420

Four hundred twenty. That's the number you get if you multiply the age of one of my patients by the number of times I've seen her this week.

Mrs S is a 105-year-old who fractured her hip after a fall. I saw her Monday evening as part of my preoperative evaluation. Her blood on the day of surgery (Tuesday) was too thin, so she got some vitamin K intravenously, and a repeat lab showed her blood just barely met the threshhold for the surgeons to operate. (I still wasn't happy about it; the case wasn't emergent, and I didn't think we should risk excess intraoperative bleeding when she wasn't really optimized. I wasn't happy about the I.V. vitamin K either. Strangely, this can rarely cause a life-threatening anaphylactic reaction, whereas intramuscular vitamin K is pretty safe. I warned the orthopedic resident to give it I.M., but the attending internist wanted I.V. (!) And so, for a non-emergent surgery, they stood by her bed and pushed I.V. vitamin K, ready to resuscitate her if needed.)

Anyway, the case was the last one of my day, and after we'd gotten her to sleep and I placed the breathing tube, I started off by sending off some baseline labs and pumping in four units of donor plasma to help her blood clot. By the time the fourth unit was in, I noticed there had been significant blood loss, so I sent another set of labs and started transfusing. (Good thing I didn't wait for the labs to come back before transfusing; her blood count had dropped significantly.)

When it was all said and done, the orthopedic surgeons had lost nearly a liter of 105-year-old blood. However, we were able to get the patient breathing & extubate her before transferring her to the unit.

I saw her again yesterday for my post-op evaluation, and then again today since another patient of mine was in the same room. She is an adorable, if slightly demented, lady; and it's amazing to think that she was a teenager during World War I. She was in her 60's when JFK was shot. And Sept 11 happened in her 100th year of life.

The other thing that will stay with me about this case is how irritating I find some surgeons' mindset. I feel like half of what I do is protect my patients from their surgeons. Especially in situations like this, where some rather unwise decisions were made.