Deep Vein Thrombosis — DVA claim example

Diagnostic Assessment — Deep Vein Thrombosis

Example 1 of 1 · fictitious patient (Veteran BW)

Diagnostic Assessment

Deep Vein Thrombosis

BOP Code: 36 of 2021 (Deep Vein Thrombosis)
RH Code: 35 of 2021 (Deep Vein Thrombosis)

ADF History

Veteran BW, date of birth 27 April 1979, Australian Army, Nursing Officer, enlisted 14 January 2002, medically discharged 30 June 2022. Operational service: Afghanistan, 12 February 2010 to 30 September 2010 (warlike); Afghanistan (Kabul), 10 September 2020 to 28 January 2021 (warlike).

Occupational History

An Army nursing officer provides inpatient, emergency and theatre nursing in garrison health facilities and deployed role 1 and role 2 hospitals. The work involves direct care of trauma, infectious and critically ill patients, handling of sharps and body fluids, and long shifts on the feet with heavy manual handling of patients and equipment.

On deployment nursing officers live and work in crowded bases with poor air quality, smoke from open burning, outbreaks of respiratory infection, and exposure to tuberculosis, blood-borne viruses and mass casualty events. Long-haul military and aeromedical flights, field detachments to remote and high locations, and disrupted access to routine health care are part of the role.

History

Veteran BW, an Army nursing officer, developed a deep vein thrombosis of the left axillary and subclavian veins on 18 March 2021, seven weeks after aeromedical repatriation from warlike service in Kabul, during treatment for left breast cancer that included surgery, an implanted venous port and radiotherapy, and after a myocardial infarction, a stroke and several infections acquired on deployment. The thrombosis worsened on 14 April 2021 with extension into the brachiocephalic vein and pulmonary embolism.

Timeline

• 18 Nov 2020 — During a mass casualty event at the role 2 hospital in Kabul the veteran sustained a needle-stick injury from a hollow needle used on a casualty. Hepatitis C RNA became positive on 15 Dec 2020. A psychiatrist diagnosed posttraumatic stress disorder on 10 Dec 2020 after nightmares, hypervigilance and avoidance following the event, with fortnightly psychology and quetiapine 50 mg at night commenced. "needle-stick, mass casualty, PTSD"
• 14 Jan 2021 — Five days after returning from a seven-day medical outreach detachment at a mountain outpost at 3,200 metres from 03 Jan 2021 to 09 Jan 2021, she developed COVID-19 pneumonia, confirmed on PCR. She was treated with dexamethasone 6 mg daily for ten days and developed hyperglycaemia that persisted after the steroid stopped, with an HbA1c of 7.4 per cent, and diabetes mellitus was diagnosed. "SARS-CoV-2 PCR positive, dexamethasone"
• 22 Jan 2021 — A pregnancy test was positive at six weeks, conceived despite continuous combined oral contraceptive pill use since September 2020, after an episode of gastroenteritis with vomiting in December 2020. She miscarried on 24 Jan 2021. On examination a 2.5 cm hard mass was found in the upper outer left breast with a palpable left axillary node. She was aeromedically repatriated on 28 Jan 2021, a journey of 20 hours, much of it on a stretcher. "positive hCG, left breast mass"
• 09 Feb 2021 — Biopsy had confirmed an invasive ductal carcinoma of the left breast, oestrogen receptor positive, with nodal metastasis. Staging CT on 04 Feb 2021 also showed a saccular aneurysm of the left axillary vein. She underwent left mastectomy, axillary clearance and insertion of an implanted venous port through the left subclavian vein under general anaesthetic. On 12 Feb 2021 a tender red cord in the left cephalic vein at a cannula site was confirmed on ultrasound as superficial vein thrombosis. "mastectomy, axillary clearance, port inserted"
• 16 Feb 2021 — She had acute chest pain with ST elevation and a troponin rise. Angiography showed spontaneous coronary artery dissection of the left anterior descending artery, an acute myocardial infarction. Echocardiogram showed an ejection fraction of 35 per cent with an apical thrombus, and heart failure was diagnosed. On 20 Feb 2021 she had an embolic right hemisphere stroke with left arm weakness, fell and fractured her right ankle, which was immobilised in a cast boot. She was confined to bed from 20 Feb 2021 to 02 Mar 2021. "SCAD infarct, EF 35 per cent"
• 05 Mar 2021 — A chest X-ray for persistent cough showed right upper lobe cavitation and sputum was smear-positive for acid-fast bacilli, confirmed as Mycobacterium tuberculosis. A contact trace linked it to a patient she had nursed in Kabul. Primary cytomegalovirus infection had been confirmed on 01 Mar 2021, with positive IgM and IgG seroconversion. Platelet count was 780 x 10^9/L. Tamoxifen was commenced on 01 Mar 2021 and radiotherapy to the left chest wall, axilla and supraclavicular fossa began on 08 Mar 2021. "smear-positive tuberculosis, CMV IgM positive"
• 19 Mar 2021 — In the rehabilitation unit she reported swelling, heaviness and aching of the whole left arm from 18 Mar 2021, with dilated veins over the left shoulder and chest. Blood cultures from 16 Mar 2021 had grown Staphylococcus aureus from the port, with a red tender port pocket. Creatinine had risen from 70 to 150 micromol/L within 48 hours. She had been doing intensive left arm rehabilitation, including rowing ergometer and resisted shoulder abduction, twice daily. A duplex ultrasound was requested but was not available until 24 Mar 2021. "swollen left arm, port bacteraemia"
• 24 Mar 2021 — Duplex ultrasound confirmed occlusive thrombus in the left axillary and subclavian veins, extending around the port catheter, with a 4 cm axillary seroma compressing the axillary vein and thrombus within the axillary vein aneurysm. Enoxaparin was commenced and the port was removed. A haematologist confirmed upper limb deep vein thrombosis. "occlusive axillary-subclavian DVT confirmed"
• 14 Apr 2021 — Anticoagulation had been interrupted from 03 Apr 2021, when she was transferred between facilities and her rivaroxaban was not dispensed. She presented with sudden breathlessness and pleuritic chest pain. CT pulmonary angiogram showed bilateral segmental pulmonary emboli and extension of the thrombus into the left brachiocephalic vein. Anticoagulation was restarted and later continued indefinitely. "thrombus extended, pulmonary emboli"

Symptoms

At onset the veteran had swelling, heaviness and aching of the whole left arm, a bluish discolouration of the hand when it hung down, and dilated veins over the left shoulder and upper chest. Symptoms were worse with arm use and eased with elevation.

After the April 2021 worsening she had breathlessness and pleuritic chest pain from the pulmonary emboli. She now has post-thrombotic syndrome of the left arm, with persistent swelling, aching after use, reduced grip endurance and a 3 cm increase in forearm circumference, and she requires lifelong anticoagulation.

Imaging

• 04 Feb 2021 — CT chest, abdomen and pelvis (staging): "Left breast mass with enlarged left axillary nodes. Saccular aneurysm of the left axillary vein, 18 mm. No distant metastases."
• 12 Feb 2021 — Ultrasound left upper limb superficial veins: "Non-compressible thrombus in the left cephalic vein at the forearm, consistent with superficial vein thrombosis. Deep veins patent."
• 16 Feb 2021 — Coronary angiogram and transthoracic echocardiogram: "Spontaneous dissection of the mid left anterior descending artery. Left ventricular ejection fraction 35 per cent with apical akinesis and apical thrombus."
• 20 Feb 2021 — CT and MRI brain: "Acute infarct in the right middle cerebral artery territory involving the motor cortex."
• 05 Mar 2021 — Chest X-ray: "Right upper lobe consolidation with cavitation, consistent with pulmonary tuberculosis."
• 24 Mar 2021 — Duplex ultrasound left upper limb: "Occlusive thrombus in the left axillary and subclavian veins surrounding the port catheter and within the axillary vein aneurysm. 4 cm axillary seroma compressing the axillary vein."
• 14 Apr 2021 — CT pulmonary angiogram: "Bilateral segmental pulmonary emboli. Thrombus extending from the left subclavian vein into the left brachiocephalic vein."

Onset Date

The most likely date of onset of this condition is 18 Mar 2021.

At that date the veteran was serving full time, admitted to a rehabilitation unit after aeromedical repatriation from warlike service in Kabul on 28 Jan 2021. She had undergone left mastectomy, axillary clearance and port insertion, had a myocardial infarction and a stroke, was receiving radiotherapy to the left axilla and supraclavicular fossa, and was being treated for port-related bacteraemia, tuberculosis and cytomegalovirus infection.

This date is appropriate because the rehabilitation physician's examination on 15 Mar 2021 recorded symmetrical upper limb circumferences and no swelling, and she first reported the swelling on 19 Mar 2021, dating it to the previous day. Duplex ultrasound on 24 Mar 2021 confirmed the thrombus. It falls within continuous full-time service.

For the three-month factors, the 3 months before onset run from 18 Dec 2020 to 18 Mar 2021; they contain the continuous oral contraceptive use to 22 Jan 2021, the altitude detachment of 03 Jan 2021 to 09 Jan 2021, COVID-19 on 14 Jan 2021, the pregnancy to 24 Jan 2021, the port inserted on 09 Feb 2021, the myocardial infarction of 16 Feb 2021, the stroke and ankle fracture of 20 Feb 2021, tamoxifen from 01 Mar 2021 and radiotherapy from 08 Mar 2021. The 6 months before onset, from 18 Sep 2020 to 18 Mar 2021, contain the surgery of 09 Feb 2021 and the superficial vein thrombosis of 12 Feb 2021. The 30 days before onset, from 16 Feb 2021 to 18 Mar 2021, contain the cytomegalovirus infection and the active tuberculosis. The 4 weeks before onset, from 18 Feb 2021 to 18 Mar 2021, contain her bed rest from 20 Feb 2021 to 02 Mar 2021, and the 8 weeks before onset, from 21 Jan 2021 to 18 Mar 2021, also contain the 20-hour aeromedical repatriation of 28 Jan 2021. The 7 days before onset, from 11 Mar 2021 to 18 Mar 2021, contain her twice-daily intensive left arm rehabilitation. She stopped smoking on 28 Jan 2021, within six months before onset.

For the worsening, the thrombosis began on 18 Mar 2021 and worsened as documented on 14 Apr 2021, with extension into the brachiocephalic vein and pulmonary emboli, after anticoagulation was interrupted from 03 Apr 2021.

1. What is the formal diagnosis of the condition claimed above?

The formal diagnosis is Deep Vein Thrombosis of the left axillary and subclavian veins (ICD-10 I82.8), an upper limb deep vein thrombosis, complicated by extension into the left brachiocephalic vein and pulmonary embolism, under the Statements of Principles concerning deep vein thrombosis, Balance of Probabilities No. 36 of 2021 and Reasonable Hypothesis No. 35 of 2021.

Deep vein thrombosis is the formation of a blood clot within the deep venous system. It results from a combination of slowed or obstructed venous flow, damage to the vein wall and increased coagulability of the blood. In the upper limb it is most often caused by central venous catheters and ports, cancer and its treatment, compression of the vein at the thoracic outlet or axilla, and strenuous repetitive arm use. It causes swelling, pain and venous distension of the limb, and the clot can propagate centrally or break off to the lungs as a pulmonary embolism. Post-thrombotic syndrome with chronic swelling and pain is a common long-term consequence.

The thrombosis followed breast cancer surgery with an implanted port, radiotherapy, myocardial infarction, stroke and several infections after warlike service in Kabul. It began on 18 March 2021, was confirmed on duplex ultrasound on 24 March 2021 and worsened on 14 April 2021.

2. For each diagnosis identified, please also provide the following dates:

When did the veteran first experience symptoms attributable to this condition?

18 March 2021.

When did the veteran first present to a health / medical provider for this condition?

19 March 2021.

When was the condition confirmed / formally diagnosed?

24 March 2021.

When did the veteran first present to you (or your practice) for this condition?

21 February 2025.

3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?

The diagnosis was confirmed by duplex ultrasound on 24 March 2021, which showed non-compressible occlusive thrombus in the left axillary and subclavian veins with absent flow, surrounding the port catheter and extending into the axillary vein aneurysm. This is formation of a blood clot within the deep venous system and meets the Statement of Principles definition of deep vein thrombosis; it does not involve any of the excluded veins.

The clinical picture was typical, with swelling of the whole left arm, venous distension over the shoulder and chest, and a raised D-dimer. A haematologist confirmed the diagnosis and commenced anticoagulation. CT pulmonary angiography on 14 April 2021 confirmed the worsening, with extension into the left brachiocephalic vein and bilateral segmental pulmonary emboli.

4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.

Legislation: the clinical onset of this condition was on 18 March 2021, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Balance of Probabilities instrument applies to peacetime service. The Reasonable Hypothesis instrument applies to the veteran's warlike service in Afghanistan in 2010, where burn pit smoke contributed to her lung disease, and in Kabul from September 2020 to January 2021, where she acquired hepatitis C, posttraumatic stress disorder, COVID-19 and tuberculosis, served at altitude, and from which she was aeromedically repatriated.

Each factor must be related to the person's relevant service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.

Balance of Probabilities — Statement of Principles concerning Deep Vein Thrombosis, No. 36 of 2021

Causative factors

Factor 9(1): having superficial vein thrombosis within the six months before the clinical onset of deep vein thrombosis; — MET

- Ultrasound on 12 February 2021 confirmed thrombus in the left cephalic vein at a cannula site used during her surgery of 09 February 2021, a superficial vein thrombosis in the same limb. This was 34 days before onset, within the six months before onset, from 18 September 2020 to 18 March 2021.

Factor 9(2): having external compression of the affected vein or a vein draining the affected vein, at the time of the clinical onset of deep vein thrombosis; — MET

- A 4 cm seroma in the left axilla after axillary clearance compressed and displaced the axillary vein, shown on duplex ultrasound on 24 March 2021 and present at onset. The seroma is an endogenous structure compressing the affected vein.

Factor 9(3): having an infection involving the affected vein at the time of the clinical onset of deep vein thrombosis; — MET

- Blood cultures from 16 March 2021 grew Staphylococcus aureus from the port catheter lying in the left subclavian vein, with a red, tender port pocket. The infection involved the catheterised subclavian vein and was present at onset on 18 March 2021.

Factor 9(4): for deep vein thrombosis in an upper limb only, engagement in exercise of the affected upper limb within the seven days before the clinical onset of deep vein thrombosis; — MET

- This is an upper limb deep vein thrombosis. From 03 March 2021 the veteran undertook intensive rehabilitation of the left arm after her stroke and axillary surgery, including rowing ergometer sessions and repetitive resisted shoulder abduction with weights for 45 minutes twice a day, documented by the physiotherapist on each day from 11 March 2021 to 18 March 2021, the seven days before onset.

Factor 9(5): having acute myocardial infarction within the three months before the clinical onset of deep vein thrombosis; — MET

- On 16 February 2021 she had an acute myocardial infarction from spontaneous dissection of the left anterior descending artery, with ST elevation and a troponin rise. This was 30 days before onset, within the three months before onset, from 18 December 2020 to 18 March 2021.

Factor 9(6): having heart failure at the time of the clinical onset of deep vein thrombosis; — MET

- Echocardiogram on 16 February 2021 showed an ejection fraction of 35 per cent after the infarction and a cardiologist diagnosed heart failure with reduced ejection fraction, treated with an ACE inhibitor, beta-blocker and diuretic. It was present at onset on 18 March 2021.

Factor 9(7): having a malignant neoplasm at the time of the clinical onset of deep vein thrombosis; — MET

- Invasive ductal carcinoma of the left breast with nodal metastasis was confirmed on biopsy in early February 2021 and was under active treatment with radiotherapy and tamoxifen at onset on 18 March 2021.

Factor 9(8): having an aneurysm of the affected vein at the time of the clinical onset of deep vein thrombosis; — MET

- Staging CT on 04 February 2021 showed an 18 mm saccular aneurysm of the left axillary vein, and duplex ultrasound on 24 March 2021 showed thrombus within it. The aneurysm was present at onset.

Factor 9(9): being overweight or obese at the time of the clinical onset of deep vein thrombosis; — MET

- Her weight was 74 kg and height 1.64 m on admission on 29 January 2021, a BMI of 27.5, and it was unchanged at onset on 18 March 2021.

Factor 9(10): having sleep apnoea at the time of the clinical onset of deep vein thrombosis; — MET

- Polysomnography on 21 August 2019 showed obstructive sleep apnoea with an apnoea-hypopnoea index of 18 events per hour, diagnosed by a sleep physician during service. It was present at onset.

Factor 9(11): being pregnant within the three months before the clinical onset of deep vein thrombosis; — MET

- The veteran was pregnant until her miscarriage on 24 January 2021, confirmed on a positive pregnancy test at six weeks on 22 January 2021. This is within the three months before onset, from 18 December 2020 to 18 March 2021.

Factor 9(12): having infection with human immunodeficiency virus or hepatitis C virus at the time of the clinical onset of deep vein thrombosis; — MET

- Hepatitis C RNA became positive on 15 December 2020 after a needle-stick injury while nursing a casualty during service on 18 November 2020, and the infection remained untreated, with detectable RNA, at onset on 18 March 2021.

Factor 9(13): having infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) within the three months before the clinical onset of deep vein thrombosis; — MET

- SARS-CoV-2 infection with COVID-19 pneumonia was confirmed on PCR on 14 January 2021, within the three months before onset, from 18 December 2020 to 18 March 2021.

Factor 9(14): having an autoimmune disease at the time of the clinical onset of deep vein thrombosis; — MET

- A rheumatologist diagnosed seropositive rheumatoid arthritis on 14 June 2016, during service, with positive rheumatoid factor and anti-CCP antibodies and synovitis of the hands. It was active, with a raised CRP and synovitis, at onset on 18 March 2021, when her antirheumatic treatment had been suspended because of her infections.

Factor 9(15): having diabetes mellitus at the time of the clinical onset of deep vein thrombosis; — MET

- Diabetes mellitus was diagnosed in January 2021 with an HbA1c of 7.4 per cent after dexamethasone treatment for COVID-19, and hyperglycaemia persisted after the steroid stopped. She was on metformin at onset on 18 March 2021.

Factor 9(16): having a hypercoagulable state as specified at the time of the clinical onset of deep vein thrombosis; — MET

- Her platelet count was 780 x 10^9/L on 05 March 2021 and 812 x 10^9/L on 19 March 2021, a reactive thrombocytosis from surgery, infection and tuberculosis. Thrombocytosis is on the specified list and was present at onset.

Factor 9(17): having a kidney disease from the specified list of kidney diseases at the time of the clinical onset of deep vein thrombosis; — MET

- With the Staphylococcus aureus bacteraemia her creatinine rose from 70 micromol/L on 16 March 2021 to 150 micromol/L on 18 March 2021, an increase of more than 26.5 micromol/L within 48 hours. This is acute kidney injury as defined, present at onset.

Factor 9(18): having a device implanted within the affected vein for a continuous period of at least 24 hours within the three months before the clinical onset of deep vein thrombosis; — MET

- An implanted venous port was inserted through the left subclavian vein on 09 February 2021 and remained in place continuously until its removal on 24 March 2021. It was within the affected vein for more than five weeks within the three months before onset.

Factor 9(19): having surgery requiring a general, spinal or epidural anaesthetic within the six months before the clinical onset of deep vein thrombosis; — MET

- She underwent left mastectomy, axillary clearance and port insertion under general anaesthetic on 09 February 2021, within the six months before onset.

Factor 9(20): having an injury or illness as specified within the three months before the clinical onset of deep vein thrombosis; — MET

- On 20 February 2021 she fell at the onset of her stroke and fractured her right ankle, a limb fracture immobilised in a cast boot for six weeks. This is within the three months before onset. The stroke also caused significantly reduced mobility.

Factor 9(21): having restricted mobility for a continuous period of at least four hours within the four weeks before the clinical onset of deep vein thrombosis; — MET

- After the stroke and ankle fracture she was confined to bed from 20 February 2021 to 02 March 2021, continuous periods far exceeding four hours, within the four weeks before onset, from 18 February 2021 to 18 March 2021.

Factor 9(22): having a neurological disease that causes loss or impairment of motor function of a limb within the three months before the clinical onset of deep vein thrombosis; — MET

- The embolic right hemisphere stroke of 20 February 2021, confirmed on MRI, caused weakness of the left arm with power of 3 out of 5 at the shoulder. This impairment of motor function of the affected limb occurred within the three months before onset.

Factor 9(23): taking a drug from the specified list of drugs within the three months before the clinical onset of deep vein thrombosis; — MET

- She took tamoxifen, a selective estrogen receptor modulator, from 01 March 2021, and quetiapine, an anti-psychotic drug, nightly from 10 December 2020. Both were taken within the three months before onset.

Factor 9(24): taking combined estrogen-progestogen contraception or taking menopausal hormone therapy as an oral estrogen, or a non-oral estrogen combined with a progestogen, for a continuous period of at least four weeks, within the three months before the clinical onset of deep vein thrombosis; — MET

- The veteran took a combined estrogen-progestogen oral contraceptive pill continuously, without pill-free intervals, from September 2020 for menstrual suppression on deployment, until the positive pregnancy test on 22 January 2021. From 18 December 2020 to 22 January 2021 she took it for five continuous weeks within the three months before onset.

Factor 9(25): having smoked tobacco products: (a) in an amount of at least one pack-year before the clinical onset of deep vein thrombosis; or (b) in an amount of at least 10 cigarettes per day, or the equivalent thereof in other tobacco products, for a period of at least three months before the clinical onset of deep vein thrombosis; and if smoking has ceased before the clinical onset of deep vein thrombosis, then that onset occurred within six months of cessation; — MET

- The veteran smoked about 20 cigarettes a day from 2002, an amount of about 18 pack-years, with her intake rising on both deployments. She stopped on 28 January 2021 when repatriated, and onset on 18 March 2021 was within six months of cessation.

Factor 9(26): being at an altitude of at least 3,000 metres for a continuous period of at least five days within the three months before the clinical onset of deep vein thrombosis; — MET

- The veteran was on a medical outreach detachment at a mountain outpost at 3,200 metres for seven continuous days, from 03 January 2021 to 09 January 2021, within the three months before onset, from 18 December 2020 to 18 March 2021.

Worsening factors

Factor 9(27): inability to obtain appropriate clinical management for deep vein thrombosis. — MET

- Duplex ultrasound was not available for five days after she reported the arm swelling on 19 March 2021, so anticoagulation was delayed until 24 March 2021. Her rivaroxaban was then not dispensed for eleven days after a transfer between facilities from 03 April 2021, and on 14 April 2021 the thrombus had extended into the brachiocephalic vein with bilateral pulmonary emboli. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.

Reasonable Hypothesis — Statement of Principles concerning Deep Vein Thrombosis, No. 35 of 2021

Causative factors

Factor 9(1): having superficial vein thrombosis within the twelve months before the clinical onset of deep vein thrombosis; — MET

- The left cephalic vein superficial thrombosis of 12 February 2021, within the twelve months before onset, arose at a cannula site during surgery that followed her aeromedical repatriation from warlike service in Kabul, where the breast cancer was found.

Factor 9(2): having external compression of the affected vein or a vein draining the affected vein at the time of the clinical onset of deep vein thrombosis; — MET

- The axillary seroma compressing the left axillary vein, present at onset, followed the axillary clearance performed after her repatriation from warlike service in Kabul.

Factor 9(3): having an infection involving the affected vein at the time of the clinical onset of deep vein thrombosis; — MET

- The Staphylococcus aureus infection of the port in the left subclavian vein was present at onset. The port was inserted for treatment that began with her repatriation from warlike service in Kabul.

Factor 9(4): for deep vein thrombosis in an upper limb only, engagement in exercise of the affected upper limb within the seven days before the clinical onset of deep vein thrombosis; — MET

- From 11 March 2021 to 18 March 2021 she performed rowing ergometer and repetitive resisted shoulder abduction exercise of the left arm twice daily, as rehabilitation following her repatriation from warlike service in Kabul.

Factor 9(5): undergoing a course of therapeutic radiation for cancer, where the affected vein was in the field of radiation, within the three months before the clinical onset of deep vein thrombosis; — MET

- A course of radiotherapy for left breast cancer to the chest wall, axilla and supraclavicular fossa began on 08 March 2021, with the left axillary and subclavian veins in the field, and eight fractions had been given by onset on 18 March 2021. The cancer was found on deployment in Kabul and treatment began after her repatriation from warlike service.

Factor 9(6): having acute myocardial infarction within the six months before the clinical onset of deep vein thrombosis; — MET

- The acute myocardial infarction of 16 February 2021, from spontaneous coronary artery dissection, occurred within the six months before onset, three weeks after her pregnancy loss and repatriation from warlike service in Kabul.

Factor 9(7): having heart failure at the time of the clinical onset of deep vein thrombosis; — MET

- Heart failure with an ejection fraction of 35 per cent, following the infarction of February 2021, was present at onset.

Factor 9(8): having a malignant neoplasm at the time of the clinical onset of deep vein thrombosis; — MET

- The left breast cancer, first detected on examination on warlike service in Kabul on 22 January 2021, was under active treatment at onset.

Factor 9(9): having an aneurysm of the affected vein at the time of the clinical onset of deep vein thrombosis; — MET

- The 18 mm left axillary vein aneurysm shown on staging CT on 04 February 2021, after her repatriation from Kabul, was present at onset and contained thrombus.

Factor 9(10): being overweight or obese at the time of the clinical onset of deep vein thrombosis; — MET

- Her BMI was 27.5 at onset. She gained 6 kilograms on deployment in Kabul, where movement off the base was restricted for security reasons.

Factor 9(11): having chronic obstructive pulmonary disease at the time of the clinical onset of deep vein thrombosis; — MET

- A respiratory physician diagnosed chronic obstructive pulmonary disease on 02 May 2018, with a post-bronchodilator FEV1/FVC ratio of 0.64, attributed to smoking and eight months of burn pit smoke on warlike service in Afghanistan in 2010. It was present at onset.

Factor 9(12): having sleep apnoea at the time of the clinical onset of deep vein thrombosis; — MET

- Obstructive sleep apnoea, confirmed on polysomnography on 21 August 2019, was present at onset, and worsened with the weight gain on deployment in Kabul.

Factor 9(13): being pregnant within the three months before the clinical onset of deep vein thrombosis; — MET

- The veteran was pregnant on warlike service in Kabul, with a positive test on 22 January 2021 and a miscarriage on 24 January 2021, within the three months before onset.

Factor 9(14): having cytomegalovirus infection of new onset within the 30 days before the clinical onset of deep vein thrombosis; — MET

- Primary cytomegalovirus infection was confirmed on 01 March 2021, with positive IgM and IgG seroconversion from a negative test on her pre-deployment screening, within the 30 days before onset, from 16 February 2021 to 18 March 2021. It was acquired during her hospital admission after aeromedical repatriation from warlike service.

Factor 9(15): having infection with human immunodeficiency virus or hepatitis C virus at the time of the clinical onset of deep vein thrombosis; — MET

- Hepatitis C infection, acquired from a needle-stick injury while nursing a casualty during a mass casualty event at the role 2 hospital on warlike service in Kabul on 18 November 2020, was present at onset.

Factor 9(16): having active tuberculosis disease within the 30 days before the clinical onset of deep vein thrombosis; — MET

- Smear-positive pulmonary tuberculosis was diagnosed on 05 March 2021, within the 30 days before onset, and contact tracing linked it to a patient she nursed on warlike service in Kabul.

Factor 9(17): having infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) within the three months before the clinical onset of deep vein thrombosis; — MET

- SARS-CoV-2 infection was acquired on warlike service in Kabul and confirmed on PCR on 14 January 2021, within the three months before onset.

Factor 9(18): having an autoimmune disease at the time of the clinical onset of deep vein thrombosis; — MET

- Seropositive rheumatoid arthritis, diagnosed in 2016, flared after her antirheumatic treatment was suspended for the infections acquired on warlike service in Kabul, and was active at onset.

Factor 9(19): having diabetes mellitus at the time of the clinical onset of deep vein thrombosis; — MET

- Diabetes mellitus followed dexamethasone treatment for COVID-19 acquired on warlike service in Kabul in January 2021, and was present at onset.

Factor 9(20): having a hypercoagulable state as specified at the time of the clinical onset of deep vein thrombosis; — MET

- Reactive thrombocytosis, with a platelet count of 812 x 10^9/L on 19 March 2021, was driven by tuberculosis acquired in Kabul and by her surgery and infections, and was present at onset.

Factor 9(21): having a kidney disease from the specified list of kidney diseases at the time of the clinical onset of deep vein thrombosis; — MET

- Acute kidney injury, with creatinine rising from 70 to 150 micromol/L within 48 hours from 16 March 2021, was present at onset, caused by port bacteraemia during treatment that followed repatriation from warlike service.

Factor 9(22): having a device implanted within the affected vein for a continuous period of at least 24 hours within the six months before the clinical onset of deep vein thrombosis; — MET

- The implanted port in the left subclavian vein from 09 February 2021 to 24 March 2021 lay within the affected vein within the six months before onset, inserted for treatment of the cancer found on warlike service in Kabul.

Factor 9(23): having surgery requiring a general, spinal or epidural anaesthetic within the six months before the clinical onset of deep vein thrombosis; — MET

- The mastectomy, axillary clearance and port insertion under general anaesthetic on 09 February 2021, within the six months before onset, followed repatriation from warlike service in Kabul.

Factor 9(24): having an injury or illness as specified within the six months before the clinical onset of deep vein thrombosis; — MET

- The right ankle fracture of 20 February 2021, immobilised in a cast boot, occurred within the six months before onset. In addition, her COVID-19 pneumonia on warlike service in Kabul in January 2021 confined her to bed for nine days, an illness causing significantly reduced mobility.

Factor 9(25): having restricted mobility for a continuous period of at least four hours within the eight weeks before the clinical onset of deep vein thrombosis; — MET

- On 28 January 2021 the veteran was aeromedically repatriated from warlike service in Kabul to Australia, a 20-hour journey mostly on a stretcher. This is within the eight weeks before onset, from 21 January 2021 to 18 March 2021.

Factor 9(26): having a neurological disease that causes loss or impairment of motor function of a limb within the three months before the clinical onset of deep vein thrombosis; — MET

- The stroke of 20 February 2021, with left arm weakness, occurred within the three months before onset, from embolism of an apical thrombus that followed her infarction after repatriation from Kabul.

Factor 9(27): having a clinically significant disorder of mental health as specified at the time of the clinical onset of deep vein thrombosis; — MET

- A psychiatrist diagnosed posttraumatic stress disorder on 10 December 2020 after the mass casualty event at the role 2 hospital on warlike service in Kabul on 18 November 2020. She was managed with fortnightly psychology and medication, and it was present at onset.

Factor 9(28): taking a drug from the specified list of drugs within the three months before the clinical onset of deep vein thrombosis; — MET

- She took quetiapine, an anti-psychotic drug prescribed for posttraumatic stress disorder arising from warlike service in Kabul, nightly from 10 December 2020, and tamoxifen from 01 March 2021, within the three months before onset.

Factor 9(29): taking combined estrogen-progestogen contraception or taking menopausal hormone therapy as an oral estrogen, or a non-oral estrogen combined with a progestogen, for a continuous period of at least four weeks, within the three months before the clinical onset of deep vein thrombosis; — MET

- She took a combined estrogen-progestogen pill continuously for menstrual suppression on warlike service in Kabul, including the five weeks from 18 December 2020 to 22 January 2021 within the three months before onset.

Factor 9(30): having smoked tobacco products: (a) in an amount of at least one pack-year before the clinical onset of deep vein thrombosis; or (b) in an amount of at least 10 cigarettes per day, or the equivalent thereof in other tobacco products, for a period of at least three months before the clinical onset of deep vein thrombosis; and if smoking has ceased before the clinical onset of deep vein thrombosis, then that onset occurred within six months of cessation; — MET

- She smoked about 20 cigarettes a day, about 18 pack-years, increasing to 25 a day on warlike service in Kabul, and stopped on 28 January 2021, within six months before onset.

Factor 9(31): being at an altitude of at least 3,000 metres for a continuous period of at least five days within the three months before the clinical onset of deep vein thrombosis; — MET

- On warlike service in Afghanistan she spent seven continuous days at a mountain outpost at 3,200 metres, from 03 January 2021 to 09 January 2021, within the three months before onset.

Worsening factors

Factor 9(32): inability to obtain appropriate clinical management for deep vein thrombosis. — MET

- The five-day delay in duplex ultrasound and the eleven-day interruption of anticoagulation from 03 April 2021 occurred during the care that followed her repatriation from warlike service in Kabul, and the thrombosis extended with pulmonary emboli on 14 April 2021.

The % contribution of the causes is 100% and significant.

Sequelae

The deep vein thrombosis is a sequela of the veteran's breast cancer treatment, accepted myocardial infarction and stroke, and of the infections and posttraumatic stress disorder acquired on warlike service in Kabul. It has in turn caused pulmonary embolism, post-thrombotic syndrome of the left arm and the need for lifelong anticoagulation, with an increased bleeding risk.

Unintended Consequence

Met. The thrombosis is in part an unintended consequence of the implanted venous port, the axillary clearance with its seroma, tamoxifen, quetiapine and radiotherapy to the axilla, all provided and paid for through Defence health services while the veteran was serving (section 6A of the DRCA and the equivalent provisions of the MRCA).

Inability to Attain Appropriate Medical Management

MET. The veteran reported the swelling of her left arm on 19 March 2021, but duplex ultrasound was not available at the rehabilitation unit for five days, so diagnosis and anticoagulation were delayed until 24 March 2021. After her transfer between facilities on 03 April 2021 her rivaroxaban was not dispensed for eleven days, and on 14 April 2021 the thrombus had extended into the brachiocephalic vein with bilateral pulmonary emboli. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), delayed diagnosis and an interruption of anticoagulation outside the veteran's control amount to an inability to obtain appropriate clinical management, which contributed directly to the worsening.

5. Please provide a Health Summary and a medication / prescribing history.

See attached report.

References

1. 14 Jun 2016, Rheumatology consultation, Rheumatologist
2. 02 May 2018, Respiratory function testing and consultation, Respiratory physician
3. 21 Aug 2019, Diagnostic polysomnography report, Sleep physician
4. 18 Nov 2020, Sharps injury report and post-exposure record, Role 2 hospital, Kabul
5. 10 Dec 2020, Psychiatric assessment, Consultant psychiatrist
6. 14 Jan 2021, Deployed health record, Medical Officer, Kabul
7. 22 Jan 2021, Deployed health record and aeromedical evacuation record, Medical Officer, Kabul
8. 04 Feb 2021, Staging CT report, Radiologist
9. 09 Feb 2021, Operation report, Breast surgeon
10. 12 Feb 2021, Ultrasound left upper limb, Radiologist
11. 16 Feb 2021, Coronary angiogram and echocardiogram, Cardiologist
12. 20 Feb 2021, MRI brain and stroke unit admission, Neurologist
13. 05 Mar 2021, Infectious diseases consultation, Infectious diseases physician
14. 08 Mar 2021, Radiotherapy treatment plan, Radiation oncologist
15. 15 Mar 2021, Rehabilitation medicine review, Rehabilitation physician
16. 24 Mar 2021, Duplex ultrasound left upper limb, Radiologist
17. 24 Mar 2021, Haematology consultation, Haematologist
18. 14 Apr 2021, CT pulmonary angiogram, Radiologist
19. Statement of Principles concerning Deep Vein Thrombosis (Balance of Probabilities) No. 36 of 2021, Repatriation Medical Authority
20. Statement of Principles concerning Deep Vein Thrombosis (Reasonable Hypothesis) No. 35 of 2021, Repatriation Medical Authority