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RE: Ask the Doc - February 27, 2008 9:34:43 PM   
Dr.Wagner


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Pushing thrombolytics if you have a missed head bleed is essentially a death sentence.


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RE: Ask the Doc - March 4, 2008 6:02:22 AM   
tucker

 

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Doc,

Speaking of SAH and bleeding,...What is your recommendation for acute care therapists mobilizing patients who are over anticoagulated?  There seems to be a wide range of physican preferences and no hard evidence when therapy should be held.

My personal view is that if INR is 3 to 5 and patient is a high fall risk, hold therapy.  If the patient is a low fall risk, first get the physician's written approval to mobilize the patient.
If INR is > 5, hold therapy for all patients due to the risk of spontaneous bleeding. 

Most MDs agree witholding therapy over 5, some withold if over 3, but I recall one plastics MD telling me to mobilize a patient with an INR of 7.  Any suggestions?  I have had no luck with the lit search, but an MD told me he saw a study that showed risk of spontaneous bleeding if INR was over 5.  That would be sufficient evidence if I could find it.  Thanks in advance for your thoughts on the subject!

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RE: Ask the Doc - March 5, 2008 3:27:03 AM   
Dr.Wagner


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I am with you, if the INR is above 4 or 5 and they are a fall risk...then wait a day and let the INR go down.  Lastly, Plastic Surgeons and medicine don't mix well. 

Virtually all INR complications show up in the ED first, and dealing with those bleeds (even if they are minor) are a big pain in the arse.  Let alone muscular hematoma due to a fall...or worse.


< Message edited by Dr.Wagner -- March 5, 2008 3:30:58 AM >


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RE: Ask the Doc - March 22, 2008 9:11:57 PM   
jma

 

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Speaking of bleeds, are there certain things to watch out for when treating patients who have hemophilia? What are considered referrals to the ER/MD?

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RE: Ask the Doc - March 22, 2008 9:47:43 PM   
Dr.Wagner


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Are you speaking of hemarthrosis?  I think ANY time you suspect one, then refer out.


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RE: Ask the Doc - March 22, 2008 10:10:43 PM   
jma

 

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If this falls under the category of complications with patients already diagnosed with hemophilia, then yes. Say for example, one patients comes in an shows a black and blue in the lower thoracic area, perhaps maybe due to a bump on a wall. Would this be an emergency to refer back to the MD?

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RE: Ask the Doc - March 23, 2008 1:37:27 PM   
Shill

 

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I can tell you that people with bleeding disorders such as hemophilia, are usually so in tune with what is going on that they will know when they have a bleed that needs attention before you will.  Trauma, knock to the head, obvious things like that are reasons for referral, but not necessarily all joint bleeds.  Asking them about their history, their factor self administration schedules, etc, will guide whether they need to return to MD or not.

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RE: Ask the Doc - March 23, 2008 3:24:35 PM   
jma

 

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Thanks for the info!

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RE: Ask the Doc - March 23, 2008 3:53:34 PM   
kamryn


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Dr Wagner - What are your thoughts regarding thrust spinal manipulation and INR?  Is there a certain point with the INR for pts on anticoagualants that you would not recommend thrust manipulation (or even jt mobs)?

Thanks. 

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RE: Ask the Doc - March 23, 2008 5:21:08 PM   
Dr.Wagner


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Wow, great question.  A patient on Coumadin (which elevates the INR) is at risk for "all cause" bleeding. Personally, I would think an INR of >2 and cervical manipulation is a BAD combination.  Furthermore the "drug of death"...oops I mean Plavix is also a big concern.  There is no way to follow coagulation and plavix (unless you count bleeding time), therefore I would be VERY wary of those on Plavix as well. 
LVHA manipulations should simply be watched for force.  HVLA simply seems like a bad combination...unless you are willing to take the risk.  There are no absolute contraindications though.
Just be aware that if a hemarthrosis develops, you will likely be liable.


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RE: Ask the Doc - March 29, 2008 11:13:35 PM   
jma

 

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Hello, I am hearing that angiograms for individuals with possible cardiac disease is getting bad press. Is there something new that has been developed that is being used more commonly? Curious.

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RE: Ask the Doc - March 30, 2008 2:48:23 PM   
Dr.Wagner


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Well there has been question on the appropriate risk stratification for non emergent caths...do we cath the wrong patients and therefore do they go through un-necessary risk. 
In my humble opinion...no.
Of course I see the worst cases, and my patients need cathed.  But one has to wonder WHY would USA Today write an article, on their front page, virtually SCARING patients about a life saving procedure?  Of all of the things going on right now in the world, this deserves front page media attention?  Come on.


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RE: Ask the Doc - March 30, 2008 3:54:20 PM   
TexasOrtho


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I think the media has some interest in building a wall of fear and suspicion between patients and providers.  It must drive headlines.  You hear more language coming from patients and more left-leaning media outlets that their providers are either out to get them directly or at least have some interest in seeing a less than optimal outcome.  It makes no sense to me, but that's the way things are right about now.  I hope the pendulum swings the other way soon.

< Message edited by TexasOrtho -- March 30, 2008 4:27:05 PM >


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RE: Ask the Doc - April 12, 2008 3:00:10 AM   
jma

 

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I would like to know what the progression is for someone who had a baby,who now has diastasis recti. Are there guidelines to follow? Haven't read too much about it? Any precautions? Thanks in advance.

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RE: Ask the Doc - April 19, 2008 12:48:14 PM   
Dr.Wagner


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I know of no warnings with the diastasis.  I have NEVER seen a complication...but this is just reference to my own personal cases, but I have never seen any problems.


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RE: Ask the Doc - May 2, 2008 7:49:43 AM   
T_Thom

 

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Hi Dr. Wagner,
Have Medicare rules (or rule enforcement) recently changed regarding admitting a patient due to 'weakness', 'significant fall risk', or 'inability to ambulate' if they do not have an accompanying medical diagnosis? What do you do in this situation?

Thx, Taylor

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Post #: 36
RE: Ask the Doc - May 2, 2008 5:19:24 PM   
Dr.Wagner


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These patients are "labbed up"...I may use dehydration (if the numbers fit), failure to thrive, fall with severe pain, intractible pain, multiple trauma from fall,etc.  But, I am a "wall" generally and I try to keep only "sick" people in the hospital.  If there is no coexisting medical illness or trauma that resulted from a fall, I likely will not admit.


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RE: Ask the Doc - May 12, 2008 1:47:33 AM   
jma

 

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Hello. A colleague of mine would like to know if there are any concerns with a 10 yr old with a hx of rickets to have ankle pain with weightbearing but no known pathologies seen with x-rays. No observable ankle deformities but bowlegged in tibia and femur. Pt with difficulty with prolonged weightbearing. Is this an issue for the long term. Thanks in advance.

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RE: Ask the Doc - May 24, 2008 5:59:11 PM   
jma

 

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Any thoughts to my previous question?

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RE: Ask the Doc - May 26, 2008 4:15:00 PM   
Dr.Wagner


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JMA,

I would imagine your thoughts, as well as mine, would focus on the biomechanics of the issue.  Have you seen him?


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