Hematology Expert Opines on Missed Deep Vein Thrombosis

    Hematology Expert WitnessThis case involves a middle-aged, obese woman who suffered an injury to her right leg during a fall from the bleachers at her son’s baseball game. Immediately after the accident she was taken to the emergency room, where x-rays indicated a possible injury to her knee. The patient’s knee was immobilized via splint and she was given a referral to an orthopedic surgeon. She was seen by the surgeon, who ordered an MRI that indicated significant injury to the patient’s ACL. Surgery was scheduled for a few days later, however the next day the patient returned to the ER with complaints of a significant burning pain in her leg. Doctors performed a a venous ultrasound of the patient’s leg, which returned normal. A few days later, the patient was taken in for arthroscopic surgery for her knee as scheduled. Following surgery, the patient was unresponsive and a code was called. The patient expired a few hours later. An autopsy found that the patient had suffered from a significant pulmonary embolism, and that there were multiple blood clots in her leg.

    Question(s) For Expert Witness

    • 1. What are the indicators for suspected DVT? Under what circumstances would you perform a D dimer in a patient with this type of presentation?
    • 2. In general, what medical treatment would be given if a DVT is diagnosed prior to surgery?

    Expert Witness Response E-031759

    If the DVT was diagnosed prior to the arthroscopic surgery, the patient could have surgery delayed and been treated therapeutically with anticoagulation until DVT resolved, or an IVC filter placed and proceed with surgery. There was no urgency to the arthroscopic surgery to prevent a delay including to repeat the Doppler US prior to surgery especially if the patient had not had improvement in leg pain and/or was not put on preventive anticoagulant despite the negative initial Doppler ultrasound study. I would not rely on D-dimer at her presentation to the ER on the second occasion, when Doppler US was negative because she already had recent leg trauma which would have elevated the D-dimer, although obtaining the D-dimer may serve as a baseline for later comparison or, if extremely high, would warrant consideration for missed venous thromboembolism. I have had patients referred to me for similar clinical history who were inadequately evaluated / treated for DVT prior to arthroscopic surgery.

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