Featuring: The Vampire Diaries. (Does not contain spoilers). Season 6 Episode 1.
Doctor doing teaching session: “Patient attends with chest pain and shortness of breath, what kind of tests would you do?”
Elena Gilbert: “Pulmonary angiogram to show pulmonary embolism.”
NO, that is NOT the first line investigation for chest pain and shortness of breath, especially with the lack of history! If anything, it’s more likely to be a heart attack (common things are common) so you need an ECG and troponin, or a chest infection, so you need a chest x-ray and common blood tests. If they describe pleuritic chest pain in someone who is at high risk of a leg clot (DVT) that can be thrown up to the lung (just got off a plane, on combined oral contraceptives/hormone replacement therapy, previous leg clots/lung clots, pregnant) THEN you’re thinking maybe pulmonary angiogram. You would also do blood tests first — clotting screens, blood count, kidney/liver functions, d-dimer (quick blood test to reliably prove it’s not PE if the number is low enough but means nothing if it’s high). This is particularly important because if their kidney function is low enough, if you give them the high-flow contrast in the scan this will KILL them.
And other things to think of is: is it a large vessel dissection? Is it a collapsed lung (which would also give you the same symptoms, which would also show up on a chest x-ray)? Is it angina?
And why is this important? Because treatment for all of those is very different and the CTPA (CT pulmonary angiogram) might not add anything to it. Because CTPA require high flow contrast, which can be detrimental to the kidneys in at-risk individuals, some people can develop allergic reactions to the contrast, if it tissues in the arm it’s really bloody sore, and the scan contains a LOT of radiation. If you’re really thinking it’s a PE then yes, the risks are worth it considering you can die from a PE. But if it’s a simple chest infection that you can SEE on a chest x-ray and you can see raised infection markers, why stick them through all the aforementioned risks when you can easily go without and give them bloody antibiotics?! And what if, common things being common, it’s a heart attack in the end, which will not show up on CTPA and the patient just sits with a steadily dying heart because you didn’t think to do routine tests first and jumps straight to the specialist ones?!
*pulls out hair*
This may be the first of many posts of TV series portraying medical conditions horrifically incorrectly.