A patient is high risk
The standard treatment for smokers in the late stages of emphysema, when most are too debilitated even to get around, is simply to ease their physical distress by giving them supplemental oxygen, inhalers, and other drugs. Many patients never hear about an option called lung volume reduction surgery that might actually restore some quality of life. Their primary-care doctor may not know about the treatment, which is done at only a handful of medical centers. And lung-care specialists might not bring it up. Says pulmonologist Philip Diaz, medical director of lung volume reduction surgery at the Ohio State University Medical Center in Columbus: "They may figure the person is untreatable--why put them through surgery?"

People with late-stage emphysema don't make good surgery candidates. Their damaged lungs have left them with little strength or stamina. Most have a higher-than-usual chance of a heart attack or arrhythmia during surgery because of high blood pressure or heart disease. Yet, when the disease is concentrated in the upper part of the lungs, removing those portions may bring enormous relief.

Indeed, many people who need treatment but are at high risk for a poor outcome are apt to be turned away by their local health care system. Meantime, the country's best hospitals are constantly devising ways to overcome medical handicaps such as old age and obesity, the latter a real and growing concern.

Not long ago, for example, advanced years were an automatic disqualifier for big operations, and many surgeons still are uncomfortable working on people above a certain age. But physicians have developed ways to cope with fragile tissue and bone, and elderly patients have shown themselves to be quite resilient after the insults of surgery. At large referral centers, even nonagenarians now roll into operating rooms at a steady pace.

Obesity needn't preclude treatment, either, but it's a reason to look for expertise. Penetrating thick layers of fat and keeping far more blood vessels than usual from turning into bleeders add to the time spent under anesthesia, itself a risk. And a drumbeat of studies demonstrates that obesity worsens the outcomes of many procedures. Findings released in May, for example, show that abnormal heart rhythms were 61 percent more likely after radio-frequency ablation, a corrective treatment, in patients with a body mass index above 30 (indicating obesity) than in those whose BMI was normal. Next month, the journal Cancer will report that obese patients with prostate cancer who are treated with radiation are two-thirds more likely to have a recurrence than those who aren't obese.

One important job of the experts is to figure out which vulnerable patients can't be helped. A long list of potentially dangerous complications--infection, collapsed lung--faces candidates for the lung volume reduction operation, for example. A team of specialists is needed, just as it is with transplant surgery, to screen out the highest risks, identify the patients most likely to benefit, and work with them after they recuperate to keep up their gains. At Ohio State, which recently became the first hospital to meet specific new standards for lung volume reduction programs set by the Joint Commission on Accreditation of Health care Organizations, 75 percent to 80 percent of those who come seeking care are rejected.

Sandra Lecraft of Coshocton, Ohio, made it through the screening. Housebound and barely able to walk 100 feet, she had been using oxygen tanks 24 hours a day. The payoff was immediate. "I woke up in the ICU and said, 'I don't feel like there's somebody sitting on my chest,'" says Lecraft, 63. Out went the oxygen tanks. Lecraft now walks 3 to 4 miles four times a week, rides an exercise bike twice weekly, and occasionally swims.

ICU time is a possibility
A serious case of pneumonia or heart failure, say, or a complex surgical procedure such as the removal of part of a cancerous organ is most likely to mean a day or more in an intensive care unit. If there's time to make a choice of hospitals beforehand, a large center could be your best shot at being cared for in an ICU run by trained, certified intensivists.

Patients in ICUs are the sickest of the sick--many are breathing with the help of mechanical ventilators, and all are closely monitored 24 hours a day. At most hospitals, they are under the care of the doctor who admitted them--most often a surgeon in the case of a stubborn post-op infection, say, or an internist or other primary-care physician. Few of these physicians are trained to treat critically ill patients.

Intensivists are. They're expert, for example, at staving off lethal infections, stabilizing an erratic heartbeat, and catching potential drug interactions. An eye-opening analysis in 2002 by Johns Hopkins's Pronovost and others found that patients are almost 40 percent less likely to die in ICUs supervised full time by these specialists. Yet only about 20 percent of hospitals--most of them referral centers--have intensivist-directed ICUs.

An intensivist-run ICU is so valuable, Pronovost believes, that it more than cancels out the disadvantage of going to a hospital that doesn't see a large number of patients with a particular condition. Not having intensivists "is part of the invisibility of poor quality," he says. "No hospital is going to tell you your father died because he didn't have an intensivist--they'll say it was pneumonia or a blood infection or something else."

A technology is new
An implanted titanium apparatus relieves breathing and heart problems for a child with a severely deformed chest and spine. MRIs during surgery indicate whether cancerous tissue has been completely removed. Without treatment, a carotid aneurysm--a weakened, bulging spot in one of the arteries to the brain--kills more than 70 percent of its victims. Surgery to reinforce the artery or to tie off the bulge can damage nearby nerves, risking death or major stroke. But a new, less drastic alternative pushes a mesh cylinder through a catheter to the aneurysm. The "stent graft" isolates the aneurysm and reinforces the artery walls. Only at referral centers are such technologies tested and refined, and until they are, only at such centers will patients be able to exploit them.

Bobbie Nuhfer's good fortune was to find such experience near her home in Orlando. From the time she was a young girl in West Virginia, Nuhfer, 62, had been passing out briefly, sometimes twice a week. Her own children "knew if I reached out and grabbed hold of them, they were to set me down easy," she says. In 2003, a cardiologist found the explanation: an atrial septal defect--a hole between two chambers of Nuhfer's heart that was short-circuiting oxygenated blood.

Nuhfer could have had open-heart surgery. But she'd been told about the recently approved Amplatzer septal occluder, which was pushed through a catheter to seal the hole. The year before, a study of the repair had put the rate of major complications at 1.6 percent, compared with 5.4 percent for open-heart surgery. Evan Zahn, chief of cardiology at Miami Children's Hospital's congenital heart institute and one of the few doctors familiar with the plug, took her on and installed the device. "I have not fainted once," she says, since seeking out the treatment she considered best. "Minor surgery is what they do on you," says Nuhfer. "Major is what they do on me. And I wanted minor."

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