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families

NEFL.MedicalJournal.Round 2.5.10:Layout 1 5/14/10 4:16 PM Page 1

www . DCMS online . org Northeast Florida Medicine Vol. 61, No. 2 2010 3

Features9 LikeTallPines,ResidentsReachforHighGoals

11 ResidentScholarlyActivityFocusesonthePursuitofKnowledge J.BrackenBurns,Jr.,DO,GuestEditor

12 AbstractCategory1-Prospective

17 AbstractCategory2-Retrospective

21 AbstractCategory3-CaseStudy27 FromaResident’sPerspective SpecialArticles35 HighRiskStressinHighRiskCareers:ManagingPhysicianStress(CME)KamelaK.Scott,PhDandDavidJ.Chesire,PhD

44 SpecialCaseStudy-IsEarlyTPNinHyperemesisGravidarumWorththeRisk? KarishmaRamsubeik,MD,etal

45 UpdateonHaitiReliefEfforts

VOLUME 61, NUMBER 2ResidentResearchSummer2010

EDITOR IN CHIEFJoanL.Huffman,MD

MANAGING EDITORLeoraLegacy

ASSOCIATE EDITORSRaedAssar,MDHernanChang,MDKathyHarris(Alliance)JoanHarmon(Alliance)SunilJoshi,MDJamesJoyce,MDNeelKarnani,MDSenthilMeenrajan,MDTimothySternberg,MD

Executive Vice PresidentJayW.Millson

DCMS FOUNDATION BOARD OF DIRECTORSBenjaminMoore,MD,PresidentToddL.Sack,MD,VicePresidentKayM.Mitchell,MD,SecretaryJ.EugeneGlenn,MD,TreasurerGuyI.Benrubi,MD,ImmediatePastPresidentMohamedH.Antar,MDRaedAssar,MDAshleyBoothNorse,MDJ.BrackenBurns,DOMalcolmT.Foster,Jr.,MDJeffreyL.Goldhagen,MDJeffreyM.Harris,MDMarkL.Hudak,MDJoanL.Huffman,MDSunilN.Joshi,MDDanielKantor,MDNeelG.Karnani,MDJohnW.KilkennyIII,MDSherryA.King,MDHarryM.Koslowski,MDEliN.Lerner,MDR.StephenLucie,MDJesseP.McRae,MDSenthilR.Meenrajan,MDNathanP.Newman,MDMobeenH.Rathore,MDRonaldJ.Stephens,MDJeffreyH.Wachholz,MDAnneH.Waldron,MDDavidL.Wood,MD

Northeast Florida Medicine is pub-lished by the DCMS Foundation,Jacksonville,Florida,onbehalfoftheCountyMedicalSocietiesofDuval,Clay,Nassau,Putnam,andSt.Johns.Except for official announcementsfromtheCountyMedicalSocieties,nomaterialoradvertisementspublishedinNEFMaretobeseenasrepresent-ingthepolicyorviewsoftheDCMSFoundationoritscolleagueMedicalSocieties.AlladvertisingissubjecttoacceptancebytheEditorinChief.Ad-dresscorrespondenceandadvertisingto:555BishopgateLane,Jacksonville,FL32204(904-355-6561),oremail:[email protected].

COVER: Photograph of pine trees in Guana River State Park, Ponte Vedra Beach, FL by a resident, Dr. Adithya Suresh.

Inside this issue of

Departments4 FromtheEditor’sDesk5 FromthePresident’sDesk8 DCMSHistoryBook34 Ole’TimeReunionPhotos

Northeast Florida Medicine

4 Vol. 61, No. 2 2010 Northeast Florida Medicine www . DCMS online . org

From the Editor’s Desk

Solidarity Needed to Improve Patient CareOnMarch23,2010,PresidentBarackObamasignedintolawthePatientProtectionandAffordableCareAct(PPACA-H.R.

3590).Thenewlaw,themostsweepinghealthcarereformsince1965,willimpactpatients,employers,insurancecompa-nies,healthcarefacilitiesandproviders.MuchhueandcryaccompaniedthebillonitswaybackandforththroughtheHouseandSenate,andcontinuestocarryaburdenofcontroversy;however,therearemanypositive,long-neededchangesasaresultofitspassage.

Physicianswillfeeltheimpactofthebillinapersonalwaythatmanyotherprofessionalsmaynotexperience.ButbeforeyoubegintowaveyourTeaPartyflag,CoffeePartybanner,ordragoutyourDemocrat,RepublicanorIndependentpodium, let’sexaminethepositivebeforewethrowtheinfantlegislationoutwiththebathwaterofrejection.Wecanthenintelligentlytalkabouthowwecanbandtogetherasphysicianstomaximizeourimpactonimprovingthecurrentlaw.

OftheAmericanMedicalAssociation’s(AMA)sevenessentialelements,fivewerefulfilled:thefirst two, expandedhealth insurance coverage andwellness andprevention initiatives,willhelppatientswithimprovedaccess,aswellas,bothphysiciansandinstitutionswiththeoverwhelmingburdenofuncompensatedcare.Thethird,removalofpre-existingconditionslimitations,will aidpatientswithchronicdiseaseand/orcancerdiagnosesand the fourth,qualityimprovementincentives,willrewarddoctorsforprovidingexcellentevidencedbasedmedicalcare.Finally, thefifth, simplified insuranceclaimsprocessing,will reducecostsofbillingandcollections.

Severalseriousareasofconcernfordoctorsare:TortReform,theSustainableGrowthRate(SGR),IndependentPaymentAdvisoryBoard(IPAB)andPhysicianWorkforceExpansion.Physiciansneedtobeprotectedfromfrivolousandastronomicalsuitswhichcolortheirpracticewithdefensivemedicinethatinturnelevateshealthcarecost.TheSGRmustbeaddressedwithapermanentfixratherthananannualpush-back.TheAMAopposestheinstitutionof

theIPAB,anindependentcommissionthatcouldmandatepaymentcutsforproviders.Andfinally,withincreasedaccesstocare,morephysicianswillberequiredtotreatthelargernumberofpatients.

Whilemostdoctorsagree inprinciplethatreformwasneeded,manydisagreewiththestrategyandtacticsutilizedtoachievetheresultantproductandthechallengerequiredforimplementation.Inresponsetotheconcernsandvariedopinionsoflocaldoctors,theDCMSBoardofDirectorshasinitiatedabipartisanHealthSystemReform(HSR)TaskForce.AttherecentvisitofCecilB.Wilson,MD,President-ElectoftheAmericanMedicalAssociation,theAMA’sposi-tionwaselucidated;andattheMayBi-AnnualPhysicianTownHallmeetingmanyofourmembers’thoughtswereaired.Uponthisfoundation,theTaskForcecanmoveforwardtoproduceasummaryDCMSpositionstatementthatbridgesourdifferencesandleadstotheformulationofanon-polarizingactionplan.Welookforwardtoworkinginacollabora-tivemannerthatgivesvoicetoallsidesofthematterandaddressesareasofspecificconcerntoourprofession.PleasecontinuetocommunicateyourconcernsandideasregardingPPACAwithDCMSExecutiveVicePresidentJayMillsonatjmillson@dcmsonline.org.

Let’sworktogetherinacommonbonddedicatedtoimprovingpatientcareandshareourthoughtsinaunifiedvoiceaboutwhatsuccessofamendedhealthcarereformwouldlooklikeforbothpatientsandphysicians.Wehaveanopportu-nitytostrengthenthelawbyaddressingtheissuesthatarenotinourbestinterestsandbybecomingpartofthesolution,nottheproblem.

JoanL.Huffman,MD,FACSEditor-in-ChiefNortheast Florida Medicine

Update on Haiti Relief EffortsAn“UpdateonHaitiReliefEfforts”byDCMSmembersandJacksonvillemedicalgroupsbeginsonp.45ofthisissueand

continuesonpp.48&49.Dr.HuffmanmadeasecondtriptoHaitiApril9-17,andshereportsonthesituationinHaitiin“How’sHaiti”(p.45&p.48)

TheCrudemFoundationthatsupportstheSacredHeartHospitalinMilot,Haitineedsortho/scrubtechs,ORnurseswithorthopaedicexperience,orthoPAs,anesthesiologistsandphysicaltherapiststovolunteertheirservicesinHaiti.LearnmoreabouttheFoundationatwww.crudem.organdifinterestedinvolunteering,[email protected].(ThisisthehospitalwhereDr.JohnLovejoydonateshistimeandservices.Seepp.48-49)

mailto:[email protected]


From the President’s Desk

The Times They Are A-Changin’*AswemullovertherecentlyenactedlawthatmanyknowastheHealthSystemReformLegislation,itisapparentthat

ourresponsesfallacrossawidespectrum.Atoneendistheratherobstructionistviewthatisopposedtotheveryessenceoftheproductaswellastheprocessthatwasusedincraftingit.Attheotherextremeistheoverlyoptimisticviewthatourmedicalsystemwoesaresoontobesolved.Aswe’dexpect,thesediametricallyopposedextremesarethepurviewofthosewithpolitical‘axestogrind’.Whenqueriedobjectively,thesestiltedreviewsharborlittleconcernforusorourpatients.

Manyaspectsofpatientcarewillbechanged,thoughtheactualregulationsthatwillbedefinedfromthislegislationarestillbeingformulated.Thisispreciselythepointintime,whereweasorganizedphysicianscanhavethemostimpactonhowthislawwillultimatelyaffectourpatientsandourrelationshipswiththem.Wehaveseenthedifficultyof‘mixingitup’withtheprimaryplayersofthisrecentlyenactedlegislation:theindustriesofinsurance,drugs,hospitalsandmedical

devices.Wehaverecoiledatthesightofbackroomdealsandbemusedlyobservedlargepre-negotiationconcessionsresultingingenerousfavoritisminthefinishedproduct.

ThreeareasindireneedofrectificationaretheSGRfiasco,tortreformandphysicianshort-ages.I’dliketofocusonthelatter.Inpreviouscolumns,Ihaveoutlinedtheominousstatisticsfromourownstate,groundedinathought-provokingsurveybyourcolleaguesinPalmBeachCountylastyear.Lookingtothefirststatetoenactsignificanthealthsystemreformonitsown,Massachusetts,therearesimilarnumbersofconcern.AccordingtotheMassachusettsMedicalSociety,inthenextdecade,one-thirdofthestate’spracticingdoctorsenterretirementage,andonly13percentofthestate’spracticingphysiciansare35oryounger.

Primarycarespecialistsaretheveryfoundationuponwhichourentirehealthcaresystemrelies.Itisherewherethefocusisondiseasepreventionratherthantreatment.Inaddition,thisiswherepatientswithchronic,complexdiseasesaremanaged.Inmostareasofthiscountry,thisisalsowheresubstance-abuseandmental-healthproblemsareaddressed.Researchhasshownthatgeographicareaswithmoreprimary-carephysicianshavebetterhealthoutcomesatalowercost.

Thenumberofmedicalstudentsgoingintofamilymedicineresidencieshasdroppedover50%inthelastdecade.Duringthepastthreeyears,only15percentofU.S.medicalschoolgraduateschosecareersinprimarycare.Atthesametimethatthefederalgovernmentismandatingmedicalinsurancecoveragefortensofmillionsofourcitizenry,itisalsorestrictingthenumbersoftheverysameprimarycarephysiciansthatarerequiredfortheircare.Overthelastdecadetherehavebeendrasticcuts(55%inrecentyears)inthefundingoffederalgrantsforthetrainingoffamilypracticephysicians(Section747ofaprogramcalledTitleVII).

Thecomplexityofcaringfortheincreasingnumbersofaging‘babyboomers’,diminishingreimbursementratesinthefaceofproliferatingregulationsandtimeconsumingpaperwork,andeverspiralingstudentloandebtshaveonlyexacerbatedtheproblem.Onanannualbasis,ithasbeenestimatedthatphysiciansinprivatepracticespendthreeweeksoftheirtimeand$68,000worthofstaffingcostsinordertodealwiththeadministrativeconstraintsofthevariousthird-partypayersofhealthinsurance.Witheachpolicy’spermutations,itbecomesmoreandmoredifficultforaphysiciantodeviseacareplanthatwillcomplywithapatient’sparticularcoverage,e.g.,uniquedrugformularies.

Istherestof‘thehouseofmedicine’readytoconformandchangetotheconceptsthatarerequiredtoamelioratethisconundrum?Althoughhigherremunerationforprimarycareisrequired,therehasalreadybeenunderstandableresistancefromspecialiststotakepaycutsaspartofanyzerosumformulation.Butpaymentisonlypartoftherevampingthatisneeded.Primarycarephysicianswillneedlargerteamsof‘midlevelproviders’toassistthemincaringfortheseburgeon-ingpopulationsofpatientsintheir‘medicalhomes’.Theseentitieswillneedtobeequippedwithsystemssuchastrulyfunctionalelectronicmedicalrecordsthatwillhelpthemmanagethefloodofinformationthatthey’realreadyconfrontedwithonadailybasis.

Inordertoprovidethehighestqualitycareforourpatients,howarewetoremedythisimpendingcrisisofbeingwoe-fullyshort-handedinprimarycare?AfteryearsofsteadfastlyopposinganynumberofScopeofPracticeintrusionsinourLegislature,arewewillingorabletoadapttothesentimentthatlargeportionsofprimarycarecanbedeliveredbynon-physicianteammembersinafarmoreexpandedfashionthanwepresentlyhave,albeitoverseenbythephysicianteamleader?Yourrepresentatives,medicalandlegislative,needtoknowyouropinionsbeforethedecisionsaremadeforyou.

(*Song title by Robert Allen Zimmerman)

John W. Kilkenny III, MD2010 DCMS President


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Recognize These Physicians?

Abel S. Baldwin, MD had a town named after him because of his reputation as a physician and community leader. E. Thomas Sellers, MD had the medical society lecture hall named after him (Sellers’ Auditorium - first “permanent home” of the DCMS) because of his influential leadership. Emmet F. Ferguson, Jr., MD had many young surgeons who revered his name because he mentored them and was a model of a “good man and good physician.”

The impact of these physicians (and many others) on the DCMS and surrounding area will be forgotten and lost unless the DCMS updates its published history. So DCMS is chronicling 157 years of medicine in a coffee table book. Two thirds of the book will include significant events that left a lasting impression on Northeast Florida and the local medical community. The remainder of the book will feature physician and practice histories and profiles, purchased by physicians, families, and groups who want to chronicle their footprint in Jacksonville’s storied history.

Be a Part of History!Contact Mr. John Compton, Publisher

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If you do, it is because these DCMS Past Presidents helped shape medicine in Duval County.


Like Tall Pines, Residents Reach for High GoalsAdithyaSuresh,MD,isthephotographerwhosnappedthisissue’scovershotofthetallpinetreesatGuanaRiverStatePark

isinSt.JohnsCountyalongAIAbetweentheFloridacitiesofSt.AugustineandJacksonville.Thesepinesreachtowardtheskyjustasresidentsstretchthemselvesmentally,emotionallyandphysicallytoreachhighprofessionalgoalstheyhavesetforthemselvesandtheirmedicalcareers.

Dr.Suresh,aPGY-3residentintheDepartmentofSurgeryattheUniversityofFlorida,CollegeofMedicineinJacksonville,hasacareergoalofbeingasurgeonandpursuingfurthertraininginminimallyinvasivesurgery.

Alongwiththisambition,heenjoysphotographybecauseashesays,“Agreatpictureisonethatcapturesthemoodoftheset-tingandcreatesmemoriesthatcanberevisitedmanytimesover.Forexample,thecoverphotographwastakeninGuanaRiverStateParkinPonteVedraBeach,Florida,oneofmyfavoriteplacestovisit.Photographyalsogivesmeachancetoexplorethecreativesideofmyself,andthishasprovedtobeaveryenjoyableoutlet.”

Hetookthecoverphotointhespringof2008.Herecalls,“Iwasstill‘new’toJacksonville,andIwouldspendmyfreetimeexploringthecityanditssurroundingparksandnaturepreserves,mycamerainhand.Thisparticularlocationsoonbecameoneofmyfavoriteplacestovisit,andIreturntoitateveryopportunityIhave.”

Besidesaninterestinmedicine,photographyhasbeenapassionforDr.Sureshsincehishighschoolyears.Hesaid,“Igotinterestedat the time thefirstconsumerdigital camerasbecameavailable.What fascinatedme themostwasbeingable toinstantlyviewmy‘results.’WhenIwasincollegeIwasthechiefphotographerofthecollegenewspaper.Itwasagreatexperi-encethatnotonlyallowedmetocontinuetotakepicturesonaprofessionallevelbutalsoindulgemyhobbyoftakingpictureswheneverpossible.”

Inadditiontotalltrees,Dr.Sureshlikestophotographlandscapes,flora,fauna,buildingsand“sometimesevenpeople”.Withallofthesesubjects,hewantsto“capturetheessence”ofplaceshevisits,suchasthephotographofhiminKinderdijk,NetherlandsinOctober2009.(see below) Hesaid,“Ihavealwayshadaninterestintravelingaroundtheworld,andIhavebeenfortunateenoughtovisitmanyexoticlocations.Thisnaturallyfueledmydesiretocapturethebeautyofthoselocations.”

AsforGuanaRiverStatePark,heremembers,“Lookingupandseeingthetipsofthetalltreesandthescuddingcloudsabovethembroughtasenseofserenitythatwasrefreshinglydifferentfromthefreneticpaceatthehospitalandtherigorofatypicalworkday.EverytimeIamthereIexperienceabsolutepeaceandsolitude.”


Medical residents, students, and professionals

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This Issue’s Focus: Resident Research

Resident Scholarly Activity Focuses on the Pursuit of Knowledge

Socratessaid“Theonlygoodisknowledgeandtheonlyevilisignorance.”InthisissueofNortheast Florida Medi-cine,werecognizethepursuitofknowledgeofindividualsinpost-graduatetraining.Inparticular,werecognizethepursuitofknowledgeintheformofscholarlyactivity.

Whatisscholarlyactivity?ConradWeiserinhis1996article“TheValueSystemofaUniversity–RethinkingScholarship”definesscholarshipas“creativeintellectualworkthisisvalidatedbypeersandcommunicated.”1Hefurtherdescribesfourformsofscholarship:discoveryofnewknowledge;developmentofnewtechnologies,methods,

materials,oruses;integrationofknowledgeleadingtonewunderstanding;andartistrythatcreatesnewinsightsandinterpretations.

In this issue, we feature articles that represent three distinct categories of residentscholarlyactivity:prospectivestudies,retrospectivestudies,andcasestudies.Eacharticlemakesitsowncontributiontothebodyofscholarlyactivityinexistence.Thisyearwearealsohighlightingresidentcommentariesonpublichealthin“FromaResident’sPerspec-tive.”Thefactthattheseworkswerecreatedwithinourregionisasourceofprideandatestamenttotheregionaldedicationtotheeducationalprocess.

Iamsuremanyoftheauthorsinthefollowingpageswouldagreeitischallengingtofindtimetodedicateandcompletescholarlyactivity.Scholarlyactivityisalsochalleng-ingtomanypotentialauthorsbecauseitisoutsidethenormalrealmofpatientcare,butitcertainlyhasitsplaceinboththeartandscienceofmedicine.Scholarlyactivitycan

beparticularlychallengingasastudent,resident,orfellowfacingpotentialobstaclessuchasscheduleissues,lackofsupport,andinexperienceintheprocessofcreatingsuchwork.Therefore,Icommendboththeauthorswhoarestillintrainingandtheirmentorswhohelpedthemproducethescholarlyactivityinthisissue.

Ithasbeenapleasure,anhonor,andachallengetoserveastheGuestEditorforthe2010ResidentScholarlyActivityissueofNortheast Florida Medicine.Reference:1Weiser,ConradJ.,“TheValueSystemofaUniversity–RethinkingScholarship.”1996.http://www.adec.edu/clemson/papers/weiserhtml.AccessedApril30,2010.

J. Bracken Burns Jr., DOAssistant Professor of Surgery,Division of Acute Care Surgery,University of Florida, Collegeof Medicine, Jacksonville, FL

J.BrackenBurns,DO,receivedthe2009PhilipH.GilbertYoungPhysicianLeadershipAwardatthe2010DCMSAnnualMeeting.Thisaward,createdtohonorthememoryandserviceofPhilipH.GilbertwhoservedasExecutiveVicePresidentoftheDCMSfrom1984untilhisdeathin2004,recognizesYoungPhysicianswithleadershiptraitsthatMr.Gilbertwouldhaveadmired.Candidatesmustmeetthefollowingeligibilitycriteria:A“YoungPhysician”fromNortheastFlorida,under40yearsofageorwithinthefirsteightyearsofprofessionalpracticeafterresidencyandfellowshiptraining,asdefinedbytheAMA;activeintheDCMSorotherorganizedmedicineservice;activeincivicservice;medicalstaff(orsimilar)leadershipexperience;andbeastrongadvocateformedicine.

(Left) Dr. Burns with Dr. John Kilkenny III, DCMS President. (Center) A special pencil sketch of Philip Gilbert. (Right) Dr. Burns receiving his award from Dr. R. Stephen Lucie, DCMS Immediate-Past President.

Pencil sketch by Alexander Braddock


High Recruitment Efficiency Associated with a Study Evaluating Health Literacy in Patients Hospitalized with Acute Ischemic Stroke

Kalina Sanders, MD1; LorettaSchnepel,ARNP1;KatryneLukens-Bull,MS2;NaderAntonios,MD1;DavidWood,MD3andScottSilliman,MD1

UniversityofFloridaCollegeofMedicine,JacksonvilleCampus,DepartmentsofNeurology1,OfficeofResearchAffairs2,andPediatrics3

Abstract Category 1 - Prospective

Background:Strokeisacommonandsignificantcauseofmorbidityandmortality.Approximately780,000casesofstrokearereportedintheU.S.eachyear,ofwhich180,000representstrokerecurrence.Healthliteracyisthepatient’sabilitytoobtain,process,andunderstandhealthinformationandservices.ImprovinghealthliteracyinstrokesurvivorsmayultimatelyreducethenumberofrecurrentstrokesintheU.S.viabetteradherencetomedicaltherapiesandhealthybehaviors.Theprevalenceofpoor,marginal,andgoodhealthliteracyamongU.S.strokesurvivorsisunknown.AtShands-Jacksonville,theStrokeProgramisconductingastudythatisevaluatinghealthliteracyinacohortofpatientswithacuteischemicstroke(AIS).Wereporttherecruitmentefficiencyassociatedwiththefirstfourmonthsofthisstudy.

Methods:ConsecutivepatientswithradiographicallyconfirmedAISwhohavebeenadmittedtotheShands-JacksonvilleStrokeUnithavebeenevaluatedforinclusionintothestudysinceSeptember8,2009.Allconsentedpatientsundergovalidatedteststoassesstheirhealthliteracyduringtheirhospitalization.Demographic,educational,stroke-specificandsocioeconomicinformationisprospectivelycollectedonallconsentedpatients.Reasonsforstudyexclusionarecollectedforallnon-consentablepatients.Thenumberofpatientsrefusingtoconsentisalsocollected. Aninterimanalysis evaluatingnumberofstudyrecruitsandnonrecruitswasconducted.

Results:BetweenSeptember8,2009andJanuary15,2010,89patientshadradiographicallyconfirmedAIS.Ofthese,34(38%)wereexcludedfromstudyparticipation.Theprimaryreasonsforexclusionwerelethargy(n=11),dysphasia(n=10),andhospitaldischargepriortorecruitment(n=7).Oftheremaining55patientsthatwereapproachedforstudyparticipation,40(73%)consentedtoparticipateinthestudy.Theaverageageofenrolleesis60yearsofage.Twenty(50%)ofthoseenrolledweremaleand25(62.5%)wereAfrican-American.

Conclusion:Duringthefirstfourmonthsofourstudy,recruitmentefficiencyhasbeenhighwithanaverageof9.5patientspermonthconsentingtoparticipate.Almostone-half(45%)ofalladmittedAISpatientshaveundergonehealthliteracyassessment.Thishighrecruitmentefficiencyisprimarilyduetoahighrateofconsentinstudy-eligiblepatients.OurinterimexperiencesuggeststhathospitalbasedstudiesevaluatinghealthliteracyinpatientswithAISisfeasibletoconductinanurbansetting.Inaddition,ourexperiencesuggeststhataraciallydiversestudycohortcanberecruitedintoahospitalbasedhealthliteracystudy.

ED Documentation Training in the Face of ED Overcrowding

Ben Lenhart, MD:KellyGray-Eurom,MD;andDavidCaro,MDUniversityofFloridaCollegeofMedicine,DepartmentofEmergencyMedicine

Editor’s Note: Due to production constraints, Figures 1 & 3 are not printed in the journal. They are available online at www.dcmson-line.org as a web illustration.

Background: ResidencytraininginthefaceofEmergencyDepartment(ED)overcrowdingcanpresentmanychallenges.UniquemethodsareoftenneededtomaintainaneducationalenvironmentconducivetopreparingemergencymedicineResidentstobecomecompetentpractitioners,especiallyineducationalareasidentifiedas“holes”inthemodelcurriculum.AnAmericanCollegeofEmergencyPhysicians(ACEP)sponsoredsurveyofnewEmergencyMedicine(EM)graduatesidentifieddeficienciesintrainingcustomerserviceconceptsandpracticemanagementcriticaltosuccessintheworkenvironment.AnACEPsponsoredsurveytomedicaldirectorsofnon-academicemergencydepartmentsregardingtheirperceptionofthedeficienciesseeninnewEMgraduatesidentifiedpracticemanagement,administrativefunctions,andcommunicationskillsasbeingareasinmostneedofimprovement.Ouremergencydepartmentisanacademicurbanprogramthatseesapproximately90,000patientsannually.

Editor’s Note: The following data are presented clearly and conclusions are consistent with the data. Because of space limitations, we are only publishing abstracts. It is, therefore, inherently difficult to determine if some conclusions may overstate the magnitude or causality of the relationships identified. Resident author names are in bold


EDandhospitalovercrowdingimpactsourdepartmentonadailybasis,withEDlengthofstaytimesofgreaterthan11hoursforadmittedpatients,andoverallturnaroundtimesfordischargedpatientsexceeding5.5hoursoverthepastyear.Ourdepart-mentidentifiedtheeducationalaspectofbusinessmanagement,andinparticularimprovingcodinganddocumentation,asoneofourtraininggoalsinNovemberof2008,asanincreaseindeficienciesindocumentationperformanceandchartcompletionwereidentifiedinconjunctionwiththelengthofstaydelays.Thedepartmentusesatemplateddocumentationsystem(XpressCharts,XPressTechnologies©2009) torecordemergencydepartmentdocumentation. CompletedEDtreatmentrecordsarescannedintoacomputerizedchartmanagementsystemafterpatientdispositionintheED.

Methods:Aneducationalpresentationwasgivenduringoneoftheresidency’splannedweeklydidacticsessions.Chartdocu-mentationeducationalreviewwastheninitiated.Departmentalbillingspecialistsforwardedcodingdowngradedchartstothedepartment’smedicaldirector.Abriefchartdocumentationeducationalreviewwasthenperformed,whichincludedmissingdocumentation,whatlevelthechartshouldhavebeenbilledascomparedtothelevelofmedicalserviceprovided,whatlevelthechartwasactuallybilledat,andwhatrevenuelossoccurredduetothisdowngrading. (Figure 1, www.dcmsonline.org) Thischartdocumentationeducationreviewwasthensenttotheresidentproviderforreassessmentandeducation,especiallyinsystemsbasedpracticeandpractice-basedlearningandimprovementcompetencies.ThisdatahasbeencollectedforqualityreviewandisanalyzedmonthlyduringEDoperationsanalysis.(Figure 2)

Results:DatarevealedthatdespitelengthofstayandoverallEDpatientvolumebeingrelativelyconsistent,theaveragechargeperresidentchartduringthefivemonthsbeforeandafterthiseducationalactivityincreasedfrom$313.44to$394.76.(Figure 3, www.dcmsonline.org) Residentsseemsatisfiedwiththiseducationalcomponentcoveringaneducationalaspectthatisofteninsufficientduringresidencybutexpectedaftergraduation.Thisreviewprovidesanothermethodoftrainingandassessmentfordepartmentswhoseattendingphysiciancoverageisattimesstretchedanddetailedanalysisofchartsanddiscussionofthedetailsofdocumentationfromabusinessperspectivecansometimesbedifficulttoperform.

Conclusions:Acombinationofdidactictrainingandreal-timeContinuousQualityImprovement(CQI)reviewbothimprovedresidentphysicianmeanchargesperchartandE&Mcodinglevels,eveninthesettingofextendedlengthofstayinacrowdedED.Thisprocessprovidesamethodofcompetency-basedtrainingandassessmentforemergencyresidenciesinthesettingofEDovercrowding,targetinganeducational“hole”intheEMModelCurriculumthatiscurrentlyinneedoffurthertraining.Inparticular,itfocusesonpractice-basedlearning,systemsbasedpractice,andwrittencommunicationskillcompetencies.

Figure 2 Monthly ED Operations Analysis


Pupillary Response After Neuromuscular Blockade

Steven Andescavage, DO; DavidCaro,MD;MohsenAkhlaghi,MD;ColleenKalynych,MSH,EdD;ChristinaHanna,BSandJackieBarzyk,BD

UniversityofFloridaCollegeofMedicine,DepartmentofEmergencyMedicine

Editor’s Note: Due to production constraints, Figure 1 is not printed in the journal. It is available online at www.dcmsonline.org as a web illustration.

Background:Neuromuscularblockers,bothnon-depolarizinganddepolarizing,arecommonlyusedintheEmergencyDepart-mentforintubationofcriticallyillpatientsviarapidsequenceintubation(RSI).RSIinvolvesadministeringasedative-inductionagentfollowedbyaneuromuscularblockingagenttorenderapatientsedatedandparalyzedtooptimizefirst-attemptintubationsuccess.Neuromuscularblockersworkspecificallyatnicotinicacetylcholinereceptorsattheneuromuscularendplateofstriatedmuscle,andthereforeshouldnotaffectthepupillarymuscleresponsetolightstimulation.Ciliarymuscleactivationandpupil-laryconstrictionismediatedbycholinergicreflex,andthereforeisprimarilycontrolledbymuscarinicreceptors(Figure 1, www.dcmsonline.org).Thelossofpupillaryresponsetolightisoftenusedforcriticalclinicaldecision-making,includingthedetermina-tionofpresenceofcriticalintracranialhypertensionintheemergencysetting,andbraindeathinthecriticalcaresetting.

Objective: Wesoughttodetermine ifpupillaryresponsetolightisaffectedbypharmacologicneuromuscularblockadeduringRapidSequenceIntubation(RSI)inanemergencysetting.

Methods:ThisInstitutionalReviewBoard(IRB)approvedprospective,observationalstudyconsistedofaconveniencesampleofpatientsina100,000patient/year,inner-cityemergencydepartment(ED)betweenFebruary2008andFebruary2009whoreceivedadepolarizingornondepolarizingneuromuscularblockadeforrapidsequenceintubation.Patientswereeligibleforthestudyiftheirpupilsdisplayedbrisk(<1second),>1mmconstrictiontolightchallengepriortointubation.Twophysicians(oneresident,oneattending)independentlyreviewedpupillaryreactivitypriortoandafterintubation.Datacollectedincludedthepatients’age,gender,weight,admittingdiagnosis,finaldiagnosis,RSIandParalyticmedication(s)givenwithdosages;Pupillaryresponsepriortoandpostintubation.

Results:Ofthe96patientswhometinclusioncriteria,90hadpupillaryactivityafterRSIconfirmedbybothphysicians.TwopatientshadphysiciandisagreementonreactivitypostRSIand4patientshadnopupillaryreactionconfirmedbybothphysiciansafterRSI.Grossagreementofpupilreactivityoftheobserverswas98%(95%CI93%-100%),with κ=0.82.Acombined,liberalmeasurementofreactivityafterparalytics(includingthetwopatientswithphysiciandisagreement,or92/96patients)yields96%(95%CI90%-99%),whereasconservativemeasurement(excludingthetwopatientswithphysiciandisagreementor90/96)yields94%(95%CI87-98%).

Conclusions:Todate,neuromuscularblockadewithdepolarizingornondepolarizingneuromuscularblockingagentsappearsnottoinhibitpupillaryreactivityinthevastmajorityofpatientswhosepupilsarereactivepriortoRSI.Asingularcaseofmiosisoccurredinanelderlywomanwhoreceivedmorethan2mg/kgofsuccinylcholine,whichsuggestsmuscarinicactivationbyanexcessivedose.AllpatientsintubatedforneurologicreasonsdemonstratednormalpupillaryactivityafterparalysisduringRSI.

Use of Broselow Tape to Determine an Optimal Dosing Weight in Overweight Patients

Jason Lowe, DO; RobertLuten,MD;ColleenKalynych,MSH,EdD;andChristineHanna,BSUniversityofFloridaCollegeofMedicine,DepartmentofEmergencyMedicine

Editor’s Note: Due to production constraints, Figures 1,2 & 3 are not printed in the journal. They are available online at www.dcmson-line.org as a web illustration.

Background:TheBroselowTape(BT)hasbecomewidelyacceptedasarapid,accuratemethodofapproximatingmedicationdosagesinthepediatricpopulation.(Figure 1, www.dcmsonline.org)Byestimatingapatient’sweightusinghis/herheight,valuabletimecanbesaved.SeveralstudieshavebeenpublishedquestioningthevalidityoftheBT;especiallyinatimewhenobesityratesareclimbingamongchildren.Findingsinthesestudiesarenotconclusive,yetauthorsimplythatpatients,especiallytaller/largerones,maybereceivinglowerdosesofmedicationsthanwhatwouldbeadministeredifthepatient’strueweightwasknown.Othersystems,particularlythedevisedweightestimationmethod(DWEM)attempttoadjusttheweightestimatedbythepatient’s


lengthbyhavingthepractitionerdeterminethepatient’sbodyhabitus.ConsiderationtomakeasimilaradjustmentbasedonbodyhabitushasalsobeenmadefortheBT.Theaimsofthisstudyweretodeterminehowaccuratehealthcarepractitionerswereatestimatingbodyhabitus;todetermineifaddingbodyhabitusestimatesincreasestheaccuracyoftheBT;tocomparethedosagesderivedbytheBT,theBTadjustedforbodyhabitusandthepatient’sactualweightbaseddosage;andtore-evaluatetheoverallaccuracyoftheBroselowTapeanditsutilityinthefaceofrisingobesityrates.(Figures 2 & 3, www.dcmsonline.org)

Methods:AconveniencesampleofpatientspresentingtoUniversityofFlorida–Shands,Jacksonville’sPediatricEmergencyDepartmentfrom12/07to2/08wereenrolledintothestudywithparentalconsent.Thereweretwotypesofstudyparticipants.Thefirstsetwaschildrenaged0-12years.Studyinvestigatorsgatheredtheage,gender,race,weightandthepatient’sheight/lengthattriage.Oncedataonthepatientwasgathered,theinvestigatorsthenaskedhealthcareproviders(HCPs–secondtypeofstudyparticipant)toestimatethepatient’sbodyhabitusasnormal,underweightoroverweight.Healthcareproviderswereblindedtoallthepatient’sdata.Severalhealthcareproviderswereaskedtoevaluatethesamepatientasthegoalwastoachieve300encountersor“guesses”overall.Eachsubsequent“guesser”wasblindedtopreviousguesser’sanswer.Further,healthcareproviderswerenotgivenorremindedoftheclinicaldefinitionsofoverweight(95th%-ile)orunderweight(<3%-ile).

Results:Atotalof122patientswererecruitedduringthestudyperiod.Fromthese,441estimationsweremadeaboutpatients’bodyhabitusfrom59distincthealthcareproviders(residents,fellows,attendingsandphysicianassistants).Asa“test”,ourHCPshadasensitivityof67%andspecificity95%.Differencesbetweennon-adjustedweightsandadjustedweightswerecomparedbycalculatingpercentofweighterror(PE=((ActualWeight-BroselowWeight)/ActualWeight))100.APEof15%orlessisconsid-eredtobeacceptable.ThemeanPE(Table 1)was36.7%fornon-adjustedand17.17%forhabitusadjustedweights(P<0.0001).Non-adjusted,thetapeprovided60%ofweightswithin15%.Afteradjustment,weightswerewithin15%ofactual80%ofthetime.Wefoundthatthedifferences(Table 2, p.16) betweenAdjustedandNon-adjustedPEandalsoEstimatedWeightandActualWeightvaluesareonlysignificantinOverweightpatients(p<0.0001).Inter-observerreliabilitywasassessedwithakappascoreandshowntobeacceptablewithavalueof0.48.Despitethisseeminginaccuracy,wefoundthatallowingHCPstomakesuchadeterminationimprovestheaccuracyofthetapeby25%.Also,wefoundthat15%ofpatientswerefoundtobeoverweight,whichisinlinewithnationaldatafromtheNationalHealthandNutritionExaminationSurvey2004(NHANES),whichestimatedtherateofoverweightbeing~17%inchildren.DemographicdatashowsourstudypopulationtobesimilartoouroverallpatientpopulationatShandsJacksonville.(Table 3, p.16)

Conclusions:Recent literaturehasbeenpublishedcautioningusersoftheBroselowtape.Althoughadverseoutcomeswerenotnoted,authorswarnagainstpotentialunderdosingofobesepatientswhenusingtheBroselowsystem.Contrarily,othersnotethatoptimaldosingmaynotbebasedon“fatbodyweight”butmoreappropriatelybyidealbodyweight,whichiswhattheBroselowsystempresents.TheinitialstudiesoftheBroselowsystemdiscoveredthepotentialforunderestimatingweight,andinactuality,concurwithdatapresentedinthemorerecentstudies.Atthistime,ithasnotbeendeterminedwhetherthisunderdosingisdetrimental.Otherworkneedstobedone,butitappearsthataskinghealthcareproviderstomakeadjustmentstotheBroselowsystemwouldhelp,although30%ofthetime,anincreaseddosewouldnotbegiven.Thisisacceptable,because70%ofthetime,overweightstatusisdetectedandthisimprovestheBroselowtape’sabilitytoestimateweightby25%.Admit-tedly,ourkappavalueisnotoptimal;however,wehadabroadrangeoftraininglevelsamongourestimators,includinginterns.OurnextstepwillbetoimplementtheHealthCareProviders(HCP)bodyhabitusestimationsintoarealtimesettinganddetermineiftheyremainfeasibleandpracticalinapediatricER.

% Weight Error Adjusted % Weight Error

Patient Body Habitus N Mean Std Dev Mean Std Dev

Overweight 58 36.70 10.78 17.17 15.29

Normal 348 7.11 11.05 8.06 16.68

Underweight 32 -18.22 20.16 -5.68 32.32

Table 1 Mean % Weight Error versus Adjusted Mean % Error


Table 2 Difference Between Mean % Weight Error and Adjusted Mean % Error

Adjusted - Non-Adjusted Percent of Weight Error

Tape Weight - Actual Weight

Patient Body Habitus N Mean Std Dev Mean Std Dev

Overweight 58 -19.52 17.75 14.51 11.33

Normal 348 0.95 14.12 -1.32 2.57

Underweight 32 12.17 40.4 1.31 0.87

Number (n) Percentage (%)

Male 47 38.5

Female 74 60.7

Caucasian 12 9.8

Hispanic 2 1.6

AA 80 65.6

Asian 1 0.8

Unknown (not recorded) 25 20.5

0-4 years old 81 66.3

5-8 years old 21 17.1

9-12 years old 19 15.5

Overweight Body Habitus(BMI>95th%ile)

17 13.9

Underweight Body Habitus(BMI<3rd%ile)

4 3.3

Table 3 Study Demographics

Dr. Baker Receives the Philip H. Gilbert Award

StephenBaker,PhD.,JacksonvilleUniversityPoliticalScienceProfessor,receivedthe2010PhilipH.GilbertAwardfromtheNortheastFloridaHealthyStartCo-alitionforhisvolunteereffortsaschairoftheCommunityAdvocacyandPublicPolicyCommittee.Picturedat left isKarenWolfsen,ChairoftheCoalition,presentingtheawardtoDr.Baker.

Dr.Baker,aHealthyStartBoardmembersince2001,hastakenaleadershiproleindevelopinganadvocacystrategyfortheorganizationthatincludesvolunteertraining,developmentofissuepapersaddressinglegislativeprioritiesandannuallegislativevisits.Hehasalso recruitednewmembersandworked to link theCoalitiontothelargernon-profitcommunity.

Theawardwascreatedin2006tohonorPhilipH.Gilbert,thefoundingchairmanoftheCoalitionandalsoapastDCMSExecutiveVicePresident.


Abstract Category 2 - Retrospective

Background:Thisstudywasdesignedtoexamineindication,dosing,andoutcomesassociatedwithinhalednitricoxide(NO)useforacuterespiratorydistresssyndrome(ARDS)atShandsJacksonvilleMedicalCenter.

Methods: AdultintensivecareunitpatientsfromJanuary2006throughSeptember2008whoreceivedNOforARDSwereretrospectivelyassessedforindication,dosingandoutcomes.ActualuseofNOwascomparedtorecommendationsdevelopedatShandsJacksonvilleMedicalCenterinJanuary2009.Thosewhometalloftherecommendedcriteriaforindicationanddosewereconsideredcompliantandallotherswereconsiderednoncompliant.Therecommendedcriteriaforuseincludes:aninitialNOdoselessthanorequalto10ppm,PaO2/FiO2oflessthan200mmHg,anFiO2greaterthanorequalto80%,positiveend-expiratorypressure(PEEP)greaterthanorequalto12cmH2O,andNOdosesnotexceeding20ppmthroughoutthecourseoftherapy.Outcomesincludedin-hospitalmortality,mechanicalventilation(MV)days,andcostsofNOtherapy.

Results: Tenpatientsmetthecriteriaforuseanddosingrecommendationsandwereincludedinthecompliantgroup,withtheremaining63patientsallocatedintothenoncompliantgroup.In-hospitalmortalityoccurredin71%ofthosepatientsconsideredtobecompliantand56.3%ofthenoncompliantgroup(p=0.053).PatientsincompliancewiththepolicywereonMVforanaverageof28days(median,19.5days)comparedto10.8days(median,5days)forthosewhodidnotmeettherecommendations.ThedifferencebetweenMVdaysbetweenthegroupsisstatisticallysignificant(p=0.048).AveragehospitalacquisitioncostsforNOinthecompliantgroupwas$18,206(median,$9,687)and$13,802(median,$6,853)inthenoncompliantgroup(p=0.732).Sevenand32patientsinthecompliantandnoncompliantgrouprespectively,hadeitheraPaO2orSaO2valuerecordedwithin60minutesofNOinitiationand,therefore,providedenoughdatatoevaluateoxygenationresponse.Fivepatientsinthecompliantgroupand18patientsinthenoncompliantgroupachievedafullresponse(p=0.678),definedasgreaterthan20%increaseinPaO2orgreaterthan10%increaseinSaO2within60minutesofNOinitiation.

Conclusion:Themajorityofpatients(63of73)whoreceivedNOwouldnothavemetthenewcriteriaforuse;thosewhosatisfiedthesecriteriawereassociatedwithimprovedoxygenation,longerdurationofmechanicalventilation,andhighercostwithoutsignificantimprovementinpatientoutcome.

Nitric Oxide Use in Adults with Acute Respiratory Distress Syndrome

Nai Chao, PharmD; PaulTan,PharmD,FASHP;andAmyRockwell,PharmDShandsJacksonvilleMedicalCenter,DepartmentofPharmacy

Ibuprofen lysine: A Modified Dosing Regimen for Patent Ductus Arteriosus*

Stephen J. Tan, PharmD; RenuSharma,MD;WilliamH.Renfro,PharmD;LindaHastings,PharmD;andMarkSchreiber,PharmD

ShandsJacksonvilleMedicalCenter,DepartmentofPharmacy

Background:In2006anIVformofibuprofenlysinewasapprovedforpatentductusarteriosus(PDA)closure.Basedonrecentpharmacokineticstudies,dosingregimenshavebeendevelopedthatmayincreasethesuccessofPDAclosurewithibuprofenlysinewhiledecreasingadverseeffects.Therationaleofthisstudyistoobservetheeffectivenessofamodifieddosingregimeninaclinicalsetting.

Methods: Thiswasconductedasanobservational,retrospectivereviewofpreterminfantswithadocumentedPDAadmittedtotheNeonatalIntensiveCareUnit(NICU)serviceatShandsJacksonville.Inclusioncriteriaconsistsofpatientsbetweenthegestationalageof25and34weeks,postnatalageof1to11days,withmoderatetosevererespiratorydistressneedingmechanicalventilation,aechocardiograph(ECHO)documentedPDAandreceivingibuprofenlysinefortreatmentofPDA.TheprimaryoutcomewillbeECHOconfirmedclosureofPDAthroughcomparisonofamodifiedversustraditionaldosingregimenofibu-profenlysine.Secondaryoutcomeswillevaluatethesafetyofthemodifieddosingregimenthroughadverseevents.Theprimary

Editor’s Note: The following data are presented clearly and conclusions are consistent with the data. Because of space limitations, we are only publishing abstracts. It is, therefore, inherently difficult to determine if some conclusions may overstate the magnitude or causality of the relationships identified. Resident author names are in bold.


objectiveofthisstudyistocomparetheefficacyandsafetyofamodifieddosingregimenwhencomparedtoatraditionaldosingregimenofibuprofenlysinewhenusedforPDAclosure.

Results: TherewasnostatisticaldifferenceinPDAclosure(p=0.443)orsafetyoutcomeswhencomparingamodifieddosingregimentoatraditionaldosingregimenofibuprofenlysinewhenusedinneonates.

Conclusion: ThisstudywasnotabletocollectenoughdatatostatisticallyshowadifferenceinPDAclosureorsafetyoutcomeswhenusingthemodifieddosingregimen.Currentlydatahasbeencollectedon22patientsinthetraditionaldosinggroupversus10patientsinthemodifieddosinggroup.Datacollectionisongoing.

*UnrestrictedEducationalGrantReceivedfromOvationPharmaceuticalsInc.

Effects of Severe Hypoglycemia on Trauma Patientsin an Intensive Care Unit

Nicole Scott, PharmD; PaulTan,PharmD;KathleenRottman,PharmD;andJulieOffutt,PharmDShandsJacksonvilleMedicalCenter,DepartmentofPharmacy

Background: Manyfactorsinfluencetheoutcomeofpatientsinintensivecareunits.Ageandseverityofthediseasestatehavebeenlongstandingfactorsthatleadtoincreasedmorbidityandmortality.Withinthelasttwentyyearsuncontrolledglyce-miclevelshavebeenassociatedwithanincreasedriskofadverseoutcomesincriticallyillpatients.Themainfocushasbeenonhyperglycemia,whichhasledtothemajorityofICUpatientsbeingplacedonaninsulininfusionandhavingtheirbloodglucoselevelstightlycontrolled.However,recentstudieshaveshownthatseverehypoglycemiamayplayaroleinpoorpatientoutcomes.Forthesereasonsthepurposeofthestudywastodeterminetheeffectsofseverehypoglycemiaontraumapatientsinanintensivecareunit.

Methods: Thestudywasaretrospective,singlecenter,observationalcohortstudyconductedbetweenJanuary2007–June2008.Onegroupconsistedoftraumapatientswhohavesufferedatleastoneepisodeofseverehypoglycemia(bloodglucoselevel<40mg/dL).Theothergroupconsistedoftraumapatientswithsimilarcharacteristicsbutwithatleastonebloodglucoselevel

Evaluation of Adequate Use of Antibiotics for Suspected Ventilator-associated Pneumonia in Critically Ill Trauma Patients

Claire Chan, PharmD; PaulTan,PharmD;ElainePoon,PharmD;NadiaShami,PharmD;andMarciDelossantos,PharmD

ShandsJacksonvilleMedicalCenter,DepartmentofPharmacy

Background:Currently,thereisgrowingevidenceontheimportanceofinitiatingappropriateantibioticsforsuspectedventila-tor-associatedpneumonia(VAP).ThisstudywillassesstheuseofantibioticsforsuspectedVAPintraumapatientsadmittedtothesurgicalICU(SICU)atShandsJacksonvilleMedicalCenter.

Methods:ThisisanIRB-approved,observational,retrospectivereviewofdatabasesthatincludedtraumapatientsintheSICUonaventilatorgreaterthan48hours,withsuspectedVAP,andwithabronchoalveolarlavage(BAL)completedbetweenAugust1,2006-2008.Fisher’sexactandT-testswereusedtoanalyzethedata.TheprimaryendpointwasfrequencyofadequateinitiationofantibioticsforsuspectedVAPbasedonBALresults.Secondaryendpointsinclude:appropriateantibioticdoseandduration,appropriatechangeintherapybasedonBALresult,outcomes(ICUdays,ventilatordays,andICUmortality),andappropriateantibioticde-escalation.

Results:Therewas94%frequencyofadequateinitiationofantibiotics.Oftheadequatelytreatedgroup,81%hadappropriatedose,8.5%hadadequateduration,and55%hadappropriateantibioticde-escalation.TheadequateandinadequatetreatmentgroupshadmeanICUlengthofstayof21.6daysversus12.7days(p=0.076),respectively.Theadequatetreatmentgrouphadmeanventilatordaysof15.7;whileinadequatehad12.7ventilatordays(p=0.608).Theadequatetreatmentgrouphad26%mortality;whileinadequatehad33%mortality(p=1.00).

Conclusion:Antibioticswereadequatelyinitiated94%ofthetime.TherewasnosignificantdifferencebetweentheadequatetreatmentgroupandinadequatetreatmentgroupsformeanICUlengthofstay,ventilatordays,ormortality.


Comparative Study of the Clinical and Tumor Characteristics in Women with Breast Cancer of Different Age Groups

Atman U. Shah, MD; FauziaRana,MDandElenaM.Buzaianu,PhD(Statistician)UFShands,Jacksonville,DepartmentofMedicine

Background: Adjuvantchemotherapyforbreastcancerimprovessurvivalinpatientswithearlybreastcancerwithnodepositivedisease.Thegoaloftreatmentwithadjuvantchemotherapyistopreventcancerrecurrenceandreducecancerrelatedmortality.Thechoicetoadministeradjuvanttherapyisprimarilybasedonthepredictedbenefitsandrisksforthepatient.Alargeamountofliteraturedescribesage-dependentvariationsintreatment,showingthatolderwomenwithbreastcancerarelesslikelytoreceiveadjuvantchemotherapythanyoungerwomen.Wesoughttoidentifypatientandtumorcharacteristicsinwomenofdifferentagegroupswhoreceivedsystemicadjuvanttherapiesatourinstitution.

Methods: Wecollectedclinical,demographicandtreatmentdatafromelectronicdatasources,includingtumorregistrydataandpatients’medicalrecords.Dataof465womenwithbreastcancerwasreviewedandanalyzedusingSASstatisticalsoftwareversion9.1.ThesewomenreceivedadjuvantchemotherapyandwerefollowedattheUniversityofFlorida,ShandsHospitalfromJanuary2001toDecember2007.Theauthorsrandomlyselected465of1,265patientswithbreastcancerwhoreceivedadjuvantchemotherapyanddividedtheminto3groupsonthebasisofage.Eachgroupwasstudiedcloselyfordifferencesinsocialfactors(suchasraceandinsurancestatus),clinicalcharacteristics(hormonereceptorstatus,nodeinvolvement,tumorsize,typeofsurgeryperformed,andmortality)andpathologicalfactors(tumormorphology).

Results: Dataof465patientswasanalyzed.Womenwithagelessthan58wereplacedingroupA(n=155),ageswithin58-69ingroupB(n=155)andagegreaterthan70ingroupC(n=155).Therewasasignificantly(p=0.004)higherincidenceofin-filtrativeductalorlobularcarcinomainyoungerwomen(GroupA,BandChad80%,73%and60%respectively).Therewasnosignificantdifferencebetweenestrogenorprogesteronereceptorstatusbetweenthethreeagegroups.Youngerwomenhadasignificantlyhigherincidenceofnodeinvolvementthanolderwomen(p=0.001).Youngerwomen(groupA;53%)weremorelikelytoundergomastectomythanolderwomen(groupC;36%,P=0.02).Therewasnosignificantdifferencebetweentheproportionsofwomenwhoreceivedendocrinetherapies.Thelikelihoodofdevelopingasmalltumor(<2cm)increasedwithage.WomenwithsmalltumorsingroupA,BandCwere28%,34%and46%respectively(p=0.023).Olderwomenweremorelikelytohaveinsurancethanyoungerwomen(p<0.0001).

Conclusion: Theincidenceofbreast cancer increaseswithadvancingage, andalmosthalfof allnewbreast cancers in theUnitedStatesoccurinpatientsover65yearsofage.Somecliniciansarehesitanttoprescribeadjuvanttherapiestoolderbreastcancerpatients.Ourdatashowedthatelderlywomenhadsomefavorableprognosticfactors.Olderwomenwerelesslikelytohavelargetumors(>2cm)andlesslikelytohavepositivenodes.Infiltrativeductal/lobularcarcinomasweremorecommoninyoungerwomen.Therewerenodifferencesbetweenhormonereceptorstatuses.Olderwomenweremorelikelytohavemedicalinsuranceatourinstitution.

between70–150mg/dLbutwithnobloodsugarlessthan40gm/dL.Allpatientsenrolledinthestudywereplacedonaninsulininfusionperthestresshyperglycemiainsulininfusionprotocoltitratedtoatargetglucoselevelsbeing80-120mg/dL.Glucoselevelsweremonitoredhourlyuntiltargetlevelswereobtainedfor3consecutivetimesinarow.Thereafterbloodglucoselevelswerecheckedevery2-4hrs.

Results: Atotalof219patientswereincludedinthestudy,ofwhich73wereinthehypoglycemicgroupand146wereinthenon-hypoglycemicgroup.Mortalityoccurredin25%ofpatientsinthehypoglycemicgroupversus12%inthenon-hypoglycemicgroup(p=0.01).TheaveragetotalICUdaysforthehypoglycemicgroupwas28(2-152)and13(2-133)inthenon-hypoglyce-micgroup(p<0.0001).Inaddition,thehypoglycemicgrouphadlongeraveragetotalventilatordays(21vs.8;p<0.0001)andoverallhospitaldays(40vs.22;p=0.0002).Theinfectionratewasalsohigherinthehypoglycemicgroupascomparedtothenon-hypoglycemicgroup(75%vs.36%;p<0.0001).Whenanalyzingthemaincauseofthehypoglycemicevent,insulinwasthemostcommonagentused(64%).Thisisanimportantfactortonotesincetightglucosecontrolisalwaysatopicofdebate.DuringthestudyperiodthegoalglucoselevelforpatientsonaninsulindripinanICUwas80-120mg/dL.Havingthisnarrowglucoserangemayhaveincreasedthechancesforthehypoglycemicevent.Thereforeitcanbepostulatedthatraisingthetargetrangeto<180mg/dlcouldleadtofewerhypoglycemiceventsthusimproveoutcomeoftraumapatients.

Conclusion: Overallpatientsinthehypoglycemicgroupexperiencedpooreroutcomesascomparedtothenon-hypoglycemicgroup.Patientswithbloodglucoselevelslessthan40mg/dLappearedtohaveahigheracuitywithhigherinjuryscoresandhavemorehyperglycemicepisodes.Thiswasreflectedintheirworseningoutcome.Hypoglycemiawithbloodglucoselevellessthan40mg/dLappearedtobeapoorprognosticindicatorfortraumapatient.


2nd Annual Quality/Safety Forum Draws Crowd

John A. BeAls AwArdfor medicAl reseArch

G. shAhin AwArdfor reseArch By A physiciAn in trAininG in duvAl county

Articles submitted for the Beals Award must have been written by a member of the Duval County Medical Society, based on work done in Duval County. They must have been published between January 2009 and December 2009 in a peer reviewed periodical listed in the MEDLINE / PubMed journal database.

Articles submitted for the G. Shahin Award must have a resident or fellow in training in Duval County as the lead author. The majority of the work must have been done while the resident or fellow was training in Duval County. They must have been published between January 2009 and December 2009 in a peer reviewed periodical listed in the MEDLINE / PubMed journal database.

it’s time for the 2010 BeAls & shAhin AwArds!

Beals and Shahin Awards will be considered in three categories: Original Investigation • Clinical Observation • Review Articles

suBmission deAdline is August 6, 2010. All winners will be recognized and receive plaques at the DCMS / Navy Meeting in late September,

with the winners in the Original Investigation categories also receiving monetary awards. Please login to the DCMS website (www.dcmsonline.org) and follow the Beals / Shahin link (under “Quick Links”) to submit your article for consideration. You will be asked to complete a brief form with contact information, award category, and publication details, and if available, email a PDF file of your article as it appeared in print or electronically.

If you have questions, please contact Marigrace Doran at 355-6561 ext. 101 or [email protected].

The130attendeesatthe2ndAnnualQuality/SafetyForum,May7,2010attheUniversityofNorthFloridaUniversityCenter,heardKeynoteSpeakerDr.BrentJames(leftatpodium),theChief Quality Officer, Executive Director, oftheInstituteforHealthCareDeliveryResearch,IntermountainHealthcareinSaltLakeCity,Utahandseveralpanelists.

Panelistspicturedare(left,LtoR)DCMSmem-bersDr.RobertNussandDr.WilliamRupp,MichaelSpigelofBrooksHealthandDCMSmemberDr.JayCummingsonthe“CreatingaCulture toFosterOutstandingQuality andSafety”panel.

The forum focused on Creating a Culture ofQuality, Communication and Collaboration.Itwashostedby theUNFCenter forGlobalHealthandMedicalDiplomacyandtheDuvalCountyMedicalSociety.

(Farleft,LtoR)Dr.&Mrs.YankD.Coble,Jr.(Dr.CobleistheDirectorandDistinguishedProfessorof theCenter forGlobalHealth&MedicalDiplomacyattheUniversityofNorthFlorida) with Dr. David Moomaw. (Left, LtoR)DCMSExecutiveDirectorJayMillsonandDCMSPresidentDr.JohnKilkennychatduringabreak.


Abstract Category 3 - Case Study

Editor’s Note: The following data are presented clearly and conclusions are consistent with the data. Because of space limitations, we are only publishing abstracts. It is, therefore, inherently difficult to determine if some conclusions may overstate the magnitude or causality of the relationships identified. Resident author names are in bold.

Molecular Analysis of Intravascular Large B-Cell Lymphoma with Paraneoplastic Neoangiogenesis

HanW.Tun,MDandChristina Saurel, MDMayoClinic,Jacksonville,FL,DepartmentofHematology/Oncology

Background:IntravascularlargeB-celllymphoma(IVLBCL)isararesubtypeofnon-Hodgkinlymphoma.InWesterncoun-triesIVLBCLhasapredilectionforthecentralnervoussystemandtheskin.Werecentlydiagnoseda77-year-oldwomanwhopresentedwithextensive,painfulcutaneousnodulesandspiderangiomasofthetorsoandlegs.Aleftthighnodulewasbiop-siedandleadtothediagnosisofIVLBCLwithassociatedangiomaandangiolipomaformation.FourothercasesofpatientswithasimilarpresentationhavebeenreportedintheEnglishliteraturebutthepathogenesisforthisneoangiogenesisremainsunknown.Weperformedanin-depthmolecularandpathologicanalysistoelucidatethemolecularbasisfortheparaneoplasticneoangiogenesis.

Methods:Theskinbiopsywasfixedinformalin,embeddedinparaffin,andsectionedat3-micrometerintervals.SingleantibodystainwasperformedforVEGF.Threeobserversevaluatedtheimmunohistochemicalresults.Dualimmunohistochemicalstud-ieswereperformedwiththecombinationofFactorVIII/CD20,FactorVIII/Osteopontin(SPP1),andCD20/SPP1.PresenceofmembranestainingforCD20,cytoplasmicstainingforFactorVIII,predominantnuclearstainingforSPP1,cytoplasmicstainingforVEGFwerescoredaspositive.TotalRNAfrombiopsyspecimenwasextractedusingRNeasyMiniKit,accordingtomanufacturer’sprotocol.ThecontrolgroupconsistedofdiffuselargeB-celllymphoma(DLBCL)tissuesamplesfromvarioussites.Nineprimersetstargetedthefollowinggenetranscripts:vascularendothelialgrowthfactor(VEGF)A,VEGF-B,VEGF-C,VEGF-D,VEGF-R1,VEGF-R2,VEGF-R3,andSPP1.

Results: Wereviewedtheslidesoftheskinexcisionalbiopsy.ThedualstainforfactorVIIIandCD20demonstratedCD20+neoplasticBcellswithinthevessels,highlightedbyfactorVIIIstaining,consistentwithIVLBCL.IntravascularneoplasticBcellsshowedstrongexpressionforSPP1.TheneoplasticintravascularlymphocytesalsoexpressedVEGF.qRT-PCRconfirmedtheelevatedexpressionofVEGF-A,VEGF-C,VEGF-D,andSPP1 inourcasecomparedtootherDLBCLs.

Conclusion:OurexperimentselucidateamolecularbasisforparaneoplasticneoangiogenesisincutaneousIVLBCL.LymphomacellsproducedproangiogenicagentssuchasVEGFandSSP1,whichhasbeenshowtopromoteangiogenesisinothercancers.Theseproangiogenicfactorsappearedtohaveaparacrineeffect,leadingtoangiomaformationintheskin.SPP1inIVLBCLhasnotbeenpreviouslyreported.Inthefuturetreatmentofpatientslikeours,theadditionofantiangiogenicagentsshouldbeexplored.However,itisnotcompletelycleartouswhetherantiangiogenictherapywouldhavehadaclinicallysignificantimpactonoutcome,asneoangiogenesismaynotbedirectlyinvolvedinthedevelopmentandmaintenanceofIVLBCL.

IleoSigmoid Knotting: Take a Second Look

Ainsley Freshour, MDandJ.BrackenBurns,Jr.,DOUniversityofFlorida-Jacksonville,DepartmentofAcuteCareSurgery

Introduction: IleoSigmoidKnotting(ISK)isararecauseofintestinalobstructionthatcarriesaveryhighmorbidityandmortal-ity.Awarenessofitsexistenceandpathogenesisincreasespromptrecognitionanddirectsappropriatesurgicaltherapy.

Case Description:A19-year-oldmalepresentedwithacuteperitonitis.ACTscanobtainedpriortosurgicalconsultshowedmarkedascites,air-fluidlevels,anda“whirl”signmid-abdomensuggestiveofvolvulus.Atlaparotomy,weencounteredacopi-ousamountofdarkbrownsero-sanguineousfluidandnecroticsmallandlargebowelthatwereintertwined.Partialsigmoidcolectomyandenterectomyoftheinvolvedsmallbowelwasperformed,andthepatientwasleftindiscontinuity,pendingasecond-lookoperation.AfteraggressiveresuscitationintheICU,asecondlookoperationwasperformed36hourslaterwhichrevealedviablebowelendsandtwoanastomoseswereperformedinahemodynamicallystablepatient.Thepatientunderwentanuneventfulrecoveryandwasdischargedhomeonpost-operativeday7/5.


Discussion: With amortalityof40%andamorbidityofnearly100%,knowledgeofIleoSigmoidKnotting(ISK),itspatho-genesis, and itsappropriatemanagement is essential.Throughauniquemechanism,adouble-loopobstructioncanrapidlyprogresstogangreneofthesmallbowelandoftenthesigmoidcolonaswell.Therecanalsobeassociatedthrombosisofthesuperiorrectalvesselswhichcanleadtolaterectalnecrosis.Patientsfrequentlypresentwithacuteonsetperitonitisandoftenhaveaccompanyingshock.Atlaparotomy,darkbrownascitesandobviouslynecroticbowelisencountered.Thiscanbeconfus-ingforasurgeonwhohasneverheardofISKbecausetherearenecroticareasofbothsmallandlargebowelthataredifficulttountwistwithoutperforation.KnowledgeofISKisimportantbecausetherapyneedstotakeintoaccountthepossibilityoflaterectalnecrosis.Traditionally,ISKpatientshaveundergoneilealresectionwithentero-enterostomyandsigmoidcolectomywithcolostomy.Weproposeusing“damagecontrol”principlesandplanningasecond-lookoperation.Thisaccomplishesseveralthings:initialoperativetimeisshortened;questionablyviablebowelcanbeleftinthehopesofrecovery;thepatientcanundergoearlyaggressiveresuscitation;bowelviabilitycanbereassessedatthesecond-look;anyanastamosesperformedcanbedoneinacontrolledenvironmentonamorestablepatient;andtheneedforacolostomymaybeavoided.HopefullybyincreasingtheawarenessofIleoSigmoidKnottingandproposingthissurgicaltherapy,wecandecreaseboththemorbidityandthemortalityofthisrarecondition.

Spindle Cell Carcinoma: A Rare and Challenging Disease Entity

Atman U. Shah, MD; MuhammadA.Salahuddin,MD;LindaR.Edwards,MD; Elaine Salazar, MD andRonaldM.Rhatigan,MD

University of Florida, Health Science Center, Jacksonville, FL, Department of Medicine

Editor’s Note: Due to production constraints, Figure 3 is not printed in the journal. It is available online at www.dcmsonline.org as a web illustration.

Abstract: Spindlecellcarcinoma(SpCC)isararehistologicvariantofsquamouscellcarcinomawithanaggressivemetastaticcourseandahighpropensityforrecurrence.Thediagnosisismadehistopathologicallywiththehelpofimmunohistochemicalstains.Ourcaseexaminesthisrarecutaneousspindlecellcarcinomathatinvolvedtheperioralregioninourpatient.Ourgoalistoincreaseawarenessofthisraremalignancyandbrieflyreviewthecurrentlyavailableliterature.

Case Presentation: A44-year-oldCaucasiangentlemanwithamedicalhistorysignificantofHIV(CD4countof18)wasbroughttotheemergencyroomintubated,afterbeingfoundunresponsive.Hewassuccessfullyextubatedafterbecomingmorealertandoriented.Hecomplainedofgeneralizedfatigue,weightloss(20lbwithinthelast3months),leftupperarmweak-ness,aswellassevereneckpainthathadbeenongoingforalmostayear.Hissocialhistorywaspositivefora50packsperyearhistoryofsmoking.Onphysicalexamheappearedcachecticandpale,butnotinapparentdistress.Hehadnoticeablefingerclubbing.Thephysicalexamrevealeda2x3cmleftupperlip,exophyticulceratedlesionof1monthduration.Theremainderofthephysicalexamwasunremarkable.

Achestradiographrevealedacavitarylesionintherightupperlobe.CTscanofchestalsoshoweda3x5cmcavitaryrightupperlobelesion(Figure 1, p.23)aswellasmultiplelyticlesionspredominantlyinvolvingthethoracicspineandanassociatedcom-pressionfractureatT9consistentwithosseousmetastases.Thenon-contrastheadCTshowednoacuteinfarctorhemorrhagebutdidshowmultiplelyticlesionswithinthecalvariumandcervicalspine(Figure 2, p.23).

Initialdifferentialdiagnosisincludedmultiplemyelomaand/oraninfectiouspathology(tuberculosis,fungal)inthepulmonarysystem.Multiplemyelomawasruledoutbyabonemarrowbiopsythatwasnegativeforneoplasmorinfection.AbronchoalveolarlavageandaCTguidedbiopsyofthelunglesionwerebothnegativeforneoplasmorinfections,suchasPneumocystisCariniiPneumonia (PCP)andtuberculosis.

Duringthehospitalcourse,thepatienthadagradualworseningofleftupperextremityweakness.AnMRIofthespinerevealedseverecordcompressionatC3.Thepatientwasapoorsurgicalcandidateandwasstartedondexamethasoneinadditiontobeingplacedinacervicalcollar.Finallyinsearchofatissuediagnosis,abiopsyoftheupperliplesionwasperformedandpathologywaspositiveforspindlesquamouscellcarcinoma.Priortobeingtransferredtoanursinghome,thepatienthadanacuterespira-torydecompensationandexpired.

Discussion: Spindlecellcarcinoma(SpCC)isararehistologicvariantofSquamouscellcarcinoma(SCC)havinganaggressivemetastaticpotentialandahighrateofrecurrence.Itmayappearasanexophytictumororanulceratedmassonthesun-exposedskin.Spindlecelllesionsaremorelikelytooccurwithintheheadandneckregionswheresunexposureismostprominent.1,2

Westudiedthecasereportsinliteraturetobecomemorefamiliarwiththeapproachtoevaluationandtreatmentofthisrarediseaseentity.SpindlecellSCCwasinitiallyreportedbyMartinandStewartin1935.Itwasbelievedthatpreviousradiationwasthemostimportantcause,assixoftheeightpatientsinitiallyreportedbyMartinandStewart,hadahistoryofradiationand


halfofthemdiedofcancer.3In1972,Smithet.alproposedthatSpCChadamoreaggressivecoursewhentheyaroseatasiteofpreviousradiation.4SpCCwasalsobeenreportedbyHarwoodin1996,inacaseseriesofrenaltransplantpatients,ofwhich25%ofpatientsdevelopedmetastaticdisease.5

Histopathology: SpCCispartofagroupoftumorsthatreflectacontinuuminhistologicheterogeneityaswellasepithelialandmesenchymaldifferentiation.Inourcase,afinaldiagnosisofpoorlydifferentiatedspindledsquamouscarcinomawasreachedbycombiningcytopathologicandimmunocytochemicalinformation.

SpCCmustbedistinguishedfromspindlecell/desmoplasticmelanoma,cutaneousleiomyosarcoma,atypicalfibroxanthoma,andscartissue,allofwhicharehistologicalmimickers.Onobservation,thelesioniscompletelyintradermalwithnoepidermalinvolvement.Itiscomposedofverypleomorphicspindlecellsarrangedinawhorledpattern.Thespindlecellshaveprominentnucleoli,scanteosinophiliccytoplasmandindistinctcellborders(Figure 3, www.dcmsonline.org).Numerousmitoticcellsarepresent.

Inourcase,thetumorstainedpositiveforhigh-molecularweightcytokeratin(CK),vimentinandEMA.Thetumorstainednega-tivefordesmin,CD31,HHV8andS-100,thusrulingoutmelanomas(S-100positive)andatypicalfibroxanthomas(vimentinpositive).However,somepoorlydifferentiatedspindlecellsquamouscarcinomasmayshowlossofcytokeratinexpressionandaberrantvimentinexpression,makingthediagnosisevenmorechallenging.

Conclusion: Cutaneous spindle cell carcinoma is anuncommonmalignancymarkedbyboth local recurrence anddistantmetastases.Theincidenceofthiscancerisunknown,withonlyanumberofindexcasesreportedinliterature.Mostcommonsitesofthiscancerareonsunexposedareasoftheheadandneck.Somestudiesindicatethatpreviousradiationexposureisassociatedwithhigherriskofdevelopingspindlecellcarcinoma.Histologically,itsdominantcomponentshavebothepithelialandmesenchymaldifferentiationthatmimicsothercutaneouspathologies,makingadiagnosisbycytopathologyalonedifficult.Therefore,immunocytochemicalinformationisrequiredtoconfirmthisdiagnosis.

Noclearmanagementguidelinesexistforthisraremalignancy.Earlydiagnosisandsurgicalexcisionoflesionsaremostlikelyrelatedtoabetterprognosis.Unfortunately,nolargestudieshavebeenconductedregardingtheprognosisofSpCC,especiallycomparingdenovolesionswithradiation-associatedlesions.TheadoptionofacomprehensiveanduniversaltreatmentapproachtoSpCCwillhelpinunderstandingtheroleofsystemicchemotherapyinpatientswithmetastaticdisease.

References1. SomerenA,KarciogluZ,ClairmontAJr.Polypoidspindlecellcarcinoma(pleomorphiccarcinoma).Oral Surg 1976;42:474–89.

2. RandallG,AlonsoW,OguraJ.Spindlecellcarcinoma(pseudosarcoma)ofthelarynx.Arch Otolaryngol 1975;101:63–6.

3. MartinHE,StewartFW.Spindlecellepidermoidcarcinoma.Am J Cancer.1935;24:273-297.

4. SmithJL.Spindlecellsquamouscarcinoma.In:GrahamJH,JohnsonWC,HelwigEB,eds.Dermal Pathology.Hagerstown,Md:HarperandRow;1972:631-635.

5. HarwoodCA,ProbyCM,LeighIM,etal.Aggressivespindlecellsquamouscellcarcinomainrenaltransplantrecipients.Br JDermatol.

1996;135:23.

Figures 1 & 2 CT Scan of Chest and of Spine (L and R)


An Unusual Case of Pancytopenia

Shimona Bhatia, DO, MPHUniversityofFlorida,CollegeofMedicine-Jacksonville,FL,DepartmentofPediatrics

Editor’s Note: Due to production constraints, Figures 1-5 are not printed in the journal. They are available online at www.dcmsonline.org as web illustrations.

History of Present Illness:Analmostthree-year-oldboypresentedtotheERinJuneof2008withathree-weekhistoryofweakness,decreasedactivity,fussiness,decreasedappetite.Healsohadatwo-dayhistoryoffever(Tmax=102.8F),drycoughandarunnynose.Healsohadafewepisodesofnon-bloody,non-biliousvomitinginthelastday.Hewasseenatanurgentcarecenterthedaypriortoadmissionandprescribedamoxicillin.Earlierintheday,hewasseenathisprimarycarephysician’sofficeatwhichtimehewas“ill-appearing”andhadsymptomsofrespiratorydistress.

Past Medical History: Hehasnosignificantpastmedicalhistory.Hisimmunizationswereup-to-date.Hismedicationsincludedmontelukastandamultivitamin.Therewerenoknownsickcontacts.Heeatsanormaltoddlerdiet.

Physical Exam:T:38.6C,Pulse:156,BP:112/80,RR:26,O2saturation:100%on2LO2,Weight:13.9kg,Height:98cm.General:pale,mildrespiratorydistress.HEENT:normocephalic,clearTMsandoropharynx,PERRLA.Heart:tachycardia,regularrhythm,nomurmurs.Lungs:poorairmovement,cleartoauscultationbilaterally.Abdomen:soft,nontender,mildsple-nomegaly,normoactivebowelsounds.Lymph:shottycervicallymphadenopathy.Extremities:peripheralpulses2+bilaterally,capillaryrefill=3seconds.Neuro:nofocaldeficit,normalgaitandsensation.Musculoskeletal:4/5strengthinbilateralupperandlowerextremities.

Laboratory Studies:Initiallaboratoryinvestigationrevealedamarkedpancytopenia.(Table 1)

Discussion:Duetothesevereanemia,hereceivedapRBCtransfusionandhadabonemarrowbiopsy.Sincehislaboratoryevaluationrevealedapancytopenia,hewasgiventhepresumptivediagnosisofleukemia.Bonemarrowbiopsyrevealedahyper-cellularmarrow,virtuallynoblasts,giantbandsandmegakaryocytes.Megaloblasticerythroidprecursorcellswerepresentwithcharacteristicsconsistentwithnuclearcytoplasmicasynchrony(largeimmaturenucleusinamaturecytoplasm).Themyeloidtoerythroidcellratio(M:Eratio)was1to2-3(normal=3:1).Furtherevaluationofhis initialCBCrevealedasignificantmacrocytosis.

Thework-upincludedmicroscopicevaluation,measurementofmarkersofrapidcellturnover(lactatedehydrogenase,uricacidandunconjugatedbilirubin)andanevaluationofthereticulocytecount.Thesimultaneouspresenceofincreasedmarkersofrapidcellturnover,lowreticulocytecount,highmeancorpuscularvolume,highredcelldistributionwidthandahypercellularmarrowindicatesineffectiveerythropoiesiswhichisconsistentwithmegaloblasticanemia.Megaloblasticanemiaischaracterizedbythepresenceofovalmacrocytesandhypersegmentedneutrophilsonaperipheralbloodsmear.(Figures 1-5, www.dcmsonline.org)

MegaloblasticanemiaiscausedbyeitheradeficiencyoffolateorvitaminB12(cobalamin).HisserumvitaminB12levelwasfoundtobemarkedlylow.Aendoscopywasperformedandrevealednormalgastricandduodenalmucosa.Hewasfoundtohaveserumantibodiestointrinsicfactor.HewastreatedwithIMB12for5-6days.HisrepeatB12levelwasnormal,sohewasdischargedhomewithoralhigh-doseB12.Hisfinaldiagnosiswasantibody-positivecongenitalperniciousanemia.Todate,intheliteraturetherearenoisolated,recordedcasesofcongenitalantibody-perniciousanemiainanotherwisehealthychild.”

Table 1 Laboratory Values

(Normal values) Initial Evaluation Post-Treatment Evaluation WBC 2.19 (6-17.5) 8.55 (6-17.5) Hg / Hct 2.8 (11.2-14.3) / 8.1 (34-40) 13.6 (11.2-14.3) / 39.4 (34-40) Plt 72 (150-450) 241 (150-450) MCV 109.2 (75-87) 79 (75-87) Reticulocyte count 6.1%/50,000 Not done B12 73 (190-914) >1500 (190-914) Folate 15 (3-17) Not done MMA 2.423 (0.073-0.376) 0.152 (0.073-0.376)


Olfactory Neuroblastoma with Hyponatremia

Altman U. Shah, MD; Jamie Woodcock, MD; andFauziaN.Rana,MDUniversityofFlorida,HealthScienceCenter,Jacksonville,FL,DepartmentofMedicine

Abstract: Olfactoryneuroblastoma(ONB),alsoknownasesthesioneuroblastoma,isararemalignanttumorofneuroectodermaloriginwithanestimatedincidenceof0.4permillion.Itrepresentsonetofivepercentofmalignantnasaltumors.Earlydiagnosisisuncommonbecauseofvaguesymptomatologyatpresentation.NoTNMstaginghasbeencreatedforthistypeoftumor.Imagingisusefulinassessinglocalinvasionoftumor,althoughisinsufficienttomakeadiagnosis.Definitivediagnosisrequiresexaminationofhistologyandconfirmationwithelectronmicroscopyandimmunohistochemistry.Wedescribeapatientthatpresentedwithuncommonfeaturesandreviewthecurrentavailableliterature.

Case Presentation: A26-year-oldCaucasianstudentwhopresentedtoclinicwitha2-yearhistoryofsinusitisandnasalconges-tionthatwasalsoassociatedwithchangesinsmell.Hehadnohistoryofbleeding,facialpain,discharge,recurrentinfections,headache,orvisualcomplaints.Hismedicalrecordsrevealedananxietydisorderandhypertension,aswellas,chronichypona-tremiaandSyndromeofInappropriateAntidiureticHormoneHypersecretionproduction(SIADH).HewasbeingtreatedwithDemeclocycline.Onevaluation,hewasfoundtohaveapolyp,left-sidedsino-nasalmasswithanotherwisenormalexam.

CTimagingrevealeda3.9cmexpansilemassoftheleftanteriorethmoidsinuswithextensionintotheleftsuperiormedialmaxillarysinusandsuperiorleftnasalcavity.AnMRIshowedscatteredwhite-matteredlesions.APETscanshowedmildlyhypermetaboliclymphnodeatoftheleftsuperiorjugularlymphnodechain,measuredabout1.3cminsizeandasinonasalmassthatwasencroachingontheleftmedialorbitaswellasseveralplaquesinthewhitematter.

Hewastakentotheoperatingroomwhereanendoscopicdissectionandbiopsywasperformed.Definitiveresectioncouldnotbeperformedduetomassivebleeding.Heunderwentlymphnodedissection,andalllymphnodeswerenegativeforneu-roblastoma.Leftmaxillarybiopsywasconsistentwithpigmentedolfactoryneuroblastoma.Thetumorinvolvedtheboneandsinonasalstructures.Itwascomposedofprimitivesmallcluecellswithfocalrosetteformation.Themitoticactivitywaslowandmoreconsistentwithlow-gradeolfactoryneuroblastoma.

Followingsurgeryhishyponatremiacompletelyresolved.Hereceivedpostoperativelow-doseCisplatin20mg/m2onaweeklybasisalongwithradiationtherapytwiceperday.After16monthsoffollowup,therewasnoevidenceofrecurrence.

Discussion: Olfactoryneuroblastoma(ONB)isanuncommonmalignanttumorthatrepresentsupto5%ofmalignantnasaltumors.Ithasnopredilectionforraceorsex.1Thereisawideagedistributionwithbimodalpeaksinincidencebetween11-20and51-60yearsofage.TherearenoknowngeneticmutationsoretiologicagentsforONBinhumans.ONBoriginatesfromthebasalolfactoryepithelialstemcellslocatedintheupperthirdofthenasalcavity.Grossly,itappearsasasmooth,hemorrhagic,andpolypoidmass.2Microscopically,itiscomposedofuniformcellswithscantcytoplasmandsmall,roundnucleilocalizedtonestorlobulesinthesubmucosaandstroma.3

Themostcommonpresentingsymptomsareunilateralnasalobstruction,epistaxis,andpersistentnasaldischarge.Lesscommonsymptomsincludeheadache,hyposmia,anosmia,visualdisturbances,proptosis,facialpainandswelling,andsyncope.4Inmostcasesthediagnosisisdelayedformonthsbecausethecommonsymptomsareoftenpassedoffasbenignsinonasaldisease.Di-agnosingONBrequireshistochemicalanalysisinordertoruleoutothersmallroundcellmalignantneoplasmsofthesinonasaltract.Thedifferentialdiagnosisincludesundifferentiatedcarcinoma,lymphoma,melanoma,embryonalrhabdomyosarcoma,andextramedullaryplasmacytoma.5-6

ThesetumorsaregradedbyHyam’sclassificationsystem,whichiscomprisedoffourgradesdifferentiatedbyhistologiccharacter-istics.Gradingisbasedonthepresenceofcertainhistologicfeaturessuchaslobulararchitecture,nuclearpleomorphism,rosettes,mitoticactivity,andcellularnecrosis.Thelessdifferentiationatumorshows,thehighergradeitreceivesonascaleof1through4.7StagingforthesetumorsusestheKadishsystem.Inthissystem,stageAisconfinedtothenasalcavity,stageBspreadstotheparanasalsinuses,andstageCextendsbeyondtheseregionstoincludetheorbit,intracranialcavity,skullbase,cervicallymphnodes,ordistantmetastases.Hightumorgradeanddiseasestagecorrelatewithapoorprognosisforthepatient.8

Conclusion: AdiagnosisofONBrequiresproper tumorgradingandclinical stagingwithradiologic imaging, followedbyrigoroustreatment.Aggressivesurgicalresectionfollowedbyadjuvantradiationtherapyisthemainstayoftreatmentforanyneoplasticstage.Thiscombinationtherapyhasbeenshowntohavethehighestcurerate.Chemotherapyisusuallyreservedforadvanceddiseaseduetoitslimitedsuccessasacurativemodality.

Five-yearsurvivalrangesfrom40%to80%dependinguponthestateandgrade.Patient’swithlow-gradetumorshave80%five-yearsurvival,butthosewithhigh-gradehave40%survival.About30%candeveloplocalrecurrenceusuallywithinthefirst2years,and15%havecervicallymphnodemetastasis,and10%willdevelopmetastasisatsomepointduringthecourseofthedisease.9


References1. SheldonR,BrownSR.Esthesioneuroblastoma.Otolaryngology

Head and Neck Surgery 2007;137(5):835-6.

2. CastelnuovoP,BignamiM,DelùG,etal.Endonasalendoscopicresectionandradiotherapyinolfactoryneuroblastoma:ourexperience.Head Neck 2007;29:845–50.

3. Esposito,DFKellyandHVVinterset al.,Primarysphenoidsinusneoplasma:areportoffourcasewithcommonclinicalpresentationtreatedwithtranssphenoidalsurgeryandadjuvanttherapies,J Neurooncol76 (2006),pp.299–306

4. SampathP,ParkMC,HuangD,etal.Esthesioneuroblastoma(olfactory neuroblastoma) with hemorrhage: an unusualpresentation.Skull Base 2006;16(3):169-73.

5. PagniF,DiBellaC,BonoF,etal.A37-year-oldwomanwithepistaxis and unilateral nasal obstruction. Neuropathology 2007;27(6):609-11.

6. CapelleL,KrawitzH.Esthesioneuroblastoma:acasereportofdiffusesubduralrecurrenceandreviewofpublishedstudies.Journal of Medical Imaging and Radiation Oncology 2008;52(1):85-90.

7. HyamsVJ,Batsakis JG,MichaelsL (1988) Atlas of tumor pathology.ArmedForcesInstituteofPathology,Washington,pp240–248

8. KadishS,GoodmanM,WangCC.Olfactoryneuroblastoma:aclinicalanalysisof17cases.Cancer1976;37:1571–1576.

9. DulguerovP,AllalAS,CalcaterraTC.Esthesioneuroblastoma:ameta-analysisandreview.Lancet Oncol 2001;2:683–690.

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From a Resident’s Perspective

Editor’s Note: The opinions expressed in these essays are the personal perspectives of the resident authors and may or may not represent the views or ideology of the publisher, the University of Florida or Shands Jacksonville. Resident author names are in bold.

AnunfortunatecircumstanceaffectingthecityofJacksonville,FloridaandtheUnitedStatesistherisingnumberofgirlsinvolvedinthejuvenilejusticesystem.Inanationalsurveyconductedin2001,thedelinquencycasesforgirlshadincreasednationallyby83%,asignificantincreaseworthyofintervention.CurrentlyinFlorida,almostoneoutofeverythreejuvenilesarrestedisfemale.Girlsarethefastestgrowingsegmentofthejuvenilejusticesystem,anditistimetotakeactiontostopthisgrowingtrend.

Thereappearstobealinkbetweenvictimizationanddelinquencyamongthispopulation.InJacksonville,itwasnotedthatupto73%ofthegirlsinvolvedinthejuvenilejusticesystemreportedbeingvictimsofviolence,especiallysexualabuse,famil-ialsubstanceabuse,domesticandcommunityviolence.Emotionalfactorsalsoplayahugepartintheirdelinquentbehaviors.Seventy-ninepercent(79%)ofgirlsintheresidentialprogramsand84%ofgirlsinthenon-residentialprogramssufferedfromdepression,trauma,anger,self-destructivebehaviororothermentalhealth/clinicaldiagnoses.

Thefactremains,however,thatthetypesofoffensesforwhichgirlsarearrestedandincarceratedarelessseriousthanthoseforboys.Theiroffensesrangefromstatusoffenses(18%)totechnicalviolations(15%)andsimpleassault(15%).Detainedgirlsposelessofapublicsafetyriskcomparedtoboys,makingitmorebeneficialtoinvestinlessexpensivecommunity-basedservicesforthemratherthanthemorecostlyresidentialcommitment.

Duringmycommunityrotation,IwasabletointeractwithgirlsatthePACECenter.ThePACECenterforGirlsisafree,non-residentialprivateschoolforhigh-riskgirlswhohavenotyetenteredthejuvenilejusticesystem,butarefromhigh-riskenvironments.Thesegirlsexperienceanaverageoffiveriskfactorsincludingchronictruancy,learningdisabilities,documentedchildabuse,parentalincarceration,substanceabuse,runningaway,gangmembershipandabsenteeparents.Itisunfortunatetothinkthatthesechildrenwerealreadyatadisadvantagefrombirthbasedontheirenvironments.ThePACECenterofferssoundacademics, intensivetherapeuticcounselingandcasemanagement,familycarecoordination,healtheducationandremedialacademicattention.

Ihadtheopportunitytoobserveaone-on-oneinteractionbetweentheschoolnursepractitionerandoneofthePACEstudents.Thestudentcametotheschool-basedclinicatPACEfor“headaches”,acommoncomplaintamongthesegirls.Hersocialhistoryrevealedthatshehadbeensexuallyassaultednumeroustimesbyamaleadultfamilymember.WealsolearnedthatherunclehadjustdiedinIraqandwasbeingbroughthomeforfuneralservicesthatweekend.Thelistofstressesandproblemsexperiencedbythisyounggirlwerenumerous.Itwasdishearteningtohearthattheseso-calledheadacheswerequitecomplicatedandrequiredamorein-depthtreatmentthanjust2Tylenol.

PACECenterforGirlsinJacksonvilleisaverysuccessfulprogramwithextraordinaryoutcomes.AccordingtothePACECenterwebsite,100%ofthegirlsenrolledintheprogramhadnoinvolvementwiththejuvenilejusticesystemwithinayearofleavingPACE,100%wereinschooloremployedthreeyearsafterleavingPACEand97%improvedtheiracademicperformance(www.pacecenter.org).Thisprogramreallyhelpstoenhancethefutureofthesevulnerablegirls.

Ithinkitisimportantforpediatricianstoensurethatthesegirlsreceiveproperhealthcareinasafemedicalenvironment.Itisessentialtoadvocateforthesegirlsclinicallysotheydelaypregnancy,practicesafesexandliveinasafehome.Itisalsocriticalforpediatricianstoadvocateonthelocal,stateandnationallevelstopromotepublicpolicyforimprovedoutcomesforthesegirls.

Prescribing Justice for Girls: More Than 2 Tylenol

Monica Marcus, MDUniversityofFlorida,CollegeofMedicine,Jacksonville,FL

http://www.pacecenter.org


Hostage Situation: Rescuing the Children of New Town

Ngozi Ogbuehi, MDUniversity of Florida, College of Medicine, Jacksonville, Department of Pediatrics

Eyesfixed,heartpounding,sweatdripping,Iwatchalovedonelingeringclosetodeath.Fearcapturesmybody.IwanttoscreamandIwanttoshout,butwhatdifferencewillmyvoicemake?Iamoneperson.WhatcanIdotostopthis?WheredoIevenbegintohelp?Iaminundatedwithfeelingsofhelplessness.YetallIcandoisstandandwatchasmylovedoneisheldhostageinthegripsofanattacker;onethathasnoothergoalbuttostripmylovedoneofdignity,strength,andeventuallylife.

Nowimaginethatthehostageisnotalovedonebutacommunityandtheattackerisnotdeathoramaskedgunmanbutwell-knownoffendersthathavebeenaroundforyears–povertyandcrime.

NewTown,aoncethrivingcommunityofJacksonville,isheldhostagebypovertyandcrime.Itisanareaofthecitynotmentionedintouristbrochures.Ninety-sevenpercent(97%)ofNewTownresidentsareAfricanAmericanand35%ofresidentsliveinpoverty.Roughlyhalfoftheadultsdonothaveahighschooldiplomaandtheeffectscanbeseeninpovertyandviolentcrimerates.ThehomiciderateinNewTownisthehighestinJacksonville.1,2

Thereareover1,500childrenlivingintheNewTowncommunity.Theyareresilientchildrenwhohavefacedstaggeringoddsfrombirth.Sixty-fourpercentoftheirfamiliesareheadedbysinglemothers.In2000,therewerenearly400birthsinNewTown,with23%ofthesebirthstoteenagemothers.1ThisisnotsurprisingsinceNewTownisnestledwithintheurbancoreofJacksonvillewhichhasthehighestrateofteenpregnancyinthecity.In2000,81per1000girls,ages15-19yearsold,becamepregnantinthisarea,comparedtothecountyaverageof51per1000girls.Theseteenmothersareamongtheadolescentsandyoungadults,ages15-24yearsold,withthehighestratesofsexuallytransmittedinfections(STIs)inDuvalCounty.Theco-factorsofyoungmothers,STIs,povertyandloweducationalattainmentcombinetoproducethehighestratesoflowbirthweightbabiesandinfantmortalityinDuvalCounty.Withaninfantmortalityrateof13per100,000livebirths,whichissignificantly

Asphysicians,weneedtowritetoourlegislatorstoencouragestableandongoingfundingforplaceslikethePACECenterforGirls.Wealsoneedtoadvocateforasafeenvironmentforthesegirlstogotoiftheyarenotbeingprovidedoneathome.

Programsthatofferspecializedmentalhealthservices,substanceabusetreatment,familyfocusedservices,specializedmedicalcare,educationalandvocationalservices,transitionalplacementsandservicesneedtobeappropriatelyfundedandmadeacces-sibletothesegirlsandtheirfamilies.

Itisimperativethatphysiciansstayinformedaboutandsupportprogramsthatpromotegender-specificstrategiesforatriskgirlsthatwillpreventthemfromenteringthejuvenilejusticesystem.OnesuchprogramistheNationalCouncilonCrimeandDelinquency(NCCD)CenterforGirlsandYoungWomen,anewlyformedorganizationinJacksonvillethatprovidescommu-nityandprofessionaleducationandtraining,assessment,research,evaluationandadvocacytoensurethecontinuedwell-beingofatriskgirls(www.justiceforallgirls.org).

Thetimeisnow.WemustadvocateforthelivelihoodandwellbeingofthesegirlsandtheprogramsthatservicetheirneedsTODAY!

References1. PatinoV,RavoiraL,WolfA.Arallyingcryforchange:chartinganewdirectioninthestateofFlorida’sresponsestogirls

injuvenilejustice.Focus Views from the National Council on Crime and Delinquency,2006,pp.1-62. Children’sCampaign,Inc.GirlsinFlorida’sjuvenilejusticesystem;dowetrulyseetheirpain?pp.1-3.http://www.iamforkids.org/promises/promise5/facts5.asp.Accessed4/29/10.3. Jacksonville’s Children’s Commission. 2009 state of Jacksonville’s children: racial and ethnic disparities report, pp.

76-87. http://www.coj.net/NR/rdonlyres/ehcqorshfk35wi27tk6n7isj4g5lxoq5rn25g76kgriokkozpqkfmxh356lnbwekyt3tjefzlhzlgijocfc5uto25yb/2009+Racial_Ethnic_Disparities_Report.pdf.Accessed4/29/10.

http://www.justiceforallgirls.org


higherthanthecounty,stateandnationalrates,survivingbirthandlivingbeyondthefirstyearoflifeisadauntingtaskforNewTowninfants.2

ThechildrenofNewTownattendtheneighborhoodschools,S.P.LivingstonElementaryandEugeneButlerMiddleSchools.Livingstonisan‘F’gradeschoolandButlermiddleisa“C”gradeschoolbyFloridaDepartmentofEducationstandards.Over90%ofthestudentsareAfrican-Americanandparticipateinthefreeorreducedlunchprogram.3BothschoolsarechallengedbytheurgencytoimprovestudentFCATscoresandoverallacademicperformance.

OncethechildrenofNewTownleaveschool,theyencountertheotherfactorsthatimpactthetrajectoryoftheirlives.Theyseejoblessness,withunemploymentratesinthisareadoubletheDuvalCountyrate.Theyseetheirlovedonesdyingprematurelyfromand/orlivingwithcomplicationsofdiabetes,heartdisease,andHIV/AIDS,allofwhichhavethehighestratesinthisareaofJacksonville.HIV/AIDSrelateddeathsinthiscommunityoccurin42.4per100,000persons,whichisalmost4timesashighastheDuvalCountyrateof11.8per100,000persons.2ThisareaalsohasthehighestratesofasthmahospitalizationsinJacksonville.2

Whendrivingthroughtheneighborhood,itiseasytoseehowthephysicalenvironmentalsoaffectsthelivesofthechildren.Manyofthehomesareoldandindisrepair.Thereareseveralboarded-upshopsinthearea,areminiscentsignofatimewhenthiscommunitythrived.Childrenarerarelyseenplayingoutside.Theviolentcrimerateortheperceptionofhighcrimemayleadparentstokeeptheirchildrenindoors.Thereisanoticeableabsenceofgrocerystoresinthisneighborhood.Thechildrenhavenoaccesstofreshfruitsandvegetables,onlyfastfoodrestaurantsandconvenienceor“momandpop”storessellingprocessedfoodsandhigh-caloriesnacks.Howcanweexpectchildrentomaintainnormalweightsiftheyarenotabletoplayoutsideandtherearenohealthyfoodoptions?

Evenwithsomanyfactorsnegativelyaffectingthem,thiscommunityisresilient.Althoughtheyhavebeentakenhostage,theyarefightingback.In2008,agroupoflocalcivicleadersformedacoalitiontoimproveNewTown.TheNewTownSuccessZoneSteeringCommitteewasinspiredbytheprogressoftheHarlemChildren’sZoneinNewYorkCity.Thegroup,undertheleadershipoftheJacksonvilleChildren’sCommission,engagedtheJacksonvilleSheriff’sOffice(JSO)andnonprofitorganiza-tionsandgroupstocreateaconveyorbeltofservicestoimprovethelivesofchildreninNewTownfrombirththroughcollegegraduation.

Althoughstillinthebeginningphases,thegrouphasmadeprogress.Inthepastyear,policeofficersfromJSOhaveincreasedtheirpresenceintheneighborhoodandhaveworkedhardtostrengthentheirrelationshipwithresidentsinanefforttoreducecrimeandgaintrust.TheDepartmentofChildrenandFamiliesenlistedthefarmer’smarket,locatednearNewTown,tobegintakingFoodStampsasameanstoincreaseresidentaccesstofreshfruitsandvegetables.TheNortheastFloridaHealthyStartCoalitionincreasedservicesforpregnantwomenandalongwithotherorganizations,providesparentingandmaleinvolvementclassesinNewTown.BaptistHealthprovidesasthmaeducationforchildrenwithasthmawhoattendS.P.LivingstonElementaryandEugeneButlerMiddleschools.TheyrecentlycontractedwiththeHealthPlanningCouncilofNortheastFloridatoworkwithNewTownresidentstoconductathoroughcommunityassessmentofNewTown.

Afterschoolprogramsandactivitieshavebeenmadeavailableforthechildren,givingthemasafeplacetoplayandlearnoutsideofschool.EdwardWatersCollege,asmallhistoricallyblackcollegelocatedinthecenterofNewTown,openeditsdoorstothecommunity,volunteeringitsfacilitiesforcommunitymeetingsandavarietyofmuchneededcommunityservices.Thereishopethatbringingtheneighborhoodresidentsoncampuswillinspirethemtoexplorehighereducationandjobtrainingopportunities.

AlthoughtheSteeringCommitteehasmadegreatprogress,ongoingeffortstokeeptheresidentsinformedaboutprogramsandopportunitiesinthecommunityandinvolvetheminstrategiestoimprovetheirownneighborhood,iscritical.IftheNewTownresidentsareinvolved,feelempoweredandareabletomakedecisionsabouttheirowncommunity,thenthepositiveimpactthatiscurrentlybeingmadewillcontinue,longafterfundingendsandorganizationsmoveontotheirnextprojects.

WhenIfirstlearnedaboutNewTown,Ifeltlikethehelplesspersonwatchingalovedonebeingheldhostage.TheproblemsofNewTownarelarge,complexandoverwhelming.HowdoIhelp?WhatcontributionscouldImake?

NowthatIamlearningmoreabouttheimportantadvocacyroleofpediatriciansandallphysiciansinthecommunity,Iam


empoweredtojoinwiththeNewTownSuccessZoneSteeringCommitteetoimprovethelivesofthechildrenwithinNewTown.MyvoicewillnotbesmallwhenIjoinachorusofothersspeakingforthesameissue.

WhatI,asapediatrician,candotoaidinthemissionoftheNewTownSuccessZoneiswhatanyphysicianinJacksonvillecandotoadvocateforchildrenandthecommunitiesinwhichtheylive.

• Becomemoreknowledgeableaboutthecommunity,itsdemographics,anditsresidentsbyspendingtimevolunteeringwithvariousorganizationsandprogramsinthecommunity.

• Understandthesocialandenvironmentaldeterminantsofhealthmostaffectingchildren’shealthoutcomesandimplementevidence-basedstrategiesthathaveworkedtoimprovetheseoutcomeselsewhere.

• Formrelationshipswiththelocal,stateandnationalpolicymakerswhoareresponsibleforthisareainordertopromotemoreeffectiveadvocacyforthechildrenandfamiliesofthiscommunity.

ThechildrenandfamiliesofNewTownhavethepotentialtoovercomethehardshipsthathavebefallentheirpredecessorsandbecomethehostageswhosuccessfullybreakfromthegripsoftheirattackers–povertyandcrime.Thiscanbedonemoreeffectivelythroughthehelpandsupportofothers-peoplelikemeandyouwhoarenolongerafraidtofacetheattackersandconquerthem.

If you would like to support the activities of the New Town Success Zone Steering Committee, visit the website http://www.jaxkids.org/Departments/Childrens+Commission/Community+Information+and+Resources/New+Town+Success+Zone.htm for more information or contact Program Manager Irvin “Pedro” Cohen at (904) 630-6339 or [email protected]

References1. Jacksonville Children’s Commission. Success Zone Briefing Paper I http://www.jaxkids.org/NR/rdonlyres/

pxcnydddwn2uxrfihsipynstqkagfymuf/Success+Zone+Briefing+Paper+I.pdfAccessedMarch2010.2. DuvalCountyHealthDepartment.Health:Place Matters.2008;Issue1,7:1-10.3. FloridaDepartmentofEducation.SchoolGradesbyCountyhttp://schoolgrades.fldoe.org/default.asp.AccessedMarch2010.4. UnitedStatesDeptofAgriculture.IncomeEligibilityGuidelineforFreeandReducedLunch.http://www.fns.usda.gov/

cnd/Governance/notices/iegs/IEGs09-10.pdf.AccessedMarch2010.

The Problem with the American Health Care System

Nararjun Rayapudi, MD andJosephJ.TepasIII,MDUniversity of Florida, College of Medicine, Jacksonville, Department of Pediatrics

IntroductionAsaninternationalmedicalgraduate,IhadminimalexposuretotheAmericanhealthcaresystembeforestartingresidency

training.IgraduatedfrommedicalschoolinIndiaandrealizedthatIwasworkingandlearninginanunderdevelopedhealthcaresystem.Manypatientswerenotgettingadequatehealthcarebecauseoflackoffacilities,money,oravailableskilledperson-nel.Iwantedtopursuefurthereducationinwhatisrecognizedasoneofthebesthealthcaresystemsintheworld.ThisledmetotheUnitedStates.Inmytraining,Ipickeduptheclinicalaspectsofpatientcareveryquickly,however,Idevelopedseveralquestionsaboutthesystem.

My ProjectTogaindeeperunderstandingoftheAmericanhealthcaresystem,Ispentsixweeksonanelectiverotationinhealthadminis-

tration.IwasassignedtotheadministrationdepartmentofShandsJacksonville;a696bed,tertiarycare,teachinghospital.MyfacultymentoralsoarrangedaoneweekrotationatOrangeParkMedicalCenter,aHCAhospital.Thishelpedmeappreciatethedifferencesbetweenasafetynethospitalandaprivatehospital.MycolleaguesintheadministrationatShandshospitalin-cludedtworesidentswhohadfinishedMBAsinhealthcareadministrationandweredoingaoneyearinternshipatthisfacility.IfunctionedasthethirdresidentunderthementorshipofMr.SteveBlumberg,VicePresidentofBusinessDevelopmentandStrategicPlanning.

Asanadministrator,Iattendednumerousbusinessmeetings,interviewedpersonnelfromvariousdepartmentsofadministration

http://www.jaxkids.org/Departments/Childrens+Commission/Community+Information+and+Resources/New+Town+Success+Zone.htm

http://www.jaxkids.org/Departments/Childrens+Commission/Community+Information+and+Resources/New+Town+Success+Zone.htm

mailto:[email protected]

http://www.jaxkids.org/NR/rdonlyres/eqvijwu2wfkjv22otlt2mvxmdujchrkz5ma7moqzimf4ys7szqltr2xtyspxcnydddwn2uxrfihsipynstqkagfymuf/Success+Zone+Briefing+Paper+I.pdf

http://www.jaxkids.org/NR/rdonlyres/eqvijwu2wfkjv22otlt2mvxmdujchrkz5ma7moqzimf4ys7szqltr2xtyspxcnydddwn2uxrfihsipynstqkagfymuf/Success+Zone+Briefing+Paper+I.pdf

http://schoolgrades.fldoe.org/default.asp

http://www.fns.usda.gov/cnd/Governance/notices/iegs/IEGs09-10.pdf

http://www.fns.usda.gov/cnd/Governance/notices/iegs/IEGs09-10.pdf


andlearnedtheirperspective.Iconductedone-on-oneinterviewswithpersonnelfromseveraldepartmentsincludinghumanresources,patientsafety,financialevaluation,quality improvement, infectioncontrol, labor,purchasing,pharmacy,andriskmanagement.

Impressions of a TraineeFirstandforemost,thereismindbogglingcomplexityintheAmericanhealthcaresystem.Itbecameincreasinglyapparent

thattheorganizedsystemofhealthcareisfragmentedandconfusing.Ifthisweremyperceptionasaprovider,Icouldonlywonderabouttheintensityofchallengeforsickpatientsandtheirfamilymemberstryingtodecipherthissystemintimesofneed.Perhapsasimportantly,thisincrediblecomplexityalsocontributestohighcostofhealthcareasisclearlyevidencedbythefactthatalmost25to33%ofU.S.healthcarespendinggoestoadministrativefunctions,notclinicalservices.

Thereisahugedifferenceinperceptionofthehealthcaresystembyadministratorsincomparisontohealthcareproviders.Throughinterviewsandobservations,Inoticedthatthefocusofmostadministratorswasimprovingthefinancialperformanceofthehospitalsandtryingtosurviveinachallengingeconomythatincludesintensecompetition.Clinicians,ontheotherhand,weremorefocusedonimprovingqualityofcareandpatientoutcomes.Itappearedtome,oftentimes,theclinicians’commitmenttoprovidingwhatisconsideredtobeoptimalcaredidnotincludeconsiderationofpotentiallycontrollablecosts.Conversely,administratorsconstantlystruggledwiththemandatetoprovideanappropriatemargintocontinuesupportoftheclinician’smission.Onsomeoccasions,thisdisconnectbetweenperspectivesseemedtoindicatethatthecliniciansandadministratorsareworkingagainsteachother.

Amajorcontributortothisdisconnectisthevariabilityofpayermixamongdifferenthospitals.Atmostsafetynethospitalsthepercentageofselfpay,mostlyuninsuredpatients,approached30%,whereasatprivatehospitalsapproximately10%ofpatientsareuninsured.Throughoutmyresidency,IhaveencounteredmanypatientswhowereseenandevaluatedatotherhospitalsandreferredtoShandsbecausetheylackedinsurance.Itappearsthatabsenceofinsuranceisabiggerproblemthancancer,coronaryarterydisease,ormanyotherpotentiallycatastrophicillnesses.ItisunfortunatethattheU.S.istheonlyindustrializednationthatdoesnotprovidesomeformofbasichealthcaretoitscitizens.Althoughqualitycareatahighcostisreadilyavailabletomany,almost50millionAmericansareuninsuredanddon’thavesuchaccess.Inaddition,16millionpeopleareconsideredunderinsured.Theseworkingpooraremorelikelytodiefrompreventableillnessesandpresentwithadvanceddiseasestatesbecausetheyhavenoaccesstoroutinemedicalcare.

Thethirdobservationthatispossiblyevenmorecompellingisthatourexcessivespendingdoesnottranslatetobetterhealthcomparedtoothernations.ThelifeexpectancyinUnitedStatesis78,whichranks50thintheworld,wellbehindSingapore,Japan,Bermuda,Greece,JordanandBosnia.TheInfantMortalityRateis6.26(per1000births)intheU.S.whichishigherthanmostofthedevelopedcountries.TheWorldHealthOrganization(WHO)rankedthehealthcaresystemof191nationsin2000.FranceandItalywerefirstandsecond:theU.S.wasinthe37thposition.

Finally,itappearsthatdespitetheaboveproblems,theU.S.spends16%ofitsGrossDomesticProduct(GDP)onhealthcare,whichisthehighestproportionamongallothernationsintheworld.Thenearestrival,Switzerland,spends11.5%ofitsGDP,followedbyGermany(10.6%ofitsGDP),andNorway(8.9%ofitsGDP).Theproblemisnotjustthatthecurrentspendingandcostsarehigh,butthattheyareprojectedtoincreasesignificantlyandmaybankruptAmericainthefuture.

ConclusionsMyillusionatthetimeofbeginningofmyresidencytrainingwasthattheAmericanhealthcaresystemisthebestintheworld.

Yet,thissystemhasmajorproblems.ItappearsthattheU.S.providesthebesthealthcareavailabletopatientsattheindividuallevelbutfailsatthesystemlevel.Thiscountrylagsbehindotheradvancednationsindeliveringqualityhealthcareinatimelyfashion.Healthcarehereisexpensiveandnotaccessibletoallpeople.Bothqualityandcoverageareinconsistent.Therecentlypassedhealthcarereformlegislationaddressessomeoftheproblemsbyexpandinginsurancecoverage,focusingoncostcontain-ment,andincreasingregulationofinsurancecompanies.Ibelievehealthcarereformisanecessarystepintherightdirection,butAmericaisstilldecadesawayfromparitywithmanyindustrializednationsintermsofhealthcaredeliveryatasystemlevel.

Thecurrenttrendisthattheresidentslearnabouttheadministrativeaspectsandbusinessofhealthcareaftertheygraduateandenterpractice.ItappearsthattheresidencytrainingcurriculumadequatelyaddressesmostoftheACGMEcorecompetenciesexceptconceptsofsystembasedpractice.Asachiefresidentonlymonthsawayfromenteringpractice,Ifindthatthisparticular


corecompetencyhasbeenthemostdifficulttoachieve.TheAmericanhealthcaresystemisincrediblycomplex,andIamreallygladIhadanopportunitytolearnabouttheadministrativeaspectsofthesystemduringmyresidencytraining.

Idecidedtopursuetraininginaspecialtythatinvolvesenormousamountsofphysicalandmentalefforttomaintaincon-tinuedexcellenceandcompetency.Duringtraining,Inoticedthatmanyresidentsspendcountlesshoursatthebedsideofthepatientlearningabouttheclinicalaspectsofthepatientcarebutdonotdedicateenoughtimefortheequallyimportantaspectoflearningaboutthesystemthatdeliversthepatientcare.

Asasurgeon,Iwillsoonhavetheprivilegeofopeningapatient’sabdomenandquicklyaddressingsevereorlifethreateningproblems.Withthisprivilegecomestheresponsibilitytolearnandbeanintegralpartofthesystemthatdeliversthecareforthepatientswhoplacetheirtrustinmyskillandjudgment.

ThejourneyoflearningaboutAmerica’shealthcaresystemistrulyalifelongprocessasthesystemcontinuestoevolve.Thisjourneyshouldideallystartinmedicalschoolandcontinuethroughresidencytrainingratherthanstartingafterresidencytrain-ing.Ibelievethatmandatoryeducationabouthealthcaresystemfunctioninmedicalschoolandresidencywillhelpadministra-torsandyoungcliniciansworktogethertoimprovethecareofallpatients.Iamcertainthatthehealthadministrationelectivedeepenedmyinsightintowhatgoesonbehind-the-scenesinthehospitalwhileIamtakingcareofpatients.

Acknowledgments - I could not have done this elective rotation without the mentorship of Dr. Joseph J. Tepas, III. He not only guided me through setting up this rotation but also encouraged and challenged me to explore and learn about the health care system. I also wish to thank Dr. Michael Nussbaum, Chairman of Surgery, for encouraging my efforts to learn about the system. And finally, I would like to thank the administration departments at Shands Hospital and Orange Park Medical Center for their support in making this rotation a great learning experience.

For more information, contact Shelly Hakes, Director

of Society Relations at (800) 741-3742, Ext. 3294.In a MEDICaL MaLPRaCTICE CLaIM:Be ready for anything and everything.


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Endorsed bySignificant discounts available for eligible DCMS members.

Duval BW 7x4.75.indd 1 4/26/10 2:31:08 PM


Find it on the Website

Looking for the illustrations that accompany clinical articles in this issue?

GototheDCMSwebsiteatwww.dcmsonline.org.Click“NEFM”,“CurrentIssue”,andthen“TableofContents”.Allarticlesarelistedthere(withlinks)andthewebillustrationsaswell.

See the digital version of the journal! (followdirectionsabove)

2 1 Student Athletic Screenings

The DCMS needs YOUR help with the

Share your expertise at the JSMP Athletic Screenings

Saturday, August 7 – high school athletesSaturday, August 14 – middle school athletes

Nemours Children’s Clinic & Wolfson Children’s Hospital

JSMP coordinates free pre-participation athletic screenings for student-athletes in Duval County. Primary care physicians, orthopedic surgeons, cardiologists, pulmonologists, other medical specialists, physician assistants, and allied health professionals participate in the screenings. Physician and PA volunteers are coordinated through the DCMS.

These screenings are provided at no charge to student athletes, most from homes with limited means, and are not intended to replace annual physical exams performed by pediatricians and primary care physicians. Follow up care with individual physicians is encouraged when screenings indicate potential problems which may impact the athlete’s participation in sports activities.

Want to Help?Watch your email or fax for

registration forms, visit our website, or contact Barbara Braddock at [email protected]

or 355-6561 ext. 107.

Find it on the Website

Looking for the Post Test for the CME article in this issue or for other CME courses to complete?

GototheDCMSwebsiteatwww.dcmsonline.org.

Click“NEFM”,“CurrentIssue”,andthen“Tableof

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(withaPostTest link)ORclick“CMEArticles”

under“NEFM”andseealistofalltheCMEarticles

stillavailableforcredit.

See the digital version of the journal! (followdirectionsabove)


InFebruary,75attendedthe25thAnnualGood‘OleTime’ReunionforDCMSmemberswhopracticedduringthe“GoldenAge”ofmedicinepriorto1970.Onceresidentsandyoungpractitioners,theyarenowseasonedphysicians.Mostwhoattendthiseventareretired,andtheylookforwardtogatheringeachyearandreconnectingone-on-one.

(Left,toptobottom)Dr.GeorgeTrotterandDr.RossKrueger;Dr.&Mrs.JimDyer;Dr.RobertThrelkel,Dr.CharlesHayes,Dr.EugeneGlenn,&Dr.TaylorKing;andMrs.JerryFergusonandMrs.LindaMoseley.(Rightcolumn)Allattendeesenjoyhavingtabletalktimeandminglingwithfriends.CongratulationsandthanksgotoJerryFergusonfororganizing,yetagain,anothermemorableandenjoyableevent.

Once Residents...Now Good Ole’ Time Reunion Attendees


High Risk Stress in High Risk Careers: Managing Physician Stress

Background - Benefits that Matter!TheDuvalCountyMedicalSociety(DCMS)attemptstoprovideitsmemberswiththebenefitsthatconsistentlymeetyourprofes-

sionalneeds.OneexampleofhowthisisbeingaccomplishedisbyprovidingtoDCMSmembersfreeContinuingMedicalEducation(CME)opportunitiesinthesubjectareasmandated/andorsuggestedbytheStateofFloridaBoardofMedicinetoobtainandretainmedicallicensure.TheDCMSwouldliketothanktheSt.Vincent’sHealthcare(SVHC)CommitteeonCMEforreviewingandac-creditingthisactivityincompliancewiththeAccreditationCouncilonContinuingMedicalEducation(ACCME).HelenaKarnani,MD,ChairoftheCMECommittee;BetsyMiller,Director,MedicalStaff,QualityManagement;andCindyWilliamson,CMECo-ordinator,fromSVHCdeservespecialrecognitionfortheirworkonbehalfofDCMS.

ThisissueofNortheast Florida Medicine includesanarticle,“HighRiskStressinHighRiskCareers:ManagingPhysicianStress”au-thoredbyKamelaK.Scott,PhD,andDavidJ.Chesire,PhD(see pp. 37-41),whichhasbeenapprovedfor1.0AMAPRACategory1credit(s).™ForafulldescriptionofCMErequirementsforFloridaphysicians(MD/DO),pleasevisittheDCMSwebsite(http://www.dcmsonline.org/cme_requirements.aspx).

Faculty/Credentials: KamelaK.Scott,PhD,isanAssociateProfessorandDavidJ.Chesire,PhD,isanAssistantProfessor,DepartmentofSurgeryattheUniversityofFloridaCollegeofMedicine-JacksonvilleinJacksonville,FL.

Objectives for CME Journal Article

1. Beabletorecognizethephysiologicaleffectsofstress2. Beabletorecognizethepsychologicaleffectsofstress3. Beabletoidentifyminimallythreewaystoeffectivelymanageexperiencedstress

Date of Release: June 8, 2010 Date Credit Expires: June 8, 2011 Estimated time to complete: 1 hr.

Methods of Physician Participation in the Learning Process1.Readthe“HighRiskStressinHighRiskCareers:ManagingPhysicianStress”articleonpages37-41

2.CompletethePostTestandEvaluationonpage36

3.Cutout&faxthePostTestandEvaluationtoDCMS(FAX)904-353-5848ORmembersgotowww.dcmsonline.org&submittestonline

CME Credit EligibilityInordertoreceivefullcreditforthisactivity,aminimumpassinggradeof70%mustbeachieved.Onlyonere-takeopportunitywillbegrantedif

apassingscoreisnotmadeonthefirstattempt.DCMSmembersandnon-membershaveoneyeartosubmittheposttestandearnCMEcredit.Acertificateofcredit/completionwillbeemailed,faxedorUSPSmailedwithin4-6weeksofsubmission.Ifyouhaveanyquestions,pleasecontacttheDCMSat355-6561,ext.103,[email protected].

Faculty Disclosure InformationDr.ScottandDr.Chesirereportnosignificantrelationshipstodisclose,financialorotherwisewithanycommercialsupporterorproductmanufacturerassociatedwiththisactivity.

Disclosure of Conflicts of InterestSt.Vincent’sHealthcare(SVHC)requiresspeakers,faculty,CMECommittee,andotherindividualswhoareinapositiontocontrolthecontent

ofthiseducationalactivitytodiscloseanyrealorapparentconflictofinteresttheymayhaveasrelatedtothecontentofthisactivity.AllidentifiedconflictsofinterestarethoroughlyevaluatedbySVHCforfairbalance,scientificobjectivityofstudiesmentionedinthepresentationandeducationalmaterialsusedasbasisforcontent,andappropriatenessofpatientcarerecommendations.

Joint Sponsorship Accreditation StatementThis activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medi-

cal Education through the joint sponsorship of St. Vincent’s Healthcare and the Duval County Medical Society. St. Vincent’s Healthcare is accredited by the Florida Medical Association to provide continuing medical education for physicians.

The St. Vincent’s Healthcare designates this educational activity for a maximum of 1.0 AMA PRA Category 1 credit(s) .TM Physicians should only claim credit commensurate with the extend of their participation in the activity.


1.Stressisthecombinationofphysiologicalandpsychologicalvariablesthatleadapersontojudgeasituationas:

a.Threatening&requiringsomecopingmechanism b.Intolerableandbeyondone’scopingability c.Requiringprofessionalinterventiond.Seenas“eustress”,requiresactivecopingstrategy

2.Stressintheworkplacehasbeenassociatedwith: a.Hypertensionb.Highplasmafibrinogenconcentrations c.Highlevelsofcatecholamines d.Alloftheabove

3.Uniquesourcesofstressforphysiciansincludepatientvariablessuchas: a.Patientageb.Severityofillnessorinjuryc.Patientabilitytocope d.Alloftheabove

4.Generally,thetermusedtodescribewhenanindividualworking in a high-stress work environment becomesmoredetachedfromtheworkitselfis:

a.Isolation b.Burnoutc.Withdrawald.Disentanglement

HighRiskStressinHighRiskCareers:ManagingPhysicianStressCMEQuestions&Answers(CircleCorrectAnswer)Free-DCMSMembers/$50.00chargenon-members*

(Return by June 8, 2011 by FAX: 904-353-5848, by mail: 555 Bishopgate Lane, Jacksonville, FL 32204 OR online: www.dcmsonline.org)

Evaluationquestions&CMECreditInformation(Pleaseevaluatethisarticle.Circleonenumberusingthisscale:1=StronglyAgreeto5=StronglyDisagree)Thearticlemetthestatedobjectives: 1 2 3 4 5Thearticlewasappropriatetomypractice: 1 2 3 4 5Thetopicwascurrentandwellpresented: 1 2 3 4 5Comments:_______________________________________________________________________

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5.Atermassociatedwiththebluntingintheabilityofacaregivertobearthesufferingofothersis:

a.Compassionfatigueb.Apathy c.Sufferingseclusiond.Dispassionateretreat 6.Greenbergadviseswhichofthefollowingsituationinterventions: a.Donottakeworkhome b.Workthroughlunchtomanagetimec.Discussbusinessoverlunchwithcolleaguesd.Ignoreyourfeelingsaboutoccupationalstress7.BensonandMagraith’sreviewonstressreductionadvises

whichofthefollowing:a.Notexpectingtoomuchofoneselfb.Maintainingagoodsenseofhumorc.Participatinginoutsidehobbiesd.Alloftheabove

8.Contributingfactorstomaritalstressinclude: a.Physiciansescapeintoworkthinkingitiseasiertosolveclinicaldilemmasthandomesticproblems b.Aphysician’s“need”tobeincontrolcanconveyalackofrespectfortheirpartnerasanequalc.Inabilityforthepartnertotrulyunderstandthepressuresofthejob d.AandB


High Risk Stress in High Risk Careers: Managing Physician StressKamelaK.Scott,PhD;KristinStaggs,MSandDavidJ.Chesire,PhD

AddressCorrespondence:KamelaK.Scott,PhD,AssociateProfessor,DepartmentofSurgery,UniversityofFloridaCollegeofMedicine,Jacksonville,FL.Email:[email protected]

Abstract: The medical field is one in which professionals expose them-selves to the physical and emotional pain of those they seek to help, and this exposure can lead to them experiencing their patient’s pain. Medical personnel are particularly vulnerable to suffering from the physical and psychological consequences of occupational stress. Ironically, there is a pervasive attitude in the medical profession that suggests practitioners should be invulnerable to the stress-related consequences of their field, and many practitioners neglect to effectively attend to their own needs. The fallout of such neglect may manifest itself as burnout and compas-sion fatigue and affects those close to the physician as well, including family members and patients. A review of the literature indicates a need for physicians to be mindful of their own well-being. Strategies are presented to help physicians avoid the negative effects of working in a high risk profession.

IntroductionFriday night, 2:13 a.m. – “Beep… Beep…,” the pager

goesoffyetagain,indicatingthependingarrivalofalevelone trauma. A 19-year-old driver, motor vehicle collision(MVC)intubatedinthefield,isactivelybeingresuscitated.Onarrival tothetraumacenter, it isapparentthepatienthasincurredalethalbraininjury,yettheteammakeseveryattempttocontinuetheresuscitationtosavethisyounglife.At2:51a.m.thecallismaderegardingtimeofdeath.Theattendingphysicianisinformedtheyoungboy’sparentsarewaitinginthefamilyquietroomforwordabouthisinjuries,andsheknowsshe’snowtaskedwithdeliveringthedevastat-ingnews.

InanEmergencyRoom,a15-year-oldgirlisbroughttothehospitalbyafriend.Shehasbeenthevictimofabrutalrapeandisseverelybeaten.Perprotocol,thesexualassaultteamisnotified,andanofficerapproachesthebedtoobtaincontactinformationforthegirl’sparents.Thepatientreachesoutandgrabsthephysicianbythecoat,pleading,“Pleasedon’ttellmydaddy!”Thephysicianishitwiththerealityhisowndaughterisnow14-years-old.Whatwouldhewant,asherfather?

Saturdayafternoonatthebaseballpark,ablond-haired,9-year-oldboyapproachesthe“on-deck”circle.Whilenothisfirstgameoftheseason,thisoneisspecial;it’sthefirstgamehisdadhasbeenabletoattend.He’sproudthathisdadisadoctor,andheunderstandsthatmanypatientscountonhim.Hewantstomakecertainhisdadseesagreatgame!Ashestandsondeck,helookstohisdadinthestands,smiling.Atthatmoment,hisfather’scellphonerings,andhisphysi-ciandadistoldheisneededatthehospitalbecauseofanemergency.Theboyapproachestheplate,buthisdadmissesthisimportantmomentbecausehehadtoleaveimmediately.Theboy’smothershuddersindisappointment.

Occupational Stress Thelifeworkofaphysicianyieldssignificantstressdueto

themyriadpressuresfacedinthelineofduty.Daily,physi-ciansareaskedto“domorewithless,”tomakelifeanddeathdecisions,andtohealandmendbattered,tornanddiseasedbodies. Medicine is, indeed,a“highriskcareer”thatcangenerateagreatdealofpersonalstress.Theartofmedicinealone,however,doesnotaccountforthisexperiencedstress;indeed,itmaybetheleaststressfulpartofbeingaphysician.Onecanlearn,practiceandmasterknowledgeandaction.Itistheemotionalsideofthepracticeofmedicinethatmaynotbesopreciseorsoeasy.Howdoesoneseparateouttheemotionalresponsewhenconfrontedwithhumananguishandpain?Howisonetobalancethedemandsoftheprofessionwiththeneedsoffamily–spouseandchildren?

Occupationalstressisnotconfinedtothemedicalprofes-sion,andjustasallindividualsintheworkplacearepotentiallyatriskforthenegativeeffectsassociatedwithstress,thereisnothinguniqueaboutphysiciansorothermedicalworkersthatinoculatethemfromstressreactions.Anargumentcanbemade,infact,thatmedicalprofessionalsareparticularlyvulnerabletooccupationalstressbecausetheywillinglyputthemselvesinharm’sway,directlyexposingthemselvestothepainandtraumaoftheirpatients.Infact,ithasbeendem-onstratedthatobservingothersinpainevokesactivationintheneuralnetworkoftheobserverthatisresponsibleforpaintransmissionandtheprocessingoffearandanxiety.1,2

Stressisthecombinationofphysiologicalandpsychologicalvariablesthatleadapersontojudgeasituationasthreaten-ingandasrequiringsomesortofcopingmechanism.3Oc-cupationalstressresultswhencharacteristicsofthejobandjobrolerequireanindividualtoemploycopingmechanismstodealwiththeoccupationaldemands.Stressitselfisveryindividualized.Whatmaybestressful tooneperson,maynotbetoanother.Perceivedstresscancomefromavarietyofsources,anditisnotalwaysevidentthatasituationmight,infact,bestressful.Forexample,earlyresearchonstressandstressmanagementsuggestedthatanxietyisabi-dimensionalconstructcomprisedof“facilitating”anxietyand“debilitat-ing”anxiety.Facilitatinganxietyactuallyimprovesoptimalperformance, while debilitating anxiety impedes optimalperformance.4Morerecently,stresshasbeenidentifiedascom-ingfrombothnegativesources(distress)andpositivesources(eustress).5Bothdistressandeustressmayresultinsimilarstressconsequences,andeachrequireeffectivecoping.

Symptoms and EffectsOccupationalstresscanresultinnegativephysiologicaland

psychologicaloutcomes.Therehavebeenseveralinvestigationsintothephysiologicaleffectsassociatedwithincreasedlevelsof stress.Stress in theworkplacehasbeenassociatedwith


hypertension6,7,elevatedserumcholesterollevels8,increasesinleftventricularmass9,highlevelsofcatecholamines10,highplasmafibrinogenconcentrations11,andincreasedtobaccoandalcoholuse.12,13Highlevelsofstressintheworkplace,whenaworkerisfurtherexposedtounpleasantworkplacecondi-tions(suchassexualharassment),havealsobeenassociatedwithheadaches,gastrointestinaldisturbances,fatigue,sleepdisturbances,nausea,weightloss,lossofappetite,neckandbackpain,anddentalproblems.14-22Similarly,highlevelsofworkplacestressmaymanifestaspsychologicalandbehavioralissues. Stress may result in low self-esteem, increased jobtension,andlowerjobsatisfaction;23itmayresultinimpair-mentsintheabilitytostore,retain,andretrieveinformationfrommemory.24,25Stresscanalsonegativelyimpactdecisionmaking26andoverallgroupperformance27.

Acutestressinthemedicalworkplacehasalsobeenshowntohavenegativeimplicationsforpatientcare.28Forphysicians,uniquesourcesofstressinvolvesuchareasaspatientvariables(e.g.,patientage,severityofillnessorinjury,patientabilitytocope,etc.),settingvariables(e.g.,workhours,resources,collegialrelationships,autonomy,etc.),andpersonalvariables(physiciancopingstrategies,experience,individualpersonal-ity,etc.).Thisexperiencedstressmayalsospillovertothefamilyofthephysician,impactingapartner,children,andrelatives.Ironically,thecultureofmedicinetendstoperpetuatethenotionthatphysiciansshouldbeimmunetoworkplacestress;therefore,physiciansmaytendtoviewstress-reductionworkshopsandtechniquesashavinglittlevalue.29

Twoareasofparticularconcernforphysiciansandothermedicalproviders,whenworkinginahighstressenvironment,areburnoutandcompassionfatigue.Theterm“burnout”isgenerallyused todescribe theprocesswhenan individualworking within a high-stress work environment becomesmore and more detached from the work itself. Particularsymptomsassociatedwithburnoutincludelowworkermorale,increased absenteeism, job turnover, physical illness, drugandalcoholabuserates,andfamilydiscord.30 Individualsexperiencingburnoutgenerally exhibit a reduced senseofhumor, increased physical complaints, social withdrawaland isolation, decreased job performance, self-medication(includingillegaldrugabuse),andpsychologicalsymptomssuchasanxietyanddepression.

“Compassionfatigue”isatermthatisassociatedwiththebluntingintheabilityofacaregivertobearthesufferingofothers.Inessence,thetermreferstothesecondarytraumathat isexperiencedbyaprofessionalwhenhe/sheengageswith traumatized patients.31 Compassion fatigue, unlikeburnout,tendstobuildquickly,andtheeffectsusuallyleavetheprofessionalfeelingconfused,helpless,andisolated.32Ithasalsobeenproposedthatcompassionfatigueismoreac-curatelyviewedasaformof“moralstress”,wherethecaregiverrequiresoutletstodiscussthemoralimplicationsinherentincompassion fatigue.33 Together, burnout and compassionfatiguecanisolateaphysicianfromhis/herpeers,impairingoverallworksatisfactionandimpedingoverallpatientcare.Theeffectscan reachbeyondworkplace settingsandhave

devastatingeffectsonrelationshipswithfamilyandfriends,furtherisolatingtheindividual.

Stress Reduction Strategies Becauseoftheoveralldeleteriouseffectsofoccupational

stress on work performance, job satisfaction, mental andphysical health, and other areas, there have been manystrategiesproposedforidentifyingandcombatingnegativestresssymptoms.Greenbergdividedhisdiscussionofman-agingoccupationalstressintofourcategories:life-situationinterventions, perception interventions, emotional arousalinterventions,andphysiologicalarousalinterventions.34Forlife-situationinterventions,hemakesthefollowingrecom-mendations:Donottakeworkhome,takeafulllunchhour,donotdiscussbusinessoverlunch,anddiscussyourfeelingsaboutoccupationalstress.Forperceptioninterventions,hesuggestslookingforhumorinthestressorsatwork,tryingtoseetherealityofthesituationratherthanfocusingononlythenegative,distinguishingbetweenneedsanddesires,notbasingself-worthonthetaskathand,andemployingappropriatecopingstrategiesforappropriatesituations(e.g.,donotwastetimetryingtochangethingsthatcannotbechanged).Foremotionalarousalandphysiologicalarousal,Greenbergrecom-mendsrelaxationtrainingandphysicalexercise,respectively.Overall,theimplicationisthatanindividualneedstoseetohis/herownneeds,ensuringthathe/sheishealthyphysicallyandpsychologicallybeforeembarkingonattendingtotheneedsofothersoroftheinstitution.

In a similar report, Benson and Magraith identify thatprogramsdesignedtohelpphysiciansmanageoccupationalstress should focus collectively on personal, professional,andorganizationalissues.35Theirreviewonstressreductionadvisesontheimportanceofamaintainingagoodsenseofhumor,sharingofemotions,participatinginoutsidehobbies,andtheimportanceofnotexpectingtoomuchofoneself.Further,organizationally, it is important to engage in lesstraditionalworkactivities,inadditiontotheprimaryrole,suchasteachingorresearch.Professionally,theyrecommendtheparticipationinBalintgroupsandvaryingthenatureofone’swork.

The literature is rife with studies documenting similarstress theoriesanduniversal reductionstrategies. Mostofthesereportsdescribegeneraltechniquesdesignedtohelpallprofessions.However,inthecaseofBalintgroups,thisstressreduction technique isdirected specifically to themedicalprofessional. In Balint groups, physicians discuss variousphysician-patientencounterswiththeircolleagues,specifi-callyfocusingonthefeelingstheencounterevoked.Thegoalistofacilitateanenhancedawarenessandunderstandingofthephysician-patientrelationshipsothatthephysician’sownskillsinhandlingsuchencounters,whilecontrollingtheirownemotionalandpersonalinvestment,arestrengthened.Whileproposedtohavethepotentialtoaidinthepreventionofcompassionfatigueandburnoutingroupparticipants,Balintgroupsrequirealong-termcommitmentonthephysician’spartforatrueandsustainedeffect.Suchgroupsdoprovide


aneffectiveforum,nonetheless,forphysicianstoexplorekeyprofessionalandpersonalvariablesnecessaryforstressreduc-tion,suchasprofessionalboundarykeeping,settingofrealisticexpectations,andlearningeffectivemeansof“nottakingworkhome.”36Anexamplemaybedevelopinganewroutineoflisteningtoaudiobooksduringthedrivehome,torefocusthemindonalternativestowork-relateddemands.

Personal Stress Reduction Whilereviewoftheliteratureprovidesmanysuggestions

foridentifyingandaddressingexperiencedoccupationalstress,therearesomecommonstrategiesthathealthcareproviderscanemploytomoreeffectivelytakecarethemselves.First,inthearenaofpersonalstrategiesformanagingstress,essentiallyalifeoutsideofmedicineneedstobecultivatedandappreci-ated.Formanyphysicians,thismayrequiretheyonceagain“learntoplay.”37Asstrategiesforaddressingstress,physiciansshouldutilizehumor,relaxation,physicalandmentalexercise.Theyshouldengageinhobbiesandoutsideinterests,respecttheirownlimits,maintaintimeforself-careactivities,propernutrition,andengageinspiritualandfamilyrelations.Somework sponsored programs have developed brief remindersheetstoberegularlydistributedtophysicianstaffadvisingthefollowing:

1. Getaway2. Seekhelp3. Manageburnout(makeitaprioritytogetadequate

sleep, daily physical exercise, to work reasonableamounts,andto“cutyourselfsomeslack”)

4. Renewyourrelationships5. Re-evaluateyourworksituation6. Feedyourspirit38

Zeckhausen similarly suggests additional strategies formanagingpersonalstresssuchasemphasizingtheimportanceofavoidingcynicismanddoingmorethancommiserating.39Alsosuggestedisdemystifyingpsychologicalsupportandcon-sideringtherapyorasupportgroupaspositiveresourcesratherthansignsofweakness.Ultimately,personalmanagementofstressrequiresbalance,whilealsoenhancingperceptionsof“meaning”inwork–physiciansmustfindmeaningintheirwork,andtheymustfindbalanceintheirlives.40

Intheorganizationalarena,thecruxofstressmanagementlies in the cultivationof a true cultureof caring,not justforthepatientbutalsoforthephysician.Thismayincludepoliciesthatpromotework-lifebalanceandrestorephysicianautonomy,andcultivateefficiency,autonomyandmeaninginworkthroughcontinuousqualityimprovementprocesses.Team-basedburnoutinterventionprogramscanfurtherpro-videaforumforphysicianstodiscusswork-relatedfeelingsandexperiencesandwork-relatedproblemsandwaysofsolvingthem.41Regular,interactiveprocessesofinquiryandfeedbackfromphysicianscanhelptoidentifyissuesthatnegativelyaf-fectoverallwellbeing,andalsocanidentifyobstacles,withintheorganization,tobringimprovement.Suchprocessesmayenhancephysicianjobautonomyandfeelingsofjobcontrol

andmayprovidephysicians’theperceptionofaloudervoiceinorganizationaldecision-making.42,43

Stress Impact on Relationships“Medicalmarriages”requirespecificattentionasexcessive

maritalstressmaybeexperiencedduetolackof“togethertime”,lengthyworkdays,fatigueandthesensethattheca-reeralwayscomesfirst–eitherbynecessityorbychoice.Itiswell-knownthatphysiciansnecessarilymustperformlongdutyhoursandthatoverwork isnormative;.Yethowthistranslatestothemaritalrelationshipiskey.Physiciansmayescapeintoworksinceitcouldseemeasiertosolveclinicaldilemmasthandomesticproblems.Also,aphysician’s“need”tobeincontrolcanconveyalackofrespectforthepartnerasanequal.Noboundaries,whereinworkandhomebecomeblurred(especiallywhenoncall)cancreatesignificantmaritalandfamilystress.Thecommonstanceofmakingmentalhealthalowpriorityand/orthe“personofsteel”mentalityoftenprevalentinmedicine,maymakethedecisiontoengageinmaritalcounselingverydifficult.Forinstance,adoctormaybereluctanttoacknowledgetoanotherdoctorthathis/herrelationshipisintrouble;fearfulitisasignofweakness.

Commonsensestrategiesforavoidingsuchpitfallsmayinclude:

1. Maketimeforoneanother2. Safeguard time for communication and fun in an

otherwiseverybusylife3. Keepasenseofhumor4. Trytofindothervenuesto“vent”thestressfromwork

otherthanwithinthehomesetting5. Developinterestsoutsidemedicineandwork6. Havefriendsoutsidemedicineandwork.

Additionally,considerconsistentlyreviewingdutyhoursandsettingboundarieswhenable;compromising;puttingthemarriagefirst,ensuringthattimetogetherisapriority,andidentifyingaproblemandthendoingsomethingaboutit.Challengethe“Icanhandleitalone”mentality.Mostim-portantly,monitorandeffectivelycarefor,notonlyoneself,butalsoone’spartner,givingthemarriagethesamedegreeofattentionthatisgiventhemedicalcareer.

Conclusion Medicineisindeeda“highriskcareer”inlightoftheinherent

highdegreeofexperiencedstress(“highriskstress”)thateachphysicianmusteffectivelymanage.Thiscareerchoiceembodiesaninordinatedegreeofpersonal,professional,organizationalandmaritaldemands,anditistheperceptionsofone’srole,ineachoftheseareas,thatdefineone’sexperiencedstress.Themannerinwhicheachindividualmanageshis/herownstressdictatestherolethatstressplaysin,notonlyone’sphysicalhealth,butalsoone’spsychologicalhealthandwellbeing,andoverallprofessionalism.

Physiciansmusttaskthemselveswiththeresponsibilityofself-care,inthesamemannersuchexpectationsareplacedupontheirpatients.Specificstrategiesmustbeemployedto


promotetheeffectivebalancebetweenjobfunction,jobmean-ing,andoverallsenseofpurpose–bethatasaphysicianorsimplyasaperson,partner,colleague,orfriend.Thesocietalburdenplaceduponphysiciansstandsonlytoincreaseinthiseraofhealthcarereform,emphasizingthepersonalneedandprofessionalresponsibilityforselfcare.Patient-centeredcarerequires“person-centered”providersandmandatesphysicianself-careandattentiontostressandwell-being.Thesearethecornerstoneofoverallprofessionalism.

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DCMS Membership Applications

These physicians’ applications for membership in the Duval CountyMedical Society are now being processed. Any information or opinionsyoumayhaveconcerningtheeligibilityoftheapplicantslistedheremaybedirectedtoAshleyBoothNorse,MD,DCMSMembershipCommitteeChair(904-244-4106orBarbaraBraddock,MembershipDirector(904-355-6561x107).

Daniel J. Matricia, DOUrgentCare/OccupationalMedicine/EmergencyMedicineAmeliaUrgentCare510AirportCenterDr.MedicalDegree:DesMoinesUniversityCollegeofOsteopathicMedicineInternship:ITEADoctor’sHospitalResidency:ITEANorthlakeRegionalHospitalNominatedby:NassauCountyMedicalSociety

Patrick J. DeMarco, MDAllergy/ImmunologyAllergy&AsthmaSpecialistsofNorthFlorida3636UniversityBlvd.S.#A-3MedicalDegree:HahnemannSchoolofMedicineInternship/Residency/Fellowship:UniversityofSouthFloridaCol-legeofMedicineNominatedby:EdwardMizrahi,MD;PaulWubbena,MD;SunilJoshi,MD

Cheryl Lynn Dixon, MD AnesthesiologyJacksonvilleAnesthesiaCorporation,Inc.820PrudentialDr.#606MedicalDegree:MedicalCollegeofOhioatToledoResidency/Fellowship:UniversityofFloridaCollegeofMedicineNominatedby:FranciscoJimenez,MD;PamelaRama,MD;EdwardYoung,MD

Brian R. Emerson, MDAnesthesiologyUFAnesthesiology655W.8thSt.2ndFLClinicalCenterMedicalDegree:VanderbiltUniversityMedicalSchoolInternship:AustinMedicalEducationProgramResidency:MayoClinicFellowship:SeattleChildren’sHospitalNominatedby:UFJP

Ruple J. Galani, MDCardiology/InternalMedicineJacksonvilleHeartCenterPA14546St.AugustineRd.#103MedicalDegree:MedicalCollegeofOhioMedicalSchoolResidency:UniversityofFloridaCollegeofMedicineFellowship:OhioStateUniversityMedicalCenterNominatedby:JoelSchrank,MD;KennethAdams,MD;ShannonLeu,MD

Carol Mannings, MDPediatricsDuvalCountyHealthDepartmentMedicalDegree:UniversityofMiamiSchoolofMedicineResidency:UniversityofFloridaCollegeofMedicine/JaxNominatedby:UFJP

Jerry P. Matteo, MDDiagnosticRadiologyUFRadiology655W.8thSt.2ndFLClinicalCenterMedicalDegree:RossUniversityMedicalSchoolInternship:FlushingHospitalResidency:LongIslandCollegeHospital

Fellowship:MedicalUniversityofSouthCarolinaMedicalSchoolNominatedby:UFJP

Gabriel Paulian, MDInternalMedicine/Hospice&PalliativeMedicineShandsCommunityHealthCenter655W.8thSt.4thFLACCMedicalDegree:RossUniversityMedicalSchoolInternship:MountSinaiSchoolofMedicine/BronxVAMedicalCenterResidency/Fellowship:UniversityofFloridaHealthScienceCenterNominatedby:UFJP

Adil Shujaat, MDPulmonaryMedicineUFCriticalCare655W.8thSt.7thFLClinicalCenterMedicalDegree:KingEdwardMedicalCollegePunjabUniversityResidency/Fellowship:SaintLukes-RooseveltHospitalNominatedby:UFJP

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RECORDS THAT NEVER RELOCATE


AddressCorrespondenceto:MohammadA.Khan,MD,MRCPI,UniversityofFlorida-Jacksonville,DepartmentofInternalMedi-cine,653W,LRC4,8thStreet,Jacksonville,FL32209.Phone:(904)343-3038.Email:[email protected].

Special Case Report

Is Early TPN in Hyperemesis Gravidarum Worth the Risk?KarishmaRamsubeik,MD;RavindraP.Maharaj,MD;

MohammadA.Khan,MD,MRCPIandShilpaC.Reddy,MD

Editor’s Note: Due to production constraints, Figures 1 & 2 are not printed in the journal. They are available online at www.dcmsonline.org as a web illustration.

Case ReportWereportacaseofbacterialendocarditisasacomplication

ofaperipherallyinsertedcentralcatheterinthetreatmentofapatientwithhyperemesisgravidarum.A26-year-oldAfri-canAmericanfemalegravida4,para3withanintrauterinepregnancy at 26 weeks was diagnosed with hyperemesisgravidarumduringherfirsttrimester.Aperipherallyinsertedcentralcatheter(PICC)linewasinsertedtoallowdeliveryof total parenteral nutrition due to non-tolerance of oralintake.ThePICClinewasremovedassoonasshetoleratedoralnutrition.Herhyperemesisrecurredaftersixweeks,andasecondPICClinewasplaced.ThepatientdevelopedfeverandthePICClinewasremovedandwasreplacedbyathirdPICCline.ThefeverreturnedafterthethirdPICClinewasinserted.Onexamination,shehadstablevitalsexcepttachy-cardiawithaheartrateof100beatsperminute.AgradeIIIsystolicmurmurwasaudibleattheleftsternalborder.Therestofherphysicalexamwaswithinnormallimits.Labora-toryinvestigationrevealedawhitebloodcellcountof19000permicroliter,Hemoglobin12.2g/dl,Hematocrit35%andplatelets273000permicroliter.Herchemistrywaswithinnormallimits.Thebloodculturesandfungalculturewerenegative.

Theechocardiogramrevealedmildlyreducedleftventricularfunctionwithanejectionfractionof55to60%.Therewasmildbiatrialenlargementwithmoderatemitralregurgitation.Mildtomoderatetricuspidregurgitationwithpulmonaryarterysystolicpressureof43mmHg(Figure 1, www.dcmsonline.org)wasnoted.Posteriortricuspidleafletvegetation,measuring1.8x2.9cmandaseptaltricuspidleafletvegetation,(Figure 2, www.dcmsonline.org)wasrevealed.Therewasnoevidenceofaperivalvularabscess.AntibiotictreatmentwasinitiatedwithintravenousNafcillin.AhighresolutionCTscanofthechestrevealedalargefillingdefectatthebifurcationoftherightmiddleandlowerlobepulmonaryarteriesconsistentwithanembolusandmultiplenodularopacitiesinbothlungs,suggestinganinfectiousorinflammatoryetiology.Basedonthehistoryandlaboratorydata,adiagnosisoftricuspidvalveendocarditiswithsepticembolismwasmade.

DiscussionHyperemesisgravidarumaffectsabout2%ofallpregnant

women1.Onemustfirstconfirmaviableintrauterinepreg-nancy.Supportivecareisthemainstayoftherapy.Lifestylemodificationsmaybeattemptedtohelpthepatienttolerate

oralintake,suchaseatingdry,blandcarbohydrates,havingsmallfrequentmealsandavoidingunpleasantsmells.Withincreasingsymptoms,antiemeticsmaybeinstituted.Correc-tionoffluidandelectrolytedeficitsshouldalsobeundertakenandintravenoustherapymaybeused.VanStuijvenbergetal1observedthatvomitingsubsidedin24hoursaftertreatmentofpatientswithhyperemesisgravidarumifgivenintravenousadministration,normalsalinesolutionandoneampuleofanintravenousmultivitaminpreparation.Hsuetal2dem-onstratedsuccessfuluseofnasogastric(NG)tubefeedinginpatientswithhyperemesisgravidarumandassociatednauseaandvomitingimprovingwithin24hoursafterNGtubeplace-ment.In2004,Folketal3comparedtheobstetricandmaternalcomplicationsinpatientswithhyperemesisgravidarumtreatedwithtotalparentalnutrition(TPN)versusthosewhodidnotreceiveTPN.Theyfoundthatthetwogroupsweresimilarregardingtheincidenceofpregnancy-relatedandmaternalmedicalcomplications;howevertheTPNgrouphadahigherincidenceofTPNassociatedcomplicationsincludingsepsis,bacterialendocarditisandpneumonia.In2008,Holmgrenetal4observedthatmaternalcomplicationsassociatedwithPICClineplacementweresubstantialdespitenodifferencein neonatal outcomes. In fact, there was a 66.4% rate ofinfectivecomplications,thromboembolismorbothduetoPICClineuseinhyperemesispatients.

Conclusion Theinfectivecomplicationsofcentralintravenousaccess

over peripheral intravenous access cannot be emphasisedenough.Thisyoungladyhasnowbeencommittedtolong-termendocarditismanagementwiththeadditionalrisknowaffecting the patient and her fetus. This could have beenavoidedbyconservativemeasuresandlessinvasiveintravenousaccess.Inaddition,aPICClinehastheadditionalcostburdencomparedwithsimpleperipheralIVaccessandconservativemanagement.TheriskofTPNinshort-termmanagementofnutritionalneedsfaroutweighsthebenefitsashighlightedbythiscase.TheuseofPICClinesforhyperemesisgravidarumisrarelyindicatedandshouldbeavoidedifpossible.

References1.VanStuijvenbergM.E,SchabortI,LabadariosD,J.TN,The

nutrionalstatusandtreatmentofpatientswithhyperemesisgravidarum. American Journal of Obstetrics and Gynecology 1995;172(5):1585-1591.

2. Hsu JJ, Clark-Glena R, Nelson DK, CH K. Nasogastricenteral feeding in hyperemesis gravidarum Obstet Gynecol. 1996;88(3):343-346.

3.FolkJ,Leslie-BrownH,NosovitchJ,SilvermanR,AubryR.Hyperemesis Gravidarum: Outcomes and ComplicationsWithandWithoutTotalParenteralNutritionJ Reprod Med 2004;49:497-502.

4.HolmgrenC,Aagaard-TilleryKM,SilverRM.Hyperemesisinpregnancy:Anevaluationoftreatmentstrategieswithmaternalandneonataloutcomes.Am J Obstet Gynecol2008(198):56.


Update on Haiti Relief Efforts

Baptist Health Affiliated Physicians Provide Assistance to Haitians

IntheweeksandmonthsfollowingtheJanuary12,2010earthquakeinHaiti,anumberofphysiciansandstaffaffili-atedwithBaptistHealthinJacksonville,FLtraveledtoHaititoprovidemuchneededmedicalassistance.ThosefeaturedbelowarealsoDCMSmembers.

Doug Johnson, MD, a radiation oncologist at BaptistCancerInstitute,isamemberoftheFlyingPhysiciansAs-sociation.ThisgroupworkedwiththeU.S.StateDepart-mentandtheUnitedNationstogetneededsuppliestotheFondParisianFieldHospitalinHaiti.OnFebruary8,Dr.Johnsonandotherphysicianpilotsflew24privateaircraftloadedwith95boxesweighingnearly1,500poundstotheDominicanRepublicwhereaUNhelicopterthentransportedthesesuppliestothehospitalinHaiti.Dr.Johnsonsaid,“Oursuppliesgotwheretheyneededtobeandwereexactlywhattheclinicneeded.”

Richard Picerno, MD, anorthopaedicsurgeonwithJack-sonvilleOrthopaedicInstituteandMeridith Farrow, MD, anobstetricianwhopracticesatBaptistBeaches,werepartofa12-personteamthatwenttoHaitiFebruary2-11undertheauspicesoftheSouthernBaptistConvention.TheyworkedattheNationalHospital,amedicaltentcompoundcreatedafter the earthquake. They triaged and treated up to 400patientsadaywhohadmultipletypesofmedicalproblems.Dr.Picernosaid,“Itwaslife-changingforusjustseeingthepeopleandhearingtheirstories.”

John Von Thron, MD, anorthopaedicsurgeonwithJack-sonvilleOrthopaedicInstitute,wenttoHaitiattheendofJanuarywithaPresbyterianMinistriesteamtohelppatientsatageneralhospitalinPort-Au-Prince.Dr.VonThronprovidednon-surgicalorthopaediccareanddressingchanges.Hesaid,“Itwasquiteanamazingsighttoseepeoplefromallovertheworldhelpingout.”

Brooks Donates to Doctors Without Borders and its Haiti Recovery Efforts

BrooksRehabilitationinJacksonville,FLdonated$50,000toDoctorswithoutBorders/MedecinsSansFrontieres(MSF)tohelpfunditseffortsforHaitiduringthatcountry’sreha-bilitationandrecoverystages.

DougBaer,PresidentandCEOofBrookssaid,“WewantedtofindawaytohelpthepeopleofHaitithatwouldbetruetoourmissionof advancing thehealth andwell-beingofpersonsrequiringrehabilitation.WefeelDoctorsWithoutBorders/MSFsharethesamevaluesandwewantedtosupportthemintheiron-goingefforts.”

In emergencies, MSF provides essential health care, re-habilitatesandrunshospitalsandclinics,performssurgery,responds to epidemics, carriesoutvaccinationcampaigns,operatesfeedingprogramsformalnourishedchildren,andoffersmentalhealthcare.

Onitswebsite(www.doctorswithoutborders.org),DoctorsWithoutBordersdescribesitselfas“amedicalhumanitarianorganization” and states, “MSF is continuing to developstrategiestorespondtotheevolvingrealitiesonthegroundandserveboththeimmediateandthelonger-termneedsoftheHaitianpeople.”

Continued, page 48

How’s Haiti?Joan Huffman, MD, FACS,

Editor-in-Chief,NortheastFloridaMedicine

NinetydaysafterthehorridJanuary12earthquakethatrockedandflattenedPort-au-Prince,progressispalpabletothereturnvisitor,butinvisibletoanewinitiate.(ObservationsbasedonmyApril9-17returntriptoHospiceSt.JosephinHaiti)

Food: Thete marchant(smallmerchants)havereturned,lin-ingthestreets,eachprofferingtheirsmallquantityofgoods–mangoes,charcoal,orfly-coveredchicken.Worldaidpestersthetentcities–womenmustlineupat12midnighttoacquiretheirdailyfoodcouponandthenreturntoqueueat6AMforaday’srationofriceandbeansthattheymightreceiveby12noon.90%ofmypatientscomplainoftet fe mal, verti, vant doule(headache,dizzinessandstomachpain);inotherwords,HUNGER.AfterawhileIstopaskinghowmanymealstheyeataday–atmostoneortwo,formothers,less.Theyfeedtheirsmallportionstotheirchildren.TheHospicestaffteachesustosingtheblessingforourrice,beans,andplantaindinner,“Merci a Papa, Merci a Mama…”Wearetrulythankful.

Shelter: Thecityhasinspectedandmarkedthebuildings.Aredstampdemandsdemolition;yellowallowsrenovation;onlygreenpermitshabitation.Iseemanyredstamps.Menarmedwithpickaxes,sledgehammersandshovels,laborfromdawn

(L, top) Dr. Richard Picerno attends a Haitian patient while working at the National Hospital under the auspices of the Southern Baptist Convention. (R) Dr. John Von Thron with two Haitians he met and assisted while at a general hospital in Port-Au-Prince with a Presbyterian Ministries team. (L, bottom) Dr. Doug Johnson unloads supplies he helped fly to Haiti.

http://www.doctorswithoutborders.org


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AMA Leadership Dinner Reunites Friends

AttheAMALeadershipDinner,April26hostedbytheDCMS,Dr.YankD.Coble, Jr. (left, above) andDr.CecilB.Wilson(right,above)enjoyedsharingstoriesandmemoriesfromtheirmanyyearsservingorganizedmedicinetogetherthroughtheirlocalmedicalsocieties,FloridaMedicalAssociation(FMA)andtheAmericanMedicalAssociation(AMA).

Dr.Coble.apastDCMS,FMA,AMAandalsoWorldMedi-calAssociationpresident,isnowtheDirectoroftheCenterforGlobalHealthandMedicalDiplomacyattheUniversityofNorthFlorida.Dr.Wilson,apastOrangeCountyMedicalSocietyandFMApresidentisthePresident-ElectoftheAMA.

DinnerguestsheardDr.WilsonspeakabouttheAMA’sresponsetohealthcarereformandenjoyedapatioreceptionandmealatEppingForest.


todusk,takingdownthecity,concretechunkbychunk.ClustersofstakesshadedwithshowercurtainshavemorphedintoShelter-boxtentsandUSAIDtarps.

Water: InJanuary,thirstanddehydrationdroppedcitizensand volunteers. Now the monsoons have arrived. Eachnight torrential rainfall brings homeless residents to theirfeet,beddingsoakedbyrivuletsofrunoff,patchedsheltersleakinglikecolanders.

Sanitation: TentcitiesdevoidoftoiletsarenowringedwithPorta-Potties.Notbadifyoudon’tmindsharingthefacilitiesatarateof1:100.InSolino,deepinthepoorerheartofthecity,theproportionworsensexponentially.

Healthcare: Ourhosthasreopenedtheirmaternal-childclinicwhichisnowhousedinacorrugatedtinstructureboastingalimitedpharmacy,twocloset-sizedexamroomsandatiny,notyetfunctionallab.Thestaffhasreturned,theirpersonaltragediesallayed–twonurses,apharmacist,ageneralmedi-caldoctorandapediatrician.Theystruggletoprovidecarewithminimaldrugsandsupplies.

Eachmorningbeforedawn,patientslineupoutsidethecom-poundwalls,streaminat6a.m.andwait,quietly,patientlyuntiltheclinicopensat8a.m.By2p.m.theydwindleaway,wilted,weakintheafternoonsun.

HospitalGeneral,theteachinghospitalsoldierson:moreorganized but still makeshift. An admissions desk triagespatients;staffnowidentifiedbyT-shirtsratherthantape&markernametags.Pre-opandpost-opstillsheltersinlargemilitarytents.Wespendamorningatatentcityfullofor-phans,mothers,childrenandoldmen.Thereisnoevidenceofpriorhealthcarehere.

Education: Schoolsarebeginningtoreopen.Childreningingham-check dresses and shirts, reminiscent of colonialtimes,walkthroughrubbletorenovatedclassrooms.HospiceStJosephnowhostssixclassesaday,threeeachmorning,threeeachafternoon.Everystudentgetsameal,theironlyoneoftheday.Therearenobooks,justerasableboardsforteachersandrotelessons.

The People: Haitianspersevere-ChristRoiisexuberanttoseetheirblanfriendsreturn,showeringuswithdouble-cheekkisses.Webringlaughterandmerrimenttochildrenandadultsalike,includingasmallshell-shockedboywhohasn’tsmiledinthreemonths.Theygiggleatourattemptstomakeakite

A Caring Jacksonville Community Reaches Out to Haitian Amputees

John Lovejoy, MD

thatrefusestobecomeairborne;twogrownmenspendhalfadayconstructingaproperHaitiankite,neighborhoodboyssolemnlyinstructDokteEricinthefinerpointsofkiteflying.Weshareournon-perishablefoodswiththecookladies.Theyare ecstatic to receive cannedpeaches and tuna.Childrentreasureeverylittlejellybeanasitifwereagoldnugget.

SohowisHaiti?Port-au-Princemarchesalongfromravagedtoresilient.Ateenmothertriestopassherinfantthroughthebuswindow–hopingforafutureforherchild.Eachmorningat5a.m.hymnsliftoverthedestruction,prayingforstrengthforanotherday.Haitistillbleeds,andwewillreturn.

Dr. Joan Huffman dresses a wound on a patient dur-ing her first trip to Haiti. Both times in Haiti, she has worked at field hos-pitals with only primitive equipment.

Continued from p. 45

Thisisastoryaboutacaringcommunity…Jacksonville,FL.AftermakingtwotripstoHaitifollowingtheJanuary12,2010earthquakeandperformingmanyamputations,Iaskedmyself,“HowaretheHaitianpatientsgoingtodealwithalltheseamputations?”

Frommyprevioustrips,IknewhowdifficultitistogetaprosthesisinHaiti,muchlessonethatfitswell.Uponre-turningtotheU.S.,IcouldnotgetthethoughtsoutofmymindonhowtofitmyHaitianspatientswithaprosthesis.Mike Richard, CPO/LPI, President/Owner of AdvanceProsthetics&Orthotics, (APO)andIhaddealtwiththisproblembefore inGrenada,soIwenttoseehim.Inthatsituation,wehadsuccessfullyturnedashippingcontainerinto aprosthetic lab.Weknewwecoulddo it again,butthistimewedecidedtooutfitthecontainercompletelyasaworkingprostheticshop.

This iswhere the caring community comes intoplay. Imentionedthisprojecttoafewclosefriendsandtheyen-thusiasticallyjumpedonboard.

First,wehadtosecurea40-footshippingcontainer.TheJacksonvillePortAuthorityfoundusanallmetalcontainer,buttheWilliamsScotsmanCompanyofferedusaninsulatedandlightercontainerthatwasonceusedtoshippineapplesandbananasandthatScotsmanhadconvertedintooffices.IthadA/C,windowsandelectricity,soitmademoresensetogowiththisoption.SinceScotsmanreducedthepriceby80%,wecouldaffordit.Next,wecontactedSuddathRelocationServicestomoveit.Theygraciouslyofferedtheirservices.

Next,EdDoherty,retiredCOOofAtlanticMarine(AM),arrangedtotakethecontainertoAMwhereitwascleaned,painted,flooredandfittedwithanelectricpanel,outletsandlights.Icannotexpressthepridetheworkerstookinthisgratisproject.Theyinstalledthecabinets,drains,floor,trim,watersupplyandoutletandA/C.Mr.Dohertywasthereeachdaymakingsureeverythingwasdoneproperlyjustlikeitwasoneofhisownprojects.Heandhisworkerstrulytookasow’searandturneditintoasilkpurse.


Jon M. Fletcher, a Florida Times-Union (TU) photographer took this photograph which appeared in the April 3, 2010 TU with the caption, “Retired orthopedic surgeon John Lovejoy of Jacksonville has been coordinating and laboring to complete a prosthetics lab to be shipped to Hospital Sacre Coeur in Milot, Haiti. The lab, which was built inside of a freight shipping container, would help victims of the January earthquake. Several local companies and individuals contributed to make the project possible.” Special thanks to the TU for use of this photograph, the caption, and for featuring this project in its publication.

IcalledmyfriendsatExactInc.,WillAllen,CharlieToddandBuzzyAllen, andasked them if they couldmake thestainlesssteelworkbenchesandsink.Theirreplywas,“Ofcourse!”Iofferedtopayforthematerial,buttheirsupplierdonateditasawaytosupporttheproject.Weneededasinktoputintheworkbench,andIaskedthemaintenancemanat the JacksonvilleSpecialtyHospital, andhe saidhe justhappenedtohavepulledoneoutandwasgettingreadytodisposeofit.Someonewassurelywatchingoverus!

ItseemslikeallalongthewaytheJacksonvillecommunitywantedtobeinvolved.Somuchwasdoneonfaith.Whenwepurchasedthecontainer,mychurch,AllSaintsEpiscopal,raisedthemoneytobuyit.Ipersonallyguaranteedthecostoftheequipment,andwebegantoorder,puttingitonmycharge account. Then people, too numerous to mention,cameforwardtoparticipate.Someoftheonesthattouchedmy heart were friends, patients and families whom I hadtreatedandawidowwhogavehermiteoutofloveforoth-ers.Finally,theKnightsofMaltaofferedtobecomeamajorsponsor. My personal guarantee really was not necessarybecausethecommunitysteppedforwardandshowedhowtheycaredaboutothers.

IamsureIhaveforgottensomeonewhodeservesthanks,butIwillneverforgetourcommunity’swillingnesstohelp

others.AssistancecamefromtheretailerswhodiscountedtheirgoodsandcompanieslikeHomeDepot,Sears,AdvancedFurnitureSolutions,andWalMart(whoofferedtwochairandtable sets for$50eachandthengavemea$100giftcardtopayforthem).TheJacksonvilleJaguarsandownerWayneWeaverdonatedamuchneededminiambulanceforthehospital.BoPhillipsatCannonWeldingfabricatedtheawningandDillonSignspaintedallthelogosonthelab.Thecreditlistgoesonandon.

Besidesthefinancialgifts,therewasalsoalotofdonatedtimeandlabor.MostimportanthasbeenthecommitmentofMikeRichardsandhisstaffatAPO.Theyputinlonghoursdesigning,buildingandorderingequipment.DowningNight-ingaleofLambsYachtCentermadeinhisshopthecabinetstoholdtheplasticandpaintedthestepssoitwouldlookgoodtoallwhovisited.Mike’slandlordletusparkthelabbehindhisshopandthelocalsecurityagencywatchedoveritwithcaringeyes.Finallywhenitwasfinished,SuddathmovedittoFt.LauderdaleforshippingtoCapeHaitian,Haiti.TonyMarcelli,aSanteShippingagent,gottheshippingcostwavedandhadthelabtoploadedforsafety.

It isamazingwhatacaringcommunitycandowhenitpullstogether!


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For 30 years, family medicine physicians such asDr. Stephen Clark have helped Northeast Floridaresidents and their loved ones have a better qualityof life. For patients with advanced illness whoneed specialized care, these professionals callon Community Hospice of Northeast Florida.

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