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Military Medicine
Overview and Introduction for the Military Health Institute By Byron C. Hepburn, MD and Dean Ronald Rodriguez ......................................................12 Local research combats PTSD By Alan Peterson, PhD .......................................................13 Leading advances in trauma care By Donald Jenkins, MD, FACS ...........................................16 Injury as moder-day epidemic By Brian Eastridge, MD ......................................................18 Health and well-being for military and veteran caregivers By Roxana Delgado, PhD ...............................19 Epilepsy and traumatic brain injury By Mary Jo Pugh, PhD .......................................................21 Acute management of genitourinary injuries By Michael Liss, MD ...........................................................23 Long-term outcomes of extremity injuries from the Iraq and Afghanistan wars By Paula K. Shireman, Jessica Rivera, Mary Jo Pugh .............................................................................24 Non-invasive neuromodulation for posttraumatic stress disorder By Peter T. Fox, MD, Felipe Salinas, PhD, Mary Unzueta, MD, John Roache, PhD, Jack L. Lancaster, PhD .............................26 Microbiomes and traumatic brain injury By Susannah Nicholson, MD, MS ......................................30 Transition to solo private practice Kenneth Yu, MD ..........................................................................32 A quality and patient safety chief resident in the VA? By David Dooley, MD, FACP ......................34 Nodding syndrome and the fog of war By David Schulz ...................................................................36 Working at the VA provides an eye-opening experience By Scott DePaul, MD .............................38 US Army Institute of Surgical Research By Lt. Col. (Dr.) Erik K. Weitzel, USAF .................................40
BCMS President’s Message ............................................................................................................8 BCMS News.............................................................................................................................................10 BCMS Legislative News............................................................................................................................42 BCMS Alliance..........................................................................................................................................45 BCMS Circle of Friends Directory ..............................................................................................................46 In the Driver’s Seat ....................................................................................................................................50 Auto Review: 2017 Ford F-350 By Steve Schutz, MD ..............................................................................52 ON THE COVER: This sculpture titled “Medic” is in front of the U.S. Army Medical Museum at Fort Sam Houston in San Antonio. A plaque on it reads: “In honor of the soldier medics who serve their country in combat. 9 Nov. 1979”.
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4 San Antonio Medicine • August 2017
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BCMS BOARD OF DIRECTORS ELECTED OFFICERS Leah Jacobson, MD, President Adam V. Ratner, MD, Vice President Sheldon Gross, MD, President-elect Jayesh B. Shah, MD, Immediate Past President Gerald Q. Greenfield Jr., MD, PA, Secretary John Robert Holcomb, MD, Treasurer
DIRECTORS Rajaram Bala, MD, Member Lori Boies, PhD, BCMS Alliance President Josie Ann Cigarroa, MD, Member Kristi G. Clark, MD, Member George F. "Rick" Evans Jr., General Counsel Vincent Paul Fonseca, MD, Member Michael Joseph Guirl, MD, Member John W. Hinchey, MD, Member Col. Bradley A. Lloyd, MD, Military Rep. Rodolfo Molina, MD, Board of Mediations Chair John Joseph Nava, MD, Member Gerardo Ortega, MD, Member Robyn Phillips-Madson, DO, MPH, Medical School Representative James E. Remkus, MD, Board of Censors Chair Ronald Rodriguez, MD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative David M. Siegel, MD, JD, Member Bernard T. Swift, Jr., DO, MPH, Member
CEO/EXECUTIVE DIRECTOR Stephen C. Fitzer
CHIEF OPERATING OFFICER Melody Newsom Alice Sutton, Controller Mike W. Thomas, Director of Communications August Trevino, Development Director Brissa Vela, Membership Director
COMMUNICATIONS/ PUBLICATIONS COMMITTEE Rajam S. Ramamurthy, MD, Chair Kenneth C.Y. Yu, MD, Vice Chair Carmen Garza, MD, Community Member Kristi Kosub, MD, Member Lauren Michael, Medical Student Sara Noble, Medical Student Fred H. Olin, MD, Member Jaime Pankowsky, MD, Member Alan Preston, Community Member Adam Ratner, MD, Member David Schulz, Community Member J.J. Waller Jr., MD, Member Jane Yoon, Medical Student
6 San Antonio Medicine • August 2017
PRESIDENT’S MESSAGE
San Antonio – “Military” (Medicine) City, USA By Leah Jacobson, MD, 2017 BCMS President
As many of you know, San Antonio has long been known as "Military City, USA." In fact, just this Summer, the City of San Antonio announced that it had registered the trademark “Military City, USA,” making it official. I do not have much personal experience with the military, other than being born on an Air Force Base to a father that was the base veterinarian. But I know that many of our members have served, or are still actively serving in some capacity. San Antonio has been an important military location for centuries, and we are very fortunate to have top physicians at SAMMC and affiliated centers, as well as "retired" military doctors who actively practice in San Antonio and Bexar County. SAMMC is a unique facility that provides state-of-the-art healthcare to the military and surrounding areas. Some highlights regarding SAMMC include: • Largest DoD (Department of Defense) inpatient facility and only DoD Level I trauma center in United States with 425 inpatient beds and 32 operating rooms for inpatient and ambulatory surgery; providing trauma care to both DoD beneficiaries and the local community • Largest DoD Outpatient Ambulatory Surgical Center • DoD’s only American Burn Association-verified Burn Center • DoD’s only Bone Marrow Transplant Unit and Hematology/ Oncology Clinic (ranking among the top cancer programs in the nation) • The associated Center for the Intrepid provides a full spectrum of amputee rehabilitation as well as advanced outpatient rehabilitation for burn victims and limb salvage patients with residual functional loss. • It provides renowned graduate medical education program (San Antonio Uniformed Services Health Education Consortium – SAUSHEC) with 35 programs and over 600 residents in training.
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One of my first clinical experiences as a medical student at UTHSCSA involved cancer patients at what was then BAMC. I remember driving from the Medical Center to BAMC thinking how far it was and that I was sure to get lost. This was in the Spring of 1991 (pre- 9/11), so I easily drove on to the Post and miraculously found the building where I was supposed to meet my preceptor. After a brief orientation, I was sent to interview and examine a female veteran with breast cancer. As I began to take her history, I was amazed at her life history, not just her medical history. She stated that she had waited to seek medical care and now wasn't sure what could be done. On exam, she had extensive involvement of the breast with erosion of the skin and tissue. It was quite a site for a naive medical student to see. As you can see, she made quite an impression on me — a patient I have not forgotten. We as a country should never forget these brave men and women. We owe these veterans and their military caretakers our gratitude. Their sacrifices and acts of service allow us, as Americans, to remain "the land of the free and the home of the brave." In this expanded edition of San Antonio Medicine, many of our military and academic colleagues have contributed to enlighten us on exciting and innovative new ideas to help in both the military and civilian populations. We, at the Bexar County Medical Society, appreciate our relationship with SAMMC/Brooke Army Medical Center and the military physicians. It is my hope to continue and build on this relationship by involving more military and former military physicians on BCMS committees, councils, etc. Once again, a personal thank you to all BCMS members who have served or are serving in the military. Sincerely, Leah Jacobson, MD
BCMS NEWS
Looking for a place to meet? One benefit of membership in the Bexar County Medical Society is access to the abundant meeting space in the new BCMS Building at 4334 N. Loop 1604 W., Suite 200. The Executive Boardroom can fit a dozen people comfortably, while the Large Conference Room can accommodate groups of 70 to 100 with an adjoining kitchen and the latest in audio/visual technology. To check availability and to reserve space call 210-301-4388.
10 San Antonio Medicine • August 2017
MILITARY MEDICINE
Overview and Introduction for the Military Health Institute By Byron C. Hepburn, MD and Dean Ronald Rodriguez
We established the Military Health Institute (MHI) at UT Health San Antonio in 2014. Our mission is to enhance the collaborative efforts of our university with local, state and federal government, and non-governmental organizations, to improve the health and resiliency of our nation's military service members, veterans and their families through advances in education, research, and health care. The genesis of our mission is threefold: First, we have a long history of military collaboration at UT Health San Antonio — nine percent of faculty and staff on our campus have a military background; second, we live in Military City, USA (San Antonio); and third, quite simply, it is the right thing to do. Since the MHI has been established, we have made significant progress in all our mission areas. We have increased Department of Defense-funded research by an estimated $4 million, hosted grant workshops to educate investigators on the ins and outs of grant writing for the DoD, and sponsored several pilot research projects. We also established a Postdoctoral Fellowship in Military Health and have invited distinguished lecturers on a variety of military health topics. Equally importantly, we have advocated for military health at the state and national levels through numerous venues including the University of Texas National Security Advisory Group and the Association of Military Surgeons of the US. (AMSUS) . Perhaps two of the more significant MHI accomplishments include leading the university’s effort to join the Army's Medical Technology Enterprise Consortium (MTEC), which facilitates university, federal government, and industry partnering to expedite military medical product development. The second is leading the establishment of the Trauma Research Consortium of San Antonio. Much of our work impacts not only military health but civilian medical research as well. 12 San Antonio Medicine • August 2017
The work being done by UT Health San Antonio faculty members is broad and comprehensive. Consider the work of Alan Peterson, Ph.D., who is conducting ground-breaking research in PTSD and has formed the STRONG STAR Consortium and the Consortium to Alleviate PTSD. Additionally, the clinical experience and research of one of our trauma surgeons, Dr. Donald Jenkins, has resulted in a number of life-saving techniques and procedures. These are but two examples of many. In this issue of San Antonio Medicine magazine, you’ll find a number of articles that speak to the groundbreaking advances by researchers at UT Health San Antonio. This collection is not intended to be comprehensive, but simply to provide you with an example of what we are doing in trauma, caregiving and other disciplines. We are proud to be a part of the Military Health Institute and even prouder of the excellent work done by UT Health’s educators and researchers to fulfill our mission. We owe nothing less than our best effort to support our nation’s military service members, veterans and their families. We hope you enjoy reading and following our progress. For up to date news on MHI and our collaborative partners please visit us at uthscsa.edu/military. Dr. Byron C. Hepburn, Maj. Gen. USAF Ret., is associate vice president and the inaugural director of the Military Health Institute at the University of Texas Health Science Center at San Antonio. Ronald Rodriguez, MD, Ph.D., is the interim Dean of the School of Medicine at the University of Texas Health Science Center at San Antonio.
MILITARY MEDICINE
LOCAL RESEARCH NETWORK COMBATS By Alan Peterson, Ph.D. Since Sept. 11, 2001, more than 2.5 million service members have deployed to the Middle East in support of combat operations. Of those, an estimated 14 percent suffer from post-traumatic stress disorder (PTSD), and as many as 25 percent report some psychological problems. This is why, along with traumatic brain injury, PTSD has been identified as one of the signature wounds of post-9/11 deployments. Unfortunately, despite major medical advancements that are saving wounded warriors from war-related injuries they might not have survived in years past, clinicians have a dearth of information to guide them on how effectively to treat combat-related PTSD. There are few evidence-based treatments for PTSD, and even these had previously been studied only in civilian populations or with Vietnam-era veterans, with no adaptations to the unique challenges of treating combat PTSD or to improve the feasibility of delivering these treatments in military settings. Located in Military City USA (San Antonio), home to military medical education, and in the region with the largest concentration of active duty military and post-9/11 veterans, UT Health San Antonio has felt a sense of duty to prevent the development of chronic PTSD in a new generation of war veterans and has responded to address this national public health crisis like none other. Over the past 10 years, UT Health San Antonio has emerged as the nation’s leading academic institution of higher education in the development and evaluation of evidenced-based treatments for combat PTSD and related conditions (traumatic brain injury, chronic pain, sleep disorders, substance use disorders, tinnitus and suicide) in active duty military personnel and recently discharged veterans. UT Health San Antonio has established the STRONG STAR Consortium and the Consortium to Alleviate PTSD. These partnering, federally-funded, multi-institutional initiatives together form the world’s largest research group focused on combat PTSD and commonly co-occurring conditions. STRONG STAR — an acronym for the South Texas Research Organizational Network Guiding Studies on Trauma And Resilience — was originally selected by the Department of Defense (DoD) in 2008 for peer-reviewed funding of approximately $40 million to support 14 clinical research projects targeting active duty military and veterans throughout Texas and to foster the collaboration of many of the nations’ top scientists and clinicians to develop and evaluate the best possible treatments for combat-related PTSD and co-morbid conditions. Since that time, the consortium has partnered with nationwide
investigators and institutions of higher education to secure approximately $50 million in additional peer-reviewed funding from the DoD, the Department of Veterans Affairs (VA), the National Institutes of Health (NIH), and private foundations to support more than 20 additional STRONG STAR-affiliated projects. In 2013, UT Health San Antonio was selected, in partnership with the VA’s National Center for PTSD, to receive $46 million in joint funding by the DoD and VA to lead the Consortium to Alleviate PTSD (CAP). The CAP supports 11 nationwide research projects targeting combat PTSD and related conditions. Now with over 150 collaborating investigators from more than 40 partnering military, VA, and civilian institutions across the country, STRONG STAR and CAP have assembled an unprecedented collaboration of highly qualified researchers and clinicians and established an unparalleled network of clinical trials. Many of these trials are evaluating the leading civilian treatments for PTSD and co-occurring conditions with a focus on how best to adapt and tailor them to meet the unique needs of our nation’s war fighters. This collaboration unifies the critical mass of talent required to make significant scientific advances in PTSD research and to develop and deliver PTSD treatment programs that are relevant, effective and feasible in military and VA settings. Today, the group’s impact is being felt. One way is through the direct care and treatment of psychologically wounded warriors. Through its large clinical trials network that includes many of the military’s seminal studies on PTSD and related conditions, STRONG STAR and CAP have provided state-of-the-art clinical assessments and treatments to over 6,000 post-9/11 service members and veterans. In many cases, this treatment is by credentialed UT Health San Antonio research staff embedded into military and VA treatment facilities, significantly reducing patient care burden for busy military and VA providers. The long-term impact of STRONG STAR and the CAP will come — and is already beginning — through research findings that will influence the treatment of military service members and veterans for many years. With the conclusion of STRONG STAR’s original studies, including several of the largest randomized clinical trials in history to evaluate cognitive-behavioral therapies for the treatment of psychological health conditions in active duty military populations, research investigators are busy presenting and publishing findings about what treatments work best and how best to deliver those treatments to maximize access and effectiveness. continued on page 14
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MILITARY MEDICINE continued from page 13
Following are some of the most significant findings to date that have been published or soon will be published related to the treatment of PTSD and commonly co-occurring conditions: • •
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A high-impact publication that received significant national attention showing that a brief form of cognitive-behavioral therapy reduced suicide attempts by 60 percent among high-risk military personnel (Rudd et al., 2015). A publication showing that Cognitive Processing Therapy can be effectively delivered in a group format (Resick et al., 2015), making CPT an important option in settings where therapists are limited. A highly publicized paper in JAMA Psychiatry comparing group and individual Cognitive Processing Therapy for PTSD, demonstrating that individual CPT leads to greater and quicker reductions in PTSD symptoms (Resick et al., 2017). A paper reporting that long-term reductions in PTSD symptoms were maintained for six months and one year after treatment with an adapted form of Prolonged Exposure delivered in military primary care settings (pilot study findings, Cigrang et al., 2016; RCT findings, Cigrang et al., manuscript submitted for publication). A paper reporting on the efficacy of both in-person and Internet-delivered Cognitive-Behavioral Therapy for Insomnia with
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active duty (Taylor et al., in press), findings that could facilitate effective, non-medication-based treatment for one of the most common problems of service members following deployment. A paper reporting on the effectiveness of Prolonged Exposure for PTSD among active military when delivered in its traditional format and in a massed format, delivered daily over the course of two weeks (Foa et al., manuscript submitted for publication).
Other STRONG STAR publications to date have shared important findings from preclinical and epidemiological studies on factors that influence both the development and treatment of combat-related behavioral health problems, on common data elements for PTSD research, and other topics. Even these are just the tip of the iceberg, since over the next several years, STRONG STAR and CAP are expected to produce an unprecedented body of scientific knowledge that will significantly advance the treatment of combat PTSD and related conditions. In this way, results of these studies have had and will continue to have a significant impact on science, public health, military policy, and most importantly, on the lives of military service members, veterans and their families. Alan Peterson, Lt Col, U.S. Air Force, Ret., is Director of the STRONG STAR program at UT Health San Antonio.
MILITARY MEDICINE
Leading Advances in Trauma Care By Donald Jenkins, MD, FACS
Injury in motor vehicle crashes will take the lives of an estimated 3,500 people on Texas highways this year alone. Contextually, that is more than the total number of U.S. military deaths in wartime in Afghanistan over the last 15-year period. Approximately 14,200 deaths due to injury of all types are expected this year in Texas, with falls being one of the most frequent causes. Working closely with the partner organizations in 22 South Texas counties, the Southwest Texas Regional Advisory Council (STRAC) seeks to limit death and disability due to injury. Seventy-four hospitals and over 70 EMS agencies collaborate to achieve this goal. Featured prominently in the center of this life-saving care are the adult and pediatric trauma centers at University Hospital, the trauma center at San Antonio Military Medical Center, and the burn center at the Institute of Surgical Research at Fort Sam Houston. The trauma centers regularly exchange ideas and lessons learned through interactions that STRAC facilitates. The Military Health Institute at UT Health helps facilitate this work through a number of mechanisms, many of which have research into life saving techniques and procedures at their core. The trauma surgery division at UT Health has a long history of excellence in trauma care and trauma research. Every surgeon is currently engaged in more than one research project, has benefitted from small research grants through MHI and some larger grants through the Department of Defense. The largest current study, Remote Trauma Outcomes Research Network (RemTORN), is a DoD, UT Health, UH and STRAC collaboration studying outcomes of people injured in South Texas. The next large DoD grant will be used to study preventable deaths due to injury and will be a national study run out of STRAC and UT Health. Both studies 16 San Antonio Medicine • August 2017
were designed to capture lessons learned from patient outcomes and to develop new and better ways to treat injured patients. Hemorrhage remains the number one factor associated with preventable death due to injury. Thus, another local collaborator is South Texas Blood and Tissue Center, responsible for the procurement and distribution of the majority of the blood donated and used in South Texas. Together with the previously mentioned groups, a plan is underway for the development of a new blood product line, cold stored whole blood, which preserves the clotting function of a unit of blood that is not retained once the donated blood is broken down into its components. Long the gold standard in transfusion (230,000 cold stored whole blood units transfused by the U.S. in Vietnam), this highly potent product will be able to be carried by the five helicopter EMS agencies for use in bleeding patients prior to their arrival at the hospital. This is a necessity as the time and distance to definitive care across the 26,000 square miles of STRAC is daunting; numerous patients die prior to or nearly immediately upon arrival to definitive care. The MHI at UT Health supports these research endeavors, holds workshops to train investigators how to successfully apply for grant funds to support research and facilitates the coordination of research efforts among these various collaborators. To that end, at a single scientific meeting, UT Health in conjunction with MHI, will present six papers/posters at the Military Health System Research Symposium this August in Florida. San Antonio is uniquely positioned to learn about injury care best practices both on the streets of the city and also from the battlefield due to this unique collaboration, and to share those lessons bi-directionally so that U.S. troops and citizens of South Texas all benefit from improvement in injury care.
MILITARY MEDICINE
Injury as a modern-day epidemic By Brian Eastridge, MD
Death from injury was described as the neglected epidemic of modern medicine by the Institutes of Medicine in 1966. Despite dramatic advances in acute trauma care over the last several decades, including resuscitation of massive hemorrhage, damage-control surgery and technological advances in critical care, the health burden of injury on our society remains substantial. From a public health perspective, injury remains the leading cause of death in individuals up to the age of 45 and is responsible for a domestic cost of more than $406 billion in medical care and lost productivity each year. The majority of injury mortality occurs in the field without access to hospital care or prior to hospital admission. Within the past 15 years of war, a tremendous amount of evidence has been amassed validating improvements in combat casualty care once a casualty has reached a military medical treatment facility (MTF). It was noted by military surgeons that a discrete “blind spot” in the data was evidenced by the fact that no studies comprehensively evaluated the outcomes of combat casualties who succumbed to their injuries before reaching an MTF. As a result, a multidisciplinary military review group was formed that produced the most comprehensive analysis of pre-hospital injury death to date. This review of all battlefield deaths from 2001-2011 demonstrated that 87 percent of battlefield mortality occurred in the field before the casualty reached an MTF. Of the pre-hospital battlefield deaths, 24 percent were deemed potentially survivable under optimal medical circumstances as qualified by the analysis. Assuming similar potential survivability of injury in the civilian injury environment, the number of annual trauma deaths in the United States being approximately 40 times per year the number of deaths in the 2001-2011 military analysis. Put in perspective, the public health implications are staggering. In 2014, the number of potentially survivable injuries in the United States was estimated to be 147,790, according to the 2016 National Academies of Science, 18 San Antonio Medicine • August 2017
Engineering and Medicine report titled “A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury.” In combat, tactical and logistical issues may cause protracted time periods from point-of-wounding to resuscitative surgery. As a result, military and civilian trauma thought-leaders have begun to investigate the concept of Remote Damage Control Resuscitation (RDCR), whereby Damage Control Resuscitation (DCR) principles are projected forward into the combat casualty care setting. This research effort is the Remote Trauma Outcomes Research Network and is a combined effort of UT Health San Antonio, the San Antonio Military Medical Center and the Southwest Texas Regional Advisory Council serving Texas Trauma Service Area P. The first goal of the research was to develop a linked field and clinical test-bed for the study of the interplay of out-of-hospital care, new diagnostic and therapeutic agents, and medical direction that could provide a civilian research model for clinical testing of RDCR protocols and outcomes. Although RDCR is only in preliminary stages of development, a critical component of evaluation and eventual fielding will be clinical trials of diagnostics, therapeutic agents and outcome. In addition, the impact of time-distance sequencing on the development of the “Lethal Triad” during evacuation to surgical care will be more comprehensively analyzed. With the damage control resuscitation and surgery principles already established at Role II/III, similar to civilian trauma centers, the exploration of outof-hospital treatment and transport and the use of RDCR interventions may contribute to greater casualty survival. Civilian regional trauma systems possess many salient characteristics analogous to those encountered in the military operational environment. Improving our understanding of pre-hospital injury care and outcomes is a vital component of trauma system maturation and optimization and stands to benefit the composite military-civilian trauma care system.
MILITARY MEDICINE
Health and Well-being for Military and Veteran Caregivers By Roxana Delgado, Ph.D.
The wars in Iraq and Afghanistan have resulted in higher survival rates compared to other wars. The higher prevalence of wounded, ill and injured veterans may require short- and long-term medical companionship and assistance, often offered by family and friends. Family members and friends become the veteran’s primary caregiver. They are our nation’s hidden heroes. We know from a large-scale needs assessment study conducted by Ramchand and colleagues (2014) that military caregivers from the post-9/11 wars are mostly spouses (33 percent) and parents (25 percent), with the majority being young adults with children. The unique challenges of military caregivers may be impacted by the biopsychosocial factors when experiencing complex injuries like the ones seen in veterans with polytrauma (i.e. traumatic brain injury, post-traumatic stress, pain, amputation). To date, the only large-scale study regarding military caregivers’ health and well-being is provided by Ramchand and colleagues (2014). They found significant disparities between civilian and military caregivers. Military caregivers reported worse physical and mental health issues than civilian caregivers and non-caregivers, among other social and financial characteristics. My colleagues and I at UT Health San Antonio are currently conducting a one-year longitudinal study in pre- and post-9/11 military caregivers. The research team will identify, explore and understand military caregivers’ health and well-being, the determinants of their quality of life, and social development. Much is known about caregivers of patients with catastrophic and neurological diseases, but the limited literature in military caregivers coupled with the reported disparities when compared to civilian
caregivers poses an imminent need to explore further. For the first time ever, we are gathering information on this population of pre- and post-9/11 military caregivers including: the incidence of conditions and diseases; behavioral health characteristics to include suicide ideation; children in the role of caregiving; and stressors that are culturally congruent to military and veterans. In an attempt to better understand the impact of caregiving in the family system, Dr. Kimberly Peacock’s focus is the military child and, within this study, the characteristics of children fulfilling the caregiver role. Given the limited literature and evidence in the military caregiver population, we used a unique approach to design the study: incorporating a Military and Veteran Caregiver Advisory Group (MVCAG). The MVCAG consisted of military caregivers in communities across the United States. With the help of organizations serving this population and partnerships, we have successfully recruited over 400 military caregivers. As anticipated, the majority of the participants were women — spouses (92 percent) under the age continued on page 20
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MILITARY MEDICINE continued from page 19
of 40 years old (59 percent). At the time of the baseline survey, almost half (48 percent) of the participants had been a caregiver between five and 10 years, mostly caring for a veteran with a polytrauma (behavioral conditions, chronic pain and traumatic brain injury). The time spent assisting veterans with activities of daily living and instrumental activities of daily living was approximately 40 hours or more (57 percent). We also measured specific health-related outcomes in the areas of behavioral and physical health, quality of life and social aspects of human development. I’m the wife of a combat wounded veteran (Purple Heart recipient), and Dr. Peacock is a Gold Star Wife (Desert Storm). We are invested in understanding the health and well-being of military caregivers and the potential sequela to future generations. It is imperative to start the conversation and conduct studies that can attend the immediate needs of this population as well as identifying the long-term consequences of caregiving. Different than civilian caregivers, for the most part, post-9/11 military caregivers are responsible for the veteran’s medical care plan for a significant period of time, in some cases up to four
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decades. How will this plan affect the caregiver’s life? What is the socioeconomic impact on their families and the veterans? What types of programs are needed to better meet the needs of this population and what policies are required to support these families? These are some of the issues we plan to study and follow in the years to come. Roxana Delgado, PhD, is a health scientist, epidemiologist and the wife of SFC(Ret) Victor L. Medina, MRC, CRC, a combat wounded veteran. SFC(Ret.) Medina is a Purple Heart Recipient, wounded in Iraq on June 29, 2009, sustaining a moderate traumatic brain injury that resulted in long lasting physical and cognitive disabilities. Dr. Delgado assumed the caregiving role, something that later inspired her career path and research interest.
MILITARY MEDICINE
Epilepsy and traumatic brain injury By Mary Jo Pugh, Ph.D.
Epilepsy is a chronic disorder, the hallmark of which is recurrent, unprovoked seizures. Epilepsy affects one in 26 Americans and is a potential result of traumatic brain injury (TBI). This is a significant concern for the Department of Defense (DoD) and Department of Veterans Affairs (VA) given that approximately 20 percent of more than 1.2 million service members have suffered a TBI while deployed in support of the wars in Iraq and Afghanistan (post-9/11). TBI severity can range from mild (e.g. concussion) to severe and/or penetrating, although approximately 80 percent of head injuries are considered to be mild (mTBI). The Office of the Army Surgeon General identified approximately 300,000 documented incidents of TBI among deployed and non-deployed service member between September 2001 and June 2015. Studies of veterans from World War II, the Korean War and Vietnam have found that individuals with combat-related penetrating TBI were more likely to later experience epilepsy (or posttraumatic epilepsy) for up to 40 years following injury. However, these studies did not explore the development of posttraumatic epilepsy among those with mTBI — one of the signature injuries of post-9/11 wars. Because the majority of head injuries are mild, even a slightly elevated risk of posttraumatic epilepsy following mTBI could substantially increase the burden of epilepsy on patients and families and increase the care burden for epilepsy on the DoD and VA health care systems. My colleagues and I are conducting a longitudinal study to describe the impact of mTBI on epilepsy, and the burden of epilepsy on the veteran, the family and the health care system.
Burdens of epilepsy Existing studies reveal that people with epilepsy identify cog-
nitive impairments (i.e., memory, concentration) as a major complaint, which is a particular concern in the post-9/11 cohort, where cognitive problems are already well described. Other difficulties among people with epilepsy include lifestyle change (e.g. inability to drive, change in activity levels) and loss of confidence about their own abilities. Studies of the impact of epilepsy in veterans with epilepsy conducted by our team suggest that the impact of epilepsy on patients is likely broad, and significantly affects community integration and participation. Epilepsy also has significant costs to the patient and the health care system. Studies have estimated that the annual cost of epilepsy care in the U.S. was $12.5 billion in 2000, and that indirect costs (e.g. caretaker time away from work) comprise 67 percent of the cost of epilepsy. Given the relatively young age of post-9/11 veterans, these costs of care, both personal and financial, may profoundly affect the lives of those veterans, their families, and the health care systems on which they depend for care. Better understanding these burdens was identified as a high priority of Congress to ensure that DoD and VA are equipped to provide superior health care that maximizes the quality of life for all military personnel and veterans with epilepsy.
Study reveals insights Our team has designed a comprehensive study to examine the association between mTBI and epilepsy using data from the DoD, the VA, and participant self-report. This multifaceted approach will allow the team to not only examine the emergence of epilepsy among individuals with mTBI, but it will also provide insight on how blast-related TBI may differ from non-blast TBI, and how deployment related mTBI is associated with epilepsy in the concontinued on page 22
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text of all the other TBI experienced throughout the lifetime (e.g., childhood sports injuries to motor vehicle accidents).
reduce the impact of epilepsy on employment, social, mental health and physical functional status for veterans with epilepsy.
This groundbreaking study will also provide the first population-based study to describe health outcomes of post-9/11 veterans with epilepsy on measures of work, social and functional status compared to similar veterans without epilepsy. By partnering with the Chronic Effects of Neurotrauma Consortium (CENC), the team will contribute to the ongoing CENC Longitudinal Study of the post-9/11 cohort that includes advanced clinical, behavioral, cognitive, genetic and neuroimaging assessments. These data will allow help in answering questions immediately (are there differences in neuroimaging and cognition between VWE with and without mTBI exposure?) and will also provide insights into epilepsy etiology and ultimately identify specific aspects of mTBI (and other risk factors) that will allow early identification of those at greatest risk of PTE. This comprehensive assessment will provide information that will help DoD and VA better understand the health care needs of this population and, to the extent possible, help government agencies
22 San Antonio Medicine • August 2017
Mary Jo Pugh is a Professor of Epidemiology and Biostatistics at the University of Texas Health Science Center at San Antonio and a Research Scientist at the South Texas Veterans Health Care System. Her work uses existing data to develop “phenotypes” or groups of people with similar characteristics, followed by survey data collection, interviews, biological specimens and neuroimaging to understand the long-term outcomes associated with military experiences including deployment, combat, and training injuries. Her current work is focusing on the chronic effects of traumatic brain injury and injuries of the arms/legs (amputations, vascular) in Veterans of the wars in Iraq and Afghanistan, and Gulf War Illness.
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Acute management of genitourinary injuries By Michael Liss, MD
Complex battlefield genitourinary injuries remain poorly characterized beyond initial quantitative studies and recommendations for acute management. The far-reaching impact of these injuries in the domains of urinary, endocrine, reproductive, sexual and psychosocial function mandate thoughtful and comprehensive multidisciplinary medical care. Genitourinary reconstruction is often done in a staged fashion over the course of months to years and in the context of concurrent attempts at limb salvage and physical rehabilitation. A study done at UT Health San Antonio is particularly significant in light of recent health care policy initiatives. The National Defense Authorization Act of 2014 calls for a “comprehensive policy on improvements to care and transition of members of the Armed Forces with Urotrauma.” We aim to characterize the quality and efficiency of transition of care. Herein, we focus on the transition of recovering service members from the Department of Defense to the Department of Veteran Affairs. Our group will be the first to address genitourinary trauma access to care issues and propose solutions regarding veterans transitioning to Veteran’s Affairs Health System and community care. Significantly, strides have been made in the areas of screening for Agent Orange in Vietnam-era veterans and for traumatic brain injury in OEF/OIF deployments; however, the rise in genitourinary trauma has highlighted a need for improvement in care of genitourinary trauma issues. These injuries have long-term effects and urgently need research to assess and address the needs of current and future veterans afflicted with these injuries. Our proposal will provide the necessary information to develop screening tools, assessments, and additional specialized clinics to address these concerns.
Dr. Michael Liss is a member to the TOUGH (Trauma Outcomes and Urogenital Health) project joining Byron Hepburn, M.D., representing the Military Health Institute at UT Health San Antonio, and Lt. Col. Michael Davis, M.D. (transplant, reconstruction), Maj. Steven Hudack M.D., and Jean Orman MsC. MPH at and SAMHS and Mary Jo Pugh, Ph.D. Dr. Liss is a VA investigator employed by the VA and UT Health and is initiating the collaboration to the South Texas Veterans Affairs Medical System specifically at the Audie Murphy VA in San Antonio.
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Long-term outcomes of extremity injuries from the Iraq and Afghanistan wars By Paula K. Shireman, Jessica Rivera, Mary Jo Pugh Vascular injuries are present in 12 percent of wounded soldiers from Afghanistan and Iraq (Operations Enduring Freedom/ Iraqi Freedom/New Dawn; OEF/OIF/OND) and extremity injuries comprise 50 to 60 percent of casualties. The rate of vascular injury is five times higher than in previous wars, and multiple injuries with open fractures are common due to the increased use of rocket-propelled grenades and improvised explosive devices (IED). In parallel, improvements in body armor as well as medical and surgical care have increased survival.1 Meeting the complex needs of these veterans poses a critical challenge demanding greater understanding of the long-term medical and psychosocial needs of veterans with injured extremities. While the care of service members with vascular injuries has been studied in every war, the OEF/OIF/OND conflict established the Department of Defense Trauma Registry (DoDTR) database to capture information on injury demographics. Approximately 86 percent of service members with an extremity vascular injury that was repaired remain free of amputation five years post-injury.2 Long-term outcomes of extremity vascular repairs are not available in the civilian or military trauma literature in regards to limb function and repair patency. Our ongoing Veterans Administration (VA) Vascular Injury Study (VAVIS)3 used the DoDTR to identify service members with extremity vascular injuries, and we are determining long-term repair patency, limb function and limb salvage using VA medical records and surveys to define the outcomes and needs of our veterans. Our team, along with with our colleagues at Johns Hopkins University, is also performing a DoD funded, follow-up study on extremity orthopedic injuries in OEF/OIF/OND, the Military Extremity Trauma and Amputation/Limb Salvage II (METALS II). The first METALS was a retrospective cross-sectional study that included 324 U.S. service members who had sustained major lower limb trauma as a result of high-energy blast and ordnance-related mechanisms. Both unilateral and bilateral lower limb traumatic injuries were included. Patients in the limb salvage and amputation groups reported significant disability compared to normal popula24 San Antonio Medicine • August 2017
tions, and 38 percent screened positive for depressive symptoms, with 34 percent not working or in school. However, service members with amputations experienced better functional outcomes compared to limb reconstruction patients as well as lower rates of post-traumatic stress disorder.4 The DoD responded to these findings by developing more support and rehabilitation programs for limb salvage patients, such as the Return to Run Clinical Pathway5 and the Intrepid Dynamic Exoskeletal Orthosis (IDEO).6 METALS II is performing 10 year outcomes for the original METALS cohort and establishing a second cohort that may have benefited from the improvements in limb salvage care. Our university/VA/DoD team and presence in San Antonio uniquely position us to identify service members/veterans with extremity injuries to determine long-term care and outcomes. The results of these studies will help the VA and DoD to identify areas where specialty care or tele-health options are lacking, thus allowing for better planning and resource utilization within VA and DoD systems, improving DoD to VA care transitions, and providing data that can inform current management and/or guide development of new approaches for PACT
MILITARY MEDICINE care within the VA for patients with injured extremities.
References 1. White JM, Stannard A, Burkhardt GE, Eastridge BJ, Blackbourne LH, Rasmussen TE: The epidemiology of vascular injury in the wars in Iraq and Afghanistan, Ann Surg 2011, 253:11841189 2. Stannard A, Scott DJ, Ivatury RA, Miller DL, Ames-Chase AC, Feider LL, Porras CA, Gifford SM, Rasmussen TE: A collaborative research system for functional outcomes following wartime extremity vascular injury, J Trauma Acute Care Surg 2012, 73:S7-S12 3. Shireman PK, Rasmussen TE, Jaramillo CA, Pugh MJ: VA Vascular Injury Study (VAVIS): VA-DoD extremity injury outcomes collaboration, BMC Surg 2015, 15:13 4. Doukas WC, Hayda RA, Frisch HM, Andersen RC, Mazurek MT, Ficke JR, Keeling JJ, Pasquina PF, Wain HJ, Carlini AR, MacKenzie EJ: The Military Extremity Trauma Amputation/Limb Salvage (METALS) study: outcomes of amputation versus limb salvage following major lower-extremity trauma, J Bone Joint Surg Am 2013, 95:138-145
5. Crowell MS, Deyle GD, Owens J, Gill NW: Manual physical therapy combined with high-intensity functional rehabilitation for severe lower extremity musculoskeletal injuries: a case series, J Man Manip Ther 2016, 24:34-44 6. Hill O, Bulathsinhala L, Eskridge SL, Quinn K, Stinner DJ: Descriptive Characteristics and Amputation Rates With Use of Intrepid Dynamic Exoskeleton Orthosis, Mil Med 2016, 181:77-80 Paula Shireman, MD, MS is a Professor in the departments of Vascular and Endovascular Surgery with a secondary appointment in Microbiology & Immunology at the University of Texas Health San Antonio. She is an academic vascular surgeon and basic/translational science researcher and holds the Dielmann Chair in Surgery endowment.
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Non-invasive Neuromodulation for Posttraumatic Stress Disorder: A Trial of Image-guided, Robotic, Transcranial Magnetic Stimulation By: Peter T. Fox, M.D.1,2,3,4,5, Felipe Salinas, Ph.D.1,5, Mary Unzueta, M.D.6, John Roache, Ph.D.3,5, Jack L. Lancaster, Ph.D.1,2 1. Research Imaging Institute, UT Health San Antonio, San Antonio, Texas
pression (LTD), which have been firmly established in a wide
2. Department of Radiology, UT Health San Antonio, San Antonio, Texas
range of species, including humans. Based on the Hebbian neu-
3. Department of Psychiatry, UT Health San Antonio, San Antonio, Texas
romodulatory principal, repetitive TMS has been tested in hun-
4. Department of Neurology, UT Health San Antonio, San Antonio, Texas
dreds of trials in scores of disorders, including major depressive
5. South Texas Veterans Health Care System, San Antonio, Texas
disorder (MDD) and PTSD. TMS received FDA approval for
6. Laurel Ridge Treatment Center, San Antonio, Texas
use in treatment resistant MDD, based on a multi-site RCT (O'Reardon et al., 2007). TMS is not yet FDA approved for
Posttraumatic Stress Disorder or PTSD is a debilitating anxiety disorder experienced by ≥ 7.8 percent of the United States
PTSD, although preliminary trials are promising (Karsen et al., 2014; Clark et al., 2015).
populace over the course of their lifetime. Since 2001, over 2.5 million U.S. Service members have been deployed in combat op-
Connectomic Imaging
erations, resulting in higher rates of PTSD in combat veterans re-
Imaging studies have definitively demonstrated that TMS neu-
turning from Operation Iraqi Freedom (OIF; 12-20%) and
romodulatory effects are network based, simultaneously modu-
Operation Enduring Freedom (OEF: 6-12%). Although pharma-
lating multiple, interconnected brain regions and extending over
cologic and psychotherapeutic treatments have been shown to
long distances (Fox et al., 1997, 2004, 2006; Laird et al., 2008;
help reduce PTSD symptoms, there is no definitive treatment for
Narayana et al., 2012). Further, TMS effects at different nodes in
PTSD. The success of PTSD treatments has been is limited by
a stimulated network can have different valences (excitatory or
medication side effects and discontinuation of cognitive and be-
inhibitory) for the same stimulus frequency (Salinas et al., 2013,
havioral therapy. Consequently, alternative treatments, including
2016). This neurological complexity argues that TMS therapeu-
neuromoduation, need further exploration.
tics must be informed by realistic models of human neural net-
Transcranial Magnetic Stimulation or TMS is a noninvasive
works. The richest sources of such models are a new generation
means of electrically stimulating the human brain. Magnetic fields
of imaging modalities that map and quantify brain connectivity,
pass readily through biological tissues, including bone. Rapidly
often termed connectomics or connectomic imaging. In addition
changing magnetic fields induce electrical currents that, in turn,
to providing models of neural networks performing specific func-
depolarize neurons. In the 1950’s, Donald Hebb described the
tions (e.g., somesthesis, visuomotor control or language produc-
principal of Hebbian learning, which states that repetitive firing
tion), connectomic imaging can be used to detect disease-specific
of a neural system will be neuromodulatory, modifying the synap-
abnormalities of information transfer. Ongoing advances in con-
tic weights of the stimulated circuits. Current formulations of
nectomic imaging offer the potential for “personalized” neuro-
this principal are long-term potentiation (LTP) and long-term de-
modulatory treatments, in which the treatment plan is informed
26 San Antonio Medicine • August 2017
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by imaging in individual patients. The RCT described here ap-
2012). Based on these imaging observations, the authors (Fox et
plied meta-analytic connectomic imaging (meta-connectomics)
al., 2004) demonstrated that TMS efficacy — its ability to mod-
to create a group-wise (population) model of the network being
ulate neurons locally and remotely — is jointly determined (as a
treated; it then invidualizes this model, using structural and func-
vector dot product) by E-field orientation and columnar orienta-
tional MRI acquired per patient.
tion of neurons in the stimulated cortex. Optimal orientation (maximal stimulation efficacy) is with the E-field column aligned;
TMS Navigation
the least effective orientation is 90° from column aligned. This
The vast majority of TMS clinical trials have not employed
principal — termed the cortical column cosine (C3) principal —
image-guided neuronavigation despite that facts that: 1) the orig-
was confirmed in numerous studies by the authors (Fox et al.,
inal motivation to target dorsolateral prefrontal cortex (DLPFC)
2006; Salinas et al., 2007; Rabago et al. 2009, Narayana et al.,
was based on neuroimaging studies in MDD (George et al.,
2012) and independently (Sommer et al., 2012; Krieg et al. 2013)
1997); and, 2) numerous trials have acknowledged the need to
and is now generally accepted. The most precise and reliable man-
accommodate individual differences in structural and functional
ner in which to implement image-guided TMS is with a purpose-
neuroanatomy and have recommended imaging as the means to
built robot (Lancaster et al, 2004), a patented implementation
this end (e.g., O’Reardon et al, 2007). In a meta-analytic review
(Fox & Lancaster, 2006, 2010, 2015). To this end, the Research
of TMS trials in psychiatric disorders, Slotema (et al., 2010) ar-
Imaging Institute (RII) at UT Health San Antonio UTHSCSA
gued that a large portion of inter-subject and inter-trial variability
has developed three generations of image-guided robotic systems
was attributable to: 1) inadequate neuroanatomical specification
for TMS delivery, with a 4th generation in development. The 3rd
of treatment targets; and, 2) delivery imprecision, i.e. inadequate
generation system (Figure 1) is being used in the clinical trial now
neuronavigation. Growing awareness that TMS effects are multi-
in progress.
regional and network based has lead to the recommendation that
DLPFC is a large, functionally heterogeneous region with an
neuronavigation be implemented based on connectomic princi-
antero/medial-to-postero/lateral functional gradient (Koechlin et
ples, i.e. based on the network properties of the brain regions
al., 2003; Cieslik et al., 2012). Meta-analytic connectivity based
stimulated (Fox et al., 2012; Fox et al., 201 4; Clark et al., 2015).
parcellation (CBP) of DLPFC (Figure 2A) identified two discrete
The PI and colleagues have applied neuroimaging methods in
subregions: an antero/medial zone projecting to anterior cingulate
conjunction with acute and chronic TMS delivery for almost 20
cortex (ACC) and subgenual cingulate (SGC) and a postero/lat-
years and have applied this knowledge base to develop the TMS-
eral region projecting to intraparietal cortex and mid-cingulate
specific neuronavigation method used in the RCT described here.
motor areas (Cieslik et al., 2012). Applying this finding to per-
Combining TMS with neuroimaging demonstrates that TMS
subject resting-state fMRI data, we use the ACC and SGC sites
effects are precisely multi-focal. That is, TMS effects are not dif-
jointly as seeds to identify the anterior subregion of DLPFC as a
fuse local effects, spreading over a large area under the stimulating
regional constraint on treatment planning (Figure 2B). Treatment
coil, as was previously assumed. Rather, they are highly spatially
planning incorporates cortical- and scalp-surface modeling to
precise at the stimulation site and propagate to remote regions
compute orientation and depth-corrected E-field values and iden-
along well-established network connections. The initial
tify optimal coil positioning and intensity settings.
TMS/PET study unequivocally demonstrated this property of precise multi-focality (Fox et al., 1997) and these results have
Study Design And Rationale
been replicated and extended in numerous subsequent reports
The ongoing trial uses a 2-arm randomized, double-blind de-
(Fox et al., 2004, 2006; Lancaster et al., 2004; Laird et al., 2008;
sign to determine the efficacy of rTMS to right DLPFC as an
Salinas et al., 2007, 2009, 2011, 2013; 2016; Narayana et al.,
add-on to inpatient treatment as usual for PTSD. All patients in continued on page 28
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this study will concurrently receive trauma-focused therapy and
Innovation
standard pharmacotherapy as a standard-of-care 30-day inpatient
Innovative features of this proposal include: 1) neuronavigation
admission at the LRTC. Our study seeks to replicate and extend
using the UTHSCSA image-guided, robotic TMS delivery sys-
the Cohen (et al., 2004) and Boggio et al. (2010) reports of right-
tem; 2) 20-Hz stimulation protocol; 3) daily treatments (7
DLPFC TMS in PTSD, the trials with the largest effect sizes in
days/week) for 20 days; 4) inpatient cohort; and, 5) pre- and post-
PTSD (Hedges G = 1.84 and 3.78, respectively). Stimulation will
treatment fMRI to assess treatment mechanism of action.
use the 20-Hz protocol of Boggio rather than the 10 Hz protocol
The UTHSCSA neuronavigation system has been subject to mul-
used by Cohen. Novel aspects of the study are: 1) a cohort com-
tiple validations of its underlying theory (Fox et al., 2004, 2006;
posed of active-duty and veteran service members; 2) in-patient
Rabago et al., 2009; Sommer et al., 2012; Krieg et al., 2013) and
population; 3) use of image-guided neuronavigation and robotic
has been successfully applied in motor-learning trials (Narayana et
TMS delivery; 4) treatment for 20 sessions over 3 weeks (7 daily
al., 2014), lesion-deficit investigations (Narayana et al., 2009), and
sessions/week) rather than 10 sessions over 2 weeks (5 daily ses-
network-property quantification in humans (Laird et al., 2008;
sions/week); 5) obtaining pre- and post-treatment imaging to de-
Narayana et al. 2012) and non-human primates (Salinas et al., 2011,
termine the neurophysiological effects of this treatment protocol;
2013, 2016). This will be its first use in a controlled trial of a psy-
and 6) conducting a 3 month follow-up assessment.
chiatric disorder. This will also be the first release of this UTHSCSA technology to an outside institution (LRTC).
Participating Sites This RCT is being performed as a collaboration between UT
Impact
Health San Antonio and Laurel Ridge Treatment Center. UTHSA
The intended impact of this proposal is far reaching. Confirm-
provided the trial designed and oversees all aspects of the trial.
ing prior estimates of the high effect size (3.78) of TMS in an ac-
Imaging, treatment planning and image analysis are performed at
tive-duty population would have substantial positive impact on
the UTHSA Research Imaging Institute. Treatment delivery and
PTSD treatment options in both military and civilian popula-
symptom assessment are performed at LRTC. In preparation for
tions. A rapid (20 consecutive days) treatment protocol for short-
delivering irTMS treatments, an irTMS system (developed at the
stay (~ 30 days) inpatients could have substantial therapeutic
RII) has been installed at LRTC and LRTC staff have been bully
impact on active-duty military and critical-duty civilian PTSD
trained in its use.
patient populations. Confirming the efficacy of high-frequency TMS on a disorder characterized by diffuse hyperactivity would
Investigators
be impactful both theoretically and practically. Providing quan-
Peter T. Fox, M.D. is a neurologist, Director of the RII and co-
titative neuroimaging data on the mechanism of action, including
inventor of irTMS. Jack L. Lancaster is a medical physicist spe-
symptoms corrections with path-specific effective-connectivity
cializing in image-analysis algorithms and co-inventor of irTMS.
adaptations would have substantial theoretical impact.
John Roache, Ph.D. is a neuropharmacologist specializing in clinical trial design. Felipe Salinas, Ph.D., is a biomedical engineer with > 10 years of TMS training and experience, including elec-
Military Relevance and Access to Military/ VA Populations
tromagnetic field modeling. Mary Unzueta, M.D., is a psychia-
For active duty military personnel, a diagnosis of PTSD may
trist and Medical Director of the Mission Resiliency Program at
affect all facets of military operations—including, but not limited
LRTC, an inpatient program that serves active-duty uniformed
to, mission readiness and resource allocation. Although pharma-
services members.
ceutical and psychotherapeutic interventions are effective at re-
28 San Antonio Medicine • August 2017
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Figure 1. rTMS aiming and delivery. A. E-field effect on cortical neurons is a vector-vector interaction with cortical columns orientation (Fox et al., 2004). B. 3rd generation UTHSCSA irTMS system now sited at LRTC.
ducing PTSD symptoms, there is no definitive treatment for
Dr. Peter Fox is a neurologist with a career-long
PTSD. This RCT has the potential to advance knowledge regard-
focus on brain imaging research. He has pioneered nu-
ing the efficacy of network-based, image-guided rTMS on PTSD
merous methods for functional and structural map-
and may also contribute to the understanding of the neuroplastic
ping of the human brain, including the use of
effects of rTMS on PTSD brain networks. If successful, we plan
standardized coordinates for brain imaging and combining transcra-
to expand the availability of the proposed rTMS treatments to
nial magnetic stimulation (TMS) with positron-emission tomography
both active duty and VA-referred patients with PTSD. Our team
(PET) to map neural circuits and systems. Dr. Fox is the founding
is well positioned to perform this type of work due to our collab-
Editor of Human Brain Mapping, a Fellow of the American Associ-
orations on existing studies of OEF/OIF/OND veterans and ac-
ation for the Advancement of Science, a recipient of the Presidential
tive duty service members, and our prior experience with active
Research Scholar Award from the University of Texas Health Science
duty and veteran populations.
Center, and has been designated a Top-100 Most Highly Cited Scientist by the Institute for Scientific Information.
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Microbiomes and Traumatic Brain Injury By Susannah Nicholson, MD, MS Trauma is a major understudied health problem in the United States, yet it remains the leading cause of death in people under the age of 40. A wide range of post-injury complications can develop that contribute to the associated high morbidity and mortality. Patients may survive the initial insult but die later during their hospitalization from inflammatory and infectious complications. The microbiome is defined as the collective genomes of the microbes that live inside and on the human body. Recently, disruption of the gut microbiome has been linked to cardiovascular disease, inflammatory bowel disease, obesity, and a number of other disease states. Despite efforts focusing on the role of commensals in human health and disease, data is sparse concerning the interactions of the microbiome in trauma and traumatic brain injury (TBI). Our group has conducted pre-clinical and clinical research, through the support of the UT Health San Antonio Military Health Institute, evaluating the role of the gut microbiome following trau-
30 San Antonio Medicine • August 2017
matic injury and TBI and its relationship to inflammation and clinical outcome. The objective of these studies is to better understand the role of the gut microbiome in patients following traumatic injury and TBI and lead to the development of a clinical strategy to manage complex trauma patients to reduce morbidity and mortality. Our work utilizes innovative techniques in metagenomic sequencing to facilitate a greater understanding of the complexity of the environment within the gut following trauma. Dr. Susannah Nicholson is a trauma surgeon and Assistant Professor at UT Health San Antonio, Department of Surgery, Division of Trauma and Emergency Surgery and serves as the Director of Trauma Research for the Division of Trauma and Emergency Surgery. Dr. Lora Talley Watts is an Assistant Professor in the Departments of Cell Systems & Anatomy and Neurology and the Research Imaging Institute.
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TRANSITION To Solo Private Practice
By Kenneth Yu, MD
For many military physicians—whether they serve a few years or retire—the next stage is civilian practice. Options range from private practice to academic to government (ie VA or contractor in the military health system). Some may even pursue part time work as locum tenens. Each choice presents its own advantages and disadvantages, and each doctor chooses the practice that best meets his/her goals. As a facial plastic and reconstructive surgeon, I decided to pursue a solo private practice. In my opinion, this is the most risky model, but which also holds the most potential reward. For me, I was attracted by the freedom of being my own boss. I make all the decisions, and don’t need to run decisions by any committee or commander. I also liked the concept of growing my own practice. While I had been tasked to grow departments in the Air Force, or lead a group of men and women to complete a mission, the idea of creating my own business, growing it, creating jobs and delivering a desired product was very appealing. Although I decided to open my own practice fairly early, I admit I did not dedicate myself to formulate a detailed road map to achieve this. I had a vague idea of what I wanted to do, but it was mainly from anecdotes of what I heard other military surgeons had done before they started their practice. In a nutshell, 32 San Antonio Medicine • August 2017
I would start my own practice a year before I retired-- basically “moonlight” in my practice after hours. I wouldn’t have the pressure to generate positive income early since I was still employed in the Air Force. I would use those initial years to build up a patient base so that when I did retire, I could work full time with an established clientele and start making money. This grand plan quickly collided with the cold reality of business, and I learned that making money is not a guarantee. Once I started, I gave myself two choices. One, I could hire a professional consultant to help me start my practice. I know Texas Medical Association offered such a service to its members, and I suspect there are other consultants who do the same. In my mind, the advantage was an easier, quicker, and more thorough path to opening my practice. The biggest disadvantage would be cost; I learned these services are fairly expensive. The second choice was to learn the steps on my own. The advantage was eliminating a major expense. The main disadvantage would be a more painful and frustrating journey. When I weighed the two choices, I decided on the second path. I had time since I still had another year in the Air Force and could afford to make mistakes. For me, minimizing my start up costs was very important. Many years ago, I was influenced by a presentation by a successful
MILITARY MEDICINE
facial plastic surgeon. His take home message was -- don’t take on an unmanageable loan. Once I chose my path, I researched what I needed to do to open a practice. First, I talked to colleagues I trusted. One was Dr. Earl (Ted) Ferguson, a plastic surgeon who was my squadron commander when I first moved to San Antonio. Ted was always fair and honest with me when I worked for him. He had retired from the Air Force and was in private practice. He told me first I needed an attorney to form a business entity, and also referred me to a contact at Medical Protective to obtain my own malpractice insurance. Two basic steps were established. My attorney, Mr. Edgar Duncan, was also very helpful and pointed me to other contacts. Though I knew I needed an office, I did not want my own office while still in the Air Force. Since I would be moonlighting in my own office, I wanted to sublet a space before I finally retired. But how does one look for space to sublease? Here’s where I learned the value of connections. I talked to various colleagues, who suggested various physicians to talk to. But a key connection came from my wife’s friend, whose husband was a successful podiatrist in town. Dr. Russell Stanley referred me to his colleague, Dr. John Winston, a colorectal surgeon in Stone Oak. Dr. Winston turned out to be a terrific colleague. Though all the other doctors I talked with were open to meeting me, I felt their priority was maximizing their profit with me. I was not offended—I understand that’s business. But Dr. Winston was the only colleague who truly wanted to help me, and embodied the philosophy of “paying it forward.” He offered a reasonable lease, but the most valuable assistance he gave me was his openness to discuss any business questions I had. Dr. Winston shared his process to meet referring doctors and strategies to improve referrals. I also appreciated his happiness to recommend various business partners critical to private practice—from banks to accountants to even Information Technology (IT) companies. His office manager, Velma, was also extremely helpful. Velma showed me the basics of insurance billing, credentialing, and contracting—all completely foreign concepts to me. In a sense, I received an “internship” in private practice while working there, and I didn’t need to hire a consultant to help me start. With a foundation established, opening my own office was much easier. I found a real estate broker through another of my wife’s friend. Carl Salvato was experienced in medical offices, and he guided me through the process of finding space, negotiating the lease, and finding a contractor to build out the space. From
my time at Dr. Winston’s, I met Tom Rosol, the local representative for Henry Schein. Tom also turned out to be a valuable resource since equipping an office is another critical element of starting a practice. However, I quickly learned the number one challenge to solo practice is generating patients. All the steps needed to open a practice involved time, money, and some frustrations, but there were always certain promised outcomes. But just because I have a practice, I learned patients wouldn’t simply come. As a friend told me, once you get out of the Air Force— regardless of your reputation—“you don’t exist.” You have to pound the pavement to get referrals. My case was a bit different since the predominant patient base I needed was for cosmetic procedures. I quickly discovered advertising is another important expense that, unfortunately, is very expensive and whose return on investment is difficult to judge. With the bombardment from multiple companies seeking my business (i.e. Search Engine Optimizing (SEO), print advertising, TV etc), I felt like throwing darts and just hoping something will stick. In the cosmetic industry, I knew effective SEO is the first priority. I’m also trying print advertising; I’m currently still in the contract period and will monitor the return. Meeting potential referring providers also exposed a harsh reality. Not every practice was cordial; I was surprised to discover many never returned my calls, or promised their doctors would call but never did. The hardest thing for me to accept is not to take things personally. Still, it’s frustrating to be treated like a vendor vs. a medical colleague. I’m still in the early stages of my private practice, and friends always ask how my experience has been. My answer is the same— it’s exciting, yet a bit scary at the same time. I had reached the pinnacle of my Air Force career. I was promoted to colonel, had served as chief of otolaryngology at SAMMC (or BAMC—I could never keep the politics straight), had deployed to Afghanistan, and served as a squadron commander. Creating and growing my own practice is a challenging endeavor that I find very stimulating and one that motivates me daily. I’ve made my share of mistakes and believe these will only help me grow. Though the Air Force didn’t teach me any business principles, I strongly believe its core values—integrity, leadership, and the essential role of developing strong teams—are critical to success for any organization. Dr. Kenneth Yu is a facial plastic & reconstructive surgeon in private practice in San Antonio and is vice chairman of the BCMS Publications Committee.
visit us at www.bcms.org
33
MILITARY MEDICINE
A Quality and Patient Safety Chief Resident in the VA? By David Dooley, MD, FACP
It’s still early in the morning at San Antonio’s Audie L. Murphy
San Antonio (UTH-SA) Internal Medicine interns in tow, she
Memorial Veterans Hospital VAMC and Dr. Michelle Ogunwole
makes her way through the procedures, coaching and correcting
has already received three requests for help in performing bedside
the learners to ensure that no harm is done. Preliminary training
procedures on veteran patients: one diagnostic paracentesis on a
is commonly done in the new Audie Murphy Simulation Center.
medical ward, one thoracentesis, and another large-volume para-
Dr. Ogunwole is the most recent of the Chief Residents in
centesis in the internal medicine clinic. With her two UT Health-
Quality and Patient Safety (CRQS) at the South Texas Veterans
34 San Antonio Medicine • August 2017
MILITARY MEDICINE
PHOTO AT LEFT: Dr. Michelle Ogunwole instructs her intern, Dr. Andrew Donati, in ultrasound-guided internal jugular access on a manikin in the Audie Murphy Simulation Center. Ms. Deb Bartoshevich, VA Simulationist, observes. (Photo courtesy of STVHCS Medical Media)
Health Care System. Over the past six years, they have taught
be 60 such chiefs in the room with her from VA facilities na-
invasive procedures to medicine residents with such care that
tion-wide, indicating how widely the program has spread. One
complications have plummeted. Over the first two years of the
such site, stimulated in part by observing the VA/UT CRQS
program, when the CRQS introduced ultrasonography to the
success, is the San Antonio Military Medical Center, whose ex-
thoracentesis protocol, pneumothoraces dropped from a 12 per-
perience can be found published in Military Medicine (Ferraro
cent incidence to 3 percent. Complications from central line
K. et al., March-April 2017).
placement in the Audie Murphy medical ICUs have frankly be-
Another role Dr. Ogunwole plays is that of leader of a cohort
come rare. VA patients are fortunate to have doctors who have
of medicine residents in pursuing a process improvement project
had intense, repetitive training in the safest techniques for in-
over the course of the academic year. All medicine residents are
vasive procedures.
assigned to one of five such cohorts, and four other young and
When Drs. Pat Wathen, George Crawford, and David Dooley
energetic faculty members lead the other teams. Engagement in
proposed to obtain a salary line from the VA’s Office of Academic
the hands-on application of quality improvement processes is thus
Affairs (OAA, VA’s directorate for medical education) six years
embedded in the residents’ training. While this has been driven
ago, only five of 140 VA Medical Centers in the country had a
in medicine by the energy and interest of Dr. Wathen as the pro-
CRQS. The concept of such a position had been jointly developed
gram director, the incorporation of QI into the curriculum of
by VA leadership in OAA and in VA’s National Center for Patient
every residency program has become standard in 2017. (A man-
Safety in Ann Arbor. Audie Murphy was in the second group of
date from the ACGME, the accreditation agency for training pro-
five in the nation to acquire the position. The slot is filled each
grams, has helped). Physicians in every specialty who completed
year by one of the UTH-SA Internal Medicine Residency’s four
their training more than 10 years ago might be pleased and sur-
Chief Residents, a highly select group. Recruitment into the slot
prised to know of the opportunities that are now routinely offered
is not difficult as it attracts internists who love both teaching as
to their successors.
well as performing procedures. Dr. Karthik Garapati, the CRQS
By mid-morning the CRQS is having to apologize to requestors
from 2016-2017 who is just cycling back into a gastroenterology
for limiting procedural consultations to four for that day; other
fellowship, estimates that he (or Chief Resident colleagues who
inpatient teams are going to have to do their own. The lunch hour
shared this duty) performed over 200 paracenteses, over 150 tho-
and the afternoon are already scheduled for the Morbidity and
racenteses, and over 100 lumbar punctures with trainees over this
Mortality conference she arranges and presents and then to attend
past year.
residents in Audie Murphy’s internal medicine clinic. But by in-
But Dr. Ogunwole also teaches the entire sphere of Patient
vesting in and developing academicians like Dr. Ogunwole, the
Safety (PS) within the Internal Medicine program at Audie Mur-
VA has changed and broadened the landscape for our Affiliates’
phy. She received an extensive exposure to PS elements during
physicians in training.
her own training (including Quality Improvement principles, Root Cause Analyses, Simulation Training, Team Training,
Dr. David Dooley is the associate chief of staff for education at
Human Factors Engineering, et al.), receives a brief refresher in
South Texas Veterans Health Care System and a professor of medicine
June, and in September will attend a week of more intense on-
at UT Health San Antonio.
site training with other CRQSs on the same topics. There will visit us at www.bcms.org
35
MILITARY MEDICINE
Nodding syndrome and the fog of war By David Schulz
Note: San Antonio has great health-related nonprofits, many created by doctors who also practice, research and teach. They see the dire needs and are moved to address them directly, leveraging community strength through volunteer leadership. San Antonio Medicine Magazine will spotlight a variety of these organizations in coming months, in this case one with a global perspective — and tell of the inspirations that guide them.
A philanthropic passion is typically passed from parent to child. But when a neurologist’s daughters returned from a trip abroad, reporting on the massive outbreak of a new neurological disease, their stories set Dr. Suzanne Gazda of the Neurology Institute of San Antonio and Medical Director for the South Texas Multiple Sclerosis Center on a new mission of service and volunteerism. The family had already made a few trips to Uganda that deeply affected them. “When I set foot in Uganda in 2008, it changed me, seeing poverty at that level, seeing people that live on the edge of life and death every day with degraded and antiquated healthcare system in shambles and yet they were happy, joyful and provided a warm welcome to all,” Gazda said. But it all became more personal, “When my daughters came home from Uganda in 2011 and they told me that the women in the villages are talking about how sick their kids are with a neurological disease called Nodding Syndrome.” “Being a neurologist, my first step was to review the literature on this topic to try and understand the problem. I soon found that there was little written — a few articles by CDC, and WHO, but all-in-all it was a very mysterious, NEW disease. “So, I researched more broadly and began reading anything I could find including reports from the Ugandan newspapers — sort of like reading the local paper for medical news in terms of
36 San Antonio Medicine • August 2017
reliable information. And what I learned was astonishing: there were thousands of children afflicted with a condition that impaired their brains that had never been seen in the area before; it only affected children, creating intractable seizures, cognitive impairment, behavioral problems and weird growth retardation. In response to her new understandings, Gazda formed her nonprofit, “Hope For Humans.” After an exploratory mission to Northern Uganda in May of 2012, her imperative was simple: “I have to help these children!!” The onset of this disease coincided with a 10-15-year period of a Ugandan Civil War, raging in Northern Uganda from 1983 to 2005. The conflict was made even more notorious by Joseph Kony building an army of child soldiers, robbing central Africa of a generation. Some say that Nodding Syndrome has also contributed to the demise of the future of this tribe of people by destroying their children. War is an evil encounter. Says Dr. Gazda, Nodding Syndrome is a brand-new disease with 99 percent of the cases having onset while living in the horrid internally displaced person (IDP) camps. Concentration camps was the original expression. Dr. Gazda says “Something very bad happened to these children during their time spent in the camps.” Was there exposure to a chemical? Or was a vaccine given? Or
MILITARY MEDICINE
in the relief food provided, recalling though that this is limited to children. Suspects Dr. Gazda, “There’s so much information that we think is out there, but the fog of war is keeping data hidden, being shielded, never to be published, so we may never know what caused it.” There are more questions than answers. Data recently cited in various media sources like NPR and as identifying the source as a parasite from the black fly, appears flawed due to investigator bias that ignores inconvenient considerations… “Why do we only see it in one part of the world, where these conditions also exist elsewhere … a ‘black fly’ parasite that’s also evident in South America and throughout Africa.” Her suspicions are echoed by Kilak Member of Ugandan Parliament Gilbert Olanya, a member of the Nodding Syndrome Task Force. He claims the report disseminated "Does not hold water." But funding for this research, primarily from the Ugandan Government, flows in a direction that doesn’t permit full disclosure of the war’s details, chemicals and materiel used. “It’s much easier to blame an infection from a fly but there’s
been no coordinated research by the CDC and WHO to explore any other causes” Dr. Gazda points out. “The Government wants this to be the answer, so there are more questions about “nodding syndrome.” Dr. Gazda believes Nodding Syndrome is similar to a late onset form of autism, a condition affecting millions of children all over the world. So why is this important to a neurologist 8,500 miles away? Why was Hope for Humans founded here? “We are all interconnected in this world and in this day and age … disease knows no boundaries. Other diseases: Zika, HIV, Ebola, all started in East Africa and like them, I fully expect one day we’ll see Nodding Syndrome in new and other regions. A larger payoff: If this mystery was further studied, we’d learn a lot about epilepsy, autism, and about environmentally induced diseases. “This research would help advance medicine … all over the world!” concludes the San Antonio neurologist. David Schulz is a member of the BCMS Publications Committee.
visit us at www.bcms.org
37
MILITARY MEDICINE
Working at the VA provides an eye-opening experience By Scott DePaul, MD “CODE BLUE, 4A, room 422. CODE BLUE, 4A, room 422.” Cue the lights, sirens.
from me, a crowd amassing. While anxiously making my way there it did dawn on me if the patient had even understood what
Our Sunday morning rounds had just started to
I meant by “coding,” probably not, but from all the bells and
gain traction when they were brought to a shrieking
whistles and general urgency of the situation, I think she mostly
halt by the god-like voice emanating from the intercom. The
understood.
pleasant, elderly Hispanic woman who offered her time to such
I entered the room to find my senior resident at bedside flanked
announcements was more accustomed to inviting everyone to the
by a crash cart and three nurses. In the bed lay a middle-aged fe-
weekly catholic mass, not declaring medical emergencies. This
male. Even at first glance, one could tell the recent years had been
was different.
tough. One nurse rhythmically pushed on the patient’s chest, an-
“I’m sorry ma’am, but I have to go. A patient is coding.”
other grabbed the Ambu Bag to assist with her breathing, while
With those words, I abruptly ended the interview with one of
the last nimbly worked the pads from the crash cart and activated
our more challenging patients and hurried out the room. I could already see bodies flying toward the door just two rooms down 38 San Antonio Medicine • August 2017
the defibrillator. “So, what’s the status,” I stated calmly.
MILITARY MEDICINE
between Wilford Hall and Brooke Army Medical Center. When discussing my military time with others, what outsiders seem to find most odd relates to the patient population. Yes, I did care for several basic trainees and the occasional active duty member, but on the whole, elderly retirees more reminiscent of a Medicare population made up the vast majority of my patients. Of course, this was in large part self-selection, as most active duty personnel were fairly healthy and could readily be cared for in a Family Practice setting. Regardless of the exact demographic, most of my patients shared several common traits, especially desirable from a physician’s perspective: stable social/living situations, invested in their care, followed directions, reliable with follow-up. To illustrate this point, when caring for patients in the hospital, someone leaving “Against Medical Advice” was almost unheard of during my time as a resident/staff. “Tele called, said she was in V-tach. When we came to check on her she was unresponsive and cyanotic, so we started CPR.”
Having completed my active duty payback to the Air Force, I was finally free to go my own way, but San Antonio had a hold
“Anyone know why she was admitted,” I asked.
of me. Warm weather, good cost of living, I was already starting
“Alcohol and opiate withdrawal.” Her nurse skillfully stated
to call this home. Consequently, I took a job at the VA as a full-
with no interruption in chest compressions. Shortly thereafter the ICU team arrived and what followed was
time hospitalist, a natural transition for many a prior active duty member.
a well-orchestrated effort to save this patients life. Fortunately for
Shortly after starting work at the VA, though, it was evident
her, three shocks and a dose of epinephrine later, that’s exactly
this veteran population was different than the one I had become
what happened. She quite literally came back to life and was scur-
so accustomed to in the military. Drug and alcohol abuse, often
ried off to the ICU for further monitoring.
running hand-in-hand with mental health issues, are dealt with
With that crisis averted my team and I regrouped and labori-
on a daily basis. All too often veterans have little to no social sup-
ously worked the long list of patients on this busy post-call day.
port or are presently homeless. I have become all too familiar with
It was a smattering of the usual — gastrointestinal bleed, cellulitis,
the various homeless shelters and substance abuse treatment cen-
pneumonia, heart failure, COPD, alcohol withdrawal — most
ters San Antonio has to offer. Not surprising, due to the afore-
with equally complex social situations to boot. Fortunately,
mentioned issues, patient compliance with medications and
though, the remainder of the day ran relatively seamless compared
treatment plans is often sub-par at best. Of course, not all patients
to the morning endeavors.
I treat fall into this category. There are those “good” patients that
This fall will mark four years of working at the Veterans Affairs
follow our instructions to the letter and have loving, supportive
(VA) Hospital in San Antonio. Having grown up in San Diego,
families waiting to take them home. However, like in other av-
Calif., I never thought I would end up in Texas. I had no family
enues of life, it is often the more difficult situations that really
or specific connections here, but as it goes with so many, this is
stand out.
where my job took me. After completing medical school in Pitts-
My work at the VA has opened my eyes to a side of the veteran
burgh, I undertook an Internal Medicine residency at Wilford
population that I did not fully appreciate while on active duty.
Hall Medical Center, once the flagship of Air Force medicine. My
This veteran group is ever growing and has a unique set of health
training complete, I was fortunate enough to serve back my active
care needs. Each day is a challenge, but one which my colleagues
duty commitment as a staff internist here in San Antonio, rotating
and myself gladly accept. visit us at www.bcms.org
39
MILITARY MEDICINE
U.S. Army Institute of Surgical Research By Lt. Col. (Dr.) Erik K. Weitzel, USAF Deputy Director, U.S. Army Institute of Surgical Research The U.S. Army Institute of Surgical Research (ISR) is proudly recognized as the premier military medical research institution in the world. Currently at 74 years old, this institution located at Joint Base San Antonio-Fort Sam Houston, has led the field of burn research for decades and has contributed greatly to the fund of knowledge for all aspects of combat casualty care. From the point of injury to comprehensive rehabilitation, the ISR researches innovative solutions to every facet of the Wounded Warrior’s completed recovery. The mission of the Institute is to “Optimize Combat Casualty Care.” In order to accomplish this, 10 independent scientific task areas split the complexities of battle injury, from Damage Control Resuscitation and Tactical Combat Casualty Care to Pain Management and Regenerative Medicine. To highlight some of the spectacular and wide-ranging projects occurring within the ISR, I sat down with a few of the Task Area Managers to discuss their research. Jose Salinas, Ph.D., Task Area Manager for the Clinical Decision Support and Automation Research Branch, runs a lab whose purpose includes development of algorithms and systems to support real-time decision making for combat medics during battle and assist with defining the best treatment and triage of Wounded Warriors. A recently released public video from this lab shows a simulated battle scenario that evokes scenes from the movie, “The Minority Report.” Medics wear specially manufactured mixed reality glasses that overlay heads up translucent windows containing patient status, vital signs, and records while the patient is undergoing treatment. Consultants from thousands of miles away quickly pop in and out to add in their assessments and guide the medics through best practice treatments. In this way, the wounded soldier can receive the best possible care by experts in the field within seconds of injury. The equipment, currently on display in Dr. Salinas’ lab, represents an awe-inspiring leap into the future of battlefield medicine. Exploring another aspect of the ISR’s broad-ranging mission, I spoke with Task Area Manager Col. Elizabeth Mann-Salinas, RN Ph.D. One of her current research focus items includes something that is quite dear to physicians who perform procedures. She is studying competency of the support team with regards to combat readiness. Specifically, she is developing a series of core competencies for nurses who support interventional procedures and mapping out 40 San Antonio Medicine • August 2017
how different tasks they perform contribute to their readiness to support the task at hand. This program, entitled “Transition in Practice Towards Optimal Performance” is defining how many hours each nurse must be supervised prior to becoming independent. She can also track whether student nurses are missing expected milestones and should be diverted to other career fields. We all know that the medical team is only as strong as its weakest link. A nurse who isn’t up to speed or who has not been trained to support the task at hand is a major liability for the patient’s outcome. Col. Mann-Salinas’ goal is to make sure each patient has a solid chain of qualified individuals supporting their acute interventions. Finally, I spoke with the outgoing Deputy Commander of the ISR and Director of the RESTOR regenerative medicine program, Lt. Col. (Dr.) Michael Davis. Lt. Col. Davis is internationally recognized for his work in reconstructive transplantation. He has developed novel immunomodulatory strategies to reduce and even possibly obviate the need for systemic immunosuppression when transplanting arms and faces. These treatments, once refined could allow severely injured service members to be made whole again through transplantation following devastating injury. Arm amputations remain a significant surgical challenge due to the immense amount of sensory input they require for appropriate function. Unlike the leg, which tends to be rehabilitated quite well with prosthetics, the best option for functional rehabilitation of arm amputations is an allograft transplant. The problem here is that in order to prevent donor rejection, toxic chemicals must be administered to the amputee to support the transplanted limb, placing the patient’s overall health at risk. Lt. Col. Davis reports that RESTOR researchers have recently identified a new technique for delivering localized immune modulation to overcome the need for systemic immunosuppression thereby eliminating one of the major hurdles for successful limb transplant. In reporting on just three of the myriad projects occurring at the USAISR, I have become amazed at how impressive a research engine we have in San Antonio. Surprisingly, the researchers themselves are incredibly humble. Ubiquitously, they point to their mission as their strength. They coalesce around the Wounded Warrior as their purpose, allowing them to put aside their egos and become great collaborators for improving Combat Casualty Care.
BCMS LEGISLATIVE NEWS
42 San Antonio Medicine • August 2017
BCMS LEGISLATIVE NEWS
visit us at www.bcms.org
43
BCMS LEGISLATIVE NEWS
50,000 Members Strong Working together helped medicine prevail in the 2017 Texas Legislative session We Succeeded with Good Bills SB 507 by Hancock, expanding balance billing mediation SB 680 by Hancock, allowing physician override on medication step therapy HB 10 by Price, improving access/benefits for mental health and substance use HB 62 by Craddick, banning texting while driving SB 1107 by Schwertner, allowing telemedicine services HB 435 by King, restricting carrying handguns at state hospitals SB 1148 by Buckingham, limiting maintenance of certification
We Defeated Bad Bills HB 719 by Wu, indexing caps in the 2003 tort reform law HB 1070 by Leach, prohibiting refusal to care for a patient based on immunization status HB 1415 by Klick, allowing APRNs full practice authority HB 593 by Burrows, allowing psychologist to prescribe SB 728 by V. Taylor, allowing direct access to physical therapists SB 2127 by L. Taylor, interference with physicians collecting on unpaid bills HB 4011 by Burrows, requiring physicians to present exact estimates before providing services HB 1675 by Flynn, requiring physicians to accept health plans’ payments via virtual credit card HB 1124 by Krause, making it easier to opt out of vaccinations
We Continue to Work on Important Bills HB 2760 by Bonnen, requiring daily updates of health plan network directories HB 2249 by Sheffield, protecting parents’ right to know about vaccine exemptions HB 1908 by Zerwas, raising the age for using tobacco products from 18 to 21 HB 3124 by Gooden, allowing physicians to compare data in physician-run ACOs SB 833 by Hughes, protecting whistleblowers and prohibiting the corporate practice of medicine
www.texmed.org 44 San Antonio Medicine • August 2017
BCMS ALLIANCE
Preparing for College? Lori Boies, 2017 Bexar County Medical Society Alliance President
Aside from the volunteer work that I do for the BCMS Alliance, I am a faculty member at St. Mary’s University, and one of my primary teaching duties is first year Introductory Biology for science majors. Helping students navigate their early years through college is one of my career passions. Before students become college freshmen, they must navigate the (sometimes difficult) landscape of not only college applications, but also interviews and creating competitive scholarship submissions. Once that leg of the journey is complete, students must then turn their efforts towards a successful first year in college. I have seen first-hand how, for many students, this presents challenges in time management, believing in one’s self, balancing social commitments, and even finding the major that truly sparks passion.
Several BCMS Alliance members are teaming up to provide an informational seminar for High School students (open to children of BCMS, BCMSA members, and their friends). Topics to be addressed include: college application process, scholarship and interview process, college preparedness and keys to successfully navigate that Freshman year! Cost to attend is $10 per person, and all proceeds will benefit our Junior Volunteer Council (JVC). The JVC is a community service organization open to the teens of BCMS and BCMSA members (community involvement is important for those college applications)! All the Best, Lori Boies
visit us at www.bcms.org
45
BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Please support our sponsors with your patronage; our sponsors support us.
ACCOUNTING FIRMS RSM US LLP (HH Silver Sponsor) RSM US is one of Texas’ largest, locally owned CPA firms, providing sophisticated accounting, audit, tax and business consulting services. Vicky Martin, CPA 210-828-6281 vicky.martin@rsmus.com www.rsmus.com “Offering service more than expected — on every engagement.” Sol Schwartz & Associates P.C. (HH Silver Sponsor) We specialize in areas that are most critical to a company’s fiscal well-being in today’s competitive markets. Jim Rice, CPA 210-384-8000, ext. 112 jprice@ssacpa.com www.ssacpa.com “Dedicated to working with physicians and physician groups.”
ACO/IPA
IntegraNet Health (HHHH 10K Platinum Sponsor) IntegraNet Health is an Independent Physician Association that helps physicians achieve higher reimbursements from insurance companies whereby some of our higher performing physicians are able to achieve up to 200% of Medicare FFS. Executive Director Alan Preston, MHA, Sc.D. 1-832-705-5674 Apreston@IntegrNetHealth.com www.integraNetHealth.com
ASSET MANAGEMENT
Intercontinental Wealth Advisors LLC. (HHH Gold Sponsor) Your money’s worth is in the things it can do for you, things that are as unique and personal as your heart and mind. We craft customized solutions to meet in-
46 San Antonio Medicine • August 2017
vestment challenges and help achieve financial objectives. Vice President Jaime Chavez, RFC® 210-271-7947 ext. 109 jchavez@intercontl.com Wealth Manager David K. Alvarez, CFP® 210-271-7947 ext. 119 dalvarez@intercontl.com Vice President John Hennessy, ChFC® 210-271-7947 ext. 112 jhennessy@intercontl.com www.intercontl.com “Advice, Planning and Execution that goes beyond portfolio management”
ATTORNEYS
Kreager Mitchell (HHH Gold Sponsor) At Kreager Mitchell, our healthcare practice works with physicians to offer the best representation possible in providing industry specific solutions. From business transactions to physician contracts, our team can help you in making the right decision for your practice. Michael L. Kreager 210-283-6227 mkreager@kreagermitchell.com Bruce M. Mitchell 210-283-6228 bmitchell@kreagermitchell.com www.kreagermitchell.com “Client-centered legal counsel with integrity and inspired solutions”
Norton Rose Fulbright (HHH Gold Sponsor) Norton Rose Fulbright is a global law firm. We provide the world’s preeminent corporations and financial institutions with a full business law service. We deliver over 150 lawyers in the US focused on the life sciences and healthcare sector. Employment & Labor Mario Barrera 210 270 7125 mario.barrera@nortonrosefulbright.com Life Sciences and Healthcare Charles Deacon 210 270 7133
charlie.deacon@nortonrosefulbright.com Real Estate Katherine Tapley 210 270 7191 katherine.tapley@nortonrosefulbright.com www.nortonrosefulbright.com “In 2016, we received a Tier 1 national ranking for healthcare law according to US News & World Report and Best Lawyers”
Strasburger & Price, LLP (HHH Gold Sponsor) Strasburger counsels physician groups, individual doctors, hospitals, and other healthcare providers on a variety of concerns, including business transactions, regulatory compliance, entity formation, reimbursement, employment, estate planning, tax, and litigation. Carrie Douglas 210.250.6017 carrie.douglas@strasburger.com Cynthia Grimes 210.250.6003 cynthia.grimes@strasburger.com Marty Roos 210.250.6161 marty.roos@strasburger.com www.strasburger.com “Your Prescription for the Common & Not-So Common Legal Ailment”
BANKING
Amegy Bank of Texas (HHH Gold Sponsor) We believe that any great relationship starts with five core values: Attention, Accountability, Appreciation, Adaptability and Attainability. We work hard and together with our clients to accomplish great things. Jeanne Bennett 210- 343-4556 jeanne.bennett@amegybank.com Karen Leckie 210-343-4558 karen.leckie@amegybank.com www.amegybank.com “Community banking partnership”
BB&T (HHH Gold Sponsor) Checking, savings, investments, insurance — BB&T offers banking services to help you reach your financial goals and plan for a sound financial future. Stephanie Dick Vice President- Commercial Banking 210-247-2979 sdick@bbandt.com Ben Pressentin 210-762-3175 bpressentin@bbandt.com www.bbt.com
BBVA Compass (HHH Gold Sponsor) Our healthcare financial team provides customized solutions for you, your business and employees. Commercial Relationship Manager — Zaida Saliba 210-370-6012 Zaida.Saliba@BBVACompass.com Global Wealth Management Mary Mahlie 210-370-6029 mary.mahlie@bbvacompass.com Medical Branch Manager Vicki Watkins 210-592-5755 vicki.watkins@bbva.com Business Banking Officer Jamie Gutierrez 210-284-2815 jamie.gutierrez@bbva.com www.bbvacompass.com “Working for a better future”
Broadway Bank (HHH Gold Sponsor) Healthcare banking experts with a private banking team committed to supporting the medical community. Ken Herring 210-283-4026 kherring@broadwaybank.com www.broadwaybank.com “We’re here for good.”
BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Ozona Bank (HHH Gold Sponsor) Ozona National Bank is a full-service commercial bank specializing in commercial real estate, construction (owner and non-owner occupied), business lines of credit and equipment loans. Lydia Gonzales 210-319-3501 lydiag@ozonabank.com www.ozonabank.com
The Bank of San Antonio (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians. Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community. Brandi Vitier 210-807-5581 brandi.vitier@ thebankofsa.com www.thebankofsa.com
210-476-4833 gmiller@ssfcu.org Firstmark Credit Union (HH Silver Sponsor) Address your office needs: Upgrading your equipment or technology? Expanding your office space? We offer loans to meet your business or personal needs. Competitive rates, favorable terms and local decisions. Gregg Thorne SVP Lending 210-308-7819 greggt@firstmarkcu.org www.firstmarkcu.org Frost (HH Silver Sponsor) As one of the largest Texas-based banks, Frost has helped Texans with their financial needs since 1868, offering award-winning customer service and a range of banking, investment and insurance services to individuals and businesses. Lewis Thorne 210-220-6513 lthorne@frostbank.com www.frostbank.com “Frost@Work provides your employees with free personalized banking services.”
BUSINESS SERVICES RBFCU (HHH Gold Sponsor) RBFCU provides special financing options for Physicians, including loans for commercial and residential real estate, construction, vehicle, equipment and more. Novie Allen Business Solutions 210-650-1738 nallen@rbfcu.org www.rbfcu.org
SSFCU (HHH Gold Sponsor) Founded in 1956, Security Service provides medical professionals with exceptional service and competitive rates on a line of mortgage products including one-time close construction, unimproved lot/land, jumbo, and specialized adjustable-rate mortgage loans. Commercial Services Luis Rosales 210-476-4426 lrosales@ssfcu.org Investment Services John Dallahan 210-476-4410 jdallahan@ssfcu.org Mortgage Services Glynis Miller
New York Life Insurance Company (HHH Gold Sponsor) We believe that any great relationship starts with great core values: Attention, Accountability, Appreciation, Adaptability and Attainability Financial Consultant Doug Elley 210-961-9991 delley@ft.newyorklife.com www.newyorklife.com
CONTRACTORS/BUILDERS /COMMERCIAL
Cambridge Contracting (HHH Gold Sponsor) We are a full service general contracting company that specializes in commercial finishouts and ground up construction. Rusty Hastings Rusty@cambridgesa.com 210-337-3900 www.cambridgesa.com
Huffman Developments (HHH Gold Sponsor) Premier medical and professional office condominium developer. Our model allows you to own your own office space as opposed to leasing. Steve Huffman 210-979-2500 shuffman@huffmandev.com Lauren Spalten 210-667-6988 lspalten@huffmandev.com www.huffmandev.com
FINANCIAL SERVICES
Northwestern Mutual Wealth Management (HHHH 10K Platinum Sponsor) Our mission is to help you enjoy a lifetime of financial security with greater certainty and clarity. Our outcomebased planning approach involves defining your objectives, creating a plan to maximize potential and inspiring action towards your goals. Fee-based financial plans offered at discount for BCMS members. Eric Kala CFP®, AEP®, CLU®, ChFC® Wealth Management Advisor | Estate & Business Planning Advisor 210.446.5755 eric.kala@nm.com www.erickala.com “Inspiring Action, Maximizing Potential”
Aspect Wealth Management (HHH Gold Sponsor) We believe wealth is more than money, which is why we improve and simplify the lives of our clients, granting them greater satisfaction, confidence and freedom to achieve more in life. Jeffrey Allison 210-268-1530 jallison@ aspectwealth.com www.aspectwealth.com “Get what you deserve … maximize your Social Security benefit!”
e3 Wealth, LLC (HHH Gold Sponsor) Over $550 million in assets under management, e3 Wealth delivers truly customized solutions to indi-
viduals and businesses while placing heavy emphasis on risk minimization, tax diversification, proper utilization and protection for each client's unique financial purpose. Managing Partner Joseph Quartucci, ChFC® 512-268-9220 jquartucci@e3wealth.com Senior Partner Terry Taylor 512-268-9220 ttaylor@e3wealth.com Senior Partner Jennifer Taylor 512-268-9220 jtaylor@e3wealth.com www.e3wealth.com
Intercontinental Wealth Advisors LLC. (HHH Gold Sponsor) Your money’s worth is in the things it can do for you, things that are as unique and personal as your heart and mind. We craft customized solutions to meet investment challenges and help achieve financial objectives. Vice President Jaime Chavez, RFC® 210-271-7947 ext. 109 jchavez@intercontl.com Wealth Manager David K. Alvarez, CFP® 210-271-7947 ext. 119 dalvarez@intercontl.com Vice President John Hennessy, ChFC® 210-271-7947 ext. 112 jhennessy@intercontl.com www.intercontl.com “Advice, Planning and Execution that goes beyond portfolio management”
RBFCU (HHH Gold Sponsor) RBFCU Investments Group provides guidance and assistance to help you plan for the future and ensure your finances are ready for each stage of life, (college planning, general investing, retirement or estate planning). Shelly H. Rolf Wealth Management 210-650-1759 srolf@rbfcu.org www.rbfcu.org First Command Financial Services (HH Silver Sponsor) Nigel Davies 210-824-9894 njdavies@firstcommand.com www.firstcommand.com
continued on page 48
visit us at www.bcms.org
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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 47
GRADUATE PROGRAMS Trinity University (HH Silver Sponsor) The Executive Master’s Program in Healthcare Administration is ranked in the Top 10 programs nationally. A part-time, hybrid-learning program designed for physicians and healthcare managers to pursue a graduate degree while continuing to work full-time. Amer Kaissi, Ph.D. Professor and Executive Program Director 210-999-8132 amer.kaissi@trinity.edu https://new.trinity.edu/academics/departments/health-careadministration
HEALTHCARE REAL ESTATE SAN ANTONIO COMMERCIAL ADVISORS (HH Silver Sponsor) Jon Wiegand advises healthcare professionals on their real estate decisions. These include investment sales- acquisitions and dispositions, tenant representation, leasing, sale leasebacks, site selection and development projects Jon Wiegand 210-585-4911 jwiegand@sacadvisors.com www.sacadvisors.com “Call today for a free real estate analysis, valued at $5,000”
HOME HEALTH SERVICES Abbie Health Care Inc. (HH Silver Sponsor) Our goal at Abbie health care inc. is to promote independence, healing and comfort through quality, competent and compassionate care provided by skilled nurses, therapists, medical social worker and home health aides at home. Sr. Clinical Account Executive Gloria Duke, RN 210-273-7482 Gloria@abbiehealthcare.com "New Way of Thinking, Caring & Living"
HOSPITALS/ HEALTHCARE SERVICES
Southwest General Hospital (HHH Gold Sponsor) Southwest General is a full-service hospital, accredited by DNV, serving San Antonio for over 30 years. Quality awards include accredited
48 San Antonio Medicine • August 2017
centers in: Chest Pain, Primary Stroke, Wound Care, and Bariatric Surgery. Director of Business Development Barbara Urrabazo 210.921.3521 Burrabazo@Iasishealthcare.com Community Relations Liaison Sonia Imperial 210-364-7536 www.swgeneralhospital.com “Quality healthcare with you in mind.”
Warm Springs Medical Center Thousand Oaks Westover Hills (HHH Gold Sponsor) Our mission is to serve people with disabilities by providing compassionate, expert care during the rehabilitation process, and support recovery through education and research. Central referral line 210-592-5350 “Joint Commission COE.” Methodist Healthcare System (HH Silver Sponsor) Palmire Arellano 210-575-0172 palmira.arellano@mhshealth.com http://sahealth.com Select Rehabilitation of San Antonio (HH Silver Sponsor) We provide specialized rehabilitation programs and services for individuals with medical, physical and functional challenges. Miranda Peck 210-482-3000 mipeck@selectmedical.com Jana Raschbaum 210-478-6633 JRaschbaum@selectmedical.com http://sanantonio-rehab.com “The highest degree of excellence in medical rehabilitation.”
DMarino@swbc.com Wealth Advisor Gil Castillo, CRPC® 210-321-7258 Gcastillo@swbc.com Mortgage Kristie Arocha 210-255-0013 karocha@swbc.com SWBC Mortgage www.swbc.com Mortgages, investments, personal and commercial insurance, benefits, PEO, ad valorem tax services
TMA Insurance Trust (HHHH 10K Platinum Sponsor) Created and endorsed by the Texas Medical Association (TMA), the TMA Insurance Trust helps physicians, their families and their employees get the insurance coverage they need. Wendell England 512-370-1746 wengland@tmait.org James Prescott 512-370-1776 jprescott@tmait.org John Isgitt 512-370-1776 www.tmait.org “We offer BCMS members a free insurance portfolio review.”
Humana (HHH Gold Sponsor) Humana is a leading health and well-being company focused on making it easy for people to achieve their best health with clinical excellence through coordinated care. Jon Buss: 512-338-6167 Jbuss1@humana.com Shamayne Kotfas: 512-338-6103 skotfas@humana.com www.humana.com
INSURANCE/MEDICAL MALPRACTICE
INSURANCE
SWBC (HHHH 10K Platinum Sponsor) SWBC is a financial services company offering a wide range of insurance, mortgage, PEO, Ad Valorem and investment services. We focus dedicated attention on our clients to ensure their lasting satisfaction and long-term relationships. VP Community Relations Deborah Gray Marino 210-525-1241
Texas Medical Liability Trust (HHHH 10K Platinum Sponsor) Texas Medical Liability Trust is a not-for-profit health care liability claim trust providing malpractice insurance products to the physicians of Texas. Currently, we protect more than 18,000 physicians in all specialties who practice in all areas of the state. TMLT is a recommended partner of the Bexar County Medical Society and is endorsed by the Texas Medical Association, the Texas Academy of
Family Physicians, and the Dallas, Harris, Tarrant and Travis county medical societies. Patty Spann 512-425-5932 patty-spann@tmlt.org www.tmlt.org Recommended partner of the Bexar County Medical Society
The Bank of San Antonio Insurance Group, Inc. (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians. Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community. Katy Brooks, CIC 210-807-5593 katy.brooks@bosainsurance.com www.thebankofsa.com “Serving the medical community.” The Doctors Company (HH Silver Sponsor) The Doctors Company is fiercely committed to defending, protecting, and rewarding the practice of good medicine. With 78,000 members, we are the nation’s largest physician-owned medical malpractice insurer. Learn more at www.thedoctors.com. Susan Speed Senior Account Executive (512) 275-1874 Susan.speed@thedoctors.com Marcy Nicholson Director, Business Development (512) 275-1845 mnicholson@thedoctors.com “With 78,000 members, we are the nation’s largest physician-owned medical malpractice insurer” MedPro Group (HH Silver Sponsor) Medical Protective is the nation's oldest and only AAA-rated provider of healthcare malpractice insurance. Kirsten Baze 512-375-3972 Kirsten.Baze@medpro.com www.medpro.com ProAssurance (HH Silver Sponsor) Group (rated A+ (Superior) by A.M. Best) helps you protect your important identity and navigate today’s medical environment with greater ease—that’s only fair. Keith Askew Market Manager kaskew@proassurance.com
BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Mark Keeney Director, Sales mkeeney@proassurance.com 800.282.6242 www.proassurance.com
MEDICAL SUPPLIES AND EQUIPMENT
Henry Schein Medical (HHHH 10K Platinum Sponsor) From alcohol pads and bandages to EKGs and ultrasounds, we are the largest worldwide distributor of medical supplies, equipment, vaccines and pharmaceuticals serving office-based practitioners in 20 countries. Recognized as one of the world’s most ethical companies by Ethisphere. Tom Rosol 210-413-8079 tom.rosol@henryschein.com www.henryschein.com “BCMS members receive GPO discounts of 15 percent to 50 percent.”
OFFICE EQUIPMENT/ TECHNOLOGIES
agement, Workers’ Compensation, Risk Management and Employee Benefits. Kristine Edge Sales Manager 830-980-1207 Kedge@swbc.com Working together to help our clients achieve their business objectives.
www.LegacyAtForestRidge.com “Assisted living like you’ve never seen before.”
PRACTICE CONSULTANTS
Favorite Healthcare Staffing (HHHH 10K Platinum Sponsor) Serving the Texas healthcare community since 1981, Favorite Healthcare Staffing is proud to be the exclusive provider of staffing services for the BCMS. In addition to traditional staffing solutions, Favorite offers a comprehensive range of staffing services to help members improve cost control, increase efficiency and protect their revenue cycle. Brody Whitley, Branch Director 210-301-4362 bwhitley@ favoritestaffing.com www.favoritestaffing.com “Favorite Healthcare Staffing offers preferred pricing for BCMS members.”
New York Life Insurance Company (HHH Gold Sponsor) Our Goal, increase patient & employee satisfaction, generate more free time for practitioners and mitigate both business and personal financial risk. (No Cost Financial and Business consulting including HIPAA audit evaluations, BCMS members only). Doug Elley 210-961-9991 delley@ft.newyorklife.com www.newyorklife.com “20+ years helping Physicians to increase practice profits and efficiencies, reduce operations stress”
PROFESSIONAL ORGANIZATIONS Dahill (HHH Gold Sponsor) Dahill offers comprehensive document workflow solutions to help healthcare providers apply, manage and use technology that simplifies caregiver workloads. The results: Improved access to patient data, tighter regulatory compliance, operational efficiencies, reduced administrative costs and better health outcomes. Major Account Executive Wayne Parker 210-326-8054 WParker@dahill.com Major Account Executive Bradley Shill 210-332-4911 BShill@dahill.com Add footer: www.dahill.com “Work Smarter”
The Health Cell (HH Silver Sponsor) “Our Focus is People” Our mission is to support the people who propel the healthcare and bioscience industry in San Antonio. Industry, academia, military, non-profit, R&D, healthcare delivery, professional services and more! President Kevin Barber 210-308-7907 (Direct) kbarber@bdo.com Program Coordinator Valerie Rogler 210-904-5404 Valerie@thehealthcell.org www.thehealthcell.org “Where San Antonio’s Healthcare Leaders Meet”
PAYROLL SERVICES
Legacy at Forest Ridge (HH Silver Sponsor) Legacy at Forest Ridge provides residents with top-tier care while maintaining their privacy and independence, in a luxurious resortquality environment. Shane Brown Executive Director 210-305-5713 hello@legacyatforestridge.com
SWBC (HHHH 10K Platinum Sponsor) Our clients gain a team of employment experts providing solutions in all areas of human capital – Payroll, HR, Compliance, Performance Man-
SENIOR LIVING
STAFFING SERVICES
To join the Circle of Friends program or for more information, call 210-301-4366 or email August.Trevino@bcms.org Visit www.bcms.org
One of Your Valuable Benefits
One of the benefits of being a member of the Bexar County Medical Society is the Circle of Friends (COF) program. Using your COF program offers a great way for you to save money on services and products that your practice uses every day. It’s like an Angie’s List for doctors. The Circle of Friends have vendors that range from accounting and banking to insurance and medical supplies… A-to-Z! Please note, all Circle of Friends sponsors pledge superior service and special discounts for Bexar County Medical Society members like yourselves. Just as important is the fact that their financial donations help keep the cost of your dues down and fund many of the society’s important programs and events.
It’s a win-win scenario! Please Support our Sponsors with your Patronage — Our Sponsors Support Us!
A complete directory of vendors and services can be found at http://www.bcms.org/b usdir/index.html On the BCMS app. visit us at www.bcms.org
49
RECOMMENDED AUTO DEALERS AUTO PROGRAM
• • • •
We will locate the vehicle at the best price, right down to the color and equipment. We will put you in touch with exactly the right person at the dealership to handle your transaction. We will arrange for a test drive at your home or office. We make the buying process easy! When you go to the dealership, speak only with the representative indicated by BCMS.
Ancira Chevrolet 6111 Bandera Road San Antonio, TX
Batchelor Cadillac 11001 IH 10 W at Huebner San Antonio, TX
Jude Fowler 210-681-4900
Esther Luna 210-690-0700
GUNN AUTO GROUP
GUNN AUTO GROUP
GUNN AUTO GROUP
GUNN Honda 14610 IH 10 W San Antonio, TX
GUNN Infiniti 12150 IH 10 W San Antonio, TX
GUNN Acura 11911 IH 10 W San Antonio, TX
GUNN Nissan 750 NE Loop 410 San Antonio, TX 78209
Bill Boyd 210-859-2719
Pete DeNeergard 210-680-3371
Hugo Rodriguez and Rick Tejada 210-824-1272
Coby Allen 210-625-4988
Abe Novy 210-496-0806
Alamo City Chevrolet 9400 San Pedro Ave. San Antonio, TX 78216
Cavender Audi 15447 IH 10 W San Antonio, TX 78249
Cavender Toyota 5730 NW Loop 410 San Antonio, TX
Northside Ford 12300 San Pedro San Antonio, TX
David Espinoza 210-912-5087
Sean Fortier 210-681-3399
Gary Holdgraf 210-862-9769
Wayne Alderman 210-525-9800
Ancira Chrysler 10807 IH 10 West San Antonio, TX 78230
Ancira Nissan 10835 IH 10 West San Antonio, TX 78230
Jarrod Ashley 210-558-1500
Jason Thompson 210-558-5000
GUNN AUTO GROUP
GUNN AUTO GROUP
GUNN Chevrolet GMC Buick 16550 IH 35 N Selma, TX 78154
Ancira Buick, GMC San Antonio, TX Jude Fowler 210-681-4900
Ingram Park Nissan 7000 NW Loop 410 San Antonio, TX Alan Henderson 210-681-6300 KAHLIG AUTO GROUP
Ingram Park Auto Center Dodge 7000 NW Loop 410 San Antonio, TX
Ingram Park Auto Center Mazda 7000 NW Loop 410 San Antonio, TX
Mercedes Benz of San Antonio 9600 San Pedro San Antonio, TX
Mercedes Benz of Boerne 31445 IH 10 W Boerne, TX
North Park Subaru 9807 San Pedro San Antonio, TX 78216
Daniel Jex 210-684-6610
Frank Lira 210-381-7532
Richard Wood 210-366-9600
John Wang 830-981-6000
Mark Castello 210-308-0200
KAHLIG AUTO GROUP
KAHLIG AUTO GROUP
KAHLIG AUTO GROUP
KAHLIG AUTO GROUP
KAHLIG AUTO GROUP
North Park Subaru at Dominion 21415 IH 10 W San Antonio, TX 78257
North Park Toyota 10703 SW Loop 410 San Antonio, TX 78211
North Park Mazda 9333 San Pedro San Antonio, TX 78216
North Park Lexus 611 Lockhill Selma San Antonio, TX
North Park Lexus at Dominion 21531 IH 10 W San Antonio, TX
Stephen Markham 877-356-0476
Justin Boone 210-635-5000
Scott Brothers 210-253-3300
Jose Contreras 210-308-8900
Justin Blake 888-341-2182
KAHLIG AUTO GROUP
KAHLIG AUTO GROUP
North Park Lincoln 9207 San Pedro San Antonio, TX
North Park VW at Dominion 21315 IH 10 W San Antonio, TX 78257
Land Rover of San Antonio 13660 IH-10 West (@UTSA Blvd.) San Antonio, TX
Porsche Center 9455 IH-10 West San Antonio, TX
James Cole 800-611-0176
Ed Noriega 210-561-4900
Matt Hokenson 210-764-6945
Sandy Small 210-341-8841
AUTO PROGRAM
Call Phil Hornbeak 210-301-4367 or email phil.hornbeak@bcms.org
THANK YOU to the large group practices with 100% MEMBERSHIP in BCMS and TMA ABCD Pediatrics, PA Clinical Pathology Associates Dermatology Associates of San Antonio, PA Diabetes & Glandular Disease Clinic, PA ENT Clinics of San Antonio, PA Gastroenterology Consultants of San Antonio General Surgical Associates Greater San Antonio Emergency Physicians, PA Institute for Women's Health Lone Star OB-GYN Associates, PA M & S Radiology Associates, PA MacGregor Medical Center San Antonio MEDNAX Peripheral Vascular Associates, PA Renal Associates of San Antonio, PA San Antonio Gastroenterology Associates, PA San Antonio Infectious Diseases Consultants San Antonio Kidney Disease Center San Antonio Pediatric Surgery Associates, PA Sound Physicians South Alamo Medical Group South Texas Radiology Group, PA Tejas Anesthesia, PA Texas Partners in Acute Care The San Antonio Orthopaedic Group Urology San Antonio, PA WellMed Medical Management Inc.
Contact BCMS today to join the 100% Membership Program! *100% member practice participation as of July 23, 2017.
visit us at www.bcms.org
51
AUTO REVIEW
2017 Ford F-350 By Steve Schutz, MD
I am not a pickup fan. Never owned one,
My first impression of the F-350 was,
Before it arrived, I fantasized (not really)
don’t want one. But I know many of my
“Big.” I mean, it’s really big. I’m 6’2” tall,
about taking the F-350 out and rolling coal
readers own pickup trucks, so I said yes
and the Super Duty is taller than me at
— the annoying big truck thing that in-
when I had the chance to drive the all-new
6’6”, and it’s wide too, like almost-as-wide-
volves flooring the throttle so you can cover
2017 Ford F-350 Super Duty pickup.
as-the-road 80 inches wide. Wow, just big.
the car or bicycle behind you with a cloud
Naturally, I had other reasons too. Ford
Once you climb up into the cab though, it
of diesel soot — as I accelerated away from
makes a lot of money on these big trucks —
shrinks. No, it never made me think,
any number of Toyota Priuses, but no luck,
up to $15,000 or more on each one by some
“Wow, it’s like a Fusion or an Accord,” but
the new Super Duty diesel pickups are too
estimates — which comprise about 30 per-
it certainly drives smaller than it is. While
clean. No matter what you do, these new
cent of that company’s total F-series output,
you sit up higher than just about anybody
trucks are models of civility and don’t release
and like the best selling F-150, the latest
else on the road, the F-350 is maneuverable
any visible smoke from their exhaust pipes.
Super Duty pickups now have aluminum
and easy to manage in most driving situa-
As an avid cyclist, let me say, “Thank you
bodies. And while I’m a sports car guy at
tions, including city streets. Honestly, I
Ford Motor Company” for that.
heart, I always want to be in the know about
thought it would be like living with a trac-
There’s not much to say about the design
any important happenings in the automo-
tor trailer for a week, but it wasn’t, it was
of the F-350. It’s a big pickup, full stop. Sure
tive industry, including truck news. But
easy. Yes, parallel parking and doing any-
it has LED lighting, aerodynamic exterior el-
mostly I wanted to experience a vehicle
thing in a parking garage were difficult, but
ements, and chrome accents galore, but ul-
which, though clearly meant to do work, is
everything else was much easier than I an-
timately it looks like what it is. Is it better
surprisingly popular as an everyday driver.
ticipated. I could drive this every day.
looking than its GM and Ram competitors?
52 San Antonio Medicine • August 2017
AUTO REVIEW
I don’t think so, but fanboys of Ford, GM,
engine, and the extra torque was wonderful.
tow anything during my time with the F-
and Ram pickups will continue to argue this
Was it $8,595 wonderful? That’s up to you.
350, so I’ll leave it at that.
point forever.
Ford offers the F-350 in XL, XLT, Lariat,
The new aluminum bodied Ford F-350
The interior, on the other hand, is a lot
King Ranch, and Platinum trim levels. My
pickup is a huge vehicle that has amazing
more advanced than interiors used to be in
test truck was a King Ranch, which was cer-
towing and hauling capabilities, and yet it
pickups. The seats are comfortable and al-
tainly nice thanks to many creature comforts
has a nice ride as well as luxury car-like tech
most infinitely adjustable, the gauges and
that used to be the exclusive purview of lux-
and creature comforts. While I’d never do it,
dials are fully electronic and oh-so high tech,
ury cars. Having said that, my tester had a
I can see why some owners use their Super
and the materials you see and touch are al-
sticker price of, gulp, just over $80,000. For
Duties for everyday transportation. They’re
most — almost — luxury car nice. There’s
a pickup truck.
impressive vehicles.
also Bluetooth phone and audio connectivity,
apps
like
Pandora,
and
Ford Super Duty pickups have always
Apple
been about towing horse trailers, campers,
If you’re in the market for this kind of ve-
CarPlay/Android Auto. Pickups used to be
and boats, and with that in mind Ford
hicle, call Phil Hornbeak at 210-301-4367.
so utilitarian back in the day. Not anymore.
boasts that the F-350 can now pull up to
F-350s come standard with a 6.2-liter V-
32,000 pounds of whatever behind it. If you
Steve Schutz, MD, is a
8 engine and a six-speed automatic transmis-
need to approach the towing limits of this
board-certified gastroenterolo-
sion. Ford offers its 6.7-liter turbo-diesel V-8
big beast, you’ll need the optional goose-
gist who lived in San Antonio
on all models for an $8,595 upcharge. That
neck/fifth-wheel trailer attachment, but the
in the 1990s when he was sta-
extra money buys you greater towing capac-
standard (adjustable) under-bumper receiver
tioned here in the U.S. Air
ity, a heavy-duty transmission, and better
hitch is rated for towing up to 21,000
Force. He has been writing auto reviews for
fuel economy. My tester came with the diesel
pounds, which is a pretty big boat. I didn’t
San Antonio Medicine since 1995. visit us at www.bcms.org
53
54 San Antonio Medicine • August 2017