[2 patients with signs of venous thromboemolism: deviations from the guidelines]

Deviations from the relevant guidelines occurred during the diagnosis of 2 patients with clinical signs of venous thromboembolism (VTE). In a 73-year-old man with bladder cancer and dyspnoea in whom pulmonary embolism was suspected, pulmonary angiography was not performed following a negative ventilation/perfusion scan; instead, a less invasive spiral CT scan was performed. Because the communicated outcome of 'pulmonary embolism' was incorrect, the patient was treated with anticoagulants and began bleeding from a duodenal ulcer. In a 32-year-old man with minor clinical signs of deep-vein thrombosis in his right leg, additional investigation was not pursued following negative echography. After 3 weeks, the thrombosis was extensive and pulmonary embolism developed, and it appeared that there was a family history of VTE. Both patients were later adequately diagnosed and treated. Guidelines are increasingly used in legal matters as a gauge in the assessment of medical care. Physicians and hospital directors are responsible for a policy on guidelines and the (possible) compliance therewith. Physicians should and must deviate from guidelines if there are good reasons. They must justify the deviation from protocol in the medical records.