Teachings for coumadin

You KNOW that I have issues w people being reliable. PTSD tied into people not doing what they say they will. But who cares right? Because that's only me, not you, right? Cancel twice in a row with no apologies? Of course! Who cares, right?
You have been mean to me in the past about me supposedly calling too much and thus I stopped calling completely. But you called me on Weds to make plans. Every. Wednesday. That's just how it went. Seriously? You NEVER noticed that?
You make friendship a game and change the rules to whenever it suites you. You make it "me vs you" then set it up so it's "Damned if I do; damned if I don't." (e.g. You're upset when I call. You are upset when I don't.) I can't "win." Do you honestly not see how this is totally irrational? And it's only the most recent example. You are too old to only think about yourself. Good luck finding another green early 20s female to put up with the selfishness and gaslighting like your wife and I both did back in the day. And my eye is better. Thanks for asking.
And thank you for worsening my PTSD by NEVER listening to me, NEVER allowing me to talk, NEVER being there when you knew all I needed at times was literally a hug but you didn't give a fuck (or just not being there at all like tonight and last week), minimising my illness by saying "well why don't I make up an illness and then I'd have an excuse too," literally leaving my bed to GO HOME the ONE time I needed to talk about my sexual abuse after being sexual. Thanks for the bruises that you "don't care, they are only bruises." (Yet on YOU, a small bruise from taking Coumadin is of course the end of the world.)
NO NORMAL AND MENTALLY HEALTHY MALE has the impulse to "teach [a girl] a lesson" or "scare the shit out of [her]" by physical violence for anything. Even less are so paranoid to confuse someone slamming a door with someone trying to push them down the stairs! Maybe our friendship was really over when you said that you could see me accusing you of rape. That cut me deep. Either you still don't "know me" at all and/or still see every "outsider" as a threat. But how much can a person as self-involved as you really have room in their brain to "know" anyone? Maybe it was before that when you said "I don't like the way you are holding your knife [while you cut and eat your chicken], I feel very threatened." Paranoia, lack of empathy, plus rage issues is a very dangerous personality combination. I should probably consider myself lucky to have cut you out of my life before there was more physical harm. I am. And I do.
Control issues- WORK ON THEM. No normal human gets UPSET w someone merely texting to vent re PTSD issues- that had nothing to do with YOU at the time- unless they have major rage and control issues. I knew you were asleep. I knew it wouldn't wake you. I just needed someone to "listen." SorryNotSorry my pain in written form was "too long" for you.
This may shock you but most NORMAL people would've shown love and kindness (how weak of them right?) And no one calls the cop on another person while they are crying literally because they rolled their eyes at them! That is some crazy fucked up control issue shit right there. It's up there with not "letting" me eat a cookie which is now only my second all time favourite story about you to my eye rolling.
Can you really not see that you are escalating? Like a psychopath who starts out hurting animals and works up, you have gone from yelling (which you now have graduated to screaming "I'M NOT YELLING" when you do), to throwing, to physically grabbing, shoving and shaking.
The cops thing wasn't about my eye rolling, it was about control. You had been jonesing to call the cops ever since I said I would call them if you ever touched me again. I would've hoped that empowering big-boy call that you made at least served to get some of that anger out of your system. Instead, you and the cops only sent a drunk, sobbing girl on a long drive.
Given what I've endured/witnessed with your lack of empathy, OF COURSE you gave your wife headaches! Any normal human can see that. And OF COURSE you will never admit this to yourself because you are incapable of taking responsibility for the downfall of any of your friendships and relationships. Advice: Change your phone number. She is never going to call. She has grown up. You fucked up. Accept it. Learn from it. Stop repeating it.
There is a universal reason why EVERY woman you have dated gets married immediately after breaking up with you. You make every other guy in the world look Prince Fucking Charming. Maybe your life does serve a purpose after all…
So glad for me that I gave you back "your box" and there is nothing left to remind me.
So glad for the world that you are sterile.
PS- This is genuinely a very tough thing for me because I did value our friendship.

Hey there,
I'm writing this as my third year has ended and I'm staring into my dedicated period to study for Step2 and Step 1. I decided to take Step 1 after clinical year since I was not confident in my ability to score high enough for it to be in my favor and I was given the option since the exam became pass/fail. I wanted to give myself the opportunity to apply my pre-clinical knowledge in third year to make it make sense.
The kind of student I am: I would say I was always an average student and met expectations but worked really hard to do that. I have always been concerned for ADHD but I was able study for hours in college and did really well (magna cum laude at a top 50 ranked US private universities). Did not do a masters program, and got in on my first application to medical school. I never failed any of the quarters I had in medical school, but did pass two NBME exams by the skin of my teeth. In addition to lectures (that was my mistake for making it a main resource when lectures should've been supplementary), what I learned from for my pre-clinical years: I used USMLE-RX and Amboss with the question books from Robbins and Pre-test, and learned from the main three video resources most med students used; I didn't use anki because I didn't set it up properly and that set me back so much because it was so helpful in clinical year once I finally correctly set it up with the help of another med student (if you are in pre-clinicals, please PLEASE use Anki even if it takes you 3 hours to set it up on a weekend). I never finished a q bank (it should've been my goal but I didn't know) until I got to clinical year with Uworld for Step 2. I'm mentioning this mostly because most of the time I come on to Reddit, most of the upvoted highlighted posts are about high scoring, highly accomplished students and I'm hoping those who struggled like me would feel seen and get some guidance from this post.
Why I decided to pay for a course: My clinical NBME exam grades were not as great as I wanted them to be and I felt like I was still not getting it: how to study efficiently, how to make the material connect, how to answer questions with confidence and to not change my answers when my gut told me I was right the first time. I blame part of it on having to learn remotely during the pandemic and not taking care of myself, but I also think that time management was important because I wasted time on using resources that were not helpful (re-watching school lectures is NOT the way, nor is reading textbooks that go into deep detail about pathology; watch the shortened videos from outside resources and do anki instead). I reached out to my dean and he said that the only students who took courses failed or had taken a year off, but it wasn't reassuring enough because I didn't want to have to fail to figure out I needed a course, and I want to do well on both. I decided to pay for the W0lfP@cc study program since I tried to do self study and could not get a regular schedule going during my first attempt when trying to study for step 1 and so I decided since this is my only chance to do well on both, I invested in a program thinking it would give me structure. A friend of mine used W0lfp@cc and said that it saved her from failing Step 1 and while I'm not worried about failing, I want to make sure I do well enough on both to be competitive to get in somewhere. I read that W0lfp@cc integrates physiology really well which worked for me since I have to review it all for both exams.
My plan: I gave myself 8 weeks to study for step 2 first, and four weeks to study for step 1 immediately after. As of now, I took a practice Step 1 NBME and failed it by two points for the new score (passed if it was based on the old score) but I want to do more assessments. I hope to not push step 1 back but being flexible makes things seem less catastrophic, but I'm not banking on it.
Right now, I'm really annoyed at the cost of the course for W0lfp@cc and I've seen few reviews about it online so I'm not sure if they found a way to make it less searchable, but just incase, I changed the spelling so anyone who wants a true opinion of the course can find it here. I don't know if I'll love the lectures since I'm worried I'll be reviewing things I already know, but if I knew it well then I wouldn't have to make this decision. What I hope to gain from this is the tutoring help and a good means of reviewing the material based on what I have missing from my knowledge, while reinforcing the foundational knowledge I should've had by now. I will update once my course is complete and after I get my scores, good or bad, at least it's honest.
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Update week 1:
It's been one week with the Wolfpacc program and I feel like I got everything I needed from the first week. The lectures are a great review for both exams but the tutoring is awful. The tutors don't really give the impression that they know the material the instructors cover which is ridiculous since we know the schedule. The tips they give made a huge difference for me and gave me more confident that I knew more than I thought. So far, I don't know if I would've paid for this based on the first week but up to you to know whether you should take a course for step. It definitely helps with discipline, but pricey. I took an NBME CCSS and failed by a few points to show my baseline for the program.
Update week 2:
The tutoring got better after getting paired with a good instructor. One of the frustrating things about Wolfpacc is that they refuse to give out the recorded lectures to students who cannot make it to the sessions. I think this is his way of making sure students focus while they're in the lectures and don't treat it like an optional thing to get the most out of the lectures and to force people to prioritize their dedicated 12 hour study days. But internet connectivity has been a problem for many. Being in person has that benefit, plus being in an isolated center where you have no obligations beside study is much more ensuring of focus. This is probably why they don't give online students that same privilege of retaking the course if they fail their step exam. Nonetheless, when I try to consider what I would've been doing if I had the discipline to stick to my own schedule and learn this material on my own, I probably don't know how I would've synthesized it well enough to cover the high yield material. Maybe by using CaseFiles as my outline? But then how would I have incorporated my Step 1 foundation for the clinical aspects of learning? Sharing these questions incase someone has an answer to this. The drawings and the mental stories and mnemonics help: as I'm doing Uworld questions, the recall of that is there, and what they do that is particularly great is that they try to group things from everywhere together so you can see the commonalities (ie. in our ped lecture we'll talk about trisomy 21 and the feature of atlantoaxial instability and be reminded that it's found in rheumatoid arthritis and connect it to management of the airway for both for anesthesia). But the methods they suggested for us to do (blocking the answer choices, making a differential before answering, etc.) has helped tremendously and gave me much more confidence to trust myself a little more. What's left is to build on the stamina.
Update week 4:
Still not feeling like this was worth it. The instructor, as helpful as he could be, refused to refer to other students by their chosen pronouns and blatantly said he "doesn't play that game". I feel bad for the student who paid a man $4000 to be disrespected. I took my second assessment and dropped substantially. This may have slowed me down instead of helping me advance. I did pick up a couple of great physiology concepts but I definitely would've gained more from a physiology based q bank if one existed that was better than USMLE RX. I really wish I had a solid group of peers in medical school who would've done questions with me daily instead as accountability and as a means of learning. What I'm learning from the tutors I don't think I would've missed from a sturdy upperclassman or even a resident that tutored in their free time. Some of the material they teach is outdated (ie using Coumadin as first line treatment for PE).
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Final Update: I don't think it was worth it. The best advice I got was to guess my answers before looking at the choices, which other medical students advised me to do anyway. As my dean suggested to me, only use it if you've failed multiple sections of foundations or if you failed a previous step exam. I feel like it was helpful for discipline as they how ran their schedule.

Ok this is going to be complicated, I apologize. Trying to write clearly, but my mind is a mess. My mom is 80 yo, has sort sort of dementia, and things have gone to bleep recently.
1st, mom's main doctor is the VIP of his large department. He's being moved into mostly admin of residents (no med school here, our MT town is basically a satellite for a west coast med school), but he's been one of the main teaching doctors for years, and he is keeping only a small group of "lucky" patients. She & he go to the same church, are very friendly socially, and are nearly the same age. We live in a small city, my mom grew up dirt poor, & she has an unusual congenital physical disability. In her youth, doctors were the only local VIPs who treated her well, so her current relationship with Doc is very precious to her. Unfortunately, Doc is likely being moved because he's struggling to keep up. He has been extremely resistant to info from me, despite years of growing concerns. He is very protective of mom's autonomy, which I do appreciate, but now things are out of control (will explain further on). She admits she has been lying to him. I am not allowed in appointments & mom increasingly blames me for everything. My dad has more advanced dementia, but his MD is a med-magician & has calmed dad and enabled him to relax and enjoy his days, without becoming a zombie.
Today we are seeing another MD for mom, but he is a student working directly with Doc. I won't be able to address my concerns about the Doc in front of mom, she is terrified of being kicked out of the practice (not going to happen, but she's far too stressed to push it right now).
So, now the actual story - on Monday she came home from MD (I had planned to drive, got home 5 mins late, she & Dad had driven themselves - Doc says she's fine, but I have ridden with her - she is not). She had a cut on her head & a black eye. Someone shoved her in the elevator, I am trying to get an investigation, but CYA behavior is in full force (I did get very insistent with hospital but they were not willing to even review security footage, and there's no time for lawsuits right now). She refused to go back to MD, but I was able to get her in to ER on Tues, per doctor office instructions, for several scans & neuro tests. She's on coumadin & has to be evaluated for these injuries. I should have insisted Mon. She saw her podiatrist Mon, who knew she had fallen, and cleaned up cut, but ignored her file & history. She fibbed at first about the injury, and passed it off as just a fall due to her mobility issues. She has been mentally stuck in 1947-1960 lately (not thinking it is 1950, but only interested in those years), her childhood, and she knew back then that if she got hurt or bullied, the solution was always to make her go away.
On Wednesday & Thursday, she engaged in a series of phone calls that sounded normal but were actually a nightmare. I overheard one reminder call for an Rx, then she said she had to call the doctor back, they wanted to switch up meds. Long story short, she proceeded to cancel medications, harass pharmacy staff, incl places she does not go, and left confusing messages for Doc's RN staff. On Wed I was able to talk to the RN. I have worked in non-profits where we work with MDs and RNs a lot, RN def was concerned & her voice was very tight regarding Doc not being concerned. Mom is always kooky but this is not that. I was able to get the med she needed before the pharma returned it to stock, thank goodness. Spent an hour convincing her I was not lying. Booked appt with Student MD for Fri. Thursday I cancelled everything I could (I work part time), but left for 90 mins. Same thing happened. Found out pharmacy harassment & shenaniganss been going on 2 weeks. Def getting both their med lists reviewed today as well.
Switching to the other hospital isn't an option. They kept trying to force DNRs for non-long term issues (for my mom and my brother, an adult with Down Syndrome), so we do not go there. We are all about planning intentionally for end of life, but no, influenza & sudden blood pressure issues are not DNR situations, we are not trying to kill our family members, thank you Catholic hospital (this institution has a bad track record with this, they try to do the same to 20-something drug addicts and other 'undesireables,' but everyone I have heard from has been able to stand up to them, thankfully).
Anyway, I do not think we are just looking at the injury, and her brain scan was 👍. It seems to me that she got stuck in a compulsion loop regarding the pharmacy a few weeks ago, I am guessing the stress & multiple med visits this week kicked it up; it's absolutely like compulsive behavior I have observed in clinical settings. I know that the practice doesn't like to overmedicate, but I am at my wit's end. Is there a better way to tell this to help him see the big picture for her? I am open to getting home health assistance, and I will quit my job (absolute dream job, but requires me to be gone 8 hrs on Saturday and I cannot leave) if needed. I do not qualify for FMLA by hours or by institution (too small for me to have rights). However, I don't want to quit if I can avoid it and I do not think letting mom hassle the very busy (and extremely kind) pharmacy is good.
The nurse seems frustrated, the pharmacies were frustrated enough to express that they cannot believe her doctor is still giving her the go-ahead to drive & make independent decisions, but the doctor himself has not indicated any sense of urgency here. He's the one who has dragged this out with piecemeal appointments & instructions all week.
I know I need to be calm & sweet, but I am slipping into a mental health crisis of my own over this. Any advice or ideas or new ways to communicate would be appreciated. Sorry to blather on.

Hey guys, given the good response from the last case I posted, I wanted to keep this going. Again, this is a case not so much about the diagnosis (which is interesting), but the process of caring for this patient. This case will not have a good outcome like the last, but there are always important teaching points and learning points for myself with every case, good or bad.
A little background information about me. I'm a US emergency medicine attending who works in a community/academic setting. This case is at a 45 bed 70,000 annual visit ER in a hospital that is part of a large system of hospitals in the city I live in. This hospital and ER is very well staffed, we have 12 nurses, 3 techs, an RT, there are 2 other attending ER docs on with me at the time and 1 medical student who is doing their EM rotation with me. My shift ends at 4am.
So it is 0100, I am 3 hours away from the end of another uneventful shift. I only have three other active patients, all non-emergencies. As I am sitting at my computer, a nurse runs up to me and tells me they don't have a lot of information, but they are going to need my help in bed 7 immediately.
I walk into the room as they are wheeling in a minimally responsive 30 something yo Hispanic male who is pale and breathing 45x a minute. His LLS score is positive. The report I got from the nurse that found him was that he was dropped off by some "friends" who didn't know his name or any of his medical problems. They said something about there being a lot of blood and then took off.
The patient is confused, agitated, intermittently responsive, but unable to answer any questions. His shirt is already off, there is a small amount of dried blood on his abdomen, and some more on his jeans.
Outside of obtaining vitals, what is the first couple assessments you should be making in this patient?
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There are a couple answers for this, but the best answer is the ABC's of resuscitation, or airway, breathing, circulation, and importantly, exposing the patient. All we know is that the patient was dropped off, he is pale, looks like shit and likely on the verge of death, and there was reportedly "a lot of blood", so we should be considering trauma. His airway was patent as he intermittently screamed, he was severely tachypneic but breath sounds are normal and symmetrical, and he has faint pulses in all extremities w/ an absence of cap refill. We then cut his jeans and underwear off and quickly looked for any wounds including looking at his back and perineum. There was no evidence of any trauma to his body. Of note, his upper abdomen did appear to be distended.
His initial VS were HR 111, BP 70/33, RR 45, O2 sat 99% on RA, T 35.6C.
What are you thinking as the likely diagnosis? What are the initial tests you want to order? And how are you going to immediately treat this patient?
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So I knew the diagnosis, immediately, but still wanted to cast a broad net in case I was wrong. I ordered a CBC, BMP, Liver profile, VBG, Type and cross for 8 units, lactic acid, coags, CXR, blood cultures. I also had our charge nurse run down to obtain 4 units of emergency release blood. The nurses caring for the patient immediately placed 2 18g IVs in bilateral arms. The blood that returned from the IV was like nothing I had ever seen before. It had the appearance and consistency of watered down red cool-aid.
I had a nurse call the charge to tell her we are changing the emergency release order to a massive transfusion protocol. I also asked that we not bother with the blood cultures, as this individual was going to need every single RBC possible. I had my medical student do a quick FAST exam to make sure we were not missing a spontaneous splenic rupture. His FAST exam was negative for obvious intra-abdominal free fluid. There was a large amount of fluid in the patients stomach. This patient was clearly having a massive upper GI bleed.
So ignoring the severity of this case how do we typically medically manage undifferentiated acute upper GI bleeds in the ER?
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So there will be variance in practice, especially for the undifferentiated upper GI bleed; however, the most common therapies are proton pump inhibitors, octreotide (a somatostatin analogue), antibiotics for spontaneous bacterial peritonitis (SBP) prophylaxis, and pRBC transfusion using a transfusion threshold of hgb <7 g/dL.
PPIs have no mortality benefit, but potentially reduce incidence of re-bleeding and need for surgical intervention in the management of bleeding peptic ulcers.¹ Given the lack of mortality benefit, PPIs are not a priority treatment in my practice, especially given that in the studies of the meta-analysis cited, PPIs were given after endoscopy. When they actually did study the timing of PPI administration (before vs after endoscopy), they found no difference in patient oriented outcomes.² It is also sufficient to give high dose PPIs (my typical dosing is 80mg of pantoprazole), rather than a bolus and drip during initial management, which in a case such as this is meaningful, as a drip means wasting a line on a drug that has no mortality benefit. I strongly suspected this was a esophageal or gastric variceal bleed, so I did not bother with a PPI.
Octreotide also has no mortality benefit, with its main benefit being a reduction of 0.7 units of pRBCs per patient it is used on.³ The proposed mechanism for its effect is vasoconstriction of the splanchnic circulation so it should be reserved for patients where there is a high clinical suspicion for a variceal bleed. Typical dosing is IV bolus and drip (50mcg bolus, 25-50mcg/hr drip). Again, given the lack of mortality benefit, and in this case, taking up a line, this was certainly not a priority treatment in the massive upper GI bleed patient.
Antibiotics for SBP ppx is one of the few therapies in upper GI bleeds (specifically cirrhotics with variceal bleeds), where there actually is a mortality benefit.⁴ A third generation cephalosporin like ceftriaxone is sufficient, typical dosing being 1-2g IV. I make sure to give all suspected cirrhotics (hx of significant alcohol intake, liver pathology, etc.) with an upper GI bleed a dose of antibiotics as this is definitely a priority therapy, although in this case, not as important as blood products.
Transfusion thresholds of <7 g/dL for GI bleeds for the most part come from a single trial, the 2013 Villanueva trial. Here we found that a restrictive strategy for transfusion (7g/dL threshold) reduced incidence of mortality, bleeding, and adverse events compared to the liberal strategy for transfusion (9g/dL threshold). There was a few very important caveats to this study. The first is that every single patient in this trial received at minimum 1u of pRBCs. Per the trial's protocol, all patients received a unit of pRBCs prior to obtaining a hemoglobin level, and then received additional pRBCs if below their respective designated thresholds. The other caveat was that patients were excluded if they had a massive hemorrhage which was not defined and left up to the treating physicians.⁵ This last caveat is important to remember, as a patient that is dying in front of you might have a Hgb of 8, but the liter of blood they just vomited might also have a hgb of 8, so recognize when you should deviate from protocol. This patient was obviously someone that would have been excluded from the trial.
NOW BACK TO THE CASE: VBG comes back with a pH 6.9, pCO2 20, HCO3 5, Lactic acid 45, and hgb was unable to be obtained. At this point I needed to make the decision of whether I should intubate or not. Intubating him would risk killing him due to any prolonged apnea time leading to near immediate death and being completely unable to match his minute ventilation on the vent and adding increased intrathoracic pressure leading to diminished venous return which would exacerbate his hemorrhagic shock. Not intubating him would mean gambling on whether he will vomit or not because if he vomits the contents of his stomach, there is a high probability he aspirates and dies, it also means I would be unable to place a cordis to assist in rapid transfusion due to how agitated he was. I chose to resuscitate him first rather than intubate.
Another treatment I considered was tranexamic acid (TXA); however, the HALT-IT trial demonstrated a lack of benefit to TXA in GI bleed patients,⁶ and I didn't want to take up another line for an ineffective treatment.
To assist with transfusion efforts, I placed bilateral IO lines in bilateral proximal humerus. While we were transfusing him, I got a call from lab that they could not run a CBC on him. Having experienced this before with low hemoglobin levels, I told them to report the results, as the sample was not diluted, it was legitimate. They stated they believed me, but the issue was that there was literally not enough RBCs to run a CBC. At this point I put out several calls to get some help with this patient including to our intensivist and on-call GI. The intensivist immediately came down to help with resuscitation so that I could discharge my other 3 patients so I could focus entirely on this one patient. Luckily I had 2 other ER docs on shift to help pick up the patients that continued to check in. It would have been a mess had I been by myself.
Unfortunately, I realized who was on call for GI that night, and as usual with this one particular GI attending, he was of little assistance, stating "well, if he is alive in the morning, I'll check on him, but it sounds like he needs to be resuscitated." Of course, in his defense, this patient was sick AF, and to my understanding, current GI recommendations are to scope these patients within 13 hrs of presentation for high risk upper GI bleeds, and a recent NEJM trial demonstrated no mortality or transfusion difference in patients randomized to urgent vs early endoscopy (although this patient would have been excluded from the trial for being too unstable and would have received emergency endoscopy).⁷ And unfortunately our IR docs will not perform TIPS unless GI has first performed an endoscopy first.
I then get a call from blood bank that we are running out of emergency release blood (they only have 2u pRBCs left, as they used 20 units 2 nights before on another massive GI bleed), and they are unable to type the patient's blood due to not enough RBCs being present. At this point, the patient has received 4u pRBCs: 4u Plts: 4u FFP. I told them that we need to call around to get blood then because this guy still needed significantly more blood. I was then informed the patient's INR was >10 (important to note that INR levels are worthless for transfusion thresholds for FFP outside of coumadin use, and should not be used to guide therapy). This patient was receiving FFP not for their INR, but for balanced transfusion.
The patient was now regaining a slight amount of color, his BP had improved to 90/50. This was now about two hours in, I decided that this was probably the appropriate time to take control of the patient's airway. I started the patient on peripheral levophed for the intubation, and drew up a syringe of epinephrine and diluted it to use as a push dose pressor. I made sure that we went straight from pre-oxygenation, to intubation rather than bagging due to the obvious risk of insufflating the stomach in someone with a massive amount of blood in it. The patient was intubated with the head of the bed at 45 degrees to reduce the risk of aspiration. I had our intensivist give a dose of the push dose pressor while I was placing the endotracheal tube. The intubation went successfully, thankfully.
The next concern was what to set the vent settings at. This was a patient that had extremely high minute ventilation prior intubation and still had a 6.9 pH, so we needed to try to match it as best we could. This is one of the few settings where I throw lung protective settings out the window and aim for higher tidal volumes. So I started this 5'3" gentleman on 550mL tidal volume at a RR of 35 and advised the RT to repeat a gas in 30 minutes. Meanwhile, the intensivist placed a cordis so that we could expedite transfusion and placed an A-line. Nurses also placed an NG tube which put out 1.5L of blood.
We did draw slightly more blood for a repeat type and screen and CBC. His CBC came back this time with a hgb of 2.0 g/dL (the patient had 4.5 units pRBCs by this point). The patient was then whisked up to the ICU.
I spoke with the intensivist the next day. He ended up placing a Blakemore tube in the ICU as the patient deteriorated which was unsuccessful (I have very poor experiences with Blakemore tubes and find them to be largely useless, but that is a personal opinion). The blood bank ended up using the last of their emergency release blood on the patient, and prior to them obtaining more from surrounding hospitals, the patient coded and was pronounced approximately 10 hrs after he had arrived in the ER. They could not type and cross the patient due to almost all of his circulating RBCs being from donors.
This was a very unfortunate case and there were certainly several less than ideal circumstances in this case that potentially could have lead to a better outcome in this patient, but in my experience, circumstances are almost never ideal.

1. Leontiadis GI, McIntyre L, Sharma VK, Howden CW. Proton pump inhibitor treatment for acute peptic ulcer bleeding. Cochrane Database Syst Rev. 2004;(3):CD002094. doi: 10.1002/14651858.CD002094.pub2. Update in: Cochrane Database Syst Rev. 2006;(1):CD002094. https://pubmed.ncbi.nlm.nih.gov/15266462/
   
2. Sreedharan A, Martin J, Leontiadis GI, Dorward S, Howden CW, Forman D, Moayyedi P. Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding. Cochrane Database Syst Rev. 2010 Jul 7;2010(7):CD005415. doi: 10.1002/14651858.CD005415.pub3. https://pubmed.ncbi.nlm.nih.gov/20614440/
   
3. Gøtzsche PC, Hróbjartsson A. Somatostatin analogues for acute bleeding oesophageal varices. Cochrane Database Syst Rev. 2008 Jul 16;2008(3):CD000193. doi: 10.1002/14651858.CD000193.pub3. https://pubmed.ncbi.nlm.nih.gov/18677774/
   
4. Chavez-Tapia NC, Barrientos-Gutierrez T, Tellez-Avila F, Soares-Weiser K, Mendez-Sanchez N, Gluud C, Uribe M. Meta-analysis: antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding - an updated Cochrane review. Aliment Pharmacol Ther. 2011 Sep;34(5):509-18. doi: 10.1111/j.1365-2036.2011.04746.x. Epub 2011 Jun 27. https://pubmed.ncbi.nlm.nih.gov/21707680/
   
5. Villanueva C, Colomo A, Bosch A, Concepción M, Hernandez-Gea V, Aracil C, Graupera I, Poca M, Alvarez-Urturi C, Gordillo J, Guarner-Argente C, Santaló M, Muñiz E, Guarner C. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013 Jan 3;368(1):11-21. doi: 10.1056/NEJMoa1211801. Erratum in: N Engl J Med. 2013 Jun 13;368(24):2341. https://pubmed.ncbi.nlm.nih.gov/23281973/
   
6. HALT-IT Trial Collaborators. Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. Lancet. 2020 Jun 20;395(10241):1927-1936. doi: 10.1016/S0140-6736(20)30848-5. https://pubmed.ncbi.nlm.nih.gov/32563378/
   
7. Lau JYW, Yu Y, Tang RSY, Chan HCH, Yip HC, Chan SM, Luk SWY, Wong SH, Lau LHS, Lui RN, Chan TT, Mak JWY, Chan FKL, Sung JJY. Timing of Endoscopy for Acute Upper Gastrointestinal Bleeding. N Engl J Med. 2020 Apr 2;382(14):1299-1308. doi: 10.1056/NEJMoa1912484. https://pubmed.ncbi.nlm.nih.gov/32242355/
   

TLDR: A confused 30 something yo M gets dropped off. We have no information on him. Clinical exam demonstrates a likely massive upper GI bleed. MTP was activated. His hgb is too low to count by lab. GI refused to come in overnight. Blood bank ran out of emergency release blood. The patient died.

Dear Reddit,
A few months ago, I started a new ICU rotation at a community hospital. I love the ED, but ICU medicine will always have a special place in my heart.
My first patient of that month was named Mina.
Mina was in her 60s. The day before I met her, she slipped in the shower at home, hitting her head on the edge of the tub.
Coumadin and showers, friends.
She came to the ED talking. She left the CT scanner confused. She arrived to my ICU with the blood pooling in her right lateral ventricle.
Good morning, Mina. I press as hard as I can on her left thumbnail.
Nothing.
I watch her gasp. “Guppy breathing,” as we call it.
She’s mostly protecting her airway, so I grab a coffee and scan her chart. The ED note lists that her family was updated before she came up to the ICU, a husband named John.
I pick up the phone and call the listed number.
“Hello?”
I say good morning and feel my soul twinge when the first thing he asks is about visitors.
I try to guide the conversation to code status. An irregular breathing pattern precedes very, very regular breathing most of the time in medicine.
He immediately directs me to a new number. “Please call Emily. She’s a doctor and training and she should make these decisions.”
I call Emily.
Emily tells me that she’s a resident at a nearby hospital. Or will be, starting July 1st. A new intern.
I can’t explain it that first day, but for some reason, this hurts.
I walk her through the CT scan over video chat. I list out labs and teach her how to arrange them the way every medicine service ever has. I walk her through AKIs, urine electrolytes, hypernatremia. Instead of translating a creatinine of 4.0 in to “her kidneys are injured,” Emily has me teach her how to make that translation on her own.
I realize on day two: I’m slowly teaching a co-resident over the phone how to see their mother die.
A couple times her voice catches mid-call. We pause when this happens, I try to not think of how this could be any of us, and when she says “okay,” I launch in to details about her mother’s acid-base balance.
Over the next few days, Mina gets worse. Her broken brain can’t regulate her temperature, so the fevers of 105F make her tachycardiac and tachypneic. She stops moaning to pain and just lies there. The hypertension becomes harder and harder to control. “Guppy breathing.” Emily might be learning medicine, but she knew her mom.
Do not intubate my mom, please. She wouldn’t want that.
I pour through literature on brains. I argue during rounds for the “it’s not proven, but it theoretically could help.” I get more frequent labs to help normalize her sodium.
My updates to Emily start becoming less about medicine. “Today your mom listened to jazz while I re-wired her a line.”
After about six days in the ICU, I run out of things to do for Mina.
I call Emily.
Emily says a halted thank you and hangs up.
Mina died at home a few days later. Emily came in to the hospital to see her at the request of the inpatient palliative care team, and brought her home that evening so that she would die surrounded by family.
On July 1st, Emily will wake up and start taking care of patients. She will call, and translate, and help guide conversations about what a sodium of 160 means.
May I never forget that we all have things to make us tired.
Cheers, to an intern.
-a tired resident

I really enjoyed seeing this complete thrashing.
I was reading a post on Physicians for Patient Protection, which talked about how an NP was urging her fellow NPs to stop making online posts and social media posts, asking low level basic questions in regards to their respective specialties, because it makes them look bad, and reduces the value of them urging for independent practice. Instead of addressing the core issue of having better training, she mentions this garbage. An NP (probably) made a comment saying, “well, doctors ask questions online too”, and then she got dealt with. Fun read.

Leah Hughes
FIrst - the defense of "well others do it too" is a very very weak defense. It seems you are defending the practice.
Second - I have seen both physician and NP sites and the type of questions. THERE IS NO COMPARISON. Physicians, by and large know their area and don't need to ask questions. When they do, they consult other physicians. On my subspecialty message board there are occasionally case of interest posted - sometimes they are very sticky questions, sometimes just classic cases. NEVER have I seen or heard a physician asking very very basic questions like I see on the NP sites. You may not see these. Let me acquaint you:
"Does anyone recommend good study or teaching for learning how to diagnose and treat common primary health issues in the adult population" i.e. How do you do all of medicine? And you went to school? What was in your courses?
What's your recommendation on a diabetic pt not newly dx but A1C of 9.4 and BMP of glucose of 262 who is on levimire 20U at bedtime and novolog 10U in AM." This sort of question was on our medical school tests. We would never get close to treating a patient unless we could answer this.
Has anyone seen a patient with elevated WBC and that's it?" This is a situation Internists and FM docs will see frequently. THEY know what to do. She is baffled. Poor patient. Someone suggested a CT scan. Really.
”I am looking to transition some patients off coumadin to Eliquis/xarelto is there a transition process for this or can I simply switch from one to another." VERY basic stuff. And she is actually treating patients.
I have others, of course.
On our specialty board, there is almost no discussion of how to make diagnoses, what to do. Why not? because we have done that all day, every day for 5 years before we ever get into practice. I rarely see something I am not familiar with, and when I do, I have my deep resources -NOT FACEBOOK to consult.
But there is a recent helpful post - A link to a video presentation on frequently missed injuries of the superior peroneal retinaculum. Posted by the guy who researched and wrote it.
Another was a question on who was doing fractional flow reserve on CT scans and what vendors were supporting it. Note - there was no question of how to do it. The people knew, and they knew how to read it and what it meant. They want in the field information about how each CT vendor is implementing it in their software.
So you can't say - "well docs ask questions too", and dodge these obvious problems- NPs asking incessant questions about the simplest things they should have learned before ever seeing a patient on their own. Even if you do not see the problem, your leaders and other NPs concede that they know there is a problem. Their approach is not "ensure better education", They want to HIDE it.
That is an indefensible position.

I will admit, I’m not an MD, at least not yet, but man, Yall are way too badass.
Link

********Give away is done*******
​
First person to answer this question correctly and i'll send you the link for the gift code
​
Warfarin sodium has been prescribed, and the nurse teaches the client about the medication. Which statement by the client indicates that further teaching is necessary?

• “I won’t play football anymore.”
• ******“I won’t take any over-the-counter medications except aspirin.”******
• “I’ll use an electric shaver until the doctor stops the Coumadin prescription.”
• “I’ll buy one of those medication alert tags that tells people I’m taking an anticoagulant.”

Rationale: No over-the-counter medications of any kind should be ingested by a client taking an anticoagulant. This is especially true of aspirin and aspirin-containing products (because of the potential for bleeding). The other options are correct statements. Strenuous games (e.g., contact sports) that may result in bruising and skin breakdown should be avoided. Electric shavers are less irritating to the skin than razors and less likely to cause skin breakdown. Medication alert tags are recommended in case of emergency. The client should also be taught to carry an identification card listing all medications currently being taken.

Scheduled for Wednesday, August 9th, 8 pm - 9 pm EDT
Register Here

Subject

Are you an adult congenital heart disease (ACHD) patient who takes warfarin (Coumadin) as a blood thinner? Do you know about the new blood thinners that are widely used in acquired cardiovascular disease? Have you ever wondered if these can be used in ACHD patients? If so, you don't want to miss this webinar. Dr. Karen Stout, ACHD Medical Director at the University of Washington and Seattle Children's Hospital will tell you what these new medications are and whether they can be used in adults with congenital heart disease.

About the Speaker

Karen Stout
Karen Stout, MD, teaches in the outpatient clinics at Seattle Children’s Hospital and is assistant professor at the University of Washington School of Medicine. She is director of the Adult Congenital Heart Disease program at the university, and she teaches inpatient and outpatient echocardiography. Dr. Stout earned her MD at the University of Arizona, Tucson.
She completed her internal medicine residency at Oregon Health Sciences University. She completed her cardiology fellowship followed by an advanced congenital heart disease fellowship at Seattle Children’s Hospital and University of Washington Medical Center. Her clinical interests include adolescent and adult congenital heart disease. Her research focuses on adolescent and adult congenital heart disease, as well as pregnancy and heart disease.

This is going to be very long. I've tried to remember everything that happened and write as many details as possible, but I'm sure there's things I missed.
I was sent to a specialty hospital on August 26th for testing ~2 hours away from my home. They established that my baby was IUGR and had an intermittent absent flow from baby back to the placenta. They sent me to a children's hospital closer to my home for further testing, ~30 minutes from where I live. I ended up being admitted for the weekend and had to miss my baby shower which was to be August 27th. By Monday morning I was told that they would be keeping me in the hospital until the baby would be born and we were going to take things a week at a time and try to get me to 37 weeks at best (I was 31 weeks).
From here I'll break things down by day.
Wednesday August 31, 2016 - First thing in the morning my high risk doctor took me for an ultrasound to see what was happening with baby. Baby turned back head down (baby was breech the evening before), so that was good and everything looked the same as it had been; the placenta still had that intermittent absent flow and no growth for baby. But, baby was fine and the heartbeat was perfection. I thought that meant good news and that I'd get to keep cooking baby for another week or two at least. Then my Doctor said the sentence I wasn’t ready to hear. He wanted to get labor started asap because he would rather deliver my baby while healthy and not risk letting baby get sick. He told me to call my husband and have him leave work just in case things progressed quickly.
I called my husband and told him the news. We agreed he shouldn’t leave work right then, as it was only 8am, but that he would leave at lunch time. I took a photo of myself on my hospital bed with my baby bump showing, not realizing that would be the last baby bump photo I would get to take during my pregnancy. It's now one of my favorite photos. In the early afternoon my Doctor got the ball rolling on getting me ready for labor. I was given Cervidil to try to make my body dilate. Hours later they checked to see how dilated I was and it was just about 1cm. The medicine was working, albeit slowly. They took the medicine out so I could eat, shower, and be normal for a bit. My husband and I cuddled on a chair together, with him holding my belly, before they came back to give me another round of Cervidil. From there we went to sleep and waited.
Thursday September 1, 2016 - At 7am my Doctors checked to see if the Cervidil worked but I was still only 1cm dilated. So they started me on Pitocin to try and get labor going while hoping it would help me dilate. I never wanted to be the person who needed Pitocin but at 31 weeks pregnant, it's not like I had choices. The Pitocin was definitely working as I was feeling contractions. By 10:30am my contractions were ~2 minutes apart, but my body wasn’t dilating beyond 2-3cm. I made it to about 12:30pm without any pain medication but the contractions were getting too intense so I caved and asked for an epidural. I’d like to think I could have gone longer if my body had been naturally going into labor and not forced via Pitocin. I was never against getting an epidural but I wish I could've held off a while longer. The epidural itself was not nearly as painful as I was anticipating, but I was practically vibrating off of the bed in fear. I jumped a tiny bit when the needle went in my back but other than that it was just an uncomfortable feeling as they put the medicine and catheter in. The pain relief was wonderful and I felt less stressed out, but it was awful being confined to the bed.
Around 2:30pm my Doctors ordered for me to be on another magnesium drip for about an hour. That’s when things got really bad. I made it half way through the bag and then I started vomiting. I hadn’t eaten, so nothing was coming up but it was near constant retching. Thankfully my MIL was there because I honestly needed a mom around. She kept getting cold rags for me to put on my head and just "mothering" over me. I never wanted anyone with us while I was laboring, but I was glad she was there considering the circumstances. And I stayed sick like that well into the night. When the Residents checked to see if I made any progress as far as dilating, I was still 2-3cm. They turned the Pitocin down to a slow drip for the night so I could try to sleep. Which, I didn’t get much sleep because the vomiting kept coming in waves but I did eventually rest.
Friday September 2, 2016 - The day Phoebe was born! I was woken up early and they started slowly increasing the Pitocin every half an hour. After the little I sleep I’d gotten I was hoping I wouldn’t be sick anymore but my body had other plans. And unfortunately, my body wasn’t responding to the forced labor. I was definitely still having contractions, but I was not progressing as far as dilation. I kept vomiting, shaking, and by noon I caved and agreed to a cesarean. My body had been tortured enough; for just over 30 hours I tried my hardest for the "natural labor" that I wanted but it just wasn’t going to happen for me. Not at 31 weeks+6 days pregnant when my body wasn't ready. After I agreed to the cesarean I figured I would have a little time to cope with my decision, but I was wrong! They came in at 1:15pm and told me I would be going into surgery at 1:45pm. Everything started happening very quickly.
It was just my husband and my MIL there with me. My MIL braided my hair in pigtails while I skyped with my parents to tell them I was going into surgery. I never wanted my mom there more than in that moment. I'm grateful I was at least able to see them for the few moments I could. I wish my parents could have been there so badly. I could tell they were nervous for me and I was trying my best not to cry and just reassure them that I would call once I was out of surgery. Meanwhile, my husband called his dad to let him know that the baby would be there today and that we'd update him as soon as we could.
I was shaking uncontrollably again as they were prepping me for surgery. I was honestly terrified that I would be shaking so hard that when they cut into me I'd mess everything up because I couldn't be still. I'm so thankful it wasn't an emergency situation so I didn't have to be under anesthesia and my husband was able to be in the room with me. Having him with me made all of the difference. I was glad to have him to talk to during the cesarean, although we couldn't find much to talk about. I think we were both just waiting in anticipation of finding out what our baby was! I couldn't feel much but I could feel a little bit of tugging as they were pulling the baby out. It was the most awkward feeling I have ever felt but it didn't hurt. The moment I heard them say "It's a girl" I lost it and then I heard her cry and lost it some more. Phoebe Reese (Last Name) was born on September 2nd, 2016 @ 2:31pm. I was 31 weeks + 6 days. She weighed 2 pounds 9 ounces and was 16 inches long. I started sobbing and was looking around trying to see her. They brought her over to a table to my left side and my husband walked over to see her and take pictures of her first moments. It felt like an eternity before they held her up so I could see her, and when they did I just barely got a glimpse. A few moments later they had her bundled up and she was well enough that they brought her over to me and laid her by my side. My husband passed the camera off to one of the Nurses in the room so we could have a moment with our baby girl. She was the most perfect and beautiful little bundle I'd ever seen. My husband and I agreed after seeing her that her name would be Phoebe Reese (Last name). We were able to touch her sweet little face and I even got to give her kisses before they had to take her off to the NICU. My husband followed along with her and I was left to wait while they closed me up. That was the worst. It felt like hours were passing while they worked on me. Without my husband there I really didn't have anyone to talk to as a distraction. Some of the Nurses did make small talk with me but I can't remember anything that was said. And because the hospital is a teaching hospital I listened to my Doctor instruct and discuss with the Residents what they were doing, as they were doing it to me. That was unnerving.
Finally, I was wheeled out of the OR and into recovery. My husband was there waiting for me. He told me all the little details about Phoebe. He showed me the pictures he took of her on the camera and I did my best not to cry while I waited to be moved again, so I could hopefully go see her.
I asked the Nurses when we could see Phoebe and they told me I had to rest for a while because of the surgery, but that they'd let me see her soon. Soon wasn't until about 1:30am and we were both falling asleep, but the second the Nurse came in and asked if I wanted to see her I got myself up. I only managed to see Phoebe for about 45 minutes but it was the most precious 45 minutes I'd had yet. Phoebe was in her little incubator attached to all these wires and tubes, with tape all over her face, and settled in a nest of blankets. I couldn't hold her just then as I was in a wheelchair and barely functioning, but at the very least I touched her. We took some pictures and just looked at her tiny hands, tiny feet, tiny everything. It was hard when I had to go back to my room to sleep because I didn't want to leave her but I was so exhausted.
Saturday September 3, 2016 - This is the day where everything went to hell. I woke up feeling okay, showered, ate, and was preparing for visitors. The worst of it was my stomach hurt from the incision and my legs were the size of tree trunks from all of the liquid IV stuff they'd been pumping into me during my labor.
My husband and I went to see Phoebe a few times and that's when we found something was wrong with me. My MIL noticed I was short of breath when I took her to the NICU to meet Phoebe and so did one of the NICU Nurses. I brushed it off as just having had a c-section and being nervous that I was going to see my baby and possibly hold her. Then while I was skyping with my mom while in the NICU my mom told me I didn't look right. So I agreed I'd tell my Nurse when I went back to my room.
After talking to my Nurse I was set up to have an x-ray and an CT scan. One of the Doctors came in to deliver the news about my test results. I was told I had two PE's. My brain wasn't catching up and I was just blank for a moment. Then she explained that those are pulmonary embolisms and I knew that meant blood clots. I started hyperventilating and crying the hardest I'd ever cried in my life. I immediately started thinking I was going to die. The Doctor told me they were going to do an ultrasound on my legs to check for more blood clots or to see where the clots came from and that they would be moving me out of the maternity ward, away from my baby, and to another floor of the hospital where they could properly monitor my condition. I skyped with my mom and was trying to hold it together but I'd never been so scared in my life. My mom has had a blood clot before so I knew she would understand. I can't remember if my mom started crying too, I think she did, but she was trying to tell me to calm down and that it would be alright.
It was late when we were moved to the new room across the hospital and I was immediately started on an IV of Heparin. Then around 1am they took me to do an ultrasound on my legs. When we were taken back to my room my hsuband pulled the reclining chair up next to the bed and held my hand. I was still crying on and off, afraid I'd die at any moment. I knew what pulmonary embolisms were but I didn't realize how they worked exactly. So I didn't know that the blood clots had already passed through my heart to settle in my lungs. If I was going to die, it would have happened (well, it could have still happened because the clots could have damaged my heart and could still have damaged my lungs). But I didn't know that and I was just too busy panicking.
During those first few hours after finding out about the blood clots and all the emotions running through me is when I realized just how much I love my husband. I always knew I loved him since we were kids, but it hit me then that I was terrified of not growing old with him and him living without me. And when I looked over and saw his eyes bloodshot and could see him trying to hold it together I knew he was just as scared. I remember telling him that I loved him and that I was scared. I told him that it figures this would happen because I've been too lucky. How many people can say they've spent 13 years with the person they love since they were kids? And that we got to have a beautiful baby girl together. I felt like the universe had been too kind to me and that's why all of this was happening. Eventually my husband fell asleep and he never took his hand off of me the entire night. Unfortunately, sleep did not come easy for me because I was scared I would die in my sleep. That something else would go wrong.
Sunday September 4, 2016 - I finally got the results of the ultrasound on my legs and they didn't find anything, so that was good news!
A Hematologist came to see me. She told me that it wasn't my body that naturally produced the blood clots, it happened because of the bed rest for several days and then having major surgery. Likely the blood clots formed in my pelvis. She told me that I could come off of the IV of Heparin and just be on Lovenox, blood thinner shots to the stomach 2x a day. She mentioned another medication (I forget the name of it) and we were trying to decide which would be safest for me and the baby. She said if I could take the Lovenox and have my husband inject the shot then I could be moved back to the Maternity section on the hospital and be near Phoebe; that became my goal. Being free from the Heparin IV meant I could go to the NICU and see Phoebe. I had to wait to get permission from all my Doctors to go see her because I was no longer right down the hall from the NICU. Finally I got permission and was given a wheelchair to go in. My husband pushed me across the entire hospital (literally, I was moved to basically the furthest section of the hospital, ugh). This was the first time we were actually able to hold Phoebe. I had to wait 2 freaking days to hold my baby girl and it nearly killed me. When we returned to my room I had to pump and it was also the first time my body actually produced a little milk!
When it came time for me to get blood thinners for the evening there was a whole issue because the Hematologist changed the medication I was supposed to be getting to something else and we had a whole argument thing (well not me, my MIL argued for me while I was in the NICU). Finally I got the Lovenox shot for the first time and holy shit, it was the worst thing I'd ever experienced as far as shots go. I cried so hard because it burned so badly.
Monday September 5, 2016 - I don't remember much from this day. I know I woke up with my boobs leaking milk though and that I was super excited about it! Haha!
The Hematologist said that I could transition from Lovenox to Coumadin but it would take a few days for my levels to be therapeutic. She wanted to make we aware though that if I were to switch to Coumadin it requires weekly blood work and a strict diet of very little vitamin K. My mom took Coumadin years ago, so I was familiar with how it worked, and agreed that it would be something I could handle.
I finally got to have my first skin to skin time with Phoebe. I wanted that so badly after labor but with my having a caesarean, it just wasn't an option I was ever offered. It wasn't true skin to skin as I had a nursing bra on and a hospital gown pulled down around my neck, but it was the closest we'd gotten yet.
Tuesday September 6, 2016 - First thing in the morning my high risk OBGYN Doctor comes to see me and he did not come with good news. He basically told me that if I ever get pregnant ever again that I will have to take Lovenox shots in my stomach 2x a day throughout my pregnancy. And that if I ever have major surgery or get in an accident or anything, I'll have to make the doctors aware that I have a history of blood clots and I'd likely be put back on blood thinners. He told me that I absolutely could not breastfeed if I was going to take Coumadin and the Resident that was with him agreed. They left the room and I sobbed.
Then the Hematologist came to see me again and she told me that what my OBGYN Doctor said is not true, that I could be on Coumadin and breastfeed. She also said I may not have to go on blood thinners during my next pregnancy, that I could probably take baby aspirin and be fine. I had no idea what to think because I was getting two completely different opinions from both of them. Thankfully one of the Nurses I had was super attentive to me and wanted to help me get things figured out. She called the Maternity section and had someone notified that I needed to get my baby's birth certificate paperwork done and that I needed to speak to a Lactation Consultant regarding medication and breastfeeding.
The Lactation Consultant came and went over Lovenox and Coumadin with me. According to the book she had, Coumadin is actually regarded as safer during breastfeeding than Lovenox, and that confirmed my decision to switch. Had it said the Lovenox was safer I would have suffered through the shots every day for the sake of Phoebe. But being that the Coumadin is a pill and easier on me emotionally/physically than the agony of those shots, I decided it would be best for Phoebe and myself.
Thursday September 8, 2016 - Possibly the second most frustrating day in the hospital since finding out about my pulmonary embolisms. I had to stay another night because the hospital Social Workers and doctors were trying to find out if my insurance would cover a Nurse to come to my home and draw blood for me daily, so that I wouldn’t have to drive to the hospital. Apparently, the Nurse wouldn’t be sent out unless they’re administering the Lovenox and teaching someone how to do it. Which my husband already knew how to give me the shot. But the way they were describing it, it sounded like the Nurse wouldn’t draw my blood at home anyways… so I was confused as to why we were even discussing this if the entire reason for a Nurse coming to my home wasn’t going to happen.
The Nurse and the Social Worker were very pushy and kept suggesting that I just stay on the Lovenox because it’s “easier” (no dietary restrictions, no daily/weekly blood work) whereas Coumadin has those things. They were acting like my aversion to having 2 shots a days in my stomach wasn’t a good enough reason to not take the Lovenox. And here I am being concerned with which medication is better while breastfeeding, the fact that Coumadin is a pill and not an awful shot 2x a day, and that Coumadin can be reversed with vitamin K if I were to start bleeding too heavily – while Lovenox cannot be reversed. Yeah, Coumadin might be a bigger hassle but it sounds safer to me and considering I may be taking this shit for 3 months to a year… I’d like to not be stuck with needles and have a medicine that can be reversed.
Well, the Social Worker was royally pissing me off and I said that if this couldn’t be resolved that I’d rather deal with the damn blood clot than all this medicine. I was being sarcastic and angry, which she damn well knew because she was provoking me. The next thing to come out of her mouth almost made me slap her. She said to me "what if your daughter has a condition where she needs shots and has to go to the hospital, would you refuse to give her medicine or take her to the hospital just because you don't like those things?" I swear, it took everything I had not to punch the bitch. How fucking out of line can you get!? I told her that I would always do what's in the best interest of my baby and that everything I'd been doing was all for her. Well she didn't seem satisfied and then she suggests that I talk to a Psychiatrist because post-partum depression is more likely for me because of all I'd been through and how I was responding to her questions.
Next thing I know there are two young student-looking people in my room who work under the hospital Psychiatrist and they're asking me questions. They leave, I shower, and then the Psychiatrist shows up with the students. I basically get asked the same questions again (during the middle of all of this my MIL shows up) and the Psychiatrist, who practically loved to hear himself talk, ends the discussion saying that he thinks I'm just fine. That if I was to seek out counseling or medication because I believe I need it, that's okay to do. I tell him I'm just fine without more medicine to take and that I'm certainly not as incapable of handling myself as the Social Worker seemed to think.
I spent the majority of my day after that hellish morning in the NICU with Phoebe. Finally in the late afternoon I was given my discharge paperwork and set free! I'd never been so happy to leave a hospital before. The only downside of leaving meant being a 30 minute drive from Phoebe and not a walk down the hall, but I couldn't stay there any long for the sake of my sanity.
Being home for the first night without Phoebe nearby was hard. If it weren't for exhaustion I don't think I would have slept. We watched her on the live-stream camera setup by her bed so that helped a little. That camera is the best thing ever.
Friday September 16, 2016 - I woke up Friday morning feeling pretty crappy, but I had to go get blood work done and I wanted to see Phoebe because she turned 2 weeks old! (Her gestational age being only 33 weeks + 6 days). I'm glad I pushed myself to go because I finally had the opportunity to try and breastfeed with her! Phoebe naturally went to breast and knew what to do, which is amazing considering everything. Though, because she is so little she really couldn't get much milk out, I had to massage some out by hand for her, but she at least got the idea of how it's supposed to work. After feeding she fell asleep on my chest and it was the most wonderful feeling in the world.
I'm so sorry that was so long. If anyone read it, I applaud you. If you're just here for cute baby photos that's cool too! I just wanted to share my experience figuring maybe it could help someone else in the future. All in all I'm doing okay. Recovery from the c-section has been rough and being on blood thinners has done me no favors there. Phoebe is worth everything I've been through and she's really a little fighter. She has a few minor complications because she's a preemie, like anemia that might require a blood transfusion, and she has hypothyroidism that we're hoping she grows out of but otherwise she's gaining weight and doing well. We're hoping she can come home by the middle of October.
Baby Tax!

Hi! Just found this sub and thought I'd introduce myself!
I got my first DVT in the first trimester of my pregnancy about six years ago. I did over 1000 heparin injections (3x daily for almost a year) before I was switched to Coumadin. I hemorrhaged in childbirth and gave back the full blood transfer they had given me in anticipation of that possibility. I became superthereputic multiple times and spent weeks in the maternity ward just laying there wait for my protime to drop. I had a full battery of tests done and was told I had no genetic factors and that pregnancy can trigger DVTs. I'm very fit and teach and practice yoga regularly. I never took hormonal birth control or smoked. I had zero risk factors. My doctor said that I just "got lucky."
Baby was born healthy and adorable! Six month later they took me off the Coumadin. Three months after that, I got a new DVT. Back on the injections and pills. This time they start looking for cancer. I cried as I held my small baby thinking that I might not be around much longer.
Nine more months of tests and treatment and they give me a clean bill of health. Cancer seemed unlikely and I was taken off of Coumadin.
Over a year passed and I thought my DVT troubles were behind me. Nope. New DVT in the other leg. This time they decide I'll be on anticoagulants for life. So, here we are, more than a year and a half since the third one and I'm still on rat poison.
I am certain I have post thrombosis syndrome (or whatever it's called). My legs swell, hurt and look so gross. I've used NormaTec boots to reduce the edema and they help a lot.
One question: did anybody else get sick from the Lovenox? I've been prescribed twice and both times I ended up feeling like I had had a chemo treatment: Indescribable fatigue, nausea, brain fog to the point of being unable to even function...
We'd love another baby, but we are scared of the rollercoaster. We'll see...