June 2013 JMSMA by Journal MSMA

June

VOL. LIV

2013

No. 6

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Biloxi

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 Steven L. Demetropoulos, MD President James A. Rish, 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.

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Official Publication of the MSMA Since 1959

JUNE 2013

VOLUME 54

NUMBER 6

Scientific Articles Just Off the Press - Info You Want to Know: Omega-3 Fatty Acids and Cardiovascular Risk Leslie G. Kruse, PharmD and Richard L. Ogletree, Jr., PharmD

156

Bedside Ultrasound Detection of Long Bone Fractures Rachana M. Patel, MD and Brian J. Tollefson, MD

159

Top 10 Facts You Need to Know- About Severe Sepsis and Septic Shock Dominique J. Pepper, MBChB, MD; Rajesh Bhagat, MD, PhD; Feriyl Bhaijee, MBChB; John Spurzem, MD, PhD

163

Series: Concepts in End-of-Life Care, Do Not Resuscitate (DNR) Lindsey T. Norris, MD and Sharon P. Douglas, MD

169

President’s Page The Annual Session Steven L. Demetropoulos, MD, MSMA President

167

Related Organizations Mississippi State Department of Health Information & Quality Healthcare Office of Mississippi Physician Workforce American Medical Association

158 174 175 177

Departments From the Editor: Our Democratic MSMA Letters MSMA Annual Session

154 174 179

About the Cover: Around the Bend - “This pathway leads to the Cataloochee Valley nestled in the Smokey Mountains. It was home to many families prior to the formation of the Great Smokey Mountains National Park. It is now a pastoral setting complete with a herd of elk and babbling brooks. As a place of serenity, it whispers of the enduring nature of life. My thoughts go here when I need a few moments away from the din of the office. It possesses a surpassing beauty. Though the way may be dark and steep, the canopy lets in a few glimmers of redemptive light. Beyond the leaves, there is a house. I am almost home, even if only for a few seconds on the busiest day.” —William “Will” H. Sorey, MD, Professor of Pediatrics and Medical Director of the Eli Manning Clinic for Children at The University of Mississippi Medical Center. r June

VOL. LIV

2013

No. 6

JUNE 2013 JOURNAL MSMA 153

From the Editor: Our Democratic MSMA

any of my personal heroes are MSMA members. Among those heroes is the brilliant and gracious Dr. Dan Edney, a general internist of Vicksburg. Ever since he graduated with the highest academic average in his medical school class at UMMC, he has been a leader in thought and action in our profession. He has served in a variety of key leadership positions, from the Board of Trustees, to Chair of our AMA Delegation, to Speaker of the House. He is nationally recognized for his work in medical disaster response. Younger physicians always recall his proactive recruitment of their talents within our association to make our MSMA a vital and effective organization. Dan’s exemplary service as Speaker of our House always impressed me. Having been trained by Dr. George McGee, a gifted Speaker before him, Dan embraced not only the Speaker’s responsibility to run an orderly, fair, and democratic House of Delegates, but also the Speaker’s responsibility away from Annual Session to be the “conscience of our House” at every meeting of the Board of Trustees. That duty involved protecting the House’s interests and reminding the Board that their primary duty was to execute the will of the House. He frequently would advise them that certain issues needed to “go before the House”

to seek their consent or opinion before going forward. “It’s not about you,” he would remind the Board, “It’s about the House of Delegates. You must never forget that your job is simply to serve them.” Ever since the late 1890s, when a grassroots effort took the power of the MSMA away from an out-of-touch Board and placed it within its component Editor Dr. Luke Lampton societies (which composed the House), our MSMA has been a very democratic organization. The average MSMA member can shape both the present and future of our profession by making their voice heard, and the place to do that is Annual Session. The opinion of a physician in Iuka or Gulfport or Natchez or Clarksdale holds just as much weight and importance as the physicians of Jackson, but only if they show up to Annual Session! So come to the 145th Annual Session of the House of Delegates on Friday, August 16, and Saturday, August 17, at the Norman C. Nelson Student Union at UMMC. See pages 179-180 for full schedule and registration details! Contact me: LukeLampton@cableone.net. —Lucius M. Lampton, MD, JMSMA Editor

Journal Editorial Advisory Board R. Scott Anderson, MD, FACR Chair, Journal Editorial Advisory Board Radiation Oncologist and Medical Director, Anderson Regional Cancer Center, Meridian Diane K. Beebe, MD Professor and Chair, Department of Family Medicine, University of MS Medical Center, Jackson Claude D. Brunson, MD Senior Advisor to the Vice Chancellor for External Affairs, University of Mississippi Medical Center, Jackson Jeffrey D. Carron, MD, FAAP, FACS Associate Professor, Department of Otolaryngology & Communicative Sciences, University of Mississippi Medical Center, Jackson Gordon (Mike) Castleberry, MD Urologist, Starkville Urology Clinic Mary Currier, MD, MPH State Health Officer Mississippi State Department of Health, Jackson Thomas E. Dobbs, MD, MPH Epidemiologist Mississippi State Department of Health, Hattiesburg Sharon Douglas, MD Chair, AMA Council on Ethical & Judicial Affairs Professor of Medicine and Associate Dean for V A Education, University of Mississippi School of Medicine, Associate Chief of Staff for Education and Ethics, G.V. Montgomery VA Medical Center, Jackson Daniel P. Edney, MD Executive Committee Member, National Disaster Life Support Education Consortium, Internist, The Street Clinic, Vicksburg

154 JOURNAL MSMA JUNE 2013

Owen B. Evans, MD Professor of Pediatrics and Neurology University of Mississippi Medical Center, Jackson Maxie L. Gordon, MD Assistant Professor, Department of Psychiatry and Human Behavior, Director of the Adult Inpatient Psychiatry Unit and Medical Student Education, University of Mississippi Medical Center, Jackson Scott Hambleton, MD Medical Director Mississippi Professionals Health Program, Ridgeland John Edward Hill, MD, FAAFP Residency Program Director North Mississippi Medical Center, Tupelo John D. Isaacs, Jr., MD Infertility Specialist, Mississippi Fertility Institute at Women’s Specialty Center, Jackson Kent A Kirchner, MD Nephrologist G.V. Montgomery VA Medical Center, Jackson Brett C. Lampton, MD Internist/Hospitalist Baptist Memorial Hospital, Oxford Philip L. Levin, MD President, Gulf Coast Writers Association Emergency Medicine Physician, Gulfport William Lineaweaver, MD, FACS Editor, Annals of Plastic Surgery Medical Director JMS Burn and Reconstruction Center, Brandon John F. Lucas,III, MD Surgeon Greenwood Leflore Hospital

Gailen D. Marshall, Jr., MD, PhD, FACP Professor of Medicine and Pediatrics, Vice Chair for Research, Director, Division of Clinical Immunology and Allergy, Chief, Laboratory of Behavioral Immunology Research The University of Mississippi Medical Center, Jackson Alan R. Moore, MD Clinical Neurophysiologist Muscle and Nerve, Jackson Paul “Hal” Moore Jr., MD, FACR Radiologist Singing River Radiology Group, Pascagoula Jason G. Murphy, MD Surgeon Surgical Clinic Associates, Jackson Ann Myers, MD Rheumatologist Mississippi Arthritis Clinic, Jackson Jimmy L. Stewart, Jr., MD Program Director, Combined Internal Medicine/ Pediatrics Residency Program, Associate Professor of Medicine and Pediatrics University of Mississippi Medical Center, Jackson Samuel Calvin Thigpen, MD Hematology-Oncology Fellow, Department of Medicine University of Mississippi Medical Center, Jackson Thad F. Waites, MD, FACC Clinical Cardiologist, Hattiesburg Clinic Chris E. Wiggins, MD Orthopaedic Surgeon Bienville Orthopaedic Specialists, Pascagoula John E. Wilkaitis, MD, MBA, CPE, MS Chief Medical Officer Brentwood Behavioral Healthcare, Flowood

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JUNE 2013 JOURNAL MSMA 155

• Just Off the Press - Info You Want to Know •

Omega-3 Fatty Acids and Cardiovascular Risk Leslie G. Kruse, PharmD and Richard L. Ogletree, Jr., PharmD

rticle: Rizos EC, Ntzani EE, Bika E, Kostapanos MS, Elisaf MS. Association between omega-3 fatty acid supplementation and risk of major cardiovascular disease events: a systematic review and meta-analysis. JAMA. 2012 Sep 12; 308(10):1024-33. Background: Omega-3 polyunsaturated fatty acids (PUFA’s) have an FDA indication for triglyceride lowering in patients with hypertriglyceridemia. Some European agencies have also approved omega-3 fatty acids for cardiovascular risk modification. Several major societies in the US also recommend their use following myocardial infarction. Objective: The purpose of this review was to assimilate available evidence from randomized controlled trials into one systematic review to determine the association between omega-3 fatty acids and cardiovascular outcomes. Design: Systematic review of randomized, controlled trials with meta-analysis Methods: PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials (up to August 2012) were searched

using a predefined algorithm. All randomized trials evaluating omega-3 polyunsaturated fatty acid supplementation in adults were considered. Trials selected were all randomized, controlled against another diet or placebo, and implemented in primary or secondary cardiovascular disease (CVD) prevention settings. Trials with duration less than 1 year were excluded. Outcomes eligible for review included all-cause mortality, cardiac death, sudden death, MI, and all types of stroke. Fatty acids could be given through diet or through supplements. Additionally, references listed in reviews were screened. Two investigators independently extracted data. Another investigator resolved discrepancies. Results: After retrieving 3,625 citations, 20 studies involving 68,680 participants were included. Two trials used dietary counseling to provide omega-3 fatty acids. The rest used supplements. In the 2 trials using dietary fatty acids, allcause mortality and cardiac death were assessed and showed associations in opposite directions; therefore, with these discrepancies, quantitative synthesis of these trials was not performed.

Table. Efficacy of Omega-3 PUFA Supplements by Outcome Measure

Outcome All cause mortality

Number of studies

Participants

63,279

Relative risk (95% CI) 0.96 (0.91 – 1.02)

Cardiac death

56,407

0.91 (0.85 – 0.98)

Sudden death

41,751

0.87 (0.75 – 1.01)

Myocardial infarction

53,875

0.89 (0.76 – 1.04)

Stroke

52,589

1.05 (0.93 – 1.18)

Adapted from: Rizos EC, Ntzani EE, Bika E, Kostapanos MS, Elisaf MS. Association between omega-3 fatty acid supplementation and risk of major cardiovascular disease events: a systematic review and meta-analysis. JAMA. 2012 Sep 12; 308(10):1024-33.

156 JOURNAL MSMA JUNE 2013

Conclusion: This meta-analysis of omega-3 fatty acid supplements showed no statistically significant lowering of risk for all-cause mortality, cardiac death, sudden death, myocardial infarction, or stroke. These data are displayed in two forms for your reference as a table and a Forest plot. Use of omega-3 fatty acids as a strategy to prevent adverse cardiovascular outcomes, based on this review, is not justifiable in clinical practice settings or in guideline recommendations.

Figure. Forest Plot of Omega-3 PUFA Supplements Efficacy Across Different Outcomes

Favors omega-3 PUFA’s

Favors control

All cause mortality Cardiac death Sudden death Myocardial infarction Stroke 0.6

0.7

0.8

0.9

1.1

1.2

Relative risk (95% confidence interval)

Reviewer’s Comments: While this review indicates that omega-3 fatty acids should not be recommended for use to alter all-cause mortality, omega-3 fatty acids do carry an FDA-approved indication for use in hypertriglyceridemia. The review included omega-3 fatty acid use in the settings of primary and secondary prevention of cardiovascular disease but did not provide information on the number of patients using omega-3 fatty acids for hypertriglyceridemia. With regard to cardiac death, the authors report conflicting information. The relative risk for cardiac death was decreased with omega-3 use (as seen above), but when correction for multiple comparisons was made, the differences were not significant. r

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158 JOURNAL MSMA JUNE 2013

• Scientific • Bedside Ultrasound Detection of Long Bone Fractures Rachana M. Patel, MD and Brian J. Tollefson, MD [Stay tuned for a coming series on use of ultrasound in primary care practice by Dr. Tollefson in future issues of the Journal MSMA.] —Richard D. deShazo, MD, Associate Editor

bstract

Introduction: Rapid identification of fractures of long bones is prudent, since associated bleeding and neurovascular compromise can cause significant morbidity and mortality. We describe two patients who presented to the Emergency Department with orthopedic trauma and underwent bedside ultrasound of the affected extremity. Ultrasound rapidly revealed fractures in both patients, and led to early treatment and disposition. Materials and methods: Rapid bedside ultrasound of long bones was performed on affected extremities and compared to X-rays. Conclusion: Bedside ultrasonography of long bones is a rapid, reliable, and non-invasive method of evaluating patients with suspected orthopedic trauma.

Keywords: Emergency Ultrasound, Long Bone Fractures, Orthopedic Trauma Introduction Ultrasound detection of long-bone fractures has been described as a simple, non-invasive method of evaluating for orthopedic trauma. Traditionally the use of ultrasound in orthopedics has been limited to evaluating hip dysplasia in infants, suspected clavicular fracture in newborns, and more recently, rotator cuff pathology in adults.2,4 Several studies have demonstrated improved sensitivity of ultrasound in detection of long bone fractures when compared to physical Author Information: Emergency medicine resident at the University of Mississippi Medical Center (Dr. Patel). Assistant professor and ultrasound program director of emergency medicine, University of Mississippi Medical Center. Board certified in emergency medicine with CAQ in sports medicine and registered diagnostic medical sonographer (Dr. Tollefson). Corresponding Author: University of Mississippi Medical Center, Department of Emergency Medicine, 2500 North State Street, Jackson, Mississippi 39216 Fax: 601-984-5583 [abby807@aol.com or btollefson@umc.edu].

examination. One study suggested the addition of extremity ultrasound to the trauma assessment called FASTER, aimed at improving overall trauma diagnosis.5 In this case series, we describe two patients who underwent bedside ultrasound of long bones in evaluation for fractures.

Case Series Case 1 A 32-year-old healthy female presented to the Emergency Department with a complaint of left lower leg pain, left knee pain, and left thigh pain after a motor vehicle collision that occurred overnight. She was a restrained driver of a truck that ran off the road and flipped. She was subsequently ejected from her vehicle. She was seen at another hospital afterwards and reportedly had negative CT head and CT C-spine. The patient states plain X-rays were taken of her femur, and she was told she had a fracture. She was sent home on crutches and had not been able to bear weight or lift her leg off the bed since then. She presented to University of Mississippi Medical Center Emergency Department for continued pain and a second opinion. The patient reported loss of consciousness and denied fever, chills, headache, breathing problems, chest pain, and abdominal pain. On examination, her vital signs were normal except a mild tachycardia of 110 bpm. The complete physical examination was unremarkable except for ecchymosis of the right forehead, tenderness of the left distal femur and knee, and multiple areas of ecchymoses and abrasions to bilateral forearms and legs. She underwent bedside ultrasonography of the left lower extremity which revealed a proximal fibula fracture (Figures 1, 2, 3, and 4). On X-ray, she was noted to have proximal fibula fracture and a possible tibial plateau fracture. She underwent CT of the left lower extremity, which showed a comminuted, minimally displaced fracture of the tibial intercondylar eminence and a comminuted, minimally displaced fracture of the fibular head. The radiologist recommended MRI of the knee to evaluate for ACL injury. Orthopedics and Trauma Surgery were consulted, and she was admitted to Orthopedics for further management

JUNE 2013 JOURNAL MSMA 159

proximal fibula fracture and a possible tibial plateau fracture. She underwent CT of the left lower extremity and it s comminuted, minimally displaced fracture of the tibial intercondylar eminence and a comminuted, minimally displa fracture of the fibular head. The radiologist recommended MRI of the knee to evaluate for ACL injury. Orthopedic Trauma surgery were consulted and she was admitted toFigure Orthopedics for further management of her fractures. She of her fractures. She underwent MRI of the left knee which 4. X-ray of left knee (AP view) showing fractures underwent MRI of the left knee, which did not show any ligamentous injury. She had an uneventful hospital course of the proximal tibia and fibula. did not show any ligamentous injury. She had an uneventful was discharged days later. 6 days later. hospital course and6was discharged Figure 1. Normal longitudinal ultrasound of left proximal tibia without discontinuity of bony cortex.

Figure 2. Longitudinal ultrasound of left fibular head

showing1minimally displaced fracture. Figure Normal longitudinal ultrasound of left proximal tibia

Figure 3. X-ray of left tibia/fibula (AP view on left and lateral view on right) showing a comminuted fracture Figure Figure 2 2 of the proximal fibula. Therehead also a minimally fracturedisplaced of the fracture. Longitudinal ultrasound of left fibular showing Longitudinal ultrasound ofisleft fibular head showing intercondylar eminence.

Case 2 A 54-yearold man with a past medical history of diabetes and hypertension presented to the University of Mississippi Medical Center Emergency Department with pain and deformity of the right ankle. He suffered an inversion injury of his right ankle when he tripped at Figure 4 X-ray left knee (AP view)He showing fractures the proximal home of earlier that morning. reported pain andofdeformity and tibia and fi Figure 4 denied numbness, paresthesias, loss of sensation or weakness Case from#2 baseline. He was(AP initially seen at anotherfractures hospital andof the pro X-ray of left knee view) showing without discontinuity of bony cortex. Awas 54 year-old man a past medical history of diabetes transferred forwith right distal tibia and fibula fracture.and Onhypertension Medical Center Emergency Department with pain and deformity of the righ examination, vital signs were normal. The complete physical right ankle Case #2 when he tripped at home earlier that morning. He reported pain examination loss wasof unremarkable except forfrom moderate swelling, paresthesias, sensation weakness baseline. Heofwas initially Atenderness, 54 year-old man withorarange pastofmedical history diabetes deformity, limited motion, and pain onsigns were n right distal tibia and fibula fracture. On examination, the vital Medical Center Department with painlimited and def motion of distal rightEmergency lower leg.swelling, He underwent bedside ultrasounremarkable except moderate tenderness, deformity, ran right ankle when he tripped at home earlier that morning. lower leg. He underwent bedside ultrasonography of right lower extremity, nography of the right lower extremity which revealed a distal (Figures 6, 7, and X-rays,5,he6,was noted have distalbaseline. tibia and fi tibia and5,fibula fractures and 8).toOn X-rays, paresthesias, loss8).ofOn(Figures sensation or7, weakness from the injured extremity was reduced and splinted. He was admitted he wasdistal noted tibia to haveand distal tibia and fibula fractures. Ortho- to Ortho right fibula fracture. On examination, the lower extremity. He had an uneventful hospital course and was discharged pedics was consulted, and moderate the injured extremity wastenderness, reduced unremarkable except swelling, defo and splinted. He was admitted to Orthopedics and underwent lower leg. He underwent bedside ultrasonography of right external fixation of right lower extremity. He had an uneventful (Figures 5, 6,and 7, was anddischarged 8). On the X-rays, he day. was noted to have hospital course following

the injured extremity was reduced and splinted. He was a Figure extremity. 5. Normal longitudinal ultrasound of right lower He had an uneventful hospital course an proximal tibia without discontinuity of bony cortex.

minimally displaced fracture.

Figure 5 Normal longitudinal ultrasound of right proximal tibia without discontinuit

Figure 3

Figure 5 Normal longitudinal ultrasound of right proximal tibia wi

X-ray JOURNAL of left tibia/fibulaMSMA (AP view onJUNE left and lateral 160 2013view on right) showing a comminuted fracture of the proximal fibula. There is also a fracture of the intercondylar eminence.

Figure 6. Transverse (left) and longitudinal (right) ultrasounds of right distal tibia showing a displaced fracture.

Figure 6

Figure 7. Longitudinal ultrasound of right distal fibula Discussion Transverse (left) and longitudinal (right) ultrasounds of right distal tibia showing a displaced fracture. showing a displaced fracture. Ultrasound has proven to be accurate in focused examinations, such as the Focused Assessment with Sonography for Trauma (FAST). Several recent studies have evaluated the use of ultrasound in a wider range of clinical conditions, ranging from eye complaints to musculoskeletal Figure 6 complaints. Although ultrasound was previously thought to Transverse (left) and longitudinal (right) ultrasounds of right distal tibia showing a displaced fracture. be limited in the evaluation of bone abnormalities secondary to the very large acoustic impedance which caused complete reflectance of the acoustic waves and dorsal shadowing, it is now considered to improve visualization of cortical disruptions.1,5 Ultrasound is also useful to evaluate associated fracture hematomas and can be used for procedural guidance for anesthesia for a hematoma block. The bony cortex can be readily visualized with a high-frequency linear array probe. If there is abundant overlying soft tissue, a lower-frequency curvi-linear probe may be needed. At least two views are required, longitudinal and transverse.7 Initially the ultrasound Figure 7 is conducted with the transducer oriented longitudinally to Figure 8. X-rayultrasound of right ankle (AP view left and lateral a displaced Longitudinal of right distalonfibula showing fracture. Figure view7on right) showing comminuted fractures of the distal evaluate cortical disruption. False-positive results have been Longitudinal tibia and ultrasound fibula. of right distal fibula showing a displaced fracture. noted by scanning the fracture parallel to its axis.5 A transverse view of the site of interest should be performed to confirm the fracture. In a study by Grechenig et al. ultrasound was able to detect cortical disruptions of 1 mm and larger in cadavers.1,5 Marshburn et al. found that ultrasound had improved sensitivity and less specificity when compared to physical examination in the detection of long bone fractures. It was also noted that ultrasound detection of fractures might be most useful in detecting and ruling out femoral shaft and humerus fractures only, since there was 100% sensitivity at those sites. In that study, ultrasound was limited in detection of fracture near the hip and above the intertrochanteric line.1 In a study by Hunter et al. ultrasound detected a fibula fracture in an adult male that was not apparent on initial plain radiographs. He proposed using ultrasound in cases where this a high index of clinical suspicion and an unremarkable X-ray.2 Figure 8 X-ray of right ankle (AP view on left and lateral view on right) showing comminuted fractures of the distal tibia and fibula.

JUNE 2013 JOURNAL MSMA 161

Conclusion Ultrasound detection of long bone injuries may be useful in situations where radiographic capabilities are not readily available.3 It may allow prompt diagnosis and early stabilization in severely injured patients. It has been proven to be more sensitive than physical examination alone. It has been noted that missed injuries in trauma are most frequently musculoskeletal with extremity fractures being the most common.5 These injuries may be easily evaluated by the addition of musculoskeletal ultrasound during the initial trauma assessment. Evaluation of fractures by ultrasound has the advantage of immediate clinical correlation and can be performed by people with minimal training in ultrasound.6

Noble VE, Legome E, Marshburn T. Long bone ultrasound: making the diagnosis in remote locations. J Trauma. 2003;54:800.

Weiss DB, Jacobson JA, Karunakar MA. The use of ultrasound in evaluating orthopedic trauma patients. J Am Acad Orthop Surg. 2005;13:525–533.

Al-Kadi AS, Gillman LM, Ball CG, Panebianco NL, Kirkpatrick AW. Resuscitative long-bone sonography for the clinician: usefulness and pitfalls of focused clinical ultrasound to detect long-bone fractures during trauma resuscitation. Eur J Trauma Emerg Surg. 2009;4:357-363.

Heiner JD, McArthur TJ. The ultrasound identification of simulated long bone fractures by prehospital providers. Wilderness Environ Med. 2010;21:137-140.

References 1.

Marshburn TH, Legome E, et al. Goal-directed ultrasound in the detection of long-bone fractures. J Trauma. 2004;57:329-332.

Hunter JD, Mann CJ, Hughes PM. Fibular fracture: detection with high-resolution diagnostic ultrasound. J Accid Emerg Med. 1998;15:118.

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• Top Ten Facts You Need to Know • About Severe Sepsis and Septic Shock Dominique J. Pepper, MBChB, MD; Rajesh Bhagat, MD, PhD; Feriyl Bhaijee, MBChB; John Spurzem, MD, PhD

ntroduction

Severe sepsis and septic shock are life-threatening conditions that progress rapidly to death. Diagnostic criteria for sepsis include a known or suspected infection and the presence of two or more criteria for the systemic inflammatory response syndrome: temperature >100.4°F or <96.8°F; leukocyte count > 12,000/µL or < 4,000/µL or at least 10% bandemia; respiration rate >20bpm or PaCO2 <32mmHg; and heart rate >90bpm.1, 2 The diagnosis of severe sepsis requires evidence of sepsis-induced organ dysfunction. Septic shock is sepsis with hypotension refractory to intravenous fluid resuscitation requiring vasopressor therapy.1-3 The following article provides clinicians with the top ten facts they need to know about the Surviving Sepsis Campaign Guidelines (2004, 2008, and 2012).4, 5 Only strong recommendations with grade A (from randomized controlled trials [RCT]) or grade B (downgraded RCT or upgraded observational studies) evidence are included.4, 5

1. Administer broad-spectrum antibiotic therapy within 1 hour of diagnosis of septic shock. Each hour of delay in antimicrobial administration after the recognition of septic shock decreases survival by 7.6%.6 2. Administer crystalloids (normal saline) rather than colloids for initial volume resuscitation. While outcomes Author Information: PGY-3 Resident, Department of Medicine, University of Mississippi Medical Center (UMMC), Jackson (Dr. Pepper). VA MICU Director, Associate Professor & Staff Physician, Division of Pulmonary, Critical Care & Sleep Medicine, UMMC & G.V. Sonny Montgomery VA Medical Center Jackson MS. (Dr. Bhagat). PGY-3 Resident, Department of Medicine, UMMC (Dr. Bhaijee). Professor and Chief of Division of Pulmonary, Critical Care & Sleep Medicine, UMMC (Dr. Spurzem). Corresponding Author: Dominique J Pepper, MBChB, MD, University of Mississippi Medical Center, Department of Medicine, 2500 North State Street, Jackson, Mississippi 39216 [dpepper@ umc.edu]

are similar at 28 days when using 4% albumin and normal saline as resuscitation fluid, saline is inexpensive compared to 4% albumin.7 90-day mortality in ICU patients is similar when using 6% hydroxyethyl starch (HES) or saline as a resuscitation fluid, but 6% HES significantly increases the relative risk of requiring renal-replacement therapy by 21%.8 3. Norepinephrine is the preferred first vasopressor in septic shock. Dopamine and norepinephrine as the first-line vasopressor agent in patients with shock have similar rates of death. However, compared to norepinephrine, dopamine significantly increases the occurrence of sinus tachycardia (6% vs. 25%) and arrhythmias (12% vs. 24%).9, 10 4. In the absence of tissue hypoperfusion, coronary artery disease, or acute hemorrhage, target a hemoglobin of 7–9 g/dL. A restrictive strategy of red-cell transfusion (targeting a hemoglobin concentration of 7–9g/dL) has a similar 30-day mortality rate compared to a liberal strategy of red-cell transfusion (targeting a hemoglobin concentration of > 10 g/dL). Moreover, compared to a liberal strategy, a restrictive strategy significantly decreases mortality in those with lower APACHE II scores (9% vs. 16%) and younger age (6% vs 13%).11, 12 5. Maintain head of bed elevation in mechanicallyventilated patients unless contraindicated. Compared to supine positioning during invasive mechanical ventilation, semi-recumbent positioning significantly decreases the frequency of clinically-suspected nosocomial pneumonia (8% vs. 34%).13 6. Target a tidal volume of 6ml/kg (predicted) body weight in patients with acute lung injury or adult respiratory distress syndrome. Among intubated patients with acute lung injury or adult respiratory distress syndrome, a lower tidal volume (6ml/kg of predicted body weight) significantly decreases both mortality (31% vs. 40%) and number of days without ventilator use (12 vs. 10) compared

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to traditional tidal volumes (12ml/kg of predicted body weight).14 7. Use a sedation protocol in mechanically-ventilated patients. Compared to non-protocol-directed sedation in mechanically-ventilated ICU patients, protocol-directed sedation significantly decreases duration of mechanical ventilation (56 hours vs. 117 hours), length of ICU stay (5.7 days vs. 7.5 days), and length of hospital stay (14 days vs. 19.9 days).15 8. Avoid neuromuscular blockers. Neuromuscular blockade in mechanically-ventilated patients with severe sepsis or septic shock improves respiratory compliance but does not significantly influence mucosal pH, oxygen delivery, oxygen consumption, or oxygen extraction ratios.16 9. Do not use high-dose corticosteroids (hydrocortisone dose > 300mg/day). Compared to placebo, high dose corticosteroids do not prevent shock, reverse shock or decrease mortality.17 In patients with elevated serum creatinine levels, high dose corticosteroids increase mortality.17 Current evidence provides no support for the use of corticosteroids in patients with sepsis or septic shock and suggests that their use may be harmful.18 Stress-dose steroids (hydrocortisone < 300mg/day) may be used for those on chronic steroid therapy. 10. Provide prophylaxis for deep vein thrombosis and stress ulcers. Subcutaneous low-dose heparin reduces the rate of venous thrombosis by 50% compared with no prophylaxis.19, 20 Antacids and H2-receptor antagonists decrease overt gastrointestinal bleeding compared to placebo.21

org/2012/critical-care-review/surviving-sepsis-guidelinesupdated-at-sccm-meeting/. 6.

Kumar A, Roberts D, Wood KE et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006;34:1589-1596.

Finfer S, Bellomo R, Boyce N et al. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med. 2004;350:2247-2256.

Myburgh JA, Finfer S, Bellomo R et al. Hydroxyethyl starch or saline for fluid resuscitation in intensive care. N Engl J Med. 2012;367:1901-1911.

De Backer D, Biston P, Devriendt J et al. Comparison of dopamine and norepinephrine in the treatment of shock. N Engl J Med. 2010;362:779-789.

10. Patel GP, Grahe JS, Sperry M et al. Efficacy and safety of dopamine versus norepinephrine in the management of septic shock. Shock. 2010;33:375-380. 11. Hébert PC, Wells G, Blajchman MA et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med. 1999;340:409-417. 12. Hébert PC, Yetisir E, Martin C et al. Is a low transfusion threshold safe in critically ill patients with cardiovascular diseases? Crit Care Med. 2001;29:227-234. 13. Drakulovic MB, Torres A, Bauer TT et al. Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial. Lancet. 1999;354:18511858. 14. ARDS Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342:1301-1308.

Conclusion

15. Brook AD, Ahrens TS, Schaiff R et al. Effect of a nursingimplemented sedation protocol on the duration of mechanical ventilation. Crit Care Med. 1999;27:2609-2615.

Severe sepsis and septic shock are best managed in intensive care units where invasive monitoring and access to mechanical ventilation, inotropes, and vasopressors is readily available.

16. Freebairn RC, Derrick J, Gomersall CD et al. Oxygen delivery, oxygen consumption, and gastric intramucosal pH are not improved by a computer-controlled, closed-loop, vecuronium infusion in severe sepsis and septic shock. Crit Care Med. 1997;25:72-77.

References

17. Bone RC, Fisher CJ, Clemmer TP. A controlled clinical trial of high-dose methylprednisolone in the treatment of severe sepsis and septic shock. N Engl J Med. 1987;317:653–658.

American College of Chest Physicians/Society of Critical Care Medicine. Consensus Conference: Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med. 1992;20:864-874.

Levy MM, Fink MP, Marshall JC et al. 2001 SCCM/ESICM/ ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med. 2003;31:1250-1256.

Annane D, Bellissant E, Cavaillon JM. Septic shock. Lancet. 2005;365:63-78.

Dellinger RP, Levy MM, Carlet JM et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med. 2008;36:296-327.

Pulm CCM 2012 Retrieved December 5, 2012. http://pulmccm.

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18. Cronin L, Cook DJ, Carlet J et al. Corticosteroid treatment for sepsis: A critical appraisal and meta-analysis of the literature. Crit Care Med. 1995;23:1430–1439. 19. Attia J, Ray JG, Cook DJ et al. Deep vein thrombosis and its prevention in critically ill adults. Arch Intern Med. 2001;161:1268-1279. 20. Geerts W, Cook D, Selby R et al. Venous thromboembolism and its prevention in critical care. J Crit Care. 2002;17:95-104. 21. Cook DJ, Witt LG, Cook RJ et al. Stress ulcer prophylaxis in the critically ill: a meta-analysis. Am J Med. 1991;91:519-527.

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for iPhone, iPad, Android, and all web-enabled mobile devices MSMA has gone social! Quickly and easily join our nearly 1,000 Twitter followers and Facebook fans by downloading our app and selecting the Social Media link. #GetTheApp #Thanks

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• President’s Page • The Annual Session

very year your State Medical Association hosts its annual session. In the past this has been a combination of CME and a business meeting as well as activities for family and members. This year we will be doing something different and that is having a separate business meeting. The purpose of the annual session is to develop policy for the association going forward, to hear from its membership, and to allow for debate and consensus building around issues that face physicians in our state. One way a member becomes involved is to put forward a resolution in which the Association is asked to look into, make policy on, or address a particular topic. This can come from an individual or it can come from a Steven L. Demetropoulos, MD component society or from one of the state specialty societies. All of these 2012-13 MSMA President are originated by members within our association. So you as an individual member can actually develop policy for our whole association. This is so very important because it shows the type of grassroots involvement that we offer to our members. We as an organization need that involvement in order to reflect the sentiments of the physicians that are in the trenches all across the state. Don’t let resolution writing be a barrier to your being involved. Our association staff can take you through all the steps and help you put together the resolution that you would like to present at the annual session. The annual session also provides an opportunity for you to network with doctors from across the state and hear other experiences and points of view. It really creates a great opportunity for us to develop a well thought-out consensus on difficult issues that we struggle with. In order for us to be well represented, we need physicians from academic settings, private practice, rural communities and urban areas. We really need input from as many physicians as possible in order to adequately represent our membership. The second way that you can be involved at annual sessions is to come as a delegate. Each component society has one delegate for each ten members, and it is a great way to begin your involvement in organized medicine in the state. That is how I got started. It allows you to see the process of addressing issues and problems that we face as physicians. It is a great entry way but it is also a very needed and important position for the annual session to be able to function. We need members who are willing to be delegates this year. We need members that are willing to come to Jackson and be engaged in the process of making policy for our organization. The meeting will be held on August 16 and 17 at University Medical Center (UMC) in Jackson. The purpose of choosing this location is to take advantage of their advanced telecommunications equipment so that we can have the possibility for some virtual interaction which house delegates have asked for in the past. The House of Delegates will convene at 1:00 pm on Friday afternoon and end by about 5:00 pm. That evening we will have the presidential inaugural gala as well as the MSMA Alliance silent auction which will be our social events for that night. The next day we will begin our meetings again and try to be finished by 3:00 pm on Saturday, the 17th. Jackson was picked as our meeting place because of its more central location. The largest proportion of doctors is there, and we have use of UMC equipment with which we could begin the process of virtual interaction with some of our reference committees. In the past we have tried lots of different things to increase our attendance at this business meeting. We have held it in different parts of the state. We have tried holding it at resort areas like Point Clear, Alabama, or Sandestin. We have tried to have more family-friendly events and special speakers or writers, but we haven’t been able to get more than about 160 doctors for the past seven years. That is what prompted us to change the whole format and have a separate business meeting so that we could try to increase attendance. This too will fail if we don’t have involvement of you, the Mississippi physician, coming and supporting the annual session. We need your support. It is important for the health and wellbeing of our organization. We need your input, we need your judgment, and we need your engagement. I look forward to seeing you at the next annual session August 16 and 17 in Jackson.

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ust what the doctor ordered EASY PASTA DISH

his next dish is a very simple pasta dish. It is actually very popular in Rome. There, they use only black pepper and Pecorino Romano cheese, but I like to add a little garlic to it. My favorite rendition of this recipe uses a whole garlic that is already roasted. You can usually find that at Fresh Market. I slice the garlic and warm it in olive oil. Then I use my favorite pasta—mine is bowtie or penne pasta. I toss the garlic and olive oil with the penne pasta and then salt to taste. In Rome they like to use a lot of pepper and so do I. Then you add the Pecorino Romano cheese. It is the real star of this recipe. You can find it at Fresh Market, too. I like to have it grated, and use a generous portion which I mix with the pasta and then toss again. You can finish it with some shredded fresh basil leaves. This is a very simple pasta dish— just cheese, a generous portion of olive oil, and garlic. Try that with any of your summer dishes like fish, lamb, or steak.

Bon Appétit! Steve Demetropoulos, MD

Component societies meet with a beat... Address local concerns

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168 JOURNAL MSMA JUNE 2013

Develop grassroots support for issues Improve the health of their communities.

Visit the SOCIETIES page at MSMAonline.com for local medical societies’ listings. Email officer updates and upcoming meetings/events to Virginia Jackson (VJackson@MSMAonline.com) or call 601-853-6733, ext. 307. • Coast Counties Medical Society - 6:00 pm, Aug. 8 and Nov. 14 The Great Southern Club, Hancock Bank Building, Gulfport • Prairie Medical Society - 6:30 pm, Sept. 10, Old Waverly, West Point

• Scientific •

Series: Concepts in End-of-Life Care Do Not Resuscitate (DNR) Lindsey T. Norris, MD and Sharon P. Douglas, MD [This is the third article in a 5-part series: Concepts in End-of-Life Care. Previous articles addressed general concepts in end-of-life care and palliative care. The next article in the series will cover advance directives and the final article will address grief. The series is edited by Richard D. deShazo, MD, Associate Editor.]

ntroduction

Issues surrounding cardiopulmonary resuscitation (CPR) or its opposite, Do Not Resuscitate (DNR), can be complex and confusing. Yet, such decisions are often made in haste when the patient’s medical condition is critical. A clear understanding of the definition and use of the DNR order is vital. More importantly, a clear understanding of patients’ wishes for medical interventions along with appropriate medical explanations by physicians relative to interventions in the pericardiopulmonary arrest period is necessary. This approach promotes patient autonomy, delineates goals of care, and is ideally conducted before the patient is in a medical crisis. This article reviews the origins of CPR and thus DNR, discusses the definition of DNR and some DNR statistics, reviews how discussions of code status should be done and noted, and suggests how to address conflicts over CPR effectiveness.

Case

A 52-year-old African-American woman with multiple myeloma, hypertension, diabetes mellitus, and chronic kidney disease III was admitted to the hospital for elevated white blood cell count and fever. No clear source of infection had been found. Chest x-ray had shown right lower lobe density. Although a diagnosis of pulmonary thromboemboli was considered, the patient’s chronic kidney disease stage III precluded computed tomography of the chest with pulmonary emboli protocol (CT PE protocol). Broad-spectrum antibiotics and heparin infusion were started. Author Information: Internal Medicine Resident, Department of Medicine, University of Mississippi Medical Center (Dr. Norris). Pulmonary Physician, Professor of Medicine, Department of Medicine, Associate Dean for VA Education, University of Mississippi Medical Center (Dr. Douglas). Corresponding Author: Lindsey T. Norris, MD, Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, Mississippi 39216 [LTNorris@umc.edu].

On the evening of hospital day three, the patient had sudden shortness of breath and confusion with vital signs showing heart rate 182/min, blood pressure 84/46 mmHg, respiratory rate 30/min, afebrile, and room air saturation 88%. Rhythm strip and EKG showed regular narrow complex tachycardia. The patient’s code status was Do Not Resuscitate (DNR). Vagal maneuvers were attempted. Questions arose. How much should be done in this patient whose code status is DNR? Should synchronized cardioversion or adenosine be considered? If the adenosine caused asystole in this patient with DNR code status, would we then be obligated to address the adenosine initiated asystole despite her code status?

History of CPR and thus DNR

The term cardiopulmonary resuscitation was first publicized over 50 years ago.1 Cardiac massage has evolved from open-chest cardiac massage in the 1900’s2 to external cardiac massage, now known as chest compressions. Use of external cardiac massage was first published in The Journal of the American Medical Association (JAMA) in 1960, where four cases of cardiac arrest and one case of ventricular fibrillation were evaluated. 3 All four cases of cardiac arrest had successful resuscitation with external cardiac massage and in the other case there was cessation of ventricular fibrillation with external cardiac massage and then defibrillation. These five cases were pivotal in prompting the use of closed chest cardiac massage in cardiac arrest. No longer was thoracotomy needed for cardiac massage. Training in CPR became necessary for health care professionals and lay persons.2 In 1966, the National Academy of Sciences’ National Research Council sponsored a conference on CPR that recommended training all medical personnel in CPR.3 Recommendations made by this conference resulted in acceptance of CPR and training of individuals in the health care setting. In 1973 the American Heart Association (AHA) and the National Academy of Sciences-National Research Council sponsored a National Conference on Standards regarding CPR which resulted

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in recommended techniques for basic and advanced life support, CPR training according to AHA standards, training medical and allied health personnel in CPR, role of Red Cross in training lay public, and medicolegal aspects of CPR and ECC. The American Heart Association also became the first medical organization to recommend documentation in patients’ charts stating whether or not resuscitation should be implemented. The AHA also suggested documentation if CPR would be a futile effort and would violate an individual’s right to die with dignity. This could benefit nurses or other personnel called upon to initiate CPR. Code status for patients admitted to the hospital became common practice in American hospitals primarily based on the AHA recommendations.3 DNR orders have been both useful and problematic. Over time DNR orders have been viewed as a negative order by many patients and health care providers. DNR orders have been misinterpreted to withhold more than just CPR. A DNR order does not necessarily sway diagnostic evaluation or aggressive treatment prior to the time of cardiopulmonary failure, unless such decisions have been made already by the patient and physician. Also, issues can arise regarding the specific interventions each patient desires or does not desire, not just related to chest compressions and defibrillation but also to insertion of an endotracheal tube with implementation of mechanical ventilation. For example, a patient may wish partial resuscitation such as chest compressions and defibrillation but without intubation. Often such limits or partial resuscitation plans are documented as orders in medical records as partial limits on resuscitation.

DNR Definition A DNR order precludes resuscitative efforts in the event of cardiopulmonary arrest, cessation of heartbeat and respiratory effort. This order is written with the patient’s consent. In the event that the patient cannot make the decision, an appropriate surrogate can make this decision based on the patient’s previously expressed wishes or best interests if previous wishes are not known. This order should be documented in the chart along with a progress note reflecting the discussion.

DNR Continuum

The DNR order, in and of itself, should not influence other medically appropriate interventions unless such interventions have also been declined by the patient.5 However, orders for DNR are often misinterpreted to preclude medical interventions, sometimes even prior to cardiopulmonary cessation, that the patient may have indeed wished to have had or wished to have considered.6 Health care providers may also mistakenly interpret a DNR order to mean decreasing intensity of care in general that is provided to patients.6 A DNR order may be seen as part of a continuum where some patients wish to be DNR-AND (allow natural death) at one end but where other patients lie somewhere further along the continuum wishing to be DNR with at least some aggressive measures and other interventions intended up until the time of cardiopulmonary cessation. (Figure 1) DNR “Hand-off” Communication When a patient has chosen to forego cardiopulmonary resuscitation with a DNR order, it is imperative that a clear understanding be reached about the patient’s goals of care prior to cardiopulmonary cessation. Then these goals of care must be carefully documented and also conveyed in “handoff” communication to other healthcare providers in the patient’s care.

Some DNR Statistics There are numerous studies on the outcomes of CPR. Two studies suggest that about 17% of adult inpatient cardiac arrest victims survive to hospital discharge after inpatient CPR.8,9 In a study of elderly patients, prior to learning the survival rate of CPR, 41% of patients wanted CPR performed. However, after learning of CPR survival rate, only 22% of elderly patients wanted CPR. In this same study only 5% of patients who had a life expectancy of less than 1 year wanted CPR after a full understanding of survival post CPR.10 In a meta-analysis of cancer patients, localized malignancy was associated with a 9.5% successful resuscitation rate vs metastatic disease with 5.6% successful resuscitation rate.11 In another meta-analysis, factors associated with failure of adult

Figure 1. The Continuum of DNR DNR Allow natural death

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Aggressive until cardiopulmonary cessation

inpatients to survive CPR to hospital discharge were: sepsis, serum creatinine >1.5 mg/dl, cancer, dementia, and location of resuscitation on a ward rather than in an ICU.12 Surviving CPR should not be the only outcome discussed with patients. Functional status and long-term outcomes are important. Based on a study in 2013, in outcomes for adults > 65 years old, only 40% were discharged home, 55.3% to inpatient facilities, and 4.8% to hospice setting. In the same study 42.2% had severe neurologic disability defined as conscious yet dependent on others for daily support due to impaired brain function.13 As with any medical intervention or set of medical procedures, a patient has the right to, and physicians the ethical responsibility to, ensure that there is informed understanding of the patient’s specific prognosis and the risks, benefits, and outcomes of any procedures or interventions. This information assists patients in shared decision-making discussions with physicians.

Patient-Physician DNR Discussions

When

Decisions about resuscitation status should include wider issues of end-of-life care rather than just whether or not cardiopulmonary resuscitation measures will be employed when the heart and lungs cease to work.7 In most cases this conversation should be initiated in the outpatient setting with the patient’s primary care physician. This conversation should not be initiated for the first time during a time of hasty decisions and minimal time to explain complicated procedures and interventions, such as in an intensive care setting.

With Whom It is advisable to initiate these discussions with patients with end stage heart failure, liver failure, chronic obstructive pulmonary disease (COPD), or other end stage organ disease; terminal illness; a low likelihood of surviving resuscitation; or increased risk for cardiac or respiratory arrest.6 If possible, the patient’s next of kin should be involved in this initial discussion to help the patient make decisions and then to support these decisions if/when the patient loses decision making capacity. What Components of Conversation End of life discussions should contain key points to help guide conversation and ensure that patient and physician are in agreement regarding this very important decision (Table). Discussions should begin with a statement that the physician wishes to engage the patient in a conversation that discusses end-of-life decisions including the patient’s current prognosis and desired goals if his/her clinic status were to deteriorate. Next, the patient’s values, expectations, and goals of care should be explored. Conversations regarding life sustaining measures (mechanical ventilation, CPR, other invasive procedures) should occur in the context of the patient’s life goals along with

their expectations for his/her hospital course and remaining years of life. Prognosis relative to surviving CPR and current disease progress should be also addressed. When patients have misunderstandings about their specific disease prognosis, they may have unrealistic expectations. Information given should be relative to risks and outcomes with CPR that relate to that specific patient’s course.14 The physician should then make a recommendation based on the medical information (prognosis, risks, benefits, outcomes) as well as what the patient has expressed to be goals of care. The conversation should close by determining that the patient understands prognosis, goals of care, and outcome.14 Who Else It is the responsibility of the physician to facilitate and guide patients through medical decisions surrounding end-oflife care. The physician understands the intricacies of medical interventions and should use the patient’s values, goals, and beliefs to help determine outcomes that would be acceptable to the patient so that a treatment plan can then be developed that best achieves the patient’s goals in the given clinical setting.15 Nurses and other healthcare providers including primary care staff can be important contributors to such discussions, acting as liaisons, advocates, educators, and mediators.16 Range of Decisions Discussed with DNR Orders Medical interventions provided to a patient with a DNR order should serve the goals of the patient. If the goal of treatment is to allow death to come as comfortably as possibly, the decision should not include life-extending aggressive interventions and the implied concept of “allow natural death” should be conveyed to all who care for the patient in “hand-off” communication. In contrast, if the goal of treatment is to forego resuscitation in the event of cardiopulmonary cessation while extending the patient’s life with effective life-extending interventions before such arrest, patients who wish DNR may be medically eligible for interventions such as vasopressors or cardioversion.17 Table. Elements of a DNR Discussion •

Introduction

•

Investigate patient’s goals, values, and expectations

•

Insure patient understand prognosis

•

Explain nature, risks, and outcomes of CPR

•

Make a recommendations consistent with the patient’s prognosis and goals of care

•

Close conversation

J Gen Intern Med. 2011 April 26(4): 359-366

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Discussions with patients who wish DNR status yet want life-extending interventions up until such arrest should fully inform the patients, or surrogates where applicable, of the implications of such interventions. Implications should include risks, invasiveness, potential discomfort, potential change in quality of life, potential need for transfer of care, and estimates of length of life extension. This discussion may include, but is not limited to, use of bipap, vasopressors, inotropic support, blood products, and even ICU transfer. This discussion should focus on exploring what the patient would want if a catastrophic event were to occur and what his/her goals would be if his/her clinical state should deteriorate prior to cardiopulmonary cessation. This information should be matched with the patient’s goals and understanding of his/her disease process. Such discussions are a necessary piece of the informed consent dialogue and undergird the ethical principle of autonomy. At what other time in life is the concept of informed consent and the ethical principle of respecting autonomy more important than in the dying part? Decreasing Misinterpretations Patients and surrogates, as well as some health care providers, may have misinterpretations of what a DNR order means. Decreasing misinterpretation may minimize confounding variables in decisions relative to cardiopulmonary resuscitation or withholding of it.16 For example, if a patient believes that the mechanical ventilator will cure the underlying severe chronic obstructive pulmonary disease (COPD), this misunderstanding should be corrected and the patient should be aware that such treatment will at best will return him/her to the baseline state of current severe COPD or perhaps reduce his/her baseline status even further.

POLST-Physician Orders for Life-Sustaining Treatment Even when code status has been discussed in the past, such information can be limiting if the patient cannot currently express his/her wishes and a prior DNR order cannot be located in a medical emergency. Physician Orders for Life-Sustaining Treatment (POLST) is a program used in many states to ensure that a seriously ill person’s wishes regarding life sustaining treatments are known, communicated, and honored across all health care settings,18 including the community, by physician orders. This program was first initiated in Oregon in 1991 with the first POLST form being released in 1995.19 Most states have endorsed this program. Mississippi is not one of them. POLST is useful for critically ill patients who have a life expectancy of less than one year or anyone of advanced age interested in discussing and defining his/her end-of-life wishes.4 A standardized form is discussed with the patient and then filled out by the physician. Patients can keep a copy of this form on their person at all times. This ensures that in a medical emergency the patient’s wishes are carried forward regardless of the setting.

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Interestingly, POLST addresses more than just CPR. Goals of the patient are discussed ranging from maximize comfort by symptom management to full treatment including life support measures. POLST is unique in that it is a standing order whether the patient is at home, in a nursing home, or in a hospital setting. In a hospital the POLST form is part of the medical record. If the patient is at home, the form should be visible to first responders so they can follow the wishes of the patient as outlined by the POLST form. In summary, POLST addresses more than just CPR versus DNR. It can be wishes about resuscitation itself as well as wishes about other treatment including general life support specifics and/or comfort measures.

Conflict Over Effectiveness of CPR CPR is not effective in some situations.20 Thus, the patient’s decisions regarding code status should be coupled with the physician’s medical opinion about the effectiveness of CPR and whether performing CPR will be of benefit to the patient. When interventions to prolong the life of a patient become medically ineffective, physicians are obliged to discuss with the patient the potential plan of shifting the intent of treatment toward comfort.21 Good communication about resuscitation can resolve or prevent many conflicts about medical interventions and their effectiveness. During these conversations, goals of the patient, relative to the treatments recommended by the physician, should be agreed upon so that everyone involved understands the planned medical course. If conflict does exist steps should be taken to help mitigate any conflict. If a patient, or patient’s surrogate, wishes resuscitation when a physician feels it would not be medically effective, the physician should seek to resolve such conflict through a process such as that described in the AMA’s Code of Medical Ethics that follows a due process approach. Hospitals or other health organizations should have policies regarding a process for resolving conflicts about DNR issues.5, 21

Case Presentation Outcome Returning to our case presentation, the patient had a DNR order; yet this should and did not limit our intervention regarding her tachycardia. She still had pulse, BP, and respiratory function. She did not have a “comfort-care-only” status. She was a candidate to receive vagal maneuvers, cardioversion, and/or adenosine. Discussions were held with her son who was next of kin. She continued to receive intravenous fluids and antibiotic therapy as well as the heparin infusion. With these interventions her tachycardia stabilized.

Summary and Recommendations Do Not Resuscitate (DNR) means do not initiate cardiopulmonary resuscitation in the event of cardiopulmonary ces-

sation. DNR does not stand for “do nothing routinely.” DNR is a specific order that only means to withhold chest compressions and respiratory support when there is no pulse and respiratory effort. Decisions regarding code status need to be initiated by the patient’s primary care physician and revisited with subsequence disease course. Physicians should have these discussions with patients with end stage organ disease, terminal illness, low likelihood of resuscitation survival, or are at risk for cardiac and/or pulmonary arrest. Conversations should include eliciting the patient’s understanding of his/her disease process and then educating the patient, and surrogate if available, about the facts and prognosis of the patient’s disease. Misunderstandings about the disease course and its treatment options should be corrected. DNR orders exist on a continuum of care where some patients wish to have a DNR order and comfort measures only. Other patients wish no resuscitation with cardiopulmonary cessation but interventions, sometimes aggressive, short of cardiopulmonary cessation. Clear understanding of the goals of care and treatment plans should be negotiated and these plans should be communicated clearly in “hand-off” communication. Physician Orders for Life Sustaining Treatment can be a way to convey code status wishes as well as other life-sustaining wishes so decisions do not have to be made during a time of crisis. The State of Mississippi should consider initiating POLST statutory support to better serve the residents of Mississippi. Mississippi physicians should take the lead in POLST support to allow patients autonomy in decisions regarding provision of end-of-life treatments regardless of settings. When conflict arises over effectiveness of CPR or use of DNR orders, clear communication should occur with the patient and any surrogates about misunderstandings and reasonable medically obtainable goals of treatment. A multidisciplinary approach may be helpful in such cases. In conclusion, decisions about end of life care including wishes about resuscitation should be an important part of communication by physicians, starting in the outpatient setting. These discussions must be conducted by physicians who can guide patients in understanding their disease processes and prognoses. Done well, these discussions can save time in the long run and unwanted or unnecessary medical interventions for the patient. There is likely no time in the patient’s disease course when true informed understanding of treatment plans is more important than when making resuscitation and other endof-life decisions.

References 1.

Cooper JA, Cooper JD, Cooper JM. Cardiopulmonary resuscitation: history, current practice, and future direction. Circulation. 2006;114:28392849.

Kouwenhoven WB, Ing D, Jude JR, et al. Closed-chest cardiac massage. JAMA. 1960;173:1064-1068.

Standards for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC). JAMA.1974; 837-866.

Summary Points about DNR 1. DNR does not equal do nothing routinely. Many patients wish aggressive care up until the time of cardiopulmonary cessation. 2. Physicians should have resuscitation discussions with patients who have end stage organ disease, terminal illness, low likelihood of resuscitation survival, or are at risk for cardiac and/or pulmonary arrest. 3. The primary care physician should initiate code status conversations and such decisions should be fluid with time. 4. It is important that patients understand their specific prognosis as well as risks, benefits, and outcomes of CPR interventions so that any unrealistic expectations can be reconciled. 5. Decisions about CPR should be made in a shared decision-making model discussion between the patient and physician focusing on goals of care. 6. Physicians should understand that DNR orders exist on a continuum of care where some patients wish to have a DNR order and also have comfort measures only while other patients have a DNR order but do wish interventions, sometimes aggressive, short of cardiopulmonary cessation. 7. Where applicable, and with consent of the patient, the surrogate(s) should be made aware of the patient’s decisions about CPR. 8. Mississippi should consider implementing POLST.

Bomba, PA, Kemp M, Black JS. POLST: An improvement over traditional advance directives. Cleve Clin J Med. 2012;79:457-464.

Council on Ethical and Judicial Affairs. Code of Medical Ethics of the American Medical Association. Opinion 2.22.Do-Not-Resuscitate Orders. Chicago; American Medical Association; 2012-2013.

Yuen KY, Reid MC, Fetters MD, et al. Hospital do-not-resuscitate orders: why they have failed and how to fix them. J Gen Intern Med. 2011;26:791-797.

Burns JP, Edwards J, Johnson J, et al. Do-not-resuscitate order after 25 years. Crit Care Med. 2003;31:1543-1550.

Peberdy MA, KayeW, Ornato JP, et al. Cardiopulmonary resuscitation of adults in the hospital: A report of 14,720 cardiac arrests from the national registry of cardiopulmonary resuscitation. Resuscitation. 2003;58:297308.

Saket G, Nallamothu BK, Spertus JA, et al. Trends in survival after inhospital cardiac arrest N Engl J Med. 2012; 367:1912-1920.

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10. Murphy DJ, Burrows D, Santilli S, et al. The influence of the probability of survival on patient’s preferences regarding cardiopulmonary resuscitation. N Engl J Med. 1994;330:545-549.

• Letters •

11. Reisfield GM, Wallace SK, Munsell MF, et al. Survival in cancer patients undergoing in-hospital cardiopulmonary resuscitation: a metaanalysis. Resuscitation. 2006; 71:152-160. 12. Ebell MH, Becker LA, Barry HC, et al. Survival after in-hospital cardiopulmonary resuscitation: a meta-analysis. J Gen Int Med. 1998;13:805-16. 13. Chan PS, Nallamothu BK, Krumholz HM, et al. Long-Term outcomes in elderly survivors of in-hospital cardiac arrest. N Engl J Med. 2013;368:1019-1026. 14. Anderson WG, Chase R, Pantilat SZ, et al. Code status discussion between attending hospitalist physicians and medical patients at hospital admission. Journ of Intern Med. 2011;26:359-366. 15. Goldberg GR, Meir DE. A swinging pendulum. Striking a balance between physician responsibility and patient autonomy. Arch Int Med. 2011;171: 854. 16. Venneman SS. Narnor-Harris P. Perish M, et al. “Allow natural death” versus “do not resuscitate”: three words that can change a life. J Med Ethics. 2008;34:2-6. 17. Chen YY. Younger SJ. “Allow natural death is not equivalent to do not resuscitate”: a response. J Med Ethics. 2008: 34: 887-888. 18. POLST: Physician orders for life-sustaining treatment paradigm. Available at: http://www.ohsu.edu/polst/programs/state+programs. htm. Accessed June 6, 2013. 19. Hickman SE, Sabatino CP, Moss AH et al. Use of the physician orders for life-sustaining treatment (POLST) paradigm program in the hospice setting. J of Palliat Med. 2009;12:133-141.

Terminal Care Dear Editor Lampton,

have been asked to serve as honorary pallbearer for a dear friend who died at Beacham Memorial Hospital yesterday (age 96). This has caused me to re-visit my own wishes for terminal care, and I re-read the essay [Murray KL. How doctors die. J Miss Med. Assoc 2013;54:67-69] in the March issue of the Journal MSMA. It expresses my own thoughts so well; I made two copies of the article and put each in a separate envelope with instructions to be used as a guide for my terminal care, if I am unable to make these decisions for myself. I gave one envelope to my long-term (40 years) secretary and put the other with my estate planning notebook which should be about the first thing my daughters see if I become terminally ill. I want to thank you personally for re-printing this essay. Best regards, Ralph L. Brock, MD; McComb

20. American Heart Association. Part 2: Ethical Aspects of CPR and ECC. Circulation. 2000; 102: I-12-I-21. 21. Council on Ethical and Judicial Affairs. Code of Medical Ethics of the American Medical Association. Opinion 2.037. Medical Futility in End-of-Life Care. Chicago: American Medical Association; 20122013.

Medicine

Step up to the Mic for

Submit resolutions now for MSMA Annual Session 2013!

MSMA is now accepting resolutions to be presented to the House of Delegates at the 2013 MSMA Annual Session business meeting, August 16-17, at the Norman C. Nelson Student Union in Jackson. For information on how to draft a resolution visit MSMAonline. com or contact MSMA staff for a checklist to help streamline the process. 174 JOURNAL MSMA JUNE 2013

• IQH • IQH Board Officers Elected

r. Edward Bryant of Kosciusko has been re-elected chairman of the Information & Quality Healthcare (IQH) board of directors. Dr. Bryant has been a board member of the Medicare Quality Improvement Organization since May 2012. Dr. Frank C. Wade Jr. of Magee was elected vice chairman. Dr. Wade has served on the board since May 2010. Dr. Michael D. Maples of Ridgeland, a board member since May 2012, was elected treasurer. Newly elected board members are Dr. Helen R. Turner and Bo Bowen, both of Jackson, and Dr. Dan Jackson of Rolling Fork. They join current members, including Walter Howell of Clinton, John Dawson of Kosciusko, Beth Embry of Ridgeland, Dr. Lee Giffin of Vicksburg, Gerald Wages of Tupelo, Kathy Fender of Lucedale, Dr. Tom Skeleton, Billy Sims, and Robert M. Pugh, all of Jackson. IQH also provides Tobacco Quitline services for Mississippi and Alabama. Release prepared by IQH under contract with Centers for Medicare & Medicaid Services (CMS), an agency of the U. S. Department of Health and Human Services. Contents presented do not necessarily reflect CMS policy. Publication No. 10SOW-MS-Comm-1979-13

• Office of Physician Workforce • OMPW Adds Hope for Mississippi’s Healthcare Future John Mitchell, MD, Chairman, Advisory Board, Office of Mississippi Physician Workforce

or many years, Mississippi has been last when it comes to the ranking of healthcare outcomes as compared to other states. Not surprisingly, Mississippi ranks first in many disease state categories, but one very telling statistic is that Mississippi ranks number one in the fewest number of physicians per 100,000 population. In a recent article by 24/7 Wall Street ranking the top 10 states with the most and the fewest physicians per 100K, you got it: Mississippi ranked No. 1 for fewest. Per this article, Mississippi has on average 159.4 physicians per 100K whereas Massachusetts which had the most physicians per 100K had 314.8 physicians per 100K, almost double Mississippi. To put this comparison in a national perspective, by looking at the US physician population and the total US population, the average physician per 100K is approximately 266 per 100K compared to Mississippi’s 159.4. Why is this important? It is generally accepted in the literature that a higher number of physicians per population (and in particular primary care physicians) correlates with improved healthcare outcomes. This is particularly evident in the research by Barbara Starfield which has proven that increased contributions by primary care not only improve individual health outcomes but also population outcomes. Therefore, one would theorize that the fewer physicians per population the worse the health outcomes, and with Mississippi being lowest in physician ratio per 100K and last in many major health outcomes this would definitely support that theory. We have already highlighted where Mississippi stands with its overall physician workforce. So how does Mississippi compare with its primary care workforce, you might ask? Currently, per the July 2012 Mississippi Board of Medical Licensure statistical data, Mississippi has a primary care physician workforce of 2,267. Included in the primary care physicians total are the specialties of family medicine, general internal medicine, pediatrics, med-peds, and obstetrics/ gynecology. Converting this to a ratio of per 100K population, Mississippi has 75.9 primary care physicians per 100K. National average for primary care is roughly 127 per 100K. Mississippi would need a primary care workforce of 3,791 to be at the current national average. That breaks down to the fact that Mississippi needs 1,524 primary care physicians today just to have an average US primary care workforce.

There are many headlines and news stories about what is being commonly referred to as “Obama care,” the Patient Protection and Affordable Care Act, but whatever you call it, it is about expanding populations and expanding coverage for populations now underserved or not served at all. Regardless of where you stand on this issue, what this means is there will be more demand on an already undermanned primary care workforce nationally, and for the poorest, worst health outcomes, most undermanned state in the US, there will be many unforeseen challenges for the existing physician workforce for the next several years. However, there is a ray of hope for Mississippi’s healthcare workforce future, and it is in the potential of the Office of Mississippi Physician Workforce (OMPW). In 2007, through the work of the Mississippi Academy of Family Physicians (MAFP) and the Mississippi State Medical Association (MSMA), the Mississippi Legislature passed a bill forming what is now known as the Mississippi Rural Physician Scholarship Program (MRPSP). This was a huge step for Mississippi to start priming the primary care workforce pipeline. Under the dynamic leadership of director Janie Guice, the program set out to identify college students from rural communities that had a burning desire to make a career in medicine and in particular were interested in primary care and returning to their “roots” in rural Mississippi. The program focuses on identification, selection, nurturing, and financial support. There are many factors for why medical students were not and aren’t choosing primary care specialties, and there are also many reasons why they don’t establish in the most needed and underserved areas. Many of these issues won’t be easily fixed but much research supports the conclusion that a significant portion of the problem is attributable to the medical school selection process and financial debt. Research supported that individuals from rural backgrounds were statistically more likely to return to rural areas than urbanites. Thus was born the MRPSP, and they adopted the slogan of “growing our own” for obvious and important reasons. The program continues to be a resounding success and currently has 54 scholarship recipients. Given the above statistics, it is no secret, Mississippi desperately needs more physicians, in particular primary care physicians, and they need them today. As you would expect, the MRPSP is very important, but it alone cannot yield the

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results or numbers of Mississippi physicians that the state desires and needs without added emphasis on the problem. In 2012, through continued work and initiatives by the MAFP and the MSMA, the Legislature passed HB317 which established the OMPW. Through the success of the MRPSP, it was actively priming the primary care pipeline, but there was an obvious and glaring deficiency in the state. This glaring deficiency related to the low number of primary care residency training slots in our state. Research related to where physicians practice following their post graduate training showed that the vast majority of physicians remained within a 100 mile radius of where they train. Relating this important research to family medicine residency training, Mississippi was at a great disadvantage. States adjoining Mississippi range from 50 to 60 plus first year family medicine training slots, and Mississippi currently only has 18 first year slots. To potentially magnify the issue of relatively few primary care training slots even more for Mississippi was the fact that in March of 2008 William Carey University College of Osteopathic Medicine (WCUCOM) was established. This was great news for Mississippi because it was about to essentially double Mississippi’s medical school training slots, but the downside was that there had been no change in corresponding postgraduate training slots. With WCUCOM’s first graduating class projected for the summer of 2014, it became imperative that exploration and assistance be given to establishing new primary care training sites. The immediate task given the OMPW by the Legislature was to identify and assist in the establishment of additional family medicine residency training programs. One such opportunity was identified in Hattiesburg in conjunction with Hattiesburg Clinic and Forrest General Hospital which had already done much of the ground work for the establishment of a new family medicine training program. All they needed was for the OMPW to identify this as an opportunity to expedite technically and financially the process. The process to establish new ACGME accredited training programs is long and arduous but with a little luck and their previously laid foundation this program will be able to accept its first training class in the spring of 2014. There is no overnight fix for the physician shortage and in particular the primary care physician shortage in Mississippi or any other state for that matter. I have outlined some very positive and encouraging events that are occurring in our state related to influencing positively the physician workforce and what this means. There is hope in our future. Mississippians, all Mississippians, deserve an opportunity to access the healthcare system in a timely and appropriate manner. The next time you see one of your legislators, thank them for their support of these programs that positively affect your healthcare access and encourage their continued support.

As the MRPSP slogan states, “growing our own” is a great long range goal, and we must stay vigilant with the mission, but we must parallel that mission with intense broad efforts to market the potential of our state, recruit, and retain the best available physicians for our state. There is not one project or program that can or will solve our immediate and ever growing healthcare access problem and physician shortage. History tells us that more can be accomplished through team-based approaches. The Patient Centered Medical Home model stresses a team-based approach to the care for our patients. It behooves us to look at the research and work to strengthen and maximize the use of this model in the care of our growing patient populations. At the center of this journey, for the improvement in healthcare access and improvement in healthcare outcomes for all Mississippians, was the establishment of the OMPW. Along with its immediate task of identifying, nurturing, and supporting the development of family medicine residencies is the broader, more long-range, and exciting task of overseeing research to develop strategies for adequate and geographic distribution of a physician workforce for all specialties and continually assessing the current and future physician workforce needs for Mississippi. There is much work to be done, but there is truly hope for Mississippi’s healthcare future. r

Pen > Sword

xpress your opinion in the JMSMA through a letter to the editor or guest editorial. The Journal MSMA welcomes letters to the editor. Letters for publication should be less than 300 words. Guest editorials or comments may be longer, with an average of 600 words. All letters are subject to editing for length and clarity. If you are writing in response to a particular article, please mention the headline and issue date in your letter. Also include your contact information. While we do not publish street addresses, e-mail addresses, or telephone numbers, we do verify authorship, as well as clarify ambiguities, to protect our letterwriters. You can submit your letter via email to: KEvers@MSMAonline.com or mail it to the Journal office at MSMA headquarters: P.O. Box 2548, Ridgeland, MS 39158-2548. JUNE 2013 JOURNAL MSMA 176

• AMA • The Physician Payment Sunshine Act is Here – Are you Ready? Jeremy A. Lazarus, MD, AMA President “Information is a source of learning. But unless it is organized, processed, and available to the right people in a format for decision making, it is a burden, not a benefit.” — Former ServiceMaster CEO C. William Pollard

he new Physician Payment Sunshine Act (Sunshine Act) was created by Congress to ensure transparency in physicians’ interactions with the pharmaceutical, biologic and medical device industries as well as group purchasing organizations. Physicians elected to our House of Delegates have developed strong ethical standards and made clear that physicians’ relationships with these industries should be transparent and focused on benefits to patients. Many interactions between physicians and the pharmaceutical, biologic and medical device industries occur to advance clinical research that is essential to discovering treatments and improving patient care. The Sunshine Act is not meant to stifle these important interactions. The AMA has provided input to the Centers for Medicare and Medicaid Services (CMS) on how to present a meaningful picture of physicianindustry interactions and give physicians an easy way to correct any inaccuracies. Our efforts were aimed at ensuring the benefits of transparency and avoiding the burden of incorrect information. Research shows that physicians are not yet aware of many of the changes coming from the Sunshine Act. Here is what you need to know right now: Beginning in August, pharmaceutical and medical device companies must begin tracking information on their interactions with physicians, which they will report to CMS from that point forward. CMS is creating a public database on its website that will display the information reported by the pharmaceutical, biologic and medical device companies. This database will go live in September of 2014. CMS incorporated a number of our comments in the final rule governing the Sunshine Act. We are pleased that they will not require the reporting of pharmaceutical industry funding to CME providers as long as the CME complies with existing requirements for certification and accreditation. There are other exclusions as well, including product samples and in-kind donations for charity care.

Accuracy is just as important as transparency, so we are also pleased that physicians will have a minimum of 45 days to challenge any information before it is public and can dispute inaccurate reports and seek corrections during a two-year period. Physicians can, and absolutely should, review information submitted about them before it becomes public so they can correct any inaccuracies. This can be done by asking manufacturers and their representatives to provide the information they intend to report, or by registering with CMS (beginning January 1, 2014) to receive a consolidated report on your activities each June for the prior reporting year. Now is the time to get up to speed on this major change, and the AMA is offering resources to help. An easy way to get started is by viewing a webinar I recently hosted. This resource provides information on what is happening and when, and what you need to do to be ready. Because this information is critical for all physicians to have, the AMA is providing this webinar free of charge. I hope you will tune in and encourage your colleagues to do so as well. We are also developing tools to aid physicians in talking with their patients about the transactions included in the new Sunshine Act database. These and other resources – including answers to frequently asked questions, important dates to remember and information on how to challenge incorrect reports – are available at www.ama-assn.org/go/sunshine. We will continue to update this page and offer the latest information and tools to help you prepare for the changes coming from the Sunshine Act. r This column originally appeared on KevinMD

JUNE 2013 JOURNAL MSMA 177

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PHYSICIANS NEEDED Internists, Cardiologists, Ophthalmologists, Pediatricians, Orthopedists, Neurologists, Psychiatrists, etc. interested in performing consultative evaluations according to Social Security guidelines.

OR Physicians to review Social Security disability claims at the

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178 JOURNAL MSMA JUNE 2013

MSMA 145th Annual Session Business Meeting

AGENDA

Friday, August 16

10:45 a.m. MSMA Alliance Past President’s Luncheon (invitation only) 11:30 a.m. Board of Trustees Lunch Meeting 1:00 p.m. House of Delegates Addresses of MSMA President, AMA President, and Alliance President

Let’s Get Down to

BUSINESS MSMA 145th Annual Session of the House of Delegates

August 16 – 17, 2013 UMMC Student Union · Jackson Online Registration Opens May 31 Preferred Accommodations Hilton Hotel 1001 East County Line Road, Jackson Phone at 601.957.2800 Online at Jackson.Hilton.com Group Code: MSMA Reservations Deadline: July 16

2:00 p.m. Reference Committee Hearings 2:00 p.m. MSMA Alliance Pre-Convention Board of Directors Meeting 7:00 p.m. MSMA Alliance Scholarship Fund Silent Auction Inauguration of 146th MSMA President James A. Rish, MD Hilton Hotel

Saturday, August 17

8:30 a.m. MSMA Alliance House of Delegates & Officer Installation 9:00 a.m. MSMA Excellence in Medicine Awards 9:45 a.m. Candidate Speeches 10:30 a.m. Caucus Meetings 11:30 a.m. Voting & Lunch Board of Trustees Meeting 12:00 p.m. MSMA Alliance Awards Luncheon 1:00 p.m. House of Delegates 3:30 p.m. Board of Trustees Meeting 6:30 p.m. UMMC Alumni Dinner

JUNE 2013 JOURNAL MSMA 179

Online Registration Opens May 31 OR Register by Mail with this Form

FOR MEDICINE Name: Email:

Specialty / Title: Address: MSMA is now accepting resolutions to be presented to the House of Delegates (HOD) at the 2013 MSMA Annual Session business meeting August 16-17 in Jackson.

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Any MSMA member in good standing may submit a resolution. Any local medical society may submit a resolution that has been approved by majority in accordance with local society bylaws.

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Resolutions received after August 2, 2013 are considered late and must be presented at the opening session of the HOD on Friday, August 16, 2013. The Committee on Rules and Order will determine whether it is of an emergency nature and will be accepted for consideration. Resolutions received on time will be posted at MSMAonline.com August 1-10 so members may review the resolutions online and submit comments to be considered by the appropriate reference committee. Any member of the association may submit online comments and/or testify in person at reference committee hearings. Only delegates present at the House of Delegates meeting may vote on resolutions. Online comments will be accepted through August 10; however, any member may testify in person August 16. Therefore, to make your views known after August 10, plan to testify in person on August 16. Please limit inperson testimony to topics or points you have not already raised via online comments. A resolution that proposes to change the MSMA Bylaws is required to be presented to the HOD a minimum of one day before the day on which it is voted. However, a resolution that proposes to amend the MSMA Constitution must be submitted to membership at least 90 days before the meeting; therefore, submit constitutional amendment resolutions by May 1 for distribution by May 10. We can help! For assistance in drafting a resolution contact MSMA Executive Director Charmain Kanosky at CKanosky@MSMAonline.com or 601-853-6733 Ext. 306. 180 JOURNAL MSMA JUNE 2013

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Credit Card #: Name on Card: Please check the boxes and indicate number of attendees for each event below. PHYSICIAN REGISTRATION FRIDAY, AUGUST 16

House of Delegates ____ Reference Committee Hearings ____ Presidentâ&#x20AC;&#x2122;s Gala ($100 per person) ____

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Excellence in Medicine Awards ____ Candidate Speeches ____ Lunch & Voting ____ House of Delegates ____

ALLIANCE REGISTRATION FRIDAY, AUGUST 16

Alliance Past-Presidents Luncheon ____ Alliance Board Orientation ____

SATURDAY, AUGUST 17

Alliance House of Delegates ____ Alliance Installation Luncheon ____

MAIL COMPLETED FORM TO: MSMA c/o Becky Wells PO Box 2548, Ridgeland, MS 39158-2548 Questions? BWells@MSMAonline.com or 601-853-6733

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MPCN - THE OBVIOUS CHOICE Change Networks. Not Doctors. 601-605-4756 • www.mpcn-ms.com Sponsored by the Mississippi State Medical Association

Have You Considered a Life Settlement For Your Old Life Insurance Policy? What is a Life Settlement? A life settlement is the sale of an existing life insurance policy on the secondary market to a third party investor.

Who or What May Qualify?  If the person insured by the policy is age 70 or older  If the person insured has any major medical conditions  If the policy has a death beneﬁt of $250,000 or more  Policies including, but not limited to, universal life, term insurance, variable life insurance or whole life insurance  If any cash value exists in the policy, the amount is relatively small

For More Information on Life Settlements, contact: H. Larry Fortenberry, CPA, CLU, ChFC Executive Planning Group, PA 1640 Lelia Drive, Suite 220 PO Box 16566 Jackson, MS 39216 (601) 982-3000

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

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