There are two ways of practicing medicine, “By the book,” or
using your brains. Though they’re not
mutually exclusive, they usually end up at the same point, albeit, with
different courses. This example is not recent, names are changed as are details.
Mary Smith came to our E.R. complaining of pain in her right
leg. She told the E.R. doctor (not me)
she had a history of blood clots in her leg and that she was on Coumadin. The E.R. doctor checked her blood
thinner level and found her blood to be appropriately thin. (Normal “INR” is 1.0. To be therapeutic with blood thinning on
Coumadin we like to have the INR at 2.0-3.0, or 2 to 3 times thinner than
normal. Hers was 2.5, perfect). That was the right thing for the E.R. doctor
to do. He sent her home.
Her pain didn’t get better, so 2 days later Mary went to one
of the walk-in clinics. The doctor
there told her she probably had a blood clot and sent her back to our E.R. with
instructions to get a Doppler study for blood clots.
I told her she didn’t have a blood clot. Her history (a burning sensation over her
entire leg, mostly in the back, that turned into an ache) was typical of
sciatica. Her leg didn’t have any signs
of a blood clot; no swelling, no change in color or temperature, normal pulses, and no calf tenderness. I told her she couldn’t have a blood clot because
her Coumadin level was high enough to prevent any clotting. I told her I wasn’t going to do the Doppler,
because even if she DID have a blood clot, since she was already on a full dose
of Coumadin, there was nothing more we could or would do about it anyway.
She wanted to know why the clinic doctor had sent her to get
a Doppler. Because, well, read the first sentence of this blog.
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