As was reported yesterday, the season of Cleveland Browns offensive lineman Jason Pinkston has ended because of a blood clot in his lung.
someone who has had multiple rounds of blood clots the past few years
(multiple clots in my lung in 2008, and then a huge blood clot in my leg
following back surgery last year), I wanted to provide some background
on what Pinkston is going through. Blood clots are kind of mysterious
and scary, and my intent here is to provide a better idea of what they
are all about.
I'll say upfront that I am not a doctor and have
no medical training. What I'm writing here is based on my experiences
and what I've learned as a patient. If any doctors or medical
professionals happen to stumble across this piece and can provide additional information, I welcome
I also know nothing about Pinkston's specific case, other
than the bits that have been reported in the media. So when I make a
guess about what he is going through, it is just that -- my best guess,
based on my experience of having been exactly where he is right now.
That said, let's look at the most likely questions:
What is a blood clot? What is a deep vein thrombosis (DVT)? What is a pulmonary embolism (PE)?
blood clot is just what its name suggests -- a collection of blood
cells that lump together. Often times, blood clotting is desirable.
Any time we cut ourselves, our blood coagulates (clots) so that we do
not keep bleeding.
But within the blood vessels, blood clots are
generally not a good thing. They are the equivalent of a bad accident
on the highway -- blocking most/all of the vessel so that less/no blood
can get through.
Most blood clots start in the veins in the legs. The medical term for this is a deep vein thrombosis (often abbreviated DVT).
may or may not feel symptoms with a DVT. The first time I had blood
clots, they started as a pain in my calf. I thought it was nothing more
than a cramp, or maybe that I had bumped my leg on something. I had no
idea it was a clot. I was still able to walk and run, even though I
had some pain at the site of the clot. The skin was a little warm to
the touch. It certainly wasn't anything I thought would be life
threatening. Other patients may have more/less symptoms.
in and of itself, is not life threatening. But what you have to watch
out for is the clot breaking off from the wall of the vein, and then
traveling through your circulatory system. When it does that, it
travels through the larger veins, into the heart, and then through the
pulmonary artery into the lungs, where the blood vessels thin out, and
the clot eventually becomes stuck.
A blood clot in the lungs is known as a pulmonary embolism,
and it is a much more serious situation than having a clot in the
legs. First of all, if the embolism is trapped in the pulmonary artery,
then you'll die pretty much immediately, because the entire circulatory
system is stopped (think of it like stepping on a garden hose). Even
if the clot makes it through the pulmonary artery and then becomes
trapped in the lungs, it's still a serious and potentially
life-threatening situation. Depending on the number and size of the
clots, the lung capacity will be diminished, possibly seriously. You
can become short of breath, feel pains in your side or chest, and have
trouble with basic activities like walking.
More than likely,
Pinkston's clot started in his legs. He may not have even known it was
there. Even if he did feel something, it probably wouldn't have been
enough for him to really worry about it -- especially as a pro football
player who is used to having plenty of aches and pains. Somewhere along
the way, the clot broke off from the vein in his legs, traveled through
his heart, and ended up in his lungs. That's when he started suffering
the more serious symptoms that landed him in the hospital.
Why do blood clots form?
clots form for many reasons. They could be because of a genetic
condition. They can also occur because of lifestyle factors. One of
the biggest factors is being sedentary, especially after a surgery. (In
my example, I had back surgery last year, and about nine days later a
large clot formed in my leg. Although I wasn't completely sedentary, I
was moving around a lot less than would normally have been the case.)
Blood clots can also be an indicator of cancer.
Unfortunately, in many cases (my doctor estimated about 25% of the time), blood clots are idiopathic (a big word that means "we really don't know how they happened").
my case, while I was in the hospital, I was given a battery of tests to
check for various clotting disorders. All of the tests came back
negative. According to my doctor, there were some conditions that they
couldn't test for because I was already on blood thinning medications
(more on those later), and in order to have an accurate test, I would
have needed to not be on any blood thinners. (They weren't about to
take me off blood thinners, and possibly risk my life, just so I could
take some tests.)
I'm guessing that the same thing is happening to Pinkston
now -- they've probably taken plenty of his blood to do a number of
different tests, in hopes of finding out why his blood clot occurred.
As was true in my case, they may never find out exactly why he suffered
What are the risks of blood clots?
suggested before, if a blood clot is left untreated, it can cause
serious damage to the body, and perhaps even result in death. A PE can
cause death to the surrounding lung tissue; depending on how much tissue
is involved, and the patient's condition otherwise (i.e., are they a
distance runner or a three-pack-a-day smoker), it can be life-changing.
my case, I was lucky that my episodes with blood clots (particularly
the time that two clots ended up in my lungs) really didn't change my
life at all. I can walk, run, play with my kids, and otherwise do the
same activities that I did before. I was also in very good shape, and
generally don't have any negative lifestyle factors (non-smoker,
exercise a lot, etc.).
For Pinkston, my guess is that he will
come out of this episode just fine. If any damage has occurred because
of this clot, it's already been done; it is not like it is going to get
worse at this point, because he is in the hospital and is getting the
care he needs. Depending on the size of the clot and how much damage it
did, it may affect his lung capacity. Because he is a pro athlete, I
would guess he was in pretty good condition to begin with, so hopefully
he won't have any lasting effects from this clot.
How do doctors treat blood clots?
with medications. In unusual cases, such as a huge clot, a doctor may
choose to remove it surgically. (That happened to me last year, the
second time I had clots. I developed a huge clot that extended from my
navel to my knee -- that is an unusually large clot, and my vascular
surgeon later told me it was the largest clot he had ever removed in his
~30 years in practice.) But usually doctors will want to treat the
clots with medications that are designed to thin the blood and make it
less susceptible to clotting.
The times I have had clots, I've been treated with two separate medications. One is heparin
(which often goes under the name Lovenox). It it given by needle --
you need to inject it along your waistline, just below the skin (not a
problem for most of us, and certainly not for a hefty offensive
lineman). In my experience, you take the heparin twice a day for a week
or two, in order to kick-start the process of thinning out your blood.
Once your blood is in the target range of thickness (more on that
shortly), then you no longer have to take the heparin injections.
The other medication commonly used to treat blood clots is warfarin
(commonly known as Coumadin). Warfarin is taken as a pill every day.
Believe it or not, it is actually rat poison, just in a different
dosage/form. It works by interfering with vitamin K, which causes blood
to clot. (For that reason, patients with blood clots are actually
discouraged from eating otherwise-super-healthy foods like spinach or
kale, because those foods are so high in vitamin K. I do have to say,
being told "you shouldn't eat spinach" didn't upset me too much.)
is a long-established drug. There are several newer blood thinning
medications, but none of them have (yet) been indicated for prevention
of blood clots/DVTs.
My guess is that Pinkston has been getting
Lovenox injections twice a day, and has also been started on Coumadin
and is taking it every day.
Why is Pinkston still in the hospital?
is the tricky part. The funny thing is that Pinkston probably doesn't
look sick now. I would guess that he feels fine and is absolutely
chomping at the bit to be released from the hospital. I definitely felt
that way when I was in the hospital with clots in my lung. It's not
like you are going off to tests all the time, or that you are undergoing
constant treatments. Instead, it's more like a nurse draws blood for
testing, then gives you your Lovenox injection ... and then you lay in
bed all day, with basically nothing to do. It's very frustrating.
why is he in the hospital? Because the doctors want to make sure that
his blood has thinned enough before releasing him. Blood thickness is
measured by a value called the International Normalized Ratio, or INR.
On the INR scale, a lower number indicates thicker blood, and a higher
number indicates thinner blood. A value of 1.0 is average. For a
patient on blood thinners, doctors will want to see the INR rise to a
range of 2.0 to 3.0 before they'll be comfortable releasing you from the
hospital. They want to be near-certain that the existing clot has
dissolved and that further clots are very unlikely to develop.
My best guess at Jason Pinkston's typical day is something like this:
7:00 AM: Have blood drawn for INR testing.
Shortly after 7:00 AM:
INR results come back. They show that his INR is still not above 2.0.
Maybe it is 1.4, or 1.6, or 1.8; but it still hasn't hit the 2.0 level
where doctors would feel comfortable releasing him
Rest of Day: Lay
in hospital bed, eat crappy food, feel frustrated at being cooped up in a
hospital bed despite generally feeling good, and hoping that tomorrow's
test brings better results.
When Pinkston does get released from
the hospital (and I'm guessing it will happen in the next few days),
that will be the sign that his INR has risen to that 2.0 level.
How long do you need to be treated for a blood clot?
a first clot, and particularly one that doesn't have a known cause, you
will be on blood thinners for probably three to six months. During
that time, you will have to go to the hospital routinely (probably
multiple times per week at first, gradually decreasing to every 3-4
weeks) to get your INR tested. It turns out that INRs can fluctuate
quite a bit, and thus you'll be tested pretty frequently to make sure
that the Coumadin dosage is at the right level. (If the INR is
dropping, they'll make the daily dose higher; if the INR is above 3.0,
they'll probably scale it back a bit.)
Generally, doctors do not
want to keep you on blood thinners forever. The side effect of having
thinner blood is that you are more susceptible to losing a lot of blood
(and potentially dying) from a large cut or from an internal injury. I
don't want to exaggerate the effects of blood thinners here. It's not
like you nick yourself shaving and blood starts shooting from the wound
like a fire hose; nothing like that at all. Instead, when you cut
yourself, it just takes longer for the bleeding to stop. If we're
talking about a small cut (like nicking yourself when shaving), it's an
annoyance, but you're not going to bleed to death. But if you do have a
large cut, or an internal wound (say, the kind you can get from heavy
contact sports like football), then you could lose a lot more blood than
if you weren't on blood thinners.
The point here is that doctors
are balancing the need to get rid of the clot, and to make sure that it
is gone and that more clots do not occur, against the risk of
unusual/heavy bleeding from a wound or accident. And it seems that the
consensus is that being on blood thinners for three to six months is the
right way to balance those offsetting risks.
Now, if it turns
out that you have some genetic factor that could lead to more clots, or
that you've had other clots in the past, then you're looking at being on
blood thinners like Coumadin for longer, perhaps for life. In my case,
I've now had two separate blood clots, so I now take Coumadin every
day, have for the past year (since clot #2), and will for the rest of my
life. If Pinkston turns out to test positive for some rare genetic
clotting disorder, he could be looking at being on Coumadin for life as
well. But that's a pretty big "if".
Can a patient return to normal activity after having blood clots? Will Pinkston ever play again?
yes, in my experience. As I mentioned earlier, I can do everything now
that I did before my clots. Even though I am now permanently on blood
thinners, I still do everything that I used to do, including higher-risk
activities like trail running through remote areas.
most of us, "normal activity" doesn't include "smashing into 300-pound
men at top speed 50-60 times every Sunday." Of course, that's what
Jason Pinkston does for a living. And when you smash into defensive
tackles over and over again, you bleed, whether through cuts or
internally. So he's at a much higher risk of a bleed-out type injury than the rest of us.
athletes in other sports have successfully returned to action after
being treated for PEs. Serena Williams immediately comes to mind as a
recent example. But football is different. Serena could fall and cut
herself when she dives for a ball, but even on blood thinners, she's not
going to bleed to death. But she doesn't have 300-pound men pounding
her on every play. She doesn't have the risk of damage to internal
organs that a pro football player has.
So my best guess at what Jason Pinkston's future holds:
He'll continue to stay in the hospital until his INR is in the
therapeutic range above 2.0. Again, that will probably happen very
soon, within the next couple of days.
- He'll take blood thinners
(Coumadin) for three to six months. That would put us into early 2013
before he stops treatment (and explains why he was put on IR for this
- If a cause for the clot has not been found by then
(based on the tests he's undergone while in the hospital), then they'll
take him off Coumadin. After his blood has returned to normal, they'll
perform more tests on him (the ones that are dependent on him not being
on blood-thinning medication), in hopes of finding the cause of the
- If the cause of the clot is traced back to some genetic
condition, then he'll be on blood thinners for life, and his NFL career
will likely be over. Even though he will seem healthy enough to play,
he will not want to take the risk of him bleeding to death from some
injury sustained on the field (an injury that would not have the same
bleeding risk for any other player). And even if he is okay with taking
that risk, the Browns and the NFL would not be; I am sure that he would
fail his physical simply on the basis of being on blood thinners.
If the cause of the clot is never determined, or is determined to have
resulted from some factor unlikely to recur (I'm not 100% sure what that
would be), then he'll likely be cleared to play again in 2013. If he
ever suffers another blood clot, then he will probably need to be put on
blood thinners permanently, and his career will likely be over. (I
would especially pay attention if he ever needs a surgery; again, clots
often develop when you are sedentary, and post-surgery is a time when
you are about as sedentary as you ever get. I could definitely see him
going in for, say, knee surgery, then developing a clot in the days
following surgery, and his career ending as a result.)
it would be disappointing if he never plays football again. But that
could end up being less disappointing than some of the alternatives.
There are still a lot of cards face down on the table, and until we see
what they are, we won't know for sure whether he'll play again.