Multiple times this week our team (plastic surgery) experienced this conundrum. We have one elderly patient that just had surgery a week ago, and he has an artificial valve in his heart so he takes coumadin (a blood thinner) on a regular basis. This predisposes him to bleeding problems. After the surgery he developed a hematoma in his wound and had to go back to the OR to evacuate it. Every time we try to get him back to his usual dose of coumadin, he bleeds from somewhere. But he has to have it or he could get a clot in his heart valve and have a stroke and die. What is usually a routine postoperative course has gotten this man 5 blood transfusions and an extra week and a half in the hospital (so far).
That's just one example but if you think about it this type of problem is frequently encountered in medicine. Drugs have side effects. Surgeries have complications. Patients are not textbooks. For every action there is a reaction, and it is not always beneficial. These situations make me realize that there really is an art to medicine. There's no algorithm for what to do NOW with our bleeding patient beyond vague recommendations, yet we have to deal with it. We are still dealing with it.
I feel like a lot of choices in life are between the lesser of two evils. Either the patient will bleed or clot. Which do we choose?
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