Caring for Kids in the CVICU

By Jeffrey Alten, M.D.

Dr. Alten is the Medical Director of the Pediatric Cardiovascular Intensive Care Unit at Children’s of Alabama, Medical Director of the Cardiac ECMO program and serves as Director of the Pediatric Cardiac Clinical and Translational Research Program at Children’s. He is an Associate Professor in the Department of Pediatrics, Division of Pediatric Critical Care, at UAB. He received his MD from the University of Missouri Columbia with additional training at Arkansas Children’s Hospital and Texas Children’s Hospital.


As a pediatric cardiac intensivist, I start each morning by making my rounds in the cardiovascular intensive care unit at Children’s of Alabama. It doesn’t sound out of the ordinary, except every other week I’m handling it from 500 miles away at my home office in St. Louis, Mo., from an app on my phone where I am able to interact with the physicians that are at the patients’ bedside. While I spend the other weeks in Birmingham on-site at the hospital, technology has given me the flexibility to live remotely while still ensuring the highest level of care for my patients.

That’s the power of mobility in healthcare: I can be hundreds of miles away or just in a meeting down the hall at the hospital, but thanks to an application on my phone, I never truly have to leave my patients’ bedsides. The ability to do mobile “rounds” in the unit has become a necessity. I can constantly monitor their conditions no matter where I am and work closely with my colleagues in Birmingham to know exactly what is happening and catch minor deteriorations that could become life-threatening situations.

Most children we care for have congenital heart disease, and about 70 percent of them are awaiting, or have had heart surgery. The rest have acquired heart disease such as myocarditis or cardiomyopathy. While heart conditions at any age can be dangerous, pediatric cardiac conditions are even more dangerous and need careful monitoring because children don’t have the physiological reserve that adults do. With adults, and even children without cardiac disease, a slight delay in recognition of subtle clinical deterioration can often be managed without detriment to the patient. However, we don’t have this luxury in children with heart disease – each second is precious and critical.


The complex and tenuous condition of our patients requires an “all hands on deck” approach – true multidisciplinary team management to have the best outcome. It is comforting to know that our patients all have the ability to have multiple experts “at the bedside” consulting 24/7, 365 days a year. Whether it be a cardiologist evaluating a new arrhythmia in real time or another cardiac intensivist helping the doctor in the CVICU through a crisis by monitoring the child’s response to resuscitation in the middle of the night –mobile technology definitely improves the safety of our patients in the CVICU.


Ultimately, the goal is to prevent the subtle decline of our patients’ conditions and avoid the snowball effect that could end in cardiac arrest. With multiple eyes watching our patients every day, small changes in temperature, breathing indices, and cardiac pressures are more likely to be noticed and communicated before a dangerous change in condition occurs.


Mobility has given us the flexibility to care for patients when we can’t be at the bedside, the resources to make clinical decisions with all the facts, and the comfort that we can address issues as quickly as possible. From my office in St. Louis, I can participate in a team-based management plan and keep my patients safe. It’s all about early recognition and management before it becomes a problem — like the saying, “a stitch in time saves nine.”

Cloud Appeal: Why OpEx Economics Has Begun Replacing CapEx in the IT Industry

By: TekLinks

Simply put, OpEx (operating expenditure) investments generally require ongoing operating costs that have the benefit of a reduction in initial investments. Conversely, CapEx (capital expenditure) solutions have larger up-front costs for hardware that depreciate over time. So, as cloud services providers have honed their deployment, service, and support models, businesses are finding that, over time, the OpEx IT solutions available in the cloud are preferable, not only because they require less startup investments, but also because they reduce the overall maintenance (and replacement) costs associated with traditional CapEx IT solutions.


Traditionally, CapEx investments resulted in on-premise data centers that took up space, consumed electricity, needed cooling, and required a staff dedicated to their maintenance. OpEx solutions greatly eliminate those costs in that, while an off-site data center provides the client with constant connectivity, storage, and redundancy, the service provider takes on the maintenance and the “power-cool-connect” costs of running the data center. So businesses can simply include the predictable costs of these cloud services in their overall operating budget, rather than paying for a support staff and gathering funds every three to five years to purchase expensive hardware in need of upgrades. This kind of “pay-as-you-consume” model is particularly attractive to owners and managers of small-to-midsize companies, who often lack the resources to employ their own IT staff.


“Historically, businesses chose the on-premise CapEx model because they could see that their data would be both private and secure, but in the past few years, people have begun to move their mission-critical data to the cloud because of security, not in spite of it,” says David Powell, TekLinks’ VP of Managed & Cloud Services. “Cloud services providers now provide their clients with environments that are fully redundant, encrypted, and protected against the threat of malicious attacks or downtime. So business owners are trusting the cloud more and more to help them achieve their performance goals in a cost-effective way.”


Moreover, OpEx solutions in the cloud add flexibility to the work environment so that employees can communicate in more innovative and effective ways, while freeing up funds that can be used toward other investments and big projects related to their line-of-business requirements.

" What cloud services providers like TekLinks are doing is simply operationalizing your CapEx, and we’re doing it much better than most business owners could do on their own.”


“When you think about moving any of your IT needs to the cloud – whether it’s voice-over-IP, email, backups, the list goes on – what many should keep in mind is the cost of managing your IT resources. What cloud services providers like TekLinks are doing is simply operationalizing your CapEx, and we’re doing it much better than most business owners could do on their own,” says Donny McCarty, TekLinks’ Director of Telecom Services. “The cloud provides businesses with a predictable monthly (or yearly) budget, greater flexibility and scalability, and evergreen technology that you don’t need to worry about keeping updated. That’s really appealing when you don’t have the time or capital to spend on IT in addition to running your business.”


To learn how moving to the cloud can benefit your company, call us at 205.314.6600, email our sales team at info@teklinks.com

Show Me Your Feet!

By Christopher M. Huff, M.D.

As my patients will tell you, my first item of business during a physical exam is to evaluate the feet. Particularly, I am interested in determining if the appropriate amount of blood has managed to navigate its way from the heart, along the arterial highway, to the farthest outreach of the body…the toes.  Though the coronary arteries will forever remain in the spotlight of cardiovascular disease, atherosclerosis does not show favoritism and can affect any artery.

Peripheral arterial disease (PAD) is associated with a 5 year risk of death that is greater than Hodgkins disease or breast cancer.  The reason for this is the strong link between PAD and myocardial infarction or stroke.  Thus, patients with PAD require more aggressive risk factor modification and closer follow-up than patients without PAD.  In addition, lower extremity revascularization can improve quality of life in patients with claudication and prevent amputation in patients with critical limb ischemia.  Unfortunately, PAD often goes undetected due to the lack of appropriate screening from medical professionals.

We often find ourselves asking patients about chest pain, but how often are we asking about claudication?  A few simple questions about exertional leg discomfort can help identify patients with PAD, but screening should not end there.  Only 10% of patients with lower extremity PAD report classic symptoms of claudication, with 40% being asymptomatic.  If the suspicion for PAD is high, as determined by risk factors and/or physical exam, non-invasive testing can assist in the diagnosis.  Ankle-Brachial Index (ABI) is a simple non-invasive screening tool for PAD, and an ABI of <0.9 confirms the diagnosis.

There are two important caveats to be aware of when ordering and interpreting ABIs.  First, similar to coronary artery disease, blood flow in the setting of PAD may be sufficient at rest, but insufficient with exertion. Therefore, if a patient can walk, rest and exercise ABIs should always be performed.  Next, patients with diabetes and/or ESRD can have a normal ABI and still have an ischemic foot ulcer.  This is due to poor collateral formation between the tibial vessels in these patients.  Remember, the highest pressure between the dorsalis pedis artery (DPA) and the posterial tibial artery (PTA) is used to calculate the ABI.  Thus, a diabetic patient with an occluded anterior tibial artery (ATA) but a patent PTA may have a normal ABI and an ischemic foot ulcer because of lack of collaterals.  Given this, in diabetic and/or ESRD patients with a non-healing ulcer, it is important to look at the specific pressure for both the DPA and PTA.  Toe pressure can be particularly helpful in this setting, as a toe pressure of less than 30 mmHg suggests that the ulcer is ischemic and will not heal without revascularization.

If there is any question regarding the presence or significance of PAD and the appropriate management strategy, do not hesitate to seek input from a PAD specialist.  With appropriate screening, aggressive risk factor modification, and prompt referral to a specialist, the complications of PAD can be managed successfully.

Christopher M. Huff, M.D. practices cardiology with Cardiovascular Associates.

DO I NEED A HAND SURGEON?

By: Kathleen E. McKeon, M.D.


Injuries to one’s wrists, hands and fingers are an inevitable part of life. We’ve all experienced jammed fingers, lacerations, and occasional numbness in our hands. Most of the time, these problems can be treated at home with rest, ice, anti-inflammatories, etc.


However, because we’re used to treating our hand problems at home, some patients with potentially serious conditions may delay seeking treatment.


So when should you see a hand surgeon?


1) Numbness – If you have numbness, or a “pins and needles” feeling, in your hands or fingers that occurs more frequently than twice a week. If this occurs at night and is waking you from sleep, seeing a physician is definitely recommended.

2) Misalignment – If a finger looks crooked or rotated after an injury. This misalignment will likely not correct itself on its own and will need to be fixed surgically.

3) Deep Laceration – If you have a laceration in the wrist, hand, or finger that goes all the way through the skin. There are nerves and tendons very close to the surface that may be injured, even if the laceration seems small.

4) Decreased Range Of Motion – If you have stiffness in a joint that is present for more than one week. Stiffness can become permanent if it is not addressed.

5) Mass – If you notice a bump or mass in your wrist, hand, or finger. Malignant tumors in the arm are very rare, but any mass should be evaluated by a physician.

6) Persistent Pain – If you have pain in any part of your wrist, hand, or fingers that has been present for more than 6 weeks. The most common causes of persistent pain in the hand are tendonitis and arthritis.


These symptoms can all lead to permanent problems if the patient does not seek care from a qualified professional in a timely manner. Some of these conditions, such as numbness and misalignment, can often be completely cured with appropriate treatment if they are taken care of quickly. Other conditions, such as arthritis, cannot be cured, but treatment may dramatically improve pain and quality of life.


An excellent, more comprehensive, online resource is http://handcare.assh.org/. This webpage is published by the American Society for Surgery of the Hand and contains well organized information about hand anatomy, hand safety, and assorted hand conditions.


Andrews Sports Medicine and Orthopaedic Center’s Kathleen E. McKeon M.D., specializes in hand, wrist and upper extremity orthopaedic surgery, including fracture care, nerve surgery, joint reconstruction, microsurgery and sports injuries.


For questions or to schedule an appointment, contact Andrews Sports Medicine and Orthopaedic Center at 205.939.3699 or visit AndrewsSportsMedicine.com

Trinity Medical Center to Host Blood Drive_Birmingham AL

Trinity Medical Center is partnering with the American Red Cross to host a blood drive on Thursday, September 18, from 7:30 a.m. to 5:30 p.m. in Linn Henley Auditorium on the first floor of the hospital. The public is welcome and encouraged to give blood. All donors will receive refreshments, a free meal ticket, and an entry to win a Black & Decker 20V Lithium Drill/Driver & 133 piece tool kit and case.

To make an appointment, please go to www.redcrossblood.org and use sponsor code trinity medical. Appointments are encouraged but walk-ins are accepted. Please bring a photo ID or American Red Cross donor card with you. Free parking will be available. Donors can bring their parking ticket with them for validation. #Blooddrive #redcrossblood #RedCross

State of Alabama Number One in Prostate Cancer Deaths

*in photo_ Dr. Andrew Strang and Governor Robert Bentley signing proclamation declaring September as Prostate Cancer Awareness in the State of Alabama

Alabama is the number one state per capita, in the nation in prostate cancer deaths among African American men and third overall for others. Prostate cancer is the second leading cause of cancer deaths among all men in the United States.


In 2014 Alabama is expected to have 3,760 new cases of prostate cancer and 540 deaths resulting from this disease. The high prostate cancer mortality rate among African Americans can be attributed to several factors, including genetics, environment, education and socio-economic conditions according to Dr. Andrew Strang, urologist at Urology Centers of Alabama, but the failure to have a simple prostate cancer screening is a major contributing factor.


Governor Robert Bentley has proclaimed September as Prostate Cancer Awareness Month in the State of Alabama and an opportunity to renew the state’s commitment to find a better way to prevent, detect and control this disease. According to Governor Bentley and Dr. Strang the state has made significant progress in the fight against prostate cancer and will continue to bring greater awareness to prostate cancer and to educate men on the importance of prostate cancer screenings. Early detection and treatment are the key factors in addressing this disease states Dr. Strang.


No one knows the exact cause of prostate cancer and why one man develops the disease and another does not, however research has shown that men with certain risk factors are more likely than others to develop the disease. The biggest risk factor is age along with a family history of the disease. Men with a father or brother who have been diagnosed with prostate cancer have more than twice the risk of being diagnosed. Race is also a risk factor.


During September Dr. Strang along with Urology Centers of Alabama invites the state of Alabama to come together to raise awareness about prostate cancer and to stress the importance of men knowing their PSA scores. The screening for prostate cancer consists of a simple blood test (PSA) and a brief examination (DRE). This screening takes ten minutes and it is ten minutes that could save a man’s life. Now is a good time for men to take charge of their health.



Learn more about prostate cancer by visiting www.urologycentersalabama.com.

Heat Illness

By : Dr. Terri Coco is a pediatric emergency medicine specialist at Children’s of Alabama and an associate professor at UAB. Her area of interest is injury prevention.


Every summer stories appear in the media about children gaining access to or being left in hot vehicles. It’s a nationwide tragedy and, unfortunately, not uncommon. As of July of this year, there were 23 heatstroke deaths of children who had been left in cars. Last year, these fatalities totaled 44, according to researchers at San Francisco State University. A total of 630 children have died this way since 1998.


This is terribly sad on many levels, with most of these deaths being preventable. And while we are thankful that we don’t diagnose much heat stroke in the Children’s Emergency Department, we do occasionally treat heat exhaustion. This is, after all, the South, where we get high humidity along with high temperatures. Children who are outside for long periods of time participating in organized sports need to get plenty of water and electrolytes, which are contained in sports drinks. Getting dehydrated exacerbates heat illness and heat exhaustion. Young children and adolescents need to wear proper clothing, be given periodic breaks and be monitored for symptoms of heat exhaustion, which can develop into deadly heat stroke.


It’s difficult to say precisely when and where pediatricians can effectively educate patients about the dangers of heat stroke—or hyperthermia—to their patients and caregivers. Perhaps a good time would be during a well child check, or while discussing car safety. Also, many good articles have been written that provide parents with helpful tips such as creating reminders by putting something like a purse or briefcase in the back seat next to a child.


It’s important to understand that this danger exists in even moderate temperatures. Of course, heat stroke can strike anybody. Young children and infants are just more susceptible to it because they have less ability to regulate their core body temperature. Consider the basic biology of hyperthermia, and its three progressive stages:


1. Heat stress. That is simply the discomfort we feel when we are exposed to heat. Generally, it’s harmless but uncomfortable, especially if we drink plenty of fluids and don’t overdo it.

2. Heat exhaustion. This is where heat illness becomes mild to moderate and unhealthy. It is often associated with dehydration along with achy joints and rising temperature, similar to a flu-like illness. Symptoms can include: intense thirst, fainting, dizziness, vomiting, weakness, discomfort, anxiety, confusion, headache and flush, dry skin. People suffering from heat exhaustion should been seen by a physician.

3. Heat stroke. In this is the final stage of heat illness, a person’s temperature skyrockets to over 104 degrees, and their central nervous system malfunctions. Organs begin failing. Delirium, convulsions, coma and death can follow.


Treatment for heat exhaustion is fluids and being removed from a hot environment. The person should be cooled down with wet rags and ice packs, especially in neck, groin and under the arms. This will help lower the core body temperature. Evaluation by a physician is recommended to prevent the progression to heat stroke.

There is one other condition worth mentioning, although it’s not considered a heat illness. It’s called rhabdomyolysis. We see it fairly often in young people, and it can be caused by exercising too much, or over-exertion without enough hydration. Essentially, the red blood cells break down, and kidneys can fail. Symptoms may include muscle aches, stiffness or weakness, along with darkened urine. It can be serious.