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Publications Committee Dwalia S. South, MD Chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD Leslie E. England, MD, Ex-Officio Myron W. Lockey, MD, Ex-Officio and the Editors The Association Thomas E. Joiner, MD President Steven L. Demetropoulos, MD President-Elect J. Clay Hays, Jr., MD Secretary-Treasurer Lee Giffin, MD Speaker Geri Lee Weiland, MD Vice Speaker Charmain Kanosky Executive Director
Journal of the Mississippi State Medical Association (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices. CORRESPONDENCE: Journal MSMA, Managing Editor, Karen A. Evers, P.O. Box 2548, Ridgeland, MS 39158-2548, Ph.: (601) 853-6733, Fax: (601)853-6746, www.MSMAonline.com. Subscription rate: $83.00 per annum; $96.00 per annum for foreign subscriptions; $7.00 per copy, $10.00 per foreign copy, as available. Advertising rates: furnished on request. Cristen Hemmins, Hemmins Hall, Inc. Advertising, P.O. Box 1112, Oxford, Mississippi 38655, Ph: (662) 236-1700, Fax: (662) 236-7011, email: cristenh@watervalley.net POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 391582548. The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association. Copyright© 2011 Mississippi State Medical Association.
SEPTEMBER 2011
VOLUME 52
NUMBER 9
Scientific Articles
Suspected Bile Duct Injuries and Appropriate Early Referral Can Reduce Chances of Litigation
275
Emily A. Rogers, MD; Shou-jiang Tang, MD; John Porter MD, FACS; Naveed Ahmed MD, FACS
UpToDate Medicine: Use of Non-Invasive Ventilation in General Ward for the Treatment of Respiratory Failure Sadeka Tamanna, MD, MPH and M. Iftekhar Ullah, MD, MPH
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Thomas E. Joiner, MD; MSMA President
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“Let us never forget,” in memory of 9/11 ten years ago — Martin M. Pomphrey, Jr., MD, a semi-retired orthopaedic surgeon sub-specializing in sports medicine who practiced with Oktibbeha County Hospital (OCH) Bone and Joint Clinic in Starkville, created this cover from separate photographs. Dr. Pomphrey photoshopped the Twin Towers and surrounding buildings, superimposing the images onto a picture he took of the American flag. The still peaceful image is in contrast to that the New York Times reported on 9/12/01:“Hijackers rammed jetliners into each of New York’s World Trade Center towers yesterday, toppling both in a hellish storm of ash, glass, smoke, and leaping victims.” Americans are asked to come together as a nation for a Moment of Remembrance at 1 p.m. EDT on September 11, 2011 to memorialize the 10th anniversary of the 9/11/01 terrorist attacks. The reflective memorial moment calls for state and local governments, media, houses of worship, military and veteran organizations, airports and railroads, sports teams, businesses and individuals should cease all work or other activity for one minute and mark the moment in an appropriate manner, such as by ringing bells or sounding sirens and other actions to remember the victims. The 9/11 Memorial at the World Trade Center site in New York City will be dedicated in a special ceremony on 9/11/11 for the victims’ families. The National September 11 Memorial & Museum in New York City is scheduled to open to the public on 9/12/11. A live webcam offers high definition views of the construction at: 911memorial.org/911-memorial-webcam. r September
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• Scientific Articles • Suspected Bile Duct Injuries and Appropriate Early Referral Can Reduce Chances of Litigation Emily A. Rogers, MD; Shou-jiang Tang, MD; John Porter MD, FACS; Naveed Ahmed MD, FACS
I
ntroduction
Bile duct injury following laparoscopic cholecystectomy is one of the most feared complications related to performing a cholecystectomy. Early identification and repair can be life saving for patients with bile duct injuries. Since the early 1990s, laparoscopic cholecystecomy (LC) has replaced open cholecystectomy as the preferred treatment of symptomatic cholethiasis, biliary dyskinesia, and cholecystitis. LC has decreased the length of hospital stay and post-operative pain and resulted in a subsequent faster return to normal daily activities; nonetheless, LC has a higher incidence in bile duct injury as compared to open cholecystectomy. Nearly all studies report the incidence of bile duct injury following open cholecystectomy between 0.1% and 0.2%. In comparison, LC has a reported incidence of bile duct injury between 0.4% and 0.7%.1 The aim of this article is to review our initial experience with work-up and repair of bile duct injuries following LC performed at outside facilities and referred to the University of Mississippi Medical Center (UMMC) for definitive therapy. We will also review the classification of these injuries, preferred methods of diagnosis, and benefits of early treatment as well as factors that frequently lead to litigation following bile duct injury. Author Information: Dr. Rogers – Prior to graduation in June, Dr. Rogers was administrative chief resident in the Department of General Surgery at the University of Mississippi Medical Center. She has begun a critical care fellowship at The Johns Hopkins Hospital in Baltimore, Maryland. Dr. Tang – Associate Professor in the Division of Digestive Diseases at the University of Mississippi Medical Center with specific training in advanced endoscopy. Dr. Porter – Chief of Trauma and Acute Care Surgery in the Department of Surgery at the University of Mississippi Medical Center. Dr. Ahmed – Associate Professor of Surgery in the Department of Surgery at the University of Mississippi Medical Center with specialized training in hepatobiliary surgery. Corresponding Author: Naveed Ahmed, MD, 2500 N. State Street, Department of Surgery, Jackson, MS 39216 Telephone: (601)9845120, Email: (nahmed@umc.edu).
Key Words: Bile Duct Injury, Cholecystectomy, Litigation Methods We review four patients referred to us in the last year (Jan 1, 2010- Dec 31, 2010) with suspected bile duct injuries. Our review examines the types of duct injuries identified, the severity of duct injuries, and the time after LC to diagnosis of injury. We also discuss the patients’ opinion of care provided by both the referring physician and the accepting surgeon at UMMC. Over the period of 1 year, 4 patients were seen for suspected bile duct injuries: 3 patients were referred by their physicians and 1 patient came for a second opinion. The injuries in our patients fell into three categories: 1) No injuries 2) Early referrals 3) Late referrals
Results No injury category
This patient had persistent jaundice after LC and was transferred from an outside emergency department. The working diagnosis on arrival was bile duct injury. A computed tomography (CT) scan was obtained which was suspicious for an E4 duct injury. The original surgeon was contacted and reported that an intraoperative cholangiogram (IOC) was performed and was normal. A diagnostic laparoscopy was then performed at UMMC which revealed no adverse changes. Intraoperatively, an endoscopic retrograde cholangiopancreaticography (ERCP) was performed by our advanced GI colleague who demonstrated normal post-operative anatomy. The procedure was terminated after a laparoscopic liver biopsy.
Early Category
Two patients with suspected bile duct injuries were referred in by their original operating surgeons with suspected
September 2011 JOURNAL MSMA 275
bile duct injuries within 72 hours of completion of the original operation. Both of these patients had E4 injuries and underwent a Roux-en-Y Hepaticojejunostomy (HJ) with no post-operative complications. Both patients were upset with this complication but understood that this was a known complication of LC and had no interest in litigation.
Figure 1. Surgical clip on the bile duct resulting in non-filling of intrahepatic ducts
Late Category
This patient was referred five days after LC and presented with biliary ascites and jaundice. An ERCP completed by our advanced GI associate showed complete transection of the common bile duct (Figure 1). This patient had CT guided drainage and percutaneous transhepatic cholecystomy (PTC) tube placement for worsening sepsis (Figure 2). This patient was treated conservatively for eight weeks and then a Roux-en-Y HJ was completed. Post-operatively, we had a lengthy conversation with this patient regarding common bile duct injuries. We discussed openly that a common bile duct injury is a known complication of LC and that at least one of the UMMC staff surgeons has had a bile duct injury in their career; however, even after frank discussion, this patient fails to understand and wants to pursue a legal route.
Discussion Bile duct injuries following LC, while not common, do occur and can lead to litigation in specific situations. Early referral to a tertiary center with a trained hepatobiliary specialist improves patient morbidity and reduces the incidence of litigation. It is reported that 32% of patients who have a major bile duct injury pursue litigation.2 There are two factors associated with an increased likelihood of litigation by patients with major bile duct injuries: first, patient age younger than 52 years and second, immediate repair performed by the referring surgeon rather than a hepatobiliary specialist.2 Management of bile duct injuries following LC is dictated by two major factors – type and severity of injury and time to diagnosis of the injury. Early recognition of bile duct injuries, either intraoperatively or immediately postoperatively, led to improved outcomes and reduced morbidity for these patients. Unfortunately, only 35% of bile duct injuries are recognized intraoperatively.3 If there is suspicion for an injury intraoperatively, conversion to open cholecystecomy should be performed as well as a cholangiogram to determine the location and extent of injury. At this point, the surgeon has the option to place drains and transfer the patient to a tertiary referral center or repair the injury independently. Retrospective reviews demonstrate a 17% success rate following repair by the primary surgeon compared to a 94% success rate when the injury was repaired by a tertiary care hepatobiliary specialist.4 Bile duct injuries that are recognized early in the postoperative period typically present with non-specific symptoms that include abdominal pain, nausea, vomiting, jaundice, peritonitis and sepsis. If a bile duct injury is suspected, a CT scan should be obtained during the initial workup and sepsis must be controlled.
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Figure 2. PTC catheter in proximal bile duct, with surgeon’s index finger on portal vein
7, 8 5,6 Table1. 1. Strasberg-Bismuth Strasberg-BismuthClassification Classification Injuries Table of of Injuries
Type A Type B Type C Type D Type E1 Type E2 Type E3 Type E4 Type E5
Cystic duct leaks or leaks from small ducts in the liver bed Occlusion of part of the biliary tree, typically clipped and divided right hepatic ducts Transection (but not ligation) of the aberrant right hepatic ducts Lateral injuries to major bile ducts Common hepatic duct division, >2cm from bifurcation Common hepatic duct division, <2cm from bifurcation Common bile duct division at bifurcation Hilar stricture, involvement of confluence and loss of communication between right and left hepatic duct Involvement of aberrant right hepatic duct alone or with concomitant stricture of the CHD
Intra-abdominal fluid collections are typically drained percutaneously and broad spectrum antibiotics instituted. While CT is a valuable imaging modality initially for assessing intra-abdominal fluid collections and ductal size, MRCP or ERCP is the best modality to determine the extent and location of the bile duct injury. After identifying the location and extent of the injury, operative repair should be planned. If this is within the first 24-48 hours following LC, then proceeding with a Roux-N-Y HJ is the best course of action after defining the anatomy with an ERCP or MRCP. Since success rates following repair of
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bile duct injuries without obtaining a cholangiogram are poor, ranging from 4 to 31%, it is definitely beneficial to get proper imaging.4,5,6 In comparison, there is a reported 84% success rate when a cholangiogram is completed preoperatively. If the time to diagnosis is longer than 48 hrs, PTC placement with adequate drainage for 6-8 weeks is the best option with eventual return to the operating room for HJ. Injuries are typically classified using the Bismuth-Strasburg classification system (Table 1). This identifies the injury based on the surgical injury site and provides a system for clear surgeon communication. With respect to litigation following bile duct injury after LC, the biggest risk factors identified in a recent study are young age (patient age less than 52 years), related vascular injury, and immediate repair by the primary surgeon rather than a hepatobiliary specialist.2 The results of our case series yield similar results with one out of the three patients referred with bile injuries pursuing litigation. Early consultation for possible bile duct injuries will improve the outcome of these patients.
References 1.
Adamsen S, Hansen OH, Funch-Jensen P, Schulze S, Stage JG, Wara P. Bile duct injury during laparoscopic cholecystectomy: a prospective nationwide series. J Am Coll Surg. 1997;184:571-8.
2.
Perera MTPR, Silva MA, Shah AJ, Hardstaff R, Bramhall SR, Issac J, Buckels JAC, Mirza DF. Risk factors for litigation following major transactional bile duct injury sustained at laparoscopic cholecystectomy. World J Surg. 2010;34:26352641.
3.
Sicklick JK, Camp MS, Lillemoe KD et al. Surgical management of bile duct injuries sustained during laparoscopic cholecystectomy: perioperative results in 200 patients. Ann Surg. 2005; 241:786-92.
4.
Stewart L, Way LW. Bile duct injuries during laparoscopic cholecystectomy. Factors that influence the results of treatment. Arch Surg. 1995;130:1123-8.
5.
Bismuth H, Majno PE. Biliary strictures: classification based on the principles of surgical treatment. World J Surg. 2001;25: 1241-44.
6.
Strasberg SM, Hertl M, Soper NJ. Analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg. 1995;180:101-25.
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September 2011 JOURNAL MSMA 277
• UpToDate Medicine • Use of Non-Invasive Ventilation in General Ward for the Treatment of Respiratory Failure Sadeka Tamanna, MD, MPH and M. Iftekhar Ullah, MD, MPH
I
ntroduction
Non-invasive ventilation (NIV), the provision of ventilatory assistance without an artificial airway, has emerged as an important ventilatory modality over the last 20 years. Delivery of pressured air at a certain level through a nasal or oro-nasal mask improves oxygenation and reduces ventilatory muscle fatigue. The equipment consists of a ventilator (typically a CPAP or BiPAP machine) with tubing, headgear, nasal or facial mask, filter and humidifier (Figure 1). In this article, we will discuss the medical literatures that support the use of NIV safely and effectively on the general medical floor to treat respiratory failure secondary to acute exacerbation of chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF).
CPAP machine
Nasal mask
Key words: Non invasive ventilation, COPD, CHF
Trachea Tube connected to CPAP/ BiPAP machine
Background Continuous positive pressure ventilation (CPAP) and bilevel positive pressure ventilation (BiPAP) are the two major types of NIV in clinical use. Obstructive sleep apnea and respiratory difficulty from neuromuscular diseases were the primary indications for NIV when it was first introduced in early 1980’s. NIV was used to treat acute respiratory failure to avoid risks of intubation in the mid-nineties. Many applications of NIV have been tried in critical care settings while only four of them have been recommended after multiple randomized controlled trials (RCTs). Those four indications include acute exacerbation of chronic obstructive pulmonary disease (COPD), cardiogenic pulmonary edema, facilitation of extubation in COPD patients and immune-compromised patients who are at higher risk of complication from intubation.1
Author Information: Dr. Tamanna is an assistant professor in general internal medicine and sleep medicine at the University of Mississippi Medical Center. She is medical director of the sleep disorders laboratory at the G.V (Sonny) Montgomery VA Medical Center in Jackson. E-mail: stamanna@umc.edu; sadeka.tamanna@ va.gov. Dr. Ullah is an assistant professor in the division of general internal medicine at the University of Mississippi Medical Center, E-mail: mullah@umc.edu.
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Strap retaining the mask
September 2011
Figure 1: Non invasive ventilation (NIV) using a nasal mask ( CPAP machine connected to a dummy shown in the upper right corner)
Patients with respiratory failure either from COPD or congestive heart failure (CHF) exacerbation, are admitted frequently in every hospital. While NIV is already used in the ICU to treat the above cases helping to reduce intubation and long term hospital stays, not all of these patients meet the criteria for entry into the ICU on the first day of admission. Mild to moderate cases of respiratory failure that decompensate over hours to days despite optimal medical management on the medical floor need to be evaluated for transfer to the ICU or get intubated on the floor after sudden deterioration, only to be sent to ICU. The medical literature now supports the early use of NIV for certain patients on the general medical ward to prevent intubation and decrease mortality. The opportunity for a successful intervention may be lost if delay arises in initiating NIV, allowing the underlying disease to progress too far.2
NIV in Acute Exacerbation of COPD COPD carries a tremendous financial, medical and psychological burden on society. Acute COPD exacerbations are responsible for more than 500,000 hospitalizations per year in the United States, and 6% to 34% of them die.3 Adding noninvasive ventilation to conventional therapy of COPD showed promising results. Bott et al. first published results of an RCT comparing conventional treatment and conventional treatment plus NIV for acute exacerbation of COPD. NIV was shown to improve the pH significantly in such patients (p<0.001) and caused steady gradual fall in pCO2 (p<0.001) compared to the control group.4 Patients with acute respiratory failure eventually develop inspiratory muscle fatigue and mere increase in the respiratory rate does not fully compensate for the ventilatory insufficiency. NIV provides a larger tidal volume with the same inspiratory effort helping to improve alveolar ventilation. 5 It also decreases the work of breathing by partially overcoming the auto-PEEP (positive end expiratory pressure) in certain situations. An auto PEEP is the abnormal residual pressure greater than the atmospheric pressure remaining in the alveoli at the end of exhalation due to air trapping in severe COPD. Improvement of gas exchange by improving alveolar ventilation lowers mortality, decreases the length of hospital stay and need for critical care admission and thus lowers the overall hospital cost. Plant and colleagues randomized two groups of patients to NIV (BiPAP with face mask) and standard treatment for COPD exacerbation in the general ward. In this study, NIV has been shown to decrease the mortality and need for intubation significantly. PH, respiratory rate and PCO2 also improved significantly in the NIV group. 2 In another systematic review of randomized controlled trials that compared NIV and usual medical care in patients admitted to the hospital with respiratory failure resulting from COPD exacerbation demonstrated a lower mortality (RR 0.41, 95% CI 0.26-0.64), a lower need for intubation (RR 0.42, 95% CI 0.31-0.59), a lower likelihood of treatment failure (RR 0.51, 95% CI 0.38%-0.67%) and greater improvements at 1 hour of PH, PaCO2 and respiratory rate. The average length of hospital stay for COPD exacerbation with optimal medical treatment is usually 6-7 days.6 Use of NIV has been found to shorten the hospital stay (mean 3.24 days, 95% CI 4.42-2.06) and decrease complications associated with treatment (RR 0.32, 95% CI 0.18-0.56).7 This may translate into reducing the financial burden significantly on hospitals and patients as well. These findings have been further supported by a meta analysis of 15 RCTs comparing the addition of NIV to standard therapy alone for acute COPD exacerbation, showing a decrease in the rate of endotracheal intubation (RR 28%, 95% CI 15-40%), length of hospital stay (absolute reduction 4.57 days, 95% CI 2.3-6.83), and hospital mortality rate (RR 10%, 95% CI 5-15%).8
NIV in Acute Exacerbation of CHF Heart failure affects 5 to 6 million North Americans each year and continues to be associated with repeated hospitalizations, high morbidity and mortality. The average length of hospital stay for patients with heart failure was found to be about 5.9 days.9 An RCT comparing oxygen, CPAP and BiPAP in patients with acute cardiogenic pulmonary edema found a significant reduction in the need of intubation in NIV group (p=0.001). 10 Up to 51% of patients with CHF have been found to have sleep-related periodic breathing disorders. 11 It is well known that CPAP improves arterial oxygenation and decreases left ventricular after-load, as well as the work of breathing in patients with acute cardiogenic pulmonary edema. CPAP has shown to improve the morbidity, mortality and left ventricular ejection fraction among patients with heart failure and sleep disorder. According to the European Cardiology Task Force, non-invasive ventilation and CPAP are regarded as first line treatments together with standard medical therapy when respiratory failure ensues from cardiogenic pulmonary edema. Oxygen masks are primarily used for the treatment of hypoxemia in heart failure. Two randomized controlled trials showed that CPAP use may cause significant improvement in PaO2 and stroke volume index while decreasing intrapulmonary shunt and alveolar arterial oxygen gradient in acute cardiogenic pulmonary edema compared to the treatment with oxygen only. 12, 13 CPAP has been recommended as the initial noninvasive treatment of choice due to its greater simplicity and lesser expense.12, 14 NIV induces a more rapid improvement in respiratory distress and metabolic disturbance than does standard oxygen therapy but had no effect on short term mortality. 13 Despite the benefits and approved guidelines, the utilization of NIV is still not adequate. In a survey in the Massachusetts and Rhode Island area in 2006, it was found that only 33% of patients with COPD and heart failure, who may have been candidates for NIV, were actually receiving it.15 Potential reasons for lower utilization include lack of awareness among physicians about its indication and efficacy, lack of sufficiently trained respiratory therapists, and lack of sufficient equipment in the hospital.
Who is a candidate for NIV in the general ward? Patients with mild respiratory acidosis (pH as low as 7.30) and mild to moderate respiratory distress caused by an acute COPD exacerbation or hypoxemia from heart failure are the ones that benefit most from non-invasive ventilation. Hemodynamically stable patients with mild to moderate COPD exacerbation (pH â&#x2030;Ľ 7.30) and cardiogenic pulmonary edema with hypoxemia can be treated safely and effectively in the general ward if the hospital physicians and the staff have appropriate expertise.2, 16 Very recently, the Canadian Medical Association has published clinical practice guidelines after reviewing 3033 studies and 146 RCTs and recommended NIV for severe COPD exacerbation and cardiogenic pulmonary edema (in the absence of shock or acute coronary syndrome requiring urgent coronary
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Table 1: Indications, Contraindications and Risks of NIV in General Ward ( Modified from Nava et al. Non-invasive ventilation in acute respiratory failure. Lancet. Jul 18 2009) 1 Table 1. Indications, Contraindications and Risks of NIV in General Ward1
Indications
Contraindications
Risks
Clinical observations:
Absolute Contraindications:
Potentially fatal:
Increased dyspnea-moderate to severe
Respiratory arrest or impending respiratory failure
Progressive respiratory decompensation
Tachypnea (>24 breaths per minute in obstructive, >30 per min in restrictive)
Unable to fit mask
Cardiorespiratory arrest
Relative Contraindications:
Non fatal:
Medically unstable: hypotensive shock, Signs of increased work of uncontrolled cardiac ischemia or breathing, accessory muscle use, arrhythmia, uncontrolled copious Upper and abdominal paradox GI bleeding Gas exchange parameters: PaCO2>45 mm Hg pH 7.3-7.35 Hypoxemia (use with caution), Pa02/Fi02 ratio <200
Aspiration of gastric content Gastric distention
Agitated, uncooperative or profoundly drowsy
Skin necrosis of the face at the site of mask
Unable to protect airway
Difficulty in clearing airway secretions
Swallowing impairment Excessive airway secretions, not managed by secretion clearance techniques Multiple organ failure (two or more) Recent upper airway or upper gastrointestinal surgery
revascularization).17 The need for sedation in NIV is minimal or none compared to intubation, and thus the patients can maintain spontaneous breathing and can be weaned off more easily. However, it should be avoided in patients with contraindications (see table 1). Those patients should be treated in the intensive care unit with prompt intubation as soon as possible.
medical floor outside intensive care units. If used early during hospitalization, it helps prevent intubation, reduce mortality and decrease the length of stay in the hospital. However, it
Key points
Risk of NIV Use on the General Medical Floor Despite numerous benefits of NIV, it is not without risks. Patients may start to deteriorate while on NIV, and they may go unnoticed by the ward staff, thinking that they are being safely managed by NIV. To avoid that, a formal protocol of monitoring respiratory rate, hypoxemia and blood gases for these patients must be in place. Table 1 describes the potential risks associated with NIV, along with its indications and contraindications.
1. NIV ( CPAP/BiPAP) may be used safely on the general medical floor to treat respiratory failure from COPD and CHF.
Conclusion
4. It should be used when trained physician and personnel are available to monitor the patient on the medical floor with a formal treatment protocol in place.
On the basis of controlled trials, NIV is now considered as a safe and effective therapy to treat patients with respiratory failure from COPD or congestive heart failure on the general
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2. If used early during hospitalization, it helps prevent intubation, reduce mortality, and decrease the length of stay in the hospital. 3. It reduces the need for sedation and improves patient comfort.
should be done in a closely monitored setting by trained physician and personnel following an appropriate treatment protocol to avoid potential complications.
References 1.
Nava S, Hill N. Non-invasive ventilation in acute respiratory failure. Lancet. 2009;374(9685):250-259.
2.
Plant PK, Owen JL, Elliott MW. Early use of non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease on general respiratory wards: a multicentre randomised controlled trial. Lancet. 2000;355(9219):1931-1935.
3.
Connors AF, Jr., Dawson NV, Thomas C, et al. Outcomes following acute exacerbation of severe chronic obstructive lung disease. The SUPPORT investigators (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments). Am J Respir Crit Care Med. 1996;154(4 Pt 1):959-967.
4.
Bott J, Carroll MP, Conway JH, et al. Randomised controlled trial of nasal ventilation in acute ventilatory failure due to chronic obstructive airways disease. Lancet. 1993;341(8860):1555-1557.
5.
Mehta S, Hill NS. Noninvasive ventilation. Am J Respir Crit Care Med. 2001;163(2):540-577.
6.
Mushlin AI, Black ER, Connolly CA, Buonaccorso KM, Eberly SW. The necessary length of hospital stay for chronic pulmonary disease. JAMA. 1991;266(1):80-83.
7.
8.
Lightowler JV, Wedzicha JA, Elliott MW, Ram FS. Non-invasive positive pressure ventilation to treat respiratory failure resulting from exacerbations of chronic obstructive pulmonary disease: Cochrane systematic review and meta-analysis. BMJ. 2003;326(7382):185. Keenan SP, Sinuff T, Cook DJ, Hill NS. Which patients with acute
exacerbation of chronic obstructive pulmonary disease benefit from JNLMSMed-BW2 noninvasive positive-pressure ventilation? A systematic review of the literature. Ann Intern Med. 2003;138(11):861-870.
9.
Malki Q, Sharma ND, Afzal A, et al. Clinical presentation, hospital length of stay, and readmission rate in patients with heart failure with preserved and decreased left ventricular systolic function. Clin Cardiol. 2002;25(4):149-152.
10. Park M, Sangean MC, Volpe Mde S, et al. Randomized, prospective trial of oxygen, continuous positive airway pressure, and bilevel positive airway pressure by face mask in acute cardiogenic pulmonary edema. Crit Care Med. 2004;32(12):2407-2415. 11. Javaheri S, Parker TJ, Liming JD, et al. Sleep apnea in 81 ambulatory male patients with stable heart failure. Types and their prevalences, consequences, and presentations. Circulation. Jun 2 1998;97(21):2154-2159. 12. Lin M, Yang YF, Chiang HT, Chang MS, Chiang BN, Cheitlin MD. Reappraisal of continuous positive airway pressure therapy in acute cardiogenic pulmonary edema. Short-term results and long-term followup. Chest. 1995;107(5):1379-1386. 13. Gray A, Goodacre S, Newby DE, Masson M, Sampson F, Nicholl J. Noninvasive ventilation in acute cardiogenic pulmonary edema. N Engl J Med. 2008;359(2):142-151. 14. Lin M, Chiang HT. The efficacy of early continuous positive airway pressure therapy in patients with acute cardiogenic pulmonary edema. J Formos Med Assoc. 1991;90(8):736-743. 15. Maheshwari V, Paioli D, Rothaar R, Hill NS. Utilization of noninvasive ventilation in acute care hospitals: a regional survey. Chest. 2006;129(5):1226-1233. 16. Nieminen MS, Bohm M, Cowie MR, et al. Executive summary of the guidelines on the diagnosis and treatment of acute heart failure: the Task Force on Acute Heart Failure of the European Society of Cardiology. Eur Heart J. 2005;26(4):384-416. 17. Keenan SP, Sinuff T, Burns KE, et al. Clinical practice guidelines for the use of noninvasive positive-pressure ventilation and noninvasive continuous positive airway pressure in the acute care setting. CMAJ. 2011;183(3):195-214.
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September 2011
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Having a chance to serve as the Mississippi State Medical Association liaison to the MACM Board of Directors has given me a unique opportunity to see how the Company works for physicians. I have been impressed by the financial stability of the Company and the strong management team. This gives me great confidence that MACM will be around for years to come. I also like the fact that MACM is not a static company. Constant ongoing review and benchmarking with national standards keeps MACM in the upper echelon of malpractice insurance companies.
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• President’s Page •
Chewing the Fat on Cutting Fat
O
ne thing I do not do is writing. I knew I couldn’t write in junior high and high school. All of my assignments looked and sounded like a fifth grader wrote them. I do love to read and enjoy the writings in this journal, so the literary contributions are here for you to enjoy, most toward the back of the magazine. Personally, I have never shot elephants, drunk Ernest Hemingway’s whiskey, nor had any adventure to base such a tale on, but I love to read about it and am glad it is there. Thanks, Scott.
Thomas E. Joiner, MD 2011-12 MSMA President
In fact, I always knew I would never preach to anyone, would rarely give speeches, and would never be politically inclined. I guess you could say that that just didn’t work out for me. I now find myself getting ready to embark on a tour of all the component societies and to represent MSMA at the state capital and in Washington. This is as foreign from my character as I can imagine but, in a funny sort of way, I look forward to it. I guess I am looking forward to it because I believe in us, in what we do, and the nobility of it. Additionally, if someone entrusted me with this profession then I should do my best to protect and preserve it for our children and grandchildren.
Besides the site visits and political aspect of serving as president, I have the opportunity to write this page each month. In the slow months of summer, I find it hard to come up with anything that I am not planning to write about later in the year when activity picks up. Therefore, I am going to take this opportunity to elicit your support in the public health area of our activities. During the last annual session, I introduced a resolution (which passed) to form a committee dealing with the obesity crisis and we are now working on it. We are beginning to talk to prospective members and welcome anyone who may have an interest. The reason for this committee is twofold. First, we need it. You know all the statistics concerning obesity in our state and the projected cost to the health care system in the future. I am not going to repeat them here. However, when we look at these numbers we all have to realize that we are treating numbers and not people. When we treat a disease, we know that we do not cure the disease until we get rid of the source of the disease which rests in actual people and not numbers. That is for politicians. Second, the state Legislature passed this measure, but Gov. Barbour vetoed it. I agree with him. There is no need to saddle the state with the cost of such a large and bureaucratic monster (see the original legislation); we should have the expertise to offer such guidance to schools and parents where we need such intervention. We want committee members who are concerned with the health of fellow Mississippians and not someone wishing for economic gain. The “cure,” as we all know, is not telling an overweight person to stop eating so much. If your practice is like mine, all my obese patients tell me they do not eat more than the amount of food between two fingers anyway. This generational thing has its roots in the parents, schools, and way of life of our next generations. If we are going to save them, we have to do it now!
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• Special Articles • Remembering Peru: What Those Who Made the Journey Had to Say Nicholas Whipple, MD
A
bstract
Each year, the University of Mississippi Medical Center (UMMC) Department of Infectious Diseases teams up with Project Amazonas (www.projectamazonas.org), a humanitarian aid organization whose home base is Peru. Together healthcare workers and humanists travel by boat to the wilds of Peruvian Amazon to bring aid and education to a beautifully hidden and underserved world of Amazonian River people.
The Medical Team Two weeks of infectious disease training from physicians and professors in Mississippi, multiple vaccinations, and a bit of fundraising prepared the team for departure. Dr. Svenja Albrecht led our 2010 Project Amazonas team with Medicine Resident Elizabeth Paine and Medicine-Pediatrics Resident Johann Hsu at her side. Four M4s, Priya Srivastava, Christian Paine, Jennifer Samples, and Nicholas Whipple, brought the UMMC total to seven.
Arrival, shortly after landing in Peru — Pictured l. to r.: Priya Srivastava, Jennifer Samples, Nicholas Whipple, Christian Paine, Elizabeth Paine, Johann Hsu
Caring for Caretakers of the Amazon
Nicholas Whipple, MD, Pediatrics PGY-2, University of Utah Medical Center, Salt Lake City, Utah: When we first docked on shore, a beautiful swarm of dark-skinned children ran to meet us at the Amazon River’s edge. Children between three and fifteen years of age began to board, many of them carrying a much younger sibling in arms. Little muddy footprints now decorated the bow of the boat, all excited to see American doctors coming to visit their small village. Hundreds of miles from any city with streets or lights, our UMMC team of one attending, two residents, and four students had finally arrived in Peru. Surrounded by a mysteriously attractive jungle and at the mercy of an untamed river, we had made it to the Amazon. Each morning began with a delightful breakfast including fresh local fruit and juice—papaya, mango,
The Amazon River — The boat traveled an enjoyable, slow steady pace each day along the Amazon River, transporting the medical team from village to village.
September 2011 JOURNAL MSMA 289
chirimoya, guanábana, and maracuyá. Water pumped directly from the Amazon River below gave opportunity for freshening up and was much needed after a night of Deet repellant and profuse sweating. For 12 days, we traveled the Peruvian Amazon to remote villages in need of both simple and advanced healthcare. One village in the morning and one village in the afternoon was our routine with a break at midday for lunch and a swim in the Amazon. Our fourteen-passenger boat provided an excellent 15-foot-high launching pad into a river of gray and pink dolphins, piranhas and anacondas, and a steady traffic of thin wooden canoes which provided the only mode of transit for our Peruvian friends. In the evenings, a cool river breeze provided the perfect spot atop our boat for reviewing tropical medicine, reading fun books, and remembering our fun day. For those who dared, there were nighttime safaris through the dense Amazon jungle with our biologist guide, Devon Graham—rubber boots and more Deet being our only hope of prevailing against nature. And, just before bedtime, a quick inventory of the pharmacy helped prepare for another day. To the credit of Peru’s government, each village boasts a school made of concrete blocks and mortar. Bright blue, yellow, and red paint often decorate the outside walls. Amongst a community of simple huts made from bamboo, palm leaf, and local wood—always raised on stilts in anticipation of rising waters Nicholas Whipple with Ruth Katerina after and annual flooding—these schools stand as a sign of advancing trading children’s clothing with her mother for beautiful handcrafted Peruvian art — Their village, civilization in each river village. It was in these schools that we Comandancia, organizes a trading post each year inside set up clinic and made new friends. It was in these schools that an exquisite bamboo hut. UMMC visitors observed we came to know a truer meaning of preventive medicine. It was dozens of artisans displaying their handiwork in hopes in these schools we shared with the Peruvian River people how to of exchanging for clothing, fishhooks, and batteries. enjoy safer, healthier, and perhaps more rewarding lives. Teams of two sitting at old wooden schoolhouse desks welcomed recently triaged patients. Upon entering the clinic, each village resident was immediately given Albendazole to treat probable worm infestation, each sharing the same small red plastic cup for water. Their weight, temperature, and history were noted on pieces of 8 x 11 inch paper cut half wise. Along with each patient’s subsequent diagnosis and course of treatment, this information was later meticulously entered into an ever-growing medical database to promote research-based advances in care. Crowds of people lined the walls of each schoolhouse inside and out. We quickly became thankful for the simple architecture of our makeshift clinics, for Christian Paine, Nicholas Whipple, Devon Graham, and Svenja Albrecht together with many of our new friends after finishing clinic one evening — it allowed a welcomed breeze to pass We were invited to stay and participate with the village residents in a traditional through easily. Peruvian ceremony. The event served as dedication for a newly constructed village Mothers of big-bellied children meeting place and as a commemoratory service honoring Devon Graham for his many years of devotion to their community. frequently gave histories of pinworm
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(nighttime anal itching secondary to small, white worms which exit the anus at night to lay eggs) and Ascaris (giant intestinal roundworms 15-30 cm in length that exit the GI tract via stool and emesis). Scabies was nothing less than endemic, for we could not count the number of times we applied fullbody Permethrin Cream to cute, itching infants and toddlers. Fungal infections ran rampant and included tinea versicolor, corporis, cruris, capitis, and pedis. Urinary tract infections, otitis media, pneumonia, pharyngitis, amenorrhea, headache secondary to dehydration and unrelenting sun exposure, rheumatoid arthritis, osteoarthritis, trauma, conjunctivitis, pterygium, pinguecula, pregnancy, heart failure, and fever of unknown origin were conditions encountered daily. Less common and more devastating discoveries included scorpion and snake bites, physical findings suspicious for cancer (breast, cervical, skin), neurofibromatosis, genu varum, cerebral palsy, suspected Meniere’s disease, tuberculosis, malaria, and malnutrition.
Praise and training were provided them in the same rudimentary but sincere fashion a parent would congratulate a student for a commendable report card. By the end of our jungle adventure, we were all spending as much clinic time educating patients as we were treating them. The following phrases became routine expressions: “Sir, you must allow Project Amazonas to build latrines in your community. Otherwise, you will continually contaminate your drinking water.” “Ma’am, please boil your water and do not drink straight from the river. Your children will have fewer episodes of bloody diarrhea if you do this.” “Citizens, bathe and wash clothing downstream from your water source. Drink two liters of water a day, instead of two glasses, and we promise that your headaches and fainting episodes will subside.” “If your infants and toddlers must ride in a canoe, please have an adult and not a 7-year-old accompany them.” Similar to our own problems of obesity, hypertension, and diabetes at Education and the Need for Change home in Mississippi, the major medical problems facing Peru, In most villages there is a designated health promoter. we learned, are largely preventable—choice, personal drive, This individual receives no remuneration and often has very and education being the key determinants of success. few supplies at his command, yet he stands guard as best he There is a growing, in fact spiraling upward, trend of can in preventing disease outbreaks and in transporting the global outreach to the medically misfortuned. It is penetrating very sick to the nearest health post for whatever medication every country and climate and becoming curriculum is available. At the end of each village’s clinic day, the local at all medical institutions. I finally came to appreciate, health promoter met with our medical team to hold a yearafter a week in Peru, what must become ubiquitous in in-review discussion. It was during these conferences that these extracurricular excursions if there is to be sustained unique, perplexing cases were discussed, the severity of success—namely, education. Education will promote longmalaria season was reported, and concerns were resolved. term change more effectively than temporary treatments and yearly Albendazole, albeit necessary they are. Repeated moments of both spontaneous and orchestrated education will slowly though surely teach stepwise behavior changes that will build communities and improve health. Education, time-consuming and usually frustrating, is what will, in the end allow our friends along the Amazon River—and at home in charming and quaint towns near our own mighty river, Mississippi—to take control of debilitating diseases and untimely handicaps. In the form of fireside chats, colorful pamphlets, encouraging encounters, or relay races, we can provide this. We were thankful for the opportunity Sweat — Whether or not there was a complaint of illness, each mother asked us to and pleased to provide our new perform a physical examination on her children. For some children, it was the first South American friends with well-child-check they had ever received. The medical team was amazed at how well education on preventive health behaved and disciplined the children were. They patiently allowed one to examine and treat them. The Peruvian people were so very thankful for the aid provided. care and progressive reform.
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We will miss the welcoming parties of elementary school children who loved to board our boat and have their picture taken. We will miss the minutes shortly before sundown when we put away our books and stared at the Amazon and its jungle. We will miss the muddy walks uphill to schoolhouses, the skinny canoes floating by, and afternoon swims with the dolphins. We will miss the thrill of tropical diagnosis, the circus of jungle animals made pets by the villagers, and watching Peruvian children nap in hammocks. We will miss little Eduardo and Lupe asking for money and food in Iquitos before boarding our boat. We will miss trading clothing, fishhooks, and batteries for beautifully crafted arts, woven baskets, and tribal masks. We will miss little Ruth Katerina and her proud smile while wearing new clothes at the fiesta in Comandancia. We will miss grateful mothers leaving clinic with vitamins for their children and a resolve to boil drinking water more frequently. We will miss our new friends and their lovely world along the Amazon River. And we are grateful that UMMC will have the opportunity again each year to visit them, to help them, to love them. Priya Srivastava, MD, Pediatrics/Psychiatry/Child Psychiatry PGY-2, Mt. Sinai Hospital, New York, New York: Last February, I was fortunate enough to travel with Project Amazonas to Peru, my first medical trip abroad. While I knew that medical care and resources in Peru would be grossly inadequate compared with those we have available in the U.S., I was nevertheless surprised by how much I had to rely on my own medical judgment rather than lab tests to diagnose and treat patients. Adding to this enhanced sense of responsibility, I knew that my treatment and instruction would have to be even more comprehensive as these patients would not receive follow-up care for several months, or perhaps, not at all. I walked away from this experience with a greater confidence in my ability to rely on clinical history and physical exam. More importantly, I developed the desire and a sense of responsibility to seek opportunities to practice global medicine again in the future. Devon Graham, PhD, President / Scientific Director of Project Amazonas, Inc.: Over the past 10 years, Project Amazonas has partnered with the University of Mississippi Medical Center in conducting medical service expeditions in the Peruvian Amazon. These trips have treated many thousands of patients living on isolated rivers, providing curative and preventative care, education, and improving overall health standards in indigenous and mestizo villages in the region. Equally important, UMMC students and faculty have worked closely with Peruvian colleagues, developed professional contacts and friendships, practiced tropical medicine and medical Spanish, and experienced what it is like to work in situations where the most basic laboratory and diagnostic resources are non-existent. Exactly the sort of people I’d want on my side in the event of a
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natural or other disaster back home! Mississippi can be justly proud of the training and professionalism of UMMC staff and students, and I’m delighted to have this opportunity to express my thanks on behalf of the people of the Peruvian Amazon. Svenja Albrecht, MD, MPH, Assistant Professor of Medicine, University of Mississippi Medical Center: Over 60 UMMC trainees and faculty have participated in our medical outreach in the Peruvian Amazon. For many North Americans this is often the first exposure to healthcare in a developing country, and participants have benefited from the opportunity to see tropical diseases firsthand. This program has allowed our trainees to encounter and solve health challenges unique to the tropics. The biggest benefit, however, comes from witnessing the improved health of our local partner communities.
Acknowledgement Indeed, a debt of gratitude is owed to our supporters who made the trip possible— UMMC Department of Infectious Diseases; Central Medical Society; Children’s Medical Group; local churches; and Drs. Jerry Clark, LouAnn Woodward, Helen Turner, and Frank Bowen. UMMC dental students greatly supported our cause by providing over 400 toothbrushes and tubes of toothpaste to distribute to dentitionpoor Peruvian patients. For your time, unselfish donations, and support, we thank you. For the change you made possible and the experiences you created, Peru returns its love.
Corresponding Author: Nicholas Whipple, MD; 150
South 800 East, #D4, Salt Lake City, UT 84102. (nicholas. whipple@hsc.utah.edu).
en is Mighter The P n Tha the Sword Express your opinion in the JMSMA through a letter to the editor or guest editorial. The Journal MSMA welcomes letters to the editor. Letters for publication should be less than 300 words. Guest editorials or comments may be longer, with an average of 600 words All letters are subject to editing for length and clarity. If you are writing in response to a particular article, please mention the headline and issue date in your letter. Also include your contact information. While we do not publish street addresses, e-mail addresses or telephone numbers, we do verify authorship, as well as try to clear up ambiguities, to protect our letter-writers. You can submit your letter via email to KEvers@MSMA online.com or mail to the Journal office at MSMA headquarters: P.O. Box 2548, Ridgeland, MS 39158-2548.
• Special Article •
When Time is Muscle: An Update on Mississippi’s STEMI System of Care Plan
C
Karen A. Evers, Managing Editor
ardiovascular Disease in Mississippi Cardiovascular disease (CVD), encompassing both coronary heart disease and stroke, is defined as a disease of the heart and blood vessels (arteries, veins, and capillaries). Mississippi’s mortality and mordity from CVD is the highest in the nation , accounting for 41% of all deaths (11,557) in 2001.1 Three-fourths of Mississippians have at least one cardiovascular disease (CVD) risk factor. More Mississippians die each year from CVD than from all types of cancer, traffic injuries, suicides, and AIDS combined.2 A substantial number of these deaths are premature: one in five CVD deaths in 2001 occurred in Mississippians under 65-years-old.3 Coronary heart disease (CHD) and stroke are the two most common forms of CVD. Another significant public health problem, said State Health Officer Dr. Mary Currier, is ST-elevation myocardial infarction (STEMI) which also carries a high risk of death and disability.” The American Heart Association (AHA) estimates that as many as 400,000 people will suffer from a STEMI each year in the United States. Over the last 20 years, advances in the treatment of STEMIs have resulted in dramatic reductions in death. Rapid reperfusion of the STEMI patient, utilizing either fibrinolytic therapy, or primary Percutaneous Coronary Interventions (PCI), is the most important therapy in reduction of death from STEMI heart attacks. “Unfortunately, over 30% of STEMI patients fail to receive any form of reperfusion therapy. In those patients whom either receive no reperfusion therapy or delayed reperfusion therapy, the short and long-term outcomes are significantly worse, as compared to patients treated according to the American College of Cardiology (ACC)/ AHAguidelines.
Background The Mississippi Cardiovascular Health Program began in September 1998 with funding from the Centers for Disease Control and Prevention (CDC). The Mississippi State Department of Health (MSDH) formed a committee of external and internal partners to begin laying the foundation for a comprehensive plan for cardiovascular health promotion and disease prevention and control in Mississippi.5 During the 2001 Legislative session, House Bill 759 created the Task Force on Heart Disease and Stroke Prevention within the Mississippi Department of Health. Senate Bill 2314 revised the membership of the Task Force on Heart Disease and Stroke Prevention and clarified the reporting requirement of the task force. This task force, composed of 17 members representing various health-related state agencies, professional associations, the State Legislature, and non-profit educational organizations, was asked to study heart disease and stroke in Mississippi and develop a comprehensive plan of action to CVD in the state. 6 According to J. Clay Hays, Jr, MD, FACC, chair of the Task Force on Heart Disease and Stroke Prevention, the initial goals of the task force were to increase physical activity and to decrease deadly risk factors like obesity and improper nutrition, high blood pressure, and elevated cholesterol. “Racial, ethnic, and geographic disparities are central issues, and primary prevention is a key,” he added during a meeting of the task force (June 10, 2011) .
Objectives STEMI patients should be recognized as quickly as possible to identify those eligible for thrombolytic or primary PCI therapy. Research has shown that both morbidity and mortality can be reduced by the approach of rapid interventional reperfusion within ninety (90) minutes of hospital arrival. Additional research has demonstrated that inthe-field recognition by pre-hospital providers utilizing 12-lead ECG, coupled with pre-hospital notification of the receiving facilities, can further reduce time to reperfusion, resulting in increases in outcomes.
Prevention “Making a difference requires intervention at all levels from cultural norms, policy, community, and individual behaviors,” Dr. Hays explained. “A centerpiece of the Mississippi State Plan is increasing both awareness and knowledge of CVD risk factors across the state. Developing a statewide registry of risk factor information was given high priority. Using a combined health screening and education program, ‘Know Your Numbers,’ developed by the Mississippi Chronic Illness Coalition, the State Plan aims to collect and track data on height, weight, body mass index, blood pressure, glucose, and cholesterol for Mississippi
The Mississippi public must be educated in the recognition of the symptoms of STEMI and the benefits of utilizing the 9-1-1 system.4 Unfortunately, less than 50% of myocardial infarction patients are transported to the hospital by ambulance. It is recognized that major delays from patient symptom onset to presentation for medical care also exist.
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residents, as well as their knowledge of these risk factors. This bold plan will link health care provider and health screening efforts throughout the state using a COMMAND database developed by the Information and Quality Health Care. The plan includes valuable tools on screenings, prevention, detection, and treatment of CVD,” he said. Additional core strategies include disseminating the plan to all key constituencies as well as developing and disseminating “tool kits” for use in all venues. One example of a toolkit developed was included in the treatment of STEMI. Treatment: Using the STEMI Toolkit Dr. Hays described the toolkit: “Most that are used outside a healthcare facility resemble a fishing tackle box labeled STEMI. In it are forms carefully adapted using whatever details you feel are important for a best-practice STEMI ALERT. The kit includes easy-to-follow STEMI algorithms or flowcharts for all scenarios. Whenever a STEMI is recognized, ED staff automatically open the toolkit. This provides immediate access to the provider checklists and data collection sheets that give every STEMI ALERT the guidance
STEMI Program Regional Design Affiliated PCI Centers
needed for precise execution. This basic approach works for all treatment strategies – emergent PCI, patient transfer or on-site thrombolytic therapy. The provider checklists keep the process on track and encourage early decisions,” he explained. According to Dr. Hays, at a non-PCI center, the STEMI ALERT Packet is the key to triggering the reperfusion process. Use of a STEMI ALERT Packet is a key step in optimizing treatment of the STEMI patient. “Opening a STEMI ALERT Packet upon first recognition of STEMI acts as the ‘reperfusion trigger’- shifting the focus from early recognition to immediate reperfusion! This if/then action (Recognize STEMI…Open Packet!) provides ED staff with a concrete response whenever they detect a STEMI,” he said. Each bright red STEMI ALERT Packet contains colorcoded versions of basic forms, usually a checklist for the physician, nurse and scribe as well as data collection forms. The two data sheets collect valuable real-time QI data. Statewide STEMI Approach While groups like the Mississippi Chronic Illness Coalition (MCIC), Mississippi Cardiovascular Health Program, and the
Goals of STEMI Program •
Create collaborative quality improvement efforts involving Mississippi Hospitals, EMS Services, & medical professionals
•
Develop state and regional network of hospitals and EMS services based on best care protocols
•
Utilize institutional level heart attack teams to collect, analyze and react to quality outcomes.
North Region Baptist Memorial Hospital – Desoto Baptist Memorial Hospital – Golden Triangle Baptist Memorial Hospital – North Mississippi Delta Regional Medical Center Magnolia Regional Health Center
Short Term Goals
North Mississippi Medical Center • Seek grant opportunities for the state
Central Region
•
Jeff Anderson Regional Medical Center Central Mississippi Medical Center
Establish Regional STEMI Network within the state (North, Central, South divisions)
Mississippi Baptist Medical Center
• Designate leadership/educational teams for each . region
River Region Medical Center
• Create standardized educational tools
Rush Health Systems
• Use MHCA tools to educate all non-PCI centers about best care protocols and NCDR-Action/GWTG registry
St. Dominic Hospital • The University of Mississippi Medical Center
South Region
Achieve 100% data entry from all PCI centers into NCDR-Action/GWTG registry (Data entry beginning with July 2010 discharges)
Forrest General Hospital
Intermediate & Long Term Goals Gulfport Memorial Hospital •
Improve Mississippi’s EMS response
•
Facilitate EMS-EKG training
•
Equip ambulances with EKG transmission capabilities
•
Educate public of prevention, signs & symptoms and importance of 911
•
Improve public utilization of 911 services
•
Reduce mortality and morbidity of Mississippians suffering from Heart Attacks
•
Facilitate research
Singing River Health System Southwest Mississippi Regional Medical Center Wesley Medical Center
Areas of Focus • • • • •
EMS Non-PCI hospitals Inter-Facility-Transfer PCI referral Centers Public Education
Source: Mississippi Healthcare Alliance
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MCIC Cardiovascular Advisory Committee were early iniators of the CVD state plan, the most recent statewide development has been a collaborative effort of the Mississippi Healthcare Alliance (MHCA), The American Heart Association (AHA) Mission Lifeline, the Mississippi Hospital Association, and the Mississippi State Department of Health (MSDH). The STEMI project in Mississippi incorporates integrated systems for the timely treatment and transfer (when appropriate) of patients with ST Segment Elevation Myocardial Infarction (STEMI). This project will expedite care to Mississippi residents who have a heart attack. Baptist Cardiovascular Services Director Heather Sistrunk who serves as secretary on the board of the MHCA explained, “The Door to Balloon Initiative (D2B), organized and spearheaded by the American College of Cardiology (ACC), was extremely successful in helping optimize STEMI care at PCI centers through its attention to systems level improvement as the key to sustainable success. The overarching goal of the initiative is to reduce mortality and morbidity for STEMI patients and to improve their overall quality of care.” The AHA refers to the 90-minute period as “the golden time” from door-to-balloon (from the time the patient presents with a heart blockage to the time intervention in an open heart facility is provided). The project accomplishes this by empowering emergency medical services personnel and emergency department physicians to implement destination protocols.
Robert Galli, MD addresses the Mississippi Task Force on Heart Disease and Stroke Prevention— Dr. Galli, who initiated the UMC TelEmergency Program in 2003, is working on developing a Telestroke program with neurologists across the state. “If you’re a believer that the clot-busting medicine, tPA, is going to reverse damages of stroke, you need to deliver it to the stroke patient within 3 hours, hopefully within 90 minutes. Just getting patients from their homes, recognizing they’ve been stricken and need to travel to a hospital, to a neurologist who’s qualified, kills all of that time. We want to be able to get them to our telemedicine hospitals where they can get a CT-scan, then a neurologist to see them, and deliver the drug there. Then they’ve got time to be transferred. The trauma system is an example of the drip & ship coordinated systems of care that is vital because if you have to drive 2 hours to get to a cath lab you’ve lost 2 of the 3 critical hours in which the new stroke meds must be administered,” he said. “We aim to model a regionalized stroke system after the STEMI program. It works ideally to overlay a stroke network over the heart network over the trauma network.” Dr. Galli is a professor in the Department of Emergency Medicine at UMMC and past department chair. He is the executive director of TelEmergency and medical director of AirCare Helicopter Transport.
Conclusion Dr. Harper Stone, MD, president of the MHCA, has played a critical role in bringing together healthcare leaders from across the state to establish a statewide protocol for all STEMI patients. “Time is muscle. The longer the delay, the worse the outcome,” he told the Journal (August 3,2011). He commented that the idea originated at a cardiology gathering in Oxford during the annual MSMA meeting in 2009. The Mississippi STEMI project allows paramedics and emergency department MISSISSIPPI HEALTHCARE ALLIANCE STEMI PROTOCOL CRITERIA: personnel to initiate ST Elevation Myocardial Infarction (MI) with onset of symptoms less than 12 hours treatment, improving communication, 1. Activate team and/or activate referral PCI hospital integration, and 2. Monitor, Oxygen, IV with saline feedback. Each hospital 3. Aspirin – 81 mg (give 4 chewable – even if patient already took an aspirin that day) 4. Clopidogrel (Plavix) 600 mg PO* OR Prasagrul (Effient) 60 mg PO collects data before and 5. Nitroglycerin 0.4 mg SL (repeat as needed or IV) after interventions to 6. Heparin: loading dose of 60 units/kg IV (4,000 units max) or Lovenox 30 mg IV increase the proportion 7. Beta Blocker: Metoprolol 25 mg PO (5 mg IV q 5 minutes x 3 if unable to take PO) of eligible patients 8. Chest X-ray – portable if time permits receiving treatment and 9. Morphine Sulfate as needed for pain 10. Second IV saline locked reduce D2B time. 11. Attach hands-free defibrillator pads In a conversation 12. In-the-door to out-the-door goal is less than 30 minutes (August 12, 2011) Jim Craig, director of the MSDH Office of Health Protection
This information is intended only as a guideline. Please use your best judgment in the treatment * If patient takes Plavix, lower to 300 mg PO.
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which oversees the Bureau of Emergency Medical Services, said, “At their summer meeting, the Board of Health approved the STEMI System of Care Plan for use in the State. Implementation of the plan will begin with the selection of members to the STEMI System Advisory Committee upon review by CMS. This committee will determine the requirement for new or additional regulations to administer the STEMI system.” The draft plan contains five elements necessary for consideration as a community plan: 1) Organization, 2) Facility Standards and Designation Criteria, 3) Pre-hospital / Hospital Treatment Protocols, 4) Data System, and 5) Performance Improvement Process. Dr. Hays notes the prevalence of numerous articles highlighting the success of the STEMI System of Care Plan. National progress has been achieved in the timeliness of treatment of patients with STEMI who undergo primary percutaneous coronary intervention.7 There were corresponding increases in the percentage of patients who had times under 90 minutes (44.2% to 91.4%), as well as under 75 minutes (27.3% to 70.4%), according to the study published online in Circulation: Journal of the American Heart Association.7 Moreover, from 2005 to 2010, D2B time declined from a median of 96 minutes to 64 minutes, reported Harlan R. Krumholz, MD, from Yale University School of Medicine, and colleagues.8 “This improvement, experienced across the country and across different types of hospitals, represents a remarkable elevation in practice that was achieved over a relatively short period of time and in the absence of financial incentive,” researchers wrote. They also said that these improvements were likely due to multiple factors,8 rather than one single overriding action, including: • Published articles that identified strategies for improving door-to-balloon time • National initiatives by various organizations • Identifying “exceptional” performers and analyzing their methods • CMS’s emphasis on quality improvement in this area Dr. Luke Lampton, Chairman of the Board of Health, commented to the Journal: “These coordinated approaches to reduce cardiovascular death in Mississippi are a model for organized medicine across the country. These visionary physicians, largely members of our MSMA, have joined together to solve a significant medical problem. They should be praised for emphasizing collaboration over competition to improve outcome for our patients of all races and all income levels.” Lampton concluded, “Not only are we saving myocardium, but also state physicians are showing the way to attack other entrenched medical problems, including trauma and stroke, within our state’s borders. Poverty, race, low education levels, and geography can be overcome. A coordinated approach using cutting-edge science and
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collaboration across geographic lines will impact the health of all Mississippians. By doing this, our state won’t be on the bottom of the heap any more, but rather showing the way for others.” North Carolina was the first state in the nation to implement a statewide project such as the STEMI project. “Mississippi physicians are pleased that Mississippi is the second to put a fully integrated program in place,” Dr. Lampton added. References 1.
2004 Mississippi State of the Heart Report, Mississippi State Department of Health.
2.
2001 Mississippi Behavior Risk Factor Surveillance System, Mississippi State Department of Health.
3.
Mississippi Vital Statistics, Mississippi State Department of Health. 2001.
4.
Mississippi State Department of Health STEMI System of Care Plan, May 11, 2011.
5.
2001 Mississippi Youth Behavior Risk Factor Surveillance System. Mississippi State Department of Health.
6.
Mississippi State Plan 2004 – 2013 Heart Disease and Stroke Prevention and Control website. Available at http://msdh.ms.gov/msdhsite/_static/resources/1670. pdf. Accessed August 2, 2011.
7.
Krumholz HM et al Improvements in door-to-balloon time in the United States, 2005 to 2010. Circulation. 2011 Aug 22. [Epub ahead of print] Available at: http:// circ.ahajournals.org/content/early/2011/08/21/CIRCULATIONAHA.111.044107. abstract?sid=26d6a076-0a37-4a29-8723-9afffc57aa5f. Accessed August 24, 2011.
8.
Kaiser C. Cardiology Editor, MedPage Today website. Published: August 22, 2011. Available at: http://www.medpagetoday.com/Cardiology/MyocardialInfarction/ 28148. Accessed August 24, 2011.
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• Editorial • Grits Report 2011: Much Accomplished by Mississippi at AMA (Despite Smaller Number of Delegates)
D
own to only 4 delegates and 4 alternates (once 7 and 7), Mississippi’s American Medical Association (AMA) delegation came to Chicago June 18 to 22 for the AMA House of Delegates (HOD) Annual Meeting, the “big dance” in national organized medicine. The work team consisted of Drs. Hugh Gamble, Dan Edney, Clay Hays, Tim Alford, Jim Rish, Tom Joiner, Randy Easterling, Lee Voulters, Scott Anderson, Claude Brunson, and me, sitting next to Dr. Edward Hill, our AMA past president, who has a permanent, non-voting seat at Mississippi’s AMA table. Most of the work of the delegation came from the resolutions submitted and debated by state physicians at Tupelo’s MSMA annual meeting in May, as well as from review and voting on resolutions submitted by other states. Besides revisiting two past state resolutions still being discussed, Mississippi introduced five important resolutions for national debate at the AMA reference committee meetings and on the floor of the AMA House. Mississippi first brought forth a resolution on suicides, accidents, and accidental deaths back at the 2009 AMA Annual Meeting. Then, the resolution, which had been originally proposed by Dr. Jim Nobles of McComb, had been referred to the AMA Board of Trustees for a study and report back. That resolution asked: “That our AMA study the issue of debilitating accidents, accidental deaths, and suicides of medical students, residents, and young physicians in the United States and explore ways to address this critical problem.” Unfortunately, the resulting study of the Council on Science and Public Health which was presented in 2010 focused only on the issue of suicide by physicians and physicians-in-training, ignoring the topic of serious accidents or accidental deaths. The Council justified its omission by stating that “no information currently exists to formally capture these events, and to establish a baseline for medical students would require a modification in the annual survey distributed to medical schools.” Significant testimony was heard at both the MSMA and AMA annual meetings in 2009 which suggested that increased accidents and deaths due to accidents were occurring among physicians-in-training in the United States. That testimony indicated that the causes of these accidents were complex and included a lack of situational awareness often precipitated by lack of sleep, drugs, and alcohol. Current programs in place for medical students and residents address general wellness and suicide risk but seldom confront the issue of avoidable accidents and accidental death. Thus, Mississippi’s delegation brought back a resolution on the topic, requesting “that our AMA request modification in the annual survey distributed to medical schools in order to assess the topic of serious accidents and accidental deaths; and that our AMA request modification of other annual surveys of medical schools, residency directors, and other medical educators in order to assess the topic of serious accidents and accidental deaths among physicians-in-training.” This resolution did pass, after much work on the floor of the House (for the reference committee had ruled that it not be accepted). Further resolutions on this topic may be needed in the future as data returns from these annual surveys, but Mississippi made significant progress in bringing suicide and accidental deaths of physicians to the national spotlight. Another past resolution from Mississippi which received noteworthy debate was a 2010 resolution which asked the AMA to consider “significantly lower dues” for its member physicians and free membership to all residents, fellows, and medical students in the U.S. The resolution, which had been referred to the Board last year for study, returned with a report from the Board which indicated that dues revenue remains critical to support AMA’s “core activities.” Most of the debate at the reference committee against lowering dues centered on the “devaluation of AMA membership,” although many voices continue to ask the AMA to explore modifying dues as part of its attempt to increase national membership. Although the resolution was not adopted, it spurred positive discussion for two years at the national level. Another Mississippi resolution focused on the “simplification and reimbursement of prior authorization process and required formulary paperwork.” This resolution asked that the AMA take steps to ensure that physicians are paid appropriately and promptly for any and all services performed for their patients required by insurance companies, Medicaid, or Medicare. It also asked for the AMA to encourage forms to be simplified and procedures streamlined to reduce the burden on physicians and staff. Much support was heard for this resolution, and the reference committee noted that the AMA considers this a priority issue
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and is currently at work on it. Thus, current AMA policy was reaffirmed in lieu of this resolution. Also reaffirmed after positive discussion was Mississippi’s resolution on preserving federal funding for essential public health services in rural and underserved areas. Another state resolution encouraged the AMA to ask the Robert Wood Johnson Foundation to substantiate report findings regarding nurse practitioners. A recent joint report of the Robert Wood Johnson Foundation and the Institute of Medicine entitled “The Future of Nursing” had endorsed independent practice by advanced practice nurses. There was concern noted that more politics than evidence had been utilized in the widely distributed report and that the Robert Wood Johnson Foundation would better serve the national interest by re-focusing its energies on health care delivery through a coordinated, physician-led, patientcentered medical home. This resolution passed. Other resolutions from Mississippi also met with success and favorable discussion. The resolution on a commemorative postage stamp for Dr. Joseph Goldberger’s Mississippi pellagra experiments received largely favorable comments and was referred to the Board for decision. One speaker in opposition asked the AMA to ascertain if the research which involved prisoners was voluntary and ethical. Current ethical research standards were not in place in 1915 when the experiment occurred, and all of the prisoners, who were white, volunteered for the experiment, were fully informed of the research’s dangers, survived without any permanent harm, and were fully pardoned from their lengthy sentences after the experiment. It is interesting that Goldberger’s important research (which was among the earliest on living humans) remains controversial 100 years afterwards. Mississippi’s resolution on “Making GME Financing and Reform a Priority for the AMA” was addressed during discussion of a similar resolution from the New York Delegation which included most of our resolution’s essential points. After quality debate, this resolution was reaffirmed as current AMA policy. (This issue may be one of the most significant facing our profession. At our medical schools, class sizes have increased, but these increasing numbers of students are a facing a road block in a few years with stagnant or declining slots in most post-graduate programs.) The so-called “elephant in the room” at the meeting was Obamacare, also known as PPACA, the Patient Protection and Affordable Care Act, and there were hours of divisive debate on the House floor, all hoping to change, amend, or delete offensive parts of PPACA. One highly contentious resolution, supported by Mississippi, asked for a “compromise” which stated that “our AMA advocate that the choice to implement a requirement for individuals to purchase health insurance be left exclusively to the states.” Dr. Stormy Johnson, former AMA President and Speaker from Louisiana, spoke for many when he asked the House to find a common ground with divisive issues: “I searched for some way to find common ground, and I think this amendment does that. It offers an opportunity for us to leverage our intellectual diversity to see which idea works best in the real world.” He also reprimanded the more liberal HOD majority: “Quit voting down divisive issues one way or another.” The argument came down to “federalism vs. states’ rights,” which has been argued passionately since this country was founded more than 2 centuries ago. As in the antebellum period before, a middle ground seemed elusive, and regional accents were often segregated by their position on mandates. (One of Mississippi’s delegates joked: “We are losing the Civil War, again…”) After many hours of impassioned testimony and discussions of constitutional legality, vote after vote failed in the range of 43% to 57%. “This goes down to individual freedom,” said one doctor from New York, speaking against mandates. “There are some things more important than health care, and that is the personal liberty not to have a government telling you that you have to purchase something.” The majority of the AMA House could not swallow the word “mandate,” but despite this, Dr. Jeff Terry of Alabama, a warrior against mandates, tried with Mississippi’s support to include wording that our AMA “vigorously work to change the PPACA accurately to represent our AMA policy…and oppose any mandates not consistent with our policy.” While direct opposition to mandates was never included, the resolution passed and title changed to read “AMEND PPACA.” Further battles await us! There was much outstanding and constructive debate at the meeting, but the AMA House remains plagued with irrelevant and self-interested resolutions leaving our delegation exasperated, asking Dr. Hugh Gamble’s oft repeated question: “And what does that have to do with the practice of medicine?” However, these ridiculous resolutions should not distract us from our mission. Make no mistake about it: the assaults on the private practice of medicine are unrelenting and real. The enemies of medicine are varied with corporate and federal entities attempting to turn physicians into secretaries and scriveners rather than diagnosticians, artists, and healers. The AMA is the best national forum for Mississippi physicians to save our profession which is not headed in the right direction. As Dr. Claude Brunson once advised, “Now is not the time to withdraw. It is the time to reclaim the AMA for our profession and start a revolution.” The November interim AMA House of Delegates meeting will be in New Orleans this year (Nov. 12 to Nov. 15). Coming down and watching the reference committees and attending some of the open meetings would be an educational experience for interested MSMA members. Rarely are AMA meetings so close to home! Contact one of your AMA work team listed in the first paragraph or MSMA staff for details. Oh yes, about the grits in Chicago: the green-coated, bow-tied Dr. Joe Bailey of Georgia judged them to be “remarkably good in view of the strike of the hotel employees!” — Lucius “Luke” Lampton, MD Editor
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• Images in Mississippi Medicine •
Future Doc Frank Bowen in Goat Wagon, 1922— Dr. Frank Bowen of
Carthage celebrated his 90th birthday recently, May 5, 2011. The above photo was taken of Dr. Bowen in a cart or wagon in 1922, as a young chap about to tell his goat “giddy-up.” These carts or wagons were common in Europe and America during the Victorian era. The wagons were often utilized to carry garden products, pulled by a goat or dog, but many parents would keep a goat cart simply to pull around the kids for fun. A native of Memphis, Dr. Bowen graduated from the University of Tennessee in 1951. After an internship at Methodist Hospital in Memphis, he entered into the private practice of family medicine at Walnut Grove, Mississippi. He moved his practice to Carthage in 1957, where he remained for the rest of his career. For more than a half century a member of the MSMA, he served as President of the Mississippi Academy of Family Physicians and as President of Central Medical Society. He was a charter Diplomate of the American Board of Family Medicine and a charter Fellow in the American Academy of Family Physicians. He was also selected as “Mississippi Physician of the Year” in 1996 by the Mississippi Academy of Family Physicians and was recipient of the MSMA Community Service Award in 2009 . In reflecting on his medical career, Bowen reveals his decision to become a physician came at an early age. In seventh grade he began to “read biographies of famous doctors, including Edward Jenner, who discovered the smallpox vaccination; and Albert Schweitzer, who was a missionary, a physician, and a talented musician…which had an effect on my decision to become a physician.” He adds that Dr. Arthur Guyton was a major influence in his medical life, stating, “In spite of his handicaps, he was a wonderful teacher and very brilliant. He actually recommended me for medical school.” Looking over his career at the age of 90, Dr. Bowen advises other physicians: “Think of the people you serve. Have a good bedside manner. Be able to communicate. Take part in community activities. Do things for other people, not just for money or yourself.”(For a longer article on Dr. Bowen, see The Meridian Star, September 12, 2010.) We at JMSMA salute Frank W. Bowen, MD, for his exemplary career as a physician. If you have an old or even somewhat recent photograph which would be of interest to Mississippi physicians, please contact the Journal or me at lukelampton@cableone.net.
—Lucius Lampton, MD; Editor September 2011 JOURNAL MSMA 299
• Poetry in Medicine • [This month, we print a poem by John D. McEachin, MD, a Meridian pediatrician. This poem, written recently, represents a subject “that is a thorn for every pediatric/parent relationship,” according to Dr. McEachin. He explains: “The most trying discussion between physician and parent in pediatric practice is the debate dealing with febrile illness. The approach of the Doc should be based on concern for the child but with firm adherence to the precise reason for supportive medication. The purpose of the therapy must focus on ‘relief of discomfort’ and not on ‘chasing the temp.’ To double doses or alternate drugs at varying, odd intervals is disingenuous therapy that instructs patients incorrectly. We must take the time to explain decisions, stick by them, and deal with exceptions on an individual basis!” The prolific Dr. McEachin holds a special place at the Journal as our unofficial poet laureate. For more of Dr. McEachin’s poetry, see past JMSMAs and look for more in coming months. Any physician is invited to submit poems for publication in the journal, attention: Dr. Lampton or email me at lukelampton@cableone.net.]—Ed.
Childhood Fevers (Friend or Foe?)
Fever, Fever, Go Away! Don’t Come Back Another Day! Know you’re there for good reason,
I hope to recall the keys:
But you’re surely not pleasin’.
Hydration, alertness, please.
You visit my child at night;
Fever varies in degree;
That’s why I get so “up tight!”
Its job is to help, you see!
Doc’s just waiting for my call;
How high the temp is no clue;
Knows I probably will bawl!
Doesn’t mean your life is through!
He’s told me, “Don’t go berserk!!
So, do use some common sense;
That fever’s doing its work.
Play it smart, and don’t be dense!
It’s so simple and so pure;
Fluids, cool cloths, watch and pray!
Fever is part of the cure.
Thermometers--- throw away!!!
Yes, Acetaminophen, Or its friend, Ibuprofen Are fine if you know the dose; But don’t give doses too close! Dare to ‘alternate’ these meds, And we’ll have some rolling heads! If it’s dose you do not know, Giving NONE’s the way to go!!!” 300 JOURNAL MSMA
September 2011
—John D. McEachin, MD Meridian
• Physician’s Bookshelf • White Coat, Black Hat: Adventures on the Dark Side of Medicine By Carl Elliott, Beacon Press, 2010, 224 pages, $24.95 [Hardcover, also available in electronic versions]
N
ot many people would call doctors morally degenerate, but Dr. Carl Elliott unabashedly proclaims the entire medical profession to be full of “narcissistic sociopaths” in his new book, White Coat, Black Hat: Adventures on the Dark Side of Medicine. He gives the reader fair warning of his upcoming commentary in the introduction, stating, “My interest is in how medicine has gone wrong, not in what there is to admire.” From there, he methodically details the ways in which the golden days of medicine have been dismantled by capitalism – specifically, by pharmaceutical companies. Dr. Elliott is a Professor in the Center for Bioethics at The University of Minnesota. As a non-practicing physician with dual appointments in the school of medicine and department of philosophy, Elliott has dedicated his career to investigating the effects of market economic forces on medicine. On the surface, his book describes the various tactics pharmaceutical companies employ to increase profits. From the ubiquitous sales representatives to the not-so-well-known individuals who enroll in clinical trials for a living, Elliott dives into each of these topics armed with first-hand accounts, statistics, and a flare for story-telling. Each chapter of the book is dedicated to a different aspect of the pharmaceutical machine. Few outside the pharmaceutical bureaucracy comprehend the extensive nature of the beast and Elliott captures its complexity with ease. White Coat, Black Hat is also well researched with excellent historical insight into the field of medicine. Elliott explains how the practice and marketing of medicine have changed and expanded within the past 50 years. He marks each major change by commenting on the laws, Supreme Court decisions, or economic pressures that preceded it. Like most physician writing in medical journals, the book has an extensive references section. Any physician or medical student would benefit from the depth of history covered in this text. To read the book for its educational benefit would not be entirely missing its point. Beneath its surface, White Coat, Black Hat is bristling with a strong moral backbone. Elliott calls out nearly all physicians and every medical institution. Nothing and nobody are safe from Elliott’s scathing evaluations: JAMA, general practitioners, department heads, and even other bioethicists. The brunt of the criticisms goes directly towards doctors. He criticizes physicians who consult for pharmaceutical companies, calling them “drug whores” because they often speak for a number of different companies. He criticizes physicians who accept gifts as oblivious to the psychological effects of developing relationships with drug representatives. He also criticizes medical journals and CME events for accepting sponsorship from pharmaceutical companies. Ultimately, he criticizes society as a whole for failing to recognize the changes in medicine within the last 50 years, stating, “We simply live in a country that has decided the traditional figure of the doctor is not worth preserving in the face of modern economics. Instead, we Americans put our trust in the market.” Throughout Dr. Elliott’s analyses and criticisms, he conveniently forgets to put forth any alternatives to the status quo. How should pharmaceutical companies promote their products ethically? How should CME events be funded? What
September 2011 JOURNAL MSMA 301
should physicians do when sales representatives offer free samples, which often provide much needed help to desperate patients? These are all unanswered questions. Additionally, in his zeal to condemn the entire medical establishment, Elliott contradicts himself. For example, Elliott argues that clinical trials are often tainted, manipulated, and even manufactured by pharmaceutical companies and therefore, they cannot be trusted. Later in the text, however, he uses results from clinical trials to defend his statements. These sorts of inconsistencies are common-place and make the reader wonder whether Dr. Elliott is providing a unique perspective on the pharmaceutical boom or if he is simply fundamentally critical of the industry. Most physicians see only a few aspects of the pharmaceutical industry. Some may interact with pharmaceutical sales reps in their offices, and others may participate as an industry thought leader. Many, however, never gain a full perspective of the multiple weapons pharmaceuticals have at their disposal to increase sales. White Coat, Black Hat provides this full perspective, and for any physician, it has excellent educational value. However, be warned that some may feel insulted and disappointed in Dr. Elliott. For all his deep analyses, Elliott misses the ultimate goal of a critique like his: what is the solution?
—Lily Huang, M3 Tulane University School of Medicine
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September 2011
ONLINE JOB BANK Free position listings for MSMA members and for group clinics which employ at least 70% MSMA-member physicians • To list a position visit MSMAonlinejobs.com.
• For more information, contact Anna Morris: AMorris@MSMAonline.com, 601-853-6733, Ext. 324 My solo practice listed a free position on the MSMA online job bank, and within only a couple of weeks we received several inquiries from qualified candidates and were able to fill the position quickly and easily. I highly recommend the job bank! —Tom Joiner, MD
• The Uncommon Thread •
Give Me Fiction Please
R. Scott Anderson, MD
L
ately it’s become fashionable for 70-something-yearold novelists to announce that they’ve given up reading fiction. Phillip Roth just has. He says he finally wised up. David Markson did six years ago. I’m not sure that one was such a surprise. What do you expect from a guy that wrote a novel titled This is Not a Novel? Markson’s dead now so it’s hard to know if he still feels that way.
I’m not seventy and a lot can happen in the next fifteen years, but I don’t see myself giving up on fiction. Hell, I prefer fiction. I may announce that I’ve given up reading all non-fiction any time now, including the news. The whole Casey Anthony thing comes to mind. Who wants to know the truth about that? I want to imagine that I can spot a killer in a heartbeat. I almost always can in my imagination anyway. I expect a mother who killed her small child to be discernibly evil, not someone I could easily miss at Wal-Mart if I passed her in the chloroform aisle. How much easier is it to read about a fictional 6-year-old washed adrift on a kitchen door in a Tsunami in Okinawa in 1898 than to read about a real Japanese child who lived in the shadow of a now destroyed nuclear reactor and is at an appallingly high risk for thyroid cancer or leukemia before he reaches adulthood? The world is not an easy place. Fiction is so much more palatable. There is a therapeutic benefit to that disconnect. It allows us, the reader, to explore those edges without really having to engage our morality to the extent that we have to in the real world. This isn’t a unique point of view. English professor Timothy Aubry has a new book out entitled Reading as Therapy. He looked at six novels, all best sellers, four being selected for Oprah’s book club, and tried to analyze what readers were getting for their investment of time and effort into reading the book. He found that even when readers didn’t really “get” the book, they still felt like they got something out of the book. Some shared perspective that gave them guidance in living their everyday life. Oprah said it pretty well, “It’s like a life experience. It’s getting to know people, getting to know people in a town. It’s not everything laid out.” What the professor and Oprah miss though is that it’s getting to know people without the burden of responsibility for knowing them. It frees the reader from the need for objectivity and allows us to look at things through the mirror of our own preconceptions and from a safe distance. When you’re done you close the book. There are no malignancies to worry about and no chewed up children’s bones to dispose of. It’s just like our goals for any modern theraputic modality: safe and sanitary. So, as for me, give me fiction, please. The dirt, pain, and misery of the real world are a heavy burden to bear. I should know. I’m a physician, and these all too real tumors I have to deal with every day are giving me a severe pain…in my heart.
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.
September 2011 JOURNAL MSMA 303
general e-mail: info@msmaon kevers@msmaonline.co
• Placement/Classified • PHYSICIANS NEEDED
Physicians (specialists such as cardiologists, ophthalmologists, pediatricians, orthopedists, neurologists, etc.) interested in performing consultative evaluations (according to Social Security guidelines) should contact the Medical Relations Office.
Toll Free 1-800-962-2230 Jackson 601-853-5487 Leola Meyer (Ext. 5487)
DISABILITY DETERMINATION SERVICES Calling all Mississippi Physician-Photographers for the 2012
COVER PHOTO CONTEST Load your camera or grab your digital. Shoot landscapes, people, animals, or anything else you can capture on film. Photos of subjects indicative of Mississippi will be given the highest consideration. Photos of original artwork are also acceptable. The Committee on Publications will judge the entries on the merits of quality, composition, originality and appropriateness to the JMSMA. Specifications: Color slides, digital files & photos. Size: Vertical format 5 x 7” or 8 x 10.” A hard copy print is required for judging. Entry deadline: November 21, 2011 For more info contact: Karen Evers, managing editor 601-853-6733, ext. 323 or KEvers@MSMAonline.com
304 JOURNAL MSMA
September 2011
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Mississippi Physicians Care Network is your network... Strength in numbers – Our provider network is growing...currently over 3,500 physicians and allied providers, with new providers credentialed each month. Competitive statewide PPO – MPCN represents over 100,000 lives statewide and is contracted with over 50 payors. In touch with your legislative and clinic management needs – MPCN is a subsidiary of the Mississippi State Medical Association, your physician advocate organization. Physician managed organization – Your voice is heard on our Board... MPCN’s Board of Directors is physicians only.
If you’re not a “Physicians Care” Provider, join today! If you are... Congratulations, you’re with the right network. PCP ... “Physicians Care” Provider The best specialty
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