Version for the medical world
I would like to share a very interesting and entertaining story that occurred during my Internship, in Internal Medicine.
In the early 1990’s, I attended my 1st year of residency, internship, at a northeast hospital associated with a very prestigious medical school. I soon learned that one of the most frequent times I would be paged, by the nurses, would be to adjust the heparin IV drip strength for use as a blood thinner, for patients admitted for cardiac issues.
In those days the PTT (partial thromboplastin time) test was used and checked every four hours. The PTT test measured the time needed for blood to clot in the laboratory. We (the interns) would be notified of the value, if not in range, and adjust the drip strength accordingly.
The PTT test of those days is now called the aPTT (activated partial thromboplastin time). For this article I will just call it the PTT test. In addition, the PTT test was measured in seconds, but for the purposes of this article the “seconds” will be omitted.
A very interesting issue came about that year. There were probably slightly over twenty cardiologists who admitted patients to that hospital. There was an ongoing rule at the hospital that only interns or residents could place orders by writing them into the charts. In those days it was done the old-fashioned way with pen and paper, whereas nowadays it’s all electronic. The reason we had that rule is twofold. First, we wanted the interns/residents to have as much direct care as possible. The second reason was that nothing could be changed without one of the intern’s knowledge.
At that hospital, with one exception, the cardiologists would always write, “Suggest PTT 30-40.” One cardiologist there would always write, “Suggest PTT 40-50.” Throughout the entire year this was a mystery to all of the interns. We would often wonder why would this one cardiologist use measurement parameters that were different from all the other cardiologists. We often wondered why he would risk a hemorrhagic event by using this higher value of the PTT.
For the purposes of this article, I will refer to the cardiologist, who suggested the PTT 40-50, as Dr X. The interesting thing about Dr X, was that he was very well established. He was in his mid-50’s, very well respected by the attendings and residents, came from a top medical school, would attend world conferences, and completed a prestigious residency and cardiology fellowship. As residents we all knew what an excellent clinician he was.
During a meeting of several residents during sit down rounds, I asked a few of the other residents about this PTT issue with Dr X. The general consensus was that none of us knew why he used those parameters, but knowing Dr X, there had to be a good reason. We all knew him and respected him very much.
Well, this went on throughout the year. It was now towards the end of May and my PGY-1 year would be ending soon. I was treating one of his patients, on Heparin with suggested PTT of 40-50, and I decided I would find out why he used those parameters. I would be leaving this residency program to attend a specialty residency out West, and I was thinking about passing this information to residents out there.
I kept meaning to ask him in person, but kept missing him due to him stopping by when we were in meetings. On the last day of the rotation, the last day of May, I called his office and told the secretary I had a question for Dr X. I told her there was no issue with a patient, but I had a general question for him.
He got on the phone, and I identified myself. I said to him, “Dr X, there is an issue with your treatment that has baffled me for the entire year, and other residents as well. All the other 20 or so cardiologists at the hospital recommend keeping the PTT 30-40. You are the only one who recommends to keep the PTT at 40-50. All the residents know you well and respect you very much. We realize that there must be some reason you use these parameters. Is there some article where you saw it, or did you learn this at a conference you attended, or did you learn this information some other way?”
At that point, there was about 5 seconds of silence on the phone. I asked, “Dr X, are you there?” He replied, “yes, I’m here. Did you say all the other cardiologists recommend a value of 30-40 on the PTT test?” I replied, “Yes, that’s correct, but we all know you well enough to know there must be a reason for this.” Then again, another 5 second pause. He replied, “I .. ahh… I have to go. I have a patient waiting. I’ll get back to you on that.” I thanked him and the conversation ended.
After hanging up, I stood there very perplexed for 20 seconds. I was trying to contemplate what just happened. Then it came to me, “Oh my gosh, he has no reason for using the range of 40-50. For the entire year, and much longer, he had been using the wrong parameters for the PTT test.” Luckily, there were no known side effects of his patients that were on the higher dose.
Given his reputation, none of us ever bothered to question why he did it. As interns/residents, we are privy to the treatment options of many attending physicians. But even as an attending, as part of a group, he has access to the other patients in his medical group. I was baffled at how this could have gone on for so long. How could the other four members of his group practice not have noticed this and questioned him? The only answer I could surmise is that the PTT measurements and heparin strength were always taken care of on the intern/resident level. The nurses would never call a covering attending about this issue. In fact, they would usually tell us when it was Dr X’s patients so we would know the target range for the PTT. The nurses never questioned his parameter range either.
I thought to myself, oh boy that was interesting. I wondered what was going to happen now. I didn’t tell any of the other residents about this, since it was towards the end of the day. I was post call, and wanted to go home.
The next morning, I got to the hospital, and met up with the post call intern. He immediately told me that something “odd” occurred last evening. Dr X had stopped by, and written orders for all his patients on heparin to have a PTT between 30-40. I only responded by saying, “Hmmm… that is interesting.” That was the last I ever heard about the PTT 40-50 issue for Dr X.
The lesson to be learned here, is that if something is different and seems “off”, don’t be afraid to question it, no matter the source.