This story is a little old. I remembered it in connection with another thing, which I will write about some other time. In the first story, my Registrar was agitated.
"Sir, we have a woman with warfarin toxicity and hemoperitoneum. She has been taking warfarin without supervision and her PT-INR is above 30."
I was taken aback. I had never seen so high PT-INR. Warfarin is a drug used to prevents blood clotting. Its effectiveness is measured by checking the recipient's PT-INR. PT-INR is calculated by using a formula comparing the patient's prothrombin time (PT) to a normal control's PT, the result being known as international normalized ratio (INR). Recommended value for that woman was 2.5
"Ask the hematologists to transfer her to their ward and treat her" I said.
"They won't do it" the Registrar said. "now that she is admitted in our ward. Their Registrar has advised a huge list of investigations and gone."
I was not surprised. Specialists always advised a big list of investigations, super specialists even more so. But they practically never transferred a patient in need of their treatment.
"I will talk to their boss" I said and called their ward. It turned out their boss away somewhere. I was disappointed but not surprised. I am usually unable to contact big bosses in their offices, and I am reluctant to call them on their mobiles, because I believe they must be doing something important wherever they are. I spoke to the next in command, who was an Assistant Professor.
"Why don't you transfer this patient and treat her coagulation abnormality?" I asked her/him.
"We do not have vacant beds" came the answer.
"My wards are full too. In fact the bed occupancy is about 200%" I said. "We keep the extra patients on low cots or even on mattresses on the floor. But we treat them all."
"Our boss' policy is not to take such patients" came the answer. The boss was not there to answer my question, I thought.
"OK. Why have you asked for such a lot of investigations? Surely warfarin toxicity can be managed without all of them? Our hospital does not have facility to perform those tests, and the patient is poor. She cannot get them done in a private lab."
"Which test are you talking about?" I was asked.
"D-dimer" I said. "Why do you need that?"
"D-dimer" she/he sniggered "is required to diagnose disseminated intravascular cogaulation (DIC)."
I could hear the satisfaction in the voice of the super specialist of having put an ordinary gynecologist in his place - especially when he was Professor and Head of his department. Fancy him not knowing what D-dimer was tested for, I could almost hear the thought behind that snigger.
"I know its purpose" I said patiently, "but why do you think a woman with warfarin toxicity would have DIC too?"
There was profound silence. DIC is a condition in which the blood has used up all clotting factors due to some disease and hence the patient can bleed from anywhere and everywhere. It is a dictum of clinical medicine that one should not suspect and diagnose two different conditions at the same time, though rarely they may co-exist accidentally. This person had no business thinking of DIC when there was proved warfarin toxicity and no disease that could cause DIC.
"Um..." she/he said breaking the silence eventually "just to rule it out, if it is ... um...there too."
"I understand perfectly" I said. "Thanks."
I put down the phone, and told my Registrar "we will treat the woman ourselves. You heard my part of the conversation and you understood it, I hope."
"Yes, Sir" she said. That patient went home fine from our ward after receiving appropriate treatment.
"There is no wisdom in considering everyone else a fool" I told my Registrar, especially when one is not perfect oneself. Humility comes with true wisdom. Beware of those who show no humility. Beware of those even more if they lack expertise themselves and still show no humility."
"Sir, we have a woman with warfarin toxicity and hemoperitoneum. She has been taking warfarin without supervision and her PT-INR is above 30."
I was taken aback. I had never seen so high PT-INR. Warfarin is a drug used to prevents blood clotting. Its effectiveness is measured by checking the recipient's PT-INR. PT-INR is calculated by using a formula comparing the patient's prothrombin time (PT) to a normal control's PT, the result being known as international normalized ratio (INR). Recommended value for that woman was 2.5
"Ask the hematologists to transfer her to their ward and treat her" I said.
"They won't do it" the Registrar said. "now that she is admitted in our ward. Their Registrar has advised a huge list of investigations and gone."
I was not surprised. Specialists always advised a big list of investigations, super specialists even more so. But they practically never transferred a patient in need of their treatment.
"I will talk to their boss" I said and called their ward. It turned out their boss away somewhere. I was disappointed but not surprised. I am usually unable to contact big bosses in their offices, and I am reluctant to call them on their mobiles, because I believe they must be doing something important wherever they are. I spoke to the next in command, who was an Assistant Professor.
"Why don't you transfer this patient and treat her coagulation abnormality?" I asked her/him.
"We do not have vacant beds" came the answer.
"My wards are full too. In fact the bed occupancy is about 200%" I said. "We keep the extra patients on low cots or even on mattresses on the floor. But we treat them all."
"Our boss' policy is not to take such patients" came the answer. The boss was not there to answer my question, I thought.
"OK. Why have you asked for such a lot of investigations? Surely warfarin toxicity can be managed without all of them? Our hospital does not have facility to perform those tests, and the patient is poor. She cannot get them done in a private lab."
"Which test are you talking about?" I was asked.
"D-dimer" I said. "Why do you need that?"
"D-dimer" she/he sniggered "is required to diagnose disseminated intravascular cogaulation (DIC)."
I could hear the satisfaction in the voice of the super specialist of having put an ordinary gynecologist in his place - especially when he was Professor and Head of his department. Fancy him not knowing what D-dimer was tested for, I could almost hear the thought behind that snigger.
"I know its purpose" I said patiently, "but why do you think a woman with warfarin toxicity would have DIC too?"
There was profound silence. DIC is a condition in which the blood has used up all clotting factors due to some disease and hence the patient can bleed from anywhere and everywhere. It is a dictum of clinical medicine that one should not suspect and diagnose two different conditions at the same time, though rarely they may co-exist accidentally. This person had no business thinking of DIC when there was proved warfarin toxicity and no disease that could cause DIC.
"Um..." she/he said breaking the silence eventually "just to rule it out, if it is ... um...there too."
"I understand perfectly" I said. "Thanks."
I put down the phone, and told my Registrar "we will treat the woman ourselves. You heard my part of the conversation and you understood it, I hope."
"Yes, Sir" she said. That patient went home fine from our ward after receiving appropriate treatment.
"There is no wisdom in considering everyone else a fool" I told my Registrar, especially when one is not perfect oneself. Humility comes with true wisdom. Beware of those who show no humility. Beware of those even more if they lack expertise themselves and still show no humility."
