Pulmonary Embolism: The silent killer




MR Ahmed was diagnosed with cancer of the prostate and decided to go to India for treatment. A few days after he came back to Nigeria, he complained of dizziness, headache, swollen legs which the family attributed to the long flight.

When he kept complaining, they decided to take him to see his doctor but before they could get to the hospital, he gave up the ghost. His death was attributed to the prostrate cancer. There have been many such cases in recent times especially with the upsurge in the phenomenon termed Medical Tourism.

This phenomenon is not new in Nigeria, what is new, however, is the risk for the patient who sits immobilised in an airplane for hours. This, experts say, kills more than the main sickness for which medical attention was sought in the first instance.

In this chat with Dr. M. Obinna Nwaneri, a US-based oncologist/haematologist and Dr. Yemi Johnson, an interventional cardiologist and medical director of First Cardiology Consultants Lagos, they spoke on the need for patients to be well informed on the risks involved in such long trips. Excerpts:

THE culprit: According to Dr. M. Obinna Nwaneri; “Recently, with the increased number of people travelling from Nigeria and back with things like cancers, kidney disease and heart diseases, there has been a upsurge in people dying suddenly a few hours, days, or usually less than a week after they either got to the place of treatment or back from the place of treatment such as India for example.

Currently, a lot of people travel outside the country for health care and the most common reason these days is for cancer care and major medical problems like kidney problems. However, this travel entails air travel and sitting in an airplane immobilised for several hours.

Some people go to South Africa, Egypt, Europe, North America and most recently, a lot of people have been going to India which entails 10-16 hours flight and people on these trips are usually sick and tend not to move around in the airplane which results in their suffering from the condition called Deep Vein Thrombosis, DVT, which is a blood clot in the veins.

The clot can then break up and go to the blood vessels in the lungs and cause Pulmonary Embolism (PE) which can be fatal. It has been known to kill a lot of people. Pulmonary Embolism has also been associated with air travels and it used to be called euphemistically the Economy Class Syndrome because people in economy class are usually sitting in a cramped position and don’t move very much and the thought is that it could be associated with having blood clots.” Corroborating, Dr. Johnson said; “Deep Vein Thrombosis is a much more common problem than people think and it can lead to pulmonary embolism which can be fatal.”


Signs and symptoms: Dr. Johnson said he has seen a lot of such patients in his hospital. “We have seen a lot of patients, some straight from the airport. These patients who go abroad, are already sick, they have various illnesses that put them at risk of deep vein thrombosis and then they embark on a long journey without taking any precaution and then when they get to where they are going or when they are coming back, they develop DVT and PE and some of them die from a purely preventable case.

Shortness of breath

So after a long journey, you discover you have developed swelling on your legs or you get short of breath, it is a sign that something is wrong and you should check it.”

Said Nwaneri: “These blood clots usually go into the heart and lungs causing PE and end up presenting symptons like shortness of breath, rapid heart rate, severe tiredness, dizziness, chest pain and all of these tend to be confused for the primary illness that the person has and if the doctors do not check, patients can die suddenly.”

Solution/Precautions: “Doctors who take care of patients in Nigeria and the patients also should have a high index of suspicion so that if there is such a symptom of either leg swelling, chest pain, rapid heart rate, from one who has been immobilised or has travelled for a long period of time or has a cancer, heart disease or kidney disease diagnosis, they should be tested for DVT by carrying out Doppler Ultrasound of the lower extremities, looking at the lower extremity veins or a Computed Axial Tomography (CT or CAT) scan of the chest where they can discover whether there are blood clots in the blood vessels in the lungs. This can help diagnose quickly and can help treat patients with this life- threatening medical condition.

“Also, patients, their families and doctors should be warned prior to taking on such long trips that this is a possibility so that patients will know the kind of risk they may be taking and ask to have preventive measures put in place before starting the long (sometimes lasting from 8 to 24 hours) journey to the UK or India for much needed medical care,” advised Nwaneri.

On his part, Johnson noted that between the patient, the receiving doctor and the sending doctor, there should be some understanding of the risks involved in the patient embarking on such long trips.

“There are precautions you can take to prevent it from happening. Number one thing is to make sure you don’t sit down on the plane for 12 hours without moving around. You should get up at least every two hours; just walk up and down the airplane aisle, then back to your seat. Also, while sitting down, you should move your legs and keep moving the legs periodically because if you don’t, the blood could clump or develop clots in your lower leg veins; called deep vein thrombosis. When this breaks up and goes to the lungs; it is called pulmonary embolism (which can be fatal if unrecognised, undiagnosed and untreated on time.) And when you are sick, especially with illnesses like cancer or orthopaedic problems, you are more at risk of developing a blood clot.

It is very important someone with a broken leg, after orthopaedic surgery, or kidney problems, advanced cancer or receiving cancer treatment or significant heart disease, who is travelling long distance, talk to their doctors about DVT prophylaxis.

Significant heart disease

There are drugs that can be given to reduce the chances of getting blood clot. These are blood thinners, called unfractionated heparin or low molecular weight heparin which are injected some hours before the long trip. And if it happens, you can get a treatment if you come on time.”

Asked whether they are advocating discouraging patients from seeking health care abroad, they answered in the negative. Drs. Nwaneri and Johnson are not against persons receiving health care in any part of the world; however, patients who need to travel for health care should be aware of this risk factor.

Said Johnson; “No. No. No! Not at all but it is important the doctors involved and the patients should all be aware and take adequate precaution to prevent DVT and or PE – which can be fatal, if untreated. “May be why it was not thought of much in the past was because it was difficult to diagnose but these days, there are simple radiological tests that can be done if you go to the appropriate places. There are tests like D-dimer test (a blood test), Venous Doppler ultrasound of the lower legs to look for DVTs can be done. These are all currently available in Nigeria. So may be 10 years ago, they were not but now, they are all available.

“For someone with a broken leg who cannot move around, he is at very high risk, so he should be given heparin to prevent blood clot from developing. You are given enoxaparin once every 12 hours so for a 12-hour journey, all you need is one injection before you leave.”

“I do not advocate discouraging people from getting health care any where in the world but they should have all the information when they go to get this health care. So doctors should advise patients and their families about their blood clot risks when they are going on these long trips. Patients and their family members should emphatically discuss this concern with all of their health care givers – their regular doctor in Nigeria, the specialist doctor or whoever is coordinating their referral abroad, and the doctor they are going to see abroad so that they get the best and safest care they can get.

“Some physicians are actually recommending small amounts of blood thinners (enoxaparin 20-40 mg sub cut daily or every 12 hours until the patient is walking around freely) on these trips so they are protected from having blood clots but that is still an experimental way of managing or preventing blood clot. No formal clinical trials have been done to confirm that this works well or works all the time to prevent blood clots.


“There is also recommendation for patients to wear what we call support hoses or anti-thrombosis hoses/socks – various brands – Jobst stockings; which go from the foot/ankle to just below the knee on both legs. These are a pair of tight socks worn to prevent people from having blood clots in the legs which can break up and go to the lungs.

“Patients on long plane and even long car rides should move around periodically as advocated by Dr Johnson.

“With this, most patients should be protected but again, the most important thing is for patients to have the full information as to the risk of this silent killer,” said Nwaneri.




vanguard