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Whatever it takes. Advocate, MD understands what we are protecting.

We Fight For Our Customers Above All Else! Our core group of attorneys is highly specialized in the medical malpractice field and has a reputation for providing aggressive defense for our physicians. We take pride in promptly investigating , realistically evaluating, and expeditiously handling all incidents, claims and lawsuits. We provide unrivaled protection so that you can focus on protecting and serving your patients. It’s your money, your policy, your decision to fight or settle a case. Advocate, MD now offers Medical Defense Coverage with separate limits, no deductible and no co-insurance provision. Coverage includes: Medicare/Medicaid (CMS) billing and abuse, HIPAA / HITECH, EMTALA / Patient Anti-Dumping, Medical Associations, Subpoenas, Professionals Licensing Agencies, CLIA, ADA, OSHA, Billing Errors, Peer Reviews, Hospitals / Surgical Centers, Stark & Anti-Kickback, RAC Audits and Shadow Audits.

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Lucius M. Lampton, MD Editor D. Stanley Hartness, MD Richard D. deShazo, MD AssociAtE Editors Karen A. Evers MAnAging Editor PublicAtions coMMittEE Dwalia S. South, MD Chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD Leslie E. England, MD, Ex-Officio Myron W. Lockey, MD, Ex-Officio and the Editors thE AssociAtion Tim J. Alford, MD President Thomas E. Joiner, MD President-Elect J. Clay Hays, Jr., MD Secretary-Treasurer Lee Giffin, MD Speaker Geri Lee Weiland, MD Vice Speaker Charmain Kanosky Executive Director JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices. CORRESPONDENCE: JOURNAL MSMA, Managing Editor, Karen A. Evers, P.O. Box 2548, Ridgeland, MS 39158-2548, Ph.: (601) 853-6733, Fax: (601)853-6746, www.MSMAonline.com. SUBSCRIPTION RATE: $83.00 per annum; $96.00 per annum for foreign subscriptions; $7.00 per copy, $10.00 per foreign copy, as available. ADVERTISING RATES: furnished on request. Cristen Hemmins, Hemmins Hall, Inc. Advertising, P.O. Box 1112, Oxford, Mississippi 38655, Ph: (662) 236-1700, Fax: (662) 236-7011, email: cristenh@watervalley.net POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 391582548. The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association. Copyright© 2010, Mississippi State Medical Association.

AUGUSt 2010

VOlUMe 51

nUMBer 8

Scientific ArticleS

Blood lead levels in Mississippi children

206

clinical Problem-Solving: Off by a factor of eight

211

Robert D. Cox, MD, PhD; Patrick B. Kyle, PhD; Bruce Brackin; Teri Snazelle, MS and Joe Surkin

Edward B. Eldred, DO, MBA

SPeciAl ArticleS

Willard Boggan, MD: A Giant of Mississippi Medicine

214

Day 100 of the BP Oil Spill Disaster and Public Health in Mississippi

224

Philip L. Levin, MD

Karen A. Evers, Managing Editor

PreSiDent’S PAGe rising tides

217

Tim J. Alford, MD; MSMA President

eDitOriAlS

A trip to Boston: reflections on Battling the Obesity epidemic

219

the Perfect Storm: A clinical Vignette

220

Joanna Miller Storey, MD

C. Ron Cannon, MD

relAteD OrGAnizAtiOnS

Mississippi State Medical Association Alliance Mississippi State Department of Health University of Mississippi School of Medicine

231 232 234

DePArtMentS

letters new Members images in Mississippi Medicine Poetry in Medicine the Uncommon thread Placement/classified

222 230 236 237 238 239

ABOUt tHe cOVer:

“cOUntry cOMeS tO tOWn At tHe fArMerS’ centrAl MArket”—

VOL. LI

August

No. 8

2010

This image was captured at the original farmers’ market located by the railroad near the corner of Woodrow Wilson and West Streets in Jackson. Despite the opening of the new High Street farmers’ market downtown, the old market has hardly felt a hit. With more than three regular vendors and two wholesale businesses supplying restaurants, ample parking, and an authentic open-air atmosphere, this market has been open six-days-a-week for years. The regular stall operators are acquainted with their customers, and locals return to familiar faces. A Mississippi attraction since 1948, the Farmers’ Central Market retains its old style allure. Photo by Catherine H. (Cathy) Stroud, MD, a retired internist, avid photographer and community volunteer who resides in Madison County with her husband, Larry. r August

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Medical Medical A Assurance ssurance Company Company o off M Mississippi ississippi An outside perspective and appreciation of MACM

My possition on the American Board of Family Medicin ne’s credentials committee gives me new i i h and appreciation for the critical role that insight MACM plays in the lives of our state physicians. MACM’s involvement with its insureds — from risk management to liability and scope of practice issues — has their best interest, and that of the public they serve, at heart. Particularly at the level of the Risk Management Committee, many of these issues are handled constructively and effectively to improve and ensure quality care for patients, while guiding physicians from potential hazards. In many states, without the commitment of an organization like MACM, physicians and patients are far less protected and similar issues result in adverse actions that often result in licensure and practice restrictions.

All insureds of MACM should be grateful for the naagement role MACM and their experts in Risk Mana play in keeping us (physicians and patients) ntts) safe.

Diane Beebe, MD Family Medicine Jackson, Mississippi

For over 30 years, Mississippi physicians have looked to Medical Assurance Company of Mississippi for their professional liabilit y needs. Today, MACM is an integral part of the health care communit y through its dedication to risk management services for our insureds. A dedicated staě and physician involvement at every level guarantees that the interests of our policyholders remain the top priorit y. This, combined with the many years of loyalt y and support from our insureds, is what allows us to be the carrier of choice in Mississippi. Please call on us to assist with your professional liabilit y needs.

1.800.325.417ŘȱȊȱwww.macm.net

IIn n Partnership Partnership with with Insureds Insuredss


• sCIENtIFIC aRtICLEs •

Blood Lead Levels in Mississippi Children Robert D. Cox, MD, PhD; Patrick B. Kyle, PhD; Bruce Brackin; Teri Snazelle, MS and Joe Surkin

A

BStrAct

Lead is toxic to the nervous system and has been shown to have deleterious effects on the developing nervous systems of children. Widespread exposure to lead has occurred in the past due to the use of lead as a gasoline additive and as a paint additive. Children are usually exposed to lead in the home. Prevention of exposure to lead through monitoring is the most effective way to reduce childhood toxicity. Lead levels were determined in 24,736 children in Mississippi. The percentage of 1-5-year-old children with blood lead levels > 10 µg/dL in Mississippi is less than those seen nationally, and mean levels are comparable to national ones. In Mississippi, the age of housing is not a viable predictor of risk for elevated lead levels in children.

key WOrDS:

Lead, ChILdren, ToxICITy

intrODUctiOn Lead is a naturally occurring metal found in the earth’s soil and crust. Lead has numerous industrial applications including battery production, bullets, solder and some glazes. Past use of lead as a gasoline additive and emissions from smelters has led to global contamination. Lead has also been used in paints in the past. The primary source of lead in the environment has been from anthropogenic sources with leaded gasoline accounting for 90% of all emissions up to 1984.1 Soil around the home may be contaminated with lead from exterior leadbased paint or from the past deposition of lead particles from automobile emissions in high traffic flow areas. In 1990 the Fda estimated that 75% of the lead exposure of toddlers came from dust.1 Lead is toxic to the nervous system. While high lead levels can cause encephalopathy, peripheral neuropathies due to lower-level AUtHOr infOrMAtiOn: Dr. cox is in the Medical toxicology service, Department of Emergency Medicine and Mississippi Poison Control Center, university of Mississippi Medical Center. Dr. kyle is in the Department of Pathology, university of Mississippi Medical Center. Bruce Brackin is in the Mississippi agromedicine Program, Department of Emergency Medicine, university of Mississippi Medical Center and is Consulting Environmental Epidemiologist for the Mississippi state Department of Health. teri Snazelle is in the Department of Biochemistry, Mississippi Public Health Laboratory, Mississippi state Department of Health. Joe Surkin is with the Public Health Information Network (PHIN), Mississippi National Electronic Disease surveillance system (NEDss), Offices of Health Informatics/Epidemiology, Mississippi state Department of Health. cOrreSPOnDinG AUtHOr: Robert D. Cox, MD, PhD, Department of Emergency Medicine, university of Mississippi Medical Center, Jackson, Ms, 39216, Phone: (601)984-5577, Fax: (601)984-5579, Email: rcox@umc.edu

chronic exposures are more common in adults.2 Children are more sensitive to lead toxicity than adults, especially with respect to their developing nervous systems. The gastrointestinal absorption of lead is greater in young children, particularly in the setting of nutritional deficiencies of iron and calcium. The primary concern of low-level environmental lead exposure in young children is its adverse effect on intellectual development.2-4 Lead has been associated with behavioral problems in children, ranging from aggression in school to antisocial, delinquent behaviors.5,6 The use of lead in domestic paints was restricted in 1978, and its use as a gasoline additive was banned in 1996. Since that time, lead levels in americans have declined significantly. Between 1976 and 1994 the percentage of children with elevated blood lead levels (BLLs), defined as > 10 µg/dL, decreased from 88.2% to 4.4%. Between 1999 and 2002, the level dropped to 2.2% in children 1-5 years old, although it was still higher in minorities.7 In an attempt to detect and stop early childhood exposures, the Centers for disease Control and Prevention (CdC) recommends that all states monitor lead levels in children.8 Screening for lead is required for all children enrolled in Medicaid at ages 12 and 24 months and at 36-72 months for those children who have not been previously screened.9 The CdC and american academy of Pediatrics recommend that preventive care for every child should include obtaining an environmental history and an occupational history for all household members.3,4 although lead screening is routinely performed in Mississippi, no repository for the information exists. While most cases of elevated lead levels in children are reported to the Mississippi State department of health (MSdh), the number of non-elevated levels is not known. Thus, it has been impossible to determine the prevalence of elevated lead levels in the state or for counties or smaller geographic entities within the state. The purpose of this project was to define the prevalence of elevated lead levels in children in Mississippi and to identify any areas within the state that may have an elevated prevalence.

MetHODS This work was performed in conjunction with the Surveillance and analysis Workgroup, Childhood Lead Poisoning Prevention advisory Board, Mississippi State department of health, Jackson, Mississippi. data on lead levels in children were obtained from two august

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sources: the Mississippi State Public health Laboratory at the MSdh and the University of Mississippi Medical Center Clinical Laboratory. The MSdh operates health clinics in counties throughout the state, providing care for primarily low-income children and adults. routine screening of children for lead is performed in these clinics, and the blood is analyzed in a single laboratory at Mississippi Public health Laboratory in Jackson, Mississippi. The primary health department program that conducts BBL testing is the early and Periodic Screening and diagnosis Program (ePSdT). The MSdh laboratory uses three Perkinelmer eLan drC II (Perkinelmer Life and analytical Sciences Inc, Shelton, Connecticut) inductively coupled plasma-mass spectrometers which are sensitive to 0.3 µg/dL. The University of Mississippi Medical Center (UMMC) operates several large pediatric clinics in Jackson. The primary referral sources for these clinics are the surrounding counties of central Mississippi, although UMMC serves as the state’s tertiary referral center for pediatrics and acquires referrals from the entire state. The UMMC Clinical Laboratory uses a Perkinelmer a-600 graphite furnace atomic absorption spectrometer sensitive to 1.8 mcg/dL. all laboratory data were obtained in an electronic data format from the laboratory databases. The initial datasets were obtained in a Microsoft excel spreadsheet format and after cleanup were imported into Microsoft access database. Since laboratory data can contain duplicate values and multiple samples on the same patient, cleanup of the laboratory data was required. data was obtained over a two-year period from July 2005 through June 2007. The MSdh clinics used a combination of capillary and venous blood sampling. Capillary sampling can introduce skin contamination and false positive values. Therefore, venous sampling should follow an elevated result. The initial dataset from the MSdh contained 24,459 entries. Cleanup of the MSdh laboratory dataset involved the following: • removal of duplicate entries • removal of data entries in which the zip code of source could not be identified • removal of data entries in which the age of the source could not be identified • inclusion of only the first data entry on the source • removal of an initial lead value if obtained on a capillary sample if a venous sample was available within one month The final MSdh dataset contained 20,463 entries from 92 clinics. each entry represented a single individual. The initial dataset from the UMMC laboratory contained 4,333 entries. all data from this laboratory were obtained on venous samples. data cleanup for this dataset involved: • removal if a repeat value was performed within 1 month • removal if no zip code or address • removal if out of state zip code • inclusion of only the first data entry on the source • removal if no lead value The final UMMC dataset contained 4,235 entries. each of these represented a single individual. For both datasets, values listed as below a detection limit were entered as the detection limit divided by the square root of two for numerical purposes. Counties were determined by the zip codes. The

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distribution of housing ages for counties was obtained from the 2000 census. all queries were run in Microsoft access. Geometric means and deviations were calculated in Microsoft excel. tABle 1: COMPaRIsON OF tHE DatasEts Subjects Black, non-Hispanic White, non-Hispanic Other

MSDH 20,522 14,375 (70.0%) 5,240 (25.5%) 907 (4.5%)

UMMC 4214 3,344 (79.3%) 784 (18.6%) 86 (2.1%)

Sample Type Capillary Venous

20,055 (97.7%) 467 (2.3%)

0 4,214 (100%)

Age <12 mo 12-36 mo >36 mo – 19 yrs

589 (2.9%) 12,621 (61.5%) 7,312 (35.6%)

1,687 (40.0%) 1,406 (33.4%) 1,121 (26.6%)

Location - Counties Hinds, Madison, Rankin

162 (0.8%)

3,648 (86.6%)

Lead >10 g/dL All Venous only

302 (1.5%) 139 (0.7%)

44 (1.0%) 44 (1.0%)

reSUltS a comparison of the datasets from the two laboratories is shown in Table 1. In combination, both datasets contained blood lead values from a total of 24,736 children. This shows that some of the data obtained from the two laboratories and some of the populations are different. data from both laboratories showed that proportionately more samples were obtained on black, non-hispanic children than on the state’s general population. overall, 71.6% of the data was from black, non-hispanic children. data from the Mississippi State department of health were performed primarily using capillary samples. elevated levels obtained from capillary samples were supposed to be followed with venous sampling, but this did not always occur. The age distributions showed that the MSdh’s dataset was primarily from children between 12 and 36 months of age, whereas only 33% of the samples in the UMMC dataset were from children in this age range. The locations of residence show that the UMMC dataset was complementary to that of the MSdh. only a very small percentage, less than 1% of the MSdh dataset, covered children from the state capital area of central Mississippi. on the other hand, 86% of the samples from UMMC were from children residing in the counties around the capital (hinds, Madison and rankin). overall, 1.5% of the MSdh children and 1.0% of the UMMC children had BLLs greater than 10 µg/dL. Some of this difference may be due to the fact that many of the MSdh samples were capillary samples without venous confirmation and could have been contaminated during collection. The MSdh dataset had only 0.7% elevated BLL when only venous positives were considered. Children in the two datasets were from different areas of the state that may have had a different prevalence of elevated lead. Therefore, it is impossible to draw any conclusions on these small differences between the datasets. a comparison of the BLLs found in Mississippi children to levels found in children nationally in the national health and nutrition examination Survey (nhaneS) is shown in Table 2. The most recent summary of this data covered the 1999 - 2002 survey.6 In Mississippi,


the percentage of 1-5-year-old children with BLL greater than 10 µg/dL was lower than those found nationally for both non-hispanic white and non-hispanic black children. For 6-19-year-old children the percentage with elevated BLL greater than 10 µg/dL was above those in the national database. The geometric mean BLL found in 1-5-year-old Mississippi children was similar to those found nationally whereas the geometric mean BLLs in the 6-19-year-old age group was somewhat higher than those found nationally. tABle 2: COMPaRIsON OF BLOOD LEaD LEvELs IN MIssIssIPPI CHILDREN NatIONaL HEaLtH aND NutRItION ExaMINatION suRvEy (NHaNEs), uNItED statEs, 1999-2002. tO tHOsE IN tHE

Age 1-5

Source Miss NHANES

n 21,004 893

6-19

Miss NHANES

543 3,472

Age 1-5

Source Miss NHANES

n 21,004 893

6-19

Miss NHANES

543 3,472

Blood Lead Level >10 g/dL Percent (95% confidence interval) White, non-Hispanic Black, non-Hispanic 0.8 (0.6-1.1) 1.8 (1.6-2.0) 1.3 (0.6-2.5) 3.1 (1.7-4.9) 1.5 * 0.2 (0.0-0.6)

1.7 (0.6-3.7) 0.3 (0.1-0.6)

Geometric Mean Blood Lead Level g/dL (95% confidence interval) White, non-Hispanic Black, non-Hispanic 2.0 (1.9-2.1) 2.5 (2.4-2.6) 1.8 (1.6-2.0) 2.8 (2.5-3.1) 2.2 (1.9-2.4) 1.1 (1.0-1.1)

2.5 (2.3-2.6) 1.5 (1.4-1.6)

Blood lead levels in 1-5-year-old children have decreased significantly since 1991. a comparison of the percentage of 1-5-year-old children with BLLs greater than 10 µg/dL between 1991 and 2006 is shown in Figure 1. Between the 1991-1994 survey time and the 19992002 survey, BLLs decreased significantly in both black non-hispanic and white, non-hispanic children. additional data from the 2003-2006 nhaneS survey were analyzed to determine if the downward trend in BLLs over time continued since current Mississippi data are from 2005 to 2007. These later data showed no significant decrease in BLLs compared to the previous four years. The percentage of children with elevated BLLs in Mississippi between 2005 and 2007 was approximately half those found nationally for black, non-hispanic and for white, nonhispanic children compared to the 2003-2006 survey. fiGUre 1: PERCENt OF CHILDREN 1-5 yEaRs OF agE WItH BLL>10µg/DL NatIONaLLy aND IN MIssIssIPPI IN DIFFERENt tIME PERIODs.

The data were also analyzed by county in Mississippi to determine if there were geographical areas of high concern for future surveillance work. The 3% level for 1-3-year-old children is used by the US Centers for disease Control and Prevention (CdC) as a low-level

cut off for routine screening.7 Six counties were found to have greater than 3% of the children tested with BLL greater than 10 µg/dL (Table 3). also shown in Table 3 is the percentage of housing built prior to 1950 in each county based on the 2000 census and how that county ranks compared to other counties in the state of Mississippi with regard to the percentage of pre-1950 housing. tABle 3: MIssIssIPPI COuNtIEs WHERE > 3% OF CHILDREN HaD BLOOD LEaD LEvELs > 10 µg/DL. County Webster Coahoma Smith Jones Tunica Leflore

Population 10,294 30,622 16,182 64,958 9,227 37,947

Percent with BLL>10 g/dL 5.9 5.4 4.5 4.7 3.7 3.1

% pre-1950 Housing 17.1% 16.3% 11.2% 16.6% 8.5% 15.0%

Housing State Rank* 10 12 56 11 74 22

* statE RaNk BasED ON PERCENt OF HOusINg IN COuNty BuILt PRIOR tO 1950 Out OF 82 COuNtIEs, RaNkED gREatEst tO LEast.

Twelve counties were identified that had BLL data on fewer than 50 children during the collection time period. Most of these are sparsely populated counties with populations ranging from 2,27448,621. however, when the data from all 12 of these counties were combined, only one of 354 children was found to have a blood lead level greater than 10µg/dL. This corresponded to a percentage of elevated BLLs of less than 0.3% for the children sampled in those counties providing some assurance that there are not significant numbers of children with elevated BLLs in these counties, even with the low degree of sampling. tABle 4: COMPaRIsON OF LINEaR REgREssION MODELs OF tHE PERCENt BLL>10 µg/DL IN MIssIssIPPI COuNtIEs vs. PERCENt OF OLDER HOusINg.

Housing Age pre-1950 pre-1960 pre-1970 pre-1980

Slope 0.7 1.4 1.7 1.2

Slope p-value 0.04 0.004 0.007 0.08

Correlation Coefficient 0.23 0.32 0.30 0.19

Since other studies have shown that the number of older homes in a given area correlates to the percentage of children with elevated BLL,10 we compared the percentage of children with BLL >10 µg/dL in each county to the percentage of housing built prior to 1950, 1960, 1970 and 1980. The results of linear regression analyses on these comparisons are shown in Table 4. a positive non-zero slope was found to be statistically significant for all time periods. The pre-1960 and pre1970 time periods had the best statistical fit for a positive relationship between older housing and BLL. however, for all time periods, the data scatter was significant as evidenced by the low correlation coefficients. a plot of the percent BLL >10 µg/dL versus the percent of housing built prior to 1960 for all Mississippi counties is shown in Figure 2. This figure graphically demonstrates that the percentage of older homes cannot be used as a predictor of increased BLL in children in Mississippi. The percentage of older housing that would capture all of the six counties with >3% BLL>10 µg/dL would exclude only a few counties. august

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fiGUre 2: LINEaR REgREssION PLOt OF PERCENt BLL>10µg/DL as a FuNCtION OF PERCENtagE OF PRE-1960 HOusINg IN MIssIssIPPI COuNtIEs.

DiScUSSiOn Low-level exposure to lead has been shown to have an adverse effect on intellectual development in children in a number of studies.2-4 nationally, the primary source of exposure to lead in young children is due to dust from lead paint in the home.1,9 Since treatments such as chelation therapy have not been shown to have an effect on the developmental toxicity of lead,11,12 the main emphasis has been on the prevention of lead exposure in children.3,4 The neuro-developmental effects of lead toxicity are very subtle and in general will not be detected during routine physical examination. Thus, screening has been the main tool for detection of elevated lead in children. as of 2005, all Medicaid eligible children are required to be screened at 1 and 2 years of age.9 It has been estimated that this group represents 60% of children with BLL > 10 µg/dL.13 however, studies have shown that only 17%-52% of Medicaid eligible children are screened for lead.7,9 The CdC has defined a level of 10 µg/dL as a threshold level to prompt public health action, realizing that this is not a threshold for the toxic effects of lead.9 all states are required to develop monitoring plans to detect children with elevated levels of lead. Up to this point, there have not been reliable data on the prevalence of children with elevated blood lead levels in Mississippi. There is no repository for lead levels in Medicaid children or in the general population, and previous studies on the prevalence of lead in children nationally have not included any data on Mississippi children.7 The data included here provide an estimate of the baseline level of children with elevated BLLs in Mississippi and identified counties with an increased percentage of children with elevated BLLs. This information is being used to help the state develop a comprehensive plan for screening children for lead. as of May 2008, the Mississippi State Board of health requires laboratories performing lead determinations in children in Mississippi to report all test results to the MSdh. When this new system is fully functional, it should provide ongoing information concerning lead levels in Mississippi children. nationally, average blood lead levels and the percentage of children with elevated BLLs have decreased dramatically since the late 1970s. It has been estimated that between 1976-1980 88% of children 1-5 years of age had BLL greater than 10 µg/dL.7 With the removal of lead from paint and gasoline in combination with federal prevention

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programs, BLLs fell dramatically, reaching a level of 8.6% in 1988 and 2.2% by 2000. There has been a marked disparity in the percentage of black children with elevated blood lead levels compared to white or hispanic children. Through efforts in the 1990s, lead levels in children have dropped dramatically with the sharpest decrease being observed in black children. as shown in Figure 1, the percentage of black, non-hispanic children, 1-5 years of age with elevated BLL in Mississippi is below that seen nationally. Similarly, the level of white, nonhispanic children, 1-5 years of age with elevated blood lead levels is also less than that seen nationally. The geometric mean blood lead level for each group was very similar to those seen nationally. There were not enough hispanic children in the datasets to provide comparison data. In the 6-19-year-old age group, the percentage of children in Mississippi with elevated BLL was higher than that seen nationally. In addition, the geometric mean blood lead levels for these groups were also higher than those seen nationally. This is most likely a function of selection bias in this age range. This age category constituted only 2.5% of the children in the database. Since the vast majority of the screening efforts involve younger children, it is likely that older children were tested when a younger sibling was found to have an elevated BLL. Thus, it is likely that this age range is not a random sample as in the nhaneS dataset. The CdC screening guidelines give recommendations for sampling areas within a state based on the percentage of children within a given geographical area with elevated blood lead levels.9 If greater than 12% of children within any given area have elevated blood lead levels, then universal screening is recommended for that area. If the percentage of children in a given area with elevated blood lead levels is less than 3%, then methods other than routine screening are recommended. For geographical areas where 3-12% of children have elevated blood lead levels, targeted screening is recommended. If reliable data on the percentage of children with elevated blood lead levels in a given area do not exist, then surrogate markers such as the percentage of housing built prior to 1950 may be used. The CdC recommends a cutoff of 27% of housing built prior to 1950 as a surrogate indicator of the percentage of children with elevated blood lead levels. In Mississippi, only 1.5% of the children tested had elevated BLLs. at this prevalence, the CdC guidelines suggest that neither universal nor targeted screening is necessary. however, when breaking down the state data, six counties were identified in which greater than 3% of the children tested had elevated BLLs. These counties should have targeted lead screening of their children. Medicaid guidelines recommend screening all children between one and three years of age. If there are large percentages of Medicaid children in the six counties, this should suffice for the necessary targeted screening. no counties approached the prevalence of 12% of children with elevated BLLs, the CdC’s recommended cutoff for universal screening. The highest prevalence of elevated BLL found in any county was 5.9%. nationally, the percentage of children with elevated blood lead levels in given areas has been proportional to the percentage of housing built prior to 1950. It has been estimated that 68% of homes built prior to 1940 have lead hazards, 43% of homes built between 1940 and 1959, and only 8% of homes built between 1960 and 1977.14 an esti-


referenceS

mated 4.1 million homes in the United States have a lead-based paint hazard, and children less than 6 years of age are living in 25% of these. The majority of these older homes are located in the northeast and Midwest United States.14 There is a much lower prevalence of older housing in Mississippi. according to the 2000 Census, only 11.6% of the homes in Mississippi were built prior to 1950. The county with the highest percentage of homes built prior to 1950 had only 21% older homes. These numbers fall far below the level of 28% of homes built prior to 1950 that CdC states can be used as a surrogate marker for lead screening.8 The low percentage of older homes in Mississippi explains the poor correlation between the percentage of older housing in a county and the percentage of children with elevated BLL. This data suggests that in Mississippi, the percentage of older housing should not be used as a prediction tool. also, since the overall percentage of children in Mississippi with elevated BLL is very low, other factors such as lead in window blinds, electrical cords and toys will have a much greater impact.

9.

cOnclUSiOn

10.

Lead exposure in young children can have a deleterious effect on intellectual development. Lead toxicity in children is a completely preventable disease. adequate monitoring of blood lead levels in young children is the only method to help identify children who have been exposed and to allow clinicians and public health officials to initiate steps to prevent further exposure. In Mississippi, the percentage of black non-hispanic children and white non-hispanic children with elevated blood lead levels is below that observed nationally. Six counties have been identified with greater than 3% of the children tested with elevated blood lead levels. These counties need to be targeted for future lead screening.

1. 2. 3. 4. 5. 6. 7. 8.

11. 12. 13. 14.

agency for Toxic Substances and disease registry. Toxicological Profile for Lead. atlanta, Ga: US department of health and human Services; 2005. Belinger dC. Lead. Pediatrics. 2004;113:1016-1022. Centers for disease Control and Prevention. Preventing Lead Poisoning in Young Children. atlanta, Ga: Centers for disease Control and Prevenstion; 2005. american academy of Pediatrics Committee on environmental health. Lead exposure in children: prevention, detection, and management. Pediatrics. 2005;116:1036-1046. Byers rK, Lord ee. Late effects of lead poisoning on mental development. Am J Epidemiol. 1943;66:471-494. needleman hL, reiss Ja, Tobin MJ, Biesecker Ge, Greenhouse JB. Bone lead levels and delinquent behavior. JAMA. 1996;275:363-369. Myer Pa, Pivetz T, dignam Ta, homa dM, Schoonover J, Brody d. Surveillance for elevated blood lead levels among children--United States, 1997-2001. MMWR Surveill Summ. 2003;52:1-21. Centers for disease Control and Prevention. Screening Young Children for Lead Poisoning: Guidance for State and Local Public Health Officials. atlanta, Ga: Centers for disease Control and Prevention; 1997. advisory Committee on Childhood Lead Poisoning. recommendations for blood lead screening of young children enrolled in Medicaid: targeting a group at high risk. MMWR Recomm Rep. 2000:49(rr-14)1-13. Lanphear BP, Matte Td, rogers J, et al. The contribution of leadcontaminated house dust and residential soil to childrenâ&#x20AC;&#x2122;s blood lead levels. a pooled analysis of 12 epidemiologic studies. Environ Res. 1998;79:51-68. rogan WJ, dietrich Kn, Ware Jh, et al. The effect of chelation therapy with succimer on neuropsychological development in children exposed to lead. N Engl J Med. 2001;344:1421-1426. Liu x, dietrich Kn, radcliffe J, ragan B, rhoads GG, rogan WJ. do children with falling blood levels have improved cognition? Pediatrics. 2002;110:787-791. United States General accounting office. Medicaid: Elevated Blood Lead Levels in Children. Washington, dC: Gao publication (hehS) 98-78: 1998. Jacobs de, Clicker rP Zhou Jy, et al. The prevalence of lead-based paint hazards in U.S. housing. Environ Health Perspect. 2002;110:a599-a606.

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â&#x20AC;˘ CLINICaL PROBLEM-sOLvINg â&#x20AC;˘ Presented and edited by the Department of Family Medicine, University of Mississippi Medical Center, Diane K. Beebe, MD, Chair

Off by a Factor of Eight Edward B. Eldred, DO, MBA

A

53-year-old African American female presented to the emergency department complaining of left leg pain and swelling. She described a 5 month history of progressive cramp-like pain worsened by activity and improved with rest. Coinciding with her left leg pain was bruising, which initially appeared around her ankle but had progressed to involve her entire lower left leg. Upon questioning, she admitted to generalized fatigue of unknown duration as well as easy bruising, blood in her stool and mild weakness in the left leg. She denied trauma or injury to the left leg. She denied palpitations, chest pain, shortness of breath or rash. She had a history of hyperlipidemia, but simvastatin (Zocor) therapy was discontinued by her primary care physician secondary to her leg pain. She had a history of high blood pressure for which she was prescribed valsartan (Diovan) and hydrochlorothiazide (HCTZ) and a history of systemic lupus erythematosus (SLE) for which she was prescribed hydroxychloroquine (Plaquenil). A week prior to presentation, she called her rheumatologist due to her left leg pain and swelling, and subsequently she was sent for duplex ultrasound of the left leg to evaluate for deep venous thrombosis (DVT). In a 53-year-old with complaints of leg pain, swelling and bruising, the differential is broad. We must rule out dVT as it commonly causes lower leg swelling and pain. We will review her report from previous duplex ultrasound. Furthermore, we should consider trauma, myositis (such as dermatomyositis or polymyositis) and iatrogenic myopathy related to simvastatin and hydroxychloroquine therapy. We will order a plain radiograph and magnetic resonance image (MrI) of the left lower extremity, erythrocyte sedimentation rate (eSr), C-reactive protein, creatine phosphokinase and complete metabolic panel. With her bruised left leg, history of easy bruising and history of blood in her stool, we are concerned about a bleeding disorder and order complete AUtHOr infOrMAtiOn: Dr. eldred is in the Department of Family Medicine at the university of Mississippi Medical Center. cOrreSPOnDinG AUtHOr: Edward B. Eldred, DO, MBa, university of Mississippi Medical Center, Department of Family Medicine, 2500 North state street, Jackson, Ms 39216 Phone: (601) 984-5426, Fax: (601) 984-6812, Email: eeldred@familymed.umsmed.edu

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blood count, prothrombin time and a stool occult blood test. In a middle-aged patient with cramp-like pain that increases with activity and improves with rest, we consider peripheral vascular disease as a cause of her pain, though it would not explain her bruising. On examination, she had normal temperature and pulse. Her respiratory rate at 28 breaths per minute and her blood pressure at 134/72 mmHg were elevated. She was a black female who appeared younger than her stated age and was well groomed. She had normal respiratory, abdominal, neurological and psychiatric examinations. Her cardiovascular examination revealed a grade 3 out of 6, systolic murmur but normal rate and rhythm. She had grade 3 out of 5 strength on knee extension, left foot plantarflexion and left foot dorsiflexion. She had extensive ecchymosis of anterior and posterior left lower leg as well as medial thigh. Duplex ultrasound performed 10 days prior to presentation was negative for DVT. The remainder of requested laboratory studies was pending. her physical examination does little to reduce our differential. however, polymyositis can be moved lower on the differential because her weakness is unilateral, distal, and there is no rash, which one would expect in dermatomyositis. although she recalls no trauma, we still consider compartment syndrome given her weakness on examination. Iatrogenic myopathy is still on our differential given her weakness. her bruising is extensive, and she has symptoms of anemia (tachypnea, systolic murmur); thus, a bleeding disorder remains high on the differential. Her left lower extremity radiogram was negative for fracture. Her MRI showed moderate to prominent myositis of gastrocnemius and soleus muscles. Her hematocrit was low at 19.1% (36.0-46.0%), her mean corpuscular volume was decreased at 77.5L (80-96L) and her platelet count was normal. Her complete metabolic panel showed elevated blood urea nitrogen at 33mg/dL (720mg/dL), an elevated creatinine at 1.7 mg/dL (0.7-1.5mg/dL) and low potassium at 3.5 meq/L (3.6-5.0 meq/L). Her creatine phosphokinase was 115 U/L (35-232 U/L). Her ESR was elevated at 88 mm/hr (0-30 mm/hr), and her C-reactive protein (CRP) was slightly elevated at 0.7 mg/dL (<0.5 mg/dL). Stool test for occult


blood returned positive. The prothrombin time (PT) was normal at 14.5 seconds (11.9-14.9 sec). We immediately provided a therapeutic transfusion with 2 units of packed red blood cells. her severe anemia is likely a result of iron deficiency from blood loss given her low mean corpuscular volume and possibly acute renal failure shown by an elevated blood urea nitrogen and creatinine. The significant anemia with a positive stool blood test suggestive of a gastrointestinal bleed keeps bleeding disorder high on the differential. also, her MrI result keeps iatrogenic myopathy related to hydroxychloroquine or simvastatin therapy on the differential as well. At this point, we admitted her to the hospital for severe anemia, acute renal failure and myositis. We provided intravenous fluids with potassium supplementation. We consulted the patient’s rheumatologist to help further investigate for possible hydroxychloroquine induced myopathy. We held her hydroxychloroquine treatments. Day 1 post admission our patient was feeling better. She still complained of some leg pain, however. Her repeat complete blood count showed improvement in her hematocrit to 27%, and her complete metabolic panel showed normalization of her potassium and creatinine at 3.9 meq/L and 1.4 mg/dL, respectively. Her respirations were normal at 20 breaths per minute. Her left lower extremity bruising remained unchanged from admission. A rheumatology consultation was pending. although she continues to be anemic, she has improved somewhat symptomatically. despite the patient having discontinued her simvastatin 5 months prior to presentation, she was still experiencing pain in association with her distal muscle weakness. Symptoms of statin induced myopathy should have resolved days to weeks following discontinuation of the medication. Further, the condition is uncommon with approximately 0.5% of patients affected.1 hydroxychloroquine induced myopathy is uncommon as well, with an incidence of 1 per 100 patient years, and is usually unaccompanied by pain.2 neither statin induced myopathy nor hydroxychloroquine induce myopathy are associated with bruising as in our patient. Therefore, iatrogenic myopathy appears lower on the differential. Day 2 post admission, she noted further improvement in her pain. Her vital signs were normal, and her hematocrit was stable. There was no change in her left lower extremity bruising. A rheumatologist did not think she had myopathy, despite the MRI report. He ordered a partial thromboplastin time (PTT), which was prolonged at 90 seconds (23.7-37.7 sec). The PTT result suggests a problem in the intrinsic and common coagulation pathway (Figure 1), which includes coagulation factors VIII, Ix, xI and xII. We discuss the results with the rheumatologist and order factor VIII, IX, XII, and von Willebrand factor assays and consult a hematologist. Given her microcytic anemia, normal PT, with prolonged PTT, the hematology consultant ordered a mixing study and thrombin time (TT). What information is gained by a mixing study? The mixing study evaluates for the presence of a coagulation inhibitor. The patient’s plasma is combined in equal parts with “normal” plasma, and the partial thromboplastin time is recorded with this mixture. an inhibitor in

fiGUre 1: tHE CLOttINg CasCaDE

usED WItH PERMIssION: aNaEstHEsIauk. COaguLatION - CLassICaL MODEL. avaILaBLE at: HTTP://WWW.FRCA.CO.UK/ARTiCLE.ASPx? ARTiCLEiD=100096%20. aCCEssED MaRCH 17, 2010.

the patient’s plasma is likely if the PTT remains prolonged. however, a coagulation factor deficiency is likely if the PTT value returns to normal. TT is useful to exclude heparin contamination as cause of prolonged PTT. Day 3 post admission, vitals signs, hematocrit and physical examination findings were unchanged. The mixing study showed a PTT of 39 seconds (23.7-37.7 sec). Factor assays showed factor IX 145% (80-120%), factor XII 40% (50-150%), factor VIII 1% (80120%), and von Willebrand factor 232% (70-120%). TT was normal at 16.7 sec (13-17.5 seconds). The prolonged mixing study and greatly reduced factor VIII value indicates the patient has an acquired factor VIII deficiency, which explains her extensive left lower leg eccymosis and easy bruising. acquired factor VIII deficiency is a rare disorder with an incidence of 1 to 4 cases per million per year. approximately half of the cases are idiopathic, and the remainder have an underlying condition such as autoimmune disease, solid tumors, lymphoproliferative malignancies or pregnancy.3,4 The autoimmune, collagen vascular disorders, such as SLe, are the most common of these underlying conditions.5 The pathophysiology of acquired factor VIII deficiency is incompletely understood, but is associated with the deregulation of normally occurring polyclonal immunoglobulin G autoantibodies. The deregulation increases the autoantibodies directed at factor VIII.6 Lupus anticoagulant antibody testing is ordered, even though one would not expect excessive bleeding with the presence of this proaugust

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coagulant antibody. The patient was begun on factor VIII replacement therapy with a loading dose of 1500 IU followed by 850 IU every 12 hours. Her lupus anticoagulant was negative. replacement dose of the deficient factor should be great enough to overwhelm the circulating inhibitor. Factor replacement will generally be ineffective at high inhibitor titers. We await the effect of factor VIII replacement and order repeat factor VIII determination. Day 4 post admission, our patient continued to feel better. She had improvement in her strength to level of 4 out of 5. Her bruising showed mild improvement. Her vital signs and hematocrit were still stable. Her factor VIII value had increased from 1% to 2% (80-120%). Because she had only a modest increase in her factor VIII value, a factor VIII inhibitor assay to assess inhibitor value is appropriate. at the recommendation of the hematologist, treatment will be changed to factor VIIa and desmopressin. Factor VIIa will be used as a bypassing agent and desmopressin, a vasopressin analog, will help decrease bleeding.4 Day 5 post admission, she had no complaints. The pain, swelling and bruising in her left lower leg had improved. Her hematocrit and vital signs were stable. The factor VIII inhibitor assay returned a value of 16 Bethesda units (<10 Bethesda units). We continued bypassing with factor VIIa, stopped desmopressin and began rituximab (Rituxan). her inhibitor value is above the generally accepted value of 5 Bethesda units; desmopressin is effective below 5 units. The factor VIIa bypassing is continued as an anti-hemorrhage regimen. rituximab is started to eradicate the circulating factor VIII inhibitor. rituximab is a mouse-human chimeric anti-Cd20 antibody commonly used in the treatment of B-cell lymphoma. Therefore, rituximab will bind to plasma B-cells which express the Cd20 antigen on their cell surface and effectively reduce the number of circulating B-cells in the plasma. Given the plasma B-cellsâ&#x20AC;&#x2122; role in autoimmunity, reducing circulating cells will decrease circulating auto-immune immunoglobulins.7 Day 7 post admission, she had no leg pain or swelling, and bruising was reduced in her left ankle. Her hematocrit continued to be stable. The hematologist recommended rituximab 640mg IV every week for additional 3 weeks as an outpatient. She was discharged from the hospital in stable and greatly improved condition and scheduled to follow up with her hematologist as an outpatient After discharge, she finished 3 weeks of rituximab therapy; additional factor VIII values showed only modest increases. She was administered 2 additional rituximab treatments. Although her factor VIII values remain decreased, she has had no more bleeding episodes. In her case, SLe is the cause of her acquired factor VIII deficiency; SLe is thought to be involved in approximately 5% of factor VIII cases.5 The hematologist suspects her factor VIII values will continue to remain low and plans to follow her periodically. She continues to visit her rheumatologist regularly.

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I wish to thank Janet Bishoff, BS, MLS, Research Librarian for her assistance.

referenceS 1. 2. 3. 4. 5. 6. 7.

hansen Ke, hildebrand JP, Ferguson ee, Stein Jh. outcomes in 45 patients with statin-associated myopathy. Arch Intern Med. 2005;165:2671-2676. estes ML, ewing-Wilson d, Chou, SM. Chloroquine neuromyotoxicity.Clinical and pathologic perspective. Am J Med. 1987;82:447-455. Franchini M, Lippi G. acquired factor VIII inhibitors. Blood. 2008;112:250-255. huth-Kuhne a, Baudo F, Collins P, et al. International recommendations on the diagnosis and treatment of patients with acquired hemophilia a. Haematologica. 2009; 94:566-575. akahoshi M, aizawa K, nagano S, et al. acquired hemophilia in a patient with systemic lupus erythematosus: a case report and literature review. Mod Rheumatol. 2008; 18:511-515. Kessel C, Konigs C, Linde r, et al. humoral immune responsiveness to a defined epitope on factor VIII before and after B cell ablation with rituximab. Molecular Immunology. 2008;46:8-15. Stachnik JM. rituximab in the Treatment of acquired hemophilia. Ann Pharmacother. 2006; 40: 1151-1157.


• sPECIaL aRtICLE •

Willard Boggan, MD: A Giant of Mississippi Medicine By Philip L. Levin, MD

o

ver the past sixty years, medicine has evolved from the introduction of penicillin to MrI miracles. Thanks to leaders like Willard Boggan, Md, Mississippi has stayed in the forefront of these changes. one of the first board certified internal medicine physicians in Jackson, he spearheaded the creation of three hospitals, taught as a founding instructor at the University of Mississippi School of Medicine, and retired after almost fifty years of full-time practice, respected by colleagues and loved by his patients. Born in Memphis, Tennessee, in 1921, Willard henry Boggan’s interest in medicine came at an early age. Spurred by helping his mother recover from fourteen major operations, by the time he was five-years-old Willard had decided he would become a physician. he took pre-med classes at Mississippi College, completing four years of work in two. While in college he played football, tennis, and baseball. The latter was always his favorite, and to help pay for his school expenses he went semi-pro with a local baseball team, earning fifteen dollars a game playing for the yellow Cab Team. (“Good money in those days,” he claims.) These were war years, and Willard joined the navy in 1941. he was called into active duty and put into a program called hVP which prevented him from being sent overseas until he could finish his medical school at the University of Tennessee. Graduating in 1946, dr. Boggan did his internship at WILLaRD BOggaN, CHIEF FELLOW IN BIOLOgy at MIssIssIPPI Pensacola naval COLLEgE IN 1940, ExaMINEs tHE HuMaN aNatOMy. hospital. after his stint at the naval hospital, he transferred to Whiting Field, home of the Blue angels with whom he served as flight surgeon. on his weekends off, dr. Boggan drove into Pensacola and worked in the e.r. of Sacred heart hospital from 6 p.m. until 6 a.m. for $20 a night. dr. Boggan remained on active duty until 1949, when he switched to the reserves and moved to Memphis to begin a residency in internal medicine at the University of Tennessee Va hospital. he remembers being at a drive-in during his residency when the movie was interrupted to announce that the north Koreans had crossed the 48th parallel. The next day he received his orders to report to active duty. his professors asked if the navy could delay taking Willard just three months so he could finish his residency, but the request was denied. They needed physicians with navy experience right away. dr. Boggan reported to duty at Millington navy hospital, Tennessee, at 4 p.m., and received orders to board a flight to yokosuka, Japan at midnight. Bare minutes before he boarded, the Commanding officer of the base pulled him aside, telling him that the navy hospital was receiving 200 casualties. When the marines arrived, their frostbitten digits were coming off in dr. Boggan’s hand. They had been fighting in the Korean winter with only summer uniforms. While stationed at the naval hospital he did special studies on malaria and the new drug to fight it, Primaquin, eventually presenting a paper on its use at the medical society in Memphis. dr. Boggan authored several papers, including one about cystic medial necrosis of the aorta (the cause of John ritter’s death), published in the Annals of gRaDuatION PHOtO OF CaDEt WILLaRD BOggaN at Internal Medicine. he served there until the war ended in 1953. uNIvERsIty OF tENNEssEE MEDICaL sCHOOL, 1946 august

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after returning to finish his residency in internal medicine, dr. Boggan opened a private practice in Jackson. The Legislature had just created the medical college there, so he volunteered to be one of the initial instructors, staying on for 35 years. “Though they never paid me,” he said, “they did slip me the occasional pair of football tickets.” When he reflected on why he put in all that time at the university he said, “It was my duty.” In the 1950s it was routine for a new physician to become a junior partner with an already established physician. dr. Boggan interviewed several and was just ready to join a practice when he developed hepatitis, lapsing into a coma for two weeks. he was hospitalized four months and couldn’t work for a year. once recovered, he went to work with Gayden Ward, Md, a board certified internist from the University of Pennsylvania. he was paid $800 a month. he separated from dr. Ward in 1959, opening his own practice. The early days were tough. If his patients didn’t have money, they’d pay with whatever they had: handmade napkins, sweet potatoes, or food from their freezers. Willard’s wife, Lottie, claims they tHE BOggaN FaMILy IN 1962. PICtuRED LEFt tO had the largest collection of hand-knit toaster covers in the nation. RIgHt: BILL, LOttIE, BOB, Pat, aND LINDa. Medical care in those days was time intensive. The office opened at 8 a.m. and continued until noon. dr. Boggan took lunch across the street at the University hospital, where with interns and residents in tow, he made rounds on his patients. Three days a week he also gave lectures to the medical students. after lunch it was back to the office for patients, rarely returning home before 7 p.m. he would seldom enjoy a quiet evening at home; patients would call or he’d be off making house calls. often he’d be called to the emergency room where he would take care of not only his patient, but any others who came in. at that time, Jackson had two other major hospitals, Baptist and St. dominics. dr. Boggan served on committees of both hospitals, as well as several civic communities. he became frustrated when the physicians could not get the policies and equipment they wanted so he decided to build his own hospital. In the early 1960s he began calling on doctors “like a detail man.” he recruited 25 physicians to his cause, requiring each doctor to give $1,000 cash and a promissory note for $30,000. With this financial backing, he contracted with Lamar Life Insurance Company using his “good name” as credit, and secured a loan to begin the hospital. Working with a company in St. Louis, they built doctor’s hospital, which opened in 1963. he and his colleagues ran the hospital from a physician’s viewpoint, and ran it quite successfully. after a half dozen years, several hospital companies were eager to buy it from them. The board decided to sell it to what was then a small company mostly involved in nursing homes, humana, out of Louisville, Kentucky. as a sidelight that no one expected, the hospital that doctors had built for patient care became a financial success for its investors. once again, though, dr. Boggan felt the hospital had lost its focus on the patient, so he began planning to build another hospital. This time 85 doctors jumped in. he secured 20 acres on the north side of Jackson, where he felt the city was most likely to experience growth. In 1981 river oaks hospital opened, where he practiced for the rest of his career. he had no intention of going through that process a third time, but a group of psychiatrists approached him, requesting he spearhead the construction of a hospital unique to their patient needs. The committee studied color schemes that would be restful and built with all curved walls. dr. Boggan remained involved in many of the important decisions, and a few years later Charter hospital joined the Jackson medical landscape. dr. Boggan introduced many unique concepts to Mississippi medicine. one day a patient came to him impressed with how an acupuncturist in north Carolina had cured his headache. dr. Boggan contacted the physician, a doctor who had trained in China, and invited him to grand rounds. The fellow came and demonstrated his skills, including placing a dozen needles into a resident who suffered with a frozen shoulder. after the treatment the fellow had complete relief of pain and full roM. one of his patients spoke of how dr. Boggan saved her husband’s life. It was 1964 and the man had persistent G.I. bleeding. The surgeons were at a loss as to where to operate. dr. Boggan tied a “life saver” to a string and had the patient swallow it in the evening. The next morning he pulled the string back out and determined where the bleeding was coming from by how high the blood level registered on the string. They actually did surgery based on these results. one time dr. Boggan was playing golf when a player in the group just behind him collapsed with a heart attack. Willard climbed into the ambulance with the fellow and stayed with the man at the hospital for three days straight. In all his years as a physician, there was never a single lawsuit filed against him. one can’t write about Willard Boggan without putting in a few words about his wife of 52 years, Lottie. he recounts how he watched her grow up in the house across the street, hoping they would marry someday. even now, he swears she is the most beautiful woman in the whole state of Mississippi. “Fact, not brag,” he says. In high school there was a contest DR. WILLaRD BOggaN IN tOkyO, JaPaN, 1970, WHILE attENDINg a MEDICaL MEEtINg. where they would recruit a celebrity to examine photos of all high school seniors each year

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and choose the prettiest. In 1952, Cecile de Mille picked little Lottie. Today she remains by his side just as happy and full of spunk as the day he wed her. Lottieâ&#x20AC;&#x2122;s a local girl. She says her fatherâ&#x20AC;&#x2122;s claim to fame was Brentâ&#x20AC;&#x2122;s drugs, the first drugstore in uptown Jackson. opened in the Morgan Center (now Woodland hills), some say it was the first shopping center in the state. Lottie says the most important rule about Willard is always to be on his team because heâ&#x20AC;&#x2122;s going to win. once, playing tennis, she was on the other side of the net, and she claims his forehand smashes almost killed her. dr. Boggan hated to retire, but at 72-years-old in 1992 he finally closed his doors, though he remains active to this day. his most recent sports victories include two For a birdâ&#x20AC;&#x2122;s eye view on gold medals hanging in his bedroom, won medicine follow MSMA on at the national Senior NOW REtIRED, DR. BOggaN sPENDs tIME olympics at the age RELaxINg ON HIs PatIO (2010). of 81. When asked, â&#x20AC;&#x153;Whatâ&#x20AC;&#x2122;s the biggest change you saw in medicine in your 50 years of practice?â&#x20AC;? he didnâ&#x20AC;&#x2122;t hesitate a moment. â&#x20AC;&#x153;doctors no longer talk to their patients. My patients were my friends. I listened to them, and as a result, they listened to me. all you have to do is listen to them, and theyâ&#x20AC;&#x2122;ll tell you whatâ&#x20AC;&#x2122;s wrong with them.â&#x20AC;? â&#x20AC;&#x153;I enjoyed practicing medicine,â&#x20AC;? dr. Boggan said. â&#x20AC;&#x153;I still have patients call me every week asking me for medical information.â&#x20AC;? and he still has the love of the community, and the memories of all he trained and helped. Mississippi medicine is forever grateful. r MSMA1

MSMA icon. â&#x20AC;&#x153;Followâ&#x20AC;? next to the MSMA1 and clicking http://twitter.com/ following web page by going to the you can add MSMA signed up with Twitter, rates apply). Once youâ&#x20AC;&#x2122;re standard text messaging phone number (optional, address and mobile your name, email com and submit visit www.twitter. yourself. Simply Twitter account for you can set up a free In about three minutes, via â&#x20AC;&#x153;Twitter.â&#x20AC;? communicating are, MSMA is now matter where you you stay in touch no if youâ&#x20AC;&#x2122;re on the go. To help itâ&#x20AC;&#x2122;s easy to miss something on in organized medicine so Thereâ&#x20AC;&#x2122;s a lot going

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• PREsIDENt’s PagE •

Rising Tides

a

tiM J. AlfOrD, MD 2010-11 MSMA PreSiDent

t its 163rd annual meeting in Chicago, our aMa delegation had finished up four hours of reviewing resolutions and board reports in the a.m. and four more hours of “house activity” in the p.m. a few moments were left to take in a museum, shop or jog in the rain. I opted for the latter. There is nothing like processing a little more oxygen to clear a cluttered head! The reality that almost 70% of our MSMa membership had deunified from the aMa weighed heavily on my mind. The fact that many would have our delegation “give it up” was not helping my headache. earlier that morning I heard J. James rohack, Md, aMa past president, stand by his year of service as president of the aMa. he once again explained the aMa’s qualified support for the new “Law of the Land.” dr. rohack acknowledged deficiencies in the legislation but was unapologetic that the aMa continues to participate in the process.

The aMa put up fierce resistance over the advent of Medicare in the 1960s, which culminated in the infamous Madison Square Garden speech given by dr. edward annis, then chief spokesperson for the aMa. dr. annis spoke to vacant seats in the Garden on the very spot where President Kennedy had given the pro-Medicare speech two days earlier. The Social Security act of 1965 became law due to a ground swelling, and for almost fifteen years physicians were assigned the role of spectator as one regulation after another rolled out without physician input. dr. annis maintained that the aMa failed with these efforts because “we were not militant enough.” Like it or not, this time around physicians are not speaking to empty seats. rather, they have a seat at the table. There will be no symbolic speeches to an empty audience railing against the throes of government. rather, we will have prime seating at a most important table along with nurses, pharmacists, hospital administrators, and insurance executives as the regulation process begins. But I digress – back to my jog. I headed north toward Lake Michigan and found myself at a dead end near Chicago’s navy Pier, a national landmark. “Can you get me in the door?” asked a young mother, also a census worker, who was being escorted by her precious two daughters riding pink bikes with training wheels. The mother had mistaken me for a local resident and was trying to gain access to the adjacent apartment complex to complete a census interview. Coincidentally, just one hour earlier reference Committee C report 15a had referred to U.S. Census data which projects the U.S. population will reach 350 million by 2025 and that the numbers of Medicare beneficiaries will double during this time due to the boomer effect, the first wave of which is due January 2011. The report states that the nation’s physician workforce reflects the broader society with over 1/3 of our workforce over the age of 55. even with efforts to graduate more physicians, the prospect of adding 40 million patients to the existing workload nationwide seems overwhelming, and most of us will have retired at the crest of this tsunami. as I watched the two girls navigate their bikes, I apologized to the mom that I could be of no help to her. The rain let up, my head cleared and I adjusted my course. I passed the embronzed “Captain on the helm Statue,” the mariner statue that stands guard over Chicago’s navy Pier. I noticed the engraved words on the pedestal. “We shall never sail this vessel by this way again.” I thought once again of James rohack’s remarks earlier

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that day that seemed to stand at odds with so many of our members of MSMa. What could be wrong with getting more americans insured so that fewer live sicker or die younger? or reforming an insurance system whose main business model was designed to avoid coverage for those who needed it the most? or casting light on a 10-year-old perpetual game of chicken with Congress over the fatally flawed SGr formula used to calculate physician fees? The aMa’s position is, scrap it or fix it. More to the point, Congress, you broke it; you fix it. Watch this year as the new proposed Medicare physician reimbursement cut grows from 21 to 26% by november 2010. The good that many see in the health reform legislation is at least partially eclipsed by this ever enlarging and unpaid Medicare bill. one hundred percent coverage for preventive health care services under Medicare, bringing Medicaid payments up to Medicare levels and a 10% pay enhancement for up to 60% of primary care physicians and rural general surgeons – these positive features are drowned out by the constant threat of the SGr formula. The daunting challenge and expense of embracing health information technology is very much dependent on Medicare and Medicaid funding remaining intact. This is especially true for so many physicians, particularly in Mississippi. now we once again have a temporary fix through november 30th of this year with a 2.2% update retroactive to June 1. a permanent fix breaks down along party lines in the Senate, but our senators should realize that the stakes are higher for Mississippi than any other state. of the total population of payers in Mississippi, Medicare makes up 11.2% and Medicaid 21.2% equalling 32.4%. This is soon to grow by another 10% as health reform becomes reality. In many rural practices across Mississippi, this percentage of Medicare and Medicaid patients is as high as 60%. Senators Cochran and Wicker should be reminded that when physicians stopped delivering babies ten years ago due to the malpractice crisis, they never went back to that skill even though now physicians’ malpractice insurance premiums are more affordable. Mississippi’s infant mortality rate has suffered as a result. as Medicare cuts loom larger and larger, the concern is that physicians will cease seeing new Medicare patients or opt out all together, and our state will feel the repercussions of this debacle like no other. It is time to stop thinking in terms of the short cycle fix to which we seem to be addicted and help our public officials understand the magnitude of this problem. I jogged around the corner away from Lake Michigan and back toward the hotel on the return leg of my loop. I noticed two pink bicycles with training wheels locked to the step rail outside an apartment building. I imagined the mother dutifully carrying out her census interview, adding one more to the swell of the wave. This jog in the cold rain cast a new light on the day’s proceedings at the aMa, and it served as a reminder that the tsunami loaded with baby boomers is headed our way. as we move toward higher ground, we must continue to remind our congressional delegation that the tide is rising and our patients deserve more than a mere flotation device.

Tim J. Alford, MD President, Mississippi State Medical Association

What You Can Do to Stop the Rising Tide of Medicare • Inform patients about the Medicare crisis by placing an informational flyer in your waiting area. Visit www.MSMaonline.com for a printable sample. • Contact your elected officials (and ask patients to do the same) to express your concerns. Visit www.contactingthecongress.org, and enter your home address to view the names and contact information of your U.S. Senators and Congressmen. • Write a letter to the editor in your local paper to inform the community about the Medicare crisis. For an example letter, visit www.MSMaonline.com. (Go to www.mspress.org for a full listing of weekly and daily newspapers, along with their contact information, in the state of Mississippi.) • Write a letter to your patients and ask for their help. For a sample patient letter, visit www.MSMaonline.com. august

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• EDItORIaLs • A Trip to Boston: Reflections on Battling the Obesity Epidemic

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t is hard to be a physician in Mississippi without being deeply troubled by the obesity epidemic. almost every day in my pediatric practice I have conversations with concerned parents and their overweight children about this issue. We discuss improving diets, increasing physical activity, and making lifestyle changes that can lead to better health. These discussions rarely seem to help. Feeling frustrated, I registered for a harvard Medical School CMe course this summer --“The 24th annual International Conference on Practical approaches to the Treatment of obesity.” a good portion of the advertised syllabus was devoted to pediatrics. Perhaps, I thought, there is a new approach or pill or diet being employed elsewhere that could benefit my patients. The conference started on a good note. The keynote speaker, an Md/Phd neuroscientist, presented his research on a noninvasive therapy called transcranial magnetic stimulation (TMS). his studies have identified an area in the right prefrontal cortex that governs decision-making and commitment to long-term goals, an area that tends to be hypoactive in obese patients. Stimulating this region of the brain using TMS has been found to reduce food cravings and decrease appetite. Studies have also indicated that regular exercise produces positive changes in this cortical region—another reason to exercise! From there the conference sessions became increasingly discouraging. The director of the Comprehensive Weight Control Program at new york’s Presbyterian hospital talked about the scant handful of drugs currently being used for weight loss. none is particularly effective (average 3-4 kg of weight loss); all have significant potential for side effects; and there are no safety or efficacy data in children. a psychiatrist from the University of Pennsylvania reported modest sustained weight loss among participants in an intensive year-long counseling and nutrition program promoting diet and lifestyle modification at his institution. This program is supported by a large grant from the department of health & human Services and a manufacturer of meal replacement shakes featured prominently in the diet plan (Slim-Fast, Unilever United States, Inc.; englewood Cliffs, new Jersey). It seems obvious that our overweight patients will benefit from more contact with counselors and dieticians as they attempt to slim down. yet how will most patients afford such treatments when insurance companies refuse to cover even a doctor’s visit coded for obesity? The most enthusiastic and excited speakers were the surgeons, and why not? Surgery is curing diabetes, hypertension, sleep apnea and dyslipidemia all over the globe. I learned about lap banding, gastric bypass, and a procedure called sleeve gastrectomy that many are thinking will be the future of bariatric surgery. apparently safety data are acceptable and the success rates are high. Why, postulated one surgeon, should we be offering the most successful therapy for morbid obesity to less than 1% of the population who needs it? Perhaps it’s a non-surgeon’s viewpoint, but I find it depressing that the best modern medicine has to offer obese patients is major anatomy-altering procedures. another disappointment: hardly a word spoken on prevention at the conference. Several presenters referred to Michelle obama’s “Let’s Move” campaign and then said something like, “I hope she gets somewhere with that.” Surely more can be done to understand the best ways of preventing obesity. Can physicians partner with schools, community organizations, and governments to make a difference? So, after three days in Boston, I am left with the same impression that I had at the outset: doctors have yet to figure this out. at present, the success or failure of most weight-loss efforts rests with the patients. There are, of course, a few people who have had tremendous successes. and when I encounter them I am often compelled to ask how they did it. Most of the time their stories begin with a simple phrase like, “I just decided.” or, “It was time.” These individuals have been able to tap into the areas of their brain governing resolve and then make commitments to prolonged changes in their behavior. The most recent story I heard came from a parent in my practice who lost almost 50 pounds. When I asked how she got started, she told me that she changed her diet and began exercising regularly when her internist encouraged her to lose weight. I guess I’ll keep having those conversations with my patients and their parents, even if success is a long shot. —Joanna Miller Storey, MD Jackson

The Pen is Mightier than the Sword! express your opinion in the JMSMA through a letter to the editor or guest editorial. The Journal MSMA welcomes letters to the editor. Letters for publication should be less than 300 words. Guest editorials or comments may be longer, with an average of 600 words. all letters are subject to editing for length and clarity. If you are writing in response to a particular article, please mention the headline and issue date in your letter. also include your contact information. While we do not publish street addresses, e-mail addresses or telephone numbers, we do verify authorship, as well as try to clear up ambiguities, to protect our letter-writers.

you can submit your letter via email to Kevers@MSMaonline.com or mail to the Journal office at MSMa headquarters: P.o. Box 2548, ridgeland, MS 39158-2548.

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• EDItORIaLs •

The Perfect Storm: A Clinical Vignette

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he movie “The Perfect Storm” released in the year 2000 starred George Clooney as fisherman Billy Tynes. at the confluence of bad decisions, a large storm, and a small boat, a group of men lost their lives while fishing. Like those fishermen, we as physicians often make decisions that affect the lives of not only our patients but their families as well. a 55-year-old woman in otherwise good health had complaints of intractable pain due to degenerative changes associated with scoliosis. She was to undergo repair of her scoliosis in a staged fashion. her hematocrit in her initial surgery was slightly low at 36% (she had donated autologous blood for her surgery). The first portion of the procedure went well, and she was scheduled for alignment of her spine and placement of surgical hardware two days later. however, her hematocrit had dropped to 20.7% by the morning of her second surgery. aware of the low hematocrit, the surgeon decided to proceed with an elective procedure without any evaluation of her drop in hematocrit or transfusion of the patient before proceeding. additionally, the patient was not seen by the anesthesiologist prior to her second procedure but instead was seen by the nurse anesthetist. The nurse anesthetist was aware of the low hematocrit but did not report it to the supervising anesthesiologist and instead relied on the discretion of the operating surgeon. Finally, the patient was being followed by an internist while the hospital. The internist had ordered a hematocrit on the morning of her second surgery. It was dangerously low, but the nurse, instead of calling the ordering physician, called the operating surgeon instead. The patient was taken to surgery. during the procedure, she lost both sensory and motor nerve function indicating significant cerebral hypoxia about an hour before a cardiac arrest occurred. at the time of cardiac arrest, her hematocrit was 14% and she required 9 units of blood that day during her resuscitation. a stormy postoperative course ensued which included acute renal failure and a tracheotomy for prolonged intubation. She resided in the neurological intensive care unit for three months, was sent to the Shepherd Brain Center in atlanta for six weeks, and transferred back to the Methodist rehabilitation Center for another month before returning home. Currently, she has severe anoxic brain damage and is in a persistent vegetative state. She has cortical blindness and is quadriplegic requiring total 24/7 home care including PeG feedings. a patient undergoing medical treatment has certain rights. among others these include: a) taking part in treatment decisions and b) considerate and respectful care from his or her doctors, these according to the U. S. advisory Commission of Consumer Protection and Quality in healthcare Industry (1998). In this vignette, did the patient benefit from: • a delay in surgery to evaluate the drop in her blood count? • Blood transfusion prior to surgery? • adequate informed consent prior to her second procedure? The low hematocrit was never discussed preoperatively with the patient or her husband (who is a physician) • anesthesiologist seeing his patient prior to surgery? • Structured chain of command in which the mid-level provider (Crna) reports to the anesthesiologist? • Medical system protocol in which the nursing service informs the ordering Md of the abnormal STaT lab? The answer to each of these questions is a resounding no! Medical care should be a collaborative effort with checks and balances to protect the patient; there should be redundancy in the system to prevent errors. To borrow a sports metaphor, there were four “ blown” assignments in this vignette. The surgeon's poor judgment, the anesthesiologist's abrogation of his responsibility to see the patient himself, lack of command structure in which Crna reports to the supervising anesthesiologist and not the surgeon, and finally, the absence of a hospital protocol in which the abnormal lab data is called to the physician who ordered the lab test. Unlike a game or team, this patient will not have another play; there is no next year for her. Through no fault of her own, she does not get another chance to participate in the game of life. Formed in 1970, the Institute of Medicine (IoM) is a division within the U. S. national academy of Science (chartered by Congress in 1853). The IoM published a consensus report in november 1999 entitled “To err is human: Building a Safer System.” This report, they detail 44,000 to 98,000 hospital deaths per year as a result of medical errors, more than those due to MVa, breast cancer or aIdS in a year. The cost per year ranges from 17 to 29 billion dollars. This does not take into account the accompanying toll in human misery. Initially, on reading this report, I did not think these types and the sheer number of incidents were possible. Sadly, I am now a believer. For this incident did not occur in new york or some far off place but in the metropolitan Jackson area. The woman mentioned in this vignette is not only a patient but my best friend and wife of 35 years. august

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My plea to the JMSMA readership is simple and may be summarized as follows: • Primum Non Nocere. The watchwords of hippocrates, “First do no harm,” remain true. Proceed cautiously; be conservative in your treatments. Investigate, evaluate, and then act. If in doubt, consult others. Communicate with your patients and other medical professionals. • Take responsibility for your actions. your patients have entrusted their health and their very lives to you. Live up to that heavy responsibility. Give the best of your training and expertise. no one can do that but you! See your own patients. don’t rely on others to do your job. • Become a patient advocate. The needs of the patient come first and outweigh yours. Personal concerns come second, i.e., take care of the patient even if it causes some disruption in your planned schedule. dedicate yourself to the well being of your patient. • Finally, practice the “Golden rule” of medicine (Matthew 7:12). Simply put: treat your patients as you like to be treated. This can be as easy as letting your patient know when you will be making rounds, staggering time of arrival for your patients for procedures to minimize their wait time, and calling your post-op patients at home to check on them. It can be as important as taking time to discuss abnormal labs, instituting a thorough work-up prior to a procedure, or even deferring a surgery if a significant problem is found. In so doing, the health of our patients will be improved, and tragedy averted. —C. Ron Cannon, MD Jackson

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• LEttERs • Observations, Analysis, Consideration, and Concerns of a Delegate

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joined the american Medical association (aMa) in 1944, as a student. I joined Central Medical Society (CMS) and Mississippi State Medical associations (MSMa) in 1948, when I entered the practice of private medicine in Jackson.

Thirty years later, I finally dropped my aMa membership because I had long realized that repetitively and continuously it did not represent me but did support and promote the unconstitutional intrusion of the federal government (and its retainers) into the practice of medicine. Because of the then recently added requirement of MSMa that I also be a member of the aMa (and I was not), I was expelled from CMS and MSMa. What irony! at the request of MSMa executive Secretary rowland Kennedy in 1971, I had flown aMa President Bornemeier from new orleans to Biloxi in our Piper Comanche n987Md for him to address the MSMa house of delegates. dr. Bornemeier cajoled the house to sign on to joint membership to get “in the mainstream” when there were only two other states with joint membership, at the time: oklahoma and Illinois. Corollary to this, wife Lynn’s membership in the auxiliary (later alliance) was also cancelled. She had been president of central and state auxiliaries. My decision and action cut her off /out of an activity she greatly enjoyed and at which she was very adept. It weighed, and still weighs, heavily on me. The alliance officers graciously continued to invite her to their functions, in respect and deference. With the removal of required joint membership last october 3 (MSMa was the only remaining one of the 54 state medical societies to so require), Lynn and I claimed reinstatement that very Saturday afternoon and were granted same on Monday morning – after an absence of 30 plus years. of practicing physicians, 17% or less are currently members of the aMa with membership dwindling due to the aMa’s repeated support of obamacare. There are rumblings that the aMa is considering greatly reducing its dues, inferring that its low membership is due to high membership fees. Same are high, but such an action would only be shouting admission that the dollar amount is of no real importance to the aMa, since 80% of its income is from sources other than dues. For instance, the net profit after expenses from the aMa’s over 100 books and products, including CPT coding copyright royalties, is $33,600,000 annually. Thus, the dues could be $0.00 and still have no real effect on its financial status. Lynn, the queen of my home for 69 years, went to glory on april 25. In natchez on June 5 I sat in on the alliance meeting in the ballroom of the Grand hotel in her stead. her accomplishments were extolled. Per Lynn’s directive, I distributed copies of her book, When God Said No. Therefore, when I attended the MSMa meeting in natchez this past weekend I was alone. While participating as a delegate from Central, I observed that in spite of the overwhelming expression of the membership at the special called meeting of the house, the board of trustees persists in wimpy temperance. one past president suggested that it was premature for the MSMa to take action now regarding obamacare – but should wait until the implementing regs are published. That is like the girl waiting until during the act to object to what her assailant was fixing to do. another MSMa officer exclaimed that (after a fellow delegate had pointed out the dismal historic failure of timidity and appeasement in fending off the forbidden intrusions of Medicare and the other third party interventions) he had left his hip waders at home, implying that the delegate’s presentation was trochanter-high in fresh cow pies. how undignified! Members of these families have been patients of mine. I was also impressed that some physicians, with at least two degrees following their name, should never have been promoted out of third grade english. There were expressions like “each one of you give their opinion” and “irregardless.” The U.S. Constitution, the “supreme law of the land,” forbids the central government to be in medicine (also education, insurance, welfare, power, banking, agriculture, etc.). eighty percent of what Congress enacts the Constitution forbids. Therefore, the only law-abiding position for MSMa to hold regarding obamacare, Medicare, Medicaid, Social Security, etc. is “no.” even sections 1801, 1802, and 1803 of the Medicare law itself orders government non-interference, in print. representatives and Senators take an oath to obey the Constitution. a vote otherwise is perjury – a felony. as a matter of ethics, the practice of medicine entails one patient and his chosen physician – PerIod. all other entities are Pinocchios, interlopers, opportunists, exploiters – sticking their noses into the affair of patient/physician though forbidden to do so. The cost of “health care” inherently includes hospitals, brace shops, helicopters, ambulances, large bureaus, huge buildings, thousands of employees, and thousands of regulations. obamacare calls for upwards of 150 new bureaus. It will require at least 16,000 new employees in the department of Internal revenue alone. Medical care, on the other hand, is the voluntary interaction of but two people. nine percent of the health care dollar goes to physicians. continued next page...

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yet, we are blamed for health care being so expensive – an obvious misstatement, to say the least. a citizen having insurance does not equate with his receiving care. ask Canadians or those in the United Kingdom. In 1965, I wrote, personally stamped, licked, and mailed a letter to each of the 1,900 physicians in MSMa (3910 today) listing 110 reasons for Mississippi physicians noT to participate in Medicare. When I made a truncated presentation verbally to a local hospital medical staff (of which I had been chief), I was booed loudly. Some of those who booed now put their arm around me and say they should have listened. Well, listen, react, and act now. again (still), it is time to say, “no.” In reality, the current issue is not about “health or medical care.” It is about the rescinding by government, contrary to the supreme law of the God-endowed, inalienable liberty of every patient and each physician i.e., freedom from tyranny. —Curtis W. Caine, Sr., MD Brandon P.S. – Support hr 5444 and hr 4005.

In Reply to Editorial, “But Will It Take?” cartoon by ross turner

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he cartoon here is offered affectionately in response to an editorial, which appeared in the april JMSMA (J Miss Med Assoc. 2010;51:123), written by Stanley hartness, Md. In the editorial, dr. hartness, who recently retired from Kosciusko Medical Clinic, questions how patients will react to the latest hospitalist plan. To reiterate, he wrote:

“The basic plan goes something like this: Each week a different clinic physician manages all hospitalized patients (except for the ones under the care of those high-priced longhorn recruits). The remaining clinic physicians, no longer obligated to hospital rounds, begin morning appointments earlier and are free in the evenings to vacate the premises when the last patient is seen. Well, this old dog, only a heartbeat away from retirement at the time and fairly resistant to “tHey Are My BrOtHerS, BUt i SAy, tHrOW tHe GOlf PlAyinG MOney new tricks especially when they involve my GrUBBerS UnDer tHe BUS.” patients, opted out of the hospitalist rotation, continued to make morning AND EVENING hospital rounds (which seemed to be appreciated by both patients and nursing staff), and conducted a clinic practice as usual. Just as questions continue to swirl about national healthcare reform, several uncertainties concerning the local variety waft through my head. Are patients content to absolve "their doctor" of their hospital care? …Will patients view the hospitalist system as self-serving for moneygrubbing doctors anxious to head out early to the golf course? … I'm now removed from the scenario described above, but I plan to monitor the process. I would venture to guess that many of our readers have answers to the above questions. If not answers, then surely opinions ... unless already totally spent on Obama/Reid/Pelosi!” —Your band of brothers and one sister at Kosciusko Medical Clinic The comments expressed in this Journal are those of the indicated authors. Letters and opinions are not expressions of the views or official policies of the Mississippi State Medical Association. We invite the membership to submit comments for publication regarding any opinion expressed or information contained in the Journal. Send to: Lucius Lampton, MD, Editor, P.O. Box 2548, Ridgeland, MS 39158-2548 or email KEvers@MSMAonline.com. We encourage your comments.

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• sPECIaL aRtICLE •

Day 100 of the BP Oil Spill Disaster and Public Health in Mississippi By Karen A. Evers, Managing Editor

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Photo by nAncy Morris

uly 28 marked the 100th day of the worst offshore oil spill disaster in U.S. history. as much as 4.9 million barrels, or 205.8 million gallons, of oil have spewed into the Gulf since the deepwater horizon rig, leased and operated by British Petroleum (BP), exploded april 20, killing 11 workers. Since then, the Mississippi State department of health (MSdh) has developed a surveillance plan to monitor the potential health effects in the state’s affected communities. “While ecological impacts are more likely, there may be human health effects,” said State health officer State dr. Mary Currier. “We are cooperating with state and federal agencies to evaluate possible human health risks in addition to the effects already seen on animal and marine life.” according to dr. Currier, Mississippi is also reviewing information electronically submitted by emergency departments about each patient’s chief complaint. health authorities perform this review daily to identify unusual trends that possibly related to the oil spill. Mississippi is also looking at Mississippi Poison Control Center data to determine the number of calls related to the oil spill and to watch for unusual trends. health care providers who encounter patients that have symptoms that may be due to exposure to petroleum products are encouraged to call the Mississippi Poison Control Center for consultation or reporting, at (800) 222-1222. The Centers for disease Control and Prevention (CdC) has been providing MSdh with data on similar syndromes through BioSense, a surveillance network that monitors visits to department of defense and Veterans administration facilities on the coast. In addition, chief complaint data reported electronically from three coastal emergency departments is monitored for increases in the following four syndrome categories: 1. febrile respiratory illness 2. rash 3. afebrile respiratory illness 4. other (nausea, vomiting, and headache) If unusual trends are found in any of the four syndrome categories, Mississippi’s state and local departments of health will work to see if there is a relationship between the oil exposure and the symptoms. dr. Currier said, “So far no increases in illness have been identified as associated with oil exposure.”

SUrVeillAnce ActiVitieS on May 10, 2010, MSdh began enhanced syndromic surveillance looking for potential acute health effects related to the oil spill. Five coastal hospitals and four inland hospitals (to serve as comparisons) are providing data. MSdh is receiving daily reports of emergency department visits that fall into the four syndrome categories listed above. “as of June 11, we asked the coastal hospitals to collect also information about possible oil exposures among these patients,” dr. Currier said.

tArBAll - FREsH sPLOtCHEs OF CHOCOLatE-COLORED CRuDE, PROBaBLy gLOBuLEs BROkEN aPaRt By CHEMICaL DIsPERsaNts sPRayED By

BP WItH gOvERNMENt aPPROvaL,

stILL WasH uP aLMOst DaILy ON PROtECtIvE BOOM aND IN MaRsHEs IN REOPENED FIsHINg gROuNDs East OF tHE

MIssIssIPPI RIvER. WHILE sOME taRBaLLs May BE as LaRgE as PaNCakEs, MOst aRE COIN-sIzED (a RELatIvELy LaRgE taRBaLL Is sHOWN IN tHE PHOtO aBOvE). taRBaLLs aRE PERsIstENt IN tHE MaRINE ENvIRONMENt aND CaN tRavEL HuNDREDs OF MILEs.

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one of these is Memorial hospital of Gulfport where staff physician dr. Philip Levin reports, “We are seeing surprisingly few cases directly attributable or identifiable as related to toxic effects of the oil. despite the several thousand workers on our beaches and near-shore waters involved with direct contact oil spill cleanup, we are seeing fewer than five a day in our e.r. however, it’s important to note we would not be seeing workers who are involved with deeper water clean-up, such as on boats,” he said. “We are seeing mostly minor respiratory illnesses; sinus congestion, and asthma. I treated a 16-year-old girl this week. She runs every day for exercise in her home state of Georgia. Visiting her father this week, and running on the beach, she had her first asthma episode in over five years. This was most likely caused by stimulus from oil residual, though not proven,” dr. Levin said. “no oil associated illness increases have been detected at this time.”

rePOrt exAMPle: MSDH recent finDinGS (JUly 7 – JUly 12) • on July 7, health authorities detected an increase in the rash syndrome in the coastal hospitals. Further investigation revealed that this increase was not oil-related. • on July 8, 11, and 12, health authorities detected an increase in the “other” syndrome (headache, nausea, vomiting) in the coastal hospitals. Further investigation revealed that these increases were not oil-related. • Since June 11, patients seen in the coastal hospital emergency departments have reported 27 of their own oil-related visits. • The Mississippi Poison Control Center reported three calls, which callers said were related to the oil spill during this period.

POtentiAl HeAltH effectS

Photo by nAncy Morris

Individuals may be exposed to the oil through direct skin contact, ingestion through contaminated food or water, airborne particulate matter that could result from in situ burning of the oil, or exposure to oil odors. Symptoms vary dependent on the pathway of exposure. Prolonged skin contact with crude oil may lead to slight to moderate skin irritation, and ingestion may lead to gastrointestinal complaints such as nausea and vomiting. The oil that most individuals may be exposed to is heavily weathered and emulsified, with significant evaporation of the volatile organic compounds which are of most concern in crude oil vapors. The substances that are evaporated from oil can be smelled at levels far below levels of concern for health. Some individuals may be more sensitive to the odors or particulate matter, which can lead to headaches, nausea, vomiting, and exacerbations of chronic respiratory illness.

BUrneD Oil - tHIs DaRk-COLORED PIECE OF EMuLsION Is LIkELy a

BP OIL sPILL. WHEN CRuDE OIL FLOats ON tHE OCEaN DuRINg tHE FIRst FEW HOuRs OF a sPILL, tHE OIL sPREaDs INtO a tHIN sLICk. WINDs aND

REMNaNt OF tHE

suRFaCE, Its PHysICaL CHaRaCtERIstICs CHaNgE.

WavEs tEaR tHE sLICk INtO sMaLLER PatCHEs tHat aRE sCattERED OvER a MuCH WIDER aREa.

vaRIOus PHysICaL, CHEMICaL, aND tHEsE PROCEssEs aRE gENERaLLy CaLLED “WEatHERINg.” INItIaLLy, tHE

BIOLOgICaL PROCEssEs CHaNgE tHE aPPEaRaNCE OF tHE OIL.

LIgHtER COMPONENts OF tHE OIL EvaPORatE MuCH LIkE a sMaLL gasOLINE sPILL. IN tHE CasEs OF HEavIER tyPEs OF OIL, suCH as CRuDE OIL, MuCH OF tHE OIL REMaINs BEHIND.

sOME CRuDE OILs MIx WItH

WatER tO FORM aN EMuLsION tHat OFtEN LOOks LIkE CHOCOLatE PuDDINg.

tHIs EMuLsION Is MuCH tHICkER aND stICkIER tHaN tHE WINDs aND WavEs CONtINuE tO stREtCH aND tEaR tHE OIL PatCHEs INtO sMaLLER PIECEs, OR taRBaLLs. taRBaLLs tEND tO HavE a CONsIstENCy sIMILaR tO PEaNut ButtER. ORIgINaL OIL.

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DiSPerSAnt cHeMicAlS AnD GUlf cOASt tOxicity SynDrOMe (GctS) recently coined by bloggers, GCTS is a catch phrase suggesting illnesses caused by the oil spill and the chemicals released. These include both aromatic and heavier hydrocarbons. These toxic chemicals include carbon rings, such as benzene, and toxic hydrocarbon compounds, such as hydrogen sulfide and methylene chloride. The agency for Toxic Substances reports, “Benzene is a human carcinogen, and can cause various forms of cancer from prolonged exposure. exposure to high levels of benzene shows association with leukemia cancer. Benzene-related leukemia has been reported to develop in as short as nine months.” dr. Levin says, “Volatile hydrocarbon (VoC) toxicity can be an acute illness, but like many poisons, once past the initial resuscitation, long term effects can be deadly. I have surveyed my colleagues and none has reported treating a significant toxicity to date. Most of these VoC dissipate quickly and are mostly acutely toxic only in high density. “as the spill is over a hundred miles from our coast, the acute toxicity is less likely to be a problem (except for those highly sensitive, such as asthmatics) than the buildup. It is worth noting that the cleanup workers are wearing gloves but are not wearing masks,” he said. “another concern is absorption of oil byproducts through the skin. Polycyclic aromatic hydrocarbons (Pah) are ubiquitous in our society, air-borne in smoke from oil burns, in fumes from pumping gasoline, and in certain shampoos. Mothballs, creosote, and blacktop


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roads all contain Pah. It is believed Pahs are also present in large quantities in the oil spill residue. In laboratory animals, studies have shown Pahs cause lung and skin cancer, effect reproductive organs, and result in renal damage,” dr. Levin cautioned. “Unfortunately, our mental health services are already overtaxed. Memorial hospital of Gulfport (MhG) is the regional center for acute psychiatric triage and evaluation. our five-bed unit has been taxed, near and over-capacity for several weeks. This weekend we had overflow so that we were holding ten patients for psychiatric disposition,” dr. Levin said.

SeAfOOD SAfety fOllOWinG tHe GUlf Oil SPill “Part of the federal government response to the oil spill in the Gulf of Mexico is the monitoring of conditions that might affect public health and the safety of seafood,” dr. Currier said. aERIaL OBsERvatIONs OF tHE guLF REvEaL OIL sHEEN aND EMuLsIFIED The CdC warns the ongoing oil spill disaster in the Gulf of OIL at tHE suRFaCE, tHOugH tHERE Is NO DOCuMENtED CasE OF Mexico has the potential to raise concerns about possible health effects LIquEFIED OIL REaCHINg MIssIssIPPI's sHORELINE at tHIs tIME. from contaminated seafood harvested from the Gulf. The United States Food and drug administration (Fda) and other federal and state agencies are monitoring the seafood supply for signs of oil contamination. For the seafood to pose a health risk, the food would have to be heavily contaminated with oil, and would therefore have a strong odor and taste of oil. Presently, the Gulf States, Fda and the national oceanic and atmospheric administration (noaa) are conducting testing of seafood from the Gulf. CdC is monitoring for potential illnesses across the United States that may be associated with exposure to contaminated seafood. Persons who consume seafood contaminated by oil may experience the following symptoms: nausea, vomiting, diarrhea, and abdominal pain. “We understand that these symptoms are general, and that consumption of contaminated seafood might not necessarily be the cause,” dr. Currier said. • Drinking Water - at this point, the oil spill is not expected to affect public drinking water supplies or private well water. • Fish and Shellfish - any fish available for commercial sale, such as fish in grocery stores, comes from non-contaminated waters. Contaminated fish and seafood will not be allowed on the market by regulatory agencies. however, if fish or shellfish obtained from any source smells or tastes like oil, do not eat it. While both the MSdh and CdC websites make the above claims, the people who make their living off the seafood-rich waters of the Gulf of Mexico are skeptical of the government's assurances that fish harvested in the shallow, muddy waters just offshore must be safe to eat because they don't smell too bad. Shrimpers fear when the season opens and they drag their nets they will also collect traces of oil and dispersants — and that even if his catch doesn't smell, buyers and consumers will turn up their noses. The big economic question now is whether the american public is ready to buy Gulf seafood again. Some fishermen are worried about the buried oil, fearing that storms could stir it up and coat vital shrimp or oyster grounds, a possibility the government has not ruled out. yet Louisiana wildlife regulators have reopened state-controlled waters east of the Mississippi to harvesting of shrimp and “fin fish” such as redfish, mullet and trout. Smell tests on dozens of specimens from the area revealed barely traceable amounts of toxins, the federal Food and drug administration said. The tests were done not by chemical analysis, but by scientists trained to detect the smell of oil and dispersant. Chemical tests on fish for oil-related compounds are routine, but no such test exists for detecting levels of dispersant, said Meghan Scott, Fda spokeswoman. Federal scientists are developing one, she said. Though, it wasn't clear when one would be ready. The dispersants can kill incubating sea life, experts say, though its long-term effects are unknown. In humans, long-term exposure can cause central nervous system problems or damage blood, kidneys or livers, according to the Centers For disease Control and Prevention. Congressional investigators claim that the Coast Guard routinely approved BP requests to use thousands of gallons of dispersant a day despite a federal directive to cut its use. retired Coast Guard adm. Thad allen said that federal regulators did not ignore environmental guidelines, but that some field commanders were given the authority to allow more dispersants on a case-by-case basis.

Air MOnitOrinG ePa responders began portable monitoring of air quality on april 28, and began water sampling on april 30. aircraft were deployed to collect air sample data and provide aerial photographs and will continue tracking. The results of ePa's sampling efforts will be posted at www.epa.gov/bpspill. ePa will make recommendations for the public based upon the results of environmental monitoring. In addition, the august

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Center for Toxicology and environmental health (under contract with BP) is monitoring air quality between Venice, Louisiana, and Pensacola, Florida. The Mississippi national Guard has also performed air monitoring.

lOnG-terM HeAltH effectS The MSdh reports if exposure is brief long-term health effects are not anticipated.

exPOSUre tO Oil you should avoid direct contact with the oil, or oil-contaminated water or sediment. • • • •

If you get oil on your skin, wash it off with soap and water. Wash your hands before eating to avoid accidently swallowing oil. If you get oil on clothing, wash it with regular detergent separately from family laundry. harsh detergents, solvents or other chemicals are not needed to wash oil from your skin or clothing, and their use is discouraged.

MiSSiSSiPPi JOint OPerAtiOnS center Oil SPill OPerAtiOnS UPDAte On tHe 100tH DAy Of tHe Oil SPill –JUly 28: • Seismic and acoustic testing continues to ensure the integrity of the wellhead. • Pressure in the capped well continues to rise; today’s readings show that all indications are stable and no anomalies have been detected. The well continues to be secure and demonstrate integrity. • In the relief well, the development driller III’s riser is latched in and currently displacing sea water with mud. Blowout Preventer testing continues. • The anticipated start date for the hydrostatic Control Plan or static well kill is in early august. • The well has been capped for 12 days. • a total of 237 vessels are available for deployment today. Skimmers deployed Tuesday: n Bayou Caddy: 11 skimmers. n Bay St. Louis/henderson Point: 12 skimmers. n Biloxi: 10 skimmers. n Pascagoula/Petit Bois Island: 14 skimmers. • Twelve gallons of oil/water was collected. no boom was deployed or removed Tuesday. Continued general boom maintenance. an estimated 7% of boom was displaced by Tropical Storm Bonnie. Vessels of Opportunity deployed Tuesday: n Bayou Caddy: 38 vessels. n Pascagoula: 44 vessels. n Pass Christian: 49 vessels. n Point Cadet: 33 vessels.

WHAt’S next? as the calendar turns from July to august, crews have taken another step toward readying the relief well expected to kill the Gulf of Mexico oil gusher. Federal officials said yesterday they’ve removed the plug they had popped in before clearing the area ahead of Tropical Storm Bonnie last week. They also say a temporary cap on the busted well is holding firm and there is very little oil sheen on the water's surface 100 days after the rig explosion. retired Coast Guard adm. Thad allen said during a news conference in new orleans that officials are taking every precaution as they move toward a permanent fix. on a positive note, CBS news Correspondent Mark Strassmann noticed a changed, visibly cleaner Gulf while flying over Mississippi's entire coastline with the Civil air Patrol. he reports from Gulfport, “With the well capped and the spill breaking up it's tough to find any oil on the surface of the Gulf.” Considering the well spewed for 85 days, fouling marshes, killing wildlife and threatening the livelihoods of thousands of Gulf residents, it appears the Mississippi coast has been spared the worst. however, more than 2,200 closings, health advisories or notices were issued by state or local authorities through the end of July because of oil from the over three-month-long spill. despite the beach closings, “it is important to note there is no documented case of any liquefied oil reaching Mississippi. only tarballs and tar patties, in a solid or semi-solid form, have impacted Mississippi,” said George Malvaney, chief operating officer of United States environmental Services, one of the nation’s leading providers of oil and hazardous materials emergency response, currently serving as a liaison between the State of Mississippi and BP. “We actually interface with multiple state and local agencies,” Malvaney added. “oil has a finite life span in the environment,” Malvaney said, after a recent fly-over of the Gulf including the area between the

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Mississippi coast and the spill site. “at this point, there is almost no visible surface oil remaining. It appears to have dissipated.” The dissolution of the slick should reduce the risk of oil killing more animals or hitting Mississippi’s shorelines. Scientists believe the rapid dissipation of the surface oil may have been due to a combination of factors, including the natural capacity of the region to break down oil. Petroleum normally leaks from the ocean floor by way of thousands of natural seeps and certain bacteria are able to consume it. Winds from storms appeared to have aided in rapidly dispersing the oil, and the clean-up response by BP and the government helped control surface slicks. “Much of the oil may have simply evaporated at the ocean surface near the spill site,” Malvaney said, “including the more volatile and potentially toxic fractions of crude oil.”Conversely, a recent government report finds that about 26% of the oil released from BP’s runaway well is still in the water or onshore in a form that could, in principle, cause new problems. The report says most of the remaining oil is light sheen at the ocean surface or in a dispersed form below the surface, and federal scientists believe that it is breaking down rapidly in both places. assuming that the government’s calculations are accurate, “There’s no evidence that there’s any significant concentration of oil that’s out there that we haven’t accounted for,” said Jane Lubchenco, head of the national oceanic and atmospheric administration, the lead agency in producing the latest government report, released august 5th. She emphasized, however, that the government remained concerned about the ecological damage that has already occurred and the potential for more, and said it would continue monitoring the Gulf. “I think we don’t know yet the full impact of this spill on the ecosystem or the people of the Gulf,” dr. Lubchenco said. among the biggest unanswered questions, she said, is how much damage the oil has done to the eggs and larvae of organisms like fish, crabs and shrimp. That may not become clear for a year or longer, as new generations of those creatures come to maturity. efforts are still under way in Louisiana, Mississippi, alabama and Florida to clean up more than 600 miles of oiled shoreline. according to the report, the government and BP collected 35,818 tons of oily debris from shorelines through august 1. The report is a result of an extensive effort by federal scientists, with outside help, to add up the total volume of oil released and to figure out where it went. as the scientists did their calculations, they were able to rely on direct measurements of the fate of some of the oil that spewed from the broken well. For example, BP and its contractors succeeded in capturing about 17% of it with various containment mechanisms, the report says. The outcome for much of the oil could not be directly measured but had to be estimated using protocols that were scrutinized by scientists inside and outside the government, dr. Lubchenco said. The report calculates, for example, that about 25% of the chemicals in the oil evaporated at the surface or dissolved into seawater in the same way that sugar dissolves in tea. (The government appears to have settled on a conservative number for that estimate, with the scientific literature saying that as much as 40% of the oil from a spill can disappear in this way.) The aggressive response mounted by BP and the government — the largest in history, ultimately involving more than 5,000 vessels — also played a role in getting rid of the oil, the report says. Fully 5% of the oil was burned at the surface, it estimates, while 3% was skimmed and 8% was broken up into tiny droplets using chemical dispersants. another 16% dispersed naturally as the oil shot out of the well at high speed. all told, the report calculates that about 74% of the oil has been effectively dealt with by capture, burning, skimming, evaporation, dissolution or dispersion. Much of the dissolved and dispersed oil can be expected to break down in the environment, though federal scientists are still working to establish the precise rate at which that is happening. “I think we are fortunate in this situation that the rates of degradation in the Gulf ecosystem are quite high,” dr. Lubchenco said. The remaining 26% of the oil “is on or just below the surface as light sheen or weathered tar balls, has washed ashore or been collected from the shore, or is buried in sand and sediments,” the report says. The report comes as BP engineers began pumping heavy drilling mud into the stricken well on with the hope of achieving a permanent seal or at least revealing critical clues about how to kill the well before the end of the month.

iMPOrtAnt PHOne nUMBerS: Mississippi Emergency Management Agency Hotline: 866-519-6362. Submit claims to BP: 800-440-0858. Report oiled wildlife: 866-557-1401. Report oiled shoreline/vandalized, broken or damaged boom: 866-448-5816. Alternative technology, services or products/ vessels of opportunity: 866-279-7983. Report stranded dolphins or sea turtles: 888-767-3657. Report dead fish, birds or animals: 228-523-4128. Wildlife rescue training: 866-647-2338. If not satisfied with BP’s claims resolution, call the National Pollution Funds Center: 800-280-7118.

skIMMINg vEssELs CONDuCt CLEaNuP OPERatIONs NEaR tHE sItE OF tHE DEEPWatER HORIzON OIL RELEasE. august

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STATE AGEnCY ROUnD-UP OF REPORTS On DAY 100: JULY 28, 2010 MS Department of Environmental Quality (MDEQ ) and MS Department of Marine Resources (MDMR): a mandatory crab trap removal order by MdMr and MdeQ is only for the closed waters of the Mississippi Sound. In an effort to increase the survivability of any sea turtles that may become captured in a skimmer shrimp trawl, dMr is partnering with the national Fish and Wildlife Foundation, through the BP recovered oil for Wildlife Fund, to provide free of charge turtle excluder device gear and installation instruction to Mississippi commercial shrimpers who agree to voluntarily use Teds in their skimmer trawls. Tar patties were spotted in harrison County on a two mile stretch of beach between the Long Beach harbor and South Seashore avenue. Mars Lake beaches are clean in Jackson County, however, sporadic tar balls were spotted on the west end of Bellefontaine Point in ocean Springs and between Fifth Street and boat launch on Pascagoula Beach. Sporadic tar balls/patties were spotted east of Buccaneer State Park on the Waveland beach in hancock County. MdMr and MdeQ have opened Mississippiâ&#x20AC;&#x2122;s territorial marine waters to licensed live bait shrimping and recreational catch-andrelease hook and line fishing in areas previously closed. These areas are not open to any commercial harvesting activities. The beach advisories in hancock, harrison and Jackson counties remain in effect. Mississippi national Guard: The Mississippi national Guard flew four missions Tuesday in support of operation deepwater horizon response and will continue flying daily reconnaissance missions to locate oiled beaches, damaged boom and oil nearing the shores. BP and Incident Command Post Mobile: BP reports 19,691 claims in Mississippi and $22,133,734.48 has been paid. Claims offices in Mississippi are located in each of the coastal counties. office locations, contact information and more about the claims process can be found at http://bp.com/claims. Mississippi Emergency Management Agency: MeMa staff is working with BP to resolve reimbursement issues for local and state governments and assisting with individuals as the need arise. operations staff are visiting Vessel of opportunity collection points and verifying the amount of petroleum product collection. Three area Coordinators were deployed to coordinate information with local emergency managers in hancock, harrison and Jackson counties. Mississippi Commission for Volunteer Service (MCVS): Volunteers are needed for the following organizations: hancock Chamber of Commerce, Bay St. Louis Childcare development Center, Coastal rivers in south Jackson County waterways, humane Society of South Mississippi, Waveland animal Shelter, Bay area Food Bank, Mississippi-alabama Sea Grant, Institute for Marine Mammal Studies, Gulf Islands national, Walter anderson Museum. For more information on volunteer opportunities and responsibilities, visit www.mcvs.org and click on register to volunteer. MS Department of Employment Security: MdeS is accepting applications for Mississippi residents seeking paid oil response work. Visit www.mdes.ms.gov, and click on the oil spill link.

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• NEW MEMBERs • ADAMS, CRAIG V., Jackson; Born 7/19/1961 Pittsburg, Pa; Graduated M.d. Georgetown University School of Medicine, Washington 1986; Specialty: Cardiothoracic Surgery; Cardiovascular Services of Central MS.

GREnFELL, RAYMOnD F., Jackson; Born 7/5/1977 Cleveland, MS; Graduated M.d. University of Mississippi Medical Center, Jackson; Specialty: endocrinology, diabetes & Metabolism.

MnZAVA, CHRISTY, Meridian; Born 10/8/1977 Flowood, MS; Graduated d.o. ohio University College of osteopathic Medicine, athens 2006; Specialty: Family Medicine; riley My Choice Medical Clinic.

AGnOnE, JOHn H., Vicksburg; Born 10/7/1950 new Castle, Pa; Graduated M.d. Tulane University School of Medicine, new orleans 1976; Specialty: Cardiothoracic Surgery; Physicians of river region.

HAnD, DWIGHT E., Meridian; Born 3/18/1956 Covina, Ca; Graduated M.d., Ph.d. 1988; Specialty: Thoracic Surgery; rush heart Institute.

MOURAD, HATEM, Meridian; Born 6/26/1982 alexandria, eqypt; Graduated M.d. St. Christopher’s College of Medicine, england 2005; Specialty: Family Medicine; anderson hospital Medicine Group.

COYLE, JAnET A., Meridian; Born 2/6/1953 Colorado; Graduated M.d. Morehouse School of Medicine, atlanta 2002; Specialty: Family Medicine; riley hospital.

HOLBERT, ROBERT, Gautier; Born 8/28/1940 San Francisco, Ca; Graduated M.d. Tulane University School of Medicine, new orleans 1967; Specialty: Internal Medicine; Gautier Medical Center.

DIRMEYER, STEVEn n., Pontotoc; Born 12/5/1979 Memphis, Tn; Graduated M.d. University of Mississippi Medical Center, Jackson 2007; Specialty: Family Medicine; Pontotoc Medical Clinic.

JAVED, SHAZIA, Meridian; Born 3/19/1971 Pakistan; Graduated M.d. King edward Medical College, Lahore, West Pakistan 1995; Specialty: Family Medicine; Meridian hMa Clinic Management Group.

EVAnS, ERIC C., Jackson; Born 2/27/1978 Jackson, MS; Graduated M.d. University of Mississippi Medical Center, Jackson 2009; Specialty: Internal Medicine; Premier Medical Group of MS.

KILLEBREW, LARRY H., Gulfport; Born 2/10/1952 Greenwood, MS; Graduated M.d. University of Mississippi Medical Center, Jackson 1978; Specialty: General Surgery; General Surgery & MhG.

FYKE, KRISTEn T., Starkville; Born 1/3/1979 Meridian, MS; Graduated M.d. University of Mississippi Medical Center, Jackson 2006; Specialty: obstetrics & Gynecology; Starkville Clinic for Women.

LEnOX, VALERIE R., Biloxi; Born 4/10/1960 Washington, dC; Graduated M.d. Louisiana State University School of Medicine, new orleans 1987; Specialty: Internal Medicine; Cedar Lake Internal Medicine.

GREGG, FREDERICK O., hattiesburg; Born 2/9/1976 hattiesburg, MS; Graduated d.o. University of Kansas School of Medicine, Kansas City 2005; Specialty: orthopedic Surgery; Southern Bone & Joint Specialist, Pa.

MISKELLEY, MARK A., Bailey; Born 7/24/1960 russellville, alabama; Graduated M.d. University of alabama School of Medicine, Birmingham 1985; Specialty: emergency Medicine.

PATEL, SAGAR H., Jackson; Born 7/10/1977 Woodland, Ca; Graduated M.d. University of Mississippi Medical Center, Jackson 2003; Specialty: Psychiatry; St. dominic Medical associates. SCHAEFER, MARY A., Meridian; Born 1/27/1959 Temple, Texas; Graduated M.d. University of north Texas health Science Center, Ft. Worth 1993; Specialty: Pediatrics; riley hospital. SIMMOnS, EARnEST C., Meridian; Born 5/10/1945 Georgia; Graduated M.d. Medical College of Georgia, School of Medicine, augusta 1976; Specialty: Family Medicine; riley hospital. WEBSTER, STEVAn A., Brandon; Born 5/2/1951 Muncie, Indiana; Graduated M.d. Indiana University School of Medicine, Indianapolis 1977; Specialty: Internal Medicine; rankin hospitalists.

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• MsMa aLLIaNCE • Alliance Past President’s Spotlight Faye B. Lehmann 1969-1970, Natchez Raised:

north Carolina.

Married:

Met my husband, the late dr. Louis C. Lehmann, when I was a student nurse at Jackson Memorial hospital in Miami while he was an intern from Mississippi.

Children:

Louis Charles Jr., born 1953, lives in houston, Texas. Geoffrey Ray, born 1956, lives in natchitoches, Louisiana. Amy L. Garraway, born 1958, lives in hattiesburg. Lucy L. Sook, born 1967, lives in raleigh, north Carolina.

Hobbies:

Bridge, used to do a lot of needlework, reading, church and natchez Garden Club. I serve on the board of directors for Garden Clubs of Mississippi.

LEFT TO RigHT: FayE LEHMaNN WItH HER gRaNDDaugHtER, gREER gaRRaWay, ON HER DEBut aLONg WItH HER MOtHER aMy gaRRaWay, FayE’s DaugHtER.

Favorite Alliance (Auxiliary) memory: Probably going to national in Chicago and my own state convention, and all the friends I made along the way. The highlight was probably getting the bylaws changed to allow a chair to serve only two 2-year terms. Prior to then, some people kept the same job for 20 years or more. It was done to get more young people involved. It made me unpopular with some. also, while I was president, the auxiliary was given an office at MSMa for the first time. It was a little room next to the computer room. That first computer was as large as a small bus. I will never forget that for it was the first computer I had ever seen. r

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f you want to be “in the know” send an email message to sashley@MSMAonline.com. If your email has changed make sure you send your new address to the MSMA. You may update your profile information online anytime.

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• MsDH •

Physicians Can Make A Child’s Smile

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ental caries is an infectious disease usually passed by transfer of pathogenic bacteria from mother/caregiver to child in conjunction with high sugar content in the diet and the absence of good oral hygiene. More than 40% of children have tooth decay by the time they reach kindergarten, and more than 52 million hours of school are lost each year because of dental problems, as cited by the US department of health and human Services. In Mississippi, three in five (63%) third-grade children have experienced dental caries and one in three (31%) children has untreated disease. We know that parental guidance, good hygiene and a proper diet are critical to caring for kids’ teeth. yet, the crisis of poor oral health in Mississippi’s children is not attributed principally to parental inattention or poor nutrition. Systemic factors also play a role, such as in some communities there are not enough dentists able to provide dental care to young children. and, low-income children are disproportionately affected by a lack of access to care. Still, this growing problem is almost completely preventable through early intervention. We know that good oral health is conclusively linked to better overall health. In May 2003, the american academy of Pediatrics (aaP) published its first oral health policy statement, “oral health risk assessment Timing and establishment of the dental home,” urging pediatric medical providers to begin administering oral health risk assessments at 6 months of age. This was reaffirmed in the policy statement, “Preventive oral health Intervention for Pediatric Medical Practitioners,” published in the december 2008 issue of Pediatrics. Patients who have been determined to be at risk of development of dental caries or who fall into recognized risk groups should be directed to establish a dental home 6 months after the first tooth erupts or by 1 year of age (whichever comes first). Pediatricians will typically see these children long before their first dental visit. We are strongly encouraged to integrate oral health screening, anticipatory guidance, and referral to a dental home into every well child visit. approximately 40% of Mississippi's children receive Medicaid benefits, which places them in the high risk category for developing dental caries. It has been shown in recent studies that children who fall into high risk groups are 4 times less likely to develop dental caries if they receive at least 2 fluoride varnish applications per year. To enable Mississippi physicians to provide this service to their patients, Medicaid has developed a policy to reimburse medical providers for oral health assessment and fluoride varnish application for children under age three. Participation in the Mississippi Cool Kids (ePSdT) program is not required for reimbursement of these services. Physicians will be reimbursed for varnish application up to two (2) times per fiscal year per child, at least five (5) months apart. The dental procedure codes can be billed on the same claim with the other procedure codes for Mississippi Cool Kids (ePSdT) screening. To locate the physician guidance, go to the division of Medicaid website at http://www.medicaid.ms.gov/Programs.aspx, scroll down to Oral Health Assessment and Fluoride Varnish for Children Under Age Three. The billing codes associated with the oral health risk assessment and varnish application are: • d0145 – oral evaluation for a patient under three years of age and counseling with primary caregiver (with a reimbursement of $33.04) • d1206 – Topical fluoride varnish; therapeutic application for moderate to high caries risk patients (with a reimbursement of $22.42) In the past, medical practitioners considering an early dental referral were met with a two-fold challenge. Too few dentists were willing to accept infants into their practices, and many families with ‘at risk’ infants lacked the resources to access dental care. As physicians, we should reach out to dentists and dental organizations to establish collaborative partnerships and identify area dentists who will accept these referrals. These referrals should be made as with any other referrals, by contacting the dentist's office and assisting the patient in scheduling appointments. Together, we can make a child’s smile. Oral Health Resources • The aaP oral health Initiative offers a free, one-hour online CMe activity, Oral Health Risk Assessment: Training for Pediatricians and Other Child Health Professionals, to get you started with the basics. you can access this activity at http://www.aap.org/oralhealth. august

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• The Society of Teachers of Family Medicine and the american academy of Family Physicians offers Smiles for Life: A National Oral Health Curriculum. This is a comprehensive oral health curriculum designed for primary care clinicians with interactive online courses and clinical cases for individual and small group education, downloadable PowerPoint modules suitable for larger group presentations, instructional videos, and patient education materials. Free access to all materials through the support of the dentaQuest Foundation is available at http://www.smileforlifeoralhealth.org. • The Bright Futures in Practice: Pocket Guide for oral health can be accessed at http://www.brightfutures.org/oralhealth/about.html. • The University of Minnesota offers a free online course titled Training for Oral Health Assessment and fluoride varnish application with support from the Santa Fe Group/the american dental Trade association, the ruben-Bentson Chair in Pediatric Community health, delta dental of Minnesota, the Medica Foundation, UCare Minnesota, and the national Children's oral health Foundation. The course can be accessed at http://www.oralhealthzone.edu/. • dental providers participating in the Medicaid dental Program can be located from the Provider Search feature on the Mississippi division of Medicaid web site at www.medicaid.ms.gov. Elizabeth M Felder, MD, FAAP Mississippi AAP Chapter Oral Health Advocate Nicholas G. Mosca, DDS State Dental Director, Mississippi State Department of Health

MPHA Seeks Contributions to Fund Portrait for Dr. F.E. “Ed” Thompson, Jr. State Public Health Laboratory

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ore than $7,000 has been raised through generous contributions for the Mississippi Public health association (MPha) portrait of former State health officer dr. ed Thompson to hang in the new public health laboratory. Construction of the dr. F.e. “ed” Thompson, Jr. State Public health Laboratory is slated for completion in the fall. a grand total of $12,000 is needed for the commissioned piece. “The goal is in sight, but we’re not quite there yet,” said State health officer dr. Mary Currier. “Since the new Mississippi State Public health Laboratory currently under construction will bear the name of the health official who pushed for eD tHOMPSOn, MD, MPH its completion, we’re accepting donations to commission an official portrait. dr. Thompson was all about 1947-2009 the data and the evidence, and his efforts have made it possible to have an even stronger public health laboratory that will produce clean and strong evidence. The laboratory will not really be complete without his portrait in the lobby.” “ed Thompson served his state with brilliant talent and unimpeachable integrity. he was a true medical statesman who impacted this state’s public health in ways which will be felt for generations. he was a great credit to our profession, and he always appreciated and admired so much his fellow physicians, whom he considered the front line of public health. I would like to encourage that front line to join me in giving to this very worthy effort,” said dr. Lucius “Luke” Lampton, Chairman, Mississippi State Board of health. MPha is requesting your assistance with this project. Individual and organizational tax deductible contributions are being accepted and can be made payable to: Mississippi Public Health Association ATTn: Dr. Ed Thompson Memorial Portrait Fund Post Office Box 4834 Jackson, MS 39296

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• uMMC sOM •

University of Mississippi School of Medicine – Moving in the Right Direction

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he University of Mississippi School of Medicine (SoM) ranked high in two recent nationwide studies of medical schools, one that tracked rural physician placement and a second that ranked schools on progress in their social mission.

a study in the april issue of Academic Medicine listed the UMMC School of Medicine second in the nation among M.d.-granting institutions by percentage of graduates practicing in rural areas. When the nation’s 26 d.o.-granting schools were included, the UMMC SoM ranked third. The rural practice study analyzed medical school graduates from 1988 through 1997 who were practicing in rural areas in 2005. according to the report, 32% of UMMC’s physician graduates were practicing in the state’s rural areas during that period. West Virginia University School of osteopathic Medicine ranked first in the study with 41% of its d.o.s engaged in rural practice. The University of Minnesota-duluth, which was established to provide physicians for rural Minnesota and native-american populations, ranked second with 36% of its graduates practicing in rural areas. In a separate study evaluating the social mission of medical schools, the school placed 13th of 141 when analyzed for three aspects of social mission: percentage of graduates in primary care, percentage practicing in federally-identified health Professional Shortage areas and percentage of underrepresented minority graduates. The social mission study, published in the June 15 issue of Annals of Internal Medicine, used data from medical school graduates between 1999 and 2001. authors of the social mission study pointed out the nation’s three historically black institutions with medical colleges – Morehouse College, Meharry Medical College and howard University – not unexpectedly scored significantly higher than other schools. at UMMC, the School of Medicine’s mission is to admit and train students from Mississippi who will eventually take care of patients in Mississippi. The School of Medicine operates under the philosophy that students from rural communities are the people most likely to return and practice in a rural setting as physicians. We know, in both an anecdotal sense and from hard numbers, that Mississippi needs more primary care physicians and health-care professionals of all kinds. Considering the state’s largely rural population and that it often ranks last nationally in health factors such as obesity, heart disease, diabetes and stroke, it is our mission and our duty to educate physicians to meet those needs. nationally, medical schools struggle to achieve diversity in their enrollment. diversity often implies only race and ethnicity. But as it pertains to medical school admissions, we think of many other dimensions, such as geography, personal experiences and attributes, educational background, gender, and socioeconomic status. Mississippians will be served best by a diverse physician workforce. The recent strong showing in the two studies is not a fluke. efforts to recruit a diverse student body begin long before the application process. Pipeline programs run by the division of Multicultural affairs bring Mississippi school children to the Medical Center as early as sixth grade for extracurricular enrichment and introduction to health careers. numerous programs expose high school students and undergraduates to medical and research careers and provide test preparation for various entrance exams. The School of Medicine’s admissions committee aggressively recruits top undergraduates and maintain strong relationships with Mississippi’s colleges. UMMC offers multiple full and partialtuition scholarships, some for students underrepresented in medicine, some that encourage rural practice. The Mississippi rural Physicians Scholarship Program offers $30,000 scholarships to students who commit to practice primary care in a rural area. In the last 10 years about 28% of the school’s entering students came from rural counties. The school also offers two diversity-related scholarship programs, one from the robert M. hearin Foundation, the other funded by the Barksdale Foundation. august

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The medical school curriculum provides a number of opportunities for exposure to and emphasis of primary care. Preceptor programs in the departments of Medicine and Family Medicine provide increased awareness of the need for their future services in the state’s rural and underserved areas. The SoM is committed to continuing these important efforts to recruit and retain our best students in Mississippi – all of our best students. We are increasing the class size at a pace as rapid as funding and accreditation bodies allow. as we grow, we are careful to ensure we provide a quality program. In fact, in the last few years, while the number of students has grown, the performance of our students on national examinations has also improved each year. our senior students have exceeded the national mean year after year on the major national standardized exam which serves as one of our key benchmarks. With a continued focus on the need for more quality health-care providers, more physicians in rural Mississippi, more primary care providers, and the recruitment of a truly diverse student body, the School of Medicine and indeed all of UMMC continues to move in the right direction to improve the health and lives of Mississippians. The rural practice study is available at: http://journals.lww.com/academicmedicine/Fulltext/2010/04000/Which_Medical_Schools_Produce_rural_Physicians__a.17.aspx The social mission study is available at: http://www.annals.org/content/152/12/804.full —Lou Ann Woodward, MD Vice Dean, School of Medicine Associate Vice Chancellor for Health Affairs

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• IMagEs IN MIssIssIPPI MEDICINE •

FIN DE SIECLE GROSS ANATOMY FOR MEDICAL STUDENTS— This original photograph, previously unpublished and taken in 1898, is of the freshman medical school class of Long Island College Hospital at the turn of the last century. Gross anatomy has long been a rite of passage for physicians in training, and at the end of the nineteenth century, it was no different. This photograph had written on it in black ink: “L. I. C. H. 1898, Class of 1901.” Long Island College Hospital was founded in 1858 as a medical school and hospital and in 1860 became the first American medical school to require bedside teaching as a part of its standard curriculum. LICH faculty introduced use of the stethoscope and also early utilized anesthesia. It remains a 506 bed, teaching hospital located in the Brooklyn Heights/Cobble Hill section of Brooklyn, New York. While this photograph is not from a Mississippi medical school (Meridian had a school at the time, soon followed by the University in 1903), Mississippi doctors did attend this school and attended similar anatomy classes at the time. The students act as students always do, flippantly and immaturely. One dangles a cigarette from his mouth, while another points downward in exaggerated pose at the cadaver’s chest. Some are attired in aprons and gowns, while others wear coat, tie, and hat. Note the angled dissection tables and the condition of the linen wrapped corpses. I am sure they also named their corpses back then, for all medical students form a great attachment to that dear old body so kindly donated that we could learn. (There were still resurrectionists and grave robbers in 1898, unlike now!) I remember my dissection partners lovingly called our female cadaver “Gloria Vanderbilt!” If you have an old or even somewhat recent photograph which would be of interest to Mississippi physicians, please contact the Journal or me at lukelampton@cableone.net. —Lucius Lampton, MD, Editor Magnolia

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• POEtRy IN MEDICINE • [This month, we print a poem by William C. “Bill” Lineaweaver, MD, FACS, a Brandon plastic surgeon who operates the Joseph M. Still Burn and Reconstructive Center. Dr. Lineaweaver has an extraordinary talent with poetry, and your editor is particularly taken with this submission. The poem refers to Icarus, of Greek mythology, who attempted to escape imprisonment in Crete utilizing a pair of wings constructed out of wax and feathers by his father, the master Athenian craftsman Daedalus. Ignoring his father’s instructions not to fly too close to the sun, Icarus fell to his death after the wax holding the feathered wings together melted. Dr. Lineaweaver has broad interests and wrote an essay on the state of burn care in Mississippi, which was published in the April 2009 JMSMA (find and read if you haven’t!). For more of Dr. Lineaweaver’s poetry, see past JMSMAs. Also, Dr. Lineaweaver serves as Editor-in-Chief of the Annals of Plastic Surgery. Any physician is invited to submit poems for publication in the journal, attention: Dr. Lampton or email him at lukelampton@cableone.net.] —ED.

Echocardiogram: A Reading My heart strokes and flutters on the screen, an orchestra of unseen blood, a conductor of a flood, a secret, preyless bird, hovering on blood. We’ll all be like Icarus When we die; Breath, wings and heartbeat stop, and amazed, we drop In the mystery of miracles That stop.

— William C. Lineaweaver, MD Brandon

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• tHE uNCOMMON tHREaD •

Evidence Based r. Scott Anderson, MD

S

o you say, but what constitutes the evidence you base things on?

In Birmingham near the dawn of time when I was going through a course called Physical diagnosis, I remember hearing again and again and again, “don’t order a test unless you already have a pretty good idea of what you’re going to find based on your examination.” It made a lot of sense. That was when we still did stuff like pneumoencephalography. It would be another year before the first clinical C.a.T. scan was operational, and even then we could image only round stuff like a head. Back then if the test you were thinking about ordering involved sticking a needle into the ventricular system of somebody’s brain, pumping it full of air, and then standing the patient on his head, you didn’t want to do too many extra ones. That was the reason old fussbudgets like Sir William osler and Tinsley harrison insisted on dwelling so much on signs and symptoms of diseases and not just on which tests you should order to obtain a diagnosis. There’s another part of medicine. It’s the essence of what is almost magical about the way some physicians get to the heart of the matter while others never do. There’s something that even the best teachers can’t teach and the best physicians all have. It isn’t anything you can explain. you can call it intuition. you can call it sixth sense or whatever you like. But to figure out what is really going on requires paying attention and applying the knowledge we were given by all those physicians who came before us. I have to tell you that with CPT codes, standardized algorithm, and differential diagnoses that require unending testing, we’re losing something. Who said, “oh shut up!”? yeah, I know as a radiation oncologist that everybody already comes to me fully worked up, diagnosed, and ready to treat. But not always. I actually did learn a thing or two all those years working in e.r.’s and dive lockers around the world. The thing that seems to be most important in getting to the root of the problem is just listening. you have to listen hard to what the patient is really saying (and not hearing only the things you can bill for). When one of our divers was just driving everyone else in the dive locker nuts, I remember an old dive master telling me, “he’s got a bubble in his head.” “What makes you say that?” I asked affronted. after all, I was the newly minted diving medical officer with an M.d. after my name. “Two things,” the salt replied. “I know he did an exceptional exposure two days ago, and I know he’s acting like an a—hole!” “We can’t stick him in a chamber and press him just because he’s acting like a jerk,” I insisted. august

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“Sure we can,” he answered, with his nose two inches from mine. “I’m the master diver, and I say he needs to be pressed. you’re the doc and you can say he doesn’t, but you damned sure better be right because if a bunch of those bubbles gather up and block more blood flow to his brain, he’s gonna be a vegetable by morning.” We did, and he was his same old self before we ever hit 60 feet. I’ve used that same trick to diagnose a dozen primary brain tumors and probably 30 to 40 cases of brain mets since then. It’s not magic. It’s just knowing what you’re looking for and paying enough attention to recognize it when it shows up. Sometimes is happens when you least expect it. It’s not even a patient who needs help. I remember the day I went into the planning room only to find my dosimtrist lying on the keyboard of her computer crying. “What’s wrong?” I asked.

PLaCEMENt/CLassIFIED

PHYSICIANS NEEDED Physicians (specialists such as cardiologists, ophthalmologists, pediatricians, orthopedists, neurologists, etc.) interested in performing consultative evaluations (according to social security guidelines) should contact the Medical relations office. toll Free 1-800-962-2230 Jackson 601-853-5487 leola Meyer (Ext. 5487)

She looked up from the keyboard without raising her head and replied, “I don’t know. My neck hurts, and I feel awful.” “you’re having a heart attack,” I answered as I picked up the phone and dialed 911. It seems stupid, but she was, and she did, and she recovered. She asked me later how I knew. It seemed simple to me: people don’t keep lying on a computer crying when all you want them to do is a simple prostate plan. But how do you justify that to a raC auditor? Who knows? I guess I’ll find out. I’ve just received my first request for records. I hope I documented any intuition I might have had on the case. even if I did, I’m guessing that they aren’t going to say that there’s been a big mistake and that they’ve dreadfully underpaid me for my genius. I’ll let you know, but don’t hold your breath. I’ve got this feeling you’ll die of asphyxia in the meantime.

DISABILITY DETERMINATION SERVICES

1-800-962-2230

Locum Tenens Pathologist Needed Surgical Pathologist with Mississippi license needed to fill in at small practice in North Miss. Proficient in GI biopsies, routine surgicals and non-gyn cytology. Oxford Pathology, Inc. E-mail: 1210lcb@bellsouth.net

See ya in the funny papers.

— R. Scott Anderson, MD Meridian

PLEASE TELL OUR ADVERTISERS THAT YOU

R. Scott Anderson, MD, a radiation oncologist, is medical director of the Anderson Regional Cancer Center in Meridian and past vice chair of the MSMA Board of Trustees. Additionally, he is an accomplished oil-painter and dabbles in the motion-picture industry as a screen-writer, helping form P-32, an entertainment funding entity. 239

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FOUND THEM IN THE


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August 2010 JMSMA  

The Journal MSMA has a circulation of 4,200 which includes the membership of the Association and paid subscribers. The year 2010 represents...

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