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...