October 2010 JMSMA

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Lucius M. Lampton, MD EDITOR D. Stanley Hartness, MD Richard D. deShazo, MD ASSOCIATE EDITORS Karen A. Evers MANAGING EDITOR PUBLICATIONS COMMITTEE Dwalia S. South, MD Chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD Leslie E. England, MD, Ex-Officio Myron W. Lockey, MD, Ex-Officio and the Editors THE ASSOCIATION Tim J. Alford, MD President Thomas E. Joiner, MD President-Elect J. Clay Hays, Jr., MD Secretary-Treasurer Lee Giffin, MD Speaker Geri Lee Weiland, MD Vice Speaker Charmain Kanosky Executive Director JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual).

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Official Publication of the MSMA Since 1959

OCTOBER 2010

SCIENTIFIC ARTICLES

VOLUME 51

NUMBER 10

Abstracts from the 2010 James D. Hardy Surgical Forum

282

Clinical Problem-Solving: The Gastroenteritis That Wasn’t

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Submitted by the University of Mississippi School of Medicine Department of Surgery David R. Norris, MD

PRESIDENT’S PAGE

Playing Like a Team

293

Tim J. Alford, MD; MSMA President

SPECIAL ARTICLE

On Disaster Response Call with Dr. Dan Edney

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Karen A. Evers, Managing Editor

EDITORIAL

Getting Over It

295

D. Stanley Hartness, MD; Associate Editor

RELATED ORGANIZATIONS

Mississippi State Department of Health Medical Assurance Company of Mississippi Information and Quality Healthcare University of Mississippi Health Care UMMC School of Medicine MSMA Alliance

292 296 301 305 306 309

DEPARTMENTS

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October

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OCTOBER 2010 JOURNAL MSMA

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• SCIENTIFIC ARTICLES •

Abstracts from the 2010 James D. Hardy Surgical Forum Submitted by the University of Mississippi School of Medicine Department of Surgery

JAMES D. HARDY LECTURESHIP IN SURGERY

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

T

he Department of Surgery is proud to share the abstracts from the MARC E. MITCHELL, MD presentations given at the tenth James D. Hardy Surgical Forum held JAMES D. HARDY PROFESSOR on May 14, 2010, at the University of Mississippi Medical Center.

AND CHAIR DEPARTMENT OF SURGERY The Hardy Forum is held annually, and it is named to honor the first chairman of UNIVERSITY OF MISSISSIPPI the Department of Surgery at the University of Mississippi School of Medicine.

SCHOOL OF MEDICINE The name of this event recalls the Mississippi Surgical Forum that Dr. Hardy started and that brought renowned teachers to Jackson annually. The Hardy Surgical Forum features presentations of original scientific investigations by the chief residents in the Department of Surgery and the James D. Hardy Lecturer in Surgery. David Spencer, MD and W. Dotie Jackson, MD shared honors and were each awarded a prize at our annual departmental banquet for the best resident presentation at this year’s Forum. The Department of Surgery is committed to the excellence in research that so distinguished Dr. Hardy’s career. We hope that you will find the following abstracts stimulating.

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Short and Medium Term Results of Iliac Artery Angioplasty and Stenting Combined with Superficial Femoral Artery Atherectomy Bashar Ghosheh, MD; Huey B. McDaniel, MD; Fred W. Rushton, MD; Zachary Baldwin, MD; Mathew J. Hunt, MD; Marc E. Mitchell, MD

Background: Iliac artery stenting with angioplasty is the preferred treatment of peripheral arterial disease (PAD). SuperďŹ cial femoral artery (SFA) atherectomy is a new method for treatment of PAD. The above treatment options are frequently done together to treat claudication and limb threatening ischemia. They offer many potential advantages over traditional open surgery, including less procedural morbidity and shorter hospital stays. This study reviews the results of iliac artery stents and angioplasty combined with SFA atherectomy.

Methods: All patients undergoing iliac artery stenting and SFA atherectomy at the University of Mississippi Medical Center and Jackson Veterans Affairs Medical Center between August 2005 and March 2008 were retrospectively reviewed. Trans-Atlantic Inter-Society Consensus (TASC) scores were assigned to the lesions by review of pre-procedural imaging including magnetic resonance angiography and arteriography. Duplex ultrasound and noninvasive pressure measurements were performed pre-procedure, immediately post-procedure, 6 months, 12 months and 18 months following the procedure.

Results: A total of 25 procedures were performed on 25 limbs in 19 patients during the study period. Indications for intervention were claudication in 20 of 25 cases (80%), rest pain in 5 of 25 cases (20%). The lesions fell into the following TASC categories: TASC A - 8 (32%), TASC B - 7 (28%), TASC C - 7 (28%), and TASC D - 3 (12%). Restenosis or reocclusion requiring repeat intervention occurred in 3 patients. One patient died of myocardial infarction 1 month after the procedure. One patient required above the knee amputation. Resolution of symptoms was noted in 23 of 25 patients. The mean pre-procedure, immediate postprocedure, and 6 month and 12 month post-procedure ABI measurements were 0.59, 0.75, 0.84 and 0.8 respectively. All patients with claudication had early improvement of their symptoms.

Conclusion: Iliac stenting combined with SFA atherectomy is an acceptable treatment option in patients with claudication, resulting in resolution of symptoms in all the patients. It is also a promising intervention in the treatment of critical limb ischemia as evidenced by the improvement in ABI. The long-term patency of the procedure is not known and requires further study. â?’

Comparison of Conventional Laparoscopic Appendectomy and Single Incision Laparoscopic Appendectomy in Pediatric Patients: A Retrospective Review Brian S. Hamilton, MD; David E. Sawaya, MD; Christopher J. Blewett, MD; William H. Replogle, MD

Background: Over the past several years, many advances have been made in minimally invasive surgery in both the adult and pediatric populations. Over the past 10 years, operative techniques for appendectomy have included open appendectomy (OA), conventional laparoscopic appendectomy (CLA), and single incision laparoscopic appendectomy (SILA). This study compares conventional laparoscopic appendectomy (CLA) and single incision laparoscopic appendectomy (SILA) for treatment of appendicitis in the pediatric population in relation to operative time, length of stay, pathology, and post-operative complications.

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Methods: Retrospective chart review included all pediatric patients with diagnosis of appendicitis by ICD-9 codes from July 2008-December 2009 who underwent laparoscopic appendectomy for initial diagnosis of acute appendicitis. Variables evaluated included age, sex, operation type (CLA/SILA), operative time, conversion rate, length of stay, pathology (perforated, acute, normal/lymphoid hyperplasia), and post-operative complications.

Results: Eighty-six patients underwent laparoscopic appendectomy, 73 CLA and 13 SILA. Mean age for CLA and SILA was 10 years and 9 years (p< 0.30). Mean length of stay was 2.56 days and 1.54 days (p< .001). OR times for LA and SILA were similar (37.85 and 35.85 minutes, p< .65). In the CLA group, 1 required postoperative drainage of an intra-abdominal abscess (1.4%), 1 had a stitch abscess (1.4%), and 4 (5.5%) were converted to open appendectomy. SILA was converted to CLA in 2 of 13 cases (15%) due to difficulty mobilizing the appendix. Pathologic evaluation of specimens showed acute appendicitis in 64 specimens, perforated appendicitis in 11 specimens, and 8 normal/lymphoid hyperplasia specimens. All perforated appendectomies were performed by CLA. Perforation (5 days) had increased length of stay compared to normal (2.9 days, p< 0.001) and acute pathology (1.9 days, p< .014). OR time was increased with perforated appendicitis (47.6 minutes) compared to normal (33.7 minutes, p< 0.07) and acute pathology (36.4 minutes, p< 0.04).

Conclusions: SILA has similar mean OR times and length of stay compared to CLA and can be performed for uncomplicated cases of acute appendicitis as long as the appendix and colon can be mobilized into the midline. Perforated appendicitis can be performed initially with CLA but may require conversion to open procedure. Perforation increases OR time and length of stay. ❒

Sacral Neuromodulation in Patients with Voiding Dysfunction and Concomitant Gastrointestinal Dysfunction Allen M. Haraway, MD; Mark A. Runnels; Thomas L. Abell, MD; William L. Duncan, MD

Background: Neuromodulation of the sacral nerves has shown excellent results in treating patients with voiding dysfunction refractory to conservative therapy. It is known that patients with gastric motor disorders often have co-existing abnormalities of the genitourinary system. Through a validated questionnaire, we report the symptom scores before and after the placement of a sacral nerve stimulator (SNS) for voiding dysfunction, quality of life, and constipation in a unique group of patients with gastric motility disorders.

Materials and Methods: A questionnaire was designed to assess voiding dysfunction, quality of life, and constipation in patients that had both a gastroesophageal stimulator and SNS. Patients answered questions relating to voiding dysfunction (i.e. difficulty voiding, trouble starting urinary stream, urgency, incontinence, urinary retention, frequency, and number of pads) on a scale of 0 (none) to 4 (all of the time). Quality of life was characterized on a scale from -3 (very unhappy) to +3 (very happy).

Results: The questionnaire was completed and returned by a total of 36 patients. One patient did not fully complete the questionnaire and was not included in the study. There was a total of 34 females and 1 male. Ages ranged from 19 – 76. The scores were analyzed as continuous variables and a two-tailed, paired t-test was used for calculating significance. Mean voiding dysfunction scores improved from 8.1+/- 3.6 before treatment to 2.6 +/- 3.1 after treatment (p<0.0001). Mean quality of life scores improved from -2.29 +/- 1.53 before treatment to 1.58+/- 1.59 after treatment (p<0.0001). Mean constipation scores improved from 4.0+/-1.8 before treatment to 2.2 +/-1.4 after treatment (p<0.0001). Three patients showed no change in voiding dysfunction and 1 patient reported worsening of symptoms. All patients except 1 had improvement in quality of life after the placement of the SNS.

Conclusion: We report the results of voiding dysfunction and quality of life in patients with gastric motor disorders after the placement of a sacral nerve stimulator. Both voiding dysfunction and quality of life were significantly improved after the placement of an SNS. Constipation was also improved in these patients. Sacral nerve stimulation appears to improve voiding dysfunction as well as concomitant gastrointestinal motility dysfunction. ❒

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Impact of the Night Float System on Resident Operative Experience Matthew J. Hunt, MD; Michael W. Morris, Jr., MD; Jon D. Simmons, MD Background: Since its inception in 2003, residencies of every specialty have been restructured to accommodate the 80-hour work week for trainees. In compliance, programs have reevaluated the manner in which they deal with all facets of their makeup, including vacations, days off and most importantly, in-house call. One method for managing in-house call introduced to facilitate reducing the work hours was the institution of the night-float system. Under the night-float scheme, residents, simply put, work assigned night shifts for 2 months each year to alleviate the burden of nighttime in-house call. In many specialties, this is favorable in regards to both educational benefit and lifestyle. Surgery education, however, includes an operative experience that is achieved only by being present and actively participating in operations. As the majority of operations occur during the daytime shift, one might assume that a trainee’s operative case load would be negatively affected by a night-float call system. A few small studies were performed immediately after the institution of the 80-hour work week under the night-float system to assess this. With little or no difference in the early studies, we set out to reevaluate this. Only 2 classes of residents have now graduated under the restricted schedule. The University of Mississippi Surgery Education Office instituted the night-float system last year in an effort to better comply with the ACGME rules. The purpose of this study is to revisit the operative impact of the night-float on our residents with specific focus on the PGY4 chief residents.

Methods: A nonrandomized retrospective evaluation of the ACGME surgery resident operative logs from 2007-2010 was reviewed. The review has been specifically directed at the PGY4 level residents since they act as the highest level within the nighttime in-house call schedule. The night-float system was instituted to accommodate nighttime call at the University Hospital. Under the night-float system, residents participate in 2 months of nighttime in-house call per calendar year. During the remainder of the year at the University, they participate in 4 weekend call days per month. In the previous years included in the study, the department existed under the traditional Q4 call schedule. The operative logs for all PGY4 residents during the study period were analyzed and compared. The participation in rotations away from the University Hospital were excluded from the study in order to accurately evaluate the call scheme as it relates to operative cases rather than just total cases. Twenty PGY4 residents were available for study, but only nineteen were included in the study because of a maternity leave and relative difference based on unequal time.

Results: After evaluating the 2009/2010 case logs under the night float system, residents performed an average of 131 (sd = 50 [70,194]) cases at the University Hospital. In the previous two years, 2007/08 and 2008/09, the average caseloads were 188 (sd = 62 [101,265]) and 186 (sd =54 [97,259]) respectively.

Conclusions: Based on the results, operative experience is maximized by daytime participation in surgical residency. Solely based upon the comparison of cases, there is negative reflection on the night-float’s ability to provide operative educational benefits. By this, however, it is unclear that the discrepancy is equilibrated on the remainder of the regularly scheduled rotations throughout the residents’ year. Further evaluation should be conducted to discern how best to maximize the utility of the system to recapture PGY4 operative cases throughout the remainder of the year. ❒

Improvement of Pre-Arterialized Venous Flap Survival Rate with Surgical Delay in the Rat Model W. Dotie Jackson, MD; Feng Zhang, MD; Michael F. Angel, MD

Background: In microsurgical and reconstructive surgery, conventional arterial flaps are restricted to their skin areas, and available free flaps based on named arteries are limited and often associated with significant donor-site morbidity. Venous flaps have the advantages of preservation of the main artery of the donor site: thin, non-bulky, and easy elevation without deep dissection. Flaps based on venous anatomy would greatly increase the diversity of tissues available for reconstruction. The purpose of this

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experimental study is to investigate the improvement in venous flap survival of pre-arterialization with a surgical delay procedure in venous flaps in rats.

Methods: Our experimental studies were performed on forty-six Sprague-Dawley rats randomized into four groups: 1) group of arterialized venous flaps, 2) group of venous flaps of pre-arterialization with delay procedure, 3) group of flaps with arterial inflow and venous outflow, and 4) group of flaps with venous pedicles for both sides as control group, one and two respectively. Direct observation, histological analysis and vascular perfusion examination by Indian ink injection were performed for flap assessment.

Results: The percentage of flap survival was 89.51 ± 1.01%, 11.25 ± 0.78%, 41.56 ± 2.38% and 98.04 ± 1.78% in these four groups respectively. Significant differences were noted between groups (p<0.05) except between groups of arterialized venous flaps and flaps by pre-arterialization with delay (p>0.05). Vascular perfusion studies revealed that the India ink filled the entire flaps in comparison with partially-filled flaps in other groups. Histological examination showed more small vessels observed through all layers of the flaps as well as dilated superficial veins in the group of pre-arterialization with delay procedure than those in other groups.

Conclusion: In conclusion, pre-arterialization with a delay procedure can improve the viability of the flap, and this method may be a strategy for flap prefabrication based on the venous network. ❒

Operator Estimate of Surgical Margins in Colon and Rectal Surgery Michael A. Keller. MD; David C. Snyder, MD; David E. Sawaya, MD

Background: Appropriate colon and rectal staging currently relies on optimal examination of both local invasion of tumor with respect to the colon wall and evaluation of lymph node spread. Recommendation for minimum lymph node sampling number to accurately assess stage is 12. Current practices dictate that a 5 cm resection margin should allow the pathologist enough accessible mesenteric tissue to find and evaluate at least 12 lymph nodes. Any margin less than 5 cm runs the risk of accessing less than 12 nodes, and the staging becomes more inaccurate. There are no formal studies that have evaluated how accurate margin distance estimates are among practicing surgeons who perform colon and rectal resections.

Methods: A single institutional prospective study was performed involving adult patients undergoing elective colon operations by the general surgical staff at the University of Mississippi Medical Center between October 2009 – March 2010. During operative resection for visible or palpable colon or rectal cancers, the operating surgeon will estimate his or her distal resection margin with respect to the cancerous lesion prior to transecting the bowel lumen. At the conclusion of the case, the specimen is then opened and physically measured for the actual margin. Results will be compared to measure the accuracy. Groups will be separated by means of operation involving right hemicolectomy, left hemicolectomy, low anterior resection, segmental resections, and subtotal colectomy. There will also be two subgroups further analyzed as to whether the case was performed laparoscopically or open.

Results: A total of 19 cases qualified for this study (right hemicolectomy – 7, left hemicolectomy – 1, segmental – 6, low anterior resection – 2, subtotal colectomy – 3). Overall there was 2.5 cm average marginal difference between estimated and actual margins. Ten cases involved an underestimation of the actual margin by an average of 2.4 cm. Eight cases involved an overestimation of the actual margin by an average of 2.9 cm. One case (sigmoidectomy) was completely accurate. Only 2 cases were performed laparoscopically involving right hemicolectomy and sigmoidectomy averaging a 5.1 cm difference between estimated and actual margins. With regard to estimated margins, those involving an estimate of 5 cm or less were most accurate averaging 1.3 cm difference compared to the actual margin. Margins perceived between 5.1 to 10 cm averaged 2.6 cm difference. Those greater than 10 cm averaged 3.8 cm difference. With regard to the specific procedures involved, the average differences in estimated and actual margins are as follows: right hemicolectomy – 4.5 cm, left hemicolectomy – 5 cm, segmental resection – 3.9 cm, low anterior resection – 2.4 cm, subtotal colectomy – 0.9 cm.

Conclusion: Surgeons are fairly accurate when performing resections for colon and rectal cancer with respect to the estimated distal margin. One should be wary that inaccuracy increases during laparoscopic cases and those involving anticipated margins of greater than 5 cm. ❒

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Advanced Squamous Cell Carcinoma Presenting as Osteomyelitis of the Hand: Midpalmar Resection and Suspensionoplasty Closure of Complex Defect Robert S. Myers, MD; Phillip K. Blevins, MD

Background: Seventy-seven year old male presented with infection of his left middle finger. Patient had a history of having attempted to remove unsuccessfully a lesion one year prior with a “band-aid wart remover.” There were radiological signs of bony destruction compatible with osteomyelitis. Initial clinical impression was severe hand infection with osteomyelitis. Due to the suspicious nature of the presentation, a frozen section in the operating room revealed squamous cell carcinoma.

Purpose: 1) To focus attention on the look-alike potential for squamous cell carcinoma of the hand and the consequent tissue invasion and destruction caused by delayed diagnosis. 2) To describe a suspensionoplasty or tendon wrapping method that can help close complex defects of the hand, especially in cases where multiple ray amputations must be performed.

Methods/Results: After the biopsy proved the lesions were squamous cell carcinoma, amputation of left middle finger and excision of a palmar lesion were done. Quite expectedly, margins were positive. Control of infection allowed time for discussion of treatment options with the patient. Metastatic workup was negative. An enlarged auxillary lymph node proved to be non-cancerous.

En bloc resection was subsequently performed of the middle and ring fingers in wedge-like fashion to the metacarpal-carpal junction.

Tendon suspensionoplasty of the cleft-like defect was utilized to facilitate closure. Radiation therapy was given post-operatively. The patient has adequate pincer function and use of his hand after the initial reconstruction. Follow-up for recurrence is mandatory.

Conclusion: Recognizing pathology by clinical context is important for diagnosis and proper treatment because inadequately treated skin cancers may result in deep tissue involvement, including bone. Squamous cell carcinoma is the most common malignancy of the hand and upper extremity. Appreciating the frequency of this condition is necessary to minimize delay of diagnosis or treatment. Malignancy needs to be included in differential diagnosis of infections, including osteomyelitis. In advanced presentation, this malignancy can metastasize, impacting function and survival. Reconstructive challenges arise with larger resections especially in a structure as complex as the hand. Tendon suspensionoplasty can effectively close the gap caused by tumor extirpation from the hand as in the described case and may also have reconstructive application in select mutilating hand injuries. ❒

Impact of 80-Hour Duty Restrictions Upon Self-Reported Total Operative Experience Emile A. Picarella, MD; Jon D. Simmons, MD; Karen R. Borman, MD; Marc E. Mitchell, MD Background: On July 1, 2003, it was mandated that all residencies restrict resident work hours to a maximum of 80 duty hours per week. There has been much debate and conjecture regarding the impact of duty hour restriction on surgical residency training.

To date, the literature has focused on the total mean number of resident cases performed before and after duty hour restriction implementation as well as affects on ABSITE scores and resident publication volume. There is inadequate literature that examines the number of operations in which a resident directly participates but is not the primary surgeon.

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Methods: The impact of the 80-hour work week on the total operative experience from the general surgery graduating chief residents at the University of Mississippi Medical Center from 2002 to 2008 was examined retrospectively. Data collected included all cases that were coded by each chief in the following categories: Surgeon Chief (SC), Surgeon Junior (SJ), Teaching Assistant (TA), and First Assistant (FA). All the cases were individually self-reported on the ACGME website throughout the duration of the residency. The total mean number of cases was identified as well as the mean number of cases in each category separately. Any resident who did not complete all five years of general surgery training at the University of Mississippi Medical Center was excluded.

Results: A total of 31 graduating Chief Residents were identified. There were no differences between SC, SJ, and TA cases during the study period. There was a significant decline in the amount of cases reported as FA over the seven-year period. Linear regression analysis revealed a decline of -55.23 (slope) FA cases per year and a correlation coefficient of -0.9938.

Conclusion: There is literature which concludes that the total mean number of cases coded SJ and/or the number of cases in which the resident is the primary surgeon has not significantly declined since the implementation of duty hour restriction. However, the number of FA cases has declined at our institution. Since a surgeon is the sum of his cumulative operative experience whether as the primary surgeon, chief surgeon, teaching assistant, or first assistant, one must deduce that surgical residents’ total operative experience has declined since the inception of the duty hour restriction at our institution. ❒

Radical Prostatectomy for High-Risk Prostate Cancer: A Single-Center Experience David L. Spencer, Jr., MD; Joshua G. Griffin, MD; Jason P. Bridges, MD; E. James Seidmon, MD; Charles R. Pound, MD Background: Radical prostatectomy (RP) remains an important primary therapy in the management of high-risk prostate cancer (HRCAP). The oncologic control provided by RP in VA patients with a preoperative Gleason score of >7 on biopsy or prostatic specific antigen (PSA) ≥10 ng/mL was assessed.

Methods: A retrospective review of HRCAP patients with a biopsy Gleason score of >7 or PSA ≥10 ng/mL was performed on patients who underwent RP between 2000 and 2008. Treatment failure was defined as a PSA of ≥0.4 ng/mL or initiation of adjuvant therapy.

Results: A total of 436 RPs were performed at our institution over this time period with 77 RPs performed on patients with HRCAP. Overall, 66 patients without preoperative hormone therapy and at least 1 year of follow-up were included in our analysis.

Median follow-up was 40.5 months and mean age was 60 ± 6 years (46-72). The mean preoperative PSA was 13.2 ± 5.6 ng/mL (4.238.8). Of the 66 total patients, 56 (85%) had preoperative PSAs of ≥10 ng/mL, 14 (21%) had a biopsy Gleason score of >7, and 4 (6%) had both. After pathologic analysis, there were 44 (67%) stage pT2, 9 (14%) stage pT3a, and 13 (19%) stage pT3b patients.

Four of 56 patients (7%) with biopsy Gleason scores of ≤7 and PSAs of ≥10 ng/mL were upgraded to >7 on final pathology. Nine of 14 patients (64%) with biopsy Gleason scores of >7 were downgraded to ≤7 on final pathology. Lymph nodes were positive for metastatic disease in 10 of 66 (15%) patients, and surgical margins were positive in 21 of 66 (32%). Excluding the patients with positive lymph nodes, there were 11 of 56 (20%) biochemical recurrences at a median time of 6 months (0-31). Adjuvant treatment consisting of external radiation therapy in 9, hormone therapy in 7, and both in 4, was given to 20 of 66 patients (30%). There were 6 (9%) total deaths with 1 (1.5%) death due to prostate cancer.

Conclusions: RP is a reasonable therapeutic option for men with HRCAP. In this single institution cohort, over half of the men with Gleason scores of >7 on biopsy were downgraded on final pathology. Less than 10% of men with biopsy Gleason scores of ≤7 and PSAs of ≥10 ng/mL were upgraded to >7 on final pathology. Men in this high-risk group should be counseled that they may require adjuvant therapy. ❒

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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

The Gastroenteritis That Wasn’t

A

David R. Norris, MD

63-year-old African American male presented to the emergency department (ED) complaining of a five-day history of severe nausea and vomiting unrelated to eating and temporarily relieved by promethazine (Phenergan). He had been seen twice in an urgent-care clinic and once in the same ED for this complaint; each time he had received anti-emetics with improvement of his symptoms. At the last visit to the urgent care clinic he had also been prescribed amoxicillin (Amoxil) for what he described as a skin infection on his face.

The causes of nausea and vomiting are numerous. Broad categories include iatrogenic, toxic, infectious, central nervous system and psychiatric conditions, metabolic disorders and endocrinologic causes. However, the most common cause is gastroenteritis. The history and physical examination are key to diagnosis.1 Initial treatment is symptomatic control followed by correction of the underlying disorder.

Upon further questioning, the patient reported no history of similar symptoms and had no known sick contacts.

Associated symptoms included a mild headache, the skin infection on his face and generalized fatigue. He specifically denied photophobia, neck, chest, back and abdominal pain as well as dysuria, diarrhea and weight loss. His past history included Type 2 diabetes mellitus and hypertension. He had no history of surgical procedures and denied illicit drug use.

He had previously smoked with a 25 pack-year history; he quit smoking 10 years ago. Alcohol use was limited to the weekends during which he reported he would usually drink 1 to 2 six-packs of beer. The patient was married to his second wife and had previously been employed as a truck driver. He had not traveled outside of the state in the previous year.

AUTHOR INFORMATION: Dr. Norris is an assistant professor and former resident in the Department of Family Medicine at the University of Mississippi Medical Center.

CORRESPONDING AUTHOR: David R. Norris, MD, Department of Family Medicine, University of Mississippi Medical Center, 2500 N. State Street, Jackson, MS 39216; Telephone: 601-984-5426 (office) Fax: 601-984-6889 E-mail: drnorris@familymed. umsmed.edu.

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At this point the history provides little further guidance.

The absence of pain and neurological findings provides no helpful localizing signs; therefore, most causes still cannot be ruled out. While his previous antibiotic use may suggest the possibility that his illness could be partially iatrogenic in nature, other causes should still be sought, particularly given that his symptoms preceded use of the antibiotic. Additionally, his history of diabetes may suggest the possibility of gastroparesis; however, this does not fully explain his symptoms. The work-up should proceed with the physical examination while administering symptomatic treatment.

On physical examination, the patient was noted to be afebrile with vital signs all within normal limits. His abdominal examination revealed normal bowel sounds with no tenderness, rebound or guarding noted. Heart rate was regular with a normal rhythm, and pulmonary auscultation revealed normal breath sounds. There was no evidence of temporal wasting or other signs of malnutrition noted. His cranial nerve function was intact, and upper and lower extremity reflexes were 2 plus and equal bilaterally. The only abnormal finding was the presence of multiple papules on the patient’s face that were draining purulent fluid and were suggestive of folliculitis. The patient reported that these had been present for several weeks.

The patient’s vital signs suggest that he is stable and not significantly dehydrated. Though the most likely diagnosis remains gastroenteritis, the presence of the papules on his face suggests the possibility of bacteremia or early sepsis from systemic spread of the soft-tissue infection. Blood cultures should be collected to search for other causes.2 A complete blood count revealed no leukocytosis, anemia or thrombocytopenia. No left or right shift was noted in the differential. Shortly thereafter, the comprehensive metabolic profile showed a normal blood urea nitrogen, creatinine, glucose and electrolytes. Cultures of both blood and the purulent drainage were obtained with results pending.

Flat and upright abdominal radiographs revealed no abnormality. Administration of intravenous ondansetron (Zofran) provided the patient with only partial symptomatic relief; consequently the decision was made to admit the patient for observation while awaiting the results of his blood cultures. We also wanted to initiate oral trimethoprim-sulfamethoxazole (Bactrim) for his folliculitis; however, the patient refused and insisted on continuance of amoxicillin.

Again, the findings of laboratory and radiologic studies are of little diagnostic benefit except in helping us rule out possible causes. The patient does not appear to have a serious infectious or gastrointestinal cause of his symptoms nor is there anything to suggest metabolic or toxic causes. Although amoxicillin is not the preferred treatment for skin infections because of its lack of coverage of Methicillin-resistant Staphylococcus aureus, the patient’s request was honored.

The following morning the patient showed near complete resolution of his gastrointestinal symptoms and was noted to have been afebrile overnight. He requested to be discharged. The nursing staff had cleaned his wounds, and a more thorough examination was undertaken. It revealed the presence of multiple umbilicated flesh-colored papules that did not favor the initial diagnosis of folliculitis. Because umbilicated papules could be representative of cutaneous Cryptococcus neoformans, a screen for human immunodeficiency virus (HIV) and a skin biopsy were obtained.

Though a serious cause seemed more likely at this point, the patient was insistent upon being discharged and acknowledged his understanding of the risks. Additionally, he continued to be free of signs or symptoms such as meningismus or photophobia which would suggest a cryptococcal infection commonly seen in patients with meningitis. The gram stain obtained on the blood cultures was negative, and his laboratory studies remained stable. Given this, the patient was discharged and close outpatient follow-up was advised.

The following day, the patient returned to the ED with worsening of his initial gastrointestinal symptoms. His presentation included extreme sensitivity to light and a severe headache. His HIV screen was positive, and his skin biopsy confirmed the diagnosis of cutaneous Cryptococcus. A negative computed tomography of the head was obtained prior to lumbar puncture (LP). Opening pressure from the LP was elevated at 88 mm, and cerebrospinal fluid (CSF) was cultured. The laboratory quickly reported that the India ink stain was positive for many encapsulated yeast consistent with Cryptococcus. The patient was readmitted to the hospital, given intravenous amphotericin B (Abelcet) and an infectious disease consultation was requested. A CD4 and HIV viral load were also ordered, both of which returned with results consistent with acquired immune deficiency syndrome (AIDS).

Cryptococcus neoformans is encapsulated yeast that lives in the soil and bird excrement. It is generally acquired through

inhalation. Though it can affect immune competent patients, in the United States it is most often found as a complication of immune compromise from HIV infection or immunosuppressant drugs such as those used for autoimmune diseases and chemotherapy.3 Treatment is through the administration of intravenous antifungals, usually amphotericin, and if possible, correction of the underlying immune deficiency. Symptomatic relief may be provided by lowering the elevated intracranial pressure 4 through LP. Upon questioning of the patient and his wife, further social history revealed the likely source of his infection. The patient had one previous marriage in which his wife had admitted to infidelity and had subsequently contracted and perished from HIV infection. The patient had been tested once after her death but had never returned for follow-up.

The patient had followed the typical course of untreated HIV infection, progressing to full-blown AIDS in approximately ten years. The fact that his initial, and only, screen for the disease was negative can be accounted for by the window of HIV infection. This is the period during which the virus is present in the body but before measurable antibodies are present, the basis of HIV screening tests. The window-period generally lasts from 28 weeks with an average of 25 days. However, in rare cases it may take up to 6 months. Therefore, the current Centers for Disease Control recommendation is for a repeat screen 6 months after the initial test to confirm the absence of the disease.5 Though the patient showed initial improvement in his symptoms and was able to be discharged home the following week, he returned multiple times in the following months with recurrent meningitis despite outpatient intravenous antimicrobial therapy. Over the following 2 months he was admitted 7 times and received 10 therapeutic LPs before Interventional Radiology inserted a lumbar drain. Despite aggressive interventions, he continued to decline, developing blindness, deafness and ataxia. Ultimately, 3 months after his initial diagnosis he agreed, with his wife’s concurrence, to be admitted to an inpatient hospice facility where he died one week later. His wife has been tested for HIV twice and has remained negative.

This case is representative of the inherent uncertainty that often accompanies the presentation of certain illnesses. The classic presentation of Cryptococcus is that of meningitis: headache, photophobia, meningismus, nausea and vomiting. However, in this case only the later, and less specific, signs were initially present. Only the presence of the cutaneous lesions gave a hint of the pathology underlying the patient’s symptoms, emphasizing the need for a thorough physical examination and an open mind when making a diagnosis.

KEY WORDS:

NAUSEA AND VOMITING,

AIDS,

CRYPTOCOCCAL MENINGITIS

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โ ข SCIENTIFIC โ ข REFERENCES: 1.

Scorza K, Williams A, Phillips D, Shaw J. Evaluation of nausea and vomiting. Am Fam Physician. 2007;76(1):76-83.

2.

Malagelada JR, Camilleri M. Unexplained vomiting: a diagnostic challenge. Ann Intern Med. 1984;101;211-218.

3.

Kumar V, Abbas AK, Fausto N, eds. Pathologic Basis of Disease. 7th ed. Elsevier Saunders: 2005. Philadelphia.

4.

Wachter RM, Goldman L, Hollander, H, eds. Hospital Medicine.

2nd ed. Lippincott, Williams &Wilkins: 2005. Philadelphia.

5.

Center for Disease Control and Prevention. Revised guidelines for HIV counseling, testing and referral. Morbidity and Mortality Weekly Report. 2001;50(RR19);1-57.

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July 2010

* Totals include reports from Department of Corrections and those not reported from a specific district NA - Not available (temporarily)

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

292

• PRESIDENT’S PAGE •

Playing Like a Team

C

harles Dickens wrote, “Home is a name, a word, it is a strong one; stronger than the magician ever spoke or the spirit ever answered to in the strongest conjuration.” Another writer, Thomas Wolfe, said, “You can’t go there again.” Most of us still try – if not in body, at least in spirit.

TIM J. ALFORD, MD 2010-11 MSMA PRESIDENT

The world of primary care has staked its claim on the powerful image of home by adopting the goal of a “medical home” for all patients. Intrinsic to this claim is the age-old, sacred doctor-patient relationship. Combining modern communication and a team approach, the world of medicine will be re-defined through the medical home model. The American College of Physicians, the American Academy of Family Physicians, the American Academy of Pediatrics and the American Osteopathic Association make up the better part of a 333,000 primary care coalition that has embraced this concept.

It is instructive when considering the team component of the medical home to draw the analogy of the medical home to the sport of basketball. To those who follow college basketball, the late and legendary John Wooden of UCLA quickly comes to mind. He won ten national championships in twelve seasons. Coach Wooden spoke with the precise language of the English teacher that he was and would simply say, “If you don’t play like a team, you sit.” He attended to the basics. His first lesson to each recruiting class was entitled, “How To Tie Your Shoes Correctly.” His disdain for the dunk over a simple lay-up to the goal put team ahead of show. An admirer of Wooden’s coaching and another helpful basis for analogy is Coach Mike Krzyzewski of Duke. Coach K’s ability to inspire teamwork helped him to heal the USA Olympic basketball team after its abysmal showing in the 2004 summer Olympics. At that time, the USA Olympic team, even with the best players in the country, lost three in a row to Portugal, Lithuania and Argentina and limped away from Athens in utter humiliation. Simply put, the best players in the world were not playing like a team. Coach K was brought in to counteract personal egos and agendas so that team effort prevailed. His mantra is that effective teamwork begins and ends with great communication. He also preaches, “Every loose ball has your name on it!”

Mississippi physicians faced with seemingly insurmountable health problems do not go as deep on the roster as the rest of the country despite the fact that we have a lot of loose balls on the court. We are as good as anybody at working on and, in many cases, fixing the terminal consequences of diseases, but we are not gaining ground in areas of disease management and prevention. Considering we are ranked (you guessed it) 50th in physician to patient ratio (1:12,000), can we make the case we should be playing more like a team? We must lead our offices to play more cohesively for the common purpose of taking care of our patients. We are so busy with the episodic nature of our practices that we seldom have time to go to the game board and plan strategy towards more efficient management of even the most common disease states.

The Patient Centered Medical Home (PCMH) is based on the simple principle that ongoing access to health care includes diligent preventive care and more thorough monitoring of chronic diseases. This will yield better outcomes than episodic symptom-based care with considerable long-term savings. Inherent in the PCMH model is the acknowledgement that despite all of the modern tools at hand to prevent or to manage and cure diseases, compliance can be elusive. Real value is to be added in the broken health care system through wrestling down this issue of patient compliance. The name “medical home” reminds those of us that are parents of similar struggles with compliance in child rearing. In both instances, compliance involves staying on message and extra communication.

Over the past 25 years literally thousands of articles have been published on the issue of medication compliance. Non-compliance is typically cited as occurring in up to 75% of patients, and this rate is even higher in patients with chronic diseases. Cost of non-compliance is estimated at $100 million a year in the United States and is the result of adverse outcomes such as hospitalizations, complications, disease progression, disabilities and even death. Should it be any wonder that up to 25% of patients never fill their prescriptions? Sixty percent of patients cannot identify their own medications, and 50% ignore or compromise instructions from their physician. Diabetes affects 17 million

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people nationwide, and the complex nature of medical regimens in a diabetic leads to even higher rates of non-compliance. Because of the need for adherence to diet, exercise and medications, the PCMH approach is emerging as the solution.

It is no accident that the Meaningful Use Final Rule regulation issued by CMS on July 14, 2010, which provides incentives up to $44,000 for physicians who see Medicare patients and up to $63,750 for physicians who see at least 30% Medicaid patients includes many of the components of the medical home. The Meaningful Use refers to the highly lauded electronic health record (EHR) and how we use that record.

When physicians adopt certified EHR technology and use it to achieve specified objectives, they will be eligible for these incentives. Providers will have to meet 25 requirements in their use of EHR. Below are just five of the menu items within this list of 25 objectives: • Computer order entry

• Computer prescriptions • Quality measurement

• Systematic reminders to patients

• Clinical summaries to patients

This extensive list of objectives is rather dry and boring at face value and will require difficult and hard work. The medical home approach provides the environment to bring this list of x’s and o’s to life. To take any problem or disease, to highlight that problem and to reorient the office staff to more of a team approach have proven to take well over a year to implement.

Now the National Committee for Quality Assurance has rankings for medical homes, levels I–III. Northeast Mississippi is the only system in our state with a Level III, ranking, and the 21st Century Clinics of the Delta Health Alliance are very advanced in the principles of the medical home. These clinics view their electronic health records not as an encumbrance but as a tool to tackle the compliance challenge.

Imagine your whole office staff oriented in the direction of diabetic control for all of your diabetic patients. Think about a caseworker helping to ensure compliance at home in a notoriously non-compliant patient. What if patients who present to the emergency room with complications of diabetes are referred to their medical home accompanied by full documentation of their emergency room visit? As a footnote– as you contemplate your EHR vendor, you should insure that the hospital electronic record system and clinic system are interoperable.

For outpatient clinics to pull this off, there will need to be team meetings where common goals of disease management and prevention strategies are discussed. Old rituals and jobs that have been held “sacred” will need to be reassigned–“pass the ball.” Some will learn new jobs and roles. For example, your best nurse or nurse practitioner could direct a Coumadin clinic with physician oversight. As many of you know, PT and INR levels on our patients are presented at odd times throughout the course of the clinic day. Grouping of such information has been shown to be a much safer approach for our patients where trend analysis and non-compliance can be handled in a more systematic fashion.

Dr. Marion Burton of South Carolina, president-elect of the American Academy of Pediatrics, was a recent guest of the Mississippi State Medical Association and also appeared on Dr. Rick’s Southern Remedy on Mississippi Public Broadcasting. Dr. Burton stated that the medical home is an opportunity to integrate and coordinate specialty care so that our specialists spend their valuable time doing what they are trained to do. Indeed, there is room for those in the primary care world to direct our patients more accurately to the appropriate specialist in a more timely fashion. Regardless, which part of the Home we attend to, this approach strikes at the heart of the compliance challenge, whether we are trying to prevent the acute M.I. or enforcing the drugs after the stent has been placed.

Coach K instituted the Sixth Man at Duke which recognizes the importance of everyone on campus contributing to the success of the team all the way to the Cameron Arena janitor. In fact, he refers to his pep rallies as “team meetings.” Everybody in Cameron puts pressure on the ball. If you don’t play as a team, you sit. Helping our patients achieve better compliance is not found under the microscope or some newfound remedy. Rather, it is about working as a team and using all the personnel and resources at hand. Perhaps we begin by learning to tie our shoes.

References:

Elliot RA, Marriott JL. “Standardised assessment of patients’ capacity to manage medications: a systemic review of published instruments.”

BMC Geriatr. 2009 Jul 13;9:27.

Osterberg L, Blaschke T. “Adherence to Medication” N Eng J Med. 2005;353(5):487-97.

Robert Graham Center. The Patient Centered Medical Home. History, Seven Core Features, Evidence and Transformational Change. Available at: http://www.graham-center.org/PreBuilt/PCMH.pdf. Accessed August 30, 2010.

Mississippi Public Broadcasting: MPB Radio Southern Remedy. Program Archive; August 25, 2010 (Open Topic). Available at: http://www.etv.state.ms.us/podcast/SouthernRemedy/2010/SR082510.mp3.

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• EDITORIAL •

I

Getting Over It

honestly never thought it would bother me like it has.

For several years before my retirement I served as medical director for an outpatient hospice service headquartered in Carthage.

Strangely (and probably a sure sign of the economic times), almost every physician I know has an affiliation as medical director with a hospice group…or home health agency…or nursing home…or personal care home…or ambulance company…or (fill in the blank). Some contend that we lend credence to their operations; all agree that we help keep the feds at bay.

My stock seems to have soared with retirement. Not only am I working three days a week at an outpatient clinic in Jackson (the fact that my wife may not have been ready for me 24-7 sound familiar?), the opportunity to add the title of inpatient hospice director to my outpatient duties presented itself. I thought, “What the heck…I’ve got the time, we could use the extra income, and, besides, I’d never been to Marion, Mississippi!”

So every Friday morning finds me making the trek to our inpatient unit in this bustling metropolis on the other side of Meridian. I round on our patients after being briefed by the nurses and signing the appropriate documents. At other times I’m on call for any unforeseen problems.

My entire professional career has been focused on getting patients well— or at least making them feel better. To be honest, I have major problems wrapping my mind around the concept of watching helplessly as people cloistered in a hospice inpatient setting wither on the vine and ultimately succumb. Thankfully, any sense of personal guilt and failure is slowly being assuaged by a renewed appreciation of God’s mercy and grace.

Another personal peccadillo that has plagued me all my life has been the desire to be liked…by everyone. And becoming a doctor only compounded this situation. The older African-American gentleman was already a patient when I assumed my in-house hospice duties, and his clinical appearance certainly belied his diagnosis of inoperable glioblastoma. By way of introduction, I reassured him that I’d practiced medicine in Kosciusko for 40 years. I even joked that I’d been Oprah Winfrey’s grandmother’s family doctor— but that she (Oprah) didn’t pay her (the grandmother’s) bills!

Each subsequent visit saw our relationship grow more and more chilled. I thought it had all to do with the fact that I wouldn’t discuss with this man with the terminal brain malignancy who’d experienced a grand mal seizure as one of his presenting symptoms his burning desire to drive again! I was wrong. Several Fridays later after rounds had been made and as the nurse and I were finalizing orders, the door opened slowly and in shuffled my cold-war adversary. “I’m jes’ gonna give it to you straight,” he began. And then the bombshell, “I don’t like you.”

Unbeknownst to me, we had apparently gotten off on the wrong foot from the get-go when I interjected Oprah into my attempt at a folksy intro.

The patient interpreted what I had said as, “Oprah didn’t pay her bills, and (by inference) I’ll bet you don’t pay your bills either.”

From the look on his face and the set of his jaw, in that instant I knew that not even the slickest Philadelphia lawyer could convince him otherwise. Resigned to the discomfort of our Mexican standoff relationship but resolved to provide compassionate, appropriate end-of-life care, I was shocked to learn of my patient’s unexpected death less than two weeks later. My only consolation was the mental image of him honking his horn impatiently at the Pearly Gates anxious for his maiden voyage through the Streets of Gold. Maybe he’ll run into Oprah’s grandmamma, and she can set the record straight!

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—D. Stanley Hartness, MD Associate Editor

â&#x20AC;˘ MACM â&#x20AC;˘

Maplesâ&#x20AC;&#x2122; Musings: Assessing Risks

I

would like to argue that assessing risks is one of the most fundamental tasks determining our survival as humans.

MICHAEL D. MAPLES, MD MEDICAL DIRECTOR MEDICAL ASSURANCE COMPANY OF MISSISSIPPI

When we walk across a busy street, when we drive a car, when we decide to see a doctor, we all assess the risks before we act. At least most of us who survive uninjured do. Now the risk associated with physical activity depends on our ability to perform â&#x20AC;&#x153;vector analysisâ&#x20AC;? and relate that to our physical abilities and goalsâ&#x20AC;&#x201D; all tasks learned from an early age. Choosing a doctor and following his or her advice is a more difficult and different assessment.

We at MACM have found most people want to know the risks involved with a particular course of action. At least judges and juries seem to like to see documentation that it has been presented to them. I find it odd that so many of our insured physicians resist documenting that they tried to present the risks to a fellow human being. Granted, some patients do not want to hear the risks of a particular medicine or surgical procedure. I can only assume that they are deferring that assessment to their family or the medical school or board of medical licensure or to the politicians. Our duty (so far) remains to our patients.

In the early days of cardiac surgery, the cardiopulmonary bypass machine was known as the â&#x20AC;&#x153;purple people eater,â&#x20AC;? and the techniques for surgical repair of complex congenital heart disease were primitive at best. Although he risks associated with cardiac surgery were great, many opted for the chance. A prominent cardiac surgeon was asked how he could perform a procedure with 30% mortality and supposedly he remarked, â&#x20AC;&#x153;The patient and I both understand the options and the risks.â&#x20AC;? In many ways, the situation with complex congenital heart disease was easier than what many doctors face today. A family with a â&#x20AC;&#x153;blue babyâ&#x20AC;? gasping for every breath and worsening by the day has a clear understanding of the non-surgical option while patients today canâ&#x20AC;&#x2122;t readily see the consequences of non-treatment. This in and of itself makes informed consent even more important. I cannot imagine why a physician would not explain and document the risks of treatment and non-treatment especially in non life threatening situations. It is part of risk management.

Assessing risks is critical to being alive and being a doctor. It is also critical to the successful management of an insurance company.

Source: The Risk Manager, Medical Assurance Company of Mississippi

Physicians Needed

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• 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.

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

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There’s a lot going on in organized medicine so it’s easy to miss something if you’re on the go. To help you stay in touch no matter where you are, MSMA is now communicating via “Twitter.”

In about three minutes, you can set up a free Twitter account for yourself. Simply visit www.twitter. com and submit your name, email address and mobile phone number (optional, standard text messaging rates apply). Once you’re signed up with Twitter, you can add MSMA by going to the following web page http://twitter.com/ MSMA1 and clicking “Follow” next to the MSMA icon.

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• SPECIAL ARTICLE • On Disaster Response Call with Dr. Dan Edney Karen A. Evers, Managing Editor The recent anniversaries of Hurricane Katrina and 9-11 remind us that the most devastating impacts of disaster are local. September was National Preparedness Month, an opportunity to renew our commitment to strengthen the ability of individuals and communities to rebound from traumatic, tragic, unpredictable events. Everyone knows the importance of planning before an emergency or crisis situation instead of reacting after a disaster. However, Daniel P. Edney, MD knows first-hand. Here the JMSMA looks at lessons learned by Dr. Edney and some preparedness areas that need attention. —ED.

F

or Dr. Daniel P. Edney, an internist in Vicksburg, medical volunteerism in general and disaster response medicine in particular are important priorities in his personal as well as professional life. “Serving others whether in desperate need due to socioeconomic pressures or catastrophic physical disasters has truly been part of my practice of medicine since 1997,” he said.

It was then Dr. Edney was led to help his church start a free clinic in his community for the working poor. He saw firsthand the impact one physician can have in making a difference in the lives of others in need when doctors are mentored and trained to be able to do so.

A few years later when our Mississippi State Medical Association offered the Basic Disaster Life Support (BDLS) Course for continuing medical education credit at MSMA Annual Session, Dr. Edney became BDLS certified.

The course aims to improve the care and coordination of response in disasters and other public health emergencies by developing a common approach and language among multiple disciplines in the health care community.

“I was first convicted about this issue in response to the 9-11 attacks. That fateful day was a wake-up call for physicians as well as the general population. I knew at that time that physicians, nurses, paramedics, and virtually all types of health care workers would be on the very front line of any mass casualty event.

At that time, our greatest concern was either bio-terrorism or nuclear/radiologic terrorism,” Dr. Edney recalled.

So that America’s health care system would be better prepared, the AMA and Center for Disease Control (CDC) jointly developed specialized training for working mass casualty events based on the model of basic and advanced life support. Dr. Edney said, “Unfortunately, medical school and residency programs were and are unable to dedicate the time it takes for training young doctors how to respond to such attacks. I was fortunate to be able to take the very first course as it was conducted at one of our AMA meetings.

“I did indeed pass the course and became certified in disaster life support. Thankfully, we have had no successful terrorist attacks on the Homeland since 9-11, and thus this training has not been put to the test for such situations. However, a catastrophic mass casualty event did occur on 1226-04 known as ‘the tsunami.’ As I heard the testimonies of physicians who had been caught in this tragedy and the great work they did to serve the people of the Indian Ocean rim, I was struck with the thought that my mass casualty training could also be used for natural disasters. It appeared to me this training

ON MISSION IN HAITI — Dr. Edney hugs a young man he befriended, McKenzie, the teenage son of one of the ladies in the compound's kitchen. His mother helped prepare meals while Dr. Edney was in the field doing clinic. “I saw him our first day doing clinic. He had a severe respiratory infection with fever and dehydration.

He was a sick young man. He was treated with IV antibiotics and given IV fluids while at clinic with us and completed his course of therapy with oral meds. He perked up quite quickly and we became fast friends. He followed us everywhere we went and wanted to help with any little chore we would give him to do. He quickly became our team mascot. This picture was taken the first day of our second trip to Haiti. As we were unloading, I felt a tap on my shoulder. When I turned in response, I was greeted by a most wonderful smile and in sweet Creole accent I heard, ‘Hello, Dr. Danny.’ It was McKenzie and, thankfully, someone caught and photographed our reunion. Hence, the picture I love,” Dr. Edney remarked.

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prior disaster-relief experience are generally not selected for assignments would equip me to be part of a relief effort team,” he explained. because they could inadvertently burden an ongoing relief effort.

The Indian Ocean Tsunami devastated Southeast Asia and “Because this training has made a difference in my practice life became the largest natural disaster in recorded human history. With a and my experience working level 3 disasters has shown me many areas few inquiries through the Mississippi Baptist Convention disaster that need further study in this field, I have great interest serving in this leadership, Dr. Edney was placed on a team that worked in Banda Aceh, capacity,” he said.

Indonesia.

Dr. Edney’s disaster response history clearly shows his level of “This was the first and hardest hit area within the tsunami zone. dedication to relief work, and his history of service in organized Indeed, the excellent training I had received was invaluable in working medicine demonstrates his commitment to the profession at large. effectively in this environment. I was honored to have had the opportunity to serve God in this manner,” he said.

“Working this natural disaster reinforced the importance for EDNEY APPOINTED TO THE EXECUTIVE COMMITTEE OF THE physicians to be trained in how to work and serve in this unique NATIONAL DISASTER LIFE SUPPORT EDUCATION CONSORTIUM environment. This fact was punctuated by volunteer physicians who Recently, Dr. Edney was appointed to serve a two-year term on were not appropriately trained working in this dangerous environment,” the Executive Committee of the National Disaster Life Support Dr. Edney said.

Education Consortium (NDLSEC) representing the American Medical One may recall in the immediate disaster response period Association (AMA). The NDLSEC promotes excellence in education, following Hurricane Katrina there were many well-meaning physicians training, and research to advance medical teams that respond to natural wanting to volunteer at the same time. “This is one of the many areas and man-made disasters. The consortium also promotes public health that needs attention,” Dr. Edney said. “Training is pivotal. You must preparedness for all medical professionals based on sound educational know how to respond properly.” principles, scientific evidence, and best clinical and public health In mass casualty events, physicians and other health care workers practices. must be knowledgeable of the need for efficient coordination among Dr. Edney’s first-hand experience in disaster response includes local, state, and federal emergency response efforts; how to protect clinical experience in the field with international and domestic medical themselves and others from further harm; how to communicate disaster response teams, leading training sessions in disaster effectively with other emergency personnel and the media; and how to preparedness and developing response capabilities. In recent years, he address the unique psychological impacts and related social chaos that has volunteered in the following ways in response to national disasters may ensue. “During a catastrophic emergency you don’t want across the globe: spontaneous unaffiliated volunteers (a phrase he termed SUVs) who get in the way of the chain-ofcommand,” Dr. Edney said.

This experience and knowledge prompted Dr. Edney to accept the opportunities to teach and train others interested in this aspect of medicine and to be an advocate for any potential first responder physician to become BDLS certified.

Physicians have skills that can be useful to those affected by the shortand long-term health consequences associated with disasters, such as the devastating Indian Ocean tsunami late last year.

While many opportunities At a makeshift clinic, Daniel Edney, who traveled to Haiti with a Mississippi Baptist disaster relief medical exist for physicians to team, prays over a man suffering from a high fever, dehydration, and serious infections. Dr. Edney said the become involved in disaster man developed pneumonia while trying to survive after the earthquake. Upon receiving IV antibiotics and relief, volunteers without fluids, he did very well.

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• led medical teams to Haiti as part of Baptist Global Response following earthquakes in 2010; • served on the medical response team in Southern Lebanon after the IsraeliLebanese War with Medical Mission Response in 2006; • served as a member of the medical response team to Banda Aceh, Indonesia, following the Indian Ocean tsunami disaster in 2005; and • served as medical coordinator for health care professionals from around the world and was responsible for acquisition and deployment of supplies and personnel for the Incident Command of the Mississippi Emergency Management Agency following Hurricane Katrina in 2005.

Dr. Edney is an internal medicine physician in Vicksburg and has been a member of the MSMA since 1993. He is an Assistant Professor of Medicine at the University of Mississippi School of Medicine where he teaches medical students clinical application of medical ethics and outpatient primary care and has also been active in mentoring students and residents in medical volunteerism. He is married to wife Lori, and together they have three children: Daniel, age 23; Meredith, age 21 and Meg, age 18.

The NDLSEC, an organization jointly-sponsored by the AMA and the National Disaster Life Support Foundation, Inc., is made up of professional organizations and individuals with an interest in public health preparedness and includes nationallyrecognized individuals, national medical specialty societies, state medical societies, academic medical centers, federal agencies, and other related organizations. Executive Committee members like Dr. Edney provide leadership and direction to the organization. The committee consists of seven AMA representatives, seven NDLSF representatives, three NDLSEC representatives and federal liaisons from the Department of Defense, Department of Health and Human Services, Department of Homeland Security, and Veterans Health Administration. For more information about the NDLSEC, visit the program website: http://www.ama-assn.org/ama/pub/physicianresources/public-health/center-public-health-preparedness-disaster-response/national-d isaster-life-support/ndlsec.shtml.

Lessons learned from these disasters, particularly Hurricane Katrina, can direct the efforts of those involved in public health response and planning. Volunteer medical personnel have been utilized to provide medical assistance to a large number of impacted persons. Many of our nation’s health professionals have been eager and willing to provide volunteer health services. Utilizing these volunteers in times of an emergency, however, presents challenges for hospital, public health, and emergency authorities, and raises a host of legal issues. The JMSMA will follow-up in subsequent issues with more information on the integration of the Medical Reserve Corps and the Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP), as well as other volunteer opportunities.

Mississippi Baptist Disaster Relief invites physicians and other health-care professionals to volunteer their time and skills through this or other relief organizations. For more information medical volunteers may contact Don Gann: (601)968-3339 or visit www.mbcb.org.

VIPR is Mississippi’s Emergency System for the Advance Registration of Volunteer Health Professionals (ESAR-VHP). The Mississippi State Department of Health Bureau of Emergency Preparedness and Planning Office of Emergency Planning and Response/MEMA Office also maintains a secure database of precredentialed health care professionals. For more information contact the State Volunteer/Medical Reserve Corps/ESAR-VHP CoordinatorLaveta Moody-Thomas, MPH, MSW, CHES: (601)933-6872 or e-mail: laveta.moodythomas@msdh.state.ms.us. Online volunteer registration is available at http://volunteer.msdh.state.ms.us. ❒

WHAT THEY SAY ABOUT HIM...

Daniel P. Edney, MD Medical Unit Director Mississippi Baptist Disaster Relief

The Mississippi State Medical Association was pleased to endorse the nomination of Dr. Daniel P. Edney to a position on the National Disaster Life Support Education Consortium Executive Committee. We believe his personal and professional dedication to disaster relief efforts demonstrates his interest and aptitude in this unique medical arena. Additionally, Dr. Edney has coordinated the efforts of both faith-based and lay disaster response teams and volunteers, which provides him with a unique perspective that would be valuable to the committee. —Tim J. Alford, MD, President, Mississippi State Medical Association

Dr. Edney has worked as a volunteer in Mississippi Baptist Disaster Relief for the past five years. He has served as a leader helping medical teams respond in disaster settings around the world. He has served in Indonesia following the Southeast Asia Tsunami. He led a team supported by Mississippi Baptist Disaster Relief to Lebanon following that country’s war with Israel. He also taught medical disaster response to doctors in Indonesia in 2007. Dr. Edney was also active in coordinating the Mississippi Baptist Disaster Relief medical response to Hurricane Katrina. He helped coordinate volunteer medical teams responding in the aftermath of the storm. He has been supportive and a mainstay of Disaster Relief in Mississippi. —Jim Didlake, Director, Mississippi Baptist Disaster Relief, Mississippi Baptist Convention

Dr. Edney has done at least six missions representing Southern Baptist Disaster Relief. He is visionary in his understanding of helping people in disaster settings world-wide. Dan is a dependable leader, a tireless worker, a compassionate caregiver, an insightful physician possessing a delightful sense of humor in the hottest, hardest, remotest places in the world. We have endured earthquakes, eternal plane rides, odd food, and strange diagnoses. Dan has a great ability to care for people within the cultural settings respectfully while taking the skills of western medicine and implementing them for the good of people in disaster settings around the world. —Don Gann, Assistant Director of Mississippi Baptist Disaster Relief

Dr. Edney is an extremely experienced and dedicated internal medicine physician with exceptional credibility within and beyond the medical profession. —J. Edward Hill, MD, Chair of Council, World Medical Association; Former AMA President

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• IQH •

Information & Quality Healthcare

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r. Dale Bratzler, a nationally known physician, author and lecturer on health care quality, will speak at a November program sponsored by Delta Regional Medical Center in November. Dr. Bratzler serves as the chief executive officer of the Oklahoma Foundation for Medical Quality.

Designated for one AMA PRA Category 1 Credit, the program has been planned for physicians, nurse practitioners, and other allied healthcare professionals and will be held at Vince’s in Leland on November 8 at 6 p.m. Dr. Bratzler’s topic will be “Why Physicians Should Care: Transformation to a Culture of Quality and What It Means for Your Future Medical Practice.”

He previously served as medical director for the Oklahoma Foundation for Medical Quality’s national quality improvement efforts. He was presented the Excellence in Physician Leadership Award by the James Q. Cannon Memorial Endowment and was named the 2002 American College of Osteopathic Internists Researcher of the Year. He is a past president of the American Health Quality Dr. Dale Bratzler Association and currently serves on the National Advisory Council for the Agency for Healthcare Research and Quality. He serves on the Editorial Advisory Board of the “Joint Commission Journal on Quality and Patient Safety” and on the editorial board for “Osteopathic Medicine and Primary Care.” Cited as co-author on over 100 publications on a variety of medical topics, he reviews manuscripts for 16 medical journals.

Dr. Bratzler received his Doctor of Osteopathic Medicine degree at the University of Health Sciences College of Osteopathic Medicine in Kansas City, MO. He obtained his master of public health degree from the University of Oklahoma Health Sciences Center College of Public Health and is board certified in internal medicine. He serves as an adjunct associate professor of health administration and policy at the University of Oklahoma College of Public Health.

Interested persons are invited to attend and should register with Angie Savoie by calling at 662-725-2699 or e-mailing her at asavoie@deltaregional.com.

Drs. Hartness and Herrin Join IQH Staff

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r. Stanley Hartness and Dr. Thomas Herrin, Jr. have joined the staff of IQH. Dr. Hartness is serving as medical consultant, and Dr. Herrin is medical director of review. “We welcome Dr. Hartness and Dr. Herrin to IQH,” said Dr. James S. McIlwain, president. “They bring valuable expertise to the mission of healthcare quality that IQH pursues with physicians and healthcare providers throughout the state.”

Dr. Hartness, the recipient of the IQH A. A. Derrick Physician Quality Award in 2005, has supported the quality efforts in numerous capacities over the years, serving on the IQH board of directors, as chairman of the board, and on various committees.

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Dr. Stanley Hartness

Dr. Thomas Jerrin, Jr.

A native of Kosciusko, Dr. Hartness studied at the University of Mississippi School of Medicine. He has specialty certifications as a diplomate in the American Board of Family Practice. After graduation and a rotating internship at UMC, Dr. Hartness was in practice with the Methodist Healthcare Family Care Center and then the Kosciusko Medical Clinic. He is a past president of the Mississippi Academy of Family Physicians. A former president of the Mississippi State Medical Association, Dr. Hartness is an associate editor of the Journal of the Mississippi State Medical Association.

Dr. Herrin received his medical degree from the University of Mississippi School of Medicine and is board certified in anesthesiology. He completed his residency at the University of Texas Medical Branch Hospital in Galveston. Dr. Herrin was a faculty member at Baylor College of Medicine in Houston, Texas, and the University of Mississippi Medical Center. At St. Dominic-Jackson Memorial Hospital, Dr. Herrin served as anesthesiologist, anesthesia service chief, medical staff secretary, and most recently as the medical director.

He served as anesthesia section chair of the Southern Medical Association and president of the Mississippi Society of Anesthesiologists. Active with the American Heart Association, Dr. Herrin has served as the Mississippi Affiliate president, the Southern Region chairman, and regional vice president and member of the board of directors. He also was editor of several American Heart Association CPR publications. â?&#x2019;

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HEALTHCARE BILL OFFERS OPPORTUNITY

By Stanford A. Owen, M.D.

On September 23, 2010 mandatory first dollar coverage for Preventive Healthcare from all insurance providers becomes law (Heatlhcare.gov). First dollar means pre-co-pay, precoinsurance, and pre-deductible payment for services. Coverage for Preventive services is mandatory for all health insurance policies. Many services not previously covered such as Nutrition Counseling, Diabetes Nutrition Therapy, and Obesity management are now mandated coverage. Up to two billion dollars per year are allocated for reimbursement.

This may offer significant opportunities for primary care physicians and certain Specialty physicians, especially those practices laden with Nutrition or Obesity-related illness: Diabetes Mellitus, Hypertension, Hyperlipidemia, Sleep Apnea, Back and Joint disease, Heart Disease, or Acid Reflux.

To qualify for reimbursement care must be part of a comprehensive nutrition plan and have demonstrable endpoints for treatment outcomes. Care must be provided by a qualified and licensed healthcare provider (MD, DO, FNP, PA, RD, PT) or direct (in office) supervision by physician-designated staff. Care must be individualized and documented or part of group counseling sessions combined with personal management. The law encourages all eligible patients to participate in Nutrition Therapy programs, prescriptive exercise, or services aimed at preventing illness or medication. The explicit goal is to reduce healthcare expenditures by preventing disease or using non-medication lifestyle interventions as initial/adjunctive treatment.

Recommendations are in line with all major textbooks, professional organizations, NIH, and CDC guidelines recommending Nutrition Therapy and/or exercise as primary treatment for many chronic diseases. That physicians receive minimal Nutrition or exercise education is a challenge.

Few commercial diet or Nutrition Therapy programs fulfill recommended requirements.

PrescriptFit™ Medical Nutrition Therapy, developed by Stanford A. Owen, M.D. of Gulfport, MS is a Nutrition Therapy program that routinely measures clinical outcome, is entirely self-teach to patients, requires no additional staff, and allows providers to follow and counsel patients as normally as prescribing medication. The program was developed specifically to treat Type 2 Diabetes but measures outcomes of 20 clinical endpoints including symptoms: fatigue, dyspnea, edema, heartburn, joint pain, urinary incontinence, headache, etc. or measures: blood pressure, A1C, lipid levels, liver enzymes (steatosis), PrescriptFit™ teaches nutrition, offers unique dietary strategies that allow individual customization, and excludes no food group. Portions are not restricted.

PrescriptFit™ is offered in clinics throughout Mississippi. For more information about offering Nutrition Therapy to maximize revenue and improve patient care, contact Dr. Owen at drowenmd@drdietcom or 228-864-9669. Visit the website at www.drdiet.com. Be sure to watch the video components in the left link.

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• UMHC •

UMHC Congenital Heart Surgeon Makes Mississippi History

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r. Jorge Salazar, University of Mississippi Health Care’s chief of congenital heart surgery, has performed the state’s first arterial switch on a Heidelberg newborn.

On August 4, Dr. Salazar performed the Medical Center’s first arterial switch procedure on Zavin, a complex procedure that involved switching the heart’s major arteries, which are reversed, back to their normal position and moving the delicate coronary arteries with the aorta. With the help of a highly skilled team of medical professionals, the surgery was successful.

“It’s one of the most complex heart surgeries done in children, and it’s the first time it has ever been performed in the state of Mississippi,” Dr. Salazar said. “This surgery represents the fact that we offer all congenital heart services here in Mississippi with excellent results.”

Since joining the Medical Center in April, Dr. Salazar and the congenital heart team have operated on 55 children with heart defects –all with excellent outcomes.

Jorge Salazar, MD and Zavin Georgianna Joe noticed her youngest son Zavin’s strange breathing when he was three days old. “I could see his stomach going in and out, in and out. He was breathing heavy,” she said.

The mother of two older sons, ages 8 and 9, couldn’t shake her concern, so she told a nurse who alerted a physician.

“He told me when he listened to his heart, he heard an echo. They said his oxygen level was low,” Joe said.

A short time later, an AirCare crew flew to Laurel to bring Zavin to the University of Mississippi Medical Center (UMMC) for a thorough examination. The diagnosis: transposition of the great vessels and a ventricular septal defect.

Transposition of the great vessels reverses the way blood circulates through the body, reducing the amount of oxygen in the blood. Without adequately oxygenated blood, the body can’t function properly.

In other words, Zavin was born with two major heart vessels switched and a hole in his heart.

“I remember when they told me. I just cried a lot,” Joe said. “But we had lots of prayers.”

Before Dr. Salazar joined the University of Mississippi Medical Center, Zavin and his mother would have had to abruptly leave the state and fly to another medical center to repair the defects. Instead, they made UMMC and Mississippi history.

Dr. Giorgio Aru, professor of surgery and heart transplant surgeon, said UMMC continues its legacy as a frontrunner in the treatment of cardiovascular diseases.

“For many years, the Division of Cardiothoracic Surgery has been actively looking for a national leader in pediatric cardiac surgery totally dedicated to the creation and leadership of a pediatric cardiac center,” he said. “We were finally able to recruit Dr. Salazar, who has the skills and the vision necessary to place the University of Mississippi Medical Center at the same level of the major centers in the country for pediatric cardiac care.”

Joe said support from hospital staff helped her cope with stress during what’s typically a joyous time. Often, her husband, Roberto Arellano, had to work and care for the other children while she remained at the hospital.

“It was scary at first, but whatever that would help him survive, we had to do it,” she said.

Dr. Salazar said the congenital heart program is just one way the Medical Center is working to improve children’s health.

For that, Joe said she was grateful. Zavin’s heart is now completely normal, and he will have the opportunity for a normal life.

Hospital beds have been Zavin’s only home since his birth July 21. Joe looks forward to taking her now 1-month-old son to meet family and friends for the first time and to sleep finally in his own bed. ❒

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• UMMC SOM •

U

The School of Medicine Class of 2014

niversity of Mississippi Medical Center School of Medicine class of 2014 matriculated 135 new students in August, making it the largest entering medical school class in over two decades. The diversity of the class can be described by several parameters. For example, members of the class have earned 28 different baccalaureate degrees from 29 different colleges and universities (12 in-state, 17 out-of-state); 38 of the students attended a junior or community college for at least one academic year. Average class metrics are: 28.4 MCAT sum, 3.64 science and math GPA and 3.7 overall GPA. The average age of the class is 23.8 years (range 22-32). All of the students are Mississippi residents, 54% are from medically underserved counties, 33% are female, 31% were repeat applicants, 18% are from rural counties, 16% are children of physicians, 10% are African American and 10% self-declared that they were from a disadvantaged background. There is every reason to expect this diverse group of students to perform as well as any class that went before it and yield the capable and compassionate physicians Mississippi needs to provide quality and equitable healthcare for all our state’s citizens.

—Steven T. Case, PhD Associate Dean for Medical School Admissions Professor of Biochemistry University of Mississippi Medical Center

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• PHYSICIAN'S BOOKSHELF •

Stiff: The Curious Lives of Human Cadavers

By Mary Roach ISBN 978-0-393-32482-2 303 pages. Includes introduction, images, and bibliography. $13.95, paperback. Distributed by W. W. Norton & Company, Inc.

I

n this 2003 New York Times Bestseller, Mary Roach explores the (mis)adventures that bodies take once their owners have expired as she details the historical uses that others have found for their anatomy from antiquity up to today. Roach, who had previously lent her pen to travel and popular science journalism, admits her initial naïveté before researching her subject. As she approaches the science of the dead from her own perspective, her sharp wit and undeniable sense of humor shine through as her eyes are opened to the myriad utilities of man’s earthly remains in the name of science.

Although the title of her book may be “Stiff,” Roach covers applications of the tissues of the dead that take place well before rigor mortis has set in. She details the use of the bodies of the very recently deceased for training students and residents in the skills of intubation and catheterization while simultaneously acknowledging the internal ethical debate surrounding it within the medical community. There is also a whole chapter devoted to the concept of the “beating heart cadaver”: a brain-dead cadaver whose tissues are being kept viable by artificial respiration for the purpose of transplantation into a patient on an organ waiting list. Roach truly shines in this chapter entitled “How to Know If You’re Dead,” as she delves into the historical searches for the corporal location of “the soul” and how they pertain to a legal definition of death.

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Roach leaves no stone unturned when examining the various motives some have had for modifying, disfiguring, or destroying a cadaver. There are the obvious medical uses of a body: teaching first year medical students anatomy, training surgeons in the latest techniques, and harvesting organs for transplantation. Then there are practical reasons for studying the dead. Learning how a body naturally decays in various conditions can help advance the study of forensic pathology.

Determining the physical thresholds of the human body to impact can provide information that makes a safer automobile.

Putting a human leg in protective gear that might see combat and then having that leg step on an anti-personnel landmine can aid in deciding what equipment will minimize the sufferings of soldiers.

However, the chapters that make Stiff so intriguing – albeit in a morbid sort of way – are those that involve the lesser-known uses of dead bodies throughout history. It is evident that Roach did her research when she discusses how dead bodies have been (or are being) used for everything from compost to test subjects in the investigation of the validity of the Shroud of Turin. One chapter is devoted to cannibalism – a practice that has been justified by reasons of survival, ritual, and medical benefit. Thankfully, Roach has decided to spend most of this chapter discussing the last rationale although what she finds in her research could be more unsettling than any commonly perceived aspect of anthropophagy.

Ultimately, the subject of this book is the author herself. Roach acknowledges in the Introduction that her only experience with a dead body prior to writing Stiff was with that of her mother in a funeral home, and even then she writes, “My mom was never a cadaver; no person ever is…My mother was gone.” Yet, as she explores the life of the dead more and more, she is forced to confront the fact that the deceased were once the living, and what happens to them now that they’ve passed can have just as strong of an effect on those who are still alive as they might have had before they died. Stiff becomes a discussion of necroeconomics: the potential benefit of a cadaver’s destruction is weighed against the cost of sacrificing reverence for the person who became that “hull.” As Roach examines that debate through her extensive exploration of a world few get to see, she comes to decide what she wants done with her own corpse when her time comes, which she reveals in the final chapter, “Remains of the Author.”

Roach lays out the details of death that she discovered as an outsider for an audience of outsiders, and it is for this reason that this book is a great read for any physician. It is important for those who have learned their trade through direct use of the dead and who probably have experienced death several times over as part of their job to remember that what they do is not normal. Very few people are as comfortable with death and the dead as doctors, and this new-comer’s reactions to what she’s discovering for the first time, all of which may or may not be common knowledge for a physician reading this book, are a refreshing flashback to the first day of gross anatomy lab, a moment of conflicting emotions and new sights and smells.

Also, if for nothing else, Stiff is a great read because its topic is instantly interesting, it’s very well written, and Mary Roach is downright hilarious.

—Alex Roy, M3 Tulane University School of Medicine, Class of 2012

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• ALLIANCE SPOTLIGHT •

Past President’s Spotlight: Mrs. John McRae (Eileene) MSMAA President, 2002-2003 • Hattiesburg

Far Right: Neva Eileene McRae takes the oath of office as 2002-03 President of the MSMA Alliance, administered

by Dr. J. Edward Hill.

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Dr. and Mrs. John M. McRae

here did you grow up? I was born in Moss Point. At age four, my father was transferred to Natchez, for his job with International Paper. I grew up in Natchez until I graduated from high school.

How did you meet your physician spouse? I met John while I was working in Jackson at the National Council on Alcoholism and Drug Dependence. I was the counselor there who had been hired to write programs for children who lived with parental addiction. John was working at the V.A. Hospital during this time and came to the National Council to read the newspaper during lunch each day.

What are the names and ages of your children? I have two stepdaughters: Lisa Steck, age 50, who lives in Boston; Katie Crenshaw, age 48, who lives in Olive Branch; and I have two sons: Travis Bedwell, age 40, who lives in Charlotte, North Carolina, and Matthew Bedwell, age 39 who lives in Starkville. We have eleven grandchildren ranging in age from 20 to 2-years-old: Adam Steck, Sophie Steck, John Murrell McRae, Austin McRae, Brennan Beheler, Lassiter Bedwell, Landry Bedwell, Alex Bedwell, Andrew Bedwell, Anderson Bedwell and Alli Bedwell.

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How do you spend your free time? Reading and writing are my hobbies. My favorite books have always been Lanterns on the Levee by William Alexander Percy and Gift from the Sea by Anne Morrow Lindbergh.

JOURNAL MSMA OCTOBER 2010

How did you come to join the Alliance? My good friends Mary Margaret Tatum and Peggy Crawford got me interested in the Alliance.

What is your favorite Alliance memory? My favorite Alliance memory is going to Chicago for the first time to Leadership Development Conference. I came home excited about the friends I had made during the meeting and about the wonderful work the Alliance does across our nation.

What are the highlights of your presidential year?

Two highlights come to mind during my year as president.

Firstly, traveling throughout the state with our membership chair, Karen Morris, singing the “Flamingo Song” encouraging unified membership was a real highlight. I also enjoyed hosting the 2003 Miss America, Erika Harold, during our annual session. Miss Harold’s platform was Preventing Youth Violence & Bullying: “Respect Yourself, Protect yourself.” Her keynote address was to “kick off” Phase II of the 2003-2004 MSMAA Health Project, “I Can Handle Bullies.” Plus, all the little girls at annual session (and my husband) enjoyed having their pictures taken with her while wearing her crown.

Do you have any advice for fellow physician spouses? My only advice would simply be to jump right in and become a member of the one of the best organizations there is. We truly are a medical family, and we do wonderful health work in our organization. ❒

• THE UNCOMMON THREAD •

Connect the Dots You know you’re still a passenger that’s passing on your way,

S

R. Scott Anderson, MD

Just trying to see what you can do to blunt the pain today?

he glides gracefully, feeling the wind slide over her wings, taking the longer path, keeping her aloft. She’s one with the sky, until she spots what it is that she’s been looking for, and then she adjusts the tension to correct her course, staying high, staying high until it’s almost too late. And then she drops. Talons out, extended, open.

Bracing for the shock of contact.

His name was Hugh Hefner. He’d heard the jokes his whole life. He wouldn’t hear them much longer. But he didn’t know that, or that the electric hedge trimmer was even plugged in.

Wheeling, wheeling almost too high to believe, she could see where the pine forests gave way to a small clearing with a tar paper shack in the middle of it.

Billy let his fingers slide along the sharp metal strings. It was a kid’s guitar, a little Yamaha. The neck was too narrow for his big old fingers, but he didn’t guess it mattered much any more if he buzzed a note or muffed a chord. He wasn’t going to get famous, maybe in another life, but not any time soon, anyway. At least he didn’t have to go back to the paper mill again.

He stopped playing for a minute and took a deep drag off of the cigarette between his lips. He held his breath for as long as he could, which wasn’t that long any more, before he let the smoke trickle out his nose. It had been more fun at eighteen. Smokin’ dope and playing guitar. He could see his future back then, he thought as he took another drag. It just didn’t quite turn out the way he saw it. He laid the joint down in the ashtray and went back to playing.

He started in on “El Camino Dolo Rosa,” the Mott the Hoople song, it was sad enough and he let the song wind around and around with a few variations each time around, before he let it ease into the rhythm line from “Southbound Again.” He’d liked that first album… time.

He stopped and sighed. I guess I got eternity to sit here and play, eternity and no time at all both together at the same

That’s what they mean by relativity, whatever you got is all relative. Thank God for the relatives; if it wasn’t for them his butt would starve. He reached for the joint that was smoldering in the ashtray, but the guitar bumped it and knocked it over. It was kind of weird to watch the red tip burn a hole in his pajama pants, the black ring growing, and not feel a damned thing. Couldn’t move his leg to shake it off, trying to get his arm out from around the little guitar to smack it off of him. He didn’t want holes burned in him if he could feel them or not. He smacked and fell sideways off the bed, the guitar broke as it hit the floor beside him.

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She was not so big a bird, not the bird that would not let it come day, her powers were small.

Mary was the mother of God, but she didn’t feel much like it as she walked down the children’s hallway at Central Baptist Church. She was picking her little girl up from the nursery just like her mama had when she still felt like she belonged here. When church was still a holy place. When she was a little girl. Before she changed.

Before she’d lost her virginity at fourteen, to Wiley Thomas, in the back of the choir box.

She looked at the sweet-faced Jesus standing in a flock of lambs that reached his hand out to her as she passed the stained glass window. Jesus is supposed to be merciful. If he was so merciful how’d he let her get pregnant by such a worthless shit as Frankie Wright? He hadn’t even seen the baby since it was born and now she was three years old, and he shows up, comes in off working the oil rigs in the Gulf and saying that he wants custody. Marries that little coonass tramp and now that makes him a daddy. He better hope Jesus forgives, she thought, cause if it was me I’d send his ass on the express elevator, straight down to hell. She never saw the Toyota car before it ran through the window, its gas pedal stuck to the floor. Jesus became a million diamonds that all rushed to her at once.

The bird called Death floated up again and flapped just once, before she started to glide, it had been a long day and she was full now. It was time to rest. She’d hunt again tomorrow, but for today, she was done.

A strange little idea that grew, and then she flew.

—R. Scott Anderson, MD Meridian

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

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JOURNAL MSMA OCTOBER 2010

Haǀe zŽu ŽŶƐidered a LiĨe SeƩlemeŶƚ &Žr zŽur Kld LiĨe /ŶƐuraŶcĞ WŽlicLJ? tŚĂƚ ŝƐ Ă >ŝĨĞ ^ĞƩůĞŵĞŶƚ͍ ůŝĨĞ ƐĞƩůĞŵĞŶƚ ŝƐ ƚŚĞ ƐĂůĞ ŽĨ ĂŶ ĞdžŝƐƟŶŐ ůŝĨĞ ŝŶƐƵƌĂŶĐĞ ƉŽůŝĐLJ ŽŶ ƚŚe ƐĞĐŽŶĚaƌLJ ŵĂƌŬĞƚ ƚŽ Ă ƚŚiƌĚ ƉĂƌƚLJ ŝŶǀĞƐƚŽƌ͘

tŚŽ Žƌ tŚĂƚ DĂLJ YƵĂůŝĨLJ͍ 9 /Ĩ ƚŚĞ ƉĞƌƐŽŶ ŝŶƐƵƌĞd ďLJ ƚŚĞ ƉŽůŝĐLJ ŝƐ ĂŐĞ ϳϬ Žƌ ŽůĚĞƌ 9 /Ĩ ƚŚĞ ƉĞƌƐŽŶ ŝŶƐƵƌĞd ŚĂƐ ĂŶLJ ŵĂũŽƌ ŵĞĚŝĐĂů ĐŽŶĚŝƟŽŶƐ 9 /Ĩ ƚŚĞ ƉŽůŝĐLJ ŚĂƐ Ă ĚeĂƚŚ ďeŶĞĮƚ ŽĨ ΨϮϱϬ͕Ϭ0Ϭ Žƌ ŵŽƌĞ 9 WŽůŝĐŝĞƐ ŝŶĐůƵĚŝŶŐ͕ ďƵƚ ŶŽƚ lŝŵŝƚĞĚ ƚŽ͕ ƵŶŝǀĞƌƐaů ůŝĨĞ͕ ƚĞƌŵ ŝŶƐƵƌĂŶĐĞ͕ ǀĂƌŝĂďůĞ ůŝĨe ŝŶƐƵƌĂŶĐĞ Žƌ ǁŚŽůĞ ůŝĨĞ ŝŶƐƵƌĂŶce 9 /Ĩ ĂŶLJ ĐĂƐŚ ǀĂůƵĞ ĞdžŝƐƚƐ ŝŶ ƚŚĞ ƉŽůŝĐLJ͕ ƚŚĞ ĂŵŽƵŶƚ ŝƐ ƌĞůĂƟǀĞlLJ ƐŵĂůů

&Žƌ DŽƌĞ /ŶĨŽƌŵĂƟŽŶ ŽŶ >ŝĨĞ ^ĞƩůĞŵĞŶƚƐ͕ ĐŽŶƚĂcƚ͗ ,͘ >ĂƌƌLJ &ŽƌƚĞŶďĞƌƌLJ͕ W ͕ >h͕ Ś& džĞĐƵƟǀĞ WůĂŶŶŝŶŐ 'ƌŽƵƉ͕ W 1640 Lelia Drive, Suite 220 PO Box 16566 Jackson, MS 39216 ;ϲϬϭͿ ϵϴϮͲϯϬϬϬ

tŚLJ hƐĞ Ă >ŝĨĞ ^ĞƩůĞŵĞŶƚ͍ 9 dĞƌŵ lŝĨĞ iŶƐƵƌĂŶĐĞ ƉŽůŝĐLJ ǁŝůů ĞdžƉŝƌĞ 9 KůĚ ƉŽůŝĐLJ ƚŚĂƚ iƐ ŶŽ ůŽŶŐĞr ŶĞĞĚĞĚ Žƌ ƉƌĞŵŝƵŵƐ ĐĂŶŶŽƚ ďĞ ƉĂŝĚ 9 ƉŽůŝĐLJ ƚŚĂƚ ǁĂƐ ƉƵƌĐŚĂƐeĚ ĨŽƌ Ă ďƵƐŝŶĞƐƐ ďƵLJ/ƐĞůů ĂŶĚ ŝƐ ŶŽ ůŽŶŐĞƌ ŶĞĞĚĞĚ 9 ƉŽůŝĐLJ ǁĂƐ ƉƵrĐŚĂƐĞĚ ĨŽƌ Ă bƵƐŝŶĞƐƐ ƚŚĂƚ ŚĂƐ ďĞĞŶ ƐŽůĚ Žƌ ŝƐ ŶŽƚ Ŷeeded 9 dŚĞƌĞ ŵĂLJ ďĞ Ă ďĞƩeƌ ƉŽůŝĐLJ ĂǀĂiůĂďůĞ Ăƚ Ă ůŽǁĞƌ ĐŽƐƚ

9 ƐƚĂƚĞ ǀĂůƵĞ ŚĂƐ ĐŚĂŶŐĞĚ ĂŶd ƚŚĞ ƉŽůŝĐLJ ŝƐ ŶŽ ůŽŶŐĞƌ ŶĞĞded

^ĞĐƵƌŝƟĞƐ KīĞƌĞĚ dŚƌŽƵŐŚ sĂůDĂƌŬ ^ĞĐƵƌiƟĞƐ͕ /ŶĐ͘ DĞŵďĞƌ &/ER ͕ ^/W /ŶǀĞƐƚŵĞŶƚ ĚǀiƐŽƌLJ ^ĞrǀŝĐĞƐ KīĞƌeĚ dŚƌŽƵŐŚ sĂůDĂƌŬ dǀŝƐĞƌƐ͕ /ŶĐ͘ Ă ^ ZĞŐŝƐƚĞrĞĚ /ŶǀĞƐƚŵĞŶƚ ĚǀŝƐŽƌ ϭϯϬ ^ƉƌŝŶŐƐŝĚĞ DƌŝǀĞ͕ ^ƵŝƚĞ ϯϬϬ ŬƌŽŶ͕ KŚŝŽ ϰϰϯϯϯ-ϮϰϯϭΎ ϭͲϴϬ0-765-5201 džĞĐƵƟǀĞ WůĂŶŶŝŶŐ 'ƌŽƵƉ ŝƐ Ă ƐĞƉaƌĂƚĞ ĞŶƟƚLJ ĨƌŽŵ sĂlDĂƌŬ ^ĞĐƵƌŝƟĞƐ͕ /ŶĐ͘ ĂŶĚ sĂůDĂƌŬ dǀŝƐĞƌƐ͕ /ŶĐ͘ In a lifĞ ƐĞƩůement agreement, the current life insurance policy owner transfers the ownership ĂŶĚ ďĞŶĞĮĐŝĂrLJ ĚĞƐŝŐŶĂƟons to a third party, who receives the death proceeds at the passing of the insured. As a result, this buyer has Ă ĮŶĂŶĐŝĂl interest in the seller’s death. When an individual decides to sell their policy, he or she must provide complete access to his or her medical history, and other personal inforŵĂƟŽŶ͕ ƚhat mĂLJ Ăīect his or her life expectĂŶĐLJ͘ dŚŝƐ ŝŶĨŽƌŵĂƟon is requested during the ŝŶŝƟĂl ĂƉƉůŝĐĂƟŽŶ for a life ƐĞƩůĞŵĞŶƚ͘ Ōer the coŵƉůĞƟŽŶ ŽĨ ƚhe sale, there may be an ongoinŐ ŽďůŝŐĂƟŽŶ to disclose siŵŝůĂƌ ĂŶĚ ĂĚĚŝƟonal inforŵĂƟŽŶ Ăƚ Ă ůater date. ůŝĨĞ ƐĞƩlement may aīect the seller’s eligibility for certain public assistance programs, such as Medicaid, and there may be tax consequences. Individuals should discuss ƚŚĞ ƚĂdžĂƟŽŶ of the proceeds received with their tax advisor. ValMark SecƵƌŝƟĞƐ considers Ă ůŝĨĞ ƐĞƩůĞŵĞŶƚ Ă ƐecuritLJ ƚƌĂŶƐĂĐƟŽn. ValMark and its registered represĞŶƚĂƟǀĞƐ ĂĐƚ ĂƐ brokers on the transacƟŽŶ ĂŶĚ ŵĂLJ receive a fee from the purchaser. A life seƩůĞŵĞŶƚ tƌĂŶƐĂĐƟon may require an extended period oĨ ƟŵĞ ƚo complete. Due to complexity of tŚĞ ƚƌĂŶƐĂĐƟon, fees and costs incurred witŚ ƚŚĞ ůŝĨĞ ƐĞƩlement tranƐĂĐƟŽŶ ŵĂLJ ďe ƐƵďƐƚĂŶƟally higher than otheƌ ƐĞĐƵƌŝƟes.