When Will Hospitals Learn How To Use Heparin?

Heparin is one of the most basic medicines used in medicine, the primary anticoagulant used by hospitals, which is why it’s part of the World Health Organization’s List of Essential Medicines.

But anticoagulants are so powerful that they are used as rat poison. Anticoagulants make a patient 10 times more likely to develop intracerebral hemorrhage, and thus all of them — Heparin, Coumadin, warfarin — have to be used with the utmost caution.

The Legal Intelligencer reported yesterday:

A Philadelphia jury has hit the Hospital of the University of Pennsylvania with a $44.1 million verdict for failing to recognize a woman’s adverse reaction to anti-coagulant medication before she suffered a brain hemorrhage.

While at the neurological intensive care unit, Tate was given the heparin. Using an activated partial thromboplastin time (or aPTT) test, staff measured coagulation in Tate’s blood as it rose from 19 seconds to nearly 32 seconds, court papers said. Testing then stopped for two days, until Tate sustained the brain hemorrhage, Tate’s memo said. When she was tested again, her aPTT level was 61, according to Tate’s memo.

The amount of heparin given is typically based upon a “nomogram,” in which the patient’s initial heparin dose is calculated purely on the basis of their weight. But that’s just to start the heparin. The cardiovascular system is dynamic and constantly changing in response to conditions, including both whatever medical condition brought the patient to the hospital (like surgery) and to reactions to the medicine itself. Thus, as a 2012 review by the American College of Chest Physicians noted, “because the anticoagulant response to heparin varies among patients, it is standard practice to monitor heparin and to adjust the dose based on the results of coagulation tests.” There’s a couple different types of coagulation tests. For years, aPTT was the most common, although newer evidence points towards using the antifactor Xa test.

Once the patient is on the heparin, they have to be continually monitored to make sure something hasn’t changed that either makes the heparin dose so low as to be ineffective (sometimes known as “heparin resistance”) or, as in this case, so high as to pose a risk to the patient. It doesn’t take years of medical training to know how often to perform another “aPTT” test to see how the patient is doing: as the American Heart Association said 15 years ago in a Scientific Statement, “aPTT should be measured ≈6 hours after the bolus dose of heparin, and the continuous IV dose should be adjusted according to the result.”

That didn’t happen. She went two days with no testing at all, even after she showed a pronounced response to the heparin. It’s simply inexcusable.

The above malpractice verdict is what I sometimes refer to as a “smartphone” case, in which the patient would have been better served by an app on an iPhone or the like than they were by the actual nurses and doctors that cared for them. It wouldn’t take much work to program an app to remind the providers that a patient on heparin needs to be monitored.

And, yet, like all medical malpractice cases, the case wasn’t by any means easy. Malpractice insurance companies are quite skilled at coming up with excuses. As The Legal Intelligencer noted: “The defense’s memo also said Tate was monitored closely by two physicians, and the coagulation levels were within the normal range.”

In a sense, they’re right: the patient’s readings before the brain hemorrhage (19 and 32) and after the brain hemorrhage (61) were all “within the normal range,” but the only reason the hospital can say that is because they didn’t bother to check her levels in between. And yet, the defendants thought that fact could be used in their favor? Little wonder the verdict was so big.

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