TB or Not TB: Isn't That the Question?

The only thing more confusing to me than this tuberculosis (TB) fiasco is how I am still the first to use this line for my title. The antagonist in the international bacterial bruhaha is a young personal injury lawyer who either knowingly or unknowingly flew off to his honeymoon in Greece with a multi-drug-resistant strain of TB (MDR-TB). Actually, the Associated Press reported yesterday that he had an even more resistant strain of Mycobacterium tuberculosis, called extremely drug-resistant TB (XDR-TB). Infectious disease is not my specialty but since when did we start assigning diseases cool prefixes that make them sound like luxury cars? We have heard rumors circulating that the 2008 model will be the YF'd-TB?

So the story goes that an excited newlywed personal injury lawyer goes to the doctor a few days before his honeymoon and is told that he "has TB". Speaker has also said that he was advised by Fulton County, Ga., health authorities that he was not contagious or a danger to anyone. Officials told him they would prefer he didn't fly, but no one ordered him not to, he said.

Let's stop here for a minute. There are really 2 kinds of "have TB"s. There is the positive PPD test for TB in which your body has formed antibodies to Mycobacterium tuberculosis after you have been exposed to it but you are symptom free and otherwise healthy, i.e. latent TB (LTB). Then there is the really have TB in which you are symptomatic, with clinical manifetations usually associated with the pulmonary system. Patients typically present with cough, fever, chills, night sweats, weight loss, bloody sputum, anorexia, etc etc. In this form, one is capable of actively spreading the infection.

Many, many Americans, and even more internationals "have TB" in the former sense and a great deal of them are probably unaware as they have never had a PPD test to detect its presence. And if all of those fliers with latent TB were quarantined, it would probably require a holding room the size of Giants Stadium. But very few Americans with dormant TB ever develop the active form of the disease unless they become immunosuppressed, as in the case of patients with HIV/AIDS or chemotherapy. Moreover, these carriers are not infective to anyone unless the disease becomes active. Lastly, his XDR-TB status does not make his disease any more transmissable than your run-of-the-mill TB, it is just harder to eradicate.

The fact that his new wife and he traveled to Greece makes you think (and hope) that he wasn't hacking up blood-tinged hunks of sputum during his "I do's". Thus, we are making the assumption that Speaker only had the presence of XDR-TB in his blood, making him no different from thousands of other air passengers who travel with latent TB on a daily basis. So what's the big deal? That's what we're trying to figure out. We are guessing all the tumult is a result of him ignoring the Man who told him not to fly.

But where did he get such an uncommon strain of the mycobacteria, that is found much more commonly in Asia and the former Soviet Union? Several reports have claimed that he was exposed when he visited a health clinic last year in Vietnam. We are not disputing that this is a possibility, but it turns out his father-in-law, Robert Cooksey, is a microbiologist for the Centers for Disease Control (CDC) who actually specialized in TB. [The plot thickens...] The same CDC that initiated Mr.Speaker's quarantine - the first of a human being since 1968. In medicine, we have a saying that common things happen commonly and if we follow that theory than it seems less likely that one week in Vietnam accounted for his infection than his chronic and long-term exposure to his microbiological father-in-law.

This is a bold call but we're betting serious money that the wife's father will be investigated and it will turn out that he, too, has XDR-TB (*cue the Law & Order dun-dun). Oh yeah, the father-in-law is the source and he is going down for this in the very near future. Or is he?

Currently, Speaker is taking up residence in a Denver hospital until he is given the green light to travel again. Perhaps we will find out that he indeed does have active TB infection but that will bring up an entire set of additional questions like why a young, healthy man in his thirties develops active TB infection in the setting of a normal immune system. (Dun-dun)

Organ Vendors

In Lahore, Pakistan yesterday, 6 people were arrested, including 3 doctors and the owner of a private hospital, after authorities identified them as key participants in an illegal kidney transplant "ring"? Can we even call it a "ring"? I'm not sure what one would call that.

Authorities in eastern Pakistan said that many men, like the ones seen here with healing nephrectomy scars, are selling their kidneys on the black market for about $1000 to pay off debts.


Turns out that rumors of people selling organs on the "Black Market" are quite true - as if there was a doubt. They may not be waking up in a bathtub with a note on the wall written in blood but whenever medicine is practiced secretively corners are cut (no pun intended) and there is usually little recourse for those under the knife.


It does bring up an interesting question, though. If done safely and properly, what is the harm of selling an organ that you can safely live without in return for monetary compensation? Before we continue the dialogue though, let me clarify that I would never, ever advocate such a practice - unless, of course, it was sanctioned by our federal government and overseen by a tightly controlling administrative body with all the proper governmental bells and whitsles, etc etc.


That said, the benefits to private citizens selling kidneys could, if done properly, save billions of dollars in the United States alone - not to mention thousands of lives. Hundreds of thousand of kidneys fail each year and patients often end up on chronic hemodialysis, despite the fact that renal transplant is the treatment of choice. Dozens of studies have shown that a successful kidney transplant improves the quality of life and reduces the mortality risk for most patients, when compared with maintenance dialysis. Chronic renal failure is a major cost burden on our health system and also brings with it or accelerates a slew of other concomittant diseases, like coronary artery disease, heart failure, hypertension, liver disease, stroke, and on and on and on.


In the US, there is an ever-rising incidence and prevalence of kidney failure and the number of patients enrolled in the end-stage renal disease (ESRD) Medicare-funded program has increased from approximately 10,000 beneficiaries in 1973 to 86,354 in 1983, and to 452,957 as of December 31, 2003. Impressive? How about this: The total cost of the ESRD program in the US was approximately $27 billion. Now, of course, not all of these patients who are maintained on dialysis would be candidates for a transplant, but if we had more kidneys, we would also be able to loosen our restrictions on who can and who cannot receive a kidney. Restoration of renal function to these patients not only changes the way theiur kidneys function but allows these patients to get back a significant portion of their life that is spent sitting in chairs receiving HD for 3-4 hours thrice weekly.


And what of the seller's role in all of this? Healthy kidney donors actually function quite well with one kidney. Is it better to have a back-up? Of course. But perhaps the seller really needs the money for his own health or children or whatever. We allow people to sell everything and anything in this country, why not body parts? In order for one to give up body parts , they actually have to be dead. And they don't even make any money from it? [Which brings up another interesting question? If they paid families for the organs of relatives that passed away, would the frequency of organ donation increase?] What about American football players? Are they not indirectly selling their body parts for a salary? A knee? A shoulder? A brain?


Another potential benefit to the practice of buying and selling kidneys on the free market would be the negative impact it would have on the so-called "black market". The desire to seek out dingy hospitals in the Third World to avoid waiting on the transplant list would be quelched if you could do the same thing at a strictly regulated American hospital.


In 2002, Charles Erin an John Harris put forth a rough sketch of how they thought this could work in the Bristich Medical Journal:

The bare bones of an ethical market would look like this: the market would be confined to a self governing geopolitical area such as a nation state or indeed the European Union. Only citizens resident within the union or state could sell into the system and they and their families would be equally eligible to receive organs. Thus organ vendors would know they were contributing to a system which would benefit them and their families and friends since their chances of receiving an organ in case of need would be increased by the existence of the market. (If this were not the case the main justification for the market would be defeated.) There would be only one purchaser, an agency like the National Health Service (NHS), which would buy all organs and distribute according to some fair conception of medical priority. There would be no direct sales or purchases, no exploitation of low income countries and their populations (no buying in Turkey or India to sell in Harley Street). The organs would be tested for HIV, etc, their provenance known, and there would be strict controls and penalties to prevent abuse.

So what is the argument against allowing citizens to sell organs in a controlled and organized fashion? I suppose that it might pose a significant health risk in that there is a surgical organ extraction and that later on down the line there might be an additive health risk associated with having one kidney or half of a liver. Actually the short-term complication rate of kidney donation has hovered around 20%, while the mortality rate is less than 1%. Moreover, the risk of chronic renal failure amongst those donating their kidneys is equal to that of the general population.


Perhaps people have a "moral" objection to the business of body parts? But synthetic or manufactured body parts are okay - just not organs that come form a living human?


Some have argued that the rich will benefit while the poor will continue to suffer and be more likely to represent the majority of organ sellers. And that differs from the current system how? No matter what schema or health care plan we use in this country, those with money will always obtain "better" (i.e. more expensive) care because they can pay for it, and ostensibly they have a higher level of education enabling them to ask the right questions and find the right people. However, if anything, legalized organ doantion levels the playing field as more organs will become available and a regulated system of organ procurement will prevent those with all of the advantages ftrom taking advantage.


Buying and selling of human organs is not a new topic of discussion. It is a popular topic of conversation in the medical literature - especially amongst those in the University and Hospital Ethics departments, where procrastination and idle discussions are a favorite pasttime.


The truth is, this would never happen in the U.S. - not becaue it is wrong, but because we value opinion and discussion and democracy. And there are just too many people that would make fighting this their cause. For what reason? Your guess is as good as mine, but if you doubt it, just look at how stem cell research - probably the most promising new technology of our century - has fared. Literally stifled by the President of the United States. And I have never heard him speak intelligently about that.

Top 5 Worst Hospital Jobs

1. Sharps Box Changer Guy – This guy is just plain crazy. His task in life is to remove plastic containers overflowing with butterfly needles and discarded IV’s contaminated with Hep C, HIV, and God knows what else. These guys should have a reality show and carry anti-viral medications in their pocket. The funny thing is that these guys never seem to wear any protective gear - I’d be wearing steel gloves and a football helmet.

2. Nurse’s Aid - It is difficult to imagine that there is a worse job in the world, let alone the hospital. A typical morning will involve weighing six to eight combative and/or demented patients. Then comes “bathing” time, in which the term “bathing” is used loosely; then re-cleaning them 30 minutes later when their Dulcolax has kicked in. This is often followed by the business end of the “Out of Bed to chair” order in which they get to lift the patient to a geri-chair. Finally, the shift ends with a round of vital signs. The only thing smaller than the qualifications needed for this job, is the pay that they receive. But at least they have their union.

3. ECG tech – Can you imagine a worse job than removing 20 patients’ gown(s), getting all up in their chest fat and breasts, and occasionally shaving excessively hairy individuals in order to paste on some stickers? Welcome to the wonderful world of the ECG technician. The best part? They get to it again 3 minutes later when they have to remove the stickers. And then come back the next day and repeat the process. Wanna really be grossed out? Stay tuned for our upcoming documentary: “Things Found in the Folds – the Story of one ECG tech and his battle to leave his job.”



4. Laundry – Ever wonder where those melena-laden sheets go after they’re thrown in the soiled utility? These people don’t. They use to smell them coming down the laundry chute but lost their olfactory senses a long time ago as a protective measure. Blood, shit, puke, urine, and all other bodily secretions end up in the laundry and these brave souls remove them. God bless them.

5. Intern - Take all the jobs above and add phlebotomist, proctologist, transporter, and general, all-around hospital bitch. That's an intern.

The Mighty Have Fallen

Crusading televangelist and father of the Christian Right, Jerry Falwell, has passed away.

CNN is reporting that Falwell was found unresponsive in his Liberty University office and despite aggressive resuscitative measures, could not be revived.

Falwell founded the Moral Majority in 1979 and is a nationally known voice for conservative Christian views.

The Associated Press reported that Dr. Carl Moore, Falwell's physician, said the evangelist had a heart rhythm abnormality. Most likely, this is atrial fibrillation for which Falwell probably took a blood thinner, i.e. warfarin (Coumadin).

While this may not have helped things, a-fib was almost certainly not the cause of death. Much more likely was the pastor’s history of coronary disease for which he had a stent placed in 2005.
When someone dies suddenly it is typically classified as a sudden cardiac death (SCD) and SCDs are usually the result of a very fast and unstable heart rhythm like ventricular tachycardia (VT) or ventricular fibrillation (VF).

Doctors Sue Back

According to the Associated Press, a group of doctors has filed suit against the state of Louisiana seeking $100 million they say they are owed for providing free care to poor and uninsured patients following Hurricane Katrina.

In all, 381 physicians at West Jefferson Medical Center, says the state failed to reimburse them for treating indigent patients since the Aug. 29, 2005, hurricane closed the state-funded Charity Hospital in New Orleans.

Despite many years of poorly reimbursed training, excessively long hours, and thousands of dollars in loans, you would be hard-pressed to find anyone crying for doctors. And I’m not saying we should start the water works just yet. But I am proud of my fellow colleagues for standing up for themselves and not simply accepting the role of martyr while everyone else collects a paycheck. I am quite sure the rest of the hospital staffers and administrators got their compensation – the union would make sure of it.

For years, physicians have taken a passive role in their reimbursement for a number of reasons. Firstly, they rightfully believe that people must be cared for regardless of compensation and like me, have a slight complex about “fighting” for money. Next, by convention, doctors are hard-working individualists who have to deal with complex billing systems and shrewd insurance companies. This makes for big trouble when trying to advocate on their behalf. Lastly, no one cries for doctors as most are quite comfortable.

It was probably a very difficult decision to sue the state of Louisiana after such a tragedy and I am sure it was not an easy undertaking to get these physicians to sign on. Many will scowl at the thought of doctors suing – as if they need the money. Evidently, they do. And they are not suing the indigent who received care, they are suing the state that is supposed to provide for their constituents – rich and poor, black and white, blue collar, white collar or no collar.

I am (quietly) proud of these physicians for taking a stand and not becoming the good martyrs in this instance. They trained long and hard for their degree and the privilege to call themselves physicians and they deserve compensation like everyone else. Chalk one up for the white coats – at least until the next billing scandal.

Larry King Recovers from Cartoid Surgery

When it rains, it pours. And this week it was pouring 70-something talk show hosts with serious vascular issues. First Regis and now Larry King. Charles Grodin and Charlie Rose better pack a bag.

While Reege is hopefully thinking about discharge, the 73 yo King is fresh out of a carotid endarterectomy (CEA) and his camp says he'll be back by Monday to interview Sen. Barack Hussein Obama (that name is like a SNL joke - he couldn't have worse luck if his name was Stalin Bitler).

Larry King is no stranger to vasculopathy and has a history of 4-vessel CABG way back in 1987. Which also implies that he has probably had subsequent cardiac caths to open of some grafts or possibly even an ancient native vessel. King's propensity for vascular disease makes one wonder what risk factors he wields.

It is very likely he is hypertensive and most certainly takes a statin for high cholesterol. Is he diabetic, too? Probably not - all those years of poorly controlled blood pressure, cigarettes, drugs?, and booze is most certainly enough to give you the old coronary-carotid double feature.

Prior to surgery King definitely had a carotid ultrasound to assess the degree of stenosis. The question is, did symptoms prompt this vascular study or was it a smart doc who knew the talk show host's propensity for vascular atherosclerosis? Either way, he had enough of a lesion to dictate that medical therapy, compared with surgical revascularization, would be more likely to result in a stroke or even death.

What about his outcome? Well, all of the following characteristics have been associated with an increased risk of poor outcome (stroke, myocardial infarction, or death) at 30 days after CEA:

• Age 80 or older
• Severe heart disease
• Severe pulmonary dysfunction
• Renal insufficiency or failure
• Stroke as the indication for endarterectomy
• Anatomical issues including limited surgical access, prior cervical irradiation, prior ipsilateral CEA, and contralateral carotid occlusion

Surgical Methods

Carotid endarterectomy (CEA) is most often done through a neck incision either bordering the sternocleidomastoid muscle, or more esthetically, with a horizontal incision in a skin crease at the level of carotid bulb. Either way, the scar will be small and discrete enough to be covered by a good layer of pancake, so don't expect to see it on Monday unless King wants you to.

The underlying platysma (muscle) and sub-Q tissues are dissected and the carotid artery is isolated, from the common carotid to well beyond the bifurcation of its internal and external branches. After proximal and distal control of the artery is obtained, the patient is given anticoagulated. The internal, common, and external arteries are then clamped sequentially and a the artery is opened at the level of the bifurcation and extended proximally and distally. Some surgeons use a cerebral shunt which is inserted at this time.

The carotid plaque, consistently found at the carotid bifurcation and the origin of the internal carotid artery, is dissected out and removed through a dissection plane developed between the media and intima. Surgeons take great pains to create a smoothly tapered transition between the endarterectomized portion of the artery and its normal distal extent. This maneuver avoids intimal flaps which might lead to arterial dissection after flow is reestablished or perhaps become a nidus for platelet adhesion and thrombogenesis.

After careful inspection of the now clot-free surface, special attention is directed at repair. Some surgeons choose to repair primarily, while others patch the artery with saphenous vein or prosthetic material such as Dacron or polytetrafluoroethylene (PTFE).

Before the artery is closed, the internal carotid artery (ICA) is unclamped distally and flushed free of debris in a retrograde fashion. This vessel is then reclamped and the common and external arteries are opened. This way, all the left over aretreial "gunk" is jettisoned via the external carotid artery prior to restarting antegrade flow, i.e. that blood which goes to the brain. This technique is based on prior experience showing that patients were coming out of surgery with new neurologic events despite the best efforts of the surgeons to remove all the plaque adhered to the wall of the artery. [Interestingly, when carotid stenoses are done percuatneously, i.e. by catheter, interventionalists use a distal occlusion device to prevent embolic events. However, the interventional community is having a tough time showing benefit, or even equivalence to CEA.]

Once hemostasis is achieved, a Jackson Pratt drain is left in the wound to minimize neck hematomas and the muscle and skin are closed. when King was waking from his anesthesia, a neuro check was performed and repeated probably every 10 mins for the first hour and then every hour during recovery to make sure the talking head wasn't slurring as a result of the arterial manipulation.

Below is a sweet slide presentation we found that provides a step-by-step approach to carotid surgery.

http://www.pvss.org/Cases/CartEnd/car3.htm

Regis on the OR Schedule for CABG

Celebrity tak show host Regis Philbin dropped a bomb on his audience yesterday when he informed them that he would soon undergo coronary artery bypass surgery (CABG).

"I got to do it," Philbin said at the start of "Live With Regis & Kelly." "Darn it, I don't want to do it. Nobody wants to do it, I guess."

The diminutive but spry 75 yo male had been on a short hiatus, most likely to evaluate some ongoing chest pain issues that he had admitted to: "I had been feeling chest pains, you know, and, uh, shortness of breath and all those little symptoms that you hear about."

Philbin's refreshing candor about such a serious operation will most likely go a long way to educating his viewers about coronary artery disease and its treatment options. It also cuts out a lot of the investigative and speculative fun of our Celebrity Illness article, but don't worry, there's plenty to discuss.

Reege, as he is affectionately known, most likely presented to his PMD with c/o chest pain and fatigue and who knows what else. The guy is a huge college football fan and constantly boasts about his superior physical shape which will serve him well during this process.

Upon hearing his symptoms, it is possible that Reege was sent directly for cath, (i.e. cardiac catheterization) but more likely had a exercise-nuclear stress test first which should have suggested significant ischemia. Either way, coronary angiography was performed.

Why isn't he going for stent you ask? Currently, there are only a few hard and fast indications for CABG: 1) Left main (LM) coronary artery blockage >50%; 2)Triple vessel disease or 2-vessel disease involving the early portion of the left anterior descending artery (LAD).

If it was the former, there would have been no discussion and Reege would have most likely already been on the OR table by now. Thus, it is much more likely that he has stable multivessel disease and will have a left internal mammary artery (LIMA) graft to the LAD as well as some saphenous vein grafts harvested form his legs.

Coronary artery bypass graft surgery is associated with significant morbidity. Major complications include death, myocardial infarction (MI), stroke, wound infection, prolonged requirement for mechanical ventilation, acute renal failure, and bleeding requiring reoperation. This doesn't even include the nearly 50% incidence of post-op atrial fibrillation and all fo the complications inherent in AF. Using registry data in the United States, the perioperative and in-hospital mortality rate after CABG averages about 1% for the lowest risk elective patients, and 2-5% for all patients.

There are a few risk-predicting algorithms as outcome is hinged on comorbids but we're not gonna go there. Here are some factors that have a major impact on survival and complications:

- Pre-op LV function
- Age
- Kidney function
- Coronary diameter
- Operator experience


Are we getting too data-y for you? It's a tough surgery and you should know this before you send patients (or go for it as a patient) for what has become thought of as a fairly routine deal. It is also important to keep in mind that it has amazing benefits in almost 98% of patients.

Philbin will be facing a difficult recovery as his sternum will be sawed open to expose the heart and although he will be under general anesthesia at the time - he hopefully won't stay that way. After the recovery room, he'll be monitored in a special cardiac surgery ICU where they will hope to extubate him as soon as he can tolerate it. He will also have chest tubes and a pericardial drain following the surgery, all which will hopefully come out after POD#3. He should be out of the hospital b/n 5-7 days where he will gently recuperate and be maintained on good pain meds.

After about a month, Reege will be able to get his groove on again and we predict a late April/early May return for the daytime maven of talk.

We wish Philbin a speedy recovery and hope that he uses this opportunity to educate his audience about his experience and the preventive measures that can take in order to avoid a similar prognosis.

Hepatitis A Scare for Beyonce's Party

An unlucky employee of Wolfgang Puck Catering diagnosed with hepatitis A may have donated his virus to guests at several high-profile functions, including Sports Illustrated's swimsuit issue party attended by Beyonce Knowles and other pseudo-celebs, officials said.

The risk of illness was 'quite low,' but anyone who ate raw food at the magazine's Feb. 14 party was urged to receive a preventive shot by Wednesday, the LA County Department of Public Health said Tuesday.

The affected employee was placed on medical leave, said Carl Schuster, president of Wolfgang Puck Catering.

'We immediately worked to take every precaution to further safeguard our patrons and other employees,' Schuster said in a statement.

Sports Illustrated said in a statement that it was taking the situation very seriously and was working directly with county health authorities.

'We are alerting our guests and staff as quickly as possible to ensure they receive the relevant health warnings,' the statement said.

Hep A (HAV) is usually spread via the fecal-oral route, i.e. infected people share the yellowing virus through food and water that they handle – after touching their ass. It is more prevalent in low socioeconomic areas in which a lack of adequate sanitation and poor hygienic practices facilitate spread of the infection.

To get technical on your ass, (and for those of you prepping for Boards) Hepatitis A is a 27 nm, nonenveloped, icosahedral, positive-stranded RNA virus classified in the Heparnavirus genus of the Picornaviridae. But you knew that.

According to our favorite medical resource, UpToDate.com, community outbreaks due to contaminated water or food have also been described, shellfish being the most popular offender. However, several outbreaks related to consumption of “contaminated” green onions have been reported in the literature.

HAV infection usually results in an acute, self-limited illness and only rarely leads to fulminant hepatic failure.

The two most common physical examination findings are jaundice and hepatomegaly, which occur in 70% and 80% of symptomatic patients, respectively. Less common findings include splenomegaly, cervical lymphadenopathy, evanescent rash, arthritis, and, rarely, a leukocytoclastic vasculitis.

Laboratory findings in symptomatic patients are notable for marked elevations of LFTs (usually >1000 IU/dL), serum total and direct bili, and alk phos. Typically, ALT is higher than the AST and bilirubin levels above 10 mg/dL are not uncommon.

The diagnosis of acute HAV infection is made by the detection of anti-HAV antibodies in a patient with the typical clinical presentation. Serum IgM anti-HAV is the gold standard for the detection of acute illness.

Because the disease is usually self-limited, the treatment is supportive.

But believe us, it would be a lot more than supportive if one of the celebs turned yellow.

Notre Dame Head Coach Sues for Botched Bypass

Charlie Weis, head coach of the Notre Dame Fighting Irish and former Super Bowl winning offensive coordinator, testified yesterday in his lawsuit against two surgeons from prestigious Massachusetts General, who he claims were negligent following his gastric bypass surgery.

According to ESPN.com, the now svelte Weis said he spent more than a month in various hospitals, and following his release, had problems walking and could get around only with the help of a wheelchair or electric cart. His lawyer, Michael Mone, told the jury during opening statements Tuesday that Weis still suffers nerve damage in his legs.

How was his ambulation when he tipped the scales at 400 lbs? And his diabetes? And HTN? And obstructive sleep apnea, etc etc?

I am astonished that someone who signed a contract for $30-40 million over 10 years and is now healthy enough toWeis2.jpg walk the sidelines and handle a high-stress job like his, would sue doctors who are at the top of their field and clearly did not mean any harm.

Gastric bypass is inherently a complicated procedure and when a morbidly obese individually undergoes the surgery, this is explained to him or her. If the physicians made a erred during the surgery and corrected their error enabling him to successfully drop weight and return to coaching, what is he suing for?

Obviously, we are not privy to the details of the case but we do know he is coaching and that hey are Harvard surgeons who want the bet for their patients - especially high-profile ones like Weis.

Can the Fighting Irish fans sue Weis every time he makes a bad call or for their pitiful performance in Bowl games?

Doctors explained to Weis the risk of the surgery and he, in fact, waived a psychological assessment period so that he could be ready in time for football season. Now he is suing them?

Weis, as a head football coach, and a man who is familiar with risk-benefit analysis, whould recognize the complications inherent in such an invasive procedure - particularly in such an unhealthy individual. Big rewards can be gained form big risks - but like the deep pass and the double reverse, catastrophe can also occur. Weis is lucky that he is alive, healthier than before, and actively coaching a marquee program. And who does he have to thank for that? His team? His family?

No. His doctors.