November 2010 JMSMA

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VOL. LI

2010

No. 11

The T he c change hange tto o IICD-10 CD-10 c codes odes ttakes akes e effect ffect o on nO October ctober 1 1,, 2 2013.

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w www.cms.gov/ICD10 ww.cms.gov/ICD10

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NOVEMBER 2010 SCIENTIFIC ARTICLES

VOLUME 51

NUMBER 11

Chemical Colitis from a Hydrogen Peroxide Enema Yagnesh Desai, MD and Jeffery Orledge, MD

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Bilateral Cavernous Sinus Thrombosis Following Community-Acquired 317 Methicillin-Resistant Staphylococcus aureus Infection: A Case Report and Review of the Literature

Rebecca S. Chick, BS; James K. Glisson, MD, PharmD; Samuel Pierce, MD

Clinical Problem- Solving: Deceptive Irritations

David R. Norris, MD

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• SCIENTIFIC ARTICLES •

Chemical Colitis from a Hydrogen Peroxide Enema

A

Yagnesh Desai, MD and Jeffery Orledge, MD

BSTRACT

Background: Constipation is a common complaint seen in the emergency department for which patients will try many different remedies. Objectives: This case report discusses the outcome of a patient who developed a chemical colitis after using a hydrogen peroxide enema to relieve his constipation. Case Report: A 43-year-old male with a history of chronic constipation presented to the Emergency Department (ED) with complaints of abdominal pain and hematochezia after self-administering a commercial sodium phosphate/sodium biphosphate enema mixed with hydrogen peroxide. The patient began to have left-sided abdominal cramping pain afterwards.

He also began to have bowel movements mixed with bright red blood every 30 minutes. An abdominal computed tomography scan showed moderate to severe bowel wall thickening consistent with colitis involving the rectum extending to the distal one third of the transverse colon. The patient was admitted to the internal medicine service for further monitoring. Gastroenterology was consulted for further management. Conclusions/ Summary: The abdominal pain and hematochezia resolved and the patient was discharged the next day without complications.

KEY WORDS:

INTRODUCTION

CHEMICAL COLITIS, HYDROGEN PEROXIDE ENEMA, CONSTIPATION, COLITIS, HEMATOCHEZIA

Constipation is a common complaint that presents to the emergency department. Common treatments include laxatives, mineral oil, over-the-counter enemas, and fiber supplements.

Hydrogen peroxide enemas were once used for removing meconium in neonates, fecal impactions, and to remove gas from the intestines prior to performing an abdominal roentgenography.1

AUTHOR INFORMATION: Dr. Desai is a fourth year resident in the Department of Emergency Medicine at the University of Mississippi Medical Center in Jackson. Dr. Orledge is an assistant professor for the Department of Emergency Medicine at the University of Mississippi Medical Center in Jackson.

CORRESPONDING AUTHOR: Yagnesh Desai, MD, University of Mississippi Medical Center, Department of Emergency Medicine, 2500 North State Street, Jackson, MS 39216. Phone: (601) 984-5582. Fax: (601) 984-5583.

Email: ydesai@umc.edu.

Due to its irritating effects to the colonic mucosa, its use is no longer popular in medical practice. However, when a patient is unable to gain results from traditional treatments and is at his wit’s end, he may try novel methods for evacuation. We report a case of chemical colitis caused by a self-administered hydrogen peroxide enema.

CASE REPORT

A 43-year-old male with a history of chronic constipation presented to the emergency department (ED) with complaints of left-sided abdominal pain and hematochezia. The patient reported the symptoms began the previous night after he introduced hydrogen peroxide into a commercial sodium phosphate/ sodium biphosphate enema in an attempt to increase efficacy. He emptied one-third of the original enema volume and filled that amount with over-the-counter hydrogen peroxide. He did not recall the concentration of the hydrogen peroxide. He evacuated the enema immediately after self-administering it and then had a bowel movement that was of normal consistency. He began to have diffuse abdominal cramping approximately thirty minutes after and passed blood from his rectum. He continued to pass blood from his rectum throughout the night at intervals of approximately thirty minutes. He described the blood as bright red and quantified it as a small amount that would pool in the toilet. He denied passing any clots, stool, or mucus with the blood.

As his symptoms did not resolve, he came to the ED to be evaluated. He had pain that localized to his left abdomen.

He had nausea with two episodes of vomiting without hematemesis but with minimal rectal pain. He denied fevers or chills, diarrhea, or recent weight loss. He had never experienced these symptoms previously. He had never had a colonoscopy.

The patient had a past medical and surgical history significant for hemorrhoids treated with hemorrhoidectomy. He denied the use of tobacco, alcohol, or illicit drugs. He denied a family history of colon cancer or similar problems.

Vital signs for the patient were temperature of 35.1 degrees Celsius, heart rate of 69 beats per minute, respiratory rate of 18 breaths per minute, and blood pressure of 146/91 mmHg. On physical examination, he appeared well-hydrated with good

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respiratory effort. He had a regular cardiac rate and rhythm, a normal S1 and S2, and no murmurs, rubs, or gallops. His abdomen was non-distended, and bowel sounds were present in all quadrants; his abdomen was soft with moderate tenderness in the left upper and lower quadrants with no rebound or guarding present. No masses could be palpated, and no hepatosplenomegaly was appreciated. Rectal examination revealed intact sphincter tone, no external or internal lesions, no tenderness, no stool in the vault, no sentinel pile or anal fissure, small amount of red blood with a positive hemoccult test.

A complete blood count had 11,200 white cells, hemoglobin of 15.7, hematocrit of 45.8, and 262,000 platelets. Prothrombin time was 12.9 seconds, activated PTT was 25.3 seconds, and international normalized ratio was 1.2. There were no abnormal values on the chemistry panel. Flat and upright abdominal x-rays were normal. Computed tomography of the abdomen and pelvis done with oral and intravenous contrast showed continuous moderate to severe bowel wall thickening, submucosal edema, and mucosal enhancement involving the distal one third of the transverse colon extending to the rectum, consistent with colitis. No free intraperitoneal air was present, and no venous or arterial thrombus was visualized in the vasculature to this segment of the colon to indicate ischemic colitis (Figures 1,2,3).

Intravenous morphine sulfate was given for pain relief.

The patient had four episodes of hematochezia during his stay in the ED. The patient was admitted to internal medicine for monitoring and follow-up by the gastroenterology service. Over the next 24 hours, the hematochezia decreased and the patientâ&#x20AC;&#x2122;s abdominal pain resolved. He was able to tolerate a regular diet without any further hematochezia, nausea, or vomiting. Gastroenterology recommended the patient follow-up outpatient for a flexible sigmoidoscopy in two months to allow ample time for the chemical colitis to completely resolve. He was discharged in improved condition the next day with a bowel regimen consisting of docusate sodium, fiber supplementation, and polyeth-

Fig 1. Axial view of the distal colon showing mucosal thickening consistent with colitis

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ylene glycol. The patient was contacted at home two months after discharge and his hematochezia had completely resolved.

His constipation had improved with the bowel regimen. He opted not to schedule a sigmoidoscopy.

DISCUSSION

Hydrogen peroxide is an oxidizing agent that can cause corrosive damage, gas formation, and lipid breakdown in colonic tissue.2 As hydrogen peroxide penetrates into the epithelium and capillaries, microbubbles of oxygen form. Blood is forced out of the vasculature and replaced with this oxygen.3 Gas embolism may occur if a large amount of gas is produced that does not dissolve in the bloodstream. Rapid distention of

Fig 2. Coronal view of the sigmoid colon with evidence of proximally extending mucosal thickening

Fig 3. Coronal view of the proximal descending colon showing the extent of mucosal thickening

Gastroenterologists have reported a finding known as “snow white sign” occurring during colonoscopy after the use of colonoscopes that were cleaned with hydrogen peroxide but incompletely flushed with water. Reports discuss immediate formation of white plaques and frothy effervescence of the mucosa after depressing the water button during the procedure and, instead, spraying hydrogen peroxide into the colon.3,6,7 Biopsy specimens have been collected and different histological appearances have been found based on the concentration of hydrogen peroxide that was used. Dilute solutions caused no changes. Concentrated solutions have resulted in the appearance of fat-infiltrated mucosa, submucosa, serosa, and abdominal lymph nodes which progresses to mucosal hemorrhage, ulceration, and necrosis.3 This fat-infiltrated appearance of the mucosa results from tiny, gas-filled cysts that have been described as pseudolipomatosis coli.6 Few of the endoscopy cases resulted in serious consequences. In three case reports, colonic ulcers were resolved on follow-up colonoscopy done one to two months later, and no further complications arose.3,6,7

CONCLUSION

Table 1: Reports of Chemical Colitis from H2O2

the bowel due to gas formation can also cause rupture or pneumatosis coli.2 Sepsis can occur from colonic bacteria entering the bloodstream through mucosal disruption. In most reported cases, patients were admitted to the hospital to be monitored and recovered without adverse complications (see Table 1). Symptoms included bloody bowel movements, lower abdominal pain/cramping, tenesmus, fever, and leukocytosis.1,2,4 Meyer et al. reported three cases of hydrogen peroxide colitis which were treated with ampicillin and gentamicin as well as corticosteroids empirically. Antibiotics were used as these patients had fever and elevated white blood cell counts. They performed endoscopy on the three patients while in the hospital and found friable necrotic mucosa with multiple ulcerations.1 In our patient, as he remained afebrile and had a normal white blood cell count, no antibiotics were administered. He was simply treated with intravenous fluids and kept nil per os overnight.

Sheehan experimented with hydrogen peroxide enemas in rats. He followed the mucosal changes that took place over time.

Immediately upon administration of the hydrogen peroxide enema, the colon became emphysematous and gas bubbles were noted in the portal vein, right heart, lungs, liver, spleen, inferior vena cava and renal veins. Within one hour, the mucosa became dark purple and congested and began to hemorrhage. At five hours, the mucosa was ulcerated. After 24 hours, gangrenous necrosis of the mucosa and submucosa was noted. After approximately one week, active and healing ulcers were observed.

Ten out of 14 rats healed their colonic ulcers by ten weeks.

Three of 14 were still healing, and one rat still had active ulcers at ten weeks. Sheehan also found that retention of the enema for more than four seconds led to death by gas embolism.5

After our own experience with this rare condition and review of the current literature, it seems appropriate to treat patients presenting with hydrogen peroxide colitis conservatively.

In the ED, intravenous fluids, anti-emetics, and analgesia should be given. An abdominal computed tomography scan with oral and intravenous contrast is appropriate to exclude bowel perforation and to assess the degree of colonic inflammation. Intravenous antibiotics are recommended if there are any signs of sepsis, and the patient should be kept nil per os until symptoms begin to resolve. As hydrogen peroxide causes mucosal breakdown, endoscopy may be better done at a delayed time after initial exposure to prevent iatrogenic perforation through friable mucosa. Inpatient monitoring is indicated until pain and hematochezia resolve, and a regular diet is tolerated. Most patients should do well with tincture of time.

REFERENCES 1.

2.

3.

4.

5.

6.

7.

Meyer CT, Brand M, DeLuca VA, et al. Hydrogen peroxide colitis: A report of three patients. J Clin Gastroenterol. 1981;3:31-35.

Almalouf P, Shehab TM, Daniel AMR, et al. Therapeutic hydrogen peroxide enema causing severe acute colitis. Int J Colorectal Dis. 2008;23:1139-1140.

Bilotta, JJ, Waye JD. Hydrogen peroxide enteritis: the “snow white” sign. Gastrointest Endosc. 1989;35:428-430.

Ryan CK, Potter GD. Editorial: Disinfectant Colitis. J Clin Gastroenterol. 1995;21:6-9.

Sheehan JF, Brynjolfsson G. Ulcerative colitis following hydrogen peroxide enema: Case Report and experimental production with transient emphysema of colonic wall and gas embolism. Lab Invest.

1960;9:50-168.

Cammarota G, Cesaro P, Cazzato A, et al. Hydrogen peroxiderelated colitis (previously known as “pseudolipomatosis”): a series of cases occurring in an epidemic pattern. Endoscopy. 2007;39:916919.

Schwartz E, Dabezies MA, Krevsky B. Hydrogen peroxide injury to the colon. Dig Dis Sci. 1995;40:1290-1291.

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• SCIENTIFIC ARTICLES •

Bilateral Cavernous Sinus Thrombosis Following Community-Acquired Methicillin-Resistant Staphylococcus aureus Infection: A Case Report and Review of the Literature

A

Rebecca S. Chick, BS; James K. Glisson, MD, PharmD; Samuel Pierce, MD

BSTRACT

Objectives: We describe a case of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) skin infection leading to bilateral cavernous sinus thrombosis (CST) and subsequent left eye blindness in a previously healthy, immunocompetent woman. A secondary objective is to document all published cases of MRSA induced CST. Data Source and Study Selection: To identify all relevant publications on MRSA-induced CST in adults. Results: Seven publications were included in this review describing patients age nineteen or older. Together, with the case included in this publication, a total of 8 cases of MRSA induced CST have been documented since 2003. Of interest, to our knowledge this is the first reported case of CA-MRSA CST temporally associated with nasal H1N1 vaccination. Conclusion: In selecting empiric antibiotic coverage for septic CST, the practitioner should use antibiotics that are active against CA-MRSA to help prevent morbidity and mortality.

KEY WORDS:

INTRODUCTION

METHICILLIN-RESISTANT STAPHYLOCOCCUS

AUREUS, STAPHYLOCOCCAL INFECTIONS, CAVERNOUS SINUS THROMBOSIS, VACCINATION

H1N1

Methicillin-resistant Staphyloccocus aureus (MRSA) is an important cause of skin and soft tissue infections, pneumonia, and osteoarticular infections in the hospital setting and in certain high risk groups including inmates, prisoners, men who have sex with men, athletes, military recruits, Native Americans, Alaska

AUTHOR INFORMATION: Ms. Chick is a student in the School of Medicine, University of Mississippi Medical Center, Jackson. Dr. Glisson is an Assistant Professor in the School of Medicine, Department of Internal Medicine, University of Mississippi Medical Center, Jackson. Dr. Pierce is a resident in the Department of Internal Medicine, University of Mississippi Medical Center, Jackson.

CORRESPONDING AUTHOR: James K. Glisson, MD, PharmD, Department of Internal Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson MS, 39216

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natives, children, and methamphetamine users.1 Over the past few decades, MRSA has been acquired in the community in subjects that were not considered high risk. We report a case of community-acquired MRSA (CA-MRSA) skin infection leading to altered mental status, bilateral cavernous sinus thrombosis (CST), bilateral superior ophthalmic vein thrombosis, and left optic nerve infarct with subsequent left eye blindness in a previously healthy, immunocompetent woman who recently received the nasal H1N1 vaccination. We also reviewed all cases of MRSA-associated CST available in the literature.

CASE REPORT

A previously healthy, immunocompetent 19-year-old woman presented to the emergency department in moderate distress with a 5 day history of progressive headaches and periorbital swelling. She reported taking the nasal H1N1 vaccine (Influenza A (H1N1) 2009 Monovalent Vaccine, MedImmune LLC, lot number 500782P, exp. date 1/15/2010) at her college 8 days prior. Two days post vaccination, she developed a small vesicular 0.5 cm lesion on the right tip of her nose which she described as a “cold sore.” One day after the development of the lesion, she began having frontal headaches, photophobia, and blurry vision in her left eye. She also reported subjective fever but denied any other neurological deficits. She denied taking any medications or dietary supplements, had no known drug allergies, and was up to date on all vaccinations. She was a college student and lived in the dormitory with no significant past medical history. She denied any exposure to friends with similar illness or health care workers. She denied tobacco, alcohol, or illicit drug use. Vital signs on examination were T 37.8°C, P 61, BP 115/53, RR 16. Physical exam revealed bilateral periorbital cellulitis, left greater than right. She was unable to open her left eye. Otherwise her physical exam was normal. Specifically, she had no neurological deficits or abnormalities other than her ophthalmic exam.

vaccine. At the time of discharge her WBC was 20.1 th/cmm, and she continued vancomycin intravenously for 6 weeks as an outpatient and warfarin. Follow-up MRV 3 weeks post-discharge showed complete resolution of bilateral cavernous sinus thromboses. She also had follow-up clinic appointments with ophthalmology and internal medicine. The residual sequalae of her CST were complete left eye blindness with mild proptosis.

Of note, tetanus, pneumococcus and Haemophilus titers, total complement concentrations (CH50), and quantitative immunoglobulins were obtained to evaluate her immune status as well as a complete hypercoagability profile. She was deemed immunocompetent based on the results and did not have a hypercoaguable state. Additionally, HIV serum tests were negative. Finally, the genotyping of all four samples of MRSA from blood cultures revealed the isloate to be the USA300 strain. Additionally, the isolates demonstrated staphylococcal cassette chromosome (SCC) SCCmec IV and were Panton-Valentine leukocidin (PLV) positive and SPA t008.

Fig 1. MRI T1 coronal image demonstrating enlarged cavernous sinuses with filling defect in left cavernous sinus consistent with thrombus. Right cavernous sinus thrombus was demonstrated on other images.

Initial laboratory values including serum chemistries and complete blood count were all essentially normal other than a white blood cell count (WBC) of 27.6 th/cmm. Initial CT scan demonstrated only minimal left preseptal edema with no evidence of cavernous sinus thrombosis. She was admitted to the general medicine service and started on vancomycin, ceftriaxone, ampicillin and sulbactam, and acyclovir. On day three of inpatient treatment, she became less responsive and experienced altered mental status and her fever peaked at 39.4°C Magnetic resonance imaging (MRI) demonstrated bilateral cavernous sinus thrombosis (Figure 1), bilateral superior ophthalmic vein thrombosis, and an infarct of the left optic nerve. The diffusion series on MRI showed punctuate scattered areas of restricted diffusion (acute infarct) involving the bilateral centrum ovale white matter in the frontal lobes and a focus in the parietal lobes. A magnetic resonance venogram (MRV) confirmed lack of blood flow to the bilateral cavernous sinuses. She was started on a heparin infusion and transferred to the intensive care unit (ICU) for closer monitoring. Physical exam at that time revealed bilateral proptosis, left greater than right, and blindness in the left eye. Again, no other neurological deficits were noted.

Blood cultures obtained on admission and repeated on hospital day three were positive for methicillin-resistant Staphylococcus aureus. The patient slowly improved while in the ICU. She was continued on vancomycin, ampicillin and sulbactam; her fever resolved, her WBC declined and she was transferred to the general hospital ward on hospital day five. The nurse at the university clinic was contacted, and no other reports of skin infections were reported by students who received the same nasal

METHODS AND MATERIALS Data Source, Study Selection, Data Extraction and Synthesis: Our goal was to identify all relevant publications on MRSA induced CST in adults. As a research strategy, we included publications in human adults with no restriction on the article type. English publications in the adult population were included. The searches were performed by two authors (RC and JG) independently in May, 2010. The National Library of Medicine’s PubMed database was searched from 1950 to 2010 using the Medical Subject Headings (MeSH) or keywords both stand alone or in combination: methicillin-resistant Staphylococcal aureus, Staphylococcal infections, cavernous sinus thrombosis, humans, and adult. A Google® Internet search was also performed to locate additional scientific publications. Our publication selection strategy is demonstrated in Figure 2.

Manual Search N=2

Pubmed Search N=17

Total Search N=19

Total Selected Publications N=7

12 Excluded Publications: Pediatric cases= 4 Other intracranial venous sinus=2 Non-English publication =1 Non S. aureus=2 Methicillin sensitive S. aureus = 3

Fig 2. Publication, search and selection process NOVEMBER

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source of infection. They suspected the organism to be community-acquired but failed to identify the isolate.

Snyder and Pothuru and Lim et al also both failed to determine the MRSA isolate. Of note, four of seven patients in the selected cases had not been recently hospitalized.2-4,7 Exposure to healthcare workers or recent hospitalization was not commented on in the remaining publications.

DISCUSSION

Cavernous sinus thrombosis can be a result of either noninfectious or infectious etiology. Staphylococcus aureus is implicated in nearly two thirds of cases of septic CST while streptococcal species are responsible for the majority of the other cases.9 The most common sites of infection preceding septic cavernous sinus thrombosis are the midface between the glabella and the upper lip2 and paranasal sinusitis (usually sphenoid or ethmoid) followed by dental abscess and otitis media.9,10 The common clinical manifestations of CST are listed in Table 2.9,10 A frequent characteristic of CST is spread to the opposite cavernous sinus within 1-2 days after presentation of original symptoms.3,9,10 Diagnosis is usually achieved via magnetic resonance imaging or high-resolution computed tomography.We consider the Table 1. MRSA induced cavernous sinus thrombosis publications main reason for the CST was the severe and rapid swelling over the previous three days, thus leading to sluggish flow and clot development.

The treatment of both MRSA and CST is beyond the scope of this report, but practitioners should choose appropriate empiric antibiotic coverage for MRSA even in the absence of common predisposing factors for colonization. This potentially lethal illness must be recognized, diagnosed, and treated early to avoid serious complications including, but not limited to, cranial Table 2. Clinical manifestations of cavernous sinus thrombosis* *Adapted from DiNubile et al. [9] and Ebright et al. [10] nerve dysfunction, blindness, or death. The treatment of MRSA CST includes appropriate empiric antibiotics RESULTS and surgery in select cases.9-11 The use of anticoagulation in the A total of 7 publications were included in this review detreatment of CST remains controversial, however, Bhatia and scribing patients age 19 or older. Together, with the case included Jones performed a retrospective review of the literature and conin this publication, a total of 8 cases of MRSA-induced CST have cluded that adjunctive anticoagulation can be used safely in the been documented since 2003. The majority of excluded publicaabsence of any potential intracranial hemorrhage. This can be tions involved pediatric cases or review articles. Table 1 lists pubconfirmed radiologically prior to initiation of anticoagulants.11 lications included in this review and a brief description. Of Our patient was unique in that she did not have any risk interest, to our knowledge this is the first reported case of CAfactors for MRSA colonization other than residing in a college MRSA CST temporally associated with nasal H1N1 vaccination. dormitory. High risk groups include people who are in settings A total of 7 cases of possible MRSA-induced CST have of prolonged close contact including inmates, men who have sex been described in the literature; however, the cases reported by with men, athletes, and military recruits.1 A field investigation by Asbury et al. and Muhtaseb et al. may represent the same paTang et al described an outbreak of infections with CA-MRSA tient. It has been suggested that chronic intravenous drug abuse, transmitted by a single colonized healthcare worker during rouchronic sinusitis, and imprisonment are risk factors that can pretine subcutaneous and intramuscular vaccinations.12 It was disdispose to the development of MRSA bacteremia and resultant covered that all four children with skin and soft tissue infections CST.2-4,7 Asbury et al failed to provide an adequate antecedent developed infections at the site of injection. Of note, our patient history of the patient and also failed to identify the primary was vaccinated with the nasal H1N1 influenza vaccine two days

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prior to developing her first symptoms. The vaccine can be administered intranasally as a live, attenuated monovalent vaccine or intramuscularly as a monovalent, inactivated split-virus or subunit vaccine.13 The U.S. Vaccine Adverse Event Reporting System received 13 reports of patient deaths after receiving the H1N1 vaccination, 3 of these after nasal administration. These three deaths were due to pneumococcal pneumonia/H1N1 influenza, massive aspiration/sudden cardiopulmonary arrest and pneumococcal sepsis. The number of days from vaccination to onset for these patients was 0-6 days. An additional 49 cases of nonfatal serious adverse events from the nasal vaccination were reported. These events include life-threatening illness, hospitalization, prolongation of hospitalization, persistent or significant disability, or congenital anomaly. No patterns were identified.13

CONCLUSION

Cavernous sinus thrombosis is a potentially lethal complication of mid-facial infections, sinusitis, and non infectious etiologies. With the prevalence of CA-MRSA increasing in the population, it is important for clinicians to diagnose and treat these patients promptly. In selecting antibiotic coverage for septic CST, the practitioner should use antibiotics that are active against CA-MRSA to help prevent morbidity and mortality. It is important to note that even with prompt and proper treatment of this condition, serious neurological sequelae and death are still possible outcomes.

Acknowledgment: We would like to thank Dr. Richard deShazo for his comments and review of this manuscript.

REFERENCES

Patel M. Community-associated methicillin-resistant Staphylococcus aureus infections: epidemiology, recognition and management. Drugs.

2009;69:693-716.

2. Asbury S, Waddilove L, Beharry N, et al. Cavernous sinus thrombosis in the ITU. Clin Intensive Care. 2003;14 (3-4):99-103.

3. Muhtaseb M, Marjanovic V, Waddilove L, et al. Cavernous sinus thrombosis secondary to MRSA septicaemia. Neuro-opthamology.

2004;28(5-6):245-250.

4. Rutar T, Zwick OM, Cockerham KP, et al. Bilateral blindness from orbital cellulitis caused by community-acquired methicillin-resistant Staphylococcus aureus. Am J Ophthamol. 2005;140:740-742.

5. Munckhof WJ, Krishnan A, Kruger P, et al. Cavernous sinus thrombosis and meningitis from community-acquired methicillinresistant Staphylococcus aureus infection. Intern Med J. 2008; 38(4):283-287.

6. Snyder GM, Pothuru S. Cavernous sinus thrombosis associated with MRSA bacteremia. Am J Med Sci. 2008;336(4):353.

7. Naesens R, Ronsyn M, Druwé P, et al. Central nervous system invasion by community-acquired meticillin-resistant Staphylococcus aureus. J Med Microbiol. 2009;58(9):1247-1251.

8. Lim S, Lee S, Yoon T, Lee J. Lemierre syndrome caused by acute isolated sphenoid sinusitis and its intracranial complications. Auris Nasus Larynx. 2010;37(1):106-109.

9. DiNubile MJ. Septic thrombosis of the cavernous sinuses. Arch Neurol 1988;45(5):567-572.

10. Ebright JR, Pace MT, Niazi AF. Septic thrombosis of the cavernous sinuses. Arch Intern Med 2001;161(22):2671-2676.

11. Bhatia K, Jones NS. Septic cavernous sinus thrombosis secondary to sinusitis: are anticoagulants indicated? A review of the literature. J 1.

Laryngol Otol 2002;116(9):667-676.

12. Tang CT, Nguyen DT, Ngo H, et al. An outbreak of severe infections with community-acquired MRSA carrying the Panton-Valentine leukocidin following vaccination. PLoS ONE 2007;2(9):e822.

13. Safety of Influenza A (H1N1) 2009 monovalent vaccines – United States, October 1– November 24, 2009. MMWR 2009 Dec. 11;58(48):1351-6.

Calling all Mississippi PhysicianPhotographers

SEEKING PHOTOS TAKEN BY MISSISSIPPI PHYSICIANS FOR 2011 COVERS OF THE

JOURNAL MSMA

• Load your camera or grab your digital. Shoot landscapes, people, animals, or anything else you can capture on film. Photos of subjects indicative of Mississippi will be given the highest consideration.

Photos of original artwork are also acceptable.

• The Committee on Publications will judge the entries on the merits of quality, composition, originality and appropriateness to the JOURNAL MSMA and select the best cover photos. All images selected require the photographer and subjects contained therein to release “permission to reprint” and "publicize on websites featuring the JMSMA.”

• Specifications: Color slides, digital files and photos. Size: Vertical format 5 x 7" or 8 x 10". A hard copy print of the image is required for judging.

Deadline: November 26, 2010 Send entries with a brief description of the subject as well as of yourself to: Karen Evers, managing editor JOURNAL MSMA, P.O. Box 2548 Ridgeland, MS 39158-2548 or deliver to: MSMA headquarters: 408 West Parkway Place Ridgeland, MS 39157

For more information: contact Karen Evers ph.:(800)898-0251 or (601)853-6733 ext.323

NOVEMBER 2010 JOURNAL MSMA

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Doctor

of the Day

Sen. Terry Burton, Augustus Soriano, MD, and Evelyn Johnson, RN

Make medicine’s Make medicine n s presence presence vvisible is tto o le legislators gislators iin n a unique unique way… wa serve ass tthe State Capitol serve a h S he tate Ca pito Doctor Day! Doctor of of the th e D ay!

And don’t don’t forget forg r et your your w hite coat! c And white

Brent Smith, MD, and Sen. Buck Clarke

MSMA M SMA p physicians hysicians who who vvolunteer olunteer tto o serve serve a ass D Doctor octor o off tthe he D Day… ay…

x see see p patients, atients, iincluding ncluding llegislators egislators a and nd ttheir heir st staff, aff, ffor or a vvariety ariety off ccommon ommon ai lments iin n tthe he Capitol Cap a itol M edical Clinic; Clinic; ailments Medical x se serve rve al alongside ongside M MSMA SMA S Special pecial P Projects rojects O Officer fficer E Evelyn velyn Johnson, Johnson, R RN, N, iin n a cclinic linic equ ipped w ith a s tate-of-the-art telemedicine telemedicine connection connection to the the U MC equipped with state-of-the-art UMC E mergency D epartment; Emergency Department; xa are re g granted ranted floor floor p privileges rivileges iin n both both chambers chambers o off the the S State tate L Legislature egislature and and a are re in troduced in the th he House House and and tthe he Senate Senate at at the the opening opening of of each each day’s day’s session; session; introduced x exp experience erience a c close-up lose-up v view iew o off leg legislative islative a action; ction; and xp promote romote tthe he p practice ractice o off me medicine dicine tto o our our elected elected o officials fficials w with ith a d distinctive istinctive a and nd personal ap proacch! personal approach!

2011 Legislative 2011 Legislatiive S Session: ession: Tuesday Tuesday JJan. an. 4 – S Saturday aturday Ap April ril 2, 2, 2011 2011 Doctors D octors o off tthe he D Day ay a are re ne needed eded M Monday onday through through Friday!

Friday!

Sign today!

Contact Sign up up toda y! C ontact Evelyn Evelyn Johnson Johnson EJohnson@MSMAonline.com Johnson@ @MSMAonline ne.com 601-853-6733, orr EJ aatt 60 1-853-6733, Ext. Ext. 3302 02 o 321

JOURNAL MSMA NOVEMBER 2010

NOVEMBER 2010 JOURNAL MSMA

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• CLINICAL PROBLEM-SOLVING •

Presented and edited by the Department of Family Medicine, University of Mississippi Medical Center, Diane K. Beebe, MD, Chair

Deceptive Irritations

A

Nathan Darby, MD

56-year-old white male was seen in an outpatient family medicine clinic with the chief complaint of abdominal bloating. He reported having no significant past medical history other than intermittent problems with a “nervous stomach” dating back many years. He was taking no medications and was last seen by a physician approximately 15 years ago. At that time he was seen for a “nervous stomach,” with symptoms of bloating, abdominal pain and intermittent constipation. The workup included an abdominal radiogram, an upper gastrointestinal series and a barium enema; all tests were negative. His symptoms gradually resolved, and he had no further problems for many years. In our clinic, he reported having episodic abdominal bloating and pain that had been gradually increasing in severity over the past 3 to 4 months.

During this time he had experienced a large amount of work stress and thought this might explain his symptoms. He was passing gas normally and having regular bowel movements almost daily, although at times he did have alternating constipation and diarrhea. His symptom severity seemed to vary with changes in diet. A bland diet made the symptoms better while spicy or fatty foods tended to worsen symptoms.

Also, his symptoms of pain, bloating and, at times, diarrhea seemed to coincide with the timing of his meals. Usually the bouts began while eating or up to an hour after the meal. He also thought the symptoms might vary depending with his stress level. During the 2 weeks prior to this visit his symptoms had become particularly severe, so he scheduled an appointment. However, in the 2 days prior to his appointment, his pain had completely resolved, and he generally felt much better. On the day of his appointment, he was having no pain at all, although he did complain of some persistent mild abdominal bloating that never seemed to resolve completely.

Physical examination revealed a thin, cheerful male in

AUTHOR INFORMATION: Dr. Darby is a primary care and sports medicine physician with the Hattiesburg Clinic in Hattiesburg.

CORRESPONDING AUTHOR: Nathan Darby, MD, 36 Bellegrass Blvd., Hattiesburg, MS 39402. Telephone: 601-613-6351 . E-mail: nathandarby67@hotmail.com.

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no distress. He had no pain and was actually quite jovial during the examination. His vital signs were normal, and a thorough physical examination was normal with the exception of a moderately distended abdomen. It was slightly tympanitic to percussion, and his bowel sounds were slightly decreased. No masses were palpated.

The differential is quite broad. Based on his history of abdominal cramping, bloating and diarrhea coinciding with the timing of meals, it would be reasonable to establish a tentative diagnosis of irritable bowel syndrome and treat him on an outpatient basis. Given his history and the physical examination, this diagnosis is highest on the differential. Other considerations include Crohn’s disease, gastroenteritis, impaction with episodic diarrhea, cancer, various infectious processes, paralytic ileus, mechanical obstruction and various relatively rare conditions such as sprue. Irritable bowel syndrome is a very common condition, and our patient’s symptoms fit this nicely. We could treat the patient empirically for irritable bowel syndrome with follow up a few weeks later. However, given the abdominal distention and tympany, we think it best to order an abdominal radiogram to investigate for a mass or obstruction.

Abdominal film findings were compatible with a bowel obstruction. There were several significantly pronounced air-fluid levels and multiple greatly distended loops of bowel.

No discrete masses or other abnormalities were seen. A normal amount of stool was noted in the colon and rectum, along with a small amount of air. No free air was seen in the abdomen.

Given the radiographic findings, a working diagnosis of small bowel obstruction is made, and we begin making arrangements for further studies. We are surprised by the markedly abnormal radiogram, given the rather benign clinical appearance of the patient. Based solely on the radiogram, one would have expected the patient to be in a significant amount of pain or discomfort.

The patient initially refused any further workup because he could not afford time away from work and absolutely did not want to be admitted to the hospital. After

much discussion, he agreed to go to the emergency department to have a computed tomography (CT) scan and further evaluation if indicated. A contrasted CT of the abdomen showed multiple air-fluid levels and was concerning for a mechanical obstruction at the ileocecal valve. No masses were visualized, and no infarcted bowel was seen. Further incidental findings were moderate cholelithiasis and diverticulosis. In light of the findings of the CT, the on-call resident ordered a comprehensive metabolic panel and complete blood count. These were all unremarkable. Despite the initial reluctance to be admitted to the hospital. He expressed in clinic, once the seriousness of his findings were explained he agreed to be admitted to the family medicine service. He was held to a clear liquid diet and a gastroenterologist was consulted due to the possibility of a mechanical obstruction being present.

The first imaging for patients with a suspected bowel obstruction should be a supine and upright radiogram. This remains the initial test of choice due to easy availability and low cost.1 However, a plain radiogram is only 50%-65% sensitive for small bowel obstruction.2 CT with oral and IV contrast is a very valuable imaging method for the diagnosis of small bowel obstruction. CT can provide more detailed information, not only confirming a small bowel obstruction but also determining the level, severity and often the cause of the obstruction.3 It is also very useful to visualize signs of bowel ischemia and has an overall sensitivity and specificity of 90% and 95% respectively for small bowel obstruction.4 Given the findings of our patientâ&#x20AC;&#x2122;s CT, we can now confirm our diagnosis of partial small bowel obstruction. We are now faced with finding the cause of his obstruction while managing his clinical care. Common causes of mechanical small bowel obstruction include surgical adhesions, hernias, volvulus, tumors and foreign bodies. Our patient has no history of abdominal surgery, so the chance of him having adhesive disease is relatively small. He also has no history of hernia or any current physical signs of a hernia, and no foreign bodies were identified with CT. The gastroenterologist agreed with an initial conservative treatment course of observation and serial abdominal examinations with a low threshold for surgical consultation if the obstruction persisted. The patient was still having regular bowel movements and passing gas although by hospitalization day 2 he was again having abdominal pain and increasing distention. These symptoms continued to the morning of day 3, and, given their persistence, a general surgeon was consulted. The surgeon ordered a small bowel follow-through which was consistent with the earlier CT in showing multiple loops of distended small bowel with a probable mechanical obstruction in the terminal portion of the ileum. Contrast medium was noted to pass through the partial obstruction and into the colon although transit was significantly delayed.

For a patient who has a small bowel obstruction, priority must be placed on detecting and correcting any volume loss or electrolyte abnormalities that may be present. In our patient this is not an issue, likely due to his lack of vomiting or diarrhea and his taking in a normal amount of fluids over the last several days.

Next we need to determine the need for surgical intervention. It is critical to rule out bowel strangulation and resultant ischemia in a patient with small bowel obstruction. Fever, persistent tachycardia and peritoneal signs on abdominal examination are indicative of strangulation. Strangulation is a surgical emergency with any delay increasing mortality. Mortality rates as high as 25% have been reported when surgery is delayed more than 36 hours.5 This high mortality led to the classic surgical adage, â&#x20AC;&#x153;Never let the sun rise or set on a small bowel obstruction.â&#x20AC;?

However, with the advent of modern imaging modalities, this is no longer always the case. CT sensitivity and specificity for intestinal ischemia are 93% and 96% respectively.6 This gives us the ability to safely and successfully manage many patients conservatively and non-operatively, especially patients such as ours with a partial obstruction.7 A significant majority of patients with partial small bowel obstruction will have resolution of the obstruction with conservative management.7 The best course of action with a partial obstruction is continued observation, serial abdominal examinations and supportive care. This is the course we decide to follow with our patient, along with a surgical consultation. We think it is important to have early consultation with a surgeon who can become familiar with the patient and follow him with us in the event urgent surgery is needed.

The patient was observed for 3 more days with minimal change in symptoms and findings on physical examination. Given this persistence of the partial obstruction, surgery was scheduled for the following day. On hospital day 7, the patient was taken for exploratory laparotomy. A large mass involving the ileocecal valve was found. The surgeon resected the mass along with substantial margins of bowel.

Several enlarged mesenteric lymph nodes were removed as well. Pathology reported tissue samples to be consistent with carcinoid.

The discovery of a malignancy leads us to reflect on how close we came to sending this patient home from clinic with empiric treatment for irritable bowel syndrome. The day he was seen was a very busy and hectic day in the clinic. It would have been quick and easy to treat him for irritable bowel syndrome based on his history instead of taking the additional time and expense of ordering radiographic studies. There have been multiple case reports of this scenario where patients with an abdominal carcinoid tumor were misdiagnosed with irritable bowel syndrome.8 Very often their symptoms were noted to have been present for years prior to the eventual final diagnosis. The slowly progressing, often minimally symptomatic nature of intestinal carcinoid can make rapid diagnosis difficult, and resultantly many patients have widespread disease by the time a diagnosis is made. The critical importance of early diagnosis is illustrated

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• SCIENTIFIC •

by a 5-year survival rate of 65% in patients with localized disease compared to only 36% in patients where metastases are present at the time of diagnosis.9 After surgery, the primary team took a more focused history to identify possible missed symptoms that would have been suggestive of carcinoid syndrome. The patient did have some intermittent diarrhea as had been previously revealed; however, he denied having any of the other typical symptoms of carcinoid syndromes such as flushing, wheezing, vomiting, peripheral edema or telangiectasias.

It is important to remember the relative rarity of carcinoid syndrome which only occurs in about 10% of patients with a carcinoid tumor.10 Too often a carcinoid tumor is not suspected until the symptoms of carcinoid syndrome are present. Unfortunately these symptoms usually do not manifest until after metastasis to the liver or lungs.11 This is because the vasoactive hormones secreted by an intestinal carcinoid tumor, most importantly serotonin, will first pass through the portal circulation where they are metabolized to an inactive form. However, once the tumor has metastasized to the liver or the periphery, it is able to release serotonin and other hormones directly into the systemic circulation, resulting in the symptomatic manifestations we know as carcinoid syndrome. However, the five-year survival rate drops significantly after there have been distant metastases. This highlights the importance of diagnosing these tumors before they have made themselves obvious by the symptoms of carcinoid syndrome Following surgery the patient had a slow but steady recovery. After several days he was tolerating a diet and was having normal bowel function. The oncology service scheduled a 6-week follow-up for an octreotide scan and urine 5HIAA determination but recommended no adjuvant treatment. The follow up octreotide scan showed 3 small suspicious areas near the right kidney, but the oncologist recommended only continued periodic observation of these areas. The patient returned to the family medicine clinic several times for follow-up. Approximately nine months after surgery, he was doing quite well, was free from any symptoms of carcinoid syndrome and reported feeling “better than I have in years.”

Management of patients with carcinoid tumors is complex with decisions dependent on tumor location, presence of metastases and symptoms. Symptomatic management of carcinoid syndrome is also important when it is present in patients with a carcinoid tumor. This is often done using somatostatin analogues. In addition, there are several chemotherapy regimens being used as well as hepatic artery embolization or partial hepatic resection in some patients.12 The results of these techniques are mixed. Whatever course of treatment is used, frequent follow-up and good communication and coordination of care between the physicians treating patients with carcinoid tumors is vital. Early detection is critical with surgical resection of early stage tumors the only curative option.8

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REFERENCES 1.

2.

3.

4.

5.

6.

7.

8.

9.

Lappas JC, Reyes BL, Maglinte DD. Abdominal radiography findings in small-bowel obstruction: relevance to triage for additional diagnostic imaging. Am J Roentgenol. 2001;176:167-174.

Khan AN, MacDonald S, Howat JM. Small bowel obstruction.

Available at: http://emedicine.medscape.com/article/374962overview. Accessed March 18,2009.

Megibow AJ, Balthazar EJ, Cho KC, Medwid SW, Birnbaum BA, Noz ME.Bowel obstruction: Evaluation with CT. Radiology.

1991;180:313-318.

Nobie BA Obstruction, small bowel. Available at: http://emedicine.medscape.com/article/774140-diagnosis. Accessed March 18, 2009.

Jancelewicz T, Vu LT, Shawo AE, Yeh B, Gasper WJ, Harris HW. Predicting strangulated small bowel obstruction: An old problem revisited. J Gastrointest Surg. 2009;13(1):93-99.

Zalcman M, Sy M, Donckier V, Closset J, Van Gansbeke D. Helical CT Signs in the diagnosis of intestinal ischemia in smallbowel obstruction. Am J Roentgenology. 2000;175:1601-1607.

Brolin RE, Krasna MJ, Mast BA. Use of tubes and radiographs in the management of small bowel obstruction. Annals of Surgery.

1987;206:126.

Wilson HM. Chronic subacute bowel obstruction caused by carcinoid tumour misdiagnosed as irritable bowel syndrome: a case report. Cases J. 2009;2(1):78.

Eriksson B, Klopel G, Krenning E, et al. Consensus guidelines for the management of patients with digestive neuroendocrine tumors – well-differentiated jejuno-ileal tumor/carcinoma. Neuroendocrinology. 2008;87:8–19.

10. Horton KM, Kamel I, Hofmann L, Fishman EK. Carcinoid tumors of the small bowel: a multitechnique imaging approach. Am J Roentgenology. 2004;182:559-67.

11. De Vries H, Verschueren RC, Willemse PH, Kema IP, De Vries EG. Diagnostic, surgical and medical aspect of the midgut carcinoids. Cancer Treat Rev. 2002;28:11-25.

12. Kalia V, Saggar K, Sandhu P, Ahluwalia A. Carcinoid tumor of the ileum. Ind J Radiol Imag. 2006;16:4:503-504.

Save the date...

MSMA 143rd Annual Session May 19-22, 2011 Tupelo BancorpSouth Conference Center

Details forthcoming...

Peace of mind begins here.

You and your patients can take comfort in the knowledge that University Heart specialists are on your side.

University Heart is one of the regionâ&#x20AC;&#x2122;s finest cardiovascular centers. Our heart specialists offer the most comprehensive cardiac care in Mississippi. As part of an Academic Medical Center, University Heart specialists have access to the most current research and the latest technology. Our commitment to communication and collaboration with referring physicians ensures that you maintain contact with our mutual patients.

Contact a University Heart physician through our dedicated doctor line, 866.UMC.DOCS, or learn more at umhc.com/heart.

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

August 2010

* Totals include reports from Department of Corrections and those not reported from a specific district NA - Not available (temporarily) **Address unknown for 10 cases.

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For the most current MMR figures, visit the Mississippi State Department of Health web site: www.HealthyMS.com JOURNAL MSMA NOVEMBER 2010

TRAGIC BUT IRONIC...

Our media focuses so much on homicides (317) in 2008 while 25% more people die from suicides (398).

SUICIDES ARE PREVENTABLE. -YVU[ YV^ SLM[ [V YPNO[! +Y )LUQHTPU 2LYY +Y (S 1VOUZVU" )HJR YV^ SLM[ [V YPNO[! +Y ,YPJ )HSMV\Y +Y 6YOHU 0SSLYJPS

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C

• PRESIDENT’S PAGE •

A Prayer for Baby Cobb

omfort the sweet young mother whose water has broken just as You planned, whose anticipation of Your creation shadows all fear and pain. Be near her and attend to her dear child emerging into Your amazing world.

Be with the daddy whose cup runneth over but for the moment must play the smaller role less incur the wrath of his beloved at the peak of a contraction. Grant him patience and endurance for long nights of rocking and lullabies, That his hands would be swift and adept at diapering and drying tears.

Thank you, Lord, for the ward clerk Who stands at the gate And forgives the errant behavior of loving families So eager over the prospect of new life that they Fear not the hospital commandment of “two visitors to a room.”

Protect the anesthesiologist who frees Those laboring from earthly pain And whose gentle touch finds the epidural space With accuracy and skill as he lends a divine calm, Restoring desperate souls.

Shine upon the obstetrician, The good shepherd amongst physicians Who often stands alone keeping watch Not resting until all unto his keeping are safe, Seeking the lost at times down darkened paths with Transcendent vision and answering with patience And swiftness the cry from those who labor, “Get this baby out!”

Bless the labor angel (nurse) for long hours of toil Absolving mother’s pain amidst her own sore feet and tired back While heeding the shepherd’s call remaining steadfastly calm Knowing the depths of the valley even amidst the triumph at hand.

She shall forever be remembered By those who labor with love and gratitude.

Peace be to the pediatrician who suffers the children unto You And ceaselessly tends to the sick amongst them, Hearing the cry we cannot hear, the tender reflexes we cannot discern Conceding to mothers the wisdom that is inherently theirs.

BABY COBB— Dr. Alford's first grandchild,

son of Mr. and Mrs. (Leah Alford) Tal Hendrix (M4)

Bless and protect baby Cobb, a healthy infant boy, Who brings inexorable joy to family and friends now Making diaper rash the most serious malady on earth And the anointment of anti-monkey butt cream An hourly ritual.

Above all, defend all of baby Cobb’s friends And peers – those who are smaller and weaker Not so fortunate, who inherit a world in disarray.

Save them from ignorance and greed.

Lead them to the life-giving stream Of gifted teachers and at least one loving parent, For surely theirs is the kingdom of heaven.

Thank you, Lord, for Daddy Bump who left this world on the day that baby Cobb arrived, Having watched Cobb’s mother somersault into his swimming pool as a child.

You know, Lord, having endured the loss of your own Son, The grace and humility of the circle of life.

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NOVEMBER 2010 JOURNAL MSMA

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• EDITORIAL •

T

Humanism HE

GOLD (MD) HUMANISM SOCIETY AT UMMC

Several years ago, the University of Mississippi Medical Center joined many other academic health centers in establishing a chapter of the Gold Humanism Society in the School of Medicine. Classmates elect fellow students to be members of this society, sponsored by the Arnold P. Gold, MD Foundation, on the basis of five attitudes and behaviors that “foster relationships with patients and other caregivers who are compassionate and empathetic.” These are integrity, excellence in clinical practice, compassion, altruism, and respect. The premise of the Gold Foundation is that recognition is a “strategy that can elevate humanism in the academic environment” and counter influences in the medical education process that “discourage the spirit of caring.”

This student-run society has been enthusiastically adopted by the medical students at UMMC and now involves six different activities including a “White Coat Ceremony,” selection of residents for a Humanism and Excellence in Teaching Award, and a “key-note address” for an annual ceremony. This year the society evidently had difficulty finding a key-note speaker and asked me to speak. I wanted to share the brief talk I gave, not because it was that good but because it underlines our worsening health status, the important roles practicing physicians play in the state and how I see them as role models for our students. Moreover, I wanted to make sure our students understand the significance of their calling to medicine, to the patients we serve, and to the needs and opportunities we have here in Mississippi.

I realize there are many of you who could have given a better talk than I and would have been asked to do so by them if you had more contact with our medical students. We are working on getting them out of the academic health center and into the communities as much as possible. Regardless, please consider this talk as an editorial acknowledgement of how much I, as an academic physician, have come to respect the physicians of our state and their commitment to stay here and make a difference when working elsewhere might have been a better financial choice.

WHAT I SAID

This was a difficult talk for me to put together as I have so many things I would like to share with you. For the last several years, I have been increasingly alarmed about our health situation in Mississippi. I hope when I am through sharing what may seem like a string of random thoughts, you will see the points I am trying to make.

First of all, I wish I had time to share some details about my own life experience in medicine with you. About how many times I have fallen short of the goals of the Gold Society. About how many opportunities to make a difference I have missed and how I have tried to learn from those experiences. For instance, I have learned to jump in quickly to serve when a worthwhile opportunity presents itself, not think about it until the opportunity is gone. Unfortunately the desire to serve frequently causes confusion about career choices. In my case, I ended up with a double major in chemistry and religion as a senior in college.

There’s real confusion! Fortunately, my college counselor who had worked with other similarly confused students gave me good advice that I have followed over the years. He explained that the best way to make career choices was to identify needs I felt passionate enough about to spend my life trying to address.

Last month we listened to a group of African American pastors in Humphreys County, Mississippi, tell us how difficult it is for folks to get basic health care in the Delta, a theme we have heard in many areas of the state. Last week, my colleague Dr. Debbie Minor and I took a trip to Social Science Research Center in Starkville to review the latest Mississippi demographics.

This year’s data show that 30% of children in Mississippi live in abject poverty. Seventeen percent live in dire poverty because they don’t have enough to eat. We continue to have the highest rates of infant mortality, obesity and diabetes, and the lowest ratio of physicians to patients in the U.S., rates comparable to those in developing countries.

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Tonight, I wish I could have brought Dolphus Weary from Mendenhall to tell the story he wrote in his book, I Ain’t Coming Back. Why, after growing up in poverty in Simpson County, farming with a mule and plow, and using basketball as a vehicle to leave Mississippi and get a college education in California, he came back to Mississippi to invest his life here, working on spiritual and physical health and racial reconciliation. He would tell about the experience of setting up the Voice of Calvary Medical Clinic for the poor in Mendenhall amid almost incalculable odds to fail. It worked. He is glad that he made what seemed like an irrational choice to his The needs here are friends.

opportunities to make a big difference with even a small effort. Opportunities abound to make Mississippi’s needs your own and spend your life as a servant leader meeting those needs. What a joyful life you can have and how much good you can do right here at home.

I wish I could have brought Drs. Aaron Shirley, Bob Smith, and James Anderson from Jackson. Itwould have been great to expand on the stories told about them in the new book, The Good Doctors. All three of them left Mississippi to get their MD degrees since they were not eligible for admission to medical school at UMC. When they returned to Mississippi to practice, they had great difficulty getting hospital privileges because they were black. They took that injustice and turned it to good by helping start the first rural federal community health center in the U.S. at Mound Bayou and subsequently, the Jackson-Hinds Community Health Center. The movement which they helped start has developed into over 20 of these community health centers in Mississippi alone. These centers provide a health safety-net for the poor of all races.

I wish we had more time to share stories about other role models for medical humanists. Physicians like Albert Schweitzer who left a career as a concert organist in Europe to spend his life as a physician in the African jungle. In his book, About My Life and Thought, he explained that humanism is only the beginning step to a higher call that goes to the needs of all people and all living things. Then there was Dietrich Bonhoffer who concluded that altruism is not about “giving back.” In his book, The Cost of Discipleship, he makes it clear that the prerequisite for “giving back” is getting your needs met first. To the contrary, he claimed that a life of service is the example of the widow’s mite. That is, giving even when you have limits on what you have to give. I know many of you are doing that. Thank you.

Bonhoffer also showed how costly a life of service can be. It costs a very precious commodity, your time, and puts you at risk of being misunderstood, mistreated, or worse. In his case, it meant death on Hitler’s orders one week before the surrender of Germany. That point came home to me in the life of my medical school classmate, Martha Myers, who on a junior elective identified her future life’s work at a point of need, caring for mothers and children at a remote hospital in Yemen. You may have heard her story. On December 31, 2001, after 24 years of service there, she was shot to death in her clinic by a terrorist. She would not have lived her life in any other way.

Lately, I have been getting to know physicians all over the state of Mississippi I have not previously had the opportunity to meet. They made the same choices you have to make now, to identify a need here in Mississippi, where there are many, or go to a place of lesser need. That’s just about anywhere else. The stories I have heard from physicians like Dr. Joe Moak in Brookhaven and Drs. Mack and Carlton Gorton in Belzoni show that they have found great joy in a life of service here in Mississippi. Many other Mississippi physicians have also found that example has helped their children develop into humanists and respond to similar needs. The needs here are opportunities to make a big difference with even a small effort. Opportunities abound to make Mississippi’s needs your own and spend your life as a servant leader meeting those needs. What a joyful life you can have and how much good you can do right here at home.

I know many physicians who would like to talk with you about that. I am one of them.

WHAT THEY SAID BACK

From conversations afterwards, it was clear that our medical students really do get it. They see medicine as a priesthood and a noble calling. Hopefully, pointing out that they don’t have to go to Africa or Yemen to live a life service will encourage them to help us address the needs we see every day.

—Richard D. deShazo, MD Associate Editor

NOVEMBER 2010 JOURNAL MSMA

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I

• LETTERS •

Why Fight When You Can Go Cash?

’d like to thank MSMA President-elect Dr. Thomas Joiner for his feelings, “Let’s Not Go Down Without a Fight,” an editorial in the September issue (J Miss Med Assoc. 2010;51(9):257). There is something we can do: quit playing the game. I opted out of Medicare, Medicaid, and all private insurance. I went to cash. Patients can pay me $450/year or $38/month. For that they get annual lab, unlimited visits, immediate email or beeper contact, EKG/stress tests, bone density testing then labs at cost (over the annual panel) and injections for $10 or cost (flu is $20). My overhead dropped from 85% to 30%.

I went from six employees to one and a half-time employee. I lost NO Medicare patients (and gained many). I have approximately 1,500 patients (do the math), see 20-30 patients per day, with an average waiting time of less than eight minutes. I do everything: draw blood, blood pressure, EKG or stress tests, etc, and patients love it. Many state I'm the first doctor to touch them! I am no longer hostile, paranoid, suspicious, and frustrated. My charting is for my eyes and memory, not some third-party computer or coder. I can put down my pen and talk to patients eye-to-eye. I am rarely rushed. I enjoy medicine again— more than ever in my 31 year career.

If anyone thinks they will fight this system or change the system and win— they are in the wrong battle. Patients still want caring physicians with loads of skill and knowledge. They will pay for it, especially when faced with the option of touchless physicians or non-physician “healthcare providers.” —Stanford A. Owen, MD Gulfport

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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JOURNAL MSMA NOVEMBER 2010

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• SPECIAL ARTICLE •

Mississippi Welcomes First Osteopathic Medical School

W

Karen A. Evers, Managing Editor

hen one thinks of the pristine William Carey University campus and the school’s traditional Baptist curriculum, the last thing one might think of is bodies stored in immersion tanks. The bodies will be used to teach human anatomy, their arrival representing another step in the opening of the school’s College of Osteopathic Medicine.

Designed to attract in-state students as well as those from the surrounding states of Alabama, Louisiana and Arkansas, William Carey University College of Osteopathic Medicine (WCU-COM) is the state’s second medical school and the first in the region to focus on osteopathic medicine.

The building, which will be open to students 24-hours-a day by key card, is a model in symmetry. A walk through the campus-facing entrance reveals two identical lecture halls on the right, each with 126 seats.

In the center is a lobby adjoining a small study area. On the left, on opposite ends of a corridor, stand two large laboratories. One will enable the study of the cadavers. ...CONTINUED PAGE 335...

O

n October 23, 2007, the Board of Trustees at William Carey University (WCU) unanimously voted to authorize Dr. Tommy King, president, to employ a dean for the College of Osteopathic Medicine (COM). The rationale was to open the COM to address the severe shortage of physicians in Mississippi and surrounding states and to impact the healthcare of rural Mississippians.

D

MICHAEL K. MURPHY, DO, FACOFP, DIST., FAODME VICE PRESIDENT AND DEAN WILLIAM CAREY UNIVERSITY COLLEGE OF OSTEOPATHIC MEDICINE

ean Murphy is a 1973 graduate of the Kirksville College of Osteopathic Medicine. He received his B.S. from King’s College in Wilkes-Barre in 1969. Dr. Murphy was commissioned an Ensign in the United States Navy in 1970 and did his internship and residency in Family Practice at Navy Hospital Camp Pendleton, California.

During his over 29 years of service in the Navy he was stationed all over the United States and the world and served as the Commanding Officer of a Navy Hospital. Retiring as a Captain in the United States Navy Medical Corps in 1998, he took the position of Dean of the College of Osteopathic Medicine at Des Moines University.

In 2000 he was recruited to the Pikeville College School of Osteopathic Medicine as Professor in Family Medicine, Associate Dean for Post graduate Studies and Executive Director for the Appalachian Osteopathic Postgraduate Training Institute Consortium.

On July 1, 2003, he was appointed as Associate Dean for Postgraduate Training and Associate Dean for Clinical Sciences in 2006 at PCSOM. Dr. Murphy was appointed the Vice President and founding Dean for at the William Carey University College of Osteopathic Medicine in January of 2008. The American College of Osteopathic Family Physicians granted Dr. Murphy his Fellowship in 2000 and his distinguished Fellowship in 2007. The Association of Osteopathic Directors and Medical Educators (AODME) awarded Dr Murphy his Fellowship in May of 2007.

Currently, Dr. Murphy serves the osteopathic profession as Trustee of the American Osteopathic Association. He also serves as a Trustee of the National Board of Osteopathic Medical Examiners (NBOME) and the AODME.

NOVEMBER 2010 JOURNAL MSMA

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The other lab has beds that will allow students to practice “manipulation of musculoskeletal parts of the body,” according to William Carey President Tommy King.

When asked how the core competencies of the osteopathic medicine profession differ from those of an allopathic medical school curriculum, Dean Murphy explained, “The core competencies are similar with the addition of Osteopathic Principles and Practice. This area integrates the philosophy of osteopathic medicine across all other competencies – the body is a whole and that if maintained in the proper balance, it is capable of healing itself. It is the job of the physician to find and maintain health. The osteopathic physician may use classic treatments, manipulation or a combination of the two.”

The main thing Dean Murphy wants MSMA members to know about the program is that WCU-COM is here to augment the state’s physician population.

“We are looking for community based preceptors. We are a mission-driven organization focused on training and retraining physicians in the South. I would love the opportunity to address the MSMA,” he said. ❒

335

• SPECIAL ARTICLE •

William Carey University

College of Osteopathic Medicine Established:

(WCU-COM)

Building dedicated:

Inaugural class size:

Initial graduation date:

The school is actually a three-phase project totaling 46,000 square feet. The building contains approximately 30 faculty offices, more classroom space and a clinic.

FRONT OF ACADEMIC BUILDING, DEDICATED JUNE 2010

It contains: • Two class rooms seating 126 • An Anatomy lab for complete cadaveric dissection • An Osteopathic Principles and Practice lab • An anatomical model room • 8 individual study cubicles • A 1,500 sq. ft lounge

The medical Arts building was dedicated on August 26 and it contains: • A clinical training space – 8 examination rooms and a clinic with cameras for recording standardized patient encounters • 2 simulator labs • An AV room to broadcast lectures to students via the internet • 7 Breakout rooms • 16 faculty offices • 2 student government and club offices with

JOURNAL MSMA NOVEMBER 2010

March 3, 2008 July 30, 2010

108 students May 2014

Applications: Prioritized more than 1,000 , inviting the most qualified of the candidates for interviews. Of the 100 students offered admission, 46 come from Mississippi.

Economics: School is estimated to employ 50 new employees with a $5 million payroll.

DR. JIM WEIR

ASSOCIATE DEAN OF STUDENT SERVICES

storage space for community involvement • A student galley for food preparation • 8 individual study cubicles • A 1,500 sq. ft lounge

The Asbury Administration Center will be ready in December 2010 and will contain: • The Dean’s offices • Admissions and Student Affairs • Dean’s conference room • Faculty lounge • 19 faculty offices • Student lockers • A 1,000 sq. ft lounge The AV equipment is all digital and at present WCU-COM is the only educational facility with such technology. This permits communication and sharing of video between all labs and lecture halls. The Breakout rooms have 42” monitors for projection.

D

EDUCATION AND CLINICAL TRAINING

CLINICAL HUB SITES Pine Belt • Wesley Medical Center, Hattiesburg • Hattiesburg Clinic, Hattiesburg • Forrest General, Hattiesburg • South Central Regional Medical Center, Laurel Gulf Coast • Biloxi Regional Medical Center, Biloxi • Hancock Medical Center, Bay St. Louis • Gulfport Memorial, Gulfport • Keesler Medical Center (USAF) • Singing River Health System Delta • North Sunflower Medical Center, Ruleville • Delta Regional Medical Center, Greenville • Bolivar Medical Center, Cleveland • Chicot Memorial Hospital, Lake Village Arkansas • South Sunflower Medical Center, Indianola • Sharkey-Issaquena, Rolling Fork Northeast • Magnolia Regional Health Center, Corinth • North Mississippi Medical Center, Tupelo Meridian • Rush Health Systems/Rush Foundation Hospital • Riley Hospital, Meridian • Jeff Anderson Regional Medical Center, Meridian Central • Baptist Memorial Hospital North MS, Oxford Jackson Area • HCA Hospital System of Mississippi

ean Murphy says, “The osteopathic medical education is four years, just the same as the MD education. The curriculum is very similar but with a greater emphasis on primary care and viewing the body as a whole inter-related system.”

The clinical training sites used will be communitybased. WCU-COM will use a “Hub site” system. A hub site is a location with a healthcare facility or facilities that are capable of supporting all required rotations. This can be a single facility or system that can provide all needed outpatient and inpatient clinical experiences. If more than one facility is utilized, travel time should be no greater than 60 minutes.

Students begin practical clinical exposure their first year with an osteopathic principles and practice curriculum and an introduction to physical diagnosis. The second year students will have a more integrated clinical experience in the Pine Belt where they will work with primary care preceptors. In the third and fourth years they will go to their hub site and participate in their core rotations in the community hospitals within their site. These core rotations are: • Family Medicine – 2 months • General Internal Medicine – 2 months • General Surgery- 2 months • Pediatrics – 2 months • Emergency Medicine – 2 months • OB/GYN – women’s health – 1 month • Community and Behavioral Medicine1 month • Osteopathic Principles and Practices – 1 month • There will also be three months of surgery and medicine selectives • Four months of elective rotations Students must pass national boards – COMLEX (Comprehensive Osteopathic Medical Licensure Examination) and complete all required and elective course work to be eligible for graduation. In their fourth year, they will compete for residency/postgraduate training in DO and MD hospitals using the DO match, the NRMP or both.

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NOVEMBER 2010 JOURNAL MSMA

336

Growth in Osteopathic Physicians — DOs are one of the fastest growing segments of health care professionals in the United States. At the current rate of growth, it is estimated that more than 100,000 osteopathic physicians will be in active medical practice by the year 2020. The graph above shows the exponential growth in the number of DOs since 1935. These numbers do not include 2010 osteopathic medical school graduates.

SOURCE: Centers for Disease Control and Prevention/National Center for Health Statistics, National Ambulatory Medical Care Surveys, 2001-2007.

Office Visits — During the early 1900s, the AOA fought for recognition of the osteopathic medical profession by federal health programs. For example, in 1938 the AOA worked to amend the 1935 U.S. Employees’ Compensation Commission, which defined a physician as an MD, to include DOs. The table above indicates the number of office visits osteopathic physicians reported between 1991 and 2007.

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JOURNAL MSMA NOVEMBER 2010

• SPECIAL ARTICLE •

THE STETHOSCOPE

• The stethoscope represents the scientific methodology and the use of current clinical diagnostic technology.

THE HAND

• The hand represents the human touch. Osteopathic physicians use their hands for diagnosis and treatment of their patients.

THE LAMP

• The lamp is representative of academics and the knowledge it will take to become a successful doctor of osteopathic medicine.

THE NUMBERS 1906 AND 2010

• 1906 was the year the predecessors of William Carey University was founded (South Mississippi College, 1911 Mississippi Women’s College, 1954 William Carey College, and 2006 William Carey University).

LOGO OF WILLIAM CAREY UNIVERSITY SCHOOL OF OSTEOPATHIC MEDICINE THE CRUSADER SHIELD

• The crusader shield is a representation of William Carey University’s motto “Expect Great Things From God; Attempt Great Things For God.”

THE HEART

• The heart represents the compassion that is needed to be a successful doctor of osteopathic medicine.

• 2010 was the year the first class of William Carey University College of Osteopathic Medicine matriculated.

THE COLORS RED, BLACK, AND WHITE

• Red, black, and white are William Carey University’s colors; as a part of the university, the College of Osteopathic Medicine has adopted its colors.

THE CIRCLE

• The circle represents the care of the whole person – body, mind, and spirit.

• The circle also represents the comprehensive nature of the osteopathic medical education. William Carey University College of Osteopathic Medicine graduates will be known for their competence, confidence, and compassion. ❒

Osteopathic Physician Payment —The following data aggregated between 2001 and 2005 show differences between DOs and MDs in the percentage of office visits paid by payment source. Source: National Ambulatory Medical Care Surveys, 2001-2005. Data aggregated across surveys to meet Federal government requirements regarding anonymity.

NOVEMBER 2010 JOURNAL MSMA

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• SPECIAL ARTICLE •

Sources: The table includes only DOs in active practice and out of postdoctoral training. All DOs who graduated after Jan. 1, 2006, are assumed to be in an internship or residency. The AOA Masterfile and data licensed from the Association of American Medical Colleges were used to identify DOs in residency programs. “Pediatrics and adolescent medicine” include all specialties where the patient is a child or an adolescent and includes both general pediatricians and pediatric specialities. The categories “Family and general practice” and “General internal medicine” do not include family physicians, general practitioners and general internists who also practice secondary specialties. Those osteopathic physicians are counted under “Other Specialty.” The category “OMT/OMM” includes family physicians who stress OMT in their practices in addition to osteopathic physicians who specialize in OMM. Board certifications were used when self-identified practice specialty was not available but this does not equate to the entire population of DOs.

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JOURNAL MSMA NOVEMBER 2010

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NOVEMBER 2010 JOURNAL MSMA

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• THE UNCOMMON THREAD •

The Loss of Magic

A

fter 31 years of being able to create magic in the world, it all came to a crashing end tonight.

Undone by a clumsy moment. It will be a hard thing to do, to face the world for the rest of my life without it.

Sure, I can watch as others assume the role I once filled, but it won’t be the same, at least not for me.

It started last night when the flick of a wrist and the almost imperceptible sound of two tiny objects landing on the carpet R. Scott Anderson, MD brought me to my knees.

“Whatchu doing?” my 11-year-old daughter, Maddie, asked sleepily as my hand closed on the first of the two objects I was after. The sounds of my crawling around on the floor next to her bed had roused her from what was obviously not as deep a sleep as I’d expected.

“I dropped something,” I answered. I didn’t offer anything further. I never was much of a liar. Best to stay with as much truth as possible.

“Will you scratch my back?” she asked.

“Sure, baby,” I answered, as I lay down on the bed beside her and began to rub her back, hoping that she would fall right back asleep.

“What’s that in your hand?” she asked.

“Just some dirt or something that was on the carpet. I didn’t look at it,” I answered and moved my hand into the dark away from her line of sight.

“That’s one of my teeth. It’s the little one, the one I’ve been saving up ’til I got that big one out, the one I pulled tonight so I could put them both into the pillow for the tooth-fairy.” Mat was never one to rush pulling her teeth. They would stay in and wiggle around for days and weeks before she felt like they were loose enough to go ahead and snag them out of there, just the opposite of her sister Allison. Allison, now, she’d pull out teeth that weren’t even loose yet just so she could get her tooth-fairy money.

My mind raced, well, it tried to race, but it wasn’t getting too far. Damn, I needed Charlene for this; she can lie to a kid without blinking an eye.

“Well…ummmm…well…I had just fallen asleep when I was saying prayers with you, and I was just sleeping, and…uuhhh…like this here…” I closed my eyes and pretended to be asleep for a minute, to stall…nothing was coming into my brain…so I just laid there pretending to be asleep.

“But you got up after we said prayers. Remember, you had to turn out my closet light?”

“I turned off the closet light? That was last night,” I tried to be emphatic.

“No, it was just a few minutes ago. I wasn’t asleep yet.”

“Well…see…before I got up to do that, I saw something that looked like a bug or something…”

“There’s a bug in my bed?”

I had to deal with this one quickly or she’d be in the bed with her mother in a heartbeat, and I’d get to spend the rest of the night with her knees and elbows jabbing into my kidneys every time I fell asleep. “No, no, I thought it was a bug, but then something hit me in the eye.”

“What hit you in the eye?”

“Well, I thought it was the bug, but after I left, I was worried about a bug being in your room so I came back.”

“You left me in the room with a bug in it?” the pitch of her voice was rising. “Why would you leave your daughter in a room if you thought a bug was in it.”

“That’s what I thought too, so I came right back.”

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JOURNAL MSMA NOVEMBER 2010

â&#x20AC;&#x153;But what does that have anything to do with why you have my tooth?â&#x20AC;? She grabbed the tooth-fairy pillow off her bedside table. â&#x20AC;&#x153;Hey look, I got twenty dollars. Thatâ&#x20AC;&#x2122;s not bad. I got ten dollars for each tooth.â&#x20AC;? She thought for a minute. I was hoping that the twenty dollars would take her mind off the tooth. â&#x20AC;&#x153;Wait a minute. Thatâ&#x20AC;&#x2122;s not right. She only got one tooth. You got the other one. How come she paid me for two teeth, but only took one of them?â&#x20AC;? â&#x20AC;&#x153;Becauseâ&#x20AC;Śseeâ&#x20AC;Śwhat hit me in the eye was your other tooth. She must have dropped it when I wiggled my hand because I thought she was a bug,â&#x20AC;? I answered with what I thought was a great save.

She bought it. â&#x20AC;&#x153;Wow, now I can put it back in the pillow tomorrow night and sheâ&#x20AC;&#x2122;ll have to give me another ten dollarsâ&#x20AC;ŚIâ&#x20AC;&#x2122;ll have thirty dollars then.â&#x20AC;? â&#x20AC;&#x153;I donâ&#x20AC;&#x2122;t think it works like that. I think she already paid for that one. It isnâ&#x20AC;&#x2122;t fair to try and cheat her. Sheâ&#x20AC;&#x2122;ll probably come back later for it. We should just leave it right here for her.â&#x20AC;? â&#x20AC;&#x153;Okay,â&#x20AC;? she said, reluctantly, and laid the little tooth next to the pillow.

I scratched her back for a good while after I could hear her softly breathing, her breaths deep and regular in a way that I knew she was asleep. Only then did I retrieve the little tooth. Then I pushed the button on my phone, used the light from it to find the other tooth, and hurried out of there before I got caught again.

When I finally got back to our bedroom, Charlene was asleep too, maybe not breathing as softly as our baby, but she was not going to want to be gotten up to deal with some teeth.

So I put the two teeth in the little bowl Char puts her jewelry in at night, so sheâ&#x20AC;&#x2122;d see them in the morning to put them in her treasure box thatâ&#x20AC;&#x2122;s filled with the teeth, notes to Santa, the Easter bunny, and the tooth-fairy sheâ&#x20AC;&#x2122;d collected from the seven children weâ&#x20AC;&#x2122;ve raised together. Then I went to sleep and forgot about the teeth.

Until today. As I was sitting in the sunroom reading a novel, Maddie walked in slowly and sat down beside me. â&#x20AC;&#x153;Whatâ&#x20AC;&#x2122;s up, Mat-Pat?â&#x20AC;? I asked.

She held out her hand with the two teeth. â&#x20AC;&#x153;The tooth fairy is a fake, isnâ&#x20AC;&#x2122;t she?â&#x20AC;? â&#x20AC;&#x153;No baby, sheâ&#x20AC;&#x2122;s not a fakeâ&#x20AC;Śâ&#x20AC;? I started. â&#x20AC;&#x153;Pinky swear!â&#x20AC;? she challenged. â&#x20AC;&#x153;Noâ&#x20AC;Śâ&#x20AC;? â&#x20AC;&#x153;She is a fake,â&#x20AC;? she wailed. Within two minutes, weâ&#x20AC;&#x2122;d dispensed with the Easter Bunny and Santa, too.

And that was the end. After 31 years and seven children, the magic was gone, and for some reason that kind of breaks my heart. â&#x20AC;&#x201D;R. Scott Anderson, MD Meridian R. Scott Anderson, MD, a radiation oncologist, is medical director of the Anderson Regional Cancer Center in Meridian and past vice chair of the MSMA Board of Trustees. Additionally, he is an accomplished oil-painter and dabbles in the motion-picture industry as a screenwriter, helping form P-32, an entertainment funding entity.

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342

• UNA VOCE •

Meditations from Room 324

“S

hug, I’m not going to make it, am I?”

These words incised the rapidly growing lump in my throat on that bright blue October Monday morning. I was clumsily dressing my acutely breathless, cancer-stricken husband for what proved to be his final palliative radiation treatment.

Subduing rising tears I replied, “Yes, Baby, we are going to make it, the way we always have, one day at a time.”

It was one of those occasions when the frantic soul mate part of the mind has trumps over the cool and practiced physician brain. I cerebrally knew when we left the driveway that my husband would become an inpatient admission before the day was out. I knew that I should have packed a few things necessary for the self-comfort of a spouse camping a little while in the Dwalia S. South Bitter, MD wilderness that is a modern hospital stay. In my emotional urgency, I was reduced to the status of the frenzied caregiver armed with not so much as a toothbrush or a single change of underwear.

Sixty-two miles later, we arrived at the cancer center as appointed but minus our leisurely good cheer and the now customary box of donuts for the staff. The ladies in Radiation Oncology knew that sign and the look of fear and dreading in our eyes.

After a morning in the cancer clinic and an afternoon in the imaging center, some hurried consultations revealed that my husband was suffocating from a malignant pleural effusion that had developed over the weekend. We were then instructed to go to the main hospital for inpatient admission. To accomplish this we first had to visit the Emergency Department where, of course, we would be re-evaluated by another doctor whom we had never heard of and admitted to the medical service of the on-call hospitalist physician whom we had never met. All of these machinations were in order to evaluate and stabilize my husband medically prior to the chest surgeon’s consultation and treatment. This motley methodology seems to be the normal state of affairs in today’s hospital environment. What is there to do but comply with the dysfunctional process and continue to ride the grand conveyer belt?

The Emergency Department waiting room was another obstacle course entirely. This was the height of the H1N1 viromania and everyone checking in the ER was issued a mask to wear. An air-hungry and exhausted Robert was slumped in his wheelchair while I busied myself once again filling out the ridiculously redundant paperwork for the smiling desk clerk whose apparent primary job was to furnish us with the third set of HIPAA forms for the day. At this point, I was not appreciative of her change-of-shift perkiness. More white plastic armbands and copying of Medicare and insurance cards followed.

I won’t belabor the details of the seemingly endless languishing stint in the ER prior to admission or the myriad medical and surgical procedures which ensued throughout the next seven days. To do this would risk missing the point of this meditation.

I will now simply say that 14 hours after leaving home with my agonized husband we were at last to become official residents of room 324.

From the vantage point of room 324, there were marvels awaiting the prepared and unprepared mind. I arrived there equipped with only my black ditty bag that goes with me to work at the clinic every day. Normally when going on a trip, I always pack books for I feel quite naked without them. More important to me than a clean shirt or a candy bar is something delicious to read. On this day, of course, I had packed nothing, but in the bottom of my bag I rediscovered two small books. A tiny white Gideon New Testament and a slim volume called 101 Elegant Paragraphs. Both proved inspirational pastimes during those trying days. Scratched on the pages of the books were thoughts and observations on this hospital stay and the final week of my life with my husband. I now share some of those random thoughts with you.

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MEDITATION ONE: “The hospital gown is the great equalizer of humanity.”

The high-performing modern medical facility is now defined by its overtly and obsessively displayed ‘attempts’ at maintaining patient privacy. One is then struck by how many open patient room doors there are on the surgery ward. The patients and their families do this primarily to stave off claustrophobia or perhaps to ventilate the various odors of excrement and gangrenous discharges from diabetic feet awaiting removal. After all, the damn windows won’t open.

Traversing the hallway provides the ambulatory visitor with successive views of pairs of white stocking legs punctuated by ‘non-skid’ booties poking out of the invariably blue and white patterned cotton frock… de rigueur hospital fashion. One can view a virtual succession of apparitions in all states of healing or decay. If you amble slowly close to the side of the hall, you may read the names of those contained within the room. The homeless man in 316 slumbers adjacent to the wealthy local banker in 318. They are identically dressed in the same simple garb issued to us all. We get the same meals, the same cable channels, and the same visitor cots. We are all dying of the same diseases. No patient is or should be any more ‘special’ than any one else here.

The lowly hospital gown is a reminder to everyone of our basic human sameness and need for equal care and respect as patients.

MEDITATION TWO: “HIPAA regulations are the Golden Rule as interpreted by the Federal Government.”

The way I have it figured, the core intent of HIPAA is to “do unto others as you would have them do unto you.” This voluminous and dysfunctional monstrosity that has become the bane of existence for all healthcare facilities and their employees is an illustration of what happens when the Federal Government tries to insinuate itself into basic human civility. It is a wrongheaded assault on common sense medicine. It is also a bitter aperitif for the future of American healthcare.

MEDITATION THREE: “A hospital is a dangerous place to be.”

Despite all the precautions taken, there is much room for confusion, accidents, and error in even the best hospital system.

There are simply too many variables… too many wires, buttons, bells and whistles. The patient is something of a prisoner and totally out of control of his situation. There is a tube or hose in every arm and orifice and there are even some newly acquired orifices. I would dearly love to be the inventor of a new method to incorporate or consolidate this myriad of tubes dangling precipitously in every direction and which cause the patient to appear decorated like a psychotic Christmas tree. I shudder to think what would happen if no one was in the room to orchestrate these appendages for Rob or any other patient. Every patient needs an advocate with him or her at all times in the hospital setting. The nurses are neither omniscient nor omnipresent. If you care anything at all about a person, you should see to it that they are never in a hospital room alone. It is indeed a dangerous place to be.

MEDITATION FOUR: “There is no finer workman on God’s green planet than a good and caring doctor or nurse, and nothing lower or sorrier than a bad or unhappy one.”

During this hospital stay, I was reminded of something Dr. Peter Blake used to tell the University med students, “In this class, you are all equals …but some of you are just better than others.” This was brought to mind not in reference to patients but rather those of us who attend to them for a living. The doctors, nurses, and staff of this particular hospital are uniformly excellent in every department. Some folks are beyond simple excellence. Some become instant, trusted, and indispensable old friends.

These are “the called.” They make life in the hospital at once bearable and a joyful reveling in the true meaning of God’s love.

These people are totally enamored with what they do professionally and it shows.

On the other side of the stethoscope, it becomes easy to discern the difference between someone who is in the medical field for a steady paycheck and someone who is called into this service to humanity. Many would argue this point with me. I stand fast in my position.

People who are “called” into medical fields are in general happier than those who simply chose them for monetary gain and job security. The patient feels it in the care they provide, the human touch and the kind words they speak. I have learned there are folks “called” into medical service from every religion and every walk of life. Some of them even make appearances in the hospital on Ole Miss football homecoming weekend. Now that is true love above and beyond “the call.”

MEDITATION FIVE: “Angels who reside in hospitals usually appear to us in uniform.”

A quality hospital stay is not defined solely by interaction with the doctors and nurses. Always welcome sights are an ebullient housekeeper who comes in with a dust mop and a quip about the weather, as well as the respiratory therapy guy who brings sweet momentary relief with a breathing treatment. However, the folks with their little pinion wings tucked into their

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uniforms are those from the dietary department bearing food. One particular worker cherub always arrived with Rob’s tray singing low and sweet with a voice just this side of the Promised Land. With a little encouragement each evening, he would regale us with soothing or stirring a cappella songs. Uncannily, his choice of music would unfailingly be just what we needed to hear at that moment. One troubled evening near the end of our stay, this diminutive black man named Steve chose “Precious Lord, Take My Hand.” A tired, weak, and worn Rob listened with softly closed eyes and slept peacefully that night having been transported onestep closer to heaven by this angel in uniform.

All music is spiritual at some level. If it is not, then it isn’t really music at all.

MEDITATION SIX: “A good night’s sleep is a pearl of great price.”

This maxim holds for patient and visitor alike. Come to think of it, it is a universal truth. A whirring fan blowing in the background helps to calm you after you have gotten up for the seventeenth time to reset the squealing alarm of the IV machine. I often wondered for whom the alarm tolls. No one outside the room can actually hear it. This is one reason “Meditation Three” holds so much truth for us.

Multiple blankets soften the unforgiving plastic couch-a-bed you are provided. The objects casually referred to as pillows make you moan for home and goose feathers.

In those rare moments when it comes, an hour of uninterrupted sleep here is a blissful respite.

MEDITATION SEVEN: “The savvy and unscrupulous visitor can survive any hospital stay.”

If a fellow wants some milk and cereal at 1:00 a.m., there is a nutrition room down the hall where these can quickly be procured. Hot fresh coffee (otherwise known as the elixir of life) is there round the clock and is a comforting stimulus shared by literally everyone on the floor. If you want some vanilla ice cream and the freezer compartment on your floor is empty, you can cruise one flight up to another ward and find it in their nutrition room. Got a Campbell’s chicken noodle soup craving? Not a problem. Even a penniless visitor will not starve in a hospital. During this ordeal one is reminded that the original meaning of hospitale was “a guesthouse or inn,” having the same root word as ‘hospitality.’

There are other necessities. As far as clean clothes went…another angel appeared to me: Dr. Ford Dye. Ford loved Rob and came to see him in the hospital on more than one occasion. One afternoon, Ford swung by for a visit and took me over to the doctors’ dressing room in the surgery suite for some clean scrubs to lounge around the hospital in. God bless him.

Wearing the ubiquitous ceil blue scrubs, one can move about the hospital freely and virtually invisibly. This works especially well if you can adopt a brisk pace and look like you know where you are going and what you are doing. This requires a bit of practice and avoiding sustained eye contact with the actual employees.

I could almost hear their thoughts… “Hmm, that must be another one of those new Hospitalists.”

MEDITATION EIGHT: “SOMETIMES THE NEAREST AND BEST PHARMACY IS A PACKAGE STORE.”

The view from our window in 324 overlooked bustling Lamar Street and afforded a great opportunity for those of us who enjoy ‘people watching’ as a pastime. Of particular interest were the goings-on in a business directly across from us. This obscure birdhouse brown board and batten enterprise appeared to be the nerve center of the entire area. Under its sagging soffits were the letters CM PS. The M was actually missing but its imprint was still there. The first night, being illuminated from within, I was able to discern that this was actually a liquor store. Adjacent to it was a convenience store selling beer, sodas, snacks and smokes.

These institutions and Phillip’s Grocery (“home of the world’s best hamburger”) were the only businesses within easy walking distance of the hospital entrance. Smoking being verboten on Baptist Memorial grounds, hospital folks could be seen making the easy stroll across the street to stand in their parking lot and puff away. It is no stretch of the imagination that patients were included in this number. I did see one or two in hospital gowns. I chatted with one of the nurses about the activities and learned that this obscure package store was known to have the “best prices in town” and the owner had strict instructions for his employees not to sell to anyone wearing a plastic hospital armband. Despite this admonition, we know that surely treacherous tipplers do score there from time to time. Once the owner caught a patient wearing an overcoat from whose sleeve he spotted a Foley catheter hose snaking its way into her purse. This could have been avoided if her doctor had simply recognized her physical need for ethanol and written orders for her to have a daily dose of Spiritus frumenti. But, come to think of it, this is a Baptist Hospital. Administration would perhaps frown on that.

On the Saturday afternoon of the big Ole Miss football game, this establishment was a beehive of activity. Scores of gleaming and massive SUV’s strained in and out of the tiny parking lot throughout the day. A winding checkout line of customers, mostly men dressed in red or blue polos and khakis bearing coolers, meandered all the way out the front door. It gave me pause to wonder if a few of these folks might become casualties in our ER across the street before the night was over.

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MEDITATION NINE: “The Gideon Bible is the one comforting constant presence for any way worn traveler.”

In the beginning of our stay my reading was primarily from the little white pocket New Testament that I keep in my black bag. I soon realized that I was not obliged to strain my eyes with it…there was a bold print one in the room’s bedside stand. The comforting blue bound Gideon Bibles are on every end table in every waiting area throughout this and every other hospital I have been in. Through repeated use, those seem to open up to passages of scripture that are a healing balm in times of fear and suffering. Psalm 38 was the chapter that room 324’s Bible first fell to: Verse 6-10: “I am troubled; I am bowed down greatly; I go mourning all the day long. For my loins are filled with a loathsome disease: and there is no soundness in my flesh. I am feeble and sore broken: I have roared by the reason of the disquietness of my heart. Lord, all my desire is before thee; and my groaning is not hid from thee. My heart panteth, my strength faileth me: as for the light of mine eyes, it is also gone from me.”…

Verse 21: “Forsake me not, O Lord: O my God, be not far from me.”

You can’t hit the nail on the head any more squarely than this. The Gideon’s International, a Christian laymen’s service organization, has placed 1.5 billion Bibles in hotels, schools, hospitals, military bases and prisons since 1908. I greatly admire and appreciate their work and never more so than during this hospital stay. The thing I like most about the Gideons is they don’t try to preach to anyone; they let the Bible do the work.

MEDITATION TEN: “Just as you never fully appreciate your health until you learn you have lost it, you will never truly know how much or how deeply you love your spouse until you learn you are losing him.”

One evening as I lay in the twilit chamber of room 324, I once again recalled some words of my dying grandfather that became etched on my12-year-old mind. My burly and beloved fishing buddy had become a leather-draped skeleton as he literally starved to death after ‘cobalt’ treatments for esophageal cancer. He said, “Gal, you have something that all the money in the world can’t buy for me…your health. Enjoy your life fully, but treasure your good health while you still have it. I never appreciated mine until it was lost.”

Exactly a year before as I was receiving radiation therapy for my own head and neck cancer, these words had come flooding back to me with a vengeance. Despite his admonition, my good health always seemed to be a given entitlement. I had not appreciated the preciousness of it until it indeed was lost.

Robert Bitter was not like this. He joyously and daily celebrated his life and good health as no one I have ever known. Rob was the most hopeless romantic I have ever met. He wanted us to be married a few days before his 70th birthday because “the Lord has only promised me three-score and ten and I’m not taking any chances.” Throughout our twelve years together, we were as ‘Chang and Eng,’ congenitally conjoined at the chest, and never spent even one night apart. I never failed to be pleasantly surprised when from time to time I would get ‘anniversary’ cards in the mail on the 27th of the month. Any month. Rob said he wanted to squeeze in all the anniversaries he possibly could, that every month of our lives together was simply “gravy on the biscuit” and that it should be celebrated as such. And he was so very right.

MEDITATION ELEVEN: “We are past all comforts here but prayers and opiates.”

I realized that I had never truly mastered the art of prayer or even fully appreciated the power of the prayers of others until my own ‘deer caught in the headlights’ experience with cancer. Most of the praying I had done prior to that time was either somewhat akin to long ago rote recitations or simply a quick ‘prayer on the hoof’ for some inane thing such as “Oh, Lord, I’m about to give this old boy with the ‘clap’ a penicillin shot…Dear God, please don’t let him have a reaction!”

I came to realize that I had a “prayer attention deficit disorder.” In times past, I would lie abed upon awakening and try to compose a profound prayer for the coming day; then my mind would go off on some tangent of pondering the facts of the case, so to speak, and at once, I would become frustrated with never forming a coherent invocation that would be “pleasing to God.” I had it all wrong. Cancer will teach you how to pray. A good prayer need never fit a standard pattern or even be finished once it is uttered. It is an ongoing conversation with God throughout the day. Our Creator hears when we pray an intercessory prayer. He responds perfectly, wisely, and consistently within the context of His master plan.

My selfish previous prayers for Rob and me to be able enjoy just a few more good days together quickly mutated. During those final days of crescendo agony, most of my prayers were for Robert simply to have a semblance of comfort. Frequently uttered were many quiet prayers for the nurse to hurry with his next dose of pain medicine. There have been times when all I could think to say to Him was “Help us, Lord…Help, us Lord,” like a mantra breathed until the passing of a perceived crisis. And somehow they always passed. I gave God thanks for the blessed gift of opiates on numerous occasions during our stay in room 324.

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Rote prayers and on-the-hoof prayers are fine, but the best prayers are simply conversations with God interspersed through one’s day. Just as with our flesh and blood friends, sometimes these little talks with the Lord are in-depth discussions over a lingering cup of coffee, but also sometimes two or three well chosen words lovingly tossed across the room will suffice. Properly applied, these conversations bring about life and sanity, sustaining changes within us. Somehow I don’t think God needs changing.

MEDITATION TWELVE: “The peaceful acceptance of impending death is sometimes the best option.”

Near the end of this week in the hospital, I spent most of my time sitting on the side of the hospital bed holding and kissing Rob’s hands and telling him that I loved him. I would repeatedly and tearfully read his most recently applied plastic armband which labeled my husband “Robert W. Bitter - 7/30/28 - DNR.” {Do Not Resuscitate} Never at any point did I muster the guts to speak to him of the pre-eminence of what was happening to us. Never did I find the good grace to ask my husband whether he had any last wishes or requests. Though I had rehearsed them, the words would not come out of my mouth. As the Mother’s child that I am, the hopelessness and finality of the situation did nothing to deter me from persistently poking food at him, begging him to eat something…anything…the gooey gray oatmeal, the electric green jello, the tepid chocolate pudding. He would take one bite, wince, and weakly whisper, “Hon, just let me rest a while. Don’t make me eat this stuff.”

Nearing the finish line, I began to ask myself, “Why? Why are we doing all of this?” It was indeed all so pointless. Robert had collapsed in the kitchen one sultry August morning while canning pickles. If he had quietly succumbed to this cardiac event a few weeks earlier as nature perhaps intended, we would have never known about this hidden lung cancer. He would not have ever faced these final days of anguishing pain and the unrelenting torment of breathlessness. These are choices and circumstances well beyond our means to influence as spouses or physicians.

I began to sit on my cot for hours on end thinking of whom to choose as his pallbearers, making lists of relatives to inevitably call with particulars of Rob’s funeral arrangements. I would occupy my mind with this until I would become nauseated from it, wash my face and then watch the third cable incarnation of CSI of the day… or was it NCIS? Why indeed were we doing all this? I began to wonder if the doctors were treating me and not the patient. Robert wanted to let go of this ragged shell of a body he was forced to inhabit; I was the fierce overseer, unwilling and unable, it seemed, to let my husband go.

In one of the books I mentioned earlier, 101 Elegant Paragraphs, I found a rather profound passage: “Take away but the pomps of death, the disguises and solemn bugbears, the tinsel, and the actings by candle-light, and proper and fantastic ceremonies, the minstrels and the noise-makers, the women and the weepers, the swoonings and the shriekings, the nurses and the physicians, the dark room and the ministers, the kindred and the watchers; then to die is easy, ready, and quitted from its troublesome circumstances.”

—Jeremy Taylor, The Rules and Exercises of Holy Dying, 1651

In the four hundred year interval since this was written it has never been said more succinctly. Death and dying are quite holy things and most frequently sullied by most of our vain human interventions.

POSTSCRIPT:

After exactly one week and countless silent prayers since coming to room 324, on Monday morning October 12, Dr. Brett Lampton (Luke’s brother and the director of the Oxford Baptist Memorial hospitalist team) helped me formulate the overdue decision to take Rob home for hospice care. I drove him home at dusk that evening in his beloved silver Lincoln. With some of the last complete sentences he pronounced, Rob still tried to tell me how to drive his car. Less than 48 hours later Robert received the blessing I had prayed for him to have, a sacred and peaceful release.

[Una Voce (With One Voice), is a column in the JMSMA featuring the prose of Dwalia South, MD. Having served as an associate editor of the JMSMA, she currently chairs the MSMA Committee on Publications. A past president of the MSMA and the Mississippi Academy of Family Physicians (MAFP), Dr. South is a family physician in Ripley affiliated with North Mississippi Primary Care Associates, Inc. She is a past recipient of the MSMA James C. Waites Leadership Award, the MAFP “Family Physician of the Year Award” known as the John B. Howell Memorial Award, and was named one of America’s Top Family Doctors of the Year: 2004-2005. She has served on the Mississippi State Board of Medical Licensure and the Mississippi Foundation for Medical Care Board of Trustees. In addition to writing, Dr. South enjoys the art of oral storytelling and operating her family farm business, Green Hills Farm, producing Quarter horses, Longhorn cattle, and pine trees.] —ED.

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