Sandy Brown, MD


February 27, 2007

To coumadinize or not to coumadinize? That has always been the question for me in dealing with older patients with atrial fibrillation who are subject to falls. On one hand, there is the risk for a fatal intracranial hemorrhage if you do coumadinize; on the other, a devastating stroke if you don't coumadinize. The literature supports coumadinization, so I do it with trepidation, paying meticulous attention to my patients' International Normalized Ratios (INRs). But all it takes is one anecdotal experience to make the scientific data go down the drain.

Shaun was an 83-year-old patient with longstanding polycythemia vera. For years, I treated him with frequent phlebotomies, until he eventually stabilized -- requiring less than 1 phlebotomy a year. Then atrial fibrillation developed, which also developed in his wife, Judy, so that each month they appeared in my office for their ritual prothrombin time measurements. Both were fairly stable on their Coumadin doses, running INRs between 2 and 3. The visits were always the same: a blood pressure check; a blood draw; a call in the morning with their results; dose adjustments, if needed; and Shaun asking if they owed me anything on the way out. If he ever forgot to ask, I knew something had to be wrong.

Over time, a foot problem developed in Shaun, along with severe degenerative arthritis in his knees, and he became an unsafe ambulator. I suggested that he use a cane. When he still appeared shaky, I prescribed a walker. In spite of that, he appeared in my office 1 day after a fall with multiple abrasions on his scalp. "What happened?" I asked him. "Did you trip? Get dizzy? Pass out?" "Don't know, Doc," Shaun said, "Except that they had to call the fire department to get me to the hospital. They checked me out at the ER, released me, and told me to follow up with you." Dalia asked for the medical records and I found, incredulously, that Shaun hadn't had a head CT. "I think you're okay," I told him, "But we need to scan your head to be sure."

The scan was negative except for cortical atrophy. I sent the pair home and admonished him to be careful. Two weeks later, when due for their monthly prothrombin time measurements, Judy called to say they would be late because Shaun had fallen again. She had lifted him up by herself this time. On examination, he had a few skin tears on his arms and not much else, although he appeared to be weaker since using the walker. I had Dalia set him up for physical therapy. "Call you tomorrow," I said. "Owe you anything, Doc?" Shaun said, on the way out.

Later that night, I was woken up by a call from the emergency department. "Your patient, Shaun F., was just brought in by ambulance obtunded with a blown pupil," the ER doc said. "Does he have anisocoria?" "No," I said. We both knew it was a subdural hematoma. A CT scan confirmed it. A neurosurgeon at the nearest tertiary care center said that Shaun's mortality risk was 100% and advised only comfort care. He died a few days later.

Of note was Shaun's INR, which had inexplicably risen to 4.8. The perfect storm, I thought -- extreme hypercoagulability, cortical atrophy, and a fall. I had seniors on Coumadin who had done face plants resulting in broken noses and raccoon eyes, who hadn't gotten subdural hematomas. Yet this patient, who hadn't even hit his head, managed to shear some bridging veins between his cortex and dura and bleed to death. As hard as I tried to beat myself up over this one, I realized that it wasn't my fault. It was just bad luck.


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