This case involves a 39-year-old severely obese man who presented to the hospital with severe right flank pain. Upon admission, the patient had a CT scan which showed a hematoma on the right side. The hospital staff elected to not put him on anti-coagulants for prophylaxis; due to a possible ongoing bleed even though the patient was bed ridden and not improving. One week into his hospital stay, the patient experienced severe shortness of breath and leg swelling. The only treatment he received was Albuterol. The patient was not given compression stockings nor was he considered for more advanced DVT prophylaxis such as an IVC filter. A pulmonologist was not called in for a consult until patient’s condition deteriorated to the point of intubation. The patient was eventually diagnosed with a pulmonary embolism and died shortly thereafter.
Question(s) For Expert Witness
1. What precautions should have been taken with this type of patient?
Expert Witness Response E-000565
A patient with a hematoma would not be a candidate initially for anti-coagulation. Once there was no further evidence of bleeding, and ideally, the cause of the hematoma understood, prophylactic dosages of subcutaneous heparin or low-molecular weight heparin could be administered to prevent deep venous thrombi (DVT) in a bedridden patient at risk for this common disorder. In a patient with increased risk of DVT who has a relative contraindication for anti-coagulation, sequential compression devices (SCD's) could have been used to decrease his risk of DVT and subsequent PE. This device could have been used upon his admission to the hospital. Once he became short of breath and developed leg swelling, pulmonary embolism should have been considered and a diagnostic study performed. PE is a major killer in this country and most deaths occur without an antemortem diagnosis and the opportunity for effective treatment.
