TUESDAY — post-implant

Nancy now has a cardiovertor defibrillator monitoring her heart functions and ready to intervene should said heart develop electro-mechanical problems.  The worst of these, sudden cardiac arrest, can lead to death in minutes.<Insert big sigh of relief here.>

Nancy and I have been playing puppy-tag for the past week – meaning when Nancy would show up at the whelping box I could leave and then I would return and she could leave.  Six of the puppies would likely survive an extended period without intervention but the seventh, a small male, is not bulky enough to keep from getting shoved aside by the others.

One plan was for us to use the pick-up with the canopy and cart mother and pups along to Yakima in separate housing, then there, I could put them together for a bit, then isolate them again, and so on.  The truck is designed for heavy loads and trailer pulling and is a rough rider.  This, I thought, would shake all of the animals, and us, unnecessarily.  Also, when contemplating this maneuver I did not know what the weather would be like.  If “hot and sunny” the back of the pick-up could be like and oven.  So, while doable, this appeared to be a humungous hassle and prone to problems.

Instead of attempting the shake-&-bake approach Nancy enlisted the driving prowess of a friend, R, and I stayed home.  Nancy left home about 7 A.M.  R lives (almost) on the path Nancy would take so the extra time needed was very small.  Nancy got checked in starting at about 8:30, saw a short video on what to expect, got prepped, and began the procedure shortly after 11.  They finished in about an hour and called me shortly after Noon.

Nancy was with a nurse in a room near where the procedure was done and lunch had been ordered.  Sometime in the afternoon she would go to a room to spend the night.  Not knowing any more, that is all I can write.

SATURDAY — Sweet Clover

I (John), being raised in Pennsylvania, took a college class about the geography and history of my home State.  One region we learned of was “The Land of Milk and Honey,” also known as the Wyoming Valley in the northeastern part.  Honey implies bees and bees need blossoms, and blossoms need, what else, Sweet Clover.  [The Wyoming Valley played an important role in the Revolutionary War, including an early battle and later providing food for soldiers.]

Down through the years from the time of settlement sweet clover has been used as a cover crop (for green manure) and as a hay crop in northern U.S. and Canada.  A problem can develop because a component of sweet clover is coumarin.  It has a sweet scent, readily recognized as the scent of newly-mown hay. Some say it smells like vanilla.  In its succulent stems Sweet Clover hay can harbor fungi, some of which can transform the coumarin into an anticoagulant called dicoumarol.

Anticoagulants can be useful or deadly.  Sweet clover was widely used as hay in the early part of the 1900s when a series of wet summers, and lush clover, led to an epidemic of “bleeding disease” in cattle.  One such place this occurred was in Deer Park, Wisconsin in the northwest part of that state.   In 1933 a farmer from Deer Park showed up at the School of Agriculture and walked into a professor’s laboratory with a milk can full of blood which would not coagulate. In his truck, he had also brought a dead heifer and some spoiled clover hay. He wanted to know what had killed his cow.  When the researchers succeeded in isolating the anticoagulant the Wisconsin Alumni Research Foundation (known as WARF) became involved in seeing that the University benefited from the commercial application of the compound.  For a name they concocted Warfarin from WARF + (coum)arin. A major early use was for rodent killer. The compound Warfarin Sodium is marketed by the global biopharmaceutical company Bristol-Myers Squibb as Coumadin®.

Coumadin® (Warfarin Sodium) is used to help prevent and treat blood clots in the legs, lungs, and those clots associated with heart-valve replacement or an irregular, rapid heartbeat called atrial fibrillation.  Despite its effectiveness, treatment with Warfarin has several shortcomings. Many commonly used medications interact with Warfarin, as do some foods, and its activity has to be monitored by frequent blood testing for the international normalized ratio (INR) to ensure an adequate yet safe dose is taken.  The test is used to determine the clotting tendency of blood.

After trial-and-error adjustments over the last couple of months Nancy’s INR has just recently settled into the desired range.  Thus, it seems the appropriate dosage for her has been determined given her current diet, exercise, and whatever else is involved.

So yesterday she stopped taking it.

We are in the approach period for the implantation of a cardioconverter-defibrillator.  The clotting ability of her blood has to happen faster for the procedure to be safe, that is, excessive bleeding is to be discouraged.

We expect the implantation to be on Tuesday, June 1, mid-morning.  One night in the hospital is scheduled and she should be back home by late afternoon on Wednesday.

We’ll celebrate with a warm toasty muffin spread with Sweet Clover honey.

SUNDAY — searching

Today I’ll continue with the “life happens while you are making plans” theme.

Nancy woke up long enough to take two pills and is now sleeping again.  It is cold and windy outside and I need to feed horses and uncover my garden – that is, 4 tomato plants.  I’ve about given up growing veggies and things here but figured I could handle 4 plants.

We had below freezing temperatures Friday and Saturday nights.  The first week of the month it was so cold that all the main buds died on the walnut trees (both black and Carpathian).  The black walnut trees are about 18 years old and the others about 10 years and all were producing.  Just this week they were starting to push out new leaves from secondary buds.  As neither are native to this area and frosts are common here at 2,200 feet elevation, I have to keep this in perspective.  If they do not recover I can try something else or just photograph the naked trees and call it my contribution to folk art.

Nancy’s sore throat and sniffles are fading so won’t threaten the implantation scheduled for June 1st, a week from Tuesday. Meanwhile she has gone through several boxes and sorted out a few keepers but most of the stuff will be recycled or go to the “covered” transfer station – the place we take our garbage.  Times change.  Years ago the place where one took garbage was called a dump, was outside, and was home to rats and mice.  My father (when young) and a friend would each get a nickel and buy a box of 22 ammo for a dime, go to the dump and practice shooting.  After tiring of hitting cans and bottles and a few rats they would hold sticks out with their hands or with their teeth and try to hit what the other was holding.  About the time I got big enough to try such things they closed the dump and Father and older brothers monitored shooting activities more closely.

Two months ago, when I thought I was monitoring our dogs closely by closing our “in-season” female into a bedroom – I goofed.  She was in a different room.  When I let the male in from the yard he ran down the hall and found her and we had a mating before I had the sliding-glass door closed.  Oops!  So as fast as Nancy could clear away a stack of boxes I replaced it with a new set as I made space for whelping quarters for our expectant mother (that would be “b—h” in dog language).  Luckily the mother-to-be has gotten too wide to crawl under the bed so I have a chance to get her to accept the whelping pen (this has inside panels so she can’t crush a puppy against the inner wall) as the preferred birthing place.  She may attempt to carry them under the bed afterward (when she is thinner) but I’ve seen that trick before and will be firm in refusing her intentions.

There are lots of other things going on this week so we do not need and did not want this puppy-thing.  At least the births will happen a week before Nancy’s ICD is implanted.  That’s good.  I will have to contend with week-old puppies and their new mother while Nancy spends two days in the hospital in Yakima, 50 miles away.  I’m having a hard time finding the good in that.*  It must be there so I’ll keep searching.

————————————

*To read “The Pony in the Dung Heap” visit the link below and scroll down to the “Michele W—- on December 30, 2009 at 3:48 pm” entry.

http://goodvibeblog.com/2009/12/qa-how-to-deal-with-multiple-difficulties/

THURSDAY — Making plans . . .

It is said, by whom I have no idea, that life happens while you are making plans.  The truth is, and you can quote me on this, one has to do both.  So we went to Yakima to have a session with an assistant to the implantation doctor.

The session was designed for us to review the reasons for having and ICD implanted and to have the nature of the procedure explained to us.  As I have been searching the internet for information and showing it to Nancy, and summarizing some for this to report here, we were able to ask questions and understand the answers.  There are small pamphlets available at the Heart Center about various heart issues but we find them short of information.  From the internet we can get detailed drawings, photos, animations, and video.  Only about 18 months ago did we get a high speed connection to the Web and we could not have learned what we have without it.

So, back to life and plans.  Life first.  Nancy has developed a sore throat and head cold but these seem unrelated to anything other than being out-and-about. She continues to function doing the things she has, such as music and physical therapy and an increasing number of domestic chores.  This approaching week has been scheduled with master thesis defenses for students that Nancy has had in classes.  Now retired but as an Emeritus Professor she can (and wants to) participate in these activities.  Guess who looks on this situation disapprovingly?  The up-side is that she may throw off the sore throat and cold before she goes to the hospital.

We have managed to squeeze this potential life saving procedure into the very busy schedule on June 1st — twelve days from today.  With that date set we can back off from that 5 days and cease taking Coumadin® so that Nancy won’t bleed overly-much when the implant is done.  The dropping level of anti-coagulation will be of concern but can’t be avoided.

There is a nice vein below one’s collarbone within which leads can be threaded into the right atrium.  From there the lead will pass through the tricuspid valve into the right ventricle.  Near the bottom of that chamber where the wall-muscle is close to the left-ventricle, the plastic-coated metal lead will be stuck into the muscle (the myocardium).  This will be near pathways (bundle branches) for the movement of electrical signals along and through the ventricular walls.

The device can monitor the heart rhythm and sense and record any problems with the coordinated contractions and relaxations.  As necessary it can slow the beating if it is too fast (called tachycardia, TAK-ih-KAR-de-ah), speed it up if it is too slow (called bradycardia (bray-de-KAR-de-ah), and convert a fibrillating (quivering) pattern into a regular one.  This last situation – especially ventricular fibrillation, can stop the forward motion of blood through the body and lead to sudden death.  See the following for more info:

http://www.nhlbi.nih.gov/health/dci/Diseases/scda/scda_whatis.html

The implanted device is a sophisticated tiny computer with storage and the information it monitors is available for review.  A companion unit can be placed on a bed-side table and then at night the information about your heart will be moved to the bedside, then to a distant computer, analyzed, and searched for anything that suggests a problem.  If anything is found then you and your doctor can be alerted and in you go for a LOF.  Well not exactly but that is what the dealer said when I called about the car – Her exact statement was “So we need to schedule a LOF.”  I had to ask. It’s a lub-oil-filter procedure.  What the tune-up for an ICD is called, I have no idea.

Next entry is “planned” for Sunday morning.  Enjoy your weekend.  Enjoy life!

MONDAY — defibrillation issues

On Tuesday (May 18th) Nancy is scheduled to have an examination meeting with an assistant of the doctor who will soon outfit her with an implantable cardioverter defibrillator (ICD).  There are many pages on the web that can be found using this 3-word phrase.  However, the basic concept is that of using something to provide an electric impulse to convert an abnormal heartbeat into a normal heartbeat.  Just a few years ago there was interest in (chemical) medications to accomplish cardioversion (the conversion of one cardiac rhythm to another) but rapid development of implantable devices (following the introduction of the simple pacemaker) has driven the modern usage to be synonymous with defibrillator.  We’ll get to that in a bit.

A Canadian named John Hopps was trained as an electrical engineer (EE) and conducted research on treating hypothermia (cold core body temperature). While experimenting with radio frequency heating to restore body temperature, Hopps made an unexpected discovery: if a heart stopped beating, it could be started again by using an electric impulse.  By 1950 he had developed a rather large device that could be used (externally) as a pacemaker.  Shortly after that another EE named Wilson Greatbatch had his own eureka moment that inspired his invention of the implantable cardiac pacemaker, and following that he developed the corrosion-free lithium battery to power it.  Wilson Greatbatch is thus considered the inventor of the pacemaker.

The 60 years following these early inventions has seen rapid progress in understanding the electrical nature of the heart, electrical-electronics concepts, and miniaturization capabilities.

The heart is a 4-chambered muscle with blood from the body seeping into one chamber from which it is then forced out when the muscle contracts in response to a body-generated electrical pulse – the beginning of the heartbeat.  That impulse is developed and sent out from the sinoatrial node, often called the SA node. This is located on the inside surface of the upper-right part of the heart in the Right Atrium – the chamber into which oxygen-depleted blood from the body seeps.  When this chamber contracts blood is sent to the chamber below it – the right ventricle – by way of the tricuspid valve.  The blood in the right ventricle will go to the lungs for a fresh supply of oxygen.

Re-oxygenated in the lungs the flow from there is collected in the left atrium, also an upper chamber.  That blood will next pass into the lower chamber on the left – the left ventricle – which is the largest chamber of the heart and its contraction forces blood out into the body.  The more the wall muscle is stretched, the more forceful the contraction and the better the body’s cells receive oxygenated blood.  The mitral valve opens to allow the flow from the left atrium into the left ventricle.  It closes for the contraction so that the blood goes out into the body and not back up into the left atrium.

There is a lot to go wrong as the heart beats, pressures rise and fall, valves open and close, and blood flows.  The electrical impulse that starts in the SA node in the upper right has to move in perfect rhythm to the different parts such that each job is done in collaboration with the others.  One of Nancy’s major problems – now fixed – was the poorly performing mitral valve.  Because some of the blood was forced back into the chamber above it, the blood from the lungs seeping into the left atrium was encountering pressure that should not be there.  That blood should have been going through the aortic valve, into the aorta – the major artery supplying fresh blood to the entire body. The imbalances of pressures and the leakage caused the heart to enlarge.

Also, the left atrium contraction fills the arteries that supply the heart muscle with oxygen.  The two main arteries (lying on the outside surface) of Nancy’s heart were narrowed and this was the site of the clot that sent her to the ER on Friday following Thanksgiving.  The lack of oxygen-rich blood to this part of the muscle caused damage/death to some of the cells of the heart wall.  Thus, it doesn’t stretch and contract as it should.  Furthermore, (the following seems reasonable to me but I can’t find a web article to confirm it) the stretching and dying of the heart wall should alter the paths and timing of the electrical signals flowing down through the heart.  It seems to me that the heart is working around this damage but is more likely to loose its natural rhythm (experience arrhythmia).  When the left ventricle is experience this loss of natural rhythm it is called ventricular fibrillation (v-fib) and instead of stretching and contracting normally the muscle quivers rapidly and irregularly.

When this happens, the heart pumps little or no blood to the body. V-fib is fatal if not treated within a few minutes.  Most cases of sudden cardiac arrest (SCA) are caused by ventricular fibrillation.  What actually sets the heart into v-fib is another matter but studies show that it is more likely to happen when the efficiency of the heart as measured by the ejection fraction is below 35%.  Scroll back to the page for SUNDAY – April 25th where, in the bottom part, this is explained further.

If any part of the heart is experiencing fibrillation (and it is serious) than the solution is to convert it into a normal rhythm, and thus is born the term defibrillation.  The thing that does this is a defibrillator based on the idea of the conversion of a bad rhythm into a good rhythm.  Modern science and medical technique now can miniaturize the necessary components, doctors can implant the unit under a person’s skin with leads to the heart and should the fibrillation occur the patient is saved by the implanted cardioverter defibrillator (ICD).

Simple really.  We are off to the heart clinic on Tuesday to set the plan in motion.

SATURDAY — on the hunt, again

Garage/yard sales are the order of the day.  It is 6:30, the sun is barely up, it is cold out, and the wind is still blowing.  About that wind – for about 3 weeks the sustained velocity has been above 25 mph, often in the low 30s, and gusts up to 50.  Yesterday was the first day in three weeks I didn’t do something outside – I fed and watered the horses.  I’m sure they were thrilled with their day of rest.  Sunday morning the forecast claims the blowing will be down to 10 mph.

I tagged along with Nancy Friday afternoon to a meeting of the Trustees of Central Washington University.  First order of business was to have someone say nice things about recent retirees from across the employment categories.  They don’t give out gold watches.  Maybe the deep thinkers finally realized that someone that is retiring really doesn’t have the need for a watch, gold or otherwise, that might have been useful while they had a job.

The Trustees are empowered to vote on bestowing titles on faculty and in the current situation have voted to name Nancy as an Emeritus Professor of Geography.  She got to say a few words of thanks to and appreciation of CWU and of her joy of working with students.  I took a couple of pictures that are not too bad considering the nasty lighting, and then we (all the various honorees and tag-alongs) hightailed it out of there before the trustees and CWU administrators got back to figuring out how to run the University in a period of declining State revenue.

In addition to the new title, Nancy will be given a continuing parking decal which, truthfully, will be more useful than the gold watch they didn’t give her. In her remarks, Nancy was dignified as is appropriate for one with such a high-falutin ’ phrase in front of one’s name.  She did manage to insert a comment about her under- appreciation of “departmental politics” and that created a moment of hilarity.

MONDAY — just thinking

We are at that time of the year when the daylight hours are increasing and the weather is more conducive to being outside – sort of.  Last week three days of 45 mph wind didn’t help and now it is cool and slightly wet.  I still have 7 Ponderosa Pines to plant and lots of other things to do outside.  I mention this because during the winter (when Nancy was in critical care) there wasn’t much I could do, and so I grasped at all the information about her condition and treatment, and using the internet, tried to figure out what was happening, and then shared it with any that cared to read about it here.  There was a daily immediacy to the events and I began very unaware of all the medical possibilities and it was a steep learning curve.  So, I put lots of details in my winter reports.

There is less now on a daily basis to report and while we are very busy with all sorts of things, many are not exciting, and none are life threatening unless you count driving on narrow roads with right-angled turns every little bit (a consequence of our square survey grid). My (and our) reports now are more abbreviated but I still hope that on the medical issues I provide a good summary and appropriate links and key words that if you want to explore the issues more fully you will find it easy to do so.

I chose not to open this thing up to comments initially knowing it would be difficult for me to deal with personal issues (talking on the phone was an even more wrenching experience).  In one respect allowing comments would have made it easier for us to learn about what has been going on in the lives of others had you wished to share publicly but e-mail does work and we are learning a lot.  We thank you for updating us and we find it somewhat appalling that we have failed to keep up with all the goings on in your lives.  There have been accidents, hip replacements, surgeries, deaths, and new partners, and new grand children and many other things.  Wow!   [ nancyh@ellensburg.com ]

During last Saturday morning’s swing through the garage sale circuit John bought a pair of work shoes and an 18 inch pipe wrench.  Nancy bought a tear-dropped shaped mountain dulcimer (4 strings with C or D fretting).  You can look it up – I have no idea.

Nancy writes:

I want to put this next part in, because in this new exercise class I’m in, is a woman who had BOTH hips replaced less than a year ago.  She is doing really well in the class.  Maybe that will be encouraging to those of you with hip problems or replacements.  There are also people in the class who have knee replacements and they are up on their feet doing well.  We heard yet another family member just had one of those.  I’m still having trouble lifting my own body from a sit to stand without using my hands, but I’m told I will be better and able to do that at the end of three months.  I’m ready for that.

The program I joined is called SAIL—not as Sailing with the wind, but is an acronym for Stay Active & Independent for Life.  I joined a SAIL class, at the Adult Activity Center in Ellensburg.  It is an exercise class, developed by two women in the State of Washington.  It meets 3 days / week MWF from 1:30 to 2:30 and costs $3.00 for 3 months.  It is low impact aerobic stretching, balance, and strengthening exercises sitting or standing behind your chair, or walking around the room of chairs… to music.  We have a certified leader.  Today (Monday)  there were 21 people in attendance.  The oldest is 93 years young, and she “runs” / “walks” circles around most of us.

I’m still sorting through the clothes I bought at an estate sale.  Some low cut blouses (because of my heart surgery scar I don’t want to show) I’m giving to my neighbor.  My older bigger clothes, I’m portioning out to friends who can wear them.  I will never be in 2X again; that I know for sure.  I even had a few 3X blouses.  Now they swallow me.

One night last week we went to an orchestra presentation at the new music building where the acoustics are lovely; almost perfect from every seat in the house, and the Symphonetti from Rexburg, ID gave a great performance for about 1.5 hrs.

While I went to my normal nursing home music venue on Thursday afternoon with the Kittitas Valley Fiddlers and Friends, (I fiddle and sing), John planted trees, and cut off a matted (too bad to separate) tail of one of the new horses (Cheyenne).  I also attended a thesis defense for one of the REM graduate students who was in my class last fall.  So while I have retired, I still can find time to support some of the student activities that are meaningful to them and their families.

John reported I bought a dulcimer that I now have to learn to play.  A year ago I got  mandolin – also used much in old time music.  John says when we win the lottery and build a mansion with a great-stone room with a fireplace we can hang all the musical instruments we don’t play on the wall next to a large window looking out on the horses we don’t ride. Until that day, we plan to both play and ride.

SUNDAY — unexpected turns

We went to sleep last night expecting a freezing temperature at daybreak this morning.  We are finishing breakfast while watching deer amble around the back fence just 30 feet away and the thermometer reads 40 degrees Fahrenheit (~5C).  The sky was clear last evening and (apparently) expected to stay that way so we would have experienced rapid radiative cooling.  Instead, the flow of the jet stream shifted unexpectedly our way from over the Pacific Ocean just off Washington State’s NW corner.  That shift brought enough moisture into our atmosphere to prevent the cooling we were told to expect.  Either that or there is one huge forest fire sending a pall of smoke and warmth our way and covering the sky.  Without further investigation it is hard to tell.

Nancy’s recovery is continuing but there too is an unexpected turn.  I suppose it is unexpected for us but not for the cardiologists involved in her case.  (Metaphor alert!)  They, having been years at this, are not surprised by much and have gone down all the various paths, even those less traveled.  At our recent appointment, the receiving (or check-in) nurse was a heart patient and the doctor too.  His pulmonary valve had been replaced by the same surgeon that replaced Nancy’s mitral valve.  About 8 years after the replacement that tissue valve began to fail and he then had an artificial valve implanted.  The parts in our truck don’t last that long but, still, when you fix something you like to think it will stay fixed.

With hearts there are many things to measure besides beats per minute and the one at the top of the list today is called the ejection fraction.

Below is a link that gives a clear explanation:

http://www.medhelp.org/posts/Heart-Disease/EJECTION-FRACTION-/show/869616

“Ejection fraction (EF) is a measurement of how well the heart is pumping.  It represents a percentage of the total blood volume in the left ventricle that is pumped (ejected) with each beat of the heart.  As with any pump not all of the liquid is pumped out with each cycle.  Normal EF is in the 50-60% range.  Values higher than this are termed “hyperdynamic”, meaning that the heart is forcefully contracting.  The lower the EF the worse the heart function.  A general breakdown of values is as follows: 40-50 % mild dysfunction; 25 – 39% moderate dysfunction; < 25% severe dysfunction.”

The most recent test of Nancy’s heart (done when she went to the ER a few weeks ago – and under the stress of excess fluid) showed and ejection fraction of about 25% — note this is about half the normal as defined by the above statement.

Nancy’s heart also exhibits atrial fibrillation. The Mayo Clinic staff have a description of “a-fib” on the web:

http://www.mayoclinic.com/health/atrial-fibrillation/ds00291

As I read that I think of the most recent truck repair – replacing all the wiring components that keep the spark plugs firing well and in proper sequence.  I knew this work need doing and so, just before we went to pick up the new horses, into the mechanic we went.  I hate breakdowns at any time, but with 3 horses that are new to us and on an interstate highway such an episode is to be avoided.

Well, the human body functions with electrical impulses also and those that are directing Nancy’s heart are a little bit in need of help.  The help comes in the form of a modern “pace maker” and is called an implantable cardiovertor defibrillator or ICD.  The link here is helpful:

http://www.nhlbi.nih.gov/health/dci/Diseases/icd/icd_whatis.html

The very last paragraph of the above page mentions a special procedure called cardiac resynchronization therapy (CRT) involving a device able to pace both ventricles at the same time.  Nancy’s primary cardiologist suggested we discuss this route with the implanting specialist.  His opinion, at the moment, is that this is a less traveled road and one she need not take.

SUNDAY — Many faithful readers

Well, okay, one actually: It’s only been since last Wednesday we (John) wrote, but had a request today from one of you in Blog land, that it was time for an update.

Things have continued going well with Physical Therapy and with getting out to go places.  Nancy went today to an award ceremony (for a prior student) at CWU, and John went on a field trip to Umptanum Falls and to patterned ground up on top of Manastash Ridge just a few miles south of EBRG.  John has continued every afternoon,  until today, to do “ground” work with the horses in the round pen.

We hit a few more yard sales and got me more clothes for the thinner body.  Nice to get them at these prices and not at store prices.  Goodwill is a good source too, but about 4 times as expensive.  I am still excited about the shoe-style boots we found in Yakima Goodwill for John, and the work boots I found for him at a yard sale, for $3.  The strangest coincidence happen with this purchase.  An hour after I returned home with the boots we went out again to watch a young friend play baseball, and behold, there sitting on the end of the bleacher was the previous owner – there to watch his grandson.

We do have to go to a doctor this Wednesday to talk about a possible implant of a device to control my atrial fibrillation but then the next appointment – a follow-up with the cardiologist isn’t for nine weeks.  I’m not sure I wish to go back in the hospital again any time soon, especially with my complications with Heparin, the blood thinner.

Nancy

WEDNESDAY — taking stock

Nancy and I went to Yakima today for a visit with the cardiologist.  He reviewed her history and records from the time she entered Yakima Regional Hospital with an on-going heart attack on the Friday morning after Thanksgiving.  This was interesting – his view – but it was not new material.  He reviewed all the medications and recent tests and suggested some adjustments and a substitution.  He also made a referral to another doctor in the practice, this one is an implantable device specialist.

One med problem is that the desired action of Coumadin (Warfarin) as an anticoagulant isn’t being maintained with the 2.5 unit dose and creeps up with the 5 unit dose.  Thus, until there is a 3 unit dose we are back to taking the larger dose about every third day.

He is recommending stopping the Lisinopril and substituting Telmisartan at its lowest dose.  These meds are to help maintain blood pressure in an appropriate range and one advantage of the new med is that it lasts longer in the body than the other.  Deciphering all the other differences of these types of drugs will involve more reading than I want to do tonight, so no more about them now.

The referral to the implantable device specialist is to get an opinion on whether or not one of the modern gadgets would work for Nancy in controlling heart functions.  There may be benefits with some implanted device but there is also the problem of her reaction to heparin such that any procedure would be more problematic.  That appointment (about 2 weeks off) has yet to be scheduled, so again, there is not much more to be said tonight.