Anyone who has visited the Disney Pirates of the Caribbean ride has heard the entertaining recital of the phrase “Dead men tell no tales.” Unfortunately, in the real world, dead men can leave behind quite a tale, often in the mode of a malpractice suit.
The following case settles this month and illustrates a problem that I had discussed in an earlier blog (http://www.podiatrytoday.com/blogged/why-a-post-op-fatality-is-a-wake-up...  ). Different case, same problem.
A middle-aged male with no medical history presented to a foot and ankle surgeon with a history of ankle pain and swelling. Other than some obesity, he was not under care for any diagnosed medical problems. His diagnosis was posterior tibial tendon dysfunction stage III/IV and his physician recommended surgery.
The patient underwent a posterior tibial tendon repair with flexor hallucis longus reinforcement and a posterior calcaneal osteotomy. Following surgery, he was immobile in a cast.
Two days after surgery, the patient’s wife contacted the surgeon and informed his office that her husband “felt funny” and “weird.” The office assistant took the phone call but the surgeon did not personally speak to the wife. The assistant did not seek any further details about the patient. The doctor found out about the call and elected not to speak to the patient or his wife. Instead, he directed his assistant to tell the patient’s wife that “if it is a big concern, take him (the patient) to an emergency room. If not, then keep his scheduled appointment.”
The patient died 24 hours later from a massive pulmonary embolism (PE).
Prior to surgery, the foot and ankle surgeon’s office records indicate that the patient's brother had died of a blood clot following knee surgery and that his father may have died of a blood clot. There were no other notes beyond the patient’s wife’s message.
Preoperative evaluation of any patient should include any history of wound healing, bleeding or coagulation disorders. The preoperative evaluation should also include any details for the affirmative. I always include in my notes when applicable, “No history of any wound healing, bleeding or anesthesia related problems. No personal or family history of deep vein thrombosis (DVT) or coagulation disorders.” Assuming there is no such history, this simple documentation demonstrates that you, as a surgeon, at least asked about such problems.
Unfortunately, many coagulation disorders initially manifest following surgery. You cannot be held accountable for previously undiagnosed hypercoagulable states such as factor V Leiden mutation, hyperhomocysteinemia or thrombocytosis. A complete screening is not the standard of care.
However, in this case, the patient stated and the surgeon recorded a history of possible hypercoagulable disease. A brother dies following knee surgery. A father possibly dies of a blood clot. This should suggest the possibility of a hypercoagulable state.
Given the fact that disorders such as protein C or S deficiency, von Willebrand disease and factor V Leiden mutation are genetic in etiology, the surgeon, knowing that he or she is to perform a surgery involving tourniquet hemostasis and post-op immobilization, has to consider the possibility of such problems with such a history.
Foot and ankle surgeons have several options. One option is to refer the patient for appropriate preoperative evaluation to identify the coagulation disorder. Another option for physicians is to work up the patient themselves. Finally, one must consider prophylactic DVT therapy.
The surgeon followed none of these options in this case. The patient died of a pulmonary embolism. Was this death preventable? Did this dead man tell a tale?
The “standard of care” for DVT prophylaxis in foot and ankle surgery remains unclear. Readers likely know that the incidence of DVT/pulmonary embolism following foot and ankle surgery is generally reported as low. However, statistical protection is not absolute protection.
Recommendations range from no prophylaxis to aspirin to early mobilization to compression to coumadin/warfarin to low molecular weight heparins. However, there is no established standard of care for prophylaxis in the average patient absent a history of possible coagulation disorders. That is a fact.
I should at this point like to reiterate a call that I made earlier. The American College of Foot and Ankle Surgeons, the American Society of Podiatric Surgeons or the American Podiatric Medical Association should make it their business to provide guidelines for the perioperative management of patients who may be at risk for DVT.
Absent guidelines from within our own profession, your clinical decision making will be derived through perversions of literature available in the orthopedic literature referable to hip and knee surgery or “expert opinions.”
It is prudent to document when appropriate an examination for evidence of DVT on postoperative visits. I typically note the following: “no pain or swelling in the calf or thigh. Negative Homan‘s sign, negative Pratt‘s sign.”
In this manner, I demonstrate that I have looked for evidence of DVT. Again, when appropriate, I note “no headache, dizziness or visual difficulty. No cough, wheezing or hemoptysis. No chest pain, orthopnea or dyspnea.”
Dead men do tell tales.