For those of you that are familiar with "Virtual Colonoscopy Anyone" thread
Here is an update on my father.
Still in Long Term Care Facility Columbus Ohio. It has been over 4 months since the stroke and allthough he is doing quite well mentally he still has no use of his left arm or leg and has no awareness of things to his left. Prognosis is still same as before, will not be comming home.
I have put together a short story and facts from his medical records and it's quite shocking (to me anyway) the way his anticoagulation management was handled. Here it is
On March 8, 2004 my father had a routine Colonoscopy with no complications and biopsy was not performed. I took him home around 4 pm that afternoon. I returned to the house that evening about 10 pm and found him on the floor covered in vomit. I called 911 and he was taken to the ER. It was not long before we found out he had suffered a massive right side embolic stroke.
Today is June 28, 2004 and my father is in a long term care facility in Columbus Ohio. Although his mental capacity is quite good, he has no use of his left arm and leg. It is unlikely that he will ever return home.
He was a very healthy 73 year old man with a St Jude Mechanical Mitral Valve. Ballroom dancing several day?s per week, golf 3 day?s per week, etc. Now he is reduced to a bed and wheel chair. Can?t even have a motorized chair due to the lack of awareness of his left side.
At first I thought it was just an unfortunate unavoidable event in his life. Several day?s after being in the hospital the Cardiologist conducted a procedure to look at his Mechanical Mitral Valve. It was determined that the stroke had been caused by clotting around his Mitral Valve most likely due to the stopping of his Coumadin for the Colonoscopy. The Cardio told him that if he ever had a Colonoscopy again to either be admitted several day?s prior and go on a Heparin drip or not to stop taking his Coumadin at all due to the risk of stroke compared to the risk of bleeding.
That started me thinking and something inside me said something is not right here. I then started extensive research about Coumadin and Elective procedures. What unfolded through my research is almost unbelievable.
First of all, keep in mind that the neither the Gastroenterologist nor my father?s Physician of approx 10 years who prescribed the Colonoscopy discussed my father?s condition risk (Mechanical Mitral valve, AFIB, etc.) in relation to stopping of his Coumadin for the Colonoscopy. Risk of stroke compared to risk of bleeding.
When it comes to Colonoscopy and patients on long term anticoagulation therapy it seems that a lot of Gastroenterologist?s don?t consider bridge therapy or conducting the elective procedure with the patient fully anticoagulated. They seem to be more worried about bleeding than they do about stroke. Same goes for a lot of dentists and doctors that perform other elective low bleed risk procedures. I have searched and searched trying to find written procedures that tell the doctors to have there patients stop taking coumadin for elective procedures and it seems that all written guidelines are just the opposite. For example, the ASGE has guidelines written by the Standard?s of Practice Committee in 2002 that state for low bleed risk procedure such as Colonoscopy + or ? biopsy for high risk condition patient (mechanical heart valve in the Mitral position) there is no need to have patient stop taking Coumadin. Perform with patient fully anticoagulated. The same pretty much goes for the American Heart Association, American Medical Association, American Dental Association, etc.etc.etc. Yet every day there are many doctor?s out there that put heart valve patients at risk of stroke or death because they don?t follow the recommendations of the associations they belong to.
After a while I was getting very bitter towards the doctor who performed my father?s Colonoscopy until I discovered the information listed below in a review of his medical records. All of a sudden it brought my father?s family physician into the picture in a big way.
Here are the events that took place from the start of my father?s anticoagulation therapy up to the Colonoscopy and stroke.
Oct 15, 1999 letter from cardiologist to family physician about dad?s AFIB and MI and suggesting long term anti-coagulation therapy with Coumadin titrated to and INR of 2-3 .
Oct 19, 1999 Family physician starts coumadin therapy. The COUMADIN ANTICOAGULATION RECORD from DU PONT PHARMA was used.
The form showed INDICATON afib/mi target range 2.0 ? 3.0
(Rember this form later in the chain of events)
Oct 26, 1999 through Nov 8, 1999 INR levels 1.3, 1.6,1.5,and 1.9 Theraputic Range Protocol 2.0 to 3.0
Nov 23, 1999 Heart surgery St Jude Mechanical #31 Mitral Valve.
Nove 27, 1999 letter from heart surgeon to dad?s physician informing of Mechanical Mitral Valve and recommending changing long term anticoagulation therapy to achieve theraputic range of 2.5 to 3.5 .
Nov 29, 1999 dad?s physician receives letter from heart surgeon and makes handwritten note on ?COUMADIN ANTICOAGULATION RECORD? as follows: (see new drug list) and also hand writes (mitral valve replacement mechanical double bypass)
Keep in mind that the original form from oct 19,1999 showing target rang 2.0 ? 3.0 is used all the way up till Feb 20, 2004. The physician never changes to a target range of 2.5 to 3.5 which is the protocol for indication of mech mitral valve and is what the heart surgeon recommended.
From Nov 29, 1999 till Feb 20, 2004 the INR levels were as follows (He now has a mech mitral valve/afib)
Date Coumadin dose Patient (sec) INR Coumadin new dose Re Check
11/29/99 2mg 18.3 2.3 same Thursday
12/02/99 2mg 16.1 1.7 4mg fri, 2mg oth days 10 days
12/10/99 2mg 15.4 1.6 3mg 2 wks
12/24/99 3mg 17.8 2.1 same 2 wks
01/07/00 3mg 17.4 2.0 same 3 wks
01/21/00 3mg 15.4 1.6 4mg 1 wks
01/28/00 4mg 19.5 2.6 same 3 wks
02/14/00 4mg 19.5 2.6 same 1 mth
03/22/00 4mg 16.9 2.0 same 1 mth
06/12/00 4mg 16.7 1.9 same 2 mth
10/19/00 4mg 16.2 1.7 same 1 mth
01/23/01 4mg 17.0 2.0 same 1 mth
02/26/01 4mg 18.0 2.2 same 1 mth
03/30/01 4mg 17.0 2.0 same 2 mth
06/05/01 4mg 16.2 1.7 same 2 mth
07/31/01 4mg 17.0 2.0 same 2 mth
10/25/01 4mg 15.9 1.7 same 2 mth
12/07/01 4mg 15.8 1.7 6 mg Sunday 1 mth
01/14/02 6mg sun 4 all oth 17.8 2.1 same 2 mth
04/30/02 same 16.9 1.9 same 2 mth
07/08/02 same 16.1 1.7 6mg sun 2 mth
10/01/02 6s/w 4 oth 18.3 2.2 same 2 mth
12/22/02 same 17.0 2.0 same 2 mth
03/12/03 same 17.1 2.0 same 2 mth
06/19/03 same 14.8 1.5 6 tnt, resume 2 mth
07/22/03 same 16.4 1.8 same 2 mth
09/04/03 same 15.7 1.6 6tnt sat Tuesday 1 mth
12/01/03 same 15.7 1.6 same 2 wks
12/15/03 6mwf 4 oth 17.1 2.0 same 1 mth
02/20/04 6mwf 4 oth 15.2 1.5 6 tnt then resume after colonoscopy
Note: Bold INR levels indicate UNDER STANDARD THERAPUTIC RANGE 2.5 TO 3.5
02/24/04 Dad goes in for INR check and it is 1.5. He is instructed to stop taking his Coumadin as of March 4 in prep for his colonoscopy that is scheduled for 3/8/04. He is told that they will re check his INR after the Colonoscopy.
Well, his INR did get checked after the Colonoscopy but not by his physician. It got checked at the ER when he was taken there for his stroke. The INR level was 1.1
For whatever it is worth, the following are the questions that stick in my mind>
l. Why would my father?s physician of approx 10 years let his INR levels stay under theraputic range for over 4 years. Especially when he had received a letter from the heart surgeon on Nov 29, 1999 informing him of the mech mitral valve and the coumadin protocol?
2. Why was the physician scheduling INR checks 2 months apart even when the INR was as low 1.5?
3. Why didn?t the family physician ever show any concern about dad?s INR level?s being so low over the past 4 years.
4. Wasn?t it the Physician?s Duty to my father to discuss the risks of going off of the Coumadin in prep for the Colonoscopy?
5. On Feb 20, 2004 my father?s INR was1.5, and the physician did not see any reason to check it again until after the Colonoscopy which was scheduled for March 8. Why was the INR not checked prior to having him stop on March 4,2004 keeping in mind how low it was on Feb 20, 2004?
6. With my father having a High Condition Risk why was his anticoagulation stopped for a Low Risk Procedure?
7. Wasn?t it the Gastroenterologist?s Duty to discuss my father?s Condition Risk and the risk of stopping Coumadin for the Colonscopy?
8. Isn?t it the Duty of both the Physician and the Gastroenterologist to stay current with there medical knowledge.
9. Why did neither the Family Physician or the Gastro follow the written protocol?s and written standard guidelines for there area?s of expertise?
10. How would the Hospital look at the fact that the Gastroenterology Group practicing in there facilities does not follow the Guidelines as set forth by the Standard?s of Practice Committee for the ASGE?
11. Isn?t it the Hospital?s Duty to there patients to ensure that the doctor?s operating within there facilities are following the guidelines set forth for there specialty.
12. If they are so worried about people on Coumadin bleeding during Colonoscopy, then why did they not check his INR just prior to the procedure.
13. How will my father?s stroke be statistically recorded?
14. Why was the Procedure Screening Form from the Gastroenterology Group not signed were it says reviewed by and no comments made? Since it was not signed, I would have to assume that it was not reviewed.
15. Why didn?t the Gastroenterologist have my father sign the informed consent form?
16. If they had known that his INR was 1.1 would they still have done the Colonoscopy or would that have done something to give him some proteciton????
Here is an update on my father.
Still in Long Term Care Facility Columbus Ohio. It has been over 4 months since the stroke and allthough he is doing quite well mentally he still has no use of his left arm or leg and has no awareness of things to his left. Prognosis is still same as before, will not be comming home.
I have put together a short story and facts from his medical records and it's quite shocking (to me anyway) the way his anticoagulation management was handled. Here it is
On March 8, 2004 my father had a routine Colonoscopy with no complications and biopsy was not performed. I took him home around 4 pm that afternoon. I returned to the house that evening about 10 pm and found him on the floor covered in vomit. I called 911 and he was taken to the ER. It was not long before we found out he had suffered a massive right side embolic stroke.
Today is June 28, 2004 and my father is in a long term care facility in Columbus Ohio. Although his mental capacity is quite good, he has no use of his left arm and leg. It is unlikely that he will ever return home.
He was a very healthy 73 year old man with a St Jude Mechanical Mitral Valve. Ballroom dancing several day?s per week, golf 3 day?s per week, etc. Now he is reduced to a bed and wheel chair. Can?t even have a motorized chair due to the lack of awareness of his left side.
At first I thought it was just an unfortunate unavoidable event in his life. Several day?s after being in the hospital the Cardiologist conducted a procedure to look at his Mechanical Mitral Valve. It was determined that the stroke had been caused by clotting around his Mitral Valve most likely due to the stopping of his Coumadin for the Colonoscopy. The Cardio told him that if he ever had a Colonoscopy again to either be admitted several day?s prior and go on a Heparin drip or not to stop taking his Coumadin at all due to the risk of stroke compared to the risk of bleeding.
That started me thinking and something inside me said something is not right here. I then started extensive research about Coumadin and Elective procedures. What unfolded through my research is almost unbelievable.
First of all, keep in mind that the neither the Gastroenterologist nor my father?s Physician of approx 10 years who prescribed the Colonoscopy discussed my father?s condition risk (Mechanical Mitral valve, AFIB, etc.) in relation to stopping of his Coumadin for the Colonoscopy. Risk of stroke compared to risk of bleeding.
When it comes to Colonoscopy and patients on long term anticoagulation therapy it seems that a lot of Gastroenterologist?s don?t consider bridge therapy or conducting the elective procedure with the patient fully anticoagulated. They seem to be more worried about bleeding than they do about stroke. Same goes for a lot of dentists and doctors that perform other elective low bleed risk procedures. I have searched and searched trying to find written procedures that tell the doctors to have there patients stop taking coumadin for elective procedures and it seems that all written guidelines are just the opposite. For example, the ASGE has guidelines written by the Standard?s of Practice Committee in 2002 that state for low bleed risk procedure such as Colonoscopy + or ? biopsy for high risk condition patient (mechanical heart valve in the Mitral position) there is no need to have patient stop taking Coumadin. Perform with patient fully anticoagulated. The same pretty much goes for the American Heart Association, American Medical Association, American Dental Association, etc.etc.etc. Yet every day there are many doctor?s out there that put heart valve patients at risk of stroke or death because they don?t follow the recommendations of the associations they belong to.
After a while I was getting very bitter towards the doctor who performed my father?s Colonoscopy until I discovered the information listed below in a review of his medical records. All of a sudden it brought my father?s family physician into the picture in a big way.
Here are the events that took place from the start of my father?s anticoagulation therapy up to the Colonoscopy and stroke.
Oct 15, 1999 letter from cardiologist to family physician about dad?s AFIB and MI and suggesting long term anti-coagulation therapy with Coumadin titrated to and INR of 2-3 .
Oct 19, 1999 Family physician starts coumadin therapy. The COUMADIN ANTICOAGULATION RECORD from DU PONT PHARMA was used.
The form showed INDICATON afib/mi target range 2.0 ? 3.0
(Rember this form later in the chain of events)
Oct 26, 1999 through Nov 8, 1999 INR levels 1.3, 1.6,1.5,and 1.9 Theraputic Range Protocol 2.0 to 3.0
Nov 23, 1999 Heart surgery St Jude Mechanical #31 Mitral Valve.
Nove 27, 1999 letter from heart surgeon to dad?s physician informing of Mechanical Mitral Valve and recommending changing long term anticoagulation therapy to achieve theraputic range of 2.5 to 3.5 .
Nov 29, 1999 dad?s physician receives letter from heart surgeon and makes handwritten note on ?COUMADIN ANTICOAGULATION RECORD? as follows: (see new drug list) and also hand writes (mitral valve replacement mechanical double bypass)
Keep in mind that the original form from oct 19,1999 showing target rang 2.0 ? 3.0 is used all the way up till Feb 20, 2004. The physician never changes to a target range of 2.5 to 3.5 which is the protocol for indication of mech mitral valve and is what the heart surgeon recommended.
From Nov 29, 1999 till Feb 20, 2004 the INR levels were as follows (He now has a mech mitral valve/afib)
Date Coumadin dose Patient (sec) INR Coumadin new dose Re Check
11/29/99 2mg 18.3 2.3 same Thursday
12/02/99 2mg 16.1 1.7 4mg fri, 2mg oth days 10 days
12/10/99 2mg 15.4 1.6 3mg 2 wks
12/24/99 3mg 17.8 2.1 same 2 wks
01/07/00 3mg 17.4 2.0 same 3 wks
01/21/00 3mg 15.4 1.6 4mg 1 wks
01/28/00 4mg 19.5 2.6 same 3 wks
02/14/00 4mg 19.5 2.6 same 1 mth
03/22/00 4mg 16.9 2.0 same 1 mth
06/12/00 4mg 16.7 1.9 same 2 mth
10/19/00 4mg 16.2 1.7 same 1 mth
01/23/01 4mg 17.0 2.0 same 1 mth
02/26/01 4mg 18.0 2.2 same 1 mth
03/30/01 4mg 17.0 2.0 same 2 mth
06/05/01 4mg 16.2 1.7 same 2 mth
07/31/01 4mg 17.0 2.0 same 2 mth
10/25/01 4mg 15.9 1.7 same 2 mth
12/07/01 4mg 15.8 1.7 6 mg Sunday 1 mth
01/14/02 6mg sun 4 all oth 17.8 2.1 same 2 mth
04/30/02 same 16.9 1.9 same 2 mth
07/08/02 same 16.1 1.7 6mg sun 2 mth
10/01/02 6s/w 4 oth 18.3 2.2 same 2 mth
12/22/02 same 17.0 2.0 same 2 mth
03/12/03 same 17.1 2.0 same 2 mth
06/19/03 same 14.8 1.5 6 tnt, resume 2 mth
07/22/03 same 16.4 1.8 same 2 mth
09/04/03 same 15.7 1.6 6tnt sat Tuesday 1 mth
12/01/03 same 15.7 1.6 same 2 wks
12/15/03 6mwf 4 oth 17.1 2.0 same 1 mth
02/20/04 6mwf 4 oth 15.2 1.5 6 tnt then resume after colonoscopy
Note: Bold INR levels indicate UNDER STANDARD THERAPUTIC RANGE 2.5 TO 3.5
02/24/04 Dad goes in for INR check and it is 1.5. He is instructed to stop taking his Coumadin as of March 4 in prep for his colonoscopy that is scheduled for 3/8/04. He is told that they will re check his INR after the Colonoscopy.
Well, his INR did get checked after the Colonoscopy but not by his physician. It got checked at the ER when he was taken there for his stroke. The INR level was 1.1
For whatever it is worth, the following are the questions that stick in my mind>
l. Why would my father?s physician of approx 10 years let his INR levels stay under theraputic range for over 4 years. Especially when he had received a letter from the heart surgeon on Nov 29, 1999 informing him of the mech mitral valve and the coumadin protocol?
2. Why was the physician scheduling INR checks 2 months apart even when the INR was as low 1.5?
3. Why didn?t the family physician ever show any concern about dad?s INR level?s being so low over the past 4 years.
4. Wasn?t it the Physician?s Duty to my father to discuss the risks of going off of the Coumadin in prep for the Colonoscopy?
5. On Feb 20, 2004 my father?s INR was1.5, and the physician did not see any reason to check it again until after the Colonoscopy which was scheduled for March 8. Why was the INR not checked prior to having him stop on March 4,2004 keeping in mind how low it was on Feb 20, 2004?
6. With my father having a High Condition Risk why was his anticoagulation stopped for a Low Risk Procedure?
7. Wasn?t it the Gastroenterologist?s Duty to discuss my father?s Condition Risk and the risk of stopping Coumadin for the Colonscopy?
8. Isn?t it the Duty of both the Physician and the Gastroenterologist to stay current with there medical knowledge.
9. Why did neither the Family Physician or the Gastro follow the written protocol?s and written standard guidelines for there area?s of expertise?
10. How would the Hospital look at the fact that the Gastroenterology Group practicing in there facilities does not follow the Guidelines as set forth by the Standard?s of Practice Committee for the ASGE?
11. Isn?t it the Hospital?s Duty to there patients to ensure that the doctor?s operating within there facilities are following the guidelines set forth for there specialty.
12. If they are so worried about people on Coumadin bleeding during Colonoscopy, then why did they not check his INR just prior to the procedure.
13. How will my father?s stroke be statistically recorded?
14. Why was the Procedure Screening Form from the Gastroenterology Group not signed were it says reviewed by and no comments made? Since it was not signed, I would have to assume that it was not reviewed.
15. Why didn?t the Gastroenterologist have my father sign the informed consent form?
16. If they had known that his INR was 1.1 would they still have done the Colonoscopy or would that have done something to give him some proteciton????
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