Nurse, a memoir

About questions and answers.

One of the reasons I have seen patients in clinic is for management of warfarin. Warfarin is an anticoagulant (a “blood thinner”) and it requires a blood test for dosing. It is used to prevent things like strokes and pulmonary emboli. It requires monitoring to determine the proper dose so the patient does not bleed and does not have a blood clot. Blood is tested, you get a number, and then based on that number the dosing of warfarin is adjusted.

Recently I saw a patient for monitoring of this medication. Her number was really low. A completely normal number, as if she had no warfarin in her system at all. She is at high risk for a stroke which is why she is on this medication and with a low number she is at her highest level of risk. She refuses to take the newer medications that don’t require monitoring, “I don’t trust that new-fangled-tom-foolery,” has been her response when I’ve tried to switch her over. Low numbers can be due to missing doses, not taking your warfarin, diet changes, medication changes, activity changes and so forth. The visit went something like this…

Your number is really low today. Did you possibly miss any doses of warfarin?

No. I didn’t miss any doses. I take everything I’m supposed to take.

Any changes in your diet or what you’re eating?


Any changes in your medications, let’s review your list…?


Any new supplements or vitamins or herbals or teas?


Any changes in your activity level? More walking? More exercise?


Any changes you can think of that would have caused your number to drop so much?

No… but I’m really angry with the pharmacy. You (points a long bony finger at my nose), you ordered my warfarin two weeks ago and they never delivered it or called me. I’m mad about that.

Oh, well let’s look at that (checking of the computer and such ensues). Yup, we ordered it two weeks ago and it went through, but you never received it?


So did you miss any doses of warfarin.

No. I already told you that.

OK, yes. Did you… run out of warfarin?

Yes, one week ago when the new prescription didn’t come.

OK, so have you taken any warfarin this past week?

No, how would I do that? I don’t have any to take because it didn’t get delivered.

Oh… But you didn’t miss any doses?

What’s wrong with you today? I already told you this. I did NOT miss any doses of warfarin.

But you didn’t take it for the past week?

Yes, because it wasn’t delivered. And then she sat and glared at me.

Oftentimes real life is more interesting than anything I could make up. This was one of those moments. I kept expecting her to yell “gotcha” or pull out a video camera or start laughing. But alas she did not. Because this was real life and not a script.

Needless to say I followed up regarding her medication. It had been delivered over a week ago. When she went home she found it tucked behind something on her counter. She resumed taking it. Her blood check when she returned was fine. It turns out when you take your medication it works better.

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