Sonoma Medicine Summer 2014

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Volume 65, Number 3

I NTE RV I E W

SCMA PRESIDENT ROB NIED, MD FEATURE ARTICLES

HANDS and FEET

Summer 2014 $4.95


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Volume 65, Number 3

Summer 2014

Sonoma Medicine The magazine of the Sonoma County Medical Association

FEATURE ARTICLES

Hands and Feet

5 7 11 13 16 19

EDITORIAL

Hands and Feet

“Newborns seem to know about their hands, but not their feet.” Allan Bernstein, MD

HAND/WRIST SYNDROMES

Carpal Tunnel A to Z

“There is a common misconception that carpal tunnel syndrome is the result of our modern-day reliance on computer keyboards.” Marcia Luisi, MD

Page 33: VeloMed

HAND SURGERY

Are new treatments for CTS and Dupuytren’s really better?

“In recent years, new treatment options for two common hand problems seen by orthopaedic surgeons—carpal tunnel syndrome and Dupuytren’s contracture-—have been introduced.” Michael Bollinger, MD

MANUAL DEXTERITY

Classical Music, Hands On

“Like music, surgery—performed in the surgical theater—is a dynamic process that has its own harmony and resolution of dissonance.” Karen Leung, MD

Page 35: On the Brink

HEEL PAIN

Plantar Fasciitis Q&A

“Plantar fasciitis is the most common cause of plantar heel pain and can be a frustrating, disabling condition for patients.” Shawn Hsieh, MD

COMMON INJURIES

Understanding Ankle Fractures

“As with all other aspects of medicine, the understanding of ankle fractures has greatly matured over the decades.” Kenneth Lopez, DPM Table of contents continues on page 2.

Cover: SCMA President Rob Nied, MD. Photo by Duncan Garrett.


Sonoma Medicine DEPARTMENTS

23 27 30 33 35 38

INTERVIEW

SCMA President Robert Nied, MD

“I think the challenge for CMA, and especially SCMA, in the coming years is how to have that collective voice, how to be cohesive when gathering physicians is notoriously like herding cats.” Steve Osborn

LOCAL FRONTIERS

Office-Based Balloon Sinus Dilation

“No surgery that otolaryngologists perform conjures up more intense imagery than sinus surgery.” Stefan Zechowy, MD

LOCAL FRONTIERS

Suboxone Treatment for Opioid Dependency

“People who suffer from chronic pain and have a history of substance abuse are highly susceptible to opioid dependence.” Anish Shah, MD

COMMUNITY INVOLVEMENT

VeloMed Protects Sonoma County’s Bicyclists

“Serious injuries often occur during organized bicycle rides in remote areas of Sonoma County. In these situations, an ‘on-bike’ first responder can make a critical difference.” Stephen Meffert, MD

OUTSIDE THE OFFICE

On the Brink

“I catch a flash of scarlet so striking that its brilliance stands out from the darkened foliage like a torch.” T.W. Hard, MD

CURRENT BOOKS

Where’s the Magic?

“The title of the book is Do You Believe in Magic?, by John Offit, MD. The subtitle explains it: ‘The Sense and Nonsense of Alternative Medicine.’ Already, I’m put off.” Rick Flinders, MD

40 CMA NEWS 42 SCMA WINE & CHEESE RECEPTION 46 NEW MEMBERS 48 SCMA ALLIANCE & FOUNDATION NEWS

SONOMA COUNTY MEDICAL ASSOCIATION Mission: To enhance the health of our communities and promote the practice of medicine by advocating for quality, ethical health care, strong physician-patient relationships, and for personal and professional wellbeing for physicians.

Board of Directors Rob Nied, MD President Mary Maddux-González, MD President-Elect Regina Sullivan, MD Treasurer Peter Sybert, MD Secretary Stephen Steady, MD Immediate Past President Peter Brett, MD Maryann Dakkak, MD Brad Drexler, MD Rick Flinders, MD Catherine Gutfreund, MD Leonard Klay, MD Marshall Kubota, MD Clinton Lane, MD Anthony Lim, MD Rachel Mayorga, MD Richard Powers, MD Phyllis Senter, MD Jan Sonander, MD Jeff Sugarman, MD

Staff Cynthia Melody Executive Director Rachel Pandolfi Executive Assistant Steve Osborn Managing Editor Linda McLaughlin Graphic Designer Susan Gumucio Advertising Representative Alice Fielder Bookkeeper

Membership Active members 605 Retired 177

SCMA

E CHEES WINE N TIO RECEP

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Sonoma Medicine

LIVING WITH

hipor knee

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Editorial Board Jeff Sugarman, MD Chair Allan Bernstein, MD Peter Bretan, MD James DeVore, MD Rick Flinders, MD Rachel Friedman, MD Jessica Les, MD Rob Nied, MD Brien Seeley, MD Mark Sloan, MD

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Steve Osborn Editor Cynthia Melody Publisher Linda McLaughlin Designer Susan Gumucio Advertising Sonoma Medicine (ISSN 1534-5386) is the official quarterly magazine of the Sonoma County Medical Association, 2901 Cleveland Ave., Suite 202, Santa Rosa, CA 95403. Periodicals postage paid at Santa Rosa, CA, and additional mailing offices. POSTMASTER: Send address changes to Sonoma Medicine, 2901 Cleveland Ave., Suite 202, Santa Rosa, CA 95403. Opinions expressed by authors are their own, and not necessarily those of Sonoma Medicine or the medical association. The magazine reserves the right to edit or withhold advertisements. Publication of an ad does not represent endorsement by the medical association. Email: scma@scma.org.

Individual results vary. Not all patients will have the same post-operative recovery and activity level. See your orthopaedic surgeon to discuss your potential benefits and risks. Stryker Corporation or its divisions or other corporate affiliated entities own, use or have applied for the following trademarks or service marks: Stryker. All other trademarks are trademarks of their respective owners or holders. NL10-AD-HI-3624

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EDITORIAL

Hands and Feet Allan Bernstein, MD

N

ewborns seem to know about their hands, but not their feet. They look at their feet; they play with them, but they don’t know how to use them. Unlike most mammals, human babies are very slow to get up, bear weight and ambulate independently. When they eventually attain the upright position, their foot bones splay out in different directions, their muscles aren’t well coordinated, and their brains don’t seem to know where the feet are located. Human babies topple over, a lot. Once they get going, however, their feet become incredible machines, bearing massive amounts of weight over a lifetime. Our feet are subject to repeated strains in daily activities and additional demands during exercise—and are asked to adapt to weight gains, weight losses and the effects of pregnancy. Injuries to our backs, hips and knees change the way weight is distributed in our feet. Yet, we take it for granted that our feet will carry us through. Then, we add shoes. Very few shoes are designed to match the actual shape of our feet. We wear tight shoes, pointy shoes, stiff shoes and shoes that looked good in the store but hurt badly after we are in them for more than an hour. And why do we want women to shorten their Achilles tendons and Dr. Bernstein, a Sebastopol neurologist, serves on the SCMA Editorial Board.

Sonoma Medicine

shift their weight onto the metatarsal heads in the name of fashion? The result is foot abuse, along with secondary ankle, knee, hip and back abuse. When we’re young, we twist ligaments and break bones in our feet. As we get older, the nerves in our feet, the longest nerves in the body, are the first to show their age. We get a little numb, and we start to lose a sense of where our feet are. Our gait gets broader, just to keep our balance. Our midsection gets wider, and we start to lose sight of our feet. They’re down there somewhere, sort of like at the beginning; we just need some help in taking care of them. Nerves to the feet are the last to develop and the first to die back from old age. The feet just can’t seem to win. In contrast, our hands are important from day one, and remain so for our entire life. When we look at the homunculus on the surface of the brain, the two largest representations for motor and sensory functions are for the tongue and the thumb. Everything else seems to be secondary. The feet barely register on that diagram. We hold things, we eat, we play and we learn, all through our hands. Some of us even talk with our hands. If our hand is in a cast, we have a harder time communicating. Hand injuries change our careers. When I was a medical student, starting a surgery rotation, I broke my hand in a skiing accident. I was reassigned to a rotation where I only needed one hand, i.e., neurology. The rest is history. We engage in fine motor activity and great feats of strength, often at the same

time, using our hands. Think about a magician, a baseball player, a card dealer, a saxophone player, a sculptor and a plumber, all completely dependent on the multifunctional use of their hands. We certainly beat up our hands, as witnessed by the common occurrence of carpal tunnel and other overuse syndromes. Hand surgery, initially related to birth defects and industrial trauma, is now used for sports injuries, hobby-related injuries, “texting thumbs” and computer keyboardrelated syndromes. Hands have an emotional connection for us. There are multiple paintings and sculptures of hands. How many are there of feet? How many of those stick in our minds? Are hands really sexier? Hands and feet have taken a serious beating in the recent military conflicts, with body armor protecting the torso, leaving the limbs and head exposed to shrapnel and other blast injuries. Rebuilt, artificial and computer-controlled hands and feet are some of the results of our current rehabilitation of wounded warriors. The results are good, but never as good as the originals. If we follow evolutionary principles, each of us should be developing bigger hands and smaller feet. A bionic foot is getting close to reality. A bionic hand, while very good at many tasks, still can’t play the violin or even fix the plumbing. Email: bernsteinallan@gmail.com

Summer 2014 5


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HAND/WRIST SYNDROMES

Carpal Tunnel A to Z Marcia Luisi, MD

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ut I couldn’t possibly have carpal tunnel syndrome. I don’t use a computer that much!” This is a frequent initial reaction when I tell patients they have carpal tunnel syndrome, based on history, physical exam and electrodiagnostic (EDX) tests. There is a common misconception that carpal tunnel syndrome (CTS) is the result of our modern-day reliance on computer keyboards. But CTS was recognized for many years before the information age and is often due to a variety of circumstances. Clinical presentation, along with an understanding of the anatomy and associated conditions, is critical for correct diagnosis. EDX, which consists of electromyography (EMG) and nerve conduction studies (NCS), is useful for diagnosing and classifying the degree of CTS. The test results can guide treatment and help differentiate CTS from other conditions. The prevalence of CTS varies from 5–8% of the U.S. population.1–5 It is the most common entrapment neuropathy, comprising approximately 90% of all diagnosed nerve entrapments.3 The first cases were described in the mid-19th century and were primarily due to trauma. However, the term “carpal tunnel syndrome” was not coined until 1930. Diagnosis of CTS beDr. Luisi, a board certified physiatrist, has practiced electrodiagnostic medicine in Santa Rosa for 25 years.

Sonoma Medicine

came more common in the 1960s due to increased physician awareness. 6 Patient awareness through popular media, increased diabetes and obesity, and increased computer use may have contributed to an even greater recognition of CTS since the 1980s. In one study, the incidence increased by 164% between 1981 and 2005, with the greatest increase in the elderly.7 The lifetime risk of acquiring CTS is estimated at just under 10%.5–7 CTS is created by compression of the median nerve within the carpal tunnel, an anatomical space located at the hand/wrist junction. This space is defined by the flexor retinaculum on the ventral surface and carpal bones on the dorsal surface. Nine flexor tendons pass through the tunnel, along with the median nerve. Conditions that decrease the size of the tunnel and/or increase pressure within the tunnel can lead to focal compression, resulting in both ischemia and mechanical damage to the nerve fibers.8 Sustained compression of the median nerve disrupts myelin and causes axonal conduction dysfunction, which is detectable by EMG/NCS with a specificity of 95% and a sensitivity of 85–90%.3,8,9 Associated conditions and known risk factors for CTS include advanced age, f e m a le ge nder, pr eg n a nc y, trauma, mass lesions, tenosynovitis, diabetes mellitus, arthritis, thyroid disease, renal disease, autoimmune disorders, a strong family history, and anatomical variation of the wrist and hand.3

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ertain occupational associations with CTS are clearly established. There is an increased risk with work that requires prolonged and highly repetitive flexion/extension of the wrist, especially when combined with forceful gripping.10 The repetitive use of vibrational tools is another risk factor.10 Workers with high occurrence of CTS include mechanics, welders, dentists, carpenters, assembly line workers, maintenance workers, construction laborers and musicians.10 The question of intense computer use causing CTS remains unanswered. Many of the studies that have attempted to clarify this association have serious limitations, so no definitive conclusion regarding CTS and computers can be made.11 The closest association showed a correlation between CTS and using a mouse more than 20 hours per week.11 However, a definite cause-and-effect relationship between CTS and computer keyboard use alone without a mouse has not been determined.11,12 Nevertheless, most of us have seen patients suffering from the effects of long hours of computer use, be they musculoskeletal issues and/or symptoms strongly suggestive of CTS. The potential risk of developing CTS with use of computers may be due to improper technique, such as having the wrist hyperflexed or hyperextended and/or gripping the mouse too tightly while resting the base of the hand on a hard surface. Whether or not computer use is a direct cause of CTS remains unproven, but it is likely an exacerbating factor. Summer 2014 7


D

espite increased awareness, CTS can still be a challenge to diagnose and treat. CTS can mimic other clinical entities as well as coexist with tendonitis, arthritis, peripheral polyneuropathy, radiculopathy and plexopathy. Patient history and physical exam are the key components to making an initial diagnosis. In the early stages of CTS, patients complain of intermittent numbness and/or tingling with or without pain, typically described as if “the hand is going to sleep.” This can occur at work, while driving, cycling, reading or engaging in any grasping activity. As symptoms progress, patients often have nocturnal awakenings with severe paresthesias that can be accompanied by pain frequently described as a burning sensation. They frequently state that their hand feels swollen, but it doesn’t look swollen. In more severe cases, the pain may radiate to the forearm, upper arm and shoulder, and symptoms may be constant. Classically, the paresthesias are in the median nerve distribution: the thumb, index finger, middle finger and half of the ring finger. Frequently, however, the patient complains of tingling in the whole hand or just two or three digits in the median distribution, which makes diagnosis more difficult. When proximal symptoms are present during the day as well, the diagnosis of radiculopathy must be considered. Provocative tests like Tinel’s or Phalen’s can raise the clinician’s suspicion of CTS but, unfortunately, the specificity and sensitivity of these tests is low.3,5 Tinel’s sign is done by tapping lightly on the median nerve at the wrist and the base of the hand. Phalen’s sign is done by maintaining hyperflexion of the wrist for one minute. A positive test in either case occurs when paresthesias are reproduced. The flick sign (the patient reports shaking the hand or flicking the wrist to alleviate symptoms) correlates with a positive EMG/ NCS abnormality in 93% of cases.6 Severe cases of CTS often present with thenar atrophy, weakness in thumb abduction muscles and loss of twopoint discrimination. 8 Summer 2014

Conservative treatment is recommended for mild cases of CTS that present with intermittent symptoms of paresthesias with or without mild pain. Treatment consists of splinting at night, icing after use and modification of work activities. A short course of oral corticosteroids produces symptom relief, with benefits waning over a period of eight weeks after discontinuation.2 Cortisone injections are an effective intermediate solution, with relief of pain and paresthesias lasting 3–12 months.3,13 NSAIDS and gabapentin may help reduce pain while they are taken, but they do not change the pathophysiology of compression and therefore will not alter the long-term course of CTS.2,12,13 Therapeutic ultrasound, iontophoresis, and tendon/nerve gliding exercises may be helpful for some individuals, but studies don’t consistently support these treatments.14,15 Pyridoxine (vitamin B6) and diuretics have been shown to be no more helpful than placebo.2,12 The effectiveness of acupuncture varies depending on the study, but it may be helpful for short-term symptom relief in mild to moderate cases.16,17 Of course, treatment of any underlying condition is indicated.

I

f the patient presents with intermittent mild symptoms, it is reasonable to treat for 2–8 weeks. If there is no response to conservative treatment, then referral for EMG/NCS testing is recommended to clarify the diagnosis and classify the degree of CTS, if present. When the patient presents with severe symptoms of constant paresthesias with or without severe pain and/ or weakness and atrophy, referral for electrodiagnostic studies and surgical consultation should proceed directly to avoid possible permanent damage to compressed nerve fibers. Electrodiagnostic testing is also helpful in cases that don’t present with classical symptoms. As mentioned previously, because CTS can mimic a variety of conditions, EDX studies can help differentiate the syndrome from cervical radiculopathy, brachial plexopathy, peripheral polyneuropathy,

other nerve entrapment syndromes and musculoskeletal disorders. When constant whole-hand paresthesia is present, it is important to differentiate CTS from a central nervous system process. Recently, I had a patient referred with a preliminary diagnosis of CTS, but there were no significant EMG/NCS abnormalities. In view of the patient’s presenting symptoms, physical exam and normal EDX testing, an MRI of the brain was ordered, revealing an astrocytoma. EDX studies combined with history and physical exam continue to be the most accurate way to establish the diagnosis of CTS.6,8 An experienced electrodiagnostician is able to reliably differentiate CTS from coexisting or alternative diagnoses after taking a history, conducting a directed physical exam and using sophisticated EMG/ NCS equipment. Automated hand-held “nerve conduction” devices have gained popularity but have limited NCS diagnostic accuracy, do not have EMG capability and have not demonstrated equivalent diagnostic reliability or accuracy when compared to EMG/NCS testing.18,19 Additional diagnostic tools such as CT and MRI may be indicated when structural lesions are suspected or there is a history of wrist trauma, bone disease or joint disease.20 The use of neuromuscular ultrasound as a diagnostic tool for CTS may also be helpful if EMG/NCS is inconclusive.20,21

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arpal tunnel surgery, consisting of complete division of the flexor retinaculum, is recommended for moderate to severe cases of CTS.13 Delay in releasing the tunnel in these cases can result in long-term permanent nerve damage and muscle atrophy. Surgery may also be an option in mild to moderate cases when conservative treatment has failed and a patient feels that his or her work and/or lifestyle is significantly compromised due to numbness, pain or weakness.13 Carpal tunnel release is among the most common surgeries performed in the United States. A minimal incision, Sonoma Medicine


often not more than one inch long, is made to identify and divide the flexor retinaculum and accomplish median nerve decompression. The procedure can also be performed endoscopically, although visualization of vital structures may be more difficult. In various trials, 70–90% of patients who underwent surgery were free from nighttime pain afterward.12 Surgery is also successful in reducing other symptoms associated with CTS. One study reported 95% satisfaction and complete or significant relief of symptoms in 100 patients.22 When clinical history and physical exam are combined with EDX studies, there is a statistically significant correlation between these tests and successful surgical outcomes.13 Prevention in the workplace and at home is key to reducing the incidence and severity of CTS. Some suggestions for prevention include keeping the wrist and hand in a neutral position, limiting repetitive forceful gripping and vibrational hand activities, taking breaks, using voice recognition software, alternating hands for mouse operation, applying ice after significant hand use and wearing splints at night when mild symptoms develop. Hand and wrist exercises may also help reduce the risk of developing CTS.12 Ergonomic work stations and instructions to employees engaged in frequent hand use would help lessen the occurrence of CTS. CTS has been a condition described and treated for many years. Clinical acumen in diagnosing and treating this syndrome and knowing when to refer for testing and surgery will assist physicians and their patients in dealing with the challenges of this increasingly common condition. Email: mluisimd@att.net

References

1. Dale AM, et al, “Prevalence and incidence of CTS in US working populations,” Scandinavian J of Work, Environment & Health, D01:10:5271 (2013). 2. LeBlanc KE, et al, “Carpal tunnel syndrome,” Am Fam Phys, 83:952-958 (2011).

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3. Wang, Leile, “Electrodiagnosis of CTS,” Phys Med Rehab Clinics N Am, 24:67-77 (2013). 4. Luckhaupt SE, et al, “Prevalence and work-relatedness of CTS in the working population,” Am J Ind Med, 56:614-615 (2013). 5. Watson JC, “Electrodiagnostic approach to CTS,” Neurologic Clinics, 30:457-478 (2012). 6. Rosenbaum RB, Ochoa JL, CTS and Other Disorders of the Median Nerve, 2nd ed, Butterworth Heinemann (2002). 7. Gelfman R, et al, “Long-term trends in CTS,” Neurology, 72:33-41 (2009). 8. Werner RA, et al, “Electrodiagnostic evaluation of CTS,” AANEM Monograph (2011). 9. AANEM, “AANEM practice topic in EDX medicine,” Muscle Nerve, 25:918-922 (2002). 10. Palmer KT, et al, “CTS and its relationship to occupation,” Occ Med, 57:57-66 (2007). 11. Thomsen, et al, “CTS and the use of computer mouse and keyboard,” BMC Musculoskeletal Disorders, 9:134 (2008). 12. U Maryland Medical Center, “Carpal tunnel syndrome,” www.umm.edu (2014).

13. AAOS, Clinical Practice Guideline on the Treatment of CTS, AAOS (2008). 14. Page MJ, et al, “Exercise and mobilization interventions for CTS,” Cochrane Database, 13;6: CD009899 (June 2012). 15. Page MJ, et al, “Therapeutic ultrasound for CTS,” Cochrane Database , 28;3:CD009601 (March 2013). 16. Yang CP, et al, “Acupuncture in patients with CTS,” Clin J Pain, 25:327-333 (2009). 17. Khosrawi S, et al, “Acupuncture in treatment of CTS,” J Res Med Sci, 17:1-7 (2012). 18. Schmidt K, et al, “Accuracy of diagnoses delivered by an automated hand-held nerve conduction device,” Muscle Nerve, 43:9-13 (2011). 19. England JD, et al, “Automated hand-held nerve conduction devices,” AANEM 60th Annual Meeting (2013). 20. Bhandari M, et al, Evidence-based Orthopedics, John Wiley and Sons (2011). 21. Cartwright MS, et al, “Evidence-based guideline: Neuromuscular ultrasound for the diagnosis of CTS,” Muscle Nerve, 46:287-293 (2012). 22. Park SH, et al, “Surgical outcome of endoscopic carpal tunnel release in 100 patients with CTS,” Minim Invasive Neurosurg, 47:261-265 (2004).

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HAND SURGERY

Are new treatments for CTS and Dupuytren’s really better? Michael Bollinger, MD

O

rthopaedic surgeons try to stay current on new surgical techniques and treatment options that are designed to alleviate risks, speed recovery and improve a patient’s overall experience. While these new techniques and technologies play a vital role in advancing orthopaedics, it should not be assumed that they are appropriate options for every patient. In fact, some introduce their own risks, can be more costly and may yet be unproven. In recent years, new treatment options for two common hand problems seen by orthopaedic surgeons—carpal tunnel syndrome and Dupuytren’s contracture—have been introduced. While certainly worth consideration, these options may not be right for everyone.

Carpal Tunnel Syndrome

Carpal tunnel syndrome is one of the most common problems seen in an orthopaedic practice, with approximately 400,000 carpal tunnel surgeries performed annually in the United States. The traditional surgery is an open approach where the surgeon makes an incision longitudinally over the carpal tunnel to release the flexor retinaculum. This approach has long been relied upon by surgeons as an effective means of correcting the problem. That said, possible complications, although rare, include wound dehiscence and risk of prolonged discomfort and swelling at Dr. Bollinger is a Sebastopol orthopaedic and hand surgeon.

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the incision site during recovery. To combat these risks, proponents of a relatively new endoscopic approach claim their method is superior to the open approach, because it is less invasive (requiring smaller incisions) and offers faster recovery times (potentially up to a week faster). While this may be true, it comes at a cost. Endoscopic surgeons use an endoscope to visualize the carpal tunnel and its contents while they divide the transverse carpal ligament via one or two small incisions. Due to its more complicated nature, endoscopic surgery takes longer for most surgeons to perform and requires the purchase of specialized equipment. These factors make endoscopy a more expensive procedure than the open approach. Of greater concern is the higher risk of transient or permanent nerve injury that may occur in cases where a less experienced surgeon performs the procedure. Despite the wealth of studies comparing the two approaches, no definitive answer exists as to which one is superior. Ultimately, the most appropriate approach should be determined by the patient’s surgeon and should be based on individual patient circumstances.

Dupuytren’s Contracture

Dupuytren’s contracture affects approximately 4% of the U.S. population, making it a relatively common medical complaint. Once contracture has advanced to the point that hand function is limited—generally at about

30 degrees of contracture—treatment is recommended. Traditionally this consisted of an open subtotal fasciectomy to help restore finger motion. This surgery involves long incisions from palm to finger in order to remove the diseased fascia. While the larger incisions allow for good visualization of a patient’s anatomy, swelling and soreness are common postsurgical complaints. In addition, this approach can potentially cause significant scarring, with increased potential for scar contracture. Use of a modified open technique (where multiple small incisions are made, rather than a long one) works well because the skin bridges preserved during surgery significantly reduce the amount of scarring. The bridges also make wound closure easier and lead to less postoperative swelling, leading to potentially faster recovery times and a lower rate of recurrence. A relatively new nonsurgical option that is drawing a lot of attention involves injecting Xiaflex (collagenase clostridium histolyticum) into the affected hand. During the first office visit, the surgeon numbs the hand and injects the Xiaflex enzyme directly into diseased tissue. Once injected, the enzyme works to dissolve the contractile tissue. The patient then returns to the office 1–2 days later for manipulation of the finger under local anesthesia in an attempt to straighten the digit. Xiaflex is an attractive option for many patients because it potentially avoids the risks associated with open Summer 2014 11


surgery, such as injury to nerves and blood vessels and possible infection. While avoiding risks is a strong draw for some patients, Xiaflex is not without its own costs and risks. Single injections cost about $4,500 each, and multiple injections are often required before the problem is solved. There is also the potential for negative unintended reactions caused by the injections, such as dissolving or rupturing the tendon and other important collagen-based structures in a patient’s palm, or for the patient to experience an allergic reaction to Xiaflex. Neither the surgical nor the Xiaflex option prevents recurrence of Dupuytren’s (which approximately 20% of patients experience), making the Xiaflex option potentially more expensive than its surgical counterparts, particularly since the rate of recurrence may be higher with Xiaflex. Additionally, Xiaflex does not remove diseased tissues from the patient’s hand, resulting in a less appealing cosmetic result. While Xiaflex presents exciting possibilities for certain patients—including those who have had multiple surgeries to treat their recurring condition, or those who otherwise would not be suitable candidates for surgery—it is still too early to determine whether Xiaflex is the better choice for most patients.

Conclusion

Increased options for treating carpal tunnel syndrome and Dupuytren’s contracture are good news for orthopaedic surgeons and our patients. With any new treatment solution, however, there can be a tendency to focus on the “new” aspect of the approach and potentially miss the broader issues, such as increased risk or increased cost. As in all areas of medicine, no single approach is right for all patients. Rather, it is up to the experienced physician to look beyond the promise of new technology and evaluate all options to determine (based on thorough examination and other patient circumstances) what the correct course of treatment should be. Email: surgeons@sonic.net

12 Summer 2014

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MANUAL DEXTERITY

Classical Music, Hands On Karen Leung, MD

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rom vinyl 45s and 78s, to eighttracks, cassettes, CDs, iPods, rehearsals and concerts, music has always been an integral part of my life and continues to be for our entire family. Music has woven inspiration, creativity, communication, determination, discipline and cultural awareness into the fabric of my being and has come to define me. I know that many medical and surgical colleagues have had similar experiences with music’s benefits. My own musical inclinations started prior to conception. Music resonated with my mother when she was a young girl in Taiwan, and she was naturally musical in grade school. Despite an offer for free piano lessons, her strict professor father preferred she concentrate on studies—but her musical dreams never entirely went away. After immigrating to Canada to work as a nurse in a university hospital, my mother met my then medical student father. They eventually settled in the frigid mining town of Timmins, Ontario. Mom begged the only violin instructor, a high school teacher by day, to give me lessons. Working inside a covered porch transformed into a tiny studio, Mr. Lake taught me to play “Twinkle, Twinkle Little Star” on an eighth-size violin. I was a chubby 7-year-old with crooked thick bangs. He used the Suzuki method, which teaches children as young as three to learn to play by ear. Reading musical notes comes later. Dr. Leung, an ob-gyn at Kaiser Permanente Santa Rosa, is an accomplished violinist.

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I added the piano shortly thereafter. Practice on both instruments was supposed to be daily, but I remember cramming a bit before my weekly violin lessons. Piano was a different story. Mrs. Goltz, a strict but loving Latvian exile, was a former concert pianist who fled Soviet communism and was forced to leave behind her cherished grand piano. On a simple upright, she now taught the Canadian Royal Conservatory of Music methodology. She exuded discipline and demanded daily practice devotion. Every year, I learned progressively more advanced songs, scales, chords and arpeggios, and I memorized music theory for yearly examinations. Fear of failure really doesn’t exist when you’re young. Playing music unconsciously so you can lose yourself entirely is one of the beauties of learning music as a young child. Music grows with the child and becomes natural and innate. A few years later, a conductor from a larger neighboring city, who later would become my new teacher, drove into town weekly to start a community orchestra. Mr. First, desperate for new members, placed me, now 12 years old, in the back of the second violins. Playing in an orchestra increases your accountability. I was embarrassed if I couldn’t keep up with everyone else, so I started regularly practicing my part. Although I was the youngest member of the orchestra, I belonged to the group. Unprejudiced and egalitarian, music does not care about sex, age, race or other social factors. Mom often marveled at our smalltown general surgeon, who started

violin lessons the same year I did. Five years later with devoted practice, he sounded better than me and was sitting second chair to Anne, the concertmistress of the orchestra. We surmised that because of his dexterity as a surgeon, he was able to master the violin. His grit and his determined drills bore fruit, despite most adults having difficulty mastering string instruments.

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hen I was a teenager in the 1980s, our family moved to Midland, Texas, during the oil boom. Moving to a larger city had its advantages. I became involved in the orchestra scene again, this time in the West Texas Youth Orchestra and the Robert E. Lee High School Orchestra. As seen in the hit television drama “Friday Night Lights,” football was king in Midland/Odessa, but our high school was getting some added culture. Thanks to the foresight of a talented young African-American conductor named Karen Walker, orchestra was offered as a high school class for the first time. For our first big concert, we played classical music on the football field at halftime. Today, the orchestra is well established and has received top honors. My first introduction to philosophy, deduction, deconstruction and reconstruction was with my violin teacher Gene Perdue, concertmaster of the Midland/Odessa Symphony Orchestra and leader of the Thouvenel Quartet. Gene, stroking his beard, would go beyond the notes on the page and try to give insight to the composers’ lives and their temporal context. Gene pushed my comfort level with ever more difficult pieces. Summer 2014 13


I love how the violin’s tone reveals This is the same “zone” that athletes music in the background, concentration itself, manipulated to mimic the human or others striving for excellence expebecame focused and studying felt less voice. However, the violin can also be rience. I even entertained music as a lonesome. I was again “in the zone.” exasperating and brutal. You need to career or as a minor in college studies. That same zone occurs while percoordinate getting your fingers to play Attending the Colorado Rocky Ridge forming surgery. The numerous daily in tune while making the bow hand and University of Texas summer piano procedures we perform are really expressive with different bow strokes. music camps, however, was an eyemasteries of many sequential smaller This combination leaves many a musiopener. Practicing two hours daily tasks, which carry from one to another cian discouraged. was gratifying, but the professionally without much thought. Reviewing Gene prepared me for behind-therequisite five to six hours daily would these procedures with medical stuscreen auditions. He broke difficult be misery; music was not all-encomdents and residents harkens back to passages into easier bite-size chunks. passing to me. I still had other interests. learning musical notes and employing Feeling a bit like a hand muscle memparrot, I would try ory. In surgery, this to mimic Gene’s memory is imporplaying st yle in tant, so that we are these smaller not ta xed by t he phrases and task itself. As the then connect the task becomes secphrases into longer ond nature in our ones. Gene taught hands, our minds me how to “sing” are free to deliberphrases with an ate the next steps. overarching beLi ke music, su rginning, middle, gery—performed and end, just like in the surgical thea structured writater—is a dynamic ten passage. We acprocess that has its tually would sing own harmony and and hum musical resolution of dissopassages together. nance. The surgical I surprised everyteam and I experione, including myence the zone with self, by becoming quiet satisfaction concertmistress of af ter a c hallengDr. Leung (center) with her daughters (left to right) Emily, Madeline, the West Texas All ing case. Elizabeth and Caroline Chu. Region Orchestra as a freshman and making the Texas ttracted by a strong pre-med prohad the same mantra as my parents All State Symphonic Orchestra. gram and a generous scholarship, in passing the gift of music educaAlthough violin was socially reI attended a small Catholic liberal arts tion to my children. Each of our four warding, mastering a string instruschool, the University of Dallas. Sadly, daughters started violin lessons as 3ment was frustrating, so I gravitated there was no music department. An or 4-year-olds with their diminutive more to the piano. Because of regular orchestra director from an adjacent city sixteenth-size violins. As instructed by “grunt work” in scales and not needconducted a small orchestra, which also the Suzuki method, I practiced violin ing to worry about intonation, playing teamed up with the drama department with my girls when they were small, advanced pieces was easier than on for school musicals. but I gave that up long ago. Their sheer the violin. With each successive high In medical school and residency, numbers and the time required overschool year, I tackled a new concerto practice was even more limited. With whelmed me. At one point, they were movement—Haydn, Shostakovich, a dearth of funds and time, enjoying a playing in all four of the Santa Rosa Beethoven, Chopin—along with other concert was only an occasional perk. Symphony youth orchestra ensembles solo pieces. I learned to “practice” with What I do recall is that my CD collection because of their different levels. just my score and to rehearse in my burgeoned. While studying, I found About five years ago, I took private mind. Often, I found myself immersed, solace listening to classical radio, jotting violin lessons again as an adult. I figlost “in the zone” while practicing. A down my favorite concertos or operas ured if the kids were having lessons couple of hours could easily disappear. that I would later buy. With classical and getting better over time, I could

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14 Summer 2014

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do the same. With work and family life, however, practice time escaped me. Moreover, though I could grasp my teacher’s requests, now my fingers had a tougher time following through than I remember as a child. My frustration with each weekly lesson’s arrival without adequate practice grew, and performing in recitals brought much more anxiety than in the past. As a family, we have had some memorable musical moments. As conductor emeritus Bob Williams said before one Discovery Youth Orchestra concert: “There were the Andrews sisters, the Pointer sisters, and now the Chu sisters.” What pride and fun my three older daughters and I had playing the Vivaldi Concerto for Four Violins with the orchestra. Recently, our two older daughters took master classes and performed with the renowned Midori at the Green Music Center. Through auction fundraisers for the Santa Rosa Symphony, we have hosted home concerts that support music education in Sonoma County. With joy, we are able to share classical music not only with our four daughters, but also with colleagues and friends. One memorable affair was when Grammy award-winning classical guitarist Sharon Isbin remarked on the number of physicians at our hosted concert: “I don’t want to ever get sick, but this might be the one place that it is okay.” Music feeds the soul. It heals the heart and resonates with us, but the benefits go beyond that. Through dedication, innovation, inspiration and collaboration, making music creates a sum greater than its parts. In our household, classical music has been the gateway to much more than the mere enjoyment of music performed by others. Our hands-on approach has truly benefited our lives. Now, I think I should go practice. Email: karen.l.leung@kp.org

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Summer 2014 15


HEEL PAIN

Plantar Fasciitis Q&A Shawn Hsieh, MD

What is plantar fasciitis? Plantar fasciitis is the most common cause of plantar heel pain and can be a frustrating, disabling condition for patients. The plantar fascia is an inelastic aponeurosis (like a flat broad tendon) of the foot muscles. It spans from the anterior calcaneus down to the metatarsal heads of the foot. As such, it acts as a main stabilizer of the longitudinal arch of the foot, absorbing the shock of weight-bearing activities. Plantar fasciitis is not usually caused by an isolated injury, but rather by a progressive overload of the structure, causing repetitive micro-tears.1,2 How does plantar fasciitis present? Sufferers with plantar fasciitis usually complain of heel pain that is more prominent with standing or walking for prolonged periods of time. Another classic symptom is pain in the first minutes of the day after getting out of bed, or after sitting for a long time.2 It’s important to ask patients which situation leads to their pain, as this can impact the type of treatment you choose. Pain will typically be located at Dr. Hsieh is a physiatrist and sports medicine physician at Kaiser Permanente Santa Rosa.

16 Summer 2014

the anterior-medial-plantar calcaneus (in 80% of cases), but can also be located along the arch of the foot. The pain often is described as a burning or tearing sensation. What are the risk factors? Risk factors for plantar fasciitis other than prolonged standing/walking activities include: • Being overweight or obese • Tight calf muscles • Footwear with inadequate cushioning or arch support • Overpronated or flat feet • High-arched feet Many scientists note that the term “plantar fasciitis,” which implies an inflammatory process, should be renamed “plantar fasciosis” because histologic studies indicate disorganized collagen and collagen degeneration, with a lack of inflammatory cells.2

patient’s toes into passive dorsiflexion can also cause plantar foot pain or at least a feeling of tightness. It is also important to assess pes planus or pes cavus (low or high arches) by looking at the patient’s foot while he or she is standing. An equally important part of the evaluation is to rule out other diagnoses. If neuropathic symptoms are present (pins and needles sensation, numbness, tingling), you should consider peripheral neuropathy or tarsal tunnel syndrome. An adolescent who has pain near the posterior calcaneus more likely has Sever’s disease (calcaneal apophysitis, like Osgood Schlatter). Plantar fasciitis is not the only diagnosis that results from overuse. Other diagnoses include tendonitis, calcaneal stress fractures and fat pad syndrome (in which pain is more posterior, directly under the heel).1

What clues point toward this diagnosis? Physicians should inquire into recent changes in activity that might have led to the problem. For instance, is the patient training for his or her first running event? Has the patient started a new job involving extensive weight bearing? During physical examination, you should look for point tenderness at the anterior medial calcaneus. Pushing the

What studies should be ordered? Plantar fasciitis is a clinical diagnosis. Imaging studies are only needed to rule out other diagnoses or clarify the clinical picture if a patient has not responded to initial treatment efforts over 6–8 weeks. The usual initial study is foot X-rays, which in some cases will demonstrate a bone spur. Having a spur is often a disconcerting thought for patients, and Sonoma Medicine


they may interpret it as the cause of their pain. In fact, about 15–40% of the general population has a calcaneal spur on films, but only one in 20 with a spur has heel pain. The physician should not overemphasize the presence of a spur, as it generally doesn’t influence diagnosis, prognosis or choice of treatment. Musculoskeletal ultrasound is an increasingly used imaging option. Though not essential, it can help if the diagnosis is in question, and it is faster and less expensive than MRI.3,4 In general, a plantar fascia >4 mm with hypoechoic signal is suggestive of plantar fasciitis. What are the first steps of treatment? Basic initial treatment includes NSAIDs, icing and self-massage. Icing should be done after activity. Ice massage can be performed by freezing a water bottle and rolling the foot over it. An alternative massage is to roll the foot over a tennis ball. Self-massage can also be performed after activity or first thing in the morning by pulling the toes into dorsiflexion and compressing the plantar fascia with the knuckle of the thumb (Figure 1). History-taking will guide recommendations regarding activity modification. For instance, if patients stand for prolonged periods at work, they should talk to a supervisor about taking sit breaks. Patients with exercise-related plantar fasciitis can temporarily switch to lower-impact activities such as swimming. Runners should be advised not to increase their mileage too rapidly. In general, the running distance should be increased by about 10% each week. Overweight or obese patients should be advised to lose weight. This is usually not the first time these patients have been advised to lose weight, so the message should be delivered in a positive, encouraging manner. Some of these patients may have been trying to lose weight with exercise, and heel pain can be a setback on their journey. What types of exercise are beneficial? One study compared treatment options for plantar fasciitis and concluded Sonoma Medicine

that stretching is the most effective treatment (83% success rate), compared to injections, heat, orthotics and shoe changes.5 Calf stretches should be done daily, holding for at least 30 seconds. Two types of calf stretches should be performed: • A stretch focusing on the gastrocnemius, in which the person tries to lean forward and straighten the knee without the heel lifting up (Figure 2). • A stretch focusing on the soleus and Achilles tendon, during which the heel is planted on the ground as the person “sits down,” trying to drop the knee down to the ground (Figure 3). Strengthening exercises should be directed at the intrinsic muscles of the foot, which serve as dynamic stabilizers, complementing arch support. One example is using the toes to curl up a towel or pick up coins. How about shoes and orthotics? One should discuss wearing wellcushioned shoes. Running shoes should be replaced roughly every 400 miles. Patients should be advised to minimize prolonged standing or walking barefoot or in unsupportive footwear, such as sandals. Arch supports can also be helpful.6 Patients should be advised to try a few supports and use the densest material that is still comfortable. Custom arch supports are an option, but cost can be a limiting factor (often $250 to $300). A recent Cochrane review indicates there is no advantage to custom vs. prefabricated foot orthoses for plantar fasciitis.7 Because of their feet are still growing, adolescents should use over-the-counter arch supports. For patients with prominent early morning symptoms, orthotics can be used at night. We sleep with our feet plantar flexed, leaving the plantar fascia in a shortened position all night. Night splints prevent this shortening and have a high success rate (80%), but compliance is poor because they are hard to sleep in and may disrupt one’s partner.8,9 The Strassburg sock is similar but lighter and better tolerated (Figure 4).

Figure 1. Self-massage of plantar fascia

Figure 2. Forward stretch

Figure 3. Sitting stretch

Figure 4. Strassburg sock

Summer 2014 17


What should be offered if these initial measures fail? If initial measures fail, it is reasonable to refer the patient to a podiatrist, physiatrist or sports medicine physician. These specialists may try a steroid injection. This procedure has an approximate success rate of 70%, but patients should be advised of likely pain, along with the potential for infection, fat pad atrophy and plantar fascia rupture.10,11 The real consequence of such rupture is controversial because some practitioners don’t view rupture as a negative outcome, given that the next more aggressive step is surgery, in which a partial release of the plantar fascia is performed. . Regenerative medicine is an upand-coming area of musculoskeletal medicine. Regenerative treatments include platelet rich plasma (PRP) and autologous blood injections (ABI). Many of these therapies try to use the body’s own potential to heal by releasing growth factors from platelets that can aid fibroblast migration and collagen

deposition. So far, PRP is considered an experimental therapy with small studies and inconsistent results. One study examined PRP injections for plantar fasciitis and noted a promising 88% satisfaction rate.12 Another one compared steroid injections to PRP injections in 60 patients and found no significant difference in pain or patient satisfaction.13 Does surgery help? At least 90% of plantar fasciitis cases improve with conservative measures alone, so patients should complete a minimum of 12 months of nonsurgical therapy before considering surgery. Trials have indicated an approximate 70% success rate with surgery.14,15 Patients should be advised of risks, including failure to relieve pain, nerve injury, infection and a 4–12 month recovery time. When does plantar fasciitis resolve? Physicians should urge patients to be patient and try treatments for at least two months before judging their effectiveness. Multiple simultaneous treatments are more effective than trying one alone. Typical resolution of symptoms is in the range of 6–18 months. Treatment must be continuous until the pain has resolved for at least three months. The prognosis may depend upon the etiology. If the pain is from training for a running event, for example, it can resolve after the event. If the pain is jobrelated, the patient may find themselves in a difficult situation. Plantar fasciitis can frustrate both patients and physicians, but a diligent and collaborative effort can usually lead to a successful outcome. Email: shawn.hsieh@kp.org

866-294-LEGS (5347)

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Petaluma Santa Rosa Kentfield

References

1. Young C, et al, “Treatment of plantar fasciitis,” Am Fam Phys, 63:467-474 (2001). 2. Goff JD, Crawford R, “Diagnosis and treatment of plantar fasciitis,” American Fam Phys, 84:676-682 (2011). 3. Akfirat M, et al, “Ultrasonographic appearance of plantar fasciitis,” Clin Imaging, 27:353-357 (2003). 4. Kane D, et al, “Role of ultrasonography in the diagnosis and management of idiopathic plantar fasciitis.” Rheumatology, 40:1002-08 (2001). 5. Wolgin M, et al, “Conservative treatment of plantar heel pain,” Foot Ankle Int, 15:97-102 (1994). 6. Lynch DM, et al, “Conservative treatment of plantar fasciitis,” J Am Podiat Med Assoc, 88:375-380 (1998). 7. Hawke F, et al, “Custom-made foot orthoses for the treatment of foot pain,“ Cochrane Database, 16.3 (2008). 8. Powell M, et al, “Effective treatment of chronic plantar fasciitis with dorsiflexion night splints,” Foot Ankle Int, 19:10-18 (1998). 9. Batt ME, et al, “Plantar fasciitis: a prospective randomized clinical trial of the tension night splint,” Clin J Sports Med, 6:158-162 (1996). 10. Acevedo JI, Beskin JL, “Complications of plantar fascia rupture associated with corticosteroid injection,” Foot Ankle Int, 19:91-97 (1998). 11. Sellman JR, “Plantar fascia rupture associated with corticosteroid injection,” Foot Ankle Int, 15:376-381 (1994). 12. Ragab E, Ahmed M, “Platelet-rich plasma for treatment of chronic plantar fasciitis,” Arch Ortho & Trauma Surgery, 132:1065-70 (2012). 13. Akşahin E, et al, “Comparison of the effect of corticosteroids and platelet-rich plasma for treatment of plantar fasciitis,” Arch Ortho & Trauma Surgery, 132:781-785 (2012). 14. Daly PJ, et al,” Plantar fasciotomy for intractable plantar fasciitis,” Foot Ankle, 13:188-195 (1992). 15. Benton-Weil W, et al, “Percutaneous plantar fasciotomy: a minimally invasive procedure for recalcitrant plantar fasciitis,” J Foot Ankle Surg, 37:269-272 (1998).

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COMMON INJURIES

Understanding Ankle Fractures Kenneth Lopez, DPM

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s with all other aspects of medicine, the understanding of ankle fractures has greatly matured over the decades. Detection of clinically significant ankle fracture and the desire for judicious use of radiography led to the well-known Ottawa Ankle Rules.1 These rules have proven to be an excellent guide in finding fractures that require treatment other than normal ankle sprain management. The rules are specifically beneficial in correcting the traditional belief of “If the patient can bear weight on their foot, they do not have a clinically significant fracture.” They emphasize the importance of understanding that one cannot ignore the physical exam. If osseous tenderness is present, radiography is clearly indicated. When evaluating X-rays of a fractured ankle, there are two basic questions: Does the ankle require reduction? Is this ankle fracture stable? The answers to these questions will lead one to the appropriate pathway of treatment. A trimalleolar ankle fracture normally equates to an unstable ankle because the medial, lateral and posterior aspects of the ankle are all disrupted and not providing any form of stability. Hence, the chance of the ankle displacing during conservative treatment is high. It is believed that a shift of position from anatomic fracture alignment of only 2mm can change the contact area between the talus and the tibia by Dr. Lopez is a podiatrist at Kaiser Permanente Santa Rosa.

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as much as 45%.2 This dramatic change in joint alignment can further cause ankle arthritis over time. Bimalleolar ankle fractures have the same concern for instability as trimalleolar ankle fractures. The absence of both a medial and a lateral malleolus equates to a talus shifting laterally due to the absence of a bony buttress (the fibula) and a stable anchor (the medial malleolus). When a bimalleolar or a trimalleolar ankle fracture presents for diagnosis and initial treatment, it is imperative to place the lower extremity into a belowthe-knee splint and to ensure that the ankle joint is appropriately aligned. If the ankle joint is allowed to remain displaced for an extended period of time, the displacement applies a great deal of pressure along the tension side of the ankle. Most dislocations are located laterally, so there are medial soft tissue concerns. It is not uncommon to see fracture blisters that can progress to complete ulceration if they remain non-reduced for several hours. Fracture blisters may be associated with a higher rate of postsurgical complications,3 so any subluxation of the ankle mortise should be aggressively reduced as early as possible. Some physicians believe that ankle reduction requires extensive sedation, but performing simple, easily learned local anesthetic injections into the dislocated joint can provide similar results in the patient’s pain and satisfaction and can facilitate the reduction.4

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he unimalleolar ankle fractures are the most misleading in terms of stability. Physicians are often misled into thinking that the fracture is stable, since only one malleolus is fractured and also nondisplaced. This may be far from the case. The most common isolated malleolus fracture is that of the fibula. When the fibula is fractured, the ankle has potentially lost its “lateral buttress” that is preventing the talus from migrating laterally. Hence, it is imperative to determine if the “anchor” on the medial side remains. This anchor is the deltoid ligament that is attached to the intact medial malleolus. If patients have a fractured fibula with a ruptured deltoid ligament, they may have an unstable ankle fracture. This is often referred to as a “bimalleolar equivalent” ankle fracture, since the treatment rationale of bimalleolar ankle fractures applies. How does one determine if a “bimalleolar equivalent” fracture is taking place? One option is to review the Lauge Hansen classification system of ankle fractures.5 I have found, however, that Lauge Hansen may be too complex to remember for someone who does not see ankle injuries on a daily basis. When dealing with an isolated fibular fracture, knowledge of the Danis Weber classification6 is optimal in guiding non-specialist care. An isolated fibular fracture below the level of the tibiotalar joint line is a Weber A fracture and is deemed stable. One reason for this is that you have maintained the “lateral buttress” Summer 2014 19


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to prevent migration of the talus. When An isolated fibular fracture well racture fixation techniques have the fracture line begins at the level of proximal to the ankle joint is classified advanced over the years. Two main the tibiotalar joint, the fracture is a Weas a Weber C. This fracture is much advances are locking plate fixation and ber B. This is perhaps the most complex more ominous because it is frequently the use of sutures to fix the syndesmoankle fracture to determine stability associated with a rupture of the ankle sis. Medicine is still in the infancy of when it occurs in isolation. If the lateral syndesmosis. With such a rupture, the discovering the “truth” of these fixation malleolus breaks at this level, it no lontalus is no longer stabilized between the techniques and determining which one ger can prevent lateral migration of the medial and lateral malleolus because the yields long-term benefits for patients. talus. Hence, the primary question in tibia and fibula are no longer stable. The Locking plate fixation allows the this setting should be, “Does the talus distal articulation between the distal screws that are placed through the have an anchor medially plate to “become one” (the deltoid ligament) to with the plate. In order prevent lateral migrafor one screw to “fail” in tion?” Unfort unately, the construct, the entire the answer is not always construct must concurstraightforward. rently fail. This type of If the medial gutter fixation may be beneficial (the medial vertical joint in osteoporotic fractures space between the meand highly comminuted dial malleolus and the fractures. In the realm talus) of the ankle joint of ankle fractures, the is wider compared to utility of locking plates the horizontal tibiotalar is most optimal in the joint, the widening is a highly comminuted tibial clear sign of instability. plafond (pilon) fracture. You should consider reLocking plates for the duction, employ splint imfibula have also been demobilization, and realize veloped, and they offer that surgery is likely. potential benefit in osIf there is no widenteoporotic fractures and ing present medially, those of relatively high you need to use another comminution. means of determining if The use of sutures to the deltoid ligament is fix the syndesmosis is a Isolated posterior malleolar ankle fracture that requires evaluation ruptured. If the patient relatively new advanceof the syndesmosis. has no tenderness along ment. When the syndesthe deltoid ligament on physical exam, tibia and the distal fibula has been dismosis is ruptured, the classical fixation you might conclude that the deltoid ligarupted, and the stabilizing syndesmosis technique is to place one or more screws ment is not ruptured. Unfortunately, ligaments torn. This situation routinely from the fibula to the tibia. The screws this is simply not the case. Pain on requires surgical intervention. maintain the close relationship of the palpation provides false positive and The other injury that may present two bones, with the expectation that the false negative rates that are too high on routine ankle radiographs is the isosurrounding ligament will heal. Some for palpation to be a reliable measure lated posterior malleolar ankle fracture. surgeons feel that the screws should be of clinically significant deltoid injury.7 When this fracture occurs in isolation, removed because the construct does Fortunately, stability or instability can it often seems relatively nondisplaced. not allow the physiologic motion that be determined fairly reliably with stress Unfortunately, isolated posterior malis meant to occur between the tibia radiographs.8 leolar ankle fractures are uncommon, and fibula. It has even been shown Many different treatment parameters so the finding can be associated with a that removal of the screws can result are considered acceptable in patients proximal fibular fracture that you are in improved reduction in certain cases.9 with isolated fibular fractures without unable to see on simple ankle X-rays. Other surgeons feel that the screws medial gutter widening. Hence, you Hence, acquiring full tib-fib X-rays is should be allowed to remain in place. should partner with your receiving imperative when ankle films demonOne study found that if patients truly specialist to determine what they feel strate an isolated posterior malleolar require motion they will either break is the best initial treatment until they ankle fracture without obvious fibular the screw or prove to be symptomatic are able to further evaluate the patient. fracture. six months after implantation.10 20 Summer 2014

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Suture button fixation has shown early promise, but conclusions about its benefit have not yet been made.11 Surgeons who use suture button fixation argue that fixing ligament tissue with sutures allows for normal physiologic motion. In their view, removing the device is unnecessary, and the patient can bear weight immediately because fear of breaking the implant is low. Early weightbearing postoperatively is another new trend in treating ankle fractures. When the patient has full sensation, the fracture pattern does not involve the tibial plafond, and the fixation construct obtained during surgery is deemed solid, then it is safe to allow patients to ambulate almost immediately.12 This trend has improved care for elderly and obese patients, whose morbidity with nonweightbearing status can be quite significant. Understanding and reviewing the various ankle fracture patterns would be advantageous for your patients. In addition, it would be wise to review with your specialists their preference in ankle fracture care in the setting of the isolated Weber B ankle fracture that is apparently nondisplaced. I feel it is an exciting time to be involved in ankle fracture care. Technological strides coupled with welldeveloped studies are allowing us to come closer to an evidence-based utopia of ankle fracture care that I would define as “almost immediate return to full pre-injury activity without pain.” Email: kenneth.t.lopez@kp.org

References

1. Stiell IG, et al, “A study to develop clinical decision rules for the use of radiography in acute ankle injuries,” Ann Emerg Med, 21:384-90 (1992). 2. Harris J, et al, “ Effects of isolated Weber B fibular fractures on tibiotalar contact area,” J Foot Ankle Surg, 43:3-9 (2004). 3. Strauss EJ, et al, “Blisters associated with lower-extremity fracture,” J Orthop Trauma, 20:618-622 (2006). 4. White BJ, “Intra-articular block compared with conscious sedation for closed reduction of ankle fracture dislocations,” J Bone Joint Surg Am, 90:731-734 (2008).

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5. Lauge-Hansen N, “Fractures of the ankle,” Arch Surg, 60:957-985 (1950). 6. Weber BG, “Injuries of the tibiotalar joint,” Current Problems in Surgery (1966). 7. Schuberth J, et al, “Deltoid ligament integrity in lateral malleolar fractures,” J Foot Ankle Surg, 43:20-29 (2004). 8. Van den Bekerom MP, et al, “Evaluation of the integrity of the deltoid ligament in supination external rotation ankle fractures,” Arch Orthop Trauma Surg, 129:227-235 (2009).

9. Song D, et al, “Effect of syndesmosis screw removal on the reduction of the distal tibiofibular joint,” Foot Ankle Int, 35:543-548 (2014). 10. Tucker A, et al, “Functional outcomes following syndesmotic fixation,” Injury, 44:1880-84 (2013). 11. Wang C, “Internal fixation of distal tibiofibular syndesmotic injuries,” Int Orthop, 37:1755-63 (2013). 12. Black J, et al, “Early weight-bearing in operatively fixed ankle fractures,” Foot, 23:78-85 (2013).

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The

Power of

CMA-SCMA MeMberShiP why Join TodAy? If you aren’t at the table,

you’re on the menu . . .

CMA, representing 40,000 physicians, influences public policy at the federal and state level.

• In the world of politics, having a seat at the table can make all the difference. Here in California, no other advocacy organIzatIon commands a sImIlar level of respect in the state capitol as CMA. CMA’s CEO, Dustin Corcoran, has been featured on Capitol Weekly’s list of top political power players every year since 2009. • Understanding the mutually beneficial relationship that can exist between organized medicine and medical groups, several key names In calIfornIa’s health care Industry have joIned cma, dramatically altering the association’s membership. These shifting membership trends are evidenced in recent policy enacted by CMA’s House of Delegates, which contains a strong delegation from medium and large medical groups.

• Recent additions to the association include Mercy Medical Group in

Join todAy

to activate your personal web account at www.cmanet.org.

Sacramento and Loma Linda University’s Faculty Medical Group, while other partners such as The Permanente Medical Group, the Annadel Medical Group, the Palo Alto Foundation Medical Group and the Sharp Rees-Stealy Medical Group have long-standing membership commitments to CMA.

A major player in health care’s top issues • CMA continues to be the leadIng advocate for bolsterIng the state’s medI-cal program. CMA is currently sponsoring legislation to restore the 10% cut to Medi-Cal provider reimbursement rates enacted in the 2011 State Budget Act. • CMA has also been the most ardent defender of calIfornIa’s medIcal Injury compensatIon reform act (MICRA), one of the nation’s most important examples of tort reform. CMA is a leading partner in a coalition assembled to defeat a proposed anti-MICRA ballot measure

CMA is only a phone call away! Our live-person call center is available Monday–Friday during business hours at 800-786-4262.

• Through aggressive legislative and regulatory advocacy, CMA has positioned itself as one of the most vocal stakeholders In the state’s ImplementatIon of the affordable care act (ACA).

A commitment to public health • CMA’s sponsored bill package also routinely includes legIslatIon aImed at ImprovIng publIc health. Recent examples include bills to advance immunization education and access, remove sugary beverages from schools, and place warning labels on sugar-sweetened beverages.


INTERVIEW

SCMA President Robert Nied, MD Steve Osborn

Born in Long Beach in 1971, new SCMA President Dr. Robert Nied is a habitual multitasker. In high school, for example, he played on the football team, the soccer team, the track team, the orchestra and the jazz band, as well as serving on the student council and participating in several clubs. “Throughout my life,” he reflected in a recent interview, “that’s been kind of a recurring theme: I tend to have my hands in a lot of pots.” Inspired in part by his mother, a nurse, and his father, a U.S. Treasury agent and volunteer fireman, Nied volunteered in an emergency room after his first year at UC San Diego. That experience set him on the path to becoming a doctor. After graduating from UC San Diego in 1993, he was accepted into the UCLA School of Medicine and soon decided to become both a family physician and a sports medicine specialist. His decision was influenced by his “underlying desire to have my hands in everything—I liked being able to treat the whole spectrum.” Dr. Nied graduated from UCLA in 1997, and then completed his family medicine internship and residency at the University of Michigan in 2000. After a year-long fellowship in sports medicine at Michigan State, he returned to California to take a job with Mission Medical Associates in San Luis Obispo. In 2003, he headed north to Kaiser Permanente Santa Rosa, where he has worked ever since. His current title is Assistant Physician in Charge, Specialty Care, an administrative job he holds in addition to his family medicine practice and his sports medicine referral clinic. Mr. Osborn edits Sonoma Medicine.

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Dr. Nied and his attorney wife, Kris, live in Santa Rosa with their two children, Savannah, 13, and Sophie, 11. This interview was conducted at Kaiser Permanente Santa Rosa on May 1. After you finished your training, your first job was at Mission Medical Associates in San Luis Obispo. What was that like? We could spend the whole hour talking about what happened to me there. It was a baptism by fire of what it means to be a physician in a capitalist society. Unfortunately, what happened was I got there in August, and in November the group declared bankruptcy. We were in Chapter 11 protection through that winter, and they tried to work out their contracts. In March we went to Chapter 7, and we closed over Memorial Day weekend. So I’m suddenly without a job. I then worked for a series of urgent care clinics and a worker’s comp clinic. I kind of bounced around trying to find someplace I could land permanently. It was a very challenging time. I was literally working day-to-day on an hourly wage with my medical school loans. My wife was pregnant at the time, and she had a very complicated pregnancy. She ended up being hospitalized several times, and I had no insurance. It made me really question what I was doing. And it made me very empathetic to the plight of the solo physician, and the person who is trying to hang a shingle. I decided at that time it was no longer a viable option for a new doctor to go out and hang a shingle unless you were in a narrow niche. Especially as a primary

care doc, I didn’t think you could do it. So I started looking around for big groups that I could join, and the Kaiser Permanente model made the most sense to me. We came to Santa Rosa because this was the only place Kaiser Permanente was hiring in the months that I was looking. Fortuitously, it turned out to be a fantastic place! And now it’s a fantastic place to live—we love being here. We love the community. My kids have grown up here; they don’t know anything other than Santa Rosa. If we ever think of leaving or talk about other opportunities, they say, “No! We don’t want to leave! We love it here!” So, I just got lucky that I landed here. But, as they say, it was a crucible the first year and a half that really formed a lot of my thinking about American medicine. As you mentioned, it’s really difficult to be in private practice now. The forces are all toward large physician groups and consolidation. In fact, one of the reasons I got involved in SCMA and organized medicine is because the small group and the solo practitioner have no voice. They are just blowing in the wind. And the forces in our society are really toward looking at physicians as a commodity. You listen to the folks on Wall Street and at big organizations talking about the cure for American medicine: it involves the commoditization of physicians. That’s the force. You get driven into a large group because it looks like the way to have a voice and any protection: a seat at the Summer 2014 23


table. But even The Permanente Medical Group, which is the largest doctor group in the world, doesn’t have a seat at the table. We’re not even big enough to do that. So, you need to have a collective—a collective physician voice. I think the challenge for CMA, and especially SCMA, in the coming years is how to have that collective voice, how to be cohesive when gathering physicians is notoriously like herding cats. Because what we’re talking about is physician autonomy, a physician’s ability to define how they practice, what is their practice structure. And that is being swallowed up in this drive for efficiency. At the same time, I completely agree with the drive toward quality. That is one of the things I love about working at Kaiser Permanente. My incentives are all aligned with quality. When they do my evaluation, it’s not about how many patients did you see or how much revenue did you capture. It is about how well controlled are your diabetics? How well controlled are the hypertensives in your practice? Those are the things that I get judged on. That’s perfect, that’s what I want, is to be judged by the quality of the care that I do, not by the quantity of care that I do. The real challenge for physicians who aren’t in a group like ours is to figure out how to change the pay model so it aligns with quality. Physicians want to do the right thing, they want to take care of their patients, but they are stuck in a system that rewards them only for work and not for care. To change that model requires having a seat at the table, a voice, and individually we are too small. It really has to be in organized medicine. And then it is incumbent upon the leadership of CMA and especially SCMA locally to speak to the physicians. One of the reasons SCMA has been such a great medical organization for so long is because the physicians live here, they are invested in this community. What is the balance in your practice between sports medicine and family medicine? Is it half and half? It’s close. I spend roughly half my time 24 Summer 2014

doing primary care. I’m a panel-carrying family physician, and I do full scope, from newborn nursery all the way up through hospice. I then do sports medicine for half my time, and then the third half is administrative. Three halves. Right now I work in sports medicine three half-days a week. That’s a referral clinic, and I have a couple of partners who do that with me. And in that practice we also branch out a little bit into the community. We cover Sonoma State, so I’m one of the team physicians there, and we work with a number of the clubs at Santa Rosa JC, although we are not officially team docs there. A few years ago you wrote an article for Sonoma Medicine about diagnosing and treating concussions. What are the key points physicians should know about concussions? Concussions are probably more ubiquitous than we used to think, and the consequences of those concussions are maybe more serious than we used to think. Over the last couple of years, we are getting more and more evidence demonstrating a longer-term issue with repeated concussions. Our understanding of the pathology, the pathophysiology of what a concussion is, has really exploded. Our ability to image the damage has expanded, and our ability to identify neurocognitive deficits down the road is getting better. Because of that, we are unearthing these problems that we are attributing to past concussions. Of course, in the early stages, it is hard to know cause and effect. There is always going to be some aspect of genetics or physiology that will influence how an individual responds to the same trauma. But we are finding more and more that this is a serious issue. Unfortunately, that puts us in a quandary right now, where patients come in saying, “I’m reading all of this horrible stuff about chronic traumatic encephalopathy and postconcussion syndrome. What does it mean for my kid?” or “What does it mean for me?” And I’m left saying I don’t know. Those are real things, but I don’t know neces-

sarily if they will apply to you. I don’t have a test to do that. All we can do at this point is to err on the conservative side. You mentioned in the article that you were hoping to implement the Play It Safe program in Sonoma County. What’s the status of that? Play It Safe is a national program that was created by Jimmy Andrews and the American Orthopedic Society for Sports Medicine. We created our own group here, called North Coast Concussion Management, or NCCM. Dr. Ty Affleck is the point person for NCCM. It’s a not-for-profit group that includes Ty, myself, Todd Weitzenberg, and Steve Wolf. We are the core physicians in the group, and we have some community partners that are on the board. What we have done over the last year is to provide concussion education for high school athletes and baseline computerized testing, so that if they have a subsequent injury they have a baseline they can compare it to—that makes it more valid. In the 2012-13 academic year, NCCM went to the five Santa Rosa high schools in the fall, the winter, and the spring. Every athlete in those schools received concussion education and a baseline test. That’s very impressive! We are expanding the program and trying to do pretty much all the high schools in the county; I think that will be our ultimate goal. We are also starting to do some of the club sports. We have been in conversation with Santa Rosa United and the rugby team to provide concussion education across the board. This is all voluntary. We have nonprofit status, but the IRS is three years behind on doing applications, so we are still six months to a year away from actually having our tax ID number, which means we can’t accept donations yet. Right now we are kind of limited by the volunteer hours that we can put in, but our hope is to expand the program to do more coaches’ education and parent nights. From there we hope to do Sonoma Medicine


more stuff on an ongoing basis with the schools, using athletic trainers. The safety of a high school athlete is not the education they get at the beginning of the season or having an impact test done. The safety of the kid is really the coach and the parent keeping an eye out for them, and having a neutral third party, which is the athletic trainer, who recognizes injuries and can intervene. And that’s not just concussions, it’s ACLs and spinal cord injuries, it’s everything. In my mind, if there was one thing we could do to improve the safety of our athletes in our community, it would be having athletic trainers. Can you talk about the importance of physician well-being? Actually, my wife just asked me this question the night before last, which was, “Are you still happy?” And what I told her is that everything that I do, I love doing. There isn’t one thing that I don’t enjoy doing. There is just too much Sonoma Medicine

of it. And I think that’s physician wellness. Right now, most physicians still love being a doctor. They love what they do. There is just too much of it most of the time. Our drivers are production, ever more production, ever more production. And that’s the mal-alignment between what a capitalist society is pushing on medicine, trying to make it a business, versus quality and efficiency. I think people love to hear President Obama and Hillary Clinton talk about that. In fact, when Hillary spoke (at the recent CMA conference) in San Diego, one of the things she said was that the big problem is there is no ICD-9 code for caring. Which, I think, summed it up. We don’t pay, in the system we have now, to heal or to care. We only pay to produce, perform. It’s proceduraldriven. It’s hard! SCMA recently adopted a new strategic plan, which includes a new vision statement: “Leading Sonoma County

into Better Health.” What do you see as the main problems that need to be improved? The first is access. Access to care in Sonoma County is like anywhere else, and there is a significant percentage of people who don’t have it because we have a system that is based on employment. In our county, we have a lot of small employers, and you are not going to get your insurance through there. We have a great FQHC (federally qualified health center]) network here, but not everybody qualifies to go there, either. So we have this big group in the middle that is working but doesn’t have access to care. There are a lot of ways to approach that. We’ve worked with Operation Access, and we’ve tried to work with different partners. But, really, the solution is at a bigger level. That’s why defending MICRA (Medical Injury Compensation Reform Act) is important, so we don’t further remove access to care, and also Summer 2014 25


the Affordable Care Act, and going back to organized medicine and getting a seat at the table so we can talk about payment systems and reorganizing the way that we provide care. How can physicians be involved in this effort? My first thought is to create an SCMA passbook. You would have in there all the potential things you could do to be involved in the physician family of Sonoma County. That might include going to a social function or participating in something that is happening in the community. We have a tremendous community in terms of community support and organizations and nonprofits. It’s just a matter of finding how we can partner with those. If you take that passbook and sign up for Walk with a Doc, or join the access committee, or whatever the list of things is, then you get credit for those things. These are all of the things that we do that can get you involved in being part of our community and promoting

health. At the end of the year, maybe you get so many raffle tickets for the number of points you got, and you get a chance to win an iPad or something like that. The passbook is a way to promote the organization and get people involved. From your perspective, what are the main benefits of membership in SCMA and CMA? I think the benefits of membership fall under two basic categories. One is the business of medicine and organized medicine, and that’s because we don’t practice in a vacuum, we practice in the real world. We certainly have fantastic successes to show there, such as the GPCI fix and the SGR. There are lots of things we can point to and say, “If not for CMA and organized medicine, things would be different than they are now.” That’s a very rational argument. I can sit down and justify why I’m writing the membership check, because I can see a tangible benefit. There’s also an intangible part,

which is what I was alluding to before, and that is the community, the family of being a physician. Dr. Robert Pearl (CEO of The Permanente Medical Group) recently wrote a great article for Forbes. com about what it means to be sitting in a room with a patient: that intimate relationship, the things that patients share with you that don’t happen anywhere else. It takes years to learn that, and no one else can really appreciate what it’s like to be there other than another physician. So there is a family, a tribe, that being a physician means. That’s the message that we are going to try to distill this year, that there are all of these tangible things, but really you have to want to be part of the group. You can rationalize writing the check when you think about all the things you’re getting back for it. But if your only thing is dollars and cents and the bottom line, then that’s running a business. And for some people, that’s maybe what it is. But for most of us, I think it needs to be this: this is the group, this is my tribe.

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26 Summer 2014

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LOCAL FRONTIERS

Office-Based Balloon Sinus Dilation Stefan Zechowy, MD

N

o surgery that otolaryngologists perform conjures up more intense imagery than sinus surgery. Even today, when discussing treatment options with patients for chronic sinusitis, I am confronted with the ghosts of sinus surgery past. Stories come up of relatives or friends who had intense pain and pressure in the postoperative period, with complete nasal congestion and black eyes, topped off by excruciating removal of packing. Thankfully, these situations rarely occur with current sinus surgery. Historically, sinus surgery was performed through an external approach. In 1912, Harris Mosher observed, “Theoretically, an ethmoidal operation is easy; in practice, however, it has proved to be one of the easiest operations with which to kill a patient.”1 In the century since Mosher’s humble statement, sinus surgery has undergone several transformations that have allowed easier access and better surgical visualization with more precise imaging and a more thorough understanding of sinus physiology. Until the 1970s, the maxillary sinuses were accessed by an incision on the mucosa above the gum line in the gingivobuccal sulcus, known as the Dr. Zechowy is a Santa Rosa otolaryngologist.

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Caldwell-Luc procedure. The anterior face of the bone would be chiseled away, and the mucosa of the sinus would be stripped. This was a straightforward operation anatomically, but it was also a blunt, invasive approach that did not allow for normal functioning of the sinus afterward. A direct open approach to the frontal sinus involved a full cranial incision, drilling out the anterior table of the frontal sinus, stripping the mucosa off the bone, and replacing the initial bony window. A less invasive approach used a trephine (small burr hole) to drain the sinus externally through an incision next to the nasal bridge, but this would only resolve acute infections without addressing any chronic problems. For life-threatening infections, these were the only options available. The purpose of these early types of sinus surgery was to drain pus and prevent or treat serious complications, which were mostly orbital and intracranial. Although the first endoscopic manipulation of the maxillary sinuses came in 1902, it wasn’t until 1959, when Harold Hopkins invented rod lenses, and 1963, when Karl Storz combined rod lenses with fiber bundles for illumination, that the technology for the endoscopic approach to the sinuses became available.

I

n Europe during the 1970s, Hilding Messerklinger, Wolfgang Draf and Malte Wigand advanced the concept of natural mucociliary drainage pat-

Figure 1. Natural mucociliary drainage pattern in a maxillary sinus

SOURCE: See reference 11.

terns in the sinuses. Every sinus has an ostium that needs to be patent for the sinus to function properly. Establishing the patency of the ostium would allow for normalization of the sinus mucosa, with a resolution of inflammation and a return of the mucociliary drainage. Prior to this, sinus surgery was directed at removing diseased mucosa and relied on gravitational drainage. This approach was often unsuccessful in treating the diseased sinus. 1n 1985, in the United States, David Kennedy built upon the concepts developed in Europe and coined the term “functional endoscopic sinus surgery” (FESS) to focus on returning function to the sinuses in a more natural way, without stripping away mucosa. FESS was done completely endoscopically Summer 2014 27


Figure 2. BSD procedure

1. Introduction

2. Dilation

3. Irrigation

4. Removal SOURCE: See reference 12.

28 Summer 2014

and was a significant step in the evolution of sinus surgery.2 The frontal sinuses have one mucosal duct leading to the nasal cavity; the maxillary and sphenoid sinuses have one ostium. These exits are the natural focal points for mucociliary clearance of the sinuses. The ethmoid sinuses are more like a honeycomb of cells lined with mucosa, and the cells must be removed, all the way up to the mucosal lining of the bony skull base. In an FESS operation, the goal is to open up the natural sinus exits, and to preserve mucosa wherever possible, removing only the mucosa and bone that would otherwise prevent the return of normal sinus function. Over the next 20 years, FESS became more refined, with even greater attention paid to preserving normal structures such as the inferior and middle turbinates. As normal mucosa was left, both intraoperative and postoperative bleeding were decreased, and the need for obstructive packing was largely obviated. FESS has been successful in increasing quality of life and in decreasing the frequency and severity of chronic sinusitis symptoms in those patients who fail medical therapy.3,4 Unlike a tonsillectomy, which generally cures all tonsil-related problems, the success of sinus surgery depends on the ability of the underlying mucosa to return to normal. Sometimes, there is dysfunctional mucosa that will never return to normal. At other times, postsurgical scarring closes areas that were once open. Continued mucosal inflammation can occur secondary to allergic or non-allergic rhinitis, or there can be regrowth and return of polypoid tissue. Inability to remove all obstructing tissue may also play a role, either due to distorted anatomy, or proximity to the orbit or dura. A good rule of thumb is that patients with mild disease tend to do better in the long term postoperatively than patients with more severe disease. The patients who do the best are those with purely anatomic blockage, with no inherent underlying mucosal dysfunction.

One example of this is a patient who has recurrent acute sinus infections because of narrowing of the sinus exits, which are transiently blocked during an acute upper respiratory infection. Widening the exits surgically can prevent the inflammatory cycle that leads to these sinus infections.

I

n 2005, the FDA approved a new device to open the sinuses. 5 The device was based on the concept of widening the sinus exits without dissecting or removing surrounding tissue. The technique calls for a thin flexible wire to be threaded through a handpiece that allows its manipulation and placement into either the maxillary, frontal or sphenoid sinus. The ethmoid sinus is not anatomically compatible with this technique, as it does not have a single ostium or duct, being a collection of mucosa-lined cells. After the guidewire is placed into the proper sinus, its anatomic position is confirmed visually. The first iteration of the device used X-ray fluoroscopy; later versions use a bright light at the tip of the guidewire for trans-illumination of the sinuses. A small balloon (the active portion is typically 6 mm x 16 mm) is then slid over the guidewire, Seldinger-style, until it is at the ostium or duct of the sinus. The balloon is inflated to dilate the ostium or duct, and then deflated and removed. A special catheter is then used to irrigate the sinus. This technique is called balloon sinuplasty or balloon sinus dilation (BSD). There is now more than one company producing equipment for BSD. Several studies have focused on its efficacy with the frontal and maxillary sinuses, finding the results non-inferior to traditional FESS.6,7 Most surgeons initially used BSD in conjunction with FESS tools to access the sinuses and clear disease. The frontal sinus was an especially attractive place to use BSD, as the duct could be quite narrow and is very near the thin bone that covers the skull base. The two main advantages of using BSD in the operating room are confirmation of sinus location and reduction Sonoma Medicine


in tissue removal, which theoretically leads to decreased postoperative pain, crusting and scarring. The disadvantage, however, is that if no diseased tissue is removed, there can potentially be recurrent disease. In addition, there is no direct endoscopic visualization in the office postoperatively of the maxillary sinus, and possibly of the frontal sinus, which makes diagnosis of any sinus-related symptoms more difficult in the future. Severe polyposis and thickened mucosa around the ostia are also not ideal environments for BSD. In the operating room, I have used BSD sparingly, mostly reserving it for frontal sinuses that would be difficult to access in a more traditional endoscopic fashion because of anatomic characteristics. One additional use of BSD is in the pediatric population. In 2009, a pediatric indication was made, and children with chronic sinusitis who had BSD of the maxillary sinuses in addition to an adenoidectomy had an 87% success rate of clearing the sinusitis, compared to 50% with adenoidectomy alone.8 BSD allows more effective treatment for children with chronic rhinosinusitis unresponsive to medical therapy, especially as FESS in children is becoming more controversial.

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n 2012, researchers published a prospective multicenter study (albeit sponsored by a BSD device manufacturer) on the efficacy of using BSD techniques in offices.9 The study showed clinically significant improvements in quality of life in patients with chronic sinusitis two years postoperatively. Using topical anesthesia, supplemented with injected anesthesia, the same tools that one uses in the operating room can be used on a patient who is fully awake in an exam-room chair. The office procedure is not a hybrid surgery combining BSD with other techniques, but rather a pure BSD surgery. This significantly alters the risk/benefit ratio in assessing intervention for patients with sinusitis. In a pure BSD surgery, there are no incisions and no removal of tissue, allowing quick return to normal activity. Sonoma Medicine

The rare risks associated with FESS are essentially eliminated, and there is no general anesthesia. For patients who have recurrent acute sinusitis multiple times per year, but do not want to undergo a full FESS in the operating room, office-based BSD allows an option that is compatible with their level of disease. The surgeon explains that traditional FESS may be necessary if the office procedure fails, and a decision is made about the best treatment plan for each patient. For patients who cannot tolerate general anesthesia, BSD is the only surgical option available. As with any procedure, careful selection of patients is key. In my two years of experience with in-office BSD, patients with some of the following characteristics have done well: • Recurrent acute sinusitis that is bothersome to patients, but clears in between • Isolated maxillary, frontal or sphenoid disease • Mild to no nasal inflammation • Mild to early moderate thickening of mucosa on CT scan • No polypoid disease • No significant ethmoid disease • No known ciliary dysfunction Patients who are not good candidates for BSD include those with severe sinus disease, sinonasal polyposis, or significant septal deviation. As BSD does involve manipulation of sinus tissue, patients with low pain thresholds or squeamishness also do not do well. Some studies have suggested that patients with more severe disease or ethmoidal disease can benefit from BSD.10 These patients may opt for a trial of office-based BSD, knowing that it may be unsuccessful. If it is successful, however, the indications may be expanded. At this point, FESS is still the gold standard for many chronic sinusitis patients, but the new option of avoiding general anesthesia, experiencing easier recovery and essentially eliminating rare but potential complications make office-based BSD an attractive new tool in the fight against chronic sinusitis.

References

1. Mosher HP, “Surgical anatomy of ethmoidal labyrinth,” Ann Otol Rhinol Laryngology, 38:869-901 (1929). 2. Kennedy DW, et al, “Functional endoscopic sinus surgery,” Arch Otolaryngol, 111:576-582 (1985). 3. Kennedy DW, “Prognostic factors, outcomes and staging in ethmoid sinus surgery,” Laryngoscope, 102;12 Pt 2 Suppl 57:1-18 (1992). 4. Senior BA, et al, “Long-term results of functional endoscopic sinus surgery, Laryngoscope, 108:151-157 (1998). 5. www.acclarent.com. 6. Cutler J, et al, “Standalone balloon dilation versus sinus surgery for chronic rhinosinusitis,” Am J Rhinol Allergy, 27:416-422 (2013). 7. Plaza G, et al, “Balloon dilation of the frontal recess,” Ann Otol Rhinol Laryngol, 120:511-518 (2011). 8. Ramadan HH, “Safety and feasibility of balloon sinuplasty for treatment of chronic rhinosinusitis in children, Ann Otol Rhinol Laryngol, 118:161-165 (2009). 9 Karanfilov B, “Office-based balloon sinus dilation,” Int Forum Allergy Rhinol, 3:404-411 (2013). 10. Achar P, et al, “Endoscopic dilatation sinus surgery versus functional endoscopic sinus surgery for treatment of chronic rhinosinusitis,” Acta Otorhinolaryngol Ital, 32:314-319 (2012). 11. Stammberger H, Hawke M, Essentials of functional endoscopic sinus surgery, Mosby (1993). 12. www.balloonsinuplasty.com/what-isballoon-sinuplasty/procedure-overview.

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Summer 2014 29


LOCAL FRONTIERS

Suboxone Treatment for Opioid Dependency Anish Shah, MD

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pioid dependence is often the result of regularly consuming prescribed forms of opioids, such as oxycodone and hydrocodone, or illegal drugs such as heroin. Opioids bind to mu receptors in the brain, and this interaction initially decreases the perception of pain, thereby providing pain relief. However, when opioids are consumed chronically, the pain-relieving effect begins to decrease, which causes a need for higher doses. Higher doses, in turn, may lead to opioid dependence, a condition where people cannot stop using opioids. People who suffer from chronic pain and have a history of substance abuse are highly susceptible to opioid dependence.1 Both oxycodone and hydrocodone are among the most commonly misused substances in the United States. Research indicates that misusing these prescription opioids may lead to heroin use, since heroin is less expensive and more easily obtained than prescription medication.2 According to the National Institute on Drug Abuse, more than 4 million Americans (12 years Dr. Shah is a Santa Rosa psychiatrist.

30 Summer 2014

or older) reported using heroin at least once in their lives, and approximately 23% of the individuals who use heroin become dependent on it.3 The binding of opioids to mu receptors leads to the release of the neurotransmitters that influence mood, which results in a sense of euphoria and other pleasurable feelings, as well as decreased pain perception.4 Consuming opioids regularly, however, can lead to tolerance and dependence. Taking opioids repeatedly reduces their effect on mu receptors and causes people to feel as if they need to consume the drug more often or at a higher dosage. These inclinations to escalate consumption are a sign of opioid tolerance. In addition to the significant decline in opioid-induced activity that characterizes opioid tolerance, individuals who have repeatedly taken opioids may experience intense withdrawal symptoms if they abruptly stop taking them. Having to continue taking opioids in order to avoid withdrawal symptoms is a sign of dependence.5

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nce an individual becomes dependent on opioids, he or she usually struggles to end the dependence on their own or through counseling. Clinical treatment for opioid depen-

dence often involves detoxification with medications such as naltrexone, methadone and buprenorphine. These medications transition patients off opioids with fewer side effects than if they abruptly stop taking opioids, but the rate of relapse and death due to an opioid overdose is generally high.6-8 Naltrexone treatment, in particular, has been associated with a high incidence of relapse and opioid overdose, typically occurring within two weeks of discontinuing naltrexone.6 In one study, patients on methadone also had high relapse rates, and many began to consume opioids as soon as the methadone treatment stopped.7 Buprenorphine treatment has demonstrated a therapeutic efficacy that is similar to low doses of methadone, but this approach has several disadvantages. For example, it entails an involved process of phases, including induction, stabilization and maintenance. Also, buprenorphine therapy must be initiated at the onset of withdrawal; otherwise the likelihood of efficacy is diminished. Another disadvantage of buprenorphine involves its potential inefficacy in individuals who required high methadone doses prior to buprenorphine treatment.9,10 Research regarding the underlying mechanism Sonoma Medicine


of buprenorphine is also somewhat fraught with conflicting opinions about whether it functions as a full or partial opioid agonist, but the most recent study indicates that buprenorphine is a partial opioid agonist.11 Despite these limitations, buprenorphine has unique properties that make it moderately effective for patients who display certain characteristics, such as withdrawal symptoms, anxiety problems, no prior history of substance abuse, and being a non-smoker.10 The properties that make buprenorphine unique include its high affinity for mu receptors (which prevents full opioid agonists from binding to the receptors); its low intrinsic activity; and the ceiling effect that it demonstrates for respiratory depression.12 A number of opioids cause a dosedependent respiratory depression that can lead to death, but buprenorphine levels off at approximately 50% of the baseline with treatment doses.12 Because of these specific properties, buprenorphine has been more effective than methadone for patients with the aforementioned characteristics. Buprenorphine treatment has also been shown to reduce withdrawal symptoms, cravings, and feelings of euphoria in these patients.13 Research further indicates that the efficacy of buprenorphine for these patients can be partially attributed to treating the patients in an office-based setting in combination with individual counseling.14 In other words, patients are able to receive their daily dose by reporting to the treatment office, rather than having to be admitted into a rehabilitation clinic.

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uprenorphine may be prescribed as Subutex (buprenorphine alone) or Suboxone (buprenorphine and naloxone). Naloxone is an opioid antagonist that functions as an abuse deterrent. It has been shown to prevent buprenorphine from being converted into an injectable form, which has been linked to several cases of buprenorphine-related deaths.8 If naloxone is taken alone, it can cause precipitated withdrawal, but taking it in conjunction with buprenorSonoma Medicine

phine ameliorates this effect. The United States was the first country in which Suboxone was widely prescribed as an office-based replacement therapy for opioid dependence. The provisions of the Drug Abuse Treatment Act allow physicians to undergo an 8-hour training course and subsequently apply for a license that allows them to prescribe Suboxone to opioiddependent outpatients. When these patients begin replacement therapy, they typically receive a Suboxone tablet containing buprenorphine (16 mg) and naloxone (4 mg) in an office-based setting for a minimum of four weeks for adults or a minimum of 12 weeks for adolescents. Afterward, the dosage is tapered down to buprenorphine 2 mg and naloxone .05 mg. Ultimately, patients are taken off the medication to achieve abstinence. Replacement therapy is usually administered in conjunction with counseling, and maintaining tapered doses long-term decreases the occurrence of relapse.

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esearch has shown that the rate of abstinence is longer for methadone treatment than buprenorphine, but that there is a lower overdose risk for buprenorphine. One study showed that the average length of abstinence was 271 days for methadone patients and 40 days for buprenorphine patients.15 Another study evaluated the risk of death due to overdose in 13,718 methadone patients and 2,716 buprenorphine patients over a 9-month period.16 There were 60 methadone-positive deaths and 7 buprenorphine-positive deaths. These findings suggest that the risk of overdose is lower for buprenorphine patients. Although having to take a maintenance regimen is a disadvantage of Suboxone therapy, certain individuals who receive additional drug counseling have a higher probability of overcoming opioid dependence.17 One recent study, for example, found that heroin users who received additional drug counseling were more likely to achieve abstinence, but only if they attended at

least 60% of the drug-counseling sessions.18 Overall, opioid-dependent patients are a heterogeneous population that warrants different treatment strategies tailored to each patient. Based on previous and current research, however, patients who are non-smokers with no prior history of substance abuse, a high level of withdrawal symptoms, anxiety problems due to opioid intake, and strict adherence to their personal treatment plan are more likely to benefit from buprenorphine treatment and maintenance. Email: ashah@siyanclinical.com

References

1. Boscarino J, et al, “Risk factors for drug dependence among outpatients on opioid therapy in a large US healthcare system,” Addiction, 105:1776-82 (2010). 2. Davis WR, et al, “Prescription opioid use, misuse and diversion among street drug users in New York City,” Drug Alcohol Depend, 92:267-276 (2008).

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Summer 2014 31


physician job opportunities Annadel Medical Group, a premier multi-specialty practice based in Santa Rosa and Petaluma, has openings for the following specialties: Hospitalist (FP or IM) Family Practice

Internal Medicine OB/Gyn

As a proud member of St. Joseph Health, Annadel Medical Group is fully integrated with Santa Rosa Memorial Hospital, a Level II Trauma Center, and Petaluma Valley Hospital. Generous salary, retirement, and attractive benefits are available! Interested parties should send CV to Paul Martyr: paul.martyr@stjoe.org.

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3. National Institute on Drug Abuse, “DrugFacts: Heroin,” www.drugabuse. gov (2013). 4. Kosten TR, et al, “Neurobiology of opioid dependence,” Sci & Prac Perspec, 1:13-20 (2002). 5. Camí J, et al, “Mechanisms of disease: drug addiction,” NEJM, 349:975-986 (2003). 6. Digiusto E, et al, “Serious adverse events in the Australian National Evaluation of Pharmacotherapies for Opioid Dependence,” Addiction, 99:450-460 (2004). 7. Ling W, et al, “From research to the real world,” J Substance Abuse Treat, 38:S53S60 (2010). 8. Pirnay S, et al, “Critical review of the causes of death among post-mortem toxicological investigations,” Addiction, 99:978-988 (2004). 9. Blum K, et al, “Can the chronic administration of the combination of buprenorphine and naloxone block dopaminergic activity?” Mol Neurobiol, 44:250-268 (2011). 10. Ziedonis DM, et al, “Predictors of outcome for short-term medically supervised opioid withdrawal,” Drug Alcohol Depend, 99:28-36 (2009). 11. Polomeni P, et al, “Management of opioid addiction with buprenorphine,” Int J Gen Med, 7:143-148 (2014). 12. Dahan A, “Opioid-induced respiratory effects,” Palliat Med, 20 S1:3-8 (2006). 13. Walsh SL, et al, “Clinical pharmacology of buprenorphine,” Drug Alcohol Depend, 70 S2:13-27 (2003). 14. Fudala PJ, et al, “Office-based treatment of opioid addiction with a sublingualtablet formulation of buprenorphine and naloxone,” NEJM, 349:949-958 (2003). 15. Bell J, “Comparing retention in treatment and mortality in people after initial entry to methadone and buprenorphine treatment,” Addiction, 104:1193-1200 (2009). 16. Bell JR, “Comparing overdose mortality associated with methadone and buprenorphine treatment,” Drug Alcohol Depend, 104:73-77 (2009). 17. Katz EC, et al, “Brief vs. extended buprenorphine detoxification in a community treatment program,” Am J Drug Alcohol Abuse, 35:63-67 (2009). 18. Weiss RD, et al, “Who benefits from additional drug counseling among prescription opioid-dependent patients receiving buprenorphine-naloxone and standard medical management?” Drug Alcohol Depend (April 2014).

Sonoma Medicine


C O M M U N I T Y I N VO LV E M E N T

VeloMed Protects Sonoma County’s Bicyclists Stephen Meffert, MD

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r. Doug Green was alone and exhausted, after 92 miles of riding his bike in Levi’s Gran Fondo, when he rounded a corner and saw a rider face down in a pool of blood. The rider wasn’t breathing. Despite his 15 years of experience in vascular surgery and trauma care, Dr. Green felt unprepared and was uncertain about how to proceed. His wealth of medical experience had occurred in the relatively controlled environment of the hospital, with readily available instrumentation and assistance. Nevertheless, with a few maneuvers, he was able to open the injured rider’s airway. His quick actions—along with able assistance from other riders with medical training—kept the patient stable until paramedics arrived, and they probably saved the patient’s life. This incident was just one of several experiences that prompted the genesis of VeloMed, a medical service project designed to match a need (cycling injuries) with a resource (medical training). Serious injuries often occur during organized bicycle rides in remote areas of Sonoma County. In these situations, an “on-bike” first responder can make a critical difference. With so many medically trained cyclists participating in local rides, the responders are already present. Dr. Meffert, a Santa Rosa retinal surgeon and avid cyclist, cofounded VeloMed with Dr. Dave Robertson.

Sonoma Medicine

VeloMed Mission Statement VeloMed, a team of medical professionals who are avid cyclists, provides voluntary riding medical support for organized bicycle rides and promotes bicycle safety in Sonoma County. As every cyclist knows, the best ideas come to you during a ride when all the natural opioids and “feel good” neurotransmitters hit their peak. Such was the case with VeloMed. Dr. Dave Robertson and I had just finished a beautiful fall mountain bike ride in Annadel State Park when Dave explained his idea for what would later become VeloMed. We both realized that the idea was too good to let pass and, at that moment, we committed to making it happen. The support we have had from the medical and cycling community of Sonoma County has been overwhelming and a bit humbling. This positive response has allowed VeloMed to grow rapidly, mobilizing a contingent of medical professionals who can provide firstresponder care for injured cyclists. Our mission is to provide voluntary medical support for organized bicycle rides and to promote bicycle safety (see box).

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he project began with modest ambitions and a small selection of key medical cyclists to help guide VeloMed to what we hope will be a

successful future. Dave and I asked Drs. Dave Giannetto, Doug Green and Brian Schmidt, along with lawyer David “Max” Beach, to join us on the board of directors and lend their advice and guidance. As our “staff attorney” and general legal guru, Max has been instrumental in informing us about the Good Samaritan guidelines. Simply put, these guidelines offer medical-legal protection to medically licensed individuals who provide emergency care. VeloMed has been carefully shaped to abide by Good Samaritan principles. The physicians on our board include experts in emergency and trauma medicine, specialties that are key to our mission. To fulfill the other part of our mission, promoting bicycle safety, we have partnered with the Sonoma County Bicycle Coalition. SCBC has taken VeloMed under its 501(c)(3) nonprofit wing, providing critical fiscal and tax structure, as well as technical support. The coalition is an enthusiastic partner, and we support and augment its bicycle safety program. As Billy Crystal famously said as Fernando on Saturday Night Live, “Remember, my darlings, it is better to look good than to feel good.” To this end, we knew that a VeloMed team cycling jersey and shorts (or “kit”) had to not only reflect our medical mission, but also add flair and style. We turned to Kim Dow, a well-respected Healdsburg graphic designer with deep cycling Summer 2014 33


roots, to transform our vague ideas into a cohesive, knockout design. Kim patiently tolerated our lengthy discussions and redesigns, and we eventually arrived at a kit that, it would be safe to say, exceeded all our expectations. This kit makes VeloMed riders identifiable as medical support and is easily recognizable from a distance . . . and it looks marvelous. Once the organizational framework, logo and kit were determined, the VeloMed team sent out an invitation to doctors and nurses involved in cycling. We were surprised and gratified when we gradually built to 70 members, and the organization continues to grow. Of the current members, most are physicians, with about 20 nurses and allied medical personnel making up t h e r e st. Th i s response has been r e m a r k a bl e, a n d the new members’ enthusiasm for participating in training and meetings has been impressive.

tion benefits. In the compartmentalized medical landscape of Sonoma County, VeloMed establishes a uniting force around a common mission. As such, VeloMed serves not only the bicycling community, but also the medical community. The purpose of VeloMed is to provide the finest first-responder care for cyclists in need. Although we are all comfortable caring for patients in the office or hospital, it is quite a different matter in the field. VeloMed has introduced mandatory field medicine training designed and taught by Drs. Mark LaGrave and Dave Giannetto.

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lthough accidents will happen, one could argue that preventing accidents is equally as important as attending to accident victims—and perhaps even more so. The second requirement of VeloMed membership is joining the Bicycle Coalition and promoting its bicycle safety education programs. Our alliance with the SCBC allows VeloMed to augment its bicycle safety efforts, particularly in reaching out to primary school students. VeloMed adds a meaningful voice when it comes to delivering safety messages to children and their parents. Bicycle companies and manufacturers of safety accessories also seem quite interested in donati ng safet y equipment to VeloMed, so we may be able to contribute valuable equipment to be distributed through the SCBC’s safet y programs. NorCal BikeSport and Spec i a l i z e d Bic yc le s have long supported Northern California cycling and are eloMed draws enthusiastic about its members VeloMed. They will from all parts of the supply both medical medical community, and safety related and this diversity items. Velomed members (left to right) Hilary Bartels, MD, Dave Robertson, DO, has broadened our VeloMed memSteve Meffert, MD, and Nanette Anderson, RN. Photo by Joey Benton, RN. k n owl e dg e ba s e. bers look forward to Physicians and nurses affiliated with With their extensive experience in giving back to the community and the Sutter, Kaiser and Memorial hospitals emergency medicine and paramedic sport we love by providing emergency are all well represented. Although training, these two professionals have medical care to cyclists in need. We also VeloMed particularly benefits from been able to create a top-notch program hope to promote bicycle safety among medical personnel with trauma and that has been well received and eagerly our younger riders so they may safely emergency training, doctors from many attended by VeloMed members. enjoy the health benefits of cycling. This specialties have volunteered as well, Training begins with the basics of project has provided a rallying point including four ophthalmologists. scene control, victim assessment, cervifor medical professionals of differing VeloMed includes riders of all levels, cal spine precautions, and paramedic backgrounds to work together on a from Ironman triathletes and racers interface. Following that, the trainers common mission. So if you see your to newcomers who prefer the shorter lead on-bike scenarios where VeloMed fellow physicians or nurses riding in events. The diversity of volunteers, riders encounter a staged accident and full VeloMed regalia, be sure to give both in medical background and riding practice their response. As we move them a thumbs up! experience, is a valuable asset. When forward, VeloMed will offer refresheveryone brings different skills and ers of the basic course and add more Email: smeffert@sonic.net experience to the table, the organizaadvanced instruction.

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34 Summer 2014

Sonoma Medicine


OUTSIDE THE OFFICE

On the Brink T.W. Hard, MD I Nothing ever reached these islands easily . . . even trees arrived in the dark belly of some wandering bird, or precariously perched on the feather of a thigh. —James Michener We are perched on a small platform overlooking a steep gorge just inside Haleakala National Park. The elevation is 7,000 feet. Ahead, the surrounding cloud forest is intermittently obscured by mist and rain. Behind us is a nature trail that winds through a sandalwood forest, beginning at a campsite called Hosmer’s Grove. Among the endemic ferns and mosses are ohi’a bushes and an occasional koa tree. Along the path grow Hawaiian raspberries and the small silver geranium, a plant found nowhere else in the world. Here, too, are remnant strands of foreign trees—eucalyptus, sugi pine, Douglas fir—all imported by Ralph Hosmer in 1910 with the failed hopes of creating a timber industry. Below us, the volcanic rock falls 200 feet into a depression formed by a riverbed. The overlook provides a strategic vantage point for watching the birds that forage across the valley. Our goal this morning is to photograph a brilliant red, endangered bird called the ‘i’iwi (ee-EE-vee), a species of honeycreeper whose feathers once adorned the cloaks of Hawaiian kings. For an hour nothing Dr. Hard is an emergency physician at Sutter Medical Center of Santa Rosa.

Sonoma Medicine

has moved. Have we come too late? Are the birds no longer here? My mind begins to wander when my friend Bob grabs my arm. “There,” he whispers. “There!” I catch a flash of scarlet so striking that its brilliance stands out from the darkened foliage like a torch. The ‘i’iwi flies across the gorge in an erratic fashion, darting from tree to tree. For a moment, we lose it entirely. Then, suddenly, it is here, clutched in a bush a few feet from our hiding spot. Grabbing my 400 mm telephoto lens, I cautiously raise the camera. But the ‘i’iwi is too close to focus. The patch of red continues to move, flitting from one limb to the next, ducking in and out of a maze of branches that block everything from view. For an instant, I can almost reach out and touch it. I am hoping for a static image that will provide clear detail and precise focus. Here, there is no opportunity to spread a tripod, no space to back up. Worse, every time I find a possible shot, the camera focuses upon a twig just in front of my target. I snap a couple of hurried images, but all are soft and blurred. And then the ‘i’iwi is gone. We catch a final glimpse of red, like a disappearing flare, looping into the distant trees. Over the years, I’ve learned successful bird photography requires good lenses, immense patience, and a fair amount of luck. I’ve read of photographers who spend weeks in the jungles of New Guinea searching for birds-ofparadise. There you sneak into a camouflaged blind and remain fixed and immobile, 12 hours at a time.

Here we have no such luxury. We are a couple of amateur nature enthusiasts wishing for a little magic and a bit of luck. On this particular trip, the photography has been reduced to a single morning on a single day. We finally sit back in the overlook and wait. Maybe more ‘i’iwi will come. Maybe the gods of Haleakala will be kind to us this day. I am traveling with my good friend, and former president of the Sonoma County Medical Association, Dr. Bob Scheibel. Bob is a retired radiologist and is fortunate to have a condominium in Maui where he spends a number of his days. He has joined me this morning to see if we can find some of the vanishing, endangered birds of Hawaii—species once so plentiful, it is said, that over a quarter million birds were used to make a single cape. The story of Hawaiian honeycreepers and the evolution of these birds is strikingly similar to the famous Darwin finches of the Galapagos. Like the Galapagos, the Hawaiian Islands were formed by volcanic activity from hot spots along the ocean floor. Islands made in this fashion are considered by evolutionists as “ground zero.” New species that arrive in the islands have no natural enemies and little competition. Those that are fortunate enough to persevere begin to evolve in different radiant directions, moving into niches that are most advantageous for their survival. DNA evidence has traced the beginnings of the Hawaiian honeycreepers to a group of Eurasian rose finches who drifted east two to three million years ago. Perhaps it was a mating pair or Summer 2014 35


possibly a flock. In all probability these ancestral birds were carried in a storm. From these accidental beginnings, the birds began to change, filling unoccupied niches and adapting to favorable environmental conditions. Over time, this single group of birds diverged into 50 different species. The ‘i’iwi (Vestiaria coccinea) we are seeking is one of those species. The bird, about the size of a small thrush, has black wings and brilliant crimson plumage. The shape of its decurved bill has given it a particular advantage in sipping nectar from cup-like flowers. Here the ‘i’iwi often clings upside down, dangling from plant to plant, sometimes flitting like a hummingbird. We have come here because these birds are on the brink of extinction. Of the 50 or so radiant species of honeycreeper that once existed on the islands, less than half remain. A magnificent black honeycreeper with yellow wing patches called the ‘o’o is already gone. Extinct too, is the ‘akialoa, an olive green bird with a long decurved bill. What happened to these birds, and why are they so rare? In her recent book The Sixth Extinction, science writer Elizabeth Kolbert identifies the source. No species has had a more devastating effect in the history of the world than humans. We have cut away the forest, acidified the ocean, killed off competing species, and generally changed the landscape to the detriment of life forms that have existed, quite comfortably, for hundreds of thousands of years. But not all the species loss in the Hawaiian Islands is due to modern people. Polynesians migrated to the island chain approximately 1,000 years ago. Before the arrival of Europeans, it is estimated that half of the endemic honeycreepers were already gone. Today, only 21 species survive. II When the last individual of a race of living beings breathes no more, another heaven and another earth must pass before such a one can be again. —William Beebe 36 Summer 2014

Before traveling to Haleakala National Park, I visited the Bishop Museum in Honolulu to better understand the importance of honeycreepers to the early Hawaiians. The museum contains the largest collection of Polynesian cultural artifacts in the world. On the first floor are displays of stone idols, mask carvings, and shell fishhooks. Further in, a fascinating section illustrates the development of Polynesian tattoos. In a back corner of the first floor are several exhibits featuring feathered capes and cloaks. To the early Hawaiians, the unique colors and rarity of feathers from birds like the ‘i’iwi soon gave rise to creating spectacular red and yellow capes for royalty to wear. These capes were used to distinguish members of the royal family, especially during times of celebration. On occasion, they were worn by chiefs in battle. To gather the feathers, bird catchers developed special skills for capturing the honeycreepers. Some used nets, others a type of sticky sap that could be dabbed along branches to entrap the unsuspecting birds. A fine string mesh provided a framework for the cape. The colored feathers were then woven into the netting to create the design. On display in the museum is a beautiful feathered cape made for King Liholiho in 1823. The description says that the feathers of 250,000 birds were used to construct the cape, which is advertised as “The Most Splendid Article of Feathers Ever Made.” According to some sources, few birds were killed to make the capes. The sources claim that bird catchers captured the honeycreepers, removed a patch of feathers, and set the birds free. Of this, however, I’m not so sure. Microscopic examination of these capes has revealed tiny remnants of bird skin entwined within the mesh; hence, it is likely many of the birds were sacrificed. Because the yellow-shouldered ‘o’o was nearly extinct by the middle of the 19th century, it is hard to blame European colonization for its demise. For the remnant honeycreepers, the

threats to extinction are more clear. Loss of habitat, introduction of competing species, and transmission of virulent diseases take their toll. For the ‘i’iwi, a mosquito-borne avian malaria is now the greatest threat. The bird has no natural immunity for this disease, and a single bite from an infected mosquito is reported to bring nearly 100% mortality. At one time the ‘i’iwi were commonly found across all of the Hawaiian islands. Now the surviving species have retreated to small patches of native forest above 4,000 feet. Here it is too cold for mosquitoes to follow. But, alas, global warming may raise temperatures at these higher elevations, so the remaining birds may become vulnerable again. III A true conservationist is a man who knows that the world is not given to him by his father, but borrowed from his children. —John James Audubon A Hawaiian bird once critically endangered deserves mention here. One of Hawaii’s greatest restoration projects has been the Hawaiian crow or ‘alala (Corvus hawaiiensis). Endemic to the Big Island, the crow was reduced to a few individuals by 1992. Beginning in 1993, 27 captive-bred crows were released into the wild, but by 1999 most had been killed by hawks or disease. The remaining six were recaptured and returned to captivity. In recent years, the Zoological Society of San Diego began assisting with a captive breeding program. Gradually, the crow population has grown to 90 birds. The current ‘alala recovery plan developed by the U.S. Fish and Wildlife Service has a target goal of 400 birds, enough to take the crow off the critically endangered list. The cost for this project has been estimated at $14 million dollars. “Fourteen million dollars for a frigging crow!” Bob is quick to exclaim. “Hell, we used to shoot them in Minnesota and get a quarter a skin!“ “Yeah, but these are Hawaiian crows, Sonoma Medicine


not Minnesota crows,“ I gently remind race. During the last year of her life, she not in bloom. Maybe this is the reason him. “And the Hawaiian crows were spent a number of days in intensive care we don’t see many birds, or possibly once sacred to the Polynesians. They at great cost. It has been estimated that we’ve come too late in the morning, or were thought to be the souls of lost an80% of an individual’s lifetime healthperhaps there just aren’t many endancestors.“ care costs are incurred during the last gered honeycreepers any more. Bob listens graciously and concedes. few weeks of life. Defeated, we trudge back to the Yet, I understand his reasoning. Nothing A friend recently confided that her campsite parking lot. Amid the cars about these crows is particularly attrac80-year-old mother was admitted for and tents, screaming kids run back tive. They are not graceful or beautiful heart surgery. The bill after a month and forth. We are loading up the car, birds, and their calls sound like a rusty in the hospital was $700,000! Who is to putting the cameras back, when Bob gate. I tend to categorize them with the pay for this? And where does the money pulls at my arm. delta smelt and the tiger salamander. come from? “Not so fast,” he murmurs. They, too, are species on I follow the directhe brink. tion of his gaze toward a If successf ul, t he small shrub with yellow Hawaiian Crow Project flowers next to the road. could join that of the There is an ‘i’iwi, its whooping crane and brilliant red like a fairy the California condor. fire, dancing through But the costs of such the bush. The distance restorat ion projec t s is perfect, and the bird have run into millions is feeding on a group of of dollars. And the quesflowers, taking its time, tion remains, is this the working from clump to best use of our dollars— clump. In an instant I dollars that might go to have the camera up and schools, or the betteram rolling out photos as ment of healthcare, or fast as I can. improved conditions “Got him!” I exclaim. for the poor? Bob and I exchange high I think back on the fives. The gods of HaleLa Brea Tar Pits in Los akala have been good to Angeles. There are a us this day. number of species that ‘I’iwi in Haleakala National Park. Photo by Dr. T.W. Hard. existed on the North Email: travishard@aol.com American plains a mere 10,000 years ago. Now all are extinct. And what about your relatives verBibliography The saber-toothed tiger, the dire wolf sus mine? It’s okay to pull the respirator Buck P, “Evolution of Hawaiian feather and the wooly mammoths are gone. on somebody else, my kids are quick capes and cloaks,” J Polynesian Soc, 53:1Certainly, if these animals were on the to say, but for you, Pops, we are not so 16 (1944). brink today, we would probably try to sure. Considering crows and condors, Hawaiian Audubon Society, Hawaiian save them. But what if we had? How where do you draw the line? Birds, Island Heritage Publishing, 6th many dollars would it cost, and where ed. (2005). would a group of saber-toothed tigers IV Kolbert E, The Sixth Extinction, Henry Holt live? In Yellowstone? In Yosemite? Not (2014). a chance. Most likely they would be It is the ancient wisdom of birds, that battles Reif R, “Glorious feathers, the relics of royal confined to a specialized zoo. are best fought with song. Hawaii,” New York Times (July 28, 1991). No one is a stronger supporter of —Richard Nelson US Fish and Wildlife Service, “Revised conservation than myself. Yet, I’m rerecovery plan for the ‘alala,” Region 1 report (2009). minded of one of the most endangered It has been a frustrating morning. USGS, “Abundance, distribution, and popuindividuals in the world: my grandA lot of waiting, a lot of watching, and lation trends of iconic Hawaiian honeymother. At the age of 97, there was no very little to show. I’ve got six lousy, creepers,” file report 2013-1150 (2013). one else quite like her. Like the Galablurred images, at best. As we ponder pagos tortoise Lonesome George, she the situation, I note the flowering ohi’a was a unique specimen of the human plants that attract honeycreepers are Sonoma Medicine

Summer 2014 37


CURRENT BOOKS

Where’s the Magic? Rick Flinders, MD

Do You Believe in Magic? The Sense and Nonsense of Alternative Medicine, Paul Offit, MD, Harper Collins, 336 pages (2013).

I

t’s our last morning at Green Gulch Zen Center, where we gather each year for UCSF’s annual faculty writing workshop. A “personal day” for the monks, so I’m in the Green Dragon Zendo by myself at 5 a.m. But I don’t feel alone. The converted old barn literally breathes and groans with the wind, as I respire slowly and silently through the words of St. Francis of Assisi, and then Canto Two of the Shvetashvatara Upanishad. No sutras in here this morning. Sorry, Buddha, I can’t even remember your Twin Verses. An hour later, still in only starlight, I follow the path from the Zendo down the gulch toward the Pacific Ocean. A warm wind blows through the eucalypDr. Flinders, a clinical professor of family and community medicine at UCSF, teaches in Sutter’s Family Medicine Residency Program and serves on the SCMA Editorial Board.

38 Summer 2014

tus trees, and specks of eucalyptus pollen dance like snowflakes in the beam of my headlamp. They flutter randomly, like the ideas I’ve been trying to gather for this book review, which I’ve been struggling to write for Sonoma Medicine the past six weeks. Ironically, I’m leading today’s workshop on “How to Break Through Writer’s Block.” The title of the book is Do You Believe in Magic?, by John Offit, MD. The subtitle explains it: “The Sense and Nonsense of Alternative Medicine.” Already, I’m put off. “Here we go again,” I told my editor five months ago. “I’ve done my time there. I’ve had my moment of reckoning, decades ago, and moved on. It’s the same old story. Why not just practice good medicine, the best medicine, and call it whatever you like?”

“But this guy’s good, as good as Gawande, the best I’ve read.” Well, that got my attention (my editor knows how much I like Gawande). “OK, I’ll give it a read,” I promised him, “and I’ll write a fair review . . . and at the end I’ll even say whether or not I believe in magic.” It was due three months ago, for our spring issue, but I got stuck. Until this morning.

M

y editor was right. Dr. Offit, an infectious disease specialist at Children’s Hospital in Philadelphia, is a good writer: clear, communicative, incisive. He’s also knowledgeable and reasonable, and he’s a dedicated, compassionate advocate for patients. To top it off, he is fair to everyone. The best message from Offit’s book is the one with which I began. There are only two kinds of medicine: medicine that works and medicine that doesn’t. It’s true that sometimes (often, in fact) we can’t tell the difference. Less than half of what we do can be corroborated with good evidence for its efficacy and relative safety. Experience, good judgment, and clinical and common sense have to suffice when evidence is insufficient. But it’s unfair (as well as unscientific) to hold Sonoma Medicine


different scientific standards for different therapies based on political or financial bias. Some reviewers have characterized Offit’s book as an exposé of alternative practices. He is pretty harsh on some people (he probably won’t be joining Suzanne Sommers and Jenny McCarthy on Oprah). But he is no less scathing in his criticism of common practices of conventional practitioners, when the same weak methods of scientific support are exposed. The target of his attack is bad science, whether it be in the conventional or alternative communities. He saves his best, however, for the anti-vaccine movement and provides scary evidence of where the pockets of unvaccinated people are the greatest. Belief trumps knowledge, especially where the institutional memory of polio or congenital rubella has faded. Why get vaccinated and expose my child to an adverse reaction if the disease is not a threat?

D

o I believe in magic? Yes! But it’s not in the false hopes or phony cures, whether they come from hucksters selling snake oil or from hallowed university trials claiming “significant” (statistically) likelihood of limited benefit to patients at the expense of life quality and at the cost of a king’s ransom. Especially when those trials are designed and controlled by the same pharmaceutical enterprise that makes and sells the drug, and then promoted by the same people who write advertising copy for cosmetics and breakfast cereal. The magic in medicine is the patient. In particular, in the relationship granted by their willingness to reveal to us their pain and suffering, and to place their trust in our care. It is the care in which one human being encounters another human in dialogue, in sincere conversation. It is a labor-intensive, nonprocedural relationship in caring. It includes diagnosing, prescribing, repairing, informing, advising, educating and advocating. It’s a partnership. Sonoma Medicine

Above all, it is personal. And most of all, it requires listening. The late Dr. Gayle Stephens, speaking of just such a doctor-patient relationship, said: “When this simple and profound idea is acted out, something remarkable happens. Both patient and doctor cease to be ordinary to the other.” William Carlos Williams, one of the most respected voices in American medicine, writes of the same magic:

So, yes, I believe in magic. Didn’t know it, but I always have. The magic is the doctor-patient relationship, practiced by our predecessors for centuries and elucidated by contemporary physicians such as Williams, Michael Balint and Gayle Stephens. It was Stephens, again, in his now famous essay “The Parable of the Big Red Bull,” who extolled the benefits of personal medicine in general, and the doctor-patient relationship in particular:

So for me the practice of medicine has become the pursuit of a rare element which may appear at any time, at any place, at a glance . . . when the patient struggles to lay himself bare before you . . . We catch a glance of something, from time to time, which shows us that a presence has just brushed past us, some rare thing—and for a moment we are dazzled. The relationship between physician and patient, if literally followed, leads to experience which we barely deserve . . . it is there, it is magnificent, it fills my thoughts, it reaches to the farthest limits of our lives.

Not only does it provide the foundation of good medicine, the doctor-patient relationship is itself therapeutic and validates the humanity of our role, gratifying the instincts that led us into medicine in the first place. It confirms our calling and connects us to the longest tradition in medicine—the works of mercy and the “ancient conversation” that has anchored physicians for the past 1,500 years, a time when medicine earned the capital of public trust upon which we all still draw interest. Email: flinder@sutterhealth.org

Sonoma County Physician Directory Order Your 2014 Edition Today . . . The 2014 Sonoma County Physician Directory is an indispensable reference book that includes physician listings, specialty indexes, medical groups and an extensive resource guide. And new this year: a list of physician affiliations. SCMA members get a free copy, but nonmembers and the public can purchase copies for just $40, or $35 when buying 5 or more. (SCMA members can get extra copies for $30 each.)

. . . get extras while they last! To order, contact Rachel Pandolfi at 707-525-4375 or visit the Sonoma County Physician Directory page at www.scma.org.

Summer 2014 39


CMA NEWS

Join the Effort to Defeat Proposition 46 Peter Bretan, MD

Y

ou may have hea rd t hat Proposition 46—the trial lawyersponsored ballot measure that aims to undermine the protections of the Medical Injury Compensation Reform Act (MICRA)—has officially qualified for the November ballot. On Nov. 4, these trial lawyers will ask voters to weigh in on “The Troy and Alana Pack Patient Safety Act,” an initiative that was carelessly thrown together without any concern for taxpayer pocketbooks, privacy, patients or health care. If trial lawyers get their way, California will be saddled with a costly threat to privacy that we simply cannot afford. If Proposition 46 is approved by voters, malpractice lawsuits and payouts will skyrocket, adding “hundreds of millions of dollars” in new costs to state and local governments, according to an impartial analysis conducted by the state’s Legislative Analyst. Someone will have to pay, and that someone is providers, taxpayers and consumers. The California Medical Association Dr. Bretan, a Sebastopol urologist, serves on the CMA board of directors.

40 Summer 2014

(CMA) has joined a campaign coalition to oppose Proposition 46, because it will be costly for consumers and taxpayers, endanger patient access to quality health care, and jeopardize the privacy of our personal health information. This group, “Patients and Providers to Protect Access and Contain Health Costs,” is a diverse and growing coalition of trusted doctors, community health clinics, hospitals, family-planning organizations, local leaders, public safety officials, businesses, and working men and women formed to oppose Proposition 46. This costly, dangerous ballot proposition would make it easier and more profitable for lawyers to sue doctors and hospitals. Proposition 46 would also have devastating effects on access to care for patients everywhere, especially in rural and already underserved areas. Community health care clinics like Planned Parenthood and the Central Valley Health Network are already warning that Proposition 46 will cause ob-gyns and other specialists to reduce or eliminate services to their patients. Proposition 46 could also cause doctors to leave the state, meaning thousands of Californians could lose access to their trusted physicians.

O

ver the next few months, you’ll hear a lot of rhetoric from the proponents of Proposition 46—but really, this is just another example of special-interest groups trying to fool the voters into thinking Proposition 46 is something that it’s not. Authors purposely added doctor drug testing to disguise the real intent behind Proposition 46—to increase lawsuits against health care providers, which will increase health care costs and reduce access to quality health care. According to the Los Angeles Times: “The drug rules are in the initiative because they poll well, and the backers figure that’s the way to get the public to support Proposition 46. ‘It’s the ultimate sweetener,’ says Jamie Court, the head of Consumer Watchdog.” Proposition 46 also forces doctors and pharmacists to use a massive statewide database known as the Controlled Utilization Review and Evaluation System, or CURES, filled with Californians’ personal medical prescription information—a mandate our state government will find impossible to implement, and a database with no increased security standards to protect your personal prescription information from hacking and theft. Although the CURES database alSonoma Medicine


ready exists, it is underfunded, understaffed and technologically incapable of handling the massively increased demands Proposition 46 will place on it. Proposition 46 will force CURES to respond to tens of millions of inquiries each year—something the database simply cannot do in its current form. A non-functioning CURES database will put physicians and pharmacists in the untenable position of having to break the law to treat their patients, or break their oath by refusing needed medications to patients. Most concerning, the massive rampup of this database will significantly put patients’ private medical information at risk. Proposition 46 contains no provisions and no funding to upgrade CURES with increased security standards to protect personal prescription information from government intrusion, hacking, theft or improper access by non-medical professionals. Proposition 46 is bad for patients, taxpayers and health care as a whole.

There has never been a greater need for physicians to band together and fight for our patients.

A

s you can see, Proposition 46 is fraught with problems and would prove detrimental to California’s health care system. SCMA and CMA are asking each of you to join the effort to defeat Proposition 46. By doing so, you will protect access to care and prevent higher health care costs for all Californians. Together, we’re sure to be victorious. As we forge ahead to Election Day, it is more important than ever to make sure physicians are speaking as a unified, coordinated voice. If you haven’t done so already, please visit CMA’s website at www.cmanet.org/micra for the latest information, handouts and to sign up as a campaign coordinator in your area. Please also visit the campaign website at www.NoOn46.com to sign up to become an official opponent of Proposition 46.

From the website you can: • Sign up to add your name to the growing list of individuals and groups opposed to Proposition 46. • Get important facts, downloads and information that will help you spread the word about Proposition 46. • Be part of our outreach team. If you have direct patient contact, become part of our outreach team. Visit CMA’s MICRA resource page to sign up as a campaign coordinator. The address is www.cmanet.org/issuesand-advocacy/cmas-top-issues/micra/ join-the-fight/. • P articipate in message/media training. The campaign is also looking for physicians interested in taking on a more public role speaking to community groups about why Proposition 46 should be defeated. Contact Molly Weedn at mweedn@cmanet.org for more information. Email: bretanp@msn.org

elebrate C The Spirit of Hippocrates! Come celebrate The Spirit of Hippocrates to honor the service and retirement of Dr. Jerry Connell, a longstanding volunteer and medical director at the Jewish Community Free Clinic. Support the JCFC in our mission to ensure care for the uninsured. Enjoy delicious hors d’oeuvres, local wine, music by the Bootleg Honeys, and a joyous meal—all in great company.

Sunday, Sept. 14, 4 p.m. Congregation Shomrei Torah 2600 Bennett Valley Rd., Santa Rosa

Tickets: $54/person or $360/table of 8 • To RSVP, email director.jcfc@gmail.com. • To purchase tickets, mail a check to the Jewish Community Free Clinic, 50 Montgomery Dr., Santa Rosa 95404.

Get Into the Spirit! Sonoma Medicine

Summer 2014 41


SCMA NEWS

Wine & Cheese Reception CHRISTOPHER CREEK WINERY hosted the 14th annual SCMA Wine & Cheese Reception on Tuesday, June 10—a brilliant, breezy evening in the vineyards south of Healdsburg. Against a scenic Sonoma County backdrop, guests enjoyed camaraderie and wine tasting. The event closed with the ceremonial passing of the SCMA gavel and brief remarks by outgoing president Dr. Stephen Steady and incoming president Dr. Rob Nied.

Clockwise from upper left: SCMA Executive Director Cynthia Melody; guests sampling Christopher Creek wines inside the winery and guest house; Dr. Julie Philp; Dr. James Pyskaty; Dr. Dale Westrom and his wife, Thelma.

42 Summer 2014

Sonoma Medicine


Clockwise from upper left: SCMA President Dr. Rob Nied and his wife, Kris; Dr. Cindy Scharfen, her husband, Jeffrey, and Dr. Gary Barth; former SCMA President Dr. Jeff Sugarman and his wife, Lisa; SCMA PresidentElect Dr. Mary Maddux-Gonzรกlez; former SCMA President Dr. Paul Marguglio; Drs. Tim Regan and David Staples; Drs. Gary Barth, Paul Marguglio, Stephen Steady and Richard Powers; Dr. Peter Brett; Thelma Westrom, Charlene Staples and Kevin White; Dr. Robert Woodbury. Center: Dr. Rob Nied presents outgoing president Dr. Stephen Steady with framed cover photo from Sonoma Medicine.

Sonoma Medicine

Summer 2014 43


2014 ANNUAL AWARDS

Dear Colleague: The SCMA Awards Committee is seeking nominations for the 2014 Annual Awards, which honor physicians who have demonstrated sustained and exemplary service. The awards, to be presented at the Annual Awards Dinner Dec. 2, 2014, reflect a significant tribute of respect, recognition, and appreciation of SCMA membership. Awards are also given to nonphysicians who have made significant contributions to the advancement of medical science, medical education or medical care. The four awards are as follows: Outstanding Contribution to the Community (OCC) Presented to an SCMA member whose work has benefited the community Outstanding Contribution to Local Medicine (OCLM) Presented to an SCMA member who has improved local medical care Outstanding Contribution to SCMA (OCS) Presented to an SCMA member who has served the medical association beyond the call of duty Recognition of Achievement (ROA) Presented to a nonphysician who has helped advance local medicine Past recipients are listed on the following page. Physician candidates must be SCMA members, and may be nominated for more than one award. Please use the form below and return your nominations by Friday, September 5. For more information, contact Cynthia Melody at 525-4375 or cmelody@scma.org. Sincerely,

Leonard Klay, MD Past President and Awards Committee Chair

SCMA 2014 Annual Awards Nomination To:

Leonard Klay, MD

From: _______________________________________________________________________________________________________________________________________________________ (Name required)

Nominee:

___________________________________________________________________________________________

Award: __________________________________

(Use abbreviation from above)

For more than one nomination, kindly submit separate forms for each. Please provide support information, including accomplishments and contributions, that will help the Awards Committee evaluate your nominee for the award selected. Nominations must received at SCMA by 5 p.m. on Friday, Sept. 5. Submit by any of the following: Fax to 525-4328 E-mail to scma@scma.org Mail to SCMA, 2901 Cleveland Ave. #202, Santa Rosa, CA 95403


THREE DECADES OF AWARDS RECIPIENTS Outstanding Contribution to the Community

Outstanding Contribution to Sonoma County Medicine

Outstanding Contribution to SCMA

James Gude, MD Richard Barnett, MD

John Kenney, MD Joseph Schaefer, MD Robert Butler, MD Carl Anderson, MD

Special Award for Recognition of Achievement

1985 1987 1988 1989

R. Lee Zieber, MD Frank Norman, MD Horace Sharrocks, MD Carroll Andrews, MD John Roberts, MD

1990 1991 1992

Marshall Kubota, MD William Ellison, MD Harding Clegg, MD Tetsuro Fujii, MD Thomas Honrath, MD John Sweeney, MD Kenneth Howe, MD

Louis Menachof, MD Harry Ackley, MD John Reed, MD

Ransom Turner, MD James Clegg, MD L. Reed Walker Jr., MD

Lucius Button, MD William Dunn, MD Maurice Carlin, MD Winston Ekren, MD

Thomas Maloney, MD Leonard Klay, MD

Michael Gospe, MD

Jerome Morgan, MD

Brother Toby

Salute to Community Service James McFadden, MD Mark DeMeo, MD

Salute to Community Service Donald Van Giesen, MD Clinton Lane, MD

Daryl Schloss

2000 2001 2002

Gary Johanson, MD Harry Richardson, MD Salute to Community Service Gregory Rosa, MD Chris Kosakowski, MD Brian Schmidt, MD Katherine Walker, MD Jeffrey Miller, MD Bob Schultz, MD

Frank Miraglia, MD Robert Huntington, MD Louis Menachof, MD

Cynthia Bailey, MD William Meseroll, MD Paul Marguglio, MD

2003 2004 2005 2006 2007 2009 2010 2011 2012 2013

Amy Shaw, MD Michael Martin, MD Richard Powers, MD Rick Flinders, MD Jose Morales, MD Walt Mills, II, MD Stacey Kerr, MD Alan Bernstein, MD Jeff Haney, MD Robert B. Mims, MD

Brien Seeley, MD Jan Sonander, MD Mary Maddux-Gonzalez, MD Leigh Hall, MD James Gude, MD Jeff Sugarman, MD Lyman “Bo” Greaves, MD Enrique Gonzalez-Mendez, MD Mark Netherda, MD Peter Brett, MD

Ron Van Roy, MD Dan Lightfoot, MD

1993 1994 1995 1996 1997 1998 1999

Helen Rudee

Lynn Mortensen, MD Phyllis “Jackie” Senter, MD Brad Drexler, MD Richard Andolsen, MD Kirk Pappas, MD Catherine Gutfreund, MD Walt Mills, MD

Steve Osborn / Joan Chilton Andrea Learned / Larry McLaughlin Cynthia Melody / Harry Polley / Assemblywoman Patricia Wiggins Elizabeth Chicoine / Cheryl Negrin-Rappaport Sharon Keating Medicare Campaign Leaders Robert Pelligrini Kay Reed & David Anderson, MD Santa Rosa Family Medicine Residency Consortium Operation Access Redwood Community Health Coalition Northern California Center for Well-Being

Save the Date! Join us for the annual SCMA Awards Dinner at Vintner’s Inn

TUESDAY, DEC. 2, 2014 Watch for details at www.scma.org, in the monthly News Briefs, and in the fall issue of Sonoma Medicine.


NEW MEMBERS Daniel Ahn, DO, Ophthalmology, 181 Andreiux St. #100, Sonoma 95476, New York Coll 2008 Deidre Bass, DO, Pediatrics, 3925 Old Redwood Hwy., Santa Rosa 95403, Nova Southeastern Univ 2010 Ricardo Budjak, MD, Psychiatry, 401 Bicentennial Way, Santa Rosa 95403, Temple Univ 2009 Christopher Clark, MD, Psychiatry*, 3554 Round Barn Blvd., Santa Rosa 95403, Yale Med Sch 1977 Jeannette Currie, MD, Family Medicine, 1275 4th St. #151, Santa Rosa 95404, Albert Ludwigs Univ 1998 Armando de Pala Jr., MD, Pediatrics*, 1500A Professional Dr. #200, Petaluma 94954, Univ Philippines 1983 Michelle DeSanto, DO, Family Medicine*, 401 Bicentennial Way, Santa Rosa 95403, Western Univ 2010 Wendy Dryden, MD, Family Medicine, 3569 Round Barn Cir., Santa Rosa 95403, Virginia Univ 2013 Valerie Ebel, MD, Family Medicine, 3569 Round Barn Cir., Santa Rosa 95403, Rush Univ 2013 Kareen Espino, MD, Family Medicine, 3569 Round Barn Cir., Santa Rosa 95403, UC Irvine 2013 Omar Ferrari, DO, Emergency Medicine, 1165 Montgomery Dr., Santa Rosa 95405, Touro Univ 2013 Ann Figurski, DO, Family Medicine 717 Center St., Healdsburg 95448, Arizona Coll Osteo Med 2007 Olivia Gamboa, MD, Family Medicine, 3569 Round Barn Cir., Santa Rosa 95403, Univ North Carolina 2013 Stephen Gamboa, MD, Family Medicine*, Emergency Medicine*, 401 Bicentennial Way, Santa Rosa 95403, Univ North Carolina 2004 Maria Garcia, MD, Family Medicine*, Women’s Health, 401 Bicentennial Way #215, Santa Rosa 95403, UC San Francisco 1994 Karen Kai Gelphman, MD, Family Medicine*, Women’s Health, 3883 Airway Dr #202, Santa Rosa 95403, Univ Washington 1992

46 Summer 2014

Michael Gerstein, MD, Emergency Medicine, 401 Bicentennial Way, Santa Rosa 95403, St. George’s Univ 2009 Vishal Goyal, MD, Cardiovascular Disease, 3536 Mendocino Ave. #300, Santa Rosa 95403, St. Louis Univ 2007 Susan Gross, MD, Family Medicine*, 3900 Lakeville Hwy., Petaluma 94954, Univ Alabama 1998 Mette Hansen, MD, Physical Medicine & Rehabilitation, 3975 Old Redwood Hwy., Santa Rosa 95403, UC Los Angeles 1997 Karen Holbrook, MD, Infectious Disease*, Internal Medicine*, 625 5th St., Santa Rosa 95403, Chicago Med Sch 1989 Jasper Hollingsworth, MD, Psychiatry*, Child & Adolescent Psychiatry*, 3554 Round Barn Blvd., Santa Rosa 95403, Univ Alabama 1995 Michael Hubbard, MD, Internal Medicine, 401 Bicentennial Way, Santa Rosa 95403, Kirksville Coll Osteo Med 2009 Gabriel Klapman, MD, Family Medicine, 3569 Round Barn Cir., Santa Rosa 95403, UC Los Angeles 2013 Robin Knuttel, MD, Dermatology*, Hair/Nail Diseases, 181 Andrieux St. #103, Sonoma 95476, Tufts Univ 1986 Jeffrey Kuhn, MD, Anesthesia*, 837 Fifth St., Santa Rosa 95405, Univ Chicago 1985 Yelena Lapan, DO, Family Medicine*, 401 Bicentennial Way, Santa Rosa 95403, Touro Univ 2010 Michael Lazar, MD, Urology*, Prostate Cancer, 1140 Sonoma Ave. #1A, Santa Rosa 95405, Univ Arkansas 1978 Kim Hoang Le, MD, Internal Medicine*, 401 Bicentennial Way, Santa Rosa 95403, Univ Washington 2010 Elizabeth Losada, MD, Pediatrics, 3925 Old Redwood Hwy., Santa Rosa 95403, UC Davis 2008 Robert Martinez, MD, Family Medicine*, 401 Bicentennial Way, Santa Rosa 95403, Univ Cincinnati 2007 William McClure, MD, Plastic Surgery, 596 First St. East, Sonoma 95476, UC San Diego 1978

Susan Milam Miller, MD, Child & Adolescent Psychiatry*, 725 Farmers Ln. #16, Santa Ros00a 95405, Albert Einstein Coll Med 2001 Merle Miller, MD, Emergency Medicine*, Hospice & Palliative Medicine*, 500 Doyle Park Dr. #G04, Santa Rosa 95405, Univ North Carolina 1989 Julie Philp, MD, Dermatology*, Pediatrics*, 990 Sonoma Ave. #2, Santa Rosa 95404, Stanford Univ 2005 Toni Marie Ramirez, MD, Family Medicine, 3569 Round Barn Cir., Santa Rosa 95403, Virginia Univ 2013 Jill Rushton-Miller, MD, Family Medicine, 4700 Hoen Ave., Santa Rosa 95405, Marshall Univ 2008 Noel Santo-Domingo, MD, Cardiovascular Disease*, 3536 Mendocino Ave. #300, Santa Rosa 95403, UC Davis 1991 Jamie Schick, MD, Emergency Medicine*, 501 Bicentennial Way, Santa Rosa 95403, Pennsylvania State Univ 1992 Henry Schwartz, MD, Internal Medicine*, Endocrinology, Diabetes & Metabolism*, 3559 Roundbarn Blvd., Santa Rosa 95403, UC Davis 1996 Erika Simpson, MD, Obstetrics & Gynecology, 401 Bicentennial Way, Santa Rosa 95403, Meharry Med Coll 2009 Leo Smith, MD, Family Medicine*, 500 Doyle Park Dr. #GO4, Santa Rosa 95405, Oregon Health Sciences Univ 2006 Elise Sullivan, MD, Family Medicine, 6800 Palm Ave. #C2, Sebastopol 95472, Univ Colorado 2007 Alexandra Takayesu, MD, Family Medicine, 3569 Round Barn Cir., Santa Rosa 95403, Univ Hawaii 2013 Morgan Theis, MD, Family Medicine, 3569 Round Barn Cir., Santa Rosa 95403, Stanford Univ 2013 Bentley Thomason, MD, Family Medicine, 3569 Round Barn Cir., Santa Rosa 95403, UC Irvine 2013 Ashmi Ullal, MD, Family Medicine, 3569 Round Barn Cir., Santa Rosa 95403, UC Davis 2013 Shannon Vargas, MD, Anesthesiology, 401 Bicentennial Way, Santa Rosa 95403, Ross Univ 2007 Sonoma Medicine


Lisa Ward, MD, Family Medicine*, Obstetrics & Gynecology, Public Health & General Preventive Medicine, 3569 Round Barn Cir., Santa Rosa 95403, UC San Francisco 2001 Tracy White, MD, Family Medicine, 3569 Round Barn Cir., Santa Rosa 95403, UC San Francisco 2013 Emily Wilkinson, MD, Family Medicine, 3569 Round Barn Cir., Santa Rosa 95403, Univ Arizona 2013 James Wong, MD, Surgery*, Vascular Surgery*, 401 Bicentennial Way #270, MOB East, Santa Rosa 95403, Robert Wood Johnson Med Sch 1991

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Center for Well-Being, North Bay’s premier health education and wellness center assists in improving the quality of life and health of our Sonoma County community through evidencebased preventive services and self-care classes.

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Summer 2014 47


SCMA ALLIANCE & FOUNDATION NEWS

The Next Generation of Health Care Professionals Maria Pappas

The future’s so bright, I gotta wear shades. —Timbuk3

W

ith graduation behind them, high school and college students in Sonoma County are celebrating their achievements and looking forward to the next phase of their education. For students pursuing careers in health care, that next phase may include receiving a Health Careers Scholarship to help pay for their education. Since 1965, SCMA and the SCMA Alliance have awarded Health Careers Scholarships to students with exceptional academic records and proven financial needs. The scholarships help cover some of the cost of their healthrelated education. As part of the application process, each candidate is asked to convey their personal motivation for pursuing a future in health care. Each of these detailed and moving descriptions have at their core not only how the student has developed their desire to care for others, but also how to influence and shape our next generation of health care professionals. Brianna Hitman, a recipient of the Health Careers Scholarship for the past two years, discovered that developing a passion was an important component in understanding what career path she would take. This 2007 El Molino High School graduate was in her teens when the notion of caring for others took on a significant meaning in her life. “My Ms. Pappas is vice president for marketing and communications at the SCMA Alliance & Foundation.

48 Summer 2014

Health Careers Scholarship recipient Sahar Rosenblum.

epiphany came when I was playing in a soccer tournament,” she recalls. “One of the opposing players hurt her ankle, and my coach, who was a medical doctor, ran over to assist the injured athlete.” The actions of that physician inspired Brianna to “have the knowledge to aid another’s physical needs.” She decided to focus on physical therapy and developed a true passion for that field—all because of her coach’s seemingly simple action. “Being in a physical therapy clinic for the first time was complete affirmation that everything I thought about the profession was true,” she explains. Her eyes were opened to the healing, motivating and coaching that therapists provide. This August, she will be graduating from University of the Pacific with a Doctor of Physical Therapy degree. For Sahar Rosenblum, currently a junior at the UCLA David Geffen School of Medicine, his mother’s words of wisdom prompted him to consider medicine as a career. “A patient’s emotional needs are equally important to their physical needs,” she told him from

an early age. As an acupuncturist and Chinese herbal specialist, she shared her perspective about the qualities physicians should display. Her message to her son asserted that “a patient’s physical needs were paramount. However, only by displaying compassion, empathy and genuine caring, could a physician be considered a great healer.” Being presented with such a perspective brought this 2005 graduate of Cardinal Newman High School to consider how he could fulfill this ideal view of a physician as he entered college. “I yearned to observe my mother’s philosophy in action, and to see if I possessed the motivation and enthusiasm for a life in medicine,” Sahar recalls. Positive experiences in clinical settings have deepened his commitment to honoring both the mental and physical aspects of patient care as he forges his path to becoming an orthopedic surgeon. He has been awarded the Health Careers Scholarship for the past two years. The next generation of health care professionals is prepared to be influenced. Let us work together in encouraging them to explore and discover their potential to become physicians, physical therapists and more. Make a commitment this year to promote a career in health care at high school career days, to tell your own story of developing a passion for caring, and even to share how attention to academics can allow these students to change the path of their lives. More information about the Health Careers Scholarship is available at our website, www.scmaa.org. Email: communications@scmaa.org

Sonoma Medicine


Not just patients, not just clients, but

GUESTS because we’re real people helping real people.

Are you looking for a quality treatment center where you can recommend patients? We can help. Contact our referral network manager to setup a tour and meet our clinical team. Robb Schuler 707-942-6888

Duffy’s napa valley

3076 Myrtledale Road Calistoga, CA 94515 www.duffysrehab.com


PROUD TO BE ENDORSED BY THE SONOMA COUNTY MEDICAL ASSOCIATION

NORCAL Mutual is owned and directed by its physician-policyholders, therefore we promise to treat your individual needs as our own. You can expect caring and personal service, as you are our first priority. Contact a NORCAL Mutual agent/broker today.

norcalmutual.com 844.4NORCAL


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