louisville medicine - Greater Louisville Medical Society

Transcription

LOUISVILLE
GREATER LOUISVILLE MEDICAL SOCIETY
MEDICINE
VOL. 62 NO. 4 SEPTEMBER 2014
SMOKING
50 YEARS AFTER THE LANDMARK 1964
SURGEON GENERAL’S REPORT
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LOUISVILLE MEDICINE
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GLMS BOARD OF GOVERNORS
James Patrick Murphy, MD, MMM, board chair
Bruce A. Scott, MD, president and AMA delegate
Robert H. Couch, MD, MBA, president-elect
Heather L. Harmon, MD, vice president
John L. Roberts, treasurer
Tracy L. Ragland, MD, secretary
Frank R. Burns, MD, at-large
John D. Kolter, MD, at-large
Jeffrey L. Reynolds, MD, at-large
Neal J. Richmond, MD, at-large
Wayne Tuckson, MD, at-large
Regi Varghese, MD, at-large
Fred A. Williams Jr., MD, KMA president
Randy Schrodt Jr., MD, KMA 5th district trustee
David R. Watkins, MD, KMA 5th district
alternate trustee
K. Thomas Reichard, MD, GLMS Foundation president
Stephen S. Kirzinger, MD, Medical Society Professional Services president
Toni M. Ganzel, MD, MBA, dean,
U of L School of Medicine
LaQuandra S. Nesbitt, MD, MPH, director,
Louisville Metro Department of Public
Health & Wellness
Karyn Hascal, The Healing Place president
Michelle Feger & Rhonda Rhodes ,
GLMS Alliance co-presidents
LOUISVILLE MEDICINE EDITORIAL BOARD
Editor: Mary G. Barry, MD
Elizabeth A. Amin, MD
Waqar C. Aziz, MD
Deborah Ann Ballard, MD, MPH
R. Caleb Buege, MD
Arun K. Gadre, MD
Stanley A. Gall, MD
Larry P. Griffin, MD
Jonathan E. Hodes, MD, MS
Martin Huecker, MD
Thomas James, III, MD
Teresita Bacani-Oropilla, MD
Tracy L. Ragland, MD
Ben Rogers, MD
M. Saleem Seyal, MD
Dave Langdon, Louisville Metro Department
of Public Health & Wellness
James Patrick Murphy, MD, MMM, board chair
Bruce A. Scott, MD, president
Robert H. Couch, MD, MBA, president-elect
Lelan K. Woodmansee, CAE, executive director
Bert Guinn, MBA, CAE, associate executive director
Kate Williams, communications designer
Aaron Burch, communications specialist
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LOUISVILLE MEDICINE is published monthly by the
Greater Louisville Medical Society, 101 W. Chestnut St.
Louisville, Ky. 40202 (502) 589-2001, Fax 581-9022,
www.glms.org.
Articles to be submitted for publication in LM must
be received on electronic file on the first day of the
month, two months preceding publication.
LOUISVILLE
GREATER LOUISVILLE MEDICAL SOCIETY
MEDICINE
VOL. 62 NO. 4 SEPTEMBER 2014
FEATURE ARTICLES
6
CASTRATION RESISTANT
PROSTATE CANCER: NOT
GRANDPA’S DISEASE
Arash Rezazedeh Kalebasty, MD
19
SECOND STRING FULLBACK, FIRST
STRING CARDIOLOGIST
Henry Sadlo, MD
20
9
ANOTHER SGR REPEAL FAILS;
WE MUST FACE THE MOUNTAIN
AGAIN
Gordon R. Tobin, MD
SMOKING 50 YEARS AFTER THE
LANDMARK 1964 SURGE ON
GENERAL’S REPORT
LaQuandra Nesbitt, MD, MPH
27
13
BELLE
Aaron Burch
LOUISVILLE WELCOMES NEW
MEDICAL STUDENTS
Aaron Burch
16
29
SUPPLIES OVER SEAS: TODAY AND
TOMORROW
Gordon R. Tobin, MD
Aaron Burch
GLMS POLICY AND ADVOCACY
IN 2014
DEPARTMENTS
5 FROM THE PRESIDENT
- WHITE COAT
Bruce Scott, MD
11 REFLECTIONS
- CERTAINTY
24 ALLIANCE NEWS
Michelle Feger
32 PHYSICIANS IN PRINT
33 DOCTORS’ LOUNGE
- SHOW ME THE MORONS
Mary G. Barry, MD
- LETTER TO THE EDITOR
James Patrick Murphy, MD, MMM
- LETTER TO THE EDITOR
C. Kenneth Peters, MD
- CYCLISTS’ SAFETY
Stanley A. Gall, MD
38 FROM THE BLOGOSPHERE
-1
4 YEAR OLD WITH CHEST PAIN
Thomas Cunningham, MD
Opinions expressed herein are those of individual
contributors and do not necessarily reflect the position
of the Greater Louisville Medical Society. LM reminds
readers this is not a peer reviewed scientific journal.
LM reserves the right to make the final decision on
all content and advertisements.
Circulation: 4,000
GLMS Mission
Promote the science, art and profession of medicine; Protect the integrity of the patient-physician
relationship; Advocate for the health and well-being of the community; Unite physicians regardless of
practice setting to achieve these ends.
SEPTEMBER 2014
3
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From the
President
BRUCE A. SCOTT, MD
GLMS President | [email protected]
WHITE COAT
E
ach morning as I arrive at the office or
the hospital, I don my white coat as a
matter of habit. For over twenty years
I have done this, never having any thought
about the symbolism or the significance of
this act; that is until recently.
effect given to them by local physicians to
welcome them to our community and our
great profession.
The smiles and looks of pride were visible
on the students’ faces, and were mirrored
on the ebullient faces of their beaming
parents and friends. To the new class, the
white coat has a special meaning. It is an
acknowledgement of their intelligence and
which makes clear that wearing the white
coat brings not only honor but responsibility
and obligations. As I listened to the oath
I appreciated the awesome privilege and
responsibility each of us have in caring for
our fellow human beings. I encourage each
of you to read the oath and embrace the
concepts embodied.
As President of the Greater Louisville Medical Society, I was honored to be part of
a recent White Coat Ceremony. Doctor
In a world where the practice of medicine
Arnold Gold*, a pediatric neuhas become less personal, more
rologist, began the White Coat
technology driven and increasDeclaration of Geneva
Ceremony at Columbia College
ingly defined by non-physicians,
of Physicians and Surgeons in At the time of being admitted as a member of the medical profession, I my wish is that each day, when
1993. He felt students should solemnly pledge myself to consecrate my life to the service of humanity. each of us puts on the white coat
take the Hippocratic Oath (now
( if only metaphorically for some)
I will give to my teachers the respect and gratitude which is their due;
the Declaration of Geneva) and
we shall practice medicine the
I will practice my profession with conscience and dignity;
be welcomed to the medical proway we envisioned it the day
fession upon entry into medical
we first wore it. Since we startThe health of my patient will be my first consideration;
school, not upon graduation.
ed medical school we now truly
I will respect the secrets which are confided in me;
The White Coat, the symbol of
appreciate both the privilege
our profession, would be given
and responsibility of caring for
I will maintain by all the means in my power the honor and the noble
to each student during a formal
our fellow human beings. Even
traditions of the medical profession;
rite of passage. In a few years, the
within the hustle of our ever
My colleagues will be my brothers and sisters;
concept spread to over 100 medbusier schedules, we shall wear
ical schools; now, the ceremony
our white coats with that same
I will not permit considerations of religion, nationality, race, gender,
welcomes incoming students at
pride and humanism that was the
politics, socioeconomic standing, or sexual orientation to intervene
medical schools in 14 countries.
dream of Dr. Gold, and the reality
between my duty and my patient;
Dr. Gold deeply valued the hufor the entering class of 2018 at
manistic side of medicine. To Dr.
their white coat ceremony.
I will maintain the utmost respect for human life; even under threat, I
Gold, the white coat is our pro* Dr. Arnold Gold started
will not use my medical knowledge contrary to the laws of humanity.
fession’s “Cloak of Compassion.”
the Arnold P. Gold Foundation
He envisioned a ceremony that
I make those promises solemnly, freely, and upon my honor.
in 1994. The Gold Foundation
would emphasize the values of
continues to support White Coat
caring and compassion so inteCeremonies around the world. Dr. Scott had
gral to the patient /physician relationship.
hard work that have brought them to the
the pleasure to serve with Dr. Gold on the
threshold of their medical education. It’s a
The GLMS and GLMS Foundation sponAmerican Medical Association Foundation
symbol of everything that they will stand
sor the White Coat Ceremony at The UniBoard of Directors. Dr. Gold remains dedifor in the years to come. It is an honor only
versity of Louisville School of Medicine.
cated to the professionalism and humanity
a select few earn.
As I told the incoming students, because
of medicine. L
GLMS is a membership organization and
the Foundation is supported by donations
from physicians, their white coats were in
After a white coat had been placed by a
dean or faculty member onto each student,
all then recited the Declaration of Geneva,
M
Dr. Scott, board certified in OtolaryngologyHead & Neck Surgery, is the president of
Kentuckiana Ear, Nose, and Throat, PSC.
SEPTEMBER 2014
5
CASTRATION RESISTANT PROSTATE
CANCER: NOT GRANDPA’S DISEASE
Arash Rezazedeh Kalebasty, MD
P
rostate cancer remains one of the most
common malignancies among men.
PSA screening resulted in an increased
rate of diagnosis of this disease. Men who are
diagnosed with an early stage of disease can
expect a high rate of cure with surgical and
radiotherapy approaches. Over time there has
been a significant improvement in techniques
for radical prostatectomy utilizing robotic
surgery. Radiation therapy can be delivered
with modern techniques including image guided radiation therapy,
intensity modulated radiation therapy and proton therapy. Other
techniques including Cryotherapy are available in United States for
local recurrence of prostate cancer after radiation therapy.
There is ongoing research to tease out the “high risk” prostate
cancer to avoid the morbidity of surgery and radiation for what
ultimately would be indolent disease. These methods include serial
MRIs of the prostate gland and image-guided biopsy for patients
who are offered watchful waiting over time. Gene expression profiles
on prostate cancer biopsy material can help with determination of
“high risk” disease.
Despite high rates of cure with definitive treatment of localized
disease, metastatic disease leads to death in majority of patients.
Metastatic adenocarcinoma of the prostate gland has a good initial
response to lowering testosterone to castrated levels. This response
sometimes last for several years. Cardiac morbidity, loss of bone,
central obesity, loss of muscle mass and metabolic changes are among
long term side effects of androgen deprivation therapy (ADT).
Literature suggests that statins as well as metformin - data only in
diabetics at this time - may have a role in management of prostate
cancer. Bone health remains an important part of management of
prostate cancer.
Metastatic prostate cancer eventually becomes “castration resistant.” Generally cancer starts to behave more aggressively in this
state. Historically metastatic castration resistant prostate cancer
(mCRPC) was treated with second line hormonal therapy. This
class of hormones led to a short response followed by disease progression and death.
There has been significant improvement in the treatment of
prostate cancer in the last decade. Docetaxel was the first chemotherapy that showed a survival advantage in patients with mCRPC.
Interestingly it has been suggested that its effect on disease control
is very likely to be via an androgen receptor pathway. Second line
chemotherapy with Cabazitaxel has shown efficacy with improved
survival.
Research has shown that despite disease progression on castrated
patients, the tumor remains hormone dependent. In fact, it was
shown that prostate cancer cells can produce androgen to activate
androgen receptor and continue to grow. Further work on the androgen axis led to the discovery of Abirateron Acetate, which blocks
the androgen synthesis in adrenal gland and prostate cancer cells. It
is an oral therapy. Common side effects of this compound result from
6
LOUISVILLE MEDICINE
relative hyperaldosteronism causing hypertension, peripheral edema
and hypokalemia. Liver toxicity is of concern and liver enzymes
have to be monitored over time. Low dose prednisone has to be
taken with abiraterone to attenuate the resulted hyperaldosteronism.
Enzalutamide was the second oral therapy, which was introduced
to the market for treatment of mCRPC. It is a potent androgen receptor blocker and needs to be taken once daily. Enzalutamide showed
improved survival in both the pre-chemotherapy and post-chemotherapy state for patients with mCRPC. The side effect profile for
this agent was generally favorable. Common side effects include
diarrhea and fatigue. One study showed a 0.9 percent risk of seizure.
Metastatic CRPC was the first cancer which was treated successfully with an autologous immunotherapy (Sepulucil-T) and gained
FDA approval for improvement in survival rate. Therapy with this
product can be completed in about four weeks with three infusions
two weeks apart. Immunotherapy with Sepulucil-T is generally well
tolerated with the side effect of infusion reaction - generally short
lived - being the most common.
Bisphosphonates have been available for reduction of skeletal
related events (SRE) in patients with mCRPC. A head to head trial
comparing the efficacy of Denosumab to Zoledronic acid led to the
approval of Denosumab for prevention of SRE. Moreover, treatment
of osteopenia during ongoing androgen deprivation therapy is
being offered to men with non-metastatic prostate cancer, because
prevention and delay of SRE adds to quality of life with less need
for procedures, radiation therapy or hospitalization.
Samarium/starnsium is an IV radioisotope which has been used
for palliation of pain. Significant bone marrow toxicity, resulted from
treatment with this agent, made this agent less favorable. Radium 223
is a bone seeking agent which gained FDA approval after showing
palliation of pain as well as improved overall survival in treatment
of mCRPC. Radium 223 is an alpha-emmiter radioisotope with
much less marrow toxicity compare to previously available agents
in this class of drugs.
The treatment of prostate cancer has improved considerably in
the last decade. We now have advanced hormonal therapies, immunotherapy, bone targeted therapy and finally, effective chemotherapies available for these patients. Therapies are more effective
and importantly much more tolerable for our elderly patient population fighting mCRPC. There are several agents in the research
pipeline with hope for further improvement in the management
of prostate cancer.
A multidisciplinary approach with an expert team of Urology,
Radiation oncology, Behavioral oncology and Medical oncology
for the treatment of prostate cancer is extremely important, and
has already become the standard in some of the major academic
centers. Despite all improvements, patients still die of advanced
prostate cancer. We should all think about enrolling our patients
in clinical trials for further advancement of the field. LM
Note: Dr. Rezazedeh Kalebasty practices Oncology/Hematology with
the Norton Cancer Institute.
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DO YOU NEED A PRESCRIPTION FOR LONGTERM CARE PROTECTION?
By: Calvin R. Rasey
Long-term care insurance has been around since the 80’s and most people are somewhat familiar with the product. The question then
becomes DO YOU NEED the PROTECTION? There is no simple answer to this question; different circumstances call for different
solutions. Long- term care insurance is designed to help pay the cost of providing assistance for those who can no longer perform normal
daily activities. There are four topics to consider when reviewing the need for Long Term Care:
1. Providing protection for our parents.
2. Age gap between you and your spouse.
3. Your healthy life style and the impact it may have.
4. Wealth preservation.
Many of us who have living parents may find it necessary to help with personal care. In our grandparent’s day, families weren’t dispersed
across the country and family members often took care of relatives in need. That’s not always the case today; sometimes circumstances
do not allow children to perform the care for the parents. In these situations, the only option may be a paid caregiver or assisted living
facilities. These facilities and caregivers can have a significant cost which could affect our retirement planning as well as college education
for our children. Medicare programs do pay limited benefits for rehabilitation and recovery at a skilled nursing facility immediately
following a hospital stay, but won’t pay for the slow decline in daily activities. Medicare also does not pay for custodial care to support
issues with dressing, bathing or pre-primary meals.
In many marriages there is an age gap between the spouses. The need for long-term care by an older spouse could cause significant
problems among the children and the healthy spouse. In this situation, long-term care cost could deplete assets that the younger spouse
may need for children’s education or normal living expense for the next 10, 20, 30 or even 40 years. Also, for those in second marriages
there is a common misconception about Medicaid and eligibility determined by evaluating a person’s assets and income. Many second
marriage couples believe that if a pre-nuptial agreement is in place, which separates the couple’s funds, they will not have to spend down
their combined assets before qualifying for welfare. The truth is, pre-nuptial agreements do not protect a couples assets from Medicaid’s
spend down requirements.
Did you ever stop to think that good health at retirement is going to cost you more money? Organizations such as Center for Retirement
Research at Boston College and the Association of American retired Persons have indicated that a couple in good health at age 65 in can
expect to pay on average $260,000 (with a 5%risk of exceeding $570,000) for out of pocket health care expenses. While a couple with at
least one chronic disease will end up spending on average $40,000 less. Boston College goes on to explain that:
“First; people in good health can expect to live significantly longer. At age 80, people in healthy households have a remaining life
expectancy that is 29% longer than people in unhealthy households, and, therefore, are at risk of incurring health care costs over more
years. Second, many of those currently free of any chronic disease will succumb to one or more such diseases. For example, our simulated
individuals who are free of any chronic diseases at age 80 can expect to spend one- third of their remaining life suffering from one or
more diseases. Third, people in healthy households face an even higher lifetime risk of requiring nursing home care than those who are
not healthy, reflecting their greater risk of surviving to advanced old age, when the risk of requiring such care is highest”.
So if you’re around longer, chances are you’re going to run into more medical costs, not to mention a higher risk for nursing home care.
For a significant amount of physician’s wealth, preservation has become an area of concern, due to the volatile stock market and small
yields seen on relatively safe investments. Physicians that once thought they could pay for care out of pocket may not be able to generate
enough income from their portfolio without dipping into the principal. If one is conservative by nature or is at the point in their life that
investment risk needs to be reduced or is unnecessary long-term care insurance can be the right match. Transferring the risk of the ever
increasing long-term care to an insurance company would not be a waste of money, but a way to preserve wealth.
In essence, long term care insurance is a good option for many Americans, but not all. One of the main objectives of long-term care
insurance is to protect our assets, so if there are no assets to protect, then you shouldn’t purchase long-term care insurance. Also be aware
that in order to be eligible for a claim, your doctor must certify that you are not able to perform two or more activities of daily living
functions for a period of three months or more. These include, but are not limited to: bathing, eating, dressing, continence, transferring
and toileting or suffer from a cognitive impairment such as Dementia. You must carefully weigh the pros and cons before jumping into
this decision, but more often than not it is a wise choice to get covered.
Securities Offered Through Securities America, INC.*Member FINRA/SIPC • Calvin R. Rasey • Registered Representative
Advisory Services offered through Securities America Advisors, INC.• A registered Investment Advisor·Calvin R. Rasey • Investment Advisor Representative Physicians
Financial Services II, LLC and Securities America Companies are NOT UNDER Common Ownership
Representatives of Securities America do not offer tax or legal advice
The opinions and forecasts expressed are those of Calvin R. Rasey, are general in nature and cannot be guaranteed.
Securities America and its representatives do not provide legal advice. For questions about a specific situation please consult your legal advisor.
ANOTHER SGR REPEAL FAILS;
WE MUST FACE THE MOUNTAIN AGAIN
Gordon R. Tobin, MD
AN ACCUMULATING
INJUSTICE
Intense efforts for over a decade to repeal
the faulted Sustainable Growth Rate (SGR)
formula for physician services to Medicare
patients have repeatedly been denied by Congress. Amidst this, in 2003, Congress opened
unfunded cash-flow spigots to investor-owned
insurance corporations (Medicare Advantage
Plans) and pharmaceutical corporations (no-bid drug benefits),
as physicians continued to face scheduled annual payment cuts
of about 5.5 percent. To prevent physician exodus from Medicare
participation, these cuts were deferred by sequential short-term
“patches,” which failed to keep up with practice expense increases
and created a massive accumulating physician payment cut (now 24
percent).1 This spring, another repeal effort was denied by partisan
Congressional intransigence, and another 1-year “patch” was again
required. This cyclical, tragic farce has come to resemble the ancient
Greek myth of King Sisyphus, who was fated to push a heavy boulder repeatedly up a steep mountain, only to have it escape before
reaching the top and tumble back to the valley floor (Fig. 1).
SG
RE R
PE
A
L
ANOTHER CORRECTION ATTEMPT
More than any previous attempt, the efforts of organized medicine
and other patient advocates this spring seemed hopeful of reaching
the summit of permanent SGR repeal. A path of opportunity appeared in 2013 from the effect of recent decreases in overall health
spending on the SGR formula, which lowered the calculated cost of
permanent repeal to under half the cost of just two years ago. The
American Medical Association and virtually all specialty societies
made a united press for SGR repeal.2 A year-long, collaborative
effort between key medical stakeholders and Congress resulted in
an initial bipartisan, bicameral agreement for SGR repeal before
the existing patch expired on April 1. Hopes were high, but the
agreement collapsed at the last minute under the forces of partisan,
ideological politics, and the boulder rolled back down the mountain
once again.
POISONOUS POLITICS
The events of the collapse are summarized in the June 2014 Bulletin
of the American College of Surgeons titled, “The SGR Repeal: How
Bad Politics Ruined Sound Policy.3” The effort failed principally
due to irresolvable funding disputes between House (H.R. 4015)
and Senate (S.2000) versions of the bill, which split over funding
sources to offset the repeal cost. A Senate majority selected offset
funding drawn from the Oversees Contingency Operating funds,
but this lacked the 60 votes necessary to defeat a filibuster. The
House majority added a last-minute amendment to fund the bill
by a five-year delay (to 2018) of the individual mandate provision
in the Affordable Care Act (ACA). Fierce partisan recriminations
The modern curse of Doctor Sisyphus. Modified from Friedrich John (19th cent.).
erupted. House Republicans affirmed enduring opposition to the
ACA and its individual mandate. Democrats claimed the House
amendment to be a “poison pill” that would leave uninsured about
13,000,000 additional Americans by 2018, which would never be
acceptable to the Senate or President. With no hope of resolution
by the April 1 deadline, the initiative failed, and another 1-year
“patch” was enacted to avert the 24 percent Medicare payment cut
to physicians on April 1 (P.L. 113-93). Unfortunately, this “patch”
further harms physicians by compelling them to pay part of the
cost through “rebalancing,” an internal cost-shifting scheme not
previously used.
MEDICAL GROUPS OBJECT
The outcome was condemned throughout organized medicine, with
forceful statements from virtually all medical societies, including the
American College of Physicians, the American College of Surgeons,
the American Academy of Family Physicians, and the American
Medical Association (AMA). Family Physician Academy President,
SEPTEMBER 2014
9
Reid Blackwelder, M.D. stated, “We’re dismayed that Congress
sabotaged their own work by linking this legislation to unrelated,
ideological issues – particularly in light of the nearly universal
opposition to such action from patients, insurers, and the medical
community.” AMA Immediate Past-President, Ardis Hoven, M.D. of
Kentucky, added, “This was not a failure of physicians or organized
Medicine. This was a failure that must be laid directly at the feet of
our elected members of Congress. This was all about politics, not
about what is important in our country.”
LEARNING WISER APPROACHES
In spite of profound disappointment, physicians must immediately
recover, and once more push the SGR repeal boulder up the legislative mountain. The current formula is an unacceptably unfair
burden on physicians, and ultimately on Medicare patients. Also,
there is real urgency, as the window of lowered cost will likely not
be lasting. There remains a very slim hope for action this session, as
our unified medical organizations continues to pursue SGR repeal.4
However, Congress must overcome its partisan, ideological gridlock,
and begin serving patients over politics. Important lessons should
be learned from the recent bitter experience. Physicians must lead
by pressing Congress to reach consensus on funding sources that
are not ideologically divisive. In future health care legislation, we
must insist that funding sources be agreed upon at the beginning
of the process, rather than left to the last-minute. Strong ideological
differences in Congress are unlikely to disappear in the foreseeable
future, so wisdom should instruct us to firmly insist upon non-ideologic solutions from the onset that are acceptable to both parties.
HOLD PATIENTS ABOVE POLITICS
In addition to strongly supporting the efforts of the AMA and
other organized medicine groups, physicians should work intensely
within their chosen political parties to emphatically and repeatedly
prioritize SGR repeal. The fundraisers and campaign activities of
the upcoming months present opportunities to seize this initiative
and make recipients of our political support clearly realize that
we hold patient care foremost, that SGR repeal is essential to that
principle in Medicare service, and that these are our highest legislative priorities. Thus, our patient advocacy will provide the lifting
power to climb over steep partisan politics and finally reach the
summit of SGR repeal.
REFERENCES
1. Tobin GR. Eight-six the SGR. Louisville Med 2009;57(7):20-21.
2. American College of Surgeons. SGR opposition letter to Congress. Available at www.facs.org/ahp/medicare/sgr-patch-opposition-letter0314.pdf. Accessed April 8, 2014.
3. Hedstrom J. The SGR repeal: How bad politics ruined sound
policy. Bull Am Coll Surg 2014;99(6):9-12.
4. As this issue went to press, Congress left on summer recess
choosing to ignore SGR repeal. LM
Note: Dr. Tobin is a professor at the University of Louisville School
of Medicine, Department of Surgery, Division of Plastic and Reconstructive Surgery. He practices with UofL Physicians-Plastic &
Reconstructive Surgery. Dr. Tobin is a member of the Innominate
Society, Louisville’s medical history society.
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Reflections
CERTAINTY
G
reeting people as they enter the USA
at New York harbor is the magnificent and towering Statue of Liberty,
a symbol and beacon of hope to the outcasts
and downtrodden of the world. Her famous
inscription reads:
“Give me your tired, your poor,
Your huddled masses, yearning to breathe
free,
The wretched refuse of your teeming shore,
Send these, the homeless, tempest tost to me,
I lift my lamp beside the golden door.”
A poem by Emma Lazarus (1883)
Powerful, inviting and caring, it was a message that many accepted
to start life anew.
The ebb and flow of history clearly demonstrates that the problems that we face today, individually and as a nation are not new.
Populations grow, disasters strike, bad weather prevails, crops fail,
and famine follows. Against all dangers and odds, people leave the
familiar and seek a place where they can sustain life again.
Ideologies are born, their founders and followers insist everyone
should think their way, politics enter the fray, and persecutions follow. Those that do not agree stand their ground, fight for their rights,
or failing this, flee. Through persistence, trial and error, blood and
tears, they start over. How many among us are descended from or
came to this country, the great USA, under similar circumstances?
Unfortunately, huge incursions or migrations into a settled host
country for whatever reason, self-preservation, invasion, domination, or altruism i.e. to improve and educate the natives, have their
flip sides. How many empires, once thriving in solitary splendor have
been decimated or wiped out by what seems so trivial by modern
standards but so deadly in their times? Transmitted viruses like
smallpox and measles and “Johnny come lately” HIV, the bacilli
that caused the plague – all were imported from elsewhere and
caused their havoc. So did superior weapons that helped ambitious
conquerors deprive their less equipped and savvy indigenous adversaries. Thus, host countries have to be wary lest in their generosity
they may be harmed.
Now, a new plague has descended upon us. The use of addictive
mind and behavior altering drugs have been on the rise. The profits
that derive from their sales and distribution has created a frenzy
of greed and violence that has affected our lives as well as those of
our southern neighbors. Its curse has enticed rich and poor alike.
Due to increasing poverty, lack of alternatives, and a certain naiveté,
the less endowed and suffering population south of the border have
been lured by promises of release from their misery and a better
life if they cross the border into the USA, the land of opportunity.
By the hundreds, and now the thousands, they have pushed their
way north and are wanting in, without adhering to the laws of this
country, overwhelming those that would impose order, and creating
dissensions among our citizens.
They are the new poor, the wretched refuse of their teeming
impoverished countries, the new homeless, those whom the poem
at Lady Liberty’s feet talks about. What do we do with them? Are
we to believe that the lice infested, non-immunized, snotty, hungry, unaccompanied three-year-old who just crossed the border
is a threat and not worthy of attention? We presume his parents
thought long and hard before giving up their life savings and their
trust to a coyote in the hope that their beloved child will escape the
intolerable situation they are in. Is he less valued as a human being
because of his geographical origin? Historically, the people of the
USA say he is not.
In retrospect, in the late 1800’s and early 1900’s, did we do right
to allow a family to disembark at Ellis Island while detaining their
sick mother? Did we, as a nation, pool enough resources to impose
the rules of entering this country? In these enlightened times of
instant communications, electronic surveillances, and weapons
galore, can we still do so? Do we think we can solve the problems
of housing, feeding, quarantining the sick, and relocating people
which we so adeptly do (although somewhat belated sometimes) to
huge populations in times of disaster both abroad and here at home?
Or, could we have changed our minds and our hearts? Are we now
having second thoughts that we’ve been remiss in protecting that
which we carefully crafted against those that would abuse or harm
us? Are we ready to modify our laws and our methods of implementing them? Are we still willing to share the bounty of this land
with others? Do we still believe that the infusion of new ideas, new
blood, brains and brawn will eventually benefit this bountiful land?
Is it time to rethink what we stand for and proclaim it with
certainty, that is: Preservation of life, liberty, and the pursuit of
happiness, and act accordingly? LM
Note: Dr. Oropilla is a retired psychiatrist.
SEPTEMBER 2014
11
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BELLE
Aaron Burch
T
here are few Louisville icons more noteworthy than the Belle
of Louisville steamboat.
Sitting on the southern bank of the Ohio River it calls home,
the Belle has been a Louisville staple for 51 years. However, the historic river runner’s life began much earlier. On October 18, 2014,
the celebrity steamboat turns 100, making her the oldest steamboat
in America and the second oldest in the world.
The City of Louisville will celebrate this extraordinary 100th
birthday in a six-day festival taking place from Oct. 14-19, and
culminating that Saturday with a parade of river boats, exclusive
dinners and a fireworks celebration. The entire event will also feature
an on-land festival at Waterfront Park, “The Centennial Festival of
Riverboats,” including live concerts, children’s games, art booths,
craft vendors and special bourbon and wine tastings for adults.
Belle of Louisville CEO Linda Harris has collaborated with the city
for four years to make this celebration come to life. “At 100 years,
this boat is as beautiful as she’s ever been,” said Harris, who has
helped steer the Belle for the latest 10 years of her life. “We feel like
this birthday bash will be the biggest party Louisville has ever seen
for this famous Kentucky lady. We’re going to have five river boats
including the Belle on the waterfront for all six days with guests
able to take cruises out in the morning, noon, night and late night.”
Just weeks away from the event, Harris took time to remember
where the Belle of Louisville began and how it came to be so revered
in Derby City. “The Belle has had so many jobs in her 100 years. I
like to refer to her as a rock star because she has kept reinventing
herself to stay a viable entity,” said Harris.
The Belle of Louisville began life as the Idlewild in 1914. Built
by the West Memphis Packet Company of Memphis, Tennessee,
the Idlewild moved cargo, cattle, cotton, whiskey and more from
Tennessee to Arkansas for over ten years, before trading packets
for people. During these early transports, the Idlewild first visited
Louisville where she served as a seasonal excursion boat from 1934
through the end of World War II. She did her part for the war,
when special bumpers attached to her bow allowed her to push
supply barges during the day. At night, she docked and turned into
a nightclub for USO troops.
“She’s never been an overnight boat,” said Harris. “She’s never had
cabins, so she’s a day boat. But, she could travel to different cities,
stay for a season and run excursions out of each city.”
In 1947, the Idlewild was sold to J. Herod Gorsage, who changed
her name to the Avalon to fulfill a deathbed wish made by the boat’s
master captain at the time. The Avalon continued to travel up and
down the Mississippi, Ohio and Missouri rivers offering cruises of
all types. One of her most popular features was a large dance floor,
where popular bands and singers attracted new guests wherever
the boat tied up.
“This boat has been all the way down to the Gulf of Mexico, all
the way up to Wisconsin and Pittsburgh. She has traveled every
navigable water way in the Mississippi-Ohio system, and she’s been
able to do that because she only has a five foot draft. So she could
go back in little rivers and give people the steamboat experience
that other steamboats couldn’t do,” said Harris.
Today, the Belle of Louisville holds the distinction of being the
most traveled steam boat in American history. A large portion of
those miles came from the boat’s time as a tramp steamer, when as
the Avalon she traveled day by day to towns along the Ohio River.
(continued on page 14)
SEPTEMBER 2014
13
(continued from page 13)
“People would come down to the waterfront when she arrived, take
a day excursion on her, and then she’d move on to the next city,”
said Harris. “She did that for 13 years, and it nearly proved to be
her destruction.”
Falling apart and losing money, the Avalon’s owners planned to
scrap the boat in the spring of 1962 when a Cincinnati reporter
succeeded in getting a court order to put the boat up for auction.
Due to the boat’s shared history with the city, Louisville Mayor
Charles Farnsley bought it at auction for $34,000 and helped the
Avalon to chug slowly back to Kentucky.
The citizens of Louisville appeared split on the purchasing decision. Many were thrilled and volunteered their time to help get the
boat in proper working order again. Painters, carpenters and engineers all got involved. Businesses donated supplies. The rebuilding
took nearly a year of constant labor.
At the same time, however, some Louisville citizens considered
the purchase wasteful. “They’d meet with Mayor Farnsley and say,
‘How could you spend $34,000 for an old steam boat?’ and the
Mayor would reply, ‘You know that steamboat cost each tax payer
just seven cents?’ Then the mayor would go in his drawer and give
them seven cents back,” said Harris.
“So Louisville came to love the Belle,” Harris continued. “She is
a treasure and an icon for Louisville. You don’t see too many commercials without that pretty red paddle wheel.”
The refurbished and renamed Belle of Louisville made her debut in
a steamboat race with the Delta Queen on April 30, 1963. Though she
lost that race, the Belle won the possessive pride of many Louisville
residents from that day forward.
Linda Harris’s earliest memories of the boat date to the 1970s when
she visited the city for the first time. “My in-laws loved the Belle and
had a house on the river. We used to sit on their front porch and
watch her go by,” said Harris. “I have a picture of my daughter in
1974, sitting on the wharf with the Belle behind her. It was the first
thing I noticed when I came to Louisville and it’s very interesting
that this has come full circle for me.”
SUPPORT LOUISVILLE’S MEDICAL
LEGACY OF EXCELLENCE
With the support of generations of physicians, the Greater Louisville Medical Society Foundation has been an integral
part of Louisville medicine since 1958. Now we need your help to continue building that legacy. Please consider how
you can support the growth and ongoing activities of the GLMS Foundation’s three main service areas.
LOCAL AND INTERNATIONAL
MEDICAL MISSIONS
Help us reduce the burden of poverty and
disadvantage, break generational cycles of poor
nutrition and insufficient access to health care in
communities in local, regional and
international communities.
OLD MEDICAL SCHOOL
PRESERVATION
Continue the preservation of the building that
serves as a reminder of Louisville’s medical history
and continues to be a gathering place for those
responding to current medical challenges
in the community.
MEDICAL STUDENT
SCHOLARSHIPS
Develop a pipeline of innovative and devoted
physicians by providing bright and determined
medical students with scholarships to lighten the
burden of medical school tuition.
14
LOUISVILLE MEDICINE
You Can Help Louisville’s Medical
Legacy Live On
We earnestly invite you to join us to grow
and secure our three initiatives into perpetuity
through a monetary or planned giving gift.
Naming opportunities are available to
recognize a person, family of physicians, or
graduating class.
Terry Todd, Foundation Director
GLMS Foundation
101 West Chestnut St., Louisville, KY 40202
www.glmsfoundation.org
[email protected] or 502-736-6356
Now the Belle of Louisville spends her days at the 4th Street Wharf.
Since she was renamed, the Belle has offered cruises to nearly seven
million people and shows no signs of slowing down, as she is constantly being checked upon, tested and updated.
“In 2008, we air conditioned the ballroom of the Belle,” said Harris.
“It’s very subtle. It doesn’t look historic, but you don’t even notice it.”
When the steamboat was undergoing renovation, a marine architect
company was consulted to make sure the Belle had good stability.
Between winter repairs and summer cruises, the Belle staff is
always on duty. They also operate the Belle’s sister ship, the Spirit of
Jefferson. Throughout the year, the two boats get different times to
shine such as Thunder over Louisville, holiday cruises, Valentine’s
Day dinners and more. Still, Captain Doty said his favorite event
of the year has to be the Kentucky Derby’s Great Steamboat Race.
“That’s the one day out of the year where the Belle really gets to
shine. People line up on both sides of the river banks to watch her.”
“They did a thorough examination of the Belle, and found that
she was a little overweight. Her paddle wheel was sitting a little low
in the water. So we replaced iron sewage tanks, and took off more
than 2,000 pounds in stages,” said Harris.
This year, the Belle of Louisville will take center stage for a celebration of her own. Although the boat is a regular attraction to
Louisville, visitors from all 50 states and 21 foreign countries visited
the Belle in 2013. So this October celebration promises to bring
something unique to the Louisville waterfront.
In addition to the famous red paddle wheel, the Belle has two
reciprocating engines which turn the wheel, put on in 1914 but
dating back to the 1880s. The engines were recently re-drilled and
rounded out for efficiency.
“For the festival, the Louisville Convention Bureau is expecting
approximately 350,000 over the six days and an impact of more
than six million dollars,” said Harris. “Don’t miss the Belle’s birthday
party. It’ll be a once in a lifetime event.”
“The Smithsonian sent a letter 20 years ago wanting these engines
for their transportation museum, but they’re still waiting and they’re
going to be waiting a long time,” said Harris. “There’s no reason this
boat could not have another 100 years in her”
For ticket information and event planning, visit
www.festivalofriverboats.com. There, guests can find all the information they might need on the Belle of Louisville’s 100th Birthday
Celebration.
The Belle of Louisville has no modern navigation systems inside,
and only about seven people in the world could operate the Belle
at first glance, Harris explained. One of those is current Master
Captain Mike Doty who has worked on the Belle since July 7, 1981
when he began as a deck hand.
“There’s no one who works with the Belle very long who doesn’t
fall in love with her,” said Harris. “When you hear that paddle wheel
swishing, you know she has a heartbeat. She has a soul. She is just
something you love.” LM
“We have a legacy program trying to bring younger people up,”
said Doty, who’s taken countless trips in his 33 years on the Belle.
“Because it takes a year to learn. Even if you have a 500-ton license,
it takes a year to learn to operate the Belle’s ins and outs.”
Aaron Burch is the communications specialist for the Greater
Louisville Medical Society.
SEPTEMBER 2014
15
SUPPLIES OVER SEAS:
TODAY AND TOMORROW
Gordon Tobin, MD and Aaron Burch
T
here stands on Arlington Avenue in
Clifton a non-descript building with
a large docking bay flanking one side.
On the street, passersby have no idea that
thousands of families around the world have
been given new leases on life, thanks to the
work taking place within. A child in Ghana, a
family of four in Ecuador, an elderly woman in
Haiti: the organization’s reach is almost incalculable, with an outlook and set of goals neither flashy nor arrogant.
Supplies Over Seas, a Medical Surplus Recovery Organization,
asks health care facilities from across Kentucky, Indiana and Ohio to
donate their used medical supplies to save them from being dumped
into landfills. SOS funnels those supplies into connections with
governments and individuals the world over, getting the needed to
the needy. The result is an amazing repurposing of would-be trash,
powered by hundreds of volunteers with a desire to help people they
will most likely never meet.
“We’re a throwaway society,” said Karen Womack. “So much more
of a hospital’s supplies now are disposable, and tossing aside what
we don’t need is so easy.”
Womack, SOS Medical Outreach and Volunteer Manager, joined
the organization in 2010, months prior to the federal government
approving Louisville’s Supplies Over Seas as a 501(c)(3) non-profit,
the only one of its kind in the state of Kentucky. Prompted to apply
for non-profit status in response to the devastating Haitian earthquake that year, SOS has been expanding steadily since its creation
in 1992. Then GLMS President Norton Waterman, MD, was inspired
by a similar concept at Yale Medical School, “Remedy,” created by
New England anesthesiologists.
Waterman and the GLMS found seed money and building space
on the basement floor and former morgue of The Old Medical School
Building, which had been recently renovated as a home for the society. The generosity and hard work of Kentucky physicians propelled
SOS forward over the next two decades. T. Jeffrey Weiman, MD,
SOS Medical Director and Eugene Conner, MD, Anesthesia Chief
at Methodist Evangelical Hospital next took steps to find additional
space for volunteers to sort supplies. They also solicited funding
from Louisville medical staff and the Norton hospital system.
“I think hospitals understand that donating and saving supplies
is the right thing to do. Once you start making that change, you
16
LOUISVILLE MEDICINE
realize how many things can be taken out of the waste stream,” said
Melissa Mershon, SOS President and CEO.
That waste stream is a large one. Hospitals in the United States
throw away some six million tons of supplies each year. To date,
SOS has collected approximately 800 tons of dry medical supplies,
everything from beds, stretchers and surgery lights to smaller instruments and gauze by the pallet full. With so much still going to
waste, the effects can seem small, but SOS has made an enormous
difference in Kentucky and across the globe.
Out of the 85 tons of medical supplies SOS collected from Kentucky medical facilities last year, a mere five percent ended up in the
trash. Almost anything SOS deems unusable for shipment to other
countries, usually due to expiration dates or lack of sterility, is recycled and appropriated to nursing schools and other groups capable
of effectively using the tools. This year round effort is facilitated
by 14,000 hours of volunteer work at the Louisville facility alone.
“People come from all over, from every background,” Womack
said, noting monetary and volunteer contributions from local banks,
church groups and university students from Western Kentucky and
Murray State Universities. In her four years with SOS, Womack has
been charged with continuing to build the organization’s base of
helping hands. “There are multiple ways we reach out to volunteers.
Television ads and newspapers are some, but I’ve found the best
way is a personal touch.”
Word of mouth helps too. Partners and volunteers, who have seen
tons of unsorted materials enter SOS and come out as full pallets of
useful supplies, end up encouraging others to join and to take part
in the selfless effort. Meanwhile, SOS keeps steady contact with the
hospitals already taking part.
“We’re encouraging hospitals to take more responsibility and
specialize recycling to their own needs. I tell doctors, ‘I know you’re
busy, but take five more steps and drop this in the recycle bin. It’s a
big help,’” said Womack, who worked for several medical facilities
throughout Louisville and Southern Indiana before settling at SOS.
Some locations take the act of donating one step farther. Small
hospitals in Mount Sterling and London invited SOS to come in
(above left) Student volunteers pack and ready supplies for Supplies Over Seas. Any
unexpired medical tool can potentially be repurposed for use around the globe.
(above right) Examples of countless medical tools line the walls of the SOS’s first
sorting room, so volunteers may more quickly direct hundreds of pounds of donated
supplies.
and take any used material they needed as new hospitals were being built. Womack says
hospital beds are one of the most important donated items, as patients in third world
countries will often have to lay on the floor awaiting treatment.
But, donations don’t have to be as large as beds or stretchers. Even local families can
donate crutches and write it off their taxes. The important thing is that supplies reach
the hands of those who need them.
“A political representative from Ecuador visited recently. He toured the warehouse and
when he saw we had oxygenators, he actually began to cry. We had five available and
his hospital only had one that two small children were forced to share until one passed
away. The man immediately requested all five,” Womack said.
Supplying foreign countries with medical items can be a lengthy process. An individual
or group of representatives will contact SOS and fill out an application. Then the two
groups collaborate to discover what exactly is available for delivery. “It can be difficult
to get the particulars correct,” said Womack.
First, the larger things are decided, such as beds, stretchers, operating room lights,
etc. Then, the smaller supplies. Pallets of gauze and most medical instruments fall into
this category. From there, SOS works to fill any remaining room in the container with
supplies from the country’s list. Each shipping container costs the purchaser $12,500.
“But depending on the list, there can be between $150,000 and $200,000 worth of supplies
inside,” Womack said.
There are smaller supply options available as well. A $50 donation to SOS will get an
organization 50 pounds of supplies to take with them. “After that it’s $2 per pound,” said
Womack. “But, if you’ve ever filled a box with 50 pounds of medical dressing, you know
you’re getting a lot of bang for your buck.”
The facility takes almost every medical supply other than pharmaceuticals, nutrition
and fluids. “Nurses come is and say ‘I didn’t know you were collecting this. I’ve been
throwing them away,’” said Womack, motioning to a large room in one section of the
SOS facility dedicated to bio-technology. One of SOS’s biggest needs at the moment is
volunteers in the bio-tech room who can calibrate the machinery for reuse.
Theresa Burridge is the SOS Director of Marketing and Development. “The work done
by SOS is not just a drop in the bucket. The places we reach end up being some of the
major health facilities in their region. Sometimes, they’re the only facility for hundreds
of miles.”
“Our organization has three missions in one,” Burridge said. “Environmental stewardship, humanitarian aid and global health equity: all in one.”
In addition to the health facilities who contact SOS, the facility also keeps an in-house
medical team “store,” from which short term mission trips can pull necessary supplies
to take with them overseas. In 2013 alone, SOS helped supply 75 medical mission trips
into 20 different countries across Central America, South America and Africa. “All we
ask is for stories and pictures of the group using our supplies. We need accountability
with the work we do,” said Womack.
As a non-profit, the little money made goes toward a large overhead cost. Due to the
size of the SOS facility and warehouse full of supplies, Womack estimates the cost of rent
and electricity and other basic needs at nearly $35,000 per month. There are only four
paid employees at SOS - everyone else volunteers time as they see fit.
Sharon Schuppert was an operating room nurse for 40 years. Now retired, she’s been
volunteering for SOS for more than a year. Quietly sorting supplies with other volunteers,
Schuppert smiled and said, “It’s been very rewarding.” Womack expounded, “Sharon is
here almost every day. She’s been a huge help, and her experience has helped us identify
supplies, eliminate some unknown materials and organize even better.”
Martha McCoy, MD, a retired general surgeon, sorts supplies side by side with Schup(continued on page 18)
(top to bottom) A Kenyan nurse sorts through a fresh set of supplies sent by Supplies Over Seas volunteers;
Workers in the Manabi Province of Ecuador unload a new shipment of SOS supplies; Kenyan Member of Parliament and Activist Wesley Korir opens a container of supplies for a local village; Korir, pictured center, collaborated with Louisville’s Supplies Over Seas to bring necessary supplies to disease and drought ravaged villages.
SEPTEMBER 2014
17
pert. Both are regulars by now. Volunteers most often come in on
Mondays, Tuesdays, Thursdays and Saturdays, but larger groups of
university students make special trips to SOS, often to fulfill service
hours or learn about medical supplies first hand. Outside the facility,
supply distributors such as Cardinal Health, Owens & Minor and
Medline all help bring supplies to the facility’s doorstep and have
been doing so since SOS was officially named a non-profit.
“Being named as a non-profit was kind of our re-birth. It allowed
us to develop new goals moving forward,” said Womack. “We’re
one of the greenest corporations in Louisville and hardly anyone
knows it.”
As supplies arrive to the building on Arlington Avenue, they sit
unsorted in rows of cardboard boxes. Each box is weighed before
every single piece is checked for expiration dates and sterility. Once
that test is passed, bins of segregated supplies are filled. From there,
volunteers pick a theme, such as women’s health or infant supplies,
and fill boxes upon boxes and then pallets with the chosen utensils.
From there, basic supplies go to the warehouse where they await
shipment to countries in need. A shipment is already scheduled for
a hospital in The Philippines for later this year.
“We’re improving all the time, and we’re always looking for leaders,” said Mershon. “We’d all be happier if the warehouse was empty.
We’re gatherers and preparers of surplus. Supplies Over Seas doesn’t
want to run a warehouse. Our whole goal is to get these supplies to
people who need us.”
In just over 20 years, SOS has moved from the basement of the
medical building to a large facility of its own. From nothing, more
than 100 countries have benefited. Countless lives of children and
adults have been improved thanks to the work done in an unobtrusive side road in Louisville, Kentucky. In a world where five million
children die each year due to a lack of basic health care, this mean
more than we can imagine.
“The members of GLMS need to be very proud that they helped
create this,” Mershon said. “They knew the statistics. They knew what
was going to waste and so many of them have worked to prevent
it. They stayed with the concept to move it to where it is today. The
GLMS members submitted their talent and time to this mission,
and they are marvelous.”
While people across the globe continue to need assistance, the
positive responses are starting to pile up. More than 1,000 volunteers
visited the SOS facility in 2013, and the number is expected to grow
even more in the coming months. Inside, Karen Womack walked
past a row of hospital beds and began to ruminate on where they
would find a home.
“We have so many good stories to tell.”
18
LOUISVILLE MEDICINE
(Above, left to right) SOS Hospital Outreach and Volunteer Manager Karen
Womack shows a standard box of fresh supplies, usable items of all shapes and
sizes from local hospitals; Physician volunteers sort through supplies at the Supplies
Over Seas building, preparing packages for delivery; SOS houses a warehouse full of
sorted supplies awaiting shipment to countries worldwide.
SOS is poised to substantially expand its recovery services to
many additional hospitals across Kentucky and Indiana. To facilitate this, GLMS is spearheading a KMA effort to enlist all our
physicians as advocates to the community hospitals for promoting
SOS partnerships. This effort seeks to inform the hospital medical
staffs, administrators and key employees of the substantial economic savings, the public relations advantages, the environmental
benefits and the life-saving consequences across the world that SOS
partnerships bring.
The SOS program is one of the greatest legacies of GLMS. We all
should become ambassadors in support of expanding this fine legacy.
Informational Accompaniment:
•
Groups and individuals who are interested in volunteering should contact SOS via their website
(www.SuppliesOverSeas.org), or email Karen Womack at
[email protected]
•
SOS accepts donations from individuals as well as hospitals!
Donations may be dropped off 8am - 4pm, Monday - Friday.
Please call (502) 736-6360 to schedule your drop-off.
•
Are you planning to provide healthcare in an under-resourced
community abroad? Consider visiting the SOS Medical Team
“Store.” where you can conveniently and affordably pack your
suitcase with the medical supplies and equipment you need
for your trip. LM
Note: Dr. Tobin is a professor at the University of Louisville School
of Medicine, Department of Surgery, Division of Plastic and
Reconstructive Surgery. He practices with UofL Physicians-Plastic
& Reconstructive Surgery.
Aaron Burch is the communications specialist for the Greater
SECOND STRING FULLBACK, FIRST
STRING CARDIOLOGIST
Henry Sadlo, MD
S
tarting in middle-age, some of my friends
have begun to worry out loud to me about
health issues, especially those who have relatives who have had heart attacks and open-heart
surgery
A good friend of mine, who played football at
St. Xavier with me, was asking me some questions
about his risks and the fact that his father had several heart attacks before age 60. He was soon approaching that age. I told him that to start,
he needed a primary care physician, and a lipid profile, and then we
would talk about various things such as risk stratification and possibly
a coronary calcium scan since he was a likely intermediate risk patient,
and coronary calcium scanning is now a level II recommendation for
intermediate risk patients.
Well, of course as many of us middle-aged people do, he put off
seeing the primary care doc, but did heed my advice to at least get the
coronary calcium scan. We were pleasantly shocked when he had a zero
score, but there were noted calcifications around the area of the aortic
valve. I once again recommended that he now even more needed to get
with his primary care physician and although he was asymptomatic, I
told him it would be a good idea to get an echocardiogram.
Once again, being asymptomatic he wasn’t all that rushed to follow
this advice. However one hot day while exercising in the back yard,
he fainted.
When he called me, I was in a restrictive period from my previous job,
where I was not allowed to work or have an office until the period was
over (somewhat of a creative paid sabbatical). (I told him that I could
not see him in an office but remembering in that he had calcifications
around his aortic valve, I told him that if he truly had aortic stenosis,
this syncope counted as medically urgent.)
He was seen in a local emergency room and released, and I’m not
sure they picked up on his calcium on his coronary calcium scan, but
in any regard he did obtain an appointment with a primary care doc,
but it was three weeks away. I was worried about my good friend,
former star fullback, and told him that I was meeting another good
friend the following day, Dr. Robert Lawrence, who was taking me
to Churchill Downs to see the early - morning workouts two weeks
before the Kentucky Derby - what an honor to be able to see the horses
without the large crowds! As a former chairman of the equine industry
program at the University of Louisville, Bob was highly knowledgeable
about the horse industry, and had access to going around the Downs
at restricted times such as this morning.
We were going to try to eat a heart healthy breakfast at Wagner’s
Pharmacy. Well, we had bacon, eggs and hash browns; a little treat
every now and then is appropriate even per Dr. Bryant Stamford, my
friend and respected medical writer for the Courier-Journal health
section, in keeping with his 80/ 20 rule. Wagner’s falls squarely into
the 20 percent of meals which we should avoid; it was a treat type of
breakfast, and what a great breakfast they serve. Derby On.
So Dr. Lawrence and I met over at the pharmacy and I told my
good football buddy, that if he would stop by Wagner’s on his way to
his work that day at 7 a.m., I would at least put my stethoscope to his
chest to see if I should judge his syncopal episode as serious, and see
if he truly had aortic stenosis.
We all pulled up in our cars bright and early, on a partially cloudy,
pretty April morning in Kentucky. I got my stethoscope out and told
him to sit in the front seat of my car. There I heard a loud harsh grade
3/6 crescendo decrescendo murmur, rather classic for significant aortic
stenosis. This was a murmur that Dr. Mary Barry would’ve called multiple medical students into the room to listen to. We of course didn’t
have that option in the parking lot of Wagner’s, but the importance
of that simple five second auscultation totally changed the urgency of
his evaluation.
I called the primary care doc that he was slated to see and told him
that he needed urgent evaluation from a cardiac standpoint due to what
I suspected was severe aortic stenosis, and that I would not want to
have something happen to my dear friend while he was waiting three
weeks to get it to see a primary care, and then who knows how long
it would take to see a cardiologist (who could practice “regular,” as I
temporarily could not do).
None of this would’ve been a problem, had the legal system not tied
me up from practicing, but that’s the way it was.
I wasn’t shocked when I heard about his diagnosis of severe to critical
aortic stenosis noted on an echocardiogram, and off the patient went
to see the consultants.
Several weeks later, after having a cardiac catheterization by Dr.
Mike Flaherty, he had an elective aortic valve replacement by Dr. Brian
Ganzel, followed by a splendid recovery. In fact he even went home
from the hospital in three days, which is likely a tribute to his having
taken good care of himself, never smoking cigarettes, and having
always been athletic.
My football player and I grew up and went to grade school together.
His father was my eighth-grade baseball coach, and was a hell of a guy.
I had the honor of being his cardiologist 20 years ago when he had a
small heart attack and needed bypass and valve surgery. I took care of
my coach, my friend’s father, for almost 20 years, and like so many other
things in Louisville, what starts in childhood flourishes in adulthood.
I had to apologize to my football buddy because I could not personally take care of him in his time of need, but would do everything
within my contractual constraints to at least help guide him in the
right direction. I thank the good Lord that I was able to pick up my
stethoscope for a five second auscultation which clearly changed the
outcome of his syncopal episode evaluation. Who knows, it may have
saved his life, compared to if he had waited and waited.
Although listening to someone’s heart with a stethoscope in the
gravel parking lot of Wagner’s pharmacy would surely be anything but
conventional, somehow I feel that Dr. Willis Hurst was peering down
from the heavens over my shoulder, smiling, and saying to himself, “I
taught that boy well.”
Growing up and playing football in grade school and high school
with my good friend, I was always the second string fullback, but
now at this stage of life I felt like I’d been promoted to at least the first
string cardiologist. LM
Dr. Sadlo practices Cardiology with UofL Physicians-Cardiovascular
Medicine.
SEPTEMBER 2014
19
SMOKING 50 YEARS AFTER THE
LANDMARK 1964 SURGEON
GENERAL’S REPORT
LaQuandra Nesbitt, MD, MPH
T
his year marks the 50th anniversary of the
landmark 1964 Surgeon General’s Report
that first alerted our country to the very
significant health hazards of tobacco use. While
the prevalence of smoking has declined over
the past 50 years - from 42 percent in 1965 to
18 percent in 2012 - it remains the number one
cause of preventable death in America today.
Each year smoking is responsible for more than
480,000 premature deaths in Americans age 35 and older.
Women who smoke have about the same high risk of dying from
lung cancer as men.
Since the first Surgeon General’s report in 1964, smoking has
killed more than 20 million Americans. More than 87 percent of
lung cancer deaths, 61 percent of pulmonary disease deaths and 32
percent of all deaths from coronary heart disease are attributable to
smoking and exposure to secondhand smoke. More than 10 times
as many Americans have died from diseases related to cigarette
smoking as have died in all the wars fought by the United Sates in
its entire history!
According to the 2008 Louisville Behavioral Risk Factor Surveillance
Survey, 32 percent of Louisville adults smoke. This is considerably
higher than the national rate of 18.1 percent. Not surprisingly, the
age adjusted cancer death rate for lung cancer in Louisville from 2006
to 2010 of 63.9 deaths per 100,000 was also considerably higher than
the national rate of 51.3 per 100,000. Smoking, among other factors,
is having a significant impact on the lifespan of Louisville residents
The 2014 Surgeon General’s Report asserts that much still needs
to be done to end our country’s tobacco epidemic, particularly to
prevent an early death in young people who are now taking up the
habit. The report projects that if smoking persists at the current rate
among young adults, 5.6 million Americans now younger than 18
years of age will die from a smoking related illness.
LOUISVILLE
2014 SURGEON GENERAL’S REPORT
A new Surgeon General’s Report published earlier this year expands
the long list of diseases and other adverse health effects caused by
smoking and exposure of nonsmokers to tobacco smoke. These
new findings include:
•
Liver cancer and colorectal cancer are added to the long list of
cancers caused by smoking;
•
Exposure to secondhand smoke is a cause of stroke;
•
Smoking increases the risk of dying from cancer and other
diseases in cancer patients and survivors;
•
Smoking is a cause of age –related macular degeneration;
•
Smoking increases both the risk for tuberculosis and dying
from it;
•
Maternal smoking during pregnancy is a cause of ectopic pregnancy and orofacial clefts in the newborn;
•
Smoking is a cause of male erectile dysfunction;
•
Smoking is a cause of diabetes mellitus;
•
Smoking causes general adverse effects on the body including
inflammation and it impairs immune function; and
•
Smoking is a cause of rheumatoid arthritis.
Many of the findings of the 2014 Surgeon General’s report have
particular relevance to women who smoke. For the first time, women
are now as likely as men to die from many of the diseases caused
by smoking. The relative risk of dying from coronary heart disease
for women age 35 and older is actually now higher than for men.
20
LOUISVILLE MEDICINE
SMOKING CESSATION
Physicians can have a huge impact on the public health of our
community by directing patients to stop smoking and prescribing
effective treatment programs. According to the CDC report, Best
Practices for Tobacco Control Programs, tobacco use screening and
brief intervention by clinicians is a top-ranked clinical preventive
service in terms of its relative health impact and cost-effectiveness. According to the report, tobacco stoppage treatment is more
cost-effective than other commonly provided clinical preventive
services, including mammography, colon cancer screening, Pap
tests, treatment of mild to moderate hypertension, and treatment
of high cholesterol.
In February, Mayor Fischer and I unveiled Healthy Louisville
2020, our community shared agenda for significantly improving
the city’s health over the next six years. The report contains data
on key health indicators such as local rates of tobacco use, cancer
mortality, chronic disease, infant mortality and obesity. It lays out
specific goals and strategies to improve health in Louisville by the
year 2020.
A top strategy of Healthy Louisville 2020 is to increase physician
and health provider referrals to effective smoking cessation programs. One such program is the Cooper/Clayton Method to Stop
Smoking. Developed by two University of Kentucky professors, the
science-based model uses education, group support and nicotine
replacement therapy. Nicotine patches, lozenges and gum help
patients overcome their physical addiction to nicotine, weaning
them with step-down reductions in dosage over the 13-week course.
The program also provides weekly group support sessions led by
trained facilitators, many former smokers themselves, to deal with
the psychological issues often associated with smoking cessation.
The Cooper/Clayton method boasts a 42 percent success rate
upon completion of the 13-week course. This compares to a 5
percent success rate among those trying to quit with no nicotine
replacement or group support and a 9 percent success rate among
those using nicotine replacement alone. The Department of Public
Health and Wellness and its community partners sponsor Cooper/
Clayton smoking cessation classes throughout the community. For
a list of classes, visit www.louisvilleky.gov/. Your patients may also
enroll in a class or get more information by calling 574-STOP (7867).
Another smoking cessation program locally available is the Kentucky Quit Line. By calling 1-800-QUIT-NOW (1-800-784-8669),
your patients can get free one-on-one help from smoking cessation
coaches. An on-line version of the Kentucky Quit Line is also
available at QuitNowKentucky.org. The on-line version also has a
section for physician referrals.
Healthy Louisville 2020 also recommends increasing smoking
cessation services for expectant parents. Smoking during pregnancy is especially dangerous. It can cause birth defects, low birth
weight and premature delivery. The 2014 Surgeon General’s Report
now adds ectopic pregnancy, in which the embryo implants in the
Fallopian tube or elsewhere outside the uterus, to the list of birth
defects caused by maternal smoking during pregnancy. Ectopic
pregnancy is very rarely a survivable condition for the fetus and is
a potentially fatal condition for the mother. The 2014 report also
finds that maternal smoking during early pregnancy can cause
orofacial clefts in infants. After delivery, smoking in the home
continues to be a major cause of Sudden Infant Death Syndrome
(SIDS). Smoking cessation efforts, therefore, should focus on both
parents and everyone else living in the home.
QuitNowKentucky.org has a pregnancy and postpartum program.
The Louisville Metro Department of Public Health and Wellness
is also using the Smoking Cessation and Reduction in Pregnancy
Treatment (SCRIPTS) Program in its Healthy Start home visitation
case management program. The program provides comprehensive
counseling to help pregnant woman quit or greatly curtail smoking
during pregnancy and helps them establish a smoke-free home for
the new baby.
YOUTH SMOKING
The 2014 Surgeon General’s Report asserts that more than 3.5 million
middle and high school students in America smoke cigarettes. The
vast majority (88 percent) of new smokers
start smoking before age 18 and nearly all
first use of cigarettes occurs before age 26.
Policies to curtail the initiation of smoking among young people can significantly
reduce tobacco’s toll on life and health in
America in future years. Here in Louisville our young people are also taking up
the tobacco habit in alarming numbers.
During the 2011 – 2012 school years,
14.8 percent of Jefferson County Public
Schools reported smoking within the past
30 days. Healthy Louisville 2020 advocates
raising the state cigarette tax, which has proven to decrease smoking
initiation among teens and pregnant women. Healthy Louisville
2020 also recommends reducing tobacco advertising, particularly
in close proximity to schools and strengthening enforcement of
existing laws prohibiting selling tobacco to minors.
SEPTEMBER 2014
21
22
LOUISVILLE MEDICINE
NEW CHALLENGES – E-CIGARETTES AND
HOOKAH
New products such as e-cigarettes and reemerging practices such
as hookah use are posing new public health challenges. Electronic
cigarettes, or e-cigarettes, are battery-powered devices that provide
doses of nicotine and other additives to the user in an aerosol.
Most e-cigarettes are currently unregulated by the Food and Drug
Administration. The percentage of U.S. middle and high school
students who use e-cigarettes more than doubled from 2011 to 2012.
A CDC study showed that the percentage of high school students
who reported ever using an e-cigarette rose from 4.7 percent in
2011 to 10.0 percent in 2012. In the same time period, high school
students using e-cigarettes within the past 30 days rose from 1.5
percent to 2.8 percent. Use also doubled among middle school
students. Altogether, in 2012 more than 1.78 million middle and
high school students nationwide had tried e-cigarettes.
The study also found that 76.3 percent of middle and high school
students who used e-cigarettes within the past 30 days also smoked
conventional cigarettes in the same period. In addition, 1 in 5 middle school students who reported ever using e-cigarettes say they
have never tried conventional cigarettes. This raises concern that
there may be young people for whom e-cigarettes could be an entry
point to use of conventional tobacco products, including cigarettes.
E-cigarettes are also an increasing poisoning risk for children
age 5 and younger. In 2013 the Kentucky Regional Poison Control
Center of Kosair Children’s Hospital saw a 333 percent increase in
calls resulting from young children ingesting nicotine and other
toxins from e-cigarettes. Nationally, poison centers saw a 161 percent increase.
We are also seeing an increase in the number of hookah bars
throughout Louisville especially in areas frequented by young people,
many near college campuses. A hookah is a single or multi-stemmed
instrument for vaporizing and smoking flavored tobacco or herbs
called shisha in which the vapor or smoke is passed through a water basin before inhalation. Although Louisville’s smoke-free law,
which bans smoking tobacco in any public indoor space, prohibits
smoking products containing tobacco in Louisville hookah bars, it
is often difficult to determine whether the substance being smoked
contains tobacco or not. Certainly shisha containing tobacco has
the same addictive properties as cigarette smoking, which can lead
a hookah user to begin using cigarettes or becoming a dual user of
hookah and cigarettes.
Even smoking non-tobacco shisha in a hookah has the significant
health risk of inhaling combusted charcoal. When charcoal is burned
in the hookah, it releases toxic chemicals in the process, carbon
monoxide (CO) and polyaromatic hydrocarbons (PAH). Hookah
smokers inhale large quantities of these combustion-related toxins
— which can lead to cancer and heart disease.
To protect children from the new health risks posed by e-cigarettes and hookah products Healthy Louisville 2020 recommends
banning their sale to minors. This recommendation has already
been acted on. In April, the Louisville Metro Council unanimously
passed and Mayor Greg Fischer signed an ordinance banning the
sale of e-cigarettes and herbal hookah products to those younger
than age 18. A new state law also bans the sale of e-cigarettes (but
not hookah products) to minors.
SMOKE-FREE PUBLIC SPACES AND RENTAL
HOUSING
Once considered the home of big
tobacco, Louisville now has a very
strong smoke-free law that bans
smoking in every public indoor
space and workplace. A 2008
study by Dr. Ellen Hahn of the
University of Kentucky and others documented significant improvement in indoor air quality
in Louisville bars, restaurants and
other entertainment venues after
the implementation of the comprehensive smoke-free law. Healthy Louisville 2020 calls for expanding
city-wide smoke-free areas to include outdoor public spaces, such as
playgrounds, parks, special events, and public areas around downtown hospital campuses. Louisville’s three Olmstead parks - Cherokee, Shawnee and Iroquois - currently have a voluntary smoke-free
policy in and around playgrounds and spray-grounds. Posted signs
ask patrons not to smoke in the play areas. This policy is now being
expanded to 11 additional spray-grounds and five Metro Parks pools.
Healthy Louisville 2020 also recommends creating demand for
more smoke-free public and private multi-unit rental housing. All
228 public housing units in the new Sheppard Square development
will be smoke-free. The Louisville Metro Housing Authority is also
phasing in smoke-free units at its other complexes throughout the
city. The Department of Public Health and Wellness has also been
working with private rental property firms such as Blairwood Apartments on Linn Station Road to implement smoke free rental units. The
department has been providing signage and technical assistance. For
more information, visit www.louisvilleky.gov/HealthyHometown/.
A CALL TO ACTION
The 2014 Surgeon General’s Report has as its goal to eliminate
tobacco smoking. To this end the report advocates such proven
strategies as smoke-free air policies, optimal tobacco excise taxes,
barrier-free cessation treatment, hard hitting media campaigns
and comprehensive tobacco control programs funded at CDC
recommended levels.
Here locally, Healthy Louisville 2020 echoes many of those same
strategies. It calls for physicians and health providers to refer their
patients who smoke to effective cessation programs. It advocates
increasing the state cigarette tax and for more smoking cessation
programs for pregnant parents. It promotes expanding smoke-free
areas to include outdoor public spaces and creating demand for more
smoke-free public and private multi-unit rental housing. Healthy
Louisville 2020 champions prohibiting the sale of e-cigarettes and
hookah products to minors and reducing tobacco advertising,
particularly near schools.
Fifty years after the first Surgeon General’s Report, due to better
science, we know more about what will work to end America’s and
Louisville’s tobacco crisis. We now must act accordingly to improve
the health of our community! LM
Note: Dr. Nesbitt, a family physician, is the director of the Louisville
Metro Department of Public Health and Wellness.
SEPTEMBER 2014
23
Alliance News
MICHELLE FEGER | GLMSA CO-PRESIDENT | [email protected]
BE A PART OF THE GREATER LOUISVILLE MEDICAL SOCIETY ALLIANCE THIS YEAR
H
i, my name is Michelle Feger. I am
co-president of the Greater Louisville
Medical Society Alliance with Rhonda
Rhodes for the 2014-2015 year. I am excited to
serve with Rhonda this year, as we have many interesting and appealing opportunities planned.
I have been married to Tim Feger, MD, for 27
years. Tim is an allergist with Family Allergy
and Asthma. We have three daughters ranging from 24 to 18 years
of age. I am an RN who started my nursing career at Kosair Children’s Hospital in the Neonatal Intensive Care Unit many years ago.
I continued working at the Visiting Nurse Association in pediatric
home health and then in a physician’s office until I retired to raise
my children. I became a member of the GLMSA about eight years
ago. I love the social and service aspects of the Alliance, along with
the comraderie of being with other amazing people who face the
same issues and challenges I do during this ever-changing time in
medicine.
I look forward to the year ahead! Jenny Jacob worked hard last
spring to update our dues statement to make it clear, concise, and
easier to read. That really helped us get our dues mailing out for the
upcoming year, which we did in early June. We’re getting ready to
kick off our year with a busy September.
First we will have our opening luncheon September 2nd at
11:30am at my house to outline our events/activities for the year.
•
24
The next opportunity to get involved is the Walk to End Alzheimer’s on September 6th at the Great Lawn at Waterfront Park.
Registration starts at 9 a.m. and the walk starts at 10 a.m. We
LOUISVILLE MEDICINE
(left) GLMSA members gather at the home of Michelle Feger to help with the
2014-2015 dues mailing. (right) GLMSA Co-presidents Michelle Feger and Rhonda
Rhodes.
will have a group walking that day. Rhonda and I have both
been touched very closely by this disease. Rhonda’s mother
passed away after a battle with Alzheimer’s and my mother is
in the midst of her journey with Alzheimer’s now.
•
Next the Kentucky Medical Association Alliance annual meeting
is September 14-16th at the Hyatt Regency, here in Louisville.
•
After that, the GLMS Foundation Scholarship Golf Tournament
is September 22nd. Please consider putting a team together for
this wonderful event. If you’re not a golfer, the awards reception that follows the tournament is fun to attend. For more
information, go to glms.org and look under upcoming events.
•
Lastly, John and Rhonda Rhodes will host “Pumpkins and
Politics,” a KPPAC Legislative Reception, on September 27th at
their home. It will be a great opportunity to learn what’s going
on in the upcoming legislative session.
We would love for you to join us this year. Being a member will
offer you the opportunity to build friendships, attend interesting
meetings, volunteer for various service opportunities, and learn
of legislative changes that are affecting medical families today.
The dues statement is available online at www.glms.org under the
membership tab. LM
Note: Michelle Feger is the co-president of the GLMS Alliance with
Rhonda Rhodes.
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LOUISVILLE WELCOMES
NEW MEDICAL STUDENTS
Aaron Burch
T
he 157-student strong Class of 2018 joined the University
of Louisville School of Medicine during the annual White
Coat Ceremony held Sunday, July 27, 2014. Welcomed by
physicians, professors and peers, the students put on their white
coats for the very first time and listened intently as their elders
offered advice on how to approach the difficult task of becoming a
physician. One of the most inspiring speeches of the evening came
from the 2017 School of Medicine Class President Matt Woeste,
who said, “Never lose that hunger to wear (the white coat). In the
end, there will be 157 exquisitely unique new UofL physicians.”
Following the ceremony, a record 146 students took advantage of
free professional photography and activated their GLMS student
membership. The GLMS and the GLMS Foundation jointly shared
the expense of providing a white coat to each incoming medical
student. LM
Note: Aaron Burch is the communications specialist for the Greater
GLMS President, Bruce Scott, MD, congratulates the students.
(left) Alexandra Bacani Kiefer, granddaughter of Teresita Bacani-Oropilla, MD, after
receiving her white coat.
UofL Dean Toni Ganzel, MD, MBA, FACS,
welcomes the participates and guests.
Taylor Marie Hodge, Daughter
of Kenneth Hodge, Jr, MD,
receives her white coat from Mike
Osapchuk, MD, MSEd.
The class of 2018 recites the Declaration of Geneva.
Ishita M. Jain greeting Dean
Toni Ganzel, MD, MBA, FACS.
Matt Woeste, President of the Class of
2017, gave student remarks.
(left) David P. Brown, son of Matt Brown,
MD, received his white coat.
David Dunn, MD, PhD, presented the
keynote address.
SEPTEMBER 2014
27
Amadeo L. Abraham, M.D
M. Lynell Chamberlain, M.D.
Sonia Vishin Compton, M.D.
Christopher B. Howerton, M.D.
Zaka U. Khan, M.D.
J. Wesley McConnell, M.D.
Josephine Mei, M.D.
The physicians of Kentuckiana Pulmonary Associates
are excited to announce that
Rahel Teferra, M.D.
will be joining our practice
Effective August 2014
Medical School
Gondar College of Medical Sciences
Gondar, Ethiopia
Internship and Residency
Howard University
Internal Medicine Residency
Ohio State University Wexner Medical Center
Pulmonary-Critical Care Fellowship
University of Louisville
Department of Sleep Medicine Fellowship
Specialist in Internal Medicine
Pulmonary Critical Care and Sleep
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28
LOUISVILLE MEDICINE
GLMS POLICY AND
ADVOCACY IN 2014
T
he GLMS Policy and Advocacy Team
was very active during the 2014 session of the Kentucky General Assembly.
We personally interacted with nearly every
member of the Jefferson County Delegation,
the majority of leadership in both the House
and Senate, and several legislators representing other areas of the Commonwealth. After
hosting a reception for the Delegation in early
January, GLMS had a presence weekly in Frankfort until the end of
the session in April. Team members attended committee meetings,
offered formal testimony in hearings, met individually with legislators, and took part in rallies and press conferences in support of
efforts to improve Kentucky’s healthcare environment.
At the start of the session, the team focused on four pieces of
legislation: SmokeFree Kentucky (SB 117 and HB 173), a proposal to
ban smoking in public spaces throughout our state; Expert Witness
Requirement (SB 134), a long-supported idea to require board certification and significant local experience in a physician-defendant’s
specialty as a prerequisite for physicians who wish to work as paid
experts in medical malpractice suits in Kentucky; MOST (HB 145),
a proposal to establish a Medical Order for Scope of Treatment, a
standardized, portable, and physician-signed form that documents
a patient’s health care decisions; and Good Samaritan/911 -- SB 62,
a straightforward bill that proposed allowing limited immunity
from prosecution for people who call 911 or another authority upon
witnessing a potential overdose taking place, and SB 5, an omnibus
bill that included SB 62’s language in addition to a very controversial
measure that would have required homicide convictions for people,
including addicts, found guilty of indirectly causing on overdose
death by selling drugs to an individual who then dies or miscarries
as a result of taking them.
As the weeks went on, the Team ended up actively supporting 5
other bills as well: Prescription Eye Drops (SB 118), which allows
for health plan coverage of more frequent refills of prescription eye
drops; Medical Review Panels (SB 119); Tanning Bed Restrictions
(HB 310), a proposal to prohibit children under the age of 18 from
using a tanning bed without a prescription from a physician; Pediatric Abusive Head Trauma (HB 157), which established both a
requirement for a one time CME on recognizing head trauma in
children for Pediatricians, Family Physicians, Emergency Physicians,
Urgent Care Physicians, and Radiologists, as well as a sunsetting
of the current HIV CME requirement for all Kentucky physicians;
and Insurance Opt Out legislation (SB 185), a bill that would make
it illegal for an insurance company to create a situation where a
provider is automatically in agreement to a contract change or new
product offering (with no requirement for meaningful communication on the change) unless he or she “opts out” of the agreement.
For a variety of reasons, only Prescription Eye Drops and Pediatric Abusive HeadTrauma successfully passed both chambers and
were signed into law. Strong opinions of several legislators and their
constituents on politically divisive issues such as property rights and
individual liberty, an individual’s right to life versus right to choose
across the entire life spectrum, and the ongoing so-called war on
drugs negatively affected the outcome of SmokeFree Kentucky,
Tanning Bed Restrictions, MOST, and Good Samaritan-911. Likewise, the ongoing opposition to anything resembling tort reform
by most leaders in the House harmed the prospects of Medical
Review Panel legislation.
Expert Witness Requirement, a less controversial and very modest
approach to addressing the malpractice issue, appeared to have a
good chance of passing until a perfect storm hit: a series of events
led the bill’s sponsor to focus almost exclusively on the passage
of Juvenile Justice Reform legislation during the last half of the
session and, simultaneously, the lobbyist who led the “boots on
the ground” effort early on had to attend full time to her child who
became gravely ill during the middle of the session. Last but not
least, Insurance Opt Out legislation was filed late in the session. It
received intense criticism from both commercial health plans and
Medicaid MCO’s because these groups (according to their many
lobbyists) believe the bill’s requirement for simple communication
between providers and payers would lead to severe burdens for the
corporations’ business practices and harm their bottom line. The
MCO’s went so far as to threaten the Cabinet for Health and Family
Services with higher charges for managing the Medicaid plans if
the legislation passed.
This analysis helps bring clarity to what it takes to get laws and
regulations passed or changed. It is not enough to pass a resolution
at the KMA, the AMA, or our specialty societies. If an organization
really wants to have a hand in bringing about major change for the
benefit of its members (in our case physicians and the patients we
SEPTEMBER 2014
29
serve), it seems as if it needs at least two, and preferably all three,
of the following key components: a champion in Government (for
the purposes of this article, Government will refer to the legislature,
although executive and judicial champions are needed as well);
effective professional lobbying; and robust member (physician)
engagement across the specialties and in partnership with other
groups and organizations. Our local pediatric colleagues in the
Kentucky chapter of the American Academy of Pediatrics and at the
University of Louisville benefited from a strong grassroots movement, negotiation and cooperation with other physician groups,
and a dedicated legislative champion as they succeeded in helping
Pediatric Abusive Head Trauma become law. Prescription eye drops,
not as overwhelmingly popular with legislators initially, ultimately
benefited from all three key components: a great lobbying team with
McBrayer, McGinnis, Leslie and Kirkland (MMLK), actively engaged
ophthalmologists of the Kentucky Academy of Eye Physicians and
Surgeons and other physicians of the GLMS Policy and Advocacy
Team and other groups, and Senator Julie Denton, who sponsored
the bill energetically. Although the bill had an excellent chance of
passing from the outset because it offered to help many people with
little cost to the state, it is still a great model to follow for all of our
legislative and regulatory goals.
Politically charged issues, where there is division among lawmakers, professionals, organizations, and the public, are stressful and
challenging. However, the right combination of legislative leadership,
professional lobbying, and grass roots physician involvement can
make all the difference in these areas as well. The story of the Advanced Practice Registered Nurse (APRN) compromise legislation
(SB 7) speaks to this concept on many levels. Most all Kentucky
physicians are by now somewhat aware of the new state law that
significantly expands the prescriptive authority of APRN’s in the
Commonwealth. Our Policy and Advocacy Team did not actively try
to influence this legislation during the session because lengthy negotiations between the Kentucky Medical Association, the Kentucky
Academy of Family Physicians (KAFP), and the Kentucky Coalition
of Nurse Practitioners and Nurse Midwives (KCNPNMW) were
finalized well before the 2014 session began in January. However,
since the GLMS took the initiative in moving KMA policy toward
developing a model for the physician-led team approach to patient
care several years ago, and also considering that 2 GLMS members
-- myself and Dr. Ron Waldridge, II -- were very involved in the
process that led to the compromise legislation, a few more details
of the behind-the-scenes events that led to SB 7 deserve reporting
in this context. I have devoted several paragraphs in an attempt to
tell the story.
KCNPNMW has displayed a fantastic effort, strong and persistent,
over many years in its aim to eliminate the statutory requirement
for collaboration between APRNs and physicians in the area of prescription writing. (The group had already won the right for APRNs
to practice and order tests independently without physician collaboration or supervision in 1996.) Their organization has extremely
strong member participation at the grass roots level. Most every state
legislator and regulatory leader has heard repeatedly from APRNs
30
LOUISVILLE MEDICINE
on this issue. The group also works with very effective lobbyists - a
retired psychologist Democrat who believes fully and passionately
in the organization’s mission and a Republican who enjoys strong
relationships with most every GOP legislator in both the House
and Senate. Both of them are respected and hard-working. Also
critically important, KCNPNMW has had legislative champions on
this and other issues. Representative Mary Lou Marzian, a Louisville
Democrat and nurse, was devoted to the effort from the time the
collaborative prescribing agreement was established as a condition
of independent practice in 1996 until well after the first call for its
elimination in 2010. Later, Senators Gary Tapp and Paul Hornback,
both Republicans from Shelby County, were tireless and vocal leaders
in the legislature and helped sway a bipartisan effort on the issue.
The proposal to move away from supervisory and collaborative
requirements steadily became accepted by most lawmakers as a
way to counter inadequate access to primary care physicians in
many underserved areas of the state. KMA historically opposed the
effort, however, citing patient safety concerns. Since the majority
of legislators had come to believe that the issue was purely a turf
battle, the APRN-backed legislation would have become law during
the 2013 session if not for a handful of senators who were deeply
concerned about the issue - primarily Carroll Gibson of Leitchfield
and President Pro Tem Katie Stine of Southgate. Also, the emergence
of a new-to-Frankfort group, the Kentucky Academy of Family Physicians (KAFP) which, together with the group’s lobbyists, MMLK,
and several individual physicians, lent “credibility” to the physician
argument, according to many legislators. In April 2013, the three
organizations - KAFP, KMA, and KCNPNMW - were asked by
legislative leaders to work out a compromise during the interim.
A large and diverse group of nurses, physicians, lobbyists, and
legislative staff met several times between May and November of
2013. Determined to make sure the compromise actually helped to
erase chronic provider shortages, discussions began by addressing
how the collaborative agreement requirement in Kentucky was
reportedly limiting access to care in some instances. According to
the KCNPNMW: the collaborative agreement, with no standardized
feature, added no value to patient care; some APRNs were in danger
of losing their practices if their collaborating physicians retired,
moved, or died; and some physicians were charging excessive fees
for signing these agreements. After lengthy discussions, it became
apparent that these problems represented the extremely rare exception, not the rule. Nevertheless, each point was carefully considered.
In July of last year, the Joint Licensing and Occupations committee
heard a progress report from the group. Physicians revealed the
national and state-wide trend of APRNs working increasingly in
non-primary care specialties while generally being no more likely
to practice in rural and underserved areas than primary care physicians. They reiterated the importance of the substantial educational
gaps between nurse practitioners and physicians (especially with
the recent development of “fast tracks” toward RN and advanced
practice degrees) and shared that every state surrounding Kentucky
continued to maintain stricter laws than ours regarding collaboration
between nurses and physicians. Further discussion drew attention
to the fact that non-controlled drugs include extremely potent med-
ications that have complex interactions and potential side effects
that are less predictable than controlled substances, despite claims
to the contrary. Physicians finally presented how physician-led
team-based care, along with efficient applications of technology, can
dramatically reduce the impact of physician shortages. In hopes of
improving collaborative agreements in Kentucky, KMA and KAFP
offered to develop a clearinghouse of physicians who would be
willing to work with nurses who lose their collaborating physicians
through no fault of their own, and the organizations recommended
building on legislation proposed in the Senate for the previous two
years regarding improving the collaborative agreement in a way
that would allow for better transparency and for efficient and fair
resolution of grievances, including complaints of excessive fees.
After further discussions revealed that the KCNPNMW was
committed to eliminating rather than improving the collaborative
agreement, and proposals to develop a Joint Medical/Nursing Board
while holding independently prescribing APRNs and physicians to
the same professional liability standards were deemed non-starters
for further discussion, physicians proposed the following: (a) form
a Joint Advisory Committee made up of equal parts Kentucky
Board of Nursing and Kentucky Board of Medical Licensure, and
charge it with monitoring APRN-written prescriptions, developing
a standardized collaborative agreement form, and advising each
Board on the issue; (b) develop a process for APRNs who wish to
practice and prescribe independently that includes a requirement to
complete several years of meaningful collaborative practice with a
physician who specializes in the APRNs area of focus; (c) incentivize
APRNs to serve in one of Kentucky’s approximately 80 medically
underserved areas by establishing a rural/underserved area carve out
for nurses who opt to prescribe without a collaborative agreement;
and (d) allow APRN’s to maintain the protection of their existing
collaborative agreements as the default.
The final agreement that is now law was made within the confines
of a smaller group that Dr. Waldridge and I were not a part of. In
essence, it establishes a requirement for a newly graduated APRN to
maintain a collaborative agreement for four years, after which time
the APRN may opt to prescribe independently in any part of the
state with no stipulation about his or her area of practice. Meaningful
collaboration is not required during any part of the process. The Joint
Advisory Committee will be established with no definitive authority
to make recommendations regarding collaborative agreements or
prescribing, and it will not monitor prescriptions written by APRNs
who have opted out of the collaborative agreement requirement.
It may, however, develop a standardized collaborative agreement
form, and hopefully it will opt to do that in a manner that provides
transparency and guidance without being unnecessarily restrictive.
(See 2014 Senate Bill 7.)
The combination of focused physician engagement, enhanced
professional lobbying, and dedicated legislative champions allowed
for compromise with physician input on the APRN collaborative
agreement issue. Ultimately, however, KCNPNMW, the group that
had been the most active -- both in Frankfort where policy is made
and in individual districts throughout the Commonwealth where
the political advocacy that lays the groundwork for policy change
happens -- was the most satisfied with the outcome. It is exciting
to think what could happen in the future on the issue of physician
workforce shortages, other priorities such as tort reform and insurance/payer reform, and a myriad of public health/patient safety
projects. If physicians from multiple specialties could regularly and
productively meet with each other and with other health professionals, insurers, attorneys, and leaders in government, academics,
and business, we could realistically have a hand in eliminating the
problem of inadequate access to high quality care, growing local
economies, improving physician career satisfaction, and most importantly, improving the health and well-being of all the citizens
of this great Commonwealth.
Building on the lessons learned and momentum built from the
last year’s activities, the Policy and Advocacy Team has had a busy
summer and is looking forward to a busier fall as we move closer
to the 2015 session of the Kentucky General Assembly. Since each
team member has different interests and talents, we have begun to
organize into smaller workgroups focused on specific goals in order
to maximize efficiencies and hopefully, with the aid of a web-based
app that is helping us keep projects organized, accomplish more
with less labor and fewer formal meetings. So far, we have 4 growing
workgroups: insurance/payer group, legal issues/tort reform group,
workforce/scope of practice group, and public health/safety group.
Each group is focusing on one or more issues and will be helping
to guide the development of public policy through legislative/
regulatory and other forms of advocacy. We are on track to establish, in the next few months, 3-4 key physician contacts for each
Greater Louisville area legislator and all members of leadership in
the KGA. And we are following the advice of several legislators as
we try to identify at least one physician constituent who either lives
or works in a legislator’s district to serve as his or her key contact.
This is easier said than done, especially in Louisville’s south and
west ends, but it’s very important as ultimately our lawmakers are
politicians and are more concerned about earning the votes of their
constituents than listening to physician experts explain why they
should vote a certain way. Team members have continued to be very
active in attending and hosting several receptions, benefits, and
small get-togethers with legislators and other leaders over the last
several months. More informational gatherings are being planned
in different parts of Greater Louisville in the next few months, as
well, and we plan to focus each gathering on key topics that our
four workgroups are advocating for.
In our next writing, we will share the team’s top three or four
issues we are focusing on going forward and provide updates to
our summer and fall activities. If you have an interest in advocacy
on any level, please join the Policy and Advocacy Team. Keep
your eyes and ears open for invitations to upcoming events, and
try to join us if you can. It is a lot of fun and you will make a
difference! LM
Note: Dr. Ragland is the Vice Chair of the Policy and Advocacy
Team and practices Internal Medicine and Pediatrics with Internal
Medicine & Pediatric Associates.
SEPTEMBER 2014
31
PHYSICIANS IN PRINT
Abdolmohammadi A, Sears W, Rai S, Pan J, Alexander J, Kloecker G.
Survey of primary care physicians on therapeutic approaches to lung
and breast cancers. South Med J. 2014 Jul;107(7):437-42. PubMed
PMID: 25010586.
Al-Salem KM, Schaal S. Age-related macular degeneration and early
diagnosis of dementia. JAMA Ophthalmol. 2014 Jul 1;132(7):906-7.
PubMed PMID: 25010180.
Bays HE. Lowering low-density lipoprotein cholesterol levels in
patients with type 2 diabetes mellitus. Int J Gen Med. 2014 Jul
5;7:355-64. PubMed PMID: 25045281.
Brenner MJ, Goldman JL. Obstructive Sleep Apnea and Surgery:
Quality Improvement Imperatives and Opportunities. Curr
Otorhinolaryngol Rep. 2014 Mar 1;2(1):20-29. PubMed PMID:
25013745.
Bumpous J, Celestre MD, Pribitkin E, Stack BC Jr. Decision Making for
Diagnosis and Management: Algorithms from Experts for Molecular
Testing. Otolaryngol Clin North Am. 2014 Aug;47(4):609-623. PubMed
PMID: 25041961.
Calobrace MB, Capizzi PJ. The biology and evolution of cohesive gel
and shaped implants. Plast Reconstr Surg. 2014 Jul;134(1 Suppl):6S11S. PubMed PMID: 25057753.
Calobrace MB, Kaufman DL, Gordon AE, Reid DL. Evolving Practices
in Augmentation Operative Technique with Sientra HSC Round
Implants. Plast Reconstr Surg. 2014 Jul;134(1 Suppl):57S-67S.
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El-Kersh K, Yasin M, Cavallazzi R, Perez RL. Mounier-kuhn syndrome.
Imaging and bronchoscopic findings. Am J Respir Crit Care Med. 2014
Jul 1;190(1):e2-3. PubMed PMID: 24983230.
Greene JW, Zois T, Deshmukh A, Cushner FD, Scuderi GR. Routine
Examination of Pathology Specimens Following Knee Arthroscopy: A
Cost-Effectiveness Analysis. J Bone Joint Surg Am. Jun 4; 96(11):917921, 2014.
Greene JW, Guild GN, Zois T, Scuderi GR. History and Examination for
the Painful Total Knee Arthroplasty. Techniques in Revision Hip and
Knee Arthroplasty. WB Saunders, Elsevier Health Science Company,
Philadelphia, pp 7-12, 2015.
Huecker MR, Shoff HW. The law of unintended consequences: illicit
for licit narcotic substitution. West J Emerg Med. 2014 Jul;15(4):561-3.
Wadhwa A, Kabon B, Fleischmann E, Kurz A, Sessler DI. Supplemental
postoperative oxygen does not reduce surgical site infection and
major healing-related complications from bariatric surgery in
morbidly obese patients: a randomized, blinded trial. Anesth Analg.
2014 Aug;119(2):357-65. PubMed PMID: 25046787.
NOTE: GLMS members’ names appear in boldface type. Most of the references have been obtained through the use of a MEDLINE computer search
which is provided by Norton Healthcare Medical Library. If you have a recent reference that did not appear and would like to have it published in our
next issue, please send it to Jennifer Howard by fax (502-736-6363) or email
([email protected]). LM
SPEAK YOUR MIND If you would like to respond to an article in this issue, please submit an article or letter to the editor.
Contributions may be sent to [email protected] or may be submitted online at www.glms.org. The GLMS Editorial Board reserves
the right to choose what will be published. Please note that the views expressed in Doctors’ Lounge or any other article in this
publication are not those of the Greater Louisville Medical Society or Louisville Medicine.
SHOW ME THE MORONS
Mary G. Barry, MD
M
Louisville Medicine Editor
[email protected]
issouri, the Show-Me state, has
just shown the country how low
it can go on the IQ scale, or on
any common-sense measure of valuing
patient care. In early July, Gov. Jay Nixon
signed into law Senate Bill 716, allowing
medical school graduates fresh out the door
– without any residency training whatsoever – to hang out their shingles in private
practice. The intent is “to improve access to
health care,” as if the quality of that care does
not matter. As the law is written, this applies
to work in rural and medically underserved
areas only. These “Assistant Physicians” are
required to have close supervision by a licensed physician for only one month, defined as a physician who practices within 50
miles, as well as an ongoing chart review of
10 percent of patients seen, every two weeks.
There is no time limit in this law, so that in
a year, the “experienced” doctor reviewing
the brand new one could have only his own
year of teach-yourself medicine to rely on.
Teach-yourself medicine is good for
looking things up, supposing the texts you
use are authoritative, current, and correct.
Teach-yourself medicine in daily primary
care – when you have never once independently diagnosed and treated anything
– anything! – means disaster. You will make
major mistakes. You will be overwhelmed
and probably hysterical by the end of the
first day, when you have just been presented with 20 people with laundry lists of
symptoms, some of whom have dangerous
problems, like rheumatic heart disease with
cor pulmonale, which you have never even
heard of. You will not know what half their
medicines are. You will not know why they
are really there. You will not know what is
wrong with them, or how bad it is, or what
you and they should do about it. After you
fail to ask the right questions (and while
you are getting panicky about how long
this seems to take) you will miss telltale
physical signs. You will send home the lady
with early bowel obstruction. You will put
the asthmatic on water pills, and the man
with heart failure on inhalers. You will fail
to note the CVA tenderness, forget to do a
pregnancy test, and think the breast mass
is a cyst. You will not stop to palpate the
tender temporal artery, since you doubtless
have never heard of vasculitis.
They will bring you a sick child, yet you
only had two months of pediatrics, so you
will ask the parents what they think it is,
and pray. Half your mind will still be on the
child when you see the drug abuser who is
delighted that he has a newbie to tell about
his pain, and you will use your newly issued
powers to give him Vicodin. You will let
your medical assistant take the vital signs
with a machine, and thus your farmer with
new-onset atrial fibrillation, who smiled at
you even though he has been short of breath
lately, will have an aphasic stroke out in the
field the very next day. (You did diagnose
him with COPD, since you have heard of
that before.) When his daughter calls to tell
you he can’t talk or move his leg, you will
still have no idea why that happened, or that
it was preventable, and you will have nightmares (as will your malpractice insurer) for
months. And by the way – who in his right
mind will underwrite you?
Then you get to do it all over again the
next day, all by yourself. You don’t know how
to get any test authorized, even though you
Googled what test was needed (presuming
you are somewhere in the neighborhood of
the correct diagnosis). If that test is normal,
then what? You have no clue. Somewhere
in the back of your mind you remember
that you are supposed to be doing preventive care, but who needs what, and when,
and anyway you don’t have time. And then
you get to take weekend call, and cannot
get through dinner, much less sleep, and
your spouse looks at you in the morning
and thinks, “We were out of our minds to
do this.”
Amazingly, the Missouri State Medical
Association supported this measure. Said
Jeffrey Howell, “Missouri has an opportunity to be a trailblazer on this type of licensure
and solving the health care access problem.
This is a brand new idea and something we
can really take advantage of.” Howell et al
were unswayed by the fierce opposition of
the AMA, both the national and Missouri Academy of Family Physicians, and the
ACGME (Accreditation Council for Graduate Medical Education). Additionally, the
national and state Academy of Physician
Assistants lobbied strenuously against this,
since the “Assistant Physician” name – it(continued on page 34)
SEPTEMBER 2014
33
DOCTORS’ LOUNGE
self a false designation as regards the actual
practice situation – describes half-baked
doctors who are clinically far less astute than
an experienced PA. “We are very concerned
about the confusion for patients and the
fact that this is an untested model,” said
Ann Davis, VP of the American Academy
of Physician Assistants. Hans Duvefelt, MD,
who has practiced in rural Maine for 30
years, said, “Those patients don’t need the
B team. Primary care requires more of you
than other specialties, because you are IT
in a remote area.”
Gov. Nixon signed the law on July 3 “with
reservations,” writing, “Considering that
this new category of licensure would make
Missouri unique among states and would
embark upon uncharted waters in providing health for Missourians, it is imperative
that there be comprehensive and rigorous
oversight and regulation.” It’s set to take
effect August 28, a bare seven weeks later:
this is long? Does this allow careful thought,
scrutiny and planning? “Railroaded” is a
term that comes to mind.
What patients need is for the doctor to
be right, and for the doctor to know what
to do and whom to call, and for the doctor
to care enough about them to explain it all
well, and for all this to happen pretty fast.
Residencies and fellowships were created to
teach medical graduates who had a beginning set of skills and knowledge how to become competent and safe at recognizing and
treating ailments of graduated complexity,
with measured increases in responsibility as
their abilities were proven – on rounds, at
the bedside, in the OR, in the ER – proven,
not taken for granted. The raw MD diploma
holder has never been combat-tested, never had to recognize a complication, never
had to deal with an emergency, never had
to shoulder the massive burden of being
The Man. The buck always stops with the
doctor. When the doctor, or almost but not
really doctor, or APN, or DNP, or PA is
wrong, there must be a clear line of referral
and damage control and consultative and
emergency help. If you’ve just picked up
the primary care of several thousand people
out in the country, I doubt very much you
know whether you are wrong, or whom to
call, even if you figure out what happened.
Having the buck stop with you for the first
time ever, was for all of us when new, an
occasion of primal fear. Having no one in
the next room who is better than we are
represents planning at its worst, so far as the
care of human beings is concerned.
Missouri has ignored history, ignored
Flexner, ignored the counsel of thousands
of medical experts across the country and
ignored its own homegrown Family Medicine physicians, all in a blind rush to get
somebody in a white coat out into the sticks.
They have refused to understand what the
practice of medicine truly demands. Patients may get seen closer to home: but
getting seen is not getting doctored. Show
me the way to bad decisions, and I’ll show
you the legislators’ treatment of rural
Missourians. LM
Note: Dr. Barry practices Internal Medicine
with Norton Community Medical Associates-Barret. She is a clinical associate professor at the University of Louisville School of
Medicine, Department of Medicine.
LETTER TO THE EDITOR
James Patrick Murphy, MD, MMM
D
ear Editor,
Drug abuse is epidemic. So no one
should trash talk about Martha Elson’s excellent article, Dispose of Prescription
Drugs? It’s Not Easy in Louisville1. But the
trash is exactly where leftover abusable drugs
can go. Ms. Elson exposed the number one
suppliers of abused pills, and surprisingly,
it’s not the doctors. It’s you and me. In fact,
about two-thirds of all abused pills come
from family and friends, often right out of
unlocked medicine cabinets. As a specialist
in Pain Medicine and Addiction, I require
my patients to lock up their medications
and properly dispose of any leftovers. But
with so few drug drop-off boxes available,
34
LOUISVILLE MEDICINE
what’s a responsible person to do?
Trash them!
Yes, if you can’t get to a drop-off box,
the FDA says it is acceptable to throw
your old medications in the trash, provided you first “doctor them up” a bit. (www.
fda.gov/forconsumers/consumerupdates/
ucm101653.htm) Simply mix the pills with
kitty litter or coffee grounds. Seal it in a
leak-proof bag (like a zip-lock) and toss it
in the garbage. Easy.
The more potent the drug is, the greater
the need for disposal of the unused leftovers.
The FDA has even determined that the danger from keeping unused powerful narcotics
is so ominous, that flushing leftovers down
the toilet is acceptable when a drop-off box
is unavailable. The Environmental Protection Agency is OK with this policy. The
FDA says there has been no indication of
adverse environmental effects due to flushing leftover pills.
However, leftover pills do contribute to
adverse societal effects. About one-fourth
of high school age youth have abused prescription drugs. Approximately three Americans die every hour of every day from a
drug overdose. More Kentuckians die from
overdose than die in automobile accidents.
A very large percentage of these overdose
deaths involve prescription drugs.
DOCTORS’ LOUNGE
Ms. Elson’s timely article brought to light
the progress we are making. More and more
drug drop-offs are becoming available. We
should take advantage of them when we can.
But please do not let your busy schedule,
your concern for the environment, or your
unfamiliarity with regulations deter you
from properly disposing of your unused
medications. We are battling a drug abuse
epidemic. People are dying. Make sure you
are not an unwitting supplier. You may save
the life of someone you love… And that’s
not talking trash. L
M
The Courier-Journal Columnist Martha
Elson’s “Dispose of Prescription Drugs? It’s
Not Easy in Louisville” first appeared in the
July 8th edition of The Courier-Journal and
is available to read on-line at the newspa1
per’s website, www.courier-journal.com.
Note: Dr. Murphy, board-certified in Anesthesiology, Pain Medicine and Addiction
Medicine, is the president and medical director of Murphy Pain Center. He is an assistant clinical professor at the University of
Louisville School of Medicine and serves on
the board of the International Association of
Pain and Chemical Dependency.
LETTER TO THE EDITOR
C. Kenneth Peters, MD
K
udos to Gordon R. Tobin, MD and
everyone who contributed to the
July LM article, “Celebrate a Quarter-Century of Compassion at The Healing
Place.” We certainly have cause to celebrate
at the 25th Anniversary observances in August.
I would like to offer one historical footnote because The Healing Place almost certainly would not have survived to become
the life-saving organization it is today without the incredible generosity and dedication
of two individuals who predated most of the
wonderful people mentioned in the article.
In our first year of operation after accepting the Men’s shelter property from Father
Morgan, along with a shoestring $125,000
for operating expenses, we had no money
for staff.
It was to our great fortune that Rose Gardner, wife of 1979 AMA President Hoyt D.
Gardner, MD, and retired cardiologist Donald H. Mosley, MD, volunteered their time
to run the shelter full time without a cent of
compensation or reimbursement for nearly
the first year and a half of our involvement.
In the Medical Society’s May 1990 Annual
Report Dr. Will Ward wrote, “Day-to-day
supervision of the operation and management of the properties has been ably carried
out by Rose Gardner and Don Mosley.”
These were accomplished, but unassuming individuals. Rose Gardner had served
as president of the JCMS and KMA Alliances, and in the 1970s she was National
Legislative Chair of the AMA Auxiliary. Her
involvement was part of the JCMS Auxiliary’s spectacular support. Dr. Mosley had
recently retired after a 25-year career with
Cardiovascular Associates, and in his words
“was at loose ends” when he answered my
request to help out.
He recalls getting faint and falling around
while painting the decrepit men’s communal
restroom with epoxy paint, venturing into
standing water in the basement across the
street to restore electrical power during a
torrential rainstorm, but also the consideration and appreciation always shown by
the shelter residents.
When asked if he foresaw then what The
Healing Place would become, he responded, “Oh, heaven’s sakes, no! We all were
concerned that the model we had was as an
overnight shelter and a holding area across
the street. We were uneasy that there was no
rehab. If JCMS had not found Jay Davidson,
I don’t think we would have survived.”
Outreach program, he did two years of parttime study toward a Master’s of Religious
Thought at the Presbyterian Seminary. He
spent the next several years of similar dedication to Hospital Hospitality House, the
adult counterpart to the Ronald McDonald
House. Now 80, he still volunteers at church.
Of the Healing Place he recalled, “It was a
good run in my life, and also in the life of
the Medical Society.”
The dedication and self-sacrifice of Rose
Gardner and Don Mosley deserve to be remembered, because almost single-handedly,
they kept the shelter and soup kitchen afloat,
learning each day, so that Jay Davidson and
Chris Fajardo could arrive later, assess the
clients’ needs and devise the recovery model
that has restored so many lives and made
The Healing Place respected around the
world. LM
Dr. Peters is a retired family physician.
Sadly, Rose Gardner died in 2002.
Dr. Mosley resides in Louisville where he
is “re-retired.” After his stint with the JCMS
SEPTEMBER 2014
35
DOCTORS’ LOUNGE
CYCLISTS’
SAFETY
Stanley A. Gall, MD
A
not just beginners.
n increasing theme in medical care
is the emphasis on prevention of
disease or injury. We advise patients to receive vaccines to prevent infectious diseases and for cancer prevention,
to have regular mammograms, and have
the first colonoscopy at the age of 50. The
state mandates automobile seatbelts and we
should mandate motorcycle helmets for all,
Kentucky statues also mandate that bicyclists (cyclists) display
a flashing white and red light at the front of the bicycle and at the
rear of the bicycle (reflectors do not count). Since we encounter
cyclists daily, how many have you noticed who are in compliance
with the law? (Less than two percent). I believe cycling is a great
sport for fitness and enjoyment. However, the average cyclist seems
to have forgotten the physics of an automobile versus a bicycle.
The modern cyclists have also forgotten that the background in
Kentucky is green and an increasing number of cyclists wear
dark colored clothing, making themselves perfectly camouflaged
to motorists.
Most cyclists have forgotten about bicycle etiquette and ride like
they own the road (i.e. two to three across rather than single file).
They do not own the road, yet the current mayor is trying to act
like a caring person for cyclists, but he would rather be known as
trying to keep up with other mayors in the competition for the
number of miles of roads converted to bicycle paths.
To address the prevention of unnecessary cyclists’ deaths, the
cyclists must be responsible for their own actions. Firstly, the bicycle should be compliant with state laws by having the flashing
white and red lights on both the front and rear of the bicycle.
Secondly, the cyclist is advised not to be camouflaged and to wear
bright colored clothing. Thirdly, the cyclist must remember the
laws of physics of the automobile versus the bicycle and adopt
an attitude of accommodation rather than confrontation with
the motorists. LM
Dr. Gall practices Obstetrics, Gynecology and Women’s Health as
part of the University of Louisville Physicians Group.
36
LOUISVILLE MEDICINE
HEART CARE
PERSONALIZED FOR YOU.
LOUISVILLE CARDIOLOGY GROUP
WELCOMES
JESSE ADAMS III, MD, FACC
Dr. Adams is board certified by the National Board of
Medical Examiners, the American Board of Internal
Medicine and the American Board of Internal Medicine
Division of Cardiology. He is a Fellow with the
American College of Cardiology.
Accepting New Patients!
1023 New Moody Lane, Suite 101
La Grange, KY 40031
502.222.8540
3900 Kresge Way, Suite 60
Louisville, KY 40207
502.893.7710
BaptistMedicalAssociates.com
FROM THE BLOGOSPHERE
Editor’s note: Emergency Medicine residents and faculty at the University of Louisville have a private blog called
Room9ER.com. With permission, we share select posts with Louisville Medicine readers.
14 YEAR OLD WITH CHEST PAIN
Thomas Cunningham, MD
14
yo male presents to ER triage as a
level 2 in severe respiratory distress.
The nurse calls for a doc and I stroll
into the trauma bay for what I think is another
run-of-the-mill asthma exacerbation. I walk by the respiratory
therapist and even say. “Hey we’re gonna need a mini-neb in here
can you get that started.” This kid is working hard to breathe, accessory muscle use, speaks in short sentences. He looks like your basic
asthmatic, sitting up leaning forward supporting his body with his
arms on his knees. His mother tells me that he has been complaining
of SOA for the last 2 days and that last night he wasn’t even able
to lie flat because he couldn’t breathe. So I put the kid back to see
what happens: “NO, no, don’t do that it hurts my chest and I can’t
breathe.” The respiratory therapist is now getting ready to put the
breathing treatment on him and the nurse is getting him hooked up
to the monitor. On exam he has some wheezes bilaterally, but not
to the degree that you would expect given his work of breathing;
no complaints of abdominal pain, just can’t lie flat and can’t seem
to get his breath.
I glance up at the monitor as the nurse is getting the first pressure
to cycle. Sat 93% on NRB. Breaths>40. Pressure is.....85/67.?!? Not
what I expected...can we get a Chest X-Ray in here. TEMP? JVD?
At this point I’m thinking, “Did this kid blow a bleb, undiagnosed
cardiac abnormality!?” Mom is now at bedside and starts to give
some more history - she states he hasn’t really been feeling well over
the last week; little cough but no fever, no n/v/d/ or constipation.
No heart trouble and no history of asthma. No family history of
heart abnormalities, arrhythmias; never been in the hospital. She
says she thought he had GERD over the last two days based on his
complaints but now his SOA is worse.
SO I’m thinking lets slap the bedside ultrasound on this kid and
get an ECG ....
ECG:
hmmmm.....diffuse ST elevation, PR depression. Pericarditis! In a
14y/o, what? Well we have our answer for the chest pain, but what
about his SOA. So I slap on the cardiac probe, parasternal long axis.
Bedside ECHO:
Best freezed image of what we saw:
No JVD
TEMP: 97.8F
CXR:
This young man had pericarditis with a 3cm effusion. We contacted
interventional cardiology and he was whisked to the cath lab for a
tap. I followed and watched as they did a formal US which confirmed
the findings at bedside, 2.7cm at its largest point in the apex and
1.3 cm posteriorly. The RV and RA had some dyskinetic motion
suggestive of early tamponade. His vitals remained around 90/60’s
with sats in the low 90%. Anesthesia sedated him with ketamine and
the interventionalist aspirated the fluid under ultrasound guidance.
Take it into your own hands. LM
Note: Dr. Cunningham is a third year Emergency Medicine resident
at the University of Louisville.
OK...no pneumothorax, no widened mediastinum, no tracheal
deviation.....generous, ok BIG heart.
38
LOUISVILLE MEDICINE
BUSINESS CARD GALLERY
GLMS Busines Card Ad MRG 2014.pdf 1 2/4/2014 8:35:34 AM
100 WEST MARKET STREET
C
M
Y
CM
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Michele R. Graham, CPA
CY
CMY
K
800.880.7800 ext. 1360
www.hsccpa.com
Louisville, KY • Evansville, IN
9,750 sq. ft. medical office
Available March 2015
Surface parking on property
Couch
CONTACT Jim
502-567-2328
Beargrass Realty
Parent of HSC Medical Billing & Consulting, LLC
SEPTEMBER 2014
39
ADVERTISERS’ INDEX
Avery Custom Exteriors
39
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Baptist Health
25
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baptistmedicalassociates.com
Beargrass Realty
National Insurance Agency
Norton Healthcare Physicians
IBC
www.mynortondoctor.com
39
Physicians Financial Services
8
physiciansfinancialservice.com
Commonwealth Bank & Trust Co
23
www.cbandt.com
Elmcroft Health & Rehabilitation
PNC
22
pnc.com/hcprofessionals
2
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39
7
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12
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Fleur de Lis Development
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Harding Shymanski & Co PSC
proassurance.com
28, 39
Republic Bank & Trust Co
37
Semonin (Joyce St Clair)
www.hsccpa.com
Kentuckiana Pain Specialists
republicbank.com
www.painstopshere.org
Kentuckiana Pulmonary Associates
28
IFC
1,39
Supplies Over Seas
28
suppliesoverseas.org
4
magmutual.com
Medical Society Employment Services
Signature Green Properties
www.signaturegreenproperties.com
www.kentuckyonehealth.org
MAG Mutual
39
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www.kpadocs.com
KentuckyOne Health
10
The Pain Institute
OBC
www.thepaininstitute.com
14
Walker Counseling Services
39
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Murphy Pain Center
10
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PROFESSIONAL
ANNOUNCEMENT PACKAGE
Do you have a
new physician
joining your
practice?
Are you
opening a
new satellite
office?
Are you
moving to a
new office
location?
The GLMS Professional Announcement Package provides
mailings and printed announcements in the monthly publications
to let your colleagues know about changes in your practice.
Outsource your next mailing to GLMS.
CONTACT
Cheri McGuire, Director of Marketing
502.736.6336
[email protected]
40
LOUISVILLE MEDICINE
Norton Leatherman Spine Center
is pleased to welcome
Jeffrey L. Gum, M.D.
Dr. Gum joins the world-renowned team at
Norton Leatherman Spine Center, offering
specialized expertise in surgical and
nonsurgical spine care. Call (502) 584-7525
to refer a patient.
Visit NortonHealthcare.com/Leatherman-Spine
to learn more.
Mitchell J. Campbell, M.D.
Charles H. Crawford III, M.D.
Steven Glassman, M.D.
John R. Dimar II, M.D.
R. Kirk Owens II, M.D.
Mladen Djurasovic, M.D.
Rolando M. Puno, M.D.
Greater Louisville Medical Society
101 WEST CHESTNUT STREET
LOUISVILLE, KY 40202
PRSRT STD
U.S. POSTAGE
PAID
LOUISVILLE, KY
PERMIT NO. 6
EXPERTISE.
As a Board-Certified Anesthesiologist Fellowship-Trained
in Pain Management, Dr. Larry Zhou takes great pride
in The Pain Institute, the region's premier center for pain
management. There he practices up-to-the-minute pain
techniques, including radio frequency, fluouroscopic-guided
procedures and the latest imaging technologies. Together with
his colleagues, he uses knowledge, experience and state-ofthe-art medical technology to provide relief for debilitating pain.
Trust your patients to the expertise of Dr. Zhou
and The Pain Institute. Where relief is reality.
For more information, visit our Web site at www.thepaininstitute.com
or for immediate, personal response, call us at 502.423.7246.
252 Whittington Pkwy • Louisville, KY 40222

louisville medicine - Greater Louisville Medical Society

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