MAR-B-12
CONSULTATION REGARDING A POST-OPERATIVE PATIENT ON ANTICOAGUALTOIN FOR THROMBOEMBOLISM INTERESTED IN CLIMBING AND SCUBA DIVING
Dear Fred:
You had apparently known
that I am an active climber, diver, endurance runner and adventure traveler in
some of the world's more spectacular, but medically user-unfriendly, places,
and have had an interest in Wilderness Medicine. I am returning to Nepal next month with a group of students and
will be back on the Kumbu Ice Fall with pulse oximeter at my finger tips.
Fortunately, I also have
some good friends smarter than I am in areas related to your three part
question:
Enclosed is the response
from the world's premier high altitude physiologist and climbing physician, Dr.
Peter Hackett. I will say only this to
add to his reference to the paper outlining the case report by Budda Basnyat
MD, a friend of mine in Kathmandu, Medical Director of the HRA (Himalayan
Rescue Association) on the case reported whom I saw. There were other circumstances in this instance, and I presume
that your patient will not be doing the extreme exposures of the "Roof of
the World." I find no absolute
embargo of her proposed activities.
She should be aware that she
has a non-zero risk (as, of course, do I) but that hers is more significant
than mine in a scale quantifiable on no empiric data. The major risk as far as
I can see would be a somewhat more rapid access to medical care and testing in
her case should she have troubles, not always possible in the remote settings
that these activities usually have as their venue.
Second, is the scuba diving
question, in many ways the obverse of the altitude question. I am going to defer to the expert I had
previously emailed to you about, and until his response is in, I will hold my
opinion, which is a grade above that for the altitude exposure.
The third question is in the
middle of my own strike zone and is the easiest to answer. With the underlying problem physiologically
corrected, her post-operative history is in no way a proscription for her
pursuing each of the activities planned.
The presence of the caval filter has a slightly higher possibility of
becoming a caval occlusion (Geelhoed, "Thromboembolism and Its
Prevention" American Family Physician 19: 147=153, March, 1979)) with increased
external compression or Valsalva, but that is chronically easier to accommodate
than it would be for an acute event, and she has had the filter long enough to
encourage collateralization.
On my third of the question,
I have no reservation about her proposed activities. I add only my usual caveat (which has to be understood coming
from a Mountaineering, Diving Ultra-runner):
"Moderation in all things---above all, in the practice of
moderation!"
Cheers!
GWG
Glenn-
This is an issue much
debated. Acute hypoxia studies indicate no change in
coagulation in people with
Factor V Leiden. However, no long-term field
studies are available.
Thrombosis is a risk at high altitude because of
dehydration,
hemoconcentration, and sometimes forced inactivity. Also, many
trekkers travel on
long-range flights to get to Nepal, etc. It's impossible
to sort out all the
variables. There are reports of folks with familial
thrombophilia developing
thrombosis at altitude, but perhaps they would
have at sea level. (Basnyat
B, Graham L, Lee S, Lim Y. Case report: A
language barrier, abdominal
pain and double vision. Lancet 2001;357:2022. A
case of a man with
antiphospholipid antibody who developed mesenteric and
cerebral venous thrombosis
at high altitude.) Without controlled studies,
risk is really unknown. If
she is on Coumadin, and checking her INR, I
would be less concerned. If
not on Coumadin, then perhaps aspirin would be
indicated?
I agree that available
evidence hardly justifies proscribing her desired
activity. Still, she needs
to be informed that there may be a risk (albeit
unknown) and her physician
can help minimize the risk.
At altitude, meticulous
attention to hydration, avoiding inactivity, etc
are all important.
Best regards,
Peter
At 3/19/2002, you wrote:
>I have an inquiry, on
which I wish to give very specific advice (see
>attached.)
>
>What would you
recommend?
>
>Thanks for your help!
>
>GWG
>Date: Mon, 18 Mar 2002
08:24:57 -0500
>From: "Frederick
Rickles" <resfrr@gwumc.edu>
>To: "Glenn
Geelhoed" <msdgwg@gwumc.edu>
>Subject: Fwd: scuba
diving
>Mime-Version: 1.0
>Content-Type:
multipart/mixed; boundary="=_2D708BBD.A4C5AC1B"
>
>Glenn: A patient of mine (see attached), who has
Factor V Leiden and a
>history of IBD, S/P
colectomy with pancreatitis at the time and an IVC
>clot after which a
Greenfield filter was placed, is now returned to full
>function and is very
active. She has a great desire to go
hiking in
>Nepal (at high
altitudes) and to go deep sea diving at depths not
>recommended by the
company sponsoring the trip for individuals with past
>abdominal surgery. She asked me to check with someone who might
know the
>risk/benefit
profile. As far as I am concerned, her
anticoagulant status
>is not an absolute, albeit relative, contraindication to either
>activity. While I would not actively prohibit either I
am not
>thrilled. What would you advise?
>
>Frederick R. Rickles, MD
>Professor of Medicine
and Pediatrics
>Associate Vice President
for Health Research,
> Compliance and Technology Transfer
>The George Washington
University
>Ross Hall 712E
>2300 Eye St NW
>Washington, DC 20037
>Tel: (202)994-2995
>Fax:(202)994-0465
>email: resfrr@gwumc.edu
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>Subject: scuba diving
>To: "Frederick
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>
>Dr. Rickles,
>
>Thanks for your help with
LabCorp.
>
>I've gone ahead and
ordered the ProTime. I'm hoping my company will pick up
>the full tab, but I'll
purchase it either way. The current system just
>wasn't working because
it's difficult for me to eke out time in my busy
>schedule for lab tests.
I have a better appreciation now for the risks, and
>the fact that my INR is
difficult to regulate in the absence of monitoring,
>even when I'm taking my
medicine. Of all people I should have known better,
>because my dad is on
Coumadin and a doctor. Anyway, I'm sorry for the major
>lapse on my part. I feel
very fortunate to have you for my hematologist and
>don't want to jeopardize
our doctor-patient relationshop.
>
>You asked during my
recent visit to send a reminder to ask your colleague
>about the risks
associated with scuba diving for someone with my medical
>history (colectomy,
pancreatitis, and blood clots with filter). There's no
>rush, but I'd appreciate
any information you can provide. If I need to
>schedule a visit with
him, I could do that also.
>
>Thank you!
>
>Lorene
Peter H Hackett, M.D.
President, International
Society for Mountain Medicine
610 Sabeta Drive
Ridgway, CO 81432-9335
Ph: (01) 970-626-2477, Fax:
(01) 970-626-2467, Email: Hackett@ismmed.org
Register now for the Vth
World Congress on Mountain Medicine, in Barcelona,
April18-22, 2002.
See www.ismmed.org for details and registration.