Running head: Ethical-Legal Issues of DVT Treatment

Scholarly Ethical and Legal Issues Paper

Brandon Keys
Florida Gateway College

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Ethical-Legal Issues of DVT Treatment.

Abstract
We are presented with an unfortunate scenario of a 34 year old, mother of three, who
came to the emergency department complaining of right thigh pain. To honor HIPPA laws we
shall nickname her Mrs. Smith for this paper. This paper will have two parts. Part one will
provide arguments on behalf of the plaintiff. Part two will provide arguments on behalf of the
defendant.

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Part One
The medical care Mrs. Smith received at the emergency department was standard but not
thorough. Had the physicians who were responsible for her care been more cautious, they could
have advised her to get a surgically implanted Inferior Vena Cava Filter (IVCF) to prevent a
pulmonary embolism (PE). IVCFs reduce the risk of embolic complications and can be used
temporarily, according to Merck Manuals. Given that death from a DVT is attributed to a
massive PE, this would have saved her life. PE is the leading cause of preventable mortality for
in-hospital patients, and causes 300,000 American deaths each year (Patel, 2014).
While Mrs. Smith did not present with abnormal vital signs, there may have been more
insidious processes in action that her physicians failed to see. When a PE occurs, there is a 25%
probability of sudden death without any warning (Cunha, 2015). While anticoagulation therapy
lowers the risk for death, it does not eliminate it. Was Mrs. Smith explained all of the treatment
options available to her? Or perhaps she was just thrown a prescription for Lovenox and
instructed to keep her leg elevated and use compression stockings. In essence, who decided to
take the risk for out-patient treatment, Mrs. Smith or the doctor?
The vignette explains that she was assigned an ESI of 3. Given the outcome of her day,
this seems to be underscored. She had moderate pain in her leg as well, yet there is no mention
that they treated her pain. As there is no mention to blood work being done, it follows she did not
have an IV. The IV insertion was likely initiated later during the code to give Epinephrine.
It was explained in the article that Mrs. Smith was placed in a wheelchair and left in the
waiting room until her family came to pick her up. At some point after this a code blue was
announced. How long was Mrs. Smith slumped down in that wheelchair, dying, until the staff

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noticed? Was the waiting-room nurse on her phone? Was Mrs. Smith dead before they even
announced the code blue?
The facility may not have appropriately trained the waiting room nurse for these
scenarios. Perhaps the facility was under staffed that day and therefor unable to spot her warning
signs. Or perhaps the system in place did not provide Mrs. Smith a way to tell anyone she had a
sudden onset chest pain and/or shortness of breath, we will never know.
What we do know is that the staff had a duty to care for this patient, and yet she died. We
know that a breach of said duty occurred because they failed to monitor her. Hospital staffs are
not supposed to ignore you once you sign the discharge papers. Because no one noticed that she
suddenly became unresponsive, the staff failed their duty to this patient and resulted in her death.
These four elements of negligence are sufficient to show that the standard of care was not met
(Ball, 2008).

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Part two
The medical care Mrs. Smith received at the emergency department was appropriate and
the standard of care. The primary objective for treating a DVT are to prevent a PE, reduce
morbidity, and minimize the risk for postthrombitic syndrome. The main aspect of this treatment
has been used since the 1930s when heparin was introduced (Patel, 2014). As the article states,
Mrs. Smith received Lovenox, which is a form of heparin.
While the mortality rate of a PE is 25%, this is significantly reduced with anticoagulation
therapy (Cunha, 2015). The physician was prudent in ordering a CT and ultrasound of the
affected extremity. The initial and repeat vital signs were all within normal limits. At no point
during her stay did Mrs. Smith report shortness of breath or chest pain. We have no way of
knowing if she was minimizing real symptoms. Certain individuals do not want to sound like
their complaining or want to appear weak.
This patient was at low risk for a PE. She had a non-obstructing DVT of the lower
extremity. Her recent commercial flight was only 4 hours in duration. Furthmore, she was a
young otherwise healthy female, with no listed history of medical problems. She waited only 12
minutes in the waiting room, which is impressive when compared to other wait times.
This case does not have all four required elements of negligence, which is needed to
prove malpractice. While the staff did indeed have a duty to Mrs. Smith, they satisfied this.
Appropriate care was delivered in a timely safe manner. Nowhere in this article is a breach of
duty apparent. This is not one of your res ipsa loquitur cases, the thing speaks for itself (Ball,
2008). While damage is undeniable, there is no clear link to causation. An expert witness is
required to show the court that the standard of care was provided, and that a rare and unfortunate

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event occurred nonetheless. Most patients with a confirmed DVT can be safely treated as an
outpatient (Patel, 2014).
Mrs. Smith was escorted in a wheelchair to the waiting room, which is a normal
occurrence for the emergency room. We have no data about the other visitors interactions with
Mrs. Smith. Did someone fail to be a good Samaritan and let the pivot nurse know? We are not
even sure what caused her death, it may not have been a PE. Did Mrs. Smith visit the restroom
and use illegal drugs which could interact with the Lovenox she just received? We have no report
of how she got to the floor. Did she trip and hit her head on the floor causing an intracranial
hemorrhage? We may never know.
What we do know is that the emergency room staff responded to the code blue. Her initial
rhythm on the monitor was asystole, a very poor indicator. They provided CPR and advanced
cardiac life support for approximately 42 minutes. It appears that the staff worked very hard to
try to save Mrs. Smith, but were unable to obtain to.

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References

Ball, B. S. (2008, November 26). An Introduction to Medical Malpractice in the United States. In
NCBI. Retrieved April 6, 2015, from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2628513/
Cunha, J. P. (2015, March 3). Deep Vein Thrombosis (DVT) Prevention. In emedicinehealth.
Retrieved April 6, 2015, from
http://www.emedicinehealth.com/blood_clot_in_the_legs/page5_em.htm#deep_vein_thro
mbosis_dvt_prognosis
Douketis, J. D. (2014, May). Deep Venous Thrombosis (DVT). In Merck Manuals. Retrieved
April 6, 2015, from
http://www.merckmanuals.com/professional/cardiovascular_disorders/peripheral_venous
_disorders/deep_venous_thrombosis_dvt.html
Patel, K. (2014, August 28). Deep Venous Thrombosis . In Medscape. Retrieved April 6, 2015,
from http://emedicine.medscape.com/article/1911303-overview