Medical Justice provides consultations to doctors facing medico-legal obstacles. We have solutions for doctor-patient conflicts, unwarranted demands for refunds, online defamation (patient review mischief), meritless litigation, and a gazillion other issues. We also provide counsel specific to COVID-19. If you are navigating a medico-legal obstacle, visit our booking page to schedule a consultation – or use the tool shared below.
“Can Medical Justice solve my problem?” Click here to review recent consultations…
all. Here’s a sample of typical recent consultation discussions…
- Former employee stole patient list. Now a competitor…
- Patient suing doctor in small claims court…
- Just received board complaint…
- Allegations of sexual harassment by employee…
- Patient filed police complaint doctor inappropriately touched her…
- DEA showed up to my office…
- Patient “extorting” me. “Pay me or I’ll slam you online.”
- My carrier wants me to settle. My case is fully defensible…
- My patient is demanding an unwarranted refund…
- How do I safely terminate doctor-patient relationship?
- How to avoid reporting to Data Bank…
- I want my day in court. But don’t want to risk my nest egg…
- Hospital wants to fire me…
- Sham peer review inappropriately limiting privileges…
- Can I safely use stem cells in my practice?
- Patient’s results are not what was expected…
- Just received request for medical records from an attorney…
- Just received notice of intent to sue…
- Just received summons for meritless case…
- Safely responding to negative online reviews…
We challenge you to supply us with a medico-legal obstacle we haven’t seen before. Know you are in good hands. Schedule your consultation below – or click here to visit our booking page.
In one sense, we are all living on borrowed time. How hard should we look to find the ticking time bombs? When we find one, what do we do?
In terms of knowing whether we’ve made good decisions, we only connect the dots looking backwards. Still, I wonder what the right balance is – between “looking harder” and “ignoring what may go away on its own.”
Some background.
Two years ago, I fractured my left fibula. It was treated with 8 weeks of bracing. When I took the brace off, my calf was enormous. Not what one would expect with decreased use – and even predicted atrophy. I had zero pain. A doppler venous flow study showed extensive deep venous thrombosis, affecting calf veins going up into deep veins of the thigh. Rut roh.
The orthopaedic surgeon called my mobile as I left the doppler test, exhorting me to go straight to my internist – to start anticoagulation. I was already in my internist’s parking lot.
I did 12 weeks of Xarelto. I started wearing compression hose. All was well.
Fast forward two years.
Ten days ago, I went cycling. I’m an avid cyclist. I’m one of the older guys in the group. My compadres are fast. And it’s hell to keep up with them. We rode for 60 miles at a blistering pace. When we finished, my right calf was sore. No surprise. I figured it was a sore muscle and it would get better on its own.
It didn’t.
It was still sore 5 days later, a Thursday. And tender.
There was no swelling or bruising. I was leaving for a meeting in Miami the following day.
I thought, this couldn’t be a DVT, could it?
Nah.
To reassure myself, I ordered a D-Dimer test, fully expecting it to be negative.
I flew to Miami on Friday.
The D-Dimer results came back Friday afternoon at 4:50 PM. Naturally.
It was positive. The reference range was 0 to 0.5 mg/L. MY value was 5.0 mg/L.
Adopting Apollo 13’s command pilot, Jack Swigert’s famous line, “Miami, we have a problem.”
I was at a medical meeting and asked locals if they knew where I could get a venous Doppler flow study to rule out DVT on this late Friday afternoon – other than spending the night in an emergency department.
I called two vein treatment centers. One was closed. Another was fully booked with zero open slots. No luck.
I made the leap I had what I had. I went to Walgreens at 5:55 PM. They had already closed their register. Nonetheless, good fortune ruled. I was able to “score” 10 Xarelto pills.
Treatment had begun though the presumed diagnosis was unconfirmed. Still, the Xarelto bought me time.
Candidly, I felt relief.
That evening, I found a website touting portable diagnostics. They’d bring a Doppler ultrasound to a doctor’s office. They would also bring it to my hotel room. I scheduled the test online and put down a deposit. I was on for 9AM, Saturday. You gotta love the “innovations” and new services of the 21st century.
9AM passed. No show.
10 AM, I received a call. The company was sorry. They don’t work weekends. The scheduling module on their website should have blocked out weekends. It didn’t. They could do the test on Monday. I explained I’d be back in North Carolina then. They apologized profusely and said they “comp” me a free Doppler test next time I’m in Miami.
AWESOME. THANKS!
Well, I made it back to North Carolina. Doppler venous study showed a localized DVT in deep muscle (gastrocnemius) veins. There was adjacent trauma to the muscle – from that brutal cycling ride.
My internist believes these two events were “provoked.” Regardless, past tests to look at how thrombotic I might be were negative.
He suggested 12 weeks of Xarelto. Again. Plus, compression stockings.
The literature (as summarized in the updated guidelines from American College of Chest Physicians) is not definitive on whether patients with isolated distal DVTs even benefit from full anticoagulation. The risk of PE is not high. Another option is doing serial Doppler scans to see if the clot propagates to become a proximal DVT. The literature IS definitive on treating proximal leg DVTs with full anticoagulation. The Guidelines conclude the best course of action is shared decision making with one’s physician. Of course.
More unknowns. How soon could I go back to brisk exercising?
Plus, my wife and I will be heading to northern Finland for a long-overdue vacation. Right, northern Finland in the winter. I’ll report back. What if I have a medical problem in Lapland? I have no idea how sophisticated the hospitals are in the tundra.
Back to where I started. Most of us likely would have ignored the symptom as being self-limited. The pain and tenderness in my unswollen calf abated 8 days after it started. It would have been easy enough to ignore. Most of us would have ignored it. Even physicians. Even physicians with a prior provoked DVT. I was close to being that person.
Makes me wonder what other time bombs are looming. Anyway, we live to fight another day.
Medical Justice provides consultations to doctors facing medico-legal obstacles. We have solutions for doctor-patient conflicts, unwarranted demands for refunds, online defamation (patient review mischief), meritless litigation, and a gazillion other issues. We also provide counsel specific to COVID-19. If you are navigating a medico-legal obstacle, visit our booking page to schedule a consultation – or use the tool shared below.
“Can Medical Justice solve my problem?” Click here to review recent consultations…
all. Here’s a sample of typical recent consultation discussions…
- Former employee stole patient list. Now a competitor…
- Patient suing doctor in small claims court…
- Just received board complaint…
- Allegations of sexual harassment by employee…
- Patient filed police complaint doctor inappropriately touched her…
- DEA showed up to my office…
- Patient “extorting” me. “Pay me or I’ll slam you online.”
- My carrier wants me to settle. My case is fully defensible…
- My patient is demanding an unwarranted refund…
- How do I safely terminate doctor-patient relationship?
- How to avoid reporting to Data Bank…
- I want my day in court. But don’t want to risk my nest egg…
- Hospital wants to fire me…
- Sham peer review inappropriately limiting privileges…
- Can I safely use stem cells in my practice?
- Patient’s results are not what was expected…
- Just received request for medical records from an attorney…
- Just received notice of intent to sue…
- Just received summons for meritless case…
- Safely responding to negative online reviews…
We challenge you to supply us with a medico-legal obstacle we haven’t seen before. Know you are in good hands. Schedule your consultation below – or click here to visit our booking page.
Learn how Medical Justice can protect you from medico-legal mayhem…
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Jeffrey Segal, MD, JD
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Dr. Jeffrey Segal, Chief Executive Officer and Founder of Medical Justice, is a board-certified neurosurgeon. Dr. Segal is a Fellow of the American College of Surgeons; the American College of Legal Medicine; and the American Association of Neurological Surgeons. He is also a member of the North American Spine Society. In the process of conceiving, funding, developing, and growing Medical Justice, Dr. Segal has established himself as one of the country’s leading authorities on medical malpractice issues, counterclaims, and internet-based assaults on reputation.
Dr. Segal was a practicing neurosurgeon for approximately ten years, during which time he also played an active role as a participant on various state-sanctioned medical review panels designed to decrease the incidence of meritless medical malpractice cases.
Dr. Segal holds a M.D. from Baylor College of Medicine, where he also completed a neurosurgical residency. Dr. Segal served as a Spinal Surgery Fellow at The University of South Florida Medical School. He is a member of Phi Beta Kappa as well as the AOA Medical Honor Society. Dr. Segal received his B.A. from the University of Texas and graduated with a J.D. from Concord Law School with highest honors.
In 2000, he co-founded and served as CEO of DarPharma, Inc, a biotechnology company in Chapel Hill, NC, focused on the discovery and development of first-of-class pharmaceuticals for neuropsychiatric disorders.
Dr. Segal is also a partner at Byrd Adatto, a national business and health care law firm. Byrd Adatto was selected as a Best Law Firm in the 2021 edition of the “Best Law Firms” list by U.S. News – Best Lawyers. With decades of combined experience in serving doctors, dentists, and other providers, Byrd Adatto has a national pedigree to address most legal issues that arise in the business and practice of medicine.
First, your problem: you plainly have abnormal intima, so if you aren’t already taking statins, you might consider starting them. If it can happen on the venous side from just extreme exercise, it can happen on the arterial side, and then where will your loyal following be?
Next to what happens when doctors get sick? It’s interesting–isn’t it?–that this is not covered in medical school–at least not in the one I attended (Tulane). I had just such a problem about 30 or so years ago….
Back in the day before neurointerventional surgery was even called that, there were precious few people doing it in the US. I happened to be lucky enough to have been one of them. Since the club was so small, I did a lot of moonlighting. I was in Louisiana in 1990 and had lined up a total of 9 cases that I planned to do over three days. First two days went very smoothly, but I had a lot of trouble sleeping the night before the third day and when I got up to shower, I was overcome by fatigue the likes of which I had never experienced.
First two cases were trivial, so I felt confident. The third case, though, was a basilar apex aneurysm found incidentally as part of a screening exam on a lady who had had breast cancer. No way was I going to treat her the way I felt then. What to do, what to do?
I went to her room and talked with her and her husband, telling them that I was ill and couldn’t treat her that day, but that I’d either return and treat her at a later time, or I could refer her to another colleague. Her almost predictable response was to think I was lying to her and that we had found something we didn’t want to tell her. I went through it all again with the same response.
I finally took her hand and held it against my then-hot forehead and told her that I was the one who was sick and I wasn’t going to lead her into harm’s way being any less than 100%, lest I kill her. Her husband ultimately chimed in and told her that I had said I was sick. I returned 2 weeks later and detached a balloon in the aneurysm. And she did well.
Lesson? Be honest with patients and don’t try to be a hero when you’re gambling with their lives. Seemed kinda obvious in retrospect. Might be a good thing to throw into medical school curricula–shouldn’t take more than about 3 minutes on a busy day.
Nothing suffices for vascular surgery training. I did two years of surgical residency before anesthesia residency and fellowship. With a prior history of DVT, one is always at risk in the future. While this may be an intimal problem of the deep veins, one of the other causes (as I was taught) was prior trauma to the legs at some point in the past. If only one could remember the incident of trauma to the leg. In fact we all at one point or another have had injuries to our legs that seemed trivial at the time, but did some trauma to the veins of the leg. Swelling, redness or perhaps just pain. There is also a condition, called for lack of a better descriptor, perforating vein impending phlebitis. There is tenderness, and perhaps warmth and occasionally redness of the perforating veins (connecting the deep and superficial veins of the leg. It can proceed to DVT but often remains isolated. There is usually no swelling. But these perforating veins are superficial. Today we would get an ultrasound, but back in the day that was not available. The standard treatment for phlebitis was warmth, elevation, compression socks. Aspirin was felt to be helpful. It is unclear if the treatment today would be Xarelto. But with someone with your history, long plane flights with venous stasis would be a no no. Folks are no longer allowed to stroll along the aircraft isles as they were 40 years ago. For those of us who are taller, being jammed into a coach seat dislocating our patella on the seat in front of us while trying to find a comfortable position for our legs is torture. Better to pay to fly first class so one can stretch out and recline to prevent venous stasis and a DVT.
You could also have a genetic predisposition…. I’d consider checking a few tests: Factor V Leiden, Protein C & S, antithrombin III activity & antigen, plasma homocysteine, prothrombin G20210A gene, lupus anticoagulant, anticardiolipin antibody, anti-beta-2 glycoprotein, and Lipoprotein (a) (and if LP(a) is high, then LPA genoype).