A wartime surgical mission; treating heart failure: Upstate Medical University's HealthLink on Air for Sunday, Feb. 4, 2024

Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a reconstructive urologist tells about a surgical mission to Ukraine to help injured soldiers.

Dmitriy Nikolavsky, MD: ... When we left the surgeons that work with us, we contacted every single day since we left Ukraine: How are they doing? What is the temperature? What is the output? Are the catheters out? Are they ambulating, are they walking around? So it, it was a constant remote follow-up.

Host Amber Smith: And two members from the Heart Failure Clinic explain how a formal program helps patients manage their disease.

Kristin Ramella, NP: ... It is very, very difficult to manage, as it is a continually dose-adjusted, symptom-changing disease process. ...

Host Amber Smith: All that, and a visit from The Healing Muse, right after the news.

This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith.

On this week's show, we'll learn how people with heart failure can manage their disease with the help of the Heart Failure Program.

But first, a daring trip to a war zone to provide specialized surgery to soldiers.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

Two Ukrainian-born surgeons have recently returned to Syracuse after a medical mission to Kyiv, Ukraine. Here to tell us about it is Dr. Dmitriy Nikolavsky. He's the director of reconstructive urology at Upstate, and he's an internationally recognized expert in the highly specialized field of reconstructive urologic surgery.

Welcome back to "HealthLink on Air," Dr. Nikolavsky.

Dmitriy Nikolavsky, MD: Thanks. Thanks for having me here. Great to be here.

Host Amber Smith: Upstate's urologic chief, Dr. Gennady Bratslavsky, has a foundation -- Ukraine1991.org -- that has raised a lot of money to help pay for medical supplies and ambulances and other things that are needed since the Russian invasion. But at the end of November, you and he were part of a mission to Ukraine to help wounded soldiers who needed your expertise. How did this come about?

Dmitriy Nikolavsky, MD: So I was thinking about how to help from the first days of war, and I was hoping that my expertise will be requested or needed. And several times I reached out to my colleagues in my native city, in Odesa, and in Kyiv, and I would hear something like, "Well, it's not really an issue right now. We have bigger problems. We need some other things. We need vascular surgeons. We need orthopedic surgeons." They'd say people either so minorly wounded that that's the least of their problem, or they're so majorly wounded that somebody like you cannot help them.

But, in May of this year, suddenly in the middle of my workday, Dr. Bratslavsky reached out to me. He said, "Hey, join this Zoom meeting. There is this military urologist, and they're actively looking for somebody like you." So it was an interesting, sudden Zoom meeting. I explained that, oh my God, I was trying to find a way to help all this time. By then, it was more than a year. And I was told urology is not really needed. And they're like, "No, this is not true. This is not true. They just don't know. We see all these wounded soldiers. This is a military hospital. You can't imagine what kind of wounds are here, and we don't have expertise."

So it appeared that before the war, this super, super subspecialty was not considered a real specialty in Ukraine. Cancer, (kidney) stones were the real specialties they considered. And whenever it was reconstruction, I think the idea was like, "Aw, anybody can do it." And so suddenly after the war, that was not the case. And the injuries were tremendous. And the need was tremendous, apparently.

And finally the right people contacted me, and we started thinking, what could be done? So at first it was maybe we could open our doors here and have patients travel here. But the logistics and finances and countries at war ... there's no way to cross the borders for the soldiers.

Then, idea was maybe I can travel to Poland. We can travel to Poland with a team. I know that many in reconstructive society all this time were reaching out to me, like, "How can we help? Anything you need?" And I'm like, "There's no need to help." We are not needed. Until now. So I thought maybe organize something to Poland. Then they say, "Still, it's crossing the borders, for soldiers, logistics and transportation. And you don't understand: Many of them have no limbs, and they're still recovering from other trauma. No, it has to be in Ukraine."

So slowly it was, OK, maybe I can just step over the border, and in some nearby village we could do it there. "No, you don't understand. There's no conditions." So slowly, slowly, it was "No, you have to actually come to Kyiv." And, I agreed. Meanwhile, while it was all happening, the second project was going on. We offered to host two military urologists, very interested and eager to learn reconstruction. So the first contact was in May. Then in August these two urologists came for a month, and we just booked many, many cases for them to see the world of reconstruction. And they were writing things down and asking many questions and didn't skip a day. They were so dedicated. And then I know that they left back to Kyiv and immediately started doing the surgeries,as much as they could.

It was great to hear from them almost every day. And they would bring some new cases and ask, "What would you do?" And then sometimes in the middle of the case, they would contact me: "Hey, am I doing it right? Do you approve?" And then we would follow these patients remotely for days and weeks.

And then finally we set up the date, and that's it. We were supposed to arrive on Dec. 1. It just happened. So, Dr. Bratslavsky and I went through Poland. In Poland we met our Polish colleague that also volunteered to come and our Mexican colleague that we had done multiple other missions and trips over the last seven or eight years in different countries. So a trusted team like this. Damián López is the name of the Mexican friend and colleague, and now we're like brothers after this. And Maciej (Oszczudlowski) is the young reconstructive urologist from Poland. So he met us there.

We immediately boarded the train, and that was a very tortuous, long journey on the train through Ukrainian border, and I think it was about 15-hour trip. Very anxious and excited. By the time we arrived, it was only three of us because, turns out that Dr. López didn't have visa, and he was sent back to Poland. And it took couple of days for him to get visa, and then he later joined us.

But three of us -- Dr. Bratslavsky, Dr. Maciej and myself -- we arrived to Kyiv at about noon. And when people, when they greeted us, they said, "Oh, just in time, we have an air raid right now. It's just to welcome you." (Air raid siren recorded by Nikolavsky.)

So they kind of, they take it with humor

now. You don't see anybody running for shelters; nobody's hiding. So we kind of took a cue and laughed and smiled. And they took us straight to the hospital, and there was a huge reception. It was Saturday, and everybody was waiting. Nurses, for them it was not the day off. So it was it was very touching.

The next day we operated. Again, everybody showed up to work like it's a regular day.We did four surgeries, from the morning until the night. And then in the night there is a curfew. So you can't really see anything. You can't really be a tourist during the curfew. They take it seriously. And then Monday, Tuesday, by Tuesday Dr. López finally arrived after his convoluted journey. And we did a couple of more surgeries with him, very complex surgeries.

On Wednesday, we needed to go to city called Irpin. People know Bucha. So Irpin is right next to Bucha. There was a tremendous suffering and destruction in both of the cities. So by 9 o'clock we were supposed to come to Irpin, and there was still one unfinished case. We still planned to do one more surgery that day. So we proposed how about we start at 5 a.m. And everybody said, "No problem. 5 a.m. it is." The only problem is that the curfew stops at 5 a.m. Between midnight and 5 a.m. curfew. It's very serious. You cannot be on the street. So it means that nobody can travel to work to start surgeries at 5 a.m. And then they immediately came up with a solution, without us asking. They say, "You know what? We'll just sleep in the hospital."

Host Amber Smith: So you were connected, obviously, with some dedicated surgeons on that end as well?

Dmitriy Nikolavsky, MD: Oh yeah. It's not just surgeons we're talking about. This was anesthesiologists and scrub techs and, all the support, the nurses. They just kind of, when we discussed it, it was like a big gathering after the very last case on Tuesday, they said, "Oh, not a big deal. It's not a problem." It was very easy. There was no voting or anything. They just, "Yeah, yeah, yeah." So they all stayed in the hospital, and our hotel was right next adjacent to the hospital. So, by 5:05 we just walked in, and we started the very last surgery.

Host Amber Smith: I want to ask you, if you can, I know these were very severe injuries. These are soldiers who obviously survived, but with severe, some of them lost their limbs, and they're left with tubes, unable to urinate, right?

Dmitriy Nikolavsky, MD: Yes.

Host Amber Smith: What were you able to do? What were you able to do for them?

Dmitriy Nikolavsky, MD: So injuries were very different. One of the first cases was an abdominal disaster when it just happened. I think it was some kind of explosion, maybe a missile or a mine. I'm not sure. Many organs were damaged. So this patient was probably operated on multiple times for a year, so it's not something new.

And, the one residual injury that is left -- the tube that connects the kidney to the bladder. It's called ureter. So one kidney was OK, and the other kidney on the right side, that natural tube that delivers urine, was obstructed by all the scar. And so the original surgeons, maybe about six months ago, they tried to reestablish the passage, and it just failed. So patient was obstructed and had to live with tubes going through his backto an external bag for him just to survive. He was recovering from all other injuries, meanwhile. But one of the tubes he would have to live with, a catheter sticking out of his back and draining into a bag that he would carry around. And so, that was a very tricky, dangerous surgery because he had so many other operations, so much scar. So no robot, no laparoscopic equipment. It was all open (surgery). And, that was the first surgery that Dr. Bratslavsky was doing, very carefully. It's almost like a mine in the minefield to find all the organs, not to damage them, not to get into the bleeding, and reconnect the ureter to the bladder.

And in other cases it was not the ureter. It may be the bladder, or it may be the urethra, which is the tube connecting the bladder to the outside world and allows people to urinate. And in some cases it was a scar tissue that doesn't allow passage of urine, so they, they have to live with tubes sticking straight from the bladder.

In some other cases, it was complete destruction. It was some kind of violent explosion or blunt injury that completely disconnected and stayed disconnected like this for six months to a year, sometimes even for 18 months.

That's not life threatening once you have the tubes, but it's extremely poor lifestyle and debilitating. So none of these things that we did are lifesaving, but they return dignity, I hope, and they return function. Now we call this field of urology "functional reconstruction," so we return back the function.

Host Amber Smith: So, while you were there in the hospital, what did you notice that the hospital needs, that the surgeons need, that you have come back and would like to raise money to buy this equipment for them? Can you tell us about that?

Dmitriy Nikolavsky, MD: Well, they need everything, but we need to go on a scale of preference. What do they need first? So they need our specialized urologic reconstruction instruments. And I brought them whatever I could. I gave them whatever I could when they were here. So they're getting their kit together for actual surgeries.

What I noticed that we here take for granted, there are special stirrups to support patient's legs during the surgery that are safe. And when we showed up there, the stirrups, the old-fashioned stirrups that they use, are not exactly safe. Nobody uses them here anymore. I have traveled in many countries, operated in all kind of conditions, and I would say half of the time people don't use this kind of stirrups. And the reason is that it's too easy to create damage to nerve structures and muscles in the leg. And imagine you operate for one quality of life, and you return urination, and suddenly in the worst case scenario, patients can't walk anymore. That's how bad it could be. And so we operate in with the old-fashioned beds and old-fashioned stirrups, and of course one of the patients had minor complication of the sort. It's reversible, but it kind of was a sign, OK, we need to take it seriously.

So, good, safe stirrups, brand new ones, they could be like $17,000. So they don't need brand new ones. They just need functional in a good condition stirrups. And I found a vendor who sells refurbished stirrups for three and half thousand dollars. This is a huge discount. So at least one or two pairs of these would change the safety and outcomes of the surgery.

The second thing that we take for granted is the prevention of clots in the legs during any surgery. And these are these mechanical pneumatic massagers that every patient gets as soon as they get to the hospital here. So if you go bed-to-bed or operating room-to-operating room, that's the first thing you'll notice. Everybody wears these massagers pneumatic compression devices. And there was none in that entire hospital, not even one unit like this. Apparently it's not a thing. We need to provide at least several of these machines. They're, again, refurbished, maybe under $1,000, maybe a couple of them. Ideally everybody in the hospital would get them eventually, but at least for people during the surgery or recovering from surgery, they need to be connected to those massagers.

And finally, when we operated, there was a very specialized retractors that a previous group -- there was a previous group from Cleveland, maybe two months ago -- they came, they donated specialized retractors, but, they didn't have proper attachments for the surgery. So fortunately I had some attachments that I travel with, in my travel kit. So we were able to use them. But now I know that we need couple of thousand dollars to supply them with the proper attachment to do the surgeries.

And that's to start. Of course, they need all the fancy sutures that we use, and they need loops, and they need headlamps. But that's for later. For right now, I think these three things are the No. 1, 2, and 3 priority.

Host Amber Smith: You already have a foundation already set up for this.

Ukraine1991.org is the website people can go to to make donations now.

Dmitriy Nikolavsky, MD: So yes, this is Dr. Bratslavsky's effort with his family and friends. I think he created it the first week after the war started. And it's not specifically for this mission. This foundation, there is a lot of help, hundreds of thousands of dollars worth of medications and several trips when they delivered ambulances to different hospitals,first aid kits, tourniquets, you name it, you could see all the missions that they had.

But, we're joining right now specificallyfor this mission or for the following mission.So then in the next couple of months, all these donations hopefully will go toward these goals to supply this hospital with everything that is immediately necessary to help the soldiers.

Host Amber Smith: Upstate's "HealthLink on Air" has to take a short break, but please stay tuned for more about the medical mission to Kyiv to provide urologic reconstructive surgery to Ukrainian soldiers.

Welcome back to Upstate's "HealthLink on Air." I'm your host, Amber Smith, and I'm talking with Dr. Dmitriy Nikolavsky, the director of reconstructive urology at Upstate.

So getting back to the soldiers, will you be able to follow up with them? Because you don't just do the surgery, and it's done, right? They have got some care afterward. How does that work?

Dmitriy Nikolavsky, MD: So while we were there, we were rounding and seeing them every day. When we left the surgeons that work with us, we contacted every single day since we left Ukraine: how are they doing? What is the temperature? What is the output? Are the catheters out? Are they ambulating, are they walking around? So it, it was a constant remote follow-up. And we left behind all our protocols how to follow up patients in situations like this. Once the catheters are out, they will be seeing them every three to four months for the first year, with certain tests that we usually do, what to do if something goes wrong.

They're in constant contact with us about this and future patients. Because while I was there, they brought up patients that were kind of straight from the front lines. And there's nothing we could do yet for those additional 10 patients that we have seen, but maybe they'll be ready in about six months. Hopefully we'll come again in six months. We'll be able to follow up on our current patients and do something good for patients that will be accumulated by then.

I guess these injuries are so common that the list -- they have a list of everybody that needs help -- the immediate list was about 60 -- 6-0 -- 60 patients. The surgeons that we trained diminished that list a little bit. And then the group from Cleveland came and took care of 19 or 20 patients.

We came, we had 19 patients on the list for different reasons, transportation or issues, we were able to operate on 13 patients that were ready, and the other six were just not ready for a variety of issues. But some of the surgeries that we did were stage 1 of a multi-stage reconstruction, so we will have to come back for stage 2.

And by then, I hope not, but I expect that by then there'll be more patients ready for more surgery.

Host Amber Smith: Why were you willing, and Dr. Bratslavsky and the other doctors, from Poland and Mexico, why were you willing to go into a war zone?

Dmitriy Nikolavsky, MD: Because that's where the patients were. There was no other way.

Host Amber Smith: Was it scary?

Dmitriy Nikolavsky, MD: It was scary to prepare and to think about the worst-case scenarios. And I have to say that when the train was moving in the middle of the night, there was all kind of noises and I'm, through my sleep thinking, are we being bombed? And then I went back to sleep, kind of like, nah, I would know if we were bombed. So, it was kind of, it wasn't a fear. It was just kind of anxiety. How's it going to go? What will happen? But then you arrive there, and everybody (is) kind of so chill about it, and they just go on with their life.

When you're surrounded with brave people, it's kind of, you have no choice and just blend in. Apparently, when we were operating, the air raid alerts were sounding all the time, but everybody has apps, a special app for the air raid alert. They kind of put them on silent because it just happens too often, and they can see that it's disruptive. So we didn't even know. We were working. Nobody ran out. Nobody was hiding. We probably worked 40 minutes, probably, there were air raid alerts. Nobody panicked. We just continued. It would be very strange if one of us started running out and hiding in the basement.

Host Amber Smith: What was communication like?

Dmitriy Nikolavsky, MD: My first language is Russian. I was born in the previous century, and the city Odesa was, at that point, predominantly Russian speaking. I don't know, now. We didn't visit Odesa. And I understand that the language was not a big deal until the war. The Russian invasion made it about the language, but it was never about the language. They just didn't want to be part of Russia.

And, so I'm guilty. I never learned Ukrainian. I should. So it was strange. I had to apologize just because I didn't feel good about it. So I said I could speak English if it sounds better. I could speak Russian with accent by now. I made a joke. There was an interview. I said, "I apologize. I speak every language with accent right now, so you know, if you don't mind, I'll speak Russian, language with (accent)." But nobody cared. They're like, "Hey, whatever." So I felt internally guilty, but it doesn't matter. To them it doesn't matter. You know, we came to help, and they appreciated it.

Host Amber Smith: So I know you mentioned after the surgeries you took sort of a side trip to Bucha and Irpin. Can you tell us more about that?

Dmitriy Nikolavsky, MD: Yes. So that, that was in itself an interesting story. So we finished that early morning case. It was our very last case of the day, of the trip, and we were about to leave the hospital, but then all the hallways, all the staircases, all the entrances, I guess the whole streets around this hospital were blocked by security.It's interesting thatI think internet was also interrupted for that purpose, and we knew that somebody big and important was visiting the hospital. And we were not able to move for a little bit.

And then later when we were out of the hospital, from the news, we found out that, actually President Volodymyr Zelenskyy visited the hospital, and including visiting our patients that we just rounded on and shook their hands and gave some medals to leaders of that hospital. We were kind of sad. We thought, well, if we stayed in the room for a little bit longer, maybe we would get to meet Zelenskyy. But in reality, it would never happen.

So anyway, after we were allowed to leave, we went to Irpin, and there was a huge ceremony. It was a "Day of the Defenders," so they had a huge ceremony, maybe a couple of hundreds, maybe thousands of people were in the main plaza. The city that suffered 70% destruction just 18 months ago was completely rebuilt. And they took huge pride in the fact that anytime something explodes, even now, drone or a bomb anywhere and destroys the building or windows or asphalt, immediately they clean it up, asphalt the place, paint, put flowers, put the windows back, rebuild it. So when we came to Irpin, we expected, like we were told, 70% destruction. They had hard time, just as an example, showing us destroyed buildings because everything was nicely cleaned. Beautiful shops, gift shops, restaurants, planted trees, everything is painted, beautiful. So in the center, there was a big ceremony. And I found out -- I didn't know what to expect -- but I found out that mayor of Irpin -- big hero who defended the city from the invasion successfully -- would be there. And he called Bratslavsky. And, and during the ceremony, Bratslavsky donated four pickup trucks to the defense efforts.

So we were there. It was interesting. We were given Syracuse flag to represent Syracuse. We were, all of us, the whole medical group, was holding Syracuse flag next to these donated cars. And many other volunteers and donors were there donating other things. So Bratslavsky gave a speech in pure Ukrainian. I was so surprised. He speaks Ukrainian really well. We received some kind of diplomas that we were there and thank-you certificates. But actually the whole thank you should be to Bratslavsky and his organization, because it's just one of the things that he is relentlessly doing over the last, I would say, 20 months.

While we were there in Irpin, while we were in Kyiv, I saw many times the different people from different organizations came to say thank you for everything that his organization donated. So I didn't know. He is not showing off here what he is doing, but I just got to witness this huge appreciation to different projects that he is doing, including receiving -- and justifiably receivingcertificate of appreciation for the cars that he donated, his organization.

And then we were invited to go to city hall, full of people. And to me, again, I didn't know what to expect, so it seemed to me like a concert, like people were, the whole audience, there was no more places to sit, standing room only. And, I thought it was a concert because somebody was singing in the beginning. There were speeches. And then suddenly they said, "And now we'll be posthumously giving awards to fallen soldiers from Irpin, the heroes of Irpin." And they started calling the families to the stage. This was probably the most devastating, to me, moment. The mothers, the wives, would come to the stage one by one, receive some kind of, I don't know, medal or some kind of little box, and then cry and sit in silence. Just people crying. And it seemed that the list was endless. Now, I assume that everybody who were seated probably were relatives. So that it was, that was very hard.

So then we were given a tour of Bucha. They were showing us Bucha again. The city was also rebuilt. It's almost impossible to see the signs of damage. And, we got a chance to spend some time, have lunch with the mayor of Irpin, andthat was a huge honor. And then after that, we just had to go back and meet the the doctors at the train station, and that was the end of the trip.

So I don't know at what point, now it's hard to say. Even before we were through the border, even before on the train, maybe that day or maybe the day before -- I was already, I knew that we need to come again.

Host Amber Smith: It sounds like the need is still going to be there.

Dmitriy Nikolavsky, MD: Unfortunately. And besides that, we'll be doing other projects. We'll invite the two military doctors, the two military urologists that are so eager to learn reconstruction, we'll try to invite them to any possible workshop that we do around the world. One is upcoming in Mexico. I'm hoping that they'll get permission to join there, hands-on reconstructive workshop. There is one in Texas, big reconstructive meeting, national meeting, in May. We'll try to get them here again to present what they see because their experience is unique. And also to keep teaching them and try to help that reconstructive center, the only one in Ukraine, the first one, and so that would be my big accomplishment, if it happens.

Host Amber Smith: Was there, did you find adequate food and water? And you said the hotel was right next door, so you had a place to stay. Was there anything lacking that jumped out at you or that people asked you about?

Dmitriy Nikolavsky, MD: No. It's good thing, but it's also confusing thing because it looks like, on the street, life goes on. The restaurants, the stores, even luxury stores and luxury restaurants and Christmas decorations,the traffic. It felt like just a regular European city, like nothing is happening. And the only giveaway would be on the sides of many roads there were these pieces of fortifications that they used when the city was surrounded. This is like anti-tank metal porcupines. I think I translated them -- porcupines, made out of railroad pieces and concrete. They call them, I think, "teeth of dragon." So if you put them in the middle of the street, then somehow it protects from tanks and machinery. So right now it's not in the center of the streets. It's kind of swept to the sides. So almost every road has a collection, a pile of both of these fortifications. And so every so often you pass, and that reminds you that, OK, so that's actually happening.

Every so often there would be military equipment, I guess anti-drone machinery driving around. Actually, I'm not sure what it was, but I assume that that was the anti-drone unit. But other than that, everything is open. No bread lines. The food was spectacular. When we arrived, I guess they waited for us for so long, and nobody could believe that we actually arrived, and they cooked a storm -- I think it's nurses and scrub techs -- amazing foods that I haven't tried anything like this for the last 30 years.

Host Amber Smith: Wow. Did you bring back any souvenirs?

Dmitriy Nikolavsky, MD: Yes. So, we got many interesting surprises. When we were leaving at the train station, the whole battalion of doctors in military uniform showed up in the train station. They showed up with flags -- an American flag, a Mexican flag, a Polish flag too, to honor. It was a surprise. And two Ukrainian flags, and one flag was signed by all the soldiers that we treated. And another flag was actually signed by (General Valerii) Zaluzhnyi, which is his (President Zelenskyy's) main general in Ukraine right now. He is like a mythical figure, so it was remarkable. So we got these two flags as gifts. So one of the flags is in our clinic here. We have picture with nurses. Nurses also donated a lot of money for the ambulances. There was a drive a year ago and still continues, so it was really cool to have all the nurses pose next to the flag. That was actually their help went there. So it's kind of a full circle.

And we got a traditional Ukrainian vodka and a couple of souvenirs. I'll keep it unopened until victory.

Well, I'm really glad that you made it back safely, and I'm appreciative that you took the time to tell us about your trip. And I want to make sure that listeners know Ukraine1991.org is the website where they can go to make donations for equipment and medical supplies for the future.

Thank you.

Host Amber Smith: My guest has been Upstate's director of reconstructive urology, Dr. Dmitriy Nikolavsky. I'm Amber Smith for Upstate's "HealthLink on Air."

How the Upstate Heart Failure Clinic works -- next, on Upstate's "HealthLink on Air."

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

Studies show that people with heart failure do better if they're part of a formal heart failure disease management program rather than regular medical care.

Today we'll learn about Upstate's Heart Failure Clinic and how it works from nurse practitioner Kristin Ramella and nurse Sarah Bobenhausen, who's the clinical leader of the Heart Failure Clinic.

Welcome to "HealthLink on Air," both of you.

Kristin Ramella, NP: Thank you very much for having us.

Sarah Bobenhausen: Thank you.

Host Amber Smith: Let's start with an explanation. Why is it important for the Heart Failure Clinic to exist?

Kristin Ramella, NP: Heart failure affects millions of Americans every year. It is very, very difficult to manage, as it is a continually dose-adjusted, symptom-changing disease process.

Typically, one set of medications does not work for the same two people, and also the same person might need frequent medication dose adjustments in order to effectively treat them, to get them to feel well.

The Heart Failure Clinic is used for patients that need frequent follow-up, and really our main goal is to keep people out of the hospital.

We do a lot of interventions in the office, particularly for that reason. If someone's having symptoms, and they need some urgent help, but maybe they don't need to be admitted to the hospital yet, our main goal is to do some things in the clinic, adjust their medications, give them IV medicine, anything we can do to keep them out of the hospital.

There's also a big improvement in mortality and patient satisfaction when they have a good rapport with the clinic staff. We know them well. We know what works for them, what doesn't work for them, and they are able to come to us and share in that decision-making process.

Host Amber Smith: Do all hospitals have heart failure clinics?

Sarah Bobenhausen: No. There is another local hospital that offers some limited services, but Upstate is the only hospital around in Syracuse that gives more of the intense therapy. We give IV push medications, IV drip medications. We give quite a few different medications.

Host Amber Smith: Are the Heart Failure Clinics meant for people who have been diagnosed with heart failure, or are they people who are in danger of developing heart failure?

Sarah Bobenhausen: The Heart Failure Clinic sees patients who have already been diagnosed with heart failure.

Host Amber Smith: Let's talk about what exactly heart failure is, because when you look at it, heart failure, it sounds like the heart has stopped, but that's not necessarily what's going on, right?

Kristin Ramella, NP: Heart failure is a very fancy term for saying that the heart is not pumping well enough to give blood to the body.

There are particularly two forms of heart failure that we talk about. One is heart failure with reduced ejection fraction, or there's inability of the heart to pump enough blood to feed the body. The other form is heart failure with preserved ejection fraction. That is when the heart has a difficult time relaxing to fill with blood, so there is not appropriate amount of blood that's distributed to the body in that way.

There are very particular treatments for those types of heart failure, and underneath those categories of heart failure with reduced ejection fraction and heart failure with preserved ejection fraction, there are many reasons that can contribute to that diagnosis.

For example, when the ejection fraction is reduced or that pumping action is weak, we look at: Was there a heart attack? That's something we need to look into immediately because the patient may qualify for emergent intervention that can fix that reduced ejection fraction. If that is not the case, then we look into other alternatives.

Is there an arrhythmia or an electrical problem with the heart that's causing the heart muscle to work harder?

Is there an autoimmune disorder? Are there other contributing factors? Drugs and alcohol is another big one that we tend to see, in our population in this area.

Then when you're looking at heart failure with preserved ejection fraction, hypertension or high blood pressure is a very, very highly linked, other diagnosis that leads to that type of heart failure.

Other forms can be sleep apnea. We have patients that are obese, with diabetes. Those tend to lead towards that heart failure with preserved ejection fraction.

Host Amber Smith: So it sounds like you have a wide variety of patients, even if they all have the same diagnosis, heart failure, but it sounds like they all have a lot of different things potentially happening.

Kristin Ramella, NP: Yes. We see anywhere from 18-year-olds all the way up to even 90-year-olds who have heart failure, and the underlying causes of those vary widely.

Host Amber Smith: How many people are enrolled in the Heart Failure Clinic at Upstate?

Sarah Bobenhausen: So we see, on average, about 80 visits per month. In October we had 79 visits, and out of those 79 visits, there were 37 different patients: 28 of those visits were acute visits, 36 of those were chronic visits. We see patients that were admitted in the hospital within seven days of their discharge for heart failure. It varies every month how many patients we see. It really depends on the need.

Host Amber Smith: I was going to ask how often patients have appointments, but you just answered that. It kind of varies, depending.

Now, are appointments at the clinic paid for by Medicare or other insurances?

Kristin Ramella, NP: Yes, the Heart Failure Clinic appointments are considered a nurse visit, even though a provider is there to oversee it and to determine what the course of action is or what the treatment plan is going to be.

There is no copay typically for those visits, either, because they're billed as a nurse visit, and insurance will cover those visits as well. It's not an out-of-pocket expense. To piggyback off what Sarah was mentioning about the appointments, it really does depend on the patient. So, typically, if we see someone who's newly diagnosed. They will have appointments almost once a week for the first two, three, four weeks, until we can get their medical therapy or their medications, ideally, at the right doses. And there's also a lot of education that goes into a newly diagnosed heart failure patient.

Typically, they're taking two to maybe three medications a day. And then once you earn that diagnosis of heart failure, your medication list goes from that two to three, to five or six or seven because it requires multiple medications, each doing something different to treat that heart muscle. That could be a very tough adjustment for patients and families and a lot of the Heart Failure Clinic visits, not only are we assessing their heart rate, their blood pressure, we're also doing a lot of education. How is your diet? How is your salt intake? How are you doing with your medications? Do we need assistance in getting your medications? Is there a better way that we can help you organize your medication, so it's easy for you to take?

So it's really a holistic approach to treating the patient, during those clinic visits. And then once it's a patient that gets established, we know them very well, they've been coming for several months, then some patients come for maintenance therapy, where they need an IV dose of medication once a month, once a week. Or there's other times where we have patients that we know that call us up and say, "Hey, I'm not feeling well. Can I come in?" And we get those patients in to be seen, and we get them treatment again, with our goal being to keep them out of the hospital.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith.

I'm talking to nurse Sarah Bobenhausen and nurse practitioner Kristin Ramella. They both care for patients in Upstate's Heart Failure Clinic.

Now I'd like to have you walk us through what a brand-new patient might experience coming for their first visit. Is the Heart Failure Clinic in the hospital proper?

Sarah Bobenhausen: No, the Heart Failure Clinic is located at 90 Presidential Plaza, at UHCC (University Health Care Center). We are located in the Upstate cardiology office. It's its own clinic within the cardiology office.

Host Amber Smith: So what would be included in the first visit?

Kristin Ramella, NP: Typically, if the patient is newly diagnosed, and they're coming from the hospital as a hospital discharge, ideally they would see a provider in the office, whether it be myself as a nurse practitioner, a PA ( physician assistant), or one of the physicians in the office.

And then we would have them talk about the diagnosis, assess their medications, and then we would send them, oftentimes that same visit, right over to Sarah in the Heart Failure Clinic to continue that education piece. That's ideally what the first visit looks like.

Sometimes, if we don't have available appointments for patients soon enough after discharge, but we really want to get them in to get that education and to see if their medications are OK, they sometimes see Sarah in the clinic first, and the provider will stop in quick, make sure the patient's doing well, again, make any recommendations that are needed.

I always tell my patients when I see them after the hospital, especially, every visit will not be as long as the first visit. There's so much education involved, there's so much to absorb, so much talking, so much just to process everything that happened. And follow-up visits are typically not nearly as long as that first visit.

We also have, as far as exercise, we have a cardiac rehab program right here in our office.

If the patient is diagnosed with heart failure with a reduced ejection fraction, they are a candidate for receiving a cardiac rehab, which is a three-day-a-week program run by cardiac nurses. It's overseen by a cardiologist, and there are physical therapists. During the exercise program, a patient's heart is monitored to make sure that the program and what they're doing is OK for what their heart can handle. So the entire program is tailored to what that particular patient is able to do.

Host Amber Smith: So how long might a patient stay with the Heart Failure Clinic?

Kristin Ramella, NP: Forever. We really keep tabs on these patients forever. They call if they're not in an exacerbation, and they're still currently seeing a cardiologist, they call us when they are experiencing symptoms. And we bring them in. Sometimes we see patients once a week for years. Sometimes we see patients once or twice a year, but they never expire out of the program.

Host Amber Smith: Have you ever seen someone improve so much that they're no longer considered to be in heart failure?

Kristin Ramella, NP: Yes, we do often see that, particularly if the underlying cause is something that is reversible or that we can intervene on fast enough. For example, a lot of the drugs and alcohol that induce heart failure, if we can take away that substance and the reason why the heart is having to work so hard, if we catch it fast enough, the heart muscle can recover.

Some of the other things that heart failure can easily respond to is if there's an electrical problem with the heart, and the electrical activity is making the heart work harder. If we can fix that electrical problem, and again, if we can do it fast enough, that, with support of medication, we can get that heart failure to significantly improve.

Host Amber Smith: For the patients that are enrolled in the Heart Failure Clinic, what happens if they experience a problem, and they feel like they need to be seen, or they need to get some medical advice, are they able to get same-day appointments? And what happens if it's the evening or the weekend?

Sarah Bobenhausen: They absolutely are able to get same-day appointments. Many of my patients call me that morning and have an appointment that afternoon or the next day. Or, if they're seeing a provider in the clinic, the provider will bring them over right after the appointment. We are very flexible in the Heart Failure Clinic.

Host Amber Smith: What if a patient who's part of the Heart Failure Clinic has an emergency? Do they go to the emergency room?

Kristin Ramella, NP: Sarah does a lot of what we call triage phone calls. So if a patient calls in, they explain their symptoms. If Sarah feels that they are safe enough to come to the office, to the Heart Failure Clinic, for treatment, we bring them in. If their symptoms over the phone sound severe enough, then we will recommend that they either call an ambulance or report directly to the emergency room.

Very often though, we are able to get patients in to avoid that hospital trip. That is one of our main goals, as we mentioned, to keep people out of the hospital.

And once patients get comfortable with what we do in the clinic, they will often catch those signs and symptoms at the earlier stages before it gets to the point where they're needing to go emergently to the hospital.

Host Amber Smith: To join the Heart Failure Clinic, people are referred by physicians, is that right?

Kristin Ramella, NP: Yeah. As of right now, we, are able to see any patient that has a cardiologist within the Upstate system. And typically, if it's a cardiologist that's not working directly in our office, they will reach out and request for their patient to be seen in the Heart Failure Clinic, and Sarah and our other nurse, Patsy, are in frequent communication with them, as far as their treatment plan.

Host Amber Smith: Well, I want to thank both of you for making time to tell us about the Heart Failure Clinic.

Sarah Bobenhausen: Thank you. It was my pleasure.

Kristin Ramella, NP: Thank you, Amber. It was great speaking with you. Heart failure is something Sarah and I are very passionate about. We appreciate you taking the time.

Host Amber Smith: My guests have been nurse practitioner Kristin Ramella and nurse Sarah Bobenhausen, who's the clinical leader of the Heart Failure Clinic at Upstate.

I'm Amber Smith for Upstate's "HealthLink on Air."

And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.

Deirdre Neilen, PhD: Patricia Behrens is a poet from New York City. She writes movingly of the experience of caring for an ill spouse. Here is her poem "Normal."

Walking up 83rd from Columbus Avenue

we pretend we are climbing Everest --

the restaurant on the corner

is base camp; the first brownstone

halfway up the street, camp one;

the taller one further on, camp two.

Once past the synagogue, we are

on the final summit push.

The we of this, of course,

is partly pretend, too --

I'm the climbing guide; but you,

the climber, are doing all the work.

You, the unwell one, must endure, bear up;

I, the well one, must only cherish my good luck.

And this is how we live.

This is our version of normal.

And yet, and yet,

there are times I wonder

(if I'm honest, I admit it)

what would it be like to be released ?

To loosen my shoulders, free up my breath

refocus my eyes away from vigilance?

Would it be like arriving in the tropics

shedding winter clothes in sun?

Could I slip again into being just one --

just one person, someone, no one?

Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York. Next week on "HealthLink on Air": Is it COVID, the flu or another respiratory illness?

If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org.

Upstate's "HealthLink on Air" is produced by Jim Howe, with sound engineering by Bill Broeckel.

This is your host, Amber Smith, thanking you for listening.