Robespierre

I presented at the ER with swelling, discoloration and pain in my right calf, and the first thing they did was a sonogram. Upon visualizing the clot, they immediately administered Lovenox and Coumadin.

If you are manifesting symptoms (see webmd.com), <b>go to the Emergency Room <i>immediately</i></b> (don't waste critical minutes trying to find your doctor - he'll tell you to go to the ER).

AR

Erm...no Walkinaround. That was one of the accurate points of the post! The problem is that you obviously don't understand what you've just said!

If you think that saying that Venography is a gold standard of DVT diagnosis is sacrcasm then you're more misinformed than I thought!!

Venography is indeed a failsafe was to diagnose thrombosis. D-dimers are easy and cheaper.

The rest of Anthony's post was sacrcasm, but that one point certainly wasn't.

Robespierre - your Wells score was obviously high and as such clot visualisation was the correct course of action as was the administration of low molecular weight heparin and Warfarin.

walkinaround

you said:
but no medical establishment is going to dive straight into such a procedure and to suggest that is misleading.
&gt;&gt;&gt;&gt;&gt;&gt;

the sarcasm was to suggest that you should or would have this procedure done immediately with a few symptoms.

you apparently took this part seriously as you accused him of being misleading in suggesting it would be done immediately. sarcasm, if taken literally, is always misleading!

anyway, not worth discussing further.

Sue_xx_yy

AR

I cannot claim to be a legal expert, but my guess is that the legal side of this is going to be quite complicated.

While an airline could issue a disclaimer to thrombophilic clients, not to mention clients in general, one wonders how they could obtain evidence or proof that someone had this condition, short of requiring medical histories to be surrendered by passengers. It's one thing for airlines to refuse passage to people actually in a given condition (e.g. women in late trimester pregnancy, or people requiring oxygen) and quite another to refuse passage to people merely at a theoretical risk of being in a particular condition. Furthermore, airlines not being insurance companies, one wonders if privacy laws would allow them to demand such information. It also seems nonsensical of them to refuse to carry someone whose very medical history is proof that the airline would not be principally at fault in the event of a DVT, assuming there is even fault found at all. (A British court recently sided with the airline in an attempted lawsuit involving a DVT, claiming successfully that DVT wasn't an accident under the Warsaw convention for international air travel. And international the travel is likely to be, since long-haul flights tend to cross borders, and the longer the flight, the greater the probability that the person is immobile and at risk, regardless of their medical history. So international law is very likely going to be involved - not just American law, which is notorious for being biased toward the plaintiffs.)

Also regarding thrombophilic people (how I love that term, as if I were in love with a clot!) you speak as if the airlines were the most likely defendant in any lawsuit. But if the condition is known to the traveller, presumably that means they've seen a doctor and in all likelihood not just a GP but a specialist. In that case, the doctor/specialist would be the one first in the line of fire - for a malpractice suit. As it is, most specialists are careful to give the latest advice (for which in most countries there must be hard evidence, not just speculation) on what the patient can or cannot do. My haemotologist didn't seem concerned about the length of flights I normally take, and believe me, I am more concerned with safeguarding my life, than with arranging handsome lawsuit payouts to my survivors.

Orlando_Vic

It is because of the possibility of DVT, that I bought (and used) some compression stockings just prior to our trip to Australia. It may not provide total protection, but it is something to consider if you take any long haul trips.

AR

Sue. This is certainly an area that we, as laboratory haematologists, are severely concerned about.

I can only speak with absoluteness about the UK, but I know that after attending several International conferences in both mainland Europe and the US, the same sorts of issues are problematic.

My concern is that we perform (in the UK) thrombophilia screens if asked. I know that 99% of GPs just ask for this screen without fully understanding the various tests being performed - and our worry is that three of the tests in the thrombophilia assay portfolio are genetically based (MTHFR, Prothrombin Mutation and the one that most people have heard of - Factor V Leiden). These three tests involve PCR gene detection. We do not obtain patient consent for these tests (it's not just us, but this is constant accross the UK).

Therefore, my point is that if a patient had a chest pain or sore leg and the GP or A&amp;E SHO requested a thrombophilia test, they would get one. Should that patient be found to have a thrombophilic state then no treatment is offered.

When that person fills out their insurance form (life or travel) and states that they have not had any genetic testing (as they didn't realise they had), they are in fact lying through ignorance. Should they then contract a DVT after a flight and sue the airline, their medical history would be requested as part of the investigation. The fact that they HAVE indeed had genetic tests would be brought up thereby nullifying any insurance.

To counter this, we now refuse all thrombophilia tests by asking the requesting doctor to contact us and justify the request.

We had notification that Quantas was looking into this very matter. I am not a lawyer but was scared to think that we may inadvertantly be breaking individual's rights by performing genetic tests with no consent. BTW, we didn't invent the thrombophilia assay portfolio, it is a standard set of assays. The genetic ones have been slowly introduced into routine testing.

As for your haematologist, remember that if you test positive for any of the thrombophilia assays, you have an 8x higher risk of developing a clot. Take Oral Contraceptives and this rises to 30x. Any haematologist that didn't advise for at least basic caution for anyone with a positive thrombophilia screen is just not doing their duty.

The same problem is seen with universal thalassaemia testing for pregnant ladies. Anyone on this forum who has been seen in an Ante Natal Clinic in a London hospital, for example, will have automatically had a Hb Electrophoresis test that has a genetic base. Can everyone say hand on heart that they were informed fully at the point of phlebotomy and gave consent for this?

I've now long since left the realms of travel but you seem to have an excellent grasp of medical ethics and I would genuinely appreciate your advice on how we should look at this issue.