Since the launch of the COVID Confirmed (COCO) Clinic in early April, over 4,700 patients with COVID-19 have been given virtual follow-up services after being discharged from the hospital. Not only has this virtual outpatient clinic helped patients on their road to full recovery and often kept them from being readmitted to the hospital, it also provided resident physicians and senior medical, nurse practitioner, physician assistant, PharmD, social work and behavioral health students, with a place to complete their clinical rotations. In mid-March, the Association of American Medical Colleges (AAMC) issued new guidance for medical student clinical rotations during the coronavirus which stated that it, “strongly supports medical schools pausing all student clinical rotations, effective immediately, until at least March 31,” due to concerns about the availability of personal protective equipment (PPE) and to give time for appropriate educational strategies and alternative clinical experiences to be developed and implemented.

Volunteers and trainees played vital roles within the clinic which included conducting regular welfare checks, offering support and discussing any symptoms that haven’t been resolved. Social work and behavioral health students were not originally part of the COCO Clinic when it first launched, but the team quickly realized that COVID-19 and quarantine could severely impact a patient’s mental health and so the interprofessional team expanded. The medical, social, and mental health assessments screened for depression, anxiety and substance abuse, and if a patient answered “yes” to any of the questions, they were offered resources or referrals to support. According to Asa Oxner, MD, FACP, COCO Clinic operations director, one patient agreed to being referred to the mental health team of COCO and a real suicide attempt was mitigated.

In addition to regular follow-up assessments, nurse practitioner students were in charge of monitoring the dashboard that displays the oxygen levels and heart rates of high-risk patients who were wearing a special device on their wrist.

A patient wearing one of the COCO Clinic’s monitors. Photo by CBS affiliate, 10 Tampa Bay, from their, “COVID-19 Telehealth Clinic Getting Overloaded with Tampa Bay Patients” video.

“Volunteering with the clinic has been a unique educational experience. The clinic administrators do a great job of turning every opportunity into a teaching moment,” said Joshua Mizels, Morsani College of Medicine fourth-year medical student and past clinic volunteer. “My classmates who all volunteer have had the opportunity to keep interacting with patients, giving us the opportunity to learn more about what they are going through during this pandemic.  The experience from this opportunity has been invaluable toward my medical education. ”

Lucy Guerra, MD, MPH, FACP, and Asa Oxner, MD, FACP, co-coordinators of the COCO Clinic, along with Elimarys Perez-Colon, MD, medical director, Christine Jennings, RN, nurse manager, and Rachelle Idziak, MD, data manager, led the effort to get the clinic up and running and play a pivotal role in helping the community. For their dedicated efforts, the doctors received a USF Health Culture Coin from Chief Medical Officer, Dr. Mark Mosely.

Dr. Asa Oxner (left) and Lucy Guerra (right), COCO Clinic co-coordinators, were presented with USF Health culture coins by Dr. Mark Moseley, USF Health chief medical officer, for leading efforts to get the virtual clinic up and running.

“We have been successful in offering close follow up to patients keeping them out of the hospital when able, monitor patient’s vital signs remotely to identify patients at higher risk, safely linking patients to care and offering education and reassurance to patients with COVID19 in the Hillsborough county,” said Dr. Elimarys Perez-Colon, assistant professor of medicine, vice chief of medicine at Tampa General Hospital, and medical director of the COVID-19 Confirmed Clinic. “The data collected will assist our department of health to better understand the distribution and epidemiology of COVID19 in our county. This effort wouldn’t have been successful without the assistance and compassionate care offered by our trainees.” In the first three months, over 150 trainees played a part in the care of patients.

The COCO Clinic has been the talk of the town, featured in news stories by ABC Action News, Baynews 9, 10 Tampa Bay, among others.

After the success of the virtual clinic for COVID-19 patients, clinic leaders began working with partners at Tampa General Hospital and the Florida Department of Health to make the clinic a permanent resource for the community. As of November 12th, the COCO Clinic transitioned management of the clinic to TGH and became the TGH Transitional Care Center. “This transition will allow the clinic to continue operating and provide excellent care to our patients impacted by COVID-19, while allowing USF Quality and Clinical Operations Department staff who have been assisting the COCO clinic to return to their normal non-COVID duties,” said Dr. Moseley. “The clinic will continue to provide hours to our medical, pharmacy, and nurse practitioner students and our teaching attendings will continue to support the clinic. TGH has also been able to hire several RNs and Mas, who have been training in the current clinic and will be able to facilitate a smooth transition.” An emphasis will be put on taking care of COVID-19 ‘long haulers,’ virus survivors who continue to have side effects weeks, or months, after surviving the coronavirus. Caring for these patients will also help conduct research into the little known long term effects of COVID-19. Beyond COVID-19, the clinic can continue to help patients using the same monitoring and staffing model, but for serious chronic diseases such as heart failure or chronic obstructive pulmonary disease (COPD).

Robby Wu, DO, assistant professor of medicine in the Morsani College of Medicine and advanced heart failure and transplant cardiologist for USF Health and Tampa General Hospital, joined the team in August of this year to help strengthen the growing heart failure program. “I did my advanced heart failure and transplant fellowship at USF Health and loved my experiences at TGH, so stayed on as faculty with USF Health,” Dr. Wu said.

Robby Wu, DO, advanced heart failure and transplant cardiologist for USF Health and Tampa General Hospital.

One of the procedures that Dr. Wu performs as an advanced heart failure and transplant cardiologist is the implantation of Abbott’s CardioMEMS HF System. This device is a remote monitoring platform that is FDA approved for wirelessly measuring and monitoring pulmonary artery pressure and heart rate in the New York Heart Association (NYHA) Class III heart failure patients who have been hospitalized for heart failure in the previous year. The catheter-based procedure through the right groin takes about 30-45 minutes and once the paper clip-sized, pressure-sensing device is implanted, the patient will use an at-home electronics unit to take daily pressure readings. This measurement process takes less than a minute and the hemodynamic data and real-time notifications sent to your physician can be used for heart failure management with the goal of reducing heart failure hospitalizations. Patients can also stay engaged with their care by using the myCardioMEMS app where they can keep track of their uploaded readings, set medication reminders, and talk directly with their care team.

The sensor, app and at-home electronics unit used to take the daily measurements. CardioMEMS is a trademark of Abbott or its related companies. Reproduced with permission of Abbott, © 2020. All rights reserved.

Normally, to measure pulmonary artery (PA) pressure, the patient would have to visit a clinic and have a “balloon catheter” inserted by a venous approach. Frequent visits would be time consuming and costly but monitoring the pressure of blood through the PA is critical for heart failure patients. “These hemodynamic changes occur earlier than clinical symptoms such as shortness of breath or leg swelling, so we can catch these changes and act on them before the patient gets into trouble,” Dr. Wu said.

When relying on a manual measuring system at a clinic, the patient is then left in the dark about their health when they’re not hooked up and so, with little ability to take preventative action, rehospitalization is more likely. According to a randomized controlled trial for wireless pulmonary artery haemodynamic monitoring in chronic heart failure referenced by Abbott, “each time you are hospitalized for heart failure, your heart is damaged, which may contribute to your heart failure getting worse.”¹

CardioMEMS is a trademark of Abbott or its related companies. Reproduced with permission of Abbott, © 2020. All rights reserved.

The CardioMEMS HF System was FDA approved in 2014 but was not commercially available to Florida until July of last year. Previously, Tampa General Hospital had been implanting the device on a research-only basis. “The system has been used in many other parts of the country with tremendous success,” Dr. Wu said. “The COVID pandemic has placed a larger emphasis on the critical need for remote monitoring devices and so clearance in Florida was expedited for this use.”

According to Abbott, this remote monitoring platform is the only one on the market that is clinically proven to aid physicians in preventing worsening heart failure,⁴ lowering mortality rates³ and improving quality of life.²

• 33% overall reduction in heart failure hospitalizations over an average of 18 months²
• 50% reduction in heart failure hospitalization for HFpEF patients over an average of 18 months⁵
• Shorter length or stay when patients are hospitalized¹
• 6% freedom from device or system related complications¹
• No pressure sensor failures¹
• Better patient quality of life as shown by significant improvements in Minnesota Living with Heart Failure Questionnaire scores¹

Dr. Wu is passionate about patient-centered care, collaborative team management, and outcome driven protocols and USF Health is glad to have him on board and making life better for patients in the Tampa Bay community. “I am looking forward to the collaboration between USF and TGH and am excited to be a part of such a robust academic health system, Dr. Wu said. “I’m really proud to be working at the best cardiac hospital in Florida.”

Dr. Wu sees patients at USF Health Morsani Center for Advanced Healthcare and USF Health South Tampa Center for Advanced Healthcare (STC). To schedule an appointment, call 813-259-0600.

REFERENCES

1. Abraham, W. T., Adamson, P. B., Bourge, R. C., Aaron, M. F., Costanzo, M. R., Stevenson, L. W., … Yaday, J. S. (2011). Wireless pulmonary artery haemodynamic monitoring in chronic heart failure: A randomized controlled trial. The Lancet, 377(9766), 658-666. n=550. http://dx.doi.org/10.1016/S0140-6736(11)60101-3
2. Abraham, W. T., Stevenson, L., Bourge, R. C., Lindenfled, J., Bauman, J., & Adamson, P. B. (2016). Sustained efficacy of pulmonary artery pressure to guide to adjustment of chronic heart failure therapy: Complete follow-up results from the CHAMPION randomized trial. The Lancet, 387(10017), 453-461. http://dx.doi.org/10.1016/S0140-6736(15)007233-0

1. Abraham J, et al. Association of Ambulatory Hemodynamic Monitoring with Clinical Outcomes in a Concurrent Matched Cohort Analysis. JAMA Cardiology. 2019; 4(6):556-563.
2. Adamson PB. Pathophysiology of the transition from chronic compensated and acute decompensated heart failure: new insights from continuous monitoring devices. Current Heart Failure Reports. 2009; 6:287-292.

5. Adamson, P. B., Abraham, W. T., Bourge, R. C., Costanzo, M. R., Hasan, A. H., Yadav, C., … Stevenson, L. W. (2014). Wireless pulmonary artery pressure monitoring guides management to reduce decompensation in heart failure with preserved ejection fraction. Circulation: Heart Failure, 7(6), 935-944.  http://dx.doi.org/10.1161/circheartfailure.113.001229

TGH and USF sign founding document that will create a new organization dedicated to world-class patient care, education and research

Tampa, FL (July 23, 2020) — Tampa General Hospital and the University of South Florida today announced the formation of a new clinical affiliation, a significant milestone that will further solidify one of the largest academic medical centers in Florida and build upon their longstanding relationship and commitment to improving health care in Tampa Bay.

The enhanced affiliation enables the two organizations to align administrative and clinical practice areas into a new organization, an effort mirrored across the country as most top-ranked medical schools and hospitals move towards integrated models that bolster both academics, research and clinical care. TGH’s Board of Directors and the USF Board of Trustees previously approved the new organization, which will be jointly governed by both organizations.

The new USF and TGH focus means Tampa Bay’s best health care providers are well-positioned to deliver the cutting-edge care and innovative treatments that are a hallmark of academic medicine.

The new affiliation will benefit patients across Tampa Bay by enabling the region’s only academic medical center to provide seamless, comprehensive care for patients, said John Couris, TGH President and CEO, and Steven C. Currall, President of USF.

“This is a great day for health in Tampa Bay,” Couris said. “TGH, USF and our private practice physicians have always had the most success when working together to improve health in Tampa Bay. Now that we are more strategically aligned, we can create a powerhouse that delivers world-class health care on the west coast of Florida.”

TGH and USF have worked closely together for nearly 50 years, since the opening of the medical school in the early 1970s. This new endeavor builds on this long-standing relationship and will enable the two organizations to advance more quickly and broadly on a variety of strategic goals.

“Strengthening and expanding upon the affiliation between the University of South Florida and Tampa General Hospital presents extraordinary benefits and new opportunities for education, health care and research in the Tampa Bay region and beyond,” Currall said. “Our joint vision is to become one of the nation’s most outstanding academic medical centers.”

The ultimate beneficiary of this agreement is the community, as physicians from both groups are coming together to provide tightly coordinated, seamless patient care.

“As the only academic medical center in the region, USF and TGH are uniquely positioned to offer premier, nationally ranked, academically productive sub-specialty programs to enhance our residency and medical student training efforts, as well as increase academic support funding for research and enhance our growing ability to recruit top talent,” said Dr. Charles J. Lockwood, senior vice president for USF and Dean of the Morsani College of Medicine. “We are stronger together and we’ll offer an environment full of collaborative clinical care and research opportunities for the future physicians of Florida.

The new affiliation also will benefit the private practice physicians on staff at Tampa General Hospital by offering purchased services and management services through the new company.

“Our private practice physicians are integral partners to Tampa General Hospital and USF, and providing them the opportunity to participate in this partnership in a way that benefits their practices was a cornerstone to our agreement,” Couris said.

Next steps include launching a national search for an executive to lead the new organization and implementing clinical integration.

This new partnership will offer comprehensive pediatric surgical services for patients in the Tampa Bay community.

Tampa, FL (July 14, 2020) – Tampa General Hospital and USF Health are teaming up with Johns Hopkins All Children’s Hospital in St. Petersburg to expand pediatric general surgery services at Tampa General Hospital’s Children’s Medical Center. This collaboration will serve to enhance the comprehensive pediatric services already offered at TGH and will provide expanded access to pediatric general surgery interventions for patients and their families.

“We are excited to partner with a world-class pediatric care partner like Johns Hopkins All Children’s Hospital,” said John Couris, Tampa General Hospital’s president and CEO. “By partnering, we are bringing pediatric general surgery experts from Johns Hopkins All Children’s Hospital together with the TGH Children’s Medical Center team and the pediatric specialists from USF Health and our private practice physicians to create a collaborative environment in which innovative ideas and best practices are shared, our students learn, and our youngest, most vulnerable community members benefit.”

In the new agreement, pediatric general surgeons from Johns Hopkins All Children’s Hospital will provide services to TGH in the areas of pediatric general surgery consultations and procedures, pediatric trauma surgery and prenatal counseling and intervention. In addition, the pediatric general surgeons will work with the TGH team to develop clinical protocols to ensure the highest degree of quality and patient safety related to pediatric general surgery. “We are honored to serve Tampa Bay area families who have pediatric general surgery needs,” said Thomas Kmetz, president of Johns Hopkins All Children’s Hospital. “This collaboration with TGH not only expands our specialized pediatric general surgery services but improves access for children throughout Hillsborough County and beyond using the expertise of Johns Hopkins All Children’s Hospital’s pediatric general surgeons.”

In addition to the partnership around pediatric general surgery, Johns Hopkins All Children’s Hospital pediatric general surgeons will open a comprehensive Pediatric General Surgery Clinic on the campus of Tampa General Hospital – inside the USF Health South Tampa Campus – where patients and families can be seen for pre and post-surgical care and other necessary follow-up appointments.

“When a family hears their child must have an operation, pediatric general surgeons are not only counted on to provide unique expertise and quality care for little ones, but also to comfort the families who are understandably stressed and worried,” said Paul Danielson, M.D., Chair of the Johns Hopkins All Children’s Department of Surgery. “The Johns Hopkins All Children’s team has extensive experience in pediatric surgery and trauma care and expanding our relationship with TGH will bring great benefits to children in need throughout the community.”

The new partnership provides additional learning opportunities for medical students and graduate medical education trainees to learn from the pediatric general surgeons from Johns Hopkins All Children’s Hospital while consulting with and treating patients at Tampa General Hospital.

“The new relationship ties us closer together and will help demonstrate the power of academic medicine to the Tampa Bay community,” said Dr. Mark Moseley, Associate Dean for Clinical Affairs at USF Health Morsani College of Medicine. “We are all committed to delivering world class care through the academic medical center at TGH, but also to train the next generation of healthcare professionals and make discoveries through research that translate to the bedside.  Our shared commitment to academics makes us unique.”

The partnership between Tampa General Hospital, USF Health Morsani College of Medicine and Johns Hopkins All Children’s Hospital allows for the continued pursuit of excellence in clinical outcomes, quality and patient satisfaction in the field of pediatric surgery. Tampa General Hospital and Johns Hopkins All Children’s Hospital both earned recognition in U.S. News & World Report’s best hospital rankings. TGH was named the top hospital in the Tampa-St. Petersburg Metro Area and Johns Hopkins All Children’s had the most children’s specialties ranked in Florida for the 2020-2021 list.

A short, yet powerful “they saved my life” is how Jeremy Blythe describes the team at the Tampa General Hospital + USF Health Bariatric Center.

Weight had always been a struggle for Jeremy while growing up, but he never let being “the big guy” stand in his way of living his life, even when simple tasks like tying his shoes or putting on a belt became a challenge. Standing over 6 feet tall, Jeremy weighed 612 pounds by his thirties. After seeing his father and other family members pass away before age 60, Jeremy decided that he was not going to follow that same path. “I want a family with my wife, and I want to be able to be around a long time and be able to do things with them,” Jeremy said.

That’s when Jeremy decided to take control of his life and seek professional help from the TGH + USF Health Bariatric Center, a team that came highly recommended to him. The TGH + USF Health Bariatric Center is a Comprehensive Center with Adolescent Accreditation under the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program. Within a supportive and encouraging atmosphere, patients have access to both surgical and non-surgical bariatric services, and the goal of the team approach to care is to help patients not only lose weight but improve their overall health. “When your weight gets that high, your body just can’t tolerate it and it’s not about the illness Jeremy currently had, but all of the future illnesses he was destined to get,” said Christopher DuCoin, MD, MPH, FACS, medical director and bariatric surgeon at the TGH + USF Health Bariatric Center.

Dr. Ashley Mooney and Dr. Christopher DuCoin worked together on Jeremy’s bariatric surgery at the TGH + USF Health Bariatric Center.

The robotic assisted sleeve gastrectomy was selected as the best option for Jeremy because, as Dr. DuCoin describes it, the procedure is extremely safe, even safer than gallbladder surgery, a hysterectomy, or elective knee surgery, and has quick patient recovery. Gastric bypass was considered, but it’s an intense operation that is often used for patients with Type II Diabetes and severe reflux disease. Since Jeremy did not have those comorbidities, there was no need to add any unnecessary risk to his surgery.

“When you combine laparoscopy, or small incisions, with robotic surgery, it really aids the surgeon in the visualization of the operative field, dexterity and the safety profile of the procedure,” Dr. DuCoin said.

The TGH + USF Health Bariatric Center is one of the busiest academic centers in Florida for bariatric robotic surgery. The facility is equipped with chairs, toilet seats, beds, doorframes, wheelchairs and scales that are specifically made for patients of a larger size. Even the operating table and instruments that are used for bariatric surgery are designed with the needs of that patient population in mind. Patients also have access to telehealth appointments to prevent mobility, transportation, or distance impeding a patient getting the services they need. Being a part of a large hospital also means that if a patient suddenly needs intensive care or specialized medical support during or after surgery, the infrastructure would be able to take care of them. The hospital staff and the entire system is trained to care for these patients from a holistic perspective and they not only know the safest way to transfer and move these patients, but also how to empathize.

“The team really facilitates a no-judgement atmosphere where these patients can feel welcome and are somewhere where they can come and be themselves,” said Ashley Mooney, MD, bariatric surgeon at the TGH + USF Health Bariatric Center.

Deciding on the best procedure for Jeremy was only the beginning of the six-month, pre-operative process. In order to be approved for surgery, Jeremy had to be cleared by the entire bariatric team after meeting their designated goals for him such as, “reaching a weight around 577 pounds, getting out of the pre-diabetic range, improving his iron and Vitamin D deficiencies, stopping his vaping habit, and consistently wearing a continuous positive airway pressure (CPAP) sleep apnea machine,” said Erica Francois, DNP, APRN, bariatric nurse practitioner at the TGH + USF Health Bariatric Center. During this part of Jeremy’s journey, he met with nurse practitioners, nutritionists, psychologists, cardiologists, pulmonologists, sleep study therapists, lab technicians, among many others who played a crucial role in Jeremy’s success in the program. This team-based care conveniently falls under one roof and not only makes having a variety of specialty appointments and accessing medical records a seamless process for patients, but it also facilitates collaboration.

“We’re all on the same page, we speak the same language,” Dr. Mooney said. “All the providers meet weekly and discuss difficult patients or patients who are on the path to surgery, so the communication is incredibly effective.”

The TGH + USF Health Bariatric Center team

A critical piece of the pre-operative process for Jeremy was addressing his emotional eating habits.

“This part of the journey was important because for me, and I firmly believe that, for most people, it is a head game,” Jeremy said. “Getting your head right and dealing with the emotional side of your eating issues will make or break you. Mental health is a key factor in the success of this process.”

The Center’s Clinical Bariatric Psychologist Rebecca Chermak, PsyD, explains that receiving cake as a celebratory reward or ice cream when you have a bad day can start from great intentions in childhood, but can quickly turn into an emotional eating habit in adulthood.

“Food is the most easily accessible, readily available, and non-judgmental ways to navigate through some of life’s stressors,” Dr. Chermak said. “Even though Jeremy always had a smile on his face, he acknowledged that he was hurting on the inside and had been struggling with depression ever since he was a young boy and often used food as a way to cope.”

“Dr. Chermak is one of the best psychologists I have ever spoken with,” Jeremy said. “She doesn’t come at you from a medical standpoint as much as a human to human. Her ability to connect with and help her patients is unbelievable.”

Patients also have to understand and prepare for the lifelong commitment they’re making before going into surgery.

“You have to realize that you won’t just wake up and be ‘skinny’ – there is work involved,” Jeremy said. “You must change your eating habits: how you drink, how you eat, when you drink, when you eat. Everything changes, and you have to position yourself to be as ready as you can before going into the surgery.”

Another crucial part in the success of this lifelong commitment is the support of friends and family. Jeremy’s inspiration for changing his life was to be around as long as possible for his family. But in order for him to get to that healthier place, he was going to need their support, too. Luckily, Jeremy was surrounded by an extended family and close friends who are very supportive, especially the love of his life and wife of 10 years, Hannah.

After months of hard work and the support of family and the services offered by the Bariatric Center, Jeremy was able to achieve his goals and was approved for surgery. Jeremy said he was able to stay positive and on track to his goal by keeping his “eye on the prize.”

“In the beginning, you’re going to hate it, I won’t lie,” Jeremy said. “It’s all very difficult. What you have to continue to remind yourself of is, look at what you’re gaining. I’m going to live, hopefully, an additional 20 to 40 years because I am investing in myself. I am taking care of myself for me and my family. As you start to drop weight and feel better, it almost becomes automatic. Be patient, be kind to yourself and listen to your body.”

On January 28, 2020, Jeremy had his surgery and was in and out of the hospital in under 24 hours.

“I was excited, I was scared, I was worried, but most importantly, it was the first time in my life I didn’t feel hopeless,” Jeremy said. “I didn’t feel like I couldn’t fight the weight loss fight any longer. I had hope and to me, that is worth more than my weight in gold! That’s a lot of gold.”

Jeremy has lost 161 pounds since his surgery (Photo: Courtesy of Jeremy Blythe)

Jeremy has lost 161 pounds after five months post-operation. The first 6 to 12 months after surgery is an intense, rapid-weight loss phase in which Jeremy frequently visits with dieticians and nurse practitioners at the TGH + USF Health Bariatric Center as a part of the post-op care program. By the second year, he will visit on an annual basis for continued long-term support. The entire medical staff at the Bariatric Center echoes the sentiment that when you become their patient, you’re their patient for life.

“They are invested with you along the entire process. Everybody there is so supportive and genuine,” Jeremy said.

“I think we all feel much more confident that Jeremy’s going to live a much longer, healthier, hopefully happier life and I think we see that every time we encounter him. It’s really why a lot of us do this because we know we are making a substantial impact in their life,” Dr. DuCoin said.

Jeremy’s goal weight is 275 pounds and he looks forward to the day that he’s able to experience canoeing, horseback riding, and kayaking for the first time because his weight has always restricted him from participating. He also looks forward to once again being able to ride roller coasters and fly on airplanes. “My current weight loss success makes me feel so happy,” Jeremy said. “I feel refreshed and ready to conquer the world and to keep fighting for a healthier body.”

To the team at the TGH + USF Health Bariatric Center, Jeremy says, “Thank you for giving me hope. Thank you for giving me the opportunity to show myself that I can do this. Thank you from the bottom of my ‘no longer enlarged heart due to heavy weight’ for saving my life. You have given me purpose and you have truly done something for me that I will never, ever forget and for doing it with such compassion, poise, and confidence. You are my true miracle workers, my true heroes.”

After gaining his new lease on life, Jeremy wants to encourage others who are significantly struggling with their weight to leave their inhibitions behind, believe in themselves and give the TGH + USF Health Bariatric Center a call. He believes that even though making that first step is scary, the alternative is worse.

“It’s a very humbling experience once you realize that how you have been living is no longer working for you,” Chermak said. “The amount of bravery that it takes to initially call and make that first appointment is one of the most powerful things anyone can do towards their future.”

For more information about the bariatrics services available at the TGH + USF Health Bariatric Center, email bariatriccenter@tgh.org or call (813) 844-7473. 

Inside four bustling rooms at USF Health Center for Advanced Medical Learning and Simulation (CAMLS), emergency medicine residents from USF Health, emergency nurses from Tampa General Hospital, and paramedics from Tampa Fire and Rescue worked together in simulation exercises to improve how they work as a team during intense emergency situations. Over the course of the day, the residents rotated through four scenarios: a patient with undifferentiated chest pain, a 5-year-old with complications from a snakebite, an infant with an unstable abnormal heartbeat, and a patient in cardiac arrest.

Ryan McKenna, DO, director of the interprofessional simulation fellowship at USF Health CAMLS and director of simulation for Emergency Medicine, guides participants through the snakebite simulation.

A team of emergency medicine residents from USF Health work together to help a manikin with undifferentiated chest pain.

The interprofessional team involved in the cardiac arrest simulation, practiced the process and communication of the transition from the pre-hospital team to the emergency department. This scenario was intentionally cut short after the first five minutes as a part of its educational design, also called scaffolding, said Ryan McKenna, DO, director of the interprofessional simulation fellowship at USF Health CAMLS and director of simulation for Emergency Medicine. The goal of this kind of teaching method is to make the information more manageable to retain by breaking up the lesson into segments. Not only does scaffolding avoid students becoming overloaded, but it also allows learners to identify subtle ways to improve that might be missed in a larger scenario.

“When you have focused efforts, you have a chunk of a component of that training that can now be brought into clinical practice and everyone has the same mental model and is applying it in the same way,” said Yasuharu “Haru” Okuda, MD, FACEP, FSSH, executive director of CAMLS and executive director of interprofessional education simulation programming for USF Health.

Paramedics from Tampa Fire and Rescue helped to bring the cardiac arrest simulation to life.

During one of the run-throughs of the cardiac arrest simulation, an observing resident noticed that the nurse performing chest compressions on the manikin might benefit from standing on a nearby stool to improve her ability to perform compressions. He brought it over to her and placed it by her feet, but the message about the height-assistance was lost in the chaotic sounds of the emergency department and she did not notice the stool was there until the end of the simulation. That is just a simple example of the kind of communication gaps that can result in a missed opportunity or medical error in a hospital and it’s a small area for improvement that would have been missed in a more complex simulation. Many of the residents reported back to Dr. McKenna that they were already using the skills they learned to improve the hand-off in the subsequent days following the simulation-based training.

An interprofessional team including emergency medicine residents from USF Health, emergency nurses from Tampa General Hospital, and paramedics from Tampa Fire and Rescue, came together for simulation-based training.

In November 1999, the Quality of Health Care in America Committee of the Institute of Medicine (IOM) released a report called To Err is Hu­man: Building a Safer Health System that stated as many as 98,000 hospital deaths occur each year due to medical error. Communication error is described as the cause of 60% to 70% of those preventable hospital deaths.

“We’ve done a lot of amazing things in technology and medical knowledge and science, but I think one thing that we haven’t done well enough in health care is really learning to work together in teams,” Dr. Okuda said.

Twenty years after the IOM’s report, the statistics are still alarming. In an effort to make life better and combat medical errors, USF Health incorporates interprofessional education as a primary part of its curriculum.

“Especially in the ER, it’s a team discipline,” said Kelsey Hundley, MD, second-year emergency medicine resident with the USF Health Morsani College of Medicine. “Learning how to interact with people with different backgrounds and roles on the team is really important.”

Kelsey Hundley, MD, second-year emergency medicine resident with the USF Health Morsani College of Medicine, works with her team to help the infant with an unstable abnormal heartbeat.

Simulation exercises as a part of interprofessional education allows participants to practice in a realistic but safe environment, both for the learners and for the patients.

“It was a pretty enjoyable experience,” said Adam Koby, MD, second-year emergency medicine resident with the USF Health Morsani College of Medicine. “We see these scenarios all the time in real life, but there’s always the opportunity to improve and I feel the way that you would improve the most is to practice those situations. During these simulations, we learn about individual pathologies, but more importantly, about team building.”

Adam Koby, MD, second-year emergency medicine resident with the USF Health Morsani College of Medicine (right), listens to Dr. McKenna during the debrief of the snakebite simulation.

When the various medical professions came together and were working in a training environment, “I saw smiles, energy and enthusiasm and I’ll bet you, for many of these folks, they won’t forget this,” Dr. Okuda said. “They shared the passion and I think coming together outside the clinical environment often builds stronger teams. So beyond just the training, there are the personal connections and the bonds that were created through this environment and interaction.”

Participants shared laughs and smiles during the simulation-based training held at the USF Health Center for Advanced Medical Learning and Simulation.

Inside the mother’s womb, a fetus exchanges oxygen through the umbilical cord. Once the fetus is delivered, the umbilical cord is clamped, giving the baby the ability to breathe oxygen independently. In rare cases, the fetus has a severe congenital abnormality that obstructs the airway and makes independent breathing after delivery difficult or impossible. Instead of a traditional birth, an innovative surgical procedure, the Ex Utero Intrapartum Treatment (EXIT), is performed to deliver the baby. During this procedure, the baby’s head and shoulders are delivered by an elective Cesarean section, leaving the umbilical cord and placenta intact while pediatricians establish an independent, free airway. After the airway is well established by the pediatricians, the umbilical cord is clamped, and the baby is delivered completely. The procedure may take up to five to ten minutes and requires full coordination between obstetrics, anesthesia, and pediatric teams. USF Health and Tampa General Hospital’s multidisciplinary team performed its first EXIT procedure in 2009 and second in 2016. January 2019 marked the third time in order to deliver a baby with a growth from the tongue that was compressing the airway.

The January 2019 EXIT delivery team featured Sarah Obican, MD, high-risk obstetrician, maternal-fetal medicine subspecialist, who performed the surgery and delivery of the baby in order for the airway to be established. (Photo courtesy of the USF Health Fetal Care Center of Tampa Bay)

“When you do cases of such complexity, you can’t do it alone. You need to have an institution that offers all these subspecialists in one setting and that’s what USF offers,” said Prasad Burjonrappa, MD, MBA, division chief of Pediatric Surgery. Dr. Burjonrappa’s role during the 2019 EXIT procedure was to work alongside Jaime Flores-Torres, MD, neonatologist, to evaluate the infant’s airway and determine if he was a candidate for endotracheal intubation, the placement of a tube into the trachea through the mouth or nose, or if the baby needed a tracheostomy, a surgical procedure to create an opening through the neck into the trachea.

(Left) The baby was born with a growth from the tongue that was compressing his airway. (Right) After the removal of the mass, the baby went home a few days later with no complications. (Photos courtesy of the USF Health Fetal Care Center of Tampa Bay)

An EXIT procedure involves two patients – mother and baby – who each need specialized care to avoid complications. This is why the procedure requires a multidisciplinary team of up to 20 physicians and other health practitioners. With such a large team working together, the procedure needs to be highly coordinated because it’s critical that everyone knows their role, when to act, and how long they have to finish. The USF-TGH team establishes protocols and contingency plans and practices mock surgeries to prepare for every outcome. To ensure the procedure runs smoothly, Anthony Odibo, MD, MSCE, FRCOG, FACOG, director of the USF Health Fetal Care Center of Tampa Bay, oversees and directs the various teams that come together to make the high-risk delivery a success.

“The most challenging part of this is the unknown,” said Sara Zientara, fetal care coordinator for the Fetal Care Center. “You don’t know exactly how that baby is going to come out. You don’t know exactly how that surgery is going to go and you just have to take it as it comes and be able to multitask and problem solve, so preparing everyone for what their role is and could be is important.”

Thanks to the well-established USF Health Fetal Care Center at Tampa General Hospital and the prepared and coordinated team, the January 2019 delivery was yet another success. Once the baby was born and was transferred to an ICU, the baby stayed intubated until the procedure to remove the mass was complete, and then the mother and baby went home a couple of days later without any major complications.

A small part of the EXIT procedure team at the USF Health Fetal Care Center of Tampa Bay located at Tampa General Hospital. (From left to right) Amy Amato, clinician of operations for the TGH women’s operating room, Jaime Flores-Torres, MD, neonatologist, Prasad Burjonrappa, MD, MBA, division chief of Pediatric Surgery, Sarah Obican, MD, high-risk obstetrician, maternal-fetal medicine subspecialist, Sara Zientara, coordinator for the Fetal Care Center, Chinedu Nwabuobi, MD, MS, 3rd-year maternal-fetal medicine fellow. (Photo by Allison Long)

Learn more about the USF Health Fetal Care Center’s multidisciplinary team involved in this EXIT procedure.

Story by Torie Doll. Videos by Torie Doll and Allison Long.

For generations, nurses tending to newborns have been able to tell the subtle difference between a baby’s cry of hunger and that of pain.

That ability to distinguish those differences is now being combined with continuous facial expression recognition software in hopes of offering a new way to help health care providers more precisely gauge whether a baby is experiencing pain or simply needing a diaper change.

Neonatal experts in the USF Health Morsani College of Medicine are partnering with facial expression recognition experts in the USF College of Engineering to build data that combines known information collected through facial expression recognition capabilities and the known information from nurses who have years of training and on-the-job experience using the neonatal infant pain scale (NIPS).

“Our intent is to develop a methodology and technology to allow us to better detect when the patients we are caring for experience pain,” said Terri Ashmeade, MD, professor of pediatrics in the USF Health Morsani College of Medicine and chief quality officer for USF Health.

“Babies hospitalized in the NICU experience many painful procedures and research has shown that these painful experiences are associated with altered development of the infants brains and can impact them long term. Babies cannot tell us when they are experiencing pain, or how intense their pain might be. So the most important thing about this research is that, by coupling computer vision technology with vocal responses, we can have a fuller understanding for what our patients are experiencing and know when we should intervene. And that precision in knowing when they are feeling pain would prevent us from exposing babies to medications they don’t need.”

Dr. Terri Ashmeade at Tampa General Hospital’s Jennifer Leigh Muma NICU.

The preliminary study looked at 53 infants in the Jennifer Leigh Muma Neonatal Intensive Care Unit at Tampa General Hospital. Using small video cameras attached to infant incubators, the researchers collected footage of the young patients before, during and after scheduled procedures and interventions. The footage was examined later through facial expression analysis software and was also coupled with vital signs that were measured in sync with the footage, with audio that was also collected, and with near-infrared spectroscopy (NIRS), which measures oxygen levels in the brain.

All of those datasets – facial expressions, body movements, sounds of crying and vital signs – were combined and then matched with the nurses’ own professional expertise of what particular cries and facial expressions mean, the NIPS score. The resulting overlay could provide a tool in a NICU that would constantly monitor a baby and then alert the health care team when there is evidence the baby is feeling any distress from pain. Currently, these NICU-skilled nurses build in typically hourly assessments of the infants to gauge a NIPS score – the new technology would offer round-the-clock monitoring.

Cameras continually monitor the newborns.

This new use of computer vision and pattern recognition adds a new dimension to existing software, said Rangachar Kasturi, PhD, the Douglas W. Hood Professor in the Department of Computer Science and Engineering, USF College of Engineering.

“USF’s expertise in computer vision and pattern recognition is well known, so naturally we have a strong interest in using it to help this population,” Dr. Kasturi said.

“The key difference here is that we’re not trying to recognize or identify a face, we are measuring the baby’s muscle movement and how their creases and lines move, to determine if they are experiencing pain. We are comparing the nurses’ scores with those we get from the technology to determine how accurate our scores are. We want to replicate what these talented nurses do so the babies can be constantly monitored.”

USF engineering professor Dr. Rangachar Kasturi and USF doctoral student Ghada Zamzmi. Photo by Ryan Noone.

In gauging facial expression, capturing known meanings in babies can be difficult, said Ghada Zamzmi, a doctoral student in the USF Department of Computer Science and Engineering.

“There are common expressions such as happy, sad, angry etc. that we know about adults, but those cannot be applied to newborns,” Zamzmi said. “In this study, we are capturing the facial muscle movements in video, or optical flow, and classifying them as relating to pain or no pain. In addition to facial expression, we are automatically analyzing other signals such as sounds, body movement, and heart rate to increase the reliability of detecting pain in case of missing data. We believe developing an automated multimodal system can provide a continuous and quantitative assessment of infants’ pain and lead to improved outcomes. ”

This type of technology and assessment could be used beyond the NICU, including for any patient who is not able to communicate directly with their health care team about whether or not they’re experiencing pain, such as elderly patients with dementia, Dr. Ashmeade said.

NICU babies are some of the most vulnerable and require multiple medical procedures – even surgeries – that are painful, Dr. Ashmeade said.

Babies may require multiple medical procedures while in the neonatal intensive care unit.

“These newborns, many of them born prematurely, cannot communicate their feelings, which is why and how the nursing staff has become the go-to experts for gauging the babies’ needs,” she said. “While we have had many successes in neonatal care and improving survival of our babies, what we really want to focus on is a great outcome. Anything we can do to foster appropriate development, especially of the brain, is what we want for these babies.”

In addition to Drs. Ashmeade and Kasturi, and Zamzmi, researchers on the study included: Chih-Yun Pai, Dr. Dmitry Goldgof, and Dr. Yu Sun. This preliminary research was supported, in part, by a 2016 USF Women’s Health Collaborative Seed Grant. The team has applied for further funding with the National Institutes of Health and expects to hear if an expanded study is approved by next Fall. In June, the research will be presented in Norway at the Scandinavian Conference on Image Analysis, which is sponsored by the International Association for Pattern Recognition.

Story by Sarah Worth, photos by Eric Younghans, USF Health Communications

The Lane family visits USF Health Pediatrician Dr. Cristina Pelaez (left) for a check up, and a flu shot.

It is unlikely that Tim and Angel Lane will ever move from Tampa. At least, not in the next couple of decades.

Their proximity to a network of experts who care for their son Jameson is too important to risk trying to find something similar elsewhere.

Jameson has a genetic form of hypotonia, meaning he has muscle weakness throughout most of his body. Both he and his twin brother Walker were born with hypotonia, turning their expected healthy birth – albeit an early one – into a dire emergency. Having little to no muscle control at birth meant the babies could not breathe on their own or suck or swallow.

“There was a great deal of stress from the get-go,” Tim said, recalling the intensity of everyone in the delivery room. “Neither boy could suck or swallow. Neither could blink.”

“We were all on pins and needles, even the doctors,” Angel said.

***

The Lanes’ first experience with the Doctors of USF Health was when their twin boys were transferred to the Muma Neonatal Intensive Care Unit (NICU) at Tampa General Hospital when they were 3 months old. They were in need of more advanced care and it was in the Muma NICU that the Lanes met a team of experts from the USF Health Morsani College of Medicine.

USF maternal-fetal medicine specialists, neonatologists, pediatric surgeons, pediatric radiologists, pediatric cardiologists, pediatric neurologists, geneticists, and many other health care specialists surrounded the twin boys over the many months they stayed in the NICU, followed the boys as they progressed to the pediatric intensive care unit, and there the many times the Lanes brought them to TGH’s emergency room. Even for ongoing visits, it’s a team of USF Health pediatricians who check progress and address issues.

By connecting with USF Health, the Lanes found an integrated team of experts within one group, providing seamless care to Jameson and Walker. But what the Lanes also found was a medical home – a patient-centered approach to delivering primary care that allows families to rely on only one group of health care providers.

Young Jameson sits patiently for Dr. Cristina Pelaez during a recent check up.

“USF’s medical home concept made caring for our boys so much better,” Tim said.  “There is an entire team of professionals here who knew the nuances of their condition. We have to be advocates for our children, who needed very specialized care. And to do that, we need help from top experts in uncommon conditions, as well as an integrated approach. That level of coordinated care means Jameson’s history is known by everyone on the team.”

“We were new parents, so to have doctors and nurses already aware of our entire story made every visit so much more seamless,” Angel said. “Without that transition from NICU to USF Health, I don’t know how successful we would have been in caring for our boys.”

Angel Lane.

“Our goal with acting as a medical home for patients really starts with the needs of the patients and their families,” said Cristina Pelaez, MD, assistant professor of pediatrics and director of the Medical Home Program for USF Health Pediatrics. “Medical homes provide families with a support system of experts who work with each other and talk with each other. In a broader sense, a medical home can also reduce medical costs in the long term, help children have better access to health care and improve health care use patterns, thus preventing disease for these children.”

***

Many different diseases and disorders cause the symptoms of hypotonia. But diagnosing the disease or disorder causing the problem can be challenging. It could be one of as many as 500 different conditions, Dr. Pelaez said.

For the Lanes, not knowing the underlying problem meant they had to take it day by day, with round-the-clock monitoring of their breathing and oxygen intake and feeding them through a feeding tube.

Tim Lane.

“They were amazing and prepared us before we took the boys home,” Tim said. “When we were discharged from the NICU, went home with a full entourage. That’s the scariest thing you face, is leaving. Before discharge came along they started working with us, showing how to use the pulse ox (pulse oximetry, used for monitoring oxygen saturation) and how to suction to clear their airways. We needed to suction the boys 30 to 40 times a day.”

But even with that level of attention, Walker succumbed to pneumonia from influenza and died in February 2013, just shy of his second birthday. The Lanes, still unaware of the root cause of the hypotonia, weren’t sure what the future held for Jameson.

Tim and Angel Lane hear details of on-going care from Dr. Cristina Pelaez, as Jameson and his older brother Braden play.

For two years, Jameson remained undiagnosed while doctors took blood samples and biopsies to conduct tests that ruled out the many possibilities of underlying conditions, including cerebral palsy, muscular dystrophy, among others.

It took a specially trained metabolic geneticist to finally determine Jameson’s root problem. Amarilis Sanchez-Valle, MD, is assistant professor of pediatrics in the USF Health Morsani College of Medicine and the only board-certified medical biochemical geneticist in the region.

What Dr. Sanchez-Valle found for the Lanes was that Jameson has nemaline myopathy, a congenital, hereditary neuromuscular disorder. Children born with nemaline myopathy often gain strength as they grow, and those with mild forms eventually walk independently, although often at a later age than their peers.

The firm diagnosis for the Lanes means they will worry a bit less — nemaline myopathy is not progressive so Jameson’s condition will not worsen – and are in a better position to help their son grow.

***

Jameson is walking. He’s even running around and playing, chasing his older brother Braden. Physical and occupational therapy are helping him learn to swallow and helping with his speech. Individuals with NM are usually highly sociable and intelligent, so on-going therapy will help him thrive.

“Jameson continues to flourish,” Tim said. “He would not be without help from TGH, and USF, and Dr. Pelaez.  She really took our boys under wing. We did not want for anything. Here, we are listened to, we are heard, and get to weigh in on decisions. The team put us in the best possible position for success.”

Jameson needs comfort from Dad after getting his flu shot.

And then, tearfully, accepts his well-earned sticker from pediatric nurse Rafael Uribe

The Jennifer Leigh Muma Neonatal Intensive Care Unit

Thousands of babies who are born too early benefit from the generosity of Pam and Les Muma. In 2009, the Mumas provided $6 million to USF Health to establish a highly specialized neonatal intensive care unit in the heart of Tampa General Hospital’s Children’s Medical Center. Their gift, one of the largest in Florida to support research and care for newborns, resulted in $14 million with eligible state and internal USF matches.

Named after their daughter who died in a neonatal nursery, the Jennifer Leigh Muma Neonatal Intensive Care Unit (NICU) was created to provide leading-edge treatment, training and research. With more than 50,000 square feet, the entire space is designed with a baby’s family in mind, from the colors of the corridor walls to the placement of telephones in each patient room. The NICU features 80 single-family rooms, a procedure room, and a semi-private area for 12 transitional babies. Light switches are placed strategically and bulbs angled to ensure the babies will not be startled by unintended bright light in the softly lit atmosphere. Even the hallways keep babies in mind with acoustic ceiling tiles that absorb excess noise.

Teaching and research are also key components of the NICU mission and environment, transforming patient care here, as well as advancing the study of neonatology in medical and academic institutions around the world. Neonatology fellows, pediatric residents and nurse practitioner students learn together, with a majority of teaching taking place bedside, patient to patient. The partnership between TGH and USF is the key to those efforts.

The Lane family, from left, Braden, Angel, Tim and Jameson.

Story by Sarah A. Worth, photos by Eric Younghans, USF Health Office of Communications

Jeana Hadley considers herself a decent example of good health – she eats right, exercises and maintains a healthy weight. But that model of healthy living is worlds away from the path she was on five years ago, when she weighed 300 pounds.

Jeana Hadley said the desire to live for her family when confronted with an obesity-related heart scare motivated her to commit to weight-loss surgery and a new healthy lifestyle.

What caused her to turn things around, to stop overeating, to stop secretly eating, and to finally be able to stick to (at least most of the time) common sense food choices and serving sizes?

Hadley doesn’t hesitate with an answer. It’s because of bariatric surgery. More specifically, its’ because of the team of experts at the TGH+USF Bariatric Center who, well before her surgery, looked at every aspect of her struggle with obesity: her co-morbid conditions, her eating and exercise habits, and her tendencies and associations with food.

“The bariatric surgery saved my life, but it was the entire team who helped me to succeed with keeping the weight off for these five years,” Hadley said.

****

Obesity is complicated and can only be treated successfully when a high level of attention is given to every issue that surrounds it.

That’s why the TGH+USF Bariatric Center has grown to be so successful – it is staffed with experts trained to address every issue related to the patient’s obesity. Those issues not only include the secondary health problems that haunt obese patients, such as diabetes, sleep apnea and hypertension, but the other aspects of obesity that have kept these patients from keeping their weight down in the past, such as the psychological reasons for overeating and the physical issues of exercise.

“We are looking at the patient as a whole and helping them with every area that is keeping them from succeeding,” said Michel Murr, MD, professor of surgery at the USF Health Morsani College of Medicine and director of TGH+USF Bariatric Center.

Dr. Michel Murr

USF has been offering bariatric surgery since 1998 and has gained a national reputation for its integrated and comprehensive approach. In 2013, the team moved into a 5,500-square-foot facility in the Harbourside Medical Tower on the Tampa General campus. The expanded space features examination rooms and education rooms where patients work with Center staff as they progress through the program. Anyone interested in bariatric surgery must attend an informational session held at the Center weekly. Patients admitted to the program then spend three to six months learning the nuances of what bariatric surgery means – the life-long commitment and dietary regimen they face – before surgery is performed.

USF President Judy Genshaft and Dr. Murr, center left and right, with officials from Tampa General Hospital and USF Health, at the grand opening last year of the TGH+USF Bariatric Center.

At its core, Dr. Murr said, the TGH+USF Bariatric Center offers patients a truly interdisciplinary approach to treating obesity.

“When we started this program in 1998, we knew the value of an interdisciplinary approach to treating patients,” he said. “It’s used extensively and successfully in the treatment of cancer. And we know the importance of continued follow-up care, the very same idea used so successfully in cardiac rehabilitation.”

But in the management of obesity, these approaches tend to be absent, he said.

The team at the USF Bariatric Surgery Program offers patients surgeons, dieticians, psychologists, internists, exercise physiologists, among others. Basically, there is an expert for every health issue facing obese patients, Dr. Murr said.

“Patients are successful because we help them with every roadblock and issue they are likely to face,” he said.

****

Jeanna Hadley vividly remembers the day she decided to pursue bariatric surgery. It was in 2007.

She had already faced doctors diagnosing her with high-blood pressure, acid reflux, ulcers, and prediabetes. And her family history made her realize she could die young – Hadley’s father died of a heart attack at age 56. Her grandfather died in his 40s.

The clincher, however, – the moment that awakened something unstoppable inside of her – was when she had her own heart scare at age 40. Knowing her family history helped elevate the panic she felt when doctors prescribed a round of heart tests.

“I was a single mom and I realized no one else would raise them like a mother could,” she said. “I realized I needed to live.”

Hadley’s bariatric surgery was on June 29, 2010.

“There was a little pain, but overall, totally manageable,” she said. “Of all the improvements this surgery provided, what happened fastest was that my high blood pressure returned to normal immediately after surgery. It really worked! Now I don’t have to take these stupid blood pressure pills anymore.”

In addition to reversing her high blood pressure, the surgery also caused Hadley’s sugars, triglycerides and cholesterol numbers to improve, dropping by half.

“Body-wise, the surgery was like a chemical re-set button,” she said.

Because success depends a lot on the individual, Hadley was adamant with herself to stay on track, starting with some of the “techniques” even before the surgery.

“I followed the guidelines to the letter,” Hadley said. “I figured I had made the monumental decision to have the surgery and I actually had the surgery, so why would I do something to screw things up and keep the surgery from helping me succeed.”

She even started her routines before surgery, measuring foods to get a feel for the right amount and keeping a food journal, Hadley said.

Post-surgery, starting in the hospital, compliance meant a clear liquid diet for three days, followed by a few days of a full liquid diet that included protein shakes, then four weeks of soft, pureed foods, mostly protein based.

“They said I could eat strawberries after six weeks but I didn’t have any for six months, that’s how obsessed I was with doing this right,” she said. “I pureed everything. The mini food processor and I got really close those first few months.”

Central to every step, though, was protein.

“Protein has to be a focus and includes supplements,” said Erica Govsyeyev, MS, RD, LDN, clinical nutrition specialist and a dietitian for the TGH+USF Bariatric Center. “There is no wiggle room when you’re eating such small amounts so it’s important to get as many nutrients as possible with each meal.”

While most people should aim for 45 to 60 mg of protein each day, Govsyeyev said, bariatric patients should nearly double that, aiming for 60 to 80 mg each day.

Today, Hadley still eats very small meals focusing on healthy choices, including lean proteins (fish, skinless chicken and lean beef).

Her 5-year path from surgery to this point went something like this:

• Her weight went from a peak of 300 pounds to 285 prior to surgery to a low of 133 a year later, a weight she realized was too low so now she hovers in the low 150’s (she’s 5’6” tall). She weighed herself every day for several years, but now only every few days.
• Post-surgery was a six-week gradual increase in food density: a liquid diet to soft foods to regular food (only about three ounces at each meal). Today, she eats four to six meals each day, each about four to five ounces, depending on the density of the food.
• Pre-surgery and immediately post-surgery, she could barely walk a mile. By four months after surgery was able to walk five miles. Then she started running. And now is running regularly and racing in marathons.
• Since the surgery, she takes daily supplements of specialized multi-vitamins, calcium and vitamin D, gets B12 shots twice a month and an iron infusion once a year for anemia, a side effect for some bariatric patients.

*****

USF’s Bariatric Surgery Program is standing out nationally, not just for its team approach for treating patients, but also because the team tracks each patient’s progress both during the program and for more than five years after surgery. The goal is to pinpoint what is working and what is not working for the patients, Dr. Murr said.

“We are evidence-based and outcome-driven,” he said.

That kind of data is what Dr. Murr is publishing in journals and sharing with colleagues around the globe. The results are showing that bariatric surgery works and there are immediate and long-term improvements to the co-morbid conditions of obesity, such as diabetes, hypertension, sleep apnea and stress urinary incontinence.

Some of Dr. Murr’s newest research is showing that bariatric surgery can also result in significant improvement in nonalcoholic fatty liver disease (NAFLD), resolving liver inflammation and reversing early-stage liver fibrosis, the thickening and scarring of liver tissue, by reducing fat deposits in the liver.

Data are also showing that, because of the intense team approach, these patients are successful in keeping their weight under control.

Team Approach

The process is this.

First, patients undergo an initial evaluation and are provided with information about the surgery, which lays out what their realistic expectations should be.

Then patients attend several support groups and an orientation program that describes the surgery, its outcomes, its long-term effects and who qualifies for it. This gives them a realistic snapshot of what surgery is and what it means for the rest of their lives.

Next is an extensive psychological evaluation, where patients and psychologists really delve into a patient’s perception of health, the surgery and the life-long commitment it requires.

If patients have passed muster to this point, they then meet with team members to set up a personalized plan for post-operative care and follow-up, including extensive input from dieticians and exercise physiologists.

“Surgery doesn’t fix everything,” dietitian Govsyeyev said.

Govsyeyev meets with bariatric patients like Hadley long after their surgeries, using realistic food props to help illustrate portion size and a meal’s health components.

“You’re still going to have challenges and stresses,” she said. “We work to define areas where they may struggle to help set them up for success.”

In addition, many secondary problems are addressed: high blood pressure is under control, sleep apnea is under control, etc.

Only at this point do they undergo bariatric surgery.

The entire process can take six weeks or more, but that pace is a good thing, Dr. Murr said.

“Each patient has to have all of the information necessary to make such a huge decision and to be completely sure that surgery is right for them and that they know full bypass is not reversible,” he said. “They have to have realistic expectations of the surgery. I want them to be ready and not rush to a decision.”

This extensive process offers the best outcomes with the fewest complications, he said.

The team approach is so powerful that many times a patient will not require surgery in order to successfully manage their weight. Many times, it’s during that intense evaluation that a patient’s core problems are addressed, and a plan is defined that will help the patient succeed without having to go to the extreme of bariatric surgery, Dr. Murr said.

****

At home, Hadley is straightforward with her boys.

“Before the surgery, I told them ‘This is what Mommy is doing and I need your support,’” she said.

Her boys, ages 15 and 17, never had a problem going along with her new health and food regime.

“They were great,” she said. “They never told me ‘I’m not eating that!’ And the boys are healthier because I’m paying so much more attention to healthy foods. They are so much healthier than I was at those ages. But I tell them they still need to watch. They still have our family genes.”

For Jeana Hadley, the surgery saved her life. She even continues attending the educational sessions at the Bariatric Center, although this time she brings the post-operative patient perspective.

“Now I’m sharing my success story with people considering the surgery,” she said. “I tell them ‘I was where you are now,’ because I know how great it is to talk to someone who has already gone through the journey.”

“And the USF team was great and was in touch with what my individual needs were.”

To hear more about the TGH+USF Bariatric Center, please call (813) 844-7473.

Notes from Jeana Hadley

– Form good habits: start a food log and measure food before the surgery. Better yet, start before the education sessions. “We’re all creatures of habit, so establishing habits ahead of time makes it much easier after surgery.”

– Make the best use of the education sessions. Keep attending to reinforce the information and tips.

– Your taste buds will change. Everything will taste differently. “Diet drinks now taste sour.”

– Know your limit: Always measure because, while one piece should satisfy, more will make you sick.

Photos by Eric Younghans, USF Health Office of Communications