Treating Pulmonary Embolisms
November 24, 2023

Written by John Ferrari | Photographed by Philicia Endelman

When patients arrive at Torrance Memorials emergency department, they have this working in their favor: The staff knows time is critical. Younger patients in serious distress with no obvious trauma or comorbidities often have one of two conditions, says emergency physician Richard Bracken, DO: a vascular catastrophe, such as a heart attack, or a pulmonary embolism (PE). Thats why he rushed to the ambulance bay with a portable ultrasound machine when Aziz Wanis arrived the afternoon of New Years Eve last year.

When he came in to the hospital, he was pale, confused and young,” Dr. Bracken recalls. It was obvious he was very sick. Ultrasound is the fastest way to determine whats going on. You can quickly look at the heart, the lungs and the vascular system.”

Wanis, 43, had woken up that morning feeling fine. Although it was Saturday, he had planned to go to work. So he went downstairs, leaving his wife asleep. Thats when the day took a turn for the worse. He fell, knocking himself unconscious. He hadnt eaten the night before and attributed his fall to low blood sugar levels.

Going up the stairs to go back to bed was like climbing a mountain,” Wanis remembers. He tried to rest, but when his wife, Amira Wanis, checked on him a while later, the sheets were drenched with sweat and he was breathing hard.

Every time I breathed out, I made a loud snoring sound,” he says. When I breathed, I could feel my spirit coming out.” Amira called 911, and Aziz was rushed to Torrance Memorial. By now it was more than five hours since his fall. Whatever was wrong, there was no time to waste.

The ultrasound gave Dr. Bracken a good idea of the problem. The right ventricle was very enlarged,” he says, typical in patients with a massive pulmonary embolism.”

Thats when Wanis, now near death, had something else working in his favor: Torrance Memorials focus on treating PEs—blood clots that stop the flow of blood to an artery in the lungs.

The hospital is working toward its certification as a PE Center of Excellence—the first hospital on the West Coast to do so. As part of that goal, Torrance Memorial is creating a pulmonary embolism response team (PERT)—a group of medical staff across departments trained to quickly and in coordination diagnose, respond to and treat PE cases. Although the PERT is still being developed, Dr. Brackens reflex actions underscore the importance of quick action.

When you have someone that sick, its all kind of simultaneous,” he explains. Im helping nurses get him ready for the CT scanner, ordering blood clot-busting drugs from the pharmacy. During the CAT scan, Im calling the interventional radiologist, asking for a review of the CAT scan images immediately. We try to decrease any delay in care as much as possible. It was on the order of half an hour to 45 minutes from the time Mr. Wanis hit the door to get him to interventional radiology and surgery.”

While Dr. Bracken coordinated with the hospitals departments, ED medical director Gretchen Lent, MD, was in charge of Wanisinitial treatment. His vital signs were OK; thats why we had time to order the blood clot-busting medication, CT scan and everything else,” she says. With a young, healthy man PE is more likely than a heart attack or stroke. As soon as we had our suspicions, we called to bring in an interventionist.”

The interventional radiologist (IR) was George So, MD, who remembers the case well. We want every single PE case to be like that case,” he says. Everyone involved acted like a PERT team. That organization, just training for it, allowed for a very, very quick response. With a PERT, we know exactly who is doing what. Theres coordination between the ED physicians, technologists and nursing staff, and the IR team that includes radiologists, nursing staff, anesthesiologists and the IR physicians.”

The preliminary PE diagnosis was confirmed by a CT pulmonary angiogram study. Thats an advanced scan to detect PE in the lungs,” Dr. So explains. We have AI-driven software that pre-scans the images to detect anomalies like blood clots and alert the radiologist to them. Its another way we save time.”

This is where Wanis had one more factor working in his favor: Torrance Memorial recently started using PE aspiration devices. These are essentially sophisticated catheters used to perform aspiration (suction) thrombectomies; that is, they remove blood clots causing PEs in minimally invasive procedures.

We usually insert the catheter into a vein in the groin, guide it through the heart to the pulmonary arteries, remove the clot and filter the patients blood to be returned to the body,” Dr. So explains. It typically takes about an hour.”

These devices are a game changer in the treatment of PEs, Dr. So says, adding an option in addition to the use of the clot-busting drug tPA (tissue plasminogen activator). tPA takes about two days to work,” says Dr. So. The medication saves lives, but its high risk. There can be serious side effects: bleeding in the brain or stomach. Using the new aspiration devices, the patient can avoid those side effects.”

The devices are also a generation ahead of older mechanical thrombectomy devices. Traditional thrombectomies (blood clot removals) involve the loss of a significant amount of blood along with the clot material. The new devices filter the patients blood so it can be returned to the body.

The end result? Patients dont have to go to the ICU and can be discharged as soon as the next day,” Dr. So says. Its a paradigm shift in how we think about PE, completely changing how we treat this condition.”

Thats important, he shares. PEs are one of the deadliest conditions that can happen—not just to the elderly but very young people too. Theyre usually caused by a blood clot traveling from the leg to an artery supplying blood flow to the lungs, so blood and oxygen cannot get to the lungs. Blood cannot be oxygenated, causing internal suffocation. If patients with PE arent diagnosed quickly and treated accurately, theres a very high mortality rate.”

Unlike tPA treatment for PE, the effects of an aspiration thrombectomy are immediate. The patients oxygen levels go up, his heart rate goes down and he can breathe easier,” Dr. So says. Its gratifying to treat this type of condition. You can see the reversal right away.”

Earning the PERT Consortiums PE Center of Excellence certification will mean Torrance Memorial has achieved high standards in every aspect of PE care. To qualify, they track all parameters of treatment and outcomes at the hospital,” Dr. So says. Its the pinnacle of PERT success.”

For Aziz and Amira Wanis, success is Aziz continuing with his life as before. While he is now on blood-thinning medication to prevent any additional clots, he says he is back to normal life. Im very grateful to the doctors and everyone at the hospital. They took care of everything.” •