Lovin' Ox

One of the many joys of having a hip replacement is the outside possibility that you will develop a blood clot which, depending on where it develops, can break off, travel to your lungs or heart and kill you. It is called a VTE or venous thromboembolism and usually develops in the lower leg due to "stasis" which is an extended period of decreased activity resulting in reduced blood flow. Types of conditions that contribute to this event are being bed-ridden following a traumatic event like surgery or sitting for long periods of time on planes or in automobiles without moving the lower extremities. There is a phenomenon known as "Virchow's Triad" which is the perfect storm for a VTE. Virchow's triad is characterized by venous stasis (caused by reduced activity and blood flow), vessel wall injury, and a hypercoagulable state, meaning an increased reason to clot. Generally, when the body senses that it is bleeding, it initiates a clotting cascade as a protective mechanism. When one has a vessel wall injury either due to trauma or surgery, this cascade is in full bloom. Therefore, it's better to increase movement and blood flow to prevent blood from pooling and subsequently clotting. Most of the time, small clots that form dissolve spontaneously. However, of the VTE's that develop, about 3% will travel to the pulmonary bed and cause disastrous results. When one has major surgery, there is a 40-60% possibility that a venous thromboembolism will develop if left untreated. Anything over 50% in my book means you have a better than half chance that you are going to have this complication. Hence, I was a nervous wreck before I had my hip replacement surgery. The good news is, it is treatable in many ways. My personal favorite is getting my lazy butt out of bed and walking around. Movement of the lower extremities increases blood flow and therefore blood can't sit around and clot. Lazy or not, I still need my 8 hours of sleep at night and that's a long time to let blood lay around. So, the next best treatment is anticoagulant therapy. Traditionally, patients are placed on a drug called Warfarin Sodium, known specifically as Coumadin. Coumadin is a good, effective drug. It is so effective though, one can become a little too "anticoagulated" meaning you could probably bleed to death from a paper cut or worse, suffer a life debilitating stroke. If you had a surgery such as mine where you may have minor bleeding in the area, coumadin therapy may turn a small bleed into a big one. Coumadin is a Vitamin K antagonist, meaning that patients must watch what they eat because there are many foods with Vitamin K that can affect the effectiveness of the drug. Coumadin is also very "touchy" and it is very difficult to assess the right dose as each person responds differently to it. For this reason, patients who take Coumadin have to have regular checks of their bleeding time to make sure that the medicine is working properly and not causing problems.

There is another anticoagulant therapy called Enoxaparin. Enoxaparin is a low-molecular weight heparin and it's effectiveness is based on the weight of the patient. It is not affected by foods ingested and generally works on everyone in a predictable fashion. The drawback is it can only be administered by injection. On either therapy, you are bound to get poked a few times.

I was deathly afraid of throwing a clot. Between that and infection, I was totally freaking out about my hip replacement. The problem with being a nurse is you know enough to be dangerous but not quite enough to be confident. After seeing many patients with blood clots and infections, I was not especially excited to have this happen to me. So when I was asked whether I wanted to take a pill or inject myself daily with my blood thinning agent, I chose the injection. It seemed like it had less to worry about and I was good at giving injections. After 12 years of nursing, I figured being able to inject myself was sort of a "perk". I'd save myself a visit by a home health RN (to draw blood to check bleeding time) and the nightmare of wondering if my Coumadin was therapeutic or if I'd eaten too many green leafy vegetables. I recently modified my diet to include green leafy vegetables and it was murphy's law that now I would be expected to limit them. No way. I'll take the injection instead and keep the worrying to a minimum.

Enoxaparin is the generic name of the drug that a company called Sanofi Aventis markets as "Lovenox." The dose is based on how much you weigh and is delivered via an injection into the subcutaenous fat portion of the skin. Most people are familiar with the traditional intramuscular injection which is the shot in the arm or the butt with a long needle. Subcutaenous injections or "SQ" injections are given with a tiny needle into a pinch of fat much like how diabetics deliver insulin to themselves. It's pretty easy, although I had an interesting dilemma.

I am a woman of moderate height and stature. I am small-breasted and thin in my mid-section and carry most of my weight in my legs and my rear-end. The contemporary description of "too much junk in the trunk" fits me well and I could pinch all kinds of fat between my hip bones and my knees. I also have a nice little fat deposit in the tricep region at the back of my arm. Trust me, I am not without a subcutaneous layer. However, when one self-administers Lovenox, they recommend pinching the fat of the abdomen and injecting the drug in this region. Ironically, I can barely pinch an inch here. I am having a heck of a time conjuring up a big enough pinch to stick the needle into. On more than one occasion, I have hit the muscle underneath which really hurts when you inject Lovenox. It stings like crazy. Everynight it's a new adventure trying to pinch enough fat on my stomach with the great irony being that if I injected it into my butt, I'd have no trouble finding enough fat. I tried using my tricep fat, but it's impossible to pinch and inject at the same time. And trying to pinch and inject into my backside was a comical display of me chasing my own tail.

I am not especially psyched about this injecting every night, but given that it will probably save my life. I stick with it. I also bought two pairs of compression hose that I wear every night to bed. One night, I woke up with searing pain in the back of my heel. I was convinced that I had a small clot. I pumped my foot back and forth as vigorously as I could, worried that this thing was going to either, get stuck and get worse, or break free and travel into my chest. After a couple of agonizing minutes, the pain went away. I waited for chest pain and shortness of breath that never came. I felt like I had dodged a bullet.

Another night, I asked my 8 year old daughter to give me my shot. She was so intrigued by the skin preparation, the pinching and the poking. I asked if she wanted to do it and she said "Sure!" The first night, after I used my syringe, I had her practice on a tangerine. She used the dirty needle and stabbed this poor tangerine over and over, injecting with varying speed. When it was time for my shot the next night, I must admit, I was a bit nervous after watching her anticoagulate a tangerine over and over. However, when it came time, she was quite nervous and a little subdued. She very, carefully cleaned the site with the alcohol wipe and then, on command, jabbed me in the small pinch of fat that I was able to muster with excellent aim. She slowly injected the medicine and did a fabulous job. It was the best injection I'd had in the last two weeks and she was so very proud of herself. I, personally, was happy to have the night off. She had a heck of a story to tell at school the next day.

So, you see? Lovenox is so easy even an 8 year old can do it. If you have the choice between Coumadin or Lovenox, take the Lovenox. And if you are skinny in the middle, you might want to hit the carbs a little harder prior to surgery. If you already have that spare tire, you will be happy to know that it is good for something. Lovenox therapy continues for three weeks total. After that, I get to switch to Aspirin. Even though my 8 year old can show me how it is done, I am running out sites on my abdomen. I will be happy when the injections are done.