Jumping the Queue

Faced with too many kids with heart problems in Ireland, one surgeon devised a transatlantic solution.

When cardiac surgeon Mark Redmond returned to his native Ireland in 2000 after 12 years of training at Johns Hopkins, he found a country blessed with a robust new economy. The hospitals were clean, well equipped and smartly staffed. But Redmond also noticed a disturbing overflow of patients in need of life-saving cardiac procedures.

The problem was especially acute among children: With 150 patients waiting for heart surgery, only one hospital in a nation of nearly 5 million could handle their care. Meanwhile, an ongoing surge in population meant that the need for these vital heart operations was growing.

Redmond didn’t blame his country’s system of socialized medicine for the backlog, but he was determined to expand Ireland’s ability to take care of these desperately ill children. Yet even as he began forming plans for a modern new hospital outside Dublin, the waiting list of young patients continued to grow. Where could they go for help? For Redmond, the answer was straightforward.

Three times a year since the fall of 2000, Mark Redmond has been quietly selecting up to eight children to accompany him on a 10-day pilgrimage to Johns Hopkins, where he retains a faculty appointment. His fellow travelers range in age from just weeks old to teenagers. Usually, the children’s parents come along.

If all goes well, Redmond operates on two children each day for the next week. For many, he performs time-sensitive valve replacements. In some of the most pressing cases—as with the infant in the photograph at left—he repairs holes in the hearts of babies suffering from Down syndrome, where the procedure’s optimal surgical window closes after six months. Once the patients are out of surgery, Redmond presides over their postop recovery and then flies them back to Ireland by the end of the week.

Typically quiet affairs, Redmond’s transatlantic medical tour draws little public notice in the Emerald Isle. Still, with his most recent round of seven operations here in November, he has repaired the hearts of nearly 100 Irish children in Baltimore over the last six years. During that time, the number of Irish babies and young people waiting for heart surgery has dramatically declined—from 150 at the start to just 40 patients now.

Ramsey Flynn

An Icon Turns 100

Backstory of an artistic medical masterpiece

The Four Doctors have turned 100. Putting it more precisely, John Singer Sargent’s portrait of the School of Medicine’s four founding physicians—certainly, the University’s most prized artistic possession—has reached a century.

Unveiled here on the evening of Jan. 19, 1907, the painting shows William Welch, William Halsted, Sir William Osler and Howard Kelly looking like vaunted European academics instead of practicing American physicians. Attired in black robes, they pose before a massive Venetian globe and an El Greco painting. Nearby lies a 1515 edition of Petrarch.

Welch, who was on hand for the portrait’s unveiling, described the sittings in the artist’s London studio during the summer of 1905. All four physicians were there—a scheduling feat that had taken two full years to coordinate. As work began, Sargent was distinctly not pleased. “It won’t do,” he had declared. “It isn’t a picture.” Then he brought in the globe, and by the next sitting, happiness reigned. “Now,” he pronounced, “we have got our picture.”   

Hopkins treasured “The Four Doctors” from the start. Although it was soon loaned to the Corcoran Gallery in Washington and then sent to the Carnegie Institute in Pittsburgh, it was never loaned again. Its immense size (10 feet 9 inches by 9 feet 1 inch) and construction on four separate canvasses made moving it too risky. In 1938, as World War II began in Europe, the painting’s protective glass was removed and it was covered instead with a screen. If bombs fell on Baltimore, everyone wanted the great work to come through unscathed.

“The Four Doctors” has been restored three times, most recently in 2001. Before the last cleanup, Halsted had appeared lost in the shadows—some believed because Sargent didn’t like the surgeon and intentionally obscured his features. As layers of grime and dirt fell away, though, Halsted emerged in all his glory. Today the Four doctors look just the way they did when they were unveiled 100 years ago.  

Anne Bennett Swingle

Hearts of Steel

Who says a working heart has to beat?

Artificial hearts may have finally arrived. With healthy donor organs in chronic short supply, surgeons here are gaining confidence in high-tech answers for patients with late-stage cardiac failure. Consider the HeartMate II device in the photograph at right. It’s a major leap forward from its first generation from five years ago—smaller and more reliable. Doctors implanted 15 of them here in 2005, with promising results. At a cost of $65,000 each (with “implant kit”), surgeons think they herald a new frontier. Though John Conte would typically refer to one of these as a “left ventricular assist device” (LVAD), he sometimes tells patients unfamiliar with the pumps to “think of it as an artificial heart.” Conte and cardiologist Stuart Russell say the device provides a continuous flow of blood rather than the “pulsatile” quality normally associated with a human heartbeat. It’s expected to extend the lives of end-stage patients by up to seven years. Five years out, they say, Hopkins will implant up to 75 such devices. And it gets better: A new device that will have no metal-on-metal contact whatsoever (no ball bearings to wear out) has just entered phase 1 trials. The “Rotary VAD” uses magnetic levitation to drive its moving parts. They could extend lives by up to 10 years.

Ramsey Flynn

A Talk Before Cutting

Surgery now starts with introductions all around.

It typically takes about two minutes. The operating team gathers around an anesthetized patient and the head surgeon begins. “My name’s Rich Schulick.”

“I’m Ryan Katz, resident,” comes the next person, followed by “Adriana Schwent, nurse.” From behind their surgical masks, one by one, all seven give a name and a role.

So begins the ritual that is unfolding with growing frequency in ORs nationwide: Surgical teams have adopted a protocol devised by the aviation industry—the preflight safety check. In two specialties here—surgery and anesthesiology—those practices have come to include establishing an accord among the team members before a procedure begins. For today’s operation, for instance, Schwent reads from her checklist: “We’re doing an exploratory laparotomy, a distal pancreatectomy and a splenotomy.”

“I agree,” says Schulick.

“I agree,” says Katz.

On Schulick’s signal, Schwent takes the group through a list of 16 points concerning the coming procedure—which medications the patient is currently using, the estimated time of the operation, the blood supply that should be on hand—all details that must be taken into account before the first incision is made.

Under increasing pressure to reduce medical mishaps, the Joint Commission two years ago ordered these formal “time outs” before every surgery. But at Hopkins, adaptation was spotty at first. The guidelines, many believed,  failed to include issues that could afflict cases as complicated as those seen here.

Enter Lisa Rowen, director of surgical nursing, who made a series of revisions to the mandated checklist based on discussions with surgeons, nurses and anesthesia providers. The expanded tool, which debuted May 1, blends the Joint Commission’s list into one quick series of checks amid a more comprehensive process. It’s been embraced from the top down.

Besides introductions—seemingly common sense, but until recently rarely practiced—the process includes a post-op debriefing before the surgeon leaves the room. It reviews issues that arose during the operation and goes over steps that could increase safety. It also reviews plans for immediate post-op care.

“The linchpin of the process,” Rowan says “is the attending surgeon. The surgeon needs to show buy-in.” 

Ramsey Flynn

Equal Footing

Rich or poor, the care’s the same

Talk to faculty physicians here about why they put up with the pressures and smaller paychecks that can define academic medicine and you’ll often get this response: “There’s something about Hopkins that’s different.”

Some say it’s the unusual comradeship among colleagues that characterizes clinical practice here. For others, it’s the thrill of being part of the intellectual firmament of this place. For Ted DeWeese, director of radiation oncology, it’s those things and more.

DeWeese, a specialist in urologic malignancies, loves the idea that he’s able to offer similar treatment to all of his patients."No matter their financial status or where they come from,” he says, “they get the same care." He even cites the ultimate pair of cases to demonstrate what he means.

Three years ago, two men from opposite ends of the social spectrum came to him almost simultaneously with nearly identical stages of prostate cancer. One was the head of a major European conglomerate, the other a gravedigger from Orleans Street in East Baltimore. DeWeese, who’s known for his proficiency in delivering subtle doses of radiation into malignant tumors, treated the men identically.

Today, the corporate titan is 65; his medical fellow traveler is 68. DeWeese has given both the “all-clear” signal.  What’s really interesting, though, is that during their prolonged series of treatment visits, the two men struck up a relationship in the waiting room of DeWeese’s department. Like other patients in similar circumstances, they bonded with each other after repeated encounters. (A local businessman and a dockworker, even meet for lunches several times a year.)

Ramsey Flynn

Doctor Click

Technology has unleashed torrents of possibilities for saving lives. But when the heat is on, it takes a wunderkind to sort it all out.

> Click to see the instruments described in detail

Timesaver   Residents once spent hours manually compiling data for patients’ daily progress notes. Lehmann co-authored a program that compiles it all in less than five minutes.  “Smart Drip”  For pediatric patients, physicians once used an error-prone technique to make drip calculations. This team’s automated calculation program has reduced errors by 90 percent. Quicker Approval  When antibiotics are called for, time is key. One Lehmann program accelerated the approval process, reducing the risk for resistant bacteria and saving $400,000 annually. Safer Chemo Pediatric chemotherapy requires delicate measurements. Lehmann’s team assessed high-risk procedures and created an order-entry tool that reduced errors. Steadier Infusions   In a noted breakthrough, the group standardized calculations for delivery of continuous medications. Order-Entry Execution  In collabora-tion with safety experts, Lehmann designed a better system for ordering medications, nutrition, tests—and phototherapy levels. Error Reduction  For “old style” nutrition infusers like this one, the Lehmann team crafted a calculator that reduced dosing errors by 89 percent. Online CPR Guide When a heart stops, the team must think fast. This “CPR card” is automatically tailored to the patient’s metabolic particulars and weight.

The call came in on Friday night. A 2.2-pound preemie with a failing heart, failing lungs and failing kidneys was inbound to the Hopkins NICU. Neonatologist Chris Lehmann dispatched a fellow to oversee the transfer and warn the parents their baby could die within hours. At 10 p.m., as the infant boy arrived in the neonatal intensive care unit, six specialists descended. Each set about negotiating fast-moving medical details and equipment. “For two hours,” says Lehmann, “this room was pandemonium.”

With so many of the baby’s vital systems in peril—and some 50 different medicines and dosing levels to choose from against a loudly ticking clock—the team faced its ultimate test. Which drugs? How fast? Which doses? Luckily for this newborn, the physician in charge—Lehmann—had personally overseen the programming of nearly all the technology in the room. These machines had answers.

Chris Lehmann came here in 1995 for a neonatology fellowship and quickly got bored. He found himself gravitating toward the “informatics nuts” who toil at computers trying to devise smarter and safer ways to govern the minutiae of lab values, contagions and pharmaceuticals that affect outcomes. Quickly encountering the glitches in programs, he began tailoring them to the particular needs of his colleagues in pediatrics. Then he began writing software programs from scratch, rolling them out, debugging them as he went along. The tools turned mountains of scut work into manageable molehills; his programs helped avert medical mistakes.

In one feat, Lehmann programmed the machines in neonatal suites to send alerts to busy residents whenever their patients’ lab values slipped into the abnormal range. When residents complained that the alerts set off their pagers unneccessarily, Lehmann made adjustments. Soon, pagers were beeping but a few times in a 12-hour shift. Without the “noise,” outcomes improved. Lehmann’s colleagues began extolling the virtues of his systems to co-workers over lunch.

Today, Lehmann presides over five servers from his office. “All of my servers monitor each other,” he quips. And though the technology allows him to multitask with the best of them, Lehmann makes clear “it’s not for the love of gadgetry that I do this. It’s all about these babies.” The infant boy in this case, for example, was transferred to a lower level of care less than two weeks after checking in. “He’ll do well.”

 Ramsey Flynn

ALPHA DOCS

Hot Dang!

Years after his cold arrival as a refugee, our vice dean for research reaches a pinnacle in American medicine.

>Chi Dang in his office, flanked by a 1967 photograph of his brother and him with their new American family. (He’s front left.)

One of his first memories of life in America was watching the mist his breath created in the cold Michigan air every time he exhaled. In the 39 years since that chilly beginning as a fresh-faced 12-year-old refugee from Vietnam, Chi Van Dang has engineered a much warmer reception in his adopted country: In October, the School of Medicine’s vice dean for research was welcomed into the National Academy of Sciences’ Institute of Medicine, one of the most respected honors in his field.

For Dang, such prospects might once have looked like a long shot. One of 10 children of the late Dang Van Chieu, Vietnam’s first neurosurgeon and dean of the University of Saigon’s School of Medicine, Dang was shipped off in 1967 with his brother to live with an American family in Flint, Michigan. His parents wanted to spare the two boys from the war that was raging in their country.

Chi Dang took quickly to the American ziggurat. After obtaining his undergraduate degree at the University of Michigan and a doctorate in chemistry from Georgetown, he arrived at Hopkins as a medical student and—except for a couple of years at UCSF as a fellow—has never left. Today, in addition to his vice dean responsibilities, Dang is a noted hematology researcher whose work on the MYC cancer gene is considered pathbreaking. He serves on the editorial boards of several scholarly journals and mentors Ph.D. candidates and postdoctoral fellows.

Still, few colleagues knew of Dang’s refugee story until last July, when a feature about that long-ago chapter began circulating on the news wires. “My friends find this history interesting because I have no Vietnamese accent,” he says. “I tell them I have a Michigan accent.”

A knowledgeable coterie of Dang’s fans have figured out, however, that he is now the highest ranking physician of Vietnamese descent in academic medicine—not just in the United States, but in the world. In 2005, his proud expat countrymen honored him at the Vietnamese American National Gala with their Gold Torch Award for medicine and education.

Still, if he were not in the higher reaches of medicine at Hopkins, what might he have become?

“Deep in the crevices of my mind,” Dang told the writer of a Vietnamese-American lifestyle magazine, “I dream of the serenity and bucolic existence of a country doctor. Like my father, I wish to be remembered first and foremost as a teacher and compassionate healer.”

Neil A. Grauer

Ultimate Teacher

New physiology chief pursued childhood fascination.

David Hellmann might strike some as looking not much older than the medical students he teaches, but those students know that behind those boyish looks they find an unforgettable mentor. That trait was also recognized last fall by the American College of Physicians, which named Hellmann—a rheumatologist and director of the Department of Medicine at Johns Hopkins Bayview—its Distinguished Teacher of the Year. The citation, which will be presented at the College’s national meeting in San Diego this April, states that Hellmann’s renown as a teacher has been proven “by the acclaim and accomplishments of former students,” many of whom have gone on to become leading medical teachers themselves.

More Alpha Docs

Deborah Armstrong, associate professor of oncology, gynecology and obstetrics, has been awarded the first annual Health Breakthrough Award from the Ladies’ Home Journal. The award recognizes her work on delivering chemotherapy through a catheter directly into the abdomens of ovarian cancer patients.

Harry (Hal) Dietz, Victor A. McKusick Professor of Genetics and Medicine, has received the American Society of Human Genetics’ Curt Stern Award for his ground-breaking research on Marfan syndrome and other genetic diseases.

Todd Dorman, associate professor of anesthesiology, surgery and medicine, and vice chair for critical care services in Anesthesiology and Critical Care Medicine, is president-elect of the American Society of Critical Care Anesthesiologists.

Joel Gallant, professor of medicine and assistant director of the Hopkins AIDS Service, has received the Emerging Leader in HIV Clinical Education Award from the HIV Medicine Association. Besides his reasearch and a well-known text, he’s known for Web-based additions to patient education.

Elizabeth Jaffee, professor of oncology and pathology, has received the National Cancer Institute’s 2006 Outstanding Specialized Programs of Research Excellence (SPORE) Investigator Award for her work in pancreatic and breast cancer vaccine development.

Sean Leng, assistant professor of geriatrics, has received the Paul Beeson Career Development Award in Aging Research, one of the most prestigious in the field of geriatric research.

David Nichols, professor of anesthesiology, critical care medicine and pediatrics, and vice dean for education, has received the American Academy of Pediatrics’ Critical Care Distinguished Career Award.

Arnall Patz, director emeritus of the Wilmer Eye Institute, has been elected to the American Printing House for the Blind’s Hall of Fame for Leaders and Legends of the Blindness Field.

Richard Rubin, associate professor of medicine and pediatrics, has been elected president of health care and education for the American Diabetes Association. He’s author of the Johns Hopkins Guide to Diabetes.

Charles Silberstein, associate professor of orthopedic surgery, has received the American Orthopaedic Society for Sports Medicine’s Thomas Brady Award, recognizing his exceptional treatment of local athletes, including members of the Baltimore Orioles.