Each year in the United States, doctors invade the chests of more than 750,000 patients to repair their hearts and clear their coronary arteries. Heart surgery once meant almost certain death for patients. Today, some say it has risen to the level of mass production. The annual surgical score-card for the United States reads as follows:• 400,000 bypass procedures, in which unclogged veins from legs and arms, and unblocked arteries from chests, are used to bypass clogged ones• 300,000 angioplasty operations, in which doctors snake tubes from the leg artery to the narrowed blood vessel, where they insert a balloon to push aside cholesterol blockage• 58,000 repairs to damaged heart valves• 2,000 transplants of healthy hearts into patients whose own hearts cannot be repairedThe cost of these operations is roughly 50 billion dollars a year, or 6 percent of the nation’s annual 900 billion dollars medical bill. But is this money well spent? Can patients be helped with far less risk and at considerably reduced expense? Experts are now asking, How necessary is heart surgery?If you’re slated for heart surgery, heed the saga of my good friend, Mimi Cole of Wayne, New Jersey.Years ago, Mimi danced with the Martha Graham Company. On stage, she was a luminous young woman – a pleasure to watch as she swept across the floor. She is now 70 and still teaches dance occasionally. Mimi thought she was in good condition. But, in 1992, trouble arose.”My chest felt funny,” she recalls. “I could not easily walk up a hill. I had a pain in my shoulder. My cardiologist in New Jersey sent me to a surgeon who examined me, found my arteries were blocked, and recommended surgery. I was terrified.”Blood could not pass through the plugged blood vessels to feed oxygen to Mimi’s heart muscle. Her doctor’s plan was to allow the blood to bypass the obstruction by taking unblocked veins from her legs and grafting them onto the heart arteries. But there was no way to accomplish this: the appropriate veins, which had become varicose, had been surgically stripped from her legs years ago.The alternative, her doctor said, was to use arteries from her abdomen or chest. He recommended a specialist at the Cleveland Clinic in Ohio. Mimi did not want to go so far from home. Instead, she found her way to Dr. Eric Rose, chief of cardiothoracic surgery at Columbia-Presbyterian Medical Center in Manhattan. Dr. Rose told Mimi he could work with her arteries, but first he wanted her to be examined by Dr. Michael Cohen, a heart specialist at Columbia. She agreed.Two days before the scheduled surgery, Drs. Rose and Cohen called Mimi in and announced that they preferred to treat her condition first with medication rather than surgery. It proved a good decision. They prescribed beta-blockers, which controlled the rhythm and power of her heart, eliminating her pain and shortness of breath. Mimi resumed playing tennis. In her case, the surgery remained unnecessary.Mimi Cole’s experience forces us to wonder how many other heart patients could have survived with an affordably priced pill instead of a costly and painful operation.*13/266/5*
During CPAP you wear a nasal mask attached to a machine that pumps air and provides a constant degree of background pressure in the airway. This pressure keeps the passage between the mouth and the lower pharynx open. CPAP is widely available commercially, reasonably inexpensive (compared to surgery), and relatively simple to operate. But, as one sleep researcher put it, “you have to sleep with a machine that sounds like a vacuum cleaner for the rest of your life.” CPAP can be uncomfortable and irritating; in some cases eye complications, stemming from the presence of the mask, have been reported. The most important drawback, however, is psychosocial. For many of my patients, especially the younger ones and their spouses, the thought of sleeping with a nasal mask and an air compressor every night can be disheartening. In those cases where CPAP is appropriate, the patients must possess the proper mental attitude to use the technique correctly and faithfully.*146\226\8*
Since almost everyone suffers from headache at some time, it is often not regarded as a disease, although clearly it is ‘disease’ (i.e. not being at ease). But since headache interferes considerably with the lives of significant numbers of people, it seems illogical to regard it as normal. However, the changes occurring in the body are subtle, so that it is exceedingly difficult to analyze changes taking place, even with sophisticated research tools. Often, no sooner has some abnormality been discovered, than it is shown to be only secondary to pain, or not to be present in all who supposedly have the same symptoms. By comparison, the understanding of an obvious abnormality such as an infected chest is simple, as not only can changes be seen on an X-ray, but the ’cause’ can be isolated by observing the germ in the laboratory.The fact that a number of people have a specific form of headache does not necessarily mean that the cause is the same in all of them. In the same way, a blocked nose and sore throat may be caused by infection with germs or by allergy; the symptoms can be identical but the treatment of each is very different. Treating a ‘runny’ nose due to hay fever with antibiotics is worse than useless.The situation in the classification of headaches is analogous, except that a good deal is known about the structures concerned with pain and the nerves which carry the sensation.