Once again, this deserves some commentary and analysis.

Most third year medical students recognize a risk for DVT associated with prolonged periods of immobility.The 'media' has even commented on prolonged sitting for airplane and bus trips.

Add morbid obesity, sometimes indicative of metabolic hazards - and always a 'red flag' to make one at least slightly suspicious that obesity sort of goes with early onset CAD and, at least, pre-hypertension [ if you take the time to look ] then, YES, this scenario begins to offer the distant odor of another doctor not taking the time to think about these possibilities - at least for the purpose of calling a friendly internist to cover his behind; nothwithstanding his obligation to the patient to do so.

Verdict for the plaintiff.Hands down.

William Mangino M.D.

You must be Dr. West.

Wm. Mangino M.D.

Dr Mangino:
Of course we don't know the whole story here and how the pt presented but a few questions since you know all the answers.
1: Do you refer every obese woman with a sprained ankle to a vascular surgeon?
2: Do you get an LE U/S on every obese woman with an sprained ankle?
3: Do you give full dose lovenox/coumadin to every obese woman with an sprained ankle?

The fact is we in medicine are still lousy a picking up PE's, hence why every SOB person gets a D-dimer and then when positive a spiral CT just in case. Get off your high horse when none of us really knows what happened.

And they turn on their own if you dare speak the truth.

To Dr. Mangino:

Obviously, you're privy to some evidence-based guidelines regarding sprained ankles that the less informed among us aren't aware of.

Perhaps you'll choose to cite them rather than dogmatically decide how this case should be adjudicated?

My sense is that:

1) Sprained ankles are incredibly common (perhaps even more so in obese patients).

2) The vast majority of obese patients with sprained ankles are treated conservatively without anticoagulants and without any thromboembolic consequences.

3) That being the case, the risks of anticoagulation likely far outweigh any possible benefits.

Therefore, any physician treating a sprained ankle with anticoagulants would expose his or her patient to completely unjustifiable risks. I also have no doubt that any patient so treated who had a bleeding complication would have a far stronger malpractice case than the patient described in this article.

Dr. Mangino, are you just trying to bait us?

John

I meant no disrespect toward you other practitioners. I was only trying to indicate that obese patients have different metabolic responses-which I'm sure you already know.

I thought this case was about an obese patient who suffered an embolic complication.

Since that event moves this discussion from the theoretical to the real - why do you come after me for my aggressive stance on this issue.

I believe that obese people temporarily immobilized, to whatever degree, need anticoagulation-especially with a lower extremity injury.

These people are set-ups for the development of chronic pain conditions-and some of them actually do die from clotting disturbances.

As a pain specialist- I have been asked to follow these complications.

I do feel empathy for the orthopedists faced with this dilemma. I am not your enemy. Pardon my tongue-in-cheek response guys, but the fact of the matter remains-an ounce of even apparent prevention is worth the pound of cure we all heard about in grade school.

Would you rather risk overcoagulation or sudden death from an embolism.

It is your choice-not mine. If I didn't care about the docs, as well as the patient-I would not have commented.

My true best to all of you.