D-Dimer Dilemma

A patient came to our hospital with warfarin toxicity. She had been taking warfarin without supervision and any sort of monitoring. Her PT was 120 sec while the PT INR was not measurable (i.e. Above 6). She had intraperitoneal hemorrhage due to ruptured corpus luteum hematoma. She was a high risk case for surgical management even after possible control of the deranged PT INR, because she had had abdominal tuberculosis and was likely to have intense intraperitoneal adhesions. The problem was that the hematoma would continue to bleed even after correction of the coagulation problem because the bleeding vessels could remain open. In that case she would require a laparotomy. My associate professor had advised accordingly. Our hospital being a multispecialty hospital, we had hematology services available. So we made a hematological reference. We had asked the hematologist for advice on correction of the warfarin toxicity. They had a new lecturer after ages. This lecturer saw this patient and advised a host of investigations. By the time all those tests were done, the patient would either have recovered by herself (miraculously) or died (if treatment was withheld awaiting the test results). The said lecturer had been quite rude to our associate professor and the plan of management proposed, though it was beyond me to understand how she would know gynecology more than my associate professor. I finally called her myself. “Is that the hematology lecturer?” I asked. “Yes?” she said. I could not understand the question mark, but I had more important issues to understand from her. So I let it go. “I am the head of obstetrics and gynecology department. You have seen our patient who has warfarin toxicity and hemoperitoneum due to rupture of a corpus luteum hematoma.” “Yes?” she said. Perhaps they put a question mark after 'yes' in the part of the country that she came from. “I want to know why you have advised her to have D-dimer level tested.” “That is for diagnosing DIC” she sniggered. She must be looking down upon us obstetricians for our poor knowledge of hematology. I could not blame her. I had had similar experiences from some superspecialists in the past. “I understand” I said. “What I don't understand is why you think she could have DIC when she has warfarin toxicity, which is due to unmonitored warfarin consumption.” There was profound silence at the other end of the telephone line. She perhaps understood that she had goofed. “You may not do that test” she said “or you may do it later on.” She disconnected the line after I thanked her for her advice.