This case involves a sixty-one-year-old male who entered an emergency room complaining of leg cramps and swelling in his upper thigh. He has been highly active throughout his life, playing basketball and tennis on a weekly basis. His medical history provided information of a heart attack, hence his new active lifestyle. The pain had been reoccurring and the patient indicated he took over the counter ibuprofen to manage the pain. The emergency medicine physician examined the patient’s knee joint and sent him in for an x-ray. The results showed that he was suffering from osteoarthritis and he was given NSAIDs. The patient was sent home and the swelling and pain subsided. Three days later, the patient began to cough up blood. He complained of back and chest pain, and his wife explained that he could not stand. He was rushed to the hospital and was pronounced dead on arrival. An autopsy revealed that the patient had passed from a pulmonary embolism.

The emergency medicine physician failed to identify the deep vein thrombosis, which was the cause of the pulmonary embolism that killed the patient. The patient’s leg cramps and swelling stemmed from a blood clot, although the misdiagnosis of osteoarthritis was sufficient for the emergency medicine physician. An ultrasound or venography should have been ordered which would have diagnosed the DVT. In this case, only an x-ray scan was completed, which did not catch the clot. The patient also had a history of a heart attack, which is a common occurrence for patients who are diagnosed with DVT. The prescription NSAIDs may have helped with the swelling, but the clot would have to be stabilized or removed in order for guaranteed survival. This could have accomplished with Herapin injections, Coumadin pills, and if necessary clot-busting drugs. This blood clot traveled to the patient’s lungs, which caused the pulmonary embolism. The pulmonary embolism had similar symptoms to a heart attack, but at the point when the patient reached the hospital, it would have been untreatable. Had the DVT been diagnosed earlier, the patient most likely would have survived.

1. Did the emergency medicine physician follow the proper standard of care for a sixty-one-year-old patient with a history of a heart attack?

Southwest

Oklahoma

Misdiagnosis of Deep Vein Thrombosis by Emergency Medicine Physician

A hematology expert witness opines on a case involving a twenty-nine-year-old female patient with a past medical history of atopy, including eczema, hay fever and asthma. Her primary care physician prescribed Cymbalta when she began experiencing ADD and anxiety symptoms. The physician did not order any blood tests to monitor serum levels until the patient presented complaining of fatigue and non-specific aches and pains. At this point she had been on the medication for almost a year. Labs showed elevated liver enzymes and elevated total bilirubin. She returned to the treating physician with the complaints of jaundice. She ceased taking Cymbalta. Blood test results revealed her total bilirubin had risen to 4.4. Abdominal sonogram revealed some mild splenomegaly. The PCP referred the patient to a gastroenterologist. Under the care of the gastroenterologist the bilirubin continued to rise, now at 5.2. She presented to the ER soon after complaining of feeling feverish, itchy and more jaundice. Tests for leptospirosis were negative and the patient was released.

The treating gastroenterologist ordered a liver biopsy. She was admitted to hospital for the procedure and Lovenox was administered despite the plan to biopsy. The gastroenterologist who performed the ultrasound-guided biopsy as planned. The patient began complaining of severe abdominal pain shortly after the procedure. A CT scan revealed a subscapular hematoma. An embolization of the right hepatic artery was performed the following day. The patient suffered multiple complications including vascular damage and intubation. The liver biopsy report showed increased iron stores within the hepatocellular cells. The medical records all indicated that the Cymbalta caused the hepatoxicity. There was also a query as to whether the patient had hemochromotosis. She was treated with routine phlebotomy. It was felt it was due to drug induced hepatitis versus hereditary hemochromatosis. The patient was seen by a hepatologist who concluded that the diagnosis was drug induced hepatitis.

Lovenox is a low molecular weight heparin used to prevent deep vein thrombosis (DVT) or pulmonary embolism (PE). It is frequently used as an anticoagulant prior to surgical procedures to prevent thrombotic events due to prolonged episodes of hemostasis. However, when a patient is undergoing a procedure with a high risk of hemorrhage such as a biopsy of an internal organ, as is the case here, anticoagulants and antiplatelet medications use is contraindicated most of the time. The treating hepatologist must also ensure that the patient’s INR and platelet count are within the normal limits at least a month prior to the procedure. Further testing may be indicated closer to the time of the procedure. Any possible benefit from the standpoint of DVT and PE prophylaxis is outweighed by the risk of bleeding complications post-biopsy. In this case compression stockings would have been adequate prophylaxis against deep vein thrombosis which could have resulted as a subsequence of the procedure.

Should Lovenox have been administered prior to the liver biopsy?

Hematology expert witness opines on anticoagulant therapy prior to a liver biopsy

This case involves a woman who was injured when another passenger’s bag fell on his leg during a flight. The woman had a past medical history of DVT and was being treated with anticoagulants at the time of the incident. The bag caused some significant bruising but no fractures. Since the incident, the patient claimed that her existing DVT had been exacerbated, and that the airline should have taken steps to ensure that baggage did not fall on passengers.

If the patient is adequately anticoagulated, she should not develop new deep vein thrombosis. Deep vein thrombosis does occur after minor leg injury. (van Stralen et al. Minor injuries as a risk factor for venous thrombosis, Archives of internal Medicine 2008) If she is anti- coagulated, bleeding could have resulted; the bleeding usually results in a bruise which eventually resolves. Bleeding in a muscle can result in compartment syndrome, which can cause require surgical intervention and result in permanent damage. Just having deep vein thrombosis can damage the leg vein which can result in chronic leg swelling ("postphlebitic syndrome"). This occurs in about 1/3 the cases of venous thrombosis and might explain the patient's new symptoms and would be independent of the new trauma.

1. Do you routinely treat patients with DVT? 2. What impact may mild trauma to the calf have on the patient's DVT?

Airplane Passenger With Pre-Existing Condition is Injured by Falling Luggage

This case involves a patient who had a medical history of clotting issues who developed a hematoma on her upper right thigh. She presented to the hospital and was admitted with an elevated INR as well as swelling in the affected leg. The patient’s anticoagulation was stopped and vitamin K was given in order to stabilize her INR levels. While her INR was brought back into acceptable ranges, as well as the presence of other reassuring test results, anticoagulation was not resumed. However, doctors did choose to implant an IVC filter. A few weeks later the patient was killed by a massive pulmonary embolism.

In a patient with a history of venous thrombosis, Coumadin should be resumed as soon as the bleeding has stopped. Filters are placed to prevent pulmonary embolism, but do not prevent deep vein thrombosis. In this case the filter may have been tilted allowing a clot from the leg veins to go past the filter into the lungs, the filter may have been in a renal vein, or a clot could have been trapped in the filter and continued to grow on the upstream side of the filter and then broke off, going to the lungs. It is well recognized in the literature that pulmonary embolisms do occur after filter placement. The PREPIC study is the longest duration study showing this. The hospital records will display the size of the filter (it is most likely 30mm). It is not critical to measure the vena cava, since after deployment, the struts expand until they poke into the vena cava wall. Measuring the vena cava takes back seat to making sure the filter is in the vena cava and is properly oriented. Filters have been used to prevent pulmonary embolism for a limited time in patients who cannot be anticoagulated. Prolonged substitution for anticoagulation is not one of the indications for filters. Risks of filters include deep vein thrombosis, clogged filter, migrated filter, and fractures of the filter.

1. How is it determined if Coumadin should be re-started? 2. In a patient with this presentation, under what circumstances should the inferior vena cava be measured? 3. Can an IVC filter ever be used in place of anti-coagulation?

Hematology Expert Opines on Pulmonary Embolism Linked to IVC Filter

This case involves a 60-year-old male that was prescribed testosterone for 6 months. He was found to have a pulmonary embolism and deep vein thrombosis at the end of the 6 months. Testing was done which showed he had developed Factor V Leiden blood-clotting disorder. An expert familiar with Factor V Leiden was sought to discuss the correlation between coagulopathy and the use of testosterone.

I am a board-certified hematologist and professor of medicine and hematology at a large university medical center in the midwest. I have been practicing medicine for 40 years. As part of my practice, I see men taking testosterone who have developed venous thrombosis and/or elevated hematocrit. Risk factors for clot formation in males include major surgery, cancer, and inherited coagulation abnormalities such as factor V Leiden mutation. It is increasingly apparent that both obesity and sedentary behavior are also risk factors. Polycythemia, increase red blood cell, is also a risk factor to especially in the gene mutation which causes polycythemia vera. The recent study by Martinez 2016 shows the risk of venous thrombosis with testosterone use peaks in the first 6 months and drifts down after that. The Martinez article finds the risk increased with other risk factors were present, but as far as I can tell they did not determine factor V Leiden status. Testosterone can raise the hematocrit (a source of referrals for hematologist), but it appears testosterone-associated clots can occur in the presence of a normal hematocrit. I have lectured on factor V Leiden and the etiology of venous thrombosis.

1. What are risk factors for clot formation in males? 2. What are side-effects that have been observed with testosterone use in males?

Patient Develops Blood Clotting Disorder From Testosterone Use

This case involves a 62-year-old female patient who was admitted to the hospital and diagnosed with Guillan-Barre Syndrome. Because the patient was assessed at a high risk of developing deep vein thrombosis (DVT) and pulmonary embolus (PE), the patient was given heparin to prevent blood clots while she was inpatient. However, the patient was not prescribed any anticoagulation or blood thinners upon discharge. The patient complained of discomfort in her legs and made slow gains with physical therapy. Several weeks after her discharge, the patient returned to the emergency room with dropping oxygen saturation, labored breathing, and abnormal clinical signs. She was diagnosed with a massive saddle embolus via MRI and was transferred to a university hospital facility. Upon arrival, the patient became hypotensive and developed oxygen deficiency in her blood. She eventually went into cardiac arrest. Despite the emergency department’s resuscitative efforts (including CPR and intubation) the patient unfortunately died. An expert in hematology was sought to comment on the standard of care in regards to the anticoagulation protocol for patients at risk of developing DVT.

My expertise is in laboratory diagnosis to manage clinical bleeding and thrombosis disorders. I have recommended the management of DVT and PE for 30+ years by studying the blood markers of hypercoagulability. Based on the hypercoagulability plasma levels, I advise the use of anticoagulation and the anticoagulant best suited for the patient and the disorder. I have reviewed more than 50 cases yearly from the US and other countries in the world. Guillan-Barre is a condition that causes temporary loss of motor function in upper and lower limbs (varying degrees of paralysis). Guillan-Barre is caused by infectious agents and the lung function is often impaired. In one of my articles, I report that the incidence and prevalence of DVT and PE with spinal cord injury is very high even with anticoagulation. However, risk and prevalence are determined by the degree of paralysis. When the paralysis results in flaccid muscle tone, DVT is provoked from the subsequent loss of venous tone in leg veins. The degree of motor function loss is not clear in the case report, especially the condition at discharge. There is little information on the state of paralysis and the recovery from the initial paralysis. I do not consider the treating physician to have been negligent because of the individual's age. If the patient had been much older, the risk for thrombosis would have been much higher and anticoagulation or mechanical prevention of thrombosis would have been necessary. The critical indication for anticoagulation in a 62-year-old patient diagnosed with Guillan-Barre is flaccid lower limb paralysis.

1. How often have you anticoagulated and managed DVT and/or PE? 2. What kind of anticoagulant would have prevented the development of a pulmonary embolus in a patient with Guillan-Barre Syndrome and under what circumstances is it warranted to discharge such a patient with anticoagulation?

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DVT Expert Witness Case Studies

Misdiagnosis of Deep Vein Thrombosis by Emergency Medicine Physician

Hematology expert witness opines on anticoagulant therapy prior to a liver biopsy

Airplane Passenger With Pre-Existing Condition is Injured by Falling Luggage

Hematology Expert Opines on Pulmonary Embolism Linked to IVC Filter

Patient Develops Blood Clotting Disorder From Testosterone Use

Hematologist Neglects To Prescribe Blood Thinners For DVT-Risk Patient

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