[HSF] Too scared to touch.....

Thu May 3 10:35:22 EDT 2007

Hal, Don ,
it seems that my  anecdote spiced  the discussion little too much.
My point was completely different; how to deliver fair ( if  you are not
able to deliver complete and appropriate) treatment with limited
resources available. It is obvious that  the record from the spa
hospital is ridiculously fake , but it  has been partially  based on
presumption that  LM disease  must have  the highest priority.
Let's take the case of Bojan Biocina : by today  297 pts. on  the
waiting list ,  possible workload 4 cases/wk . There  is at least  50 LM
, another 50  severe tripple vessel disease patients. If we forget 
other pathology ( valves  , combined etc. for a while ) , if you were me
, how  would you handle the list : to operate LM first ( and to allow
any new LM to jump the queue), to mix  the order with more serious 
tripple vessel ( criteria?) , or  to try to  judge  clinical criteria  
of  "stability"?
With almost unlimited resources ( often seen today in Western  countries)
 medical/moral responsibility ih still high enough , but with  limited
resources  it  could be much higher. In  light of  all of that , I think
 studies like  the Canadian one might help ( although , obviously , 
judgment based on them might hurt  a particuklar individual).

Bojan

On 5/3/2007, "hgrmd at aol.com" <hgrmd at aol.com> wrote:

>Don,
>  Let's kick Prasanna's butt!
>Hal
>
>-----Original Message-----
>From: donross at bigpond.com
>To: OpenHeart-L at lists.hsforum.com
>Sent: Wed, 2 May 2007 6:45 PM
>Subject: Re: [HSF] Too scared to touch.....
>
>
>Prasanna,
>Indeed, a lot of what we practice will be found to be imperfect , but a lot of the so called evidence based practice is also bullshit.
>Do you really believe all Bojan's waiting list deaths had critical LM disease?
>Remember the bikini and statistics?
>Don
>
>PS It is great to have Hal onside for a change!
>
>On 02/05/2007, at 9:20 PM, psimha wrote:
>
>> Hal,
>> Please read carefully, In never said anything about critical left > mains.
>> Also if you carefully see what I said I said where is the > evidence . Some things that we practice need not necessarily be right.
>>
>> Prasanna
>> hgrmd at aol.com wrote:
>>> Don,
>>> I agree with you. If Prasanna wants to send out critical LM's >> or LAD's hanging by a hair after an MI, that's his business. >> Around here, if such patient went home without surgery and boxed, >> we'd definitely hear about it.
>>> Hal -----Original Message-----
>>> From: donross at bigpond.com
>>> To: OpenHeart-L at lists.hsforum.com
>>> Sent: Wed, 2 May 2007 4:40 AM
>>> Subject: Re: [HSF] Too scared to touch.....
>>>
>>>
>>> When they have LM or TVD + poor LV....... most of my patients. I >> hope, therefore, you are not trying to put me out of a job? Don On >> 02/05/2007, at 10:53 AM, prasannasimha wrote:
>>>> Where in literature has it been shown that a patient who is >>> stable > after an MI benefits from urgent in house >>> revascularization ? Prasanna
>>>> Donald Ross wrote:
>>>>> Also, one wonders about the not infrequent peri-op AMIs during >>>> non->> cardiac surgery that come our way for revascularisation >>>> prior to >> discharge. Is this unnecessary surgery as well, >>>> given it carries the same >> indications as regular coronary >>>> surgery? Don On 01/05/2007, at 10:04 PM, Hgrmd at aol.com wrote:
>>>>>
>>>>>> Ajit, I invested the time it took to read all of Prasanna's >>> >>>>> abstracts. I'm still not convinced that medical therapy with >>>>> beta-blockers is >>> the way to go for nearly every case. >>>>> Again, if a stress test in an asymptomatic >>> patient shows a >>>>> lot of myocardium with reversible ischemia, it would be >>> >>>>> potentially foolhardy not to cath that patient. Over the years, >>>>> we've been >>> referred lots of patients with left mains or >>>>> critical 3vd that were cathed prior >>> to an elective >>>>> noncardiac procedure (usually carotid, ischemic leg, or AAA). >>>>> >>> We did the CABG, they eventually got the vascular >>>>> procedure, and they did >>> fine. I've yet to recall "graft >>>>> closure" while the subsequent case was done. In >>> light of >>>>> the problems with DES, the cardiologists are much more likely >>>>> to use >>> bare metal stents in such scenarios. I do agree that >>>>> beta blockade, possible Swan, and a competent >>> ca
> rdiac >>>>> anesthesiologist suffice for the vast majority of cardiac >>> >>>>> patients getting noncardiac surgery. However, there are plenty >>>>> of asymptomatic >>> cardiac time bombs waiting to explode for >>>>> those that never cath and treat >>> preemptively. Hal
>>>>>>
>>>>>>
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