Economy class syndrome: Deep vein thrombosis among airline passengers

Michael Rieff, a 53-year-old American executive with Royal Dutch Shell, took long flights almost half the time when he traveled. Several years ago, he was hospitalized with life-threatening blood clots in his lungs (from "deep vein thrombosis," or DVT) after a flight from Houston to Amsterdam. Now he has cut his flying in half, and walks up and down the aisles on long flights to restore his circulation.

Though it is often called "economy class syndrome" because of the cramped conditions there, DVT also occurs among business class and first class passengers. Indeed, Michael, Shell's head of global compensation and benefits, always flew in business class or first class.

DVT occurs when a blood clot forms within the large deep veins of the body, usually in the legs. If not treated, part of the clot can break off and travel to the lungs, where it can block blood flow (in a "pulmonary embolism"). DVT often causes unexplained pain, tenderness, redness and swelling, often in the leg. Once a clot reaches the lungs, chest pain and breathing difficulties are common.

DVT can be hard to diagnose, because other conditions have similar symptoms. Randy Fenninger, the president of the nonprofit National Alliance for Thrombosis and Thrombophilia, entered a hospital E.R. with chest pain, but was not properly diagnosed for seven hours.

Randy's organization increases public awareness of the condition, and ways to prevent it. Bravo for helping others with your condition!

Advice to travelers: Walk, or find ways to exercise, during long airplane flights.

Read a sadder DVT story, or read Tanya Mohn's source story in today's New York Times.

Take your cues from him: Patient’s role in medical decision-making

Granny Tiger (not her real name, I assume) wrote perceptively about the role that patients want in medical decision-making. Her comment responds to Dr. R.W. Donnell’s thought-provoking blog post about the ways doctors can think; both appear below.

Dr. R.W. Donnell:
We should allow patients to be involved to the extent they wish. But I would caution that unless we apply rigorous principles of evidence-based medicine to the discussion with the patient, the decision making process becomes flawed. So if patients’ decisions need to be evidence-based just as doctors’ decisions do how do we bring that about? Is there enough time in our busy practices to do it?

Consider these case examples. You are counseling your patient about upcoming knee replacement. You plan to give enoxeparin for DVT prophylaxis. How do you inform the patient? Sure, you know that it’s the right thing to do and all the experts recommend it, but the patient deserves evidence. So, you do a Pub Med search (or, somewhat more easily, consult a filtered resource such as Up To Date) and cull out the studies you critically appraise as valid and applicable to your patient. In order to advise your patient on the magnitude of benefit of the proposed treatment you look for, or calculate the absolute risk reduction (ARR) for the proposed treatment as well as the absolute risk increase (ARI) for bleeding. In order to translate this into language the patient can understand you then, from the absolute risk reduction for DVT and the absolute risk increase for bleeding, calculate the number needed to treat (NNT) and number needed to harm (NNH) respectively. You then have the discussion with the patient, modifying it as necessary to take into account any unique attributes of your patient which might increase bleeding risk. If the patient is to be discharged early after the surgery you must also provide information concerning the cost of continued enoxeparin at home, taking into account the patient’s financial condition and payer sources. Then you ask the patient and any concerned family members if they have questions, answer them as they arise, and document your discussion in the medical record. Time consuming, eh?

Of course if this is not your first patient to receive enoxeparin for orthopedic prophylaxis maybe you’ve done the drill before, but the discussion still takes a lot of time….

Grannytiger’s reply:

My goodness. If my physician went to all that trouble for me, I'd require resuscitation from the shock. But to tell you the truth, such extreme conscientiousness -- while I applaud it -- is not only impractical in terms of time (yours!) but also overestimates by a long shot what most patients would expect in terms of empowerment.

We certainly want to be informed but there are much less time-consuming ways to help us achieve it. Offer a pamphlet on DVT prophylaxis to the knee replacement patient. You probably already have a pretty standard informed consent "spiel"; give the patient that, and then take your cues from him. If the situation warrants, make a quick diagram of his anatomical problem and what the proposed treatment will do. If he is one of the relatively few patients who really seem to need the specifically tailored information you describe, fine. But most of us will not.

As long as we know you are open to answering questions, even ones we think of after we leave the office, most patients feel that we have a role in the decision-making process.

Advice to doctors with Web-savvy patients: To get a more useful discussion next time with patients, tell them the evidence-based web site/s you respect.

Read one of our informed consent stories, or read more from the source blog post by Dr. R. W. Donnell.

The bomb that got him was within his own body: A missed diagnosis story

The story of his widow, Melanie Bloom:
He had been on some really long-haul flights between New York and Kuwait in the weeks and months leading up to the war. He was sleeping with his knees up to his chin in a cramped tank night after night.

 The supply lines were dwindling and so he wasn't as hydrated....He did share with me on a phone call home two nights before he died that he was sleeping outside on top of the tank to stretch his legs because he said he had these cramps. 

Huge warning flag, but again, not having heard of DVT or knowing any of the risk factors, we didn't even think to do anything.


He had pain in his leg, and then the pain went away, he was feeling great.

 He called me the morning of the day he died. He ... sounded upbeat, he wasn't limping and everything was good.

 They were going to make the push across the Baghdad border and that night...he abruptly collapsed to the ground and died. The clot had broken free, so his leg didn't hurt anymore. But it had made its way to his lungs.


[David Bloom, NBC News correspondent, had been covering the war.]

Two million Americans will develop a DVT each year. Out of that, 600,000 will go on to develop the pulmonary embolism. Out of that number, 300,000 will be fatal.



Her Advice:
People can take a little test [on the Web] and test their own risk level, because that's the biggest piece of it - just knowing, "Do I fall into these risk categories?" and if you do, talk to your doctor.

(We're) encouraging people to take their risk assessment tool results to their physician and start that dialogue.


[If] you might have pain in the leg, you might have swelling or tenderness to the leg, and that's good if you have those warning signs because you should immediately get to your doctor and get that checked out.



Read another Iraq story, or read Dawn Sagario’s source story in the Des Moines Register.