Inside Medicine Spring 2018

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Inside Medicine | Spring Issue 2018

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TREATMENT

that stands up A strong back is essential to doing all the things you enjoy. Being active again can come from a balanced treatment approach designed by our rehab specialists, physicians and nurses. With a custom treatment plan you are one step closer to getting back to your life.

(256) 533-1600 | spineandneuro.com 2

Inside Medicine | Spring Issue 2018


You love growing your practice.

Then you’ll love this bank. Whether you’re ready to expand the office or fine tune your cash accounts, Progress Bank has all the features of a big bank but with the local connections and welcoming service of the local bank we are. You’ll find: • lending options • checking & saving accounts • electronic services • treasury & merchant services

Huntsville • Jones Valley • Madison Decatur • Florence • Birmingham Member FDIC.

®

myprogressbank.com Inside Medicine | Spring Issue 2018

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HUNTSVILLE

MADISON

ATHENS

DECATUR

Orthopaedic Surgery Sports Medicine Joint Replacement Spine Surgery Neurosurgery Physiatry Podiatry Workers’ Comp

256.881.5151 4

Inside Medicine | Spring Issue 2018

sportsmedalabama.com


Only hospital in North Alabama* to achieve Healthgrades® America’s 100 Best Hospitals for Spine Surgery™ for 2 years in a row (2017-2018)

*”Region” includes Colbert, Cullman, Dekalb, Franklin, Jackson, Lauderdale, Lawrence, Limestone, Madison, Marion, Marshall, Morgan, and Winston counties

Inside Medicine | Spring Issue 2018

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features &

CONTENTS

Sharing with Purpose

Inside Medicine | Spring Issue 2018

VOL 2

ISSUE 9

CO N T R I B U T ORS

Kimberly Waldrop, MA

FEATURES Radiation Oncology new technology for faster treatment

Gallbladder Q&A frequently asked questions about gallbladder disease

Pediatric Endocrinology a physician’s homecoming benefits children with diabetes

08 24

CONTENT HIPAA Compliance risk analysis and risk management

Is the Customer Always Right

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The Faceless Soldier

Jeff Olson Kevin E. Fernandez Jason Lockette, MD, MBA Kari Kingsley, MSN, CRNP

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delivering quality customer service in healthcare

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Larry Parker, MD

Neeta Kohli-Dang, MD Ray Sheppard, Jr., MD Jarrod Roussel, PA-C Anne C. Jewell

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Recognizing those whose identity can’t always be shared

Steve Smith Tiernan O’Neill Jackie Makowski Steve Doyle Ben Murray Ashleigh McKenzie Jennifer Jeffers

MD

Join our mission to establish our community and healthcare providers. Together, we can change

the way healthcare information has been and will be distributed

for years to come. To reach our readers, whether through editorial contribution or advertising, please contact Kelly Reese

at kellyreese.im@gmail.com or

Making a Difference

and grow an alliance among

256.652.8089

The information and opinions contained in this publication constitute general medical information only and should not be construed as medical advice. Before making important medical decisions, readers should consult with a physician or trained medical provider of their choice and have their needs and concerns assessed in a clinical setting appropriate for their problem.

S A LE S & M A R K ETIN G

Kelly Reese, Founder Lisa Layton, VP Sales/Marketing Heather Mendez Will Steward CH I E F E D I T O R I A L W RITER

Kimberly Waldrop, MA G R A P H I C D E SIGN

Leigha Parker Karen Gauthier P U B LI S H E RS

Blake Bentley, President www. in s ide me dic in e magaz ine.com

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} FROM THE EDITOR

Dear Readers I am so excited about this edition of Inside Medicine. We are working through our 2nd year of this special publication and it brings us such joy to feel the community support and encouragement grow with every issue. It is our hope you find something useful or inspiring in every magazine. We have some really heartfelt stories this time, as well as lots of wonderful medical information. In “The Faceless Soldier”, Sam’s story as an Army Ranger reminds us there are military personnel fighting for their lives, and our lives, every day. They are not working for the glory but for a higher calling that everyone can’t understand. It is important that we honor their sacrifice, and understand their sacrifice, all throughout the year. We are so blessed to have two different local pastors as guest writers in this issue. Both of their contributions help put a Biblical perspective on living life and living for God. Make sure you read Ben Murray’s devotion on corporate worship and Steve Smith’s devotion about Jesus. Don’t miss tips on treating hay fever, long term care ideas, how to be a good customer, primary care physicians, and many more! This issue is packed full of great stories and great ideas. As always, our prayer with Inside Medicine is to help our community and show a love for our Savior. We are always looking for new content and features. Please contact us if you ever have an idea for a story or want to be included in our magazine. We love hearing from you and appreciate your support!

iK mberly Waldrop

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} COVER FEATURE

Radiation

Oncology

Thanks to powerful new technology at Alliance Cancer Care in Huntsville, radiation treatment for certain brain tumors that used to take six weeks can now be completed in minutes.

Photo Credit: Steve Babin

The Alliance office on the Huntsville Hospital campus is the first medical practice in Alabama, and one of only 10 nationwide, to pair a latest-generation Versa HD linear accelerator with ExacTrac advanced image guidance. Radiation oncologist Dr. John F. “Jack” Gleason Jr., medical director of Alliance’s radiosurgery program, said the new system improves both the speed and the effectiveness of radiation therapy for certain tumors. The advanced image guidance ensures that the radiation beam hits only the tumor, Dr. Gleason said, which better preserves the surrounding healthy tissue. And because the new linear accelerator delivers radiation in higher doses than conventional radiation therapy, it can kill a brain tumor in a fraction of the time. Instead of 30 or more visits spread across six weeks, Dr. Gleason said many patients treated with the new radiosurgery system will need a single non-invasive treatment lasting about half an hour. “If we deliver all the radiation to a tumor in one day, it’s harder on the tumor than spreading the same dose over 8

Inside Medicine | Spring Issue 2018

several weeks,” he said. “So this is a more clinically effective dose.” Alliance Cancer Care has three Huntsville locations – at Huntsville Hospital, Crestwood Medical Center and Clearview Cancer Institute – plus offices in Decatur and Florence. The Huntsville physician team includes Dr. Gleason, Dr. Hoyt A. “Tres” Childs III, Dr. Noel C. Estopinal, Dr. Elizabeth Falkenberg and Dr. Harry James McCarty III. Dr. Traci McCormick and Dr. Stanley Clarke see patients at Alliance’s Decatur and Florence offices, respectively. The new system in Huntsville eliminates the need for one of the most unpleasant parts of radiosurgery: head frames. With many older systems, a large frame would be attached to the patient’s skull with bone screws. The frame provided the coordinates needed to direct the radiation beam to the tumor lurking inside the brain, but it could be painful.

Photo Credit: Steve Babin


Introducing our latest technology:

Alliance Radiosurgery: Focused on you. Dr. Hoyt A. “Tres” Childs, III Dr. Noel C. Estopinal Dr. Elizabeth Falkenberg Dr. John Francis Gleason, Jr. Dr. Harry James McCarty III Dr. Traci Cole McCormick (Decatur) Dr. Stanley Clarke (Florence)

Locations

Clearview Cancer Institute Crestwood Hospital Huntsville Hospital/Blackwell Medical Tower Decatur Florence

AllianceCancerCare.com/ Alliance-Radiosurgery

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...cont’d from page 8

Physicians now instead use image guidance from MRI and CT scans of the patient both before and during treatment, along with the ExacTrac system which gives instantaneous feedback on patient position in all six dimensions, to make sure the radiation beam hits the target with an accuracy of less than a millimeter. No frame necessary. If a patient has more complicated brain lesions or a condition like trigeminal neuralgia that can be treated with either radiation or surgery, Alliance physicians and the neurosurgeons at Huntsville Hospital Spine & Neuro Center collaborate on a treatment plan. Dr. Holly Zywicke is medical director of the neurosurgery side of the partnership. The multidisciplinary approach “improves the safety and quality of treatment, and it spares the patient from having to go see two different physicians,” said Dr. Zywicke. The term “radiosurgery” is a bit of a misnomer since it’s not a surgical procedure. There are no incisions, and the patient remains awake while the radiation attacks the tumor. “Patients don’t even feel the treatment,” said Dr. Gleason. Alliance Cancer Care’s radiosurgery program can treat these cancerous and non-cancerous conditions: • Brain metastasis • Trigeminal neuralgia • Meningioma • Acoustic neuroma • Recurrent glioma • Lung Stereotactic Body Radiotherapy (SBRT) • Liver SBRT • Spinal SBRT • Bone metastasis

Our therapists provide highly specialized treatments based on a thorough hands-on manual techniques and exercises to facilitate quick and complete recovery.

Call Today 256.883.0636

www.focus-physio.com 1140 Eagletree Lane SE • Huntsville, AL 35801

Photo Credit: Elekta 10 Inside Medicine | Spring Issue 2018


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the truth about by, Larry M. Parker, MD

Laser Spine Surgery

What is Laser Spine Surgery? Can spine surgery be performed more effectively and with less complications using a laser? Why is the word “laser” almost synonymous with spine surgery? Of those three questions, the last one is the easiest to answer. That answer happens to be marketing. Google anything regarding disc or spine surgery and you will immediately see advertisements about laser spine surgery. Watch daytime television and you will see countless advertisements about laser spine surgery. So what about the first two questions? What is laser spine surgery and does it make spine surgery more effective or safer? Let’s discuss. First of all, laser spine surgery is NOT a defined surgical procedure and subsequently it is not recognized specifically as a procedure by Medicare or private insurance companies. Microdiscectomy, Decompressive Laminotomy or Laminectomy are examples of defined surgical spine procedures accepted by insurers and Medicare. The confusion really comes from associating, through marketing, the word laser with the concept of Minimally Invasive Surgery. Without a doubt, microdiscectomy surgery and decompressive laminectomy or laminotomy surgery can be done successfully with minimally or least invasive techniques. So the real question is-does the laser make spine surgery less invasive or safer than using a scalpel or electrocautery? The answer is absolutely and unequivocally NO! For a sobering assessment about the subject, search laser surgery criticisms or complications and read the articles by Bloomberg or Business Week. There is a reason why the laser is not routinely used as a tool for spine surgery in peer reviewed institutions like the Mayo Clinic or UAB Hospital. This also includes our local institutions Huntsville Hospital and Crestwood Hospital, and that reason is because a laser does not make spine surgery better or safer. Let’s reset the discussion. New technology and advancing surgical procedures is one of the pillars of modern medicine. No better example of that is surgery for gall bladder disease. In the early 1980’s, cholecystectomy surgery was done with a large abdominal incision. I have some painful memories as a medical student holding a Dever Retractor with two hands while the attending surgeon removed the gallbladder with an open technique. In just a matter of a few years, with the development of minimally invasive laparoscopic techniques, the paradigm completely changed and the laparoscopic technique became the standard of care.

In Spine surgery, there has been a tremendous amount of new technology in the last few decades. Kyphoplasty, Artificial Disc Technology, and advances in fusion techniques with better instrumentation are all examples of peer reviewed technology that has been proven safe and effective and therefore incorporated into mainstream spine surgery throughput the world. You may have read recently about the Mazor Robot or the O-arm which are a couple of new technologies recently introduced into the Huntsville spine market. The laser, as a surgical tool, is not one of them. A laser is essentially a cutting tool that can be used to cut soft tissue. As a spine application, it can be used to perform a procedure called Facet or Dorsal Rhizotomy, a non-surgical pain management procedure to treat back pain, but the laser has not been shown to perform that procedure any better than radio frequency or electrocautery. Using a laser as a surgical tool to treat nerve pain related to disc herniations or spinal stenosis has not been proven safer or more effective than a scalpel or electrocautery and further does not make disc or spinal stenosis surgery anymore minimally invasive. Let’s keep it simple, if the laser was a great tool that made spine surgery better, spine surgeons all over the country, including the local spine surgical community here in Huntsville, would be using it. To conclude, most spine surgery for leg or arm pain caused by a disc herniation or spinal stenosis can be performed with a small incision as an outpatient procedure. In our community, spine surgeons perform these procedures and send people home the same day, every day. Just remember that in most cases, it is not the surgeon that makes the procedure large or small, it is the diagnosis that makes the procedure necessary to fix it “large or small”.

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} FEATURE

HIPAA compliance

Do you REALLY know if you are HIPAA Compliant? Do you know where your Data is stored? Is that location protected? Are you utilizing Risk Analysis, or are you adding Risk Management also?

by Jeff Olson

Risk Analysis, a single Snapshot-in-Time. It identifies problems and suggests remediations. Then What? Risk Management, a continual Risk Analysis. Identify the problems, suggest the remediations, correct the problems then do it again. Risk Analysis and Risk Management are two areas from FAR 164.308 that are to be followed to remain HIPAA Compliant. According to the “CMS White Paper Volume 2/Paper 6”, here are steps for Risk Analysis and Risk Management. Note: CMS is not recommending that all covered entities follow this approach, but rather is providing it as a frame of reference. EXAMPLE RISK ANALYSIS STEPS: 1. Identify the scope of the analysis. 2. Gather data. 3. Identify and document potential threats and vulnerabilities. 4. Assess current security measures. 5. Determine the likelihood of threat occurrence. 6. Determine the potential impact of threat occurrence. 7. Determine the level of risk. 8. Identify security measures and finalize documentation.

The time to be Compliant and Secure is now. Don’t be the example that others learn about. Be the example that others learn from.

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Inside Medicine | Spring Issue 2018

EXAMPLE RISK MANAGEMENT STEPS: 1. Develop and implement a risk management plan. 2. Implement security measures. 3. Evaluate and maintain security measures. Cyber Security is an integral part of being HIPAA Compliant. HIPAA rules and Cyber Security are an ever-changing environment. Just as patient care is a layered approach and ever changing, so should be the security against Cyber Threats. Cyber Security is a journey, not a destination. It is not a set it and forget it. You protect the building with locks, cameras and alarms, but your data is only protected with locks that Cyber Thieves have keys to?


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Building your Legacy starts with Our Premier Planning Team

Through our individualized case development process, we listen and understand what’s important. With our nationwide agency network, we’ve been down this path hundred of times before, helping clients reach their retirement, estate and business planning goals and objectives.

Kevin E. Fernandez Agent, New York Life Insurance Company Registered Representative, NYLIFE Securities LLC (Member FINRA/SIPC), a Licensed Insurance Agency

New York Life’s Advanced Planning Group is a team of over 30 professionals with specialized training in law, taxation accounting, business, insurance, finance and philanthropic planning. With more than 300 years of collective experience, the APG supports a variety of wealth strategies and business planning objectives in these key areas: Personal Planning:

New York Life & NYLIFE Securities 200 Clinton Ave W, Suite 600 Huntsville, AL 35801 kefernandez@ft.newyorklife.com

256.517.5962 16

• Life Insurance • Long term care Insurance • Disability Insurance • 401K Rollover • Traditional IRA • Roth IRA • SEP IRA • Estate Planning • Retirement Planning • College Funding & 529 Plans • Annuities • Mortgage Protection (Life Insurance)

Business Planning:

• 401K • Employee Benefits • Group Life Insurance • Short term Disability • Long term Disability • Executive long term care arrangements • Executive bonus plans • Payroll deduction programs • Employee Whole Life • Key Person Insurance

Fernandez Financial Group LLC is not owned or operated by NYLIFE Securities LLC or its affiliates. Neither New Your Life Insurance Company, nor its Please consult your own tax, legal or accounting professional before making any decisions. I n agents, s i d e Mprovides e d i c i ntax, e |legal, S p r ior n gaccounting I s s u e 2 0 1 advice. 8


} FINANCE

Succession planning

for small business owners by, Kevin E. Fernandez

Most business owners want to grow their business and maybe even pass it on to the next generation. But how many owners actually succeed? Relatively few, as it turns out. Studies show only a third of family firms make it to second generation and just a sliver get passed onto the third generation.* A key reason for this is that many companies lack proper succession plans. Consider the situation your family, employees and company would be in if something unexpected were to happen to you. What would happen to your business? Would it stay in the family? Could it realistically stay solvent without you at the helm? Or would it be sold? And then there’s the million-dollar question: Do you even know what your business is worth? The answers to these questions may not be as straightforward as you imagined. That’s why you should start planning now even if you don’t intend on leaving the business for years to come. So what options are available? If and when you exit your business, there are four possible successors: family members, co-owners, key employees or an outside third party. That brings us to a succession action plan and exactly what that entails. First, select your successor(s); it may require careful analysis. Next, determine your business valuation; bear in mind when a business is sold to family members, the transaction

draws extra scrutiny from the IRS. Lastly, develop a plan to transfer your business interest quickly to minimize operational disruptions. Once you identify your successor(s), you must make sure that the individual(s) are in a position to take over the company - and ensure a smooth transition by outlining the terms of succession in advance. A buy-sell agreement will work differently depending on the type of business entity and the number of owners. Each type of agreement helps create a smooth process for transferring ownership of the business. The buyer can purchase a life insurance policy to help make sure they have available funds to purchase the business when the time comes. Additionally, a buy-sell agreement helps show creditors and customers that your business is more sustainable because you are taking action to mitigate risk. While each business is unique, succession planning is something that all businesses should consider.

*Source: Molly, V., Laveren, E., and Deloof, M. (2010) Family Business Succession and Its Impact on Financial Structure and Performance. Family Business Review, Vol 23 (2) 131-147

Neither New York Life Insurance Company nor its Agents or affiliates provide tax or legal advice. Consult your legal or tax advisor to find out whether the concepts in this essay apply to your personal circumstances. This educational third-party article is provided as a courtesy by Kevin Fernandez, President, Fernandez Financial Group LLC, Agent, New York Life Insurance Company. To learn more about the information or topics discussed, please contact Kevin Fernandez at Kevin@Fernandezfinancialgroup.com or call (256) 517-5962.

Inside Medicine | Spring Issue 2018

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Do You Really Need a

PRIMARY CARE PHYSICIAN? by, Jason Lockette, MD, MBA

When trying to decide which healthcare provider is best for you, it can be confusing sorting through all of the different medical terminology. Do you need an Emergency Room, an Urgent Care Center, a specialist, or a Primary Care Physician? Urgent Care Centers and Emergency Rooms serve an important role by providing extended hours access. Emergency Rooms, in particular, are equipped to handle most any life-threatening injury or illness. An unfortunate consequence, though, is that patients with non-life-threatening conditions often experience lengthy wait times. In addition, there is a separate facility fee associated with using an Emergency Room, which is why most patients will experience significantly higher costs. Urgent Care Centers have come along to fill the void between the Emergency Room and your Primary Care Physician. They are more cost-effective than the ER but are often staffed with many different physician and non-physician providers meaning that you seldom get to see the same team of providers. Where do you go, then, if you have a chronic condition such as high blood pressure, diabetes, or high cholesterol? These conditions are best managed when you have a relationship with the same provider or team of providers. After all, we stick with the same people who cut our hair and repair our car. Why should our healthcare be any different? But, what if you have a new symptom or problem that needs immediate attention? It can be hard to know how best to handle a new problem and traditional Primary Care cannot usually accommodate same day appointments. Why is this? Providers are being asked to do more and more administrative tasks that take away from their time with patients. The result is decreased job satisfaction, increased stress, early retirement, and, in some cases, depression and anxiety. Today’s increasingly complicated healthcare system requires a level of expertise and time that most physicians simply do not have. Lessening the administrative burden on providers, for example, requires a team of billing/coding professionals, scribes, legal/compliance experts, and a whole team of administrative/clerical personnel, something small and even medium sized Primary Care practices simply cannot afford. At Integrity Family Care, we have created a different, more friendly and usable Primary Care experience. Patients have access to the same team of providers every visit and, if needed, we can accommodate same day appointments for most acute problems.

AT INTEGRITY FAMILY CARE, WE HOPE TO HELP YOU...

Live Life Well

Jason Lockette MD, MBA, President, Integrity Family Care 1041 Balch Rd #300, Madison, AL 35758 256-325-1540 www.integrityfamilycare.com 18

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FEELING FOGGY? A look at how your inner ear can affect the brain and cognitive thinking. by, Kari Kingsley, MSN, CRNP

Several years ago, I developed intermittent bouts of what I would later term brain fog in which I experienced nonlucid moments, similar to waking up after anesthesia. The first and most memorable of these occurred while I was driving on I-565 to work one morning. While not exactly dizzy, I recall feeling so strange that I pulled the car over on the interstate and waited for the spell to pass. After a few minutes, the episode subsided and I went on with my busy day, forgetting about the strange incident. Months later, similar spells began occurring more frequently, heightening my preexisting hypochondriac tendencies that I had developed from years of reading medical books and watching TV programs about the rarest medical conditions in the world.

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The spells would come on suddenly, without warning, and felt like a cloud engulfing my consciousness. I had a really hard time explaining the symptoms to my family practitioner at the time. “You know that feeling… where you’re having a dream… and then you start to fall… but then you don’t fall… but the ground is moving… and your thoughts don’t come as crisply or clearly…” Gosh, I sounded crazy even to myself. I further tried to explain that words sometimes did not come easily, decision making became more difficult, and my concentration span seemed shortened. After some routine blood work, I was reassured that my symptoms were likely from fatigue with an added dash of anxiety. But something felt wrong. The foggy spells progressed and I began experiencing pressure in my head, although the entire myriad of symptoms remained very non-specific. Being in my late 20s and a medical provider with just enough medical insight into her own health to be unbiased, I did what any circumspect and logical person would do: I Googled it. After hours of pouring over medical articles, researching medical websites and reading the rantings of a few passionate bloggers, I settled on a very rational explanation for my symptoms…I had a brain eating amoeba. My family practice provider referred me to a neurologist where I was subjected (at my insistent request) to nearly every test known to man…MRI scans, toxicology, blood tests, nerve studies…you name it! The only time he laughed at me was when I asked him (only half-jokingly) if he would do a brain biopsy to make sure the large amounts of sushi I had been consuming hadn’t left an uninvited parasite swimming in my gray matter. The testing came back completely normal. No multiple sclerosis, no brain tumor, no lead poisoning, and certainly, no brain-eating amoeba. I was the picture of health. Now, if you’re like me, there is nothing in the world more frustrating than knowing something is wrong and not having an explanation. What I’ve failed to mention thus far is that at this point in my life, I was working as an Ear, Nose, and Throat nurse practitioner, specializing in dizzy patients. As I continued to see patients day-after-day and listened to the way they described their symptoms, something clicked for me. My patients with inner ear conditions, specifically Meniere’s Disease, complained of dizziness, lightheadedness, vertigo and a feeling of being “foggy headed”. Eureka! But I wouldn’t describe my spells as dizziness exactly, more like a deviation from my normal clear thinking. About this time, I began noticing the pressure in my head was centered over my right ear and that I had developed a faint humming and roaring tone. Feeling a bit silly to have struggled for so long with what was quickly becoming a familiar ENT scenario, I asked our audiologist to check my hearing and run a simple sound test for Meniere’s Disease. It was positive in my right ear. Suddenly the brain eating amoeba had a name!

But I had been treating patients with inner ear conditions for years and was completely oblivious to the fact that I had developed Meniere’s Disease! I laughingly tell my patients how I came to realize I had Meniere’s Disease. They too are generally relieved to have a diagnosis; especially one that is treatable. My best advice as a Meniere’s patient (and as their provider): STAY OFF GOOGLE! Dr. Google is the most dangerous physician in the world because he plays on the fears of uncertainty lurking in the dark parts of our (amoeba eaten) brain. Meniere’s Disease is an inner ear condition usually characterized by dizziness, ear fullness, tinnitus (or noise in the ear), and hearing loss. You can have a combination of symptoms or all of the symptoms which can vary case-by-case. Meniere’s Disease is thought to arise from genetic and environmental factors, although the exact etiology is unknown. Pathophysiology is not fully understood, but thought to be related to a variety of events that lead to elevated pressure in the endolymph fluid causing a condition known as hydrops. Although dizziness can be Pandora’s Box in terms of differential diagnoses, inner-ear should always be a consideration once acute issues such as cardiac, vascular, and neurological conditions have been excluded. The history is critical. Find an ENT team (hint, hint) that will take the time to listen to your symptoms. Standard workup includes a hearing test (or audiogram) along with simple sound tests to measure inner ear pressure. Not to brag (cough, cough) but our practice recently upgraded to stateof-the-art inner ear test equipment that is second to none. As advances in technology continue to grow, we work closely with our audiological team to interpret results so that we can appropriately treat our patients. Upon confirmation of a Meniere’s Disease diagnosis, treatments include initiating a low-salt, low-caffeine diet and medications such as diuretics, steroids, anti-nausea pills and drying agents (anticholinergics) depending upon the individual patient. Trans-tympanic steroid perfusion therapy offers a minimally invasive, in-office procedure that provides significant lasting relief for most patients. Some of the more invasive procedures and surgeries such as endolymphatic sac decompression should be reserved for more severe cases and are generally performed by board-certified neuro-otologists at universities in larger cities such as Birmingham and Nashville. Destructive procedures, such as gentamycin perfusions and labyrinthectomy can cause irreversible effects such as permanent hearing loss and are reserved for dire cases. (These are the Dr. Google recommendations we try very hard to stay away from). Most patients respond well to steroid perfusion therapy and rarely require further action. Inside Medicine | Spring Issue 2018

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...cont’d from page 21

Balance therapy may be indicated for some, but for the majority of patients based on our clinical experience, this is generally not necessary. Theories exist as to why a condition within the ear affects brain consciousness creating the sensation of fogginess. After pouring over the literature, my professional opinion is: no one knows. My personal opinion, having suffered this condition for many years, is that Meniere’s Disease creates a constant symptom of imbalance in which the body fights tirelessly to try to “right itself ”. This constant exertion probably tires you, not only physically, but also mentally, creating a murkiness in your daily thoughts. Severity ranges from a mild brain mist all the way to a giant wall cloud. Foggy-headedness can also arise from a number of additional medical conditions. Medications, migraine headaches, fibromyalgia, anxiety, sinus infections, allergies, multiple sclerosis, attention deficit disorders (and probably brain-eating amoebas) make the list. Accompanying symptoms such as nausea, vomiting, blurred vision, headaches, chest pain, syncope and of course ear symptoms will help your medical team zone in on which appropriate tests, procedures and referrals to order. Many patients ask, “How do I fight the fog?” For me, achieving a low-salt, low caffeine diet (although I frequently cheat), and responding to ear steroid perfusions fought most of the battle. Staying physically active with aerobics such as, horseback riding, and waterskiing has also helped… not that I am graceful or even good at these activities! For older patients, other recommendations include walking, water aerobics, and staying active in general can help to improve vestibular function, physical health, and emotional wellbeing. I read (and write) as much as possible and practice sudoku puzzles to help improve my mental acuity. “Use it or lose it”, we often hear. Practicing mentally challenging activities has been helpful for me. I am often reluctant to tell patients how well I’ve done from treatments because I would hate for them to have a less effective result and compare themselves to my experiences. Nearly all of them appreciate the candidness and understand that each patient can have a different outcome. However, the vast majority of our patients do respond well to treatment and their quality of life improves vastly. I am fortunate to work with one of the most knowledgeable ENT physicians in North Alabama. Dr. Neeta Kohli-Dang and I share a passion for diagnosing and treating dizziness in addition to a multitude of other ENT conditions. We’ve had numerous patients visit us over the years with symptoms similar to mine. When I was initially diagnosed, I was embarrassed that I had ig-

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nored my own signs of inner ear. What kind of a provider doesn’t realize she has the very condition that she treats? But after seeing Meniere’s patients for the majority of my nurse practitioner career, I’ve come to the realization that one size certainly does not fit all. I am able to chalk it up to the vagueness of my clinical presentation. Once clear-cut Meniere’s symptoms arose, I jumped on it like a duck on a June bug. And I certainly have no trouble telling my story, no matter how self-deprecating; if it helps someone lift the fog.

Kari Kingsley, MSN, CRNP works as an otolaryngology nurse practitioner in collaboration with Dr. Neeta Kohli-Dang. Together they share nearly forty years of ENT experience. They treat dizziness, ear infections, hearing loss, nasal congestion, sinus infections, thyroid nodules, tonsillitis, neck masses, hoarseness, trouble swallowing, and a multitude of other ear nose and throat conditions. Please call 256-882-0165 to schedule an appointment with Dr. Neeta Kohli-Dang and Kari Kingsley.


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GallBladder by Ray Sheppard, Jr., MD

Do you know anyone who has undergone gallbladder surgery? Chances are you do! There are an estimated 750,000 gallbladder surgeries per year in the United States. Gallbladder problems are a very common reason to visit a family doctor or GI doctor (gastroenterologist). Usually people are experiencing episodes of abdominal pain or nausea and are looking for answers to why they feel bad. Here are some frequently asked questions about gallbladder disease.

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} SURGICAL TECHNOLOGY

What are gallstones? Sometimes a crystal forms within the stored bile of the gallbladder and slowly a stone grows. This is similar to a pearl forming within an oyster. Stones can figure grow 2quite large or they may remain small like sand particles. How do gallstones affect you? At times, these stones or particles can obstruct the outlet of the gallbladder. If an obstruction is present while the gallbladder contracts to eject bile, a person will generally feel a sharp attack of pain and possibly nausea and vomiting. Some people only sense nausea but no pain. These attacks are generally after eating. What is a gallbladder? The gallbladder is an egg-sized hollow organ that stores bile which is produced in the liver. In fact the gallbladder is partially attached to the liver and joins the duct system that exits the liver. Where in your body is the gallbladder located? The gallbladder is located in the right side of the upper abdomen. Can it ever be located somewhere else? Yes. A condition named situs inversus is present in 1/100,000 people. In these situations the person’s organs are located on the opposite side of normal. I have encountered this twice during my career. What does the gallbladder do? The purpose of the gallbladder is to store bile and then eject the bile into the intestine when you eat. Why is bile important? Bile acts as a detergent to break fatty foods into smaller particles which are more easily digested. Does the gallbladder make bile? No. The gallbladder only stores the bile. The bile is actually produced in the liver. A duct system exits the liver and a small channel between the gallbladder and this duct system allows the passage of bile into and out of the gallbladder. How does the gallbladder know to send bile into the intestine? Sensors in the lining of the stomach are activated by fat molecules that you eat. Those sensors release a chemical into your blood stream call CCK (cholecystokinin). The CCK travels to the gallbladder and tells it to push the bile into the duct system that ends in the intestine.

Where is the pain located? The location of the pain varies from patient to patient. Most frequently the pain is in the middle of the upper abdomen (the epigastrium). Others experience pain in the right side of the abdomen. Some will relate pain from both locations. Often this pain radiates to the back or shoulder blade. Rarely the pain is in the right side of the lower abdomen or left side of the upper abdomen. How long does the pain last? Fortunately, most gallbladder attacks will fade away with a few minutes to hours. Some attacks are minor and others create severe pain. Once a person has developed a gallbladder attack, they will probably have additional attacks in the future. Can more serious problems occur? Sometimes a gallbladder becomes completely obstructed to the point that infection is produced. This requires immediate attention. In rare cases a gallbladder may actually rupture. How do you know if you have gallstones? The best test to look for gallstones is an ultrasound of the abdomen. This will not detect all gallstones, however ultrasound is about 95% accurate. A CT scan is not as good at finding gallstones as an ultrasound, but it is sometimes helpful. What if I have gallbladder symptoms but I do not have gallstones? The bile within the gallbladder can become thick like motor oil. When this happens, it can be difficult for the gallbladder to eject the fluid through its outlet. Imagine trying to suck thick syrup through a straw? The gallbladder will send your brain the same signals as if it were obstructed.

Inside Medicine | Spring Issue 2018

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...cont’d from page 25

How do you know if your gallbladder is having trouble ejecting the bile? A gallbladder test called the HIDA scan can measure the ability of the gallbladder to eject the bile. A special tracer is placed through an IV that accumulates in the bile. The messenger chemical, CCK, is then injected through your IV to stimulate gallbladder contractions. The scanner will watch the gallbladder and calculate how well it ejects the bile (ejection fraction). Normally, the ejection fraction is 70-90%. When the ejection fraction approaches 35%, it is likely that symptoms are due to a dysfunctional gallbladder. This condition is also known as biliary dyskinesia.

What is the treatment for biliary dyskinesia? The only treatment is gallbladder removal (cholecystectomy). Biliary dyskinesia is not life-threatening, so a person can decide that their symptoms are not severe enough to warrant surgery. Very few people are willing to volunteer to be subjects of gallbladder surgery research, so scientific data is limited and conclusions of studies vary. We do know that greater than 90% of patients will feel better after gallbladder removal. We know that many patients will experience miserable episodes until their gallbladder is removed. We also know that some patients may experience many years of normal life in between attacks. Overall, it depends upon how bad a person feels. What if my HIDA scan is normal but I experience gallbladder symptoms? If CCK administration recreated your gallbladder symptoms, then gallbladder removal will be beneficial in 90% of cases. If CCK did not recreate your symptoms, then we need to look for other causes of pain such as ulcers, Crohn’s disease, ulcerative colitis, irritable bowel syndrome, or more rare disorders. In some situations, no cause for the symptoms can be identified and gallbladder removal has been helpful for these patients.

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Can gallstones pass through the channel out of the gallbladder? Yes. This is a less common but more serious problem. After gallstones leave the gallbladder, they may obstruct the ducts between the liver and the intestine. This can produce a severe life-threatening infection called ascending cholangitis. I have heard that gallstones can cause pancreatitis. This is true. The duct of the pancreas joins the duct that passes from the liver to the intestine. When a gallstone travels through the bile duct, it may temporarily obstruct the pancreas duct and lead to inflammation of the pancreas. How are gallstones treated? Since there is no easy way to get of rid of the gallstones, surgery to remove the gallbladder (cholecystectomy) is the treatment of choice. A medicine to dissolve gallstones exists, but it does not work very well and is reserved for patients that can not safely undergo gallbladder surgery. Can sound waves be used to destroy gallstones? This is a useful technique for some kidney stones, but it is more complicated for gallstones. First, as the gallstones are fragmented they are likely to leave the gallbladder and clump together in the bile duct that passes between the liver and the intestine. This obstruction can, in turn, create life-threatening complications of liver infection or pancreatitis. When kidney stones are fragmented, a stent is placed in the urine passageways to prevent obstruction. Stenting of the major bile duct is much more difficult and carries its own risks. In addition, a person who forms gallstones is likely to form more in the future. That patient would have to face this same problem once again. Have you ever known a person that has suffered from multiple kidney stone attacks? I know someone who had a drain placed in their gallbladder. This can useful if someone has developed a gallbladder infection and is so severely ill that surgery is not safe. After numbing the abdominal wall, a drain is placed through the skin into the gallbladder with X-ray or ultrasound guiding the doctor. This is called a cholecystostomy tube. The drain will need to stay in place for 6 weeks and then surgery can be performed when it is safer. What happens if a gallstone is lodged in the bile duct between the liver and the intestine? Usually these stones can be retrieved through tiny instruments that are passed through a special scope which is placed through the mouth, down the esophagus and stomach, into the intestine. This is called endoscopic retrograde cholangiopancreatography or ERCP for short. In rare circumstances ERCP is not possible and the bile duct must be approached through a surgical procedure.

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Inside Medicine | Spring Issue 2018

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HudsonAlpha receives $40,000 grant for ALS sequencing project by HudsonAlpha and Crestwood ALS Care Clinic

HudsonAlpha Institute for Biotechnology has been awarded a $40,000 grant from the Crestwood ALS Care Clinic, a National ALS Association Treatment Center of Excellence in Huntsville, Ala. In this collaborative project, called Impacting ALS, HudsonAlpha scientists will conduct genomic sequencing and analysis of ALS patients to better understand the underlying cause of the disease.

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} RESEARCH

ALS (amyotrophic lateral sclerosis), also known as Lou Gehrig’s disease, is a progressive neurodegenerative disease that affects nerve cells in the brain and the spinal cord. Michelle Amaral, PhD, a senior scientist in the HudsonAlpha Myers lab, is leading the project. “Through genomic sequencing and analysis, we hope to identify genetic variants that contribute to ALS,” said Amaral. “We want to understand the mechanisms that cause the disease as well as the differences between sporadic and familial ALS. The ultimate goal is to discover biological targets that may be useful for the development of new treatments and therapeutics.” In the beginning stages, the project will enroll patients that are currently being treated at the Crestwood ALS Care Clinic, where physicians and researchers will collaborate to return and discuss results with families. Sherry Kolodziejczak, an occupational therapist and Director of the Crestwood ALS Care Clinic/Cardiac Rehab/Therapy Services/Workers Program, said patients treated at the clinic report a higher quality of life and longer life expectancy. “Our clinic manages each ALS patient case throughout the course of the illness. We have to prevent the crisis before they come, not when they get here, and that’s how we can prolong life and give good quality of life,” she said. Led by co-medical directors David White, MD, and Aruna Arora, MD (both neurologists), the Crestwood ALS Care Clinic is the only ALS Association Treatment Center of Excellence in the state of Alabama. The Crestwood ALS Care Clinic is also a Northeast ALS Consortium (NEALS) site. The mission of NEALS is to rapidly translate scientific advances into clinical research and new treatments for people with ALS and motor neuron disease.

ALS patient Bryan Stone of Sylacauga, Ala., a NEALS ambassador for the Crestwood ALS Care Clinic, is happy to see that research is happening right here in Huntsville. “It’s exciting to see the testing and the collaboration done here at home and that we can take part in it,” said Stone. “ALS has forced me into retirement and there are a lot of activities that I’m not able to do, but then again, it’s opened up other avenues for me to work with the ALS community and help others.” “Crestwood has had a strong clinical relationship with the ALS chapter, our patients, and physicians and staff who really go above and beyond to take care of patients, but this project is the next step,” said Pam Hudson, MD, CEO of Crestwood Medical Center. “We need to get to the cause of the disease, and not solely focus on the treatment.” The $40,000 grant from the Crestwood ALS Care Clinic will be used to launch the Impacting ALS project, which will start enrolling patients in March. Additional gifts are being accepted and will be used to enroll even more patients who are battling ALS. Donations to Impacting ALS can be made to the HudsonAlpha Foundation at 601 Genome Way, Huntsville, AL 35806.

HudsonAlpha collaborates with institutions all over the world. It is especially exciting to be working on a project like this in Huntsville, so we appreciate Crestwood’s support and look forward to making even more advances in ALS. - Rick Myers, PhD, HudsonAlpha president and science director From left to right: Michelle Amaral, Rick Myers, Pam Hudson, Sherry Kolodziejczak

Inside Medicine | Spring Issue 2018

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Before Hayfever Goes Haywire by Jarrod Roussel, PA-C

It’s that time of year again. The sun peeks over the horizon a little earlier. The birds sing a little louder. The temperature is a bit warmer to the point that you dare to cast off pants in favor of shorts. Coffee in your favorite mug even just seems to taste better.

That’s right - it’s spring! 32

Inside Medicine | Spring Issue 2018


This morning starts like every other morning, however, something is different, a little off. You can’t place your finger on it, but you just know it’s there. Peering out the window, you catch a glimpse, and then you realize why. There is a yellowish-green haze that blankets everything as far as the eye can see. And then it happens, “ACHOO!” Allergy season has descended upon you just like the pollen on the hood of your car. You know that a trip to the pharmacy or your doctor’s office seems eminent, but you want to try something natural to ward off the sneezing, running nose, and watery eyes. You begin to wonder if there’s something that fits the bill. I have great news for you. The answer is, “yes!” Here is a list of a few oils, herbs, and supplements that have been shown through many years of use, and even clinical studies, to be helpful with seasonal allergies.

Peppermint

Using peppermint essential oil in a diffuser is very helpful to open the airways, act as an expectorant, and numb sore throats. If you don’t have a diffuser, you could simple place a few drops on a cotton ball and breathe in a few whiffs that way. You can mix a drop or two of the oil with a carrier oil, such as almond, coconut, or rosehip, and rub it directly onto your chest. Peppermint oil has been clinically shown to have airway opening properties in animal model studies. I have personally found this one to be very beneficial.

Eucalyptus

Eucalyptus essential oil has similar benefits to that of peppermint essential oil, although, there are different compounds found in each. It has been shown to have anti-inflammatory and antispasmodic activity within the airway. It can be mixed and applied just like peppermint oil.

Boswellia

Boswellia is known to be a natural anti-inflammatory with properties that can inhibit airway congestion. It is reported to inhibit leukotriene formation ; it works similarly to the popular asthma and allergy medication montelukast. It has numerous other reported health benefits as well. My wife and I have personally used boswellia with great success for inflammation and pain. It is important to note that boswellia can also thin your blood like aspirin so you should consult with your PCP if you are on blood thinners. Boswellia is available as a powdered herb in a capsule. For dosage recommendations, consult the directions on the packaging.

Stinging nettle

Stinging nettle may sound familiar if you ever spend any time in the woods. The herb that packs quite an annoying sting

if brushed across your skin also has histamine blocking properties as well as blocking other pro-inflammatory enzyme activity . It is available as a loose powder, in capsule form, or as a tea.

Mullein

Mullein is an herb native to Europe from which a tea can be made. It is shown to have potent anti-inflammatory activity thus easing symptoms associated with seasonal allergies. Mullein is also touted as an expectorant.

Magnesium

This is a mineral that is necessary within the human body for over 300 biochemical reactions. It plays an important role in normal nerve and muscle cell function, helps to maintain strong bones, and assists in the regulation of blood sugar just to name a few. Increasing our intake of magnesium may help to reduce airway overreaction to allergens Magnesium deficiency can actually exacerbate the release of histamines by mast cells, which are part of the white blood cells that deal with our allergic responses. A large portion of the population in general is deficient in magnesium to some degree. You can purchase it as a supplement from your preferred vitamin supplier. Generally, 400mg of magnesium per day is recommended per current guidelines.

Quercetin

This is a flavonoid found in many different natural foods such as fruits, vegetables, leafy greens, berries, and grains. Typically, it can be purchased in capsule form from your vitamin supplier. Clinical studies on animal models showed significant decrease in the level of histamines in the blood stream when taking Quercetin.

Local Raw Honey

The principle behind this remedy is believed that it works like allergy injections such that your body is exposed to local pollens. Your body then becomes desensitized to those pollens. One short-term study showed no effect, but studies with higher dose exposures over a course of eight weeks showed significant reduction in allergy symptoms. Honey has also been shown to contain quercetin, which may add to the therapeutic effect. Now, anything that works to support your immune system can also help with your allergies since allergies are an overactive response to substances in the environment that are otherwise harmless. Inside Medicine | Spring Issue 2018

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...cont’d from page 33

So there you have it! We have only scratched the surface of potential ways to naturally treat your seasonal allergies, and these just happen to be some of our favorites. The next time springtime hits and you start to feel that familiar twinge in your nose, like a sneeze about to sneak attack you, reach for your favorite remedy. Never fear the pollen again! For more information on feeling better and living longer, be sure to tune into www.thecrunchycouple.com *As always, consult with your primary healthcare provider before starting these or any other natural remedies, especially if you take medications or have a history of any medical conditions. Remember that herbs can potentially cross react with medications. Never stop a medication or take a medication in any manner other than prescribed without consulting your doctor, PA, or NP. If you have a serious or life-threatening allergic reaction, seek immediate medical attention. Jarrod Roussel, PA-C is Co-founder of The Crunchy Couple, LLC www.crunchycouple.com Reference: 1. J Ethnopharmacol. 2011 Oct 11;137(3):1528-32 2. J Nat Prod. 2002 Dec;65(12):1939-41 3. Adv Exp Med Biol. 2016;928:291-327 4. Phytother Res. 2009 Jul;23(7):920-6 5. Phytother Res. 2012 Nov;26(11):1681-7 6. Lancet. 1994 Aug 6;344(8919):357-6 7. J Allergy Clin Immunol. 2005 Jan;115(1):171-8

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}MISSIONS } MISSIONS

JESUS IS OUR by Steve Smith

Match

We hosted a “Be the Match” bone marrow drive at the church where I serve. One of our members is an amazing young man who is a great husband, father, and friend and in need of a bone marrow transplant. On the day of the drive, the church stepped up, and many from the community came and swabbed their cheeks and agreed to be a bone marrow donor if they “matched” this young man or anyone else who might need a transplant in the future. The turnout was amazing. We were told that most drives are only able to add about 25 potential bone marrow donors to the world wide registry. We had 175 people added to the registry that day. Praise the Lord!

For Christ also suffered once for sins, the righteous for the unrighteous, that he might bring us to God… 1 Peter 3:18 As I sat there welcoming people as they came in and went through this process, God was working on my heart. I was reminded of something…every one of us needs someone to be our “match.” We have all been diagnosed with the terminal disease called SIN. Romans 3 reminds us that the “Wages of sin is death.” Our hope for a cure is NOT found in trying harder, it is NOT found in being better than the other people around us, it is NOT found in doing more good than bad, or having a more positive mental attitude. Our only hope is for someone to step in to donate to us, someone who has not been infected by the same SIN disease. Romans 3:10, however, gives us some pretty grim news “there are none who are righteous, not even one.” No match is available for us. Swab every person on planet earth and there would still be no match for us. We are hopeless for a cure and unable to save ourselves. UNTIL God decided to do for us what we could not do for ourselves. Enter Jesus Christ. Emmanuel. God “with” us. He is the only One in the history of the world not corrupted by SIN. Every thought he had was in tune with God’s. Every decision he made…right. Every temptation (and he was tempted in every way like every one of us are

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tempted) never led him once to giving in or giving up. Yes, he was God’s son, yes He was divine but He emptied himself of all of that and took on flesh and experienced everything we experienced with ONE gigantic difference. He NEVER sinned. Never. When He saw our condition, when He saw our hopelessness, when he saw that there were no matches to be found…He “swabbed” himself on the cross and became THE blood donor for all of us. When we unite with Him…the sin that infected us is CURED. The disease called “SIN” that threatened our lives…gone. But Jesus takes it a step further…he doesn’t just cure our sin problem…He gives His perfect righteousness to us. Paul says it this way, “God made him who knew no sin to be sin for us that we might become the righteousness of God in him.” Thank you Jesus! The young man we hosted the drive for and his extended family were all at the drive the entire day. They thanked every person that came in. They hugged the necks of strangers who came to support them. To put it mildly, it was an emotional day. That got my mind racing some more. How do you thank someone who is willing to do whatever they can to possibly save your life? Great question. That is really our question too, isn’t it? How do we thank God for allowing His only Son to “be our match” and sacrifice so much for us? • We thank Him every day. • We remember what He did every day. • We cherish the new life that we have and make the most of it. • We point others to the cure that we have found. Steve Smith, Pulpit Minister Beltline Church of Christ 2159 Beltline Rd SW, Decatur, AL 35601 256-353-1876 www.beltlinechurchofchrist.org


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} FEATURE

IS THE CUSTOMER ALWAYS RIGHT?

by Tiernan O’Neill

Health care will always be a service that is provided to the public. As such, we must not forget that health care is a customer service business. Delivering quality customer service is essential in the health care industry whether it is a facility or clinic looking to increase their market share or other providers simply maintaining their standing within the community. With this, medical personnel are ultimately confronted with the concept “The Customer is Always Right.”

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This old adage seems to have become old, tired, and no longer applicable. I am seeing this as I work in the current climate of health care, having worked in other traditional customer service industries before my career in health care, as well as having professional and personal contacts who continue to work in traditional customer service roles. The topic of the customer ultimately being right fills many of our work conversations. Many people have come to this position recently. I believe it can stem from the appalling disrespect and civility which seems to have grown in recent years throughout the public arena. This includes the anonymous troll on the internet, the partisan and demagoguery nature of our politics, and even the clever weasel who has figured out the squeaky wheel gets the grease in most commerce situations. There has clearly been a break down of appropriate and respectful dialogue in society whether it be in this country or another. Ultimately, it is not enough to just point fingers to the other side when you try to prove the customer is not always right. A better way would be to focus on the principles and virtues of the side of the health care worker which makes them above being wrong in most typical situations. We will start with the provider. We must agree and understand they are trained professionals. They have dedicated hours, years, finances and lifetimes towards practicing the skill and their profession. Their educational base and attention to all of the information available on medical subjects nearly makes them beyond reproach on medical decision making. As well, I can speak from a position of familiarity that I have observed nearly all of these professionals possessing a care and concern for others that is not commonly found in all people. Therefore, when patients believe they know better because of suspect articles they have read online in their spare time or have interests of pure self-motivation, it would be near possible to see how they (the patient) can possibly be right. After the provider, the various support staff within the medical community need to be observed. This would include all of the nurses, technicians, medical assistants and so on who help the doctor deliver health care in the best way they see fit. Often, these staff and support members are also viewed with a skepticism that does not best acknowledge their education or skill sets as authorities on health care. Lastly, we cannot forget all of the administrative positions, clerical staff, and various other support staff that assist in health care. While they might not have all of the same qualities and wisdom the provider has, in many cases, they have at least dedicated the time towards their profession. For example, when a patient is dissatisfied or disagrees with how a prescription or insurance claim is handled, the argument which ensues is really nonsensical considering the patient has limited experience with the situation, whereas the staff in question do this sort of thing day in and day out throughout countless days, weeks, and years.

All the above mentioned health care professionals would likely (and probably rightfully) ignore and discount the notion the customer is always right. They are using their time, skills, and aptitude of their chosen profession, not to mention wisdom and years of experience, to deliver health care as they best see fit. To be met with and possibly influenced by constant objections and arguments that would delay or derail their mission based on the flippant notion of customer satisfaction would be the very definition of negligence and malpractice. However, it would still be rather foolish to completely discount, ignore, or marginalize the “customer” in these situations. Patients are not simple drones who must adhere to orders, to take services and medications they either disagree with or have yet to understand. Of course there is a place for them to question, debate, and participate in the decision making of their health care. You must also always allow for the possibility of mistakes and oversight in the jobs of the professionals and authorities as we have deemed them. As well, patients should always voice their concern or report any member of a medical team’s staff who seems to fail at the lofty objectives that are the purpose of their occupations. When finally deciding if the customer is always right, it should be well understood at this point that granting the stance of “always” would be completely misguided. Whether it be in favor of the patient, customer, or professional, “always” is a big word. Rather then, the customer/patient should always have a say in the care and treatment they receive, but it would also be expected they approach and coordinate with the professionals in the way they best see fit. The sheer sample size of their knowledge base and dedication of those individuals in health care should be respected and taken into consideration. As in any business setting, the customer can vote with their dollars and feet to best show their dissatisfaction by choosing other health care providers or facilities. This can easily be accomplished without shouting or crying about an outdated or inapplicable cliché.

Inside Medicine | Spring Issue 2018

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Diabetic Nerve Pain

Prevention and Treatment Alternatives by Jackie Makowski

The prevalence of diabetes is growing at an epidemic rate. More than 30 million Americans have diabetes and experience its associated long-term complications.

Diabetic neuropathy is one of the most common complications of both type 1 and type 2 diabetes and affects half of the diabetic population. Diabetic neuropathy is nerve damage caused by diabetes. Over time elevated blood sugar levels can cause damage to the nerves in the hands and feet. This can result in numbness and tingling as well as burning, sharp or aching nerve pain. Patients also describe diabetic nerve pain as shooting pain, sensation of pins and needles, throbbing or radiating pain or a stinging, shock-like sensation. Symptoms are usually mild initially but can worsen over time spreading up the effected extremities. These complications can affect mobility in many patients. Walking can be excruciating and even light touch can be unbearable. Diabetic nerve pain can also affect the ability to sleep, decrease the quality of life and increase the risk of depression.

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“Diabetic nerve pain, or polyneuropathy, is multifaceted and can cause debilitating extremity pain or total loss of sensation substantially decreasing a patient’s quality of life,” said Dr. Morris Scherlis, Anesthesiology & Pain Management physician with Tennessee Valley Pain Consultants. “Developing a comprehensive treatment plan is important for not only treating neuropathic pain but preventing further nerve damage.” Nerve pain is more prevalent in people who have had diabetes for several years especially in those whose blood sugar is not controlled effectively. Patients experiencing painful neuropathy often decrease exercise and physical activity which are key components to increasing circulation and preventing additional damage. Unfortunately, nerve damage cannot be reversed but prevention can help reduce decline of symptoms.


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Inside Medicine | Spring Issue 2018

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Diabetic Nerve Pain Symptoms: • Shooting Pain • Burning Sensation in Hands or Feet • Pins and Needles sensation • Numbness or Tingling • Throbbing or Radiating Pain • Stinging or shock-like feeling

Prevention

There are many ways to prevent or delay nerve damage including blood sugar control, physical activity and annual foot exams.

Controlling blood sugar so damage does not progress

Uncontrolled or fluctuating blood sugar levels can cause nerve damage. The American Diabetes Association recommends A1C levels tested twice a year and a goal of 7% or lower.

Diet and exercise help decrease blood sugar to a healthier range

Regular exercise has been shown to help manage A1C levels over time. Diet is a critical component in managing blood sugar levels. Eating lean proteins, fruits and vegetables while cutting carbohydrates is a good way to reduce blood sugar levels. It is also important to monitor health risks that can worsen diabetes such as weight gain and smoking.

Annual foot exam for wound prevention

The American Diabetes Association recommends physicians perform annual diabetic foot exams. This includes assessing feet for health of skin, muscles, circulation and sensation. Some patients with diabetic neuropathy will not experience pain but rather will lose feeling in their feet. This can cause complications if a foot injury occurs and is left untreated.

Developing a Treatment Plan

The decline in overall quality of life can be debilitating when daily activities are impacted by diabetic pain. There are options for treating diabetic neuropathy which include prescription nerve medication and non-steroidal nerve blocks.

First line medications for pain relief include anticonvulsants, such as pregabalin and gabapentin and antidepressants, especially those that act to inhibit the reuptake of serotonin and noradrenaline. Medications such as gabapentin can relieve pain and reduce burning, numbness and tingling. These medications work by calming damaged or overactive nerves that cause diabetic nerve pain. Medication is only part of the treatment plan. Diet, exercise and healthy lifestyle choices assist in the reduction of diabetic nerve pain.

Non-steroidal nerve blocks

A non-steroidal lumbar sympathetic block can also provide significant relief for patients with advanced nerve pain especially in the feet. The sympathetic nerves are located on both sides of the lumbar spine. Pain signals travel to the brain via the sympathetic nerve. A mixture of anesthetic, saline and anti-inflammatory medication is injected into or around the sympathetic nerves to disrupt pain signals thus reducing pain. Lumbar Sympathetic Blocks are performed in an outpatient setting and assist patients who have moderate to severe pain. The goal of nerve blocks is to increase quality of life through reduction of pain allowing patients to resume previously limited activity. "Sympathetic nerve blocks can be helpful in a comprehensive pain management plan for diabetic polyneuropathy,” said Dr. John Roberts, Anesthesiology & Pain Management physician with Tennessee Valley Pain Consultants. “Numbing medicine and steroids injected can have a powerful effect to decease painful impulses resulting from injured nerves from diabetes that can last several months and provide lasting pain reduction and improvements in quality of life." The double board-certified Anesthesiology and Pain Management physicians at Tennessee Valley Pain Consultants, Drs. Ronald Collins, Morris Scherlis, Roddie Gantt, John Roberts and Thomas Kraus, treat patients with diabetic nerve pain. Visit tnvalleypain.com to learn more about pain relieving procedures or to request an appointment.

Lumbar Sympathetic Block Diabetic nerve pain signals travel to the brain via the sympathetic nerve. A lumbar sympathetic block disrupts pain signals at point of injection.

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The Road to Pain Relief Starts Here. Precise Pain Relief for: Back & Neck Pain Nerve Pain and Sciatica Knee and Hip Pain Shoulder Pain Discogenic and Radicular Pain Shingles Pain Cancer Pain

Non-Surgical Solutions to Restore your Active LIfestyle.

Team of Double-Board Certified Anesthesiology & Pain Management Physicians Ronald Collins, M.D. Morris Scherlis, M.D. Roddie Gantt, M.D. John Roberts, M.D. Thomas Kraus, D.O.

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256.265.PAIN (7246) Inside Medicine | Spring Issue 2018

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Pediatric

Endocrinology A physician’s homecoming benefits children with diabetes by Steve Doyle

Guntersville native Linnea Larson-Williams, MD, has returned to North Alabama to practice medicine, and that’s a very good thing for families raising children with diabetes in our community.

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Last August, Dr. Larson-Williams opened Huntsville Hospital Pediatric Endocrinology, the area’s only medical practice for children with Type 1 and Type 2 diabetes, abnormal thyroid or adrenal glands, and other endocrine system problems. Her arrival means local children with diabetes and their parents will no longer have to travel 180 miles round trip to Birmingham or Nashville to see a pediatric endocrinologist. Melissa Nevitt’s 10-year-old daughter, Ainsley Faith, is one of those young patients. When the family moved to Huntsville in 2016, they were disappointed by the absence of pediatric endocrinologists. They seriously considered driving back and forth to Mobile for care before finding a childhood diabetes specialist at Children’s Hospital in Birmingham. When Dr. Larson-Williams came to Huntsville, they were relieved to have a local specialist. “Having Dr. Larson-Williams nearby is going to be great for kids with diabetes in North Alabama,” Nevitt said. “And there are a lot of them.” Dr. Larson-Williams, who graduated from UAB School of Medicine and completed her residency training in Birmingham, said she is thrilled to bring pediatric endocrinology to the Rocket City. “It’s going to be much more convenient for families,” she said. “People will no longer have to drive to UAB or Vanderbilt for quality care.” Type 1 diabetes is an autoimmune disease that causes the pancreas to stop producing insulin, a hormone that allows people to convert food into energy. It usually strikes suddenly in childhood or adolescence, and those who have it must take synthetic insulin through daily injections or infused through a pump. In Type 2 diabetes, the body does not use insulin properly – a condition known as insulin resistance. Over time, the pancreas can’t produce enough insulin to keep blood glucose levels normal. This type of diabetes is treated with lifestyle changes, oral medications and insulin. Dr. Larson-Williams will care


} FEATURE

for children with both Type 1 and Type 2 diabetes. The Juvenile Diabetes Research Foundation estimates 200,000 young people in the U.S. are living with Type 1 diabetes. Failure to properly manage the disease can lead to a slew of complications including kidney failure, blindness, nerve damage, heart attack and stroke. The daughter of a family physician from Marshall County, Dr. Larson-Williams completed a three-year pediatric endocrinology fellowship at UAB. Before moving back to North Alabama, she spent two years as an assistant professor of pediatrics at the Medical College of Georgia in Augusta. She is board certified in general pediatrics as well as pediatric endocrinology. “My husband and I have talked for a long time about coming back to North Alabama to raise our children, and we’re so grateful this opportunity came along,” said Dr. Larson-Williams. “Because I grew up in the area, I already have a vested interest in the community and in the health of its children.” Huntsville Hospital Pediatric Endocrinology 401 Lowell Drive, Suite 5 Huntsville, AL 35801 256-265-3250

Dr. Linnea Larson-William takes a stroll with 10-year-old Ainsley Faith Nevitt on the Huntsville Hospital campus.

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Inside Medicine | Spring Issue 2018

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} TESTIMONIAL

The Faceless

Soldier by, Kari Kingsley, MSN, CRNP

Recognizing those whose identity can’t always be shared.

Settling snugly into my bed with its memory foam mattress and fleece blanket, I gently lay my head on my orthopedic pillow and listen to the hum of my air purifier. My 3-year-old tabby cat, Moxie, is curled around my ankles and a cool air diffuser lightly mists the room with an essential oil blend touting “stress relief”. After an appropriate 15 minutes silently reenacting and pontificating the days stressful events and anxieties in my life, I smoothly drift into a deep and restful sleep. Now, this opening paragraph reads like the diary of a very spoiled young woman; but the attempt is to set the stage for the stark contrast to the lives (and bedtime routines) of the men and women sworn to protect our country so that we can take for granted just how great we really have it.

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I recently approached an Army Ranger with 10 years of combat experience and asked him to discuss his story. Having known him briefly, I was already aware he had sustained several life-threatening injuries over the course of his service. The nature of his profession prevents us from knowing his real name. For the purpose of telling his story, we’ll call him Sam… (perhaps a Freudian slip in reference to Uncle Sam). Sam began his military career in 2007. He is quick to acknowledge his reasons for joining are not necessarily the reasons that drive him today. After falling in with a “bad crowd” forcing him to hustle to make ends meet, he left his home country of Puerto Rico and moved to the United States to enlist in the military. With English as his second language, Sam admits that his bilingual shortcomings actually served to help promote his career. He passed verbal aptitude tests that most Americans failed because it took him a split second longer to discern the meaning of the actual words rather than rushing to solve timed puzzles presented to test ingenuity. Say the word “RED”….. Now spell it….. R-E-D….. Now say it 5 times.............RED. RED. RED. RED. RED. Spell it................ R-E-D. Say it........RED........ Now, what do you do at a green light? YOU STOP. Or, at least, that’s what I said when Sam asked me. Oops. Green light. Go. My excellent understanding of the English vernacular and need to answer his question as quickly and efficiently as possible made me stumble. Several more brain teasers convinced me that I was interviewing no lightweight. Sam jokes that while in basic training, an Army Ranger recruitment group visited his platoon asking, “Who wants to join Ranger School?” Sam was the only one in the room who raised his hand. All eyes immediately locked on his. Power Rangers looked like such a cool vocation on TV, who wouldn’t want to join? Some words just don’t translate outright. Although Sam didn’t know exactly what he had signed on for, he didn’t look back. After months of parachute jumps, rappelling off of skyscraper sized towers, survival training consisting of eating bugs… or not eating at all, daily physical training, and mental acuity testing, all while being expected to operate effectively under extreme mental and physical stress, Sam was deemed fit to serve as an Army Ranger. Similarly, Sam raised his hand for SERE training: Survival, Evasion, Resistance, and Escape. He was hoping for a raise, but to his disappointment, it was only more torture school. And again, Sam volunteered for level 3 Army Combative School. He jokes that, in his mind, he pictured himself as Chuck Norris, standing over his aggressors with a smirk on his face. Reality usually had him lying on the floor….. bleeding. Assignments sent him to Afghanistan, Korea, Kuwait, Spain, Germany, and Africa, (that he can confirm anyway). Sam’s first major injury came in 2007. Sam was required to engage the enemy in close combat quarters when a “bogie” got the jump on him. A 6-inch blade (likely a homemade shank) was thrust deep into his right forearm just between the ulna and radius. To save his life, Sam used his biceps muscle

to pull his assailant away, breaking his own ulna and radium in the process. Sam recalls very little after the Medivac arrived and airlifted him back to the forward operating base in Afghanistan. He was given several ampules of morphine and recalls hearing the Smashing Pumpkins play The World is a Vampire on the flight and eating peanut M&Ms. With local anesthesia, (meaning twilight sedation but not fully under), a metal rod was inserted with 4 titanium screws placed in his forearm and 26 stitches placed to put him back together. He told me that doctors told him his bones grew so fast that removal wouldn’t be an option. Six months later, Sam was back in action and ready to save the world. The second major injury occurred in 2009 when Sam was shot in the right upper thoracic area with an AR15 5.56 round. Sam was fortunate enough to have his ceramic body armor in place but unlucky enough to sustain a right pneumothorax with bruising covering most of his upper torso. Sam states that he felt like he was on fire. He jokingly quotes the movie, Talladega nights, in which Ricky Bobby thought he was on fire and insisted on stripping down to his tidy whiteys and running around telling his crew-mates he was on fire. Apparently, that happened; leaving his comrades to give him all kinds of nicknames. Talladega, Salsa-verde, and Sriracha. After his injury he was sent to Kuwait and later to Germany for his recovery. Again, 4 months later, Sam was back on the front lines. Later in 2009, Sam was traveling in an Army convoy to Kabul, Afghanistan when a daisy chain IED exploded underneath their vehicle (which ironically was a MRAP- Mine-Resistant Ambush Protected vehicle specifically designed to ((in theory)) withstand explosive devises) sending a piece of shrapnel into Sam’s right groin, nicking his femoral artery. Not realizing the implications, Sam dislodged the shrapnel from his upper thigh, further potentiating the bleeding. Sam Inside Medicine | Spring Issue 2018

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was in a dangerous situation as rapid blood loss depleted vital organs of necessary oxygen perfusion, a condition known as hypovolemic or hemorrhagic shock. Sam received 3 units of blood, in addition to plasma, platelets and other clotting products within minutes through as a Level 1 Rapid Infuser sending 1100mL/min of warmed blood back in to his exsanguinating body. Sam has permanent varicose veins on his lower extremities following the rapid transfusions. He told me had no idea that blood coagulated so quickly, but recalls squeezing one of the medical sponges lying near his hand and clots forming on the bedsheets. He was told multiple times by surgeons and medical staff that he was lucky to be alive. Sam’s most recent injury came in 2016 when he was hit in the right eyebrow causing bruising and a small facial laceration when he was hit with the butt of an enemy assailant’s AK 47. He recalls being dizzy but being able to reengage and neutralize his opponent. I asked Sam several questions about his life and mindset involving his experiences. Humbling to say the least. How do you feel about risking your life? – “Everyone risks their life every day. Whether it’s driving a car or crossing enemy lines. To me, what makes life is living every moment. The good and the bad. When you feel pain, it’s good. You know you’re still alive.” How do you feel about taking a life? – “I’m defending what’s important. Important to me. Important to those like me.” Tell me about the first time you took a life. – “I was in Afghanistan. We try to honor our enemies in death. We wrap their bodies and they go through mortuary affairs. They are then placed in green zone for their loved ones to retrieve. I waited 4 hours to see who came. I watched a woman drop to her knees when she approached his body.” Sam’s story trailed off after saying this. How hard is it to transition to and from the civilian world after deployment? – I have a rule that I don’t drive my first day back. Looking around at everyone and seeing them having a normal life…. Arguing with a sales clerk at Wal-Mart…. Drinking cappuccino at Starbucks and talking about their previous night’s events… Everything is perspective. Small problems are big to some people. And vice versa. Once back in the states, I always go to a local brewery and order a local beer. I drink all but the last sip and leave the rest for the fallen. I always go to a Chik-fil-A and order a Spicy Deluxe Chicken Sandwich. I sit there and eat it and watch the people converse and think, ‘you’re welcome’.” Sam is not a braggadocios or arrogant person. He said “you’re welcome” in the most non-condescending or resentful way. He genuinely means, “you are welcome”. Sam is unassuming, somewhat hesitant to talk, and carefully chooses his words. He tells his story in a humble and sometimes jokingly self-deprecating way. He has a casual almost non-acknowledgement of past events. What was

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your worst night’s sleep you ever had? “The worst night’s sleep came sleeping in a building where my enemies lay dead. The emotional and physical exhaustion of the day’s events unfolding in my head.” As he told me this, my mind briefly flashed to my comfy bed with oversized comforter and fluffy Tabby cat. Night and day, it would seem. Sam wears a bracelet in honor of a dear friend that died in his arms during combat. Although he is reluctant to share details of this event, the mental burdens he carries is palpable in the room as he tells his story. Ironically, all of the injuries he has sustained have been on the right side; his bracelet is worn on his right arm, just below his forearm scar, silently signifying his mental, not only physical injuries. While the reasons Sam joined the armed forces are no longer the reasons that drive him, he has a deep appreciation and bond with his fellow soldiers. My last question to Sam was: What keeps you going when you want to quit? He told me, “Three things: Comradery, brotherhood, and the support I have back home. And when he says the support back home, he means the support of his friends, family and those that love him. They are able to accept him for who his is and what he does. He feels that the less people know about him and the cause he serves, the better. Not only for him but for the bigger picture at large. Sometimes as a writer, it becomes difficult to differentiate subjectivity from objectivity. While most


nonfiction writers strive for fair and impartial journalism, chronicling a story like Sam’s becomes difficult because of the deep visceral response it elicits. Hearing first hand an Army Ranger’s courageous stories and near-death experiences make it particularly difficult to remain unbiased and prepossessed. A brief glimpse through the eyes of an active combat soldier leaves a mark on your soul. As a thank-you, I gave Sam a small Saint Christopher medallion. Saint Christopher is the guardian saint of travelers. It seemed appropriate to bestow a small token of appreciation for this man who risks so much to travel the world to protect us from those that wish to harm us. I later received a text picture from an undisclosed location of the charm, covered in sand, but hopefully doing its job to protect one of America’s 1% elite. Our military veterans are honored with one holiday a year. Veteran’s Day. They honor us for a full 365 days. Sam has changed many lives for the better; mostly by protecting people that will never know his actions. I feel very fortunate to lay my head down at night, and be complacent….. to worry about relatively small non-life-or-death things and sleep soundly. Thanks to men and women like Sam, we all can.

In memory and forever grateful

to our military.

“Kari Kingsley, MSN, CRNP is an otolaryngology nurse practitioner with over 8 years of ENT experience who currently works at Huntsville ENT (256-882-0165). She is a medical writing consultant for Inside Medicine and enjoys writing articles on pertinent material to keep the residents of North Alabama up to date on the forefront of medicine.” Inside Medicine | Spring Issue 2018

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} TESTIMONIAL

UNITY in Worship by Ben Murray

Corporate worship is one of the most enriching aspects of the Christian life. In moments of corporate worship one may be encouraged, healed, delivered, forgiven, or simply reminded of God’s grace and mercy. That is because God shows up in a powerful way when His children come together in His name. Please understand that God can also do wonderful things during your time of private worship when it’s just you and God. So what’s the difference? UNITY with other believers!

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Corporate worship is one of the most enriching aspects of the Christian life. In moments of corporate worship one may be encouraged, healed, delivered, forgiven, or simply reminded of God’s grace and mercy. That is because God shows up in a powerful way when His children come together in His name. Please understand that God can also do wonderful things during your time of private worship when it’s just you and God. So what’s the difference? UNITY with other believers! One of the things that makes Daystar Church unique is that there are worshippers from every denominational background. We’re like one big melting pot. It is wonderful to see Lutherans, Methodists, Catholics, former Atheists, Baptists, Nazarenes, and Pentecostals worshipping the same God under one roof. However, one of the challenges within congregational worship at Daystar Church is that there are worshippers from every denominational background. If we are not careful we could allow traditions to prevent us from engaging in unified worship. One person may be outwardly expressive in their worship (shouting, clapping, and lifting hands, dancing) while another may internalize the moment with God (hands folded, standing still). Unity in worship is not measured by whether everyone is expressing their love of God in the same manner. The most important matter isn’t how you express your love to God, but it’s the posture of your heart. 2 Chronicles 5:11-14 offers us an inside look into what happens when we worship in UNITY. Take a moment to read that scripture from your Bible. Here are some key factors for unity in worship. First, give thanks to God. One of the best ways to start your worship experience is to honor God for all of His goodness in your life. We often say thanks, but we seldom acknowledge the individual blessings that he's given us. When is the last time you thanked God for your eye-

balls, your vehicle, and your lungs? You can name stuff for a lifetime, but it's not for God's benefit, it's for yours. Thanking God reminds us of his goodness to us. Sometimes giving a general thanks is interpreted as, "Thanks for Nothing." Secondly, purify yourself. We know that sin and impurity separates us from God. When you come before God in worship, either publicly or privately, search your heart and ask the Holy Spirit to shine His light on anything that doesn’t belong in your life. When He shows you these things, it is up to you to repent and purify yourself. Third, Worship TOGETHER. The scripture says they, “performed together.” One may be distracted when there are hundreds of people around. Unity in worship require focus. Choose not to be consumed with the days plans, the roast in the crockpot, or the man singing off key nearby. We believe that worship is love expressed God’s way. Some common ways we can corporately express worship to God are singing, clapping, bowing on our knees, shouting, lifting our hands, and posturing our heart in submission to God. Be a participator in the worship experience. Finally, corporate praise invokes God’s presence. The result of unity in worship is the presence of God. Did you notice in the scripture how they raised their voices and praised God with a song? They did not raise their voice in protest. They did not raise their voice to be heard. They didn't cause division with their voices. They didn't gossip with their voices. Their goal was very simple - to praise the Lord. Zach Neese of Gateway Worship in Southlake, TX, says, “Praise has a purpose. Praise is to acknowledge or declare what God has done, what God is doing, and what God will do. Praise is birthed out of an experience and is grounded in expectancy. Praise affects what we see. Praise sets things in motion. Praise is a weapon...someone has to pull the trigger. That person is you.” When we worship together in unity, the presence of God shows up.

Ben Murray is the campus pastor of Daystar Church in Madison. Daystar Church meets at Horizon Elementary School on Sundays at 10:30 am. Visit Daystar Church online at www.daystarchurch.tv.

Inside Medicine | Spring Issue 2018

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NOTHING CAN KEEP HIM DOWN

Meet Tom Phillips! Tom is an 84 year old guy with so much spunk in him it is contagious! You can just feel his love of life in his voice. He enjoys being active and keeping healthy. This poor guy started having what he calls, “severe knee pain”. He described it as a “bone on bone” type situation that was extremely painful. It became so bad it made it difficult to walk. Before seeking any medical advice, Tom tried all kinds of pain relievers, ice packs, gels, and even his own physical therapy. He was getting no relief and finally succumbed to going to see a professional. As soon as he hobbled into the doctor’s office, he had a diagnosis and he was not surprised, at all! First, they tried injections but they did not help enough to keep Mr. Phillips’ active lifestyle. So, the doctor recommended a total knee replacement surgery to cure his ailments. Dr. Eric Janssen, orthopaedic surgeon at SportsMED, Lee Warlick, DPT and Nathan Crawford, PTA have been a life saver for Mr. Phillips. Two weeks after total knee replacement surgery, Mr. Phillips was back on his feet. Within four weeks, he was out walking his dog to the park and enjoying life again. Mr. Tom Phillips is a remarkable success story. Nothing can keep him down and it’s exciting and encouraging to see how well he is doing! We wish him nothing but FUN in the future!

Kombucha

Take a stroll in any major grocery store, and your bound to come across some tasty ‘boock in a variety of flavors. Many are now discovering the benefits of this “elixir of life” health beverage. But, what is Kombucha? Kombucha is a fermented sweet tea beverage with a S.C.O.B.Y. (symbiotic colony of bacteria and yeast) or also known as, “The Mother” the magic ingredient! The fermentation process metabolizes the sugars and caffeine. It’s believed that Kombucha tea provides healthy bacteria (probiotics), micronutrients (including all the B vitamins), enzymes, antioxidants and organic acids. These elements combine to make Kombucha, a health promoting beverage that can be helpful for improving digestion, detoxification, immunity, weight loss, appetite control and balancing the pH of the body. Kombucha acts as an adaptogen, meaning it doesn’t cure anything, but rather help your body react to any stress. Adaptogens help balance, restore and protect the body. Fermentation has been around for thousands of years. Cultures all over the world once relied on this food preserving technique. Once refrigeration was introduced, many Western diets lack a variety of fermented foods. Kombucha may sound like the next “trendy” health food, but the first known origin of Kombucha dates back to China 221 BC. Kombucha is a great alternative for sugary sodas, if you’re curious to try for yourself find Tribal Kombucha at The Juicery Press in Madison. Inside Medicine | Spring Issue 2018

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Tough Mudders:

Helping to Serve AHERO’s Purpose by Ashleigh McKenzie

When I was asked to write an article around the partnership between AHERO and Tough Mudder, my initial thought was, “Sure, why not?” As the deadline loomed, though, my thought changed to “Why did I think this was a good idea?” It was as if someone had asked me to climb Mt Kilimanjaro. I had a college degree and the experience of running a company; yet writing a small article became something difficult for me. How could I encourage others to face challenges to help others, if I myself could not overcome the fear of writing? Much of what I live for is to help others develop the skills to overcome moments of doubt, such as these. Now, after much soul-searching, I discovered that by writing the article I could share my heart as it really is and not as comfortable as it may seem. If comfort were the case, I would have simply submitted to the editors the pictures of our Mudders and their physical challenge of a 12-mile run tackling 20 obstacles in the mud. My surreal moment of “why” I do what I do began five years ago. Only a few weeks into my father’s retirement, I learned my hero had been diagnosed with cancer. My parents had envisioned their retirement for years. It would be filled with travel and enjoyment. Instead, this new chapter in life would involve treatment facilities, doctor appointments, and scans. According to his doctors, his condition could have been caused by the drinking water at Camp Lejune back during his basic training days. I found myself distraught that the selfless act of serving in the military could so negatively impact my father's life years later. There are two types of practical reactions to such circumstances: You decide to be either the caregiver or the provider. At this point, I was just learning how to cope myself. And while my professional career is in the medical field, it has nothing to do with the clinical side, and I felt I wouldn’t be a really good caretaker. That left me with “provider.” But how do you provide support, education, and awareness not only to your own family but to others affected by disease, loss, diagnosis and disabilities? I was lucky enough to find AHERO just then, as I was reaching my tipping point. I learned I could became tough for others in the middle of being the most mentally broken I had ever been. Partnering with AHERO has helped me and others bridge the gap and provide hope to those seeking help.

When you know your "why," your "what" finds its purpose. I am uncertain how I originally learned about the Tough Mudder, but when I realized the charitable benefits it could offer AHERO, the Mudder became my “what.” My “why” had begun with coping with my father’s cancer diagnosis. Now I was able to combine the two. Consider post-traumatic stress (PTS), which has unimaginable effects on how one responds to something that, to the average person, is emotionally manageable. In a few short years, AHERO has helped many who struggle with PTS and other conditions resulting from military service. AHERO’S relationship with Tough Mudder has grown through the running of 27 courses to-date, with more than 100 participants on the "Tough for AHERO" team! Running a Tough Mudder doesn’t necessarily have to do with being in tip-top shape. It doesn’t mean that you must train for months. But many feel that they can’t do it, much as I felt I couldn’t write this article for AHERO. Yet in writing this, I realized my mission is to reveal my passion through something that at first may have caused me anxiety, fear, and doubt, but ultimately opened my heart to motivate others to find their own purpose. Given a purpose, most anyone can achieve previously unimaginable goals. It takes perseverance to see the finish line. Yet the result of knowing your efforts are giving someone else needed support is greater than happiness. It is true JOY. Joy in purpose is something we all strive for, though it is sometimes hard to find. But have faith ... and just like the tiny mustard seed, it will grow, and continue to grow.

Ashleigh McKenzie is president of MDreferralPRO and is the national coordinator for Tough Mudder events that benefit AHERO. To learn more, visit AHEROusa.com

Inside Medicine | Spring Issue 2018

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Are you Being Diagnosed with the Wrong form of Diabetes? Adults Just as Susceptible to Develop T1D as a Child, Based on Recent Research Findings by Jennifer Jeffers

There appears to be a rising trend of the misdiagnosis of adult type 1 diabetics (T1D) not only across the U.S. but around the world. We are finding more and more stories of adults initially being diagnosed with type 2 simply because they are over the age of 30. As a matter of fact, we are now seeing cold-hard facts from researchers that T1D is no longer consider a child-based disease. Furthermore, research by the University of Exeter Medical School found that adults are as likely to develop type 1 diabetes as children, with more than 40 percent of T1D cases occurring after the age of 30.

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Now, one might say they know what the term diabetes means, but many do not understand the varying forms. More accurately many do not understand the difference between T1D and T2D. For those not aware, T1D was previously referred to as “juvenile diabetes”. It is an autoimmune disease in which the body’s own immune system sees the beta cells within the pancreas (which produces insulin) as the enemy and begins to kill off these cells until they are all gone. The pancreas no longer has the ability to produce insulin, a vital function to breaking down the food we ingest. Eventually, all T1D’s become what many refer to as “Insulin Dependent” and will die without this hormone. When you have type one diabetes the treatment regimen consists of multiple shots given daily (MDI) or with an insulin pump. A T1D must also must check their blood sugar levels by pricking their finger at least 8 to 10 times a day or more in some cases. Furthermore, there are countless trips to the doctor for checkups and multiple visits to the ER for the common cold or stomach bug that the average person can manage without medical intervention. In addition, by law, children with T1D must have a parent, nurse or caretaker with them to attend all school related functions including field trips, club meetings or sporting activities. Lastly, on top of all this, diabetics must watch and count carbs for everything they ingest. Determining the appropriate insulin amounts consists of a mathematical equation that even the best at math have trouble figuring out – it is just complicated being a T1D. All of this complexity is the reason why it is such a growing concern that adults are being diagnosed with the wrong form of diabetes and it is becoming a common trend. An example of someone wrongly diagnosed, was Prime Minister Theresa May, who initially was told she had T2D based on the fact she was in her in mid-50’s. May was initially given oral medication and told to watch her diet. After some time and little response to her blood sugar levels, doctors finally realized they were treating for the wrong form of diabetes. May is just one of the hundreds if not thousands of adults being misdiagnosed and understandably so. Not only are there many misconceptions about the disease, but a lot of doctors have been taught via their textbooks that T1D is a disease found during childhood. Its lead author Richard Oram, at the University of Exeter, said: "Diabetes textbooks for doctors say that type 1 diabetes is a childhood illness. But our study shows that it is prevalent throughout life. These miss-teachings can have serious and sometimes fatal consequences”. This is why publications such as Inside Medicine, play an integral role in the dissemination of accurate, and in some cases, life-saving, information throughout our community. One of the other reasons, which is no fault to anyone, is that both disease’s share the majority of the same symptoms: headaches, nausea, vomiting, frequent urination, extreme

thirst, wounds heal slowly, blurry vision, sleepiness, etc… Actually, one might think weight loss is just associated with T1D but in some cases, T2D’s do lose weight as well. So as you can see, it is easy to get the two confused. It’s important to understand the symptoms but there are a few signs to look for when you have been recently diagnosed with T2D: • Consistent vomiting for over two hours • Sharp stomach pains or upset belly • Breathe smells like fruit • Easily get weak, tired, confused, or dizzy • Trouble breathing While we may feel that our doctors should have the answer to everything they aren’t mind-readers. It is imperative for you to pay attention to your blood sugar levels and report them back to your doctor if you notice that the medical plan you are on is not working. It is also important to make sure you are answering questions from your doctor thoroughly and honestly as well as asking your own questions. Here are a few key things to ask yourself and discuss with your doctor if you have recently been diagnosed with T2D and have any concerns: • You are somewhat thin; • You are following the management plan and it’s not working; • You are taking multiple medications and having to increase the dose; • You or another family member has other autoimmune diseases. It is important to note that I am not a medical professional but have worked with JDRF, the world’s

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leader in diabetes research for close to 6 years and I am a type 2 diabetic myself, so I understand diabetes firsthand. I also have had several of our adult T1D’s recently mention that they were initially incorrectly diagnosed with T2D in which one almost lost their life. It was his story that prompted this article. If anything, use this information as a guide on what to look for and do your homework and hopefully, it may make you aware of something you might not have known about otherwise. More importantly, talk to your doctor. Don’t be afraid to question your own health provider. I can promise most doctors will be receptive if you do it in the right way. There is nothing wrong with you taking charge of your own health to ensure accurate diagnosis of any ailment.

Paying attention to your own symptoms, it just might save your life! Lastly, to help answer all your diabetes questions, JDRF is hosting our annual Walk on April 21, 2018 at 9 AM hosted at/by Redstone Federal Credit Union on Wynn Drive. We will have a vast array of diabetic-related providers on hand to answer all of your questions, including Huntsville Hospital’s Diabetes Center. In addition, we will have great kid’s activities, live entertainment and free food/beverages. There is no charge to attend this event but you must register under a Walk team, create your own team or register as an individual to participate-walk.jdrf.org/northlababama! We hope to see you there!

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Inside Medicine | Spring Issue 2018