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Duval County Medical Society Foundation 555 Bishopgate Lane Jacksonville, FL 32204 ADDRESS SERVICE REQUESTED

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Inside this issue of

VOLUME 61, NUMBER 2 Resident Research Summer 2010 EDITOR IN CHIEF Joan L. Huffman, MD MANAGING EDITOR Leora Legacy ASSOCIATE EDITORS Raed Assar, MD Hernan Chang, MD Kathy Harris (Alliance) Joan Harmon (Alliance) Sunil Joshi, MD James Joyce, MD Neel Karnani, MD Senthil Meenrajan, MD Timothy Sternberg, MD

Executive Vice President Jay W. Millson DCMS FOUNDATION BOARD OF DIRECTORS Benjamin Moore, MD, President Todd L. Sack, MD, Vice President Kay M. Mitchell, MD, Secretary J. Eugene Glenn, MD, Treasurer Guy I. Benrubi, MD, Immediate Past President Mohamed H. Antar, MD Raed Assar, MD Ashley Booth Norse, MD J. Bracken Burns, DO Malcolm T. Foster, Jr., MD Jeffrey L. Goldhagen, MD Jeffrey M. Harris, MD Mark L. Hudak, MD Joan L. Huffman, MD Sunil N. Joshi, MD Daniel Kantor, MD Neel G. Karnani, MD John W. Kilkenny III, MD Sherry A. King, MD Harry M. Koslowski, MD Eli N. Lerner, MD R. Stephen Lucie, MD Jesse P. McRae, MD Senthil R. Meenrajan, MD Nathan P. Newman, MD Mobeen H. Rathore, MD Ronald J. Stephens, MD Jeffrey H. Wachholz, MD Anne H. Waldron, MD David L. Wood, MD Northeast Florida Medicine is published by the DCMS Foundation, Jacksonville, Florida, on behalf of the County Medical Societies of Duval, Clay, Nassau, Putnam, and St. Johns. Except for official announcements from the County Medical Societies, no material or advertisements published in NEFM are to be seen as representing the policy or views of the DCMS Foundation or its colleague Medical Societies. All advertising is subject to acceptance by the Editor in Chief. Address correspondence and advertising to: 555 Bishopgate Lane, Jacksonville, FL 32204 (904-355-6561), or email: llegacy@dcmsonline.org.

Northeast Florida Medicine

Features

9

Like Tall Pines, Residents Reach for High Goals

11 Resident Scholarly Activity Focuses on the Pursuit of Knowledge J. Bracken Burns, Jr., DO, Guest Editor 12

Abstract Category 1 - Prospective

17

Abstract Category 2 - Retrospective

21

Abstract Category 3 - Case Study

27 From a Resident’s Perspective

Special Articles

35 High Risk Stress in High Risk Careers: Managing Physician Stress (CME) Kamela K. Scott, PhD and David J. Chesire, PhD

44 Special Case Study - Is Early TPN in Hyperemesis Gravidarum Worth the Risk? Karishma Ramsubeik, MD, et al 45

Update on Haiti Relief Efforts

Departments

4 5 8 34

From the Editor’s Desk From the President’s Desk DCMS History Book Ole’ Time Reunion Photos

COVER: Photograph of pine trees in Guana River State Park, Ponte Vedra Beach, FL by a resident, Dr. Adithya Suresh.

www . DCMS online . org

Northeast Florida Medicine Vol. 61, No. 2 2010 3


From the Editor’s Desk

Solidarity Needed to Improve Patient Care On March 23, 2010, President Barack Obama signed into law the Patient Protection and Affordable Care Act (PPACA-H.R. 3590). The new law, the most sweeping health care reform since 1965, will impact patients, employers, insurance companies, health care facilities and providers. Much hue and cry accompanied the bill on its way back and forth through the House and Senate, and continues to carry a burden of controversy; however, there are many positive, long-needed changes as a result of its passage. Physicians will feel the impact of the bill in a personal way that many other professionals may not experience. But before you begin to wave your Tea Party flag, Coffee Party banner, or drag out your Democrat, Republican or Independent podium, let’s examine the positive before we throw the infant legislation out with the bathwater of rejection. We can then intelligently talk about how we can band together as physicians to maximize our impact on improving the current law. Of the American Medical Association’s (AMA) seven essential elements, five were fulfilled: the first two, expanded health insurance coverage and wellness and prevention initiatives, will help patients with improved access, as well as, both physicians and institutions with the overwhelming burden of uncompensated care. The third, removal of pre-existing conditions limitations, will aid patients with chronic disease and/or cancer diagnoses and the fourth, quality improvement incentives, will reward doctors for providing excellent evidenced based medical care. Finally, the fifth, simplified insurance claims processing, will reduce costs of billing and collections. Several serious areas of concern for doctors are: Tort Reform, the Sustainable Growth Rate

Joan L. Huffman, MD, FACS (SGR), Independent Payment Advisory Board (IPAB) and Physician Workforce Expansion. Editor-in-Chief Physicians need to be protected from frivolous and astronomical suits which color their practice Northeast Florida Medicine

with defensive medicine that in turn elevates health care cost. The SGR must be addressed with a permanent fix rather than an annual push-back. The AMA opposes the institution of the IPAB, an independent commission that could mandate payment cuts for providers. And finally, with increased access to care, more physicians will be required to treat the larger number of patients.

While most doctors agree in principle that reform was needed, many disagree with the strategy and tactics utilized to achieve the resultant product and the challenge required for implementation. In response to the concerns and varied opinions of local doctors, the DCMS Board of Directors has initiated a bipartisan Health System Reform (HSR) Task Force. At the recent visit of Cecil B. Wilson, MD, President-Elect of the American Medical Association, the AMA’s position was elucidated; and at the May Bi-Annual Physician Town Hall meeting many of our members’ thoughts were aired. Upon this foundation, the Task Force can move forward to produce a summary DCMS position statement that bridges our differences and leads to the formulation of a non-polarizing action plan. We look forward to working in a collaborative manner that gives voice to all sides of the matter and addresses areas of specific concern to our profession. Please continue to communicate your concerns and ideas regarding PPACA with DCMS Executive Vice President Jay Millson at jmillson@dcmsonline.org. Let’s work together in a common bond dedicated to improving patient care and share our thoughts in a unified voice about what success of amended health care reform would look like for both patients and physicians. We have an opportunity to strengthen the law by addressing the issues that are not in our best interests and by becoming part of the solution, not the problem.

Update on Haiti Relief Efforts An “Update on Haiti Relief Efforts” by DCMS members and Jacksonville medical groups begins on p.45 of this issue and continues on pp.48 & 49. Dr. Huffman made a second trip to Haiti April 9-17, and she reports on the situation in Haiti in “How’s Haiti” (p.45 & p. 48) The Crudem Foundation that supports the Sacred Heart Hospital in Milot, Haiti needs ortho/scrub techs, OR nurses with orthopaedic experience, ortho PAs, anesthesiologists and physical therapists to volunteer their services in Haiti. Learn more about the Foundation at www.crudem.org and if interested in volunteering, contact Carol Fipp at cfipp@bellsouth.net. (This is the hospital where Dr. John Lovejoy donates his time and services. See pp.48-49) 4 Vol. 61, No. 2 2010 Northeast Florida Medicine

www . DCMS online . org


From the President’s Desk

The Times They Are A-Changin’* As we mull over the recently enacted law that many know as the Health System Reform Legislation, it is apparent that our responses fall across a wide spectrum. At one end is the rather obstructionist view that is opposed to the very essence of the product as well as the process that was used in crafting it. At the other extreme is the overly optimistic view that our medical system woes are soon to be solved. As we’d expect, these diametrically opposed extremes are the purview of those with political ‘axes to grind’. When queried objectively, these stilted reviews harbor little concern for us or our patients. Many aspects of patient care will be changed, though the actual regulations that will be defined from this legislation are still being formulated. This is precisely the point in time, where we as organized physicians can have the most impact on how this law will ultimately affect our patients and our relationships with them. We have seen the difficulty of ‘mixing it up’ with the primary players of this recently enacted legislation: the industries of insurance, drugs, hospitals and medical devices. We have recoiled at the sight of back room deals and bemusedly observed large prenegotiation concessions resulting in generous favoritism in the finished product. Three areas in dire need of rectification are the SGR fiasco, tort reform and physician shortages. I’d like to focus on the latter. In previous columns, I have outlined the ominous statistics from our own state, grounded in a thought-provoking survey by our colleagues in Palm Beach County last year. Looking to the first state to enact significant health system reform on its own, Massachusetts, there are similar numbers of concern. According to the Massachusetts Medical Society, in the next decade, one-third of the state’s practicing doctors enter retirement age, and only 13 percent of the state’s practicing physicians are 35 or younger.

John W. Kilkenny III, MD 2010 DCMS President

Primary care specialists are the very foundation upon which our entire health care system relies. It is here where the focus is on disease prevention rather than treatment. In addition, this is where patients with chronic, complex diseases are managed. In most areas of this country, this is also where substance-abuse and mental-health problems are addressed. Research has shown that geographic areas with more primary-care physicians have better health outcomes at a lower cost.

The number of medical students going into family medicine residencies has dropped over 50% in the last decade. During the past three years, only 15 percent of U.S. medical school graduates chose careers in primary care. At the same time that the federal government is mandating medical insurance coverage for tens of millions of our citizenry, it is also restricting the numbers of the very same primary care physicians that are required for their care. Over the last decade there have been drastic cuts (55% in recent years) in the funding of federal grants for the training of family practice physicians (Section 747 of a program called Title VII). The complexity of caring for the increasing numbers of aging ‘baby boomers’, diminishing reimbursement rates in the face of proliferating regulations and time consuming paperwork, and ever spiraling student loan debts have only exacerbated the problem. On an annual basis, it has been estimated that physicians in private practice spend three weeks of their time and $68,000 worth of staffing costs in order to deal with the administrative constraints of the various third-party payers of health insurance. With each policy’s permutations, it becomes more and more difficult for a physician to devise a care plan that will comply with a patient’s particular coverage, e.g., unique drug formularies. Is the rest of ‘the house of medicine’ ready to conform and change to the concepts that are required to ameliorate this conundrum? Although higher remuneration for primary care is required, there has already been understandable resistance from specialists to take pay cuts as part of any zero sum formulation. But payment is only part of the revamping that is needed. Primary care physicians will need larger teams of ‘mid level providers’ to assist them in caring for these burgeoning populations of patients in their ‘medical homes’. These entities will need to be equipped with systems such as truly functional electronic medical records that will help them manage the flood of information that they’re already confronted with on a daily basis. In order to provide the highest quality care for our patients, how are we to remedy this impending crisis of being woefully short-handed in primary care? After years of steadfastly opposing any number of Scope of Practice intrusions in our Legislature, are we willing or able to adapt to the sentiment that large portions of primary care can be delivered by nonphysician team members in a far more expanded fashion than we presently have, albeit overseen by the physician team leader? Your representatives, medical and legislative, need to know your opinions before the decisions are made for you. (*Song title by Robert Allen Zimmerman) www . DCMS online . org

Northeast Florida Medicine Vol. 61, No. 2 2010 5


Offering the most comprehensive care possible so our patients can achieve the most complete recovery possible. Brooks Rehabilitation has been a leading provider of physical rehabilitation services in Northeast and Central Florida for more than 35 years. With expertise in treating stroke, spinal cord injury, hip fracture/orthopedics, pediatrics, and brain injury, Brooks offers a full continuum of services to support patients, including: • One of the largest inpatient rehabilitation hospitals in the Southeast • An extensive network of more than 25 outpatient centers • An established home health services division and • A cutting-edge research facility currently conducting over 20 clinical trials. With an extensive array of preventive, educational, and community-based services such as adaptive sports, Brooks is deeply committed to improving the health of the community, especially for those living with a disability.

BrooksRehab.org Rehabilitation hospital

home health CaRe

6 Vol. 61, No. 2 2010 Northeast Florida Medicine

outpatient theRapy

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www . DCMS online . org


Isn’t It Time You Called The Med Mal Experts? Danna-Gracey is an independent insurance agency with a statewide team of specialists dedicated solely to insurance coverage placement for Florida’s doctors. With offices located throughout Florida, Danna-Gracey works on behalf of physicians – well beyond managing their insurance policy. By speaking, writing and educating, we hope to effect positive change in the healthcare industry. We make it our practice to genuinely care about yours. For more information, please contact Stephanie Johnson at 904.215.7277 or stephanie@dannagracey.com.

Ask us about our Workers’ Comp dividend program for Duval County Medical Society members!

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Northeast Florida Medicine Vol. 61, No. 2 2010 7


Recognize These Physicians? If you do, it is because these DCMS Past Presidents helped shape medicine in Duval County.

Abel S. Baldwin, MD had a town named after him because of his reputation as a physician and community leader. E. Thomas Sellers, MD had the medical society lecture hall named after him (Sellers’ Auditorium - first “permanent home” of the DCMS) because of his influential leadership. Emmet F. Ferguson, Jr., MD had many young surgeons who revered his name because he mentored them and was a model of a “good man and good physician.”

The impact of these physicians (and many others) on the DCMS and surrounding area will be forgotten and lost unless the DCMS updates its published history. So DCMS is chronicling 157 years of medicine in a coffee table book. Two thirds of the book will include significant events that left a lasting impression on Northeast Florida and the local medical community. The remainder of the book will feature physician and practice histories and profiles, purchased by physicians, families, and groups who want to chronicle their footprint in Jacksonville’s storied history.

Be a Part of History! Contact Mr. John Compton, Publisher at 904-355-6561 x110 johncompton@dcmsonline.org 8 Vol. 61, No. 2 2010 Northeast Florida Medicine

www . DCMS online . org


Like Tall Pines, Residents Reach for High Goals Adithya Suresh, MD, is the photographer who snapped this issue’s cover shot of the tall pine trees at Guana River State Park is in St. Johns County along AIA between the Florida cities of St. Augustine and Jacksonville. These pines reach toward the sky just as residents stretch themselves mentally, emotionally and physically to reach high professional goals they have set for themselves and their medical careers. Dr. Suresh, a PGY-3 resident in the Department of Surgery at the University of Florida, College of Medicine in Jacksonville, has a career goal of being a surgeon and pursuing further training in minimally invasive surgery. Along with this ambition, he enjoys photography because as he says, “A great picture is one that captures the mood of the setting and creates memories that can be revisited many times over. For example, the cover photograph was taken in Guana River State Park in Ponte Vedra Beach, Florida, one of my favorite places to visit. Photography also gives me a chance to explore the creative side of myself, and this has proved to be a very enjoyable outlet.” He took the cover photo in the spring of 2008. He recalls, “I was still ‘new’ to Jacksonville, and I would spend my free time exploring the city and its surrounding parks and nature preserves, my camera in hand. This particular location soon became one of my favorite places to visit, and I return to it at every opportunity I have.” Besides an interest in medicine, photography has been a passion for Dr. Suresh since his high school years. He said, “I got interested at the time the first consumer digital cameras became available. What fascinated me the most was being able to instantly view my ‘results.’ When I was in college I was the chief photographer of the college newspaper. It was a great experience that not only allowed me to continue to take pictures on a professional level but also indulge my hobby of taking pictures whenever possible.” In addition to tall trees, Dr. Suresh likes to photograph landscapes, flora, fauna, buildings and “sometimes even people”. With all of these subjects, he wants to “capture the essence” of places he visits, such as the photograph of him in Kinderdijk, Netherlands in October 2009. (see below) He said, “I have always had an interest in traveling around the world, and I have been fortunate enough to visit many exotic locations. This naturally fueled my desire to capture the beauty of those locations.” As for Guana River State Park, he remembers, “Looking up and seeing the tips of the tall trees and the scudding clouds above them brought a sense of serenity that was refreshingly different from the frenetic pace at the hospital and the rigor of a typical work day. Every time I am there I experience absolute peace and solitude.”

www . DCMS online . org

Northeast Florida Medicine Vol. 61, No. 2 2010 9


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This Issue’s Focus: Resident Research

Resident Scholarly Activity Focuses on the Pursuit of Knowledge Socrates said “The only good is knowledge and the only evil is ignorance.” In this issue of Northeast Florida Medicine, we recognize the pursuit of knowledge of individuals in post-graduate training. In particular, we recognize the pursuit of knowledge in the form of scholarly activity. What is scholarly activity? Conrad Weiser in his 1996 article “The Value System of a University – Rethinking Scholarship” defines scholarship as “creative intellectual work this is validated by peers and communicated.”1 He further describes four forms of scholarship: discovery of new knowledge; development of new technologies, methods, materials, or uses; integration of knowledge leading to new understanding; and artistry that creates new insights and interpretations. In this issue, we feature articles that represent three distinct categories of resident scholarly activity: prospective studies, retrospective studies, and case studies. Each article makes its own contribution to the body of scholarly activity in existence. This year we are also highlighting resident commentaries on public health in “From a Resident’s Perspective.” The fact that these works were created within our region is a source of pride and a testament to the regional dedication to the educational process. I am sure many of the authors in the following pages would agree it is challenging to find time to dedicate and complete scholarly activity. Scholarly activity is also challenging to many potential authors because it is outside the normal realm of patient care, but it certainly has its place in both the art and science of medicine. Scholarly activity can be particularly challenging as a student, resident, or fellow facing potential obstacles J. Bracken Burns Jr., DO such as schedule issues, lack of support, and inexperience in the process of creating Assistant Professor of Surgery, such work. Therefore, I commend both the authors who are still in training and their Division of Acute Care Surgery, University of Florida, College mentors who helped them produce the scholarly activity in this issue. of Medicine, Jacksonville, FL

It has been a pleasure, an honor, and a challenge to serve as the Guest Editor for the 2010 Resident Scholarly Activity issue of Northeast Florida Medicine. Reference: 1Weiser, Conrad J., “The Value System of a University – Rethinking Scholarship.” 1996. http://www.adec.edu/clemson/papers/ weiser html. Accessed April 30, 2010.

J. Bracken Burns, DO, received the 2009 Philip H. Gilbert Young Physician Leadership Award at the 2010 DCMS Annual Meeting. This award, created to honor the memory and service of Philip H. Gilbert who served as Executive Vice President of the DCMS from 1984 until his death in 2004, recognizes Young Physicians with leadership traits that Mr. Gilbert would have admired. Candidates must meet the following eligibility criteria: A “Young Physician” from Northeast Florida, under 40 years of age or within the first eight years of professional practice after residency and fellowship training, as defined by the AMA; active in the DCMS or other organized medicine service; active in civic service; medical staff (or similar) leadership experience; and be a strong advocate for medicine.

Pencil sketch by Alexander Braddock

(Left) Dr. Burns with Dr. John Kilkenny III, DCMS President. (Center) A special pencil sketch of Philip Gilbert. (Right) Dr. Burns receiving his award from Dr. R. Stephen Lucie, DCMS Immediate-Past President.

www . DCMS online . org

Northeast Florida Medicine Vol. 61, No. 2 2010 11


Abstract Category 1 - Prospective Editor’s Note: The following data are presented clearly and conclusions are consistent with the data. Because of space limitations, we are only publishing abstracts. It is, therefore, inherently difficult to determine if some conclusions may overstate the magnitude or causality of the relationships identified. Resident author names are in bold

High Recruitment Efficiency Associated with a Study Evaluating Health Literacy in Patients Hospitalized with Acute Ischemic Stroke Kalina Sanders, MD1; Loretta Schnepel, ARNP1; Katryne Lukens-Bull, MS2; Nader Antonios, MD1; David Wood, MD3 and Scott Silliman, MD1 University of Florida College of Medicine, Jacksonville Campus, Departments of Neurology1, Office of Research Affairs2, and Pediatrics3

Background: Stroke is a common and significant cause of morbidity and mortality. Approximately 780,000 cases of stroke are reported in the U.S. each year, of which 180,000 represent stroke recurrence. Health literacy is the patient’s ability to obtain, process, and understand health information and services. Improving health literacy in stroke survivors may ultimately reduce the number of recurrent strokes in the U.S. via better adherence to medical therapies and healthy behaviors. The prevalence of poor, marginal, and good health literacy among U.S. stroke survivors is unknown.At Shands-Jacksonville, the Stroke Program is conducting a study that is evaluating health literacy in a cohort of patients with acute ischemic stroke (AIS). We report the recruitment efficiency associated with the first four months of this study. Methods: Consecutive patients with radiographically confirmed AIS who have been admitted to the Shands-Jacksonville Stroke Unit have been evaluated for inclusion into the study since September 8, 2009. All consented patients undergo validated tests to assess their health literacy during their hospitalization. Demographic, educational, stroke-specific and socioeconomic information is prospectively collected on all consented patients. Reasons for study exclusion are collected for all non-consentable patients. The number of patients refusing to consent is also collected. An interim analysis evaluating number of study recruits and non recruits was conducted. Results: Between September 8, 2009 and January 15, 2010, 89 patients had radiographically confirmed AIS. Of these, 34 (38%) were excluded from study participation.The primary reasons for exclusion were lethargy (n=11), dysphasia (n=10), and hospital discharge prior to recruitment (n=7). Of the remaining 55 patients that were approached for study participation, 40 (73%) consented to participate in the study. The average age of enrollees is 60 years of age. Twenty (50%) of those enrolled were male and 25 (62.5%) were African-American. Conclusion: During the first four months of our study, recruitment efficiency has been high with an average of 9.5 patients per month consenting to participate. Almost one-half (45%) of all admitted AIS patients have undergone health literacy assessment. This high recruitment efficiency is primarily due to a high rate of consent in study-eligible patients. Our interim experience suggests that hospital based studies evaluating health literacy in patients with AIS is feasible to conduct in an urban setting. In addition, our experience suggests that a racially diverse study cohort can be recruited into a hospital based health literacy study.

ED Documentation Training in the Face of ED Overcrowding Ben Lenhart, MD: Kelly Gray-Eurom, MD; and David Caro, MD University of Florida College of Medicine, Department of Emergency Medicine Editor’s Note: Due to production constraints, Figures 1 & 3 are not printed in the journal. They are available online at www.dcmsonline.org as a web illustration.

Background: Residency training in the face of Emergency Department (ED) overcrowding can present many challenges. Unique methods are often needed to maintain an educational environment conducive to preparing emergency medicine Residents to become competent practitioners, especially in educational areas identified as “holes” in the model curriculum. An American College of Emergency Physicians (ACEP) sponsored survey of new Emergency Medicine (EM) graduates identified deficiencies in training customer service concepts and practice management critical to success in the work environment. An ACEP sponsored survey to medical directors of non-academic emergency departments regarding their perception of the deficiencies seen in new EM graduates identified practice management, administrative functions, and communication skills as being areas in most need of improvement. Our emergency department is an academic urban program that sees approximately 90,000 patients annually.

12 Vol. 61, No. 2 2010 Northeast Florida Medicine

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ED and hospital overcrowding impacts our department on a daily basis, with ED length of stay times of greater than 11 hours for admitted patients, and overall turnaround times for discharged patients exceeding 5.5 hours over the past year. Our department identified the educational aspect of business management, and in particular improving coding and documentation, as one of our training goals in November of 2008, as an increase in deficiencies in documentation performance and chart completion were identified in conjunction with the length of stay delays. The department uses a templated documentation system (Xpress Charts, XPress Technologies © 2009) to record emergency department documentation. Completed ED treatment records are scanned into a computerized chart management system after patient disposition in the ED. Methods: An educational presentation was given during one of the residency’s planned weekly didactic sessions. Chart documentation educational review was then initiated. Departmental billing specialists forwarded coding downgraded charts to the department’s medical director. A brief chart documentation educational review was then performed, which included missing documentation, what level the chart should have been billed as compared to the level of medical service provided, what level the chart was actually billed at, and what revenue loss occurred due to this downgrading. (Figure 1, www.dcmsonline.org) This chart documentation education review was then sent to the resident provider for reassessment and education, especially in systems based practice and practice-based learning and improvement competencies. This data has been collected for quality review and is analyzed monthly during ED operations analysis. (Figure 2) Results: Data revealed that despite length of stay and overall ED patient volume being relatively consistent, the average charge per resident chart during the five months before and after this educational activity increased from $313.44 to $394.76. (Figure 3, www.dcmsonline.org) Residents seem satisfied with this educational component covering an educational aspect that is often insufficient during residency but expected after graduation. This review provides another method of training and assessment for departments whose attending physician coverage is at times stretched and detailed analysis of charts and discussion of the details of documentation from a business perspective can sometimes be difficult to perform. Conclusions: A combination of didactic training and real-time Continuous Quality Improvement (CQI) review both improved resident physician mean charges per chart and E&M coding levels, even in the setting of extended length of stay in a crowded ED. This process provides a method of competency-based training and assessment for emergency residencies in the setting of ED overcrowding, targeting an educational “hole” in the EM Model Curriculum that is currently in need of further training. In particular, it focuses on practice-based learning, systems based practice, and written communication skill competencies.

Figure 2 Monthly ED Operations Analysis

www . DCMS online . org

Northeast Florida Medicine Vol. 61, No. 2 2010 13


Pupillary Response After Neuromuscular Blockade Steven Andescavage, DO; David Caro, MD; Mohsen Akhlaghi, MD; Colleen Kalynych, MSH, EdD; Christina Hanna, BS and Jackie Barzyk, BD University of Florida College of Medicine, Department of Emergency Medicine Editor’s Note: Due to production constraints, Figure 1 is not printed in the journal. It is available online at www.dcmsonline.org as a web illustration.

Background: Neuromuscular blockers, both non-depolarizing and depolarizing, are commonly used in the Emergency Department for intubation of critically ill patients via rapid sequence intubation (RSI). RSI involves administering a sedative-induction agent followed by a neuromuscular blocking agent to render a patient sedated and paralyzed to optimize first-attempt intubation success. Neuromuscular blockers work specifically at nicotinic acetylcholine receptors at the neuromuscular endplate of striated muscle, and therefore should not affect the pupillary muscle response to light stimulation. Ciliary muscle activation and pupillary constriction is mediated by cholinergic reflex, and therefore is primarily controlled by muscarinic receptors (Figure 1, www. dcmsonline.org). The loss of pupillary response to light is often used for critical clinical decision-making, including the determination of presence of critical intracranial hypertension in the emergency setting, and brain death in the critical care setting. Objective: We sought to determine if pupillary response to light is affected by pharmacologic neuromuscular blockade during Rapid Sequence Intubation (RSI) in an emergency setting.  Methods: This Institutional Review Board (IRB) approved prospective, observational study consisted of a convenience sample of patients in a 100,000 patient/year, inner-city emergency department (ED) between February 2008 and February 2009 who received a depolarizing or nondepolarizing neuromuscular blockade for rapid sequence intubation. Patients were eligible for the study if their pupils displayed brisk (<1 second), > 1 mm constriction to light challenge prior to intubation. Two physicians (one resident, one attending) independently reviewed pupillary reactivity prior to and after intubation. Data collected included the patients’ age, gender, weight, admitting diagnosis, final diagnosis, RSI and Paralytic medication(s) given with dosages; Pupillary response prior to and post intubation. Results: Of the 96 patients who met inclusion criteria, 90 had pupillary activity after RSI confirmed by both physicians.  Two patients had physician disagreement on reactivity post RSI and 4 patients had no pupillary reaction confirmed by both physicians after RSI. Gross agreement of pupil reactivity of the observers was 98% (95% CI 93% - 100%), with κ = 0.82. A combined, liberal measurement of reactivity after paralytics (including the two patients with physician disagreement, or 92/96 patients) yields 96% (95% CI 90% - 99%), whereas conservative measurement (excluding the two patients with physician disagreement or 90/96) yields 94% (95% CI 87-98%).  Conclusions: To date, neuromuscular blockade with depolarizing or nondepolarizing neuromuscular blocking agents appears not to inhibit pupillary reactivity in the vast majority of patients whose pupils are reactive prior to RSI. A singular case of miosis occurred in an elderly woman who received more than 2 mg/kg of succinylcholine, which suggests muscarinic activation by an excessive dose. All patients intubated for neurologic reasons demonstrated normal pupillary activity after paralysis during RSI.

Use of Broselow Tape to Determine an Optimal Dosing Weight in Overweight Patients

Jason Lowe, DO; Robert Luten, MD; Colleen Kalynych, MSH, EdD; and Christine Hanna, BS University of Florida College of Medicine, Department of Emergency Medicine Editor’s Note: Due to production constraints, Figures 1,2 & 3 are not printed in the journal. They are available online at www.dcmsonline.org as a web illustration.

Background: The Broselow Tape (BT) has become widely accepted as a rapid, accurate method of approximating medication dosages in the pediatric population. (Figure 1, www.dcmsonline.org) By estimating a patient’s weight using his/her height, valuable time can be saved. Several studies have been published questioning the validity of the BT; especially in a time when obesity rates are climbing among children. Findings in these studies are not conclusive, yet authors imply that patients, especially taller/larger ones, may be receiving lower doses of medications than what would be administered if the patient’s true weight was known. Other systems, particularly the devised weight estimation method (DWEM) attempt to adjust the weight estimated by the patient’s 14 Vol. 61, No. 2 2010 Northeast Florida Medicine

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length by having the practitioner determine the patient’s body habitus. Consideration to make a similar adjustment based on body habitus has also been made for the BT. The aims of this study were to determine how accurate health care practitioners were at estimating body habitus; to determine if adding body habitus estimates increases the accuracy of the BT; to compare the dosages derived by the BT, the BT adjusted for body habitus and the patient’s actual weight based dosage; and to re-evaluate the overall accuracy of the Broselow Tape and its utility in the face of rising obesity rates. (Figures 2 & 3, www.dcmsonline.org) Methods: A convenience sample of patients presenting to University of Florida – Shands, Jacksonville’s Pediatric Emergency Department from 12/07 to 2/08 were enrolled into the study with parental consent. There were two types of study participants. The first set was children aged 0-12 years. Study investigators gathered the age, gender, race, weight and the patient’s height/ length at triage. Once data on the patient was gathered, the investigators then asked health care providers (HCPs – second type of study participant) to estimate the patient’s body habitus as normal, underweight or overweight. Health care providers were blinded to all the patient’s data. Several health care providers were asked to evaluate the same patient as the goal was to achieve 300 encounters or “guesses” overall. Each subsequent “guesser” was blinded to previous guesser’s answer. Further, health care providers were not given or reminded of the clinical definitions of overweight (95th%-ile) or underweight (<3%-ile). Results: A total of 122 patients were recruited during the study period. From these, 441 estimations were made about patients’ body habitus from 59 distinct health care providers (residents, fellows, attendings and physician assistants). As a “test”, our HCPs had a sensitivity of 67% and specificity 95%. Differences between non-adjusted weights and adjusted weights were compared by calculating percent of weight error (PE=((Actual Weight-Broselow Weight)/Actual Weight)) 100. A PE of 15% or less is considered to be acceptable. The mean PE (Table 1) was 36.7% for non-adjusted and 17.17% for habitus adjusted weights (P<0.0001). Non-adjusted, the tape provided 60% of weights within 15%. After adjustment, weights were within 15% of actual 80% of the time. We found that the differences (Table 2, p.16) between Adjusted and Non-adjusted PE and also Estimated Weight and Actual Weight values are only significant in Overweight patients (p <0.0001). Inter-observer reliability was assessed with a kappa score and shown to be acceptable with a value of 0.48. Despite this seeming inaccuracy, we found that allowing HCPs to make such a determination improves the accuracy of the tape by 25%. Also, we found that 15% of patients were found to be overweight, which is in line with national data from the National Health and Nutrition Examination Survey 2004 (NHANES), which estimated the rate of overweight being ~17% in children. Demographic data shows our study population to be similar to our overall patient population at Shands Jacksonville. (Table 3, p.16) Conclusions: Recent literature has been published cautioning users of the Broselow tape. Although adverse outcomes were not noted, authors warn against potential underdosing of obese patients when using the Broselow system. Contrarily, others note that optimal dosing may not be based on “fat body weight” but more appropriately by ideal body weight, which is what the Broselow system presents. The initial studies of the Broselow system discovered the potential for underestimating weight, and in actuality, concur with data presented in the more recent studies. At this time, it has not been determined whether this underdosing is detrimental. Other work needs to be done, but it appears that asking health care providers to make adjustments to the Broselow system would help, although 30% of the time, an increased dose would not be given. This is acceptable, because 70% of the time, overweight status is detected and this improves the Broselow tape’s ability to estimate weight by 25%. Admittedly, our kappa value is not optimal; however, we had a broad range of training levels among our estimators, including interns. Our next step will be to implement the Health Care Providers (HCP) body habitus estimations into a real time setting and

determine if they remain feasible and practical in a pediatric ER.

Table 1 Mean % Weight Error versus Adjusted Mean % Error % Weight Error

Adjusted % Weight Error

Patient Body Habitus

N

Mean

Std Dev

Mean

Std Dev

Overweight

58

36.70

10.78

17.17

15.29

Normal

348

7.11

11.05

8.06

16.68

Underweight

32

-18.22

20.16

-5.68

32.32

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Table 2 Difference Between Mean % Weight Error and Adjusted Mean % Error Adjusted - Non-Adjusted Percent of Weight Error

Tape Weight - Actual Weight

Patient Body Habitus

N

Mean

Std Dev

Mean

Std Dev

Overweight

58

-19.52

17.75

14.51

11.33

Normal

348

0.95

14.12

-1.32

2.57

Underweight

32

12.17

40.4

1.31

0.87

Table 3 Study Demographics Number (n)

Percentage (%)

Male

47

38.5

Female

74

60.7

Caucasian

12

9.8

Hispanic

2

1.6

AA

80

65.6

Asian

1

0.8

Unknown (not recorded)

25

20.5

0-4 years old

81

66.3

5-8 years old

21

17.1

9-12 years old

19

15.5

Overweight Body Habitus (BMI>95th%ile)

17

13.9

Underweight Body Habitus (BMI<3rd%ile)

4

3.3

Dr. Baker Receives the Philip H. Gilbert Award Stephen Baker, PhD., Jacksonville University Political Science Professor, received the 2010 Philip H. Gilbert Award from the Northeast Florida Healthy Start Coalition for his volunteer efforts as chair of the Community Advocacy and Public Policy Committee. Pictured at left is Karen Wolfsen, Chair of the Coalition, presenting the award to Dr. Baker. Dr. Baker, a Healthy Start Board member since 2001, has taken a leadership role in developing an advocacy strategy for the organization that includes volunteer training, development of issue papers addressing legislative priorities and annual legislative visits. He has also recruited new members and worked to link the Coalition to the larger non-profit community. The award was created in 2006 to honor Philip H. Gilbert, the founding chairman of the Coalition and also a past DCMS Executive Vice President.

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Abstract Category 2 - Retrospective Editor’s Note: The following data are presented clearly and conclusions are consistent with the data. Because of space limitations, we are only publishing abstracts. It is, therefore, inherently difficult to determine if some conclusions may overstate the magnitude or causality of the relationships identified. Resident author names are in bold.

Nitric Oxide Use in Adults with Acute Respiratory Distress Syndrome Nai Chao, PharmD; Paul Tan, PharmD, FASHP; and Amy Rockwell, PharmD Shands Jacksonville Medical Center, Department of Pharmacy

 Background: This study was designed to examine indication, dosing, and outcomes associated with inhaled nitric oxide (NO) use for acute respiratory distress syndrome (ARDS) at Shands Jacksonville Medical Center.   Methods: Adult intensive care unit patients from January 2006 through September 2008 who received NO for ARDS were retrospectively assessed for indication, dosing and outcomes. Actual use of NO was compared to recommendations developed at Shands Jacksonville Medical Center in January 2009. Those who met all of the recommended criteria for indication and dose were considered compliant and all others were considered noncompliant. The recommended criteria for use includes: an initial NO dose less than or equal to 10 ppm, PaO2/FiO2 of less than 200 mm Hg, an FiO2 greater than or equal to 80%, positive endexpiratory pressure (PEEP) greater than or equal to 12 cm H2O, and NO doses not exceeding 20 ppm throughout the course of therapy. Outcomes included in-hospital mortality, mechanical ventilation (MV) days, and costs of NO therapy. Results: Ten patients met the criteria for use and dosing recommendations and were included in the compliant group, with the remaining 63 patients allocated into the noncompliant group. In-hospital mortality occurred in 71% of those patients considered to be compliant and 56.3% of the noncompliant group (p = 0.053). Patients in compliance with the policy were on MV for an average of 28 days (median, 19.5 days) compared to 10.8 days (median, 5 days) for those who did not meet the recommendations. The difference between MV days between the groups is statistically significant (p = 0.048). Average hospital acquisition costs for NO in the compliant group was $18,206 (median, $9,687) and $13,802 (median, $6,853) in the noncompliant group (p = 0.732). Seven and 32 patients in the compliant and noncompliant group respectively, had either a PaO2 or SaO2 value recorded within 60 minutes of NO initiation and, therefore, provided enough data to evaluate oxygenation response. Five patients in the compliant group and 18 patients in the noncompliant group achieved a full response (p = 0.678), defined as greater than 20 % increase in PaO2 or greater than 10% increase in SaO2 within 60 minutes of NO initiation. Conclusion: The majority of patients (63 of 73) who received NO would not have met the new criteria for use; those who satisfied these criteria were associated with improved oxygenation, longer duration of mechanical ventilation, and higher cost without significant improvement in patient outcome.

Ibuprofen lysine: A Modified Dosing Regimen for Patent Ductus Arteriosus* Stephen J. Tan, PharmD; Renu Sharma, MD; William H. Renfro, PharmD; Linda Hastings, PharmD; and Mark Schreiber, PharmD Shands Jacksonville Medical Center, Department of Pharmacy

Background: In 2006 an IV form of ibuprofen lysine was approved for patent ductus arteriosus (PDA) closure. Based on recent pharmacokinetic studies, dosing regimens have been developed that may increase the success of PDA closure with ibuprofen lysine while decreasing adverse effects. The rationale of this study is to observe the effectiveness of a modified dosing regimen in a clinical setting. Methods: This was conducted as an observational, retrospective review of preterm infants with a documented PDA admitted to the Neonatal Intensive Care Unit (NICU) service at Shands Jacksonville. Inclusion criteria consists of patients between the gestational age of 25 and 34 weeks, postnatal age of 1 to 11 days, with moderate to severe respiratory distress needing mechanical ventilation, a echocardiograph (ECHO) documented PDA and receiving ibuprofen lysine for treatment of PDA. The primary outcome will be ECHO confirmed closure of PDA through comparison of a modified versus traditional dosing regimen of ibuprofen lysine. Secondary outcomes will evaluate the safety of the modified dosing regimen through adverse events. The primary www . DCMS online . org

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objective of this study is to compare the efficacy and safety of a modified dosing regimen when compared to a traditional dosing regimen of ibuprofen lysine when used for PDA closure. Results: There was no statistical difference in PDA closure (p=0.443) or safety outcomes when comparing a modified dosing regimen to a traditional dosing regimen of ibuprofen lysine when used in neonates. Conclusion: This study was not able to collect enough data to statistically show a difference in PDA closure or safety outcomes when using the modified dosing regimen. Currently data has been collected on 22 patients in the traditional dosing group versus 10 patients in the modified dosing group. Data collection is ongoing. *Unrestricted Educational Grant Received from Ovation Pharmaceuticals Inc.

Evaluation of Adequate Use of Antibiotics for Suspected Ventilator-associated Pneumonia in Critically Ill Trauma Patients Claire Chan, PharmD; Paul Tan, PharmD; Elaine Poon, PharmD; Nadia Shami, PharmD; and Marci Delossantos, PharmD Shands Jacksonville Medical Center, Department of Pharmacy

Background: Currently, there is growing evidence on the importance of initiating appropriate antibiotics for suspected ventilator-associated pneumonia (VAP). This study will assess the use of antibiotics for suspected VAP in trauma patients admitted to the surgical ICU (SICU) at Shands Jacksonville Medical Center. Methods: This is an IRB-approved, observational, retrospective review of databases that included trauma patients in the SICU on a ventilator greater than 48 hours, with suspected VAP, and with a bronchoalveolar lavage (BAL) completed between August 1, 2006-2008. Fisherâ&#x20AC;&#x2122;s exact and T-tests were used to analyze the data. The primary endpoint was frequency of adequate initiation of antibiotics for suspected VAP based on BAL results. Secondary endpoints include: appropriate antibiotic dose and duration, appropriate change in therapy based on BAL result, outcomes (ICU days, ventilator days, and ICU mortality), and appropriate antibiotic de-escalation. Results: There was 94% frequency of adequate initiation of antibiotics. Of the adequately treated group, 81% had appropriate dose, 8.5% had adequate duration, and 55% had appropriate antibiotic de-escalation. The adequate and inadequate treatment groups had mean ICU length of stay of 21.6 days versus 12.7 days (p=0.076), respectively. The adequate treatment group had mean ventilator days of 15.7; while inadequate had 12.7 ventilator days (p=0.608). The adequate treatment group had 26% mortality; while inadequate had 33% mortality (p=1.00). Conclusion: Antibiotics were adequately initiated 94% of the time. There was no significant difference between the adequate treatment group and inadequate treatment groups for mean ICU length of stay, ventilator days, or mortality.

Effects of Severe Hypoglycemia on Trauma Patients in an Intensive Care Unit Nicole Scott, PharmD; Paul Tan, PharmD; Kathleen Rottman, PharmD; and Julie Offutt, PharmD Shands Jacksonville Medical Center, Department of Pharmacy

Background: Many factors influence the outcome of patients in intensive care units. Age and severity of the disease state have been long standing factors that lead to increased morbidity and mortality. Within the last twenty years uncontrolled glycemic levels have been associated with an increased risk of adverse outcomes in critically ill patients. The main focus has been on hyperglycemia, which has led to the majority of ICU patients being placed on an insulin infusion and having their blood glucose levels tightly controlled. However, recent studies have shown that severe hypoglycemia may play a role in poor patient outcomes. For these reasons the purpose of the study was to determine the effects of severe hypoglycemia on trauma patients in an intensive care unit. Methods: The study was a retrospective, single center, observational cohort study conducted between January 2007 â&#x20AC;&#x201C; June 2008. One group consisted of trauma patients who have suffered at least one episode of severe hypoglycemia (blood glucose level < 40 mg/dL). The other group consisted of trauma patients with similar characteristics but with at least one blood glucose level

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between 70 â&#x20AC;&#x201C; 150 mg/dL but with no blood sugar less than 40gm/dL. All patients enrolled in the study were placed on an insulin infusion per the stress hyperglycemia insulin infusion protocol titrated to a target glucose levels being 80-120 mg/dL. Glucose levels were monitored hourly until target levels were obtained for 3 consecutive times in a row. There after blood glucose levels were checked every 2-4 hrs. Results: A total of 219 patients were included in the study, of which 73 were in the hypoglycemic group and 146 were in the non-hypoglycemic group. Mortality occurred in 25% of patients in the hypoglycemic group versus 12% in the non-hypoglycemic group (p = 0.01). The average total ICU days for the hypoglycemic group was 28 (2-152) and 13 (2-133) in the non-hypoglycemic group (p < 0.0001). In addition, the hypoglycemic group had longer average total ventilator days (21 vs. 8; p < 0.0001) and overall hospital days (40 vs. 22; p = 0.0002). The infection rate was also higher in the hypoglycemic group as compared to the non-hypoglycemic group (75% vs. 36%; p < 0.0001). When analyzing the main cause of the hypoglycemic event, insulin was the most common agent used (64%). This is an important factor to note since tight glucose control is always a topic of debate. During the study period the goal glucose level for patients on an insulin drip in an ICU was 80-120 mg/dL. Having this narrow glucose range may have increased the chances for the hypoglycemic event. Therefore it can be postulated that raising the target range to <180mg/dl could lead to fewer hypoglycemic events thus improve outcome of trauma patients. Conclusion: Overall patients in the hypoglycemic group experienced poorer outcomes as compared to the non-hypoglycemic group. Patients with blood glucose levels less than 40 mg/dL appeared to have a higher acuity with higher injury scores and have more hyperglycemic episodes. This was reflected in their worsening outcome. Hypoglycemia with blood glucose level less than 40mg/dL appeared to be a poor prognostic indicator for trauma patient.

Comparative Study of the Clinical and Tumor Characteristics in Women with Breast Cancer of Different Age Groups Atman U. Shah, MD; Fauzia Rana, MD and Elena M. Buzaianu, PhD (Statistician) UF Shands, Jacksonville, Department of Medicine

Background: Adjuvant chemotherapy for breast cancer improves survival in patients with early breast cancer with node positive disease. The goal of treatment with adjuvant chemotherapy is to prevent cancer recurrence and reduce cancer related mortality. The choice to administer adjuvant therapy is primarily based on the predicted benefits and risks for the patient. A large amount of literature describes age-dependent variations in treatment, showing that older women with breast cancer are less likely to receive adjuvant chemotherapy than younger women. We sought to identify patient and tumor characteristics in women of different age groups who received systemic adjuvant therapies at our institution. Methods: We collected clinical, demographic and treatment data from electronic data sources, including tumor registry data and patientsâ&#x20AC;&#x2122; medical records. Data of 465 women with breast cancer was reviewed and analyzed using SAS statistical software version 9.1. These women received adjuvant chemotherapy and were followed at the University of Florida, Shands Hospital from January 2001 to December 2007. The authors randomly selected 465 of 1,265 patients with breast cancer who received adjuvant chemotherapy and divided them into 3 groups on the basis of age. Each group was studied closely for differences in social factors (such as race and insurance status), clinical characteristics (hormone receptor status, node involvement, tumor size, type of surgery performed, and mortality) and pathological factors (tumor morphology). Results: Data of 465 patients was analyzed. Women with age less than 58 were placed in group A (n=155), ages within 58-69 in group B (n=155) and age greater than 70 in group C (n=155). There was a significantly (p = 0.004) higher incidence of infiltrative ductal or lobular carcinoma in younger women (Group A, B and C had 80%, 73% and 60% respectively). There was no significant difference between estrogen or progesterone receptor status between the three age groups.Younger women had a significantly higher incidence of node involvement than older women (p = 0.001).Younger women (group A; 53%) were more likely to undergo mastectomy than older women (group C; 36%, P = 0.02). There was no significant difference between the proportions of women who received endocrine therapies. The likelihood of developing a small tumor (< 2 cm) increased with age. Women with small tumors in group A, B and C were 28%, 34% and 46% respectively (p = 0.023). Older women were more likely to have insurance than younger women (p < 0.0001). Conclusion: The incidence of breast cancer increases with advancing age, and almost half of all new breast cancers in the United States occur in patients over 65 years of age. Some clinicians are hesitant to prescribe adjuvant therapies to older breast cancer patients. Our data showed that elderly women had some favorable prognostic factors. Older women were less likely to have large tumors (> 2cm) and less likely to have positive nodes. Infiltrative ductal/lobular carcinomas were more common in younger women. There were no differences between hormone receptor statuses. Older women were more likely to have medical insurance at our institution. www . DCMS online . org

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2nd Annual Quality/Safety Forum Draws Crowd The 130 attendees at the 2nd Annual Quality/ Safety Forum, May 7, 2010 at the University of North Florida University Center, heard Keynote Speaker Dr. Brent James (left at podium), the Chief Quality Officer, Executive Director, of the Institute for Health Care Delivery Research, Intermountain Healthcare in Salt Lake City, Utah and several panelists. Panelists pictured are (left, L to R) DCMS members Dr. Robert Nuss and Dr. William Rupp, Michael Spigel of Brooks Health and DCMS member Dr. Jay Cummings on the “Creating a Culture to Foster Outstanding Quality and Safety” panel. The forum focused on Creating a Culture of Quality, Communication and Collaboration. It was hosted by the UNF Center for Global Health and Medical Diplomacy and the Duval County Medical Society. (Far left, L to R) Dr. & Mrs. Yank D. Coble, Jr. (Dr. Coble is the Director and Distinguished Professor of the Center for Global Health & Medical Diplomacy at the University of North Florida) with Dr. David Moomaw. (Left, L to R) DCMS Executive Director Jay Millson and DCMS President Dr. John Kilkenny chat during a break.

it’s time for the 2010 BeAls & shAhin AwArds! John A. BeAls AwArd

G. shAhin AwArd

for medicAl reseArch

for reseArch By A physiciAn in trAininG in duvAl county

Articles submitted for the Beals Award must have been written by a member of the Duval County Medical Society, based on work done in Duval County. They must have been published between January 2009 and December 2009 in a peer reviewed periodical listed in the MEDLINE / PubMed journal database.

Articles submitted for the G. Shahin Award must have a resident or fellow in training in Duval County as the lead author. The majority of the work must have been done while the resident or fellow was training in Duval County. They must have been published between January 2009 and December 2009 in a peer reviewed periodical listed in the MEDLINE / PubMed journal database.

Beals and Shahin Awards will be considered in three categories: Original Investigation • Clinical Observation • Review Articles suBmission deAdline is August 6, 2010.

All winners will be recognized and receive plaques at the DCMS / Navy Meeting in late September, with the winners in the Original Investigation categories also receiving monetary awards. Please login to the DCMS website (www.dcmsonline.org) and follow the Beals / Shahin link (under “Quick Links”) to submit your article for consideration. You will be asked to complete a brief form with contact information, award category, and publication details, and if available, email a PDF file of your article as it appeared in print or electronically. If you have questions, please contact Marigrace Doran at 355-6561 ext. 101 or mdoran@dcmsonline.org.

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Abstract Category 3 - Case Study Editor’s Note: The following data are presented clearly and conclusions are consistent with the data. Because of space limitations, we are only publishing abstracts. It is, therefore, inherently difficult to determine if some conclusions may overstate the magnitude or causality of the relationships identified. Resident author names are in bold.

Molecular Analysis of Intravascular Large B-Cell Lymphoma with Paraneoplastic Neoangiogenesis Han W. Tun, MD and Christina Saurel, MD

Mayo Clinic, Jacksonville, FL, Department of Hematology/Oncology

Background: Intravascular large B-cell lymphoma (IVLBCL) is a rare subtype of non-Hodgkin lymphoma. In Western countries IVLBCL has a predilection for the central nervous system and the skin. We recently diagnosed a 77-year-old woman who presented with extensive, painful cutaneous nodules and spider angiomas of the torso and legs. A left thigh nodule was biopsied and lead to the diagnosis of IVLBCL with associated angioma and angiolipoma formation. Four other cases of patients with a similar presentation have been reported in the English literature but the pathogenesis for this neoangiogenesis remains unknown. We performed an in-depth molecular and pathologic analysis to elucidate the molecular basis for the paraneoplastic neoangiogenesis. Methods: The skin biopsy was fixed in formalin, embedded in paraffin, and sectioned at 3-micrometer intervals. Single antibody stain was performed for VEGF. Three observers evaluated the immunohistochemical results. Dual immunohistochemical studies were performed with the combination of Factor VIII /CD20, Factor VIII/Osteopontin (SPP1), and CD20 /SPP1. Presence of membrane staining for CD20, cytoplasmic staining for Factor VIII, predominant nuclear staining for SPP1, cytoplasmic staining for VEGF were scored as positive. Total RNA from biopsy specimen was extracted using RNeasy Mini Kit, according to manufacturer’s protocol. The control group consisted of diffuse large B-cell lymphoma (DLBCL) tissue samples from various sites. Nine primer sets targeted the following gene transcripts: vascular endothelial growth factor (VEGF) A, VEGF-B, VEGF-C, VEGF-D, VEGF-R1, VEGF-R2, VEGF-R3, and SPP1. Results: We reviewed the slides of the skin excisional biopsy. The dual stain for factor VIII and CD20 demonstrated CD20+ neoplastic B cells within the vessels, highlighted by factor VIII staining, consistent with IVLBCL. Intravascular neoplastic B cells showed strong expression for SPP1. The neoplastic intravascular lymphocytes also expressed VEGF. qRT-PCR confirmed the elevated expression of VEGF-A, VEGF-C, VEGF-D, and SPP1 in our case compared to other DLBCLs. Conclusion: Our experiments elucidate a molecular basis for paraneoplastic neoangiogenesis in cutaneous IVLBCL. Lymphoma cells produced proangiogenic agents such as VEGF and SSP1, which has been show to promote angiogenesis in other cancers. These proangiogenic factors appeared to have a paracrine effect, leading to angioma formation in the skin. SPP1 in IVLBCL has not been previously reported. In the future treatment of patients like ours, the addition of antiangiogenic agents should be explored. However, it is not completely clear to us whether antiangiogenic therapy would have had a clinically significant impact on outcome, as neoangiogenesis may not be directly involved in the development and maintenance of IVLBCL.

IleoSigmoid Knotting: Take a Second Look Ainsley Freshour, MD and J. Bracken Burns, Jr. , DO University of Florida - Jacksonville, Department of Acute Care Surgery

Introduction: IleoSigmoid Knotting (ISK) is a rare cause of intestinal obstruction that carries a very high morbidity and mortality. Awareness of its existence and pathogenesis increases prompt recognition and directs appropriate surgical therapy. Case Description: A 19-year-old male presented with acute peritonitis. A CT scan obtained prior to surgical consult showed marked ascites, air-fluid levels, and a “whirl” sign mid-abdomen suggestive of volvulus. At laparotomy, we encountered a copious amount of dark brown sero-sanguineous fluid and necrotic small and large bowel that were intertwined. Partial sigmoid colectomy and enterectomy of the involved small bowel was performed, and the patient was left in discontinuity, pending a second-look operation. After aggressive resuscitation in the ICU, a second look operation was performed 36 hours later which revealed viable bowel ends and two anastomoses were performed in a hemodynamically stable patient. The patient underwent an uneventful recovery and was discharged home on post-operative day 7/5.

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Discussion: With a mortality of 40% and a morbidity of nearly 100%, knowledge of IleoSigmoid Knotting (ISK), its pathogenesis, and its appropriate management is essential. Through a unique mechanism, a double-loop obstruction can rapidly progress to gangrene of the small bowel and often the sigmoid colon as well. There can also be associated thrombosis of the superior rectal vessels which can lead to late rectal necrosis. Patients frequently present with acute onset peritonitis and often have accompanying shock. At laparotomy, dark brown ascites and obviously necrotic bowel is encountered. This can be confusing for a surgeon who has never heard of ISK because there are necrotic areas of both small and large bowel that are difficult to untwist without perforation. Knowledge of ISK is important because therapy needs to take into account the possibility of late rectal necrosis. Traditionally, ISK patients have undergone ileal resection with entero-enterostomy and sigmoid colectomy with colostomy. We propose using “damage control” principles and planning a second-look operation. This accomplishes several things: initial operative time is shortened; questionably viable bowel can be left in the hopes of recovery; the patient can undergo early aggressive resuscitation; bowel viability can be reassessed at the second-look; any anastamoses performed can be done in a controlled environment on a more stable patient; and the need for a colostomy may be avoided. Hopefully by increasing the awareness of IleoSigmoid Knotting and proposing this surgical therapy, we can decrease both the morbidity and the mortality of this rare condition.

Spindle Cell Carcinoma: A Rare and Challenging Disease Entity Atman U. Shah, MD; Muhammad A. Salahuddin, MD; Linda R. Edwards, MD; Elaine Salazar, MD and Ronald M. Rhatigan, MD University of Florida, Health Science Center, Jacksonville, FL, Department of Medicine Editor’s Note: Due to production constraints, Figure 3 is not printed in the journal. It is available online at www.dcmsonline.org as a web illustration.

Abstract: Spindle cell carcinoma (SpCC) is a rare histologic variant of squamous cell carcinoma with an aggressive metastatic course and a high propensity for recurrence. The diagnosis is made histopathologically with the help of immunohistochemical stains. Our case examines this rare cutaneous spindle cell carcinoma that involved the perioral region in our patient. Our goal is to increase awareness of this rare malignancy and briefly review the currently available literature. Case Presentation: A 44-year-old Caucasian gentleman with a medical history significant of HIV (CD4 count of 18) was brought to the emergency room intubated, after being found unresponsive.He was successfully extubated after becoming more alert and oriented. He complained of generalized fatigue, weight loss (20 lb within the last 3 months), left upper arm weakness, as well as severe neck pain that had been ongoing for almost a year. His social history was positive for a 50 packs per year history of smoking. On physical exam he appeared cachectic and pale, but not in apparent distress. He had noticeable finger clubbing. The physical exam revealed a 2 x 3cm left upper lip, exophytic ulcerated lesion of 1 month duration. The remainder of the physical exam was unremarkable. A chest radiograph revealed a cavitary lesion in the right upper lobe. CT scan of chest also showed a 3x5 cm cavitary right upper lobe lesion (Figure 1, p.23) as well as multiple lytic lesions predominantly involving the thoracic spine and an associated compression fracture at T9 consistent with osseous metastases. The non-contrast head CT showed no acute infarct or hemorrhage but did show multiple lytic lesions within the calvarium and cervical spine (Figure 2, p.23). Initial differential diagnosis included multiple myeloma and/or an infectious pathology (tuberculosis, fungal) in the pulmonary system. Multiple myeloma was ruled out by a bone marrow biopsy that was negative for neoplasm or infection. A bronchoalveolar lavage and a CT guided biopsy of the lung lesion were both negative for neoplasm or infections, such as Pneumocystis Carinii Pneumonia (PCP) and tuberculosis. During the hospital course, the patient had a gradual worsening of left upper extremity weakness. An MRI of the spine revealed severe cord compression at C3. The patient was a poor surgical candidate and was started on dexamethasone in addition to being placed in a cervical collar. Finally in search of a tissue diagnosis, a biopsy of the upper lip lesion was performed and pathology was positive for spindle squamous cell carcinoma. Prior to being transferred to a nursing home, the patient had an acute respiratory decompensation and expired. Discussion: Spindle cell carcinoma (SpCC) is a rare histologic variant of Squamous cell carcinoma (SCC) having an aggressive metastatic potential and a high rate of recurrence. It may appear as an exophytic tumor or an ulcerated mass on the sun-exposed skin. Spindle cell lesions are more likely to occur within the head and neck regions where sun exposure is most prominent.1,2 We studied the case reports in literature to become more familiar with the approach to evaluation and treatment of this rare disease entity. Spindle cell SCC was initially reported by Martin and Stewart in 1935. It was believed that previous radiation was the most important cause, as six of the eight patients initially reported by Martin and Stewart, had a history of radiation and 22 Vol. 61, No. 2 2010 Northeast Florida Medicine

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half of them died of cancer.3 In 1972, Smith et.al proposed that SpCC had a more aggressive course when they arose at a site of previous radiation.4 SpCC was also been reported by Harwood in 1996, in a case series of renal transplant patients, of which 25% of patients developed metastatic disease.5 Histopathology: SpCC is part of a group of tumors that reflect a continuum in histologic heterogeneity as well as epithelial and mesenchymal differentiation. In our case, a final diagnosis of poorly differentiated spindled squamous carcinoma was reached by combining cytopathologic and immunocytochemical information. SpCC must be distinguished from spindle cell/desmoplastic melanoma, cutaneous leiomyosarcoma, atypical fibroxanthoma, and scar tissue, all of which are histological mimickers. On observation, the lesion is completely intradermal with no epidermal involvement. It is composed of very pleomorphic spindle cells arranged in a whorled pattern. The spindle cells have prominent nucleoli, scant eosinophilic cytoplasm and indistinct cell borders (Figure 3, www.dcmsonline.org). Numerous mitotic cells are present. In our case, the tumor stained positive for high-molecular weight cytokeratin (CK), vimentin and EMA. The tumor stained negative for desmin, CD 31, HHV8 and S-100, thus ruling out melanomas (S-100 positive) and atypical fibroxanthomas (vimentin positive). However, some poorly differentiated spindle cell squamous carcinomas may show loss of cytokeratin expression and aberrant vimentin expression, making the diagnosis even more challenging. Conclusion: Cutaneous spindle cell carcinoma is an uncom­mon malignancy marked by both lo­cal recurrence and distant metastases. The incidence of this cancer is unknown, with only a number of index cases reported in literature. Most common sites of this cancer are on sun exposed areas of the head and neck. Some studies indicate that previous radiation exposure is associated with higher risk of developing spindle cell carcinoma. Histologically, its dominant components have both epithelial and mesenchymal differentiation that mimics other cutaneous pathologies, making a diagnosis by cytopathology alone difficult. Therefore, immunocytochemical information is required to confirm this diagnosis. No clear management guidelines exist for this rare malignancy. Early diagnosis and surgical excision of lesions are most likely related to a better prognosis. Unfortunately, no large studies have been conducted regarding the prognosis of SpCC, especially comparing de novo lesions with radiation-associated lesions. The adoption of a comprehensive and universal treatment approach to SpCC will help in understanding the role of sys­temic chemotherapy in patients with metastatic disease.

References

1.

Someren A, Karcioglu Z, Clairmont A Jr. Polypoid spindle cell carcinoma (pleomorphic carcinoma). Oral Surg 1976;42:474–89.

2.

Randall G, Alonso W, Ogura J. Spindle cell carcinoma (pseudosarcoma) of the larynx. Arch Otolaryngol 1975;101:63–6.

3.

Martin HE, Stewart FW. Spindle cell epidermoid carcinoma. Am J Cancer.1935;24:273-297.

4.

Smith JL. Spindle cell squamous carcinoma. In: Graham JH, Johnson WC, Helwig EB, eds. Dermal Pathology. Hagerstown, Md: Harper and Row; 1972:631-635. Harwood CA, Proby CM, Leigh IM, et al. Aggressive spindle cell squamous cell carcinoma in renal transplant recipients. Br JDermatol.

5.

1996;135:23.

Figures 1 & 2 CT Scan of Chest and of Spine (L and R)

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An Unusual Case of Pancytopenia Shimona Bhatia, DO, MPH University of Florida, College of Medicine - Jacksonville, FL, Department of Pediatrics Editor’s Note: Due to production constraints, Figures 1-5 are not printed in the journal. They are available online at www.dcmsonline. org as web illustrations.

History of Present Illness: An almost three-year-old boy presented to the ER in June of 2008 with a three-week history of weakness, decreased activity, fussiness, decreased appetite. He also had a two-day history of fever (Tmax = 102.8 F), dry cough and a runny nose. He also had a few episodes of non-bloody, non-bilious vomiting in the last day. He was seen at an urgent care center the day prior to admission and prescribed amoxicillin. Earlier in the day, he was seen at his primary care physician’s office at which time he was “ill-appearing” and had symptoms of respiratory distress. Past Medical History: He has no significant past medical history. His immunizations were up-to-date. His medications included montelukast and a multivitamin. There were no known sick contacts. He eats a normal toddler diet. Physical Exam: T: 38.6 C, Pulse: 156, BP: 112/80, RR: 26, O2 saturation: 100% on 2L O2, Weight: 13.9kg, Height: 98cm. General: pale, mild respiratory distress. HEENT: normocephalic, clear TMs and oropharynx, PERRLA. Heart: tachycardia, regular rhythm, no murmurs. Lungs: poor air movement, clear to auscultation bilaterally. Abdomen: soft, nontender, mild splenomegaly, normoactive bowel sounds. Lymph: shotty cervical lymphadenopathy. Extremities: peripheral pulses 2+ bilaterally, capillary refill = 3 seconds. Neuro: no focal deficit, normal gait and sensation. Musculoskeletal: 4/5 strength in bilateral upper and lower extremities. Laboratory Studies: Initial laboratory investigation revealed a marked pancytopenia. (Table 1) Discussion: Due to the severe anemia, he received a pRBC transfusion and had a bone marrow biopsy. Since his laboratory evaluation revealed a pancytopenia, he was given the presumptive diagnosis of leukemia. Bone marrow biopsy revealed a hypercellular marrow, virtually no blasts, giant bands and megakaryocytes. Megaloblastic erythroid precursor cells were present with characteristics consistent with nuclear cytoplasmic asynchrony (large immature nucleus in a mature cytoplasm). The myeloid to erythroid cell ratio (M:E ratio) was 1 to 2-3 (normal = 3:1). Further evaluation of his initial CBC revealed a significant macrocytosis. The work-up included microscopic evaluation, measurement of markers of rapid cell turnover (lactate dehydrogenase, uric acid and unconjugated bilirubin) and an evaluation of the reticulocyte count. The simultaneous presence of increased markers of rapid cell turnover, low reticulocyte count, high mean corpuscular volume, high red cell distribution width and a hypercellular marrow indicates ineffective erythropoiesis which is consistent with megaloblastic anemia. Megaloblastic anemia is characterized by the presence of oval macrocytes and hypersegmented neutrophils on a peripheral blood smear. (Figures 1-5, www.dcmsonline.org) Megaloblastic anemia is caused by either a deficiency of folate or vitamin B12 (cobalamin). His serum vitamin B12 level was found to be markedly low. A endoscopy was performed and revealed normal gastric and duodenal mucosa. He was found to have serum antibodies to intrinsic factor. He was treated with IM B12 for 5-6 days. His repeat B12 level was normal, so he was discharged home with oral high-dose B12. His final diagnosis was antibody-positive congenital pernicious anemia. To date, in the literature there are no isolated, recorded cases of congenital antibody-pernicious anemia in an otherwise healthy child.”

Table 1 Laboratory Values (Normal values) WBC Hg / Hct Plt MCV Reticulocyte count B12 Folate MMA

Initial Evaluation 2.19 (6-17.5) 2.8 (11.2-14.3) / 8.1 (34-40) 72 (150-450) 109.2 (75-87) 6.1%/50,000 73 (190-914) 15 (3-17) 2.423 (0.073-0.376)

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Post-Treatment Evaluation 8.55 (6-17.5) 13.6 (11.2-14.3) / 39.4 (34-40) 241 (150-450) 79 (75-87) Not done >1500 (190-914) Not done 0.152 (0.073-0.376)

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Olfactory Neuroblastoma with Hyponatremia Altman U. Shah, MD; Jamie Woodcock, MD; and Fauzia N. Rana, MD University of Florida, Health Science Center, Jacksonville, FL, Department of Medicine

Abstract: Olfactory neuroblastoma (ONB), also known as esthesioneuroblastoma, is a rare malignant tumor of neuroectodermal origin with an estimated incidence of 0.4 per million. It represents one to five percent of malignant nasal tumors. Early diagnosis is uncommon because of vague symptomatology at presentation. No TNM staging has been created for this type of tumor. Imaging is useful in assessing local invasion of tumor, although is insufficient to make a diagnosis. Definitive diagnosis requires examination of histology and confirmation with electron microscopy and immunohistochemistry. We describe a patient that presented with uncommon features and review the current available literature. Case Presentation: A 26-year-old Caucasian student who presented to clinic with a 2-year history of sinusitis and nasal congestion that was also associated with changes in smell. He had no history of bleeding, facial pain, discharge, recurrent infections, headache, or visual complaints. His medical records revealed an anxiety disorder and hypertension, as well as, chronic hyponatremia and Syndrome of Inappropriate Antidiuretic Hormone Hypersecretion production (SIADH). He was being treated with Demeclocycline. On evaluation, he was found to have a polyp, left-sided sino-nasal mass with an otherwise normal exam. CT imaging revealed a 3.9 cm expansile mass of the left anterior ethmoid sinus with extension into the left superior medial maxillary sinus and superior left nasal cavity. An MRI showed scattered white-mattered lesions. A PET scan showed mildly hypermetabolic lymph node at of the left superior jugular lymph node chain, measured about 1.3 cm in size and a sinonasal mass that was encroaching on the left medial orbit as well as several plaques in the white matter. He was taken to the operating room where an endoscopic dissection and biopsy was performed. Definitive resection could not be performed due to massive bleeding. He underwent lymph node dissection, and all lymph nodes were negative for neuroblastoma. Left maxillary biopsy was consistent with pigmented olfactory neuroblastoma. The tumor involved the bone and sinonasal structures. It was composed of primitive small clue cells with focal rosette formation. The mitotic activity was low and more consistent with low-grade olfactory neuroblastoma. Following surgery his hyponatremia completely resolved. He received post operative low-dose Cisplatin 20 mg/m2 on a weekly basis along with radiation therapy twice per day. After 16 months of follow up, there was no evidence of recurrence. Discussion: Olfactory neuroblastoma (ONB) is an uncommon malignant tumor that represents up to 5% of malignant nasal tumors. It has no predilection for race or sex.1 There is a wide age distribution with bimodal peaks in incidence between 11-20 and 51-60 years of age. There are no known genetic mutations or etiologic agents for ONB in humans. ONB originates from the basal olfactory epithelial stem cells located in the upper third of the nasal cavity. Grossly, it appears as a smooth, hemorrhagic, and polypoid mass.2 Microscopically, it is composed of uniform cells with scant cytoplasm and small, round nuclei localized to nest or lobules in the submucosa and stroma.3 The most common presenting symptoms are unilateral nasal obstruction, epistaxis, and persistent nasal discharge. Less common symptoms include headache, hyposmia, anosmia, visual disturbances, proptosis, facial pain and swelling, and syncope.4 In most cases the diagnosis is delayed for months because the common symptoms are often passed off as benign sinonasal disease. Diagnosing ONB requires histochemical analysis in order to rule out other small round cell malignant neoplasms of the sinonasal tract. The differential diagnosis includes undifferentiated carcinoma, lymphoma, melanoma, embryonal rhabdomyosarcoma, and extramedullary plasmacytoma.5-6 These tumors are graded by Hyamâ&#x20AC;&#x2122;s classification system, which is comprised of four grades differentiated by histologic characteristics. Grading is based on the presence of certain histologic features such as lobular architecture, nuclear pleomorphism, rosettes, mitotic activity, and cellular necrosis. The less differentiation a tumor shows, the higher grade it receives on a scale of 1 through 4.7 Staging for these tumors uses the Kadish system. In this system, stage A is confined to the nasal cavity, stage B spreads to the paranasal sinuses, and stage C extends beyond these regions to include the orbit, intracranial cavity, skull base, cervical lymph nodes, or distant metastases. High tumor grade and disease stage correlate with a poor prognosis for the patient.8 Conclusion: A diagnosis of ONB requires proper tumor grading and clinical staging with radiologic imaging, followed by rigorous treatment. Aggressive surgical resection followed by adjuvant radiation therapy is the mainstay of treatment for any neoplastic stage. This combination therapy has been shown to have the highest cure rate. Chemotherapy is usually reserved for advanced disease due to its limited success as a curative modality. Five-year survival ranges from 40% to 80% depending upon the state and grade. Patientâ&#x20AC;&#x2122;s with low-grade tumors have 80% five-year survival, but those with high-grade have 40% survival. About 30% can develop local recurrence usually within the first 2 years, and 15% have cervical lymph node metastasis, and 10% will develop metastasis at some point during the course of the disease.9

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References 1.

Sheldon R, Brown SR. Esthesioneuroblastoma. Otolaryngology Head and Neck Surgery 2007; 137(5): 835-6.

2.

Castelnuovo P, Bignami M, Delù G, et al. Endonasal endoscopic resection and radiotherapy in olfactory neuroblastoma: our experience. Head Neck 2007;29:845–50.

3.

Esposito, DF Kelly and HV Vinters et al., Primary sphenoid sinus neoplasma: a report of four case with common clinical presentation treated with transsphenoidal surgery and adjuvant therapies, J Neurooncol 76 (2006), pp. 299–306

4.

Sampath P, Park MC, Huang D, et al. Esthesioneuroblastoma (olfactory neuroblastoma) with hemorrhage: an unusual presentation. Skull Base 2006; 16(3): 169-73.

5.

Pagni F, Di Bella C, Bono F, et al. A 37-year-old woman with epistaxis and unilateral nasal obstruction. Neuropathology 2007; 27(6): 609-11.

6.

Capelle L, Krawitz H. Esthesioneuroblastoma: a case report of diffuse subdural recurrence and review of published studies. Journal of Medical Imaging and Radiation Oncology 2008; 52(1): 85-90.

7.

Hyams VJ, Batsakis JG, Michaels L (1988) Atlas of tumor pathology. Armed Forces Institute of Pathology, Washington, pp 240–248

8.

Kadish S, Goodman M, Wang CC. Olfactory neuroblastoma: a clinical analysis of 17 cases. Cancer 1976; 37:1571–1576.

9.

Dulguerov P, Allal AS, Calcaterra TC. Esthesioneuroblastoma: a meta-analysis and review. Lancet Oncol 2001; 2:683–690.

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From a Resident’s Perspective Editor’s Note: The opinions expressed in these essays are the personal perspectives of the resident authors and may or may not represent the views or ideology of the publisher, the University of Florida or Shands Jacksonville. Resident author names are in bold.

Prescribing Justice for Girls: More Than 2 Tylenol Monica Marcus, MD University of Florida, College of Medicine, Jacksonville, FL

An unfortunate circumstance affecting the city of Jacksonville, Florida and the United States is the rising number of girls involved in the juvenile justice system. In a national survey conducted in 2001, the delinquency cases for girls had increased nationally by 83%, a significant increase worthy of intervention. Currently in Florida, almost one out of every three juveniles arrested is female. Girls are the fastest growing segment of the juvenile justice system, and it is time to take action to stop this growing trend. There appears to be a link between victimization and delinquency among this population. In Jacksonville, it was noted that up to 73% of the girls involved in the juvenile justice system reported being victims of violence, especially sexual abuse, familial substance abuse, domestic and community violence. Emotional factors also play a huge part in their delinquent behaviors. Seventy-nine percent (79%) of girls in the residential programs and 84% of girls in the non-residential programs suffered from depression, trauma, anger, self-destructive behavior or other mental health/clinical diagnoses. The fact remains, however, that the types of offenses for which girls are arrested and incarcerated are less serious than those for boys. Their offenses range from status offenses (18%) to technical violations (15%) and simple assault (15%). Detained girls pose less of a public safety risk compared to boys, making it more beneficial to invest in less expensive community-based services for them rather than the more costly residential commitment. During my community rotation, I was able to interact with girls at the PACE Center. The PACE Center for Girls is a free, non-residential private school for high-risk girls who have not yet entered the juvenile justice system, but are from high-risk environments. These girls experience an average of five risk factors including chronic truancy, learning disabilities, documented child abuse, parental incarceration, substance abuse, running away, gang membership and absentee parents. It is unfortunate to think that these children were already at a disadvantage from birth based on their environments. The PACE Center offers sound academics, intensive therapeutic counseling and case management, family care coordination, health education and remedial academic attention. I had the opportunity to observe a one-on-one interaction between the school nurse practitioner and one of the PACE students. The student came to the school-based clinic at PACE for “headaches”, a common complaint among these girls. Her social history revealed that she had been sexually assaulted numerous times by a male adult family member. We also learned that her uncle had just died in Iraq and was being brought home for funeral services that weekend. The list of stresses and problems experienced by this young girl were numerous. It was disheartening to hear that these so-called headaches were quite complicated and required a more in-depth treatment than just 2 Tylenol. PACE Center for Girls in Jacksonville is a very successful program with extraordinary outcomes. According to the PACE Center website, 100% of the girls enrolled in the program had no involvement with the juvenile justice system within a year of leaving PACE, 100% were in school or employed three years after leaving PACE and 97% improved their academic performance (www.pacecenter.org). This program really helps to enhance the future of these vulnerable girls. I think it is important for pediatricians to ensure that these girls receive proper health care in a safe medical environment. It is essential to advocate for these girls clinically so they delay pregnancy, practice safe sex and live in a safe home. It is also critical for pediatricians to advocate on the local, state and national levels to promote public policy for improved outcomes for these girls.

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As physicians, we need to write to our legislators to encourage stable and ongoing funding for places like the PACE Center for Girls. We also need to advocate for a safe environment for these girls to go to if they are not being provided one at home. Programs that offer specialized mental health services, substance abuse treatment, family focused services, specialized medical care, educational and vocational services, transitional placements and services need to be appropriately funded and made accessible to these girls and their families. It is imperative that physicians stay informed about and support programs that promote gender-specific strategies for at risk girls that will prevent them from entering the juvenile justice system. One such program is the National Council on Crime and Delinquency (NCCD) Center for Girls and Young Women, a newly formed organization in Jacksonville that provides community and professional education and training, assessment, research, evaluation and advocacy to ensure the continued well-being of at risk girls (www.justiceforallgirls.org). The time is now. We must advocate for the livelihood and wellbeing of these girls and the programs that service their needs TODAY! 1.

References

Patino V, Ravoira L, Wolf A. A rallying cry for change: charting a new direction in the state of Florida’s responses to girls in juvenile justice. Focus Views from the National Council on Crime and Delinquency, 2006, pp.1-6

2. Children’s Campaign, Inc. Girls in Florida’s juvenile justice system; do we truly see their pain? pp. 1-3. http://www. iamforkids.org/promises/promise5/facts5.asp. Accessed 4/29/10. 3. Jacksonville’s Children’s Commission. 2009 state of Jacksonville’s children: racial and ethnic disparities report, pp. 76-87. http://www.coj.net/NR/rdonlyres/ehcqorshfk35wi27tk6n7isj4g5lxoq5rn25g76kgriokkozpqkfmxh356lnbwe kyt3tjefzlhzlgijocfc5uto25yb/2009+Racial_Ethnic_Disparities_Report.pdf. Accessed 4/29/10.

Hostage Situation: Rescuing the Children of New Town Ngozi Ogbuehi, MD University of Florida, College of Medicine, Jacksonville, Department of Pediatrics

Eyes fixed, heart pounding, sweat dripping, I watch a loved one lingering close to death. Fear captures my body. I want to scream and I want to shout, but what difference will my voice make? I am one person. What can I do to stop this? Where do I even begin to help? I am inundated with feelings of helplessness. Yet all I can do is stand and watch as my loved one is held hostage in the grips of an attacker; one that has no other goal but to strip my loved one of dignity, strength, and eventually life. Now imagine that the hostage is not a loved one but a community and the attacker is not death or a masked gunman but well-known offenders that have been around for years – poverty and crime. New Town, a once thriving community of Jacksonville, is held hostage by poverty and crime. It is an area of the city not mentioned in tourist brochures. Ninety-seven percent (97%) of New Town residents are African American and 35% of residents live in poverty. Roughly half of the adults do not have a high school diploma and the effects can be seen in poverty and violent crime rates. The homicide rate in New Town is the highest in Jacksonville.1,2 There are over 1,500 children living in the New Town community. They are resilient children who have faced staggering odds from birth. Sixty-four percent of their families are headed by single mothers. In 2000, there were nearly 400 births in New Town, with 23% of these births to teenage mothers.1 This is not surprising since New Town is nestled within the urban core of Jacksonville which has the highest rate of teen pregnancy in the city. In 2000, 81 per 1000 girls, ages 15-19 years old, became pregnant in this area, compared to the county average of 51 per 1000 girls. These teen mothers are among the adolescents and young adults, ages 15-24 years old, with the highest rates of sexually transmitted infections (STIs) in Duval County. The cofactors of young mothers, STIs, poverty and low educational attainment combine to produce the highest rates of low birth weight babies and infant mortality in Duval County. With an infant mortality rate of 13 per 100,000 live births, which is significantly 28 Vol. 61, No. 2 2010 Northeast Florida Medicine

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higher than the county, state and national rates, surviving birth and living beyond the first year of life is a daunting task for New Town infants.2 The children of New Town attend the neighborhood schools, S.P. Livingston Elementary and Eugene Butler Middle Schools. Livingston is an ‘F’ grade school and Butler middle is a “C” grade school by Florida Department of Education standards. Over 90% of the students are African-American and participate in the free or reduced lunch program.3 Both schools are challenged by the urgency to improve student FCAT scores and overall academic performance. Once the children of New Town leave school, they encounter the other factors that impact the trajectory of their lives. They see joblessness, with unemployment rates in this area double the Duval County rate. They see their loved ones dying prematurely from and/or living with complications of diabetes, heart disease, and HIV/AIDS, all of which have the highest rates in this area of Jacksonville. HIV/AIDS related deaths in this community occur in 42.4 per 100,000 persons, which is almost 4 times as high as the Duval County rate of 11.8 per 100,000 persons.2 This area also has the highest rates of asthma hospitalizations in Jacksonville.2 When driving through the neighborhood, it is easy to see how the physical environment also affects the lives of the children. Many of the homes are old and in disrepair. There are several boarded-up shops in the area, a reminiscent sign of a time when this community thrived. Children are rarely seen playing outside. The violent crime rate or the perception of high crime may lead parents to keep their children indoors. There is a noticeable absence of grocery stores in this neighborhood. The children have no access to fresh fruits and vegetables, only fast food restaurants and convenience or “mom and pop” stores selling processed foods and high-calorie snacks. How can we expect children to maintain normal weights if they are not able to play outside and there are no healthy food options? Even with so many factors negatively affecting them, this community is resilient. Although they have been taken hostage, they are fighting back. In 2008, a group of local civic leaders formed a coalition to improve New Town. The New Town Success Zone Steering Committee was inspired by the progress of the Harlem Children’s Zone in New York City. The group, under the leadership of the Jacksonville Children’s Commission, engaged the Jacksonville Sheriff’s Office (JSO) and nonprofit organizations and groups to create a conveyor belt of services to improve the lives of children in New Town from birth through college graduation. Although still in the beginning phases, the group has made progress. In the past year, police officers from JSO have increased their presence in the neighborhood and have worked hard to strengthen their relationship with residents in an effort to reduce crime and gain trust. The Department of Children and Families enlisted the farmer’s market, located near New Town, to begin taking Food Stamps as a means to increase resident access to fresh fruits and vegetables. The Northeast Florida Healthy Start Coalition increased services for pregnant women and along with other organizations, provides parenting and male involvement classes in New Town. Baptist Health provides asthma education for children with asthma who attend S.P. Livingston Elementary and Eugene Butler Middle schools. They recently contracted with the Health Planning Council of Northeast Florida to work with New Town residents to conduct a thorough community assessment of New Town. After school programs and activities have been made available for the children, giving them a safe place to play and learn outside of school. Edward Waters College, a small historically black college located in the center of New Town, opened its doors to the community, volunteering its facilities for community meetings and a variety of much needed community services. There is hope that bringing the neighborhood residents on campus will inspire them to explore higher education and job training opportunities. Although the Steering Committee has made great progress, ongoing efforts to keep the residents informed about programs and opportunities in the community and involve them in strategies to improve their own neighborhood, is critical. If the New Town residents are involved, feel empowered and are able to make decisions about their own community, then the positive impact that is currently being made will continue, long after funding ends and organizations move on to their next projects. When I first learned about New Town, I felt like the helpless person watching a loved one being held hostage. The problems of New Town are large, complex and overwhelming. How do I help? What contributions could I make? Now that I am learning more about the important advocacy role of pediatricians and all physicians in the community, I am

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empowered to join with the New Town Success Zone Steering Committee to improve the lives of the children within New Town. My voice will not be small when I join a chorus of others speaking for the same issue. What I, as a pediatrician, can do to aid in the mission of the New Town Success Zone is what any physician in Jacksonville can do to advocate for children and the communities in which they live. • Become more knowledgeable about the community, its demographics, and its residents by spending time volunteering with various organizations and programs in the community. • Understand the social and environmental determinants of health most affecting children’s health outcomes and implement evidence-based strategies that have worked to improve these outcomes elsewhere. • Form relationships with the local, state and national policy makers who are responsible for this area in order to promote more effective advocacy for the children and families of this community. The children and families of New Town have the potential to overcome the hardships that have befallen their predecessors and become the hostages who successfully break from the grips of their attackers – poverty and crime. This can be done more effectively through the help and support of others- people like me and you who are no longer afraid to face the attackers and conquer them. If you would like to support the activities of the New Town Success Zone Steering Committee, visit the website http://www. jaxkids.org/Departments/Childrens+Commission/Community+Information+and+Resources/New+Town+Success+Zone.htm for more information or contact Program Manager Irvin “Pedro” Cohen at (904) 630-6339 or ICohen@coj.net

References

1.

Jacksonville Children’s Commission. Success Zone Briefing Paper I http://www.jaxkids.org/NR/rdonlyres/ pxcnydddwn2uxrfihsipynstqkagfymuf/Success+Zone+Briefing+Paper+I.pdf Accessed March 2010. 2. Duval County Health Department. Health: Place Matters. 2008; Issue 1,7:1-10. 3. Florida Department of Education. School Grades by County http://schoolgrades.fldoe.org/default.asp. Accessed March 2010. 4. United States Dept of Agriculture. Income Eligibility Guideline for Free and Reduced Lunch. http://www.fns.usda.gov/ cnd/Governance/notices/iegs/IEGs09-10.pdf. Accessed March 2010.

The Problem with the American Health Care System Nararjun Rayapudi, MD and Joseph J. Tepas III, MD University of Florida, College of Medicine, Jacksonville, Department of Pediatrics

Introduction As an international medical graduate, I had minimal exposure to the American health care system before starting residency training. I graduated from medical school in India and realized that I was working and learning in an underdeveloped health care system. Many patients were not getting adequate health care because of lack of facilities, money, or available skilled personnel. I wanted to pursue further education in what is recognized as one of the best health care systems in the world. This led me to the United States. In my training, I picked up the clinical aspects of patient care very quickly, however, I developed several questions about the system.

My Project To gain deeper understanding of the American health care system, I spent six weeks on an elective rotation in health administration. I was assigned to the administration department of Shands Jacksonville; a 696 bed, tertiary care, teaching hospital. My faculty mentor also arranged a one week rotation at Orange Park Medical Center, a HCA hospital. This helped me appreciate the differences between a safety net hospital and a private hospital. My colleagues in the administration at Shands hospital included two residents who had finished MBAs in health care administration and were doing a one year internship at this facility. I functioned as the third resident under the mentorship of Mr. Steve Blumberg, Vice President of Business Development and Strategic Planning. As an administrator, I attended numerous business meetings, interviewed personnel from various departments of administration 30 Vol. 61, No. 2 2010 Northeast Florida Medicine

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and learned their perspective. I conducted one-on-one interviews with personnel from several departments including human resources, patient safety, financial evaluation, quality improvement, infection control, labor, purchasing, pharmacy, and risk management.

Impressions of a Trainee First and foremost, there is mind boggling complexity in the American health care system. It became increasingly apparent that the organized system of health care is fragmented and confusing. If this were my perception as a provider, I could only wonder about the intensity of challenge for sick patients and their family members trying to decipher this system in times of need. Perhaps as importantly, this incredible complexity also contributes to high cost of health care as is clearly evidenced by the fact that almost 25 to 33% of U.S. health care spending goes to administrative functions, not clinical services. There is a huge difference in perception of the health care system by administrators in comparison to health care providers. Through interviews and observations, I noticed that the focus of most administrators was improving the financial performance of the hospitals and trying to survive in a challenging economy that includes intense competition. Clinicians, on the other hand, were more focused on improving quality of care and patient outcomes. It appeared to me, often times, the cliniciansâ&#x20AC;&#x2122; commitment to providing what is considered to be optimal care did not include consideration of potentially controllable costs. Conversely, administrators constantly struggled with the mandate to provide an appropriate margin to continue support of the clinicianâ&#x20AC;&#x2122;s mission. On some occasions, this disconnect between perspectives seemed to indicate that the clinicians and administrators are working against each other. A major contributor to this disconnect is the variability of payer mix among different hospitals. At most safety net hospitals the percentage of self pay, mostly uninsured patients, approached 30%, whereas at private hospitals approximately 10% of patients are uninsured. Throughout my residency, I have encountered many patients who were seen and evaluated at other hospitals and referred to Shands because they lacked insurance. It appears that absence of insurance is a bigger problem than cancer, coronary artery disease, or many other potentially catastrophic illnesses. It is unfortunate that the U.S. is the only industrialized nation that does not provide some form of basic health care to its citizens. Although quality care at a high cost is readily available to many, almost 50 million Americans are uninsured and donâ&#x20AC;&#x2122;t have such access. In addition, 16 million people are considered underinsured. These working poor are more likely to die from preventable illnesses and present with advanced disease states because they have no access to routine medical care. The third observation that is possibly even more compelling is that our excessive spending does not translate to better health compared to other nations. The life expectancy in United States is 78, which ranks 50th in the world, well behind Singapore, Japan, Bermuda, Greece, Jordan and Bosnia. The Infant Mortality Rate is 6.26 (per 1000 births) in the U.S. which is higher than most of the developed countries. The World Health Organization (WHO) ranked the health care system of 191 nations in 2000. France and Italy were first and second: the U.S. was in the 37th position. Finally, it appears that despite the above problems, the U.S. spends 16% of its Gross Domestic Product (GDP) on health care, which is the highest proportion among all other nations in the world. The nearest rival, Switzerland, spends 11.5% of its GDP, followed by Germany (10.6% of its GDP), and Norway (8.9% of its GDP). The problem is not just that the current spending and costs are high, but that they are projected to increase significantly and may bankrupt America in the future.

Conclusions My illusion at the time of beginning of my residency training was that the American health care system is the best in the world. Yet, this system has major problems. It appears that the U.S. provides the best health care available to patients at the individual level but fails at the system level. This country lags behind other advanced nations in delivering quality health care in a timely fashion. Health care here is expensive and not accessible to all people. Both quality and coverage are inconsistent. The recently passed health care reform legislation addresses some of the problems by expanding insurance coverage, focusing on cost containment, and increasing regulation of insurance companies. I believe health care reform is a necessary step in the right direction, but America is still decades away from parity with many industrialized nations in terms of health care delivery at a system level. The current trend is that the residents learn about the administrative aspects and business of health care after they graduate and enter practice. It appears that the residency training curriculum adequately addresses most of the ACGME core competencies except concepts of system based practice. As a chief resident only months away from entering practice, I find that this particular www . DCMS online . org

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core competency has been the most difficult to achieve. The American health care system is incredibly complex, and I am really glad I had an opportunity to learn about the administrative aspects of the system during my residency training. I decided to pursue training in a specialty that involves enormous amounts of physical and mental effort to maintain continued excellence and competency. During training, I noticed that many residents spend countless hours at the bedside of the patient learning about the clinical aspects of the patient care but do not dedicate enough time for the equally important aspect of learning about the system that delivers the patient care. As a surgeon, I will soon have the privilege of opening a patient’s abdomen and quickly addressing severe or life threatening problems. With this privilege comes the responsibility to learn and be an integral part of the system that delivers the care for the patients who place their trust in my skill and judgment. The journey of learning about America’s health care system is truly a lifelong process as the system continues to evolve. This journey should ideally start in medical school and continue through residency training rather than starting after residency training. I believe that mandatory education about health care system function in medical school and residency will help administrators and young clinicians work together to improve the care of all patients. I am certain that the health administration elective deepened my insight into what goes on behind-the-scenes in the hospital while I am taking care of patients. Acknowledgments - I could not have done this elective rotation without the mentorship of Dr. Joseph J. Tepas, III. He not only guided me through setting up this rotation but also encouraged and challenged me to explore and learn about the health care system. I also wish to thank Dr. Michael Nussbaum, Chairman of Surgery, for encouraging my efforts to learn about the system. And finally, I would like to thank the administration departments at Shands Hospital and Orange Park Medical Center for their support in making this rotation a great learning experience. Decades of experience, true financial stability, and a toughas-nails defense team make First Professionals a wellrounded — and yes, affordable — choice when it comes to protecting your medical reputation and career. No other Florida medical malpractice provider knows the industry quite like we do, nor do they defend our doctors with as much tenacity. We’re committed to protecting you and everything you’ve got, with everything we’ve got.

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32 Vol. 61, No. 2 2010 Northeast Florida Medicine

Significant discounts available for eligible DCMS members.

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Find it on the Website

The DCMS needs YOUR help with the

Looking for the illustrations that accompany clinical articles in this issue?

2 1 Student Athletic Screenings

Go to the DCMS website at www.dcmsonline.org.

Share your expertise at the JSMP Athletic Screenings

Click “NEFM”, “Current Issue”, and then “Table of Contents”. All articles are listed there (with links) and the web illustrations as well.

Saturday, August 7 – high school athletes Saturday, August 14 – middle school athletes

Nemours Children’s Clinic & Wolfson Children’s Hospital See the digital version of the journal! (follow directions above)

Find it on the Website Looking for the Post Test for the CME article in this issue or for other CME courses to complete? Go to the DCMS website at www.dcmsonline.org. Click “NEFM”,“Current Issue”, and then “Table of Contents”. The current CME article is listed there (with a Post Test link) OR click “CME Articles” under “NEFM” and see a list of all the CME articles still available for credit.

See the digital version of the journal! (follow directions above)

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JSMP coordinates free pre-participation athletic screenings for studentathletes in Duval County. Primary care physicians, orthopedic surgeons, cardiologists, pulmonologists, other medical specialists, physician assistants, and allied health professionals participate in the screenings. Physician and PA volunteers are coordinated through the DCMS. These screenings are provided at no charge to student athletes, most from homes with limited means, and are not intended to replace annual physical exams performed by pediatricians and primary care physicians. Follow up care with individual physicians is encouraged when screenings indicate potential problems which may impact the athlete’s participation in sports activities.

Want to Help?

Watch your email or fax for registration forms, visit our website, or contact Barbara Braddock at membership@dcmsonline.org or 355-6561 ext. 107. Northeast Florida Medicine Vol. 61, No. 2 2010 33


Once Residents...Now Good Ole’ Time Reunion Attendees In February, 75 attended the 25th Annual Good ‘Ole Time’ Reunion for DCMS members who practiced during the “Golden Age” of medicine prior to 1970. Once residents and young practitioners, they are now seasoned physicians. Most who attend this event are retired, and they look forward to gathering each year and reconnecting one-on-one. (Left, top to bottom) Dr. George Trotter and Dr. Ross Krueger; Dr. & Mrs. Jim Dyer; Dr. Robert Threlkel, Dr. Charles Hayes, Dr. Eugene Glenn, & Dr. Taylor King; and Mrs. Jerry Ferguson and Mrs. Linda Moseley. (Right column) All attendees enjoy having table talk time and mingling with friends. Congratulations and thanks go to Jerry Ferguson for organizing, yet again, another memorable and enjoyable event.

34 Vol. 61, No. 2 2010 Northeast Florida Medicine

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High Risk Stress in High Risk Careers: Managing Physician Stress

Background - Benefits that Matter!

The Duval County Medical Society (DCMS) attempts to provide its members with the benefits that consistently meet your professional needs. One example of how this is being accomplished is by providing to DCMS members free Continuing Medical Education (CME) opportunities in the subject areas mandated/and or suggested by the State of Florida Board of Medicine to obtain and retain medical licensure. The DCMS would like to thank the St. Vincent’s Healthcare (SVHC) Committee on CME for reviewing and accrediting this activity in compliance with the Accreditation Council on Continuing Medical Education (ACCME). Helena Karnani, MD, Chair of the CME Committee; Betsy Miller, Director, Medical Staff, Quality Management; and Cindy Williamson, CME Coordinator, from SVHC deserve special recognition for their work on behalf of DCMS. This issue of Northeast Florida Medicine includes an article, “High Risk Stress in High Risk Careers: Managing Physician Stress” authored by Kamela K. Scott, PhD, and David J. Chesire, PhD (see pp. 37-41), which has been approved for 1.0 AMA PRA Category 1 credit(s).™ For a full description of CME requirements for Florida physicians (MD/DO), please visit the DCMS website (http://www. dcmsonline.org/cme_requirements.aspx).

Faculty/Credentials: Kamela K. Scott, PhD, is an Associate Professor and David J. Chesire, PhD, is an Assistant Professor, Department of Surgery at the University of Florida College of Medicine - Jacksonville in Jacksonville, FL.

Objectives for CME Journal Article 1. Be able to recognize the physiological effects of stress 2. Be able to recognize the psychological effects of stress 3. Be able to identify minimally three ways to effectively manage experienced stress

Date of Release: June 8, 2010 Date Credit Expires: June 8, 2011 Estimated time to complete: 1 hr.

Methods of Physician Participation in the Learning Process

1. Read the “High Risk Stress in High Risk Careers: Managing Physician Stress” article on pages 37-41 2. Complete the Post Test and Evaluation on page 36 3. Cut out & fax the Post Test and Evaluation to DCMS (FAX) 904-353-5848 OR members go to www.dcmsonline.org & submit test online

CME Credit Eligibility

In order to receive full credit for this activity, a minimum passing grade of 70% must be achieved. Only one re-take opportunity will be granted if a passing score is not made on the first attempt. DCMS members and non-members have one year to submit the post test and earn CME credit. A certificate of credit/completion will be emailed, faxed or USPS mailed within 4-6 weeks of submission. If you have any questions, please contact the DCMS at 355-6561, ext. 103, or llegacy@dcmsonline.org.

Faculty Disclosure Information

Dr. Scott and Dr. Chesire report no significant relationships to disclose, financial or otherwise with any commercial supporter or product manufacturer associated with this activity.

Disclosure of Conflicts of Interest

St. Vincent’s Healthcare (SVHC) requires speakers, faculty, CME Committee, and other individuals who are in a position to control the content of this educational activity to disclose any real or apparent conflict of interest they may have as related to the content of this activity. All identified conflicts of interest are thoroughly evaluated by SVHC for fair balance, scientific objectivity of studies mentioned in the presentation and educational materials used as basis for content, and appropriateness of patient care recommendations.

Joint Sponsorship Accreditation Statement

This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of St. Vincent’s Healthcare and the Duval County Medical Society. St. Vincent’s Healthcare is accredited by the Florida Medical Association to provide continuing medical education for physicians. The St. Vincent’s Healthcare designates this educational activity for a maximum of 1.0 AMA PRA Category 1 credit(s) .TM Physicians should only claim credit commensurate with the extend of their participation in the activity.

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Northeast Florida Medicine Vol. 61, No. 2 2010 35


High Risk Stress in High Risk Careers: Managing Physician Stress

CME Questions & Answers (Circle Correct Answer)

Free-DCMS Members/$50.00 charge non-members*

(Return by June 8, 2011 by FAX: 904-353-5848, by mail: 555 Bishopgate Lane, Jacksonville, FL 32204 OR online: www.dcmsonline.org) 1. Stress is the combination of physiological and psychological variables that lead a person to judge a situation as: a. Threatening & requiring some coping mechanism b. Intolerable and beyond one’s coping ability c. Requiring professional intervention d. Seen as “eustress”, requires active coping strategy 2. Stress in the workplace has been associated with: a. Hypertension b. High plasma fibrinogen concentrations c. High levels of catecholamines d. All of the above 3. Unique sources of stress for physicians include patient variables such as: a. Patient age b. Severity of illness or injury c. Patient ability to cope d. All of the above 4. Generally, the term used to describe when an individual working in a high-stress work environment becomes more detached from the work itself is: a. Isolation b. Burnout c. Withdrawal d. Disentanglement

5. A term associated with the blunting in the ability of a caregiver to bear the suffering of others is: a. Compassion fatigue b. Apathy c. Suffering seclusion d. Dispassionate retreat 6. Greenberg advises which of the following situation interventions: a. Do not take work home b. Work through lunch to manage time c. Discuss business over lunch with colleagues d. Ignore your feelings about occupational stress 7. Benson and Magraith’s review on stress reduction advises which of the following: a. Not expecting too much of oneself b. Maintaining a good sense of humor c. Participating in outside hobbies d. All of the above 8. Contributing factors to marital stress include: a. Physicians escape into work thinking it is easier to solve clinical dilemmas than domestic problems b. A physician’s “need” to be in control can convey a lack of respect for their partner as an equal c. Inability for the partner to truly understand the pressures of the job d. A and B

Evaluation questions & CME Credit Information

(Please evaluate this article. Circle one number using this scale: 1= Strongly Agree to 5= Strongly Disagree)

The article met the stated objectives: 1 2 3 4 5 The article was appropriate to my practice: 1 2 3 4 5 The topic was current and well presented: 1 2 3 4 5 Comments:_______________________________________________________________________ __________________________________________________________________________________________ _________________________________________________________________________________________ Name (Print)___________________________________________Email__________________________ Address/City/State/Zip_________________________________________________________________ Phone__________________________Fax_____________________DCMS Member (circle) YES NO *Non-Member Charge ($50.00) - See payment options below Credit card:

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Account #___________________________________Expiration date:_____________________________ Signature_____________________________________________________________________________ 36 Vol. 61, No. 2 2010 Northeast Florida Medicine

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High Risk Stress in High Risk Careers: Managing Physician Stress Kamela K. Scott, PhD; Kristin Staggs, MS and David J. Chesire, PhD Abstract: The medical field is one in which professionals expose themselves to the physical and emotional pain of those they seek to help, and this exposure can lead to them experiencing their patient’s pain. Medical personnel are particularly vulnerable to suffering from the physical and psychological consequences of occupational stress. Ironically, there is a pervasive attitude in the medical profession that suggests practitioners should be invulnerable to the stress-related consequences of their field, and many practitioners neglect to effectively attend to their own needs. The fallout of such neglect may manifest itself as burnout and compassion fatigue and affects those close to the physician as well, including family members and patients. A review of the literature indicates a need for physicians to be mindful of their own well-being. Strategies are presented to help physicians avoid the negative effects of working in a high risk profession.

Introduction

Friday night, 2:13 a.m. – “Beep… Beep…,” the pager goes off yet again, indicating the pending arrival of a level one trauma. A 19-year-old driver, motor vehicle collision (MVC) intubated in the field, is actively being resuscitated. On arrival to the trauma center, it is apparent the patient has incurred a lethal brain injury, yet the team makes every attempt to continue the resuscitation to save this young life. At 2:51 a.m. the call is made regarding time of death. The attending physician is informed the young boy’s parents are waiting in the family quiet room for word about his injuries, and she knows she’s now tasked with delivering the devastating news. In an Emergency Room, a 15-year-old girl is brought to the hospital by a friend. She has been the victim of a brutal rape and is severely beaten. Per protocol, the sexual assault team is notified, and an officer approaches the bed to obtain contact information for the girl’s parents. The patient reaches out and grabs the physician by the coat, pleading, “Please don’t tell my daddy!” The physician is hit with the reality his own daughter is now 14-years-old. What would he want, as her father? Saturday afternoon at the baseball park, a blond-haired, 9-year-old boy approaches the “on-deck” circle. While not his first game of the season, this one is special; it’s the first game his dad has been able to attend. He’s proud that his dad is a doctor, and he understands that many patients count on him. He wants to make certain his dad sees a great game! As he stands on deck, he looks to his dad in the stands, smiling. At that moment, his father’s cell phone rings, and his physician dad is told he is needed at the hospital because of an emergency. The boy approaches the plate, but his dad misses this important moment because he had to leave immediately. The boy’s mother shudders in disappointment. Address Correspondence: Kamela K. Scott, PhD, Associate Professor, Department of Surgery, University of Florida College of Medicine, Jacksonville, FL. Email: kamela.scott@jax.ufl.edu www . DCMS online . org

Occupational Stress

The life work of a physician yields significant stress due to the myriad pressures faced in the line of duty. Daily, physicians are asked to “do more with less,” to make life and death decisions, and to heal and mend battered, torn and diseased bodies. Medicine is, indeed, a “high risk career” that can generate a great deal of personal stress. The art of medicine alone, however, does not account for this experienced stress; indeed, it may be the least stressful part of being a physician. One can learn, practice and master knowledge and action. It is the emotional side of the practice of medicine that may not be so precise or so easy. How does one separate out the emotional response when confronted with human anguish and pain? How is one to balance the demands of the profession with the needs of family – spouse and children? Occupational stress is not confined to the medical profession, and just as all individuals in the workplace are potentially at risk for the negative effects associated with stress, there is nothing unique about physicians or other medical workers that inoculate them from stress reactions. An argument can be made, in fact, that medical professionals are particularly vulnerable to occupational stress because they willingly put themselves in harm’s way, directly exposing themselves to the pain and trauma of their patients. In fact, it has been demonstrated that observing others in pain evokes activation in the neural network of the observer that is responsible for pain transmission and the processing of fear and anxiety.1,2 Stress is the combination of physiological and psychological variables that lead a person to judge a situation as threatening and as requiring some sort of coping mechanism.3 Occupational stress results when characteristics of the job and job role require an individual to employ coping mechanisms to deal with the occupational demands. Stress itself is very individualized. What may be stressful to one person, may not be to another. Perceived stress can come from a variety of sources, and it is not always evident that a situation might, in fact, be stressful. For example, early research on stress and stress management suggested that anxiety is a bi-dimensional construct comprised of “facilitating” anxiety and “debilitating” anxiety. Facilitating anxiety actually improves optimal performance, while debilitating anxiety impedes optimal performance.4 More recently, stress has been identified as coming from both negative sources (distress) and positive sources (eustress).5 Both distress and eustress may result in similar stress consequences, and each require effective coping.

Symptoms and Effects

Occupational stress can result in negative physiological and psychological outcomes. There have been several investigations into the physiological effects associated with increased levels of stress. Stress in the workplace has been associated with Northeast Florida Medicine Vol. 61, No. 2 2010 37


hypertension6,7, elevated serum cholesterol levels8, increases in left ventricular mass9, high levels of catecholamines10, high plasma fibrinogen concentrations11, and increased tobacco and alcohol use.12,13 High levels of stress in the workplace, when a worker is further exposed to unpleasant workplace conditions (such as sexual harassment), have also been associated with headaches, gastrointestinal disturbances, fatigue, sleep disturbances, nausea, weight loss, loss of appetite, neck and back pain, and dental problems.14-22 Similarly, high levels of workplace stress may manifest as psychological and behavioral issues. Stress may result in low self-esteem, increased job tension, and lower job satisfaction;23 it may result in impairments in the ability to store, retain, and retrieve information from memory.24,25 Stress can also negatively impact decision making26 and overall group performance27. Acute stress in the medical workplace has also been shown to have negative implications for patient care.28 For physicians, unique sources of stress involve such areas as patient variables (e.g., patient age, severity of illness or injury, patient ability to cope, etc.), setting variables (e.g., work hours, resources, collegial relationships, autonomy, etc.), and personal variables (physician coping strategies, experience, individual personality, etc.). This experienced stress may also spill over to the family of the physician, impacting a partner, children, and relatives. Ironically, the culture of medicine tends to perpetuate the notion that physicians should be immune to workplace stress; therefore, physicians may tend to view stress-reduction workshops and techniques as having little value.29 Two areas of particular concern for physicians and other medical providers, when working in a high stress environment, are burnout and compassion fatigue. The term “burnout” is generally used to describe the process when an individual working within a high-stress work environment becomes more and more detached from the work itself. Particular symptoms associated with burnout include low worker morale, increased absenteeism, job turnover, physical illness, drug and alcohol abuse rates, and family discord.30 Individuals experiencing burnout generally exhibit a reduced sense of humor, increased physical complaints, social withdrawal and isolation, decreased job performance, self-medication (including illegal drug abuse), and psychological symptoms such as anxiety and depression. “Compassion fatigue” is a term that is associated with the blunting in the ability of a caregiver to bear the suffering of others. In essence, the term refers to the secondary trauma that is experienced by a professional when he/she engages with traumatized patients.31 Compassion fatigue, unlike burnout, tends to build quickly, and the effects usually leave the professional feeling confused, helpless, and isolated.32 It has also been proposed that compassion fatigue is more accurately viewed as a form of “moral stress”, where the caregiver requires outlets to discuss the moral implications inherent in compassion fatigue.33 Together, burnout and compassion fatigue can isolate a physician from his/her peers, impairing overall work satisfaction and impeding overall patient care. The effects can reach beyond workplace settings and have 38 Vol. 61, No. 2 2010 Northeast Florida Medicine

devastating effects on relationships with family and friends, further isolating the individual.

Stress Reduction Strategies

Because of the overall deleterious effects of occupational stress on work performance, job satisfaction, mental and physical health, and other areas, there have been many strategies proposed for identifying and combating negative stress symptoms. Greenberg divided his discussion of managing occupational stress into four categories: life-situation interventions, perception interventions, emotional arousal interventions, and physiological arousal interventions.34 For life-situation interventions, he makes the following recommendations: Do not take work home, take a full lunch hour, do not discuss business over lunch, and discuss your feelings about occupational stress. For perception interventions, he suggests looking for humor in the stressors at work, trying to see the reality of the situation rather than focusing on only the negative, distinguishing between needs and desires, not basing self-worth on the task at hand, and employing appropriate coping strategies for appropriate situations (e.g., do not waste time trying to change things that cannot be changed). For emotional arousal and physiological arousal, Greenberg recommends relaxation training and physical exercise, respectively. Overall, the implication is that an individual needs to see to his/her own needs, ensuring that he/she is healthy physically and psychologically before embarking on attending to the needs of others or of the institution. In a similar report, Benson and Magraith identify that programs designed to help physicians manage occupational stress should focus collectively on personal, professional, and organizational issues.35 Their review on stress reduction advises on the importance of a maintaining a good sense of humor, sharing of emotions, participating in outside hobbies, and the importance of not expecting too much of oneself. Further, organizationally, it is important to engage in less traditional work activities, in addition to the primary role, such as teaching or research. Professionally, they recommend the participation in Balint groups and varying the nature of one’s work. The literature is rife with studies documenting similar stress theories and universal reduction strategies. Most of these reports describe general techniques designed to help all professions. However, in the case of Balint groups, this stress reduction technique is directed specifically to the medical professional. In Balint groups, physicians discuss various physician-patient encounters with their colleagues, specifically focusing on the feelings the encounter evoked. The goal is to facilitate an enhanced awareness and understanding of the physician-patient relationship so that the physician’s own skills in handling such encounters, while controlling their own emotional and personal investment, are strengthened. While proposed to have the potential to aid in the prevention of compassion fatigue and burnout in group participants, Balint groups require a long-term commitment on the physician’s part for a true and sustained effect. Such groups do provide

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an effective forum, nonetheless, for physicians to explore key professional and personal variables necessary for stress reduction, such as professional boundary keeping, setting of realistic expectations, and learning effective means of “not taking work home.”36 An example may be developing a new routine of listening to audio books during the drive home, to refocus the mind on alternatives to work-related demands.

Personal Stress Reduction

While review of the literature provides many suggestions for identifying and addressing experienced occupational stress, there are some common strategies that healthcare providers can employ to more effectively take care themselves. First, in the arena of personal strategies for managing stress, essentially a life outside of medicine needs to be cultivated and appreciated. For many physicians, this may require they once again “learn to play.”37 As strategies for addressing stress, physicians should utilize humor, relaxation, physical and mental exercise. They should engage in hobbies and outside interests, respect their own limits, maintain time for self-care activities, proper nutrition, and engage in spiritual and family relations. Some work sponsored programs have developed brief reminder sheets to be regularly distributed to physician staff advising the following: 1. Get away 2. Seek help 3. Manage burnout (make it a priority to get adequate sleep, daily physical exercise, to work reasonable amounts, and to “cut yourself some slack”) 4. Renew your relationships 5. Re-evaluate your work situation 6. Feed your spirit38 Zeckhausen similarly suggests additional strategies for managing personal stress such as emphasizing the importance of avoiding cynicism and doing more than commiserating.39 Also suggested is demystifying psychological support and considering therapy or a support group as positive resources rather than signs of weakness. Ultimately, personal management of stress requires balance, while also enhancing perceptions of “meaning” in work – physicians must find meaning in their work, and they must find balance in their lives.40 In the organizational arena, the crux of stress management lies in the cultivation of a true culture of caring, not just for the patient but also for the physician. This may include policies that promote work-life balance and restore physician autonomy, and cultivate efficiency, autonomy and meaning in work through continuous quality improvement processes. Team-based burnout intervention programs can further provide a forum for physicians to discuss work-related feelings and experiences and work-related problems and ways of solving them.41 Regular, interactive processes of inquiry and feedback from physicians can help to identify issues that negatively affect overall wellbeing, and also can identify obstacles, within the organization, to bring improvement. Such processes may enhance physician job autonomy and feelings of job control www . DCMS online . org

and may provide physicians’ the perception of a louder voice in organizational decision-making.42,43

Stress Impact on Relationships

“Medical marriages” require specific attention as excessive marital stress may be experienced due to lack of “together time”, lengthy work days, fatigue and the sense that the career always comes first – either by necessity or by choice. It is well-known that physicians necessarily must perform long duty hours and that overwork is normative;. Yet how this translates to the marital relationship is key. Physicians may escape into work since it could seem easier to solve clinical dilemmas than domestic problems. Also, a physician’s “need” to be in control can convey a lack of respect for the partner as an equal. No boundaries, wherein work and home become blurred (especially when on call) can create significant marital and family stress. The common stance of making mental health a low priority and/or the “person of steel” mentality often prevalent in medicine, may make the decision to engage in marital counseling very difficult. For instance, a doctor may be reluctant to acknowledge to another doctor that his/her relationship is in trouble; fearful it is a sign of weakness. Common sense strategies for avoiding such pitfalls may include: 1. Make time for one another 2. Safeguard time for communication and fun in an otherwise very busy life 3. Keep a sense of humor 4. Try to find other venues to “vent” the stress from work other than within the home setting 5. Develop interests outside medicine and work 6. Have friends outside medicine and work. Additionally, consider consistently reviewing duty hours and setting boundaries when able; compromising; putting the marriage first, ensuring that time together is a priority, and identifying a problem and then doing something about it. Challenge the “I can handle it alone” mentality. Most importantly, monitor and effectively care for, not only oneself, but also one’s partner, giving the marriage the same degree of attention that is given the medical career.

Conclusion

Medicine is indeed a “high risk career” in light of the inherent high degree of experienced stress (“high risk stress”) that each physician must effectively manage. This career choice embodies an inordinate degree of personal, professional, organizational and marital demands, and it is the perceptions of one’s role, in each of these areas, that define one’s experienced stress. The manner in which each individual manages his/her own stress dictates the role that stress plays in, not only one’s physical health, but also one’s psychological health and wellbeing, and overall professionalism. Physicians must task themselves with the responsibility of self-care, in the same manner such expectations are placed upon their patients. Specific strategies must be employed to Northeast Florida Medicine Vol. 61, No. 2 2010 39


promote the effective balance between job function, job meaning, and overall sense of purpose – be that as a physician or simply as a person, partner, colleague, or friend. The societal burden placed upon physicians stands only to increase in this era of healthcare reform, emphasizing the personal need and professional responsibility for self care. Patient-centered care requires “person-centered” providers and mandates physician self-care and attention to stress and well-being. These are the cornerstone of overall professionalism.

References

1.

Akitsuki, Y, Decety, J. Social context and perceived agency affects empathy for pain: an event-related fMRI investigation. NeuroImage. 2009;47:722-734.

2.

Jackson, PL, Rainville, P, Decety, J. To what extent do we share the pain of others? Insight from the neural bases of pain empathy. Pain. 2006;125:5-9.

13. Niedhammer, I, Goldberg, M, Leclerc, A, et al. Psychosocial work environment and cardiovascular risk factors in an occupational cohort in France. Journal of Epidemiology and Community Health. 1998;52:93100. 14. Benson, DJ, Thomson, GE. Sexual harassment on a university campus: The confluence of authority relations, sexual interest, and gender stratification. Social Problems. 1982;29:236-251. 15. Crull, P. Stress effects of sexual harassment on the job: Implications for counseling. American Journal of Orthopsychiatry. 1982;52:539-544. 16. Fitzgerald, LF, Drasgow, F, Hulin, CL, et al. Antecedents and consequences of workplace sexual harassment in organizations: A test of an integrated model. Journal of Applied Psychology. 1997;82:578-589.

3.

Lazarus, RS, Folkman, S. Stress, appraisal, and coping. 1984. New York: Springer. (Pg. 141.)

17. Glomb, TM, Richman, WL, Hulin, CL, et al. Ambient sexual harassment: An integrated model of antecedents and consequences. Organizational Behavior and Human Decision Processes, 1997;71:309-328.

4.

Nideffer, RM. The relationship of attention and anxiety to performance. 1978. In WF Straub (Ed.) Sport Psychology: An Analysis of Athlete Behavior. (Pgs. 231-235). Ithica, NY: Mouvement.

18. Glomb, TM, Munson, LJ, Hulin, CL, et al. Structural equation models of sexual harassment: Longitudinal explorations and cross-sectional generalizations. Journal of Applied Psychology, 1999;84:14-28.

5.

Selye, H. The stress concept: Past, present, and future. 1983. In CL Cooper (Ed.) Stress Research. (Pgs. 1-20) NY: John Wiley & Sons.

19. Gutek, BA. Sex and the workplace. 1985. San Francisco: Jossey-Bass.

6.

Landsbergis, PA, Schnall, PL, Warren, K, et al. Association between ambulatory blood pressure and alternative formulations of job strain. Scandinavian Journal of Work and Environmental Health. 1994;20:349363.

7.

Van Egeren, LF. The relationship between job strain and blood pressure at work, at home, and during sleep. Psychosomativ Medicine. 1992;54:337-343.

8.

Theorell, T, Hamsten, A, de Faire, A, et al. Psychosocial work conditions before myocardial infarction in young men. International Journal of Cardiology. 1987;15:3346.

9.

Schnall PL, Pieper C, Schwartz JE, et al. The relationship between ‘job strain,’ workplace diastolic blood pressure, and left ventricular mass index. 1990;JAMA 263(14):1929-1935.

10. Harenstam, AB, Theorell, TPG. Work conditions and urinary excretion of catecholamines-A study of prison staff in Sweden. Scandinavian Journal of Work and Environmental Health. 1988;14:257-264. 11. Brunner, E, Davey Smith, G, Marmot, M, et al. Childhood social circumstances and psychosocial and behavioural factors as determinants of plasma fibrinogen. Lancet. 1996;347:1008-1013. 12. Cohen, S, Schwartz, JE, Bromet, EJ, Parkinson, DK. Mental health, stress, and poor behaviours in two community samples. Preventative Medicine. 1991;20:306-315.

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20. MacKinnon, C. Sexual harassment of working women. 1979. New haven, CT: Yale University Press. 21. Holgate, A. Sexual harassment as a determinant of women’s fear of rape. Australian Journal of Sex, Marriage and the Family. 1989; 10:21-28. 22. Williams, J, Fitzgerald, LF, Drasgow, F. The effects of organizational practices on sexual harassment and individual outcomes in the military. Military Psychology, 1999;11:303-328. 23. Jackson, S, Schuler, R. A meta-analysis and conceptual critique of research on role ambiguity and role conflict in work settings. Organizational Behavior and Human Decision. 1985;36:16-28. 24. Buchanan, TW, Tranel, D, Adolphs, R. Impaired memory retrieval correlates with individual differences in cortisol response but not autonomic response. Learn Mem. 2006;13:382-387. 25. Dominique, JF, de Quervain, DJF, Roozendaal, B, et al. Acute cortisone administration impairs retrieval of long-term declarative memory in humans. Nature Neuroscience. 2000;3:313-314. 26. Shaham, Y, Singer, JE, Schaeffer, MH. Stability/ instability of cognitive strategies across tasks determine whether stress will affect judgmental processes. Journal of Applied Social Psychology. 1992;22:691-713. 27. Driskell, JE, Salas, E, Johnston, J. Does stress lead to a loss of team perspective? Group Dynamics. 1999;3:291302. 28. LeBlanc, V. The effects of acute stress on performance: www . DCMS online . org


Implications for health professions education. Academic Medicine. 1009;84:25-33. 29. Clark, C. Doctors bristle at proposed physician wellness program. Media Health Leaders. 2009. <http://www. healthleadersmedia.com/content/PHY-232864/ Doctors-Bristle-at-Proposed-Physician-WellnessProgram>. Accessed March 12, 2010. 30. Jones, JW. A measure of staff burnout among health professionals. Paper presented at the annual meeting of the American Psychological Association. September 1980. Montreal. 31. Najjar, N, Davis, LW, Beck-Coon, K, Doebbeling, CC. Compassion fatigue: A review of the research to date and relevance to cancer-care providers. Journal of Health Psychology. 2009;14:267-277. 32. Figley, C. Compassion fatigue: Psychotherapistsâ&#x20AC;&#x2122; chronic lack of self care. JCLP/In Session: Psychotherapy in Practice. 2002;58:1433-1441. 33. Forster, D. Rethinking compassion fatigue as moral stress. Journal of Ethics in Mental Health. 2009;4:1-4. 34. Greenberg, JS. Stress Management, 8th ed. 2002. New York: McGraw-Hill. 35. Benson, J, Magraith, K. Compassion fatigue and burnout: The role of Balint Groups. Australian Family Physician. 2005;34:497-498. 36. Kjeldmand, D, Holmstrom, I. Balint groups as a means to increase job satisfaction and prevent burnout among general practitioners. Annals of Family Medicine. 2008;6:138-145. 37. Peisah, C, Gautam, M, Goldstein, M. Medical masters: A pilot study of adaptive ageing in physicians. Australian Journal on Ageing. 2009;28:134-138. 38. Schumer, D. How to defuse an exploding physician. Family Practice Management Web. 2006. <http://www. aafp.org/fpm>. Accessed March 12, 2010. 39. Zeckhausen, Z. 8 ideas for managing stress and extinguishing burnout. Family Practice Management. 2002;9:35-38.

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40. Shanafelt, TD. Enhancing meaning in work: A prescription for preventing physician burnout and promoting patient-centered care. JAMA. 2009;302:13381340. 41. Hotchkiss, N, Early, S. The differences in keeping both male and female physicians healthy. The Health Care Manager. 2009;28:299-310. 42. Dunn, PM, Arnetz, BB, Christensen, JF, Homer, L. Meeting the imperative to improve physician well-being: Assessment of an innovative program. Journal of General Internal Medicine. 2007;22:1544-1552. 43. Heponiemi, T, Kouvonen, A, Vanska, J et al. The association of distress and sleeping problems with physiciansâ&#x20AC;&#x2122; intentions to change profession: The moderating effect of job control. Journal of Occupational Health Psychology. 2009;14:365-373.

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DCMS Membership Applications These physicians’ applications for membership in the Duval County Medical Society are now being processed. Any information or opinions you may have concerning the eligibility of the applicants listed here may be directed to Ashley Booth Norse, MD, DCMS Membership Committee Chair (904-244-4106 or Barbara Braddock, Membership Director (904355-6561 x107).

Daniel J. Matricia, DO

Urgent Care/Occupational Medicine/Emergency Medicine Amelia Urgent Care 510 Airport Center Dr. Medical Degree: Des Moines University College of Osteopathic Medicine Internship: ITEA Doctor’s Hospital Residency: ITEA Northlake Regional Hospital Nominated by: Nassau County Medical Society

Patrick J. DeMarco, MD

Allergy/Immunology Allergy & Asthma Specialists of North Florida 3636 University Blvd. S. #A-3 Medical Degree: Hahnemann School of Medicine Internship/Residency/Fellowship: University of South Florida College of Medicine Nominated by: Edward Mizrahi, MD; Paul Wubbena, MD; Sunil Joshi, MD

Cheryl Lynn Dixon, MD

Anesthesiology Jacksonville Anesthesia Corporation, Inc. 820 Prudential Dr. #606 Medical Degree: Medical College of Ohio at Toledo Residency/Fellowship: University of Florida College of Medicine Nominated by: Francisco Jimenez, MD; Pamela Rama, MD; Edward Young, MD

Brian R. Emerson, MD

Anesthesiology UF Anesthesiology 655 W. 8th St. 2nd FL Clinical Center Medical Degree: Vanderbilt University Medical School Internship: Austin Medical Education Program Residency: Mayo Clinic Fellowship: Seattle Children’s Hospital Nominated by:UFJP

Ruple J. Galani, MD

Cardiology/Internal Medicine Jacksonville Heart Center PA 14546 St. Augustine Rd. #103 Medical Degree: Medical College of Ohio Medical School Residency: University of Florida College of Medicine Fellowship: Ohio State University Medical Center Nominated by: Joel Schrank, MD; Kenneth Adams, MD; Shannon Leu, MD

Carol Mannings, MD

Pediatrics Duval County Health Department Medical Degree: University of Miami School of Medicine Residency: University of Florida College of Medicine/Jax Nominated by: UFJP

Jerry P. Matteo, MD

Diagnostic Radiology UF Radiology 655 W. 8th St. 2nd FL Clinical Center Medical Degree: Ross University Medical School Internship: Flushing Hospital Residency: Long Island College Hospital

42 Vol. 61, No. 2 2010 Northeast Florida Medicine

Fellowship: Medical University of South Carolina Medical School Nominated by: UFJP

Gabriel Paulian, MD

Internal Medicine/Hospice & Palliative Medicine Shands Community Health Center 655 W. 8th St. 4th FL ACC Medical Degree: Ross University Medical School Internship: Mount Sinai School of Medicine/Bronx VA Medical Center Residency/Fellowship: University of Florida Health Science Center Nominated by: UFJP

Adil Shujaat, MD

Pulmonary Medicine UF Critical Care 655 W. 8th St. 7th FL Clinical Center Medical Degree: King Edward Medical College Punjab University Residency/Fellowship: Saint Lukes-Roosevelt Hospital Nominated by: UFJP

Residents/Fellows - University of Florida, Jacksonville Emergency Medicine Charles Fawsett, MD

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Northeast Florida Medicine Vol. 61, No. 2 2010 43


Special Case Report Is Early TPN in Hyperemesis Gravidarum Worth the Risk? Karishma Ramsubeik, MD; Ravindra P. Maharaj, MD; Mohammad A. Khan, MD, MRCPI and Shilpa C. Reddy, MD Editorâ&#x20AC;&#x2122;s Note: Due to production constraints, Figures 1 & 2 are not printed in the journal. They are available online at www. dcmsonline.org as a web illustration.

Case Report

We report a case of bacterial endocarditis as a complication of a peripherally inserted central catheter in the treatment of a patient with hyperemesis gravidarum. A 26-year-old African American female gravida 4, para 3 with an intrauterine pregnancy at 26 weeks was diagnosed with hyperemesis gravidarum during her first trimester. A peripherally inserted central catheter (PICC) line was inserted to allow delivery of total parenteral nutrition due to non-tolerance of oral intake. The PICC line was removed as soon as she tolerated oral nutrition. Her hyperemesis recurred after six weeks, and a second PICC line was placed. The patient developed fever and the PICC line was removed and was replaced by a third PICC line. The fever returned after the third PICC line was inserted. On examination, she had stable vitals except tachycardia with a heart rate of 100 beats per minute. A grade III systolic murmur was audible at the left sternal border. The rest of her physical exam was within normal limits. Laboratory investigation revealed a white blood cell count of 19000 per micro liter, Hemoglobin 12.2g/dl, Hematocrit 35 % and platelets 273000 per micro liter. Her chemistry was within normal limits. The blood cultures and fungal culture were negative. The echocardiogram revealed mildly reduced left ventricular function with an ejection fraction of 55 to 60 %. There was mild biatrial enlargement with moderate mitral regurgitation. Mild to moderate tricuspid regurgitation with pulmonary artery systolic pressure of 43 mmHg (Figure 1, www.dcmsonline.org) was noted. Posterior tricuspid leaflet vegetation, measuring 1.8 x 2.9 cm and a septal tricuspid leaflet vegetation, (Figure 2, www.dcmsonline.org) was revealed. There was no evidence of a perivalvular abscess. Antibiotic treatment was initiated with intravenous Nafcillin. A high resolution CT scan of the chest revealed a large filling defect at the bifurcation of the right middle and lower lobe pulmonary arteries consistent with an embolus and multiple nodular opacities in both lungs, suggesting an infectious or inflammatory etiology. Based on the history and laboratory data, a diagnosis of tricuspid valve endocarditis with septic embolism was made.

Discussion

Hyperemesis gravidarum affects about 2% of all pregnant women1. One must first confirm a viable intrauterine pregnancy. Supportive care is the mainstay of therapy. Lifestyle modifications may be attempted to help the patient tolerate Address Correspondence to: Mohammad A. Khan, MD, MRCPI, University of Florida - Jacksonville, Department of Internal Medicine, 653W, LRC4, 8th Street, Jacksonville, FL 32209. Phone: (904) 343-3038. Email: mohammad.khan@jax.ufl.edu.

44 Vol. 61, No. 2 2010 Northeast Florida Medicine

oral intake, such as eating dry, bland carbohydrates, having small frequent meals and avoiding unpleasant smells. With increasing symptoms, antiemetics may be instituted. Correction of fluid and electrolyte deficits should also be undertaken and intravenous therapy may be used. Van Stuijvenberg et al1 observed that vomiting subsided in 24 hours after treatment of patients with hyperemesis gravidarum if given intravenous administration, normal saline solution and one ampule of an intravenous multivitamin preparation. Hsu et al2 demonstrated successful use of nasogastric (NG) tube feeding in patients with hyperemesis gravidarum and associated nausea and vomiting improving within 24hours after NG tube placement. In 2004, Folk et al3 compared the obstetric and maternal complications in patients with hyperemesis gravidarum treated with total parental nutrition (TPN) versus those who did not receive TPN. They found that the two groups were similar regarding the incidence of pregnancy-related and maternal medical complications; however the TPN group had a higher incidence of TPN associated complications including sepsis, bacterial endocarditis and pneumonia. In 2008, Holmgren et al4 observed that maternal complications associated with PICC line placement were substantial despite no difference in neonatal outcomes. In fact, there was a 66.4% rate of infective complications, thromboembolism or both due to PICC line use in hyperemesis patients.

Conclusion

The infective complications of central intravenous access over peripheral intravenous access cannot be emphasised enough. This young lady has now been committed to longterm endocarditis management with the additional risk now affecting the patient and her fetus. This could have been avoided by conservative measures and less invasive intravenous access. In addition, a PICC line has the additional cost burden compared with simple peripheral IV access and conservative management. The risk of TPN in short-term management of nutritional needs far outweighs the benefits as highlighted by this case. The use of PICC lines for hyperemesis gravidarum is rarely indicated and should be avoided if possible.

References

1. Van Stuijvenberg M.E, Schabort I, Labadarios D, J.T N, The nutrional status and treatment of patients with hyperemesis gravidarum. American Journal of Obstetrics and Gynecology 1995;172(5):1585-1591. 2. Hsu JJ, Clark-Glena R, Nelson DK, CH K. Nasogastric enteral feeding in hyperemesis gravidarum Obstet Gynecol. 1996;88(3):343-346. 3. Folk J, Leslie-Brown H, Nosovitch J, Silverman R, Aubry R. Hyperemesis Gravidarum: Outcomes and Complications With and Without Total Parenteral Nutrition J Reprod Med 2004;49:497-502. 4. Holmgren C, Aagaard-Tillery KM, Silver RM. Hyperemesis in pregnancy: An evaluation of treatment strategies with maternal and neonatal outcomes. Am J Obstet Gynecol 2008(198):56.

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Update on Haiti Relief Efforts Baptist Health Affiliated Physicians Provide Assistance to Haitians

Brooks Donates to Doctors Without Borders and its Haiti Recovery Efforts

In the weeks and months following the January 12, 2010 earthquake in Haiti, a number of physicians and staff affiliated with Baptist Health in Jacksonville, FL traveled to Haiti to provide much needed medical assistance. Those featured below are also DCMS members.

Brooks Rehabilitation in Jacksonville, FL donated $50,000 to Doctors without Borders/Medecins Sans Frontieres (MSF) to help fund its efforts for Haiti during that country’s rehabilitation and recovery stages.

Doug Johnson, MD, a radiation oncologist at Baptist Cancer Institute, is a member of the Flying Physicians Association. This group worked with the U.S. State Department and the United Nations to get needed supplies to the Fond Parisian Field Hospital in Haiti. On February 8, Dr. Johnson and other physician pilots flew 24 private aircraft loaded with 95 boxes weighing nearly 1,500 pounds to the Dominican Republic where a UN helicopter then transported these supplies to the hospital in Haiti. Dr. Johnson said, “Our supplies got where they needed to be and were exactly what the clinic needed.” Richard Picerno, MD, an orthopaedic surgeon with Jacksonville Orthopaedic Institute and Meridith Farrow, MD, an obstetrician who practices at Baptist Beaches, were part of a 12-person team that went to Haiti February 2-11 under the auspices of the Southern Baptist Convention. They worked at the National Hospital, a medical tent compound created after the earthquake. They triaged and treated up to 400 patients a day who had multiple types of medical problems. Dr. Picerno said, “It was life-changing for us just seeing the people and hearing their stories.” John Von Thron, MD, an orthopaedic surgeon with Jacksonville Orthopaedic Institute, went to Haiti at the end of January with a Presbyterian Ministries team to help patients at a general hospital in Port-Au-Prince. Dr. Von Thron provided non-surgical orthopaedic care and dressing changes. He said, “It was quite an amazing sight to see people from all over the world helping out.”

(L, top) Dr. Richard Picerno attends a Haitian patient while working at the National Hospital under the auspices of the Southern Baptist Convention. (R) Dr. John Von Thron with two Haitians he met and assisted while at a general hospital in Port-Au-Prince with a Presbyterian Ministries team. (L, bottom) Dr. Doug Johnson unloads supplies he helped fly to Haiti.

www . DCMS online . org

Doug Baer, President and CEO of Brooks said, “We wanted to find a way to help the people of Haiti that would be true to our mission of advancing the health and well-being of persons requiring rehabilitation. We feel Doctors Without Borders/MSF share the same values and we wanted to support them in their on-going efforts.” In emergencies, MSF provides essential health care, rehabilitates and runs hospitals and clinics, performs surgery, responds to epidemics, carries out vaccination campaigns, operates feeding programs for malnourished children, and offers mental health care. On its website (www.doctorswithoutborders.org), Doctors Without Borders describes itself as “a medical humanitarian organization” and states, “MSF is continuing to develop strategies to respond to the evolving realities on the ground and serve both the immediate and the longer-term needs of the Haitian people.”

How’s Haiti? Joan Huffman, MD, FACS, Editor-in-Chief, Northeast Florida Medicine

Ninety days after the horrid January 12 earthquake that rocked and flattened Port-au-Prince, progress is palpable to the return visitor, but invisible to a new initiate. (Observations based on my April 9-17 return trip to Hospice St. Joseph in Haiti) Food: The te marchant (small merchants) have returned, lining the streets, each proffering their small quantity of goods – mangoes, charcoal, or fly-covered chicken. World aid pesters the tent cities – women must line up at 12 midnight to acquire their daily food coupon and then return to queue at 6 AM for a day’s ration of rice and beans that they might receive by 12 noon. 90% of my patients complain of tet fe mal, verti, vant doule (headache, dizziness and stomach pain); in other words, HUNGER. After a while I stop asking how many meals they eat a day – at most one or two, for mothers, less. They feed their small portions to their children. The Hospice staff teaches us to sing the blessing for our rice, beans, and plantain dinner, “Merci a Papa, Merci a Mama…” We are truly thankful. Shelter: The city has inspected and marked the buildings. A red stamp demands demolition; yellow allows renovation; only green permits habitation. I see many red stamps. Men armed with pickaxes, sledge hammers and shovels, labor from dawn Continued, page 48 Northeast Florida Medicine Vol. 61, No. 2 2010 45


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Continued from p. 45

to dusk, taking down the city, concrete chunk by chunk. Clusters of stakes shaded with shower curtains have morphed into Shelter-box tents and US AID tarps. Water: In January, thirst and dehydration dropped citizens and volunteers. Now the monsoons have arrived. Each night torrential rainfall brings homeless residents to their feet, bedding soaked by rivulets of runoff, patched shelters leaking like colanders. Sanitation: Tent cities devoid of toilets are now ringed with Porta-Potties. Not bad if you don’t mind sharing the facilities at a rate of 1:100. In Solino, deep in the poorer heart of the city, the proportion worsens exponentially. Healthcare: Our host has reopened their maternal-child clinic which is now housed in a corrugated tin structure boasting a limited pharmacy, two closet-sized exam rooms and a tiny, not yet functional lab. The staff has returned, their personal tragedies allayed – two nurses, a pharmacist, a general medical doctor and a pediatrician. They struggle to provide care with minimal drugs and supplies. Each morning before dawn, patients line up outside the compound walls, stream in at 6 a.m. and wait, quietly, patiently until the clinic opens at 8 a.m. By 2 p.m. they dwindle away, wilted, weak in the afternoon sun. Hospital General, the teaching hospital soldiers on: more organized but still makeshift. An admissions desk triages patients; staff now identified by T-shirts rather than tape & marker name tags. Pre-op and post-op still shelters in large military tents. We spend a morning at a tent city full of orphans, mothers, children and old men. There is no evidence of prior health care here. Education: Schools are beginning to reopen. Children in gingham-check dresses and shirts, reminiscent of colonial times, walk through rubble to renovated classrooms. Hospice St Joseph now hosts six classes a day, three each morning, three each afternoon. Every student gets a meal, their only one of the day. There are no books, just erasable boards for teachers and rote lessons. The People: Haitians persevere-Christ Roi is exuberant to see their blan friends return, showering us with double-cheek kisses. We bring laughter and merriment to children and adults alike, including a small shell-shocked boy who hasn’t smiled in three months. They giggle at our attempts to make a kite

Dr. Joan Huffman dresses a wound on a patient during her first trip to Haiti. Both times in Haiti, she has worked at field hospitals with only primitive equipment.

48 Vol. 61, No. 2 2010 Northeast Florida Medicine

that refuses to become airborne; two grown men spend half a day constructing a proper Haitian kite, neighborhood boys solemnly instruct Dokte Eric in the finer points of kite flying. We share our non-perishable foods with the cook ladies. They are ecstatic to receive canned peaches and tuna. Children treasure every little jelly bean as it if were a gold nugget. So how is Haiti? Port-au-Prince marches along from ravaged to resilient. A teen mother tries to pass her infant through the bus window – hoping for a future for her child. Each morning at 5 a.m. hymns lift over the destruction, praying for strength for another day. Haiti still bleeds, and we will return.

A Caring Jacksonville Community Reaches Out to Haitian Amputees John Lovejoy, MD

This is a story about a caring community…Jacksonville, FL. After making two trips to Haiti following the January 12, 2010 earthquake and performing many amputations, I asked myself, “How are the Haitian patients going to deal with all these amputations?” From my previous trips, I knew how difficult it is to get a prosthesis in Haiti, much less one that fits well. Upon returning to the U.S., I could not get the thoughts out of my mind on how to fit my Haitians patients with a prosthesis. Mike Richard, CPO/LPI, President/Owner of Advance Prosthetics & Orthotics, (APO) and I had dealt with this problem before in Grenada, so I went to see him. In that situation, we had successfully turned a shipping container into a prosthetic lab. We knew we could do it again, but this time we decided to outfit the container completely as a working prosthetic shop. This is where the caring community comes into play. I mentioned this project to a few close friends and they enthusiastically jumped on board. First, we had to secure a 40-foot shipping container. The Jacksonville Port Authority found us an all metal container, but the Williams Scotsman Company offered us an insulated and lighter container that was once used to ship pineapples and bananas and that Scotsman had converted into offices. It had A/C, windows and electricity, so it made more sense to go with this option. Since Scotsman reduced the price by 80%, we could afford it. Next, we contacted Suddath Relocation Services to move it. They graciously offered their services. Next, Ed Doherty, retired COO of Atlantic Marine (AM), arranged to take the container to AM where it was cleaned, painted, floored and fitted with an electric panel, outlets and lights. I cannot express the pride the workers took in this gratis project. They installed the cabinets, drains, floor, trim, water supply and outlet and A/C. Mr. Doherty was there each day making sure everything was done properly just like it was one of his own projects. He and his workers truly took a sow’s ear and turned it into a silk purse. www . DCMS online . org


Jon M. Fletcher, a Florida Times-Union (TU) photographer took this photograph which appeared in the April 3, 2010 TU with the caption, “Retired orthopedic surgeon John Lovejoy of Jacksonville has been coordinating and laboring to complete a prosthetics lab to be shipped to Hospital Sacre Coeur in Milot, Haiti. The lab, which was built inside of a freight shipping container, would help victims of the January earthquake. Several local companies and individuals contributed to make the project possible.” Special thanks to the TU for use of this photograph, the caption, and for featuring this project in its publication.

I called my friends at Exact Inc., Will Allen, Charlie Todd and Buzzy Allen, and asked them if they could make the stainless steel workbenches and sink. Their reply was, “Of course!” I offered to pay for the material, but their supplier donated it as a way to support the project. We needed a sink to put in the work bench, and I asked the maintenance man at the Jacksonville Specialty Hospital, and he said he just happened to have pulled one out and was getting ready to dispose of it. Someone was surely watching over us!

others. Assistance came from the retailers who discounted their goods and companies like Home Depot, Sears, Advanced Furniture Solutions, and WalMart (who offered two chair and table sets for $50 each and then gave me a $100 gift card to pay for them). The Jacksonville Jaguars and owner Wayne Weaver donated a much needed mini ambulance for the hospital. Bo Phillips at Cannon Welding fabricated the awning and Dillon Signs painted all the logos on the lab. The credit list goes on and on.

It seems like all along the way the Jacksonville community wanted to be involved. So much was done on faith. When we purchased the container, my church, All Saints Episcopal, raised the money to buy it. I personally guaranteed the cost of the equipment, and we began to order, putting it on my charge account. Then people, too numerous to mention, came forward to participate. Some of the ones that touched my heart were friends, patients and families whom I had treated and a widow who gave her mite out of love for others. Finally, the Knights of Malta offered to become a major sponsor. My personal guarantee really was not necessary because the community stepped forward and showed how they cared about others.

Besides the financial gifts, there was also a lot of donated time and labor. Most important has been the commitment of Mike Richards and his staff at APO. They put in long hours designing, building and ordering equipment. Downing Nightingale of Lambs Yacht Center made in his shop the cabinets to hold the plastic and painted the steps so it would look good to all who visited. Mike’s landlord let us park the lab behind his shop and the local security agency watched over it with caring eyes. Finally when it was finished, Suddath moved it to Ft. Lauderdale for shipping to Cape Haitian, Haiti. Tony Marcelli, a Sante Shipping agent, got the shipping cost waved and had the lab top loaded for safety.

I am sure I have forgotten someone who deserves thanks, but I will never forget our community’s willingness to help

It is amazing what a caring community can do when it pulls together!

www . DCMS online . org

Northeast Florida Medicine Vol. 61, No. 2 2010 49


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Summer 2010 Journal