In this podcast episode, Dr. Scott Weingart addresses the complexities of treating sick pulmonary embolism (PE) patients, arguing for a more nuanced classification system beyond the traditional stable, submassive, and massive categories. He suggests using five categories to guide treatment decisions better, focusing on critically ill patients. Dr. Weingart emphasizes the importance of risk stratification using vital signs, clot size, and biomarkers such as lactate and troponin levels. For sick submassive patients with low bleeding risk, he recommends a lower dose of fibrinolysis, specifically 25 mg of Alteplase over six hours, as a safe and effective option. He explains that the choice of fibrinolytic dose should be balanced with the severity of PE and the patient's bleeding risk to ensure optimal care.