FAILURE TO ANTICOAGULATE PATIENT LEADS TO DVT

I have a case where a 24-year-old male with a Leiden Factor V deficiency undergoes knee surgery on (a Fulkerson procedure with tibial tubercle osteotomy same-day procedure). He is not placed on anti-coagulants postoperatively. Ten days later, he develops swelling of his right leg and chest pain and goes to the ER. Doppler studies show he’s got severe DVT in the popliteal and femoral vein. CT scan of the chest shows atelectasis / multiple infarctions in the right lung / PE.

Since then, the DVT issue has continued to be a big problem. He cannot stand or walk for extended periods of time without extreme swelling and pain.

The overall question here is, a patient undergoing this type of procedure with a Factor V Leiden deficiency must be placed on anti-coagulants post op, correct?

EXPERT RESPONSES

I and most orthopedists are unfamiliar with this factor deficiency. The standard of care would likely require a consult with / deference to a hematologist. Dr RC, Orthopedist

Yes definitely correct. Heparin anticoagulation required. Dr JV, Hematologist

Yes it’s a breach in the standard of care for an orthopedist not to heparinize a patient and/or make the decision without a hematology consult. Dr JP, Hematologist

In this case it appears a hematologist’s opinion would be required regarding the standard of care in the perioperative period in patient’s with Leiden Factor V deficiency. Dr JN, Orthopedist

FAILURE OF ER, GP AND CARDIOLOGIST TO TIMELY DIAGNOSE HEART ATTACK LEADS TO DEATH

31 year old man goes to Clinic for Chest pain on Sunday pm and told he has GERD, but should be checked out. Makes appt with his primary care doctor for Thursday. In so much pain, goes to ER on Wednesday evening. Despite blood pressure 213/167, extreme chest pain and shortness of breath, EKG shows sinus tachycardia but nothing else and ER doctor says he called cardiologist on call and he said to discharge the patient. The following day, he presents to primary Dr. who says he was not complaining of anything except “shortness of air” and he provided prescriptions for asthma. The following Monday, he had a massive heart attack and despite being rushed to the hospital for emergent care, did not survive.

Issues:

1. Did primary care doctor fall below standard by not doing more?

2. Was cardiologist negligent is approving discharge?

EXPERT RESPONSES

If blood pressure was truly documented at 213/167 then this would represent a medical emergency requiring hospitalization. Both ER doc and cardiologist could/would be liable. Regarding primary MD visit, it would depend on the documentation. Dr BG, ER

Obviously sounds terrible….possibly negligence by GP as well. -Dr SR, General Practitioner

Acute coronary syndrome and MI were in the differential diagnosis and needed to be ruled out, despite his young age. A blood pressure of 213/167 is hypertensive urgency if asymptomatic; this sounds more like malignant hypertension. We would need to know what information the PCP had access to and what information he sought or elicited. Sure sounds like negligence. -Dr PG, Internist

Sounds like there may be a deviation. Sent home with chest pain and a diastolic of 167?? Hard to believe. With regard to PCPwould need to see chart to figure out what he knew and when he knew it. – Dr JG, Cardiologist

Both GP and cardiologist are negligent.

– Dr JM, Cardiologist

This might be a very tough case to win against the GP…the primary care doctor’s position might be that if the chest pain clinic, ER doctor, cardiologist and with several more symptoms when in the ER all got it wrong, a primary care doctor with only shortness of breath is not below the standard of care. – Dr MM, General Practitioner