By Bob Aller:
Deep vein thrombosis (DVT) is a potentially fatal blood clot that forms in the deep veins of the legs. A DVT may break off and make its way to a lung, blocking blood flow. Unfortunately, such clots often becomes a fatal pulmonary embolisms (PE). The CDC estimates roughly 900,000 Americans have a DVT each year. 60,000 to 100,000 patients die each year from a DVT.
For good reasons, the Centers for Medicare and Medicaid Services (CMS) require hospitals to maintain policies that prevent such fatalities. Sometimes, however, hospital staff fail to comply. As a result, people die.
The 436-bed Brandon Regional Hospital in the Tampa metro area is owned by HCA Healthcare. On December 1st and 2nd, 2020, an investigation was conducted at Brandon by the Florida Agency for Healthcare Administration. Investigators found 62-year-old Keith Davis died after multiple providers disregarded the hospital’s DVT risk assessment policy designed to prevent harm from a DVT.
A Statement of Deficiencies was issued on December 17, 2020. According to the report, a “DVT Risk Assessment” was required at admission, at each shift, and at any change in the level of care.
The policy required early prophylaxis medication for the prevention of complications. The attending is required to write an order for prophylaxis at admission or, alternatively, to document why the patient did not need DVT prophylaxis. Yet, despite medical records citing Mr. Davis’ history of a DVT at this hospital and the patient’s use of an anticoagulant, there was no documentation whatsoever indicating compliance with the hospital’s “DVT Risk Assessment” policy over a 6-day period of hospitalization..
(Hospital Watchdog asked Brandon Regional Hospital to provide a copy of the “DVT Risk Assessment” policy, but Brandon did not respond to the request.)
In addition to the patient’s medical history of a DVT, presenting symptoms included an extremely painful swollen left leg. The patient was unable to walk. The left leg skin was discolored, with irregularities and redness as seen in a cell phone image taken by Mr. Davis on October 1st.
An examination of the medical records shows that multiple providers failed to assess whether Mr. Davis’ presenting symptoms and medical history reflected a possible DVT. An ultrasound and a D-dimer blood test, two key diagnostic tests for a DVT, were not conducted.
Hospital Watchdog interviewed Mr. Davis’ daughter, Sabrina Davis, CMA. (The interview was edited for brevity.) Ms. Davis was present with her father in the ER. In addition, Ms. Davis spoke on the phone and texted her father during the following 5-days of hospitalization. Ms. Davis recounted that both she and her father made multiple oral pleas for an ultrasound to determine if a DVT was present. Oral requests described by Ms. Davis do not appear in the medical records.
However, on October 12, 2020 (3rd day of hospitalization), Mr. Davis texted his daughter informing her that he asked the staff that day for an anticoagulant. No anticoagulant was provided.
However, after informing staff that he used compression socks at home the staff promptly placed a sequential compression device (SCD) on his left leg. However, the use of an SCD prior to testing for a DVT is contraindicated by some experts. We recommend screening patients by ultrasound routinely to identify significant occult DVT (unrecognized thrombus) capable of producing a pulmonary embolism before the placement of SCD’s since clinical examination is not reliable.
Mr. Davis texted his daughter on October 12th, expressing grave concerns to no avail. “A second opinion is what I need. If I need some kind of surgery or something I will get it done… He (Dr. Moorthy, medical unit attending) doesn’t seem to care if I sit here and have a clot.”
Dad knew if this happened again it could be fatal. He had retired from the Navy. During his career, he served on a ballistic missile submarine, the USS Stonewall Jackson. He served as a Quartermaster involved in ship navigation. He knew how to follow a strict regimen. After that incident, he was diligent with taking his blood thinner. On any long car drive, he took breaks to stretch his legs. He had a daily walking regimen. I was thinking about that as I was driving to the ER. After my Dad’s death, I was unable to find a prescription bottle with his anticoagulant, Eliquis. He did have free samples of Eliquis. It made me wonder whether he had been taking Eliquis regularly before the DVT occurred.
With the ER delays, I made it in time to be present during my Dad’s initial exam with what we thought was a regular ER physician. Later, I learned that Ali Kamel Al-Marzoog was a resident.
My Dad and I told him that in 2008 my Dad was diagnosed with a large blood clot in his right leg. We explained that since that time my Dad had taken a blood thinner.
The resident ordered an x-ray and a CT scan. He came back with the result of the CT scan. He told us it showed fluid on the knee. I asked whether a CT scan could show if a blood clot was also present. He answered: “No.” I then requested an ultrasound to see if a blood clot was present. He said the test was not needed. He said the problem is fluid on the knee. I remember looking the resident right in his eyes. I touched my Dad’s knee that was warm to the touch. It was also swollen, bruised, and painful. I said, “These are symptoms of a blood clot.” I repeated my request for an ultrasound. Before I could finish my Dad spoke up and said that his left leg felt exactly as his right leg did in 2008 when he was diagnosed with a blood clot. Again, the resident insisted that an ultrasound test was not needed. He touched my Dad’s leg and acknowledged that my Dad’s leg was warm to the touch. The resident discarded my Dad’s medical history and symptoms. He repeatedly said the problem was fluid on the knee.
Dr. Sergio Martinez was responsible for supervising the resident. Dr. Martinez made one entry in the chart and agreed with the resident’s plan. The resident had rejected our description of my Dad’s previous blood clot, his symptoms of a DVT in the ER, and our request for an ultrasound. Dr. Martinez wrote: “I have reviewed and agree with the resident’s note and I have reviewed all labs, ECGs, and imaging studies or reports. I agree with the resident’s findings, exam, and plan.” While my Dad was in the ER no blood was drawn and there were no labs.
Correction of 1/12/2022: This article was first published on July 27, 2021. The Statement of Deficiencies for this case indicated that a hospital policy required the attending physician for inpatient services to write an order for prophylaxis at admission or to document why the patient did not need DVT prophylaxis. We regret that this report mistakenly indicated Dr. Martinez, the physician supervising the resident in the ER, failed to make the required entry in the chart. The physician who failed to make that entry was Dr. Moorthy, the inpatient attending.
Sabrina Davis was permitted to be with her Dad during the ER visit. However, once her Dad was admitted to the medical unit on October 10, 2020, the hospital’s Covid policy did not allow her to be present in his room. During her Dad’s inpatient stay all of Sabrina’s subsequent conversations with her father and hospital staff were by phone and text.
On Monday, October 12, Dad texted me. He said, “the physical therapy lady pushed a folded sheet under my leg pointing the toes straight up. I yelped in agony. It hurt bad.” I read about the Homan’s sign test and wondered whether that’s what this was.
Hospital Watchdog consulted a surgeon knowledgeable about DVTs. He commented on Mr. Davis’ text: “From my training and experience, this is basically a Homan’s sign test and it was exquisitely positive. The resulting pain from this maneuver should have suggested to the physical therapist a possible DVT. The positive results should have triggered further testing to see whether a DVT was present or not.”
Nevertheless, the medical records do not include any entry by a physical therapist regarding the test described by Mr. Davis.
At 10:40 am, 30 minutes after I got off the phone with my Dad, I received a call from a number I did not recognize. I took my phone to my room because my son was on the computer doing schooling on zoom with his second-grade class. A lady asked if I was Sabrina. I replied, “Yes.” The lady bluntly informed me that my Dad had gone code blue. She stated he was not breathing and had no pulse. She asked, “What would you like us to do?” Those were her exact words.
I told her there’s no way. I had just spoken to my Dad and he was fine. He’s being discharged.
She repeated: “M’am, what would you like us to do?” I told her “You get my Dad back and you do not stop until you do.” She said OK. I could hear beeping and a lot of commotion. I asked when did this happen She said about 10 minutes ago. I wanted to stay on the phone with her but she said she couldn’t. She needed to get back in the room. We hung up. I called back a few minutes later. She said they were trying but they hadn’t made any progress. I assured her my Dad was fine as I had just talked to him a bit ago. She told me not to get my hopes up. She told me: “Be prepared.” I asked if she could put the phone to my Dad’s ear. She said, “No, I’m not in the room.” I asked, “Can you go into the room?” She was insistent and said “No.” She said, “He wouldn’t hear me anyway.” That hurt. We hung up.
I called her back several times afterward. She did not answer. I never heard from her again.
I waited anxiously, not knowing what to do. Later, I would read in the medical records that CPR was conducted for 53 minutes. At 11:20 am, I got a call from a different number. It was Dr. Blake Spain. He was the Medical Director of the ICU. He called with a calming voice telling me that all life-saving techniques were unsuccessful. I asked him why did this happen? What time did this happen? He told me at 10:28 am a hospital physical therapist was in the room. My Dad tried to stand. He complained of dizziness. He laid back down in the bed and became unresponsive. That’s when code blue was called, he said. I asked Dr. Spain to put the phone to my Dad’s ear. He said he would do that. I made some promises to my Dad. I said, “I will find out what happened and if it was preventable.” I said, “I’ll make sure July (Mr. Davis’ cat), is safe and taken care of.” I cried harder than I ever have in my life.
Days later I was googling and came across a study that says a person’s hearing may be the last sense to go after death. I do feel like my Dad heard me.
Right after I spoke with Dr. Spain, I phoned my Dad’s physician, Dr. Moorthy. I was distraught. In fact, I was crying. I asked him to order an autopsy. He told me that he had never ordered an autopsy. I reminded him that earlier in the day when he told my Dad he was discharged I was on the phone with my Dad. He was doing well. I said, “An autopsy is needed.” I literally begged him to order an autopsy. Whatever I said had no effect. Dr. Moorthy refused to request an autopsy.
At that moment I sensed I wasn’t going to get any help. I told Dr. Moorthy I would get a private autopsy. I told him I would try to find out exactly what happened to my Dad. I was angry. I hung up the phone.
By refusing to order an autopsy, Dr. Moorthy avoided the possibility of having to address the reporting requirements of the Florida statute for an adverse incident involving a death.
The results of the autopsy confirmed my instincts. Dr. Schultz reported that “the autopsy disclosed a massive pulmonary saddle embolism at the main pulmonary artery at the bifurcation of the right and left arteries.”
“The use of anticoagulation therapy and a variety of measures… may have altered the course”
The providers’ failure to follow the hospital DVT protocol led to my father’s death. To them, they lost nothing. No one from the hospital even called me to just say they were sorry.
I lost my best friend. Dad was always honest with me. He was always there to listen to me no matter what time it was. I loved listening to him play on his acoustic guitar. He always made sure I knew how proud he was of me. My Dad was always into sports. He particularly enjoyed watching his grandson progress with the game of golf. Luke started playing at age 4 and at age 7 Dad was cheering him on in tournaments. He told me “that boy is going places.” I know he is smiling upon us.
It’s common for patients with a bad experience in a hospital to post their strongly-felt views on social media. When Ms. Davis expressed her critical comments on the Brandon Facebook page in early January 2021, she included a link to the adverse ruling by the Florida Agency for Healthcare Administration.
On January 15, 2021, attorney Tracy Falkowitz wrote to Ms. Davis: “Brandon Regional Hospital insists that you cease and desist all such activities to defame the hospital and tortiously interfere with business practices. Should you have any questions regarding liability for any future postings or defamatory comments regarding Brandon Regional Hospital, I urge you to retain your own personal counsel.”
Ms. Falkowitz followed up with another letter dated February 23, 2021. “Further, it is my understanding that despite my prior notice, you have continued to post inflammatory and defamatory statements in social media. Please know that this is the final notice to cease and desist this activity. Should you continue to do so, my client will consider action against you for same.”
After Keith Davis died, Brandon Hospital management did not offer condolences to Mr. Davis’ family. However, hospital management did feel a need to silence Ms. Davis.
Florida is the only state in the U.S. with a law denying family members, other than a spouse or child under age 25, the right to seek accountability in the courts for grossly negligent care in hospitals. (FS 768.21 subsection 8)
