While discussing a case with one of the nurses with whom I work, I saw how once again defensive medicine had affected my medical practice.
I gave a few examples of defensive medicine in a post several years ago and I also mentioned how sometimes doctors have to prove a negative when dealing with patients. Both of those posts are pertinent to this case.
A patient with a history of a clotting disorder has arthroscopic knee surgery. He has had two prior blood clots in his leg and one prior blood clot in his lung, so he’s on lifelong Coumadin. His doctors told him to stop taking the Coumadin for the week prior to his surgery to prevent bleeding during surgery. The surgery went well and he was discharged the same day.
The following day he started taking Coumadin again. However, he also noticed some pain in his calf. The pain was there after his surgery, but it seemed to be a little worse the following day. He took some pain medication and kept ice on it.
Two days out from his operation he was still having some pain in his calf, so he called the orthopedist. The orthopedist told him to go straight to the emergency department for an ultrasound of his leg to make sure that he didn’t have another blood clot. The possibility of a blood clot worried the patient, so he followed the doctor’s recommendations.
When I saw him, based on his clinical exam I could tell – with a reasonable degree of medical certainty – that he didn’t have a blood clot. His leg wasn’t red or swollen. We measured the circumference of both legs at the thigh and at the calf. His normal leg was actually a centimeter larger in diameter than the leg that underwent surgery. The pain was in the belly of the calf muscle – where orthopedists will sometimes apply pressure to get the leg in the correct position during a surgery. There was no thigh pain and there were no palpable cords.
It was a Saturday evening, so doing an ultrasound to look for a blood clot meant that we would have to call in the ultrasound tech from home and the patient would have to sit in the emergency department for at least a couple of more hours.
I told him “Based on my exam, it is pretty unlikely that you have a blood clot in your leg. Keep taking your Coumadin, keep putting ice on the tender area, keep taking your pain medications, and follow up with your doctor on Monday.”
He said “I have a history of blood clots in my leg before, it feels like a blood clot now, and my orthopedist said I need an ultrasound. You need to do the ultrasound.”
Now if there wasn’t any concern about liability or other repercussions, I probably would have told him that the ultrasound wasn’t indicated and that we didn’t need to do it that night.
But there is a concern about liability and other repercussions.
Even if the patient didn’t have a blood clot on this visit, what would happen if the patient developed a blood clot the following day? And what if that blood clot broke off, caused a pulmonary embolism, and the patient died? How could I prove that there was no clot present when I evaluated the patient – especially when purported “expert” witnesses testify under oath that it is “grossly negligent” to miss a diagnosis of pulmonary embolism in a teenager after knee surgery? It is much easier to order a test than it is to defend your reasonable and evidence-based approach for not ordering the test in the event of a bad outcome.
What if the patient had a clot despite the lack of physical findings for a blood clot? We often hear the phrase “nobody’s perfect”, but if you don’t order testing and miss a diagnosis, there is really not much tolerance for less than perfection in cases like this. It is much easier to order a test than it is to defend your reasonable and evidence-based approach for not ordering the test in the event of a bad outcome.
I’ve seen more than a few specialists and primary care docs who send a patient to the emergency department for testing and who then complain to hospital administrators that the dumb emergency physicians don’t do the tests that they wanted.
And let’s not forget that sending a patient home without getting the tests that the patient wanted is a sure way to tank your patient satisfaction scores.
So we ordered the ultrasound and called in the ultrasound tech.
A few hours later we got back the report from the radiologist showing no DVT. The patient got to go home and I’m sure that he slept better.
I’m sure that the orthopedist was able to sleep better, also.
The whole episode didn’t have much of an effect on my sleep pattern. I knew the patient didn’t have a blood clot when I first examined him … but now I had objective proof of my clinical findings and everyone got what they wanted.
Just think, it only cost the system a few thousand extra dollars.
This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on Dr.WhiteCoat.com, please e-mail me.