White Coat Underground

Friday writer’s block open thread

Things have been rather busy at Pal’s place. For whatever reason, the complexity of patients has been pretty high lately, so I haven’t had a chance to get in my usual once or twice a day post.

I’m told that “back in the day” internal medicine patients were a bit less complicated. These days, to get admitted to the hospital, you have to be pretty damned sick. The hospital has to be able to justify your admission based on “severity of illness” and “intensity of service”. In simple terms, you have to be sick enough to need care that cannot be provided elsewhere. The days of being admitted for “rest” or for “a workup” are gone.

It’s not uncommon for a typical hospitalized patient to have several illnesses, and for the treatment of one to be incompatible with the treatment of another. Many, many patients are treated with various sorts of medications to prevent blood clotting. People with a common heart rhythm problem called atrial fibrillation are usually on a potent anticoagulant called warfarin. Patients with drug-eluting stents in their coronary arteries are often treated with an anti-platelet drug called clopidogrel. If a patient on these drugs develop gastrointestinal bleeding—a common enough problem even without blood thinners—treating them becomes a real dilemma. Stopping the blood thinners may lead to devastating clots, but failing to may lead to life-threatening bleeding.

Patients with atrial fibrillation may have a risk of stroke as high as 8-10% per year, a risk that can be cut in half with warfarin. The risk of severe gastrointestinal bleeding is lower than that (depending on a number of factors), but it still happens. Given this, we’re going to see a lot of people with atrial fib in the hospital, either for GI bleeding or for stroke (not to mention for control of the arrhythmia itself).

All this is my way of saying medicine is never boring. But it’s sometimes busy.

In addition to hospital rounds, I’m going to a birthday party for a five year old buddy of my kid. Other than that, who knows?

So, what are you up to this weekend?


  1. #1 Dianne
    March 5, 2010

    Warfarin’s a horrible drug. It’s very restricting for the patient and hard to get the right balance. LMWH is a little better, but still problematic because it’s not oral. I’m hoping that the FDA will get around to approving one of the oral thrombin inhibitors one of these days. They’ll be expensive but easier all around. We still need better thrombosis drugs, though.

    I’m going skiing this weekend. For the fourth time in my life. I’m probably too old to be taking up knee destroying sports, but the young one likes it and who needs sense or anterior cruciate ligaments anyway?

  2. #2 k8
    March 5, 2010

    It’s supposed to rain all weekend. So I’m planning a day in for movies and laundry. What more could you ask for? Snuggly cats and coffee? Sounds splendid to me. And I got my free heirloom vegetable seeds in the mail, so I’m probably going to try to figure out how to start my seedlings. Last year, I just threw all my seeds in the ground and went for it, but there’s still four feet of snow on the ground here in South Dakota, so early planting is OUT.

    Have a great weekend. I love hearing about your work.

  3. #3 Donna B.
    March 5, 2010

    Pal — you are blessed to live in interesting times 🙂

    Dianne — I watch mogul skiing and think… they don’t have knees they have mechanical springs and shock absorbers! Growing up in SW Colorado, I did a lot of skiing and ice skating. Now I just watch.

    This weekend, I’m coddling and pampering myself trying to make sure that this cold I have does not progress to bronchitis, as almost all colds I get seem to do. Frequent naps, extra fluids in the form of OJ (which is a treat!), mucinex, and tylenol are scheduled.

  4. #4 Diane-with-one-N
    March 5, 2010

    I am going skiing with my family tomorrow, trying to get the last of the snow before it melts away in this el nino year. Sunday we are throwing out all the remaining stuff in my late mother’s house, hoping that we are near the end of this incredibly sad process.

  5. #5 SKM
    March 5, 2010

    I’ll be reading The Immortal Life of Henrietta Lacks (which just arrived today!) and sewing spring clothes for myself and my niece and nephew.

  6. #6 The Blind Watchmaker
    March 7, 2010

    To top it off, clopidogrel is less effective if used in combination with acid reducing drugs such as omeprazol.

    People with ulcers and coronary artery disease with stents are kind of screwed.

    Take care of yourselves early in life. I tell my patients that once problems start, it is a slippery slope. Don’t wait till then.

    I’m going to the Michigan State vs. Michigan Basketball game to end out the regular season. Should be fun. Sunny and in the 50’s.

  7. #7 the Blind Watchmaker
    March 7, 2010

    If you’re interested in a good book, get “Evolution Rx” by William Meller.

    It is good for lay folk who are wondering why the body and mind seem to work (and not work) the way it does from and evolutionary perspective. A fairly quick read for a lazy weekend.

  8. #8 Dacks
    March 7, 2010

    Well, the skiing was awesome this weekend! Controlled falling. The only serious spill was at the midstation hut, where I slid on wet decking. My feet went out, my butt went down, in front of about 30 people. How embarrassing!

  9. #9 E
    March 7, 2010

    It’s been a quiet weekend. So I sent the following to the website of the American Board of Medical Specialties. I’d been meaning to do this for a long time now and thought I would share it here:

    “Can you please make your ‘Is your doctor certified?’ section accessible without having to join and sign-in to your website each time?

    This would really help the average patient more easily verify a doctors credentials. It would also help more easily prove when a doctor is misrepresenting her/himself. Like when vermin Kent Holtorf cunningly portrayed himself on Fox News and The Glenn Beck Program as a “Board Certified Endocrinologist and Infectious Disease Expert.” In contacting those programs to point out that he is neither, it would have been easier to just say ‘go here and type in that name to see for yourself.’ Same story when The Rush Limbaugh Show inaccurately described him in the same way.

    The website of the American Board of Internal Medicine, ABIM.org, has their main page set up in this manner. Its great that someone can go to that website and easily access the following fabulous bit of truth about, again for example, Kent Holtorf: “This physician has not completed the requirements for ABIM certification.”

    Any consideration on this matter is appreciated. Thank you.”

  10. #10 Dianne
    March 7, 2010

    The skiing was slushy but fun where I was. I managed to go down a blue run for the second time in my life and collect a “there but for the grace of modern skis goes my ankle” moment on my third one.

    APT102 will save us all on the platelet front, if the company can manage to get an endotoxin free prep ever.

  11. #11 Diane-with-one-N
    March 7, 2010

    as for me, the skiing was beautiful and great fun, even with the slushy snow (and ice in many places). But, alas, on the last run of the day, I foolishly raced my teenager and fell so hard i cracked my helmet. Needless to say, Pal’s blogs last year about brain injury were running through my head after that! But seems like I got lucky–no concussion, and nothing broken, just a strained neck.

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