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Robert E. Guide, M.D.

The Heart Institute for C.A.R.E.

image006.jpgOne Care Circle

Amarillo, TX 79106 - 1825

 

Dear Bob:

 

We enclose a copy of our report. to the Society f or Cardiac Angiography and Interventions of our visit to your laboratory on May 7 and 8, 1991. You may use it in any way that seems helpful. We presented it to the Laboratory Survey Committee, and in a summary form to the trustees of the Society. It was approved by each of of these groups.

 

We thank you again for the warm welcome given us by

everyone we met in Amarillo.

Sincerely yours, 

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DGG/WFW:klf

Enclosure

REPORT OF A CONSULTATION VISIT TO

THE HEART INSTITUTE FOR C.A.R.E.,

DR. ROBERT GULDE’S OFFICE, IN AMARILLO, TEXAS

MAY 7 AND 8, 1991

                 On May 7 and 8, 1991, we visited the Heart Institute for C.A.R.E. in Amarillo, Texas. The Heart Institute for C.A.R.E. is the private office of Dr. Robert Guide. Here he performs out-patient cardiac catheterization and angiography. He is hoping to recruit a partner to join him in less than two months.
   
            We
were met at the Amarillo Airport and had dinner with Dr. Gulde and his administrator, Ron Welty. Over dinner we learned of some of the accomplishments and some of the problems of this independent office catheterization unit.
   
            The following morning after breakfast with Ron Welty we drove to the Heart Institute for C.A.R.E. It is a one-story building of light tan brick with 10,000 square feet of space situated on U.S. Route 40 opposite the Westgate Mall. The building was designed specifically for the purpose of office cardiology including office out-patient cardiac catheterization and angiocardiography. (See Appendix A).
            We were received warmly by everyone we met in the facility. (See Appendix B). The laboratory was entirely at our disposal. There were no restrictions on answers to any of our questions. We felt the laboratory was well organized for our visit with a planned, typewritten schedule. Not only was everything open to us. Dr. Guide makes a practice of preparing a report which usually runs to half a dozen pages. This not only goes in the files and to the referring physician, but also a copy goes to the patient.
             A technique which has worked well for us in visits of this sort is to pick ten cases at random from the recent film file when we first arrive at a laboratory so that the reports and records of these patients may be pulled from the files for our comparison with the films. The excellence of records is hard to overemphasize. We found the quality of all the records we saw to be superb.                 The top priority was given to observing Dr. Guide and his team in action performing four studies on the day we were there. Each of these patients seemed to have appropriate indications for study. The technique of study was excellent. We noted manifest sympathy and concern of all personnel for relief of anxiety. There was proper attention to analgesia, sterility, accurate pressure measurements, and excellent radiological technique, which produced high quality films.                 The four cases we saw were all done by the Judkins technique from the right femoral artery. Antacids are prescribed for the evening before and the morning of catheterization. No sedation is given before the procedure, and the only analgesia is provided by the local anesthetic at the site of the arterial puncture. Heparin is usually used, the dose depending on the brachial or femoral approach. Any family members present are allowed to watch the whole procedure through a large window in one end of the laboratory, and to join the patient for an exit interview. Dr. Guide has recently changed from number 8 to nuinber 7 cardiac catheters. He starts with an injection of contrast into the root of the aorta. With this injection he views the aortic root at a slight left anterior oblique angle and then pans rapidly to the vessels of the arch going as far as necessary to include the bifurcations of the common carotids and then follows rapidly down the aorta in time to see the origins of the renal arteries and the terminal aorta and its common iliac branches. He then follows with measurement of left ventricular pressure and generally two left ventriculograms, one in each oblique projection. He then selectively catheterizes the right coronary artery and takes pictures in each oblique. He takes selective renal arteriographic pictures as the catheter is withdrawn and exchanged for a left coronary artery catheter for multiple projections and multiple angles of the left coronary artery.
            After the catheter is withdrawn hemostasis is provided by manual pressure for twenty minutes. The patient then moves to a recovery area, but is ambulatory by 90 minutes. The films are developed in the laboratory using an ancient, but serviceable Jamieson processor. The Philips x-ray apparatus is fifteen years old. He says that it needs some maintenance to keep in top form. Judging by the pictures which we saw this has not handicapped his clinical results. Following a review of the films we sat in on a couple of exit interviews which Dr. Guide had with the patient and the patient’s family with whom he reviewed the films. He outlined the findings and the problems and his suggested plan for further treatment. He also emphasized the dietary and drug measures which he wanted the patient to follow and the instructions for the next visit. We felt his decisions in regard to the handling of the various patients were appropriate to the findings and the patient’s clinical  condition.

            When we were not engaged in observing the direct patient contacts we reviewed the ten films we had picked at random. We discussed and came to agreement on the findings and then turned to the written reports and recommendations. In each case we found only mild and unimportant differences in the descriptions of the lesions which we had made and the findings in the written reports which Dr. Guide had made. The discrepancies involved slight differences in quantitative estimations of the severity of coronary artery narrowings. Since we did not have time to make caliper measurements and were simply making eyeball conclusions, small differences in these evaluations are to be expected. Part of our ability to come to the same conclusions as Dr. Guide comes from the excellence of the films. We found no exceptions to this high standard of films in all those we looked at. This excellence may in part be due to the meticulous attention to radiological technique with daily densitometry.             Dr. Guide has a written contract assuring admission of a patient with a complication to a local hospital if necessary. We reviewed all the cases with complications in the past three years. We also investigated 1984, 1985, and 1986. In those three years 599 cases were studied without a fatality. In 1988 185 cases were studied. There were four major complications, one of hypo­tension which responded well to treatment, two pseudo aneurysms of the fernoral artery which were repaired surgically with no difficulty thereafter, and one death which occurred after the  catheterization.             This patient’s course we reviewed in some detail. She had a recurrence of angina a week before the study with mild nausea and diaphoresis. An exercise stress test showed 1-mm ST depression from the second minute of exercise to more than the fifth minute of recovery. An exercise echocardiogram showed light calcification of her aortic valve and hypokinesis of the left ventricle. A chest film on September 9 showed pulmonary edema and a central venous line. A repeat on September 25 showed no active disease. On September 23 she had two left ventriculograms, one aortogram, and multiple views of the right coronary artery, a left coronary arteriograrri, and right and left renal arteriograrns. After repeat left ventricular pressures a right coronary arteriogram was repeated because of persistent chest pain. Early in the procedure she developed left bundle branch block and left anterior hemiblock. She was treated with nitroglycerin, oxygen, dilaudid, heparin, and furosemide. She had a lactic acidosis which was normalized before surgery and she was pain-free without additional narcotics. A coronary bypass was recommended and carried out after she was transferred to the High Plains Baptist Hospital. Before surgery in the hospital she was stable, felt well, and was making urine. In the operating room she had an acute drop in blood pressure with an emergency sternotorny and canalization for bypass. She was put on inotropic support and given 4 units of albumin. She was transferred to the surgical intensive care unit in a relatively stable condition. She then developed hypotension and died. At autopsy there was a leak of the suture line of the graft to the left coronary artery resulting in cardiac tarnpcnade from hemopericardiuni.  

This case is carried as a cardiac death in the laboratory because it occurred following the angiographic study. On the other hand a review of the chart makes it clear this patient died of an unfortunate surgical mishap.


In 1988 there were four minor complications, a hematoma of the groin and hypertension, a hematoma which resolved at home, a third hematoma, and hypotension treated with intravenous and oral fluids.

 In 1989 there were 126 cases with one death and six other major complication~. The patient who died, R.L.G., age 81, was brought to the office by ambulance. At angiogr~phy he was noted to have a rigid right femoral artery which could not be catheterized. The right brachial artery was obstructed 5 cm above the elbow where the catheter was inserted. There was also tight obstruction in the axillary artery with aneurysmal dilatation before the axillary narrowing. Coronary arteriography showed complete obstruction of the right coronary artery, severe stenosis of the main left coronary artery with thrombus formation, total early obstruction of the anterior descending coronary artery, and 85 percent stenosis of the proximal circumflex coronary artery. At the end of the procedure there was good bidirectional flow in the brachial artery. He got intravenous Ringers for hypotension and Mylanta for emesis. He was then transferred to the hospital. He was noted to have right bundle branch block with anterior injury on the electrocardiogram. Attempts to cannulate the fernorals and the left brachial for counterpulsation with an aortic balloon were unsuccessful. He did not respond to Dopamine, Levophed, and Isuprel. Efforts were then discontinued and he died. Permission for autopsy was refused.

This patient had severe generalized arteriosclerosis which is a life-threatening complication of coronary arterial disease. It was so severe that the usual resuscitation measures could not be carried out. This case must be counted as an angiography death. It is the only one which should be counted as a death as a result of angiography in the history of the laboratory.

            The other major complications include an episode of ventricular fibrillation which was reversed with closed chest massage and defibrillation. The next had a hematoma with repair of a pseudoaneurysm two days later. The next developed dyspnea and hypotension. It was treated with steroids, adrenaline, Ringers solution, and elevation of the feet. That patient had a meal and then went shopping. The next was a hemorrhage from the femoral artery twenty hours after catheterization. This was treated surgically. Later there was some minor infection of the operative site which cleared with appropriate treatment. The next was dissection of the femoral artery with later oliguria and hypotension. The pulse in that vessel faded and then returned. The last was a hernatoma of the fernoral artery with a pseudo­aneurysm which was treated surgically.  

In 1989 there were four minor complications. One patient with
no history of allergies developed hives and edema when given Angiovist. Treatment with Tagamet and Benadryl gave prompt relief. The next was a vascular perforation with escape of contrast and no sequelae. The third was late suspicion of a pseudoaneurysm with none found, and the fourth was orthostatic hypotension with nausea and vomiting treated with fluids.

In 1990 there were 79 cases with no major complications and two minor complications. The first was ventricular tachycardia or fibrillation following a right coronary artery injection, successfully treated with cardioversion and the other was a small hematoma after the procedure. In 1991 67 studies have been done with no complications.

The record thus for the past three-plus years is of the treatment of 457 cases with one death which was clearly not attributable to the procedure and one death which was attributable to the procedure. In the three previous years, 1984, 1985, and 1986, 599 patients were treated without a death. In fact the only death following a procedure other than the two already described was a patient seen in 1974 who was clearly a salvage patient. The attempt to save the life of this patient probably had little hope from the onset and was unsuccessful. Taking the series from 1984 through 1991 there were a total of 1056 studies with one death. This works out to approximately one death per thousand. This is the same as the mortality in the thousands of cases studied in the laboratories of the registry of the Society for Cardiac Angiography and Interventions. Of the 457 patients studied in 1988, 1989, 1990, and 1991, the series of patients we reviewed most carefully, there were 447 cases studied without a major complication. This amounts to 97.8 percent of the series. This result is almost the same as the results of laboratories in the Society for Cardiac Angiography and Interventions registry of 98.3 percent. Furthermore, Dr. GuIde has included patients that would not be considered major complications in the Society registry.  

At lunch we met nine of Dr. Guide’s colleagues. (See Appendix C)  

            They all seemed to be solid citizens established in the community. From each of them we gathered that there is a significant demand for high-quality cardiac catheterization and angiocardiography in Amarillo. Patients are referred from the surrounding communities as well as Amarillo itself. It is also clear that these physicians from the community feel that Dr. GuIde is meeting this demand in an exemplary fashion. Dr. Phillip McGraw, a psychologist, is engaged in helping Dr. Guide recruit three more professional people at a technical level, as well as a cardiological partner whom they expect to have on board in two months.

           Additionally, he and Dr. GuIde are going to review the extensive data bank which has been accumulated by Dr. Guide in relation to habits of diet, alcohol, tobacco, associated diseases, and demographics. They hope to review some of the traditional ideas in these fields and see how well they are borne out by the data. This seems like an ambitious and very exciting development. Dr. Guide is clearly not resting on his laurels, but is planning for the future in an imaginative and inspiring way. We were impressed with the excellent patient education and instruction which is carried out by the personnel, by the audiovisual material which is abundantly available, and by the personal efforts of Dr. Guide himself.

Dr. Guide has recently done coronary arteriography on a nationally known radiology consultant who in the course of his business visits many laboratories throughout the United States. He is not a native of Amarillo, but apparently selected Dr. Guide as the place for his coronary arteriography because of his high opinion of the quality of the work.


In summary we find the Heart Institute for C.A.R.E., Dr. Guide’s office, is providing a high quality of general medical care with the emphasis on cardiology which is probably not surpassed in any doctor’s office in the country. The facilities, the technique, the personnel, and the results would be highly commendable in any hospital. In a doctor’s office they are clear evidence that it is possible to do this kind of work in an independent doctor’s office with a high degree of safety and accuracy and at a much lower cost than many places. Each of us came to the conclusion that while we might not travel to Amarillo for our next coronary arteriograrn, if we had to have another coronary arteriogram we would be glad to have it done by Dr. Guide in his office.


An essential ingredient is an extraordinary physician with the technical skills, leadership, organizational ability, and humanity

      

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represented by Dr. Guide. One reason that there are not more such laboratories is that persons with his abilities are so rare. The patients studied in his laboratory represent not just easy cases which could be done well anywhere, but represent diagnostic and technical challenges which would test any facility. We have no reservations in giving full approval to Dr. Guide for the work in his laboratory. It is one of the best laboratories either of us has ever visited. We look forward with enthusiasm to hearing of the future developments he has in mind.

Respectfully submitted,

map of building

map of office

              ,                                                                                                                                                                                Appendix B

Cath Lab Staff Listing

                                                                        May 8,1991

1.          Jim Fowikes, RT(R), RDMS - Clinical Consultant & Echo Tech

Address: P.O. Box 9414, Amarillo, Texas 79105

Phone:   806-353-1900

2.         Ernest Bates,     R.N. - ACLS Certified/Instructor - Director of Nurses, Cath Lab

            Nurse

     Address:  Route 1, Box 503, Canyon, Texas 79015

     Phone:    806-655-0550

3.          Kenneth Payton, RMT, TDH-CMRT, HEW-CLT, MRt - Medical Technologist,

             Radiology Technologist

Address: P.O. Box 341, Groom, Texas 79039 Phone: 806-248-7083

4.          Thomas DiSalvio - B.S. Exercise Technology - EKG Technician Address: 3610 Lynette, Amarillo, Texas 79109 Phone: 806-352-8546

5.          Star Tucker - Nurse Technician

            Address:           3707 Catalpa, Amarillo, Texas 79109

            Phone:                                  806-353-1822

                 ,                                                                                                                                                                                              Appendix C

Physician Listing

Luncheon - May 8, 1991

1.          John Alpar, M.D., P.A. - Fellow of American CoUege of Surgeons -

Ophthalmo!ogist - referring physician - Quality Assurance Committee member.

Address:           5311 West Ninth Avenue, AmariHo, Texas 79106-4161 Phone: 806-359-3937

2.    Narsyana               PiHai, M.D. - FeUow of Associated College of Physicians - Oncologist -

                     Diplomat          American Board of nternal Medicine and Oncology - referring

     physician         - provides coverage white I am out of town - Chairman, Quality

  Assurance Committee Heart Institute For CARE.

      Address:              1901 Medi Park, Suite 1002, Amarillo, Texas 79106

        Phone:               806-353-8011

3.          L.A. White, M.D. - Family Practitioner - referring physician.

Address:           1920 Medi Park, Suite 1, Amarillo, Texas 79106

Phone:                                                    806-359-3193

4.          Donald Frank, M.D. - Family Practitioner - referring physician. Address: 521 1 West Ninth Avenue, Amarillo, Texas 79106

            Phone:                                  806-359-8583

5.          Richard Archer, M.D., P.A. - Diplomat American Board of Internal Medicine -

                                                  referring physician.

Address:           1900 Coulter, Suite M, Amarillo, Texas 79106 Phone: 806-353-381 1

6.          Mrs. Richard Archer - Dr. Richard Archer’s wife.

Address:           6867 Fulton Drive,Amarillo, Texas 79109 Phone: 806-355-0789

7.          John Easy, MD., PA. - Fellow of American College of Surgeons -

Cardiovascular & Thoracic Surgeon - consulting physician.

            Address:           706 North Polk, Amarillo, Texas 79107

            Phone:              806-372-2988

8.         Phil McGraw,   PhD - Board Certified in Behavioural Medicine - consultant.

            Address:           Professional Technologies, nc., 4225 Wingren Road,

                                                 Irving, Texas 75062

                Phone:                    214-717-1477

9.              Bob Lieman - patient - Consultant for Heart Institute For C.A.R.E. Foundation

President of International Platform Association.

Address:           2937 Westbrook Drive #419A, Fort Wayne, ndiana 46805 Phone: 219-483-2300