July 2013

Physician

FOCUS

News for South County Hospital Medical Staff



July 2013

Ethics Committe Helps You Make the Tough Decisions

This Issue

I

Message from Medical Staff President

t doesn’t happen every day, but there are times when physicians are faced with such weighty ethical dilemmas, they need help. That was the case recently with John Heffernan, MD, FACS, a urologist from Urology Associates, when presented with a profoundly mentally challenged woman in her eighties with gross hematuria, fever, and an infected renal mass. The woman was non-verbal, had no family and no legal guardian. She was

unable to participate in any aspect of medical decision making. How to treat her rested solely on Heffernan. He determined that removing the tumor could extend her life but its placement presented the possibility that she could die during surgery due to her age, the potential for blood loss, and the location of the mass. Seeking additional

guidance, Heffernan contacted South County Hospital’s Ethics Committee. His presentation addressed the high risk of perioperative sepsis or death for any patient of this age with this condition. The fact that the patient could not understand the anticipated pain, the risks involved or give consent was also noted. Following a course of antibiotic therapy at South County Hospital, the patient was asymptomatic

A Word With Fred Browne Mark Your Calendar! Welcome to the Staff CME Opportunities Creating a Family Story On the Bookshelf Of Interest

Continued

VNS Home Health Services Adds Advanced Technology Portable ultrasound used for wound care

T

hanks to the generosity of a gift from the GFWC Women’s Club of South County, the clinicians of VNS Home Health Services have at their fingertips the latest technology for lower extremity wound care. VNS has recently purchased two Huntleigh Mini Dopplex Doppler vascular ultrasound Continued

Lou’s Health Wave

For expert care, look no further

Marybeth Butler, RN, WCC, CCP, West Team Clinical Manager at VNS Home Health Services with the Huntleigh Mini Dopplex Doppler, a special portable ultrasound for wound care that measures lower-extremity blood flow of homebound patients.

Medical Staff President

What is the Role of Emergency Medicine in Today’s Healthcare System?

R

ecent events in Boston highlight the importance of having a wellprepared Emergency Medical Response System. The medical treatment provided to more than 200 victims of the marathon bombing began within seconds of the terrorist attack. Fortunately, emergency responders—from EMTs to nurses to Emergency physicians—were already staffing medical tents as part of the planned event. Considering the

P

hysician Focus is a publication to serve the medical staff of South County Hospital. Questions or comments should be directed to Martha Murphy at 401 788-1606 or Jane Goodger at 401 788-1137.

M S O edical

taff

fficers

Medical Staff President William Sabina, MD 401 788-8020 [email protected]

Vice President

Lisa Rameaka, MD 401 788-3255 [email protected]

Secretary/Treasurer

Aaron Weisbord, MD 401 294-5831 weisbord@southcountycardiology. com

devastation, the loss of life was small and while the scope of injuries was tremendous, the number of lives saved was even more so. This speaks to the capabilities of a well-prepared, wellsupported and well-practiced emergency medical care system. What doesn’t get national headlines, however, is the extraordinary work that happens across the nation’s emergency rooms every day. According to a new National Healthcare survey by Rand Health Corp., the 4 percent of America’s doctors who staff Emergency Departments (EDs) provide 11 percent of all outpatient visits in the US, 28 percent of all acute care visits, half of the acute care visits by Medicaid beneficiaries and two-thirds of all acute care visits for the uninsured. We have also become the go-to resource for primary care physicians who depend on emergency departments for complex diagnostic workups and facilitating admissions of acutely ill patients. The study also validates a number of anecdotal reports in the EM literature pointing to the growing number of complex medical problems that must be evaluated in an ED before a decision for inpatient admission can even be

entertained. Increasingly, ED providers are not only the “gateway to the hospital” but they must often be the “doorstop to the unwisely spent healthcare dollar.” This dual role sometimes leaves us in quandaries whose solutions cannot be found in rule books or Interqual Manuals. Increasingly, we face the wrath of auditors and government agencies questioning our decisions months later, only to tell us after the fact that we will not be paid for the work we did because in the end the patient didn’t really need that test or that medicine. The Rand study recommends that hospital administrators, policy makers, payers, and federal research agencies recognize the current reality in emergency departments across the nation and the valuable role they play in coordinating care for millions of people. This is a time of historic change in healthcare, when everyone is asking: What does healthcare reform mean for me? How will it affect my practice? While we hope you never personally need us, we hope you understand how important emergency care is for everyone—your family, your friends, your patients. [email protected]

Of the Month Last summer we debuted our new Emergency Department TV ad. It’s still running this summer (summer is when South County’s population nearly doubles). Have you seen it? Click to view video

Cover Story ETHICS Continued from page one and fit to return to a supervised setting. Carefully weighing all considerations and with contributions from all members, the committee ultimately concurred with Dr. Heffernan’s recommendation to provide comfort measures only and allow her to return to familiar surroundings.

Framework developed Approximately four years ago, the Ethics Committee, with the help of consultant Christine Mitchell, a nurse ethicist from Boston Children’s Hospital, developed a framework to review cases so that all ethics matters would undergo the same process. This framework has made making such difficult decisions easier. For the sake of uniformity, the committee now fills out a standardized form for each case. Although all hospitals have ethics committees, Sharon DeLuca, MS, RN, CNS, chairwoman of the committee, said there is some confusion among the medical staff about the purpose of the committee. “I want the medical staff to know

that when they have an ethical question, when they don’t know the right thing to do, there is a group here to help.” The committee is not in any way punitive and can help in any situation when “it’s not clear what’s right and what’s wrong.”

Committee is a cross-section The committee is a Board level committee made up of 25 members consisting of a cross-section of the Hospital community. Co-chaired by Fred Browne, chief medical officer and vice president of medical affairs, the committee meets every other month. During emergency situations, however, as many committee members as possible are gathered to review the case, DeLuca said. Eve Keenan, RN, Ed.D, South County Hospital Board of Trustees chairwoman, is the Board representative. For more information about the Ethics Committee, contact DeLuca ([email protected]) or Browne ([email protected]).

DOPPLER Continued from page machines, which are used to determine

used on that person. Compression

the amount of blood flow in the lower

therapy is not recommended and

Before the use of the portable

extremities—essential information in

should not be used when there is

Doppler units, the person’s physician

the treatment of wounds.

arterial disease, which is another reason

had to refer the patient to a wound care

it is important to know blood flow when

center or to a physician’s office where an

“The Doppler tells us whether the patient has enough blood flow to heal a lower-extremity wound,” Marybeth Butler RN, WCC, CCP explained. “Without sufficient blood flow, a wound

biggest categories.”

ABI could be performed.

“At least 25 percent of our patients have

lower extremity wounds.”

— Marybeth Butler RN, WCC, CCP

For homebound patients, or those with transportation problems, this can be

will not heal and even the smallest blockage or decrease in blood flow can

treating a lower-extremity wound. Any

difficult. With the portable Doppler

delay wound healing.” Lower blood

problem with vascular or heart disease

units, the visiting nurse can quickly fax

pressure in the legs than in the arms

compromises blood flow to the area

or call the physician with the ABI range,

is an indication of peripheral vascular

and, therefore needs to be known and

allowing the physician to make a timely

disease.

assessed by the healthcare provider.

determination of the best treatment

The Doppler units allow the

“At least 25 percent of our patients

choices. Sometimes that includes

visiting nurses to take the homebound-

have lower extremity wounds,” Butler

a referral to a vascular surgeon for

patient’s ABI (ankle brachial index) and

noted. “Specifically venous stasis ulcers

stenting or re-vascularization.

through an equation obtain a number

and arterial ulcers are common. Along

For information about this or any

that determines, among other things,

with diabetic wounds, pressure ulcers,

other VNS service, call 401 782-0500.

whether compression therapy can be

and traumatic ulcers, these comprise the

A Word With Fred Browne, MD

Consumers More Aware of Healthcare Choices

T

he days of using the closest healthcare facility simply because of its proximity are long over. That’s why we need to think of our patients not only as people looking for the best healthcare, but as healthcare consumers. Customers of every service— whether it’s for a plumber, painter or landscaper—are not only looking for the best deal, they are looking for who can give them the best service. That pertains to hospitals today as much as any other service provider. Rhode Island is a small state and people have many healthcare choices—all within a forty-minute drive or less. That’s why it is so important for our system to act as a system—a system that provides a

seamless continuum of care that is easy for our patients to navigate. We can’t assume that the people living in our community will use our healthcare services simply because of their proximity. I came across an interesting article about a study of healthcare consumers: The 2012 Survey of U.S. Health Care Consumers: Five-Year Look Back. This study, conducted by Deloitte, stresses that consumers are becoming more aware that they have choices. People no longer head to the Yellow Pages to find a physician; they go online and take a deeper look at their provider and the services they offer. Consumers are far more informed today than even ten years ago. Today, consumers not only talk about their healthcare experiences, they put their opinions online, instantly reaching thousands.

In many cases, healthcare consumers are far ahead of the industry that serves them. Consumers are demanding better service and choosing their healthcare provider accordingly. At South County Hospital, we are aware of this shift and are making moves to meet our patients’ demands by developing a group of multidisciplinary healthcare providers who can care for all of our patients’ needs. This seamless approach to healthcare will make it easier for the patient to navigate the sometimes complex system. Keeping one step ahead of what our patients expect will keep South County Hospital thriving in this competitive market.

[email protected]

Mark Your Calendar 22nd Annual Golf Tournament What: To benefit VNS Home Health Services When: Monday, July 8, 1 p.m. Where: Shelter Harbor Golf Club, Charlestown How: Register by calling 401 788-1610 or emailing [email protected].

Women’s Wellness Day What: An educational, enlightening, and fun day focused on women’s health and wellness. Who: Keynote speaker, Harvard neurologist Marie Pasinski, MD, author of Beautiful Brain, BeautifulYou. When: Saturday, Sept. 21, 2013, from 8 a.m. to 3 p.m. Where: Newport Marriott How: Reserve your spot online

Medical Staff News

Creating A Family Story on a Cross-Country Trip by Eric Buchbaum, DPM, FACFAS

O

ur daughter, Delia, loves stories. About our day, our childhood, our siblings, and our life before she

was part of our lives. She particularly likes stories of our adventures and somewhere along the way a story came up about "Simon," our old orange VW Westfalia that we sold when my wife, Teresa, was pregnant. The Westfalia was the VW version of a small RV with a "pop-top" tent ceiling to accommodate up to four, with two sleeping up top and two sleeping below. It also had a refrigerator, sink and stove. Production of this model ceased in 1991, so it has become a sought-after niche commodity. We would pile in a few days worth of necessities and travel (with large dog at the time) to wherever we pleased. This was one of those "we should have never sold that" vehicles.

Delia and Teresa Buchbaum with Ida May pot. Up through southern Utah to visit some old favorite places found us in Zion and Arches. Another night under the desert stars in Canyonlands and then our plan was off to spend a day and night in Denver with some friends. And then there was weather.

We Need Another Camper Van Delia is now seven and after any story where Simon played a role she would say, "We need another camper van," and her persuasions succeeded. With the world at a computer screen, forums and groups abound of online enthusiasts, we started our search. Which brought us to California, the land of rust-free vehicles preserved in time. The three of us flew out over spring break and picked up a well-loved 1987 VW Vanagon Westfalia (without a name) to drive to its new home in RI. We had 10 days to travel coast to coast with the intention of stops at natural wonders, the home’s of old friends dappled across the country, and anywhere else we found interesting along the way. We had no specific route in mind, allowing our daily whims and a map to guide us (yes, maps still exist in this GPS world!). We camped our first night on Huntington Beach and dipped our feet into the Pacific to start our journey. Night two was spent in Death Valley and felt like a visit to another planet. Temperature at 8 a.m. and 86 meters below sea level was 84 degrees. Night three found us in Las Vegas for a shower and a swim along with a meal not cooked in one

The hot, dry desert winds that met us in California and Nevada quickly turned to precipitation. The April storm that dumped several feet of snow in the mountains flooded the plains, and seemed to be the beginning of the string of devastating tornados that decided to come along for the ride. We had built in a few "unexpected event" days in our trip-planning and used them all. I assumed any delays would be as a result of mechanical issues; and other than figuring out exactly where the vehicle runs out of fuel (it happens to be just below the last line), we were spared any vehiclerelated delays.

Tornado Alley With all three passes through the Rockies closed, we were stuck one day on the western slopes. With all the torrential rain in the Midwest, we were slowed significantly across the huge middle section of the country. Camping at night in the Midwest, listening for the telltale train sound of a tornado, kept me half awake as well as second-guessing the choice of our spot based on the potential for flooding or surrounding trees uprooting from the wind. Ribs in St. Louis made all of that worrying worthwhile.

Continued

Medical News/Surgical

Department Chiefs Anesthesiology John Grahm, MD [email protected] Diagnostic Imaging James Blechman MD [email protected] Emergency Medicine—acting Timothy R Drury, MD, FACEP [email protected] Medicine Stuart Demirs, MD [email protected] Family Medicine Dariusz Krostrzewa [email protected] OB/GYN Jeffrey Joseph, MD [email protected] Pathology/Laboratory James Carlsten, MD [email protected] Pediatrics Roger Fazio, MD [email protected] Orthopedic Surgery David Burns, DO [email protected] Surgery James McCormick, DPM [email protected]

Do You Want To Submit an

CME Opportunities The 2013 Cardiometabolic Health Congress When: Oct. 2-5, 2013 Where: Boston, MA Description: This CME provides the most effective, current strategies for the prevention, diagnosis, and management of type 2 diabetes, atherosclerosis, hypertension, dyslipidemia, obesity, thrombosis, chronic kidney disease, insulin resistance, hypertriglyceridemia and related comorbidities. Learn more.

Pitfalls In Radiology When: Oct. 4-5, 2013 Where: Venetian and Palazzo Resort Hotel, Las Vegas, NV Description: In this CME you will learn: The financial and health costs of overly vague or incorrect different diagnoses, and other interpretive errors; how to use decision-support tools that can help radiologists make more accurate diagnoses; and how to optimize those imaging and viewing protocols that may impair the ability of radiologists to make accurate and clinically useful diagnoses. Learn more.

New Concepts and Emerging Therapies in Metabolic Disorders and Vascular Disease When: Oct. 5-6, 2013 Where: Monterey, CA Description: This CME focuses on: • Re-evaluation of diagnostic approaches and treatments of secondary hypertension • Differences in men’s and women’s cardiovascular disease • Meditation and cardiovascular disease • Diastolic dysfunction: the new heart failure • Update in diabetic nephropathy • The progression in atherosclerosis in pictures Learn more.

Idea/Story for Next Issue? Contact Jane Goodger at [email protected] or 788-1137

Have you attended a particularly informative CME? Let your colleagues know so they can attend next year. Email [email protected] with the details.

Medical Staff News

Welcome to the Medical Staff! Robert Fox, MD

Ehsun Mirza, MD

After Robert Fox, MD, graduated from Ross University School of Medicine in the West Indies, he completed his residency in Internal Medical at Roger Williams Medical Center. Fox most recently was in private practice and staff physician at Westerly Hospital. One of his more interesting assignments was as a physician assistant to inmates for the U.S. Department of Justice, Federal Bureau of Prisons, U.S. Penitentiary at Leavenworth. [email protected]

Ehsun Raza Mirza, MD, has joined the Hospital’s Intensive Care Unit from Kent County Hospital, where he worked as a staff Intensivist for nearly 10 years. Board Certified in Internal Medicine; Critical Care; Nephrology, Mirza received his medical degree from Dow Medical College in Karachi, Pakistan and completed his Internal Medical Residency at the Pinnacle Health System in Harrisburg, PA. He also completed a renal fellowship at Rhode Island Hospital and critical care medicine fellowship at Miriam Hospital. [email protected]

Patricia Way, NP Patricia Way, APRN, BC received her nurse practitioner degree from the University of Utah, and her Master in Nursing, specializing in oncology, from the University of California. Way is Board Certified by the American Nurses Credentialing Center. She has worked in a variety of healthcare facilities in New England, including Home and Hospice Care of Rhode Island, Riverbend Medical Group in Chicopee, Mass.; and St. Francis Hospital and Medical Center in Hartford, CT. [email protected]

Gary D. Zimmer, MD Gary D. Zimmer, MD, FACEP, has joined the Hospital’s Emergency Department. Zimmer received his Doctor of Medicine from Cornell University Medical College, then completed his Harvard Affiliated Emergency Medicine Residency at Brigham and Women’s Hospital. He comes to South County Hospital from St. Mary Medical Center in Langhorne, PA. He was also medical director of the Newtown Ambulance Squad in Bucks County. [email protected]

Heart Healthy Recipe of the Month

Zucchini Bread

Health eCooking

Ingredients

Preparation

•1 cup all-purpose flour

Preheat oven to 350°. Lightly coat a 9 x

•1 cup whole wheat flour

5-inch loaf pan with nonstick cooking spray.

•2 tsp ground cinnamon

Into a medium bowl, sift flours, cinnamon,

•1 tsp baking soda

baking soda, baking powder and salt. In

•1 tsp baking powder

a large bowl, beat sugar, applesauce, oil,

•1/4 tsp salt

eggs and vanilla. Mix in zucchini. Add

•1 cup sugar

dry ingredients and walnuts and stir well.

•1/2 cup applesauce

Transfer batter to prepared pan. Bake until

•2/3 cup olive oil

tester inserted into center comes out clean,

•2 eggs

about 1 hour 20 minutes. Cool bread in pan

•1 tsp vanilla extract

on rack for 15 minutes. Cut around bread

•3 cups grated zucchini

to loosen. Turn out onto rack and cool

•1/2 cup chopped walnuts, toasted

completely. Yield: 14 servings

The Back Page

Of Interest... Futuristic Medical Fraud Prevention. Glass Hospital article about the lastest high tech efforts to stop medical fraud—a problem that is likely worse than we believe. Doctor Performs First Google Glass-equipped Surgery. Article from PC Magazine about surgery performed at the Eastern Maine Medical Center. If Obesity is a Disease, Why are so Many Obese People Healthy? Time article about the recent American Medical Association classification of obesity as a disease—and the consequences of that decision.

On The Bookshelf... Stiff: The Curious Lives of Human Cadavers by Mary Roach In this fascinating, ennobling account, Mary Roach visits the good deeds of cadavers over the centuries—from the anatomy labs and human-sourced pharmacies of medieval and nineteenthcentury Europe to a human decay research facility in Tennessee.

Continued from page five Soon we were within the 200-mile AAA towing radius to home! An internal sigh of relief that we were going to make it! A trip to Narragansett beach for an evening foot dip in the ocean

Dipping toes in the Atlantic after a cross-country trek

completed our coast-to-coast

Medical Detectives: The Lives & Cases of Britain’s Forensic Five by Robin Odell The development of forensic pathology in Britain is told here through the lives of five outstanding medical pioneers. Spanning 70 years, their careers and achievements marked major milestones in the development of legal medicine. Country of Ash: A Jewish Doctor in Poland by Edward Reicher “It’s the rough texture of Reicher’s tale— like grainy celluloid from a bygone era—that gives such a powerful, deeply disturbing immediacy to the ghetto inhabitants he remembers.” —Milwaukee Journal Sentinel

adventure. Our "new" van passed a pretty rigorous shakedown test with elevation from 282 feet below sea level to over 11,000 feet, temperatures ranging from the low 30s to the high 90s, weather from dry desert to flooded plains. We passed the test as well with a reconnection of our family unit for 10 straight days together; not done since Delia was born. It was a great experience with breathtaking sights and newly-minted memories. The van will be a continuous work in progress as older vehicles tend to be. We have a few more trips planned this summer and hope to see much of our great country (and nearby countries) over the coming years. Perhaps Ida May (named by Delia for Ida "may" make it up this hill!) will appear in stories our daughter will tell her children and the cycle will continue. [email protected] If you have a great getaway or travel tip, please share it here. Email Jane Goodger at [email protected]