VOLUME VOLUMEVII V ISSUE 2
HouseCall
The next generation of vascular surgery HIGHLY TRAINED SURGEONS PLUS HIGH-TECH TOOLS EQUAL SUPERIOR PATIENT CARE ( PAGE 2 )
inside
Foot And Ankle Surgeon Offers Unique Skills I Update: Pain Protocol For Knee And Hip Replacement Patients A Huge Success I Sophisticated Video EEG Monitoring For Epilepsy Patients Ask The Doctor I Reaching Out To The Community I The Region’s Only ‘A’ Grade
ADVANCED TECHNOLOGY
Advanced vascular surgery provides myriad of benefits It had been a special holiday season for Joseph Shimek of Collier Township. His son, Russell, 26, who is serving in the Navy, had come home to spend Christmas with Joe, his wife Annette, and their daughter Jamie, 29. The family had just finished dinner on New Year’s Day and Joe, 62, who works as a commercial carpenter, sat down to relax and watch TV. He was immediately stricken with sudden, severe pain in his upper back. Nothing brought relief and when the pain worsened, he and Annette headed to St. Clair Hospital’s Emergency Room. “I never had pain like that before,” he recalls. “I didn’t think it was a heart attack. I had no shortness of breath or chest pain. I didn’t know what it was.”
F
ortunately for Joe, doctors at St. Clair knew exactly what it was. Thomas
A. Simone, M.D., a vascular surgeon who had recently joined the staff of the Hospital, examined Joe in the ER and recognized a classic presentation of an emergency condition called thoracic aortic dissection. The diagnosis
was confirmed by a CT angiogram, and in a short time Joe was in the
Intensive Care Unit (ICU), where he spent the next three weeks. In the ICU, his condition was stabilized and medically managed by Dr. Simone and the ICU clinical staff in
preparation for eventual surgery. The aorta is the largest blood vessel in the body. It sits slightly behind the heart, arching above it, and runs through the chest and abdomen. Although the aorta typically functions normally throughout one’s lifetime, it is a delicate structure. Sometimes, it develops a weak spot that results in a balloon-like bulge called an aneurysm. An aortic aneurysm can occur in the thoracic region of the aorta, nearest the heart, or more commonly in the abdominal section. It may be the result of an aortic dissection, which occurs when blood flow, usually in the presence of high blood pressure, forces the layers of the aortic wall to separate, or dissect, weakening the entire structure. If not
ABOUT THE COVER
found, an aortic dissection can rupture or develop an aneurysm, with potentially grave
Vascular Surgeon Thomas A. Simone, M.D.
consequences, including massive internal bleeding.
and his team perform next-generation surgery at St. Clair Hospital’s Interventional Radiology Continued on page 4
2 I HouseCall I Volume VII Issue 2
(IR) Lab.
“
ENDOVASCULAR SURGERY IS
MUCH LESS INVASIVE THAN THE OPEN CHEST PROCEDURES OF THE PAST... IT MEANS A SMALLER INCISION, LESS PAIN AND TRAUMA, A SHORTER ADMISSION AND FASTER RECOVERY.
Vascular surgeon Thomas A. Simone, M.D. in St. Clair Hospital’s new multi-million dollar Interventional Radiology (IR) Lab with the Artis Zeego, a three-dimensional imaging system.
”
THOMAS A. SIMONE, M.D. VASCULAR SURGEON, ST. CLAIR HOSPITAL
Volume VII Issue 2 I HouseCall I 3
ADVANCED TECHNOLOGY Continued from page 2
“Mr. Shimek had an acute thoracic aortic dissection,” explains Dr. Simone. “The dissection
What is aortic dissection?
penetrates but doesn’t go through all three
Aortic aneurysms are potentially serious health problems since a burst aorta results
layers of the wall. It splits the layers apart,
in massive internal bleeding that can be fatal unless treated rapidly by an experienced
creating a new passage. It causes severe
emergency medical team.
tearing pain. Mr. Shimek’s dissection was
Aneurysms often affect the body’s largest artery, the aorta. The aorta carries blood away from the heart and it runs from the heart through the chest and abdomen. The normal diameter of the aorta in the abdomen is a little less than 1 inch. An aneurysm is considered to have formed if the aorta grows to more than 1½ to 2 times its normal diameter. Over time, blood pressure and other factors can cause this weak area to bulge like a balloon
uncomplicated, meaning that the blood flow was going where it was supposed to go and his perfusion was normal. But his dissection was long, and that made it a challenge.” To prepare Joe for surgery, Dr. Simone
and it can eventually enlarge and rupture.
treated him with anti-hypertensive medications,
Endovascular stent graft repair is designed to help prevent an aneurysm from bursting.
blood pressure low is critical, as it helps to
pain medication and sedatives. Keeping the A stent graft is a tube composed of fabric supported by a metal mesh designed to reinforce a weak spot in an artery and seal tightly with the artery above and below the aneurysm. The graft is stronger than the weakened artery and it allows blood to pass through it without pushing on the bulge.
relieve stress on the weakened segment of the aorta. Sedatives also play a role, assisting with blood pressure but more importantly, helping to keep the patient at rest to augment
“Endovascular” means "inside blood vessels." To perform endovascular procedures, vascular
respiratory support. “Respiratory failure is
surgeons use special technologies and instruments which require only a small incision
a common issue with aortic dissection,”
or puncture in an artery or vein. Through these punctures, a vascular surgeon inserts
Dr. Simone says. “It can evoke inflammation,
long, thin catheters to carry the stent graft to the location of the aneurysm, where it is
causing fluid to accumulate in the lung space.
placed to realign and strengthen the artery. Generally endovascular treatments allow patients
This can make the patient agitated and anxious.
to leave the hospital sooner and recover more quickly, with less pain and a lower risk of
We find that patients do better if we can get
complications than traditional surgery.
them through this inflammatory period and
Source: www.vascularweb.org/vascularhealth/Pages/endovascular-stent-graft.aspx
then do the repair.” After three weeks in St. Clair’s ICU, Joe had a short stay in rehab and was discharged to
DESCENDING THORACIC ANEURYSM
ENDOVASCULAR SURGERY
home for a period of stabilization and healing. He returned to St. Clair in March for endovascular stent-graft surgery, an advanced, stateof-the-art approach that utilizes minimally
aorta------>
invasive surgical technology and cutting-edge imaging capabilities. “Endovascular” means
guide wire---------->
that the procedure takes place within the blood vessels, as opposed to an open incision in the chest. Through a small puncture in the groin, Dr. Simone guided a thin, flexible catheter
aneurysm------->
aneurysm------>
<------stent graft
containing a compressed stent-graft (a hollow sleeve made of fabric) through the blood vessels, accessing the site of the aortic dissection.
<---catheter
While monitoring the advancement of the catheter on a screen, he placed the stent-graft at the site of the dissection, where it expanded
4 I HouseCall I Volume VII Issue 2
and opened, allowing blood to pass through. The stent is permanent, and will gradually merge with the aorta, strengthening it. The injured tissue of the dissection will recede. “Endovascular surgery is much less invasive than the open chest procedures of the past, which could require a 12-inch or more incision. It means a smaller incision, less pain and trauma, a shorter admission and faster recovery for the patient,” Dr. Simone says. “The concern with aortic dissection repair is that there is the potential to deprive the spinal cord of blood during the surgery; the aorta supplies blood directly to the cord. This can lead to devastating consequences. We place a drain in the epidural fluid
“
”
MY PHILOSOPHY IS ONE OF RESPECT: RESPECT FOR THE PATIENT, THEIR BODY, AND THEIR ILLNESS.
around the cord, to facilitate perfusion of the cord. Post-operatively, the patient must lie flat for 24 hours until the spinal fluid is replenished.” For Joe, that was the most challenging
THOMAS A. SIMONE, M.D. VASCULAR SURGEON, ST. CLAIR HOSPITAL
aspect of the surgery. “When I woke up, the pain was gone,” he says. “I just needed a pain pill to sleep. I stayed in the ICU for four days to recover, then I went home and felt fine.
Vascular Surgery Residency Program at
other specialties. Vascular surgery interested
I have no scar, just two tiny dots. Dr. Simone
Dartmouth-Hitchcock Medical Center (DHMC),
me because of the great variety within it and
prepared me well; he gave me good explanations
a tertiary care hospital affiliated with Dartmouth
the opportunity to work on all different parts
of everything. He wants you to know what
University in New Hampshire. The five-year
of the body.”
to expect.”
program begins with a general surgery
On Becoming A Surgeon Dr. Tom Simone is a native of Mt. Lebanon,
Vascular surgery treats disorders of the
residency, followed by three years of special-
arterial, venous and lymphatic systems and
ization in vascular surgery and one year of
has evolved into one of the most innovative
research. Considered one of the top programs
and dynamic disciplines in medicine, with
who grew up in a family of five and played football
in the world, DHMC’s vascular surgery training
tremendous growth in the past decade alone.
at Mt. Lebanon High School and Vanderbilt
program was the first in the U.S. to be approved
It has become increasingly specialized and
University in Nashville. He is the oldest son
after the American Board of Medical Specialists
sophisticated, utilizing both open surgery
of St. Clair Hospital vascular surgeon Samuel
named vascular surgery a primary specialty
techniques and minimally-invasive technology
T. Simone, M.D., and esteemed Pittsburgh
in 2005. Prior to that, vascular surgeons were
to access and repair various organs and tissues
stage and film actress Helena Ruoti. After
first fully trained as general surgeons, spending
via the blood vessels. Frequently, endovascular
graduation, he took a year off from academics
as many as nine total years in residency.
to travel and volunteer with Operation Safety
“My Dad, Dr. Sam Simone, exposed me to
procedures are revascularizations: procedures that restore blood flow to a body part that
Net, an award-winning outreach program that
vascular surgery when I was young, sometimes
is deprived of it, due to a narrowing or an
provides medical care to the homeless of
taking me on rounds (seeing post-surgery
obstruction. There are two ways to achieve
Pittsburgh. He attended Philadelphia’s Jefferson
patients) at St. Clair, but he never put any
this, says Dr. Simone: a bypass, in which a
Medical College, graduating in 2008, and then
pressure on me,” Dr. Tom Simone says. “I
was accepted into the prestigious Integrated
wanted to be a surgeon, but I was open to
Continued on page 6
Volume VII Issue 2 I HouseCall I 5
ADVANCED TECHNOLOGY Continued from page 5
“
WE ARE TAKING REVASCULARIZATION PROCEDURES TO AN UNPRECEDENTED LEVEL.
”
SAMUEL T. SIMONE, M.D. VASCULAR SURGEON, ST. CLAIR HOSPITAL
vein graft or artificial graft is employed to
lower extremities to restore blood flow to
pass a blockage to an open vessel, or an
legs and feet affected by peripheral vascular
endovascular approach, using guide wires
disease; performs ablations to remove
and catheters to open the blockage with
varicose veins; places and revises fistulas
balloons and stents. The challenge, he says,
in the arms of dialysis patients; and treats
is to determine which approach is best for
patients with deep vein thrombosis, or
the individual patient.
blood clots. Vascular surgery addresses
At St. Clair, Dr. Simone repairs
vascular disease throughout the body,
aneurysms and aortic dissections; performs
except for the coronary arteries and the
endarterectomies to open up narrowed
intracranial arteries.
carotid arteries; revascularizes ischemic
Dr. Sam Simone, a vascular surgeon at St. Clair since 1982, has witnessed the dramatic evolution of the field. “Endovascular technology has revolutionized vascular surgery,” he says, “leading to our ability to perform more complex, technically difficult procedures on a variety of patients. We are taking revascularization procedures to an unprecedented level. We have an adept team to do that at St. Clair.” The Hospital’s Interventional Radiology (IR) Lab uses the most advanced technologies, including a three-dimensional imaging system from Siemens called the Artis Zeego in the Hospital’s new multi-million dollar IR lab. “It’s a robotic system that features an arm that can move along the patient’s body in any position, providing tremendous flexibility and visualization,” Dr. Tom Simone says. “It’s used in the IR, not only by vascular surgeons but also by interventional radiologists, as well as cardiac, neuro, orthopaedic and trauma surgeons. One of the greatest advantages is that it brings highly advanced imaging technology right into the IR so there’s no need to move the patient. The Artis Zeego is an advanced tool for diagnostic and interventional imaging, and saves on radiation and contrast for the patient.”
(At left) Thomas A. Simone, M.D. (seated) and Samuel T. Simone, M.D.
6 I HouseCall I Volume VII Issue 2
New Options For Vascular Surgeons
elevates our department and means that
Dr. Tom Simone echoes his father’s
we’re able to offer the community the most
sentiments on standards of care. “My philosophy
Mark Hirko, M.D., FACS, is a member of
progressive endovascular surgery procedures.
is one of respect: respect for the patient, their
the Community Outreach Committee for the
The new hybrid procedures that Tom has been
body and their illness. I try to be relaxed with
Society for Vascular Surgery and Chair of the
trained in are now available at St. Clair on
patients, to make time to listen and hear their
Department of Surgery at Barnabas Health
a regular basis. We share and discuss cases
questions. I explain things in simple terms
in New Jersey. According to Dr. Hirko, who
with our colleagues, including our partner,
without jargon. I make it my practice not to
trained as a vascular surgeon in the 90s, there
Michael Lally, M.D. Within such a rapidly
leave the room until I’m sure they understand
were two options at that time for treating
changing field, an ongoing education process
the plan and know what is going to happen.
vascular problems: medical management, or
is essential.
Once they know, they can relax.”
open surgery. “Vascular surgery was propelled into the future by interventional radiology and
“Improvements in pre-op and post-op care, better anesthesia, an enhanced ability to monitor
It’s been an eventful year for Dr. Simone. He completed his training program at
cardiology. Today we have new models for
and care for patients and more sophisticated
Dartmouth-Hitchcock Medical Center last
training and for practice, and medical students
critical care units have also played a significant
June; got married in September; moved with
view vascular surgery more positively. Vascular
role in the evolution of vascular surgery,” he
his wife, Tara, an attorney, to Pittsburgh;
surgeons have many options; they can focus
adds. “Today we have more medical specialists,
and in October, began practicing at St. Clair.
on wound care, revascularization, carotids,
surgical recovery units, and nursing specialists.
“I’m very pleased to be at St. Clair,” he says.
or endovascular procedures. They can do
Home care is better, enabling us to send patients
“My Dad gave me a warm welcome. We did
hybrid procedures, which is doing two or three
home earlier where there is less risk of infection
cases together for the first few months and he
procedures at the same time, if the patient
and disorientation. At St. Clair, we have kept up
shared his techniques with me. St. Clair is a
has multiple blockages.
with all this progress; our ability to offer advanced
great place for a young surgeon to practice.” ■
“Vascular disease permeates the entire body and is prevalent in the senior population,
procedures in the patient’s community is an advantage and a convenience.”
and the need for vascular surgeons is growing. The future looks exciting: a lot of new procedures are in development, but there is also better medical management of vascular disease and fewer people are smoking. Vascular surgery is a satisfying specialty, knowing that you can gain a patient’s trust and save their leg or save their life.” Dr. Sam Simone, a graduate of Temple University College of Medicine and a vascular
SAMUEL T. SIMONE, M.D. Dr. Simone specializes in vascular surgery. He earned his medical degree at Temple University School of Medicine, Philadelphia. He completed his internship and residency at Mercy Hospital of Pittsburgh, and a fellowship in vascular surgery at PresbyterianUniversity of Pennsylvania Medical Center, Philadelphia. Dr. Simone is board-certified by the American Board of Surgery. He practices with General & Vascular Surgery Associates, Inc. To contact Dr. Simone, please call 412.391.4360.
surgeon since 1982, is well acquainted with that satisfaction. He says it was a logical decision to have Dr. Tom join his practice, General & Vascular Surgery Associates, Inc.
THOMAS A. SIMONE, M.D.
and sometimes share cases with him. “It’s an
just completed one of the best programs at a
Dr. Simone specializes in vascular surgery. He earned his medical degree at Jefferson Medical College, Philadelphia, and completed an Integrated Vascular Surgery Residency Program at DartmouthHitchcock Medical Center, a tertiary care hospital affiliated with Dartmouth University in New Hampshire. Dr. Simone practices with General & Vascular Surgery Associates, Inc.
leading institution. The combination of my
To contact Dr. Simone, please call 412.391.4360.
honor and a privilege, and an exciting adventure, to have my son as a partner. I have over 30 years of vascular surgery experience, and he’s
expertise and experience, and his training,
Volume VII Issue 2 I HouseCall I 7
EXPERT CARE
Getting patients back on their feet
again
Foot surgery patient Douglas Mack and Grace are back to their usual walks at South Park.
8 I HouseCall I Volume VII Issue 2
ST. CLAIR HOSPITAL FOOT AND ANKLE SURGEON OFFERS UNIQUE SKILLS IN AND OUTSIDE THE OPERATING ROOM
W
ith 26 distinct bones and an intricate support system of muscles, tendons and ligaments, the human foot bears our weight, keeps us upright, propels us forward, acts as a shock absorber and helps maintain our balance. Engineered to carry us through our entire lives, the feet take an enormous amount of wear and tear. By age 50, the average American has walked over 75,000 miles, according to the American Podiatric Medical Association. When something goes seriously wrong with these crucial body parts, such as arthritis, fractures of the foot or ankle, tendon or ligament injuries, or overuse conditions such as tendonitis, it can bring normal life to an abrupt and painful halt. Injured feet need expert care, and at St. Clair Hospital, foot and ankle surgeon Damon B. Combs, D.P.M., possesses the expertise, along with the experience, to get patients suffering from foot injuries literally back on their feet again.
Douglas Mack of Bethel Park will never forget the sound of his bones cracking as he slipped on a patch of black ice in his driveway and hit the ground, his feet twisting grotesquely beneath him. It was a freezing cold January day, and the 42-year old financial analyst had his little rescue dog, Grace, in his arms and could not brace himself or stop his fall. “Grace was spared, but I wasn’t,” he says. “My right foot hurt a lot, but I tried to tell myself that it wasn’t a fracture. I hobbled around, hoping it would start to feel better. A friend convinced me to see a physician who specializes in cases like mine.” The doctor he chose is one of the most highly qualified and sought-after foot and ankle surgeons in the region, Damon B. Combs, D.P.M. Dr. Combs, who practices with South Hills Orthopaedic Surgery Associates and is a member of the medical staff at St. Clair Hospital, offers unique care, given his superlative training as a podiatrist and a foot and ankle surgeon. Following his graduation from the Ohio College of Podiatric Medicine, he completed a podiatric residency at UPMC. He was then awarded a fellowship in reconstructive foot and ankle surgery and limb salvage, also at UPMC. Continued on page 10
Damon B. Combs, D.P.M.
Volume VII Issue 2 I HouseCall I 9
EXPERT CARE Continued from page 9
Dr. Combs closes an incision after surgically repairing a young female patient’s broken ankle in an operating room at St. Clair Hospital. Assisting him are, left to right, Jennifer Ackaoui, ST; Lauren Totino, R.N., and Joe Toth, R.N.
Included among the elite 1 percent of podiatry
ligament tears, and revisions of previous
and my foot was misshapen. Once the swelling
residents to get an orthopaedic surgery fellow-
surgeries. Dr. Combs also treats severe
went down, I had outpatient surgery. Dr. Combs
ship, Dr. Combs is exceptionally well qualified
injuries, such as heel bone fractures. Some
had to re-align the bones, fuse a joint, put in two
to treat all types of foot and ankle injuries and
of the most common procedures he does are
plates and 10 small screws. It was a complicated
conditions. Having these credentials enhances
ankle fractures and reductions of multiple
surgery.” Post-operatively, Doug was restricted
Dr. Combs’ practice because he has mastered
fractures and dislocations, metatarsal fractures,
from weight-bearing on his foot for several
both the podiatric medicine side and the
ligament, tendon and bone reconstructions.
months. He was able to work at home while he
Douglas Mack’s injury required an open
healed, and four months later, he says his foot
orthopaedic side. He is qualified to do any and all procedures, including fracture care, on the
reduction and internal fixation procedure.
feels wonderful. “Everyone says that Dr. Combs
ankle and below. He treats patients of all
“Dr. Combs explained to me that I broke the
is the best and I agree. He has a down-to-earth
ages, including children and teens. He does
bones in the top of my foot,” Doug recalls.
manner that is calming; that was helpful because
reconstructions of deformities, treats severe
“I needed surgery because the bones shifted
I had never had a fracture or surgery before.
arthritis — either conservatively or with
and misaligned when they broke. I had to wait
He explains everything clearly and his care
surgery — acute injuries such as tendon or
two weeks because there was severe swelling
is impeccable.”
10 I HouseCall I Volume VII Issue 2
Being Fast On His Feet Leads To An Interest In Foot And Ankle Care As a former college athlete, Dr. Combs knows well the importance of strong, healthy legs and feet. He knew in high school that he
walk, you can improve your overall fitness and
your problem can be successfully treated with
your cardiovascular health. For me, it’s an
conservative approaches.”
incredible opportunity to be able to do this for people.”
A native of Dayton who majored in biology at the University of Kentucky and at Wittenberg
A member of the American College of
University in Springfield, Ohio, Dr. Combs
would go into medicine, and he later chose to
Foot and Ankle Surgeons and the American
thoroughly enjoys practicing his chosen
pursue foot and ankle surgery because he
Podiatric Medical Association, Dr. Combs
profession. “The human body is so impressive
wanted to help people by improving their ability
encourages people to attend to foot problems
in its ability to adapt and heal. I love being able
to walk and live without foot pain: “This specialty
as soon as they arise. “Feet are vulnerable
to get people walking again, and free of pain.
was the best avenue for me. Healthy feet are a
to injury. If you are in pain, you should see a
They get their lives back. One of my patients
solid foundation for living your life. When a
doctor and not try to tolerate it. The sooner
once said to me, ‘When you fixed my feet,
patient who was unable to walk into my office,
you are seen, the greater the likelihood that
you fixed my life.’ That’s so satisfying.” ■
walks out, free of pain, it’s the best feeling for me,” he says, “and it can be life changing for the patient. Mobility, the capacity to ambulate, is freedom. Once the problems are corrected and the pain and disability are gone, you’re free to give your attention to other things and enjoy your life again. It impacts the whole
DAMON B. COMBS, D.P.M. Dr. Combs specializes in foot and ankle surgery. He earned his medical degree at the Ohio College of Podiatric Medicine. He then completed a residency and fellowship in reconstructive foot and ankle surgery and limb salvage at UPMC. Dr. Combs practices with South Hills Orthopaedic Surgery Associates. To contact Dr. Combs, please call 412.283.0260.
person, and the positive effects on one’s health go beyond the feet. If you’re able to
“
Everyone says that Dr. Combs is the best and I agree. He has a down-to-earth manner that is calming; that was helpful because I had never had a fracture or surgery before. He explains everything clearly and his care is impeccable.
”
DOUGLAS MACK PATIENT, BETHEL PARK
Douglas Mack and Grace. Volume VII Issue 2 I HouseCall I 11
QUALITY OUTCOMES
60
C E L E B R AT I N G
Y E A R S | 19 5 4 - 2 014
V ISSUE 2 1 VOLUME VOLUMEVI
HouseCall A REVOLUTIONARY APPROACH TO KNEE AND HIP REPLACEMENT
Taking the offensive against pain
Orthopaedic Pain Protocol Update EDITOR’S NOTE: Volume VI, Issue 1 of HouseCall magazine, which was mailed to homes throughout St. Clair Hospital’s service area in April of 2014, featured a cover story (“Taking the offensive against pain”) on orthopaedic surgeon Brett C. Perricelli, M.D. and his perioperative pain protocol, a regimen designed to improve pain control throughout the perioperative period, before, during and after knee and/or hip replacement surgery. What follows
Plus Urgent Care Opens at Village Square Please see page 18
inside
is an update on how the perioperative pain protocol is changing how knee Broken Heart Syndrome I From Hospital Gown To Wedding Gown Ask The Doctor I History Minute I Focus On Giving Again Ranked Among The 100 Top Hospitals® In The Nation
and hip replacements are done, here, and throughout the nation.
Controlling pain in knee and hip replacement patients has proven to be a huge success
A
12 I HouseCall I Volume VII Issue 2
few years ago, when St. Clair Hospital
regimen that meticulously targets pain directly at
orthopaedic surgeon Brett C. Perricelli, M.D.
the surgical site.
made rounds on his postoperative knee and
The multimodal pain protocol is based on peri-
hip replacement patients, he often found them sitting
articular injections (injections around the joint). It was
in bed hunched over a basin, tethered to a morphine
first implemented at St. Clair by Dr. Perricelli, who
drip, miserable and groggy with nausea and intense
serves as Chief of Orthopaedic Surgery at St. Clair.
pain. Today, when he enters the rooms of his post-op
It has transformed the patient’s experience of major
patients, he is more likely to find them awake and
joint replacement surgery and gained widespread
alert, sitting up in a chair, perusing an iPad, a laptop
attention across the country as a groundbreaking
or a book, relaxed and comfortable.
advance in surgical pain management. With this
What made the difference? In 2013, Dr. Perricelli
protocol, the pain of hip and knee replacement is
launched a radically innovative approach to surgical
anticipated and prevented as much as possible,
pain management that has dramatically changed
before, during and after a procedure. It’s a significant
orthopaedic surgery at St. Clair Hospital, and trans-
departure from only treating pain postoperatively,
formed the postoperative experience of the patient.
after the joint is affected by surgery. This approach
Dr. Perricelli and several colleagues collaborated
not only significantly eases pain, but also facilitates
and developed a “perioperative pain protocol,” a
rehabilitation and recovery, producing better clinical
comprehensive, pre-emptive, multimodal analgesia
and economic outcomes.
Inadequate management of surgical pain
“
IMPROVED PAIN MANAGEMENT
hip replacement. Opioids, including morphine,
IS A KEY CONTRIBUTOR IN
can actually inhibit certain parts of recovery and
has many negative consequences. Beyond the physical and emotional suffering of patients, it
be associated with nausea, delirium and hypoxia
impedes rehabilitation by making it more difficult
THE HOSPITAL BEING RANKED
(low oxygen concentrations). With the pain
for patients to adhere to their post-op rehabili-
AMONG THE TOP ONE PERCENT
protocol, there have been fewer falls, less nausea
tation regimen. Uncontrolled pain can extend the
FOR PATIENT SATISFACTION
and vomiting, and less delirium; these things
length of a hospital stay; lead to complications; and increase costs to health insurers and
BY PATIENTS WHO UNDERWENT
patients. In some cases, uncontrolled pain may
KNEE OR HIP REPLACEMENTS
lead to chronic pain and dependence on pain
AT ST. CLAIR.
medication, even addiction. Eighteen months, and more than 500 knee and hip replacement surgeries since the perioperative pain protocol was initiated, Dr. Perricelli is confident that this approach is superior to
”
are among the adverse effects of opioids that are common when post-op patients get a lot of narcotic pain medication. Intravenous morphine is now a thing of the past.” Dr. Perricelli says these patient experiences validate the premise that better pain management is key to better outcomes. “The protocol does
BRETT C. PERRICELLI, M.D. CHIEF OF ORTHOPAEDIC SURGERY, ST. CLAIR HOSPITAL
not make surgery pain free, but it is a vast improvement over traditional pain management techniques. Improved pain management, as well
traditional surgical analgesia. “I’m more convinced than ever that this is a better way,” he says. “Patients have lower pain
as excellent nursing care and rehabilitation services, is a key contributor
scores, less nausea due to narcotic analgesics, and length of stay is down
in St. Clair being ranked among the top 1 percent in the nation for patient
40 percent for these patients. They feel better — they’re more comfortable
satisfaction by patients who underwent knee or hip replacements.”
in their recovery and are back on their feet faster. People are going home
Ultimately, Dr. Perricelli says, better pain management is all about the
earlier and, as a result of pain reduction, they perform better with physical
patient. “Patient education and expectations are still paramount to recovery.
therapy. Patients are up and walking sooner, but they still need physical
Overall, patients are ecstatic, especially if they have had a previous joint replacement done the traditional way. I’ve been asked, ‘When is it going to
therapy, and time to heal. It doesn’t happen overnight.” “This approach,” he continues, “decreases many of the ‘opioid-related side effects’ that used to be commonplace in a patient who underwent knee or
start to hurt?’ At St. Clair, everything we do is driven by our commitment to improving the patient’s experience.” ■
NEW PAIN PROTOCOL ASSOCIATED WITH BETTER OUTCOMES
PATIENT SATISFACTION
DR. PERRICELLI’S PATIENTS AFTER NEW PAIN PROTOCOL
Dr. Perricelli’s percentile rank nationally
= TOP 1%
NATIONAL BENCHMARK
100
4.7% 80
TOP 1%
99TH
60
3.06
40
1.96
1.6%
20
0
LENGTH OF STAY (days) (lower is better) DATA SOURCE: CRIMSON
COMPLICATION RATE (%) (lower is better)
PATIENT SATISFACTION “How well was your pain controlled?” (percentile rank) DATA SOURCE: PRESS GANEY. HIP AND KNEE REPLACEMENT PATIENTS WITH DISCHARGE DATES: 11/01/2013–3/31/2015.
Volume VII Issue 2 I HouseCall I 13
DIAGNOSTIC INNOVATIONS
Advanced video EEG monitoring makes medical treatment more precisely targeted
State-of-the-art video EEG monitor records brain waves to help diagnose and treat seizure disorders such as epilepsy.
T
o better diagnose patients with epilepsy, St. Clair Hospital uses sophisticated video EEG (electroencephalography) monitoring, a non-invasive procedure that can locate the region
of the brain where seizures originate, making medical treatment more precisely targeted and successful. These tests are performed at the Hospital, where seizures can be safely monitored. “There are many different types of seizures and epilepsies, each with its own treatment protocol,” says Kiran A. Patil, M.D., a neurologist at St. Clair Hospital, and an expert in treating epilepsy. “Video EEG monitoring allows us to record the electrical activity of the brain when a patient is having an episode.” Similar to a traditional EEG, small electrodes are placed on the patient’s head. These electrodes are connected to a small portable box worn on the hip so EEG activity can be continuously recorded. Unlike a routine EEG, which provides physicians a snapshot of brain activity during a short timeframe — usually about 30 minutes — video EEG monitoring gives them a more comprehensive picture of the brain’s activity.
14 I HouseCall I Volume VII Issue 2
What is epilepsy? Epilepsy is a chronic disorder of the brain characterized by epileptic seizures. Patients who have been diagnosed with epilepsy often have recurrent and unprovoked seizures. They may also have other symptoms of neurological problems. “Depending on the type of seizure, some people could have a staring spell,” says Kiran A. Patil, M.D., a neurologist at St. Clair Hospital. “Other people who have an episode may shake or even lose awareness of what’s happening.” A seizure could last from a few seconds to a few minutes, notes Dr. Patil. Seizures do not necessarily mean you have epilepsy. They can also occur due to other medical problems such as a high fever, low blood sugar, or alcohol or drug withdrawal. Today, about 65 million people worldwide have epilepsy, according to the Epilepsy Foundation. Neurologist Kiran A. Patil, M.D. with the Natus Neurology video EEG monitor, which records the electrical activity of the brain when a patient is having an epileptic seizure.
One in 26 people in the United States will have a seizure at some point in their lifetime. Continued on page 16
The patient must stay within the video camera's range during the testing, but he or she is free to move about the room. As the EEG records electrical activity in the brain, a camera delivers a live video stream of the patient to clinicians monitoring the patient in the EEG lab. Neurologists can compare the patient’s physical activity with their brain activity. Through this method, they can also tell if the seizure was related to the electrical activity in the brain. If so, then it’s an epilepsy (as opposed to other types of) seizure. “We can watch what happens to the patient clinically during the seizure, because different seizures have different clinical presentations,” says Dr. Patil. “In epilepsy, the neurons in the brain tend to be hyperexcitable. By video monitoring the patient and their brain activity, it helps us identify the type of seizure, as well as the exact location of the brain which is causing that seizure.”
Continued on page 16
St. Clair Hospital Lead EEG Technologist Kellie L. Kioalicas demonstrates how a patient is prepared for video EEG monitoring on St. Clair Cardiac Lab Technician Adam Martinez. Volume VII Issue 2 I HouseCall I 15
DIAGNOSTIC INNOVATIONS Continued from page 15
What causes epilepsy? Epilepsy can be caused by several conditions affecting your brain. Known causes include: • Stroke • Loss of oxygen to the brain • Infections • Traumatic brain injury • Genetic disorders • Brain tumor and mass lesions such as Arteriovenous Malformation (AVM) • Other neurologic diseases (such as Alzheimer’s Disease, MS, Tuberous sclerosis)
How is epilepsy treated? The two most common treatments for epilepsy include: Medicine: Anti-seizure drugs can lessen the frequency and spread of seizures in the brain. Surgery: Seizures that originate from a single region of the brain, called focal seizures, can sometimes be treated with surgery. The part of
St. Clair Hospital Neurologist Kiran A. Patil, M.D. and Lead EEG Technologist Kellie L. Kioalicas prepare the Natus Neurology video EEG monitor for a patient suffering from epilepsy-related seizures.
the brain causing the seizures can be removed to stop future seizures or even make seizures easier to control through anti-seizure drugs.
Continued from page 15
Epilepsy surgery is used when the seizure focus is located in the temporal lobe of the brain.
If epilepsy surgery is necessary, knowing the exact location of where the
KIRAN A. PATIL, M.D.
seizure originates is essential. Recording
Dr. Patil specializes in neurology. He earned his medical degree at Byramjee Jeejeebhoy Medical College, India, completed his residency at Westchester Medical Center, Valhalla, (New York Medical College, Westchester County, New York) and an epilepsy fellowship at SUNY Downstate Medical Center, Brooklyn. Dr. Patil practices with Southwestern PA Neurology Associates.
Helping someone during a seizure
determine if the patient is indeed having
Since most epileptic seizures can last for just
a seizure.
a few seconds, there is not much time to do
the brain activity also helps neurologists
Seizures are often unpredictable.
anything. But if your loved one is having a
Since a seizure may not occur during
seizure, Dr. Patil says the first step is to try
video EEG monitoring, in select cases,
to turn that person over on their side. Don’t
dosages of seizure medication can be
attempt to put anything in their mouth, he
lowered to help initiate a seizure so it
warns. Putting something in their mouth
can be recorded. The length of testing
could cause injuries to their jaw.
depends on how often the patient has
“The tendency is to put something into the person’s mouth. That should never be done,” Dr. Patil says. “However, you should make sure he or she is breathing okay. You can use your finger to clear their mouth of any obstruction. Finally call for emergency help if the person is still having difficulty breathing once the seizure ends.”
seizures, the type of seizures, and why the monitoring is being done. Testing typically lasts between 24 to 48 hours.
“This type of monitoring is going to be really useful for us and beneficial for the patient,” adds Dr. Patil. “It provides us with more accurate information and we can see firsthand what is happening. We can also see if the patient has more than one type of seizure and how long they last. Some patients might just have a single episode in which they lose consciousness, stop talking, or are unresponsive. During the time we are recording their electrical brain activity we will be able to capture these episodes to see if it is related to the brain or if it’s something else.” ■
16 I HouseCall I Volume VII Issue 2
To contact Dr. Patil, please call 412.942.6323.
ASK THE DOCTOR
Ask the Doctor Q A
RONALD A. LANDAY, M.D.
What should I do if I’m allergic to insect stings?
As the weather gets hotter, the number
loss of consciousness and sometimes
• Avoid loose-fitting garments that can
of stinging insects soars and people
even death.
trap insects between material and the skin.
allergic to them need to take extra
The most common stinging insects
If you have previously experienced a
precautions. It is estimated that up to
in the United States include:
reaction to insect stings or you think you
5 percent of Americans are at risk for
• Yellow jackets: black with yellow
may be allergic, consult with an allergist/
a severe, potentially life-threatening
markings, found in various climates;
immunologist to accurately diagnose and
• Honeybees: a round, fuzzy body
treat your condition. The doctor may
covered with dark brown and yellow
prescribe emergency medications to be
results in temporary pain, redness and
markings;
used in the event of a sting. Allergy shots,
swelling at the site of the sting. For those
• Paper wasps: slender, elongated
also known as immunotherapy treatment,
with allergies to insect stings, however,
bodies that are black, brown or red
may also be suggested. Venom immuno-
a sudden, severe reaction called
with yellow markings;
therapy shots take effect within a few
anaphylaxis can occur. This may be fatal
• Hornets: black or brown with white,
months and are the closest thing to a
allergic reaction to insect stings. For most people, getting stung
if not treated immediately, so a trip to
orange or yellow markings and larger
“cure” for allergic reactions. They have
the nearest Emergency Room is essential.
than yellow jackets; and
been shown to be 97 percent effective
Symptoms of anaphylaxis to watch for
• Fire ants: reddish-brown ants living
in preventing future allergic reactions
include itching and hives, swelling in the
in large mounds, primarily in the South.
to stings. Precautionary measures in
throat or tongue, difficulty breathing,
Anyone with allergies to insect stings
combination with professional treatment
dizziness, loss of consciousness, stomach
should take precautions to avoid a
will help to keep the insect-allergic
cramps, nausea and diarrhea.
potentially dangerous reaction. To avoid
patient safe. ■
Most people, unfortunately, are not aware they are allergic to insect stings
being stung, one should: • Avoid the “territory” of the stinging
until after they experience a reaction.
insect’s nest. These insects are most likely
An allergic reaction occurs when the
to sting if their homes are disturbed.
immune system overreacts to the insect
• Remain calm, quiet and slowly move
venom. When this happens, an allergic
away from stinging insects. Do not
person’s body produces a substance
swat them.
called Immunoglobulin E (IgE) antibody,
• Avoid brightly colored clothing and
which reacts with the venom. This triggers
perfume that may attract stinging insects.
the release of histamine and other
• Be careful when cooking, eating or
chemicals that cause allergic symptoms
drinking sweet beverages outdoors.
and, in the most severe cases, difficulty
Keep all food and beverages covered
breathing, a rapid fall in blood pressure,
until consuming them.
Ronald A. Landay, M.D.
RONALD A. LANDAY, M.D. Dr. Landay specializes in allergy/immunology. He earned his medical degree at the University of Pittsburgh School of Medicine and completed his internship and residency in pediatrics at Children’s Hospital of Pittsburgh. Dr. Landay completed a fellowship in allergy and clinical immunology at the National Jewish Hospital and Research Center, Denver. He is board-certified by the American Board of Allergy and Immunology and the American Board of Pediatrics. He practices with Allergy & Clinical Immunology Associates. To contact Dr. Landay, please call 412.833.8811. Volume VII Issue 2 I HouseCall I 17
PATIENT PROFILE COMMUNITY OUTREACH
Free health screenings benefit community wellness ST. CLAIR HOSPITAL CLINICIANS PROVIDE A VALUABLE HEALTH & WELLNESS PROGRAM TO LOCAL RESIDENTS
St. Clair Hospital continued its long tradition of community outreach when it recently partnered with Brookline-based Community Three For One to provide free health screenings and health-related education to residents of Brookline and Beechview. Screenings included bone density; head and neck exams for cancer; blood pressure; respiratory; glucose and cholesterol; stroke; and more. In addition to taking advantage of the screenings, attendees spoke with health educators on oncology; psychiatry and mental health; diabetes; baby/child care and safety; exercise; nutrition; and accessing free transportation to St. Clair and its outpatient centers. The Hospital partnered with Casa San Jose to provide translation services to Hispanic residents who attended the event. Brookline-based Casa San Jose is a community resource center that links Latino families in need with various service providers. â&#x2013;
18 I HouseCall I Volume VII Issue 2
Volume VII Issue 2 I HouseCall I 19
St.Clair Hospital 1000 Bower Hill Road Pittsburgh, PA 15243 www.stclair.org
General & Patient Information: 412.942.4000 | Physician Referral Service: 412.942.6560 | Medical Imaging Scheduling: 412.942.8150 Outpatient Center–Village Square: 412.942.7100 | Urgent Care–Village Square: 412.942.8800 | Outpatient Center–Peters Township: 412.942.8400
MAKE SURE ST. CLAIR HOSPITAL IS IN YOUR HEALTH INSURANCE NETWORK.
Health insurance in our region is changing rapidly. Fortunately, St. Clair Hospital makes navigating these changes easier because St. Clair participates with every major insurer in almost every product. That means ST. CLAIR IS AN IN-NETWORK PROVIDER for these insurers and products. And, if you have a health insurance product (like a high-deductible health plan) that requires you to share in the cost of paying for services, you’ll be pleased to know that ST. CLAIR IS OFTEN THE LOWEST COST PROVIDER. For more information, please call Customer Service at 412.344.3408 to speak to a St. Clair representative. For a complete list of insurers currently contracted with St. Clair to provide IN-NETWORK services to their members, please visit WWW.STCLAIR.ORG.
AWARDS & RECOGNITION
31%
ONLY OF HOSPITALS IN THE NATION RECEIVED AN ‘A’ GRADE IN THE LATEST REPORT.
LEAP ABOVE ST. CLAIR HOSPITAL AWARDED THE REGION’S ONLY ‘A’ GRADE IN PATIENT SAFETY National accolades for St. Clair Hospital’s quality
, which has been cited by The Hospital Safety Score®
continue. The Leapfrog Group, a national, nonprofit
MSNBC, The New York Times, and AARP The Magazine,
hospital safety watchdog, awarded St. Clair the region’s
uses national performance measures from the Agency
only ‘A’ grade in its most recent Hospital Safety Score
for Healthcare Research and Quality (AHRQ), the Centers
report. The grades — with ‘A’ being the best and ‘F’ being
for Disease Control and Prevention (CDC), the Centers for
the worst — rate how well hospitals protect patients from
Medicare and Medicaid Services (CMS), and other survey
preventable medical errors, injuries and infections.
instruments. Leapfrog assigns patient safety grades
Founded in 2000 by the Business Roundtable, AARP,
every six months to the nation’s acute care hospitals.
and multiple large employers (including Boeing, CBS, and
Only 31 percent of hospitals in the nation received an ‘A’
FedEx), Leapfrog’s goals are to “support informed health-
grade in the most recent rankings. ■
care decisions and to promote high value healthcare.”
HouseCall
is a publication of St. Clair Hospital. Articles are for informational purposes and are not intended to serve as medical advice. Please consult your personal physician.
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