A Study in Scarlet
“All knowledge comes useful to the detective.”
-Sir Arthur Conan Doyle
While at the unit secretary’s desk last Friday afternoon I placed a chart in the rack and paused to strike a pose of thoughtful dignity, no doubt causing nearby onlookers to wonder who that man with the Lincolnesque comportment was. Why I lingered I haven’t the foggiest idea - if I had used common sense I would have dropped the chart and run like the March Hare on his way to tea. I didn’t slip away fast enough, though, and the secretary pounced on me with a smarmy grin and announced in her sing-song voice:
“I’ve got a consult for you!”
Oh, no…just when I was ready to peel out of the parking lot, secure in the fact that not being on call I could therefore enjoy my usual weekend activities without interruption. I fought the urge to slump into a chair and begin whimpering, and bravely took up the new chart. Sure enough, there was the order with my name on it, written into the permanent record just minutes before. I flipped a few pages and suddenly produced a facial expression like a nun at a Friar’s Club roast. Approximately twenty minutes later I was out the door for good, still shaking my head at the inhumanity of it all.
You see, the consult was for anemia; more specifically it was for a woman whose hemoglobin level was normal when she was admitted but now was low. How could this have happened? Why on earth would such a nice lady be stricken so mysteriously with such an insidious turn of events, or in other words - where did the blood go? In the spirit of the famous resident of 221b Baker Street I decided to approach the case deductively:
“Well, Watson, fact number one is that we know she had a history of diverticulosis which can produce gastrointestinal bleeding.”
“That’s all very well, Holmes, but not one of the staff observed any blood in her bowel movements.”
“Not with the naked eye, dear fellow, but notice in the laboratory section of the chart that of the three stool specimens submitted for analysis, one was indeed reported as positive for occult blood.”
“Not enough to send her haemoglobin level that low, I would say.”
“And right you are. Do you observe anything else about this section of the chart?’
“Hmm…there are lots of test results, aren’t there?”
“Precisely, and each test requires a sample of blood, does it not? Look here, Watson - for the past three days she has had a fever and has had six sets of blood cultures drawn.”
“Six sets, at twenty milliliters of blood per set - that’s certainly a bit more blood gone, isn’t it? Let me see the chart. I say, Holmes - do you notice this entry from last Tuesday? ‘Patient found out of bed on floor - complaining of right hip pain.’ You don’t suppose she fractured her hip that night, do you?”
“Did you happen to examine the patient’s right hip when we were in the room?”
“No, I didn’t even think of it, old boy.”
“Well I did, and it was covered with an enormous ecchymosis. I believe that hip fractures can produce blood loss, n’est ce-pas?”
“Oui, tout a fait - up to three units of blood can leak into the soft tissues around a break in the femoral head or neck. Don’t tell me you’ve found the cause of the old girl’s anemia?”
“Not one cause, Watson, but multiple causes. In my experience most patients who develop occult anemia during a hospitalization do so from several sources, the most likely being multiple phlebotomies for laboratory testing, or silent gastrointestinal bleeding.”
“By Jove, Holmes, you’ve done it again!”
“Thank you, my dear doctor. Now let us write an order for a roentgenograph of that right hip and suggest a visit from a good orthopaedist.”
I’ve said it time and time again - a good doctor in many ways is like a good detective, with the visual acuity of an eagle, the mental dexterity of a supercomputer and a keen sense of intuition best exemplified in the stories describing the exploits of the most famous sleuthing duo in all of literature.
