A distinct sort of society

Whether you agree with him or not, you have to admire David Brooks' ability to turn a phrase, and more. Here is a remarkable summary of aspects of the American character, particularly with regard to the nature of change in our country. My readers from other countries might find that it provides a window into our politics. I think it says a lot about the current debate on health care issues and why a consensus in this complex field is difficult -- for example, why the single payer movement runs into problems, but also why advocates of laissez-faire get little traction. It comes from a column in the New York Times this past weekend.

We in this country have a distinct sort of society. We Americans work longer hours than any other people on earth. We switch jobs much more frequently than Western Europeans or the Japanese. We have high marriage rates and high divorce rates. We move more, volunteer more and murder each other more.

Out of this dynamic but sometimes merciless culture, a distinct style of American capitalism has emerged. The American economy is flexible and productive. America’s G.D.P. per capita is nearly 50 percent higher than France’s. But the American system is also unforgiving. It produces its share of insecurity and misery.

This culture, this spirit, this system is not perfect, but it is our own. American voters welcome politicians who propose reforms that smooth the rough edges of the system. They do not welcome politicians and proposals that seek to contradict it. They do not welcome proposals that centralize power and substantially reduce individual choice. They resist proposals that put security above mobility and individual responsibility.

Fresh fish frenzy

What do you do when your hunter-gatherer spouse has a successful session on Cape Cod Bay and you find yourself with lots of blues and stripers? Here -- in a healthier version of Julie and Julia -- are three of my simple recipes, enjoyed by us and lots of friends this weekend.

Grilled bluefish
Put freshly caught bluefish fillets on the grill, skin side down, with a coating of yogurt mixed with enough soy sauce to create a smooth mixture. Cook with the cover down for 12-15 minutes, never turning. Eat while hot.

Leftover bluefish fillets
Find neighbors willing to take them.

Ceviche (variation on my cousin's recipe from Panama)
Skin and fillet a striped bass. Cut into 2cm cubes. Prepare a bath of chopped onions, corn kernels from fresh corn on the cob, chili powder, ground pepper, and enough fresh squeezed lime juice (about 2 cups) to cover the fish. Let marinate in the refrigerator for 24 hours. Serve cold with taco chips.

Whole poached striped bass (in memory of my mother's approach)
Prepare the bass by scaling and gutting, leaving all skin and fins in place. Place on a large piece of heavy duty aluminum foil. Lay on fresh parsley and oregano, and place more of the same in organ cavity. Squeeze lemon juice atop and place sliced lemons on the fish. Apply ground pepper. Seal the aluminum foil tightly around the fish. Place on a cookie sheet in a pre-heated 425 degree oven for 40 minutes. Options: Eat while hot with no accompaniment, or let cool to room temperature or refrigerate over night and serve with raita.

Leftover fresh striped bass
There never is any, but neighbors are always willing to solve this problem.

A music break

As I take a short blogging break for a few days, I leave you with excerpts of this speech forwarded to me by a friend. The talk was by Karl Paulnack, Director of the Music Division of the Boston Conservatory, delivered in September 2004. Read the whole thing. There is one particularly moving section that I have not put here. (Comments are welcome, but they will not appear for a while.)

One of my parents' deepest fears, I suspect, is that society would not properly value me as a musician, that I wouldn't be appreciated. I had very good grades in high school, I was good in science and math, and they imagined that as a doctor or a research chemist or an engineer, I might be more appreciated than I would be as a musician. I still remember my mother's remark when I announced my decision to apply to music school—she said, "you're wasting your SAT scores!" On some level, I think, my parents were not sure themselves what the value of music was, what its purpose was. And they loved music: they listened to classical music all the time. They just weren't really clear about its function. So let me talk about that a little bit, because we live in a society that puts music in the "arts and entertainment" section of the newspaper, and serious music, the kind your kids are about to engage in, has absolutely nothing whatsoever to do with entertainment, in fact it's the opposite of entertainment. Let me talk a little bit about music, and how it works.

One of the first cultures to articulate how music really works were the ancient Greeks. And this is going to fascinate you: the Greeks said that music and astronomy were two sides of the same coin. Astronomy was seen as the study of relationships between observable, permanent, external objects, and music was seen as the study of relationships between invisible, internal, hidden objects. Music has a way of finding the big, invisible moving pieces inside our hearts and souls and helping us figure out the position of things inside us. . . .

I have come to understand that music is not part of "arts and entertainment" as the newspaper section would have us believe. It's not a luxury, a lavish thing that we fund from leftovers of our budgets, not a plaything or an amusement or a pass time. Music is a basic need of human survival. Music is one of the ways we make sense of our lives, one of the ways in which we express feelings when we have no words, a way for us to understand things with our hearts when we can't with our minds. . . .

What follows is part of the talk I will give to this year's freshman class when I welcome them a few days from now. The responsibility I will charge your sons and daughters with is this:

"If we were a medical school, and you were here as a med student practicing appendectomies, you'd take your work very seriously because you would imagine that some night at two AM someone is going to waltz into your emergency room and you're going to have to save their life. Well, my friends, someday at 8 PM someone is going to walk into your concert hall and bring you a mind that is confused, a heart that is overwhelmed, a soul that is weary. Whether they go out whole again will depend partly on how well you do your craft.

You're not here to become an entertainer, and you don't have to sell yourself. The truth is you don't have anything to sell; being a musician isn't about dispensing a product, like selling used cars. I'm not an entertainer; I'm a lot closer to a paramedic, a firefighter, a rescue worker. You're here to become a sort of therapist for the human soul, a spiritual version of a chiropractor, physical therapist, someone who works with our insides to see if they get things to line up, to see if we can come into harmony with ourselves and be healthy and happy and well.

Frankly, ladies and gentlemen, I expect you not only to master music; I expect you to save the planet. If there is a future wave of wellness on this planet, of harmony, of peace, of an end to war, of mutual understanding, of equality, of fairness, I don't expect it will come from a government, a military force or a corporation. I no longer even expect it to come from the religions of the world, which together seem to have brought us as much war as they have peace. If there is a future of peace for humankind, if there is to be an understanding of how these invisible, internal things should fit together, I expect it will come from the artists, because that's what we do."

Jeans and Genes on Groupon

And now for a gentle laugh. Today's post from groupon.com had an ad for a local store selling blue jeans. There is often a humorous commentary associated with these ads, and this one struck my fancy: "Jeans are not to be confused with genes, the DNA components that contain cell-building information and hereditary traits. However, there is some overlap between the two. Here's a helpful Venn diagram to help you keep them straight."

By the way, if you are not familiar with Groupon, check it out as a prime example of Internet-based marketing. The retailer offers a discount deal in the city of your choice, but only if enough people sign up for it. The viral power is amazing, because after you sign up for something you want, you contact all your friends asking them to do the same so you can get the deal. Meanwhile, the retailer gets noticed by people with an affinity for his/her product or service, and gets a bundle of cash in prepayments. The folks at Groupon get some kind of fee. Everyone is happy.

Thoughtful views on hospital infections

Sharon B. Wright, MD, MPH, Director of Infection Control/Hospital Epidemiology at our place, sent me this note back in March:

I was at the national hospital epidemiology meetings about 1.5 weeks ago and was talking with some of my colleagues about your blog. Seems like they went back to their institutions and thought up what I think is a great idea – starting our own blog about thoughts on current controversies in infection control.

Well, the group has kept it going, and the blog is very good. I think many would find it of interest, so here's the link to Controversies in Hospital Infection Prevention.

Standards for this blog

The commentary on a post below prompts me to write this post. I have been writing this blog for three years and have had very few occasions to reject comments submitted by readers. Indeed, there have been many thoughtful, heartfelt, heated, and humorous contributions. Even those who disagree with what I or others have said have done so in a fashion that is not disagreeable.

During this time, the readership of the blog has grown substantially, and I think that has a lot to do with the level of civility on these pages. But as readership has grown, it has attracted some people who might be used to the kinds of comments found on many other blogs and in the comment section of newspaper websites. So, I thought it would be good to reiterate the standards that I apply for this blog.

First, as noted at the outset, I cannot comment on individual and legally confidential patient care issues in this forum -- although I can refer patients of our hospital to the appropriate people if they have problems or complaints. I also cannot comment on individual and legally confidential personnel matters of our employees -- although I can refer people to the appropriate folks in the hospital to help them. Accordingly, if you submit a comment that falls in to these categories, I will not post it, but I will refer it along.

Second, I will not post comments that make ad hominem arguments and use foul language, that "flame" rather than make points in a civil fashion, or that have prejudicial implications about race, religion, ethnicity, or sexual orientation.

Third, I will not post comments that are clearly designed to advertise a for-profit product, service, or company in the health care field. I retain discretion to post comments that advertise something that would be of general interest.

Fourth, I usually will not post comments that are excessively long. This is tricky because sometimes the person has something interesting to say, but my sense is that most blog readers do not want to drag through very long posts and comments. Encountering a really long comment, many will give up and not reach other comments that follow. So please do the opposite of Pascal: If you have something to say, take the time to write a short letter.

Sometimes I will post a comment telling the commenter that his or her comment has been received but not posted. Other times, I will simply delete it.

Anonymous comments are fine, and I understand why they might be prudent in some cases, but I personally think you can often be more persuasive if people know who you are and where you come from. Also, it feels good to "stand on a soapbox" and be "seen." People have given their lives to allow us to have freedom of speech. Try it!

So, please dive in, keep reading, and send us all your thoughts on the issues of the day. Thank you for your loyal readership and for spreading the word about this blog.

And now for an entirely different view

A friend referred me to this article by David Goldhill in the Atlantic. It raises some provocative thoughts about whether the current Washington approaches to health care coverage will help. It is worth reading in its entirety, but here are two key paragraphs from the conclusion. I'm still mulling it over. See what you think:

The most important single step we can take toward truly reforming our system is to move away from comprehensive health insurance as the single model for financing care. And a guiding principle of any reform should be to put the consumer, not the insurer or the government, at the center of the system. I believe if the government took on the goal of better supporting consumers—by bringing greater transparency and competition to the health-care industry, and by directly subsidizing those who can’t afford care—we’d find that consumers could buy much more of their care directly than we might initially think, and that over time we’d see better care and better service, at lower cost, as a result.

A more consumer-centered health-care system would not rely on a single form of financing for health-care purchases; it would make use of different sorts of financing for different elements of care—with routine care funded largely out of our incomes; major, predictable expenses (including much end-of-life care) funded by savings and credit; and massive, unpredictable expenses funded by insurance.

A surgeon's story: The sequel

Jim Hurst, who's story you read below, was honored last night at Fenway Park. A group of nurses from the TSICU paid him a surprise visit.

Yours truly on NECN

I don't often lead you to television appearances that I have made, but I think this recent one on New England Cable News with Chet Curtis is pretty cogent. See if you agree.

That's one big green bus

Arriving home the other day, I was confronted by this rather large vehicle parked on our narrow street. After a moment's confusion as to why a big bus, green at that, would be parked there, I realized that Ben Gifford must have come home for a visit with his friends.

The Big Green Bus is a project of a group of Dartmouth students. Their philosophy: With a grass roots approach, meeting American citizens one-on-one across the country where they live and work and play, we can prompt individual action and lifestyle changes that will all add up to a difference for the future.

Read more on their website and enjoy the energy and idealism of these young people as they try to make a difference in the country's use of energy. As someone who began my career in promoting energy conservation, efficiency, and renewable resources, I love to see college students engaged in this cause.

By the way, of course the bus runs on waste vegetable oil. The fast food places love to see it arrive, and not just because the vehicle is full of hungry young people!

My son's story -- Part 1

From a friend of a friend, a compelling story.

My son is sleeping right now...had a rough weekend - his blood pressure dropped, his blood count was decreasing, and he had chest and neck pain. The clinical team adjusted his meds, gave him a unit of blood, and are now trying to figure out what to do next. He is scared and worried and wants so desperately to be "normal" again. He is scheduled for leg surgery this afternoon and then we wait to see what the next steps will be.

While I have a few quiet moments, I thought I'd document the story of how he made it this far....it is a story of extraordinary luck and a fair amount of clinical heroism.

My son was born 17 years ago with transposition of the great arteries (his heart had over-rotated and was pumping in a way that didn't allow oxygenated blood to move from the lungs to the body and back again) so he had a 9 hour operation at a week old to reconstruct his heart. Luckily, we lived in a city where the Children's Hospital happened to have the pediatric cardiac surgeon who had trained with the surgeon who had developed the arterial switch, the new and better corrective surgery indicated for TGA. He obviously made it out of that surgery fine and he grew up to be an active, curious, intelligent, athletic, musically gifted young man. His older brothers cherished him but didn't coddle him....he was just one of three rambunctious, rollicking boys who all played sports and games with abandon.

He was cleared every year for athletics by pediatric cardiologists...the anatomy of his reconstructed heart was "unusual" and his EKG was abnormal but he had no activity restrictions. Once he got to high school, he ran cross country, dove, and played lacrosse. My only three sport athlete, to be honest.

Saturday, August 1st was the time trial for the cross country season....a chance for the boys to set their initial times for the year and to show the coaches their level of fitness. My son had trained hard this summer and had experienced a bit of a growth spurt, so he was pretty excited about posting a great time. He was laughing and joking during warm-ups. I stood in my typical spot, removed from other parents so I could watch him circle the open part of the course 3 times during the race. He looked over at me and gave me his million-watt smile and a thumbs up.

My son is not a top runner....in fact, he usually finishes in the bottom third of the team during races...but the team wins State nearly every year and the coach is a remarkable, inspirational man who had encouraged his older brothers to also run CC in the fall to stay in shape for their main sports, so my son had decided to join and stay with the team despite his poor finishes. That all meant that I would be one of the last parents on the course waiting for him to round the bend, run up the last hill, and then turn and sprint into the stadium and cross the finish line.

My son stayed with the middle of the pack for the first 2 laps but faded somewhere in the woods during the final lap....so he ran up and down the hill past me with only 2 runners behind him, neither of whom were in sight...so he was, in essence, running the last lap alone. I told him he was doing great and that he only had about a mile left, back thru the woods and out again. He was struggling, but he always struggled at this part of the race. I watched him run between the baseball field and the football stadium and into the woods along the creek for his final mile. I saw him run across the opening of the woods as he circled back to finish the race, but he disappeared into the trees and I waited for him to pop out the other side.

I noticed some commotion a moment later as some of the front runners who had already finished sprinted into the woods...then a few parents ran in...but I was on the other side on the hill so I focused my attention on the other side of the woods to see him emerge so I could cheer him as he sprinted into the stadium. Then I heard someone yell "Runner down!" and saw the trainers flying toward the woods in their golf cart. The odds were pretty high that my son could be the runner who had fallen - I figured he might have sprained his ankle or hurt his leg, so I started to run the 150 yards to the woods.

I reached the path and saw a group of runners kneeling in the dirt in a circle, praying, and a clump of adults hunched over a prone body on the path...I walked up and saw my youngest and most precious son lying in the mud, blue and not breathing, as the trainers and a parent and his coach worked on him...the trainers were hooking up the portable AED to his chest, with its strangely robotic voice telling them what to do with each step....the parent giving him chest compressions and directing everyone in a calm but authoritative tone....his coach on all fours over him, yelling in his distinctive voice that this was his race and all he needed to do was breathe no matter how hard it seemed for him - just finish the race and take a breath, over and over again.

I watched them try to revive him as I called his mother, who was working, to tell her he had collapsed....I narrated the action to her on the phone as they fired the AED, gave him CPR, yelled at him to breathe, and finally, finally watched him take a few deep, ragged breaths on his own. The parent found his pulse - it was weak but there, and he checked my son's pupils to make sure they were reactive...he was still unconscious but back with us.

The ambulance arrived, they got him on the stretcher and starting bagging him as his breathing had stopped again....they asked what hospital we wanted him to go to....the local children’s hospital where he received all his cardiac care or the closest hospital....I thought for a second and said "please just take him to the closest one".

I raced out of the woods and up the hill to my car so I could get to the hospital to meet his mom and prepare for whatever came next.

Continued below.

My son's story -- Part 2

Continuing from above:

Here is what I have been able to piece together from various people who had been at the school during the race....the stuff I didn't see happen.

The team was supposed to run a new, different course that would have sent them on a big loop of the campus with only a single opportunity to see the runners after the start before they returned for the finish... the rains before the race caused the coaches to decide to use the "old" course which keeps them fairly close to the parents and coaches. This would prove to be the first link in my son's incredible luck chain...had they run the "new" course, he would not have been seen or had the chance for as quick of a response from the trainers, etc.

A part-time landscaper came in on his off day to make sure the path in the woods was clear of debris and to groom any part of the trail that had been impacted by the recent rains - no one asked him to do it but he didn't want any of the boys to get hurt on "his" trail so he came in on Saturday just to make sure....this landscaper, having finished his work for the morning, was in his cart ready to drive back to the Physical Plant building and wash up to go home...his normal route back was blocked by the parents and some of the runners who had already finished the race, so he decided not to disturb them and he turned the other way to go into the woods to take the much longer route on the path.

He saw a runner ahead of him as he turned into the woods and he called out that he was passing on the left...the runner moved over a little and the landscaper passed him....this runner was obviously my son...after he passed my son, he turned in his seat to look back over his shoulder....he didn't hear a sound....he didn't sense any danger or distress...he simply turned back to look at the runner he had passed - at that very moment, my son had his heart attack and fell sideways to the right, down the steep bank of the creek, headfirst between two large chunks of ragged concrete and a big tree into a pile of brush right above the creek.

The landscaper turned his cart around, yelled for help, got to my son to try and pull him up but he was down too far and wedged in, so the landscaper called 911 and ran out of the woods still yelling for help. This was clearly the second link in the chain....had he not come in that morning, had he not decided to be a nice man and not disturb the parents by the normal exit...had he not entered the woods when he did...had he not turned to watch my son fall...no one would have known what had happened until it was too late.

His calls for help were heard by 3 boys, two current members of the team and a third who had graduated but was there to watch....they sprinted into the woods and saw my son in his precarious position and tried to pull him up....a fourth boy ran in and called 911 as well and then ran back out to get help from the coach, who then yelled for the trainers and they all went into the woods.....the boys couldn't get him up because the bank was muddy and very steep, and he was about 6-7 feet below them.

Another person, a parent, had heard the calls and entered the woods about 20 seconds behind the boys....as luck would have it, this parent was a renowned general surgeon (whose son was the senior captain and one of the boys trying to pull my son up the bank) who, without hesitation, leaped from the bank all the way down into the pile of brush below my son and started carrying him by the shoulders up the bank, with the runners lifting his legs. They were able to extricate him from his awkward position and lay him on the trail. The parent/doctor then began to do chest compressions and direct the just-arrived trainers to get the AED up and running. This was the third link.....had he not been there or close enough to hear the cries for help, my son would have most likely died in the ravine.

We learned much later that the problem that caused the heart attack was due to his reconstructive surgery when he was a baby...as he grew and became more active, one of the reimplanted coronary arteries became pinched between the rebuilt pulmonary artery and the aorta....this was an inevitable result of the surgery that saved his life 17 years ago and would have happened at some point - while swimming, riding his bike, walking in the neighborhood, playing lacrosse, or running by himself in the neighborhood as he trained for cross country....so the fourth link - he happened to have his attack while at a school with trainers equipped with an AED, with coaches and parents and teammates right there ready and able to help him. He wasn't alone....and he was in the best possible place to have his attack (even though he complicated things a bit by having it in the woods and falling down a steep bank)

Continued below.

My son's story -- Part 3

Continuing from above:

I arrived at the hospital about 3-4 minutes before the ambulance....it is amazing how fast you can drive when you just don't care if you get a ticket. I met his mom at the entrance to the ER and waited. The ambulance pulled in and they unloaded my son, still bagging him. The parent/doctor had ridden in the ambulance and he had already called the hospital to alert the cardiologists and the trauma team (they didn't really know if he had also received a brain injury when he fell down the ravine).

They packed him with ice to lower his body temp to help protect the brain function and reduce the damage from the heart attack and put him on a ventilator to allow them to stop bagging him
They took him to the Cath Lab to take a look at his heart and determine what might have caused the attack - his arteries were wide open so it wasn't from a blockage in an artery.

They took him to Radiology to get a CT scan of his head to see if there was any swelling or trauma from the fall - luckily there was no evidence of trauma, but he was still unconscious
They then rushed him to ICU where the cardiologists and Critical Care Team tried to get him stabilized, assessed, and cleaned up.

Finally we were allowed back to see him in ICU after about an hour.....he was connected to all kinds of machines, pumps, and IVs....and he was completely non responsive. The cardiologist walked us out and told us what was going to happen next - they were going to do an EKG and an Echo-cardiogram to figure out what his heart function was and to assess the damage to the heart muscle. She told us he was "very sick" (a term she used with us over the next 36 hours) but that they were going to do all they could to fix him. I signed a bunch of non-specific releases and went back to the waiting area to, well, wait.

Four hours later she came back out with a cardiac surgeon....and with the parent/doctor who had been with my son since the event. They pulled us aside and told us his heart function was drastically reduced (an ejection fraction of 20%), his lungs were filling up with fluid despite the diuretics they had him on, and his vital signs were dropping....they wanted to discuss options with us....they also told us they had put him on a unique cooling machine called Arctic Sun (which sounded like a juice box flavor) that would keep him at a constant lowered temperature for the next 20 hours and that they had called in an interventional cardiologist in on his off day to help them decide what kinds of things they could do to prevent him from failing completely. I signed a few more release forms and we went back to wait.

By now the waiting room at the hospital had about 60 people in it all for my son....teammates, classmates, teachers, coaches, family, friends, neighbors, random people, etc. I was on point to come out and give the crowd updates as we had them....

A few hours after the last conversation with the trio of doctors, the cardiologist came back out and told us that they were going to have to do an aggressive and fairly unique combination of interventions - a TandemHeart centrifugal pump to take the load off of his laboring heart and ECMO to essentially provide a lung/heart bypass to take the load off of his lungs and to oxygenate his blood for him. It was the only hope to keep him alive long enough to give his heart and lungs a chance to recover. The major complication from the intervention was the likelihood he would lose blood flow to his right leg as they were bypassing his circulatory system via a large catheter in his femoral artery. They would try a percutaneous bypass from his left leg to his right leg to give it some blood flow but clots could still form in his right leg that would require a vascular surgeon to remove....so they had called in the top vascular surgeon in the area to come in on his off day to be at the ready – he gladly agreed to help as was the father of a former classmate of one of my other sons.

They performed the emergency interventions at his bedside in ICU and we waited... a few hours later we were told that the pump and the ECMO were doing their jobs and the leg bypass was giving his leg some blood, but it had become apparent his lower leg was getting no circulation....a clot or clots had formed but he was too unstable to move from ICU to the OR....at 2am, the interventional cardiologist told us he was most likely going to lose his leg but he wouldn't survive the amputation even if they could get him to the OR, so we just had to wait and see through the night.

The next morning the crowd grew as more and more people heard the news....I gave the room the latest discouraging update and we all settled in to wait for the next communication from the clinical team. Sometime that morning the cardiac surgeon and the vascular surgeon came out and told me they thought his heart and lungs were sufficiently strong enough now to do the frantic sprint to the OR to perform a fasciotomy to remove the clots and try and save as much of his leg as they could. Seven hours later, the vascular surgeon came out to tell us he had opened up his leg and cleaned out dozens of clots, large and small, and the blood flow had returned to his leg to about mid-foot...it looked like his leg would not be lost, but that he would most likely lose the forefoot. They had also started to warm him up and to take him off of the drugs that had kept him in an induced coma....we would be finding out soon enough whether or not he had any brain function impact from being without oxygen on the trail.

He stayed in ICU that night and the next morning we were told his heart function was stable and his lungs greatly improved, so they were going to take him off the pump and the ECMO and the ventilator to see if he could do it all by himself...he did....later that day, the parent/doctor came back to tell us, with tears in his eyes, that my son had responded to some yes/no questions he had posed with a squeeze of his hand! We waited and watched him the rest of that day but he was still mostly unconscious.

Early the next morning, the cardiologist came out and told us to follow her into the ICU....she walked up to his bed and told him to open his eyes....he did....she asked him his name and he responded with a coarse whisper and then asked what had happened. The cardiologist started crying at this point. We were able to bring more and more people back to see him in the ICU and he started joking with his brothers and friends and talking more and more.

Continued below.

My son's story -- Part 4

The final chapter, continuing from above:

The next few days were a blur of more tests, more proof that he was back (he still couldn't remember the day of the race but remembering all kinds of things), and a move to the CIU step-down unit and then to a private telemetry room. He was stable and recovering but a bit sad and scared as the reality of his situation settled in.

His leg is still open from the fasciotomy with a wound pump affixed, and he will require surgeries to debride the dead muscle and to put a skin graft over the two openings....he doesn't have much feeling in the lower leg and can't really move his toes yet, but the blood flow has improved so much he won't even lose a part of a toe, let alone his forefoot.

After an MRI, a CT scan, and a contrast angiogram, they discovered without a doubt that the attack was caused by the pinching of his anterior descending coronary artery...the fix is most likely a single bypass that should remove all risk of a recurrence going forward (pending reviews by a few other cardiologists at other renowned hospitals), but that surgery will have to wait until the leg heals a bit and he is done with rehab. He is on the road to improvement and I am so thankful he is here to hang out with me still.

So here are the last few links in his luck chain...the clinical ones:

There are 6,000 hospitals in the country....only 300 or so have the Arctic Sun technology to lower a patients temp accurately and in a monitored way...and the hospital he was brought to is the only hospital in our area with the machine...that 24 hours of cooling helped protect his brain function, but as importantly they believe, helped keep his leg healthy enough to survive the surgery and let the blood flow return almost to normal.

There are 6,000 hospitals in the country....only 100 or so have the TandemHeart and ECMO combo technology and the experience to use it...the hospital he was brought to is the only hospital in our area with the technology and a doctor who can use it - the interventional cardiologist they pulled in that first weekend is the only one at the hospital who has used it...in fact, he is the one that brought the technology with him when he came to this hospital a year ago...there is no question the time and support the combo intervention provided allowed my son to live through that first night critical night....

The parent/doctor who stayed with my son for the first 72 hours is one of the top surgeons in this city, and he was so emotionally invested in my son's care that he called in a bunch of favors to get the right vascular and plastic surgeons to be put on his case, and he called the head of the renowned rehab centers in the area to "encourage" them to take him on for inpatient rehab on his leg…his constant attention and compassion pulled us and my son and the other doctors and nurses through the first tough few days.

My son is receiving absolute top-notch care from the only place in the area that could have saved him, but was by luck, not by any “consumerism” on our part - we didn't Google "teenage arterial switch survivor with heart attack" or pull up HealthGrades to find the best hospital or doctors to treat him....we have benefited from the kindness and skill of a community of health care providers affiliated with a hospital that was uniquely situated to help him, but the only choice we had in this was what hospital to drive him to.

I don't know how often this kind of story happens in the U.S....or how much our connections the parent/doctor helped us get to the right place at the right time for the right care from the right providers...I want to believe we experienced a normal level of care or attention, but I don't know if another 17 year old would have been swarmed by a whole hospital of care givers and given a chance to have the best people available help him purely by luck...it scares me a bit to think how different this would have turned out if we hadn't landed at this hospital...if he hadn't collapsed at a meet at his well-prepared and wonderfully staffed school....if all the random and independent coincidences and factors hadn't lined up perfectly, in the right order, to create the chain that kept him alive and now thriving.....it is amazing and scary all at the same time.

His story isn't over....but the trajectory of his recovery and the continued excellent care he is receiving gives me a significant amount of hope that this will all have a very happy ending....

Explain the tangible benefits

A last thought for today on the health care legislation, this from Dan Balz in the Washington Post. I found it very interesting and perceptive. I don't generally mean this blog to be so focused on politics, but this issue is just too big and fascinating to let go.

But then I saw this comment under the article and thought I would share it with you, as also being a really interesting view. I don't know the author. I shared the post with friends who join me in really wanting a health care bill and really wanting the President to be successful, and they thought that AOS1 had nailed at least part of the problem.

Dan Balz-

I like this column, but I'd go one step further to say that what we are seeing on the health care debate is the inevitable extension of a character trait of President Obama's -- one that has served him well before, but isn't serving him well now.

"Barry" Obama, Candidate Obama, Senator Obama and President Obama have all been particularly effective active listeners. By facial expression, body language, and in his responses, he comes across as someone who is genuinely (and I don't doubt his sincerity) listening to what you have to say. In responding, though, the active listener is usually trying to convey that he/she has heard and understood what you said -- not necessarily what his/her own position is.

As a result, Obama has always struck me as something of a Rorshach test -- love him or hate him, you could see in him what you wanted to see. That's great for getting votes, not so great when you are leader of the Free World. On healthcare, that means left wing Democrats could see the avatar who'd bring about single payor (or darn close), and right wing Republicans could see a big-government loving socialist.

The truth is somewhere in between, as is the bill that President Obama would ultimately like to sign. To get to that bill he needs to develop a short list of items that explains the tangible benefits -- I agree with your column. But he also can't continue to allow people to believe what they want to believe about his position. He needs to affirmatively state what his position, and correct those (on both sides of the debate) who continue to see what they want to see.

The health care bill can't be a thousand page ink blot.

-AOS1

How to deal with the public option

Richard Thaler, in Sunday's New York Times business section, offers a cogent description of the issues surrounding the public option for health insurance. Read the article here.

His conclusion:

ALL of this leads me to conclude that if we impose sensible rules on the public option, it will neither save nor destroy the health care system because it will simply not get much market share. And if we do not impose those rules, the public option will hurt rather than help.

So here’s some free advice to members of Congress: While you are enjoying your August recess and town hall meetings, instead of arguing about whether to have a public option, argue about the ground rules.

To the Republicans, I say this: If you can get real assurances that the public option has to break even, and that it will get no special deals from suppliers, let the Democrats have it but ask for concessions on tort reform in return. (That could actually save some money.) The resulting public plan will be too small to notice.

To the Democrats, I say this: If you want competition in health care, you won’t get it if the public option can make deals its competitors can’t. So either give the Republicans hard assurances that the public option would have to break even and not get special treatment, or, better yet, just give it up to ensure that some useful health care reform is passed. A public option is neither necessary nor sufficient for achieving the real goals of reform, and those goals are too important to risk losing the war.

In memoriam: A. Stone Freedberg

Last April, A. Stone Freedberg, the former chairman of Cardiology at the Beth Israel Hospital, celebrated his 100th birthday with a special concert at Symphony Hall. I sadly report that he passed away yesterday at 101.

Warren Manning, one of our cardiologists, notes that Dr. Freedberg did extensive research in cardiac physiology, especially with regards to thyroid disease (working with George Kurland and others) with a long bibliography. Read, too, this fascinating story about him from the New York Times. After he retired from the BI, he served as the Harvard Medical School student physician for nearly 2 decades. Warren notes that "his mind was razor sharp" until the very end. He will be missed by many.

Deadlock in Congress

The Onion, as usual, has a serious message hidden in a funny story.

Insurance Protections

I was sent a copy of a letter from David Axelrod, Senior Adviser to the President, with a list of things that the Administration hopes to include in the health care reform legislation to deal with nasty practices of some insurance companies. While some of these protections exist in some states to some extent, it would be great, as I have mentioned earlier, if these regulatory requirements could be extended nationwide. I haven't heard much objection to them, even from people in the insurance industry, so I am hopeful they will survive the legislative process.

The one thing I do not see here and have not seen elsewhere is a prohibition against balance billing, e.g., when a doctor charges you the difference between what an insurer covers and what he or she wants to charge. This is not legal in Massachusetts, but is common practice in states like New York. Has anyone out there heard of interest in changing this on the national level?

Here's the list:

1. Ends Discrimination for Pre-Existing Conditions: Insurance companies will be prohibited from refusing you coverage because of your medical history.
2. Ends Exorbitant Out-of-Pocket Expenses, Deductibles or Co-Pays: Insurance companies will have to abide by yearly caps on how much they can charge for out-of-pocket expenses.
3. Ends Cost-Sharing for Preventive Care: Insurance companies must fully cover, without charge, regular checkups and tests that help you prevent illness, such as mammograms or eye and foot exams for diabetics.
4. Ends Dropping of Coverage for Seriously Ill: Insurance companies will be prohibited from dropping or watering down insurance coverage for those who become seriously ill.
5. Ends Gender Discrimination: Insurance companies will be prohibited from charging you more because of your gender.
6. Ends Annual or Lifetime Caps on Coverage: Insurance companies will be prevented from placing annual or lifetime caps on the coverage you receive.
7. Extends Coverage for Young Adults: Children would continue to be eligible for family coverage through the age of 26.
8. Guarantees Insurance Renewal: Insurance companies will be required to renew any policy as long as the policyholder pays their premium in full. Insurance companies won't be allowed to refuse renewal because someone became sick.

Learn more and get details: http://www.WhiteHouse.gov/health-insurance-consumer-protections/.

Request from Health Care for All

I am posting this at the request of our friends at Health Care for All:

Have you ever had a bad experience in a hospital or other health care setting?

Has someone in your family received poor health care in Massachusetts?

Have you been an advocate for someone or helped them navigate the complex health care system?

If you answered yes to any of these questions, please consider joining the Consumer Health Quality Council, a coalition of consumers who advocate for improving the delivery of health care in Massachusetts. The Consumer Council was founded by Health Care For All close to three years ago to respond to growing concerns about the quality of health care nationally and in Massachusetts.

The Consumer Council’s mission is to empower those impacted by health care quality issues to have a voice in our health care system, to engage fellow consumers to be active partners in their health care, and to advocate for high quality, safe, and accessible health care for all Massachusetts residents.

Here are two examples of how Consumer Council members share their stories to advocate for change in how health care is delivered:

Robena Reid’s mother, Marie, entered a Boston area hospital in December of 2006. Her mother was diagnosed with a rare type of cancer affecting the pleural membrane surrounding her lungs.

While in the hospital, her mother contracted an intestinal infection caused by clostridium difficile. Because of this hospital-acquired infection, her mother was unable to receive treatment for the cancer and passed away. Robena has become an advocate for improving care and testified at the Massachusetts State House, with the help of Health Care For All, to encourage public reporting of hospital-acquired infections.

Lucilia and Joe Prates’ father, Antonio, went into a hospital to have kidney stones removed in January of 2005. As a result of the procedure, Antonio became a victim of a hospital-acquired infection and an adverse medical event, which ultimately led to his death in August of 2005. Lucilia and Joe share their father’s story in hopes of improving the quality of care that others receive.

You can view additional videos of Consumer Council members’ stories at www.hcfama.org/quality/stories . Since its inception, the Consumer Council has been successful in advocating for state laws that aim to improve the delivery of health care and make it safer for patients and families. Massachusetts leads the nation in many measure of health care quality, but there is a lot of room for improvement. We can, and should, always strive to do better.

The Consumer Council and Health Care For All urge those of you who have received poor quality care to start speaking up and sharing your stories and to work with us toward the common goal of providing high quality care to all residents of Massachusetts. For more information about the Consumer Health Quality Council and how to become a member, please contact Kuong Ly at Health Care For All: kly [at] hcfama [dot] org or 617-275-2940.