Castanos, Abbott share ‘Great Catch’ Patient Safety Award
Yelitza Castanos, DNP ’21, an assistant professor, and Maura Abbott, PhD, assistant dean of clinical affairs, received a Great Catch Award this March for pinpointing the source of a patient’s unusual symptoms—and possibly saving her life.
The patient, a 75-year-old retired travel agent, first visited the emergency department in January due to severe swelling in her right leg. Venous ultrasound found no clots in her legs, and a chest CT found no pulmonary embolism, although the patient’s D-dimer levels were elevated. She was discharged home and told to follow up with her primary care provider (PCP), Castanos, a nurse practitioner at ColumbiaDoctors Nurse Practitioner Group.
“When she came to see me, her right leg was really, really swollen. It was painful. It was difficult for her to walk, which is new because she was a fairly active patient,” Castanos recalls. Normally able to walk miles without difficulty, the patient was exhausted after the three-block walk from her home.
She told Castanos she first noticed the swelling a week after making a nine-hour cross-country trip, which suggested that a clot could be responsible for her symptoms. She also had bruising on her right leg and the right side of her arm.
The following day, when the patient sent her a photo showing bruising around her right eye, Castanos advised her to go to the ED immediately. But blood work found no issues, and the patient was again discharged and told to follow up with her PCP. A second ultrasound of her legs found no clots.
Meanwhile, the patient was set to go to Iceland in a few days. “She was planning on going on her flight regardless,” Castanos says. “Her friends had told her, ‘oh, that happened to me too. All you need to do is just wear an ACE bandage or compression stocking and it'll go away.’”
But the patient’s unilateral swelling suggested something more serious than peripheral edema. Castanos thought she had a clot that just hadn’t been discovered. She started her on baby aspirin for anticoagulation and consulted with Abbott, who agreed that a clot was the likely cause.
“We said, ‘Let's do a CT scan of her abdomen. Maybe the clot is further up from her leg that the ultrasound just isn't capturing it.’”
Castanos sent the patient back to the ED, requesting abdominal and pelvic CT scans through the electronic health record (EHR). She and Abbott also consulted with hematologist David Diuguid, MD, on the case.
“She needed to go to the emergency room because she wasn't a candidate to stay outpatient to wait this process out,” Castanos explains. “And especially because she had a flight that was pending.”
This time, the scans revealed a huge thrombosis above the patient’s right hip, completely obstructing the right iliac vein near the bifurcation. This explained her unilateral symptoms, as well as her exhaustion with exertion.
She was admitted for an emergency thrombolectomy and treated for a month with injectable anticoagulants. When Castanos next saw the patient, her leg swelling had resolved. She could walk without getting breathless or fatigued and was excited to be planning a trip to Florida.
The ability to request the scans through the EHR, and quick communication with residents and providers at the ED, was essential to getting the patient the care she needed, Castanos says. “I think it really was a team effort.”