An old take on "transitionalists" Plus, dialysis and dabigatran
Published in the March 2012 issue of Today's Hospitalist
As someone who has been functioning in the role of a "hospitalist" since 1991, well before the phrase was coined, I read with interest your article on "transitionalists" in the February issue ("Walking the walk for better transitional care").
The author notes that more and more "ists" have evolved over the years. But it seems to me that the evolution is coming full circle to the only "ist" that is really needed: the experienced, knowledgeable "internist" who is willing to take responsibility for the entirety of his or her patient's care, whether as an inpatient or outpatient.
Who among us as physicians would not prefer this type of care? The extinction of this complete physician will be one of the true tragedies of the evolution that is American medicine.
Kirth W. Steele, DO
Your recent article on dabigatran ("What you need to know to prescribe dabigatran") pointed out some of the drug's drawbacks. The biggest problem mentioned is the question of how to reverse its effects if a patient is bleeding.
But I was surprised to read that Tracy Minichiello, MD, cited dialysis as a strategy to consider in an effort to remove the drug in a bleeding situation. Placing a Quinton catheter could injure a major blood vessel in the process—and make for a very bad day for a patient whose anticoagulation can't be reversed.
Stella Fitzgibbons, MD
Dr. Minichiello responds: There are limited data to help the clinician in the setting of hemorrhage in a patient on dabigatran. Dialysis is listed as a possible intervention in the prescribing information, as the drug is primarily excreted in the urine and shows low plasma protein binding.
This intervention has been used to reverse coagulopathy associated with intravenous direct thrombin inhibitors in the setting of life-threatening bleeding. As dialysis requires placement of a catheter, the bleeding risk of the procedure must be considered. However, patients who present with severe bleeding— particularly those with intracranial, intraspinal and pericardial involvement in whom hemostasis cannot be achieved, despite local measures and blood product transfusion—may benefit from dialysis.