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.
For some reason, I imagined you having that conversation with yourself out loud, and your secretary looking on quizzically.
(btw, for some reason that emedicine link goes to a placeholder site)
Comment by Ali — April 8, 2006 @ 3:00 pm
Thanks, Ali - I changed the link to a site that hopefully is active.
BTW - you should see the look on my secretary’s face when I emerge from my office on a Friday afternoon and announce, “I’ve been blogging.” Her expression is best described as a cross between a Sunday School teacher asking a room of juvenile delinquents to open their Bibles and a driving school instructor who has just watched his pupil back into a parked car. Oh, the price of fame!
Comment by The Cheerful Oncologist — April 9, 2006 @ 6:01 am
I can so relate to the anemia from a hospitalization after spending 9 days in a hospital post-surgical. (Let alone already low from chemo)…. we sure could use research to work on bloodless lab tests - ala Star Trek. oops I think that’s the 25th century.
Comment by Vicki — April 9, 2006 @ 11:17 pm
I was doing a search on the recent British Phase I Clinical Trial Disaster (TGN1412) and for some reason, your blog popped up. I found myself so caught up in your writing that I completely forgot that I had intended to head for the MSKCC site and see if Dr. Cheung and his posse had anything to say with regard to the monoclonal antibody study but I’m going to dive back into your archives. With all due respect to the NB team at Sloan, your site offers more of the lighter side I may not have been seeking, but obviously needed. Thanks for that. Keep writing - you’re highly entertaining and more than sardonic enough to hold one’s attention. Cheers! Susie Parker-Perry, Wilmington, NC.
Comment by Susie — April 10, 2006 @ 3:45 am
I love Sherlock Holmes. But then, who doesn’t?
Comment by StarFirstbaseman — April 11, 2006 @ 8:13 pm
Maybe you’ve heard this one before. . . .
Sherlock Holmes and Watson were out on a camping trip. Holmes said,”Watson, look up in the sky. What do you see?”
“Stars, Mr. Holmes.”
“And what do you deduce from that?”
“Well, let me consider . . . . There are hundreds of thousands of stars in the sky. If only one of a thousand has planets in orbit around it, then there are thousands of planets up there. And if one of a thousand planets have life on them, certainly that means that somewhere, up there, there is likely to be intelligent life somewhere. How is that for an answer?”
“Watson, you idiot,” Holmes said. “If you can see stars, it means someone has stolen our tent.”
Comment by mchebert — April 11, 2006 @ 10:49 pm
Can’t the patient being somewhat dehydrated prior to admission, and then put on the mainenance IV fluids all doctors love cause the appearance of “anemia” as well, from hemodilution?
And I’ve always loved that Sherlock Holmes / Watson joke…
Comment by DisappearingJohn — April 12, 2006 @ 12:08 am
“roentgenograph” … love it. And hey, that Sherlock Holmes joke was scientifically shown to be the funniest joke of all time.
Comment by Nick — April 12, 2006 @ 12:59 am