Thoughts on the immigration crisis

One day, a family is eating dinner, and Johnny the neighbor child knocks on the door. 

"I'm hungry," Johnny says.  So the family shares a meal with Johnny.

The next night, Johnny comes for dinner again.  Johnny comes over hungry every day.  Pretty soon, the caring family asks, "What's going on at Johnny's house?  We're happy to feed Johnny- but is there a problem at Johnny's house?"

A week later, Johnny comes back with his five brothers and sisters.  "We're hungry."

What's the compassionate family to do? 

Feed the hungry kids?  Of course. 

Find out what's going on at Johnny's house?  That's the deeper issue.  How can we help Johnny's family feed their kids?

Of course, the family could adopt Johnny and all his brothers and sisters.  This will meet the immediate need- but the deeper issues remain.  What about Susie's family across the street?  Johnny's cousin Jimmy across town?  At some point, no matter how many hungry kids the family adopts, questions will arise.

• Where are we going to put all of these hungry neighbor kids?
• How many hungry neighbor kids can we afford to feed?

Maybe their own kids want a new Playstation.  Dad wants a new motorcycle.  Mom wants a vacation.  Of course, these are all frivolous concerns compared to feeding the hungry neighbor kids.  But what about the kids' college fund?  Do they cash out the IRA's? 

Suppose one of the hungry neighbor kids is a troublemaker?  How does the family respond if their own children are getting bullied by the hungry kids?  That doesn't mean that ALL neighbor kids are bad… but isn't it reasonable to take precautions to protect their own family?

Suppose we send money to Johnny's family to help them feed Johnny.  Instead of feeding the kids, Johnny's daddy buys a big-screen TV and the kids are still hungry? 

Can this family feed the hungry neighbor kids effectively if Mommy and Daddy are more concerned about fighting each other? 

Solutions

• Let's try to feed the hungry kids
• Let's establish some reasonable guidelines about letting hungry kids into the house
• Let's try to figure out what's happening at Johnny's house
• Let's make sure that Johnny's family uses our resources responsibly
• Let's make every effort to get Mommy and Daddy on the same page
• Are there other wealthy families in the neighborhood who can contribute to feeding the hungry kids? 
• What is the role of WHO, UNICEF, United Nations, and other support organizations?

The Best Doctor Visit Ever

Not the best news, but the best medical evaluation I have ever undergone.

Was seen today at the University of Wisconsin Cardiology Clinic by Dr. Heather Johnson (http://www2.medicine.wisc.edu/home/people-search/people/staff/3153/JOHNSON_HEATHER_M/), who specializes in Preventive Cardiology.  I had originally sought a preventive cardiologist for some advice on my exercise routine with the blood pressure problems, but when I had the misadventure last week with the Dobutamine test, they called Dr. Johnson and she opened a slot for me immediately.

Dr. Johnson took the most thorough history I have ever been subjected to.  She pursued every detail of every heart issue I have experienced over the past 10 years.  Every medication trial, every procedure.  She questioned me thoroughly about every symptom I have experienced, the timing, severity, and progression of each.  She explored every potential risk factor, family history, the whole enchilada.

Having completed the interview, Dr. Johnson conducted an equally thorough review of my medical data.  She had spoken with both the cardiologists who evaluated me last week, and read their reports.  But that wasn't enough- she went back and looked at the catheter studies on video- and she uncovered details that weren't reflected in the written reports- things that I had never heard of- and pieced the facts together to a complete picture of what is happening.

For the medical folks- the next couple of paragraphs are going to get technical, so you can skip ahead.  But the details were fascinating to me, so I will recount them here.

The good news is- no blockage in any of my coronary arteries.  I have a dominant Right Coronary, which is a normal variation- and it's a BIG SUCKER.  Wide open!  Left Anterior Descending is wide open too.  The interesting finding was the Circumflex- the one that loops around to the back side of the heart.  No blockage, which was accurately reported- BUT- this guy took a lot longer to fill up when she watched the video.  She showed me the video three times- and sure enough, there was a distinct pause in the filling of the Circumflex compared to its neighbors.  The cause- endothelial cell dysfunction.  The underlying reason- blood pressure and cholesterol causing and microvascular inflammatory reaction which is impeding the blood flow.  Not going to cause a massive coronary- but the type of pathology which puts additional strain on the heart over time and contributes to the thickening of the heart wall.

The thickening of the heart wall is problem #2.  The medical term for this is Left Ventricular Hypertrophy (LVH).  The original echocardiogram in February 2012 described this as "mild", and my primary doc tried to reassure me that this wasn't a major abnormality.  But seen through the eyes of the experienced cardiologist, this took on new meaning.  At 48, I am a young guy for LVH to be occurring.  Dr. Johnson went back through my entire record, looked at every BP reading over the past two years, and pieced together the progression of the blood pressures and the heart wall thickening.  She went back and looked at the echo images as well.  Turns out, the thickening of my heart walls is causing the left ventricle volume to collapse.  The thickened walls come together and briefly stick to each other- kinda like your lips do when they are dry.  A normal heart doesn't behave that way, but when the walls are thickened they are more likely to make contact and cause the walls to stick together and collapse the LV volume.  This is most likely to happen when the patient is a little dehydrated and blood volume is down- particularly in setting like:

• Diuretic therapy (water pills, like I was taking for the blood pressure).
• Decreased fluid intake (like the 'nothing by mouth for eight hours' prep before last week's test).
• Vigorous exercise

To further clarify the picture- when the walls gets stuck together, a little bit of cellular damage occurs.  Not a massive insult like a heart attack- but enough to cause little elevations in the troponin level like I had last week.  So, there we have it!  Dr. Johnson put the pieces together and explained the thickened heart, the symptoms- and the blood test results that stumped everybody last week.  How did she do it?

• A tremendous understanding of the anatomy and physiology of the heart from years of study and experience;
• Carefully listening to the patient to get a complete understanding of the symptoms, the heart history, and the risk factors;
• Thoroughly reviewing every available piece of information- vitals, labs, imaging studies.

Her treatment plan was just as thorough:

• Dietary consult to get proper instructions on the hypertension (DASH) diet;
• Specific exercise instructions:
• no more vigorous weightlifting- raises the blood pressure and strains the heart
• regular aerobic exercise- treadmill, to a moderately fast rate to strengthen the heart but not to the point of strain
• keeping strictly hydrated before, during, and after exercise to prevent the cavity collapse
• Medication adjustment: 
• ACE inhibitor to reduce the strain on the heart and the endovascular dysfunction
• No more diuretics- these were inadvertently contributing to the problem
• Statin therapy to improve the cholesterol levels and reduce the inflammatory components of the endovascular dysfunction
• Fish Oil to augment the efects of the statins and correct the imbalance of the triglycerides and the good cholesterol
• Aggressive goals for blood pressure, cholesterol, and weight management.
• Additional imaging studies- a cardiac MRI, mainly to rule out other possible causes for the heart wall thickening.
• Follow-up lab studies to keep monitoring the cholesterol and the effects of the other medications.

When I left the appointment, I realized that I felt better already, simply by understanding the problem and the solution.  It's gonna be a lot of work, and a lot of consistency- so I appreciate the support of all my friends and I covet your prayers.  I am deeply thankful for the support messages you have sent this week.  God has blessed me with many friends.  I am also deeply blessed that God pointed me to Dr. Johnson- this lady is a terrific clinician and she is going to keep me alive- and thriving- for a long, long time!

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Now what?

So, I posted a blurb on my Facebook about the cardiac cath yesterday. Here's the full scoop:

As many of you know, I had heart issues (atrial fibrillation) from 2004 - 2007, when I was finally treated successfully at the Cleveland Clinic. Since I came to Madison, I have been working out faithfully, both with the treadmill and with kettle bells, but recently I began to experience some tightness in my chest and shortness of breath with activity.

So, back to the doc. High blood pressure, started on medication, with good control. Echocardiogram showed thickening of the heart wall (left ventricular hypertrophy), not terribly severe.

Yesterday, they took me in for a dobutamine stress test to look more closely at my heart as part of a research study. At the end of the test, I had an episode of chest pain, and blood tests showed that I had an elevated Troponin Level. That indicates heart muscle damage, so I was taken to the cath lab.

The cool thing is, they did a cath study through my wrist! I had never seen that before- Having been through the procedure on three previous occasions, they always went though the leg- which meant 8 hours of lying flat, motionless, under a sandbag until the entry wound healed. Yesterday they put a bandaid on me and I was out of the hospital by 5:00 pm.

The cath showed no blockage of any of the arteries. Interestingly, they had some blood from the beginning of the day, before the test. They ran a Troponin level on that sample and it was also positive! This is what they cannot explain-

Why is my heart enlarged?

Why am I having chest pain?

Why do I have elevated Troponin levels?

Three cardiologists had to confer, and none of them had a good explanation for yesterday's events. I will be scheduled for a Cardiac MRI next and I will keep folks posted.

Thanks in advance for your prayers and your concerns.

Has it been this long?

September, October, November, December have flown past without a blog. But, on December 31, I suppose it is natural to reflect back over the past 12 months.

One year ago today, I celebrated (with mixed emotions) my last day on faculty at Wright State after 18+ years of service. I didn't know where I would end up, except for a three-month agreement to provide coverage for a family medicine center in Cedarville. But look at the changes over the past year!

The new job at Epic- everything I have dreamed of!

The move to Madison- a big change for all of us, particularly Sharon and the boys. They have been exceptionally supportive and encouraging.

Chad's graduation- he is still finding his way in life. The college life is not cut out for him at this point in time. I hope and pray that the path he chooses will be sufficient to meet his needs, or that soon enough he will reconsider his future.

New church- we have been led to High Point Church in Madison, which is under the new leadership of a very bright and very young pastor. The church is a very sound, evangelical, Bible-believing church and we are beginning to establish some friendships.


So, what will the next 12 months bring?

The new job will continue to progress. We are finalizing all the Meaningful Use tools for the new version of the software, and I have several other projects lined up for 2011. I have also been working to develop my skills at doing sales demos- I had a successful audition today with the medical director of the sales team, and within a few more weeks I will probably be ready to do some sales trips- ideally not more than 2 per month.

We are hopeful to complete the membership class at High Point, and to get started with a small group for some more intimate fellowship.

We want to continue to travel back to Ohio when we can- although we are limited by Sharon's work schedule and Chris' basketball games. Once per month would be ideal, but we will take those opportunities as they arise.

Hope you will all keep in touch! Happy New year!

Meaningful Use and more family shenanigans

My last several weeks of professional time have been filled with analysis of the Final Rule on Meaningful Use.

In short, the government has designed a program to reward physicians for practice good medicine, and using Electronic Health Records to document the quality of care. It's our job as EHR developers to build the tools that the physicians will need to capture the data necessary to qualify for the incentive payments.

The long story is... the Final Rule on Meaningful Use is 864 pages long! Not just any old 864 pages, but 864 pages of Government Rules and Regulations :) So, our team of programmers, quality reviewers, and physician content experts has been grinding out the computer protocols ('rules') to assess 45 different criteria ('measures') for the docs to apply to their practices.


Most of the measures are quite sensible. For example:

• Don't overuse x-rays for patients with back pain;
• Make sure to counsel your smokers to quit;
• Be sure your patients get their flu shots and pneumonia shots...

The concepts are straightforward, but the government regulations are strict.

• Who is "my patient"? Someone who just came in once for a quick rash or runny nose? Or does the distinction require evidence of a more consistent relationship?
• What about the patient who is allergic to the flu shot? Or the patient who just doesn't want one? Are they going to be counted against my immunization rate?

And finally, the computer logic required to document these requirements is even more complex:

• "If the patient was seen at your office twice in the past 12 months, OR if the patient was in the hospital in the past 12 months, they are included in the denominator."
• "If the patient had the new onset of back pain, AND if they didn't have cancer, trauma, IV drug use, or evidence of nerve damage, AND if they did NOT have a previous episode of back pain in the 6 months before this episode of back pain..."

So, the logic involved in creating a rule within the EHR, both from the medical, technical, and governmental perspectives, has been a highly complex and thought-provoking endeavor. It is a very challenging and stimulating role, and I love this job more and more each day!

Life for the kids has not been nearly so stimulating. Four weeks in a new town with no school and no friends has made the boys bored and antsy. So, like any good brothers do, they cope by turning to each other. Not as friends, as TARGETS! Witness the hilarity of this recent exchange:

I am sitting in the family room with Paul, when Chris walks in. Suddenly I hear a ringing "SMACK"!

"Oh no...", I think to myself, "this is really going to escalate!"

Paul: "Chris!!! WHAT did you just hit me with?!?!?"

Chris: "A Fruit Roll-up."

Paul: "Oh.. we have Fruit Roll-ups? SWEET!"

Paul bounds away happily, headed to the pantry, and the situation ends without bloodshed.

Together again!

It has been a delightful past three weeks! Sharon and the younger two boys have arrived! I could not be happier.

The house sold successfully, after a heroic effort by Sharon to get it ready to market.

The kids are still pretty bored. Paul has taken up skateboarding, in addition to video games, and we are getting him a keyboard for his 13th birthday (which is TODAY!) Chris found a health club across the street which is open 24 hours and has a basketball court. They're both doing their best to stay occupied and stay positive. School starts September 1, so we are hopeful that the boys will make friends and get settled in better when the pace of life picks up for them.

We have really enjoyed the family time. The boys are home, and not running about, so we are having dinner as a family every night and watching '24' together. The kids have always been really busy with friends, and activities, but for this brief hiatus it is a true pleasure to just hang out together without all the running about.

We really didn't have time to get to know the community in Madison, so rather than purchasing a house, we are renting a townhouse. It's a good bit smaller than the Ohio house was, so we are spending a good bit of time sorting through the (embarassing amount of) stuff in the garage, to be kept / placed in storage / donated / recycled. Our goal is to be able to get a car into the garage before the snow hits!

A great piece of news is that Sharon has, indeed, been able to keep her job! We set up her workstation in the master bedroom, where she can open the windows and have daylight and fresh air while she talks. We are both very blessed and fortunate to have such great jobs that we enjoy!

This entry is mostly autobiographical, catching up with the details of life. I doubt if I will promote this one to the world. But in response to the critic who responded to my previous blog ("Is it really necessary for you to inform the WHOLE WSU FACULTY when you have something to say?")- my response is this: it's called, keeping in touch with old friends. I'll not speculate whether or not my critic is familiar with the concept :) But, I will keep my WSU friends appraised of topics of interest periodically, and send a special thanks to the respondent who enjoys my ramblings. I do have some academic ideas to float, so I hope it will be less then 3 weeks before I post again.

Our corporate culture

It's a funny place, this company. Patterned after the Microsoft / Google model of casual dress and loosely structured work environments. It's made even more interesting by the corporate policy of hiring most of the employees straight out of college! A few amusing incidents have occurred along the way:

• My first day of class, we were instructed to "find a seat and grab a companion". I was rather alarmed at first, thinking, "I am a happily married man!" Turns out, "companion" is the company's buzz word for the training manuals :)

• My birthday occurred the second week of classes. Ironically, another trainee shares my birthday. She wrote a message to the 50 members of the training group, "Please feel free to join my boyfriend and me for dinner to celebrate my birthday." Since it was my birthday too, I RSVP'ed and went with a bunch of other folks to the celebration for my co-worker... who turned TWENTY-TWO !!!

• A few weeks back, my son Chris (age 15) spent the week here with me. I had just moved into a new office, with an extra desk. After helping me move, Chris sat down at the spare desk, put on his headphones, and started listening to some music on the laptop. The Division Assistant coordinating the move dropped in, and I asked her to have the extra desk removed. She said it would be fine, but then gestured at Chris and added, "after we get him moved into his new office".

• Finally... I still get the occasional call from job recruiters. When I tell them I have been hired at my new company, the response is typically, "Wow! They only hire the best and the brightest. You must feel like you're 21 years old working there." My reply: "Naw... I feel more like I am 100."

It's true, the hiring process here is based largely upon APTITUDE. The strategy is, find the best available talent, bring them on board while they are young, and you can train them with the skills and attitudes necessary for success. Of course, that doesn't hold true for the docs they hire, because the clinical experience adds credibility. But I still had to go through an entire battery of aptitude tests with my interview.

The success of the hiring strategy is evident in the success of the company. Here's a testimony to the quality of the people who work here:

http://histalk2.com/2010/07/07/histalk-interviews-daniel-barchi/