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Thin white line?


BlsdMama
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Is there some kind of medical code of honor to not step on another doctor's toes?

 

So two weeks ago today, I had the PICC put in my arm to right above my heart.  

Less than fantastic experience-  took three tries including one without anesthetic, but it's over.

 

That Friday?  With chest pressure, went into the ER and found out I had a clot.  Got put on the blood thinner Xarelto.

Thought nothing of it.

 

Busy weekend.

That Tuesday my home health nurse accidentally pulled out too much of the PICC while doing a dressing change.  Went to ER AGAIN.  \

Had to have the PICC pulled and replaced.  This team (local) was amazing.  Placed the new PICC, great experience.

Wednesday -dressing change for mild/moderate bleeding, made total sense because I was on blood thinners.  Made a call to my local doc wondering if Xarelto was a good fit for me because I am a fall risk.  Doc tells me (through his nurse) that people are at a very low risk of falling overall.  Dude, you DID get the report from Mayo where I just spent a few days getting a billion tests done, right?  Sigh.  

 

(There is no "antidote" for Xarelto.  If you take a fall and begin to bleed, you wait for it to wear off.  The greatest risk to a PLS patient is falling because we drag one or both feet and our balance sucks.)

 

He says no.  Says he'd like to see me first but he's going on vacation and can fit me in on the 15th.

 

Saturday I have to go back in - bleeding from PICC and soak the foam pad around it.  Office tells me to discontinue Xarelto for now.  Saturday night back to ER for chest pressure and arm pain.  It's nothing.  And no, we're going to keep the Xarelto.  At least he had an awesome sense of humor.  Keep my appt. on the 15th.

Sunday back in again to change the dressing again  - bleeding from PICC and soaks the foam pad and compromises the boundary of the dressing because more blood.

Monday - go in to see my doc's partner.  I explain to him the fall risk.  

First, I really like this guy.  But he seemed VERY torn about switching me.  Is there some kind of medical code of conduct I don't know about?  If Xarelto is just not a good fit for me, switch.  Why the guilt?

 

And he did switch me (to Coumadin) but it seemed uncomfortable for him, but he LISTENED to me about fall risk.  

 

I think there is some odd white line the docs never want to cross?

 

Oh, and PSA - beware of the new blood thinners.  They are great in that you don't need weekly blood measurements HOWEVER there is NO antidote if something happens, unlike warfarin or coumadin.  I already do weekly blood draws so this is a non-issue for me.

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We opted against Xarelto. That "no antidote" business scared us too much. - when combined with the deaths and the pending lawsuits! My son is a Coumadin patient for life. His hematology team believes the new meds will get there sooner or later, safety wise, so my son hopes he can take something else someday. He gets tired of the Coumadin dietary restrictions. Other than that, Coumadin has been a good option for him.

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Yes, there is a professional etiquette issue.

 

And it does relate to patient care - especially with a complicated patient, it really isn't a great idea to have a second, temporary doctor changing things or second guessing the main caregivers approach.  It can cause problems.

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:grouphug: no advice, just sympathy. I've run into the same issue before. Many doctors seem to consider it second-guessing another doctor's opinion. You're the patient though and if you are concerned about fall risk, the primary doctor should have listened and switched you OR explain to you (not his nurse) why he wouldn't recommend switching you. 

 

 

Pradaxa has an antidote.

 

I just educated myself about this because my husband had a Pulmonary embolism yesterday.  We spent the day in the ER.  

 

He will probably be on something for life now.  

 

:grouphug:

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Yup there is. I discovered it after having my daughter. The large low income practice OB clinic called 2 days before my 6 week postpartum checkup - to reschedule it for nearly 3 months later because one of their OB's had an issue and they were shifting patients. I needed cleared for work. No one else in my large city would touch me as a patient even just to clear me! And that was with a very uncomplicated delivery too. 

 

I finally had to call supervisors and throw a fit until they squeezed me in so I could return to work. 

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Be very careful with Xarelto! It caused a stomach bleed in my dad that landed him in Intensive Care getting large amounts of blood.

 

Yes, doctors don't like to offend other doctors since they often need to work together and  they don't like to have their own judgement questioned.

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Some physicians are hesitant to change meds or a course of treatment because: you may not be their regular patient (it's impossible to get a whole backstory in five minutes), they may not be familiar with the medicine enough to know why another physician choose to use it instead of a different choice, they may not know why a different physician choose a specific medicine so to change it could cause a cascade effect of problems.

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There is a line. I had a pediatrician for ds that we just butted heads about everything. She said I would be best served elsewhere. My dd had seen another Dr in the practice so I thought I could just change visits to her. She and I got along great, but she told me if one Dr dismisses you the others can't see you. So we had to leave the practice.

 

Hope the new medicine works better for you

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Pradaxa has an antidote.

 

I just educated myself about this because my husband had a Pulmonary embolism yesterday.  We spent the day in the ER.  

 

He will probably be on something for life now.  

 

:ohmy: Sorry you all went through this!

 

OP, YOUR health is what trumps the docs' "professional courtesy." 

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I am on warfarin for life.  I was put on it in 2010 after a huge clot.  I go to a coumadin clinic and have asked a few years ago whether they are losing patients to the new drugs.  They said sometimes yes but often they come right back after a bit.  I did hear that Pradaxa now has a reversal so I am waiting now a few years to see how that plays out before going to switch to that.

 

As to the dietary restrictions- having been on the drug for 7 years, I am now good with knowing usually how to switch things around if I eat certain things or drink a bunch of cranberry juice or need to take more steroids, The nurses at the coumadin clinic have told me several times that I am so good at managing my levels by myself (as long as my body cooperates and it does not always and it isn't dependent on what I eat then) that I could really work there.  So really the main change I have is that we no longer use any soybean oil or canolo oil but stick to corn, grapeseed and olive oils for our normal cooking.  I do still go to Chinese and Japanese restaurants- I just make sure I drink some more cranberry juice.  Same if I am eating more salads or more cruciferous vegetables, more cranberries.  If I have a half glass of wine (the limit I am supposed to have and have only started doing that occasionally now that I have been on it for seven years), I do eat a salad or have some broccoli.  It isn't that hard to manage.

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My son has learned to manage the INR levels, too...he has his adjustment foods, as well, and is always within his therapeutic range. It's just annoying as a college student to have to manage it; finals week always throws his numbers off, as do major changes in sleeping and eating schedules for summer jobs. He would like to occasionally binge on pizza or after being too busy to eat properly for a couple of days, or eat nothing but movie theater popcorn on a Saturday now and then, like a normal college student. LOL He intends to stay on it for life, has no interest in the new drugs yet, but thinks it will be easier to fool with when he's out of school and into adult routines.

 

Note: ds has comorbid health issues that make the Coumadin lifestyle more complicated for him.

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All of the coumadin lifestyle tips are *very* helpful to me - thank you.

 

 

 

Yes there is a line that they are uncomfortable crossing if you are someone else's patient. Can you switch to the partner as your doctor?


Sent from my iPhone using Tapatalk

 

I wondered that but I am thinking that might be really uncomfortable.
The most challenging part is this:

 

I have a Lyme specialist in Minnesota.  BUT I need an Iowa doc to write my orders - PICC line care, weekly blood draws, etc., to get these things done locally.  This doc has agreed to do these things for her, but I don't see a new doc doing these things.  I am actually very concerned he is going to be insulted when he gets back from vacation and sees I went around him.  I didn't do so intentionally.  Asked the question, accepted the answer.  It was only after I had more bleeding via the PICC that I needed someone to address my concerns immediately.  I am concerned it won't be seen that way and I am going to be in a position without a family doc that will handle these orders from the MN doctor locally.  Sigh.

 

 

 

Pradaxa has an antidote.

 

I just educated myself about this because my husband had a Pulmonary embolism yesterday.  We spent the day in the ER.  

 

He will probably be on something for life now.  

 

Oh wow.  Do you know what caused it?  Random?  That is really frightening.  
I admit to not being too worried - we know it was the PICC insertion that caused bleeding the vein so the cause seems relatively benign and chances are good it's cleared because that PICC was removed already.  But in your husband's case that would have been so frightening.  Chest pressure, short of breath, sweating?  Was that the presentation?

 

 

 

Yes, there is a professional etiquette issue.

 

And it does relate to patient care - especially with a complicated patient, it really isn't a great idea to have a second, temporary doctor changing things or second guessing the main caregivers approach.  It can cause problems.

 

Yes, I can absolutely see this.  But I also think there is an ego issue at play here when no one wants to ruffle feathers by saying, "Your plan was solid, but maybe we need to take a closer look at the needs of this particular patient," kwim?
It has been incredibly challenging coordinating care between specialists.  I am finding myself wondering all the time how older patients struggling with memory,etc., are EVER supposed to keep appointments, med, important info, etc., straight.  This has to just be SO overwhelming for them.

 

 

 

Be very careful with Xarelto! It caused a stomach bleed in my dad that landed him in Intensive Care getting large amounts of blood.

 

Yes, doctors don't like to offend other doctors since they often need to work together and  they don't like to have their own judgement questioned.

 

YikeS!  I had read this.  No fall associated - just random internal bleeding?  That is so frightening.

 

 

There is a line. I had a pediatrician for ds that we just butted heads about everything. She said I would be best served elsewhere. My dd had seen another Dr in the practice so I thought I could just change visits to her. She and I got along great, but she told me if one Dr dismisses you the others can't see you. So we had to leave the practice.

Hope the new medicine works better for you

 

That is a shame. :(  And how hard for you!

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Doctors definitely hesitate to change serious medications of someone who isn't their patient. Probably moreso when they're the longtime patient of a partner. They don't know why the other doctor chose that drug. It could have been for a specific reason based on knowledge for the prior patient relationship.

 

More advice on Coumadin--my mom was recently put on it, and the clinic basically told her to avoid one or two specific vegetables. Uh, no... So I found a PDF online with a list of all the Vitamin K levels in fruits and vegetables. She got a scale to weigh things. It's been about 9 mos, and she's much more relaxed now and knows most of it in her head. The nurses are always impressed at her control level compared to their other patients. Well, sure because you're giving inadequate advice to manage diet! 

 

I'm sorry you have one more thing to manage right now. :grouphug:

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Yes there is a line that they are uncomfortable crossing if you are someone else's patient. Can you switch to the partner as your doctor?

 

 

Sent from my iPhone using Tapatalk

 

Yes, the stepping on each other's toes is taken seriously in that community. I suppose docs don't want to be known as taking patients from other docs and, even worse (evidently) changing previous orders.

BUT you are the patient and you make your choice. Consider changing to the doc whom you like if you feel he is very competent and easy to converse with.

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All of the coumadin lifestyle tips are *very* helpful to me - thank you.

 

 

 

 

I wondered that but I am thinking that might be really uncomfortable.

The most challenging part is this:

 

I have a Lyme specialist in Minnesota.  BUT I need an Iowa doc to write my orders - PICC line care, weekly blood draws, etc., to get these things done locally.  This doc has agreed to do these things for her, but I don't see a new doc doing these things.  I am actually very concerned he is going to be insulted when he gets back from vacation and sees I went around him.  I didn't do so intentionally.  Asked the question, accepted the answer.  It was only after I had more bleeding via the PICC that I needed someone to address my concerns immediately.  I am concerned it won't be seen that way and I am going to be in a position without a family doc that will handle these orders from the MN doctor locally.  Sigh.

 

 

 

 

Oh wow.  Do you know what caused it?  Random?  That is really frightening.  

I admit to not being too worried - we know it was the PICC insertion that caused bleeding the vein so the cause seems relatively benign and chances are good it's cleared because that PICC was removed already.  But in your husband's case that would have been so frightening.  Chest pressure, short of breath, sweating?  Was that the presentation?

 

 

 

 

Yes, I can absolutely see this.  But I also think there is an ego issue at play here when no one wants to ruffle feathers by saying, "Your plan was solid, but maybe we need to take a closer look at the needs of this particular patient," kwim?

It has been incredibly challenging coordinating care between specialists.  I am finding myself wondering all the time how older patients struggling with memory,etc., are EVER supposed to keep appointments, med, important info, etc., straight.  This has to just be SO overwhelming for them.

 

 

 

 

YikeS!  I had read this.  No fall associated - just random internal bleeding?  That is so frightening.

 

 

 

That is a shame. :(  And how hard for you!

 

 

I did a post about my dh so I wouldn't keep t/jing.  But yes, shortness of breath, nausea, and dizziness.   

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Yes, I can absolutely see this.  But I also think there is an ego issue at play here when no one wants to ruffle feathers by saying, "Your plan was solid, but maybe we need to take a closer look at the needs of this particular patient," kwim?

It has been incredibly challenging coordinating care between specialists.  I am finding myself wondering all the time how older patients struggling with memory,etc., are EVER supposed to keep appointments, med, important info, etc., straight.  This has to just be SO overwhelming for them.

 

 

 

 

 

 

Ego can be an issue.

 

But it's more than that.  A primary doctor has taken on a measure of responsibility for the patient.  So there is a hierarchy that doctors are meant to recognize.  Until there is a formal change, someone who is not your primary doctor will not take on that role.  It's a bit like a transfer of power in government.

 

With specialists, they are generally collaborating, and that is handled a bit differently.  

 

The problems for older patients are significant, fr sure.  Many need help from family.  IN an ideal world, their GP plays an important role there too - particularly with keeping track of what is coming in from all the specialists and knowing the patient well enough to make sure the care is really towards his or her health goals.

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Doctors definitely hesitate to change serious medications of someone who isn't their patient. Probably moreso when they're the longtime patient of a partner. They don't know why the other doctor chose that drug. It could have been for a specific reason based on knowledge for the prior patient relationship.

 

 

Ego can be an issue.

 

But it's more than that.  A primary doctor has taken on a measure of responsibility for the patient.  So there is a hierarchy that doctors are meant to recognize.  Until there is a formal change, someone who is not your primary doctor will not take on that role.  It's a bit like a transfer of power in government.

 

With specialists, they are generally collaborating, and that is handled a bit differently.  

All of the above. They also have to be careful what they say--if they criticize another practitioner vs. just giving you their own opinion of your issues, they can be sued for professional libel. That is a subjective line, so they tend to stay clear of it.

 

You can probably just ask them their opinion about the various options in your scenario. Sometimes they are on autopilot, honestly. They try to avoid that, but sometimes, they don't hear or don't read the chart as much as they should, or they might get the timeline wrong--like, they might think something is recent that's actually not or the other way around. They are keeping a lot in working memory while they talk, read your chart, etc. For a rare disease, they might know something about the disease, but they might not realize what stage or manifestation you are at in particular. So, rather than talking about the fall risk associated with your disease, you might mention that you drag your foot, fall however often, etc. and mention that it's part of the disease process overall.

 

It's hard. You run the risk of being compared to someone else (positively or negatively) if you get really specific, but there is a huge difference between evidence-based care for a group of people with a disease vs. one person with the disease. Ideally, the doctor will look at the patient in front of them, just like we do with our kids and homeschooling. You might have to draw the attention there by being super specific. They want to treat you like an individual, but they can err on "just because it's not recommended for this group, and you are part of this group, it doesn't mean it's not okay for you" and on the side of "are you sure you are part of that group--you seem just fine." Ideally, they will be able to find a happy medium and treat you thoughtfully.

 

Not to excuse the doctors who are just not listeners--I have had more than my share of that. But, I am also married to someone in the medical field, and he's pretty up front about categorizing for me the shortcomings he tries to avoid. He works with doctors every day, and he still formulates a plan ahead of time for how to talk to them when he's the patient, or when he is advocating for a family member. It's crazy.

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I don't know anything about your situation, and I'm sorry that happens to you, but yes, I do think there is a professional courtesy where they won't step on each other's toes.

 

After my preeclampsia, my MFM and primary care docs referred me to both cardiology and nephrology. They both checked me out, and then cardiology said, "I'm going to bow out here and defer to the nephrologist so as not to have too many cooks in the kitchen." Nephrology says that he wants to see me when I get pregnant again but that he'll defer to MFM. So yeah I think they like not to step on each other's toes.

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