Patient is Injured by Cessation of Warfarin

This case takes place in New York and involves a female patient who had been taking warfarin for several years before undergoing an elective surgery. In advance of the procedure, she saw a hematologist, who took her off warfarin in preparation for the procedure. At that time, although the hematologist did not order lab studies or any other diagnostic procedure, he concluded that the patient did not need to take warfarin at all. The elective surgery was uneventful, and the patient saw the hematologist again post-procedure. The hematologist told the patient she did not need to go back on warfarin. Within days, the patient was found unresponsive on her kitchen floor. She was taken to the ER, where it was discovered that the patient was suffering from extensive blood clots. The patient was left permanently injured from the experience, and her quality of life has suffered greatly.

Question(s) For Expert Witness

Expert Witness Response E-000029

It appears that the treating hematologist did not restart anticoagulation with warfarin and did not start alternative anticoagulation, such as with low molecular weight heparin, before completing the workup. As a result, the hematologist already had raised the possibility of a hypercoagulable state. More importantly, the history of multiple, serious incidents of clotting in the past were not taken into consideration. In the past 5 years, I have treated approximately 5 of these cases per year. I prescribe and treat patients on warfarin frequently. If consequences of stopping anticoagulation are potentially serious, the patient can be switched to heparin, which can be stopped two hours before the procedure and restarted within a few hours. After that, heparin can be tapered in conjunction with restarting warfarin. At other times, it can be stopped and restarted without heparin coverage, but in my opinion, not in this case.

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