Tuesday, May 15, 2012


Falstaff, one of Shakespeare's best characters, said in Henry IV "Discretion is the better part of valor", and nothing illustrates that quote better than this picture.  Operating on any patient with a coagulopathy, either iatrogenic (coumadin, Plavix, Effient, steroids, heparin or its analogs, etc.)  or self-induced (as in aspirin, alcohol, Vitamin E, fish oil, garlic, ginseng, gingko biloba, NSAIDS, etc.) or idiopathic (as in this case of ITP, liver failure, coagulation factor deficiencies, etc.) requires a lot of nerve, especially when most of those problems can be corrected with good ol' science.  

This gentleman was operated on for a BCC on the forehead in spite of platelet dysfunction, and although the technicolor results are dramatic, he did quite well in the post op period.  Had the surgeon known he had ITP, no doubt he would have given him a 6 pack or two of platelets, but to be honest, all of us who operate come in contact with patients who are relatively coagulopathic (if I may coin a word).  I usually have at least half of my patients on thinners of one sort or another, and most of them completely ignore my proscriptions against alcohol before surgery.  

So, what's a surgeon to do?  My best advice is to look carefully at the patients when they are biopsied.  If they bleed profusely, but without an obvious reason (as listed above), OR show evidence of extremely abnormal bruising (I saw one of those guys today) then ordering a CBC with plts, and a PT/PTT and an INR for those who are eating rat poison is a good idea.  If they display a coagulopathy and you can't find an obvious cause, send them for a workup via their PCP.  It will save you a lot of patient animosity, diminution of your street cred with the PCPs and sleepless nights.

If you named any reason for coagulopathy, you got credit for the right answer.

For extra credit, how could you reverse a coumadin overdose?

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