San Antonio Medicine July 2018

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Maternal Mortality Trending Down Globally Where do mothers in USA fit?

By Rajam Ramamurthy, MD ...........................................12

Maternal Mortality in Bexar County: How are we addressing the issue?

By Dr. Margaret Kelley...................................................20

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Yoga in Pregnancy By Hetal Nayak, MD..........................24 Mommies Program Benefits Mothers with Substance Use Disorders and Their Babies in Bexar County

By Jamie Estrada, MD...................................................................................................................26 Role of Faith-Based Institutions in Addressing Public Health By Rev. Ann E. Helmke ................28 BCMS President’s Message ...............................................................................................................8 BCMS Legislative News ............................................................................................................................10 Feature: Brothers in Arms By Samantha Gomez Ngamsuntikul, MD ..........................................................30 Boxes: More Complicated than you Think By Fred H. Olin, MD.....................................................................32 BCMS News .............................................................................................................................................33 Review: Welcome Stranger: Alzheimer’s Caregivers Guide By Sherman P. Mcdaniel, Review by Adam Ratner, MD .................................................................................................................34 BCMS Circle of Friends Directory ..............................................................................................................36 In the Driver’s Seat ....................................................................................................................................42 Auto Review: 2018 Infiniti Q50 By Steve Schutz, MD ..............................................................................44

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San Antonio Medicine • July 2018

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Black Herstory and the Maternal Mortality Crisis among African American Women

By S. Michelle Ogunwole, MD........................................22

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Maternal Mortality in Texas: Our Grim Past and Promising Future?

By Patrick S. Ramsey, MD, MSPH .................................16

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San Antonio Medicine is the official publication of Bexar County Medical Society (BCMS). All expressions of opinions and statements of supposed facts are published on the authority of the writer, and cannot be regarded as expressing the views of BCMS. Advertisements do not imply sponsorship of or endorsement by BCMS.

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BCMS BOARD OF DIRECTORS ELECTED OFFICERS Sheldon G. Gross, MD, President Gerald Q. Greenfield Jr., MD, PA, Vice President Adam V. Ratner, MD, President-elect Leah H. Jacobson, MD, Immediate Past President Kristi G. Clark, MD, Secretary John Robert Holcomb, MD, Treasurer

DIRECTORS Rajaram Bala, MD, Member Jenny Shepherd, BCMS Alliance President Josie Ann Cigarroa, MD, Member Kristi G. Clark, MD, Member George F. "Rick" Evans Jr., General Counsel Vincent Paul Fonseca, MD, Member Michael Joseph Guirl, MD, Member John W. Hinchey, MD, Member Col. Charles Mahakian, MD, Military Representative Gerardo Ortega, MD, Member Robyn Phillips-Madson, DO, MPH, Medical School Representative Manuel Quinones, MD, Member Ronald Rodriguez, MD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative David M. Siegel, MD, JD, Member Bernard T. Swift, Jr., DO, MPH, Member

BCMS SENIOR STAFF Stephen C. Fitzer, CEO/Executive Director Melody Newsom, Chief Operating Officer Alice Sutton, Controller Mike W. Thomas, Director of Communications August Trevino, Development Director Mary Nava, Chief Government Affairs Officer Phil Hornbeak, Auto Program Director Mary Jo Quinn, BCVI Director Brissa Vela, Membership Director Al Ortiz, Chief Information Officer

COMMUNICATIONS/ PUBLICATIONS COMMITTEE Kenneth C.Y. Yu, MD, Chair Kristi Kosub, MD, Vice Chair Pavela Bambekova, Medical Student Darren Donahue, Medical Student Carmen Garza, MD, Member Leah Jacobson, MD, Member Fred H. Olin, MD, Member Jaime Pankowsky, MD, Member Alan Preston, Community Member Rajam S. Ramamurthy, MD, Member Adam Ratner, MD, Member David Schulz, Community Member Austin Sweat, Medical Student J.J. Waller Jr., MD, Member

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San Antonio Medicine • July 2018

PRESIDENT’S MESSAGE

Let’s Make Maternal Health A Priority

By Sheldon Gross, MD, 2018 BCMS President

Dear Colleagues,

This month’s issue of San Antonio Medicine is focused on maternal health and dealing with the issue of maternal mortality. I would encourage you to read the multiple thought provoking articles contained in this month’s issue. There is no debate about the importance of carefully examining the issues involved in maternal mortality and doing everything possible to ensure the health of delivering mothers. At a recent meeting of the Texas Medical Association, our President, Dr. Carlos Cardenas, stated that our goal should be zero maternal deaths. I agree with that. Upon reading these articles, several things become quite obvious.

First, one cannot isolate the issue of maternal mortality without looking at the entire fabric of our healthcare system and our society in general. The issue of access to care is fundamental in this discussion. Without ensuring that all mothers have access to the best prenatal care possible, we will never make the type of progress that we would like to see. This involves our state and federal legislatures.

This involves funding mechanisms on a county, state, and national level. This involves the political will to ensure that all Americans have access to care. This also explains why so many physicians feel the importance of involvement in our political and legislative system.

Secondly, we are able to determine specific populations of mothers that are at higher risk for complication. Several articles discuss the increased risk for African-American mothers. The factors involved in this are discussed quite thoroughly. Again, it seems that there are specific interventions that physicians can make. However, it also becomes apparent that public health and broader societal issues play a role as well.

As a child neurologist, I frequently deal with children who undergo a neonatal abstinence syndrome at birth. It is not only tragic to see neonates having to go through drug withdrawal, but also can result in significant long term developmental problems. As we deal with the opioid crisis in this country, we need to focus specifically on the opioid crisis regarding pregnant women.

Lastly, it seems to me that if we are able to put men on the moon, cure genetic illness by repairing the DNA, and see new treatments come on market on a daily basis, we as a society should be able to tackle the problem of maternal health and specifically, maternal mortality quite effectively. The issue is not one of lack of technology. This is an issue of priorities. We as a country have to ask ourselves where on our list of priorities does maternal health rank? In my mind the answer to that question is obvious. I hope you will find the following articles as thought provoking as I have. As always, we recommend feedback and letters to the editor. Enjoy the summer.

Sincerely, SHELDON GROSS, MD President, Bexar County Medical Society

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San Antonio Medicine • July 2018

BCMS LEGISLATIVE NEWS

Border Health Conference 2018 Scheduled for Sept. 11-12 TMA’s Border Health Caucus (of which BCMS is a member) has announced registration and schedule information for its upcoming Border Health Conference, Sept. 11-12 in Washington, DC. The group, now in its 17th year, holds the Border Health Conference annually, alternating between Washington, DC and a Texas border city. The conference brings together physicians, federal and state officials, hospital and health plan officials, along with community

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San Antonio Medicine • July 2018

leaders to find solutions to barriers to health care. The event schedule includes a dinner and issues briefing on Sept. 11 followed by a full day of meetings and visits with agency officials and offices of the Texas members of the U.S. House and Senate on Sept. 12.

Event concludes with a dinner on Sept. 12.

TMA has set up a room block at the Phoenix Park Hotel, 520 N. Capitol Street NW, Washington, DC 20001. You may now book

BCMS LEGISLATIVE NEWS

hotel accommodations by calling toll free at 855-371-6824 and using the Group Code: 22456 or Texas Medical Association – Border Health Caucus. Deadline to make reservations under the room block is August 13, 2018.

For more information regarding the conference, please contact Dave Wilhelm in the TMA Advocacy Office at 512-370-1352 or by email at david.wilhelm@texmed.org.

For local discussion on this and other legislative advocacy topics, consider joining the BCMS Legislative and Socioeconomics Committee by contacting Mary Nava, chief government affairs officer at mary.nava@bcms.org.

visit us at www.bcms.org

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MATERNAL MORTALITY

Maternal Mortality Trending Down Globally

Where Do Mothers in USA Fit?

By Dr. Rajam Ramamurthy

is striking when a man walks in alone into the University Hospital Premiere Clinic holding an infant in one arm and pushing a stroller with another infant in it. The babies were three months old. You quickly murmur greetings and scroll down the computer screen frantically to see if there is any information on the mother. There is none on the infant’s chart, only her delivery record, a healthy 21 year old who delivered premature twins at 33 weeks. He was a strikingly fit, tall handsome dad. He was comfortably bottle-feeding one of the girls.

Intuitively I felt the sadness in him and as I barely got out the words “and mom,” he blurted out, “she is gone when they were 6 weeks old – hemorrhage – too late.” Who takes care of the babies, I asked.

He smiled, “I do, and they are good babies.” Who helps when you are working? “I can’t work, and I do odd jobs on weekends when my sister helps.” When a mother dies, the family unit dies with her.

Globally, the Maternal Mortality Ratio - MMR fell by nearly 44 percent from 1990 to 2015. In numbers that is 532 maternal deaths per 100,000 live births in 1990 to 216 per 100,000 in 2015. The chances of a woman dying related to pregnancy decreased from 1:73 to 1:180. Planning and accountability for improving maternal health, and assessment of the World Health Organization’s programs, Millennium Development Goal (MDG 5) and Sustainable Development Goal (SDG) targets, require accurate and internationally comparable measures of maternal mortality.

Given the challenges of obtaining accurate and standardized direct measures of maternal mortality, the Maternal Mortality Estimation Inter-Agency Group (MMEIG) partnered with a team at the University of Massachusetts Amherst (USA), the National University of Singapore, and the University of California at Berkeley, USA, to generate internationally comparable MMR estimates with independent advice from a technical advisory group (TAG) that includes scientists and academics with experience in measuring maternal mortality. Not infrequently, affluent nations that fall short of expectations invoke doubts about accuracy of data in developing countries before glancing at their own backyard. Globally five complications arising directly from pregnancy account for 70 percent of maternal deaths.

It

Causes of maternal deaths globally: • Hemorrhage (25%) • Infection (15%) 12

San Antonio Medicine • July 2018

• Unsafe abortion (13%) • Eclampsia – very high blood pressure leading to seizures – (12%) • Obstructed labor (8%).

Most of the women who die from these causes do so because they had no access to skilled routine care.

Globally, approximately 1.6 percent (4,700) of all maternal deaths are estimated to be AIDS-related indirect maternal deaths. In subSaharan Africa, 2.0 percent of all maternal deaths are estimated to be AIDS-related indirect maternal deaths, yielding an AIDS-related indirect MMR of 11 maternal deaths per 100,000 live births. In 2015, there are five countries where 10 percent or more of maternal deaths are estimated to be AIDS-related indirect maternal deaths: South Africa (32%), Swaziland (19%), Botswana (18%), Lesotho (13%) and Mozambique (11%).

In 2000, the United Nations (UN) Member States pledged to work towards a series of Millennium Development Goals (MDGs) Included in this was a ¾ reduction in the 1990 MMR to be achieved by 2015. Table 1 shows the MMR for comparable industrialized wealthy countries and the U.S. It also shows developing countries, neighboring countries and a few countries that are of interest where there is U.S. involvement. With the exception of two countries, U.S. and South Africa where MMR has trended up, in all others it has reduced significantly.

In the U.S. the Center for Disease Control (CDC) has also grappled with the issue and come up with a set of guidelines. In the ‘70s, dismantling of maternal mortality review committees in most states was pursued following the rapid decline of MMR. Now there is a scramble to resurrect these committees in the environment of HIPPA regulations that have slowed progress. As per CDC, a fully functional MMR review committee should have a set of guidelines (Figure 1). CDC developed, Maternal Mortality Review Information Application (MMRIA) a tool that is adopted by many states.

An analysis of information gathered from nine states that used MMRIA gave eye-opening information about associated factors in maternal deaths. When 237 maternal deaths from nine states who used MMRIA were analyzed; 38 percent of the mothers died during pregnancy, 45 percent within 42 days and 18 percent within 43 days to one year. The leading underlying causes of pregnancy related death are shown in (Figure 2) Slide 22 of Duah. Hemorrhage and underlying cardiovascular condition accounted for 28 percent of the deaths. 33.5 percent of the deaths were not preventable. 63.2

MATERNAL MORTALITY percent were preventable and 3.2 percent were undetermined. 68.2 percent of cardiovascular conditions and 70 percent of hemorrhages were preventable. Distribution of contributing factors among pregnancy related deaths shows 38.2 percent were patient and family related and 33.9 percent were provider related (Figure 3) slide 27 from John Duah.

CDC also found that there will be a giant impact when social determinants of health are addressed.

A report published in the September issue of the journal Obstetrics & Gynecology found that from 2000 to 2014, the maternal mortality rate for 48 states in the U.S. and Washington, D.C. increased 27 percent from close to 19 deaths per 100,000 live births to close to 24 deaths per 100,000 live births.

This one publication has generated an avalanche of activities particularly in Texas that was shown to have the highest MMR in the country. Nationally and in Texas the number of African-American mothers dying is three times as high as white mothers. AfricanAmerican mothers in Texas are dying at the highest rates of all.

A 2016 joint report by the Texas Department of State Health Services’ Maternal Mortality and Morbidity Task Force found that black mothers accounted for 11.4 percent of Texas births in 2011 and 2012, but 28.8 percent of pregnancy-related deaths.

Bexar County is carrying its own burden as well. (Table 2.) As per the statistics from the Texas department of state health services who publish health, stats there were 11 maternal deaths in Bexar County in 2016. Nothing more than this number can be obtained as the medical records are HIPPA protected.

Metro Health Department has setup a taskforce to review maternal mortality in Bexar County. Work of the taskforce is impeded by lack of access to the mother’s medical records. The cause of death, circumstances of death, location, outcome of the infant are all questions that have no answers. We have no idea about the ethnicity of these mothers.

TABLE 1

FIGURE 1

Often Hispanic mothers are neglected, invoking the ‘Hispanic Paradox’ which states that infant mortality and maternal mortality in the Hispanic and Latino populations is comparable to non-Hispanic whites.

Irrespective of all considerations, one maternal death is one too many regardless of who dies and where she died. It is clearly shown in the CDC analysis that the largest impact will be to address the social determinants of health. It takes a village to raise a child.

Nurturing the mother to be and the new mother is everyone’s concern.

In the Premiere clinic I performed my duties mechanically. I knew one of the baby

continued on page 14

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FIGURE 2

continued from page 13

girls will have challenges. This dad will have to pull the burden alone. There is gaping emptiness, and yet there is so much abundance. Let us begin filling.

The Public Health Action Committee of the Faith Based Initiative of the City of San Antonio hopes to work on community-wide initiatives through the faith organization in a community to focus on nurturing women before, during and after pregnancy.

Rajam Ramamurthy, MD, Professor Emeritus, Department of Pediatrics. UT Health. San Antonio.

Leader, Public Health Action Committee of the Faith Based Initiative of the City of San Antonio.

Suggested Reading:

• United Nations, Department of Economic and Social Affairs - Population Division - World Population Prospects, the 2015 Revision • https://www.npr.org/2017/05/12/5280 98789/u-s-has-the-worst-rate-of-maternal-deaths-in-the-developed-world

• Obstet Gynecol. 2016 Sep;128(3):447-55

TABLE 2

****Maternal Deaths are reported as the number of deaths due to pregnancy, childbirth, the puerperium up to six weeks post-delivery, and any obstetric cause from 42 days to a year post-delivery and its sequelae (ICD-10 codes O00-O99).

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San Antonio Medicine • July 2018

FIGURE 3

Photo by Piron Guillaume on Unsplash

MATERNAL MORTALITY

MATERNAL MORTALITY

Maternal Mortality in Texas: Our Grim Past and Promising Future?

By Patrick S. Ramsey, MD, MSPH

mage the birth of a child… the joy and celebration of the family… the wonder of the new life brought into the world. The miracle of birth. In a moment the occasion turns to terror with onset of torrential vaginal bleeding.

Efforts to treat and manage the blood loss are futile and hours later the mother lays pale and pulseless.

The above scenario unfortunately occurs all too often and leaves a permanent scar on the newborn, family, entire provider care team and our society. Maternal death is a major marker for health of our state and nation. Maternal mortality is defined as a ratio of the number of maternal deaths occurring during pregnancy or within the 42 days following the end of pregnancy per 100,000 live births (some definitions extend the period up to one year following the end of pregnancy). In spite of spending over $98 billion annually on hospitalization for pregnancy and childbirth, the United States maternal mortality rate has doubled in the past 25 years (Figure 1).

Today, more women die in the U.S. from pregnancy-related complications than in any other developed country. Between 2011 and 2013, maternal mortality in the U.S. was 17.3/100,000 live births.

Tragically, there are striking racial/ethnic disparities present with African American women being 3-4 times (43.5/100,000 live births) more likely to die from a pregnancy-related condition than non-Hispanic white women (12.7/100,000 live births. Leading causes of maternal mortality nationally include cardiovascular disease, infection/sepsis, obstetric hemorrhage, cardiomyopathy, pulmonary embolism and hypertensive disorders of pregnancy (Figure 2).

I

Maternal Mortality In Texas:

What about maternal mortality in Texas? Between the years of 2012 and 2015 there were 382 maternal deaths recorded during pregnancy or within the first year following the end of pregnancy in Texas. Of these deaths 38 percent occurred during pregnancy or within 42 days of the end of pregnancy. The leading causes for these deaths included cardiac/cardiovascular events, infection/sepsis, obstetric hemorrhage, and hypertension/eclampsia. The remaining 62 percent of maternal deaths occurred between 43 days and one year following the end of pregnancy. In contrast to those deaths occurring during pregnancy or early following the end of pregnancy, the leading causes for these later maternal deaths included drug overdose, homicide, cardiac events, and suicide. Contributing factors 16

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identified related to these maternal deaths include obesity, maternal medical comorbidities, advanced maternal age, late access to prenatal care and mental health disorders. Similar to national statistics, the rates of maternal mortality in Texas are highest among women of African-American descent.

Causes for Increasing Maternal Mortality:

A number of potential factors which may account for the increasing rate of maternal mortality are noted above. Factors including impaired access to care, defunding of family planning services, and state non-participation in the Affordable Care Act (ACA) exchanges may be partially contributing to the increasing rate of maternal mortality. Inaccurate data collection and reporting may also be a potential cause for the observed increase in maternal mortality. Concerns have been raised regarding the disparate personnel training and variable completion for death certificates leading to inaccurate coding. In addition, the introduction of the “pregnancy check box” in 2003 has been questioned as partial cause for the increase. In the May issue of Obstetrics & Gynecology, Baeva and colleagues evaluated the standard approach for collection of maternal mortality to an enhanced method assessing for obstetric cause of death codes as evidence of pregnancy and data matching with birth or fetal death record. This enhanced approach resulted in a corrected maternal mortality estimate for 2012 of 14.6/100,000 live births vs 38.4/100,000 live births using standard methods. This observation is important to refine our approach to collect accurate data but in no way diminished concerns for maternal mortality. Any women lost as the result of pregnancy is an unacceptable loss in modern obstetrics.

Severe Maternal Morbidity in Texas:

While maternal mortality is fortunately uncommon, maternal morbidities are far more common. It is estimated that severe maternal morbidity occurs between 50 and100 more often than maternal mortality making efforts to reduce these adverse outcome highly important in our efforts to prevent maternal death. In Texas in 2014, the estimated overall rate of severe maternal morbidity, defined as obstetric hemorrhage, disseminated intravascular coagulopathy (DIC), eclampsia, emergency hysterectomy or thromboembolism was noted in 195.2/10,000 deliveries. The rate

MATERNAL MORTALITY FIGURE 1

www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html

of obstetric hemorrhage was 129.8/10,000 deliveries with disseminated intravascular coagulopathy occurring in 25.8/10,000 deliveries, cardiac events occurring in 20.4/10,000 deliveries, emergency hysterectomy occurring in 13.9/10,000 deliveries, and eclampsia occurring in 7.1/10,000 deliveries. These severe morbidities represent potential “near misses� for maternal mortality and efforts to prevent these untoward outcomes represent key targets for efforts to reduce maternal mortality in Texas and nationally. In a publication by Main and colleagues in Obstetrics & Gynecology in 2015, it was noted that there was a good-to-strong chance to prevent maternal death in 41 percent of cases, with the highest rates of preventability among cases of hemorrhage (70%) and preeclampsia (60%).

Texas Initiatives to Prevent Maternal Morbidity and Mortality:

We are fortunate today that there are a number of efforts underway in Texas to address the scourge of maternal morbidity and mortality. Ongoing initiatives such as Healthy Texas Women, Someday Starts Now, Preconception Peer Education Program, One Key Question, and others have been implemented to provide increased access and education to patients related to family planning and optimal pregnancy preparation. The Texas Electronic Vital Events Register (TxEVER) program is also underway to increased death certificate accuracy. The Texas Collaborative for Health Mothers and Babies (TCHMB) was formed as a state perinatal collaborative in 2013 and has the mission to advance health care quality and patient safety for all Texas mothers and babies. The collaborative has undertaken state quality improvement initiative to assist hospitals

provided obstetric services to implement Maternal Early Warning Signs (MEWS) protocols to provide early identification of pregnant women at high risk for maternal morbidity and mortality.

In 2014, the 83rd Texas Legislature, during regular session, passed House Bill 15 establishing a process for designation of neonatal and maternal levels of care for health care facilities in Texas. In March of this year the final maternal rules were published and maternal delivery facilities from around the state are actively preparing for site surveys to meet maternal designation deadline of September 1, 2020. This initiative has great promise to improve care for pregnant women in our state and to ensure that each center has critical processes in place for identification and care for women with pregnancy complications. The designation process will help to ensure women who develop pregnancy complications are cared for at the appropriate level of care for their condition. The Texas Maternal Mortality and Morbidity Task Force was also created in 2013 through Senate Bill 495. This multidisciplinary task force reviews cases of pregnancy-related deaths and trends in severe maternal morbidity and makes formal recommendations to the Texas Legislature for efforts to help reduce the incidence of pregnancy-related deaths and severe maternal morbidity in Texas. Last summer as an extension of these state efforts, the Bexar County Metropolitan Health District formed a Bexar County Morbidity and Mortality Task Force composed of a diverse array of stakeholders from San Antonio and Bexar County to explore local factors related to these adverse events.

In January of this year, Texas became an official member of the Alliance for Innovation on Maternal Health (AIM) as part of the Council on Patient Safety in Women’s Health Care. AIM is a national data-driven maternal safety and quality improvement initiative focused on improving maternal safety and outcomes. Obstetric care bundles and toolkits are promoted to optimize maternal care through four main focal areas: Readiness, Recognition and Prevention, Response, and Reporting/Systems learning. Since the launch of TexasAIM in January, as of June 8, 2018, a total of 172 of the 239 hospitals (72%) providing obstetric care in Texas have enrolled to participate in AIM. Previous work through AIM has demonstrated that implementation of patient safety bundles can result in a significant decrease in severe maternal morbidity.

Finally, in September of last year the Texas Medical Association convened a forum focused on the issue of maternal morbidity and continued on page 18

visit us at www.bcms.org

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MATERNAL MORTALITY continued from page 17

mortality. Stakeholders from around the state presented concepts and ideas to promote improved care for women with the goal to affect maternal morbidity and mortality in Texas. In a follow-up, the TMA hosted a Maternal Health Congress in March of this year during which proposed resolutions for reducing maternal morbidity and mortality were presented. The result of this highly impactful event was the development of a TMA 7-point plan to stop maternal deaths in Texas. This plan focused on several actionable resolutions encompassed in the areas of access to care, behavioral health prevention and treatment, access to long-acting reversible contraceptives, quality improvement initiatives, and public health programming (See Box for additional information).

FIGURE 2

Next Steps:

Maternal mortality remains a major concern nationally and for us in Texas. It is encouraging that many efforts are underway in the state to address the problem and with hope in the near future we will see tangible reductions in this unfortunate pregnancy complication. With the next legislative biennium on the horizon, we all need to be strong advocates for promotion of women’s health issues, specifically those related to reduction in maternal morbidity and mortality in the state.

REFERENCES:

MacDorman MF, Declercq E, Cabral H, Morton C. Recent Increases in the U.S. Maternal Mortality Rate: Disentangling Trends From Measurement Issues.

Obstet Gynecol. 2016 Sep; 128(3): 447-55.

Baeva S, Saxton DL, Ruggiero K, Kormondy ML, Hollier LM, Hellerstedt J, Hall M, Archer NP. Identifying Maternal Deaths in Texas Using an Enhanced Method, 2012. Obstet Gynecol. 2018 May; 131(5): 762-769.

Main EK, McCain CL, Morton CH, Holtby S, Lawton ES. Pregnancy-related mortality in California: causes, characteristics, and improvement opportunities.

Obstet Gynecol. 2015 Apr; 125(4): 938-47

Dr. Patrick S. Ramsey is a maternal-fetal medicine specialist at Professor in the Department of Obstetrics and Gynecology at the UT Health San Antonio. Dr. Ramsey serves on the Bexar County and Texas Maternal Mortality and Morbidity Task Forces as well as the Executive Committee for the Texas Collaborative for Healthy Mothers and Babies (TCHMB).

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San Antonio Medicine • July 2018

www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html

NATIONAL/STATE/REGIONAL MATERNAL MORBIDITY AND MORTALITY INFORMATIONAL RESOURCES Centers for Disease Control and Prevention Pregnancy Mortality Surveillance System www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html Texas Maternal Levels of Care Designation: https://dshs.texas.gov/emstraumasystems/maternal.aspx Texas Maternal Morbidity and Mortality Task Force: https://dshs.texas.gov/mch/maternal_mortality_and_morbidity.shtm Texas Alliance for Innovation on Maternal Health (AIM) Initiative: www.dshs.texas.gov/mch/TexasAIM.aspx Texas Collaborative for Healthy Mothers and Babies (TCHMB): www.tchmb.org/ Texas Medical Association (TMA) Maternal Mortality and Morbidity www.texmed.org/MMM/ South Texas Regional Advisory Council (STRAC) Regional Perinatal Committee: www.strac.org/perinatal

MATERNAL MORTALITY

Maternal Mortality in Bexar County: How are we addressing the issue?

By Dr. Margaret Kelley

2017, the Texas Maternal Mortality and Morbidity Task Force and Department of State Health Services released its 2016 Biennial Report. The calendar year of 2011 -2012 was studied. There were 189 maternal deaths that year. Any woman who died 365 days from a birth was included in the analysis. The leading causes of maternal death were cardiac events, drug overdose, and hypertension/pre-eclampsia, hemorrhage, sepsis, homicide and suicide. Black women had the highest rates of maternal death. While black women compose 11.4 percent of all births in Texas, they comprised 28.8 percent of maternal deaths. Hispanic women had lower death rates compared to total percentage of births. High deaths from drug overdoses, mainly opiates, were a surprise finding of the study. A profound finding of the Task Force was that there were 16.9 per 1,000 obstetrical hospitalizations related to hemorrhage and transfusion. Given these findings the questions arise as to what are our maternal mortality statistics in Bexar County and what can be done to lower maternal morbidity and mortality? In this light, in 2017 the Bexar County Maternal Mortality and Morbidity Review Task Force (MMMR) was established.

The Bexar County Maternal Mortality and Morbidity Task Force was established with funding from the Metro Health Healthy Start Grant. The objective of the MMMR is to “improve maternal and perinatal outcomes by adopting and applying locally relevant strategies and interventions to prevent future deaths. Furthermore, the MMMR will prioritize critical health services, and community resources to address the unmet health needs for black women who are three to four times more likely to die from pregnancy-related complications than white women.”

One may ask why does Bexar County need its own MMMR? One reason is to look specifically at our local data. The State Maternal

In

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San Antonio Medicine • July 2018

Morbidity Task Force will not release locally specific data or findings to the local health departments. Therefore, the Metro Health Department, without doing its own study, is not able to specifically relate maternal morbidity and mortality outcomes for Bexar County.

This data is needed to improve a community network of stakeholders to systematically lower maternal morbidity and mortality in Bexar County.

The MMMR is composed of a wide range of community leaders who encounter an obstetrical patient, including obstetricians, internists, nurses, pediatricians, a pathologist, and epidemiologists.

There will be three subcommittees: Data Collection, Case Review and Community Action. Data collection of pregnancy related deaths remains very challenging. Information on death certificates can be inaccurate. Therefore, it is necessary to verify a pregnancy and to ask “if the patient had not been pregnant would the patient have died.” Thereafter, it will be necessary to determine if the pregnancy-related death was “complication of pregnancy itself, a cascade of events initiated by pregnancy, or the aggravation of an unrelated condition or event by the physiologic effects of pregnancy.” Moreover, the Case Review subcommittee with help identify pregnancy-related deaths and analyze and interpret the findings. Finally, the Community Action subcommittee will be tasked to partner with local organizations to further make recommendations to improve obstetrical outcomes.

While the recent news of maternal morbidity and mortality is sobering, one can reflect on history to have hope that improved obstetrical outcomes are possible. In 1846, Dr. Igaz Semmelweis was appalled by the high rates of maternal deaths from “puerperal fever,” at the General Hospital in Vienna. He systematically investigated this issue and discovered that women cared for by the physicians and medical students had higher death rates than those cared

MATERNAL MORTALITY for by the midwives. What he discovered was that the physicians, who performed autopsies, would then go to the maternity ward to deliver babies. The midwives did not perform autopsies. He hypothesized that the bacteria from the autopsies were being transferred to the laboring patients. Dr. Semmelweis ordered that the physicians to wash their hands and instruments with soap and chlorine prior to delivering the mothers. With this intervention, maternal mortality decreased dramatically. What this story of Dr. Semmelweis demonstrates is that with careful study of maternal mortality, systemic interventions were implemented which then lowered the maternal mortality.

In 2011, Dr. Robert Schorlemer, Dr.Margaret Kelley, and Dr. Brian Harle, under the auspices of the American College of Obstetricians and Gynecologists District XI Section V, led an initiative to combat postpartum hemorrhage in San Antonio, the fourth leading cause of maternal death in Texas. The OB/GYN Department at the UT Health Department had initiated a Massive Transfusion Protocol at University Hospital. This protocol immediately made available six units of RBCs, FFP, and platelets at the time of massive hemorrhage. However, this protocol was not implemented in the Methodist Healthcare System or the Baptist Hospital System. The

local ACOG leadership held a conference where Dr. Lillian Liao, pediatric trauma chair at University Hospital, lectured on massive hemorrhage and the massive transfusion protocol to local OB/GYNS. Thereafter, the local ACOG leadership spearheaded the effort to implement this protocol in the largest hospital systems.

The rapid availability of blood products undoubtedly has saved many mothers in San Antonio.

In summary, I mention Dr. Semmelweis and the implementation of ‘Massive Transfusion Protocol’ as examples of addressing two causes of maternal death, infection and hemorrhage that were reduced through physician- initiated protocols. Under the leadership of the Bexar County Maternal Mortality and Morbidity Review Committee, a thorough investigation of maternal deaths will be performed to decrease maternal morbidity and mortality in Bexar County.

Margaret A. Kelley, M.D. is a graduate of the Warren Alpert Medical School of Brown University and the UT Health at San Antonio OB/GYN Residency Program. She practices at Southeast OB-GYN Associates, P.A. She is the Chairman of the Bexar County Maternal Mortality and Morbidity Task Force.

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MATERNAL MORTALITY

Black Herstory and the Maternal Mortality Crisis among African American Women

By S. Michelle Ogunwole, MD

am young, I am a physician, and I am highly educated. I have financial advantages that are above average. I have access to healthcare, healthy foods, clean water, and a safe environment.

And yet‌ If I have a child, none of these things will save me from having a substantially increased risk of an adverse outcome, or even death.

Why? Because in addition to all of the things I described; I am an African-American woman. And, more than any of the things that define me, this is the label that most profoundly informs my chances at a healthy life before, during, and after pregnancy.

all maternal mortality rate;3 the notion that African-American women face profound disparities in maternal morbidity and mortality is so glaringly apparent in the data that it has remained the most unwavering fact in the crisis of rising U.S. maternal mortality rates.

So why are black women dying? Why are they facing complications and adverse outcomes, and why are all of things happening at such a profound rate, and with such a sharp disparity?

The reports by the Texas Maternal Morbidity and Mortality Taskforce show that a rise of chronic disease: pre-pregnancy obesity, diabetes, and hypertension may partly be to blame, yet the rates are rising for everyone.

Here are the facts:

So, why are black women dying?

I

Within the field of obstetrics and gynecology, disparities in pregnancy-related mortality among African-American women have led to a mortality rate greater than three times that of their white counterparts.1 While racial and ethnic disparities in maternal mortality disproportionally affect African-American women nationwide, nowhere is this disparity more prominent than in the state of Texas where African-American women make up only 11.4 percent of the population of women who give birth, yet account for 28.8 percent of maternal deaths.2 Even amidst claims of calculation errors leading to an inflated over22

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When the task force evaluated causes of death by race and ethnicity, they found that pre-eclampsia and cardiovascular disease were among the leading causes of death for all women, but again black women were disproportionately affected.

So, why are black women dying?

Is it simply a matter of physiological predisposition? The same way that African-American people are more likely to have sickle cell anemia, or Ashkenazi Jews to have Tay-Sachs disease (a rare neurologic disorder). Should we just accept that black women have higher rates of chronic disease and fare worse than others as a matter of

MATERNAL MORTALITY predetermined genetics?

While this reasoning may seem attractive, it oversimplifies a complex problem. Though genetic predisposition may play a small role, mounting evidence suggests that the social determinants of health: education, poverty, geographic location, etc. have a much greater impact on health, and preventable mortality.4 However, I opened this piece with a proclamation that even with all the social advantages, African-American women still fare worse in pregnancy.

So, why are black women dying?

It seems that of all the social determinants of health, race and ethnicity most strongly predict the quality and intensity of care received. The 2002 Institute of Medicine Report Unequal Treatment found that racial and ethnic disparities contribute to worsened healthcare outcomes independent of factors related to access to care. Furthermore, the report implicated physician bias, stereotyping, and prejudice as important contributors to this problem.5 Based on this, I submit that that there is perhaps an alternative narrative, one that is darker, one that is more uncomfortable, one that asks you to consider the history that shaped the treatment of black women in the healthcare system and what impact this has on the present state.

Here is the history:

Modern gynecology was perfected through the unimaginable exploitation of black women’s bodies. Dr. Marion Sims (hailed as the father of modern gynecology) performed countless gynecological procedures on his slaves without the use of pain medication or anesthetic. He asked other slaves to hold each “patient” down and muffle their screams as he went about his work, inviting other colleagues to observe the horrific experimentation. He then went on to addict these women to opioids; furthering the reach of his control over their bodies.

Across the country, Dr. Marion Sims has statues erected in his honor, and while recognition of his contributions to the field of obstetrics and gynecology are plentiful; the costs of those contributions are rarely mentioned. And worse yet, the reproductive exploitation of black women did not stop with him. It continued on in history in many ways. It occurred in the form of federally-funded reproductive health procedures which amounted to coerced sterilization; and persisted in segregated healthcare practices that denied black women the standard of care. This is all part of the historical context that shaped society’s valuation of black women’s bodies.

And while understanding the historical context is only one of the

myriad considerations for addressing disparities in maternal mortality; the systematic oppression of black women and the impact that this repetitive and unyielding trauma (both physically and emotionally) has had on their bodies; is a story that is too often discredited as relevant to the problem.

But how does this help us move forward toward improving maternal mortality disparities? I make no conscious claims to having the solution for this problem. As with all wicked problems, the solution is multifaceted. However, I do have a proposition on where to begin.

Here is what I know:

I am a primary care provider; I believe that lifestyle changes and medications can reduce chronic disease. I believe that in conjunction with good obstetric care and follow up, access to a primary care provider prior to and in the year following pregnancy can help black women have healthier lives through conception and beyond.

And yet…

I know that solving this complex problem is not just about healthcare. That it is also about recognizing the social and environmental factors that influence a black woman’s health, and about empowering her to choose behaviors that promote self-care.

Even with these things, however, acknowledgment remains the first act of any lasting recovery. And so, we must acknowledge.

Acknowledge that the black woman may still be healing from historical wounds, that she is perhaps trying to build trust within a healthcare system that has cultivated generations of mistrust. That she is trying to teach herself and her community that her strength is not measured by her capacity to endure pain and suffering, and that prioritizing her own health is not a fatal flaw, that it is, in fact, the opposite, a radical act of self-preservation.

That for all we ever try to accomplish to solve this problem, our interventions will be inane unless they acknowledge, respect and incorporate her story.

References

1. Creanga AA, Syverson C, Seed K, Callaghan WM. Pregnancy-Related Mortality in the United States, 2011–2013. Obstet Gynecol. 2017.

2. Shirley A. Maternal Mortality and Morbidity Task Force and Department of State Health Services Joint Biennial Report. 2016.

3. Baeva S, Saxton DL, Ruggiero K, et al. Identifying Maternal Deaths in Texas Using an Enhanced Method, 2012. Obstet Gynecol. 2018;131(5):762-769. doi:10.1097/AOG.0000000000002565.

4. McGinnis JM, Williams-Russo P, Knickman JR. The Case For More Active Policy Attention To Health Promotion. Health Aff. 2002;21(2):78-93. doi:10.1377/hlthaff.21.2.78.

5. Smedley BD, Stith AY, Nelson AR. Unequal Treatment. National Academies Press (US); 2003. doi:10.17226/12875.

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MATERNAL MORTALITY

By Hetal Nayak, MD

he majority of women will experience pregnancy during their lifetime. A majority of families will go through the experience of childbirth. This is a unique opportunity that we as healthcare providers should recognize.

This is the time when young adults are focusing on the health of the women and practicing selflessness and are willing to bring changes in lifestyle that can be beneficial and everlasting. It is a time when a holistic practice such as yoga can be introduced and encouraged by the healthcare providers if we ourselves are equipped with the “science of yoga“ and “yoga as medicine.”

Watching a class full of pregnant women with round bellies, it is easy to see where the concept of the Earth as a mother came from.

Just as the Earth sustains all life, a mother-to-be provides a life-sustaining environment for her baby. And a prenatal yoga class can create an environment that nurtures the nurturer.

Yoga is a holistic practice, meaning it works on many different

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levels. It impacts your physical body, your nervous system, your endocrine system, and even heals on a mental and emotional level.

There are many wonderful types of physical fitness practices in the world, but yoga is unique in that its benefits are often far-reaching and integrative. For these reasons, many women find it an incredibly powerful tool during pregnancy. Here’s what yoga can do for you: ● Stimulates & trains your parasympathetic nervous system (your rest and relaxation response)

● Reduces your heart rate, slows respiration and promotes a sense of peace

● Builds pelvic floor strength, tone, and awareness (crucial for birthing) ● Creates long, lean muscles for hormonal health, strength and energy

● Encourages flexibility and comfort in your changing body as your baby grows inside you.

MATERNAL MORTALITY Shari Barkin, M.D., a pediatrician at Wake Forest University/Brenner Children’s Hospital in Winston-Salem, N.C., who practiced yoga during her two pregnancies, supports general guidelines that beginners should practice only prenatal yoga while pregnant, while someone with a strong yoga practice prior to pregnancy may be able to continue a fairly strong practice with modifications after the first trimester. Barkin cautions against beginning any new kinds of strenuous activities during pregnancy.

The first trimester is an essential time for the baby’s formation as the fetus is implanting into the uterine wall and the risk of miscarriage is highest. At this time, experts such as Barkin recommend doing a gentle physical practice or none at all.

“Do not do inversions, twists, or jumps in your first trimester,” Barkin says. “Step back; don’t jump back in Sun Salutations. It’s important not to jar or threaten implantation of the fetus and placenta.” Barkin also recommends practicing Camel Pose or Bridge Pose, which pulls less on the stomach muscles, instead of Full Wheel. It’s important to listen to the body “especially sensitively during this very important time for your baby,” says Elena Brower, a yoga teacher and mother based in New York City. “No twisting and nothing too vigorous. Maintain with gentleness what you’ve always done.”

Breathing techniques such as Ujjayi Pranayama, also known as victorious breath, in which one breathes in and out through the nose, and Nadi Shodana, or alternate-nostril breathing, are especially beneficial practices during pregnancy. Both of these techniques help balance the body’s energy flows and maintain calm by creating an even flow of breath in and out the nose. Keach advises against “any kind of breath retention or hyperventilation that could limit the baby’s oxygen supply,” such as in breath of fire and kapalabhati.

By the second trimester, nausea typically subsides, and experienced yogis with a strong practice may choose to invert again during this time. “This is when I felt strongest,” says Brower. “I loved my practice during this very beautiful and robust time of pregnancy.”

Women should be aware that higher levels of endorphins, the body’s “feel-good” hormone, are produced as pregnancy progresses, making it more difficult to feel injury, writes Desai in Yoga Sadhana for Mothers. She also advises that women should not practice closed twists or poses that put weight on the abdomen such as Locust Pose.

By the third trimester, balance and breathing become difficult as the body holds more weight. In the book “Relax and Renew,” Judith Lasater, Ph.D., P.T., advises women after the first three months of pregnancy to practice Savasana by lying on the left side with padding between the knees instead of on the back. Also, to avoid compressing the belly, pregnant women frequently modify standing poses

such as Chair Pose by taking their feet into a wider stance. “This may be a good time to spend extra breaths in postures that are noted for helping during labor, such as baddha-konasana [Bound Angle Pose] and upavistha konasana [Wide-Leg Seated Forward Bend],” Desai writes, as well as sequences that “encourage the baby into an optimal position for birth, for example, going on all-fours and circling the hips.”

Practicing yoga during pregnancy is especially personal and can be unspeakably rich and rewarding. It allows a sacred opportunity for a woman to deepen her relationship to the wisdom of her body, her baby, and to herself.

As yoga’s popularity has continued to soar in the U.S., so too has the popularity of yoga practice during pregnancy. The breathing techniques used in yoga aids in childbirth and helps to ease the burden of pain from the body and helps increase flexibility.

While the benefits of prenatal yoga are vast, the biggest reward remains the spiritual connection that ties together two bodies and two unique souls. These opportunities wait for us all; to know our true selves by embracing responsibility and accountability to the people in our lives. Those who – if we let them – teach us that only when we give up life as a ‘What is in it for me’ exercise do we find true peace, joy, and fulfillment… as well as who we really are.

Hetal Nayak MD, E-RYT200, International Day of Yoga ~ San Antonio Founder / Community Outreach & Development. Webpage: 4th International Day of Yoga – San Antonio, Texas. Facebook: www.facebook.com/idoyogasa/ visit us at www.bcms.org

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MATERNAL MORTALITY

Mommies Program

Benefits Mothers with Substance Use Disorders and their Babies in Bexar County

By Jaime Estrada, MD

ccording to a new study published in the journal Pediatrics (1), in this country every 15 minutes an infant is born with withdrawal symptoms from having been exposed to opioids in the womb. Infants experiencing opioid withdrawal are irritable, can have feeding and breathing problems and are more likely to be born with low birthweight.

From 2004 to 2014, the number of U.S. infants diagnosed with opioid withdrawal symptoms, known as neonatal abstinence syndrome (NAS), increased 433 percent, from 1.5 to 8.0 per 1,000 hospital births. The increase was even more pronounced in state Medicaid programs – rising from 2.8 to 14.4 per 1,000 hospital births. Medicaid covered more than 80 percent of NAS births nationwide in 2014. Medicaid covered 48 percent of all births in 2014.

Adjusting for inflation, total hospital costs for NAS births that were covered by Medicaid increased from $65.4 million in 2004 to $462 million in 2014 in this study. NAS has been linked to the use of both illicit opioids such as heroin and legal opioids like Vicodin.

There were 324 babies diagnosed with NAS born in Bexar County in 2015, the most recent year state statistics are available.

Bexar has consistently ranked first in NAS cases since the state began recording the data in 2009 with 300 to 400 babies born with NAS per year. The total number of NAS cases in Texas increased by 75 percent from 2010 to 2015.

Yolanda Aldana first became dependent upon Vicodin prescribed for persistent pain after an epidural procedure she received when delivering her second child. She felt this medication relieved her anxiety and depression after the child was hospitalized for seizures and brain surgery for Chiari malformation.

Once her prescriptions ran out, she began snorting heroin, which was cheaper and lasted longer. She quickly became addicted. The elementary school reported her to CPS when her daughter arrived wearing the same dress several days in a row. She failed a drug test. CPS developed a safety plan. Her mother and sister agreed to care for the children while Yolanda attended rehabilitation. This didn’t work, and she left her mother’s home after two days and continued to use.

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After a few days in jail for petty theft, she found that she was 16 weeks pregnant. Upon release, she was sent to the Restoration Center, operated by the Center for Health Care Services, and joined the Mommies Program.

The program, which requires near-daily participation for about three months, is free to any pregnant woman diagnosed with a substance use problem. The women work with a clinician to manage their opioid addictions with methadone or buprenorphine and receive free transportation, child care and parenting classes. In spite of participating in the program, Yolanda experienced break-through withdrawal symptoms and continued using heroin until one month before delivery.

Yolanda went into labor at 30 weeks. She remembers how cold and unkind hospital staff was when informed of her drug use. The attitude of staff can be critical in helping drug addicted mothers get past the shame and form strong attachments to their babies. “It takes time and training to help clinicians understand the impact of stigma and bias,” says Lisa Ramirez, Coordinator of the Texas Department of State Health Services Women’s Substance Use Disorders Services. Yolanda's daughter was born 10 weeks premature and weighed only 3 pounds. She was diagnosed with NAS and hospitalized for seven weeks for supportive care.

Yolanda requested to participate in the Kangaroo Mother Care (KMC) Study which had been mentioned at a class in the Mommies program. Dr. Lisa Cleveland, Principal Investigator of the KMC Study, leader of the Bexar County Neonatal Abstinence Syndrome Collaborative and faculty at the UT Health San Antonio School of Nursing, came to the hospital to assist Yolanda in doing KMC and helped educate the staff on its use with infants experiencing opioid withdrawal.

The infant, dressed in only a diaper, is cradled against the mother’s bare chest, allowing the baby to smell her mother and hear her mother’s heartbeat. This also makes on-demand breastfeeding more likely. This continuous skin-to-skin contact between mom and baby provides comfort to both. Yolanda recalls feeling “like being in a

MATERNAL MORTALITY bubble, one with her baby, free of the guilt.� She spent most of each day in the NICU until the baby was discharged.

Yolanda has been in recovery on daily methadone for almost three years and recently delivered her fourth baby. She’s become an active advocate for vulnerable women who are going through the same issues. She sits on the advisory board of The Bexar County NAS Collaborative working to address the local prevalence of NAS. Women in the Mommies program, administered by the Center for Health Care Services (CHCS), are advised to enter outpatient medication-assisted treatment (MAT) during their pregnancies.

Many of the women experienced trauma in childhood or adulthood, so the program provides counseling to address that trauma. Additionally, the women are required to take courses in parenting, relapse prevention, and life skills. Clinicians in the hospital teach the women about prenatal care, NAS, and how to soothe a baby experiencing withdrawal symptoms through the use of the KMC. More than 1,000 women have now been through the Mommies Program, and many have been able to maintain custody of their children. The CHCS is in partnership with University Hospital and the State continue to fund the program.

Since the Mommies Program was implemented, there has been a

33 percent reduction in the time NAS babies spend in the NICU. The program has been so successful that the state is working with hospitals and treatment programs in five other Texas counties with high rates of NAS to expand use of this model using the Mommies Toolkit which outlines how other communities can add resources similar to the Mommies Program. As a result, there are now 13 Mommies Programs throughout the state.

As medical professionals we need to do everything in our power to strengthen the bond between high risk, addicted mothers and their NAS babies through compassionate care, while providing them with the tools and support in programs like Mommies which will allow them to recover and be able to care for their children. This will require a culture change within the healthcare system toward a more accepting and judgment-free environment.

Reference:

(1) Incidence and Costs of Neonatal Abstinence Syndrome Among Infants with Medicaid: 2004-2014. Winkelman TNA, Villapiano N, Kozhimannil KB, Davis MM, Patrick SW. Pediatrics. 2018 Apr;141(4).

Jaime Estrada, MD, is Board Chair and President of Texas Doctors for Social Responsibility.

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MATERNAL MORTALITY

Role of Faith-Based Institutions in Addressing Public Health

By Rev. Ann E. Helmke

iven that the community of faith within urban settings is one of the largest natural resources available, it only stands to reason the large potential that access to this resource might provide when it comes to addressing the health of the public. Perhaps even more significant to this largess is the depth within belief systems of the ethic of reciprocity – the treating of others in ways we wish to be treated ourselves. This is more commonly known as the Golden Rule and the common denominator found in all the world religions.

It is fascinating to watch and to participate in a world where the above connections could be obvious but it is taking research, pilot projects, storytelling and evidenced practices to bring all of this to light. Even in faith-based institutions. San Antonio is no exception.

There is significant movement afoot that is providing the evidence of greater potential in addressing public health.

An excellent example of health programs within faith-based organizations, throughout San Antonio and beyond, is the Wesley Nurse program. It is a part of the well-known Methodist Healthcare Ministries of South Texas, Inc. The program is professional and holistic, provides health education and facilitation of resources, is

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free to individuals and groups, located in churches but open to all without promoting denominational beliefs. Such programs are monitored and measured for effectiveness in providing significant quantities of healthcare beyond the healthcare system.

Faith-based institutions also provide broad and deep access into community. There are approximately 1400 congregations of all faith traditions and religions spread across San Antonio’s geography.

These locations provide nearer access to at least the navigation of healthcare system as congregations are in neighborhoods and in proximity to where people live. Whereas more traditional healthcare providers might be more centrally or collaboratively located in not so convenient locations for vulnerable families and communities.

Educational access into community is also an asset when it comes to the faith-based community addressing public health. Consider the variety and the capacity of resources found in congregations – from congregants who are professional healthcare providers and educators to easy-access classrooms and free parking.

Within the San Antonio Faith-Based Initiative there is a public health action team focusing in on maternal health. That team is intentionally partnering with professionals within the healthcare sys-

MATERNAL MORTALITY tem while utilizing both the geographical and educational access of vulnerable areas, lack of food pantries and desert areas of needs. the faith community. There are steps within the action plan but Leaders gathered together. New food pantries have been assemeventually the educational awareness and resource engagement will bled and opened. Financial management as well as mental health go into congregations and neighborhoods to reach broad and deep classes are now being offered. Faith leaders are working and talkinto communities. Mapping of combined data from healthcare and ing with civic leaders. Policy makers are better informed. The faith institutions also help to reveal the disparities and bring further public is being better served. The community is growing stronger. focus to engaged access into specific communities.

It is healthier.

It is not a stretch to begin to see what kind of advocacy dynamic Within faith and religious traditions, members learn about values, of mobilization can moral obligations and occur from the the ability to respond above when it comes in care of self, others to changing behavand the world around What could and might happen if the faith iors, laws, policies, us. Such teachings, community and government agencies and nonprofit etc. which all impact undergirded by the organizations and community groups began to health disparities. ethic of reciprocity, intentionally relate more to each other in addressing Programs within prime faith-based inour largest and shared community concerns? faith institutions stitutions toward begin to share ideas, public health initiaoutcomes and practives and the care of What could and might happen if more intentional tices. Congregations creation to create a partnerships were formed across these entities begin to partner in safer, healthier enviand geographies? the networking of a ronment.

History variety of services to points us to numerbetter serve the ous times of social What could and might happen if more services were needs of their justice advocacy and intentionally networked across the institutions and nearby communities. human rights efforts agencies towards efficiency and effectiveness?

Families and individfrom within faithuals begin to get a based groups.

What could and might happen to the lives better understanding Consideration through education needs to be given to of families and communities that are the and the navigation the endless possibilimost vulnerable? of systems. Once ties of the faith comthese factors begin munity in San What could and might happen to San Antonio? to combine, health Antonio as one of its disparities become largest natural reclearer and more evsources.

Public Who might we be? ident on a collective health. Mental health. scale. Faith leaders Children. Foster care. and nonprofit leadLiteracy. Immigrants ers and healthcare leaders begin to come together for solutions, to and refugees. Environmental sustainability. It is an endless list of organize in giving greater voice to policy development. possibilities to be harnessed around people coming together and Early in 2018, a pilot project began in southeast San Antonio around a shared ethic of reciprocity. to address the needs of hunger and those without permanent shelter in their lives. Mapping occurred from the combined data The Rev. Ann E. Helmke is the Community Faith-Based Liaison for the of the city, faith institutions and nonprofits. Assessments revealed Department of Human Services, City of San Antonio. visit us at www.bcms.org

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FEATURE

in Arms

By Samantha Gomez Ngamsuntikul, MD

The South Texas Blood & Tissue Center, working in conjunction with regional medical helicopter providers and the Southwest Texas Regional Advisory Council, has launched a new program for emergency transfusions called “Brothers in Arms.”

The program, which has the potential to dramatically change trauma care in this country, began earlier this year. It provides specially tested whole blood for transfusion use in 18 medical helicopters, as research has shown whole-blood transfusions are better than pRBC or component therapy at countering blood loss, dramatically improving survival rates.

San Antonio is one of the first cities to implement the system, which is based on a battlefield program developed by the U.S. military and later adapted at the Mayo Clinic trauma center. The 75th Ranger Regiment “O Low-Titer Whole Blood Program” was the recipient of the Army’s Greatest Innovation Award in 2017.

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San Antonio Medicine • July 2018

by the San Antonio Medical Foundation.

“Implementing this program for civilian use will truly transform how emergency care can be administered on medical helicopters and significantly improve survival rates for trauma victims.” said Elizabeth Waltman, COO of the South Texas Blood & Tissue Center, which is a subsidiary of San Antonio nonprofit BioBridge Global.

“This is also the first step toward a longer-term solution for saving more lives in mass-casualty situations, especially if we are able to expand the program in the future to include emergency care provided by ambulance services.”

Blood donations for Brothers in Arms come from a group of male O-positive blood donors who have low titer levels of anti-A and anti-B antibodies (IgM). The cutoff level is a ration of less than 1:256; approximately 15 percent of male O-positive donors are considered low-titer under those criteria. Donors in the program are tested annually.

As of April 17, STBTC has 179 donors enrolled in the program, with more added

every week. A total of 136 units have been collected from that group.

Using blood from O-positive donors, the most common type in the United States, can help reduce ongoing strains on the O-negative inventory.

Kept in proper conditions, the whole blood also preserves platelets and their functionality beyond the current 5-day shelf life – up to 35 days under proper conditions.

South Texas Blood & Tissue Center’s sister blood-testing organization, QualTex Laboratories, worked with the military to develop the testing protocol to identify Opositive donors with low antibody levels, making it possible to use O-positive blood for these trauma victims.

The program is targeting male O-positive donors because men tend to have lower levels of certain types of antibodies in their blood than women, reducing the possibility of transfusion related acute lung injury (TRALI) among patients.

STBTC is developing a committed pool of male O-positive donors for the

FEATURE

Brothers in Arms program to ensure a regular supply. The goal is to expand the program to provide whole blood to area emergency vehicles and trauma centers throughout the region.

Blood for the program does not undergo any modification at STBTC. Brothers in Arms represents a collaboration among the South Texas Blood & Tissue Center, the Southwest Texas Regional Advisory Council, University Health System, the San Antonio Military Medical Center, The U.S. Army Institute of Surgical Research, the UT Health Science Center and medical helicopter services Air Evac Lifeteam, PHI Inc. and San Antonio AirLIFE. Research led by Dr. Donald Jenkins, a former U.S. Air Force officer and the principal architect of the Joint Trauma Theater Trauma System in Iraq and Afghanistan, showed that combining the practice of pre-hospital transfusions with specially tested units of whole blood – rather than transfusing individual blood components of red cells, plasma or platelets – is most

effective in treating trauma victims suffering from significant blood loss.

“The general mortality rate for critically injured patients requiring massive transfusions at hospital trauma centers is 75 percent,” said Jenkins. “Our battlefield experience showed that providing earlier, pre-hospital transfusions of whole blood, rather than blood components or primarily red blood cells, brought mortality rates down as low as 20 percent.”

Jenkins later began to transfer the program to civilian use as trauma medical director at the Mayo Clinic. He is now a surgical critical care specialist affiliated with University Hospital in San Antonio, and the Betty and Bob Kelso Distinguished Chair in Burn and Trauma Surgery at UT Health San Antonio.

The idea of using type O whole blood in emergencies dates to battlefield use in World War I, and during the latter stages of World War II, the concept of using only low-titer type O blood for emergency use was introduced. The system remained in place through the Korean and

Vietnam wars.

It was discontinued when the process of separating red cells from platelets and plasma became common during the 1970s.

Blood for emergency use is stored at the helicopters’ base station in a monitored refrigerator. The units are moved to a transport container when the helicopters receive a call.

The South Texas Blood & Tissue Center is a nonprofit community blood center that provides blood, plasma, platelets and other blood components to more than 70 hospitals in more than 40 counties in South Texas. It is the largest blood supplier in our region.

STBTC has seven donor rooms in South Texas and conducts thousands of mobile blood drives each year. More information about the center and the Brothers in Arms program is available at SouthTexasBlood.org.

Dr. Samantha Gomez Ngamsuntikul is Associate Medical Director for BioBridge Global in San Antonio. visit us at www.bcms.org

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FEATURE

More complicated than you think

By Fred H. Olin, M.D. One day this spring my wife and I attended an event that included box lunches for participants. The marching band I play in did a short parade and a concert for “Spring Fest” at the University Health System’s Clinic on 36th Street near Highway 90. We’ve done it for several years, and it’s always fun. There are games and rides for kids and various “mascots” from the theme parks, HE-B, etc., that show up. There are educational materials about health care for the adults, some other music than ours, and everyone seems to have a good time.

Anyway, we got the aforementioned box lunches when we were done, and my wife and I decided to take ours home and eat them there. When the boxes had been emptied of the sandwich, chips, fruit cup, cookie, plastic wear and little foil packets of condiments I got to looking at mine and realized it was really pretty complicated for a “simple” box. Since we had two of them, I carefully pulled mine apart and spread it out. The pictures with this note show the box closed, then opened up and then the spread out as dismantled cardboard. I can just imagine a committee consisting of a designer, an engineer, a machinery company’s rep, a printer and the box-maker all working together to produce this little gem.

It’s an intricate piece of work that has to be cut just so (with minimum waste), printed, folded, glued, stacked and packed for delivery to the ultimate user. It makes corrugated board boxes, simple rectangles, look primitive by contrast.

This little adventure has caused me to pull apart a few more unusually-shaped boxes that have come our way. For example, if you get the 13-bagel deal at Einstein Bagels on Mondays, they come in a box that is a truncated pyramid with integral carrying handles. It too is a clever bit of design and production.

So, I challenge you to take another look at the stuff of life that we all take for granted: I’m continually amazed at the ingenuity that surrounds us.

Fred H. Olin, M.D. is a semi-retired orthopaedic surgeon who tries to understand what’s going on around him, and occasionally succeeds.

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San Antonio Medicine • July 2018

BCMS NEWS

BCMS Scholarship Ceremony The Bexar County Medical Society, through its 501c3 Philanthropic organization the Bexar County Medical Library Association, gave $2,500 scholarships to six students planning to study some field of medicine.

The recipients include (L-R) Jacky Zhu, Emily Spiekerman, Viviana Quezada, Abigail Munteanu and Sophia Zabul. Presenting doctors and sponsors included (L-R) Gerardo Ortega, MD, Sheldon Gross, MD, Michael Clark, Robyn Phillips-Madson, DO, Troy Halprin, MD, John Hinchey, MD, Adam Ratner, MD, Eric Lawitz, MD, Richard Jones, MD, and Ronald Rodriguez, MD. The scholarships were presented on May 29 during a ceremony downtown at the Fogo de Chao Brazilian Steakhouse.

The Passing of Esteemed Physician Colleagues or Their Spouses

The Bexar County Medical Society would like to show proper respect whenever a member physician or their spouse passes away. Please advise the Society whenever you learn of a member who has died so that BCMS may notify other members of the Society and send flowers and condolences from the Society as appropriate. If you have information about funeral services or about the wishes of the departed one, please send us that information as well.

Contacts:

Melody Newsom at 210-301-4363; email Melody.Newsom@bcms.org.

Steve Fitzer at 210-301-4383; email Steve.Fitzer@bcms.org.

Thank you, Bexar County Medical Society

visit us at www.bcms.org

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REVIEW

Are You or Your Patients Caring for Someone with Dementia?

Welcome Stranger:

Alzheimer’s Caregivers Guide

By Mr. Sherman P. Macdaniel A brief review by Dr. Adam Ratner

More of us are caring for loved ones with dementia. The burdens on caregivers are enormous and most of us are unprepared, ignorant and consequently stressed, frustrated and not optimally effective in dealing with our loved ones with dementia. According to a Stanford University study, 40 percent of family caregivers of Alzheimer’s patients die from stress-related disorders before the person in their care dies.

Mr. Sherman Macdaniel, the grandson of 1917 BCMS president, Alfred McDaniel, MD, wrote this brief guide to begin to address the challenges of being an Alzheimer’s caregiver. He states that the purpose of the manual is to help Alzheimer’s caregivers reduce stress and anxiety. He does this by relating his personal challenges and experiences of taking care of his late wife and provides very practical yet compassionate and spiritual suggestions for caregivers in similar circumstances. He also draws on the wisdom and experiences of knowledgeable friends to create this brief guide.

You and your patients can also read or download a free copy of the book by going to The Patient Institute website (http://www.patientinstitute.org/alzheimers-caregiversguide/) Physical copies of Welcome Stranger may be obtained by contacting the author: Mr. Sherman P. Macdaniel PO Box 429 Fayetteville, TX 78940 Adam V. Ratner, MD, FACR, President-elect, BCMS; Chairman, The Patient Institute; Professor of Radiology, Health Policy and Medical Humanities, University of the Incarnate Word, School of Osteopathic Medicine

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San Antonio Medicine • July 2018

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Please support our sponsors with your patronage; our sponsors support us.

ACCOUNTING FIRMS Sol Schwartz & Associates P.C. (HH Silver Sponsor) We specialize in areas that are most critical to a company’s fiscal well-being in today’s competitive markets.

Jim Rice, CPA 210-384-8000, ext. 112 jprice@ssacpa.com www.ssacpa.com “Dedicated to working with physicians and physician groups.”

ACCOUNTING SOFTWARE

Express Information Systems (HHH Gold Sponsor) With over 29 years’ experience, we understand that real-time visibility into your financial data is critical. Our browser-based healthcare accounting solutions provide accurate, multi-dimensional reporting that helps you accommodate further growth and drive your practice forward.

Rana Camargo Senior Account Manager 210-771-7903 ranac@expressinfo.com www.expressinfo.com “Leaders in Healthcare Software & Consulting”

ASSET MANAGEMENT

Avid Wealth Partners (HHH Gold Sponsor) The only financial firm that works like physicians, for physicians, to bring clarity and confidence in an age of clutter and chaos. You deserve to be understood and well-served by a team that's committed to helping you avidly pursue the future you want, and that's our difference.

Eric Kala CFP®, CIMA®, AEP®, CLU®, CRPS® Founder & Wealth Management Advisor 210.446.5752 eric.kala@nm.com avidwealthpartners.com “Plan it. Do it. Avid Wealth”

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San Antonio Medicine • July 2018

The Mani Johnston Group at UBS (HHH Gold Sponsor) Advice Beyond Investing, Dedicated Client Service Team, 4 decades serving the Bexar County medical community. Specialization in customized asset management and lending services supported by the strength of the UBS Global Bank.

Senior Vice President – Wealth Management Senior Portfolio Manager Carol Mani Johnston 210-805-1075 Carol.manijohnston@ubs.com www.ubs.com/team/manijohnston "UBS is honored to be named Best Bank for Wealth Management in North America for 2017 by Euromoney."

ATTORNEYS

Constangy, Brooks, Smith & Prophete (HHH Gold Sponsor) Constangy, Brooks, Smith & Prophete offers a wider lens on workplace law. With 190+ attorneys across 15 states, Constangy is one of the nation’s largest Labor and Employment practices and is nationally recognized for diversity and legal excellence.

Mark R. Flora Partner and Office Head 512-382-8800 mflora@constangy.com William E. Hammel Partner 214-646-8625 whammel@constangy.com John E. Duke Senior Counsel 512-382-8800 jduke@constangy.com www.constangy.com “A wider lens on workplace law.”

Kreager Mitchell (HHH Gold Sponsor) At Kreager Mitchell, our healthcare practice works with physicians to offer the best representation possible in providing industry specific solutions. From business transactions to physician contracts, our team can help you in making the right decision for your practice.

Michael L. Kreager 210-283-6227 mkreager@kreagermitchell.com Bruce M. Mitchell 210-283-6228 bmitchell@kreagermitchell.com www.kreagermitchell.com “Client-centered legal counsel with integrity and inspired solutions”

Norton Rose Fulbright (HHH Gold Sponsor) Norton Rose Fulbright is a global law firm. We provide the world’s preeminent corporations and financial institutions with a full business law service. We deliver over 150 lawyers in the US focused on the life sciences and healthcare sector.

Mario Barrera Employment & Labor 210 270 7125 mario.barrera@nortonrosefulbright.com Charles Deacon Life Sciences and Healthcare 210 270 7133 charlie.deacon@nortonrosefulbright.com Katherine Tapley Real Estate 210 270 7191 katherine.tapley@nortonrosefulbright.com www.nortonrosefulbright.com “In 2016, we received a Tier 1 national ranking for healthcare law according to US News & World Report and Best Lawyers”

ASSETS ADVISORS/ PRIVATE BANKING

U.S. Trust ( Gold Sponsor) At U.S. Trust, we have a long and rich history of helping clients achieve their own unique objectives. Since 1853, we've been committed to listening, building long-term relationships, and helping individuals and their families realize the opportunities they create for themselves, their children, businesses, communities and future generations.

SVP, Private Client Advisor, Certified Wealth Strategist® Christian R. Escamilla 210.865.0287 christian.escamilla@ustrust.com “Life’s better when we’re connected®”

BANKING

Amegy Bank of Texas (HHH Gold Sponsor) We believe that any great relationship starts with five core values: Attention, Accountability, Appreciation, Adaptability and Attainability. We work hard and together with our clients to accomplish great things.

Jeanne Bennett 210- 343-4556 jeanne.bennett@amegybank.com Karen Leckie 210-343-4558 karen.leckie@amegybank.com www.amegybank.com “Community banking partnership”

BB&T (HHH Gold Sponsor) Checking, savings, investments, insurance — BB&T offers banking services to help you reach your financial goals and plan for a sound financial future.

Stephanie Dick, Vice PresidentCommercial Banking 210-247-2979 sdick@bbandt.com Ben Pressentin 210-762-3175 bpressentin@bbandt.com www.bbt.com

BBVA Compass (HHH Gold Sponsor) Our healthcare financial team provides customized solutions for you, your business and employees.

Mary Mahlie Global Wealth Management 210-370-6029 mary.mahlie@bbvacompass.com www.bbvacompass.com “Working for a better future”

Broadway Bank (HHH Gold Sponsor) Healthcare banking experts with a private banking team committed to supporting the medical community.

Ken Herring 210-283-4026 kherring@broadwaybank.com www.broadwaybank.com “We’re here for good.”

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Ozona Bank (HHH Gold Sponsor) Ozona National Bank is a full-service commercial bank specializing in commercial real estate, construction (owner and non-owner occupied), business lines of credit and equipment loans.

Sam Fisher Vice President/Commercial Lender 210-319-3503 samf@ozonabank.com www.ozonabank.com

The Bank of San Antonio (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians.

Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community.

Brandi Vitier, 210-807-5581 brandi.vitier@ thebankofsa.com www.thebankofsa.com

RBFCU (HHH Gold Sponsor) RBFCU provides special financing options for Physicians, including loans for commercial and residential real estate, construction, vehicle, equipment and more.

Novie Allen Business Solutions 210-650-1738 nallen@rbfcu.org www.rbfcu.org

Synergy Federal Credit Union (HHH Gold Sponsor) BCMS members are eligible to join Synergy FCU, a full service financial institution. With high savings rates and low loans rates, Synergy can help you meet your financial goals.

Synergy FCU Member Service (210) 345-2222 or info@synergyfcu.org www.synergyfcu.org “Once a member, always a member. Join today!”

BUSINESS CONSULTING Alto Vista Enterprises, LLC (HH Silver Sponsor) We specialize in helping physicians grow their business according to the goals and timeline of the practice. Customized business development strategies are

executed by an experienced and dedicated team of consultants.

Michal Waechter, Owner (210) 913-4871 MichalWaechter@gmail.com “YOUR goals, YOUR timeline, YOUR success. Let’s grow your practice together”

EMPLOYEE MANAGEMENT

Beyond (HHH Gold Sponsor) Beyond helps you take care of your people with a single-source, cloud-based human resources system that is simple yet powerful enough to manage the entire employee life cycle. From online onboarding to certification tracking to payroll processing, manage your people anytime, anywhere.

Founding Member Division Sales Director San Antonio and Austin Jeromé Vidlock 972.839.2423 jerome.vidlock@getbeyond.com www.getbeyond.com "Beginning relationships honorably with a clear understanding of what you can expect from us"

FINANCIAL ADVISOR

Elizabeth Olney with Edward Jones ( Gold Sponsor) We learn your individual needs so we can develop a strategy to help you achieve your financial goals.

Join the nearly 7 million investors who know. Contact me to develop an investment strategy that makes sense for you.

Elizabeth Olney, Financial Advisor (210) 493-0753 Elizabeth.olney@edwardjones.com www.edwardjones.com/elizabetholney "Making Sense of Investing"

FINANCIAL SERVICES

( 10K Platinum Sponsor) SWBC SWBC helps physicians keep order in both their personal and business financial matters. For individuals, we stand ready to assist with wealth management and homebuying services. For your practice, we can help with HR ad-

ministrative tasks, from payroll services to securing employee benefits and P&C Insurance.

Cleo Garza SWBC Mortgage 210-386-0732 cgarza@swbc.com Leslie Barnett SWBC Mortgage lbarnett@swbc.com Gil Castillo SWBC Wealth Management 210-321-7258 gcastillo@swbc.com Kristine Edge SWBC PEO – Professional Employer Organization 830-980-1207 kedge@swbc.com Debbie Marino SWBC Insurance & Benefits 210-525-1241 dmarino@swbc.com www.swbc.com SWBC family of services supporting Physicians and the Medical Society

Avid Wealth Partners ( Gold Sponsor) The only financial firm that works like physicians, for physicians, to bring clarity and confidence in an age of clutter and chaos. You deserve to be understood and wellserved by a team that's ommitted to helping you avidly pursue the future you want, and that's our difference.

Eric Kala CFP, CIMA, AEP, CLU, CRPS Founder & Wealth Management Advisor 210.446.5752 eric.kala@nm.com avidwealthpartners.com “Plan it. Do it. Avid Wealth”

Aspect Wealth Management (HHH Gold Sponsor) We believe wealth is more than money, which is why we improve and simplify the lives of our clients, granting them greater satisfaction, confidence and freedom to achieve more in life.

Jeffrey Allison 210-268-1530 jallison@aspectwealth.com www.aspectwealth.com “Get what you deserve … maximize your Social Security benefit!”

Beyond ( Gold Sponsor) Beyond is a financial technology

company offering a suite of business tools including payment processing, employee management (payroll, HR, compliance), lending, and point-of-sale. Beyond demonstrates business ethos with unwavering commitment and delivers results that make a difference.

Founding Member Division Sales Director San Antonio and Austin Jeromé Vidlock 972.839.2423 jerome.vidlock@getbeyond.com www.getbeyond.com "Good enough is not nearly enough. We go Beyond!"

Elizabeth Olney with Edward Jones ( Gold Sponsor) We learn your individual needs so we can develop a strategy to help you achieve your financial goals.

Join the nearly 7 million investors who know. Contact me to develop an investment strategy that makes sense for you.

Elizabeth Olney Financial Advisor (210) 493-0753 Elizabeth.olney@edwardjones.com www.edwardjones.com/elizabeth-olney "Making Sense of Investing"

RBFCU (HHH Gold Sponsor) RBFCU Investments Group provides guidance and assistance to help you plan for the future and ensure your finances are ready for each stage of life, (college planning, general investing, retirement or estate planning).

Shelly H. Rolf Wealth Management 210-650-1759 srolf@rbfcu.org www.rbfcu.org

The Mani Johnston Group at UBS (HHH Gold Sponsor) Advice Beyond Investing, Dedicated Client Service Team, 4 decades serving the Bexar County medical community. Specialization in customized asset management and lending services supported by the strength of the UBS Global Bank.

continued on page 38

visit us at www.bcms.org

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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 37

Carol Mani Johnston Senior Vice President – Wealth Management Senior Portfolio Manager 210-805-1075 Carol.manijohnston@ubs.com www.ubs.com/team/manijohnston "UBS is honored to be named Best Bank for Wealth Management in North America for 2017 by Euromoney."

GRADUATE PROGRAMS Trinity University (HH Silver Sponsor) The Executive Master’s Program in Healthcare Administration is ranked in the Top 10 programs nationally. A parttime, hybrid-learning program designed for physicians and healthcare managers to pursue a graduate degree while continuing to work full-time.

Amer Kaissi, Ph.D. Professor and Executive Program Director 210-999-8132 amer.kaissi@trinity.edu https://new.trinity.edu/academics/departments/health-careadministration

HEALTHCARE TECHNOLOGY RubiconMD (HH Silver Sponsor) RubiconMD enables primary care providers to quickly and easily discuss their e-Consults with top specialists so they can provide better care - improving the patient experience and reducing costs Shang Wang Business Development (845) 709-2719 shang@rubiconmd.com Cyprian Kibuka VP of Business Development (650) 454-9604 cyprian@rubiconmd.com www.rubiconmd.com “Expert Insights. Better Care."

HOSPITALS/ HEALTHCARE SERVICES

Warm Springs Medical Center Thousand Oaks Westover Hills (HHH Gold Sponsor) Our mission is to serve people with disabilities by providing compassionate, expert care during the rehabilitation process, and support recovery through education and research.

Central referral line

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San Antonio Medicine • July 2018

210-592-5350 “Joint Commission COE.” Methodist Healthcare System (HH Silver Sponsor) Palmire Arellano 210-575-0172 palmira.arellano@mhshealth.com http://sahealth.com Select Rehabilitation of San Antonio (HH Silver Sponsor) We provide specialized rehabilitation programs and services for individuals with medical, physical and functional challenges.

Miranda Peck 210-482-3000 mipeck@selectmedical.com http://sanantonio-rehab.com “The highest degree of excellence in medical rehabilitation.”

INSURANCE

TMA Insurance Trust (HHHH 10K Platinum Sponsor) Created and endorsed by the Texas Medical Association (TMA), the TMA Insurance Trust helps physicians, their families and their employees get the insurance coverage they need.

Wendell England 512-370-1746 wengland@tmait.org James Prescott 512-370-1776 jprescott@tmait.org John Isgitt 512-370-1776 www.tmait.org “We offer BCMS members a free insurance portfolio review.”

INFORMATION AND TECHNOLOGIES

Express Information Systems (HHH Gold Sponsor) With over 29 years’ experience, we understand that real-time visibility into your financial data is critical. Our browser-based healthcare accounting solutions provide accurate, multi-dimensional reporting that helps you accommodate further growth and drive your practice forward.

Rana Camargo Senior Account Manager 210-771-7903 ranac@expressinfo.com www.expressinfo.com “Leaders in Healthcare Software & Consulting”

Network Alliance (HHH Gold Sponsor) We are experts in managed IT services, business phone systems, network security, cloud services and telecom carrier offerings, located in the heart of the medical center at Fredericksburg & Medical Dr. Rod Tanner (210) 870-1951 rtanner@network-alliance.net Carl Lyles (210) 870-1952 clyles@network-alliance.net www.network-alliance.net “Delivering solutions through technology”

Humana (HHH Gold Sponsor) Humana is a leading health and well-being company focused on making it easy for people to achieve their best health with clinical excellence through coordinated care.

Jon Buss: 512-338-6167 Jbuss1@humana.com Shamayne Kotfas: 512-338-6103 skotfas@humana.com www.humana.com

INSURANCE/MEDICAL MALPRACTICE

The Bank of San Antonio Insurance Group, Inc. (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians.

Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community.

Katy Brooks, CIC 210-807-5593 katy.brooks@bosainsurance.com www.thebankofsa.com “Serving the medical community.”

MedPro Group (HH Silver Sponsor) Medical Protective is the nation's oldest and only AAA-rated provider of healthcare malpractice insurance.

Kirsten Baze 512-375-3972 Kirsten.Baze@medpro.com www.medpro.com ProAssurance (HH Silver Sponsor) Group (rated A+ (Superior) by A.M. Best) helps you protect your important identity and navigate today’s medical environment with greater ease—that’s only fair.

Keith Askew, Market Manager kaskew@proassurance.com Mark Keeney, Director, Sales mkeeney@proassurance.com 800.282.6242 www.proassurance.com

INTERNET TELECOMMUNICATIONS Texas Medical Liability Trust (HHHH 10K Platinum Sponsor) Texas Medical Liability Trust is a not-for-profit health care liability claim trust providing malpractice insurance products to the physicians of Texas. Currently, we protect more than 18,000 physicians in all specialties who practice in all areas of the state. TMLT is a recommended partner of the Bexar County Medical Society and is endorsed by the Texas Medical Association, the Texas Academy of Family Physicians, and the Dallas, Harris, Tarrant and Travis county medical societies.

Patty Spann 512-425-5932 patty-spann@tmlt.org www.tmlt.org Recommended partner of the Bexar County Medical Society

Network Alliance (HHH Gold Sponsor) We are experts in managed IT services, business phone systems, network security, cloud services and telecom carrier offerings, located in the heart of the medical center at Fredericksburg & Medical Dr. Rod Tanner (210) 870-1951 rtanner@network-alliance.net Carl Lyles (210) 870-1952 clyles@network-alliance.net www.network-alliance.net “Delivering solutions through technology”

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY LUXURY REAL ESTATE

Kuper Sotheby’s International Realty (HHH Gold Sponsor) As real estate associates with Kuper Sotheby’s International Realty, we pride ourselves in providing exceptional customer service, industry-leading marketing, and expertise from beginning to end, while establishing long-lasting relationships with our valued clients.

Nathan Dumas Real Estate Advisor, REALTOR 210-667-6499 nathan@kupersir.com www.nathandumas.com Mark Koehl, Real Estate Advisor, REALTOR (210) 683-9545 mark.koehl@kupersir.com www.markkoehl.com "Realtors with experience in healthcare and Physician relations"

MEDICAL BUSINESS CONSULTING

Progressive Billing (HHH Gold Sponsor) The medical billing professionals at Progressive Billing realize the importance of conducting business with integrity, honesty, and compassion while remaining in compliance with the laws and regulations that govern our operations.

Lettie Cantu - Owner 210-363-1735 Lettie@progressivebilling.com Richard Hernandez - Administrator 210-733-1802 richard@progressivebilling.com www.progressivebilling.com "We provide quality, professionalism and results for your practice."

MEDICAL BILLING AND COLLECTIONS SERVICES

Progressive Billing (HHH Gold Sponsor) The medical billing professionals at Progressive Billing realize the importance of conducting business with integrity, honesty, and compassion while remaining in compliance with the laws and regulations that govern our operations.

Lettie Cantu - Owner

210-363-1735 Lettie@progressivebilling.com Richard Hernandez - Administrator 210-733-1802 richard@progressivebilling.com www.progressivebilling.com "We provide quality, professionalism and results for your practice."

Commercial & Medical Credit Services (HH Silver Sponsor) A bonded and fully insured San Antonio-based collection agency.

Henry Miranda 210-340-9515 hcmiranda@sbcglobal.net www.cmcs-sa.com “Make us the solution for your account receivables.”

MEDICAL SUPPLIES AND EQUIPMENT

Henry Schein Medical (HHH Gold Sponsor) From alcohol pads and bandages to EKGs and ultrasounds, we are the largest worldwide distributor of medical supplies, equipment, vaccines and pharmaceuticals serving office-based practitioners in 20 countries. Recognized as one of the world’s most ethical companies by Ethisphere.

Tom Rosol 210-413-8079 tom.rosol@henryschein.com www.henryschein.com “BCMS members receive GPO discounts of 15 percent to 50 percent.”

PHYSICIAN SERVICES

( 10K Platinum Sponsor) SWBC SWBC helps physicians keep order in both their personal and business financial matters. For individuals, we stand ready to assist with wealth management and homebuying services. For your practice, we can help with HR administrative tasks, from payroll services to securing employee benefits and P&C Insurance.

Cleo Garza SWBC Mortgage 210-386-0732 Cleogarza@swbc.com Leslie Barnett SWBC Mortgage lbarnett@swbc.com Gil Castillo SWBC Wealth Management 210-321-7258

gcastillo@swbc.com Kristine Edge SWBC PEO – Professional Employer Organization 830-980-1207 kedge@swbc.com Debbie Marino SWBC Insurance & Benefits 210-525-1241 dmarino@swbc.com www.swbc.com SWBC family of services supporting Physicians and the Medical Society

PRIVATE EQUITY

Rastegar Equity Partners (HHHH 10K Platinum Sponsor) Rastegar Equity Partners is a Private Equity Commercial Real Estate Investment Firm. Rastegar focuses on building portfolios to generate above market current income along with long-term capital appreciation.

Kellie Rastegar 818-800-4901 kellie@rastegarep.com Ari Rastegar 917-703-5027 ari@rastegarep.com Sandy Fliderman 646-854-9996 sandy@rastegarep.com www.rastegarep.com

PROFESSIONAL ORGANIZATIONS The Health Cell (HH Silver Sponsor) “Our Focus is People” Our mission is to support the people who propel the healthcare and bioscience industry in San Antonio.

Industry, academia, military, nonprofit, R&D, healthcare delivery, professional services and more!

President, Kevin Barber 210-308-7907 (Direct) kbarber@bdo.com Valerie Rogler, Program Coordinator 210-904-5404 Valerie@thehealthcell.org www.thehealthcell.org “Where San Antonio’s Healthcare Leaders Meet” San Antonio Group Managers (SAMGMA) (HH Silver Sponsor) SAMGMA is a professional nonprofit association with a mission to provide educational programs and networking opportunities to medical practice managers and support charitable fundraising.

Tina Turnipseed President Tom Tidwell President-Elect info4@samgma.org www.samgma.org

REAL ESTATE SERVICES COMMERCIAL

Rastegar Equity Partners (HHHH 10K Platinum Sponsor) Rastegar Equity Partners is a Private Equity Commercial Real Estate Investment Firm. Rastegar focuses on building portfolios to generate above market current income along with long-term capital appreciation.

Kellie Rastegar 818-800-4901 kellie@rastegarep.com Ari Rastegar 917-703-5027 ari@rastegarep.com Sandy Fliderman 646-854-9996 sandy@rastegarep.com www.rastegarep.com

RESIDENTIAL REAL ESTATE

Kuper Sotheby’s International Realty (HHH Gold Sponsor) As real estate associates with Kuper Sotheby’s International Realty, we pride ourselves in providing exceptional customer service, industry-leading marketing, and expertise from beginning to end, while establishing long-lasting relationships with our valued clients.

Nathan Dumas Real Estate Advisor, REALTOR 210-667-6499 nathan@kupersir.com www.nathandumas.com Mark Koehl, Real Estate Advisor, REALTOR (210) 683-9545 mark.koehl@kupersir.com www.markkoehl.com "Realtors with experience in healthcare and Physician relations"

continued on page 40

www.bcms.org 39 39 visitvisit us us at at www.bcms.org

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 39

SENIOR LIVIING Legacy at Forest Ridge (HH Silver Sponsor) Legacy at Forest Ridge provides residents with top-tier care while maintaining their privacy and independence, in a luxurious resortquality environment.

Shane Brown, Executive Director 210-305-5713 hello@legacyatforestridge.com www.LegacyAtForestRidge.com “Assisted living like you’ve never seen before.”

curate and timely results for UDT quantitation and identification.

Jana Raschbaum, MBA, BSN, RN 210-478-6633 janelleraschbaum@gmail.com Donald Nelson, MD 928-529-5110 dhnelson@citilink.net www.trustedtox.com For questions regarding services, Circle of Friends sponsors or Joining our program.

Please contact August Trevino program director: Phone: 210-301-4366, email August.Trevino@bcms.org, www.bcms.org/COf.html

STAFFING SERVICES

Favorite Healthcare Staffing (HHHH 10K Platinum Sponsor) Serving the Texas healthcare community since 1981, Favorite Healthcare Staffing is proud to be the exclusive provider of staffing services for the BCMS. In addition to traditional staffing solutions, Favorite offers a comprehensive range of staffing services to help members improve cost control, increase efficiency and protect their revenue cycle.

Brody Whitley, Branch Director 210-301-4362 bwhitley@favoritestaffing.com www.favoritestaffing.com “Favorite Healthcare Staffing offers preferred pricing for BCMS members.”

United States Air Force (HH Silver Sponsor) As a doctor in the USAF you can practice medicine without the red tape of managing your own practice. Our doctors are free from bureaucracy and paperwork and can focus on treating their patients MSgt Robert Isarraraz, Physician Recruiter Robert.isarraraz@us.af.mil 210-727-5677 www.airforce.com/careers/ "Caring For Those Protecting The Nation"

TOXICOLOGY LABORATORY TESTING

Diagnostic Solutions, LLC (HHH Gold Sponsor) Partnering with Diagnostic Solutions allows providers to incorporate the industry’s best practices into drug compliance testing and clinical decision-making with ac-

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San Antonio Medicine • July 2018

THE BEXAR COUNTY MEDICAL SOCIETY CIRCLE OF FRIENDS PROGRAM Grow your business by supporting our Physicians and the Medical Community.

The Circle of Friends (COF) is a program design for companies and organization like yours that would like to reach out to our 5000+ membership and our medical community with your products and services.

Through our program, we have helped many businesses grow in our medical community.

In addition, your charitable donations made as sponsors in the Circle of Friends program help fund programs and events that are important to our Community's health and the physicians that serve it.

To join or for more information please contact: The director of development August Charles Trevino 210-301-4366

THANK YOU

to the large group practices with 100% MEMBERSHIP in BCMS and TMA ABCD Pediatrics, PA Clinical Pathology Associates Dermatology Associates of San Antonio, PA Diabetes & Glandular Disease Clinic, PA ENT Clinics of San Antonio, PA Gastroenterology Consultants of San Antonio General Surgical Associates Greater San Antonio Emergency Physicians, PA Institute for Women's Health Lone Star OB-GYN Associates, PA M & S Radiology Associates, PA MacGregor Medical Center San Antonio MEDNAX Peripheral Vascular Associates, PA

Renal Associates of San Antonio, PA San Antonio Eye Center, PA San Antonio Gastroenterology Associates, PA San Antonio Infectious Diseases Consultants San Antonio Kidney Disease Center San Antonio Pediatric Surgery Associates, PA Sound Physicians South Alamo Medical Group South Texas Radiology Group, PA Tejas Anesthesia, PA The San Antonio Orthopaedic Group Urology San Antonio, PA WellMed Medical Management Inc.

Contact BCMS today to join the 100% Membership Program! *100% member practice participation as of June 22, 2018.

visit www.bcms.org 41 41 visit usus atatwww.bcms.org

RECOMMENDED AUTO DEALERS AUTO PROGRAM

• • • •

We will locate the vehicle at the best price, right down to the color and equipment.

We will put you in touch with exactly the right person at the dealership to handle your transaction.

We will arrange for a test drive at your home or office. We make the buying process easy!

When you go to the dealership, speak only with the representative indicated by BCMS. GUNN AUTO GROUP

Ancira Chrysler 10807 IH 10 West San Antonio, TX 78230 Rudy Solis 210-558-1500

Ancira Buick, GMC San Antonio, TX Jude Fowler 210-681-4900

Ancira Chevrolet 6111 Bandera Road San Antonio, TX

Batchelor Cadillac 11001 IH 10 W at Huebner San Antonio, TX

GUNN Chevrolet GMC Buick 16550 IH 35 N Selma, TX 78154

Jude Fowler 210-681-4900

Esther Luna 210-690-0700

Bill Boyd 210-859-2719

GUNN AUTO GROUP

GUNN AUTO GROUP

GUNN AUTO GROUP

GUNN Honda 14610 IH 10 W San Antonio, TX

GUNN Acura 11911 IH 10 W San Antonio, TX

GUNN Nissan 750 NE Loop 410 San Antonio, TX 78209

Eric Schwartz 210-680-3371

Coby Allen 210-625-4988

Abe Novy 210-496-0806

Alamo City Chevrolet 9400 San Pedro Ave. San Antonio, TX 78216

Cavender Audi 15447 IH 10 W San Antonio, TX 78249

David Espinoza 210-912-5087

Rick Cavender 210-681-3399 KAHLIG AUTO GROUP

Cavender Toyota 5730 NW Loop 410 San Antonio, TX

Northside Ford 12300 San Pedro San Antonio, TX

Mercedes Benz of San Antonio 9600 San Pedro San Antonio, TX

Mercedes Benz of Boerne 31445 IH 10 W Boerne, TX

North Park Subaru 9807 San Pedro San Antonio, TX 78216

Gary Holdgraf 210-862-9769

Marty Martinez 210-525-9800

William Taylor 210-366-9600

James Godkin 830-981-6000

Mark Castello 210-308-0200

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

North Park Mazda 9333 San Pedro San Antonio, TX 78216

North Park Lexus 611 Lockhill Selma San Antonio, TX

North Park Lexus at Dominion 21531 IH 10 W San Antonio, TX

North Park Toyota 10703 SW Loop 410 San Antonio, TX 78211

Scott Brothers 210-253-3300

North Park Subaru at Dominion 21415 IH 10 W San Antonio, TX 78257

Tripp Bridges 210-308-8900

Justin Blake 888-341-2182

Stephen Markham 877-356-0476

Justin Boone 210-635-5000

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

North Park Lincoln 9207 San Pedro San Antonio, TX

North Park VW at Dominion 21315 IH 10 W San Antonio, TX 78257

13660 IH-10 West (@UTSA Blvd.)

San Antonio, TX

Porsche Center 9455 IH-10 West San Antonio, TX

Barrett Jaguar 15423 IH-10 West San Antonio, TX

Sandy Small 210-341-8841

James Cole 800-611-0176

Ed Noriega 210-561-4900

Matt Hokenson 210-764-6945

Victor Zapata 210-341-2800

15423 IH-10 West San Antonio, TX Dale Haines 210-341-2800

Land Rover of San Antonio

AUTO PROGRAM

Call Phil Hornbeak 210-301-4367 or email phil.hornbeak@bcms.org

visit us at www.bcms.org

43

AUTO REVIEW

2018 Infiniti Q50

By Stephen Schutz, MD

Infiniti, not generally known for powertrain leadership, recently introduced the most important new internal combustion engine in many years, the variable compression ratio KR20 2.0L four-cylinder engine, which debuted earlier this year in the QX50 crossover. It’s worth noting that, while all industry experts agree that the future of automotive propulsion belongs to electric motors, the internal combustion engine isn’t dead yet, and as long as advances like Infiniti’s new engine keep happening, it may have many years of life left.

Without nerding out too much, gasoline engines burn fuel more efficiently at high-compression ratios, but those elevated ratios endanger the engine when it’s being pushed, so engineers have to take numerous fuel-wasting steps, including actually injecting more fuel, to keep the combustion chamber from getting too hot under stress.

The KR20’s ability to use a high (14:1) compression ratio in light load situations and a low (8:1) one when you’re in a hurry allows for maximal efficiency under all conditions. Obviously, developing a variable compression engine is supremely difficult or it would have been done earlier, and I applaud Nissan/Infiniti for their achievement.

On to the subject of this month’s review, the Infiniti Q50, which ironically is not available with the KR20 engine. No matter, the Q50 is a nice car that I’m happy to write about, and one doesn’t need any

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San Antonio Medicine • July 2018

special powers of clairvoyance to predict that it won’t be long before that engine finds its way into most Infinitis, including the Q50.

Introduced in 2013, the Q50 is a mid-size luxury sedan that competes with the likes of the BMW 3-series, Audi A4, and Jaguar XE. The exterior design is best described as creased contemporary with a distinctive Japanese sensibility. And while the Q50 maintains an understated three-box sedan profile, it adds visual interest with many character lines on the sides and hood, a bold grille, and aggressively canted headlights.

Inside, the Q50 features standard Infiniti fare such as modern electronics with an ergonomic touch screen user interface augmented by many redundant knobs and buttons. No, the tech isn’t as good as the current automotive benchmark, Audi, but it’s as good as anything from Lexus or Cadillac.

Infiniti cabin materials have typically lagged behind the competition, and I was pleased to note that they have raised their game significantly in this area. Better surfaces and an attractive diamond stitching on the upholstery are welcome upgrades in the newest Q50s.

The 2018 Infiniti Q50 comes with three different engine options; a 208HP (Mercedes sourced) 2.0-liter turbo-four, a 300HP 3.0-liter,

AUTO REVIEW

twin-turbo V6, and a 302HP hybrid 3.5-liter V6 gas-electric powerplant. The Red Sport version of the Q50 gets a tuned version of the 3.0-liter twin-turbo V-6 good for 400HP. All Q50s come with a seven-speed automatic transmission.

Driving the Q50 is a bit of a mixed bag. The (non-Red Sport) twin-turbo V6 in my test car – the engine buyers choose most – provides lusty off-the-line acceleration (its 0-60MPH time is just 5.0 seconds). But a curb weight of over 4,100 lbs, relatively soft (but admittedly luxurious) suspension settings, and electric steering combine to make a spirited drive on a twisty back road more of a chore than an exhilarating experience. Perhaps the best summary of the Q50 road manners is: superb in town, especially in trafficlight duels, and also excellent on the open highway when you’ve got to eat up the miles and want to be comfortable. But less wonderful on challenging byways out in the country, where, darn it, we rarely ever venture anyway (I’m trying to post a sad faced Emoji here right now, BTW).

Infiniti is a leader in active safety technology, offering these features as either standard or optional equipment on the Q50: Active Lane Control, Intelligent Cruise Control, Distance Control Assist, Backup Collision Intervention, Blind Spot Warning and Intervention, Lane Departure Warning and Prevention, Forward Emergency

Braking, and Predictive Forward Collision Warning. We’re not in the age of autonomy yet, but we’re certainly getting closer.

In addition to the engine choices listed above, there are numerous option packages and stand-alone upgrades you can select if you decide to buy a Q50. As always, call BCMS’ Phil Hornbeak before you do anything else to ensure you get the right car at the right price.

Expect to pay in the low- to mid-$40,000 range for a popularly equipped Q50 with the twin-turbo V6.

The Infiniti Q50 is an excellent luxury sedan trying to compete in a tough market segment at a time when buyers are moving rapidly towards crossovers and away from sedans. How would I make it even more appealing to erstwhile crossover or BMW/Audi/Mercedes buyers? Give it a variable compression engine.

If you’re in the market for this kind of vehicle, call Phil Hornbeak at 210-301-4367.

Stephen Schutz, MD, is a board-certified gastroenterologist who lived in San Antonio in the 1990s when he was stationed here in the U.S. Air Force. He has been writing auto reviews for San Antonio Medicine since 1995. visit www.bcms.org 45 45 visit us us at at www.bcms.org

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San Antonio Medicine • July 2018