Cancer doctors used to think of cancer treatment in terms of extending patients’ lives by a few more months or years. Now, thanks to a better understanding of many kinds of cancer and more advanced treatments, patients often live for many years or decades after diagnosis.

As cancer survival rates have increased, we’ve learned more about how cancer therapies affect cancer survivors’ long-term heart health. Doctors across the country have begun to take a bigger-picture view of the heart’s overall health during and after cancer treatment. We call this field cardio-oncology, in which heart doctors work with cancer teams to catch or prevent any potential complications and educate patients on making heart-healthy lifestyle choices.

Related research: A Feb. 2018 publication by the American Heart Association highlights the intersection between breast cancer and heart disease.

A team approach for patients’ hearts during and after cancer treatment

Much of the early concept of heart care during cancer treatment focused on the concept of cardiotoxicity, which describes cancer therapies that directly damage the heart. We’ve since learned that we can use an approach similar to how doctors and patients manage diabetes and other chronic conditions.

This process isn’t a one-size-fits-all strategy. You may need more frequent monitoring if you have high blood pressure or other risk factors for heart disease. The doctor might ask to see you more often if you have a past history of heart problems, such as heart failure or cardiomyopathy. And we may need to alter our plans if your cancer treatment changes. My colleagues and I speak daily with our patients’ oncologists and our nurse navigators to keep us connected with every new development.

Related reading: Who’s at risk for heart problems during cancer treatment?

You play an equally important role as your doctors in keeping your heart safe over the long term. You can keep your heart beating strong through regular exercise, controlling your blood pressure and regularly checking in with your cancer doctor on whether your treatment continues to be effective or if you need to try something else.

Exercise

The most important advice I give my patients is to stay active. However, effective exercise looks different for each patient. If you haven’t exercised regularly in 20 years, you might need to start with a walk around the block. If you were running 10K races before your cancer diagnosis, a brisk stroll isn’t going to be enough exercise to be effective for you.

Getting the heart pumping is critical for both your heart health and your cancer management, but it’s also good for us as a measurement tool. By being aware of how much you can exercise—whether that’s a spin class, a vigorous game of basketball or whatever you enjoy—we can use your respiratory function as an early-warning system. A sudden shortness of breath during an activity you used to complete with no trouble may be a sign that your heart is having trouble pumping.

Blood pressure control

High blood pressure is a common side effect of several types of cancer treatment and also a risk factor for many forms of heart disease. Your cancer or heart doctor may recommend several steps to maintain a healthy blood pressure, including:

• Lose weight if you’re overweight or obese
• Reduce the amount of sodium and fat in your diet
• Stop smoking or using other forms of tobacco

If these lifestyle changes aren’t enough to improve your blood pressure, you may need to see a cardiologist, so we can prescribe medication to help.

Regular check-ins with your cancer doctor

You might not need to see a heart doctor on a regular basis if your heart is healthy, but it’s a good idea to follow up regularly with your cancer doctor even after you’ve completed treatment. Let them know about any sudden or unusual symptoms as soon as possible. Heart-related complications of cancer therapy can show up years or even decades after treatment, so we want to catch anything that may arise quickly to achieve the best possible outcomes. Stay engaged in the treatment and follow-up process. Ask questions and share any concerns you may have.

As more people continue to live longer after cancer, the issue of heart health for survivors is only going to grow in importance. Thankfully, the changes in heart function we can see during treatment may be reversible. Even if your heart’s function is reduced during cancer treatment, we can manage it well with medications and other options. It’s possible you’ll never even notice a difference.

In 2017, a long list of NFL players tore their anterior cruciate ligaments (ACL), and several were forced to sit out the entire 2017-2018 season. Some high-profile players who were injured included:

• Julian Edelman
• Deshaun Watson
• Richard Sherman

But an ACL injury can be devastating for anyone, just not athletes. The ligament is crucial in controlling rotational stability of the knee joint, which is needed for turning or twisting. An ACL injury can cause severe pain and can make walking and exercising painful, if not impossible. ACL injuries may require surgery, and the recovery process can take a year or longer.

The doctors at MedStar Orthopaedic Institute, as well as around the country, are discovering new technologies to strengthen the ACL and other crucial ligaments in the knees, ankles and elbows after reconstruction or repair. Researchers have developed an internal brace, which is an advanced suture made of polyethylene or plastic that can give the new ligament stability throughout the healing process and support safer, faster recovery.

LISTEN: Dr. Argintar discusses internal bracing in the Medical Intel podcast.

How does internal bracing work?

We perform the internal bracing and ACL surgery procedure on patients under anesthesia first. We either take a donor tendon from a cadaver (a deceased donor) or from the patient’s own body. Then, we drill tunnels into the bones of the knee, so that once the repair or replacement is complete, we can put the new ligament where the old ACL was. We insert the internal brace with the ligament, so it follows the same path and receives the same force as the new ligament. Think of it as sort of a temporary ACL while the new ACL gets stronger.

In the past, where the ACL stopped and started within the knee was not well understood or mapped. In fact, currently the most common reason for revision ACL surgery is incorrect original tunnel placement. Rehabilitation also took much longer.

We commonly see patients who had ACL surgery years ago, and we unfortunately have to operate again because they don’t have adequate range of motion or stability. What we know for all therapies is that if you go into a surgery with poor motion, you typically will have poor motion afterward. But all the research that’s come out during the last decade about understanding where the ACL starts and where it goes, coupled with the evolution of minimally invasive ways to incorporate new technologies, have combined to allow us to perform more effective, lasting repairs.

Approximately two weeks after surgery, our patients start physical therapy, and we’ve found in our experiences that internal bracing gives therapists and patients the confidence to be more aggressive in physical therapy earlier on. We’re one of only a few centers in the United States that are collecting this type of research. In fact, the strength of internal bracing now allows us, at times, to actually repair the ligament, which avoids bone tunnels completely! And as we study internal bracing, we may find that we can be more aggressive, which might reduce the amount of time people spend rehabilitating after ACL surgery.

Anecdotally, we’ve found that patients have less muscle atrophy, or loss of muscle, after ligament replacement or repair when we use internal bracing. We’ve also found that the procedure helps patients get back to sport or activity quicker. A perfect example is two firefighters we cared for in 2017. I prepared them for the standard eight to 10 months of rehab, which can be tough for people who very much want and need to be active. With internal bracing and aggressive physical therapy, they were able to get back to work in six months without restriction. The same can be said for athletes who get back to their sports stronger and safer than before.

Who’s a good candidate for this procedure?

Internal bracing is safe for anyone who needs ligament reconstruction or repair surgery. People who get ACL or elbow ligament surgery tend to be young and active, but their age is less important to me than activity level. I’ve done ACL surgery in people who were numerically older but more physically youthful than some of my college-aged patients.

There are no specific safety concerns with this procedure outside the typical risks of surgery. In fact, when I look at my ACL patients with and without internal bracing, there’s no easy way to determine who has one and who didn’t. If you or a loved one needs an ACL or other ligament surgery, consider a facility that uses this revolutionary technique. Work with your doctor to choose the procedure that will last the longest and get you back to your activities safely, whether that be playing sports, fighting fires or chasing the kids around the house.

Tug boat captain Jeff Davis spent 40 years shepherding large ships safely through treacherous waters along every U.S. coast. But it was an ordinary motorcycle ride on a summer day in the St. Mary’s Maryland countryside that proved the most dangerous voyage of his life.

When his cycle collided with a larger vehicle, gas spilled and flames alighted. Within seconds Captain Davis’s body was ablaze. Passerby’s helped smother the fire and a state police helicopter loaded Captain Davis aboard for the trip to MedStar Washington Hospital Center—and its renowned Burn Center.

The Burn Center, the only adult burn treatment facility in the Washington area, serves the District, southern Maryland, northern Virginia and eastern West Virginia. Every year, more than 1,000 patients are treated at the center by a multidisciplinary team of experts including surgeons, nurses, nutritionists, pharmacists, rehabilitation therapists and many other allied health professionals.

The Threat of Poly-Trauma

When Davis arrived at the hospital he was in critical condition. “He had multiple traumatic injuries including broken bones and very deep burns covering more than 50 percent of his body,” explains Jeffrey Shupp, MD, Burn Center director. Working collaboratively, the Trauma, Interventional Radiology and Orthopedic Surgery teams gathered to manage his complex care.

Among his serious fractures was a broken pelvis—an injury that can lead to difficult-to-control bleeding. So Davis was first rushed to Interventional Radiology for a procedure in which coils are used to block bleeding vessels in order to prevent further blood loss.

Once this threat was thwarted, the burn team turned to tackle the third and fourth degree burns that covered Davis’s body from his waist down. The damage was so severe it reached into the underlying bones, muscles, tendons and nerve endings.

“With a burn of this degree, burn shock can be lethal,” Dr. Shupp says. “Captain Davis required over 20 liters of fluid to support his cardiovascular system during the first 24 hours in the hospital. Once we get a large burn through this initial resuscitation, we need to begin debridement to remove burned tissue to stop inflammation and control infection.”

Lost in Dreams

Davis has no memory of those early days—nor the months of intensive care that followed. But he has read his wife Bonnie’s journal—a daily heart-wrenching account of the experience. That’s where he learned about his round-the-clock care and dozens of surgical procedures.

Bonnie also wrote about a sudden, unexpected wrinkle in her husband’s recovery. Many weeks into his hospitalization, Davis developed internal bleeding from an unknown source.

"It was a mystery we needed to solve quickly,” says Dr. Shupp. “But we were able to identify that the bleed was in his colon where he previously had surgery. Dr. Laura Johnson and I had to remove much of his large bowel to stop the bleeding.” It was a setback—but Davis continued to defy the odds.

“It’s strange,” Davis says now. “I think I had this recurring dream. I felt as if I was in a shallow pool with other people floating and we were in pain. We could talk with one another and to people who came and went. I must have been a bit aware of all the people helping me get better.”

The Benefit of Research

Three months into his hospitalization, it was time to graft new skin tissue on his wounds. Multiple techniques were used including cadaver tissue and an innovative new tool available in just a few hospitals nationwide.

"We have been involved in clinical trials testing a medical device called ReCell® and received a compassionate waver for Captain Davis,” Dr. Shupp explains. “ReCell® uses a very small sample of the patient’s skin to reconstitute cells into a spray to cover large areas. It’s an important additional grafting technique for patients like Captain Davis who don’t have enough healthy skin for standard grafting.”

When his wounds were adequately healed, Davis began rehabilitation. Months of sedentary hospitalization, stiffening of muscle and loss of nerve sensation made movement difficult. And his 6’ 1” frame had withered to 120 lbs."

When I first left the ICU, just getting into my wheelchair was a big feat,” he says. “But the therapists took good care of me and helped get me stronger. Everyone at the hospital was wonderful and I know it’s a miracle I’m alive. They are great people who became my friends.”

“Mr. Davis’s recovery is a testament to the multidisciplinary team taking care of him,” says Dr. Johnson. “Everyone collaborated to help him make the recovery he has; he and his wife are minor celebrities every time they come back for a visit.”

Homecoming

On December 3, 2016, more than 18 months after he first arrived, Davis was discharged. “A van picked me up and took me home to St. Mary’s,” he says. “My wife, a friend and my dog Choco were waiting for me. When I left, Choco was just a puppy, but he remembered me!”

With home nursing and physical therapy, and his wife “Bonnie’s remarkable strength, things are getting better,” he adds. “My wife and I were even able to go to Florida for a month and are planning to go back.

“I know this wasn’t the retirement we dreamed of and I don’t have great expectations. I just want to be strong enough to leave my wheelchair behind and walk unassisted into a restaurant or a friend’s home. Thanks to many people, I may just get there.”

When Scott Frank, MD, interviewed for a job as attending anesthesiologist at MedStar Washington Hospital Center in 2005, he asked Eileen Begin, MD, now the department’s chair, why she had stayed there.

"She told me that she would be bored anywhere else,” Dr. Frank recalls. “It’s been the same for me. It’s an exciting challenge every day, to stay on top of it all.”

Indeed, free time appears only rarely in Dr. Frank’s daily schedule. In addition to working with patients as they prepare for and undergo surgery, the Buffalo, N.Y., native serves as medical director for the Hospital Center’s 3^rd Floor Operating Room, and oversees anesthesia for Code Blue and Code One stroke services. Dr. Frank also participates on numerous committees, focused on topics as diverse as perioperative governance and biohazard responses.

“I do a lot of everything,” he notes with a laugh.

Choosing to Pursue Medicine

Dr. Frank might well have applied his multitasking skills to finance, his undergraduate study, had he not been visiting Germany as an exchange student when the Berlin Wall fell in 1989.

"That experience fundamentally changed my view of the world. It made me think there were other ways I could do good, rather than manage money,” Dr. Frank says.

Returning home to work for his father’s environmental consulting firm, Dr. Frank took some science classes and began thinking that medicine might be his calling. He became a paramedic, and later enrolled in medical school at SUNY Buffalo. Dr. Frank’s original plan to pursue a surgical specialty eventually evolved into a career in anesthesiology, a discipline he feels is better suited to his skills and interests.

“It’s a multidisciplinary specialty that involves patients who may be generally healthy, critically ill and everything in between,” Dr. Frank explains. “There are also Critical Care and ICU aspects—areas of medicine that I really enjoy. The only drawback is that I had to go back for training in areas that weren’t part of my surgical residency.”

The Value of Anesthesiology

Despite the many detours on his career path, Dr. Frank couldn’t be happier with his choice.

"Anesthesiology is a specialty that requires a lot of understanding and compassion,” he says. “You’re seeing a patient at a difficult time. To make them comfortable, you have to be both sensitive to their emotions, yet firm about getting them to where they need to be.”

While the anesthesiologist’s role in surgical cases is sometimes overlooked, “once patients meet us, they usually recognize and appreciate the role we play in their care.”

Life Outside the Hospital

There’s very little spare time in Dr. Frank’s life away from the Hospital Center. An avid cyclist, he participates in multiday cycling tours, as well as several one-day century rides a year. He also dabbles in cooking—French is his current focus—scuba diving, coin collecting and music.

“I’ve played guitar and bass since my college days,” Dr. Frank says, lamenting that those instruments have sat idle for the last several months. “I just haven’t been able to find the time.”

Today’s nurses have to keep track of so much more for patients than they did just 30 years ago. Millennials are used to having information at their fingertips, and nurses today have to manage an enormous amount of data simultaneously.

We have accommodated that at MedStar Washington Hospital Center in unique ways.

Just as smartphones store phone numbers and email addresses so we don’t have to remember them, our educational programming for nurses provides instant access to information. This is especially important for millennial nurses who are used to finding what they need with a few taps or clicks, which is what led us to create askNED, our nursing education app.

Just as clicking and swiping helps all nurses access information, new technologies also improve their hands-on preparation for patient care. Today, digital and real-life simulations are often used to practice and get feedback on real life situations nurses will encounter in their daily practice. We prepare our nurses with practical simulations that prepare them for patient situations they’ll encounter in a real-world setting and provide crucial feedback on how to improve patient care.

How a smartphone app streamlines nursing education

Nearly all millennials own and use smartphones, according to data from Nielsen, a global analytics group. Many healthcare apps for smartphones cater to millennials’ demand for instant information, and we encourage our nurses to use the. We also needed a way to connect our nurses directly to information that they want about education updates.

So, we use askNED, an app tailored to our education program. “NED” stands for our Nursing Education Department, which provides classroom and practical education to new nurses in our RN Residency program, as well as experienced nurses, on an ongoing basis. The askNED app is available for free on the App Store and Google Play. Some of the features our nurses use most include:

• Calendars and schedules
• Clinical update information
• Direct access to nurse educators
• Instructional videos for patient care and equipment use
• Push notifications for important events
• Note-taking
• Quick links to hospital procedures

More than half of our nurses have downloaded askNED. Instead of memorizing procedures and how to set up equipment, we provide our nurses a fast way to look up information when they come across an uncertain situation, so they can get back to caring for their patients.

Over the past few decades, weight loss surgery, also known as bariatric surgery, has become increasingly common. As such, we’ve begun to see more patients who could benefit from an additional procedure after weight loss: skin reduction surgery.

Almost everyone who has weight loss surgery will have some excess skin. When a patient loses 100 pounds or more, the skin can’t always bounce back and firm up. Some people aren’t bothered by this at all because they feel so much healthier. Others might be uncomfortable with how the excess skin looks. But for some patients, excess skin can cause painful or even debilitating health issues.

The amount of weight lost after bariatric surgery may cause a little bagging and sagging or can result in 40 to 60 pounds of excess skin. Skin reduction surgery (or excess skin removal) is elective, which means it’s totally up to the patient to have it or not. About 20 to 30 percent of our bariatric surgery patients choose to have skin reduction surgery, including both men and women.

LISTEN: Dr. Zubowicz discusses skin reduction surgery after bariatric surgery in this Medical Intel podcast.

Why do patients choose to have skin reduction surgery?

The majority of our skin reduction patients choose to have the procedure for cosmetic reasons. If a person’s excess skin issues are small or purely cosmetic, they can wear support garments to keep the skin up and tight. But when a patient has gone through all the hard work of preparing for and recovering from bariatric surgery and has lost a lot of weight, it can be hard to see all that excess skin in the mirror. Taking off those pounds of excess skin can be tremendously helpful for a patient’s self-esteem and can make exercise and hygiene easier.

For some patients, excess skin causes physical health problems. The skin folds can become a warm, wet environment that is prone to yeast infections or bacterial infections that can result in painful irritation, especially during exercise or work. Severe cases can be debilitating. Patients can help their excess skin from becoming a health concern by keeping it clean and dry, and by using antifungal powders to prevent rashes. But for long-term health, skin reduction surgery is a safe and easier option for many patients.

I’ve never had a patient tell me they regret having had bariatric surgery because of excess skin issues. Almost always, they feel so much better emotionally and physically once they lose a lot of weight. Their joints hurt less, their overall health improves and they can start exercising again. Still, a significant number of patients eventually want to have their excess skin removed as the next step to their healthier, more confident life.

How does skin reduction surgery work?

During the procedure, we surgically remove the excess skin by making incisions in the affected areas of the body. To remove excess skin on the stomach area, we make an incision at the bikini line. On the arms and legs, we make incisions on the inside of the limbs. There will be some scarring, and the surgeon will work to keep the scars as small and hidden as possible.

Patients should see doctors who are specifically trained in skin reduction surgery procedures and who do it often. Because we perform so many bariatric surgeries at MedStar Washington Hospital Center, our plastic surgeons are experienced in excess skin removal, and our cosmetic and bariatric surgeons partner closely together to ensure our patients get the best care.

We usually recommend waiting at least a year after having bariatric surgery before skin reduction surgery. Patients often continue to lose weight during this time, and if they get the surgery and then lose another 30, 40 or 50 pounds, they’ll have more excess skin and will be back where they started.

Is skin reduction surgery covered by insurance?

Health insurance coverage for skin reduction surgery varies. Many insurances only cover the procedure if a patient is having documented health issues, such as rashes, infections or irritation. Even then, it’s often covered only for the stomach area and not the arms or legs.

We understand the documentation insurance carriers require to get coverage for the procedure, and if you qualify, we can help with this process. Many patients who don’t qualify under their insurance still opt to get the procedure, paying for it out of pocket because of how much the excess skin affects their quality of life.

If you choose to have bariatric surgery, it’s important to go to a bariatric center like we have at MedStar Washington Hospital Center. You’ll have access to an entire team of surgeons, dietitians, psychologists and cosmetic surgeons who understand how to make weight loss surgery a success and are knowledgeable about living your best life after surgery.