Blood Clots in the News

NYTimes.com
December 2, 2003
BUSINESS TRAVEL

Lawsuits Cast Attention on Passenger Blood Clots
By EDWARD WONG

SAN FRANCISCO - Daniel Wylie wears tight stockings on both legs all the time now. He takes an 81-milligram tablet of aspirin every day. On flights, he drinks water like a parched camel and paces up and down the aisle and tries to stretch as best he can.

All that came about, he said, after he developed a blood clot on an American Airlines flight from Paris to San Francisco via the New York area three summers ago.

After arriving home in Windsor, Calif., he walked into a local hospital with a bluish right leg. A doctor, he said, told him he was lucky that the clot had not broken off and traveled to his lungs, which could have resulted in a fatal pulmonary embolism. Mr. Wylie was put on a series of blood thinners for six months.

He is now suing American, a unit of the AMR Corporation, and Boeing in Federal District Court here, accusing them of failing to take proper preventive measures that would help passengers avoid blood clots.

"I was very frustrated about the fact that not in any of my travels have I ever received a warning about deep vein thrombosis, or what's commonly referred to now as economy-class syndrome," Mr. Wylie said in a telephone interview from his home north of Phoenix.

Mr. Wylie's suit is coupled with one from Debra Miller of Watsonville, Calif., who accuses Air France, Continental Airlines and Boeing of the same failure. Her complaint said she developed a life-threatening clot on a two-stage flight to San Francisco after running in the Paris Marathon in April 2001.

The suits could be the first of their kind to go to trial in this country, after District Judge Vaughn R. Walker ruled against the defendants' motion to dismiss the case in July.

Representatives of Boeing and the airlines declined to comment on the matter because of the pending litigation.

The lawsuit focuses attention on the question of what kind of role air travel may play in causing blood clots, and what actions, if any, airlines should take in warning passengers and recommending preventive measures.

Debate on these matters has intensified in recent years as more than 200 suits have been filed against foreign and domestic airlines, and because better aircraft technology is making long-haul flights more common. On Feb. 3, Singapore Airlines will start operating the world's longest nonstop flight - 18 hours and 25 minutes between Los Angeles and Singapore - to be followed in August with 18-hour New York-Singapore flights over the North Pole.

A study published in the Nov. 8 issue of BMJ, formerly the British Medical Journal, found the risk of getting a blood clot or pulmonary embolism was highest within two weeks of taking a long-haul flight. The researchers, who looked at records of more than 5,400 patients admitted to hospitals from 1981 to 1999 in Western Australia, also concluded that the annual risk of developing a clot increased 12 percent if one long-haul flight was taken a year. "Airlines and health authorities should continue to advise passengers on how to minimize risk," the researchers wrote.

Despite a growing number of recommendations like that to airlines, a plaintiff has yet to win in any of the lawsuits. In this country, the most prominent suits have been filed in California and Texas. Besides the case involving Mr. Wylie and Ms. Miller, only two other suits, both in Texas, have been allowed to go to trial, and they are being delayed while an appeals court looks at issues of legal liability, said Michael S. Danko, the lawyer representing Mr. Wylie and Ms. Miller. In a case that helped to bring the problem to worldwide attention, a 28-year-old British woman died of deep vein thrombosis in October 2000, minutes after stepping off a nonstop Qantas Airways flight to London from Sydney, where she had been watching the Olympics. Her parents joined relatives of other blood- clot victims in a lawsuit against 18 airlines. The suit was dismissed by an appeals court in London in July, but lawyers for the families said they were trying to get the House of Lords to overturn the decision.

The Air Transport Association, the industry's main trade group in the United States, said it was starting to pay more attention to deep vein thrombosis, but does not require or suggest that airlines take cautionary or preventive steps.

"In our view, there are no direct relationships between air travel and deep vein thrombosis," said David A. Berg, the association's general counsel.

Deep vein thrombosis occurs when a blood clot forms, usually in the legs. Most clots dissolve, but if one breaks off, it can be fatal. Even when they are not fatal, clots can be debilitating, some people say. Ms. Miller had to have open-heart surgery after the clot moved to her heart, and she is now permanently on blood thinners, Mr. Danko said.

Certain people have greater chances of developing deep vein thrombosis - those who are older or overweight, or those who have recently had surgery.

The relationship between air travel and blood clotting is murkier, and research is still in the early stages. But many doctors and scientists say there appears to be some link.

Dr. Samuel Z. Goldhaber, an associate professor at Harvard Medical School and director of the Venous Thromboembolism Research Group, said up to 5 percent of long-haul air travelers might get tiny clots in their calf veins, although there is disagreement on this. He estimated that one in a million passengers die of pulmonary embolisms.

"There must be something to do with air quality and pressurization," Dr. Goldhaber added. Commercial aircraft cabins are pressurized at levels 5,000 to 8,000 feet above sea level and are kept very dry.

A study published in The New England Journal of Medicine in September 2001 said that about 100 cases of a pulmonary embolism occurring after air travel had been reported in the last three decades. The study found that the rate of pulmonary embolism among passengers rose as the travel distance increased. Looking at passengers arriving at Charles de Gaulle Airport near Paris, it found 4.8 cases of pulmonary embolism for each million passengers who had traveled more than 6,200 miles, compared with 1.5 cases per million passengers who traveled more than 5,000 miles.

The eight authors, all doctors, wrote that the risk of deep vein thrombosis seemed to increase during air travel because sitting still for a long time slowed blood flow and increased the thickness of the blood, while compression by the plane seats could cause blood- vessel lesions.

Anecdotal evidence suggests that athletes like Ms. Miller seem particularly vulnerable, perhaps because athletes often have bruised or torn muscles already prone to clotting or because they have a slower resting blood flow.

There is no consistent policy among many airlines on whether or how to mention deep vein thrombosis to passengers. Some, Asiana and Northwest Airlines, have pointed out the potential danger in recent flight publications and recommended that passengers do exercises while in their seats. Others, like American, post details on their Web sites but do not specifically mention deep vein thrombosis to passengers on board. Many airlines now recommend seat exercises in their in-flight videos, cards or magazines without raising any explicit health warnings.

That is the practice at Singapore Airlines, which will soon be running the world's longest flights. "We take a broader view in terms of promoting overall healthy travel," a spokesman, James Boyd, said.

But Mr. Danko, the lawyer representing Mr. Wylie and Ms. Miller, said that until research shows there is no connection between air travel and blood clotting, airlines should explicitly warn passengers about deep vein thrombosis. He said that about 80 clients have had blood-clot problems related to air travel and that he had filed suits for a quarter of them. He settled one suit with American Airlines last February for an undisclosed amount. The plaintiff, Mike Reynolds, started Airhealth.org, a Web site on deep vein thrombosis.

Mr. Wylie's and Ms. Miller's suits are based on the Warsaw Convention of 1929, which holds airlines responsible for a passenger's death or injury in the event of an accident on an international flight. Mr. Danko maintained that the "accident" in these cases was the airline's neglect to inform passengers of the potential for deep vein thrombosis, since some companies or trade groups in the industry were regularly doing so or were recommending doing so. He cited a news release from the International Air Transport Association in 2001 saying "at the time of reservation, travelers should be informed of the risks of D.V.T. and that research is currently being conducted."

Though Judge Walker ruled that the suits could proceed to trial, at least one defendant, American Airlines, maintains that not explicitly supplying information about deep vein thrombosis does not constitute an accident.

"It has to be an accident to win or have remedy under the Warsaw Convention," a spokesman, Tim Wagner, said. "That depends on whether D.V.T. can be classified as an accident or not, and obviously we don't believe it can."

A federal district judge in Anchorage, James Singleton Jr., agreed with that view last week, when he dismissed a lawsuit against British Airways, Alaska Airlines and Boeing. The plaintiff, Richard Louie, contended that a stroke he suffered in 2000 was a result of a deep vein thrombosis that developed on a flight from Anchorage to London.

In his ruling, the judge said "it is not possible to find that either a failure to warn Louie of the risk of D.V.T. or a comfortable seat with a leg rest was an accident as defined by the Warsaw Convention."

Whatever the court here ultimately decides, Dr. Goldhaber and other physicians say all airlines need to promote healthy flying. This includes telling passengers to stay hydrated, move around a lot, avoid alcohol and possibly wear compression stockings - all things that Mr. Wylie now does every time he boards a plane.

Mystery blood clots felling U.S. troops
By Mark Benjamin Investigations Editor
Published 10/6/2003 12:41 PM

WASHINGTON, Oct. 6 (UPI) -- Unexplained blood clots are among the reasons a number of U.S. soldiers in Operation Iraqi Freedom have died from sudden illnesses, an investigation by United Press International has found.

In addition to NBC News Correspondent David Bloom, who died in April of a blood clot in his lung after collapsing south of Baghdad, the Pentagon has told families that blood clots caused two soldiers to collapse and die. At least eight other soldiers have also collapsed and died from what the military has described as non-combat-related causes.

A disturbing parallel has also surfaced: soldiers becoming ill or dying from similar ailments in the United States. In some cases, the soldiers, their families and civilian doctors blame vaccines given to them by the military, particularly the anthrax or smallpox shots.

Some of the soldiers who died suddenly had complained about symptoms suffered by Bloom -- including pain in the legs that could indicate problems with blood clots.

"If there is a significant number of deaths of this type, it would make you wonder what was going on," said Rose Hobby, whose brother- in-law, Army Spc. William Jeffries, died of a massive lung blood clot and swelling of his pancreas on March 31 after being evacuated from Kuwait.

"How many others are out there?"

"I would say that that number of cases among young healthy troops would seem to be unusual," Dr. Jeffrey Sartin, an infectious diseases doctor at the Gundersen Clinic in La Crosse, Wis., said about blood clot deaths. Sartin, a former Air Force doctor, last spring treated a soldier who might have died from anthrax or smallpox side effects.

"I am not aware that there were this many cases" during the first Gulf War, Sartin said.

The Pentagon has been investigating cases of a mysterious pneumonia that has killed two soldiers and put 17 more on ventilators. Besides the pneumonia, there do not seem to be any unexpected health trends given the number of troops in the region, said Army Surgeon General spokeswoman Virginia Stephanakis.

"We are not seeing larger numbers of most illnesses than we could have expected," Stephanakis said. "We have not seen any red flags. As far as I know, there has not been a huge red flag other than the pneumonia."

UPI's investigation found 17 soldiers who died of sudden illnesses. Families say they are bewildered by the deaths.

"Bill just dropped. They thought he had been shot. That is how suddenly it happened," said Rose Hobby, the woman whose 39-year-old brother-in-law William Jeffries collapsed in Kuwait.

After being evacuated from Kuwait to Rota, Spain, he was in intensive care for a week before dying, Hobby said in a telephone interview from Evansville, Ind. A doctor in Spain said Jeffries had "the largest pulmonary embolism he had ever seen," Hobby said. Jeffries also had a swelling of the pancreas, often caused by heavy drinking or some drugs. Jeffries was not a drinker, Hobby said.

Jeffries was back in the United States just days before his death to attend his own father's funeral. He had a scab on his arm from his recent smallpox vaccination. Hobby said she does not know if he got anthrax shots also, like most soldiers in the region.

Patrick Ivory arrived in Germany Aug. 16 to see his 26-year-old son, Army Spc. Craig S. Ivory, before he died. By then, Craig Ivory was already brain dead from a blood clot that hit his brain on Aug. 11.

"I had to make a decision to turn off life support, which was the most difficult thing I have ever done in my life," Patrick Ivory said in a telephone interview from his home in Port Matilda, Pa.

In other cases of apparently healthy soldiers who died suddenly in Operation Iraqi Freedom, families told UPI they have gotten few answers from the military. Local media reports have quoted military officials saying some of the deaths were apparent heart attacks; they have occurred from the beginning of the conflict through last week.

"If anybody has a right to know what my husband died of, it is me," said Lisa Ann Sherman, whose husband, Lt. Col. Anthony Sherman, suddenly clutched his chest and died Aug. 27 in Camp Arifjan, Kuwait. "The only thing they (the military) had to tell me was severe myocardial infarction," or a heart attack.

Anthony Sherman, 43, was a marathon runner and a triathlete.

Sherman said her husband complained of pain in his legs after getting anthrax shots. She said she has since learned that he went to sick call complaining of pain in his legs on the day he died. NBC's Bloom, who also got the anthrax and smallpox vaccines, complained of pain in his legs, presumably from a blood clot that has been attributed to cramped quarters in his armored vehicle.

"I am very suspicious about the true reason behind my husband's death," Sherman said.

The Pentagon said side effects from the anthrax vaccine are generally mild and rare.

In one case, however, the military said the anthrax vaccine did cause a soldier's chronic blood-clot condition.

Capt. Jason M. Nietupksi says he has suffered severe reactions to three anthrax shots given to him in the Army Reserves in February 2000, when he was 29 years old. Nietupski said the vaccine caused chronic fatigue, a skin reaction and a blood clot condition called Deep Vein Thrombosis. Nietupski described intense pain in his legs caused by the clots from that condition.

Nietupski is on blood thinners for the rest of his life. His records from the military state his blood clot condition was caused by the anthrax shots.

"CPT Nietupski had multiple adverse medical problems associated with three anthrax vaccinations he received while assigned to the 8th United States Army," read the results of a military line-of-duty inquiry report. "A condition described as Deep Vein Thrombosis, chronic fatigue and Steven Johnson's Syndrome all are adverse reactions that developed in this previously healthy individual from the anthrax vaccine. Evaluation by Walter Reed Physicians state (sic) that his symptoms are related to the anthrax vaccine."

The anthrax vaccine label warns of infrequent reports of heart attacks or strokes among people who have taken that vaccine. Both heart attacks and strokes can be caused by blood clots.

With smallpox shots, top Pentagon health officials released a study in June that said 37 soldiers have had a swelling of the tissue around the heart probably caused by the vaccine and eight other "cardiac events" occurred within a fortnight of getting the vaccine, including heart attacks. The Pentagon said they had seen no deaths that might have been caused by the smallpox vaccine.

Civilian officials have disagreed, at least in one case.

In the April 4 death of Army Spc. Rachael Lacy of Lynwood, Ill., a civilian doctor who treated her and the civilian coroner who performed her autopsy said the smallpox and anthrax vaccines the Army gave her March 2 in preparation for her deployment for Operation Iraqi Freedom might have caused her death. Lacy had pneumonia and a swelling of the tissue surrounding the heart, among other things.

The Deputy Director of the Military Vaccine Agency, Col. John D. Grabenstein told UPI in August that Lacy's death has not been classified by the military as related to either vaccine.

"Rachael Lacy is still in the unexplained death program" at the Centers for Disease Control and Prevention, Grabenstein said.

After two health care workers died of heart attacks after getting smallpox shots, in March the Centers for Disease Control and Prevention recommended that people with a risk of heart disease not take the vaccine.

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