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2017 Education Series
Making the Decision
PRESIDENT’S MESSAGE The Power of a Smile
Volunteering as a Ski Patrol Physician
Ruenell Adams Jacobs, MD
Jack G. Bruner, MD
EXECUTIVE DIRECTOR’S MESSAGE SMART Medical Clearance: A Community Collaboration
BOOK REVIEW Destiny of the Republic
Reviewed by Kent Perryman, Ph.D.
Aileen Wetzel, Executive Director
Stop the Madness
Aimee Moulin, MD
From SMART to FAST
Amy Barnhorst, MD
GUEST EDITORIAL Sleep Deprivation – An Unresolved Problem
Evolution of the Stethoscope
Leprosy – Almost a Disease of the Past
Glennah Trochet, MD
3D Printing in Medicine
Alex Darwish, MS II
BOOK REVIEW Bellevue
Reviewed by Jack Ostrich, MD
Lee Welter, MD
Over the Hill but Worth the Climb
Ann Gerhardt, MD
Welcome New Members
Letting Go – Saying No to Cancer Treatments
Nan Crussell, SSV Medicine Managing Editor
We welcome articles from our readers by email, facsimile or mail to the Editorial Committee at the address below. Authors will be able to review articles before publication. Letters may be published in a future issue; send emails to e.LetterSSV Medicine@gmail. com or to the author. All articles are copyrighted for publication in this magazine and on the Society’s website. Contact the medical society for permission to reprint.
Visit Our Medical History Museum 5380 Elvas Ave. Sacramento Open free to the public 9 am–4 pm M–F, except holidays.
SSV Medicine is online at www.ssvms.org/Publications/SSVMedicine.aspx Our cover image entitled, “Snowy Creek,” was submitted by Dr. Jack Bruner and is a beautiful welcome to winter. Dr. Bruner also has written about volunteering as a ski patrol physician in this issue, on page 18. If skiing is your sport, this may be for you. As a ski patrol doctor, one must learn to “ski anytime, anywhere,” if necessary, to get to a ski injury site located on any part of the mountain. Ski patrol physicians are required to act as first responders when they come upon an injured skier, and to perform an on-the-hill exam, commence appropriate treatment, and call for additional equipment and assistance as needed. − email@example.com
Volume 68/Number 6 Official publication of the Sierra Sacramento Valley Medical Society 5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax firstname.lastname@example.org
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MEDICINE The Mission of the Sierra Sacramento Valley Medical Society is to bring together physicians from all modes of practice to promote the art and science of quality medical care and to enhance the physical and mental health of our entire community. 2017 Officers & Board of Directors Ruenell Adams Jacobs, MD, President Rajiv Misquitta, MD, President-Elect Tom Ormiston, MD, Immediate Past President District 1 Seth Thomas, MD District 2 Tonya Fancher, MD J. Bianca Roberts, MD Christian Serdahl, MD District 3 Thomas Valdez, MD District 4 Ranjit Bajwa, MD
District 5 Sean Deane, MD Cynthia Ramos, MD Paul Reynolds, MD John Wiesenfarth, MD Eric Williams, MD District 6 Carol Kimball, MD
2017 CMA Delegation District 1 Reinhardt Hilzinger, MD District 2 Lydia Wytrzes, MD District 3 Katherine Gillogley, MD District 4 Russell Jacoby, MD District 5 Sean Deane, MD District 6 Marcia Gollober, MD At-Large Alicia Abels, MD Ruenell Adams Jacobs, MD José A. Arévalo, MD Barbara Arnold, MD Alan Ertle, MD Richard Gray, MD Kevin Jones, DO Richard Jones, MD Charles McDonnell, MD Rajiv Misquitta, MD Janet O’Brien, MD Tom Ormiston, MD Senator Richard Pan, MD Kuldip Sandhu, MD James Sehr, MD Don Wreden, MD
District 1 Anissa Slifer, MD District 2 Ann Gerhardt, MD District 3 Thomas Valdez, MD District 4 Vacant District 5 Jason Bynum, MD District 6 Rajan Merchant, MD At-Large Megan Anzar Babb, DO Richard Bermudes, MD Natasha Bir, MD Helen Biren, MD Arlene Burton, MD Ronald Chambers, MD Amber Chatwin, MD Mark Drabkin, MD Karen Hopp, MD Carol Kimball, MD Derek Marsee, MD Sandra Mendez, MD Robert Peabody, MD Armine Sarchisian, MD Ajay Singh, MD Eric Williams, MD
CMA Trustees District XI Douglas Brosnan, MD
Margaret Parsons, MD
CMA President Ruth Haskins, MD
CMA Speaker Lee Snook, MD
Sierra Sacramento Valley Medicine, the official journal of the Sierra Sacramento Valley Medical Society, is a forum for discussion and debate of news, official policy and diverse opinions about professional practice issues and ideas, as well as information about members’ personal interests.
AMA Delegation Barbara Arnold, MD
Richard Thorp, MD
Advertising rates and information sent upon request. Acceptance of advertising in Sierra Sacramento Valley Medicine in no way constitutes approval or endorsement by the Sierra Sacramento Valley Medical Society of products or services advertised. Sierra Sacramento Valley Medicine and the Sierra Sacramento Valley Medical Society reserve the right to reject any advertising.
Editorial Committee John Paul Aboubechara, Sean Deane, MD Adam Doughtery, MD Ann Gerhardt, MD Caroline Giroux, MD Sandra Hand, MD Nate Hitzeman, MD Robert LaPerriere, MD George Meyer, MD
MS III Steven Nemcek, MS III John Ostrich, MD Neeraj Ramakrishnan, MS II Gerald Rogan, MD Glennah Trochet, MD Lee Welter, MD
Executive Director Managing Editor Webmaster Graphic Design
Aileen Wetzel Nan Nichols Crussell Melissa Darling Planet Kelly
Opinions expressed by authors are their own, and not necessarily those of Sierra Sacramento Valley Medicine or the Sierra Sacramento Valley Medical Society. Sierra Sacramento Valley Medicine reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted. Not responsible for unsolicited manuscripts. ©2017 Sierra Sacramento Valley Medical Society SIERRA SACRAMENTO VALLEY MEDICINE (ISSN 0886 2826) is published bi-monthly by the Sierra Sacramento Valley Medical Society, 5380 Elvas Ave., Sacramento, CA 95819. Subscriptions are $26.00 per year. Periodicals postage paid at Sacramento, CA and additional mailing offices. Correspondence should be addressed to Sierra Sacramento Valley Medicine, 5380 Elvas Ave., Sacramento, CA 95819-2396. Telephone (916) 452-2671. Postmaster: Send address changes to Sierra Sacramento Valley Medicine, 5380 Elvas Ave., Sacramento, CA 95819-2396.
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The Power of a Smile By Ruenell Adams Jacobs, MD I HAVE A LITTLE CONFESSION: I really like reading O, The Oprah Magazine. I was not a regular fan of her talk show while it aired, mostly because I was busy with postgraduate training, working, and later raising a family. But my mother, who loves Oprah, gifted me with a subscription and has continued to renew it on my behalf each year. The magazine is fairly eclectic, providing make up and clothing tips, highlighting products that are fun and occasionally useful to buy, and providing health and wellness suggestions, among other things. One regular section in the magazine is The Gratitude Meter where the writer shares with the readers something they are smiling about. So, since this version of our medical society magazine is coming out around the holiday season, I would like to share some of the things I am smiling about this year. The SSVMS Executive Director and staff: They took on the task of assisting the Board and other physician advisors from the Sacramento area in putting together a new program to address physician burnout late last year. They executed this plan in a way that has exceeded my expectations. In addition, they continue to provide ongoing oversight and support for existing programs. The Scholarship Committee: Every year we review applications submitted by medical
students who graduated from high schools located in either Sacramento, El Dorado, or Yolo Counties. This year we chose four recipients that we felt were deserving of this honor from among a group of highly competitive applicants.
These students are fun to interact with, and working with them reminds me why I chose medicine as a career. Medical Students: I get a chance to interact with medical students on a regular basis through medical society activities, in my office as a preceptor, and as a volunteer preceptor at one of the student-run clinics. These students are fun to interact with, and working with them reminds me why I chose medicine as a career. My medical practice: I still like going to work. The opportunity to provide compassionate care to patients in a supportive environment far outweighs some of the challenges I may have with the EHR. Lastly, my family: My husband deservedly joined the ranks of retirees earlier this year, and my youngest son finished high school and enrolled in college. Both are happy and thriving, and it’s been fun to watch them approach these major life transitions with excitement and anticipation. I end this letter with the mention of the youngest member of our family, my 2½ yearold granddaughter, who is surrounded by so many people who love her which makes her smile. And her smile has me smiling as well. Happy Holidays. email@example.com
Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com. 3
EXECUTIVE DIRECTOR’S MESSAGE
SMART Medical Clearance: A Community Collaboration By Aileen Wetzel, Executive Director
Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.
PATIENTS IN MENTAL HEALTH crisis frequently present to one of the Sacramento region’s Emergency Departments (ED) for medical evaluation and treatment. Many individuals present with symptoms consistent with psychiatric illness without underlying organic disease. These patients are frequently “boarded” in the ED, oftentimes for days, until inpatient psychiatric beds become available and the transfer process is completed. This results in extended wait times, increased lengths of stay, and higher risks of adverse outcomes for all ED patients. Bearing witness to an unprecedented increase in the number of patients in mental health crisis seeking treatment in local EDs, the Sierra Sacramento Valley Medical Society (SSVMS) published a white paper, “Crisis in the Emergency Department: Removing Barriers to Timely and Appropriate Mental Health Treatment,” (July 2015) to frame the issue and to set forth recommendations to ensure that patients receive timely access to care. One of the recommendations put forth by SSVMS to improve the quality of care for patients experiencing mental crises was to standardize the medical clearance process across all EDs and inpatient psychiatric treatment programs to facilitate the timely transfer of patients to appropriate treatment centers. To achieve this goal, SSVMS brought together specialists in the fields of emergency medicine and psychiatry to develop and implement a standardized medical clearance process using the SMART Medical Clearance algorithm, an acronym that drives real-time medical decisionmaking through a series of specific questions. The SMART algorithm was designed using
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an evidence-based approach through review of peer-reviewed articles and studies, as well as consultation with experts in the fields of psychiatry and emergency medicine, both locally and nationally. The SMART Medical Clearance form was piloted at Mercy San Juan Medical Center under the guidance of Dr. Seth Thomas, and at U.C. Davis Health System, under the leadership of Dr. Aimee Moulin (see Dr. Moulin’s article, Stop the Madness: A Smarter Way of Medical Clearance, in this issue). Dr. Amy Barnhorst, an emergency psychiatrist, was instrumental in ensuring a successful implementation at the Sacramento County Mental Health Treatment Center, and Dr. Kevin Jones is leading the implementation team within Sutter Health’s EDs. The work of this group is an example of how SSVMS excels at convening physicians from all specialties and modes of practice to address issues impacting our community. The SMART process, design, and implementation was a collaborative effort between emergency medicine and psychiatric physicians, facilitated by SSVMS. To encourage collaboration between the EDs and the inpatient psychiatric facilities, SSVMS supports a Quality Improvement process that assists with identifying and addressing outliers at both the referring and receiving facilities. SMART Medical Clearance has generated significant interest in medical communities across the state and country. To learn more about the literature behind the development of SMART Medical Clearance, visit www.SMARTMedicalClearance.org. firstname.lastname@example.org
SIERRA SACRAMENTO VALLEY
Stop the Madness A Smarter Way of Medical Clearance
By Aimee Moulin, MD
Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.
“THE PATIENT IS MEDICALLY cleared for psychiatric evaluation and transfer.” I write this statement on multiple charts on every shift. Up until last year, all this statement really meant was the patient had results within normal limits on a CBC and Chem 7. When treating patients with mental illness in the U.C. Davis Medical Center Emergency Department (ED), I’d turn off my clinical brain, click the boxes for CBC, Chem 7, salicylates, acetaminophen, ethanol levels, urine drug screen +/- LFT’s, and the patient and I would wait. I found myself replacing and repeating lownormal potassium levels, trying to thread the normal lab needle to get my patient the psychiatric evaluation they really needed. To speed things up, I’d fire off labs orders before taking a good history. Inevitably, the history you take holding a normal set of lab tests is less careful than it otherwise would be. The system was a set up for error and frustration. The concept of medical clearance is complex and poorly defined. Adding to the confusion, there is discrepancy between professional society guidelines on medical clearance from Psychiatry and Emergency Medicine. This lack of consensus has lead to considerable variation in regional practices. The Sacramento region is unique with de-centralized inpatient psychiatric care and patients that frequently cross health systems. As part of a multi-year effort to improve the care of patients with mental illness in our community, the Sierra Sacramento Valley Medical Society (SSVMS) convened physicians to coordinate a pilot trial of a pathway to standardize medical clearance. The SMART screening tool was designed to apply to patients in
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the ED setting and identify patients who do not need laboratory testing as part of the clinical decision making for medical clearance. Our goal was two-fold – to identify patients with treatable medical conditions as a cause of their symptoms, and to identify patients who were stable to be transferred to an inpatient psychiatric facility without further testing. At U.C. Davis Medical Center, we started with a pilot study of 107 patients referred for a psychiatric evaluation from the ED. Patients were evaluated by physicians using the SMART screening tool while concurrently following the standard process that includes routine lab testing. In our sample only five of the 107 patients (4.7 percent) were admitted to the hospital. In all of these cases the SMART screening tool indicated that further testing was warranted. One of the patients in our pilot was a 47-year-old female with a history of hypothyroidism. She had stopped taking her medications. She was ultimately admitted to the hospital for hypothyroidism on IV levothyroxine. This patient was initially cleared with a normal set of lab tests. However, the doctor who went through the SMART screening tool had noted her history of hypothyroidism and indicated on our SMART pilot forms that thyroid function tests should be checked. In May of 2016, with the help of SSVMS and my colleagues in Social Services and Psychiatry, U.C. Davis implemented the SMART screening tool for medical clearance. To date we have applied the SMART screening tool to 1,252 patients at U.C. Davis with just under 30 percent of patients cleared without a full set of routine labs. Most patients who need treatment in the ED or hospital are readily identified and
are not considered eligible for SMART screening. It’s the disorganized, delusional patient hit by a car in the street who presents as a trauma, or the patient that comes in confused after an overdose that needs treatment in the ED and the hospital. Interestingly, our pediatric patients are the population who are most frequently medically cleared without lab tests. Adolescents and young adult patients with acute mental health crisis benefit the most from the SMART tool. Healthy young patients and families undergoing all the stress and trauma that accompanies an ED visit now don’t have the added pain and delays of lab testing. It has required an ongoing effort, with back and forth communication to refine our process along the way. The tool is purposely vague in some areas to encourage richer clinical decision-making. It leaves room for the patient who doesn’t look well and maybe needs more evaluation, or for a patient with a chronic well-
controlled medical illness to be cleared if they had labs drawn the day before and it is clearly documented in the chart. Screening for drugs of abuse may not change a decision to medically clear a patient in the ED, but may alter disposition from a psychiatry facility. If our colleagues in Social Services or Psychiatry feel like a test will aid in clinical decision-making, I order it and it gets sent. We still send a lot of normal lab tests, but spend more time on clinical decision-making. Patients with mental illness face many barriers to timely, well-coordinated care. The SMART screening tool doesn’t begin to address many of the challenges in our system. However, we have opened lines of communication that were closed before, and have reduced one of the hoops and barriers to acute psychiatric care for patients in our community. email@example.com
Giving What’s Needed There are more ways than ever to help patients in need. Donors have a variety of options to donate blood components that help patients in specific ways. Individuals can give priceless gifts by donating whole blood, red blood cells, platelets, transfusable plasma and source plasma. Emily needed a variety of blood components to help her survive leukemia.
Visit bloodsource.org or call 866.822.5663 to learn more about the best way(s) you are able to help others. Schedule an appointment at a BloodSource Donor Center or mobile blood drive soon. Together, we do save lives.
From SMART to FAST By Amy Barnhorst, MD
Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.
THE EVIDENCE-BASED BEST practices used to develop the SMART Medical Clearance protocol were utilized to develop a tool for non-clinical personnel to use in the field as part of the Sacramento County Mobile Crisis Team program. The Field Assessment and Screening Tool (FAST form) was developed at SSVMS by two emergency medicine physicians and an emergency psychiatrist to expedite access to emergency psychiatric services at Sacramento County’s Intake Stabilization Unit (ISU). The FAST form enables non-clinician members of the Sacramento County Mobile Crisis Team to determine if an individual is appropriate for direct transport to the Sacramento County Inpatient Stabilization Unit. The FAST form is a series of questions designed to identify patients that require further medical evaluation in an Emergency Department. If a patient’s medical issues are not present, or deemed low risk for complications, the Mobile Crisis Team can bypass the ED and transport the patient directly to inpatient care at the Sacramento County ISU. Two entities in Sacramento County currently utilize the FAST form. One is the Mobile Crisis Services Teams (MCSTs), comprised of a county mental health clinician and a law enforcement officer. MCSTs are dispatched to behavioral or psychiatric emergencies in Sacramento County and have been using the FAST form since May 2015. The FAST form is also used by the Sacramento County’s Law Enforcement Consult Line (LECL). When a law enforcement agency has identified an individual who meets criteria for a 5150 hold, a county clinician reviews the FAST form questions with the officer to determine if the individual meets criteria for direct transfer to the ISU. LECL has been using the FAST form process since January 2016. The FAST form has successfully diverted
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NOTE: Dr. Amy Barnhorst, Assistant Clinical Professor, Department of Psychiatry and Behavioral Services, U.C. Davis Medical Center, is an emergency psychiatrist at the Sacramento County Mental Health Treatment.
patients who otherwise would be transported to one of the Sacramento region’s EDs. As of July 2017, MCST transported 150 people directly to the ISU by using the FAST form. Additionally, out of 169 calls to the Law Enforcement Consult Line, law enforcement officers were able to bring 94 patients directly to the ISU, thus avoiding the ED. Between the two programs, a total of 246 individuals circumvented the ED during their psychiatric crisis, and were able to instead access psychiatric care at the ISU. New MCST units are being trained on the FAST process, and it will be rolled out to more law enforcement agencies in the coming year. firstname.lastname@example.org
Do you have a fun travel image that you would like to share in our magazine? Send it in! Dr. George Meyer took this thoughtprovoking photo on a recent trip to England.
Sleep Deprivation – An Unresolved Problem By Lee Welter, MD Guest Editorials are welcome, as are comments regarding the editorials themselves. MORE THAN A DECADE AGO, the Institute of Medicine (IOM) published Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem (https://www.nap.edu/read/11617/chapter/1#xi). Still relatively little has been done to address this problem. Its study is ongoing, but the problems largely remain. The IOM reports that “cost of sleep disorders and sleep deprivation in the United States is hundreds of billions of dollars….Compared to healthy individuals, individuals suffering from sleep loss, sleep disorders, or both, are less productive, have an increased health care utilization, and an increased likelihood of accidents.” The report also states that disasters partially attributed to sleep loss and related performance failures include the tragedy at the Bhopal, India, chemical plant, the nuclear reactor meltdowns at Three Mile Island and Chernobyl, as well as the groundings of the Star Princess cruise ship and the Exxon Valdez oil tanker. One major facet of this problem – shift work, scheduling, and sleep deprivation – lends itself to prompt improvement, though resistance to change is a major obstacle. What problems? “Effects of sleep loss include involuntary microsleeps, and intensive performance is unstable, with increased errors of omission and commission,” according to the report. One dramatic effect was described by sleep researchers at a Human Factors and Ergonomics Society meeting. They had used brainstem-evoked response to demonstrate its delay in demented (aka Organic Brain Syndrome) patients. A medical resident working in the lab had served as a
normal subject. However, one morning after his 24-hour work shift, the resident’s EEG response was indistinguishable from the demented. An even more dramatic consequence is included in a different IOM publication, To Err Is Human - Building a Safer Health System; Chapter 2: Errors in Health Care: A Leading Cause of Death and Injury. The reported Medical Practice Study concludes that more than 70 percent of the adverse events found in this study were thought to be preventable, with the most common types of preventable errors being technical errors, diagnosis, failure to prevent injury, and errors in the use of a drug. The highest proportion of negligent adverse events, 52.6 percent, was in the emergency department. Shockingly, some organizations permit 96-hour work shifts. With much literature describing the hazards, relatively little seems to have been accomplished in mitigating it. The Anesthesia Patient Safety Foundation recognizes the challenge of a one-size-fits-all solution, but does offer recommendations. Stanford University Professor of Anesthesiology, Dr. David Gaba, suggests these: Education, Sleep Hygiene, Fitness for Duty Tests/Standards, Work Schedule Changes and Work Hours Limitations, At-Work Napping, Post-Shift Napping (to avoid car crashes on the trip home), Drug Therapy, and Light Therapy. While the trucking industry, airlines industry, military, and others have made some progress, constructive action in the medical domain is slim to none. Preventable error must be avoided to the greatest extent possible: let’s get it done. email@example.com November/December 2017
Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com. 9
Over the Hill but Worth the Climb A Slovenian Adventure
By Ann Gerhardt, MD
DAY 4: AS I GUTTED my way 4,000 feet up the Vršic pass in Slovenia’s Julian Alps, I practiced Spanish reflexive verbs. My mantra for the seemingly interminable ride was, “Me encantan las colinas” – I love hills. I saved “Me fastidian los grados empinados” – Steep grades annoy me – for the will-crushing inclines which materialized with increasing frequency as I neared the top. I say “gutted” because not too many people would call moving that slowly bicycling. Thankfully, that day was the hardest of a hilly 5.5-day Backroads,“The World’s #1 Active Travel Company,” bicycle trip in far eastern Italy and western Slovenia. While cycling with Backroads in Croatia last year, we learned so much about the former Yugoslavia region’s history that we tacked a fascinating Sarajevo side trip on to that vacation and resolved to see Slovenia this year. Slovenia is nestled between Italy to the west, Austria to the north, Croatia to the south and Hungary to the east. It’s the only country in the region that shows no signs of the bitter 1990’s wars after Yugoslavia’s dissolution. Slovenians anticipated conflict, mobilized defense of their borders and fought for only 10 days before the invading forces pulled out. They, thus, retained a gorgeous country, of which they are very protective. There’s basically no litter, and they recycle most everything. The economy is strong, education and health care are free, and they are part of the European Union, so crossing borders is easy. Our trip started in Aquileia, Italy, with two
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Slovenian guides and eight guests. Of the guests, two were charming young women, one was my uber-fit spousal equivalent, and five were overachieving physicians over the age of 58. One guide joked that an apple a day may keep the doctor away, but not on that trip. The first three days we rode some easy, some hard terrain past idyllic vistas through Friuli and Cividale, Italy and Bovec (pronounced Bovets), Slovenia. Then came day four. One sick millennial and one wise doctor rode the Vršic (pronounced Ver-shech) pass in the van. That left six of us to attack the pass that caused locals to wag their heads in disbelief, especially after seeing how old we are. Over 25 switchbacks the legs burned, the brain mantra-ed and fear kept me from letting speeding cars and fleets of motorcyclists knock me off the bike. Bullheadedness, peanut M&M’s and serious relaxation on the mere 6 percent grades and miraculously level outside edges of some left-hand switchbacks enabled me to finish. I may have finished last, but at 66 yearsold, just finishing sufficed. Those of us who were too scared to ride the steep, cobblestoned descent, took the van to lunch and afternoon cycling. We were rewarded with a lovely stay in Bled on its eponymous lake and a multi-course gourmet dinner in a castle. Day 5 out of Bled was no cake-walk, either, but the reward was lunch at a local farm on Lake Bohinj (Bo-hee-nee), a relatively flat afternoon’s cycle and a tour of Slovenia’s only island. After the tour’s end, we spent another week in Slovenia, a great country for walking, eating
At near left is beautiful Piran, Slovenia at dusk. Below left are Ann Gerhardt and Jim McElroy on top of Vrsic pass. Below right are love padlocks on Triple Bridge in Ljublijana, Slovena.
and people-watching (young Slovenians as a rule are very good looking). We couldn’t stop doing hills: There was a hill or stairs to mount for every castle, park, hike, and Airbnb room in which we stayed. Ljubljana (pronounced Lee-oo-blee-yawn-a) is an incredible city, with a forest of a park, a castle on a hill, summer ski-jumps, bustling outdoor markets full of enticing smells, endless restaurants with outdoor seating, remarkably talented street musicians, and many museums, including ones for puppets and illusions. Usually September is a lovely, touristheavy month. This year’s unseasonable daily rains, however, drove tourists indoors and hurt businesses. After Ljubljana, it was too rainy to
hike the mountains out of Kamnik, so we escaped to Piran, a car-less town on Slovenia’s miniscule coastline. There the rain was somewhat polite in that it never really impeded taking a dip in the Adriatic Sea or going on a long walk. After all, there was always a café in a quaint village in which we could pleasantly wait out the hard downpours. You, too, can enjoy a physical vacation, while allowing someone else to deal with details. There are quite a few companies that will make arrangements for the best route, hotels and luggage transport and others that do all that, plus provide guides, support vans and side tours. Pick your sport, country, level of difficulty and degree of pampering, then have a great time! firstname.lastname@example.org
Letting Go –Saying No to Cancer Treatments By Nan Crussell, SSV Medicine Managing Editor
“IT TURNS OUT THAT I’m hard to kill,” jokes my husband, having successfully battled several kinds of cancer over the last 17 years. This time we aren’t so lucky. This is our story about metastatic cancer and going it alone without chemo and radiation. Perhaps I could have told it as a flashback, but I don’t know how it ends. So, I will begin our journey as a travelogue, a trip for two, not knowing exactly where we are headed, but we’re on our way. My husband, Bob, has dealt successfully with several types of cancer since 2000. They included three melanomas, two bouts with bladder cancer, and Mohs surgery for squamous cell cancer on his face, neck and scalp. All three melanomas were removed with surgery and removal of some lymph nodes. I learned how to deal with neck drains and urinary catheters at home following bladder surgery. We learned that maintaining a careful height range of that catheter was important. Raise it too high and the urine flows back into the body. Carry it low and the bag spills its contents. Oh well, I have raised babies and cleaned up worse spills than urine. Bob’s first bladder cancer was removed surgically just before bleeding became a true emergency. A tumor had formed within a diverticulum in the bladder, and he had heavy bleeding with urination. Since the surgeon told us he probably didn’t “get it all” due to the bleeding, we were not surprised when it came back within four years. One more surgery and he has had no problems since. So, when the squamous cell tumor on his scalp that was removed via Mohs came right back, we faced our first “failure.” Hmm. We
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were afraid of melanoma, but not squamous cell cancer. So, not wanting to do Mohs again, Bob asked the dermatologist to just “plane” off this repeat offender. A large bandage as a headdress was his attire for a while. Within a few months it came back again, along with several more tumors around it. That was summer time. By Christmas and New Year’s, Bob said he could feel a lump at the back of his jaw, under his ear. I felt for it, but found nothing. No pain, he said, no worries. By June, I could see the lump. It was about ping-pong ball size and was hard and immoveable. It sounded like classic cancer signs. This time we were sent to an ENT. CAT scans and PET scans showed not one cancerous growth, but two, in his parotid gland and in the area behind the ear. The ENT advised removal of the parotid. He would make every effort not to cut the facial nerve that runs through it. If you cut that nerve, he explained, you wind up with Bell’s Palsy, or its twin. Bob wouldn’t be able to smile, wrinkle his nose or close his eyes. “There’s a lot I don’t want to see,” Bob joked. “Not to worry,” said the surgeon. “We can implant little gold weights into your eyelids to make them close.” Yeah, right. This cancer was going to be tough. But we had sailed through the other incidents, and we’d deal with this one. Bob agreed to the surgery and, as I had been with him through the many previous operations, I was there for this one. When the ENT came to find me in the waiting area after the surgery, he looked serious. He couldn’t remove the entire tumor and had to leave positive margins. It had also spread to two lymph nodes and he suspected it was in the nerves under the scalp. A little humor came to my mind, perhaps
as a defense mechanism. When a friend of mine many years ago developed a lump in her breast, her husband implored the doctor to start a lump growing in her other breast! But try as I may, the only light statement I could come up with was something about doing a matching facelift on his other side. Metastatic squamous cell cancer of the head and neck was the official diagnosis. Indeed, our lives were about to change. Without chemo and radiation, the attending radiologist and oncologist said Bob could be dead in six months. Six months. But chemo could give us two to three more years – maybe. Those would not be fun years, by any means. “It would be brutal,” stated the radiologist, “but I believe I can get you through it.” A feeding tube would be a reality, as would a breathing tube. Since the growths were in the head and neck, that feeding tube could become permanent if the tumor prevented swallowing. And, there might well be areas of exposed bone on the skull that would not heal. Good Halloween costume, that’s for sure. And Thanksgiving dinner through a straw? For a man Bob’s size, he would probably lose 35 pounds. Five or ten would be acceptable, but not 35. There comes a time for all of us when enough is enough. In the Sept-Oct 2015 issue of SSV Medicine, Dr. Nate Hitzeman reviewed a book by Dr. Atul Gawande entitled, “Being Mortal – Medicine and What Matters in the End.” Bob and I both read it, and it has become our Bible. In this very honest tome, the author points out that there are things the medical community cannot fix, like old age, for example. And in many serious illnesses, the treatments often not only make the patient worse, but they shorten the time remaining. Bob and I both agreed on the premises in Dr. Gawande’s writing. We spent many days and nights talking about what to do, and when he decided to turn down chemo and radiation, I totally understood. For Bob, living life on his own terms would give him strength. In his strength I would find strength. Our new journey had begun. We have been to Paris and Rome and London and many, many beautiful parts of the world together. We will travel this
Nan and Bob Crussell during healthier days preparing for the Portland Marathon.
new road together, too. That long day’s journey into night. We got our wills in place. We filled out POLST (Physician Orders for Life-Sustaining Treatment) and DNR forms. We told the kids the truth. Then we got on with our lives. The predicted death date of six months passed, and so did another six months. Bob was admitted to Hospice, but after a couple of weeks, he wanted out. It was too restrictive, and he was not ready to spend his days on the sofa wrapped in a prayer shawl. He still wanted to ride the tractor and work in the yard. He still wanted to travel. Then, via one of his doctors, we were introduced to the Advanced Illness Management (AIM) program through Sutter Health (www. sutterhealth.org/quality/focus/advanced-illnessmanagement.html.) This fairly new program helps patients take control of their health so they can focus more on their lives, not on their pending death. It’s a perfect fit for us. We have nurses available via telesupport 24/7, and they also will come to our home as needed. The physician, Dr. Mark Knoble, runs both the Hospice and AIM programs for Sutter in our area, and explains that AIM offers support not just for the
We have a new word in our vocabulary – palliative.
patient, but also for the family. Indeed, when the nurses call us, they inquire about how each of us is doing, physically as well as mentally. Bob decided to start his “never-ending farewell tour,” like Cher. A tumor had already crushed one ear canal, and we were worried about flying in a pressurized cabin. Our doctor thought his eustachian tube could handle it, so we took off for Nova Scotia to visit family. No problem flying, so we took off again for Las Vegas to see the grandkids. He had been a runner in his earlier years, having two marathons under his belt and, by gosh, he would keep running now. We entered the Fab 40’s 5k Run benefitting the Alzheimer’s Association in July in downtown Sacramento, and he won third place in his age group! Pretty heady stuff, completing a race seven months after doctors predicted he would succumb to cancer having said no to debilitating treatment! “You get busy living or you get busy dying,” we decided. Much like the old Ernest Borgnine movie, “Marty,” we ask each other every day, “What do you want to do today?” He has been taken off most of his old medicines for blood pressure and cholesterol, figuring that it’s pretty
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silly to be worrying about having a heart attack now. Actually, a heart attack isn’t so scary anymore. Old runners often say that if you have chest pains while running, “Run faster.” We have a new word in our vocabulary – palliative. Bob has been blessed in that, so far, he is not in any pain. The AIM program, as well as Hospice, is aimed at symptom management, so he will be given pain killers when needed. His diet is pretty much the same as before. He has not lost any weight, and he still welcomes his favorite martini from time to time, not through a feeding tube. He may try some palliative radiation to attempt shrinking a tumor or two, but it won’t be the seven weeks of daily zaps. Each day is a gift now. Many people never get the chance to say “goodbye,” so we consider ourselves very lucky. For the 40+ years we have known each other, I have always admired him. Perhaps now more than ever. He has chosen the highest quality of life, and I get to share that proof that the run is much more important than the finish line. email@example.com
Making the Decision By Robert Crussell INTELLECTUALLY, THE DECISION not to pursue parotid gland cancer treatment wasn’t very hard to make. The emotional justification, however, was much harder to deal with. After some six months of wondering about the growing bump on my cheek, I stopped in for a visit with my primary care doctor. He sent me on to the ENT who performed a guided needle biopsy that showed metastatic squamous cell cancer. The treatment offered was for surgery on the parotid gland followed by seven weeks of radiation therapy, five days a week – weekends and holidays off, and then on to the oncologist for the requisite chemotherapy. I have a limited knowledge of cancer and its treatment, and almost all of that was the result of losing my mother to throat cancer, my father to Multiple Myeloma, and my first wife, Pattie, to breast cancer which metastasized to bone cancer. All three died while under care, Mom after six months and Dad after three years. Pattie lived a total of seven years after first being diagnosed, so she is listed in the “cure” column. I was involved in the care of all three, really just a little with my mom, but my dad spent his last couple of years with us, and I was totally involved with Pattie. I recall sitting at the kitchen table talking to Pattie just after Dad had passed, and hearing her say, “If that had been Dude (the family dog), we wouldn’t have done that to him.” It was her way of saying that the last months of my dad’s life weren’t worth what he had to endure to experience them. Watching loved ones suffer through the last phases of life, enduring the misery that goes with prolonging life beyond the point where it makes any sense, made me reluctant to begin my own treatment. If “horns of a dilemma” means that you are down to two choices and they are both bad, then
that’s exactly where I was. I had some commitments that required me being on my feet for the next six months. I remembered how difficult it was to care for Dad and Pattie, and I didn’t want to become a burden for Nan. We would have to dispose of our home and find a place that didn’t require so much outside upkeep. The suggested treatment schedule called for radiation to begin a couple of weeks after surgery, and that would only give us a month to get everything done before I was going to be sick. There was no way to know for sure how much time denying treatment would give us, so we decided to do the surgery. In a way, it was procrastination on making the decision to begin radiation and chemo. I have had a couple of surgery experiences and I have always healed well, and the surgeon promised to try to avoid much collateral damage. The surgery went well, but exposed some residual poorly differentiated cancer. Nan and I talked it over during the two weeks after surgery and made the decision to cease treatment at that point. The specter of the side effects of the available treatment proved to be too daunting for me to contend with. Nan and I were advised by the medical specialists that it would be foolish to give up without a fight, and I agree. But the notion of fighting back by making me weaker seemed counterintuitive. It seemed to us that I should be trying to make myself stronger. We were in a spot! Now that we had made up our minds, at least about what not to do, how do we get away from worrying about whether or not we had made the right choice? And then Nan brought up the review from the September/October 2015 issue of SSV Medicine by Dr. Nate Hitzeman on Atul Gawande’s book, “Being Mortal.” I was intrigued by the review and fascinated by the book. There
are “take aways” on every page, and I eagerly sucked up every fact or notion that supported our choice of action: “No one has come up with a cure for old age.” “There are some things that the doctor can’t fix, and sometimes the treatments can make the patient’s life unbearable – and maybe shorten it.” “There is a point at which death becomes inevitable.”
There are some things that the doctor can’t fix… I had found a person in the medical community who would understand that I saw the treatment being offered to me as harmful. I was looking for things that would be good for me, in the sense that a slice of fresh apple would be good for me, and I was finding none. It became apparent that if I undertook the radiation and oncology, I would never again in my life feel as good as I did on the day I started treatment. I had already decided on the trade-offs that I was willing to make, and the quality of life I was willing to accept. This dilemma was solved, simply enough, by my suffering a TIA one evening last fall and having no idea of what was going on. A rotating MD assigned to my regular doctor’s office a couple of days a week asked us if we were involved with Sutter’s Advanced Illness Management program. Neither Nan nor I had ever heard of it. “With your diagnosis, you would probably be a good candidate,” she said. “Would you like me to refer you?” AIM turned out to be tailor made for Nan and me. We have come to think of the people who make up my care team as personal friends who are familiar with my concerns, where and how we live, what our preferences are, and they are able to address both my physical and our emotional needs. At present, I don’t require much in the way of hands-on care, but we have a lot of concerns about what is going to happen next and what we should do about it. We don’t know what the questions will be yet, but we
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know they will be coming, and we will probably need to have some answers very quickly. AIM has a 24/7 telesupport service which provides us with a triage nurse at the touch of a phone. And if we don’t call them, they call us. Every couple of weeks, I look for a call from my telesupport nurse checking up on how things are going. How am I feeling? Are there any changes? I have come to look forward to our discussions and to receiving the support and advice. Recently, I had a conflict on my calendar. Nan and I had signed up to run a 5k race in Sacramento, but on the same day I was asked to be at a memorial service for a friend. I was in a bit of a quandary, having trouble deciding, when my care team representative called to check on me. This is a woman who answers hard questions every day, so why not let her have a vote? “Hey Karen, what do you think I ought to do, which one would you go to?” It only took a moment for her to reply: “Well, things being what they are, I’d suggest that you attend whichever event you think would make the best memories for Nan.” Thank you, Karen. I have been involved in the last days of three people whom I dearly loved. Each died only after what I have come to regard as an unnecessarily prolonged, hyper-expensive, and ultimately futile series of hospital visits. Each begged me to take them home. I wish that I had, but at the time it seemed the wrong thing to do. I write this on the eve of my birthday. Another milestone in a life that has been long, and good. In the morning, I plan to start the day with one of life’s simple pleasures, an easy jog along an oak-shaded foothill country road near our home. Who knows, maybe trying to keep my heart and lungs functioning will be a beneficial thing. And as I go, I can mull over one of the lines that I just noticed in the jacket liner of “Being Mortal” … “the ultimate goal is not a good death but a good life – all the way to the very end.” firstname.lastname@example.org
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Volunteering as a Ski Patrol Physician By Jack G. Bruner, MD
WHEN I FIRST ARRIVED in Sacramento in 1969 to begin my career as a plastic surgeon, my family and I were very involved in the sport of Alpine skiing. Little did I know that, in time, I would become a member and eventually the director of the Alpine Meadows Doctor Ski Patrol, a member of the National Ski Patrol and lastly, a physician member of the U.S. Olympic Ski & Snowboard Team. No doubt, the time spent in training and going forward to become a physician ski patroller has been a life-changing experience. At the very least it has been exciting, challenging, and greatly rewarding! Here is a brief account of what is involved and how I became a physician ski patrolman. Soon after arriving in Sacramento in 1969, my wife, Annemarie, my two children (Paul and Susanne), and I became frequent skiers and very involved at the Alpine Meadows Ski Resort. It was no surprise that Annemarie immediately became a professional ski instructor, as she grew up skiing much of her life in Sweden. Our children joined the Alpine Meadows ski racing teams. They had become excellent skiers by age four. This left me to deal with the prospects of becoming the best skier that I could be. Truly, if one says that starting to ski during your mid-30s is challenging, that is a supreme understatement. Accordingly, after numerous lessons, practicing on a variety of ski terrains, and skiing with advanced skiers during the spring of 1971, my skiing skills greatly improved. I was finally able to pass all of the requirements to become a physician member of the Alpine Meadows Doctor Ski Patrol.
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As a new ski patrol doctor, I was required to complete special on-the-hill training to learn to deal with a variety of injuries and medical problems commonly seen at ski areas. First, as a ski patrol doctor, one must learn to “ski anytime, anywhere,” if necessary, to get to a ski injury site located on any part of the mountain. We are required to act as first responders in case we come upon an injured skier. By then, we have learned how to perform an on-the-hill exam, how to commence with the appropriate treatment, and, subsequently, how to make a radio request for the additional equipment and assistance as needed. Understandably, there is an overabundance of injuries or illnesses that can be encountered under these circumstances. Finally, patrollers must then determine the best form of transport off the hill. This is usually via a ski toboggan. But at times, lifeflight by helicopter assistance is necessary. The ski toboggan transport to the first aid room is managed by a National or Professional Ski Patrol member, as they will arrive to assist at the ski injury site soon after it is called in. Whereas, we, as physician patrollers, are involved in helping with injured victims on the ski slopes, much of our direct assistance to injured ski victims actually occurs in the ski area first aid room. Most often, the first time we meet an injured victim is when they are delivered to the first aid room via a ski toboggan. Also, at times, injured victims are simply able to walk into the first aid room. Again, on any given patrol day, as physician patrollers, we are presented with a variety of joint and long bone injures, back problems, head injuries, sprains, dislocations, and a
plethora of medical problems. Fortunately, welldesigned protocols have been established over the years, giving guidelines on how to deal with many of these injuries or medical problems. Additionally, it is thought that our very presence in the first aid room as health care professionals gives greater consolation to victims and their families. It is in this setting that we work closely with highly-skilled nurses, EMTs, and both National and Professional ski patrollers. There is no doubt that, collectively, we make a great team, offering a skillful, safe, and professional service. Yes, we are helpful and relevant as physician ski patrollers; however, if one chooses to go forward to become a National Ski patrolman who deals with additional untoward events, it involves quite a bit more commitment and training. These additional events can include assisting with avalanche rescues, chairlift evacuation procedures, running ski toboggans, and assisting with search and rescue activities as a means to recover missing persons, just to name a few. Accordingly, I spent a ski season training to pass the National Ski Patrol exam, and then another few months training to become a Senior National Ski Patroller. All of this training has paid off as I have been involved in a number of rescues of different sorts over the years. On one occasion, I belayed down a cliff using mountaineering techniques to treat an acutely injured lady and prepare her for transport. Then, there were times when I was involved with a “hasty search” team. This is a group of patrollers carrying special equipment who are dispatched immediately to go to an avalanche zone to search for survivors. Further, there are those times when we must deal with “missing persons” scenarios, when someone is reported missing, either in the ski area, or out of bounds. The latter, a more serious situation, might require an overnight search and rescue (S&R) effort. So, one must obtain additional training to get involved as a rescuer by taking special out-of-doors training taught by experts in S&R techniques. This can typically last for four or five
days. During my training, I was taught a variety of ways to treat these injured victims, and then transport them safely out of the wilderness. Also, what is really fun is that we get to work with rescue dogs. I can adamantly say that being involved in all of this has been a memorable, valued, and daunting experience. As a volunteer physician being involved as a ski patrolman, I feel relevant, appreciated and, that simply by being there, I can truly make a difference. In addition to my experiences as a physician ski patroller at Alpine Meadows, I also had the pleasure of being recruited to serve as a physician member of the U.S. Olympic Ski & Board Team during the 1980s. This gave me the opportunity to ski most major ski areas in both eastern and western Europe, as well as to attend a lot of World Cup ski events here in the U.S. Clearly, I came away from this experience with an enormous amount of pride and great memories. Currently, I am the Director of the Doctor Ski Patrol at Alpine Meadows and have been for many years. In that capacity, I am always interested in recruiting physicians who might be interested in training and serving as physician ski patrollers. As a requirement, a physician must be an advanced skier and be board certified in a surgical specialty. Or, if not a surgeon, one
As a ski patrol doctor, one must learn to “ski anytime, anywhere,” if necessary, to get to a ski injury site located on any part of the mountain. This photo is of Alpine Meadows.
continued on page 21
Destiny of the Republic A Tale of Madness, Medicine and the Murder of a President, by Candice Millard; Publisher Doubleday, 2011; ISBN: 978-0-385-52626-5
Reviewed By Kent Perryman, Ph.D.
OHIO SENATOR JAMES A. Garfield reluctantly accepted his nomination at the Republican Convention in 1880 for the 20th President of the United States after neither candidate, Secretary of the Treasury John Sherman, Ulysses S. Grant, nor James G. Blain, could obtain enough votes to secure the nomination. The author, Candice Millard, emphasizes that Garfield’s modest, low-keyed campaign enabled him to defeat his Democratic opponent, Winfield Scott Hancock. As a Union General during the American Civil War, Garfield was a popular candidate with both the Northern and Southern voters. What truly captures the reader’s attention from the author’s narrative of this text of the President’s brief tenure takes place after his attempted assassination shortly after assuming office. On July 2nd, 1881 while Garfield was attempting to board a train for Boston at the Baltimore and Potomac Railroad Station in Washington, D.C., Charles J. Guiteau, a delusional office-seeker believing he was doing God’s work, discharged two rounds from his .44 caliber handgun into the President. The first bullet penetrated his right arm and the second struck his back. Several physicians were immediately alerted by Patrick Kearney, a Washington Metropolitan police officer, who had escorted the President from the White House in a separate carriage, and Sarah White, the matron for the ladies waiting room. The author points out that during this time there were no Secret Service agents assigned to protect the President; the Secret Service’s main function was to secure counterfeit currency. One of the ticket agents,
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Robert Parks, quickly apprehended Guiteau where he was transferred to the district jail by Washington detectives. Guiteau’s gunshots were not fatal. The second bullet had entered the back four inches to the right of the spinal column, continuing its trajectory towards the left, lodging just behind the pancreas. Two of Garfield’s ribs were grazed, but no major arteries were damaged. The first medical doctor to arrive was the District of Columbia’s health officer, Smith Townsend, followed within the hour by nine more physicians. During this time, the President remained lying on the station floor while Dr. Townsend examined him, an action which sealed Garfield’s fate. After removing the President’s jacket and shirt, Townsend inserted his finger into the back wound entry probing for the bullet and introducing unknown contaminants that would later be more hazardous to Garfield’s health care than the actual bullet. At this point the reader appreciates the author’s medical knowledge when she explains the American medical culture’s lack of appreciation during the 19th century for germ theory and antiseptic surgery. Most of the established medical practitioners, referred to at the time as “allopaths,” were hesitant to accept James Lister’s use of carbolic acid as an antiseptic to discourage contamination or Louis Pasteur’s “germ theory” and they resorted to the ancient practice of heroic medicine. The Secretary of War, Robert Todd Lincoln, son of Abraham Lincoln, was also summoned to the train station where he requested Dr. Willard Bliss, Lincoln’s personal physician
at the time of his assassination. Garfield was friends with Bliss and supported his reinstatement into the D.C. Medical Society after his disbarment. Bliss had the President moved upstairs above the railway platform where he continued to explore the external wound entry with both his finger and a wooden probe. Eventually, Garfield was moved to his White House living quarters where he could sit up in bed and be nourished on oatmeal porridge and milk from a nearby cow. Bliss was secure in his belief that the bullet was lodged near the liver on the patient’s right side. Alexander Graham Bell believed he would be able to locate the lead bullet using a device he constructed from coils of wire and a telephone receiver that he called an “induction balance.” Several failed attempts at localizing the bullets using Bell’s crude metal detector can be attributed to Bliss’s restriction to examine only the President’s right side. Garfield’s health continued to slowly languish with copious discharges of pus exiting through drainage tubes placed in the wound opening, and his temperature eventually reaching 104 degrees. The infection spread to other regions of his body, including a large abscess in his neck. The author also points out what a deplorable condition the White House was at this time. There was no cooling system at a time when summer temperatures in Washington reached 100 degrees with high humidity. The Navy brought in blocks of ice that were placed around Garfield’s bed, which at times would lower the temperature down to
80 degrees. President Garfield succumbed to his widespread infections at 10:35 p.m. on September 18, 1881. Garfield had survived 79 days from his injury when he died of septicemia. An autopsy revealed that the bullet was encapsulated behind the pancreas where it posed no threat to his health. The assassin, Charles Guiteau, was tried in a court of law, convicted of murder and hung a year from the date he attempted to kill the President. There was some doubt as to his mental status, but there was also a lynch-mob desire that he be executed at the time, due to Garfield’s popularity. It is now the opinion of some historians that the medical establishment at the time bears some responsibility for Garfield’s death. The author, Candice Millard, suggests that one positive outcome from Garfield’s death is that, during the period of reconstruction following the Civil War, the North and South were all brought together and united as Americans. She compiled a detailed account on President Garfield, as well as on his family and friends, and provides the reader with considerable insight into this historic time period and its medical culture. The author certainly gives the reader an appreciation for living in the 21st century when it comes to medical care. This reviewer highly recommends this text to any medical professional or lay person for its insightful historical perspective.
An autopsy revealed that the bullet was encapsulated behind the pancreas where it posed no threat to his health.
Ski Patrol continued from page 19 must be substantially involved in emergency room medicine. Physician members are required to patrol during weekends and holidays for a total of 14 days. There are other benefits such as season passes and some discounts. If there are any
physician colleagues who clearly have the mountaineering spirit, and who would like to learn more about how to become a ski patrol physician, please feel free to contact me. email@example.com
Evolution of the Stethoscope By Matthew Huh Editor’s/SSVMS Museum Curator’s note: Matthew is an 11th grade student at Mira Loma High School who has done several historical reviews on artifacts in our Museum of Medical History. This is an abridged version of one of the extensive illustrated publications he did. The photos accompanying the article are of stethoscopes from our museum collection.
The stethoscope may be the most recognizable instrument representing the physician. From 1976-2000 in the U.S., there have been 318 patents related to the stethoscope. Modifications relied on trial and error, but it was the introduction of vulcanized rubber, and later plastics, that transformed the stethoscope from a rigid to a flexible one. Prior to its invention, examination of patients relied on immediate auscultation, which was essentially placing an ear on the patient’s chest and listening directly to the heart and lungs. The stethoscope eliminated the need to shake the patient, as Hippocrates did, to listen to the succussion splash that would diagnosis empyema, a collection of pus and fluid in the lung cavity. Rene Theophile Hyacinthe Laennec, a French physician, in 1816 is credited for inventing the first stethoscope. Examining a female patient by putting an ear to her chest could be awkward, so in a burst of inspiration, Laennec took his student’s notebook, rolled it up into a cylinder and listened to her chest. He was inspired by the memories of children listening at one end of a beam of wood to hear the sound as another child rubbed the opposite end.
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Laennec called his invention le cylindre (the tube). He later chose the name “stethoscope” for Greek “stethos” (chest) and “scope” (to observe.) He was also the first to describe the auscultator signs still used in medicine today. He coined terms such as “bruit” (turbulent sound over an artery), “râles” (crackling noise in the lung) and “egophony” (a resonant sound in the lung indicating pneumonia). His stethoscope allowed him to study many diseases of the chest, including tuberculosis, which caused his own death in 1826. By this time, the stethoscope was used almost universally in France and Germany. Pierre Adolphe Piorry, another French physician, in 1828 reduced Laennec’s stethoscope to about half the size, and used a narrow tube instead of a thick cylinder. It was composed of wood and ivory, and was trumpet shaped. The earpiece and chest piece were made of ivory. Most stethoscopes made after 1830 were modeled after the Piorry design. Austin Flint (1812-1886), an American physician, was dubbed the “American Laennec.” He was a founder of Buffalo Medical College, the precursor to the State University of New York at Buffalo, and he also served as president of the American Medical Association. Flint continued to evolve the art of physical diagnosis, especially percussion and auscultation, that was started earlier by Leopold Auenbrugger and Rene Laennec. He was a very influential physician and wrote “A Manual of Percussion and Auscultation.” 1829 – Nicholas Comins, an Edinburgh physician, was the first to build a “non-rigid stethoscope” which was jointed, allowing the physician to listen from a variety of positions.
He also was the first to suggest a binaural device. 1830 – Charles James Blasius Williams, an English physician (1805-1889), was one of the first to hear an atrial sound, and is credited with the term, “lub dupp.” He designed a trumpet-shaped monaural stethoscope and an early diaphragm chest piece that was more comfortable and provided better contact with the chest. However, it was awkward to use and never became popular. He also designed a binaural stethoscope with a mahogany chest piece and two bent lead tubes for ear pieces. 1841 – Golding Bird, a British medical doctor and a Fellow of the Royal College of Physicians, improved the design by modifying the monaural into a fully flexible one, consisting of tubes of coiled spring covered with woven silk, usually 14 to 18 inches long. 1851 – Arthur Leared, an Irish physician, invented a binaural stethoscope that was displayed at the Great Exhibition in London in 1851. 1851–1852 – Though Nathan Marsh, a Cincinnati physician, patented the first commercially available binaural rubber stethoscope, George P. Cammann, a New York physician, introduced the first practical binaural stethoscope made of ivory earpieces connected to metal tubes. He never patented his design because he believed it should be freely available to all doctors. 1859 – S. Scott Alison, a London-based physician, modified the Cammann stethoscope into the differential stethoscope, consisting of two independent chest pieces, which allowed the physician to listen to two different areas of the chest. It was impractical because it muffled certain sounds. 1880s – Adolphe Pinard (1844–1934), a French obstetrician and pioneer of perinatal care, invented the fetal stethoscope that rapidly became the stethoscope of choice for obstetrics. 1880s – The Lynch folding stethoscope folded onto itself and greatly reduced its length. 1885 – Charles Denison (1845-1909), an American physician, published a list of the essential requirements of a good stethoscope 1894 – Eugenio Bazzi, an Italian physicist,
and Aurelio Bianchi, a Professor of Pathology developed the Phonendoscope, the first stethoscope to incorporate the use of a rigid diaphragm membrane. It was completely collapsible and measured only three inches in diameter. The small chest piece could fit between the ribs and could convey better sounds. Its use never became widespread 1894 – Robert C.M. Bowles, a physician and engineer, patented the modern diaphragm which was on the surface of the chest piece for better contact. He also incorporated a non-compressible stem that prevented bending and interrupting sound to the earpieces, and allowed physicians to listen without requiring patients to remove their clothing, a useful concept in the Victorian era. This combination is used today. 1896 – Marsh’s Stethophone had a small dial on the back with a pointer and the letters “L,” “S,” and “W.” These stood for “Loud,” “Soft” and “Weak.” The examiner would dial in the type of sound he was listening to, to hear it better. 1913 – Fleisher Stethoscope. This stethoscope was developed by Andrew W. “Doc” Fleischer, a pharmacist who joined Becton Dickinson and Company in 1921. He improved the stethoscope, developing one that reduced extraneous sounds and allowed physicians to monitor heart sounds more accurately. 1925 – The Western electric 3A stethoscope weighed 14 pounds. It was a modified telephone receiver that, when placed on the chest, amplified the sounds. It was developed years earlier for a medical student with poor hearing. Amplified stethoscopes were abandoned until Hewlett Packard introduced their electronic stethoscope, the Stethos. 1926 – Howard B. Sprague, a Boston physician, combined the bell with the diaphragm in one chest piece. 1940 – William J. Kerr’s Symballophone. Dr. Kerr was the first full-time Professor and Chair of the Department of Medicine at the University of California San Francisco (UCSF) School of Medicine in 1927. His patent for the symballophone highlighted two diaphragms.
Charles James Blasius Williams, an English physician (1805-1889), was one of the first to hear an atrial sound, and is credited with the term, “lub dupp.”
1 Biazzi stethoscope
2 Littman stethoscope 3 Bowles-Pilling combination stethoscope 4 Early wooden stethoscope 5 Kehler stethoscope
6 William J. Kerrâ€™s Symballophone 7 Lynch folding stethoscope
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Sounds from either could be heard in both ears so that the examiner could compare sounds from different parts of the chest. 1948 – Maico Stethtron. The next step in evolution was adding electronic amplifiers. They were capable of filtering high-pitched tones to make faint tones louder, and some could provide visual or audio recordings. 1961 – Dr. David Littman was a distinguished cardiologist and international authority on electrocardiography. His 1961 article in the Journal of the American Medical Association described the ideal stethoscope as an “open chest piece for the appreciation of low-pitched sounds, a closed chest piece with a stiff plastic diaphragm to filter out low-pitched sounds, firm tubing with a single lumen bore, the shortest practical overall length, a spring with precise tension to hold the ear tubes apart, and it should be light and convenient to carry and use.” It rapidly became the stethoscope of choice in America and is still the gold standard today. In the late 1960s, 3M acquired the company and, in 1995, developed the electronic version. None of the previous electronic stethoscopes developed since the 1950s had been commercially successful. 1998 – The 3M Littman Electronic Stethoscope Model 2000 was launched and, shortly thereafter, the Model 4000, the first electronic stethoscope that could wirelessly transmit sounds to a computer. It also featured a small LCD window that displayed the patient’s heart rate in real time. 2010 – The 3M Littman Scopeto-Scope Tele-Auscultation System allows remote diagnostics. Physicians can even speak to each other through the stethoscope. 2015 – Loubani 3D-printed stethoscopes were developed by Dr. Tarek Loubani, an emergency physician working in the Gaza Strip, because of their short supply of cost-
effective medical equipment. It was inspired by his nephew’s toy stethoscope that performed much better than he expected. They discovered that it performed as well as the gold standard Littmann Cardiology 3 stethoscope. This “Glia project” was born in 2012. The 3D-printed device, now available as an open source model, can be printed for about $2-$5. 2015 iPhone apps such as the iStethoscope Pro turn your iPhone into a stethoscope. The app utilizes the built in microphone in the iPhone and provides a spectrogram of the audio. It can even email the sound in different formats. Although not currently intended as a true medical device, the technology is entertaining and has potential for future development in the field. firstname.lastname@example.org REFERENCES Over a dozen sources were cited in this article. The list is available upon request from the author.
Imagine a Financial Partner You Can Trust Families and businesses have relied on our financial advice and services since 1919. And because Baird is employee-owned, you can trust we’re focused on only your best interests. Patty M. Estopinal, CIMA®, CDFA 916-783-6554 . 877-792-3667 pattyestopinal.com | email@example.com Investment Management Consultants Association is the owner of the certification mark “CIMA®” and the service marks “Certified Investment Management AnalystSM,” “Investment Management Consultants AssociationSM” and “IMCA®.” Use of CIMA® or Certified Investment Management AnalystSM signifies that the user has successfully completed IMCA’s initial and ongoing credentialing requirements for investment management consultants. ©2017 Robert W. Baird & Co. Member SIPC. MC-100308.
Leprosy – Almost a Disease of the Past By Glennah Trochet, MD
WHILE TRAVELING WITH FRIENDS on a tour of Scandinavia this past summer, we had a few free hours in Bergen, Norway, some of which we filled by visiting a little-known museum dedicated to the history of leprosy. The museum, formerly St. George’s Hospital, was once one of three leprosy hospitals in Bergen. There has been a hospital on these grounds since the 1400s. The last two patients with leprosy died in 1946. They had lived at St. George’s for more than 50 years. The inside of the building is fairly dark, with cell-like rooms lining the walls on both levels of the main building. As one moves from one exhibit to the other, one learns the history of leprosy in Norway, and how Dr. Gerhard Armauer Hansen discovered that this was a contagious disease, and not a hereditary one, as was widely thought before then. Dr. Hansen started the first patient registry in the world, insisting that all patients with leprosy in Norway be inscribed. By studying the geographic location of patients with leprosy, he began to suspect that this was an infectious disease. He further proved this by staining material from biopsies of lepromatous nodules and seeing rod-like bacteria under the microscope. He tried to prove that this was the causative organism of leprosy, but was unable to grow the bacteria in the laboratory or to infect animals with the material. During one experiment, he then injected the cornea of a patient with mild disease with material from another patient who had a more aggressive course. No harm came to the patient, but it was done without her consent. This led to prosecution and Hansen was banned from
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practicing medicine for life. He continued to be the medical officer for leprosy in Norway, but died before anyone was able to grow the bacillus in a laboratory. The museum in Bergen describes this history as one observes the artifacts of daily life that the residents of the hospital used, as well as some of the medical instruments used. On the second floor, some of the cells have the history of individual patients. These are heart-wrenching accounts of ordinary people who were brought to this hospital and stayed until they died. There is also a kitchen with a wood stove, and one sees the table in the main hall of the first floor where, presumably, meals were served. Next to the hospital is a church that is opened once an hour for a few minutes. We were told that people who lived in the parish worshiped in this church, as well as the patients from the hospital. The visit takes about an hour. All the exhibits are labeled in Norwegian, but there is a handout with the English translation
that one can borrow. As we left the hospital, we remembered how the words “leprosy” and “leper” have such negative connotations and are used to describe people who are societal outcasts or despised in general. Most medical texts now refer to the disease as Hansen’s disease and it is now curable, obviating the need, if there ever was, of isolating those who suffer from it. Hansen’s disease is caused by Mycobacterium leprae, a very slow-growing bacterium that affects the skin and peripheral nerves. The disease is now classified by its manifestations into three groups: 1. Paucibacillary or Tuberculoid disease, which manifests itself by peripheral neuropathy resulting in loss of sensation and skin manifestations of either hyperpigmentation or hypopigmentation. Sometimes there is swelling of the peripheral nerves that can be palpated under the skin. 2. Multibacillary or lepromatous, which is manifested by more generalized involvement of the skin, with nodules that can ulcerate. There may not be loss of sensation, but the ulcers frequently involve the nasal mucosa, resulting in collapse of the nasal bridge and frequent nosebleeds. 3. Borderline or dimorphous disease, which can cause nodules or patches throughout the body, sometimes with loss of sensation due to involvement of the peripheral nerves. This is the most common manifestation of the disease. The disease is now treated with two or three antibiotics (dapsone, rifampicin and clofazimine) for about two years, and can be cured if the medication is taken regularly. During my research for this article, I discovered that there is also a Leprosy Museum in the continental United States located in Carville, Louisiana, site of the only hospital dedicated to the housing of patients with the disease in the United States. Until effective treatment became available in the middle of the 20th century, people with Hansen’s disease were required to live in Carville. The patients at Carville were the first to advocate for changing
the name of the disease from leprosy to Hansen’s disease. Also, not to be forgotten is Kalaupapa National Historical Park in Molokai, Hawaii. It was once an isolated community where people with Hansen’s disease were sent. In 1969, forced isolation for patients with Hansen’s disease was eliminated. There are still residents in the community who choose to live there. The National Park Service maintains some of the buildings that were there when it became a national park, as well as roads, markers and a museum collection that illustrates the life of forced separation that was lived there. This is still an active community where residents enjoy a slower pace of life than in other parts of Hawaii. In the United States, leprosy is reportable to the local health department. The National Hansen’s Disease Program has special clinics in every state where these patients can have access to experts in the disease. The closest clinic to Sacramento is the Martinez Hansen’s Disease Clinic, located at Contra Costa Regional Medical Center. Any physician who diagnoses Hansen’s disease should report it to the local health department where the patient resides, and they can facilitate an appointment at this clinic, as well as access to the needed medications. The visit to the Lepramuseet in Bergen reminded me of the huge amount of human suffering that can now be avoided by adequate treatment and education. firstname.lastname@example.org
At far left are leprosy coins minted in Bogota and specifically issued for three governmentsponsored leper colonies in Colombia. They were scrubbed often, so most of them are very worn. These coins are on display in the SSVMS Museum of Medical History. Above is an image of a typical patient room at a leprosy museum, formerly St. George’s Hospital, in Bergen, Norway.
REFERENCES Website of the Leprosy Museum: http://www. bymuseet.no/en/ museums/the-leprosymuseum-st-joergenhospital/ CDC website on Hansen’s disease: https://www.cdc.gov/ leprosy/index.html HRSA website on the National Hansen’s disease Program: https://www.hrsa.gov/ hansensdisease/ Kalapaupa National Historical Park: https:// www.nps.gov/kala/ index.htm
3D Printing in Medicine Current Status and Implications on the Future
By Alex Darwish, MS II
MEDICAL APPLICATIONS FOR 3D printers continue to expand from year to year and have already produced profound results in the diagnosis and treatment of various medical conditions. 3D printing is an “additive manufacturing” process that creates a physical object from a digital blueprint by adding material layer by layer. There are various printing techniques and countless materials that can be used, but this common principle remains the same. One type is selective laser sintering (SLS), which uses powdered material as the substrate for printing new objects. Lasers draw the shape of an object in powder, fusing it together and depositing more powder on top, repeating this process and allowing for detailed and delicate structures to be produced. Another printing technique, called thermal inkjet printing, deposits tiny droplets of material onto a substrate using heat or mechanical compression. This method is particularly useful in tissue engineering because of the high level of control made possible and the benign effect on mammalian cells. Bioprinting, or printing simple 2D and 3D tissues and organs, relies on this technique. The most common and inexpensive technique is called fused deposition modeling, and functions via deposition of heated plastic that cools and hardens with each successively added layer. We might think of 3D printing as occupying the absolute cutting edge in today’s technology universe, but it has actually been around for more than 30 years. American engineer Chuck Hull invented a printing process called “stereolithography” in 1983. His method allowed for the creation of solid objects by
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printing thin layers of liquid material that could be “cured” with ultraviolet light, allowing for material to be stacked upon itself. He expanded his idea beyond liquid materials and built the foundation for what we know today as additive manufacturing, or 3D printing. So, why all the fuss in recent years? In 2009, a patent for fused deposition modeling, one of the most common 3D printing techniques, expired. What once cost as much as $200,000 and was used mostly by large industry suddenly became accessible to consumers and smaller companies at a fraction of the cost (less than $2,000). Besides growing access, what benefits does 3D printing offer compared to traditional manufacturing? The greatest advantage of 3D printers for use in medicine is the freedom to produce customizable products and equipment. Prosthetics, implants, fixtures, and surgical tools made with a specific patient in mind cut down on time required for surgery, patient recovery time, and the ultimate success of surgery. Another benefit of 3D printing is cost. Although traditional manufacturing remains cheaper for large-scale production of most products, 3D printing has become more costeffective for smaller production jobs. This becomes especially important for highly complex products and those that may require frequent modifications. 3D printing is generally faster than traditional methods of manufacturing that require milling and forging, and levels of resolution, accuracy, and repeatability continue to improve. Another important advantage of this technology is the ease with which detailed design information can be shared between
researchers. Open-source databases make it possible for individuals to create exact replicas of anatomical models, labware, and replicas of proteins, viruses, and bacteria. One was started in 2014 by the National Institute of Health. One of the most exciting applications of 3D printing technology in medicine involves bioprinting of tissues and organs. At the time I am writing this article in the summer of 2017, there are 116,697 people in need of a lifesaving organ transplant in this country, according to a real-time tally by the U.S. Department of Health and Human Services. We currently rely on organ transplants from living or deceased donors, and this leaves us in a chronic shortage of organs available for transplant. Not only is availability of organs prohibitive, the cost of organ transplants and follow-up is extremely expensive, estimated at $300 billion in 2012. Using stem cells taken from the organ transplant patientâ€™s own body and then building a replacement organ avoids these issues and more, like the possibility of organ rejection and the need to take immuno-suppressants afterwards. Traditionally, this problem has been approached by isolating stem cells, mixing them with growth factors to multiply, and seeding the cells back onto a scaffold on which they can differentiate and proliferate into a functional organ. 3D printing expands this concept beyond mere scaffolding and does it with a high degree of precision and control. The proposed concept to print organs now is as follows: 1) Create a blueprint of an organ including its vascular architecture and generate a corresponding printing process plan; 2) Isolate the patientâ€™s stem cells; 3) Differentiate the stem cells into organ-specific cells; 4) Load differentiated cells into bio-ink reservoirs (much like you load ink into your printerâ€™s ink cartridge), and 5) Print. Promising proofs of concept for bioprinted organs have been well documented and have included production of heart valves, spinal
discs, an artificial ear, and a bioabsorbable tracheal splint in a baby born with tracheobronchomalacia. Parallel research to this is currently ongoing to produce small tissue samples and entire organs for the purpose of screening new drug treatments, which could potentially be tested on the individual level (to determine if a drug would be effective for a specific individual). The process will need further research and development before its use will become widespread. One major obstacle in building functional 3D organs relates to the need for extensive vasculature in larger organs. As of yet, the tissues printed have been mostly avascular, alymphatic, aneural and thin. Various techniques have recently produced simple vasculatures with bifurcations and even a perfusable network of capillaries. The medical applications of 3D printing do not focus entirely on printing new organs. Implants and prostheses have benefited tremendously from the technology. Patients previously relied on standard implants for things like spinal and cranial implants that often did not fit their unique anatomy and required surgeons to create crude modifications. With 3D printing, complex structures can be designed to exactly mirror anatomy translated from X-rays, CT scans, or MRI. Hearing aids are an example of this: 99
This Loubani stethoscope was printed with a 3D printer by Mira Loma High School student Matthew Huh. Matthew's article on the Evolution of the Stethoscope is on page 22.
continued on Page 32
Bellevue Three Centuries of Medicine and Mayhem at America’s Most Storied Hospital, By David Oshinsky; Publisher Doubleday; ISBN: 978-0385523363
Reviewed By Jack Ostrich, MD
“MIDNIGHT COWBOY,” starring Dustin Hoffman and Jon Voight, was released in 1969. Hoffman’s character, Enrico “Ratso” Rizzo, desperately wants to get on a bus to escape Manhattan and go to Miami. He is ill with a fever and is very weak. His only friend, Joe Buck, played by Voight, promises to help him get to Florida, but Joe realizes that Ratso first needs medical attention. Joe tells him, “You got the damn fever, boy!” And Ratso replies angrily, “Just get me on a bus! You ain’t sendin’ me to Bellevue!” In 1641, 328 years before Ratso’s plea, Jacobus Kip, a Dutch settler in New Amsterdam, built a house for himself and his family in what became known as the Kip’s (now Kips) Bay section of Manhattan. A neighbor built a home nearby, and, because of the pleasant view that it afforded across the river to the east, named it “Bel-Vue.” Bel-Vue subsequently was purchased, just before the American Revolution, by a man named Lindley Murray. He was a wealthy lawyer and author of popular and best-selling books on English grammar. (His family name now lends itself to the Murray Hill area of Manhattan, just to the northwest of Kips Bay.) Murray spent little time at Bel-Vue and moved to England due to his Royalist beliefs. He finally sold the land and home to Henry Brockholst Livingston who was John Jay’s brother-in-law and later became an associate justice of the Supreme Court of the United States. (John Jay was the first Chief Justice of the United States, 1789–1795.) Livingston, now spending most of his time in Washington, DC, rented out the home, and it suffered gradual deterioration until the
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Common Council of New York City bought it “to serve as a hospital for the accommodation and relief of such persons afflicted with contagious distempers.” Ever since then, there has been some sort of hospital on or near those very grounds, the present one having turned its back on the East River, the entrance now facing west on modern New York’s First Avenue. In his book, Bellevue, Three Centuries of Medicine and Mayhem at America’s Most Storied Hospital, historian David Oshinsky takes us from those early days to the recent past when, in 2012, Hurricane Sandy forced the complete evacuation of the hospital, labs, and clinics, and in 2014, when New York City’s only Ebola victim, Dr. Craig Spencer, was admitted for treatment. Spencer had contracted the virus while serving with Doctors Without Borders in the West African nation of Guinea. He was released after 17 days, declared to be “free of disease.” In the years following the end of the American Revolution, however, the major threat to the health of New Yorkers was yellow fever. In the mid to late 1600s, it had already killed thousands, but an epidemic had not occurred for many decades. Probably brought to America on slave ships, it had spread quickly, thanks to an abundance of Aedes mosquitoes. Impoverished or unidentifiable victims of the plagues were buried in designated potter’s fields, one of which lies under today’s Washington Square. As the city grew even farther to the north, other mass burials took place under what is now Madison Square and Bryant Park, which is adjacent to the main New York Public Library.
A new epidemic had erupted in Philadelphia in the mid-1780s, and so the New York Common Council, led by physician Elihu Hubbard Smith (who died at age 27 in 1798), brought forth a plan to manage the apparently inevitable “infectious distemper” in their city. Smith hired Alexander Anderson, a 20-year-old newly-minted medical doctor to be the first full time “resident” physician at the Bel-Vue facility. Many hundreds would succumb to yellow fever at Anderson’s Bel-Vue. Most victims died at their homes. People of means, even minimal means, never went to the hospital, and physicians saw their patients in the patient’s home, not the doctor’s office. Anderson’s own son, brother, and father died of yellow fever in 1793. Another outbreak in 1798 took his wife and mother. Not surprisingly, he abandoned medical practice and quite successfully turned to illustrating books, periodicals and newspapers. In 1807, he published what is still a famous political cartoon lampooning President Jefferson’s unpopular Embargo Act, showing a huge tortoise, labeled “Ograbme,” biting an American merchant as the poor fellow attempts to get his wares aboard an British export ship. Dr. Anderson later died at age 95 in 1870, the same year that Dr. Walter Reed graduated from Bellevue’s Medical School, which had opened in 1861. In 1798, the city of New York finally bought the Bel-Vue estate, but it was little used until 1811 when construction began on a new almshouse and hospital complex. Oshinsky reports that, soon thereafter, a pamphleteer wrote, “Bel-Vue, a few miles from New York, on the East River, is now considered by the people at large as A House of Death. So odious is the idea of being put there as to lessen one’s chance of recovery.” The new Bel-Vue complex was financed by a lottery, and the city appropriated almost $46,000 for the construction. Work was slowed by the War of 1812, but the place finally opened in 1816 and included an orphanage, a morgue, a “lunatic asylum,” plus a four story “infirmary and almshouse.” And it was now officially named the “Bellevue Establishment.” It was, however, not long before the Bellevue
Establishment was within the city limits. The city had grown rapidly, from about 96,000 souls in 1810 to about one million by 1860. In early 1832, Bellevue held 145 “general patients” and 97 “maniacs.” A cholera epidemic that summer resulted in about 2,000 admissions, and over 600 deaths were recorded. Most victims were described as young, single, and many were recently arrived “low Irish.” Another epidemic, the agent this time being typhus, killed thousands in 1847-48. Most victims had been living in crowded and unclean tenements. Political pressure soon grew to establish a “public” medical school at Bellevue in order to provide the burgeoning city with well trained physicians. And so it came to pass that Bellevue Hospital Medical College, the first American medical school to be located within an established hospital with its own medical staff, opened its doors on April 11, 1861. The next day, the Civil War began at Fort Sumter. Four years later, almost to the day, one of the first graduates of the Bellevue Medical College, Dr. Charles Augustus Leale, became the first physician to attend to Abraham Lincoln after the President had been shot. The new medical school attracted a host of talent. William Welch established the school’s pathology lab, while William Halsted taught and performed surgery. Soon they both moved to Baltimore where they helped start the Johns Hopkins Medical School. Lewis Sayre became the nation’s first full-time professor of orthopedic surgery. Austin Flint taught cardiology. Oscar G. Mason oversaw the creation of the first department of medical photography and mastered the art of photomicrography, as well. Surgeon Edward Dalton used his Civil War experience to design the world’s first hospitalbased ambulance fleet that began service in 1869. Drawn by horses, they answered 1,400 calls in their first year. Horses were deemed more reliable than early motor cars, so Bellevue did not close its stable until 1924, and the last two horses, Joe and Jim, were retired to pasture in upper New York State. In 1873, Bellevue opened its nursing
“Bel-Vue, a few miles from New York, on the East River, is now considered by the people at large as A House of Death…”
school based on the principles and teachings of Florence Nightingale. A separate “pavilion for the insane” was opened in 1879, and a $50,000 gift from Andrew Carnegie was enough to open the Carnegie Laboratory, which soon was renowned for its teaching and research in bacteriology and public health. At the end of the 19th century, New York University Hospital and Medical School merged with the nearby Bellevue Hospital and Medical School. Today the official name of the old Bellevue campus is “NYC Health & Hospitals/ Bellevue.” A few blocks to the north on First Avenue is the NYU-Langone Medical Center, and a few blocks south are the buildings of the VA NY Harbor Healthcare Systems. Two miles to the north, close to the First Avenue axis, there are the Weill-Cornell Medical Center, Rockefeller University Hospital, and the Memorial-Sloan Kettering complex. That stretch of clinics, labs, hospitals and medical schools has been called, by some wags, “Bedpan Alley.”
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Hello humankindness 32
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The NYC-Bellevue bed capacity is now about 1,500, which includes 300-350 psychiatric beds. There are also included 50 to 60 “alternate level of care” (ALC or ALOC) beds which are often occupied by medically stable patients for whom placement cannot be found. Oshinsky’s book is chock full of stories, details and tidbits concerning the fabled hospital; perhaps too chock full for the average reader. But Oshinsky is, by profession, a historian, and so the book that he has written is, indeed, a very thorough history of Bellevue. It is easy to read, but is never a page turner, nor was it meant to be. So, next time you find yourself in New York City with some spare time on your hands, take a walk down First Avenue along “Bedpan Alley” and, when you get to Bellevue, look to the east and try to imagine the view that Jacobus Kip must have had as he gazed at the wilderness across the East River. firstname.lastname@example.org
3D Printing in Medicine continued from page 29 percent of hearing aids today are made using 3-D printing so that the devices fit perfectly into a patient’s uniquely-shaped ear canal. Producing tangible models of patient anatomy using translated imaging has benefited surgical preparation. Neurosurgeons, for example, now are able to visualize complex relationships between cranial nerves, vessels, and brain architecture that might be poorly represented in 2D images and would have devastating consequences if mismanaged. This technological field will continue to grow and transform medicine and other fields. Existing applications are encouraging and will hopefully become more and more accessible to people who could benefit. More revolutionary applications, like bioprinting organs, will need further exploration before truly revolutionizing the current medical/surgical climate. email@example.com
Welcome New Members The following applications have been received by the Sierra Sacramento Valley Medical Society. Information pertinent to consideration of any applicant for membership should be communicated to the Society. — Chris Serdahl, MD, Secretary. APPLICANTS FOR ACTIVE MEMBERSHIP:
Heather Coffin, DO, Family Medicine, Touro University of Nevada College of Osteopathic Medicine – 2014, The Permanente Medical Group, 2155 Iron Point Rd, Folsom, CA 95630
Ravinder Khaira, MD, Pediatrics, St. George’s University School of Medicine – 1995, Capitol Pediatric Medical Group, 4617 Freeport Blvd Ste B, Sacramento, CA 95822
Zaida Albarracin, MD, Internal Medicine, University of the Andes School of Medicine – 2004, Mercy Medical Group, 3939 J St, Sacramento, CA 95819
Duojia (Michelle) Cooney, MD, Urology, Uniformed Services University of the Health Sciences - 2005, Mercy Medical Group, 3000 Q St, Sacramento, CA 95816
Peter Kim, MD, General Medicine, Loma Linda University School of Medicine – 2002, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825
Roksana Ali, MD, Family Medicine, Sri Ramachandra Medical College and Research Institute – 1993, Mercy Medical Group, 1650 Creekside Dr., Folsom, CA 95630
Kaye Cunningham, MD, General Medicine, University of Connecticut School of Medicine – 1995, The Permanente Medical Group, 1955 Cowell Blvd, Davis, CA 95618
Lacey King, MD, Emergency Medicine, University of California, Irvine – 2012, The Permanente Medical Group, 6600 Bruceville Rd., Sacramento, CA 95823
Waqar Ali, MD, Internal Medicine, David Geffen School of Medicine at UCLA – 2014, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825
Christopher Dennis, DO, Internal Medicine, Ohio University College of Osteopathic Medicine – 2003, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento, CA 95823
Sandar Aung, MD, Internal Medicine, University of Medicine & Dentistry of New Jersey - NJ Med School – 1995, The Permanente Medical Group, 6600 Bruceville Rd., Sacramento, CA 95823
Darshan Dhingani, MD, Pulmonary Critical Care, Maharaja Sayajirao University of Baroda Medical College – 2006, Mercy Medical Group, 3000 Q St., Sacramento, CA 95816
Lakshmi Avala, MD, Pediatrics, J J M Medical Coll, Mysore University - 1995, Capitol Pediatric Medical Group, 902 Cirby Way, Roseville, CA 95661
Pradeep Doddamreddy, MD, Pulmonary Critical Care, Ross University School of Medicine – 2009, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825
Mark Agius, MD, Royal College of Physicians of London – 1977, Woodland Clinic Medical Group, 515 Fairchild Ct. - Woodland, CA 95695
Amandeep Bajwa, MD, Family Medicine, American University of Antigua College of Medicine – 2009, Mercy Medical Group, 550 W. Ranch View Dr. #3000, Rocklin, CA 95765
Brandon Doskocil, MD, Radiology, University of Arizona College of Medicine – 2011, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825
Seema Kochhar, MD, Psychiatry, Ross University School of Medicine – 1999, Mercy Medical Group, 1730 Prairie City Rd, Folsom, CA 95630 Robert Levy, MD, Internal Medicine, Jefferson Medical College of Thomas Jefferson University2011, The Permanente Medical Group, 6600 Bruceville Rd., Sacramento, CA 95823 Joyce Loeffler, MD, Urology, University of Colorado – 1991, Woodland Clinic Medical Group, 1321 Cottonwood St. - Woodland, CA 95695 Kelly Mathison, MD, Emergency Medicine, University of Cincinnati College of Medicine – 2013, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825 Jason Mello, DO, Family Medicine, Touro University College of Osteopathic Medicine – 2010, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825
Harmeet Bhullar, MD, Anesthesiology, University of Medical Sciences, Malaysia – 1997, UC Davis Medical Group, 4150 V St., Sacramento, CA 95817
Elizabeth Giles, MD, Palliative Medicine, Poznan University of Medical Sciences– 2011
Antony Boody, MD, Orthopedic Surgery, Loma Linda Univ – 2001, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento, CA 95823
Roop Gill, MD, Plastic Surgery, University of Southampton – 1995, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825
Crystal Carter, MD, General Medicine, East Carolina University School of Med – 2001, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825
Vivken Goyal, MD, Hospitalist, Ross University School of Medicine – 2014, Mercy Medical Group, 4001 J St., Sacramento, CA 95819
Brian Nguyen, DO, Pediatrics, Lake Erie College of Osteopathic Medicine at Seton Hill – 2014, Woodland Clinic Medical Group, 632 W Gibson Road, Woodland, CA 95695
Andrew Chao, MD, Internal Medicine, Harvard Medical School – 2011, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825
Blake Hamby, MD, Vascular Surgery, Saint Louis University School of Medicine – 2008, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825
Bilgehan Onogul, DO, Emergency Medicine, New York College of Osteo Medicine of NY Inst of Tech – 2013, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825
Xiaopei Chen, MD, Radiology, Zhejiang Medical University – 2001, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825
Aisha Hanif, MD, Hospitalist, Ross University School of Medicine – 2013, Mercy Medical Group, 3939 J St. Sacramento, CA 95819
Sarju Patel, MD, Ophthalmology, Mount Sinai School of Medicine – 2006, Retinal Consultants Med Grp, 3939 J St #106, Sacramento, CA 95819
Shideh Chinichian, MD, Family Medicine, Medical College of Virginia Commonwealth University School Med – 2014, Mercy Medical Group, 1264 Hawks Flight Ct. #100, El Dorado Hills, CA 95762
Raselette Hunt, MD, Family Medicine, St. George’s University School of Medicine – 2007, The Permanente Medical Group, 9201 Big Horn Blvd., Elk Grove, CA 95758
Quynh Huong Pham, MD, Neurology, Howard University College of Medicine – 2012, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825
Amity Chu O’connor, MD, Emergency Medicine, Oregon Health & Science University School of Medicine – 2014, The Permanente Medical Group, 6600 Bruceville Rd., Sacramento, CA 95823
Neil Jensen, MD, Radiology, Creighton University School of Medicine – 2010, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825
Elizabeth Pontarelli, MD, General Surgery, Northwestern University Medical School – 2007, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento, CA 95823
Nathaniel Ngo, MD, Ob/Gyn, University of TexasSouthwestern – 2008, Woodland Clinic Medical Group, 1321 Cottonwood St. - Woodland, CA 95695
Harini Racherla, MD, Pediatrics, University of Health Sciences, Osmania Medical College – 2006, Capitol Pediatric Medical Group, 4617 Freeport Blvd Ste B, Sacramento, CA 95822
Jose Rosa Bonilla, MD, Emergency Medicine, Keck School of Medicine of USC – 2014, The Permanente Medical Group, 6600 Bruceville Rd., Sacramento, CA 95823
Tamara Taber, DO, Family Medicine, Touro University College of Osteopathic Medicine – 2014, Stillpoint Medicine, 6545 Sunrise Blvd. #300 Citrus Heights, CA 95610
Shelby Resnick, MD, Traumatic Surgery, University of Southern California School of Medicine – 2009, The Permanente Medical Group, 6600 Bruceville Rd., Sacramento, CA95823
Ranjit Sandhu, MD, Radiology, State University of New York Health Science Center at Syracuse – 2011, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825
Katren Tyler, MD, Emergency Medicine, The Flinders University of South Australia – 1992, UC Davis Medical Center, 4150 V Street PSSB Ste 2100, Sacramento, CA 95817
Aaron Rome, DO, Emergency Medicine, Chicago College of Osteopathic Medicine – 2014, The Permanente Medical Group, 6600 Bruceville Rd., Sacramento, CA 95823
Rahul Sachdeva, MD, Emergency Medicine, St. George’s University School of Medicine – 2014, The Permanente Medical Group, 6600 Bruceville Rd., Sacramento, CA 95823
Nalini Valluru, MD, Gastroenterology, University of Health Sciences, Vijayawada, Guntur Medical College – 2007, Mercy Medical Group, 6555 Coyle Ave, Cramichael, CA 95608
Tracy Zweig Associates INC.
Physicians Nurse Practitioners ~ Physician Assistants
Natalie Wessel, DO, OB/Gyn, Nova Southeastern University College of Osteopathic Medicine, Mercy Medical Group 8220 Wymark Dr # 200, Elk Grove, CA 95757 Schuyler Wood, MD, Family Practice, SUNY Downstate – 2014, Mercy Medical Group, 3000 Q St. Sacramento, CA 95816 Nick Youssefi, DO, Internal Medicine, Touro University of Nevada College of Osteopathic Medicine – 2011, The Permanente Medical Group, 6600 Bruceville Rd., Sacramento, CA 95823 Amira Zaid, MD, Ob/Gyn, University of California School of Medicine – Davis – 2013, Woodland Clinic Medical Group, 1321 Cottonwood St., Woodland, CA 95695 Johnathan Zhang, MD, Gastroenterology, Ohio State University School of Medicine – 2011, Mercy Medical Group, 3000 Q St., Sacramento, CA 95816
Locum Tenens ~ Permanent Placement V oi c e : 8 0 0 - 9 1 9 - 9 1 4 1 o r 8 0 5 - 6 4 1 - 9 1 4 1 FA X : 8 0 5 - 6 4 1 - 9 1 4 3
firstname.lastname@example.org w w w. t r a c y z w e i g . c o m
Tidbits from Lydia E. Pinkham’s Private Text-Book Upon Ailments Peculiar to Women (circa 1880) Hysteria is beyond question one of the most puzzling ailments with which medical science has to deal, and at the same time one with which its unhappy victim is the least likely to obtain a due sympathy. The name comes from a Greek word meaning the womb. The ailment usually affects young women of from 15 to 30 — most frequently of from 15 to 20 — with whom the condition of the womb is almost invariably responsible. Luxury, over work in school, anxiety, shock, unhappy marriage, and grief, may be other causes.
Sierra Sacramento Valley Medicine
Muhammad Zubair, MD, Internal Medicine, University of the Punjab, King Edward Medical College - 1989, Mercy Medical Group, 8220 Wymark Dr. #200, Elk Grove, CA 95757 Konstantina Zuber, MD, Family Medicine, University of Arizona College of Medicine – 2010, The Permanente Medical Group, 9201 Big Horn Blvd., Elk Grove, CA 95758 Jonathan Zumwalt, MD, Dermatology, Loma Linda University Sch of Med – 2012, The Permanente Medical Group, 10725 International Drive, Rancho Cordova, CA 95670 APPLICANTS FOR RESIDENT/FELLOW MEMBERSHIP: Magi Aurora, MD, Family Medicine/Psychiatry, UC Davis Medical Center Resident & Fellow Prog – 2022, 2230 Stockton Blvd., Sacramento, CA 95817 Farzam Gorouhi, MD, Dermatology, UC Davis Medical Center Resident & Fellow Prog – 2018, 2315 Stockton Blvd, Sacramento, CA 95817 Benjamin Oldach, DO, Family Medicine, Mercy Family Med Residency Program – 2020, 7500 Hospital Dr, Sacramento, CA 95823 Phillip Summers, MD, Emergency Medicine, UC Davis Medical Center Resident & Fellow Prog – 2020, 2315 Stockton Blvd., Sacramento, CA 95817 Enkhee Tuvshintogs, MD, Family Medicine, Mercy Family Med Residency Program – 2020, 7500 Hospital Dr, Sacramento, CA 95823
Board Briefs September 11, 2017 The Board: Received a presentation regarding Human Trafficking from Ronald Chambers, MD, Medical Director of the Mercy Family Health Center and Mercy Human Trafficking Clinic. Received a presentation regarding the Pharmacy Narcan Project from California Northstate University College of Medicine medical students, Zachary Nicholas, MS II and Roger Rothenberg, MS II. Received information regarding the legal dispute between Tulare Regional Medical Center and medical staff. Approved to authorize the Executive Committee, at its discretion, to contribute to the CMA’s Legal Defense Fund to support medical staff independence and selfgovernance in Tulare County. Received information regarding planned activities to celebrate the Sierra Sacramento Valley Medical Society’s 150th Anniversary in 2018. Approved the Second Quarter 2017 Financial Statements, Investment Reports and Recommendations. Approved the Nominating Committee Report regarding nominations to vacancies on the Board of Directors and the Delegation to the California Medical Association for 2018. Approved including Networking Solutions in the Vetted Vendor Program. Approved a request to provide a donation to the UC Davis Medical Student Chapter in Support of the 2017 Coalition for Health Equity Conference. Approved a request to purchase one table at the 2017 CMA President’s Reception and Awards Gala. Approved the Following Membership Reports: August 28, 2017 Report For Active Membership — Lakshmi Avala, MD; Harmeet Bhullar, MD; Antony Boody, MD; Christopher Dennis, DO; Seema Kochar, MD; Brian Nguyen, DO; Sarju Patel, MD; Elizabeth Pontarelli, MD; Harini Racherla, MD; Nalini Valluru, MD; Schuyler Wood, MD; Amira Zaid, MD. For Reinstatement to Active Membership — Ravinder Khaira, MD
For 65/20 Active Membership — Donald Lyman, MD For Transfer of Retired Membership to SSVMS — Larry Ozeran, MD For Transfer of Membership — Alex Buss, MD (to Alameda-Contra Costa); Morgan White, MD (to PlacerNevada); Samuel Chan, MD. For Resident Active Membership — Magi Aurora, MD; Farzam Gorouhi, MD; Benjamin Oldach, DO; Enkhee Tuvshintogs, MD. September 11, 2017 Report For Active Membership — Zaida Albarracin, MD; Roksana Ali, MD; Waqar Ali, MD; Sandar Aung, MD; Crystal Carter, MD; Shideh Chinichian, MD; Andrew Chao, MD; Xiaopei Chen, MD; Shedeh Chinichian, MD; Amity Chu O’Connor, MD; Health Coffin, DO; Duojia Michelle Cooney, MD; Kaye Cunningham, MD; Darshan Dhingani, MD; Pradeep Doddamreddy, MD; Brandon Doskocil, MD; Roop Gill, MD; Vivek Goyal, MD; Blake Hamby, MD; Raselette Hunt, MD; Neil Jensen, MD; Peter Kim, MD; Lacey King, MD; Kelly Mathison, MD; Jason Mello, DO; Bilgehan Onogul, DO; Quynh Huong Pham, MD; Shelby Resnick, MD; Aaron Rome, DO; Jose Rosa Bonilla, MD; Rahul achdeva, MD; Ranjit Sandhu, MD; Katren Tyler, MD; Natalie Wessel, DO; Nick Youssefi, DO; Johnathan Zuber, MD; Jonathan Zumwalt, MD. For Resident Active Membership — Phillip Summers, MD. Serving as the Board of Directors to the Community Service, Education and Research Fund (CSERF), the following actions were taken: Approved the Scholarship Committee’s recommendations to provide grants from the SSVMS Medical Student Scholarship Fund to the following individuals for 2016: Masumi G. Asahi, a 2nd year student at Western University of Health Sciences; Tristan T. Howard, a 2nd year student at UCLA, Charles Drew University, David Geffen School of Medicine; Ian A. Taylor, a 1st year student at UC Davis School of Medicine. Also, the first Paul J. Rosenberg, MD Medical Student Scholar was awarded to Kayla K. Sheehan, a 2nd year student at California Northstate University College of Medicine. Approved a request for CSERF to enter into a grant agreement with The Physicians Foundation to support the Joy of Medicine Program. Received information regarding the Joy of Medicine’s first annual Summit to be held Saturday September 23, 2017 at the Arden Hills Country Club.
Contact SSVMS TODAY to Access These
M EMBER O NLY B ENEFITS (916) 452-2671 BENEFIT
Reimbursement Helpline FREE assistance with contracting or reimbursement
CMA’s Center for Economic Services (CES) www.cmanet.org/ces | 800.401.5911 | email@example.com
Legal Services CMA On-Call, California Physician’s Legal Handbook (CPLH) and more...
CMA’s Center for Legal Affairs www.cmanet.org/resources/legal-assistance firstname.lastname@example.org
Insurance Services Mercer Health & Benefits Insurance Services LLC Life, Disability, Long Term Care, Medical/Dental, Workers’ Comp, and Cmacountyemail@example.com more... www.countyCMAmemberinsurance.com Travel Accident and Travel Assistance Policies This is a free benefit for all SSVMS members.
Prudential Travel Accident Policy & AXA Travel Assistance Program http://tinyurl.com/SSVMS-travel-policy
ICD-10-CM Training Deeply discounted rates on several ICD-10 solutions, including ICD10 Code Set Boot Camps
Mobile Physician Websites Save up to $1,000 on unique website packages
MAYACO Marketing & Internet www.mayaco.com/physicians
Auto/Homeowners Insurance Save up to 10% on insurance services
Mercury Insurance Group www.mercuryinsurance.com/cma
Car Rental Save up to 25% - Members-only coupon codes required
Avis or Hertz www.cmanet.org/groupdiscounts
CME Certification Services Discounted CME Certification for members
CMA’s Institute for Medical Quality (IMQ)
Health Information Technology Free secure messaging application
HIPAA Compliance Toolkit Various discounts; see website for details
PrivaPlan Associates, Inc www.privaplan.com
Magazine Subscriptions 50% off all subscriptions
Subscription Services, Inc
Medical ID’s 24-hour emergency identification and family notification services
Medical Waste Management Save 30% or more on medical waste management and regulatory compliance services
EnviroMerica www.cmanet.org/groupdiscounts www.enviromerica.com
Office supplies, facility, technology, furniture, custom printing and more… Save up to 80%
Physician Laboratory Accreditation 15% off lab accreditation programs and services Members only coupon code required
Security Prescription Products 15% off tamper-resistant security subscription pads
PUBLICATIONS CMA Publications
www.cmanet.org/news-and-events/ publications CMA Alert e-newsletter CMA Practice Resources CMA Resource Library & Store www.cmanet.org/resource-library/list? category=publications
Advance Health Care Directive Kit California Physician's Legal Handbook Closing a Medical Practice Do Not Resuscitate Form HIPAA Compliance Online Toolkit Managed Care Contracting Toolkit Model Medical Staff Bylaws Patient-Physician Arbitration Agreements Physician Orders for Life Sustaining Treatment Kit
www.ssvms.org/publications.aspx Sierra Sacramento Valley Medicine (bi-monthly magazine) Medical Society News (monthly e-Bulletin)
firstname.lastname@example.org | (916) 452-2671
Hyatt Regency Hotel | 1209 L Street, Sacramento 6:00 p.m. Social, 6:45 p.m. Dinner, 7:30 p.m. Program Installations: Rajiv Misquitta, MD, President 2018 2018 SSVMS Officers & Board of Directors Award Presentations: Golden Stethoscope Award Medical Honor Award Medical Community Service Award Dorothy Dozier Helping Hands Award
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Sierra Sacramento Valley Medicine is the official journal of the Sierra Sacramento Valley Medical Society (SSVMS) and promotes the history,...
Published on Oct 19, 2017
Sierra Sacramento Valley Medicine is the official journal of the Sierra Sacramento Valley Medical Society (SSVMS) and promotes the history,...