Question on follow up, first unprovoked thombroembolic event

[zugbug99]

Hi everyone, I was hoping to get some advice from someone with experience in this area. And maybe a recommendation of a medical provider (PCP, Internal med, etc) to establish with for long term care.

I work as a Physician Assistant at Midway Island. I have been here for 4 months, and am due to rotate out in 5 weeks back to Honolulu, then a same day flight back to Mesa/Phoenix Arizona. DIver for 40 years, Medic/DMT trained in the USARMY long ago.

I had my first thromboembolic event 2 weeks ago in the right great saphenous vein about 8cm above the ankle (anteriolateral to the medial joint). I was taking asa 325mg and ibuprofen 400mg daily at the time. I am the only medical provider for about 50 people on island. So unprovoked.

The symptoms developed over a 3 day period, and were limited to pain, swelling, bruising, warmth, redness, and edema to mid calf. I treated with high dose NSAIDS, rest, compression, and elevation.
No ultrasound is available on island. We only get commercial air every 2 weeks for resupply, and exchange of personnel. I made the decision not to call USCG for a medevac, as the symptoms seemed limited only to the lower leg, they were not worsening, and I felt my risk for DVT and PE was low.
I was in contact with my supervising doctor, who has worldwide medical experience. The decision to stay was mine. Causitive agents range from uknown (idiopathic) to cancer.

So while all symptoms but edema are improving, I need follow up in Phoenix. I am passing up diving in Hawaii (unfortunantly no diving on Midway) until I am evaluated.
Although I have great BCBS PPO insurance, my PCP retired since I was last seen, so I am stuck trying to coordinate seeing a local vascular surgeon, vs going to a local ER and asking for a US.
I worked for 10 years in multiple ER's. Since I will be 8 weeks past onset, I may be denied the imaging emergently, and told to see a vascular clinic. I have called 2 clinics with the same routine, I have to establish with a provider first, then they will schedule imaging of their choice, then follow up visit after imaging to review results. Lab evaluation of Protien C, S, Antithrombin 3, etc should be done.

I was hoping to be in Arizona for only 4 weeks, then off to Detroit Michigan where I live on a sailboat at Saint Clair Shores and sail/scuba Huron's North Channel and Georgian Bay.

DAN was contacted, there are no referral providers in the Phoenix area. There is a chamber at Scottsdale Osborn Hospital, but the MD's are internists, and treat only inpatient (mostly wound care).

There is a list of providers from the Undersea&Hyperbaric Assoc. website, and I am not against traveling to San Diego (UCSD), or Los Angeles.

So, if anyone has worked with, or had a previous experience, I would appreciate your input on how to move forward when I get back to civilization.

 

[michael-fisch]

You're a brave man, I'd be terrified of several things:
The long term damage to your leg caused by the blood clot and your trying to treat it without major anticlotting agents.
When the clot breaks up, what if parts of it cause blockages in your lungs and heart?
and the scariest thing:
What if parts of the broken up clot cause blockages in your brain (Stroke)?
ASAs are nice to take, although cardiological patients still have heart attacks with or without ASAs, otherwise THEY ARE NOT THE TREATMENT OF CHOICE.
You should be on a regulated treatment with rat poison (Warfarin, along with Heparin for the first 72 treatment hours), your clotting times should be monitored, in the beginning several times weekly and you should have quick access to a major hospital with good cardio and neurological emergency services that with a lot of luck you won't need.
Trying to save a few thousand dollars of lost wages by treating yourself with ASAs is asking yourself to end up in a wheelchair.

Michael
who is not a doctor, but occasionally sees one in a TV Hospital Show and since the internet usually knows what he wants before he goes to a doctor to get a Rx.

 

[taimen]

Which part of your problem is diving related?

 

[uncfnp]

You're a brave man, I'd be terrified of several things:
The long term damage to your leg caused by the blood clot and your trying to treat it without major anticlotting agents.
When the clot breaks up, what if parts of it cause blockages in your lungs and heart?
and the scariest thing:
What if parts of the broken up clot cause blockages in your brain (Stroke)?
ASAs are nice to take, although cardiological patients still have heart attacks with or without ASAs, otherwise THEY ARE NOT THE TREATMENT OF CHOICE.
You should be on a regulated treatment with rat poison (Warfarin, along with Heparin for the first 72 treatment hours), your clotting times should be monitored, in the beginning several times weekly and you should have quick access to a major hospital with good cardio and neurological emergency services that with a lot of luck you won't need.
Trying to save a few thousand dollars of lost wages by treating yourself with ASAs is asking yourself to end up in a wheelchair.

Michael
who is not a doctor, but occasionally sees one in a TV Hospital Show and since the internet usually knows what he wants before he goes to a doctor to get a Rx.

I have no advise for the op. He(?) is a PA with ER experience so likely knows as much about this, or more, than I and I too am a bit confused how this is dive related. But I think I do need to clarify a few things here.

First I believe he is talking about superficial thrombophlebitis not a deep vein thrombosis (DVT). Either way there is no direct risk of stroke (CVA) or heart attack (MI). There is a risk of pulmonary embolism (PE) but it is relatively low given the reported location. Treatment with NSAIDS, elevation, hot compresses, etc is an acceptable initial step, especially given his circumstances.

But yes, given the lack of reported risk factors or precipitating events, he probably does need followup with bloodwork and imaging.

 

[Duke Dive Medicine]

@zugbug99 , do you think the event had anything to do with regular ibuprofen use? Also, can you elaborate on what you're looking for exactly? Are you looking for a clearance to dive, or a referral to a practitioner in Phoenix who can help you manage this?

Best regards,
DDM

 

[zugbug99]

@zugbug99 , do you think the event had anything to do with regular ibuprofen use? Also, can you elaborate on what you're looking for exactly? Are you looking for a clearance to dive, or a referral to a practitioner in Phoenix who can help you manage this?

Best regards,
DDM

Thanks DDM! I was hoping to find if anyone new of a medical provider with diving experience in the Mesa/Phoenix area that I could establish with as a long term PCP. And also to follow up on this event prior to returning to diving.
DAN has a great consultation service with non diving MD's.

I will call tomorrow to schedule with a local vascular doctor. I will have to see them first, undergo a imaging and lab evaluation.
Then if everything looks OK work towards a medical clearance to return to diving, and also back to overseas isolated work.
I have pretty severe OA, and have controlled it well with daily ibuprofen 200mg and acetominophin 500mg taken BID (twice a day). I also take a daily asprin 81mg, but since this I have increased to aspirin 325mg.

I have improved about 90% but still with a little residual swelling of the right lower leg distal to the gastrocnemius. But we have all seen DVT's that form with no symptoms at all, until a PE shows up. So I fully realize the importance of follow up after this.

Again I appreciate your answer, its not a wise thing to act as my own provider. Maybe my days in austere conditions should come to a close.

I'll post a follow up once I am evaluated.

 

[zugbug99]

You're a brave man, I'd be terrified of several things:
The long term damage to your leg caused by the blood clot and your trying to treat it without major anticlotting agents.
When the clot breaks up, what if parts of it cause blockages in your lungs and heart?
and the scariest thing:
What if parts of the broken up clot cause blockages in your brain (Stroke)?
ASAs are nice to take, although cardiological patients still have heart attacks with or without ASAs, otherwise THEY ARE NOT THE TREATMENT OF CHOICE.
You should be on a regulated treatment with rat poison (Warfarin, along with Heparin for the first 72 treatment hours), your clotting times should be monitored, in the beginning several times weekly and you should have quick access to a major hospital with good cardio and neurological emergency services that with a lot of luck you won't need.
Trying to save a few thousand dollars of lost wages by treating yourself with ASAs is asking yourself to end up in a wheelchair.

Michael
who is not a doctor, but occasionally sees one in a TV Hospital Show and since the internet usually knows what he wants before he goes to a doctor to get a Rx.

Thank you Michael for your reply. I would call myself stupid, not brave. In retrospect, I would send anyone else on the island here with a similar presentation to Honolulu for evaluation.
But since I am the only medical provider here. There is no one who could replace me for another 2 weeks, until the next contracted air flight arrives, I did not want to leave the island unattended.
If it had worsened after the initial 72 hours, if I was hypoxic, tachycardic, febrile, or in any way felt it was worsening I would call for a Medevac to get me off island.

I didn't explain well in my initial note here why I posted to this board. I am a avid diver, and usually dive prior to coming out, and after leaving Midway. I cancelled the diving trip to Maui back wall of Molokini crater, my favorite Hawaiian dive and will travel directly home to Arizona.

I've previously had a cardiac echo, and carotid study. No PFO, ASD, or embolic disease. Diving physiology is a science that few medical doctors understand. So I need to be evaluated prior to getting back in the water again.

Again, thank you for your advice and kind words.

 

[zugbug99]

Which part of your problem is diving related?

I am concerned with my age (near 60), about returning to diving after this episode. I cancelled my planned diving trip to Maui due to this.
Everything from my eyes is pointing to a superfical emboli of the distal great saphenous vein in the solas muscle and skin structures.
I know I need follow up. I was hoping someone had contacts in the Mesa/Phoenix area they could point me to.
I currently don't have any medical doctors at home, my PCP retired.
Emergency room doctors will unlikely tie up their vascular ultrastenographer if I presented with symptoms that occurred 8 weeks prior and resolved.
I think its best if I get evaluated by a non diving physician first, and then work towards a medical evaluation specifically related to diving.
It looks like San Diego California may be my best option with the UCSD Medical Physiology/Hyperbaric program.
Thank you!

 

[zugbug99]

I have no advise for the op. He(?) is a PA with ER experience so likely knows as much about this, or more, than I and I too am a bit confused how this is dive related. But I think I do need to clarify a few things here.

First I believe he is talking about superficial thrombophlebitis not a deep vein thrombosis (DVT). Either way there is no direct risk of stroke (CVA) or heart attack (MI). There is a risk of pulmonary embolism (PE) but it is relatively low given the reported location. Treatment with NSAIDS, elevation, hot compresses, etc is an acceptable initial step, especially given his circumstances.

But yes, given the lack of reported risk factors or precipitating events, he probably does need followup with bloodwork and imaging.

Thanks UNCFNP! I should have been more clear in my first response. This episode has caused me to cancel my dive trip to Maui. I know I need evaluation first to ensure no residual filing defect, and no intrinsic, or extrinsic factors that can lead to a subsequent episode.
There appear to be no diving medical doctors in the Phoenix area, but certainly there are providers that dive.
Everything seems to be a superficial throbophlebitis, but involvement of the great saphenous vein inherently carries a risk of DVT occurring in the popliteal or higher. We all have seen PE's that present only with dyspnea, tachycardia, and sky high d-dimers.
Likely low risk for MI (unless a massive saddle thrombus), and with previous cardiac echo showing no PFO or ASD little risk of stroke from this.

I guess bottom line is maybe I need to stop working in far away places by myself.
Thank you!

 

[Duke Dive Medicine]

Thanks DDM! I was hoping to find if anyone new of a medical provider with diving experience in the Mesa/Phoenix area that I could establish with as a long term PCP. And also to follow up on this event prior to returning to diving.
DAN has a great consultation service with non diving MD's.

I will call tomorrow to schedule with a local vascular doctor. I will have to see them first, undergo a imaging and lab evaluation.
Then if everything looks OK work towards a medical clearance to return to diving, and also back to overseas isolated work.
I have pretty severe OA, and have controlled it well with daily ibuprofen 200mg and acetominophin 500mg taken BID (twice a day). I also take a daily asprin 81mg, but since this I have increased to aspirin 325mg.

I have improved about 90% but still with a little residual swelling of the right lower leg distal to the gastrocnemius. But we have all seen DVT's that form with no symptoms at all, until a PE shows up. So I fully realize the importance of follow up after this.

Again I appreciate your answer, its not a wise thing to act as my own provider. Maybe my days in austere conditions should come to a close.

I'll post a follow up once I am evaluated.

I wish I knew of someone. I have a friend out there who's a retired Navy Independent Duty Corpsman and works in hyperbarics; I just asked him recently about MDs in Phoenix who are trained and experienced in evaluating divers, and he didn't know of any. DAN would probably be your best source of information.

Best regards,
DDM