Missed Iliac Vein DVT [ Med Mal Case]

Case here: https://expertwitness.substack.com/p/missed-dvt-despite-ultrasound

Before I jump in to this case, I’ll first say I don’t think it was malpractice. Super sad case, and some learning points for sure, but not malpractice.

It’s gotten a lot of attention in the lay press so I decided to publish what’s been disclosed in the legal records to get as close as possible to the truth. I usually only publish if they include the expert opinion reports, which they didn’t, but there was still a lot of good info and I felt like it justified a post.

College student with history of protein S deficiency (edit for typo: protein C deficiency) and prior DVT comes to the ED with butt pain. Says he thinks he might have a DVT.

Also, has not been taking his anticoagulation.

I’m sure the PA thinks it’s weird (what DVT causes butt pain with no leg pain and no leg swelling), but nonetheless orders the DVT ultrasound.

It’s negative, patient sent home.

Patient codes and dies a few days later. Autopsy shows iliac vein clot and large PE.

Patients family sues and they settle for $3 million.

Not sure I would have caught this and I don’t think it’s malpractice, but here are some good learning points:

  1. Iliac vessel pathology sometimes causes referred pain to the butt.
  2. DVT ultrasound can’t see iliac vein DVTs. There might be some changes in flow with respiration but most of our techs/rads aren’t looking for that as far as I can tell.
  3. Prophylactic anticoagulation is different than therapeutic anticoagulation. I can’t tell you how many doctors sent me messages saying it didn’t matter if the DVT was diagnosed, he should have been taking his blood thinner anyway so there was no change in management. That’s not true. The dosing is different going from prophylactic to therapeutic. You could argue that therapeutic anticoagulation doesn’t prevent all PEs, but the management is definitely different.
  4. Easiest way to check the iliac veins is to do a CT venogram pelvis w contrast.

Ultimately I don’t think it’s reasonable to CT scan everyone with butt pain and negative ultrasound (especially if there’s no swelling), but in the appropriate patient, definitely worth considering.

Author: efunkEM