The Art of Clinical Decision Making: Friday Afternoon Dilemmas

The woman had a bleeding ulcer and required a blood transfusion. The hospital discharge summary said to see me in three days for a repeat CBC. But she had a late Friday appointment and there was no way we would get a result before the end of the day. She also had developed diarrhea on her pantoprazole and had stopped the medication. As if that wasn’t enough, her right lower leg was swollen and painful. She had been bed bound for a couple of days in the hospital and sedentary at home after discharge.

She could still be bleeding and she could have a blood clot. There were no openings for an ultrasound until almost a week later. Normally, with the modern blood thinners, we can just start anticoagulation until the diagnosis of a blood clot can be confirmed or disproven. But you don’t do that when somebody has a bleeding ulcer.

The radiology department solved my dilemma by pointing out that the emergency room can order an ultrasound and the department will call in an on-call technician. So that is where my patient had to go. Her blood count was stable and the ultrasound was negative. So now we just have to hope that lansoprazole, which she had taken in the past, but stopped because she didn’t have heartburn, would be effective.

Not long ago, a Friday evening telephone call from a patient with severe nasal pain and a clear discharge after a Covid swab made me think she might have a cerebrospinal fluid leak. She, too, went to the emergency room on my recommendation.

Sometimes I over-explain the reasons I recommend the ER. I will list the types of tests that could help make the diagnosis, the patient only hears “head CT” or “wrist X-ray” and shows up at radiology with no order.

In this part of the country, with sketchy cell phone reception and people not always equipped with land line answering machines, let alone cell phone voice mail, I don’t want to have someone get an imaging test done and be on their way home when I get an abnormal result without being able to reach the patient. I’ve been burned before. And writing “WET READ, PLEASE” doesn’t always result in a call while the patient is still at the hospital.

As so often in medicine, getting the test is only the first step, then there are decisions, interventions and patient education to handle.