When blood clots form in the lungs

I knew Phoebe* had arrived for her appointment at the clinic. I could hear her booming laughter from by consulting room. Phoebe is a hurricane. She is full of life and lives it like there is no tomorrow.

She walked in exactly four weeks after her last appointment with the exact same problem; her menstrual periods were too heavy. You see, at 40, Phoebe had huge fibroids causing her to bleed quite heavily during her menses. She needed treatment. We had discussed the options and she knew she needed surgery. But she had put it off for the last five years. She was too busy at work and was also travelling with her girlfriends, to make time for her health.

We had provided medical treatment previously but this only helped for just a few months, and Phoebe hated the side effects. She needed surgery, but she did not think she had six weeks to recover from it. Every time I saw Phoebe, I warned her that she was going to pass out in the middle of the street one of these days. Let’s just say that the prophecy came true all too soon.

I was called by the hospital on a Saturday morning. Phoebe had passed out at the parking garage in her home as she was attempting to drive to the hospital. The ambulance had brought her in, a bleeding mess. Trust Phoebe to live in drama right to the end. There was no way out this time round. The surgery had to be done as an emergency.

She had lost a lot of blood and we needed to remove her fibroids so as to close the tap, while hopefully sparing her uterus. All this while, she was on blood transfusion to replace what she was losing. After a dramatic three hours in surgery, Phoebe was wheeled out of the operating room to the post-anaesthesia care unit. She had received five units of blood in the operating room. She would be moved to the high dependency unit (HDU) later on for continued monitoring.

She opened her eyes briefly, mouthing a silent thanks, when I told her the surgery had gone well. I had never seen Phoebe so still and so quiet. While in the changing room taking off my soiled surgical scrubs, with the adrenaline rush finally coming down, I thought of just how close Phoebe had come to death and I was grateful that she had made it through safely.

She had no immediate family, having been born an only child and losing her parents in a tragic accident at just 25. But I knew I would find her beloved cousin Maddie* and her squad of girlfriends outside the theatre, waiting for news. Thankfully I was the bearer of good news. I couldn’t wait to get back home to a hot shower, a late breakfast and a nap. It had been a long hard week at work and the weekend was more than welcome.

Later that evening, I went back to check on Phoebe. She had done well and had been transferred out from HDU to the post-surgical ward. When I walked in, she was getting back into bed after a walk around her bed, assisted by the nurse. I stepped out to receive a call while she was being settled in.

When I got back 10 minutes later, Phoebe did not look well. She was clutching her chest, looking suddenly pale. She said she couldn’t breathe. I quickly propped up her bed and signalled for emergency response. We quickly got her hooked onto oxygen and the monitors. Her heart rate was high and her blood pressure was crashing. Two things - she was either bleeding out or she had a clot in her lungs! With no obvious blood coming out, I took my chances on the clot. The nurse sent a code for the intensive care unit and the cavalry arrived in no time.

I was walking beside Phoebe as she was wheeled to the intensive care unit (ICU), trying to reassure her that she would be fine even when I knew the odds were bad. The ICU team agreed that Phoebe was most likely having a clot in the lungs and they went about stabilising her as the cardiologist and the haematologist arrived on site to help. She needed an emergency CT scan of her chest to confirm the diagnosis, but she was not stable enough yet.

I was the least needed doctor at the time. I stepped out of the unit to call Phoebe’s cousin as she was her next of kin. She had just left the hospital about two hours earlier. This is not how I had imagined it would go, but I had to explain what was going on and why Phoebe had to be back to ICU.

Normally, blood only clots when a blood vessel is injured. The response to the breach created in the blood vessel is for the blood to form a clot to plug the leak. Therefore, for blood to clot in an intact blood vessel is abnormal and life-threatening; a condition known as thrombo-embolic disorder. Clots may form in the arteries, but they are more common in the veins, such as in the case of Phoebe.

Risk factors for development of thromboembolic disorders include a personal or family history of the same as this may point to a hereditary disorder of blood clotting; older age; smoking; obesity; pregnancy; long-standing pelvic masses; combined contraceptive pills; surgery; long durations of immobility; long-haul flights; sedentary lifestyle with no activity; fractures; Covid-19; and chronic diseases such as cancer or heart disease.

Phoebe was already a high-risk patient for clots at admission; she had carried around these large fibroids for years, was moderately obese, older, and had undergone surgery. Unfortunately, despite putting her on prophylaxis to prevent clot formation, it looked like she went into surgery with a clot already present in her right thigh vein. Following surgery, the clot travelled to the right side of her heart and was pushed to the lungs; causing her grave danger.

The odds aren’t great. In well-equipped centres, only about 55 per cent of patients with moderate clots in the lungs survive. This drops to about 30 per cent in those with large clots like Phoebe’s. Phoebe spent five weeks with us, two of those in the ICU. She was given medication to blast the huge clot she had; but that came with complications, including bleeding from the uterus that we had operated on. We had to go back to surgery to perform a hysterectomy in order to give her a fighting chance.

But Phoebe wasn’t done living! In her usual flamboyant style, she made us all proud, she went home!

Dr Bosire is a gynaecologist/ obstetrician