Virtual Colonoscopy Anyone?

[Guest]

Someone sent me this message today and gave me permission to post it here in hopes that it would save someone else the grief he is going through.

"my father (72 years old) had a routine colonoscopy performed on march 8, 2004.
the only good that came from it is that we found out that his colon is in great shape.

the downside "massive left side stroke" several hours after returning home from the procedure. embolic event from clot on his prosthetic mitral valve.

we figure he had been unattended for approx 6 to 7 hours from onset of stroke. i found him on the floor at our house late that night.

his mitral valve was replaced dec 1999 (ball in cage) i think its called. he has been on coumadin ever since with no complications until the colonoscopy. he was instructed to stop his coumadin on the thursday prior to the prodecure on the following monday.
i took him in for the procedure monday am and picked him up that afternoon. the dr. said the colonoscopy went fine and there were no problems. he told my father no alcohol for 24 hours and no driving for 12 hours. it was all so routine. i took him home and then returned later that night and found him lying on the floor covered in vomit and unconcious. i called 911 and you can probably figure the rest out yourself..like the little old lady you mentioned in your article, the prognosis is that he will never return home. what a price to pay for a procedure that probably didnt need to be done anyway. i dont understand why bridge therapy was never discussed with him or why the family physician did not consult dads heart doctor. it seems that all of the heart doctors i talk to are of the same opinion. if you have a prosthetic mitral valve then you should either be put on bridge therapy or not come off coumadin at all since colonoscopy is low bleed risk procedure. they have said that the cause of the stroke was because he was off of his coumadin and clotting formed around the rim of the prosthetic mitral valve. they also told him that if he ever has the prodecure again to be admitted 2 days prior and go on heparin drip. thats nice to know now!!!!!!!

all the research i have done over the last couple of weeks is amazing. prosthetic mitral valve is one of the biggest red flags when it comes to managing coumadin. i dont understand how something so evident gets overlooked, especially when the doctor that prescribed the colonoscopy has been my fathers family physician for almost 20 years .

for now i get to see my father everyday at whetstone care facility in columbus, oh."

 

[Nancy]

I'm very sorry about that poor man. And I'm very appreciative that you have posted this, Al.

There have been times when Joe has had to have a colonoscopy, and the first thing the GI doctor says is that he'll have to come off his Coumadin. There is never a mention of bridge therapy and it is standard operating procedure to hold Coumadin.

This is one of the situations in which medical lack of knowledge about Coumadin causes terrible harm to some patients.

When doing these kinds of procedures, it is absolutely critical that the doctor performing it speak with the person who is monitoring the Coumadin to get the proper procedure for bridge therapy.

These are the kinds of things that need to be discussed in medical society meetings so that all medical disciplines are aware of the dangers involved.

 

[ccrawford]

What a sad story - Thanks for sharing it Al. It occurs to me that maybe we need to think about creating a brief (if possible) list of items that post valvers need to be really aware of. I don't even know if this is feasible or not, but for example-if you could boil your whole web site down to no more than one page of must know things, Al, what would they be ? I've been monitoring VR.com for more than a year now, and I'm still learning stuff hand over fist. A lot of people can't do this yet would benefit from at least a short list. Any ideas ?

 

[Guest]

I am giving a talk this Thursday, so I have to prepare it this week. I think that the members could put together a list of ideas. Then I could put them together on a single page and post it on my site where everyone could copy it.

Let's start by adding ideas to this post.

I'll ask the original author to name it after his Dad. The ____ ____ Checklist of Things to Discuss With Your Doctor Before Having a Colonoscopy.

 

[RCB]

Sad and needless case

Sad and needless case

This truly an example of "First, do no harm". I had the
procedure done several years ago, due the a bad case of diverticulitis(infected pockets in the colon-which I blame on
17 years of Norpace) where the goal was to see if there was
any harm done to the lining of the colon. At first the doctor
wanted me to go off warfarin, when I protested he explained
to me that if he needed the remove a polyp it would it would be a
simple procedure if I was OFF warfarin, but that he wouldn't
do it if I was was ON warfarin. The dr. said I would have to go through the whole process again to have some thing removed. Since I had no family history of polyps, I said I
would take my chances of having to do it over. I have been
through a bad stroke and three heart surgeries- my stroke was much more disabling than my heart surgeries! The procedure was done ON warfarin, no polyps, no problems-
he recommended a high fiber diet. Since then I have had no problems.
If anyone recommends you go off warfarin without bridge therapy- run to another doctor. Also, I wonder why
in this case, would anyone in the U.S. install a ball and cage
valve in 1999- when that technology is 4 decades old and three generations away from todays valves?

 

[RCB]

To AL

To AL

In thinking about this sad case, I wonder how the stroke event will statistically be recorded:
1. That a stroke cause by mech. valve and problems with warfarin or
2. A medical mistake by a medical professional who didn't know squat about warfarin.
I can just guess! You have to look very carefully behind all statistics. Maybe warfarin is not as bad as the statistics say it is, it could just be how it is managed in practice.

 

[Ross]

Even worse is the fact that physicians all over are making people take the very same risks with other procedures as well. There really is a huge need to get the medical profession all on the same page when it comes to Coumadin therapy. I would like to see it happen in my lifetime, but I really don't think it will happen.

 

[Nancy]

Not only do many physicians know nothing about the management of patients on Coumadin, but they get very incensed when anyone suggests that this is not the right way to do things.

It's a very tough problem when a person on Coumadin has to have these kinds of procedures. They're necessary and they shouldn't have to be life-threatening.

There is a right way to do it. Ignorance is the reason it isn't done correctly.

This is not something that patients should have to teach their medical professionals. It is something they (medical professionals) should have a good handle on.

Education on the subject has to come from within the medical profession itself.

Also, every hospital should have a definite set of protocols for this kind of thing, for the safety of their patients.

 

[Guest]

I'm happy to report that the person who sent this has logged on to this site, read the message and has given permission to use his father's name.

One of my patients came 90 miles to the hospital where I work in considerable pain and had a colonoscopy with a polyp removed within a few hours of admission. She experienced no bleeding. Her pain relief was almost instantaneous. When it needs to be done, it can be done. I read her chart and confirmed it with her doctor so I know it is true.

There are legal issues with having a protocol for something that the FDA has not approved. Lovenox has never been approved for bridge therapy.

The only way that this will change is by patient persistence. Refuse to go off warfarin. Insist on bridge therapy (remember that there could still be failures). Insist on virtual colonoscopies. The market repsonds to consumer preferences.

 

[Marty]

Barium Enema Air Contrast ?

Barium Enema Air Contrast ?

The BEAC is a safe and proven X-ray test now in use over 100 years. They do it everywhere. It does not require high speed CT scanners, $50,000 software packages, or special expertise. Any radiologist should be able to do a good one ( try to get an older radiologist, the young ones are not as interested in such a simple procedure!).
It may miss some small polyps but detects the "killer" cancers. It would have been the procedure of choice for the 72 yr old in my view. .I'm 77 and had my last BEAC 5 years ago. I am due for another soon and will probably have it rather than a virtual even though my group is now doing them. Just old fashioned I guess.
I still do about 4-5 M.D. referred BEAC's every week and have not heard of anything serious that I've missed. By the way, at my clinic the gastroenterologists use the Lovenox bridge for all valve patients on warfarin prior to colonoscopy.. They say they don't care what the FDA says. No problems to date.

 

[RCB]

Al- two questions

Al- two questions

1. Doesn't protocol for bridge therapy call for a heparin drip
which is FDA approved?
2. What method of excision was used- if a laser, wouldn't that act as a cautery; hence no bleeding? Same with Cyro?

 

[bvdr]

I know that if I hadn't been insistant on staying on coumadin for my recent Mohs surgery and lip reconstruction, according to the instructions I would have been off of it for about 4 days. I had no problem with bleeding whatsoever. I believe most patients would not even question the request and that is very scary.

When I had a recent colonoscopy I was in the hospital and already off coumadin and on Lovenox. I had one Lovenox injection held and I didn't even like that.

Since Lovenox is low molecular weight heparin why isn't it approved for bridge therapy? Why would it act differently than heparin?

 

[Rich]

Some of these doctors really leave me cold.
I had one a half dozen years ago who wanted to do surgery for another problem .
So we asked him what he would do about the Coumadin.
He says 'I don't know' Duh!!
Fortunately my wife wa also in the room, she told him maybe he should consider Heparin.
He responds with "wow I bet that might work'.
My wife looks at me, I look at her and we say 'GOODBYE IDIOT"!!!
Now I have a great doctor treating the same problem. Whenever anything needs to be done he talks directly to our cardiologist and they draw up a plan which they both agree on.

I agree with Marty, what's wrong with the tried and true BEAC ?
Do insurance companies pay for the virtual tests for people like us ?

 

[Guest]

I do not think that there is an FDA approved protocol for heparin to be used as bridge therapy. Heparin is a very old drug. Doctors learned their techniques using heparin. I think that everyone assumes that since it is old that it is approved. However, the fact is that many old drugs are just assumed to be standards of therapy. I think that there is something in the package insert for heparin that says that it is acceptable for use in people with mechanical heart valves but there is no official protocol for that.

The main difference between heparin and Lovenox is that heparin can be given by an IV drip. About 4 hours before the procedure is to be done, the IV can be shut off and the the body will rid itself of the heaprin by the time the procedure is done. The convenience of being able to give Lovenox in twice daily injections is due to the fact that it is slowly cleared from the body over about 12 hours. But that lead to the inconvenience of not having rapid control over it.

What is boils down to is this.
Stopping warfarin 4 days before a procedure and then re-starting it 4 to 6 hours after the procedure means that there is little or no anticoagulation protection for about 7 to 10 days.

Using Lovenox and restarting it 4 to 6 hours after the procedure means that there is little or no anticoagulation protection for about 16 to 20 hours.

Using heparin by IV drip and restarting it 4 to 6 hours after the procedure means that there is little or no anticoagulaton protection for 12 to 16 hours.

You can see that there is always some window of no protection. Clots can occur during that window.

 

[Sherry]

What an interesting thread. I had the procedure about six years ago and was managed with heparin and then Lovenox. Didn't realize the gamble at the time. If I ever have to have it repeated, though, I'm going the virtual route. Thanks for all this insight.

 

[ccrawford]

I just had the beginnings of an idea. What if we could get the cardiologists behind a program to enlighten the rest of the medical world, and also got the makers of Coumadin to support it. Maybe they would back the distribution of an information card that all Coumadin users would get (and hopefully carrry) that would explain why a bridge therapy is needed for certain procedures and define what bridge therapy. My reason for thinking this way is to keep the patient involved and actively looking out for his/her well being. At the very least, the patient would be instructed to "be absolutely sure to show this card to all of your doctors." Let me know your thoughts. If there is any merit in this, I'll run it by my cardio and ask for guidance.

 

[Sherry]

Absolutely!! Since we share cardios, Chris, let me know what you find out. All of us on this forum, as well as all the other valve patients who don't know our site yet, will probably face some non heart-related invasive procedure at some point in our lives. It's one of those things we dread and obsess about.

 

[RCB]

Second the idea

Second the idea

Chris,
That is a great idea! I'm going to ask about the protocol when I'm at CC next. I had my gall bladder out
in '91 with bridge therapy and I assumed then that it had been approved. You never know

 

[warrenr]

Thanks

Thanks

Just wanted to take a minute and thank all that have responded to the story about my fathers stroke. It is amazing how doctors differ in there opinions.
Several days after his stroke, while still in Riverside Methodist Hospital (Columbus, Oh.) the neurologist told us that the CAT scan showed 90% right side brain affected by stroke. She then asked permission to either put on heparin or not put on heparin. She strongly advised against heparin drip because of the risk of bleeding in the brain. My fathers cardio doctor was of the opposite opinion. He said if your father is not put on heparin he will probably throw another clot from his mitral valve. needless to say we had them put him heparin drip. The neuro dr wasnt very happy about it but it way my choice for my father. By the way, when the cardio dr conducted the procedure (not sure what it is called) to look at his prosthetic mitral valve, they did find clotting around the rim of the valve. Its a good thing we had him put on heparin against the neurologist advice. He ended up being in the hospital 14 days and then was transferred to Whetsone Care facility also in columbus, oh. He is able to talk quite well and has full use of his right arm and leg. He has no use of his left arm or leg and has not showed any improvement to the left side. Time will tell. I will share all of the posts with him.

thanks
warren r mead

 

[Nancy]

Hi Warner-

I am very sorry about what happened to your father. It is a tragic thing.

It really drives home the point that there needs to be continuity of care with people on Coumadin.

Medical ignorance is NOT bliss.

I hope in time, and with further healing, your dad will regain some more use of his left arm and leg.

Send him our best, and tell him we're all pulling for him and saying some prayers.