The Medical Decoder Spring 2016

MD

Volume 7 • Spring 2016

THE MEDICAL DECODER

Providing Care in adversity

Tactical medicine pg. 20 the Syrian Refugee Crisis pg. 23

IN THIS ISSUE 4 Medicine Through Statistics Alec Straughan

Northwestern University ‘16

Science & Technology

6

Lighting Upon Solutions: Optogenetics in Brain Research Elbert Mets

Cornell University ‘17

The Medical Experience

11

A Day in the Life

The MD Contributors

Health Care & Policy

17

A Bad Case of the School Nurse Evan Sitar

Northwestern University ‘19

Human Interest

20

Excellent Care in Extenuating Circumstances: Tactical & Disaster Medicine Michael Rallo

Rutgers University ‘17

23

The Mental Health Crisis of Syrian Refugee Camps Emilie Touma

Northwestern University ‘19

26 References 2 • The Medical Decoder • Spring 2016

Editors-in-Chief Brianna Cohen Svetlana Slavin

Creative Director Lauren Kandell

Writing Staff

Elbert Mets Michael Rallo Evan Sitar Alec Straughan Emilie Touma

Editing Staff

Selina Deiparine James Guo Aayush Gupta Korri Hershenhouse Eric Kim Nathan Moxon Kelley Park Savan Patel Rachel Seng Evan Sitar Alec Straughan

The MD Contributors Andrew Donaldson Ola Issa Vivi Simon Nadia Yala

Design Team

James Guo Michael Guo Matthew Lam Alexis O’Connor

LETTER FROM THE EDITORS

Dear readers,

Welcome to the seventh edition of The Medical Decoder! This edition marks our last as Editors-in-Chief and we could not be more proud of the amazing work our team has put together for you.

The world is changing before our eyes. It seems as though threats to safety around the globe are more imminent than ever before. Michael Rallo’s article, Excellent Care in Extenuating Circumstances, illuminates the field of tactical medicine, in which doctors and emergency workers are making strides toward increasing people’s safety. Additionally, Emilie Touma paints a picture of the troubling refugee situation in Syria and the health issues that victims of conflict face in The Mental Health Crisis of Syrian Refugee Camps. Highlighting an impending crisis closer to home, Evan Sitar briefs us on the alarming school nurses shortage in A Bad Case of the School Nurse. Educating ourselves on these issues is an important step toward easing our fears as we exit the comfort of our undergraduate bubble and enter the real world.

As we move forward with our professional careers, we are excited to leave the journal in the capable and enthusiastic hands of our successors. The Medical Decoder has grown larger than we could have dreamed of and this would not be possible without the continued support of our dedicated readers. We are pleased to present the seventh edition of The Medical Decoder. Enjoy!

Sincerely, Svetlana Slavin and Brianna Cohen Editors-in-Chief medicaldecoder@gmail.com

Letter from the Editors • Volume 7 • 3

Medicine

thro

By Alec Straughan

The People’s Perspective: Which Issues are Most Important?

Last month, U.S. citizens were asked what they thought were the most serious health problems in the country. Cancer and heroin abuse were the most commonly identified issues. Chronic disease and lack of access to health care drew less focus. Flint, MI’s recent water contamination crisis was also reflected in the outcomes of the survey.1

The Flint Water Crisis may have caused a jump in the public’s view of contaminated drinking water as a serious health concern.

Epidemic Emphasis: Opioid Overdose

Over the years, opioids, drugs that relieve pain, have seen a rampant rise in abuse.

High rates of overdose mortality have occurred from recreational drugs such as heroin, synthetic opioids such as fentanyl, and prescription drugs such as oxycodone.

Heroin use alone has more than doubled in the past decade for Americans aged 18-25.2 The Centers for Disease Control and Prevention (CDC) speculates that prescription opioids are fueling the epidemic, and the most common culprits are methadone, oxycodone (OxyContin), and hydrocodone (Vicodin).3 The CDC recommends that states reduce the number of painkiller prescriptions when possible, and increase access to substance abuse treatment centers.

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ough

STATISTICS

Cancer Mortality: Then and Now Due to a combination of novel therapies, increased awareness, and more efficient screening and diagnostics, cancer mortality in the U.S. has dropped to a new low. In the context of the recently announced “National Cancer Moonshot Initiative”, led by Vice President Joe Biden, the one billion dollars allocated to research is expected to further reduce cancer mortalities.7 New and exciting treatment options are emerging in the medical field, including the 2013 success story of “immunotherapy”, a method of administering tailored drugs that allow the body’s immune system to recognize cancer cells as foreign and eliminate them.8 While steps still need to be taken to optimize and commercialize immunotherapy, this and other therapies will pave the way toward reducing the cancer burden in the future.

Cancer mortality rates have dropped steadily since 2000.3

For references, see page 26.

1.9 million 40 times 29,467 DEATHS Americans abused or were addicted to prescription opioids in 20144

Opioid addicts are

more likely to be addicted to heroin5

were caused by drug poisoning involving opioids and heroin in 20146

Medicine Through Statistics • Volume 7 • 5

Lighting Upon Solutions Optogenetics in brain research and its implications for clinical practice

By Elbert Mets

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T

o better understand behavior and cognitive function, neuroscientists have long sought the ability to activate specific neurons within the brain. For much of the field’s history, neuroscience researchers have had limited tools to selectively manipulate neurons in vivo (in a live animal) and conclusively determine their functions.

At best, scientists were able to stimulate one or several neurons with a sharp electrode and observe the subsequent neural responses by recording electrical activity at another site in the brain, or by monitoring an animal’s behavior.

Alternatively, the study of neurons in vitro (in culture) limits scientists’ ability to draw definitive conclusions about specific neurons in a living brain.

Feeling constrained by existing research methods, Stanford scientists Karl Deisseroth and Edward Boyden began seeking novel methods to selectively stimulate neurons in vivo to identify their functions in the early 2000s.1 Researchers have previously studied neural activity in response to stimulation with light, but existing technology’s limited ability to quickly activate brain cells was incongruent with research questions that demanded a finer timescale.2 Utilizing a light-related

technique, Boyden and Deisseroth began experimenting with channelrhodopsin-2 (ChR2), a cell membrane-bound ion channel that, in response to blue light, activates the neuron containing the channel.¹ They also experimented with other opsins (light-activated ion channels), namely halorhodopsin (Halo/NpHR), which deactivates neurons in response to light.¹ Boyden’s initial experiments

T

Thousands of research groups have since adopted this technique.1,4 The primary advantage of optogenetics over previously existing, coarser methods to control neurons using light is its specificity.

Because opsins are encoded by genes, they can be selectively introduced into different types of neurons, many with distinct functions, and characteristics.1 Existing treatments for epilepsy, which affects 65 million people worldwide, are limited in their effectiveness and often have adverse side effects.5 A growing body of work has used optogenetic techniques to better understand the brain basis of epilepsy, which could serve as the foundation for research into novel treatments for the disorder.5-9 Studies in mouse models of epilepsy have shown that optogenetic inhibition of excitatory cells (which normally promote seizure activity) or activation of inhibitory neurons (which normally prevent seizures), are both effective in halting an epileptic epsiode.7-9 Researchers have also developed optogenetic techniques that monitor animals’ brain activity using an electroencephalogram (EEG). The information feeds back to a light source, which shines light onto opsin-

he primary advantage of optogenetics over previously existing, coarser methods to control neurons using light is its specificity. demonstrated that rapid pulses of blue light could be used to control the activity of ChR2-containing neurons on a millisecond timescale, and his subsequent work established the technique’s viability in mammals.1-3 Shortly after the publication of Deisseroth and Boyden’s work, the technique of using light to control neuronal activity in vivo became known as optogenetics.

Science & Technology • Volume 7 • 7

containing cells to modulate neural activity as desired.8 In one such system, when the EEG readout shows increased brain activity consistent with a seizure, light is shone onto specific neurons in the thalamus, which stops the seizure.8 Another exciting application of optogenetics is in the study of strokes.10 Strokes occur when a blood vessel becomes blocked and a section of the brain is deprived of nutrients and oxygen (ischemic stroke), or when one of the brain’s blood vessel ruptures, damaging the surrounding brain cells (hemorrhagic stroke). These

function, a phenomenon thought to result from the regrowth of synapses between neurons around the injured region.10 The formation of new synapses or connections between neurons is driven by activity in parts of the brain directly surrounding the infarct (dead tissue), which is associated with increased growth factor expression and blood flow near the injury site.10 Since neural activity near the damaged neurons is important in driving recovery following a stroke, it is fitting that new treatments aim to increase activity in areas around the stroke lesion.10 Previous methods to stimulate oyden’s initial neurons around a experiments stroke have been demonstrated that rapid nonspecific and associated with pulses of blue light could be side effects such as used to control the activity of impaired speech.10 However, in one ChR2-containing neurons... study, researchers and his subsequent work demonstrated that optogenetic established the technique’s activation of viability in mammals.1-3 neurons in the primary motor vascular changes result in cortex (the brain structure neuronal death in the area responsible for movement) in surrounding the dead tissue, mice that sustained a stroke which can impair language, led to increased expression movement, or thought of neuronal growth factors. depending on the location and This was then associated with severity of the lesion. improved sensory and motor However, patients who have behavior.10 These findings suffered from strokes can suggest that the activation recover some of their lost neural of cortical motor neurons

B

8 • The Medical Decoder • Spring 2016

following a stroke improves recovery, which could present a novel target for drugs or treatment with optogenetics in humans.10 In addition to its use in the study of epilepsy and strokes, optogenetics has also been used in research surrounding the treatment of chronic pain.11 Neuronal activity in the anterior cingulate cortex (ACC) is responsible for pain sensation in both mice and humans.11 Because excitatory and inhibitory neurons are closely packed together and interspersed with one another in the ACC, past attempts to activate inhibitory (and not excitatory) ACC neurons with electrodes have had limited success.11 However, because ChR2 (the ion channel that activates a neuron when stimulated with blue light) is genetically encoded, it can be experimentally placed into specific inhibitory neurons within the ACC. This allows researchers to selectively activate these neurons, thereby decreasing overall ACC activity.11 In mouse models, the result of decreased ACC activity is reduced pain-related behavior.11 A similar intervention may hold promise for people suffering from debilitating chronic pain.

Optogenetics’ utility is not limited to addressing questions about the brain. In addition to identifying new ways to treat neurological

conditions, researchers have used optogenetic techniques to characterize cellular pathology underlying type 2 diabetes in the pancreas.12 Additionally, in the field of cardiovascular medicine, researchers have introduced opsins into heart cells in vitro.13 The ultimate goal of this technique is to develop a benign method of defibrillating the heart.13 However, in vivo manipulation of heart cells faces a number of challenges. Namely the method of delivering opsins to cells and how to effectively illuminate cells deep in the heart (cardiac tissue prevents blue light from traveling far into

the heart; a similar issue arises in the human brain).4,13 To introduce opsins into heart cells, viral vectors can be “painted” onto the heart surface, or donor cells expressing opsins can be grafted onto the heart, though both methods have limitations.13 Although neuroscientists can target opsin expression to specific types of neurons, their ability to introduce opsins into individual neurons remains limited.4 Consequently, although optogenetics has improved the capacity to stimulate specific groups of neurons rather than activating neurons nondiscriminantly.4

More broadly, optogenetics researcher and Oxford University professor Gero Miesenböck, cites “the lack of a theoretical underpinning for much of neuroscience” as a challenge facing the technique.4 Furthermore, “we don’t understand most neural systems well enough to articulate and test clear hypotheses.”4 The salient improvements seen in animal models of human neurological diseases point to the use of optogenetics in clinical medicine. The fact that opsins have been successfully introduced into, and maintained in, neurons in the brains of nonhuman primates without

Science & Technology • Volume 7 • 9

complication over a period of (here, an opsin) is inserted into of optogenetic systems. several months suggests the the genome of a virus, which will Classically, optogenetic setups technique could also be a safe then ‘infect’ specific human host involve an optrode (laser light therapeutic tool for humans.3 cells. The virus has its illness- port) implanted into an area It should be noted that causing components removed, of an animal’s skull such that although animal models are a and serves instead as a template laser light, fed through an optic powerful tool in understanding that will deliver the gene of fiber, can shine directly onto the the functions of the human brain, interest. Once inside the body, neurons of interest. research findings in animals the virus enters the host’s cells Clearly, such a set up – even those evolutionarily and incorporates its genome impedes movement, and a less close to people – do not always into the host cell’s genome. conspicuous method of light translate exactly to humans.

Subsequently, the host cell delivery would be preferable This is particularly true in brain transcribes and translates the in humans.4 To address this research since the human brain viral genome to express the concern, researchers have is substantially more complex viral proteins of interest – here, recently developed a soft, than that of even our closest an opsin such as ChR2. Despite implantable device that allows evolutionary relatives. the efficacy of viral vectors in for inconspicuous optogenetic Since light-activated stimulation in the ptogenetics presents a ion channels are not absence of a clumsy naturally expressed in novel tool in neuroscience optrode.14 mammals, one clear research, and perhaps ultimately O p t o g e n e t i c s hurdle for the use of presents a novel tool in in clinical medicine.

To date, optogenetic therapies in neuroscience research, humans is the targeted optogenetics has allowed and perhaps ultimately delivery of genes coding researchers to characterize in clinical medicine. To for opsin proteins into date, optogenetics has the function of populations patients’ brain cells. allowed researchers to of neurons and their role in Transgenic animals characterize the function (animals bred with neurological conditions including of populations of specific proteins encoded neurons and their role in epilepsy and strokes. into their genome) are neurological conditions. often used in optogenetic Still in its infancy and studies. This is not practical for animal research, the approach evolving rapidly, optogenetics treating humans, as it would poses obstacles in humans.4 promises to continue to improve require introducing genes Although work in Boyden’s our understanding of the human for opsins into the patient’s group has demonstrated the brain and may ultimately genome before they developed safety of ChR2 delivered by a present an effective method of the condition being treated, and viral vector in the brain of a alleviating patients’ suffering likely before they were born. non-human primate, there are from brain-based neurological Alternatively, opsins can be concerns about the safety of illnesses. introduced into the neurons such a therapy and the stability of a living animal using a viral of the opsins over the years.4 vector.4 Using this method, a gene A further challenge to coding for a protein of interest clinical use is the portability For references, see page 26.

O

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A Day in the Life

As pre-health students, our exposure to post-graduate programs is often limited to what we learn from brochures, TV shows, and word-of-mouth. In this article, Andrew Donaldson, Nadia Yala, Ola Issa, and Vivi Simon have shared their experiences in pursuit of various health degrees. From medical school to occupational therapy, pharmacy, and nursing programs, we have showcased a day in the life of an average student to give our readers a better understanding of the many paths one can take in working toward a career in health care.

The Medical Experience • Volume 7 • 11

Medical Doctor

By Andrew Donaldson University of Illinois College of Medicine ‘19 My name is Andrew Donaldson and I have just completed my first year of medical school at the University of Illinois College of Medicine. The first thing that I’ll say is that I love it — the students are intelligent and driven, yet really down to earth. This is very

refreshing after the competitive nature of my undergraduate studies. I think I speak for many of my peers when I say that medical school is so much more engaging than undergraduate coursework because we are finally studying the material that we have been working our way towards! In the middle of a long string of exams, I stay motivated by reminding myself of how hard I have worked to get into medical school and how

12 • The Medical Decoder • Spring 2016

it will soon pay off.

The above schedule is the closest I could get to a “usual day” considering UIC doesn’t have a set week-by-week schedule.

Some days, we’ll have four hours of lecture and then some kind of lab in the afternoon; other days, we may have only two hours of class in total. Of course the remainder of those half-days is spent studying; still, it’s nice not to sit in a lecture hall 24/7!

Occupational Therapist

By Nadia Yala Western Michigan University ‘15

An Occupational Therapist (OT) is a healthcare professional who uses a holistic approach to help people facing cognitive, physical, or emotional challenges participate in daily activities.

Interventions involve assisting children with disabilities participate fully in school and social situations, helping

individuals recovering from injury regain skills, and providing support for older adults experiencing physical and cognitive changes.

In my five-year program, courses included anatomy, physiology, psychology, neurology, and assistive technology. Some classes were lecture based, while others were more interactive. We often used case studies to gather information about a patient, discuss possible limitations in their daily life, organize the evaluation process,

and plan intervention approaches.

Because a patient’s insurance typically pays for OT intervention, we also learned about how to document the patient’s progress to show that our interventions were impactful.

After years of classes and part-time and full-time internships in various practice settings, we must pass the National Board for Certification in Occupational Therapy (NBCOT). We can then begin our careers as OTs.

The Medical Experience • Volume 7 • 13

Pharmacist

By Ola Issa Roosevelt University College of Pharmacy ’18 The average person might assume that the daily life of a pharmacist includes standing inside of a large retail store, counting pills before dispensing them to a patient. Little does he or she know, pharmacy includes a wide array of job settings that require an extensive background in clinical knowledge and clinical practice.

Pharmacists are the medication experts who work with other health care providers to ensure that patients receive the most appropriate medication based on their specific diagnosis, labs, and general health.

A d d i t i o n a l ly, pharmacists are available in hospitals, clinics, pharmaceutical industries, home-care agencies, and insurance companies, to name a few.

There are two ways to be accepted into pharmacy school: students who already know that they want to become a pharmacist can apply to a 6-year program at the end of high school. If they are accepted, they take two years of prerequisite coursework, then begin

pharmacy school. This exempts students from the Pharmacy College Admission Test (PCAT).

If a student does not get accepted into the program, or decides on a career in pharmacy later in his or her education, then he or she is required to take all of the prerequisites, the PCAT, then apply to pharmacy schools using an online application process called PharmCAS. The Roosevelt University College of Pharmacy provides students with a truncated program, so I will be able to

chemistry, pharmaceutical care, pharmacology, pharmacotherapy, and health policies. On Fridays, we complete Introductory Pharmacy Practice Experiences (IPPE), which are similar to unpaid internships in order to gain practice in different fields of pharmacy. IPPEs are required every Friday for the first two years of pharmacy school.

During our third year, we do not attend classes but are instead assigned to Advanced Pharmacy Practice Experiences (APPE).

During APPEs, we are required to gain more specific experience for about 40 hours a week in different settings such as hospitals, ambulances, and numerous other locations where pharmacists are required.

After graduation, pharmacists take the North American Pharmacist Licensure Examination (NAPLEX) in order to begin their careers.

Graduates are also required to take a law exam to receive their pharmacy license. Maintaining a strong motivation for academic achievement is essential for success in pharmacy school.

Becoming a pharmacist is a lifelong learning process that requires commitment to the field.

Pharmacists are the medication experts who work with other health care providers to ensure that patients receive the most appropriate medication. obtain a PharmD in three years, rather than the traditional four years offered by most other schools throughout the country.

Roosevelt University students take coursework during two summers to compensate for the shorter program.

Dedication and determination are key aspects for success in obtaining a PharmD. On Monday through Thursday, we spend approximately 6-7 hours in classes focusing on medicinal

14 • The Medical Decoder • Spring 2016

The Medical Experience • Volume 7 • 15

Nurse

By Vivi Simon University of Miami School of Nursing and Health Studies ‘16 This is a basic summary of a clinical day. Days vary depending on the patients’ statuses (how critical they are) and their needs. Since I am placed in an ICU, vital signs are continuously monitored. Assessments are performed by a nurse and documented every two hours.

As a student in my last semester of nursing school, I am expected to provide full care for my patients while also taking the time to critically think about presenting patient information to my clinical instructor. It is important to be alert to patient baselines and any changes that may occur.

Clinical days are exhausting, but having the opportunity to apply multi-faceted learning to clinical settings gives me a better grasp of the information and prepares me for my role as the nurse that I hope to become.

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A Bad Case of the School Nurse

by Evan Sitar

A

cross the United States, close to 4.5 million school-age children have Attention Deficit Hyperactivity Disorder (ADHD); more than 300,000 children have been diagnosed with epilepsy; and an estimated 15,000 children learn they have Type 1 diabetes every year. Likewise, three million school-aged children also deal with food allergies and nine million have asthma.1 In the midst of these alarming statistics is the reality that in the very institution where children spend half of their childhood, there are not enough resources to ensure that the health of these students is under the watch of medically-trained

adults. Fewer than half (45%) of public schools nationwide have a school nurse present for the duration of the school day. Only 30% of the remaining schools have a school nurse working part time. The ramifications of this absence of school nurses are

as there is a possibility that such cases can unfold into tragedies at startling speeds. For instance, 10-year-old Mercedes Mears passed away after suffering a severe asthma attack at her elementary school in Tacoma, WA. The existing plan detailing e m e rg e n c y a s t h m a t i c treatment for Mears was ineffective, given that the school nurse was absent.

Because none of the bystanders were medical experts, no one was able to provide her 1 sobering. with the necessary epinephrine The ability to recognize the injection or attempt any form of danger in emergencies that may cardiopulmonary resuscitation. arise in these schools is crucial, While the supply of school nurses

Fewer than half (45%) of public schools nationwide have a school nurse present for the duration of the school day.

Health Care & Policy • Volume 7 • 17

is in swift decline, demands for their presence and expertise have never been higher.2, 3 As was the case with Mercedes, students with potentially lifethreatening conditions may not receive the urgent care and attention that they need without nurses.

Furthermore, students that depend on regular medication may receive it from adults without medical expertise. It should be a priority that schoolchildren receive care and treatment from individuals with the appropriate education.

In a study published by the Journal of School Nursing, it was estimated that close to 18% of children who came to

their school health office sick or injured were sent home when evaluated by untrained staff. This was in stark contrast to the mere 5% of students sent home when assessed by a school nurse.2 The absence of school nurses can be detrimental to both the health of students and to the welfare of the communities in which these shortages are common. It was estimated that one in five children living in the U.S. experience a mental disorder each year. Given that school nurses pay attention to students and address any foreseeable mental health issues, it is possible that without the presence of a school nurse, children with physical, mental, or emotional problems may be overlooked or undiagnosed.2,4 A number of medical advances now allow children with health complications to live much longer under constant supervision either in their homes or at school.

These medical complications include diabetes, e p i l e p s y , asthma, bleeding disorders, and severe allergies. A study conducted by the Centers for Disease Control and Prevention

18 • The Medical Decoder • Spring 2016

(CDC) found that now up to 1 in 12 individuals in the U.S. have asthma. This number grew by an astonishing 28% in just the past decade.4 Scientists from the American College of Allergy, Asthma, and Immunology have observed an analogous rise in allergy rates, especially in children with asthma.

School nurses can help monitor children with these serious health conditions, and can even assist in curbing or at least mitigating the severity of complications with a number of diseases.1, 5 A report carried out by the Institute of Medicine stated that school nurses play an integral part in providing care for a rising generation.7 A very limited number of school nurses trying to serve around 50 million students nationwide in over 100,000 public schools seems like a recipe for disaster.2 Because school districts have limited budgets, there have been numerous cuts in health funds across the country.

Recently, school districts are joining a cutthroat race to raise academic scores with their evershrinking budgets. William Hite, superintendent of the School District of Philadelphia, said that because the district meets the state required ratio of one nurse per 1,500 students, hiring more school nurses is no longer a priority.6 Unfortunately, nurses are often the targets of budget cuts, as noted by Erin Maughan, director

of research at the National Association of School Nurses. Even more disillusioning is that school nurse positions are sometimes “under-filled” with health aides or licensed practical nurses, many of whom lack necessary medical expertise. This is due to the fact that a small number of states authorize a nurse to be in every school.

No federal legislation mandates school nursing, and as of 2005, only 14 states have established sufficient school nurse-to-student ratios.

Even those states with mandated nurse-to-student ratios are woefully inadequate. It was noted that Vermont had the lowest nurse to student ratio, at 396 students per nurse. Surprisingly, each district within a state has the authority to individually deem whether or not having a nurse is necessary.3,9 Across the U.S., there is a shortage of registered nurses with baccalaureate degrees.

Enrollment rates in bachelors degree nursing programs have not met higher demands for nurses caused by the rising population of aging baby boomers, recent health care reform, and a lack of baccalaureate degree programs.

According to a survey by the American Association of Colleges of Nursing, there was a 4.6% drop in enrollments in 2000 alone.

This decline in enrollment may

also be attributed to a diminished interest in nursing careers, mostly due to issues with public image and nurses’ inadequate salaries.3, 8 Recruiting school nurses is challenging for many reasons.

School nurses often earn lower salaries than their nursing peers.

On average, the annual salary for a registered school nurse is $69,790, according to the Bureau of Labor Statistics.9 School nurses also suffer from an image problem that discourages many nurses from entering the field. “People think it’s just handing out Tylenol and ice packs,” Maughan said. “But it’s much more than that.”

More alarming are the enduring and outdated stereotypes of nursing as a rigidly female profession. Most recruitment efforts to draw more individuals to nursing careers have ignored a sizable group of the population: males.

While there have been considerable attempts to revolutionize the field of nursing, the complexity of the school

nursing shortage is nowhere near resolved. Settling the recent disparities in nurses throughout the school system requires a gradual approach, starting with inspiring a younger generation of aspiring medical professionals.

The school nurse shortage cannot be ignored. Levels of health-related incidents are higher than ever before, and time is of the essence to recruit more bodies to the field. Schools with difficulty acquiring and administering basic health resources to their students must receive additional financial aid. Perhaps programs to train health aides and non-medical professionals could be harnessed in the event that the school nurse is absent. Nonetheless, school nursing has unquestionably become a disappearing profession.

For references, see page 26.

Health Care & Policy • Volume 7 • 19

Excellent Care in Extenuating Circumstances: Tactical and Disaster Medicine

By Michael Rallo

N

ot a day goes by without a tragedy. Mass shootings, major accidents, terrorist attacks, and natural disasters are constant threats to our society.

As the government, military, and other major institutions plan for these incidents, the medical field must also prepare its professionals.

Known as tactical or disaster medicine, this field encompasses a wide-range of operations related to the treatment of sick and injured individuals in unstable situations. Doctors in this field epitomize the belief that early interventions are critical to saving lives that would otherwise be lost. To understand the role of a modern battlefield doctor, one must look to the evolution of this soldier-physician throughout history.

Hippocrates, a Greek physician practicing around 400 B.C., postulated the role of medicine on the battlefield with his claim that “he who desires to practice surgery must go to war.”1 This

assertion is still supported today, as wartime surgeons repair injuries not often seen in general practice, thus enhancing their surgical knowledge and skills.

Since many of our advances in emergency care — like ambulances, tourniquets, and wound dressings — have combat origins, learning and innovation on the battlefield remain a constant theme in trauma medicine.

These examples demonstrate that improving tactical care will continue to benefit medicine as a whole.

Advancements in trauma care have boosted the survival rate in modern combat to an unprecedented 90% as compared to 80% in previous conflicts. However, of those who do die in combat, most (around 77%) succumb to their injuries before they can reach a hospital.2 Therefore, it is critical that pre-hospital care is initiated immediately following an injury and that the most advanced techniques and equipment are utilized.

20 • The Medical Decoder • Spring 2016

Although many may never serve as healthcare providers in war, there is an underlying need to understand the warzones from which emergency management is evolving. This knowledge can be applied to a variety of masscasualty incidents whether they are the strategic, battlefieldlike emergencies seen at active shooting sites or major multivehicle accidents on highways.

For example, emergency physician Dr. Michael Neeki employed the skills that he learned during the Iran-Iraq war in the 1980s to aid the victims of the mass shooting last year in San Bernardino, CA. Dr. Neeki, a member of the Inland Valley SWAT team, was able to use his combat experience to serve and protect his community during the tragic situation.3 Combat care is constantly changing; however, it has been increasingly recognized that this care is effective not just in warzones, but in civilian medicine as well. Tactical Combat Casualty Care (TCCC) is

a system for the evaluation and health management of military personnel. While based on principles of general emergency care, TCCC includes special considerations for battlefieldspecific injuries such as gunshot wounds and blast trauma. TCCC was first developed and used in the mid-1990s by Special Forces units within the U.S. Military. Its subsequent success has led to its widespread civilian adoption.4 The primary focus of TCCC is to treat three preventable causes of death on the battlefield: life-threatening bleeding, tension pneumothorax (collapsed lung), and airway obstruction, and do so while employing effective combat tactics.

In the TCCC protocol, care is provided under three distinct phases: (1) care under fire, (2) tactical field care, and (3) combat casualty evacuation care. While providing care under hostile fire, providers must focus on defending the unit, controlling any major hemorrhage, and moving the casualty to safety.

Tactical field care varies by situational constraints (i.e.. time, hazards) but typically gives the heath care provider the opportunity to secure the airway, re-inflate a collapsed lung, and continue to control any bleeding.

Additionally, combat casualty evacuation care is typically more extensive because additional

supplies and personnel can be brought in with the evacuation team.5 More recently, these guidelines have been updated and modified for civilian use under the name Tactical Emergency Casualty Care (TECC). While the focus for care in TECC remains the same as its predecessor, variations were implemented to account for a diverse civilian population.

For example, TECC includes pediatric-specific guidelines that do not apply to military personnel, who are generally

“He who desires to practice surgery must go to war.”

- Hippocrates young to middle-aged adults.6 A group of physicians have formed the Joint Committee to Create a National Policy to Enhance Survivability from Active Shooter and Intentional Mass Casualty Events. This forwardthinking team works to evaluate responses to prior incidents and implement new evidence-based care for the future.7 Those who have taken first aid classes may recall that, until recently, tourniquets (devices for blocking blood flow to an injured extremity) were either

completely removed from protocol or considered to be a last resort. It was thought that applying a tourniquet would always require the amputation of the extremity to which it was applied. However, data from the battlefield and subsequent work by the Joint Committee has reinstated the use of tourniquets in civilian emergency medical care – such as the care provided by first responders in our communities.8 The increased interest in tactical medicine has made it an active avenue of research with implications for disaster response and general trauma care.

A major focus of this research is how to translate techniques from the battlefield to civilian healthcare systems. For example, clinicians in local hospitals are in dire need of new methods for handling major blood loss. One such battlefieldderived method is massive blood transfusion, in which a severely hemorrhagic patient receives greater than ten units of blood products within twenty-four hours.9 Physicians and scientists are now working to modify techniques for use in general trauma care. The results of these trials are published regularly in several journals, such as Special Operations Medicine and Prehospital and Disaster Medicine.

Training in tactical and

Human Interest • Volume 7 • 21

disaster medicine has taken a multi-faceted approach, with healthcare providers seeking education along all levels of the medical spectrum. Emergency medical services (EMS) agencies have been a driving force in the advancement of tactical medicine in the civilian world.

Both corporations and individual providers are preparing for incidents of intentional violence by developing response protocols and training Tactical EMS (TEMS) units. The state of New York has taken a major step towards readiness through programs at the State Preparedness Training Center (SPTC) located in Orisknay, NY. The SPTC offers an intensive three-day course for EMS providers and law enforcement officers, in which students are trained in advanced tactics and combat medical care.10 For undergraduate students interested in learning more about the field, involvement in EMS is a great way to gain handson experience. Additionally, medical students can engage in more formal training through electives in areas such as EMS and Disaster Medicine. Faculty at Rutgers-New Jersey Medical School have been evaluating methods to integrate terror medicine into the medical school curriculum at multiple phases such as orientation, foundations classes, organ systems classes, and electives.11 Opportunities for training in

tactical medicine are vast for current physicians, especially those specializing in emergency medicine. In a 2008 survey of emergency medicine residency programs in the United States, 18% offered their residents some form of exposure to tactical operations during either a dedicated tactical rotation or within EMS rotations.12 While we typically think of only emergency medical technicians (EMTs) and paramedics in the context of pre-hospital care, physicians also play an integral role in providing direction and supervision to the EMS system.

The protocols under which EMS

providers operate are typically developed and approved by emergency medicine doctors.

These physicians also often provide online medical assistance to field medicine providers via phone, radio, or in person. By maintaining contact with providers, physicians can suggest treatments that

22 • The Medical Decoder • Spring 2016

otherwise would not be administered in the pre-hospital setting.

Intentional violence, such as terrorist attacks and mass shootings, and natural disasters, including forest fires, tornadoes, and floods, may not be a pervasive part of every community.

However, every municipality must work to develop a plan for how they will respond to such incidents. This can start with local police departments and ambulance services training together to improve operational interactions during true emergencies. Additionally, hospitals can consider their ability to handle a sudden influx of severely injured individuals.

Eventually, conversations should occur between public safety officials and the general public regarding expectations during major incidents.

Physicians almost always face the possibility of being the only ones standing between a patient and death during these critical situations. By being prepared with a response plan and having a passion for driving the field of tactical medicine forward, they have the potential to make a difference in the outcome of mass tragedies.

For references, see page 27.

THE MENTAL HEALTH CRISIS OF SYRIAN REFUGEE CAMPS

By Emilie Touma

O

vercrowded, impoverished, and devoid of safe drinking water, Syrian refugee camp conditions are a topic of great concern. Since the Syrian Civil War began in 2011, it is estimated that over 240,000 people have perished in the conflict,while nearly 9 million Syrians have been forced to relocate to camps in Syria and neighboring countries.1,2 The inadequacies of these refugee camps, which include unsanitary living conditions, limited access to vaccinations, and poor-quality housing, often negatively affect the health of its residents. Research has shown that Syrian refugees suffer from high rates of emotional disorders including anxiety,

depression, and post-traumatic stress disorder (PTSD).3 Unfortunately, the topic of the mental health of Syrian individuals is often marginalized or omitted from the discussion of this international crisis. These health concerns pose a serious threat to the quality of life of Syrian refugees, and therefore demand immediate and comprehensive attention from all health care professionals.

health needs. The hardship begins with the journey from their native country. Many are forced to travel long distances to reach an available camp, often doing so without adequate food and water supplies. When they arrive at the camps after enduring the burdens of travel, they are met with unsafe conditions including insufficient shelter, high population density, and a lack of clean water.

Furthermore, struggles such as waiting in line at the water Effects of Living in a tap or bathing in makeshift Refugee Camp bathtubs can also have a negative effect on mental health.

For Syrians living in refugee For children, these stressors camps, the tough conditions pose the most serious threat as make it next to impossible to care the scant conditions frequently for their physical and mental contribute to disorders such as

Human Interest • Volume 7 • 23

depression, generalized anxiety disorder, and behavioral issues.4 Moreover, those who have already endured traumatic experiences before fleeing to refugee camps are at a greater risk for developing mental health disorders.

Torture, physical malformations, amputations, and the death of loved ones are all too familiar for refugees and can result in psychological vulnerability.

The most common disorders for those who have previously experienced such circumstances are PTSD and depression. PTSD occurs in people who have lived through shocking or dangerous events and exhibit vivid flashbacks, arousal sensitivity, and emotional numbness.5 Depression is defined as a mood disorder caused by an imbalance of neurotransmitters within the brain.

Because many Syrians have fled the nightmarish, war-torn conditions of their home country, both PTSD and depression are very common within the refugee community.

Biological Responses to Refugee Camp Environments

Emotional disorders make up about 54% of the mental health disorders affecting Syrian refugees.6 Out of this large percentage, the two most common disorders are depression and anxiety. Because these disorders are exhibited across a large population, the

biological basis of each must not be ignored.

Symptoms of depression, including apathy, guilt, hopelessness, and thoughts of suicide, are primarily controlled by three neurotransmitters – serotonin, norepinephrine, and dopamine.7 Together, these neurotransmitters act to control stress, regulate emotion, and drive physical desires, including hunger. When these chemicals are disrupted in the brain, the individual will most likely exhibit depressive symptoms.

Anxiety disorders have also been linked to neurological chemical imbalances. While scientists acknowledge that genetics play a role in the onset of this condition, anxiety that manifests later in life is viewed as a result of the surrounding environment.

The neurotransmitters that play the largest role in anxiety disorders are serotonin, norepinephrine, and gammaaminobutyric acid. It remains unclear if the imbalances appear first and result in the physical manifestations of anxiety, or if the imbalances are due to an inability to rationally react to stress.8 Many refugees also experience PTSD. Each individual responds to PTSD differently. However, it is widely acknowledged that this disorder results primarily in difficulty with emotional arousal, as well as impaired memory production. This is due to damage in areas such as the hippocampus — the part of the

24 • The Medical Decoder • Spring 2016

brain that plays a role in the creation of new memories.

Because PTSD can greatly affect biological, physical, and social abilities, if left untreated, this disorder can cause longterm issues. These include detrimental changes in the quality of life for the individual exhibiting the illness, as well as problems for friends and family of the individual who are indirectly affected.

Additionally, it is vital for there to be a greater focus on the general development of a child’s brain under stressful conditions. Because children experience dramatic cognitive development from the prenatal stage through puberty, the distressing environments of refugee camps can impact the anatomical and chemical makeup of a child’s brain.

When high levels of stress and anxiety are experienced over an extended period of time, increased levels of cortisol (a stress hormone) are detected in the brain. This prolonged hormonal imbalance during development can permanently damage the hippocampus, resulting in deficits in shortterm memory.

Furthermore, prolonged exposure to high levels of cortisol can lead to later complications in a person’s ability to regulate stress.9 In refugee camps, the combination of an unfamiliar environment, high population density, and overstimulation are the perfect storm of stressors that can cause permanent

neurobiological changes. For this reason, the mental state of children in refugee camps requires more research and must be placed at the center of the conversation in order to foster the growth of a healthy and productive generation of Syrians.

What is being done now and what is the future outlook for mental health in refugee camps?

While mental health issues for refugees may not yet be a popular topic in media coverage, it is an area of concern for many organizations. Recently, the International Medical Corps started a large-scale mental health initiative with the aim of bringing increased medical and non-medical professionals to refugee camps in Jordan, Turkey, Syria, Lebanon, and Iraq.

Additionally, they have started training local workers, religious leaders, and other highly regarded individuals to assist in a community-based support system.10 Other organizations such as Doctors Without Borders have also placed a greater focus on the mental health aspect of the refugee crisis.

Looking at specific mental health disorders from a biological and emotional standpoint can aid in developing treatment and prevention initiatives for Syrian refugees.

For

In refugee camps, the combination of an unfamiliar environment, high population density, and overstimulation are the perfect storm of stressors that may cause permanent neurobiological changes. emotional disorders such as depression, anxiety, and PTSD, cognitive behavioral therapy is a recommended form of treatment. Access to antidepressants would help in treating such disorders, but current funding and accessibility require restructuring in order to provide sustainable aid.

Additionally, it could also be beneficial to take a holistic approach to this issue. For those suffering from mental disorders, the presence of a strong support system may be helpful in reducing symptoms and combating further progression of the illness. For young children especially, a strong relationship with parents and family members may increase future resilience against mental illness.

So, what does the future hold for the mental health of Syrian refugees? While the longterm effects are not yet clear,

refugees must rely on their community and the efforts of international organizations to provide some relief. With the recent emergence of conversations regarding Syrian refugees on large media outlets, one could expect to see an increase in dialogue regarding the wellbeing of the affected individuals.

Although the extent of mental harm caused by refugee camps is unpredictable, some reassurance can be found in the recognition of this issue and in the subsequent actions of organizations and healthcare providers in the region.

Raising awareness and educating others about this pressing topic will be key steps toward protecting and improving the mental health of Syrian refugees.

For references, see page 27.

Human Interest • Volume 7 • 25

Cover

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Medicine Through Statistics

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Lighting Upon Solutions: Optogenetics in Brain Research

1. Boyden ES. A history of optogenetics: the development of tools for controlling brain circuits with light. F1000 Biology Reports 2011;3.

2. Boyden ES, Zhang F, Bamberg E, Nagel G, Deisseroth K. Millisecond-timescale, genetically targeted optical control of neural activity. Nature Neuroscience 2005;8:1263-8.

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4. Adamantidis A, Arber S, Bains JS, et al. Optogenetics: 10 years after ChR2 in neurons—views from the community. Nature Neuroscience 2015;18:1202-12.

5. Krook-Magnuson E, Soltesz I. Beyond the hammer and the scalpel: selective circuit control for the epilepsies. Nat Neurosci 2015;18:331-8.

6. Krook-Magnuson E, Armstrong C, Oijala M, Soltesz I. On-demand optogenetic control of spontaneous seizures in temporal lobe epilepsy. Nat Commun 2013;4:1376.

7. Krook-Magnuson E, Szabo GG, Armstrong C, Oijala M, Soltesz I. Cerebellar Directed Optogenetic Intervention Inhibits Spontaneous Hippocampal Seizures in a Mouse Model of Temporal Lobe Epilepsy. eNeuro 2014;1.

8. Paz JT, Davidson TJ, Frechette ES, et al. Closed-loop optogenetic control of thalamus as a tool for interrupting seizures after cortical injury. Nat Neurosci 2013;16:64-70.

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12. Reinbothe TM, Safi F, Axelsson AS, Mollet IG, Rosengren AH. Optogenetic control of insulin secretion in intact pancreatic islets with β-cell-specific expression of Channelrhodopsin-2. Islets 2014;6:e28095.

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14. Park SI, Brenner DS, Shin G, et al. Soft, stretchable, fully implantable miniaturized optoelectronic systems for wireless optogenetics. Nat Biotechnol 2015;33:1280-6.

15. Russell, Lloyd, and Häusser Lab. Optogenetics. N.d. University College London, London.

16. Boyden, Ed. Sputnik Animation. N.d. McGovern Institute for Brain Research at MIT, Cambridge.

A Bad Case of the School Nurse

1. Mithers, C. (2011, April 04). Are school nurses disappearing? Retrieved February 16, 2016, from http://www.cnn.com/2011/ HEALTH/04/04/school.nurse.shortage.parenting/ 2. Children’s Mental Health – New Report. (2015, November 12). Retrieved March 15, 2016, from http://www.cdc.gov/features/ childrensmentalhealth/ 3. Bibb, S. (2016, February 29). Sandra Bibb: Nursing shortage in the United States. Retrieved March 15, 2016, from http://www. kansas.com/news/business/health-care/article63231717.html 4. School Nurse Shortage May Imperil Some Children, RWJF Scholars Warn. (2013, December 12). Retrieved February 16, 2016, from

26 • The Medical Decoder • Spring 2016

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http://www.rwjf.org/en/library/articles-and- news/2013/12/School-Nurse- Shortage-May-Imperil-Some- Children.html 5. Juarez, D. (2013, November 08). Asthma and Allergies on the Rise in the U.S. Retrieved March 15, 2016, from http://www. healthline.com/health-news/children- allergies-and-asthma-on- the-rise- 110813#1 6. DeNisco, A. (2014, January). School nurse shortages grow as budgets shrink. Retrieved March 15, 2016, from http://www. districtadministration.com/article/school-nurse-shortages-grow- budgets-shrink 7. Recruiting Men into Nursing School - Minority Nurse. (2013, January 29). Retrieved February 16, 2016, from http://minoritynurse. com/recruiting-men- into-nursing- school/ 8. Amid Nursing Shortages, Schools Employ Strategies to Boost Enrollment. (2000, June). Retrieved February 14, 2016, from http:// www.aacn.nche.edu/aacn-publications/issue-bulletin/boost-enrollment 9. DeGrandpre, Z. (2015, December 09). How to Become a School Nurse. Retrieved March 15, 2016, from https://www.innerbody. com/careers-in- health/how-to- become-school-nurse.html

Excellent Care in Extenuating Circumstances: Tactical & Disaster Medicine

1. Davis, Henry Smith. History of Medicine. Chicago: Cleveland, 1907. Print.

2. United States. Defense Health Board. Office of the Assistant Secretary of Defense Health Affairs. Combat Trauma Lessons Learned from Military Operations of 2001-2013. N.p.: n.p., n.d. Web. 3. Gupta, Sanjay. “San Bernardino Doctor Was First Responder.” CNN. Cable News Network, 5 Dec. 2015. Web. 4. Butler, Frank K., and Lorne H. Blackbourne. “Battlefield Trauma Care Then and Now.” Journal of Trauma and Acute Care Surgery S5 73.6 (2012): S395-402. Web. 5. Butler, Frank K., and John Hagmann. “Tactical Combat Casualty Care in Special Operations.” Military Medicine S1 16.1 (1996): n. pag. Web. 6. Callaway, David W., E. Reed Smith, Jeffrey S. Cain, Geoff Shapiro, W. Thomas Burnett, Sean D. McKay, and Robert L. Mabry. “Tactical Emergency Casualty Care (TECC): Guidelines for the Provision of Prehospital Trauma Care in High Threat Environments.” Journal of Special Operations Medicine 11.3 (2011): 104-22. Web. 7. Jacobs, Lenworth M., David S. Wade, Norman E. Mcswain, Frank K. Butler, William P. Fabbri, Alexander L. Eastman, Michael Rotondo, John Sinclair, and Karyl J. Burns. “The Hartford Consensus: THREAT, A Medical Disaster Preparedness Concept.” Journal of the American College of Surgeons 217.5 (2013): 947-53. Web. 8. Kalish, Jeffrey, Peter Burke, Jim Feldman, Suresh Agarwal, Andrew Glantz, Peter Moyer, Richard Serino, and Erwin Hirsch. “The Return of Tourniquets: Original Research Evaluates the Effectiveness of Prehospital Tourniquets for Civilian Penetrating Extremity Injuries.”JEMS: Journal of Emergency Medical Services 33.8 (2008): 44-46. Web. 9. Murphy, Colin H., and John R. Hess. “Massive Transfusion.” Current Opinion in Hematology 22.6 (2015): 533-39. Web. 10. “SPTC CityScape Debuts with Advanced Active Shooters Scenario (A2S2) Course.” SPTC News. State Preparedness Training Center, 21 Oct. 2014. Web. 11. Cole, Leonard A., Katherine Wagner, Sandra Scott, Nancy D. Connell, Arthur Cooper, Cheryl Ann Kennedy, Brenda Natal, and Sangeeta Lamba. “Terror Medicine as Part of the Medical School Curriculum.” Frontiers in Public Health 2 (2014): 1-4. Web. 12. Bozeman, William P., S. Brock Blankenship, and James E. Winslow. “Resident Involvement in Tactical Medicine.” The Journal of Emergency Medicine 34.3 (2008): 338-39. Web. 13. “Tactical Medicine Fellowship.” Johns Hopkins Medicine. Johns Hopkins University. Web.

The Mental Health Crisis of Syrian Refugee Camps

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3. Hassan, G, Kirmayer, LJ, Mekki- Berrada A., Quosh, C., el Chammay, R., Deville-Stoetzel, J.B., Youssef, A., Jefee-Bahloul, H., BarkeelOteo, A., Coutts, A., Song, S. & Ventevogel, P. Culture, Context and the Mental Health and Psychosocial Wellbeing of Syrians: A Review for Mental Health and Psychosocial Support staff working with Syrians Affected by Armed Con ict. Geneva: UNHCR, 2015.

Available at: http://www.unhcr.org/55f6b90f9.pdf 4. Unite For Sight. (n.d.). Retrieved March 20, 2016, from http://www.uniteforsight.org/refugee-health/module2 5. Post-Traumatic Stress Disorder. (n.d.). Retrieved March 20, 2016, from http://www.nimh.nih.gov/health/topics/post-traumaticstress-disorder-ptsd/index.shtml#part_145371 6. Hijazi, Z., & Weissbecker, I. (n.d.). SYRIA CRISIS Addressing Regional Mental Health Needs and Gaps in the Context of the Syria Crisis. Washington DC: International Medical Corps.

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References • Volume 7 • 27

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