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AN RANCISCO EDICINE S F M VOL.82 NO.2 March 2009 $5.00

JOURNAL OF THE SAN FRANCISCO MEDICAL SOCIETY

Extreme Medicine


rs e ld o h y c li o P C E I M for d n e id iv D G I B r e h t Ano hange of California Medical Insurance ExcInsurance Company ty bili Lia ont Clarem nia s of Califorpan Medical Underwriter ent com y

MIEC

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Dear Doctor:

MIEC

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for 2009 Renewal d en id iv D n o li il M n of $17 n Distributio past 19 years e th in d en id iv d th 16 v This is the miums by 26% re p ce u d re ill w is it is estimated th v On average olders for renewing policyh : based on two factors e ar s n o ti ca lo al al u v Individ er paid in over ld o yh lic o p ch ea m iu 1. How much prem the past 5 years experience in the ss lo ID PA al u id iv d 2. Policyholder’s in past 3 years to a unique advantage is n la p d en id iv d e ude of th v The magnit being with MIEC ighest quality h e th es d vi ro p It s. by its policyholder g a profit from in ek se MIEC is 100% owned t u o h it w s am vention progr lished a business b ta defense and loss pre es C IE M ed d n u ors who fo e to ask yourself av h er operations. The doct ev n u yo s re phy that ensu structure and philoso right company. e th h it w e ar u yo if 800-227-4527 CoM or Call 1. C IE M . w w w to Ion Go for MorE InforMat 527 • Toll Free: 800 -227-4 Phone: 510-428-9411 • 4 132 18946 a rni , Califo

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ue • Oakland

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Medical Insurance Exchange of California 6250 Claremont Avenue, Oakland, California 94618 • 800-227-4527 • www.miec.com SFmedSoc_ad_01.07.09 3 San Francisco

Medicine March 2009

MIEC www.sfms.org Owned by the policyholders we protect.


In This Issue

SAN FRANCISCO MEDICINE March 2009 Volume 82, Number 2

Extreme Medicine FEATURE ARTICLES

10 After Shock Mark Renneker, MD

12 In the Hurricane’s Trail Toni Brayer, MD

14 The Real ER Malini K. Singh, MD, MPH

15 Superbowl Surgery Daniel Marelli, MD, and David Bona, PhD

17 A Day in the Life of PES David Elkin, MD; Paul R. Linde, MD; and Eric Woodward, MD 20 Straight from the Emergency Department Brian McBeth, MD

MONTHLY COLUMNS 4 On Your Behalf

7 President’s Message Charles Wibbelsman, MD

9 Editorial Mike Denney, MD, PhD 43 Hospital News 46 Classified Ads 46 In Memoriam Nancy Thomson, MD SPECIAL SECTION

40 SFMS 2009 Annual Dinner

21 Relative Risk Robert Liner, MD

23 Mavericks, Missionaries, and Misfits David K. Becker, MD

25 Rock Medicine David Smith, MD, and Glenn “Raz” Raswyck, EMT

27 Rodeo Medicine Dale J. Butterwick, CAT(C), and Mark A. Brandenburg, MD 29 Medicine and the Indy 500 Geoffrey L. Billows, MD, FACEP 31 Space Medicine Karen Miller

Editorial and Advertising Offices 1003 A O’Reilly San Francisco, CA 94129

Phone: 415.561.0850 ext.261 Fax: 415.561.0833 Email: adenz@sfms.org Web: www.sfms.org Subscriptions: $45 per year; $5 per issue Advertising information is available on our website, www.sfms.org, or can be sent upon request. Printing: Sundance Press P.O. Box 26605 Tuscon, AZ 85726-6605

33 Expedition Inspiration Kathleen Grant, MD

35 Confessions of an Extreme Athlete Daniel Bikle, MD, PhD www.sfms.org

March 2009 San Francisco Medicine

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On Your Behalf March 2009 A Sampling of Activities and Actions of Interest to SFMS Members

Volume 82, Number 2 Editor Mike Denney Managing Editor Amanda Denz Copy Editor Mary VanClay Cover Artist Amanda Denz Editorial Board Chairman Mike Denney Obituarist Nancy Thomson Stephen Askin

Shieva Khayam-Bashi

Toni Brayer

Arthur Lyons

Linda Hawes-Clever

Terri Pickering

Gordon Fung

Ricki Pollycove

Erica Goode

Kathleen Unger

Gretchen Gooding

Stephen Walsh

SFMS Officers President Steven H. Fugaro President-Elect Charles J. Wibbelsman Secretary Gary L. Chan Treasurer Michael Rokeach Editor Mike Denney Immediate Past President Stephen E. Follansbee SFMS Executive Staff Executive Director Mary Lou Licwinko Director of Public Health & Education Steve Heilig Director of Administration Posi Lyon Director of Membership Therese Porter Director of Communications Amanda Denz Board of Directors Term:

Donald C. Kitt

Jan 2008-Dec 2010

Jordan Shlain

George A. Fouras

Lily M. Tan

Keith Loring

Shannon Udovic-

William Miller

Constant

Jeffrey Newman

Term:

Thomas J. Peitz

Jan 2006-Dec 2008

Daniel M. Raybin

Mei-Ling E. Fong

Michael H. Siu

Thomas H. Lee

Term:

Carolyn D. Mar

Jan 2007-Dec 2009

Rodman S. Rogers

Brian T. Andrews

John B. Sikorski

Lucy S. Crain

Peter W. Sullivan

Jane M. Hightower

John I. Umekubo

CMA Trustee Robert J. Margolin AMA Representatives H. Hugh Vincent, Delegate Robert J. Margolin, Alternate Delegate 4 5

Notes from the Membership Department CMA Legislative Leadership Day CMA’s annual Legislative Leadership Day will be held on Tuesday, April 14, 2009 at the Sacramento Convention Center. More information will be available in a few weeks. If you’ve attended previously, you know that this is always a terrific opportunity to join your fellow physicians for an interesting and productive day of advocacy, networking and legislative information exchange. If you’ve never been to a Legislative Leadership Day, consider attending this one to see­—and participate in—the power of organized medicine in action. Information, including a preliminary agenda, may be obtained through this link: www.calphys.org/assets/applets/leg_day_09.pdf. A room block has been reserved at the Marriott at $189 a night. There are 50 rooms in the block. Attendees may start making reservations by calling (800) 3313131 and stating that they are a part of the CMA room block. You may also book online at www.marriott.com/sacdt by putting CMACMAA in the group code box. For information, or to register for Leadership Day, please contact Jennifer Williams, (916) 444-5532 or jwilliams2@ cmanet.org . You can also contact Therese Porter in the SFMS Membership Department at (415) 561-0850, extension 268, or tporter@sfms.org . This year CMA is offering a kosher for Passover meal for anyone who requests it. Because they need to have an accurate count well in advance to assure enough kosher plates, please let Jennifer Williams know by March 30 if you would like this option.

CMA President Visiting UCSF

The UCSF students have arranged for Joe Dunn to speak on March 31st from noon to 1 PM. Senator Dunn will be speaking in the Health Sciences West (HSW)-

San Francisco Medicine March 2009

301 room which is at the UCSF Parnassus Campus at 513 Parnassus Ave. They have asked him to speak on the intersection of politics and health care with an emphasis on encouraging health students and practitioners to actively inform and involve themselves in the political decision making process that essentially dictates how medicine looks today. Senator Dunn’s visits to UCSF in the past have been very exciting. The students have extended an invitation to those of the membership at large who are interested to join them for Senator Dunn’s speech. Seating capacity is limited, so if you are interested please let Therese Porter in the Membership Department know as soon as possible, (415) 561-0850 extension 268.

Keep Your Contact Information Up-to-Date

Have you moved, or changed your contact information? We are beginning work on the 2009-2010 SFMS Membership Directory. The Medical Society wants to ensure that you receive important communications from us, and to make certain that the most up-to-date information appears in the Directory. A database update mailing went out a few weeks ago. Of course, you can also contact the Membership Department at any time to let us know of any changes or updates, or log on to the members section of the website.

Help Grow the SFMS/CMA and Give Yourself A Break On Dues!

Thanks to the CMA “Finders Keepers” program you can help increase membership and get a break on your next year’s dues! Recruit three new members and get 50% off your CMA dues! Recruit five new members and your next year’s CMA dues are free! SFMS dues will still be billed. Recruiting new members is easy using the online application process, and if the new member has never previously been a member of CMA they receive 50% www.sfms.org


off their first years SFMS and CMA dues. Be sure that the new members list you as the referring member to get credit for the referral. For more information, contact Therese Porter in the Membership Department.

Do You Work With Residents?

SFMS wants to reach out to residents in San Francisco’s residency programs. Thanks to arrangements made by both SFMS and CMA, dues for residents are complimentary for the duration of their residency. As with regular active membership, joining online is easy at www. sfms.org. If you are interested in helping promote membership among the residents with whom you work, contact Therese Porter in the Membership Department at (415) 561-0850, extension 268, or tporter@sfms.org for more information.

Golden Gate Restaurant Association v. San Francisco

The 9th Circuit issued a published order in Golden Gate Restaurant Ass’n v. San Francisco, denying the Restaurants’ petition to rehear en banc a prior decision upholding San Francisco’s “universal” health care program against an ERISA preemption challenge. CMA filed a brief opposing the Restaurants’ petition, so the Court’s order favors the position CMA took insofar as they argued that ERISA should not stand as a barrier to efforts at health care reform at the local levels. It was a relatively close vote—eight of the Court’s 26 active judges voted for rehearing. Fourteen votes are needed for rehearing. Also unusual is that the Court is publishing its order denying rehearing. This is quite rare and indicates the importance of the issue. Indeed, the dissenting opinion notes that “this case concerns an issue of exceptional national importance.” Given these factors—large number of dissenters on a published order involving national issues—we are certain the Restaurants will now seek certiorari from the U.S. Supreme Court. If so, CMA will have an opportunity to www.sfms.org

file further briefing before the high Court. The Law Offices of Howard Rice offered pro bono representation and helped CMA assemble the brief.

SFMS Seminars

Effective January 1, 2009, the new Joint Commission Leadership Standard requires that hospitals have a code of conduct that defines acceptable, inappropriate and disruptive behavior; and, that Leaders create and implement a process for managing disruptive and inappropriate behaviors. In response, the American Medical Association also adopted a new policy which calls for medical staffs to develop and implement their own code of conduct in the medical staff bylaws, and that hospitals also have a code of conduct applicable to members of the board, management and all employees. To assist medical staffs with implementation of a code of conduct the AMA Office of the General Counsel with the assistance of Elizabeth Snelson, Esq., in conjunction with the AMA-OMSS, drafted a model code of conduct for insertion in medical staff bylaws. It can be found on their website www.ama-assn.org/go/ omss. For more information, contact Jim DeNuccio, Director of Organized Medical Staff Services and Physicians in Practice, at james.denuccio@ama-assn.org or (312) 464.5597.

Friday, April 24, 2009 Reducing Overhead and Realizing Increased Income in Economic Downturns This half-day seminar will provide you with strategies which have been successfully implemented to reduce overhead in local practices. Specialty-specific benchmarks for line item expense ratios (rent, staff, supplies, etc.) will be provided. 9:00 AM – 12 PM (8:40 AM registration/ continental breakfast). $149 for SFMS/ CMA members and their staff ($99 each for additional attendees from the same office); $199 each for non members.

Code of Conduct Model Available

SFMS Member, Leonard Shlain, MD, to be Honored with Award

All SFMS Seminars require preregistration. Please contact Posi Lyon for more information, plyon@sfms.org or (415) 561-0850, extension 260.

Friday, May 19, 2009 Negotiating Physician PPO Agreements Effectively—The Blueprint for Success This lunch-time seminar is a must for physicians and/or their office administrators who contract with third parties. Learn to understand and utilize your power in negotiating contracts and what to look for when reviewing and negotiating the contract. 12:30 PM – 1:45 PM (12:15 PM registration/lunch). $120 for SFMS/CMA members and their staff ($99 each for additional attendees from the same office); $165 each for non members.

Wayne State University School of Medicine Alumni Association plans to present the 2009 Distinguished Alumni Award to Leonard Shlain, MD, FACS, Class of 1961, for being a pioneer in laparoscopic surgery and for his commitment to training future surgeons, mentoring the community, authoring award-winning books, and lecturing audiences internationally. Dr. Shlain is a long-time member of the SFMS.

March 2009 San Francisco Medicine

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San Francisco Medicine March 2009

www.sfms.org


President’s Message Charles J. Wibbelsman, MD

A Man for All Seasons, A Physician for All Times

T

his issue of San Francisco Medicine has some excellent articles focusing on diverse and innovative activities by some of our fellow San Francisco physicians. When glancing again at the Hippocratic Oath, I am reminded that the practice of medicine is not limited to caring for patients inside the walls of a medical office or a hospital. There are many challenges for physicians that carry one’s stethoscope to diverse settings. I am reminded of a situation that occurred in 1986, at the medical center in which I was practicing as a pediatrician, that was a definite departure from diagnosing otitis media or performing a sepsis workup. That October, there was a labor action in which a large number of nonphysician and nonnursing staff did not work. This labor action lasted six weeks, until just before Thanksgiving. I can vividly recall one of my colleagues, George Susens, MD (one of our Past Presidents), calling me at home on a Sunday afternoon to “muster the troops.” For six weeks, not only did I practice as a pediatrician in the mornings but in the afternoons I reported to the hospital laboratory, where I refreshed the skills I’d learned back when I was working in a community laboratory in Cincinnati as a medical student. I performed the tasks of the absent medical technologist, running an autoanalyser and generating data for chemistry analyses. Perhaps I was the lucky one. Some of my colleagues, including a pediatric cardiologist and a geneticist, worked as janitors for six weeks, emptying the trash and mopping the floors throughout the medical center and clinic building. A memorable highlight was a story and photo of these “physician janitors” on the front page of The New York Times. Although this was a tough time for all of us as we adapted to other activities, it was also a time when many of us had the opportunity to meet other physicians in the medical center whom we had barely ever known. I was fortunate to be working with an ophthalmologist who was answering the phones in the laboratory, and who has become a close friend for life. Another example of medicine outside of one’s traditional practice is the time I became an “instant volunteer.” When on a flight, how many physicians will respond to the overhead page, “Is there a doctor on board”? In 1996, when I was on a flight from Los Angeles to Washington, D.C., on my way to attend a medical meeting, there was such a page. There were many of my colleagues on the same www.sfms.org

flight. Many did not respond. The passenger who was ill was a young adult, age nineteen, with severe gastroenteritis a result of all-night partying and food poisoning. The other physician who responded was a cardiovascular surgeon from the Washington, D.C., metro area. He immediately took control of the situation, instructing the flight attendants to arrange for the young man to be placed in a reclining position. The surgeon informed me that I would be “his assistant.” With fluids and rest (lying down in the aisle of the plane), this young man recovered. Yet the question always remained in my mind: Why did some of my colleagues not respond to this request? In this issue of San Francisco Medicine, we salute our colleagues who are “physicians for all times,” rising to the occasion and acting as illuminating examples of physicians whose professions transcend the walls of their medical centers.

March 2009 San Francisco Medicine

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San Francisco Medicine March 2009

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Editorial Mike Denney, MD, PhD

Extreme Peer Review

I

n the year 1900, Karl Landsteiner discovered the A, B, and O blood types; Hugo De Vries retrieved a neglected thirty-five-year-old article from an obscure journal, a study written by the thendeceased Gregor Mendel that explained the laws of heredity; Santiago Ramón y Cajal demonstrated that neurons in the brain connect with one another via synapses; Alois Alzheimer described the neurological disease named after him; Sigmund Freud published Interpretation of Dreams, heralding the development of modern dynamic psychiatry; William Stewart Halsted was awarded an Honorary Fellowship in the Royal College of Surgeons in recognition of his outstanding contributions to surgical research, practice, and education; and Marion Potter became the first woman physician in the United States to be granted privileges to practice medicine in a hospital. These discoveries and actions were refined over the next 109 years to give rise to increasingly extreme medical technologies—blood replacement products, the mapping of the human genome, advanced neuroscience, new treatments for dementia, techniques to treat emotional disorders, surgical procedures such as minimally invasive and robotic surgery, and the remarkable accomplishments of women physicians in all specialties of medicine. This dramatic story of medical progress is the direct result of evidence-based medicine, with its strict peer review as the gateway for grant proposals for research studies and articles for publication in journals. The criteria of peer review are objectivity, isolation from the whole of a specific problem to be studied, and a reliable and valid quantitative and statistical scientific method. Paradoxically, the weaknesses of biomedical science may be the same as its strengths of objectivity isolation, and quantification. Ordinary biomedical science methodically excludes subjective data, minimizes the integrated wholeness of a human being, and eschews the qualitative aspects of illness. Such phenomena as a fierce intention to heal, in-depth poetic or spiritual longings, the capacity to love and be loved, the spiritual or transcendent search for harmony with the universe, prayer, and a host of as-yet-unknown physiological healing dynamics are at worst neglected or relegated to “side effects” of the treatment we propose, and at best studied by “alternative” practitioners who use the ordinary scientific methodology that itself excludes the phenomena being studied. When, as usual, such data is inconclusive, are these phenomena thereby proven to be without merit, or is it that our ordinary biomedical science is inadequate to measure the subjective, whole, and qualitative dynamics of illness and its treatment? www.sfms.org

Other even more extreme discoveries in the year 1900 may offer insight into this question. In that year, mathematicians and philosophers made startling observations that went beyond ordinary biomedical science. Henri Poincaré presented a paper on deterministic complex systems, which described the unpredictable emergence of phenomena that cannot be explained by ordinary science; Bertrand Russell discovered that mathematics and logic will always be paradoxical and incomplete; and Edmund Husserl published Logical Investigations, beginning the field of phenomenology, which honors human subjective experiences as being equal in value to objective data. Additionally, in 1900 a physicist named Max Planck originated the concept of quanta, which has developed into the most reliable description of matter. This new science presents a strange reality in which quantum particles can be in two places at the same time, can be here and appear over there without traversing the intervening space, cannot be said to exist until they are observed, and can affect one another at a distance acausally and instantaneously. These concepts have grown into such methodologies as systems theory, network dynamics, complexity theory, nonlinear dynamics, and self-organization within complex systems. And these phenomena have been especially applied by such visionaries as physicist Fritjof Capra to complex biological systems, forming a new discipline called deep ecology. In his book, The Web of Life, Capra terms these dynamics “The Systems View of Life.” Despite the fact that a human being, body and mind, is the most complex entity known to exist, these ideas of spontaneous emergent phenomena and quantum weirdness were not applied to healing during the 20th century as was ordinary biomedical science. This may be because they do not seem logical or even rational, and our ethics and the law mandate that we must do our research and practice within the “rationality” of ordinary science. Extreme discoveries in mathematics and science began in the year 1900. Now, 109 years later, they have not yet been included so as to create new theories, research methods, and clinical practice. Within our rigid peer review, we continue to function solely with a biomedical science that lost its exclusivity at the end of the nineteenth century. Yet our current peer review guarantees that nothing is going to change. If we are to explore new methodologies to study subjectivity, wholeness, and quality that include the extreme complexity and quantum realities of the 21th century, perhaps we must first develop a new paradigm. We can call it “Extreme Peer Review.” March 2009 San Francisco Medicine

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Extreme Medicine

After Shock A Physician Recounts His Experience on the Bay Bridge after the 1989 Earthquake

Mark Renneker, MD

O

n October 17, 1989, I was returning home to San Francisco after an afternoon of meetings for a cancer prevention project that I was helping organize for the West Oakland community, and I was planning to stop at an exotic-reptile store on Cypress Avenue, which is the frontage road alongside and underneath the double-decker portion of the 1-880 (Nimitz) freeway. I hoped to buy an iguana as a surprise birthday present for my girlfriend. After a hot, windless Indian-summer day, it was starting to cool down, and since it was a little after five o’clock and the third game of the World Series was about to start across the bay in Candlestick Park, on each block of this otherwise bleak ghetto were groups of people, all of them black, casually engaged in pregame festivities, wearing tank tops or going shirtless, drinking beer, sitting on their front porches or clustering on comers, many with ghetto blasters set up to broadcast the game to the neighborhood. I’d already written the Giants off after their losing performance in the first two games—Oakland seemed far too powerful to me—so I was ghetto-blasting on my own, with Steel Wheels, the new Rolling Stones cassette. Despite the pleasant temperature and apparently relaxed, happy atmosphere of the neighborhood, I had my windows rolled up and the doors locked. West Oakland can be a dangerous place. I was about a block from the freeway, near West Grand Avenue, when my van began rocking—not violently, more as if someone were bouncing up and down on the back bumper. Looking around the car, I saw a group of kids waving their arms,

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jerking their bodies, as if in a voodoo dance, and I thought they were responsible for the rocking—that they were taunting me to get out so they could mug me. I wished I could tell them that I was on their side (thinking about the cancer project) but, instead, I gunned ahead to escape and was brushed by what looked like an electrical wire, swinging down from above. I looked up and, only then, seeing everything in motion, realized that it was an earthquake. By that time, the quake was already ending. I drove on, looking for a safe place to stop. Metalogue: How long does it take to recognize a disaster? The October 17 quake lasted fifteen seconds, the duration of which I spent thinking it was anything but an earthquake. Baseball, work, my car, fear of the neighborhood I was in—these things were on my mind when the quake hit, and they clouded my thinking as I tried to comprehend what was taking place. Growing up in California, I’m no stranger to earthquakes, but having not experienced any quakes in some months (and never having been in a major quake), my “quake reflexes” were dulled and underdeveloped. Consequently, I didn’t spend those first dangerous seconds as I should have: seeking a safe place.

San Francisco Medicine March 2009

Fat into the Fire When I rounded the comer ahead, I found myself at the foot of the crumpled freeway, from which debris was still raining down. On the top deck, cars and trucks were scattered randomly—frontward, backward, some upside down, some teetering atop places where the roadbed had buckled, suspending them like rollercoaster cars ready to plunge. Some had already fallen the forty or so feet to the street below, landing front first, spreading fluorescent green oil and gas over the pavement. As I stared, people began to appear—moving slowly, dazed, atop the freeway, and below, emerging from the ghetto houses and industrial yards. I wish I could say that, being a physician, I immediately leaped into action, but that wasn’t quite the way it happened. For a dazed moment, I first considered trying to continue on my way to the pet store. Luckily, I was awakened by the sight of a tall black man stepping forward into the intersection to keep me (and cars behind me) from continuing forward into the rubble of the fallen cement columns. I pulled my van to the side, grabbed my stethoscope from my briefcase (completely forgetting the blood pressure cuff and other medical equipment I keep www.sfms.org


in the back of the car), and hurried to the closest fallen vehicle, a wide-bodied semitrailer truck. Metalogue: Why do some people freeze up at a disaster? I was senseless in the first moments after the quake, in active denial of what my eyes were seeing. It was my knowledge of CPR that brought me back to reality. In fact, simply knowing that one knows CPR empowers one to act in such a situation. CPR is the ultimate tool, far more powerful than any other medical tool. It is something that all citizens can and should learn.

The Trucker’s Death

The truck’s cab was crushed and twisted to half size. A young black girl was peering into it, crying, “He’s dead, he’s just plain dead.’” However aggravating or comforting my usual optimism may be to my patients, it is clearly so much a part of me that even at that moment it tumbled forth. “Maybe not,” I said, “let’s check.” A white man, perhaps fifty years old, lay inside the cab, unconscious. He had light, thinning hair, looked like a career trucker, and had on the kind of cheap white undershirt you can almost see through. Apart from the fact that his lower body was wedged solidly against the door by the steering column, he seemed unhurt—but he wasn’t breathing. Taking his wrist, I could clearly feel a pulse. My training told me, “Now! Do CPR. Give artificial respiration.” But there was no way to lean in to face him, to breathe into him. I tugged and tried to turn him or pull him free. As I held his wrist, his pulse dwindled and stopped. A small group of young black men had gathered around me, and I tried to organize them into a rescue squad. I told them that I was a doctor, that the trucker was dead, and that we should move on to those still alive. One of the young men, a spindly short fellow who would, in the movies, be typecast as a sidewalk thief, said, “Here, you better keep this or else someone will steal it,” and handed me the trucker’s wallet. It was one of those items you can buy at a truck stop: an inexpensive Velcro-close nylon wallet, hot pink, one side printed with black silhouettes www.sfms.org

of naked, big-breasted women. Knowing the importance of accurate identification of bodies, I wanted to be sure the wallet found its way into the proper hands, but I knew I had little time for such details. I hustled over to a policeman who had appeared and was directing traffic, but he refused to take the wallet, telling me to take it to a group of three men standing across the street. They stood like a stand of young birch trees: white, shoulder to shoulder in a half ring, as if, in this alien territory, they were holding each other up. I explained that I wanted one of them to stay with the trucker, to hold the wallet, ward off onlookers, and be ready for when the rescue and medical crews arrived, to tell them not to waste their time trying to save him. As I moved away, I looked back in time to see the man I’d left in place wandering away—not as if he were running off with the wallet, just moving off in a daze.

Saved by the Cavalry?

All this had taken little longer than a minute, and now a young black teenager had me by the wrist, urging me to come with her to where someone else “needed my doctoring.” This next victim was also in a fallen and smashed truck. He was conscious, alert, and, again, I saw no obvious injuries. But he too was pinned in the wreck. At this point I was joined by a female paramedic, in full uniform, wearing her equipment around her waist, and I felt tremendous relief, as if the cavalry had finally arrived. But there was no one with her (she’d come from home) and, looking around me, seeing so many crushed cars and hearing victims screaming, I again felt the enormity of the situation. I turned the man in the truck over to the paramedic and moved off to see where else I could help. A newsman was coming towards me, a well-known local anchorman who had somehow found his way to the disaster scene long before other reporters, but he wasn’t moving normally. He was walking as if he were wearing twenty-pound shoes, and he was frantically drawing puffs from a cigarette. I stopped him

with my hands, and said: “Hey, man, what are you doing? Don’t you see the gas on the ground? Put out your cigarette!” He snuffed it out on his open note pad, which was blank. Then he looked up at me with an equally blank, clearly in-shock expression, and asked if I’d seen his camera crew. Scanning the scene, I couldn’t see them, told him so, and he shuffled off. Metalogue: Why do people behave in such different ways at a disaster? In the face of this disaster, practically every person initially and equally “bottomed out.” It was just too much to handle, too unfamiliar. We were reduced to a group of floundering organisms. But in climbing out of that bottomed-out state was where the differences between people became evident. Each began with that which was most familiar: doctoring for me, directing traffic for the policeman, reporting for the newsman. Although we varied tremendously in our ability to accomplish these “self-jump-starts,” the take-home lesson is that when you’re bewildered and don’t know what to do, your natural inclination will be to start simply, with something you know that you can do. Let it happen; don’t expect that you’ll be thinking clearly or that you can do everything at once.

Real Heroes

Perhaps fifteen minutes had elapsed since the freeway’s collapse. By now, there was frantic activity all along the overpass: men from the neighborhood, of the sort to project an image of street brigands, were dragging ropes and rickety ladders from their garages and were scaling the face of the fallen freeway, climbing up hand over hand—like pirates boarding an enemy ship, but they were on an errand of mercy. When firemen and other rescue personnel finally arrived, victims were already being helped down, some on the backs of their rescuers, for whom my respect was, and is, enormous. (I’ve since pondered why the neighborhood people seemed so clear-minded and capable in the quake’s aftermath, but it makes sense: disasters are a fact of life in West Oakland—with crack wars and daily shootings on the streets, you learn not to Continued on page 36 ...

March 2009 San Francisco Medicine

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Extreme Medicine

In the Hurricane’s Trail Medicine in Post-Katrina New Orleans

Toni Brayer, MD

I

n September 2005, Hurricane Katrina rocked the Gulf Coast and devastated New Orleans and Biloxi, Mississippi. Those of us who responded by walking into the aftermath as volunteers encountered the remnants of a disaster unlike anything we had seen before. As a physician volunteer, my time in post-Katrina New Orleans was hectic and filled with improvisational moments in medicine. It was what I would call my closest encounter with “extreme medicine.” After the hurricane and levee break in New Orleans, I visited a Katrina disaster website and sent an email asking if help was needed. Within a few hours, I was shocked to receive a reply: “Yes, what is your ETA?” Something told me I needed to go right away, so I rounded up some supplies from CPMC and packed a sleeping bag, medical supplies, mosquito repellant, and power bars, and within twenty-four hours I was headed toward Baton Rouge, where

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all incoming flights were diverted. Upon arrival, I was told to go to the Jimmy Swaggert Center, where all the medical relief was being staged. After a brief check of my credentials, I was

“Working round the clock, we dealt with a variety of medical issues. Imagine 5,000 men, women, and children who have spent five days in scary, life-threatening conditions and are now homeless.”

deployed to the River Center. This large convention hall on the banks of the Mississippi served as a Red Cross evacuation

San Francisco Medicine March 2009

facility and was filled with 5,000 victims of the hurricane, many of whom had survived the horrors of the flood, the Superdome, and the deplorable conditions on the Interstate. Babies, frail seniors, families with toddlers and school-age kids, handicapped people in wheelchairs, and the desperately poor were all crowded together in this large center. The critically ill and trauma patients had been evacuated to surrounding ERs, but many of the River Center patients were still in shock and were ill. My job was to bring some order to the small makeshift medical area that had been speedily set up. Two Red Cross nurses were there, along with a smattering of doctors and nurses who, like myself, had just arrived wanting to help. It didn’t take me long to see that the location and setup of the clinic was inefficient. Some tables put up in a thoroughfare, with drug samples in messy boxes, would not do. Everyone was working

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hard in the midst of chaos, with no chain of command or leader. Because the medical area was stationary and everyone and everything else was in flux, we became the “go-to” site for everyone—both patients and volunteers—no matter what the issue. I was able to locate the building superintendent and we quickly found a storeroom behind a locked door that was a much better medical location. After clearing it, we worked to move cots and tables, set up a glucose check area, label drugs and supplies, and establish a wound treatment area. There were no exam tables, and no privacy, but it became a more functional MASH unit where we could work. Red Cross volunteers, a nurse, and I worked until the late hours of the night to move that equipment, seeing patients all the while. Could it be that I had only been there one day? Working round the clock, we dealt with a variety of medical issues. Imagine 5,000 men, women, and children who have spent five days in scary, life-threatening conditions and are now homeless. Many of the patients were separated from loved ones and had fled without any belongings. We saw diabetics without their insulin for a week, pregnant women, children with colds and viruses, bipolar patients off their lithium, depressed and shocked women who had to leave their beloved pets behind. People had rashes from the toxic water that they had swum in and hypertension that was out of control. The medical problems were not a stretch. We had no labs or imaging ability, so common sense and good diagnostic skills went a long way. After getting the clinic up and running, I took on a new disaster medicine job. New Orleans had been evacuated but there was still a need for search and rescue, followed by searches and body recovery in New Orleans and the surrounding parishes. The scale of this disaster had never been seen before in the United States, and the government response was so inadequate as to become a worldwide scandal. Watching people without food or water waiting on rooftops and freeways for days without rescue was more than anyone could believe. As a physician, I was www.sfms.org

seen as someone “in charge,” and yet I had no better communication or infrastructure supporting me than any of the victims. The most heartbreaking experience was going to St. Rita’s nursing home in St. Bernard’s Parish, where thirty-five elderly and disabled patients died in the flood. It was the hardest-hit area, and it looked like a bomb had been dropped there. Accompanied by paramedics, we removed bodies and rendered first aid to local police and a few stray people who saw us as “official.” Without access to medical facilities, our role was to assess, triage, and even transport them out of the devastated area when we could. After a week I had to return home, but I was shaken for months by what I had seen and experienced. I still think of New Orleans and wonder about the diaspora of people and the rebuilding of the medical infrastructure in that city. I learned a great deal from my extreme disaster experience in New Orleans, including the importance of effective communication and the need for a strong chain of command—both of which were sadly lacking after Katrina. Electronic medical records would have allowed us to know what medications patients were on and helped us assess medical problems. Since most records were destroyed in the flood, and doctors were forced to flee also, we were severely handicapped. I also learned that common sense and the ability to step out of a traditional role is an important trait when dealing with a disaster. One volunteer physician had written his plan in the makeshift chart: “Check CD4 counts, CBC.” I guess he forgot we had no lab. When the world is in upheaval, it is not business as usual. Toni Brayer, MD, has practiced Internal Medicine in San Francisco for over 20 years. Dr. Brayer has served as President of the SFMS and currently serves on the Editorial Board for San Francisco Medicine. She is a known speaker and writer on a variety medical topics and authors a blog entitled EverythingHealth. To read more of her work, visit her blog at http://healthwiseeverythinghealth.blogspot.com/.

2008 SFMS Political Action Committee Contributors Thank you to the following members who contributed to the SFMS PAC either as part of their 2008 dues or in response to the 2008 PAC fund raising letter. Gary A. Belaga, MD Joseph I. Bernstein, MD Michael W. Bigelow, MD Bernard Blumberg, MD Toni J. Brayer, MD James M. Campbell, MD Richard L. Caplin, MD Paul B. Carlat, MD Gary L. Chan, MD Kenneth D. Chan, MD Pamela G. Chan, MD Randolph H. Chase, MD Taissa Cherry, MD Lawrence Cheung, MD Allan B. Chinen, MD Edward A. Chow, MD Karen Chu, MD Crawford K. Chung, MD James A. Clever, MD Henry L. Cuniberti, MD Peter J. Curran, MD Jean-Jacques de Shadarevian, MD Kevin J. Denny, MD Eduardo P. Dolhun, MD M. Gay Ducharme, MD Roger Eng, MD Martin Fleishman, MD George A. Fouras, MD Steven H. Fugaro, MD Gordon L. Fung, MD Francisco A. Garcia, MD Albert C. Gaw, MD Richard G. Glogau, MD Erica T. Goode, MD William H. Goodson III, MD Thomas M. Jackson, MD Ilse K. Jawetz, MD James P. Krajeski, MD Alan M. Kramer, MD Janice Lee, MD Elizabeth M. Lewis, MD Carolyn Yi Li, MD Raymond K.Y. Li, MD Berty P. Liau, MD Britt Marie Ljung, MD Keith E. Loring, MD Randall Low, MD Helen Sabina Manber, MD Robert J. Margolin, MD Timothy J. Marten, MD David R. Minor, MD Piero O. Mustacchi, MD E. Ann Myers, MD Philippa Newfield, MD William L. Newmeyer, MD Peter A. Pollat, MD Ricki Pollycove, MD Winchell W. Quock, MD Joshua H. Rassen, MD Joel W. Renbaum, MD Brunno Ristow, MD, FACS Michael Rokeach, MD Ira D. Sharlip, MD Jordan Shlain, MD Rachel Hui-Chung Shu, MD Judy Lynn Silverman, MD David E. Smith MD Roderick G. Snow, MD James Y. Soong, MD James E. Storm, MD Peter W. Sullivan, MD John I. Umekubo, MD H. Hugh Vincent, MD Ralph O. Wallerstein, MD Charles J. Wibbelsman, MD Russell D. Woo, MD Frank S.K. Yang, MD Robert C. Zaglin, MD

March 2009 San Francisco Medicine

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Extreme Medicine

The Real ER A Day at San Francisco General Hospital Emergency Department

Malini K. Singh, MD, MPH

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s I rush through the waiting room of the Emergency Department at San Francisco General Hospital, with my eyes toward the floor, I try to avoid what I imagine the patients are showing on their faces. “Finally, a doctor is here!” I see their eyes convey. I throw my bag and coat onto a chair in the office and race to switch out for one of my esteemed colleagues. As I approach my new home for the next eight hours, I can usually sum up, from the number of patients in the hallway and the faces my departing team members, just what kind of shift I’m in for. As I listen to the stories of the patients that now will be under my care, I take careful notes and ask a number of “what if” questions in the event patients don’t adhere to the care plan the team has so meticulously devised. I am only minimally surprised that some of the patients are still here from my prior shift, a time frame that can sometimes span one to two days. As I make my rounds to introduce myself to my newly inherited patients, I see many tired and sad faces weathered by pain, drugs, alcohol, and depression. As my name rolls off my tongue, I am often met with blank stares that seem to say that I am just one of the sea of doctors who have come by to see them. “Doc . . . how about some water . . . a sandwich . . . pain medication . . . a warm blanket. . . .” As I take in my surroundings and begin to assess how to best keep our patient traffic moving, I notice a line developing at the main desk, with eager medical students and residents ready to present their new patients. Twenty-three-year-old male with abdominal pain . . . seventy-five-year-old female with chest pain . . . fifty-six-yearold female with headache . . . eighteen14 15

year-old male who hears voices . . . Some sound sick, some sound well, some need a doctor eventually, some needed a doctor yesterday, and some just sound like they had nowhere else to go. As I hear all their

“As I approach my new home for the next eight hours, I can usually sum up, from the number of patients in the hallway and the faces my departing team members, just what kind of shift I’m in for.”

stories, I can’t help giving them a diagnosis in my mind already, since I have heard and seen their scenarios so many times before. Let’s take the case of Ms. S, a fortyyear-old female with back pain for the past few weeks. As my medical student starts her presentation, I try hard not to interrupt and to wait till she is done. I run through a quick discussion about back pain and ask her to think of a list of possible diagnoses, even though I am sure it is the one I have already thought of. As I walk in to see Ms. S, she is lying on her left side with her back toward me, in fetal position. I introduce myself and she quietly answers, “Hi.” I lean over to see her face and I notice her cheeks are wet from fresh tears. I implore her to turn around so I can talk with her, and she reluctantly and slowly turns to her right side, staying in a fetal position. I start

San Francisco Medicine March 2009

in with my questions and wait somewhat impatiently until she answers me with her soft-spoken voice and brief answers. As I start to unravel the sheets around her body so I can examine her, she resists and pulls the sheets up closer to her chin. As I watch her do this, my pager goes off, signaling an incoming trauma patient. Behind the curtain, the voice of one of my nurses is asking aloud if anyone knows where I am, and through the speaker overhead one of the clerks is calling me to pick up line one. I tell my patient hastily that I really need to examine her, but she resists even more. At this moment, I am needed in three places at once. I tell her I will come back later—don’t know when, but will come back. The phone call is about a transfer from one of the outpatient clinics: a twenty-two-year-old pregnant female with severe abdominal pain, not just a concern in an ectopic pregnancy but potentially a life-threatening diagnosis. Then the nurse who was looking for me tells me that Mr. D, who was being admitted for alcohol withdrawal, just had a seizure while walking to the bathroom and hit his head on the floor. The trauma patient coming in was a restrained driver involved in a multiplerollover motor vehicle accident and found trapped under his car. We are told by the paramedics on scene that he was awake and breathing despite having a number of obvious injuries to his head, back, and legs. Upon arrival at the Emergency Department, his condition became more critical—he had become unconscious and stopped breathing. Our team swoops into action to help secure his airway and complete the trauma survey to identify Continued on page 16 ... www.sfms.org


Extreme Medicine

Super Bowl Surgery An Extreme Case Study

Daniel Marelli, MD, and David Bona, PhD

O

n Super Bowl Sunday, February 3, 2002, my wife was expecting our first child, and I was at a high point of my academic heart surgery career at UCLA Medical Center. I accepted a friend’s invitation to watch the Super Bowl in his media room. Tom Brady of the New England Patriots was a rising star and the opposing team, the St. Louis Rams, was known as the “Greatest Show on Turf.” U2 was to perform at halftime. My wife wanted to rest, so the timing was perfect for a boys’ football party. Shortly after halftime of the game, my pager went off. Uh-oh. “Hello?” I said, hesitating. “This is David Bona,” the speaker echoed. I recognized him as a past patient of mine. “How are you doing, David?” I asked. “I’m having aortic dissection and I need to be transferred to you right away.” I felt a bottomless pit develop in my stomach. He described how he had gone to his hometown emergency room when he had lost all sensation in both legs, while experiencing persistent chest pain. I tried to stay calm. David said, “My CT scan shows the dissection extends all the way to my legs.” “You’re a couple of hours away; such a delay in treatment could be lethal,” I suggested uneasily. “I’ll take my chances and come to you,” he replied firmly. I was flattered by David’s confidence in me, but I felt just as scared as I’m sure he did. “I’ll make the necessary arrangements to meet you in the operating room as soon as possible.” ***** On Super Bowl Sunday on February

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3, 2002, I was watching the football game with a friend. Suddenly, I began to feel a little dizzy. I tried to walk, but my left leg dragged behind me. My friend insisted on taking me to the hospital. The emergency nurse took one quick look at me, grabbed my arm, and led me to a gurney. After a CT scan and other tests, she summoned the heart specialist on call. To my dismay, he was the surgeon who had previously failed to properly treat severe postoperative pain in my sternum, which lasted for five months. I had lost trust in him. Now, deathly ill, I certainly could not trust this man with my life. “Call Dr. Marelli at UCLA,” I shouted. Marelli was the surgeon to whom I had been referred by a friend and who finally fixed my sternum after my local doctor’s procrastination. They brought me a phone, and I talked with Dr. Marelli. I insisted on being transferred. At my request and with informed consent, I would be taken by ambulance over the five miles to the nearest airport, placed into a helicopter, and flown to UCLA Medical Center. ***** As I left the Super Bowl game and headed for my car, I remembered that I had originally met David at UCLA in 2000, during my fifth year of practice. He had undergone a coronary bypass procedure at another hospital and was left with a painful sternal nonunion defect. I surgically corrected his nonunion without any problems, his pain was relieved, and he had an uneventful follow-up, taking a beta blocker and ACE inhibitor daily under the care of his cardiologist. ***** During the time that I awaited the ambulance and then was transferred to

the helicopter, I remembered how I had met Dr. Marelli. It had been two years earlier, on December 13, 2000, when I was a very healthy fifty-seven-year-old psychology professor at an advanced graduate school. On that day, I began to experience some shortness of breath and heaviness in my chest. I visited my GP, who performed an EKG and immediately sent me to a cardiologist. The angiogram showed four blocked arteries. Soon after coronary bypass surgery, however, I developed stabbing pains in my chest. My surgeon assured me that it was just ordinary chest trauma that would soon disappear. For months, the stabbing pain was intolerable. The surgeon took me to Outpatient Surgery and removed some wire stitches and placed some new ones. Still, the pain persisted. At this point, I knew that I needed a second opinion. On May 10, 2001, I called a friend who was a trauma surgeon. He sputtered with disbelief and promptly referred me to Dr. Daniel Marelli at UCLA Medical Center, who expertly fixed my unhealed sternum with no problems. Two years later, on that Super Bowl Sunday, trusting that I would soon see Dr. Marelli, I was aware of being transferred from the ambulance into the helicopter, and then I slipped into unconsciousness. I didn’t know then that I would be unconscious for a long time. ***** After that phone call from David on Super Bowl Sunday, my mind started to race. Driving to the hospital, I mused: a third sternal entry, bypass grafts embedded in scar, impending aortic rupture, possibly irreversible ischemic injury to Continued on the following page ...

March 2009 San Francisco Medicine

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Super Bowl Surgery continued ... both lower extremities, or worse, the spinal cord. How would I access the circulation for cardiopulmonary bypass? What about reattaching the bypass grafts? 11:00 p.m.: In the operating room. No sense in delaying intervention with additional tests. Induction of anesthesia and draping completed. Need access to an undamaged branch of the arterial tree in order to attach to pump. Explore the right femoral artery. Bloodless. Same on the other side. Right axillary artery. Success! Heart pump functioning. The femoral vein yields drainage. Cool David’s body to 18 degrees. February 4, 2002, 1:15 a.m.: Sternal reentry successful. Explore the thoracic cavity and assess the circulation. Arrest the circulation and start working on the arch. Arch repaired without any surprises. Distal tube graft anastomosis for arch repair completed. Start rewarming. Circulation successfully reestablished to legs. Detach the coronary bypass grafts as an island of ascending aorta remnant. Replace the ascending aorta with graft. Inspect the aortic valve. Do a standard repair. Complete the proximal anastomosis. Reimplant the island of bypass grafts. 5:00 a.m.: David off pump. Transesophageal echo shows severe aortic valve insufficiency. Bad news. Back on pump. Replace the aortic valve. 11:00 a.m.: Coming off pump again. Bleeding torrential. Heart function acceptable. Every needle hole leaking blood. Administer blood products to correct coagulopathy. Generalized edema setting in, preventing a good seal. Tissues not holding any sutures. It might be the end. Better to pack the chest open to control bleeding and do a delayed closure another day. I’m feeling tired and lonely. 3:00 p.m.: Fourteen hours in the OR. To intensive care. In a dire straits. Diuretics and topical haemostatic agents our best hope. ***** When I woke up in the intensive care unit, there was Dr. Marelli looking down at me, and I knew I was going to be all right. It was a long battle to get back to health, but everything went smoothly—no com16

plications. Now I am back to work teaching regularly, and although my exercise schedule is not what it used to be, I remain in good shape. Dr. Marelli and I have stayed in touch over the years, even after he moved to the East Coast. And, every Super Bowl Sunday, I remember his expert care and thank him for my life. ***** The day after David’s extreme surgery, I took him back to the operating room to explore his chest. The bleeding was well controlled, and I happily changed the packing. On February 6, 2002, we anatomically closed his chest, taking care to be sure his sternum was well approximated. His urinary function returned, his heart remained stable, and he was discharged within the next three weeks. I always remember David, and every Super Bowl Sunday I pray for his health. Colleagues and trainees often ask me why I do things one way or another. The story of heart surgery frequently evolves by applying techniques the “same way differently,” repetitively. One of the best examples of such progression is illustrated by surgery for dissection of the ascending aorta. Each case is unique, urgent, and death is, in many instances, one suboptimal decision away. So, to my colleagues’ questions, I give my usual answer: “Let me tell you about David Bona.” David Marelli, MD, completed his residency in cardiovascular and thoracic surgery at McGill University in Montreal, Canada. He is currently in practice at Bayhealth Medical Center in Dover, Delaware, affiliated with the University of Pennsylvania. David Bona, PhD, is a Professor of Depth Psychology at Pacifica Graduate Institute. The Real ER Continued from page 14 ... and manage any life- or limb-threatening injuries. After our surveys are complete, we summarize this accident victim: a thirty-year-old, previously healthy male who was T-boned by a midsized truck, causing his car to roll over multiple times and trapping him between the road and

San Francisco Medicine March 2009

tons of crushed metal. His injuries included a collapsed lung, blood in his abdomen, multiple large abrasions, and a spinal cord injury (given that none of us saw him move his legs once). As he is being wheeled off to CT scan, I am informed by one of my nurses that his wife, sister, and brother-in-law are in the family waiting room. I have barely taken my first real deep breath before I have to inform a wife that if her husband wakes up, he may be wheelchair-bound for the rest of his life. “Ms. S, sorry it took so long for me to get back to you . . . how is your pain now?” She is again facing away from me, still in a fetal position, telling me that nothing is helping her pain. I try this time to examine her without going through the trouble of having her turn for me, until I notice a bruise on her right hip. “Ms. S, how did this happen?” “I fell down some stairs,” she replies. This prompts me to look for other injuries from her fall, so I peel back the sheets before she has the chance to stop me. There they are: bruises on her wrists, chest, back, and legs. And then she starts to cry. I learned quickly that she has been a victim of domestic abuse for a number of years, but she has been too scared to seek help, in case her boyfriend were to find out. Here is a vulnerable, lonely woman’s first cry for help. And it is to me, in a corner of the Emergency Department that is bursting at the seams, as I am being summoned to five different rooms at once. Ms. S’s story is not unlike so many we see every day. A day in the life of the emergency physician is one that is full of chaos, overburdened staff, and lack of resources—but it is also one of opportunity to help people during their greatest times of need. As I leave the Emergency Department through the waiting room, with my head held high, I see faces that are grateful that we are always here for them. After all, we turn no one away. Malini K. Singh, MD, MPH is an assistant clinical professor of medicine at the UCSF School of Medicine and a clinical attending at the San Francisco General Hospital Department of Emergency Medicine.

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Extreme Medicine

A Day in the Life of PES Twenty-Four Hours at the Psychiatric Emergency Services Department of San Francisco General Hospital

David Elkin, MD; Paul R. Linde, MD; and Eric Woodward, MD

I

t’s 7:00 a.m., and a group of a dozen men and women—psychiatrists, social workers, nurses, and other mental health personnel—are gathered around a desk in the staff room, performing the daily ritual of the morning report in the Psychiatric Emergency Service (PES) at San Francisco General Hospital. A glowing LCD screen—one of few high-tech devices in an otherwise outdated and unadorned space—displays patients’ names, diagnoses, and lengths of stay. Almost all of the twenty patients (an average case load) are in PES on an involuntary basis. The State of California’s Welfare and Institutions Code 5150 provides the legal justification for a person to be involuntarily taken into custody for up to seventy-two hours for an evaluation on the basis of being a danger to self, danger to others, and/or gravely disabled on the basis of a psychiatric illness. The PES at San Francisco General is open for business 24 hours a day, 7 days a week, 365 days a year. It is the only designated receiving facility in the city for people placed on 5150 psychiatric holds. Often, working in PES can be compared to diving into the swirl of a cyclone and hanging on for dear life. The staff adjusts to the velocity and spin enough to manage as many as four equally compelling tasks at the same time. It helps to come equipped with an unusual combination of keen diagnostic skills, a sense of humor, tolerance for ambiguity, and the ability to react quickly to changing circumstances. The environment in PES is customdesigned to manage psychiatric emergencies. Generally, two nurses sit behind the

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triage desk, a crescent-shaped structure facing toward four seclusion rooms, each with a heavy metal locking door and each containing a steel bed equipped with four restraints, one per extremity. To the right

“The PES at San Francisco General is open for business 24 hours a day, 7 days a week, 365 days a year. It is the only designated receiving facility in the city for people placed on 5150 psychiatric holds.”

of the desk is the triage area, which is accessible from the outside corridor by set of double locked doors. This is where the police and paramedics enter to bring in patients from the streets. To the left of the desk is the sprawling “day room,” which should really be called the “24/7” room, in which patients sit and sleep on pullout chairs. Behind the desk, separated by a wall with two doors, is a cramped staff room. Some of the patients who were asleep in the day room are waking now, interrupting the report as they come to the desk to ask for medication or other requests. But the staff is busy discussing the clinical condition and disposition plans for each patient, some of whom were admitted over the night shift. This

space is not secure within a Plexiglas “fishbowl” like many psychiatric units but is instead open to the patients, except for a modest counter and half-door about four feet high. Patients do wander in from time to time, and at least two have been known to jump the wall in a single bound—once a patient punched a nurse, and another was able to escape out of a slightly ajar first-story window. The staff is alert to signs of agitation as patients approach the nurses’ station. Unlike other psych ERs, PES has no full-time security guards. Instead, police officers detailed to the medical ER and the hospital must be summoned for emergencies. The staff is keenly focused on the task when there is a loud interruption: the arrival of a new patient. The front entrance to PES requires a key to get in and out, unless you are buzzed through a double set of doors. Before police officers enter, they check their guns into a small locker—similar to a bank safety-deposit box—built into the wall outside the front door. This time, the charge nurse pushes the buttons to admit two uniformed SFPD officers. They enter through the double doors, struggling with an agitated young man in handcuffs. The man, who has multiple piercings and tattoos, strives to slam his head against the wall. He is emaciated and his teeth are jagged lumps, his pupils are saucer-sized, his brow moist, his eyes darting up into corners and then off into space, his left antecubetal region bruised and swollen. He mutters and smiles oddly, pausing only to take momentary stock, assumes a vigilant stance and then begins shouting again with renewed vigor. Continued on the following page ...

March 2009 San Francisco Medicine

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San Francisco Medicine March 2009

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A Day in the Life of PES continued ... “Try to calm down,” says the psychiatrist from a few feet away, deferring eye contact, speaking softly. “No one is going to hurt you here. This is a safe place. How about taking some medication to take the edge off? You seem pretty wound up.” “No—you’re going to poison me!” The man begins screaming and flailing again, attempting to head-butt one of the officers. “He’s going to have to be in points, and I’ll write for emergent meds,” says the psychiatrist, above the din. After the handcuffs are removed, the young man is restrained supine on a clean white sheet, his four extremities secured to Velcro/polyester restraints tied to a metal bed bolted to the seclusion room floor. He is given an IM injection of antipsychotics and benzodiazepines— California law specifies that patients can refuse medication, pending a hearing, but emergent medication is permissible when patients present an imminent threat to themselves or others. His toxicology screen later comes back positive for methamphetamine. His left arm findings suggest an intravenous route of administration. There’s no time for the staff to debrief about the incident; there’s work to be done. Patients need to be evaluated to see whether they can be discharged or need admission. Paperwork needs to be completed on each patient. The computer database in PES keeps things organized, with information easily accessible, but entering the information on each patient is a time-consuming task for the staff. Disposition is critical; PES is a small space, and patients must be either released for outpatient follow-up or admitted to an inpatient psychiatric unit within twenty-four hours. Some 500 to 700 patients are seen in PES each month, more than 7,000 patients in a given year. This does not include the significant number of patients who self-present and are turned away, or the hundreds of consults to the medical ER each year. Psychiatrically acute patients who are suicidal or psychotic and have MediCal, MediCare, or private insurance can be transferred

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for admission at other hospitals. The disposition of acute patients without insurance is more problematic. Budget cuts to SFGH have reduced the number of inpatient psychiatry beds from approximately eighty to forty. It is no longer possible to admit all patients who might need admission; the staff members, who have also been affected by budget cuts, are left to place patients in whatever outpatient resources are available. It is like playing musical chairs with fewer chairs. By noon, a half-dozen patients are discharged, but still new patients fill their places. Among the new patients are a man brought from the Golden Gate Bridge, stopped by police before he could jump off; an HIV-positive patient who was stopped by roommates before he took an overdose of medication; a man with schizophrenia who was threatening his parents. The staff needs to quickly assess each patient’s clinical condition and treat them. Many of the patients have medical problems as well: diabetes, hepatitis B or C, and other illnesses. Psychiatric diagnoses do not confer immunity to medical problems, and it is up to the PES psychiatrists to treat these too. Sometimes patients are not medically stable and need to be transferred to the medical ER. But now the medical ER is calling for a consult: a patient with borderline personality disorder is receiving stitches for self-inflicted lacerations to his wrists. A PES psychiatrist evaluates him for suicidality; he is given a referral and allowed to leave, but another patient who has been medically cleared after an acetaminophen overdose is still suicidal and is transferred to PES. The methamphetamine-intoxicated man who was brought in earlier is now out of restraints, groggy but able to be interviewed. Now, at 7:00 p.m., the mix of patients include those who were “new” twelve hours ago along with those who have just arrived, the new “new” patients. PES is a noisy place. Staff who work there become habituated to a certain dose of cacophony. PES is licensed by the state to hold and observe patients for up to twenty-four hours and not to exceed a maximum capacity of eighteen

patients. Sometimes, however, patients are confined for two or three days as they wait for inpatient beds, and the census can jump into the mid-twenties. What else can be done with psychiatrically unstable patients who are not safe to leave and have nowhere else to go? There is a diversion policy of sorts, referred to as Condition Red, when police bring involuntarily detained patients to private hospital emergency rooms in the city. But this system can result in a backup of patients at other hospitals. Psychiatrists who work at PES occasionally situate themselves in front of the nursing station—insinuated between the shift’s charge nurse and the doors of our four seclusion rooms. They are one-part psychiatrist, one-part primary care doctor, one-part traffic cop, one-part stand-up comedian, and one-part maître d’. The role strain can be challenging; fewer than half of the doctors who work here make this their full-time job, and fewer still work here for more than ten years. By 10:00 p.m., things appear manageable again. Many of the patients are settling in for the night or are asleep. But an hour later, the police bring in an agitated man who was running naked in the street, yelling at cars. He is clearly intoxicated—the staff is guessing alcohol plus cocaine. He is medicated and placed in the last of the empty seclusion rooms. Another half-dozen patients arrive by 3:00 a.m., and the charge nurse decides to call an official red alert. During the rest of the night, the new patients are worked up and several become stable enough for transfer to private hospitals. Another patient is lethargic, with a low 02 saturation, and is transferred to the medical ER. The staff continues its work, and before long the frosted windows in the staff room brighten to a light grey. It’s 7:00 a.m. once again, and the staff gathers to perform the ritual of the morning report. This time there are no interruptions, and another day officially begins smoothly. The staff knows that it won’t be long before the pace increases again, but for now it’s nice to have a quiet start.

March 2009 San Francisco Medicine

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Extreme Medicine

Straight from the Emergency Department Anecdotes from an Emergency Medicine Doctor

Brian McBeth, MD

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ebar? What the hell is rebar?” As a junior attending, one quickly learns how to cover up deficits in knowledge and experience in the trauma bay. Of course, the most effective technique is simply to keep one’s mouth shut. I’m not sure why I forgot that cardinal rule after the trauma alert toned out. “Uh, Dr. Carson, it’s those steel bars they use at construction sites. You know, to reinforce walls.” My senior EM resident this afternoon was one of the stronger ones, and apparently his skill set extended beyond ED procedural skills to construction material knowledge. “OK, Jake, I’ll take your word for it. Get all your toys ready. Do we have anesthesia backup here?” The call went like this: “Twentyeight-year-old man, fall from scaffolding, approximate height of twelve feet. No loss of consciousness. Head impaled by rebar. Prolonged extrication due to difficulty cutting through rebar. ETA three minutes.” He rolled in moments later with a flurry of chaotic shouting and diaphoretic paramedics, glistening with the perspiration of their effort and the July sun. The angry grey rod extended skyward from his right orbit, his globe forced cephalad—perhaps in an appeal for divine intervention. The other end jutted back from his occiput, and somehow they had managed to finagle a cervical collar onto his neck from transport. “Get it out, get it out, get it out. . . .” his pained but coherent moans were heard above the ruckus of the trauma bay. A is for Airway, A is for Airway, my mind perseverated as Jake was fumbling for his laryngoscope. The trauma team gawked, awaiting our intervention. The airway is the responsibility of the EM resident and 20 21

attending, and I was seeing my two-weekold academic career flash before my eyes. “The bar is in the way,” Jake was stammering. “How do we maintain C spine?” “OK, everyone quiet! I want it quiet in here!” It took me a second to realize that the voice was my own. “Airway first here. Janet—draw up RSI drugs, etomidate and sux. Ron—you will be holding C spine. RT—get the vent ready. Jake—first plan is direct, backup is ILMA. Second backup is crich. You ready?” Of course Jake got it on the first try. Of course my own tachycardia eventually resolved without medical intervention. Of course I was still employed at the end of the day. Maybe I learned the first step in being a leader is showing a little confidence when order is breaking down around you and all you feel is fear. Or maybe I just learned what the hell rebar is. Outcome: This patient unfortunately had a significant carotid artery injury, though the rebar was extracranial. It was surgically removed with a multidisciplinary approach involving ENT, neurosurgery, and trauma. Patient had profound left hemiplegia from the ischemic insult and was eventually discharged to home after extensive rehabilitation with significant residual left-side weakness. ***** I’ve never seen so many people in a single patient room. These resuscitation bays always feel way too small—especially during traumas—packed with unnecessary bodies: med students, lab techs, social workers, nursing students. The chaos and balagan as a dying patient collides with the well-intentioned but unhelpful presence of too many caregivers. But this is not a trauma patient. At least I don’t think she is. It’s tough to be certain,

San Francisco Medicine March 2009

given the circumstances. Her frail, fourweek-old body does not speak the obvious tale of the barbs and arrows. I’ve also never seen so many ED attendings in this room at any one time. This is a teaching institution, dominated by the presence of learners. But the pediatric and emergency medicine residents cling to the walls as the three of us flog this infant girl, trying to persuade her heart into beating again. Her airway is quickly secured, and an intraosseous line screwed into her tibia. One of my partners is pressing a regular and insistent rhythm into her sternum. “Let’s check for a pulse again—hold compressions, please.” “Still nothing. Another round of epi?” “Can’t hurt.” We all know the PALS and ACLS protocols by heart, but, unlike most codes, there is a constant need for confirmation from each other, a hesitancy that feels foreign to me. Emergency medicine is about being confident, even if you’re not certain. Is it because her anguished parents are watching us from the corner of the room? In the end, we do get her back, but only for long enough to get her to the pediatric ICU. A head CT showed a diffuse anoxic injury, and when I called to check on her the next day, they had withdrawn care. She remained a medical mystery, even after autopsy. Why does an infant succumb to SIDS for no apparent reason? Why do we feel so powerless—unable to affect the heavy fate so callously laid upon a child? What can you say to the parents when their only little one is wrenched from their loving embrace? Brian McBeth, MD, is an assistant clinical professorintheDepartmentofEmergencyMedicineattheUniversityofCalifornia,SanFrancisco. www.sfms.org


Extreme Medicine

Relative Risk A Public Health Doctor Returns to Afghanistan

Robert Liner, MD “There is no limit to the good you can do, if you work without caring who gets the credit.”—Source not attributable with specificity

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r. Steven Solter currently lives in Afghanistan, where he works as a consultant to the Afghan Ministry of Public Health. He is part of a team from Management Sciences for Health, a consulting firm headquartered in Cambridge, Massachusetts. This is Steve’s second round of this effort. He and his wife—a nurse midwife with a master’s degree in public health—lived there with their children from 1976 to 1979, when their work came to a halt with a pro-Soviet coup. Dr. Solter’s Afghan counterpart was executed. Full-scale Soviet invasion came soon afterward. Now, years later but still working for MSH, he’s back in Kabul, picking up where he left off, taking on the challenge of helping to implement basic health services for villages made remote by geography and continued fighting. One may wonder why a big, friendly, bookish civilian puts his life at repeated risk. If questioned about this, he responds with a demurral: “There are lots of nonmilitary Westerners in Kabul; to get hurt you’d have to be in the wrong place at the wrong time.” Press him about this issue and he might admit to a few close calls. Not long ago, one of his organization’s drivers was returning from the Ministry of Public Health when a suicide bomber, probably intending a different target, detonated himself along the route. The driver continued on his way, even though body parts later cleaned from the car must have included some of the driver’s own blood. A piece of shrapnel had passed

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Management Sciences for Health staff members in Kabul. Photo by Julie O’Brien

through his neck—in one side and out the other—without striking anything vital in between. Timing, it seems, can be measured in milliseconds. The hazards of life in Afghanistan are a long way from the relative safety of

“One may wonder why a big, friendly, bookish civilian puts his life at repeated risk.”

San Francisco, where Steve grew up. His father, Dr. Nathan Solter, was an internist with a busy practice at the corner of Balboa Street and 25th Avenue. A model physician who truly loved medicine, the elder Dr. Solter studied each issue of the New England Journal right up to the time of his death at age 96. He inspired his son’s enthusiasm for learning. The source of Steve’s passion for faraway lands and their people is less clear, but his eyes sparkle when he recalls perusing a map of the Indonesian archipelago when he was young. He explains, “I knew that someday I had to get to Sulawesi. I love the shape of the island; it looks like a butterfly.” Steve has in fact visited Sulawesi and has also worked in, among other places, Iran, India, Bangladesh, Afghanistan, Indonesia, the Philippines, Africa, and Cambodia. He has been able to satisfy with his peripatetic career not only his love of travel but also a devotion to the challenges of international public health and preventive medicine. Steve’s involvement in public health began with a randomly noticed journal

article. He recalls that, one day while a student at Stanford’s School of Medicine, he happened to be unaccountably awake in the library with a bit of time on his hands. Nearby on a table was an unshelved issue of Science. In it, he read an article titled, “Health, Population, and Economic Development,” written by Dr. Carl Taylor, first director of the Department of International Health at Johns Hopkins. Steve recalls the thesis of the article: General health and economic development around the world depend upon keeping population growth within reasonable bounds, but that can’t be done without lowering excessive rates of infant mortality. One has to “train the trainers”—local community people who can educate and implement basic public health measures. “When I put that journal down,” Steve recalls, “I knew what I wanted to do.” Afghanistan—population about thirty million—is a land of stark beauty. In its long history, the country has never been forcibly occupied for any extended period of time. Its people are fiercely independent and, at the same time, take pride in a tradition of hospitality. For a man who set his sights on improving public health, the place is a challenge. Afghanistan’s infant mortality rate is estimated at 135/1,000 live births (compared with 7.5/1,000 in the U.S. and 2.5/1,000 in Sweden). Maternal mortality is second only to Sierra Leone’s. Overall maternal mortality is approximately 1,600/100,000. In the province of Badakhshan, near the Pakistan border, where it may take days to reach help, maternal mortality has been as extreme as 6,500/100,000. Steve shakes his head, saying, “One in fifteen! Imagine Continued on the following page ...

March 2009 San Francisco Medicine

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Relative Risk continued ... what that means for a woman who, on average, will give birth seven or eight times, with those odds of dying repeated each time she gets pregnant!” Most of the deaths result from obstructed labor or hemorrhage. High fertility compounds the risk. “During the war with Russia, Afghan women living in a refugee camp in nearby Pakistan had a total fertility rate of 13.6, the highest ever recorded anywhere. And, what’s really amazing, they had all those pregnancies despite the fact that most of the men were Mujahideen fighters and away a lot of the time. That says something about the population’s reproductive efficiency.” That kind of reproductive avalanche can only be averted by education directed toward improving life expectancy—a daunting task where the rural population is generally illiterate. Steve estimates that fewer than 10 percent of village women can read. Literacy among men is not much better. Basic knowledge of hygiene and health is lacking. Of course, Afghanistan poses other challenges to health. There are improvised explosive devices, suicide bombers, and automatic weapons. There’s the Taliban and al Qaeda and bombings carried out by our own forces. Warfare and lack of infrastructure combine to make distribution of medical information, training, and supplies difficult and dangerous. And yet Afghans and various NGOs continue to do the best they can. With funding from USAID, Steve’s organization has projects in thirteen of the country’s thirty-four provinces. All of this effort is undertaken by people who don’t expect and aren’t likely to receive credit for the risks they take. “I haven’t seen this in articles,” says Steve, “but these days in Afghanistan, there’s a lot of talk about what they call the ‘Old Taliban’ and the ‘New Taliban.’ The ‘old’ ones were mostly locals. They worked out deals where, as long as a clinic was treating all comers—making no political distinctions—those clinics were tolerated. The ‘New Taliban’ are more ideological, more fanatical on average. They often come from outside 22

provinces. Some may have al Qaeda connections. These are the ones sending letters to clinics and schools threatening to kill Afghans and others working there, and some of their threats have been carried out. The fact that women and men are working together may be enough [to bring on violence]. They don’t always kill the people in the clinic; sometimes they just burn the place down.” Can health work continue under these conditions? “It takes a lot of guts for the Afghans to keep going,” Steve says. “If you quit, you tell the Taliban, ‘Yes, you can intimidate me with your threats.’ Or you can continue to work and risk being killed. It’s a tough choice. I’m really impressed and I admire the Afghans who, despite the threats and very low pay, continue to work day in and day out. It’s amazing! And it’s not just the clinical horrors. I have tremendous respect for what Afghans have been able to do to help deal with logistical problems.” He gives two examples. The first has to do with refrigerators: Vaccines, antibiotics, and other medicines commonly require refrigeration. But, of course, most rural villages in Afghanistan lack refrigerators. So they have to be brought in, usually from Pakistan. Easier said than done. In the Northeast, across the border, are the towering mountains and high passes of the Hindu Kush, where Tirich Mir, the highest peak, is over 25,000 feet. The Dorah Pass is at 14,000 feet. Afghanistan has not one mile of railroad track—not anywhere—and some of the passes are impossibly rough even for donkeys. There are patrols guarding most of the easier routes; they are on the lookout for weapons being smuggled across the border. So Afghan men carried the refrigerators strapped to their backs and hefted them across the mountains. The second example involved an ambush. A truck transporting medicines and contraceptives to Paktika province, south of Kabul, was attacked and robbed. The truck’s driver and cargo were taken away without any great hope they would be seen again. But, when the village that had expected to receive the supplies heard what had happened, they imme-

San Francisco Medicine March 2009

diately enlisted a delegation of mullahs and elders who traveled to the area of the truck’s disappearance. Arguing that these were medical supplies vital to the lives of poor people in their village, the delegation managed to rescue the driver and reclaimed the inventory without paying any ransom or bribe to the hijackers. In this instance, there was a happy outcome. Still, one may wonder how Steve keeps from getting discouraged by some of the setbacks—ones caused by forces outside the realm of science or good management. Much of the work that he and his wife did alongside Afghans back in the ’70s was significantly compromised by the Soviet invasion, and the work continues to be threatened by thirty years of subsequent fighting. In such circumstances, it would seem easy to become nihilistic. But that isn’t how Steve looks at things. Instead, he says, “I just concentrate on the work that’s in front of me. It’s interesting. It’s exciting. I enjoy working with the people I meet along the way.” He murmurs something about glasses that are half full; by nature, it seems, he can’t help being optimistic. So where will his curiosity, his desire to do useful work, his optimism take him after Afghanistan? Hard to say, but he is aware of an island called Halmahera out there among the 17,000 or so islands that form the Indonesian archipelago. He notes that it looks like a small, reversed image of Sulawesi; it too resembles a butterfly. Maybe there’s more work waiting to be done there. Robert Liner, MD, studied at Stanford and the University of Rochester School of Medicine. A fellow with the American College of Obstetrics and Gynecology, he is a former faculty member with the ob/gyn residency program at San Francisco’s Mount Zion Hospital. Currently, he is in private practice as a consultant in prenatal diagnosis and diagnostic ultrasound. He is a member of the SFMS, and hasbeen a delegate to the CMA’s House of Delegates. He is also a board member of the northern California chapter of Compassion and Choices, an educational, patient-support, and advocacy resource for individuals and families concerned with endof-life issues. www.sfms.org


Extreme Medicine

Mavericks, Missionaries, and Misfits The Call of Stories

David K. Becker, MD

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ecently a friend and I laughingly recalled the three M’s that attempt to categorize those of us who have volunteered or worked in a medical humanitarian capacity at some time in our careers: mavericks, missionaries, and misfits. It was a self-conscious laughter. We know that the way we fit into any of these categories may not reflect well on our underlying motivations. Some missionaries (whether or not they call themselves that) are criticized for overtly or covertly taking advantage of populations in distress by implying the need to convert in order to truly be helped. Mavericks may practice medicine well beyond their training, or risk the safety of their coworkers for their own thrill or perceived sense of accomplishment. And those who feel they do not fit into their home culture (be that medical, social, familial, or other) may find themselves fleeing personal or professional conflict to be immersed in other cultures or to be with others who have stepped out of their own cultures for similar reasons. But the positive sides to each of these glancingly cynical descriptors, the self-sacrifice of missionaries for a sense of purpose higher than the individual, the maverick’s creative and challenging push to excel beyond known limits, and the intuitive empathic capacity of the sensitive misfit to tend to the suffering of people in distress, are compelling motivators for many. Aspects of each of these archetypes informed my motivations (with varying degrees of self-awareness) when I volunteered with Doctors Without Borders in 1999 and, for thirteen months, took on the role abandoned by many local

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pediatricians in northern Sri Lanka who had fled due to years of intense fighting in the region. I reflected on some of them in my journal at the time: Do I look forward to working here because I feel I will be questioned less? Because I will be accepted as “all-knowing?” Will that really be the case? Will I read and keep up with info well here? Will I be able to develop teaching skills? Clinical skills? Management skills? Why do I feel calmer here, now? Is it the temporary nature of this assignment? What is it, then, that I fear when I see myself as more settled among some group? What calls us to leave our homes, our lives, the comforts of the familiar, and immerse ourselves in the circumstances of others so far away? Several times in medical school and residency I was lucky enough to take seminar classes with Robert Coles, an occasional visiting professor at UNC, Chapel Hill, where I was went to medical school and had my residency. Among more than forty books we studied was The Call of Stories, the inspiration for this essay. We also read stories by Raymond Carver, Tillie Olson, William Carlos Williams, and others. Stories that prompted us to relate differently to those we came across daily in our lives as training doctors. I loved those seminars. They instilled value in listening to the patients and families we encountered with a different ear than the one being bent by our clinical and science professors. Two weeks into the mission, and still I look for the thunderclouds out the window when I hear the shelling. What do parents tell their children? Sri Lanka has been mired in a civil war since the mid-1980s. The govern-

A young boy Becker treated in Sri Lanka ment, dominated by the majority ethnic Singhalese, has been fighting various minority Tamil insurgent groups, dominated in the last ten years by the Liberation Tigers of Tamil Eelam. The LTTE has declared itself the voice of the Tamil minority, but it conscripts young boys and girls into its forces, has been one of the most prodigious suicide bombing forces the world has known, and has ruthlessly wiped out or fought with competing Tamil insurgent and political groups. The government, for its part, has murdered its own Singhalese citizens to fend off a counterinsurgency and has “disappeared” countless Tamils outside of the conventional fighting. Over the course of a year supervising local Tamil (and a few Singhalese) resident physicians, I attended to a range of diseases and despair that eclipsed what I Continued on the following page ...

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Mavericks, Missionaries, and Misfits continued ... had seen in Central America, much less at home. They taught me more than I than I could have hoped to teach them. And I had the privilege of hearing and witnessing the most extraordinary stories. The medical extremes were certainly challenging: preterm and term newborns dying of conditions readily treatable at home; infants and children drowning in the pulmonary edema of uncorrected congenital cardiac defects. The medical complexities were a challenge I took to with pleasure, trying to diagnose and treat with extremely limited resources while staying within the bounds of my competencies. But what I found myself gravitating to—or in some instances what I had thrust upon me—were the stories of the lives I was living among. I visited an abandoned house today that is currently home for twelve families who fled the fighting in the Palai area. They left their homes for the sixth time in the last ten years as shells were falling around them. There are children of all ages, but the local schools won’t let them in. They depend on the generosity of their neighbors for clean water; the well out back is contaminated and makes their skin itch when they wash. All this and they still brought orange soda in freshly washed tumblers for my driver, translator, and me. I felt guilty taking it, though I knew the insult would be far worse should I refuse. Their mood was not quite as somber as might be expected. Their lives are certainly difficult, but they smiled, joked, and played with us. ***** I walked by the parents of the newly dead infant, feeling frustrated by having no idea why their baby died, and by having no way to communicate with them beyond the look in my eyes. ***** The smell hit me hard in the face. I don’t think I would have recognized the shapes if the driver of the cart had not been calling out in this absurdly smiley voice, “Bodies, bodies,” to anyone who seemed remotely interested. The cart was filled with black shapes. Very black. Featureless. It felt as if, had a spotlight been trained directly 24

onto the cart, it would have illuminated nothing, would have been sucked into the blackness. They were burned bodies turned over by the Sri Lankan Army as being LTTE, but I can’t imagine how they could have been identified as anything beyond human. There may have been only five, or as many as fifteen, but no bottom, no end, could be seen. Then the smell hit. ***** The people who were left this afternoon when Mariyadas, Soloman, and I drove around town were either packing to leave tomorrow, too poor to afford to move, had moved out their family and belongings and returned to watch the house, or were simply waiting for the others to leave so they could break into the empty houses. As we went around the town trying to gauge the mood of the people (we were contemplating moving the hospital as the LTTE’s assault, code-named “Unceasing Waves III,” was pushing at the outskirts of town), we came across a group of middleaged women walking in the street. One of them said something with a sardonic tone of voice and the others laughed and continued ambling down the road. Mariyadas translated for me: “Unceasing waves for them, unceasing suffering for us.” Minutes later, on the way back to the house, I was crying quietly to myself. But it wasn’t until I got home, after thirteen months in Jaffna, that I really allowed myself to feel what I had seen and heard. I’ll never forget the moment it started. I had been home for a couple of weeks, staying with friends. I was in my pickup, pulling on to a familiar two-lane highway in Chapel Hill and listening to the radio when an NPR reporter stationed in Macedonia came on. The fallout of the Bosnian-Serb conflict was being played out in the mountains of Macedonia. In the background, over the journalist’s voice, could be heard shelling, machine-gun fire, and voices. Instantly I was in tears, and bawling by the time I got the truck to the side of the road. That was the beginning of letting myself feel again. It is common for children to present to the hospital with multiple vague complaints like headaches, stomachaches, fainting spells, and pseudo-seizures. One

San Francisco Medicine March 2009

ten-year-old boy had been living in a church-sponsored home for a few years, having lost both his parents in the war. He would writhe in bed, complaining of severe cramps whenever adults, and especially caregivers, would approach him. If you left him alone, he was fine. The stress these children have internalized, only to be expressed in somaticized forms, is often reflected on the faces of their parents. The mother of a twelve-year-old boy wrung her hands constantly, relating in strained words her son’s problems with recurrent headaches, stomachaches, even diarrhea, which hadn’t responded to any treatments. The family had been displaced months previously, the boy was not in school, and her husband was out of work. Stories that take us outside ourselves, yet reflect back the nature of what we see wherever we are. I am immensely grateful for the privilege of having shared in the stories and lives of colleagues, friends, and patients who struggled amid unimaginable violence and fear. I know of no other way to honor them than by telling their stories. What I didn’t realize was how those stories would continue to affect my work today. I learned a new perspective on death and on how we spend phenomenal amounts of resources at the margins of life and disease in this country at the expense of primary preventive and wellness care (a strategy I continue to lament about to those students and residents with the patience to hear it!). I also recognized that in the extreme is the ordinary. In the extremes of chronic displacement from one’s home were the ordinary complaints of colds, diarrhea, headaches, and stomachaches. And in the ordinary complaints of colds, headaches, flu, and stomachaches that we see day in and day out are the extraordinary lives and stories that go with them. Perhaps the initial call I felt to volunteer was inextricably wrapped in my own mixed psychology of maverick, missionary, and misfit. But what sustains me now is the call of stories.

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Extreme Medicine

Rock Medicine Extreme Medicine at San Francisco Bay Area Rock Concerts

David Smith, MD, and Glenn “Raz” Raswyck, EMT

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ock ’n’ roll, by its nature, is an emotional form of entertainment. Concert patrons have a tendency to overindulge in their use and abuse of mind-altering substances. The Rock Medicine program began as an extension of the Haight Ashbury Free Medical Clinic, a clinic founded in 1967 during the “Summer of Love,” when the dominant cultural themes were drugs, sex, and rock ’n’ roll. The early days of the Clinic were funded by benefit rock concerts by such Bay Area legends as Janice Joplin, Grace Slick and the Jefferson Airplane, the Grateful Dead, Carlos Santana, Creedence Clearwater, and others. Rock impresario Bill Graham of the Fillmore Auditorium organized these benefits. In 1973, Bill Graham approached the Free Clinic’s leadership to request the formation of a medical service to address the medical emergencies that developed among concertgoers. Bill always wanted the best performances and the best services at his concerts. As a result, the Haight Ashbury Free Clinic formed the Rock Medicine program. Its initial run, in 1973, comprised back-to-back weekends of the Grateful Dead and Led Zeppelin at Kezar Stadium in the shadow of UCSF Medical Center (Gay et al, 1972 [sic]). At its peak, under the direction of Glenn Raswyck, EMT, Rock Medicine provided medical and psychiatric crisis intervention services at approximately 250 rock concerts a year, serving more than a million concertgoers at venues from Sacramento to San Jose, and occasionally in cities as widespread as Seattle, Los Angeles, and Las Vegas. These onsite services were not only valuable to concertgoers but reduced emergency room visits, thus saving local

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municipalities a good deal of public health money. In deference to the concert promoters who have supported Rock Medicine and its mission, “To get people back to their

“Rock ’n’ roll, by its nature, is an emotional form of entertainment. Concert patrons have a tendency to overindulge in their use and abuse of mind-altering substances.”

friends and family without involving the EMS systems and the law” (to quote the late George “Skip” Gay, MD), the incidents involving Rock Med reflect a very small portion of the total attendance. At some concerts and events, attendance could be as high as 300,000 fans, plus a few hundred additional stage, security, concession, parking, and band-related personnel. At rock concerts, the overwhelming drug of choice has always been alcohol, but as volunteer Kathy Ferris, RN, once said, “Some people never order a la carte, but always take the full dinner.” This desire for a poly-pharmacy mix usually leads to significant disregard for life and limb. What follows are a few case examples that come from twenty-five years of experience in Rock Medicine. Several of these case examples reflect broader problems in our society.

Case #1: Acute intoxication in a college student who chug-a-lugged a fifth of vodka on an initiation dare from a local university fraternity just prior to entering the concert. Soon after entering the concert premises, he passed out and began vomiting. A Rock Medicine team was called to his assistance by local security and the friends who accompanied him to the concert. His airway and vital signs were supported while he was carefully monitored by Rock Medicine at the concert site. When he awoke from his acute intoxication, he described being in a blackout from the time he chugged the vodka to the time he woke up. He denied any memory of being stopped by security, being on the brink of arrest by the police, being examined and monitored by Rock Med staff, and/or sleeping it off. He declared he rarely drank and had never been intoxicated before but chug-a-lugged on a dare from his friends. Binge drinking among youth is a major health problem. Its contribution to substantial morbidity and mortality as acute alcohol poisoning is potentially fatal. Binge drinking as described in this case is not only illustrative of drinking patterns for college students but demonstrates how onsite medical services, with rapid intervention, prevented a potential fatality. Binge drinking with acute alcohol intoxication is a leading problem at concerts. Case #2: A twenty-three-year-old female was reportedly given a dose of GHB, known (along with Rohypnol) as a “daterape drug,” in a glass of beer (Calhoun, 1996; Lee, 2008). She was discovered by security in a blackout having sex with the males who had slipped her the drug. After the alleged rape was disrupted, an onsite medical Continued on the following page ...

March 2009 San Francisco Medicine

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Rock Medicine continued ... examination of the patient indicated severe respiratory depression. The experience of Rock Medicine has been that GHB intoxication produces not only blackouts but severe respiratory depression that can become fatal rapidly, particularly when combined with alcohol. The patient was sent by ambulance to the local emergency room, where respiratory and other life-support measures were initiated. This case demonstrates the variety of exotic drugs at concerts that may be voluntarily or involuntarily ingested that have an additive effect with alcohol. Knowledge of these patterns, and the ability to triage the patient by determining what can be managed onsite medically by Rock Medicine and what has to be referred to the emergency medical services, is a key advantage that trained Rock Medicine personnel provide. Over the years, hundreds of medical students, interns, and residents have volunteered at Rock Medicine, receiving valuable clinical training in this setting that is so unlike their other practice settings. Case #3: The importance of evaluating physical findings in the case of severe drug intoxication. In this case, the patient had taken PCP, a potent dissociative anesthetic (Zukin et al, 2005), as well as alcohol while dancing in the mosh pit of a heavy metal concert. He became both violent and agitated and was suspected of having fallen from the shoulders of another individual, thereby injuring his head and neck. When removed from the mosh pit, he had the severe muscle rigidity symptomatic of PCP intoxication and was disoriented and agitated. He was 26

carefully transported in a C-spine to the Rock Med “hospital,” where he continued to be agitated and had to be both restrained and medicated with a dose of “2 and 2” (2 mg of Haldol and 2 mg of Ativan) (Miller et al, 1992). When he calmed down and his agitation resolved, concern that he might have suffered some residual neurological disability from his fall led to his referral to a local hospital for evaluation and subsequent physical rehabilitation. Drug intoxication may mask or mimic other physical findings of head injury and neurological disorders. Differential diagnosis by skilled clinicians with these unusual drug and medical problems is an important part of the delivery system at such large youth gatherings. Case #4: A twenty-two-year-old male with an unknown amount of PCP onboard who engaged in a fight with a concrete pole and fractured all the bones in both arms, from his hands to his forearms. He nonetheless managed to give both security and the medical team a battle in attempts to subdue him. He was eventually prepped and packaged for transport to a hospital. Case #5: A young male who, while engaged in a mosh pit at the front of the stage, was struck at the perfect angle to pop his eye out of its socket. He was rushed out of the crowd by security and the medical team, who protected the now distended eyeball with strong arms and a wet saline wrap. The volunteer doctor was nonplussed, having worked nights at the Highland Hospital ER in Oakland. He said he could put the eyeball back in but he suspected that fine bone shards from the damaged socket might

San Francisco Medicine March 2009

cause further damage. The patient was readied for transport and was asked what he could see. His response was, “A combination of you and my feet at the same time.” Some things are unforgettable. Cases #6 through infinity: Too many to mention individually, these relate to psychedelic drugs, whose use can lead to a wide variety of reactions, from rapturous to terrifying. Rock Med has seen patients strip off their clothes and run rampant through the crowd, jump from balconies, and become so fearful that fight or flight becomes fight very quickly. One very large male jumped from a fifteen-foot balcony, landing feet first on a female patron who suffered back and neck injuries while the jumper ran nonchalantly into the crowd. Another young woman wandered away from an outdoor show and decided to take a mud bath. She had unknowingly stepped into a bog, where she was slowly sinking up to her neck. She yelled for help but did not want to be rescued—she just wanted some water. The valuable services of the Rock Medicine volunteers over the years have greatly reduced the morbidity and mortality of patrons of all ages attending popular music events in the San Francisco Bay Area. The problems that occur at concerts and other events are not unique but illustrative of the broader problems facing society. The service delivery system, however, is unique and has advanced the knowledge of managing extreme medical problems at large gatherings. It has also provided valuable training to hundreds of Bay Area professionals in a setting that they would probably not otherwise see in their medical practice. David E. Smith, MD, is the founder of the Haight Ashbury Free Medical Clinic and currently serves as medical director of Center Point and Chair of Addiction Medicine of Newport Academy. He is an adjunct professor at UCSF and a past president of the American Society of Addiction Medicine.Glenn “Raz” Raswyck, EMT, directed Rock Medicine for thirteen years and volunteered for many years prior. He received the Department of Public Health’s Community Service award in 2000 for his contributions to San Francisco’s EMS Millennium celebration planning. References online at www.sfms.org/archives. www.sfms.org


Extreme Medicine

Rodeo Medicine Extreme Risk, Extreme Injury, and Extreme Medicine

Dale J. Butterwick, CAT(C), and Mark A. Brandenburg, MD

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xtreme sport implies extreme risk. Bull riding in particular, and rodeo in general, offer both. In 2007, statistical comparisons were made between injury rates of bull riders and athletes competing in a number of sports, including American football, ice hockey, and boxing. The injury rate of bull riders was found to be 1,440 injuries/1,000 exposure hours. The bull riding injury rate was 10.3 times the rate of injury in American football, 13.3 times the rate of injury in ice hockey, and 1.56 times the rate of injury in boxing. Providing care for these stoic athletes while they travel across the continent to compete is a challenge usually accomplished through organizations devoted to the practice of rodeo medicine. There is a commitment and fellowship among these medical professionals and a willingness to coordinate care for the cowboys no matter where they live. The major rodeo events include bareback riding, saddle bronc riding, steer wrestling, tie-down roping, team roping, ladies’ barrel racing, and bull riding. The rodeo cowboy is very popular among fans as an American icon, perhaps now more than ever before. The United States has the largest number of professional rodeos, professional bull ridings, and professional cowboys in the world. Canada has the closest professional rodeo links to the United States, while Canada, Mexico, Brazil, Australia, and New Zealand all have bull ridings and bull riders striving to reach the pinnacle in rodeo by competing in Professional Rodeo Cowboys Association events throughout the United States. The world’s very best cowboys participate in the Wrangler National Finals Rodeo (WNFR) in Las Vegas the first week of December. The world’s best bull riders parwww.sfms.org

ticipate in the Professional Bull Riders (PBR) events across the United States, the finals of which are held in Las Vegas every October. In 1980, Dr. J. Pat Evans and Don Andrews envisioned a nationwide network of clinics, medical centers, physicians, and athletic trainers dedicated to bringing quality health care to rodeo athletes. The vision became reality in 1981, through the late John Justin of the Justin Boot Company of Fort Worth, Texas. The Justin Sportsmedicine Center, consisting of a fully equipped truck and trailer, became the first mobile rodeo sports medical facility in North America, appearing at the 1982 NFR. The following year, this center traveled to 25 major rodeos across 50,000 miles, serving 1,500 cowboys. The Justin Sportsmedicine Team (JST) now has three mobile centers serving 115 PRCA

rodeos and about 50 professional bull ridings (PBR) annually. More than 6,000 athletes are treated by these experts every year (equaling more than $1.5 million in free services per year). The extensive injury-prevention program also serves these rodeo athletes. The JST staff has, over the years, traveled more than two million miles, providing sports medicine coverage at more than 2,400 PRCA rodeos and caring for more than 120,000 professional rodeo athletes. The Justin Boot Company’s commitment to the sport of professional rodeo exceeds two million dollars annually. Certified Athletic Therapist Dexter Nelson and Canadian Champion bull rider Don Johansen originally brought the concept of an organized rodeo sports medicine program Continued on the following page ...

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Rodeo Medicine continued ... to Canada in 1983. The program expanded with Nelson’s leadership. It has grown so that certified athletic therapists, massage therapists, chiropractors, sports medicine physicians, and orthopedic surgeons all work together to serve the cowboys injured in rodeo and bull ridings throughout Canada. The Canadian Pro Rodeo Sport Medicine Team provides rodeo medical services to about a hundred rodeo and bull riding performances across Canada each year. This coverage leads to medical referral, treatment, and injury follow-up services to injured rodeo cowboys and cowgirls, primarily at the University of Calgary. Another professional rodeo organization popular in the Eastern half of the U.S. is the International Pro Rodeo Association (IPRA). In 1988, Dr. Robert Nebergall in Tulsa, Oklahoma, established a rodeo medical team to serve the injured athletes from this rodeo circuit. Dr. Nebergall and his team of athletic trainers, chiropractors, massage therapists, emergency physicians, and orthopedic surgeons continue to provide on-site and follow-up medical care for injured rodeo athletes from the IPRA. In 1994, the founders of the Professional Bull Riders (PBR), Inc., asked the Justin Boot Company to provide medical coverage through the Justin Sportsmedicine Team for their bull riding events. The PBR’s sports medicine program is staffed by three certified, licensed athletic trainers and by one physician attending 30 to 35 of the PBR’s upper-tier events annually, and the program is supported by local physicians and EMS. The series has 45 contestants at each event, with limited turnover from week to week. Thus, similar to other major sports, the staff is able to become familiar with specific needs of each athlete while customizing treatment accordingly and consistently from event to event. During the last 14 years, the program has treated more than 2,500 new injuries sustained during the course of more than 40,000 attempted bull rides at over 350 events (one new injury every 15 to 16 attempts). The most common injury treated is concussion, comprising approximately 15 percent of all injuries. The JST has hosted two-day continuing education conferences at the WNFR since 28

1982. Speakers include orthopedic surgeons, neurosurgeons, maxillofacial surgeons, dentists, emergency physicians, physiotherapists, and certified athletic trainers, all of whom carry the banner of improving the understanding of the mechanisms, recognition, and care of injury to rodeo athletes. The First International Rodeo Research and Clinical Care Conference took place in Calgary in 2004. American and Canadian presenters shared the podium to further understand the challenges of providing care to the rodeo cowboys. Basic injury epidemiology, medical organizational paradigms, and injury prevention research projects were presented. Group participation of delegates created an agreement statement for helmet use in preventing head and facial injury in boy steer riders and junior bull riders. Further, a minimum standard for the management of concussion in rodeo athletes was also debated and refined, becoming part of the agreement statement published in the Clinical Journal of Sport Medicine. In 2008, the Second International Rodeo Medicine Conference was held in Oklahoma City. This two-day conference focused on head injuries and included in-depth discussions about the current standards of concussion management and “returnto-play” standards. Educational materials were provided by the Centers for Disease Control and Prevention, and keynote speaker Andy Tucker, MD, from the NFL’s Baltimore Ravens, provided a historical perspective of head-injury prevention and management in professional football. The Third International Rodeo Medicine Conference will take place in 2010, with plans tentatively made by the JST to hold a conference in Las Vegas during the WNFR. Cowboys are extreme athletes, participating in rodeo events with extreme risks. Understanding the demands of each rodeo event and characterizing injury rates, risks, and types have been some of the early projects of rodeo medical personnel. In a fiveyear epidemiological analysis of rodeo injury in Canada, bull riding had the highest injury rate (32.2/1,000 exposures), and bareback riding had the second-highest injury rate. It is safe to generalize that cowboys participating in these two events have the greatest likelihood of being injured in rodeo. In that

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same study, concussion was the third-highest injury type, slightly lower in frequency than shoulder and knee injuries. One retrospective bull riding study researching head injuries estimated the likelihood of a bull rider suffering a head injury as 15.4 per 1,000 exposures, or 684 head injuries/1,000 EH, assuming an 80-second exposure. Furthermore, it has been estimated that 38.5 percent of head injuries in bull riding involve concussions and 19.3 percent involve facial fractures. It has been suggested that protective headgear can decrease the incidence of head and facial injuries among bull riders. The most common head injuries among bull riders are concussion, lacerations, and facial fractures. The results of one descriptive study demonstrated that the most common mechanisms of head injury in bull riders is the rider’s head smashing against the bull’s head and impacting the ground. Bull riders not wearing protective headgear that were involved in an injury incident were more likely to sustain multiple injuries (26 percent) than those wearing protective headgear (12 percent). Recently, a group of research and clinical care experts published an agreement statement recommending the use of protective headgear in bull riding. However, more progress should be made in determining possible strategies for injury mitigation in the sport of bull riding. The very nature of trying to ride a 2,000-pound bucking bull makes is what makes this sport inherently more dangerous than any other, and it is understood by these authors that despite ideal safety equipment, bull riding will likely remain one of the most dangerous sports in the world. We have seen several injuries that are virtually unique to rodeo athletes, such as ruptured distal biceps tendons in bull riders and bareback riders, and ruptured latissimus dorsi and pectoralis major muscles in steer wrestlers. The only source of reliable data about catastrophic injury in bull riding is through the PBR. Continuous staffing, particularly from leader Dr. Freeman, provides certainty about the three catastrophic injuries that have occurred during the past fifteen years (one death and two cervical spine fractures Continued on page 35 ... www.sfms.org


Extreme Medicine

Medicine at the Indy 500 Emergency Medical Care at the Indianapolis Motor Speedway

Geoffrey L. Billows, MD, FACEP

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he Indianapolis Motor Speedway (IMS) is the oldest continuously operating motor sports facility in America. Built originally in 1909 by Carl Fisher, James Allison, Arthur Newby, and Frank Wheeler as a test facility for the burgeoning automotive industry, the Speedway is a two-and-a-half-mile rectangular oval course situated on 1,025 acres. The rich history of motor sports at the Indianapolis Motor Speedway began August 14, 1909, with seven motorcycle races sanctioned by the Federation of American Motorcyclists (FAM). Originally, fifteen races had been planned for the weekend, but the remaining were canceled due to concerns that the racing surface of crushed stone and tar was not suitable for motorcycle events. The following weekend, a series of sixteen automobile races were held, sanctioned by the American Automobile Association (AAA). Throughout the weekend there were a number of crashes, resulting in five fatalities. As a result of concern over the suitability of the track surface, the Speedway was resurfaced with 3.2 million paving bricks, hence the origin of the Indianapolis Motor Speedway’s popular nickname, “the Brickyard.” Today the start/finish line is a three-footwide line paved with some of the original paving bricks and is known as the “Yard of Bricks.”

Romantic Histories

While injured race car drivers do not have fond recollections of the circumstances under which they encounter the medical staff, at least one driver considers his chance encounter with an IMS nurse as the most significant in his life. www.sfms.org

In 1963, a young race car driver named Johnny Rutherford was trying to pass his rookie testing to qualify to drive in the Indianapolis 500. On his last attempt, as he was making his way from the garages

“While injured race car drivers do not have fond recollections of the circumstances under which they encounter the medical staff, at least one driver considers his chance encounter with an IMS nurse as the most significant in his life.”

to pit road, he noticed an attractive young nurse from the infield hospital who was off duty and watching the activities on “Gasoline Alley.” Their eyes met, and Johnny dropped his helmet into his cockpit and either winked or waved to the young lady named Betty. She returned the gesture, and Johnny went on to successfully complete his rookie test. After he returned to the garage area, Betty was still there. Johnny asked, “Haven’t I seen you somewhere before?” and asked her out on a date. Betty refused his initial invitation, but Johnny persisted and Betty acquiesced the next day. That was the beginning of a whirlwind romance that resulted in their marriage, which has persisted as a healthy and committed

relationship to this day. Johnny went on to become a three-time Indy 500 winner and continues to drive the pace car for the IndyCar Series.

The Motor Sports Hospital

The Clarian Emergency Medical Center at IMS covers approximately 6,000 square feet and is divided into a driver care area and a spectator care area. It has separate entrances to protect the drivers from curious onlookers. There are four driver beds, complete with provisions for hemodynamic monitoring in an area suitable for trauma resuscitation; and fourteen spectator beds, six of which are capable of hemodynamic monitoring. The medical center is complemented by fourteen first-aid stations strategically located around the IMS grounds, nineteen ambulances for spectator care, six track surface ambulances, seven golf cart ambulances, eight medic teams on foot, and two pit medic teams. The medical center is staffed by the medical director and medical manager, between six and ten emergencymedicine physicians (depending on track activity), up to fifteen registered nurses, and an optometrist. A communications room is located in the medical center, from which all ambulances and roving medic teams are dispatched and tracked. The original track hospital was built in 1910, a year before the inaugural Indianapolis 500-Mile Race. Built near the garage area, the first infield hospital was a small, single-story, one-room wooden structure with a platform on the roof from which the staff could watch the track activity. A new, larger hospital of similar design was subsequently built and Continued on the following page ...

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Medicine at the Indy 500 continued ... remained in service until 1948, when it was replaced with a cinder-block structure that has since been expanded to its present size.

Dedicated Staff

From the beginning, the medical staff for the Indianapolis Motor Speedway was comprised of volunteer nurses and house staff from Methodist Hospital in Indianapolis. The relationship between Methodist Hospital and the Speedway has continued over the past 100 years, with Methodist Hospital assisting with personnel and supplies for the infield hospital. The first IMS medical director was Dr. Horace R. Allen, a local surgeon who held that position until 1937. In 1932, Allen recruited a young intern named Dr. Thomas Hannah to staff an ambulance in the first turn of the track. Hannah quickly fell in love with motor sports medicine and volunteered to work every race after that until he was promoted to assistant medical director in 1952. In 1959, Hannah became medical director and continued in that position until 1981. Hannah recruited and trained two young physicians who would later become leaders in the field of motor sports medicine. Dr. Henry Bock, an emergencymedicine physician at Methodist Hospital, began his long, productive career in motor sports medicine and succeeded Hannah as IMS medical director in 1982. Dr. Steven Olvey, an intensivist at Methodist Hospital, began his career in motor sports and would later become the medical director for the Championship Auto Racing Teams (CART). Both Bock and Olvey have made significant contributions to safety and research in motor sports. In 2006, Dr. Geoffrey L. Billows assumed the responsibilities of medical director for the Indianapolis Motor Speedway, and Dr. Michael Olinger became medical director for the IndyCar Series.

The Medical Needs of Spectators

While the original mission of the IMS medical staff was the treatment of injured drivers, the volume of spectators quickly caused the medical division to expand 30

its mission to include the provision of care to spectators. From the beginning, the medical division has been intimately involved with issues of injury and illness prevention as well as treatment. Hannah was responsible for the establishment of an intensive care unit in the infield hospital for initiating treatment of patients with coronary syndromes, helicopter transport of injured drivers to the trauma center, and specialized “crash trucks” stationed at each end of the track for on-track response to race car crashes. Each crash truck is staffed with medics, a respiratory therapist, and a physician.

Advancing Medical Knowledge

The medical division has been actively involved in education and research into motor sports injuries and has made major contributions to the development of helmets, restraint systems, and crash data collection; and design improvements to cars, seats, personal protective gear, energy-absorbing barriers, and debris containment systems. Because of shared resources and shared personnel within the medical divisions of the IMS and the IndyCar Series, much of the research has focused on openwheel racing in general and IndyCar racing in particular. As a result, driver injuries have steadily decreased over the years. The Indianapolis Motor Speedway also is the site of a monthlong motor sports/mass gathering study elective offered to emergency medicine residents from the Indiana University Emergency Medicine Residency Program. Resident physicians participate in a unique opportunity to learn about not just mass gathering medicine but also race car design, ultra-high-speed crash physics, driver extrication, data collection, and approaches to injury prevention in the racing environment. During the month of May, they gain on-track experience in the medical command vehicle as well as off-track experience in the medical center and with roving units. This is believed to be the only mass gathering/motor sports elective in the United States. Although driver/participant injury rates in all events have been progressively improving with advancements in car, track, and safety equipment design, spectator

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treatment continues to require a significant allocation of resources. With large numbers of people attending an all-day event, there are the usual exacerbations of underlying chronic conditions. Weather also contributes to patient volume, with heat, humidity, and air quality index being variables that cause significant impact. IMS has installed dozens of misting stations around the grounds and has used “cooling tents” to address such concerns. While most spectator care results from minor injuries and illnesses, which are easily treated on-site, more serious presentations are stabilized and transported to one of the nearby hospitals for definitive care. From the humble beginnings of a one-room, wooden trackside hospital, the medical division of the Indianapolis Motor Speedway has risen to the challenges of modern motor sports and mass-gathering events. The mission of the medical division has expanded over the years to include comprehensive driver physicals, driver and spectator care, injury prevention both on track and within the grounds of the Speedway, and preventive health education for employees and guests of IMS. Medical personnel from IMS have made significant contributions to the science of motor sports injuries and injury prevention and remain actively involved in motor sports safety research. A graduate of the University of Cincinnati College of Medicine and the Methodist Hospital Emergency Medicine Residency Program, Geoffrey L. Billows, MD, is assistant professor of clinical emergency medicine for the Indiana University School of Medicine. Dr. Billows is the medical director for the Indianapolis Motor Speedway. The author would like to acknowledge and thank Dr. Henry Bock, past medical director of IMS; Dr. Michael Olinger, medical director of Indy Racing League; Donald Davidson, IMS historian; Ron McQueeney of IMS Photo Operations; Ron Green and Paul Kelly from IMS Public Relations; and Sherri Marley, RN, medical manager, for their contributions and assistance. Additionally, the author extends his gratitude to Johnny and Betty Rutherford for their willingness to share their story.

www.sfms.org


Extreme Medicine

Space Medicine What to Consider When Preparing a Body for Space Travel

Karen Miller

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eptember 30, 2002: Traveling can be tough on the body. Think about driving all the way from, say, Washington to Wisconsin. By the time you ease yourself from behind the wheel, your back hurts, your eyes ache, your hands are cramped. And the farther you go, the more your body suffers. If you fly to France, you’re hit by radiation. If you visit the space station, you lose gravity. Now imagine you’re heading for Mars: low gravity, radiation exposure, a six-month trip spanning millions of kilometers. Without some kinds of countermeasures to protect you, your muscles will shrivel, your bones could weaken, your genes might be damaged and confused. When you arrive, you might find it hard to even get out of your spaceship without stumbling and hurting yourself. When you take a long car trip, you just have to get out every now and then to stretch your legs. Countermeasures for a trip to Mars? Well, they’re going to be a tad more elaborate than that. Nevertheless, countermeasures do exist—or at least they can be developed. One of the biggest problems in keeping astronauts fit and healthy as they travel through the solar system is simply preventing the physiological changes caused by weightlessness, says Dave Williams, director of Space and Life Sciences at the Johnson Space Center. Muscle atrophy and bone loss are perhaps the best known alterations, but they’re hardly the only ones. Weightlessness causes a loss of blood volume, which means that astronauts newly landed on a planet (Earth or Mars, say) tend to feel light-headed when they stand up. Weightlessness also alters the sense of balance so that, for a while www.sfms.org

after astronauts return to one-g, they feel like the world is spinning whenever they move their heads. Even subtler changes are beginning to be discovered. Here on Earth, we have no trouble sensing the position of our limbs: If you decide to lift your arm, you know where it is, and how much farther you need to move it to get it where you want it to be. But in space, this proprioceptive ability doesn’t seem to work as well. And there may be other problems: slower wound healing and immune system weaknesses, for example. Right now, the chief countermeasure recommended by space doctors is simply exercise. Astronauts on the International Space Station work out about two hours a day, using treadmills, exercise bikes, and an IRED—a device specially developed to allow astronauts to do resistive or strength training. Medications, too, may help with some problems: biphosphonates, for example, used on Earth to slow the rate of bone loss in osteoporosis patients may prove useful for astronauts, too. These countermeasures seem to work well enough for short stints in space. For long-term exploration, an entirely different approach might work better: artificial gravity. “It’s very compelling as a solution,” says Williams. In theory, providing artificial gravity is easy. Ordinary laboratory centrifuges do it all the time. When they spin, their contents are pressed outward away from the axis of rotation. It’s a force that feels like gravity. Rotating an entire space ship, however, can be both costly and complex.

That’s why researchers at the NASA Ames Research Center have been developing a small, human-powered centrifuge. It’s essentially an exercise track, in which an astronaut pedals a bike up and around a 360-degree circle. By pedaling the bike around the track, explains Williams, you turn yourself into a human centrifuge. “Depending on the speed at which you’re going, and the size of track, you’ll experience a pseudoforce . . . a gravity substitute.” This kind of human-powered device would provide an intermittent exposure to artificial gravity. Researchers must still figure out how much of this pseudogravity is needed to keep astronauts fit. Furthermore, the force created by such a device would feel stronger at the astronauts’ feet than at their heads! But it might be enough like home to counteract the effects of zero-g. Bicycles won’t solve everything, though, because weightlessness is only one problem. Radiation is another. Right now, the countermeasure for radiation is limiting astronaut exposure—which means limiting the amount of time they’re allowed to be in space. But on a long-term mission of exploration, the astronauts will have to be in space for months on end, and, Continued on the following page ...

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Space Medicine continued ... importantly, the type of radiation in deep space is more damaging than the kind in low earth orbit. An exploration-class spaceship will have to include shielding that can absorb cosmic rays. The best material to block highenergy radiation is hydrogen, explains Frank Cucinotta, astronaut radiation health officer and manager for Space Radiation Health Research at the Johnson Space Center. “But you can’t make a shield out of pure hydrogen, so we look for materials than have a high hydrogen content, like polyethylene, a common plastic, which is one carbon and two hydrogens.” Water, he says, with one oxygen and two hydrogens, would be almost as good, but it’s awfully heavy and expensive to launch. To completely block radiation, hydrogen-rich shields would need to be a couple of meters thick—impractical, because of the weight and volume. But, oddly, 30 to 35 percent of the radiation can be blocked by shields just five to seven centimeters thick. That, suggests Cucinotta, might be the most efficient choice. Astronauts would still need to cope with the 70 percent of the radiation that’s getting through the shields. So Cucinotta and his colleagues are looking at other solutions, like medication. Antioxidants like vitamins C and A can help by sopping up radiation-produced particles before they can do any harm. NASA scientists are also looking for ways to help the body after the damage has been done. One, for example, may have found a way to instruct a damaged, abnormal cell to destroy itself. Another researcher is exploring the cell cycle: As a cell divides, it pauses occasionally to check its genes for any kind of damage and to repair errors. With pharmaceuticals that lengthen this part of the cycle, researchers believe they can give the cell more of a chance to fix its own problems. Even if we could prevent the damage caused by radiation and weightlessness, that would still be only part of what’s needed to explore Mars and beyond. “The other element,” says Dave Williams, “is the diagnosis and treatment of disease.” Be32

cause, as healthy and fit as astronauts are, the possibility exists that some medical problem could arise during long missions. Astronauts will need to treat any such illness or accident by themselves, using only the tools they’ve carried with them. This means developing technologies that are as smart and as capable as possible. It means developing expert systems that can work effectively regardless of the training of the people who are operating them. (A doctor would be a key part of any long-term mission, of course, but what if the doctor got sick or disabled? Other members of the crew would have to help.) Millions of miles from the nearest hospital, space doctors will need advanced medical technology: miniaturized devices to perform minimally invasive surgeries; robot helpers with supersteady hands; smart medical systems that can diagnose, and perhaps even treat, illnesses; and telemedicine capabilities that will allow the ship’s chief medical officer to consult with experts back on Earth. In fact, many of these devices are already being developed on Earth. External defibrillators are a good example, says Jim Logan, manager for the Medical Informatics and Health Care Systems Office at the Johnson Space Center. These devices, which use electrical shocks to restart a patient’s heart, are good examples of a smart medical system. “The expertise,” says Logan, “is all local, resident in the machine.” The device itself can decide whether it’s been hooked up correctly, whether the patient needs to be defibrillated, and if it decides that the answer is yes, it just goes ahead and provides the treatment. That kind of capability, which contains all its expertise in a tiny, lightweight, easy-to-use package, is a key part of what’s needed to provide clinical care on a long-term exploration mission. Robotically assisted surgery might also play a role. In space, minimally invasive surgery will be important. You don’t want to make large incisions: wounds may be slower to heal and fluids like blood harder to control. By using robots, which can make steadier, more even movements that a human hand, surgeons can make

San Francisco Medicine March 2009

smaller, finer incisions than they could on their own. Telemedicine will be another key tool, and that too is already being explored. “We have at JSC a teledermatology clinic based on the principles of space flight medicine,” says Williams. “If you come into the clinic with a skin rash, we take a high-resolution digital image of the rash and send it to an expert over the Internet. The dermatologist gives a diagnosis and recommends treatment.” The patient doesn’t need to be seen in person. For all the doctor knows, they could be on Mars. Possible technologies abound. Consider a device that could produce medicines from stored substrates—only when the medicines were needed. Long-term exploration missions are likely to exceed the life of many pharmaceuticals, explains Logan. But if you could produce pharmaceuticals as you needed them, he says, then shelf life might be much less problematic. This so-far hypothetical device would solve another problem, too. “Say someone invented a new antibiotic after you had already left Earth,” says Logan. “You can’t upload [pills], but you can upload software. So if you had the capability of manufacturing your medications on the fly, you could simply upload the structure of the new drug and make it right there.” The technologies needed for longterm exploration of the solar system are the same that are needed to provide quality medical care to an isolated rural community or to treat soldiers in the field. Many of these capabilities already exist, at least in some early form. But researchers want to make them smaller, lighter, more power-efficient, smarter, and more effective. “Our goal,” says Williams, “is to extend the distance that humans can go in space, and to increase the time that they can stay there.” Space is a tremendous driver for the development of new technologies, he believes. “And the technologies that we develop to move beyond low earth orbit are truly going to change the way we practice medicine here on Earth.” Reprinted, with permission, from NASA. www.sfms.org


Extreme Medicine

Expedition Inspiration A Group of Breast Cancer Survivors Climb Mt. Anconcagua

Kathleen Grant, MD

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r. Grant,” a patient asked, “would you consider being a team doctor for a group of breast cancer survivors climbing Mt. Aconcagua?” My patient, a woman named Laura, had recently recovered from high-dose chemotherapy and a stem cell transplant. As she awaited my response, my mind raced with the unknowns: Where’s Aconcagua? I guess I could look it up. What do I know about mountaineering medicine? I can always study it. What do I know about mountain climbing? I’d have a whole year to train. I answered her with a quick “Yes,” a response that would lead me to a life-changing experience. Seventeen breast cancer survivors from across the United States, ages eighteen to sixty-one, formed two teams for what was dubbed “Expedition Inspiration.” The summit team set out to reach the 22,800-foot top of Aconcagua, which is situated in the Argentine Andes and is the highest peak outside the Himalayas. The trek team was there to ascend to 12,000 to 15,000 feet to provide support. Two climbers were my patients; others were recruited from outdoor magazines and sports events. All had to pass the scrutiny of our head guide, Peter Whittaker of Rainier Mountaineering. The goal of Expedition Inspiration, in addition to providing these women with a life-changing climb, was to raise both awareness of breast cancer and money to promote scientific advances for its cure. There are significant dangers in any mountain climb, especially altitude sickness and trauma. Most of the climbers were premenopausal at diagnosis, as young as eighteen and twenty-six, and had received intensive chemotherapy

www.sfms.org

therapies that, in some cases, were completed less than six months before the climb. Many had received high doses of doxorubicin and other chemotherapy agents known to produce cardiomyopathy and pulmonary damage, and one third had had left breast or chest wall radiation, risking unintended heart radiation. Could there be a high risk of congestive heart failure, infarct, or respiratory failure? Yes, I thought as I was preparing my supplies, adding bottles of furosemide and digoxin to my medical duffel bag. What about the effects of chemotherapy on the blood-brain barrier and the risk of cerebral edema? I added oral and intravenous dexamethasone and mannitol, along with my ophthalmoscope. Brain metastases are typically diagnosed only after a seizure or sudden neurologic deficit, and I was concerned that the high altitude, with decreased

brain oxygenation, would unmask a metastasis with devastating sequellae. Dilantin, phenobarbital, and dexamethasone went into the bag. Another risk was a pathologic fracture. However, most breast cancer metastases to bone are osteoblastic, not lytic. Traumatic fractures have long been dealt with on mountain treks and Continued on the following page ...

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Expedition Inspiration continued ... require splinting and evacuation. Hypercoaguability intersects the worlds of cancer and high altitude. Breast cancer cells can promote thrombin generation that results in a venous clot, usually in the leg; or the sequel, a pulmonary embolus. Deep-vein thrombosis is common at high altitudes due to dehydration, use of heavy packs, and confinement in small tents to weather out storms. I included heparin for subcutaneous use but hoped that our guides’ constant admonition to “drink, drink, drink” would be an effective deterrent. Expedition Inspiration’s climb of Aconcagua was a major publicity event, filmed as a PBS documentary with two large film crews accompanying us. The video would ultimately be narrated by Bill Kurtis on The New Explorers. The medical care had to be competent, with every possible need anticipated. Medicines in my six-foot duffel—besides those already mentioned—included multiple antibiotics, morphine, oral analgesics, Monistat, and acyclovir. Sutures, a skin stapler, and a chest tube constituted equipment I hoped to avoid using. Bud Alpert, plastic surgeon, experienced mountaineer, and summit team member, would be available by radio, and I was grateful for my rotating med-surg internship, however distant. Slow acclimatization is a key factor in tolerating high altitude, and the group spent several days in Puenta del Inca, Argentina, at 9,000 feet before going to the trailhead. While we were on the mountain, two people in other groups died from sudden cerebral edema, the consequences of too-rapid ascent. Two other climbers, dehydrated and disoriented, stumbled into one of our camps after a fast ascent two days earlier. They had become confused and lost, thinking they were in Chile. My scientific agenda on the climb was to assess the effect of prior chemotherapy on the marrow’s ability to produce red cells in response to hypoxic states. Sixty percent of the women had received chemotherapy as part of their breast cancer treatment. Preclimb cbcs, reticulocyte counts, and erythropoietin levels were 35

obtained. I drew five-day post-climb samples in my hotel room in Mendoza (I’m sure the management would have been shocked) and had the studies run in a local clinical lab. Though there was no statistical significance to the results due to the small sample size, the trend was to a better reticulocyte response and higher hemoglobin in the group with prior chemotherapy than in the group with no chemotherapy. Similar results have since been demonstrated with neutrophil production. Ultimately, there were no life-threatening events in our group. A nurse trek team member was sent down the mountain with pneumonia. Three of the summit team members returned from 17,000 and 20,000 feet to the base camp suffering from high-altitude symptoms such as fatigue, dyspnea, mild disorientation, and lack of coordination; but they quickly improved at lower altitude with fluids and rest. The trek down from the base camp, where both teams had reunited, was rigorous, the first day covering twenty-five miles in twelve hours. One member of the team tripped on a rock and landed on her face, knocking out four upper teeth and one lower tooth. She slept next to me that night, and I lay awake watching for delayed bleeding or airway problems, neither of which occurred. The slogan of the team physician is the same as the guide’s: Hope for the best but prepare for the worst. I had needed virtually nothing in my huge duffel bag. How did my life change? Returning home, I focused on breast cancer in my oncology practice, and in our leisure time, my husband, Tom Jackson, and I focused on mountains, climbing in the Himalayas and the Andes and doing a breast cancer climb on Kilimanjaro with some of the EI team members. Expedition Inspiration continued its fund-raising and founded a scientific symposium, now in its thirteenth year. Through it all, I think of the mantra of my fellow climber, Nancy Knoble: Courage, compassion, strength, joy.

San Francisco Medicine March 2009

Rodeo Medicine Continued from page 28 ... with quadriplegia). The rest of the rodeo and bull riding world has no reliable catastrophic injury data. The University of Calgary has created a Catastrophic Injury Registry (www. rodeoresearch.ca) for data collection surrounding catastrophic injury mechanisms and incidence in rodeo and bull riding. The registry collects information of value both retrospectively and prospectively. The longterm goal is prevention of such injuries. The future of rodeo medicine is optimistic. Research initiatives grow monthly. A sample of such projects includes accelerometry to characterize neck movement while bareback riding (Don Andrews, Justin Sportsmedicine Team), validating a rodeo-specific concussion assessment tool (Mark Lafave, Tandy Freeman, R.P. Murray), constructing an international rodeo medicine referral database (Elise Hiza, Mark Brandenburg) and head-injury prevention and helmet advocacy in bull riding (Mark Brandenburg, R.P. Murray et al). Other projects characterize the mechanisms of injury (i.e., pectoralis major ruptures) to plan preventive strategies (Breda Lau, Dale Butterwick). Interactions over the past six years are gratifying as graduate and medical students focus research on rodeo-related projects. The rodeo and bull riding caregivers have been insistent on providing service first, while building their understanding of rodeo contestants and events through contestant interactions. This effective model is likely to serve the medical community and contestants well as long as we follow the trail that has been blazed by generations of health care providers who came before us. Dale Butterwick is a certified athletic therapist and an associate professor of kinesiology at the University of Calgary. He has active research interests in professional rodeo and has provided leadership and sports medicine care for rodeo athletes for the past 25 years. Mark Brandenburg is an emergency physician in Tulsa, Oklahoma. He is an author and clinical researcher with a long-standing interest in injury prevention and rodeo medicine, specifically in the study of helmets in bull riding and their role in preventing injuries. References and acknowledgements available online at www.sfms.org/archives. www.sfms.org


Extreme Medicine

Confessions of an Extreme Athlete What Is the Real Motivation behind Extreme Athletics?

Daniel Bikle, MD, PhD

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onfession #1: Although branded so by others, I do not consider myself to be an extreme athlete. Each year I do a half Ironman (1.2mile swim, 56-mile bike, 13.1-mile run) and a century (100-mile bike) on separate occasions. I spend the rest of the year trying to keep in shape so I do not die during these events. What is extreme? A recent article by a real Ironman (multiply the above distances by two) indicated that the way to keep in shape is to do each event three to five times a week—that means swimming 2.6 miles three to five times a week, biking 112 miles three to five times a week, and running 26.2 miles three to five times a week. Now that is extreme. At my pace, I am not sure I could complete all of that in a week going 24/7. My usual week involves runs of 5 to 10 miles Monday, Wednesday, and Friday, a 25-mile bike ride up Mt. Tam and along the coast on Saturdays, and a mile swim in a pool on Sundays. As the Ironman gets closer, I push a little harder. The question I often am asked is why I do all this training, extreme or not. Here are two reasons, neither of them mine: The glory of winning. Hardly. I feel glad to finish, but a high ranking is not in the cards. Depending on when I start (which heat the old men are scheduled to begin), I spend much of the race keeping out of the way of folks zooming by. Last year I even got passed by a seventy-yearold during the bike segment. I think I nipped him on the run, however. The endorphin high. I am still waiting for that. Running in particular is work and pain. As my very savvy daughter pointed www.sfms.org

out, even running downhill requires work. The best part of running is when I stop. Biking has its moments, however. The closest I get to a high during my training sessions is cruising down a long hill on my bike at something approaching breakneck speed and probably well over break-other-bones speed. That is a thrill. But do the math. Grinding up Mt. Tam at say, 6 miles per hour and cruising down the other side at, say, 30 miles per hour (assuming no cars are in the way to slow me down) means spending 50 minutes of hard work for 10 minutes of thrill. OK, so maybe there is a high there—but it is short-lived for the effort of getting there. Swimming is the best—rather sensuous, no hills, no sweat, only rhythmic stroking and a mild degree of hypoxia that sends me into some sort of other space. Maybe that is the endorphin high—hypoxia, hypercapnia. Here are a few more possible ways to explain why I push through: My doctor, spouse, guru told me that exercise was good for me. Well, I believe that, even if the doctor giving the advice is I. I cannot look my patients in the eye and tell them to exercise and diet when I am spending my time on the couch watching TV and snacking on potato chips, much as I might like to do that. So perhaps, like our definition of an alcoholic as one who drinks more than his physician, maybe I secretly believe my definition of a couch

potato is one who exercises less than I do. This segues to the next possibility. Pride. There is definitely an element of truth here. Not too many of my friends and colleagues, especially those in the more senior ranks of life, are out there pounding the pavement several times of week. But there are some, and at least those who compete in the Ironman are generally faster than I am. During my training sessions I am much more likely to be passed than pass. But I comfort myself in noting that my head is definitely among the greyest out there. Participants in the race that I do (it’s called the Vineman, held in Sonoma, which mightily appeals to my enology interests) are marked not only with his/her race number but also with his/her age, placed prominently on the back of the calf. Thus, passing someone younger is definitely a stroke to the ego. Of course the reverse is true, but at my age the odds are definitely in my favor of passing a slower, younger contestant than being passed by an older contestant, since there are not too many of us Continued on the following page ...

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Confessions of an Athlete continued ... more mature competitors (old geezers) out there. I want to live to 100. Another possibility. My wife and I each expect to outlive the other, but hopefully not by much. And we expect that we will celebrate our 100th birthdays along the way. My wife plans to do this by good genes, a touch of estrogen, judicious dieting, and a modicum of exercise. I plan to get there by combining good genes with lots of exercise and wine to keep the HDL level around that of the LDL to compensate for lack of estrogen and whatever else women have going for them in the longevity program. So what is the real reason? Bottom line is I like to eat good food and drink good wine and never have to step on a scale while still looking good in the tuxedo I bought twenty years ago. Exercise does that, extreme or otherwise. The brain is an incredible organ. It knows deep down that if the body is going to run the next day or ride up Mt. Tam on a bike, it had better keep a check on the lard buildup around the waist—and it does this without you really thinking about it. It’s remarkable. I eat what I want, and when I overeat, I don’t eat much the next day—too full. And my wife tells me I burn all night after overindulging, much to her irritation—to burn calories while sleeping seems unfair to her. I believe this is the real miracle of exercise. It has recently been discovered that brown fat and muscle are derived from a common mesenchymal progenitor, sibling cells if you like, and that unlike what we used to think, brown fat exists in adult humans. With the simple turning on and off of a gene, PRDM1 in this case, one gets brown fat (gene on) or muscle (gene off). White fat and brown fat are only distantly related, if at all. Brown fat is loaded with mitochondria, like muscle; but these mitochondria burn calories inefficiently because of the uncoupling protein UCP-1, which basically dissipates the proton gradient in these mitochondria, generating heat rather than ATP. So maybe exercise actually builds up brown fat as well as muscle. When too many calories percolate through the system, exceeding the

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demand by muscle, perhaps the brown fat sequesters and burns them before the white fat gets a chance to store them away—assuming of course that the ratio of brown fat to white fat is high, as it must surely be in the exercised body. Then we have all those exercise-regulated factors like insulin, ghrelin, adiponectin, and leptin coming into play, acting centrally and peripherally to control appetite upstairs and calorie utilization downstairs. But for me it all boils down to this: I exercise because I feel good afterwards. I have lots of energy during the day, sleep well at night, and can eat and drink what I want without worrying about getting fat. So let the brown fat roll, and let my body sustain the abuse for a few more years. Daniel D. Bikle, MD, PhD, is professor of medicine and dermatology at the University of California, San Francisco, and Codirector of the Special Diagnostic and Treatment Unit at the San Francisco Veterans Affairs Medical Center. He is an endocrinologist with particular interest in hormonal regulation of bone mineral metabolism and vitamin D and calcium regulation of cellular differentiation focusing on the skin. He has authored nearly 300 publications, including numerous book chapters, and edited several books in these areas of interest. He lives in Mill Valley with his wife of 44 years, Betsy, with whom he has raised two fine children, Christine and Hilary. All three believe he is slightly nuts in his athletic pursuits.

San Francisco Medicine March 2009

After Shock Continued from page 11 ... wait for civil assistance; you take matters into your own hands.) The sound of a walkie-talkie led me to a group of paramedics who had just arrived, and, in addition to identifying myself as a physician and offering to help in any way I could, I asked if they’d heard news of how things were elsewhere. I was told, matter-of-factly, that San Francisco, San Jose, and Sacramento had been hit just as hard, and that the Bay Bridge was down. I didn’t have a chance to realize the full impact of what I was being told, though, because an injured young woman making ominous gurgling sounds was placed before me by a particularly energized paramedic. I’d seen this kind of behavior before, someone practically in ecstasy during a crisis. He said, almost gleefully, “What’ya say, doc, don’t you think we should tube her?” (meaning to intubate her: to pass a tube down her throat, through her vocal cords, and attach that to an air bag that would let us keep her breathing). I said, “I guess so”— in fact, not really knowing if we should or not, thinking it would make sense to listen to her lungs first and assess whether she really needed it, but there was no time to pause and think. He slipped the tube in like a pro, as I listened with my stethoscope to see that it was in the right place. A fat video camera nosed in from the side to film us doing this (a shot that was soon broadcast nationwide), and I had a strongly negative reaction to such an intrusion—the woman’s misery was not fair game for television, nor was it legitimate to film us “saving” her (I’m still not sure that intubating her was the right thing to do). She was taken off by ambulance, and, expecting an onslaught of similar patients, I set about developing a curbside medical station (using equipment the paramedics had brought), including hanging, from the lower rungs of a telephone pole, several IV setups—bottles of saline solution, plastic tubing, and needles for giving fluid intravenously. Metalogue: What do doctors know www.sfms.org


about disaster medicine? Practically nothing—it’s not taught in medical schools. Apart from mock-disaster drills at our hospital (which were only infrequently scheduled, and then usually canceled), I’d only had advanced CPR courses and spent time in trauma rooms during residency— inadequate rehearsals for what I was facing now. And I couldn’t imagine that it would be different for most other physicians. The irony is that, as physicians, we are always “on call” to our communities in the event of a disaster, but, in truth, we emperors have no clothes.

Into the Collapse

At my elbow, wanting to help, was a twelve-year-old black girl in a pink dress. I promised her that if any children were brought down, I’d use her to help comfort them, and she was willing and eager to do that. But in the following half hour, no injured children appeared; in fact, no other victims were brought to us. It’s not that they were being taken elsewhere either, there just weren’t any. Those that had been hurt but could walk had simply walked away, and those who were still alive were trapped under the collapsed upper deck. When a paramedic called down for help with starting IVs, I decided to go up. Was I afraid to go up there? Not exactly—it felt familiar to me. I am a surfer, with years of big-wave riding experience around the world, and while I’d been waiting uselessly below with my IV setups, I’d been imagining what it would feel like to be up there: the long concrete wall of the fallen freeway reminded me of a colossal ocean wave; the spills of concrete had the appearance of falling white water; the hanging metal bars, bent in all directions, seemed like spray being blown wildly back. If I were up there, and an aftershock caused it to collapse, I somehow believed that I could safely ride it out, as if it were real surf. I went up a thin, wobbly ladder that barely reached the bottom of the lower deck, about thirty feet off the ground, slid in through a horizontal crack, then dropped down onto the deck. There was maybe four feet of headroom where I was, www.sfms.org

but the ceiling—the fissured underbelly of the upper deck—drooped elsewhere to within inches of the four-lane roadbed. I was crouched down on what had been the right-hand lane, and in the shadowy cold I could see only one trapped car, straddling the second and third lanes, barely visible between several hunched-over firemen and paramedics.

Communication Rescue

Everyone was talking at once, shouting ideas about what should be done. As I duckwalked over, a portable generator revved on, and a metal saw was soon sending off showers of sparks, illuminating rubble all around me and allowing me to see the problem: a concrete beam had fallen across the car from the windshield forward, reducing the engine block to less than a foot in height, and bringing the dash down onto the legs of two young women. I had to yell to be heard. The rescuers were glad that a physician had come to help, and there was a pause in the frantic pitch of the rescue as I squeezed in to examine the women. Both were conscious and able to speak (Spanish only, but a young Hispanic man was between them serving as a translator, holding their hands and reassuring them). There were no obvious major injuries and surprisingly little blood, other than from scratches on their swollen faces. Getting the driver out was going to be difficult; the steering column was wrapped over her right leg. The IVs were started, and the firemen stepped in with the “jaws of life” (large, powerful pneumatic metal snips), and after a number of minutes they cut the woman loose in the passenger seat. Together with the paramedics, I ascertained that she was stable for transport, and she was carried on a stretcher to the ladder and handed down. One of the paramedics was now in such emotional shock that he was becoming psychotic—at one point seeing amputated limbs that were actually intact. (I later had him removed from the scene.) He wasn’t the only one behaving illogically. I reasoned that I, too, must still be in some degree of shock when I saw

one of the other paramedics take the first woman’s blood pressure—a fundamental act in assessing a trauma victim that a medical student would think of immediately, and that I’d to that point forgotten to do (along with every other health professional I’d seen at the disaster). If a patient’s blood pressure is normal, IVs aren’t necessarily required—and the IVs we’d started had been in the firemen’s way, repeatedly kinking up or pulling out, forcing us to step back in to restart them, further delaying the rescue effort. In what was perhaps my first clear-minded act, I borrowed the blood pressure cuff and took the second woman’s blood pressure, which was completely normal. Seeing no obvious signs of internal or external bleeding, I announced that she was medically stable, that she didn’t need an IV, and that we medical people should get out of the way and let the firemen go to work and cut her free. Not surprisingly, it worked: A semblance of organization set in. Information (and the communication of that information), I realized, is the cure for chaos. Metalogue: Why is there chaos after a disaster? There is an analogy in the field of cardiology. If you expose a heart to a strong electrical shock, it will momentarily stop—called asystole (the equivalent of “bottoming out”)—and then usually restart itself (the “self-jump-start” process). When it restarts, though, it may have an abnormal rate and rhythm, or what is called an arrhythmia “chaos,” in disaster terms. The nature of heart cells is that if separated or disrupted, each cell begins beating at a different rate, a rate inherent to each individual cell. Remove the disrupting element and allow the cells to touch each other again (i.e., reestablishing communication), and the cells will return to beating at the same rate.

Fallen Bridge Vision

I moved to where I could gaze out through a crack to the west, hoping to get some idea of what was happening in San Francisco. The sun had already set. There were no lights on across the bay, and it was eerily dark in the advancing twilight. Continued on the following page ...

March 2009 San Francisco Medicine

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After Shock continued ... Smoke was rising from the north end of the city. I tried to make out the Bay Bridge and thought I saw, to my horror, only its towers still standing, with no spans between them. (I didn’t realize that I was mistaken in what I was seeing, that I was looking at the tall cranes in the Alameda shipyards, and that the Bay Bridge was essentially intact, only much farther away.) Believing the bridge to have come down, I imagined thousands of people having fallen into the bay and wondered whether tens if not hundreds of thousands of people might be dead all around the Bay Area. I felt I now understood why we weren’t getting more help—the disaster teams must have gone where things were worse. When I pointed out what I was seeing to my fellow rescuers, they made the same mistake, believing that the Bay Bridge had fallen down—something that was no doubt later passed on to other rescue personnel. This was, I realized later, the nature of “information” in a disaster; derived from disaster workers in shock (which to varying degrees, all of us were), it helped account for the garbled and contradictory reports that were then and later being issued by people who should have known better—civil authorities, public officials, the media. If information can be the cure for chaos, rumor can certainly be its cause.

No Morphine

I turned back to the trapped woman and her translator. Not surprisingly, she was asking for something for pain. It was terribly frustrating to have nothing to give her. All that I could do to be helpful was to hold up a portable light and watch as the firemen systematically removed the car’s roof, seats, dash, and steering column. Finally, after being pinned for more than three hours, she was freed. Her lower legs were apparently broken, but she didn’t appear to have other major injuries, so we put her on a stretcher and sent her down. Before our group departed, I got on my knees and peered under the concrete beam into the next freeway segment and was relieved to not see other trapped cars. On reaching the ground, I was surprised 38

to find that the woman we’d sent down was still there in an ambulance, awaiting orders on where to take her. I knew that the only trauma center in Oakland was at Highland General Hospital, but I reasoned that there were too many cases for them to handle. (I was told later by a physician friend working there that night that, in fact, they only saw a handful of major trauma cases. When the quake hit they’d lost power, and, although the hospital had an emergency generator, there wasn’t enough power for the X-ray machines, which are essential in providing trauma care.) It had now been almost four hours since the quake. I couldn’t see any rescue activity where I was, so I headed back up the street to my car. The very people who had been the major rescuers, the community people, were now cordoned off behind barricades a block away. Up ahead, bright portable lights were shining on a squadron of doctors, most of them dressed in clean green surgical scrubs, one even wearing paper shoe covers (usually used only in operating rooms). Eight gurneys were in place, along with tables holding state-of-theart equipment—defibrillators, EKG machines, chest tubes, and so forth. And behind these tables were any number of IV setups, cut tape, and various medical tools, all strung up along the length of a chain-link fence like Christmas tree ornaments. I talked to the doctor with the shoe covers, a young resident, and was told that they’d come down from Highland a full two hours ago and had been standing around ever since—that they hadn’t yet tended to a single patient. This deeply disturbed me. I couldn’t understand how or why the patient I had just helped rescue hadn’t been brought that short block here, where she would have received the kind of expert assessment and treatment that I couldn’t provide—if nothing else, a shot of morphine. When I tried to find the person in charge but couldn’t, I realized that there was apparently little, if any, communication and coordination of the overall rescue operation.

San Francisco Medicine March 2009

No News Is Bad News I did, however, run into the same paramedic who earlier on had given me the devastating news of how badly off the whole Bay Area (and Sacramento) was, and she told me she was hearing the same reports. Feeling too weary to continue, I retreated to my car, turned on the radio, and discovered, to my amazement, that I’d actually been at the worst of the earthquake disaster sites, that the Bay Bridge was essentially intact and that the other bridges were passable (meaning that I could get home that night), and that thousands of people weren’t dead ! My joy was short-lived. When I walked back to see if I could still help, what I saw was profoundly distressing. Yes, there were any number of rescue vehicles and uniformed people, but they seemed to be moving about purposelessly, as if at a swap meet. I felt I had to get out of there. I hurried back to my car, pushing my way through a mass of news reporters who were accosting all who came their way, trying to pry stories from them. As I drove home, carefully picking my way around the North Bay, using bridges and underpasses I was advised were safe by the radio, a profound distrust and anger began to rise within me: Why should I believe anything I was hearing? It was being reported that there were only six people confirmed dead—and I’d seen almost that many dead myself, so that couldn’t be true. Then it was said that 200 were dead, based on how many cars were thought to be trapped in the Cypress structure, but, at least in the segments I’d been in, there weren’t very many cars. So 200 appeared to be a gross overestimate. And it was being widely reported that the Bay Bridge would be fixed within two days, which seemed—and was—utterly impossible. Through the rest of that night, and over the next days, it seemed to me as if the news bulletins were coming from a script prepared before the quake— how swiftly the various agencies had responded after the quake, how well the rescue efforts had gone, the gore, glory, and heroism. The reality of the situation, as I experienced it, is that in the face of this www.sfms.org


relatively minor-league earthquake (not the “Great Quake”), I, along with most of the other rescue workers, had gone into varying degrees of shock and functioned accordingly—as had, apparently, the civil disaster plan for the region. Metalogue: Why don’t disaster plans work very well? I think the explanation lies in the domain of what psychiatrists refer to as denial: to deny the existence of something despite overwhelming evidence to the contrary. While denial can be regarded as a protective mechanism, it is also considered abnormal behavior and can be destructive. An alcoholic, for instance, may deny having a drinking problem, despite having lost job and family. In children, on the other hand, denial is often a healthy, normal behavior. For example, a child may have fantasies about being able to fly, which is understandable given the reality of being small and helpless. When it comes to disasters, however, a carryover from childhood is not healthy. The big, bad wolf may blow your house down, and you may end up in Oz from a tornado, but somehow you’ll survive. Even though we may hear about disasters in the news on a daily basis, we feel immune because they so rarely happen to us. It is from that mind-set, I believe, that most disaster plans are generated; accordingly, disaster plans—whether personal or governmental—consistently misapproximate what can actually happen.

What Do You Believe?

I believe the December 2, 1989, U.S. Geological Survey predictions: Another earthquake with magnitude comparable to the October 17 earthquake, but located closer to the population centers in the San Francisco Bay Area, is expected to occur, with a probability of 50 percent over the next 30 years. (Similar predictions are made for Southern California.) The U.S. Geological Survey considers the following cities at significant risk for earthquakes: Boston, Rochester, Buffalo, Charleston, Memphis, St. Louis (the largest quake in U.S. history—8.3 magnitude or greater—was in Missouri in the 1800s), Salt Lake City, Seattle, Anchorage, www.sfms.org

and Honolulu. I’m preparing for the next quake (or a similar disaster) and trying to help others to realize that they need to do the same. But I’m not sure that enough people were awakened by this last quake to achieve even rudimentary preparedness. Will the necessary billions of dollars be spent to reinforce or rebuild at least the critical public structures—particularly the hospitals—to withstand even the largest quake? Will money be spent to develop new technologies to make earthquakeproof buildings? Will all health professionals be trained in disaster medicine, so they will know better what to do? Will our society learn to take earthquakes as seriously as the Japanese, who have whole-city earthquake drills, every citizen included? We seem to be where we were with the AIDS epidemic in the early 1980s: only dimly aware of the magnitude of the crisis. It is obvious that it will take a major and enormously expensive effort to prepare for what is coming—the Great Quake. Metalogue: What is a disaster? In terms of systems theory, a disaster is an event or a series of events that halts or severely reduces the output of a system. A disaster leads to system disintegration and dissolution, a stripping away of structure and of what one has learned or knows. Rebuilding after a disaster is a lengthy and painful process.

Epilogue

The quake has left me feeling as if, for a brief time, I was a part of the Holocaust—yet I survived. (And, like Holocaust survivors, I don’t want to let people forget what happened. I’ve even thought it would have been a good idea to have left a crumpled part of the Cypress as a monument, so we would be less likely to forget.) I’ve developed a deeper mistrust of the capabilities and responsiveness of governmental agencies (a mistrust which, as an inner-city family practitioner who sees homeless and HIV-infected individuals, was already quite high). I’ve come to see more clearly how the editorial policies (and fears) of the media direct their reporting and consequently distort

information. And I’ve come to realize that this little perch of land we’re on up here, San Francisco, is to be appreciated one day at a time. Mark Renneker, MD, is a graduate of the UCSF School of Medicine and the USCF/ SFGH Family Practice Residency Program. He is an associate clinical professor in the Department of Family and Community Medicine at UCSF, and attending phsyician at Laguna Honda Hospital, and he is the founder and president of the Surfer’s Medical Association. This article originally appeared in the Western Journal of Medicine shortly after the earthquake. It has been reprinted in full with permission.

Welcome New SFMS Members! The San Francisco Medical Society would like to welcome the following new members: Arash Babaki, MD

Jennifer Brokaw, MD

John Rampulla, MD California Emergency Physicians

March 2009 San Francisco Medicine

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San Francisco Medical Society 2009 Annual Dinner Held on January 23, 2009, at the Concordia-Argonaut Club in San Francisco the SFMS Annual Dinner was a great success! Charles Wibbelsman, MD, was installed as the 2009 SFMS president and keynote speaker, Robert Pearl, MD, spoke about the importance of using technology to communicate in the field of medicine. As usual, the SFMS Annual Dinner was a fantastic opportunity for members to meet and mingle with each other and is not to be missed next year!

Above left to right: SFMS Executive Director Mary Lou Licwinko, JD, MHSA, with the 2009 SFMS Officers: Secretary George Fouras, MD; Treasurer Gary Chan, MD; President Charles Wibbelsman, MD; Editor Mike Denney, MD; and President-Elect Michael Rokeach, MD. Below left to right: Nancy Thomson, MD, and Roland Barakett, MD; Keynote Speaker of the evening, Robert Pearl, MD, with SFMS President Charles Wibbelsman, MD; Mrs. Annette White and CMA Past President Richard Frankenstein, MD.

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www.sfms.org


Clockwise from top left: Robert Owen, MD, Bill Kapla, MD, and Mark Kono; Herb Peterson, MD; Loretta and Edward Chow, MD; Peter Sullivan, MD, Michael Rokeach, MD, and Ricki Pollycove, MD; Richard Rider Jr., Anchi Lien, and William Miller, MD. The SFMS would like to congratulate Mike Denney, MD, PhD, on receiving the 2009 SFMS David Perlman Award for Excellence in Journalism! The award was presented to Dr. Denney at the annual dinner in recognition of his great contributions to San Francisco Medicine over his three-year term as Editor.

www.sfms.org

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The SFMS would like to thank the following corporate sponsors who helped make The 2009 SFMS Annual Dinner possible: California Pacific Medical Center; Chinese Hospital Medical Staff; Kaiser Permanente San Francisco; Marsh; St. Francis Memorial Hospital; St. Mary’s Medical Center; The Permanente Medical Group, Inc.; UCSF Medical Center; and a special thanks to: Duramed Pharmaceuticals, Inc.—a subsidiary of Barr Pharmaceuticals, Inc. (for sponsoring both the Perlman Award, as well as the dinner); Medical Insurance Exchange of California. This program was also supported in part by an educational grant from Eli Lilly and Company (which had no control over its content). And special thanks to St. Francis Memorial Hospital for providing meeting space and parking for the 2009 SFMS board meetings.

Clockwise from top left: Xavier Barrios, MD, and Jane Hightower, MD; Toni Brayer, MD, and Craig Patterson; Robert Margolin, MD, handing over the gavel in place of Steve Fugaro, MD, the 2008 president who could not attend; Charles Wibbelsman, MD, the 2009 SFMS President, takes the stage!

Below: Dr. Wibbelsman honors fifty-year members of the SFMS. Bottom left: Ernest Rosenbaum, MD, and Larry Jew, MD. Bottom right: Sigmund G. Ketterer, MD, and Nancy Thomson, MD.

Francisco Medicine March 2009 42 43SanSan Francisco Medicine March 2009

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Hospital News Chinese

Joseph Woo, MD

January 26 marked the beginning of the New Year for the Chinese community and is the Year of the Ox. Ox people succeed through sustained efforts and hard work, so I suspect most of our SFMS leadership have at least some ox in them. The New Year also brought in new hospital board leadership. We are proud to have Mr. James Ho as our President, taking the reins from Mr. Joe Chan. As many of you know, Mr. Ho was once the Vice Mayor of San Francisco. I was fortunate to have attended his installation ceremony, held at the Four Seas Restaurant in Chinatown on January 27. Newly elected President of the Board of Supervisors David Chiu performed the swearing-in ceremony. Our own Dr. Rolland Lowe appeared in good spirits, along with other medical staff members Dr. Grant Moy, Dr. Randall Low, Dr. Eric Leung, Dr. Sam Kao, and Dr. Ed Chow. Also in attendance were many of the leaders of the City who have supported Chinatown so vigorously, including former Mayor Willie Brown, Supervisors Carmen Chiu and Sean Elsbernd, City Administrator Ed Lee, City Attorney Dennis Herrera, Fire Chief Joanne Hayes-White, Assessor Phil Ting, and many representatives of the SFPD. On this day, Chinatown was clearly the safest place to be in the City. Congratulations are in order to Ms. Brenda Yee, who has been appointed to dual roles as CEO of both our Chinese Hospital and Chinese Community Health Plan. Also to Board Member Rose Pak, who hosted another successful golf fund-raiser at the Olympic Club last year, raising more than $500,000. And lastly to Dr. Collin Quock, who was honored by SI College Preparatory with its Christ the King award for his generous service to his church, his city, and the Chinese community.

www.sfms.org

CPMC

Kaiser

Damian Augustyn, MD

Robert Mithun, MD

For the third year in a row, California Pacific Medical Center has been named one of the Leapfrog Group’s Top Hospitals in the U.S. CPMC is one of just five hospitals nationwide to win the honor three years in succession. The voluntary survey of 1,220 hospitals provides the most complete picture of hospital quality and safety available in the U.S. No other Bay Area hospital made the list. The Leapfrog Group is an independent organization that focuses on safety, quality, and affordability in health care. Getting on the list three years in a row is a tribute to every person at CPMC and the attention we pay to putting patients first. CPMC has opened a state-of-the-art Surgical Simulation Education Center, a hightech approach to training surgeons, anesthesiologists, and nurses in the latest surgical techniques. “For years, pilots have trained on flight simulators, practicing their skills and learning new ones, to make flying safer,” says Stephen Lockhart, MD, PhD, medical director of Surgical Services at CPMC. “That’s what our new Surgical Simulation Education Center allows us to do, to train our surgical staff in new techniques and practice how to respond to emergencies, to create an ever-safer environment for our patients.” Located in the heart of downtown San Francisco, the Surgical Simulation Education Center uses computer-controlled mannequins to simulate human patients. Operators can change the way the mannequin breathes, increase or decrease its blood pressure and heart rate, alter the size of its pupils, even simulate a reaction to medications or anesthesia. This allows the surgeons, anesthesiologists, and nurses the opportunity to train for rare but life-threatening emergencies in a simulated environment, so they are better prepared should such emergencies occur in the real world.

Sitting in your home you read the news headline: “Violence is breaking out in Kenya over the disputed presidential election.” Just then, the phone rings and you are informed that you will be deploying to Kenya in three days to provide medical relief in the worst slum of Nairobi. You get your shifts covered, take care of your family obligations, and soon find yourself running trauma codes in a church recreational center in the Mathare slums. Though it may sound like a Hollywood film, disaster medicine is not all glamor. There are more challenges than getting on a plane with a moment’s notice that make disaster medical relief extreme. Once relief workers actually arrive at their destination and a team is formed, further issues unfold. In many disaster locations, personal safety is an important issue and may include structural, environmental, political, or civil dangers. Often the workplace itself will be suboptimal, with a makeshift facility, disorganization, and a shortage of supplies—many of them unfamiliar anyway—as well as a handful of environmental hazards. The patients that are evaluated may not speak English and may have drastically different cultural backgrounds and preferences. Lastly, the situation that surrounds a relief mission and the stories that patients share are often emotionally disturbing and personally stressful. Disaster relief deployments are not part of daily operations at Kaiser Permanente, but we recognize our duty to contribute to overall global health, as well as the value that it brings to its own emergency preparedness. Several physicians at our facility volunteer for disaster relief organizations and we have helped organize teams for events such as the Sri Lanka tsunami. We support our doctors’ interests in volunteering and we appreciate that the experience that they gain on relief missions helps improve the quality of emergency preparedness at our own facility.

March 2009 San Francisco Medicine

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San Francisco Medicine March 2009

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Hospital News St. Mary’s

Richard Podolin, MD

The term extreme medicine transports our thoughts to images of climbers injured on Himalayan slopes, Arctic explorers suffering from hypothermia, or divers succumbing to nitrogen narcosis on the ocean floor. The victim confronts a callous and inhospitable environment, so unforgiving that despite careful preparation and specialized equipment, human resilience is overwhelmed and normal physiology perturbed. These scenarios beyond the bounds of ordinary medicine are intriguing precisely because of their novelty and their rarity. While medicine in these extreme milieus may produce insights and techniques that ultimately have broader utility, it is important to question how we have come to accept the damages of other hostile environments as “ordinary.” Why isn’t it extreme when a homeless man is brought to the emergency room infected or hypothermic from lack of basic shelter? How can it be ordinary to treat epidemics of obesity and diabetes in children continuously exposed to toxic levels of calories and simple carbohydrates? When did it become routine practice—as it is in some trauma centers—to treat teenagers with gunshot wounds? We need to learn from the courageous few who voluntarily risk their lives and limbs to push into new and treacherous surroundings. We also need to question why many dwell in hostile environments in the midst, even in these troubled financial times, of such plenty. At St. Mary’s, it is our mission to deliver compassionate, high-quality, affordable health services; to serve and advocate for our sisters and brothers who are poor and disenfranchised; and to partner with others in the community to improve the quality of life.

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UCSF

Saint Francis

Elena Gates, MD

Wade Aubry, MD

Our medical director for Sports Medicine, Dr. James Garrick, reports, “Over the past decade, the Centers for Sports Medicine have seen a higher incidence of injuries sustained in sports such as skiing, rock climbing, and mountain biking. This is partially due to the aging Baby Boomer population staying active. We see a lot of patients who run into trouble because they don’t prepare themselves in advance for these extreme sports activities.” The Centers for Sports Medicine emphasizes exercise and rehabilitation programs to help older active individuals stay active. They remind patients that no matter how athletic you are, the aging process will take its toll on your joints and bones, so be sure your strength is adequate to continue these activities. Over the past decade, Saint Francis has organized and provided medical and emergency coverage for major golf events in San Francisco at the Olympic Club Lake Course and Harding Park Golf Course. These events included the 1998 U.S. Open, the 2004 U.S. Junior Amateur Championship, the American Express Championship in 2005, and the 2007 U.S. Amateur Championship. Several Saint Francis physicians, including Wade Aubry, Thomas Leach, Victor Prieto, Roger Smith, Rich Naidus, Richard Ward, Richard Blake, Ron Valmassey, and Remy Ardizzone, have volunteered their services and have coordinated with other volunteers (RNs, EMTs, Red Cross volunteers), standby paramedic ambulances, and the City and County of San Francisco Emergency System to support first aid and medical needs at these mass gatherings. This October, Saint Francis will again provide these services and supplies to the President’s Cup Matches at Harding Park, an international team competition sponsored by the PGA Tour. The Presidents Cup, which alternates years with the Ryder Cup, will be an exciting golf event that will once again showcase the world’s best golfers on the San Francisco stage.

UCSF is improving health in the world’s most vulnerable populations by addressing the lack of surgical care in Africa. Lack of access to basic essential and emergency surgery in rural Africa means huge mortality and morbidity from obstructed labor, simple general surgical emergencies, and trauma. “The most important limiting factor is lack of surgeons and nurses. Until this shortage is reversed, we can train nonphysician surgical extenders to provide limited but skilled care,” said Haile Debas, MD, executive director of UCSF Global Health Sciences. UCSF and its global partners are collaborating with ten African countries to improve care at the district hospital level and to develop trauma care systems in Africa. To reduce maternal mortality in childbirth, UCSF’s Safe Motherhood Program provides women in developing countries with Lifewraps, reusable neoprene garments that look like the bottom half of a wetsuit. A Lifewrap stabilizes a woman in shock from obstetric hemorrhage, the leading cause of maternal death in childbirth, by compressing her lower body to reduce bleeding and returning blood flow to her brain, heart, and lungs until she can get lifesaving treatment. “We see a 50 percent decrease in maternal mortality where we have introduced Lifewraps,” said Suellen Miller, CNM, PhD, UCSF associate professor of OB/GYN and program director. For extreme or aspiring athletes closer to home, UCSF’s RunSafe clinic offers a unique multidisciplinary diagnostic program to optimize runners’ performance and prevent injuries. A team of sports medicine physicians, physical therapists, dieticians, athletic trainers, and orthotics engineers analyze runners’ gaits as videotaped on a treadmill and advise on diets, workout programs, and footwear during a two-hour clinic. “Different professionals with different perspectives give the whole picture of running performance,” said Joe Smith, MS, ATC, CSCS, RunSafe clinic coordinator.

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Hospital News

In Memoriam

Veterans

Diana Nicoll, MD, PhD, MPA

Recent work by two SFVAMC investigators has shed light on several serious health issues in the United States: breast cancer, depression, and heart disease. A nationwide study of more than 280,000 women showed that postmenopausal women who are overweight or obese have advanced breast cancer at significantly higher rates than women of normal weight or less than normal weight. The study, published in the November 26, 2008, issue of the Journal of the National Cancer Institute, was led by Karla Kerlikowske, MD, a physician at SFVAMC and a professor of medicine, epidemiology, and biostatistics at UCSF. “The reason may be that being overweight increases circulating estrogen, which in turn promotes tumor growth,” said Dr. Kerlikowske. In 2007, she was the lead author of a major study showing that decreased use of postmenopausal hormone therapy since 2002 has contributed to a decline in the recorded incidence of breast cancer in the United States. “The good news is that there are two breast cancer risk factors that can be modified,” says Dr. Kerlikowske. “Not taking postmenopausal hormones is one. Maintaining a healthy weight is another.” Another San Francisco V.A. Medical Center study identified that patients with heart disease who are depressed are more likely to smoke, not exercise, and not be compliant in taking medications than those who are not depressed. This puts them at greater risk for stroke, heart attack, heart failure, and death, according to a study led by Mary Whooley, MD, a SFVAMC physician and a professor of medicine at UCSF. The study appeared in the November 26, 2008, issue of the Journal of the American Medical Association. Dr. Whooley is principal investigator of the Heart and Soul Study, which followed 1,017 patients with stable coronary heart disease for an average of five years. She found that the more depressive symptoms a patient reported, the more likely the patient was to have a cardiovascular event. 46

Oscar L. Daniels, MD Oscar Llewellyn Daniels, Sr., MD, one of the Bay Area’s pioneer black physicians, passed away peacefully on October 23, 2008, at the age of 94. He was born June 14, 1914, in Manhattan and raised in Brooklyn, where he began his elementary education. The family—consisting of his father, George Daniels; his mother, Marie; and his older siblings, Louise and Frank—soon moved to Hackensack, New Jersey, where he completed his secondary education. He attended Rutgers University for a year before transferring to Lincoln University in Pennsylvania, where he graduated in 1940 with a BSc in chemistry. He then went to Howard University School of Medicine and received his MD in 1944. Dr. Daniels completed his internal medicine internship and residency at Homer Phillips Hospital in St. Louis and served as chief medical resident. He brought his family to San Francisco in 1949, establishing his private medical practice in the Western Addition and joining the San Francisco Medical Society in 1950. He was called to duty in the U.S. Army in 1952 and served at Fort Ord, California, during the Korean conflict. He was honorably discharged in 1955 with the rank of captain, returned to San Francisco with his family, and resumed his private practice. He was an attending physician at Mt. Zion Hospital. He was appointed Medical Officer to the U.S. Post Office in 1963 and managed the medical unit, again the first African-American to attain that

San Francisco Medicine March 2009

position in San Francisco history, serving until he retired in 1985. However, he continued his community-based medical service until his full retirement in 1995. Dr. Daniels lived a life of service: He was a founding member of the Northern California Medical, Dental, and Pharmaceutical Association and the John Hale Medical Society, and a member of the National Medical Association. He was active in the Boy Scouts, the Urban League, and the YMCA. He served as an officer of the NCAAP and was a Golden Heritage Life Member. He was also a life member of the Alpha Phi Alpha Fraternity and a founding member of the Beta Upsilon Boule of the Sigma Pi Phi Fraternity. He belonged to the Episcopal Church of St. Cyprian and served on the Bishop’s Committee. While still in medical school, he married Ismay Richards. Their union that lasted fiftynine years, until her death. Their first son, Oscar, Jr., predeceased him, but he is survived by his son, Dr. Owen Laurence Daniels of Daly City, and his wife, Janice; and his daughters, Carol Marie Daniels of San Francisco and Lynne Estelle Daniels of Oakland; plus five grandchildren and one great-grandchild. Dr. Daniels will be remembered by his host of loving relatives, friends, and associates as a man of principle who was committed to bringing positive change to each community he embraced. —Nancy Thomson, Obituarist  

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March 2009