Venous thromboembolism (VTE), or formation of blood clots in the veins, is the top cause of death and disability in hospitalized patients. The most common site for VTE development is the deep veins of the legs, called deep vein thrombosis (DVT).
Clots are known to form in the veins in some patients who are lying down and immobilized. Surgical patients are particularly at risk because they can be in the operating room and under general anesthesia for extended periods of time.
Blood clots are normally absorbed by the body, but sometimes break loose and can cause life-threatening complications, such as pulmonary embolism. When a blood clot becomes mobile it can travel and block a blood vessel, cutting off blood supply to a major organ. When a DVT or clot restricts blood flow to the lungs it causes pulmonary embolism, which can quickly cause death.
Preventative measures
The danger of blood clots and DVTs related to surgery is so significant and well-known that the standard of care requires physicians and nurses to take preventative measures.
Serial compression devices (SCDs) wrap around the calves and automatically squeeze and release them over and over to promote blood flow. For high-risk procedures or patients, doctors often also order low molecular weight heparin to prevent clots from forming in the first place.
Blood clot and DVT danger
I have handled several cases where DVTs and blood clots led to tragedy. Two lawsuits immediately come to mind that both involved the death of young mothers.
In a Houston lawsuit that I filed, a gynecologist took a woman to the operating room for a hysterectomy, but did not take adequate measures to prevent blood clot formation. In fact, the OB/GYN surgeon should not have taken her to surgery at all. He overlooked the fact that he had previously prescribed two medications for her that had a drug-drug interaction that the manufacturer warned could cause blood clots. She died on the operating room table from a pulmonary embolism.
I recently negotiated a confidential settlement in a Dallas lawsuit where a plastic surgeon performed three cosmetic procedures on a woman during one lengthy setting in the operating room. Certain plastic and cosmetic surgery have a high risk for blood clot and DVT formation. In addition, the longer the time the patient is in the operating room, the higher the risk. The morning after this patient’s long cosmetic surgery, the surgeon discharged the patient without even seeing her in the hospital. Despite the high risks, he did not order any medication, like low molecular weight heparin, to prevent blood clot formation. The patient died a few days later from a pulmonary embolism.
D-Dimer testing
Quite often the first doctor to have the opportunity to diagnosis a dangerous DVT is an emergency physician or primary care provider. The D-Dimer test is a useful tool that can help them determine if a patient had a DVT or pulmonary embolism.
D-Dimer is a diagnostic test that is frequently used in emergency rooms, hospitals, clinics and doctors’ offices for initial screening of patients who have signs and symptoms consistent with blood clots. The classic symptoms for DVTs include swelling, warmth, or pain in one calf.
If the D-Dimer results come back positive, then the standard of care requires the physician to order diagnostic radiology imaging to rule out a DVT or VTE. There are several different radiology scans that could be ordered, including a CT scan, pulmonary angiography, ventilation-perfusion scintigraphy, or venous ultrasound.
In the decision-making leading to an order for a D-Dimer test, the doctor must assess the patient’s clinical probability for having venous thromboembolism or deep vein thrombosis.
Many doctors use the Well’s score system to divide patients into one of three groups: low clinical probability, intermediate clinical probability, and high clinical probability of DVT. In the low group, less than 5% of patients have DVT. In the intermediate group, 15% of patients have DVT. And in the high group, 70% of patients have DVT.
The Well’s score for DVT is calculated by adding one point for each of the following patient characteristics:
— Cancer
— Paralysis or recent plaster cast
— Bed rest for more than three days or surgery within the previous four weeks
— Pain on palpation (physically touching) of the deep veins of the affected leg
— Swelling of the entire leg
— A difference in diameter of greater than 3 cm for the affected calf
— Pitting edema (swelling) on the affected side
— Dilated superficial veins on the affected side
Two points are deducted from the Well’s score if there are alternative diagnoses that are at least as possible as DVT.
Once the points are tallied, a total Well’s score of 0 is a low probability of DVT; a score of 1-2 is an intermediate probability of DVT; and a score of 3 or higher is a high probability of DVT.
There is a separate Well’s scoring system for pulmonary embolism, based on these patient characteristics:
— Add 1.5 points for a previous pulmonary embolism or DVT
— Add 1.5 points for a heart rate of greater than 100 beats per minute
— Add 1.5 points for a recent surgery or immobilization
— Add 3 points for clinical signs of DVT
— Add 3 points if alternative diagnoses are less likely than pulmonary embolism
— Add 1 point for hemoptysis
— Add 1 point for cancer
Once the points are tallied, a total Well’s score of 4 or less means the patient is unlikely to have a pulmonary embolism, while a score of greater than four means that a pulmonary embolism is likely.
As a Houston, Texas medical malpractice attorney, I find tests like the Well’s scoring systems to be helpful in guiding the attention and diagnostic process of physicians. Sometimes busy healthcare providers skip important steps in working up their patients and, as a result, settle on an incorrect diagnosis when, in fact, their patients have a dangerous condition such as DVTs or pulmonary embolism. This type of medical negligence is malpractice and dangerous to the safety and wellbeing of patients.
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Robert Painter is a medical malpractice attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits against hospitals, physicians, surgeons, anesthesiologists, and other healthcare providers. In 2017, H Texas magazine named him one of Houston’s top lawyers. In May 2018, the Better Business Bureau recognized Painter Law Firm PLLC with its Award of Distinction.
