The Bleeding Patient and the Missing INR
A 68-year-old man attends for a scale and polish and possible extraction of a mobile upper premolar. He takes warfarin and says his INR was checked 'a few weeks ago and was fine'. He has not brought his record card. During scaling, you notice prolonged bleeding from the gingival margin that does not settle with pressure after several minutes. He mentions he bruised easily last week and had a nosebleed that took an hour to stop. The dentist asks you to 'just finish up quickly and send him home'.
1. What do the bleeding and bruising suggest, and what is your immediate action?
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Interpretation:
- Prolonged bleeding after scaling, easy bruising, and a prolonged nosebleed suggest his anticoagulation may be excessive (raised INR). 'Fine a few weeks ago' does not confirm his current status.
- This is a potential bleeding risk that must be addressed before any extraction.
Immediate action:
- Stop and apply sustained local pressure; use local haemostatic measures as directed by the dentist.
- Do not proceed to extraction.
- Raise your concern clearly with the dentist: the bleeding is not settling and the history suggests an unstable INR.
- Arrange for his INR to be checked before any surgical procedure, and document the episode.
2. The dentist wants to 'send him home quickly'. How do you handle this professionally?
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Professional handling:
- Sending him home without addressing active bleeding and an unstable anticoagulant status would be unsafe.
- You should state your concern factually: 'The bleeding hasn't stopped after several minutes and he reports easy bruising and a prolonged nosebleed; I think his INR needs checking before we do anything further.'
- Ensure bleeding is controlled before he leaves, and that he has clear advice on what to do if bleeding restarts.
- Document the discussion, the decision, and the plan.
Judgement tested: assertiveness and patient advocacy. You are not diagnosing, but you are escalating observable evidence that changes the plan. Deferring to seniority at the expense of safety is the wrong call.