[HSF] Ahh,
the Holiday Transfer. Would anyone do anything different?
Tea Acuff
tacuff at swbell.net
Sun Dec 2 19:19:26 EST 2007
Bill,
You doing some very interesting work. Among other things you are dealing with problems of medical access and teaching beyond the usual clamoring that our local program and its technical approach (and results) are best and must be embedded as the proper (and only) legitimate one. Offical legitimacy always will tend to limit access, even if it improves it for the some. Whether you feel that everyone should follow you at the moment is actually unimportant since you are providing a need that is in such need of imitation.
You encourage your hosts to rethink their bias and reassess their judgements. Perhaps that is what is happening with our (the STS and USA payment) universal guidelines. Perhaps we are just encouraging those that perform poorly to reassess and reprove their standards. However, I am afraid that our relentless need to recredential, issue guidelines and pay for documenting those surrogate findings are codifying self fulfilling assessments. It seems to me, whether by design or by accident, that you are doing the opposite of what is happening in the USA. How this works from place to place probably is highly dependent on multiple local factors.
Maybe I have said this before on HSF, but I attended a brief talk by Newt Gingrich at UT SW medical school in Dallas who asked us (presumbly the professors) how could we educate doctors that require 10 years to train when information is doubling in less than 6 years and accelerating. One of the emeritus professors responded that they are already in the process of solving that problem: they will soon be retesting doctors every 3 years. I almost fell out of my chair! Newt was more diplomatic in is his assessment when he pointed out that this was perhaps not really the answer to this problem.
I don't know much, but I do know that the government is not likely to be truthful when they show up saying they are here to help. They might help, but that is not their main concern. The more we as physicans act the same, and particularly the more we align ourselves with the government (or insurance companies, etc) the more we need to reassess ourselves as we will be considered as politicans (or insurance companies) by our patients.
I hope that I encourage a few to rethink their personal thinking bias, even if they think me wrong. It is clear that I never have the last word...even with myself.
tea
----- Original Message ----
From: "ichfno at aol.com" <ichfno at aol.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Friday, November 30, 2007 1:39:07 AM
Subject: Re: [HSF] Ahh, the Holiday Transfer. Would anyone do anything different?
Tea;
I don't know what will happen with the next Shone's Syndrome, but I do know this; In October 2005, we started a Stage 1 Norwood program at this institution, doing 2 Sano operations on that trip. Both kids made it to the ICU, but died 48-96 hours later in the ICU. What would happen to the next HLHS kid that needed a Norwood? Well, what did happen was 3 months later they did a Sano without me, I flew in 17 days later, kid was extubated in ICU for respiratory care only, and next to him was another un-operated HLHS kid, they wanted me to now show them a Modified Norwood 1 with typical BT shunt, so we did the child, extubated on afternoon of POD2, and there is a picture on our website of me with a Sano in one arm and Norwood in the other. What happened, well they did a couple more Sano's the rest of 2006 and early 2007 and all died (6), then I fly in on this trip and what is sitting in the ICU, a modified Norwood POD 3 with great hemodynamics, but still a
little to puffy to extuba
te. So, ball back to you buddy, what will happen to the next Shones Syndrome, I don't know but I have hope that is backed up by a historical perspective.
Tea we are collecting the data from here for the 5 years of our program, hoping to present it at EACTS in Lisbon in September, but what it is going to show is the growth of a program that had an overall mortality rate of 18% the year before we came, doing nothing more complicated than Tets and some AV Canals, to a program with less than 5% mortality rate, and only 1/18 deaths this year in the arterial switch operation, a Norwood program that shows progress, a Fontan program started from nothing now with a mortality rate of less than 5%. I agree that you never?know what will happen, but with the right people, right support and right attitude, despite some problems, great things can be accomplished.
Bill
Or what will happen with the next "similar case" when Dr. Novick is absent. What
actually changed there? There is the incident, a live child with some new
future, to which Ani alluded. But what about the other side? I would propose
nothing, a small step in another area, or least likely a quantum step (maybe
only in desire at present) forward for the same result next time. It is also
possible that success leads to a contrarian or peculiar response.
I don't know.
I just wonder.
tea
----- Original Message ----
From: Ani Anyanwu <anianyanwu at hotmail.com>
To: openheart-l at lists.hsforum.com
Sent: Thursday, November 29, 2007 9:48:46 PM
Subject: RE: [HSF] Ahh, the Holiday Transfer. Would anyone do anything
different?
Yes. That Dr Novick was right doesn't mean the Chief was wrong.
Maybe the Chief knows something we don't (e.g. about the healthcare provision or
natural history after heart surgery in his country) and what might seem the best
and successful therapy in one country might not necessarily be the same in
another. What I would want to know is what is the likelihood that this
particular 7 month old in his country would remain alive to see his 5th 10th
15th and 20th birthday after this life saving operation?
Ani
> Date: Thu, 29 Nov 2007 18:24:15 -0800> From: tacuff at swbell.net> Subject: Re:
[HSF] Ahh, the Holiday Transfer. Would anyone do anything different?> To:
OpenHeart-L at lists.hsforum.com> CC: > > How about the possibility in this case
that both the Chief and you were right with different recommendations!> > tea> >
> ----- Original Message ----> From: "ichfno at aol.com" <ichfno at aol.com>> To:
OpenHeart-L at lists.hsforum.com> Sent: Thursday, November 29, 2007 10:41:50 AM>
Subject: Re: [HSF] Ahh, the Holiday Transfer. Would anyone do anything
different?> > Okay, here is my do nothing story for the day. In a former Soviet
Union Country at present, presented a child who is 7 months old, 5 KGS, had
coarctation repair as newborn, at which time they did not address his MS, but
did send to cath lab to balloon his stenotic aortic valve. No gradient after
coarc, 60 gradient by echo after balloon, down from 90 gradient measured in lab,
left him with 1-2 plus AI. So, now
seven months later, has 22 mmHg peak mitral gradient and 1 plus MR, with single
pap muscle by echo, 2-3 plus AI and 60 mmHG LVOTO gradient with subvalve 7mm.
Massively dialated LA, LV dialated as well, cachectic, can see every rib,
breathing 45 times/minute. Chief at the Institution returns from Moscow, tells
mother child should go home to die, operation is not possible, even though we
have scheduled child for an operation. Mother says, I cannot do nothing, I must
do everything possible for my only child. Mother refuses advice of Chief, child
goes> to operating room, Chie> f makes entire surgical team sign note stating
that we know he has advised against surgery that is doomed to failure. We all
sign!> > Child is in ICU, 0.08 epi, 0.75 milrinone, sternum closed, cvp 12, BP
95/68. Did Ross-Konno, spilt single pap muscle and opened both commissures, no
LVOTO gradient, Mitral down to 4 mmHg, mild MR, no AI, no residual VSD,
sometimes you just can't do
nothing!> > > WNovick MD> > > > > If you reflect on your story, sometimes
nothing is the hardest thing to do. > It does have the advantage, however, that
one is able to reverse the choice with > better information or a change in the
situation to change your odds...possibly > including the arrival of a "better"
surgeon or better plan. > tea > > > > ----- Original Message ----> From: Michael
Firstenberg <msfirst at gmail.com>> To: OpenHeart-L at lists.hsforum.com> Sent:
Wednesday, November 28, 2007 9:18:51 PM> Subject: RE: [HSF] Ahh, the Holiday
Transfer. Would anyone do anything > different?> > So - just dont do something,
stand there....> > Michael Firstenberg <msfirst at gmail.com>> > -----Original
Message-----> From: "Tea Acuff" <tacuff at swbell.net>> To: OpenHeart-L at lists.hsforum.com>
Sent: 11/28/2007 9:55 PM> Subject: Re: [HSF] Ahh, the Holiday Transfer. Would
anyone do anything > different?> > As per some of the other comments, he had a
better chance with
nothing. Your > findings would point to that although it is a calculated quess
preop.> > tea> > > ----- Original Message ----> From: Michael Firstenberg
<msfirst at gmail.com>> To: OpenHeart-L at lists.hsforum.com> Sent: Sunday, November
25, 2007 7:52:57 PM> Subject: Re: [HSF] Ahh, the Holiday Transfer. Would anyone
do anything > different?> > The tear was at the SVG->PDA site going into the
arch (as per CT) and > down a little, but did not appear to involve the native
ostium nor > the valve - the AI appeared to be from being bicuspid/fused.> > >
-michael> > > On Nov 25, 2007, at 8:44 PM, Tea Acuff wrote:> > > What did you
find on opening the aorta? Did the dissection go > > proximal to the grafts? Was
the dissection the cause of the AI or > > was that just the biscupid valve?> >>
> tea> >> >> > ----- Original Message ----> > From: Michael Firstenberg
<msfirst at gmail.com>> > To: OpenHeart-L at lists.hsforum.com> > Sent: Sunday,
November 25, 2007 6:58:39 PM> >
Subject: Re: [HSF] Ahh, the Holiday Transfer. Would anyone do > > anything
different?> >> > he was a little wet - but not bleeding to death.> >> >> >> >
-michael> >> >> >> >> > On Nov 25, 2007, at 7:48 PM, zzhoumd at pol.net wrote:> >>
>>> >> Just wonder if Factor 7 may help.> >>> >> Sent via BlackBerry by AT&T>
>>> >> -----Original Message-----> >> From: Michael Firstenberg
<msfirst at gmail.com>> >>> >> Date: Sun, 25 Nov 2007 18:47:53> >>
To:OpenHeart-L at lists.hsforum.com> >> Subject: [HSF] Ahh,> >> the Holiday
Transfer. Would anyone do anything different?> >>> >>> >> The wonders of holiday
in the U.S. is that we (academic medical> >> centers) seem to get all of
transfers.> >> This was my case from yesterday and would be very interested in>
>> comments (besides shipping to a better surgeon......).> >>> >> 61 year/old,
hypertensive, diabetic, severe abdominal obesity (BMI> >> 48, 300 lbs, around 5'
4')> >> presents to outside hospital with refractory
chest/back pain,> >> radiating to legs.> >> CT Angio - aortic dissection, just
about the valve to the iliacs.> >> head/visceral/renal/femorals off true lumen
(but very small)> >> Surgery resident from outside hospital calls me for
transfer (on> >> cardizem drip for BP control, no beta-blockers, not working,
should> >> we heparinize...... discussion for another time!!!)> >> "oh, I forgot
to mention, he had a CABGx4 in June of this year)> >>> >> My response - esmolol
and ship quickly> >> Upon arrival, still having pain, BP OK, neuro intact, faint
femoral> >> pulses, strong radials (no A-line)> >> Reviewed still with our local
Cardiology CT expert (lucky he was in> >> house)> >> - confirm dx> >> - all
grafts patent, LIMA-LAD, SVG->PDA, SVG->Dx, SVG->Om> >> - 3 proximals coming off
the ascending aorta> >> - LIMA lateral to sternum> >>> >> Taken emergently to
OR> >> Axillary cannulation (nice artery)> >> Wire in right femoral vein (ugly
groin, lots of fat,
yeastly)> >> Intra-op TEE shows bicuspid aortic valve with mild/mod AI.> >>
Open the chest (they missed midline on the CABG and went through a> >> bunch of
ribs on the right- close to the RIMA)> >> Got in OK> >> tons of mediastinal fat
plastered to pericardium, plastered to> >> epicardial fat.> >> NO, and I mean NO
identifiable planes!> >> Finally found aorta after about an hr of digging -
found old> >> cannulation site> >> aorta looks ugly as I exposed.> >> Finally
found SVG to PDA graft - completely plastered to small right> >> atrium> >>
cannulated right vein - went on, cooled> >> could not find "the heart/apex/etc)
to vent - fortunately arrested> >> without fibbing (LV didnt look too bad on TEE
while cooling)> >> Cooled to 18C (didnt even look for the LIMA - way laterally
and> >> everything was a mess) -> kept feeding heart with cold blood> >> Finally
got around aorta - circ arrest, opened up, trimmed to hemi-> >> arch - contained
rupture, tear at
right vein graft site> >> found "something to sew to" distally in arch (30 min
of circ arrest> >> time)> >> went back on, started warming - blood coming from
grafts, left main> >> and right (all good, I assumed)> >> aortic valve -
bicuspid ->fused, but leaflets normal -> separated> >> left and non-cor leaflets
and appeared to co-apt ok and hold water> >> went closed> >> (mobilzing for AVR
would have been very difficult - at least for> >> me!)> >> On/off circ arrest,
low flow, etc to fix leaks, mobilize, visualize,> >> etc....> >> Bioglue to
proximal aorta layers and dissection plane.> >> Sewed proximal> >> root vent -
cardiopledgia> >> Sewed on very scarred, friable SVG buttons (got the right
mobilzed> >> off the RA once empty and repaired/resected tear)> >>> >> Took of
x-clamp - slowly developed junction rhythm as warming more> >> came off pump
eventually with lots of drugs, inhaled nitric> >> over an hour de-airing> >> TEE
- still mild AI> >> - felt
addressing would be futile> >> - 6 hours on pump.....30 min DHCA, 4 hr cross
clamp (on and off)> >> Anesthesia up and down with tons of drugs/fluids/products/bicarb>
>> big chest - wet lungs, hard to ventilate, very unstable, up/down> >>
acidosis......(thought making urine???)> >> Very coagulopathic (would have liked
to have had Aprotinin) but used> >> TA.....> >> Tons of products (INR>6, PTT
unmeasurable, ACT after protamine>999,> >> platelts=18), but not bleeding too
bad> >> re-enforced graft site and potential space to co-seal, flow-seal,> >>
fibrilar, NuKnit, anything that I was allowed to leave in the chest> >>
(although no potential space - other than right pleural space - to> >> bleed
into)> >> Closed chest (modified weave and lots of wires through ribs)> >>
meta-stable> >>> >> went out to talk to family.......called back in....became
brady> >> cardiac as getting ready to move to bed....pulseless.....> >> chest
open - heart dead.....open
CPR....intra-cardiac epi/vaso...> >> TEE showed LV empty......(rupture into
left chest? abd? something> >> else?)> >>> >> "the end"> >>> >> Please comment
as I know many of you have been there (either on-line> >> or in
private)..........> >>> >>> >> (fyi, this is the second post-CABG dissection we
got this week - the> >> first one was only a month out and the redo was much
easier)> >>> >> -michael> >>> >>> >>> >>> >>> >>> >>> >>> >>> >>
_______________________________________________> >> OpenHeart-L mailing list>
>>> >> Send postings to:> >> OpenHeart-L at lists.hsforum.com> >>> >> To
UNSUBSCRIBE, to CHANGE email address, or to view archives:> >>
http://mmp.cjp.com/mailman/listinfo/openheart-l> >>> >> All messages transmitted
by the OpenHeart-L are subject to the> >> policies and> >> disclaimers posted
at:> >> http://www.hsforum.com/listdisclaim> >> ----------------------------------------->
>> _______________________________________________> >>
OpenHeart-L mailing list> >>> >> Send postings to:> >> OpenHeart-L at lists.hsforum.com>
>>> >> To UNSUBSCRIBE, to CHANGE email address, or to view archives:> >>
http://mmp.cjp.com/mailman/listinfo/openheart-l> >>> >> All messages transmitted
by the OpenHeart-L are subject to the> >> policies and> >> disclaimers posted
at:> >> http://www.hsforum.com/listdisclaim> >> ----------------------------------------->
>> > _______________________________________________> > OpenHeart-L mailing
list> >> > Send postings to:> > OpenHeart-L at lists.hsforum.com> >> > To
UNSUBSCRIBE, to CHANGE email address, or to view archives:> >
http://mmp.cjp.com/mailman/listinfo/openheart-l> >> > All messages transmitted
by the OpenHeart-L are subject to the > > policies and> > disclaimers posted
at:> > http://www.hsforum.com/listdisclaim> > ----------------------------------------->
> _______________________________________________> > OpenHeart-L mailing list>
>> > Send postings to:> >
OpenHeart-L at lists.hsforum.com> >> > To UNSUBSCRIBE, to CHANGE email address, or
to view archives:> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> > All
messages transmitted by the OpenHeart-L are subject to the > > policies and> >
disclaimers posted at:> > http://www.hsforum.com/listdisclaim> >
-----------------------------------------> > _______________________________________________>
OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> >
To UNSUBSCRIBE, to CHANGE email address, or to view archives:>
http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by
the OpenHeart-L are subject to the policies and > disclaimers posted at:>
http://www.hsforum.com/listdisclaim> ----------------------------------------->
_______________________________________________> OpenHeart-L mailing list> >
Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE
email address, or to view archives:>
http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by
the OpenHeart-L are subject to the policies and > disclaimers posted at:>
http://www.hsforum.com/listdisclaim> ----------------------------------------->
> _______________________________________________> OpenHeart-L mailing list> >
Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE
email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l>
> All messages transmitted by the OpenHeart-L are subject to the policies and>
disclaimers posted at:> http://www.hsforum.com/listdisclaim>
-----------------------------------------> _______________________________________________>
OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> >
To UNSUBSCRIBE, to CHANGE email address, or to view archives:>
http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by
the OpenHeart-L are subject to the
policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim>
-----------------------------------------> > > ________________________________________________________________________>
More new features than ever. Check out the new AOL Mail ! - http://o.aolcdn.com/cdn.webmail.aol.com/mailtour/aol/en-us/text.htm?ncid=aolcmp00050000000003>
_______________________________________________> OpenHeart-L mailing list> >
Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE
email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l>
> All messages transmitted by the OpenHeart-L are subject to the policies and >
disclaimers posted at:> http://www.hsforum.com/listdisclaim>
-----------------------------------------> _______________________________________________>
OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> >
To UNSUBSCRIBE, to CHANGE email address, or to view
archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages
transmitted by the OpenHeart-L are subject to the policies and > disclaimers
posted at:> http://www.hsforum.com/listdisclaim> -----------------------------------------
_________________________________________________________________
Who's friends with who and co-starred in what?
http://www.searchgamesbox.com/celebrityseparation.shtml_______________________________________________
OpenHeart-L mailing list
Send postings to:
OpenHeart-L at lists.hsforum.com
To UNSUBSCRIBE, to CHANGE email address, or to view archives:
http://mmp.cjp.com/mailman/listinfo/openheart-l
All messages transmitted by the OpenHeart-L are subject to the policies and
disclaimers posted at:
http://www.hsforum.com/listdisclaim
-----------------------------------------
_______________________________________________
OpenHeart-L mailing list
Send postings to:
OpenHeart-L at lists.hsforum.com
To UNSUBSCRIBE, to CHANGE email address, or to view archives:
http://mmp.cjp.com/mailman/listinfo/openheart-l
All messages transmitted by the OpenHeart-L are subject to the policies and
disclaimers posted at:
http://www.hsforum.com/listdisclaim
-----------------------------------------
________________________________________________________________________
More new features than ever. Check out the new AOL Mail ! - http://o.aolcdn.com/cdn.webmail.aol.com/mailtour/aol/en-us/text.htm?ncid=aolcmp00050000000003
_______________________________________________
OpenHeart-L mailing list
Send postings to:
OpenHeart-L at lists.hsforum.com
To UNSUBSCRIBE, to CHANGE email address, or to view archives:
http://mmp.cjp.com/mailman/listinfo/openheart-l
All messages transmitted by the OpenHeart-L are subject to the policies and
disclaimers posted at:
http://www.hsforum.com/listdisclaim
-----------------------------------------
More information about the OpenHeart-L
mailing list