Heartfelt with Dr Melissa Walton-ShirleyView all posts »
Dabigatran (Pradaxa): A welcome savior too late for generations of lost talentNov 6, 2010 08:39 EDT
It has been nearly two years since I was contacted by a favorite patient of mine wanting to discuss a minor upcoming surgical procedure. We had navigated a lot together; a failed stress exam, cardiac cath, bypass surgery, carotid endarterectomy, abnormal lipids, etc throughout the years. "It's not something I absolutely have to have done, Melissa," he said, "but it's been bothering me for years, and I'd really like to put this behind me. I'm worried about coming off my Coumadin, though. You know I need both my hands to do what I do," he quipped.
I remember sitting in the darkness of the nuclear lab, the dim light barely enough to see the notepad I was doodling on. "Jack, we have a way to bridge you that will markedly reduce your stroke risk. Though your risk won't be zero, I'll advise your surgeon to bridge you with enoxaparin. You start it when your INR gets to be less than 2.0 and then resume your Coumadin the night of surgery. I've done it a million times, and though I certainly don't want you to have this surgery, I understand you are in pain and I'll be glad to help you. Just have your surgeon to contact me when you get ready."
"Well, great!" he said, "I really, really appreciate this, and I'll contact him to talk about it."
"Great," I replied, and then just like we ended every conversation we'd had for 15 years, I always said, "You behave yourself now," to which he always said, "You know me." Although I couldn't see him, I knew he was smiling that crooked half-cocked smile that had endeared me to him all those years.
Those were the last words he ever spoke to me. I never heard from his surgeon, and I never knew when he went to the hospital. I actually thought he might have just put it off as so many patients do when they consider the risks and the benefits of stopping Coumadin. Some weeks later, I left for one of the European meetings, and when I returned home, my nurse practitioner greeted me with the news that Jack had suffered a catastrophic life-changing stroke and was in Nashville. The nightmare unfolded as all strokes of that magnitude do . . . the fever, the pneumonia, the swallowing study, the conversation about a peg, nursing-home placement, the heel protectors, and then the gut-wrenching reality that he would never speak or walk or feed himself again. I wanted to go to him and try to comfort him, but my nurse told me that his son had called my office, angry about his outcome, lashing out at both me and his surgeon. He was told by the neurologists that he should have been bridged both on and off warfarin with enoxaparin and that this was completely preventable. She wanted advice, though, about his medications and my nurse worked him though it. My nurse also told him that I was never contacted about his surgery and didn't even know when he had it. I knew though that my having been there would not have likely changed his outcome. After surgery, it's been our habit to bridge off Coumadin with Lovenox, but sometimes, because of bleeding concerns, if it's not a valve issue, we place patients back on Coumadin at a high dose the night of surgery and let them drift back up to a therapeutic INR. I've done it this way since Lovenox came on the market, and I've even been careful to never use enoxaparin with valves, always implementing a heparin protocol as soon as the surgeon was comfortable. I've never seen a catastrophic stroke in 20 years of doing it this way.
Months later, I saw Jack for the first time since his stroke. His family asked me to help when he came in with another pneumonia and fast heart rate. As I approached his room, I actually felt butterflies and an intense sense of dread both because of what I would see but also because his family might still be harboring some anger toward me. I took a deep breath and slowly opened the door. It was as bad as I had ever imagined. There sat Jack, this once enormously talented woodworker in a diaper. He was thinner than last I saw him, and the small amount of drool on his left cheek belied his catastrophe. The head of his bed was positioned in typical stroke mode, "up 45 degrees," to prevent aspiration. His left arm and wrist were curled abnormally and sat silently in his lap. He stared ahead, not acknowledging my presence. His wife was sitting to his left at the bedside and her eyes met mine but there was not one single hint of animosity or anger. I don't think she had the energy for it. Sickly from years of cancer therapy, it was all she could muster to be present and supportive. I then examined Jack without his acknowledging me. I noted his heart rate, wrote some orders, and assured his wife I could get his heart rate down, now in sustained atrial fibrillation, with a little digitalis. She thanked me for coming and I turned to walk away. I couldn't help but try to see if he would remember me or look at me, so I turned back toward him, bent down and leveled my eyes with his. "Jack, it's Melissa. You better behave yourself," I said. With that, just for a moment, he stared straight into my eyes and smiled only a portion of that crooked half-cocked smile I had looked forward to for years. I knew that he recognized me, maybe not specifically, but for a moment, he seemed to recognize the same kindness and love we had shared as patient and cardiologist all those years.
The evidence for Jack's talent, signature cherry furniture pieces lovingly created and hand-turned, stand as silent monuments to his lost talent in living rooms and bedrooms all across South Central Kentucky. All the "if onlys" in the world won't help him now, but I know Jack, and he'd want me to take all the regret I have and muster it into something that would prevent others from spending their still-productive latter years waiting for their next g-tube feeding. For future patients, because they've finally made it to mainstream medicine, I'll implement a direct thrombin inhibitor and within 30 to 120 minutes, their stroke risk will be like that of an INR of 2.0. I look forward to administering this new generation of saviors with enthusiasm as a memorial to Jack and others like him who are living in nursing homes as part of that lost generation to preventable stroke still existing all across the world.