Re: Spinal surgeon was negligent in giving patient heparin too early and leaving her disabled
An argument has been put forward, with scant evidence to support or refute its principal assertion, which has found favour in this judgement.
I am not confident at all that a haematoma in this context could occur ‘beyond all reasonable doubt’ because of early use of LMWH. I would not be confident either in asserting that the haematoma occured solely on the early use of LMWH ‘on the balance of probabilities’. Had my anaesthetist suggested early use of LMWH in 2013 I may well have sanctioned its use!
Most surgeons have at times and out of necessity operated when blood coagulation was compromised, occasionally doing so unbeknownst at the time of surgery. Without complications. On one occasion I recollect a case of haematoma despite an anti platelet agent having been stopped a week prior to surgery. Was that consequence or coincidence? Post operative haematomas are not uncommon and occur in every surgical specialism. Seldom are they solely attributable to anticoagulant use. Some such as hepatic surgeons routinely operate on patients with coagulopathies.
There is however clear support for use of LMWH in the post operative period. Omitting them may lead to significant criticism if a venous thromboembolism were to occur.
What gives me onward concern is the impact this judgement has on my perception of how to manage the many patients on prophylactic anticoagulants. Should I give a longer period to wean them off before surgery and should I then delay recommencing them post operatively for fear I may be found negligent in the event of a harmful post operative haematoma? This approach will inevitably result in excess morbidity and potentially mortality for the many who are routinely on such drugs to prevent stroke, myocardial infarction and other conditions such as pulmonary embolus.
For at least 60 years we as doctors have been encouraged to practise evidence based medicine. When no clear guidance exists as is so often the case a ‘first do no harm’ or ‘the lesser of two evils’ approach may act as substitute after discussion with colleagues.
The nature of how NICE guidelines have been used retrospectively here gives me further cause for significant concern. The nature of knowledge and medical practice based upon it is necessarily provisional. I would urge an appeal is very necessary on this judgement and that until then it remains provisional too.
Rapid Response:
Re: Spinal surgeon was negligent in giving patient heparin too early and leaving her disabled
An argument has been put forward, with scant evidence to support or refute its principal assertion, which has found favour in this judgement.
I am not confident at all that a haematoma in this context could occur ‘beyond all reasonable doubt’ because of early use of LMWH. I would not be confident either in asserting that the haematoma occured solely on the early use of LMWH ‘on the balance of probabilities’. Had my anaesthetist suggested early use of LMWH in 2013 I may well have sanctioned its use!
Most surgeons have at times and out of necessity operated when blood coagulation was compromised, occasionally doing so unbeknownst at the time of surgery. Without complications. On one occasion I recollect a case of haematoma despite an anti platelet agent having been stopped a week prior to surgery. Was that consequence or coincidence? Post operative haematomas are not uncommon and occur in every surgical specialism. Seldom are they solely attributable to anticoagulant use. Some such as hepatic surgeons routinely operate on patients with coagulopathies.
There is however clear support for use of LMWH in the post operative period. Omitting them may lead to significant criticism if a venous thromboembolism were to occur.
What gives me onward concern is the impact this judgement has on my perception of how to manage the many patients on prophylactic anticoagulants. Should I give a longer period to wean them off before surgery and should I then delay recommencing them post operatively for fear I may be found negligent in the event of a harmful post operative haematoma? This approach will inevitably result in excess morbidity and potentially mortality for the many who are routinely on such drugs to prevent stroke, myocardial infarction and other conditions such as pulmonary embolus.
For at least 60 years we as doctors have been encouraged to practise evidence based medicine. When no clear guidance exists as is so often the case a ‘first do no harm’ or ‘the lesser of two evils’ approach may act as substitute after discussion with colleagues.
The nature of how NICE guidelines have been used retrospectively here gives me further cause for significant concern. The nature of knowledge and medical practice based upon it is necessarily provisional. I would urge an appeal is very necessary on this judgement and that until then it remains provisional too.
Competing interests: No competing interests