Postcards from Primary Caresville

Image by vitualis via Flickr

I was on Coumadin (aka rat poison) recently in my undisclosed location for an undisclosed problem, and wow, were the nosebleeds fun! I'd feel a little tickle and I'd look down to see that my shirt was covered with blood. No pain, just woooooooosh and wetness. Thank heavens for hydrogen peroxide and Oxyclean, let me tell you.

This reminded me of a 40-ish year old patient I had years ago. I dearly loved her and her family (several teenage children). She was so awesomely sensible, funny, and cool. To see her on my schedule at the start of the day was to know that no matter how much disease and dismay I had to do a funky monkey dance upon, there would be a bright spot.

After one delightful appointment I checked some bloodwork, and don't you know, this patient developed a huge venous thrombosis at the draw site. Aha. Blood draws are not an entirely benign procedure. (For those pracitioners playing along, she wasn't on any oral contraceptives, didn't smoke, and had no personal or family history of coagulopathy. She had used DepoProvera several years ago and found the side effects intolerable.)

She ended up on Coumadin for a few months, which ironically necessitated more blood draws since we needed to follow her coags. The Coumadin caused her already nasty, heavy periods to be absolutely atrocious, for which she cheerfully cursed me. She become mildly, then moderately anemic. I stopped the Coumadin after three months and damn if she didn't clot again after a blood draw, which ironically occured at the hematologist's office during her coagulopathy work-up (which was negative).

Back to Coumadin and menstrual cycles from hell. She became seriously anemic and much less cheerful. She had trouble working and taking care of her family. But what to do? Hgb in the 6 vicinity (loooooow). Transfuse? But then what? Stop the Coumadin? After two DVTs? We couldn't stop doing blood draws (she was on some other medication which required levels to be checked and had some--I can't remember which--other chronic health problems).

Not sure which ALGORITHM to fire up here, as this is a typical "off the grid", "oh, it's an art, not a science" problem, I called the hematologist who said he'd be quite nervous about letting her go without anticoagulation given two DVTs in five months, although he didn't have a diagnosis. He thought that oral contraceptives to control the bleeding was a very bad idea, even on Coumadin. The gynecologist didn't want to do anything definitive while the patient was anticoagulated, but suspected non-cancerous pathology in the uterus which was complicating the periods. He assured me that as long as she was anticoagulated she was going to bleed like a stuck pig, oh, and by the way, her uterus had a couple large fibroids, so the odds of an ablation helping were slim. Thanks, boys, that was a big help.

What did we do? I did a voodoo dance, hula'd around a Maypole, took the patient off anticoagulation for a few days with a few Hail Marys, had the gyn take her uterus out (adenomyosis and fibroids), threw her back on her anticoagulation immediately after surgery for three months, then switched all her meds around so that we'd have to do fewer blood draws. At the heme's suggestion, after another negative coagulopathy work-up, the patient started a full-strength aspirin daily. For the next few years all was well.

I haven't seen this patient in a couple of years, but I thought fondly of her every time I had one of those awesomely fun nosebleeds. I always think twice before I order a blood draw. It might lead to a hysterectomy.

In case you're wondering, I'm off the rat poison now. I hope she is, too.