MED-Midwest Medical Edition-March 2013 by MED- (Midwest Medical Edition)

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Contents Midwest Medical Edition

March 2013

Neurocritical Care at

Sanford Health

Psychiatrist Matthew Stanley, MD, discusses an innovative, non-invasive and non-drug approach to treating patients with depression

30 | The Nurse's Station 31 | Grape Expectations: Wine by the Numbers |

By Heather Taylor Boysen

32 | Learning Opportunities: Upcoming Symposiums, Conferences, CME Courses

In This Issue 3 | Strengthen Volunteer Relations to Boost Your Brand By Tana Phelps How leveraging your volunteers can improve your services and your reputation

4 | Supply Side vs. Demand Side Savings in Healthcare By Dave Hewett

5 | How to Handle to a Media Interview

| By Alex Strauss Never get put on the spot again. Find out how maximize this golden opportunity to reach more patients, educate the public, and look good while you do it.

15 | Clinical Spotlight New ENB Procedure for Hard-to-Reach Lung Lesions Electromagnetic navigation bronchoscopy is enabling Avera doctors to locate, biopsy, and plan treatment for lesions detected deep in the lungs.

18 | Brooking Health System Acquires Robotic Surgical System 19 | Spearfish Regional Hospital Verified as level III Trauma Center

Brain and spinal injuries are among the most life-threatening and potentially disabling of medical emergencies. Two Sanford physicians were so committed to improving outcomes for patients with neurological injuries and diseases that they sought board certification as Neurointensivists, specialists in neurocritical care. In this month’s MED Cover Feature, we explore this approach to critical care that is not only saving lives but restoring function to patients who might once have had little hope

22 | New Digestive Health Clinic Opens in Sioux Falls Gastroenterologist Mark Milone, MD, talks to MED about promising new advances in gastrointestinal medicine

27 | Matters of Women and Their Hearts

Sponsored Feature

| By Maria Stys

29 | Documentation: Are you at Risk or do you have Opportunity? By Cheri Welk

By Alex Strauss

page

From Us to You

Staying in Touch with MED

elcome to the March issue of MED Magazine. If you are picking this publication for the first time, we are glad to have you. And if you are a long-time reader, thank you. Whether you are a physician, an administrator, a nurse, or some other type of provider, we want you to know that each issue of this publication is created with a focus on your needs and interests, as a healthcare professional on the Northern Plains. How are we doing? Do you have topics you would like to see covered in these pages?MED is locally created, produced and distributed, with content from area professionals and input from local physician advisors. We invite you to send your book reviews, reminiscences, notable cases, news, hobbies and interests, and article suggestions to us any time. Your feedback and editorial contributions are a vital part of MED. In addition to several physician contributions in this issue, we hope that you will enjoy this month’s articles selected to support your practice (Documentation: Are you at risk or do you have Opportunity?, page 29), keep you up-to-date (News & Notes, page 6), and enhance your life (Wine By the Numbers, page 31). MED was proud to sponsor the American Heart Association’s 10th Annual ‘Go RED for Women’ Luncheon in February. The event helps raise funds and promotes awareness about heart disease in women. Let us know if you have a healthrelated community event you’d like MED to attend. We are committed to supporting the people and organizations working to improve healthcare in our region. Thank you for your continuing support of MED and the quality regional advertisers who make it possible. Here’s to the spring thaw!

Publisher

VP Sales & Marketing Steffanie Liston-Holtrop Editor in Chief Alex Strauss Design/Art Direction Corbo Design Cover Design Darrel Fickbohm Photographer Kristi Shanks Web Design 5j Design Contributing Editor Darrel Fickbohm Copy Editor Hannah Weise

Steffanie Liston-Holtrop

e Woruits!

Contributing Writers Heather Boysen Dave Hewett Sara McQuade Tana Phelps Maria Stys Cheri Welk

Staff Writers Liz Boyd Caroline Chenault John Knies

Contact Information Alex Strauss

—Steff and Alex

MED Magazine, LLC Sioux Falls, South Dakota

t ccep We aader re s i o n is subm

Steffanie Liston-Holtrop, VP Sales & Marketing 605-366-1479 Steff@MidwestMedicalEdition.com Alex Strauss, Editor in Chief 605-759-3295 Alex@MidwestMedicalEdition.com Fax 605-271-5486 Mailing Address PO Box 90646 Sioux Falls, SD 57109 Website MidwestMedicalEdition.com

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©2011 Midwest Medical Edition, LLC Midwest Medical Edition (MED Magazine) is committed to bringing our readership of 3500 South Dakota area physicians and healthcare professionals the very latest in regional medical news and information to enhance their lives and practices. MED is published 8 times a year by MED Magazine, LLC and strives to publish only accurate information, however Midwest Medical Edition, LLC cannot be held responsible for consequences resulting from errors or omissions. All material in this magazine is the property of MED Magazine, LLC and cannot be reproduced without permission of the publisher. We welcome article proposals, story suggestions and unsolicited articles and will consider all submissions for publication. Please send your thoughts, ideas and submissions to alex@midwestmedicaledition.com. Magazine feedback and advertising and marketing inquiries, subscription requests and address changes can be sent to steff@midwestmedicaledition.com. MED is produced eight times a year by MED Magazine, LLC which owns the rights to all content.

Midwest Medical Edition

Strengthen Volunteer Relations

to Boost Your Brand By Tana Phelps

olunteers

make

the

world work, especially in healthcare organizations. They know the ins and outs of your facility and interact with your patients and their families on a daily basis. They push wheelchairs, serve coffee and greet family members—serving as a much-needed extension of your staff. And they make a difference every day. In this way, volunteers—who number as many as 5 million in hospitals, clinics and other health facilities nationwide—are brand ambassadors, strengthening your marketing efforts from the inside out. With a cheerful smile, a knack for directions and eternal optimism, it’s these individuals who can help make good on your promise to deliver a world-class patient experience. Use these best practices to leverage your volunteers, let them know they are appreciated and inspire others to join the cause. Utilize resources wisely. Volunteers save money. In many organizations, it’s $20 per hour. If you know a volunteer has worked in a certain field where you need

help, take advantage of their experience and skills. For example, if you don’t have a strong social media presence, recruit a young adult volunteer or intern to build one for you. Also, provide leadership opportunities to those who are willing and have the time to shoulder more responsibility. Communicate consistently Regular communication is motivating for volunteers. If your organization does not have a volunteer coordinator, assign one. Also, play to volunteers’ preferences and age. Young volunteers may want info pushed from Facebook and email. Seniors may want news delivered by telephone or a printed newsletter. Tell their stories Volunteers give their free time in service toward your organization’s mission. Showcase their goodwill in newspaper ads, billboards, newsletters and on your website to personalize your brand with someone the community knows and loves. Human-interest stories are best equipped to go “viral”, so feature them on your blog and social media sites, too. Of course, volunteers should sign consent forms before being featured in promotional materials.

The Midwest is particularly celebrated for its philanthropy. South Dakota ranks fifth on the list of most volunteers per state, with almost 37 percent of the population volunteering, according to the Corporation for National and Community Service. Celebrate their success Give “Volunteer of the Month” awards, but don’t neglect the power of a hand written thank-you note. In addition, host an annual volunteer appreciation event. Promote the event via social media, and don’t forget to invite your favorite local reporter to join in the fun Make it worth their time In addition to the annual celebration, provide some extra perks. These can include free parking, flu shots or health screenings, discounts at the cafeteria or gift shop, and access to employee activities or classes. ■ Tana Phelps is a marketing specialist at Cassling, a Midwest health-care company that provides local imaging equipment sales and service, and marketing and professional services.

A talk with MED Advisor

Supply Side vs. Demand Side

Dr. Tim Ridgway MD

Savings in Health Care

Gastroenterologist & USDSM Dean of Clinical Faculty Q: You have continued to practice medicine since joining the medical school six years ago. Is it a challenge to balance the two? A: I really felt that, to maintain credibility with our faculty and students, I needed to continue seeing patients. It was not easy but having supportive patients helped. Originally, I had thought I would be able to devote half of my time to my practice and half to the med school. In reality, it has ended being about 70 percent to both. Q: It would seem that taking on these extra responsibilities would make a person more and not less likely to experience burnout. But you say that is not the case? A: A lot of people seem to think that the answer to avoiding physician burnout is to either cut back on time or make more money. But I think it’s really more about having a profession and not just a job. Being a part of something you really believe in is fulfilling. And when you are fulfilled, you are less likely to burn out. I feel like I am now part of something a little bigger than myself. Q: How do your two roles support each other? A: When you have young minds watching your every move, you become keenly aware of when you fall short of the bar. They don’t hesitate to let you know. Any physician who is around medical students knows they make us better, not only from a medical standpoint but from the standpoint of professionalism. It makes me much more aware of what I’m doing. Q: Why are so many doctors interested in what is happening at the Sanford School of Medicine? A: A lot of doctors in the state either went to this school or now serve as faculty. I think many recognize that one of the best ways to impact the quality of medicine in the region is to be involved in medical education.

By Dave Hewett n late January, the American

Medical Association hosted an important forum on health care reform in Washington DC. It happened to be on one of the CSPAN channels so chances are that viewership wasn’t that substantial, but it presented new perspectives on some well-worn themes on health care delivery and cost savings. It began with Dr. James Madera, Vice President and CEO of the American Medical Association outlining the AMA’s three point approach for moving forward with health care reform and keeping the practicing physician at the table as health care reform is refined and implemented. Dr. Madera began with the AMA’s basic tenet – to promote the art and science of medicine and to improve public health. He then proceeded to outline the AMA’s five year strategy for addressing the challenges medicine faces as America’s health care delivery system evolves and reforms.

That strategy includes: u I mprove patient outcomes and reduce costs;

u Accelerate innovations in medical education to better reflect the environment in which physicians will practice in the future; and u Enhance practice sustainability by helping physicians adopt delivery and payment models that makes sense for their communities and the patients they serve.

Calling these strategies “stretch goals” would be an understatement but they clearly reflect a forward thinking approach that actively pursue reforms to a health care delivery system that most all agree is not sustainable. The importance of those strategies was made all the more important by the comments from several participants in the forum who divided cost-saving reforms into two camps – demand-side and supplyside. For me, these are new terms for some old approaches to reform but they also capture much of the essence of the challenges ahead. On the demand-side, our challenge is the insatiable appetite of the public for services that are delivered faster, better and with less inconvenience. About the only way to reduce cost on the demand side is to appeal to the individual to limit consumption. That may happen with patients adopting healthier life styles and thinking seriously about end-of-life issues with living wills and the like. Greater cost savings, the experts believe, can be achieved on the supply side. It involves using limited resources the most effectively to maximize better health and healing. Clearly, the supply-side of the equation falls within scope of the physician and other providers to implement. The shaping of an affordable, sustainable health care delivery system must include the provider community. And that’s why the actions of the American Medical Association through Dr. Madera’s leadership are so important. ■

MED Quotes “ Scientific progress makes moral progress a necessity; for if man’s power is increased, the checks that restrain him from abusing it must be strengthened.” —Madame de Stael

Midwest Medical Edition

magine this scenario: A reporter and her photographer show up for an interview with the doctor, who’s agreed to squeeze them in between patients on a busy day. As they scan the tight hallway for some place to shoot, the doctor comes hurriedly out of a patient room, the collar of his polo shirt askew, looks at the crew and asks, “Now, what is it you wanted to talk about?” Later, the doctor is dismayed when his short sound bite makes little sense, the story is missing facts, and/or his shirt collar is still askew. Many of you know that in my past life, I was that reporter, standing in your waiting room, waiting in your office, or scrubbing in alongside your nurses outside the OR. Like all reporters, I worked on a deadline, tried hard to get my facts straight, and dearly hoped my interviewee wouldn’t be running too far behind. While there is no question that agreeing to a media interview may be inconvenient, a few tips (gleaned from my years in local TV news) can help you take full advantage of it as an opportunity to educate a wider group of people, increase awareness for your services, establish your credibility, and even boost your own (or your health system’s) brand.

March 2013

By Alex Strauss

Be prepared.

Be concise.

Once you have agreed to an interview, it is vital that you understand what information the reporter is looking for. Even when it is a subject that you know well, it pays to organize your thoughts and even jot down some notes. It’s amazing how hard it can be to think clearly when a microphone or camera is pointed at you.

The days of the 15-second sound bite are a thing of the past. These days, 5 to 8 seconds is the norm. If you want to be quoted, use short, summarizing sentences.

Pick an interview spot. While the crew can do this when they get there, choosing an interview spot ahead of time saves time for both of you and increases your control over the look of the shot. A place out of the flow of traffic, with at least a few feet of depth behind you (and no window) is best. Empty exam rooms and conference rooms are often not good choices because of their lack of visual interest or depth.

Dress the part. Casual wear in the office may make you more approachable to patients, but can have just the opposite effect on camera. A lab coat or jacket can go a long way to increasing your authoritative presence. The media outlet has turned to you because you are the expert. Make sure that you look like one.

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Give facts. At the same time, make sure the reporter has the facts he/she will need to write the piece. Recognize that you may be the primary source for the story and the reporter may not know what he doesn’t know. Written material (such as a patient education brochure, a photocopied study, etc.) is always appreciated. There is also nothing wrong with asking, “Does my explanation make sense to you? Is this what you are looking for?” With a little preparation, a media interview can be an opportunity to have a positive impact on the community, enhance your relationship with your own patients (“Doctor! I saw you on TV last night!”), and maybe even earn some ‘high-fives’ from your colleagues. In my next column, I’ll talk about ways to use video in your office. ■ Do you have a communication or marketing question that you would like Alex to address in this column? Send it to Alex@MidwestMedicalEdition.com.

Happenings around the region

South Dakota Southwest Minnesota Northwest Iowa Northeast Nebraska

News & Notes Avera

Dr. Shahid Chaudhary, a nephrologist with Avera Medical

With the opening of its eCARE Services Center, Avera now has its major eHealth services collected under one roof.

Group Nephrology Aberdeen, is the new Chief Medical Officer for Avera St. Luke’s Hospital in Aberdeen. As CMO, Dr. Chaudhary is responsible for developing and strengthening physician relationships throughout Avera St. Luke’s region, representing the physician perspective for the administrative team, and serving as a physician advocate to promote effective physician, hospital and system relationships. Dr. Chaudhary will continue to provide clinical services in nephrology/kidney dialysis and critical care, in addition to continuing with his other leadership roles within the Dialysis Unit, Intensive Care Unit and Avera Medical Group.

The so-called eCare Services Center or ‘eHelm’ includes eICU, eEmergency, ePharmacy and eAccess. The eHelm provides rural facilities 24/7 access to board-certified intensivists and emergency physicians, hospitaltrained pharmacists, and nursing staff through two-way video connections or telemedicine equipment. The new state-of-theart facility was made possible by a donation from The Leona M. and Harry B. Helmsley Charitable Trust and provides the opportunity for cross-coverage of services, innovation, efficiencies, new service line development and existing service line enrichment. The facility accommodates about 100 Avera colleagues Registered Dietitian Nicole Haberer is the

new Assistant Director of Nutrition Services at Avera Sacred Heart Hospital in Yankton. Haberer has worked at Avera Sacred Heart for more than four years as a dietitian.

Avera McKennan Hospital & University Health Center has received Healthgrades’ prestigious Distinguished Hospital Award for Clinical Excellence, the only hospital in

the state to do so. The designation puts Avera McKennan in the top 5 percent of nearly 4,500 hospitals nationwide for clinical performance. Healthgrades’ 262 Distinguished Hospitals for Clinical Excellence as a group had an overall 30.9 percent lower risk adjusted mortality rate as compared to other hospitals that did not achieve the award.

Black Hills Rapid City Regional Hospital’s Tough Enough to Wear Pink 2013 campaign sold out of more than 6,700 t-shirts and raised more than $77,000.

All proceeds benefitted the Regional Cancer Care Institute. The campaign included a Tough Enough to Wear Pink PRCA Rodeo on January 31. All those who purchased t-shirts were asked to wear them on February 1 for Tough Enough to Wear Pink Day to show support in the fight against cancer.

From left, Clint Dunker of BVL, Tim Bonnichsen – a Recreation Therapist for VA BHHCS, C.B. Alexander – Associate Director for VA BHHCS, Shawn Neilson of BVL and Jo-Ann Ginsberg – Associate Director for Patient Care Services for VA BHHCS.

The South Dakota Bowlers to Veterans Link (BVL) recently donated $4,200 for recreation therapy activities to the VA Black Hills Health Care System (BHHCS). Half of the donation

went to the Fort Meade VA Medical Center and the other half went to the Hot Springs VA Medical Center. The BVL has been a leader in support of recreation therapy for Veterans since World War II. Last year the South Dakota BVL ranked the 5th highest in the nation for BVL donations to recreation therapy.

From left: Daniel Petereit, MD, Rapid City Regional Hospital Cancer Care Institute Radiation Oncologist and Walking Forward Principal Investigator; and Red Cloud Indian students: Santianna Yellow Horse, sophomore; Santa Hudspeth-Belt, senior; and January Tobacco, senior.

Red Cloud Indian School students from Pine Ridge raised $233.85 through a cupcake sale for Rapid City Regional Hospital’s Walking Forward Program. Students

of all ages from kindergarten through grade 12 participated in the fundraiser. Walking Forward is funded by the National Institutes of Health with the goal of increasing cancer survival rates among American Indians in western South Dakota Regional Medical Clinic is offering a series of diabetes self management classes.

The series began in February and offers diabetes patients the opportunity to learn critical selfcare tools. The classes use the new interactive and behavioralbased Conversation Maps™ educational tool. This method addresses the topics participants consider most relevant to their own lives. Some topics covered include healthy meal planning, the relationship between diabetes and food, using monitoring results to manage diabetes, and ways to reduce other health risks related to diabetes.

Midwest Medical Edition

Internal Medicine specialist David Klocke, MD, is the new Vice President of Medical Affairs at Regional Health in Rapid City. Dr. Klocke received his

undergraduate degrees in Psychology and Medicine from the University of North Dakota in Grand Forks. He received his MD from the University of Colorado Health Sciences Center in Denver, and his Master of Healthcare Administration from the University of Minnesota. For the last 12 years Dr. Klocke has held several leadership positions at the Mayo Clinic including serving as assistant professor at the College of Medicine and chairing the Division of Hospital Internal Medicine, Department of Internal Medicine. Deborah Kullerd, MD, earned Hospice and Palliative Medicine Certificate of Added Qualifications from the American Board of Family Medicine. Dr. Kullerd is a family

medicine physician at Queen City Regional Medical Clinic in Spearfish Patients with special foot care needs can now be seen at Spearfish Regional Hospital at a new weekly foot care clinic. The clinic, which kicked

off in February, provides foot screening and assessments for circulation, sensation, skin conditions, and shoe fit. They also offer education on proper foot care including inspection

March 2013

methods, daily care, footwear selection, precautions, and exercise. Appointments include clipping and filing of toenails, grinding of thick nails, and buffing of corns and calluses “Enchanted Forest,” submitted by Cheryl Voorhis of Sturgis, has been selected as the theme for the 2013 Hospice of the Northern Hills (HNH) Benefit Ball. Each year, attendees at the

benefit ball submit ideas for the following year’s theme. As the winner, Voorhis received four tickets to this year’s 16th annual ball taking place in March. This formal, black-tie-optional ball is HNH’s largest fundraising event. Last year’s Benefit Ball raised more than $37,000 for Hospice patients in the northern Black Hills.

Spearfish Regional Hospital (SPRH) Hospice recently presented tickets to the 2013 theme contest winner for the 16th Annual Benefit Ball. L-R: Jennifer Murray, Supervisor SPRH Hospice; Cheryl Voorhis, 2013 theme winner; and Carla Van Dyke, Director SPRH Hospice.

Sanford A study by Sanford Research’s Kristi Egland, PhD, was featured as the cover story in the January issue of Molecular Cancer Research.

Tumorigenesis,” contains research on therapeutic targets for breast cancer. An Egland-led research team characterized the function of the protein, SUSD2, using a breast cancer mouse model. Her team found that the presence of the protein enhanced the ability of the cancer cells to escape the immune system, increased the supply of blood vessels to the tumor, and increased metastasis. Because SUSD2 makes cancer cells more aggressive, targeting the protein may inhibit cancer cell survival. Sanford Health has acquired international bio-tech company Hematech, Inc., a subsidiary

of Japanese pharmaceutical company Kyowa Hakko Kirin (KHK), Co. Ltd. The new company will be rebranded Sanford Applied Biosciences, LLC. Headquartered in Sioux Falls, the company has developed a line of cattle that produce fully human antibodies to be used as medicine for humans. Hillsboro Medical Center in Hillsboro, ND and Sanford Health have completed their merger. The non-profit critical

access hospital now known as Sanford Hillsboro Medical Center has 148 employees, 16-beds and attached 36-bed long term care and 16-unit assisted living facilities. Hillsboro is located 40 miles north of Fargo and has been managed by Sanford (previously Meritcare) since 2000.

Dr. Egland’s study, “Multiple Functions of Sushi Doman Containing 2 (SUSD2) in Breast

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Siouxland Trinity Health, the fourth largest Catholic healthcare system in the nation of which Mercy Medical Center-Sioux City is a member, has a new interim President and CEO.

Larry Warren has been chosen to serve in that capacity since Joseph R. Swedish left the organization in March to be the CEO of WellPoint. Warren, a Trinity Health Board member since July 2011, is the former CEO of Howard University Hospital and former CEO of University of Michigan Hospital. St. Luke’s College, a part of the Iowa Health System, is a winner of the 2013 Council for Higher Education Accreditation (CHEA) Award for Outstanding Institutional Practice in Student Learning Outcomes.

St. Luke’s College is one of only four institutions to receive the 2013 award, which recognizes institutions that are exceptional in developing and applying evidence of student learning outcomes to improve higher education quality and accountability. The CHEA Award recognizes St. Luke’s College’s development of specific evidence-based, student learning outcomes. St. Luke’s College outcomes are based on a threeyear average with more than 94% of graduates passing the registry examinations on the first attempt.

South Dakota Southwest Minnesota Northwest Iowa Northeast Nebraska

News & Notes Mike McCarthy has been appointed Director of Mercy Heart Center.

A U.S. Air Force major, McCarthy currently serves as the Deputy Director of the Critical Care Air Transport, Advanced Course for the Sustainment of Trauma and Readiness Skills at the University of Cincinnati Hospital. McCarthy has been deployed to Iraq, Afghanistan and Pakistan, providing critical care and trauma transport support. He has received numerous clinical awards including the 2012 Beacon Award for Critical Care Excellence. The Sioux City native received his Bachelor of Science in Nursing from Morningside College and is enrolled in the Master’s of Political Science Program at Air University.

Anita Wilson is the new Congestive Heart Failure Program Manager at Mercy Medical Center. Wilson

earned her BS in Nursing from Briar Cliff University and is currently pursuing her Doctor of Nursing Practice degree for the Adult Acute Care Nurse Practitioner track, with a cardiology emphasis, at Creighton University. She will graduate in May of 2013. A helicopter for Mercy Medical Center-North Iowa went down in a field on January 2 en route

from Mason City to Emmetsburg, killing all three medical personnel on board. Nurse Shelly

continued

Cardiovascular Associates, P.C. (CVA) has formed a partnership with St. Luke’s to expand and enhance cardiovascular care for Siouxland. Through their

combined efforts, a state-of-the art Coronary Care Unit was opened and has proven valuable in treating patients’ critical care needs. Now, with this formalized partnership, CVA and St. Luke’s will work together to operate cardiology clinics and manage outreach services and are making plans for additional hospital enhancements this Spring.

Elizabeth Hartman, MD, is the newest neurologist and multiple sclerosis specialist at CNOS in Dakota Dunes. Dr.

Hartman joins CNOS from the University of Illinois at Chicago College of Medicine where she served as Assistant Professor and Multiple Sclerosis Director in the Department of Neurology and Rehabilitation. The Chadron, Nebraska native earned her MD at the University of Nebraska. She also completed Multiple Sclerosis/ Neuroimmunology fellowship training at the University of Chicago Medical Center. Dr. Hartman is board-certified in Neurology.

Lair-Langenbau, paramedic Russell Piehl and pilot Gene Grell

died in the crash. There were no patients on board.

Peace, love and litigation support. We protect your peace of mind. And it’s why we’re the right choice for physicians. Medical liability insurance is just the beginning. We protect what matters most, with proven results. It’s a movement, and we’d love to have you join us. Contact your independent agent or broker, or go to PeaceofMindMovement.com to see what MMIC can do for you.

Other: On February 13th, a 7-year-old Bryant, South Dakota girl became the recipient of Make-AWish South Dakota’s 1000th wish. Dannika Weelborg, who suffers from cystic fibrosis, and her family boarded a plane for Hollywood to fulfill her wish of meeting the cast of her favorite television show. Make-A-Wish has been granting wishes to children in the South Dakota region with life-threatening medical conditions since 1984. Twenty-one wishes have been granted since September 2012 and more than 60 children are now in the process of receiving a wish.

MMIC has earned the AM Best industry rating of “A” (Excellent) for 20 consecutive years.

Midwest Medical Edition

Five Clinicians Win Grant Funding The 2013 Sanford Seed Grant Research Fund Recipients Sanford Seed program selects new research to support Proposals from five Sanford clinicians have been selected for funding by the Sanford Seed Grant Research Fund, established in 2011 to grow and evolve underfunded research ideas of Sanford physicians. The selection process considers proposals based on purpose and priority, scientific integrity, potential for future funding and feasibility.

Robert Edwards, OD, Sanford Downtown Eye Center (Bemidji), “The Use of Yoked Prisms Incorporated into Glasses for the Enhancement of Mobility in a Population of Parkinson’s Disease Patients” Many patients who suffer from Parkinson’s disease exhibit a visual midline shift. The perceptual shift of the visual midline can be corrected with yoked prisms incorporated into glasses. Dr. Edward’s work will analyze and statistically define the meaningful improvement in gait achieved by neutralizing Parkinson‘s patients’ visual midline shift with these yoked prisms.

Kathryn Florio, DO, Sanford Neurocritical Care (Sioux Falls), “Comparison of the 2 channel EEG Robert Edwards, OD

vs 21 channel EEG (cEEG) in Detection of Shivering during Therapeutic Hypothermia” The goal of Dr. Florio’s work is to both improve health outcomes and reduce the cost of care for patients receiving therapeutic hypothermia (TH). Early intervention to cease shivering increases the effectiveness of TH; therefore, Florio and her team are studying the use of the Philips 2 channel EEG with compression spectral array to detect shivering rather than the continuous 21 channel EEG (cEEG).

Akran Khan, MD, Sanford Children’s Specialty Clinic (Sioux Falls), “Neuromuscular Electrical Stimulation (NMES) for Dysphagia in Neonates” The goal of Dr. Khan’s work is to ensure less invasive therapies for infants with dysphagia (difficulty swallowing). NMES involves direct electrical stimulation to the skin to re-educate the neuroKathryn Florio, DO

muscular pathways involved in swallowing. Electrical stimulation has been proposed as a treatment for dysphagia in adults and children; however, to date, there has been little research in use on newborns.

Benjamin Noonan, MD, Sanford Orthopedics & Sports Medicine (Fargo), “The Reliability and Validity of the Reed Sprint Skate Test on Ice Hockey Fitness” The Reed Sprint Skate (RSS) test is a commonly used, but not vigorously evaluated, measure of Akran Khan, MD

anaerobic power and resistance to fatigue. The goal of Dr. Noonan’s work will evaluate the reliability of RSS; assess the validity of the RSS by measuring performance improvements over the course of a season and to compare this to an off-ice measure of repeat sprint performance;

• Nurse Call Systems • Synchronized Clock Systems • Low Voltage Specialists

and determine the accuracy of photocell, stopwatch, and video methods of timing. Benjamin Noonan, MD

Shelby Terstriep, MD, Sanford Roger Maris Cancer Center (Fargo), “Health Coaching for Breast Cancer Patients Undergoing Treatment to Decrease Insulin Resistance” Obesity, elevated insulin levels and insulin resistance are associated with a poorer prognosis in breast cancer patients. Breast cancer patients have higher insulin levels at the start of treatment and become more insulin resistant throughout treatment. Dr. Ter-

Shelby Terstriep, MD

striep’s objective is to decrease the development of insulin resistance through a low glycemic diet intervention with the aid of a health coach during breast cancer treatment.

Dynamic Technical Building Systems Inc 106 N Indiana Ave • PO Box 787 • Sioux Falls, SD 57103 p 605.335.4397 • f 605.335.4397 dtb@dtbsystems.com • www.dtbsystems.com

Each grant recipient will begin research during the 2013 calendar year. ■ ■

March 2013

MidwestMedicalEdition.com

By Alex Strauss

n mid-October 2012, South Dakota Highway Patrol Trooper Andrew Steen suffered a traumatic brain injury from being run down by a drunk driver in a Sioux Falls parking lot. It was the kind of injury after which many people do not survive, let alone recover. But after eight weeks in the care of Sanford’s Neurocritical Care team, who treated him using some of the most cutting edge techniques and technologies available, Steen walked out of the hospital 10 days before Christmas. The high-profile case and Steen’s remarkable recovery shone a media spotlight on a branch of medicine that has evolved in recent years from a segment of Intensive Care to its own subspecialty, with its own society, journal, research studies, and growing number of practitioners. Simply put, Neurocritical Care is the critical care of patients with injuries or acute conditions of the brain or spinal cord. Brain trauma like Steen’s, as well as stroke, subarachnoid hemorrhage, intracranial hemorrhage, subdural hematomas, seizures, spinal cord trauma, status epilepticus, and encephalitis all fall under the auspices of Neurocritical Care. “If it is something in your head, we

will take care of it,” says Larry Burris, DO. Originally trained as an internist and nephrologist, Dr. Burris, along with his partner Charles Miller, MD, is now one of the 400 or so board certified Neurocritical Intensivists in the country. “When we first started focusing in this area in the early 1990s, EEG monitoring was archaic,” recalls Dr. Burris. “As far as invasive procedures, about all we could do was take off the skull and put in an external ventricular drain (EVD). We would hang out in the ICU and try to do what we could. But we both remember people being wheeled from the ICU into the Neuro Unit just staring into space. It was very disheartening.” “It is a specialty that has developed out of a need,” agrees Dr. Miller, who comes to Neurocritical Care by way of neurosurgery. Miller says the declining number of neurosurgeons performing procedures on ER patients and the growing use of the ICU have both contributed to that need. “There has been a core of true believers who are trying innovative therapies and renewing interest and energy in Neurocritical Care as a separate and distinct specialty,” he says.

Neurocritical Care at Sanford Health Rare Subspecialty Provides Critical Interventions that Save Lives and Promote Recovery

Photos courtesy Sanford Health

Innovative Therapies

Neurocritical Care could not have emerged as its own specialty area without certain important technological advances. Drs. Miller and Burris say chief among those is the improved ability to monitor certain parameters in the injured or diseased brain, such as intracranial swelling, brain blood pressure and neurooxygenation. This ability to monitor, which Sanford uses in almost every Neurocritical case, has revolutionized the field and dramatically improved outcomes. “In many ways, the evolution of Neurocritical Care can be compared to the progress seen in cardiac care,” says Dr. Burris. “Once, if you came in with a heart attack, they put you in a room and took your pulse. Now, they give you a clot busting drug. We give tPA (tissue

plasminogen activator) for stroke. They can put in central lines and perform echocardiograms. We can do the same thing with Doppler and improved imaging studies. They measure oxygen in your finger; we can measure oxygen in the brain. They put in stents; we put in stents.” Just as cardiac care is focused on minimizing heart damage, Neurocritical Care is largely focused on reducing organ damage which, in turn, has opened the door to other types of more goaldirected therapy. This is especially critical for traumatic brain injury patients for whom the mortality rate has hovered around 50 percent. Today, with aggressive monitoring and timely intervention, Dr. Burris says that figure can be reduced by half.

Monitoring and Protection

One of the life-saving interventions made possible by improved monitoring is decompressive craniectomy, a neurosurgical procedure Dr. Miller calls one of the “coolest” he performs. The procedure is used most often in patients with traumatic brain injuries or ischemic stroke to reduce the damaging effects of intracranial pressure. A portion of the skull – sometimes as large as a hand – is removed and carefully preserved at -60° C while the patient’s potentially braindamaging inflammation diminishes. Pressure and oxygenation continue to be monitored. When it is safe to do so (which could be weeks later), Dr. Miller closes the hole with the patient’s own bone. “Novel application of acceptable

Internist/Nephrologist Larry Burris, MD (on phone), and Neurosurgeon Charles Miller, MD (at computer), are the region’s only two board-certified Neurocritical Intensivists and two of only 400 or so, nationwide.

Midwest Medical Edition

Dr. Jitendra

Sharma

Jenna Neilsen, RN, sets up a therapeutic hypothermia treatment. Using an external or internal cooling device, a patient’s body can safely be cooled to 91° F to protect delicate brain and spinal tissues from ischemic damage.

Vascular Neurologist Kathryn Florio, MD, manages the neurological problems of neurocritical care patients.

techniques allows us to go beyond standard therapies and give our patients a better fighting chance when it comes to these really terrible injuries,” he says. Another one of those acceptable but not highly-publicized techniques is therapeutic hypothermia, a method of lowering a patient’s body to a therapeutic temperature of 91° F in an effort to prevent ischemic injury to already-damaged tissues. Using a cooling pad placed on the skin or an endovascular cooling device that goes in the

March 2013

groin, the patient’s body temperature can be dropped for days or even weeks. “Unfortunately, it’s not just the injury itself which creates problems for the patient,” says Dr. Miller. “It’s the inflammatory cascade that occurs after the injury. In those inflammatory injuries, the cooling literally turns off the metabolic activity in neural tissue and blunts the inflammatory response, so that you can just deal with the injury and you don’t also have the body’s response to contend with. It effectively protects the tissue.” Therapeutic hypothermia (also called protective hypothermia), which has now been performed on more than 150 patients at Sanford, has been shown to reduce secondary neurological damage from strokes, spinal cord injuries and traumatic brain injuries. A 2002 study found that patients who had suffered cardiac arrest were less likely to also have neurological damage if therapeutic hypothermia was part of their treatment.1 Advances in EEG monitoring have also been pivotal in the development of Neurocritical Care as a specialty. With 24/7 EEG monitoring, which can be continued for

As the state’s only interventional neurologist, Dr. Jitendra Sharma supports neurocritical care with several important interventional procedures. In addition to providing coiling of aneurysms for eligible patients, Dr. Sharma provides drug therapies to dissolve clots or can remove them with an endovascular mechanical stent. These procedures can often increase the window for therapeutic stroke care from four hours to eight hours.

1 “Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest”, New England Journal of Medicine, Feb. 21, 2002.

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days, it is now possible to accurately track and measure ischemia and seizures over time. Sanford’s Neurocritical Care team is researching the use of a small intracranial EEG monitor to track microshiver (subclinical muscle tone) in patients undergoing therapeutic hypothermia. Improved EEG monitoring supports more accurate diagnoses and highly targeted interventions which, in turn, result in better outcomes.

The Team Approach

While the Neurocritical Care techniques offered at Sanford are advanced, Drs. Miller and Burris say their greatest asset is their small but comprehensive team. In addition to neurosurgeon Dr. Miller and Dr. Burris with his background in general medicine, the team includes board-certified vascular neurologist Kathryn Florio, DO, and the state’s only interventional neurologist, Jitendra Sharma, MD.

“Dr. Sharma provides the endovascular part, which is really the only thing that our program was missing,” says Dr. Burris. “There are pure neurological things, so you need someone like Dr. Florio who is welltrained in pure neurology. Then there are surgical issues, such as aneurysms that need to be fixed, etc. and we have Dr. Miller for that. Then you have the whole range of medical issues or things that may crop up in the hospital and that’s where I come in. So we have all the bases covered and that is really what makes us great.” “One type of patient that brings us Neurocritical Intensivists together with the rest of the team is a subarachnoid hemorrhage,” says Dr. Miller. “When these patients come in, they immediately need the Neurocritical Care aspect. We start putting in lines and managing blood pressure. I may call Dr. Sharma to do an angiogram to identify the aneurysm. I may go in and put in a drain.

Postoperatively, Dr. Burris would manage them in the ICU. If the person seizes or is not waking up well, Dr. Florio might be pulled in on that.” The team not only works in collaboration (Drs. Florio and Burris are married to each other), but they also round together, a fact which Dr. Miller says sometimes sparks “lively discussion”. In the end, he says, patients benefit from getting multiple perspectives on their neurocritical hospital care from physicians with a single passion. “This is the beauty of medicine: You can find your passion and follow it,” says Dr. Miller, who says few providers embrace trauma the way he and Dr. Burris do. “They don’t want to deal with the accidents and the gunshot wounds and the drunk people who fell. But these are my people. I really do thrive on this, even though there is also a lot of heartache. Overall I think we do a very good job.” ■

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Clinical Spotlight

New ENB Procedure for Hard-to-Reach Lung Lesions Avera McKennan Hospital & University Health Center in Sioux Falls is now offering electromagnetic navigation bronchoscopy (ENB), a minimally-invasive option to locate, enable biopsy, and plan treatment for a lesion detected deep in the lung. The procedure uses the superDimension i·Logic System and goes hand-in-hand with a new lung cancer screening program through the Avera Cancer Institute, which offers CT scanning for early detection in patients at high risk for lung cancer. Unlike traditional bronchoscopy which cannot reach the distant regions of the lung where more than two-thirds of all lung lesions are found, ENB uses GPS-like technology to navigate a unique set of catheters deep into the lungs. ENB guides and steers the catheters through complex airways, far beyond the reach of a traditional bronchoscope, enabling physicians to locate, test, diagnose and potentially treat lesions. For most patients, ENB is an outpatient, same-day procedure that lasts from 30 minutes to 2 hours. “ENB is an important addition to the tools we use to diagnose early lung cancer. In the right patient, ENB can provide the diagnosis with the least amount of harm when compared to other modalities,” says Pulmonologist Fady Jamous, MD. “ENB can also be used to guide radiation therapy and sometimes even assist the surgeon while performing resection surgery.” Before the development of ENB, a patient with a spot deep in the lung typically had the options of surgery to remove a section of the lung, needle biopsy, or watchful waiting. All three have drawbacks. Needle biopsy carries the risk of lung collapse, artery punctures or weeks in the hospital and conventional bronchoscopy fails to reach the lesion 65% of the time. ■

March 2013

M E D I C A L

B R E A K T H R O U G H S

Dr. Tom Stys, Medical Director of Cardiovascular Services Dr. Verlyn Nykamp, Director of Cardiac, Thoracic and Vascular Surgery

It took more than two years of preparation, A new Sanford Heart Hospital, and a team of 25 in the operating room,

All for a life-saving ten seconds. 16

Midwest Medical Edition

Transcatheter Aortic Valve Replacement. Only at Sanford Health. Dr. Adam Stys, Dr. Tom Stys and Dr. Verlyn Nykamp are the core members of an exclusive team. Late last year, they were among the first in the nation to perform the new TAVR heart valve replacement procedure. Currently, just over 200 hospitals nationwide have met the highly stringent criteria to perform this complex operation. Sanford Health in Sioux Falls and Fargo are two of those hospitals. But what did it take to become one of them?

“We started building the team about two years prior to the first case,” said Dr. Tom Stys, Sanford Interventional Cardiologist. “We have one of the best teams and programs in the country.” Teamwork describes the entire procedure. On paper, it’s simple: insert the SAPIENS replacement valve through an incision in the patient’s groin, maneuver to the heart and insert it in place. These patients, however, are too fragile for traditional open-heart surgery. And precise valve placement – utterly crucial to success – takes place in a window of about ten seconds. So typically, there are between 20 to 25 people in the operating room, including six to eight Sanford physicians from different areas of expertise. “Every single one of them has their own crucial piece that the whole procedure depends on,” Dr. Stys said.

Edwards SAPIEN transcatheter heart valve

For the full story, visit SANFORDHEALTH.ORG Keyword: TAVR

The numbers, however, don’t complicate split second decisions. Dr. Adam Stys, Interventional Cardiologist: “During the procedure, at the most crucial moment when a split-second decision has to be made whether to implant the valve at this location or change the position, all of us agree on all procedures within split seconds.” Dr. Verlyn Neykamp continued, “We are a group of physicians that has worked together so well before the TAVRs came up... we are all happy to pitch in, do what needs to be done and take care of the patient.” The results for the patient are immediate and dramatic. “We are helping patients that were helpless before,” Dr. Tom Stys said. “Patients who previously were not able to do any of their daily activities all of a sudden get up. Being able to reverse the disease by implantation of a new valve and having those symptoms resolve essentially almost overnight or a day is amazing. It gives them a second chance at life.” The breakthroughs don’t stop at TAVR. “This is just part of our plan to bring to this area the best and latest in technology and put it into use very efficiently and safely,” said Dr. Adam Stys. “This is just a piece in the whole big puzzle of modern medical care.”

Choose innovation. Choose Sanford Heart.

The Edwards SAPIEN valve is expanded into place with a balloon and the delivery catheter is ready to be removed.

March 2013

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Brookings Health System

Photo courtesy Brookings Health

Acquires Robotic Surgical System

General Surgeon Dr. Theresa Oey-Devine (left) and OBGYN Dr. Ellen Hopper.

Brookings Health System has become the third in South Dakota to use robotic technology in its operating room. The health system announced the installation of its new da Vinci Robotic Surgical System in February. Surgeons and operating room staff are currently undergoing intensive training to use the da Vinci surgical system for a range of minimally invasive procedures. Initial procedures will include gynecological procedures, such as hysterectomy, and general surgery procedures, such as gallbladder removal, with plans to add additional gynecological and general surgery procedures in the future. The da Vinci surgical system consists of

three components: an ergonomic surgeon console, a patient-side cart with three interactive robotic arms, and a video tower which houses dedicated system processors and a high definition 3D vision system. Finger tip controls at the console transfer the surgeon’s movements to the robotic arms on the patient-side cart. The surgeon’s motions are scaled to micromovements, making the technique very precise. Patient benefits of robotic surgery include less pain, a quicker recovery, and minimal scarring. “Brookings Health System’s investment in the da Vinci robot reflects our commitment to the latest technology advancements, the best outcomes for our patients, and clinical excellence for our surgeons,” said CEO and President Jason Merkley. Brookings Health System includes a 49-bed hospital, the 79-bed Brookview Manor nursing home, and Brookhaven

Brookings Health System’s new robotic surgical system will be used for a range of minimally invasive surgeries.

Estates apartments. It is a non-profit, city-owned facility that offers the community a full range of inpatient, outpatient, and extended care services. The acquisition makes Brookings Health System the third health care provider in the state to actively offer advanced robotic surgical technology. ■

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Photo courtesy Regional Health

Spearfish Regional Hospital Verified as Level III Trauma Center Spearfish Regional Hospital (SPRH) recently received verification as a Level III Trauma Center by the American College of Surgeons (ACS). This verification is an advancement for the facility, which was previously listed as a Designated Community Trauma Hospital. Now with the ACS verification, it will move up to being only the second Designated Area Trauma Hospital in the state. There is only one higher level for trauma designation in South Dakota, which has only been achieved by the three largest hospitals based on its requirements. Level III Trauma Centers provide comprehensive, 24-hour, seven-days-a-week trauma care with a trauma team including a trauma surgeon, Emergency Department staff, Emergency Department physicians, respiratory therapy, radiology services, CT scanning, operating room staff, lab and blood bank resources, and orthopedic surgeon as needed. During a two-day visit this past December, a survey team from ACS completed an on-site review and evaluation of the trauma care provided at SPRH. “The American College of Surgeons survey process is the gold standard of trauma

MED Quotes “ I have no special talent.

center verification,” said Tim Sughrue, Chief Operating Officer of Regional Health, CEO of Regional Health Network, and CEO of Rapid City Regional Hospital. “We are committed to enhancing our emergency services to meet the high standards of care for our patients.” Trauma verification by the ACS is a

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voluntary process and must be requested by individual health care facilities. SPRH in South Dakota. The state of South Dakota developed, implemented and administers a trauma care system, including a statewide trauma registry involving all hospitals in the state. ■

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March 2013

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(The Stories We Could Tell)

Case by Case

David Elson, MD, FACP

Avera Medical Group Oncology & Hematology, Sioux Falls

ther. She ne of my most unique cases involved my wife’s grandmo

was born in 1900 and lived in Northwest Iowa. She was high functioning, lived in her own home, bought her own groceries, etc. In 1989, she had surgery for a high-grade ovarian tumor. Because of her age, we decided show up in her not to do any adjuvant therapy and, when she was 90, she had a growth just become had right groin. She also had enlarged lymph nodes. The CA-125 marker

s! Write to ua

ve Do you ha ca le se or memorab share with to experience ED? agues in M your colle t: sa Write to u ition.com

alEd westMedic Alex@ Mid

available and that was elevated, too. ist, but I I was a little trepidatious when she said she wanted me to be her oncolog doses of high been have would agreed. At that time, standard of care for what she had nausea for risk Cytoxan and cisplatin, one day every 3 to 4 weeks, but there was a high white count up. and side effects. There were no colony stimulating factors to keep her This was before Taxol. carboplatin Fortunately, there was an NCI pilot going on where they were combining we did this So and cisplatin in order not to get too much toxicity from any single drug. it would be more along with a 5FU infusion. I also used a lower dose of Ifosfamide so month, with cara once days few a over hospital tolerable. We gave her treatment in the antiemetics. with along three, and boplatin on day one and low dose cisplatin on days two her arthritic of With that regimen, she never got nausea and had no myelosuppression. Some symptoms even went away. to normal. We did six rounds of treatment. After about 2 months, her CA-125 was back 2003 until lived She out. it took She had a portacath put in place, but after 3 years, we 100th great a have without ever having a relapse of her ovarian cancer. We were able to birthday party for her and she enjoyed a high quality of life until she died. also because This case is memorable to me partly because of who the patient was. But cautioned being are We now: right I think it raises an issue that we are all struggling with are situthere that to practice evidence-based medicine. But I think we have to recognize ovarian cancer ations where there just is no evidence to guide us. The median survival for this response so s, survivor r five-yea some see do we patients is about 3 to 4 years, although anything that say to prepared really was unusual. From a reimbursement standpoint, are we times many se that hasn’t been proven is ineffective? Over the years, I have had to improvi to find things that would work for a particular patient. clinical trials The other issue this raises is that of drug development. A lot of times, younger than years 15 to 10 are that in the major cancer centers are being done on patients ng thought underlyi the ones we would normally see. For a while there was almost this being treated that if they weren’t getting enough medicine to make them sick, they weren’t lymphoma, and a leukemi like things about aggressively enough. When you are talking tumors solid common most the the highest tolerable dose may be reasonable. But with In my them. cure that we find in the elderly, we aren’t necessar ily going to permanently but the lowest view, the drug dosing we should look at is not the highest they can stand, with lower better do patients some showed, ther that will work. As my wife’s grandmo doses that produce less toxicity.” g In this ongoing series, MED invites physicians around the region to share some of their most memorable cases and practice experiences.

Midwest Medical Edition

March 2013

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Digestive Health Clinic Now Open in Sioux Falls

Midwest Family Careâ&#x20AC;&#x2122;s Mark Milone, MD, Offers GI Patients Technology and Time

Gastroenterologist Mark Milone, MD, believes that extra time spent with patients can lead to more accurate diagnosis and better outcomes.

A capsule endoscope can produce 54,000 diagnostic images as it moves painlessly through the gastrointestinal tract.

Midwest Medical Edition

60 to 70 million Americans suffer from some type of digestive disease. Digestive disorders drive more than 105 million physician visits per year, cause more than 14 million hospitalizations, and are responsible for more than 240,000 deaths.1 Given those kinds of statistics and the rising availability of new medications and procedures to treat them, the head of Sioux Falls’ newest Digestive Health Clinic is likely to have no trouble attracting new patients. “One of the things that I enjoy most about gastroenterology is that we help manage chronic diseases and improve the quality of peoples’ lives, but we also provide cures, such as removing a polyp,” says board certified gastroenterologist/hepatologist Mark Milone, MD of the new Midwest Family Care Digestive Health Clinic. Dr. Milone graduated from Creighton University Medical School and spent 11 years practicing internal medicine before returning to the University of Nebraska Medical Center for fellowship training in gastroenterology. “It is very hard to be an expert in everything but when you pick a specialty area, the buck stops here, so to speak,” says Dr. Milone who treats issues ranging from heartburn and diarrhea to ulcerative colitis, Crohn’s disease, diverticulitis and anemia. As a hepatologist, he also offers evaluation and treatment of gallbladder and liver diseases. “As a gastroenterologist, it is nice to be the person that people come to for answers about their digestive health. I really enjoy having a more limited, specialty focus and helping patients utilize some of the exciting new drugs and diagnostic procedures we now have available to us.”

Advanced Technology Dr. Milone and the team at Midwest Family Care Digestive Health Clinic, a division of Sioux Falls Specialty Hospital, offer a range of screening, diagnostic and therapeutic procedures. In addition to upper endoscopy and colonoscopy, they can perform esophageal manometry with 24-hour pH testing, endoscopic retrograde cholangiopancreatography (ERCP) for treatment of problems of the bile and pancreatic ducts, and capsule endoscopy, which uses a tiny wireless camera to visualize the digestive tract. “Once it is swallowed, the capsule endoscope takes four images every second, so we end up with a total of 54,000 images of the small intestine,” explains Dr. Milone of the vitamin-sized capsule camera. The patient leaves the office wearing a small recorder to capture the images as the camera makes its way painlessly through the system. The result is a comprehensive look at the small intestine which Dr. Milone says can be invaluable in making difficult diagnoses such as obscure GI bleeding. For its ability to reveal narrowing and blockages in small passages, ERCP has

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been another important diagnostic advance. “ERCP offers us a way to get into small areas such as the common bile duct to remove stones or to make a diagnosis,” explains Dr. Milone. “Through being able to get in there, we can make diagnoses of the pancreas, as well.” Dr. Milone plans to also offer radiofrequency ablation for conditions such as Barrett’s esophagus as the new clinic ramps up to full capacity.

New Medications Thanks to new medications, specialists like Dr. Milone can now offer real hope for improvement and even remission in patients with even serious gastric or hepatic disorders such as ulcerative colitis, Crohn’s disease and Hepatitis C. “There are more and more medications coming on the market all the time for disease like ulcerative colitis and Crohn’s, so it is now more possible than ever for these patients to have a high quality of life,” says Dr. Milone. “Even in people with severe disease, we now have about an 80 percent chance of getting a good response and about a 50 percent chance of putting them in remission.”

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The remission rate for Hepatitis C has also climbed dramatically in recent years through the use of a powerful drug combination. “During the time I have been in practice, the remission rate for Hepatitis C, which had been about 25 percent when I first started, went up to 50 percent,” says Dr. Milone. “Now, in the last two years, we have seen remission rates for Hepatitis C of about 80 percent using a mix of peginterferon, ribavirin, and the protease inhibitor, boceprevir.”

Taking Time In addition to top-notch diagnostics and high quality medical care, Dr. Milone says there is something else that every digestive disease patient needs and will find at Midwest Family Care Digestive Disease Clinic: time. “I believe that one of the most important things you can do for patients is to really hear them out so that you fully understand their issues,” says Dr. Milone. “In the past, we did not always have a lot to offer these patients, but now there are so many new options. In our office, we treat patients with respect and dignity by reserving the time they need to really be heard so that we can offer them the best possible solutions.” Citing the increasingly common irritable bowel disease (IBS) as an example, Dr. Milone contends that it is only through careful listening and history-taking that it is possible to distinguish which of the five different varieties of IBS a patient may have (allergic bowel disease, intestinal bowel overgrowth, wheat sensitivity, etc.) and determine how to treat it. Midwest Family Care Digestive Health Clinic reserves space in its daily schedule to ensure that new patients can be seen within 72 hours. Physician- and self-referrals are accepted. ■

Photos by Kristi Shanks

ccording to the National Institutes of Health, an estimated

1 N ational Digestive Diseases Information Clearinghouse, National Institutes of Health

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In Review What You’re Reading, Watching, Hearing

By Karie Youngdahl and The College of Physicians of Philadelphia

The History of Vaccines Reviewed by Darrel Fickbohm, MED Contributing Editor

he History of Vaccines is a concise trip through immunization invention. It calls to mind the early adventures of experimentation and often happy accidents that make up the first line of defense in our arsenal against infectious diseases. It also outlines the public’s reactions to the discoveries which, from the beginning, were mixed. Perhaps, the most important thing that this slim book does is to intelligently summarize the subject. Even in the minds of the most knowledgeable, it can be difficult to organize thoughts on issues of vaccination while facing a skeptical patient. What seems clear to a physician living in the 21st century may not be at all clear to patients in an environment where social media lends credibility to rumors through emotional responses and accumulated “likes” on a website. Science can walk backward and lives can be at risk through ignorance. This book could be an effective tool that helps educate while saving exam room time. Especially targeted by the book are teens and college-age readers who are more in touch with the opinion-making forces that seem to prevail these days. The author, Karie Youngdahl tells MED of her book’s main purpose: “Smallpox, polio, measles, rubella – these are all illnesses that had tremendous morbidity and mortality, and this book shows people what that meant. Parents need to be aware that deciding not to vaccinate is not a riskfree choice—it’s a choice to assume the risks of easily preventable diseases. We think

this book will serve the same purpose for adolescents. They will be parents soon enough and responsible for making vaccination decisions for their own children.” It is a fascinating fact that a mere 200 years ago, scientists still did not agree on what caused diseases like cholera, smallpox, and measles. A wealth of “old wives’ tales,” superstitions and baseless theories ruled the day. Creeping smells called miasmas were thought to cause the sicknesses. And so it went until germ theory was validated by the study of microbiology. As the book moves into describing the battle with childhood diseases, we see a careful and deliberate method emerging, often featuring heroes in lab coats testing and retesting, experiencing setbacks, and refining vaccines until they are optimized. But when the resulting inoculations for children become available, an old struggle re-emerges. For although the trend in scientific method became more and more careful, the antivaccination movement strengthened by the paranoia of the mid 50s and 60s becomes a bothersome and ongoing societal fixture. Perhaps the more comfortable society becomes in this relatively disease-free age, the farther away we get from what was once the day-to-day fear of serious infection. As this happens, more forums open up to entertain superstitious thinking and outright ignorance, especially in new social media settings. The emotional anti-vaccination postings in Facebook, for instance, are remarkably similar to the posters and tracts that were circulated in the early 1800’s,

before anything was known about germs. As diseases mutate and we alter our formulae to counter the changes, so then must we battle the backward thinking that can go along with new discoveries. Thankfully, treatises like The History of Vaccines exist to re-educate and remind everyone that some things can never afford to be taken for granted and vigilance must never be subject to uneducated whim. ■

Write to us! Do you have a media review? A book, film, or article? How about an opinion on a current event? Write to us at: Alex@MidwestMedicalEdition.com

The History of Vaccines is available individually on Amazon for $9.99, but anyone interested in buying ten or more copies should contact the author at The College of Physicians of Philadelphia (kyoungdahl@collegeofphysicians.org) for a volume-rate cost.

March 2013

MidwestMedicalEdition.com

By MED Staff

Sanford Heart Hospital Celebrates Achievements, Sets Goals

One S Year Later . . .

ince Sanford Heart Hospital opened its door in March 2012, it has been on the forefront of advancing heart care in the region. The 205,000 square foot facility, which is connected to Sanford

USD Medical Center in Sioux Falls, is the center for heart and cardiovascular services at Sanford which involve some 750 doctors, nurses and support specialists. MED spoke with cardiologist Tom Stys, MD, Medical Director of the Heart Program about the strides the hospital has made in its first year, and its goals for the coming years.

First Year Milestones “One of the things we are most excited about is that we are now the only institution in all of North and South Dakota that has a cardiology fellowship training program,” Dr. Stys told MED. “In fact, when we were approved, we were the only new program approved in the whole country. Our second batch of fellows will graduate July 1st.” Another big achievement this year, say Stys, is the establishment of a Structural Heart Program. This collaborative effort between

interventional cardiologists and cardiothoracic surgeons is focused on new, less invasive ways to treat patients with structural heart diseases. Transcatheter Aortic Valve Replacement (TAVR) is an important part of this program. In the past year, a team of 8 physicians and 20 staff have completed the first 12 TAVR cases with no complications. Recently, Sanford Heart Hospital received a grant from the Helmsley Foundation to purchase robotic equipment for its cath labs in Sioux Falls and Aberdeen. The acquisition

will make Sanford one of only a handful of heart programs in the country offering robotic angioplasty, which allows new levels of precision and safety, not only for angioplasty, but also for stenting procedures.

Future Goals

Interventional Cardiologist Tom Styz, MD, performing the TAVR procedure at Sanford Heart.

Midwest Medical Edition

Photos courtesy Sanford Health

As the hospital heads into its second year, Dr. Stys anticipates being able to offer more types of interventional cardiology procedures and to reinforce the Sanford Chest Pain network, an organized initiative aimed at improving rural STEMI outcomes. The hospital will also conduct a number of new research trials, including a study of stem cell therapy for patients with significant heart muscle damage. Finally, the Sanford Heart Hospital will soon become a national training site for physicians who wish to learn the radial approach to angiography, a procedure Sanford has helped to pioneer. “We have now done the radial approach in about 10,000 patients at Sanford,” says Dr. Stys. “About 80 percent of all of our catheterizations are now done minimally invasively through a small hole in the wrist.” When the training program is up and running, doctors from around the world will come to Sanford to study the technique. ■

Photo Claussen Photography

Matters of women and their hearts By Maria Stys, MD

It’s often a silent killer. It can come

South Dakotan Featured by AHA A South Dakota woman’s heart

even vomiting can be related to a heart attack. In addition, women may also begin to sweat, feel lightheaded or dizzy and may experience an abnormal amount of fatigue. Physicians play an important role in helping women understand their risks and their symptoms. They can take action and encourage female patients to be aware of their own heart health. Just like women tend to be proactive with annual exams like pap tests and mammograms, they need to also be screened for heart disease. Women should know their cholesterol levels and, if they qualify, get a CT screen. ■

South Dakota Medical Group Management Association Spring Conference

HEALTHCARE:

What’s Your Perspective?

April 24 - 26, 2013 •

The Lodge in Deadwood, South Dakota

Featuring: Juli Burney Teacher, Humorist, Author Lt. Governor Matt Michels State of South Dakota Michael Oster Professional Training Consultant, Oster Consulting For the full schedule or to register, visit our website at www.sdmgma.org

March 2013

MidwestMedicalEdition.com

Photo courtesy Sanford Health

problem survival story was featured prominently on the American Heart Association’s national website in February. Lynn Paulson, who lives in the Black hills, told the AHA that her first symptoms included fatigue shortness of breath and a racing heart after exercise, all of which she chalked up to stress. After two years of ignoring these warning signs, Paulson finally underwent heart monitoring and discovered that she had atrial fibrillation. When medication and electrical cardioversion failed to offer a permanent solution, Paulson underwent a successful cardiac ablation. Paulsen is the first person from South Dakota to be featured in the AHA’s ‘Stories from the Heart’. ■

on without any chest pain or discomfort. Yet, more women die of heart disease than all forms of cancer combined. That’s why it is vital to seize opportunities to talk to female patients about matters of the heart. It’s important that we as physicians stress to women the importance of heart health, which is the number one killer of women in the U.S. Right now, eight million women in this country are living with heart disease. However, statistics show that only one in six of American women see heart disease as her greatest health threat. It’s a dangerous statistic because women don’t often experience the same typical heart symptoms as their male counterparts. Often, they don’t experience the crushing, clenching chest pain like men do. Less than a third of women in a recent survey reported early warning signs. In general, women will experience some sort of discomfort in their chest though it may not be severe. Instead it is more likely that a woman will experience signs unrelated to chest pain such as discomfort in their neck, shoulder, upper back or stomach. Shortness of breath as well as nausea and

Complementary Therapy Supporting a Holistic Approach

Depression is the most common mental health disorder, and an estimated one in 10 adults suffer from it. While it is often treatable with a combination of medication and talk therapy, not everyone responds to medication or can tolerate the side effects. Name

Matthew Stanley, MD Title

Psychi a rist Business

Avera Behavioral Health Center

“T

raditional therapies such as medication, psychotherapy and ECT have their place in the treatment of depression, but there is still a large number of patients we’re not able to provide a treatment for that’s acceptable or effective,” said Dr. Matthew Stanley, psychiatrist with Avera Behavioral Health Center and Avera Medical Group University Psychiatry Associates. A new treatment, known as transcranial magnetic stimulation (TMS), promises to help more people experience relief from depression, without unwanted side effects such as weight gain, insomnia or loss of libido, which some people experience on antidepressants. The prefrontal cortex of the brain, thought to control mood, is known to be underactive in sufferers of depression. TMS uses highly focused magnetic pulses to stimulate that area and restore it to normal function, thus lifting depression symptoms. TMS is a treatment for people who have failed to find relief from at least one depression medication. The treatment, recently approved by the FDA, is a non-drug, non-invasive treatment.

There’s no need for anesthesia or sedatives. TMS involves about an hour-long visit every day Monday through Friday for four to six weeks. The patient sits in a reclining chair, and the magnetic coil is placed against the patient’s head. “Electromagnetic technology, similar to MRI but more focused energy, has a long-term record of safety,” Dr. Stanley said. The patient hears a clicking sound, and feels a tapping sensation on the head. “The patient is awake and alert throughout the procedure, and may return to normal activity immediately after treatment,” he said. Patients may feel some discomfort on the scalp, which is noticed the most at the first treatment and then diminishes at future treatments. Otherwise, there are very few side effects. There is a rare chance (about 1 in 30,000) of seizures. “Many people experience significant benefits,” Dr. Stanley said. In clinical trials, one in two patients improved significantly, and one in three patients were completely free of symptoms. “Along with medication and psychotherapy, we’re able to use TMS to help more patients experience remission,” Dr. Stanley said. ■

Midwest Medical Edition

Documentation

Are You at Risk or Do You Have Opportunity?

By Cheri Welk

valuation and Management services remain on the 2013 Office of the Inspector General (OIG) Work Plan, where they are seeking inappropriate payments made for 2010 dates of service. Medicare requires providers to select the appropriate code on the basis of service content and have documentation to support the level reported. It is critical for healthcare providers to be aware of medical necessity and documentation guidelines to avoid exposure to potential compliance audits. Equally critical, it is important to be aware of opportunities for increasing revenues lost because of lacking documentation. The first step in determining a provider’s risk or opportunity is to compare the utilization of E/M codes against other physicians’ usage within his or her specialty. The Centers for Medicare & Medicaid Services (CMS) publishes Medicare Part B utilization data each year to be used for comparison. Using this data, benchmarks or bell curves can be calculated. This can then be compared to others within the same specialty using the number of allowed services for each CPT code as a percent of the total. Once the bellcurve, or benchmark as some may call it, has been determined, a comparison can be made to identify deviations. One way to illustrate this is to take data from a provider reporting New Patient E/M codes during the previous three months and compare it with data from CMS. Using the two sets of data, it is possible to create a graph that will easily identify if the providers bell curve aligns with that of CMS and how other providers within their specialty compare. By reviewing this graph, one can easily identify that this provider has opportunity to improve the current levels reported. Questions could then be asked – could this variation be due to the type of patient the

March 2013

providers are seeing – i.e. low complexity, straight forward medical decision making? Or, upon review of the documentation, are there key elements missing that are preventing a higher level from being reported? Whatever the answer, the next step would be to review a sampling of the documentation to see where the opportunities lie. A profile module located on the MGMA.com website was used to create this graph. If the provider’s office does not have access to this tool, graphs may also be created utilizing Microsoft Excel or by utilizing a third party company to complete the analysis. Historically, it’s common for providers to lack in their documentation in the area of patient history. The chief complaint is a required element, and must be clearly indicated and documented by the provider. The history of present illness (HPI) should tell the story about why the patient is in the office today. It tells the story of who, what, when, where, why, and what have you done to alleviate some of the symptoms. The HPI is often the piece that is lacking, so is an area providers may want to look back on and consider if they’ve documented everything. According to the CMS E/M guidelines, the chief complaint and the HPI must be documented by

MidwestMedicalEdition.com

the provider. The only part of the history that may be documented by a nurse, student, ancillary staff, or the patient is the review of systems (ROS) and/or past, family, and social histories. Along with opportunities comes an equal level of compliance. It is strongly discouraged to simply use the bell curve to increase your coding levels based solely on documentation. CMS is very clear that medical necessity should be the overarching criterion for reporting any service. When auditing documentation, refer to either the 1995 or 1997 Documentation Guidelines for Evaluation and Management Services from CMS to assure that the documentation is meeting all of the elements. Read the tools and resources thoroughly and consider each encounter note carefully to determine if the documentation can withstand both a coding and compliance audit. If areas of risk or concerns are identified, don’t be afraid to seek external assistance from a professional consulting company. External audits can be a valuable tool for providing feedback and education. ■ Cheri Welk, RHIT, is Director of Physician Client Services with Surgical Management Professionals.

The Nurses’ Station Nursing News from Around the Region

ANCC Magnet Recognition Program

Schumacher, Mickely Honored with DAISY Awards

Awards Local Hospital

Roxi Mickley received the January DAISY Award for Extraordinary Nurses at Rapid City Regional Hospital (RCRH) and Kristy Schumacher

For the third-consecutive

Center had to pass a rigorous

delivery of care were

received the award in December.

time, Sanford/USD Medical

and lengthy process requiring

considered for selection.

Mickley has been a Registered Nurse in the

Center has achieved Magnet

widespread participation from

Magnet recognition has

Neonatal Intensive Care Unit at RCRH for 12

recognition as part of the

leadership and staff. The

been shown to provide

years. She was nominated for the award by a

American Nurses Credential-

facility was also required to

specific benefits to hospitals

patient’s family who said Mickley “didn’t just

ing Center’s (ANCC) Magnet

submit written documenta-

and their communities:

administer great medical care, but took the time

Recognition Program,

tion demonstrating qualitative

to provide care to the entire family, as well.”

positioning the institution in

and quantitative evidence

This included keeping the family educated on

the top-1 percent of facilities

regarding patient care and

satisfaction with nurse

nationwide for nursing

outcomes, followed by an

communication,

excellence.

on-site review.

availability of help,

what was being done medically, showing concern for the family members’ well-being during a scary situation, and making sure the family was aware of what to expect going forward. Schumacher was an EMT at Lead-Deadwood Regional Hospital for 15 years and has been a Registered Nurse in the Cardiac Interventional Unit at RCRH for six months. The patient family that nominated her described Schumacher as a “hero” and “a strong,

Bestowed every four years,

The Magnet model is

• Higher patient

and receipt of discharge

the Magnet Recognition

designed to provide frame-

Program’s distinction is the

work for nursing practice and

• Lower risk of 30-day

highest honor an organization

research and measurement of

mortality and lower

can receive for professional-

outcomes. Elements like

nursing practice. Just 378 of

quality of nursing leadership

the United States’ nearly

and coordination, collabora-

6,000 facilities attained

tion across specialties and

Magnet status for this cycle.

processes for measuring and

of intentions to leave

improving the quality and

position

Sanford/USD Medical

information

failure to rescue • Higher job satisfaction among nurses • Lower nurse reports

compassionate, and caring nurse”. The nomination stated that, while Schumacher was off duty, she responded to an emergency and cared for

Online Nursing Advisor Adds Drug Guides

the patient until he arrived at the hospital. ■

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A leading online clinical decisionsupport system used by nurses in hundreds of hospitals has added two important new features. Lippincott’s Nursing Advisor announced in January that it has added a Drug Identified and a Drug Interactions Guide to its online system. The new Drug Identifier covers thousands of drugs and contains more than 5,000 color images, organized by descriptive attributes to enable fast, accurate identification of unlabeled medications. The update also adds a Drug Interactions Guide, which provides a fast and convenient way to look up interactions information for a single drug or between two or more specified drugs. Nurses can use it to view known interactions and to investigate interactions between drugs in specified contexts, such as patients with known drug allergies or with specific diseases or symptoms. Written by nurses for nurses, Lippincott’s Nursing Advisor is the leading nurse-centric resource designed for online and mobile point-ofcare environments. ■

Midwest Medical Edition

Grape Expectations

Wine by the Numbers By Heather Taylor Boysen

atings are everywhere

these days. When I was a kid, we only had three ratings for movies. Now there are too many to count. And when you last bought an appliance or car did you look up its Consumer Reports rating? The wine world, too, seems to revolve around ratings these days. It has been said been said that Robert Parker of The Wine Advocate has had an impact on the global wine economy with the rating of a single vintage year in a particular country. Stocks, wine futures, and other wine-related investments have risen or fallen based on a single rating from Parker or the “wine gods/goddesses” (as I like to call them) at Wine Spectator. Such ratings enable potential investors and traders to take a position – and affect the global market – without necessarily knowing much about the wine. Such ratings have also given new wine drinkers the ability to make decisions about wine with only a glance at a rating tag in their local wine shop. On the one hand, this makes it easy for someone to make a purchase without ever having any experience with what is actually in the bottle. On the other hand, you may buy a wine that Robert Parker gave a point value of 92 and end up absolutely hating it. Wine scores are almost as controversial as political debates. Many say that Parker’s rating are more objective because The Wine Advocate does not accept advertising from wine producers. Others assume that Wine Spectator might favor products from advertisers. Either way, a little background on what the scores truly mean is helpful.

March 2013

Just remember that it is your own opinion that matters most. Parker’s tastings are done in peer-group, single-blind conditions, which mean that the same types of wine are tasted at the same time, although the producer of each wine is not disclosed at the time of the tasting. Each wine is given an initial 50 points. General color and appearance can merit up to 5 points. Aroma and bouquet are worth up to 15 points. Flavor and finish account for up to 20 points. Finally, the ‘overall quality level or potential for further evolution and improvementaging’ merit up to 10 points. Parker’s explanation of his ratings: Rating Explanation 96-100 An extraordinary wine of profound and complex character displaying all the attributes expected of a classic wine of its variety. I think wines of this caliber are worth a special effort to find, purchase and consume.

90-95 An outstanding wine of exceptional complexity and character. I consider these terrific wines.

80-89

barely above average to very good A wine displaying various degrees of finesse and flavor, as well as character with no noticeable flaws.

70-79

n average wine with little distinction A except that it is soundly made. In short a straightforward, innocuous wine.

60-69 A below average wine containing noticeable deficiencies, such as excessive acidity and/or tannin, an absence of flavor, or possibly dirty aromas or flavors.

50-59

A wine I deem unacceptable.

Wine Spectator Magazine is a longtime advocate of the 100-point scale. This is how

MidwestMedicalEdition.com

the magazine explains its scoring system: “Wines are always tasted blind. Bottles are bagged and coded. Tasters are told only the general type of wine (varietal or region) and vintage. Price is not taken into account.” The magazine says its ratings are based on “potential quality, on how good the wines will be when they are at their peaks”. ■ Wine Spectators’ explanation of their ratings: Rating Explanation 95-100 Classic: a great wine 90-94

utstanding: a wine of superior O character and style

85-89 Very good: a wine with special qualities

80-84

Good. A solid, well-made wine

75-79

ediocre: a drinkable wine that may M have minor flaws

50-74

Not recommended

Learning Opportunities March / April 2013 March 8 8:00 am – 4:00 pm

Avera Neuroscience Institute Conference Location: Avera Education Center Information: mckeducation@avera.org, 322-8950 Registration: www.Avera.org/conferences

March 8 & 9

Emergency Conference 2013 Location: Sioux City Convention Center, Sioux City, IA Information: www.the-security-institute.org,

March 13 Internal Medicine Grand Rounds 12:00 – 1:00 pm “Novel Nonpharmacologic Approaches to Stroke Prevention in Patients with Atrial Fibrillation Location: USDSM Health Science Center, Room 106 Information: www.usd.edu/cme or cme@usd.edu March 14, 21 & 28 Pediatric Grand Rounds 8:00 – 9:00 am Location: Sanford USD Medical Center, Schroeder Auditorium (14th & 21st), USDSM Health Science Center, room 106 (28th) Information: www.usd.edu/cme or cme@usd.edu March 19 5:30 – 7:30 pm

I’m Not a Teacher, I’m a Surgeon: Educational Workshop for Surgeons Location: USDSM Health Science Center, Room 106, Sioux Falls Information: www.usd.edu/cme or cme@usd.edu

March 22 12:00 – 1:00 pm

Ob/Gyn Grand Rounds: Reducing Tobacco Dependence Through Physician Knowledge and Engagement Location: USDSM Health Science Center, Room 106

March 28 7:30 am – 4:30 pm

Perinatal, Neonatal & Women’s Health Conference Location: Sanford USD Medical Center, Schroeder Auditorium Registration: Sanfordhealth.org, keyword: perinatal Information: www.usd.edu/cme or cme@usd.edu

March 28 5:30 – 6:30 pm

Surgery Grand Rounds: Surgical Interests for LIC Location: USDSM Health Science Center, Room 106

April 5, 7:30 pm – April 6, 5:00 pm

12th Annual Sanford POWER Strength & Conditioning Clinic Location: Sanford Fieldhouse, Sioux Falls Information: 605-312-7809

April 11 8:00 am – 5:00 pm

Transplant Education Day Location: Sanford USD Medical Center, Schroeder Auditorium Information & Registration: 605-328-8290

April 16 8:00 am – 12:30 pm

South Dakota Society for Anesthesiologists Location: Clubhouse Suites, Sioux Falls

April 17 21st Annual Trauma Symposium: Excellence in Trauma & Surgical Care 7:30 am – 4:00 pm Location: Sioux Falls Convention Center Information: mckeducation@avera.org, 322-8950 Registration: www.Avera.org/conferences April 19 8:30 am – 5:00 pm

Head & Neck Cancer Symposium Location: Sanford Center, Dakota Room Information: 605-328-8200, michele.fleming@sanfordhealth.org Registration: Sanfordhealth.org, keywords: head and neck symposium

MED reaches more than 5000 doctors and other healthcare professionals across our region 8 times a year. If you know of an upcoming class, seminar, webinar, or other educational event in the region in which these clinicians may want to participate, help us share it in MED. Send your submissions for the Learning Opportunities calendar to the editor at Alex@MidwestMedicalEdition.com.

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