The Clotcast or "dueling sausages"

Blood clots are an often difficult to diagnose condition that can be fatal. In this episode we hear from a patient who had a DVT, explore the causes, diagnosis and treatment for blood clots and the importance of recognizing the symptoms of a blood clot.

We also explore a rather odd episode in medical history…… The sausage duel of 1865…..
For more information about clots please check out website of the charity Thrombosis UK:

Please subscribe, and interact with us on our Facebook page or website.

We thank our patient Nick for his contribution, and of course as ever Drew Worthley for his fabulous music

Podcast Transcript - N.B. computer generated

Although I have scanned it there may well be some inaccuracies so please bear with it. Anything obvious you see please get in touch and we will correct it - thanks

Hello and welcome to the doctor family podcast with me, Dr. David Stokes, and I’m very pleased to introduce for the first time. Dr Nina Stokes. Hello. I’m also very happy to report that within the last couple of weeks since our last podcast. We have been number one medical podcast in Azerbaijan. We are delighted with the response we’ve had from our listeners both on Facebook and our web page, and the comments that have been coming in, it’s been fabulous I really appreciate all the fields that we’ve had. And today’s show is in fact by popular request. Yes, you have been putting in some of your thoughts on what you’d like to hear about, and we’ve been putting together this bespoke podcast.

Unknown Speaker 1:07
So today we’ll be going on a journey, we’ll be going back in time. Back to our very first jobs after we qualified to find out how we save lives with a sticker. And then, believe it or not even further back into 19th century Germany, where sausages had the power to kill or cure. But before any of that. Let’s first hear from a listener, who’s experienced the condition that we’ll be exploring today.

Unknown Speaker 1:30
So, I was working with a theatre show called stomp with on the World Tour, we’d gone from Europe out to Caracas. We had a two week stint as Caracas, and I had been out in Caracas, for a couple of weeks. And towards the end of my stay I developed a cold. it wasn’t stopping me from doing work but it was making me feel pretty dire. So, so I definitely had a virus, just beforehand.

Unknown Speaker 1:57
And then on the last days we had a couple of days holiday so out to the lovely kind of game reserve called las rock. Beautiful there and we were swimming and snorkelling there and I almost didn’t go because I wasn’t feeling brilliant but probably got a bit of sunburn there, and a bit dehydrated so the next day. We hopped on a flight from Caracas to Rome vandalia didn’t really move much or flight, maybe got up twice nine hour flight. It was the usual economy class. Long Haul travel you’re cramped you’re finding any way that’s comfortable landed in Rome felt my ankles were swollen I thought that I just put them under the seat in front of the runway just pull something. The next day, got a much more severe pain, big swelling could see my ankles very red angry kind of swelling. That morning I was running around TV studios for some publicity stuff which probably wasn’t the best thing to do. And that afternoon, I had some free time before we started work. So I got the promoter, we went to get a massage first, and then to a physio because we thought I’d pulled something and stomp has regular access to those being a very physical show and couldn’t figure out what was wrong so went to the Rome University Hospital, but by that time, real pain, the doctors couldn’t figure out what was wrong with me, x rays all of that kind of stuff, and the reaction of the doctor there was right. Just as a precaution we’re going to immobilise both legs, so I was lying on a bed. He literally had the plastic cast stuff in his hands and the door was open behind him, and another doctor walked past my guy said, come and have a look at this. The doctor came in, fresh to the sceen. The next thing I knew, admitted into hospital, and I didn’t understand what was wrong. You know because I did speak Italian and I didn’t have a translator, I kept on hearing the word thrombosis or something akin to that. And so I had an inkling, and I was admitte into intensive care, and I was admitted for 10 days or so over the 10 days. I was put onto a low dose of heparin. Four days later that hadn’t had any effect. And so they put me onto a high dose of heparin, I was bed bound, my insurance company said, You’ve got to get your bloods to a certain level so I was just willing to get to that level so I get shipped home.

David Stokes 4:14
Thank you very much. As you probably gathered Nick have developed a deep vein thrombosis blood clots, both legs. And today’s podcast is all about blood clots, big ones, small ones in convenient parts of the body,

Nina 4:31
as we’ve heard from Nick sometimes it can be quite difficult to realise this is what’s going on so let’s take a look at some of the symptoms and signs that might indicate that this could be a problem.

David Stokes 4:41
I think that’s a great idea. So let’s start with the symptoms of a deep vein thrombosis particularly leg, the sorts of things that we tend to look out for are throbbing or cramping pain, generally in one leg but rarely as we heard can come in both generally in the calf or thigh. You can get swelling of the leg. But again, rarely both if both are affected. You can you can get warm skin around the painful area, and that sometimes is, which makes it difficult for a doctor to tell between for example infection or a dvt. You can also get swollen veins on the limb which sort of can be hard or sore when you touch them, which can mirror other conditions so it’s always very difficult to tell whether it is a DVT or not. We’d often need to go into a little bit more investigation before we could rule one in or out.

Unknown Speaker 5:32
Yes, I think, in my experience, I’m often being called out to try and distinguish between skin infections. And a deep vein thrombosis, and that’s because they can look similar in that when you get that clot in the leg what’s happening is the blood builds up, and the pressure builds up and the next leg starts to swell that’s why it gets bigger, and we increased, not in there, it can also look pink and becomes tender because of the pressure and the veins are there because the blood is trying to find other ways to get back to the heart and complete the circulation around the body,

David Stokes 6:07
whereas an infection can cause a similar set of signs to be seen, but through a different mechanism for

Nina 6:13
different reasons.

David Stokes 6:15
So, the other clot that we want to just mention although it’s not one that happily for Nick experience. And that’s the pulmonary embolism where the blood clot gets lodged within the lungs.

Nina 6:26
I think it’s fair to say that the clots, usually begin in the veins of the legs, and then parts of them break off and start travelling around the body. They get back to the heart and then get pumped out of the heart into the circulation going to the lungs and then because those vessels get smaller. That’s when they get stuck,

David Stokes 6:46
and it’s something that we really need to be capturing early. They can be quite subtle and similar to the way that they’re describing some of the patients with COVID-19, feeling themselves getting short of breath, without, without really realising it, I have seen a couple of patients who’ve come to me with shortness of breath, without really having much else going on and that has turned out to be a PE. The other thing that people can sometimes complain of with a pulmonary embolism is pain within the chest, having difficulty breathing and occasionally it can lead to things like coughing up blood. And sometimes, of course you need to then look down at their legs and see whether they’ve got a swollen leg DVT that’s been behind it in the first place.

Nina 7:28
All good points to raise.

David Stokes 7:30
So, before we go on further, I think perhaps if we were to look into. Why does blood clot in the first place. Perhaps we could explore that a little bit.

Nina 7:38
Well if we just try and keep things simple, and we think about the purpose of the blood clots in the body, then we need to think about it as part of the body’s defence mechanism I mean every time we cut ourselves, we need a means to not just lose all our blood in a puddle on the floor and clotting obviously does do that by blocking that cut, blocking the way out. And in doing that. It also stops bugs getting in our skin is a big barrier for all of it in the bugs that are in the outside world getting into our bodies and causing illness. And if that barrier is breached with a cut, then we’re at risk and we need a way of blocking that process.

So clotting is doing that for us,

Unknown Speaker 8:20
nice healthy scab on the outside keeping them

Nina 8:22
yeah nasties, which you shouldn’t pick, of course, you’re doing all the good work.

David Stokes 8:27
So, how does it actually do what how does a blood clot work, what’s the mechanism.

Nina 8:31
Yes, that’s it. That’s a really good question and blood. Looks like a red liquid and bit scary and it causes people to faint but it’s actually an incredible cocktail of all kinds of different things. We know that it’s full of cells that carry oxygen around our body but also the cells of our immune system to patrolling ready to fight infection, but also in the liquid is a mysterious mixture of things. they’re known as clotting factors. There’s 12 of them, and they’re just they’re sitting there in balance, not, not doing anything until they come across a trigger. And then the trigger causes a reaction as rather like a whole line of dominoes. And one thing leads to another and the end result is something called fibrin and fibrin is a substance that can stick to itself. And it’s able to form strands and ultimately kind of mesh and a net that can stick down and seal off the damage. So clotting is a good thing. Generally, it is part of the way that we’re supposed to operate. But as we so many things in medicine, good things in the wrong place at the wrong time can be bad,

David Stokes 9:44
as you’ve said clots can be involved in lots of other medical conditions as well,

Nina 9:48
all sorts of medical conditions when they’re in the wrong place they’re causing heart attacks, strokes. We’ve talked about DVT s and PE’s that we’re focusing on today. So it’s serious stuff,

David Stokes 10:01
if we think back to when we first started as doctors there was a big push to recognise the risk of people developing a clot. And to do something about preventing it happening to our patients, particularly in hospital law I suspect it’s happening elsewhere. And interestingly when I was preparing for this podcast. I looked to see what the statistics were on blood clots and the ones that I could find showed that there were 2300 deaths from pulmonary embolism in 2012, which is not the most recent data but there’s what I could find the on the British lung Foundation’s website. But interestingly when we first qualified as doctors, it was actually 30% higher than that so I suspect that some of the initiatives that were brought about at a time when we started, have had a significant impact on on the numbers of people sadly dying from, from PE,

Nina 10:52
so that’s quite a short amount of time isn’t it so in the four years from when we qualified in 2008 to when these six were reported. There had been a drop in it by a third of people dying from PE. And that, I mean that does take me back because I remember that message becoming really really clear. So I also remember very clearly, sitting down with piles and piles of drug charts and applying stickers to every single one, which was writing people up for a daily dose of a blood thinners.

David Stokes 11:26
Absolutely I still remember the way we were sort of lectured on the importance of it because a number of factors that can increase the risk of you picking up a blood clot are very common for most patients who are in patients in our hospital at the time, things like immobility infection or inflammation or having had recent surgery, all of which can increase the risk of having a blood clot.

Nina 11:49
That’s so we were doing risk assessments or that was a what was on the sticker was a guide to who should have this, but as you just highlighted, being in bed, being ill or having surgery, which was basically everyone in hospital means you need this dose, so we were pretty busy, we were,

David Stokes 12:09
we sure were and I was very grateful for those stickers that saved my, my poor tired hands from using my very illegible signature on so many drug charts. So I think if we go back to when we were actually in medical school we learned about the things that do tip people over to increasing risk of having a blood clot that we talked about those in terms of the inability and illness etc but the the initial work that was done this was an interesting German physician from the 19th century. We’ve always called him Virchow, I’m gonna play it now a colleague of mine from Germany corrected my pronunciation

Unknown Speaker 12:50
Virchow – father of German pathology.

David Stokes 12:53
Virchow described what he called his triad, three basic principles that increase the risk of forming a blood clot. One was hyper coagulability so this is tipping the balance more towards stickier blood and blood, being more prone to becoming clotted. There are hemodynamic changes which is the second point, and that’s really where there isn’t a smooth flow where the blood is pooling or not flowing as freely as it was it’s more likely to clot. And then the third of these three factors was in damage to the blood vessel walls which we know now, we didn’t know at the time, was in indeed one of the triggering factors for the clotting cascade is released by damage to the blood vessel which makes inherent sense if you think about if you cut yourself you want that signal to be transmitted and exposing the internal workings of the blood vessel wall is clearly going to be one of those potential triggers.

Nina 13:50
So while we’re on this subject I think it’s worth just spending a little bit more time taking a look at Virchow’s life as contribution to see it was actually quite an incredible man. He produced over 2000 Medical writings, during his lifetime and became known as the Pope of medicine, as well as describing the causes of DVT and PE, he also was the first to describe leukiaemia after looking under the microscope at blood. He contributed to the field of forensics by developing a way of analysing hair. And he came up with the first systematic method of post mortem. He worked for social change to fight poverty and disease, and was anti racist debunking a lot of pseudoscience that was being used as justification for these beliefs at that time. He also spent a considerable amount of time on parasitology. And it was very lucky that he did. At the time, parasitic infections were common particularly food borne infections, the likes of trichonella coming from, meat, such as pork. So I’m going to give you the gory details on trichonella, and how you get it. So, it comes from cysts that are present in undercooked meat. When you eat the meat. The cysts hatch out in your stomach to larvae and the larvae burrow into the walls of the small intestine, where they turn into adult. About a week later, the female worms produce larvae which they go on to borrow their way and find their way to your voluntary muscles the muscles that control arms and legs, and once they cause severe.

David Stokes 15:31
Just a pretty nasty effect on the body as a whole.

Nina 15:35
The idea of things burrowing through vastly different organs and parts of the body is absolutely disgusting with the, with the infection in the stomach, nausea, vomiting and diarrhoea. And then, as mentioned, once the infection against the muscle body itself tries to fight it with the immune system. And then that causes inflammation, which causes aching and

David Stokes 16:01
sore muscle. I’m pleased to say that thanks to Virchow, his work led to a significant change in the way that hygiene was managed, such that I don’t think I’ve ever even heard of the case of trichonella. Since I’ve been qualified. And again, the hygiene of meats has changed so significantly as a result of the work done by Virchow, probably the thing I’m most grateful to.

Nina 16:22
So I think with this work, he will have saved many many lives, but perhaps importantly, he also managed to save his own.

David Stokes 16:31
Are we talking about the sausage duel of 1865

Nina 16:35
sausage duel of 1865. He was you know he certainly dabbled in many things more than dabbled. What might say, and politics was also one of the things he took it in. He managed to annoy Otto Von Bismarck, and they fell out over how much money should be spent on military endeavours Bismarck being very much in favour of pouring money into the military and Virchow being less keen, perhaps, preferring to spend it on other things such as health. Anyway, Otto was so outraged by this so challenged Virchow to a duel, Virchow sat there thought to himself. He was a very busy man he didn’t actually have a lot of time for fencing, or pistol skills. So, thought long and hard and he decided that as the challenge party he was able to choose his weapons, and as it was when Otto’s assistant arrived to further the challenge. Virchow produced two sausages and said these are my weapons of choice. if Prince Otto would do me the honour of selecting a sausage both look alike, but one is laced with trichonella, and the other one is perfectly wholesome, the second wondered what his master might think of all of this, and low and behold the message was received.

David Stokes 17:57
Let’s call the whole thing. Since Porsche. So that was a fascinating, fascinating trip back into history.

Nina 18:04
It was, it was also a rather big tangent so I do feel at this point we need to bring it back. Why don’t we just recap over some of the risk factors that we’ve talked about, perhaps talk about some of the other relevant ones that we’ll be looking out for when we’re in general practice. Okay, we covered immobility being on a long haul flight for example, classic being unwell, and also surgery. But the other big ones, of course, smoking, obesity, pregnancy and being on certain hormonal contraceptives or HRT.

David Stokes 18:40
These are all things that can increase people’s background risk of developing a clot and they would also be things that we’d be looking at as a doctor to help us decide what the likelihood of someone having a clot might be if they turn up with some of these signs which we’ve described as being fairly nonspecific.

Nina 18:57
If we look at that now we know about Virchow and his triad we can see why that would be. We know that smoking causes damage to the vessel walls, for example, and pregnancy, the hormonal effects of pregnancy, tips, the blood slightly in favour of clotting as a way of preparing for the birth of the baby so that the mother doesn’t lose too much blood. And of course, taking in extra hormones through the contraceptive pill and HRT can mimic that effect.

David Stokes 20:04
There are some other ones as well such as having a previous clot or certain genetic factors suca as a condition called factor 5 Leiden and the other big one is of course cancer.

Nina 20:04
If you think you might have a DVT, what can you expect.

David Stokes 20:08
So first things first you need to see a doctor straightaway, the sorts of things you would expect would be for the doctor to examine you examine your leg to probably be measuring with a tape measure and feeling, whether you’ve got tenderness in certain areas. They may or may not do a blood test there’s there’s no brilliant test for blood clots. So, the mainstay of investigation is, if it’s thought that clinically when they look at you that this could be a clot. Then you’re likely to have some form of blood thinner given to you there and then, and then an arrangement for a scan to take place at some point in the, in the future.

Nina 20:44
Okay, so you might get the treatment before you’ve had the definitive diagnosis.

David Stokes 20:48
Yes, it’s one of those cases where you really want to make sure that you’re keeping people safe and the risk as we said in the beginning with a DVT, apart from having a fat and painful leg. It really is the risk of the clot breaking off getting its way into the lung which can of course be fatal.

Nina 21:03

David Stokes 21:04
So we would always try and if you think there is a significant risk of having a clot. Then, unless you’ve got a very strong risk from having the treatment for it, we’re likely to give you something to thin the blood, reduce that risk.

Nina 21:16
Perhaps you could tell us a bit about the treatments that people go on for this.

David Stokes 21:20
Okay so, as we heard with Nick, there are injectable treatments, which are given and they work pretty pretty quickly. And that’s the sort of sorts of medications that’s given to patients who are inpatients as we mentioned at the beginning as well where we were first doctors writing lots and lots of these injections for our patients. However, if you have had a clot and people have recognised that then you’re going to want to be on something to thin the blood for a significant length of time, a minimum is generally six months, and that would often be in the form of either warfarin, was a drug that was initially invented as a rat poison that is actually very effective at thinning the blood and preventing clots, forming and helps break down blocks that happened already, but unfortunately with that one. It does require quite a bit of tweaking about again as you get regular blood tests and the dosages of the drug need to be changed on a regular basis or out of people. Then there are the more modern drugs called DOACs or directly acting oral anticoagulants, and they are tablets that are taken every day at one dose for you, that you don’t have to change and that seems to be a little bit more convenient for a lot of our patients and that seems to be what a lot of the people are now being given once they have a clot found

Nina 22:35
that doesn’t require the monitoring that’s required with warfarin.?

David Stokes 22:38
Absolutely, it’s a lot more convenient. So, before we go further I think now might well be a good time to hear what actually happened to Nick, after he got back from Rome

So you were back in England they investigated you for potential causes for for clots. Yes. Yeah. You were put on to this medication, warfarin a blood thinner that requires a bit of monitoring you need to have blood tests.

Nick 23:04
But yeah, I was on warfarin for about six months, and it’s a bit of a pain, because as you say you’ve got to have blood tests, you’ve got to have, and they change your dosage, and so you get the, you get the tablets in I dont know what its measured in, you get a one a three or five and a ten and you’ve got to add up to what you need and, you know, being a young invincible bloke I very regularly kind of got him all wrong and you know and wasn’t particularly bothered by it. But But yes, so for a period of time I was on Warfarin.

David Stokes 23:33
So, Warfarin seems to be a bit of a tricky medication to manage for anyone. I think having listened to Nick’s story a few times now. It brings out a number of aspects about clots, which I’ve learned from, and I hopefully you have too.

He clearly had a number of risk factors coming together, such as dehydration or recent illness, immobility on a long haul flight all coming together to give the perfect conditions to form a clot. And indeed he was unlucky enough to have to. I found that shocking. And I was amazed at how lucky his escape was from the plaster room. That plaster cast applied to those legs would certainly led to an even better condition for the clot to grow from there. And if it had gone from the legs up into the lungs. If that could have been a fatal problem. It also reminds me as a doctor the difficulty that we have of identifying and diagnosing these blood clots, on occasion. Indeed. During the recording of this podcast. A patient presented to me with very subtle symptoms. Only noticing shortness of breath on exertion. Although there wasn’t very much to find. I was concerned enough to send them into a hospital, where they went on to have a scan. And indeed We found our large pulmonary embolism. I’m happy to say that they’ve been discharged now and are doing well at home. I think it’s important for everyone who’s been listening, if they’re going to take away anything from this. Be aware that a severe shortness of breath, without any other obvious cause be seen by a doctor as soon as possible. And of course anyone with symptoms with rapid swelling of the lower limbs, and any of the other symptoms as we discussed such as soreness attend to veins should probably seek medical attention as soon as possible.

Nina 25:21
So unfortunately I think that’s about all we’ve got time for today.

David Stokes 25:25
Yes, sadly it is but I’d like to thank everyone for listening and I’d like to thank, Nick for his time today. Joining us, and if people would like further information, then please do check out our show notes where I’m going to be putting links to relevant websites including to thrombosis UK, which is a charity increasing the recognition of blood clots in the general public, and please

Nina 25:44
keep contributing with your suggestions for further episodes, we’d love to hear your feedback,

David Stokes 25:50
so please do get in touch with us get involved on Facebook and our website, join our mailing list and subscribing whichever podcast, listening app.

Thank you for listening. Bye bye.