imaging was not available. It's not like I could send my post operative patient to another hospital. This is a nationwide shortage. Besides, no surgeon would accept a POD #5 patient from another hospital.
I found myself wondering how doctors in the jungles of central Africa practice without all this expensive technology. I found myself wondering how they make the diagnosis of pulmonary embolism in a post operative patient. I found myself wondering what their standard of care must be like.
There is no way to diagnose a PE short of seeing the clot or being lucky. You can develop pretest probabilities based on clinical findings, but you can't make the diagnosis definitively without seeing evidence of clot in the lungs. And you can't see a clot in the lung with out expensive imaging tests. And you can't do the imaging tests if you don't have the materials to do them.
His oxygen levels eventually improved after a few days of doing nothing. And a pulmonary embolism was not likely the cause. But it's scary to think that a major part of the medical infrastructure of this country, a country that spends more money on health care than any other country in the world, can't produce domestic nuclear tracers for medical purposes. That we are at the whim of Canada and the Netherlands to diagnose pulmonary emboli.
I have just one question. Why?
