This case involves the postoperative care of a woman who underwent a right total knee arthroplasty. The medical note indicates that the patient experienced left lower leg chronic swelling from radiation treatment several years back and also mentioned that she had a history of deep vein thrombosis for the past 20 years which was treated using Xarelto. Four days after surgery, the patient experienced a severe episode of respiratory distress and decompensated rapidly from that point onward until her imminent death. The medical record shows that the patient was not given anticoagulation during her hospital stay and was also not monitored well as a high-risk patient for possible DVT formation. An autopsy was not performed, but the cause of death is listed as cardiogenic shock, bilateral pulmonary emboli, and lower extremity DVT.

There seems to be a significant departure from recommended standards of care with regard to risk assessment and appropriate DVT/PE prophylaxis in a high risk situation. At a bare minimum this patient's significant history of DVTs in the past warrants a close monitoring of her status and the doctors on her case should be on high alert for impending clots.

1. What is an adequate anticoagulation protocol for a post-operative patient who has a significant past medical history of DVTs?

Location: New York B.S., Chemistry, State University of New York at Buffalo M.D., New York Medical College Residency, Surgery, Metropolitan Hospital Fellowship, Sports Medicine, Hospital for Special Surgery Board Certification: Orthopedic Surgery Active Medical License: New York Fellow, American Medical Association Member, New York State Society of Orthopedic Surgeons Former C**** o* O********** a* m**** N** h******* c***** Current O********* C********* m**** s***** r************* i******** Current O********* C********* M******* M****** G**** a* t** t** m****** u********* Current A****** A******** P******** G******* S***** o* E******** D********* o* P******* T****** a* t** t** m****** u********* Current A******** A******** O********* S****** a* m**** N** m****** c*****

This expert is board certified in Surgery and has additional fellowship training in Sports Medicine. He was trained at New York College of Medicine at the Hospital for Special Surgery, and is currently in active practice at a major medical center in New York City where he performs arthroscopic procedures on a daily basis. Finally, he is the chief consulting orthopedic physician for a major sports rehabilitation center in the northeast.

Woman Dies From Pulmonary Embolism After Knee Arthroplasty

This case involves a female patient who underwent a total knee replacement. After surgery, the patient was not given Coumadin, and instead received aspirin in order to prevent excess clotting. While in the hospital, she developed tachycardia and shortness of breath. Despite these symptoms, which eventually subsided, the patient was discharged from the hospital. After her symptoms returned shortly after discharge, she was admitted to another hospital where he was diagnosed with a pulmonary embolus. She was treated with Xarelto and had to remain hospitalized for an extended period of time, thereby hindering her ability to recover from his original surgery. Later on, the patient consulted with several specialists who recommended a revision of the knee replacement.

I perform total knee replacements on a weekly basis. I have published and lectured extensively on this subject. After this kind of surgery a patient should always receive deep vein thrombosis prophylaxis. The fact that the patient was given aspirin instead of something else can be due to a number of surgical or patient related factors, however her symptoms before discharge should have been cause for concern. The complication of pulmonary embolus and the patient's subsequent prolonged hospitalization could have impeded the rehabilitation and recovery process. An incomplete rehabilitation and recovery process can require a patient to undergo additional surgical interventions for their knee, as appears to have happened in this case.

1. Do you routinely perform total knee replacement surgeries? 2. After this kind of surgery, does a patient receive deep vein thrombosis prophylaxis? Is aspirin considered an appropriate medication for deep vein thrombosis prophylaxis? 3.Can the complication of pulmonary embolus and the patient's subsequent prolonged hospitalization have impeded the rehabilitation and recovery process?

Location, PA BS, Harvard MD, Harvard Internship, General Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA Residency, Pediatric Orthopaedic Surgery, Children-Ÿs Hospital of Philadelphia, Philadelphia, PA Residency, Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA Fellowship, Health Policy, American Association of Hip and Knee Surgeons Fellowship, Adult Lower Extremity Reconstruction, Mayo Clinic, Rochester, MN Fellowship, Orthopedic Trauma at the Association for the Study of Internal Fixation Board Eligible, American Board of Orthopaedic Surgery Member, American Orthopaedic Association Member, American College of Surgeons Member, American Association of Hip and Knee Surgeons Member, Association of Bone and Joint Surgeons Member, American Academy of Orthopaedic Surgeons Editor,

Pulmonary Embolism Prevents Recovery From Joint Repacement Surgery

The elderly patient sustained a knee injury, as well as a fracture of her left arm. The woman’s treating orthopedic surgeon instructed her to avoid work and any strenuous activity; as a result, the woman became sedentary at home. While she was in otherwise good health, the woman had been taking medication to control her blood pressure and cholesterol. Two weeks later, the woman called an ambulance after collapsing at home and was taken to the hospital, where she was diagnosed with a pulmonary embolism as well as atrial fibrillation. She was treated using Xarelto but the course of the patient’s recovery has since proven to be complicated, with multiple hospital stays. It was alleged that the patient’s change to a sedentary lifestyle following the accident was a direct cause of her deteriorating health.

In my clinical practice I have treated patients with deep vein thrombosis and atrial fibrillation. There are studies that show that immobilization after trauma increases the chance of venous clotting and pulmonary embolism. In a large study, 45% of patients with venous thromboembolism had more than 48 hours of immobility in the preceding month. Minor injuries may increase the rate for developing venous clotting and subsequent embolism. Another study revealed that 11.7 of nearly 2500 patients had a minor injury in the three months preceding the venous thrombosis compared to 4.4% of controls. It may have been the case that this patient's shift to a more sedentary lifestyle contributed to her eventual illness.

Do you have experience treating patients who have sustained similar injuries due to accidents of this nature? How common is it for patients to develop these sequelae after an accident?

Location: NJ BA, Rutgers University MD, Rutgers Medical School, University of Pennsylvania School of Medicine Residency, Hospital of the University of Pennsylvania Fellowship, Hospital of the University of Pennsylvania Boards: Internal Medicine, Cardiovascular Medicine, Interventional Cardiology Member, Alpha Omega Alpha (honor Former A******** P******** o* C******* M******* U**** Former C******* A******** P******** o* M******* U********* o* P*********** S***** o* M******* Former D******* C****** C************** L********* S** J******** H******* Former D******* C******* C*** U*** C***** H******** U********* M****** C***** C***** Former C********** C********** A******** C***** H****************** M****** C***** C***** Former C********* C*********** I************* C********* P*** P*********** M****** C***** Former C********* C*********** I************* C********* A******* C*** M****** C***** Former C********* C*********** I************* C********* S**** M******* H******* Former C********* C*********** I************* C********* C*** R******* M****** C***** Former C********* C*********** I************* C********* N******* H******* Former C********* C*********** I************* C********* M**** F********* H******* Former C********* S**** C*********** I************* C********* V***** M****** C***** Current

This case involves an elderly female patient in otherwise good health who was still working, driving, and living independently when she suffered a trip and fall accident in the parking lot of a major big box retailer.

Cardiology Experts Discuss Pulmonary Embolism Following Trip and Fall Accident

This case involves an otherwise healthy patient that presented to his primary care physician with extreme shortness of breath in Utah. He was admitted and was discharged almost immediately with a prescription for Xarelto. Several days later, the patient suffered a stroke while at work. He presented to the emergency room within an hour of the onset of his symptoms. However, he was not given tPA or an IVC Catheter due to the fact that he was on blood thinners. The patient was then transferred to a larger hospital for surgical intervention; however, by the time he arrive the clot had grown too large to operate on. The patient died several days later while in the hospital.

It is possible for the delay for care by the neurosurgeon to have caused the clot to increase in size and thus render it inoperable. The images would determine if that may have caused it. If a patient has a cerebral blood clot, the required response time for intervention is critical. Time is brain; thus, the sooner the better. Currently, the AHA recommends a door-to-puncture of the groin of less than 90 min after hospital arrival. If everything goes right, the recanalization of the vessel should be completed within 120 min of arrival. I participate on Quality Improvement Committees at different institutions. As such, I review cases like this on a frequent basis, and have lectured on this topic before.

1. Could the delay for care by the neurosurgeon have caused the clot to increase in size and thus render it inoperable? 2. What is the required response time for attending to a patient that has a cerebral blood clot for intervention?

Location: Midwest BS, MS University of Buenos Aires, Argentina MD, University of Buenos Aires, Argentina Internship, Internal Medicine, Stroke Hospital of Cook County Residency, Neurology, University of Chicago Fellowship, vascular neurology, University of Illinois at Chicago Board Certified, neurology, vascular neurology Fellow, American Heart Association Member, American Academy of Neurology Publications, 24+ Peer-reviewed articles, 16 Book chapters, 40+ lectures/ presentations Current S***** I******** D******* a* a m**** u********* m****** c***** i* t** m******* Current S****** H*** V******* N******** a* a m**** u********* m****** c***** i* t** m*******

West Coast

Utah

This extremely qualified expert completed his residency in Neurology at the prestigious University of Chicago. He then went on to finish a Vascular Neurology fellowship at the University of Illinois in Chicago. He has published over 24 peer-reviewed articles and book chapters in his field. He is currently the Stroke Medical Director at a major university hospital in the Midwest. The expert leads a comprehensive stroke center that serves as a leading referral tertiary care center for stroke in one of the largest cities in the midwest.

Stroke Patient’s Clot Allegedly Grows to Inoperable Size Due to Delay in Treatment

This medical malpractice case involves a male patient who suffered from heart disease, was placed on the blood-thinner Xarelto, and faced rapidly declining health. Five days after a cardiac catheterization, the patient developed a groin hematoma with multiple cavities; an ultrasound showed pulsatile arterial blood flow in the largest hematoma chamber. After the patient was transferred to a different facility, it was concluded that he had frank bleeding from his groin which was unable to clot. The bleeding showed signs of bacterial infection, and though the hematoma was operated on his rapidly declining health caused him to pass away shortly after the procedure. An expert in prescription blood thinners was sought to comment on the use of Xarelto in the case.

I do routinely prescribe blood thinners. The tests that must be ordered to confirm suitability are routine coagulation panels. I have lectured and published extensively on cardiovascular disease in general. I have not prescribed Xarelto to a patient who consequently developed an adverse reaction to the drug, but a patient can certainly develop an adverse reaction if great care is not taken.

1. Do you routinely prescribe blood thinners? If so, what testing must be ordered to confirm suitability for a given patient? 2. Have you ever prescribed Xarelto to a patient who consequently developed an adverse reaction to the drug?

Cardiologist Sued for Xarelto Prescription

This case involves an elderly woman, with a medical history of hypertension, who underwent a cardiac catheterization for a heart attack that showed multiple significantly blocked arteries. She was placed on Xarelto following the cardiac catheterization and was discharged. The patient returned 3 days later with lower leg hematoma. An ultrasound revealed arterial blood flow in the largest hematoma. However, no interventions was taken at that time. She was taken to the operating room for excision of her infected hematoma. The patient continued to decline over the next couple of months and died.

I do routinely prescribe blood thinners. The tests that must be ordered to confirm suitability are routine coagulation panels. I have lectured and published extensively on cardiovascular disease in general. I have not prescribed Xarelto to a patient who consequently developed an adverse reaction to the drug, but a patient can develop an adverse reaction if great care is not taken.

1. Do you routinely prescribe blood thinners? 2. If so, what testing must be ordered to confirm suitability for a given patient? 3. Have you previously published or lectured on this subject? 4. Have you ever prescribed Xarelto to a patient who consequently developed an adverse reaction to the drug?

Location: NY BA, Vanderbilt University MD, Emory University School of Medicine Residency, Internal Medicine, Emory University Affiliated Hospitals Fellowship, Cardiovascular Biology Laboratory, Harvard University Fellowship, Cardiology, The University of Texas Medical Branch at Galveston Board Certified: Cardiovascular Disease Member, American College of Physicians Member, American College of Cardiology Member, American Heart Association Member, Association of University Cardiologists Former S**** P******** T** U********* o* T**** M****** B***** i* G******** Former A******** P******** C********* U********* o* N**** C******* a* C***** H*** Former C**** C********* U********* o* N**** C******* a* C***** H*** Former P***************** U** C***** f** H**** a** V******* C*** Former A******** P******** N** Y*** P*********** H******* Former C**** O******** O****** N** Y*** P*********** H******* Current C********* a* A* m****** u********* Current P******** C********* a* A* m****** u*********

This highly qualified and board-certified expert received his MD from Emory University School of Medicine. He went on to complete a residency in internal medicine at Emory University, a research fellowship in cardiovascular biology at Harvard University, and a fellowship in cardiology at the University of Texas at Galveston. Elected as a fellow of both the American College of Physicians and the American College of Cardiology, the expert has written hundreds of articles on the topic of cardiac diagnosis and treatment. Previously, this expert served as the chief of cardiology, physician-in-chief, and professor at the University of North Carolina, Chapel Hill. He also previously served as a cardiologist and chief operating officer at New York Presbyterian Hospital. Currently, this expert is a professor of cardiology and chancellor at a medical university in Arkansas.

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Xarelto Expert Witness Case Studies

Woman Dies From Pulmonary Embolism After Knee Arthroplasty

Pulmonary Embolism Prevents Recovery From Joint Repacement Surgery

Cardiology Experts Discuss Pulmonary Embolism Following Trip and Fall Accident

Stroke Patient’s Clot Allegedly Grows to Inoperable Size Due to Delay in Treatment

Cardiologist Sued for Xarelto Prescription

Elderly Woman Dies From Hematoma After Using Xarelto

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