Surgery and anticoagulation

[DrAllan]

I am a retired surgeon and thought I would share my experience and feelings regarding surgery and anticoagulation. My reading of this board and others is that there is confusion amongst patients and sheer stupidity in the medical profession regarding the issue. Your primary care doctor has little appreciation of the nature of surgical bleeding and tends to panic with the idea of Coumadin and any bleeding. Your surgeon, depending on the site of the surgery and past experience may or may not be knowledgeable. Let me try to elucidate.

For instance, if you are having coronary artery bypass, or correction of a carotid artery stenosis, all of which involve large blood vessels, you are routinely anticougulated with heparin type drugs to prevent clotting during the procedure. The reason for this is that the blood supply to the affected vessels is clamped off, and when this degree of stasis occurs, clotting can happen. The reason the surgeon does not worry about bleeding is that they are controlling the vessel.

When doing many other kinds of surgery, during the dissection to get to the affected region or organ, tissue plans are separated. There are always various sized blood vessels that get cut during this procedure. The larger ones require being sutured, tied, or cauterized. The smaller ones in non-anti coagulated patients clot by themselves, or do so with some pressure. This is no different than what one does to an abrasion to the skin which is damaged, such as a “skinned” knee. Needless to say if on anticoagulants, this does not stop as quickly. A got comparison is the bleeding that may occur from a finger stick with home INR testing, or the venipuncture at the lab, which requires a ‘band-aid’. These small blood vessel areas are referred frequently to by the surgeon as “oozers”, and unless significant are ignored while other work is being done. Sometimes the area is packed off with a pressure type bandaged wedged into place to apply pressure. However, when the pressure is removed the bleeding can start again relatively immediately, or later when the tissues move and rub against themselves as the patient moves while awake. If these areas or close to the surface so that another bandage type material can be applied to apply pressure than oozing can be safely tolerated. If the area is not accessible, say inside your colon, bladder or brain, then it is not a good idea to leave the area capable of bleeding.

Further complicating the issue is that during the healing process, the body has the tendency to dissolve clots that form in blood vessels, and the areas that are tied or cauterized have a tendency to slough off and leave a raw area that can bleed. Again, this is more of a problem when anticoagulated.

The advantage of “bridging” therapy is that heparin (or low molecular heparin such as Lovenoix) acts rapidly and can be rapidly reversed.

Statistically, the majority of embolic strokes in patients stopping well-controlled Coumadin occur between the 4-5th day after stopping. Thus is you stop therapy 2 days prior to surgery and take 4-5 days to return to control INR on oral Coumadin, you are at great risk from the day after surgery for another 5 days. Tell that to your physician. Inform your family, and send a note to your malpractice attorney.

I hope that this adds some information to the bleeding surgery issue and will provide you with a format to carefully question the medical professionals caring for you.

[allodwick]

Thanks, Allan.
We are all here because we are trying to learn. Mostly the people on warfarin have to educate themselves and those taking care of them. Sometimes they sound frustrated because these educated patients understand more than their providers, so they know when they are being mismanaged.

I'm trying to learn from the people who actually take the stuff.

We need your expertise here too.

We have a "semi-retired" radiologist and a podiatrist who are regular contributors. Please hang around more than just giving a one-shot entry.

[gijanet]

for the info. I try and arm myself with as much knowledge as possible 'cuz with my Katie I never know when I might need it (knocking on wood). 'Course she developed HIT during her last surgery, so we can't do heparin and have to do argatroban instead, but the bottomline is still the same. I second Al's last line. Take care and please DO stick around. Janet P.S. We go through Battle Creek when we go to Ann Arbor. Pretty up there, but too darn cold for my tastes. Katie's third surgery was in April 2004, and it SNOWED!!!! Geez! In April?!

[JimL]

Welcome, Dr. Allan! We drive past Battle Creek often. I've lived in four different places in Michigan, in sort of a large circle around Battle Creek, but have never really been there, other than fast food at exit 95 on 94 and the rest area just north on 69.

April snow is wonderful! It's beautiful, but doesn't last long. We're getting our April showers today...

[hensylee]

welcome, Dr Allan. We always appreciate a professional being a member of this fine group. It's an ongoing educational site for all of us and we appreciate all the input we can get. We think the professionals could learn a lot from this site, as well. There's so much beyond the 'office'.

My brother is not a valver, but is on coumadin to prevent stroke so I need all the info I can get because he is disabled and can't do it for himself.

Thank you for being a part.

[Nancy]

Welcome to the site. I'm happy to see your post.

My husband has been on Coumadin for 28 years. He has had three valve surgeries, 2 lung surgeries, has a pacemaker, is in chronic aflutter or fib, has longstanding CHF, is in renal failure sometimes, has cardiac cirrhosis with heptaomegaly and splenomegaly, and has hemolytic anemia and pulmonary hypertension. He's a true medical marvel or nightmare depending your viewpoint. He's had many other type of surgeries throughout the years and has many other very, very serious medical problems and takes somewhere in the neighborhood of 16 medications per day depending on what is going on.

He will NEVER go without bridging with Heparin drip for any reason, if we have any control of it. He had a massive post surgical bleedout with Lovenox which almost cost him his life. And "holding" his Coumadin for days is extremely dangerous for him. He recently had some splenic infarctions and then a retinal artery occlusion.

His INR range has been raised from 2.5-3.5 to 3.5-4.0.

Surgeons kinda shy away from him :p

He is due for a pacemaker replacement soon. We'll see what they propose for that. Fortunately, the hospital he now uses for cardiac things keeps people like Joe anticoagulated for many procedures that other hospitals would take a patient off Coumadin for.

[jeffp]

Welcome Dr. Allan! I think it is very dependent on the local customs, as to whether to "un-anticoagulate" or not during surgery. I never encountered any significant problems with minor procedures in the office with anticoaguloation, but my hosptial protocol was (and still is) that all surgery patients are off anticoagulants 2 days prior to surgery and go back on 3 days post.:eek: At the time, that seemed reasonable. Since I became "one of them", I've become a real advocate of staying on the ACT for lesser type procedures, such as the foot and ankle stuff I do (did). As I've gotten my mental state closer to normal (for me at least) I've been speaking to groups and advising them to consider their current stance on ACT and surgery. As an example of the misinforamtion that is still out there: my PCP (whom I think is very capable) got absolutely freaked when I had an INR a few months after surgery of 5.4. He took me off ACT for 2 days, it dropped to 1.5 and took almost 2 weeks to get back around 3.0. After we had long talk about ACT management, he felt comfortable with me self managing the dosing. He even invested in a Coagucheck unit for his office soon after that. Regardless of the journal articles, we get little CE on ACT (unless you're in the field directly) and I think the scare cases we had during our training years are so well intrenched into our psyches, it may take a generation to weed out us old guys by attrition. By then ACT will lilely be completely different.
Its good to see you on the forum. Please come visit and leave comments every so often.

[lance]

Many thanks for your very informative posting about the necessity of bridging for some surgical procedures.

Every anticoagulated patient needs to know as much as they can absorb about warfarin therapy. Most of what I know about warfarin I learned from this site. One dentist wanted me off warfarin for 5 days prior to tooth scaling.

This website, and Al's , provided me with enough info so that I could speak intelligently (I hope) with my doctors when recent surgery was required. I was lucky, they listened. The surgeon himself, a recent graduate in his first private practice, had operated on other anticoagulated patients, but I was the first mechanical valve he encountered. To his great credit, he listened and checked everything out with his alma mater. Initially he wanted me off warfarin for five days before and two days following the procedure. But I knew better thanks to this board and now so does he. So probably do a lot of other patients and their practitioners.

Great to have you here.

Sandra

[allodwick]

One of my clinic patients went to the hospital with abdominal pain. She was referred to a GI doc who did the colonoscopy immediately while she was fully anticoagulated. He even snipped off a few polyps with no problem. Every other one I've ever seen this doc do he insisted that they be off anticoagulation for 3 to 5 day. He still does. What was the justification for doing this one. The only thing that I could see was that it was 4 PM on Friday and he was going to be off the next week. $$ rule.

[DrAllan]

Interesting question regarding a colonoscopy for a diagnosis of abdominal pain. For the moment lets forget the Friday and $$ question. As opposed to a routine colonoscopy on an elective basis, dealing with the ACT is both appropriate and timely. This case sounds like a more urgent issue and the luxury of changing therapy not allowed. Also this was more likely a look see issue rather than a biopsy issue. Besides if one found a significant lesion on colonoscopy causing significant abdominal pain then that was an abdomen most likely needing to be opened that evening.

Finally, the timing of the decision regarding Friday and $$ would also heavily depend on whether the operating colonoscopist was on call, his partner, or he was signed out to his worst enemy and competitor. The ugly interpersonal relationships of physicians are always in the background.

[allodwick]

I went to a store today to purchase a few items that they had on special. On one there was a limit of four - they only had three on the shelf. On another nobody could find it. They called the manager who had absolutely no idea what was in the ad. It came out on Sunday and this was Tuesday afternoon. I had to explain the whole thing to him. I suddenly had the feeling that this is what many of the people on this website are describing when they need to have a procedure done. So many doctors are afraid of warfarin and have no experience with the risks that people with mechanical valves are exposed to when warfarin is stopped.

The colonoscopy presents a special problem. The consequences can be serious if it is not done. But, the huge majority of them are negative. The American Society of Gastroenterology recommends not stopping warfarin for a routine screening colonoscopy. But most doctors try to get people off of it for a week. So there are people who were not managed within the guidelines, who pass their test with no problem yet are unable to feed or dress themselves because they had a stroke while they were off warfarin. I asked one doctor about this when one of my patients had this happen to her and he just shrugged his shoulders. Too many have the attitude that what happens in the brain is not my problem, I deal with the colon.

I have asked about a dozen trauma surgeons in the past year if they ever recall someone who died from a cut to the arm or leg even if they were on warfarin. The answer is universally, "No".

When somebody tells me that they are going off warfarin for a week to have a tooth pulled, I advise them to ask the dentist if they think that they will bleed more than if they had a gunshot wound. If the answer is, "No" then they should either stay on their warfarin or find a different dentist.

I have been an expert witness in cases defending dentists, defending physicians and for the plaintiff against physicians, hospitals and the NYPD. When they have followed my advice they have won, when they did not they have lost in every case. The first thing I try to do when contacted by a plaintiff's attorney is to try to talk them out of the case. If I can back them down then they had no case in the first place.

[Nancy]

"Too many have the attitude that what happens in the brain is not my problem, I deal with the colon."

Perhaps their brain is up their colon!:D

[RCB]

As one who has a lot of experience dealing with the medical system and these forums, never have I read three post in a row that stated such profound wisdom so precisely and so simply!

DrAllan:
"The ugly interpersonal relationships of physicians are always in the background"

allodwick:
"So many doctors are afraid of warfarin and have no experience with the risks that people with mechanical valves are exposed to when warfarin is stopped."

Nancy:
" "Too many have the attitude that what happens in the brain is not my problem, I deal with the colon."

Perhaps their brain is up their colon!:D"

You can't buy this sage advice anywhere and here you get it for FREE!

[catwoman]

"Too many have the attitude that what happens in the brain is not my problem, I deal with the colon."

Perhaps their brain is up their colon!:D

Love it!

I also agree with everyone else's comments...

[Marty]

Love it!

I also agree with everyone else's comments...

I second the motion.

My dentist is a no nonsense kind of guy. Been with him 35 years. Never has recommended stopping warfarin for anything he did, but did say oral surgeons who do extractions might. And get this- he never recommended antibiotics when all I had was MVP, and now that I have a mechanical valve he still doesn't. I've never contracted endocarditis. He said he never has had a case in his practise. He said he looked into antibiotic prophylaxis and that there is no valid evidence in favor of it. I think antibiotic prophylaxis is prescribed primarily to blunt a lawsuit in case anything like endocarditis did develop. Three years ago I saw a young fit looking man for a GI series. he was having some epigastric discomfort. His stomach was fine but I noticed he had a mechanical mitral valve. One year postop, on warfarin and doing well. He said he never had any heart problems, no MVP, nothing, but he developed severe endocarditis
about two weeks after a routine dental cleaning and one filling! Go figure!

[Blanche]

Marty:
It was because of endocarditis, from dental work, that Al needed valve replacement. And, he was properly medicated, yet he still got endocarditis. I certainly don't agree with your dentist. That's the problem with ancedotal information. I like Nancy's clever observation and might add to it by saying it is most likely that some dentists have their brains.......you know the rest.
With all due respect,
Blanche

[Natanni]

I am totally on board about the the idea of not stopping ACT...but endocarditis is not something to play Russian Roulette with. Prophylactic treatment is our only defense in prevention....

[RCB]

"he looked into antibiotic prophylaxis and that there is no valid evidence in favor of it"

My wife was at a lecture where the researcher's prelimenary evidence
was showing no difference between pre-medication and a sugar pill!

Only reason to do it is because it SOP to protect against mal-practice suits.

[Blanche]

Just because someone, be it researcher, doctor, or voodo practitioner, says something is so... does not make it so. Where are the research studies, double-blind, control groups, research menthods, number of subjects, etc. Then, let's evaluate that research by looking at reliability, validity, procedures and a whole host of other things that go into making good research conclusions. So far, all we have is someone's speculations.

Finally, I always allow for error. I could be wrong and have been wrong many times. Actually, learned alot from being wrong. Maybe the researcher has something.....Until proven otherwise, I highly recommend that all folks with MVP or a mechanical valve medicate before dental work.

"Show me the money...."
Blanche

[Marty]

Just because someone, be it researcher, doctor, or voodo practitioner, says something is so... does not make it so. Where are the research studies, double-blind, control groups, research menthods, number of subjects, etc. Then, let's evaluate that research by looking at reliability, validity, procedures and a whole host of other things that go into making good research conclusions. So far, all we have is someone's speculations.

Finally, I always allow for error. I could be wrong and have been wrong many times. Actually, learned alot from being wrong. Maybe the researcher has something.....Until proven otherwise, I highly recommend that all folks with MVP or a mechanical valve medicate before dental work.

"Show me the money...."
Blanche

You are right Blanche, According to my dentist this type of evidence based study has never been done to justify giving every body antibiotics. We do it because it makes most dentists feel better and would look good if there was ever a malpractise case.Patients feel better too- except those unfortunates who have an allergic reaction. When I remember it, I sometimes take a biaxin before going to the dentist. I'm not allergic so it doesn't hurt.Well it may help certain bacteria get resistant. Does it really help? Who knows? Years ago at the Mayo one of their prominent internists ran a study where half the patients before an injection got a swipe of alcohol and the other half got nothing.
Result- no differance in the infection rate. However he found out later there was no way he could stop doctors, nurses, lab techs, etc. from the alcohol swipe. I know I still won't give a shot without it. I'd feel guilty if I didn't.

[allodwick]

It is called evidence-based medicine and the better the evidence, the more sure that you are on the right track. However, sometimes there is just no evidence.

Who would pay millions of dollars to do a study on dental prophylaxis, when the resulting sales would amount to peanuts at best. At worst it might be found out that it didn't work and then the sales would drop to nothing.

The neurosurgeon whose office is down the hall from mine says that he has very little evidence to base his decisions on. This is because it is so hard to recruit a placebo group to have fake operations on their brain tumors, broken necks, etc.

[Cris N]

I, for one, would rather be safe than sorry.

Cris

[Nancy]

Interesting thing is that antibiotic prophylaxis is indicated for not only heart type problems. On the Breast Cancer site I go to, a woman developed an enormous infection in her newly reconstructed breast after dental scaling. Others followed her post to say they too had had that happen and also some of their relatives who had had hip or knee replacements. All anecdotal for sure, but is something to think about. These people are all now taking antibiotics prior to dental work.

Sounds like bacteria like to head for any disturbed area in the body and set up housekeeping.

Maybe this needs much more investigation on all fronts.

[Mary]

Interesting thing is that antibiotic prophylaxis is indicated for not only heart type problems. On the Breast Cancer site I go to, a woman developed an enormous infection in her newly reconstructed breast after dental scaling. Others followed her post to say they too had had that happen and also some of their relatives who had had hip or knee replacements. All anecdotal for sure, but is something to think about. These people are all now taking antibiotics prior to dental work.

Sounds like bacteria like to head for any disturbed area in the body and set up housekeeping.

Maybe this needs much more investigation on all fronts.

I read this in today's newspaper.

"Prosthetic heart valves, hips, knees and other types share one common characteristic. They are all susceptible to bacterial infections . . .not really infection in the classic sense, but bacteria can circulate in the bloodstream, especially after dental work, bowel procedures and so forth. They can land on and stick to the prosthetic material--which has no blood supply to protect itself--set up colonies and cause severe consequences if pockets of bacteria break off and are carried by the blood to other, nonprosthetic sites, such as the brain."

[lance]

Last summer I was searching the website--Manufacturs and User Facility Device(MAUD) for info on mechanical valve deaths. A patient with a mechanical died one month following a dental appointment from an infection--endocarditis.

Pre-medicate or do not premedicate, stop warfarin or continue reminds me of the old joke about why elephants paint their toe-nails red. They do it to hide in cherry trees. Ever seen an elephant in a cherry tree? No? So obviously it works.

I for one prefer to pre-medicate and heparin bridge for surgery.

Cheers!

[RCB]

We seem to be forgetting the lessons of the past, so let me explain why this is important.

During the fifties, they were still not sure how to use antibiotics, because
they had only been discovered a little over twenties years ago. If you had a fever or something, the protocol said take it till you felt better, then you could stop taking it. It wasn't till the mid-60s they realized that this was actually
harmful to certain diseases like RF. What happened was the antibiotics only killed the weaker strains of the pathogens, leaving only the strongest and most destructive to breed and attack the body? A pt. felt better after a few days of meds. because the body’s immune system thought it had won the battle against the disease( I am simplifying this process for clarity, because it really complex and the medical community still is unsure of how this works) when in fact stopping the antibiotics had really only forced a regrouping of the attacking pathogens. When it was discover what was going on. It led to the stick on label phrase “Important! Finish all the medication, even if you feel better!”

Another disaster that happened out of ignorance was it was routine during the late ‘50s and ‘60s to supply anybody who had RF or certain other diseases with a DAILY supply of antibiotics for free. Every month a package arrived with the medication and a short letter explaining why it was necessary to take it. I don’t remember when it stopped, but I do remember a dr. in Texas who was treating me for a fever in the late ‘70s, informed me that it was no longer SOP.

An awareness of the overuse of antibiotics began to creep in to minds of the public heath official when they began to see more and more cases of diseases that seemed resistance to the frontline antibiotic drugs. If anyone was paying attention in Ohio( I was because I had my stroke and 3rd HVR, being scared to death of getting this new strain of RF) during the early eighties, there was a higher than normal number of cases of RF that seemed resistance to the normal antibiotic therapy- a so called “Super Germ!” This prompted a discussion by the infectious disease expert as
to why this was happening. As they began to examine the pt. records they saw a pattern had developed where drs. were over prescribing and wrongly prescribing antibiotics to pts. In many case, drs. admitted to doing it just to make the pt. happy. How many of us have gone to a dr., feeling sick as a dog, only to be told it was a virus and to go home- rest and drink plenty of clear liquids. We were disappointed if we didn’t get some meds. This over prescribing led to antibiotics being less and less effective and the breeding of some pretty nasty “Super Germs!”

Now the question is which is the bigger problem, the disease or over prescribing that creates even more virulent pathogens. It has never been demonstrated that the use of prophylactic antibiotic therapy (PAT) prevents anything, because pts. still get infections after procedures in which they had taken their medications. One might wonder about what is the harm? The answer...the germ breeding cycle that takes place as PAT becomes routine for more and more people.

With my dentist, I have gotten use to PAT. In life, I have learned to pick my battles and I don’t see this one as decisive or worth the effort- of course, I have been lucky not to be attacked by a “Super Germ.” Medical standards can change so as to discontinue PAT as SOP for dental procedures, just as they did daily PAT during the ’50s and ‘60s.

We must all remember that as medicine is an evolving science, its practice is also an art.

[Nancy]

Joe will always pre-medicate for anything invasive, PERIOD. Last time he was in the hospital, he got Klebsiella bacteremia while in the hospital. I can tell you that there were VERY concerned doctors taking care of him. Endocarditis was on everyone's mind. He ended up on 6 weeks of Cipro since he couldn't take anything in the cephalosporins family. This was in September. He's still being tested for any lingering bacterial infection. So far it has come out clean.

It's definitely not worth the risk of getting endocarditis. Valve folks are more susceptible than the ordinary population to developing unusual things. I understand the deal about too much antibiotic prescribing, but this is different.

Why would anyone want to risk getting endocarditis and having an explant or explants and new implant or implants?

Plus those with pacemakers can get bacterial infections in the pacemaker too.

Very messy stuff. If it can be avoided, why not do that instead?

[Marty]

"Infective endocarditis is seldom associated with dental procedures. The efficacy of antibiotic prophylaxis against IE has not been demonstrated. The use of antibiotics carries risk for both the individual patient (from adverse events) and the community at large (by introducing selective pressure on drug resistant organisms). It is time for a thoughtful review of current practices by both the reference organisations and by health care practitioners."

Nancy,This is a summary from a 2001 paper in HEART. The author also notes that chewing and brushing teeth cause bacteremia!

[Nancy]

I think they will need to break out from that potential policy, the people who are at the most risk, and I do believe that heart valve implant people are among that group.

It may be just fine and dandy for the general public.

For some reason it was decided many, many years ago that antibiotics were important for heart valve people. Joe was told that in 1977. There must have been a reason to do that. Society wasn't as litigious then as now, so that wasn't as much of a motivation to CMA.

I hate sweeping decisions which don't take into consideration some fine tuning for those at risk.

But then maybe "Heart" doesn't think there is any risk. I would like to hear their exact opinion on whether there is a risk or not for valve patients. It would be interesting to see what they say about that. I would guess there would be a real squirmy answer, if any.:)

[allodwick]

What Marty is saying is that every time any antibiotics are given, the bacteria develop some resistance. The more resistance that develops the greater the chance that a person will die of a resistant infection. Our antibiotics are rapidly losing their effectiveness. Once an antibiotic drops below about 75% effective against an organism it becomes virtually useless. Cipro and others are dropping rapidly, in part because it has been believed that they need to be used in situations where there may actually be no need. The really scary part is that there are no - repeat no - unique new antibiotics for anything coming out in the next 10 years. This means that in 2015 we are going to be using the same things that we have now. If we give a little Cipro (or anything else) for every procedure the bugs become resistant. It is also thought that they can transmit this resistant strain to members of the household (by sneezing for instance). We need research to find out if giving Joe antibiotics for cleaning his teeth is increasing Nancy's chance of dying from an infection for which there is no treatment. It sounds a little far-fetched, but this is the type of discussions that are going on among infectious disease specialists. Since the 1940s we have believed that antibiotics would put an end to infections but it just may be the opposite.

Back in the 1940s when bacteria had never been exposed to antibiotics you could give one dose of 4,000 Units of penicillin and a fever would drop from 104 to 98 degrees in 4 hours. Now you could give 20,000,000 units of the same penicillin every 4 hours to combat the same bacteria and it would have about the same effect as running water over your hand.

In the 1960s when bacterial resistance was first becoming an issue, a drug was developed called kanamycin. It worked great but it caused deafness. Fortunately safe drugs came soon after it so kanamycin went into disfavor. Kanamycin is getting another look now for multi-resistant antibiotic infections that are occurring mainly in big medical centers. Will we be willing to accept deafness as an outcome because there are no other antibiotics left?

[Marty]

Nancy, If we valve patients should take antibiotics each time we go to the dentist, we should also take antibiotics before brushing our teeth or eating a steak. Both of these activities have been shown to produce showers of bacteria in the bloodstream.
As Al says we are falling behind in keeping antibiotics one step ahead of the bugs. This makes hospitals particularly dangerous places right now.

Don't worry though, nothing is going to change in the recommendations for dental prophylaxsis- or for the alcohol "swipe" before giving an injection.

[perkicar]

Today I had my INR checked for the first time since my colonoscopy last week. I went back on coumadin the day after my procedure, and took 10 mg the first day, then went back to my 7.5 mg Fri/5 Sat/ 7.5 Sun Mon and Wed/ and 5 on Tuesday.
I was taken aback when the nurse called and told me that the cardio wants me to say on my 7.5 4 days a week and 5 3 days a week and get checked again in 2 weeks!!! I called her back and told her I wasn't comfortable with that, and that I'd be back on Monday to get re-checked and we'd take it from there.
How long should it take for your INR to return to normal after being off for 4 days???
carolyn

[Nancy]

I'm not worried about prophylaxis antibiotics for Joe. He'll stay on them, no matter what.

Everyone has the right to make up their own mind as to whether they want certain medical standards or procedures.

Joe will do what he thinks is safe for him, and what he was told was safe for him, and what he continues to be told is safe for him. Others will do likewise using their own convictions.

But I certainly don't want some insurance company bean counters deciding to change things with sweeping decisions, because they think they'll save money, and leaving the sickest of the sick "swinging without a net".

Endocarditis is a GREAT BIG BOOGEYMAN and a potential killer! Joe has enough to worry about, that's for sure.

:) :)

[allodwick]

Carolyn,
A week to two weeks in not unusual. I don't like to test people until they have been back on it for at least a week because the INR is not really a significant number before that time.

[perkicar]

Carolyn,
A week to two weeks in not unusual. I don't like to test people until they have been back on it for at least a week because the INR is not really a significant number before that time.

thanks Al--that eases my mind somewhat. I still think I will go get re-tested on Monday just to prove to my self that I'mm continuing to trend up. Waiting two full weeks would have had me in a real worried fit!