Look again, it is a doodle of a CT scan of a patient with an Ancure stent graft with sac shrinkage
I remember in the mid-2000’s, driving very fast to Lutheran Hospital in Des Moines on a Saturday night to fix an aneurysm that had ruptured. He was a man over 70 years of age with a type III endoleak from a component separation. The endografts had been placed by a cardiac surgeon who had taken some courses. I rescued him by open replacement of the aneurysm with a tube graft after I pulled out the endografts. Later, as the patient recovered, I asked him why he never followed up as required on his stent graft. His answer was, in typical Iowa farmer fashion, “Welp. If it was fixed, why should I?”
Indeed, why should he? Looking at his chart from the time of his EVAR, he was determined to be a “high risk” patient, necessitating the new minimally invasive procedure EVAR in 2003. Seeing that he survived the stress test of a ruptured aneurysm, it was clear he was not all that “high risk.” I did reassure him that with the open repair, he was basically cured. Despite scheduling a followup appointment, he never showed up. And that was okay.
EVAR is a treatment for AAA, but currently not a cure. All of the devices instructions for use stipulate the need for lifelong followup with CT scans with contrast and visits with qualified specialists. As I have mentioned in the past, what other condition requires surveillance CT scans with contrast and followup with a specialist? Cancer in remission. For those with good cardiac risk and functional status, placing an endograft rather than open repair creates “Aortic Aneurysm in Remission.” If they are in the majority of patients with a stable aneurysm sac, their endografts are sitting in a bag of static, aging blood. If there are type II endoleaks, and it is my belief that the majority of stable aneurysm sacs have some type II endoleaks that blinker on and off depending on the hemodynamics, particularly through needle holes, they are circulating the products of breakdown of that bag of old blood and exposing a perfect culture medium to potential inoculation. These type II and IV endoleaks can inflate the aortic sac over time. Occasionally, the residual AAA sacs rupture, erasing any of the early advantage conferred by the minimally invasive index procedure in long term followup EVAR v OPEN repair.
What is a cure? A cure is when you quell an infection with an antibiotic. A cure is when you’ve taken out an inflamed appendix. It’s when you’ve eradicated early stage cancer. It’s when you perform an open aortic graft and the patient can disappear after you remove the dressings and never followup, sure in the knowledge that the aneurysm in that spot will never bother them again. With EVAR, only a minority get to the state (figure at top) a sac shrunk intimately around the endograft. Most are not cured but enrolled in a regime of lifelong surveillance and maintenance.
EVAR does allow people to leave the hospital with less scarring and pain, but the consequences of its popularity are:
1. Letting more practitioners, not all of them vascular surgeons, treat aortic aneurysm disease with less training and with less or no ability to manage the inevitable failures surgically.
2. Creating the business model for “Advanced, Minimally Invasive, Super-Fantastic Aortic Centers of Excellence” which is predicated on the business of surveillance and maintenance of aortic endografts. It is a busy-ness that generates revenue, but burdens the country with more healthcare costs. It ultimately siphons business away from true centers of excellence involved in training the next generation of vascular surgeons.
3. Skewing the training curriculum of trainees to endovascular so much that I have met vascular surgeons who have done no aortic operations. That was the case when I sat in on an open aortic surgery class at the 2017 ESVS meeting in Lyons, France. All the attendees were very eager to try sewing anastomoses, but felt they needed proctoring which isn’t available.
4. Establishing the expectation that open aortic surgery is a failed, antiquarian, obsolete technique to be relegated to the history books. This last one is infuriating and not true but it is out there in the claims of the aorticians.
5. Resulting in palliation when the aortic aneurysm in remission ruptures and there are no readily available open-capable surgeons experienced in rescuing these patients. This happens. Don’t let it happen to you.
Various solutions have been broached including regionalization of aortic aneurysm care, superfellowships in exovascular surgery to complement the widespread endovascular training, and going back to open aortic surgery as the norm as had been proposed controversially in the UK. There is no turning back the clock. The moment that Dr. Parodi combined an aortic graft with Dr. Palmaz’s stent, a quantum leap occurred. The operation of aortic aneurysm surgery was changed from a challenging operation mastered by a few to a straightforward procedure performed by many.
Interesting to me is that illustration at the top of the post is of a common observation – the obliteration of the aortic aneurysm sac around a Guidant Ancure stent graft. When the sac disappears, it is as close to a cure that you can get. For some reason, I see this more frequently with Ancure than with other grafts over the past twenty years.
Odd fact -I may have been the last surgeon to implant an Ancure in the world. In 2003, I was treating a AAA with an Ancure graft when the delivery system froze in mid deployment. I called Dr. Dan Clair away from some meeting, and he called for pliers, screw drivers, and a saw, and after deconstructing the delivery system, deployed the graft and returned to his meeting with nary a word. The Guidant rep, who had been on the phone, looked up with saucer eyes, and said, “Wow. They’ve pulled Ancure off the market.”
I think it is because of the design, which is now off the market. When stents are sewn to cloth, the needle holes leak, and leak particularly where the stent graft makes a turn, stretching the suture hole. Junctions and seams leak. The Ancure, aside from the stents at top and bottom in the seal zone, has no such holes as it is unsupported and manufactured as a single piece with no junctions or seams. It is the closest you get to sewing in a graft by open surgery. If it weren’t for its overly complicated delivery system which was its downfall, I think it would be in its third generation with visceral branches that are created off the textile machines rather than joined inside the patient. There are lessons to be learned from this abandoned tech.
I believe a treat once and walk-away cure is achievable in EVAR. The idea is not to be satisfied with anything less than a cure, anything that ends with aortic aneurysm in remission. We have to understand we have chosen a path of iteration and continuous but slow improvement in the EVAR space. The front end benefits of EVAR are clear but it is in the long term we have to focus. Until then, warranties would be great.
Distraction Free Writing: Portable, Disconnected, AA Battery Powered
Distraction free writing has been a buzzword. It used to be the norm with computers by their limitations and design to focus you on writing. Today, technology is increasingly put in front of you to entertain and distract. The problem for students and writers is that your computer and phone are gateways to music, video, and communication in ways that were only dreams twenty years ago. The key elements of distraction free writing are a decent keyboard, extended battery life, simple interfaces, lack of connectivity, and absence of party line operators. Each of these elements formed the core of our computers back in the 1980’s, when computers were rarely networked, they were all monochrome, and your words were all that you saw. This desire is driving the market for distraction free writing software and hardware, but you can find ways to create your own portable distraction free writing tools without dropping a fortune. And distraction-free writing is also intrusion-free -something to consider in today’s shifting privacy boundaries. At the end, the best distraction free options may be in reconsidering decades old devices that may be picked up cheaply used or at greatly reduced prices for new. Most current devices are made to last about a thousand recharges, and struggle with purposeful obsolescence. You may find that there are many fine older options that will suit your writing needs while greatly increasing your productivity while avoiding costs.
Consider the keyboards we had back in 1985. They were all mechanical spring keyboards which made a nice click sound. Writing was a tactile pleasure. This was in contrast to the membrane based keys seen on games and toys, and mistakes like the PCjr. You see them today as controls for microwave ovens. The moving keys send a message of accomplishment to your brain. Despite this, flat keyboards with no physical component are still being thrown up to see if they would stick. The smartphone keyboard on the first iPhone killed the physical ones on Blackberry and the Treo’s after all. Manufacturers are still experimenting with flat keyboards such as on the latest Yoga Book’s e-ink keyboard, and the upcoming Microsoft Surface Duo devices.
flat screen based keys like on the latest Yoga Book takes some getting used to
These software and touch display based keyboards rely on spelling correction and ultimately constant connectivity to minimize error. The push for ultra-portability means dispensing with the original mechanical keyboard which was descended from electric typewriters like the IBM Selectric. This resulted in the terribly mushy, mass produced keyboards introduced in the 1990’s, getting ever worse. The high point of this design viewpoint was introduced in the 2015 MacBook and recently retired in the 2019 Macbook Pro when Apple realized everyone hated typing on superflat keys meant to accommodate flatness over functionality. There is a welcome movement back to reasonable keyboards. I would even claim that the persistent life and value of the Thinkpad line is the focus on the keyboard that remains preserved after IBM sold it to Lenovo. The new-old keyboard on the 2019 MacBook Pro 16’s are a concession to the realization that typing is a core function of these machines.
There is a push back as writers, office workers, and gamers have created a market for mechanical keyboards. These are usually Bluetooth connected devices, and typically paired to tablets for writing. Unfortunately, separate keyboards connected to tablets are not as portable as a laptop.
QWERKYwriter is a retro mechanical keyboard for tablets but try taking that onto an airplane
I would argue that laptops are not as portable as they could be. The Freewrite (link) was designed with writers in mind as an update to electric typewriters with cloudbased file management and an e-ink display with days of battery life on a single charge. I almost bought one but the small display and the relatively bulky size kept me from springing. I have ordered a Freewrite Traveler (link) which is their mini-laptop version, but since I ordered one last spring, it has remained vaporware with its delivery date pushed back from summer 2019 to spring 2020.
Battery life is a sore point for me. Laptops are now expected to be wonderful if they exceed 8 hours of battery life, but I remember that the original portable computers like the Radio Shack 100 series could go days on AA batteries. Writing appliances were introduced in the 80’s including electric typewriters with single line LCD displays and single file memory which would allow you to compose and edit. I had such a device from Japan in high school that had a four line LCD display, built in thermoelectric (fax paper) printer, and battery life that went several days on 4 AA batteries.
By using computers and smartphones, which function as portable televisions and multi-function, shopping kiosks which use Watts of power, the trade off is battery life and constantly worrying about plugging in for a recharge. We forgot the days of battery life and are happy with 8 hours. The battery power bar is terribly distracting for me and I tend to stop working to find an outlet to recharge when it inevitably drops and when my productivity is nearly always highest. If I’m traveling, this means carrying the power brick, another injury to this one who remembers AA battery powered writing tools.
In 2017, the Samsung Galaxy Note 7 was famously recalled after spontaneously combusting and were banned from airplanes. All Lithium batteries must now be hand carried. Just recently, I was told while checking in that Apple Macbooks could not be turned on during flight because of heating issues. This is a consequence of the greatly increased energy densities of Lithium cells and their chemical volatility. AA batteries and their nickel metal hydride (NiMH) rechargeable variants suffer from no such problem.
Even with great battery life, you have to remember most of that power, and therefore bulk and weight of the Lithium batteries is devoted to painting vivid colors on the screen, communicating via radio signal to the world, and keeping dozens of apps updated on your activities, and not to writing.
The Lithium battery which can power a car because of its energy density is overkill if all you want is to write. The modern computer operating systems, Windows, MacOS, iOS, and Android, are all over-powered for the simple act of preserving words. Consider the lowly text file to a modern Word file. The text file for a novel might take kilobytes of memory, but the same Office Word file is measured in megabytes -thousands of times bigger. Try emailing a fully formatted Word file through your corporate firewalls if it exceeds your company’s limits on attachment file sizes. The size and complexity of information that is exchanged burns power. Compare that to the notes you might write onto paper. The few microcalories used to power your neurons and move pencil on paper, the motor and optics circuitry processing the information at a speed suitable for your ape brain.
My friend and early mentor, Professor David Tilson, refused to relinquish his DOS based word processor even well into the Windows era. And I understood. The monochrome and monotype letters forced you to look at the words and not the style of the words. While I admire Steve Jobs, and his introduction of fonts to our everyday lives, the ability to shape the look of your writing intrudes on its composition. Monochrome does not mean monotonous, and modern distraction-free software efforts like IA Writer embrace simplicity. The emergence of dark mode is another effort at rolling back the clock. When you enable it for your iPhone, it reaffirms the utility and critical need for focus and simplicity. Do you need millions of colors or just letters on a simple background? While you can change the color setting of your laptop screen or your writing software, the ultimate in monochrome experience is an e-ink display.
The e-ink display is what you see on Amazon Kindles. Originally meant for low power usage, high contrast functions like in store signs, e-Ink is currently used for e-Readers, although there is a niche market for e-ink based displays and tablets which do offer the low power hi contrast display perfect for a focused writing work station – you can find them on Amazon and eBay. Unfortunately, because these e-Ink tablets are run typically on Android, there is no escaping the internet on these, and because they do so, their battery lives are not that much different from standard tablets. What the we need is for Amazon to gift the writers of the world with Bluetooth or wired keyboard functionality to their Kindles and offer a text writer that can be synced to their cloud..
What the we need is for Amazon to gift the writers of the world with bluetooth or wired keyboard functionality to their Kindles and offer a text writer that can be synced to their cloud.
The constant need for connectivity drives software and hardware inefficiency. Writing requires intimacy and privacy. Just as you cannot write while engaged in a shouting match with someone, you cannot write with notifications of arriving messages, pictures, and videos. I cannot write while watching a movie or listening to certain music, but all of these distractions are baked into the function of modern computers and smartphones. This uses up battery life. The devices are in a race to maximize the battery and screen size at the cost of purpose and meaning aside from commerce.
Party line operators were a feature of the early telephone systems. Your locality was serviced by an operator that routed your calls and inevitably your conversations were open to intrusion both intentional and unintentional. When all your work is kept on a cloud server, it really is no different. And it isn’t that hackers that may take all your work. My generation grew up with the Cold War, and its dark tales of thought crimes and writers imprisoned for samizdat -ideas forbidden by a state entity. In a time when your social media is a subject for governmental and not just consumer interest, returning to off line options is something to consider seriously. The meaning of party line operators is in this context wholly changed.
The one feature of cloud based options is the convenience of accessing it across all of your devices. But are you really going to be writing on your iPhone, then on your desktop, then on your laptop, then from an airport kiosk? Your file can be lost during the sync process or changed to a competing version from another computer you were working on. And goodbye work if you get hacked or if your cloud service shuts you down or out. While you write, you have to keep a local version and back up to a nonvolatile storage option.
Not connecting to the internet saves you battery life. It also frees you from taking deep YouTube dives into funny cat videos or answering emails or Facebook posts. The stillness you need to just write is difficult to achieve with a modern laptop, tablet or smartphone. It can be attained with these older devices which people in the know still value decades after they left their boxes. I suggest these options if you are thinking of trying a focused writing appliance (a typewriter!).
Option 1: King Jim Pomera DM100 (link) is best described as a writing appliance designed in Japan adapted for the English speaking market. It is a sleek thin portable that allows one to type words unencumbered by internet. The files on it can be transferred to another computer by Bluetooth, and to smart phones by QR code which is cool. It runs for days on AA batteries, and has a backlit monochrome LCD screen. It is priced on th high end at 392.61, but receives the best rating on Amazon which to me is a 4.5. I never come across 5 star reviews that aren’t fake. One reviewers comment that the keyboard is cramped and takes getting used to. It can be used as a Bluetooth keyboard and stand for iOS devices.
Option 2: Neo 2 Alphasmart Word Processor with Full Size Keyboard,, Calculator
The Alphasmart Neo2 (link) was the last of a line of writing appliances put out by a pair of former Apple engineers who wanted to provide affordable word processing options on a full mechanical keyboard. The Neo2 is the most available and apparently the most usable, allowing one to type out hundreds of pages and transfer to a computer via USB connection. The screen is an LCD screen like on a calculator. The killer feature on this device is nearly forever battery life on AA cells. It has a rabid following of professional writers who appreciate the pared down experience for productive writing. It achieves that perfect 4.5 star rating. This is for a device discontinued in 2007 and sells for about 40-50USD in used condition. Reviewers rave about turning it on and instantly being able to type without bootup, and avoiding distraction by email, notifications, social media etc.
Option 3: Psion Series 5MX
The Psion Series 5MX represented the apex of portable computer design in the late 1990s. It was a computer made from the ground up from circuits, hardware, operating system, and apps by British engineers and it was a thing of beauty. Made in the late 1990’s, this device’s killer features, long battery life via AA cells, ultraportabiity, and lack of easy internet access puts it in a separate class. Not everyone like the keyboard, but I have long been able to type on it without difficulty with average to large sized hands. I had one during residency in the 1990’s and it followed me into fellowship. Before EHR, I composed full consultation notes and H&Ps on it and filed them on my password protected CF drive for later retrieval and update for frequent flyer patients. I picked up a pair of these for about 90USD from the Netherlands, but the going priced varies from about 70 to 200USD for a used one in good condition. New ones pop up but they go for nearly their original price -they are that good. I suspect I got a deal because they were Ericsson MC218, a Swedish licensed clone.
It has a compact flash drive, and with the save as text file function in the built-in word processor which works fast and reliably, it is possible to back up to a nonvolatile memory (the CF drive) and transfer to a regular computer. The one caveat is that the maximum size of CF drive it will see seems to be 128mB -that is megabytes which is hard to find. In certain older industrial machinery, instructions are uploaded via CF cards of these size, and so these cards are available on Amazon. Or look in a drawer for an old unused CF card.
I wrote this post on the Psion, and never once looked at emails, social media, or Youtube.
I wrote this post on the Psion, and never once looked at emails, social media, or Youtube.
View out of my balcony, sometimes you need many pieces to assemble a beautiful whole
Innovating Our Way Out of Not Having Enough Vascular Surgeons
This year’s SVS meeting featured a sobering assessment about the vascular manpower deficit affecting North America at the E. Stanley Crawford Critical Issues Forum, moderated by Dr. Michel Makaroun, MD, president-elect of the SVS. 35-45% of practicing vascular surgeons plan on retiring in the next decade by conservative estimates. We are not attracting enough candidates for the training programs. The solutions, including decreasing the length of training, public relations campaigns, and incentivizing retention have had mixed results, but we have yet to see a sustainable rise in vascular surgeon numbers.
Burnout driven by lack of work-life balance, the advent of electronic medical records optimized for billing, the passing of the private practice era, and the constant need to adapt to new techniques, create a persistent downdraft on staffing. So as some hospital face the reality of having to contract services, little attention is given to delivering best care with the staffing that we have. Changing how we practice is the only viable solution.
There are an estimated 3000 active vascular surgeons in the US. Imagine if all the cheese needs of this country could only be met by 3000 artisanal cheesemakers who make cheeses one at a time and want to live in places with international airports, BMW dealerships, and major league sports teams, and must have 3-4 partners to share cheese call. If you are a rural hospital in dire need of vascular surgery services and your one vascular surgeon is retiring, you are probably SOL.
When I was training, vascular surgery was oft touted as a primary care specialty. And that is how many of us still practice, managing risk factors, monitoring mild disease, as well as planning and performing interventions and operations. As much as I enjoy that kind of interaction, the half hour to an hour visit for a head to toe cardiovascular survey and discussion, educating patients and families about pipes and pumps, is incredibly inefficient. A healthcare system, a hospital, facing a staffing shortfall, has to do everything possible keep that vascular surgeon in the OR during work hours.
What is the core function of a vascular surgeon? Making good decisions and executing plans well. Decisions require data. What is this data? We laud the history and physical examination, but this is a throwback to another era. If you look at the diagnosis of myocardial infarction, it is not standard practice for a cardiologist to come and get a history, examine the patient, and declare that the patient is having a heart attack based solely on history and physical examination. It is a triage nurse in the ED who draws labs and orders an EKG which is read by a machine. These data points will tell you if heart muscle is being damaged. A process is started which triggers a team to come and take care of this patient. The hospitals focused on this actually drill their cath lab teams like pit crews. A stopwatch starts with the goal of revascularization under an hour.
Not so with peripheral vascular disease. The ischemic foot might have only a few hours depending on its presentation before it is irretrievably lost, but no matter -they sit in the ED until a vascular surgeon comes to speak to the patient and family, examine them, and then order tests, admission, consults, and operating room -typically all by themselves. Getting these patients into the operating room is in many places hampered by the lack of dedicated OR staffing, radiology techs, anesthesiologists, space, equipment, and critical care capacity. During work hours, there are scheduled cases that have to be delayed or canceled for another time, which takes time to do. After hours, the patient may have too many comorbidities to handle safely with the available staff. The vascular surgeon may have to bargain and cajole, to align several factions whose attention is demanded by many equally important concerns. If you decide to hold a lavish dinner party of twenty important guests -reserving space, calling caterers, inviting guests, arranging transportation – on short notice, you might pull it off once, but if you do this regularly, you are a masochist of the first order.
In the heart attack model, the history and physical examination is relegated to a series of yes/no or how long questions, and positive responses trigger a series of coordinated actions of a system -a reflex. In the leg attack model, there is no such system. I have to blame the vascular surgeons for preserving the current model. Vascular surgeons are organized as a guild. Guilds are protective of their monopolies on skills and markets and fiercely resist change. Most vascular surgeons are terrified by loss of control, and cling to the notion of being misunderstood and unappreciated saviors. We can do better.
The area that needs streamlining is at the point of referral. The majority of time of a vascular surgeon is spent working up normal blood vessels, varicose and spider veins, leg edema and pain, and mild and moderate arterial atherosclerosis. This work initially does not require a vascular surgeon but rather a focused set of policies and initial diagnostic studies that can be administered or ordered by any caregiver. Reducing the need for vascular surgeons at this point in vascular care will go a long way in extending the vascular work force at hand.
Point of Care Blood Flow Evaluation
Finding and declaring blood vessels to be normal is challenging and too often time consuming. Streamlining this will go a long way in freeing vascular surgeons to take care of disease.
The average caregiver is an inconsistent pulse taker. The palpable pulses are not always easy to find. Asking over the phone or as policy for someone to examine pedal pulses -the posterior tibial artery and dorsalis pedis artery pulses, is challenging. A positive is just as likely to be true or false as a negative. No cardiologist would ask a similarly detailed and technical question about an MI. In fact, they can’t ask, “Is there a pulse in the LAD?” Cardiologists make do with tests easy to obtain and interpret with certainty -the plasma troponin level and the EKG. The EKG is read by an algorithm so established and so tested, that it should stand as an example of early machine intelligence taking over a human job -but I digress.
What is our EKG? It is not the ABI -the ankle brachial index, because it is terrible at identifying disease, and is difficult to obtain reliably without practice. The closest thing to an EKG we have in terms of simplicity and accuracy is the pulse volume recording, the PVR (figure below). A FloLab machine, the machine used to obtain PVRs, will basically run itself once the cuffs are correctly applied on the leg, and the tracings are very easy to interpret. Unlike an EKG, there are no electrodes whose locations you must memorize. If the closest vascular surgeon is an hour away by ambulance, the transfer of a patient with flat waveforms and ischemic foot does not require a consultation on site. The patient would go to the vascular surgeon with no time wasted and no kidneys injured by CTA’s that too often fail to travel with the patient. Unlike an EKG which can be performed by many caregivers, a PVR requires both the equipment and a vascular technologist. A vascular technologist is not available 24-7 in most hospitals, and FloLab machines purchased for vascular labs are not meant to be dragged around the hospital.
So let’s think out of the box about another box in every triage nurse’s cell, every ER and ICU bed, and on every hospital nursing floor. These are pulse oximeters with a digital tracing, and bonus points, some come with strip printers! Placing a pulse oximeter probe on the second toe and comparing to an erstwhile normal wave signal such as on an index finger can provide qualitative information about normality and disease. Normal waveforms and abnormal ones can be easily discerned. A flat line is another obvious finding when in comparison, a finger or an ear on the same patient has normal signals.
How much better would a vascular surgeon feel about a transfer call that has this information, “digital waveforms are flat in this patient with rest pain and a bruised toe.” How much better would a vascular surgeon feel about a call about a patient with “digital wave forms are normal in this patient with toe pain and a bruised toe. We got an x-ray and there was a fracture.” The communication can be quite detailed and refined. For example: “The patient had no pulses, we think. Digital wave forms were dampened but pulsatile in a patient with a bruised toe, we’ll send to vascular clinic in the morning.”
A study comparing pulse oximetry signals and ABI in type 2 Diabetes Mellitus found the following results (link).[i]
Method
Sensitivity
Specificity
PPV
NPV
Pulse oximetry
74.1%
95.7%
83.3%
92.7%
ABI
70.3%
87.1%
61.3%
91.0%
These data suggests pulse oximetry signal is equal to and somewhat better than ABI. Why is this important? Cost. This information is better than asking unsure people, “Is there a pulse?” A vascular technologist need not be on call 24/7. Extra FloLabs for ED, ICU, and floors need not be purchased. The pulse oximeter with waveform tracing is nearly ubiquitous wherever patient’s oxygenation needs to be assessed in most hospitals. While not perfect, it has great potential for serving as vascular surgery’s EKG machine for critical limb ischemia. Policies and algorithms can be built out in collaboration with Emergency Departments and nursing departments that can effectively determine if blood flow is normal or abnormal at point of care. Effective emergency responses to critical limb ischemia can be authored triggered by abnormal findings. Acute limb ischemia protocols based on time sensitive responses can be initiated. All of these can flow from referring entities being able to determine objectively normal or abnormal blood flow.
Clinic
The vascular clinic is a sorting process where patients are determined to be normal or have mild, moderate, or severe disease. The vast majority of the time spent in clinic can be spent in triage by trained nurses and testing by technologists. Clear pathways and guidelines can dictate the ordering of vascular laboratory tests obviating the need for vascular consultation at this stage. Patients with normal blood vessels and vascular function are sent back to their physicians with the normal report. Patients with mild disease and moderate disease are sent to a physician with specialization in cardiovascular medicine for management of risk factors and periodic surveillance. At any point in the process, a vascular surgeon can be called to provide guidance and direct patients to different tests and consultations. The patients needing operations, based on correct indications and imaging are sent to a focused clinic where the surgeon and interventional team can review films, determine the urgency of indications balanced against risk, and plan and schedule procedures. Currently, vascular surgeons do all of this by themselves, as well as make hospital rounds, perform procedures, and interpret vascular laboratory studies, seeing one patient at a time.
In introductory computer sciences courses, search algorithms are taught to be brute force if you look at one item at a time for the thing you want, and to be efficient if you have presorted those items because every time you look, you can exclude part of the data set, ever shrinking the pool in which you search, making the search shorter and faster
The shortfalls in vascular surgeon numbers have as much to do with this dependence on the star chef cooking up one meal at a time, rather than a team working off recipes, with the chef directing the flow and occasionally jumping by the fire to make the most difficult of dishes. The first restaurant can seat three parties. The latter, easily ten times the number. Everyone gets fed.
Only asking how many vascular surgeons you need misses the big picture because there are many equally important questions. How many vascular technologists do you need? An accredited laboratory provides the critical diagnostics upon which decisions are made, and the surgeon should oversee but not be directly involved in the initial screening. Nurses trained to triage and order vascular laboratory tests and even perform the simpler ones is the second need. Third, is the cardiovascular medicine physician who manages those patients discovered to have mild to moderate disease, and depending on symptoms, refers severely symptomatic moderate disease and severe disease to a scheduling clinic. The scheduling clinic is composed of both interventionalists and vascular surgeons who plan interventions and operations.
Surgeons must be in the operating room to be effective. A well thought out and organized system, with interlocking teams, and well disseminated basic knowledge and awareness of vascular diseases reduces the need for a vascular surgeon to be present all the time in many places and ultimately increases the effectiveness of the vascular surgeons that are available by keeping them in the operating room. The system needs to be set up by the surgeon to allow clinic to be a setting mostly for consenting the patient for an operation or a discussion of treatment options.
Finally, vascular surgeons must be aligned with all the resources of the hospital including the considerable numbers of interventional cardiologists and radiologists, neurologists, and nephrologists. There is no reason someone should wait a month to get on the OR list for an iliac angioplasty and stent if an equally skilled and privileged cardiologist or radiologist has an opening the next day. The surgeon’s special talent should be open surgery and hybrid surgery -that which mixes open surgery and intervention in optimal measures which is not possible from a purely percutaneous approach. The key is frequent and easy communication between specialities and trust built by being in one shared cardiovascular institute.
Execution
There is a critical need of good operators. The acuity of disease and their solutions demand the continued presence and availability of open surgery. The fact is, many solutions are optimal in a hybrid fashion and for peripheral vascular disease, these options can only be offered via a vascular surgeon trained in both open surgery and peripheral interventions, or in a combined effort of open surgeon and interventionalist. And many disease categories can only be managed by open surgery.
The reality is that silos, economics, and practice patterns prevent this kind of combined effort. Market forces have pushed the training of vascular surgeons forcefully into the interventional realm at the cost of open surgical training. Some of the geographic maldisdribution of vascular surgeons has to do with younger vascular surgeons flocking to established practices where there are senior surgeons more comfortable in opening a belly or chest (or both). The trap they and hospital systems fall into is then allowing these new recruits to become the interventional specialist of that group, relegating the aging open surgeon to a narrow role, and then finding that the hospital has a problem when that surgeon announces retirement at 60. Every year, millennia of surgical experience retires to beaches and golf courses. The hospital systems should recognize this brain drain as a crisis and create work arounds that keep these skills going. The other opportunity lost is close coordination with interventional cardiologists, radiologists, and nephrologists who in many cases compete with vascular surgeons for the same patients but treat the patients based on their training and skill sets to the exclusion of potentially better operations offered by surgeons. This disjointed care creates both suboptimal outcomes for patients and high costs for hospital systems.
Commerce should never dictate the fate of a patient. A particular point is where competencies and privileging overlap, and guidelines recommend intervention over surgery as in the case of a TASC A or B iliac artery lesion. A patient should not be kept waiting weeks for a spot on a busy surgeon’s OR schedule when an open interventional cardiologist or radiologist slot is available for a iliac stent the next day. It should be a matter of practice that these cases are discussed and distributed, optimally in a shared indication clinic or rounds. Patients bumped off of a surgeon’s elective schedules for emergencies who could be cared for by an interventional partner without an added delay should be given that option. This kind of change requires a commitment to continual reorganization and optimization into a vascular institute.
Conclusion
The perfect vascular surgeon is a unicorn -well skilled, and experienced in open vascular surgery, but also versatile, innovative, and skillful in wielding a wire. I can name just a handful of unicorns. An apt analogy from the book Moneyball is the signing of superstars in baseball on the free agent market. The upshot of that book is that you can arbitrage for the valued metrics through signing several utility players with an aptitude for one thing or another which in sum equals or exceeds that superstar and get the final result -wins, in the same proportions as overspending on a superstar. Rather than searching for that unicorn, it is more important to set up the right system. Screening, testing, and management of mild vascular disease by a nurses and cardiovascular medicine physicians, while directing operations and interventions to vascular surgeons, cardiologists, and interventional radiologists should be the next step in the evolution of vascular care systems. There will never be enough vascular surgeons in the current system. The critical and rare competency is open vascular surgical skill. A surgeon who performs only interventions is not an “advanced minimally invasive practitioner” but rather someone equally privileged as an interventional cardiologist or radiologist, and therefore easily replaceable by an interventional cardiologist or radiologist specializing in peripheral vascular disease. A surgeon skilled in open vascular surgery is becoming rarer every year, but they are still out there, looking at brochures of real estate in sunny places. A team consisting of a cardiovascular medicine physician, many vascular technologists, nurses specializing in vascular diseases, several interventionalists, and a vascular surgeon skilled in open vascular surgery working as a single unit, is far more easy to assemble than finding and recruiting a herd of unicorns.
Innovation has become a virtue in the current culture. There is an evangelical fervor around it. What are TED Talks but tent revivals for nerds? What is the new Apple campus but a cathedral born out of the values of our time? Yet in elevating the more famous innovators and inventions to lofty heights, we lose sight of its very practical and useful daily application. Rather than treat it like inspiration from the heavens, we should approach it as a trait that we all share in.
To make it work for you, you have to think of it as a muscle, and put your reps in. Here are a few “training” tips:
If someone (maybe you) complains about something that feels like drudgery, fix it.
Fix it like a life depended on it, because it just may.
Accept that not everyone will get it.
Do this every chance you get.
Many of us have stories about how we’ve taken opportunities to innovate. Here’s mine. When I was a second-year resident in the ICU back in 1994, we had a patient with HIV infection and necrotizing pancreatitis, requiring an open abdomen with three times a day sterile dressing change. These operations were performed in the ICU where the patient was left with an open abdomen with the pancreas which had exploded with inflammation was packed. The setup was quite hazardous because all the fluid splashing around was infected with HIV, occasionally bloody. But, it wasn’t just a hazard, it was a drudgery. Frustrated with the process, I came on the idea of inserting chest tubes over the packing and under the sticky adhesive drape, and then placing these on suction. I achieved a seal, and the ICU nursing staff was pleased with the invention. Thinking that I could escape the day without another hazardous dressing change, I took the time to pat myself on the back. Of course, I was called stat to the ICU and was dressed down by the head of the ICU for being both lazy and cavalier with the risk to the patient. Interestingly, though, a company came out several years later with a strikingly similar idea, and now negative pressure wound therapy is the standard of care in such situations. In fact, it’s a multi-billion dollar industry.
Of course, money shouldn’t be the sole motivation for innovation. I was motivated by doing less work, reducing the contamination threat for the ICU nurses, and improving care. Many of the best innovations in medicine help the physician care for the patient more efficiently, with better results, and with less suffering. Similarly, the Cleveland Clinic was conceived when American physicians and surgeons, while camped in the vasty fields of northern France during World War I, came to the realization that working collaboratively in a big tent across specialties and disciplines created great efficiencies and rewards, particularly in patient outcome. This innovation, encapsulated in the words “to act as a unit,” brought to the world the first multi-specialty clinics.
Here’s one last, more-recent example. I am frequently called emergently to an operating room to help control bleeding. Typically, these requests are from surgeons here at the Clinic working on severely scarred, radiated, or previously operated tissues. The typical routine is to dig out the vessel and clamp it, which is challenging because dissecting out the vessel can cause further injury to the vessel with more bleeding. I realized that a circular compressor would control bleeding and provide space for placing a repair suture (figure). When it works, it’s surprisingly easy. You can try it yourself; if you get bleeding from a vein on the skin, compress it with the ring handle of a clamp. This idea has gone to our Innovations office, is now patent pending, and is on track to be manufactured.
We became the dominant species on this planet through the trait of innovation. We could not migrate and survive on all the continents by waiting to grow fur, wings, or gills. Rather, we sallied forth, and we invented our way through deserts, mountains, ice fields, oceans, and jungles. Yet, inventiveness is not common, and it’s too often viewed poorly as a close cousin to cunning, or even sorcery. Innovation also threatens the status quo, because it brings change, and with that obsolescence. Innovation is risky, and the stakes are even higher in medical innovation. But, it’s also the only way we will solve what ails us.
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Michael Park, MD is a vascular surgeon at the Cleveland Clinic and a 2017-2018 Doximity Fellow. He will be moving abroad to be chief of vascular surgery at Cleveland Clinic Abu Dhabi.
One of the reasons why I moved my family to Cleveland was to participate in innovation at the Clinic. One of the devices that I have been working on has reached the patent stage and I am free to divulge it. Full link below. Innovation is part of the culture here like oxygen in the air.
A Surgeon's Notes 