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Reducing intraoperative red blood cell unit wastage in a large academic medical center. - Transfusion
The wastage of red blood cell (RBC) units within the operative setting results in significant direct costs to health care organizations. Previous education-based efforts to reduce wastage were unsuccessful at our institution. We hypothesized that a quality and process improvement approach would result in sustained reductions in intraoperative RBC wastage in a large academic medical center.Utilizing a failure mode and effects analysis supplemented with time and temperature data, key drivers of perioperative RBC wastage were identified and targeted for process improvement.Multiple contributing factors, including improper storage and transport and lack of accurate, locally relevant RBC wastage event data were identified as significant contributors to ongoing intraoperative RBC unit wastage. Testing and implementation of improvements to the process of transport and storage of RBC units occurred in liver transplant and adult cardiac surgical areas due to their history of disproportionately high RBC wastage rates. Process interventions targeting local drivers of RBC wastage resulted in a significant reduction in RBC wastage (pâ€‰<â€‰0.0001; adjusted odds ratio, 0.24; 95% confidence interval, 0.15-0.39), despite an increase in operative case volume over the period of the study. Studied process interventions were then introduced incrementally in the remainder of the perioperative areas.These results show that a multidisciplinary team focused on the process of blood product ordering, transport, and storage was able to significantly reduce operative RBC wastage and its associated costs using quality and process improvement methods.Â© 2015 AABB.
In-hospital outcomes of a minimally invasive off-pump left thoracotomy approach using a centrifugal continuous-flow left ventricular assist device. - The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation
Minimally invasive left thoracotomy (MILT) and off-pump implantation strategies have been anecdotally reported for implantation of the HeartWare ventricular assist device (HVAD). We analyzed our experience with off-pump MILT implantation techniques and compared early in-hospital outcomes with conventional on-pump sternotomy (CS) implantation strategy.Between January 2013 and February 2014, 51 patients underwent HVAD implantation and were included in this study. Thirty-three patients had CS, whereas 18 patients underwent off-pump MILT. To compare outcomes of these techniques, a multivariate analysis using propensity score modeling was performed after adjusting for age, INTERMACS, Kormos and Leitz-Miller (LM) scores.Mean age at implant was 57 (range 18 to 69) years, and overall in-hospital mortality was 8%. Univariate analysis revealed a statistically significant reduction in days on inotropes (p = 0.04), and a trend toward reduced intra-operative blood product administration (p = 0.08) in the MILT group. There was no difference in intensive-care-unit length of stay (p = 0.5), total length of stay (p = 0.76), post-operative blood product administration (p = 0.34) and total time on mechanical ventilation (p = 0.32). After adjusting for age, INTERMACS profile and Kormos and LM scores, no statistically significant differences were observed between the MILT and CS groups.An off-pump MILT implantation strategy can be utilized as a safe surgical approach for patients undergoing HVAD implantation. Further large collaborative studies are needed to identify advantages of the MILT approach.Published by Elsevier Inc.
Finessing the fracture energy barrier in ballistic seed dispersal. - Proceedings of the National Academy of Sciences of the United States of America
Fracture is a highly dissipative process in which much of the stored elastic energy is consumed in the creation of new surfaces. Surprisingly, many plants use fracture to launch their seeds despite its seemingly prohibitive energy cost. Here we use Impatiens glandulifera as model case to study the impact of fracture on a plant's throwing capacity. I. glandulifera launches its seeds with speeds up to 4Â m/s using cracks to trigger an explosive release of stored elastic energy. We find that the seed pod is optimally designed to minimize the cost of fracture. These characteristics may account for its success at invading Europe and North America.
Stress hysteresis as the cause of persistent holes in particulate suspensions. - Physical review. E, Statistical, nonlinear, and soft matter physics
Concentrated particulate suspensions under vibrations can support stable, localized, vertically oriented free surfaces. The most robust of these structures are persistent holes: deep and stable depressions of the interface. Using a reduced model of the hydrodynamics we show that a rheology with hysteresis can lead to motion opposite to the time-averaged applied force. Moreover, we show experimentally that particulate suspensions of cornstarch in water exhibits hysteresis in the shear-rate response to an applied sinusoidal stress. The results of our model and our experiments suggest that hysteresis accounts for the outward force needed to support persistent holes.
Extending the use of the pacing pulmonary artery catheter for safe minimally invasive cardiac surgery. - Journal of cardiothoracic and vascular anesthesia
In this study, the therapeutic use of pacing pulmonary artery catheters in association with minimally invasive cardiac surgery was evaluated.A retrospective study.A single institutional university hospital.Two hundred twenty-four consecutive patients undergoing minimally invasive cardiac surgery through a small (5-cm) right anterolateral thoracotomy using fibrillatory arrest without aortic cross-clamping.Two hundred eighteen patients underwent mitral valve surgery (97%) alone or in combination with other procedures. Six patients underwent other cardiac operations. In all patients, the pacing pulmonary artery catheter was used intraoperatively to induce ventricular fibrillation during the cooling period, and in the postoperative period it also was used in 37 (17%) patients who needed to be paced, mainly for bradyarrhythmias (51%). There were no complications related to the insertion of the catheters. Six (3%) patients experienced a loss of pacing capture, and 2 (1%) experienced another complication requiring the surgical removal of the catheter. Seven (3%) patients needed postoperative implantation of a permanent pacemaker.In combination with minimally invasive cardiac surgery, pacing pulmonary artery catheters were therapeutically useful to induce ventricular fibrillatory arrest intraoperatively and for obtaining pacing capability in the postoperative period. Their use was associated with a low number of complications.Copyright 2010 Elsevier Inc. All rights reserved.
Routine intraoperative completion angiography after coronary artery bypass grafting and 1-stop hybrid revascularization results from a fully integrated hybrid catheterization laboratory/operating room. - Journal of the American College of Cardiology
This study sought to report our experience with a routine completion angiogram after coronary artery bypass surgery (CABG) and simultaneous (1-stop) percutaneous coronary intervention (PCI) at the time of CABG performed in the hybrid catheterization laboratory/operating room.The value of a routine completion angiogram after CABG and 1-stop hybrid CABG/PCI remains unresolved.Between April 2005 and July 2007, 366 consecutive patients underwent CABG surgery, with (n = 112) or without (n = 254) concomitant 1-stop PCI (hybrid), all with completion angiography before chest closure. Among the 112 1-stop hybrid CABG/PCI patients, 67 (60%) underwent a planned hybrid procedure based on pre-operative assessment, whereas 45 (40%) underwent open-chest PCI (unplanned hybrid) based on intraoperative findings.Among the 796 CABG grafts (345 left internal mammary artery, 12 right internal mammary artery/radial, and 439 veins), 97 (12%) angiographic defects were identified. Defects were repaired with either a minor adjustment of the graft (n = 22, 2.8%), with intraoperative open-chest PCI (unplanned hybrid, n = 48, 6%) or with traditional surgical revision (n = 27, 3.4%). Hybrid patients had clinical outcomes similar to standard CABG patients.Routine completion angiography detected 12% of grafts with important angiographic defects. One-stop hybrid coronary revascularization is reasonable, safe, and feasible. Combining the tools of the catheterization laboratory and operating room greatly enhances the options available to the surgeon and cardiologist for patients with complex coronary artery disease.
Oxygenation failure during cardiopulmonary bypass prompts new safety algorithm and training initiative. - The journal of extra-corporeal technology
Developing new strategies to improve patient safety and risk reduction is fundamental to hospital and patient success. Currently, there is a tendency in hospital safety management to focus solely on human error rather than organizational and educational causes that contribute to medical accidents. Although health care providers are the primary safety systems in medical facilities, there must be a more global, perhaps automated, approach using modern technology to prevent or reduce medical mishaps. Herein, we present an oxygenation failure with root cause analysis that prompted a new oxygenation safety algorithm and multi-service training initiative.
Wavy and rough cracks in silicon. - Physical review. E, Statistical, nonlinear, and soft matter physics
Single-crystal silicon exhibits a strong preference to cleave along a few certain planes, but in experiments we observe wavy cracks with almost no evidence of a preferred fracture direction. Furthermore, we find that the fracture surface is an anisotropic and self-affine fractal over five decades in length scale in the direction of the crack with a roughness exponent of 0.78. In our experiments a 1-4 cm wide strip of single-crystal silicon is heated to 378 degrees C and lowered into a 20 degrees C water bath at speeds of 0.2-5 cm/s. The thermal gradient produces cracks that, depending on the speed, are straight, wavy with amplitude 0.1-0.5 cm and wavelength 0.3-1 cm, or multibranched. The transition from one mode of fracture to another is discontinuous and hysteretic.
Persistent holes in a fluid. - Physical review letters
We observe stable holes in a vertically oscillated 0.5 cm deep aqueous suspension of cornstarch. Holes appear only if a finite perturbation is applied to the layer for accelerations a above 10g. Holes are circular and approximately 0.5 cm wide, and can persist for more than 10(6) cycles. Above a approximately equal to 17g the rim of the hole becomes unstable, producing fingerlike protrusions or hole division. At higher acceleration, the hole delocalizes, growing to cover the entire surface with erratic undulations. We find similar behavior in an aqueous suspension of glass microspheres.
Oscillating fracture paths in rubber. - Physical review letters
We have found an oscillating instability of fast-running cracks in thin rubber sheets. A well defined transition from straight to wavy cracks occurs as the amount of biaxial strain increases. Measurements of the amplitude and wavelength of the oscillation near the onset of this instability indicate that the instability is a Hopf bifurcation.
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