Intro: Welcome to UAB MedCast, a continuing education podcast for medical professionals. Providing knowledge that is moving medicine forward, here's Melanie Cole.

Melanie Cole, MS (Host): Developing a blood clot in the lungs is a relatively common life-threatening condition, and a number of new technologies have emerged that provide multiple options for treatment of such pulmonary emboli.

Welcome to UAB MedCast. I'm your host, Melanie Cole. And today, we're talking about pulmonary embolism response team or PERT with Dr. Samuel McElwee. He's an Assistant Professor in the Division of Cardiovascular Disease at UAB Medicine. Dr. McElwee, thank you so much for joining us today. As we get started with this topic, and you're going to be telling us about this program, I'd like you to speak first about the prevalence of pulmonary embolism in the population and what had previously been the treatment response and protocol.

Samuel McElwee, MD: Yeah. That's a great question and thanks for having me. I'm looking forward to our discussion. So, PE in and of itself, at least in the United States, it's really common. The incidence has gone up over the last 20 years, and a lot of that is largely due to we are better at detecting it. So with the advent and rollout of CT pulmonary angiography over the last 20, 25 years, we have seen a significant increase in the number of pulmonary emboli. But just in terms of general numbers, about 120 or so cases per, you know, 100,000 people, so relatively common. It can really affect a lot of different people.

So, you mentioned in the intro, there's a lot of new technology out for PE. But the vast majority of the time, especially for lower and even intermediate risk PEs, the standard of care is largely based on anticoagulation and time. You know, a lot of these people are going to get better with that supportive care. I think the challenge and what makes this field fun is for those higher risk people or for those intermediate risk people that maybe they're not getting better, maybe they're not getting better quick enough, or maybe they're getting worse, there have been a lot of new technologies out over the last 10 or 15 years. And so, that's what makes this space really, really fun to practice in.

Melanie Cole, MS (Host): Thank you for that, and I'd love for you to tell us how UAB Medicine created a pulmonary embolism response team or PERT, as I said in the intro, to provide the best possible care for patients with a PE. How did this come about?

Samuel McElwee, MD: Yeah. So, in 2018, a group of us that had interest in pulmonary emboli. And when I say us, it was, you know, a large group from number of different specialties, not only within medicine, but just, you know, across the hospital, came together and decided that maybe we could do a better job with the care of these people. And part of that was that all these new technologies were coming out and what we saw, at least within our own health system, was differences in access to care. And what I mean by that is you could be in the UAB system underneath the same proverbial roof. But one group, let's say OB-GYN, not to single them out, but let's say they had a postpartum patient with a PE and maybe they didn't know about any of these newer technologies that might have been open for that patient. And so, what we've tried to do through the PERT team or PERT is to standardize all of the things that we have underneath our roof at UAB to open up every potential treatment scenario for these patients that come into our system.

Melanie Cole, MS (Host): Well then, tell us what's involved in evaluating the patients with suspected pulmonary embolism, and how is this PERT team experienced at evaluating patients quickly and making care decisions.

Samuel McElwee, MD: That's a great question. So, what we started with and kind of what we do, especially since this is an academic center, and so you know, every July and August you have an influx of new trainees, is we try and target those with basic education on risk stratification and management of PE. And so, we have through our team kind of come to a consensus of the level of or the types of PE patients that we want to be notified about.

And so, in general, there's three different types of PEs. There's low risk, there's intermediate risk and then there's high risk. And most of the low risks they do well with anticoagulation alone, and we generally do not request that we be seen for those. But for the intermediate risks and certainly for the high risks, those are the ones that we really want to be seen or that we really want to be involved in their care. And when I say high risk, that generally means PE patients that are in shock or that are progressing to shock. Intermediate risks, those are generally PE patients that, you know, they're diagnosed by CT angiography and then they have some form of higher risk feature on their initial workup. And generally, we say if their right ventricle is enlarged on that CT, or if they have elevated biomarkers, meaning troponins or BNPs, that confers a little bit higher risk. And so, those are the types of patients that we would like to be seen.

The way that you can activate the team within the health system is by calling the operator and just asking them to page us. There's somebody on call for the team 24/7, including somebody in-house because of the participation from our cardiology fellowship program. So, between the fellows and then the primary PE attending that's on call for the team, that patient will be evaluated generally within the first hour, obviously even faster if it's a higher risk PE. But we like to have patients evaluated and at least some form of recommendations to the primary team within that first hour.

Melanie Cole, MS (Host): Dr. Samuel McElwee, if risk stratification is determined with imaging, what about EMS? What's their role for alerting you?

Samuel McElwee, MD: So generally, these are not patients that we are called about prior to their hospital arrival. The vast majority of our calls come from the emergency department, probably 80% of them. These are going to be patients that have imaging diagnoses of PE. There are occasions for patients that are already in-house, let's say they're in the trauma service of the neuro ICU service, where, you know, they have a very high risk of developing a PE and they may have a sudden clinical decline with a lot of features that screen PE, but they may have been too sick to make it to a scanner yet. We will see those patients where there is a high suspicion of PE. But Melanie, generally, most of the time these are coming through our emergency department with imaging already in place to, you know, diagnose them with their acute clot.

Melanie Cole, MS (Host): Well, thank you for clarifying that. So, I'd like you to speak about who all is involved in this special team of physicians from several medical specialties.

Samuel McElwee, MD: So, there's been some evolution of our team since we started. But the vast majority of those that are involved have different specialties. So, most of them are coming through the emergency department. So, we have representation from emergency medicine, cardiology, and then subsets of cardiology, largely interventional cardiology and critical care cardiology. We also have representation from pulmonary and critical care medicine. We have a hematologist embedded within the team. And then, we have a very robust ECMO program here, so we have representation that covers both cardiovascular surgery and ECMO.

Melanie Cole, MS (Host): It's a real multidisciplinary approach. Now, how has technology for treating PEs advanced greatly in recent years? Tell us about some of the exciting emerging technology.

Samuel McElwee, MD: Sure. With most things, just in medicine in general, there has been an explosion of really new devices and ways to employ those devices in this space. And so, there's probably two different ones that we are most familiar with using here that are probably the most familiar within the community. And they're based on two different platforms. Both are catheter-based, meaning meaning over the wire technologies, and are done in the cath lab or in the interventional radiology suite at other institutions. But one of the ones that we utilize is the EkoSonic catheter, which is a very small 5-French catheter that is placed really within the clot itself, under realtime x-ray guidance. And what this has allowed us to do is to deliver very low doses of clot-busting medicine, so tPA, at the level of the clot itself. And so, what we have seen with this in patients is improvement in their hemodynamics, improvement in their clinical picture, improvement in the way that they feel. But the nice thing about this is that it allows us to deliver much, much lower doses of tPA, which significantly decreases the bleeding complications associated with that medication. So, large, large decreases in the amount of CNS bleeds as well as just bleeding in general because we are able to deliver such a lower dose really at the level of the clot.

Melanie Cole, MS (Host): What an exciting time, Dr. McElwee, to be in your field. How have been your outcomes from the PERT response team?

Samuel McElwee, MD: What we have seen with time based on the data that we have been able to accumulate over this last five years is if you just look at it from the health system in general, now take this with a grain of salt, we are not seeing every PE that comes into the hospital, just those higher risk ones. But you can imagine that those higher risk ones are going to be the ones that are driving mortality. And so, what we have seen has been a steady decrease in the index mortality for patients that both present with PE and also those that develop PE during their hospital stay. So, we've seen a steady decline in that since 2018, since the team has started.

Melanie Cole, MS (Host): That's really what it's all about. What a great program, Dr. McElwee. I'd like you to wrap it up about what you would like to tell other providers, not only about the pulmonary embolism response team at UAB Medicine, but what you'd like them to know about creating this type of program for themselves and their institutions.

Samuel McElwee, MD: I would say that our experience has been great here. It's a lot of fun. It's especially a lot of fun to work with people from different divisions, different departments that all have an interest in this space, but that you might not have kind of connected with them otherwise. And so, that multidisciplinary aspect has been a lot of fun. It is difficult to get started. And what I mean by that is it's hard to schedule a meeting just in general with, with more than one physician in a different specialty. But it's hard to get everybody in a room, but it's worth it. And if you can get all of the stakeholders in a room just to have a conversation about how you can improve the care of these patients within your system, how you can streamline the care of these, how you can best utilize your institution's resources for the care of these patients, I think you will see significant gains at your institution.

Melanie Cole, MS (Host): Thank you so much, doctor, for joining us today and sharing the program with us and your outcomes. And for more information, please visit our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. Please remember to subscribe, rate, and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole.