THE BULLETIN

A PUBLICATION OF THE MUSCOGEE COUNTY MEDICAL SOCIETY

ERUDIRE ET DELECTARE

V O L U M E 5 9 • N U M B E R 2

FEBRUARY 2014

Diagnosis and Treatment of Hand and Wrist Injuries

Dr. Sean BlakeHand Specialist

Sean A. Blake, DO, DPT, a board-eligible orthopaedic surgeon, earned his medicaldegree from the Ohio University College ofOsteopathic Medicine in Athens, Ohio andhis Doctor of Physical Therapy degree atSlippery Rock University, Slippery Rock,Pennsylvania. Additionally, Dr. Blake completed his residency at the Ohio University College of Osteopathic Medicinein Warren, Ohio and a hand surgery fellowship at the University at Buffalo Orthopaedics in Buffalo, New York. With theexpertise of Dr. Blake, The St. Francis Orthopaedic Institute continues to ensurethe highest quality of care possible in orthopaedic surgery, joint replacement and sports medicine.

2300 Manchester ExpresswayColumbus, GA | 706-322-6646

www.sfhorthopaedics.com

Expertise is close at hand.

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THE BULLETINSociety Office: 2300 Manchester Expressway, Suite F-7 • Columbus, GA 31904

706-322-1254 • FAX 706-327-7480 • www.muscogeemedical.org

C o n t e n t sPresident’s Message . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Hospital News . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6, 10

Editor: David H. Levine, M.D. • Associate Editor: Casey Geringer, D.O.Managing Editor: Lisa Venable

Officers 2014:

President . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . James D. Majors, M.D.

President-Elect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .W. Frank Willett, III, M.D.

Past President . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Glenn E. Fussell, M.D.

Secretary-Treasurer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Glenn E. Fussell, M.D.

Director to MAG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fred Flandry, M.D.

Alternate Director to MAG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . W. Frank Willett, III, M.D.

Executive Committee: Glenn E. Fussell, M.D., David H. Levine, M.D., Raj Alappan, M.D., FredFlandry, M.D., Larry E. Brightwell, M.D., Mac Molnar, M.D., W. Frank Willett, M.D., James D. Majors,M.D., Ryan Geringer, D.O., Kurt Jacobson, M.D.

Delegates: Michael Borkat, M.D., Glenn E. Fussell, M.D., Casey Geringer, D.O., Ryan Geringer, D. O.,James Hagler, M.D., James D. Majors, M.D., Folarin Olubowale, M.D., Tom Steinberg, M.D., TimVillegas, M.D., Frank Willett, M.D. , Joe Zanga, M.D.

Alternate Delegates: Larry Brightwell, M.D. , John D. Watson, M.D.

Ad position is at the sole discretion of the Editorial Board.

Members are urged to submit articles for publication in The Bulletin. Deadline for copy is the 11th of the month preceding date of issue.The Bulletin of the Muscogee County Medical Society is the official monthly publication of the Muscogee County Medical Society, 2300Manchester Expressway, Suite F-7, Columbus, GA 31904. All material for publication should be sent to the Managing Editor not laterthan the 11th of the month. Advertising requirements and rates upon request. Opinions expressed in The Bulletin, including editorials,are those of the individual authors and do not necessarily reflect policies of the Society unless stated. Advertisements in this magazinedo not necessarily represent endorsement or support by the Muscogee County Medical Society.

My eleven year old son spends most of his free time playing inthe woods. He builds forts and digs holes and dams up thecreek. Last year, for his tenth birthday, he announced that hewanted to go on an overnight backpacking trip instead of abirthday party. I grew up backpacking on the AppalachianTrail in north Georgia so I thought it was a great idea. We wentto Dick’s and upgraded my thirty year old backpack andpurchased all the other gear required. I still had my oldbackpacking stove and the cookware.

My wife and I enjoy day hikes so we had recently discovered the Pine MountainTrail. This 23 mile trail winds through FDR State Park over Pine Mountain andhas been intentionally crafted to incorporate all the unique topography includingwaterfalls, scenic overlooks, and unique rock formations. As a family, we went onseveral day hikes to scout several sections of the trail. My then six year old twingirls were only capable of three or four miles of hiking before complaining. Myson quickly realized that this would be a father/son birthday backpacking trip. Wedecided to invite another father and son who had never been backpackingbefore. We planned to hike a 6 mile section of the trail called the Wolf Den Loop.

Once a section of trail was selected for our trip, we made on-line reservations fora “backcountry” campsite. There are 16 backcountry campsites dispersed alongthe Pine Mountain Trail and camping is only allowed in designated campsites andcampfires only allowed in designated stone fire rings. You cannot reserve aspecific backcountry campsite until the day of your trip at the FDR State Parkheadquarters. Space is limited at each backcountry campsite to approximately 15persons and most campsites are near a water source.

On a Friday morning in the last weekend in October, 2012, I was waiting at 8amat the FDR State Park headquarters to reserve the Old Sawmill campsite for ourtrip. The site was available but there were two other men there just as early toreserve their own intended campsites. That afternoon, my friend Jonathon and Ipicked up our sons at St Luke School and drove to the eastern end of the trail.There are designated overnight parking areas that require a $5 overnight permitand a dashboard display of your backcountry permit with your intendedbackcountry campsite. (The rangers need to be able to find you when you arereported missing.) We then put on our packs and then began our journey.

Because Jonathan and his 8 and 10 year old had never been backpacking before,I wanted to plan the trip for their maximum enjoyment. He and I each purchasednew 7x7 backpacking tent at Wal-Mart that weighed only 4 pounds. I planned tocarry all the food and cooking gear so that he and his sons had a good experiencewithout being overburdened with a heavy pack. As this was just an overnight trip,

P R E S I D E N T ’ S M E S S A G EJames D. Majors, M.D.

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we planned to take bottled water and not filter creek water for drinking andcooking. This was a critical mistake. My son’s pack weighed 20 pounds and hecarried the weight without complaint. My pack weighed 46 pounds, and resultedin a new left inguinal hernia.

It was a 3 mile hike in to Old Sawmill, and the trail largely follows a creek.Jonathon’s 8 year old took off his backpack and handed it to his father to carrywithin 200 yards of the trailhead. Jonathan carried it the remaining 3 mileswithout complaint. There were eleven creek crossings on step stones that theboys loved. There were several small waterfalls and the Wolf Den to explore. Wegot to Old Sawmill at nightfall and made camp. It was good cold weathercamping, requiring a hat and a fleece pullover jacket. We built a campfire andintroduced the boys to freeze dried backpacking food. I had acquired militaryMRE’s for first meal. They were surprisingly tasty. It was 46F that night buteveryone slept well. I kept the tent rain fly off and my son and I fell asleep witha view of the Milky Way visible through the tree canopy. We heard coyotesthroughout the night but at a fair distance.

The next morning we had coffee and hot chocolate and the typical backpackingbreakfast of Pop Tarts and cereal bars. The boys enjoyed learning about thebackpacking stove and how to heat water and food. They were predictably uselessin collecting proper firewood. The boys quickly found the creek and got theirshoes wet. Their moms were also predictably upset when they saw their muddywet sneakers when returning home. There were several through hikers that cameby and you could easily tell by their packs which ones where day hiking and whowas camping overnight. They were all quite friendly. Two scout troupes trampedthrough as well and seemed miserable. The troop leader appeared to be the onlyone having fun.

The hike out was much easier for me as my pack was ten pounds lighter due towater and food consumption. The difference between a 36 pound backpack anda 46 pound backpack was a halcyon moment for me. It was a huge difference andI decided immediately to purchase a water filter for drinking creek water beforeany future backpacking trip. I have since done so. My son loved the trip and asksfrequently to go again and we have. My friend Jonathan and his boys enjoyedthis trip and went on our next trip as well. I gladly agreed to more evenlydistribute the weight carried between adults on our next trip. My wife was jealousof our stories and has been invited on the 2013 birthday backpacking trip.However, that story will have to wait a month.

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COLUMBUS REGIONAL HEALTHCardiovascular Services to Expand at Midtown Medical CenterIn mid-February, Midtown Medical Center (MMC) will expand its CardiovascularServices by offering Percutaneous Coronary Intervention (PCI). Scheduled PCIand emergent ST-Elevation Myocardial Infarction (STEMI) capabilities will beadded to the current diagnostic cardiac catheterizations performed.Catheterization Lab staff has been training off-site in the busiest lab in Georgia,and post-care staff from 8 Main and ICU have also traveled for advanced training.A state-of-the-art digital Catheterization Lab with integrated fractional flow reserveand intravascular ultrasound will offer reliable diagnostic and therapeutictreatment. The new lab also offers numerous advantages, including clearerimages to visualize arteries and evaluate blood flow and reduced radiation levelsto the physician, patient and staff.

In October, MMC sponsored a “STEMI Summit” which was a two-day course toensure our community’s Emergency Medical Services providers and MidtownMedical Center’s Emergency and Trauma Center caregivers had the most up-to-date knowledge base and techniques available. The need exists for the expansionof cardiovascular services in our community to reach the more than 500,000people in our primary and secondary areas, many of whom could be at risk forcoronary artery disease. Heart disease is the leading cause of death in the UnitedStates. About 600,000 people die each year in the United States from heartdisease, which is one in every four deaths.

Laboratory Library, Conference Room Named for Dr. Alan ClepperThe laboratory library and conference room on the thirdfloor at Midtown Medical Center has been named the Alan S.Clepper Library in acknowledgement of Dr. Clepper’s manyyears of service to Columbus Regional Health and theadvancement of laboratory medicine at Midtown MedicalCenter. Dr. Clepper has dedicated much of his career toMidtown Medical Center, having started as an associatepathologist in 1972. In 1975 he became the director ofLaboratories and Chief of Pathology, which he remainstoday. “Dr. Clepper has and continues to make his mark onColumbus Regional Health’s laboratory services, being very instrumental over theyears in advocating for the space, equipment and staff to make ours thepreeminent laboratory in the region,” said Ryan Chandler, President and CEO ofMidtown Medical Center when making the announcement to a surprised andhumbled Dr. Clepper at the quarterly meeting of the Medical ExecutiveCommittee. He was also recognized at a reception in his honor and again at thefull membership meeting of the Medical Staff later in the month.

About 13 years ago Dr. Clepper supported an arrangement with LabCorp that stillexists today, which brings specimens from the patients of LabCorp-contracted

C O L U M B U S R E G I O N A L H E A L T H N E W S

Dr. Alan Clepper

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physicians and clients from all over the Columbus area to Midtown Medical Center,which serves as the testing site for much of the routine, molecular and flowcytometry testing performed in our region.

CME Opportunities Offered for PhysiciansEach of the following Continuing Medical Education (CME) opportunities forphysicians has been approved for one hour of CME credit:Pediatric Grand Rounds: Every Thursday, 8:15 a.m., Columbus RegionalConference Center at Midtown Medical Center, formerly The Medical Center.Open to any physician or other health professional providing care for children. Formore information, call Lori Sitch at 706-571-1220. Cancer Conference: Every Monday, 12:30 p.m., Conference Room at the John B.Amos Cancer Center, except for first Monday which is held at Columbus RegionalConference Center at Midtown Medical Center. (Approved as a series.) For moreinformation, call David Fletcher at 706-571-1102.

Midtown Medical Center is accredited by the Medical Association of Georgia toprovide continuing medical education for physicians. Midtown Medical Centerdesignates this live activity for a maximum of 1 AMA PRA Category 1 Credit™.Physicians should claim only the credit commensurate with the extent of theirparticipation in the activity.

COLUMBUS REGIONAL MEDICAL GROUPPediatric Hematology/Oncology Moves to New LocationDr. Paul LoDuca’s Pediatric Hematology/Oncology practice, which is part ofColumbus Regional Medical Group, has moved to a new location. The new addressis 705 17th Street, Suite 106, which is located directly behind the 18th Streetentrance to Midtown Medical Center and next to the Pediatrics After Hours office.The phone number remains 706-660-2560.

COLUMBUS REGIONAL RESEARCH INSTITUTECRRI Is Accepting Patient Enrollment in a Study for Patients Who Sufferfrom Chronic Pain(Note: If you would like to learn more about any current research trial or how torefer patients, contact Lee Starling or Amy Jenkins at 706-321-0495 or via emailat AJenkins@serrg.com, respectively.)

According to the American Pain Society, an estimated 9 percent of the adultpopulation in the United States suffers from moderate-to-severe non-malignantchronic pain. Back pain, specifically, is reportedly the most prevalent type ofchronic pain. Columbus Regional Research Institute (CRRI) is currently acceptingpatients into a clinical study who suffer from chronic pain related to herniateddiscs, post-traumatic peripheral neuropathy, osteoarthritis, or back pain thatpersists after one or two failed back surgeries. Additional research studies arebeing conducted for patients suffering from opioid-induced constipation.

Because CRRI is conducting such extensive research surrounding chronic pain, anypatient who is 18 or older and suffering from non-malignant pain for three or more

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months may be eligible to participate in a study. Female patients who are pregnantor nursing will not qualify.

Due to the serious nature of narcotics and pain management, CRRI’s on-sitephysicians are not authorized to manage pain for patients who do not qualify fora clinical research trial. Patients who do not qualify can continue to work withtheir existing physician to manage their pain.

Columbus Regional Research Institute adds new trials every month. Currently,CRRI is accepting patients for the following inpatient clinical trials: AbdominalSurgery, Atrial Fibrillation, Blood Clot Prevention, and Congestive Heart Failure.Outpatient trials include: Asthma, Chronic Sinusitis, Chronic ObstructivePulmonary Disease, Ear Infection, Endometriosis, Flu, Irritable Bowel Syndromewith Constipation, Opioid Induced Constipation, Pneumonia, Urinary TractInfection, and Weight Loss with Cardiovascular Risk.

CB&T understoodmy needs andhelped open newdoors for me.

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Columbus Bank and Trust is a division of Synovus Bank. Synovus Bank, Member FDIC, is chartered in the state of Georgia and

operates under multiple trade names across the Southeast. Divisions of Synovus are not separately FDIC-insured banks. The FDIC

coverage extended to deposit customers is that of one insured bank.

Dr. Vincent Naman Owner, Chattahoochee

Plastic Surgery, P.C.

A division of Synovus Bank,

Member FDIC

Cardiothoracic Surgeon Dr. Charles Anderson Joins St. Francis Charles Anderson, MD, a cardiothoracic surgeon, joined St. Francis January 2.Dr. Anderson is fellowship-trained in cardiac transplant and mechanicalcirculatory support. He has extensive experience performing robotic cardiac andthoracic surgery. Dr. Anderson earned his bachelor’s degree in biology fromCreighton University in Omaha, Neb., and his medical degree from the CreightonUniversity School of Medicine. He completed an internship and residency ingeneral surgery at the Tripler Army Medical Center in Honolulu, Hawaii. He alsocompleted a residency in cardiothoracic surgery at the University of Tennessee inMemphis, Tenn., and a fellowship in cardiac transplant and mechanicalcirculatory support at the Oschsner Clinic Foundation in New Orleans, La. Beforejoining St. Francis, Dr. Anderson worked most recently at PeachtreeCardiovascular Surgeons at St. Joseph’s Hospital in Atlanta and for MultiCareCardiovascular and Thoracic Surgery Associates in Tacoma, Wash.

Dr. Anderson is a diplomat of the National Board of Medical Examiners, AmericanCollege of Surgeons and the American Board of Thoracic Surgeons. He is amember of the International Society for Minimally Invasive CardiothoracicSurgery and Society of Thoracic Surgeons. He has published articles in TheAnnals of Thoracic Surgery, Digestive Surgery, Vascular Surgery and MilitaryMedicine and presented on numerous topics, including “The High Risk Sternum:A Role for Rigid Fixation” and “Aortic Graft Protection with a Small Bowel Pediclein a Porcine Model of Combined Abdominal Trauma.” He has and continues to bea sub-investigator on numerous research studies.

Register Now for the Carl Patrick Multidisciplinary Symposium The Carl Patrick Multidisciplinary Symposium will be held from 8 a.m.-2 p.m.Saturday, February 1, in the Sara Ruth Carroll Auditorium in the Fort ConferenceCenter on St. Francis’ main campus.

The symposium will feature: • Think About IT: Recognition of Drug Dependency by Tennent Slack, MD,Gainesville, Ga.• ICD-10: The Nuts and Bolts by Victor Freeman, MD, MPP; Regional MedicalDirector, JA Thomas and Associates, Washington, DC• Nutrition for the Hospitalized Patient: Separating Dogma from Data byDonald Hensrud, MD, MPH, MS, FACP, Assistant Professor of Nutrition, MayoClinic, Rochester, MN• Crew Resource Management by Peter Caulk, LifeWings Patient SafetyInstructor, Atlanta, Ga.• Endovascular Management of Stroke by Lincoln Jimenez, MD

St. Francis Hospital is accredited by the Medical Association of Georgia to providecontinuing medical education for physicians. St. Francis Hospital designates this

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live activity for a maximum of 5 AMA PRA Category 1 Credits™. Physicians shouldclaim only the credit commensurate with the extent of their participation in theactivity. An application for CME credit has been filed with the American Academyof Family Physicians. Determination of credit is pending.

Members of St. Francis Medical Staff may attend at no charge and others mayattend for $100.

For more information, contact Kristina Gray, director, Medical Staff Services, at706-660-6005 or graykr@sfhga.com.

St. Francis Receives American Heart Association’s Get With The Guidelines-Stroke Gold Plus Quality Achievement AwardSt. Francis has received the Get With The Guidelines®–Stroke Gold Plus QualityAchievement Award from the American Heart Association. The award recognizesSt. Francis’ commitment and success in implementing a higher standard of care byensuring that stroke patients receive treatment according to nationally acceptedguidelines. Get With The Guidelines–Stroke helps St. Francis’ staff develop andimplement acute and secondary prevention guideline processes to improvepatient care and outcomes. The program provides hospitals with a web-basedpatient management tool, best practice discharge protocols and standing orders,along with a robust registry and real-time benchmarking capabilities to trackperformance.

The quick and efficient use of guideline procedures can improve the quality ofcare for stroke patients and may reduce disability and save lives. “Recent studiesshow that patients treated in hospitals participating in the American HeartAssociation’s Get With The Guidelines-Stroke program receive a higher quality ofcare and may experience better outcomes,” said Lee H. Schwamm, MD, chair ofthe Get With The Guidelines National Steering Committee and director of theTeleStroke and Acute Stroke Services at Massachusetts General Hospital in Boston,Mass. “St. Francis’ team is to be commended for their commitment to improvingthe care of their patients.”

Following Get With The Guidelines-Stroke treatment guidelines, patients arestarted on aggressive risk-reduction therapies including the use of medicationssuch as tPA, antithrombotics and anticoagulation therapy, along with cholesterolreducing drugs and smoking cessation counseling. These are aimed at reducingdeath and disability and improving the lives of stroke patients. Hospitals mustadhere to these measures at a set level for a designated period of time to beeligible for the achievement awards. According to the American HeartAssociation/American Stroke Association, stroke is one of the leading causes ofdeath and serious, long-term disability in the United States. On average, someonesuffers a stroke every 40 seconds; someone dies of a stroke every four minutes;and 795,000 people suffer a new or recurrent stroke each year.

St. Francis Announces 2014-2015 Medical Executive CommitteeSt. Francis has announced members of its 2014-2015 Medical Executive

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Committee. On January 1, Dr. Bipin Patel began serving a two-year term as chiefof staff at St. Francis. Other members of the hospital’s 2014-2015 MedicalExecutive Committee include Dr. William Taylor, past chief of staff; Dr. EdwinPage, chief of staff elect; Dr. Thomas Walsh, Surgery Department Chief; Dr. GlennFussell, I/P Medicine Chair; Dr. Joseph Lewis, O/P Medicine Chair; Dr. BhushitDixit, Psychiatry Department Chair; Dr. Daniel Blankenship, ENT Chair; Dr. GaryRogers, Anesthesia Chair; Dr. Sebastian Hubbuch, Cardiology Chair; Dr. KerryPaape, CV Surgery Chair; Dr. Drew Williams, Emergency Medicine Chair; Dr. P. H.Patel, Gastroenterology Chair; Dr. John Adams, General Surgery Chair;Dr. Sylvester McRae, OB/GYN Chair; Dr. Kevin King, Hospital Medicine Chair;Dr. Cheryl Clark, Critical Care Chair; Dr. Raj Alapan, Nephrology Chair;Dr. Stephen Beaty, Ophthalmology Chair; Dr. Frank Willett, Pathology Chair;Dr. Chris Tidwell, Pulmonary Chair; Dr. Cameron Kersey, Radiology Chair; Dr. EricWesterlund, Spine and Neurology Chair; and Dr. Wylly Killorin, Urology Chair.

Comedienne Tracey Conway to Speak at Heart Truth for Women Luncheon February 11Emmy-winning actress and comedienne Tracey Conway will speak at St. Francis’10th annual Heart Truth for Women luncheon from 11:30 a.m.-1 p.m. on Tuesday,February 11, at the St. Luke Ministry Center. Conway reigned for 10 years asSeattle’s premiere funny lady, performing weekly before live audiences on thetelevision comedy show “Almost Live!” She was completing a live taping of theshow when her heart stopped beating, and she literally dropped dead fromsudden cardiac arrest. Twenty minutes later, paramedics shocked her heart intobeating again. Overcoming 20-to-1 odds, she survived and turned her miraculousrecovery into laugh-out-loud yet poignant presentations that have wowedeveryone from maximum-security inmates to Oprah Winfrey. Conway speaks atGo Red For Women events for American Heart Association across the country andis involved with national organizations promoting the use of AEDS (automatedexternal defibrillators) and the use of ICDs (implantable cardioverterdefibrillators) for heart rhythm disorders. Luncheon tickets are $25. To register,visit www.wecareforlife.com.

Associates Donate 250 Christmas Stockings to Agencies Serving Needy SeniorsSt. Francis associates gave generously to low income seniors through thehospital’s ninth annual Stockings for Seniors Christmas project sponsored by thehospital’s Mission Awareness Team. Volunteers delivered more than 250Christmas bags overflowing with goodies and essentials donated by associatesarea agencies serving seniors, including House of Mercy, Columbus Gardens,Russell County Department of Family and Children’s Services and the StewartCommunity Home.

February Educational OpportunitiesSt. Francis will offer these educational opportunities in February:Breast Cancer Conference: Friday, February 14, 7-8 a.m., St. Francis TidwellLecture Hall in the Fort Conference Center at St. Francis. Breakfast will be

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provided. A reservation is not required. For more information, contact RubyGladney at 706-660-6096 or gladneyr@sfhga.com.GI Conference: Thursday, February 18; 6 p.m., St. Francis Tidwell Lecture Hallin the Fort Conference Center. Dinner will be provided. For more information,contact Teresa Loney at 706-596-4181 or loneyt@sfhga.com.Cancer Conference: Wednesday, February 19, 12:30 p.m., St. Francis TidwellLecture Hall in the Fort Conference Center at St. Francis. Lunch will be provided.A reservation is not required. For more information, contact Ruby Gladney at706-660-6096 or gladneyr@sfhga.com.Shoulder Fellow Conference: Thursday, February 20, 7-8 a.m., SFOIConference Room. Parthiv Patel, DO, will speak on a topic to be determined. Formore information, contact Carol Capers at capersc@sfhga.com or 706-320- 3123.

St. Francis Hospital is accredited by the Medical Association of Georgia toprovide continuing medical education for physicians. St. Francis Hospitaldesignates this live activity for a maximum number of 1 AMA PRA Category 1Credit™. Physicians should claim only the credit commensurate with the extentof their participation in the activity.

Mike SeeFully Licensed GA/AL Realtor

706-315-5289 (CELL) • mikesee@coldwellbanker.com.5670 Whitesville Road • Columbus, GA 31904

www.kpdk.com

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The Forgotten Advance Directive – DNH?

Patients with advanced dementia frequently require care in the nursing homesetting. A recent study1 published in the Journal of Pain and SymptomManagement looked at hospitalization rates for these patients and the cost ofsuch care. This study was done by New York University and evaluated patients in22 nursing homes in the Boston area between 2003 and 2009. It is estimated that16% of US residents dying of dementia die in hospitals. Nationwide, 20% ofnursing home residents with advanced dementia are hospitalized near the end oftheir life. The study addresses the question of whether quality of life is enhancedfor these patients by hospitalization. They also evaluated the cost of careincurred by hospitalization.

The study demonstrated “that more aggressive treatment strategies leading tohospitalizations are not cost effective for nursing home residence with advanceddementia compared with approaches that avoid hospitalization.” Most proxies ofthese patients indicate that the primary goal of care is comfort and supportivedignified care. Hospitalization seldom achieves this goal.

Other studies have shown that pneumonia is the most frequent diagnosisprecipitating hospitalization among this population.2 Studies are lacking butdemonstrate improve survival in treating this population as compared to lessaggressive treatments in a nursing home. Hospitalized patients are more likely toundergo aggressive intervention which places them at increased risk of adversereaction or medication errors. They're also more likely to receive feeding tubeswhich many other studies have demonstrated lack benefits in this population.3

The study examined two closely related decisions regarding hospitalization.First, the presence of an advance directive to avoid future hospitalizations in theevent of an acute illness and second , decisions not to hospitalized for an acuteillness such as pneumonia. Another words, these patients had advance directivesindicating DNH (do not hospitalize).

While I very commonly see orders for DNR, I seldom see orders for DNH in ourcommunity. The study concluded with the following statement: "Policy strategiesthat change incentives to support caring for residents in the (nursing home)facility and avoiding hospitalization are warranted. At the individual level,providers should be encouraged to engage proxies in advanced care planning toestablish whether hospitalization aligns with the goals of care (of the patient). Atthe nursing home level, enhanced resources to provide both onsite palliative andacute care, and broader quality improvement incentives that aim to reducetransfers, are needed. Finally, policies that incentivize cost-effective care couldhave significant implications for the millions of Americans dying with dementia

A R T I C L E O F I N T E R E S Tby Mike Rallo, M.D. FAAHPM

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by promoting care that is less burdensome and costly and more consistent withpreferences."

With the changes that are occurring in American medicine today, physician andhospital reimbursement will be based much more strongly on quality of care andless strongly on patterns of care which use aggressive interventions that are notsupported by benefit. This study suggests that securing DNH orders in patientswho are unlikely to benefit from hospitalization to achieve their goals of careshould be strongly considered.

1. Goldfield, KS, Hamel, MB, Mitchell, SL. The Cost Effectiveness of the Decisiont to HospitalizeNursing Home Residence with Advanced Dementia. Journal of pain and symptom management 2013;46:640-6512. Mitchell SL, Teno JM, Kiely DK, et al. The Clinical Course of Advanced Dementia. NEJM 2009;361:1529-1538.3. Finucane TE, Christmas C., Travis K. Tube Feeding in Patients with Advanced Dementia. JAMA1999:282;1365-1370.

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Maria Elena Bendana, M.D. earned her medical degreefrom Escuela Autonoma de Cienciss Medicas de CentroAmerican, San Jose, Costa Rica. She completed herinternship at Hennepin County Medical Center, Minneapolis,MN in internal medicine and her internship in surgery atHospital San Juan De Dios, San Jose, Costa Rica and herresidency at Family Medicine Residency Program, ColumbusRegional Healthcare System, Department of MedicalEducation, Columbus, Georgia. Dr. Bendana practices atMidtown Acute Care. Her office phone is 706-243-3051 andher office is located at 3465-D Macon Road. We welcomeDr. Bendana to the Muscogee County Medical Society!

Raquel Lisa D. Bennett-Gittens, M.D., MSCR graduatedfrom the University of the West Indies, Mona, Jamaica.Dr. Bennett-Gittens completed her internship at QueenElizabeth Hospital, University of the West Indies, Barbadosand her residency in internal medicine at Morehouse Schoolof Medicine. Dr. Bennett-Gittens also did a cardiologyfellowship at Emory University School of Medicine and has aMasters degree in Clinical Research. Dr. Bennett-Gittenspractices cardiology at Columbus Clinic. Her office phone is706-322-7884 and her office is at 610 19th Street. WelcomeDr. Bennett-Gittens to the Muscogee County Medical Society!

Jared A. Brummel, D.O., earned his medical degree fromLake Erie College of Osteopathic Medicine. He completedhis internship and his residency in orthopedics at RiversideCounty Regional Medical Center, Moreno Valley, CA and asports medicine/arthroscopic fellowship at Hughston Clinic.Dr. Brummel practices at The Hughston Clinic as anorthopedic surgeon. His office phone is 706-884-2191. Wewelcome Dr. Brummel to Muscogee County Medical Society!

Kamesha M. Fair, M.D. earned her medical degree from theUniversity of Iowa, Roy J. & Lucille A. Carver College ofMedicine. She completed her internship and residency atMercer University. Dr. Fair practices obstetrics andgynecology at Valley Healthcare. Her office phone is706-322-9599 and her office is located at 1600 Ft. BenningRoad. We welcome Dr. Fair to the Muscogee County MedicalSociety!

W E L C O M E N E W P H Y S I C I A N M E M B E R SWe welcome our new members to the

Muscogee County Medical Society:

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Glenn E. Fleming, M.D., MPH earned his medical degreefrom Temple University School of Medicine and a Master ofPublic Health in graduate school. He completed hisinternship and his residency in internal medicine at TheGeorge Washington University Medical Center and Seton HallUniversity of Health and Medical Sciences/St. Francis MedicalCenter, Trenton, NJ where he was Academic Chief MedicalResident. Dr. Fleming practices at St. Francis Hospital as ahospitalist. His office phone is 706-596-4000. We welcomeDr. Fleming to Muscogee County Medical Society!

Angie R. Haque, D.O. graduated from the NovaSoutheastern University, College of Osteopathic Medicine.Dr. Haque completed her Transitional Internship atColumbus Regional, The Medical Center, Columbus, and herresidency in family medicine at Family Medicine Residency,Columbus Regional. Dr. Haque also did a residency inanesthesiology at Medical College of Wisconsin, Milwaukee,Wisconsin. Dr. Haque practices at Midtown Acute Care. Heroffice phone is 706-243-3051 and her office is at 3465-DMacon Road. Welcome Dr. Haque to the Muscogee CountyMedical Society!

Tammy K. McLean, M.D. graduated from the University ofSouth Alabama, College of Medicine, Mobile. Dr. McLeancompleted her internship at the University of South Alabamaand her residency in dermatology at the Medical College ofGeorgia. Dr. McLean practices dermatology at ColumbusClinic. Her office phone is 706-322-7884 and her office is at705 17th Street. Welcome Dr. McLean to the MuscogeeCounty Medical Society!

Anthony E. Miller, M.D. graduated from Wayne StateUniversity School of Medicine, Detroit, Michigan. Dr. Millercompleted his internship and his residency in family practiceat Wayne State University. Dr. Miller practices family medicineat Columbus Clinic. His office phone is 706-322-7884 and hisoffice is at 610 19th Street. Welcome Dr. Miller to theMuscogee County Medical Society!

A R T I C L E O F I N T E R E S Tby David Subich, M.D., Director Columbus Regional Research Institute

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The Principal Investigator: Confusion, Concern, Conundrum – but still Cherished

The research physician is often looked upon with respect, but to some there isconfusion as to the Principal Investigator’s role. The FDA expects theInvestigator to look out for the best interest of the trial subject and adhere toGCP (Good Clinical Practice), which involves protecting the rights, safety andwell-being of trial subjects through ethical and scientific conduct of all phases ofthe clinical trial.

Clinical research is by its very nature compartmentalized into the clinicaltreatment versus the research portion of trials (patient vs subject). Clinicalpractice is patient focused, while research is protocol focused and designed toanswer a specific scientific question. With FDA mandated, placebo controlledtrials there are times when the best clinical practices may not be followed for aspecific subject to answer a larger medical question. Research involvesuncertainties, which may necessitate non-therapeutic procedures (e.g. blooddraws, lumbar punctures, x-rays, biopsies to name a few). These uncertaintiescreate the competing roles of clinical practitioner versus research scientist. Theresearch role is very regulated and requires strict adherence to the protocol. Theprotocol must be reviewed by an Institutional Review Board, which seeks to limitany harm to any given subject. This conflict of obligations may at times bechallenging. From the research standpoint, the protocol must be followed toobtain the statistical information desired with the least amount of clinicaldiscomfort to the study subjects.

One of the clearest ways to distinguish the difference between clinical treatmentand research protocol treatment is with the Informed Consent Document. Thisdocument states the purposes of the trial, the risk/benefits, expectation of thesubject, the length of the trial, funding of the trial and more. It is easy tooverlook the importance of this document, but it provides clarity as to what is tobe done or not done. Clinical trials are designed with “clinical equipoise” toattempt to answer the question of which therapeutic intervention is better. As aresult, all trial cohorts should provide therapeutic benefit.Investigators have been criticized for conducting clinical research, stating thatthey have other interests than the subject/patient, but fundamentally, aninvestigator is still a physician and seeks to “do no harm”. Even in phase 1research, where the investigational product is administered to healthy subjectsand there is not a therapeutic benefit, the investigator still oversees the medicalsafety. Some have claimed that investigators are the fiduciaries of the studysubject but investigators cannot and are not fiduciaries, because fiduciaries havediscretion and power. In research, investigators only can follow the protocol.

Thus, they must clearly distinguish standard medical treatment from the researchfunctions.

Notably, the investigator has obligations to the FDA (form 1572), the sponsor, theInstitutional Review Board, his institution, as well as the study subject. Whatobligations does a physician owe to subjects? Within the protocol, the subject canexpect what is delineated in the informed consent as well as exams to investigateany medical changes that occur during the study. The focus in clinical care is thepatient, while the focus of studies is on generalizable knowledge, since theprotocol controls as many variables as possible. Subjects are not treated as anindividuals but according to what the protocol states. Many times subjects havean expectation that the investigational product will make them better. Thistherapeutic misconception can confound the study results. Despite all thequestioning, pressures, checking and rechecking, being an investigator stillprovides another pathway to help some patients where there are no otheroptions. As such, there is a respect of investigators that is unique to research. Iwould invite more of my fellow colleagues to join me in being an investigator tohelp our patients in ways that we cannot in clinical practice.

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Sedation of Dental Patients

Where drugs are concerned, even in a clinical setting, child death is an all toocommon occurrence. Innumerable reports chronicle many providers, includingdentists, wandering into uncharted territory trying to administer horrificconcoctions in order to quiet unruly pediatric patients. Many of these sedationsoccur, after which the child is completely covered in drapes and unmonitored,only to find a dead body after procedures lasting sometimes 2 hours ormore. These catastrophic events have even happened to trained pediatric dentists,even after training to give sedatives under direct supervision of an MD. So a generaldentist and sedation administered independently pushes the envelope.

The dirty little secret is that, under the guise of managing "dentophobic patients",dentists not trained in such techniques are now turning to sedation and analgesia"crash courses". In most cases, these dizzy ideas amount to nothing more thanrevenue enhancement; inviting, but very dangerous for the unsuspecting patient!Worse yet, well known to those with anesthesia experience and competence, themost vulnerable and clinically fragile patients are children and young adults, whorequire very skilled and competent management for prevention of disasters justsuch as this. Dentists have done just fine over the years with local anesthetics likelidocaine, which in itself can still be dangerous (see below). But sedatives andother anesthetics, now come on.

Now, in this case the general dentist had another "provider" (an officetechnician) administering the culprit, likely a common concoction of a nowlargely- abandoned combination-- demerol/phenergan/thorazine--aptly called"DETHORGAN". This combo has been implicated in a myriad of child deaths. Whileoften producing a satisfactory level of sedation, the combination was associatedwith respiratory depression, hypotension, extrapyramidal effects, and prolongedrecovery times. Growing concerns over the toxicity of the three drugs and theavailability of shorter-acting sedatives led the American Academy of Pediatrics topublish a statement in 1995 discouraging the use of these agents as sedatives inchildren.[7]

There is no way a general dentist should be administering ANY sedation--either enterally, IM, or IV in my opinion. No dental school grants anesthesiatraining to any general dental graduate, ONLY to those completing a four yearadditional hospital- based residency in oral and maxillofacial surgery (where 6months training is required specifically under the Department of Anesthesia inthe medical school and after which there is continual exposure to sedation andgeneral anesthesia during the entire four year program).

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A R T I C L E O F I N T E R E S TBy John Scuba, M.D.

Worse yet, general dentists across the country are now "getting on thesedation bandwagon". There are several notorious companies (names notmentioned to avoid libel) who now are pushing sedation and monitoringequipment to gullible dentists to "make their patients more comfy". Of course,the equipment generates millions of dollars for these companies, while puttingpatients and the public at risk. Further, in many states, and now inGeorgia, there has been a new and successful "push" by dentists forloosening requirements to obtain a "sedation" license because "too many peopleavoid the dentist out of fear". While this fear factor may be somewhat true, it isreally overblown by the equipment salesmen who also just so happen to provide(crash) training courses in anesthesia at thousands more dollars for the gullibledentists.

These new dental sedation regulations are so limited (only 60 hours didacticand then "observation of 20 patients") that it is no wonder catastrophes happen.And what happened in Hawaii is just an example of how the public mayunsuspectingly believe "any" doctor (or dentist) is qualified to do everything,including but not limited to brain surgery.

However, let's not forget that physicians too (also completely untrained insedation and analgesia) are often guilty of the same mismanagement of drugs, notto mention mood altering drugs. A five year old child died of an overdose oflidocaine given by a family physician at an urgent care center in Atlanta in August,2011 to fix her broken arm,only a few minutes from an emergency room or a fewmore minutes from Egleston. Give this one a big "what were you thinking, Doc"?

Now, this is a touchy subject but one which deserves airing. The dental board iscomprised of many savvy and wise professionals who understand that training isof the utmost importance and that dentists simply do not get anywhere nearadequate sedation training. However, strong lobbies of every subspecialty ofdentistry, along with the general dentists, have pushed very hard to successfullyloosen the reins on these requirements. I don’t think it’s in the public interest.

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2821 Harley Court, Suite 300Columbus, GA 31909

(706) 576-4900

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M C M S N E W S

Muscogee County Medical Society

UPCOMING EVENTS February 2014

Practice Change of Address:Howard C. Willis, M.D.

Columbus Medical Associates, LLC808 21st Street, Columbus, GA 31904

Kenneth L. Smith, M.D.Center for Surgical Breast CareJohn B. Amos Cancer Center

1831 5th Avenue, Columbus, GA 31904Phone: 706-320-8660 Fax: 706-320-8664

Renew your dues for 2014Muscogee County Medical Society and Medical Association of Georgia

Due January 1, 2014If you are not a member and interested in joiningplease contact lisavenable@muscogeemedical.org

If you would like to write an article for “The Bulletin”Contact Dr. David Levine or Dr. Casey Geringer

Please send all practice changes of phone, retirement or address to:706-322-1254 phone or lisavenable@muscogeemedical.org

Lynda Worthington, CRS, GRI, ABRAssociate Broker in Ga. and Ala., Military Specialist706-256-1000 BUSINESS • 888-474-9847 FAX

706-888-0629 CELLULAR

w w w. l y n d a w o r t h i n g t o n . c o m

lwforhomes aol.com5670 Whitesville Rd.Columbus, Ga. 31904

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