AW: [HSF] Acute dissection - what now?
Tea Acuff
tacuff at swbell.net
Wed Aug 15 06:40:01 EDT 2007
I think we are partly to blame for that misuse by our own faulty understanding of the patient doctor relationship which we present to the patient.
tea
----- Original Message ----
From: Macbook <grescigno at mac.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Wednesday, August 15, 2007 5:51:31 AM
Subject: Re: AW: [HSF] Acute dissection - what now?
Tea,
patients should do their job, that means to be patients. You can
discuss with them but, be honest, 50% of them are unable to
understand what you are talking about (at least in our italian rural
people). In the US you have a different medical widespread culture.
In Italy what they care a lot is to identify a hypothetical medical
error in order to take you in front of a judge.
Sincerely
Giuseppe
Il giorno 14/ago/07, alle ore 05:12, Tea Acuff ha scritto:
> What do you think of this imaginary data? We randomize everyone in
> the world to group A or group B. Group A receives a drug A (imagine
> a betablocker or ASA) and group B doesn't. There is a decade
> followup that shows Group A had a raw mortality of 1.0001% while
> Group B had 1.001% per annum. Assume (somebody could calculate the
> actual p value for that) but let's assume p is .00001 for an
> absolute survival advantage of 3,600,000/ year for Group A. Would
> your position be that drug A was helpful for everyone that took it,
> and therefore everyone who does not take drug A is mistreated and
> thereby harmed, so everyone you meet should take drug A? Even if
> Dr. Dunce noticed that half of his patients in town Y died on drug
> A with the yellow fever every year?
>
> Or would you argue that this is the most expensive, statistically
> valid, and powerful study ever done, but also perhaps the most
> stupid? What if you did the same for a statin, and Plavix and two
> or three drugs for every organ system and got similar results?
> Would that be excellent health care if we all took 30 drugs? What
> if we could imagine a hundred?
>
> Would it be better if we did one test first to sort out group A and
> B? How about two tests? Ten? All known tests? Would this help?
>
> Should we all take drugs for malaria since this imaginary study
> might actually be true for chloroquinine? We can't get a broader
> population then the known world (with a test or two thrown in) can we?
>
> If you don't think so, how is the AICD data different in kind from
> this imaginary study?
>
> How is the next study (or your latest study) that you are going to
> do be different in kind looking back at the end of your career?
>
> Or would you argue that "doctors" must make some type of
> "judgement" first for a "good" study"?
>
> What about patients? Do patients have a role what so ever,
> theoretically speaking, in good medical care other than being a
> "population" or merely following "directions" for good medical care
> based on populations? That is, other than choosing or not choosing,
> or being able to afford or not afford to have "good" medical care,
> do patients matter? How are they to decide? Based on our opinion?
> Is medicine a one way street? Be careful of your answer as it may
> redefine our analysis of "good medicine" absolutely at least on a
> theoretical basis. Or conversely, is good medical care actually
> unimaginable, theoretically speaking, without patient independent
> interaction? How does showing up at all change things for the
> potential patient or doctor? Now that is an interesting direction
> to think about.
>
> tea
>
>
> ----- Original Message ----
> From: Ani Anyanwu <anianyanwu at hotmail.com>
> To: openheart-l at lists.hsforum.com
> Sent: Monday, August 13, 2007 8:12:43 PM
> Subject: RE: AW: [HSF] Acute dissection - what now?
>
>
> Roberto
>
> That is why we need data to answer these questions.
>
> That one case was successful does not mean it (the technique) was a
> success. As I said we lost a patient 3 weeks ago from non-surgical
> management of a Type A. I disagree with Tea's thesis that if the
> patient is alive it implies your strategy was a success. A strategy
> is not based on a single patient but on a population. Its success
> is not a binary one but a probabilistic one i.e what proportion of
> patients treated with a technique will have a particular outcome.
> If you chose to stab a patient in the chest and they survive
> without surgery it is neither implies that stabbing people in the
> chest is safe nor that not operating on them is life-saving.
>
> ANi
>
>
>
>> From: battr at medizin.uni-leipzig.de> To: OpenHeart-
>> L at lists.hsforum.com> Subject: AW: [HSF] Acute dissection - what
>> now?> Date: Tue, 14 Aug 2007 02:54:53 +0200> CC: > > Ani,> How
>> many died without you knowing it??> > You know, I remember from
>> the old old first Gibbon book ( I was general> surgery resident) a
>> chapter about medical treatment in Type A as surgical> treatment
>> was extremely risky. As I moved home many time, each one I
>> cleared> my library and that book went to a Hospital library, but
>> Bob must remember> the first Gibbons.> Roberto> > -----
>> Ursprüngliche Nachricht-----> Von: openheart-l-
>> bounces at lists.hsforum.com> [mailto:openheart-l-
>> bounces at lists.hsforum.com] Im Auftrag von Tea Acuff> Gesendet:
>> Montag, 13. August 2007 04:30> An: OpenHeart-L at lists.hsforum.com>
>> Betreff: Re: [HSF] Acute dissection - what now?> > The main
>> impediment to new understanding is believing our old>
>> understanding...> > tea> > > ----- Original Message ----> From:
>> Ani Anyanwu
> <anianyanwu at hotmail.com>> To: openheart-l at lists.hsforum.com> Sent:
> Sunday, August 12, 2007 6:34:48 PM> Subject: RE: [HSF] Acute
> dissection - what now?> > > Odd how our rules change and how we
> become more accepting and non-critical> of deviations from accepted
> standards of care, when the deviation comes from> another surgeon.
> > > I bet that if a similar patient with an MI complicating a type
> A had> undergone a PCI to RCA and percutaneous drainage of the
> pericardial space> and then was sent to the CCU for 4 days with the
> dissection left untreated,> we would all be screaming murder.> > I
> have actually seen 3 type A's managed by colleagues in the last
> year where> surgery was not undertaken immediately - one also had a
> staged procedure,> one was not operated for six weeks - and all did
> well. Maybe it is time for> us to revisit the UAB paradigm.> > Ani>
> > > > > To: OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] Acute
> dissection -> what now?> Date: Sun, 12
> Aug 2007 13:26:34 -0400> From: hgrmd at aol.com> CC: >> > > Dave,>
> > ? I've never seen or heard of staging an acute dissection, but>
> your strategy seems to be working so far.? I suspect if you had
> tried to fix> the whole thing acutely, the patient would have died
> from RV failure.?> Still, I would think it's a small minority of
> acute Type A dissections that> can be staged.? If I'm not mistaken,
> the mean survival of untreated Type A's> is only a couple of days.>
> > > > Hal> > > -----Original Message-----> From:> David Harris
> <drdharris at yahoo.co.uk>> To: OpenHeart-L at lists.hsforum.com>> Sent:
> Sun, 12 Aug 2007 12:45 pm> Subject: Re: [HSF] Acute dissection -
> what> now?> > > > > Hi Prasannah,> > There was no definite site on
> the aorta, and> the aorta> was not thinned out and ready to rupture
> like I have> usually> seen. The adventitia was slightly thickened /
> > inflamed. There> was a small amount of liquid blood,> and clots,
> which were around the whole> ventricle.>
> Posterior clots were removed only once we were on> pump.> > I>
> took him back on 9 Aug for formal closure of the> chest so we could
> wean and> extubate (I had left the> sternum open to prevent any
> compression of the> RV,> which looked horrid at that stage). By
> this stage the> RV looked> normal, the aorta did not look worse
> (45mm)> externally, and echo showed no> extension of> dissection.
> He was extubated yesterday, and is still>> delirious / confused.
> Kidneys are working, creat now> 330mmol/l. I guess I> should plan
> for later this week?> > Dave> --- psimha> <prasannasimha at gmail.com>
> wrote:> > > Dave,> > How did he Tamponade ?> >> Prasanna> > David
> Harris wrote:> > > 60 yr old male presents with `acute> coronary> >
> syndrome`> > > to physician, inferior infarct pattern.> > >> > >>
> Cardiac cath done next day. L side normal, RCA> > > blocked. Aortic
> valve> intact. Aortic dissection> >> then> > > diagnosed. CT
> confirms that it extends from RCA to> > > below>
> brachiocephalic.> > >> > > Patient then referred to me:
> dehydrated,> obtunded,> > > creatinine 570mmol/l, anuric. > > >> >
> > Arrests soon after,> resuscitated. BP 50 - 60> > systolic> > >
> for 30 mins. Taken to OR for> salvage. Put on pump> > > (cannulated
> innominate) to keep him alive.> >> Tamponade> > > relieved, vein
> graft on beating heart to prox RCA.> > > Aorta> looks stable (not
> thinned out - yet)> > > Weaned with difficulty with IABP.>> > >> >
> > Now on 40%, ventilated, GCS 10, passing good> > urine,> > >>
> creatinine 500. Timing for full repair? Attempt> > cross> > > clamp
> during> repair?> > >> > >> > >> > > Dr. David G. Harris, FCS,
> MMED,> > >> Cardiothoracic Surgeon > > > Suite 207 > > > Kuils
> River Private Hospital, >> > > PO Box 1200, Kuils River, 7579, Cape
> Town, South> > Africa. > > > Tel> +27-21-9006411 > > > Fax
> +27-21-9006412 Mobile +27-83-3309587> > >>
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>> Harris, FCS, MMED,> Cardiothoracic Surgeon > Suite 207 > Kuils>
> River Private Hospital, > PO Box 1200, Kuils River, 7579, Cape
> Town, South> Africa. > Tel +27-21-9006411 > Fax +27-21-9006412
> Mobile +27-83-3309587>>
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