Health A young woman attended the emergency department with chest pains several weeks after being prescribed a birth control pill. Her X-ray was mistakenly read by the emergency room physician as negative. She was diagnosed with chest wall muscle pain and was discharged with pain pills. Three days later, she attended the family doctor who was told that the X-ray was normal − even though the X-ray report had been corrected by the radiologist as abnormal − and more pain pills were prescribed. Later that day she suddenly died, the autopsy showing that she had a pulmonary embolism. That same year, a 36-year-old healthy male who had had a fractured tibia repaired and casted for two weeks was standing waiting for his bus when he suddenly collapsed and died. Autopsy showed a pulmonary embolism arising from a clot in the casted lower leg. These were but two cases of death from pulmonary embolism that I investigated when serving as regional supervising coroner for eastern Ontario. A pulmonary embolism is a blockage in one of the arteries of the lung blocking blood flow to part of the lung, and is caused by a blood clot that travels to the lung from a deep vein in a leg or, occasionally, from other sites including the arms. Veins return the blood to the heart to be pumped out by the right side of the heart through the pulmonary artery to the lungs. (After the blood is re-oxygenated in the lungs, it travels back to the left side of the heart to be pumped out via arteries to the whole body.) When a clot released from the leg vein enters the pulmonary arteries it will eventually stop, obstructing further blood flow to that part of the lung. There may be earlier symptoms of pain and or swelling in a leg suggestive of a clot (phlebitis or deep-vein thrombosis) or no prior symptoms at all, as in the cases above. The incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) in Canada is about 1-2 cases in 1,000 adults per year and is the third most common cardiovascular disease after heart attack and stroke. This information is important, as the risk is higher in seniors and there are certain preventive measures which you should know about, especially as snowbirds. Other risk factors for DVT and PE include those who have had recent surgery with resultant immobility, casting of lower legs, cancer treatment, immobility, obesity, taking certain birth control medications, genetic predisposition, past history of DVT or PE and those suffering from COVID-19. Symptoms of DVT usually affect the lower legs with possible swelling, pain, tenderness and redness of the skin. If any of the above risk factors are present, suspicion should be high. Urgent medical assessment is indicated − not only to diagnose and treat the clots and inflammation, but also to initiate treatment to reduce the threat of embolism. Diagnosis of DVT is made by a careful history and physical examination, along with ultrasound examination of the affected area to detect any blockage of blood flow in the deep veins. If any suspicion of a pulmonary embolism exists, further tests to examine the lungs would be indicated. Treatment for DVT is the administration of anticoagulants (often called “blood thinners”), which don’t actually thin the blood but reduce the ability of the blood to clot, thereby preventing further clotting as well as allowing time to let the body reabsorb the existing clot(s). The anticoagulants may be administered initially by injection (heparin), followed by the carefully monitored use of oral anticoagulants, most commonly Coumadin (warfarin), Xarelto (rivaroxaban) or Eliquis (apixaban). Blood Clots and Pulmonary Embolism by Dr. Robert MacMillan MD 40 | www.snowbirds.org
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