Robert E. Guide, M.D.
The Heart Institute for C.A.R.E.
One Care Circle
Amarillo, TX 79106 - 1825
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.
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
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
defibrillation. The next had a hematoma with repair of a pseudoaneurysm
days later. The next developed dyspnea and hypotension. It was treated
steroids, adrenaline, Ringers solution, and elevation of the feet. That
had a meal and then went shopping. The next was a hemorrhage from the
artery twenty hours after catheterization. This was treated surgically.
there was some minor infection of the operative site which cleared with
appropriate treatment. The next was dissection of the femoral artery
oliguria and hypotension. The pulse in that vessel faded and then
last was a hernatoma of the fernoral artery with a pseudoaneurysm
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
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.
, Appendix B
Cath Lab Staff Listing
1. Jim Fowikes, RT(R), RDMS - Clinical Consultant & Echo Tech
Address: P.O. Box 9414, Amarillo, Texas 79105
2. Ernest Bates, R.N. - ACLS Certified/Instructor - Director of Nurses, Cath Lab
Address: Route 1, Box 503, Canyon, Texas 79015
3. Kenneth Payton, RMT, TDH-CMRT, HEW-CLT, MRt - Medical 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
, Appendix C
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
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
5. Richard Archer, M.D., P.A. - Diplomat American Board of Internal Medicine -
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
8. Phil McGraw, PhD - Board Certified in Behavioural Medicine - consultant.
Address: Professional Technologies, nc., 4225 Wingren Road,
Irving, Texas 75062
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