Lehigh County Health & Medicine winter 2022

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Official Publication of The Lehigh County Medical Society

Population Health


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LEHIGH COUNTY MEDICAL SOCIETY P.O. Box 8, East Texas, PA 18046 610-437-2288 | lcmedsoc.org

Oscar A. Morffi, MD Treasurer

Charles J. Scagliotti, MD, FACS Secretary William Tuffiash Immediate Past President *effective February 1, 2022 CENSORS

Howard E. Hudson, Jr., MD Edward F. Guarino, MD TRUSTEES

Wayne E. Dubov, MD Kenneth J. Toff, DO


David Griffiths Executive Officer The opinions expressed in this publication are for general information only and are not intended to provide specific legal, medical or other advice or recommendations for any individuals. The placement of editorial opinions and paid advertising does not imply endorsement by the Lehigh County Medical Society. All rights reserved. No portion of this publication may be reproduced electronically or in print without the expressed written consent of the publisher or editor.


to Improve Social Connection,

By Geoffrey G. Hallock, MD

By Mark Wendling, MD

Lehigh County Health & Medicine is published by Hoffmann Publishing Group, Inc. Sinking Spring, PA | HoffmannPublishing.com | (610) 685.0914


16 WINTER HAZARDS Beware Those Mechanized Shortcuts
LCMS NEWS 2022-23 LCMS BOARD OF DIRECTORS Rajender S. Totlani, MD President
SEE PAST ISSUES AT LH.HoffmannPublishing.com FOR ADVERTISING INFO CONTACT: Tracy Hoffmann, Tracy@hoffmannpublishing.com, 610.685.0914 x201 Sherry Bolinger, Sherry@hoffmannpublishing.com, 717.979.2858 5 IN THIS ISSUE FEATURES 6 NAMI LV CONTINUES TO EXPAND ITS OUTREACH
By Dennis Geiger, PHD
Inequities and Combat Ageism
ON THE COVER 12 POPULATION HEALTH Expanding the View and Value of Health Care
By Laura McHugh

Well, we are at the end of the year already, so we are closing out 2022 with our winter edition of Lehigh County Health and Medicine. We hope you had a good year, and we’re thrilled to provide this new service to you. As always, we look forward to your responses, ideas, and contributions.

In the Lehigh Valley we have a chapter of the National Alliance on Mental Illness (NAMI LV). They support the work of professionals to diagnose, treat and support persons with mental illness and are available to help them find the resources they need. Please read on to learn more about them.

We have all become very used to hearing about mRNA vaccines. But what do you actually know about the history of them? For instance, did you know that mRNA was first discovered in 1961? Read the article “mRNA Vaccines Have Saved Millions of Lives” to learn more.

Population Health is a term that has become increasingly used in our healthcare system. The article “Population Health: Expanding the View and Value of Health Care” can answer your questions on how Population Health can help you and your family, and the health of communities.

Working with lead is a known danger, yet industries employ upwards of half a million people in Pennsylvania, making workplace lead exposure surveillance a primary concern. Please read “Adult Pennsylvanians Working with Leaded Materials may be Occupationally Exposed to Lead” to learn more.

We hope you will enjoy this and past issues as we add to the conversation about how medicine and wellness can help us form strong communities in Lehigh County. If you enjoyed reading this edition, or just wanted to see previous editions of Lehigh County Health and Medicine online, please visit our website at https://lcmedsoc. org/our-publication.

Thank you for reading!



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NAMILVContinues to Expand ItsOutreach


As an affiliate of the nation’s largest grassroots organization dedicated to improving the lives of persons with mental illness, the National Alliance on Mental Illness of Lehigh Valley (NAMI LV) comprises a membership of persons living with a mental illness, family members, professionals and supportive community citizens. A Board of Directors provides governance, direction and oversight to the organization. The mission of NAMI LV is to advocate for non-discriminatory access to quality healthcare, housing, education and employment for people living with a mental illness, as well as to provide supportive services to all that are affected by mental illness.

NAMI LV maintains the position that mental illnesses are predominately brain-based medical disorders. As a result, persons experiencing a mental disorder are not to be blamed for the onset of their illness. However, even though individuals may not be responsible for having an illness, they are expected to be responsible for actively managing it by working with their medical providers, following treatment plans and adhering to a healthy life-style. NAMI LV is available to help persons with a mental illness find the resources they need to accomplish these objectives.

Through the work of volunteers, NAMI LV provides ongoing support groups for families and peers with mental health challenges, as well as programs that educate about mental illness to community groups, schools and hospital wellness classes. Family-to-Family and Peer-to-Peer are eight-week courses led by trained individuals and family members with lived experience that aids understanding of mental illness and recovery. NAMI LV also has a team of speakers who provide firsthand accounts of what it’s like to experience, manage and recover from a mental illness. All of NAMI LV’s services and programs are free of charge. Since the onset of COVID, volunteers have been especially challenged to present at community venues. In-person groups and classes have been impeded by social restrictions. Where possible, virtual media resources have been utilized. Despite these challenges, there are current plans to add NAMI’s wellness classes at the Easton campus of St. Luke’s Hospital to presentations already being offered at other St. Luke’s locations and at LVHN.

NAMI LV continues to support the work of professionals to diagnose, treat and support persons with mental illness. Over the past year, a member of NAMI LV, who is a licensed psychologist, has lead training sessions for providers of various supportive behavioral services by reviewing mental illness from the perspective of the DSM-5. Attendees are taught how mental illness is diagnosed using the DSM-5, and how it provides a common language for providers to share treatment information. Importantly, attendees are taught that a diagnosis does not define the identity of a person living with a disorder. In essence, a person is much more than a medical diagnosis.

NAMI LV also has provided support and consultation to Crisis Intervention Teams (CIT) training for law enforcement agencies in Northampton County. The enactment of the 988 crisis line is welcomed as a means of connecting persons experiencing a mental health episode with trained staff. It is hoped that this dedicated approach will result in a quicker and safer resolution of problems for all involved. NAMI LV also supports the Restorative Justice Movement which emphasizes “Help not Handcuffs.”

In the area of stigma reduction, several NAMI LV family members participated in a recent documentary: “Give Me Shelter: Suicide.” They told their own stories of experiencing the loss of a loved one by suicide, demonstrating that this is something any family might face, and offering hope for life after such a tragic loss. The program also outlines warning signs that someone may be struggling with depression or suicidal ideation and offered suggestions on how to help.

Lastly, NAMI LV has expanded its information outreach by making available national mental health new stories via its digital newsletter entitled “The Update.” This newsletter helps readers stay informed with current developments in the mental health field. To learn more about the services NAMI LV offers, or to sign up for the weekly “The Update” please visit our website, www.nami-lv.org, email info@nami-lv.org or call (610) 882-2102.

LCMEDSOC.ORG WINTER 2022 | Lehigh County Health & Medicine 7


Action Plan to Improve Social Connection, Overcome Inequities and Combat Ageism


8 Lehigh County Health & Medicine | WINTER 2022 FEATURE

In an effort to create age-friendly environments in the Lehigh Valley that acknowledge diversity, fight ageism and ensure that everyone has the opportunity to participate fully, United Way and Age-Friendly Lehigh Valley have launched an Action Plan in partnership with Lehigh County, Northampton County, AARP, Lehigh Valley Planning Commission and many community partners.

“Our environments play an important role in determining how we age and how we respond to disease, loss of function and other forms of adversity that we may experience at different stages of life, in particular in later years,” said Carmen Bell, Healthy Aging Director, United Way of the Greater Lehigh Valley (UWGLV). “The goal of this plan is to continue to build communities that treat all residents and visitors with respect, regardless of age, income or physical ability.”

As part of the plan’s creation, the Lehigh Valley became the nation’s first dual-county community to receive certification in the World Health Organization/AARP Network of Age-Friendly States and Communities.

“The Lehigh Valley has a history of success when we work together, and this effort is no exception. With a growing number of residents age 65 and older, we must work together to ensure the Lehigh Valley can best serve all our populations,” added Lehigh County Executive Phillips Armstrong.

Residents who are age 65 and older currently represent 15% of each county’s population, as compared to 13% nationally. Projections suggest that seniors will grow to 22% of the Lehigh Valley population by 2040.

“We offer our continued support and commitment as we launch this action plan. We applaud the leaders and stakeholders who have become champions in the field of aging and are proud to see a growing network of partners who recognize that age-friendly communities benefit everyone,” remarked Northampton County Executive Lamont McClure.

According to AARP, well-designed and age-friendly communities foster economic growth and make for happier, healthier residents of all ages.

“At AARP, we recognize that neighborhoods are where we care for our families, launch new businesses, and plan for the future,” said AARP Lehigh County Associate State Director for Outreach Kellie VonStein. “We are pleased to work in partnership with residents, community leaders and public officials to promote local

action so that our communities provide the space, services and opportunities that support people of all ages and abilities as they seek to live healthy, productive, and civically engaged lives.”

Action Plan Goals and Cornerstone Initiatives

The Plan is a “living document” developed and vetted by an active and engaged community and serves as a collective community pivot from programs and services targeted to the individual to initiatives designed to serve our community as a whole.

“Providing barrier-free and attainable housing, accessible public spaces and transportation that’s welcoming to walkers, rollers, drivers and transit users enables people to stay independent and active in their community,” said Becky Bradley, Executive Director of the Lehigh Valley Planning Commission.

The Plan serves as a call-to-action to change attitudes toward ageism, equity and inclusion and outlines the community tools needed to ensure that age-friendly programs, services and policy are available and accessible to all. It highlights several key strategies and focus areas, including:

Outdoor Spaces and Buildings: Increase accessibility to the social and physical health benefits provided by parks, trails, open spaces and public buildings. Strategy: Identify, map and communicate key points of access to outdoor spaces and public buildings that organically serve as gathering places and informal sources of information. Conduct walk audits.

Transportation: Increase awareness about transportation options that are in place Valley-wide, including public and private transit and ride-share. Increase safety and accessibility of public bus stops. Strategy: A visible transportation services campaign that provides relevant information in multiple languages and engages the community with

LCMEDSOC.ORG WINTER 2022 | Lehigh County Health & Medicine 9 LCMEDSOC.ORG
Continued on page 10
With a growing number of residents age 65 and older, we must work together to ensure the Lehigh Valley can best serve all our populations.

positive messaging about staying connected. Increase safety and accessibility of public bus stops.

Housing: Equity in access to housing for all residents. Strategy: Assess the current state and develop viable solutions for equitable and affordable housing.

Civic Participation and Employment: Encourage a positive attitude toward hiring seniors and recruiting volunteers. Strategy: Visibility campaign celebrating older adults and their ongoing contributions. Highlight the benefits of engaging with older adult workers and volunteers. Research attitudes on aging in the region. Create opportunities to showcase the talents of older adults.

Community Support, Food Security and Health Services: Increase awareness

about healthy aging in place. Keep individuals connected with family and community. Promote expanded access to services that help ensure that residents’ full range of emotional, social and physical needs are met. Increase food access. Strategy: Visibility campaign for area-wide communication and policy change that supports designation of family members and friends as essential caregivers.

Safety and Emergency Preparedness: Ensure the safety and reassurance of older adults in the event of a personal or largescale emergency. Strategy: Convene an emergency preparedness coalition utilizing a cross-section of organizations and develop a plan/website.

The Age-Friendly Lehigh Valley Leadership Team is a mix of community leaders who volunteer their time to engage the

Lehigh Valley in the Age-Friendly Communities Program under the direction and leadership of United Way of the Greater Lehigh Valley. Committee members work together to expand awareness of opportunities for residents to voice their opinions on age-friendly efforts. This committee also assists with the oversight, creation and implementation of the Age-Friendly Lehigh Valley Action Plan and will collect feedback in preparation for the next steps.

10 Lehigh County Health & Medicine | WINTER 2022
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Population Health

Expanding the View and Value of Health Care


Through data and significant analysis and research, we know that the U.S. health care system falls behind that of other countries in life expectancy and prevention of chronic disease. Yet we spend a larger portion of our gross domestic product on health care than almost any other nation. (1) These factors prompted a reason for experts to consider the underlying structure of care in this country and how to improve it. The concept of population health was the result: it’s a way to try to mitigate some of the deficiencies in our health care system, as well as improve how care is provided to patients as a whole.

Now following a value-based vs. fee-for-service reimbursement model, insurers have adopted the concept of population health with metrics and measures that hold providers accountable for panels of patients rather than each one individually. Pursuit of these universal outcomes has brought the concept to the forefront and has made it a necessary consideration for all providers, health systems, and communities.

Continued on page 14


Population health aims to keep people healthy rather than treating them after they are sick, resulting in larger groups of people with improved health. To do that requires a system-wide approach, leading to transformation of all areas of clinical practice and public health. David Nash, MD, MBA, a board-certified internist, the founding dean of the Jefferson College of Population Health, and the Dr. Raymond C. and Doris N. Grandon Professor of Health Policy at Thomas Jefferson University in Philadelphia, outlined the mechanics of population health in an article published in Pharmacy and Therapeutics (P&T)


• Connects prevention, wellness, and behavioral health science with health care delivery, quality and safety, disease prevention/management, and economic issues of value and risk—all in the service of a specific population, be it a city, provider’s practice, hospital’s primary service area, or preschool children.

• Identifies socioeconomic and cultural factors that determine the health of populations and develops policies that address the impact of these determinants.

• Applies epidemiology and biostatistics in new ways to model disease states, map their incidence, and predict their impact.

• Uses data analysis to design social and community interventions and to develop new models of health care delivery that stress care coordination and ease of accessibility.

• Emphasizes value rather than volume of services rendered.

Focusing on improving health and lowering cost at the population level has become recognized as the most viable tactic for sustaining health care nationwide. It continues to grow in significance as providers and health systems strive to transition their operations to the new paradigm. Much like trying to steer an ocean liner on a whole new course, it takes understanding, cooperation, and thought-out action.


From a population health perspective, we are partway through what could be considered the biggest challenge of all: a pandemic. Such an event clearly illustrates why the time for viewing health population-wide has arrived. This disease has affected people of all ages, it requires both physical and behavioral health assistance, it brings together clinicians from all disciplines, and it had to be attacked on a world-wide population basis. It led to timely discoveries in the need for unprecedented information sharing, proactive outreach, and increasing delivery of alternative visit models. Trying to eradicate the virus patient-by-patient would not have worked.

Public health emergencies are something we hadn’t thought about too much prior to 2020, but now are a serious part of the equation. There also has to be an increased focus on prevention, self-care, chronic disease management, and healthier lifestyles considering that 80 percent of a person’s health is determined by behavioral and social conditions. This makes it imperative to address social determinants of health as part of the big picture and includes screening patients for health disparities as well as connecting them with resources. Physicians and other providers then are able to be instrumental in social change, advocating for stable housing, anti-discrimination, and other concerns that impact the health of individuals and ultimately of populations. (2)

As we look to the future, the broader population health point of view is a given as the cost of providing health care continues to rise. Noted one health care executive: “It’s been known for a long time that the cost of providing medical services has escalated to the point where it can no longer be perpetuated into the future.” He goes on to note, “This means … providers must coordinate health care in ways that allow populations and individual patients to participate in their own care and aid decisions about medical resources, so we can manage the whole population at large.” (3)



For providers, a population health focus takes the view away from a single patient in the waiting room to a panel of patients in the EMR. It’s a major shift and requires flexibility as well as organization. The following tips originate from a chief nursing officer versed in population health (4) and can help with setting a new course that’s aligned with the direction of health care in general.

Get used to working with data. Managing the health of a given population requires data to identify who’s in need of care, measure the care provided to those populations, and deliver care to the correct people. Applying analytics to the data lets providers enhance care management and address social determinants of health along with identifying rising- and high-risk patients and the care they need. Working with a population health management firm gives providers this ability and renders them capable of using data to their benefit and that of their patients. Ideally, data is gathered from both medical records and insurance claims for a broader overview of the patient, with the idea being that outreach can be specifically targeted.

Create small groups and target certain metrics. Considering a practice’s entire patient population all at once can be overwhelming. Instead, break the population into small groups for evaluation. Start by working with a low-risk group that’s easier to manage, then move onto those that require more care. You can also focus on certain metrics, such as reducing the number of patients that use the emergency department

for non-urgent care. Once that metric has been tackled, you can move onto to another, taking with you what you learned.

Become comfortable with risk. Physicians have become crucial players in supporting integrated care, promoting best practices, and achieving the clinical efficiencies required for value-based arrangements. That entails accepting greater risk and accountability for both cost and quality of care, with insurers tracking performance and outcomes. Therefore, it behooves physicians to work closely with administrators and financial leaders, carefully considering how all the aspects of an organization’s care and services fit together from the patient’s perspective. Those with systems in place that can take on more risk to care for populations will position themselves to be successful in this value-based world. (3)

Leverage clinical and community relationships. When practices are part of a larger health system they have the advantages of the system’s resources. Those resources may include care coordination*, which can be valuable in coordinating services and after-discharge care. If a provider works independently, he or she is probably versed in what’s offered in the community and can reach out to those service providers to assist patients. Either way, including these relationships in the delivery of care serves to delegate care activities across an entire team and preserve the provider’s time for attending directly to patients.

Communicate for better engagement. It’s the consensus of many that the health of a population can’t be improved without patient engagement. The responsibility for much of that comes down to the provider. There must be good communication, understanding, and honesty. In today’s world that is enabled through emailing with patients, texting with patients, telemedicine with patients, participating in mobile health with patients, getting back to patients in a reasonable time, sharing all the information with them, and sharing decision-making with them. (5)

*Organizing the activities of participants in a patient’s health care to facilitate the appropriate delivery of services. Marshalling the personnel and other resources needed to carry out all required patient care activities relies in part on the exchange of information among participants responsible for different aspects of care.


1. https://www.commonwealthfund.org/ publications/fund-reports/2021/aug/ mirror-mirror-2021-reflecting-poorly#:~:text=The%20U.S.%20ranks%20last%20 overall,age%2060%20(23.1%20years)

2. https://postgraduateeducation. hms.harvard.edu/trends-medicine/ how-physicians-can-prepare-future-health-care 3. https://www.fiercehealthcare.com/special-report/ future-population-health-management

4. https://www.medicaleconomics.com/view/ making-population-health-work-your-practice 5. https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC5521301/




Perhaps someone [or two] may have glanced at the Spring issue of this journal, in which I had admonished all to protect their fingertips from the evils of modern machines and technology, overused with overzealous speed and efficiency as we accomplished our daily tasks (1). We knew the gloom and doom of Winter would be inevitable, bringing cold and snow hand-in-hand. Not just fingertips will be at risk this season, justifying this requested encore presentation.

We must first dig out from every blizzard so we can get to where we must go [Figure 1.]. A snow shovel may just be too slow. The magic of the snowblower is the better answer. Or is it?

Today, most snowblowers are dual-staged machines, in which the front rotating, spiral, or corkscrew shaped blades will readily push the snow backwards to encounter an even faster rotating impeller blade that expels the snow out of the exit chute [Figure 2.]. Wet snow is always heavier and more difficult to clear than a dry, powdery snowfall. This I well know, since it always means more calls from the emergency room— invariably someone has tried to unclog the obstruction the wetness has caused with their fingertips. The long(er) fingers, dominant hand, and men are most at risk—and the latter are typically experienced operators (2,3). Most admit an awareness of the safety warnings, so why was the machine usually left on (2)? And beware, even once turned off, enough rotational energy remains to still cause injury once the clog is cleared (2)! So never forget to read the safety instructions in the manual!

Unlike a lawnmower whose blades move at high kinetic energy causing “high velocity missile wounds,” the impeller blades of the snowblower are


Figure 1.: Winter—snow and cold and lest we forget—more snow. Figure 2.: A high powered snowblower—only the old broom belongs to me, for breaking up the exit chute impaction. Figure 3.: Insert not your long fingers into the snowblower to remove clogs—they WILL be crushed—or worse!

Figure 4.: Always have a back-up chainsaw when the first ceases to work—inevitable! Figure 5.: Typical jagged, mangled thumb amputation by a chainsaw, not clean nor sharp as would be the surgeon’s knife [left], great toe harvested [center], to restore a working hand [right]. Figure 6.: Diagram of a wood splitter at rest, available for rent. Figure 7.: Poorly supervised wood splitter usually just amputates those fingers still holding the log.

Figure 8.: An old-fashioned approach to wood splitting; this way always “heats you twice.”

only a meager 1/10th as energetic so only cause “low velocity missile wounds (2):” just simple cuts, fractures, and finger amputations [Figure 3.]. Remind yourself, it is far better to use an old broom handle to clean out the chute AFTER the machine is turned off. If too difficult, poor a bucket of water into the chute, as long as there’s no fear that your sidewalk or driveway will become a skating rink!

When you are at last able to go to where one must get, what about time to recover and stay warm? Cold weather reminds me of Winter days as a general surgery resident in Vermont. Every day was a snow day and outdoors your breath froze into your face. The oil truck never made it up the hill to fill your tank, and what would happen if the electricity went out? That’s why even we flatlanders all had wood stoves, and like the natives, we were prepared. We appreciated the value of wood heat knowing “it heats you twice.”

To stock a precious woodpile, a chainsaw was essential [Figure 4.]. Indeed, we knew

these toys were more dangerous than a snowblower! In the emergency room we saw two kinds of victims—the novice who had never used a chainsaw, and the old professional [Figure 5.]. Maybe he had just become too complacent?

What more to fear? Kickback of the guide bar tip, inappropriately hitting an object or pinched out by the wood, which can strike the face, extremities, or even chest (4). Once a young man we rushed to the operating room appeared to have almost completed his own median sternotomy with his chainsaw. The posterior cortex was found intact, with the visible beating heart seen just behind!

To minimize such potential disasters, again, always read the safety instructions. Also, wear appropriate clothing, boots, gloves, goggles, and earmuffs. Keep the chain and bar comfortably away from your body. Make sure the surrounding ground where you are felling, bucking, or pruning will allow unimpeded escape in case of unexpected trunk or branch spring back, as well as chainsaw kickback itself!

If the chain gets pinned, turn the engine off! Don’t lift the branch up to free it as my patient did a few weeks ago, allowing the engine to start again. The chain lacerated his knee and several hand extensor tendons—a weekend adventure for us both. Possession of a second chainsaw so when the first stops working is an excellent safety factor to allow a different trajectory.

As I get older, I hope I am getting a little wiser. Maybe. I now have a lithium battery powered chainsaw, just like the batteries used to power most of our drills and saws in the operating room, whereas before we were encumbered by electrical cords and gas lines that always got tangled around our appendages. When you take your finger off the electronic chainsaw trigger switch, the engine almost immediately ceases; and far better, will start immediately on demand by just once again compressing the trigger. So effortless, when compared to those gasoline powered chainsaws that could be a struggle

LCMEDSOC.ORG WINTER 2022 | Lehigh County Health & Medicine 17
Figure 1 Figure 2 Figure 3 Figure 4 Figure 5
Continued on page 18
Figure 6 Figure 7 Figure 8

FEATURE to both turn on and stay on. Admittedly, the battery needs recharging often since they have a short duration battery life, so it would be impractical if you’re off in the deep woods. To be safe, always have a second charged battery on hand so you are not caught in a precarious situation with a chain that has stopped.

The job is not done until the truly “Herculean” task of stacking the cords needed with wood pieces small enough to fit into your stove is completed. One of my New Hampshire mentors once wrote an article in the plastic surgery literature—no, not about facelifts, but wood splitters to simplify this aforementioned requirement (5). There are many varieties. Each log is put on a trough that at one end has a stationary sharp wedge, and the other a broad faceplate, or vice versa, where behind the mobile part, a hydraulic piston will thrust forward to split the wood [Figure 6.].

In that classic study, the most important causal factor for inadvertent injury was when a two-man operation was used, rather than a preferable (but slower) one-man show. The man operating the control level for the piston would invariably fail to wait until the man loading the log onto the trough had removed his hands from the log. I do remember that often a little alcohol was on board, but we couldn’t write about such factors.

One interesting case involved an unsupervised 11-year-old boy who tried to split his pencil (5)! Fortunately, usually only the fingers holding the logs are sacrificed [Figure 7.]. I must admit I have no personal experience with a wood splitter, only anecdotal. Instead, I am old-fashioned and still use a maul and sledgehammer, with an assortment of wedges for slow splitting [Figure 8.]—yet good enough for maintaining cardiac aerobics during these long Winter months, and usually safer!


Always FIRST read the safety manual instructions.

Wear appropriate Winter apparel.

Use protective devices, like eye goggles & earmuffs.

Get the right equipment for the right job.

Respect the capabilities of your machines.

My take-home message is repetitious: with a machine, if anything can go wrong, it will. The truth is that these devices have afflicted all socioeconomic groups, the young and the old, well-educated professionals, even doctors themselves, but rarely women (2-5)!

Beware, because injury can involve any body part, but the hands most often. If you have suffered but a simple fingertip violation, see the suggestions in the past Spring magazine to see if treatment can be straightforward (1). If more catastrophic injury occurs, having the right surgeon from the outset will be the best course of action.

I have never forgotten the chilling words of my New England mentor: “All the world is pre-op.” So, beware and be careful.


1.Hallock, GG, Watch Your Fingertips—the Dangers of Spring Cleaning, Lehigh Co Health & Med, 2001; Spring:22-24.

2.Master, D, Piorkowski, J, Zani, S, Babigian, A, Snowblower Injuries to the Hand Epidemiology, Patterns of Injury, and Strategies for Prevention, Ann Plast Surg, 2008;61:613–617.

3.Chin, G, Weinzweig, N, Weinzweig, J, Geldner, P, Gonzalez, M, Snowblower injuries to the hand. Ann Plast Surg. 1998;41:390–396.

4.Bryant, MW, Jabaley, ME, Dowden, WL, Chain Saw vs. Face—Another Hazard of Mechanized Progress, J Trauma, 1976;16:149-152.

Seek assistance when called for.

5.Jaxheimer, E, Morain, WD, Brown, FE, Woodsplitter Injuries of the Hand, Plast Reconstr Surg, 1981;68:83-88.

18 Lehigh County Health & Medicine | WINTER 2022
Respect the limitations of your machines.
Be focused and professional.

mRNA Vaccines Have Saved Millions of Lives –What’s Next

The rapid development of mRNA vaccines against the SARSCoV-2 coronavirus is truly one of the most spectacular scientific achievements of all time. A 2022 Lancet Infectious Diseases UK global study estimated that the vaccine saved 19.8 million lives over a one-year period from December 8, 2020 to December 8, 2021. Although the production of mRNA vaccines in just one year after the world learned the genetic sequence of the virus is by far the fastest vaccine development on record, this success story has much to teach us about the complicated and long process of all innovation in science and medicine.

Whenever a significant scientific breakthrough occurs there is a tendency to identify a genius individual who is celebrated and written into the history books as a hero. Think Edward Jenner and the small pox vaccine or Thomas Edison and the light bulb. In Philadelphia there is talk of future Nobel Prizes for Katalina Kariko and Drew Weissman of the University of Pennsylvania whose important contributions to mRNA science helped save those nearly 20 million lives.

Society’s need for heroes obscures the reality about how scientific innovations actually happen. A Nature article titled The Tangled History of mRNA Vaccines paints an alternative picture of decades of basic science research, twists and turns, bitter personal rivalries, and incredible persistence to get to the point that Kariko and Weissman could succeed in developing a way to get mRNA into human cells without eliciting a fatal immune response. mRNA was first discovered in 1961, but for decades researchers had difficulty studying it because of the molecule’s incredible instability. The basic science behind the development of the lipid nanoparticles that encapsulate the mRNA in vaccines dates back to 1965.

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The researchers who made important contributions to the development of mRNA vaccines did not always play nice and get along with each other. As a graduate student at the Salk Institute in California, Robert Malone in 1988 inserted strands of mRNA mixed with fat into human cells that then produced proteins. Tensions and disagreements between Malone and his academic supervisor led to Malone dropping out of the PhD program, and patent agreements between Salk and an involved biotech company did not include Malone. Malone, who did complete an MD degree at Northwestern, has called himself “the inventor of mRNA vaccines” and claims to have been written out of history. He also recently created a controversy when he was interviewed on the Joe Rogan podcast on Spotify and attacked the safety of mRNA vaccines. That interview led to protests from hundreds of physicians about Malone’s vaccine misinformation on Spotify and Neil Young and Joni Mitchell asking that their music be removed from the popular internet platform.

No one person invented the mRNA vaccine. As the Nature article makes clear, many investigators made significant contributions that paved the way for the Moderna and Pfizer vaccines. Kariko makes this point when she says, “Everyone just incrementally added something — including me.” One of the pioneers behind the development of lipid nanoparticles, Pieter Cullis, agrees when he states “You really cannot claim credit, we’re talking hundreds, probably thousands of people who have been working together to make these LNP systems so that they’re actually ready for prime time.” Many do not realize that the development of the lipid layer that coats the mRNA in the vaccine is an essential element for the vaccine to work in humans.

Many of the investigators who made important discoveries about the basic science of mRNA and lipid nanoparticles did not know if and how their work would ever contribute to medical therapies. Most basic scientists are really motivated by curiosity about how nature works, and they are now pleasantly surprised that mRNA has saved those 20 million lives. In the early days of mRNA research nobody

really thought about vaccine developments as a possibility. The Nature article quotes one scientist who states “RNA was so hard to work with if you had asked me back then if you could inject RNA into somebody for a vaccine I would have laughed in your face.”

Politicians and bureaucrats who are deciding where to put research dollars would be well advised to understand that one cannot predict which basic projects will result in “useful” results that can be applied in the clinical setting. The track record of prestigious institutions such as Harvard and University of Pennsylvania is not impressive in this regard. The Harvard Technology Development Office did not patent the early RNA research and gave away the reagents to a biotech startup company. The company sent Harvard a case of Veuve Clicquot Champagne in return. The University of Pennsylvania famously in the late 1990s did not support Kariko and demoted her with a pay cut. They also did not recognize the importance of her work and sold off some early patents. Kariko’s belief in her work and perseverance in the face of rejection is truly remarkable and admirable.

Lessons learned from the “tangled history of mRNA vaccines” have important public policy ramifications. Steven Johnson in his book Extra Life makes the case that “network narratives” are more accurate than “genius narratives” for understanding scientific innovation and medical breakthroughs. A breakthrough is often just the latest in a series of small incremental advances, and the general public does not understand this fact. A two-year internet search revealed 1096 media citations over a 2-year period for the word breakthrough, and the public love of moon shot research (think Joe Biden’s cancer program) endangers funding for the necessary but unsexy small incremental research projects. Behind every home run like the mRNA vaccine in addition to many basic science researchers, there are connectors, amplifiers, funders, champions, and evangelists who are necessary if the breakthrough is to benefit society. And many of these network roles are played by non-scientific individuals.

In addition to forever transforming the vaccine field, mRNA has other potential uses in medicine. mRNA is involved in almost all aspects of human cell biology, and important research is on the way to better understand its function. mRNA can make antigens for vaccines, antibodies, cytokines, and other immune proteins, and pharmaceutical companies are studying ways that mRNA could be leveraged in cancer immunotherapy, other infectious diseases, cystic fibrosis, multiple sclerosis, allergies, diabetes insipidus, anemia, myocardial infarctions, and genetic reprogramming. Scientists are learning how to control the amount of protein manufactured, how long it lasts, the best route of administration, which cells express the protein, and whether the mRNA produces protein that activates or suppresses the immune system.“The versatility of mRNA creates a huge design space. We have designed a diversified toolbox and by mixing and matching the modules we can design mRNA with the features we need for a particular purpose. It is a bit like writing code — by mastering programming language that is rich in terms, one can give any instructions one wants,” states Ozlem Tureci of BioNTech in a Scientific American article.

mRNA vaccines have saved millions of lives from the current pandemic, and their development highlights the complicated and convoluted path that is behind the story of any scientific breakthrough. Thousands of scientists and lay individuals have made small incremental contributions that make home runs in medicine possible, and adequately funded basic science research is needed in order to create new medical treatments as we better understand the basic biology of the human being.



Lead is a naturally occurring, toxic metal found in the Earth’s crust, and exposure is associated with many negative health outcomes. It has been traditionally used in pipes, paint, and gasoline due to its resistance to corrosion, malleability, and other properties. Although the use of lead has been banned in many materials, it is still used as an additive in battery manufacturing, bridge paint, and metal alloys. This creates the need for occupations in which the disposal, maintenance, production, and recycling of lead materials occurs. The risk of lead exposure and associated adverse health effects is high among workers within these occupations. It is an issue that needs to be prioritized and addressed, through collaborations of multiple agencies, to protect the wellbeing of the Pennsylvania (PA) workforce.

Individuals working in furniture restoration, construction and automobile repair, metal smelters and foundries, bridge sanding and painting, and battery manufacturers are among those at greatest risk. These industries employ upwards of half a million people in PA, making workplace lead exposure surveillance a primary concern. Monitoring workplace lead exposure can be accomplished by taking a venous blood sample to measure blood lead levels (BLLs). According to the National Institute for Occupational Safety and Health (NIOSH), a BLL ≥ 5 µg/dL is considered elevated in adults. PA has been, and continues to be, among the top states with adult BLLs that well exceed the elevated NIOSH case classification of 5 µg/dL. The annual prevalence rate of BLLs ≥ 25 µg/dL among adult employed Pennsylvanians in 2019 was 11.9 per 100,000. In the last five years, up to 1,300 Pennsylvanians annually have tested high (greater than 25 µg/dl BLL) and between 300 and 600 of those annually tested are newly reported cases.

Although incidence (new cases) and prevalence (existing cases) rates have declined over time, the number of individuals impacted is still great and is likely underestimated. For example, self-employed persons working in home renovation may not know that they should be monitoring their BLLs. In addition, physicians may not be aware of the many symptoms associated with lead poisoning and therefore may not recommend a blood lead test during diagnosis.

Lead cannot break down and serves no biological function in the body. Therefore, no amount of lead in blood is safe. Over time, lead can accumulate in bones, circulate in the blood, and cause damage to major organs and organ systems. Specifically, lead can harm the brain and result in symptoms such as loss of concentration, headache, irritability, difficulty remembering, and dizziness. In extreme cases, brain

swelling may occur. Low level lead exposure in adults has recently been linked to an increased risk of cardiovascular disease. Lead induces reproductive toxicity in both males and females and may cause infertility. Other symptoms of lead exposure include fatigue, anemia, nausea and vomiting, anorexia, and joint and muscle pain. Lead has also been associated with hearing loss and kidney disease. Smoking increases oxidative stress which may worsen the symptoms associated with lead exposure. Due to lead contaminated tobacco, individuals who smoke, and their families, are at greater risk for lead exposure.

Adult Pennsylvanians working with leaded materials may be occupationally exposed to lead. The primary route of exposure at work is through inhaling lead fumes or dust. Additionally, individuals may unknowingly ingest lead-contaminated food or water. Not washing hands after handling leaded products will increase the likelihood of ingestion. The Occupational Safety and Health Administration (OSHA) has regulations to help protect workers from occupational lead exposure. If lead exposure is a known risk at the workplace, the employer is required to provide a safe working environment, which includes but is not limited to providing safety training, installing ventilation systems, and supplying personal protective equipment.

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may be occupationally exposed to lead

Occupational exposure increases the risk of take-home lead. Take-home lead exposure occurs when people exposed to lead at work or in other activities unintentionally bring lead into their homes. This is often in the form of lead dust that can be carried home on clothes, shoes, skin, or hair, exposing other family members including children. Children, as well as women who are pregnant or are planning to become pregnant, are at greater risk for the adverse effects from lead exposure. Washing hands, changing out of work clothes and shoes before entering the home, and routinely cleaning the car that is used for work travel can help protect families from take-home lead exposure.

Other non-occupational sources of lead exposure can contribute to an individual’s lead burden or increase the likelihood of take-home lead. Some common activities that increase the risk of lead exposure include home restoration projects (especially sanding walls with leaded paint), fishing and hunting, metalwork, art restoration and stained-glass work, cooking with imported ceramicware or spices, wearing imported cosmetics or using imported medicines, and drinking home-distilled liquids such as moonshine. Due to the traditional use of lead in pipes, older homes built before 1986 may contain leaded pipes that increase the risk of ingestion of lead contaminated drinking water. Homes built before 1978 may contain lead paint which contributes to lead dust in the home once it begins to peel and crack. In rare cases, retaining a bullet or bullet fragments after a gunshot wound can result in continuous exposure to lead in adults.

Given the number of symptoms associated with lead exposure, along with the many potential sources, it is important for healthcare practitioners to ask questions about employers, workplace activities, and hobbies when collecting patient information and taking a patient history. If reasonable suspicion exists for lead exposure, a BLL test should be conducted. Test results of BLLs ≥5 µg/dL among individuals ≥16 years of age are reportable to the PA Department of Health (DOH) by law (28 Pa. Code § 27.34). The newly funded Pennsylvania Oc-

cupational Safety and Health Surveillance (PennOSHS) program within the PA DOH monitors workplace injury and illness in PA, including elevated BLL reports. It is critical to include employer and demographic information with test results, as this greatly enhances PA DOH lead surveillance. Many test results are submitted with “Unknown” employers which hinders the ability of PennOSHS to collaborate with industries and occupations that require updated lead exposure safety information. In efforts to increase surveillance, PennOSHS is currently conducting interviews of Pennsylvanians with elevated BLLs and no additional workplace information. One effective way to collect relevant patient information would be to revise patient intake forms to include questions on employers and hobbies.

It is important for healthcare practitioners to follow up with patients after a BLL test has been conducted and to determine the best course of action to reduce elevated BLLs. The most effective way to reduce lead toxicity is to eliminate the source of lead exposure. However, that may not be feasible especially if an individual is exposed at work and depends on that work for their livelihood. Discussing best practices to reduce lead exposure in both occupational and non-occupational settings with patients will help mitigate personal and take-home lead exposures. These may include:

• Wash hands often, especially before eating, drinking, smoking, or leaving the workplace.

• Only eat or drink in a designated clean space when at work.

• Use the appropriate personal protective equipment (PPE) when working with lead, such as gloves and respirators. Ensure that respirators, and other PPE, fit properly.

• Clean the car that is used to travel to and from work, as lead dust may accumulate there.

• Remove lead contaminated clothes and shoes at work and change into clean clothes before returning home.

In extreme cases, chelation therapy has been used to lower an individual’s BLL. Chelation therapy involves the administration of a medication, such as a chelating agent, that will bind to metals in the blood so that they may be excreted through urine. Although chelation therapy has been shown to help remove lead from the body, it does not reverse damage to organs that may have occurred. Due to the cellular toxicity of lead, treatment with antioxidants has also been shown to help in reducing harmful effects. It is also important to make sure patients are aware of take-home lead and how that may be impacting their families. If children are living in the home, and there is a chance of takehome lead exposure, then a blood lead test for the child should be recommended. BLLs should be monitored in both adults and children until the BLL has declined to less than 5 µg/dL or 3.5 µg/dL respectively. Follow-up testing is dependent upon severity of exposure and age. The higher the initial BLL and younger the individual, the more quickly follow-up and subsequent testing should be conducted to ensure that the source of lead exposure has been removed. Individuals exposed to lead should contact their primary care physician for blood lead testing and to seek medical treatment.

The PA DOH and PennOSHS program welcomes healthcare practitioners in its efforts to reduce adult lead exposure in Pennsylvania. Some resources that the PennOSHS program can offer include help in developing educational material or providing guidance on ways to collect and interpret patient information for lead exposure risk. If you are interested in learning more information, or building a partnership, please reach out to PennOSHS (email: dehe@pa.gov). PennOSHS will continue to take action to reduce lead exposure that impacts so many Pennsylvanians.

Note: Data were collected from the PA National Electronic Disease Surveillance System (PA-NEDSS) program and the Bureau of Labor Statistics (BLS) Geographic Profile of Employment and Unemployment. For more information on PennOSHS and adult blood lead surveillance please see the PennOSHS 20212022 Annual Report.

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Christian Abreu-Ramirez , MD

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Anne Borja, MD

Nancy Luz Diaz-Pechar, MD

Jean Marie Bujdos, DO

Brandon Michael Kujawski, MD

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