Eliquis and my new Cardiologist.

My new Cardiologist is out of Shreveport, Louisiana. He works closely with a circuit of Cardiologists and EP’s. He has looked at all my work from Austin etc. He is determined there is no reason I could not stop low dose of Eliquis for even 5 days for surgery, treatment etc. from a missing A Wave. He says You are not in AFIB and there is a very minimal to Zero possibility that a clot could form from this.

I am confused. I do not feel It was explained to me why I have to “bridge” with just a missing A Wave and I am in NSR and have been since June 2016. He says bridging is bad overkill and I am only on a Maintenance dose as is 2.5 mg 2x a day.

I admit this is not Austin but it is a reputable Hospital in a city of 400000 where many Ablations are done and are successful. It just stressful when one needs to be off a blood thinner for surgery etc. but many disagree how dangerous it is to possibly throw a clot when not in AFIB.

He also stated it would take many days before a clot would form if in AFIB due to how little blood actually pools. He is not against me being on 2.5 Mg of Eliquis but stated as I do know if I was in AFIB, The dosage would change to 5 mg 2x a day.
My Chads score is one because of High Blood Pressure.



Edited 1 time(s). Last edit at 06/17/2020 05:54PM by smackman.

Has your LAA been ablated?



Edited 1 time(s). Last edit at 06/17/2020 09:16PM by rocketritch.

I would only follow the advice from Austin.

What rocket and George said.

A missing A wave suggests your LAA was isolated. Is that the case? If so, you should follow Austin's advice religiously. LAA isolation is a subject not well understood by most cardiologists because it's a fairly new aspect of ablations, so take your cardiologist's advice with a big grain of salt. The fact that the hospital and the doctor are reputable doesn't mean much. Strokes have occurred in people with an isolated LAA and low flow velocity after missing just one or two doses.

Yes, My LAA has been isolated but my ejection fracture is 55-60%. I do not have low flow.

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smackman
Yes, My LAA has been isolated but my ejection fracture is 55-60%. I do not have low flow.

Yes you do. Ejection fraction (EF) is a completely different measure than the missing A wave you describe. The A wave measures blood flow in and out of your atrium, not your heart in general, which is what EF measures, so the two aren't really related. Since you have an isolated LAA and a missing A wave, you should absolutely, positively never miss a dose of Eliquis for any reason without a bridging protocol substituting. Your local cardiologist is simply uninformed on this point, which isn't surprising, unfortunately. Listen to Austin no matter what your local cardio says.

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smackman
but my ejection fraction is 55-60%.

Specifically, the EF measures the amount of blood ejected from the ventricles on each beat. As Carey says, it has nothing to do with the atria or the LAA.

I have always listened to Austin. There comes a time when individuals have to be off blood thinners. What about a colonoscopy? No one will do a colonoscopy without being off blood thinners. It’s a 15 min. Procedure but being off blood thinner is a requirement. Do you bridge for this? Also, I desperately need some pain relief in my back. I need “injections“ close to spine. It also is a 15 min. Procedure but being off blood thinner is mandatory. Bridge for this?

Understand, I do not want to have a stroke but I am miserable from back pain. It’s a damn if you do, damn if you don’t situation. Right or wrong no one will go for the bridging procedure for Pain shots, RF Ablations of Facet nerves etc. I am just tired of hurting so damn bad knowing these shots would help tremendously.

Yes, bridge for any procedure that requires you to stop Eliquis. You could make this easier by calling Natale's office and asking for a copy of the protocol so you can just hand it to local doctors and tell them you refuse to do the procedure unless they follow it.

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Carey
Yes, bridge for any procedure that requires you to stop Eliquis. You could make this easier by calling Natale's office and asking for a copy of the protocol so you can just hand it to local doctors and tell them you refuse to do the procedure unless they follow it.

Wonder if they could provide copies of or citations to research that explains the "why" this needs to be done. Might help get past resistance.

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GeorgeN

Wonder if they could provide copies of or citations to research that explains the "why" this needs to be done. Might help get past resistance.

susan.d just posted the research: [www.tctmd.com]

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Carey
Yes, bridge for any procedure that requires you to stop Eliquis. You could make this easier by calling Natale's office and asking for a copy of the protocol so you can just hand it to local doctors and tell them you refuse to do the procedure unless they follow it.

If you REFUSE, It’s no sweat off there Heads. What George said might help but no Doctor wants his patient to tell him what or how to do it much less threaten them. We do not have Doctors on every corner in Rural America.
Not that simple Carey. I have already pissed off one Cardiologist 2 years ago by asking him to read my TEE results from Austin or call Austin. Remember there is a rural America.
They pipe in sunshine where I live. It ya choice but it’s Reality for many.

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Daisy


Wonder if they could provide copies of or citations to research that explains the "why" this needs to be done. Might help get past resistance.

susan.d just posted the research: [www.tctmd.com]

No, looking for actual studies, not articles about them.

I'm guessing Smackman isn't the first person to run into this problem. In my opinion, Austin should have a packet that includes the bridging procedure as well as studies/data that make the case as to why it is necessary. This should be provided in a form that a doc can immediately see that it makes sense to do the bridging as well as what to do. That is, make it easy for them.



Edited 1 time(s). Last edit at 06/18/2020 05:43PM by GeorgeN.

Smackman, I spent a big chunk of my life living in rural America, so I'm familiar with the realities. But you seem to be saying there's no solution other than just going along with the guy and taking a monumental risk with your life. There is hard evidence that what he wants you to do is extremely dangerous. You might try printing out the research and showing it to him.

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Carey
Smackman, I spent a big chunk of my life living in rural America, so I'm familiar with the realities. But you seem to be saying there's no solution other than just going along with the guy and taking a monumental risk with your life. There is hard evidence that what he wants you to do is extremely dangerous. You might try printing out the research and showing it to him.

Solutions are slim. I will not risk my life unless it was a freaking emergency situation. I know this is hard to grasp but nobody around here has ever heard of Dr. Natale. I will take care of myself. I do not do Stupid.

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GeorgeN



Wonder if they could provide copies of or citations to research that explains the "why" this needs to be done. Might help get past resistance.

susan.d just posted the research: [www.tctmd.com]

No, looking for actual studies, not articles about them.

I'm guessing Smackman isn't the first person to run into this problem. In my opinion, Austin should have a packet that includes the bridging procedure as well as studies/data that make the case as to why it is necessary. This should be provided in a form that a doc can immediately see that it makes sense to do the bridging as well as what to do. That is, make it easy for them.

George: i shared the article and not an actual study only because Natale quoted 50% of the article. I tend to believe him over a random EP. Don’t you? I also read this week if you get spinal injections you risk being paralyzed. Another reason I don’t want to be on Eliquis for life. I trip a lot (broken bones) and prefer a spinal over general.
[www.eliquis.bmscustomerconnect.com] - Again, not a study but Eliquis is protecting themselves...so it must have had happen.

Hello David ... I've just been catching up with reading on the forum... and after reading your responses here to this thread, I'm really sorry you have this worry hanging over your head..... I know you are smart and I certainly hope you find a satisfactory solution to the dilemma. I certainly don't want you to be harmed. I can't begin to imaging your frustration and I wanted to let you know.

Kind regards,
Jackie

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Jackie
Hello David ... I've just been catching up with reading on the forum... and after reading your responses here to this thread, I'm really sorry you have this worry hanging over your head..... I know you are smart and I certainly hope you find a satisfactory solution to the dilemma. I certainly don't want you to be harmed. I can't begin to imaging your frustration and I wanted to let you know.

Kind regards,
Jackie

Thanks Mrs. Jackie. I do not want to die of a stroke. I have had some blow back from some who just do not understand dealing with Rural America. It’s not a excuse; It’s a Reality Check.
I am a retired Electronic Technology Engineer. 🧐 😂 I will not jeopardize my health but to just say FIRE HIM is out of the loop. I will just get it taken care of. Someday maybe someone can explain to me why a missing A Wave is a Catastrophic Heart Issue. Never got a explanation from Austin but I do not blame the Nurse Educator or anyone. My dosage is 2.5 2x a day of Eliquis. That itself seems to tell me that maybe just maybe it is a lot of precautionary thinking on my blood thinner.
If I have a issue, I will call Austin like I always have.We will be at you did hear it’s all twisted around

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smackman
Someday maybe someone can explain to me why a missing A Wave is a Catastrophic Heart Issue.

"The study included participants post-LAAEI who underwent follow-up transesophageal echocardiography (TEE) performed in sinus rhythm at 6 months to assess LAA function (n=1854). The researchers classified participants into 2 groups based on LAA functional parameters determined at the 6-month TEE: those with preserved LAA velocity (>0.4 m/s), preserved contractility, and consistent A waves, and those with 1 or more impaired LAA functions (velocity/contractility/ consistency of A-wave). The researchers then evaluated the incidence of thromboembolic events occurring in individuals following LAAEI “on” and “off” OAC.
The researchers found that 18% (n=336) of participants had preserved LAA velocity, contractility, and consistent A waves identified on TEE at 6 months. The remaining participants (n=1518) had abnormal parameters. All participants with preserved LAA function were off OAC in the post-ablation period, while 1086 of those with abnormal LAA contractility remained on OAC.

At long-term follow-up, participants with normal LAA function were not found to have had any stroke events. A 1.7% incidence of stroke/transient ischemic attack was noted in participants with abnormal LAA contractility who remained on OAC (n=18) compared with a 16.7% incidence in those who were off OAC (n=72)."
Source

Please read the PDF of the actual paper here. Perhaps you can print or save the PDF to give to your team.

Stroke Risk in Patients With Atrial Fibrillation Undergoing Electrical Isolation of the Left Atrial Appendage
Luigi Di Biase, MD, PHD,a,b, * Sanghamitra Mohanty, MD,a, * Chintan Trivedi, MD, MPH,a Jorge Romero, MD,b Veronica Natale, MAS,c David Briceno, MD,b Varuna Gadiyaram, MD,d Linda Couts, RN,d Carola Gianni, MD, PHD,a Amin Al-Ahmad, MD,a John David Burkhardt, MD,a G. Joseph Gallinghouse, MD,a Rodney Horton, MD,a Patrick M. Hranitzky, MD,a Javier E. Sanchez, MD,a Andrea Natale, MDd,e,f

ABSTRACT
BACKGROUND Loss of contractility leading to stasis of blood flow following left atrial appendage electrical isolation (LAAEI) could lead to thrombus formation.
OBJECTIVES This study evaluated the incidence of thromboembolic events (TE) in post-LAAEI cases “on” and “off” oral anticoagulation (OAC).
METHODS A total of 1,854 consecutive post-LAAEI patients with follow-up transesophageal echocardiography (TEE) performed in sinus rhythm at 6 months to assess left atrial appendage (LAA) function were included in this analysis.
RESULTS The TEE at 6 months revealed preserved LAA velocity, contractility, and consistent A waves in 336 (18%) and abnormal parameters in the remaining 1,518 patients. In the post-ablation period, all 336 patients with preserved LAA function were off OAC. At long-term follow-up, patients with normal LAA function did not experience any stroke events. Of the 1,518 patients with abnormal LAA contractility, 1,086 remained on OAC, and the incidence of stroke/transient ischemic attack (TIA) in this population was 18 of 1,086 (1.7%), whereas the number of TE events in the off-OAC patients (n ¼ 432) was 72 (16.7%); p < 0.001. Of the 90 patients with stroke, 84 received left atrial appendage occlusion (LAAO) devices. At median 12.4 months (interquartile range: 9.8 to 15.3 months) of device implantation, 2 (2.4%) patients were on OAC because of high stroke risk or personal preference, whereas 81 patients discontinued AC after LAAO device implantation without any TE events.
CONCLUSIONS LAAEI is associated with a significant risk of stroke that can be effectively reduced by optimal uninterrupted OAC or LAAO devices. (J Am Coll Cardiol 2019;74:1019–28)

Why do you think my dosage of Eliquis was lowered from 5 to 2.5 mg 2X a day? Thanks for the reading above.

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smackman
I will not jeopardize my health but to just say FIRE HIM is out of the loop. I will just get it taken care of. Someday maybe someone can explain to me why a missing A Wave is a Catastrophic Heart Issue.

I'm sorry that comment bothers you so much, but honestly, what else can you do with a doctor who gives you totally wrong, dangerous advice? I don't understand what possible benefit there is to seeing such a doctor. You're better off with no advice rather than wrong advice. Not sure I understand why you even need a local EP. Aren't you in NSR following Natale's ablation?

As for the missing A wave, that's not catastrophic. It doesn't rise to that level at all. The A wave is a measure of how well the left atrium is contracting. A missing A wave suggests it isn't pumping well, or possibly even at all. So you've lost your "atrial kick" and without OACs you have a high risk of clots developing in your LAA. Those are the only consequences. Although my A wave isn't missing, it was diminished to the point where I was in the same boat as you. I just happened to luck out and got into a Watchman trial. But I never even noticed the loss of the atrial kick. It made no measurable difference to my athletic abilities or anything else. So definitely not catastrophic.

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Carey
Not sure I understand why you even need a local EP. Aren't you in NSR following Natale's ablation?
.

IMHO one should have an active relationship with a local EP just so the attending doctor can be current and remember your history. What if you go into AF/flutter and need to visit the ER? One of the first questions I was always asked was the name of my EP that is attending at that hospital. It makes ECV process run more smoothly. And if one needs to be admitted (I.e. TEE example), it is way way more successful and less stressful to have your attending doctor be someone who knows you than a random hospitalist who may either be a resident or someone you really don’t want to trust your health with who doesn’t know your history.

I used to have two residences and kept an attending EP at both local hospitals because of this logic. I saw each once every 2-3 years to be current. I speculate the reason I was ECV so smoothly was having a doctor who knew me and expedited the process with less stress.

Yeah, I get the reasons for having a local EP, but my point was that having one giving you bad advice is worse than not having one at all.

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Carey
. Strokes have occurred in people with an isolated LAA and low flow velocity after missing just one or two doses.

I don’t understand. If you have been in nsr for 4 years, how can a stroke occur? Is it because the act of surgery causes blood clots, which is independent of AF?

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susan.d
I don’t understand. If you have been in nsr for 4 years, how can a stroke occur? Is it because the act of surgery causes blood clots, which is independent of AF?

No, the procedure doesn't cause the clots.

If your LAA has to be electrically isolated to stop your AF, one of the consequences of that may be that your LAA no longer pumps as effectively as it once did. It's just a small pouch, but it pumps too just like the rest of your heart, so if it's not pumping effectively, blood can pool there and form clots. The LAA is the source of 90% of all AF-related strokes, so take it seriously. The insufficient pumping will happen to about 60% of the people who have their LAAs isolated. So after LAA isolation they wait 6 months, do another TEE, and measure how effectively your LAA is pumping. If it meets their criteria, you're good to go. You can stop anticoagulants if you CHADS score warrants it. But if your LAA isn't pumping sufficiently, you'll need to remain on anticoagulants for life (or get an occlusion device), and you'll need to remain vigilant about never stopping the anticoagulants for any reason, even if some doctor tells you that you have to. If you run into that situation (surgery, colonoscopy, etc), you'll need to use a bridging protocol to get you through it safely.

If you're considering an ablation procedure that might result in LAA isolation, I would strongly advise you to do all surgeries and invasive procedures you need first. Stopping your anticoagulant now for 3-5 days probably isn't a big deal, but it will be after your LAA is isolated.

This graphic from the paper is worth viewing:

Nice graphic. Could've saved myself some typing. ;-)

I’ve found that specialists often have dedicated nurses with whom they share close communication. My cardiologist, for example, works beside his wife. I often say he does the talking and she does the listening. Perhaps you could gather the information and have a talk with the nursing staff. It’s often easier to have a longer conversation that way versus the ever hectic 15 minute office visit and it may work to plant a bug in his or her ear.

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wolfpack
I’ve found that specialists often have dedicated nurses with whom they share close communication. My cardiologist, for example, works beside his wife. I often say he does the talking and she does the listening. Perhaps you could gather the information and have a talk with the nursing staff. It’s often easier to have a longer conversation that way versus the ever hectic 15 minute office visit and it may work to plant a bug in his or her ear.

Go behind the Physician Back to communicate? I would Fire any of my employees if I felt they were trying to undermine me. I doubt very seriously a nurse can persuade a seasoned Specialist.
Once again I will get this done. Also no one answered my question of Why was I put on a low dosage of Eliquis by Dr. Natale? I am 63 and definitely not skinny.

Thank you Carey for your reply and George for this excellent paper link. The article states 27% of AF originates from the LAA while 91% are successful with having their LAA isolated—those who had positive flow and went off OAC and had zero strokes compared to those who had their LAA isolated and poor flowing resulted in having 1.7% strokes while on OAC. There is still a risk while on OAC. This data is useful for one who may jump into the ablation without much thought.

What's the difference for afibbers between CHADS2 AND CHADS-VASC scoring?

I am now 75, so I get 2 points on CHADS-VASC and 1 point on CHADS2.

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Ken
What's the difference for afibbers between CHADS2 AND CHADS-VASC scoring?

I am now 75, so I get 2 points on CHADS-VASC and 1 point on CHADS2.

Ken, I hope this helps:
[clincalc.com]

Thanks Susan,

I have seen both CHADS2 AND CHADS-VASC scoring for afib. Why both? Which is most common?

CHADS-Vasc has been shown to be a better predictor of stroke risk, particularly with those who score 1 on the CHADS2 test. There's really no reason to even use CHADS2 anymore.

If you go to the link I shared above and click “calculate”, you will see your % risk.

I notice there is no score if you are over 65. I thought that counted as one point. I thought I scored 3 points- age, gender and high blood pressure. According to this link I score 2 not 3.

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susan.d
I notice there is no score if you are over 65. I thought that counted as one point. I thought I scored 3 points- age, gender and high blood pressure. According to this link I score 2 not 3.

Clicking age >= 75 gives you 2 points, but clicking age 65-74 gives you 1 point. Note that the two are mutually exclusive. You can't be 65-74 and also be >= 75. So if you click one of them, the algorithm unclicks the other one for you. Not how I would have done it, but that's how it works. I tested it and it works correctly if you answer all the questions correctly. You get a total of 3 if you're >= 75 and have hypertension, or 2 if you're < 75 and have hypertension.

And it's worth noting that under the 2019 revised guidelines, you can ignore the point for being female if your only issue is "lone" AF.

Carey does flutter count as “lone AF? What about one time history of dvt?

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susan.d
Carey does flutter count as “lone AF? What about one time history of dvt?

Flutter (AFL) is generally equated with AF and treated the same. But what makes it "lone" is the absence of other forms of heart disease; eg, heart failure, valve disease, CAD, etc. So if you have AFL and no other heart disease, that would be considered "lone" AF. DVTs can be caused by a number of things, including simply prolonged sitting or lying, so they don't really figure in. A DVT can't originate in the atria.

By the way, I put "lone" in quotes because it's no longer an accepted term. The consensus now is that AF and AFL are themselves a form of heart disease known as atrial myopathy.

Thank you Carey for educating us

Carey said:

By the way, I put "lone" in quotes because it's no longer an accepted term. The consensus now is that AF and AFL are themselves a form of heart disease known as atrial myopathy.



results in electrophysiological and anatomic remodeling of the atria.” (12)

Most of our mechanistic understanding of the atrial myopathic state comes from research conducted either in animal models of AF or from examination of tissue removed from patients with a history of AF. In 1997, Zipes (12) first used the term “atrial myopathy” to describe that AF can lead to myopathy through atrial remodeling. The past 2 decades have seen the concept of atrial myopathy evolving. Several recent studies have demonstrated that the relationship between AF and atrial myopathy is more complex. For example, atrial myopathy may exist without AF and can facilitate the development of AF (13). Anatomical or structural changes, particularly fibrosis, play a major role i

Smackman,

Please visit last entry here

I had surgery, listened to the surgeon, went off Eliquis, had a stroke before I could start taking it again.

Carey - Thanks for your statement: The consensus now is that AF and AFL are themselves a form of heart disease known as atrial myopathy.

When I was reviewing my AF onset history and the treatment of symptoms I was having prior to my first AF event, the myopathy symptom I had presented as extreme leg muscle fatigue, pain and weakness eventually was found to be the result of a severe Vitamin D deficiency determined by testing. However, prior to the Vitamin D testing, I was referred to a Rheumatologist who ordered EMG and muscle biopsy evaluations and then, prescribed various meds to mask the pain but (obviously) did nothing to address the core cause which remained unknown. I changed to a new primary care MD who tested Vit. D and I began therapeutic restoration of Vit. D levels and I also had my I had my first AF event... so the atrial myopathy would seem to confirm that connection.

I was able to reduce the frequency of the early-stage AF as the D levels began to reach therapeutic range. . I began with D levels of 18 ng/ml and when I reach 32 ng/ml, I started feeling 'human' again but I didn't actually feel healthy until the level was 50. My MD wanted my level to be at least 60-65, so I kept dosing and eventually found that I needed to take 10,000 IU Vitamin D3 in the winter months and could lower to half that in the warmer, sunny months… as I live in NE Ohio. (And along with that, eventually came the info about using the K2 MK7 to avoid the soft tissue/arterial calcifications that can occur with elevated Vit D dosing.)

Jackie

[www.ncbi.nlm.nih.gov]

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PC, MD
Smackman,

Please visit last entry here

Agree to Disagree. My facts are real not statistics. My Wives Arrhythmia’s started 11 weeks after taking 50k iu of Vitamin D a week 1X a week. She never had issues before and the Arrhythmia’s stopped approx 2 weeks after stopping the 50000 iu a week. Our Cardiologist agrees. Also our Primary Physician agrees there had to be some “there there”.

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Jake
I had surgery, listened to the surgeon, went off Eliquis, had a stroke before I could start taking it again.[/quote
Was the surgeon the EP that Ablated you? Has your LAA been isolated? I know what my Cardiologist says but my EP Dr. Natale says to Bridge. I listen to my EP’s in Austin but I do wonder why there is such a big divide on what to do. This Bridging Technique needs to be made available freely and a explanation of WHY so someone who is Ablated in Austin goes home 12 Hours away can have a little confidence in there local EP’s recommendation. What does one do in case of a emergency and a family member must make the decision for you? They will listen to the instructions of their local Hospital because there is no way they would know better. It can be a scary situation. Most Ablated in Sustin never return to Austin after the TEE and most do not know about this Great Forum.

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smackman
I listen to my EP’s in Austin but I do wonder why there is such a big divide on what to do.

Because LAA isolation is actually a relatively new approach that most surgeons, PCPs, and even most EPs have never heard of. They heard nothing about it in med school or even during their residency and fellowship, so unless they're an EP who keeps up-to-date with the leading edge ablation literature, they still haven't heard about it and don't understand the risks. That's why your local EP is so sure of himself. He fancies himself a well-trained, up-to-date EP (and he may well be), but here you are telling him you're special and he needs to use some fancy bridging procedure that doesn't fit with his understanding of AF and ablations. So he writes you off as a patient who simply didn't understand what you were told by Natale. Yes, that's arrogance. He should have gone back to his office after your visit and read up on the literature, but we know many docs don't have that level of humility.

This is a great case study in why you have to be the most educated person in the room about your medical conditions even if it does annoy your doctor.

My cardiologist admits he doesn’t know much about AF ablation at all. He won’t really listen to what I have to say, but he won’t argue with it either. Last office visit we had a conversation about how best to use expired metoprolol and propafenone as rodenticide.

Docs not being current is common. Not listening is also common. Like Carey said, you’ve got to manage the situation. And best to have a great partner or advocate to be able to do the same for you in any sort of emergency situation.

Most individuals who go to the emergency room will be appointed a Cardiologist not a EP when coming for Arrhythmia issues. In Monroe, Louisiana I believe there is one EP in the city of almost 100000. This Cardiologist visit was my 1st visit since my 2nd Ablation with Dr. Natale. That was in 2016. I had stop going to my Cardiologist in Monroe because he would take everything so personal if I just mentioned Dr. Natale. I just could not deal with him anymore. His 1st line of Defense for someone in AFIB was Amiodarone, Beta blockers and blood thinner. I would have NEVER knew how bad Amiodarone was if I had not stumbled on this website. Shannon actually took my wife and I under his wing and it was a Godsend.
No one should be put on Amiodarone as a 1st line of defense IMO. My left arm turned grayish blue and I would swell in the sun. Bad 💩.
My knew Cardiologist is out of Shreveport, Louisiana which is a city of 300000. He seems to be sharp and listens but he firmly believes different than Austin on the necessity of bridging. I will always put Austin 1st unless some emergency came up where I would not have a voice due to injury etc. At this point, You are under the protocol of that Hospital. I believe Austin should give LAA ablated individuals the proper info to have on file so the bridging technique will be used.



Edited 1 time(s). Last edit at 06/27/2020 11:51AM by smackman.

The trouble is, even having that protocol doesn't mean a doctor will be willing to follow it. I've heard from a couple of patients who had surgeons refuse to do procedures despite having the protocol sent to them directly by Austin.

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Carey
The trouble is, even having that protocol doesn't mean a doctor will be willing to follow it. I've heard from a couple of patients who had surgeons refuse to do procedures despite having the protocol sent to them directly by Austin.

BINGO! My point from the beginning. I guess my method of communication was subpar. The Question then becomes what does one do? Give in and possibly have a stroke or refuse the procedure/ surgery which could be a life threatening condition.