Just a few more cases to go…
Jill says: June 21, 2011 at 4:58 pm (Edit)
Jim,
I am so proud of you. Never a doubt that you would dedicate yourself completely to this extraordinary experience. Your commitment to excellence is unsurpassed. It has been a sacrifice made by you, your partners and even me, but a wonderful invaluable one……sure to pay off. Now come on home…..our lives are changing by the minute.
Love you,
Jill
"No Love" in Cleveland
One has to ask, “Did anyone in Cleveland EVER like LeBron?” I would have to give him credit for showing up at a Heat/Cavs game without the Secret Service. I have yet to meet someone here who doesn’t have an opinion about him. Whew, tough crowd! I hope my exit is not so celebrated.
Looking forward to my last few days here (after my last call this coming weekend). I certainly feel like I have a whole different set of skills to work with, nascent as they may be. What is also new is the perspective of practicing vascular surgery in a manner similar in some ways yet quite different from both how I trained and how I previously practiced. Understandably the practice climate is a little different when each one of the vascular services (three) has a Fellow who is at least a PGY 6. It’s also interesting that Vascular Surgery is it’s own department with 20 surgeons throughout the network. They run their own M&M and have very little interaction with General Surgery. GS Residents do rotate through but I suspect they get a lot of their “vascular” cases at outside rotations. At least 4 of the outside hospitals are used for Vascular fellow and Vascular Resident rotations. Their endovascular practice is supported by 5 dedicated and outstanding radiology techs who work only in Vascular Surgery staffing the 4 hybrid OR’s (soon to be 6). They are recruiting another Vascular Surgeon.
Part of the difference in the practice mix is the role of Vascular Medicine in the consult mix. Many of the DVT consults we currently see are seen and managed by Vascular Medicine here. Likewise for the coagulopathy patients. Anticoagulation management is the responsibility of Vascular Medicine. What I didn’t realize until just last week is that the staff here all see patients at one of the outside hospitals each week. As in our practice, that makes sense. The difference is that they don’t operate at the outside hospitals. In-Patient rounds are fairly quick and efficient leaving lots of details to the fellows and the NP’s. The EMR facilitates discharges and follow up.
I have seen almost no interaction with trauma. There is an IR service here but they have little or no cross over with Vascular Surgery with the exception of dialysis access lysis and catheter placement. Cardiac Surgeons (Roselli and Soltesz) do EVARs on a regular basis. Cardiologists (I think) are continuing to do Carotid stents here but the Vascular Surgeons have scheduled only 3 in my three months ( and Clair was a PI on the flow reversal trials). There does not seem to be a competition between Departments and I suspect that this is because everyone is busy enough. Of course, it doesn’t hurt to have the Greenberg effect on outside referrals for complicated stent grafts.
The vascular lab remains a big part of the practice but studies are also read by Vascular Medicine. I think our lab is structured better. They lack an organized protocol system for follow up here. This may reflect the large proportion of remote patients in their practice.
What has become obvious to me (that wasn’t obvious at the beginning of this Fellowship) is that the power of this Department is the individual surgeons and their energy level for keeping this Department world-class. The reputation of the Cleveland Clinic is merely a smoky veil that will dissipate quickly over time (and has in some areas) if the quality of the staff is allowed to diminish. The institutional reputation is intimately tied to the surgeons who are driving the daily health care here. Let the staff slide and the veil quickly vanishes. The brilliance of the Cleveland Clinic is that it’s leadership has continued to recognize the critical nature of its staff and recruits outstanding individuals to care for it’s patients. Norm Hertzer and Ken Ouriel built a juggernaut that has been steered forward by Dan Clair. Picking the right people is what builds for tomorrow sometimes at a cost for today.
With my life situation both in and outside of Cleveland continuing to evolve without much control on my part I am not sure how many posts I will make in the future. This journey has been difficult, fun, anxiety provoking, rewarding, enlightening, tiring, exhausting and energizing (often in one day). I have made some very nice friends here both staff and fellows. I am a different surgeon than I was 3 months ago. I am so glad that Jay Fisher started this adventure and that we were able to take advantage of this incredible opportunity at an incredible institution. And now we have to put it in play…hopefully better than LeBron did.
There is an interesting phenomenon that occurs when you operate at the top of the mountain. There aren’t a lot of people looking over your shoulder. Historically, this was the world that William Halsted operated in claiming that the “clinic is your laboratory.” Today, litigation has removed the “laboratory” from our practice as all of our treatments must be defensible by referencing publications supporting the procedures and medications we prescribe. But the concept still survives in a few select places. These institutions, like the Cleveland Clinic, are often able to “investigate” modifications to therapy simply because their patients are convinced they are getting the best care. And they are, just maybe not the same “best care” that patients are receiving in other hospitals. While some new therapies or procedures are subjected to the rigorous microscope of an FDA trial, other modifications or therapeutic interventions are subtle enough to fly under the radar of regulatory bodies allowing very busy centers to accumulate enough outcomes data to warrant a publication. This is the constant challenge throughout medicine: to advance our knowledge in the face of “evidence based Medicine” despite its stifling grip on innovation. Along these lines I’ve had discussions with several of the surgeons about management of certain conditions that one of the senior Vascular Fellows described as “Not quite conventional” but nonetheless provided a quite conventional recovery and outcome. This is the privilege of operating at the top of the mountain. Another of the vascular fellows described it succinctly, “They operate with impunity.” I am, in no way, implying that procedures are inappropriate or cavalier. Sound surgical judgement is always the rule here and surgical technique is first rate but there is a freedom that allows for creativity in planning and approach that surgeons elsewhere can only envy.
Yes - THAT's an aneurysm
Successful stent graft repair
From a different perspective
Unfortunately this cachectic debilitated gentleman is bleeding from his lungs. His aneurysm is no longer his biggest problem.
Up all night managing glucoses, potassiums, ambien orders and confused patients.
A bit too tired to write. Planning an Endurant graft (aneurysm stent graft) in the am with a conduit for access.
My brother is slowly recovering and will likely be discharged tomorrow. My wonderful wife is home preparing for us to move with the help of her sister. I may not recognize our home when I get there!
j
At home… In Jill’s arms. Goodbye, best friend.
G-100. Where I'll be heading Monday after "On-Call" weekend
Although my schedule today was cut significantly by patient disease it still turned out to be a productive learning day. Our first case was cancelled when I noticed that the patient’s creatinine (measure of kidney function) today was significantly increased over yesterday’s despite overnight hydration with bicarb. Xray “dye” can cause decreased kidney function especially in patients who already have elevated creatinine levels. She was rescheduled for tomorrow morning but we’ll have to see where her levels are in the morning. There is virtually no consideration given to nephrology consults unless the patient needs dialysis. Generally, the staff feels that nephrologists unnecessarily delay studies and interventions with little improvement in outcomes.
We did perform an arteriogram on our second patient after he was yanked from dialysis (lest we sit around waiting with an empty OR). He had a gangrenous toe. We attempted to cross a distal SFA / Pop occlusion but were unable to make any headway through this Chronic Total Occlusion. They don’t subscribe to any of the devices for crossing these lesions. After a protracted effort we abandoned the recanalization attempt and performed the Toe Amputation. Surgical bypass is still an option if his amp site doesn’t heal but this will involve crossing through very diseased skin of the calf and ankle. Our Third case was scheduled to be a left femoral agram accessed through a right femoral to left femoral bypass graft but his admission potassium level was 6.8 (repeated). Top normal is 4.8. Potassium in high concentrations is used to arrest the heart in heart bypass operations (and also in lethal injection executions). A level of 6.8 would be considered a medical emergency and requires rapid treatment to avoid life threatening arrhythmias. He also will be rescheduled for tomorrow.
The day was made a little interesting in that I had to cover consults in the afternoon because the fellows and residents were taking a review course for the RPVI exam. I saw a patient who had suffered a STEMI (heart attack) after a rotator cuff repair at an outside hospital(OSH – I first thought that meant “Ohio State Hospital”). He underwent cardiac cath and the xray dye from the cath put him in kidney failure requiring multiple dialysis treatments. Repeated dialysis catheters or the original cardiac intervention resulted in an AV fistula (connection between artery and vein). He was not symptomatic from this fistula so we will not intervene and it will likely close on its own – over time.
A second consult was interesting in that it involved getting our opinion on a gentleman who was awaiting liver transplantation. He was on the list at HUP since 2006 and Colorado since 2004. He has autoimmune cirrhosis (his immune system is erroneously attacking his liver. He had a CT scan that showed some calcification of the origin of the celiac artery which supplies the liver. On my review of the CT scan its pretty clear that the calcium does not really narrow the artery significantly but the staff suggested we get a formal “stent protocol” CT scan to formal evaluate the artery. He had recently had a cardiac cath as part of his pre-transplant evaluation and afterwards has had changes in his speech. There is some speculation that the cath worsened his encephalopathy (brain dysfunction secondary to liver failure). I think he may have embolized. The residents taught me about the MELD score used by UNOS (the controlling organization for organ distribution) to stratify need for transplants. While his score was 15 (high enough to qualify) he was not in immediate life threatening failure. Later my medical student explained further modifications to the MELD scoring that account for hepatocellular carcinoma. This cancer is a frequent occurrence in patients with cirrhosis and when it is present it adds about 15 points to the MELD score – jumping these patients to the top of the list for transplant. Patients with long standing Hepatitis C often develop this cancer.
This little discussion had particular relevance this week as the FDA approved Teleprivir an anti-viral drug to treat patients with Hepatitis C. Previously the standard therapy for Hepatitis C involved a 48 week course of Interferon (think chemotherapy) with other antiviral drugs. The success rate in clearing the virus was only 48%. With Teleprivir the rate of clearing the virus jumps to 88% and may allow treatment to be cut down to 24 weeks. Inability to tolerate this lengthy treatment is a large part of the failure rate. Shorter treatment regimens may be better tolerated.
Later I had a chance to plan an EVAR graft for a challenging patient scheduled for Tuesday. The Staff surgeon had failed to indicate his graft selection when scheduling the case and was unavailable for the weekend. The patient will require an access graft sewn to his iliac artery to deliver the stent because the arteries to his legs are so small. In addition we will be combining two different graft manufacturers to build the required system. I’m not sure I want to give up the Tera-Recon server and software that makes aortic evaluation / graft selection so accurate and straightforward. I think we may have to ask the St. Luke’s Ball to fund this acquisition.
I'm gonna eat here before I leave Cleveland
I drive by this place twice a day and it cracks me up! I’ll try it on a day when I’m not rushing home to jump in bed.
The distinctive green glass walls in "The Emerald City"
Brazilian Teak highlights the back of the Nursing station
The “Emerald City” is my nickname for the exclusive suites guarded by ten foot frosted glass doors where special patients receive special treatment. Most notable are the additional “sitting rooms” en suite with the patients private room. Some spa amenities are available. How do they hide all that clutter we always have in the hallways?
Last night was a very long night at the end of a long day. After starting the day with a successful stent placement in an SMA (the Superior Mesenteric Artery is the main artery to the intestines) I helped in the placement of multiple stents to revise an old EVAR that had developed an endo leak and a iliac aneurysm. Following that we placed an Endologix Powerlink® EVAR graft to repair an aneurysm. Then while my staff surgeon was operating next door on a complicated re-do distal bypass I was trying to negotiate a type III aortic arch from the left arm to image a vein graft stenosis in the leg. While I wasn’t the most efficient endovascular surgeon I did finally get my catheter down into the left limb of his old EVAR graft. It happened when I “hooked” a VS-1 catheter on the Subclavian / aortic junction allowing me to advance my guidewire without flipping into the Ascending aorta. My small victory was thwarted by the fact that his Aorta (EVAR grafts) and iliac arteries were so tortuous that we could not intervene on a mid SFA /vein graft anastomotic stenosis. Length is a perennial limitation from the arm and we didn’t have an ante grade femoral option because of his girth. Home at 10:45.
Learned to use the ProStar® closure device which does what two ProGlide® devices do (places sutures into the arteries we enter when delivering the stent grafts). A bit more complicated but very secure. It requires that you hand -tie the old “fisherman’s knot” that VJ Khatri and I published in the American Surgeon back in 1995.
The complexity of my experience continues to evolve as I gain confidence in new techniques and my Bethlehem life morphs without me. Each day seems to bring new unexpected facets. My brother’s recent injury has fortunately been attended to by my very careful and conscientious colleagues. I can look at his xrays, labs and vital signs by computer and talk with him several times a day. I’ve been able to speak with several of the surgeons looking after him and that has been a very comforting crutch despite not being there. My home sale and future plans continue to challenge Jill’s and my sanity but despite the uncertainties that continue to surface I have a confident feeling that this will eventually be completed .
Not looking forward to this coming Holiday weekend as I am on call on Sunday (and there is no “night float” resident ) to field any of the calls. I think I’ll likely spend Monday sleeping it off.
After a weekend at home it’s getting harder to return to Cleveland. The “newness” of the experience and the adrenaline rush that goes with it are fading. It reminds me of the end of my Chief Resident year. Although I am not an accomplished endovascular surgeon, I understand the technology enough to quote BB King, “Thrill’s gone.” Now comes the necessary tempering that takes the ingot from the mold and hammers it into the sword. As I have noted before, there is no substitute for volume and that is true in my case as well. Time and repetition are necessary elements of any new skill. I remember Marc Granson describing one of the attributes of a good tennis player as “someone willing to hit the same shot over and over again.” Patience required. More so in endovascular work than in open surgery. This was quite evident on a case last week when my efforts to access the right femoral system from the left side were met repeatedly with my “well placed” guidewire flipping out of the right iliac artery. A maneuver that I had accomplished numerous times in an identical manner was now appearing to be impossible. My skill set was subsequently expanded in a quantum leap when my tech leaned over and whispered “try the floppy glide instead.” Duh!
The Rad Techs have been a tremendous asset to me. Jumping into the morass of products in the endovascular world has been made safer by their impressive awareness of “what works with what and what will fit through what”. Hundreds of products and compatibilities that all seem to sound the same to me are apparently quite obvious to them. It’s humbling.
I have discovered a new route to the hospital in the morning. taking the 55th Street exit from Route 77 has added a bit of variety to the routine. This takes me through some of the less affluent sections that have seemingly evolved over time. Some of the churches along this route are haunting reminders of a more grandiose era.
We actually do get some sunshine in Cleveland. The weather this morning was bordering on hot (69 degrees at 6am).
Today I’m scheduled for an arteriogram on a recent bypass patient because the surgeon was not satisfied with the proximal inflow at the time of surgery. Perhaps we will add an iliac stent. I’m aso awaiting my new leaded glasses which are scheduled for delivery today. I’ll have to “re-fit” them with my add on bifocals.
Back in Bethlehem this weekend we were caught up in the whirlwind of the home sale process. The six hour commute (each direction), Home Inspections, touring rental options and considering eventual permanent locations made for an exhausting 48 hours. We have Finances to figure out, movers to arrange, rentals to decide, an ailing dog to be nursed and packing to begin – all to be finalized in 30 days. What a perfect time for my wife Jill to be called for Jury duty! Good thing we are young and spry!! Can’t imagine this all could happen in the days before cell phones, FaceTime and the internet. I think technology might save our marriage through this process.
For those of you who wander around the previous posts on this blog you may run into two of the posts that I had to password protect. This was because they had names of some of the staff doctors in the posts and if you googled their names my blog would show up. I didn’t want to create any “on the job drama” should they happen to google their own names and find me writing about them. If you want to read those posts the password is the initials for our Vascular practice name.
Today was an interesting day with Dan. I accesed both popliteal veins on a young gentleman with extensive chronic venous thrombosis and disabling edema secondary to chronic venous obstruction. We recreated outflow in both of his legs with venous angioplasty using IVUS (IntraVascular UltraSound) to guide us through to the IVC. I actually did the entire case without him scrubbing so I felt pretty good about my ability to negotiate the anatomy.
Our second case was less satisfying. A young woman who had Gastric Bypass in 2000 and multiple complications and procedures over the ensuing years had suffered complete thrombosis of her superior vena cava ( the main vein draining the arms and head). This results in her gaining significant swelling from time to time in the face and neck. We spent about three hours accessing her thrombosed and sclerotic veins only to be unable to cross her obstructions. Surgery is not really an option for her because she has such limited inflow veins. One of the sad “perks” of being the fellow is that I don’t have to have the difficult conversation with her about how little we can do to help her.
Cleveland is an interesting town. Not particularly pretty, it has a very working class feel both in the city and in the suburbs. That’s a well deserved ambience as Steel was and still is a big part of the economy here. I drove around Parma (next to Independence where I’m living) on Saturday and was stunned by the miles of roads lined with “Levittown” homes all built around the same post war boom in the late 50’s or early 60’s. I think many of the concrete roads were also constructed around the same time – and have never been repaired since. There is an old feel to the place and a distinct lack of new development. As much as I dislike strip malls, the Westgate mall would stand out here like a Trump plaza.
Another quirky thing I noticed, I’m probably the only male walking into the Cleveland Clinic in the morning with a baseball/golf cap on.
The home front is struggling with the preparations for settlement and moving, finding a place for us to live and planning our eventual new home. All of this while I relax and enjoy “Endo Boot Camp”.
Raining again today with flooding on many of the already bad roads. This feels like living in a rain forest.
Well, not much stability in my life right now.
A favorite Georgia O'Keefe - "Ends of Barns"
Well our lysis from Thursday (the marathon man) had some re-thrombosis through the night as a result of the on call fellow stopping the TPA because of a very low fibrinogen level. But this provided a valuable lesson for me. Not only was the discontinuation of the TPA a questionable move but the management changed and we took an aternative mechanical thrombolytic route. The Trellis Catheter® allowed us to isolate the affected areas, bolus more TPA into the isolated area and mechanically macerate and aspirate the clot. In combination with the Angio-Jet pulse aspirator we cleared essentially all of his clot burden and uncovered his Iliac vein compression (May-Thurner’s syndrome). This was successfully stented. He was started on Lovenox post procedure and hopefully will go home soon.
Our second case was a continuing lysis of an aorto bifem bypass graft. He had some residual clot at the right femoral anastomosis which was treated by a Craig-McNamara catheter infusing TPA overnight. This morning he had some residual “stuff” at the anastomosis of his graft to the femoral artery. This may represent old clot or scar tissue. We ballooned the area and saw some improvement but decided it will best be managed by open endarterectomy / patch. We were able to place a 8 mm balloon expandable stent at the aorta / graft anastomosis and then post dilate to 12 mm via his 6 french brachial sheath. This looks to be an excellent result for this unfortunate gentleman.
On second call today. Made rounds on the MEGA service (acronym for the attending staff names) ICU patients. Besides the tuition payment we made for this experience the on call assignment is the cost of this education. Ravi, our second year Fellow in charge of the call calendar, is very understanding and accommodating when making my assignments. He is trying to keep me off the weekday call but this means weekends are tied up here in Cleveland. This weekend we are enjoying lovely thunderstorms. In addition, they are conducting “Spring cleaning” in the 89th street parking deck which means I had to find another place to park at 5:45 this AM. Fortunately things do quiet down a lot on weekends so there were plenty of options.
I continue to marvel at the array of patients that are cared for here at CC. One patient on the service is a homeless psychotic man who had an ax fem bypass to (hopefully) allow him to heal an above knee amputation. Last night a Kuwaiti gentleman arrived with an abdominal aneurysm and chronic abdominal pain. He also has TB. There are many patients from the Cleveland area but just as many from the wide radius of northwest Ohio. A steady cohort of patients hails from the remaining lower 48. As a consequence of their reputation, CC receives many prominent “well connected” individuals. I often hear the discussion about “special treatment” wind up with “treat ’em just like the last one.” Making exceptions for individuals seems to be the quickest route to errors and complications. This was scrupulously avoided recently with a patient on our vascular service. He was succinctly described as a “friend of Toby” as in Delos “Toby” Cosgrove, MD, the CEO of the Cleveland Clinic. This patient is widely connected to executives around the country and the world. Through his network he funnels approximately a thousand families to the Cleveland Clinic each year. Needless to say this group of patients creates a sizable stream of donations to the Cleveland Clinic Foundation. While our patient had the constant attention of one of the staff cardiac anesthesiologists (a personal friend of his) during his vascular procedures, everyone consciously tried to treat him the “same as the last one“.
Despite their outstanding well deserved reputation as an international medical and surgical destination, the Cleveland Clinic struggles with many of the same issues that every hospital faces. Among the sea of outstanding medical personnel there are a handful of individuals who “stand out” for their less than stellar qualities. A vascular surgeon who had such difficulty respecting the fellows and residents that he was removed from the teaching service, the nurse anesthetist who is so “loopy” that staff warn me to question every drug and dose she gives “just to be sure”, the radiology tech who can’t remember the button sequence for activating the Angio-Jet (after two years) and the Vascular Fellow who plods along as the department “sad-sack” raising the ire of attendings, fellows and residents on a regular basis. These people are the sand in the gears that remind me of Jay Fisher’s favorite quote (one of many) – “Never confuse success with continuing to be successful.” It takes a constant commitment to excellence to occasionally achieve success. Continuing to find the right people and placing them in the right roles and positions is the greatest challenge of leadership and is far more important than any policy, protocol or mission statement in building excellence. At the same time, reassigning, removing or weeding out the bottom 10% of employees can shackle the most deft managers requiring their relentless attention. Discriminating excellence from success was nicely examined by Joe Paterno in an address to Sports Medicine physicians in 1990.
There are many people, particularly in sports, who think that success and excellence are the same thing and they are not the same things. Excellence is something that is lasting and dependable and largely within a person’s control. In contrast, success is perishable and is often outside our control. If you strive for excellence, you will probably be successful eventually. People who put excellence in first place have the patience to end up with success. An additional burden for the victim of the success mentality is that he/she is threatened by the success of others and resents real excellence. In contrast, the person fascinated by quality is excited when he/she sees it in others.
Yes, that was Joe Paterno. I think we need to guard against the success mentality in our health care institutions and encourage our leadership and administration to build on excellence. While money can follow success, REAL money follows excellence.
Somedays I would like to be hiking in Colorado
 | Mariette on Thursday with Dan |
 | Jill on New Era |
 | Jay Fisher on Dharma 1998 – 2011 |
 | steve on Leaving Cleveland …bette… |
 | Kevin J. McGovern on Thursday with Dan |
jdbalshi 