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TPA for PE

My most dramatic save occurred in 1999, while I was working at a small hospital about an hour from Toledo. They saw about 35 patients a day in the Emergency Center.

The squad brought in a patient with respiratory distress. She complained of sudden sharp chest pain and difficulty breathing. I was able to get a good history before her condition deteriorated. She was young and healthy with no history of heart or lung problems. The only puzzling aspect of her history was that she had been evaluated a month previously for pain in her leg. She had an ultrasound of the leg and was told that everything looked good. I requested the report for the ultrasound.

The situation worsened. Her breathing became so labored and ineffectual that I had to Intubate her (insert a tube through her mouth, down her throat, and into her trachea) and assist with her ventilation. The oxygen saturation in her blood worsened.

The report from the ultrasound of her leg a month before described a blood clot in the Superficial Saphenous Vein. Superficial vein blood clots are typically not dangerous. They are treated with warm compresses and elevation. In contrast, deep vein thromboses (DVTs) or blood clots can be dangerous. Deep vein blood clots can break off and travel up the venous system through the heart and get stuck in the lung. In the lung, the blood clot can stop blood flow and thus limit the ability of the lung to oxygenate the blood. If the clot is large enough or there are many clots, then blood flow can be limited.

This patient had a documented Superficial Saphenous Vein thrombosis. Although this vein is called the Superficial Saphenous Vein, it is considered a deep vein and thus she had a DVT. Her apparent problem was a pulmonary embolism (PE). This is a blood clot that has embolized from a DVT and has become lodged in the lung.

Diagnosis of a Pulmonary Embolism is currently obtained by a specialized CT scan of the chest. Back then, PEs were diagnosed by a frequently inconclusive test called a V/Q scan.

I was convinced that she had a Pulmonary Embolism. She did not have time to wait for a confirmatory test prior to treating. I started her on intravenous Heparin, an anticoagulant (blood thinner) that limits the blood from clotting. Unfortunately, it does not treat preexisting blood clots.

The only accepted treatment for preexisting blood clots in the lung was to insert a catheter into the Pulmonary Vein and suck the clot out. That had to be done at a tertiary care center or large hospital such as The Toledo Hospital. I placed a call to transport the patient by air ambulance.

TPA was a medicine given the patients with heart attacks to dissolve blood clots in the coronary arteries. The literature was conclusive that TPA would dissolve blood clots and limit the damage from heart attacks. Theoretically, TPA should do the same for blood clots in the lungs, but no conclusive studies had been done and no protocols existed. TPA had the complication that it dissolved the clots everywhere in the body and sometimes resulted in strokes.

Had the patient remained stable, I would have sent her by helicopter to The Toledo Hospital on a Heparin drip. She did not. Her oxygenation continued to be low and her blood pressure started to trend downward. She would not survive transport.

I ordered IV TPA; it was her only chance. The results were miraculous. Her blood pressure returned to normal as did the oxygen level in her blood. Her shocky, pale, diaphoretic skin dried and became pink. She remained stable and was sent to the Critical Care Unit at The Toledo Hospital where she did well.

The patient started contacting the Emergency Center after she was released from The Toledo Hospital. The nurses told me that she wanted to personally thank me. She showed up during one of my shifts and gave me a big hug.

For over twenty years, I have received a Christmas card from her. She describes her life and her growing family and ends up by telling me that none of that would have happened if I had not saved her.

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