[HSF] Sympathy anyone.......

[Ani Anyanwu]

> With regards to the ACS....  The problem is that no longer is there> time or thought that goes into the concept of a "differential diagnosis".> Thanks to "scoring systems" there is such a rush to get them to the Cath lab> that anything that gets in the way hurts "the system". ....On the other side of the coin,> I took him right away from the Cath lab to the OR..... that helps me with my> time from Cath to OR statistics 
> > -michael
 
Well then Michael you are as guilty of what you accuse the cardiologists of - rushing the patient, who has had the condition for 4 days and just been given a host of antithrombotic drugs, straight from cath-lab to OR within minutes of seeing him cannot have given the patient due consideration and work-up either. Like the ER doctor and cardiologists, you are also following a cookbook which in our instance is that acute dissection=immediate surgery and like the cardiologist you also want a record (cath to OR) transfer time which does not consider appropriateness to the individual patient. As has been mentioned, in your patient, many would consider a delay in surgery beneficial and certainly there was no immediate need to operate asap (as having survived till four days the conditional probability of dying on the fifth day will be low - i do not know the data off hand but unlikely to even be 10% and may well be less than the incremental risk of death in operating on such an anticoagulated patient). Mind you I am not criticizing you - I have done same myself - but just trying to point out that we (cardiologists, surgeons, ER doctors) are all peas from the same pod.
 
By the way I am sure you were not serious in saying any patient with type A you do with AI will get a valve replacement or were you just referring to the Marfan's cases?
 
I would be cautious with liberal usage of blood transfusions - they are not innocuous. One day it may come back to haunt you. Ask those doctors who were jailed for giving people tainted blood in the 1980s...of all the drugs we give to bleeding patients, blood is probably the most toxic.
 
Ani
 



> Date: Fri, 2 May 2008 08:40:24 -0400> From: msfirst at gmail.com> To: OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] Sympathy anyone.......> CC: > > I also have done a few Bio-Bentall - I try to get someone to sew the valve> on to the conduit while I am doing something else. While I am concerned> about the redo also (probably less of a concern years down the road), but I> am more concerned about Coumadin. I think Coumadin is one of the most> dangerous drugs out there! Coumadin in a Marfan's patient with a chronic> type B dissection - talk about a time bomb. I think if you look at the> curves for structural valve degeneration and survival for various types of> Type A - they are probably similar.> > I think part of my maturing process that Ed is referring to is that if the> patient is dying from a lethal problem - dont get creative with valve> spairing crap.......if the valve and annulus is fine that is one thing.....> in my hands (for now) ANY AI gets a valve. Taking the cross clamp off and> finding you still have +2 AI is a VERY bad problem. Furthermore, I am not> aware of any good data about David's/etc for dissections. The Florida> sleeve looks nice, but I think the valve and annulus, again, must look> perfect.> > With regards to the ACS.... 4 days of chest pain with ST changes will and> probably should get a STEMI work-up. The problem is that no longer is there> time or thought that goes into the concept of a "differential diagnosis".> Thanks to "scoring systems" there is such a rush to get them to the Cath lab> that anything that gets in the way hurts "the system". These new protocols> have no room for individual variations - we have had post-op patients come> in to the ED with chest pain, abnormal ECGs and get taken to the cath lab> without us getting notified. Does it matter that they had a clean cath 2> weeks prior and right before their surgery and they got a valve or something> else? (so what if their ECG changes are from a pericarditis/effusion that> needs to be drained on high dose Plavix). This is what happens when Doctors> get taken out of the loop and they get replaced by automated> systems/protocols/guidelines/scorecards/etc. On the other side of the coin,> I took him right away from the Cath lab to the OR..... that helps me with my> time from Cath to OR statistics - something else that is tracked in "our> system". Fortunately, I dont get month blood utilization reports (at least> not yet) - although the % of patients who get transfused is another> "index". I guess you have to pick your battles - and me? I just want to> get them home alive and away from the perils of the heathcare system.> > -michael> > > > > On 5/2/08, Hgrmd at aol.com <Hgrmd at aol.com> wrote:> >> > Steve,> > I've done a few biologic Bentalls. It's really pretty straight forward.> > Measure the aortic annulus in the usual manner. If it's a 23 mm, add 5> > and> > use a 28 graft (I currently favor the Valsalva). The graft is attached> > to the> > valve with a running 4-0 Prolene (doesn't have to be hemostatic).> >> > Hal> >> >> >> > **************Wondering what's for Dinner Tonight? Get new twists on> > family> > favorites at AOL Food.> > (http://food.aol.com/dinner-tonight?NCID=aolfod00030000000001)> > _______________________________________________> > OpenHeart-L mailing list> >> > Send postings to:> > OpenHeart-L at lists.hsforum.com> >> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> > All messages transmitted by the OpenHeart-L are subject to the policies> > and> > disclaimers posted at:> > http://www.hsforum.com/listdisclaim> > -----------------------------------------> >> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> -----------------------------------------
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