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Wednesday, August 29, 2018

SAVR px post-op discharge week

I'm home. Discharged at 2 pm yesterday. Thanks to everyone for your kind words of concern and support.


Well, that was indeed interesting. Lots to think about and recount as I gather my thoughts. Stay tuned.

For now, Major Props to my surgical team and all of the Muir Concord Cardiovascular center staff.
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OH, YEAH, 
DON'T FORGET TO SAVE THE DATES: SEPT 16TH - 18TH, 2018

THE Health IT event of the year.
I don't guess I'll be attending this year (I've covered the past six). I applied for the press pass, but never got a response, but, as a practical matter I doubt I'd be physically up to it. Hate to miss it.

ERRATUM

RIP Senator John McCain.




Whatever you thought of his politics (and I was mostly not a fan), he served courageously, and suffered mightily for our country.

WEEKEND UPDATE


My offending aortic valve. Quite frankly, I'm lucky to be alive. There was probably heart valve failure or a stroke in my not-to-distant future.

I'm having a lot to continue to adjust to at home this week (a lot of it related to fastidious antiseptic hygiene measures). I'm out walking every day. Reading a lot. Tire easily. Vitals are stable.

My medical economist and writer pal JD Kleinke has warned me about the risk of "pump brain." Yeah, bro', I saw that in my Dad after his heart surgery in 1996.

Among my frustrations is that I will not be able to play my guitar for another 6-8 weeks (sternum pressure). Grrrr...
On a terribly sad note, I got a call from my close Seattle friend "Joey T's" cell yesterday. It was his wife Kathy, calling to say he'd died the other day from brain mets stemming from his bladder cancer. He'd been doing better of late, but things took a rapid turn south. Joey and I had talked at length about his cancer repeatedly. I knew he'd been struggling. Nonetheless he showed up unannounced at Danielle's Memorial. That is a friend.
Very sad.
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UPDATE
SAVR the experience. 


Up at 3:45 a.m., after a difficult, anxious, short night's sleep. No foods of liquids allowed. Ugh. Off to Concord, arriving at the Cardiovascular Institute at 5:23. Preregistered, straight up to “Short Stay” on the 2nd floor to begin pre-op prep. First (after vitals and a bunch of Consent signatures), neck-to-ankles full-frontal body shave (“OMG! I’m a Foster Farms Thighs & Breasts Valu-Pack!), then blood draws and chest x-rays. IV insertions next (both arms), and EKG telemetry hookups follow forthwith.

Quick discussions ensue informing my wife and sister as to where to go to wait and what to expect in the way of surgery progress notifications. The anesthesiologist comes by to introduce herself and chat reassuringly. My cardiac surgeon stops by to warmly greet and further encourage me. Cardiac staffers would subsequently remark, on multiple occasions, “boy, did you ever get the A-Team!”

All good to hear. My anxiety is pretty minimal, all things considered, but it would not be true to claim there wasn’t any. I guess I’ll wake up. Or not.

More prep — lost of stuff going on all around me in tandem — and then it’s off to the OR.

They sidle my gurney up aside the operating table, which has a large stainless steel hump on it. I’m instructed to slide over on to it, with my upper-mid back positioned over the hump. It’s uncomfortable…

That’s the last thing I remember until waking up several hours later in Cardiac ICU (it seemed like mere minutes). Eventually the intubation is removed, I and have episodic bouts of harsh coughing. Right away they push me to begin using the spirometer. Pre-op I’d been pinning it at 2,500, no sweat. Now I can barely get it to move.

In short order I start intractable bouts of rather harsh, persistent hiccups from my irritated windpipe, some of which last 2-3 hours at a time through Saturday. Nothing works to abate it. They finally resort to two sequential IM doses of thorazine, which knock me out.

I will never EVER do thorazine again. You can just forget it. The most vivid adverse side effect was my mouth feeling like the surface of planet Mercury. Bone dry. By Saturday evening I was totally exhausted.

But, that aside, rehab progress began right away. Sitting up, doing minor PT extremities’ exercises, then standing, then a walk down the hall using a walker.

By Saturday I’m moved from ICU down to the PCU (Progressive Care Unit). I quickly regain my “sea legs” and start stably lapping the PCU floor around the nurses’ stations, doing 4-6 laps at a time rather than the expected one or so.

Struggle to eat. Hospital food, man, particularly for us cardiac pts. Like eating cardboard. Ugh. I struggle to down some chow that I know I need.

By Monday, the tentative talk is that I might be able to go home Tuesday (thought my surgeon equivocates a bit). Those damned hiccups have cost me at least one additional post-op inpt day.

On Tuesday, though, the consensus on Rounds (my surgeon, my cardiologist, and his on-call practice colleague) is that yeah, I’m good to go.

More reams of paperwork, and then a protracted hurry-up-and-wait interval.

Finally, at 1:50 pm, an aide with the requisite wheelchair comes for me. Loaded into the car curbside, I have to sit in a back seat (airbag risk).

Homeward bound. Pretty happy camper at this point.

I can’t say enough good about my entire care team.

Some thoughts about my workflow observations shortly (yeah, I can't help it, I'm always watching and counting). Stay tuned.
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More to come...

Monday, August 20, 2018

SAVR px week


Thursday morning I'm getting my severely stenotic aortic valve replaced (via the "old-fashioned" open-heart SAVR px, same one my late Dad had 22 years ago at age 80). I am out of time. I've pushed the envelope all the way, owing mostly to Danielle's illness. See "My 'Check Engine' light." So, I'll probably be off line for a bit. Friday is likely to be a crappy day in the cardiac ICU. I'm told to expect 4-8 days in the hospital, depending on my post-op progress.

Interesting: During my pre-op visit last Thursday, among the many tests they ran on me was a nasal swab for "Staph au."

Then I ran across this in a book I just started:
...the global medical challenge of antibiotic-resistant bacteria, a quiet crisis destined to become noisier. Dangerous bugs such as MRSA (methicillin-resistant Staphylococcus aureus, which kills more than eleven thousand people annually in the United States and many more thousands around the world) can abruptly acquire whole kits of drug-resistance genes, from entirely different kinds of bacteria, by horizontal gene transfer. That’s why the problem of multiple-drug-resistant superbugs—unkillable bacteria—has spread around the world so quickly. By such revelations, both practical and profound, we’re suddenly challenged to adjust our basic understandings of who we humans are, what has gone into the making of us, and how the living world works.

Quammen, David. The Tangled Tree: A Radical New History of Life (Kindle Locations 65-71). Simon & Schuster. Kindle Edition.

My assays were negative. The pre-op nurse had told me that the general environmental staph contamination prevalence was now at about 30% (meaning, were you to touch anything randomly while out in public, you'd have ~30% chance of coming in contact with the staph bug).

More on David Quammen's book here, from Science Friday. Looks like a great read. "HGT?" (Horizontal Gene Transfer). Great. Add one more complex phenomenon to the "Omics" pile for medical science and practice to have to weed through.

UPDATE

 

Yeah. I've talked to a bunch of my friends who've been through Open Heart px's. Comforting.

OK, THIS IS FUNNY

From Science Based Medicine:
Bouffant caps versus skull caps in the operating room: A no holds barred cage match
Over the last few years, AORN and the American College of Surgeons have been battling it out over AORN’s 2014 guideline that has increasingly led to the banning of the surgical skull cap in the operating room in favor of the bouffant cap. Lacking from this kerfuffle has been much in the way of evidence to support AORN’s guideline, but unfortunately that didn’t stop the ACS from appealing mainly to tradition and emotion in objecting to it...
I guess I'll be looking.

8-22 ERRATUM


SAVE THE DATES: SEPT 16TH - 18TH, 2018

THE Health IT event of the year.
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More to come...

Thursday, August 16, 2018

Pancreatic cancer claims another one

Rest in peace, Aretha Franklin


Died at home, in hospice care. We know it all too well. She and our Danielle shared similar risk factors.

Only 76. Very, very sad. Our hearts go out to her family. This old washed-up guitar player knew her music so well.
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More to come...

Monday, August 6, 2018

EBM and the SOAP process

Interesting inexpensive resource ("EBM," Evidence-Based Medicine -- as opposed to "Eminence-Based Medicine"):

Foreword
This short book provides the skills and tools to empower the reader to make better sense of clinical evidence. Present-day journal articles reflect ever-increasing complexity in research design, methods and analyses, and this welcome addition to the field will help readers to get the most from such papers.

With a little practice the book will indeed make it easier to understand the evidence related to healthcare interventions; it provides a clear and accessible account across the whole subject area. The authors avoid unnecessary jargon and have designed the book to be flexible in its use – it can be read from cover to cover or dipped into for specific topics.

Clinical Evidence Made Easy is helpfully structured into two main sections. The first provides the reader with the necessary skills underpinning evidence-based practice, the second gives invaluable tools for appraising different types of articles together with practical examples of their use. Moreover, the configuration within the sections makes for easy reading: common headings are used across chapters so that the reader quickly becomes familiar with the structure and the way ideas are presented.

This is a great book for busy clinicians who want to learn how to deliver evidence-based practice and have at their fingertips the tools to make sense of the burgeoning research literature. Indeed, it will also be valuable for those engaged in research, to aid the planning and delivery of their own projects.

Preface
This book is designed for healthcare professionals who need to know how to understand and appraise the clinical evidence that they come across every day.

We do not assume that you have any prior knowledge of research methodology, statistical analysis or how papers are written. However basic your knowledge, you will find that everything is clearly explained.

We have designed a clinical evidence appraisal tool for each of the main types of research method. These can be found in the second section of the book, ‘Clinical evidence at work’, and you can use them to help you evaluate research papers and other clinical literature, so that you can decide whether they should change your practice…


Harris, Michael; Harris, Michael; Taylor, Gordon; Taylor, Gordon; Jackson, Daniel; Jackson, Daniel. Clinical Evidence Made Easy. Scion Publishing. Kindle Edition. 
I am liking it. Fairly comprehensive topical coverage.
TABLE OF CONTENTS

Understanding clinical evidence
1. The importance of clinical evidence
2. Asking the right questions
3. Looking for evidence
4. Choosing and reading a paper
5. Recognizing bias
6. Statistics that describe
7. Statistics that predict
8. Randomized controlled trials
9. Cohort studies

10. Case–control studies
11. Research on diagnostic tests
12. Qualitative research
13. Research that summarizes other research
14. Clinical guidelines
15. Health economic evidence
16. Evidence from pharmaceutical companies
17. Applying the evidence in real life

Clinical evidence at work

18. Asking the right questions
19. Choosing the right statistical test
20. Randomized controlled trials
21. Cohort studies
22. Case–control studies
23. Research on diagnostic tests
24. Qualitative research
25. Research that summarizes other research
26. Clinical guidelines
27. Health economic evidence
28. Evidence from pharmaceutical companies
29. Putting it all together…
WHAT COUNTS AS "EVIDENCE?"

* They fail to fully make clear whether "external clinical evidence" refers only to that of clinical literature, and does not include patient exam and testing data. I have to assume that eval of exam room/bedside data comes under "clinical expertise."

More broadly. "evidence" is information (typically comprising lexical/discoursive and more structured alphanumeric "data") that makes a true conclusion more likely (or, more rarely, constitutes dispositive "proof").
A "fallacy" is any assertion purporting to contain "evidence" but in fact does not. Fallacies are legion, both structural/formal, and "informal/rhetorical." Also worth noting here are the numerous "cognitive biases" that chronically afflict our ability to "reason" accurately. I have long been a student of this stuff, and spent a number of fun years teaching post-secondary "Critical Thinking."

THE SOAP PROCESS

Subjective - Objective - Assessment - Plan

Simple example here.
NOTE: My former Sup in the Meaningful Use program, Keith Parker, argued that "SOAP" should properly be "SOAPe" ("e" for Evaluation). Scroll down in this post. He's right.

A cute, brief YouTube SOAP note video:

 

"CHEIF COMPLAINT"? Lordy. Nonetheless...

A couple more of my graphic riffs on the process.


"SOAP Note" on the wiki.

I've noted the point many times that there's a lot going on in the exam room, usually with insufficient time for deeply deliberative assessment given the still-dominant economic regime of the "Productivity Treadmill."

BACK TO CLINICAL EVIDENCE MADE EASY

Search the text for "SOAP." Nothing. Search the text for "Bayes" and "Bayesian." Nothing.
(Nothing either for "exam," "differential," "rule out," "digital," "EMR," "EHR," "electronic.")
"P Value?"

23 hits. to wit,
The P value

The P value gives the probability of an observed difference having happened by chance.

P = 0.5 means that the probability of a difference having happened by chance is 0.5 in 1, or 50%.

P = 0.05 means that the probability of the difference having happened by chance is 0.05 in 1, or 5%. This is the level when we traditionally consider the difference to be sufficient to reject the null hypothesis.

The lower the P value, the lower the likelihood that the difference occurred by chance and therefore the stronger the evidence for rejecting the null hypothesis and concluding that the intervention really does have a different effect. As the P value that is normally used for this is 0.05, when P < 0.05 we can conclude that the null hypothesis is false…
[op cit, pg 38]
Yeah. That's the way they continue to teach it. Way simplistic. First a "p value" is a probability estimate, one that will also yield a variability distribution in the wake of repeated trials. Second, it assumes a perfectly Gaussian distribution (bell curve). See a 1996 ASQ newsletter column of mine, "Probability from 'C' to 'G'." (pdf)


I worked in credit risk modeling and management for five years (large pdf link). We never took p-values and distributional assumptions at face value. The name of the game was (and is) stress-tested expected value computations. We made successive record profits every year I was there. (Wrote about that time in my life here.)
In fairness, the authors do make one brief cite concerning a statistical test useful for "skewed data." But, just one simple example.
INITIAL SUMMARY TAKE

I've not read the book closely yet, but I have skimmed the chapters, and I do like what I find therein. Every chapter closes with a "Putting it all together" closing paragraph or two. It's really about assessing the "external clinical evidence" originating beyond the exam room or patient bedside.

I am a regular at SBM, the "Science Based Medicine" blog. You might like the search results there for "Evidence-Based Medicine."
There is a bit of pedantic nit-picking out there as to whether EBM differs materially from SBM. I don't think so. From the SBM site:
"Good science is the best and only way to determine which treatments and products are truly safe and effective. That idea is already formalized in a movement known as evidence-based medicine (EBM). EBM is a vital and positive influence on the practice of medicine, but it has limitations and problems in practice: it often overemphasizes the value of evidence from clinical trials alone, with some unintended consequences, such as taxpayer dollars spent on “more research” of questionable value. The idea of SBM is not to compete with EBM, but a call to enhance it with a broader view: to answer the question “what works?” we must give more importance to our cumulative scientific knowledge from all relevant disciplines."
Interesting.

Again, "Evidence" -- "that which makes a true conclusion more likely." It behooves us keep in mind that evidence itself spans a distribution, e.g.: "nil - weak - indeterminate - likely - dispositive." Gets even hairier when you add in "conjuncts" i.e., "given this and that, and that over there..." (just for starters).

I think about this stuff all the time. But what spurred this post in particular was this cool Atlantic article:


Yeah. Which returns me to this book I've been studying. Cited it earlier.


Below, another one I need to report on. Goes to the EBM thing.


Beyond those, a number of additional recent books inform my thinking (many of which I've cited on the blog before):
The Enigma of Reason
The Knowledge Illusion
The Distracted Mind
The Secret Life of the Mind
Touching a Nerve
World Without Mind
How to Think
Big Mind
Truth
The Book of Why
Snowball in a Blizzard
How Doctors Think
Thinking, Fast and Slow
Moral Tribes
More Harm Than Good
Changing minds
Levers of Influence
Pre-suasion
How to Change Your Mind
Being Wrong
There are more, but this will do for now on the topics relating to cognition. My long-time abiding interest goes to improving diagnostic (and px/tx) reasoning via understanding and explicating the salient aspects of rational clinical cognition. Inextricably intertwined with this is an understanding of the relevant aspects of Health IT. To the extent that the latter impedes the former (poor UX), well (as many complain), it contributes to adversity.

ERRATUM

18 days 'til my heart surgery. Keep singing "woke up this mornin'..." 18 more times.

AUG 7TH UPDATE ADDENDUM

apropos of continuing to wake up, saw a post about this book over at THCB.


Amazon link here. Looks interesting. I am reminded of Ann Neumann's book The Good Death.



COMING SOON


Interesting. Stay Tuned. Source, a WIRED article.
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More to come...

Wednesday, August 1, 2018

My "Check Engine" light


My mental dashboard "Check Engine" light has been blaring "on" continuously since early 2017. Or, to use another apt metaphor, I've been on


for about 19 months. SAVR px

After spending most of 2015 dealing with prostate cancer (successfully, it would thus far seem), by 2016 I was back on my Trek racing bike and back in the gym, lifting weights and holding my own at full-court pickup hoops with guys half to a quarter my age (I was 70 at the time). Mr. No-Hops, a Legend in His own Mind. He of the 6-inch Vertical, who moves in geologic time. He of the Wax Museum D...

GDaddy and the Grandson at City Sport, 2016
Dr. Daniel Kraft (cited here recently) is a fan of the "dashboard" metaphor when it comes to health monitoring apps. See a brief video featuring him, "A Virtual Dashboard of our Health." 

Cool guy. He's in a ton of videos over on YouTube.

My "Check Engine" light thing is more mundane. I don't think there are any "apps" for my evolved condition.

In January 2017 our beloved 15 yr old rescue dog Jaco was diagnosed with a large terminal tumor in his abdomen. We'd had him since we found him on a freeway ramp in Las Vegas in 2003. He was the sweetest.


The vet gave him a month or two. In late February, after monitoring him closely day-by-day, hour-by-hour, I finally had to have him put down.

Earlier in February, on the 7th, My dear old Seattle area friend of 44 years (and former bandmate, world-class drummer) Kurt Kolstad succumbed after a 12-year battle with Mantle Cell Lymphoma. Several years earlier his wife died from COPD. Too much, man, too much.

Then, on March 29th, 2017, "the dx from hell" arrived. My younger daughter was found to have Stage IV metastatic pancreatic cancer. She would live until April 27th, 2018 after a year of chemo regimens followed by 6 weeks of home hospice care here at our house.

During this time, I'd gotten a new Primary at Muir. During my first exam he told he he detected a heart murmur. He quickly looked in my chart and found my 2015 cardiac echo px (done while I was in the hospital for sepsis after my prostate biopsy). The echo result had been deemed "subclinical," but my new doc referred me to a cardiologist for closer review and follow-up.

A treadmill EKG study and series of echoes ensued ("active surveillance"), and my aortic valve condition continued to decline significantly. My dx now is "severe aortic stenosis," and I'm now scheduled for a SAVR valve replacement px in late August (ineligible for a "TAVR" but I'd decided against it anyway). I had a coronary angiogram done earlier this year, negative for blockages -- "you have the arteries of an 18 yr old" (that's gotta be my decades of gym rat hoops).

The constipating stress of Danielle's illness also surely played a role in my getting a large inguinal hernia. It got worse and worse, but cardiology refused to greenlight me for abdominal surgery, citing anesthesia risk, given my heart problem. Gotta fix the valve first. Eventually they relented, with the stipulation that I have a cardiac anesthesiologist present at the hernia scope job. Done.

That could not have gone better.

Now it's time for the Big Show. My recent chest CT confirms no aorta problem or other proximate issues, just a seriously bad valve.

I've been putting this off during Danielle's illness, and now until after my Grandson's August 10th wedding in Las Vegas, where he lives. Had it not been for these circumstances, I'd have had the SAVR px months ago. I feel like I've pushed the envelope all the way out.

Sometimes I feel like the stress of all of this has taken at least 5 years off my remaining life. I am so ready to be over all this. It's likely that I will have to miss the Health 2.0 Conference this year. I may not be cleared to drive by then. (Candidly, I'm not sure that my conference coverage M.O. is all that distinct any more, now that everyone is carrying smartphones with great optics for real- and near-real time WiFi internet sharing.)

If I don't see you there, have a great time.

SAVE THE DATES: SEPT 16TH - 18TH, 2018

THE Health IT event of the year.
_____________

More to come...