03/28/2025    Allen M. Jacobs, DPM

Podiatrist's Breach of Standard of Care Proved Fatal (PA) (Daniel Chaskin, DPM)

DVT and pulmonary embolism are concerns for any
patient immobilized or non-weight-bearing
regardless of whether or not surgery was
performed. The sophomoric suggestion that a
podiatrist has no obligation to recognize the
signs or symptoms of thromboembolic disease
because limited licensure is both dangerous thing
for the patient and podiatrist as it is hardly
likely to serve as a useful defense in a
malpractice case.

As was noted in a previous correspondence to PM
News, it is very easy to in retrospect list
multiple factors which is taken in aggregate place
a patient in a higher risk category of
thromboembolic disease. In my opinion, this is a
problem with risk assessment scales such as the
Caprini score. Many patients, if not most, have
some factors predisposing them to DVT/PE. Should a
patient suffer from a significant thromboembolic
event while under your care for a Charcot's joint,
diabetic ulcer, fracture, ankle sprain, post
bunion surgery, the question of prophylaxis may
arise.

From a medical-legal aspect, you would be asked
the following: 1. Did this patient have
predisposing factors for thromboembolism; 2. Was
the patient placed in a situation such that the
risk would be anticipated to be increased (e.g.-
immobilization or non-weight-bearing); and 3. If
you had administered DVT prophylaxis is it more
likely than not that the thromboembolic event
could have been prevented. That is reality, not an
argument that if you do not treat a particular
problem you have no duty to the patient to
recognize and refer. If a patient has a melanoma
or diabetes or PAD, do you not have a duty to
recognize and either treat or refer? Of course you
do.

Should litigation occur with a wrongful death
suit, you will be trusting support for your
decision regarding prophylaxis, diagnosis, need
for referral to a jury of non-health care
providers. Remember, the jury is held to a "more
likely than not" standard to find you guilty,
essentially slightly more than a coin flip.
"Experts" for each side will argue for and against
you.

For patient protection and for malpractice
protection, evaluate each patient individually.
Educate the patient or caretakers regarding the
signs and symptoms of DVT/PE when appropriate.
Document appropriately. Do not depend solely of
stratification of risk scales such as Caprini. For
example, the recent $1,000,000 verdict cited in PM
news included a prior diagnosis of gout as one of
the risk factors not considered by the defendant
podiatrist.

Also remember, as previously discussed, that many
thrombophilias predisposing to thromboembolic
disease are diagnosed only after the
thromboembolic event. Stratification and
assignment of risk with Caprini or other similar
scoring systems are helpful. The relevant
medical/podiatric literature is helpful. Published
clinical guidelines are helpful. However,
ultimately, patient safety would indicate that
each patient be evaluated based upon their
particular circumstances. It is probably better to
error on the side of safety in most circumstances.
Even under ideal circumstances, with reference to
thromboembolic disease, we can offer only
statistical not absolute protection.

Allen M. Jacobs, DPM, St. Louis, MO

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