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Monday, July 22, 2013

Once Again, These Doctors are Trying to Kill Him...

I swear. You'd like to think you can trust a doctor, that when a doctor tells you to do xyz, that he knows what he's talking about. That a doctor is not just guessing and meanwhile putting your loved one in harms way....

Case in point, I'm talking about the heparin bridge. And three different doctors, doing it three different ways, which makes me wonder...

Now the "heparin bridge" is done when you have take someone off their blood thinner for surgery or another procedure (such as a needle stick procedure) that may cause bleeding, but you don't want to endanger them, i.e. cause another stroke, so you "bridge" the patient with a fast-acting blood thinner like heparin. Heparin is injected into the skin, enters the blood stream fast, it also leaves the blood stream fast, unlike warfarin which is a pill and takes forever to build up in the system and lingers there a long time. Therefore you can skip just one injection of heparin, have a smaller "window" of not-to-thin blood in order to perform the procedure and immediately put the patient back on heparin afterwards. In this way, you limit the danger of the blood clotting and causing another stroke to a small period of time. And for Bob, this is very important, as he has a hereditary blood disorder which causes his blood to hypercoagulate.

Well, I've done the heparin bridge with Bob three times. The first time, the doctor ordered six syringes of Lovenox (injectable heparin) and I was given the schedule as follows:

Day 1: Stop Bob's nightly dose of warfarin
On day 3, one injection of .4 ml Lovenox.
On day 4, one injection of .4 ml Lovenox.
                       Day 5: have the procedure done in the a.m. and give one injection .4 ml Lovenox in the evening. Start Bob back on the nightly dose of warfarin.
Day 6: One injection of .4 ml Lovenox.
Day 7: One injection of .4 ml Lovenox.
Day 8: Last injection of .4 ml Lovenox.
And be sure to have Bob's blood tested for his weekly PT/INR.

So that's what I did.  And everything seemed fine. But when the results of his weekly PT/INR (which is the test for blood thickness) were scary low (too thick), I called the nurse and she told me not to worry about it because heparin will skew the results...

Then the next time I did the heparin bridge, with a different doctor and a different procedure, this doctor ordered me 5 syringes of Lovenox and I was given the schedule as follows:

Day 1: Stop Bob's nightly dose of warfarin.
Day 3: Two injections of .4 ml Lovenox, one in the a.m. and one in the p.m.
Day 4: One injection of .4 ml Lovenox.
Day 5: have the procedure done, no Lovenox.
Day 6: One injection of .4 ml Lovenox in the a.m. and start the warfarin that night.
Day 7: Last injection of .4 ml Lovenox.
And I was told not to bother with having Bob's blood tested for his 
weekly PT/INR until the next week.

Now I'm confused, because I have two different doctors doing it different. I ask the second doctor about this, but he tells me that his way is right and the first doctor was wrong.  Okey-dokey. So I do it this way, and everything seemed fine. Though the next week Bob's PT/INR was low, but the nurse told me not worry because, once again, the Lovenox had skewed the results....

Then Bob has the foot surgery, so once again we need to do the heparin bridge. I ask the foot surgeon if he will order the Lovenox and give me the schedule, but he tells me that he has no clue how to do this and sends us to see Bob's primary care doctor to set it up.

So, we went to see the primary care doctor, who was on vacation and so we saw a substitute doctor. This doctor told me he would send an order to the pharmacy for the Lovenox and gave me the following schedule:

Day 1: Stop the warfarin
Day 2: Two injections of .8 ml Lovenox, one in the morning, one in the evening.
Day 3: Two injections of .8 ml Lovenox, one in the morning, one in the evening.
Day 4: One injection of .8 ml Lovenox in the a.m. None at night.
Day 5: Have the procedure done. No Lovenox.
Day 6: Two injections of .8 ml Lovenox, one in the morning, one in the evening. Start the warfarin.
Day 7: Two injections of .8 ml Lovenox, one in the morning, one in the evening.
Day 8: One injection of .8 ml Lovenox and see me in my office that afternoon to check his PT/INR.

All righty. This is totally different. And he's ordering .8 ml instead of .4 ml. And imagine my surprise when I go to pharmacy to pick up the Lovenox and find the doctor ordered three boxes which means 30 syringes of .8 ml Lovenox! And I'm thinking wow, what am I going to do with all of this?

So we go back to see that doctor on Day 8 and he checks Bob's PT/INR, which is low (too thick). He tells me that I have to keep giving the injections until Bob's PT/INR hits 2.00 and he orders twice weekly tests to monitor it. He also tells me that it's dangerous to go back on warfarin without the Lovenox because warfarin, while it is building up in the system, can actually cause the blood to clot. And he explained that the PNT/INR test only tracks the warfarin, not the Lovenox, so the Lovenox is doing it's job until the PNT/INR levels out..

And I tell you, I used all three boxes of those syringes before Bob got back up to 2.00.

I'm thinking, I mean, I really believe this last doctor seems to be doing it right.

Now I wonder, I really wonder, were those first two doctors trying to kill him? Or are they just idiots? Or what? Jeepers.

But thank god, Bob survived these ordeals. And now, I know better...


J.L. Murphey said...

Diane, the doses of Lovenox depends on what procedure he is having and where, and how long he will be in surgery. It also depends on his last PRT/NR. If he is running thick blood then more Lovenox more often. Because Lovenox is short acting it's a trial thing where Warfin you have to build up the dose and titrated it down because it is longer acting. So in theory all the doctors know what they are doing. Make sense? I know it's confusing.

Anonymous said...

Perhaps you could talk to someone from the Lovenox manufacturer or their lab for advice/suggestions on this issue.

What J.L.M said above makes sense too.

Hugs & prayers, Dan

Diane said...

Jo, no no no, those first two doctors did not know what they were doing. First, they didn't even check his PT/INR, they asked me what it was and I told both of them (Bob is stable) it runs around 2.1 - 2.3. Second, they never bothered to check the PT/INR after they took him off the lovenox and put him back on warfarin. The second doctor actually CANCELLED the PT/INR blood tests for two full weeks after the procedure. Then when Bob was running 1.4, and 1.4 is SCARY thick, the nurse just told me NOT TO WORRY. This third doctor just shook his head when I told him that... he says PT/INR MUST BE MONITORED TO MAKE SURE Bob's levels had stabilized before stopping the lovenox. Procedures were peg tube replacement, radiofrequency denervation and foot surgery. All were done in outpatient surgery, all under anesthesia and all took about 1 and 1/2 hours, all wanted Bob off the warfarin 5 days in advance.... The third doctor also gave us one refill on three boxes of lovenox and told me that if Bob has any other procedure requiring going off the warfarin, we will do it the same way again. So I'm believing the third doctor is doing this the safest way. make sense?

Diane said...

I would also be interested to hear from anyone who has done a heparin bridge. Did the doctor monitor PT/INR to make sure it was in the therapeutic (2-3) range before discontinuing the lovenox?

Because that is my main contention with the first two doctors, they DID NOT monitor the PT/INR and just discontinued the lovenox after a couple of days and when Bob's PT/INR was low during the following two week period, they did not order more lovenox, just told me not to worry.

Rebecca Dutton said...

I'm going to print this post so I can take to any doctor that has to do surgery on me. I think doctor #3 is correct. Measuring and having a back up plan if a person's body doesn't respond as expected is better.

Jenn said...

I'm always suspicious of anyone in the medical field who tells me "not to worry". Doesn't it feel like a blow off? But, after reading your post, it seems to me the first two doctors are far less experienced with Bob's condition than the third doctor. I agree with Rebecca about having a back up.