Why ER doctors always ask patients if they take blood thinners.
A tweet about this got >1 million views. Here's the answer.
If you go to an emergency room after a trauma—even a mild one—prepared to be asked the same few questions over and over.
We ask the same questions so many times that I sometimes wonder if patients think we are the ones who need to be screened for amnesia, rather than they. One question you’ll definitely be asked: do you take any medications that thin your blood such as Warfarin (coumadin), Pradaxa (dabigatran), Eliquis (apixaban), Xarelto (rivaroxaban), or others like it?
That led to this tweet, by Third-Wave feminist turned vaccine disinformation conspiracy theorist and all-around loose cannon Naomi Wolf. (I’ll skip an older tweet where she compared Dr. Tony Fauci to, you guessed it, Satan).
Good question!
Easy answer.
No, this is not new. Asking patients in the ER after mild (or moderate) trauma whether they take blood thinners has been routine for a long time.
In fact, here are some questions we’re going to ask any patient with mild trauma:
Do you remember everything that happened? Or, its cousins: Did you black out? Do you have any memory loss from before or since the event.
If you have any memory loss from things leading up to the event, how far back does the gap go?
Did you fall down more than a few steps [if it was a fall]? Was your seatbelt on and did the car’s airbags deploy [if it was a car accident]?
Have you vomited since the trauma? If so, how many times? (Nausea without vomiting is far less important.)
Are you on blood thinning medications?
Questions like these have been on the must-ask list for decades. But these ones in particular became ascendant, after a landmark medical paper was published in the medical journal The Lancet in 2005.
The paper is entitled, “The Canadian CT Head Rule for patients with minor head injury.” The title speaks for itself. Developed by our neighbors to the north, the paper describes the features of patients who need not undergo a CT scan of the head after “minor” head injuries.
Over time, we’ve learned that patients with seemingly minor head injuries can hide “clinically important” brain injuries—like significant internal bleeding. So, we run checklists like those in the Canadian CT Head Rule to help guide our decisions.
Technically, the rule (which many have said ought to be called a “tool,” because the results are helpful but not binding) is meant to help ER doctors like me CT fewer patients than I might otherwise. In fact, if you run the checklist, you’d be surprised just how many quasi-bad things the patient can have, and still not need a CT scan! (It still amazes me that the patient can have “some” amnesia to the time before the event, just so long as the lapse in memory does not exceed 30 minutes.)
The idea is that there’s high-quality data that I can rely on when deciding to spare a patient an unnecessary CT scan. If I put “CT Canada negative” in my medical chart, it implies that any prudent doctor in my shoes would not be sending that patient to the CT scanner, unless something unusual was afoot. In the studies testing this checklist, none of the patients who “passed” the checklist were found to have any serious brain injuries. You can’t get better than a net that catches 100% of the dangerous injuries, but reduces the number of tests that need to be done. (By the way, there’s an entirely separate tool/algorithm for kids, but I won’t get into that today).
So yeah, Naomi Wolf, we have been asking about blood thinners in our mild trauma patients for a long time. But her tweet implied that she has had a lot of experience with ERs—and even with minor trauma.
So what’s changed?
Not us! But, I will say this: Patients “fail” the CT Canada criteria if they are older than age 65. Perhaps the EMS and RNs who treated Wolf, now age 60, were just running the checklist and the answer was not as obvious as it once might have been.
Growing old has its downsides, to be sure. But, it beats the alternative!
Why ER doctors always ask patients if they take blood thinners.
Thanks for the insight. A couple weeks ago I was in a car accident where the airbags deployed and I don’t remember the airbags coming out, but it was only for a second or two. I pondered if I should go to the ER but seemed okay otherwise (we all were thankfully). I’m glad it looks like I wouldn’t have needed a scan!
These protocols are definitely worth talking about and are essential to great care. I have spent a lot of time in a lot of hospitals in the US for work as well as for surgival procedures. Those hospitals that demonstrate thoughtful and current protocols for all sorts of procedures (hip replacements to infection control) , demonstrate better outcome, better prepared staff and usually better prepared patients. Moreover, have been in an ER as a patient and as a spouse and have been asked BOTH times about medication status, particularly blood thinners. I would BE surprised if it was not asked.