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the launch of a crisp smart interactive new 1. User-Friendly Interface 2. Component-Society Toolkits 3. Endless CME Opportunities 4. Detailed Advocacy Info & Action Center 5. Improved Login & Member Dashboard 6. Quick Access to Staff & Member Contact Information 7. Informative History Section 8. Easily-Found Event Info & Simple Registration 9. Relevant news featuring all MSMA publications 10. Chat rooms for students, residents, & physicians

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260 JOURNAL MSMA September 2013

hitting the web soon!

Top 10 Reasons for you to check it out:


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 James A.Rish, MD President Claude Brunson, MD President-Elect Michael Mansour, MD Secretary-Treasurer R. 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 39158-2548. 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.

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Copyright© 2013 Mississippi State Medical Association.

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Official Publication of the MSMA Since 1959

OCTOBER 2013

VOLUME 54

NUMBER 10

Scientific Articles Emergency Department Triage of Low Acuity Patients to a Federally Qualified Health Center

280

Nghia D. Nguyen, DO; Justin B. Moore, MD; Nathan P. McIntosh, MD; Michael L. Jones, RN; Jason Zimmerman, RN; Richard L. Summers, MD

Clinical Problem-Solving: I Feel like I had a Stroke in My Throat!

284

P. Brent Smith, MD

Top Ten Facts You Need to Know - About Serotonin Syndrome

286

Roy R. Reeves, DO, PhD; Mark E. Ladner, MD; Percy Smith, PA

President’s Page POLST

293

James A. Rish, MD; MSMA President

Editorial Food Stamps, Public Health, Politics, a New Mississippi Social Determinant of Health, and the MMPAC Budget

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Richard D. deShazo, MD; Associate Editor

Related Organizations Mississippi Professionals Health Program Mississippi State Department of Health

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Departments From the Editor: A Rocky Rollout MSMA: Comment on AMA Resolutions Physician’s Bookshelf: Death Foretold

277 295 301

About The Cover: Historical Fuel Prices in Mississippi - Pictured is a DX Fuel (Gasoline) pump that dispensed either Ethyl gasoline (“premium” by today’s terminology) or regular gasoline. This pump is still located in front of the Taylor Grocery and Restaurant in Taylor, Mississippi. Taylor is a village/community in Lafayette County just southwest of Oxford with a population listed as 500 following the 2000 census. William Faulkner used Taylor as one of the settings in his book, Sanctuary. Upon close inspection of this fuel pump, one can see the dispensing gasoline price listed as $0.45 per gallon. This was the approximate average price per gallon of gasoline in Mississippi in 1972. In 1971, it was $0.31 per gallon. By the end of 1973, gasoline in Mississippi was approaching the $1.00 per gallon level. (“We love to remember the good ole days,” comments the photographer.) Through the years, many have personalized the pump, leaving signatures like Laura, Beth, Madison, and Sarah. The “Open: Eat or We Both Starve” sign remains a slogan for this popular eatery. The entrance signs posted are also quaint and unique: “Cannot seat until entire party present,” “Control your pets and kids,” and “Coach and Allison are getting married May 20.” This photograph was taken by Joe R. Bumgardner, MD, of Starkville. Dr. Bumgardner is a retired general surgeon who practiced there for 27 years. r October

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From the Editor: A Rocky Rollout

M

y physician/brother Dr. Brett Lampton of Oxford was sitting next to me on that Sunday afternoon back in March 2010 when the House of Representatives narrowly passed the Patient Protection and Affordable Care Act (PPACA), what most Americans, including the President, now call Obamacare. We were watching television coverage of the House in the act of passage, and once the deed was done, Brett leaned towards me and said: “You heard it didn’t you?” And I responded, “Heard what?” His answer: “That groan of every physician in the state of Mississippi.” Perhaps not every Mississippi physician groaned with the act’s passage, but his comment captured the mood of most of the state’s physicians. Now, more than three years later, Obamacare has officially begun. October 1 saw the inauspicious and rocky rollout of health care exchanges as mandated by PPACA. This online launch of the federal health insurance marketplace at HealthCare.gov has been plagued by glitches and flaws, which has made the online enrollment process difficult and frustrating by any standard. For weeks after the rollout began, this system, which cost more than $400 million, thwarted

millions of attempts simply to log on and deeply embarrassed the White House. One insurance executive told the The New York Times, “These are not glitches…the extent of the problems is pretty enormous. At the end of our calls, people say, ‘It’s awful, just awful.’” Another computer expert termed the marketplace “a third world experience.” Lucius M. Lampton, MD Our own paper The Clarion Ledger termed the first days of the online exchanges “an inexcusable mess.” What does this unfortunate and flawed debut of Obamacare portend for medicine’s future? Will physicians face new and frustrating obstacles in our efforts to provide high quality patient care? Will administrative burdens and silly electronic requirements by those with no understanding of the patient/ physician relationship disrupt that sacred bond? Our role as patient advocates is more important now than ever, and physicians must be vigilant to be sure that our patients’ care is not lost in this brave new world of Obamacare. Contact me at lukelampton@cableone.net. —Lucius M. “Luke” Lampton, MD, Editor

Journal Editorial Advisory Board Myron W. Lockey, MD Chair, JMSMA Editorial Advisory Board Journal MSMA Editor Emeritus, Madison Timothy J. Alford, MD Family Physician, Kosciusko Medical Clinic Michael Artigues, MD Pediatrician, McComb Children’s Clinic Diane K. Beebe, MD Professor and Chair, Department of Family Medicine, University of MS Medical Center, Jackson Claude D. Brunson, MD Senior Advisor to the Vice Chancellor for External Affairs, University of Mississippi Medical Center, Jackson Jeffrey D. Carron, MD Associate Professor, Department of Otolaryngology & Communicative Sciences, University of Mississippi Medical Center, Jackson Gordon (Mike) Castleberry, MD Urologist, Starkville Urology Clinic Mary Currier, MD, MPH State Health Officer Mississippi State Department of Health, Jackson Thomas E. Dobbs, MD, MPH State Epidemiologist Mississippi State Department of Health, Hattiesburg

Bradford J. Dye, III, MD Ear Nose & Throat Consultants, Oxford Daniel P. Edney, MD Executive Committee Member, National Disaster Life Support Education Consortium, Internist, The Street Clinic, Vicksburg

Paul “Hal” Moore Jr., MD Radiologist Singing River Radiology Group, Pascagoula

Owen B. Evans, MD Professor of Pediatrics and Neurology University of Mississippi Medical Center, Jackson

Jason G. Murphy, MD Surgeon Surgical Clinic Associates, Jackson

Maxie L. Gordon, MD Assistant Professor, Department of Psychiatry and Human Behavior, Director of the Adult Inpatient Psychiatry Unit and Medical Student Education, University of Mississippi Medical Center, Jackson

Ann Myers, MD Rheumatologist Mississippi Arthritis Clinic, Jackson

Scott Hambleton, MD Medical Director Mississippi Professionals Health Program, Ridgeland John Edward Hill, MD Family Physician, North Mississippi Medical Center Tupelo W. Mark Horne, MD Internist, Jefferson Medical Associates, Laurel Brett C. Lampton, MD Internist/Hospitalist, Baptist Memorial Hospital, Oxford Philip L. Levin, MD President, Gulf Coast Writers Association Emergency Medicine Physician, Gulfport William Lineaweaver, MD Editor, Annals of Plastic Surgery Medical Director JMS Burn and Reconstruction Center, Brandon

Sharon Douglas, MD Chair, AMA Council on Ethical & Judicial Affairs Professor of Medicine and Associate Dean for VA Education, University of Mississippi School of Medicine, Associate Chief of Staff for Education and Ethics, Michael D. Maples, MD G.V. Montgomery VA Medical Center, Jackson Medical Director Medical Assurance Company of Mississippi, Ridgeland

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Alan R. Moore, MD Clinical Neurophysiologist Muscle and Nerve, Jackson

Darden H. North, MD Obstetrician/Gynecologist Jackson Health Care-Women, Flowood Jimmy L. Stewart, Jr., MD Program Director, Combined Internal Medicine/ Pediatrics Residency Program, Associate Professor of Medicine and Pediatrics University of Mississippi Medical Center, Jackson Samuel Calvin Thigpen, MD Hematology-Oncology Fellow, Department of Medicine University of Mississippi Medical Center, Jackson Thad F. Waites, MD Clinical Cardiologist, Hattiesburg Clinic W. Lamar Weems, MD Urologist, Jackson Chris E. Wiggins, MD Orthopaedic Surgeon Bienville Orthopaedic Specialists, Pascagoula John E. Wilkaitis, MD Chief Medical Officer Brentwood Behavioral Healthcare, Flowood


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Working with Young Physicians October 2013 JOURNAL MSMA 279


• Scientific Articles • Emergency Department Triage of Low Acuity Patients to a Federally Qualified Health Center Nghia D. Nguyen, DO; Justin B. Moore, MD; Nathan P. McIntosh, MD; Michael L. Jones, RN; Jason Zimmerman, RN; Richard L. Summers, MD [Previous JMSMA articles related to this subject are referenced as follows: deShazo RD. Joseph and Jefferson Davis, The community health centers, Mississippi, and 11 billion dollars. J Miss Med Assoc. 2011;52(5): 155-58 and deShazo RD. Who will care for the newly insured under health reform? J Miss Med Assoc. 2011;52:263-9.] —Ed.

A

bstract

Many emergency departments (ED) are experiencing ever increasing volumes as they serve as a safety net for patients without established access to primary care. Impending physician shortages, our aging population, and recent changes in national healthcare policy are expected to further exacerbate this situation and worsen ED overcrowding. These conditions could result in a dilution of ED resources and significantly impact the ability of emergency personnel to provide quality care for patients with serious illnesses. Previous studies have demonstrated that low acuity patients without emergencies can be safely and legally identified in triage and can be sent away from the ED for further outpatient treatment and evaluation. However, without a specific designated clinic follow up, these patients often fail to get the appropriate care required. In this study, we couple the ED medical screening exam process with a timely medical referral system to a local Federally Qualified Healthcare Clinic (FQHC). These referred patients were monitored for subsequent success in satisfaction with their primary care needs and their rate of recidivism to the ED. Most of the nonemergent patients who were judged to be appropriate to refer to the FQHC were satisfied with their medical screening process (89%) and most elected to attend the same day clinic appointment at the FQHC (85%). Only 17% of these patients who were referred out of our ED returned to be seen in our ED within the three-month interval. We concluded that referring low acuity patients out of the emergency department to a primary care clinic setting provided an opportunity for these patients to establish a medical home for future access to non-emergent health care. Author Affiliations: Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (Drs. Nguyen, Moore, McIntosh, and Summers; Mr. Jones and Mr. Zimmerman). Corresponding Author: Richard L. Summers, MD; UMMC Associate Vice Chancellor for Research, Professor of Emergency Medicine, Department of Emergency Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216. Ph: (601) 984-5586 (summers@umc.edu).

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Introduction

In hospitals across the United States, emergency departments (ED) are experiencing increasing volumes as they serve as a safety net for patients without ready access to primary care.1 Because of these increases in patient volumes, overcrowding has been a topic of great interest for the past decade with the expectation that this problem will worsen with impending physician shortages and recent changes in national healthcare policy.2,3 These ever-increasing ED volumes could result in a dilution of resources and significantly impact the ability of emergency personnel to provide quality care for patients with serious conditions.4 Multiple factors have been identified as causes for the ED overcrowding problem including our aging population and logistical systems problems inherent in current hospital practices.3,5 Perhaps one of the most commonly cited causes for ED overcrowding is an implicit requirement for care of the “nonemergent patient.”1-5 Often, these patients would be better served by seeing a primary care practitioner in an established medical home. However, these patients believe primary services are unavailable or do not know where to find them. In helping to solve the ED overcrowding problem, some institutions have tried to identify non-emergent patients and refer them to a clinic setting where they could receive health care in a more cost-effective manner. Derlet, et al, demonstrated that these “non-emergent patients” could be safely and legally discharged from the ED without a full medical workup and with directions for them to be seen by a primary care provider in a non-emergent setting.6 These emergency physicians used an EMTALA compliant medical screening exam (MSE) in combination with a strict set of local guidelines and previously published screening criteria in their triage process5 (Figure 1). It has been suggested that this protocol will reduce ED congestion and avert a costly and unnecessary hospital bill for some patients. One of the difficulties in this practice was the implicit assump-


impact on patient recidivism to the ED for non-emergent conditions is examined. The new triage process was implemented at the urban adult ED of a 722-bed academic tertiary medical center where the annual ED volume exceeds seventy thousand (Figure 1). Throughout the study period, the medical center was the only Level 1 Trauma Center in the state of Mississippi and served a variety of patients with acuity levels ranging from non-emergent to critical in a large catchment area. Patients determined by the ED triage personnel to be non-urgent, based on their history, vital signs, and ESI acuity scoring, were considered candidates for disposition to a local Federally Qualified Health Care Center (FQHC) for further medical care. The candidate patients were further evaluated by a qualified healthcare provider (CMS and EMTALA definition) using a standard EMTALA compliant medical screening exam protocol and evidence-based methods5 (Figure 1). Those patients determined to be non-urgent by the provider were then given the option to wait to be seen in the ED in a timeframe based on their acuity or be scheduled into a FQHC appointment for the same day. If a patient elected not to go the FQHC, he or she was placed back in line in the same order of priority and with no prejudice. If a patient chose to go to the FQHC clinic, he or she was given directions to the FQHC clinic (located approximately 2 miles from the UMMC campus) and his or her chart was removed from the triaged patients to be seen. Public transit was available between 8 am to 5 pm. The FQHC was informed that any patient referred by the ED who was determined to be emergent/urgent or beyond the scope of their practice should be transported back to the ED for reevaluation. The satisfaction score measurement tool used a Likert 1-5 scale with 5 being “Very Satisfied” and 1 being “Dissatisfied.”

Figure 1. Algorithm used for the medical screening and triage process.

tion that these patients who came to the ED because of their limitations in medical access would somehow now be able to obtain an appointment with a physician. A process that insures timely non-emergent medical access for these patients would provide a more comprehensive solution. Federally Qualify Health Centers (FQHC) include all organizations receiving grant monies under Section 330 of the Public Health Service Act and function as “safety net” providers.7-10 As a benefit defined by the Medicare and Medicaid statutes, the goal of the FQHC program is to improve the accessibility of essential primary and preventive healthcare services to low-income, medically underserved areas or populations.8,10 This is accomplished primarily by reimbursing Medicaid and Medicare patient visits at enhanced rates. General information about FQHCs can be found at http://bphc.hrsa.gov/about/requirements/index.html.

Methods

At the University of Mississippi Medical Center (UMMC), our emergency department chose four weekdays to create a trial referral system. Once medical screening exams at triage determined the patient to be low acuity and with a nonemergent condition, a same day clinic appointment with a local FQHC was scheduled. These clinics have flexible hours and can operate late hours to accommodate patients who arrive to the ED in the afternoon. Our hypothesis was that these patients could feasibly and expeditiously obtain the medical care they sought with the intent to establish a medical home. In this study, patient satisfaction is assessed with our process, and the

Results

In a quality assurance study of patients who chose the FQHC option, scores reflecting satisfaction with the triage process were collected at the time of the medical screening exam. A record of each individual patient’s choice was also kept for analysis. ED recidivism of patients referred to the FQHC clinic was recorded during a 3 month time period after their initial ED medical screening exam. The level of acuity (ESI rating) for patients returning within the 90 days after FQHC referral was determined at the time of their return visit.

October 2013 JOURNAL MSMA 281


During the course of the study, 170 patients were enrolled. There were 90 females and 80 males. A total of 144 patients (85%) chose to be scheduled into an FQHC appointment for the same day rather than be seen in the ED (Figure 2). However, 26 patients (15%) elected to stay and be seen by ED personnel. Of the 144 patients that were sent to the FQHC, 29 (20%) agreed to complete the satisfaction survey. In this surveyed group, 89% described their experience with the new process as satisfactory or very satisfactory. Only 24 (17%) of the 144 patients sent to the FQHC for their care returned to the ED within the next 90 days, suggesting that they had developed a medical home for Figure 2. FQHC referral vs ED evaluation

primary care. The distribution of acuity levels for this 90 day returning group is presented (Figure 3) with only one patient requiring hospital admission. Data available for a subset of the cohort (4 month period at the end of the study) showed that 71% of referred patients showed up for their assigned FQHC appointment. Of this group, only 17.2% returned to the ED within the next 6 months as compared to 41.2% of those that did not show up for their appointment. In this study, the majority of screened patients who presented to the ED with non-emergent conditions chose referral to FQHC clinic rather than a perceived prolonged ED wait. There was a non-statistically significant overall reported satisfaction with the referral process for those that agreed to complete the survey. Upon request of feedback from the FQHC at the end of the study, there were no patients in the group triaged away from the ED that were determined by their primary care providers at the FQHC to be inappropriate for outpatient care.

Discussion

N = 170 patients participated in medical screening exam, 144 (85%) chose FQHC referral vs. 26 (15%) chose evaluation in the ED. Figure 3. Acuity Levels of Recidivism Patients

Out of 24 patients who returned to UMC ED within 90 days, 20 patients seen in the ED/ FAST Track were discharged home, three left without being seen (LWBS), and the only patient with an ESI-2 was admitted for an acute on chronic process that was different than his/her prior visit’s complaint where he/she received a medical screening exam.

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Recent changes in the healthcare environment have put a serious strain on the resources of emergency departments.2,4,5 Often the ED serves a dual role for our communities by delivering emergency services to critically ill patients while serving as a safety net for those patients who do not have basic primary care.1 These divergent and often conflicting roles can potentially diminish the quality of care for both groups of patients. Emergency physicians are not oriented toward optimal management of chronic diseases such as hypertension and diabetes.2 Likewise, episodic treatments in an ED do not allow for a continuity of care. Further, large volumes of these patients can dilute the resources and personnel time that should be directed to more acutely ill patients that are the primary responsibility of an ED.2-5 The burden of these differing patient requirements for chronic care is amplified in tertiary care centers that must service the needs of both the local and broader statewide medical communities. The challenge is to devise a system that provides the best quality care for all groups of patients. Previous studies have demonstrated that low acuity patients can be safely and legally identified in triage and can be sent out of the emergency department.6,11 Our study accomplished similar results in the appropriate identification of these patients but differed in that we provided an alternative primary care venue for the same day. When a same day scheduled clinic appointment was made from the ED, we found that the patient was more likely to elect care in the outpatient setting versus waiting for an unknown amount of time to be seen in our


emergency department. Scherer et al. found that patients were unlikely to keep their follow-up appointments to the FQHC if that appointment was more than 24 hours after their visit to the ED.12 Our subset cohort analysis suggests that the majority of our patients who were given a timely appointment kept their appointments. Though EMTALA regulations require only a medical screening exam for non-emergent patients that seek care in the ED, this minimal standard does not address the ongoing primary care needs of these patients.12 While chronic care issues are not the purview of the ED, patient neglect of these unresolved medical conditions inevitably evolves into acute problems in a critical state that is even more difficult to manage. Both the ED and these referred patients benefit if these non-emergent patients are provided a medical home for ongoing primary care. In subsequent studies, we will try to analyze how many of these patients continue to follow up with the FQHC clinic. We will also analyze the cost effectiveness of having low acuity (ESI-4 and ESI-5) patients seen in the FQHC clinic versus in our emergency department. The overarching goal of this effort is to provide efficient, appropriate, and optimal care for our patients.

References 1. Lasser KE, Kronman AC, Cabral H, Samet JH. Emergency department

use by primary care patients at a safety-net hospital. Arch Intern Med. 2012;172:278-80. 2. Velianoff GD. Overcrowding and diversion in the emergency department: the health care safety net unravels. Nurs Clin North Am. 2002;37:59-66. 3. Hoot NR. Systematic review of emergency department crowding: causes, effects, and solutions. Ann Emerg Med. 2008;52:126-36. 4. Trzeciak S. Emergency department overcrowding in the United States: an emerging threat to patient safety and public health. Emerg Med J. 2003;20:402-405. 5. Derlet RW, Richards JR. Overcrowding in the nation’s emergency departments: complex causes and disturbing effects. Ann Emerg Med. 2000;35:63-68. 6. Derlet RW, Kinser D, Ray L, Hamilton B, McKenzie J. Prospective identification and triage of nonemergency patients out of an emergency department: a 5-year study. Ann Emerg Med. 1995;25:215-23. 7. Medicare program; payment for federally qualified health center services - HCFA. Final rule with comment period. Fed Regist. 1992;57:24961-84. 8. Grimaldi P. Latest Medicare benefit: FQHC (Federally Qualified Health Center) services. Healthc Financ Manage. 1993;47:34-40. 9. Sefton M, Brigell E, Yingling C, Storfjell J. A journey to become a federally qualified health center. J Am Acad Nurse Pract. 2011;23:34650. 10. Goldman LE, Chu PW, Tran H, Romano MJ, Stafford RS. Federally qualified health centers and private practice performance on ambulatory care measures. Am J Prev Med. 2012 Aug;43(2):142-9. 11. Siegel B. The emergency department: rethinking the safety net for the safety net. Health Aff (Millwood). 2004 Jan-Jun;Suppl Web Exclusives:W4-146-8. www.ncbi.nlm.nih.gov/pubmed/15451988. 12. Scherer TM, Lewis LM. Follow-up to a federally qualified health center and subsequent emergency department utilization. Acad Emerg Med. 2010;17:55-62.

Calling All Mississippi Physician-Photographers

enter the JMSMA 2014 cover photo contest

L

oad your camera or grab your digital. Shoot anything you can capture as a high-resolution image. Subjects given the highest consideration are those indicative of Mississippi. Photos of original artwork are also acceptable. The MSMA Committee on Publications will judge the entries on the merits of quality, composition, originality, and appropriateness to the JMSMA. Specifications: Color slides, digital files & photos (at least 300 DPI/PPI). A hard copy print is required for judging. Please include a brief description of the image and information about the physician/photographer. Size: Vertical format 5 x 7” or 8 x 10” Deadline: November 29, 2013 Mail to: P.O. Box 2548 Ridgeland, MS 39158-2548 or deliver to MSMA headquarters 408 W. Parkway Place, Ridgeland, MS 39157

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For more info contact: Karen Evers, Managing Editor 601-853-6733, ext. 323 or KEvers@MSMAonline.com

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• Clinical Problem-Solving • I Feel like I Had a Stroke in My Throat! P. Brent Smith, MD

I

ntroduction

A 78-year-old African-American female presented to a local emergency department with shortness of breath and wheezing for approximately 2 hours. She was accompanied by her daughter, who presented most of the history of present illness. The onset was sudden and unrelieved for 1.5 hours until nebulized albuterol treatments were administered in the emergency department. The patient reported a childhood history of asthma but none as an adult. Her review of systems was negative except for her chief complaints, and she denied chest and abdominal pain or nausea/vomiting. Further, she denied any history of smoking or alcohol use, and her past medical and surgical histories were remarkable only for hypertension and a hysterectomy. Her blood pressure on presentation to the emergency department was 210/92 mmHg. Three of her sisters and her mother had hypertension, one sister died of a stroke, and her father died of a myocardial infarction. Her presenting physical exam showed an irregular heartbeat, but adequate capillary refill and warm extremities suggested adequate perfusion. She was awake and alert and mentated normally. Her lung fields were clear, but, as her breathing had been reported as labored by the emergency room nurses, she had received a breathing treatment immediately upon arrival, prior to the physical exam. Her abdominal exam was normal, and there were no deficits in her strength and sensorium including her cranial nerves. Her initial lab studies were also negative with the exception of hypokalemia (3.1 meq/L) and a brain natriuretic peptide of 417.1 pg/mL. A computed tomography (CT) scan of the chest did not indicate the presence of a pulmonary embolism. However, the imaging demonstrated a mildly dilated and fluid-filled esophagus and a hiatal hernia. Of note, a chest radiograph (CXR) revealed a normal heart size and silhouette, unremarkable pulmonary vasculature and clear lung fields. Author Information: Dr. Smith was a resident in the Department of Family Medicine at the University of Mississippi School of Medicine. He recently completed a fellowship in Tuscaloosa, Alabama and has returned to Cleveland, Mississippi to begin a family medicine/sports medicine practice. Corresponding Author: P. Brent Smith, MD, Cleveland Medical Clinic, 802 Seventh Ave., Cleveland, MS 38732-3640 (pbrentsmithmd@gmail.com).

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Her initial presentation was fairly benign, seemingly a reemergence of a childhood problem, and she was admitted for 23 hour observation and albuterol treatments for a presumptive asthma exacerbation. There was also possibility raised that she may have chronic obstructive pulmonary disorder, though she had no smoking history. She was begun on oral prednisone and supplemental oxygen via nasal cannula administered to maintain her oxygen saturation above 92%, allowing her to rest comfortably through her first night’s stay. On day 2, she reported vomiting with the emesis noted to have the appearance of coffee grounds. Further questioning revealed that she had been experiencing intermittent nausea and vomiting for 2-3 days prior to admission. Her abdominal physical exam remained normal without tenderness and with normal bowel sounds. A gastroenterologist was consulted for evaluation of a suspected upper gastrointestinal bleed, and an esophagogastroduodenoscopy (EGD) was performed the same day. The patient was found to have a bleeding Mallory-Weiss tear at her gastroesophageal junction, and the bleeding was stopped with a submucosal injection of epinephrine. She was also noted to have a large hiatal hernia. That evening she was made nil per os (NPO), prescribed sucralfate (Carafate) and given intravenous pantoprazole (Protonix) to allow healing. Her hematocrit and hemoglobin remained stable after the procedure, though she continued to experience some mild shortness of breath and required 2 liters of oxygen to maintain oxygen saturation. The high mortality rate of upper gastrointestinal bleeds in patients her age1 shifts the emphasis of her care towards ensuring that her bleeding was controlled and her hematocrit and hemoglobin remained stable. Her active bleeding on presentation and her age raised the likelihood of complications during management of her Mallory-Weiss tear.2 Prompt endoscopy and epinephrine injection likely averted potential complications.3 On day 3, the patient was noted to have developed faint bibasilar infiltrates. This, combined with her continued need for supplemental oxygen, led to a diagnosis of pneumonia for which she was given moxifloxacin (Avelox). Per the gastroenterologist’s recommendations, she was maintained NPO through day 4. Through this period of time, her respiratory status improved, and she was weaned off supplemental oxygen. On day 6, she began a liquid diet and her antibiotics and steroids were converted to oral (PO)


forms. However, she struggled to achieve an adequate PO intake and had difficulty swallowing pills. On hospital day 7, the patient reported, “I feel like I had a stroke in my throat!” The initial struggles with swallowing were attributed to the adverse effects of the Mallory-Weiss tear and the instrumentation of her throat during the EGD. She had complained of a mild sore throat and hoarseness during this time. Her known lower esophageal problem could lead us to assume this explains her symptoms. However, her symptoms raised concern over a more proximal dysfunction. On further questioning, the patient reported difficulty swallowing pills but no feeling of fullness in her throat or chest and no regurgitation of pills after swallowing. Further, while she did have mild odynophagia, her symptoms were relieved by a mild analgesic. Another telling sign is that her dysphagia developed suddenly, over a course of 1-2 days, instead of the slow, progressive course that is typical of scarring/obstruction in the lower esophagus. These signs and symptoms point to dysfunctional swallowing and not dysfunctional locomotion of food through the esophagus. On day 7, speech therapy reported her to be completely dysphagic and requested a modified barium swallow study. The swallow study revealed the absence of a pharyngeal swallow, a condition often seen in brainstem strokes. A magnetic resonance imaging (MRI) of the brain revealed a small, acute infarct near the left pontomedullary juncture as well as evidence of severe chronic microvascular disease. A neurologist was consulted that day. The patient had no other neurological signs or symptoms of stroke. A CT angiogram of the patient’s head and neck demonstrated further vascular compromise including an occluded left vertebral artery, right vertebral artery stenosis at the skull base and bilateral carotid siphon stenosis. No evidence of acute hemorrhage was seen, and her anterior, medial, and posterior cerebral arteries as well as her basilar artery are all patent. This patient’s presentation was unique given the scarcity of symptoms. Dysphagia is common in brainstem stroke, present in 43% of infarcts affecting the pons, 40% of those affecting the medial medulla, and 57% in the lateral medulla.4 However, considering the location of her stroke, the presence of severe chronic microvascular damage, and the occlusion of both her vertebral arteries and carotid siphons, the likelihood of such a small confined stroke was miniscule. In a region packed with motor and sensory neurons in a relatively small area, her absence of motor or sensory deficits testified to the small size of her infarct. If there had been any such symptoms in someone her age and with her blood pressure on presentation, she would have undoubtedly been evaluated for stroke much sooner. The remainder of the patient’s stay involved several setbacks in the process of ensuring her nutritional status. A percutaneous endoscopic gastrostomy (PEG) tube for enteral

feeds was planned; however, the presence of a large hiatal hernia and healing Mallory-Weiss tears in her esophagus necessitated surgical rather than endoscopic implantation. These complications lengthened her stay to a total of 19 days. On discharge, she was breathing comfortably and had completed a 10 day course of antibiotics for pneumonia. She was scheduled to followup with neurology, surgery, gastroenterology, and her family physician. The final diagnosis of a brainstem stroke does not fully answer all the questions about the initial presentation. One particular concern is “when did the stroke occur?” The absence of obvious neurological symptoms, including hoarseness, on admission precluded a stroke workup. One of the other side effects of this type of brainstem stroke is nausea, which was found to occur in 27% of posterior circulation strokes in one case series.5 It can be postulated that nausea resulting from an undiagnosed stroke caused the vomiting experienced in the days before admission. If the vomiting was severe and unrelenting enough, could it possibly have caused the Mallory-Weiss tear? Further, during her swallow evaluation by speech pathology, the patient partially aspirated water while attempting to swallow. Could a silent stroke 1-2 days preadmission have caused nausea and vomiting, subsequent aspiration pneumonitis and infiltrates that led to her presenting with shortness of breath? The true lesson learned from this patient was the danger of accepting a seemingly obvious cause for a problem that appeared to have little to do with the admitting diagnosis. In this case, the patient’s continuing symptoms were not attributed to the “obvious” causes, the healing Mallory-Weiss tear and minor trauma from instrumentation during her EGD. If they had been, she could have been sent home with mild oral throat analgesics with the expectation that her symptoms would resolve soon after discharge. During this time, she would have been at risk for further aspiration, vomiting, inadequate fluid intake, and dehydration. Fortunately for the patient, we dug a little deeper in attempting to explain her difficulty swallowing and discovered the depth of her problem.

Key Words:  Mallory-Weiss tear, dysphagia,

medullopontine stroke

References 1. Hopper, AD, Sanders DS. Upper GI bleeding requires prompt investigation. Practitioner. 2011;255(1742): 15-99, 2. 2. Kortas DY, Haas LY, Simpson WG, Nickl NJ 3rd, Gates LK Jr. MalloryWeisstear: predisposing factors andpredictors of a complicated course. Am J Gastroenterol. 2001; 96(10): 2863-2865. 3. Borisov AE, Kubachev KG, Rizakhanov DM, Sagitova DS. Endoscopic methods of hemostasis intreatment of Mallory-Weiss Syndrome. VestnKhirIm I IGrekova. 2011; 170(3): 94-95. 4. Flowers HL, Skoretz SA, Steiner DL, Silver FL, Martino R. MRI based neuroanatomical predictors of dysphagia after acute ischemic stroke: a systemic review and meta-analysis. Cerebrovasc Dis. 2011;32(1):1-10. 5. Searls DE, Pazdera L, Korbel E, Vysata O, Caplan LR. Symptoms and signs of posterior circulation ischemia in the New England Medical Center Posterior Circulation Registry. Arch Neurol. 2011; Nov 14. (Electronic Version).

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• Top Ten Facts You Need to Know • About Serotonin Syndrome Roy R. Reeves, DO, PhD; Mark E. Ladner, MD; Percy Smith, PA

I

ntroduction

Serotonin syndrome is an increasingly common adverse drug reaction which can be life threatening. Although a variety of medications with direct and indirect serotonergic effects are widely prescribed and serotonin syndrome has occurred in a broad range of clinical settings, many physicians are not aware of the presentation of serotonin toxicity.1 The following facts can help clinicians recognize and manage serotonin syndrome. 1. The most widely recognized example of serotonin syndrome was the death of Libby Zion in 1984, a case that significantly impacted medical education.2 Ms. Zion was an 18-year-old female with depression treated with phenelzine and other medications. She was brought to an Emergency Department with fever, intermittent disorientation, agitation, and “strange jerking motions” of her body. A definite diagnosis could not be established, and she was hospitalized for hydration and observation. Meperidine was ordered for agitation and shivering by a medical intern. She died within 8 hours of admission, presumably because of serotonin syndrome precipitated by the combination of phenelzine and meperidine. Her death led to limits for working hours and closer supervision of residents in hospital training programs. 2. Serotonin syndrome is defined as excessive serotonin activity in the central and peripheral nervous system. The syndrome was first described in the 1960s in studies of single and combination therapy with antidepressant medication.3 Since then, however, many other drugs and medications (including non-psychiatric medications) have been found to cause or contribute to serotonin syndrome. Author Information: Dr. Reeves is chief of psychiatry, Dr. Ladner is a staff psychiatrist, and Mr. Smith is a physician assistant at the G.V. (Sonny) Montgomery VA Medical Center, Jackson MS. Dr. Reeves is professor of psychiatry and neurology, and Dr. Ladner is assistant professor of psychiatry at the University of Mississippi School of Medicine. Corresponding author: Roy R. Reeves, DO, PhD, Chief of Psychiatry (11M), VA Medical Center, 1500 E. Woodrow Wilson Drive, Jackson, MS 39216. Ph: (601)368-4159 (roy.reeves@va.gov).

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3. Serotonin or 5-hydroxytryptamine (5-HT) is a monoamine neurotransmitter that plays a role in many nervous system activities through several neuroreceptor subtypes. Besides the significant role of 5-HT2C receptors in mood and anxiety, 5-HT receptors are involved in regulating various physiological functions, including (but not limited to) neuronal inhibition, sleep, and thermoregulation (5-HT1A); muscle tone (5-HT1D); neuronal excitation (5-HT2A); nausea, vomiting, and anxiety (5-HT3); and GI motility (5-HT4).1 4. Serotonin syndrome is characterized by a triad of neuroexcitatory features including neuromuscular hyperactivity (tremor, clonus, myoclonus, hyperreflexia, and in severe cases, pyramidal rigidity), autonomic hyperactivity (diaphoresis, fever, tachycardia, tachypnea), and altered mental status (agitation, excitement, and confusion).4 However, not all these findings are consistently present in all patients with the disorder.1 Criteria have been proposed for the diagnosis of serotonin syndrome but have been criticized for not taking into account the wide spectrum of toxic effects that can occur. Some authors prefer the term “serotonin toxicity” to include earlier or milder cases. The most recent diagnostic criteria proposed are the Hunter Serotonin Toxicity Criteria5 which require one of the following features or groups of features: A) spontaneous clonus; B) inducible clonus with agitation or diaphoresis; C) ocular clonus with agitation or diaphoresis; D) tremor and hyperreflexia; or E) hypertonia, temperature above 100.4º F (38º C), and ocular or inducible clonus. 5. Serotonin syndrome can result from any drug that increases serotonin activity in the CNS, whether when high doses are used or in combination with other drugs associated with the syndrome. The clinical effects can occur by a number of different mechanisms6,7 including A) Inhibition of serotonin uptake: Selective serotonin reuptake inhibitors (SSRIs); other antidepressants such as the tricyclics, venlafaxine, trazodone, and duloxetine; amphetamines; cocaine; St. John’s wort; phenylpiperidine opioids


(e.g., fentanyl, meperidine); dextromethorphan; tramadol; and others; B) Inhibition of serotonin metabolism: Monoamine oxidase inhibitors (MAOIs); seligiline; linezolid; C) Increased serotonin synthesis: Tryptophan; D) Increases of serotonin release from neurons: Amphetamines; cocaine; fenfluramine; MDMA (Ecstasy); LSD; E) Agonist action at serotonin receptors: Buspirone; sumatriptan and related migraine medications; and F) Unclear mechanisms: Lithium. This list is likely incomplete. Thus, use of many common medications may inadvertently increase the likelihood of the occurrence of serotonin syndrome (see Item 10 below for examples). 6. The incidence of serotonin syndrome is rising. Available and prescribed in clinical settings, this increase is most likely due to the growing number of drugs that increase serotonin activity (either directly or indirectly), as well as increasing recreational use of amphetamine-like substances.8 The true incidence of serotonin syndrome is unknown because many cases are unrecognized.6 7. Symptoms of serotonin syndrome may present with a range of severity. Some symptoms may resolve quickly after simply discontinuing the offending agent(s). Others may lead to death. Symptoms may occur within six to eight hours of initiating or increasing the dosage of serotonergic medications. Drugs with long half-lives (e.g., fluoxetine) may place a patient at risk for serotonin syndrome for several weeks after discontinuation.7 The mortality rate of serotonin syndrome is unknown.9 8. The differential diagnosis for serotonin syndrome includes any disorder that can present with any combination of neuromuscular hyperactivity, autonomic hyperactivity, and altered mental status. This differential includes infections of the CNS, drug toxicity, heat strokes, acute dystonic reactions, CNS inflammatory conditions such as vasculitis, hyperthyroidism, tetanus, and to some degree, any disorder that can cause delirium.4,8,10 Neuroleptic malignant syndrome, a condition usually caused by dopamine blocking agents, is characterized by fever, autonomic instability, muscle rigidity, and mental status changes. Because of the similarities of symptoms, this syndrome may be difficult to distinguish from serotonin syndrome if a precipitating agent is not evident. Malignant hyperthermia may be precipitated by general anesthesia or by succinylcholine in genetically vulnerable individuals, leading to hyperthermia and rhabdomyolysis; this condition should be considered if there is a history of recent surgery. Anticholinergic toxicity may present with fever, confusion, and hallucinations but usually produces muscular relaxation. In situations where the diagnosis is not rapidly clear,

workup warrants extensive detective work. Laboratory tests could include complete metabolic profiles, CBC, thyroid profile, serum CPK, urine myoglobin, and blood and urine cultures. Neuroimaging, chest X-ray, arterial blood gases, and EKG may also be indicated. Lumbar puncture should be performed for patients with suspected CNS infections.4,10 9. Initial treatment of a patient with suspected serotonin syndrome involves identification of any potential causative agents, i.e., any drugs that increase serotonin activity, particularly if they have been recently started or increased in dosage. Such medications should be immediately discontinued. For patients not responding to this intervention, the underlying etiology is pursued further. Symptomatic and supportive care is a mainstay of treatment. Intravenous fluids should be given to alleviate dehydration and correct electrolyte imbalance. Fever may require physical cooling measures such as cooling blankets. Treatment in an ICU setting is optimal. Urgent medical issues must be promptly identified and addressed. Benzodiazepines may be used for control of agitation and tremor. Cyproheptadine, a 5-HT2A antagonist, should be considered in moderate cases and is recommended in severe cases. The initial dose is 12 mg followed by 2 mg every 2 hours if symptoms persist.6,10,11 10. Serotonin syndrome may occur unexpectedly in common clinical settings, and there is a need for awareness of serotonin syndrome by clinicians in general. Serotonin syndrome can occur related to a single drug that increases serotonin activity, especially if given in large doses. However, as in the Libby Zion case, accidental combination of serotonergic drugs (often ordered or prescribed by different clinicians) appears to be a particular risk. Some examples include the occurrence of serotonin syndrome after surgery with fentanyl anesthesia in a patient who had not informed her surgeon that she was on large doses of fluoxetine;12 with the addition of the antibiotic linezolid to the regimen of patients already on a serotonergic drug;13 and with the combination of SSRI and triptan drugs in cases of migraine headache.14 In theory, the addition of any serotonergic drug to another could produce this phenomenon. Of concern regarding patients with mental illness, some episodes may be precipitated when a patient, because of perceived stigma, does not report his/her psychiatric medications, a large number of which increase serotonin activity.15 Thus, clinician awareness of serotonin syndrome is crucial to avoid potentially dangerous combinations of serotonergic drugs, as well as recognition of serotonin toxicity so that treatment can be promptly initiated.16 References 1. Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med 2005;352(11):1112-1120.

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2. Brensilver JM, Smith L, Lyttle CS. Impact of the Libby Zion case on graduate medical education in internal medicine. Mt Zion J Med 1998;65:296-300. 3. Sternbach H. The serotonin syndrome. Am J Psychiatry 1991;148:705-713. 4. Dvir Y, Smallwood P. Serotonin syndrome: a complex but easily avoidable condition. Gen Hosp Psychiatry 2008;30:284-287. 5. Dunkley EJ, Isbister GK, Sibbritt D, et al. The Hunter Serotonin Toxicity Criteria: Simple and accurate diagnostic decisions rules for serotonin toxicity. QJM 2003;96:635-642.

Welcomes...

6. Ables AZ, Nagubilli R. Prevention, diagnosis, and management of serotonin syndrome. Am Fam Physician 2010;81:1139-1142. 7. Frank C. Recognition and treatment of serotonin syndrome. Can Fam Physician 2008;54:988-992. 8. Jones D, Story DA. Serotonin syndrome and the anaesthetist. Anaesth Intensive Care 2005;33:181-187. 9. Robottom BJ, Weiner WJ, Factor SA. Movement disorders emergencies part 1. Arch Neurol 2011;68:567-572. 10. Carbone JR. The neuroleptic malignant and serotonin syndromes. Med Clinics North America 2000;18:317-325. 11. American Psychiatric Association Steering Committee on Practice Guidelines. Practice Guidelines for the Treatment of Psychiatric Disorders Compendium 2006. Arlington, VA: American Psychiatric Press; 2006. 12. Choudhury M, Hote MP, Verma Y. Serotonin syndrome in a postoperative patient. J Anaesthesiol Clin Pharmacol 2011;27(2):233-235. 13. Ramsey TD, Lau TTY, Ensom MHH. Serotonergic and adrenergic drug interactions associated with linezolid: A critical review and practical management approach. Ann Pharmacother 2013;47:543-560. 14. Evans RW, Tepper SJ, Shapiro RE, Sun-Edelstein C, Tietjen GE. The FDA alert on serotonin syndrome with the use of triptans combined with selective serotonin reuptake inhibitors or selective serotonin-norepinephrine reuptake inhibitors: American Headache Society position paper. Headache 2010;50:1089-1099.

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16. Sun-Edelstein C, Tepper SJ, Shapiro RE. Drug-induced serotonin syndrome: A review. Expert Opin Drug Saf 2008;7:587-596.

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MPHP MPHP

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Fellow physicians,

nation, according to a c in the history of our mi ide ep g dru rst wo tor, Dr. Tom Frieden, the midst of the ort. The agency’s Direc rep ) DC The United States is in (C national n tio en ev Pr Control and mentioned the current y se all ea ific Dis ec for sp d rs an nte s Ce ce 2012 substan prescribing of controlled riate. condemned widespread ngerous and inapprop da as rs ille ink pa c oti arc d/n ioi trend of prescribing op Accidental ndous harm to society. me tre in ed ult res s ha substances of the injury pyramid riptions for controlled 1970, represent the top ce sin The increase in presc d, fol ten er ov d aths, which actually have increase re 37,480 overdose de we re overdose deaths, which e the , 09 20 By e. tion’s history. Overdos ription drug abus the first time in our na for ts, associated with presc g en cid dru n ac tio ffic rip tra sc of deaths from n die every day from pre surpassed the number re were 35 approximately 42 wome d an n, me wo in ted with opioid use, the d cia ete so ck as yro sk ath de ve e ha os s ath erd de every ov reports that in 2010, for ers of opioids. overdoses. The CDC and 461 nonmedical us es os erd ov tal nfa no for its emergency room vis by prescribers, and ty are often minimized cie so d an s, ilie fam to long addiction and life n and the harm emning a patient to life nd co The ravages of addictio be y ma d ioi op t “Prescribing an Dr. Frieden warns tha ns.” tio threatening complica matter substance becomes a ed sir de the of e us nt, sed. ted patie the brain become disea ember that for the addic generating regions of r vio Prescribers should rem g and ha nin be l tai rfu ob d we an po , d consequences st primitive an c mo rrifi ho the d ite an sp l, de va ce rvi su tan of subs er to continue to use the Addiction causes the us life. of us foc ry ma comes the pri be ce tan bs su the ing us ctor obtain their drugs. Do Shopping” in order to tor oc ces “D tan in bs ge su ga ed en oll en ession of contr ted patients oft ss dic po g ad , nin gly tai isin ob rpr or g su t No “acquirin violates this the Mississippi Code as that “Any person who by tes ed sta fin de de Co is e g Th pin .” op sh d the like s than one (1) year...” presentation, fraud an …confined for not les be or prescriptions by misre all sh ion ict nv co me and upon r section is guilty of a cri nt is engaging in docto blem, or that your patie pro cess g ac dru to n , tio ram rip sc og Pr pre a patient has Drug Monitoring ur yo on t pti tha cri t es ec Pr sp i su ipp u iss yo If the Miss Certificate, and offer help. Utilize scriber who has a DEA tly, pre mp y an pro t for ac t g, en pin em op uir sh is a req ssissippi 3 to register for the Mi s of your patients. This 59 ord 2-9 rec -88 n 00 tio rip 1-8 sc ll Ca pre . the l 31, 2013 tance Abuse and Menta istration is December nts to access the Subs tie and the deadline for reg cil on pa un ge Co l ura na co tio En . Na oring Program 2-HELP or the nit 66 Mo 0) ug (80 Dr at on ce pti rvi cri Se es Pr Referral (SAMHSA) Treatment 2-2255. Health Administration’s erral service at (800) 62 ref ) DD 7-3792 CA (N cy en nd pe 0-0240 • Fax: 601-70 De -42 ug Ph: 601 Alcoholism and Dr ssissippi 39157-6010 • • Ridgeland, Mi 408 West Parkway Place

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290 JOURNAL MSMA October 2013


you might be hooked. Doctor-shopping is a crime. We check prescription history and report suspected abuse to the Mississippi Bureau of Narcotics and local law enforcement. We reserve the right to report a patient who is suspected of seeking multiple/duplicate prescriptions. Help is available. Just ask the doctor or call 1-800-622-2255 to get help NOW.

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• President’s Page • POLST

N

ow with Annual Session behind us, I am excited about getting down to business as your 146th President. One of the first projects that I would like to tackle is exploring establishment of a POLST Paradigm Program in Mississippi. For those of you who are unfamiliar with POLST, it is the term used to describe Physician Orders for Life Sustaining Treatment. We have all seen the shortcomings of advanced directives in our own practice. As a critical care physician, I have repeatedly witnessed wellmeaning supportive family members who, in the heat of the moment, request aggressive support for their loved one when it is clear that the patient would have directed otherwise. By and large, physicians in the course of a busy day often defer these tough end-of-life care discussions with the patient and family James A. Rish, MD members. This is also often complicated by the discomfort patients and their 2013-14 MSMA President family members experience by these type discussions. This is truly one of the most difficult and important responsibilities that physicians bear in caring for our chronically ill patients reaching the end stage of their disease process. I was intrigued by a commentary on an article by Dr. Ken Murray originally published in 2012 in the Wall Street Journal [Entire essay published: Murray K. How doctors die. J Miss Med Assoc. 2013;54(3):67-69] which pointed out that physicians die differently from their patients. This referred to data published by Dr. Joseph J. Gallo in 2003 obtained from surveys from participants in the Johns Hopkins Precursors Study which included physicians graduating from Hopkins between 1948 and 1964. In this survey 64% of physician respondents had created advanced directives as compared to 20% of the general population. In addition 90% of the physicians did not want CPR as compared to 25% of the general public who would not want heroic measures. So what exactly underlies this significant discrepancy in responses between physicians and the general public? I suspect that this is related to the physician’s knowledge of outcomes. There is a large body of literature that supports the notion that CPR is rarely effective. Physicians are generally able to make objective assessments as to the probability of success of the various treatments in our patients. Patients on the other hand often do not fully comprehend the risks and benefits of these specific treatments. We as physicians need to do a better job in communicating these facts to our patients. The national POLST Paradigm Program is an approach to end-of-life planning based on discussions between patients, families, and medical providers. The POLST Paradigm is designed to ensure that seriously ill patients can choose the treatments they want and that their wishes are honored by medical providers. POLST will allow the translation of the patient’s preferences regarding end-of-life care into actionable medical orders in a shared medical decision-making format. By virtue of these preferences taking the form of medical orders, they will be able to unambiguously cross the different spectrums of care settings fully intact. The use of this program is expanding across the United States and has been implemented in all or part of 30 states. Unfortunately Mississippi has not been among them. Our goal is to implement the program on a statewide basis. This effort will require a coordinated collaborative approach with involvement of multiple stakeholders. It will require development of a mutually agreeable form that meets the requirements of the National POLST Paradigm Program Task Force (NPPTF) as well as a means to make this form available to providers across the state. It will require a careful review of any and all state statutes relating to current advanced directives and surrogate decision makers to avoid conflicts with existing law. Financial support including donations and grants will be needed. Educational resources will need to be made available and easily assessable. There must be a robust statewide communication network infrastructure in place. Implementation will require development and use of a registry to support data collection and measurement of quality performance with the ongoing goal of improving the effectiveness of the program and more importantly assuring that the preferences of patients with advanced illness and frailty are accurately and consistently honored. In this technologically advanced age we can readily employ life sustaining support on a variety of different levels though often at a significant compromise in quality of life. The goal of POLST is to promote earlier shared, informed decision-making so that our patients can choose the option that best fits their circumstances. This will obviously be a challenging endeavor. I feel that we are well suited to make this program a reality in Mississippi, and I will greatly appreciate your support and participation in this important effort.

October 2013 JOURNAL MSMA 293


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• MSMA • Mississippi Delegation Seeks Comments on AMA Resolutions

T

he Mississippi delegation to the AMA chaired by Dr. Sharon Douglas of Madison is taking three resolutions to the interim meeting of the AMA House of Delegates November 16-19, 2013, in National Harbor, Maryland. Dr. Douglas recently completed a seven-year term on the AMA Council on Ethical and Judicial Affairs (CEJA). She said that that it is important for MSMA members to have a voice at the national level and points out that the AMA’s Online Member Forums will be open for comments October 18 through November 3.  Any AMA member may post comments at the Online Member Forums. These forums, which were previously known as virtual reference committees, have been re-named to better engage members and secure their input on policy.  All items of business that appear in the initial AMA House of Delegates Handbook will be posted in the online forums which can be accessed directly at www. ama-assn.org/go/hodforum or through a link on the meeting website: http://www.ama-assn.org/ams/pub/meeting/index.shtml. Summaries of the comments will be prepared rather than preliminary reports with recommendations. The summary reports will include verbatim comments from participants, which will not be de-identified, and for this reason, the summary reports will be maintained in the members-only area of the AMA website, although they will be accessible through a link on the Interim Meeting website. Questions may be directed to hod@ama-assn.org.  MSMA members who are not AMA members should forward commentary to the Chair of the Mississippi delegation Dr. Douglas, sdoug777@aol.com, who will see that the Mississippi delegates are armed with information about the impact on the practice of medicine in this state. The Mississippi delegation has introduced the following three resolutions as directed by the MSMA House of Delegates: • Resolution 807 Role of Critical Access Hospitals; referred to Reference Committee J. •

Resolution 914 Change Rural and Off-Site Training Track Requirements in Order to Preserve and Encourage Interest in Rural Residency Programs; referred to Reference Committee K.

Resolution 915 Ask Joint Commission to Re-evaluate the Pain Scale of Patients; referred to Reference Committee K. r

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October 2013 JOURNAL MSMA 295


• Editorial • Food Stamps, Public Health, Politics, a New Mississippi Social Determinant of Health, and the MMPAC Budget Richard D. deShazo, Associate Editor Alimentary Intrigue A friend of mine just got hired to work in the “media intelligence unit” of an international food conglomerate headquartered in a major US city. The corporation has a group of techies in a room with glass walls looking at screens 24/7. Their job is to identify and respond to any opportunities or perceived threats to their brands reported online using audio, video, electronic, and print media in real time. I am not making this up. This really exists. It is the kind of operation that allowed the Oreo cookie folks to place an online advertisement saying Oreos are great to eat in the dark while the lights were still out at the 2012 Super Bowl. More about this operation later.

chose to specialize in public health, that concept was quickly forgotten, only to return like thunder when we started to practice medicine in Mississippi. Here we deal with the reality of the social determinants of health on a daily basis. Those factors are often more important in disease control and disease prevention than the actual health care we provide. Ever since early history records in Mississippi, the odds that any of these determinants will be in our patients’ favor have been stacked against us. New Old News In our personal lives, we regularly “work around” the social determinants of health. Most of us live in metropolitan areas of the state, frequently travel out of state, educate our children in private schools, and work the medical system to our advantage when our families need to use it. And we don’t live in poverty. Contrast our status as physicians to those of most Mississippi patients. Then, take a look at the most recent

Determinants of Health Most of us had a brief introduction to the concept of the social determinants of health during a preventative medicine course in medical school1 (Figure 1a). Unless we

Figure 1. The Social Determinants of Health: Then and Now - The social determinants of health have changed as health care has become more and more politicized over time. It seems reasonable that advocacy should now be included among them.

The Sociaal Determinan nts of Health : A New Paradigm   

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Now  


Mississippi Human Development Index, an estimate of wellbeing based on data from the Mississippi State Department of Health and Centers for Disease Control and Prevention.2 The variables in this calculation include: life expectancy at birth, access to knowledge using school enrollment age 3 and older, educational attainment of individuals 25 years and older, and the standard of living using median earnings. If you don’t live in the tri-county area around Jackson, your choices and

opportunities are limited regardless of your race (Figure 2). Overall, whites in Mississippi have Human Development Index Levels comparable to those of the average American in 1997, while African-Americans on average have index levels of the average American in 1974, a 23-year difference. Neither group is doing well. There are huge disparities between black and white. These data also track with our rankings on the social determinants of health for Mississippi which show us

Figure 2. Where in Mississippi are People’s Choices and Opportunities Greatest? (Burd-Sharps S, Lewis K, Martins EB. A Portrait of Mississippi. www.measureofamerica.org)

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at or near the bottom in every category as compared to every other state in the country with the most recent rank of 49th.3 The Poverty Millstone Many think that poverty is the major social determinant of health plaguing Mississippi’s ability to move forward in general and in public health in particular. For years, folks have been writing about poverty in Mississippi and how it affects our culture and health.4 More recently, they have been writing about how much money poverty and bad health generate for corporate America.5 If you don’t believe that, drive through any Delta town and see who has the new storefronts. It is the home health agencies. One economist, CK Prahalad at the University of Michigan, made a career out of suggesting that poverty could be looked at as economic opportunity and eventually eradicated by its own profits. I have trouble understanding economic theory. If poverty were a positive attribute, our ranking would make us the most financially privileged state in the country. Regardless, since poverty, health, and productivity track together, long term economic improvement in Mississippi is unlikely with an obese, chronically ill workforce. Over the long term, a chronically ill population is a debit, not a credit, to the economy no matter how you figure it. Let Somebody Else Lead Most of us handle our personal angst about Mississippi’s miserable health status by denial. We work hard keeping people alive and just don’t have the emotional energy left at the end of the day to deal with the rest of it. So we defer to the experts, our public health system, and the politicians. The Department of Health in Mississippi is a centralized public health system that operates under an eleven member Board appointed on staggered terms by the Governor. The budget, for the most part, comes from a variety of federal grants and funds through the Centers for Disease Control. The balance comes from state, local, and third party earnings with a mandate to collect and report data on communicable diseases, environmental issues, and other personal health activities. At approximately $10.90 per citizen of state funding, the legislature provides among the absolute lowest amounts of state support among all states, in the state with the poorest health. That says a lot about priorities. Since the majority of the public health infrastructure is state employees or appointees, it is difficult for the Department to point out these issues which are important to our health care system in Mississippi. It takes only a few minutes of conversation with legislators to figure out how the majority of them see physicians as just another special interest group jockeying for position in the marketplace. As physicians, our position has usually been to try to preserve the status quo in a health care market that is rapidly changing. And since we provide lots of

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campaign dollars, the politicians listen. However, the truth is public health issues are near the bottom of their list, and folks in poverty who benefit most from better public health don’t make campaign contributions. And when health does get attention, the real interest is not about public health; it’s about the politics of health. The Food Stamp Debate Take food stamps for example. The food stamp program, now the source of an ongoing debate about the federal farm bill, is a pretty good example of the way poverty and health have been politicized over time. The fact that this health-related program has its home in the US Department of Agriculture speaks reams. That program, now called Supplemental Nutritional Assistance Program (SNAP), was developed to support crop prices for American farmers, more than to be a public health measure. As of June 2013, there were 667,301 SNAP participants in Mississippi. Since its initiation in 1939, the food stamp program has grown exponentially to an estimated $75.6 billion federal budget item, usually concealed within farm bills already bloated with other subsidies.6 This year, the US House of Representatives split SNAP out from the $500 billion farm bill to wage war on how much money goes into the program. Progressives argue that SNAP is essential to public health, and conservatives argue that the food stamp program fosters dependency and is a waste of money. Both are probably correct. Meanwhile, the politicians play both sides against each other in order to raise the huge sums of money necessary for their next campaign. Who makes money on food stamps? It is certainly not the US government but rather a bunch of corporate contractors. They have profited by expanded services through the use of good old American technology; not tractors, but Electronic Budget Transaction (EBT) cards. Of the three firms that provide EBT services for states participating in the food stamp program (JP Morgan, Affiliated Computer Services, and eFunds), JP Morgan has received $560,492,596.02 from 18 of the 24 states with whom it contracts since 2004.6 Now that’s real money. And do you think JP Morgan and others take care of the politicians who expand the SNAP program and their business? Between 1998 and 2002, JP Morgan’s total contributions to Agriculture Committee members averaged $82,897. After JP Morgan entered the EBT market, the average donation per cycle doubled to $215,505 (Figure 3). Medical Intelligence Unit and a Realignment of Our Advocacy Budget Somewhere, long ago, somebody told us that if we did the best thing for our patients it would be the best thing for us as well. We bought in to that when we took the oath. We don’t think that way anymore. The politicians never thought that way.


Figure 3. JP Morgan donations to Agriculture Committee members double after entry into the EBT market in 2002. (Profits from Poverty: How Food Stamps Benefit Corporations. Government Accountability Institute)

What we need now is advocacy for the existing social determinants of health and a new one: patient advocacy (Figure 1b). Maybe we as an association ought to take a look at the way we spend our advocacy dollars. We could support our own “media intelligence unit” for patients, a “medical intelligence unit.” Somebody needs to let patients know the

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real threats to their health and how to address them. If we redirected the money and energy we spend on our own advocacy to advocacy for our patients’ health, maybe we would get somewhere on improving their health and the increasingly poor health of organized medicine as well. In Closing Since we know that improving the social determinants of health improves health itself, why not advocate for those in the same way we advocate for reimbursement rates, tort reform, and the rest of it? If business has already determined that advocacy for their products improves the bottom line, even if it requires a “media intelligence unit,” maybe advocacy for those factors associated with good health would improve ours. And along the way, we could prove all over again that what’s best for our patients is what’s best for us. We might even recapture our role as leaders in health care. References 1.

Wilkins R Marmot M. (ed) (2003). “The Social Determinants of Health: The Solid Facts, 2nd ed” (PDF). World Health Organization Europe. http://www.euro.who.int/__data/assets/pdf_file/0005/98438/e81384.pdf Accessed 2013-03-27.

2.

Burd-Sharps S, Lewis K, Martins EB. A Portrait of Mississippi. Mississippi State Conference NAACP. http://www.measureofamerica. org/mississippi/ Accessed September 21, 2013.

3.

American’s Health Rankings. http://americashealthrankings.org/MS/2012 Accessed September 20, 2013.

4.

Ownby, Ted. American Dreams in Mississippi: Consumers, Poverty, and Culture, 1830-1998. Chapel Hill: University of North Carolina Press, 1999.

5.

Hudson, Michael. Merchants of Misery: How Corporate America Profits From Poverty. Monroe, Maryland: Common Courage Press, 2002.

6.

Profits from Poverty: How Food Stamps Benefit Corporations. Government Accountability Institute, September 2012. http://g-a-i.org/ wp-content/uploads/2012/10/GAI-Report-ProfitsfromPoverty-FINAL. pdf Accessed September 15, 2013.

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• MSDH • Mississippi Reportable Disease Statistics

August 2013 Figures for the current month are provisional

Totals include reports from the Department of Corrections and those not reported from a specific District. For the most current MMR figures, visit the Mississippi State Department of Health website: www.HealthyMS.com. † Data not available.

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• Physician’s Bookshelf • [This book review is one of a new series, reports from UMMC Book Clubs. New accreditation rules related to education, needs for professionalism, ethics, and humanism in medicine have stimulated a new interest in books on medicine at both the student and house staff levels. We hope these reviews will be helpful to you in your own medical reading.] —Richard deShazo, Associate Editor

Report from the UMMC Internal Medicine Book Club Jacob Graham, Jackson, B.S. from Mississippi College, PGY-2

Death Foretold: Prophecy and Prognosis in Medical Care by Nicholas A. Christakis Chicago, IL: The University of Chicago Press; 1999, 374 pp.

D

eath Foretold was written by Dr. Nicholas Christakis, an internist and sociologist specializing in Hospice and Palliative Medicine. He currently studies social factors affecting health and is co-author of Connected: The Surprising Power of Our Social Networks and How They Shape Our Lives, a work published in 2009 and translated into nearly twenty foreign languages. His past work examines the accuracy and role of prognosis in medicine, ways to improve end-of-life care, and utilization and outcomes of hospice care. Death Foretold is concerned with physician use of prognosis and the difficulties involved. Dr. Christakis immediately gets to the heart of the problem. On the third page of the preface, he quotes the all too familiar story of a woman who has lost her husband to cancer and is remorseful about his last days. These were filled with painful procedures and chemotherapy in the hospital instead of with peace and symptom control at home with family. The doctor is blamed for holding out hope for a cure until the end, when the patient and family knew it was futile. Why didn’t the doctor give a realistic prognosis? Did he lack information on which to base predictions? The SUPPORT trial1, which Christakis references at multiple points, showed that giving doctors medically relevant information didn’t make them any more likely to offer prognoses to patients. Trends in the medical literature have shown that, as diagnostic accuracy and treatment efficacy have increased, emphasis on prognosis has decreased, almost as though it’s only talked about if there’s nothing better to do. Christakis brings out social aspects of prognostication, including how prognosis is altered by factors such as ability to afford medications and how social characteristics affect who is told their prognosis. Social attributes can even replace medical goals as the outcome of interest, as in the case of the potential “social failure” of a thirteen-year-old mother. In the chapter on professional norms, he includes cautionary tales about wrong unfavorable predictions (“I outlived that doctor after all”). He discusses the impossible combination of attributes a physician is supposed to possess when sharing predictions, including optimism, honesty, accuracy, realism, hopefulness, and humility. In later chapters, he gives helpful strategies for breaking bad news, as well as some approaches to avoid. The self-fulfilling prophecy, who believes in it, and how it works differently in acute versus chronic illness are explained. The final chapters ask some of the most important questions. How do physicians internalize optimism or pessimism, and what are the pros and cons of each approach? Is it prudent to “hang crepe”? Are patients not told how bad their diseases are because the doctors truly believe they will be the rare success stories? Do doctors have a duty to prognosticate? The entire book is excellent reading for anyone involved in life-threatening disease. Oncologists, intensivists, and hospice doctors will benefit from reading it, but primary care doctors who have long-term, established relationships with patients may find this book particularly useful. Residents and fellows in our Internal Medicine book club felt that some parts were pedantic and/ or “preachy,” but hopefully all were left with a sense of the importance of offering honest and educated prognoses to patients and families. I give the book a 9 out of 10 and enthusiastically recommend it. Reference: SUPPORT principal investigators. A Controlled Trial to Improve Care for Seriously Ill Hospitalized Patients: The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). JAMA 1995;274(20):1591-8.

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Save the Date! May 24-27, 2014 12th Annual CME in the Sand Sandestin Golf and Beach Resort Tentative Agenda Saturday, May 24 9:00 - 4:00 MSMA BOT Meeting 11:00 - 2:00 CME Sessions

Sunday, May 25 9:00 - 1:00 6:30 PM

CME Sessions Welcome Reception with Children’s Activities

Monday, May 26 7:15 8:00 9:00 6:30

- 8:00 -12:30 AM PM

Breakfast with Exhibitors CME Sessions Spouse/Children’s BINGO Family Dinner with Children’s Activities

Tuesday, May 27 7:15 - 8:00 Breakfast with Exhibitors 8:00 -12:30 CME Sessions

For more information visit www.MSMAonline.com October 2013 JOURNAL MSMA 303


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Have You Considered a Life Settlement For Your Old Life Insurance Policy? What is a Life Settlement? A life settlement is the sale of an existing life insurance policy on the secondary market to a third party investor.

Who or What May Qualify?  If the person insured by the policy is age 70 or older  If the person insured has any major medical conditions  If the policy has a death benefit of $250,000 or more  Policies including, but not limited to, universal life, term insurance, variable life insurance or whole life insurance  If any cash value exists in the policy, the amount is relatively small

For More Information on Life Settlements, contact: H. Larry Fortenberry, CPA, CLU, ChFC Executive Planning Group, PA 1640 Lelia Drive, Suite 220 PO Box 16566 Jackson, MS 39216 (601) 982-3000

Why Use a Life Settlement?  Term life insurance policy will expire  Old policy that is no longer needed or premiums cannot be paid  A policy that was purchased for a business buy/sell and is no longer needed  A policy was purchased for a business that has been sold or is not needed  There may be a better policy available at a lower cost

 Estate value has changed and the policy is no longer needed

Securities Offered Through ValMark Securities, Inc. Member FINRA, SIPC Investment Advisory Services Offered Through ValMark Advisers, Inc. a SEC Registered Investment Advisor 130 Springside Drive, Suite 300 Akron, Ohio 44333-2431* 1-800-765-5201 Executive Planning Group is a separate entity from ValMark Securities, Inc. and ValMark Advisers, Inc. In a life settlement agreement, the current life insurance policy owner transfers the ownership and beneficiary designations to a third party, who receives the death proceeds at the passing of the insured. As a result, this buyer has a financial interest in the seller’s death. When an individual decides to sell their policy, he or she must provide complete access to his or her medical history, and other personal information, that may affect his or her life expectancy. This information is requested during the initial application for a life settlement. After the completion of the sale, there may be an ongoing obligation to disclose similar and additional information at a later date. A life settlement may affect the seller’s eligibility for certain public assistance programs, such as Medicaid, and there may be tax consequences. Individuals should discuss the taxation of the proceeds received with their tax advisor. ValMark Securities considers a life settlement a security transaction. ValMark and its registered representatives act as brokers on the transaction and may receive a fee from the purchaser. A life settlement transaction may require an extended period of time to complete. Due to complexity of the transaction, fees and costs incurred with the life settlement transaction may be substantially higher than other securities.

October 2013 JMSMA  

The Journal MSMA has a circulation of 4,000, which includes the membership of the Association and paid subscribers. The year 2013 represents...