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jclarkdawe
01-14-2009, 05:57 AM
I'm kicking around an idea for a book.

Patient is on coumadin (a blood thinner) to prevent a stroke. Patient needs to go in to doctor and have doctor discover something that requires surgery. Problem is you can't do surgery on a patient taking coumadin. Going off of coumadin will take approximately a week.

Surgery needs to be for a condition that can wait a week to operate on, but if surgery isn't done, then patient will die.

One possibility is an infected appendix. It could be managed for a week if it had to, but I'm wondering if there's something else.

By the way, just to make it interesting, the patient needs to be able to spend this week at home, with reasonable mobility.

And it would be nice if the patient isn't in pain. He's got enough problems.

Thanks for any thoughts,

Jim Clark-Dawe

GirlWithPoisonPen
01-14-2009, 06:16 AM
Jim, I'm curious where you got the one week number for thickening up the blood. Coumadin only takes 48 hours to thin to therapeutic levels.

If he's on coumadin, anything that is bleeding internally is a disaster. A perforated ulcer? (Maybe he just thinks is bad indigestion.)

Last year, one of my friends had a CT for what they thought was persistent diverticulitis. Turned out to be a massive tumor on her kidney. You can't biopsy, so it has to come out in order to find out if it's cancerous. She went under the knife within 10 days.

Puma
01-14-2009, 06:51 AM
Hi Jim, You didn't mention the person's age, but ... with the coumadin to prevent a stroke I'm going to assume middle age plus. How about - an aortic aneurysm? If the aneurysm was large, there would need to be surgery fairly fast to prevent the possibility of rupture or seeping (which would still lead to death). It's a nasty operation.

I've had two experiences with it. My Dad had a seeping rupture and survived surgery at the age of 83. We knew my husband had an aneurysm about ten years ago but it was small enough not to worry about. Two years ago his doctor checked to see what it was doing and it had gotten past the critical for surgery stage. My hubby is on multiple medications and there had to be a "cool down" period before the surgery, but, it was critical to get the surgery done as quickly as possible. He survived but had two very "close calls" - one before surgery and one after.

If you're inclined to go with an aneurysm, I'll be glad to let you pump my brain for thoughts and experiences. Puma

emc07
01-14-2009, 07:21 AM
Hi Jim,
I will also offer information related to the aortic aneurysm if you want it. I had that surgery in September of 2008, so it was recent enough that I remember everything. I also had a valve replacement, which is also something coumadin users sometimes need.

I had reasonable mobility afterwards, but I couldn't lift more than 5 lbs. The pain factor was managed well, and I didn't have as much pain as I thought I would... I'm not sure how old your MC is, I'm 31. let me know if this interests you!

emc07
01-14-2009, 07:25 AM
Hi Jim, You didn't mention the person's age, but ... with the coumadin to prevent a stroke I'm going to assume middle age plus. How about - an aortic aneurysm? If the aneurysm was large, there would need to be surgery fairly fast to prevent the possibility of rupture or seeping (which would still lead to death). It's a nasty operation.

I've had two experiences with it. My Dad had a seeping rupture and survived surgery at the age of 83. We knew my husband had an aneurysm about ten years ago but it was small enough not to worry about. Two years ago his doctor checked to see what it was doing and it had gotten past the critical for surgery stage. My hubby is on multiple medications and there had to be a "cool down" period before the surgery, but, it was critical to get the surgery done as quickly as possible. He survived but had two very "close calls" - one before surgery and one after.

If you're inclined to go with an aneurysm, I'll be glad to let you pump my brain for thoughts and experiences. Puma

I'm glad to hear your hubby and dad are alright.

jclarkdawe
01-14-2009, 06:47 PM
I suppose I should have mentioned that the patient is 93-years-old with a history of TIAs resulting in him being on drugs for blood pressure as well as the maximum dose of coumadin.

Week was chosen mainly as a function of the book. The book is going to run through shortly after the doctor gives him the news to when he goes into the hospital and he needs some time to reflect. The surgeon I spoke to said he'd like to wait between four to six days before operating in this circumstance, but I will also check some more on this issue. This guy is on so much coumadin that a needle prick is a major bleed.

Recovery is not an issue as the book ends before the operation and I'm doubtful the patient is actually going to even make it to the operating table.

The book is what are the thoughts that go through your mind when your doctor tells you that if you do A you probably die, but if you don't, you probably die anyways. My agent thinks I have a real forte writing about that issue and what the hell do I know.

I do like the aortic aneurysm. Among others, it would be something monitored and yet sudden. My father-in-law died from that and my mother died from a stroke after going off of coumadin for a needed surgery. So this will be personal, although both died long ago and far away.

However, I'd like to look at more diseases.

Best of luck,

Jim Clark-Dawe

Puma
01-14-2009, 07:48 PM
Hi emc07 - Glad to hear you survived the surgery too - aren't you young for that type of malady?

Jim - On your what do you do issue - we had that with Dad. If nothing was done he would have died within a few days; with the surgery the odds of his survival were very low. My brother and I had to make the decision whether to let him slip away peacefully and somewhat cognizant or risk trauma and pain with possibly the same outcome or the possibility he'd never regain full coherence again. It was not an easy decision to make, especially for someone who had had a very dynamic life.

I'm going to quibble with you a bit before I quit here. The age of your MC is pretty advanced; have you thought about dropping it down ten to twenty years? I think most people would look at 93 as being on borrowed time anyway, at 73 there's still prospect for doing some things with life which I think would create more reader interest. Just a thought.

Going back to the surgery - fractured hips are very common in the elderly, sometimes requiring surgically implanted pins; gall bladder and hiatus hernia might be possible; or what about a tooth extraction? Be sure to let us know what you finally do pick. Puma

emc07
01-15-2009, 09:38 AM
I suppose I should have mentioned that the patient is 93-years-old with a history of TIAs resulting in him being on drugs for blood pressure as well as the maximum dose of coumadin.

Week was chosen mainly as a function of the book. The book is going to run through shortly after the doctor gives him the news to when he goes into the hospital and he needs some time to reflect. The surgeon I spoke to said he'd like to wait between four to six days before operating in this circumstance, but I will also check some more on this issue. This guy is on so much coumadin that a needle prick is a major bleed.

Recovery is not an issue as the book ends before the operation and I'm doubtful the patient is actually going to even make it to the operating table.

The book is what are the thoughts that go through your mind when your doctor tells you that if you do A you probably die, but if you don't, you probably die anyways. My agent thinks I have a real forte writing about that issue and what the hell do I know.

I do like the aortic aneurysm. Among others, it would be something monitored and yet sudden. My father-in-law died from that and my mother died from a stroke after going off of coumadin for a needed surgery. So this will be personal, although both died long ago and far away.

However, I'd like to look at more diseases.

Best of luck,

Jim Clark-Dawe

Thanks Jim. Good luck with the story!


Hi emc07 - Glad to hear you survived the surgery too - aren't you young for that type of malady?



Yeah, I've heard that. I was born with the condition so it's congenital. Also, since I got a tissue valve, I will have to have another surgery or maybe two more in my lifetime... I'm hoping there are large medical advancements before this valve runs out, then maybe I will only need one.

Thanks!

Puma
01-15-2009, 05:30 PM
Man EMC07 - That's rotten. Really sorry you're facing that. Thinking about it, it sounds like tissue lasts longer than the synthetic (since you're so young), is that the case? I've never checked into that, in fact I didn't realize tissue was an option.

I wish you all the best and hope your current graft holds up forever. Hate to see anyone facing that surgery (but thank heaven's it can be done!) Puma

Palmfrond
01-15-2009, 08:07 PM
Not likely that your extremely old character would be anticoagulated to such an extent just because of TIAs. At his advanced age and poor state of health, he'd probably be given only aspirin or other antiplatelet drugs for TIAs.

As far as a condition that would require life saving surgery but isn't immediately life-threatening - the common one there would be cancer surgery. Hardly ever necessary in the next week, but will kill you if not taken care of. Don't pick one that bleeds, like colon cancer. Melanoma might be good.

GeorgeK
01-15-2009, 09:00 PM
Jim, I'm curious where you got the one week number for thickening up the blood. Coumadin only takes 48 hours to thin to therapeutic levels.
.

Except that (unless I misread the OP, which is entirely possible) the question was not about going on coumadin but coming off it, and a week was always the minimum we'd wait for performing elective surgery after discontinuing coumadin. Also 2 days to therapeutic levels on coumadin probably means you've overshot your target protime and the patient will be risk of bleeding 2 or more days after your initial "therapeutic" level. Coumadin is difficult to regulate on the best of patients. It's affected by so many things, meds, diet, etc. It affects multiple stages in the clotting cascade and some of them do take a week as a realistic minimum to reverse. I've seen it take a couple weeks on some people. We had them in patient during the wait and gradually turned up a heparin drip as the protime dropped. Heparin can be reversed much easier and more quickly than coumadin, but is not an oral medication. That flipping from Coumadin to heparin then back to coumadin prior to discharge added typically 10-14 days to any hospital stay. They have newer anticoagulants nowadays. I'm not sure of the trends on them. I got sick and had to retire around the time they came out with Plavix. I'm also not sure how the whole insurance thing would work today with extending a hospital stay 2 weeks because of anticoagulants.

Appendicitis...wait and it ruptures despite antibiotics...not a good choice. Cholecystitis (gall bladder) however would be a typical adult-elderly ailment for which it wouldn't be unusual to "cool them off" with antibiotics for a few days while you took them off the coumadin and then did surgery.

ColoradoGuy
01-15-2009, 09:44 PM
I agree with George -- coumadin is quite unpredictable. If necessary, though, one can hurry along the recovery from its affects by transfusing with plasma (to replace the blood clotting factors immediately) and giving vitamin K (which is what coumadin blocks to exert its effect). In your scenario I think most folks would at least give vitamin K as well as stop the coumadin.

jclarkdawe
01-16-2009, 03:48 AM
Thanks everyone, especially George.

First off Puma, you'll be happy to know that my agent agrees with you that 70 would be better. Need to make some changes to the character, but since nothing is written yet, the poor old guy has found the fountain of youth.

I'm glad the week works. The story needs the patient at home for a week (and then maybe planned for a couple of days in the hospital before the operation -- whether he'll survive those days is immaterial). His granddaughter lives with him, and if I have to, I can make her into a nurse.

I do realize he'll need to go in and see the doctor at least a couple of times during this week to check his levels.

Doing an aortic aneurysm has the advantage to the patient of not being painful and readers would not need much explanation. I can't decide from reading whether Cholecystitis would be able to be managed for pain enough for my patient to do things. The other question is whether I'd have to spend too much time explaining the disease. Otherwise, I'd prefer the Cholecystitis because it is different.

Thanks for all your help,

Jim Clark-Dawe

Deb Kinnard
01-16-2009, 05:08 AM
I vote for a nice, hot chole. It can be causing him a whole world of hurt, end up in minimally invasive surgery, and have him back on his feet in a week or two. I had mine done laparascopically and the surgery was far more comfortable than the two weeks I spent suffering from the stones. Yipes!

And at 70, they'd do the surgery. At 93, there might be reasons not to. I'm neither a physician nor an ethicist, but at such an advanced age, the patient would have to be pretty low-mileage for the doctors I know to undertake surgery.

Cyia
01-16-2009, 08:24 AM
Use Plavix. That's what my grandfather was on (similar conditions) and when they wanted to do surgery it took a week for him to be safely able.

PennStater
01-16-2009, 09:45 PM
Here's something different.

Many people die of nose bleeds every year, sometimes because of blood thinners. In my experience, the surgeries to stop and nosebleeds are dangerous, as the patient can bleed to death on the operating room table.

The nose can be packed to prevent bleeding (sometimes a balloon is inserted and expanded), but when it is removed it will often start bleeding again. A physician would certainly want the patient off coumadin in order to perform the surgery.

In order to permanently stop the bleeding, there is an artery that stems from internal carotid artery that can be clamped. Unfortunately, the best way to get at it is through the mouth (back of the throat) by slowly dissecting through everything. It is a very risky surgery as the arteries can easily rupture. As a result, many otolaryngologists are hesitant to do the surgery and often refer them somewhere else.

So a patient could wait a week before having the surgery, especially to see if it stops bleeding before the surgery. A patient will often pass out when the nose bleeds and it will stop on its own as the blood pressure drops so much that there's effectively no more blood to pump out. It's a telling moment when the balloon is deflated whether the patient will possibly die or have a fighting chance.

Also, it's sort of a throwback to childhood, when kids often get nosebleeds for no reason at all or maybe from a thrown punch from a jilted lover. A 93-year-old man might see the irony of something coming back to haunt him at the end of his life.