Deep Vein Thrombosis (DVT)
By Bob Aller: July 27, 2021
Deep vein thrombosis (DVT) is a potentially fatal blood clot that forms in the deep veins of the legs. A DVT may break off and make its way to a lung, blocking blood flow. Unfortunately, such clots often becomes a fatal pulmonary embolisms (PE). The CDC estimates roughly 900,000 Americans have a DVT each year. 60,000 to 100,000 patients die each year from a DVT.
For good reasons, the Centers for Medicare and Medicaid Services (CMS) require hospitals to maintain policies that prevent such fatalities. Sometimes, however, hospital staff fail to comply. As a result, people die.
HCA Healthcare Hospital
The 436-bed Brandon Regional Hospital in the Tampa metro area is owned by HCA Healthcare. On December 1st and 2nd, 2020, an investigation was conducted at Brandon by the Florida Agency for Healthcare Administration. Investigators found 62-year-old Keith Davis died after multiple providers disregarded the hospital’s DVT risk assessment policy designed to prevent harm from a DVT.
Statement of Deficiencies Issued
A Statement of Deficiencies was issued on December 17, 2020. According to the report, a “DVT Risk Assessment” was required at admission, at each shift, and at any change in the level of care.
The policy required early prophylaxis medication for the prevention of complications. The attending is required to write an order for prophylaxis at admission or, alternatively, to document why the patient did not need DVT prophylaxis. Yet, despite medical records citing Mr. Davis’ history of a DVT at this hospital and the patient’s use of an anticoagulant, there was no documentation whatsoever indicating compliance with the hospital’s “DVT Risk Assessment” policy over a 6-day period of hospitalization..
(Hospital Watchdog asked Brandon Regional Hospital to provide a copy of the “DVT Risk Assessment” policy, but Brandon did not respond to the request.)
Death Certificate Listed DVT As Cause of Death
The Florida agency reported that Mr. Davis’ death certificate, (certified by an independent forensic pathologist not associated with the hospital), stated the cause of death was pulmonary thromboembolism (PE) and deep vein thrombosis of the lower left extremity.
In addition to the patient’s medical history of a DVT, presenting symptoms included an extremely painful swollen left leg. The patient was unable to walk. The left leg skin was discolored, with irregularities and redness as seen in a cell phone image taken by Mr. Davis on October 1st.
An examination of the medical records shows that multiple providers failed to assess whether Mr. Davis’ presenting symptoms and medical history reflected a possible DVT. An ultrasound and a D-dimer blood test, two key diagnostic tests for a DVT, were not conducted.
Interview With Sabrina Davis, CMA
Hospital Watchdog interviewed Mr. Davis’ daughter, Sabrina Davis, CMA. (The interview was edited for brevity.) Ms. Davis was present with her father in the ER. In addition, Ms. Davis spoke on the phone and texted her father during the following 5-days of hospitalization. Ms. Davis recounted that both she and her father made multiple oral pleas for an ultrasound to determine if a DVT was present. Oral requests described by Ms. Davis do not appear in the medical records.
Patient Requested An Anticoagulant
However, on October 12, 2020 (3rd day of hospitalization), Mr. Davis texted his daughter informing her that he asked the staff that day for an anticoagulant. No anticoagulant was provided.
Sequential Compression Device (SCD) Contraindicated
However, after informing staff that he used compression socks at home the staff promptly placed a sequential compression device (SCD) on his left leg. However, the use of an SCD prior to testing for a DVT is contraindicated by some experts. We recommend screening patients by ultrasound routinely to identify significant occult DVT (unrecognized thrombus) capable of producing a pulmonary embolism before the placement of SCD’s since clinical examination is not reliable.
“Doesn’t seem to care if I sit here and have a clot”
Mr. Davis texted his daughter on October 12th, expressing grave concerns to no avail. “A second opinion is what I need. If I need some kind of surgery or something I will get it done… He (Dr. Moorthy, medical unit attending) doesn’t seem to care if I sit here and have a clot.”
Q: What do you remember about that day when your Dad described the severe pain he was experiencing in his left leg?
A: It was Saturday, October 10, 2020. I texted my Dad at 9:31 am. Retired from the Navy submarine service, he lived near Tampa, in the small town of Thonotosassa. My text said, “Good Morning.” He texted back, “I need to go to the ER.” I phoned him immediately to find out what was going on. He said he had a painful, swollen left leg. His left knee was locked. He was unable to walk. I could sense severe pain in his voice. Instantly, I knew it was serious. I lived in Gainsville, two hours away. I told him I would call an ambulance and meet him at the ER. I called for an ambulance right away. Since my dad was immobilized and couldn’t make it to his front door, he called a neighbor, asking him to break down the front door so the EMTs could get in. I got my 7-year-old son situated with his dad before heading out. I was on the road when an EMT called to tell me what was going on. He said Dad was in an awful lot of pain. They were taking him to Brandon Regional Hospital, 10 miles from where he lived. The crises instantly brought back memories of a prior hospitalization with a DVT back in 2008.
Q: What were your Dad’s symptoms when he was diagnosed with a DVT in 2008?
A: Dad had extreme pain, swelling, trouble walking, and cramping. My Dad was taken to the same hospital, Brandon Regional Hospital, but it was 12 years earlier. At that time the ER doc promptly ordered an ultrasound. Dad had a large blood clot. The staff discussed putting in a filter in his vena cava to prevent the clot from advancing. He was promptly started on blood-thinning medication and the issue resolved over a period of days without the filter. He and I knew he had survived a close call. Later, when I was in school studying to be a CMA, I learned more about the dangerousness of DVTs.
Q: After the blood clot in 2008 how did your Dad manage his condition?
Dad knew if this happened again it could be fatal. He had retired from the Navy. During his career, he served on a ballistic missile submarine, the USS Stonewall Jackson. He served as a Quartermaster involved in ship navigation. He knew how to follow a strict regimen. After that incident, he was diligent with taking his blood thinner. On any long car drive, he took breaks to stretch his legs. He had a daily walking regimen. I was thinking about that as I was driving to the ER. After my Dad’s death, I was unable to find a prescription bottle with his anticoagulant, Eliquis. He did have free samples of Eliquis. It made me wonder whether he had been taking Eliquis regularly before the DVT occurred.
Q: What happened when you got to the ER?
A: With the ER delays, I made it in time to be present during my Dad’s initial exam with what we thought was a regular ER physician. Later, I learned that Ali Kamel Al-Marzoog was a resident.
My Dad and I told him that in 2008 my Dad was diagnosed with a large blood clot in his right leg. We explained that since that time my Dad had taken a blood thinner.
The resident ordered an x-ray and a CT scan. He came back with the result of the CT scan. He told us it showed fluid on the knee. I asked whether a CT scan could show if a blood clot was also present. He answered: “No.” I then requested an ultrasound to see if a blood clot was present. He said the test was not needed. He said the problem is fluid on the knee. I remember looking the resident right in his eyes. I touched my Dad’s knee that was warm to the touch. It was also swollen, bruised, and painful. I said, “These are symptoms of a blood clot.” I repeated my request for an ultrasound. Before I could finish my Dad spoke up and said that his left leg felt exactly as his right leg did in 2008 when he was diagnosed with a blood clot. Again, the resident insisted that an ultrasound test was not needed. He touched my Dad’s leg and acknowledged that my Dad’s leg was warm to the touch. The resident discarded my Dad’s medical history and symptoms. He repeatedly said the problem was fluid on the knee.
Q: Were there any chart notes that described the supervision of the resident?
A: Dr. Sergio Martinez was responsible for supervising the resident. Dr. Martinez made one entry in the chart and agreed with the resident’s plan. The resident had rejected our description of my Dad’s previous blood clot, his symptoms of a DVT in the ER, and our request for an ultrasound. Dr. Martinez wrote: “I have reviewed and agree with the resident’s note and I have reviewed all labs, ECGs, and imaging studies or reports. I agree with the resident’s findings, exam, and plan.” While my Dad was in the ER no blood was drawn and there were no labs.
Correction of 1/12/2022: This article was first published on July 27, 2021. The Statement of Deficiencies for this case indicated that a hospital policy required the attending physician for inpatient services to write an order for prophylaxis at admission or to document why the patient did not need DVT prophylaxis. We regret that this report mistakenly indicated Dr. Martinez, the physician supervising the resident in the ER, failed to make the required entry in the chart. The physician who failed to make that entry was Dr. Moorthy, the inpatient attending.
Sabrina Davis was permitted to be with her Dad during the ER visit. However, once her Dad was admitted to the medical unit on October 10, 2020, the hospital’s Covid policy did not allow her to be present in his room. During her Dad’s inpatient stay all of Sabrina’s subsequent conversations with her father and hospital staff were by phone and text.
Q: How often did you talk to your Dad during the five days he was in the Medical Unit?
A: We talked to each other on the phone every day. My Dad didn’t understand why he wasn’t making progress. He told me he wished they would finally check for a blood clot. He seemed frustrated with the care. He sent pics of his bad leg. He asked about his cat, July, who was staying with me at the time. Dad had a hobby rebuilding classic cars. While in the hospital he responded to texts and emails from his wide circle of fellow hobbyists.
Q: Among your Dad’s texts, did any text indicate staff tested for a DVT?
On Monday, October 12, Dad texted me. He said, “the physical therapy lady pushed a folded sheet under my leg pointing the toes straight up. I yelped in agony. It hurt bad.” I read about the Homan’s sign test and wondered whether that’s what this was.
Hospital Watchdog consulted a surgeon knowledgeable about DVTs. He commented on Mr. Davis’ text: “From my training and experience, this is basically a Homan’s sign test and it was exquisitely positive. The resulting pain from this maneuver should have suggested to the physical therapist a possible DVT. The positive results should have triggered further testing to see whether a DVT was present or not.”
A: At 8:39 am on Thursday, October 15, I was talking to my Dad on the speaker function of the phone. I heard Dr. Moorthy (the attending who was also my Dad’s primary care physician) come into the room and tell my Dad “You’re being discharged.” I said, “Hi, Dr. Moorthy,” he was in and out of the room quickly. My Dad and I continued talking. We were having a good conversation. Later, at 10:09 am, we were texting. He was happy to get out. He did say he was still in pain and he wondered why his knee was still feeling just like it did when he went to the ER. But after 6 days of bed rest, he was ready to leave. He still could not walk or stand on his own. He was being discharged to a skilled nursing facility.
A: I waited anxiously, not knowing what to do. Later, I would read in the medical records that CPR was conducted for 53 minutes. At 11:20 am, I got a call from a different number. It was Dr. Blake Spain. He was the Medical Director of the ICU. He called with a calming voice telling me that all life-saving techniques were unsuccessful. I asked him why did this happen? What time did this happen? He told me at 10:28 am a hospital physical therapist was in the room. My Dad tried to stand. He complained of dizziness. He laid back down in the bed and became unresponsive. That’s when code blue was called, he said. I asked Dr. Spain to put the phone to my Dad’s ear. He said he would do that. I made some promises to my Dad. I said, “I will find out what happened and if it was preventable.” I said, “I’ll make sure July (Mr. Davis’ cat), is safe and taken care of.” I cried harder than I ever have in my life.
Q: What made you think an autopsy was necessary?
A: My Dad went in for knee pain and didn’t make it out alive. How does that happen? He followed the hospital’s treatment plan for six days. His doctor issued a discharge order because he was supposedly doing well. I was on the phone with Dad minutes before the code blue. He said he was fine. He was looking forward to being discharged. He wasn’t having heart problems. He had the same symptoms he had in 2008 when he had a blood clot. They had refused to conduct an ultrasound even though my Dad and I had asked for an ultrasound multiple times. I knew an ultrasound was the standard of care for a suspected DVT blood clot. I strongly suspected a blood clot killed my Dad. I thought an autopsy would answer that question.
Q: Could you describe the conversation with your Dad’s attending and primary care provider after you learned your Dad died?
A: Right after I spoke with Dr. Spain, I phoned my Dad’s physician, Dr. Moorthy. I was distraught. In fact, I was crying. I asked him to order an autopsy. He told me that he had never ordered an autopsy. I reminded him that earlier in the day when he told my Dad he was discharged I was on the phone with my Dad. He was doing well. I said, “An autopsy is needed.” I literally begged him to order an autopsy. Whatever I said had no effect. Dr. Moorthy refused to request an autopsy.
At that moment I sensed I wasn’t going to get any help. I told Dr. Moorthy I would get a private autopsy. I told him I would try to find out exactly what happened to my Dad. I was angry. I hung up the phone.
By refusing to order an autopsy, Dr. Moorthy avoided the possibility of having to address the reporting requirements of the Florida statute for an adverse incident involving a death.
Q: What did you know about ordering a private autopsy?
A: From watching the news I knew next of kin could seek an autopsy. But I didn’t know anything about the process. I made a cold call to a medical examiner. As luck would have it he was compassionate. He explained the process and told me what to do. That same day, I hired a private forensic pathologist, Dr. Daniel Schultz, in Tampa, to conduct an autopsy.
“The use of anticoagulation therapy and a variety of measures… may have altered the course”
The providers’ failure to follow the hospital DVT protocol led to my father’s death. To them, they lost nothing. No one from the hospital even called me to just say they were sorry.
I lost my best friend. Dad was always honest with me. He was always there to listen to me no matter what time it was. I loved listening to him play on his acoustic guitar. He always made sure I knew how proud he was of me. My Dad was always into sports. He particularly enjoyed watching his grandson progress with the game of golf. Luke started playing at age 4 and at age 7 Dad was cheering him on in tournaments. He told me “that boy is going places.” I know he is smiling upon us.
Ms. Falkowitz followed up with another letter dated February 23, 2021. “Further, it is my understanding that despite my prior notice, you have continued to post inflammatory and defamatory statements in social media. Please know that this is the final notice to cease and desist this activity. Should you continue to do so, my client will consider action against you for same.”