A Country Doctor Writes:

“My name is DeWitt. I’m a neurosurgeon in Charleston, South Carolina,” a velvety male voice announced. I cocked the telephone receiver under my chin as I grabbed the chart Autumn handed to me.

“I have just operated on your patient, George Magnusson. He had a large subdural hematoma from a fall that happened a few days ago.” The surgeon spoke in a slow, subtle Southern accent. He continued:

“The reason I am calling is that you’ve had this man on blood thinners for several years now for a pulmonary embolus and deep vein thrombosis he suffered after a motor vehicle accident.”

I glanced at Mr. Magnusson’s problem list.

“Yes, in 2001,” I replied.

“Right,” he continued, “but he has a Greenfield filter, so he is protected from pulmonary embolization.” After a slight pause he continued in a restrained, low voice:

“I don’t believe one usually continues the warfarin under those circumstances. I had to reverse it for the surgery and will be leaving him off it while he’s here, obviously. But I would suggest you discuss the risks and benefits with him when he returns home.”

“What was his prothrombin time?” I asked.

“It was therapeutic. And I expect him to make a full recovery, fortunately for all of us,” he added. “He should be back in your area next week.”

The telephone conversation left me thinking.

George Magnusson had taken his blood thinner faithfully for ten years and had hardly ever been out of the therapeutic range. He was fairly healthy otherwise, and I seldom saw him during the three or four years he had been my patient. When I first met him, I had not questioned his need for chronic anticoagulation.

One school of thought is that patients with a definite trigger for a blood clot, such as a major fracture, can be taken off blood thinners after three to six months. Another viewpoint is that patients with a history of massive clots are better left on their blood thinners indefinitely.

Had I failed George Magnusson by keeping him on warfarin and subjecting him to an unnecessary risk of bleeding as he was getting older? After all, his clots happened after a major car accident with multiple fractures.

In my mind I went over what I remembered about inferior vena cava filters. I had very little experience with them, but never thought of them as a replacement for anticoagulation. At best they only reduce the risk that a blood clot would separate from its location in a leg and travel to the lungs, but a person who is at risk for blood clots in the legs could still develop them.

My most trusted online database stated: “Because patients with IVC filters are at risk for IVC thrombosis, insertion site thrombosis, and recurrence of the initial thromboembolic event, continued use of anticoagulants when there are no contraindications is prudent.”

When George and Ellen Magnusson returned from their winter vacation near Hilton Head, South Carolina, they both looked tired. George’s thick, gray hair had been shaved on one side of his head for the operation.

I went over the pros and cons of staying on blood thinners after trauma-related clots like George’s. Especially Ellen looked reserved.

“Dr. DeWitt was very sure blood thinners weren’t necessary,” she said.

“It’s a judgment call,” I answered. “Why don’t we get a hematology consultation? I’d like to hear what someone like Dr. Hertzog thinks about your situation.”

Ellen and George left the office and we agreed to talk again after the hematology consultation.

This morning I got a call from the Emergency Room. George just came in with a massive clot from his calf all the way up to his groin.

I guess we won’t need that hematology consult, after all.

Lester Burr was alone in the office Friday afternoon. Doris had dropped him off to go to the hairdresser. His diabetes visit went smoothly; he had normal blood pressure, cholesterol, kidney function and foot exam. His eye doctor report was up to date and none of his medications needed to be renewed. He has no history of heart disease and had not had any chest pain, heart palpitations or shortness of breath.

Just as I was preparing to leave the exam room, Lester gave me a funny look and said in a tentative voice:

“Why am I so dizzy?”

“Have you been dizzy for a long time?” I asked.

“No, it just started.”

“Do you feel like you or the room are moving or spinning?”

“Not really.”

“Do you feel sick to your stomach or lightheaded? Tell me more about what it feels like.”

“I don’t know.”

A quick neuro exam was unremarkable, but Lester started to look more and more uncomfortable. He wiped his forehead. I could see pearls of sweat. Suddenly, he burped and then said in a low voice:

“I think I’m going to be sick.”

I got him to lie down on the exam table and put an emesis basin in front of him. With my other hand on his wrist I checked his pulse. It was slow and weak. He vomited profusely.

“Hold on”, I said and stuck my head out the door to call Autumn, my nurse. She appeared instantly in the hallway.

“Autumn, call the ambulance and let’s get an EKG.”

She reappeared within moments with the EKG cart. I got another blood pressure, much lower than when Lester first checked in. His EKG had a hint of ST elevation – a possible anterior myocardial infarction.

One of the office nurses started an IV before the ambulance came.

“Which hairdresser does Doris go to?” I asked.

“The one next to the Post Office”, Lester whispered.

Autumn dashed out to call Doris, who soon appeared with her head wrapped in what looked like a turban.

By then the ambulance arrived and soon Lester was on his way to the hospital.

I knocked and entered the next exam room.

“I’m sorry to have kept you waiting. We had a little surprise with another patient…”

Early in my career I met Fran Dennison. She was a forty-something smoker with asthma and mildly elevated blood pressure. She seemed to always be under stress. A nontraditional university student, she was always trying to be in two places at the same time.

After several visits with elevated blood pressure readings, she became interested in doing something about it. Her routine chemistries and urinalysis were normal. She had normal heart and lung sounds and only a trace of ankle swelling.

My first choice of medications was a diuretic. She was eager to try it, and did her blood test as I had requested a couple of weeks after starting it.

At her next follow-up visit, her blood pressure was better, but not where it should be, so she agreed to also take an ACE inhibitor. I made her promise to get another blood test a week or two later, just to check on her kidney numbers. ACE inhibitors were brand-name drugs back then, and she asked for a 90-day prescription to keep her co-payment down.

Three months later Fran was back in the office, feeling terrible. Her complexion was pasty, almost jaundiced. Her face, hands and legs were puffy, and she had lost ten pounds due to nausea. She was exhausted and depressed.

I sent her for some bloodwork and promised to call her when the results came in.

Her liver profile was normal, but her potassium was high and her kidney function severely reduced. I called her and asked her to stop both the fluid pill and ACE inhibitor and to see me again as soon as possible.

Later that week I put my stethoscope to her abdomen and heard a faint, rhythmic hum over her abdominal aorta. The arterial pulses in her groins seemed fairly normal, but when I pumped up my blood pressure cuff on her right calf, her arterial pulse at the ankle disappeared somewhere just over 90. I got the same reading on her left leg.

“I know what’s wrong with you”, I explained. “You have coarctation of the aorta. The narrowing of your main artery is cutting off the blood supply to your kidneys, and that’s why your blood pressure in your arms is high. The kidneys are sending out chemicals to try to increase your blood pressure, and making it too high everywhere above the blockage, but it is still too low in your kidneys and in your legs.”

“Is that why my legs hurt when I walk?” she asked.

“Most likely”, I confessed. “I didn’t ask you if they did. I also didn’t listen to the arteries in your abdomen or check the blood pressure in your legs until now. And you didn’t get that blood test we talked about after you started the last medication I prescribed. That’s why we didn’t find out that the medicines were starving your kidneys of blood by lowering the pressure inside them too much.”

Fran’s kidney function returned to normal after we stopped her ACE inhibitor. Her blood pressure normalized after the vascular surgeons restored the circulation to the lower half of her body. Her leg aches disappeared and she started exercising. She even quit smoking.

Since that day I always check my hypertensive patients’ blood pressure in their legs and I always listen to their abdominal arteries

I have never come across another case like Fran’s, but if I do, I won’t miss it.

Rodney Grussman is a mild-mannered, unassuming seventy-year-old man with diabetes, emphysema and valvular heart disease. I see him every three months to monitor his bloodwork and his symptoms. He sees his pulmonologist about twice a year and has a couple of nodules in his right lung Dr. Welch is following.

At his last three-month-visit everything seemed fine, except he was at the tail end of a cold, which seemed to have left him slightly short of breath. His exam was normal, his oxygen saturation hovered around his baseline, and we agreed that he would let me know if he didn’t bounce back over the next week or so.

Almost two months later, Rodney came back to see me.

“Doctor, I am so winded. I have lost my stamina since I had that cold.”

His exam was unchanged. I wondered if he could have had a silent heart attack or if something was going on with his lungs. His EKG was unchanged, but his chest x-ray suggested a couple of new, very small nodules in his left upper lobe.

I ordered an echocardiogram because of his leaky valve and referred him back to Dr. Welch for his opinion.

The echo showed no deterioration of Rodney’s pump function; his ejection fraction was still 40%, just like three years ago. That is a little lower than the 55% considered normal. His valves looked about the same as two years ago.

I waited for Jerry Welch’s report, but didn’t hear anything for a while. Then I found out that he was trying to get insurance approval for a PET-scan because the new nodules in Rodney’s left lung looked suspicious on a non-contrast CT scan. Due to his compromised kidney function, Rodney can’t have intravenous contrast dye with his CT scans.

The PET-scan finally came back normal. Rodney came back to see me. His pulmonology report focused on the new lung nodules much more than Rodney’s shortness of breath.

As I listened to Rodney’s story again, it struck me: His heart was still decent, his lungs no worse than before, but what about the oxygen carrying capacity of his blood? A simple blood count showed he was quite anemic, and his stool test was positive for blood. He’s getting his upper and lower endoscopy next week.

I hadn’t considered all my ABC’s from my emergency training – A for Airway, B for Breathing and C for Circulation, although for more chronic conditions, perhaps it should be A for Anemia, B for Breathing and C for Circulation.