Our journey toward crossing the quality chasm - musings from the Intermountain ATP course

I spent all last week in Salt Lake City, Utah, at one of the worldwide recognized most prestigious academic activities in quality and patient safety - the Intermountain Advanced Training Program in Healthcare Delivery Improvement, which is taught by a veritable pantheon of healthcare quality improvement colossus leaded by Dr. Brent James.

This course is a 20 days course, taught over 4 weeks (one week each month for 4 months), and the attendees are the quality leaders in different institutions - all really smart and engaged individuals with a substantial amount of experience and knowledge in the field - several with 2 or 3 master degrees (MMM or MMA or MBA plus a MS or MPH). However, despite their knowledge and training, still something is missing. It is a fascinating experience to network with such a phenomenal group of professionals with a common goal - provide the best medical care in the world. 

This course helps to fill the gap - Dr. James has taken all the teachings from the gurus in quality, Dr. Deming and Dr. Shewhart and translated into healthcare. Essentially they teach how to understand that healthcare delivery is as well as in manufacturing, a series of processes which receive different inputs in order to have a final output or outcome, and its quality will depend whether it meets or not required specifications. Quality is defined by our own set of values, expectations, cultural beliefs, etc. and good quality is when the output meet specifications (which are defined expectations). The FOCUS-PDSA strategy allows to identify opportunities and implement quality improvement processes in small scales and translate subsequently toward a larger scale. It is very relevant to understand how the industry has improved and how certain industries achieve incredible safety records - e.g. aviation, car manufacturing, etc. - and how the application of Deming's philosophy has been instrumental in this incredible safety record. 

It is important to understand the history of healthcare delivery in America - how its philosophy has changed - after world war 2, there was an emphasis in ensuring access to healthcare to all the population; however after the costs started to rise and the insurance companies started to take control, the shift focused toward cost control and maximizing hospital reimbursement - this was sub-optimal as opportunities to care may have been missed by patients as insurance companies controlled the medical decision making not emphasizing at all in quality of care but just cost of healthcare delivery. However, quality of care was less than optimal and medical errors were the 6th cause of mortality in the US. This was highlighted in an publication by the Institute of Medicine called "To Err is Human" and subsequently by "Crossing the Quality Chasm". This has shifted equation of healthcare delivery toward "value" of care - which meant increasing the quality of healthcare delivery while minimizing unnecessary costs. This is the current philosophy that allows us to design the healthcare processes. 

It is important to stop practicing a highly variable "craft of Medicine" which allows for increase risk of errors and missed opportunities - it allows for an incredibly selfish and individualized practice of "what works for me". This can make a physician practice differently in a same patient/same scenario in different time periods. Patients are increasingly complex; medical knowledge is increasingly complex too - more than 10,000 different journals, it is impossible to know all the current evidence to support a safe medical practice. This is one of the reasons for having quality improvement systems in place - and to have all doctors get on board the ship of quality and safety and adopt the culture of quality as their main philosophy. 

But in order to ensure adequate quality delivery, we need to know whether we are meeting the specifications! Therefore, it is fundamental to have a clear understanding of our current performance - essentially, know well the data to be able to study and appraise it. Be able to graphically show where our performance gaps are is fundamental - using time series, pareto charts, Ishikawa (fish-bone) diagrams or other cause-effect diagrams, histograms, flow charts, etc. (Now a lot of things make more sense!). Metrics should drive performance when understood within an appropriate knowledge and understanding of our own institution philosophy, vision and mission. The graphs allows to identify outliers and areas of opportunity. Errors or mistakes are horrible words - should not be used; the purpose of quality improvement is not to punish or take action toward an individual - the context of all the theory is geared toward improving the system! Rather than using these words, it should be identified as "opportunities for improvement" or "outcomes outside of specification". All individuals within the system should be accountable, but the purpose of QI is to enhance the system in a consistent form. For example - you don't ask when climbing a regional jet whether your pilot is competent - you trust the system! The same should occur in hospitals - create systems that enhance patient safety and consistent quality delivery.

For quality improvement purposes, the most important aspect that Deming taught was to decrease variation - once variation is decreased, the area under the curve decreases - the population bell shape distribution narrows and its peak is more prominent - then it is easier to identify real outliers - the causes for real "signals" and be able to help improve. In a traditional bell shape, when arbitrary cut-offs are met, these outliers can mix with the rest of the population. So it is important to standardize processes to minimize variation. In healthcare, each patient will be different, so if we standardize our processes, the only variation will come from the patient who can receive an individualized care but the overall standards of care will be met. 

The leverage of all resources - technology: electronic health records, computerized-personal-order-entry systems (or CPOE), and non-technology: discharge processes, nurses/physician huddles, etc. - should be targeted toward minimizing variation and use all opportunities to meet top quality standards. 

Once a process is started - a work-flow diagram that illustrates the process and subsequent steps, can be modified with constant feedback from the end-users about its performance to improve it in a continuous way - what is also called continuous improvement.

A beauty if the QI philosophy is that once specifications are being met rather than "sleeping on the fame", a constant pursuit of further enhancement and refinement in the process should be maintained - this desire for continuous improvement is what creates safer and better environments - this philosophy is what helps the world to keep advancing and be a better place for the next generations. 

My responsibility will be to immediately apply all the currently acquired knowledge at my institution, as well as share this philosophy and knowledge with my peers, medical students and both Medicine and Pediatrics residents. This is important as the new generations must harbor the culture of quality and safety as their main philosophy. I'm excited as this will help to deliver a much better medical care and help to shape the Medicine of the future today. 

A safe medicine with highest quality standards allows us to practice our mantra....primum non nocere. 

Less is more - additional evidence against liberal blood transfusion (or in favor for parsimonious use of blood).

I went last year (yes, the year that just ended 2 days ago) to Mexico City to give a lecture at the International  Course of Internal Medicine sponsored by the Mexican College of Internal Medicine. My lecture was named "Blood is life: to transfuse or not" - and it was targeted toward presenting the evidence for parsimonious blood utilization. This invitation came as a result of my involvement with the preoperative anemia optimization program at the Cleveland Clinic.

At the Cleveland Clinic, a large effort was initiated about 6 years ago in order to decrease the number of transfusions, mainly red blood cells, and mostly in surgical patients. The efforts have yielded in an impressive decrease in blood utilization as well as in a more proactive behavior to optimize the patients' anemia before undergoing surgery. One of my main areas of interest is preoperative anemia optimization to minimize the risks of intra-operative or post-operative blood transfusion. We optimize the iron stores, or in special cases, use erithropoiesis stimulating agents (Jehovah's witnesses, hip and knee arthroplasties mainly).

The culture change has been slow but steady. Nowadays, nobody attempts to transfuse liberally in anybody with hemoglobin more than 7 g/dL; of course, each patients is evaluated individually and certainly you can transfuse at higher numbers in patients with other co-morbidities (for example, patients with severe chronic lung disease and active ischemic cardiomyopathy, or severe acute ischemic renal injury, etc.).

I have undergone a large review of literature which I presented in Mexico (the translated slide presentation can be seen here). The presentation raised controversy - some of my Mexican colleagues still transfuse based on "their experience" and not on the evidence; they are scared of using intravenous iron preparations; they still think an hemoglobin of 10 in a critically ill patient is an indication to transfuse. It was a big cultural shock to find out that it was in critical care patients where the evidence came from, supporting a parsimonious blood utilization. Some people advocate autologous blood donation (which we do not use here), as well as the use of perfluorocarbon blood substitutes (which as well we do not utilize here neither). A long road is to be traveled and a large educational effort is required to change long-standing practices; I was grateful by receiving the opportunity to help in the initiation of these efforts and will continue to share our experience and growing literature available.

In the past 2 weeks, two articles have come out to provide additional support to the parsimonious blood utilization - one published online in Archives of Internal Medicine which demonstrates and increased mortality in patients with acute myocardial infarction who were transfused - and the other published in tomorrow's NEJM - which fills out the missing part of the puzzle: whether pursuing a parsimonious blood utilization in active GI bleeding was a safe initiative.

The article in Archives, is a well designed metaanalysis which review 10 studies out of 729 finding interestingly a mortality risk ratio of 2.91 with a number needed to harm of 8 in patients hospitalized with myocardial infarction who were transfused. In addition, this risk was independent of the baseline hemoglobin level and to muddy the waters more, it was associated with increased risk of subsequent myocardial infarction. This is very interesting, as most guidelines recommend a higher threshold for transfusion (e.g 8 g/dL instead of 7 g/dL) in anemic patients with myocardial ischemia. I don't think clinicians should stop from transfusing patients that need blood; but I would advocate a more conservative approach looking into the causes of anemia - hematinic deficiencies (iron, vitamin B12, folate, etc.); bone marrow suppression or dysfunction; ongoing blood losses; etc. As the authors conclude a larger trial is needed and I concur; however, it is interesting to see the trend toward the worse outcomes, including reinfarction. 

The article in the NEJM, comes to provide very needed information in the actively bleeding population. We tend to transfuse as in an actively bleeding patient it is unclear whether the hemoglobin will stabilize or how low it can go. In my institution, we tend to monitor the hemoglobin every 4 to 6 hours in these patients - and hold for transfusion until the hemoglobin reaches 7 g/dL or less. This behavior is supported by this article, which certainly provides a sigh of relief to all who practice a parsimonious blood management. Of course, that in addition to this, clinicians should always optimize the hematinic deficiencies (iron stores, folate, vitamin B12, etc.), in order to maintain the substrate for an adequate hematopoietic response. I'm glad this article is out in print as certainly will provide a stronger support for all blood management programs, and minimize worse outcomes in our patients. 

Doctors and midlevel providers want the best for their patients. It is a matter of education and reaching a comfort level to pursue evidence based and common-sense based medicine. As always, we all strive for the best....primum non nocere.

Realizing the incredible frailty of life and the battle to avoid irrational exuberance: a journey into the NICU as a Med-Peds uncle.

It was September 2003. I was a recently Board certified Internist in Mexico, now repeating the residency training in the United States in a combined Internal Medicine and Pediatrics program. I was stepping for the first time in my life in a level 3 Neonatal ICU (NICU) at Metrohealth Medical Center in Cleveland, OH; a 40 beds state-of-the-art NICU, where miracles happen. Used to examine adults; used to palpate the abdomen with two hands; now my patients were smaller than my hands. I stepped into one of the rooms to see my first patient; a 24 week gestational age patient, born a week ago at age 23 weeks! As I approached the isolette, gusts of shivering invaded my body. I was anxious and scared; I was having an incredible mixture of emotions; I felt an incredible pride of being a physician as well as I was marveled by technology; nonetheless I suddenly felt I did not belong there. I was an internist trained to see adults with cirrhosis, lupus, rheumatoid arthritis, heart failure, diabetes, hyperlipidemia, etc. And now, I was in the "darkness" of an entirely unknown yet incredibly fascinating world.

Most  babies were in isolettes; however, others who required more hands-on approach were in open warmers. I came to see strange ventilators called "oscillators"; ECMO became a reality, not a fiction; and suddenly I found myself looking into numbers that were surreal....a blood pressure of 60/30???? a heart rate of 150????? that was "normal".

The most impressive thing happened when I opened the isolette and found that my patient was surrounded by a million lines and monitor cables, and his legs size were as thick as my hand ring finger and the arms were smaller than my pinkie finger and the body was thinner than my whole hand size! ....How was I supposed to examine this patient???? how was I supposed to flip him over? I was terrified of even giving my patient the slightest touch. The skin was red, transparent, I could see vessels, perhaps peristalsis. I felt inside my heart an immediate love for that baby, an immediate sense of tenderness, compassion, and acknowledge how frail, tiny and delicate my patient was. I felt an immediate commitment to be a guardian, a protector, an advocate for this tiny person's life. This challenge was as well very important...it could mean that if I didn't liked the rotation, I would switch from a Med-Peds training to just Internal Medicine.

My attending physician (the main staff who supervises the residents and fellows in an academic medical center) was one of the most important authorities in the field, Dr. Satish Kalhan. I was terrified of not giving an adequate performance after being warned who he was. I ended learning a great deal from him and finding much needed inspiration to become a Pediatrician. We became great friends with mutual respect for one another.

Time passed by, and the only way I could obtain an additional income was "moonlighting" in the NICU, so over the next 4 years, I routinely "moonlighted"; sometimes when I was in the middle of an Internal Medicine rotation, I spent a single night in the NICU - an extreme Med-Peds experience. Fortunately, I was skilled - did intubations, placed umbilical lines, PICC lines, intravenous lines, did lumbar punctures, did neonatal resuscitation, etc. I loved it, not to the point of becoming a neonatologist, but yes to the point of enjoying being a Pediatrician.

Nine years later, I found myself in the NICU, this time not in Ohio, but in Des Moines, Iowa. My brother, who is a Pediatric Nephrologist (and one of the brightest physicians I know) and his wife who is a Family Medicine specialist and a Master in Public Health, had premature babies at a gestational age of 26 weeks.
I witnessed miracles in the NICU during my residency - lots of normal patients who were very premature who developed to be children with normal intelligence and with no learning disabilities. Of course that as a Med-Peds trained person, I saw as well a lot of complex care Pediatric patients with all ranges of learning disabilities and handicaps - but these were the minority. Most patients were able to pursue a normal life.

These tiny children in Des Moines are now my blood...are my brother's offspring!, the next generation in my family!, my parents' first grandchildren!, my grandmother first great-grandchildren!. When I met them an infinite sense of pride, happiness, love and tenderness invaded my body; similar to my first experience in the NICU, I got gusts of shivering and goosebumps from the emotion. However, now I felt an immense feeling of adoration for them.

I was very worried as before I landed in Des Moines, I came to know that both of them had NEC - necrotizing enterocolitis - a potentially life threatening condition that occurs in premature babies due to immature intestinal perfusion and poor barrier for enteral bacteria. My niece was doing fine and only required a small surgery. But my nephew was very ill - he had 23 cm of his bowel resected, had acute renal failure and oliguria, had coagulopathy, developed a liver hematoma and a subdural hematoma. Due to severe hypotensive episodes likely from overwhelming sepsis due to bowel perforation he developed a watershed infarct in the brain.

My niece was in an isolette, with nasal CPAP and tolerating enteral feeding, still with total parenteral nutrition. My nephew was in an open warmer; on dopamine and dobutamine - medications to keep his cardiac output and blood pressure; morphine to keep him sedated; phenobarbital to protect his brain and to control new onset seizures. He was in the oscillator. His abdomen was enlarged, distended, blue. He received a myriad of blood products to compensate for his coagulopathy and bleeding.
I was incredibly sad and disheartened by seeing a little person with the same face as my brother's, in such a frail and incredibly life-threatening state.

I prayed, had a lot of good thoughts, supported my brother and my sister in law. Asked to my friends in the social media to pray. Tried to bring positive energy while in the back of my head I had my medical knowledge kicking and stabbing my soul. I tried to debate between whether it was an irrational exuberance to provide all this care to this baby who had a very low birth weight and that all the scientific facts in the medical literature were against his odds of living, versus my incredible and gigantic love for him as an uncle wanting to be an advocate and steward for his life. So far, my brother, a Pediatric Nephrologist fought back the Neonatologist who wanted to withdraw support. This little kid had a big ally on his side so far!

I decided that it was not irrational exuberance, and I supported to give all to him. I told my brother..."he is tiny, yes, he has a bleeding in his brain...but Hashem makes miracles, the brain plasticity is great; let him fight and let's fight with him". The next day, my nephew urinated, his creatinine started coming down; he had a meconium string (a bowel movement - which is a sign of the bowel working); he was weaned off the oscillator to a conventional ventilator; he was weaned off dobutamine and dopamine! The power of prayer was working! We had doubts about the neurological prognosis due to the abnormal cerebral images in the head ultrasound and a presumed midline shift of his brain. However his head circumference was stable and his fontanelle soft; in addition he was grimacing and moving his four limbs symmetrically, so I thought this was reassuring.

My niece on the other hand, was tolerating trophic feeds and was now providing a lot of strength to all of us.
I left Des Moines and came back to Cleveland. I gave a lecture at a Transfusional Medicine conference in Phoenix; then came back to my regular professional duties at the Cleveland Clinic (from where I'm typing this blog post on a Sunday at 2AM, working as the Medicine Triage Officer). In Phoenix I required to call one of my Pediatric Neurology colleagues at the Cleveland Clinic to ask him for insight regarding the neurological prognosis. The CT scan of the head was very disheartening - he had either severe edema versus almost an hemispheric infarct in addition to the subdural hematoma. The prognosis was looking grim and sad, but still, with some hope for the rest of the brain to take over.

My brother called me several days ago, his voice was very "dark and sad"....he said...."the baby is having severe abdominal distention; the surgeon is not available now; he got a gastrograffin enema...and the gastrograffin came through his mouth...he is now in respiratory distress....keep him in your prayers please, we think this is it....". Immediately after he told me I felt a freezing sensation and cold in all my body. I prayed, cried silently (I have not been able to put a tear out...it has been very contained and I feel a lot of pressure in my heart).

The next day he called me...."Samuel passed away at 3:45 AM, we were at his side...he stopped suffering". I can't believe how sad, disheartened, abandoned and helpless I felt. A myriad of images started crossing my mind remembering when I met him in the NICU, seeing his face so alike to my brother's, and how he fought through those 27 days of life. I prayed to Hashem to keep him peaceful with no pain, with no suffering. I felt the most  terrible pain I ever had in my heart. I adore these children. I felt terrible for my brother and his wife, for our parents, for our families....and for all the families who have lost premature babies in the NICU.

I debated on how cruel life can be...."is this fair? that I have given so much, that my brother has given so much as a Pediatric Nephrologist keeping babies alive, and we lost our child?...is this fair?....why?....why us?....". But as a non-religious but believer, I think Hashem has a reason for things to happen. Perhaps my nephew would have suffered from very debilitating disabilities from this complicated NICU course with poor neurological outcome. Perhaps this was for the best. Who knows.

How frail life is. How thin is the layer between life and death. We enjoyed him coming out to life, and so fast he went away. I realized how fascinating technology and science are, but how terrible and blinding they can be providing with false sense of hope. However...I admire the human power of having feelings and emotions....how much you can love somebody you just met, but who you know you were waiting for him or her all your life.

This is a very difficult time for us as brothers, as a father (for my brother) and as an uncle (for me). This is hard, I have a knot in my throat all the time. A squeeze feeling in my epigastric and retrosternal area is constant. My tears are contained, haven't been able to cry....feeling like so but I can't. Trying to give strength to my parents, brother and sister-in-law.

As a doctor, as a Pediatrician, as an Internist I hate futility. I believe in preserving quality of life over everything else. I believe in the most intimate respect and veneration for human dignity. I'm not sure if this NICU battle was going beyond these principles, but now this is past. Now my nephew is resting in peace and his memory will always be in my heart. I love him so much, with so much intensity, with so much appreciation for his incredible fight for life. He taught me how you can be so tiny yet so strong. He made me recall my appreciation and respect for Neonatology specialists, NICU nurses but overall, for the families and the tiny NICU patients themselves.

Now, my dear and sweet niece, so beautiful, so precious, so frail yet strong, is doing well. I keep all my feelings and prayers for her to survive the NICU and be a happy girl. I will strive to make from my standpoint what I can to make her enjoy and cherish life, have her enjoy this wonderful world full of colors, music, happiness, cultural richness and heritage. Her life is so meaningful to me as my own life. Her life represents my nephew life as well. She is living for both. She is a daughter, a granddaughter, a niece! We all love her so much. I have incredible feelings of infinite happiness for her to be alive, and a simultaneous incredible sadness for my precious nephew to having pass away.

I am experiencing very intense feelings I have shared with my friends - I am so grateful for their support and prayers, for their words. Social media is powerful. I have been able to share this important event in my family with our friends and colleagues from all the world. There are people who I may have not seen in quite a while, but whom I like and appreciate; people from whom I have learned something and shared some period of my life. People who have made me become who I am. Friends and family whom I respect and I'm infinitely grateful for their existence and for being there. I am here for them as well. In anything I can help I will always be here for them too. This is the beauty of friendship, the beauty of family, the beauty of existing - being there for the other; help each other; give a word of encouragement; and as a human being looking always to do the good and do not harm - treat others as you would treat yourself.

So much has happened lately - I realize how frail we are - we should be grateful to be alive; to have normal children; to see them grow and become independent; we should be grateful to be who we are!; to walk; to talk; to see;  travel; to be able to exist for oneself and for others. My nephew didn't have that privilege. His sister will do. Now I realize once more to never take things for granted.

I found again some sentimentalism I have always had, and I strengthened my respect for life and death, for the dignity of life, for the value of family and friendship, and most importantly, my infinite respect for all those little patients who fight like champions to perhaps, one day, become the Neonatologists who will make miracles happen and give hope to other babies and their families.

Samuel Alexander Auron (3/30/2012 - 4/27/2012) Z"L. My love for you my dear is as infinite as the universe, we promise to take good care of your little sister. You have made me be a better person and I will always follow my main principle as a doctor....primum non nocere. (I hope our irrational exuberance didn't harm you).

Preoperative anemia optimization - the role of intravenous iron in the XXI century

Intravenous iron was first used in the first half of the XX century until the decade of the 70's when it was essentially considered as a very dangerous drug with substantial potential for anaphylaxis. 

The fear prevailed for 2 decades, until the decade of the 90's when a closer look into alternatives to blood transfusion, and a desire to provide a safer medicine yielded into exploration and revision of intravenous iron as a potential therapeutic agent. In the early years of last decade, the FDA showed that even the high molecular weight dextrans were associated with a very small risk of adverse effects as well as a substantially lower cost compared with blood transfusions.

A surge in a safer practice of Medicine has blossomed in the past decade, including the famous publication of "To Err is human" from the Institute of Medicine, as well as multiple endeavors from a variety of government and private institutions, creating a real-time awareness of the need to change our practices with a safer, conservative and parsimonious use of resources as well as attention to detail. 

Among these practices, it is the practice of blood management. I won't go into deep details, however, must say that in surgical patients, it is well known that preoperative anemia is a risk factor for poor outcomes.

In this article at the ACP Hospitalist, we provide an insight on the utilization of intravenous iron as a treatment to optimize preoperative anemia and ensure that patients' preoperative hemoglobin rises enough so that after surgical blood loss, the postoperative hemoglobin levels won't reach the transfusion threshold.

We have been building experience in our institution with a substantial decrease in perioperative allogenic blood transfusion utilization, promoting patient safety and improved quality of care, obeying our medical mantra.....primum non nocere. 

What is the Ashman's phenomenon

One of the core competencies of hospitalists is the appropriate and accurate interpretation of electrocardiograms (ECG). Of course, we are Internal Medicine or Pediatrics (or both) specialists and not Cardiologists.

The ECG interpretation requires skill, close observation, excellent knowledge of the vectorial conduction of electricity in the heart, and most importantly, lots of practice and seeing multiple ECG's. In addition having the mentorship of senior Cardiologists with experience is paramount.

I had a case in the pre-operative clinic (IMPACT - Internal Medicine Preoperative Assessment, Consult and Treatment) at the Cleveland Clinic, and as part of the routine evaluation an ECG was obtained. She did have Atrial fibrillation , however some unexpected presumed premature ventricular contractions.

Further investigation on this electrocardiographic phenomena let us reassure our surgeons team and have the patient undergo surgery safely.

Read here our report in the Cleveland Clinic Journal of Medicine December 1 issue.

What to believe?

This has been a rough week for all of us involved in Perioperative Medicine. As hospitalists in a large academic medical center we take care of a large perioperative clinic that sees 16,000 and more patients every year.

In order to ensure optimal care of the patients, we use evidence based guidelines to provide the safest medical decision making.

One of the most prolific authors in the field is Dr. Don Poldermans, a very well respected and renowned cardiologist who we had the fortune of knowing as he has visited our institution for the Perioperative Summit which is now hosted by the University of Miami.

In November 16, the University of Erasmus of Rotterdam asked Dr. Poldermans to leave. This on assumptions of misconduct in research. This is a very frail moment as for any institution to take such a decision is not easy and decisions like this are not taken lightly.

For us is very hard; I just gave a lecture in Mexico City last weekend on perioperative medication management and I cited the DECREASE studies findings supporting the current evidence to use betablockers, especially the ones recommending starting low dosing with gradual increase and preferentially within 1 to 4 weeks of surgery.

The media has been taken by assault and all of us feel like orphans. Can we trust the data? Is this a precipitated decision by Erasmus? Everybody should be cautious in times like this and careful in not destroying the prestige of somebody who has been an authority in the field and a good man.

I look forward to follow closely what happens and ensuring that the evidence we use is still valid or not. We should be careful in not labeling him until further clarification occurs either from him or Erasmus.

These are some links to these news:
http://www.anesthesiologynews.com/ViewArticle.aspx?d=Web+Exclusives&d_id=175&i=November+2011&i_id=785&a_id=19726
http://retractionwatch.wordpress.com/2011/11/17/breaking-news-prolific-dutch-heart-researcher-fired-over-misconduct-concerns/#more-5216
http://ktwop.wordpress.com/tag/don-poldermans/
http://www.erasmusmc.nl/perskamer/archief/2011/3488672/
http://www.nrc.nl/nieuws/2011/11/17/nieuw-geval-van-wetenschapsfraude-hoogleraar-erasmus-mc-ontslagen/

Sigh!.......What to believe?

Perioperative management of morbid obese children

Obesity is the plague of our days. It takes years of life away in an instant. However, despite the knowledge and awareness of its terrible consequences, it seems that parents are blind to the devastating effects of it.


I presented a workshop on perioperative management of the pediatric patient in Kansas City, at the 2011 Pediatric Hospital Medicine meeting, sponsored by the American Academy of Pediatrics and the Society of Hospital Medicine.

A section I focused on, and brought special attention was the management of children with morbid obesity. You can read in further detail here.