August 2011 JMSMA

August

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Lucius M. Lampton, MD Editor D. Stanley Hartness, MD Richard D. deShazo, MD AssociAtE Editors Karen A. Evers MAnAging Editor PublicAtions coMMittEE Dwalia S. South, MD chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD Leslie E. England, MD, Ex-Officio Myron W. Lockey, MD, Ex-Officio and the editors thE AssociAtion Thomas E. Joiner, MD president Steven L. Demetropoulos, MD president-elect J. Clay Hays, Jr., MD secretary-treasurer Lee Giffin, MD speaker Geri Lee Weiland, MD vice speaker Charmain Kanosky executive director Journal of the Mississippi state Medical association (issn 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual).

Periodicals postage paid at Jackson, MS and at additional mailing offices. correspondence: Journal MSMA, Managing editor, Karen a. evers, p.o. Box 2548, ridgeland, Ms 39158-2548, ph.: (601) 853-6733, fax: (601)853-6746, www.MsMaonline.com. suBscription rate: $83.00 per annum; $96.00 per annum for foreign subscriptions; $7.00 per copy, $10.00 per foreign copy, as available. advertising rates: furnished on request. cristen hemmins, hemmins hall, inc. advertising, p.o. Box 1112, oxford, Mississippi 38655, ph: (662) 236-1700, fax: (662) 236-7011, email: cristenh@watervalley.net postMaster: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 391582548.

The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association. copyright© 2011 Mississippi state Medical association.

AUGUST 2011

VOLUME 52

NUMBER 8

Scientific ArticleS

Non-enteral Therapy for Hypertension in the Inpatient Setting

243

Ashraf S. Abdo MD and Stephen A. Geraci MD

Clinical Problem-Solving: Doctor, Please Don’t Send Me Home Like This!

PreSident’S PAge

Reflections on a Squashed Resolution

255

Thomas E. Joiner, MD; MSMA President

SPeciAl Article

Greater Jackson Chamber Partnership Announces Mississippi Healthcare Corridor

258

Karen A. Evers, Managing Editor

editoriAl

Who Will Care for the Newly Insured Under Health Reform?

263

Richard D. deShazo, MD, Associate Editor

relAted orgAnizAtionS

Mississippi State Department of Health

253

dePArtmentS

The Uncommon Thread Placement/Classified

270 272

About the cover:

Zion EvangElical luthEran church, lunEnburg, nova Scotia, a gErman SEttlEmEnt on thE atlantic coaStlinE — Hannelore H. Giles,

MD, a retired internist/ cardiologist from Hattiesburg, took this photograph on a recent visit to the Atlantic Canadian Province. This church has been described as the “Rock of Lutheranism” in Canada. It is the oldest worshipping Lutheran congregation in the country and traces its history back to the earliest days of the settlement. The church is designed in the High Victorian Gothic style. Its long gable roofed nave has a main gable end which is richly ornamented with moulded wooden belt courses, dentil courses, and a large stained glass window. Asymmetrical buttressed towers are attached at the corners of the nave. The small tower has a pointed doorway at ground level, a circular “oculus” window on the second story, paired lancet windows on the third level, and a squat, pyramidal tower with a louvered gablet on its front face and a finial at its peak.

The larger tower has a pointed arched doorway built out in relief from the main wall and an ascending series of mullioned lancet windows on the second and third stories. A tall spire caps the fourth story belfry with small louvered gablets on four sides. r August

VOL. LII

official publication of the MsMa since 1959

250

Patrick Whipple, MD

2011

No. 8

August 2011 JOURNAL MSMA 241

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242 JOURNAL MSMA

August 2011

• Scientific Articles • Non-enteral Therapy for Hypertension in the Inpatient Setting Ashraf S. Abdo MD and Stephen A. Geraci MD

A

introduction

bStrAct

Chronic hypertension requiring treatment with regularly administered oral medications is the most common cardiovascular disease among adults. When patients with hypertension suffer an illness which requires hospitalization and precludes normal oral drug intake, blood pressure may rise sufficiently to require alternative treatments. Consequences of the acute illnesses themselves and their treatments may also elevate blood pressure and further complicate antihypertensive management.

The optimal medical regimen to control blood pressure under these circumstances depends upon a number of variables, including co-morbid conditions, concurrently administered drugs, and the overall clinical stability of the patient.

This paper reviews issues related to hypertension in the hospitalized patient unable to take oral medications and summarizes antihypertensive treatment options based on clinical and pharmacological considerations.

Key WordS:

hyPertenSion, non-enterAl therAPy, inPAtient SettingS

Author informAtion: Dr. Abdo is in the Department of Medical Service at the G.V. (Sonny) Montgomery Veterans Affairs Medical Center and is also affiliated with Dr. Geraci in the Department of Medicine, University of Mississippi School of Medicine in Jackson. correSPonding Author: Ashraf S. Abdo, MD, Medical Service (111), 1500 E. Woodrow Wilson Dr., Jackson, MS 39216. Phone: 601-3641251 Fax: 601-364-1278 (Ashraf.Abdo@va.gov).

Dislosures: All authors were fully involved in all aspects of the preparation of this manuscript, qualify as contributing authors, and have approved this work in its final version. No authors have any real or apparent conflicts of interest, financial or otherwise, related to the topic or content of this article. No grant or other financial support was used in the preparation of this manuscript.

Hypertension, the most common chronic cardiovascular disease, affects millions of Americans and results in acute and chronic complications when untreated. Blood pressure control during acute illness is believed to result in better clinical outcomes and reduced costs in the intensive care and inpatient settings. 1 In hospitalized patients, uncontrolled hypertension can result in acute end organ damage and precipitate life-threatening complications including myocardial infarction, stroke, aortic dissection and acute kidney injury. Consequences of acute illnesses (including pain, anxiety, tachypnea, inflammation, viscus distention) and their treatments (saline infusion, intubations, ventilator interactions) may further elevate blood pressure, complicating hypertension management.

In contrast to patients whose acute illness is manifested by acute/severe hypertension requiring directed therapy (e.g., hypertensive emergencies, cocaine or methamphetamine intoxication, eclampsia), chronic hypertension patients who suffer any of a number of acute illnesses may be unable to take oral medications. Patients who are confused, agitated, heavily sedated, supported by mechanical ventilation, or who are physically incapacitated may not be able to swallow pills or liquids reliably. A large percentage of patients may be intolerant of any medications administered through the upper gastrointestinal tract – including those with intra-abdominal emergencies, major trauma or recent laparotomy, peritonitis, bowel obstruction or inflammation, ileus, or severe hepatobiliary disease. Yet these same individuals may have required three or more drugs several times daily to achieve blood pressure control at baseline, prior to the added stress of their acute illness. Under these circumstances, alternative treatments are often needed to maintain blood pressure in a safe range. 2

August 2011 JOURNAL MSMA 243

generAl conSiderAtionS Optimal blood pressure goals for acutely ill patients are less clearly defined and supported by less evidence than are those for stable outpatients. Maintaining systolic pressure <180 mm Hg is reasonable for most patients, but exceptions exist.

Concomitant diseases drive the clinical decision for an optimal range in many instances. Patients with subarachnoid hemorrhage, for example, often require higher systolic pressures to limit reflex intracranial vasospasm which could worsen their neurologic injury. 3 Some patients with severe systemic atherosclerosis and hypertension which has been poorly controlled chronically may also require higher blood pressures to avoid acute ischemic injury to vital organs (brain, kidney), the mesenteric bed, and/or lower extremities. Alternatively, for others following major vascular surgery, those who are pregnant or have critical coronary artery disease, usual target ranges may be too high, and pressures as low as achievable but which still maintain adequate organ perfusion may be preferable. 4,5 As opinions vary, the goal blood pressure for any given hospitalized patient should be based on the most recent research and recommendations for the disease processes present combined with clinical assessment for adequacy of perfusion and adverse effects of any pressure achieved.

The etiology of acute blood pressure elevations must be considered before starting hypotensive medications. Pain and anxiety can elevate blood pressure significantly (especially in patients with underlying chronic hypertension) and may be signs of new complications (e.g., ventilator dyssynchrony, pneumothorax, bowel or bladder distension); 6 after addressing or excluding such complications, analgesics and sedatives will often be sufficient to normalize blood pressure in these settings. Withdrawal from alcohol, narcotics or sedatives may also cause severe hypertension, and treatments directed at these conditions will reduce blood pressure in appropriate patients.

Finally, patients taking long-acting antihypertensive medications (e.g., angiotensin receptor blockers, amlodipine) prior to hospitalization will have drug effects wane with time, resulting in rising baseline blood pressure during the initial hospital days; 7 occasionally, rebound from the abrupt discontinuation of potent short-acting drugs such as clonidine can manifest as acute hypertension within the first 24-48 hours in the hospital. 8 Concurrent diseases can direct non-enteral antihypertensive medication choice in several ways. Conditions affecting drug distribution, metabolism or excretion of specific drugs or drug classes (e.g. acute kidney injury, heart failure, shock, hepatic insufficiency) may increase risk of toxicity. The pharmacologic effects of some drugs (e.g., venodilation from nitroglycerin or sodium nitroprusside, or reduced efferent arteriolar glomerular pressure from angiotensin converting enzyme inhibitors) may contra-indicate their use in patients with specific disorders (for example elevated intracranial pressure or advanced bilateral renal artery stenosis), 9 while others (e.g., angiotensin converting enzyme inhibitors) are contra-indicated in concurrent conditions such as pregnancy. 10 Ongoing obli-

244 JOURNAL MSMA

August 2011

gate treatment with medications for acute disorders (e.g., CYP 3A4-inhibiting antibiotics or proton pump inhibitors) can predispose to dangerous drug interactions with some antihypertensive medications (e.g., calcium channel blockers). 11 Conversely, when an antihypertensive drug could simultaneously treat another disorder requiring intervention, such as a beta blocker reducing ventricular response in atrial fibrillation, its aggregate benefit may suggest its use as a first option. 12 Another key consideration is the clinical stability of the patient and the probability that blood pressure fluctuations may be frequent or abrupt. In these circumstances, a highly titratable intravenous infusion drug with rapid onset of action and short effective half-life is preferable so adjustments can be made as needed with sudden changes in clinical status. As patient condition stabilizes, a change to longer-acting agents can simplify care and provide a more stable pharmacologic baseline regimen.

Patients with intact gut function but who will be unable to take pills or capsules for days-weeks may be considered for nasogastric or percutaneous-gastric tube drug administration.

Though most oral medications can be crushed and suspended or dissolved in water, or formulated in liquid preparation, several issues must be considered. Many once-daily oral medications are short acting drugs in a delayed release vehicle or tablet; such are usually designated as “LA,” “SR,” or “TR” for longacting, sustained release, or timed release, respectively. These preparations cannot be crushed, as the total amount of drug will be immediately available for absorption and cause acute toxicity; immediate release formulations of these drugs, with intermittent dosing, must be used for enteral administration. Also, some medications such as diltiazem will bind to polymers in nasogastric tubes, reducing the dose delivered to the stomach for absorption. 13 The frequent use of gastric acid suppression (histamine-2 receptor blockers or proton pump inhibitors) for stress ulcer prophylaxis can prevent acid conversion required for optimal absorption or for conversion of a prodrug to active form for some agents, while administration via tubes positioned in the duodenum (bypassing the stomach) may similarly reduce effective delivery of these agents to the circulation. 14 A few drugs are available in both enteral and parenteral formulations. Patients on chronic therapy with labetalol, certain beta blockers, hydralazine, enalapril, non-dihydropyridine calcium channel antagonists, nicardipine, and loop diuretics may be given intravenous forms of their regular drugs with appropriate dose adjustments to correct the bioavailable dose for absorption and first pass metabolism. Clonidine can be changed to a once-weekly transdermal patch though a significant delay (36-72 hours) in onset of action occurs with this route in the drug-naive patient (see below).

intrAvenouS AntihyPertenSive medicAtionS These drugs can be grouped by their mode of administration: continuous intravenous infusion, intermittent or continuous intravenous infusion, and intermittent infusion/bolus only.

Table 1: infusion medications Table 1. Intravenous Intravenous infusion medications Drug / Class

Mechanism of action

Dose

Onset

Effective half life

Metabolism / Excretion

Sodium nitroprusside9, 10 / nitrosovasodilator

Balanced arterial and venous dilation

0.1 – 10 mcg/kg/min

30 sec2 min

3-4 min

Liver / kidney

Nicardipine 11 / dihydropyridine calcium channel blocker

Systemic, coronary and cerebral arterial dilation

10 min

8 hrs

Liver

Fluid retention, headache, flushing, tachyarrhythmias

Coronary artery disease, renal failure, stroke, cerebrovascular disease, pregnant patients

Fenoldopam 12/ dopamine receptor agonist

Splanchnic vasodilation

4-5 min

3-5 min

Hepatic conjugation

Nausea, flushing, headache

Coronary artery disease, azotemia , cerebrovascular disease

Esmolol 13/ Cardiospecific betaadrenergic blocker

Reduced myocardial contractility and cardiac output

2-10 min

9 min

erythrocyte esterase

Avoid in severe systolic heart failure, bradycardia, AV block, reactive airway disease

Tachycardia, tachyarrhythmias, coronary artery disease, high sympathetic states, liver or renal dysfunction

Clevidipine 15-17/ dihydropyridine calcium channel blocker

Systemic arterial vasodilation

2-4 min

1 min

Erythrocyte esterase

Reflex tachycardia,

Liver or renal dysfunction

1-2 min

Erythrocyte s and vascular endothelium

Avoid with increased intracranial pressure, methemoglobinemia, intrapulmonary shunt in chronic lung disease

Heart failure, coronary artery disease

18

Nitroglycerin / nitrosovasodilator

Venodilation, reducing preload and cardiac output

5 mg/hr, Increase by 2.5 mg/hr every 5 min to max of 15 mg/hr 0.1 mcg/kg/min, increments 0.05 – 0.1 mcg/kg/min to max of 1.6 mcg/kg/min 500 mcg/kg load, 50300 mcg/kg/min, reload with 50 mcg.kg with each 25-50 mcg/kg/min dose increment 1-2 mg/hr, double dose at 2 min intervals, max 32 mg/hr 5-20 mcg/min, max 200 mcg/min in drug-naïve patients

1-2 min

Two transdermal agents are available for longer-term hypertension management.

Many drugs can be given by continuous intravenous infusion (Table 1). These agents typically are short-acting with a potent therapeutic effect which requires close monitoring in an intensive or special care unit.

Sodium nitroprusside Sodium nitroprusside is a high potency, highly titratable, balanced (arterial and venous) vasodilator which acts through nitric oxide. Continuous invasive blood pressure monitoring is recommended during its use. Major concerns regarding toxicity is the formation of thiocyanate and cyanide, accumulation of which can result in impaired mental status and diffuse cellular dysfunction; however, this is rarely seen unless high doses (>3 mcg/kg/min) are administered for prolonged periods (>3 days) in patients with compromised renal function (serum creatinine >3 mg/dL). Tachyphylaxis can develop from sodium retention (a reflex response to reduced renal perfusion pressure) and efficacy can usually be restored by adding diuretics to the regimen. The venodilating effect contra-indicates its use in patients with increased intracranial pressure resulting from trauma, tu-

Precautions and Adverse Effects Thiocyanate / cyanide toxicity (especially in renal dysfunction), increased intracranial pressure, headache, flushing, fluid retention, reflex tachycardia

Preferable settings

Unstable patient requiring frequent dose titration, severe hypertension

mor or hemorrhage, and reflex tachycardia can be troublesome in patients prone to arrhythmias or suffering active myocardial ischemia. The drug requires special handling and packaging to prevent degradation by light. 15, 16 Nicardipine Nicardipine, a second generation dihydropyridine calcium channel blocker, increases left ventricular stroke volume and coronary blood flow primarily through arteriolar dilation.

It is effective in the setting of acute myocardial ischemia, acute renal failure and acute stroke (hemorrhagic or ischemic) and is considered safe for pregnant patients. Because nicardipine does not cause venodilation, intracranial pressure elevations may be less frequent than with nitroprusside. Its half-life is considerably longer than nitrosovasodilators (nitroprusside, nitroglycerin). 17

1 Fenoldopam Fenoldopam, a peripheral dopamine (DA-1) agonist, reduces blood pressure primarily via splanchnic arteriolar vasodilation. Its onset and duration of action are longer than those of nitroprusside. It appears to preserve creatinine clearance, urine August 2011 JOURNAL MSMA 245

flow rates and sodium excretion in severely hypertensive patients with normal or impaired kidney function. 18 Esmolol Esmolol is an ultra short-acting cardioselective beta-adrenergic receptor antagonist. With the recommended loading dose, its onset of action is rapid. Hydrolysis by erythrocyte esterases results in a short half-life, though clearance can be prolonged in severe anemia. 19 Additional loading doses are required with each increase in infusion rate to achieve new steady state concentration and effect rapidly. It is typically selected in unstable patients specifically requiring beta blockade (e.g., patients with tachycardia/tachyarrhythmias, myocardial ischemia, or with a predominate beta agonist mechanism to their hypertension). It can precipitate bronchospasm in patients with reactive airway disease but is less likely to do so than other parenteral beta blockers. 20

Clevidipine Clevidipine is a new ultra short-acting selective arteriolar vasodilator with rapid onset and termination of action. Metabolized via hydrolysis by erythrocyte esterases, its kinetics appear predictable in patients with compromised liver and/or renal function. A third-generation dihydropyridine calciumchannel blocker, it reduces arteriolar resistance as its primary hemodynamic effect. Reflex tachycardia is generally less severe than with other vasodilating antihypertensive drugs. Its profile differs from that of nicardipine primarily by its much shorter terminal half-life. 21-23 Nitroglycerin Nitroglycerin is a potent venodilator, affecting systemic arterial and coronary resistance vessels only at high doses. Its rapid onset and short duration of action make the drug highly titratable. Nitroglycerin decreases blood pressure by reducing preload and cardiac output, limiting its safety in patients with compromised cerebral or renal perfusion or ventricular non-

Table 2. Intravenous infusion or intermittent dosing Drug/Class

Labetolol 19/ Nonspecific beta adrenergic blocker and peripheral alpha adrenergic blocker

Furosemide 20/ Loop diuretic

Bumetanide 20/ Loop diuretic

Torsemide 20/ Loop diuretic

Mechanism of action Reduced cardiac output and systemic arterial dilation Naturesis and venodilation, reduced preload causing reduced cardiac output Naturesis and venodilation, reduced preload causing reduced cardiac output Naturesis and venodilation, reduced preload causing reduced cardiac output

Dose

5 min

5 hrs

20-160 mg bolus every 6-12 hrs, 0.25-0.75 mg/kg/hr infusion

<5 min

1-8 mg bolus every 8-12 hrs, 0.5 â&#x20AC;&#x201C; 2.0 mg/hr infusion

10-20 mg bolus every 12 hrs, 5-20 mg/hr infusion

Diltiazem / Non-dihydropyridine calcium channel blocker

20 mg (0.25 mg/kg) over 2 min, repeat 25 mg (0.35 mg/kg) if needed, 5-15 mg/hr infusion

Verapamil 21/ Non-dihydropyridine calcium channel blocker

Mixed arterial and venous dilation and reduced cardiac output

0.1 mg/kg bolus, 0.1 0.2 mg/kg/hr infusion

246 JOURNAL MSMA

Effective half life

20 mg bolus, repeat 20-80 mg bolus at 10-15 min intervals, 1-2 mg/min, max dose 300 mg/24 hr

Mixed arterial and venous dilation and reduced cardiac output

21

Onset

August 2011

Metabolism/ Excretion

Precautions and Adverse Effects

Preferable settings

Liver

Avoid in severe systolic heart failure, bradycardia, AV block, reactive airway disease

Cerebrovascular disease, pregnancy, tachyarrhythmias

2 hrs

Liver and kidney

Volume depletion, Na/K/Ca/Mg loss

Volume-expanded states, second drug with vasodilators

<5 min

1 hr

Liver (oxidation)

Volume depletion, Na/K/Ca/Mg loss

Volume-expanded states, second drug with vasodilators

<5 min

3-4 hrs

Liver (oxidation)

Volume depletion, Na/K/Ca/Mg loss

Volume-expanded states, second drug with vasodilators

Liver via CYP 3A4

Avoid in systolic heart failure and bradycardia/AV block, drug interactions via CYP3A4

Tachycardia/tachyarrhythmias, peripheral arterial disease

Liver via CYP 3A4

Avoid in systolic heart failure and bradycardia/AV block, drug interactions via CYP3A4

Tachycardia/tachyarrhythmias, peripheral arterial disease

2-7 min

2-5 min

3-7 hrs

3-7 hrs

compliance. Its efficacy is limited by its predominate venodilatory action, and the drug is rarely used as a single agent to reduce blood pressure; it is considered as suitable adjunctive therapy with other intravenous agents in patients with acute coronary syndromes or hydrostatic pulmonary edema where its preload reduction is a beneficial effect. Patients who are intravascularly depleted may demonstrate profound orthostatic hypotension during nitroglycerin infusion. Methemoglobinemia has been reported rarely as has remarkable hypoxemia in patients with severe structural lung disease. 24 Drugs may be given by intermittent intravenous dosing or infusion (Table 2). These agents offer some additional flexibility in administration and can often be used outside the intensive care setting in more stable patients.

Labetalol Labetalol can be administered as a loading dose, followed by repeated incremental doses at 10 minute intervals until the desired blood pressure is achieved. This is then followed either by a continuous infusion of the drug or intermittent IV administration every 2-4 hours. Labetalol, a nonselective beta-blocker with modest peripheral alpha-1 adrenergic blocking effect, is metabolized by the liver. It may maintain cardiac output better than other beta blockers because of its vasodilatory actions. It reduces systemic vascular resistance without reducing total peripheral perfusion and does not appear to compromise cerebral, renal or coronary blood flow. Because its low lipid solubility limits transplacental transfer, labetalol can be used in pregnant patients. 25 Loop diuretics Parenteral loop diuretics are rarely used as monotherapy of hypertension. Furosemide, bumetanide and torsemide must be administered at least twice daily to reduce blood pressure reliably. Reduced creatinine clearance, hypokalemia, magnesium and calcium depletion, and hypovolemia may limit their use in the acutely ill patient. Most patients with moderate-severe

chronic hypertension require diuretics, particularly if receiving other drugs such as potent vasodilators, to reverse sodium retention from reduced renal perfusion pressure. Although furosemide can be administered by continuous intravenous infusion, this is rarely necessary when used as an adjunct to other antihypertensive drugs. Patients recovering from perioperative fluid loading and those with volume expansion from renal dysfunction or heart failure often experience effective blood pressure reduction with loop diuretic therapy. 26 Non-dihydropyridine calcium channel blockers Verapamil and diltiazem can both be administered as a loading dose followed either by continuous infusion or intermittent intravenous dosing. At equi-hypotensive doses, verapamil displays slightly more myocardial depressant activity while diltiazem produces slightly more vasodilation. Patients with diastolic left ventricular dysfunction, coronary artery disease, and chronic recurrent or acute supraventricular arrhythmias (including atrial fibrillation, atrial flutter, multifocal atrial tachycardia and atrioventricular nodal re-entrant tachycardia) may be effectively treated with either agent. Significant systolic heart failure, sinus bradycardia and AV block are considered contraindications to their use, and concurrent administration with beta blockers can result in excessive bradyarrhythmias.

Drug interactions can occur when administered concomitantly with agents metabolized by cytochrome P-450 3A4. 27 Drugs may be given by intermittent intravenous dosing (Table 3). In stable patients, these agents can usually be administered in the non-critical care setting with noninvasive blood pressure monitoring. Additional caution should be exercised until a stable dose is determined.

Beta-adrenergic blockers Metoprolol is a moderately selective beta-1 receptor antagonist while propranolol is a non-selective beta receptor blocker. Caution should be exercised when using these agents in patients with bradyarrhythmias or heart block, severe sys-

Table 3. Intermittent intravenous dosing Drug / Class

Mechanism of action

Dose

Onset

Effective half life

Metabolism/ Excretion

22

Metoprolol / Cardioselective beta adrenergic blocker

Reduced cardiac output

2.5 â&#x20AC;&#x201C; 15 mg every 4-8 hrs

2-5 min

3-6 hrs

liver

Propranolol 22/ Nonspecific beta adrenergic blocker

Reduced cardiac output

1-3 mg every 4-6 hrs

2-5 min

3-6 hrs

liver

Enalaprilat 23/ Angiotensin converting enzyme inhibitor

Arterial and venous dilation via inhibited renin angiotensin axis

1.25 â&#x20AC;&#x201C; 5 mg every 6 hrs

30 min

11 hrs

kidney

Hydralazine 24, 25/ Direct-acting arterial vasodilator

Arterial vasodilation

5-20 mg every 4-6 hrs

5 min

2-4 hrs

Liver (acetylation) / kidney

Precautions and Adverse Effects Avoid in severe systolic heart failure, bradycardia, AV block, reactive airway disease Avoid in severe systolic heart failure, bradycardia, AV block, reactive airway disease Avoid in pregnancy, bilateral renal artery stenosis, hyperkalemia, severe renal impairment, angioedema Unpredictable magnitude of doseresponse, reflex tachycardia, reduce dosing frequency in renal failure

Preferable settings Tachycardia, tachyarrhythmias, coronary artery disease, high sympathetic states Tachycardia, tachyarrhythmias, coronary artery disease, high sympathetic states

Systolic heart failure

Pregnancy

August 2011 JOURNAL MSMA 247

tolic heart failure (on acute administration) or reactive airway disease. They can be administered intermittently every 4-6 hours. Patients with resting tachycardia or requiring concurrent treatment of ischemic heart disease are excellent candidates for parenteral beta blockade. These drugs should not be used alone in patients with nonspecific adrenergic agonists (therapeutic or recreational) contributing to their hypertension, as peripheral beta-2 blockade may worsen alpha agonist-mediated vasoconstriction. 28 Enalaprilat Enalaprilat, an intravenous angiotensin converting enzyme inhibitor, demonstrates a delayed onset of action with peak effect from a single dose not achieved for about 1 hour.

Its relatively long duration of action is a disadvantage for acute hypertension control but useful for longer-term treatment.

These drugs have a ceiling effect when initially started that is largely independent of dose; therefore enalaprilat is rarely used as monotherapy except in patients chronically taking the drug orally. For patients with systolic heart failure, this drug can play a dual therapeutic role. As with all angiotensin converting enzyme inhibitors, kidney function and potassium should be monitored closely, especially among the acutely ill. Nonsteroidal anti-inflammatory drugs are contra-indicated in patients receiving angiotensin inhibitors as the combination can precipitate acute renal failure. Angioedema with upper airway obstruction can occur even in patients previously tolerant of oral formulations. Enalaprilat should not be administered if bilateral renal artery stenosis is suspected. 29 Hydralazine Hydralazine is a direct-acting arterial vasodilator. The onset of action is moderately rapid but its long duration of action (up to 6 hours) and unpredictable acute effect make titration difficult. Like labetalol and nicardipine, it is considered safe to use in pregnant patients. Reflex tachycardia, tachyarrhythmias, and sodium retention are moderately frequent side effects. Genetically-determined fast acetylators will show a blunted peak effect and shorter duration of action, requiring more frequent dosing. Longer dosing intervals are recommended in patients with significant renal dysfunction. 30, 31

trAnSdermAl AntihyPertenSive drugS

Clonidine Clonidine, a centrally acting alpha-2 agonist, is effective as monotherapy in mild-moderate hypertension and in combination with diuretics, angiotensin converting enzyme inhibitors and/or calcium channel blockers for more resistant/severe hypertension. It has been used peri-operatively and for controlling adrenergic symptoms in patients withdrawing from opiates and ethanol. In comparison with oral clonidine, a once weekly transdermal clonidine patch results in a lower incidence and reduced severity of such side-effects as dry mouth and sedation.

248 JOURNAL MSMA

August 2011

Minor skin reactions may occur at the site of patch application.

Transdermal clonidine can be a useful, convenient agent in patients who will need long-term, non-enteral therapy outside the intensive care unit. Altered mental status and bradycardia/AV block are considered relative contra-indications. It can be particularly useful in patients requiring additional rate control of permanent atrial fibrillation for whom calcium channel antagonists and/or beta blockers may be contra-indicated or are insufficiently effective. Upon initial administration, transdermal clonidine will not achieve steady-state blood levels for up to 48 hours; conversely, drug sequestration in subcutaneous fat tissue generally limits acute withdrawal when the patch is removed. 32 Nitroglycerin Transdermal nitroglycerin (in patch or ointment preparations) is another non-enteral alternative to reduce blood pressure. It is usually applied for 12-14 hours and then removed for a 10-12 hour nitrate-free interval to limit the development of tolerance. Severe hypotension, particularly with upright posture, may occur with even small doses in patients with intravascular volume depletion. Nitroglycerin may cause a â&#x20AC;&#x153;paradoxicalâ&#x20AC;? bradycardia in high doses and increased angina in patients with severe, proximal coronary obstructions. As single agents, nitrates are rarely effective in controlling hypertension due to their predominant venodilatory action and high incidence of tachyphylaxis during continuous administration. 33

rArely uSed drugS

Phentolamine is an intravenous nonspecific peripheral alpha-adrenergic blocker. It is rarely used except in cases of catecholamine excess and is generally not considered a reasonable option in other settings. 34

concluSion Management of hypertension in the inpatient setting, especially among the critically ill, remains a challenge. Currently available non-enteral antihypertensive drugs provide a wide spectrum of options, though no evidence supports improved objective clinical outcomes from any agent in this setting. Clinical considerations of patient stability, co-morbid diseases, and concurrently administered drugs guide selection of the most rational treatment options.

AcKnoWledgment

We would like to thank Ms. Dianne Jones at the G. V. (Sonny) Montgomery VA Medical Center Library Service for her continuous efforts and kind help in providing many of the needed materials required for this review.

referenceS 1.

Marik PE, Varon J. Hypertensive crises: challenges and management.

Chest. 2007;131(6):1949-1962.

2.

Ahuja K, Charap MH. Management of perioperative hypertensive urgencies with parenteral medications. J Hosp Med. 2010;5(2):E11-16.

3.

Qureshi AI, Palesch YY, Martin R, et al. Antihypertensive Treatment of Acute Cerebral Hemorrhage Study Investigators. Effect of systolic blood pressure reduction on hematoma expansion, perihematomal edema, and 3-month outcome among patients with intracerebral hemorrhage: results from the antihypertensive treatment of acute cerebral hemorrhage study.

Arch Neurol. 2010;67(5):570-576.

4.

Pisoni R, Ahmed MI, Calhoun DA. Characterization and treatment of resistant hypertension. Curr Cardiol Rep. 2009;11(6):407-413.

5.

Naylor AR. Optimal medical therapy during carotid endarterectomy: a personal view. Acta Chir Belg. 2009;109(3):285-291.

6.

Lambert E, Dawood T, Straznicky N, et al. Association between the sympathetic firing pattern and anxiety level in patients with the metabolic syndrome and elevated blood pressure. J Hypertens. 2010;28(3):543-550.

7.

Calhoun DA, Jones D, Textor S, et al. Resistant hypertension: diagnosis, evaluation, and treatment. A scientific statement from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research. Hypertension. 2008;51(6):1403-1419. Epub 2008 Apr 7.

8.

Leenen FH. Intermittent blood pressure control: potential consequences for outcome. Can J Cardiol. 1999;15 Suppl C:13C-18C.

9.

Van de Ven PJ, Beutler JJ, Kaatee R, et al. Angiotensin converting enzyme inhibitor-induced renal dysfunction in atherosclerotic renovascular disease. Kidney Int. 1998;53(4):986-993.

10.

Laube GF, Kemper MJ, Schubiger G, et al. Angiotensin-converting enzyme inhibitor fetopathy: long-term outcome. Arch Dis Child Fetal Neonatal Ed. 2007;92(5):F402-403. Epub 2007 Feb 6.

11.

Hamada A, Ishii J, Doi K, et al. Increased risk of exacerbating gastrointestinal disease among elderly patients following treatment with calcium channel blockers. J Clin Pharm Ther. 2008;33(6):619-624.

12.

13.

Belknap DC, Seifert CF, Petermann M. Administration of medications through enteral feeding catheters. Am J Crit Care. 1997;6(5):382-392.

14.

Lahner E, Annibale B, Delle Fave G. Systematic review: impaired drug absorption related to the co-administration of antisecretory therapy.

Aliment Pharmacol Ther. 2009;29(12):1219-1229. Epub 2009 Mar 6.

15.

Friederich JA, Butterworth JF 4th. Sodium nitroprusside: twenty years and counting. Anesth Analg. 1995;81(1):152-162.

16.

Gobbel GT, Chan TY, Chan PH. Nitric oxide- and superoxidemediated toxicity in cerebral endothelial cells. J Pharmacol Exp Ther.

1997;282(3):1600-1607.

17.

Broderick J, Connolly S, Feldmann E, et al. American Heart Association/ American Stroke Association Stroke Council; American Heart Association/American Stroke Association High Blood Pressure Research Council; Quality of Care and Outcomes in Research Interdisciplinary Working Group. Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update: a guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Circulation.

2007;116(16):e391-413.

18.

Bodmann KF, Trรถster S, Clemens R, et al. Hemodynamic profile of intravenous fenoldopam in patients with hypertensive crisis. Clin Investig.

1993;72(1):60-64.

19.

Varon J, Marik PE. The diagnosis and management of hypertensive crises.

Chest. 2000;118(1):214-227.

20.

Haas CE, LeBlanc JM. Acute postoperative hypertension: a review of therapeutic options. Am J Health Syst Pharm. 2004;61(16):1661-1673; quiz 1674-1675.

21.

Singla N, Warltier DC, Gandhi SD, et al. ESCAPE-2 Study Group.

Treatment of acute postoperative hypertension in cardiac surgery patients: an efficacy study of clevidipine assessing its postoperative antihypertensive effect in cardiac surgery-2 (ESCAPE-2), a randomized, double-blind, placebo-controlled trial. Anesth Analg. 2008;107(1):59-67.

22.

Kenyon KW. Clevidipine: an ultra short-acting calcium channel antagonist for acute hypertension. Ann Pharmacother. 2009;43(7):1258-1265. Epub 2009 Jul 7.

23.

Ndefo UA, Erowele GI, Ebiasah R, et al. Clevidipine: a new intravenous option for the management of acute hypertension. Am J Health Syst Pharm. 2010;67(5):351-360.

24.

Varon J. Treatment of acute severe hypertension: current and newer agents. Drugs. 2008;68(3):283-297.

25.

Pearce CJ, Wallin JD. Labetalol and other agents that block both alphaand beta-adrenergic receptors. Cleve Clin J Med. 1994;61(1):59-69; quiz 80-82.

26.

Wargo KA, Banta WM. A comprehensive review of the loop diuretics: should furosemide be first line? Ann Pharmacother. 2009;43(11):18361847. Epub 2009 Oct 20.

27.

Triggle DJ. L-type calcium channels. Curr Pharm Des. 2006;12(4):443457.

28.

Weir MR. Beta-blockers in the treatment of hypertension: are there clinically relevant differences? Postgrad Med. 2009;121(3):90-98.

29.

Johnston CI, Jackson B, Cubela R, et al. Evaluation of angiotensin converting enzyme (ACE) in the pharmacokinetics and pharmacodynamics of ACE inhibitors. J Cardiovasc Pharmacol. 1986;8 Suppl 1:S9-S14.

30.

Ludden TM, Shepherd AM, McNay JL, et al. Hydralazine kinetics in hypertensive patients after intravenous administration. Clin Pharmacol Ther. 1980;28(6):736-742.

31.

Weder AB, Erickson S. Treatment of hypertension in the inpatient setting: use of intravenous labetalol and hydralazine J Clin Hypertens (Greenwich). 2010;12(1):29-33.

32.

Burris JF. The USA experience with the clonidine transdermal therapeutic system. Clin Auton Res. 1993;3(6):391-396.

33.

Abrams J. Beneficial actions of nitrates in cardiovascular disease. Am J Cardiol. 1996;77(13):31C-37C.

34.

Tuncel M, Ram VC. Hypertensive emergencies. Etiology and management. Am J Cardiovasc Drugs. 2003;3(1):21-31.

Ott RA, Gutfinger DE, Alimadadian H, et al. Reduced postoperative atrial fibrillation using multidrug prophylaxis. J Card Surg. 1999;14(6):437443.

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August 2011 JOURNAL MSMA 249

â&#x20AC;˘ CliniCAl Problem-solving â&#x20AC;˘ Presented and edited by the Department of Family Medicine, University of Mississippi Medical Center, Diane K. Beebe, MD, Chair

Doctor, Please Donâ&#x20AC;&#x2122;t Send Me Home Like This!

Patrick Whipple, MD

A

50-year-old black female presented to the Emergency Department (ED) complaining of unrelenting abdominal pain, nausea, vomiting and diarrhea for one day. The abdominal pain was periumbilical, intermittent and without radiation. Further questioning revealed that she had these symptoms intermittently for over 1 year and that the worst episode occurred approximately 1 year ago. She stated that at that time she had a full work-up that was negative, including esophagogastroduodenoscopy (EGD) and colonoscopy.

Despite the negative EGD and colonoscopy 1 year ago, a cause originating in the gastrointestinal (GI) system is still chiefly suspect. These symptoms also seem to clearly represent a cause that is chronic in nature. Since the GI system includes multiple organs, more history and a review of systems is needed to get a clearer idea of what the cause may be. Her symptoms could be caused by chronic or subacute infection, malabsorption, autonomic dysfunction, medications, malignancy, inflammatory bowel disease (IBD) or other conditions.

Review of systems was remarkable only for a 14 pound weight-loss over the past year and mild post-coital vaginal bleeding, although the patient reported a normal Papanicolaou smear performed 2 months earlier. The patient denied hematemesis, hematochezia and melena. Past medical history was found to be positive only for hypertension, hypercholesterolemia and depression. Her past surgical history included a bilateral tubal ligation, and she denied any significant family history. Social history was negative for past or present use of tobacco, alcohol or illicit drugs; she was married and retired. She had no known allergies, medicinal or otherwise. She had not taken any new medications recently or prior to the onset of her symptoms one year ago.

Her current medications included mirtazapine (Remeron), escitalopram (Lexapro), olmesartan (Benicar), atorvastatin (Lipitor), metoprolol (Lopressor) and omeprazole (Prilosec).

Author informAtion: Dr. Whipple was a Family Medicine Resident in the Department of Family Medicine at the University of Mississippi Medical Center. He is currently associated with Mississippi Physician Services (MPS), a physician owned and managed group staffing the MEA Medical Clinics in the Jackson area and one in Laurel.

CorresPonDing Author: Patrick Whipple, MD, 713 Wildberry Pointe, Madison, MS 39110 (pdwhipple@yahoo.com).

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The absence of tobacco or alcohol use in the past, as well as any sign of GI bleeding makes malignancy less likely. It also makes a pancreatic disorder less likely, though it certainly does not rule it out. The patient has never undergone removal of an organ, so the gall bladder and appendix are possible contributors to her symptoms. Medication side effects should always be considered; however, this patient denies starting any new medications prior to the onset of these symptoms. She also does not report any abnormal laboratory tests. Physical examination, laboratory analyses and computed tomography (CT) are needed at this point to differentiate among possible diagnoses.

Physical examination was significant only for hypoactive bowel sounds and right upper quadrant and epigastric tenderness to palpation. Laboratory tests demonstrated a mild urinary tract infection, normal blood counts, normal liver function tests, normal pancreatic enzyme concentrations and a slightly elevated blood glucose concentration.

A CT of the abdomen and pelvis was significant only for scarring in the lower pole of the left kidney with one focal area of calcification, a couple of left renal cysts and multiple uterine fibroids.

While in the ED the patient was administered intravenous medications including hydromorphone (Dilaudid), metoclopramide (Reglan), promethazine (Phenergan) and ondansetron (Zofran). She stated that the hydromorphone relieved her abdominal pain somewhat.

Laboratory tests and CT did not indicate involvement of the pancreas. Although a mild urinary tract infection was discovered, no real significance is attached to the renal findings on CT at this point. Also of note was the absence of any masses in the abdomen or pelvis that would be suspicious for malignancy. Her physical examination would lead me to further investigate the possibility of gallbladder or liver pathology, which would best be evaluated by right upper quadrant ultrasound. Although the patient stated that she had an EGD and colonoscopy 1 year earlier, I will consult a gastroenterologist to repeat endoscopy with possible biopsies to investigate for gastritis, peptic ulcer disease, hiatal hernia and inflammatory bowel disease. The patient has a slightly elevated blood glucose concentration; however, she does not report a history of diabetes. Given this negative history, gastroparesis is less likely. At most, she could be pre-diabetic; however, a gastric empting scan would be a wise idea, as there are other causes of gastroparesis.1 The effectiveness of the hydromorphone is assumed to be a genuine analgesic effect.

Right upper quadrant ultrasound demonstrated a normal liver, gall bladder, pancreas, abdominal aorta and right kidney. The patient refused the gastric emptying scan, stating that she could not tolerate the oral intake necessary for the scan. On a Friday, the consulting gastroenterologist scheduled an EGD to be performed the following Monday.

Hydromorphone was administered intravenously as needed for abdominal pain. Although the patient reported symptomatic relief from both the abdominal pain and nausea, the hydromorphone also caused some sedation. Ondansetron, metoclopramide and promethazine were reported as ineffective at relieving nausea and abdominal pain.

Right upper quadrant ultrasound did not indicate the presence of cholecystitis or cholelithiasis. Although cholestasis is still possible, both gall bladder and liver disease now seem unlikely. The patient’s refusal to undergo a gastric emptying scan was a little surprising, and it frustrated our attempt to investigate for gastroparesis. We resolved to treat her nausea and vomiting over the weekend and to reschedule the gastric emptying scan.

Over the weekend, the patient continued to require regular IV hydromorphone for control of pain and nausea, stating once that “it’s the only thing that has helped my pain.” Metoclopramide was occasionally reported to help relieve her nausea. A thyroid stimulating hormone test was found to be within normal limits; however, serologic testing for a circulating antibody to Helicobacter pylori (H. pylori) bacteria was found to be positive. Furthermore, the patient was noted at times to be very somnolent. The consulting neurologist attributed this to her medications for pain and nausea.

Though it was never assumed to be the primary cause of the patient’s symptoms, the normal thyroid stimulating hormone concentration indicated that thyroid disease was not likely to be a contributing factor. The positive H. pylori test only means that this patient has been exposed to this bacterium, not necessarily that she has a current H. pylori infection. Thus, a diagnosis of gastric or peptic ulcer disease can be neither included nor excluded. Some mild sedation is expected secondary to hydromorphone, promethazine and metoclopramide use.

However, the patient’s continual request for all these medications to the point of being significantly somnolent is somewhat concerning. In particular, her regular requests for and seeming dependence on hydromorphone raises suspicion for a psychological component or physical dependence. For now we will continue these medications as needed to control symptoms so further testing can be performed to investigate for an organic cause. First, we will proceed with the EGD as scheduled.

On Monday, an EGD was performed. After the procedure, the patient reported feeling the best she had felt for the entire admission and was even able to tolerate eating carrots and gelatin. The preliminary EGD report described a small hiatal hernia and gastritis. A gastric emptying scan was also rescheduled for the following morning.

The EGD did not indicate the presence of gastric or pep-

tic ulcer disease. Gastritis and a small hiatal hernia were found and could contribute to this patient’s symptoms to some extent.

However, it is very unlikely that such significant and chronic abdominal pain with nausea and vomiting would be caused by gastritis and a small hiatal hernia alone. Moreover, instead of causing these symptoms, the gastritis could itself be caused by other underlying pathology. The EGD pathology report is needed, and the gastric emptying scan needs to be performed as scheduled. Furthermore, if the EGD report and the gastric emptying study are unrevealing, then a computed tomographic angiography scan of the abdomen and pelvis should be performed to investigate for mesenteric vascular disease.

The next morning, the patient complained of nausea and vomiting since the previous night, stating “I’m so sick I could die.” She continued requesting hydromorphone for her symptoms. The gastric emptying scan was again cancelled due to patient refusal. Consequently, a computed tomographic angiography scan of the abdomen and pelvis was performed but did not demonstrate any evidence of mesenteric vascular disease. Additionally, the pathology report from the EGD described mild to moderate chronic inflammation in the biopsy specimens; however, no H. pylori was found.

After 5 days of inpatient care and testing, chronic gastritis is the only discovered possible cause of her symptoms.

There is no evidence of involvement from the gall bladder, liver, pancreas or mesenteric vasculature. Furthermore, it seems hydromorphone is the only medication that can reliably provide symptomatic relief. More thought is now given to the possibility that the patient is a pain medication seeker or that there is a psychogenic component present. Moreover, the patient’s vital signs and lab studies have remained stable, and there is no indication of the existence of an acute cause. Consequently, we will begin planning for discharge with close follow-up with a gastroenterologist.

The intravenous hydromorphone was discontinued and an oral pain medication was substituted. Clonazepam (Klonopin) was also given for anxiety. Plans were made to discharge the patient home the following morning. As the plan was explained to the patient, she grasped the consulting gastroenterologist’s arm and begged, “Doctor, please don’t send me home like this!”

After further discussion with the patient, we resolved to try one final time to perform a gastric emptying scan.

The next morning she successfully completed the scan. The results showed markedly delayed gastric emptying. Gastric content retention values were 98% at 60 minutes, 95% at 90 minutes and 91% at 105 minutes. Our patient was diagnosed with gastroparesis.

Gastroparesis is usually associated with diabetes, probably because 30% to 50% of patients with longstanding type 1 or type 2 diabetes have been found to have gastroparesis.2 However, 35.6% (the plurality) of gastroparesis cases are idiopathic, while 29% are caused by diabetes. Other remarkable causes are post-

August 2011 JOURNAL MSMA 251

surgical complications (13%), Parkinson’s disease (7.5%) and pseudo-obstructions (4.8%).1 The treatment of gastroparesis has long been limited to medications alone, which have often been ineffective at providing symptomatic relief.3,4 However, new treatment options have recently emerged, including a gastric pacemaker.5 Arrangements were made for the patient to be transferred to a local gastroenterology service. A 4-hour gastric emptying scan confirmed the diagnosis of gastroparesis. Gastric content retention values were 100% at 1 hour, 100% at 2 hours and 91% at 105 minutes. After placement of a temporary gastric pacemaker, a repeat gastric emptying scan demonstrated the following gastric content retention values: 31% at 1 hour, 9% at 2 hours and 2% at 4 hours. Consequently, a permanent gastric pacemaker was placed a few weeks later. At a followup visit 5 months later the patient reported no vomiting since pacemaker placement, as well as only having nausea approximately once per week. She also reported a normal diet, even stating that she feared she was eating too much food. The only adverse effect reported at that time was occasional “shocking” by the pacemaker. Finally, gastric content retention values from a repeated gastric emptying scan at that time were 57% at 1 hour, 40% at 2 hours and 9% at 4 hours. Full thickness gastric biopsies performed on our patient demonstrated normal findings related to morphology, pattern and numbers of gastric smooth muscle and intramuscular plexi. However, serologic testing showed elevation of specific autoimmune markers.

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The cause of our patient’s chronic abdominal pain and nausea with vomiting is idiopathic gastroparesis. Idiopathic gastroparesis is currently the subject of much research, some of which has implicated morphologic and autoimmune causes.6 Though her gastroparesis is considered “idiopathic,” it is very possible that her condition was acquired by some autoimmune process. Whatever the specific cause, persistence and listening to our patient’s concerns led to a diagnosis and treatment. Most importantly, it remarkably improved her quality of life.

Key WordS: gAstroPAresis, ChroniC nAuseA AnD vomiting, DelAyeD gAstriC emPtying, gAstriC PACemAker

referenceS 1.

Soykan I, Sivri B, Sarosiek I, Kiernan B, McCallum RW. Demography, clinical characteristics, psychological abuse profiles, treatment, and longterm follow-up of patients with gastroparesis. Dig Dis Sci. 1998;43:23982404.

2.

Horowitz M, Edelbroek M, Fraser R, Maddox A, Wishart J. Disordered gastric motor function in diabetes mellitus: recent insights into prevalence, pathophysiology, clinical relevance, and treatment. Scand J Gastroenterol. 1991;26:673-684.

3.

Abell TL, Malinowski S, Minocha A. Nutrition aspects of gastroparesis and therapies for drug-refractory patients. Nutr Clin Pract. 2006; 21(1):23-33.

4.

Kendall BJ, McCallum RW. Gastroparesis and the current use of prokinetic drugs. Gastroenterologist. 1993;1:107-114.

5.

Abell TL, Minocha A. Gastroparesis and the gastric pacemaker: a revolutionary treatment for an old disease. J Miss State Med Assoc.

2002;43(12):369-375.

6.

Abell TL, Familoni B, Voeller G, et al. Electrophysiologic, morphologic and serologic features of chronic unexplained nausea and vomiting: lessons learned from 121 consecutive patients. J Surg. 2009;145(5):476485.

â&#x20AC;˘ msDh â&#x20AC;˘ Mississippi Reportable Disease Statistics

May 2011 Figures for the current month are provisional

For the most current MMR figures, visit the Mississippi State Department of Health web site: www.HealthyMS.com.

August 2011 JOURNAL MSMA 253

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To learn more call 800.981.5085 or visit www.athenahealth.com/tamethebeast 254 JOURNAL MSMA

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• PresiDent’s PAge •

Reflections on a Squashed Resolution

W

ell, I guess they didn’t get it [Joiner TE. President’s Page, The doctor-patient relationship: it’s worth fighting for. J Miss State Med Assoc. 2011;52(7):220]. I thought maybe the swing to the left at the American Medical Association (AMA) was ready for a correction. I anticipated the AMA would start to stand up for the rights of patients and doctors. That is why I introduced the resolution supporting the repeal of the mandates of the Patient Protection and Affordable Care Act (PPACA) at the MSMA annual session in May and took it to the AMA meeting in Chicago. Several heartland states, including Mississippi, Georgia, Kansas, Arkansas, District of Columbia, Florida, Georgia, and thomAs e. Joiner, mD Oklahoma, all presented and supported this same resolution. I thought it would pass. Boy was I wrong! Not only did it not pass, it was “squashed.”

2011-12 msmA PresiDent The MSMA president’s oath includes the pledge to support the constitution of the MSMA, Mississippi, and the United States of America.

With pride and conviction in my heart, I swore to this, and I will always be proud to do so. This is the greatest nation this world has ever seen, and we should all thank our God that we enjoy the privileges of being born here. But with this comes the responsibility to protect and care for the freedoms and liberties that these documents grant us. All freedoms! And one of the freedoms is that the government cannot force us to buy anything we do not want.

Many have heard me say that I think we all have the right to be stupid. In no way do I think that our stupidity should be allowed to harm others; in fact, this should be punished. Anyone not making provisions to provide medical care for their children should be held responsible and admonished. Our society has arranged for these situations (Medicaid, SCHIP) when one is down and cannot provide for family. I think this is appropriate and have no argument with it. It is when one has the ability to provide for family and childcare but does not that they should be punished. However, I do think that one has the right not to buy health insurance for one’s self and that the government, through the Constitution, cannot make him or her do so. With this comes the risk of not having coverage in a catastrophic situation, a decision that all adults have to make with most of us making to right decision for coverage. Sure we would all love for all our patients to have coverage, but you and I know that with that option comes loss of freedom of decision-making and limits on what we can and can’t offer. It is this freedom that concerns me the most.

The physicians from the “heartland states” that you talk to at the AMA are as conservative as you and I and are as frustrated as you and I with the direction of the AMA to the point they are voting with their feet. The numbers indicate the AMA membership is in a steady decline, now to the point that only around 11% of practicing physicians remain members. Reports claim that of 800,000 total U.S. physicians: 93,000 are full dues-paying members of the AMA (down 5.4%), 47,000 are students, 31,000 are residents, and 44,854 are in another category such as retired.

Despite the AMA’s infamous endorsement of PPACA, recent polls underscore discontent among physicians. For the healthcare community to oppose health reform may sound like a joke but consider a survey1 of physicians by the Sermo network, a so-called “virtual water cooler” that connects more than 120,000 physicians in 68 specialties in all 50 states, which reveals that: ·

79% of physicians are less optimistic about the future of medicine.

·

66% indicated that they would consider dropping out of government-sponsored health programs like Medicare and Medicaid.

August 2011 JOURNAL MSMA 255

·

53% would consider opting out of accepting all health insurance plans altogether.

Yet those left at the AMA don’t see it that way. The reason: most of your core providers have opted out leaving the AMA house to be made up of a mismatch of groups that do not see things the way most of us do. In fact, our own MSMA voted to not align with the AMA any more, a move I strongly supported.

But, I strongly support our continued participation.

Like I stated in my inaugural address, the AMA is our voice whether we like it or not. Congress, the President, news outlets all go to the AMA to see what we are thinking. We have to continue to voice our positions and make our feelings heard and let the AMA leadership know we are not happy. If we do not we are giving up, and I do not plan on giving up!

—Thomas E. Joiner, MD MSMA President 1.

Merrill M. Sermo, AMA spar over physician frustrations. Healthcare IT News. Available at: http://www.healthcareitnews.com/news/sermo-amaspar-over-physician-frustrations. Accessed July 14, 2011.

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Why join the AMA? The future of medicine should be decided by physicians themselves—not legislators or private interests like insurance companies.

The most effective way you can address the greatest public health and professional issues facing medicine today is by joining the nation's largest physician association, the AMA. By becoming an AMA member, you gain powerful representation that works for your interests, as well as those of your patients, your practice, your specialty and your state.

Learn more at www.AMA-assn.org.

Small gene pool?

Are medical journals headed for the endangered species list? Not on your life. Scientific medical publications continue to be a primary source for upto-date data. Your Journal of the Mississippi State Medical Association is alive and kicking. Immerse yourself. Read the Journal.

August 2011 JOURNAL MSMA 257

• sPeCiAl ArtiCle • Greater Jackson Chamber Partnership Announces Mississippi Healthcare Corridor Karen A. Evers, Managing Editor

Background

A

s chair of the Greater Jackson Chamber Partnership (GJCP) Board of Directors, Dr. J. Clay Hays, Jr. wanted to make sure healthcare received appropriate attention as a major driver of our local economy. The business community recognized the growth of the healthcare industry in the metro area and under Dr. Hays’s direction and leadership the Greater Jackson Chamber Partnership formed a new division titled Healthcare Initiatives.

“Creating a separate division to focus on new projects related to healthcare and promoting the Greater Jackson region as a healthcare destination is a major accomplishment,” said Dr. Hays, who serves as secretary-treasurer of the Mississippi State Medical Association (MSMA). Halfway into its first year, the division continues to help promote and develop central Mississippi health care institutions and organizations.

According to Lindsay Buford, vice president of the Healthcare Initiatives division, it also includes the ChamberPlus program which offers affordable health benefits, including life and dental, to small businesses with 1 to 50 employees through a partnership with Dr. David Powe, UMMC’s chief administrative BlueCross BlueShield of Mississippi. “Our division continues to affairs officer, and Primus Wheeler, executive focus on many upcoming economic development projects with all director of the Jackson Medical Mall, address area hospitals, healthcare related events, and the ChamberPlus small questions regarding the Mississippi Healthcare business benefits program,” Buford said.

Corridor project. A plan to unite the medical and corporate communities along a centralized area Numerous other healthcare initiatives followed over the years. was unveiled during a press conference held “Last year we hosted the first Global Obesity Summit and this further Tuesday, July 12, at the Jackson Medical Mall. increased our involvement in the health care industry,” Buford added.

A key program the healthcare initiatives division will focus on is the next Global Obesity Summit to be held in early 2012. “This event will bring together again internationally renowned scientists, clinicians, state leaders, business leaders, and health care policy makers to Mississippi to discuss innovative solutions to the causes of obesity, preventive strategies, and therapeutic management approaches,” she said.

The main focus for the division, according to Buford, is how the division can brand and promote the Greater Jackson area as a regional healthcare destination.

Logo for the Mississippi Healthcare Corridor project in Jackson

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August 2011

Healthcare Initiatives Division

A list of projects the Division continues to work on includes: ·

·

·

·

·

·

Forming a collaborative effort with all major hospitals and healthcare institutions by setting up tours and special events so the business community will know all the new activities within each facility.

Developing a study to show the economic impact of each healthcare institution in the Central Mississippi area.

Developing a public relations campaign to promote the Central Mississippi region as a healthcare destination.

Continuing to host the Heartbeats of Jackson health fair event, which is a collaboration of all major hospitals providing free cardiovascular screenings to the business community.

Organizing a new city visitation tour to focus specifically on healthcare.

Creating a healthcare corridor along Woodrow Wilson Boulevard that will include retail and mixed use development space.

Mississippi Healthcare Corridor (MHC)

The Mississippi Healthcare Corridor will be a fivemile urban corridor linking two cross-continental interstate highways from I-55 to I-220. This redevelopment project will include: · an expansion and renovation of Hawkins Field for advanced medical aviation training and additional emergency helicopters, · development of a state-of-the-art bio medical research enterprise that fosters innovation in applied therapeutics and devices, · additional advanced resources to Central Mississippi’s finest health care facilities that will attract patients from across the southeast.

At the center of the project, anchoring the district, is the Jackson Medical Mall, surrounded by colleges and universities including three historic institutions: Jackson State University, Tougaloo College and the University of Mississippi Medical Center (UMMC). Unexpected amenities include an 18-hole municipal golf course, the Jackson Zoological Park and an executive airport. New signage, green space, lighting, and landscaping would compliment a concourse for hotels, shops, restaurants, and nightlife to create a destination with a natural new “urbanesque” flavor and distinctive vibe.

Overview of the Proposed Mississippi Healthcare Corridor — Jackson business and city leaders are spearheading an effort to transform areas along Woodrow Wilson Avenue into a medical research corridor. The Mississippi Healthcare Corridor would stretch along Woodrow Wilson from I-55 to I-220. It is to include an already announced medical research park that University of Mississippi Medical Center plans to build at the old Farmers Market and an expanded/redeveloped Hawkins Field, which would try to attract more medical helicopter traffic and training. Woodrow Wilson would be redeveloped to feature more green space as well as upgraded lighting and landscaping. Map courtesy of Rich Perspectives.

August 2011 JOURNAL MSMA 259

A seven-member steering committee representing health care institutions, government, education and businesses along and near Woodrow Wilson Boulevard have worked for about a year on the concept. No specifics on finances or a timetable were available. Organizers hope to have a strategic development plan in about six months.

UMMC Associate Vice Chancellor for Administrative Affairs and Chief Administrative Officer Dr. David L. Powe said, “When developed this initiative will eventually create an economic impact in the hundreds of millions of dollars for the entire state of Mississippi.”

A video produced by Rich Perspectives described the development as “higher education brain trust working with industry to bring solutions to modern challenges.” The video is available at: http://www.richperspectives.com/.

The MHC project calls for Woodrow Wilson Blvd. to be transformed with enhanced vehicular and pedestrian circulation, greenspace, lighting, signage, and landscaping improvements. Plans call for a concourse “where pathways come together, a place with unique character offering hotels, restaurants and nightlife, and a hearty helping of the city’s legendary hospitality with places to live and play in a community where a mix of cultures is working toward a common vision of shared success.” From the promotional video produced by Rich Perspectives.

Promoting the Heart Of Mississippi Network of MultiUse Trails — To promote healthier living, past chair of the Greater Jackson Chamber Partnership (GJCP), Dr. J. Clay Hays, Jr. continues to promote the idea of a network of multipurpose trails through Jackson, Ridgeland, Flowood, and Canton, including the MHC. “Through a partnership between with the GJCP, Jackson Chamber of Commerce, Jackson Bike Advocates, Belhaven Neighborhood Foundation, Bike Walk Mississippi, Weatherford McDade, Young Professionals Alliance, and the City of Jackson, the Museum to Market Multi-use Trail is moving forward,” said Dr. Hays. When finished, this trail will allow you to ride your bicycle or walk/run from Lakeland Drive through the Belhaven neighborhood all the way to the downtown Farmer’s Market & Fairgrounds. Dr. Hays is passionate about obtaining funding and resources to coordinate this project as well as a larger network of trails known as the Heart of Mississippi Network. GJCP President Duane O’Neill said Dr. Hays does a great job of promoting the metro area. “He has been very energetic about health and wellness as well as the entire health scene, being a physician,” said O’Neill. “That’s where much of our time has been spent because of the importance of the health care industry on our economy. He’s also been very active in a number of different initiatives to promote the Jackson area like the Mississippi Healthcare Corridor,” O’Neill added. Shown l. to r.: Clinton Mayor Rosemary G. Aultman, Transportation Commissioner Dick Hall, Dr. J. Clay Hays, Jr. and Duane O’Neill.

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Officials say more than 50 community partners have signed on to the MHC project including the following community partners currently involved with the planning phases: • Baptist Health Systems • Belhaven Neighborhood Foundation • Belhaven University • City of Jackson • Cooke Douglass Farr Lemons • Department of Finance Administration • Department of Public Safety • Entergy • Fondren Association • Georgetown Community • Global Strategies • Greater Jackson Chamber Partnership • Hinds County Board of Supervisors • Hinds County Economic Development • Jackson Airport Authority • Jackson Chamber of Commerce • Jackson City Council • Jackson Heart Clinic • Jackson Hinds Comprehensive Health • Jackson Medical Mall • Jackson Public Schools • Jackson Redevelopment Authority • Jackson State University • Marvis James • Methodist Rehabilitation Center • Midtown Partners, Inc. • Millsaps College • MS Children Home Services • MS Department of Health • MS Department of Transportation • MS Development Authority • MS Main Street Association • MS Sports Medicine and Orthopaedic Center • MS State Department of Health • NewSouth NeuroSpine • Phelps Dunbar, LLP • Regions Bank • Rich Perspectives, LLC • St. Dominic Health Services • Tougaloo College • University of Mississippi Medical Center • VA Medical Center • Veteran’s Hospital • Virden Addition Community • West Jackson Community Development Corp. r

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August 2011 JOURNAL MSMA 261

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Clay Hays, MD Cardiologist and MSMA Representative to the MACM Board Jackson, Mississippi For over 30 years, Mississippi physicians have looked to Medical Assurance Company of Mississippi for their professional liability needs. Today, MACM is an integral part of the health care community, working with other organizations that have the best interest of Mississippi’s physicians in mind.

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August 2011

• eDitoriAl •

Who Will Care for the Newly Insured Under Health Reform?

C

hange is Coming The Milliman Report authorized by the Mississippi Department of Medicaid suggests that between 206,000 and 415,000 uninsured Mississippians will become eligible for Mississippi Medicaid under the Affordable Care Act (ACA) of 2010.1 With the lowest ratio of physicians to patients in the United States, how will Mississippi provide full access to healthcare and health services for these individuals?

Much less, how will we pay for it? Governor Barbour has estimated the additional state costs, even with the usually favorable federal-state Richard D. deShazo, MD match Mississippi has traditionally received, will be $210 million dollars Associate Editor in additional costs to the state per year starting in 2014 for 7 years with further escalation after that.2 Others argue that providing healthcare to the uninsured prevents chronic disease, improves the quality of the workforce and is a net saving to state.3 Existing systems of federally supported health clinics play a central role in the government’s future vision for healthcare.4 It is incumbent on us to learn more about them and the sea-change in the public-private health care interface to come if the ACA is fully implemented.

The Health Reform Package and Community Health Centers In an editorial in the May 2011 issue of the JMSMA, I reviewed the connections between Mississippi’s antebellum era history and the founding by the US government of a national system of federally subsidized primary care clinics called “community health centers.” In particular, I traced the first rural community health center in the United States to Mound Bayou, Mississippi and President Lyndon B. Johnson’s Great Society program in 1967.

I thought this was important information for a number of reasons. The 21 community health centers which are members of the Mississippi Primary Care Association have 165 service sites in the state (Figure 1). They provided 310,759 patient visits and a total of 928,033 patient encounters to the medically underserved in 2009. In order to accommodate the surge of newly insured patients, “330-B, grant funded” federally qualified community health centers (FQHCs) in the US are scheduled to receive 11 billion new dollars over 5 years (Table 1). In addition to funding for operations, the package includes 1.5 billion dollars for expansion of existing facilities and construction of new buildings.

However, FQHCs are neither the only nor the largest system of federally supported health centers in Mississippi (Table 2). For instance, there are 157 Rural Health Clinics in Mississippi (Figure 2). Familiarity with the operational aspects of these clinics will become increasingly important for all Mississippi healthcare providers. How these federally supported clinics will collaborate, compete and partner with fee for service health systems will be determined, to a large part, by the understanding of their value to both physicians and policy makers.

Types of Federally Qualified Health Centers Hopefully, what follows will provide a basic understanding of the structure and functions of these organizations (Table 2). The major differences between FQHCs, FQHC look-alikes, and Rural Health Centers are tax status (for profit vs. not for profit), types of health providers required, availability of additional services, governance and reimbursement arrangements.

August 2011 JOURNAL MSMA 263

Medicare and Medicaid statutes define the requirements for federally qualified health centers. FQHCs include all organizations receiving grants under old Section 330 of the Public Health Service Act, certain tribal organizations, and “FQHC look-alikes.” Clinics that meet requirements for FQHC designation request certification by filing an application with the US Bureau of Primary Care and then apply for annual grants. Indian Health Service funded FQHCs may differ from the requirements of other FQHCs.

Figure 1. Location of 330-B Grant Funded Community Health Centers in Mississippi

(From the Mississippi Primary Care Association)

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August 2011

Table 1. Community Health Center Operations Federal Funding, 2011-2015

Fiscal Year

Additional Funds to Trust Fund

Discretionary Funding (est.)

Total Annual Funding (est.)

Total Annual Increase

FY 2011

$1 Billion

$2.19 Billion

$3.19 Billion

$1 billion

FY 2012

$1.2 Billion

$2.19 Billion

$3.39 Billion

$200 million

FY 2013

$1.5 Billion

$2.19 Billion

$3.69 Billion

$300 million

FY 2014

$2.2 Billion

$2.19 Billion

$4.39 Billion

$700 million

FY 2015

$3.6 Billion

$2.19 Billion

$5.79 Billion

$1.4 billion

+ New dollars allocated in 2010 health reform package. The package also authorized permanent funding of the program at increased levels 2010‐2015 and subsequent increases on the basis of a formula. Source: National Association of Community Health Center Bulletin. Health Centers and Health Care Reform: Health Center Funding Growth. April 2010. www.nachc.org

Table 2. Types of Federally Supported Rural and Community Health Centers

Community Health Centers 1 Federally Qualified Health Center “Look‐a‐Likes” Healthcare in Urban Housing Clinics 1 Migrant Farm Worker Clinics 1 Healthcare for the Homeless Clinics1 Ryan White Clinics1 Rural Health Centers2 1.

Section 330 grantees receive free federal tort claim insurance, competitive grant funds, and enhanced Medicaid/Medicare reimbursement (cost‐based reimbursement). They are called Federally Qualified Health Centers as a group. Community Health Centers were the first of those.

2.

See Table 3 for differences between Rural Health Centers and FQHCs.

FQHCs Traditional Community health centers formed after the Mound Bayou model are governed by a board of directors which is composed of community volunteers, 51% of whom must be patients of the center and 49% of whom must represent the geographical area served. FQHCs must provide or arrange for the availability of dental, mental health and substance abuse treatment and transportation services and be open at least 32 hours per week. They must also have call coverage when closed with an afterhours care system. FQHCs receive start up costs, enhanced Medicare and Medicaid reimbursement, federal malpractice insurance, 340–B reduced cost drug formulary access for patients, access to National Service Corps Volunteers, the Vaccine for Children Program and other federal programs and grants. Patients are charged for services on a sliding scale based on their individual federal poverty level designation. Most patients with incomes at or below the federal poverty level receive a 100% discount plus a charge of $10 -20 per visit. However, no patient is denied care by statute.

The insurance status of patients in Mississippi FQHCs in 2009 was 43.8% uninsured, 29.3% Medicaid, 0.1% S-CHIP, 7.9% Medicare, 3.2% other public insurance and 15.8% private insurance. Ninety four percent of these patients had incomes below 200% of the federal poverty level, $18,530 for a family of 3. In addition to operations of traditional clinic facilities, community health centers in Mississippi provide healthcare at other sites, including satellite clinics, school based clinics, homeless clinics and mobile units.

1

August 2011 JOURNAL MSMA 265

FQHCs receive cost-based reimbursement through Medicare and Medicaid (as do rural health clinics) to supplement losses for care of the uninsured. Grant funding is awarded through Section 1861(22)(4) of Medicare, Section 1905(1)(2)(B) of the Social Security Act and Section 330 of the Public Health Service Act. In Mississippi, the existing FQHCs have reached consensus to promote expansion of existing FQHCS over federal approval of new FQHCs under the auspices of the Mississippi Primary Care Association.

FQHC Look-a-Likes An FQHC look-a-like is an organization that meets all of the eligibility requirements of a clinic that receives a PHS Section 330 grant funding but does not receive funding by grants. They receive many of the same benefits of FQHCs including increased Medicare and Medicaid reimbursement, eligibility to purchase medications for outpatients at a reduced cost through the 340B drug-pricing program, and automatic designation as a Health Professional Shortage Area making them eligible for National Health Services and J-1 visa international medical graduate employment. These centers may not be “owned, controlled, or operated” by another entity and are all “not for profit,” like FQHCs. Indian Health Centers The Indian Health Service (IHS) is a component of the Department of Health and Human Services. Mississippi lies within the Nashville Indian Health Service Area, one of the 12 federal administrative units. The Mississippi Band of Choctaw Indians operates the Choctaw Health Center/Women’s Wellness Center, Conehatta Clinic, Bogue Chitto Clinic, Red Water Clinic and a WIC office. Funding for the IHS supports personal health services as well as public health and community based programs not typically a part of traditional fee for service health insurance. These include certain mental health services, health and wellness programs, and alcohol and substance abuse services (Wrap Around Services). Construction expenses are also available. 5

Rural Health Clinics The Rural Health Clinics Act (P.L. 95-210) was signed into law by President Carter in 1967. This was the first legislation encouraging the use of physician’s assistants and nurse practitioners in the community setting and provided reimbursement for their services even in the absence of a full time physician. It also provided a cost-based reimbursement mechanism. In 2010, the Benefits and Improvement Act (BIPA) changed the mechanism by which the state Medicaid programs reimburse both RHCs and FQHCs and required a per patient seen (PPS) methodology, specific for each clinic. Rather than being funded by grants, RHCs receive individually negotiated, cost based, all-inclusive, per visit, Medicare fee schedule-based reimbursement. They may be operated by private physicians or others on a for-profit or on a not-for-profit basis and do not require a board of directors. Table 3 provides comparison of RHCs to FQHCs, many of which began as hospital-based clinics before 1967. There are 157 RHC in Mississippi (Figure 2). Rural health clinics are members of the Mississippi Rural Health Association.

How Will Expansion of Community Health Centers Affect the Health Status and Practice of Medicine in Mississippi?

When large numbers of Mississippians without health insurance become eligible for health insurance under the provisions of the 2010 health reform package, the demand for health services for the poor, both rural and urban, is likely to expand beyond the ability to be met by the present Mississippi health care work force. Rural health centers and FQHCs are positioned to fill the ambulatory care component of this vacuum with employment of large numbers of mid-level providers. They are also likely to offer Medical Homes within Accountable Health Care Organizations, provider-led organizations that share in cost savings they achieve for Medicare and Medicaid programs. ACO members agree to meet certain quality guidelines, engage in joint decisionmaking, and provide a continuum of care for a defined population. Physician-hospital, multispecialty practice groups, groups of physician practices and health center networks are all potential ACOs. Community and rural health centers will also provide an increasing number of referrals to hospitals and specialty practices throughout Mississippi as patients with previously untreated acute and chronic diseases seek full access to health services for the first time. For instance, referral to hospitals for specialized diagnostic services like mammograms and other imaging, colonoscopy, cardiac stress testing, and cardiovascular diagnostic and treatment services can be expected to have a major multiplier effect on demand for these services and a major financial effect. Reimbursement will be at federal health reimbursement rates.

The financial realities of this infusion of patients and lower reimbursement levels are presently unclear. Hospitals, patients, and a variety of other special interest groups are busy trying to figure this out and optimally position themselves. Physician groups are behind the curve.

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August 2011

Table 3. Comparison of Rural Health Clinics and Federally Qualified Health Clinics

August 2011 JOURNAL MSMA 267

Figure 2. Location of Rural Health Centers in Mississippi

(From the Mississippi Rural Health Association)

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August 2011

1

In the long term, we Mississippi physicians need to encourage and support MSMA’s activities to keep us abreast of the rapidly changing healthcare environment so that individual physicians may chose to participate in those options that best serve the interests of our patients. New opportunities for such partnerships will be coming our way, some good, some not so good.

Your thoughts are welcome!

— Richard D. deShazo, MD Associate Editor References 1.

Milliman, Inc. Financial Impact Review of the Patient Protection and Affordable Care Act as Amended by HR 4782, The Reconciliation Act of 2010 of the Mississippi Medicaid Budget. Mississippi Division of Medicaid 2010.

Haley Barbour. Letter to legislators concerning the Milliman Report. Office of the Governor. October 8, 2010, Available at http:// www.governorbarbour.com/news/2010/oct/Healthcareletter.pdf.

Finkelstein, A. Taubman S, Wright W, et al. The Oregon Health Insurance Experiment: Evidence from the First Year. National Bureau of Economic Research. NBER Working Paper 17190, July 2011.

Available at http://www.healthcare.gov/news/factsheets/increasing_access.html.

Indian Health Service article no. 2004-44, Indian Health Service. DHHS. Available at www.ihs.gov/nonmedicaidprograms/otp/files/ Edits.doc1997-04-12.

2.

3.

4.

5.

Acknowledgements: The author thanks Leigh Wright, BA, Helvi McCall Price, BA, Michael Jones, BSN, RN, Anita Batman, MD and Robert Smith, MD for assistance in preparation of this manuscript.

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• the unCommon threAD • Tools of the Trade

P

art One

There is something almost cyclical in nature when it comes to using an especially historic tool. It means even more if the instrument is something that has at some time belonged to and been used by one of the giants on whose shoulders you r. Scott AnderSon, md yourself stand. It’s almost like being able to reach across the bounds of time and seize the past in one’s own hands. I was reminded of this as I read an account by professional hunter Harry Selby about hunting an elephant with the little .275 Rigby that W.D.M. “Karamojo” Bell had used to harvest so many bulls in the early days of the ivory boom in Africa. Selby had been given the rifle as a gift by the famous author Robert Ruark, complete with an inscribed plaque commemorating the event. It’s an interesting and nostalgic tale that ends with the little rifle being sold off through Holland and Holland in London by Selby’s son while Selby was still alive. I couldn’t comprehend it really. How could you sell something like that? It seemed like selling your grandfather’s false teeth. Even if you didn’t plan on using them yourself, there is something unsettling about the idea of them belonging to someone else. The more I thought about it, the more I found myself enraged at the lack of appreciation and understanding that selling such a treasured artifact entailed. I determined that something had to be done to right such an egregious wrong. Someone had to take up the torch of tradition and be history’s champion. I decided right then and there that that someone was I. This would be a quest, and I set onto it like a Templar after the grail. Finding the owner of the rifle wasn’t as hard as I’d imagined. I tracked him watching carefully for his footprints along that electronic trail we call the internet. A broken twig caught my attention. The owner had taken the rifle to Botswana on safari in 2009, and much had been made of the event in the shooting press. Even seeing it in pictures I could tell how special the little gun was, but why had somebody whittled a hole in the middle of the stock? I read on gathering clues. The hole was to shove a stick in so you could carry it on your shoulder. What idiot would do that? Had they never heard of a rifle sling?

I switched from tracking the rifle to stalking the owner. I sent him an e-mail. I was cautious. I didn’t want to tip my hand and let him know how much I wanted the gun. It read, “I saw your gun on the internet. You probably should go ahead and get rid of it. After shooting that many elephants, the barrel is probably shot out already. I bet it won’t even hold a two-inch group for three shots from a rest anymore. The hole in the stock is kind of ugly, too. If you decide you want to get rid of it, I’ll give you what a new Remington costs, even though I know it’s too much.”

He didn’t respond, even after several even more lucrative offers on my part so I changed strategies. The gun’s owner didn’t really take it all that well when I showed up and knocked on his door unannounced at 5 a.m. one morning to ask if he’d gotten any of my e-mails. I didn’t get very much time to haggle though. The police station must have been less than two blocks away. The squad car was there before he even came back to the door with the gun.

With a restraining order that kept me from ever returning to Manhasset Township, it was pretty clear even to the forces of the universe that there was going to be hardly any way for me to return the gun to Africa to set it free in it’s natural environment.

Most people would have become discouraged at this point and told the cosmic forces of the universe to go to hell, but not me. I knew if I just applied a little creative thinking that there had to be some other way to set things right. I’d just have to do something else important. Something just as symbolic as getting Bell’s gun back from the domestic captivity of a gun safe in New England. Maybe I could return some other famously historic stupid ugly gun? Again I ran into the stumbling block of financial restraint. All of the famous guns I found cost too much money. I’m all for returning balance to the universe, but let’s be reasonable…I have a wife, and spending the price of a new Mercedes on a gun wasn’t going to go over all that well. There had to be something else; there was direction being provided here, a message in the failures. Finally, after several weeks of obsessive deliberations, finally I got it. I wasn’t a professional hunter. I didn’t need a famous gun. I am a writer and a physician. I needed a tool that reflected my own profession’s traditions. My grail was defined by who I was, not by a scratched and beaten up old gun with a hole in it.

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August 2011

My first try involved Hemingway’s whiskey which was, I must say, quite enjoyable at first. But the extensive training required to meet Papa’s standard of consumption (not to mention the fact that I didn’t have a lighthouse next to my home to guide me back from the bar each night) began to have an adverse effect on my ability to accomplish much of anything at all.

The crushing headaches I was getting every morning had to be another sign. I finally deduced that this was the cosmic force’s way of telling me to move on. My going to rehab was probably not what was needed to restore balance to the universe either.

I’ll spare you the details of Mark Twain’s pencil. If any one finds it (it’s the one with the bite marks that I left in that diner in Joplin), I’d like to have it back…and Roosevelt’s glasses (I couldn’t see a damned thing I was shooting at). It finally came down to a cockroach in a bottle of formaldehyde with a paper label that read F. Kafka or Marty Steiner’s Underwood.

Now Marty wasn’t as famous as some of these other folks, but he had known my aunt and had written wonderful articles in the Cincinnati Enquirer newspaper a few years ago about going to Africa during the war.

I weighed my options carefully and couldn’t come up with much to do with a pickled roach at all, even if it was named Gregor. So it was me and the Underwood, off to Africa to hunt elephants.

P

art Two

I sat in the bar at the Kalahari Sands Hotel explaining to my Professional Hunter (PH) that because of my earnest desire to avoid adversely impacting the elephantine genetic make-up of the Caprivi I thought we should try to find the oldest and most debilitated animal possible. I felt bad. For all my high flying rhetoric, I knew it was a case of the nerves. But even Bell had probably knocked off a few gimp elephants before he started blasting the big ones with a peashooter. I did detect a trace of a frown on the PH’s face when I asked if he knew of any blind or three-legged animals in the area we were going to hunt.

We cut tracks on day two; a profusion of deep ovals crossed the dust of the road. When the trackers pointed out the deep furrow created by a paralyzed leg I knew we were onto our prey. We tracked for the next two hours through the thick thorn brush. The elephant’s track was wide enough to allow us to pass without difficulty, but even at that I left the Underwood cased and in the possession of one of the trackers as we walked. There was no discussion of shoving a stick into it.

CCTB DeltaMag Final:Layout 1 9/10/10 10:15 AM Page 1 Coming around a turn I found the PH squatted, eyes hard on an opening in front of us. I eased forward, my eyes

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straining to see through the brush. With each step I could feel my heart beating ever harder in my throat. I couldn’t swallow; lACement lAssifieD I could barely breathe. There they were, three of them. A cow and calf stood patiently watching the third elephant as it gasped for breath. It was the moment of truth. Did I have the courage to do what had to come next? I wasn’t sure, but I motioned the tracker to give me the Underwood.

I aimed carefully as I edged forward and let loose. The PHYSICIANS NEEDED thump and cloud of dust told me my shot had gone low. The MedPlan works with hospitals and typewriter rolled, hitting the debilitated pachyderm in the foot. Damn, I should have taken a couple of practice throws healthcare systems in Mississippi and while I was still in Mississippi, but I hadn’t wanted to damage throughout the Southeast to identify qualified the typewriter’s delicate mechanism and then find myself in physicians of all specialties. We are retained by Africa with sticking keys. the healthcare systems and hospitals, so we are The cow and calf crashed off through the thorns plowing able to save you time as we provide information a clear trail. My target, startled, shuffled after them as fast concerning multiple opportunities, without as it could. I rushed into the clearing and snatched up my charging fees. Many of the positions have very typewriter, needing to reload as fast as possible, but before competitive compensation packages and, in another shot was required, the animal collapsed, coughed some MS cases, 408 West Parkway Place • Ridgeland, 39157school loan repayment. All once, had a small seizure, and expired. inquiries are kept confidential.

PObehind Box 2548 • Ridgeland, MS 39158-2548 “By damn,” I heard the PH mutter me. I’d met If you would like more information, please • fax.: 601-853-6746 ph.:on.

601-853-6733 the test. Now it was time to move I decided then• 800-898-0251 and contact us at MSMA www.msmaonline.com medplankab@aol.com or 205.870there it was on to Zambia to hunt river hippo withwebsite: Sir William 7068. general e-mail: info@msmaonline.com Osler’s nasal speculum. r

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R. Scott Anderson, MD, a radiation oncologist, is medical director of the Anderson Regional Cancer Center in Meridian and past vice chair of the MSMA Board of Trustees. Additionally, he is an accomplished oil-painter and dabbles in the motion-picture industry as a screenwriter, helping form P-32, an entertainment funding entity.

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Why Use a Life Settlement?  Term life insurance policy will expire  Old policy that is no longer needed or premiums cannot be paid  A policy that was purchased for a business buy/sell and is no longer needed  A policy was purchased for a business that has been sold or is not needed  There may be a better policy available at a lower cost

 Estate value has changed and the policy is no longer needed

Securities Offered Through ValMark Securities, Inc. Member FINRA, SIPC Investment Advisory Services Offered Through ValMark Advisers, Inc. a SEC Registered Investment Advisor 130 Springside Drive, Suite 300 Akron, Ohio 44333-2431* 1-800-765-5201 Executive Planning Group is a separate entity from ValMark Securities, Inc. and ValMark Advisers, Inc. In a life settlement agreement, the current life insurance policy owner transfers the ownership and beneficiary designations to a third party, who receives the death proceeds at the passing of the insured. As a result, this buyer has a financial interest in the seller’s death. When an individual decides to sell their policy, he or she must provide complete access to his or her medical history, and other personal information, that may affect his or her life expectancy. This information is requested during the initial application for a life settlement. After the completion of the sale, there may be an ongoing obligation to disclose similar and additional information at a later date. A life settlement may affect the seller’s eligibility for certain public assistance programs, such as Medicaid, and there may be tax consequences. Individuals should discuss the taxation of the proceeds received with their tax advisor. ValMark Securities considers a life settlement a security transaction. ValMark and its registered representatives act as brokers on the transaction and may receive a fee from the purchaser. A life settlement transaction may require an extended period of time to complete. Due to complexity of the transaction, fees and costs incurred with the life settlement transaction may be substantially higher than other securities.