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Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

March/April 2018

Litigated Cases That All Physicians Can Learn From As a leading California medical professional liability provider, CAP is committed to protecting our physician members with not only superior coverage, but also valuable resources, including our most-requested risk management publication, Medicine on Trial: Risk Management Lessons from Litigated Cases. We are pleased to offer this updated edition to all California physicians for a limited time, free for the asking. Each vignette serves to demonstrate how the adoption of simple policies, procedures, and personal practices can help keep you out of the courtroom.

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2018 Education Series


Annual Meeting




The AIM Palliative Health Care Program

Kayla Sheehan, MS II


IN MEMORIAM Richard L. Johnson, MD

Rajiv Misquitta, MD



George Meyer, MD


SSVMS Annual Report


Letter to SSV Medicine


2018 Committee Appointments


Early Days of the Sacramento Blood Bank


Strange But True Medical Cases


The Prescription Sins


Respiratory Rate

Caroline Giroux, MD


Public and Environmental Health Committee Report

Christian Sebat, MD, Frank Sebat, MD and Gerald Rogan, MD


Welcome New Members

Glennah Trochet, MD


Board Briefs

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.

15 Cholera

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.

Matthew Huh

SSV Medicine is online at www.ssvms.org/Publications/SSVMedicine.aspx As we continue to recognize SSVMS’ 150th anniversary, our cover image for this issue is a collage of covers from multiple Medical Society publications. The Medical Society’s first publication, “The Bulletin,” began in September 1950. The cover of the first Bulletin, along with covers from the 1960s discussing the beginning of Medicare, are highlighted in the selection. Other chosen cover photos are from earlier editions of the Medical Society’s magazine, SSV Medicine. Featured items include artifacts from the Museum of Medical History and a cover photo discussing electronic record keeping.

March/April 2018

Volume 69/Number 2 Official publication of the Sierra Sacramento Valley Medical Society 5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax info@ssvms.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. 2018 Officers & Board of Directors Rajiv Misquitta, MD, President Chris Serdahl, MD, President-Elect Ruenell Adams Jacobs, MD, Immed. Past President District 1 Seth Thomas, MD District 2 Tonya Fancher, MD J. Bianca Roberts, MD Vanessa Walker, DO District 3 Ravinder Khaira, MD District 4 Ranjit Bajwa, MD

District 5 Sean Deane, MD Cynthia Ramos, MD Vijay Rathore, MD Paul Reynolds, MD John Wiesenfarth, MD District 6 Carol Kimball, MD

2018 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 Ruenell Adams Jacobs, MD Barbara Arnold, MD Natasha Bir, MD Richard Gray, MD Kevin Jones, DO Richard Jones, MD Charles McDonnell, MD Sandra Mendez, MD Rajiv Misquitta, MD Janet O’Brien, MD Tom Ormiston, MD Senator Richard Pan, MD Kuldip Sandhu, MD James Sehr, MD Chris Serdahl, MD Don Wreden, MD

District 1 Harmeet Bhullar, MD District 2 Ann Gerhardt, MD District 3 Thomas Valdez, MD District 4 Richard Bermudes, MD District 5 Armine Sarchisian, MD District 6 Christopher Swales, MD At-Large Megan Anzar Babb, DO Helen Biren, MD Arlene Burton, MD Ronald Chambers, MD Amber Chatwin, MD Mark Drabkin, MD Karen Hopp, MD Carol Kimball, MD Derek Marsee, MD Ernesto Rivera, MD J. Bianca Roberts, MD Ajay Singh, MD Vacant Vacant Vacant Vacant Vacant

CMA Trustees District XI Douglas Brosnan, MD

Margaret Parsons, MD

CMA Immed. Past President Ruth Haskins, MD CMA Speaker Lee Snook, MD AMA Delegation Barbara Arnold, MD Editorial Committee John Paul Aboubechara, Sean Deane, MD Maria Garnica, MS II 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 Karen Poirier-Brode, 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


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. 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. 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. ©2018 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 Modern Epidemic By Rajiv Misquitta, MD NINE YEARS AGO, LIFE was going extremely well for me. I had just turned 40, and my boys were 1 and 3 years old. I was enjoying a robust medical practice and had just been elected to the board of directors of the largest physicianled group in the nation. Nutrition and lifestyle were not really on my radar. Suddenly, things took a turn for the worse. Driving to work on a cold November morning, I experienced chest pain and shortness of breath. Vivid memories of my father suffering from a heart attack at the age of 49 flashed through my mind. I stepped on the gas and somehow arrived at the parking lot of my hospital a few miles away. After steeling myself, I stumbled into the emergency room, which was two hundred yards from my car. Barely making it through the doors without fainting, I turned to my emergency medicine physician colleague and said the words you never want to hear, “I think I’m having a heart attack.” I was quickly placed on a gurney and an EKG was taken. When the nurse showed me the test results, it was clear to me that I WAS having a heart attack. I was rushed to the cath lab and had two stents placed in my coronaries. As I lay in the recovery room with a sandbag on my leg to stem any bleeding, I was struck with worry about what the future held for me. I had just shattered my youthful illusion of being indestructible. After reviewing the research, the value of a whole foods plant-based diet, exercise and stress modification became crystal clear to me. This was the doorway that led to my transformation, and some of you may have had life experiences that set you on a similar path. I sought to incorporate these learnings into my life and also share them with my patients and colleagues.  In that flash, when I switched from the

role of being a doctor to a patient, I realized the value of lifestyle in treating and preventing disease.  One hundred and fifty years ago cholera was the major cause of death in Sacramento. Today, the scourge of our civilization is not cholera, but instead non-infectious diseases like heart disease, diabetes and cancer. Like other advanced nations, we are in the midst of a health crisis, and we have become victims of factors such as obesity and diabetes, which result, in large part, from our lifestyle choices. It is no wonder that recent statistics show a decrease in life expectancy in the United States in 2015.1 The battle for survival may actually involve how we use our forks and whether we use our feet to move around. In a recent article on Lifestyle Medicine, Bodai et.al. outlines the problem and how the medical community can implement and share the power of healthy lifestyle choices.2 These chronic diseases respond quite well to lifestyle modifications.  Our Public and Environmental Health Committee at SSVMS has studied and made recommendations related to lifestyle – recommending walkable communities, advocating for shade trees at sports venues to protect spectators from sun exposure, and fluoridated water in Yolo County.  There is more we can do to advocate healthy nutrition. As physicians, the collective health of our communities is very important to us. We intuitively know the importance of society in maintaining health. I invite you to spend some time thinking about what else we can do in this arena to make a difference in the lives of our patients, and the people we love. Thank you, again, for all you do for your patients and our community.  rajiv.misquitta@gmail.com

March/April 2018

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 Gun Debate By George Meyer, MD Guest Editorials are welcome, as are comments regarding the editorials themselves.

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.

I HAVE NEVER UNDERSTOOD why, after a mass shooting such as at Sandy Hook, San Bernardino, etc., etc., etc., our leaders say it is too early to talk about a resolution while, whenever a Muslim is responsible for similar attacks, by gun, by vehicle, etc., the same leaders immediately want to ban all Muslims from our country. I believe there should be licensing of guns and a license procedure for gun ownership! That is, everyone who owns a gun should take a safety course and pass it in order to carry a license to own a gun (for each kind of gun they want to own). They should demonstrate knowledge of how to operate, how to clean, and how to fire each firearm. It should be renewed as often as the driver’s license is renewed, and an appropriate fee also be paid. The license should designate which firearms the bearer is qualified to own, just as the driver’s license states what vehicles the owner is authorized to drive. The California Medical Association this year declared firearm violence violates the fundamental human right to live safely without fear in a free society. I will try to discuss several issues related to the government’s role in controlling gun ownership rights. By way of introduction, as a child, I was an Army ROTC mascot, adopted, sort of, by the Non-Commissioned Officer in Charge (NCOIC) of the Army Tulane ROTC program. I marched with them in Mardi Gras parades and performed with them at football games. I could take apart a .45 caliber pistol, a carbine, and an M-1. While on active duty in the Air Force, I shot Expert with a pistol. • “A well regulated Militia, being necessary

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to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed.” There is nothing in the Second Amendment that says people should be able to have silencers, rapid fire automatic or semiautomatic weapons, or bump stocks. Also, there is nothing in the Second Amendment that prevents us from regulating how the government can regulate Arms ownership. The current-day militia is the National Guard. Does that mean that we should be able to restrict arms in the homes of those citizens who are not members of the National Guard? My next door neighbor is a strong believer in the right to bear arms to protect us from our own government. He says, “If they take my guns away, then they know we cannot overthrow the government.” • The Centers for Disease Control (CDC) is prevented from studying the Public Health aspects of firearm injury. In 1997 Arkansas representative Jay Dickey, the so-called point man for the National Rifle Association (NRA), slipped an amendment into an appropriations bill which says, “None of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention may be used to advocate or promote gun control.” A similar provision was included in the Appropriations Act of 2012. In 1997, along with the gun control line, came a $2.6 million budget cut – the exact amount that the agency had spent on firearm research the year prior – and a quiet wariness. In 2017, CDC policy states the agency “interprets” the language as a prohibition on using CDC funds to research gun issues that would be used in legislative arguments “intended to restrict or control the purchase or use of firearms” (http://abcn.ws/2ytv5G3). Before he died, Dickey is said to have regretted his amendment. • The Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF) cannot trace guns

electronically. Laws govern not only the tracking of gun violence statistics, but tracking of the firearms themselves, too. The Tiahrt Amendment, first sponsored by Kansas Republican Rep. Todd Tiahrt and recently reauthorized as part of another appropriations bill, prohibits the ATF from maintaining a searchable database. Instead, officers attempting to trace a gun used in the commission of a crime must use a card catalog and phone system to track the weapon. Often, officers find themselves forced to comb through boxes and boxes of paper records, many of them barely legible, by hand. The ATF Tracing Center estimates the antiquated system, which stretches the average processing time from hours to days, cost taxpayers around $60 million over the course of 12 years (http://abcn.ws/2ytv5G3). • Guns in the Home: There are more than 350 million guns in circulation in the United States – approximately 113 guns for every 100 people. 1.7 million children live with unlocked, loaded guns (1 out of 3 homes with kids have guns). According to the scientific literature, American children face substantial risk of exposure to firearm injury and death. In 2014, 2,549 children (age 0 to 19 years) died by gunshot, an average of 7 per day, and an additional 13,576 were injured. Among children, the majority (89 percent) of unintentional shooting deaths occur in the home. Most of these deaths occur when children are playing with a loaded gun in their parents’ absence (http://bit.ly/2CcE7Zx). • Public Health: In 2011, the Florida legislature attempted to prevent physicians from asking parents about gun ownership. A federal judge blocked the 2011 law from taking effect shortly after it was passed, which targeted pediatricians who asked parents about firearms in the home. Under its provisions, doctors could have been punished with a fine of up to $10,000, and were at risk to lose their medical licenses for discussing guns with patients. In 2014, a three-judge panel of the 11th U.S. Circuit Court of Appeals upheld the constitutionality of the Florida law, but in 2017, in a 10-1 decision, the full panel of the 11th Circuit Court found that the law, known as the Privacy of Firearm Owners act, violates the First Amendment rights of doctors.

• Stand Your Ground: Trayvon Martin!! Before 2005, when the state’s self-defense law required Floridians to attempt to retreat before responding to a threat with deadly violence, it would be up to a jury to decide whether this kind of killing was self-defense. But the Curtis Reeves shooting (see below) was another of the violent absurdities defense lawyers have tried to recast as Stand Your Ground cases. Recently, Miami-Dade prosecutors were forced to drop charges against two teenage gangbangers charged after a gun battle disrupted the January 16 Martin Luther King Day parade. “The problem, of course, was that under the Stand Your Ground statute, they were just a couple of mutual combatants, as my colleague David Ovalle reported. No matter that the firefight had left five teens and children, and three adults with bullet wounds and set off a panicked stampede of parade watchers.” The law has spawned scores of similar absurdities across Florida, preempting prosecution of gun thugs and armed cranks outraged that neighborhood kids had wandered onto their property, and giving the likes of Curtis Reeves a decent chance of escaping a seconddegree murder charge (http://hrld.us/2zA9Nm9). • A Good Guy with a Gun: It could have been worse, but it wasn’t – thanks to “a good guy with a gun.” That’s what several conservative media outlets, from Breitbart to Fox News to the Blaze, are suggesting following the mass shooting at a Sutherland Springs, TX church. This is fallacious! The guy who shot the attacker shot him AFTER he left the church and had killed at least 26 persons. The Las Vegas killer was quieted AFTER he had mowed down 58 concertgoers and wounded hundreds of others. The 2012 Aurora, CO movie theater incident resulted in 12 persons killed and 70 wounded. And in Colorado Springs, a man shot up a Planned Parenthood clinic in 2016. A good guy with a gun should never be the first to fire! Then there is the good guy, a retired Air Force officer and Tampa police captain, Curtis Reeves, packing a firearm in a movie theater near Tampa in 2014 who shot and killed a man who had attacked him with popcorn! His defense was that he felt a threat to his safety (Stand Your Ground Law in Florida).

March/April 2018

There are more than 350 million guns in circulation in the United States – approximately 113 guns for every 100 people.


• Silencers: Silencers currently are legally obtainable after submitting an application, passing a background check, submitting fingerprints, paying a $200 fee, and registering the silencer with the ATF. Because paperwork must be filed with the overburdened and underfunded agency, wait times can be months-long. The Hearing Protection Act, which House Republicans in June folded into the Sportsmen’s Heritage and Recreational Enhancement Act (SHARE Act), a bi-partisan package that typically passes with little drama, would do away with these hurdles (http://bit.ly/2zDRlxB). Interesting enough, the Congressman who introduced this bill was at bat and sought cover when the gunman attempted to kill members of Congress practicing for an annual baseball game. If the gunman had had a silencer, the costs would have been worse. • Automatic Weapons: New, fully automatic weapons (weapons that reload automatically and fire continuously with one trigger pull) have been banned for civilians in the United States since the Firearm Owners’ Protection Act of 1986. Rifles of all kinds constitute a small minority of

criminally-used guns: Only 2 percent of homicides were committed with rifles of any kind in 2014. Machine guns made prior to the cutoff date in 1986 remain legal but highly expensive (typically running in the five figures) and are tracked closely and individually by the Bureau of ATF. Gun owners who want weapons capable of fully automatic fire can’t legally modify the internal components of their semi-automatic rifles to accomplish this. But they can buy legal accessories like the Slide Fire or the GatCrank that help shooters mimic automatic fire without altering a semi-automatic gun’s internal mechanisms (http://slate.me/2xXlWnZ). In conclusion, the data support better control of guns and ammunition. Proper licensing and computer-based registration of all gun owners and their arms would help police in their role of protecting the citizenry. Laws that try to prevent basic public health investigations and attempt to prevent health care workers from doing their jobs are not helpful. geowmeyer@icloud.com

Letter to SSV Medicine Re: Letting Go – Saying No to Cancer Treatments by Nan Crussell, SSV Medicine Managing Editor, and Making the Decision, by Robert Crussell Dear Nan, I have been meaning to write ever since your article and your husband’s appeared in the Medical Society magazine. Going public with such intimate health issues must have been something you gave a lot of thought to, but I am grateful you did it. I have a copy of Being Mortal that I have yellow highlighted in many places because Atul Gawande’s words are so spot on, and I wanted to memorize the phrases. I used them in practice, and they come up in family conversations. I am glad you found it comforting as well.


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As a resident physician, I became very interested in the developing hospice movement and went to England to observe how they had introduced this care. It is validating that some 30-40 years later, we see that choosing quality palliative care may prolong life even more than aggressive treatments in some situations. Wherever you and your husband may now be in this journey, I wish you the best of times together, making memories that will last forever. Sincerely, –Marion Leff, MD

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The article, at left, is from the first edition of The Bulletin, September 1950. Below are photos from the early days of the Sacramento Blood Bank. SSVMS founded BloodSource in 1948 and medical society leaders were instrumental in building this blood bank into a regional blood center.

March/April 2018


The Prescription Sins The method discovered by the industry to dominate by fear (and make money out of it).

By Caroline Giroux, 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.

AS FAR AS I CAN REMEMBER, I was a good student. I studied hard and liked taking exams, because trying to find the good answer was a rewarding challenge and it gave me a sense of worth. Eventually, after the humbling experience of average scores as an adult, not to say academic struggles, I liberated myself from such a distortion of my self-perception. I wouldn’t have guessed that my chosen profession would come up with similar ways to torture me on a frequent basis: now the dilemmas that are thrown at me are like tests I have not studied for, occurring with no notice at random intervals. I saw a 20-year-old African-American man on Medi-Cal, who didn’t start the Duloxetine prescribed at 20 mg on an urgent care setting (based on chronic depression and suicidal thoughts): “The insurance company didn’t approve because the dosage was too low.” I had never heard of this before. I was quite perplexed; we have to start low, it is safer and less brutal on the body. He had been discharged, and there was no way for the prescriber to know this. A 69-year-old Caucasian woman I have known for years, on Medicare and on a modest income, had a history of significant posttraumatic disorder (PTSD) symptoms that used to be well controlled on Fluoxetine, Lamotrigine and Olanzapine. Fluoxetine had to be titrated back after taper and discontinuation based on patient’s desire to try to see how she would do without, since her coping skills were solid and she didn’t want to be on that regimen forever. It didn’t go very well, and she had significant panic symptoms, so we had to re-titrate all her meds. Halfway through titration of Fluoxetine (which is the generic of Prozac, hence it should be cheaper), she is told by the pharmacy (or


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probably the pharmacy benefit manager, or PBM) that her co-pay will be about $152 (a medication that would cost no more than $19 at Wal-Mart!). She then explains that it is because I ordered 45 tabs of 20 mg (ordered from 20 mg to 30 mg, so 1.5 tablet for 30 days=45 tablets). This is a prescription I have used many times in the past with other patients, which this particular insurance didn’t approve. That, in itself, was sufficient to throw her into re-activated PTSD (and made me feel guilty of some unforgivable transgression). In an article aptly entitled, “The Prior Authorization Predicament–Fighting With Payers Over Prior Authorizations Costs Millions of Hours in Lost Productivity, But There are Ways to Improve Your Chances of Winning the Battle,”1 author Jeffrey Bendix quoted Yul Ejnes, MD: “PAs [prior authorizations] for generics is a new phenomenon. It comes up frequently with patients over 65 who are on medications that appear on the ‘Beers list’ (medications that are potentially unsafe for the elderly).” But Fluoxetine doesn’t even appear in the Beers list. Ironically, my 69-year-old patient ended up resorting to Ativan to calm her rebound panic, a medication which is on the Beers list and was introduced by another provider, but which I am frantically trying to get her to discontinue.

How many of you ever had to spend endless minutes over the phone to try to justify what you have been trained to do…

The examples above are the two most recent I have encountered. How many of you ever had to spend endless minutes over the phone to try to justify what you have been trained to do, and often, to a non-medically trained professional? I have countless stories like that. For instance, a woman with a severe mental illness whose cancer treatment had been delayed because her insurance (Molina) had not approved the cystoscopy. The patient was non-fluent in English and couldn’t navigate our complicated, intimidating health care system without a relative. This always infuriates me. “Prior authorization (PA) is a requirement that your physician obtain approval from your health insurance plan to prescribe a specific medication for you. PA is a technique for minimizing costs, wherein benefits are only paid if the medical care has been pre-approved by the insurance company.” Minimize costs for whom? Ultimately, it costs more to society. What a great example of mystification. Or hypocrisy. We all know that greed and money only can lead to the development of such absurd, contradictory processes. Only a poorly regulated medical system would tolerate this dangerously meaningless “paperwork,” yet in a world going paperless... Is this simply a technique for minimizing costs, or ultimately making a profit, taking advantage of people’s fear, vulnerabilities and low health literacy? Some patients won’t take the risk of going without their medications. The prospect of decompensating and being admitted to a facility is too terrifying. Some will pay because they are in a state of fragility and can’t comprehend what doctors, themselves, have a hard time understanding. In a 2014 New York Times article, Danielle Offri wrote: “On average, prior authorization requests consumed about 20 hours a week per medical practice: one hour of the doctor’s time, nearly six hours of clerical time, plus 13 hours of nurses’ time. Other studies have suggested that prior authorizations could cost individual practices tens of thousands of dollars a year.”2 Having to rewrite countless prescriptions of Hydroxyzine (25 mg instead of 50 mg, or

vice-versa), because the insurance would have a rigid maximum of tabs daily it could cover (sometimes it is 45, sometimes, 90) is like a currency conversion exercise for me (25 mg times four or 100 mg is like four quarters for a dollar... If it makes them happy!). But it takes time that I could invest differently. Patients switching insurance to a new plan refusing to cover for meds that have ensured stability for many years is another common scenario. But these rules seem to be unpredictable, from one insurer to another, one patient, diagnosis, or medication to another, tablet versus capsule, tablet but not capsule, immediate versus extended release etc., etc.

It might be that the cost of production is prioritized over the inconvenience for the patient… Even though a tablet of 60 mg exists for Fluoxetine, on many occasions I had to rewrite a prescription for three tablets of 20 mg. It might be that the cost of production is prioritized over the inconvenience for the patient and the team? There are so many variables and dimensions, therefore an infinite number of “sinful” ways for us to prescribe, and infinite ways for me to get the answer wrong and fail the test. Or worse, fail my patients. I have always been quite amazed by the number of possible permutations those agencies will come up with to add more barriers to patient care. How are doctors supposed to serve people and function within such a lunatic, capricious system? This should be illegal, as it violates the trauma-informed care principles, the standard of care. It re-traumatizes people who have suffered abuse, neglect, chaos. How can we provide care embedded in a system with many conflicting interests without making those corporations (pharmaceuticals, insurance companies) accountable for such unethical conduct? I tried to find out if there were any lawsuits against pharmaceutical or insurance companies.

March/April 2018


An article I found revealed that, in fact, the burden, the pressure, the terror, are experienced by the physician! “Physicians who do not appeal limitations at odds with their medical judgment might bear responsibility for any injuries that occur.”3 We are walking on a tightrope… And while this whole administrative chemin de croix (The Way of the Cross) takes place, delays in getting approval and proper treatment can affect patients’ safety and outcomes, not to mention the therapeutic relationship. How can patients maintain trust in their doctors if there is a doubt that they will get the meds they need, no matter what? When is the initiator of such a process that creates major disruption in patient care to be held accountable? Doctors are more and more disempowered, their decisions always challenged despite heavier and more burdensome documentation requirements; yet, the corporations are trying to make the healers bear the responsibility for the delays and other unfortunate consequences caused by PAs, as the doctors try to emerge from

their astonishment and limit the damage. This is a daily ordeal for physicians. Despite the pain, most give in and go through the tedious process without questioning it or trying to change it. And that is what worries me the most: this lethargy, or willingness to engage in that justification battle. I am guilty of it too, at times, although now I know better and try to outsmart them. But it is exhausting to engage in an impromptu chess game against invisible adversaries, trying to anticipate their moves, moods or objections. The dark powers of our field… When will we finally join forces and fight back? How can we let that be? I think it’s time to set the boundaries, assert our Hippocratic Oath more than ever (primum non nocere!) and do something about this. There is an urgent need for reform. In fact, there was a coalition that came up with PA utilization reform principles.4 The AMA website lists 21 principles articulating nicely and firmly some of the concerns shared in this article. It grouped common-sense concepts into five broad categories: clinical validity, continuity of care, transparency and fairness, timely access and INC. administrative efficiency, and PLACEMENT FIRM alternatives and exemptions. Before reacting to the terror regime from the insurer, I would suggest responding, thoughtfully, by reading and applying ~ Physician Assistants those principles, and have your team and colleagues support you. Doctors have to become fierce protestors. The medical profession has been highjacked for way too long.

Tracy Zweig Associates A



Physicians Nurse Practitioners


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

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REFERENCES 1 http://medicaleconomics.modernmedicine. com/medical-economics/content/tags/ insurance-companies/prior-authorizationpredicament?page=full 2 https://www.nytimes.com/2014/08/04/opinion/ adventures-in-prior-authorization.html 3 https://www.mdedge.com/currentpsychiatry/ article/88949/practice-management/good-badand-ugly-prior-authorization-and 4 https://www.ama-assn.org/practice-management/ addressing-prior-authorization-issues

Public and Environmental Health Committee Report By Glennah Trochet, MD AT THE START OF 2017, the Public and Environmental Health Committee members were very ambitious. We wanted to examine the following topics: 1) access to health care, 2) homelessness, 3) the unintended consequences of legalizing recreational marijuana, 4) mental health, and 5) gun violence. In addition, we would deal with any other topic that surfaced during the year. In the end, after spending time learning in depth about homelessness issues, and also finding out how complicated the legalization of marijuana is, we decided to leave the topics of gun violence and mental health for further study in 2018. During the course of 2017, the committee made several findings and recommendations for the SSVMS Board. Regarding Access to Care, the committee recommended that the Board of SSVMS urge the California Insurance Commissioner, California Health Benefit Exchange, and California Department of Managed Care to monitor and enforce state laws and regulations that require health insurers and health plans to have adequate provider networks and maintain current and accurate provider directories. At the committee’s request, the Board also urged the Board of Supervisors of Sacramento County to increase enrollment in the Healthy Partners program, which was created in 2016 to give limited medical services to Sacramento County residents who are uninsured. The program is currently at capacity with 3,000 enrollees who are seen at the County Clinic. The budget for this program would allow for more enrollees. SSVMS supports Healthy Partners

through the SPIRIT Program which provides some specialty care and outpatient surgery for participants in this program. The American Lung Association asked SSVMS to sign a letter to California legislators in Congress to ask them to support the Clean Air Act which has been under attack. This was done by the Board at the request of the committee. After several meetings studying the complicated issue of homelessness, the committee learned that California is short approximately one million housing units. Programs to help people who are homeless must be able to help them find housing, otherwise the problem will continue. In addition, we learned that mental illness and substance abuse are issues that tend to keep people homeless, and that services for these problems are scarce in our community. Laura’s Law, which allows family and professionals who work with an individual with mental illness to petition the court to mandate treatment in an outpatient setting, has been implemented in El Dorado and Yolo Counties, but not in Sacramento. The law prescribes specific procedures that must be followed in order to mandate this treatment. A county’s Board of Supervisors must vote to implement it before it can be used, because once someone is required to seek treatment, county mental health services must be made available to them. In addition, the committee learned of a Hepatitis A outbreak that has been ongoing in San Diego County since 2016, and has spread to Santa Cruz and Los Angeles Counties, resulting in over 460 hospitalizations and 21 deaths. The illness has spread among homeless people and

March/April 2018

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.


‌we learned that mental illness and substance abuse are issues that tend to keep people homeless, and that services for these problems are scarce‌


injection drug users in these communities, as well as among the people who work with them. Sacramento County Public Health has implemented a Hepatitis A vaccination program, and recently San Diego County began making public toilets and hand washing stations available to homeless people as a way to stem this epidemic. In Sacramento County there is limited availability of public toilets, and many homeless people defecate in public places potentially exposing many to hepatitis. Dr. Robert Meagher and medical students from California Northstate Medical School volunteered to investigate what the obstacles might be to reopening many of the public toilets in parks and public buildings that have been closed over the past two decades. They will be reporting their findings to the committee. We noted that everyone, not just homeless people, would benefit from being able to relieve themselves while exercising or during other activities and events. As a result of these conversations, the following recommendations were sent to the Board of SSVMS, which they approved at their September 2017 meeting: 1) Encourage the Sacramento County Board of Supervisors and other elected bodies in Sacramento County to work together to address homelessness by increasing housing availability at all levels of income, but especially for low income residents of the county. 2) Encourage the Sacramento County Board of Supervisors to authorize and implement Laura’s Law, as El Dorado and Yolo counties have done. 3) Applaud the implementation of the Hepatitis A vaccine program that has been started, making it available to homeless people and injection drug users, as well as to the people who work with them. 4) Urge the Sacramento Board of Supervisors to increase access to bathrooms for homeless people and other sanitation strategies that would prevent a Hepatitis A outbreak similar to that in Southern California.

Sierra Sacramento Valley Medicine

Regarding the legalization of recreational marijuana in California, which started in January of 2018, the committee learned that there are three regulatory bodies currently developing regulations for growing, manufacturing, testing, labeling, distribution and retail sales of these products. These include the California Departments of Agriculture and Public Health, as well as a new entity called the Bureau of Cannabis Control. In addition, local jurisdictions must also authorize the growth and sale of these products within their areas of control. The committee felt that we should monitor the implementation of the law during the course of 2018, and that it is very important to do credible research on the consequences of implementing the law. The Defense Appropriations Bill in Congress forbids the Justice Department from acting against distributors in states that have passed a medical marijuana law. Attorney General Jeff Sessions wants this language removed. This language is what has kept the Justice Department from interfering with states that have legalized cannabis. The committee recommends that CMA continue to support this language in the bill and promote the ability to do medical and public health research on cannabis. This will need to be a resolution submitted to the CMA. The committee is in the process of researching the resolution process and will find a delegate to submit it. In 2018, the Public and Environmental Health Committee plans to continue to monitor all the issues they studied in 2017, but in addition, we will learn about the issues surrounding mental health services, as well as gun violence. The committee meets on the third Tuesday of most months of the year. Those who are interested in these topics are welcome to attend and to request membership in the committee. trochetg@gmail.com

Cholera 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 of artifacts in our Museum of Medical History. To help celebrate the 150th Anniversary of SSVMS and remind us of the evolution of medical care, some issues this year will contain a “disease synopsis,” illustrating the evolution of a disease over the past 150 years. TRANSMITTED BY FOOD and contaminated water, cholera is a bacterial disease caused by Vibrio cholerae. The hallmark of this disease is “rice water diarrhea” and vomiting, leading to dehydration and electrolyte imbalance, and often death. Like other infectious diseases, the lack of knowledge and proper treatment was a major contributor to the lethality. Matter of fact, the bacterium was not discovered, and therefore the disease was not recognized, until the mid 19th century. There have been seven global pandemics of cholera. Although there have been reports of cholera outbreaks in previous centuries, the story of cholera really begins in 1817 in the Ganges River Delta in India. This first pandemic called The Asiatic Cholera Pandemic of 18171823 spread throughout Asia via contaminated rice and then spread via British troops to the Middle East and Africa. From 1829-1849, cholera then spread from India to Russia, Finland, and Poland. This eventually spread to England where cholera was observed by English physician, John Snow, who is considered the Father of Epidemiology. This pandemic was highlighted by the London Cholera Epidemic of 1849. The general public believed the deaths were caused by “miasma” or “bad airs.” During this epidemic, an average of 30 in every 10,000 people died from cholera in England and Wales. The denser the popula

tion, the greater the mortality. Snow believed this was spread by a contaminated water pump, because, based on his spot map, all the cholera deaths were localized around that pump. In one month, there were 600 cases of cholera around one water well. There were 344 deaths in only four days at the worst point of the epidemic. The city did not believe Snow, however, and rejected his proposal to remove the well. So Snow pilfered the handle of the well one night, which rendered it useless, promptly stopping the epidemic in London. The third pandemic lasted from 1852-1859 and resulted in the largest mortality. It spread across Asia, Europe, North America, and Africa. In one year alone, it killed about 23,000 people in Britain. In Sacramento, during the Gold Rush of 1850, a person infected with cholera disembarked from the ship the New World. This triggered an epidemic of cholera in Sacramento that killed about 1,000 people in three weeks (including 17 physicians), approximately 15 percent of the population. As there was an exodus of settlers to the foothills, up to 5,000 others might have died from this epidemic. Often death occurred within 24 hours and, with a mortality of about 50 percent, cholera was an extremely frightening disease. The fourth pandemic lasted from 1863 to 1879, and spread throughout the Middle East from the Bengal region by Indian Muslim pilgrims visiting Mecca. By the 1880s, the treatment for cholera was still unknown. The most common treatment was treating the pain with opioids like laudanum and Majendie’s solution, which was an injectable salt of morphia. Ironically, physicians treated their patients by preventing them from drinking water. Later, treatment would actually be the opposite; patients are treated with oral and intravenous rehydration therapy March/April 2018

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. 15

Grave marker at the Sacramento Historic City Cemetery

as well as antibiotics. The fifth pandemic (1881-1896) originated in India and swept across Russia, Africa, South America, and parts of Europe. The findings of John Snow again helped to keep cholera out of Britain and the U.S. It was during this pandemic in 1892 when bacteriologist, Waldmar Haffekine, developed the human vaccine for cholera. The sixth pandemic (1899-1923) again originated in India and moved to the Middle East, Northern Africa, Russia, and parts of Europe. But by 1923, cholera was no longer a formidable threat due to the available vaccine and the knowledge of how to effectively

treat the infection. The seventh pandemic is currently sweeping third world countries across the world. It originated in 1961 in Indonesia and spread across Africa and parts of Europe in the 1970s. In 1991, cholera reappeared in Peru and killed 10,000 people. Currently there is a massive epidemic in war-torn Yemen. In developed countries, cholera has stopped being a large threat. According to the World Health Organization, there are still about 1.3-3.0 million cases of cholera and 21,000143,000 deaths worldwide. Now, a new strain of cholera has surfaced in Bangladesh and has since spread to 11 other countries raising fear of an eighth pandemic. matthewdhuh@yahoo.com REFERENCES The list of sources used in this article is available upon request from the author.

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Sierra Sacramento Valley Medicine


Annual Meeting THE 2018 SIERRA SACRAMENTO Valley Medical Society and Alliance Annual Awards and Installation Dinner was held January 11, 2018 at the Hyatt Regency Hotel in Sacramento. Nearly 300 members and guests, including a large representation of medical students from UC Davis School of Medicine and California Northstate University College of Medicine, enjoyed a very special night as the Medical Society began a year-long celebration of its 150th Anniversary. Installed as the 144th President of SSVMS was Rajiv Misquitta, MD, Internal Medicine practitioner with The Permanente Medical Group. Also installed were the following SSVMS 2018 Officers and Board of Directors: Christian Serdahl, MD, President-Elect; Ruenell Adams Jacobs, MD, Immediate Past President, Carol Kimball, MD, Secretary and John Wiesenfarth, MD, Treasurer. Directors Ranjit Bajwa, MD, Sean Dean, MD; Tonya Fancher, MD, Ravinder Khaira, MD, Cynthia Ramos, MD, Vijay Rathore, MD, Paul Reynolds, MD; J. Bianca Roberts, MD, Seth Thomas, MD, Vanessa Walker, DO. Following a Toast by President Misquitta to commemorate the Medical Society’s 150th Anniversary, special presentations were received from U.S. Representative, Ami Bera, MD, Senator Richard Pan, MD, Assemblyman Kevin Kiley and Dustin Corcoran, CEO, California Medical Association. Other resolutions were received from U.S. Representative Doris Matsui, U.S. Senator, Kamala Harris, the Sacramento County Board of Supervisors and Mayor Darrell Steinberg and the Sacramento City Council. The Society’s highest honor, the Golden Stethoscope Award, was presented to Mary Pat Pauly, MD, recently retired Gastroenterologist. Dr. Pauly received the award for her devotion to patient care and the medical needs of the community. The Medical Honor Award was presented

to Gordon Garcia, MD, in recognition of his spirit of community service and volunteerism as a child advocate, community educator and medical school instructor. The Medical Community Service Award was given to My Sister’s House, for its service as a Central Valley’s domestic violence shelter providing culturally appropriate services for Asian/Pacific Islander victims, as well as serving other underserved women and children impacted by domestic violence, sexual assault and human trafficking. The Alliance presented its highest honor, the Dorothy Dozier Helping Hands Award, to Kim Majetic for devoting her time, energy and talents to the Alliance and the community. Guests at the event were entertained with traditional jazz music by The Ruby Rhythms, a group of young musicians from the Sacramento area who play regularly throughout California.

March/April 2018

L-R Ruenell Adams Jacobs, MD Outgoing President, presents gavel to Rajiv Misquitta, MD, 2018 President.



Sierra Sacramento Valley Medical Society and Alliance Annual Dinner, January 11, 2018, Hyatt Regency Hotel Photos by David Flatter (flickr.com/davidflatter)









Sierra Sacramento Valley Medicine








5 Golden Stethoscope Award Recipient, Dr. Mary Pat Pauly with Drs. Margaret Parsons (left) and Rajiv Misquitta (right).


6 President Rajiv Misquitta, MD and Family. 7 L-R CMA CEO, Dustin Corcoran, presents a resolution to President Dr. Rajiv Misquitta commemorating SSVMS’ 150th Anniversary. 8 Alliance Members promoting their Art of Medicine Event. 9 L-R Senator Richard Pan, MD presents a CA State Legislature Resolution to President Dr. Rajiv Misquitta. 10 L-R Ruenell Adams Jacobs, MD and Rajiv Misquitta, MD lead toast to SSVMS’ 150th Anniversary Celebration.

11 1 2018 SSVMS Board Members present at the event include, L-R Drs. Paul Reynolds, John Wiesenfarth, Ruenell Adams Jacobs, Rajiv Misquitta, Carol Kimball, Sean Deane, Bianca Roberts and Vijay Rathore. 2 Medical Students from UC Davis School of Medicine and CA Northstate University College of Medicine.

11 L-R SSVMS Medical Student Scholarship Recipient, Ian Taylor, Margaret Parsons, MD, Scholarship Committee Chair and Kayla Sheehan, recipient of the Paul J. Rosenberg, MD Medical Student Scholarship. 12 L-R Dr. Rajiv Misquitta presents a plaque to Ruenell Adams Jacobs, MD for her service as 2017 President. 13 L-R Alliance President, Mary Sterner-Sosa, MD, Assemblymember Kevin Kiley, CMA Immediate Past President, Ruth Haskins, MD.

3 Medical Honor Award Recipient, Dr. Gordon Garcia with colleague and SSVMS Director, Sean Deane, MD.

14 L-R Alliance Past President, Kim Majetic, Dorothy Dozier Helping Hands Award Recipient, and Alliance Member, Patty Roberts.

4 Medical Community Service Award presented to My Sister’s House, Nilda Valmores, CEO (2nd from left) with supporters from the organization.

15 L-R U.S. Representative Ami Bera, MD presents Constitutional Proclamation to President Dr. Rajiv Misquitta.

March/April 2018







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March/April 2018



Treating Chronic Illness Sutter Health Aims High for Advance Care at End of Life

By Kayla Sheehan, MS II

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 U.S. HEALTH CARE system is undeniably good at fixing the fixable. However, as our population ages, instances of chronic illnesses with no easy fix rise, and our typically effective, yet aggressive, strategies for curing fall short. Though hospice remains the gold standard for end-of-life management, it can only accept patients with a life expectancy of six months or less. Stuck in the middle are the chronically ill, who are past interventional measures, but are not yet appropriate for, or do not wish to receive, hospice care. In 2009, Sutter Health proposed a solution to this ever-growing problem. Through its Advanced Illness Management program (AIM), Sutter bridges the gap between chronic and terminal illness, improving patient satisfaction, minimizing cost, and revolutionizing the way we treat the incurable. By 2030, California’s over-65 population is estimated to increase by four million, necessitating change in how we approach planning care for this demographic. The chronically ill are among the highest consumers of health care, and represent a disproportionate amount of Medicare spending, with 30 percent of Medicare dollars spent on the chronically ill in their last two years of life. When we approach these patients with aggressive measures, we compromise their well-being, increase the cost of their care, and often only further shorten their lifespan. Rather than give these patients a frequent flyer card to the ICU, AIM provides them with an interdisciplinary team of primary care physicians, specialists, nurses, and social workers to fully support patients in communicating, documenting, and achieving their goals of care.


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More than 90 percent of adults in the United States report that they would prefer to die at home, but more than two-thirds of them end up dying in hospitals (52 percent of deaths in institutions) and nursing homes (24 percent). AIM program director, Sharyl Kooyer, attributes this to “A culture that does not address the issues and challenges of caregiving and end of life care. We come to it as if it is an unexpected crisis, versus a planned event that we will all die one day.” One of AIM’s five pillars is advance care planning with an emphasis on personal goals. Having difficult, honest conversations with patients about their prognosis, options, wants, and needs is notoriously avoided in many practices, but it is the foundation of AIM, and a major key to the program’s success. Within 90 days of enrolling, 96 percent of AIM patients complete advance care planning documents. Additionally, AIM patients are 31 percent more likely to enroll in hospice, 29 percent less likely to die in a hospital, and 48 percent less likely to die in the ICU.

AIM patients typically have a high symptom burden, and a 12–18 month prognosis. To qualify for AIM, a patient may have two or more chronic illnesses, and at least one of them must be advancing. AIM patients typically have a high symptom burden, and a 12–18 month prognosis. AIM’s nurse-led interdisciplinary team coordinates and delivers care to patients in their homes, where they educate and empower

patients to self-manage their illness as much as possible. Through home visits, phone calls, and careful coordination with patients’ primary care and specialist providers, AIM has helped reduce unnecessary emergency department visits and hospital admissions, leading to significant savings (more than $9,000 per AIM patient within 90 days of enrolling), and more importantly, higher patient satisfaction (4.7/5). According to data from Medicare, between 2000 to 2009, hospice enrollment nearly doubled (22 to 42 percent), but much of that increase was due to shorter stays (fewer than three days), suggesting that while comfortoriented care is being provided at a higher frequency, it is being reserved for final days of life rather than integrated into a patient’s care early on. End-of-life care is notoriously expensive, as well. Medicare spends nearly $215 million annually for every 5,000 patients who are in their last year of life, and one third of that expenditure goes into the final month of life. The majority of that spending is done in the ICU (an estimated 80 percent) and on hospitalbased treatments. AIM has been shown to not only decrease visits to the ICU in the final three months of life, but to also increase hospice referrals. Once patients transition from AIM to hospice, their data are not included in AIM’s retrospective studies, and thus AIM’s contribution to health care savings in the final months of life may be even larger than reported, as hospice has been shown to significantly decrease the cost of care, particularly when started early. AIM was funded by Sutter Health and a $13 million grant from the Center for Medicare and Medicaid Innovation (CMMI), and has had more measurable quality improvement and cost reduction than any other CMMI recipient in the Complex/High-Risk Patient Targeting sector. AIM has expanded to at least 19 counties, all in Northern California, and in 2015, AIM served over 953,000 patients, with an average daily census today of about 2,700. Through AIM, thousands of patients are receiving more well-rounded, complete, and tailored care throughout the course of their chronic illnesses, and at a lower cost than their peers.

The result, as Kooyer says, is “High patient satisfaction, and high staff satisfaction as well. People appreciate being able to serve patients in their homes, and to assist them in this challenging time as they prepare to decide what choices they may want to make around their end-of-life care, and what that might look like for them and their family – how we can honor them and their goals, which may change over time as they develop a deeper understanding of where their disease is taking them.”

There is no complicated technology or intervention required; rather, AIM trains its providers using the simple “see one, do one, teach one” method… What may be most impressive about AIM is its scalability. It shows the promise of benefiting patients, providers, and insurers on local and national levels. There is no complicated technology or intervention required; rather, AIM trains its providers using the simple “see one, do one, teach one” method, and a series of in-person classes, didactics, and hands-on practice in patient homes with trained nurses and social workers. So far, AIM’s progress has been described as “reminiscent of the American hospice movement,” wherein hospice had shown tremendous success in improving health care cost and satisfaction before it became a Medicare benefit. Sutter Health is currently working with the Coalition to Transform Advanced Care (CTAC) to advocate for AIM’s coverage. AIM has attracted national attention, and may be on its way to becoming a model for cost-effective end-of-life care. By combining the best aspects of Western Medicine and all its innovations and precision with humanistic practices of communication, compassion, and patient empowerment, Sutter Health aims higher, and transforms care for this patient population in the process. kayla.sheehan1253@cnsu.edu March/April 2018


THE                     April

21, 2018




SSVMSA Auction & Dinner

The SSVMS Alliance is hosting an evening of fine art & fine wines. Proceeds go directly toward our Community Endowment Fund which is the sole source of funding for our community health grants and medical/nursing school scholarship programs. 2017: Grants $48,150 and Scholarships $15,000.

April 21, 2018 $125 Dinner and Host Bar Del Paso Country Club Join our efforts to give back to the community by joining our growing list of sponsors or by making an auction donation of wine, art, restaurant gift certificates or event tickets.



Patron Sponsors $5,000


Featured Artists

Mercy Medical Group Barbara Arnold, MD (1) SSVMSA Board of Directors Deborah Bonuccelli Sorelle Gallery Fine Art William Chambers Sutter Medical Group Gary Dinnen David Evans, MD Masters Sponsors $2,500 Dignity Health Paula Finkler (3) Dr. Allen & Glenda Morris Chris Hayman Dr. Chris and Gabby Neubuerger Gregory Kondos (2) W.L. Gore & Associates, Inc. Clay Vorhes and more! Artisan Sponsors $1,000 Dr. Barbara Arnold, Dr. Charles & Sue Brownridge, Patty French, Heritage Oaks Hospital, Kronick, Muskovitz, Tiedemann & Girard, LLC, Sierra Sacramento Valley Medical Society, Sutter Independent Physicians, Drs. Gustavo & Mary Sosa. For donations/sponsorships contact Sue Brownridge at sue_bee@surewest.net or 916- 955-7753. For reservations e-mail Jerilyn Marr at j.marr@sbcglobal.net. To view art, learn about the benefits of sponsorship or to make a reservation go to ssvmsa.org/aom-2018. SSVMSA is a 501 (c) (3): Donations and Sponsorships are fully tax deductible.


Richard L. Johnson, MD 1918–2017 DR. RICHARD JOHNSON was an extraordinary individual. He was a highly respected physician, a leader in organized medicine, an avid writer and reader, editor of multiple publications, a great listener, a story teller and a devoted father. Through medical and civic organizations, he contributed to the profession and his community. He was born an only child in Weaverville, California and grew up in Arbuckle where he graduated from high school in 1935. He earned his BA from UC Berkeley 1939. He received his MD from UCSF, School of Medicine in 1942 and completed a year internship at Sacramento County Hospital in 1943. He was a Captain in the US Army from 1943 to 1946 serving as a physician in New Guinea, the Philippines and Japan. A two-year residency in Internal Medicine was completed at Milwaukee County Hospital in 1948. He was in solo practice in Sacramento from 1949 to 1987, and served as Medical Director of Sacramento County’s primary care clinics from 1988 to 1991, and then Medical Director of Correctional Health Services 1991 to 1993. He retired from practice in 1994. His involvement in community and civic organizations was impressive. He was on the medical staffs of Sutter and Mercy hospitals where he served on numerous committees and chaired many of them. He was twice appointed to the Citizens Advisory Committee on Aging by Governors Goodwin Knight and Edwin G. Brown. He was appointed and elected to attend several White House Conferences on Aging in the pre-Medicare era. He served as President of the Sierra Sacramento Valley Medical Society in 1978, and was Editor of the SSVMS journal, SSV Medicine for 22 years. He was a delegate to the California Medical Association and a Past Chair of CMA District XI. Shortly after his retirement, he moved to

Colusa where he was active in Colusa fraternal organizations, county health and mental health committees, special taskforces and advisory committees. He was very involved with the Colusi* County Historical Society where he served as President and later as editor of their publication Wagon Wheels. Dr. Johnson was awarded the Medical Society’s highest award, The Golden Stethoscope, in January 1986 for his contributions to the community and his medical practice. His mother pointed out many years ago that his interest in becoming a medical doctor began at age four after he became ill and was treated by a family physician in his home. Failing eyesight, hearing and Richard L. Johnson, MD memory loss made his final years difficult. However, he frequently became lucid and spoke clearly about his often-repeated desire to celebrate his 100th birthday, which he missed by 55 days. Richard visited me on my first day of work as Executive Director of the Medical Society. We became close friends from that day forward and shared letters and visited many times over the years. We will all miss him. He was predeceased in death by three wives, Muriel Marie Cannon, Merrie Lou Salas, Claire Wheeler Morgan, and one daughter, Victoria Johnson Sulski. He is survived by three daughters, Elizabeth Johnson, Ellen J. Norquist, and Caroline Johnson. *Colusa, Glenn A memorial service was held on his 100th and Tehama birthday in Colusa. Donations in his memory Counties were can be made to the SSVMS Medical Student at one time all Scholarship Fund, c/o Sierra Sacramento part of Colusi Valley Medical Society, 5380 Elvas Ave, Suite County – one of 101, Sacramento, CA 95819 or www.ssvms.org/ 27 original counprograms.aspx. ties of California. See www.colusi. com.

− Bill Sandberg March/April 2018



ANNUAL REPORT 150 Anniversary Edition th

Serving Over 3,600 Physicians in El Dorado, Sacramento & Yolo Counties

ssvms.org | facebook/ssvms | @ssvms | 5380 Elvas Ave. Suite 101, Sacramento, CA 95819 | 916.452.2671

The Sierra Sacramento Valley Medical Society (SSVMS) is dedicated to bringing 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. In continuous operation since 1868, SSVMS is the oldest medical society in California with over 3,600 physician members in Sacramento, El Dorado and Yolo Counties. SSVMS is a nonprofit organization, and is a component society of the California Medical Association (CMA). SSVMS provides many benefits to our members by advocating for physicians and their patients to ensure access to quality healthcare. We achieve this through: Dedicated physician led committees; A 44-member delegation that develops and recommends health care policy positions at the local, state and national levels; Economic advocacy, legal and practice management assistance to help physicians and their practices; Events throughout the year to provide physicians fellowship and professional development opportunities; Programs that help physicians reclaim the joy of practicing medicine; Philanthropic programs that are committed to supporting the future of medicine and providing access to care to those in need. In essence, SSVMS’s core activities help physicians maintain practice viability, connect with fellow physicians, and allows them to focus on what’s most important; caring for their patients.

MeMbershiP growth

2017 President-elect Message

3500 3000 2500 2000 1500 1000 500 2013





shaPing healthcare in 2017 SSVMS and CMA advocate for physicians and the patients they serve at the local, state and national level. Significant 2017 victories: • Defended Medical Staff self-governance by protecting California law to ensure that medical staffs stay distinct and separate from hospitals. • Secured over $1 billion annually to improve Medi-Cal provider reimbursements and an increase in graduate medical education funding. • Increased funding to Sacramento County Maddy Fund by 100%. • Passed Legislation to remove pain as the fifth vital sign and allow for partial fills of opioids. • Convinced CMS to further reduce 2018 MACRA reporting burdens. Learn more at ssvms.org.

This is a special time for all of us as we celebrate the 150th anniversary of our medical society. Moving from a handful of physicians to 3,600 members now, the medical society has become a powerful guiding force for our profession that enables us to continue serving our patients. The pen 2018 President has been replaced by the computer, Rajiv Misquitta, MD and email and iPhones dominate. But compassion and connection are still elements that are vital qualities of physicians that cannot be replaced. As physicians, no matter the specialty, we all seek the same thing. Doing what is best for our patients and ensuring that our profession endures. With uncertainty in the air, and the rapidly changing insurance environment, the medical landscape is evolving at a rapid pace. Medicine is one of the most heavily regulated professions, and with so many competing demands placed on the lives of physicians, it is not surprising that burnout is on the rise within our profession. SSVMS, once again, rose to the challenge by establishing the Joy of Medicine program. I had the opportunity to chair this group, which is composed of talented physician leaders. We had a successful summit last September with 180 physicians in attendance. I have no doubt that if we put our minds together, we stand a better chance of coming up with solutions. Thank you for all you do for your patients and for the community. I look forward to your engagement as we tackle the issues of the new year and am confident that, together, we can sail through gracefully. Finally, I invite you all to take a moment to think about why you went into medicine. What better way to bring the joy back than to go back to the beginning. ~ rajiv.misquitta@gmail.com

Join over 3,600 physician members that are making a difference in the lives of colleagues and the patients they serve.

Community Programs

ssVms Has Cared For PHysiCians & tHe Patients tHey serVe For 150 years

Sierra Sacramento Valley Medical Society (SSVMS) involves physicians in community service, education, and research through its charitable programs. SSVMS’ Community Programs and services are focused on increasing access to healthcare, improving health outcomes, mental health advocacy, physician wellness and building the future of medicine. SSVMS’ Community Programs are supported by grants and generous donations from our members and from the community.

sPirit Program #SPIRITHeals SSVMS’ Sacramento Physicians’ Initiative to Reach out, Innovate and Teach (SPIRIT) program recruits and places physician volunteers to donate medical services to the medically indigent and uninsured members of our community. Working together with partner physicians and the region’s health systems, the SPIRIT Program provides uninsured people in the Sacramento region the care that helps them lead healthier, more productive lives. Since the its inception, SPIRIT has provided over $10 million in free care, treated over 50,000 patients and performed over 1,000 surgeries. In 2017: +

45 Volunteer PHysiCians 50+ surgeries PerFormed 900+ Patients treated $350k in donated serViCes rX saFe PHysiCians Program #SSVMSCares

SSVMS’ RX Safe Physicians program is a partnership with the Sacramento County Opioid Task Force and Partners in Care of El Dorado County. This physician led coalition includes community members and experts collaborating to prevent opioid misuse and abuse to help save lives The program focuses on educating providers regarding safe prescribing, promoting complimentary methods of pain management to physicians and patients and increasing access to naloxone.

Joy oF mediCine Program #SSVMSGratitude SSVMS’ Joy of Medicine program relieves physician pain and helps them to reclaim the joy of practicing medicine through education, advocacy and program services designed to nurture individual well-being and collegiality and to promote systems-wide change. Through the Joy of Medicine program, SSVMS supports physician wellness and personal resilience through no-cost consultations and education, connecting with colleagues through socials and physicians peer groups, and collaborating with leaders to foster a culture of wellness in the local physician community. For more information and to access wellness resources, visit:

JoyofMedicine.org 28

Sierra Sacramento Medicine Help Valley SSVMS change

lives. Volunteer or consider making a tax deductible donation at ssvms.org/programs.

Community Programs

ssVms Has Cared For PHysiCians & tHe Patients tHey serVe For 150 years

donate $150 to Commemorate ssVms’ 150 year anniVersary! smart mediCal ClearanCe #MentalHealthAdvocacy Patients in mental health crisis frequently present to one of the Sacramento Region’s Emergency Departments (ED) for medical evaluation and treatment. Recognizing that the ED is not an optimal environment for patients in psychological distress, SSVMS convened emergency medicine physicians and psychiatrists to develop and implement the SMART Medical Clearance protocol to standardize the medical clearance process across all EDs and inpatient psychiatric hospitals with the goal of improving the quality of care for patients in crisis. The SMART protocol facilitates the safe and timely transfer of patients to appropriate treatment centers in a resourceconscious way by relying on evidence-based medicine and thorough history and physical exams. For more information and access to resources visit:

SMARTMedicalClearance.org mediCal student sCHolarsHiP Fund #FutureofMedicine Since 1969, SSVMS has supported the future of medicine by providing scholarships to deserving medical students who have graduated from a high school in El Dorado, Sacramento or Yolo Counties. Awardees, including the Paul J. Rosenberg, M.D. Scholar, are officially recognized at SSVMS’ Annual Awards and Installation Dinner. In 2017:

$13k+ Granted

50+ years suPPorting tHe Future oF mediCine museum oF mediCal History #SSVMSTeaches SSVMS’ Museum of Medical History showcases the history of medicine in our region and features medical artifacts from the fields of Surgery, Clinical Diagnosis, Infectious Disease, Pharmacy, Radiology, Chinese Medicine, Obstetrics and Gynecology and Medical Quackery. It is staffed by the Medical Society’s Historical Committee and is operated entirely from community donations. The museum is free of charge and open to the public. In 2017:

1500+ Visitors 35+ sCHools & Community grouPs

March/April 2018 Help SSVMS change lives. Volunteer or consider making a tax deductible donation at ssvms.org/programs.


THANK YOU 2017 DONORS Jose Abad, MD Ruenell Adams Jacobs, MD Jesse Adams, MD Sallie Adams, MD -DPHV$IĂ HFN0' .DWKU\Q$PLULNLD0' Helen Armstrong, MD -RKQ%HONR0' -RDQQH%HUNRZLW]0' (/DZUHQFH%LQJKDP0' &KDUOHV%UDGEURRN0' Oliver Bray Marcia Britton-Gray, MD 'RQDOG%URZQ0' -DFN%UXQHU0' Harvey Cain, MD JD Alvin Cheung, PHARMD Randall Childers, MD Jeffrey Clayton, MD Ronald Cole, MD Michelle Corbier, MD Diana Costa Jose Cueto, MD Benjamin Cutshall, MD Sean Deane, MD 3KLOLS'LUNVHQ0'

Irene Dold 'DYLG'R]LHU-U0' Ron DuPont Thomas Ferguson, MD Christine Fernando, MD )DLWK)LW]JHUDOG0' .LHUDQ)LW]SDWULFN0' James Foerster, MD Leah Frey LaBaron 5LFKDUG)ULQN0' )UDQFLQH*DOODZD0' Enid Gallegos Bennett Genis Ann Gerhardt, MD Christopher Gresens, MD Guy Guilfoy, MD Carolyn Haase, MD Cary Hart, MD Carol Havens, MD Marti Holland Romie Holland, MD Julian Holt, MD 'RQDOG+RSNLQV0' Caron Houston, MD 0RQWH,NHPLUH0'

Richard Isaacs, MD Richard Jones, MD Mildred Kahane Robert Kahle, MD Carol Kimball, MD Ralph Koldinger, MD Linda Kuachusri Namin Kuachusri, MD 0RQLFH.ZRN0' Scarlet La Rue, MD *UDQW/DFNH\3K' Robert LaPerriere, MD Leah LeBaron Kenneth Lee, MD Daniel Lee, MD Donald Lyman, MD 6DQGUD0HQGH]0' George Meyer, Jr., MD Rajiv Misquitta, MD Susan Murin, MD Anh Huynh Nguyen, MD Northern CA Wine Society M.B. O’Neil, Jr., MD Thomas Ormiston, MD John Osborn, MD

)UDQN3DOXPER0' %KDYLQ3DULNU0' 5LFKDUG3DUN0' Gibbe Parsons, MD Mary Pauly, MD Joel Pearlman, MD Ron Petrich, MD Janet Philbin Myra Pierce, MD Gail Pirie, MD Gerald Pogoriler, MD Uday Poonamallee, MD Paul Reynolds, MD John Rice, MD Dale Robbins, MD Gerald Rogan, MD -DFN5R]DQFH0' Patricia Samuelson, MD Michael Schermer, MD 'RXJODV6FKZLON0' Christian Serdahl, MD .XSSH6KDQNDU0' Elaine Silver, MD 0DUN6NLQQHU0' Meryllene M. Smith

Craig Smith, MD /HH6QRRN0' Linda Solorio 5RQQLH6SULQNOH0' (6WURXS6NLQQHU Judith and Sol Tane Clarissa Tendero, MD Captane Thomson, MD Glennah Trochet, MD -RKQ7XFNHU0' 7KRPDV9DOGH]0' Amy Wandel, MD John Wiesenfarth, MD James Wells, MD Robert Wendel, MD Bill West Patricia Wells, MD Eric Williams, MD Rose Mary Williams, MD Frances Wilson, MD Garrett Wong, MD Gordon Wong, MD Peter Wu, MD Peter Yip, MD Ramiro Zuniga, MD

BloodSource, Inc CA Dept. of Public Health Dignity Health HUB International

Kaiser Permanente Mercy Medical Group NORCAL Mutual No. CA Lions Sight Association

Sac County Health & Human Services Serotonin Surge Charities SSVMS Alliance Sutter Independent Physicians

Sutter Medical Group The Doctors Company The Permanente Medical Group The Physicians Foundation

UC Davis Health System United HealthCare 86%DQN Woodland Medical Group

Thank you Family of Paul J. Rosenberg, MD, for a very generous donation to the SSVMS Medical Student Scholarship Fund.

THANK YOU 2017 VOLUNTEERS 0XKDPPDG$I]DO0' 6KDZQ$JKLOL0' Richard Areen, MD Richard Astorino, MD ,PUDQ$XUDQJ]HE0' <HNDWHULQD$[HOURG0' Robert Bellinoff, MD Brian Bellucci, MD 0LFKDHO%HQHNH0' Paul Bilunos, MD /DZUHQFH%LVWURQJ0' Susan Lai Boone, MD %DUWRQ%UDGVKDZ0' 3DWULFLD%UDGVKDZ -DFRE%UXEDNHU0' Margaret Chang, MD George Chiu, MD Alan Cubre, MD David Cupp, MD Richard DeFelice, MD (GZDUG'HQ]2' Pooja Patricia Desa, MD

.DSLO'KDZDQ0' Adnan Din, MD 0DUN(QGLFRWW0' Robert Equi, MD Malcolm Ettin, MD 0LFKDHO)D]LR0' )UDQFLQH*DOODZD0' 0DUYLQ*DW]0' Brian Golden, MD Nathaniel Gordon, MD Jeffrey Graham, MD $OH[DQGHU*UDQG0' Eli Groppo, MD 5LFKDUG*UXW]PDFKHU0' James Hamill, MD 5XWK+DVNLQV0' Zeenat Hasan, MD G. H. Hayat, MD Saman Hayatdavoudi, MD Donald Hayden, MD David Herbert, MD Julian Holt, MD

Susan Hooten, MD 'RQDOG+RSNLQV0' $QGUHZ+XGQXW0' 'DQLHO,NHGD0' Gabriel Jacob, MD -RHOOH-DNREVHQ0' Mary Ann Nau Johnson, MD Richard A. Jones, MD %XU]HHQ.DUDQMDZDOD0' $PLW.DUPDNDU0' Michael Kearns, MD Abdul Khaleq, MD Richard Kim, MD 6DPLUD.LUPL]0' Rosalind Kirnon, MD David Kissinger, MD Christiana Kopf, MD Robert LaPerriere, MD 0LFKDHO/DZVRQ0' Michael Leathers, MD Dennis Lee, MD Samuel Lee, MD

5LFKDUG$ODQ/HZLV0' Alan Young Lim, MD 0DUN/LVFKQHU0' Eric London, MD Sapoora Manshaii, MD (OLVDEHWK0DWKHZ0' Carlos Medina, MD Roger Mendis, MD George Meyer, Jr., MD 7LPRWK\0LFNHO0' Imran Mohammed, MD Peter Murphy, MD Richard Murray, MD Haritheertham Nagaraj, MD David Naliboff, MD Bilal Naseer, MD Helen Nutter, MD Herminio Ojeda, MD Jessica Oliver Patricia Ostrander, MD 5DQGDOO2Z0' Senator Richard Pan, MD, MPH



President - Ruenell Adams Jacobs, MD President- Elect- Rajiv Misquitta, MD Immediate Past President - Thomas Ormiston, MD Secretary - Christian Serdahl, MD Treasurer - John Wiesenfarth, MD

Alicia Abels, MD Ruenell Adams Jacobs, MD Jose Arevalo, MD Barbara Arnold, MD Sean Deane, MD Katherine Gillogley, MD Marcia Gollober, MD



District 1 - Seth Thomas, MD District 2 - Tonya Fancher, MD District 2 - J. Bianca Roberts, MD 'LVWULFW7KRPDV9DOGH]0' District 4 - Ranjit Bajwa, MD District 5 - Sean Deane, MD District 5 - Cynthia Ramos, MD District 5 - Paul Reynolds, MD District 5 - Eric Williams, MD District 6 - Carol Kimball, MD ([HFXWLYH'LUHFWRU$LOHHQ(:HW]HO

Arun Patel, MD Sarju Patel, MD Robert Peabody, Jr., MD Joel Pearlman, MD Kent Perryman, PhD Gail Pirie, MD Ajay Ranade, MD J. Brian Reed, MD Roberta Rimbault -DPHV5\END0' Garrett Ryle, MD Janahn Scalapino, MD 3DWULFLD%HDWUL]6LHUUD0' Christianna Stuber, MD &KULVWLDQ6ZDQVRQ0' David Telander, MD Michael Trauner, MD Tony Tsai, MD Robert Wendel, MD Eric Williams, MD Daniel Wong, MD Alan Yee, MD


Alternate Delegates 0HJDQ$Q]DU%DEE'2 Richard Bermudes, MD Harmeet Bhullar, MD, Natasha Bir, MD Helen Biren, MD Arlene Burton, MD Ronald Chambers, MD

District XI Trustees

Douglas Brosnan, MD, JD

Richard Gray, MD 5HLQKDUW+LO]LQJHU0' Russell Jacoby, MD Kevin Jones, DO Richard Jones, MD Charles McDonnell, MD Rajiv Misquitta, MD

Janet Oâ&#x20AC;&#x2122;Brien, MD Tom Ormiston, MD Senator Richard Pan, MD Kuldip Sandhu, MD James Sehr, MD Don Wreden, MD /\GLD:\WU]HV0'

Amber Chatwin, MD Mark Drabkin, MD Ann Gerhardt, MD Karen Hopp, MD Carol Kimball, MD Derek Marsee, MD, PhD

6DQGUD0HQGH]0' Ernesto Rivera, MD Armine Sarchisian, MD Ajay P. Singh, MD Christopher Swales, MD 7KRPDV9DOGH]0'

Margaret Parsons, MD

Sierra Sacramento Valley Medical Society 2018 Committee Appointments Editorial Drs. Sean Deane, Ann Gerhardt, Caroline Giroux, Sandra Hand, Nate Hitzeman, Robert LaPerriere, George Meyer, John Ostrich, Karen Poirier-Brode, Gerald Rogan, Glennah Trochet, Lee Welter; Medical Students, John Paul Aboubechara, MS (UCD), Maria Garnica, MS (UCD), Steven Nemeck, MS (CNSU), Neeraj Ramakrishnan, MS (CNSU); and Nan Crussell, Managing Editor.

Emergency Care Drs. Peter Hull, Chair; Seth Thomas, Vice Chair; Nicole Braxley, Matthew Donnelly, Andrew Elms, Roel Farrales, Hernando Garzon, Vinh Le, Maurice Makram, Devin Merchant, Joseph Morris, Karen Murrell, Dwight Stalker, R. Steve Tharratt, Sam Turnipseed, Justin Wagner, William Webster, David Wisner, Rodolpho Zaragoza.

Historical Drs. Robert LaPerriere, Chair; Richard Astorino, Peter Carruth, Malcolm Ettin, Christine Fernando, Francine

Gallawa, James Hamill, Julian Holt, Donald Hopkins, Rosalind Kirnon, Elisabeth Mathew, Jack Ostrich, Gail Pirie, and James Rybka; Kent Perryman, Ph.D. (guest).

Public and Environmental Health Drs. Glennah Trochet, Chair; Ruenell Adams Jacobs, Regan Asher, Ron Chapman, Clinton Collins, Anthony DeRiggi, Christine Fernando, Ann Gerhardt, Sandra Hand, Maya Heinert, Maynard Johnston, Olivia Kasirye, Samira Kirmiz, Donald Lyman, Robert Meagher, Dennis Michel, Robert Midgley, Mary Pat Pauly, Paul Phinney, Karen Poirier-Brode, Richard Sun, Nancy Williams, Medical Students Dayna Isaccs, MS (UCD) and Zachary Nicholas, MS (CNSU).

Scholarship and Awards Drs. Margaret Parsons, Chair, Ruenell Adams Jacobs, Sean Deane, Ruth Haskins, Paul Kaplan, Paul Kelly, Samira Kirmiz, George Meyer, Travis Miller, Susan Murin, Jack Ostrich, Mary Pat Pauly, James Sehr.

Strange But True Medical Cases RECENTLY, THE SSVMS Editorial Committee discussed some unusual patient complaints. We thought it might be interesting for our readers to share a case or two of “The strangest medical complaints I have encountered as a physician, and what was the final diagnosis?” Does one come to mind? Send it in and we may use it here.

An elderly female patient came into the ER having been stung by a bee. After reassuring her that she was fine, she then takes a bottle out of her purse and tells me she put the bee in it that stung her. She then asked me if it was a healthy bee or not that stung her. After examining the bee, I told her, “For a dead bee, this is the healthiest bee I have ever seen.” She was reassured and went on her way. –Robert Bellinoff, MD

March/April 2018


Respiratory Rate The Inaccurate Vital Sign – Making it Accurate – A Call to Action.

By Drs. Christian Sebat, Frank Sebat, and Gerald Rogan SUMMARY: The respiratory rate (RR) is an important vital sign of early clinical decline. Commonly it is estimated, not measured. An inaccurate estimation or measurement may hide looming, but otherwise detectable, physiologic deterioration

Christian Sebat, MD

Frank Sebat, MD

Gerald Rogan, MD


A “Code Blue” is called overhead, while you are admitting a patient through the emergency department. As the hospitalist “on call,” you run upstairs to the medical floor. Upon arrival to the patient’s bedside, you assume CPR leadership. The patient regains spontaneous circulation and is transferred to the ICU. After transfer, you debrief the nursing staff. You learn that the patient had been admitted for community acquired pneumonia and remained febrile. The patient had a change in mental status prompting the bedside RN to activate the Rapid Response Team (RRT). From review of the electronic medical record (EMR), the patient was febrile and the charted respiratory rate (RR) was 16 to 18 breaths per minute up to five minutes prior to the RRT. However, the RRT RN measured RR at 26. Upon review of the notes from one respiratory therapist, the patient had been tachypneic (22-26) since admission. Why the difference and is it important? The RR is a traditional vital sign (VS) with a normal rate between 8 and 18 in adults. It is the most sensitive (vital) sign of an early physiologic decline that may otherwise be clinically unapparent. The RR change may be measurable before a patient shows significant changes to other vital signs including blood pressure, heart rate, cognition, and urine output. Accordingly, an abnormal RR should prompt further evaluation by the patient’s nurse, primary care team or a rapid response team, and, when Sierra Sacramento Valley Medicine

indicated, prompt intervention. In addition to the well-known traditional drivers of respiration (i.e. pCO2, pO2, anxiety), RR is often increased early in acute disease due to circulating inflammatory cytokines from sepsis or SIRS. Increases in RR also can occur as a result of increased physiologic dead space and V/Q mismatch in the lung from hypovolemia, PE, hypotension, and low cardiac output states. Additional stimulation of respiratory drive also can occur from activation of lung mechano/chemoreceptors receptors from early parenchymal lung inflammation or increased lung water (i.e. chest trauma, pulmonary edema, PE, CHF or infection). These physiologic perterbations either separately, or in combination, directly affect the respiratory control centers. Thus, increased RR is a sentenal sign of early clinical decline and is often associated with a respiratory alkalosis long before the development of a metabolic acidosis, which is often a late manifestation of patient deterioration. Finally, bradypnea or a RR of 8 or less is often a sign of narcotic and/or sedative complications. Despite its importance as an early and subtle indicator of physiologic decline, RR often is estimated, not measured. The current standard for measuring RR outside of the ICU is to manually count the number of breaths over one full minute, but this is rarely done because it requires the clinician to observe both a time piece and the patient for an entire 60 seconds, apparently not an easy task given studies showing significant variability in RR determination between trained clinicians on the same patient. In practice, most clinicians base a RR

“measurement” on how the patient looks, using gestault and intuition to estimate the RR value. Some providers may actually measure the RR for 15 seconds, and then extrapolate it to one minute. This short measurement time is unreliable in adults. For example, if the true RR were 15, a 15-second measurement may show 3-5 breaths, which would yield a RR calculated of 12-20: a 25 percent variation from the true rate. By contrast, the typical heart rate is 60-100. Assume the HR is 80. A 15-second measure that misses or adds one or two beats would yield a HR of 76-84: a variation of only 8 percent. These errors in RR determination are further compounded by the clinicians’ bias toward recording values that are normal, if they think that the patient looks okay. If these problems are addressed, timely and accurate RR measurement would help identify a deteriorating patient early often before there is a significant change in mental status, HR, BP, urine output, etc., and thus, before significant complications develop. An observed change in RR should prompt a timely reassessment of the patient and intervention, if indicated, to improve outcomes. This task is now aided by newly available small, inexpensive easy to use, wireless devices to capture accurately and promptly RR abnormalities. The impact of this new technology is being studied and initial results are promising. We invite you to discuss the importance of accurate and timely RR measurement on the general ward patients with your medical staff. Your


Kelly K elly Rackham Rackha m [916] 616 6270 planetkelly@me.com www.planetkelly.com


hospital committees responsible for education and quality should consider taking up this issue to reduce failure to rescue and its associated morbidity, mortality and cost. cmsebat@ucdavis.edu fsebat@aol.com jerryroganmd@sbcglobal.net Christian Sebat, DO, is director of the Medical Intensive Care Unit at UC Davis. His father, Frank Sebat, MD, has directed critical care services for several hospitals within the central valley for over three decades and is director of Kritikus Foundation, a non-profit dedicated to reducing failure to rescue. Gerald Rogan, MD, contributed to editing the article. REFERENCES Over two dozen sources were cited in this article. The list is available upon request from the authors.

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 | pestopinal@rwbaird.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.

March/April 2018


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. — Carol Kimball, MD, Secretary. APPLICANTS FOR ACTIVE MEMBERSHIP: Jawad Ali, MD, General Surgery, University of Texas Medical School - San Antonio – 2011, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento, CA 95823 Richard Applegate, MD, Anesthesiology, Loma Linda University School of Medicine – 1982, UC Davis Medical Group, 4150 V St, Sacramento, CA 95817 Natalie Battle, MD, Hospice and Palliative Medicine, Washington University School of Medicine – 2010, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825 Andrew Bregman, MD, Psychiatry, University of California Davis Medical Center – 2012, The Permanente Medical Group, 6600 Bruceville Rd., Sacramento, CA 95823 Biljinder Chima, MD, Family Practice, Ross University School of Medicine – 2007, Rocklin Family Practice & Sports Medicine, 3104 Sunset Blvd. #2B, Rocklin, CA 95677 William Cho, MD, Urology, Indiana University School of Medicine – 1981, Mercy Medical Group, 3000 Q. St., Sacramento, CA 95816 Samjot Dhillon, MD, Internal Medicine, All India Institute of Medicine Sciences – 1997, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825 Raymond Dougherty, MD, Diagnostic Radiology, Pennsylvania State University, College of Medicine – 1984, UC Davis Medical Group, 4610 X Street, Education Building # 3124, Sacramento, CA 95817 Mohammadomid Edrissian, MD, Internal Medicine, Tehran University Of Medical Sciences and Health Services – 1995, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento, CA 95823 Joshua Elder, MD, Emergency Medicine, David Geffen School of Medicine at UCLA – 2012, UC Davis Medical Group, 4150 V Street #2100, Sacramento, CA 95817 Wei Fan, MD, Hospitalist, Georgetown University School of Medicine – 2014, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento, CA 95823 Clarisse Glen, MD, Internal Medicine, St. George’s University School of Medicine – 2007, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825 Pantea Hashemi, MD, Dermatology, Tehran University of Medical Sciences – 2005, Medical Dermatology and Cosmetic Clinic of Northern California, 650 University Ave, # 200, Sacramento, CA 95825


Kyi Kyi Htein, MD, Hospitalist, Mandalay Institute of Medicine – 2004, Mercy Medical Group, 6501 Coyle Ave., Carmichael, CA 95608 Razvan Hurezeanu, MD, Internal Medicine, Ross University School of Medicine – 2014, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento, CA 95823 Ioana Ianus, MD, Anesthesiology, Universitatea De Medicina Si Farmacie - Carol Davila – 1996, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825 Mohsin Jawed, MD, Family Practice, Ross University – 2013, The Permanente Medical Group, 10305 Promenade Parkway, Elk Grove, CA 95757

Catharine Malmsten, MD, Cardiology, University of California School of Medical - S.F. – 2003, Mercy Medical Group, 9394 Big Horn Blvd., Elk Grove, CA 95758 Abhilash Nair, MD, Pulmonary, Critical Care, Calicut University Medical College – 1994, Pulmonary Medical Associates, 5 Medical Plaza Drive, Suite 190, Roseville, CA 95661 Mark Navarro, MD, Internal Medicine, Michigan State University – 2010, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento, CA 95823 Eleanor Ormsby, MD, Radiology, University of California Irvine - CA College of Med – 2004, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825

Anthony Jerant, MD, Family Practice, Saint Louis University School of Medicine – 1991, UC Davis Medical Center, 4860 Y St #2300, Sacramento, CA 95817

Dan Parker, MD, Sports Medicine, Tufts University School of Medicine – 2008, Woodland Clinic Medical Group, 632 W. Gibson Rd., Woodland, CA 95695

James Kim, MD, Plastic Surgery, University of Pittsburgh School of Medicine – 2000, The Permanente Medical Group, 6600 Bruceville Rd., Sacramento, CA 95823

Kelly Pham, MD, Radiology, Ohio University College of Osteopathic Medicine – 1999, The Permanente Medical Group, 6600 Bruceville Rd., Sacramento, CA 95823

Philip King, MD, Family Practice, St. George’s University School of Medicine – 2006, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825

Arleen Ram, MD, Hopsitalist, Ross University School of Medicine – 2014, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento, CA 95823

Justin Kohl, MD, Family Practice, University of Minnesota Medical School – 2013, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825 Hemant Kudrimoti, MD, Neurology, University of Bombay, Grant Medical College – 1991, Mercy Medical Group, 6555 Coyle Ave. Suite 120, Carmichael, CA 95608 Jasmine Lahel, DO, Family Practice, Touro University College of Osteopathic Medicine – 2014, The Permanente Medical Group, 10305 Promenade Parkway, Elk Grove, CA 95757 Kathleen S. Larkin, MD, Ob/Gyn, Ohio State University College of Medicine – 2006, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825 Giao Le, MD, Family Practice, St. George’s University School of Medicine – 2006, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825 Andrew K. Lee, DO, Family Practice, Touro University of Nevada College of Osteopathic Medicine – 2014, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825 Laure Lee, MD, Internal Medicine, UC San Diego – 1992, The Permanente Medical Group, 1955 Cowell Blvd, Davis, CA 95616

Sierra Sacramento Valley Medicine

Jaiwant Rangi, MD, Endocrinology, Lady Hardinge Col, India – 1996, Capitol Endocrinology, 3106 Ponte Morino Drive, Suite C, Cameron Park, CA 95682 Jesse Reinking, DO, Psychiatry, Touro University College of Osteopathic Medicine – 2012, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825 Aaron Rosenberg, MD, Hematology/Oncology, Mt Sinai School of Medicine of City University of NY – 2006, UC Davis Medical Group, 4501 X St, Sacramento, CA 95817 Saman Samadani, MD, Family Practice, Ross University School of Medicine – 2010, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento, CA 95823 Jyoti Saxena, MD, Family Practice, All India Institute of Medicine Sciences – 1991, The Permanente Medical Group, 1955 Cowell Blvd, Davis, CA 95616 Brian Snyder, MD, Emergency Medicine, Southern Illinois School of Medicine – 2009, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825 Mark Sucher, MD, Orthopaedic Surgery, University of Missouri School of Medicine – 2010, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento, CA 95823

Kit Tittiranonda, MD, Radiology, Medical College of Ohio At Toledo – 1996, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825

Daniel Wong, MD, Endocrinology, Temple University School of Medicine – 2007, Sutter Medical Group, 1020 - 29th St Ste 270, Sacramento, CA 95816

Vivan Tran, DO, Hospitalist, Kansas City University of Medicine & Biosciences – 2014, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento, CA 95823

Meghan Wood, MD, Emergency Medicine, University of California School of Medicine - Los Angeles – 2009, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825

Linda Truong, DO, Internal Medicine, Western Univ of Hlth Sciences – 2012, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825

Bing Xu, MD, Family Practice, Ross University School of Medicine – 2014, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento, CA 95823

Andrew Cheng-Wei Wong, MD, Emergency Medicine, UC Davis Medical Group, 4150 V Street, Sacramento, CA 95817

Noah Yuen, MD, General Surgery, University of Hawaii School of Medicine – 2011, The Permanente Medical Group, 2025 Morse Ave, Sacramento, CA 95825

APPLICANTS FOR RESIDENT/FELLOW MEMBERSHIP: James P. Dompor, DO, Neurology, UC Davis Medical Center Resident & Fellow Prog – 2019, 4860 Y Street, Ste 3700, Sacramento, CA 95817 Eve Angeline Hood-Medland, MD, Internal Medicine, UC Davis Medical Center Resident & Fellow Prog – 2019, 4150 V Street Ste 2400, Sacramento, CA 95817

Board Briefs December 11, 2017

January 8, 2018

The Board: Received a legislative update regarding changes in the Medi-Cal program from Senator Richard Pan, MD. Received a presentation on Diversity and Inclusion from Kerry Sakimoto, CMA Research Associate for the Center for Legal Affairs. Approved the Financial Statements ending October 31, 2017. Approved the 2018 Committee Appoint-ments. Approved the Membership Report: For Active Membership – Jawad Ali, MD; William Cho, MD; Samjot Dhillon, MD; Raymond Dougherty, MD; Mohammadomid Edrissian, MD; Joshua Elder, MD; Wei Fan, MD; Clarisse Glen, MD; Razvan Hurezeanu, MD; Ioana Ianus, MD; Mohsin Jawed, MD; Philip King, MD; Anthony Jerant, MD; Justin Kohl, MD; Jasmine Lahel, DO; Giao Le, MD; Mark Navarrow, MD; Arleen Ram, MD; Saman Samadani, MD; Mark Sucher, MD; Vivan Tran, DO; Linda Truong, DO; Daniel Wong, MD; Bing Xu, MD; Noah Yuen, MD. For Resident Active Membership – James P. Dompor, DO; Eve Angeline Hood-Medland, MD. For Transfer into Active Membership from Orange County – Andrew Cheng-Wei Wong, MD. For Retired Membership – Mark Blum, MD; Gordon C. Hunt, Jr., MD. For Transfer of Membership – Nhan Nguyen, MD to San Franciso; Madison Pham, DO to Alameda-Contra Costa; Kapil Dhingra, MD to Alameda-Contra Costa; Alonzo S. Woodfield, MD to Alameda-Contra Costa; Christina Chao, MD to Alameda-Contra Costa.

The Board: Welcomed Rajiv Misquitta, MD, as the 2018 SSVMS President. Extended a thank you to outgoing President, Ruenell Adams Jacobs, MD for her leadership in 2017. Also welcomed new Directors, Ravinder Khaira, MD, representing District 3 (South Area), Vijay Rathore, MD, representing District 5 (The Permanente Medical Group) and Vanessa Walker, DO, representing District 2 (Central Area). Elected Carol Kimball, MD 2018 Secretary and John Wiesenfarth, MD 2018 Treasurer. Approved the Membership Report: For Active Membership – Richard Applegate, MD; Natalie Battle, MD; Andrew Bregman, MD; Biljinder Chima, MD; James Kim, MD; Hemant Kudrimoti, MD; Kathleen Larkin, MD; Andrew Lee, DO; Laure Lee, MD; Catharine Malmsten, MD; Eleanor Ormsby, MD; Kelly Pham, MD; Jaiwant Rangi, MD; Jesse Reinking, DO; Jyoti Saxena, MD; Brian Snyder, MD. For Reinstatement to Active Membership – Pantea Hashemi, MD. For Retired Membership – Alicia Abels, MD; Ronald Foltz, MD; Marc Schiff, MD. For Transfer of Membership – Michael Hogarth, MD (to San Diego).

March/April 2018


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CME Certification Services Discounted CME Certification for members

CMA’s Institute for Medical Quality (IMQ)

Health Information Technology Free secure messaging application

DocBookMD www.docbookmd.com/physicians/

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

MedicAlert www.cmanet.org/groupdiscounts

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%

StaplesAdvantage www.cmanet.org/groupdiscounts

Physician Laboratory Accreditation 15% off lab accreditation programs and services Members only coupon code required

COLA www.cmanet.org/groupdiscounts

Security Prescription Products 15% off tamper-resistant security subscription pads

RxSecurity www.rxsecurity.com/cma-order


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

SSVMS Publications

www.ssvms.org/publications.aspx Sierra Sacramento Valley Medicine (bi-monthly magazine) Medical Society News (monthly e-Bulletin)

info@ssvms.org | (916) 452-2671

SSVMS 150 Anniversary th


Saturday, May 5, 2018 6PM - 8:30PM Sutter’s Fort, Sacramento Experience the history of SSVMS and Sutter’s Fort with food, beverages, live pioneer music, games, & prizes Free Family-Friendly Event for Physician Members and Guests RSVP by April 27th with Mei Lin at MJackson@ssvms.org or call 916-452-2671

Profile for Sierra Sacramento Valley Medical Society

2018-Mar/Apr - SSV Medicine  

Sierra Sacramento Valley Medicine is the official journal of the Sierra Sacramento Valley Medical Society (SSVMS) and promotes the history,...

2018-Mar/Apr - SSV Medicine  

Sierra Sacramento Valley Medicine is the official journal of the Sierra Sacramento Valley Medical Society (SSVMS) and promotes the history,...