Wednesday, March 31, 2010

I Celebrate Doctors' Day!

Yesterday, twenty days after the lengthy surgery to replace his aortic valve and to perform a quadruple bypass, Steve got off the ventilator!

Steve, the Respiratory Therapist, prepared Steve, the patient, by saying:

"On the count of three, I want you to cough and spit. Ready? One, two, three, and OUT!"

And out came the endotracheal tube. Steve was off the vent. And little by little, he settled into the comfort of breathing on his own: his respiratory rate slowing while his oxygen saturation levels stayed at 100%.

About an hour later, Dr. Teply, the Heart Surgeon who spent nearly thirteen meticulous hours taking down the scar tissue from Steve's previous heart surgery, stopped in on his rounds. His face reflected the joy and relief we all felt.

"I am so grateful for the work you did, Dr. Teply. And for the courage you had to even do this surgery."

Dr. Teply smiled in an "Aw shucks" kind of way. "I'm glad we could help," he said. Dr. Tupper, the electrical engineer-turned-Anesthesiologist, also stopped by, acknowledging with a broad smile, "You made us work, Mr. Williams."

But it was really nothing short of a miracle. It was an amazing composite of medical/surgical artistry and skill. And we are so thankful.

Even Steve, his voice sounding like a baby frog, was able to squeak, "Thank you, Doctor" to Dr. Teply and "Appreciate it" to Dr. Tupper -- the two doctors whose marathon efforts had truly saved his life that long night.

Later in the evening, I stopped by the Doctors' Lounge on the way out of the hospital. A partly eaten chocolate cake was decorated with "Happy Doctors' Day." I never gave Doctors' Day any thought...until yesterday. The day I received the best possible gift from physicians of extraordinary skill.

Take care. Linda Gromko, MD

Friday, March 26, 2010

Rehab vs Skilled Nursing Facility: Could it Matter?

My husband, Steve Williams, is now a little over two weeks out from his twelve hour open heart surgery to replace his aortic valve and to perform a four-vessel bypass.

He's still on a ventilator, though he is making steady progress. Thankfully, his mind is present. This was confirmed when I asked him two days ago, "Are you a Democrat?" -- to which Steve noddded vigorously. He also nodded enthusiastic approval at the passage of the Health Care Reform Bill.

So, being the planner that I am, I asked his team about the next step. After he gets off the ventilator and goes to the regular telemetry unit, will he qualify for Rehab?

The Discharge Planner informed me that you must be physically able to do three or four hours of active physical and occupational therapy per day to be accepted into the Rehab Unit. Weak as a kitten at the moment, this goal admittedly seems distant.

"So, if he goes to a Skilled Nursing Facility, where will he get his dialysis?" I asked.

"If he goes to Rehab, he will get his dialysis at the hospital. If he goes to a Skilled Nursing Facility, he'll be transported to the Kidney Center and get his treatments there," I was told.

"We've been doing Home Hemodialysis for the last two-and-a-half years," I said. "This man went through a twelve hour surgery to save his heart. I'm not about to see him lose his emotional/spiritual heart -- and get colonized with MRSA! Let's make Rehab our goal."

The kind Discharge Planner said she'd make a note of my preference.

"It's not simply a preference; it's what is best for this patient."

The issues are complicated; the struggle is great. Steve has the strength to get throrugh, and we thank the many people who are pulling hard for his recovery.

Take care. Linda Gromko, MD

Friday, March 19, 2010

Moving from "Crisis Energy" to "Sustained Energy"

When Steve became acutely ill a couple of weeks ago and requirerd open heart surgery to replace his aortic valve and bypass four of his coronary arteries, we all operated in "Crisis Mode." He was in perilous straights and something had to done urgently -- so that he would live.

Now that the surgery has been completed, Steve -- and all of us -- switch into the longer-term "Sustained Energy" mode.

It's the difference between a sprint and a marathon. Both are important -- but at the right times.

Now, for example, we are focusing on the following:

1.  How can we support Steve's rehabilitation in the best ways possible? Clearly, he must recover from a major surgery; but he still needs dialysis on a regular basis.

2.  How can we prevent new problems, such as skin breakdown, pneumonia, or infections in his central IV lines?

3.  While he isn't alert now, we see that he is moving in that direction. How can we re-orient him to the events he's experienced, even in absentia?

4.   Nutrition changes, as he moves from TPN (Total Perenteral Nutrition through his central IV line) to "formla" through a naso-gastric tube, later to return to real food. If anything, his nutritional requirements will increase with the demands of wound healing.

5.   Deconditioning is a very real risk; we rapidly lose muscle tone -- and even bone mass -- with prolonged immobility. (As a nursing student, I remember reading an article entitled "The Dangers of Going To Bed." I'm sure in my early twenties, I had different dangers in mind!) So Physical Therapy enters into the mix tomorrow. Later, Steve will transition back to Cardiac Rehab.

As an Emergency Room physician many years ago, one of the most valuable lessons I learned was that there are really very few true emergencies.

Certainly, true emergencies include things like airway obstruction, profound hypotension (low blood pressure), hemorrhage, anaphylactic shock, potentially lethal heart rhythm disturbances, and my personal favorite: "Baby coming NOW!"

But for most other matters, you do have a moment to think, to organize, to Google up information you need, or to call someone who's smarter than you are!

For Steve, this period of re-equilibration: moving from Crisis to Sustained Energy comes as an enormous relief.

Take care. Linda Gromko, MD

Sunday, March 14, 2010

A Family Doctor in the ICU

As a Family Doctor, my would is much less high-tech than the world of the Intensivist! (That said, I'd invite any of Steve's doctors to spend a week in my world: moving from pelvic exams, to hypertension, to diabetes, to diaphragm fittings, to newborn exams, to assisting with the intricate processes of gender transition, to obesity management, to substance abuse intervention, to migraines, to skin biopsies, to depression...well, you get the idea! What we may lack in depth, we certainly make up for in the breadth of our specialty!)

In Intensive Care Medicine -- as in all medicine -- there's an urgent need to pan back and see the "big picture." A myopic specialist who sees his/her own specialty area in a vacuum would be inneffectual and even dangerous.

But journey with me now through Steve's ICU/CCU room. Surroundng him (highly sedated and essentially immobile - on purpose) we have the following:

1.  The ventilator, which breathes for him
2.  The CRRT Machine, providing twenty-four hour a day dialysis - resulting in his personal best creatinine of 1.2! We are joking that Steve could be a donor with such numbers! The advantage of CRRT, of course, is that it allows for small volumes of fluid extraction on an ongoing basis -- like healthy kidneys.
3.  The bank of IV medications with their respective pumps: at one point, he was on eleven different meds.
4.  TPN - to feed him through his central line while he is unable to eat.
5.  An impressive monitoring panel which monitors his heart rate and rhythm, BP, arterial blood pressure, pulmonary artery pressure, respiratory rate, oxygen saturation, end-tidal CO2, cardiac output and cardiac index numbers.
6.  Lines and drains:
  • three different central lines going into internal jugular vein
  • Naso-gastric tube
  • Endo-tracheal tube for ventilator
  • Chest tube to drain blood and secretions from chest cavity
  • Radial artery IV
  • Compression stockings with intermittent inflation to prevent clots in legs
(And the Intra-Aortic Balloon pump was removed yesterday, with Steve remaining stable.)

And what about nursing care? I have never seen better, more carefully performed ICU nursing than I have witnessed this week at Swedish Medical Center/Cherry Hill. This is not "following orders nursing;" this is minute-by-minute critical decision making. These outstanding nurses watch Steve for every nuance in lab values, vital signs, and any minute perturbation in his overall condition...and they respond instantly with appropriate medication adjustments and notification of other health care team members who intervene also.

It is all pretty impressive. In health care, we need everybody: primary care providers AND intensivists. It's very interesting to get such a detailed look at the other side of the spectrum. Of course, I wish it weren't in the context of my husband. But since it is, I am enormously grateful for the exceptional work being done on his behalf.

Take care. Linda Gromko, MD

Thursday, March 11, 2010

Steve Gets Continuous Renal Replacement Therapy in the CCU -- the Ultimate in Extended Dialysis

Steve is in the Coronary Care Unit, recovering from an Aortic Valve Replacement and a Four-Vessel Coronary Artery Bypass Graft (AVR and CABG).

I found it interesting that he has been placed on Continuous Renal Replacement Therapy (CRRT). This means he will be dialyzed twenty-four hours a day; he currently is running at a pump speed of 150 cc/ min and taking off only 100 cc per hour.

This must be the ultimate in Extended Dialysis: prescribed for patients who are medically fragile and cannot handle wide volume swings.

Nobody here seems to find this therapy "exotic." Why, then, is there a controversy regarding the benefits of  frequent slower and gentler extended hemodialysis in the "healthy" ESRD population?

Is this yet another example of the scarcity of common sense?

Take care. Linda Gromko, MD

Wednesday, March 10, 2010

Steve is Getting a New Aortic Valve...This Minute!

I'm writing as my husband Steve Williams is in the Operating Room at Swedish Medical Center/Cherry Hill. He's getting a new aortic valve and a coronary artery bypass graft. We expect the surgery will take eight hours!

Here's the story:

Steve had a coronary artery stent placed in November  He had been progressing well in Cardiac Rehab. Then, over the last week or so, he began having angina (chest pain) at the close of each dialysis run...during the rinse-back stage which returns an infusion of about 150 cc of blood back into the patient's circulation.  Each episode was treatable by nitroglycerine, but it was definitely a new pattern. His cardiologist admitted him to the hospital. She took him to Cardiac Catheterization Laboratory and re-stented the vessel in question.. But his chest pain persisted unrelentingly at a level of eight out of ten.

Dr. Ali then placed an intra-aortic balloon pump into Steve's thoracic aorta by way of a catheter in the groin. The intent was to reduce the workload of the heart and to augment the filling of the coronary vessels. And Steve had decidely less pain. But an echocardiogram (sound wave picture of the heart) taken the next day showed that Steve's mildly narrowed aortic valve  had worsened significantly. It was now categorized as Aortic Stenosis of a critical degree. It would have to be fixed. Either by a balloon valvuloplasty, which would be temporary, or by an open-heart aortic valve replacement. Steve and I were not enthusiastic about a temporizing measure.

The cardiac surgeon, in evaluating Steve's case, reiterated that the expected course of Aortic Stenosis is that of progression. But Steve had "accomplished" five years' worth of worsening in roughly five months!

The relationship between ESRD and ischemic heart disease, i.e. coronary artery blockages, is well known.

I think fewer people appreciate the relationship of ESRD and Aortic Stenosis - and the fact that the stenosis progresses more rapidly in ESRD patients.

So, this afternoon, with hundreds of blessings from friends and family, Steve is undergoing open-heart surgery. The atheist and agnostic prayers get extra credit.

So, how does Steve feel about all this? Well, "no other options" is a significant motivator!

Besides, to keep Steve on the Kidney Transplant Track, the valve replacement and bypass "update" would have been an absolute requirement.

Take care. Linda Gromko, MD

Tuesday, March 9, 2010

A Young Breast Cancer Survivor Talks About Discussing Chronic Conditions with Children

The other day in my office, I met with a long-term patient of mine: a woman whose second child I'd delivered. Some time later -- when she was only about thirty-three, she received the diagnosis of breast cancer. Now, after a number of surgeries, chemotherapy, and radiation therapy, she is nearly six years post-diagnosis. She has become active in a group called "Young Survivors." While breast cancer is less common in younger women, it can be more aggressive.

Young Survivors have a unique perspective. We "expect" to confront health issues in midlife and beyond. But issues involving children take on a different intensity when the children involved are pre-schoolers rather than teens or young adults.

Here are some of the recommendations she and I discussed about talking with kids about ongoing health issues, and the points certainly apply to ESRD and dialysis.

1.  Be honest.

2.  Tell what you know in age-appropriate language.

3.  It's okay not to know all the answers, but tell your kids you'll update them promptly when you do have information.

4.  Don't let your kids learn critical information from other people: they don't know the real story.

5.  Tell your kids: "Get your information from me. I will tell you what I know to be true." It's a good idea to designate an alternative source: "If you can't find me, ask Aunt Carole."

6.  Acknowledge that it can be scary not to have all the information. You may be frightened, too.

7.  Point out that every medical situation is different. "Cancer" is different in every patient.

8.  Never underestimate the power of "snippets" of information -- a one-sentence factoid delivered on a car ride will be rememebered later and it can be the grounds for later discussion.

9.  Remember that kids have a way of feeling responsible for things over which they have no control. They may make up explanations..."If I had cleaned up my room, you wouldn't be sick."

10. Expect a child to ask, "Are you going to die?" It's a fair question. Your answer, of course, depends on the specifics. It could be "I hope not," or "No, this is somethting we will have to go to the doctor from time to time to help us watch. But, I'm planning to be here for a long time." Etc.

Children and creative adults will make up information if they aren't included in the truth; their versions may be worse!

My sincere thanks to my young patient who uses her life experience in the most important way: helping others!

Take care. Linda Gromko, MD
PS - No HIPPA violation here; my patient was very willing to be represented in this blog.


Monday, March 8, 2010

Arrange2Live Comes to the International Dialysis Conference

Jane McClure and I were delighted to present "Arranging Your Life When Dialysis Comes Home" yesterday afternoon at the International Dialysis Conference in Seattle. We focused on setting up a Home Dialysis Center that is safe and efficient--but also, one that integrates INTO the home without taking it over completely.

We also focused on Caregiver Issues. While I understand the more "politically correct" term is now "Care Partner," the issues remain: somebody in the family of the "Dialyzor" is heavily invested in making dialysis go whatever form that takes.

And because this investment has the potential to detract from the Caregiver/partner's quality of life, we KNOW it's important to address!

Our conference participants seemed to agree, indicating "it's about time" that these isssues are formally--if perhaps bluntly--addressed!

Having delivered hundreds and hundreds of babies over the years, I've learned that we're better off telling our pregnant patients that labor is/can be painful....but that there are tools to help them make it through! And the results are worth it.

Same thing with Home Dialysis: there will be challenges, but there are solutions and plenty of people to help. And the results are well worth the effort in so many ways.

So let's begin by telling it like it is...our community will be better served, our ESRD folks with be healthier, and their relationships ARE more likely to thrive!

Take care. Linda Gromko, MD

Addendum: to those who have asked about my husband, Steve Williams: Steve has been in the hospital since Tuesday of last week. On Thursday, he had a Cardiac Catheterization to place a stent in a narrowed vessel.. Unfortunately, Steve's pain was refractory, and an Intra-aortic Balloon Pump was placed to help reduce the workload of his heart and to increase the filling of his coronary vessels, i.e. the vessels which feed the heart muscle. Now, we have a new challenge. Steve's aortic valve is reaching a critical degree of narrowing, and he will likely require a surgery sooner than later.

So, I did my Conference presentation with Jane, and took off  immediately to return to the CCU. I didn't make contact with a lot of the folks I'd wanted to meet....but Steve's situation trumped even the 30th Annual International Dialysis Conference!