So we did a recent analysis of some of the problems we had at the Georgetown Hospital Center. So we sort of used this to simulate discussion. I was just showing this to Randy earlier on. This is probably the reason why I was asked to do this. I don't think people knew. And I want to thank my residents, Kyle Mueller, Alex Tai, for putting this data together. I sort of skipped to the chase here. So there's MedStar Georgetown Hospital, and here's Washington Hospital Center. So we have some of the highest incidence of DVT and PE in the country. And again, this is to compare and contrast with some of the other facilities. So we said, Houston, we have a problem here. We have a real issue in terms of why is it that our incidence of DVT and PE is so high. And when you look at something like this, it really has to go through what we talk about in the military. It's like an after-action report. You have to go back and you have to go through each step of each patient and what's the process of that patient in that hospital. And again, other than ‑‑ I'm going to try to go back here. Our incidence of VTE was higher than that of orthopedic surgery and higher than that of a lot of other surgeries where you would think that this is going to be a more common entity. Well, it turned out that when we were looking through some of this analysis that at Georgetown, as I had mentioned earlier, a lot of these patients were actually not being mobilized before the operation and not being mobilized very much after the operation. And in terms of wearing the compressive pneumatic TED hose, they were prolonged periods where they were not wearing their pneumatic TED hose. So for it to be effective, they have to wear it almost 18 hours of the day. And it was almost the opposite. They were wearing it for maybe six hours of the day as opposed to the 18. So I think these are real practical elements that come into how you manage these patients. The other thing that was, I think, underreported or underappreciated is heparin-induced thrombocytopenia. So I recently had a large ACOM aneurysm that we clipped, couldn't coil or stent treat endovascularly. Very active elementary school teacher. And she was up the next day. She was discharged in three days. Three and a half weeks later, as I'm seeing her back and follow up again, and she says, I've got this funny pain in my calves instantly. The antennas go up, feel her calves, don't feel unusual. We doppler, we don't see anything. I said, if that gets worse, let me know. And she called the office back on Monday, so I saw her on Thursday. This is like three and a half weeks after surgery. Calls back and says, oh, you know, that calf problem, it's getting worse now. In fact, now the calf is swollen. I said, well, you need to come in right to the emergency room. We need to check this out. And then on her way to the emergency room, she, in fact, says, I'm also having some problems breathing. So we immediately transferred her back in. We start her on anticoagulant, or at that point she was on a heparin drip. Well, of course, she's the nicest lady in the world, and her platelets go from 250 down to about 80,000. We re-scan her head. Luckily, she doesn't have a brain hemorrhage. And as I'm coming in that morning, early in the morning, I run into my vascular surgery colleague, and he says, what do you think about treating her? And I said, well, I think we probably need to put a filter in her based on her presentation. At that point, I didn't know that her platelets were dropping. And then we had to transfer her to Herud into another agent that did not cause a thrombocytopenia. So I think these are real-world issues. And she was not overly obese. She was not someone who was particularly inactive, but she probably had some genomic risk factor for this as well in the past. And so I think that's something that, you know, the more we study our patients, the more we look at individual cases, the more we see how we have to individualize the care. I think these recommendations that you've seen today are nice in terms of challenging our thinking. Certainly, Randy made me challenge my thinking about penetrating brain injury patients. The one case he did not show, which I'll never forget, unfortunately, was a young West Point lieutenant who had a penetrating bifrontal hemicraniectomy and had a massive brain hemorrhage and expired from a ruptured pseudoaneurysm while he was on Loganox in 2005. So, you know, those are memories that are indelibly marked on us in the wartime scenario that can apply to folks elsewhere in the civilian sector as well, which is be vigilant looking for these underlying neurovascular lesions that can certainly have a problem with our breast abuse of DVT prophylaxis. We've also had other individuals, especially oncologic patients. I was up to dinner with Dan Donovan last night, one of my fellow co-residents from Walter Reed, and we had had this recollection with one of our colleagues about a patient with a cavernous sinus meningioma who underwent resection at Walter Reed, and literally the post-op day two we're talking with the patient and he expired in front of our face from a fatal cell PE. So keep this in mind in terms of tailoring the medications. I think patients who have brain tumors, patients who have underlying malignancies, cancer, spine patients, spinal metastasis might be particularly at increased risk because they have a paralysis, they have hyperchordability because of their underlying malignancy as well. Any other specific questions from the group? Yes, ma'am. Randy, what are you guys doing now at Walter Reed? What's your protocol for ventriculoscopy? If the intent is to pull the ventriculoscopy, I would hold the dose of whatever they're getting. Usually it's low molecular weight heparin, and then I will restart it at their next dose. What's that? Well, not the day before. If we're going to pull, usually we try and do this in the morning because bad things happen when you do it in the afternoon and then you're back in the operating room. So that day's dose? Right, so that day's dose they would not get. For Lovenox? That's correct. And there is a black box label for Lovenox. They want you to wait 12 hours to place or remove a catheter, 12 hours at the last dose, and wait at least 4 hours to give the next dose after you pull it or place it. And we're usually doing Q-day dosing, so it's at least 24 hours before and then we'll wait and give them their dose the next day. If it's BID dosing, hold the morning dose and then give the afternoon dose. But then, it's up to you. What's interesting is that you're talking to the people who are watching this. There's a lot of stuff. There's a lot of that. Yes, sir? How do you use Google Earth? In spine cases, do you want to take that down? Sure. In your particular patient's case, he developed a hemorrhage while on anticoagulation. Or, I'm sorry, on chemoprophylaxis. And was he on heparin or Lovenox? I think that's a valuable experience, and I would submit that your memory of that is pretty accurate. Question for you, what kind of drain do you leave in now? Okay, what I do is, unless I'm opening the dura for an intradural tumor or something like that, I use a 7mm flat Jackson Pratt 2 suction. And I can tell you, just so you don't sleep very well tonight, that I've taken people back to the operating room, not a lot, maybe two or three over, again, a 30-year experience, where the clot is very nicely sitting underneath this pretty aggressive drain. So, number one, we all have things that we do based on our experience, but then watch out, somebody else is going to have a different experience. Number two, every once in a while, and that's the problem when you're dealing with data sets where the events can be reasonably rare, is that every once in a while you're going to pull a drain on somebody who hadn't been on. For example, another habit that I know most neurosurgeons don't do, but again, because I've seen some bad stuff in my day, is I put the same Jackson Pratt drain in for any anterior cervical procedure I do, but I take it out at dawn's early light. So the next morning on rounds, it comes out. And I've had people, they haven't been on anticoagulation, right? They had their surgery, or maybe 12 hours after surgery, where none of the guidelines would say you should be starting them on some chemoprophylaxis, at least in that period, pull the drain, and they hemorrhage. So, I mean, it would be nice, again, to have a massive data set where I could come at you with not just two or three cases over 30 years, but 300 cases such as you're talking about to be able to answer your question. Also, I don't know if anyone else is afraid of this, but I've heard that it does cause a complex heart issue, and we all want to quit, you know, today. And I find that the way you're saying you are, when you talk to the outside police, is significant, when you're not so good at it. Yeah, it's broken. Thank you. I need to buy a new one. I'm experiencing that I'm not responding as effectively or not. So, as opposed to just the fact that there's a lot of bleeding, and I'm pushing the muscle. So, I think I'm not going to be worthwhile starting to do it, so I'm going to have to understand how long I'm going to be still doing it. Yeah. Oh, yeah. Another question over here. Yes, sir. Yeah. Right, right. That reminds me of another cautionary note, is that we've had a number of patients where, at the inner city hospital, we take the bone flap out, and we put it in the abdominal wall. And we've had patients where the nurse has given Lovinox or sub-Q heparin very close to the flap, and then had to take the patient back to surgery to evacuate the hematoma around the bone flap. And this probably happens once or twice a year, believe it or not. Despite us putting signs, no injections. So, I think that's true. I think there are patients who are much more sensitive to the chemoprophylaxis, and then you have to be particularly careful with, you know, explanting bone flaps in the abdomen. I think, Rock, I think where we're going, to your point, and Dan, you talked about the use of big data. If we look at what we're doing in brain tumor therapy, you know, we have targeted therapies now for many of our worst actors. These come from, you know, sort of the genetic analysis, the tumor that you're removing. I don't think we're that far off from essentially starting with populations, looking at big data, generating artificial intelligence algorithms that support machine learning, where you can actually predict in advance which patients are going to be more likely to have a problem than those that are not. But then, more importantly, that proteomic profile of the patient, how they respond to various medications, I think that's where we're going to have to go so that, in point of fact, the patient arrives at the hospital, it doesn't matter what pathology they have, you have a panel of tests that you're going to perform that will at least give you a good idea of predictive, you know, response pharmacologically to how they'll respond to whatever therapies. I think that's what the precision medicine that you're looking at, right? Precision medicine, take a pathology, analyze its pattern, whatever it is in a number of different fashions, imaging, biomarker, proteomic analysis, and then subsequently take that pathology and then do a targeted therapy and do the same analysis. And I think long-term, I think that's where we have to go, personally. You know, and again, the problem of informatics and data collection to get to that point has still not been solved. I mean, you could easily now imagine this too, and this has been one of the problems when we talk about injury cascades and traumatic brain injury, is that they are not static over time. I'm old enough to remember when free radical oxygen species were like the thing, and if we could get rid of these things, you know, we could cure people with severe TBI, and it just didn't pan out. Why is that? It's because that mechanism is active in traumatic brain injury, but it's active for a very short time corridor, okay? So a lot of these physiologic processes that have been studied in the laboratory are not invariant with time, including anticoagulation factors. So let's say that, Randy, you develop a panel of genomic or proteomic screens that you say, well, I think I can really predict the patient that needs exactly this drug and exactly this dose, but you have to follow the evolution of that panel of gene expression over, you know, maybe a week, two weeks, to understand what's really going on. It is definitely a four-dimensional problem. We feed that in, you know, to the biggest, you're talking about pedoflops and all kinds of huge data problems right there. But you're on to it. You're on to it. That's the way it's going, and maybe we get Moore's Law working in our favor finally, right? Yes, I would agree. I'd like to thank everybody for their attendance today and the whole panel. I think this was a very productive session. I certainly learned a lot. Thank you.

Georgetown Hospital Center

Deep Vein Thrombosis

Pulmonary Embolism

patient mobilization

precision medicine