November 2009 JMSMA

November

VOL. L

2009

50 Years of

CONTINUOUS PUBLICATION

No. 11

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Lucius M. Lampton, MD Editor D. Stanley Hartness, MD Michael O’Dell, 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 Randy Easterling, MD President Tim J. Alford, MD President-Elect J. Clay Hays, Jr., MD Secretary-Treasurer Lee Giffin, MD 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: $73.00 per annum; $86.00 per annum for foreign subscriptions; $6.50 per copy, $7.00 per foreign copy, as available.

ADVERTISING RATES: furnished on request. Cristen Hemmins, Hemmins Hall, Inc. Advertising, P.O. Box 1112, Oxford, Mississippi 38655, Ph: (662) 236-1700, Fax: (662) 236-7011, email: cristenh@watervalley.net POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 391582548.

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

Copyright© 2009, Mississippi State Medical Association.

NOVEMBER 2009

VOLUME 50

NUMBER 11

SCIENTIFIC ARTICLES Report Card on Tobacco Use in Mississippi, 2009 Deirdre B. Rogers, MS, CTR and Ralph B. Vance, Sr., MD, FACP

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Abstracts from the 2009 James D. Hardy Surgical Forum University of Mississippi School of Medicine Department of Surgery

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PRESIDENT’S PAGE I Think It Just Stopped Raining Randy Easterling, MD; MSMA President

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EDITORIAL Thanksgiving Michael O’Dell, MD

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RELATED ORGANIZATIONS Mississippi State Medical Association Mississippi State Department of Health Information and Quality Healthcare

390 399 400

DEPARTMENTS Letters MSMA Poster Insert Placement/Classified Una Voce

393 385 396 402

ABOUT THE COVER: “BRIDGE IN SEPIA” - The term “sepia tone” refers to a photograph printed in brownscale, rather than grayscale. This photograph taken by Martin Howard, MD pictures an active railroad bridge over the Tennessee-Tombigbee Waterway in Columbus. The Tenn-Tom Waterway is an alternate route to the Gulf of Mexico. The waterway is stimulating economic development, providing outdoor recreational opportunities, aiding navigation, and enhancing wildlife habitat.

Dr. Howard is in the private practice of pathology at Baptist Memorial Hospital - Golden Triangle in Columbus. He has been a “serious” amateur photographer since his tour of duty in Iraq in 2004 with the Mississippi National Guard. His photographic interests are Mississippi landscapes and Mississippi wildlife.

Among Dr. Howard’s favorite places to shoot photos are the Tenn-Tom Waterway throughout north Mississippi and the Noxubee National Wildlife Refuge near Starkville. ❒ VOL. L

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PUBLICATION CONTINUOUS

50 Years of

No. 11

2009

November

Official Publication of the MSMA Since 1959

VOL. L

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CONTINUOUS PUBLICATION

No. 11

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SCIENTIFIC ARTICLES

Report Card on Tobacco Use in Mississippi, 2009 Deirdre B. Rogers, MS, CTR Ralph B. Vance, Sr., MD, FACP

A

BSTRACT

Mississippians are failing in their health status particularly as it relates to tobacco use. According to the Behavioral Risk Factor Surveillance System, 2008, 22.7% of Mississippi adults are current smokers compared to 18.4% of U.S. adults. This gives Mississippi a ranking of seventh among the states and the District of Columbia. Considering that smoking is the leading cause of preventable death, change must occur in our state. Resources necessary to combat the problem of tobacco use in Mississippi are available, but it is important that tobacco users are aware of their availability and how to access those resources. Physicians can positively impact the tobacco use statistics by counseling their tobacco dependent patients on the need for cessation and what counseling and pharmacotherapy resources are available to help the patient break his or her addiction.

KEY WORDS:

MiSSiSSiPPi ToBACCo USe, MiSSiSSiPPi HeAlTH RePoRT CARD, MiSSiSSiPPi ToBACCo CeSSATion ReSoURCeS

INTRODUCTION Mississippi is one of the unhealthiest states in the United States. According to the 2008 Behavioral Risk Factor Surveillance System (BRFSS), Mississippi has the highest obesity rate in the country (33.4% for MS vs. 26.7% for the U.S.) and is seventh in current smokJOURNAL MSMA, November 2009 — Vol. 50, No. 11

ing among adults (22.7% for MS vs. 18.4% for the U.S.).1 in the United States, the American Cancer Society (ACS) estimates 215,020 new cases of lung cancer to be diagnosed with 2,290 of those being diagnosed in Mississippi.2 ACS estimates 161,840 deaths are predicted to occur in the United States from lung cancer with 2,030 of those deaths projected to occur in Mississippi.2 in Mississippi from 2003-2006, age–adjusted incidence and mortality rates were 78.61 per 100,000 and 66.71 per 100,000, respectively.3 Both rates have remained relatively constant over the 2003-2006 time period.3 The highest age-adjusted lung cancer incidence (Figure 1) and mortality rates (Figure 2) from 20032006 were seen in Public Health District iX (Coastal Counties, 84.21 per 100,000 and 74.12 per 100,000, respectively).3

BURDEN OF TOBACCO Disease inciDence Smoking-related diseases remain the world’s most preventable cause of death. in the U.S., tobacco use accounts for nearly 1 in 5 deaths (438,000 premature deaths each year, based on 2000-2004 data).2 Smoking accounts for at least 30% of all cancer deaths and nearly 90% of lung cancer deaths.2 Most people think of tobacco use as the main cause of lung cancer only. However, tobacco use is associated with at least 15 types of cancer including nasopharynx, nasal cavity, paranasal sinuses, lip, oral cavity, pharynx, larynx, esophagus, 371

Figure 1.

Figure 2.

pancreas, uterine cavity, kidney, bladder, stomach, and acute myeloid leukemia.2 Smoking is also a major cause of heart disease, cerebrovascular disease, chronic bronchitis and emphysema.2 in addition, smoking is associated with an increased incidence of gastric ulcers.2 smoker Demographics in Mississippi, black males have the highest smoking rate (29.0%) followed by white males (23.7%)

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and white females (23.7%).4 Black females have the lowest smoking rate (14.0%).4 Additionally, for all races and sex, those with lower income and lower education have higher smoking rates.4 Unemployed individuals have higher smoking rates (39.2%) than their employed counterparts (21.6%).4 overall, smoking rates are highest among people ages 45-54 (28.3%).4 However, among whites, ages 18-24 have the highest smoking rate (34.3%).4 Among Mississippi youth, in 2006, 18.7% of public high school students and 8.4% of public middle school students were current smokers.5 This is of particular importance since most life-long smokers began smoking before the age of 18.6 Smokers between ages 18-24 are more likely to quit successfully than older smokers.7 Geographically, the highest smoking rates in 2008 were seen in Public Health District iX (Coastal Counties, 26.2%) followed by Public Health Districts i and ii (northern Counties, 25.5% and 24.8%, respectively).8 cost of tobacco Annual costs in Mississippi directly caused by smoking are over $700 million of which $264 million is covered by Medicaid.9 These Medicaid medical expenditures translate to over $550 per household each year.9 in contrast, the tobacco industry spends more than $185 million in advertising tobacco in Mississippi each year.9 in addition to direct medical expenditures, smoking results in a loss of productivity due to the premature deaths of Mississippi workers, costing Mississippi $1.49 billion per year.9 Since the increased tax revenue on cigarettes was made law this year, Mississippi is projected to save $5.6 million in heart attack and stroke costs over the next five years.10 The state is projected, in addition, to save $3.7 million in smoker-affected pregnancy and birth costs over the next five years.10 This increased excise tax is also projected to save more than $372.2 million in long-term health savings from tax-prompted smoking declines.10 seconD-hanD smoke Second-hand smoke contains more than 4,000 substances, more than 50 of which are known to cause cancer in humans and animals.11 each year, over 3,000 non-smoking adults die of lung cancer due to secondhand smoke.11 Second-hand smoke causes over 35,000 deaths from heart disease in non-smokers who live with smokers.11 over 300,000 infections in children of smokers occur each year with over 7,500 hospitalizations from pneumonia or bronchitis.11 Second-hand smoke increases the number of asthma attacks in children and JOURNAL MSMA, November 2009 — Vol. 50, No. 11

the severity of the attacks.11 Scientific evidence shows that there is no safe level of exposure to second-hand smoke.11 Currently in Mississippi, 18 cities have comprehensive smoke-free ordinances.12

PREVENTION The best prevention is not to ever begin smoking.

The second best prevention is to stop smoking utilizing drug therapy and counseling. There is clear evidence that one of the best venues for prevention of tobacco use comes from the individual’s physician or healthcare provider.13 in fact, one of the goals of the Healthy People 2010 is to increase to 85% the proportion of family physicians who provide smoking cessation counseling to patients who smoke.14 To aid physicians in providing brief counseling for tobacco dependence, the ACT Center at the University of Mississippi Medical Center offers continuing education courses on how to conduct such counseling.15 Patients who desire to quit can be referred to the the Mississippi Tobacco Quitline (1-800QUiT-noW) which provides telephone counseling by trained professionals statewide.16 Additionally, the Mississippi Tobacco Quitline and interested physicians can refer patients to the ACT Center for face-to-face counseling and free pharmacotherapy.15 The ACT Center is located at the Jackson Medical Mall and has satellite offices in 15 locations around the state. information about the ACT Center may be found on its website, http://www.act2quit.org/ or by calling 601-815-1180.

Additionally, the American Cancer Society (1-800ACS-2345 or www.cancer.org) is an excellent resource for information on smoking–related cancers and access to resources for smoking cessation.

SUMMARY in tobacco use, the people of Mississippi have a failing grade. The infrastructure for educating the physicians and citizens of Mississippi is in place. Mississippians have the ability to change our statistics positively, but to do so, we must enlist the support of healthcare providers in the tobacco cessation process. Medical education has not traditionally had a focus on prevention, but rather, tended to train medical graduates in reactionary methods to deal with an active disease process.

The education piece is not just the sole responsibility of the primary care physician in our state. Many Mississippians do not regularly seek care from a primary care physician. These individuals may seek care from emergency rooms.17 The primary tobacco education piece is, therefore, the responsibility of every physician in the state who sees patients. it is imperative that JOURNAL MSMA, November 2009 — Vol. 50, No. 11

every physician accept the responsibility of educating patients about the dangers of tobacco use. lifestyle is the single biggest driver of the failing grade of Mississippi’s report card on health. The path is clear on the changes that need to be made. However, these changes require the commitment of everyone in the healthcare field.

REFERENCES 1.

CDC Web site. http://www.cdc.gov/brfss/. Accessed october 1, 2009.

2. American Cancer Society. Cancer Facts & Figures 2009.

Atlanta, GA: American Cancer Society; 2009;4-6,47.

3. Mississippi Cancer Registry on-line Query Web site. http://cancer-rates.info/ms/. Accessed october 2, 2009.

4. Mississippi State Department of Health. 2008 Behavioral Risk Factor Surveillance System: Mississippi Annual Prevalence Report. Jackson, MS: Mississippi State Department of Health Web site. http://www.msdh.state.ms.us/brfss/District%20Charts%202008.pdf. Accessed october 2, 2009.

5. Mississippi State Department of Health. 2006 Mississippi Youth Tobacco Survey. Jackson, MS: Mississippi State Department of Health Web site. http://msdh.ms.gov/msdhsite/_static/resources/3318.pdf. Accessed october 2, 2009.

6. American Cancer Society. Cancer Prevention & Early Detection Facts & Figures 2009. Atlanta, GA: American Cancer Society, 2009;3.

7. University of California, San Diego Health Sciences. Young Adults More likely To Quit Smoking Successfully. ScienceDaily Web site. 2008. http://www.sciencedaily.com / releases/2008/01/080111193824.htm. Accessed october 5, 2009.

8. Mississippi State Department of Health. 2008 Behavioral Risk Factor Surveillance System District Charts. Jackson, MS: Mississippi State Department of Health Web site. http://www.msdh.state.ms.us/brfss/District%20Charts%202 008.pdf. Accessed october 1, 2009.

9. Campaign for Tobacco-Free Kids. Toll of Tobacco in Mississippi. Washington, DC: Campaign for Tobacco-Free Kids Web site. http://www.tobaccofreekids.org/reports/settlements/toll.php?StateiD=MS. Accessed october 1, 2009.

10. Campaign for Tobacco-Free Kids. Benefits from a 50-Cent Cigarette Tax increase in Mississippi. Washington, DC: Campaign for Tobacco-Free Kids; http://www.americanheart.org/downloadable/heart/1242919436942BeneFiTS%20FRoM%20A%2050-CenT%20CiGAReTTe%2 0TAX%20inCReASe%20in%20MS.pdf. Accessed october 5, 2009.

11. U.S. Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, national Center for Chronic Disease Prevention and Health.

12. Blue Cross Blue Shield of Mississippi.

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13. Promotion, office on Smoking and Health, 2006. Guide to Clinical Preventive Services, 2009. AHRQ Publication no.

09-iP006, 2009. Agency for Healthcare Research and Quality, Rockville, MD. Web site. http://www.ahrq.gov/clinic/ pocketgd.htm. Accessed october 4, 2009.

14. U.S. Department of Health and Human Services. Healthy People 2010. 2nd ed. With Understanding and improving Health and objectives for improving Health. 2 vols. Washington, DC: U.S. Government Printing office; 2000; 3-22.

15. The ACT Center Web site. http://www.act2quit.org/. Accessed october 2, 2009.

16. Mississippi Tobacco Quitline Web site. http://www.quitlinems.com/. Accessed october 2, 2009.

17. Delia D, Cantor J. emergency Department Utilization and Capacity. Princeton, nJ: Robert Wood Johnson Foundation Research Synthesis Report no. 17; 2009. http://www.rwjf. org/files/research/072109policysynthesis17.emergencyutilization.pdf Accessed october 5, 2009.

AUTHOR INFORMATION: Deirdre b. rogers, ms, ctr is the director and statistician for the Mississippi Cancer Registry at the University of Mississippi Medical Center. She is also the immediate past chair of the Mississippi Partnership for Comprehensive Cancer Control. ralph b. Vance, sr., mD, facp is a professor of medicine in the Division of Medical Oncology at the University of Mississippi Medical Center. He is also a past national president of the American Cancer Society.

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Abstracts from the 2009 James D. Hardy Surgical Forum Submitted by the University of Mississippi School of Medicine Department of Surgery

T

he Department of Surgery is proud to sponsor the ninth annual James D. Hardy Surgical Forum. The Hardy Forum is held in honor of the first chairman of the Department of Surgery at the Marc Mitchell, MD James D. Hardy Professor University of Mississippi School of Medicine. The name of this event recalls and Chair Department of Surgery the Mississippi Surgical Forum that Dr. Hardy started and that brought renowned teachers to Jackson annually. The Hardy Surgical Forum features presentations of original scientific investigations by the chief residents in the Department of Surgery and the James D. Hardy lecturer in Surgery. The resident with the best presentation at the Hardy Forum was awarded a prize at our annual departmental banquet. The Department of Surgery is committed to the excellence in research that so distinguished Dr. Hardy’s career. We hope that you will find the presentations stimulating, and we welcome your participation.

JAMES D. HARDY LECTURESHIP IN SURGERY The James D. Hardy lecture was established to honor the founder of the Department of Surgery at the University of Mississippi Medical Center. Dr. Hardy came to the new campus of the University of Mississippi School of Medicine in 1955 with the opening of the new University Hospital and the transfer of the School of Medicine to Jackson. Dr. Hardy contributed significantly to the birth of cardiac surgery, and his research culminated in the world's first human lung and heart transplants. Dr. Hardy rose to the presidency of the American College of Surgeons. He touched the lives of countless patients, students, and colleagues in our state and throughout the world. During his 32 years as chairman of the Department of Surgery, Dr. Hardy established a high standard of surgical care in our state and in our nation through the department that he established and the residents whom he trained.

Urgent versus emergent laparoscopic appendectomy in children with acute appendicitis: Our experience over a 5-year span Altomar JL, Onwubiko C, Milbourne S, Sawaya D and Blewett C Background: Traditionally, acute appendicitis in children dictated emergent surgical management. An increasing number of pediatric tertiary care centers have delayed appendectomy for up to 24 hours without significant increase in morbidity or mortality. The evolution of laparoscopy has also shifted surgical management from the historical open procedure. our goal was to evaluate laparoscopic appendectomies (lA) performed at our institution.

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Methods: A retrospective chart review was conducted on all acute lA performed on children less than 16 years of age, from January 1, 2004 thru December 31, 2008. All cases were identified via the university billing database. Patients undergoing lA within 24 hours were stratified into either less than or greater than 8 hours to time of operation from initial emergency department (eD) presentation. Patients transferred to our eD from outlying hospitals where they initially presented were excluded. Age, initial white blood cell count (WBC), length of admission (loA), postoperative complications, and final tissue pathology were collected.

Results: A total of 88 lA was performed during our study period. The data is summarized in chart at right.

Conclusions: laparoscopic appendectomies performed within 24 hours of presentation did not have any significant differences in either length of stay or post-operative complications. The need to proceed with emergent surgical intervention is not supported by our data. r

8hrs (n 40) Average Time to OR (Hours) Range Average Age (Years) Range WBC (TH/CMM) Range LOA (Days) Range Post-Operative Complications

> 8hrs (n 48)

5:19 0:40 – 7:49

14:12 8:04 – 22:36

11 3 – 16 15.6 4.4 – 28 2 1 – 11

11 3 – 16 15.5 4.0 – 30.5 3 1 - 13

2

4

Total percutaneous endovascular aneurysm repair using perclose A-T suture-mediated closure device Berry MA, McDaniel H and Cauthen W Objective: This study is a single-center, experience of total percutaneous aneurysm repair using the Perclose Auto Tie Suture Mediated System.

Methods: Between July 2007 and May 2009, a total of 33 endovascular aneurysms was repaired using total percutaneous technique (5 mm – 10 mm groin incisions over the common femoral arteries). Forty-nine (49) femoral arteries were accessed with 12 French to 24 Fr sheaths (4.7 mm to 9.1 mm outer Diameter). Previous studies reported 8.6 mm outer diameter as being largest size but this study had five successful closures of larger diameters. Retrospective review of our institution’s vascular database and patient medical records were used to identify rates of technical success, failures resulting in conversion to open femoral artery repairs and follow-up complications.

Results: A total of 49 femoral arteries, eleven requiring 20 Fr or greater sheath size, was included. There were three failures requiring conversion to open arteriotomy repair. in total, the group’s percutaneous closure success rate was 93.4%. Two of the failures were in the 20 Fr - 24 Fr group (82% success rate) and only one failure in the 12 Fr to 18 Fr group (97% success). Failures were due to device malfunction, inability to completely control hemorrhage and arterial dissection requiring endarterectomy and patch repair. There was one re-admission for observation post operative day two for bleeding at the access site. no other complications of pseudoaneurysm, arterial stenosis or infection were seen.

Conclusions: Total percutaneous endovascular aneurysm repair is a safe technique using the Perclose device. This study showed success rates are better for smaller sheaths, but also demonstrated closure of larger diameter sheaths (9.1 mm oD) can be safely performed. Postoperative complications are very rare if closure device is initially successful. r

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Comparison of totally extraperitoneal vs. anterior repair of recurrent inguinal hernia in a university hospital setting Boyd KB, McDaniel DO, May WL, Redmond PM and Vick KD Background: laparoscopic and open inguinal herniorraphy have been extensively compared since the first laparoscopic procedure with mesh implantation by Schultz and associates, however standardization in comparing these two arms has been lacking in the literature. For instance, both totally extraperitoneal and transabdominal approaches have been lumped together as laparoscopic. Furthermore, consideration needs to be given to indications for which the laparoscopic procedure was done, most of the time for different reasons (e.g., recurrent or bilateral) than the standard open operation, for which unilateral primary hernia is the most common indication. By standardizing according to technique and indication, it is hoped that these various herniorraphy techniques may be more accurately compared. For the purposes of this study, only those patients undergoing repair for recurrent inguinal hernias with mesh via either the laparoscopic totally extraperitoneal (TePP) or anterior repair (oPen) were analyzed.

Methods: Retrospective analysis was performed by reviewing Veteran’s Administration and University of Mississippi patient charts for those adult (>18 years old) patients who underwent the laparoscopic totally extraperitoneal (TePP) placement of prosthetic mesh and open anterior placement (oPen) for recurrent inguinal hernias. Since TePP was not begun at our institution until February, 2003, only those patients from February, 2003 to February, 2009 were used in the following analyses, which are based on the 87 males who underwent TePP or oPen electively. Primary/nonrecurrent unilateral and strangulated hernias were excluded as well as those who underwent laparoscopic transabdominal (TAPP) repair. Specific comparisons will be made between the two study arms with regard to (1) demographics such as age, gender, and ethnicity (2) perioperative factors such as American Society of Anesthesiologist (ASA) class, type of anesthetic, utilization of mesh from prior herniorraphy, and (3) various related outcome parameters.

Results: Results are reported as mean ± s.d. or median (range) for continuous data and proportions for categorical data.

Comparisons between the two procedures were made using exact procedures of the nonparametric Mann-Whitney test for continuous data and Fisher’s exact test for categorical data. in the procedures, 33.3% (n=29) were treated with TePP and 66.7% (n=58) were treated oPen. TePP has some increase in hernia recurrence, postoperative urinary retention, cardiopulmonary complications, and possibly neuropathy but none reach statistical significance.

Conclusions: no significant difference exists in complications comparing TePP to oPen for recurrent inguinal herniorraphy utilizing mesh. nevertheless, seroma/hematoma rank among most common complications associated with oPen repair in contrast to TePP where urinary retention, cardiopulmonary events, and recurrence are more common. initially, TePP has significantly longer operative times as well as length of hospital stay. r JACKSON OFFICE 401 East Capitol St., Suite 600, Jackson, MS 39201 Post Office Box 651, Jackson, MS 39205-0651 PH. 601.968.5500 FAX 601.968.5593

Benefit Plans Q Compliance Programs Q Fraud & Abuse/Stark Q Labor & Employment Q Malpractice Defense Q Medicare Law & Regulation Q CON Q STARK Q

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The end of the free flap? Use of laser assisted fluorescence angiography in perforator flap reconstruction to the lower extremity Burgdorf M, Johnson A, Kochevar A and Walkinshaw M Background: lower extremity reconstruction is a challenging problem, particularly of the distal one-third of the extremity. Historically, these problems have been handled by amputation or free flap reconstruction. With the use of intra-operative laser assisted fluorescence angiography (SPY® intra-operative imaging System) the options for reconstruction can confidently be expanded to include perforator flaps. This may ultimately replace the need for free flaps as the only viable option for limb salvage reconstruction. Utilizing the SPY® intra-operative imaging System technology, 5 patients with complex distal one-third lower extremity wounds were successfully reconstructed with perforator flaps instead of utilizing free flap reconstruction techniques. We present our series here.

Methods: A series of 5 patients with complex lower extremity wounds were sequentially chosen to undergo intra-operative laser assisted fluorescence angiography (SPY® intra-operative imaging System) in order to determine the viability of perforator flap technology as a reconstructive option. The SPY® system leverages infrared laser technology, high-speed imaging, sophisticated software and a fluorescent agent to produce real-time visual images of natural blood flow and tissue perfusion in approximately two minutes. The fluorescent agent is indocyanine green (iCGreen), a water-soluble dye that is excreted exclusively by the liver into the bile and is administered via peripheral or central intravenous access. The SPY® imaging device houses a laser that causes excitation of the dye and subsequent emission of infrared energy resulting in a fluorescent image of the vascular system being examined.

Results: Upon utilizing this technology, the decision to rely solely on the perforator flap reconstruction was confidently and successfully made intra-operatively in all 5 patients, avoiding the need for free flap reconstruction.

Conclusions: With the use of intra-operative laser assisted fluorescence angiography (SPY® intra-operative imaging System), the options for reconstruction of complex distal one third lower extremity wounds can confidently be expanded to include perforator flaps. Although perforator flap technology was initially introduced to expand potential donor site options for free flap reconstruction, this technique may ultimately replace the need for free flaps as the only viable option for limb salvage reconstruction. r

Single institution results of the transobturator tape procedure for the treatment of female stress urinary incontinence Davenport TC, Koury MW, Cazayoux WR and Secrest CL Background: The surgical treatment of female stress urinary incontinence due to urethral hypermobility has changed significantly in the past decade. Since the concept of mid-urethral support without tension was first described in 1996, there has been extensive acceptance of the various midurethral sling technologies. We present our results of transobturator placement of a synthetic polypropylene tape for the treatment of female stress urinary incontinence 378

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(SUi) in a series of patients with at least 6 months follow-up.

Methods: one hundred seventy-six consecutive female patients underwent transobturator placement of a synthetic polypropylene tape for treatment of SUi from August 2003 to February 2006. Until April 2005, obTape® (Mentor Corp, Santa Barbara, CA) was placed in 125 patients. After this date, Aris® (Mentor Corp, Santa Barbara, CA) was placed in the subsequent 51 patients. Patient charts were retrospectively reviewed. The patients were asked to complete a 24 hour voiding diary, a questionnaire regarding their perceived surgical outcome, and a 24-hour pad test.

The Groutz-Blaivis simplified urinary incontinence outcome score (SUioS) was applied as the measure of outcome.

Results: ninety-three patients (53%) completed all components of the study. Patient age was 36 to 85 years (mean 62 years). All patients underwent preoperative urodynamic evaluation. SUi was demonstrated in all patients on physical exam or by urodynamics. Follow-up ranged from 6 months to 34 months (avg. 21 months). Forty-four patients (47%) underwent 72 previous failed anti-incontinence procedures. of the 93 patients, 82 (88.2%) considered themselves cured or improved and 11 (11.8%) considered the surgery a failure. Using the SUioS, 33.3% were cured, 38.7% had a good response, 16.1% had a fair response, 6.5% had a poor response and in 5.4% it was a failure. Response rates were similar for both obTape® and Aris®. no bladder or urethral injury occurred. late complications included urinary retention in 2, vaginal adhesions in 3, persistent incisional pain in 2, severe dyspareunia in 1, and de novo urgency in 8. Tape erosion occurred in 5 patients requiring removal of the sling.

Conclusions: The transobturator tape procedure is a minimally invasive surgical treatment for female SUi. in our series, at nearly 2 years average follow-up, our percentage of patients reporting a successful outcome (88.2%) is consistent with prior studies. in our experience, post-operative complications have been easily treated and have caused no long term morbidity. r

Routine use of epidural anesthesia-does it improve patient outcomes?

Nicols LM, Simmons JD, Replogle W, Fayard N and Snyder D Background: The use of epidural anesthesia has become routine for many operations, including colon surgery. This stemmed from the growing body of literature that reports better subjective pain scores postoperatively. epidurals are often thought to decrease the length of ileus and therefore decreasing hospital length of stay but the evidence is sparse.

We hypothesized that routine use of epidural anesthesia in routine colon surgery does not affect 30 day morbidity or hospital length of stay.

Methods: The routine use of epidural anesthesia at the VA hospital in Jackson, Mississippi began in 2007 for all routine colon resections. Prior to that, no epidurals were used for routine colon resections. We retrospectively reviewed all elective colon resections performed at the VA from 2004 to 2009. The patients were divided into two groups, those with an epidural and those without an epidural. Demographic and treatment outcomes were collected via electronic chart review. The major areas of interest were 30 day morbidity, return to bowel function, and length of stay.

This study was approved by the institutional review board.

Results: Demographic data were similar with the exception of ASA class. There were significantly more ASA iV in the epidural arm and more ASA ii in the non epidural arm. There were statistically less patients that developed ileus in the epidural arm (2 vs. 10 P 0.033). All other complications were similar. The epidural arm tolerated a regular diet sooner (Median 5.0 vs. 6.0 P 0.036). The epidural arm has a shorter length of hospital stay (Median 6.0 vs. 7.0 P 0.026) but a longer iCU stay (Median 3.0 vs. 2.0 P 0.035) which is likely due to a rule at the VA requiring any patient with JOURNAL MSMA, November 2009 — Vol. 50, No. 11

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an epidural to remain in the iCU regardless of their condition.

Conclusions: This study shows that the routine use of epidural anesthesia does not result in an increase in 30 day morbidity but did provide the benefit of a reduced ileus and hospital length of stay. r

Immediate mobilization following open reduction and internal fixation of mandibule fractures Persons B, Jacob S, Germany M, Sledge J and Walkinshaw M Background: To compare outcomes of open reduction and internal fixation (oRiF) of mandibular fractures followed by either immediate mobilization or 4 weeks of maxillomandibular fixation (MMF).

Methods: Thirty-five mandibular fractures treated over 2 years underwent follow up at 1, 3 and 6 months. of the 33 patients with noncondylar fractures, 19 patients underwent the standard 4 weeks of mandibulomaxillary fixation (MMF) using arch bars and 14 patients underwent open reduction internal fixation followed by immediate mobilization. The 2 patients with condylar fractures underwent MMF for 4 weeks. Follow up was over 6 months with office visits at 1 month, 3 months and 6 months. Symphyseal and parasymphyseal fractures were exposed via the transoral approach. Angle and body of mandible fractures were exposed in a percutaneous fashion. All patients were placed in MMF with arch bars and ivy loops at the beginning of the operative procedure.

Fractures were fixated with two titanium miniplates, one tension band using monocortical screws, and the other along the inferior border using bicortical screws. The 14 patients were randomized to immediate mobilization following open reduction internal fixation had their arch bars removed following the procedure. 19 patients had MMF maintained postoperatively for 4 weeks. Patients were given a regimen of strict oral hygiene and soft diet. Variables including: temporomandibular joint mobility, occlusion, oral hygiene and wound status were documented during postoperative visits at 1, 3 and 6 months.

Results: Temporomandibular joint (TMJ) mobility is followed as maximal inter-incisor distance in mm. At 1 and 3 months postoperatively patients with immediate mobilization had significantly more TMJ mobility than the MMF group (p < .001). With 2 to 3 months of intensive physical therapy, TMJ mobility improved in the MMF group to approach normal values. Postoperatively both groups achieved class i occlusion throughout the follow up period. oral hygiene was graded on a scale of 1 to 3, with 1 representing poor, 2-fair and 3-good oral hygiene. At 1 month postoperatively, oral hygiene was significantly worse in the MMF group, but improved dramatically in the following 5 months.

Three patients in the immediate release group and 2 patients in the MMF group suffered wound infection/dehiscence leading to plate removal. There was no difference for this variable between the 2 groups. osseous union was achieved 100% of both groups, and confirmed by postoperative radiological studies.

Conclusions: immediate mobilization of mandible fractures produced satisfactory results in terms of TMJ mobility, occlusion, oral hygiene and wound healing compared with 4 weeks of MMF. The presumed beneficial effects of reduced fracture line stress with MMF was not realized, with no statistically significant differences in these variables between the MMF and immediate release group. This small study supports the treatment option of immediate release of iMF following oRiF of mandible fractures. r

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Permanent sacral nerve stimulation for bladder control: clinical results and quality of life measures Rutland EH, Haraway AM and White PC Background: Sacral nerve stimulation (interstim, Medtronic inc., Minneapolis, Mn) has been approved since 1997 for the treatment of urinary urge incontinence, urgency, frequency, and refractory urinary retention. We study the outcomes of 37 consecutive patients who underwent permanent placement of sacral nerve stimulator (interStim®).

Methods: We retrospectively reviewed our sacral neuromodulation database from January 1, 2006, to May 31, 2008.

A total of 37 patients were found to have undergone permanent placement of sacral nerve stimulator. Patients underwent test stimulation for a 2-week trial period. Those who experienced 50% or greater improvement in urinary symptoms and/or catheterization frequency subsequently underwent permanent implantation. The patients answered questionnaires which queried values for before and after permanent placement of neuromodulator on difficulty voiding, trouble starting urinary stream, straining to urinate, urinary urgency, and urinary incontinence. These were scored as 0=none, 1=occasionally, 2=Half of the time, 3=all of the time. Data on overall quality of life was also collected.

A scale of -3 to +3 was used, with -3 being “very unhappy” and +3 being “very happy”.

Results: of the 37 patients, 2 were men and 35 were women. Mean patient age was 43.9 years +- 15 years (range 19 to 76). All urinary symptoms measured were significantly improved after placement of permanent sacral neuromodulator. Difficulty voiding improved from 2.1 to 0.7, Trouble starting stream improved 1.7 to 0.6, Straining to urinate improved 1.7 to 0.4, Urinary urgency improved 1.4 to 0.5, and Urinary incontinence improved 1.3 to 0.5. overall quality of life after interstim placement improved from -1.57 to +1.89.

Conclusions: Permanent sacral neuromodulation significantly improves symptoms of difficulty voiding, trouble starting urinary stream, straining to urinate, urinary urgency, and urinary incontinence. overall quality of life is also significantly improved after placement of permanent sacral neuromodulator. r

Outcomes in neonatal gastroschisis: a single center experience Seetharamaiah R, Manley J, Caskey R, Roy R, Sawaya D and Blewett C

B

ackground: Gastroschisis is a congenital defect of the anterior abdominal wall. The outcome of infants with gastroschisis has improved dramatically over the past several decades secondary to advances in neonatal intensive care and use of parenteral nutrition. Although survival rate has improved to more than 90 to 95%, serious morbidity is still very common. The purpose of the study is to compare outcomes in simple versus complex (intestinal atresia, perforation, bowel necrosis, or volvulus) gastroschisis patients.

Methods: A retrospective review of medical records (130 charts) of all neonates with gastroschisis treated at the University of Mississippi Medical Center between 2001 and 2008 was conducted. Data abstracted included demographics, prenatal diagnosis, maternal demographics, type of delivery and delivery complications, operative management JOURNAL MSMA, November 2009 — Vol. 50, No. 11

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and post operative complications, length of stay, mechanical ventilation, total parenteral nutrition, and time to full enteral feeds. Analysis of data was performed using SPSS for windows version 17.0. Data was analyzed with Chisquare test and p value less than 0.05 was considered significant.

Results: one hundred five patients with gastroschisis had Type of Gastroschisis Simple Complex sufficient data for complete analysis (57% Male, 43% Fe43 d 86 d Length of Stay male). 17% of these patients had complex gastroschisis.

(12-153) (13-213) Mean maternal age was 21.8±4.4 years and 37% were Preterm Born 56% 88% primigravida. Mean gestational age at birth was 35.8±1.6 11.4% 70% Post-operative complications (10/88) (12/17) weeks and mean birth weight 2.34±0.43 kg. A statistically Days on TPN 28.8±15.4 d 73.05±58 d significant association was seen between complex gasTime to full enteral feeds 32.03±18.9 d 53.27±32.1 d troschisis and length of hospital stay, prematurity, post-opMortality 1% 17.6% erative complications, days on TPn, time to full oral feeds and mortality. (Table) no significant difference was seen with birth weight, maternal age, maternal infections, drug abuse, or time on mechanical ventilator.

P value 0.025 0.014 0.0001 0.043 0.026 0.013

Conclusions: Type of gastroschisis is an important determinant of the outcome, including length of stay, time to full feeds, duration of parenteral nutrition, post operative complications and survival. This information will be valuable in communicating with parents and informing them of the possible course. r

Popliteal artery injuries in an urban trauma center with a rural catchment area Simmons JD, Schmieg RE, Manley JD, Gunter JW, Rushton FW, McDaniel HB, Bilski TR, Porter JM and Mitchell ME Background: Mechanism of injury, blunt or penetrating, and extended length of time from injury to definitive repair are potential predictors of amputation in patients with popliteal artery injuries. in an urban trauma center with a rural catchment area, logistical delays are frequent and may affect limb salvage following vascular trauma.

Methods: All adult patients admitted to the level one Trauma Center of the University of Mississippi Medical Center with a popliteal artery injury between January 2000 and December of 2005 were identified. Demographic, management, and outcome data were abstracted from chart review. Body mass index (BMi), mangled extremity score (MeSS), Guistilo open fracture score (GoFS), injury severity score (iSS), and time from injury to repair were determined.

Results: Fifty-one patients with popliteal artery injuries (50% blunt and 50% penetrating) were identified, all undergoing operative repair. There were nine amputations (17.6%) and one death. The amputation group had a higher MeSS, 7.8 versus 5.3 (p=0.01), and length of stay, 43 versus 15 days (p=0.01), compared to the limb salvage group.

BMi, iSS, GoFS, or time from injury to repair were not different between the two groups. The blunt group had a slightly higher amputation rate compared to the penetrating group, 25.9% versus 8.3% (p=nS).

Conclusions: length of time from injury to repair and BMi had no significant affect on limb salvage rates for patients with popliteal artery injuries. Blunt injuries tend to result in amputation more frequently than penetrating injuries. MeSS is the best predictor of amputation in patients with popliteal artery injuries. r

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PRESIDENT ’S PAGE I THINK IT JUST STOPPED RAINING it is early (6:00 a.m.), Sunday morning, october 4, 2009, a little less than 24-hours since adjournment of a historic meeting of the Mississippi State Medical Association House of Delegates. The house is quiet, rain is falling in Bovina, Janie is still asleep, and i am physically as well as emotionally drained.

The weather seems to mirror my mood as i reflect on the past 36 hours, but more so on the past four months.

By the time this page reaches your home or office, you will know that the Mississippi State Medical Association House of Delegates has voted overwhelmingly to de-unify with American Medical Association. i will make no effort to define, defend, or dissect the vote. it is what it is. if you are a member of the MSMA, you no randy easterling, MD longer are required to be a member of the AMA. it is just that 2009-10 MSMA President simple.

As i pen this fourth President’s Page, i feel compelled to reflect on our association, her impact on physicians in Mississippi (whether they are members or not) and her future. in doing so, allow me a point of personal privilege and take a moment of your time to simply talk with you.

The last four months have been difficult to say the least. on July 16, 2009, the American Medical Association leadership came out in support of HR 3200 — America's Affordable Health Choice Act of 2009.

Mississippi physicians’ response to this perceived marriage of the AMA to President obama’s efforts in reshaping health care in America has been all over the map. i can well imagine that this topic has captured and compelled the dialogue in every doctor’s lounge from Corinth to the Coast, from Vicksburg to Meridian. Rightly so, this is an issue of paramount importance to what we do, to who we are. i would suggest that this discussion has in large measure brought out the best in many of us, while unfortunately, at the same time, revealed the worst in many of us. So goes the nature of debate and disagreement.

What a boring world we would have if we all agreed on everything. However, i must confess, at this juncture i would cherish a little boredom.

Pervasive in the conversation among Mississippi physicians on healthcare reform was the issue of unification. The message seemed clear. Members of the Mississippi State Medical Association wanted the right to choose: either stay with the AMA or freedom to go elsewhere. Many felt it was time for the AMA to earn our membership and not, if you will, have it handed to them on a silver platter. in an effort to respond to our membership, your board of trustees of MSMA voted unanimously to call a special session of the Mississippi State Medical Association House of Delegates. The sole purpose of which was to give every member through their elected and/or appointed delegates, the opportunity to delete or leave in the section in our bylaws that requires AMA membership if you are a MSMA member. This step was not taken lightly. every conceivable caveat was dissected and explored. Untold hours were vested by your staff and legal counsel in an effort to make sure our actions were both legal and consistent with the word and intent of our bylaws.

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in addition, it was felt that the gravity of this issue was such that we employed a never before used vehicle of â&#x20AC;&#x153;proxyâ&#x20AC;? voting. This was felt necessary for several reasons.

First, the House of Delegates meeting was called in relatively short notice (one month). Second, the meeting was to be on the weekend. Third, the meeting was to occur in the midst of fall activities that by definition crowded our already busy schedule. We wanted to offer all our members a voice. in large measure, i feel strongly that the efforts of your staff and board of trustees were welcomed by the majority of the membership. There were, as expected, notable and well-meaning objections to our methods. Those members concerned were sincere, valid, and, i feel, by and large from the heart. The objections were heard and the democratic process prevailed. The vote was 209 in favor of deunification and 31 in favor of maintaining the status quo. enough said! now, letâ&#x20AC;&#x2122;s move on.

The events of this past weekend were both encouraging and at the same time disappointing. on one hand, the process worked. A total of 240 members of our association rose to the occasion and expressed by ballot their desire for a new direction for the Mississippi State Medical Association. That is a good thing! on the other hand, in spite of numerous efforts to inform our members, the debate continued to feel more like a visceral response toward the AMA than an informed decision as to what was best for our association. in my opinion, we are MSMA members first and AMA members second. it is our state association that by definition and/or proximity meets our membership needs and the needs of our patients in a timelier manner and with methods more consistent with Mississippi physiciansâ&#x20AC;&#x2122; specific concerns. That is the way it should be. This by no means diminishes the AMA. MSMAâ&#x20AC;&#x2122;s overriding concern is for the well being of Mississippi physicians and our patients. The AMAâ&#x20AC;&#x2122;s predominant agenda is the concerns of physicians and patients in the national and/or global arena. That, also, is as it should be. The two associations should, and most often do, complement each other. However, as it is true in matters other than healthcare, Mississippians often view issues on the national and/or international stage differently than our northeastern and/or Western colleagues. This also is good!

Well, the rain is slacking up and i hear my dear wife stirring around in the back of the house. it is time to conclude this muse and get ready for church. My thoughts and prayers this Sabbath will be, as always, for the health and well-being of my wife and children, for family and friends, for patients who no longer enjoy good health, and for those in my community and around the world who unfortunately, for whatever reason, do not benefit from the many blessings that i often take for granted. in the midst of my worship, i shall thank God for my friends and colleagues at the Mississippi State Medical t $PNQSFIFOTJWF .BOBHFNFOU Association. i will ask His guiding hand to continue to be t $PNQSFIFOTJWF $POTVMUJOH on this association that i love so much and does such good. t #JMMJOH "DDPVOUT 3FDFJWBCMF .BOBHFNFOU it is in this spirit of fellowship that i admonish you all t $PEJOH %PDVNFOUBUJPO to take stock of what our MSMA has done for your t 1SBDUJDF "TTFTTNFOUT 3FWFOVF &OIBODFNFOU profession, your practice, and most importantly your t 1SPĂśUBCJMJUZ *NQSPWFNFOU patients. t 1SBDUJDF 4UBSU VQT You will soon be asked to continue your membership t 1FSTPOOFM .BOBHFNFOU in MSMA. Please, do what you wish with AMA, but for Godâ&#x20AC;&#x2122;s sake do not leave MSMA. i think it just stopped raining.

We specialize in the business of healthcare

Your partner in making Mississippi healthier, randy easterling, mD

president, mississippi state medical association

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Whether we like it or not Health Care Reform is an important topic that provokes and requires serious consideration, with no easy answers nor unproblematic solutions. Your patientsâ&#x20AC;&#x2122; health should not be a political issue. The poster insert on the reverse is designed to reassure your patients that MSMA physicians are putting patients first.

Patients stay healthier when they stay informed, which makes communication key to the medical profession. We hope you will hang this poster in a prominent place in your clinic. You can deepen your patientsâ&#x20AC;&#x2122; confidence by letting them know MSMA continues to push for health system reforms that provide quality, affordable health care for all. MSMA members are the â&#x20AC;&#x153;Physicians Who Care for Mississippiâ&#x20AC;? working to reduce infant mortality, improve access to care for all, halt childhood obesity, prevent substance abuse and stop underage drinking.

You are your patientsâ&#x20AC;&#x2122; advocate and MSMA keeps you in touch with the latest news and information behind the practice of medicine.

What does being a MSMA doctor mean to your patients? â&#x20AC;˘ MSMAâ&#x20AC;&#x2122;s powerful legislative presence leverages physician support into positive change on dozens of medical causes. MSMA vigorously supports and publicly promotes legislative efforts to ensure that health care decisions are guided by patients and their physicians, without government intervention. â&#x20AC;˘ MSMA encourages the development of policies and mechanisms to assure the continuity, coordination and continuous availability of patient care. â&#x20AC;˘ MSMA takes public health seriously publishing an annual public health report card on Mississippi; circulating news and updates about H1n1 flu; reducing health disparities; and, promoting healthy lifestyle choices. â&#x20AC;˘ MSMA offers guidance on legal issues from the MSMA's office of General Counsel about business and management issues.

Visit MSMAonline.com for more information on the significance of being a MSMA member. â&#x20AC;&#x201D;randy easterling, mD, msma president

JOURNAL MSMA, November 2009 â&#x20AC;&#x201D; Vol. 50, No. 11

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1-877-PSYCH-4-U 601-939-5993 Flowood,MS

662-349-2818 Southaven,MS

Partial Hospital, Intensive Outpatient Therapies

PSYCAMORE PSYCHIATRIC PROGRAMS

Therapies can and do help!

all emotional/mental problems.

Pills are good but can’t take care of

Pills are good but can’t take care of all emotional/mental problems.

Mark Your Calendar!

Therapies can and do help!

the 142nd Annual session of the MsMA house of delegates and Medical Affairs Forum 2010

PSYCAMORE PSYCHIATRIC PROGRAMS

will be held

Partial Hospital, Intensive Outpatient Therapies

June 3-6, 2010

Flowood,MS 601-939-5993

in natchez.

1-877-PSYCH-4-U

Statement of Ownership, Management, and Circulation (All Periodicals Publications Except Requester Publications) 1. Publication Title

2. Publication Number

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0

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12

0

2

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6 _ 6

3

9

6

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Association membership and paid subscribers

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I certify that all information furnished on this form is true and complete. I understand that anyone who furnishes false or misleading information on this form or who omits material or information requested on the form may be subject to criminal sanctions (including fines and imprisonment) and/or civil sanctions (including civil penalties).

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MSMA

MSMA House of Delegates Votes to Make AMA Membership Optional

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y the time one reads this it will likely be old news that the Mississippi State Medical Association no longer requires members to also be members of the American Medical Association. in a special session held Saturday, october 3, 2009, by a vote of 209-31, the MSMA House of Delegates voted to no longer require members of MSMA to join the AMA. More than two hours of debate was heard on Friday night.

The House heard compelling arguments from both sides of the issue.

The initial vote to unify with the AMA occurred on May 15, 1985 during the annual session of the MSMA House of Delegates, held at the Royal d’iberville in Biloxi. The bylaws were amended to read: (Chapter 1membership: section 5) “Members of this Association shall be members of the American Medical Association.”

Twenty-four years later this special session amendment strikes this requirement.

Dr. Randy easterling, President of MSMA, said, “For the first time the AMA will have to earn your membership. i can assure you MSMA has earned every penny of your membership and will continue to do so long into the future. Do what you like in regard to the AMA, but do not leave MSMA.” Dr. easterling went on to say he will remain a member of the AMA, because he believes that is the only way to influence its actions.

By now one should have received the 2010 membership year dues statement. MSMA will continue to serve you on a statewide and national basis. efforts at the State Capitol and in Washington depend completely on physician participation. With dedication, MSMA will become stronger and more influential than ever before now that physicians in Mississippi have a choice in their AMA membership. in the history of our MSMA it’s worth noting when and for what purpose a special session of the House of Delegates has been called. The last special session of the MSMA House of Delegates occurred november 16, 1997 at the eagle Ridge Conference Center in Raymond. The managed care market had begun to expand in Mississippi and was then referred to as an HMo invasion. There was sPEAkEr oF thE housE dr. r. lEE giFFin listEns to dElEgAtEs’ some sentiment, largely from MSMA immediate tEstiMony.

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Past-President Dr. Pat Barrett, it was time to develop a health insurance plan owned and controlled by physicians themselves organized to deliver high quality medical care that is also costeffective, and this was the best opportunity for a physician-controlled entity to be successful in Mississippi.

MSMA Past-President Dr. Fred McMillan, then president of the advisory board for the proposed plan to be known as Physicians Care insurance Company (PCiC), was quoted as saying, “it is an opportunity to return to true ‘managed care’- care that is managed by the physician and patient working together in the patient’s best interest.”

Following positive response to a survey encouraging members to get involved and help

by A votE oF 209-31 thE MsMA housE oF dElEgAtEs votEd no create the details of the concept, during the first longEr to rEquirE MEMbErs oF MsMA to Join thE AMA. MorE thAn two hours oF dEbAtE wAs hEArd on FridAy night. thE special session plans were made to move forward housE hEArd coMPElling ArguMEnts FroM both sidEs oF thE with a stock offering to MSMA membership to issuE. capitalize PCiC. A stock prospectus was mailed in April and presentation meetings were conducted throughout the state though the plan never materialized. in December of 1965 the House met in special session to consider implementation of the Medicare and Medicaid programs. on october 23, 1975 another special session was held to consider the professional liability insurance crisis’ effect on Mississippi. Delegates approved an extensive legislative program for introduction during the 1976 Regular Session of the Mississippi legislature and gave the go ahead for the Board of Trustees to study and establish a nonprofit, physician membership corporation to provide a program of medical liability risk retention and education for MSMA members. our solution to the malpractice crisis was establishing of a “captive” liability insurance MsMA PAst PrEsidEnt dr. J. EdwArd hill outlinEd thE company, the Mississippi Medical Fraternal and iMPortAnt rolE thE AMA PlAys At A nAtionAl lEvEl rEPrEsEnting PhysiciAns Across thE country. educational Society. now known as Medical Assurance Company of Mississippi, MACM’s purpose remains the same today as it was when the company was founded . . . to provide quality, affordable coverage to physicians living and practicing in the state of Mississippi. Medical Assurance Company was established to protect and serve only Mississippi physicians.

While there may have been other special sessions before these, this one held october 2 and 3, 2009 at the norman C. nelson Student Union Building on the University of Mississippi Medical Center campus is certainly not the first time the House of Delegates has debated AMA unification. on four subsequent occasions, in 1989, 1994, 1997 and 2008 the House of Delegates voted to continue requiring AMA membership. “it is apparent to even a casual observer that a special called session of the MSMA House of Delegates arises out of crisis,” MSMA President Dr. Randy easterling said in remarks. “Your association has a storied history of responding, and i might add responding effectively, when our profession, our practices, but more importantly our patients are in peril.”

“As we move forward, no longer requiring MSMA members to be AMA members, be reminded of the central role that the Mississippi State Medical Association has played in your practice lifetime. Whether it be the founding JOURNAL MSMA, November 2009 — Vol. 50, No. 11

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of MACM and MPCn to offer a physician-owned alternative to commercial insurers, tort reform resulting in 50% premium cuts and rebates 5-years running or MSMA pushing thru cigarette tax increases in one year, there are plenty of reasons to stay with MSMA,” Dr. easterling said.

Though AMA membership is optional now, remember MSMA fought for physicians and restored Medicaid reimbursement to 90%. Working hand-in-hand with your state specialty society, MSMA is a professional advocate representing physicians only.

• MSMA fights against non-physicians wanting to practice medicine and insisted the legislature put doctors in charge of the Board of Health.

• MSMA led the battle against Medicare cuts saving Mississippi doctors $23,000 each per year.

• MSMA was instrumental in expanding the medical school at the University of Mississippi School of Medicine and founding the Rural dr. hugh A. gAMblE, ii, MsMA PAst PrEsidEnt And Scholars Program to curb workforce shortage.

AltErnAtE dElEgAtE to thE AMA, AskEd dElEgAtEs to • When insurers get out of line MSMA’s Claims considEr rEsigning thEir MEMbErshiP in thEir sPEciAlty Advocacy for Physicians Committee steps in. sociEty iF it is onE oF thE orgAnizAtions thAt Also • MSMA fights against non-physicians wanting to suPPortEd h.r. 3200. “thAt would bE thE only honorAblE practice medicine and advocates against Position to tAkE,” hE sAid. psychologists, pharmacists and optometrists who want to prescribe.

• MSMA “Doctors of the Day” get an inside look at Capitol politics.

• MSMA offers expert consulting on electronic medical records through a partnership with information and Quality Healthcare (iQH).

• MSMA is the voice of Mississippi physicians and offers 50 continuous years of publishing the Journal of the Mississippi Medical Association (JMSMA).

Going back through historical journals and the transactions of the MSMA House of Delegates one is reminded of the French proverb, “The more things change the more they remain the same.” The issues that concerned our MSMA’s forefathers: the public’s health, the physician-patient relationship, tort reform, AMA membership, standards and ethics and scope of practice remain. The patient’s best interest still comes first.

You can be proud knowing you are a member of the Mississippi State Medical Association. MSMA. The Physicians Who Care for Mississippi.

MsMA PrEsidEnt dr. rAndy EAstErling conFidEntly PronouncEs thE First sPEciAl sEssion oF thE MsMA housE oF dElEgAtEs AdJournEd “sinE diE.”

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LETTERS To Agree to Disagree is only Professional Dear JMSMA editor, would like to express congratulations to all those who worked so hard to organize, coordinate, and conduct our recent MSMA House of Delegates Session on october 2/3, to address the issue of our organization’s “unification” status with the American Medical Association (AMA).

Whether one is pleased with the outcome or not, it was critically important that our membership have a timely forum for frank, open discussion on this important matter. it’s clear many of us hold strong feelings about this issue, but i feel this event will serve to strengthen our professional bonds, and send a positive message to not only those who are currently MSMA members, but hopefully also to those nonmembers who have historically opposed the unification requirement. i trust they will now elect to rejoin our ranks. i was also pleased (though not surprised) at the gravity and strong sense of professionalism exhibited by all, despite what could have been a “rancorous” session. one of the (few) things that lawyers sometimes do better than doctors is to “disagree.” We physicians tend to take any difference of opinion as a person affront, whereas lawyers seem to disagree openly, brazenly, and sometimes in an apparently hostile fashion, then go out and play golf together. not to paraphrase any particular first lady, but i have never been as proud of MSMA as i am now.

Thanks again to all our membership who participated, whether by proxy, or especially by personal attendance, and to those in our leadership and our MSMA staff.

Political differences may come and go, but in the end we are all Mississippi physicians who only want the best for our patients and our communities. let’s move forward together and keep our MSMA strong.

There is still much work to do with regard to our country's efforts to achieve “health reform,” and our patients will continue to look to our MSMA for guidance.

—Joseph blackston, mD, JD Jackson

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Numbers Do Count Dear JMSMA editor, ecent health care debates are full of misfacts and bad numbers and so is the article “numbers Count” [J Miss State Med Assoc. 2009;50(10):366]. i would like to comment. The U.S. spends more than other countries on health care but not “twice as much.” We spend 16% of GDP on health care while the average organization for economic Cooperation and Development (oeCD) country spends 10%. But there are excellent valid reasons for this 60% difference.

The U.S. has entirely different population cohorts than any other oeCD country. All of these cohorts have a markedly higher burden of physical and / or psychiatric disease:

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1. 28% black / Hispanic cohort.

2. 8% military veterans.

3. 10% unvetted illegal immigrants, many of whom are sick.

These cohorts are less than 1% in the remaining 29 countries of the oeCD. Also, we share a long porous border with a Third World country across which flows drugs and associated expensive violence into inner cities. none of the oeCD countries has such a border and five are actually islands! in addition, all the oeCD countries have single payer universal health systems (SPUnS). All medical businesses must collect money to operate. This is usually about 25% of operating expenses. in health insurance in the U.S. this is done by insurers.

However, in SPUn countries the money to run the system is collected largely by tax agencies and given to the SPUn which then appears to operate much cheaper (by 25%).

But above all most of all oeCD countries have a slick mechanism to control frivolous lawsuits. The institute of Medicine recently published data to show that up to 30% of medical costs are incurred defensively by doctors and hospitals. That’s a lot of money (30% of 2.1 trillion dollars). The best method 393

to control petty lawsuits is a loser pays legal system. i never practiced defensively in my native Canada. The U.S. is the only oeCD country that does not have loser pays.

So if these additional disease, accounting and barratry burdens were added to health care costs elsewhere, the average oeCD country would spend the same as us.

And then there is the question of insurance. lack of insurance does not mean â&#x20AC;&#x153;no care.â&#x20AC;? Applying national ratios to 500,000 uninsured Mississippians reduces that number because: â&#x20AC;˘ up to 10% are illegal (census.gov) â&#x20AC;˘ 30% receive care at Federal or county health clinics (census.gov) â&#x20AC;˘ 20% pay out-of-pocket because they are â&#x20AC;&#x153;invincibleâ&#x20AC;?(ages 19-25) or have incomes greater than $75,000 (employment policies institute.org)

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So it would appear that the number of chronic

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JOURNAL MSMA, November 2009 â&#x20AC;&#x201D; Vol. 50, No. 11

working poor in Mississippi is about 200,000. So, let’s address this 7% of the population and leave the other 93% alone.

Besides, insurance does not guarantee better care. in places where all people are insured, citizens should have disease treated earlier and better and they should live longer. Yet in Canada, with universal health coverage, morbidity and mortality rates are no better than the U.S. So Canadians pay 25% more in taxes to get the same results as we do. Actually after 30 years here, i am amazed that the U.S. health system functions so well despite such an added burden of disease and barratry.

So as the article suggests – numbers do count.

But it depends on who is counting and what is counted which always reminds me of the wise dictum of Benjamin Disraeli who warned us over a century ago that there are three kinds of lies –lies, damn lies and statistics.

—calvin ennis, mD escatawpa

The Death of Unification Dear JMSMA editor, was there. it was September 29, 1962. ole Miss was playing Kentucky in Memorial Stadium. Gov. Ross Barnett, after a few rabble-rousing remarks before kick-off, received a standing ovation and more than a few Rebel yells from the crowd for his defiance of Federal authority in the controversy surrounding the admission of James Meredith to the University. never mind that his demagoguery almost caused a blood bath. never mind the absurdity of the notion that the Mississippi Highway Patrol could fend off Federal troops. never mind the abject futility of the whole exercise as a way to advance the goal of protecting the constitutional prerogatives of the states. Mob hysteria prevailed. i was mortified and demoralized. Coming back home for residency after medical school in Houston and a tour in the Air Force in illinois, i was expecting better days ahead for Mississippi after the Governorship of J. P. Coleman. it was a minor case of déjà vu for me at the Special Session of the MSMA House of Delegates the other night. Physicians are rightly upset about some of the changes in the health care system which Democrats are proposing and, in that connection, the

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AMA leadership certainly deserves to be called on the carpet for indicating a willingness to collaborate. nevertheless, the president-elect of the AMA told us in Jackson a while back that the strategy of the AMA was to avoid total exclusion from negotiations by not adopting an intractable position. Their plan is to try, by diplomacy, to get the most onerous portions of the plan deleted. However, conciliation is apparently not acceptable to our membership in this debate and in this environment. in the Special Session, nothing, including our own by-laws, was allowed to stand in the way of determination to just say no. You may recall, by the way, that James Meredith did get admitted to ole Miss in spite of all the bluster. There’s a lesson in there somewhere.

Actually, the issue of unified membership is not a big deal with me. i can argue both ways. i am more troubled by the attitude of belligerent defiance, which seems to me to be self-defeating. Actually, the AMA may turn out to be the only port in this storm, politically speaking. Weakening the AMA at this time doesn’t make a lot of sense if the object is to gain as many concessions as possible in final resolution. Be that as it may, the House of Delegates, in response to the prevailing sentiment of the membership, has certainly shown the AMA a thing or two! —noW WHAT? —W. Lamar Weems, mD past president Jackson

MPCN Notification Dear JMSMA editor, he purpose of this letter is to let you know of an upcoming change in the administering insurer of the Comprehensive Health insurance Risk Pool Association (CHiRPA), presently administered by Blue Cross Blue Shield. every three years the CHiRPA is required to select a company, through a competitive bidding process, to administer the policies issued by the Association. As a result of this process, CoreSource, inc., a nationally recognized provider of administrative services to health plans, has been selected as the administering insurer effective January 1, 2010. With the coordinated efforts of three Mississippi based provider networks, Mississippi

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Physicians Care network (MPCn), Health link, and Mississippi Health Partners (MHP), the participants of the plan should not see a gap in their network coverage.

—scott Dennis, ceo mississippi physicians care network

PLACEMENT / CLASSIFIED

A Record $2 Million Plus

PHYSiCiANS NeeDeD

[JMSMA strives to avoid any error in its content.

However, this publication is a human endeavor, and an error may occasionally occur. We will correct errors promptly. In the October 2009 issue, page 367, “Images in Mississippi Medicine,” the photo caption incorrectly reported the amount raised for the AMAERF when Mrs. J. Edward Hill (Jean) was 1989-90 president of the AMA Auxiliary. Mrs. Hill has graciously supplied the correct information below. The JMSMA editors regret this error and any confusion it may have caused.]—ED. Dear JMSMA editor, hat fond memories you kindled with your picture of Dr. lonnie Bristow and me in the october issue of the Journal MSMA. Confetti was released over the AMA House of Delegates in celebration of the Alliance (Auxiliary) for the first time, raising over TWo Million DollARS for the AMA Foundation, then known as AMA-eRF. The amount raised was $2,050,350.25.

AMA-eRF was changed to the AMA Foundation in 1998.

Dr. lonnie Bristow of California, supported by our MSMA Delegation to the AMA, became the first African American President of the AMA in 1995.

—Jean hill tupelo

Physicians (specialists such as cardiologists, ophthalmologists, pediatricians, orthopedists, neurologists, etc.) interested in performing consultative evaluations (according to social security guidelines) should contact the Medical relations office. toll Free 1-800-962-2230 Jackson 601-853-5487 leola Meyer (Ext. 5487)

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the pen is mightier than the sword express 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 try to clear up ambiguities, to protect our letter-writers.

You can submit your letter via email to Kevers@MSMAonline.com or mail to the Journal office at MSMA headquarters: P.o. Box 2548, Ridgeland, MS 39158-2548.

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EDITORIAL

Thanksgiving Thank you for patients that i serve. For those i have known like Maude, whose age has brought her wisdom and poise that is ageless. Her grace, charm, and fierce determination to live life fully, even at the end of her days became an epiphany for me as i learned to help others and live my own life. For those patients like Steve, whose urge to selfdestruction left me helpless, but encouraged me to find and improve in the ways that i reach others for healing purposes. And for so many patients, who not only trust me but also help me learn ever more about how best to serve them.

Thank you for colleagues, residents, and students. For those like Jim, whose brilliance and commitment to medicine i cannot match, but after whom i most want to model my own life as a physician. For those like larry, whose shouts of “great case!” on the wards late one night simultaneously reminded me of the joy of using intellect in diagnosis as well as the need to view patients as persons and not cases. And for John, whose premature loss poignantly contrasted and helped in understanding the value of a life of long service in the profession.

Thank you for nurses that do what i cannot, at times that i cannot, for those that i do not even know. For Pat, whose gentle nature provides her with knowledge of patients that even my best history and physical cannot rival.

There are several Pat’s in my life, and i am thankful for another Pat, this one who sees through problems and leads nursing teams to better ways of serving patients. Thank you for Cheryl, whose kindness in caring for those beyond cure leads many families to a peace they would not have otherwise known.

Thank you for staff that serves gladly, doing that without which patients and physicians would fare poorly.

Thank you for Betty, whose smile and outright joy at seeing those assembled starts yet another lunch meeting off on a positive note. For John, who can be counted on for the baseball scores while pushing yet another bin of trash off to the dock. For another Cheryl, who flawlessly deciphers the seemingly illegible and helps brings care plans to life from a lifeless set of written orders. Thank you for loralei, who delights in the hunt for articles and references leading to better care of patients.

Thank you for leaders who bring healthcare teams together for purposeful work. For community members who devote hours on the board in helping a sometimes self-insulated profession provide what the health of the community really needs. For those like Frank, whose mind for detail and probing questions reassure me that the layperson can understand medical science as well as the researchers. For administrators, who somehow nudge the multiple egos, agendas, and conflicts along a path towards needed goals.

Thank you for family to love and be loved by. This last gift, your gift of love is the most important of all.

Thank you that through the intimacy of family i have been given the opportunity to lose myself in the love of another.

And for finding out that in losing myself in love, i find myself and walk closer to You. Thank you for the profession of medicine and for giving me such opportunity to serve. Thank you for the countless times i have, through serving others, come to understand how to live my own life in ways that lead me closer to You. Amen.

—michael o’Dell, mD, msha associate editor JOURNAL MSMA, November 2009 — Vol. 50, No. 11

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JOURNAL MSMA, November 2009 â&#x20AC;&#x201D; Vol. 50, No. 11

MSDH Mississippi reportable Disease Statistics

August 2009

* totals include reports from department of corrections and those not reported from a specific district nA - not available (temporarily)

For the most current MMR figures, visit the Mississippi State Department of Health web site: www.HealthyMS.com JOURNAL MSMA, November 2009 â&#x20AC;&#x201D; Vol. 50, No. 11

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IQH IQH RECEIVES CHAMPION AWARD FROM MISSISSIPPI HEALTH INFORMATION ASSOCIATION

Patsy hathorn, rhiA, second from right, president of the Mississippi health information Management Association (MshiMA), presents dr. James s. Mcilwain, iqh president, the champion Award designation. MshiMA has recognized iqh with the special award for outstanding support of the health information management profession. observing are trannie Murphy, left, and susan McMillan, both staff members at iqh who are registered health information administrators (rhiAs).

information & Quality Healthcare (iQH) has received the first Champion Award from the Mississippi Health information Management Association (MSHiMA). The award recognizes iQH for its outstanding support of the health information management profession.

According to Patsy Hathorn, RHiA, MSHiMA president, and director of clinical resource management at Mississippi Baptist Medical Center (MBMC), iQH efforts have been outstanding in educating the public about health information and promoting professional practice standings through its Web site and quality forums.

Pointing out that the recognition reflects innovation related to health information technology, she said, “iQH has served the needs of MSHiMA members through its advocacy of patient rights and confidentiality and supporting privacy and security methods in the exchange of health information.” She added that iQH has demonstrated leadership through active participation in a variety of health information technology activities, including the Governor’s Task Force on Health information Technology, the Health information Security and Privacy Collaboration, the Mississippi Coastal Health information exchange Project, and the Doctor’s office Quality information Technology Project.

Dr. James S. Mcilwain, president, in accepting the Champion Award from Ms. Hathorn, said, “The history of iQH reflects its support of the health information profession. Since its beginning 38 years ago, iQH has included the health information discipline as an instrumental part of its staff dedicated to the mission of promoting quality healthcare improvement. We are very pleased to accept the award, and we thank MSHiMA for this special recognition.”

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UNA VOCE

DangerGenius at Work

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was twelve when my father graduated from medical school. How he convinced my mother that it was somehow reasonable to leave his job as a pharmacist with four children, the youngest still a baby, and attend medical school i will never know. it’s r. Scott Anderson, MD well beyond my powers of persuasion, i’m sure; but, somehow he did. He was at the University of Kentucky so my mom got a job as a secretary in the civil engineering department. He worked as many weekends as he could as a pharmacist and my mother typed term papers in the evenings and on weekends to try to get by. So, we weren’t poor, but we weren’t too far away. i have to say that this was a formative period of my life and helped me develop many useful skills. A key factor in this was my place as the oldest kid. i was supposed to keep an eye on the rest of the kids which taught me how to delegate almost immediately. My sister Sherry was only fifteen months younger than i was, and she liked the idea of playing house. So it was a perfect fit. She took care of the younger two, and i was left to do all the things that any self-respecting kid without too much supervision would do.

To say that a few of the ideas i came up with were unhealthy or dangerous might be true, but, in general, the degree of danger depended on what the idea was and who you were in relation to where the plan was going. Safety was always foremost in my deliberations. Take, for example, the time i convinced my little brother Jim to put on his winter coat and run around the back yard while i shot at him with my BB gun. At first blush i will admit this does appear to be a bad and dangerous thing. But you have to take into account that my parents didn’t have the money to send me on a real bear hunt and i wanted to be prepared for unexpected bear attack later in life. in truth, Jim was really in very little danger as long as i shot straight and hit him in the coat. He just had to keep his hands in his pockets and not duck or jump. A low BB and an angry mother put an end to my bear hunting practice; but, at least i know that if a bear runs around my yard (without ducking or jumping, of course) i am prepared.

At every family gathering things start out fine, but i know that before the night is over my wife and kids will be regaled by my ungrateful siblings with exaggerated tales of my childhood atrocities. They couldn’t have been that bad; nobody was maimed or permanently disfigured though scars don’t count. They don’t take time to consider all of the good i did them intellectually. i am quite sure that if someone asked my brother today to don a bulletproof vest and run around his yard so he could try to shoot him, he would decline, all because of that valuable lesson learned so long ago as a child. Yet, does he thank me for the insight that he gained from that lesson? never. lest you believe my siblings and think that they were the sole objects of what they derisively call my “crazy schemes,” you should know i prefer to think of them as manifestations of my early genius and adventurous spirit. i can cite numerous instances of crazy schemes in which no other family members were injured or even involved, for that matter.

Take, for example, the time a bunch of us boys got a wire cage from the concrete pipe factory and then used

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our belts to lash one of our friends, Davey, into place so he could travel safely when we rolled him down the railroad tracks on a long downgrade.

Davey was the daredevil of our little neighborhood gang, so it was natural that Daredevil was his favorite comic book character. now, Daredevil was a blind guy that fought crime by swinging around the city with a whip and using his karate skills and his whip to whip bad guys’ butts, as it were. Davey’s mother still kind of blamed the rest of us (and me in particular) for that concussion he got when he tried to show us how he could swing from branch to branch in that big oak tree in my back yard with the new bullwhip he got on a trip to the Smokey Mountains.

Davey, never content at action alone, had decided that if he was going to act like a super-hero he needed to dress the part as well. So he went home and put on one of those Speedo type bathing suits we all had as kids, except they came from JCPenny. His was blue and from last summer so it was way too tight. He swiped a red stretch top from his big sister with ruffles on the collar and put that on too. He tied one of his mom’s white bath towels around his neck, put on a pair of black cowboy boots, and then came clomping back across the yards. i had to admit he sure looked like a super-hero dressed like that, popping that whip in the air…CRACK. He climbed up into the tree and got out on one of the main branches, put his hand on his hip, and announced, “i am Daredevil, the boy without fear.”

“Alright, boy without fear that’s wearing his sister’s shirt, let’s see ya swing on that whip like you said you could,” i said…mad that Connie, the really cute little girl who lived between us, had told my sister how great Davey looked dressed up like that.

He bowed to the girls and they tittered. “Damned showoff,” i mumbled.

He started off like gangbusters. He snapped that whip around a fat branch and tugged on it. it was secure as could be. Then he swung straight out parallel to the ground with those shiny black boots pointing at the sky and his “cape” trailing behind him. He was looking like a real super-hero. Right up until that whip broke and he fell twelve feet, landing flat on the back of his head. He didn’t move for a real long time, and we had to run down the street and get his mom. Her response was, “not again,” as she ran across the yards behind me.

When we got there, Davey was starting to mumble something so he obviously wasn’t dead which made me take a sigh of relief. i looked at his mom. She had a really strange look on her face, kind of a mix of scared and mad and about to laugh all at the same time.

“Do you want to try and explain to me why my son is dressed up like this?” she demanded. now i’ve been a kid and a parent and there’s one thing i can tell you; there is just no use in asking questions like this. if you can’t make sense of it on the face of things, you can be pretty sure you’re not going to get a straight answer from a kid, particularly one that might incriminate himself.

“He said he was Daredevil, the boy without underwear,” i answered, trying to get even for the girls thinking he looked so cute.

Then all those girls started chiming in, saying that wasn’t it at all…they jabbered all the way back to his house while his mom loaded him up in the car for a quick trip to the emergency room. i never really got blamed for anything, and he got to stay off school for a whole week. So i guess things turned out the best that they could have except that Davey wasn’t allowed to come outside to play in the afternoons for a while, and his mom threw that bullwhip and his bathing suit away. it could have been a lot worse. i, for one, wasn’t that sad to see that bathing suit go, no matter what the girls said. it was Davey’s own idea to roll that cage down the tracks. i just bet him he was too chicken to ride it, but i was sure wrong. He climbed right in, and we all took off our belts so we could safety belt him in place. Watching that cage spin down the tracks, i was in awe of how far he’d gone without throwing up. Unexpectedly, as we watched him going along straight as an arrow down those tracks, we heard the whistle of an oncoming train. We couldn’t believe it. The train wasn’t supposed to go through there for another twenty minutes.

We ran as fast as we could but were still losing ground as the rolling cage accelerated. i guess Davey heard it too. He started thrashing around like crazy trying to get his hands and feet loose. i’m surprised he could hear anything personally. We had belted him in good and tight so he didn’t have to worry about smashing his fingers or something. All that fighting made the cage off balance and it came off one rail then flipped sideways down the embankment a good way before he even reached the trestle. But we kept on running just in case he’d gone into the unA vocE continuEd nExt PAgE...

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creek. it was slow going when the train got there because we had to get off to the side to let it pass. Davey had been real lucky though. He was nice and safe in that blackberry patch that was just above the creek bank. He did look like he’d come out on the losing end of a fight with a dozen bobcats. nothing a little mercurochrome couldn’t fix and no trip to the emergency room was needed this time.

Again, a valuable lesson was learned that would serve Davey well later in life. if he’d have been dared as a teenager to ride “The Master of Sparks” off the back of a pick-up i’m sure it would have been a big old “no.” i, myself, was not immune to the adverse effects of an active mind. one of the many instances of this that comes to mind also involved Davey. His family was a little better off than we were, and Davey was the baby of six kids so he got everything cool. At this particular point in time one of the coolest things in existence was a StingRay bicycle with front extension forks so you could ride leaning back. i had a good bike; it was a Schwinn loadmaster or something with twenty-eight inch wheels and weighing in at about a hundred pounds. if you fell over, it seemed like it took about a week to hit the ground. it was great to use on my magazine delivery route, but it wasn’t cool.

The fact that Connie would sit on the curb in front of her house and make “ooohing” and “aaahhing” sounds while Davey popped wheelie after wheelie was just like rubbing salt in a wound. i tried popping a couple of wheelies on the loadmaster. Throwing the whole of my seventy-five pounds into jerking the handle bars up, resulted in little if any discernable effect on the bike’s front wheels. The welded steel front package rack may have had something to do with that. But the decision was made. i had to come up with a cooler bike, even if i had to build it myself. i knew a place down by the creek where there was a kid’s bike frame. So i pulled that out. After i washed it off as good as i could, i discovered it wasn’t as rusty as i first thought. A couple of coats of flat black paint from my dad’s tool shed did the trick perfectly. i traded a pocket knife for a banana seat and used my magazine money to buy a set of “ape-hanger” handle bars, but it took every penny i had. There was no money left for the extension forks. i had to have the extension forks; that’s what the girls thought was so cool. i had made my pseudo-Sting-Ray from junk. i had a skateboard made from a skate and a board. There had to be a way for me to get some extension forks. i was just going to have to think of a way to do it myself. i made a trip a few houses down and “liberated” a pole from Mrs. Watson’s clothesline. Then i used a hacksaw to cut it in half and a hammer to flatten the ends. i drilled holes in the flattened ends so the axel bolts fit through, tightened them down, then flipped the bike over and hammered the free ends of the poles onto the forks of the bike. A little more black spray paint and… voilà, the coolest bike around. i can’t begin to tell you how smart i felt riding around on my own bike for the next three or four days, popping wheelies and acting too cool to notice Connie sitting there with my sister. Then it all fell apart…literally.

The days of riding around had loosened the hold that the hammered-on aluminum poles had on the front forks of the bike. i popped one wheelie too many and the whole contraption fell off. i kept pumping to keep the bike from throwing me face first onto the asphalt. There was no way to let the bike down and the more i pumped the faster i was going. Consequently, the more it was going to hurt when i did face plant. luckily a kindly bread truck was crossing the intersection as i ran the red light, and i smashed into the side of it, breaking my arm. The bike wasn’t so lucky. it went under the back wheels and looked kind of like a metal pretzel after that.

What valuable insight did i gain from this? Just because you can do doesn’t always mean you should. i’ll keep you posted on any other valuable lessons i can come up with.

—r. scott anderson, mD [R. Scott Anderson, MD, a radiation oncologist, is medical director of the Anderson Regional Cancer Center in Meridian, and vice chair of the MSMA Board of Trustees. Additionally, he is an accomplished oil-painter and also dabbles in the motion-picture industry as a screen-writer and helped form P-32, an entertainment funding entity. “Una Voce” (With One Voice) is a column in the Jmsma designed by Dr. Dwalia S. South, MSMA past president and chair of the Committee on Publications. “Una Voce” features the selected prose of MSMA members. If you are a writer and would like to submit your work for consideration please send us your contribution or contact one of the editors.]—eD.

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