Preventable CVA but who's at fault?
Case facts are as follows:
In 1999 a 67 year old male patient has mitral valve replacement (St. Jude Mechanical #31) maze procedure and double bypass. Surgery uneventfull. Thoracic surgeon sends letter to patients primary care physician informing him of the procedures and the requirement for lifelong anticoagulation (coumadin) titerated to an INR of (2.5-3.5). Primary care physician makes note in patients chart on the anticoagulation tracking chart which was allready in use for indication of atrial fib. Physician notes the valve replacement but never changes the therepuetic range from (2.0-3.0) to (2.5-3.5). Patient goes through cardiac rehab and resumes a healthy active life for the next 4.5 years. Golf three day's week, ball room dancing, gardening, etc. During the 4.5 years post surgery primary care physician maintains patient at a subtherepuetic INR ranging from (1.5-2.0) The majority of the INR readings were below 2.0 and the physician was only testing INR levels approx every 2 months usually without dosage increases. During a visit to the physician's office in 2004 the patient and physician discussed having a screening colonoscopy and the physician agreed that he should have one since he hadn't had one in the past. The colonoscopy was scheduled with a large gastroenterology group who in turn sent the preparation instructions through the mail to the patient. The instructions stated for patient to stop coumadin 4 full day's prior to procedure unless otherwise instructed by primary care physician. Patient recieved the instructions 2 weeks prior to the colonoscopy and the next day patient goes to primary care physician's office for his INR check and his INR was 1.5 and he tells the nurse that he was instructed to stop coumadin 4 day's prior to the colonoscopy. The nurse passes the information along to the physician and the instructions back from the physician are to have patient take a double dose of coumadin following the colonoscopy. At this point the physician doesn't have any interaction with the patient. The patient stops his coumadin 4 day's prior to colonoscopy. Colonoscopy is performed with no abnormalaties found. Patient goes home and suffers a massive right side CVA the same day. Upon admission to ER his INR was 1.1 and it was determined that the stroke was caused by a thrombus on his mechanical mitral valve sewing cuff most likely from the stopping of his coumadin. Patient is eventually transferred to a long term skilled nursing facility reduced to a bed and wheel chair until his death 28 months later.
Several months following the stroke it was determined that the patient didn't have a consult with the gastro prior to them having him stop taking couamdin and his first meeting with the gastro was the morning of the colonoscopy. It was also determined that there was no communications between the gastro and primary care physician concerning any of the patients conditions. The gastro was not aware of the patients mech heart valve or coumadin until the morning of the procedure. Niether the gastro nor the primary care physician had any discussion with the patient concerning the risk's of stopping his coumadin nor did they have any discussion of bridging the patient.
Case facts are as follows:
In 1999 a 67 year old male patient has mitral valve replacement (St. Jude Mechanical #31) maze procedure and double bypass. Surgery uneventfull. Thoracic surgeon sends letter to patients primary care physician informing him of the procedures and the requirement for lifelong anticoagulation (coumadin) titerated to an INR of (2.5-3.5). Primary care physician makes note in patients chart on the anticoagulation tracking chart which was allready in use for indication of atrial fib. Physician notes the valve replacement but never changes the therepuetic range from (2.0-3.0) to (2.5-3.5). Patient goes through cardiac rehab and resumes a healthy active life for the next 4.5 years. Golf three day's week, ball room dancing, gardening, etc. During the 4.5 years post surgery primary care physician maintains patient at a subtherepuetic INR ranging from (1.5-2.0) The majority of the INR readings were below 2.0 and the physician was only testing INR levels approx every 2 months usually without dosage increases. During a visit to the physician's office in 2004 the patient and physician discussed having a screening colonoscopy and the physician agreed that he should have one since he hadn't had one in the past. The colonoscopy was scheduled with a large gastroenterology group who in turn sent the preparation instructions through the mail to the patient. The instructions stated for patient to stop coumadin 4 full day's prior to procedure unless otherwise instructed by primary care physician. Patient recieved the instructions 2 weeks prior to the colonoscopy and the next day patient goes to primary care physician's office for his INR check and his INR was 1.5 and he tells the nurse that he was instructed to stop coumadin 4 day's prior to the colonoscopy. The nurse passes the information along to the physician and the instructions back from the physician are to have patient take a double dose of coumadin following the colonoscopy. At this point the physician doesn't have any interaction with the patient. The patient stops his coumadin 4 day's prior to colonoscopy. Colonoscopy is performed with no abnormalaties found. Patient goes home and suffers a massive right side CVA the same day. Upon admission to ER his INR was 1.1 and it was determined that the stroke was caused by a thrombus on his mechanical mitral valve sewing cuff most likely from the stopping of his coumadin. Patient is eventually transferred to a long term skilled nursing facility reduced to a bed and wheel chair until his death 28 months later.
Several months following the stroke it was determined that the patient didn't have a consult with the gastro prior to them having him stop taking couamdin and his first meeting with the gastro was the morning of the colonoscopy. It was also determined that there was no communications between the gastro and primary care physician concerning any of the patients conditions. The gastro was not aware of the patients mech heart valve or coumadin until the morning of the procedure. Niether the gastro nor the primary care physician had any discussion with the patient concerning the risk's of stopping his coumadin nor did they have any discussion of bridging the patient.
.
