Monday, August 27, 2007

Don't Try This At Home



In retrospect, I suppose it was stupid.

Deep vein thrombosis (DVT), meaning developing clots in the large veins of the legs which can break off and travel through the heart and into the lungs (pulmonary embolism -- PE --) is a risk of most major surgery. The general risk comes from the immobility of lying motionless on an operating table for a period of time (venous circulation in the legs depends much on muscular action, which milks blood north with the assist of one-way valves in the veins.) There was a time when such clots were an unrare complication of surgery; in fact, years ago I lost a couple of patients to it, despite doing everything we knew to do in those times. Now, because of several measures, the complication -- at least at a level where it's noticeable -- is quite rare. Those measures include much better peri-operative hydration, early ambulation after surgery, and the very common use of low-dose blood thinners before surgery along with pump devices on the legs during (and sometimes after) the operation. For certain orthopedic or pelvic operations, and with laparoscopy (which adds to risk by blowing up the belly and often tilting the patient head up, both of which tend to add to blood congestion in the legs), the risk is increased and these steps are virtually always taken nowadays. Which is a good thing. The last time I saw DVT with or without PE in a patient of mine was many years ago. I have, however, seen it quite close recently. Coulda killed me.

After I sort of retired, I did some things I'd been meaning to do for a long time. Took an acting class. (Well, that ended quickly enough: in high school and college I had some leading roles in musicals, and had delusions...) Went on a trip up the Amazon River. Got back into shape and resumed bicycling, including a couple of several hundred mile rides. All of which, you'd think....

So anyway, at the height of my healthfulness, not long after finishing a long bike ride (and many months after flying to Peru and back), one day I began to notice I was shorter of breath on biking exertion than I'd been. Figured I must have a little respiratory infection, backed off a little but kept riding. A few days later I took my son to a basketball game, seated in a place with criminally minimal foot and leg-room (anyone been to Key Arena?) Shifting uncomfortably throughout the game, I complained of my left calf in particular. But I didn't think it related to anything but the cramped quarters. Until a day or so later when I noticed the calf was pretty big. Us biker guys gots big calves and nice quads. But they're supposed to be sort of equal, side to side. This wasn't.

Reluctantly, I saw my doc. (He's "mine" in the sense that I list him as such when asked to. I don't do the, y'know, regular checkup thing.) I have to say even he figured, "Naw, couldn't be... but let's get a doppler anyway..." Having driven to his office, I also drove to the lab, where the study showed a clot flapping its way right up to my groin, big as life. (The clot, not my groin. Sadly.) I drove back to his office.

"No way," I said when he ordered me to the hospital. "It's been going on for several days, I've been biking. If it was going to kill me, it already would have, wouldn't it?" I'm bigger than he is (bigger, not smarter), and somehow he agreed to outpatient treatment. So I got daily injections of fragmin while I waited for the coumadin to take effect, and spent most of my time on my recliner. Also, I figured if a big clot broke off at home, my chances of survival were approximately the same as if it happened in front of the cardiac team; but with less fuss. The outcome is pretty much binary: fatal clots are fatal, and survivable ones would generally allow time for a ride.

Faced with a similar patient with similar demands, I'd have insisted with everything I had that he go to the hospital for a few days and stay on complete bed rest until fully anticoagulated. Or had him sign something if he refused. I still haven't decided what I'll do if I really get sick sometime. As comfortable as I've been caring for the ill, as glad to help and gratified by it, the idea of being that dependent on other people -- the idea of one person (not one person: this person) taking up that much space in the order of things seems disproportionate and uncomfortable. Don't get me wrong: it's quite OK for you. I'm just not so sure about me. And what the heck. My recliner is pretty comfortable.

[Clarification: This incident occurred a couple of years ago. Other than mild post-phlebitic syndrome, I'm fine. Maybe it was the recliner reference in the last sentence that was confusing: I was just thinking ahead...]

25 comments:

Elaine said...

Physicial, heal thyself!

Health Train Express said...

Sid, out of bloggisms? Hard to believe....Next thing you will tell us is you are a "humble surgeon"....
Gary L

Sid Schwab said...

Out of bloggerel, more like. Scraping the bottom of the brain-barrel.

rlbates said...

Sid,
After my anterior cervical fusion (back in 1991--early in my career) my friend who did the surgery keep me in the hospital for 3 days. I got up each day, dressed, and made the bed. Then sat in the chair (refused to stay in bed)and crocheted/read/watched TV. The first day he made rounds, I was so excited about the relief of pain, etc that I had to show him how I could do a pushup (off the wall not the floor)--scared the sh*t out of him. I forgot everything at that moment, but my gratitude to him! I had gone to surgery with major pain, numbness in my fingers and loss of triceps strength. I was just happy. Fortunately no damage was done.

Dr. Rob Oliver said...

Sid,

OTOH, I've seen more people die as a result of coumadin or heparin-related complications then I have from pulmonary emboli by (I'm guessing)a ration of about 10:1.

How many spontaneous retroperitoneal or GI bleeds did you have to treat from people on weak indications for anti-coagulation? I can remember dozens during my general surgery training. I've also had to work on some real bad disecting hematomas on the arms/legs of people in recent months.

Sid Schwab said...

Rob: no doubt about it. Plus a couple of bowel obstructions from spontaneous hemorrhage into the bowel wall. Anticoagulation is ripe for "damned if you do, damned if you don't" decisions.

pete said...

Dr Schwab,

You don't get regular check-ups? I find that surprising. Any reason you're better off without them?

Sid Schwab said...

Pete: absolutely not. That's another reason I titled the post "Don't try this at home."

Anonymous said...

I've had my own "DTTAH" moment fairly recently. I developed some pain in my left calf about 2 years ago. Now mind you, I had been walking (shopping) in shoes that didn't fit well, so I blamed it on that. Hard to blame the swollen part on that though, but I tried. For about 2 weeks (yeah, yeah, head in sand syndrome) until I asked a friend (physican also) about it. Got my ultrasound/doppler and voila, a clot. Only to the knee, but given I am heterozygous for factor V Leiden, got put on fragmin also. The other part is getting pregnant and having to be on that for over a year... fun!

Glad that you are now being appropriately treated. Keep well.

Kellie

mkeamy said...

You getting worked up for hyper-coagulability? It'll make a differnece on how aggresive you want to be with pharm prophylaxis

Anonymous said...

After recently suffering a PE after my gallbladder surgery, (my surgeon called me unlucky, since it's been years since he's had a patient suffer one - and never a 32 year old healthy female) and having recently started my coumadin regimen, I sympathize with you and wish you plenty of INR's between 2 and 3. Getting there is easy, staying there...that's the hard part.

Anonymous said...

A couple of comments:

"I don't do the, y'know, regular checkup thing."

Given your age sid I think that would be a mistake. We should not really treat ourselves. I am sure you are a fine surgeon, but you aren't an internist. I think surgeons more than internist's fall in the trap of trying to treat themselves outside their scope of practice.

"OTOH, I've seen more people die as a result of coumadin or heparin-related complications then I have from pulmonary emboli by (I'm guessing)a ration of about 10:1."

Again rob, You are coming from your bias as a surgeon. You see the complications of coumadin/heparin therapy. As an internist I have admitted a PE every couple of days. Additionally, as docs we are pretty bad at picking up PE's. Ask any pathologist about how many PE's he picks up at autopsy (it is pretty common). No argument about coumadin bein a drug to treat with respect though.


"You getting worked up for hyper-coagulability? It'll make a differnece on how aggresive you want to be with pharm prophylaxis"

In the setting of an initial PROVOKED DVT, the initial w/u is NOT the hypercoagulable lab panel. It is simply a CBC and PT/PTT. If concerning abnormalities are noted on coags then start the hypercoag labs. Additionally, a common mistake is to order Protein C and S on anticoagulation. Really it is very hard to interpret most "hypercoag labs" in the setting of an acute DVT (with the exception of the genetic tests such as prothrombin gene mutation and factor V leiden). Further DVT's or abnormal coags however do justify a w/u.

Patricia P said...

DVTs are scary. I walked around with one several years ago for 4 days. Went to the mall and could barely get back to my car. Called my doc, told him what was going on and he put me on hold and scheduled a doppler.

Prior to this, I'd had a PE at age 29 (possibly birth control pills)& a DVT at 32 when I was pregnant. Hadn't had any problems for years until the latest DVT.

Now, I'm taking Coumadin, which I hate. I do miss my martinis tho!!

FetchingGal said...

Awww feel better soon! :)

Terry at Counting Sheep said...

If you can pull this off at home, I say go for it by all means, and stay away from the hospital!!

Think of all the blogging you'll get done ;-)

Sid Schwab said...

I should clarify: this was a couple of years ago... Other than mild post phlebitic syndrome, I'm fine.

Anonymous said...

""OTOH, I've seen more people die as a result of coumadin or heparin-related complications then I have from pulmonary emboli by (I'm guessing)a ration of about 10:1."
Oh my... You are scaring me. My mom is on coumadin - she had an episode of atrial fibrillation recently.

SeaSpray said...

Interesting post Dr S. and very glad you are here to write about it among other things. :)

It's true (obviously) much better to be the one helping the patient. Curious though Did YOU do the right thing in not going into the hospital? I understand you have knowledge about these things but was it really the correct call given the fact that you would have wanted your patients to go in?

I find this info reassuring regarding OR procedures to take preventative measures. At least I don't have to go to the OR now. :)

I think I told that I spent too much time sitting at my computer BLOGGING/READING BLOGS this past winter and think I have created some vascular things.

Have to get a laptop!

Bongi said...

i find that every time i treat someone in the medical business, the chances of complications and things going wrong is much higher. also bearing in mind that only the good die young, i think you therefore did the right thing by not going in. you probably would have picked up some nosocomial superbug and died a slow horrible death with sirs, mods etc.

i for one am glad you didn't go in.

Greg P said...

There's always the old saying, "A physician who treats himself has a fool for a patient and a doctor."

Lynn Price said...

Totally off topic here, but where all did you go on the Amazon, Sid? You took off from Iquitos, yes? I went up the Amazon with a medical group for 17 bug-infested days and loved every minute of it.

Sid Schwab said...

Yes. From Iquitos, up river a few hours in a sort of water taxi, then to a series of three primitive lodges (no electricity or running water) on backwaters, with hikes into the rainforest, and a stay at the canopy walkway at ACEER. Eventually upriver again on a cool and funky river boat to a national wildlife reserve. It was an amazing trip, with flora and fauna to dazzle every minute!

Anonymous said...

Hey, Sid

Is it machismo that keeps you from getting a physical? If you are too worried taking a hit to your manliness to get checked out, think about all of the people who would miss you terribly if you checked out early. I love reading your blog, but it is your family and friends I am thinking about.

Ms. MOM said...

I'm currious. In our office, we document in the dictation when a patient refuses a treatment recommendation. But we've never had them sign a statement. Do you do that routinely?

Ms. MOM @ MOMrants.com

enrico said...

Hmmm....I may be talking out the caudal end of my GI tract, but perhaps you were relatively thrombocytopenic having been in Peru...I wonder if this had anything to do with an increased chance of a clot. You've also mentioned having to wear compression stockings due to statis dermatitis even in your earlier years...maybe you're predisposed to such things if the balance tips too far from normal.

I understand the idea of taking the meds and waiting it out at home--if I'm gonna have a massive PE, I'd rather have it happen @home in my skivvies, enjoying my normal routine than in some hospital gown with IVs, no privacy, no rest, etc.

I know squat about the surgical management of such things, and obviously, you've done your time w/vascular stuff, but if I saw such a clotmonster on the doppler, my reaction would be "Cut the f*cker out! I ain't waiting around like a ticking time bomb wondering when whichever breath is gonna be my last...Where's the roto-rooter?!?" But that's just me. :P

(BTW, the Toyota Center in Houston has plenty of leg room--shamelessly so, in fact. *taunt*)

Oh, and of course, I'm glad you're all well now, even if you do have an inconvenient souvenir. :)