Pulse Magazine Winter/Spring 2015 by Western Communications, Inc.

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Healthy Living in Central Oregon

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Ryan Brennecke JoeKline

FDA aims to lift blood donation ban on gay men

Meg Roussos Andy Tullis

• Corrections Healthy Living in Central Oregon

Since we reported about the delicate balance in our nation's blood supply in the Winter/Spring 2012 edition of Pulse, the U.S. Food and Drug Administrationannounced plans to recommend a change in the blood donor deferral period for men who have sex with men. In December 2014, FDA officials said they would overturn the lifetime ban and replace it with a one-year deferral since the last sexual contact. The agency has also put in place a new national blood surveillance system that will help monitor the effect of the policy change. All donated blood is tested for HIV, but the test cannot detect HIV 100 percent of the time. The estimated risk of contracting HIV from a unit has been reduced to about 1 per 2 million transfusions. The largest risk exists within what's known as the "window period," immediately after infection when the donor may not have detectable levels of the virus or antibodies. The agency plans to draft guidance for the change in policy and allow for a comment period before finalizing the new rules. — Markian Hawryluk

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Contents l HIGH DEsERT PULsE

COVER STORY ELECTRONIC HEALTH RECORDS Health authorities say they'll revolutionize

JAKE SEI OVER Spending IIhistimeonboard 'I

medicine, but some docs worry they get in the way.

FEATURE SYNDROME AND ALZHEIMER'S 22 DOWN The same brain biology might cause both, and researchers hope to learn more.

S'N/X v(Hi2

DEPARTMENTS

g}gg+i rj 4 Crr'rllr • QSZt 2 Cl'I r.rr'rrlr f EBEI-j'Cl-lo'C rr~r r

2 UPDATE Blood donation ban could be lifted for gay men. 'l2 PROFILE Sponsored skateboarder Jake Selover

SKI WAX The right coat for your skis

benefits from a dedicated family.

16 JOB Forensic nurses are responsible for far more than just comforting victims.

20 GEAR Which (ski) wax? 32 SNAPSHOT Skateboarding at Ponderosa READY 34 GET Hike the Pacific Crest Trail 36 TIPS Thinkyou know how to brush your teeth? (Don't worry, we'll tell you.) 40

PICTURE THIS Anatomy of a concussion

PACIFIC CgESTT AI L What to knog and wIhat t 'bring

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COVER DESIGN:CARLI KRUEGER CONTENTS IMAGES, FROMTOP: ANDYTULLIS, JOE KLINE, ANDY ZEIGERT GREGCROSS

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THE WAY OF THE BRUSH Ge tthemost out of your twominutes

CoverstoryiELEcTRDNlc HEALTHREcoRDs

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The advent of electronic health records promises to change the face of medicine, but some worry the cure might be worse than the disease BY TARA BANNOW

r. Eden Miller's tiny clinic in Sisters closes at 5 p.m., but her workday is far from over. The family practice physician, who works for High Lakes HealthCare, says some days she won't be done for another four hours after the "closed" sign goes up. That's because she has to write down notes from each of her patient visits that day. Later, a medical assistant will enter all that information into the clinic's electronic health records (EHR) system, a vast database that contains patients' medical information, including their demographics, diagnoses, medications and family history. Lots of doctors just type in that information while they're sitting with their patients, and many have experienced this firsthand. But Miller doesn't want to do that. She wants to make eye contact with her patients. She wants to maintain relationships. And she doesn't want to miss the more subtle things patients don't say, but that reveal themselves in facial expressions or movements. "I sacrifice my life to be able to spend more time with patients," she said. The rise of EHRs is transforming the practice of medicine. Whether that evolution has been good or bad depends on who you talk to. An estimated 8 in 10 physicians now use them. The federal government hails EHRs as a tool for collecting massive amounts of valuable data and, once the kinks are worked out,

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for ensuring patients' records follow them seamlessly as they move from one provider to another. In theory, it sounds like just the thing that could make the health care system more efficient (no more faxes from office to office), safe (no unsafe medication combinations) and population-centric. But many doctors say so far, it hasn't worked out that way. They say the systems available are hard to use, take up a significant amount of their free time, make medicine less personal and are expensive to implement and maintain, often requiring new staff members just to enter data. And despite the promises of benefits to patients, some doctors say EHRs, by and large, aren't having much of an impact yet — especially in Central Oregon, where very few EHRs currently have the ability to share data, a work in progress both locally and nationally. Local doctors, like Miller and Dr. Steve Mann, High Lakes Health Care's medical director, say they each know several doctors who've gone into retirement early because EHRs had made their practices more difficult. "Basically, they worked as hard as they could for a year or two to adapt and basically they said, 'That's it. I'm done. I wasn't planning to retire, but I no longer have a passion for medicine,"' Mann said. "It kind of killed their career." Miller isn't afraid to voice her frustration over EHRs. She estimates

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ILLUSTRATION BYCARLIKRUEGER

for every 10 minutes she spends with a patient, she spends another 20 documenting that visit. For that to happen, she said, doctors must either shorten their time with patients b e c ome "door handle docs" who never let go of the door handle o r s acrifice their own free time to enter data into their EHRs. Miller has chosen the latter. "I now spend more time with either dictation, clerical worl< or data entry than I do with the patient," she said in a meeting in her office that doubled as her lunch hour. "It now outnumbers it."

Not user-friendly In an era in which glasses allow wearers to scan the lnternet, printers produce human cells and video game characters can seemingly pop out from the screen, lots of doctors say they're miffed by the clunl<iness of today's EHR systems. A significant number of medical professionals complain about how arduous it can be to perform simple functions in their EHR systems, and the casualty of such unwieldy technology winds up being their free time. On average, family practice physicians report having lost 48 minutes per day or four hours per five-day worl< weel< of free time to their EHRs, according to a November 2014 study in the Journal of the American Medical Association lnternal Medicine. For some doctors, lil<e Miller, it's even more than that.

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Dr. Bill Reed, an emergency physician at St. Charles Bend, tal<es on a salty tone when he explains the unpleasant thing he calls "mouse miles," the amount of area his cursor must travel across his computer screen just to enter simple data about a patient. A clicl< at the bottom of the screen to order a medication, another screen pops up, you have to go to a different screen to print, confirm the print, and so on. "It is really hard on the brain," he said."Whereas, with your phone, sending a text is really easy. It's all right here in this one little tiny space. It's just designed better. That piece of it hasn't really tricl<led down to the end user yet, and maybe it will in 10 years once they've fine-tuned it." The proliferation ofless than stellar EHR platforms is often traced bacl< to the federal government's nearly $30 billion push for widespread a n d swift E H R adoption. The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, enacted under the American Recovery and Reinvestment Act, or the stimulus, created an enticing platter of financial incentives for clinics, practices and hospitals that adopted EHR platforms. That money began to flow in 2011, and by February 2014, more than half of eligible providers had received $21.6 billion in incentive payments, according to the LI.S. Centers for Medicare 8 Medicaid Services, which administers the payments.

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The payments are part of the government's so-called Meaningful Use program, which is divided into stages providers must prove they're at in order to receive payments or, in the future, avoid penalties. To reach Stage 1 of the program, providers must prove they're using EHRs to perform a number of tasks, including ordering medications, maintaining active patient diagnoses, medication and allergy lists, entering summaries for each office visit and providing patients electronic copies of their health information. Entering Stage 2 requires having the ability to share EHR records with other providers, regardless of the platform they're using. CMS data released in late 2014 showed that less than 17 percent of U.S. hospitals had reached Stage 2, and less than 38 percent of eligible hospitals had met either Stage I or 2. Beginning Jan. 1, Medicare-eligible providers who aren't at Stage 1 or 2 could be seeing less reimbursement from CMS for providing services to patients. St. Charles Bend is among the small proportion of hospitals that met Stage 2 requirements in 2014. Its other three hospitals are at Stage 1. Bend Memorial Clinic has met both Stage I and 2 requirements. Mosaic Medical, another large Central Oregon provider, has met Stage 1 requirements. The American Medical Association, along with a handful of other health care organizations, has repeatedly urged CMS to give providers more time to meet the requirements, reasoning that not doing so would lead to growing dissatisfaction with EHRs and disenchantment with Meaningful Use. Meanwhile, there's another important deadline on the horizon for providers: the implementation of a new massive set of billing codes that cover everything from diseases, symptoms and causes of injuries. It's called ICD-10 (short for International Classification of Diseases), and it's scheduled to replace its predecessor, ICD-9, on Oct. I, several years later than originally intended. Congress has pushed back the ICD-10 implementation several times, and some believe it could do so this year, too. EHRs and billing systems are intimately connected because the diagnoses and treatments entered into EHRs are used to generate bills for that care. Lots of providers are worried about the transition to ICD-10, which is significantly more detailed than ICD-9, in part because they could miss out on payments if they can't account for them in their billing systems. The ICD-10 transition is mandatory. Failing to adopt EHRs, by comparison, carries financial penalties for providers. The AMA has urged the government to repeal ICD-10, which it argues will be extremely expensive for providers. Unlike its position on EHRs, the AMA says allowing providers more time to implement ICD-I0 won't solve the problem. "The AMA haslong considered ICD-10 to be a massive unfunded mandate that comes at a time when physicians are trying to meet several other federal technology requirements and risk penalties if they fail to do so," AMA President-elect Steven J. Stack wrote in a statement. Money has indeed proven to be effective bait for getting providers to adopt EHR platforms. Sixty-two percent of doctors who adopt-

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Most does say EHRs reduee free time Q:What impact, ifany, has using EHRs had on your freetime? More free time

Much less free time

2.2%

22.1%

Somewhat more free time

12.7%

Somewhat less free time Same amount of free time

37.2%

25.8%

Source: Journal ofthe American Medical

ANDYZEIGERT

Association Internal Medicine, November 2014

ed EHRsbetween 2010 and 2013 named money as theirtop reason for doing so, compared with 23 percent who adopted them in 2009 or earlier, according to a December 2014 study by the Office of the National Coordinator for Health Information Technology, a division of the U.S. Department of Health and Human Services. But some argue it's been a little too effective and has encouraged manufacturers to push out products that weren't ready for prime time. "The government says, 'Carrot now, stick later, and here's all this money,' and the software companies are like, 'We're in. We have a product and we'll sell it to you,"' Reed said. Dr. James Verheyden, an orthopedic surgeon with The Center Orthopedic 8 Neurosurgical Care 8 Research in Bend, said despite all of the money the government is offering to give doctors and threatening to take away depending on their EHR use, there simply doesn't yet exist an EHR system that's economical, efficient and that integrates with other EHR systems. "In some ways, they've got the cart before the horse," he said.

Fast-food EHRs For some of Central Oregon's biggest providers — St. Charles Health System and Bend Memorial Clinic — such shortcomings have proven especially time-consuming and costly because they've chosen to abandon existing EHR systems for entirely new ones. St. Charles' Bend and Redmond hospitals have switched EHR platforms twice and even completed an internal investigation to determine why their third system, Paragon, was causing so much frustration for providers. « A lot of our physicians, and a lot of them here on the Bend campus, felt that it was just very inefficient and it caused them extra time," said Dr. Mary Dallas, St. Charles'chief medical information officer. Despite the complaints, though, St. Charles plans to stick with Paragon rather than avoid the massive task of transitioning to yet another system, which Dallas said is a multiyear, labor-intensive process that involves intensive training for caregivers. "It's actually almost harder to switch EMR vendors than it is to start

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from paper to electronic transition," she said. BMC, which first implemented an EHR system called Allscripts Healthcare Solutions in 2006, is in the throes of transitioning to another platform offered by Epic, a leading EHR vendor. The provider is currently ensuring all of its caregivers and staff members agree on a design — a process that began in the summer of 2014 — and plans to go live with the new system in August, said Dr. David Holloway, BMC's chief medical officer. Holloway said he disagrees that EHR systems were rushed out before they were perfected, especially when it comes to a system like Epic, which has been around for years. He said creating systems to handle data for an industry where every provider does things differently and every patient is unique is inherently going to be tricky. "You start doing a formula for how complex this is, it's just unbelievable," he said. "So how do you create a technology, an electronic record, that helps manage all of that? I just think it's tougher than everybodythought." Several physicians interviewed cited the multistate, California-based health system Kaiser Permanente as an example of a provider that's got EHRs down to a science. Its records are thorough and can be easily shared with other doctors in and out of their network. The downside, though, is that the records tend to look like pages upon pages of check boxes rather than a narrative explanation of the patient encounter. Mann, a family physician and medical director for High Lakes Health Care, said some electronic patient charts are more like "data warehouses." He said it's not uncommon for him to read through six pages of a patient's record and not fully understand what happened. "It's just page after page of data points, but nothing that creates a summary saying, 'This is how this process has evolved over the past year and here's what the patient's experience is and here are the different ideas I have about how to treat it,'" he said. "You can't data point those things." High Lakes doesn't yet have the ability to send patient records across providers using its EHR system, so Mann still faxes his notes in narrative format to other doctors who see his patients. Once the provider is able to tap into a community portal being developed that will allow providers to enter one another's patient records, that narrative will likely go by the wayside, and other providers will see only the patients' vital signs, diagnoses and physicians' assessments. Miller, of High Lakes in Sisters, said templated charts — the ones with only check boxes — tend to leave out the more subtle, yet important things. For example, if the doctor checked the patient's heart, she may have checked in the patient's record that the rhythm was regular. But perhaps the patient flinched when the doctor put the stethoscope on her chest and the doctor asked the patient whynone of that would be in the chart, she said. "You don't get any flavor," Miller said. "It's like Burger King or fast food."

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Dan McCarthy, an administrator for Adaugeo Healthcare Solutions, a company that provides local clinics with EHR and overall practice management, including billing and administration, said health care is evolving between two extremes. At one extremethe one society is slowly moving away from — is the fee-for-service world, in which a doctor might churn through 50 patients per day in order to be reimbursed for services. The move toward EHRs, however, permits a broader focus on preventative health and evaluating providers based on quality measures. "Now the extreme would be pure data and you're more of a data analyst than a provider," McCarthy said. The truth will be somewhere in between, he said.

Lackof compatibility In a perfect world, patients would be able to visit their primary care provider, hospital and a specialist, and each one would be able to instantly call up that patient's complete medical history, including all the providers she saw over the past several years. No longer would the patient need to strain to remember the last time she went in for her annual checkup, nor would she have to guess at how many milligrams of a certain medication she was taking, nor would she need to recall which grandparent died of lung cancer. All of that information would follow her there. And with those databases packed full of demographic information comes the opportunity to harness vast amounts of data about the health of populations to figure out where improvements can be made. That's the dream of EHRs. At the moment, though, it's far from reality. "That's just a joke," said Dr. Tim Hanlon, a Pendleton cardiologist who used to work at BMC. "That does not exist." If one were to chart out all the different EHR platforms operating in Central Oregon, they'd get a massive quilt sprinkled with a wide variety of players. Dallas, of St. Charles, guesses there are at least 15 different EHRs operating locally. "Different vendors, different databases, different systems, and none of them talk directly to each other," she said. "They're all separate, little, silo (electronic medical records)." And so far, the vast majority of those EHRs cannot share information when a patient moves from one provider to another. Often, it's done the old-fashioned way: fax or email, local providers say. But work is underway to bring the technology to Central Oregon that will connect those independent EHRs. The relatively new group spearheading the task is called the Central Oregon Health Information Exchange. Executive Director Pat Bracknell, the group's only paid staff member, just came on board in September. She's got 15 years of consulting experience in implementing and integrating EHRs. Until now, the work has been mostly developing privacy and security rules, which are currently under legal review. February is when the real fun began: Implementing the information exchange technology and starting to load data into it, Bracknell

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said. The group, which consists of eight local providers, including St. Charles, BMC, Mosaic Medical and the Central Oregon Independent Practice Association, already has chosen a software vendor and has an idea of how it wants the technical architecture to work. When all is said and done, the information exchange will be able to help providers access their patients' records from other providers the patients have gone to. Whether that can truly happen depends a lot on whether participating providers have EHR systems that can accept data from other interfaces, Bracknell said. The real tricky part when it comes to interoperability is making sure the data identifies each patient across the various records that are roped into the system. Some EHRs will use different identifiers to denote different patients, and it's sometimes tricky to develop an algorithm that will ensure each patient's records are merged together, Bracknell said. But to some extent, the success of a project like the information exchange is out of the hands of the people leading it. It depends on other, perhaps smaller, providers throughout the community agreeing to be a part of it. And it means they need to have their own EHRs up and running. "Without the full picture, there is going to be holes in that view," Bracknell said. "When we manage a population, we really want to manage that entire population and all of their records, so it will be important to us that we try to engage as many providers as we can. I'm not going to say we're going to fail completely if we don't have every single provider, but I'm also not going to say that, 'Eh, we don't need them.' I mean, that's just not true. We do. We need them." The U.S. Department of Health and Human Services, also eager to see interoperability succeed on a national scale, in December 2014 issued its draft Federal Health IT Strategic Plan 2015-2020, which was open for comments until early February. Soon, HHS will use the feedback to release a broad federal strategy, called the Nationwide Interoperability Roadmap, that will define how the federal government and private sector will approach sharing health information through EHRs. In Central Oregon, the information exchange is currently funded by a grant from the local coordinated care organization, the group that oversees care for the Oregon Health Plan population, the state's version of Medicaid. The funding model for the future hasn't yet been determined; one potential avenue would be providers paying fees to use the service, or it could run on donations, Bracknell said. McCarthy, of Adaugeo Healthcare Solutions, is a board member of the information exchange. He said being a part of the information exchange requires providers â&#x20AC;&#x201D; many of whom are for-profit entities â&#x20AC;&#x201D; to focus on something beyond their own bottom lines. "You have to take it as a good for the community," he said. "That's what makes it so difficult for all of us to get together."

that the exam he had performed on Hanlon had turned up normal. "I said to this other doctor, 'How did you know my exam was normal, because the first doctor never touched me,"' Hanlon said, "and he said, 'Well, it's all here in your EHR.' I said, 'That never happened. None of that ever happened.'" Hanlon's experience illustrates yet another shortcoming of today's EHRs: They make it easier than ever to commit fraud. In the past, doing so would have required a trail of lies and fraudulent note-taking. Today, Hanlon said, it's just a matter of checking boxes in the EHR. "Now, you click one button, it autopopulates an EHR, and you may not have done any of that," he said. "This goes on all the time." A January 2014 report by the HHS Office of Inspector General warned that certain EHR documentation features, if poorly designed or used inappropriately, can make it easier to commit health care fraud, which is estimated to cost between $75 billion and $250 billion annually. The OIG report placed specific emphasis on an EHR capability called copy-pasting, or cloning, which allows providers to replicate information from one note and paste it into another location. Doctors, nurses or other providers often do this speed up the process, but fail to ensure the information is updated for accuracy, which can result in inappropriate billing to patients or insurance companies, the report found. EHRs also make it easier to commit a form of fraud called overdocumentation, or inserting false or irrelevant documentation in order to bill for services that weren't performed. Some technologies let the user build templates that autopopulate fields, generating extensive documentation with a single click. Despite all this, the OIG found very few EHR vendors had stepped up their policing of EHR documentation. Further, not all of the vendors surveyed reported even having the capability to determine whether copy-pasting or overdocumentation had occurred among their clients. And such habits are becoming increasingly common, especially among medical school students, residents, and attending physicians. In fact, an examination of the notes of residents and attending physicians found 82 percent of residents and 74 percent of attending physicians had copied at least 20 percent of the notes from previous ones, according to a February 2013 study in the journal Critical Care Medicine. "The process of training is being lost," Mann said."Everybody is just kind of cutting and pasting off of each other's work and not documenting what they're actually seeing." High Lakes is among more than 80 providers that contract with Adaugeo Healthcare Solutions to manage their practices, including administration, billing, insurance contracts and a shared EHRsystem. McCarthy, Adaugeo's administrator, said his company has a control in place designed to prevent chart cloning. Certified coders reFraudmade easier view all of the providers' encounters before claims are submitted to Hanlon, the Pendleton cardiologist, recalls a time when he visited CMS, which has condemned chart cloning. So, for example, if the a physician and was shocked to subsequently learn from another coders see that a physician submits a claim for a chart note that physician that the first doctor had recorded in his patient records looks exactly the same as his previous four notes, they would go

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ANDYTULLIS

Dr. James Verheyden, middle, talks to patient Ward Bolster about his broken finger while medical scribe Brandon Georges types Verheyden's observationsinto his EHR portal during a January office visitat The Centerin Bend.

back to that physician and question whether he actually performed the service, McCarthy said. "That's a control that has to be in place," he said."Otherwise, the temptation tojust copy and send is too great. People will abuse it." Fraud isn't the only concern that grows along with EHRs. As the

prospect of linking many EHRs together starts to look more feasible, some have raised questions about whether providers can assure the information can be kept secure. Despite a federal privacy law designed to protect patient health information, numerous security breaches have taken place in recent years, including stealing patient

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information for financial gain or using the information to submit insurance claims or obtain medical treatment. Since enforcement of the Health Insurance Portability and Accountability Act began in 2003, HHS has received more than 100,000 complaints of privacy infringements regarding patient medical records. Not all of those involved EHRs, but HHS says a lack of administrative safeguards around electronic patient information is among the top compliance problems it sees. Bracknell, who heads the Central Oregon Health Information Exchange, said the system her organization will use to link EHRs is the same oneused by the U.S.Department ofDefense. "We feel like it's very secure," she said. "It's not something that we really plan to grant access to everybody and their brother to."

Patient experience The considerable benefits of having reams of data on countless patients comes at a considerable price: Someone needs to enter it all into a computer. That often ends up being the doctor, who must check boxes indicating whether a patient smokes and whether there is a firearm in the patient's home â&#x20AC;&#x201D; even if the visit is for, say, trouble sleeping. "I went to medical school to enter in smoking data? Is that the best use of my time?" said Miller, of High Lakes. Aside from being a burden on providers, it's also having an impact on the patient experience. Often, patients are separated from their doctors by a computer screen, and, in some cases, that's been detrimental to the patient-provider relationship. Eachproviderhas his orherown way of managing the new EHR responsibilities. Some enter the data into the computer while the patient is in front of them. Some have a medical assistant, nurse or other provider enter the information before the physician enters the room. Some have what are called medical scribes, trained information managers who sit in during patient visits and document the encounters, including entering EHR data, in real time. Others write down notes after the visit and enter them into the computer after the patient has left. There are other tactics, too, such as recording notes about patients into tape recorders during a visit and entering them into the system later. Some providers, like Miller, have decided that a screen separating them from their patients just won't do. To her, looking at patients while they're talking is important. She makes eye contact during visits, remembers their discussions, writes down notes after the visits and, at the end of the day, reads the notes into a voice recording. Someone else, sometimes a medical assistant, then enters that information into the EHR system. Miller estimates for every 10 minutes of time she spends with a patient results in 20 minutes of clerical work at the end of the day. "Patients love it. Why? I can listen to them," she said."I can hear them. Electronic health records are awesome for data. There is nothing that compares. The challenge is, who puts the data in? It takes time to put it in."

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When The Center went live with its EHR system, Allscripts, in August 2008, Verheyden, the orthopedic surgeon, estimates he spent between 300 and 400 hours setting up customized notes and templates to make his practice more efficient. But even with all that front-end work, he found himself spending an average of six minutes per patient visit documenting the visit, regardless of how short the visit itself was. "If I were to spend 10 minutes with a patient, it would take me six minutes to document that. It's a tremendous amount of effort." Four years ago, Verheyden became one of the first physicians in Central Oregon to make scribes a regular part of his practice. He estimates he's gone through seven or eight scribes at this point, but he's now been using the same person for the past 10 months, a fast typist who used to work in an emergency room and aspires to one day go to medical school. Using a scribe allows Verheyden to walk into the room with a patient, make eye contact, and have a conversation without worrying about writing anything down. The scribe sits at a computer behind him and enters all of the notes, diagnoses and other necessary information into the EHR. Verheyden says his observations about the patients out loud so the scribe can enter them into the computer. At first, he said he was nervous that might offend patients, but he's come to realize they appreciate it. "Even though my visits usually don't take too long, patients feel like they've had a good visit and are very appreciative," Verheyden said. There's another important, easily overlooked benefit of looking at a patient during a visit echoed by several physicians interviewed for this article: They're able to pick up on the subtle things patients don't always say, but show in their mannerisms, gestures or appearance. "If they stand up or sit down, how they move, how they walk," Verheyden said. "What they do with their hands as I examine them for scars or deformities." Hanlon, the Pendleton cardiologist, recently saw a patient complaining of chest pain. During their discussion, he noticed a change in her facial expression. "I said, 'What are you feeling right now? What's going on?' She started bawling," he said. "Had I been looking at a computer screen, I would have missed that. I wouldn't have realized how scared this woman was. That changed my whole approach of what I'm going to do with her. I have to prove to her that she doesn't need to be scared." Today,Verheyden said he' s down to two minutes of documentation per patient visit, and he sounds like walking advertisement for scribes "It's the single best thing I've done for my personal practice and from a free-time standpoint since I've started practicing," he said. But hiring someone to enter that information costs money. Verheydentakeson scribesasa personalexpense,one he sayshe'swilling to pay to improve his quality of life. Dr. Michael Murphy, the CEO of ScribeAmerica, a leading provider of medical scribes in the U.S., said, scribes are paid between $10 and

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$20 per hour. Miller said she'd love to have a scribe, but wouldn't be able to afford one. The rise of EHRs has dramatically strengthened demand for scribes. Between 2004 and 2009, ScribeAmerica went from no clients to 32 hospitals on its roster, Murphy said. In 2009 — the year that saw the passage of the federal stimulus and, with it, HITECHScribeAmerica' s demand took off.Today,the company has close to 600 hospital clients, Murphy said. Murphy said he understands the value of collecting the data EHRs contain, but the systems are not intuitive to the practice of medicine, and have turned physicians into "data entry specialists." "I don't want to say they're doing more harm than good, but they're causing a lot of difficulties," he said. "What scribes are really there for is to really put the physician back in front of the patient and allow them to just focus on what's really important: medical decision-making." Central Oregon Emergency Physicians, which employs many of the emergency physicians that staff St. Charles hospitals, contracts with a company that provides medical scribes to its physicians, said Reed, the emergency room physician who works at St. Charles Bend

but is employed by COEP. Much of the scribe industry's clients are from the emergency setting. At ScribeAmerica, 97 percent of revenue last year came from emergency medicine, Murphy said. Reed's experience with scribes was much different than Verheyden's. While he found them to be motivated and pleasant to work with, he couldn't get over the discomfort of having someone elsesomeone who didn't go to medical school — controlling his charts. "They don't know what the pitfalls are of saying things one way versus another and making sure you document this, and it's OK to skip that part," Reed said. "There are accuracy issues, flavor issues to the story." Reed used scribes for about six months, and during that time, he would spend time after every shift going over the scribe's work to make sure it was accurate. Verheyden said he still goes back after every visit and reviews his scribe's notes to make sure nothing was misinterpreted, but that still takes a lot less time than not having the scribe at all. He said scribes take patients, and generally a couple months of training on the specific system you use and jargon of your specialty. "A lot of it is really finding a good scribe," he said, "because it's just like every profession. There are some that are very good, and some that are OK."•

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Jake Selover rides as a sponsored snowboarder and skateboarder

BY DAVID JASPER

hether participating in traditional, team-oriented sports or a more individualistic activity such as snowboarding, it's critical for a teen to have supportive parents. Over the past decade, jake Selover, a sponsored skateboarder and snowboarder from Bend, has benefited from the dedication of his father, Scott, and mother, Whitney, who also have two daughters. At 17, Selover, who was home-schooled and graduated early, can get himself to contests and other snow andskateevents.Butform uch ofthe lastdecade, Scotthaschampioned and chauffeured the dual-sport prodigy. In fact, just as his father took a seat at a picnic table for an interview about his son at Sisters Skatepark,

Page 12

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Jake Selover, 17, ofBendjumps offa ramp that was builtin Drake Parkin Bend on Nov.13. MEG ROUSSOS

Jake called out to him from atop a nearby bowl. "Scott? Grab me my other board out of the car, maybe?" "Yeah, I will," replied Scott. "He was 7 when he started skating," explained Scott, back from the errand. "He got into it because a couple of his buddies were doing it. They started skating together, and it kind of took off from there." That group of neighborhood friends included acclaimed snowboarders Zach, Gabe and Ben Ferguson. "The Ferguson brothers; we

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lived in the same neighborhood at that time, and they started skating together, and then started snowboarding together, and it kind of grew from there. It was a whole little rat pack of them. It was really fun for them," Scott said. He can relate to his son's avid interest in boarding. When Scott was growing up in Portland, he would find hills to ride down or go downtown to take advantage of the abundance of asphalt and concrete. "I skated a little bit when I was younger, like junior high years, but not like he skates," said Scott, 52.

Page 13

ANDYTULLIS

Jake Selover, left, and his dad, Scott Selover, stand together at Sisters Skatepark.

ANDYTULLIS

Bend skateboarder Jake Selover grabs the nose ofhis board for control while doing a skateboard trickin the deep end ofthe big bowl at Sisters Skateparkin September.

Jakebegan skating in the summer of 2004, and by thatThanksgiving, he was also snowboarding. By the following year, Jake was entering competitions in both skating and snowboarding. Over the years since, Jake has evolved into a monster of an all-terrain boarder. On his snowboard, he rides everything from terrain parks to powder and urban environments, when there's snow for it. As a skateboarder, he rides ramps and bowls â&#x20AC;&#x201D; or "tranny" skating, in skate parlance, short for "transitions" â&#x20AC;&#x201D; prevalent in skateparks. He also street skates, finding unintended potential in manmade terrain such as handrails, stairs, curbs and ledges. By being sponsored, Jake receives free gear and clothing, and support such as help with the cost of traveling to contests. For both snowboarding and skateboarding, Jake is sponsored by Volcom clothing and Vans shoes. This winter, he gained two new snowboarding sponsors, Union Binding Co. and Crab Grab. Additionally, he's sponsored by Lifeblood Skateboards, a Portland-based skateboard manufacturer whose sponsorship he picked up last summer. "He's pretty happy to be with them," Scott said of Lifeblood. "They're a Northwest company, so that's really cool." It helps getting free boards; Jake wears them out pretty quickly.

Page 14

"In the summertime, they don't last that long, especially riding concrete," his father said. When representing Bend at contests and events elsewhere, Jake's snowboarding prowess comes as little surprise given the proximity of Mt. Bachelor to his home. With his skating, it's a different story. "When we travel to, say, California, people usually assume he's from Portland if they don't know him, as Portland has a strong skate culture," Scott said. "I think the general consensus by most is that he has traveled all over the West and skated so much different terrain ... that he is an all-around skateboarder. And the state of Oregon is generally considered a hotbed for skating everything. "There are some really great skaters here in Bend, but the reason Jake has excelled, in my opinion, is that he has been everywhere and skated tons of different stuff. And he is super creative with his riding and skating and is motivated to get better." Jake said his favorite local skate spot is the fairly new Sisters Skatepark, a so-called do-it-yourself park featuring three bowls surrounded by smaller concrete banks and mogul-like features. Farther afield, "there are so many (in Oregon) to choose from, but I'd have to say Lincoln City is my favorite. It has everything, too. It's so big," he said of the park, which is about 40,000 square feet with more features on the way, according to the website for Dreamland Skateparks, builder of the project. Asked if he has a preference between hischosen board sports, Jake answered, "At this point, I'm just trying to do both and get the most out of them that I can, pretty much. I definitely don't like skating in the winter, here (in Central Oregon) anyway." Luckily,Jake generally prefers to focus on his other boarding discipline come winter. "When it's wintertime, he likes to snowboard. When it's summer, he likes to skateboard," said Scott. For both skating and snowboarding, Jake's done well in competitions around the Northwest. This past summer, he competed at a pro-am contest at a Eugene skatepark called the 2014 Northwest Jam. Out of a field of 58 competitors, Jake placed fourth. "The other kids were all 21 or older," his father said."So he did

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really well with that. He was a younger kid." Lately, Jake doesn't compete as much at snowboarding as he used to. "He'll do a competition here or there, but I think he really likes the filming and ... backcountry element," his father said. Last winter, Jake began venturing away from lifts and groomers to explore backcountry terrain. "He really got the bug for that last year," Scott said. "That's what I'm trying to do," Jake said."I don't know how much I can really classify it as backcountry, but I try." "Yeah, that's it. Because we've got to get him more out, out, out," his father chimed in. Jake is also an all-terrain ripper enjoying slopestyle jumps as well as park features such as rails and jumps. He rode halfpipes like Mt. Bachelor's superpipe more when he was younger but more recently has enjoyed the jumps, rails and funboxes of slopestyle and park riding. Though Scott mostly watches Jake when they head to area skateparks, the two have been known to ride snow together. "When hewas younger,there wereawholebunch ofusdadswho would go out with the kids and snowboard, and as the kids have gotten older, they pretty much have taken off. They go their way, and we go ours," Scott said. "The cool thing is, all the dads want to ride pow, all the kids want to ride the park. But over the years, the kids have really gotten into riding pow and things like that, too." At his age, Jake isn't too concerned about diet and exercise, but he does a lot of hiking in the summer. That helps strengthen his legs, "but he's not really on an exercise program," his father said. "He has expressed interest in going with me to the gym at times, and he knows that will eventually be part of his routine at some point, but youth is youth, if you will." Jake's diet today is "way better than two (to) three years ago," said Scott. These days, Jake eats well and tries stay away from soda and sugary foods. "He knows and is aware of what is beneficial for him but is not a perfect eater," Scott said. Jake's not sure where he wants to go next, but he could see himself working for a board company down the line. "That's the mindset I have right now, hopefully ... get a job at some company or somewhere at that point and snowboard as long as I can," he said. He wouldn't mind a gig like former pro Remy Stratto n. "He just, like, skated forever and now he's the TM (team manager) at Volcom for the skate side," Jake said. "I'm just stoked that I've gotten to do it as much as I have, because so many kids just don't have the support to take it to even where I am right now." He's "definitely" referring to his dad, he said. "I wouldn't be anywhere without him taking me to all the skateparks that he did when I was young," he said. "I'm super hyped to have that." Scott doesn't take his time with Jake for granted either. "It's to the point my usefulness is running out. I like to hang out with him when he wants to. We went to some fun contests that he could've gone to by himself, but he asked me to go, so I enjoyed going," Scott said. "It's been a fun ride."•

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Healers at the intersection of crime and medicine BY TARA BANNOW

he biggest part of Susan Yokoyama's job as a forensic nurse is examining and gathering evidence from patients who report having been sexually assaulted. Often, they come in devastated — crying, shaking and sharing their regrets about going to a certain party or leaving with a certain person. Yokoyama, a sexual assault nurse examiner for St. Charles Health System, said she assures them it's not their fault. That no one has the right to assault them. The encounters take between an hour and a half to two hours and involve tending to injuries, preventing pregnancy and the transmission of sexually transmitted infections, developing a safety plan, collecting DNA, blood and urine samples, taking photos and documenting injuries. It's not an easy job. But the most rewarding part, Yokoyama says, is sometimes by the end, she feels like she's a part of the healing process. "At the end of the hour and a half-or-so time that they're with us, sometimes I see them heal a little bit," she said. "They lighten. Sometimes even there is a smile or a sigh of relief about part of their experience behind them, that sort of thing." Forensic nursing is a relatively new specialty within the field — the American Nurses Association officially recognized it in 1995 — so advocates say the understanding of its importance still is growing. In short, forensic nursing is the intersection between medicine and the legal system, so it becomes necessary whenever a patient has been the victim of a crime.

The largest subspecialty within forensic nursing is sexual assault examiners, but they also perform death investigations and examine child abuse and domestic violence victims. Sometimes their jobs involve recounting their findings in courtrooms. The biggest difference between general nursing and forensic nursing, some in the field say, is the painstaking documentation that's required. "We know that every single word we write or document could well end up in a court of law," said Sheila Early, immediate past president of the International Association of Forensic Nurses. In the emergency room, where Yokoyama also works as a general nurse, she'll note in a patient's chart the general location of a bruise and make sure it's not something more serious. As a forensic nurse, however, the documentation is much more involved. She measures the bruise, photographs it and writes down how the patient says he or she got the bruise so that law enforcement can investigate the story. Although most forensic nurses who specialize in sexual assaults work in hospitals, they can work in a number of settings, including stand-alone medical clinics, medical examiner's offices, child advocacy centers and others, said Early, also a forensic health sciences instructor at the British Columbia Institute of Technology. Becoming a forensic nurses requires training beyond a general nursing education in forensic science, including training in DNA collection, different bodily fluids, toxicology testing and preserving evidence. When it comes to reporting sexual assaults, the sooner the better,

Susan yokoyama, a forensicnurse and sexual assault nurse examiner at St. Charles Health System, places cotton swabsinto a holder usedin a patient examination during a demonstration ofherjob at St. Charles Bend. ANDYTULLIS

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Yokoyama said, especially if it could involve STI exposure. In Deschutes County, a forensic nurse who specializes in sexual assaults is on staff 24i7, either at St. Charles Bend, Redmond or Deschutes County Health Services, she said. (Emergency room nurses will be able to locate the forensic nurses on staff, she said.) In certain cases, such as if the patient is under 18, older than 65, disabled or mentally ill, Yokoyama has to report crimes to law enforcement. Alleged sexual assault victims receive an examination, and the nurse will gather evidence into a rape kit, including DNA left by the suspect, blood, urine, hair and other body secretion samples, photos, the victim's clothing, especially undergarments, and, in some cases, physical evidence from the scene. The patient then has six months to decide whether to report the case to law enforcement, Yokoyama said. In the mean time, the rape kits are sent to law enforcement offices without any identifying information on the outside of the box, she said. In the event the patient decides to report it, his or her information is inside. The forensic nurses in Deschutes County — 11 at St. Charles and two at the county — process between 50 and 60 sexual assault cases every year, Yokoyama said. The crucial and often difficult part of a forensic nurse's job is maintaining objectivity with patients who've been through significant trauma, Early said. That means showing empathy, but not sympathy. The difference is subtle, but it means advocating for that patient while keeping in mind that you don't know the whole story, she said. "Forensic evidence can actually help not convict someone who is not guilty of a crime, too,e Early said,eand I think that's really important, is that a forensic nurses' neutrality and objectivity are paramount n

to what they do.

ANDYTULLIS

Encouraging words are painted on the walls ofa special room used by sexual assault nurse examiners to examine patients at St. Charles Bend.

In the end, forensic nurses support patients by ensuring they collect forensic evidence according to protocols, Early said. "The reality is, forensic science and forensic evidence speak for themselves," she said. "They are the true impartial." Forensic nurses are also at risk of experiencing what Early calls "vicarious trauma," where they're changed in some way by caring for someone who experienced trauma. It happened to Early herself. She knew which building a patient of hers had been sexually assaulted in. She passed it on her way to and from work every day. "Every time I drove by, twice a day when I was at work ... I thought n of her, she said. "That's vicarious trauma." Forensic nurses often have strategies to protect themselves from such trauma. For her part, Early said she doesn't watch violent movies or listen to songs that degrade people. She also volunteers for an organization in British Columbia that develops projects to raise awareness about domestic violence. Every so often, things do hit home, Yokoyama said, but she just tries to remain objective. "Some of it is pretty extreme, you know? Pretty scary," she said. "And if you collect too much of that, you can't continue your job."•

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Waxless skis

BY MARKIAN HAWRYLUK •PHOTOS BY JOE KLINE

Despite their name, you can wax waxless skis. These sorts of skis have a textured waist to provide grip, so they don't need grip wax. But you can still benefit from some glide wax for the tips and tails. Try a glide wax which can be rubbed or wiped on, without an iron.

h, winter! The time of year when gear heads wax poetic about ski wax. There's perhaps no more quintessential Central Oregon winter experience than gliding through a Cascade wonderland on cross-country skis. A good wax job will help make your ski outing more efficient and more enjoyable. Here's a quick rundown ofthetypesofwax you need to consider:

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While many peoplethinkofwax as a wayto reducefriction and go faster, waxing classic skis is all about providing grip on the snow. Hard waxes work best for colder conditions — anything below 35 degrees — and are sold in what resembles a large crayon. Rub the wax on the middle third of the ski (the waist) with short back-and-forth strokes. Warmer temperatures require klister wax, a gluelike wax that comes in a tube and needs to be heated with an iron. Apply a base coat ofbase klister then a second coat of universal or temperature-specific klister. If that seems like too much work, you can also buy a spray wax that won't be as effective but will help with grip.

Skate skis are all about your need for speed, and while ski bases are fairly slippery on their own, a good glide wax will give that extra edge to beat your buddy to the finish line. Most glide waxes are color coded for the specific temperature in which they work best. Ifthat's too much to think about, try a universal wax that will workfor all temperatures. Glide waxes must be melted with an iron, although there are spray-on, rub-on and liquid waxes as well.

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ngelaBordeaux had always been on the high end of functioning for someone with Down syndrome. She could read and write, and once even won a contest for her poem about an otter at the Oregon Zoo. But when she started having behavior issues at her day program in Portland, her parents, Nancy and David Bordeaux,became concerned. By herlate 20s,she was having trouble reading, and by 31, Angela could no longer read or write her name. The staff at the day program urged her parents to take her to a specialist, who gave them a surprising diagnosis. Angela had a condition that typically affects individuals more than twice her age. Angela was one of the youngest patients he'd ever seen with Alzheimer's disease. There's a growing recognition among families and caregivers of what researchers had discovered years ago, that individuals with Down syndrome will invariably develop the pathology of Alzheimer's disease starting as early as their second decade of life. And if they live long enough, most will develop the dementia and clinical symptoms as well. Now that their life expectancy has been stretched into the 50s and 60s, individuals with Down syndrome represents the single largest

Page22

group with a genetic predisposition for Alzheimer's disease. As such, they have become the primary study group for new Alzheimer's tests, preventive treatments and potential cures. It now appears these individuals, who historically have been undervalued and unappreciated to the point that expectant parents often decide to terminate their pregnancies rather than have a child with Down syndrome, might hold the key to unlocking the mysteries of arguably the most feared disease of aging. "Their great gift to the world," said Huntington Potter, a researcher with the Linda Crnic Center for Down Syndrome in Denver, "will be the curing of Alzheimer's disease." The Bordeauxs, who moved to Redmond four years ago, had felt called as Christians to adopt three children with Down syndrome. "In the '70s, it was a very disposable society," David, a former Multnomah County parole officer, said. "And wedecided that God put in our hearts to adopt these kids." Nancy had been in nursing school, and the last baby born during her training program had Down syndrome. They adopted Zach, now 39,when he was 7 days old,and Angela, 38,fouryears later. LaToyya, 31, came to them from Kansas in the late 1980s. Angela's diagnosis came almost by coincidence. The staff had just completed

WINTER/SPRING20ISâ&#x20AC;˘HIGH DESERT PULSE

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Angela, center, and LaToyya Bordeaux, right, enjoy theircraft timesewing at Opportunity Foundationin Redmond on Jan.9.

a training on Down syndrome and Alzheimer's around the time her issues began to emerge. "If a normal person suddenly couldn't read, you would realize something was wrong," Nancy said. "But a person with Down syndrome, they already have deficits, so when they get Alzheimer's, it's not as obvious." Doctors put Angela on the Alzheimer's medication Aricept, and initially it seemed to help. "Mom, I can read again," she proclaimed after several months, but the recovery was short-lived. Now she can only write her name by copying the letters or if someone spells it out for her. Nobody had ever told the Bordeauxs to look out for Alzheimer's as their children aged. And while Angela's diagnosis caught them off guard, they recognized the symptoms when LaToyya started having similar issues. She began to forget things, such as asking when they were going to have dinner just after they had eaten. At times, she would break out in gibberish. Soon, doctors gave LaToyya the same diagnosis, and now Nancy wonders whether Zach is similarly affected. A bout of meningitis when he was 4 years old further sapped his limited cognitive abilities, making an accurate diagnosis difficult.

WINTER/SPRING2015â&#x20AC;˘HIGH DESERT PULSE

"He probablydoes have Alzheimer's because he hasthe gene for it," she said. "But he functions so low because of his meningitis that we don't know." The Bordeauxs say they will continue to care for all three at home as longas they can do so safely. "I really don't know what the future is," Nancy said. "Other than I expect them to continue to decline."

New connections The life expectancy for someone with Down syndrome born in 1907 was a mere 9 years. Today, they routinely live into their 60s, mainly due to better treatment of congenital heart defects and infection. Mainstreaming rather than institutionalizing individuals with Down syndrome also has allowed them to live healthier, more productive lives and is paying huge dividends in terms of longevity. But that has pushed more of them into the decades of life where Alzheimer's becomes more probability than possibility. Researchers estimate that about 10 to 35 percent of those with Down syndrome will develop dementia in their 40s, and 40 to 75 percent in their 60s. If they live longer, the rate might get closer to universal.

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.@Wn "That started out as a hypothesis and over the past 20 years, the hypothesis is proving to be correct," Potter said. "The data are pretty incontrovertible now."

The great divide The link to a condition as high profile as Alzheimer's disease has brought new attention, new resources and new grants to Down syndrome research. But in local communities, for the most part, the support structures for individuals dealing with those conditions have remained separate. Down syndrome and Alzheimer's disease organizations did not have a history of working together, and local and state agencies for developmental disabilities and aging have for most part remained separate. As a result, families and caregivers for aging individuals with Down syndrome often fall through the cracks, their needs not fully served or understood by either side. "That's a real challenge, and to be honest, I don't think the care systems, the agencies that exist in the community are really geared up to face this kind of issue," said Matt Janicki, a professor of Disability and Human Development at the University of lllinois at Chicago. "There's just not a lot of communication between the aging system and the disability system." Moreover, the lack of resources puts extra pressure on parents who have cared for a son or daughter with Down syndrome all their lives, only to find that the demands for their caregiving increase just as their ability to meet them begins to wane. Richard Marshall, 49, came to stay with Betty and Frank Kodera in York, Nebraska, in 1971 when he was just 5 years old. They had already raised two boys, one of whom was working a summer job with a local agency for the developmentally disabled. The staff was desperately searching for a family to take a young boy with Down

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Richard Marshall sits with this parents, Frankand Betty Kordera, at his care homein Hebron, Nebraska, last year. Marshall, 49, has Down syndrome and Alzheimer's disease.

syndrome. If they couldn't find a home for him within a few weeks, the boy would be put in an institution. "Leave him here until you find someone," Frank recalls telling his son. "Well, they didn't find someone." The Koderas knew little about Down syndrome at the time. They had only seen one other person with the condition, a man who never ventured beyond the fence surrounding his front yard. "We just figured we'd treat him like our two boys," Betty said. "We just figured it would take longer." For more than 40 years, they cared for Richard, shepherding him through school and work programs as they moved from Nebraska to Washington to Montana and back again. He worked various jobs operating a drill press, processing seafood, sorting recyclables. Then several years ago, on a family trip to Wyoming, they awoke one night to find Richard confused and trying to open the door of their motel room. It was one of the first signs that something was wrong.

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He started having trouble at work as well, confused about how to perform the simple tasks he had done hundreds of times before. His doctor advised them to rule out more benign possibilities but eventually in 2010, a neurologist in Lincoln, Nebraska, confirmed Richard had Alzheimer's disease. "He spent 15 minutes with us and said, 'This is what you've got. I'll give you some pills, and there's nothing else I can do,"' Betty recalled. "They drop a time bomb in your lap and say, 'Go home.'" Richard began to decline quickly. He wouldn't sleep at night and developed seizures and hallucinations. His behavior became erratic. He became terrified of a hallway mirror and once wrapped a blanket around it to hide its reflection. He took family photos off the refrigerator and hid or destroyed them. Having reached their 80s and starting to slow down themselves, Frank and Betty realized they could no longer care for Richard at home. When they found a care home thatcould take Richard an hour away in Hebron, Nebraska, they sold their house and moved there to be closer to him. "We're getting too old to be driving 50 miles on a regular basis. We wanted to see him more than once a month," Frank said. "After someone has been with you for 43 years, you're pretty much loving the guy." Richard entered the care home in April 2013. By July he could no longer walk or talk and developed swallowing difficulties. The Koderas visit regularly, often at lunch time to help feed him. They would like to take him home for visits but are no longer up to the task. Even leaning him in his wheelchair to tie a bib on him is a difficult challenge for the couple. "He has to have help with everything that he does," Betty said. "Between the two of us, we couldn't do it."

The shadow looms The average age of onset of dementia among individuals with Down syndrome is 52, which means parents are generally in their 70s or 80s when it hits. Often, one of the parents has started to show signs of dementia as well, leaving the other to care for two individuals. It's a fear that Judy Marick, of Portland, faces now on a daily basis. Her husband, Jim, has Alzheimer's and is in a group home. Her son Jason, 39, has Down syndrome and lives at home with her. "At this point, Jason doesn't have Alzheimer's, but it looms very close to my heart. It just sounds like he's going to get it," she said. "It seems every time Jason repeats a question two or three times I automatically think, 'Oh no, am I seeing the first signs of Alzheimer's now?"' Marick had never expected her son to make it to 40. She hasn't told Jason of his increased risk but has told him his father has an illness that is affecting his brain. "Jason has a real fear of 'getting what Daddy has,'" she said. "He is seeing Jim deteriorate, and Jim had gone through a segment of being aggressive and combative. And that was very scary for him."

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SUBMITTED PHOTOS

A year or two before her death, Judith Hilton smiles at her brother, Father Francis Hilton. "Even when the Alzheimer's had progressed horribly far, she neverlosttrackofme,"hesaid.

Marick, 75, has sought information and support from other parents she's come to know over the decades as their children came up together through the disability system, schools and day programs. "Alzheimer's and Down syndrome is something that parents just really fear," she said. "This is a topic that comes up a lot. Have you heard any more? Have you heard the latest? It's just a real, real fear." One ofthose friends is Yvonne Jordan, ofLake Oswego, whose son, Michael, is 41. "The secret words are people with Down syndrome 'have a higher incidence of ..."' she said. "And they just throw those at you all the way through your life, this just whole heck of a long list of things." Michael lived with his mother until moving to a group home three years ago. He still works four days a week, and volunteers with the Red Cross on Fridays. But the Jordans have a family history of Alzheimer's, so she worries that could double his genetic risk. "Anytime we would see something about Down syndrome and Alzheimer's, you're shaking in your boots a little bit," she said. "Mainly because all of us have some base of what Alzheimer's is all about." Often, by the time dementia hits, parents have died or are in no shape to provide additional care. It can then fall to siblings to pick up the slack, creating a sandwich generation like no other. "We kind of joke that we're sort of the club sandwich generation," said Sarah Jurcyk, of Kansas City, Kansas, who is the legal guardian of her sister, Lucy. "Because we're not only caring for our parents and we have kids, now we have a sibling to take care of. It's like a triple-decker thing, supporting three generations of people." Still, individuals with Down syndrome tend to unite a family, rather than divide it. Statistically, parents of children with Down syndrome are less likely to get divorced, and brothers and sisters routinely respond in surveys that their lives are richer for the experience. Father Francis Hilton, a Jesuit priest from Metuchen, New Jersey, took over as legal guardian of his younger sister, Judith, who had Down syndrome after their mother died in 2006. The family had begun to suspect something was wrong with Judith three years earlier,

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Father Francis Hilton walks with his sister, Judith, who had Down syndrome and Alzhei mer's disease, at a farm not far from her housein 2008. Judith had not walked for months but with her brother's help had left her wheelchair fora briefstroll.

when her boss expressed some concerns. The family attributed it to stress over losing her father to lung cancer and seeing her mom decline after breaking a hip. In the summer of 2003, Hilton took Judith, then 41, to see specialists at Rutgers University Medical Center. By the third visit, the doctors told him there was no other explanation: Judith had Alzheimer's. When they returned to their parents' house, Judith bounded up the stairs and told her mother how nice the doctors had been and about the lunch with her brother by the ocean shore. When she left the room, her mother asked Hilton what he had learned. "Judith has Alzheimer's, and I can't figure out why she's so happy right now," he told her. "Atsome level,she knows she'sgoing to be in good hands," his mother replied. In that moment, Hilton realized he had just inherited the responsibility of ensuring his sister's well-being. "My parents had given their lives to making Judith's world. It was time for them to move on and pass the torch," he said. "And there's no torch I would rather have received." Judith was the youngest of eight children in the Hilton family. "She was born at a time when there real-

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ly wasn't a lot going on for kids with intellectual disabilities," Hilton said. "So Judith really lived her whole life on the edge of whatever good stuffwa sgoing on." She was part of the movement in New Jersey at the time for greater inclusion of the developmentally disabled, and Judith accumulated a number of firsts along the way: attending the first classes for individuals with developmental disabilities, being the first student with Down syndrome at her high school, and the first with Down syndrome at her worksite. "She was the first person with Down syndrome to go on a cruise to Bermuda on her own," Hilton said. When she was diagnosed with Alzheimer's, the doctors told him what to expect. The first thing that will happen, they said, is she will break one or both of her feet as she struggles to adapt to her changing perceptions of the world around her. In short order, Judith broke one foot, and then the week her mother died, she broke the other stepping awkwardly off the stairs. Much to her family's chagrin, Judith's favorite movie was "Dirty Dancing," and she would annoy the Catholic family by reciting lines from the racy film. But "The WizardofOz" ran a close second, and she rarely missed an opportunity to watch it. "I feel like the scarecrow," she told her brother six months after her diagnosis. "My head is full of straw." Hilton eventually quit his job as a department chair at Rutgers University and took a sabbatical to spend more time with Judith. She had several bouts of aspirational pneumonia, a common problem for individuals with Down syndrome and Alzheimer's as swallowing becomes more difficult. Judith had lost the ability to walk and spent much of her day in bed.She had continued to decline steadily over the five years after her diagnosis, until a weekend in November 2011. Hilton was grading papers at her bedside and they were watching the Giants football game on the TV. For reasons still unclear, Judith seemed to make a remarkable rally. She noticed for the first time the

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Murphy'sdaughter, Michelle,has Down syndrome and watched two of her closest friends, including Judith Hilton, as they declined and ultimately died from Alzheimer's. Michelle spoke at a conference two years ago about what it was like to see her best friends fade away, lose the ability to feed themselves, and forget her name. Michelle has shown no signs of dementia, but having seen it firsthand, Murphy knows she must prepare for that likelihood. But there are few provisions in the community for those with intellectual disabilities and dementia. Neither day programs nor the group homes are prepared for it, nor are there many specialized facilities to meet their unique needs. Murphy said individuals often end up in nursing homes surrounded by elderly residents. "Every time I go to a nursing home, I see people with Down syndrome just sitting, vegetating in the corner," she said. "It's really sad. We needto come up with a place where we can take care ofthem, where they could possibly age in place."

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Gains and losses

RYAN BRENNECKE

Richard Robertson, clockwise from top, Jenny Blanford, Matt Wilson and Kendra Lopez at the Central Oregon Transition Plus apartment complex.

feeding tube in her nose. She questioned why her brother was giving the students all those red marks on their papers, and when the Wicked Witch of the West appeared on the television screen, Judith became animated. "She was really acting like the Alzheimer's had gone away," Hilton said. Her nurses couldn't believe the difference, asking Hilton what he had done to precipitate such a drastic change. Then late Tuesday night, at a time when it's never good news, Hilton's phone rang. Judith had felt so good that, for the first time in years, she had tried to get out of bed. She caught her foot on the bedsheet and fell, breaking her neck. "That was the end of life as I knew it," Hilton said. "I was there for her life, but I wasn't there for her final day.Judith died all by herself." Hilton said his family knew little of the increased risk for Alzheimer's. They had always been told Judith would have heart problems, but it wasn't until she was in her 40s that anyone mentioned the risk of dementia. News of the link has been slow to filter through to families, and even when it does, they often are in denial. "It's hard for families to accept that this is inevitable, because you'veworked so long and hard to change the schoolsystems and get them integrated, and then you get hit with this at the end," said Leone Murphy, a nurse practitioner working with individuals with developmental disabilities and an instructor at Rutgers University. "So many families are still not even able to accept that this is coming."

Page28

Just east of the parkway running through Bend sits a nondescript apartment complex that was born of parents' hopes and dreams but now harbors more than its fair share of fears. More than 20 years ago, a group of parents with children with developmental disabilities banded together under the name Central Oregon Transition Plus with the goal of mapping out a better future for their children. When it was time for their children to leave home and lead more independent lives, they wanted to find safe and secure housing for them but realized no such place existed. Through a partnership with Cascades Community Development, they opened two apartment complexes and a group home with just enough staffing to help the residents live on their own. The three units now house a combined 29 residents with developmental disabilities ranging in age from 29 to 58, including six individuals with Down syndrome. That means several of the residents, such at Matt Wilson, 33, are reaching the age when Alzheimer's symptoms typically appear for the first time. "Matt's grandmother died of Alzheimer's in 2000," his mother, Pam Wilson, said. "Ever since then I've watched for it very closely." Wilson hopes that even if her son starts to show signs of dementia, he will be able to stay at the complex with additional support services. But there is also an understanding among the parents that residents must be able to live relatively independently to stay there. "If he became unstable in his living environment, where he would be a danger to himself, then there would have to be a decision made," Wilson said. "He would have to go live in an environment where it would be safer for him." While the COTP parents have made individual plans to ensure their children will have ongoing support after they're gone, they also take solace in knowing that the community of parents will look out for all of the residents. "When one of the kids needs help, we all come together," said

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KarenBlanford,whose 42-year-old daughter,Jenny, has Down syndrome. "So hopefully someone in the group can help them find the services they might need." For many parents and siblings, the looming threat of Alzheimer's represents a cruel twist of fate for individuals who were born at a disadvantage and have been trying all their lives to catch up. The very families that fought for inclusion and acceptance over the past three to four decades are now among the first to face the stark reality that Alzheimer's threatens to unravel all of their hard work. "When Jason was born, it was all about early intervention," Marick said. "We all absorbed information and wanted to push our kids. We did everything and offered them everything for that reason. They were just going to be super people with Down syndrome. And in the last 10 years, we've realized that it can all be taken from them." The nation is already struggling with how it will take care of the millions of additional cases of Alzheimer's disease as the baby boomer generation ages. But within that larger demographic wave there exists a more intense riptide of individuals with Down syndrome facing the same issue. With gains in longevity, the number of individuals living with Down syndrome is expected to double from 642,000 in 2000 to 1.2 million by 2030. With no reliable treatments for Alzheimer's, efforts to help affected individuals now focus on early diagnosis to help accommodate their diminishing skills. But families, providers and caregivers will have to get much better at recognizing the early signs of Alzheimer's in order to help. Individuals with Down syndrome face myriad health issues as they age. Separating what is Alzheimer's disease from what is a thyroid problem or sleep apnea or a 812 deficiency is often impossible. "I think the important thing is to make sure you're not attributing Alzheimer's disease to something else," said Dr. Brian Chicoine, co-founder and medical director of the Adult Down Syndrome Center of Lutheran General Hospital in Park Ridge, Illinois. "We certainly see folks who have depression that looks like Alzheimer's disease that got better when you treated the depression." The center was launched in 2012 and has seen more than 5,500 adolescentsand adults with Down syndrome, whose symptoms of aging are often overlooked by less experienced eyes. The clinic's providers are careful to rule out other conditions before settling on an Alzheimer's diagnosis. "But there are certainly patients that see me for the first time that have enough of a pattern that I'd be pretty flabbergasted if I found something else," Chicoine said. When normal adults start to forget or act erratically in their later years, family and friends are quick to suspect Alzheimer's. But when individuals with Down syndrome act similarly, it's often attributed to their intellectual disabilities instead. "When symptoms start, it's too easy to blame the person because you don't know what's happening," said Sharon Miller, of Burbank, California. Miller's sister, Robin Trocki, came to live with her more than 20

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RYAN BRENNECKE

Matt Wilson, center, dishes upa plateoffoodduringa potluckat the CentralOregon Transition Plus apartment complexin January.

years ago, after their mother died in New Jersey. For years, Robin worked in a bakery and a supermarket. She had her artwork published in a book and played Sue Sylvester's sister on the television show "Glee." Her first symptoms of Alzheimer's began to appear about age 50. "She would have trouble with forgetting things, trouble with confusion. She would make little mistakes," Miller said. "And then that began to escalate." Robin began complaining about problems at work, which Miller attributed to having a new supervisor. She told Robin she had to try harder. When Robin had a series of falls, the staff at her program claimed she was merely doing it for attention, not realizing that gait issues are often the first sign of Alzheimer's. And when she became overly emotional, it was chalked up to menopause or a disagreement with her friend. "Everything was easily explained away, misunderstood and then blamed on her," Miller said. One night, Robin took everything out of her freezer and put it her sock drawer. Despite living in housing for individuals with developmental disabilities, the staff had no idea how to deal with her emerging dementia. Then, two years ago, Robin's condition began to deteriorate rapidly. She became terrified of the dark and would have psychotic breaks. She stopped walking or feeding herself. Miller brought her home in December 2013 fully prepared it would be her sister's last Christmas. But somehow, close to her family, in a environment where she felt safe and loved, her condition improved. "She got happier," Miller said. "She just wanted to be with me." Even as recently as a decade ago, learning about dementia in someone with a developmental disability was a daunting task. Miller reached out to Down syndrome and Alzheimer's advocacy groups with little success. She tracked down a friend whose son with Down syndrome had died of Alzheimer's. She met with her three weeks in a row, sitting on the woman's porch absorbing all of her hard-gained experience. "You have to tell me everything from the first sign to everything that happened at the end," she recalls telling her. "I don't want to tell you about the end," her friend replied. "I don't

Page29

Feature(DOWN SYNDROME AND ALZHEIMER'S

want to scare you." It's information they haven't been able to get until recently from national Down syndrome advocacy groups. These groups got their start in helping families dealing with the first diagnosis of Down syndrome and so not surprisingly have focused primarily on issues of early intervention and inclusion. "I think it's been slow to come to the table from a national standpoint because that's a negative thing," said Dr. Seth Keller, a neurologist from Cherry Hill, New Jersey."You're talking to these young parents with children with Down syndrome, do you really want to tell them that when their children get to be 40, 50 or 60, they're going to get Alzheimer's and die?" So until recently, there was little guidance from these groups on the realities of aging with Down syndrome. "I believe there are families that have their heads in the sand, who don't want to know what's going on," Miller said. "To me, it's scary not knowing." There's a similar disconnect among the medical professionals. While physicians who specialize in Down syndrome may have a greater understanding of the link with Alzheimer's, primary care physicians or specialists who see such individuals less frequently aren't always aware of the connection."Doctors and nurses who care for people with developmental disabilities don't know what normative aging is," Keller said. When Robin developed bladder issues and required a catheter, for example, her doctor told Miller she would have to have the catheter changed under general anesthesia every month. "To me, that's unacceptable. My question is always, 'Would you do that to me?"' Miller said. "I found another urologist who changed her catheter using kindness instead." To help improve care for individuals with intellectual disabilities and dementia, Keller, Janicki and others involved with the American Academy of Developmental Medicine and Dentistry formed the National Task Group on Intellectual Disabilities and Dementia Practices. The group has developed guidelines for care and has served as a voice at the table, ensuring the medical establishment considers the unique needs of the disabled population when putting policies and actions plans in place. Most recently, they advocated for greater consideration within the National Alzheimer's Plan for individuals with all sorts of intellectual disabilities. Such efforts are starting to have an impact. Down syndrome and Alzheimer's organizations are starting to collaborate and share information with families about aging and dementia. A recent restructuring within the federal Department of Health and Human Services created the Administration on Community Living, bridging the Administration on Aging and the Administration on Intellectual and Developmental Disabilities. Keller has also been working with Special Olympics to increase the visibility of aging issues among its athletes. The group has long had a program called Healthy Athletes, in which they screen participants for medical issues. But in some states, officials have noticed the rise

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SUBMITTED PHOTO

Sharon Miller, left, and her sister, Robin Trocki, of Burbank, California. Trocki has Down syndrome and Alzheimer's disease.

of dementia in its older athletes and are now working to integrate screening and referral for potential Alzheimer's cases as well. "For people with intellectual disabilities, I don't think we have a true blueprint of what aging looks like," said Jim Balamaci, president and CEO of Special Olympics Alaska. "So we want to help put that blueprint together by working with the provider agencies, the hospital and the school of nursing to come up with a solution that might beneficial." Recognizing those subtle, early changes can be challenging in real time and often emerge only with the clarity of hindsight. Mary Hogan, family coordinator for the National Task Group, said she missed many of the clues in her brother, Bill Hogan, who died of Alzheimer's in 2010 at the age of 49. "We would give lip service to the idea that people with Down syndrome will develop Alzheimer's, but we really didn't do our homework, and we didn't really understand the disease itself," Hogan said. "We didn't understand the progression of the disease." Bill had been methodical with his calendar all of his life, dutifully recording whether each day was a good day or a bad day, coloring in the days and marking them with his intricate system of symbols. "When he lost interest in that kind of activity, that should have been an immediate alarm for us," she said. "That's a really profound change, and we didn't connect that with where we were heading." Over time, the subtle changes seemed to come more frequently and the losses became more noticeable. Bill's last 15 months, she said, were ones of rapid decline. There's some debate over whether Alzheimer's moves at a quicker pace in Down syndrome or whether it just seems that way because the initial signs are so often masked by their cognitive deficits. Hogan said keeping track of the changes is particularly difficult when individuals live in group homes, which can have frequent turnover in staff. There's often no one there with the historical knowledge of an individual's habits and tendencies to pick up on

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50 YEARS OF DEDICATION

significant differences in behavior.

Tracking change Evelyn Fella was moving her sister, Irma Fella, into a new care home in 2001 when she heard for the first time a social worker tell the new caregivers Irma had signs of dementia. "Who decided that? Why would they say something like that?" she recalls thinking at the time. "But I'm going to say they were right." Irma was born in Detroit in 1945. After three sons, her mother was ecstatic to finally have a baby girl to take home. She was so excited, doctors couldn't bring themselves to tell her the baby girl had Down syndrome. Within two months, however, she knew something was wrong. Irma wasn't developing the same way her brothers had. Doctors broke the news and told her to put Irma in an institution. "My mother went to visit one and it was horrible, just a horrible experience," Fella said. "So my sister just continued to be part of the family, and my mother's expectations weren't any less than for any of her other children." In the early 1950s, her mother saw an ad in the newspaper from a mother looking to find other families of children with disabilities. The parents got together and created a program for their children, renting space from the parks and recreation department. It was just one of the groups being formed around the country by parents whose children were denied access to public school. Eventually some of these parent groups joined forces in the National Association for Retarded Children, which now operates throughout the country under the acronym ARC. The program served as a nursery school for Evelyn as well, who was four years younger than Irma. The public school system had no programs available for children with intellectual disabilities, but at age 16, Irma attended a live-in school run by Catholic nuns who taught individuals with disabilities academic and life skills. At age 26, she came back home and lived with her mother until 1992. After their mother's death, Evelyn brought Irma to San Diego and helped her choose a group home. Although she couldn't read, Irma always insisted she had to have a subscription to TV Guide. She would bury her head in it, perusing the listings with great concentration. Her siblings would often call her out on it: "Oh Irmy, you can't read." But when they tested her, asking her to find a given word on the page, she would locate it. Irma had a talent for matching, and having seen and heard the words on the TV screen, she had begun to recognize the show titles, days, times and channels. All her life, she loved word search puzzles, and puzzle books were a standard birthday gift. She would dutifully find and circle every word in book after book. But after Irma turned 60, Evelyn discovered one day she could no longer find the hidden words. Continued on page 54

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SnaPShOt SKATEBOARD ING A skateboarder gets air offa ramp as other skaters wait their turn on a warm January day at Ponderosa Skateparkin Bend. JOE KLINE

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BY TARA BANNOW • ILLUSTRATIONS BYGREG CROSS

hen you're brushing your teeth, do you ever just sort of go on autopilot? I mean, yeah, the brush is moving, but your brain is wondering whether that weird dream you had a few hours ago holds some greater significance. Your dentist is on to you — poor brushing habits are definitely noticed when you go in for your routine cleaning, and experts sayyou could be doing a lot better. The following tips come straight from the mouths of the experts, and may help put the focus back on your brushing habits. First things first: Holding your toothbrush. Local professionals (backed up by the American Dental Association — not that we didn't trust them) say you should hold the brush at a 45-degree angle to your gums so that the bristles bend and sweep bacteria out from beneath the gumline. Once you've got the brush properly lined up, move it across your teeth in a circular motion. Steve Timm, a Bend dentist and president of the Oregon Dental Association, said the circular motion gets more bristles between the teeth than if the brush just moves over the teeth back and forth. Obviously, they won't go all the way through to the other side, but that's what floss is for (we'll get to flossing later). That motion is where Timm said he most commonly sees his patients go wrong with brushing. They press straight down with far too muchpressure,which causes the gums to recede, he said. "A lot of us get in there and want to scrub our teeth like we're cleaning the sink," he

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Most brushing is done holding the toothbrush horizontally, but once you reach the inside of your front teeth on the top and bottom, it's important to hold the toothbrush vertically and brush one tooth at a time in order to reach them all, said Joseph Califano, a dentist and professor of periodontology in Oregon Health 8 Science University's School of Dentistry. How long you brush and how often is important, too, and many people are guilty of not brushing as much as they should. Experts say it takes two minutes, two times per day — although they inevitably squeeze in the caveat that three times per day is ideal. "A lot of people think that two minutes flies by in 30 seconds," said Tianna Jaschke, a registered dental hygienist at Bend Family Dentistry. Jaschke recommends placing a kitchen timer or hourglass near the bathroom sink to make sure you're brushing long enough. Many electric toothbrushes have timers that do that work for you, she said. Califano agrees that most people brush for 30 seconds, which he said is akin to swishing around a bit of toothpaste in your mouth. To actually remove the plaque from any one spot on your teeth, you must brush that spot for at least 10 seconds, he said. That's because

WINTER/SPRING2015.HIGH DESERTPULSE

bacteria have evolved to produce carbohydrates that allow them to stick solidly to the teeth and to one another, Califano said. Lots of people feel reassured by the tingle of a mouthwash, but Califano said they do little to kill germs. He said it's the mechanical motion that removes plaque from teeth. In fact, you could probably do just as well without using toothpaste at all, he said. Timm, who promises he's not paid to endorse electric toothbrushes, said that because they perform the circular brushing motion for you, they tend to clean the teeth much more thoroughly than a manual toothbrush. He estimates at least 50 percent of his patients show a great improvement in their gum health after switching to electric toothbrushes. Plus, all you have to do is move the electric toothbrush along the row of teeth, and it does the rest of the work for you. "So they can concentrate on putting it on where it needs to be as opposed to getting it where it needs to be and do the motion at the same time with the hand brush," Timm said. Both Timm and Jaschke said when they peer into patients' mouths, they tend to notice their back teeth aren't getting brushed as well. They agree that's because it's harder to get the cheek and tongue out of the way so the toothbrush can get back there. That's also the area where cavities most commonly occur: Between the back teeth, Timm said, which is partially just because there is more area for plaque to accumulate. One more thing: Don't forget the tongue. The experts say this is a spot where bacteria tends to accumulate. Some tongues collect more than others, but it's still good to keep those levels under control, Jaschke said. Some people have conditions that make their tongues sensitive to brush, and they can be excused from doing so, she said. One way to tell whether you're doing a good job with all this is to use disclosing tablets, little red or purple tablets that can be purchased at most drugstores (dentists have them, too). You chew them, swish them around in your mouth and they'll stain any sections of your teeth that still have plaque on them red or purple. Califanorecommends usingthese about once a week to see ifyou need to improve your technique.

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Choosing the right tools Although many people seem to be under the impression that a harder toothbrush will work better, experts near and far agree a soft bristle brush is your best bet. Unlike medium or hard bristles, soft bristles will flex enough to get around the round corners of teeth, and they also won't damage the gum tissue, Timm said. "I know a lot of people think the stiffer brush the better the job they're doing, but it's actually the opposite," he said. According to the American Dental Association, toothbrushes can

Page37

Tips IBRUSHING YOURTEETH

be replaced every three to four months depending on how frequently you brush. Timm, however, said he typically recommends people replace their toothbrushes monthly. The key indicator you need a new brush is when the bristles start bending and splaying. The replacement heads on electric toothbrushes can typically hold out longer — up to six months — because they're not rubbed against the teeth, Jaschke said. Any time you come down with the flu, you should replace your toothbrush to get rid of bacteria that could potentially linger on it and spread to another toothbrush that's stored nearby, Jaschke said. When it comes to choosing a toothpaste, Timm said most on the market should work, so long as they have fluoride in them. Some toothpastes contain a germicide called triclosan, which can cause adverse reactions for some people. For those people, Timm said a natural toothpaste such as Tom's of Maine works better. Some have questioned triclosan's safety, as some animal studies have linked it to cancer. The U.S. Food and Drug Administration asserts the ingredient, which is used in Colgate Total to help with gingivitis, is not known to be hazardous to humans, although the subject does warrant further study.

perts recommend flossing once per day.Jaschke, however, said whenever you know you've got food wedged in your teeth somewhere, it's important to get that out as soon as possible. That's because bacteria in your mouth pounces on it right away, producing acid. "Basically, you want to get all of that out of there so it doesn't create acidity in your mouth," she said."Our mouths run on a pH system, and you really want your mouth as neutral as you can get it." The technique is pretty straightforward: Run the floss up and down each side of the tooth, trying to scrape the front and back of the tooth surfaces along the way. Although manypeople leave between 4 and 5 inches between the two fingers holding the floss, Califano said they should only be about a quarter-inch apart, which will require you to saw back and for to get the floss between the teeth near the gums. Once you've done that, it's important to wrap the floss in a C-shape around the tooth "with a fair amount of force," and rub it around each tooth. "A lot of people pop the floss in and pop it out," he said."They think that's flossing, but that does essentially nothing. It actually has to wrap around the tooth." Lots of people have trouble using their fingers to thread the floss Don't forget to floss! between teeth, and that's why there are various types of floss holdFinally, because toothbrushes can't do it all, there is floss. Most ex- ers with pre-threaded floss on them.

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Kids aren't just a part of our practice. They are the practice. When you're talking about healthcare for babies, toddlers, children and teens... that's us.

Board Certified and Fellowship-Trained Pediatricians and Providers Mary Brown, MD, FAAP John Chunn, MD, FAAP Valerie Bailie, MD, FAAP Dale Svendsen, MD, FAAP Brenda Hedges, MD, FAAP Caroline Gutmann, MD, FAAP Erin Garza, MD, FAAP Linda Steiner, MD, FAAP Jennifer Lachman, MD, FAAP John Peoples, MD, FAAP Dana Perryman, MD, FAAP Megan Karnopp, MD, FAAP Logan Clausen, MD, FAAP Mary Rogers, MD, FAAP Jeff Meyrowitz, MD Cris Ricker, MS, PA-C Carissa Honeycutt, MS, PA-C Hailey Garside, PNP Including 15 pediatric specialists from leading Children's Hospitals

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Chronic traumatic encephalopathy is a degenerative neurological disease that can affect athletes in hard-contact sports, especially football and boxing. Repeated blows to the head may eventually cause symptoms, such as slurred speech, tremors and confusion. Depression and suicidal tendencies have also been noted. The NFL has resisted acknowledging links between those effects and concussion impacts.

How concussions can impact the brain • Football head impacts can bring to bear forces nearly 100 times the force of gravity • Immediate effects can include headache, dizziness, confusion, nausea, difficulty hearing and seeing

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page40

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Locations in Bend At Redmond

541-70G-7715

www.stcharleshealthcare,org

1460 NE Medical Center D.r• Bend

541-382-9383

www.corapc,com

Locaiions inBend,Redmond,Prinevile, ILMadras

541-706-7725

www.stcharleshealthcare,org

Locations in Bend At Redmond

541-382-4900

PULMONOLOGY

St. Charles Heart gt Lung Center

RADIOLOGY

Central Oregon Radiology Assodates, P.C

REHABILITATION

St. Charles Rehabilitation Center

RHEUMATOLOGY

Bend Memorial Clinic

RHEUMATOLOGY

Deschutes Rheumatology

SLEEP MEDICINE

Bend Memorial Clinic

SLEEP MEDICINE

St.Charles Sleep Center

SURGICAL SPECIALIST

St. Charles Surgical Spedalists

SURGICAL SPECLLLIST

Bend Memorial Clinic

•

Bend Memorial Clinic

URGENT CARE

Mountain Medical Immediate Care

URGENT CARE

NOWcare

URGENT CARE

St. Charles Immediate Care

UROLOGY

8 Urology 8 Associa 8 , es Bend

UROLOGY

UrologySpedalistsofOregon

VEIN SPECIALISTS

Inovia Vdn Spedalty Center

VEIN SPECIALISTS

Bend Memorial Clinic

541-548-77G1

ww w .stcharleshealthcare,org

541-382-4900

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541-382-4900

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Locations in Bend At Redmond Locations in Bend(East AtOld Mill District ) Redmond 1302 NEThird St. • Bend

end

541-317-0909

•

Bend Memorial Clinic

St. Charles Behavioral Health

www.mtmedgr.com

541-322-2273

www . thecenteroregon.com

2600 NE Neff Rd.• Bend

541-706-3700

www .stcharleshealthcare.org

R. R. R Locations in Bend At Redmond

541-382-6447

www. b endurology.com

Locations in Bend, Redmond, At Prineville

541-322-5753

www . urologyinoregon.com

2200 NENeffRd.,Suite 204 • Bend 541-382-834G

1501 NEMedical Center Dr. • Bend 5 4 1 - 382-4900 w

NGOCTHUY HUGHES, DO, PC St . Charles Surgical Spedalists

KAREN CAMPBELL, PHD

ww w .stcharleshealthcare.org

1501 NEMedical Center Dr. • Bend 5 4 1 - 382-4900 w

Bend Memorial Clinic

ADAM WILLIAMS, MD

541-70G-G905

. • . +~ • Prinevill~e Redmond

2200 NE Neff Rd.•

VASCULARSURGERY

ww w .bendmemorialchnic.com

Locations in Bend At Redmond .

URGENT CARE

•

ww w.bendmemorlalchnic.com

2200 NE Neff Rd., Suite 302• Bend 54 1 -388-3978 w w w.deschutesrheumatology.com 1080 SW Mt. Bachelor Dr.• Bend(West) 541-382-4900

•

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•

ww . bendmemorlalchnic.com www.bendvein.com ww . bendmemorlalchnic.com

•

815 SWBond St. • Bend

541-382-4900

1245 NW 4th St., Suite 101• Redmond 541-548-7761 w

2542 NE Courtney Dr.• Bend 5

41-7 0 G-7730 w

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ADVERTISINGSUPPLEMENT

2015 CENTRAL OREGON MEDICAL DIRECTORY RIANEVANS, PSYD

St. Charles Behavioral Health

2542 NE Courtn Dr. • Bend

541-70G-7730

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JANET FOLIANO-KEMP, PSYD St. Charles Behavioral Health

2542 NE Courtney Dr.• Send 5

WENDY LYONS PSYD

St.Charles Family Care

211 NW Larch Ave.• Redmond

541-548-2164

MIKE MANDEL, MD

High Lakes Health Care Upper Mill

929 SW Simpson Ave.• Send

541-3 8 9 -7741 www.highlakeshealthcare.com

St. Charles Behavioral Health

2542 NE Courtney Dr.• Bend 5

41-7 0 G-7730

www,stcharleshealthcare,org

St. Charles Behavioral Health

2542 NE Courtney D.r• Bend 5

41-7 0 G-7730

www.stcharleshealthcare.org

ONDRA MARSHALL PHD

JAMES PORZELIUS, PHD BE

BD,P YD

SCOTT SAFFOBD, PHD URA SHANK, PS

h rl

' rlH

St.Charles Family Care

2542 NE Courtney Dr.• Bend 4

41-7 0 G-7730

www

2542 NE Courtney Dr.• Bend 5

St.Charles Family Care

211 NWlarchAve.• Redm ond 5 4 1 - 548-21G4

HUGH ADAIR HI,DO

St.Charles Heart ikLung Center

JEAN BROWN, PA-C KUimERLY CANADAY,ANP-BC

rl h l

www.stcharleshealthcare.org

2965 NE ConnersAve., Suite 127 • Bend 541-70G-7730

St. Charles Behavioral Health

WHITNEY DREW, PA-C

www,stcharleshealthcare,or

KUimERLY SWANSON,PHD

SSANDRA DIXON, PA-C

www.stcharleshealthcare.org

www,stcharleshealthcare,org

41-7 0 G-7730

www.stcharleshealthcare.org

2500 NE Neff Rd.• Send

541-388-4333

www .stcharleshealthcare.org

Bend Memorial Clini

1501 NE Medical Center Dr.• Bend

541-382-4900

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Bend Memorial Clinic

1501 NE Medical Center Dr.• Bend

541-382-4900

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2500 NE Neff Rd.• Bend

541-388-4333

www ,stcharleshealthcare,org

1501 NE Medical Center Dr.• Bend

541-382-4900

ww w,bendmemorialdinic.com

St.Charles Heart gtLung Center Bend Memorial Clinic

ARY FOSTEB, MD

St.Charles Heart gtLung Center

2500 NE Neff Rd.• Bend ~

541-388-4333 •

ww w ,stcharleshealthcare,org

NANCY HILLES, NP

St.Charles Heart ikLung Center

2500 NE Neff Rd.• Send

541-388-4333

www .stcharleshealthcare.org

St.Charles Heart gtLung Center

2500 NE Neff Rd.• Bend

541-388-4333

www ,stcharleshealthcare,org

BICK KOCH, MD

Bend Memorial Clinic

Send Eastside tk Redmond

541-382-4900

ww w,bendmemorialdinic.com

JAMES LAUGHLIN,MD

St.Charles Heart gtLung Center

2500 NE Neff Rd.• Bend

541-388-4333

www ,stcharleshealthcare,org

BRUCE MCLELLAN, MD

St.Charles Heart ikLung Center

2500 NE Neff Rd.• Send

541-388-4333

www .stcharleshealthcare.org

St.Charles Heart gtLung Center

2500 NE Neff Rd.• Bend

541-388-4333

www ,stcharleshealthcare,or

GAVIN L.NOBLE, MD

Bend Memorial Clinic

Send Eastside tk Redmond

541-382-4900

ww w,bendmemorialdinic.com

ALLEN RAFAEL, MD

St.Charles Heart gtLung Center

2500 NE Neff Rd.• Bend

541-388-4333

www ,stcharleshealthcare,org

STEPHANIE SCOTT, PA-C

Bend Memorial Clinic

1501 NE Medical Center Dr.• Bend

541-382-4900

ww w,bendmemorialdinic.com

St.Charles Heart gtLung Center

2500 NE Neff Rd.• Bend

541-388-4333

www ,s charleshealthcare,org

St.Charles Heart ikLung Center

2500 NE Neff Rd.• Send

541-388-4333

www .stcharleshealthcare.org

2500 NE Neff Rd.• Bend

541-388-1G36

TONY FURNARY, MD

St.Charles Heart ikLung Center H t. Charles eart ung nter

2500 E eff Rd. • Bend

41-388-1G36

www.stcharleshealthcare.org H www,stcharleshealthcare,org

ANGELO A.VLESSIS, MD

St.Charles Heart ikLung Center

2500 NE Neff Rd.• Bend

541-388-1G36

www.stcharleshealthcare.org

HEBOLYNJENNABT PA-C

. GAUESH MUTEPPAN, HD

CHAEL WIDMEB, MD

EDDY YOUNG, MD I

JOHN D. BLIZZABD, MD

• I • •

MARIE BUDBACK, DC ORDANT. DOI MSC DC

THEBESA M.RUBADUE,DC,CCSP

Endeavor Chiropractic

RADLEY E.JOHNSON,DMD I

ww ,endeavorchiropractic.com

NorthWest Crossing Chiropractic A Health

628 NW York Dr., Suite 104• Bend 5 4 1 - 3 88-2429

www.nwxhealth,com

NorthWest Crossing Chiropractic tkHealth

628 NW York Dr., Suite 104• Send 5 4 1 - 388-2429

www.nwxhealth,com

JASONM. KREMER,DC,CCSP, CSCS WeUness Doctor

MICHAEL R. HALL, DDS

2275 NE Doctors Dr., Suite ll • Bend 54 1 -248-4476 w

1345NWWallSt.,Suite202 • Bend 5 4 1 - 318-1000 w

ww . bendwellnessdoctor.com

CentralOregon Dental Center

1563 NW Newport Ave.• Bend

541-389-0300

www.centraloregondentalcenter.net

Contemporary Family Dentistry

101 6 NW Newport Ave.• Bend

541-389-1107 wwwcontemporaryfamilydeutistrycom

ALYSSA ABBEY, PA-C L CHBISTENSEN, PA-C

Bend Memorial Clinic

2450 NEMary RosePl, Suite 220• Bend 541-382-4900 w

ww , bendmemorialdinic.com

Bend Memorial Clini

locations in Old Mill tk Redmond 5 4 1 -382-4900

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ADVERTISINGSUPPLEMENT

2015 CENTRAL OREGON M E D ICAL DIRECTORY I

WILLIAM DELGADO, MD, (MOHS) Bend Dermatology Clinic MARK HALL, MD,

CentralOregon Dermatology

FRIDOLINHOESLY, MD

Bend Dermatology Clinic R M . Bend Memorial Clinic

JAMES M. HOESLY, MD

JOSHUAMAY, MD

MS TIN NEUHAUAn

2747 NE Conners Dr.• Send

388 SW Bluff Dr. ~ Pend 2747 NE Conners Dr.• Send

541-382-5712

www.bendderm.com

541-G78-0020 www.cen aloregondermatology.com 541-382-5712

NMary Rose PL,Suite &~Bend

www.bendderm.com www.bendmemorialdintc.com

Bend Dermatology Clinic

2747 NE Conners Dr.• Send

541-382-5712

Ben Dermato o C inic

2747 NE Conners Dr.• Ben

541-382-5712

www.bendderm.com www. en erm.com

GERALDPETERSf MBf FAIS (MOitS) Bend Memorial Clinic

2450 NEMary RosePL, Suite 220• Send 541-382-4900 w

ww . bendmemorialdinic.com

ANN M. REITAN PA-C

Bend Memorial Clinic

2450 NEMary RosePL, Suite 220• Bend 541-382-4900 w

ww . bendmemorialdinic.com

ALLISON ROBERTS, PA-C

Ben d Dermatology Clinic

2747 NE Conners Dr.• Send

541-382-5712

www.bendderm.com

STEPHANIE TRAUTMAN, MD Bend Dermatology Clinic

2747 NE Conners Dr.• Bend

541-382-5712

www.bendderm.com

LARRY WEBER, PA-C

Bend Dermatology Clinic

2747 NE Conners Dr.• Send

541-382-5712

www.bendderm.com

OLIVER WISCO, DO (MOHS)

B e n d Memorial Clinic

Old Mill District tk Redmond

541 - 3 82-4900 ww w .bendmemorialdinic.com

I I

MARY F. CARROLL, MD

CK N. GOLDSTEIN, MD

Bend Memorial Clinic

TONYA KOOPMAN,MSN, FNP-BC Bend Memorial Clinic PATRICKMCCARTHY,MD E TRAVIS MONCHAMP, MD

ndoc rinology Services NW Endo c rinology Services NW

1501 NE Medical Center Dr.• Send

541-382-4900

ww w.bendmemorialdinic.com

1501 NE Medical Center Dr.• Bend

541-382-4900

ww w.bendmemorialdinic.com

1501 NE Medical Center Dr.• Send

541-382-4900

ww w.bendmemorialdinic.com

929 SWSimpson Ave.,Suite 220 • Send

541-317-5600

929 SWSimpson Ave.,Suite 220 •Send

541-317-5GOO

n/a

CAREY ALLEN, MD

St. Charles Familp Care

1103 NE Elm St.• Prineville

541-447-6263

www .stcharleshealthcare.org

HEIDI ALLEN, MD

St. Charles Family Care

1103 NE Elm St.• Prineville

541-447-G2G3

ww w .stcharleshealthcare.org

211 NW Larch Ave.• Redmond

541-548-21 G4

w w w.stcharleshealthcare.org

630 N Arrowleaf Trail• Sisters•

541-549-1318 + www.stcharleshealthcare.org

+THOMAS L. ALLUMBAUGH, MD St. Charles Familp Care SONI ANDREINI, MD

St. Charles Family Care

KATHLEEN C. ANTOLAK, MD Bend Memorial Clinic

1501 NE Medical Center Dr.• Send

541-382-4900

ww w.bendmemorialdinic.com www .stcharleshealthcare.org

JOSEPH BACHTOLD, DO ~

St. C harles Family Care

630 Arrowleaf Trail• Sisters

541-549-1318

JEFFREY P. BOGGESS, MD

Ben d Memorial Clinic

815 SWBond St. • Bend

541-382-4900

ww w.bendmemorialdinic.com

1103 NE Elm St.• Prineville

541-447-G2G3

ww w .stcharleshealthcare.org

SHANNON K. BRASHER, PA-C St. Charles Family Care

MEGHANBRECKE, DO

St. Charles Familp Care

2965 NE ConnersAve., Suite 127 • Bend

541-706-4800

www .stcharleshealthcare.org

NANCY BRENNAN, DO

St. Charles Family Care

2965 NE Conners Ave., Suite 127• Bend

541-70G-4800

www .stcharleshealthcare.org

WILLIAM C.CLARIDGE, MD

St.Charles Familp Care

211 NW Larch Ave.• Redmond

541-548-2164

www .stcharleshealthcare.org

MATTHEW CLAUSEN,MD

St. Charles Family Care

2965 NE ConnersAve., Suite 127 • Bencl

541-70G-4800

www .s charleshealthcare.org

CARRIE DAY, MD

High Lakes Health Care Upper Mill

929 SW Simpson Ave.• Bend

541-389-7741

ww w.highlakeshealthcare.com

MAY S. FAN,MD

Bend Memorial Clinic

231 East CascadesAve~ Sisters

541-549-0303

ww w.bendmemorialchnic.com

JAiiUEFREEMAN, PA-C

High Lakes Health Care Upper Mill

929 SW Simpson Ave.• Bend

541-389-7741

ww w.highlakeshealthcare,com

YVETTE GAYNOR, FPN-C

St.Charles Family Care

630ArrowleafTrail• Sisters

541-549-1318

www.stcharleshealthcare.org

MARK GONSKY,DO

St.Charles Familp Care

2965 NE Conners Ave., Suite 127• Bend

541-70G-4800

www.stcharleshealthcare,org

NATALIEGOOD, D

St.Charles Family Care

1103 NE Elm St.• Prineville

541-447-6263

www.s charleshealthcare.org

BRIANNA HART, PA-C

St.Charles Familp Care

211 NW Larch Ave.• Redmond

541-548-21G4

www.stcharleshealthcare,org

45 NW4th t. • Redmon

41-923-0119

www.co .net

Redmond Bt Sisters

541-382-4900

www.bendmemorialdinic.com

929 W tmpson ve. • Ben

41-389-7741

www. ighlakeshe thcare.com

645 NW 4th St.• Redmond

541-923-0119

www.cofm.net

211 NW Lar Ave. • Re mon

541-548-21G4

GARET4PEGGP' HAYNER,FIP

ALAN C. HILLES, MD

IDI HOLMES, PA-

MARKJ. HUGHES, D.O

•

Central Oregon Family Medidne Bend Memorial Clinic rg La es eal

are p p e r ll

Central Oregon Family Medidne St. C ar es Fam' Care

www.st ar es ea care.or

2015 CENTRAL OREGON M E D ICAL DIRECTORY PAMELAJ. IBBY, MD

St.Charles Familp Care H

DAVID KELLY, MD

High LaPes Health CareUpper Mill

541-548-21G4

www. stcharleshealthcare.org

929 SW Simpson Ave.• Bend

541-389-7741

ww w . ighlakeshealthcare.com

MAGGIE J. KING, MD

St.Charles Family Care

1103 NE Elm Str.• Prineville

541-447-6263

www .stcharleshealthcare.org

PETER LEAVITT, MD

St.Charles Family Care

2965 NE Conners Ave., Suite 127• Bend

541-706-4800

www .stcharleshealthcare,org

JINNELL LEWIS, MD

St.Charles Familp Care

480 NE A St.• Madras

541-475-4800

www . stcharleshealthcare.org

CHARLOTTELIN, MD

Bend Memorial Clinic

815 SWBond St.• Bend

541-382-4900

ww w.bendmemorialchnic.com

KAE LOVERINK, MD

High LakesHealth Care -Redmond —U~ . High LaPes Health Care Upper Mill

236 NW Kingwood Ave.• Redmond

541-548-7134

ww w .highlakeshealthcare.com

• •~+ 929 SW Simpson Ave. Bend

541-389-7741

ww w . ighlakeshealthcare.com

211 NW Larch Ave.• Redmond

541-548-21G4

www.stcharleshealthcare.org

541-923-0119

www.cohnÃt

1245 NW 4th St., Suite 201• Redmond

541-323-4545

www.redmondmedical.com

•

STEVEMANN, DO

JOE T. MCCOOK,MD

St.Charles Familp Care

G. BRUCEMCELROY, MD

Cmtral Or emj FILily Medidn

LORI MCMILLIAN, FNP

Redmond Medical Clinic

EDEN MILLEB, DO

High Lakes Health Care Sisters

354 W Adams Al 8 Sister

541-549-9609

. ighlakeshealthcare.co

KEVIN MILLER,DO

High Lakes Health Care Sisters

354 W Adams Ave.e• Sisters

541-549-9609

ww w .highlakeshealthcare.com

JESSICAMORGAN, MD

High Lakes Health Care Upper Mill

929 SW Simpson Ave.• Bend

541-389-7741

.highlakeshealthcare.co

DANIEL J. MURPHY, MD

St.Charles Family Care

211 NW Larch Ave.• Redmond

541-548-2164

www .stcharleshealthcare.org

AIMEE NEILL,MD

St.Charles Family Care

80 NE A St.• Madra

541-475-4800

www .stcharleshealthcare,org

SHERYL L. NORRIS, MD

St.Charles Familp Care

211 NW Larch Ave.• Redmond

541-548-21G4

www. stcharleshealthcare.org

AUBREY PERKINS, FNP

St.Charles Family Care

211 NW Larch Ave.• Redmond

541-548-2164

www .stcharleshealthcare.org

JANEY PURVIS, MD

Bend Memorial Clinic

815 SWBond St. • Bend

541-382-4900

ww w.bendmemorialdinic.com

NATHANBEED, D

St.Charles Family Care

1103 NE Elm St.t• Prineville

541-447-6263

www .stcharleshealthcare,org

KEVIN RUETER, MD

High Lakes Health Care Upper Mill

929 SW Simpson Ave.• Bend

541-389-7741P

DANA M. RHODE, DO

Bend Memorial Clinic

815 SWBond St.• Bend

541-382-4900

ww w.bendmemorialchnic.com

HANS G. RUSSELL, MD

Bend Memorial Clinic

1501 NE Medical Center Dr.• Bend

541-382-4900

ww w.bendmemorialdinic.com

ERIC J. SCHNEIDER, MD

Bend Memorial Clinic

1501 NE Medical Center Dr.• Bend

541-382-4900

ww w.bendmemorialchnic.com

LINDA C. SELBY, MD

St.Charles Familp Care

1103 NE Elm St.• Prineville

541-447-6263

www .stcharleshealthcare.org

CINDYSHUMAN, PA-C

Bend Memorial Clinic

815 SW Bond St.• Bend

541-382-4900

ww w.bendmemorialdinic.com

PATRICK L. SIMNING, MD

Bend Memorial Clinic

645 NW4th St.• Redl85

1501 NEMedical Center Dr. • Bend 5 4 1 - 382-4900 w

DAEIEL M.SKOTTE, SR.DO.,P.C High DesertFamily Medidne A immediateCare 5

211 NW Larch Ave.• Redmond

706 7 Beaver Dr. • Sunriver 5

41-59 3 - 5400

.hightg h 8th«

ww . bendmemorialdinic.com

n/a

PATRICIA SPENCER, MD

St.Charles Familp Care

480 NE A St.• Madras

541-475-4800

EDWARDM. TARBET, MD

Bend Memorial Clinic

815 SWBond St. • Bend

541-382-4900

JOHN D. TELLER, MD

Bend Memorial Clinic

NATHAN B. THOMPSON,MD

St. Charles Family Care

211 NW Larch Ave. Redmond

SHILO TIPPETT, PHD

St.Charles Familp Care

480 NE A St.• Madras

MATTIE E. TOWLE, MD

Bend Memorial Clinic

1501 NE Medical Center Dr.• Bend

541-382-4900

ww w.bendmemorialchnic.com

LISA UBI, MD

High Lakes Health Care Upper Mill

929 SW Simpson Ave.• Bend

541-389-7741J

.hightg h 8th«

St. Charle~

21~ Larcg ve 8 Redmond

541-548-21

.stcharleshealthcare.org

A. V A LENTI, MD

CINDIWARBURTON, FNP,DNP

St.Charles Familp Care B

BBUCEN. WILLIAMS, MD

i l yCar

M m ri

l ini

www.stcharleshealthcare,org ww w.bendmemorialchnic.com

1501 NE Medical Center Dr.• Bend 54 1 -382-4900 w

ww . bendmemorialdinic.com

541-548-21 G4

w w w.stcharleshealthcare.org

541-475-4800

www . stcharleshealthcare,org

2965 NE Conners Ave.,Suite 127 • Bend 1 1NEM i

n r Dr • B n

541-706-4800 4 1- 2 - 4

www.stcharleshealthcare.org n mm ri l

ini

www.stcharleshealthcare,org

St.Charles Familp Care

1103 NE Elm St.• Prineville

541-447-6263

Bend Memorial Clinic

Bend Eastside tk Redmond

541-3 8 2-4900

ww w .bendmemorialdinic.com

1501 NE Medical Center Dr.• Bend 5 4 1 - 382-4900 w

ww . bendmemorialdinic.com

RICHARD H. BOCHNER,MD

ELLENBORLAND, MS BN, CFEP Bend Memorial Clinic

ARTHUR S. CANTOB, MD

Bend Memorial Clinic

HEIDICRUISE PA-C MS

Bend Memorial Clinic

Bend Eastside StRedmond

541-3 8 2-4900

ww w .bendmemorialdinic.com

1501 NE Medical Center Dr.• Bend 5 4 1 - 382-4900 w

ww . bendmemorialdinic.com

ADVERTISING SUPPLEMENT

2015 CENTRAL OREGON M E D ICAL DIRECTOR ' I

L AUREL ~

LL, M D

Bend Memorial Clinic

1501 NE Medical Center Dr.• Bend

54 1 - 382-4900

www . bendmemorialdinic.com

CHRISTINA HATARA MD

Send Memorial Clinic

1501 NE Medical Center Dr.• Bend

541 - 382-4900

www . bendmemorialdinic.com

Bend Eastside 8JRedmond

541-382-4900

ww w.bendmemorialchnic.com

Bend Eastside th Redmond

541-382-4900

www . bendmemorialchnic.com

SIDNEY E. HENDERSON IH, MD Bend Memorial Clinic SANDRA K.HOLLOWAY MD

Bend Memorial Clinic

GLENN KOTEEN, MD

Gastroenterologyof Central Oregon

NIFER ~W

PA-C WEE D, MD

1501 NE Medical Center Dr.• Bend

541 - 382-4900

Bend Memorial Clinic

1501 NE Medical Center Dr.• Bend

54 1 - 382-4900 w ww .bendmemorialchnic.com

High Lakes Health Care Upper Mill

TAMMY BULL, MD

SUSAN GORMAN, MD

www . gastrocentraloregon.com

Send Memorial Clinic

OSVALDO A. SCHIRRIPA, MD, MS Central Oregon Clinical Genetics Center

JANE BIRSCHBACHI MD

2239 NE Doctors Dr., Suite 100• Bend 541-728-0535

High Lakes Health Care Women's Center

MICEAELJ.MASTEAEGELO I MBI FACS Bend Hernia Center

14 3 SW Shevlin-Hixion Sui Dro te203• Bend 541-678-5417

www . bendmemorialdinic.com

www.cocgc.org

929 SW Simpson Ave.• Bend

541-389-7741

ww w.highlakeshealthcare,com

929 SW Sim son Ave.• Ben

541-389-7741

www. i

541 - 5 04-7635

www . highlakeshealthcare,com

1001 NW Canal Blvd.• Redmond

2450 NEMary Rose Pl.• Bend

e se

ca r e.com

54 1 -383-2200 w ww. bendherniacente r.com

LAURIE D'AVIGNON,MD

Bend Memorial Clinic

1501 NE Medical Center Dr.• Bend

54 1 - 382-4900

www . bendmemorialdinic.com

JON LUTZ, MD

Send Memorial Clinic

1501 NE Medical Center Dr.• Bend

541 - 382-4900

www . bendmemorialdinic.com

CARMEN REBECCA SHERER, MD St. Charles Infectious Disease

JOEN ALLEN, NO

Bend Memorial Clinic

CERISTISR AEEERSON, PA-C

High Lakes Health Care Upper Mill

JENESS CHRISTENSEN, MD

High Lakes Health Care Upper Mill

JOHN CORSO,MD

High Lakes Health Care Upper Mill

2965 Conners Ave., Suite 127• Bend 541-706-4878

www.stcharleshealthcare.org

1501 NE Medical Center Dr.• Bend

54 1 - 382-4900

www . bendmemorialdinic.com

929 SW Sim~son Ave.• Bend

541-389-7741

www . highlakeshealthcare.com

929 SW Simpson Ave.• Bend

541-389-7741

www.highlakeshealthcare.com

929 SW Simpson Ave.• Bend

541-389-7741

929 SW Simpson Ave.• Bend

541-389-7741

.highlakeshealthcare.com ww w.highlakeshealthcare,com

CARRIE DAY, MD

High Lakes Health Care Upper Mill

CELSO A.GANGAN, MD

R dm d M di alCli ic

1245 4 t h St.,S t 20i • Redmond 5 41-323-4545

MICHAEL N.HARRIS, MD

Bend Memorial Clinic

1501 NE Medical Center Dr.• Bend

541 - 382-4900

www . bendmemorialdinic.com

ELIZABETH KAPLAN, PA-C

Bend Memorial Clnuc

1501 NEM d' i C

541-3 8 2 -4900

www . bendmemorlalchnic.com

541-548-7134

www.highlakeshealthcare.com

D • B d

www . redmondmedical.com

236 NW Kingwood Ave.• Redmond

ANITA D.KOLISCH, MD

High Lakes Health Care - Redmond R Bend Memorial Clinic

MATTHEW IL LASALA, MD

Bend Memorial Clinic

1501 NE htedical Center Dr.• Bend

MADELINE LEMEE, MD

High Lakes Health Care Upper Mill

929 SW Simpson Ave.• Bend

541-389-7741

www . highlakeshealthcare.com

MARY MANHKDI, MD

High Lakes Health Care Upper Mill

929 SW Simpson Ave.• Bend

541-389-7741

ww w.highlakeshealthcare.com

ANm KILLINGBECKI MD

www.bendmemorialdinic.com

SW veterans Way •Redm ond

54 1 - 382-4900 w ww .bendmemorialdinic.com

d A. WADE PARKER, MD

Bend Memorial Clinic

1501 NE Medical Center Dr.• Bend

MARK STERNFELD, MD

Bend Memorial Clinic

865 SWVeterans Way • Redm ond 541-382-4900

DAN SULLIVANI MD

Bend Memorial Clinic

1501 NE htedical Center Dr.• Bend

MARK THIBERT, MD

High Lakes Health Care Upper ivhll

DAVID TRETHEWAY,MD

High LakesHealth Care -Redmond

FRANCENA ABENDROTH, MD Bend Memorial Clinic

GREGORY FERENZ,DO

Bend Memorial Clinic

www . bendmemorialchnic.com .bendmemorialdinic.com

54 1 - 382-4900 w ww .bendmemorialdinic.com 541-3 8 9-77 4 1

www . highlakeshealthcare.com

236NW Kingwood Ave. •Redm ond

541-548-7134

ww w .highlakesheal thcare.com

1501 NE Medical Center Dr.• Bend

54 1 - 382-4900

www . bendmemorialchnic.com

41 382 4900

wwwbendmemorlalchnic com

54 1 - 382-4900

www b endmemorialdinic.com

929 SWSJ m p son Ave. Bend

%ARY BUCHH

54 1 - 382-4900

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1501 NE Medical Center Dr.• Bend

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ADVERTISING SUPPLEMENT

2015 CENTRAL OREGON M E D ICAL DIRECTORY I

CRAIGAN GRIFFIN, MD

Bend Memorial Clinic

RAY TIEN, MD, PHD

The Center: Orthopedic gtNeurosurgical CaregtResearch 2 2

BELZA, MD BRAD WARD, MD

Send Spine and Neurosurgery

The Center: Orthopedic I NcurosurgicalCareI Research 2 2

ANNIE BAUMANN, RD, LD

Bend Memorial Clinic

1501 NE Medical Center Dr.• Bend 54 1 - 382-4900 w

I ww . bendmemorialchnic.com

ANN-BRIDGETBIRD,MD

St.Charles Center forWomen's Health

Locations in Redmond SI Prineville

5 4 1 - 526-G635

www.stcharleshealthcare.org

KARENCASEY,WHCNP

St. Ch 1 C

Locations in Redmond SI Prineville

54 1 - 526-G635

www.stcharleshealthcare.org

NATALIE HOSHAW,MD

St. Charles Center for Women's Health

AMY B MCELROY FNP

Stbhartes Center for Women's Health

Loc a tions in Redmond 8a Prineville 5 4 1 - 526-6635 w ww. stcharleshealthcare.org ,R, R R ,R , calio n s in Redmond SI Prineville www.stcharleshealthcare.org

CLARE THOMPSON, DNP,CNM

St. Charles Center for Women's Health

Loc a tions in Redmond SI Prineville 5 4 1 - 52G-GG35 w ww . stcharleshealthcare,org

GLYNDACRABTREE, MD

Your Care

3818 SW 21St. Pl., Suite 100• Redmond 541-548-2899

www.yourcaremedical.com

ITA HENDERSON, MD

Your Care

818 SW 21St.PL, Suite 100• Redmond 541-548-2899

www.yourcaremedical.com

for W o men's Health

1501 NE Medical Center Dr.• Bend 54 1 - 382-4900 w

00 NE Neff Rd. • B end 5

The Center: Orthopedic I Ncurosurgical Care I Research

JAMES NELSON,MD

The Center: Orthopedic I Ncurosurgical Care I Research ~2

LARRY PAULSON, MD

The Center: Orthopedic I Neuroscugical Care I Research

ERIC WATTENBURG, MD

Your Care

00 NE Neff Rd. • Bend ~ 5

•

TIMOTHY HILL,MD

4 1-3 82 - 3 3 4 4

2275 NE Doctors Dr., Suite 9• Ben 5 4 1 - G 47-1G38

•

. •

4 1-3 8 2 - 3 3 44

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www.thecenteroregon.com www.belzamd.com www.thecenteroregon.com

2200 NE Neff Rd.• Bend

541-382-3344

www.thecenteroregon.com

2 0 0 NE Neff Rd. • Bend

541-382-3344

www.thecenteroregon.com

2200 NE Neff Rd• Bend

541-382-3344

www.thecenteroregon.com

3818SW21St.Pl.,Suitel00• Redmond 541-548-2899 w

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ROB BOONE, MD

St. Charles Cancer Center

Locations in Bend 8I Redmond

541-706-5800

www .stcharleshealthcare.org

CORA CALOMENI,MD

St. Charles Cancer Center

Locations in Bend SI Redmond

541-706-5800

www .stcharleshealthcare.org

B RIAN L ERI

Bend Memorial Clinic

Bend Eastside Redmond

541-382-4900

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N, M D

STACIE KOEHLER, MD

St. Charles Cancer Center

Locations in Bend SI Redmond

541-706-5800

www . stcharleshealthcare.org

STEVE KORNFELD, MD

St. Charles Cancer Center

Locations in Bend 8I Redmond

541-706-5800

www . stcharleshealthcare.org

BILL MARTIN,MD

St. Charles Cancer Center

Locations in Bend 8I Redmond

541-706-5800

www. stcharleshealthcare.org

1501 NE Medical Center Dr.• Bend

541-382-4900

ww w.bendmemorlalchnic.com

Locations in Bend 8I Redmond

541-706-5800

BENJAMIN J. MIRIOVSKY, MD Bend Memorial Clinic St. Charles Cancer Center

MICHAEL MONTICELLI,MD URIE RICE, ACNP-BC

e nd emori

inr c

WILLIAM SCHMIDT, MD

Bend Memorial Clinic

JOHN WINTERS,MD

St. Charles Cancer Center

' I

1 1

www.stcharleshealthcare.org www. endmemonaldinrc.com

edi c a l enter r.• end

Bend Eastside SI Redmond

541-382-4900

Locations in Bend SI Redmond

541-706-5800

ww w.bendmemorialdinic.com www.stcharleshealthcare.org

MATTHEW N. SIMMONS

UrologySpedalistsofO regon

1247 NE Medical Center Dr.• Bend 54 1 -322-5753 w

BRIAN P. DESMOND, MD

Bend Memorial Clinic

Bend Eastside, Westsidegi Redmond 541-382-4900

THOMAS D.FITgSIMMONS,MD,MPH

end e morsal 1

'd,

ww. u rologyinoregon.com

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' ld'

ROBERT C. MATHEWS, MD

Be n d Memorial Clinic

BendEastside,WestsideSIRedmond 54 1-382-4900

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SCOTT T.O'CONNER, MD

Bend Memorial Clinic

Bend Eastside, Westside 8I Redmond 5 4 1-382-4900

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KIT CARMIENCKE,OD

Integrated Eye Care

KHSTEN CARMIENCKESCOTT,OD Inte ated Ey a

452 NE Greenwood Ave.

541-382-5701

www.iebend.com

4 52NE

541-382-5701

www.iebend.

w odA v .

knv I

2015 CENTRAL OREGON M E D ICAL DIRECTORY I '

MARY ANN ELLEMENT, OD

Int e grated Eye Care

452 NE Greenwood Ave.

541-382-5701

MICHAEL MAJERCZYK, OD

Be n d Memorial Clinic

Bend Eastside ttr Westside

541-382-4900

www.iebend.com ww w.bendmemorialdinic.com

I •

KEITH E. KRUEGER, DMD, PC Keith E. Krueger, DMD, PC I '

1475 SWChandlerAve., Suite 101• Bend 541-617-3993 w

ww.d r keithkrueger.com

I I

AARONASKEW,MD

Desert Orthopedics

ANTHONY BINZ MD

The Center. O rthopedtc tt Neurosurgtcal Care gtResearch ~ 2 2 0 0

JEFFREY P. HOLMBOE, MD

The C enter: Orthopedic I Neurosurgical CaregtResearch Locations in Bend gt Redmond 5

4 1-3 8 2 -3344

www.thecenteroregon.com

JOEL MOORE,MD, MPH

The Center: Orthopedic tt NeurosurgicalCaregtResearch 2 2

4 1-3 82 - 3 3 4 4

www.thecenteroregon.com

I '

KNUTE BUEHLER, MD

•

Locations in Bend ttr Redmond

0 0NE Neff Rd. • B end 5

The Cent'eer: Trthopedictr NeurosurgtcalCareIhtIesear

ERIN FINTER, MD

Desert Orthopedics

MICHAEL RYAN, MD

•

www. t hecenteroregon.com

541-382-3344

www.thecenteroregon.com

2200 NE Neff Rd.• Bend

541-382-3344

www.thecenteroregon.com

Locations in Bend gt Redmond

541-388-2333

www.desertorthopedics.com

541-382-3344

www.thecenteroregon.com

541-388-2333

www.desertorthopedics.com

The Center: Orthopedic tt NeurosurgicalCaregtResearch 2 2

•

www . desertorthopedics.com

5 41-382-3344

0 0NE Neff Rd. • Bend

MICHAEL CARAVELLI,MD

ROBERT SHANNON,MD

541-388-2333

•

The Center: Orthopedic gtNeurosurgical CaregtResearch 2 2

AMES HALL MD

NE Neff Rd.• Bend

0 0NE Neff Rd. • Bend

Locations in Bend gt Redmond I

• I •

Desert Orthopedics

1303 NE Gushing Dr., Suite 100• Send 541-388-2333 w

GREG HAs MD

Desert Orthopedics

1303 NE Gushing Dr., Suite 100• Bend 541-388-2333

www.desertorthopedics,com

KATHLEEN MOORE, MD

uesert Orthopedics

1303 NE Gushing Pr., Suite 100• Send 541-388-2333

www.desertorthopedics.com

I '

•

541-382-3344

www . thecenteroregon.com

541-388-2333

www . desertorthopedics.com

00 NE Neff Rd. • Bend

541-382-3344

www . thecenteroregon.com

The Center: Orthopedic tt NeurosurgicalCaregtResearch Locations in Bend gt Redmond

541-382-3344

www . thecenteroregon.com

TIMOTHY BOLLOM, MD

The Center: Orthopedic I NeurosurgicalCareI Research 2 2

BRETT GINGOLD MD

Desert Orthopedics

SCOTT JACOBSON,MD

The Center: Orthopedic gtNeurosurgical CaregtResearch 2 2

BLAKE NONWEILER,MD I '

•

CARAWALTHER, MD I '

ww. desertorthopedics.com

1315 NW 4th St.• Redmond

• I •

Desert Orthopedics

00 NE Neff Rd. • Bend

• I •

1303 NE Gushing Dr., Suite 100• Send 541-388-2333 w

ww. desertorthopedics.com

The Center: Orthopedic I NeurosurgicalCareI Research Locations in Bend gt Redmond

541-382-3344

www . thecenteroregon.com

NNETH HANINGTON,MD +AARON HOBLET, MD

Desert Orthopedics

Locations in Bend tk Redmond

541-388-2333

www . desertorthopedics.com

Desert Orthopedics

Locations in Bend gt Redmond

541-388-2333

www .desertorthopedics.com

+ OMA LILLY,

The Center: Orthopedic gt Neurosurgical CaregtResearch ~2

2 0 0 NE Neff Rd. • Bend

541-382-3344

www . thecenteroregon.com

The Center: Orthopedic I Neurosurgical Care I Research

Locations in Bend gt Redmond

541-382-3344

www . thecenteroregon.com

MOLLY OMIZO, MD

DeschutesOsteoporosis Center

2200 NE Neff Rd., Suite 302• Bend 5 4 1 - 3 88-3978 w w w.deschutesosteoporosiscenter.com~

JENNY BLECHMAN, MD

Partners In Care

2075 NE Wyatt Gt.• Bend

541-382-5882

www.partnersbend.org

LISA LEWIS, MD

Partners In Care

2075 NE Wyatt Ct.• Bend

541-382-5882

www.partnersbend.org

RICHARD J.MAUNDER, MD

St. Charles AdvancedIllness Management

2500 NE Neff Rd.• Bend

541-706-5885

www .stcharleshealthcare.org

LAURA K.MAVITY, MD

St. Charles AdvancedIllness Management

2500 NE Neff Rod.• Bend

541-706-5885

www .stcharleshealthcare.org

MICHAEL COE,MD

JAMES VERHEYDEN, MD I ' I ' I

STEPHANIECHRISTENSEN, DMD Deschutes Pediatric Dentistry

1475 SWChandler Ave., Suite 202 • Bend 541-389-3073 w

ww.d eschuteskids.com

ADVERTISINGSUPPLEMENT

2015 CENTRAL OREGON M E D ICAL DIRECTORY STEVE CHRISTENSEN,DMD D e s c hutes Pediatric Dentistry

1475 SWChandler Ave., Suite 202 • Bend 541-389-3073

www.deschutesktds.com

BROOKS BOOKER,MD

Bend Memorial Clinic

815 SW Bond St.• Bend

KATE L. BROADMAN, MD

Ben Memorr C uuc

815

CARRIE DAY, MD

High Lakes Health Care Upper Mill

THOMAS N. ERNST, MD

S t. C ares am y a r e

JEIIFER GRISWOLD,PNP

Bend Memorial Clinic

815 SW Bond St.• Bend

541-382-4900

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MICHELLE MILLS, MD

Bend Memorial Clinic

815 SW Bond St.• Bend

541-382-4900

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on t .

541-382-4900

www. en memona uuc.com

929 SW Simpson Ave.• Bend

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541-389-7741

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MARGARET J PHILPs MD

St.Charles Family Care

211 NW Larch Ave.• Redmond

541-548-21G4

JENNIFER SCHROEDER, MD

Bend Memorial Clinic

815 SW Bond St.• end

541-382-4900

RUPERT VAL~

St.Charles Family Care

211 NW Larch Ave.• Redmond

541-548-21G4

JB WARTON, DO

Bend Memorial Clinic

815 SW Bond St.• end

541-382-4900

ww w .bendmemorialchnic.com

ROBERT ANDREWS, MD

Desert Orthopedics

Locations in Bend St Redmond

541-388-2333

ww w .desertorthopedics.com

Ha La es Heal C are Upper MTH

929 SW Stmpson Ave.• Ben

541-389-7741 w w w.ht

IND CARROLL, MD

www.stcharleshealthcare.org ww w .bendmemorialchnic.com

www.stcharleshealthcare.org

l a keshealthcare.com

TIM HILL, MD

The Center: Orthopedic A NeurosurgicalCareAResearch Locations in Bend St Redmond

NANCY H. MALONEY MD

Bend Memorial Clinic

JAMES NELSONs MD

The Center: Orthopedic StNeurosurgical CareStResearch

2200 NE Neff Rd.• Bend

541-382-3344

www.thecenteroregon.com

LARRY PAULSON, MD

The Center: Orthopedic tit Neurosurgical Care 8Research

2200 NE Neff Rd.• Bend

541-382-3344

www.thecenterore on.com

DAVID STEWART, MD

The Center: Orthopedic StNeurosurgical CareStResearch

2200 NE Neff Rd.• Bend

541-382-3344

www.thecenteroregon.com

JONSWIFT, DO

Desert Orthopedics

Locations in Bend Redmond

541-388-2333

www . desertorthopedics.com

VIVIANE UGALDE,MD

The Center: Orthopedic StNeurosurgical CareStResearch

2200 NE Neff Rd.• Bend

541-382-3344

www.thecenteroregon.com

DEAN NAKADATE, DPM

DeschutesFoot 8tAn kle

541-382-3344

www.thecenteroregon.com

1501 NE Medical Center Dr.• Bend 5 4 1 - 382-4900 w w w .bendmemorialchnic.co

929 SW Simpson Ave.,Suite 220 • Bend 541-317-5600 w w w .deschutesfootandankle.com

BROOKEHALL, MD I

St.Charles Preoperative Medidne

2500 NE Neff Rd.• Bend 5

41-70 6 -2949 w

ww. stcharleshealthcare.org

JONATHANBREWER,DO,D-ABSM BendMemorial Clinic JAMIEDAVID CONKLIN, MD S t .

LOUIS D'AVIGNON,MD

C harles Heart gt Lung Center Bend Memorial Clinic ar es ea

CHRIS KELLEY, DO,D-ABSM

StLung Cen

Bend Memorial Clinic

NATHAN M FADYEN, NP-B B e n

M emori C inic

Bend Eastside ARedmond

541-382-4900

ww w.bendmemorialdinic.com

Locations in Bend ARedmond

541-706-7715

www .stcharleshealthcare.org

Bend Eastside StRedmond

541-382-4900

ww w .bendmemorialchnic.com

Locations tn Bend gt Redmond

541-706-7715

www.s charleshealthcare.org

Bend Eastside gtRedmond

541-382-4900

www.bendmemorialdinic.com

1501 NE Medical Center Dr.• Bend

541-382-4900

ww w . en memoria inic.com

KEVIN SHERER, MD

St. Charles Heart tk Lung Center

Locations in Bend gtRedmond

541-706-7715

www.stcharleshealthcare.org

EMILY SPEELMON, MD

St.Charles Heart gtLung Center

Locations in Bend ARedmond

541-706-771 5

www.stcharleshealthcare.org

TRACI CLAUTICE-ENGLE,MD

Central Oregon Radiology Assodates, P.C. 1460 NE Medical Center Dr. • Bend 541 -382-9383

www.corapc.com

ROBERT HOGAN,MD

Central Oregon Radiology Assodates, P.C. 1460 NE Medical Center Dr. • Bend 541 -382-9383

www.corapc.com

STEVEN MICHEL, MD

Central Oregon Radiology Assodates, P.C. 1460 NE Medical Center Dr. • Bend 541 -382-9383

www.corapc.com

PATRICKBROWN, MD

Central Oregon Radiology Assodates, P.C. 1460 NE Medical Center Dr. • Bend 541 -382-9383

www.corapc.com

STEVE EJOBECH,MD

Central Oregon Radiology Assodates, P.C. 1460 NE Medical Center Dr. • Bend 541 -382-9383

www.corapc.com

AUVERTISINGSUPPLEMENT

2015 CENTRAL OREGON M E D ICAL DIRECTORY GARRETT SCHROEDER7 MD

Cen t ral Oregon Radiology Assodates, P.C. 14 60 NE Medical Center Dr. • Bend

541-382-9383

www.corapc,com

DAVID ZULAUF, MD

Central Oregon Radiology Assodates, P.C. 1460 NE Medical Center Dr. • Bend

541-382-9383

www.corapc,com

Central Oregon Radiology Assodates, P.C. 1460 NE Medical Center Dr. • Bend

541-382-9383

www.corapc,com

Central Oregon Radiology Assodates, P.C. 1460 NE Medical Center Dr. • Bend

541-382-9383

www.corapc,com

~ THOMAS KOEHLER, MD JOHH STASSEN4 MD

•

I ' ' I

•

JEFFREY DRUTMAH4 MD

Central Oregon Radiology Assodates, P.C. 1460 NE Medical Center Dr. • Bend

541-382-9383

www.corapc,com

ROHALD HAHSOE4 MD

R R . • • Q Central Oregon Radiology Assocrates, P.C.

60 N E Medical Center Dr. • Bend

541-382-9383

www.corapc,com

JAMES JOHESOH 7 MD

Central Oregon Radiology Assodates,P.C. 1460 NE Medical Center Dr.• Bend

541-382-9383

www.corapc,com

Central Oregon Radiology Assodates, P.C. 1460 NE Medical Center Dr. • Bend

541-382-9383

www.corapc,com

Central Oregon Radiology Assodates, P.C. 1460 NE Medical Center Dr. • Bend 541 -382-9383

www.corapc,com

Central Oregon Radiology Assodates, P.C. 1460 NE Medical Center Dr. • Bend 541 -382-9383

www.corapc,com

Central Oregon Radiology Assodates, P.C. 1460 NE Medical Center Dr. • Bend 541 -382-9383

www.corapc,com

Centr Oregon Ra ioogy Assodates, P.C.

www.corapc,com

~L L I AM WHEIR III, MD

LAURIE MARTIN,MD I

•

PAULASHULTZ, MD I

•

STEPHENSHULTZ, MD

hCLOESHELTOE

1460 NE Me tcaCenterDr.• Ben 541-382-9383

HOREEN C. MILLER, FHP

St. Charles Rehabilitation Center

2500 NE Neff Rd.• Bend

541-706-7725

CHRISTIMA BRIGHT, MD

Bend Memorial Clinic

Send Eastside 8t Redmond

541-3 8 2-4900

DAEIEL E. FOHRMAE 5 MD

Deschutes Rheumatology

2200 NE Neff Rd., Suite 302• Bend 54 1 -388-3978 w w w.deschutesrheumatology.com

HEATHERHAESEE-DISPEIIZA, MD

Deschutes Rheumatology

2200 NE Neff Rd., Suite 302• Send 541 -388-3978 w w w.deschutesrheumatology.com

TIAIA WELCH, PA

Deschutes Rheumatology

2200 NE Neff Rd., Suite 302• Bend 54 1 -388-3978 w w w.deschutesrheumatology.com

JOEATHAIIBREWER, DO,D-ABSM

Bend Memorial Clinic Sleep Disorders Center1080 SW Mt. Bachelor Dr.• Bend(West) 541-382-4900

ARTHUR IL COHRAD4 MD

St.Charles Sleep Center

Locations in Bend gt Redmond

541- 7 0G-G905

www.stcharleshealthcare,org

DAVID L. DEDRICK, MD

St.Charles Sleep Center

Locations in Bend gt Redmond

541- 7 0G-G905

www.stcharleshealthcare,org

CHRIS KELLEY, DO, D-ABSM B end Memorial Clinic Sleep Disorders Center1080 SW Mt. Bachelor Dr.• Bend(West) 541-382-4900 I

DAVID HERRIN7 DC

TIMOTHY L. BEARD, MD, FACS Bend Memorial Clinic DAVID CAME, MD

St. Charles Surgical Spedalists

GARY J. FREI, MD, FACS

Bend Memorial Clinic

JACK W. HARTLEY, MD, FACS

St. Charles Surgical Spedalists

SEAH HEALY, PA-C

Bend Memorial Clinic

ww w .bendmemorialdinic.com

www.bendmemorialdinic.com

ww w.bendmemorialdinic.com

Redmond WellnessggChiropractic

•

www .stcharleshealthcare,org

•

1655 SW Highland Ave,Suite 6 • Redmond

541-923-2019

1501 NE Medical Center Dr.• Send

541-382-4900

1103 NE Elm ~ PrineviHe •

Send Eastside 8t Redmond

541-545-7751 ~

541-382-4900

1245 NW 4th St., Suite 101• Redmond 541-548-77G1

1501 NE Medical Center Dr.• Send 54 1 -382-4900 w

www.drherrin,com

ww w.bendmemorialdinic.com gh 1 h 11 5

ww w.bendmemorialdinic.com www.stcharleshealthcare,org ww . bendmemorialdinic.com

2015 CENTRAL OREGON M E D ICAL DIRECTORY DARRENM. KOWALSKI, MD, FACS BendMemorial Clinic

JOHN C. LAND, MD, FACS

St. Charles Surgical Spedalists

SUZANNEMARCATO,PA

St. Charles Surgtcal Spe 'al'

ANDREW SARGENT, PA-C, MS Bend Memorial Clinic

1501 NE Medical Center Dr.• Bend 54 1 -382-4900 w 1245 NW4th St., Suite 101• Redmond 541-548-7761 w 0 3NEE1

'll

41 54 7761

1501 NE Medical Center Dr.• Bend 54 1 -382-4900 w

ww . bendmemorlalchnic.com ww. stcharleshealthcare.org

tcharleshealthcare.org ww . bendmemorialdinic.com

RONALD SPROAT MD

St. Charles Sur 'cal Spedalists

GEORGE T. TSAI, MD, FACS

S t . Charles Surgical Spedalists

JEANNEWADSWORTH,PA-C, MS

Bend Memorial Clinic

1501 NE Medical Center Dr.• Bend 5 4 1 - 382-4900 w

ww . bendmemorialchnic.com

ERIN WALLING, MD, FACS

Be n d Memorial Clinic

1501 NE Medical Center Dr.• Bend 54 1 -382-4900 w

ww . bendmemorialdinic.com

ERINBUTLER, PA-C

Bend Memorial Clinic

DIANA BURDEN,FNP-C

Mountain Medical Immediate Care

JEFF CABA,PA-C

Bend Memorial Clinic

Bend Eastside,Old Mill District, Redmond 541-382-4900

ww w.bendmemorialdinic.com

ANNCLEMENS,MD

Bend Memorial Clinic

Bend Eastside, Old Mill District, Redm

ww w .bendmemorialchnic.com

TERESA COUSINEAU, PA-C

Bend Eastside, Old Mill District, Redmond 541-382-4900

HHCIA COUTURE, FNP

Bend Memorial Clinic R Your Care

GLYNDA CRABTREE, MD

Your Care

BRIAN DAILY PA-C

Mountain Medical Immediate Care

SCOTT FLECK, PA-C

Bend Memorial Clinic

ONICA GIAMELLARO,PA-

KEITH HARRINGTON,MD

1103 NE Elm ~ Prineville

541-548-7761

1245 NW 4th St., Suite 101• Redmond 541-548-7761

Bend Eastside,Old Mill District, Redmond 541-382-4900 1302 NEThird St. • Bend

541-317-0909

541 - 3 82-4900

S81St. PL, Suite100• Redmond

541-317-0909

Bend Eastside,Old Mill District, Redmond 541-382-4900

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Irma Fella, of5an Diego, looks at the stuffed animals she received whilein the hospitalin 2013. Fella has Down syndrome and Alzheimer's disease. Atright, Fella's signatureon forms from 1999to2004show her deterioration.

Continuedfrom page 31 She had taken to merely circling every letter. There were other clues of her slow decline. One year for Christmas, Irma's brother had bought sketchbooks for everyone in the family, asking them to do a doodle each day and then return the books to him the following Christmas. "And the only person who did it was my sister," Evelyn said. But herbrother was so pleased,the sketchbook became an annual gift. Irma would draw what she saw freehand, filling page after page, before exchanging the full book for a fresh one the following holidays. With time, she could no longer draw, so Evelyn transitioned her to coloring books. She impressed the others at her day program with how well she could color within the lines. That skill soon faded as well, and she took to drawing first circles and then only straight lines. Evelyn realized her sister was backtracking through normal childhood development. While infants progress from straight lines to circles, to coloring, to freehand drawing, Irma was doing just the opposite. She was slowly but steadily regressing. In 2011, Evelyn happened upon an even more stark demonstration of her sister's decline. Each year, they would meet with the staff at the local day program, and Irma would sign her name at the bottom of her paperwork. At one of her last meetings, Evelyn glanced at the years of documents in her sister's file dating back to 1999. Then she noticed something remarkable. As she lined up the papers up, she could see the visual representation of how Alzheimer's disease was affecting Irma. The signatures had gone from a tight, neat cursive of her full name, Irmagard Fella, to increasingly more chaotic block printing of her shortened name. After 12 years, she could barely get a few letters down on the line. Evelyn took a copy of the signatory timeline and shared it with Down syndrome researchers at the University of California, San Diego. After a news report including a photo of the signatures, the image went viral garnering tens of thousands of hits and hundreds of pointed comments.

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"What was pushing everybody's buttons," Evelyn said, "was the realization of 'Look what's happening to us all."' The image had been circulating without the accompanying article and most of those responding online didn't know that Irma had Down syndrome. Evelyn realized that, for a brief moment, Irma was being treated just like anybody else's sister, mother or grandmother with Alzheimer's disease."Finally," she thought to herself, "she is equal."

New hopes fact the fates of those with Alzheimer's, whether due to Down syndrome or normal aging, are becoming increasingly intertwined. Researchers have found many treatments for Alzheimer's disease th t ork well in mice but have been hard to translate into humans, says Dr. Bill Mobley, chair of neuroscience at the University of Ca ifornia, San Diego. "One of the reasons we think that is, is that we haven't been able to start early enough," he said. "By the time people have clinical symptoms they'vehad the disease probably 20 years.We need to get to them earlier. And the people with Down syndrome offer that opportunity. In the general population, about 17 percent of women who reachage age 65 and about 9 percent of men will develop Alzheimer's disease. That means studies testing preventive treatments wouId have to enroll many more individuals to get the numbers of Alzheim er's cases needed to see a meaningful effect.Among those with Down syndrome, the lifetime risk is higher than 50 percent, so researchers would need to enroll fewer overall participants to get

WINTER/SPRING2015â&#x20AC;˘HIGH DESERTPULSE

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Feature(DOWN SYNDROME AND ALZHEIMER'S

the same number of people who ultimately develop Alz heimers. ' Mobley recalls a discussion at a research conf g over t e need foracheap, reliable diagnostictest that would ident ify much earlier in life the patients destined t d I t ose are the criteria, the answer is Down syndrome" M bl c make the diagnosis even in utero. The test I recalls say'ing. "I can use is my eyesight and my brain, and I know 50 years before the ' w with i aa onset of dementia that this is person is going to get dementia very high probability." At the time e, nobody seemed to get it. But that hashc anged now, Mobley said. "I think the reaso ason why is that they now understand it may be absolutely necessary to prevent Alzheimer's z eimers disease d' if we want to a i, e sai . "So then the genetically predisposed populations SUBMITTED PHOTO ee di iaagbecome ecome the theones onesyou o want to test,because you can makee th nosis (so much earlier)." JustineDyer , 27of , of M a ine, ata restaurantin Boston, shorti f Previousl sly, much of Alzheimer's research had a ocused f on fami- in g with Dr.nBrian Sko 8 ic n N lies with a e df «h I o Al h i ' Af-50 chanceof passing thatdefect fectedfamily members have a 50on to their children. But while scores of those ose amiies familieshave have been bee identified around the e wor, worldthere the are many more individuals wi with The Phase II study was primarily y aime aim aim dattt testingthe saf a et y of Down syndrome. the drugs in youn g adu l ts with Down syndrome and e th 23t e s t "There's not even any comparison," Mobley said. i . nt "I he U . S.,there subjectsre ortedn n ' 20000 0 people a statisticall i ifi are 200000 OD Do do o I Th egiver-reported ' cli (f il i IAI h i f ili ) i t h' g those on the medication, compared opace t I bo.. y po ' g individuals with cognitive deficits in research studies The compan y is i now planning a Phase III trial to test the dru s e challenging, because of concerns that a ethe y may ma not truly l arger group of patients. "For me iit's ' a human-rights issue," Skotkosai understand the e ris risks s involved. involved. Researchers have been collaborato r me, said. . ou "Y an dI could ing on standards for how to best explain in the e process and to make si gn n uupif i w we wanted to for clinical drug trialsan a dnow in dividuals s ure they understand they don't have toparticipate. t' with Dow wi o w n syndrome, with the guidance of their tru Justine Dyer, a 27-year old with Down own syn s ndr rome from Maine, givers, can si n u in th rt was a artici an ' I I I o d db T i io fo Therapeutics forthe drug ELND005. The com o " "" " " h r 'n N rt" ' h b ' la ar I " " " " h I3 I c l f I cl b fo y an as a treatment for viduals who might develop late-onset Alzheimer's. Alzheimer's disease. o" o iv own syn rome D d h t d to b i t h t dy "to o help m y b rain"and ' " d o n'tseeitthatway. '

," Hogan said. Her grandmother died of Alzheimer's," her r mo mother er, Bets etsy D Dyer, syndrome," ai . "If said. "So we asaa ami family are very anxious to participate in this is in kind b e t h e re, isn't it in their best interest toytroto fin o h g h of a study." s ow own the progression for them as well e as asort f h egenDyer er said the researchers did a wonderful er u jo' bexplaining the eral population?" study to Justine us ine, using pictures to help her understand. an . It would be an ironic "The bottom line ' e is ' she trusts me and she believes that I wouldn't know i ies t an t eir contri' ' 'd " f " h kh d h' h If we succeed in preventing or curing Alzheimer's di J ustine said the researchers were "reall y nice, nice" and d called Dr. Bri- Down syndrome o ,h yo ' an Skotko h a o w n y n rome M o ble a y said."I p g p ic o payattenPro ram igaors o t e study, t i o n to it. Therealit i y isisthe ey ve 'veh ad this wonderful value as huma uman "awesome." beings all along." • il

WINTER/SPRING 201 •5HIGH DESERTPULSE

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