From zzhoumd at pol.net Tue Apr 1 13:22:58 2008 From: zzhoumd at pol.net (zzhoumd@pol.net) Date: Tue Apr 1 08:23:57 2008 Subject: [HSF] RE: Timing of Surgery In-Reply-To: <001b01c8939e$d9bc6ee0$0201a8c0@yourg8he5gjrox> References: <17C1CC76913B68488A280F0651AFA6DB028B3329@CCHSCLEXMB52.cc.ad.cchs.net><001b01c8939e$d9bc6ee0$0201a8c0@yourg8he5gjrox> Message-ID: <1819186643-1207052604-cardhu_decombobulator_blackberry.rim.net-1669240353-@bxe138.bisx.prod.on.blackberry> How is your patient doing? Sent via BlackBerry by AT&T -----Original Message----- From: "Ajit Damle" Date: Mon, 31 Mar 2008 21:19:43 To: Subject: [HSF] RE: Timing of Surgery Thank you for your prompt advice. I repeated the CT scan yesterday. No change at the site of ruptured plaque. Left it alone and did AVR+CABG today. Ajit Damle -----Original Message----- From: Lytle, M.D., Bruce [mailto:LYTLEB@ccf.org] Sent: Monday, March 31, 2008 10:54 AM To: damle@cableone.net Subject: Re: Timing of Surgery Stent the descending aorta then do the heart surgeryn or, alternatively, just do the heart surgery. Bruce Lytle ----- Original Message ----- From: Ajit Damle To: 'Ajit Damle' Sent: Fri Mar 28 07:20:23 2008 Subject: Timing of Surgery I need advice on this patient urgently. 77yr old man presents with unstable angina. Previous nucleide test showed reversible ischemia in LAD territory. While waiting for an angio, he was admitted to the referring hospital 48 hours ago. In addition, to the usual treatment, he received 75 mgm of clopidogrel and 100 mgm of Enoxaparin. EKG initially showed ST changes anteriorly that resolved. He also developed severe back pain and had a CT. This shows a penetrating ulcer on the undersurface of the aorta, at the junction of the arch and descending portion. There is an intramural hematoma, not very big, and also I think some subadventitial hemorrhage that extends for 3-4 cms. It is hard to tell if it is chronic or not, but with his history of back pain, I think it is probably recent. Further down, the descending thoracic aorta is aneurysmal, some 4.5cms and horribly atherosclerotic in its entire course. There was also an abdominal aortic aneurysm that was operated on last year. He had an angio today that shows a non-stentable, ostial, tight lesion of proximal LAD. The left main is diseased, 20-30%. There is also severe AI 3 to4 +++. Fortunately he is pain free for now, although this morning he had an episode of chest pain, with anterior ST changes, that reversed after half an hour. He is very hypertensive, on multiple therapy and also I/V NTG. The back pain has subsided. I am worried that if I operate on him urgently, the heparinization (and post-op coagulopathy, should he develop one) could worsen the descending aortic bleeding. I am tentatively planning to operate on him on Monday (today is Thursday), unless he becomes symptomatic before. I will keep him on I/V NTG, beta blockers. He is also on Aspirin. What do you think? Should I do him sooner? Ajit Damle Fargo ND March 27, 2008 =================================== P Please consider the environment before printing this e-mail Cleveland Clinic is ranked one of the top hospitals in America by U.S. News & World Report (2007). Visit us online at http://www.clevelandclinic.org for a complete listing of our services, staff and locations. Confidentiality Note: This message is intended for use only by the individual or entity to which it is addressed and may contain information that is privileged, confidential, and exempt from disclosure under applicable law. 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Thank you. _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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 ----------------------------------------- From sukumarhmehta at yahoo.com Tue Apr 1 08:07:02 2008 From: sukumarhmehta at yahoo.com (Mehta Sukumar) Date: Tue Apr 1 10:07:32 2008 Subject: [HSF] "Patients don't want cardiopulmonary bypass" - the great con In-Reply-To: Message-ID: <351769.67187.qm@web36505.mail.mud.yahoo.com> Vipin, Sorry, I read your communication dated December, 2007, only just now while randomly picking up the HSF mails. I found it very apt. I agree with all the points except probably the 3rd point. ( I am neither for or against on pump or off pump and do CABGs by either technique as per my comfort level, keeping in mind the job I have to do in any given case ). My view is, heart lung bypass technology has sufficiently advanced to take care of pump times involved in carrying out 5 or 6 distals. As far as proximals are concerned, (if at all they are aorto coronary grafts), they can be done off pump, if one is concerned about pump time. Secondly, I found it difficult to understand, why "small vessels can sometimes be difficult to graft on-pump". In your communication, in para 1) you have mentioned excellent tricks and tips to a small vessel distal anastomosis off pump. The same tips and tricks can be used (if required), on pump to facilitate small vessel distal anastomosis. If at all these points have been discussed in the forum subsequently and I have missed them, I apologise. Sukumar. Vipin Zamvar wrote: Michael, Let me correct a few misconceptions that many surgeons have about off-pump surgery. The following comments (which are randomly arranged) are based entirely on my own personal experience (248 of the last 250 CABG operations performed off-pump; of the 248 off-pump operations, one needed a conversion intraoperatively.) 1) The first one is that small vessels cannot be safely grafted: To perform a safe and secure anastomosis, the diameter is a critical issue only during the learning curve. I do not feel performing an anastomosis on a 1.25 mm vessel is any more difficult than on a 2 mm vessel. There are a few tricks that can be used while grafting a small vessel. (It is absolutely essential that the stabilization is secure, so there is no or minimal motion). A shunt is an absolute must. This prevents the inadvertent taking of the posterior wall of the coronary artery. In a small vessel the shunt also helps while turning corners at the heel or toe. You can gently puncture the shunt at the heel when the needle passes through the coronary wall, and then pull the shunt away. The needle is pulled along with the shunt; then the needle can be disengaged from the shunt, and pulled away. 2) The second is that you cannot completely revascularise the patient: I routinely do 4 or 5 grafts for patients with 3 vessel disease, and occasionally also 6 grafts. The position of the coronary artery is absolutely not a problem. Again this is due to the use of many techniques, which combine to ensure that access for any part of the heart is no problem at all. These techniques include the single deep posterior pericardial stitch, opening of the right pleura, use of the trendelenburg position, and judicious use of intraoperative fluids. 3) I have often felt that if I were doing on-pump surgery, then doing 5 or 6 grafts would be fraught with the dangers of a long pump time. I also find that small vessels can sometimes be difficult to graft on-pump (For example, when I am doing AVR + CABG). 4) I often find myself comfortable in being able to offer coronary surgery to patients with diffusely diseased arteries and extensive comorbidities only because I am confident to be able to complete the operation off-pump. I often take on patients when others are more conservative or reluctant. 5) I feel that surgeons who wish to start/increase performing off-pump surgery should not select their patients on the basis of size of the coronary artery. Sometimes a 2.5 mm artery which can bleed a lot when an arteriotomy is made, can be more difficult to deal than a 1.5 mm artery which does not bleed as much. In fact if anybody is serious about persuing off-pump surgery, he must not select patients at all. He must start off-pump in all patients. 6) The one drawback I feel about off-pump surgery is that I find it difficult to give away cases to my trainees; unless they are relatively senior. I would have been able to give away a higher proportion of cases if I had been doing on-pump surgery. 7) Off-pump surgery is associated with a significant decrease in perioperative morbidity; and because of this it is of great benefit especially in high risk patients. But to be able to get excellent results in high risk patients, the surgeon has to be doing this procedure all the time. Can I add that the pump is always available to me. I will use the pump without hesitation anytime I feel that the pump would be safer. Visiting cenres or surgeons that routinely perform a high proportion of cases off-pump can be a big advantage. Vipin Zamvar --------------------------------- You rock. That's why Blockbuster's offering you one month of Blockbuster Total Access, No Cost. From prasannasimha at gmail.com Tue Apr 1 21:29:15 2008 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Tue Apr 1 10:59:49 2008 Subject: [HSF] Image of the week - Aortic ulcer Message-ID: <89c4ed2d0804010759q2de8970ey441f7b68f89dfe6a@mail.gmail.com> Picture of an aortic ulcer by Roberto. He will discyuss. What are the patients symptoms Roberto ? Prasanna -- Prasanna Simha M -------------- next part -------------- A non-text attachment was scrubbed... Name: Aortic ulcer.jpg Type: image/jpeg Size: 56758 bytes Desc: not available Url : http://mmp.cjp.com/pipermail/openheart-l/attachments/20080401/e62a7ff5/Aorticulcer.jpg From battr at medizin.uni-leipzig.de Wed Apr 2 10:35:51 2008 From: battr at medizin.uni-leipzig.de (Dr. Roberto Battellini) Date: Wed Apr 2 03:39:04 2008 Subject: AW: [HSF] Image of the week - Aortic ulcer In-Reply-To: <89c4ed2d0804010759q2de8970ey441f7b68f89dfe6a@mail.gmail.com> References: <89c4ed2d0804010759q2de8970ey441f7b68f89dfe6a@mail.gmail.com> Message-ID: <009701c89494$2d62a7d0$b3160a06@HZLPC0679> 60 year old patient, has supportable back pain since a week, and retrosternal low pain since a couple of days. He underwent a cath yesterday, no coronary lesions. He has also a 56 mm wide abdominal aortic aneurysm. The CT shows a dilated descending aorta with this ulcer, as you can see. What to do? Tom Martin? He will have something before Saturday, of course. -----Urspr?ngliche Nachricht----- Von: openheart-l-bounces@lists.hsforum.com [mailto:openheart-l-bounces@lists.hsforum.com] Im Auftrag von Prasanna Simha M Gesendet: Dienstag, 1. April 2008 15:59 An: OpenHeart-L Betreff: [HSF] Image of the week - Aortic ulcer Picture of an aortic ulcer by Roberto. He will discyuss. What are the patients symptoms Roberto ? Prasanna -- Prasanna Simha M From ebender001 at charter.net Wed Apr 2 21:54:42 2008 From: ebender001 at charter.net (Edward Bender) Date: Wed Apr 2 22:10:22 2008 Subject: [HSF] Mohr ruler Message-ID: To Roberto: I used Fred Mohr?s cordal ruler today for the first time on an anterior leaf prolapse from Barlow?s syndrome. I just wanted to pass on to the Leipzig geniuses what an extremely useful tool it was. I placed several neo cords to A2 and A3, and it took all the guess work out of setting the most appropriate length for the gortex suture. It has renewed my enthusiasm these types of repairs. Just thought some compliments were in order. Ed Bender, MD From tacuff at swbell.net Wed Apr 2 21:28:43 2008 From: tacuff at swbell.net (Tea Acuff) Date: Wed Apr 2 23:30:15 2008 Subject: [HSF] Mohr ruler Message-ID: <481316.86567.qm@web81604.mail.mud.yahoo.com> Is the Mohr ruler used with Ockhams razor? tea ----- Original Message ---- From: Edward Bender To: OpenHeart-L Sent: Wednesday, April 2, 2008 8:54:42 PM Subject: [HSF] Mohr ruler To Roberto: I used Fred Mohr?s cordal ruler today for the first time on an anterior leaf prolapse from Barlow?s syndrome. I just wanted to pass on to the Leipzig geniuses what an extremely useful tool it was. I placed several neo cords to A2 and A3, and it took all the guess work out of setting the most appropriate length for the gortex suture. It has renewed my enthusiasm these types of repairs. Just thought some compliments were in order. Ed Bender, MD _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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 ----------------------------------------- From ebender001 at charter.net Wed Apr 2 23:41:24 2008 From: ebender001 at charter.net (Edward Bender) Date: Wed Apr 2 23:42:02 2008 Subject: [HSF] Mohr ruler {OT} In-Reply-To: <481316.86567.qm@web81604.mail.mud.yahoo.com> References: <481316.86567.qm@web81604.mail.mud.yahoo.com> Message-ID: No, it is best used with an 11 blade. Occam's razor (often misspelled Ockham's razor, especially in Texas) is too dangerous in my hands. By the way, I propose the opposite of explaining phenomena simply should be called Acuff's razor (maximum complexity to explain a simple problem). Ed Bender, MD On Apr 2, 2008, at 10:28 PM, Tea Acuff wrote: > Is the Mohr ruler used with Ockhams razor? > > tea > > > > ----- Original Message ---- > From: Edward Bender > To: OpenHeart-L > Sent: Wednesday, April 2, 2008 8:54:42 PM > Subject: [HSF] Mohr ruler > > To Roberto: > I used Fred Mohr?s cordal ruler today for the first time on an > anterior leaf > prolapse from Barlow?s syndrome. I just wanted to pass on to the > Leipzig > geniuses what an extremely useful tool it was. I placed several neo > cords > to A2 and A3, and it took all the guess work out of setting the most > appropriate length for the gortex suture. It has renewed my > enthusiasm > these types of repairs. Just thought some compliments were in order. > > Ed Bender, MD > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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@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 > ----------------------------------------- From tacuff at swbell.net Wed Apr 2 21:50:17 2008 From: tacuff at swbell.net (Tea Acuff) Date: Wed Apr 2 23:51:48 2008 Subject: [HSF] why some patients might seem stupid Message-ID: <537793.74022.qm@web81605.mail.mud.yahoo.com> I have been talking with a neighbor about one of his relatives that lives in Florida and has a "bad Heart" etc, etc, and needed a valve. We talked in general terms over several weeks and I finally asked him to send some of his reports for me to look at. Turns out that his valve disease is probably not the main problem, but he has a poorly defined anterior apical "scar" and dilated heart that might be helped with an SVR/ Dor type procedure. I discussed getting a CMR to see if "resecting" the scar would be useful, but that likely the cardilogists would suggest a new pacemaker which would help some but not likely fix the problem. Sure enough the a "third wire" for the pacemaker was recommended (the patient didn't "want" surgery) but the cariologists on being questioned about other options, now are suggesting "resection". I today was asked if I knew the surgeons that were recommended (not seen yet): one a Dr. Tomas Ditto Martin and another a "Clifton" (speak up Cliff if you are a lurker). I started laughing. I thought there was only one Tomas in Florida, Tom, so I wondered if the "Ditto" means the "Tomas". I know Tea is pretty funny, but what is a Ditto? tea From tacuff at swbell.net Wed Apr 2 22:05:27 2008 From: tacuff at swbell.net (Tea Acuff) Date: Thu Apr 3 00:06:58 2008 Subject: [HSF] Mohr ruler {OT} Message-ID: <883474.18015.qm@web81604.mail.mud.yahoo.com> Actually I had two "c's" and a "k" in my first try. As to the Accuff razor, you haven't seen anything yet. It turns out to be quite difficult to explain why everyone else thinks backwards. Maybe Occham has a simple explanation. (There are actually technical reasons for why the simple explanation is not correct, but as you may also point out when I give a simple answer no one understands what I am talking about.) tea ----- Original Message ---- From: Edward Bender To: OpenHeart-L@lists.hsforum.com Sent: Wednesday, April 2, 2008 10:41:24 PM Subject: Re: [HSF] Mohr ruler {OT} No, it is best used with an 11 blade. Occam's razor (often misspelled Ockham's razor, especially in Texas) is too dangerous in my hands. By the way, I propose the opposite of explaining phenomena simply should be called Acuff's razor (maximum complexity to explain a simple problem). Ed Bender, MD On Apr 2, 2008, at 10:28 PM, Tea Acuff wrote: > Is the Mohr ruler used with Ockhams razor? > > tea > > > > ----- Original Message ---- > From: Edward Bender > To: OpenHeart-L > Sent: Wednesday, April 2, 2008 8:54:42 PM > Subject: [HSF] Mohr ruler > > To Roberto: > I used Fred Mohr?s cordal ruler today for the first time on an > anterior leaf > prolapse from Barlow?s syndrome. I just wanted to pass on to the > Leipzig > geniuses what an extremely useful tool it was. I placed several neo > cords > to A2 and A3, and it took all the guess work out of setting the most > appropriate length for the gortex suture. It has renewed my > enthusiasm > these types of repairs. Just thought some compliments were in order. > > Ed Bender, MD > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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@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@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 ----------------------------------------- From battr at medizin.uni-leipzig.de Thu Apr 3 10:13:13 2008 From: battr at medizin.uni-leipzig.de (Dr. Roberto Battellini) Date: Thu Apr 3 03:16:57 2008 Subject: AW: [HSF] Mohr ruler In-Reply-To: References: Message-ID: <00b201c8955a$2efdcf40$b3160a06@HZLPC0679> Ed, Thanks in the name of Fred. Roberto -----Urspr?ngliche Nachricht----- Von: openheart-l-bounces@lists.hsforum.com [mailto:openheart-l-bounces@lists.hsforum.com] Im Auftrag von Edward Bender Gesendet: Donnerstag, 3. April 2008 02:55 An: OpenHeart-L Betreff: [HSF] Mohr ruler To Roberto: I used Fred Mohr?s cordal ruler today for the first time on an anterior leaf prolapse from Barlow?s syndrome. I just wanted to pass on to the Leipzig geniuses what an extremely useful tool it was. I placed several neo cords to A2 and A3, and it took all the guess work out of setting the most appropriate length for the gortex suture. It has renewed my enthusiasm these types of repairs. Just thought some compliments were in order. Ed Bender, MD _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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 ----------------------------------------- From battr at medizin.uni-leipzig.de Thu Apr 3 10:20:43 2008 From: battr at medizin.uni-leipzig.de (Dr. Roberto Battellini) Date: Thu Apr 3 03:24:16 2008 Subject: AW: [HSF] Mohr ruler {OT} In-Reply-To: References: <481316.86567.qm@web81604.mail.mud.yahoo.com> Message-ID: <00b301c8955b$3b33eb40$b3160a06@HZLPC0679> I shave myself every day with an Ockham?s razor, but muy bart grows again...does anyone knows a better razor? Roberto -----Urspr?ngliche Nachricht----- Von: openheart-l-bounces@lists.hsforum.com [mailto:openheart-l-bounces@lists.hsforum.com] Im Auftrag von Edward Bender Gesendet: Donnerstag, 3. April 2008 04:41 An: OpenHeart-L@lists.hsforum.com Betreff: Re: [HSF] Mohr ruler {OT} No, it is best used with an 11 blade. Occam's razor (often misspelled Ockham's razor, especially in Texas) is too dangerous in my hands. By the way, I propose the opposite of explaining phenomena simply should be called Acuff's razor (maximum complexity to explain a simple problem). Ed Bender, MD On Apr 2, 2008, at 10:28 PM, Tea Acuff wrote: > Is the Mohr ruler used with Ockhams razor? > > tea > > > > ----- Original Message ---- > From: Edward Bender > To: OpenHeart-L > Sent: Wednesday, April 2, 2008 8:54:42 PM > Subject: [HSF] Mohr ruler > > To Roberto: > I used Fred Mohr?s cordal ruler today for the first time on an > anterior leaf > prolapse from Barlow?s syndrome. I just wanted to pass on to the > Leipzig > geniuses what an extremely useful tool it was. I placed several neo > cords > to A2 and A3, and it took all the guess work out of setting the most > appropriate length for the gortex suture. It has renewed my > enthusiasm > these types of repairs. Just thought some compliments were in order. > > Ed Bender, MD > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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@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@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 ----------------------------------------- From donross at bigpond.com Thu Apr 3 21:49:02 2008 From: donross at bigpond.com (Donald Ross) Date: Thu Apr 3 06:49:38 2008 Subject: [HSF] Mohr ruler {OT} In-Reply-To: References: <481316.86567.qm@web81604.mail.mud.yahoo.com> Message-ID: Ed, Very sharp ( and succinct ) The opposite should be Acuff's rod. Don On 03/04/2008, at 1:41 PM, Edward Bender wrote: > No, it is best used with an 11 blade. Occam's razor (often > misspelled Ockham's razor, especially in Texas) is too dangerous > in my hands. By the way, I propose the opposite of explaining > phenomena simply should be called Acuff's razor (maximum complexity > to explain a simple problem). > > Ed Bender, MD > > > On Apr 2, 2008, at 10:28 PM, Tea Acuff wrote: > >> Is the Mohr ruler used with Ockhams razor? >> >> tea >> >> >> >> ----- Original Message ---- >> From: Edward Bender >> To: OpenHeart-L >> Sent: Wednesday, April 2, 2008 8:54:42 PM >> Subject: [HSF] Mohr ruler >> >> To Roberto: >> I used Fred Mohr?s cordal ruler today for the first time on an >> anterior leaf >> prolapse from Barlow?s syndrome. I just wanted to pass on to the >> Leipzig >> geniuses what an extremely useful tool it was. I placed several >> neo cords >> to A2 and A3, and it took all the guess work out of setting the most >> appropriate length for the gortex suture. It has renewed my >> enthusiasm >> these types of repairs. Just thought some compliments were in order. >> >> Ed Bender, MD >> _______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@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@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@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 > ----------------------------------------- From Hgrmd at aol.com Thu Apr 3 08:09:58 2008 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Thu Apr 3 07:10:32 2008 Subject: [HSF] why some patients might seem stupid {OT} Message-ID: Tea, I don't know about Tom "Ditto", but I suspect "Clifton" is Clifton Lewis in Sarasota. I met him last summer at Vanermen's course in Belgium. His reputation as a valve surgeon is excellent. Hal **************Planning your summer road trip? Check out AOL Travel Guides. (http://travel.aol.com/travel-guide/united-states?ncid=aoltrv00030000000016) From tacuff at swbell.net Thu Apr 3 18:19:35 2008 From: tacuff at swbell.net (Tea Acuff) Date: Thu Apr 3 20:21:07 2008 Subject: [HSF] why some patients might seem stupid {OT} Message-ID: <521323.84018.qm@web81606.mail.mud.yahoo.com> Yes it is Lewis, but i did not want to "out" him on the forum. And yes Ditto is our own Tom Martin. tea ----- Original Message ---- From: "Hgrmd@aol.com" To: OpenHeart-L@lists.hsforum.com Sent: Thursday, April 3, 2008 6:09:58 AM Subject: Re: [HSF] why some patients might seem stupid {OT} Tea, I don't know about Tom "Ditto", but I suspect "Clifton" is Clifton Lewis in Sarasota. I met him last summer at Vanermen's course in Belgium. His reputation as a valve surgeon is excellent. Hal **************Planning your summer road trip? Check out AOL Travel Guides. (http://travel.aol.com/travel-guide/united-states?ncid=aoltrv00030000000016) _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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 ----------------------------------------- From benjamin.bidstrup at bigpond.com Sat Apr 5 19:38:00 2008 From: benjamin.bidstrup at bigpond.com (Ben Bidstrup) Date: Sat Apr 5 04:38:49 2008 Subject: [HSF] why some patients might seem stupid {OT} In-Reply-To: <521323.84018.qm@web81606.mail.mud.yahoo.com> References: <521323.84018.qm@web81606.mail.mud.yahoo.com> Message-ID: FYI The Razor Ockham's Razor Ockham's Razor (also spelt Occam's Razor) demands economy of explanation. William of Ockham's Latin dictum, pluralitas non est ponenda sine necessitate, means "plurality should not be posited without necessity" or "do not invent unnecessary entities to explain something". >Yes it is Lewis, but i did not want to "out" him on the forum. And >yes Ditto is our own Tom Martin. > >tea > > > >----- Original Message ---- >From: "Hgrmd@aol.com" >To: OpenHeart-L@lists.hsforum.com >Sent: Thursday, April 3, 2008 6:09:58 AM >Subject: Re: [HSF] why some patients might seem stupid {OT} > >Tea, > I don't know about Tom "Ditto", but I suspect "Clifton" is Clifton Lewis >in Sarasota. I met him last summer at Vanermen's course in Belgium. His >reputation as a valve surgeon is excellent. > >Hal > > > >**************Planning your summer road trip? Check out AOL Travel Guides. > (http://travel.aol.com/travel-guide/united-states?ncid=aoltrv00030000000016) >_______________________________________________ >OpenHeart-L mailing list > >Send postings to: >OpenHeart-L@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@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 >----------------------------------------- -- Ben Bidstrup FRACS FRCSEd FEBCTS Consultant Cardiothoracic Surgeon From msfirst at gmail.com Sat Apr 5 09:15:15 2008 From: msfirst at gmail.com (Michael Firstenberg) Date: Sat Apr 5 08:15:43 2008 Subject: [HSF] why some patients might seem stupid {OT} In-Reply-To: References: <521323.84018.qm@web81606.mail.mud.yahoo.com> Message-ID: The American (not English) translation is "keep it simple, stupid"? -michael On Sat, Apr 5, 2008 at 4:38 AM, Ben Bidstrup wrote: > FYI The Razor > > Ockham's Razor > Ockham's Razor (also spelt Occam's Razor) demands economy of explanation. > William of Ockham's Latin dictum, pluralitas non est ponenda sine > necessitate, means "plurality should not be posited without necessity" or > "do not invent unnecessary entities to explain something". > > > Yes it is Lewis, but i did not want to "out" him on the forum. And yes > > Ditto is our own Tom Martin. > > > > tea > > > > > > > > ----- Original Message ---- > > From: "Hgrmd@aol.com" > > To: OpenHeart-L@lists.hsforum.com > > Sent: Thursday, April 3, 2008 6:09:58 AM > > Subject: Re: [HSF] why some patients might seem stupid {OT} > > > > Tea, > > I don't know about Tom "Ditto", but I suspect "Clifton" is Clifton > > Lewis > > in Sarasota. I met him last summer at Vanermen's course in Belgium. > > His > > reputation as a valve surgeon is excellent. > > > > Hal > > > > > > > > **************Planning your summer road trip? Check out AOL Travel > > Guides. ( > > http://travel.aol.com/travel-guide/united-states?ncid=aoltrv00030000000016 > > ) > > _______________________________________________ > > OpenHeart-L mailing list > > > > Send postings to: > > OpenHeart-L@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@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 > > ----------------------------------------- > > > > > -- > Ben Bidstrup FRACS FRCSEd FEBCTS > Consultant Cardiothoracic Surgeon > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > From tacuff at swbell.net Sat Apr 5 09:58:54 2008 From: tacuff at swbell.net (Tea Acuff) Date: Sat Apr 5 11:59:24 2008 Subject: [HSF] why some patients might seem stupid {OT} Message-ID: <516136.65928.qm@web81603.mail.mud.yahoo.com> Well, I think I've got the stupid part down... tea ----- Original Message ---- From: Michael Firstenberg To: OpenHeart-L@lists.hsforum.com Sent: Saturday, April 5, 2008 7:15:15 AM Subject: Re: [HSF] why some patients might seem stupid {OT} The American (not English) translation is "keep it simple, stupid"? -michael On Sat, Apr 5, 2008 at 4:38 AM, Ben Bidstrup wrote: > FYI The Razor > > Ockham's Razor > Ockham's Razor (also spelt Occam's Razor) demands economy of explanation. > William of Ockham's Latin dictum, pluralitas non est ponenda sine > necessitate, means "plurality should not be posited without necessity" or > "do not invent unnecessary entities to explain something". > > > Yes it is Lewis, but i did not want to "out" him on the forum. And yes > > Ditto is our own Tom Martin. > > > > tea > > > > > > > > ----- Original Message ---- > > From: "Hgrmd@aol.com" > > To: OpenHeart-L@lists.hsforum.com > > Sent: Thursday, April 3, 2008 6:09:58 AM > > Subject: Re: [HSF] why some patients might seem stupid {OT} > > > > Tea, > > I don't know about Tom "Ditto", but I suspect "Clifton" is Clifton > > Lewis > > in Sarasota. I met him last summer at Vanermen's course in Belgium. > > His > > reputation as a valve surgeon is excellent. > > > > Hal > > > > > > > > **************Planning your summer road trip? Check out AOL Travel > > Guides. ( > > http://travel.aol.com/travel-guide/united-states?ncid=aoltrv00030000000016 > > ) > > _______________________________________________ > > OpenHeart-L mailing list > > > > Send postings to: > > OpenHeart-L@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@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 > > ----------------------------------------- > > > > > -- > Ben Bidstrup FRACS FRCSEd FEBCTS > Consultant Cardiothoracic Surgeon > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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@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 ----------------------------------------- From tacuff at swbell.net Sat Apr 5 10:01:04 2008 From: tacuff at swbell.net (Tea Acuff) Date: Sat Apr 5 12:01:34 2008 Subject: [HSF] cautery maze Message-ID: <545242.87748.qm@web81602.mail.mud.yahoo.com> Prasanna, do you have a reference (literature) on your or others experience with cautery for a power source for Maze"? tea From prasannasimha at gmail.com Sat Apr 5 23:00:06 2008 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Sat Apr 5 12:30:35 2008 Subject: [HSF] cautery maze In-Reply-To: <545242.87748.qm@web81602.mail.mud.yahoo.com> References: <545242.87748.qm@web81602.mail.mud.yahoo.com> Message-ID: <89c4ed2d0804050930i59e2a0f0kf142c0f1d113017b@mail.gmail.com> I have published the initial experience in the HSF Journal. I am planning to write up the 10 year results. I have presented intermediate results in our national conference. Prasanna On Sat, Apr 5, 2008 at 9:31 PM, Tea Acuff wrote: > Prasanna, > do you have a reference (literature) on your or others experience with > cautery for a power source for Maze"? > > tea > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > -- Prasanna Simha M From anianyanwu at hotmail.com Sat Apr 5 20:08:58 2008 From: anianyanwu at hotmail.com (Ani Anyanwu) Date: Sat Apr 5 15:09:30 2008 Subject: [HSF] Not all patients are stupid In-Reply-To: <537680.98996.qm@web81605.mail.mud.yahoo.com> References: <537680.98996.qm@web81605.mail.mud.yahoo.com> Message-ID: >The idea expressed is somewhat counter to the argument that all cases should be referred to experts.> tea Tea I see your words are well chosen - and of course the interpretation depends on what really yourself or the reader understands by the word 'experts'. In the USA at least, there are very few clinical problems now that are not treated by experts of one form or another. Ani > Date: Mon, 31 Mar 2008 21:21:48 -0700> From: tacuff@swbell.net> To: OpenHeart-L@lists.hsforum.com> CC: > Subject: [HSF] Not all patients are stupid> > This article was posted about a need for surgery coverage for PCI. A reader posted the following comment. Maybe we should just start talking truth to the patients instead of explaining how smart we are. The idea expressed is somewhat counter to the argument that all cases should be referred to experts.> tea > > Small hospitals push to do heart work> Associated Press, by Marilynn Marchione > Original Article: > www. news.yahoo.com/s/ap/20080329/ap_on_he_me/angioplasty_safety > > CHICAGO - Is it safe to have your arteries unclogged at a hospital that lacks heart surgeons who can operate if something goes wrong? Many states ban this except in emergencies like heart attacks. But more small hospitals are trying it in non-urgent cases, and the largest study ever done of this, released on Saturday, suggests it may not be as risky as has been feared. If confirmed by other ongoing studies, it could change policies in many states. > ********************> Reply ...> Medicare did a study comparing the outcomes of the first 60 times a surgeon did an operation to the results obtained thereafter. They did this for many surgeons and many operations. They concluded that no surgeon should ever do the first 60 of anything. > _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@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> ----------------------------------------- _________________________________________________________________ Welcome to the next generation of Windows Live http://www.windowslive.co.uk/get-live From benjamin.bidstrup at bigpond.com Sun Apr 6 08:43:10 2008 From: benjamin.bidstrup at bigpond.com (Ben Bidstrup) Date: Sat Apr 5 17:44:00 2008 Subject: [HSF] Not all patients are stupid (OT) In-Reply-To: References: <537680.98996.qm@web81605.mail.mud.yahoo.com> Message-ID: Careful with experts. Ex: an unknown quantity Spert: a drip under pressure. > >The idea expressed is somewhat counter to the argument that all >cases should be referred to experts.> tea > >Tea > >I see your words are well chosen - and of course the interpretation >depends on what really yourself or the reader understands by the >word 'experts'. In the USA at least, there are very few clinical >problems now that are not treated by experts of one form or another. > >Ani > > > > > >> Date: Mon, 31 Mar 2008 21:21:48 -0700> From: tacuff@swbell.net> >>To: OpenHeart-L@lists.hsforum.com> CC: > Subject: [HSF] Not all >>patients are stupid> > This article was posted about a need for >>surgery coverage for PCI. A reader posted the following comment. >>Maybe we should just start talking truth to the patients instead of >>explaining how smart we are. The idea expressed is somewhat counter >>to the argument that all cases should be referred to experts.> >>tea > > Small hospitals push to do heart work> Associated Press, by >>Marilynn Marchione > Original Article: > www. >>news.yahoo.com/s/ap/20080329/ap_on_he_me/angioplasty_safety > > >>CHICAGO - Is it safe to have your arteries unclogged at a hospital >>that lacks heart surgeons who can operate if something goes wrong? >>Many states ban this except in emergencies like heart attacks. But >>more small hospitals are trying it in non-urgent cases, and the >>largest study ever done of this, released on Saturday, suggests it >>may not be as risky as has been feared. If confirmed by other >>ongoing studies, it could change policies in many states. > >>********************> Reply ...> Medicare did a study comparing the >>outcomes of the first 60 times a surgeon did an operation to the >>results obtained thereafter. They did this for many surgeons and >>many operations. They concluded that no surgeon should ever do the >>first 60 of anything. > >>_______________________________________________> OpenHeart-L >>mailing list> > Send postings to:> OpenHeart-L@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> >>----------------------------------------- >_________________________________________________________________ >Welcome to the next generation of Windows Live >http://www.windowslive.co.uk/get-live_______________________________________________ >OpenHeart-L mailing list > >Send postings to: > OpenHeart-L@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 >----------------------------------------- -- Ben Bidstrup FRACS FRCSEd FEBCTS Consultant Cardiothoracic Surgeon From tacuff at swbell.net Sun Apr 6 17:36:42 2008 From: tacuff at swbell.net (Tea Acuff) Date: Sun Apr 6 19:37:24 2008 Subject: [HSF] Not all patients are stupid (OT) Message-ID: <191133.34181.qm@web81606.mail.mud.yahoo.com> I'm not really against getting the advice of an expert to help solve a problem. What i am against is letting the expert define the (my) problem. Let me give a brief description of a situation that highlights the difficulties with defining "appropiate" behavior. I recently was asked to see a 30ish year old with diffuse Wegeners disease of the lung and subsequent ESRD on dialysis for a "staph" vegation on the mitral valve. He had 3+ MR and 3+TR with PAH of 50-100 depending on the measurement. I went up to talk to patient about the surgery and complex uncertainities that we would possibly face. He was indisinterested at best. As a frequent finding with ESRD patients minor issues seemingly unrelated to his "problem" animated him more than the "severity of his situation". I discussing the case with his referring pulmonologist postop it occurred to me that what I was really saying to this patient during my "informed consent" seesion was something like, "We are going to move you to a different prison cell where we will beat you a little more than usual. What do you think of that?" Obviously nephrologists and surgeons have certain thought processes and would be best likely at WHAT THEY DO, but I suppose the patient is looking for something to help HIM not us. See my next meandering for a more formal reflection of what i am thinking around... tea ----- Original Message ---- From: Ben Bidstrup To: OpenHeart-L@lists.hsforum.com Sent: Saturday, April 5, 2008 4:43:10 PM Subject: RE: [HSF] Not all patients are stupid (OT) Careful with experts. Ex: an unknown quantity Spert: a drip under pressure. > >The idea expressed is somewhat counter to the argument that all >cases should be referred to experts.> tea > >Tea > >I see your words are well chosen - and of course the interpretation >depends on what really yourself or the reader understands by the >word 'experts'. In the USA at least, there are very few clinical >problems now that are not treated by experts of one form or another. > >Ani > > > > > >> Date: Mon, 31 Mar 2008 21:21:48 -0700> From: tacuff@swbell.net> >>To: OpenHeart-L@lists.hsforum.com> CC: > Subject: [HSF] Not all >>patients are stupid> > This article was posted about a need for >>surgery coverage for PCI. A reader posted the following comment. >>Maybe we should just start talking truth to the patients instead of >>explaining how smart we are. The idea expressed is somewhat counter >>to the argument that all cases should be referred to experts.> >>tea > > Small hospitals push to do heart work> Associated Press, by >>Marilynn Marchione > Original Article: > www. >>news.yahoo.com/s/ap/20080329/ap_on_he_me/angioplasty_safety > > >>CHICAGO - Is it safe to have your arteries unclogged at a hospital >>that lacks heart surgeons who can operate if something goes wrong? >>Many states ban this except in emergencies like heart attacks. But >>more small hospitals are trying it in non-urgent cases, and the >>largest study ever done of this, released on Saturday, suggests it >>may not be as risky as has been feared. If confirmed by other >>ongoing studies, it could change policies in many states. > >>********************> Reply ...> Medicare did a study comparing the >>outcomes of the first 60 times a surgeon did an operation to the >>results obtained thereafter. They did this for many surgeons and >>many operations. They concluded that no surgeon should ever do the >>first 60 of anything. > >>_______________________________________________> OpenHeart-L >>mailing list> > Send postings to:> OpenHeart-L@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> >>----------------------------------------- >_________________________________________________________________ >Welcome to the next generation of Windows Live >http://www.windowslive.co.uk/get-live_______________________________________________ >OpenHeart-L mailing list > >Send postings to: > OpenHeart-L@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 >----------------------------------------- -- Ben Bidstrup FRACS FRCSEd FEBCTS Consultant Cardiothoracic Surgeon _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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 ----------------------------------------- From tacuff at swbell.net Sun Apr 6 17:44:32 2008 From: tacuff at swbell.net (Tea Acuff) Date: Sun Apr 6 19:45:00 2008 Subject: [HSF] Re: so does it "matter" how we think about medicine? Message-ID: <307887.46490.qm@web81607.mail.mud.yahoo.com> (It has been a slow weekend on HSF or my computer is on the blink. Maybe some of you would be interested in one of my none Occam musings.) So what really "matters" when we try to talk about our ideas in medicine? How do we talk (think) about what we do as surgeons? How do we intelligently describe biologic phenomena? What are the limitations, if any, in how we package or think about these ideas? The mathematical or quantitative perspective is currently the dominate language and syntax for scientific methods and recommendations. What are the consequences of such language? We build a system that follows linear logic and calculative rules within which to decide "correct" behavior. We teach in this context (did you follow protocol, read the "relevant" articles, and pass the quiz?), practice in this context (did you follow the guide lines, have formal training, get credentials?), and are judged in this way (what is your mortality, how many do you do, did you meet you own guide line, doctor?). Is there a consequence to limiting medical veracity to this language or format? There is in game theory a perfect player for this or any finite, tautological game. This game might be tic tac toe, or a more complex system, say Kirkland's textbook or the stock market. This Von Neumannian "player" can calculate the proper move and form player groups to maximize the best single value: monetary, mortality, or etc. He may play at a very high (but finite) level including exploratory moves, random computed moves, or alliances. Since this player by definition is never incorrect in his numerical assessment, this player, or for us physician, would seem to be the paramount goal or ultimate status quo to be admired. There are , however, formal requirements that impact the possible outcomes of this format or permissible world view. One problem with this format is that all possible outcome and scenarios are extant INSIDE the system or tautology. This places certain constraints on this perfect player (which I will now call professor). Since the professor is "perfect", the interesting thing about this professor from the learning perspective is that while he plays perfectly it is with the level of "zero learning". As an analogy from chemical kinetics, this is "zero" order kinetics. Nothing is present to facilitate or accelerate the learning process. This perfect professor, who would be highly regarded for being "learnED", never wrong, and never sued, is unable to learn in the common sense of trial and "error". Since the professor is incapable of error, he is forced to repeat the "proper" sequence (from the tautologically or intrinsic perspective) every time, and therefore he can not "learn" to change the outcome. This system, if perfect, is a completely reductionist and calculable system in which learning might be better understood from a more typical detached or "outside" perspective not as perfect learning, but perfect adaptation. Learning seems to be missing. Should we call our training programs, both for residents and post graduates, adaptation programs or sensitivity programs? See the shift in gestalt from this mind set and language format? Another problem with this perfect Neumannian player scenario is its mathematical behavioral characteristics. The outcomes tend toward chaos and volatility. It, the player or more correctly his pursuit of the highest single value, never reaches a sustained position or homeostasis. It is not reflective of a biological or human type of activity. It is probably for this reason that despite the rational desirability to be always correct in a system, that there are no useful models in game theory or professional activity for the perfect Neumannian player. For you aviation proponents, when events or behavior is non-stylized we turn off autopilot and let the real pilot come up with a solution. On the other hand we may prefer to talk in terms more organic that feel more like the flow of phenomena we observe daily. We look at individual events for patterns, which are only sometimes numbers, that tie the events together as stories or processes. We look for context, sets, and systems that allow us to understand and change the flow of reality and outcomes. These are not determined in the main by quantities and calculations. Error is judged by time or other (outside?) perspective or value, or the perception of error at some point, is an essential part of new change or learning. At the least if no error, no need to challenge defined action or to change. Conversely action and its conscious thought may create flow changes that later may be judged tragic or heroic or wrong. A mental process extant in this system links error to learning as is destruction to creation in many ancient traditions. While we say that learning in this latter or creationist view point is to respond differently to the same stimulus or context at a later time, we are primarily talking about patterns not quantities, patterns that we build. No man can have sex with the same lover twice, at least for the first time. Thus we have to pick the relevant patterns in the flow of events. If we are inside an ideological set or tautology and wish to learn we must bring in something new: agent, timing, matrix or perspective. In doing so we also introduce and risk error. This world of creation and destruction we usually relegate to the prophets and poets, or perhaps, the politicians. But it is part of our world too. When we posit a mechanism, we destroy another. If this is too subtle, surely when we create one guide line or apply one therapy we exclude others. We can not practice medicine or recommend to others to live in one of these worlds alone. Nor can we believe that we can live in only one while having the "goal" of being in the "error less" one. If we can not quantify and then test, we can be fooled by the repetitive patterns. If we can not be free to error and reorient our patterns, not only can we not create a new world, we are doomed to live endlessly in the present one. These world views or formats are actually impossible to keep separate as they are bound together in our responses and perceptions, but it is easy to forget this tension and think we are immune from one or the other. The gap in reality that is found from either descriptive view alone is omnipresent. This gap or paradox is biologic and build into our ability to know and respond and think. Only in combining them are we truly human and truly free to change the past. and free to error in the process. This is our epistemological situation. We are dependent on our ability maintain the tension of the paradox we find in reality as we can know it. Our reality is a paradox. When we lose the paradox we lose the either the reality to measure our fate or to create a different outcome. Paradox is reflected in the very words we use, at least the more primitive non latinized (non-reified) ones. Our words are embedded with this gap or paradox. What "matters"? This word "matter" means both the stuff and the meaning among the stuff. We fool ourselves, I think, if we chose to have only one perspective for truth. It certainly makes us look foolish. I say these things to you all because our thought leaders require the wisdom that comes with both experience and clarity. I say you ALL, because I trust none of us or group of us to preserve both our potential success and our potential error, and thereby our future. This is not another rant, but perhaps, a formal tool to help recognize before the fact when we may be in danger of losing our future. For those in charge of setting policy, and we all are at some level, I will leave you with a quote from Gregory Bateson that sets out the above ideas in a concise manner: "Thus, in no system which shows mental characteristics can any part have unilateral control over the whole. In other words, the mental characteristics of the system are immanent, not in some part, but in the system as a whole." tea ----- Original Message ---- From: "rwmfglycar@aol.com" To: OpenHeart-L@lists.hsforum.com Sent: Saturday, March 15, 2008 8:46:49 AM Subject: Re: [HSF] Rt thoracotomy MVR Bravo Tohru! Bob -----Original Message----- From: Tohru Asai To: OpenHeart-L@lists.hsforum.com Sent: Sat, 15 Mar 2008 5:08 am Subject: Re: [HSF] Rt thoracotomy MVR Nand and Discussants! I am interested in this long threads. And I found that this was the problem of HSF. Why are you guys so eloquent even without seeing Nand's patient and her CT scan. I don't care about who's repair rate, who's preferred approach or generalized comments about each approach. Is Rt. Thoracotomy really a right approach specifically to her by Nand? In my mind, questions raised. How severe is her pectus? I experienced a case of pectus for mitral repair a few years ago. Her lower sternal body is literally 1 cm distance from vertebral body! Pectus is not simply sternal and caltilage problem, but the whole mediastinum shifted abnormally. In his case, he also mentioned "pectus was just filled with prosthesis", this means the view from Rt. Thoracotomy must be quite different and difficult ( not only far away but sternal body may be in the way!).Therefore, without watching CT slice, we should not mention which approach is good or bad! And if Nand is not always do rt. Thoracotomy, I am afraid that the outcome...We certainly should take his experiences into consideration in such a case, then we should comment properly. Another question, which Ani mentioned too. I want to ask, Why did he want to replace rather than repair the valve? Nand should answer why he want to choose replacement. Because of his experience? We all are not sure. If so, probably he should ask an experienced surgeon to scrub in together, or send the patient to a surgeon who is good at mitral repair and good at non-sternotomy approaches ( Lt. and/or rt.). Although I am not sure how difficult to perform sternotomy for her. Nand! Forget about asking tips. Please upload CT scan. Then we can discuss more realistic strategy and tips you want! -- Tohru Asai Shiga University of Medical Science Otsu, Japan _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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@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 ----------------------------------------- From prasannasimha at gmail.com Mon Apr 7 18:19:17 2008 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Mon Apr 7 07:49:49 2008 Subject: [HSF] Image of the week Mediastinal Thymolipoma Message-ID: <89c4ed2d0804070449j418404b1l4c1c7447847e18a2@mail.gmail.com> Patient with a history of syncope and giddiness who became very breathless and repeated syncope.Large Mediastinal thymolipoma (Benign histology)was excised in toto. Mass extended from the neck to the diaphragm and from the left chest wall to the right pleural reflection. Prasanna -- Prasanna Simha M -------------- next part -------------- A non-text attachment was scrubbed... Name: mediastinal thymolipoma eml.jpg Type: image/jpeg Size: 196692 bytes Desc: not available Url : http://mmp.cjp.com/pipermail/openheart-l/attachments/20080407/959ee575/mediastinalthymolipomaeml.jpg From prasannasimha at gmail.com Mon Apr 7 23:44:50 2008 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Mon Apr 7 13:15:23 2008 Subject: [HSF] Image of the week - Intraop stenting Message-ID: <89c4ed2d0804071014s4ea2b31dt93acf9a87d334e9b@mail.gmail.com> Roberto's case which he showed last week (Aortic ulcer +aortic aneurysm) undergoing intraop stenting to cover the aortic ulcer after aneurysmorrhaphy. Prasanna -- Prasanna Simha M -------------- next part -------------- A non-text attachment was scrubbed... Name: intropstentingeml.jpg Type: image/jpeg Size: 93069 bytes Desc: not available Url : http://mmp.cjp.com/pipermail/openheart-l/attachments/20080407/642dfec0/intropstentingeml-0001.jpg From battr at medizin.uni-leipzig.de Mon Apr 7 20:27:09 2008 From: battr at medizin.uni-leipzig.de (Dr. Roberto Battellini) Date: Mon Apr 7 13:30:15 2008 Subject: AW: [HSF] Image of the week - Intraop stenting In-Reply-To: <89c4ed2d0804071014s4ea2b31dt93acf9a87d334e9b@mail.gmail.com> References: <89c4ed2d0804071014s4ea2b31dt93acf9a87d334e9b@mail.gmail.com> Message-ID: <006c01c898d4$9bb04b90$b3160a06@HZLPC0679> We first did the abdominal aortic aneurysm with a straight prosthesis with side branch, then trough this arm the angiologists performed the stenting in the hybrid OP. Roberto -----Urspr?ngliche Nachricht----- Von: openheart-l-bounces@lists.hsforum.com [mailto:openheart-l-bounces@lists.hsforum.com] Im Auftrag von Prasanna Simha M Gesendet: Montag, 7. April 2008 18:15 An: OpenHeart-L Betreff: [HSF] Image of the week - Intraop stenting Roberto's case which he showed last week (Aortic ulcer +aortic aneurysm) undergoing intraop stenting to cover the aortic ulcer after aneurysmorrhaphy. Prasanna -- Prasanna Simha M From battr at medizin.uni-leipzig.de Tue Apr 8 08:45:19 2008 From: battr at medizin.uni-leipzig.de (Dr. Roberto Battellini) Date: Tue Apr 8 01:48:29 2008 Subject: AW: [HSF] Image of the week Mediastinal Thymolipoma-OT In-Reply-To: <89c4ed2d0804070449j418404b1l4c1c7447847e18a2@mail.gmail.com> References: <89c4ed2d0804070449j418404b1l4c1c7447847e18a2@mail.gmail.com> Message-ID: <008601c8993b$bbe61f40$b3160a06@HZLPC0679> Incredible , Prasanna -----Urspr?ngliche Nachricht----- Von: openheart-l-bounces@lists.hsforum.com [mailto:openheart-l-bounces@lists.hsforum.com] Im Auftrag von Prasanna Simha M Gesendet: Montag, 7. April 2008 12:49 An: OpenHeart-L; Ccm-l Betreff: [HSF] Image of the week Mediastinal Thymolipoma Patient with a history of syncope and giddiness who became very breathless and repeated syncope.Large Mediastinal thymolipoma (Benign histology)was excised in toto. Mass extended from the neck to the diaphragm and from the left chest wall to the right pleural reflection. Prasanna -- Prasanna Simha M From prasannasimha at gmail.com Tue Apr 8 15:35:02 2008 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Tue Apr 8 05:05:34 2008 Subject: [HSF] Image of the week Mediastinal Thymolipoma-OT In-Reply-To: <008601c8993b$bbe61f40$b3160a06@HZLPC0679> References: <89c4ed2d0804070449j418404b1l4c1c7447847e18a2@mail.gmail.com> <008601c8993b$bbe61f40$b3160a06@HZLPC0679> Message-ID: <89c4ed2d0804080205n30e42867w3ac335bcacbdbb1f@mail.gmail.com> I was worried that manipulation may result in cardiac decompensation so I asked the perfusionists to hang around. Luckily the patient did not have major hemodynamic perturburations except at one point when I had to go around dissecting the tumour off the left hilum (It had wrapped around it. The smallest blob of the mass that you see had coursed around the superior aspect of the hilum and had grown behind it pushing with it a fold of pleura. I could not keep the left pleura intact due to this herniation. Prasanna On Tue, Apr 8, 2008 at 11:15 AM, Dr. Roberto Battellini < battr@medizin.uni-leipzig.de> wrote: > Incredible , Prasanna > > -----Urspr?ngliche Nachricht----- > Von: openheart-l-bounces@lists.hsforum.com > [mailto:openheart-l-bounces@lists.hsforum.com] Im Auftrag von Prasanna > Simha > M > Gesendet: Montag, 7. April 2008 12:49 > An: OpenHeart-L; Ccm-l > Betreff: [HSF] Image of the week Mediastinal Thymolipoma > > Patient with a history of syncope and giddiness who became very breathless > and repeated syncope.Large Mediastinal thymolipoma (Benign histology)was > excised in toto. Mass extended from the neck to the diaphragm and from the > left chest wall to the right pleural reflection. > Prasanna > > -- > Prasanna Simha M > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > -- Prasanna Simha M From msfirst at gmail.com Tue Apr 8 20:46:31 2008 From: msfirst at gmail.com (Michael Firstenberg) Date: Tue Apr 8 19:53:53 2008 Subject: [HSF] ICU Management Systems Message-ID: <3526C930-95E7-458D-B6AD-A4E3C51ACC6A@gmail.com> We are in the process of exploring options to assist in the pre/post- operative care of our patients. Our current system has us taking full care and responsibility for all aspects of this process (pre-op eval/tune-ups, post-op management, line changes, vent weaning, call/ working with consults, etc). There are obvious pluses and minuses to this process. What are the other systems which people have to work with and what parts of them do they like and dislike. My concern is that there are always plenty of people who want to be Chiefs, but few who want to be Indians (American expression for many who want to direct and run the show - esp between 9am and 5pm, but few to actually do they real work - i.e. bedside care, put in orders, call and discuss with consults, lines, tubes, weaning, even talking with families and helping admit patients- and do it 24 hr a day and with the same vigor which we - as cardiac surgeons do - particularly in a world were our every move and outcome gets examined under a microscope). In short, who does the "real" work in your ICU? Thoughts? Comments? Since we obviously have answer all of the other pressing surgical questions and no one has anything else to talk about. -michael From ichfno at aol.com Tue Apr 8 21:36:22 2008 From: ichfno at aol.com (ichfno@aol.com) Date: Tue Apr 8 20:37:04 2008 Subject: [HSF] ICU Management Systems In-Reply-To: <3526C930-95E7-458D-B6AD-A4E3C51ACC6A@gmail.com> References: <3526C930-95E7-458D-B6AD-A4E3C51ACC6A@gmail.com> Message-ID: <8CA67F0DE91AFE8-110-2485@Webmail-mg03.sim.aol.com> Our Intensivists. Although I have significant input and complete veto power, if things are fine, I leave things alone, if something is amiss I make my suggestions and if things do not improve in a timely fashion (this timely fashion varies on the situation) the suggestions are no longer suggestions, but orders. WNovick -----Original Message----- From: Michael Firstenberg To: OpenHeart-L@lists.hsforum.com Sent: Tue, 8 Apr 2008 6:46 pm Subject: [HSF] ICU Management Systems We are in the process of exploring options to assist in the pre/post-operative care of our patients. Our current system has us taking full care and responsibility for all aspects of this process (pre-op eval/tune-ups, post-op management, line changes, vent weaning, call/working with consults, etc). There are obvious pluses and minuses to this process. What are the other systems which people have to work with and what parts of them do they like and dislike. My concern is that there are always plenty of people who want to be Chiefs, but few who want to be Indians (American expression for many who want to direct and run the show - esp between 9am and 5pm, but few to actually do they real work - i.e. bedside care, put in orders, call and discuss with consults, lines, tubes, weaning, even talking with families and helping admit patients- and do it 24 hr a day and with the same vigor which we - as cardiac surgeons do - particularly in a world were our every move and outcome gets examined under a microscope).? ? In short, who does the "real" work in your ICU?? ? Thoughts?? Comments?? Since we obviously have answer all of the other pressing surgical questions and no one has anything else to talk about.? ? -michael? _______________________________________________? OpenHeart-L mailing list? ? Send postings to:? OpenHeart-L@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 anddisclaimers posted at:? http://www.hsforum.com/listdisclaim? -----------------------------------------? From ebender001 at charter.net Tue Apr 8 20:57:13 2008 From: ebender001 at charter.net (Edward Bender) Date: Tue Apr 8 20:57:58 2008 Subject: [HSF] ICU Management Systems In-Reply-To: <3526C930-95E7-458D-B6AD-A4E3C51ACC6A@gmail.com> Message-ID: At our small community hospital, the cardiac surgeons manage the patients from admit to discharge. Last year, with the addition of an intensivist service, I tried using them, but there were problems with availability and expertise, so that ended quickly. I do liberally use other services when indicated, such as ID for endocarditis or severe surgical site infections, pulmonologist (not so much for ventilator management, but to aid in keeping patients off the ventilator), endocrinologist for poorly controlled or refractory hyperglycemia and/or DKA (which happens once or twice a year). I have found the best adjunct to care is a well trained, caring, and available physician assistant or nurse practitioner. Unfortunately, in our area, these folks are less easy to find. Most go into primary care, since in the USA, this is probably going to be the health care model of the future (economically doing away with primary care physicians). Ed Bender, MD On 4/8/08 6:46 PM, "Michael Firstenberg" wrote: > We are in the process of exploring options to assist in the pre/post- > operative care of our patients. Our current system has us taking > full care and responsibility for all aspects of this process (pre-op > eval/tune-ups, post-op management, line changes, vent weaning, call/ > working with consults, etc). There are obvious pluses and minuses to > this process. What are the other systems which people have to work > with and what parts of them do they like and dislike. My concern is > that there are always plenty of people who want to be Chiefs, but few > who want to be Indians (American expression for many who want to > direct and run the show - esp between 9am and 5pm, but few to > actually do they real work - i.e. bedside care, put in orders, call > and discuss with consults, lines, tubes, weaning, even talking with > families and helping admit patients- and do it 24 hr a day and with > the same vigor which we - as cardiac surgeons do - particularly in a > world were our every move and outcome gets examined under a microscope). > > In short, who does the "real" work in your ICU? > > Thoughts? > Comments? > Since we obviously have answer all of the other pressing surgical > questions and no one has anything else to talk about. > > > -michael > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- From prasannasimha at gmail.com Wed Apr 9 08:18:20 2008 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Tue Apr 8 21:48:49 2008 Subject: [HSF] ICU Management Systems In-Reply-To: References: <3526C930-95E7-458D-B6AD-A4E3C51ACC6A@gmail.com> Message-ID: <89c4ed2d0804081848p5b0a4b1x93e30de20c70e459@mail.gmail.com> We have anesthesiologists managing extubations and reintubations but otherwise we manage most of everything !! Prasanna On Wed, Apr 9, 2008 at 6:27 AM, Edward Bender wrote: > At our small community hospital, the cardiac surgeons manage the patients > from admit to discharge. Last year, with the addition of an intensivist > service, I tried using them, but there were problems with availability and > expertise, so that ended quickly. I do liberally use other services when > indicated, such as ID for endocarditis or severe surgical site infections, > pulmonologist (not so much for ventilator management, but to aid in > keeping > patients off the ventilator), endocrinologist for poorly controlled or > refractory hyperglycemia and/or DKA (which happens once or twice a year). > > I have found the best adjunct to care is a well trained, caring, and > available physician assistant or nurse practitioner. Unfortunately, in > our > area, these folks are less easy to find. Most go into primary care, since > in the USA, this is probably going to be the health care model of the > future > (economically doing away with primary care physicians). > > Ed Bender, MD > > > On 4/8/08 6:46 PM, "Michael Firstenberg" wrote: > > > We are in the process of exploring options to assist in the pre/post- > > operative care of our patients. Our current system has us taking > > full care and responsibility for all aspects of this process (pre-op > > eval/tune-ups, post-op management, line changes, vent weaning, call/ > > working with consults, etc). There are obvious pluses and minuses to > > this process. What are the other systems which people have to work > > with and what parts of them do they like and dislike. My concern is > > that there are always plenty of people who want to be Chiefs, but few > > who want to be Indians (American expression for many who want to > > direct and run the show - esp between 9am and 5pm, but few to > > actually do they real work - i.e. bedside care, put in orders, call > > and discuss with consults, lines, tubes, weaning, even talking with > > families and helping admit patients- and do it 24 hr a day and with > > the same vigor which we - as cardiac surgeons do - particularly in a > > world were our every move and outcome gets examined under a microscope). > > > > In short, who does the "real" work in your ICU? > > > > Thoughts? > > Comments? > > Since we obviously have answer all of the other pressing surgical > > questions and no one has anything else to talk about. > > > > > > -michael > > _______________________________________________ > > OpenHeart-L mailing list > > > > Send postings to: > > OpenHeart-L@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@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 > ----------------------------------------- > -- Prasanna Simha M From gbaslaim at hotmail.com Wed Apr 9 09:03:19 2008 From: gbaslaim at hotmail.com (ghassan ????? baslaim) Date: Wed Apr 9 01:04:08 2008 Subject: [HSF] ICU Management Systems In-Reply-To: <3526C930-95E7-458D-B6AD-A4E3C51ACC6A@gmail.com> References: <3526C930-95E7-458D-B6AD-A4E3C51ACC6A@gmail.com> Message-ID: In our CSICU, acute postop care is provided by CTS and once patient is declared longer ICU stay (>48 hr) 'cause of lung, sepsis, ...etc, patient's care and bed are transferred to General ICU under Intensivist's care with F/U by CTS. G. Baslaim, MD Jeddah, KSA> To: OpenHeart-L@lists.hsforum.com> From: msfirst@gmail.com> Date: Tue, 8 Apr 2008 19:46:31 -0400> CC: > Subject: [HSF] ICU Management Systems> > We are in the process of exploring options to assist in the pre/post- > operative care of our patients. Our current system has us taking > full care and responsibility for all aspects of this process (pre-op > eval/tune-ups, post-op management, line changes, vent weaning, call/ > working with consults, etc). There are obvious pluses and minuses to > this process. What are the other systems which people have to work > with and what parts of them do they like and dislike. My concern is > that there are always plenty of people who want to be Chiefs, but few > who want to be Indians (American expression for many who want to > direct and run the show - esp between 9am and 5pm, but few to > actually do they real work - i.e. bedside care, put in orders, call > and discuss with consults, lines, tubes, weaning, even talking with > families and helping admit patients- and do it 24 hr a day and with > the same vigor which we - as cardiac surgeons do - particularly in a > world were our every move and outcome gets examined under a microscope).> > In short, who does the "real" work in your ICU?> > Thoughts?> Comments?> Since we obviously have answer all of the other pressing surgical > questions and no one has anything else to talk about.> > > -michael> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@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> ----------------------------------------- _________________________________________________________________ Express yourself instantly with MSN Messenger! Download today it's FREE! http://messenger.msn.click-url.com/go/onm00200471ave/direct/01/ From alsadd at ksu.edu.sa Wed Apr 9 10:43:14 2008 From: alsadd at ksu.edu.sa (alsadd) Date: Wed Apr 9 01:47:00 2008 Subject: [HSF] ICU Management Systems In-Reply-To: Message-ID: Even though I work at a University Hospital but we follow Ed's model. Surgeons look after the patients. I believe this is the way to train future surgeons which we do. I believe it is no good to operate and let some one else manage especially when we have residents who have to learn. That of course means calls in the middle of the night for us the staff but we got used to it. I am against having an intensivist when there are residents. Ahmed -----Original Message----- From: openheart-l-bounces@lists.hsforum.com [mailto:openheart-l-bounces@lists.hsforum.com] On Behalf Of Edward Bender Sent: Tuesday, April 08, 2008 5:57 PM To: OpenHeart-L@lists.hsforum.com Subject: Re: [HSF] ICU Management Systems At our small community hospital, the cardiac surgeons manage the patients from admit to discharge. Last year, with the addition of an intensivist service, I tried using them, but there were problems with availability and expertise, so that ended quickly. I do liberally use other services when indicated, such as ID for endocarditis or severe surgical site infections, pulmonologist (not so much for ventilator management, but to aid in keeping patients off the ventilator), endocrinologist for poorly controlled or refractory hyperglycemia and/or DKA (which happens once or twice a year). I have found the best adjunct to care is a well trained, caring, and available physician assistant or nurse practitioner. Unfortunately, in our area, these folks are less easy to find. Most go into primary care, since in the USA, this is probably going to be the health care model of the future (economically doing away with primary care physicians). Ed Bender, MD On 4/8/08 6:46 PM, "Michael Firstenberg" wrote: > We are in the process of exploring options to assist in the pre/post- > operative care of our patients. Our current system has us taking > full care and responsibility for all aspects of this process (pre-op > eval/tune-ups, post-op management, line changes, vent weaning, call/ > working with consults, etc). There are obvious pluses and minuses to > this process. What are the other systems which people have to work > with and what parts of them do they like and dislike. My concern is > that there are always plenty of people who want to be Chiefs, but few > who want to be Indians (American expression for many who want to > direct and run the show - esp between 9am and 5pm, but few to > actually do they real work - i.e. bedside care, put in orders, call > and discuss with consults, lines, tubes, weaning, even talking with > families and helping admit patients- and do it 24 hr a day and with > the same vigor which we - as cardiac surgeons do - particularly in a > world were our every move and outcome gets examined under a microscope). > > In short, who does the "real" work in your ICU? > > Thoughts? > Comments? > Since we obviously have answer all of the other pressing surgical > questions and no one has anything else to talk about. > > > -michael > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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@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 ----------------------------------------- From msfirst at gmail.com Wed Apr 9 04:00:18 2008 From: msfirst at gmail.com (Michael Firstenberg) Date: Wed Apr 9 03:25:11 2008 Subject: [HSF] ICU Management Systems In-Reply-To: <89c4ed2d0804081848p5b0a4b1x93e30de20c70e459@mail.gmail.com> References: <3526C930-95E7-458D-B6AD-A4E3C51ACC6A@gmail.com> <89c4ed2d0804081848p5b0a4b1x93e30de20c70e459@mail.gmail.com> Message-ID: and what about when they leave the icu? On 4/8/08, Prasanna Simha M wrote: > We have anesthesiologists managing extubations and reintubations but > otherwise we manage most of everything !! > Prasanna > > On Wed, Apr 9, 2008 at 6:27 AM, Edward Bender > wrote: > > > At our small community hospital, the cardiac surgeons manage the patients > > from admit to discharge. Last year, with the addition of an intensivist > > service, I tried using them, but there were problems with availability and > > expertise, so that ended quickly. I do liberally use other services when > > indicated, such as ID for endocarditis or severe surgical site infections, > > pulmonologist (not so much for ventilator management, but to aid in > > keeping > > patients off the ventilator), endocrinologist for poorly controlled or > > refractory hyperglycemia and/or DKA (which happens once or twice a year). > > > > I have found the best adjunct to care is a well trained, caring, and > > available physician assistant or nurse practitioner. Unfortunately, in > > our > > area, these folks are less easy to find. Most go into primary care, since > > in the USA, this is probably going to be the health care model of the > > future > > (economically doing away with primary care physicians). > > > > Ed Bender, MD > > > > > > On 4/8/08 6:46 PM, "Michael Firstenberg" wrote: > > > > > We are in the process of exploring options to assist in the pre/post- > > > operative care of our patients. Our current system has us taking > > > full care and responsibility for all aspects of this process (pre-op > > > eval/tune-ups, post-op management, line changes, vent weaning, call/ > > > working with consults, etc). There are obvious pluses and minuses to > > > this process. What are the other systems which people have to work > > > with and what parts of them do they like and dislike. My concern is > > > that there are always plenty of people who want to be Chiefs, but few > > > who want to be Indians (American expression for many who want to > > > direct and run the show - esp between 9am and 5pm, but few to > > > actually do they real work - i.e. bedside care, put in orders, call > > > and discuss with consults, lines, tubes, weaning, even talking with > > > families and helping admit patients- and do it 24 hr a day and with > > > the same vigor which we - as cardiac surgeons do - particularly in a > > > world were our every move and outcome gets examined under a microscope). > > > > > > In short, who does the "real" work in your ICU? > > > > > > Thoughts? > > > Comments? > > > Since we obviously have answer all of the other pressing surgical > > > questions and no one has anything else to talk about. > > > > > > > > > -michael > > > _______________________________________________ > > > OpenHeart-L mailing list > > > > > > Send postings to: > > > OpenHeart-L@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@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 > > ----------------------------------------- > > > > > > -- > Prasanna Simha M > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > From giulio.rizzoli at unipd.it Wed Apr 9 18:03:21 2008 From: giulio.rizzoli at unipd.it (Giulio Rizzoli) Date: Wed Apr 9 10:58:41 2008 Subject: [HSF] ICU Management Systems In-Reply-To: <3526C930-95E7-458D-B6AD-A4E3C51ACC6A@gmail.com> References: <3526C930-95E7-458D-B6AD-A4E3C51ACC6A@gmail.com> Message-ID: <7.0.1.0.1.20080409170203.01ddac00@unipd.it> >In short, who does the "real" work in your ICU? Residents in cardiac surgery and anesthesiology ! GR Padova Giulio Rizzoli MD FETCS Cardiochirurgia Padova tel. 049 821-2408 fax 049 821-2409 e-mail giulio.rizzoli@unipd.it *************************************************************************** Ich hatte einst ein sch?nes Vaterland. Der Eichenbaum wuchs dort so hoch, die Veilchen nickten sanft. Es war ein Traum .... Heinrich Heine From msfirst at gmail.com Wed Apr 9 12:23:41 2008 From: msfirst at gmail.com (Michael Firstenberg) Date: Wed Apr 9 11:24:15 2008 Subject: [HSF] ICU Management Systems In-Reply-To: References: Message-ID: what happens when residents are not available (OR . home. busy. etc) or when things get really busy? also - not just management and supervision but also doing the work. we all take the calls and run in in the middle of the night with huge problems - but who deals with a lot of the low key stuff? On 4/9/08, alsadd wrote: > Even though I work at a University Hospital but we follow Ed's model. > Surgeons look after the patients. I believe this is the way to train future > surgeons which we do. I believe it is no good to operate and let some one > else manage especially when we have residents who have to learn. That of > course means calls in the middle of the night for us the staff but we got > used to it. I am against having an intensivist when there are residents. > > Ahmed > > -----Original Message----- > From: openheart-l-bounces@lists.hsforum.com > [mailto:openheart-l-bounces@lists.hsforum.com] On Behalf Of Edward Bender > Sent: Tuesday, April 08, 2008 5:57 PM > To: OpenHeart-L@lists.hsforum.com > Subject: Re: [HSF] ICU Management Systems > > At our small community hospital, the cardiac surgeons manage the patients > from admit to discharge. Last year, with the addition of an intensivist > service, I tried using them, but there were problems with availability and > expertise, so that ended quickly. I do liberally use other services when > indicated, such as ID for endocarditis or severe surgical site infections, > pulmonologist (not so much for ventilator management, but to aid in keeping > patients off the ventilator), endocrinologist for poorly controlled or > refractory hyperglycemia and/or DKA (which happens once or twice a year). > > I have found the best adjunct to care is a well trained, caring, and > available physician assistant or nurse practitioner. Unfortunately, in our > area, these folks are less easy to find. Most go into primary care, since > in the USA, this is probably going to be the health care model of the future > (economically doing away with primary care physicians). > > Ed Bender, MD > > > On 4/8/08 6:46 PM, "Michael Firstenberg" wrote: > > > We are in the process of exploring options to assist in the pre/post- > > operative care of our patients. Our current system has us taking > > full care and responsibility for all aspects of this process (pre-op > > eval/tune-ups, post-op management, line changes, vent weaning, call/ > > working with consults, etc). There are obvious pluses and minuses to > > this process. What are the other systems which people have to work > > with and what parts of them do they like and dislike. My concern is > > that there are always plenty of people who want to be Chiefs, but few > > who want to be Indians (American expression for many who want to > > direct and run the show - esp between 9am and 5pm, but few to > > actually do they real work - i.e. bedside care, put in orders, call > > and discuss with consults, lines, tubes, weaning, even talking with > > families and helping admit patients- and do it 24 hr a day and with > > the same vigor which we - as cardiac surgeons do - particularly in a > > world were our every move and outcome gets examined under a microscope). > > > > In short, who does the "real" work in your ICU? > > > > Thoughts? > > Comments? > > Since we obviously have answer all of the other pressing surgical > > questions and no one has anything else to talk about. > > > > > > -michael > > _______________________________________________ > > OpenHeart-L mailing list > > > > Send postings to: > > OpenHeart-L@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@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@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 > ----------------------------------------- > From msfirst at gmail.com Wed Apr 9 12:22:39 2008 From: msfirst at gmail.com (Michael Firstenberg) Date: Wed Apr 9 11:36:51 2008 Subject: [HSF] ICU Management Systems In-Reply-To: References: Message-ID: what happens when residents are not available (OR . home. busy. etc) or when things get really busy? also - not just management and supervision but also doing the work. we all take the calls and run in in the middle of the night with huge problems - but who deals with a lot of the low key stuff? On 4/9/08, alsadd wrote: > Even though I work at a University Hospital but we follow Ed's model. > Surgeons look after the patients. I believe this is the way to train future > surgeons which we do. I believe it is no good to operate and let some one > else manage especially when we have residents who have to learn. That of > course means calls in the middle of the night for us the staff but we got > used to it. I am against having an intensivist when there are residents. > > Ahmed > > -----Original Message----- > From: openheart-l-bounces@lists.hsforum.com > [mailto:openheart-l-bounces@lists.hsforum.com] On Behalf Of Edward Bender > Sent: Tuesday, April 08, 2008 5:57 PM > To: OpenHeart-L@lists.hsforum.com > Subject: Re: [HSF] ICU Management Systems > > At our small community hospital, the cardiac surgeons manage the patients > from admit to discharge. Last year, with the addition of an intensivist > service, I tried using them, but there were problems with availability and > expertise, so that ended quickly. I do liberally use other services when > indicated, such as ID for endocarditis or severe surgical site infections, > pulmonologist (not so much for ventilator management, but to aid in keeping > patients off the ventilator), endocrinologist for poorly controlled or > refractory hyperglycemia and/or DKA (which happens once or twice a year). > > I have found the best adjunct to care is a well trained, caring, and > available physician assistant or nurse practitioner. Unfortunately, in our > area, these folks are less easy to find. Most go into primary care, since > in the USA, this is probably going to be the health care model of the future > (economically doing away with primary care physicians). > > Ed Bender, MD > > > On 4/8/08 6:46 PM, "Michael Firstenberg" wrote: > > > We are in the process of exploring options to assist in the pre/post- > > operative care of our patients. Our current system has us taking > > full care and responsibility for all aspects of this process (pre-op > > eval/tune-ups, post-op management, line changes, vent weaning, call/ > > working with consults, etc). There are obvious pluses and minuses to > > this process. What are the other systems which people have to work > > with and what parts of them do they like and dislike. My concern is > > that there are always plenty of people who want to be Chiefs, but few > > who want to be Indians (American expression for many who want to > > direct and run the show - esp between 9am and 5pm, but few to > > actually do they real work - i.e. bedside care, put in orders, call > > and discuss with consults, lines, tubes, weaning, even talking with > > families and helping admit patients- and do it 24 hr a day and with > > the same vigor which we - as cardiac surgeons do - particularly in a > > world were our every move and outcome gets examined under a microscope). > > > > In short, who does the "real" work in your ICU? > > > > Thoughts? > > Comments? > > Since we obviously have answer all of the other pressing surgical > > questions and no one has anything else to talk about. > > > > > > -michael > > _______________________________________________ > > OpenHeart-L mailing list > > > > Send postings to: > > OpenHeart-L@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@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@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 > ----------------------------------------- > From prasannasimha at gmail.com Wed Apr 9 22:10:17 2008 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Wed Apr 9 11:40:46 2008 Subject: [HSF] ICU Management Systems In-Reply-To: References: Message-ID: <89c4ed2d0804090840h13ac0986se4b2991fef765acb@mail.gmail.com> The Resident does it or the Nurse does it or you yourself do it !! Prasanna On Wed, Apr 9, 2008 at 8:53 PM, Michael Firstenberg wrote: > what happens when residents are not available (OR . home. busy. etc) > or when things get really busy? also - not just management and > supervision but also doing the work. we all take the calls and run in > in the middle of the night with huge problems - but who deals with a > lot of the low key stuff? > > On 4/9/08, alsadd wrote: > > Even though I work at a University Hospital but we follow Ed's model. > > Surgeons look after the patients. I believe this is the way to train > future > > surgeons which we do. I believe it is no good to operate and let some > one > > else manage especially when we have residents who have to learn. That of > > course means calls in the middle of the night for us the staff but we > got > > used to it. I am against having an intensivist when there are residents. > > > > Ahmed > > > > -----Original Message----- > > From: openheart-l-bounces@lists.hsforum.com > > [mailto:openheart-l-bounces@lists.hsforum.com] On Behalf Of Edward > Bender > > Sent: Tuesday, April 08, 2008 5:57 PM > > To: OpenHeart-L@lists.hsforum.com > > Subject: Re: [HSF] ICU Management Systems > > > > At our small community hospital, the cardiac surgeons manage the > patients > > from admit to discharge. Last year, with the addition of an intensivist > > service, I tried using them, but there were problems with availability > and > > expertise, so that ended quickly. I do liberally use other services > when > > indicated, such as ID for endocarditis or severe surgical site > infections, > > pulmonologist (not so much for ventilator management, but to aid in > keeping > > patients off the ventilator), endocrinologist for poorly controlled or > > refractory hyperglycemia and/or DKA (which happens once or twice a > year). > > > > I have found the best adjunct to care is a well trained, caring, and > > available physician assistant or nurse practitioner. Unfortunately, in > our > > area, these folks are less easy to find. Most go into primary care, > since > > in the USA, this is probably going to be the health care model of the > future > > (economically doing away with primary care physicians). > > > > Ed Bender, MD > > > > > > On 4/8/08 6:46 PM, "Michael Firstenberg" wrote: > > > > > We are in the process of exploring options to assist in the pre/post- > > > operative care of our patients. Our current system has us taking > > > full care and responsibility for all aspects of this process (pre-op > > > eval/tune-ups, post-op management, line changes, vent weaning, call/ > > > working with consults, etc). There are obvious pluses and minuses to > > > this process. What are the other systems which people have to work > > > with and what parts of them do they like and dislike. My concern is > > > that there are always plenty of people who want to be Chiefs, but few > > > who want to be Indians (American expression for many who want to > > > direct and run the show - esp between 9am and 5pm, but few to > > > actually do they real work - i.e. bedside care, put in orders, call > > > and discuss with consults, lines, tubes, weaning, even talking with > > > families and helping admit patients- and do it 24 hr a day and with > > > the same vigor which we - as cardiac surgeons do - particularly in a > > > world were our every move and outcome gets examined under a > microscope). > > > > > > In short, who does the "real" work in your ICU? > > > > > > Thoughts? > > > Comments? > > > Since we obviously have answer all of the other pressing surgical > > > questions and no one has anything else to talk about. > > > > > > > > > -michael > > > _______________________________________________ > > > OpenHeart-L mailing list > > > > > > Send postings to: > > > OpenHeart-L@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@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@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@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 > ----------------------------------------- > -- Prasanna Simha M From msfirst at gmail.com Wed Apr 9 14:22:57 2008 From: msfirst at gmail.com (Michael Firstenberg) Date: Wed Apr 9 13:38:06 2008 Subject: [HSF] ICU Management Systems In-Reply-To: <89c4ed2d0804090840h13ac0986se4b2991fef765acb@mail.gmail.com> References: <89c4ed2d0804090840h13ac0986se4b2991fef765acb@mail.gmail.com> Message-ID: thats kind of what i thought and how i do it but what i am trying to figure out is how others work around limited rsources (80 hr rules no resident many pts all over the place problems popping up left and right) On 4/9/08, Prasanna Simha M wrote: > The Resident does it or the Nurse does it or you yourself do it !! > Prasanna > > On Wed, Apr 9, 2008 at 8:53 PM, Michael Firstenberg > wrote: > > > what happens when residents are not available (OR . home. busy. etc) > > or when things get really busy? also - not just management and > > supervision but also doing the work. we all take the calls and run in > > in the middle of the night with huge problems - but who deals with a > > lot of the low key stuff? > > > > On 4/9/08, alsadd wrote: > > > Even though I work at a University Hospital but we follow Ed's model. > > > Surgeons look after the patients. I believe this is the way to train > > future > > > surgeons which we do. I believe it is no good to operate and let some > > one > > > else manage especially when we have residents who have to learn. That of > > > course means calls in the middle of the night for us the staff but we > > got > > > used to it. I am against having an intensivist when there are residents. > > > > > > Ahmed > > > > > > -----Original Message----- > > > From: openheart-l-bounces@lists.hsforum.com > > > [mailto:openheart-l-bounces@lists.hsforum.com] On Behalf Of Edward > > Bender > > > Sent: Tuesday, April 08, 2008 5:57 PM > > > To: OpenHeart-L@lists.hsforum.com > > > Subject: Re: [HSF] ICU Management Systems > > > > > > At our small community hospital, the cardiac surgeons manage the > > patients > > > from admit to discharge. Last year, with the addition of an intensivist > > > service, I tried using them, but there were problems with availability > > and > > > expertise, so that ended quickly. I do liberally use other services > > when > > > indicated, such as ID for endocarditis or severe surgical site > > infections, > > > pulmonologist (not so much for ventilator management, but to aid in > > keeping > > > patients off the ventilator), endocrinologist for poorly controlled or > > > refractory hyperglycemia and/or DKA (which happens once or twice a > > year). > > > > > > I have found the best adjunct to care is a well trained, caring, and > > > available physician assistant or nurse practitioner. Unfortunately, in > > our > > > area, these folks are less easy to find. Most go into primary care, > > since > > > in the USA, this is probably going to be the health care model of the > > future > > > (economically doing away with primary care physicians). > > > > > > Ed Bender, MD > > > > > > > > > On 4/8/08 6:46 PM, "Michael Firstenberg" wrote: > > > > > > > We are in the process of exploring options to assist in the pre/post- > > > > operative care of our patients. Our current system has us taking > > > > full care and responsibility for all aspects of this process (pre-op > > > > eval/tune-ups, post-op management, line changes, vent weaning, call/ > > > > working with consults, etc). There are obvious pluses and minuses to > > > > this process. What are the other systems which people have to work > > > > with and what parts of them do they like and dislike. My concern is > > > > that there are always plenty of people who want to be Chiefs, but few > > > > who want to be Indians (American expression for many who want to > > > > direct and run the show - esp between 9am and 5pm, but few to > > > > actually do they real work - i.e. bedside care, put in orders, call > > > > and discuss with consults, lines, tubes, weaning, even talking with > > > > families and helping admit patients- and do it 24 hr a day and with > > > > the same vigor which we - as cardiac surgeons do - particularly in a > > > > world were our every move and outcome gets examined under a > > microscope). > > > > > > > > In short, who does the "real" work in your ICU? > > > > > > > > Thoughts? > > > > Comments? > > > > Since we obviously have answer all of the other pressing surgical > > > > questions and no one has anything else to talk about. > > > > > > > > > > > > -michael > > > > _______________________________________________ > > > > OpenHeart-L mailing list > > > > > > > > Send postings to: > > > > OpenHeart-L@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@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@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@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 > > ----------------------------------------- > > > > > > -- > Prasanna Simha M > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > From dukeb60 at aol.com Wed Apr 9 15:28:16 2008 From: dukeb60 at aol.com (dukeb60@aol.com) Date: Wed Apr 9 14:32:39 2008 Subject: [HSF] Standard of care for lawyers Message-ID: <8CA68869CF96685-1304-1F48@WEBMAIL-DC16.sysops.aol.com> ?? It has been fairly quiet on the forum so I'll post this recent response from our State Supreme Court to induce some reaction.? As you know, I am a lawyer although I have never practiced law but do have a little more background than the average person and did pass the bar.? I recently had a lawyer handle a case for me in which he performed very poorly and what I considered to be in a frankly negligent manner by not representing my interests and failing to even read some rather pertinent legal materials.? As a result, I filed a complaint with the Counsel for Discipline of our State Supreme court to review his handling of the case.? The response startled even me not so much in the conclusion but the rational for the same, which I will share.? The respondent wrote, "Isolated instances of ordinary negligence or errors of judgement do not rise to the level of a disciplinary violation and are not sufficient to warrant disciplinary action.? ? ??As stated in Modern?Legal Ethics (1986): ??? ????????? To date, the enforcement of competence standards has been generally limited to relatively exotic, blatant, or repeated cases of lawyer bungling.? Lawyers who make some showing of effort, and who do nothing other than perform badly, rarely appear in the appellate reports in discipline cases.? The lawyers who are disciplined for? incompetence have usually aggravated their situation.? For example, several cases involve lawyers who, after their incompetent work, concocted elaborate schemes or lies to decieve a client whose case was mishandled. ?? ... For the above reasons I have concluded, pursuant to Rule of Discipline 9(C), that your allegations against Attorney "X" do not warrant further inquiry by this office."? ???? So, this is the standard to which our legal professionals are held in their handling of cases.? I am quite certain it is not the same standard to which we, as medical professionals, are held in the handling of our cases.? It is okay to bungle as long as you don't concoct a scheme to conceal the bungling. ? As much as it is hard to believe that is actually what a representative of the Supreme Court wrote it is true.? Caveat emptor, clearly, is the rule in law.? While I appreciate the education of a law degree, it is indeed embarrassing sometimes to be one. ??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? Ed From tacuff at swbell.net Wed Apr 9 13:01:48 2008 From: tacuff at swbell.net (Tea Acuff) Date: Wed Apr 9 15:02:19 2008 Subject: [HSF] Standard of care for lawyers Message-ID: <173373.28945.qm@web81606.mail.mud.yahoo.com> I originally thought you were asking what standard of care we should provide for lawyers. The senario that you describe is the alternative golden rule often used by those that state their purpose as the protection of others. That is, those with the gold make the rules. tea ----- Original Message ---- From: "dukeb60@aol.com" To: OpenHeart-L@lists.hsforum.com Sent: Wednesday, April 9, 2008 1:28:16 PM Subject: [HSF] Standard of care for lawyers ?? It has been fairly quiet on the forum so I'll post this recent response from our State Supreme Court to induce some reaction.? As you know, I am a lawyer although I have never practiced law but do have a little more background than the average person and did pass the bar.? I recently had a lawyer handle a case for me in which he performed very poorly and what I considered to be in a frankly negligent manner by not representing my interests and failing to even read some rather pertinent legal materials.? As a result, I filed a complaint with the Counsel for Discipline of our State Supreme court to review his handling of the case.? The response startled even me not so much in the conclusion but the rational for the same, which I will share.? The respondent wrote, "Isolated instances of ordinary negligence or errors of judgement do not rise to the level of a disciplinary violation and are not sufficient to warrant disciplinary action.? ? ??As stated in Modern?Legal Ethics (1986): ??? ????????? To date, the enforcement of competence standards has been generally limited to relatively exotic, blatant, or repeated cases of lawyer bungling.? Lawyers who make some showing of effort, and who do nothing other than perform badly, rarely appear in the appellate reports in discipline cases.? The lawyers who are disciplined for? incompetence have usually aggravated their situation.? For example, several cases involve lawyers who, after their incompetent work, concocted elaborate schemes or lies to decieve a client whose case was mishandled. ?? ... For the above reasons I have concluded, pursuant to Rule of Discipline 9(C), that your allegations against Attorney "X" do not warrant further inquiry by this office."? ???? So, this is the standard to which our legal professionals are held in their handling of cases.? I am quite certain it is not the same standard to which we, as medical professionals, are held in the handling of our cases.? It is okay to bungle as long as you don't concoct a scheme to conceal the bungling. ? As much as it is hard to believe that is actually what a representative of the Supreme Court wrote it is true.? Caveat emptor, clearly, is the rule in law.? While I appreciate the education of a law degree, it is indeed embarrassing sometimes to be one. ??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? Ed _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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 ----------------------------------------- From msfirst at gmail.com Wed Apr 9 12:23:50 2008 From: msfirst at gmail.com (Michael Firstenberg) Date: Wed Apr 9 15:33:28 2008 Subject: [HSF] ICU Management Systems In-Reply-To: References: Message-ID: what happens when residents are not available (OR . home. busy. etc) or when things get really busy? also - not just management and supervision but also doing the work. we all take the calls and run in in the middle of the night with huge problems - but who deals with a lot of the low key stuff? On 4/9/08, alsadd wrote: > Even though I work at a University Hospital but we follow Ed's model. > Surgeons look after the patients. I believe this is the way to train future > surgeons which we do. I believe it is no good to operate and let some one > else manage especially when we have residents who have to learn. That of > course means calls in the middle of the night for us the staff but we got > used to it. I am against having an intensivist when there are residents. > > Ahmed > > -----Original Message----- > From: openheart-l-bounces@lists.hsforum.com > [mailto:openheart-l-bounces@lists.hsforum.com] On Behalf Of Edward Bender > Sent: Tuesday, April 08, 2008 5:57 PM > To: OpenHeart-L@lists.hsforum.com > Subject: Re: [HSF] ICU Management Systems > > At our small community hospital, the cardiac surgeons manage the patients > from admit to discharge. Last year, with the addition of an intensivist > service, I tried using them, but there were problems with availability and > expertise, so that ended quickly. I do liberally use other services when > indicated, such as ID for endocarditis or severe surgical site infections, > pulmonologist (not so much for ventilator management, but to aid in keeping > patients off the ventilator), endocrinologist for poorly controlled or > refractory hyperglycemia and/or DKA (which happens once or twice a year). > > I have found the best adjunct to care is a well trained, caring, and > available physician assistant or nurse practitioner. Unfortunately, in our > area, these folks are less easy to find. Most go into primary care, since > in the USA, this is probably going to be the health care model of the future > (economically doing away with primary care physicians). > > Ed Bender, MD > > > On 4/8/08 6:46 PM, "Michael Firstenberg" wrote: > > > We are in the process of exploring options to assist in the pre/post- > > operative care of our patients. Our current system has us taking > > full care and responsibility for all aspects of this process (pre-op > > eval/tune-ups, post-op management, line changes, vent weaning, call/ > > working with consults, etc). There are obvious pluses and minuses to > > this process. What are the other systems which people have to work > > with and what parts of them do they like and dislike. My concern is > > that there are always plenty of people who want to be Chiefs, but few > > who want to be Indians (American expression for many who want to > > direct and run the show - esp between 9am and 5pm, but few to > > actually do they real work - i.e. bedside care, put in orders, call > > and discuss with consults, lines, tubes, weaning, even talking with > > families and helping admit patients- and do it 24 hr a day and with > > the same vigor which we - as cardiac surgeons do - particularly in a > > world were our every move and outcome gets examined under a microscope). > > > > In short, who does the "real" work in your ICU? > > > > Thoughts? > > Comments? > > Since we obviously have answer all of the other pressing surgical > > questions and no one has anything else to talk about. > > > > > > -michael > > _______________________________________________ > > OpenHeart-L mailing list > > > > Send postings to: > > OpenHeart-L@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@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@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 > ----------------------------------------- > From ebender001 at charter.net Wed Apr 9 17:48:01 2008 From: ebender001 at charter.net (Edward Bender) Date: Wed Apr 9 17:48:45 2008 Subject: [HSF] Standard of care for lawyers In-Reply-To: <8CA68869CF96685-1304-1F48@WEBMAIL-DC16.sysops.aol.com> Message-ID: This is disturbing but not that surprising. Perhaps if lawyers were required to carry malpractice insurance that paid as well as medical malpractice insurance, there would be an incentive for one attorney to go after another. As it stands, what's in it for a prospective plaintiff? Ethics are obviously not involved. I related your story to one of my cardiologists with whom I regularly trade legal nightmare stories. He tells me of a surgeon who was in the middle of an aortic aneurysm repair who was mistakenly paged by an outside ER for a trauma case. He wasn't on call and obviously could not deal with the acute trauma during his AAA repair in any case. The correct surgeon was called, the patient was transferred but died in the ER of severe multiple trauma. The mistakenly called surgeon was named in the subsequent law suit, and the plaintiff's attorney refused to drop him from the case unless he was paid some money. This went on for years, and he was eventually dropped. The surgeon wanted to sue the attorney but could find no attorney that was willing to take the case. The surgeon was so angered by this that he spent the next year learning how to file and pursue this himself, and he eventually won a huge settlement from the litigator's law firm. The moral of the story is that litigators are scum sucking, bottom dwelling, garbage eating pig-f**kers, who have crawled out of the a**hole of hell - and I mean that with all due respect. Ed Bender, MD On 4/9/08 1:28 PM, "dukeb60@aol.com" wrote: > ?? It has been fairly quiet on the forum so I'll post this recent response > from our State Supreme Court to induce some reaction.? As you know, I am a > lawyer although I have never practiced law but do have a little more > background than the average person and did