Thursday, August 21, 2008

Hemoglobin of 6

For those not in The Biz, a normal hemoglobin in roughly in the neighborhood of 12-16 g/dL.  NewFNP is not going to lose any sleep over an 11 or even a 10, but she will assess your gender and diet and overall health and pregnancy status and miserable menstrual periods and history of hemoglobopathies, yada yada yada.  

No, newFNP doesn't go into real worry mode until she sees hemoglobins in the single digits and, really really not until it's below 9.  

But what will get newFNP's attention faster than a J. Crew shoe sale is a hemoglobin of 6.  And that is exactly what newFNP has seen this week.  


NewFNP's first crazy anemic patient is the 30-year old with AIDS.  He came in noting copious frank rectal bleeding times four days.  NewFNP saw him two weeks earlier and his hemoglobin was 10.  NewFNP placed him back on iron and instructed him to return to his HIV doctor.  He is taking the iron but is less adherent with his HIV care.  Some might say that his priorities are askew, but when your hemoglobin is 6 and you are bleeding from your rectum, newFNP doesn't have that chat with you.  She examines your bleeding after 5 minutes of hemming and hawing over the embarrassment about showing newFNP your b-hole, notes frank bleeding and transfers you to the hospital for transfusion and diagnosis of etiology.  

NewFNP spoke with his nurse at the HIV clinic a couple of days after his admission- he's hospitalized, transfused and recovering.  But, in reality, he is circling the drain.  He's failing his HIV appointments and taking his medications incorrectly and not taking all his prophylaxis meds.  It breaks newFNP's heart to see him suffering so much and to see him not adhering to his care.  Thirty years old.

The second anemic patient this week presented to clinic with vaginal itching.  She is 14 years old.  She wasn't with her parents because she's sexually active and doesn't want them to know.  NewFNP got her history and was about to begin her exam when she realized that she had forgotten to look at the lab section of the chart.  She flipped back and saw that the patient's hemoglobin was 6.1.  She asked the patient about heavy periods or dark stool or nosebleeds - nothing.  She thought that the MA must have made an error and asked her to repeat the test.  It was 6.3.

This brings newFNP to another point.  Both times, newFNP's MAs had no idea of the significance the very abnormal result held.  One MA is known to newFNP and she's not entirely surprised, but when newFNP expressed shock at the result and instructed him to repeat the test, he was in the patient's exam room, repeating the test in a fricking flash.  NewFNP saw the second patient in a clinic that is not her regular site as she was filling in for a provider who is on vacation.  Unlike the MA at newFNP's regular site, this MA did not seem very impressed with newFNP's instruction to quickly repeat the test.  Frustrating.  But it does bring to mind a few lessons:
  1. Repeat abnormal values.
  2. Work with the same MA so that you can teach him/her abnormal values that necessitate your attention.  The same MA who blew newFNP off when she asked her to repeat the hemoglobin also let a post-CVA hypertensive woman sit in the lobby for two hours after having recorded a blood pressure of 198/110.  NewFNP was displeased.
NewFNP called the fourteen-year old's mother, told her that her daughter wasn't feeling well and had come to our clinic where we detected this anemia.  Her mother told newFNP that she was anemic because she didn't take vitamins or eat well.  Hmm, not the most common reason for a hemoglobin of six, but very motherly, no?  NewFNP told her that her daughter might need a transfusion and could she please come to the clinic.  

NewFNP's big worry is cancer.  She's not sure if she'll ever know what happened with this young woman but she doesn't have a good feeling about this one.  

1 comment:

Anonymous said...

Actually a severely anemic woman who is otherwise asymptomtic, would be more likely to have either dietary issues or Celiac, just statistically.