Med Mal: Kidney biopsy --> Hemorrhagic Shock --> Pressors --> 9 fingers amputated

[bbc586]

Case here: Hemorrhagic Shock from Biopsy

Lady with antiphospholipid syndrome (also history of PE and DVT) comes to ED with SOB.

No PE/DVT, admitted.

Presumptive diagnosis of lupus nephritis made, biopsy recommended.

Warfarin held, switched to heparin before procedure, then Lovenox afterward (plan to monitor with anti Xa levels).

Anti Xa levels never come back.

Patient develops hemorrhagic shock, started on pressors, fingers ischemic. 9 digits amputated (right thumb lives to fight another day).

How commonly are ya'll using q6hr anti-Xa levels?

Some research on permissive hypotension in GI bleeds, suspect it would have been better here rather than using pressors for hemorrhagic shock and causing this mess.

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[whoknows2012]

Case here: Hemorrhagic Shock from Biopsy

Lady with antiphospholipid syndrome (also history of PE and DVT) comes to ED with SOB.

No PE/DVT, admitted.

Presumptive diagnosis of lupus nephritis made, biopsy recommended.

Warfarin held, switched to heparin before procedure, then Lovenox afterward (plan to monitor with anti Xa levels).

Anti Xa levels never come back.

Patient develops hemorrhagic shock, started on pressors, fingers ischemic. 9 digits amputated (right thumb lives to fight another day).

How commonly are ya'll using q6hr anti-Xa levels?

Some research on permissive hypotension in GI bleeds, suspect it would have been better here rather than using pressors for hemorrhagic shock and causing this mess.

As a hematologist my routine management of patients on lovenox is not necessarily to be monitoring anti-xa levels q6. Might I have checked once or twice in the above example to confirm therapeutic levels (concern being for underdose not overdose unless crcl was sufficiently low)….yes I probably would’ve. Definitely not frequent monitoring unless indicated by failure to achieve therapeutic levels

 

[Crayola227]

As a hematologist my routine management of patients on lovenox is not necessarily to be monitoring anti-xa levels q6. Might I have checked once or twice in the above example to confirm therapeutic levels (concern being for underdose not overdose unless crcl was sufficiently low)….yes I probably would’ve. Definitely not frequent monitoring unless indicated by failure to achieve therapeutic levels

You would have checked at least once is the point. The other point is that it took 3 days for her results to get back. Clearly wasn't fast enough.

Ordering tests themselves incurs liability. Because it is difficult to argue to a court you did NOT need the results of the tests you ordered to manage the patient. Even if that were true, as a defense it tends not to be very convincing.

It's essential that when you order a test, you review it in a timely fashion.

If there is a delay that is not appropriate for the test ordered, then the expectation is that you document trying to do something about it. Otherwise it looks bad for you and it becomes impossible to shift the liability for the hold up elsewhere.

Before we discuss permissive hypotension (which from what I can tell, makes zero sense in this case), the MedMalReviewer points out that she never got a transfusion apparently.

The thing about so many med mal cases, is that it becomes less about, would this have happened even if you hadn't made these mistakes, and becomes a lot about whatever things arguably could/should have been done even without knowing more (how things would have turned out).

 

[chessknt]

It is nuts to see cases like this settle for 11 figures. Was there an issue with not checking an anti-xa? Maybe I guess but she still had a dangerous condition that needed anticoagulation and one of the risks of anticoagulation is bleeding. You bet your ass if they hadn't anticoagulated her or only started her AC off low and had a PE or arterial embolus there would have been a lawsuit there as well.

I start people on therapeutic lovenox all the time and dont check anti-xa levels for several days because it isn't accurate to check it immediately and usually only in really fat people where I am worried about under-dosing on accident. She had underlying medical conditions that basically made any form of critical illness high risk--that isn't malpractice that is just bad luck. Blaming the vasopressors that were needed to save her life for the loss of her fingers is accurate but also moot--she was dying so what was the alternative according to the hematologist? Would the settlement have been a lot less if she hadnt lost the fingers (again due to her underlying medical disease, not mismanagement)--I am going to guess yes.

 

[bronx43]

Why are they even sending out Anti Xa levels if they're taking 3 days to come back? Did the hematologist not know this?

 

[chessknt]

I guess one detail missing from the case is if the lupus nephritis resulted in a significant AKI where the providers (and pharmacists) should have known better than to use lovenox. If that was the case then I understand the lawsuit though the finger loss that was undoubtedly the primary fixation is again more related to underlying disease than the malpractice component. That apparently would have happened if they got a bad UTI and needed pressors.

 

[Radetzky]

Why would you start lovenox the evening after a biopsy? Even with a condition like APS the chances of clotting that evening is far outweighed by the risk of bleeding.

 

[Crayola227]

It is nuts to see cases like this settle for 11 figures. Was there an issue with not checking an anti-xa? Maybe I guess but she still had a dangerous condition that needed anticoagulation and one of the risks of anticoagulation is bleeding. You bet your ass if they hadn't anticoagulated her or only started her AC off low and had a PE or arterial embolus there would have been a lawsuit there as well.

I start people on therapeutic lovenox all the time and dont check anti-xa levels for several days because it isn't accurate to check it immediately and usually only in really fat people where I am worried about under-dosing on accident. She had underlying medical conditions that basically made any form of critical illness high risk--that isn't malpractice that is just bad luck. Blaming the vasopressors that were needed to save her life for the loss of her fingers is accurate but also moot--she was dying so what was the alternative according to the hematologist? Would the settlement have been a lot less if she hadnt lost the fingers (again due to her underlying medical disease, not mismanagement)--I am going to guess yes.

Yes but, what do you make of her not getting a transfusion in this scenario?

Whether she bled or got a clot - the issue in either case is were any mistakes made. It's hard to convince a court none were made when the results of the ordered tests got back so late. If the tests weren't needed, why were they ordered? You realize a jury isn't likely to trust your competence with what you did do if your main defense is that you ordered tests you really didn't need? Sounds like an after the fact sort of defense. You've already made the best argument against yourself by ordering the damn test to begin with. People are not going to second guess that you needed the test you yourself ordered that others expert witnesses agreed with the need to order.

And actually, this isn't a lot of money for the injury suffered. It's really peanuts. They got off easy.

 

[Chemist0157]

I wonder what they saw on testing that prompted them to do a kidney biopsy. Presumably mix of elevated creatinine, hematuria, proteinuria. There should have been a lot of hand wringing about sending her for biopsy.

I’m not familiar with following levels after Lovenox. Either okay to give based on GFR or not. They could not just have her continue heparin then back to warfarin? Maybe they thought Lovenox would be therapeutic more quickly? That raises bleeding risk too. Just seems like an odd approach if you had to rely on levels you don’t have readily available.

I’m not that impressed by the transfusion/pressor thought. You can do both depending on the situation. They could just as easily say digit loss was from the underlying ischemia/shock than therapy IMO.

 

[Crayola227]

I wonder what they saw on testing that prompted them to do a kidney biopsy. Presumably mix of elevated creatinine, hematuria, proteinuria. There should have been a lot of hand wringing about sending her for biopsy.

I’m not familiar with following levels after Lovenox. Either okay to give based on GFR or not. They could not just have her continue heparin then back to warfarin? Maybe they thought Lovenox would be therapeutic more quickly? That raises bleeding risk too. Just seems like an odd approach if you had to rely on levels you don’t have readily available.

I’m not that impressed by the transfusion/pressor thought. You can do both depending on the situation. They could just as easily say digit loss was from the underlying ischemia/shock than therapy IMO.

The medmalreviewer said standard of care for hemorrhagic shock is transfusion. There was probably less risk of Raynaud's from a blood bag than from pressors? I don't claim to be any expert on these issues.

But if there is a good case to be made for giving a transfusion and they didn't and instead relied on pressors, one could see why the case went the way it did.

 

[Chemist0157]

The medmalreviewer said standard of care for hemorrhagic shock is transfusion. There was probably less risk of Raynaud's from a blood bag than from pressors? I don't claim to be any expert on these issues.

But if there is a good case to be made for giving a transfusion and they didn't and instead relied on pressors, one could see why the case went the way it did.

The text says she was given blood transfusions.

 

[Crayola227]

The text says she was given blood transfusions.

Oh, OK, I see the point being made is this:

"MedMalReviewer Analysis:

The lawyers and expert witnesses missed a big opportunity for criticism here. The treatment for hemorrhagic shock is transfusion. Vasopressors are often used in practice, but in theory have no role in the treatment of hemorrhage. They could have easily named the intensivists in this lawsuit.

What is fair compensation for losing all of your digits except a thumb? The physicians should definitely settle this case within the limits of their liability insurance. This case will be easy for the laypeople of a jury to understand and I expect them to be very sympathetic.
I think the patient will likely end up with a few million dollars, minus the 30-60% fees (plus expenses) that her attorneys will charge."

 

[Crayola227]

Why would you start lovenox the evening after a biopsy? Even with a condition like APS the chances of clotting that evening is far outweighed by the risk of bleeding.

And what do people make of this point?

 

[Crayola227]

It was literally explained to me there's a difference in medmal between missing a heart attack, where you explain your rationale for not ordering an EKG and troponin, or even where you don't exactly until you're in court, and missing one where you ordered an EKG but for whatever reason don't review it in a timely fashion.

The former you have a defense. The latter, no one is going to much care about the details.

In the former, you can try to explain why it wasn't needed for management. In the latter, it looks like you had enough concern to order the test. So then when you miss whatever was on the test, you have a harder time claiming it was irrelevant to the outcome of the case when it comes back abnormal.

I don't know how they can say the test in this case was irrelevant here in a way that wins with a jury. So instead you have a settlement.

 

[Clean7795]

And what do people make of this point?

The risk of a clot is highly elevated but someone with APS or any clotting disorder would have lived several years, or even decades without their condition causing a problem (until their first thromboembolic event).

So yea, I would think starting anticoagulation several hours after the biopsy of a highly vascular organ as overly aggressive.

 

[Clean7795]

It is nuts to see cases like this settle for 11 figures...You bet your ass if they hadn't anticoagulated her or only started her AC off low and had a PE or arterial embolus there would have been a lawsuit there as well.

Perhaps, but there would have been a lot more protection for the physicians involved. The fact that they have APS diagnosed means the patient probably already had a thromboembolic event. The patient/family knows that it is part of the disease process and are a lot more likely to understand if it happened again because anticoagulation had to be stopped for a procedure.

Getting a biopsy and losing all your fingers as a result of a **** up is not something the jury will forgive you for.

 

[mszzeta]

I wonder what they saw on testing that prompted them to do a kidney biopsy. Presumably mix of elevated creatinine, hematuria, proteinuria. There should have been a lot of hand wringing about sending her for biopsy.

I’m not familiar with following levels after Lovenox. Either okay to give based on GFR or not. They could not just have her continue heparin then back to warfarin? Maybe they thought Lovenox would be therapeutic more quickly? That raises bleeding risk too. Just seems like an odd approach if you had to rely on levels you don’t have readily available.

I’m not that impressed by the transfusion/pressor thought. You can do both depending on the situation. They could just as easily say digit loss was from the underlying ischemia/shock than therapy IMO.

I totally agree. Why Lovenox not UFH? Even if pt has normal creatinine, UFH is much easier to monitor with aPTT

The kidney biopsy would be a discussion between nephrologist and hematologist. In some typical case, one may argue that empirical treatment might be a wiser choice

 

[whoknows2012]

And what do people make of this point?

heparin gtt until bleeding risk drops. Depends on procedure normally I’d discuss with the consultant doing the procedure and go from there. Gun to my head in this case would have probably started with hep gtt monitored for 24-48h and if acceptable gfr switched to lovenox

 

[whoknows2012]

The risk of a clot is highly elevated but someone with APS or any clotting disorder would have lived several years, or even decades without their condition causing a problem (until their first thromboembolic event).

So yea, I would think starting anticoagulation several hours after the biopsy of a highly vascular organ as overly aggressive.

This doesn’t really make a lot of sense. If someone meets criteria for bridging ac then the standard of care is to bridge with therapeutic ac. This case wasn’t lost on the hematologist making the wrong decision to anticoagulate; if the hematologist decided against any ac until bleeding risk resolved and the pt had a massive PE and died he/she would’ve been liable. The case was lost on deciding to use most likely the wrong anticoagulant (though lovenox with timely anti-xa levels would probably have been fine) without any way of monitoring (given way too long turn around time of the labs) in a patient with a significantly elevated bleeding risk

 

[Crayola227]

I guess one detail missing from the case is if the lupus nephritis resulted in a significant AKI where the providers (and pharmacists) should have known better than to use lovenox. If that was the case then I understand the lawsuit though the finger loss that was undoubtedly the primary fixation is again more related to underlying disease than the malpractice component. That apparently would have happened if they got a bad UTI and needed pressors.

Yeah but reading about this more, septic shock is not the same as hemorrhagic and I don't see evidence that she had the former. The implication from the reviewer of the case, is that it isn't a slam dunk that pressors should have been used to treat this patient. Yes, she could have lost her fingers from hypotension, but she got pressors and it sounds like arguably maybe that wasn't necessary. You can now never rule out the maybe unnecessary treatment as the cause of her fingerlessness now. You don't have normal Xa levels received in a timely fashion to try to establish she wasn't overcoagulated. (Edit: overanticoagulated)

You can argue that any poor outcome could result in a case where every conceivable precaution was taken, no mistakes, everything was SOC, and that's valid.

The issue in every single one of these cases, is not being able to establish that any deviations from SOC or delays, are NOT responsible for the poor outcome.

 

[Crayola227]

This doesn’t really make a lot of sense. If someone meets criteria for bridging ac then the standard of care is to bridge with therapeutic ac. This case wasn’t lost on the hematologist making the wrong decision to anticoagulate; if the hematologist decided against any ac until bleeding risk resolved and the pt had a massive PE and died he/she would’ve been liable. The case was lost on deciding to use most likely the wrong anticoagulant (though lovenox with timely anti-xa levels would probably have been fine) without any way of monitoring (given way too long turn around time of the labs) in a patient with a significantly elevated bleeding risk

Also doesn't sound like use of pressors was a slam dunk decision to have made.

It reads like they basically caused a bleed and then treated the bleed in way that put her fingers at considerable risk, and a case can be made for how this could have been avoided. Getting labs late rarely ends up being a winning defense in these cases.

 

[chessknt]

Yeah but reading about this more, septic shock is not the same as hemorrhagic and I don't see evidence that she had the former. The implication from the reviewer of the case, is that it isn't a slam dunk that pressors should have been used to treat this patient. Yes, she could have lost her fingers from hypotension, but she got pressors and it sounds like arguably maybe that wasn't necessary. You can now never rule out the maybe unnecessary treatment as the cause of her fingerlessness now. You don't have normal Xa levels received in a timely fashion to try to establish she wasn't overcoagulated.

You can argue that any poor outcome could result in a case where every conceivable precaution was taken, no mistakes, everything waa SOC, and that's valid.

The issue in every single one of these cases, is not being able to establish that any deviations from SOC or delays, are NOT responsible for the poor outcome.

Have you ever treated someone in non-traumatic hemorrhagic shock (ie medically ill hemorrhagic shock)? Assuming they have adequate IV access (never the case) they usually have underlying comorbidities and some range of diagnostic uncertainty barring a clear GIB as the process evolves that makes the thoughtful intensivist at least a little hesitant transfuse 4+ liters of colloid as therapy. What happens if it isnt working after the first unit is squeezes in? Add a pressor or get the level 1 and drill a cordis in to the neck and start pouring in a liter a minute (again without diagnostic certainty at this point)? Mixing pressor to buy time for workup and evaluation of response is standard of care despite what the hematologist says because this isn't a trauma case where there is a visible artery bleed or a + FAST exam with a liver lac.

I imagine the ICU getting called on an APLS patient who is hypotensive and tachycardic, had biopsy done 1-2d prior with flank pain. Sepsis and hemorrhage are at the top of the list but depending on the time course I might also be thinking anaphylaxis or HITT (if the labs support) or myocarditis in setting of SLE. For this armchair dinosaur to pretend that we should rush in to the room with 12 units of blood and pour a criminal amount of fluid in to this (at the time) undifferentiated patient is the standard of care is ridiculous. He doesnt know the standard of care because he doesnt treat hemorrhagic shock just like I dont know what the standard of care is for peri-procedural anticoagulation in APLS. I give pressors to people all the time and their fingers dont fall off--assuming that a ridiculous pressor amount wasnt given that is NOT a normal response to pressors and indicative of underlying medical vascular disease not something the physician did wrong. Also labs in hemorrhagic shock are generally useless except maybe for a lactate--it is a clinical diagnosis.

And 11 figures is getting off easy? How much is the hand worth in this person, a billion dollars? It isnt like someone cut off a normal hand in negligence, this person had severe vascular disease and suffered a known side effect of a life saving medication. If someone has anaphylaxis to penicillin given for septic shock and ends up with a trach due to airway compromise does that person get to sue too?

 

[chessknt]

Perhaps, but there would have been a lot more protection for the physicians involved. The fact that they have APS diagnosed means the patient probably already had a thromboembolic event. The patient/family knows that it is part of the disease process and are a lot more likely to understand if it happened again because anticoagulation had to be stopped for a procedure.

Getting a biopsy and losing all your fingers as a result of a **** up is not something the jury will forgive you for.

Bleeding was disclosed as part of the biopsy risk though and if someone bleeds a lot they can get very ill and die. What is the point of informed consent if an adverse event occurs and we still get sued over it?

 

[Radetzky]

Have you ever treated someone in non-traumatic hemorrhagic shock (ie medically ill hemorrhagic shock)? Assuming they have adequate IV access (never the case) they usually have underlying comorbidities and some range of diagnostic uncertainty barring a clear GIB as the process evolves that makes the thoughtful intensivist at least a little hesitant transfuse 4+ liters of colloid as therapy. What happens if it isnt working after the first unit is squeezes in? Add a pressor or get the level 1 and drill a cordis in to the neck and start pouring in a liter a minute (again without diagnostic certainty at this point)? Mixing pressor to buy time for workup and evaluation of response is standard of care despite what the hematologist says because this isn't a trauma case where there is a visible artery bleed or a + FAST exam with a liver lac.

I imagine the ICU getting called on an APLS patient who is hypotensive and tachycardic, had biopsy done 1-2d prior with flank pain. Sepsis and hemorrhage are at the top of the list but depending on the time course I might also be thinking anaphylaxis or HITT (if the labs support) or myocarditis in setting of SLE. For this armchair dinosaur to pretend that we should rush in to the room with 12 units of blood and pour a criminal amount of fluid in to this (at the time) undifferentiated patient is the standard of care is ridiculous. He doesnt know the standard of care because he doesnt treat hemorrhagic shock just like I dont know what the standard of care is for peri-procedural anticoagulation in APLS. I give pressors to people all the time and their fingers dont fall off--assuming that a ridiculous pressor amount wasnt given that is NOT a normal response to pressors and indicative of underlying medical vascular disease not something the physician did wrong. Also labs in hemorrhagic shock are generally useless except maybe for a lactate--it is a clinical diagnosis.

And 11 figures is getting off easy? How much is the hand worth in this person, a billion dollars? It isnt like someone cut off a normal hand in negligence, this person had severe vascular disease and suffered a known side effect of a life saving medication. If someone has anaphylaxis to penicillin given for septic shock and ends up with a trach due to airway compromise does that person get to sue too?

Excellent point. Easy to say “this is how you treat hemorrhagic shock” when you know that’s the clear diagnosis in retrospect.

This doesn’t really make a lot of sense. If someone meets criteria for bridging ac then the standard of care is to bridge with therapeutic ac. This case wasn’t lost on the hematologist making the wrong decision to anticoagulate; if the hematologist decided against any ac until bleeding risk resolved and the pt had a massive PE and died he/she would’ve been liable. The case was lost on deciding to use most likely the wrong anticoagulant (though lovenox with timely anti-xa levels would probably have been fine) without any way of monitoring (given way too long turn around time of the labs) in a patient with a significantly elevated bleeding risk

I’m not aware of any standard of care that says bridging anticoagulation must always be started ASAP. Its always a balance of risks and benefits based on the specific situation. Talking about choosing an anticoagulant that you can easily reverse/monitor is all good in theory but in practice by the time you figure out what’s going on and give reversal you’ve already likely got a significant life threatening bleed.

 

[Crayola227]

Have you ever treated someone in non-traumatic hemorrhagic shock (ie medically ill hemorrhagic shock)? Assuming they have adequate IV access (never the case) they usually have underlying comorbidities and some range of diagnostic uncertainty barring a clear GIB as the process evolves that makes the thoughtful intensivist at least a little hesitant transfuse 4+ liters of colloid as therapy. What happens if it isnt working after the first unit is squeezes in? Add a pressor or get the level 1 and drill a cordis in to the neck and start pouring in a liter a minute (again without diagnostic certainty at this point)? Mixing pressor to buy time for workup and evaluation of response is standard of care despite what the hematologist says because this isn't a trauma case where there is a visible artery bleed or a + FAST exam with a liver lac.

I imagine the ICU getting called on an APLS patient who is hypotensive and tachycardic, had biopsy done 1-2d prior with flank pain. Sepsis and hemorrhage are at the top of the list but depending on the time course I might also be thinking anaphylaxis or HITT (if the labs support) or myocarditis in setting of SLE. For this armchair dinosaur to pretend that we should rush in to the room with 12 units of blood and pour a criminal amount of fluid in to this (at the time) undifferentiated patient is the standard of care is ridiculous. He doesnt know the standard of care because he doesnt treat hemorrhagic shock just like I dont know what the standard of care is for peri-procedural anticoagulation in APLS. I give pressors to people all the time and their fingers dont fall off--assuming that a ridiculous pressor amount wasnt given that is NOT a normal response to pressors and indicative of underlying medical vascular disease not something the physician did wrong. Also labs in hemorrhagic shock are generally useless except maybe for a lactate--it is a clinical diagnosis.

And 11 figures is getting off easy? How much is the hand worth in this person, a billion dollars? It isnt like someone cut off a normal hand in negligence, this person had severe vascular disease and suffered a known side effect of a life saving medication. If someone has anaphylaxis to penicillin given for septic shock and ends up with a trach due to airway compromise does that person get to sue too?

Rereading the case, it's implied she had a CT scan showing the renal hematoma before she was put on pressors or transferred to the ICU.

I also don't know for how long they had her on pressors and how that might have affected the Raynaud's. You describe using pressors in the face of diagnostic uncertainty, and it doesn't seem from reading the case that that was the only context for using them in this case.

Perhaps all this is why the intensivists and the transfusion issue didn't come up in the lawsuit - it wasn't the tack to take with this case.

But still, no one can explain to me why Xa levels were ordered if they weren't going to affect management, and that they weren't needed to result for 3 days. From what I can tell, this is pretty much how they hung themselves in this case.

Maybe the physicians could have shifted liability to the hospital if they tried to reorder stat or they complained to the hospital about the time issue.

But it also seems within this forum that we do agree other management decisions in light of the case and not getting these results, would have been reasonable. The fact we can have this debate, is alone a reason for the hospital to settle. Especially given the financial considerations the reviewer brings up.

 

[Crayola227]

Also the MedMalReviewer indicated the settlement offered seemed within the med mal limits for the number of doctors sued (which makes sense), and that settling for this amount probably amounted to a "good deal." She likely would have been entitled to more if this went to jury. This seems believable to me so I'll take their word on this.

Make sure you only order tests that will affect management, and that if you do, that you demonstrate follow up in a timely fashion. This is 100% how physicians get boned barring many other caveats in a case.

I'm not saying what you're saying about informed consent and bad outcomes and such isn't true. But the above is how settlements and lost lawsuits come about regardless. To me, that's the lesson here, not how unavoidable a bad outcome is or isn't. It may not matter if they show you didn't follow up on a test result that presumably it could be expected you may have needed (it's by your own admission that was needed, because you ordered it).

Obviously not every lab result the ball gets dropped on can be linked logically to a particular bad outcome. But if it can.... here we are.

 

[chessknt]

Also the MedMalReviewer indicated the settlement offered seemed within the med mal limits for the number of doctors sued (which makes sense), and that settling for this amount probably amounted to a "good deal." She likely would have been entitled to more if this went to jury. This seems believable to me so I'll take their word on this.

Make sure you only order tests that will affect management, and that if you do, that you demonstrate follow up in a timely fashion. This is 100% how physicians get boned barring many other caveats in a case.

I'm not saying what you're saying about informed consent and bad outcomes and such isn't true. But the above is how settlements and lost lawsuits come about regardless. To me, that's the lesson here, not how unavoidable a bad outcome is or isn't. It may not matter if they show you didn't follow up on a test result that presumably it could be expected you may have needed (it's by your own admission that was needed, because you ordered it).

Obviously not every lab result the ball gets dropped on can be linked logically to a particular bad outcome. But if it can.... here we are.

Easy to say if you are somewhere where that works. If I have a patient who has a dropping platelet count and intermediate 4Ts score at one hospital I can get a PF4 back in 24 hours, in another one it takes over a week. So should I just never send it because I wont get it back in time to matter and just flag a heparin allergy that doesn't exist? Sure I can start argatroban on both of them but if it is negative in the first hospital it is only 24 hours of exposure as opposed to forever in the second one (if I never send the test). What if they bleed on argatroban, do I get sued then too because the 'standard of care' for an intermediate score is to send the test and await the results?

There is an enormous amount of art and variability to practice. The entire concept of some universal standard of care that applies to every case is complete bull**** and in this case I would absolutely need to see more detail but the way the medical witness outlines the case does not convincingly show that there was a negligent problem with management. Anti-Xa levels dont matter for normal sized people who are not COVID + or critically ill with intact renal function.

Also as an aside the renal capsule can't really hold enough blood to put somebody in to hemorrhagic shock--I am going to be suspicious of an alternative etiology with the scan as it was described.

 

[Crayola227]

Easy to say if you are somewhere where that works. If I have a patient who has a dropping platelet count and intermediate 4Ts score at one hospital I can get a PF4 back in 24 hours, in another one it takes over a week. So should I just never send it because I wont get it back in time to matter and just flag a heparin allergy that doesn't exist? Sure I can start argatroban on both of them but if it is negative in the first hospital it is only 24 hours of exposure as opposed to forever in the second one (if I never send the test). What if they bleed on argatroban, do I get sued then too because the 'standard of care' for an intermediate score is to send the test and await the results?

There is an enormous amount of art and variability to practice. The entire concept of some universal standard of care that applies to every case is complete bull**** and in this case I would absolutely need to see more detail but the way the medical witness outlines the case does not convincingly show that there was a negligent problem with management. Anti-Xa levels dont matter for normal sized people who are not COVID + or critically ill with intact renal function.

Also as an aside the renal capsule can't really hold enough blood to put somebody in to hemorrhagic shock--I am going to be suspicious of an alternative etiology with the scan as it was described.

But aren't we saying she likely didn't have intact renal function? Isn't that likely part of the problem with how she was treated?

A lot of what you're saying defending the use of lovenox and pressors, seems like the whole point is that maybe this is exactly the kind of patient you don't default to these things.

And while it's fair enough that her bleed on CT may not have coincided with when she developed shock, it does establish a source and a likely etiology for her shock. You want to argue septic shock for a patient with no fever and confirmed source of bleed over hemorrhagic? Uh, OK. But your decision in that case to use pressors on someone with Raynaud's could cost them their hands. You made the comment that you use pressors all the in people and their hands don't fall off. Do those same people have evidence of serious autoimmunity and Raynaud's? You sure don't you want to treat this as hemorrhagic shock avoiding pressors now?

You're basically arguing that everything done for this patient makes total sense, but you are actually acknowledging that these things make sense for a patient that doesn't match the description of the actual patient in this case.

 

[chessknt]

But aren't we saying she likely didn't have intact renal function? Isn't that likely part of the problem with how she was treated?

A lot of what you're saying defending the use of lovenox and pressors, seems like the whole point is that maybe this is exactly the kind of patient you don't default to these things.

And while it's fair enough that her bleed on CT may not have coincided with when she developed shock, it does establish a source and a likely etiology for her shock. You want to argue septic shock for a patient with no fever and confirmed source of bleed over hemorrhagic? Uh, OK.

You're basically arguing that everything done for this patient makes total sense, but you are actually acknowledging that these things make sense for a patient that doesn't match the description of the actual patient in this case.

We dont know if the renal function was intact or not because the medical expert did not think that renal function was relevant in his commentary, another sign of the genius level intellect being deployed in this case.

I am saying that if I put 2 units of blood quickly in to someone who is still hypotensive and in shock I am going to add pressor and reassess the assumption that hemorrhagic is the primary problem, not get a level 1 transfuser out with a large bore resuscitation line to put 4/4/1 + calcium in the next 10 minutes for a renal capsular bleed that didn't show up for 2 days. Then when a hematologist says the standard of care was violated because pressors were used he can go **** himself right back to the chemo clinic he apparently doent make enough money from to be rendering such an ignorant opinion.

 

[Crayola227]

We dont know if the renal function was intact or not because the medical expert did not think that renal function was relevant in his commentary, another sign of the genius level intellect being deployed in this case.

I am saying that if I put 2 units of blood quickly in to someone who is still hypotensive and in shock I am going to add pressor and reassess the assumption that hemorrhagic is the primary problem, not get a level 1 transfuser out with a large bore resuscitation line to put 4/4/1 + calcium in the next 10 minutes for a renal capsular bleed that didn't show up for 2 days. Then when a hematologist says the standard of care was violated because pressors were used he can go **** himself right back to the chemo clinic he apparently doent make enough money from to be rendering such an ignorant opinion.

Clearly there's more to say on the case, and a lot of it is being said here. Others have said there is a case to be made that her anticoag may have been overly aggressive and her renal function has come up. The pressors might have been appropriate, but it hardly matters if mistakes with ac are the reason she needed them to begin with.

The fact that some of this hasn't come up in the court documents so far of an ongoing case, doesn't mean that it wouldn't, or that it isn't appropriate for the hospital to settle. I would expect the hospital itself to have the answers to all our questions and also be able to assess the case.

Clearly there's enough here the hospital, their lawyers, and their physicians, seem to think $12 million is the better bargain. It probably is.

 

[chessknt]

Clearly there's more to say on the case, and a lot of it is being said here. Others have said there is a case to be made that her anticoag may have been overly aggressive and her renal function has come up. The pressors might have been appropriate, but it hardly matters if mistakes with ac are the reason she needed them to begin with.

The fact that some of this hasn't come up in the court documents so far of an ongoing case, doesn't mean that it wouldn't, or that it isn't appropriate for the hospital to settle. I would expect the hospital itself to have the answers to all our questions and also be able to assess the case.

Clearly there's enough here the hospital, their lawyers, and their physicians, seem to think $12 million is the better bargain. It probably is.

The reason to settle often has little to do with case merits--it is because a trial is a circus of laypeople being manipulated by lawyers and whenever there is a clear injury (ie digital amputation) that is working from a position of extreme weakness because that deformity will be on display every day the trial is underway. If it was a jury of physician peers in the specialties in question it would actually be a fair trial because those people would know whether or not negligent mistakes were made without some ancient mercenary writing down his opinion like some dictate on high as if he can define the holy standard of care. It is a horrible system and we all know it.

 

[Chemist0157]

I guess the hospital/docs would have to make a case that using Lovenox was a superior option compared to anything else, AND it was warranted so much that it needed to be done even if a level was not readily available. They could demonstrate that kidney function was okay enough to use Lovenox. They could demonstrate or at least explain at the time there was more concern for thrombosis than bleeding.

I’m pretty disappointed though that labs prompting the biopsy are not available nor what her BP was after transfusions nor hemoglobin checks.

 

[end stage fibro]

IWhy Lovenox not UFH? Even if pt has normal creatinine, UFH is much easier to monitor with aPTT

While i agree with using ufh, i don't think aptt is reliable in APLS? Probably would still need anti xa

 

[mszzeta]

While i agree with using ufh, i don't think aptt is reliable in APLS? Probably would still need anti xa

Good point. I did not think of that aPTT would be prolonged in APLS that may not be reliable for monitor. Thanks for the reminder

 

[whoknows2012]

Good point. I did not think of that aPTT would be prolonged in APLS that may not be reliable for monitor. Thanks for the reminder

If there’s a lupus anticoagulant (which there doesn’t have to be in APLS) then it is likely that the aPTT is interfered with and is thus unreliable. There is a LA-insensitive PTT that can be drawn and followed but assume in this case that may have needed to be sent out as well.

 

[Chemist0157]

So the above would be in favor of using Lovenox and if they thought risk of thrombosis was higher than risk of bleeding, it was not unreasonable to start therapy prior to level being available...?

 

[FutureInternist]

I don’t get the urgency in restarting her anticoagulation specially when there is documentation of no active clots, and the labs are not resulting (which one would think the ordering doc would know about)

 

[aafisahar]

I don’t get the urgency in restarting her anticoagulation specially when there is documentation of no active clots, and the labs are not resulting (which one would think the ordering doc would know about)

Maybe, maybe not, I'm surprised at what's a send out and what's not. For example, at one of the places I moonlight, H pylori antibodies are a send out while another place will turn it around in a couple hours.

 

[whoknows2012]

I don’t get the urgency in restarting her anticoagulation specially when there is documentation of no active clots, and the labs are not resulting (which one would think the ordering doc would know about)

The urgency depends on how “clotty” the patient is. APLS is a high risk thrombophilia. I’m by no means a benign heme expert (my specialty is leukemia) but in cases similar to these during fellowship we’ve rapidly reinitiated AC given high clot risk. Despite a bleeding risk. Of course we weighed risks and benefits and monitored levels, again reiterating the issue in the case is not that they started ac it’s that they weren’t able to follow up the levels (and possibly should’ve considered hep gtt in that case?)

 

[chessknt]

The urgency depends on how “clotty” the patient is. APLS is a high risk thrombophilia. I’m by no means a benign heme expert (my specialty is leukemia) but in cases similar to these during fellowship we’ve rapidly reinitiated AC given high clot risk. Despite a bleeding risk. Of course we weighed risks and benefits and monitored levels, again reiterating the issue in the case is not that they started ac it’s that they weren’t able to follow up the levels (and possibly should’ve considered hep gtt in that case?)

So to be clear if you had been consulting on this case in a community hospital you would tell your medical team that lovenox in a renally intact patient is malpractice without an anti xa level within a few hours of initiation? So does this apply to every indication for lovenox or just people with apls?

 

[Crayola227]

So to be clear if you had been consulting on this case in a community hospital you would tell your medical team that lovenox in a renally intact patient is malpractice without an anti xa level within a few hours of initiation? So does this apply to every indication for lovenox or just people with apls?

Why do you keep emphasizing renally intact? What evidence do you have that a patient presenting with concern for lupus nephritis necessitating biopsy despite a serious coagulopathy would have been renally intact? Is that common?

 

[chessknt]

Why do you keep emphasizing renally intact? What evidence do you have that a patient presenting with concern for lupus nephritis necessitating biopsy despite a serious coagulopathy would have been renally intact? Is that common?

What evidence do we have that the patient wasn’t? The fixation on anti xa levels is irrelevant—if there was renal impairment it shouldn’t have been used period. If there wasn’t the levels wouldn’t have mattered is my point.

 

[Crayola227]

So to be clear if you had been consulting on this case in a community hospital you would tell your medical team that lovenox in a renally intact patient is malpractice without an anti xa level within a few hours of initiation? So does this apply to every indication for lovenox or just people with apls?

So far every person with a heme background has said they would get at least one anti-Xa level or consider heparin gtt in this patient. So much for the "whoopsy" theory in this case.

 

[HemeOncHopeful19]

I’ve never heard of Q6h Anti-Xas for Lovenox. We usually get one a few hours after the 3rd dose but again that’s usually in overweight people to confirm they aren’t subtherapeutic, or someone who has had a breakthrough clot on Lovenox.

I’d really like to know what the Creatinine and BMI was in this patient and I’d love to read the Heme consult. I make no assumption about the Creatinine because it isn’t mentioned in the “testimony” that the plaintiff’s lawyer wrote for the docs.

I usually write “can restart anticoagulation once felt safe from bleeding risk by surgeon/proceduralist” but in private practice people may get pissy about that.

 

[chessknt]

So far every person with a heme background has said they would get at least one anti-Xa level or consider heparin gtt in this patient. So much for the "whoopsy" theory in this case.

And I am saying that in real life this is not typically done on an urgent basis. We’ll check a level after a few days in a morbidly obese person. I have never checked this within 24 hours of starting it and the medical expert witness fixation with this shows he does not practice inpatient medicine since an intern at a decent hospital would know he is blowing smoke out his ass fixating on this. If there is an emergent need like an unstable pe use a heparin gtt.

 

[Crayola227]

Admittedly I'm not an expert in these issues. Can someone explain why they used lovenox and why they didn't use heparin gtt in this particular patient? Besides ease of administration I'm don't see why besides what seems like cookie cutter medicine.

 

[Crayola227]

And I am saying that in real life this is not typically done on an urgent basis. We’ll check a level after a few days in a morbidly obese person. I have never checked this within 24 hours of starting it. If there is an emergent need like an unstable pe use a heparin gtt.

To be fair, it wasn't just a level within 24 hrs they were lacking. It was at least 3 days worth.

 

[chessknt]

Admittedly I'm not an expert in these issues. Can someone explain why they used lovenox and why they didn't use heparin gtt in this particular patient? Besides ease of administration I'm don't see why besides what seems like cookie cutter medicine.

Heparin drips are more nursing and lab draw intensive and usually only needed in high risk scenarios. For someone who is on chronic ac and needs to be started back up but with a reversible agent lovenox for a few days is a fine choice. I imagine no levels were checked because it was going to be swapped to an oral medication soon. It is like checking a vanco trough on the last day of antibiotics.

 

[Crayola227]

Heparin drips are more nursing and lab draw intensive and usually only needed in high risk scenarios. For someone who is on chronic ac and needs to be started back up but with a reversible agent lovenox for a few days is a fine choice. I imagine no levels were checked because it was going to be swapped to an oral medication soon. It is like checking a vanco trough on the last day of antibiotics.

But you can't say no levels were checked. 3 days worth were drawn, results just never came back. As I've said, not the same malpractice argument can be made when that happens vs never checking and for a rationale.

 

[chessknt]

But you can't say no levels were checked. 3 days worth were drawn, results just never came back. As I've said, not the same malpractice argument can be made when that happens vs never checking and for a rationale.

That is a convincing to a lay person but shouldn’t be to us. People check daily CBC in stable patients all the time who gives a **** what the results are if it isn’t relevant to what is going on. Same applies here—the levels weren’t back so they had the same amount of information any standard of care would have had which is to say none because it isn’t obtained outside of some narrow scenarios.