Attention to Detail Saves Lives

Attention to detail is one of the most important qualities for a good health care provider and student. By trade, we have to be attentive and cognizant of the smallest factors that may impact a patient’s life.

That extra zero in a medication order could end up causing a major complication for a patient, or a prescription for an antibiotic could interact to increase a patient’s potassium level.

The ability to read through a situation, patient history, or hospital discharge summary and find the one or two minor, yet possibly very important factors to a patient outcome, takes time to master. Perhaps this trait is passed down from a knowledgeable preceptor to an astute student, or it can be a learned skill over time, or the result of a clinician missing one of those important details previously.

A prime example could be the evaluation of a young patient with nosebleeds.

Recently, we spent some time discussing nosebleeds as a general topic, causes, anatomy, pathophysiology, management, and ultimate treatment.

In family medicine, we commonly see patients after they have been in the emergency department or urgent care for a visit. The common statement from those providers is “Follow up with your PCP if you are not improving”.

At the follow up visit, commonly we review the emergency department course, follow up on tests, imaging, and assure that the patient understands discharge instructions, new medications, and most importantly, make sure that the patient is getting better or has improved.

It can seem like a lot to cover, and certainly it is. So, it really takes a lot of diligence to cover all of the above and then still have the time to look outside the box at the diagnosis.

 

Case Presentation...

Let’s say the patient in question has been seen for three emergency department visits in the last year for nosebleeds...

  • Should we go through the motions and do the visit?
  • What if we take a step back and ask WHY is the patient getting nosebleeds?
  • Should we continue to assume that potentially irritated tissue in the nose from allergies has caused this repeat flare up?

We absolutely shouldn’t shouln't assume.

This is how mistakes originate and continue.

If we take a step back and do a more thorough history and physical, family history, we may be shocked at what we find.

Rarer causes than “digital trauma” do exist!

It is the same reason that when reviewing a radiograph of a patient who has just fallen on their wrist, we do not stop reading and analyzing once we have seen one fracture. We keep looking, because there are other answers out there if we are willing to find them.

 

Von Willebrand Disease

Von Willebrand Disease is an inherited bleeding disorder categorized by a deficiency in Von Willebrand Factor. Von Willebrand Factor (Which will be referred to as VWF), is very important for primary hemostasis, as its’ function is to bind to platelets and the endothelial surface after an injury. It also helps bind platelets to platelets. A deficiency in VWF is the most common inherited bleeding disorder, impacting up to 1% of the population.

Patients with VWD may not have any symptoms, as the disease course tends to be very mild. In patients with symptoms, common complaints include easy bruising, easy bleeding, a history of heavy menses, or frequent and recurrent nose bleeds.

Do we have our answer from the above?

Another possible clue may come from taking a patient’s surgical history. The surgical history should ask about surgeries the patient has had, but also should ask about complications. In patients with VWD, history may show that the patient has had surgeries in the past with prolonged bleeding. Patients under going wisdom tooth extraction may have excess bleeding, or a pregnant patient may have been treated for excessive bleeding in the post partum setting.

Once the diagnosis is suspected, there should be evaluation of a thorough family history. Similar histories in family members is also suspicious and should be investigated. Patients may not be willing to bring this to the clinician’s attention, as the condition may be described as “minor” and the patient may not think it important.

When evaluating with lab work, the patient initially may have a normal CBC. Thrombocytopenia is not typical of VWD. PT is usually normal, but PTT may be increased.

Evaluating specifically for VWD will include a VWF antigen, VWF activity, and Factor 8 level. VWF antigen may be positive and VWF may be decreased. More complicated assays and further evaluation via lab work can be undertaken by an experienced hematologist.

The treatment of von willebrand disease is the use of desmopressin. It is important to recall that the vast majority of patients with VWD are asymptomatic and do not need any intervention.

Patients with moderate to severe disease may have bleeding episodes that are provoked by procedures, which can be treated with synthetic desmopressin. Desmopressin is available intravenously, subcutaneously, and intra-nasally. Side effects of desmopressin include facial flushing, headache, nausea, vomiting, hypotension, and hyponatremia.

For patients with severe depletion or reduction in VWF levels, synthetic VWF can be administered. This should be managed by a hematologist.

Additionally, patients should be reminded about the risks of OTC medications such as ibuprofen and aspirin which should be avoided in this particular population.

I hope that today’s article has been helpful on a few different levels. First, it serves as a reminder to be thorough, accurate, and always thinking outside of the box. Secondly, it is a review of the most common inherited bleeding disorder, sure to come up on an end of rotation exam or with the patient sitting in front of you complaining of a nose bleed.

If you're interested in diving deeper on nose bleeds, here's a video we posted sharing what you need to know...

Rick, Margaret (2018). Clinical evaluation and diagnosis of Von Willebrand Disease. UpToDate. Date of access 17 December 2018.

Rick, Margaret (2018). Treatment of von Willebrand Disease. UpToDate. Date of access 17 December 2018.