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Thursday, February 25, 2010

Fish, buffalo, salad, and Air Force 2: Dick Cheney's Fifth Heart Attack

Katie Drummond writes engagingly on "How Does Dick Cheney’s Ticker Keep on Ticking?"

The recent Vice President suffered another mild heart attack – his fifth – and was released from the hospital earlier this week. He has had eight cardiac events, which have been treated with a quadruple bypass (a CABG), an implanted stent, an implanted cardioverter defibrillator, which was later replaced, and many medications.

The secret of his survival? Cheney has performed aggressive and sustained self-care. After his first heart attack, at age 37, Cheney ended his 20-year heavy smoking habit. Later, before becoming Vice President, he lost 25 pounds. When he flew on Air Force 2, he often brought his elliptical trainer. Aides say his diet now consists of "fish, buffalo, and salad."

Another secret to his survival has been his top-flight, 24/7 medical attention. While he was Vice President, the White House Medical Unit accompanied him with a fully loaded medical bag. As Cheney commented in 2003, "I've got a doc with me 24 hours a day who watches me very carefully."

Advice to heart patients who don't have Air Force 2 and your own 24-hour doctor: Safeguard your own health as actively as Dick Cheney.

Read a story about former president George W. Bush. Thanks to Katie Driscoll for the source story in the AOL News of Feb. 24.

Friday, February 19, 2010

A pretty fair trade: Abdominal surgery in Bangkok

From James Cameron Mielke's Christmas letter:
While packing for my summer visit to the USA, I noticed a slight bulge in my abdominal incision, and headed instead to Bangkok for surgery - it all seemed like such a breeze compared to the nightmare I endured three years before when admitted in emergency and life-threatening condition – this time was so much easier just to check in as scheduled. With practiced precision, the nurse located one of my elusive veins to start the IV, the anesthesiologist wished me a pleasant snooze, and after 90 minutes on the table my surgeon had successfully inserted a large mesh across my entire abdomen – like getting a new set of surgically implanted "six-pack" abs!

Man, what a deal! Emerging from the unexpected surgery and almost relieved to have to cancel my USA trip – I was dreading the long journey anyway, and with all the economic stress and other difficulties there…and I was able to recover my frequent flier miles as well! Interestingly, I had been feeling strangely resistant to the whole thing - as if some underlying intuitive awareness was trying to alert me to this potentially disastrous trip. Apparently, I was literally coming apart at the seams - the longitudinal incision that runs from stem to sternum was ripping apart and the muscles were separating, which meant that I was a walking time bomb. It would not have been at all pleasant if my guts had decided to spill out while on the plane or somewhere away from home. And of course, I would have taken a huge financial hit if I had needed emergency surgery while in the USA. Thank goodness I live in Thailand where my highly specialized state-of-the-art surgery, anesthesiology, and three days of in-patient hospital care came to just $2,000, which is about what my USA holiday would have cost - a pretty fair trade considering I can now look forward to an even better quality of life for years to come! Many of the competent and eager nurses remembered me from before, and my cost-conscious surgeon even gave me the remaining portion of high-tech mesh that another patient had purchased but didn't use. My sister Jean also enjoyed high quality, efficient and affordable health care during her visit to Phuket during Christmas week.

So, once again, I cannot believe my good fortune, not only to have avoided another possible disaster, but also to be given what now seems like a gift – such a wonderful gift of enhanced quality of health and blessed freedom to continue enjoying my life! I can only feel the deepest gratitude for it all – and am humbled once again by the amazing blessings that keep coming my way. As the risk for infection decreased with each day of healing, and with deep, slow-dissolving sutures like a set of guitar strings holding me together, I set off for my annual four months of work. This year I joined a team of consultants to design a five-year $60 million regional communicable diseases control project in Cambodia, Lao PDR and Viet Nam.

Read a story about another American's health crisis far away from the U.S.

Friday, February 12, 2010

The former Commander in Chief toed the line: Bill Clinton's self-care

Former President Bill Clinton, now 63, has a history of heart trouble. In 2004, he experienced chest pain and shortness of breath, and had quadruple coronary artery bypass graft (CABG) surgery. Later, feeling that it was hard to breathe because of a rare complication of scar tissue and fluid build-up in his lung, he had another operation, in March 2005.

He experienced chest pain again a few days ago, and had another operation on Thursday. Surgeons in a New York hospital placed two stents (metal mesh tubes) inside a blocked heart artery to prop it open, after his bypass graft had become obstructed. Such vein segments taken from the patient's leg often become clogged in this way after a few years, requiring another operation.

I've seen stent surgery, and it's magical. The surgeon snakes a long narrow tube up several feet through a tiny incision in the inside upper thigh of the patient, while the surgeon watches a monitor that shows the patient's arteries and the progress of the long sheath, illuminated as needed by puffs of a fluoroscopic dye. The stent, initially compressed, is slid through the sheath, opening itself as it leaves the sheath. The only analogy is the way that a model ship in a bottle snaps out into its final form after emerging through the bottleneck. Finally, only a Bandaid is needed to protect the site of the incision.

Mr. Clinton did not suffer a heart attack. (Indeed, he was continuing to talk on a cell phone about relief and recovery efforts in Haiti, even as he was being wheeled into the operating room.) Rather, he heeded his body's signals by seeking medical attention promptly.

The head of Cardiology at New York-Presbyterian/Columbia hospital, Dr. Allan Schwartz, noted that "President Clinton has really toed the line in terms of diet and exercise," and said his cholesterol numbers were normal.

Advice to middle-aged men with chest pain:
Don't ignore your body's pain signals.

Read another story of a famous person’s successful heart surgery. Thanks to Peter Baker and Angela Macropoulos for the source story in today's New York Times.

Wednesday, February 10, 2010

But for the grace of God: Abigaile LeBron and caps on medical malpractice damages

After vaginal bleeding from unknown causes in the third semester of her pregnancy, Frances Lebron had a very difficult labor, and gave birth by C-section to Abigaile LeBron in an Illinois hospital in 2005.

It's hard to know exactly what went wrong. A jury agreed that Frances' Ob-Gyn doctor and nurse had not performed appropriate and timely tests on Frances, and/or didn't recognize, and appropriately intervene upon discovery of, a non-reassuring fetal heart tracing, and/or inappropriately continued labor-delaying ("tocolytic") medication, and/or failed to perform the C-section promptly enough.

The poor little girl suffered severe and lasting brain injury, and cerebral palsy, among other results, and will not be able to feed herself; she needs a gastronomy tube. She'll need substantial help for the activities of daily living, probably throughout her life. Of course, that will cost a lot of money – which the jury awarded.

The Illinois Supreme Court recently decided an appeal of that decision. The state Supreme Court ruled that a newly legislated cap on damages for medical malpractice is unconstitutional. The result is that the jury's award will indeed be able to help Frances care for Abigaile.

There, but for the grace of God, go I. Twenty years ago, doctors at a Harvard teaching hospital slowed my wife's premature labor with such a "tocolytic" drug (Turbutalene), and continued the drug too long, as with Frances – but my son was born healthy, and my wife had no ill effects. We were lucky.

I'm sorry for the anguish suffered by Frances and Abigaile, and by their doctor and nurse.

Advice for people who've suffered catastrophic medical errors:
Ask potential lawyers if you'll be faced with a cap on damages in your state.

Read another story on a C-section error. Thanks to Illinois attorney Martin Dolan and Lauren Bishop for discussing and forwarding this story.

Saturday, February 6, 2010

He had to be re-admitted: Rep. John Murtha's hospital acquired infection

U.S. Representative John Murtha, Chairman of the House military appropriations committee, is recuperating in the intensive care unit after a surgical infection from his gallbladder surgery. He'd had laparoscopic surgery to remove the gallbladder in late January, and had to be re-admitted to a hospital because of the infection.

He was in grave condition following the hospital infection. Now the infection is responding to antibiotics, and the condition of the 77-year-old congressman has been improving.

Nurses should provide antibiotics before surgery (prophylactic antibiotics) to prevent surgical infections, but don't always do so. A surgical checklist should remind nurses and doctors about the antibiotics, but checklists are not always used.

Advice to patient advocates of patients undergoing surgery: Ask the surgeon beforehand if he or she uses a checklist. If you don't hear Yes, choose another surgeon. If they don't use a checklist, or if they bristle at the question, that might indicate arrogance that can intimidate their clinical teammates into silence when a surgical error is about to occur.

Read other surgical infection stories. Thanks to Carol D. Leonnig and Paul Kane for their background article in the Washington Post of Feb. 3.

Friday, February 5, 2010

It entitled him to Medicaid coverage: A pharmacy benefit error

Zumante Lucero struggled with asthma for the last nine years, since he was three months old. He loved karate, drawing cartoon figures, and riding bikes with his brothers and sisters near their Denver home. His doctor said his lungs were severely inflamed, so he required Advair twice a day. Zumante's condition had been so severe since age six that he was covered by Social Security, which entitled him to Medicaid coverage.

Yet the retail pharmacy's computer system mistakenly showed he was not eligible for prescription drug coverage.

He was brought to the Emergency Room in May and June and given free samples of the medicine.

But it was not enough. On July 16, his mother heard him call from upstairs: he couldn't breathe. She called an ambulance, but Zumante lost consciousness before it arrived, and never regained consciousness.

Advice to parents: If you can't get the medicine your child needs after three calls to the insurer, go to the CEO – and to the press, if necessary.

Read another asthma story. Thanks to Allison Sherry for the source story in the Denver Post on Feb 4.

Thursday, February 4, 2010

What we have known all along: ACGME's review of guidelines for residents' work hours

I still remember the helpless fear I felt on a bus in 1978 as we twisted our way along the narrow hilly road leading to Jerusalem, steered by a sleepy bus driver. Each time he nodded off, his head then snapped right up again. Thank God, we arrived safely.

But God didn't prevent an accident from exhaustion when my son was born, 12 years later. Going into premature labor eight weeks early, my wife was admitted to a Harvard teaching hospital, where doctors delayed her childbirth for a week. Then when hearing one evening that she was experiencing abdominal pain, the sleep-deprived residents confidently attributed them to gas pains! Finally the next morning, a pelvic exam revealed her cervix was nearly fully dilated, ready for delivery. Exhaustion had ruined their judgment, so my wife had to suffer the pain of childbirth for 12 hours without any pain medication.

Now the Accreditation Council on Graduate Medical Education (ACGME) may start facing what we have known all along: exhaustion creates errors. Even for very intelligent and dedicated doctors. At ACGME's Board meeting on Feb. 7 they'll consider whether to restrict the hours that hospital residents can work.

Supporters of the status quo say that shorter work hours require more dangerous hand-offs from one doctor to another. This is seductive but misleading. Yes, sometimes an alert and well-rested resident hands off the responsibility for a patient's care to another alert and well-rested resident, and communicates clearly and comprehensively. But much more often, an exhausted resident hands off to a chronically sleep-deprived resident. We know that exhaustion fogs memory, and clouds judgment and complex thinking, like the ability to prioritize and summarize. So it's hard to imagine that hand-offs as they are now performed consistently provide a clear and thorough briefing for a patient's care.

The best solution is both to reduce the use of exhausted residents, and thoughtfully improve the hand-off process. Error-proof it by minimizing the reliance on memory. For example, how about a "Hand-off" command in the electronic medical record system that could automatically summarize the patient's diagnosis and recent key lab results and vital signs for a doctor coming on shift? Or the audio recording of the hand-off communication as it occurs, for prompt automatic transcription into the electronic medical record?

A bereaved mother and national patient safety leader – Helen Haskell – organized a press conference today on these topics. She is leading an effort to reduce residents' work hours – which could have saved the life of her 15-year-old son, Lewis Blackman. See the new website on shortening residents' work hours, and share your story there.

Would you want my Israeli bus driver as your child's doctor in the hospital?

Read a fatal fatigue error story.

Wednesday, February 3, 2010

Bring a man's shirt: A recovery wear garment for mastectomy patients

Peg Feodoroff's story:
As a result of my and my youngest sister's cancer experiences, we were compelled to start a company that would improve the environment in which people are asked to heal and recover. We designed a Recovery Wear garment that we call the Original Healing Threads. This was our first project and we have many other ideas to further our mission. However, we need to be profitable before we can proceed.

Hospitals cannot afford to purchase our Healing Threads for their patients. We do have 4 hospitals throughout the USA that have forward-thinking decision makers who give our Healing Threads to their mastectomy patients before their surgery. They raise the money to pay for them via the medical institution's philanthropic arm. Wearing our Healing Threads allow women to recover and heal with their dignity and modesty intact. The patented break-away panels allow only the body parts that need to be exposed, to BE exposed. The interior pockets hold post-surgery drainage bulbs discreetly and comfortably. Did you know that the medical community has a common practice of preparing women for breast surgery by suggesting that they bring a MAN'S SHIRT to the hospital for their trip home? Now, your breast or 2 has been removed and now they confirm your feelings of inadequacy as a woman by advising you to bring in a man’s shirt! Not so subliminal a message there! Oh, and then they clip the drainage bulbs to said shirt where they constantly remind you that you no longer have a breast. The Hippocratic Oath states, "First, do no harm," and obviously is taken as an admonition against physical harm. The psychological harm being done is undeniable and endless.

Our garments provide our customers with dignity, modesty, and empowerment. Being able to say "no" to a hospital gown empowers a person to say "no" to other directives: to ask questions; to get 2nd or 3rd opinions; to dialogue with the doc re options, side effects, etc., etc.. To take control and ownership of their own health, their own illness or disease. To bring to the battle the mind, the body and the spirit. Without all 3 working together recovery is not possible.

Yes, you do have a choice, a choice that has won praise from many medical personnel who have worked with patients wearing it. Our Healing Threads are not only attractive, they are supremely functional.

Read a story about hospital gowns. Thanks to Peg Feodoroff, the president of Healing Threads, for the story.