DVT R-O at night

[WheezyBaby]

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Wow, I hope I don't end up at your hospital if I ever have a DVT. Jeez.

Wasn't so long ago that I took care of a patient who had the DVT travel to his lung and coded -> anoxic brain injury -> dead. I do consider DVTs as an emergency and I sincerely hope most people do

If they're emergencies then why aren't we doing routine CDT / mechanical thrombectomy / placing filters? Do you feel a small time delay to noac initiation is going to make a dramatic difference in outcomes?

 

[thegenius]

While we're on the subject of ultrasound, what about things like r/o torsion? I wonder who is going down when the patient loses an ovary cause the tech takes 2 hours to come in or you have to transfer for a u/s.

Never had a pt over three years come in overnight at my part time ER where I had concern for ovarian torsion. A couple of times it's on the differential along with appendicitis, etc. So I CT them first. If they don't have an adnexal mass then I don't bother.

I did have acute testicular torsion overnight. This 13 yo kid came in with tons of pain, his testicle was horizontal, neg cremaster, etc. I "opened" the book about 180 degrees and he started having MORE pain...at that time I called Urology and he very happily rushed in, detorsed it and sent the kid home.

He said in the future (and said it very nicely), that you really have to open the book like 360 degrees so what I was doing was right, I just needed to continue to do it.

 

[thegenius]

Yeah you can. You've met the standard of care. Workup for DVT US as a risk stratification with ddimer, bedside US, obtaining confirmatory studies, etc. That's a completely defensible approach.

I think this OK if you are credentialed to do and interpret these kinds of ultrasounds. Attendings who graduated recently probably have experience with this.

if you have a + d-dimer and RF high for DVT, and things like a + Homans sign and stuff like that, it may not be defensible. Depends on how saavy the prosecution is.

But I do agree this is a very rare thing, because you also have to show harm. So the f^@#ker has to embolize and cause serious harm before you get the confirmatory study.

 

[TooMuchResearch]

Yeah, we have US that will come in from home at a 6k ED. They also do Peds appy (not intussusception...so?). I've also never heard of a vascular sonographer, it's all one person and read by radiology.

60K an no 24h U/S tech?

Everywhere I work at, the U/S tech does everything - belly/Vascular/soft tissue.

I never knew there were techs does everything but vascular, odd.

 

[gamerEMdoc]

Wow, I hope I don't end up at your hospital if I ever have a DVT. Jeez.

Wasn't so long ago that I took care of a patient who had the DVT travel to his lung and coded -> anoxic brain injury -> dead. I do consider DVTs as an emergency and I sincerely hope most people do

We have all seen people die of PE. It can be devastating. No one is saying not to work up or treat a DVT. Its that there is no evidence that treating it immediately vs a few hrs later if the patient has a negative bedside US makes any difference. There is plenty of evidence showing that DVT is safely treated as an outpatient anyways. It is, for the most part, an outpatient disease. As physicians we should make decisions based on evidence based medicine, not bad outcomes of cases we once saw.

 

[deleted109597]

We have all seen people die of PE.

More importantly, with all the machinery we have created to help diagnose them, we haven't changed the mortality one iota. Some of them simply die no matter what.
New ECMO stuff may shift the needle a little, but not in 99% of the country for a very long time

 

[Groove]

Yes we're trained in US but the national standard of care across all EDs is not a POCUS exam by an EP (and probably not your regional standard either). Most of us have no formal certification that standardizes the quality or competency of our ultrasonography skills. Ultrasonography education in US residencies is anything but standardized. Even if you somehow made a plausible argument that all EM trained physicians in the past 15 years possess ultrasonography skills good enough to perform a DVT exam of the same quality vis-a-vis an RDMS sonographer, you still don't make up anywhere near the majority of EPs in the country. I can guarantee you that there are plenty of EM trained docs who are going to prefer a formal US for all the benefits that it provides (increased thoroughness, better quality, provides a higher legal standard of care, is read and interpreted by a vascular surgeon and/or radiologist, etc..) How many of these do we do on a monthly basis? A handful? What about an RDMS sonographer? Hundreds? Who's got the better US for vascular studies? (In most cases, the RDMS) As for all the other IM/FM trained guys, I guarantee you they have probably never had any sort of formal US training and certainly have never performed a DVT US study.

What you're doing in these cases is making an argument for an idealistic standard of care, but that's a far cry from a realistic or even practical standard of care. Is it a reasonable approach in some cases? Sure, I'm not arguing against that at all. Especially when combined with shared decision making with the patient. But implying that you'd somehow be insulated from culpability in a lawsuit with this approach is ridiculous. The plaintiff's attorney is simply going to ask you who's most qualified to read and interpret DVT US studies in the hospital, or ask an expert witness to testify to this account. It will always turn out to be RDMS is the most skilled to perform and a vascular surgeon and/or radiologist is the most qualified to interpret the studies. Why then doctor, were neither resources utilized with this particular patient? Now, if you simply can't get the service at night, then sure...you've got a decent argument. For me though, I would definitely be utilizing shared decision making in these cases and probably always bringing them back to the hospital for an a.m. study. and getting the hospital to put themselves on the hook by having the entire protocol in writing.

All of us that find ourselves in situations where we can't get a definitive study after hours and are faced with having to anti-coagulate a pt WITHOUT a diagnosis of DVT should be highly uncomfortable with this approach. Here's a few snippets from Risk Management Monthly (I'm a subscriber):

Another listener writes about a patient with suspected DVT who complained about a charge for Lovenox. There was no ready access to ultrasonography after 3pm in this small hospital. Administration is considering providing access to an on-call ultrasound technician at the discretion of the ED physician (this is currently available for some emergent situations such as suspected testicular torsion or ectopic pregnancy). The listener noted that other hospitals in the area do provide 24/7 ultrasound services.

• A shortage of ultrasound technicians can make it difficult to find techs who are willing to take call. It might not be unreasonable to send the patient to another hospital where ultrasound is available in this situation. Another rational approach might be to arrange to share on-call technicians with other hospitals. In the risk management arena, it might be somewhat difficult to defend being given a potent anticoagulant in the situation in which a patient did not need it (the ultrasound was negative for a DVT) and the patient sustained some sort of serious trauma while under the influence of unneeded Lovenox and had a life-threatening bleed.

12. The verdict favored the emergency physician defendant in a case involving a woman who initiated a malpractice lawsuit citing failure to prescribe anticoagulants. The patient presented with leg pain but there was no evidence of deep vein thrombosis (DVT) at the time of the ED evaluation (although the plaintiff probably alleged otherwise). She subsequently developed deep vein thrombosis and pulmonary embolism requiring a prolonged hospitalization and insertion of a Greenfield filter.

• It is not the standard of care to prescribe anticoagulants in the absence of a definitive diagnosis of DVT. The summary of the case did not establish whether the alleged clot was proximal or distal.
• There is substantial controversy regarding whether or not to treat distal DVT. Dr. Bukata suggests treatment. However, if the clinician prefers not to treat, serial ultrasonography to identify proximal progression is considered an alternative.

4. MedMalReviewer.com by Eric Funk, M.D.
Eric does super-detailed reviews of malpractice cases with the reprinting of all sorts of redacted documents concerning the cases - but we'll just hit the highlights of one

• A 70-year-old male who presented to the VA with the chief complaint of left leg pain after a fall of two feet off of a deck one week prior to presentation.
• The patient had chronic atrial fibrillation, was on warfarin and his INR was 1.5. The leg was swollen, bruised and very painful, but the x-rays revealed no fracture but diffuse edema on the leg was noted. There was concern that the patient had a DVT and, before being transfer to another facility where an ultrasound would be performed, the patient was given 5mg of warfarin and 100mg of subq enoxaparin (Lovenox). The ultrasound was negative, and the patient was discharge with a knee immobilizer and crutches.
• Shortly after discharge, the patient fell and hit his head on the ground in the hospital parking lot, he was brought back into the emergency department at which time an abrasion to the head was noted, otherwise he had a normal exam and no complaints. It was noted that patient wanted to go home and was discharged.
• Very unfortunately, the patient was found dead the next morning. Autopsy showed a large subdural hematoma with onset less than 24 hours prior to death.
• The patient's family filed lawsuits against the nurses involved, as well as the physician who discharged him. The case was filed in federal court because the nurses worked for the VA, although the physician was a locums. Ultimately, the federal cases were dismissed without trial. The case against the physician was then re-filed in state court and an undisclosed settlement was reached prior to trial.

As for the question about whether there's been any sort of lawsuit about someone developing a PE within 24 hours from a DVT, here you go:

https://www.clinicaladvisor.com/home/my-practice/legal-advisor/liability-after-a-missed-diagnosis/

https://www.chaffinluhana.com/missed-dvt-pe-diagnosis-lawsuit/

Just do a search for "failure to diagnose DVT lawsuits" and you'll find copious links on Google from major law firms. It's a very common lawsuit, many times with big buck settlements or jury wins.

VTE is a spectrum of disease with significant morbidity and mortality and can culminate in catastrophic complications and should never be minimized. We've become so de-sensitized to DVTs because we pander to hospital policies that are enacted to coddle specialists and convenience the hospital staff. Most of us don't think anything about these pt's because we never see them again and their presentations aren't emergent. We forget though, that 99% of our critical PEs and a significant number of our cardiac arrests present to the ED with a disease progression that began as a DVT.

 

[Groove]

If they're emergencies then why aren't we doing routine CDT / mechanical thrombectomy / placing filters? Do you feel a small time delay to noac initiation is going to make a dramatic difference in outcomes?

Well, one of the indications for admission and evaluation for greenfield filter placement or thrombectomy are massive ileofemoral DVTs.

As for the time delay...probably not, but look above to some of the links in my post....sometimes, it can certainly make a dramatic difference. Being able to identify which ones are low risk and which ones are high risk is not always straightforward unfortunately.

 

[gamerEMdoc]

The only case I saw in that link was a patient with a delay in diagnosis of 3 weeks. I'm not even talking a delay in 24 hours. I'm talking a delay of less than 8 hours, and that's for a formal study. One of the other links for missed diagnosis was an ED bedside US with no followup. And the EP won the case. I'm not even suggesting that.

I'm suggesting ddimer which is a validated rule out test. I'm then suggesting an ED US if positive, they be treated with a dose of anticoagulation, and if the ED US is negative, use your pre/post test probability in terms of consideration of a single dose of anticoagulation with shared decision making while awaiting a formal study in less than 8 hours. Many ED's have a longer wait time than this to be seen. If we are saying a patient can't wait 8 hours for a formal DVT study, then I would argue every single person that comes to the ED with calf pain needs to go immediately back to the back.

 

[gamerEMdoc]

Maybe I just see a lower risk of DVT rule out patient at night time. I swear, our positive rates for formal and informal DVT US's are pretty low. Most of the patients coming in thinking they have a DVT have no leg swelling, no redness, and symptoms less than 24 hours. Every person who has a minor muscle injury "heard from a friend" it could be a DVT. The DVT paranoia is strong. My pretest probability is quite low on many of these people that come in.

 

[WheezyBaby]

Well, one of the indications for admission and evaluation for greenfield filter placement or thrombectomy are massive ileofemoral DVTs.

As for the time delay...probably not, but look above to some of the links in my post....sometimes, it can certainly make a dramatic difference. Being able to identify which ones are low risk and which ones are high risk is not always straightforward unfortunately.

Proximal ileofemoral are certainly a high risk subset but is that really a clear indication for intervention? I've read a bit but I certainly wouldn't consider myself well versed in the literature. I've previously had discussions (granted about a year ago at this point) with heme and vascular about proximal ileofemoral and theyve not considered it a clear indication for filter or CDT/thrombectomy in the absence of preexisting pulmonary/hemodynamic compromise or phlegmasia

 

[emergentmd]

Ever major City I have worked in have always had 24 US and MRI Avail and I get them no questions asked. Heck, I have gotten MRI of the knee in the ER before when tech wasnt busy for pt satisfaction. Every FSER I have worked in have 24 US avail.

Are these all BFE places?

 

[WheezyBaby]

Ever major City I have worked in have always had 24 US and MRI Avail and I get them no questions asked. Heck, I have gotten MRI of the knee in the ER before when tech wasnt busy for pt satisfaction. Every FSER I have worked in have 24 US avail.

Are these all BFE places?

I'm not an em resident but at a top em program, big busy EDs. Echo and vasc lab are available 24/7, but late night / early am are stats only and tech gets called in

 

[thegenius]

As for the question about whether there's been any sort of lawsuit about someone developing a PE within 24 hours from a DVT, here you go:

https://www.clinicaladvisor.com/home/my-practice/legal-advisor/liability-after-a-missed-diagnosis/

https://www.chaffinluhana.com/missed-dvt-pe-diagnosis-lawsuit/

Just do a search for "failure to diagnose DVT lawsuits" and you'll find copious links on Google from major law firms. It's a very common lawsuit, many times with big buck settlements or jury wins.

VTE is a spectrum of disease with significant morbidity and mortality and can culminate in catastrophic complications and should never be minimized. We've become so de-sensitized to DVTs because we pander to hospital policies that are enacted to coddle specialists and convenience the hospital staff. Most of us don't think anything about these pt's because we never see them again and their presentations aren't emergent. We forget though, that 99% of our critical PEs and a significant number of our cardiac arrests present to the ED with a disease progression that began as a DVT.

The second one above was a person who had chest pain and SOB and they missed a PE. So not quite germaine to this discussion.

But here is another one:
$1.8 Million Settlement in Medical Malpractice Case Involving Failure to Diagnose and Treat Deep Vein Thrombosis | Rapoport Weisberg & Sims P.C. | Illinois

Reading all this stuff makes me want to order dopplers on anyone with leg or arm pain
regardless of the physical exam.
if you have a symptom in your leg, regardless of what it is, you get a doppler.

These are hawkish lawyers who don't care about anything besides making money.
What they don't realize is prompt treatment of a DVT, while reducing complications, doesn't 100% prevent complications. The person above in my link could have been started on lovenox or heparin and the venous thrombosis could have still broken off and caused a PE in the first 12-24 hours (or longer) and they still would have died.

I hate lawyers. I wonder if they recognize that much of the waste in our society, in all areas of work (not just medicine) occur due to lawyers and their lawmaking. There will come a point in the future that there are so many laws we can't keep track of all the laws. They don't actually care about patients.

Just me ranting.

 

[thegenius]

The only case I saw in that link was a patient with a delay in diagnosis of 3 weeks. I'm not even talking a delay in 24 hours. I'm talking a delay of less than 8 hours, and that's for a formal study. One of the other links for missed diagnosis was an ED bedside US with no followup. And the EP won the case. I'm not even suggesting that.

The link above in my prior post sounds like the US study was ordered, not done that day, and the pt died the next day. Hence, < 12-24 hours (more or less despite not looking at the chart).

The problem with these kinds of things is its one-in-a-million. Most DVT's that embolize and cause death are probably in people who have had calf or leg pain for weeks, never saw a doctor, then died.

I did a search on the internet like @Groove suggested "failure to diagnose DVT lawsuits" and the vast majority of the hits on the first two pages, from Google, are lawfirms that specialize in bringing lawsuits for missed DVTs. Very scary.

 

[thegenius]

I can see why everyone just get's ultrasounds when they are suspicious for DVT. This is from Wells' Criteria for DVT - MDCalc

Patients can be divided into “DVT unlikely” and “DVT likely” groups based on Wells score. An additional moderate risk group can be added based on the sensitivity of the d-dimer being used.

• A score of 0 or lower is associated with DVT unlikely with a prevalence of DVT of 5%.
  • These patients should proceed to d-dimer testing:
    • A negative high or moderate sensitivity d-dimer results in a probability <1 % and no further imaging is required.
    • A positive d-dimer should proceed to US testing.
      • A negative US is sufficient for DVT rule out.
      • A positive US is concerning for DVT; strongly consider treatment with anticoagulation.

• A score of 1-2 is considered moderate risk with a pretest probability of 17%.*
  • These patients should proceed to high-sensitivityd-dimer testing (moderate sensitivity d-dimer is not sufficient).
    • A negative high-sensitivity d-dimer is sufficient for rule out of DVT in a moderate risk patient with a probability of <1%.
    • A positive high sensitivityd-dimer should proceed to US testing.
      • A negative US is sufficient for ruling out DVT.
      • A positive US is concerning for DVT, strongly consider treatment with anticoagulation.

• A score of 3 or higher suggests DVT is likely. Pretest probability 17-53%.
  • All DVT likely patients should receive a diagnostic US.
  • D-dimer testing should be utilized to help risk-stratify these DVT-likely patients.
    • In DVT likely patients with negative d-dimer:
      • A negative US is sufficient for ruling out DVT, consider discharge.
      • A positive US should be concerning for DVT, strongly consider treatment with anticoagulation.
    • In DVT likely patients with a positive d-dimer:
      • A positive US should be concerning for DVT, strongly consider treatment with anticoagulation.
      • A negative US is still concerning for DVT. A repeat US should be performed within 1 week for re-evaluation.

*Moderate risk group should only undergo d-dimer testing for rule out without ultrasonography if a high-sensitivity d-dimer is being used.





All of this makes sense...but it too cumbersome. Well I have to admit I've learned something about DVTs on this thread. I had the general response that someone posted prior that prompt outpatient workup (within a day, let's say) for DVT should be fine, but everything that I've read so far and from the lawyers (ack!!!!) makes me think otherwise. I guess I'll be ordering a lot more ultrasounds in the future.

Just another step in making healthcare insurmountably unaffordable for most 100's of millions of people in the US. We are getting close. Step by step we will get there...

 

[Fox800]

Ever major City I have worked in have always had 24 US and MRI Avail and I get them no questions asked. Heck, I have gotten MRI of the knee in the ER before when tech wasnt busy for pt satisfaction. Every FSER I have worked in have 24 US avail.

Are these all BFE places?

No. Some hospitals in metro Austin (embarassingly) have US only available during business hours. It's ridiculous. Yes, I can do my own DVT and GB US studies. I trained at a program with some of the strongest US training in the country. However...if I work for the largest hospital system in Texas, in the hottest metro area in the state for people to move to, I *shouldn't* have to. This isn't rural Iowa. It's just a matter of money.

 

[Groove]

So, here's how it all went down. I was not privy to the initial discussion that probably happened between our CMO and current FMD regarding the new policy of no US availability at night. Regardless, after our last quarterly meeting I voiced enough of a concern from all the rest of the docs that we were supposed to have a meeting with the CMO and vascular surgeon to give us a platform to voice those concerns.

I get a call from the FMD that the CMO in so many words told him that there was no need for any meeting and he wasn't particular concerned with how we feel about the policy and that it was going live on Monday. (Today)

So, there you have it. No more US after 8p.m. at night and it just goes to show how little respect the hospital staff or admin have for the ER physicians. No opportunity to voice concerns over a policy that directly affects us. Nobody cares, it's just..."You don't like it? Deal with it." I'm not even talking about viability or evidence based indications for management in an environment with no US, I'm just upset at the slap in the face we get over this new policy. But hey...we're just triage docs to everyone else, right? Docs willing to work in the ass crack of the hospital where no one else wants to go.

 

[Brigade4Radiant]

If I don’t have ultrasound I just give lovenox and tell them to come back in the morning.

We give patients lovenox all the time when we admit them also yes I do some bedside ultrasounds but mostly as something to do if I’m bored they still need a formal

 

[thegenius]

So, here's how it all went down. I was not privy to the initial discussion that probably happened between our CMO and current FMD regarding the new policy of no US availability at night. Regardless, after our last quarterly meeting I voiced enough of a concern from all the rest of the docs that we were supposed to have a meeting with the CMO and vascular surgeon to give us a platform to voice those concerns.

I get a call from the FMD that the CMO in so many words told him that there was no need for any meeting and he wasn't particular concerned with how we feel about the policy and that it was going live on Monday. (Today)

So, there you have it. No more US after 8p.m. at night and it just goes to show how little respect the hospital staff or admin have for the ER physicians. No opportunity to voice concerns over a policy that directly affects us. Nobody cares, it's just..."You don't like it? Deal with it." I'm not even talking about viability or evidence based indications for management in an environment with no US, I'm just upset at the slap in the face we get over this new policy. But hey...we're just triage docs to everyone else, right? Docs willing to work in the ass crack of the hospital where no one else wants to go.

If there's one thing as a resident that I wasn't truly prepared for and has been a source of constant demoralization during my career....is the complete disdain, lack of respect and lack of authority we have as emergency physicians. You think you're special? You think the hospital needs you? Think again. We are cogs in the wheel and utterly replaceable at a moment's notice. Our opinions simply don't matter and they never will. We like to think people would notice if we suddenly left the ED, but you know what? They probably wouldn't.

Sorry, I'm just bummed out and sick of this s***. Just when I think I've escaped burn out, I have days like today where I'm just sick of EM. Sick of the entitled patients who have no intention of ever paying their bill and are completely disrespectful, demanding and insulting, sick of the MVC gangsters that threaten physical violence when you try to help them. Sick of the plastic surgeons in town that bring in their post op complications (perf through the abdomen and small bowel with liposuction cannula) and helicopter around you the entire shift, demanding a million consults and VIP treatment as if their pt is the only one in the ED. Sick of the angry, hostile alcoholics that police dump on your door step because they don't want to take them downtown. Sick of lazy nurses, sick of hospital admin, sick of signing high risk APC charts, sick of working for CMGs, sick of "metric based" medicine, sick of no temperatures on my patients and most of all...sick of f'ing triage protocol'd lactates.

One more shift, then I've got a few days off. Hopefully I feel better.

Just terrible Groove. Sorry about that. Keep up the good fight. It seems like very few months I get a day that I just want to shoot myself in the head. Or have 1000 pins poke me everywhere on my body. because death or unending whole body pain seems better than what I'm currently going through in the ER.

 

[bravotwozero]

That sucks Groove, I know how that feels, although things are better where I work, particularly since our CMO is one of our pit docs who still pulls shifts in the ED.

One suggestion: What are you supposed to do if someone with an ischemic limb comes in at night? Can the US tech be called for a stat arterial doppler? If the answer is yes, you could perhaps trying calling them for acute ischemic limb and be like, well since you're doing arterial, can you check the veins...? or are they telling you to just get a CTA and/or call vascular/transfer?

 

[RoyBasch]

Yes we're trained in US but the national...

Great post! Very informative. Particularly appreciated the case law.

 

[RoyBasch]

That sucks Groove, I know how that feels, although things are better where I work, particularly since our CMO is one of our pit docs who still pulls shifts in the ED.

One suggestion: What are you supposed to do if someone with an ischemic limb comes in at night? Can the US tech be called for a stat arterial doppler? If the answer is yes, you could perhaps trying calling them for acute ischemic limb and be like, well since you're doing arterial, can you check the veins...? or are they telling you to just get a CTA and/or call vascular/transfer?

I don't mess with US for critical limb ischemia. If i have a cold foot I call vascular and go straight to a CTA while the vascular surgeon is driving in.

 

[Siggy]

(In most cases, the RDMS) As for all the other IM/FM trained guys, I guarantee you they have probably never had any sort of formal US training and certainly have never performed a DVT US study.

The Society of Critical Care Medicine's 2 day ultrasound course includes LE US to R/O DVT.

 

[deleted109597]

Sub-nuclear option.
Admit every one of them to obs and then get the US in the morning.
When the patients themselves complain, things will happen.

 

[Groove]

Thanks guys. Moment of weakness....I feel much better today. It probably has something to do with the fact that I'm not working!

 

[Groove]

I'm finally finishing up this damn APCA POCUS EM Cert. I did this sort of mini US fellowship during my 4th year in residency and never got around to taking my ARDMS after SPI. When I finally got around to it, they had switched to APCA for physicians and they had an EM specific cert. It has a gazillion test modules. I'm almost done with it but I figured it can't hurt in case I ever got sued for missing a DVT. If I got called to testify on my qualifications to perform DVT US, I suppose I could point to both residency as well as this Cert.