blood clots

Monday, August 11, 2014

In August, a Philadelphia sports fan should be thinking about the Eagles and the Phillies but not necessarily the Flyers…okay, perhaps not the Phillies either, so it would have been easy to miss the news in the City of Brotherly Love, that Flyer defenseman, Kimmo Timonen, was hospitalized in Finland for blood clots in his leg and lung. The 39 year old was supposed to play an important role for the Flyers in the coming season, but team General Manager Ron Hextall was uncertain whether he could play: “This could be a long term thing…Could he play next season? I don’t have an answer to that.”

The answer begins with the treatment for DVT, deep venous thrombosis or blood clot in a vein, and PE, pulmonary embolism or blood clot in the lung. Anti-coagulation or blood thinning is the treatment of choice for both DVT and PE and while on that treatment, Mr. Timonen will not be playing hockey. By interfering with the body’s ability to clot blood, minor injuries can become major disasters, especially in hockey where falls and body contact are routine parts of the game. A minor bump to the head can cause lethal bleeding in the brain. A blow to the chest or abdomen can cause uncontrolled bleeding and shock if the body cannot mend itself. The big question to be asked is how long does he have to be on blood thinners? And that is where the science of medicine is not quite as precise as we have come to expect.

There are a few reasons why a blood clot or thrombus might form. The big three categories are vein injury from trauma, blood stasis and problems with the blood clotting mechanism. If the body is immobile, there is less muscle activity to squeeze blood back to the heart and stagnant blood tends to clot. Patients who are bedridden due to stroke or surgery (especially after pelvis, hip or leg operations) and those that have casts in place are at risk, as are people who sit in an airplane or car for hours. Decreased blood flow from the legs may also occur in obese people and can also be seen in pregnancy where the enlarged uterus compresses veins in the pelvis. Underlying medical problems can increase the risk of blood clot formation and range from genetic predisposition, to cancer, to smoking and the use of birth control pills.

DVTs are common but the big complication occurs when the thrombus breaks off and embolizes or travels through the heart and gets lodged in the lung arteries. More than 600,000 people are diagnosed with a PE every year in the US and the death rate is about 25%, but those numbers may significantly underestimate the problem. Based on death studies, there may be more than double that number and the diagnosis of pulmonary embolus often occurs autopsy. When a PE occurs, it affects the ability of the lung tissue to transfer oxygen from the air in to the blood stream and depending upon the amount of clot, the symptoms may be mild (sharp chest pain and mild shortness of breath) to collapse and sudden death.

The diagnosis is always in the back of the doctor’s mind to at least be considered when caring for people with shortness of breath. The diagnosis is entertained based upon history, physical examination, clinical suspicion and risk factors. It is confirmed in a variety of ways depending upon the clinical situation and the patient’s stability. Often, it may include, EKGs, blood tests, ultrasounds and CT scans.

For most people the treatment is anticoagulation, the use of medications to thin the blood. There are a variety of choices, depending upon the patient’s situation but most involve a combination of heparin injections to immediately thin the blood while also taking Coumadin by mouth. It takes a few days for Coumadin to reach effective blood levels, so dual therapy often occurs. Newer anti-coagulation drugs have been developed and in the past few months, Xarelto (rivaroxaban) has been approved as a single step oral treatment for PE. But in critical situations, emergency surgery may be required to remove or dissolve blood clots in the lung.

With that background, the question remains. How long should treatment last? For the first DVT or PE, anticoagulation is recommended for 3 months, as long as there is no underlying reason to consider longer therapy. Imagine a cancer patient or one who has an abnormal blood clotting disorder. For recurrent clot, the recommendations are less clear and consideration may be given to life-long treatment. The duration of therapy recommendations are more than a little vague for those patients.

This is the second time around for Mr. Timonen with clots. In 2008, he developed a DVT after being hit by a puck in the foot. Now the questions that face him and his doctors include whether that first DVT was due to trauma and does not count in deciding how long the anticoagulation should last. And they need to decide what caused this episode of DVT and PE and whether there should be a search for any underlying risk factor. And that leads to the question posed by the Philadelphia general manager as to whether Mr. Timonen will play in the coming NHL season that begins in about a month. And the answer is…not anytime soon.

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domestic violence

Sunday, August 3, 2014

Players know the rules and understand that violence needs to be contained within the sidelines. A great hit on the football field is flagged as a penalty if it happens out of bounds. But the violent actions that are celebrated and relived in slow motion replay, are not the real world. In the real world, violence should never be an accepted or explained, but for too many people, violence is their normal. The Ray Rice domestic violence story perhaps allows an opportunity for us to understand the depth and pervasiveness of this disaster, which is not limited by national border, race or social class.

Briefly, Ray Rice, an NFL running back, plead not guilty to third degree aggravated assault charges after police were called to a dispute at a New Jersey hotel and video showed him dragging his unconscious, soon-to-be-wife out of an elevator. By entering and completing the terms of a diversion agreement, the charges will be dropped but the arrest record will remain. The arrest might have been forgotten, it happened 5 months ago, except for the two game suspension levied by the NFL under its personal conduct policy. There was no Goldilocks scenario for the NFL ruling. People felt it too harsh or too lenient but none thought it just right, except perhaps for the NFL Commissioner’s office.

Domestic violence continues to be a hidden public health crisis, not only in the United States but worldwide. It is estimated that 1.3 million women are abused in this country every year. There are no firm numbers, because victims of domestic abuse often do not step forward to report the crime. For a variety of reasons, even after seeking care for major trauma in the ER, women hide the true cause of their injuries, even when confronted with indisputable proof.

“Violence against women is often accompanied by emotionally abusive and controlling behavior, and thus is part of a systematic  pattern of dominance and control. Domestic violence results in physical injury, psychological trauma, and sometimes death. The consequences of domestic violence can cross generations and can truly last a lifetime.”

–National Coalition against Domestic Violence

Leaving an abusive situation is complicated and decisions that victims make may not seem reasonable to an outsider unfamiliar with the situation. Often it is because options are lacking. Children may be put at risk, there may not be any money to help leave and then there is always the fear of retribution. Even with police protection, the use of women’s shelters or relocation, there can be the fear that the batterer will stalk the victim and the next attack could result in death. There is usually a next attack.

In medicine, prevention is always preferable than diagnosis and treatment, but for victims of domestic violence, major societal change will need to occur before an individual assault can be prevented. Poverty and unemployment, economic stress, low educational achievement and weak community infrastructure, where neighbors are unwilling to intervene, are risk factors that an individual victim cannot fix. The spiral of marital instability, a history of being abused or watching abuse occur when growing up leads to behavior repetition. But we should not presume that domestic violence is only a class issue.

Victims come from all neighborhoods, all jobs and all ethnic and religious backgrounds. There is no typical victim and there is no typical abuser. Last month, John Michael Farren, former White House lawyer and general counsel for Xerox, was found guilty of attempted murder of his wife, after breaking her face with a flashlight and strangling her. She was able to escape with her two children from their mansion in Connecticut. It took 4 ½ years to get the conviction after the domestic assault in 2010. Most victims cannot hide and live in fear for that long.

The story of Ray Rice is yet to be written. He is a first offender. His victim is now his wife. He stood in front of the press and explained his commitment to family including his 2 year old daughter. He has returned to the Baltimore Raven training camp, where fans wore his #27 jersey and cheered loudly as he made his entrance. One act of violence may not define a person but regardless of the performance during a game, the decision as to whether an athlete should be cheered and considered a hero needs to be based upon their actions away from the field of play. And no matter how many yards rushed or passes caught, Ray Rice will not be a hero.




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