Coumadin, yes or no?

Cardiology EP NP · Jan 30, 2010

This is a tough one. We encounter similar patients in our practice as well who have been taken off of coumadin due to fall risk. Since this patient has a strong hx of DVTs, I really think he should be on an anticoagulant because, imho, the benefit outweighs the risk. How closely do you think you will be able to monitor his ability to get his INRs checked? I know you mentioned he is homeless. If you do put him on an anticoagulant, will he even be compliant and take it? It's always hard with the homeless population to know what to do. Can he live in a group home for awhile, particulary while he is on anticoagulant, just so he could be monitored a little more closely? There are so many issues to take into account, but because of his strong DVT hx, it's just so hard not to give him coumadin. I feel for ya, that's a hard decision.

core0 · Jan 30, 2010

I have a patient who was admitted to the hospital today for a DVT (his 2nd) in his thigh. He has all sorts of medical issues, and should be on anticoagulant therapy for the rest of his life. But here's the catch-he is at great risk for injury due to active alcoholism and homelessness, and is frequently falling and getting beat up out on the streets. He's had some pretty serious injuries over the last few years, and I'm afraid that anticoagulating him is going to leave him vulnerable to a serious or life threatening bleed. Of course, the flip side isn't great either-he's at risk for another DVT or PE if he's not on coumadin. He'll be seeing me for followup, and I'm not sure what the best course of action is. Any thoughts or advice?

Greenfield filter. Call it a day.

David Carpenter, PA-C

Trauma Columnist · Jan 30, 2010

Yep - Greenfield filter.

Cardiology EP NP · Jan 30, 2010

Yes, greenfield filter is the way to go right now, BUT I still think he should be on an anticoagulant to prevent further clots from forming just based on his hx. We might fix the problem for now, but we should think down the road too.

Editorial Team / Admin · Jan 30, 2010

Greenfield filter. Call it a day.
David Carpenter, PA-C

Yep - Greenfield filter.

Agree...

Have you consulted with your medical director/physician colleague?

allnurses Guide · Jan 30, 2010

Thanks for all of your input. We thought about the Greenfield filter, but the patient has no insurance, and would have to go into Boston for the procedure so he can get free care. That's unlikely to happen-he has no family and won't go of his own volition. I'll probably do the coumadin and hope for the best. He's unlikely to be compliant, anyway. He'll come in for his INR checks, as he likes to come to the clinic, so we'll be able to keep an eye on him. Poor guy....

kanzi monkey · Feb 1, 2010

Can you get him into the McInnis House for a while? (Boston Healthcare for the Homeless--they're across the st from BMC) It's a really nice facility and patients tend to really like it (as they keep returning, time and time again ) Patients usually stay at least a couple of weeks, and when I was doing my clinical rotations there we had a few patients starting coumadin and having INRs measured. It could at least give you and the patient a sense of whether or not a life on coumadin could work. He may also get hooked up with other services while he's there. Or he could end up wandering the streets around the Mass Ave/Albany St intersection meeting all sorts of colorful and shady people. It's a crap shoot

jlcole45 · Feb 1, 2010

He is too high risk for Coumadin, besides the fact he will not be compliant.

How many homeless alcoholics have you even known who are compliant with their meds?

NONE.

allnurses Guide · Feb 1, 2010

Can you get him into the McInnis House for a while? (Boston Healthcare for the Homeless--they're across the st from BMC) It's a really nice facility and patients tend to really like it (as they keep returning, time and time again ) Patients usually stay at least a couple of weeks, and when I was doing my clinical rotations there we had a few patients starting coumadin and having INRs measured. It could at least give you and the patient a sense of whether or not a life on coumadin could work. He may also get hooked up with other services while he's there. Or he could end up wandering the streets around the Mass Ave/Albany St intersection meeting all sorts of colorful and shady people. It's a crap shoot

I would love to get him into McInnis House, but he refuses to leave Brockton. We are affiliated with a homeless shelter that he will stay in when the weather is bad, but he prefers to be on his own. I'll try and talk to him next time I see him. Maybe something will sink in.

kanzi monkey · Feb 1, 2010

Man, it's been soooo cold out recently! It's toasty warm at BMH, 3 meals a day, clean facilities, nice non-judgemental providers to chat with every day, pool table, individual TVs....

Anyway, when you see him again, I hope it goes well. It can take a long time and a lot of effort to help some patients in bad situations, but you've got to try. Trying to anticoagulate a high risk DVT/PE homeless patient has got to be one of the biggest challenges. How potentially long-term can an IVC filter be?

allnurses Guide · Feb 2, 2010

Kanzi,

That makes perfect sense to you and me, but his reality is clouded by mental illness and substance abuse. He did come into the shelter tonight (I work there for a couple of hours on Mondays), but wouldn't talk much. He's not taking his coumadin, and didn't want to hear about going to Boston. I did re-iterate all the danger signs of PE/DVT and told him to tell someone or go to the hospital if they happen again. I'll keep trying...sometimes you have to move mountains one pebble at a time.

Thanks for your ideas and support:)!