white coat notes

Doctor tells of pressure during face transplant

Unflappable seems a good way to describe Dr. Bohdan Pomahac, the bold young surgeon who has successfully completed four face transplants at Brigham and Women’s Hospital, often involving risky patients.

But in a New Yorker magazine profile of Dallas Wiens, one of his patients, Pomahac reveals that the unparalleled time pressure involved in removing the face from Wiens’s donor was almost unbearable - and something he is unlikely to attempt again.

The absorbing piece, by Raffi Khatchadourian, delves into Wiens’s troubled past and the power line accident in Texas that burned most of his face to the bone. It also describes how little time Pomahac and Dr. Elof Eriksson had to retrieve the donor’s face. Normally, the doctors require about six hours to dissect the nerves and blood vessels and prepare the face for transport to Brigham and Women’s. But transplant surgeons from another unnamed hospital needed the donor’s liver for a very sick patient - a life-saving operation that takes precedence.


Pomahac negotiated three hours from the other surgeons, who then moved in to begin removing the liver. The New Yorker reported:

Without blood, the facial tissue would survive for no more than four hours. “The clock started ticking,’’ Pomahac said. He and Eriksson had dissected about two-thirds of the face. “We tried as fast as we could to finish. . . . At one point, I was wondering, am I crazy? . . . Is it even worth it, to put myself in such a situation? I could have had a heart attack.’’

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When I asked Pomahac about the operation, which took place last spring and was Brigham and Women’s first full face transplant, he said the situation “was very unhealthy. I think it cut out 10 years of my life.’’

Of course, he is pleased the transplant turned out well for Wiens, who lives with his grandparents in Texas. But until the operation becomes more routine, he won’t try to remove a face again with that little margin for error, he said.


Records used for marketing

I have written often about the many ways electronic records could help doctors improve the health of patients, empowering them to catch adverse drug interactions, communicate with each other, and identify those who are due for preventative screenings.


But Phil Galewitz reported for Kaiser Health News about how some hospitals use the records to improve their financial health.

The records provide a wealth of marketing data, allowing hospitals to pitch their more profitable services to patients who have the insurance coverage to pay for them.

Galewitz quotes hospital representatives who say the approach is an effective way to connect people with services they need, offering lung cancer screenings to longtime smokers, for example, just as online commerce sites like harness customers’ purchasing histories to target advertising.

Plus, attracting patients who can pay puts hospitals in a better position to serve those who can’t pay.

But some consumer advocates say the practice goes too far. Galewitz wrote:


“While the practice is legal, most people would be shocked to know their records may be shared with nonmedical personnel and outside firms to help hospitals attract business, says Pam Dixon, executive director of the World Privacy Forum, an advocacy group based in California. ‘I am really bothered by the overabundance of information that is flowing that is unnecessary and risky,’ she says.

“While hospitals may profit from offering cholesterol tests and mammograms, the big payoff is in what those screenings may lead to - additional tests and procedures, including surgery.’’