Cedars-Sinai Medical Center

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A BI-WEEKLY PUBLICATION FROM THE CEDARS-SINAI CHIEF OF STAFF March 15, 2013 | Archived Issues

Curb Your South Mezzanine Parking - or Risk Losing Access

Physicians are reminded to please restrict their use of the South Mezzanine parking lot to short visits only. Use of the South Mezzanine lot is intended to provide easy access to the campus for physicians who come here for brief periods to round on their patients or attend meetings.

» Read more

Memorial Service for Leon Morgenstern, MD, Set for April 18

A memorial service for Leon Morgenstern, MD, will begin at 4 p.m. Thursday, April 18, in Harvey Morse Auditorium. Morgenstern was the founding director of Surgery for Cedars-Sinai and senior adviser to the Center for Healthcare Ethics.

» Read more

New Guidelines for Blood Transfusions Implemented

With a 200-year history that includes numerous safety advances, blood transfusion is one of medicine's oldest and most widely accepted practices. Yet recent studies have been unable to confirm the practice's benefit for many patients amid mounting evidence that it does more harm than good.

» Read more

Link Between Lifestyle, Insurance Premiums Subject of Debate

Residents Seth Felder, MD, and Tsuyoshi Todo, MD, will take the podium at the 10th Annual Dr. Leon Morgenstern Great Debates in Clinical Medicine Resident Competition on Thursday, April 18, at 8 a.m. in ECC A-C.

» Read more

CS-Link Tip: Creating a Quick Note

You can create a very fast addendum explaining the result of a test ordered in an office visit, without actually having to go in and open, sign and close an addendum.

» Read more

Improvements Made to CS-Link

Several improvements were added to CS-Link™ earlier this month. They include updates to Task Reminder and Chart Review, expansion of the Inter-Facility Transfer workflow, and improvements in the Notes function.

» Read more

Circle of Friends Honorees for February

The Circle of Friends program honored 136 people in February. Circle of Friends allows grateful patients to make a donation in honor of the physicians, nurses, caregivers and others who have made a difference during their time at Cedars-Sinai. When a gift is made, the person being honored receives a custom lapel pin and a letter of acknowledgement.

» Read more

July Is Coming, and So Are Fireworks, Sand 'N' Snore

It's not too early to start thinking about summer, and July has a couple of treats in store for medical staff members and their families.



» Read more

A Benign Brain Tumor, a Malignant Tumor, a Love Story and a Doctor's Reassuring Presence

Heather and Tony Tommasi's story involves a benign brain tumor, a malignant brain tumor, a Cedars-Sinai neurosurgeon and frequent reference to the word "fortunately."


» Read more

Curb Your South Mezzanine Parking - or Risk Losing Access

Above: Parking can be difficult in the South Mezzanine lot.

Physicians are reminded to restrict their use of the South Mezzanine parking lot to short visits only. Use of the South Mezzanine lot is intended to provide easy access to the campus for physicians who come here for brief periods to round on their patients or attend meetings.

Physicians who routinely violate the medical center's policy that restricts South Mezzanine parking to four hours or less during business hours (weekdays from 8 a.m. to 5 p.m.) are at risk of losing access to the lot. Warning letters to repeat offenders are being mailed to those individuals beginning this month.

"The vast majority of physicians who are on campus all day abide by the rules and park in other areas," said Chief of Staff Steve Galen, MD. "Unfortunately, a select few have chosen to park in the South Mezzanine all day, every day, making parking difficult for everyone else. We encourage you to park elsewhere, such as in Lot 8, which offers reserved parking for MDs and currently has an overabundance of these spots."

Memorial Service for Leon Morgenstern, MD, Set for April 18

A memorial service for Leon Morgenstern, MD, will begin at 4 p.m. Thursday, April 18, in Harvey Morse Auditorium.

Morgenstern, the founding director of Surgery for Cedars-Sinai and senior adviser to the Center for Healthcare Ethics, died Dec. 23 at his home in Malibu at age 93.

He joined Cedars of Lebanon as an attending physician in 1953, then became an attending in 1954 at Mount Sinai Hospital. He became Cedars of Lebanon's director of Surgery in 1960, and in 1970, at the creation of Cedars-Sinai, he retained that title.

Morgenstern served as Cedars-Sinai's director of Surgery until 1988, presiding over a time of sweeping change in his field, in medicine and at the medical center. He said the Department of Surgery had only 1.5 staff members when he started; there are more than 80 general surgeons alone in the department now.

Under his leadership, Cedars-Sinai won recognition for its pre-eminence in cardiothoracic and intestinal surgery. New techniques in surgical specialties were quickly adopted, including intraocular lenses and laser surgery in ophthalmology, artificial joints in orthopedics, prosthetic grafts in vascular surgery, kidney stone dissolution in urology, and the Swan-Ganz catheter and valve replacement in cardiac surgery.

For more information about the memorial service, contact Marina Gudelman at Marina.Gudelman@cshs.org or (323) 866-6250.

Morgenstern's obituary ran in the Jan. 4 issue of Pulse.

Memorial Service for Leon Morgenstern, MD - April 18 (PDF)

New Guidelines for Blood Transfusions Implemented

With a 200-year history that includes numerous safety advances, blood transfusion is one of medicine's oldest and most widely accepted practices. Yet recent studies have been unable to confirm the practice's benefit for many patients amid mounting evidence that it does more harm than good.

Patients who receive blood transfusions are at risk for adverse reactions that include transfusion-related acute lung injury, transfusion-transmitted infections, fluid overload, allergic reactions and hemolytic transfusion reactions.

Platelet Transfusion Guidelines

Platelet transfusions are the subject of a new alert being piloted on 4 South. Platelet transfusions are used in patients who have leukemia, are undergoing chemotherapy or have taken Plavix or aspirin when they arrive at the hospital bleeding or needing emergency surgery.

A Cedars-Sinai Medicine task force, which studied the appropriateness of blood transfusions, launched the alert, which pops up on CS-Link™ when physicians order platelet transfusions that do not meet the task force guidelines.

The guidelines, which are suggested but not mandated, recommend restricting platelet transfusions to patients with platelet dysfunction or patients with the following platelet counts:

  • Less than 10,000 u/L
  • Less than 20,000 u/L where there is evidence of bleeding, febrile neutropenia, sepsis or recent surgery
  • Less than 50,000 u/L prior to an invasive procedure
  • Less than 100,000 u/L with central nervous system bleeding or before invasive eye or brain surgery

"Evidence is accumulating to show that patients who receive blood transfusions do not have better outcomes, and often do worse, than similar patients who are not transfused," says Ellen Klapper, MD, medical director of Cedars-Sinai's Division of Transfusion Medicine. "Yet blood transfusion remains a standard accepted practice, as much an icon to medicine as apple pie is to America."

To ensure patients are spared the risks of unnecessary blood transfusions, Cedars-Sinai Medicine appointed a multidisciplinary task force which has developed best-practice guidelines in the appropriate use of blood transfusion therapy. The team reviewed published data and the recommendations of nine international bodies to develop guidelines for each blood component.

According to the new guidelines, red blood cell transfusions – the most common type – are appropriate but not mandated for patients with the following conditions:

  • Active bleeding
  • Hematocrit less than or equal to 21 percent or hemoglobin less than or equal to 7g/dL
  • Hematocrit less than or equal to 24 percent or hemoglobin less than or equal to 8g/dL for patients with coronary artery disease
  • Hematocrit less than or equal to 30 percent or hemoglobin less than or equal to 10g/dL for patients with subarachnoid hemorrhage with vasospasm (a serious type of stroke and complications)

The hemoglobin thresholds do not apply to patients experiencing active bleeding or symptoms related to hypoxemia, nor to patients for whom significant blood loss is anticipated, such as in the Emergency Department, operating rooms, procedure rooms or labor and delivery.

The C-S Medicine task force embedded the guidelines in an electronic alert on CS-Link™ that lets physicians know when an order for a red blood cell transfusion does not conform to trigger thresholds. Successfully piloted on three units before it was rolled out hospitalwide earlier this year, the alert does not prevent transfusion orders, but asks that physicians provide the reason they want to override the recommendations.

"These guidelines were developed after review of the best evidence in the literature," says Klapper, who served on the Cedars-Sinai Medicine task force, "but in no way do they replace clinical judgment."

The blood transfusion guidelines are among several best practices developed by Cedars-Sinai Medicine and are being implemented in collaboration with Nursing, Transfusion Medicine and EIS. Cedars-Sinai Medicine is under the direction of Glenn D. Braunstein, MD, vice president for Clinical Innovation.

Blood Transfusion Guidelines - 2013 (PDF)

Link Between Lifestyle, Insurance Premiums Subject of Debate

Residents Seth Felder, MD, and Tsuyoshi Todo, MD, will take the podium at the 10th Annual Dr. Leon Morgenstern Great Debates in Clinical Medicine Resident Competition on Thursday, April 18, at 8 a.m. in ECC A-C.

The topic is "Should Lifestyle Choices Affect Health Insurance Premiums?" Felder will argue that health insurance premiums should be tied to lifestyle choices. Todo will argue in opposition.

Click here to read about last year's debate, which focused on the influence of technology on the traditional doctor-patient relationship.

CS-Link Tip: Creating a Quick Note

You can create a very fast addendum explaining the result of a test ordered in an office visit, without actually having to go in and open, sign and close an addendum.

Follow these steps to create rapid documentation (details and screen shots can be found at cslinkcentral.org):

In your InBasket, Results Folder, click on the Result Note icon.

Document your thoughts in the main text box at the top right of the screen. The patient will be able to read your comment in their My CS-Link™ application, so remember it is very important that you write in terms the patient will understand (e.g.: no abbreviations. SmartPhrases are handy to quickly document wordy patient-friendly comments). Creating a Result Note will lock your interpretation against the result, which can be seen in when someone looks in Chart Review for the lab or procedure.

Just underneath this field, check the "Also File as a Quick Note" box. This places the exact same interpretation/follow up plan back on the encounter at which the test was ordered. (Another good reason for CPOE at the time of the visit.)

Routinely, if the physician does not wish to call the patient or write a letter, the result note is routed to appropriate staff to communicate with the patient. You can accomplish all of this (write the note, check the Quick Note box, route the chart to staff) with one action. 

The Quick Action functionality will be the subject of your next tip.

Visit cslinkcentral.org for details.

Improvements Made to CS-Link

Several improvements were added to CS-Link™ on March 5. They include updates to Task Reminder and Chart Review, expansion of the Inter-Facility Transfer workflow, and improvements in the Notes function.

Details and screen shots of these changes can be found at cslinkcentral.org

Updates to Task Reminder

Physicians who have telephone orders that have been unsigned for more than 36 hours will receive a "pop-up" alert (task reminder) directing them to their inbasket to sign them at log in.

This improvement will:

  • Eliminate unsigned orders over a 24-hour period
  • Increase ordering efficiency
  • Result in fewer physicians on suspension

Expansion of Inter-Facility Transfer Workflow (Form)

The new Inter-Facility Transfer workflow provides an electronic form for physicians (NPs or PAs) transferring their patient to a skilled nursing facility. This form captures critical elements needed to ensure high-quality patient care at the nursing facility. Once completed in CS-Link, the form is printed to accompany the patient to the skilled nursing facility.

The inpatient special providers piloted this form over the last several months. It will now be available to all units and services and is to be used in place of the paper process.

This improvement will streamline the efforts for coordinating and communicating pertinent clinical information between the medical center and patient's post-discharge care facility.

Updates to Chart Review

Improvements to Chart Review will provide a more user-friendly experience when searching for information within Chart Review.

These updates will take place in four categories:

  • Columns have been updated to provide consistency between tabs with matching content sources.
  • Quick filters have been added to provide easy access to pertinent data elements that might otherwise be easily buried in a large sum of records.
  • User-defined filter options have been updated and adjusted to provide intuitive and relevant choices.
  • Some content has been reorganized, such as transfusions moving to the Other Orders tab and Central Line, and theoracentesis and paracentesis procedures moving to the Procedures tab. Inpatient Consult orders have been updated to reflect as such and display their own tab.

This improvement will:

  • Provide a more user-friendly experience when searching for data
  • Allow for user-defined filter options

Updates to Notes Structure

Changes to the Notes activity improve physicians' ability to search and locate notes in a more intuitive fashion.

All midlevel and physician notes will display in the Physician tab, and the Progress Notes and Misc tabs have been removed. There is now a Use of Service field for midlevel and attending providers.

New notes types have been created which include Pre-Op and Post-Op. New note types will also include cosign note settings.

Improvements to existing note types include:

  • The Psych Note has been changed to Psych Consult – Initial
  • Operative Report now replaces OR Surgeon

All procedure-based notes will fall under the Procedures tab.

This improvement will:

  • Allow more efficient Note documentation
  • Allow for easy usability

Updates to Diabetes Alerts

CS-Medicine has requested diabetic Best Practice Alerts for the Inpatient setting. These BPAs will alert care givers to provide statins in the appropriate setting and use metformin with caution when diabetes patients have elevated creatinines.

This improvement will increase patient care and safety.

Improvements to Hospice/Palliative Ordering

The order for Consult to Hospice/Palliative Care is now split into two separate orders: Consult to Hospice, and Consult to Palliative Care.

This improvement will:

  • Improve patient documentation
  • Eliminate the misperception that palliative care and hospice are the same thing

Prevention of Duplicate Vent Check Orders

In the recent past, Respiratory Therapy started noticing duplicate vent procedures for certain patients who are already on an active vent. The duplicate procedure adds an extra point in the Points by Region Report when the staff changes shift. The solution to this issue is a new duplicate procedure check that verifies a patient is already on an active vent.

Improvements specific to Emergency Department

Updates to the Cedars-Sinai Emergency Department Notewriter Procedure preference lists allows for Emergency physicians to have access to existing Intubation, Central Line, and Chest Tube Insertion Notewriter Smartforms available to the Emergency physicians

Seven new Procedure Notewriter Templates determined by ED Only Procedures have been created:

  • Laceration Repair
  • Suture Removal
  • Epistaxis Management
  • Foreign Body Removal
  • Ear Cerumen Removal
  • Orthopedic Injury Treatment
  • Splint Application

Flowsheet name has been changed from "Flo G SHCH ED Ice Pack Given" to "Ice/Heat Applied" to allow for ED techs to include documentation if heat was applied to an area on the patient

Modifications have been made to Physician Notewriter print group to show only the final version of the note, eliminating unnecessary addendums to print appropriate discharge instructions for the patient.

Other general changes to CS-Link

  • Results Review Tree: Changes to the Results Review Tree enable end users to easily locate lab results that were not previously categorized. Previously, these lab results typically fell under the "Other" section.
  • After Visit Summary: The AVS will automatically pull in MRSA and Coumadin information, which will benefit patients who receive information about self-care. The change also improves compliance with state laws.
  • Home Health: Home health coordinators will now be able to ensure a smooth transition between inpatient care and home health agencies by having the ability to edit and annotate relevant patient information with the creation of a new SmartText. Upon its completion, home health coordinators can then print and fax the note to the agencies.
  • New RT orders: "PEP Valve" and "Acapella Flutter" procedure orders will now be available for Respiratory Therapy.

For more information and screen shots of these improvements, visit cslinkcentral.org

Circle of Friends Honorees for February

The Circle of Friends program honored 136 people in February.

Circle of Friends allows grateful patients to make a donation in honor of the physicians, nurses, caregivers and others who have made a difference during their time at Cedars-Sinai. When a gift is made, the person being honored receives a custom lapel pin and a letter of acknowledgement.

Click here for more information about the program and for a list of past honorees.

  • Daniel C. Allison, MD
  • Peter G. Anderson, RN
  • Jennifer T. Anger, MD, MPH
  • Laura G. Audell, MD, MS
  • Ana Maricel D. Basto, RN, ANCC
  • Andrew M. Braun, RN
  • Barry J. Brock, MD
  • Mathew H. Bui, MD
  • Christiane Michele J. Burnison, MD
  • Ilana Cass, MD
  • Henry H. Chen, MD
  • Donald S. Cohen, MD
  • Christine Collins, MD
  • Jeffrey L. Conklin, MD  
  • Ruth Cousineau, MD
  • Alice C. Cruz, MD
  • Scott A. Cunneen, MD
  • Dudley S. Danoff, MD
  • Mark M. Davidson, MD
  • Rick B. Delamarter, MD
  • Kathleen C. Delorimier, RN, BSN
  • J. Kevin Drury, MD
  • Marla C. Dubinsky, MD
  • Cheryl L. Dunnett, MD
  • Sylvia S. Estrada, RN, WHCNP-BC, MSN, MSHCM, BSN, CBCN
  • Joel D. Feinstein, MD
  • Larry Froch, MD
  • Gerhard J. Fuchs, MD
  • Rodney A. Gabriel, MD
  • Ryan P. Galang, RN-BC
  • Eden J. Garcia
  • Robert G. Garvin (deceased)
  • Ivor L. Geft, MD
  • Jordan L. Geller, MD
  • Armando E. Giuliano, MD
  • Richard N. Gold, MD
  • Neil J. Goldberg, MD
  • Marc T. Goodman
  • Lloyd B. Greig, MD
  • Hope C. Gruendler, RN, MSN, CNRN
  • Ankur Gupta, MD  
  • Michele A. Hamilton, MD
  • John G. Harold, MD, MACC, MACP   
  • Jeremy R. Herman, MD
  • Stuart Holden, MD
  • Keith W. Hoshal, MSN, RN-BC
  • Jethro L. Hu, MD
  • Wei G. Hu, RT, (R) (M)
  • Gabriel E. Hunt, Jr., MD
  • Bree Hysjulien
  • Marshal B. Kaplan, MD  
  • Saibal Kar, MD
  • Scott R. Karlan, MD
  • David Kawashiri, MD
  • Ali Khoynezhad, MD, PhD
  • Jacqueline S. King, RN, MSN  
  • Cord Kirshner, RN
  • Jon A. Kobashigawa, MD
  • Steven G. Koopman, MD
  • Penelope Grace Kornbluth, MSN, ANP, APRN-BC
  • Timothy LaBelle, BA, RT(T)
  • Nadia U. Lansing, RT, (R) (M)
  • Kara E. Lauko, RN
  • Anita S. Lee, RN
  • Nora B. Levid, RN
  • Andrew J. Li, MD
  • Aliza A. Lifshitz, MD
  • Stephen W. Lim, MD
  • Cynthia A. Litwer Schwieger, MD
  • Joyce G. Lopez
  • Patrick D. Lyden, MD
  • James F. MacDonald, RN, BSN, MPH
  • Ezra Maguen, MD
  • Rajendra Makkar, MD
  • Lucy Mathew, NP
  • Ruchi Mathur, MD
  • David N. Matsumura, MD
  • Robert Maxwell, RN
  • Nancy M. McCreary, MS, DABR
  • Robert J. McKenna, Jr., MD
  • Zoila I. Melara
  • Leslie Memsic, MD  
  • Stewart Middler, MD, PhD
  • Doris S. Moradzadeh, MD
  • Jaime D. Moriguchi, MD
  • Franklin G. Moser, MD
  • Howard M. Moss, MD
  • Larry H. Nagaoka  
  • Ronald B. Natale, MD
  • Adriana N. Neff, RN, MSN
  • Christopher S. Ng, MD
  • Victoria K. Nigro, RN-BC
  • Nicholas N. Nissen, MD
  • Dorothy J. Park, MD
  • Jhomania Parker
  • Mark Pimentel, MD
  • Terry E. Podell, MD
  • Ralph T. Potkin, MD
  • Levon Qasabian, MD
  • Alexandre Rasouli, MD
  • Bobbie J. Rimel, MD
  • Robert M. Rose, MD
  • Barry E. Rosenbloom, MD
  • Howard L. Rosner, MD  
  • Allison E. Rotter, MSW
  • Jeremy D. Rudnick, MD
  • Gregory P. Sarna, MD
  • Jay N. Schapira, MD
  • Stephanie A. Schick, RN
  • Prediman K. Shah, MD
  • John L. Sherman, MD
  • Randolph Sherman, MD
  • Takahiro Shiota, MD
  • Robert J. Siegel, MD
  • Allan W. Silberman, MD, PhD
  • Suzanne Silverstein, MA, ATR
  • Jasprit K. Singh, CNMT
  • R. Kendrick "Ken" Slate, MD
  • Enrique Slodownik, MD
  • Jonathan Soldwisch
  • Karyn Morse Solky, MD
  • Carlos E. Sosa
  • Andrew Ira Spitzer, MD
  • Jerrold H. Steiner, MD
  • Leslie Stricke, MD
  • Ronald Sue, MD
  • Steven W. Tabak, MD
  • Katie D. Tran, RN, BSN, PCCN
  • Irina Vinogradova, RN, BSN, PHN
  • Christine S. Walsh, MD
  • Alan Waxman, MD
  • Jonathan M. Weiner, MD
  • Michael H. Weisman, MD
  • Joanna L. Wilson, RN
  • Edward M. Wolin, MD
  • Sheila A. Wood

July Is Coming, and So Are Fireworks, Sand 'N' Snore

It's not too early to start thinking about summer, and July has a couple of treats in store for medical staff members and their families:

Hollywood Bowl Fireworks – July 3

Celebrate Independence Day with fireworks and music by the Hollywood Bowl Orchestra and special guest Josh Groban. The event on Wednesday, July 3, is open to Cedars-Sinai physicians and their immediate family members. Cost is $125 per adult and $60 per child younger than 12. To reserve tickets, call Cheryl Verne (in the office of Marjorie Santore Besson) at (310) 423-2681.

>> See coverage of last year's event.

Sand 'N' Snore – July 19

The dinner, sleepover and breakfast starts Friday, July 19, at the Jonathan Beach Club in Santa Monica. Those who don't want to sleep on the sand are welcome to enjoy dinner and the evening with colleagues and their families. There's a limit of one tent per physician. Tickets for the whole event are $65 per adult and $40 for each child under age 12. Tickets for Friday's dinner only are $50 per adult and $20 for each child younger than 12. Call Cheryl Verne (in the office of Marjorie Santore Besson) at (310) 423-2681 to reserve your spot.

>> See coverage of last year's event.

A Benign Brain Tumor, a Malignant Tumor, a Love Story and a Doctor's Reassuring Presence

Keith L. Black, MD, (left) with Heather and Tony Tommasi and their children.

Heather and Tony Tommasi's story involves a benign brain tumor, a malignant brain tumor, a Cedars-Sinai neurosurgeon, and frequent reference to the word "fortunately."

It started 19 years ago, long before the Southland couple met, when Heather, then 19, fell while mountain biking, suffering a concussion. She was treated at a community hospital and released but had a seizure the next morning and was rushed back to the facility, where doctors discovered she had a brain tumor.

"One of their brain surgeons saw me, and what he said was very scary: 'You'll probably lose motor skills and you might not be able to speak anymore.' It was just terrible," said Heather Tommasi, recalling the doctor's gruff bedside manner.

Fortunately, Heather's grandmother, a psychologist, was familiar with the work of Keith L. Black, MD, professor and chair of the Department of Neurosurgery at Cedars-Sinai. Heather's family arranged a consultation.

"It was a Friday, and he said, 'You'll be fine. You're just going to be sick for a while. We can't use lasers or anything. We have to go in through the top of your head.' We booked the surgery for the following Monday," said Heather, who suffered from a colloid cyst of the third ventricle, one of the chambers through which cerebrospinal fluid flows to bathe the brain.

According to Black, it is a benign tumor that can have life-threatening consequences.

"In some patients, this is associated with a syndrome called sudden death. Even though the patients may not have any symptoms, when they make very quick head movements or bend forward, the tumors can move and irritate the area around the third ventricle. We don't know quite what the mechanism is, but these people can suddenly die. The tumors also can affect short-term memory, and they can block the fluid's ability to get out of the brain, building up dangerous pressure," said Black, director of the Maxine Dunitz Neurosurgical Institute and the Johnnie L. Cochran Jr. Brain Tumor Center and the Ruth and Lawrence Harvey Chair in Neuroscience.

"To take these tumors out, we use a corridor to go between the left and right halves of the brain, where they are separated by a very thick membrane," Black added. "We can sneak down and make just a little incision, about a half inch long, in the area called the corpus callosum, which puts us right at the third ventricle. We then use microscopic guidance to remove the tumor."

Heather's surgery and recovery progressed according to plan, and she soon resumed her normal life. Ten years later, she went to work for an Internet marketing company, where she met, became friends with, and fell in love with Tony Tommasi, one of the founders. She was at his apartment in August 2004 when Tony had a seizure. She called paramedics, who took him to the hospital where her tumor had been diagnosed 11 years before.

When a CT scan revealed a golf-ball-size tumor in the left frontal lobe of Tony's brain, dangerously close to areas controlling language, Heather predicted that Tony would receive a visit from a blunt doctor with a gloomy prognosis. She was right. Fortunately, she already knew, as she describes him, a skilled, calming and reassuring neurosurgeon; she had even done volunteer work at Cedars-Sinai's Department of Neurosurgery as a way to help patients and to express her appreciation for the care she had received.

"We just adore him and his staff. They're amazing," she said. She collected Tony's scans and had them at Black's office when it opened in the morning.

Unlike Heather's tumor, Tony's was malignant, an aggressive grade III anaplastic oligodendroglioma. Black was able to remove the entire tumor visible under magnification and imaging — a key factor because tumors can regrow from any cells left behind. Tony was awake during the operation to be sure his language areas remained intact. He followed up with a course of chemotherapy pills and got into the routine of undergoing regular MRIs to detect any recurrence as early as possible.

Tony and Heather got married on Aug. 6, 2006, and now have three children. The couple continued to work together in Internet marketing and recently started a new venture that enables customers, using a computer and webcam, to "try on" clothing and accessories before buying.

But last August, Tony suffered another seizure, and after again being transported to the small hospital's emergency room — "I always end up there," he says with a laugh — he quickly made his way back to Cedars-Sinai. The tumor had returned, but fortunately, the new growth was very small. Even more fortunately, after Black removed it on Sept. 25 — again with "awake surgery" that protected Tony's language skills — it was found to be a less aggressive, lower-grade form than the original.

Noting that the first surgery and treatment gave him eight good years without recurrence of the aggressive tumor, Tony looks at this battle with characteristic humor. "I've had my second surgery and everything is positive and optimistic so far. I'm just going into the chemical phase to see if we can extend my life with the 15- or 20-year plan," he said. "Dr. Black is a man of few words, and he doesn't need to speak much. He's very optimistic about this round, and I'm going to try to keep him out of my brain as much as possible."

From left: Gabriella, Maximillian, Heather and Angelica Tommasi; Keith L. Black, MD; and Tony Tommasi.