Internal Medicine Expert Witness Evaluates Negligent Coumadin Management

Case Overview

This case involves an elderly female patient in New Jersey who had a medical history significant for atrial fibrillation, for which she was being treated with Coumadin. The patient was receiving Coumadin daily, in 5mg doses, while under the care and supervision of an internal medicine physician. During one of her appointments, the patient’s INR was logged as 3.7, which caused her physician to stop her treatment for 2 days and to modify her dosage. During this change, the patient’s INR was registered at 3.1, and she continued to receive Coumadin at this modified dosage. A few days later, the patient presented to her internist for another visit, however, no INR was performed. Later that day the patient was brought to the emergency room with massive internal bleeding, which eventually proved fatal.

Questions to the Internal Medicine expert and their responses

Do you routinely manage patients on Coumadin?

I prescribe Coumadin approximately 2 times every day of the year and manage Coumadin monitoring in a very tight manner exactly to avoid catastrophic results such as this.

Can you speak to appropriate monitoring of INRs/adjustment of dosage for these patients?

Appropriate INR monitoring requires in office testing with a machine that gives rapid, real-time results and clear concise instructions of what signs or symptoms to look for in regards to possible internal or external hemorrhage. Keeping the INR 2.0 to 3.0 is the goal. Realizing that the initial INR was too high with just a few days of Coumadin administration should have prompted the thought that the patient has a heterozygous status (genetic) for Coumadin oversensitivity, thus her maintenance dose of Coumadin would have been 2 mg daily (possibly 2.5 mg) and she would not have been prescribed 5 mg daily.

Have you ever had a patient develop this outcome?

Having had a dozen patients with that diagnosis in my career, I can speak from experience as to how I have managed each of them. Commonly, the use of anticoagulation after cardiac catheterization has been the situation that led to the bleed (the catheter being traumatic to the artery) however, the status of the patient's vascular system coupled with the dose regimen for the Coumadin are determinants in the likelihood of this outcome. All values were higher than that making the risk increase for both spontaneous intracranial hemorrhage and retroperitoneal hemorrhage. The inexperience of the doctor in managing Coumadin in the elderly is apparent.

About the expert

This highly qualified hospital physician has over two decades of clinical experience. He completed his undergraduate education at the University of Wisconsin and earned his MD degree from the Medical College of Wisconsin. He completed a Residency in Internal Medicine at Loyola University Medical Center. He is a member of the American Medical Association, the American College of Physicians and the American Society of Internal medicine. He has won multiple awards throughout his career including America's Top Doctor for three consecutive years. He is currently a physician in private practice as well as an attending internal medicine physician at three New Jersey hospitals.