-Sir William Osler, First Physician-in-Chief, Johns Hopkins Hospital
It’s been an interesting week for me in my various healthcare roles. I’m currently en route to Dallas, where I will participate in a summit on using a balanced scorecard to assess and compare individual physician performance, as a preface to public reporting. The long awaited Accountable Care Organization guidelines (429 pages) were released. At the same time, Hospital Sacre Coeur and CRUDEM are working to expand interventional cardiology services to include treatment of rheumatic heart disease. Finally, I have been involved in the recruitment of an individual involved in public health. When I asked how he would measure his success, he said that one key would be the elimination of syphilis in urban areas. (and this was in the US!)
It is easy to forget, that a century ago infectious diseases and their complications were the leading cause of death and disability. Syphillis caused more than genital lesions. The spirochetes would house in the walls of the aorta, especially exiting the heart, causing weakening, dilation, and death from rupture. In other forms, it manifest as neurosyphilis , causing confusion and delusions. Some have hypothesized the former Ugandan dictator Idi Amin’s bazaar behavior was due to neurosyphillis. One of our most shameful legacies in human subjects research was the Tuskegee experiment, where minority individuals with syphilis were not treated to follow the natural history of the disease. The concept of “bad blood” reflected the explanation given for the progressive illness. Many died of the one of the multitudes of complications.
Rheumatic heart disease is the sequelae of untreated streptococcal infections of childhood, such as recurrent tonsillitis, and strep throat. Although these are easily treated now with antibiotics, this is not the case in Haiti. The antibodies to strep can form vegetations on the heart valves, especially the mitral valve between the left atrium and left ventricle. This cause stiffening and narrowing of the valve, reducing blood flow from the lungs to the rest of the body. Patient develp a classic murmur, then progressive pulmonary edema and eventually heart failure. This is especially tragic in Haiti, when young woman die during pregnancy as their hearts cannot increase output in responses to the demands of pregnancy. Medications can only do so much. Autopsies confirm this is a mechanical problem. As surgeons, we seek mechanical solutions. How can you mend a broken heart? (Sorry Barry Gibb)
Before the development of cardiopulmonary bypass in the 1950’s and 60’s, and cardiac procedures were done with the heat still beating. Normal output from the heart is about a gallon a minute, and the mitral valve was accessible only by opening the heart muscle. As early as 1925, Souttar reported an elegant, if somewhat simple solution. There is a small outpouching from the left atrium, the appendage. If a purse string suture is placed around the appendage at its base, the tip can be cut off and a finger placed into the left atrium, until it reached the mitral valve. The opening was restored by fracturing the vegetations with the finger, hopefully not completely destroying the valve. The finger was removed and the purse string tied down, closing the hole. Subsequently, devices for mitral commisurotomy were developed to replace the finger and provide a more controlled dilation. With the sophistication of cardiopulmonary bypass, we now arrest the heart, and physically replace the valve. But what about countries like Haiti, where there just isn’t the infrastructure yet to carry a patient safely through cardiac surgery, let alone long term followup?
It may be time to look back to guide how we go forward.
Several years ago, the cardiac surgery team at my previous place, the Miriam, travelled to Africa and did open mitral commisurotomies without bypass, as I described. The patients overall did well. Since then, intervention techniques that can access the heart via an artery may be able to obviate the need for a surgical incision. Mitral commisurotomy can now be accomplished with a specialized balloon, under fluoroscopic guidance, in a cath lab environment.
We are examining how to accomplish this in Milot. We do have some fluoroscopy equipment and improving ICU capabilities. Teams of cardiologists can come for a week at a time to do the actual procedure, but we must involve our Haitian colleagues in the preoperative identification and postoperative care of these patients, eventually training them in cath procedures. This starts with using echocardiograms to assess degree of stenosis and heart function. When I was in Milot in September, Dr William Battles, an echocardiographer was training the first group. As he was doing it, I watched. He smiled and said, “so simple a surgeon could do it.” (Later that night, a man came in with multiple deep facial and arm lacerations from a machete. Bill was the only other doc around. I took him to the OR, reassuring him that “even an echocardiologist can do this…”, but that’s for another blog.)
While reflecting on the high yield from treating basic infectious disease and public health problems I am concommitantly overwhelmed with the amount of data we collect and policies we propagate trying to make American medicine affordable, effective, and appropriate. We need to help physicians understand how they practice and how we can learn from each other to optimize care. We can legislate to align incentives, with both a carrot and a stick. I’m still not sure how it will drive behavior.
But I do know that I never again want to watch a 23 year old Haitian girl die of progressive heart failure from untreatable rheumatic heart disease. I look forward to when we can bring the balloons to Milot, and if not, there’s always your index finger and a 2-0 Prolene suture for the left atrium.
…and I’m not sure how that will fit into the ACO paradigm.
No comments:
Post a Comment