Dr. Morris Salem - phaware® interview 483

Dr. Morris Salem is a pediatric congenital cardiologist and adult congenital heart disease specialist at Kaiser Permanente in Southern California. He takes care of patients of all ages, from fetuses to elderly individuals. Dr. Salem's primary focus is interventional cardiac catheterization, specifically the closure of holes in the heart. He also deals with pulmonary hypertension and collaborates with referring physicians throughout Southern California. Dr. Salem works within the Kaiser system, which provides care to all patients regardless of age, race, or financial abilities.

My name is Dr. Morris Salem. I am a pediatric congenital cardiologist as well as an adult congenital heart disease specialist at Kaiser Permanente in Southern California. I take care of patients from San Diego to Bakersfield, all around Southern California. The age groups are really from fetuses all the way up to 80, 90 year-olds, so cradle to grave.

Just to give you a little idea of what a typical day for me is, today is a Monday. I came in this morning. I went over to the OB facilities, where I saw several fetuses. These are babies inside their mothers who have been diagnosed with heart problems. That was my morning, counseling these families, helping them to understand what to expect, how we can shepherd this pregnancy along so that they have a healthy delivery. Once the baby comes out, then we can take over from there.

That led to noontime, where I did a consultation on a 65-year-old with a hole in her heart that we're hoping to be able to close in a noninvasive, or, I should say, less invasive, fashion, where she would stay in the hospital overnight and go home the next day.

Very briefly, I'll be talking to a family of a 4-year-old who was born with a heart problem that was inadvertently not picked up until very recently. We're going to try to help that child have a healthy and happy, normal, active life.

So a typical day for me is very unpredictable. I never know what I'm going to be dealing with. I never know the age groups of the patients I'm going to be dealing with. I come in, it could be a baby, it could be a fetus, it could be an adult. It keeps me on my toes. What makes it exciting is that it's always different. It's always interesting. It's always unpredictable. I never know what I'm dealing with as compared to other types of doctors, where they might see one type of patient day in and day out. That is not what I do.

My primary focus is interventional cardiac catheterization. We have a program here where we are very, very aggressive in transcatheter procedures and specifically with closure of holes inside the heart. We get referrals from all over Southern California. Part of our protocol is to do a diagnostic catheterization to really go inside and make sure that we're not missing anything, any diagnoses that have been potentially missed. As part of that, we measure pressures. We measure oxygen levels. We measure all sorts of different values and take pictures in all the different portions of the heart and the lungs to understand exactly what these numbers are. Is it okay for us to proceed with these interventional procedures, or are we going to do more harm by trying to intervene?

One of the procedures that we're very involved in is, again, the closure of these septal defects, specifically atrial septal defects. In the olden days, this is prior to 2000, most of these procedures were being done surgically. The patients would get referred to surgery, the surgeon would operate not really knowing or understanding exactly what the pressures were inside the heart and the lungs. A lot of those patients did not do very well. Now, with these alternative techniques that we have using devices, we are very, very careful to know and understand precisely what the pressures are. That's specifically to try to avoid these potential complications that can occur if you actually do proceed with the closure.

What we do is we measure everything, and if the numbers look favorable, we then proceed with the catheterization. If the numbers are not favorable, then what we try to do is do additional studies in the cath lab while the patient is still there to measure the response to various different medications so that we can offer the patient additional treatments so that someday we can come back and potentially close the hole in a much safer way.

Pulmonary hypertension is a big part of what we have to deal with, especially with patients who are born with these septal defects, whether they're between the upper chambers of the heart or the lower chambers of the heart. It's something that we see a lot of, and understanding the hemodynamics is very, very important before you can manage them with any kind of procedure.

When I first started my job, I used to travel to different hospitals, but I became so much busier that that just proved to be impossible driving around Los Angeles. It was really a waste of time, all those hours is going from hospital to hospital in a car. What we've developed is really a network model where a lot of doctors actually know me and they have my cell phone contact information. From San Diego all the way to Bakersfield, I get a lot of phone calls from these referring physicians who run things by me. if the patient sounds like there's something that needs to be done or intervened on or that we need to evaluate further, they're referred all the way up to Los Angeles where I can see them and deal with them, whether it's through some kind of a diagnostic procedure or a CT scan, MRI, or whatever the procedure may be. But that's how the referrals come up to us.

One of the advantages of the Kaiser system -- we're a massive, massive system close to 5 million members. And one of the advantages here is that we don't have to think about whether a patient is actually covered for a particular procedure or a particular problem. Once the patient is within our system, they get taken care of regardless of age, race, financial abilities. We take care of everybody once they're within our system. Oftentimes, that's without any out-of-pocket expenses.

Once they're in the Kaiser system, and the Kaiser system has different ways we get members, we have a lot of unions, we have individual companies that sign up for coverage. We have individual patients who find us through the internet, but we also have about a 20% rate of Medi-Cal patients. These are patients who typically do not have the resources to get private insurance, but they're assigned to Kaiser. Regardless of who they are, how they get Kaiser, and how they're assigned to one of the various different hospitals within Southern California, once they're within our system, we get them, we take care of them, whatever they need.

When I see a pregnant mother with her husband who have come in and they've had a recent diagnosis of a baby or fetus with a severe type of heart problem, it always comes as a shock to these families. As one would expect, both parents always internalize this, and they feel that it's their fault. That they did something wrong. That they didn't do something properly, they didn't eat the right kinds of foods, or they didn't exercise enough. Or maybe they walked by somebody who was smoking marijuana or something, anything. They reach for straws. It is incredibly difficult to try to impress upon these families that this really has nothing to do with that. It is not their fault.

These types of rare problems occur through nobody's fault, and regardless of how well you take care of yourself, what you do, that's not to say that you shouldn't do all of those things, but when it does happen, it's not your fault. We are here to help these parents and these families through this process and make sure that their children get the best care possible and the latest technology that is available to make sure that they live a long and healthy, happy life.

Honestly, whether you're 6 or 16 or 60, it makes no difference. You deserve the same exact quality of care, which is the absolute best that we can give you.

My name is Dr. Morris Salem, and I'm aware that my patients are rare.

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