27 June 2013

Six common surgeries often done unnecessarily

Story originally appeared on USA Today.

Caution: Six common surgeries are often done unnecessarily, including stents, pacemakers and spinal fusions, according to medical research and government databases

Here are six common surgeries that carry significant risks of being done without medical necessity, according to federal data and independent studies.

Cardiac angioplasty, stents:

A 2011 study in the Journal of the American Medical Association looked at angioplasty procedures, which often include insertion of stents. In cases where patients were not suffering acute heart attack symptoms, 12% of all angioplasty procedures were found to lack medical necessity.

"This procedure (angioplasty), along with stenting, has been proved to protect the heart or prolong life only in people highly susceptible to heart attack," Consumer Reports wrote in 2005. "In everyone else, it appears only to ease angina. Further, the procedure has risks, including, in two to six percent of patients, heart attack, stroke or death."

Cardiac pacemakers:

A 2011 study in the Journal of the American Medical Association reviewed records for 112,000 patients who had an implantable cardioverter-defibrillator (ICD), a pacemaker-like device that corrects heartbeat irregularities. In 22.5% of the cases, researchers found no medical evidence to support the installation.

A 1988 study in the New England Journal of Medicine reviewed 382 pacemaker implants at 30 Philadelphia-area hospitals and found that 20% of the procedures were not medically warranted.

Back surgery, spinal fusion:

A 2011 study, in the journal Surgical Neurology International, assessed the medical records of 274 patients who were told they needed spinal surgery. More than 17% had no abnormal neurological or radiographic findings in their case histories.

"Since the 1980s, operations for low-back pain have increased from about 190,000 to more than 300,000 per year," Consumer Reports noted in 2005. "Many of those operations are probably unnecessary."

Hysterectomy (surgical removal of the uterus):

In a 2000 study for the American College of Obstetricians and Gynecologists, researchers assessed hysterectomies on 497 women in Southern California. They found the surgery was recommended inappropriately in about 70% of cases, often because doctors did not try non-surgical approaches.

"The conditions that most often cause pelvic pain or abnormal bleeding — fibroids, or benign tumors; endometriosis, or growth of uterine-like tissue on abdominal or pelvic organs; and hormonal imbalances — can all be treated less aggressively," Consumer Reports reported. Other potential options: therapy to reduce estrogen levels or surgery to remove fibroids but retain the uterus.

Knee and hip replacement:

In a 2012 study in Health Affairs, researchers provided patients in a Washington state health system with "decision aids," which included information on joint replacements and alternative treatments. The researchers found that patients who got the information had 26% fewer hip replacements and 38% fewer knee replacements.

Cesarean section:

In a 2013 study in Health Affairs using data from 593 hospitals nationwide, researchers found that cesarean rates varied tenfold across hospitals, from 7.1% to 69.9%. Among women with lower-risk pregnancies, where researchers expected less variation, cesarean rates varied by a factor of 15, from 2.4% to 36.5%. "Vast differences in practice patterns are likely to be driving the costly overuse of cesarean delivery in many U.S. hospitals," the study concluded.

24 June 2013

Men Over 40 Should Think Twice Before Running Triathlons

Story Originally Appeared in Bloomberg News

For men competing in triathlons past the age of 40, the grueling slog to the finish line could be their last.

As the average age of competitors in endurance sports rises, a spate of deaths during races or intense workouts highlights the risks of excessive strain on the heart through vigorous exercise in middle age. Among the recent casualties: Michael McClintock, senior managing director of Macquarie Group Ltd. and a triathlete, who died at age 55 of cardiac arrest earlier this month after training.

The 40-to-60-year age bracket, often referred to as middle aged men in Lycra, or Mamils, now holds 32 percent of the membership in USA Triathlon, the sport’s official governing body in the U.S. More fitness conscious than previous generations, their numbers in competitive races are swelling, along with their risk of cardiac arrest. Triathlons, the most robust of endurance races requiring swimming, biking and running, are also believed to be the most risky.

“People need to understand that they’re not necessarily gaining more health by doing more exercise,” said David Prior, a cardiologist and associate professor of medicine at the University of Melbourne. “The attributes to push through the barriers and push through the pain are common in competitive sport, but that’s also dangerous when it comes to ignoring warning signs.”

While benefits of exercise are well-known, researchers now suspect that there may be a point at which exertion becomes dangerous, especially for middle aged men who, because of gender and changes that accompany aging, are more susceptible to cardiac arrest caused by vigorous exercise.

Cardiac Arrest

Cardiac arrest, which occurs when the heart suddenly stops beating, can be caused by almost any heart condition, including abnormal heart rhythm, thickening heart muscle and arteries -- changes that can occur silently as healthy people age. The risk of sudden cardiac arrest, which can be brought on with physical stress, increases with age, and men are two to three times more likely to suffer from it than women, according to the National Institutes of Health.

McClintock, the Macquarie Bank executive who died on June 2 at his home in Larchmont, New York, was an avid skier, biker and golfer. The previous September, he completed the Jarden Westchester Triathlon, his first Olympic-length event, taking less than 4 hours to swim 0.9-miles (1.4 kilometers), cycle 25 miles and run 6.2 miles.

While McClintock’s death can’t be directly linked to the race, USA Triathlon has noted an increase in race-related fatalities, with the highest number occurring in the 40-to-49-year age group.

Triathlon Risk

The death rate for triathlons is about twice that of marathons because of increased intensity of the competition and the initial swimming leg of the events, according to a 2012 study published last year in the journal Mayo Clinic Proceedings.

“The swim seems to be a particularly dangerous time,” said Andre La Gerche, a cardiologist at Melbourne’s St Vincent’s Hospital and marathoner. “Paradoxically, in the marathon, it’s the opposite: it’s the last mile of the event where the vast majority of fatalities occur.” Researchers speculate that sprinting to the finish produces a rush of adrenalin that may trigger an abnormal rhythm in runners with susceptible hearts.

‘Fighting to Breathe’

The swim leg of the triathlon, often held in open water, can be “extraordinarily stressful,” said La Gerche, who has also competed in more than 100 triathlons. “You have people climbing all over you. Sometimes you’re fighting to breathe, and that’s not something the body is used to.”

Open-water racing triggers a clash of two mechanisms of the involuntary nervous system, according to researchers at England’s University of Portsmouth. A “fight or flight” response activated by physical exertion, cold water temperature or anxiety tries to speed up the heart rate and causes hyperventilation, just as the body tries to slow the heart rate to conserve oxygen in response to facial wetting, water entering the mouth, nose and throat, and extended breath-holding, the scientists said.

“Normally the two responses don’t happen at the same time, but when they do, the heart can go into abnormal rhythms, which can cause sudden cardiac death,” Mike Tipton, who runs the university’s Extreme Environments Laboratory, wrote in a commentary for the British Journal of Sports Medicine in February.

Train to Sprint

Runners should maintain their pace or slowdown in the last mile and not sprint unless they have trained for it, the International Marathon Medical Director’s Association, a doctor’s group, said in 2010 in a list of recommendations in response to race-related sudden deaths.

Running appears to lower the risk for mortality when an athlete doesn’t exceed more than 20 miles a week, log more than five to seven miles per hour, or run more than two to five times a week, researchers at the Ochsner Health System of New Orleans and the University of South Carolina found in a study last year.

More than 2 million people participate in long-distance running races in the U.S. each year -- a number that has doubled since 2000. Even though the risk of death from marathon-running is small, increased participation has resulted in a higher incidence of sudden death at the events, according to a study published in the New England Journal of Medicine in January 2012. Out of 11 million long-distance runners, 59 people suffered cardiac arrest, 51 of them men.

Causes of cardiac events in athletes vary depending on age. For those under 35, cardiovascular conditions are usually inherited. Heart incidents in older athletes can be due to coronary artery disease that they don’t know they have, Melbourne cardiologist Prior said.

Vessel Disease

By middle age, most people have developed some underlying early stage vessel disease, such as hardening or plaque buildup in their coronary arteries, said Kade Davison, who teaches clinical exercise science at the University of South Australia in Adelaide.

“If anyone is going to have a cardiac event they’re far more likely to have one during exercise,” said Davison. A person is seven times more likely to have a heart incident while exercising than at rest, he said, citing a 1984 New England Journal of Medicine study.

A person’s electrolyte balance changes while doing long distance endurance events like marathons or long cycle rides, Davison said. People might also suffer potassium or sodium depletion, or become dehydrated, which also contributes to extra stress on the heart.

Heart Tears

Intense exercise for periods longer than one to two hours can cause over-stretching and tiny tears of the heart’s tissue, said James O’Keefe, a sports cardiologist and head of preventative cardiology at the Mid America Heart Institute in Kansas City, Missouri. This type of repeated injury over years can cause irregular heart rhythms, increased inflammation, scarring and stiffening of the arteries, he said.

Athletic over-achievers tend to think that “more is better,” though when it comes to health, “moderation is almost always best,” said Mid America Heart Institute’s O’Keefe.

As a precaution, getting a computerized tomography, or CT, scan of the heart to look for calcified plaque is a good way for endurance athletes to check if their workouts are putting their heart at risk, O’Keefe said. Yet there is no agreement on what the best strategy is for testing.

‘No Good Test’

“The throwaway line is to consult your doctor to make sure you’re fit to race,” said Melbourne cardiologist La Gerche. “The only good tests depend on people having symptoms and telling their doctors. In healthy asymptomatic people, there is no good test to see if someone is at risk of sudden death.”

Those who experience a bit of chest pain or become breathless should see a doctor to check it out, especially if the discomfort occurs during training, said University of South Australia’s Davison. Sudden events that occur in people who have had no previous sign of heart disease usually indicate a build-up of plaque.

When plaque ruptures, it can cause a clot in an artery, which often doesn’t show up in typical stress tests of ECG monitoring of the heart’s electrical activity. Clots aren’t often detected until the heart becomes stressed enough to cause a rupture, causing sudden onset of chest pain, Davison said.

Screening typically would have more value in people who are new to exercise and don’t know whether they have developed a disease. People who regularly exercise without any symptoms aren’t likely to show any signs in a stress test, Davison said.

Competition Changes

World Triathlon Corp., the owner of the sport’s Ironman-branded events, made changes to the swim portion of select races after an increase in competitor deaths in recent years, the company announced last month.

Events in Coeur d’Alene, Idaho; Lake Placid, New York; and Mont-Tremblant, Quebec, no longer feature a mass swim start, eliminating a long-standing Ironman tradition. Athletes at those races will either enter the water in a continuous stream through an access point, with their time starting when they cross a timing mat, or in staggered waves based on their age group.

The changes came two months after Ross Ehlinger, a 46-year-old man from Austin, Texas, died during the swim portion of the Escape from Alcatraz Triathlon and nine months after Andy Naylor, a 43-year-old member of the Hong Kong Police Force, died near the conclusion of the 2.4-mile swim portion of the New York City Ironman. In 2011, two competitors died during the swim portion of the Olympic-distance New York City Triathlon.

MetaMan Iron

Other organizers are also taking precautions. On the last day of August, triathletes will gather on the beach of Bintan, Indonesia and participate in the MetaMan Iron Distance race. Two speedboats will be on hand to help racers in the event of a medical emergency, said organizer spokeswoman Hollie Avil.

O’Keefe advises his patients, especially those over 45, to run no more than 20 miles a week, spread out over three to four days.

“That’s not to say you can’t get problems when you’re under 45,” said O’Keefe. “But you’re much more susceptible when you’re over 45 because it just takes longer for your body to recover and when you hammer it day in and day out, it just takes a toll on your body.”

21 June 2013

Cardiac deaths like James Gandolfini's are too common

 Story Appeared in USA TODAY

The American Heart Association's president talks about how heart attacks can be avoided.

The news that James Gandolfini, 51, star of The Sopranos, died of cardiac arrest stunned his fans, but for medical experts, it was a reminder of the thousands who remain at risk of a similar fate all the time.

Claudio Modini, head of the emergency room at the Policlinic Umberto I hospital in Rome, said Gandolfini suffered a cardiac arrest and was pronounced dead at 11 p.m. Wednesday after resuscitation efforts in the ambulance and hospital failed. An autopsy will be performed. Originally, it was reported that Gandolfini died of a heart attack.

A heart attack may cause cardiac arrest and sudden death. Heart attacks are caused by a blockage that stops blood flow to the heart. Cardiac arrest is an abrupt loss of heart function caused when the heart's electrical system malfunctions. About 360,000 cardiac arrests are assessed by emergency medical services in the USA annually.

About 715,000 people in the USA will have a new or recurrent heart attack this year, according to the American Heart Association. The average age of the first heart attack is 64.7 years for men and 72.2 years for women.

USA TODAY talked to Donna Arnett, the president of the American Heart Association and the American Stroke Association, about the risk of having a heart attack and ways to avoid it. Arnett is chairman of the department of epidemiology in the School of Public Health at the University of Alabama at Birmingham.

The answers below are from both Arnett and the American Heart Association website:

Q: What is a cardiac arrest? Is it the same as a heart attack?

A: No. The term heart attack is often mistakenly used to describe cardiac arrest. Though a heart attack may cause cardiac arrest and sudden death, the terms don't mean the same thing. Heart attacks are caused by a blockage that stops blood flow to the heart. A heart attack refers to death of heart muscle tissue due to the loss of blood supply, not necessarily resulting in the death of the heart attack victim.

Cardiac arrest is caused when the heart's electrical system malfunctions. In cardiac arrest, death results when the heart suddenly stops working properly. This may be caused by abnormal, or irregular, heart rhythms called arrhythmias. A common arrhythmia in cardiac arrest is ventricular fibrillation. This is when the heart's lower chambers suddenly start beating chaotically and don't pump blood. Death occurs within minutes after the heart stops.

Cardiac arrest may be reversed if CPR (cardiopulmonary resuscitation) is performed and a defibrillator is used to shock the heart and restore a normal heart rhythm within a few minutes.

Q: How common is it for someone in their 50s to have a heart attack?

A: Though risk for heart attacks increases with age, it is not uncommon for a heart attack to occur in the early 50s. Data from one study show that for every 1,000 men, ages 45-54, three will have heart attacks every year. This is why it is important for men and women to visit their health professional to be screened for conditions that increase heart disease risk, such as high blood pressure, high blood cholesterol and type 2 diabetes.

Q: Could Gandolfini's weight have contributed to heart troubles?

A: Obesity is a contributor to the risk of heart attack. We know that excess body weight raises blood cholesterol and blood pressure and can induce type 2 diabetes.

Q: What is a heart attack?

A: A heart attack occurs when the blood flow that brings oxygen to the heart muscle is severely reduced or cut off completely. This happens because coronary arteries that supply the heart muscle with blood can slowly become narrow from a buildup of fat, cholesterol and other substances that together are called plaque. This slow process is known as atherosclerosis.

When plaque in a heart artery breaks, a blood clot forms around the plaque. This blood clot can block the blood flow through the heart muscle. When the heart muscle is starved for oxygen and nutrients, it is called ischemia. When damage or death of part of the heart muscle occurs as a result of ischemia, it is called a heart attack or myocardial infarction (MI). About every 34 seconds, someone in the USA has a myocardial infarction or heart attack.

18 June 2013

Hospitals and doctors should be required to carry medical malpractice insurance

Story Originally Appeared in the Chicago Tribune

Corporations, hospitals and insurance companies have fought for more than two decades to chip away at Americans' right to enter a courtroom and seek damages for medical negligence. The most publicized of these efforts has taken the form of capping the damages that patients can collect.

Now there's another effort to limit medical negligence claims. It has the effect of preventing an injured patient from filing a lawsuit at all.

Hospitals and doctors are simply "going bare" — in other words, not carrying medical malpractice insurance. Hospitals and doctors will often set up a corporation, forgo the purchase of malpractice insurance, and if the corporation is sued, file for bankruptcy and set up a new corporation.

In Illinois, although a driver must have insurance to get behind the wheel, a hospital that cares for thousands of patients is not required to have insurance.

In one case, in 2007, a 21-year-old woman had a baby at a South Side hospital, St. Bernard. Due to a lack of oxygenated blood, the baby's brain was damaged. We sued St. Bernard on behalf of the child, alleging negligence. The hospital said that it had no malpractice insurance to cover the claim. Now, the young mother and her baby must go through life without enough money for proper care. (St. Bernard says the infant was treated appropriately and it has done what it can to resolve the matter.)

Hospitals and doctors that choose to go bare often claim they cannot afford to pay high insurance premiums while at the same time caring for their patients. Insurance companies blame the high premiums on large verdicts that they allegedly pay out. Yet, the blame for the inflation of premiums in Illinois must be placed on the insurance companies. It has been proved that even where insurance companies have had to pay out large jury verdicts or settlements, increased premiums do not correlate with the increase or decrease in payouts during any given year.

Every hospital in Illinois should be required to carry a minimum of $5 million in liability coverage. A small tax could be charged on those hospitals that can afford the coverage, which could be used to supplement the payments of hospitals that cannot afford it. This would allow all hospitals to have some insurance coverage while motivating hospitals to press insurance companies to lower premiums.

The solutions are not complicated, yet they require action soon. This reform will not come without pressure from all parties — the doctors and hospitals that buy insurance, the Illinois legislature and trial lawyers.

Deratany and MacIver are lawyers at the Deratany Firm in downtown Chicago.

Physicals at $2,500 Lure Executives With Thorough Scans

Story Originally Appeared in Bloomberg News

Physicals at $2,500 Lure Executives With Thorough Scans

Standard physicals are, well, pretty standard. During a visit geared more toward detecting disease than preventing it, your doctor makes you cough and checks your numbers. If there’s an abnormality -- your blood pressure has spiked or your liver enzymes are elevated -- it’s your schedule that suffers as you’re shuttled between specialists.

Now, there’s an alternative, loosely known as the executive health checkup. Participants in these programs spend $2,500 and up to receive daylong, state-of-the-art examinations administered by top U.S. hospitals, such as the Ronald Reagan UCLA Medical Center in Los Angeles, and specialty clinics, like the Princeton Longevity Center in New Jersey, that have emerged as global pioneers of the service. The aim: a more complete picture of your health, with clearer, actionable takeaways, Bloomberg Pursuits will report in its Summer 2013 issue.

Investment banker Mark Sweeney enrolled in the Princeton program after his primary-care physician told him he needed a statin to help control his elevated cholesterol.

“Considering the possible side effects of the drug and the limited usefulness of a standard cholesterol test, I didn’t feel comfortable with that course of action,” says New York-based Sweeney, 43, who maintains his 5-foot-9-inch (1.8-meter), 165-pound (75-kilogram) frame through healthy eating and regular running.

Cholesterol Picture

At the Princeton facility, an hour’s drive from Manhattan, exam day begins with blood work at 9 a.m. During this phase, clients such as Sweeney learn that the cholesterol picture has become more complicated in recent years, as research has shown that some forms of the so-called bad LDL cholesterol may actually be benign.

“The standard cholesterol test is about as useful as flipping a coin,” says Dr. David Fein, the program’s director.

Clients then receive a whole-body CT scan that Fein scours for tumors, aneurysms and plaque buildup. A series of other tests examine lung function and declines in bone density, hearing and vision. Patients will also see an exercise physiologist, who looks for imbalances and weaknesses in the body, as well as a nutritionist, who makes dietary recommendations.

The dozens of hospitals now offering such programs take a similar approach, with the all-in-a-day aspect specifically designed for the busy executive.

“Many of my clients are on the road half the year,” says Dr. Mark Moon, medical director of the Mayo Clinic’s Executive Health Program, in Jacksonville, Florida. “This is often the only time they see a physician.”

CT Scans

One concern surrounding CT scans is radiation exposure. However, according to the Environmental Protection Agency, the radiation from newer machines is the same as you would be exposed to by living in Denver for two years rather than at sea level.

Michael Ray, 58, credits the tests he received at the UCLA Comprehensive Health Program with helping him lose 50 pounds.

“It’s hard to ignore the facts when you’re looking at a complete picture of your health,” the Woodland Hills, California-based chief executive officer of Orchid Insurance Brokers says.

Another concern is the risk of false positives, which can lead to unnecessary treatment.

False Positives

“The more tests you do, the more likely one is to turn up positive,” says Dr. Stephen Lefrak, a professor of medicine and expert in medical ethics at the Washington University School of Medicine in St. Louis. “Only a handful of screening tests beyond those for cervical, colon and rectal cancer are of proven efficacy in terms of prevention.”

One thing directors of these programs prefer not to test for is Alzheimer’s disease.

“We can tell you that your risk of developing the disease might be 30 percent,” Fein says, “but the value of that information is pretty limited.”

When the day concludes, around 4 p.m., clients depart with their scans and test results bound into a thick dossier. At Princeton, if a recommendation such as losing 25 pounds seems too daunting, a subsequent program for $500 a year includes videoconferencing and an iPhone app to monitor diet and exercise.

Sweeney didn’t require such a follow-up, as Fein deemed his overall health picture good, including the cholesterol levels that had brought him to the Longevity Center in the first place.

’Valuable Base Line’

Fein did inform Sweeney that he had poor upper-body muscle mass for his age, putting him at risk of osteoporosis later in life. Weaknesses in his back were also compressing his vertebrae, and although Sweeney didn’t yet feel pain, the condition could eventually become debilitating.

“The results provide a valuable base line,” says Sweeney, who’s now pursuing a rigorous strength-training regimen and will return again in five years.

“Executives are goal oriented, and that’s how we are,” says Dr. Benjamin Ansell, director of the Comprehensive Health Program at UCLA. “If we explain the science to them, they usually take that data and make good decisions.”

U.S. charges 89 people with healthcare fraud

Story Appeared on REUTERS

U.S. Attorney General Eric Holder said on Tuesday the Department of Justice had charged 89 defendants in eight cities with healthcare fraud, and warned that budget cuts could limit future efforts to crack down on fraudulent claims.

The government's sixth national crackdown on healthcare fraud since 2010 involved $223 million in fraudulent claims in jurisdictions including Miami, Detroit, Los Angeles and Brooklyn, New York, the Justice Department said.

But Holder said efforts to expand the battle against fraud is being affected by automatic across-the-board federal budget cuts, known as sequestration, which have stripped $1.6 billion in funding from the Justice Department for the fiscal year ending September 30.

"Unless Congress adopts a balanced deficit reduction plan and stops the reductions currently slated for 2014, I fear our capacity to protect the American people from healthcare fraud ... will be further reduced," Holder said.

Since 2007, officials say the government's Medicare Fraud Strike Force has charged more than 1,500 defendants who have falsely billed the Medicare program for the elderly and disabled for $5 billion.

(Reporting By Susan Heavey and David Morgan; Editing by Sandra Maler and John Wallace)

Post-childbirth stroke didn't stop mother from raising her boys

Story Appeared on Detroit Free Press

• Editor's note: We asked Free Press readers to share their reflections on motherhood. They responded in a big way. Jim Boyle, a Detroit-based marketing executive, told a powerful story of triumph about his mother, Liz Boyle.

I was born in Detroit at 8:58 a.m. Aug. 22, 1969. Sometime around 9:58 a.m., my mother, Liz Boyle, suffered a major stroke.

She was 27. Her last rites were administered, but she’s really not that easy to erase, either from this world or, as people often tell me, your thoughts in general. From that day forward this was our bond, her and I. This moment of my birth. A bond not unlike other mothers and sons, but not exactly the same either.

My mom is paralyzed on the right side of her body. She lost the use of her strong, right-hand side. She had to learn to walk and talk all over again. The day after my birth, my dad, Rory Boyle, turned 30. His wife was in a coma, and he had four boys, age 6 and younger. My mom and I were separated at birth, at least for a few months, with her in the hospital and me with my Uncle Mike and Aunt Connie.

While my mother was recovering, one knuckle-headed doctor suggested to my parents that my mom be institutionalized. Permanently. She stammered, spit, kicked and hit in response. “I don’t think she agrees with you,” my dad chuckled to the doctor. From that moment, my mom insisted in very clear terms –– even though she couldn't talk at the time –– on three things: she would be with her husband, she would raise her boys and she would drive (my particular favorite).

From what I remember in my early years, she really did achieve the level of normalcy she desired, at least in my mind. When I was 3, my parents moved to the quiet town of Port Austin, on Lake Huron, where they still live today, for a slower life that provided a little more independence.

In between heavy speech therapy and becoming a rock star in the physical therapy community, with a noticeable schedule of workouts that she continues to this day, my mother shuttled my brothers and I to basketball, football, track and more. My older brothers have stories of early seizures that have long since stopped, and I remember the day she traded in the heavy metal brace and went on a shoe-shopping spree to rival Imelda Marcos.

Over the years, stories of “Liz’s episode” were told, but they became sort of folklore. Even though she walked differently and talked slowly, and my friends asked about her every once in a while, she was just Mom. Ridiculously funny, socially gifted (regardless of any speech issues), fearless and big-hearted — the center of a family. She helped zip up my coat, but she did it with one hand. She folded my clothes using her teeth. She drove a crazy car with an extra gas pedal for her left foot (my brother Brian once mistook it for the brake, but that’s another story). Her one-armed bear hugs couldn't have been any bigger if she had three arms.

I remember one time in particular when the full weight of her greatness hit me. When I was about 16, my mom’s brother, Joe, sought my brother Ray and I out at a wedding. He deeply adored my mother and, for that, we adored him.

That night he hunted us down with purpose. We stood there, him between us. He was animated at first, and then settled into a stare-ahead posture that was a weird mix of discomfort and certainty. And then began the story of a dinner party. It was at my parents’ house with he and Aunt Shirley, his wife, and my Aunt Lou (my mom’s sister) and Uncle Ray. My mom was in the infancy of her recovery, shuffling very slowly with a heavy brace and still teaching her mouth to catch up with the wonderful thoughts in her brain.

It was apparent, my uncle explained, that she was determined to be the hostess, doing what hostesses do –– greeting, setting the table, cooking, retrieving, and so on, but moving painfully slow. Others, of course, started tripping over themselves to help her out. I imagine taking dishes out of her one good hand, stepping quickly around her to gather stuff — all before she could communicate her own intent.

“Your dad, he stops right there in the middle of the room and tells everyone to sit down,” my uncle told us. “While your mom just keeps going, slowly. It’s excruciating to watch your sister this way.

“I ignored him and kept helping. Everyone did. And then ... he just grabbed my arm, looked me in the face like he was about to hit me and says, ‘Joe you can sit down, or you can leave,’ ” Uncle Joe told my brother and I.

“So I sit down. Mary Lou sits down. We all sit. Even your dad sits at times. I’m clutching the table like I’m gonna turn it over. No one says anything. It felt like forever. Your mom just goes to work. Your dad chipping in, but no one else. Your Aunt Lou is crying. I wanted to kill your dad as we all watched my sister, your mom, plod on.”

Uncle Joe is just staring straight ahead, like we weren’t even there and I could tell he was about to cry. Right there in the middle of a wedding reception, describing a moment in time 15 or 16 years after it happened.

Then he kinda snaps back and says, “those are some amazing people you have as parents” and ambles away. Now it’s important to note that those of us in the know intuitively understand that the decision to proceed with dinner in that fashion was in no way a singular decision. My father is not a cruel man by any means, and my mother is no shrinking violet. This was, and always will be, a partnership forged in what I consider to be one of the greatest love stories ever. Together, this is how they got better.

Either way, I’ll never forget that story. The courage it must have taken both my parents to defy every instinct they and everyone around them had. The love it must have taken, and the immeasurable trust –– bigger than their own families –– required between both of them on that day, and in a million little moments since, as they raised four little people to be pretty OK big people.

The courage of my mom, in particular, has grown in my mind as I’ve aged to understand its depth. Slowed but determined, of sound mind, but not always able tell everyone else that she knew in her heart that everything would be OK. That things would be “normal.”

At 43, I now know that my mom is some sort of superhero. Like most moms, but not exactly the same either. In many ways, I’m sure that’s what makes many moms, moms –– that unheralded quality.