What Are Your Thoughts On Taking Blood Thinners??

By Roberta Palmer, RN and Patty Kunze, BSN, RNC

So…a topic that was presented to The Rollin’ RNs involves taking blood thinners. One of our readers wanted our thoughts about how long she should stay on her blood thinner prescribed to treat a blood clot.
That’s a great question worth digging into but ultimately this is a question that needs to be discussed with your doctor. It’s a very important and individualized decision that will depend on some key factors such as:

  • The location of the blood clot
  • Why the clot formed (what risk factors contributed to your clot)
  • An assessment of your risk for developing future clots if your blood thinner is stopped (what risk factors you have which may cause a clot recurrence)
  • How you have tolerated the blood thinner and what your risk for bleeding is if you stay on a blood thinner.
  • Are you still having frequent blood levels drawn per your physician’s orders?

Lets start with a little background on blood clots

Blood clotting is a normal, complex process that prevents excessive bleeding when a blood vessel is injured. Sometimes, clots form abnormally within a blood vessel and can occur in both arteries and veins.Blood clots, which form in veins, are very different from clots, which occur in arteries. Arteries are the blood vessels that carry blood away from the heart to your extremities (legs, arms, abdomen, brain). Think ‘A’ for Away!! While veins are the blood vessels that carry blood back to the heart from the extremities.Blood clots, which form in arteries, may lead to stroke, transient ischemic attacks (TIAs or mini strokes), and heart attacks because they lead from the heart. Stop and let that sink in!When a clot forms in the deep veins of the body, it is called deep vein thrombosis (DVT). DVTs occur most commonly in the leg; however, it can occur anywhere in the body, such as the veins in the arm, abdomen, pelvis, or around the brain. 

A potentially life-threatening complication of deep vein thrombosis (DVT) is pulmonary embolism (PE). A PE occurs when a blood clot breaks off from a DVT and travels through the blood stream and lodges in the lung. Occasionally, a PE can form in the lung itself. Clots that break off from a DVT and travel do not typically lead to stroke, as they get filtered out by the lung. We are not here to frighten you, but just to make you aware of these potential nasty complications.

The following factors increase your risk of developing a blood clot:· Obesity· Pregnancy· Immobility· Smoking· Inactivity (long trips by plane or car)· Oral contraceptives· Certain cancers· Trauma· Certain surgeries· Age (increased risk for people over age 60)· A family history of blood clots· Chronic inflammatory diseases· Diabetes· High blood pressure· High cholesterol· Prior central line placement

Treating Blood Clots

Your doctor will give you medicine that makes your blood slower to clot. These drugs, called anticoagulants or blood thinners can keep a DVT from getting bigger while your body breaks it down. They can also help keep another clot from forming. Some are given as shots, and some are pills.It usually takes about 3 months to treat a DVT. If you aren’t likely to have another one, you may be able to stop taking your blood thinner. People at higher risk may need to stay on them for years, possibly life. That’s why it’s so important to talk with your doctor about what’s best for you.

Your treatment plan will be different depending on which medication you take. For decades, Warfarin has been the go-to drug for treating a DVT. It can take a few tries to get the dose right, and it may need to be changed from time to time, so you’ll get your blood tested often — maybe two or three times a week at the beginning of treatment. Later, you may only go in once a month.

The things you eat and drink and the drugs and supplements you take can affect the way Warfarin works, so you may need to make some lifestyle changes. For example, Vitamin K helps your body form blood clots (think K for Klotting!), and foods that have a lot of it may keep blood thinners from working as well as they should. That means you may need to limit things like green leafy vegetables, fish, and other foods high in Vitamin K.The newer “kid on the block” medicine is a class of blood thinners that doesn’t require frequent blood testing while taking them and you don’t have to be as careful with food or other medications. These can include drugs like Eliquis, Pradaxa, and Xarelto.

A downside to taking blood thinners is that they can put you at risk for uncontrolled bleeding so keep an eye out for these signs:

  • Easy bruising
  • Nosebleeds
  • Intense headache
  • Stroke symptoms like confusion, weakness, or slurred speech
  • Throwing up blood
  • Blood in your urine or stool
  • Unusually heavy vaginal bleeding
  • Low blood pressure symptoms like weakness, dizziness and shortness of breath

In addition to taking your medication as instructed by your doctor, you can do a few other things to make another DVT less likely:

  • Get up and around as soon as you safely can after an injury or surgery. Just getting out of bed and into your wheelchair moves blood through your system. (You’ll see this in action in the hospital setting when the nurse has their patient sitting up and dangling their legs on the side of the bed or even walking around as early as the same day or day after a procedure.)
  • Try not to sit for more than a couple of hours at a time. Along with your frequent pressure reliefs, if you can, manually pick your legs off your footplate one at a time and move them around or massage them to promote blood circulation. (However, DO NOT massage any area if you suspect a DVT* or you’re recovering from one.)
  • On long trips, wear compression stocking to keep blood from pooling in your lower legs.
  • Stay a healthy weight.
  • Don’t smoke.
  • Drink plenty of water.
  • Let all your doctors know you’ve had a DVT or are taking blood thinners, including your dentist.
  • Wear compression stockings and elevate legs to keep blood from pooling in your lower legs.
  • Exercise regularly to get blood moving through your system.

Remember, it usually takes about 3 months to treat a DVT. If you aren’t likely to have another one, you may be able to stop taking your blood thinner. However, people at higher risk may need to stay on them for years, possibly life.

So that’s a lot of information we’ve thrown at you. We hope it gives all of you a little more insight on blood clots, risk factors, treatments and prevention. Talk with your doctor about your situation and together you can come up with a plan individualized for you.

It’s all good, so keep on rollin’.Roberta, RN and Patty, BSN, RNC

My Non-Surgical Quest for a Pain-Free Shoulder Part 2

By Wendy Crawford

NOTE: This is a personal recount of a shoulder problem written in laymen’s terms. The author is not a medical professional. For medical advice, please consult your physician for the best course of action pertaining to your condition.
In a previous article, ”My Non-Surgical Quest for a Pain-Free Shoulder – Part “, I wrote about my attempts of trying to eliminate pain in my shoulders caused by calcific tendonitis and additionally, a slight tear in my rotator cuff tendon on my left WITHOUT surgery. Eventually, through a combination of ultrasound guided barbotage, TENEX procedures and exercise, my right has improved to the point that I am now pain-free and functioning normally.

Ultrasound guided barbotage is a technique using an ultrasound guided needle that breaks up calcium deposits under local anesthetic.Tenex is a procedure that uses ultrasound waves, inserted through a small incision in the skin, to identify and break up calcification and chronic tendinosis. It was much more aggressive than the ultrasound guided barbotage and according to my orthopedist, extremely effective. Right after the procedure, it was necessary for a cortisone shot to help with inflammation to promote healing. After 2 weeks, I started to introduce exercise slowly and gradually built up to full resistance, avoiding all overhead exercises.The theory is that once the calcification is broken up and the majority removed, the remaining particles will gradually disappear with exercise. Upon providing a letter of medical necessity, my insurance covered these procedures.
As happy as I was with the results of my right shoulder, I was still struggling with pain on my left. X-rays and an MRI revealed that there was very little calcification remaining but there was a slight tear. As mentioned in Part 1, my orthopedist was strongly against surgery and wanted to explore EVERY option available. He said that there was no guarantee that surgery would work and could in fact, make my shoulder worse. He was also worried that I may damage it unintentionally, during the recovery because it’s such a long process and is difficult for wheelchair-users to not use it inadvertently.
The cortisone shots were becoming more frequent (every 3 months) and less effective. I was so limited with exercising that I knew that my strength was decreasing. I appreciated that he wasn’t pro-surgery right away but I was starting to think that perhaps, it was my only option and maybe I should take the risk.  I scheduled an appointment and told him that I was frustrated and wanted to move forward with surgery. He paused and sounded so reluctant to schedule the surgery that I changed my mind! I went home determined to find another option and then through divine intervention, a coincidence or whatever you want to call it, an alternative appeared!
Days later after my last appointment, I was visiting my friend’s organic farm when I happened to meet another wheelchair-user at the market. I had seen him before but usually I was leaving in my car when he would arrive. We started chatting and somehow my shoulder came up in conversation. He told me that he had been in the chair for over 40 years and had very similar issues with his shoulder.  He had declined surgery and instead tried stem cell injections which were not yet FDA approved. Now, he could transfer in and out of his car and was pain free. This concept was completely new to me! The company that he went through was called Regenexx and I immediately called for more information from the local doctor that performed the procedure.

I learned that there was a 2-part process once I was evaluated to see if I was a candidate. The first step involved extracting stem cells from my hip which then would be injected into my shoulder, with the intention of reducing inflammation and possibly healing the tendon. After reviewing my medical records, an assistant explained to me that the doctor did not feel comfortable harvesting the stem cells from me since I had a higher level spinal cord injury and it could cause autonomic dysreflexia. Because the procedure is not approved by the FDA, it is performed in a clinic and could not be done in the hospital where he would have access to medical resources, if needed. He was however, willing to inject platelet rich plasma (known as PRP) which can be extracted through centrifugation, from my own blood. Platelets are commonly known for clotting blood but also have proteins called growth factors which are extremely important in the healing of injuries.
After discussing the pros and cons with my orthopedist, I decided to give it a shot (no pun intended!). Although I didn’t want to spend the money, if it worked, it would be worth every penny. On May 9, the platelets were injected into several locations in and around my shoulder. Although I was numbed prior, it still was probably the most painful procedure out of all that I’ve had. 
I went through a similar recovery as TENEX but eased into the exercise a little more slowly. It takes three months to get the full result so I’m almost there. Although I have not had a cortisone shot for over 6 months (and not allowed post-procedure), the pain has reduced significantly and I’m able to exercise at full strength! I must admit that some exercises still cause it to flare up but then I take it easy and gradually, it feels better again.
How long will it last? Will I need to repeat the procedure? Will I eventually need surgery? These are questions that run through my head and probably no one can really answer. After all these years and procedures, being pain free had seemed like an unattainable goal so I do know that for me, this journey was worth it.

My Non-Surgical Quest for a Pain-Free Shoulder – Part 1

By Wendy Crawford

NOTE: This is a personal recount of a shoulder problem written in laymen’s terms. The author is not a medical professional. For medical advice, please consult your physician for the best course of action pertaining to your condition.

IIt all started about 11 years ago when the side of my left upper arm began to ache. It was one of those aches that is just kind of always present and didn’t really matter what I did or did not do. Keep in mind at this point, I had been paralyzed for 25 years due to a C5/6 level Spinal Cord Injury that I sustained in a motor vehicle accident. To say that my arms have been overused is probably an understatement! Given that the prevalence of shoulder pain rises to a peak of 50% of the general population ages 55-64 years old and much higher for wheelchair users, it is unfortunately a common problem.I first went to my general practitioner who thought I was having an inflammation issue and recommended that I start taking large amounts of Advil, several times a day. I wasn’t thrilled about it but if it was going to remedy the situation, I was willing to try it.
After a month or so, this pain was still present and it didn’t seem like it was helping at all. It was also recommended that I go to physical therapy to exercise my shoulder and rotator cuff along with ultrasound therapy on the side of my arm. I had some slight relief but the pain still lingered so finally I was referred to an orthopedist.. After having an X-ray, she pointed to the tiniest microscopic dot and told me that was calcification forming which was causing me pain. I was finding it hard to believe that such a tiny speck on the x-ray could be the source of so much discomfort. I was also confused because it was the side of my arm that hurt not my shoulder. She explained that it was called “referred pain” which is very common with shoulders. She gave me a steroid Cortisone shot in the shoulder and told me to keep exercising.
Within a day, my pain was actually feeling so much better and I was thrilled that it was such a simple fix. About every six months, I would visit the orthopedist and she would give me another shot. I was told that I shouldn’t get them too often as it could compromise the tendon but every six months was completely safe.

Gradually, the shot did not last as long and the pain was increasing. I was going about every four months until  my orthopedist retired. I was ecstatic to find another orthopedist who actually worked with professional baseball players so had a lot of experience with injured, overused shoulders.
He too took x-rays and I had much more calcification than before and some arthritis. He suggested that I possibly get surgery but I wanted to try every option first. We continued with the Cortisone shots but he also referred me to a specialist who did a procedure called “ultrasound guided barbotage“.

When I met with the new doctor, I wasn’t sure what to think. After seeing my X-rays and doing an ultrasound, he painted a bleak picture; I was the worst case of calcification that he’s ever seen. He told me “ You could get surgery but it will be a disaster for recovery. You could do nothing and you will be miserable or we can try the ultrasound guided barbotage and that might work.”  Given these negative options, I chose the latter.
I changed into a hospital gown and was able to stay in my wheelchair. First he cleaned the area and then numbed it by injecting all around my shoulder. Just the numbing was painful so I wasn’t looking forward to the actual procedure.
After the numbing took affect, he used the ultrasound to find the spots of calcification. He then injected a long syringe and moved it back-and-forth breaking up the calcification. The movement kind of reminded me of someone getting liposuction on television!. Even though my arm was supposed to be frozen, the pain shot down my arm and I must admit that I used a few choice words to get through it. It took about 20 minutes, I think, but felt like an eternity and then he gave me a Cortisone shot to help the inflammation from the procedure.
I had to keep my arm moving so as not to get frozen shoulder and slowly went back to doing exercises. I saw him about every six month. At this point, I had pain in both shoulders so we kept doing the procedures on both shoulders for a total of three per shoulder.
The good news is that my right shoulder gradually got better and has not had any pain there since! Keep in mind, I have omitted all exercises above the shoulder, as recommended by the doctor.
There are a few important factors that I would like to emphasize. I have been susceptible to urinary tract infections since my injury and I’ve taken a lot of antibiotics, over the years. One of those being Cipro which I took off and on. One day, I noticed a warning that it can be harmful for your tendons and my doctor confirmed this was true! I have no idea how much this contributed to my shoulder problems but I wish that I would’ve been more thorough in my research and asked for an alternative drug. The second main point is after years of getting Cortisone shots, one of the nurses was going over the post-procedure care and happen to mention that my blood sugar would rise temporarily. I found this interesting because I had recently had my blood sugar checked and it was told that I was becoming insulin resistant. I was shocked that no one had mentioned it before so that I could’ve been more careful in regards to my diet. Thankfully, it is temporary but definitely motivated me to find other options for my left shoulder. Lastly, I recently learned from my urologist  that Cortisone can make you more susceptible to urinary tract infections so be aware of the side effects of Cortisone,  prior to an injection.

Stay tuned for Part 2 to learn more about my non-surgical quest for a happy and healthy shoulder.

Epidemiology of Shoulder Pain
Association of Shoulder Pain with the Uses of Mobility Devices in Persons  with Chronic Spinal Cord Injury

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