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Deep Vein Thrombosis Following Orthopedic Surgery

Deep Vein Thrombosis (DVT) is the formation of a blood clot in a deep vein, usually in the legs. These clots, also known as a thrombus, can detach and travel to the lungs, causing severe injury or death (pulmonary embolism).

Virchow’s Triad

Briefly, it is important to understand the process by which clots can form. In the 1850’s, a German doctor, Rudolph Virchow, studied the factors leading to blood clots and developed a triad of factors. “Virchow’s Triad” consists of the 3 likely factors that lead to the development of a deep vein thrombosis. They are:

  1. Local trauma to the vessel wall
  2. Hypercoagulability
  3. Stasis

Simply put, venous stasis can be considered a decreased blow flow rate; hypercoagulability can be an increased tendency to clot and changes to the blood vessel wall from injury can actually change the biochemical pathways which activates the clotting cascade.

When considering orthopedic surgery, especially such procedures as total hip replacement, total knee replacement, lower extremity trauma surgery, and joint repair, among other procedures, it is easy to demonstrate how the principles of “Virchow’s Triad” can come into play.

In the case of a traumatic injury, frequently vessels are damaged or crushed. Most surgical patients will have periods of immobilization. Frequently, tourniquets are used during surgical procedures. Following surgery, patients will refrain from weight-bearing or other movements. Each one of these could lead to the development of a DVT and it’s potentially fatal counterpart, a pulmonary embolism.

The Deep Vein Thrombosis Prophylaxis Debate in Orthopedic Surgery

Much attention is given to the topic of deep vein thrombosis prophylaxis in orthopedic surgery. This means the prevention of DVT, either in preparation for surgery or following surgery. It is universally accepted that some form of anti-coagulation is indicated in procedures such as a total hip replacement and total knee replacement. There is extensive disagreement on the need for chemoprophylaxis or mechanical methods of preventing the formation of DVTs in orthopedic surgical patients.

Routine anticoagulation can be achieved through such agents as Heparin, Coumadin, Fondaparinux, or other chemoprophylatic agents. While certain medical societies have published guidelines regarding the need for prophylaxic antithromobolitics in total knee and hip replacements, there is a great degree of controversy among chest physicians, orthopedic surgeons, and cardiologists regarding the need for mandatory antithrombolitic prophylaxis in other orthopedic surgical procedures. Apparently, the potential risks of these therapies may outweigh the benefits they impart. Oftentimes, the patient will develop medical difficulties such as increased bleeding and other significant side effects from chemoprophylaxis agents. The most severe of these complications can actually include pulmonary embolus or heparin-induced thrombocytopenia, which can be limb or life threatening.

Patients Most at Risk of Developing a DVT

The orthopedic surgeon must evaluate the patient’s risk factors in order to determine whether or not chemoprophylaxis agents should be utilized in their surgical patients. The American College of Chest Physicians published an evidence-based clinical practice guideline regarding DVTs. This paper, entitled “Antithrombotic therapy and prevention of thrombosis”, 9th edition, American College of Chest Physicians Evidence-Based Clinical Practice Guidelines, Chest, 2002, discusses prediction probability methods for DVTs. One widely used criterion to measure DVT probability actually scores risk factors in order to create a probability range. Some of the criteria used to determine risk are whether or not the patient has or had the following:

  • Active cancer
  • Paralysis
  • Paresthesis or recent cast immobilization of lower extremities
  • Major surgery requiring regional or general anesthetic in the past 12 weeks or was recently bedridden for greater than 3 days
  • Recent long-distance travel
  • Localized pain along distribution of deep venous system
  • Swelling of entire leg and/or calf greater than 3 centimeters
  • Pitting edema
  • Collateral superficial veins
  • Previously documented DVT or PE

Most studies seem to correlate the increased incidence of deep vein thrombosis with non weight-bearing status and immobilization after surgery.

There are other methods of treatment and prevention of deep vein thrombosis besides medication. Weight-bearing, physical activity, mechanical devices including pneumatic compression devices, compression garments, and, in rare cases, internal filter placement.

It is essential for the orthopedic surgeon performing lower extremity surgery to consider the risk of DVT. The more that the physician and patient understand this complex problem, the better the exchange of information needed to assess the risks to that particular patient. Failure to consider the possibility of DVT and/or failure to recognize the existence of a DVT post-surgically can lead to disastrous consequences.

About Jeffrey R. Davis, P.A.

Jeffrey R. Davis, P.A. represents victims of medical negligence throughout the state of Florida. The firm has a specific interest in working with cases involving medical mishaps due to the failure to avoid and/or timely recognize the development of deep vein thrombosis and pulmonary embolism. If you or your loved one has experienced this type of medical difficulty or damage following orthopedic surgery, please consider consulting Jeffrey R. Davis, P.A. to fully explore your options.

Knowing Too Much Can Be Bad For Your Health – Patient Knowledge in Medical Malpractice Cases

“You have terminal cancer”

Words that would make any patient develop instant and profound perspective into how important they consider their lives to be. When a patient is faced with a diagnosis such as this, they often go through what is considered the Five Stages of Death – Denial, Anger, Bargaining, Depression, and Acceptance. As a coping mechanism, many patients in the Bargaining stage attempt to look for an answer to their problems. Some turn to religious support while others turn to uncovering everything humanly possible about their disease and “bargaining” ways in which they can defeat it.

For some, it might seem unimaginable that trying to understand and attempting to learn everything about your disease could end up hurting you. Yet, the dark truth is that what you know CAN be used against you. In fact, it’s occurring right now inside Florida courtrooms. Courts have started to hold patients more accountable for their medical care. Some people feel that educated patients have been penalized for their knowledge, with medical malpractice cases arguing that these patients failed to adequately care for themselves throughout the treatment process. The rationale behind this is that technology and the advancement of education has made the public more savvy to medical issues, thus the public bears a share of the responsibility for their treatments. Countless medical malpractice suits have resulted in reduced liability for practitioners and increased expectations for educated patients.

In a medical malpractice suit, patients sue medical practitioners, such as doctors, for any medical malpractice that the doctor committed – malpractice such as failing to take adequate care of the patient or failing to prescribe the patient the necessary medications. However, courts have recently held that since patients are now more knowledge about their condition or diagnosis, they should be charged with more responsibility and less should be placed on the medical professional. Therefore, in a medical malpractice action where a doctor did something wrong in the medical procedure, the patient may not have sufficient remedy if the doctor can prove that the patient did or did not do something he knew he should or should not have done, but something the doctor might have neglected to explain thoroughly.

So is Florida medical malpractice law sufficiently protecting patients now? Has precedent tipped the scales in favor of doctors too much now and neglected unaware patients?

The “Traditional” Relationship of Trust

Traditionally, courts assumed that in doctor-patient relationships, the physician had superior knowledge while the patient had little experience and information in regards to any health issues. As such, patients placed great trust in a physician’s decision-making ability and authority. Because of this, physicians were held to a higher standard of care. The traditional physician-patient relationship was based on the patient’s “blind faith” and the physician’s expert and superior guidance.

The New Relationship in the Age of the Internet

The traditional physician patient relationship was based on faith and trust. Unfortunately, the increasing number of medical malpractice cases coupled with the dawning societal realization that doctors can be wrong has led patients to find, explore, and educate themselves with all of the relevant and expert information available via the internet. Patients have started to arm themselves with knowledge about their illness and the steps they must take to better themselves. With the growth of easily accessible scientific knowledge and higher levels of education among the public, many physicians have difficulty maintaining credible claims of special status and judgment. Patients have removed the blindfolds of trust they placed on themselves for their doctors and have instead started to complement doctor information with information they acquire from medical journals, condition-specific books, and the vast, knowledge-rich world of the Internet.

The Ugly Result of Patient Education

In the past, courts were less likely to hold patients responsible for their own care in a medical malpractice action because practitioners had vastly superior knowledge. Physicians had a difficult burden in demonstrating that a patient was negligent with his own care. Now, with the evolution of the doctor-patient relationships, courts have begun to hold that patients are no longer presumed oblivious and unaware of health care needs. Thus, patient negligence that occurs after physician negligence can, in some cases, be used against the patient.

The Medical Malpractice Action

For a patient to effectively assert a medical malpractice action, the patient must show that the physician had a duty, the physician breached that duty, the physician was the cause of the harm, and that an actual harm occurred. The burden to prove this falls on the patient as the party seeking relief.  The duty must be based on a physician-patient relationship, and sometimes a recognized standard of care in the medical community is used to determine whether the doctor had a duty or not. To prove that the doctor breached the duty, the doctor must have failed to comply with that standard in the care of the patient. Lastly, the cause of the harm must result from a casual connection between the breach of duty and the injury sustained by the patient. To succeed the patient must prove all of these elements.

However, in Miami, Broward, West Palm, and other Florida courts, physicians are more often asserting the affirmative defense of comparative negligence – a defense that allows physicians to show that the patient’s negligence, rather than or in addition to the physician’s negligence, was the cause of the patient’s injury. Traditionally, a defense of comparative negligence in a medical malpractice action was often unsuccessful due to the unique characteristics of the physician-patient relationship – the physician’s superior knowledge, the patient’s inexperience, and the high standard of care demanded of the physician. All that has changed.

Comparative Negligence – Did the Patient Breach His Own Duty of Care?

When a physician is sued for medical malpractice, a physician can assert comparative negligence – a defense that reduces the patient’s recovery in the medical malpractice action. The defense ascribes negligence of the patient as a contributing cause to the damages that are being claimed.

To establish the defense of comparative negligence in a medical malpractice action, a physician must prove each of the following elements of negligence:

  1. The patient owes himself or herself a duty of care
  2. The patient breaches that duty; and
  3. The breach of the duty is proximately connected to the damages the patient sustains.

A doctor would have to prove that the patient was well-informed regarding the severity of their condition and the significance of the treatment of the condition. In addition, to establish that the patient had a duty of care for themselves, there is a requirement that a patient exercise the degree of care expected of a reasonable person under similar circumstances. This standard of care can be modified depending on the pain, disability, medication, the effects a disease has on the patient, and the difference in levels of knowledge between the doctor and patient.

Proximate cause in comparative negligence in a malpractice law suit occurs where the patient’s action was the natural, direct, and continuous sequence between the negligent act of the patient and the injury that it caused. Common instance of where courts have held that comparative negligence occurs is where a patient fails, disobeys, or delays to follow a physician’s advice. The result is that since patients have become more knowledgeable about medical issues, a patient’s refusal or inability to exercise due care to protect his own health needs is more likely found to be the proximate cause of the harm to the patient. Therefore, no longer is it just the doctor who is the target for the negligence in a medical malpractice action – the patient is now partially at risk.

What is the Modern Patient Left To Do?

No one expects patients to stop informing themselves about their diseases, diagnosis, or general health issues, especially when so much information is so readily available. Therefore, as an informed modern patient, it is necessary to understand that a patient’s role in understanding the nature of their care has increased. Consequently, patients have much greater responsibility in the eyes of the courts than in the past.

To have a viable claim for medical malpractice and to make sure that doctors do not transfer responsibility to patients, it is important that patients:

  • Follow the directions and prescription instructions provided by their doctors. Patients must follow doctor directives as best as possible in order to minimize the likelihood of a comparative negligence defense undermining the ability of the patient to seek full damages
  • Ask their doctors additional questions if they feel that the directions or prescriptions are not accurate due to their prior information on a health issue. If a patient is still uneasy, get in writing the reasons why a specific instruction or prescription has been given.

Are the courts fairly holding patients more accountable for their own standard of care? Are patients partially negligent in instances they fail or disobey instructions by a medical practitioner? Tell us what you think in the comments below.