LouisviLLe Medicine - Greater Louisville Medical Society

Louisville

GREATER LOUISVILLE MEDICAL SOCIETY

Medicine VOL. 61 NO. 7 December 2013

Ralena G. Heart Transplant 2007

More experience in organ transplants. More lives saved every year. Jewish Transplant Care leads Kentucky in both total procedures performed and survival rates for heart, kidney, liver, lung and pancreas transplants. For referral information, call 800-866-7539 or visit jhsmh.org/transplant.

Scientific Registry of Transplant Recipient 1/1/08 - 6/30/11

LOTS FOR SALE Beech Spring Farm

Located off Barbour Lane, Beech Spring Farm offers flat and walkout lots backing up to woods and open areas. Lots priced from $79,950. Home prices start at $399,950.

Spring Farm Pointe

Wolf Pen Springs

Located off Spring Farm Drive, Spring Farm Pointe offers beautiful lots in a spectacular setting starting at $69,950. Homes starting at $299,950.

Located off Chamberlain Lane, Wolf Pen Springs offers large lots starting at only $89,950. Home prices start at $399,950.

site of homearama 2014

Spring Farm Glen

Located off Spring Farm Drive, Spring Farm Glen offers large lots in a prestigious area starting at only $139,950. Home prices begin at $650,000.

Harrods Glen

Located off Wolf Pen Branch Road, Harrods Glen offers beautiful estate lots beginning at only $229,950. Best lot values in eastern Jefferson County. Home prices begin at $1.0 Million.

Poplar Woods

Located off Highway 42 in Goshen, Poplar Woods offers large private lots in a spectactular setting. Lot prices start at $119,950 with homes starting at $599,950.

Glenview Park

Located on Cabin Way, off Lime Road, this beautiful development offers estate lots from $219,950. Homes begin at $1.0 Million.

Shakes Run

Located off Eastwood Fisherville Road, this clubhouse community offers large private lots starting at $69,950. Homes start at $349,950.

Villas at Glenview Park

Located within Glenview Park, lots are priced from $159,950. Home prices begin at $650,000.

Canfield Development is proud to offer the finest selection of prime homesites in the Louisville Metro area. We have hundreds of homesites to choose from in Jefferson and Oldham Counties. Home Buyers in all price ranges will delight in the care and attention given to architecture and land planning that is more environmentally sensitive than any other communities in the region. We are proud to have the first conservation subdivisions ever approved in Jefferson, Oldham and Shelby Counties. When you decide to purchase a homesite from Canfield Development you have joined a growing movement that values timeless architecture and cutting edge land planning. For more information about these homesites, contact Steve Canfield at either 245-4427 or 649-5687.

WWW. CANFIELDDEVELOPMENT .COM |

502.245.4427

I don’t just have insurance. I own the company. Katrina Hood, M.D., F.A.A.P. Pediatrician PEDIATRIC & ADOLESCENT ASSOCIATES, LEXINGTON, KY

Medical Professional Liability Insurance

“Like me, you’ve probably noticed some professional liability insurance providers recently offering physicians what seem to be lower rates. But when I took a closer look at what they had to offer, I realized they simply couldn’t match SVMIC in terms of value and service. And SVMIC gives me the peace of mind that comes when you’re covered by a company with more than 35 years of service and the financial stability of an “A” (Excellent) rating. At SVMIC, I know it’s not just one person I rely on… there are more than 165 professionals who work for me. That’s because SVMIC is owned by you, me, and over 14,000 other physicians across the Southeast. So we know our best interests will always come first.”

Mutual Interests. Mutually Insured.

Contact Jesse Lawler or Susan Decareaux at [email protected] or 1-800-342-2239. Follow us on Twitter @SVMIC

www.svmic.com

GLMS Board of Governors Russell A. Williams, MD, board chair James Patrick Murphy, MD, MMM, president Bruce A. Scott, MD, president-elect and AMA delegate Heather L. Harmon, MD, vice president Robert H. Couch, MD, treasurer Robert A. Zaring, MD, MMM, secretary and AMA alternate delegate Rosemary Ouseph, MD, at-large Tracy L. Ragland, MD, at-large Jeffrey L. Reynolds, MD, at-large Neal J. Richmond, MD, at-large John L. Roberts, MD, at-large Wayne B. Tuckson, 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 Ilene Bosscher, GLMS Alliance president 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 Kenneth C. Henderson, MD Jonathan E. Hodes, MD, MS Martin Huecker, MD Teresita Bacani-Oropilla, MD Tracy L. Ragland, MD Ben Rogers M. Saleem Seyal, MD Dave Langdon, Louisville Metro Department of Public Health & Wellness Russell A. Williams, MD, board chair James Patrick Murphy, MD, MMM, president Bruce A. Scott, MD, president-elect Lelan K. Woodmansee, CAE, executive director Bert Guinn, MBA, CAE, associate executive director Ellen R. Hale, communications associate Kate Allen, communications designer Advertising Cheri K. McGuire, director of marketing 736.6336, [email protected] Follow us on Linkedin, Facebook, Twitter, YouTube and Vimeo

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

Medicine Vol. 61 No. 7 December 2013

Greater Louisville Medical Society

feature articles departments 7

5

The Ripple Effect James Patrick Murphy, MD, MMM

9

Reflections Home Visit, 2013 Teresita Bacani-Oropilla, MD

13

Alliance News Ilene Bosscher, MA, MDiv, LMFT, LPCC

22

Book Review Brotherhood: Dharma, Destiny, and the American Dream M. Saleem Seyal, MD, FACC, FACP

Many Thanks Martin Huecker, MD

27

Restaurant Review Elizabeth Amin, MD

The Unspoken Lesson James Bradley

29

Physicians in Print

Students’ Lounge The Conversation With My Grandparents Ben Rogers

32 35

We Welcome You

37

From the Blogosphere Breathe In……and Exhale Neagum Patel, MD

The Richard Spear, MD, Memorial Essay Contest: 2014 Mary G. Barry, MD

11

Vaccinations for Adults: You Are Never Too Old to Get Immunized Stanley A. Gall, MD

15

What Are You Afraid to Miss? Part 1 Stephen Wright, MD, FAAP

20

Holidays to Remember Autumn’s Gift Elizabeth Amin, MD

24

30

The Test Drive Kenneth C. Henderson, MD

Doctors’ Lounge No Bells Here Mary G. Barry, MD

Pelvic Mass!! Robert Vichich, MD “Shortness of Breath” Benjamin Favier, 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 December community; Unite physicians regardless of practice setting to achieve these2013 ends.

3

Defending physicians for more than 30 years We invest our financial strength in you • Consistent dividends* • The best Kentucky attorneys • Peer physician claims review • Industry leading Patient Safety • Owners Circle® rewards program • Doctor2Doctor® peer support

Medical malpractice insurance for Kentucky physicians Call 1-800-282-4882 or visit MagMutual.com *Dividend payments are declared at the discretion of the MAG Mutual Insurance Company Board of Directors. Since inception, MAG Mutual Insurance Company has distributed more than $120 million in dividends to our policyholders. Insurance products and services are issued and underwritten by MAG Mutual Insurance Company and its affiliates.

From the

President JAMES Patrick Murphy, MD, MMM GLMS President [email protected]

THE RIPPLE EFFECT

I

n the fall of 1992, fresh from residency training, “…including sudden death” was the standard ending to my “risks of surgery” informed consent spiel. Usually my patients recoiled, shivered, sighed, and ultimately signed by the “X.” But her response caught me off guard. She smiled a grandmother’s smile. And as though to comfort me, she offered, “I’m not worried.” Then, noticing my curious half smile, she bobbed her arthritic index finger down and up one time, gazed at me warmly and answered, “That’s why.” ****** Worry can be paralyzing. So how can you cope? In my career as a Navy flight surgeon, anesthesiologist, pain & addiction specialist, husband, father, and son I have been blessed with the opportunity to connect intimately with people on many levels. I’ve noticed those who preserve their joy despite insurmountable challenges seem to share certain themes. To beat worry, they “prep” themselves. P Firstly, they address their PHYSICAL needs. You live inside a body. And your body has tremendous influence on how you handle stress. You should promote its physiological well-being. Get enough sleep. Eat well. Exercise. Also, since we are what our chemicals tell our brain we are, do what you can to optimize your chemicals. This means if your serotonin is low, your hormones are deficient, your endorphins are depleted, or any other ailment needs medical attention - tend to it. Your body is the only vessel you will ever have on life’s journey - better to patch the holes than to be constantly bailing.

R Secondly, they RESEARCH. Compared to other animals, humans have huge frontal lobes. This allows your brain to analyze facts. Do this. Uncertainty breeds worry. The more you understand a situation, the more likely you are to find solutions. So when faced with worry, gather as much information as possible, realistically predict what might happen, and then take actions to improve the likelihood of the better outcomes. E Thirdly, they have an EXTERNAL focus. Doing something for someone else or a cause that benefits others, with passion, selflessly, will make your problems seem less ominous. Frankly, it is impossible to think about yourself when you are locked into thinking of someone else. Living at the center of the universe can be very lonely. P Finally, they have PERSPECTIVE. Humans are the only organisms aware of concepts like the past, the future, beauty, love, death, and eternity. Try as you may, the past cannot be undone. The future is no different than a dream. You have complete control of your perception of beauty and how deeply you love. These certainties coupled with awareness that one day the mystery of eternity will be answered should prompt you to ask yourself, “Do I really want to spend so much time worrying about _______ (fill in the blank)?” You probably have bigger fish to fry. ****** That morning my grandmotherly patient went on to explain the significance of her bobbing finger. “Your life is like dipping your finger in water. No matter how much you want it to be different, you only make ripples that just fade away with time.”

I have never forgotten that simple metaphor of a finger dipping into water. A life’s dissipating ripples in time are more harmonious when sheltered from the dissonance of worry. It is essential to PREP. Optimizing your physical health, researching the facts, externalizing your focus, and gaining perspective are effective techniques to conquer the paralysis of worry. This is not always easy and takes some discipline, but I have witnessed remarkable people overcoming unbelievable challenges - this has been their path. LMthe ripples they have left behind These are for us. 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.

Let’s Connect Email me at [email protected]. Follow me on Twitter @jamespmurphymd. Connect with me on LinkedIn. Sign up for, visit and comment on the new GLMS blog (instructions at www.glms.org). Download the GLMS mobile app (instructions at www.glms.org). Or just give me a call. My number is in the GLMS “mug book” and the new mobile app. December 2013

5

D

r. Richard Spear was a highly respected and much loved general surgeon who was born in Newcomerstown, Ohio, in 1919. He studied at the Ohio State University where he played trumpet in the marching band. He trained at the Mayo and served in the Army of Occupation in Japan. In 1951 he moved here and practiced downtown for 35 years. He chaired the departments of Surgery at the old Baptist Hospital and at St. Anthony’s, but in keeping with the times served as U of L faculty and operated in every downtown hospital. His patients always sought his advice first. He loved to read. He died in 2007, and left our medical society a generous bequest expressly intended to promote good writing about Medicine. This year, for our seventh edition of the contest to honor him, we have tweaked the rules. We have changed the deadline – essays are now due March 3 – around here, March Madness brings too much distraction to write. In addition, it’s different to write about the practice of medicine when you have just now donned the white coat, and so we have created for our physician-in-training/medical student category a separate theme: “What Patients Have Taught Me.” For the grown-up doctors, we thought long and hard and decided that we are a restless and opinionated bunch, and that giving us free rein is good. Over and over we hear of problems related to the Balkanization of local and regional practice. Therefore we have chosen as our theme, “Current Practice: Realities and Controversies.” You have 800-2,000 words and your deadline is Monday, March 3, 2014. NOT APRIL! It will be winter – huddle up by the fire, or the Starbucks counter, and write. As Jeff says on “Survivor” – you want to hear what you’re playing for? It’s cold cash – for the young ones, $750 to the winner, and for the fully qualified, $1,500. The all-volunteer judges will consider excellence in expression, creativity, readability, clarity, plus the power of your message. These are essays, not research papers – write from what you know and what you feel. The winning essays will be announced at the GLMS President’s Celebration and published in the July issue of Louisville Medicine, and many of the other entries will be run in subsequent issues. Sometimes we judges award an honorable mention gift card. In addition, the judges wish to recognize outstanding writing about medicine or health care for a general audience that has appeared in the lay press through the Medical Writing for the Public award. The winner will receive a non-monetary award at the President’s Soiree. And finally: an essay may not be your thing. You might prefer to write a review of a book or restaurant, or contribute a travel piece, or write about a hobby, or write a short opinion about any medical subject. These entries would not be part of the contest, but could be submitted directly to us for review for publication. If you are tentative about having anyone read it before you have perfected it, that is where I can help. You can send it directly to me at [email protected] and I will read it, edit it, and send it back for comment before you submit it to the full editorial board. Writers want their work to be read: that is where we come in. This is your opportunity to have your voice brought to life. LM

The Richard Spear, MD, Memorial Essay Contest: 2014 Mary G. Barry, MD

Louisville Medicine Editor

Guidelines You must be a GLMS physician member (practicing or retired), GLMS in-training member or University of Louisville medical student to enter.

Themed essay contest: All entries

must be original, unpublished writing intended solely for publishing in Louisville Medicine. Essays must be pertinent to the theme “Current Practice: Realities and Controversies” for the practicing/life physician category or “What Patients Have Taught Me” for the physician-intraining/medical student category.

Length: 800 to 2,000 words. Format: Do not put your name on your es-

say! Judges are blinded to authors. Instead, include a separate cover letter with name, entry category, essay title and contact information.

Medical Writing for the Public Award: You may enter an article of any

length, written on a medically related topic for readers in the general public, that was published in a newspaper, magazine or book anytime during 2013. The submission may not be a selfpublished work. Include a copy of the article along with a cover letter with the name and date of the publication and your contact information.

Deadline: Monday, March 3, 2014. Submission: Send via email as an attach-

ment to Ellen Hale at [email protected]. Email submissions are highly preferred, but if not possible, send entry by fax to 502-736-6339 or by mail to 101 W. Chestnut St., Louisville, KY 40202. December 2013

7

LEAVE THE WORRIES TO US Call GLMS for Your Staffing Needs CLERICAL | CLINICAL | MANAGEMENT | ALLIED HEALTH

WE PROVIDE:

» Direct placement » Temporary placement » Temp to hire

WE GUARANTEE:

» » » » » 8

Criminal background checks Reference checks Credit checks Drug screening Skills testing

LOUISVILLE MEDICINE

Serving greater Louisville and southern Indiana with a 60-year track record of quality and dedication. Call Ludmilla Plenty, employment director, at 502-736-6342 or visit us at www.glms.org.

MedicaL Society Professional Services A Greater Louisville Medical Society Company

REFLECTIONS HOME VISIT, 2013 Teresita Bacani-Oropilla, MD

A

shimmering Japanese ornamental koi, released back to its familiar pond, swam gracefully to seek its old haunts, leaving a gold streaked trail behind it. Like this colorful creature, sometimes we long to swim in the warm waters of memory and leave evanescent trails behind us.

around seven then. The other vividly recounted how I had approved her young husband’s (now a retired police officer) admittance to the police force. I had forgotten that in the remote past, following my mother’s demise, I took her place as Police Commissioner in the growing provincial capital (now a large city) and helped draft the qualifications for police officers. It probably has withstood the test of time.

The latest yearning for this activity began when it was time to revisit family and friends in my original home country, tropical Philippines. The idea was to make a sentimental journey in style, while still on one’s feet, hook up with colleagues and friends and hope that they too still had their boots on.

What a boon that youth could be so bold and decisive! Maybe age has a way of making one more timid and decline challenges, or maybe wiser and more circumspect so as not to stick one’s nose in whatever business is at hand. It also emphasized that what one does ordinarily without much thought may actually impact other’s lives in a very significant way, hence the need for constant responsibility for one’s actions.

Fortunately, this prospect of reminiscing and catching up with the years was given a boost when it coincided with the release of the 50th anniversary yearbook of the founding of the southern chapter of the Philippine Pediatric Society of which my former colleagues and I were charter members. (A former pediatric resident, U of L 1956-58, I practiced as a pediatrician in rural Philippines the first 15 years of my medical career.) In black and white pictures and essays, we saw our accomplishments documented. We marveled at the energy and vitality of our younger selves and concluded that given our resources then, we did an excellent job in meeting the needs of our patients and in paving the way for the training of subsequent pediatricians that would eventually take our places. Part of revisiting a place is to note progress. The physical changes of the landscapes that I had known were astounding. Where once stood vacant second growth forests, now sprouted modern subdivisions. Rice fields had been decimated as towns have crept into them. Concrete highrises have taken over some commercial districts. Shopping malls the size of several football fields displayed the latest oriental and western amenities. At these malIs and elsewhere it was amazing how everyone seemed to have gadgets in their hands, even little toddlers, toying with iPads and white-haired grandparents with their iPhones. It seems also, that it has become prevalent and acceptable to answer text messages and carry on another phone conversation in the presence of one’s visitors or company. Thus, social norms too, had shifted, begging the question of whether we need a revised edition of Emily Post’s rules of conduct soon. Despite these few perceptible changes in behavior that go with our times, the warmth, openness, and closeness of relationships of the people still prevail. An incident or two illustrates this and bears sharing. While sauntering thru old haunts, two ladies inquired about my taking souvenir pictures. When I introduced myself, Surprise! They knew me from 40 years back. The younger one remembered me as treating her and her siblings whenever they got sick. She was

If self interest in going back was to moon over the past, I got a quick jolt. Upon arrival in Manila, the capital city of the Philippines, the tail end of the Pacific typhoon Santi demonstrated what a tropical thunderstorm was. The rain literally looked like it was poured from buckets and flooded the streets in minutes, holding up traffic for hours. This storm was followed in a few days by a terrible earthquake that measured 7.2 on the Richter scale and devastated the islands of Bohol and Cebu, toppling 16th century churches and bell towers, destroying beaches and tourist attractions, killing people and leaving threatening miles-long cracks on the ground that could swallow anything with the next tremblor. As I write, government entities, the Red Cross, and other local and foreign charities are mobilizing resources to provide water, food, shelter, and medical supplies to the victims. We, family and friends, visited the local archbishop and offered what help we could thru church based organizations which are always present even in the remotest barrios to allocate distribution for those in need. Thus once more, we witness our global world separated by man-made boundaries and ideologies yet interdependent one on the other in times of tragedy and suffering. Sentimental journeys hope to consolidate the past with the present, to take stock of how high up the mountain of life one has reached, or to swim once more in the comforting waters of the youthful past. Such things do not always happen as we wish them to be. Instead, we are faced with the reality that each life has a purpose and must be lived fully each day. L

M

Note: Dr. Oropilla is a retired psychiatrist.

December 2013

9

“As physicians, we have so many unknowns coming our way... One thing I am certain about is my malpractice protection.” Medicine is feeling the effects of regulatory and legislative changes, increasing risk, and profitability demands—all contributing to an atmosphere of uncertainty and lack of control. What we do control as physicians: our choice of a liability partner. I selected ProAssurance because they stand behind my good medicine and understand my business decisions. In spite of the maelstrom of change, I am protected, respected, and heard. I believe in fair treatment—and I get it.

Professional Liability Insurance & Risk Management Services ProAssurance Group is rated A+ (Superior) by A.M. Best. ProAssurance.com

502.423.7201

Vaccinations for Adults:

You Are Never Too Old to Get Immunized Stanley A. Gall, MD

G

etting immunized is a lifelong, life-protecting job that is the responsibility of both patients and physicians. The patient should not leave the health care provider’s office without making sure he/she is up to date on all the needed vaccinations.

Vaccine

Do You Need It?

Influenza

Yes: Influenza vaccine is recommended for all persons over 6 months of age each year to protect the patient and others around you.1

Tetanus, Diphtheria and Pertussis (Whooping cough) (Tdap)

Yes: All adults need to get Tdap. Women who are pregnant need this vaccine with each pregnancy. After that, you need a Tdap booster every 10 years. All persons in contact with children should receive Tdap.2-4

Hepatitis A (Hep A)

Yes: You need the vaccine if you have one of 15 risk indications for hepatitis A virus infection or simply want protection from this disease. There are frequent reports of food-borne hepatitis A, and protection is warranted. The vaccine’s given in two doses, six to 18 months apart.5

Hepatitis B (Hep B)

Yes: You need this vaccine if you have one of 27 risk indications or simply want to be protected from this disease. This vaccine is indicated during pregnancy. The vaccine is given in three doses over six to 12 months.2,6

Pneumococcal (PPSV23, PCV 13)

Yes: You need one dose of PPSV23 at age 65 (or older), or if your previous vaccination was at least five years ago. You need this vaccine if you are pregnant or have one of 21 risk indications including smoking cigarettes or having diabetes mellitus. Immunosuppressed persons will need to receive PCV 13.2,7,8

Human Papillomavirus (HPV)

Yes: You need this vaccine if you are a woman 26 years or younger, or a man 21 years through 26 years who has sex with other men. Any man aged 22 through 26 years who wants to be protected from HPV may receive this vaccine too. The vaccine is frequently administered to women and men who are older than age 26 who want to be protected. The vaccine is given in three doses over six months.9,10

Measles, Mumps, Rubella (MMR)

Maybe: You need one dose of MMR if you were born in 1957 or later and if you were screened Rubella nonimmune during pregnancy. You will need to receive MMR immediately postpartum with a second dose in six weeks.11

Meningococcal (INCV4) (MPSV4)

Maybe: You need this vaccine if you are 19-21 and a first-year college student living in a residence hall and you either have never been vaccinated or were vaccinated before age 16.12

Varicella (Chicken Pox)

Maybe: If you have never had chicken pox or were vaccinated and received only one dose, you can obtain a varicella Ig6 blood test and then if it is negative, receive the vaccine.13

Herpes Zoster

Maybe: If you are age 60 or older, you should receive a one-time dose of this vaccine now. The vaccine is also licensed by the FDA for administration at the age of 50 years and up.14

If you are planning to travel outside the United States, you may need additional vaccines. The CDC provides information to assist travelers and health care providers in deciding which vaccines, medications and other measures are necessary to prevent illness or injury during international travel. The CDC’s website is www.cdc.gov/travel or call 800-CDC-INFO (800-232-4636). LM References 1. CDC. Inactivated Influenza vaccine. Dated July 26, 2013. www.cdc.gov/vis. 2. Gall SA. Maternal Immunizations: Times for a new paradigm. Contemp OB-GYN 2011: 56: 36-48. 3. CDC. Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Tdap) in pregnant women. Advisory Committee on Immunization Practices, 2012. MMWR 2012: 62: 131-135.

4. CDC. Updated recommendations for the use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine in adults age 65 years and older. Advisory Committee on Immunization Practices, 2012. MMWR 2012: 61: 468-470. 5. National Center for Immunizations and Respiratory Diseases. General recommendation on immunization – recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Weekly Rep. 2012: 60: 1-64.

6. Mast EE, Weinkarum CM, Flore AE, et al: A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendation of the Advisory Committee on Immunization Practice (ACIP) Part II: immunization of adults. MMWR Recomm Rep. 2006; 55(RR-16): 1-33. 7. CDC. Updated recommendations for prevention of Invasive pneumococcal disease among adults using the 23 – Valent pneumococcal poly-

(continued on page 12) December 2013

11

(continued from page 11)

James Patrick Murphy, MD

Experience

Small enough to be like family, large enough to exceed expectations Conditions Treated • • • • •

Work Injuries Back Injury Neck Injury Headaches Sports Injury

• • • • •

Relief

Our OFFICE Location

Care

Arthritis Pain Surgical Pain Shingles Sympathetic Pain Cancer Pain

• Fibromyalgia • Facial Pain • Rational Use of Medications

MPCSI Murphy Pain Center of Southern Indiana Adjacent to Clark Memorial Hospital Medical Arts Building, Suite 100 207 Sparks Avenue | Jeffersonville, IN 47130 (812) 284-HELP | (812) 284-4357

www.murphypaincenter.com

saccharide Vaccine (PPSV23). MMWR Morb Mortal Wkly Rep. 2010; 59: 1102-1106. 8. CDC. Use of 13 – Valent Pneumococcal conjugate vaccine and 23 – Valent pneumococcal polysaccharide vaccine for adults with immune compromising conditions. Recommendations of the Advisory Committee on Immunization Practices. MMWR 2012: 61: 816-819. 9. CDC. Quadrivalent human papillomavirus vaccine: Recommendations of the Advisory Committee on Immunization Practices. MMWR 2007: 56 (RR-2). 10. CDC. FDA licensure of Quadrivalent Human Papillomavirus vaccine (HPV4 Gardasil) for use in males and guidance from the Advisory Committee on Immunization Practices. MMWR 2010: 5a: 630-632. 11. CDC. Prevention of Measles, Rubella, Congenital Rubella Syndrome and Mumps, 2013. Summary Recommendations of the Advisory Committee on Immunization Practices. MMWR 2013: 64: 1-34. 12. CDC. Prevention and Control of Meningococcal Disease. Recommendations of the Advisory Committee on Immunization Practices. MMWR 2013: 62: 1-28. 13. CDC. Prevention of Varicella. Recommendation of the Advisory Committee on Immunization Practices. MMWR 2007: 56 (RR-04) 1-40. 14. CDC. Prevention of Herpes Zoster. Recommendations of the Advisory Committee on Immunization Practices. MMWR 2008: 57 (RR-05) 1-30.

Note: Dr. Gall is a professor at the University of Louisville School of Medicine, Department of Obstetrics, Gynecology and Women’s Health, Division of Maternal-Fetal Medicine. He practices with UofL Physicians-Maternal-Fetal Medicine.

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] 12

LOUISVILLE MEDICINE

Alliance News Ilene Bosscher, MA, MDiv, LMFT, LPCC

GLMSA President [email protected]

(left to right) Lincoln Diniz, MD, George Sonnier, MD, Carl Paige, MD, Udaya Kayerker, MD, Robert Hendren, MD, James Patrick Murphy, MD, MMM

GLMS Alliance Upcoming Events December 3 – Lexington Medical Society holiday brunch December 12 - Book Club

Tracy Ragland, MD and James Patrick Murphy, MD, MMM (l to r) Ruth Ryan, Debi McDonald, Ilene Bosscher, Jenny Jacob

(front row left to right) Chitra Kayerker, Josephine Diniz, MD, Karin Sonnier, Barbara Cox, Jenny Jacob, Ilene Bosscher, Barbara Davis (middle row left to right) James Patrick Murphy, MD, MMM, Terri Paige, Millicent Evans, Udaya Kayerker, MD, George Sonnier, MD (back row left to right) Robert Hendren, MD, Dominique Hendren, (l to r) Colleen White, A. Franklin White, Debi McDonald, Carl Paige, MD, Donald Evans, MD, C. Dean MD, Margaret White, Ilene Bosscher Furman, JD, Ruth Ryan, Lincoln Diniz, MD, Christian Furman, MD

Dominique Hendren, Ilene Bosscher and Rhonda Rhodes

A

Home of the Innocents Tour Guide Jennifer Zanchi with Ilene Bosscher, Michelle Feger, Angie DeWeese and Karin Sonnier

s the holidays of this season draw near we look back and celebrate what we have accomplished thus far this year. The Alliance membership has increased by 50% from last year with 15% of our present membership for the first time being male. The Men in the Alliance took part in the GLMS Foundation’s Golf Outing as well as hosted a skeet shooting and wine tasting event in November. Our opening Harvest Moon gathering’s silent auction raised $300 for the GLMS Foundation Scholarship Fund as we honored the former GLMSA and KMAA President Barbara Cox. We raised over $1,000 during our luncheon and tour at The Home of The Innocents in October where we honored Past GLMSA Presi-

Barbara Cox and Ilene Bosscher

C. Dean Furman, JD, Christian Furman, MD,George Sonnier, MD, Kristi Mattingly, Doug Mattingly, MD, Brian Briscoe, MD

dent and social worker Margaret White. Our three clubs - Bridge, Book and Health and Wellness - have met several times and found enjoyment in these activities. Looking ahead, we will join the Lexington Alliance on December 3rd for their annual Christmas Bazaar as well as coordinate an outreach of wish list items for the Center for Women and Families this month. We send everyone our heartfelt wishes of fulfillment and peace throughout the coming year! LM Note: Contact Ilene Bosscher at [email protected] or 502-5527319. To contact the Men in the Alliance Committee, email [email protected]. December 2013

13

SEE BETTER

Education, Experience & Compassion A perfect combination for your patients.

RICK D. ISERNHAGEN, MD

JOHN W. KITCHENS, MD

THOMAS W. STONE, MD

ANDREW A. MOSHFEGHI, MD

WILLIAM J. WOOD, MD

Impressively trained and highly respected by both patients and peers, the physicians at Retina Associates of Kentucky have been trusted to care for Kentucky’s retina patients since 1975. Dr. Thomas Stone is proud to announce that Retina Associates of Kentucky has opened its Louisville office in The Springs Medical Center, at 6420 Dutchmans Parkway. Dr. Stone, managing partner of the Louisville office, received his training at Duke and Emory Universities. He and his highly recognized partners at Retina Associates focus on medical and surgical disorders of the retina, including macular degeneration, diabetic retinopathy, macular disease and retinal detachment. SEE BETTER with Retina Associates of Kentucky–now accepting new patients.

Retina Associates of Kentucky retinaky.com / (502) 895-2600 14

LOUISVILLE MEDICINE

6420 Dutchmans Parkway - Louisville, KY

What are you afraid to miss? Part 1 An ongoing series from the Partnership to Eliminate Child Abuse Stephen Wright, MD, FAAP

T

he events at Penn State in November 2011 brought a resurgence of attention to the issue of childhood sexual abuse (CSA). However, the critical teachable moment about the full implications of CSA and our responsibilities as community and health care leaders remains upon us. This is really a public health pandemic! It is imperative that we seize this moment and bring greater attention to a significant health issue we may very well be missing in our patients’ lives, in the lives of those we know and love, and perhaps even in our own lives. Childhood sexual abuse and its effects have long-term and unrecognized health consequences. Current estimates indicate that 1 in 4 girls (25%) and 1 in 6 boys (16%) are sexually abused before the age of 18. Only 1 in 10 report the abuse, which means 90% of children who are victimized become adults who do not receive proper intervention.1 The implications of these alarming statistics bear great relevance to pediatric and adult health practitioners in every discipline.

What is Child Sexual Abuse?

A leading organization in CSA prevention, Stop It Now, defines childhood sexual abuse as “all sexual touching between an adult and a child. Sexual touching between children can also be sexual abuse when there is a significant age difference (often defined as 3 or more years) between the children or if the children are very different developmentally or size-wise. Sexual abuse does not have to involve penetration, force, pain, or even touching. If an adult [or older child] engages in any sexual behavior (looking, showing, or touching) with a child to meet the [older person’s] sexual needs or interest, it is sexual abuse.”2 Additionally, the development of the internet and electronic media has introduced covert methods of exploiting children via child pornography and child sex trafficking, creating international, billion dollar industries. Darkness to Light, another leading prevention organization, indicates that 30-40% of victims of CSA are abused by family members. As many as 60% are abused by people the family trusts. Nearly 40% are abused by older or larger children. As these numbers

illustrate, in the vast majority of cases, children are sexually abused by someone they know, trust and love.3 Understanding this reality is essential so that practitioners can respond appropriately to a suspected case of CSA. It is also wise to understand the neurobiology of trauma as we do so.

Early Detection Early Treatment – for Children

Research in developmental neurobiology of post-traumatic stress disorder (PTSD) resulting from childhood trauma and abuse shows significant impact on three interrelated developmental pathways of the brain: (1) on the maturation of specific brain structures at particular ages, (2) on physiologic and neuroendocrinologic responses, and (3) on the capacity to coordinate cognition, emotion regulation, and behavior.4 Simply stated, childhood sexual abuse is as much a “traumatic brain injury” as it is a “traumatic body injury.” The results of this neurobiological damage are significant and can be long lasting without proper intervention, while they may often appear to be “invisible” to practitioners. This complex dynamic may, in part, help explain why CSA is a silent health pandemic. Statistics indicate that those who are responsible for sexually abusing children often have a history of being physically or sexually abused themselves.5 This suggests that we must look at the problem of CSA as a medical issue as well as a moral one or we will not be well equipped to understand why it is so prevalent in our culture – and why it is essential that we appropriately intervene to stop the cycle of abuse, while promoting healing from the embodied trauma it creates.

Child Advocacy Centers in Kentucky

Responding to child sexual abuse is a complex process and requires the input and effort of a wide variety of professionals. In Kentucky, there are fifteen Children’s Advocacy Centers (CAC’s) dedicated to gathering community professionals to work toward the best outcomes possible to ensure the safety and well-being of children who have experienced sexual abuse (www.kacac.org). Specialists at the CACs are best equipped to provide a safe, childfriendly environment where the child and non-offending caregivers can find a full array of services including forensic interviewing, advocacy, and mental health and medical services which are provided by a multidisciplinary (continued on page 17) December December 2013 2013

15 15

JEFFERSON MANOR HEALTH & REHABILITATION 1801 Lynn Way Louisville, KY 502.426.4513

JEFFERSON PLACE HEALTH & REHABILITATION 1705 Herr Lane Louisville, KY 502.426.5600

MEADOWVIEW HEALTH & REHABILITATION 9701 Whipps Mill Road Louisville, KY 502.426.2778

OAKLAWN HEALTH & REHABILITATION 300 Shelby Station Drive Louisville, KY 502.254.0009

ROCKFORD HEALTH & REHABILITATION 4700 Quinn Drive Louisville, KY 502.448.5850

SUMMERFIELD HEALTH & REHABILITATION 1877 Farnsley Road Louisville, KY 502.448.8622

Giving 110% to get her back to 100%. 16

LOUISVILLE MEDICINE

At Elmcroft, our highly skilled and compassionate nurses go above and beyond to get patients home and back to normal as soon as possible. For faster recovery and better outcomes, call any of our six Louisville communities. Elmcroft.com/skillednursing

(continued from page 15) team at no cost to the child’s family. Lisa Pfitzer, MD, Fellowship Director, Kosair Charities Division of Pediatric Forensic Medicine, Department of Pediatrics, University of Louisville School of Medicine, says that “The first step for a health care provider who suspects that a child may have experienced CSA is to make a report to the child abuse hotline. Then work with child protection to create a safety plan so that the alleged perpetrator will no longer have access to the child. This can be very challenging when the perpetrator is a caregiver or a sibling or both, but a committed plan is crucial for the child’s safety and mental well-being. If the sexual abuse has occurred within the last 96 hours it is very important the child receive medical attention as soon as possible for assessment and collection of forensic evidence as clinically indicated. If more than 96 hours has passed, a timely exam should still be performed, particularly if the child is within the first seven days of the last occurrence of sexual touching.” Contrary to popular belief, and due to the nature of the overall secrecy associated with sexual abuse, abnormal physical findings are not typical. Up to ninety five (95) percent of exams for the sexual abuse victim are normal. Injuries such as bruising, abrasions and superficial tears heal rapidly. Children who are seen acutely should then have a two-week follow up exam to screen for pregnancy and sexual infections. Children who report intimate sexual activity or where there is concern for exchange of body fluids (perhaps a child offers some information but photos are found to reveal more activity than what was disclosed by the child) should have serology checked for hepatitis, syphilis and HIV and have a six-month follow up for the same serology. Initial and serial photos of injuries can be extremely helpful in the sexual abuse investigation.” It is also important to note that in Kentucky, it is mandatory by law that ANY citizen must report suspected child abuse. Reports can be made to any of the following: Statewide Abuse Reporting Hotline, 1-877-KYSAFE1 or 1-877597-2331 Cabinet for Health & Family Services, Division of Protection & Permency (local office or regional intake) Kentucky State Police or any local law enforcement agency Local Commonwealth’s Attorney or County Attorney

though parents and physicians certainly need to be aware of any of the following: • Pain, discoloration, lesions, bleeding or discharges in genitals, anus or mouth • Persistent or recurring pain during urination and bowel movements • Wetting and soiling accidents unrelated to toilet training

BEHAVIORAL WARNING SIGNS

Any one sign doesn’t mean that a child was sexually abused, but the presence of several suggests that parents begin asking questions and consider seeking help. Pediatricians should be proactive in dialoguing with parents about their children’s behavior changes in both sick and well child visits.

Behaviors that may be exhibited by children or adolescents: • • •

• • • • • • • • • • •

Has nightmares or other sleep problems without an explanation Seems distracted or distant at odd times Has a sudden change in eating habits o Refuses to eat o Loses or drastically increases appetite; has frequent and unexplained stomach aches o Has trouble swallowing Sudden mood swings: rage, fear, insecurity or withdrawal Doesn’t want to visit or stay with indicated person Leaves “clues” that seem likely to provoke a discussion about sexual issues Writes, draws, plays or dreams of sexual or frightening images Develops new or unusual fear of certain people or places Refuses to talk about a secret shared with an adult or older child Talks about a new older friend Suddenly has money, toys or other gifts without reason Thinks of self or body as repulsive, dirty or bad Exhibits adult-like sexual behaviors, language and knowledge Sexually acts out towards other children

Signs more typical of younger children: • • • • • • •

An older child behaving like a younger child (such as bedwetting or thumb sucking) Has new words for private body parts Resists removing clothes when appropriate times (bath, bed, toileting, diapering) Asks other children to behave sexually or play sexual games Mimics adult-like sexual behaviors with toys or stuffed animal Wetting and soiling accidents unrelated to toilet training Doesn’t want to stay with or visit indicated person

Signs more typical in adolescents Warning Signs in Children and Adolescents of Possible Child Sexual Abuse6 PHYSICAL WARNING SIGNS

As Dr. Pfitzer described, physical signs of sexual abuse are rare,

• • • • • • • •

Self-injury (cutting, burning) Inadequate personal hygiene Drug and alcohol abuse Sexual promiscuity Running away from home Depression, anxiety Suicide attempts Fear of intimacy or closeness

(continued on page 18) December December 2013 2013

17 17

(continued from page 17) • • •

Compulsive eating or dieting Sexual infections Pregnancy – more than 60% of teenage mothers have been sexually abused in their past

Complicating factors for diagnosis One main reason it is often difficult for parents, caregivers, or practitioners to diagnosis an occurrence of CSA in a child is that it can take 6 months to 2 years for the short-term effects of CSA to begin to show themselves in the behavior changes of the child.7 So it may be difficult to trace these symptoms, when they arise, to the actual abuse occurrences. Moreover, the effects listed above may vary depending upon the child’s developmental stage and the circumstances of the abuse, including: the gender of the perpetrator, the number of perpetrators, the nature and closeness of the relationship between victim and perpetrator, the duration and frequency of the abuse, characteristics of the abuse itself (e.g., contact vs. noncontact, penetration, etc.), the use of threats or force, and the age of the victim at the time of the abuse.8

The Need for Family Services Certainly, treatment for a child who has been sexually abused should not end at the examination table. The process to heal from childhood sexual abuse is a lengthy one, and while the abuse does not always occur within the immediate or extended family system, this is the case a significant percentage of the time. Thus, intervention should be considered for the entire family system. It is important to recognize the signs of possible abuse early and refer children for individual and, when appropriate, family counseling, to ensure optimum health outcomes. Without proper intervention in childhood, the negative effects of child sexual abuse can affect the victim for many years and into adulthood.

Additional resources: Prevention: stopitnow.org/ d2l.org

Adult Survivors: Wingsfound.org 1in6.org malesurvivor.org rainn.org

Prevention/Intervention, including for those who have sexually abused a child: http://www.safersociety.org/

18 18

LOUISVILLE LOUISVILLE MEDICINE MEDICINE

Kentucky: KACAC.org KASAP.org

References 1 “Statistics.” Darkness to Light. Retrieved on July 16, 2013 from http:// www.d2l.org/site. 2 “What is Considered Child Sexual Abuse?” Stop It Now. Retrieved July 15, 2013 from http://www.stopitnow.org/warning_signs_csa_definition. 3 “Step 1: Learn the Facts and Understand the Risks.” Darkness to Light. Retrieved July 15, 2013 from http://www.d2l.org/site/c.4dICIJOkGcISE/ b.6241181/k.DEE3/Step_1_Learn_the_Facts_ and_Understand_the_ Risks.htm. 4 van der Kolk, Bessel A., M.D. (2003). “The neurobiology of childhood trauma and abuse” in Child Adolescent Psychiatric Clinic N Am 12; 293–317. 5 “Understanding Child Sexual Abuse: Education, Prevention, and Recovery.” American Psychological Association. Retrieved July, 13, 2013 from http://www.apa.org/pubs/info/brochures/sex-abuse.aspx. 6 “Warning Signs in Children and Adolescents of Possible Child Sexual Abuse.” Stop It Now. Retrieved July 12, 2013 from http://www.stopitnow. org/warning_signs_child_behavior. 7 “What are the effects of child sexual abuse?” American Psychological Association. Retrieved July 12, 2013 from http://www.apa.org/pubs/ info/brochures/sex-abuse.aspx?item=4. 8 Schachter, C.L., et al. (2009). Handbook on sensitive practice for health care practitioner: Lessons from adult survivors of childhood sexual abuse. Ottawa: Public Health Agency of Canada.

Co-authored by: Jennifer Stith, MAT, MA Interim Executive Director for the WINGS Foundation Stephen P. Wright, MD, FAAP Medical Director, Kosair Children’s Hospital Professor and Academic Advisory Dean University of Louisville School of Medicine Lisa Pfitzer, MD LM Associate Professor University of Louisville School of Medicine Fellowship Director Kosair Charities Division of Pediatric Forensic Medicine Note: Dr. Wright is medical director of Kosair Children’s Hospital. He is a professor and academic advisory dean at the University of Louisville School of Medicine, Department of Pediatrics. GLMS is an ally in the Partnership to Eliminate Child Abuse chaired by Dr. Wright.

MedicaL Society Professional Services A Greater Louisville Medical Society Company

OWn OCCUpatiOn DisabiLity insURanCE & GROUp tERm LifE insURanCE sOLUtiOns simple 1-page applications no tax return requirements to apply High quality portable benefits

Woodford R. Long, CLU | [email protected] | 800-928-6421 ext 222 | www.niai.com

Underwritten by New York Life Insurance Company, 51 Madison Avenue, New York, NY 10010 on Policy Forms GMR and SIP. December 2013kit. #1212 19 Features, Costs, Eligibility, Renewability, Limitations and Exclusions are detailed in the policy and in the brochure/application

Holidays to Remember

Stories celebrating the season from Louisville Medicine Editorial Board members

Autumn’s Gift Elizabeth A. Amin, MD

D

uring the last week of September I noticed that my Lily of the Valley were starting to fade. For me this is the sure indication that Autumn has arrived. The sturdy, smoothly marginated, deep green leaves, which have remained upright throughout the hot, humid summer, start to yellow at the edges. Slowly they turn brown and break up, cluttering the ground beneath like other fallen leaves.

They look forlorn. However, as strange as it may sound, they are my reminder that the holiday season will soon be upon us. They take me back in time as they also point me toward the current end of year events. I must have over a hundred square feet of the plants, so fragrant in the spring when the flowers seem to burst overnight from the earth. They are all the offspring of a handful of pips brought lovingly from England by my mother in the days when such activity was legal. She needed a small corner in my garden to remind her of home. She monitored their progress over the years on her annual 6 month visits. When our boys were small mother would arrive in late October and stay until the appropriate date in April as specified on her visa - 180 days. That way she could avoid the truly dreary weather and short days of a north of England winter. She could celebrate the holidays here as well as hers, my husband’s and my birthdays. Her first introduction to Thanksgiving in November 1974 was not entirely smooth. For her, as for me until my arrival here, turkey was the Christmas feast. Why could we not have some nice roast beef and Yorkshire pudding, she would ask. She would then ponder (over) the prospect of Christmas Dinner without turkey. I embraced the Thanksgiving holiday as part of my new life here in the US. For me its history was to be written. Christmas on the other hand was not something I looked forward to with unadulterated

20

LOUISVILLE MEDICINE

joy. It wasn’t the memory of the spats between my parents - over whether or not it was my paternal grandmother’s year to dine with us or whether it was her year to spend Christmas with my father’s sister, my mother‘s rival in things domestic. It was a much more somber event: the death of a loved one, one week before Christmas, the year that I was twenty. The point is not who that person was or my status in life at that time. The point is that for decades following, Christmas for me was a period of mourning. In the early years while I was still in medical school and later, newly graduated, I would throw myself into a frenzy of voluntary activity during the holiday season. I felt angry and alienated from the goodwill that everyone exuded. Even after my arrival in Louisville and subsequent marriage, the black hole consumed me. I tried to compensate, trying to be what people expected of me, hosting the family feast over the years - not always graciously and not always without resentment. In recent years the arrival of Autumn has found me somewhat more sanguine. It comes as an early warning signal. I have time to deal with my feelings and to plan for the festivities to come. This year - unexpectedly - Autumn has brought tranquility. I will work to make it last. I wonder if this new-found state could be related to the fact that we now have three beautiful grandchildren. They keep me in the moment. There are no black thoughts. They expect us both to take full part in holiday events. Amazingly we do or at least we do our best. Indeed the Autumn of the year and the Autumn of my life are proving to be truly full of blessings. LM Note: Dr. Amin is a retired diagnostic radiologist.

Many Thanks Martin Huecker, MD

S

days off.

eeing the photo on display at my mother’s new home, I had to smile: my grandfather with a huge grin, sitting next to three glowing women. My wife and my two cousins were pregnant at the same time and all made it to Thanksgiving dinner, 2011. I didn’t. In my second to last month of residency, I was seeing patients in the U of L ER but looking forward to the next several

The next day started out uneventfully. My wife watched while my kids and I listened to music and danced. I went to exercise just down the street and got a frantic phone call. My daughter was beckoning me home. “Mom is sick!” I instructed her to give mom juice (“her sugar must be low”) and that I’d be right there. Driving home I got another call. This time I heard Braidi, my wife, crying in the background. I tore into the house to find her on the floor with abdominal pain. Within minutes the kids were with the neighbors and I was committing traffic violations. We still curse the driver of a silver BMW that tried to block the road as I ran a stop sign. Dr. Thomas Tabb, our infinitely skilled obstetrician, was serendipitously on call and in the hospital. As I ran to a nurse to ask for a wheelchair, my wife wiggled out of the car and ambled right past me to Labor and Delivery. Dr. Tabb, who trained my wife in residency, diagnosed her placental abruption. One hour after that first phone call our twenty-six week preemie twins were born. I was not allowed into the operating room for the crash section. In the waiting room, I mechanically explained abruption to my mother and realized the threat to not two but three of my loved ones – feeling the curse of just enough medical knowledge. Atlas’s half of the placenta was no longer implanted and he received twenty seconds of CPR. Owen needed a little less attention and was swiftly intubated by the neonatal fellow, one of our med school classmates. Atlas stopped misbehaving, got a pulse, and got tubed. Minutes later I was looking at two swaddled, two-pound vent patients – our babies - on their way to neonatal intensive care. The Kosair NICU was where I would spend my holidays that year: where I would cry, laugh, obtain deserved but disturbed sleep, and feel powerless frustration followed by nourishing relief. The emotional vicissitudes would have been sharper if not for our classmate, Dr. Ramon Ymalay, who on Day One delivered to Braidi and me a head-to-toe explanation of struggles the twins might face ( including, but not limited to) head bleeds, chronic lung problems, feeding tubes, and the looming threat of NEC (necrotizing enterocolitis).

One month later we had witnessed our twins code on the same day while my wife held me back from intervening. Owen had been extubated successfully a second time, had a huge pneumatocele, and had had an IV misplaced into his brachial artery. Atlas had barely dodged reintubation but still had an arrhythmia. Both had overcome sepsis but were underweight and had too much white in their lung fields. The scarring would later go away only after Dr. Dan Stewart boldy ordered steroids, despite the risks. One of our favorite nurses, Anna, sent a photo of the two little miracle roommates in their Christmas outfits. They were together in one incubator for the first time. It was Christmas Eve. I held it next to that picture of my grandpa with my pregnant wife. Had all of this really happened or was it a dream? We bravely attended the family gathering with my still-pregnant cousins. We relived the delivery story, told of the triumphs these babies had already achieved, and went back to Kosair that night. Our daughter (10) and son (3) still could not meet their baby brothers, even on Christmas (RSV season, no siblings in the NICU). We cried for our disappointed kids. My wife cried for her robbed last trimester of pregnancy. It was a somber Christmas. But looking back, it was beautiful, as holidays are when we cherish what we have and consider what we could have lost. I think about my grandmother whom we had lost two years prior on December 22. She never got to meet the twins. I think about my grandfather - this will be our first holiday season without him. The twins are turning two this year with perfect health other than being skinny little peanuts. They are wonderfully wild and would have driven my grandfather crazy while my grandmother laughed. This year we will tell stories and watch all of these healthy babies play and unwrap presents together. We will all gather in my mom’s new home, the house she grew up in. Thinking about what my family has endured and all that could have gone differently, I wouldn’t change a thing. We went through three dark, tormenting NICU months and came out stronger on the other side. I know what my grandma would have said. “Many Thanks.” LM Note: Dr. Huecker practices Emergency Medicine with Physicians in Emergency Medicine. He serves as gratis faculty for the University of Louisville School of Medicine, Department of Emergency Medicine.

December 2013

21

Book review Brotherhood: Dharma, Destiny, and the American Dream Deepak and Sanjiv Chopra New Harvest, May 2013 Reviewed by

M. Saleem Seyal, MD, FACC, FACP

I

mmigrant physicians constitute 25 percent of the total physician population in the United States. Initially designated as FMGs (Foreign Medical Graduates), which many considered as rather pejorative, the term has since been sanitized to IMGs (International Medical Graduates). “Immigrant physicians,” however, is a more apt and palatable designation for physicians who received their medical education overseas and have now made America their permanent home. All of these physicians had to go through rigorous screening prerequisites before being accepted into accredited graduate education programs in the United States for their residencies/fellowships. The first wave of IMGs (1933-1948) included European refugee physicians. With the Exchange Visitor program introduced in 1948, IMGs started coming to the United States for training, and many stayed. To standardize the procedure, the Educational Council for Foreign Medical Graduates (ECFMG) was created in 1956, which administered the qualifying ECFMG examination and opened the door for non-European IMGs to come to America in the mid-1960s. In 1971, to address the physician shortage, permanent residency was offered to IMGs as an enticement. According to AMA statistics, immigrant physicians have hailed from 127 countries, with the largest group (more than 25 percent) coming from the Indian subcontinent (India, Pakistan, Bangladesh). Over the past half a century or more, immigrant physicians have assimilated splendidly into the fabric of America and have contributed significantly as practitioners, specialists, teachers, researchers, innovators, authors and entrepreneurs. Brotherhood is a dual memoir of two brothers; immigrant physicians who left India in the 1970s after receiving their medical degrees and came to the United states for their postgraduate training. Dharma and karma are two Sanskrit words that appear in the book 22

LOUISVILLE MEDICINE

and need to be defined. Karma is an important concept in Hindu and Buddhist philosophy of reincarnation and essentially means one’s path in life is determined by one’s actions in previous lives. Dharma simply connotes fulfilling one’s moral and ethical duty cheerfully. Deepak Chopra is two years older than Sanjiv Chopra, children of British-trained cardiologist Krishan Chopra, who had a kind heart and a very busy practice. Krishan had graduated from the prestigious King Edward Medical College in Lahore, which is now a part of Pakistan. Their upbringing was replete with the many privileges of being children of a respected, very prosperous physician with a cadre of servants in their big house. Deepak describes the family’s stay in the palace of a prince who was a patient of Dr. Krishan Chopra: “… The India of our childhood: beggars outside the high walls that protected the wealthy, and the sounds of merchants hawking their goods, while inside a white tiger sat placidly on a perfectly manicured lawn.” However, Deepak stresses the importance of dharma because of their privileged status, to “behave responsibly, to respect other people, and to give back at every conceivable opportunity.” The two brothers have written alternating chapters in the book, narrating their own perspectives, reminiscences and memories of childhood, adolescence and adulthood. Deepak was the studious one, while Sanjiv was more of a free-spirit and athlete. Like most other immigrant physicians to the United States, they came with their intellectual property of a medical degree and successful completion of the ECFMG examination, and their objective for emigration from India was to pursue postgraduate education and eventually become citizens of this great country and achieve their American Dream. Deepak is a board-certified endocrinologist who no longer practices mainstream medicine but since the 1980s has become an exponent

of the mind-body connection, a mingling of Western medicine with Eastern wisdom traditions including Ayurvedic medicine of ancient India. He is a prolific author who has written more than 70 books, many on The New York Times Best Sellers List, a sought-after speaker and an entrepreneur. He has millions of admirers who revere him, but there is no dearth of detractors who label him as a self-promoting charlatan. He has been called the “prophet of alternative medicine,” “fringe medicine man” and “guru to the Stars.” Sanjiv, on the other hand, has followed the mainstream and academic path, becoming a professor of medicine and the dean for continuing medical education at Harvard Medical School. Deepak arrived in America with his new wife, Rita, and started an internship at Muhlenberg Hospital in Plainfield, New Jersey, in July of 1970. After a year, he moved to Boston to do two years of Internal Medicine residency at the Lahey Clinic, during which he wrote of the brutal hours and perpetual exhaustion. Sanjiv and his wife, Amita, both physicians, came in 1972 and also started their residencies at the Muhlenberg Hospital. Sanjiv describes his and Amita’s Americanization process quite lovingly: “Everything about America surprised us.” They were enchanted, amazed and mesmerized by the color television, by the beautiful young women and handsome young men singing on The Lawrence Welk Show, the Sanford and Son TV show, shopping at the massive supermarket, the magical experience of their first snowstorm and encounters with a multitude of helpful, generous and friendly Americans. They moved to Boston for their residencies, Sanjiv in Internal Medicine and Amita in Pediatrics. Sanjiv then completed his Gastroenterology/Hepatology fellowship while Deepak took a hiatus from Endocrinology to work as an ER physician for two years and then resumed his fellowship, later followed by private practice. Eventually he became disillusioned and burnout set in, and he changed his focus to Transcendental Meditation. In his quest for an alternative to what he had thus far done, he got to know Maharishi Mahesh Yogi and started spending a lot of time with him, eventually joining his Ayurvedic Clinic. This was the fork in the road between the two siblings, which is discussed in some detail in the book, along with a decade-long association of Deepak with the Maharishi’s organization as its chief spokesperson. He eventually goes on his own, moves to California and starts his own multifaceted new life, which has paid handsome dividends. An interesting documentary called Decoding Deepak has been made by his son Gotham Chopra, who tries to reconcile the dichotomy between his father, the spiritual figure who is constantly in the eyes of the media, and the same man he has known at home. This dual memoir is unique in its execution, since the two brothers are writing alternative chapters chronologically starting from their life in India and through their permanent presence in America with their unique perspectives on the Americanization process. Straddling two cultures is a beautiful thing. Deepak and Sanjiv both love their country of birth, India, and they are devoted and immensely enamored with their adopted country, America, and like other successful immigrants in this country, they will be leaving a great legacy of dual cultural heritage for their offspring. LM Note: Dr. Seyal practices Cardiovascular Diseases with Floyd Memorial Medical Group-River Cities Cardiology.

LOOKING FOR A BANK THAT UNDERSTANDS

YOUR UNIQUE BANKING NEEDS?

+ Bu si + Co ness Ac coun mm ercia ts + Li l Loa nes o ns f + Eq Cred ui it + Pe pment Leas rson ing a +M l Ch ortg ecki ng age Loan Ste s ve Cha T r irma age n an r dC E O-

Rep ubli c Ba nk

Republic Bank Has Been Serving the Medical Community for Over 25 Years. Please contact any of our medical finance specialists for your banking needs: SHARON MCGEE VP, TREASURY MANAGEMENT OFFICER (502) 560-8616

DAVID BUCHANON VP, SR PRIVATE BANKING OFFICER (502) 420-1821 (NMLS ID #419159)

ASHLEY MAST AVP, PRIVATE BANKING OFFICER (502) 394-4483 (NMLS ID #419157)

Stay Connected with GLMS between publications

facebook.com/GreaterLouisvilleMedicalSociety

@LouMedSociety

linkedin.com/groups/ Greater-Louisville-Medical-Society-1174357

Students’ Lounge A monthly feature written by the students of U of L Medical School 24

The Unspoken Lesson James Bradley

W

alking through the front doors of the Magnuson Clinical Center on the first day of my internship, I was still in a state of shock and awe. After hearing of all the great work that had come out of this institution for decades, I was still wondering, “How had I managed to get this job?” It was not until later that I would realize how much influence my time at the NIH would impact my future career choices. I began to think back to the arduous path I had traveled down just to arrive at this point in my life… Like many undergraduates who have their sights set on becoming a physician, I began doing research because I was told that it was highly recommended in order to get into medical school. However, it quickly became something that held more value to me than simply an activity that one must do in order to look good on a medical school application. I started to appreciate the scientific process and creativity found within the research community. It wasn’t until I got to the NIH though that I began to perceive the sheer breadth of research in medicine. While I had had some formal research training before arriving at the NIH, it wasn’t until I met Dr. Yun Chang that I truly felt I was being taught how to conduct research efficiently and accurately. Dr. Chang is an exemplary research scientist and an even better teacher. Even when I didn’t understand the concepts he taught me, his patience prevailed and he would devise a completely new explanation out of thin air. His abilities as a teacher have developed from his experience as a research scientist at the NIH for many years, where he has taught many students and postdocs who have come through the Clinical Infectious Disease Lab at NIAID. He had the uncanny ability to know how much work I could handle, because he always provided me with an adequate number of projects to work on such that there was never any down time. In our weekly meetings, everyone in the lab would discuss their work and argue about the best approach to proceed with their respective projects, and I found it to be an incredible learning opportunity to hear about how this group of scientists at the NIH conducted their research. Oftentimes I didn’t understand what they discussed, but Dr. Chang always encouraged me to ask questions and learn. The most gratifying lesson Dr. Chang taught me was an unspoken lesson, one that was never addressed directly but was ever present in his day-to-day work. I could see it in his work ethic and in his attitude. In my opinion, it is one of the qualities

LOUISVILLE MEDICINE

that has made him the successful scientist that he is today. He always came into the lab earlier than anyone else and was the last one to leave. His work had a deeper meaning to him than just a simple paycheck or a job title, and this fervor soon took hold of the other members of the lab. He had a strange sense of urgency and purpose in the way he carried out his work. He taught me that people must use their gifts to give back to society, and to encourage and push others to succeed. As a government employee, he truly believed it was his job to use his talents as a scientist to give back to society. Now that I’m in medical school, I feel that not all of my peers have that same sense of purpose behind their work that I saw every day at the NIH. The sense of purpose that Dr. Chang encouraged me to develop has pushed me to study many nights when I would have preferred to just go to sleep. His unspoken lesson has motivated me to pursue my work with zeal and focus. The guidance that I received from Dr. Chang has been lifealtering for me. He helped to identify and cultivate my interests in research, allowing me to return to the NIH several times. He has continually encouraged me to pursue a dual MD/PhD degree due to my interest in an academic career as a physician-scientist. Like Dr. Chang, I believe we are all given certain gifts or abilities that help shape what we can do best, but it is our choice to use those gifts to give back to society. Not everyone enjoys science or wants to become a doctor, but everyone can benefit from the gifts of others. Mentors adept at nurturing these gifts have a prodigious and everlasting influence on the lives of their students. The lessons that Dr. Chang taught me have not only helped me to succeed in medical school as a student, but have also laid the foundations for what I envision in my future career as a physician-scientist, a teacher and a mentor. His never-ceasing patience, his commitment to his work and his strong sense of duty are admirable. It is that to which I hold myself to. In retrospect, I now recognize and applaud the influence my time at the NIH with Dr. Chang has had on my life choice to become a physician-scientist. LM Note: James Bradley is a second-year medical student at the University of Louisville.

M

y grandmother could make a boot taste good. Even as a child, I would eat vegetables as long as she’d made them. She was also an infallible shopper with impeccable taste in dress clothes. My grandfather is the type of man you’ll never see angry. From his interactions with people in the town where I grew up, to helping raise my brothers and me, I can’t recall hearing him raise his voice once. The world is a steady place with them in it: unchanging, comfortable and constant. I must admit that although I have not even broached the subject, it makes me miserable even thinking about ruining a quiet dinner or summer afternoon by asking them how they want the end of their lives to look. Still, I know I must. The world we live and die in is not the world their grandparents lived and died in. There were no choices then, no machines that breathed for you, no pacemakers or defibrillators or sophisticated monitors that alarmed when things went wrong. People simply tried to accept the hand that fate gave them. Things are different now. Decisions are as various as the person making them, and medicine has progressed a great deal. We now have measures to extend a person’s life, or at least reduce the suffering involved with the transition. Yet with these myriad options, we have created quite a bit of confusion. Seven out of every 10 patients report that they’d like to die at home1. However, the reality is that only three actually do. Furthermore, eight out of 10 people with chronic disease say they’d like to avoid hospitalizations and intensive care when they are dying. Given these statistics, it should make it even more frustrating that Medicare spends nearly $50 billion each year caring for those in their final two months of life2 (which, I might add, is more than the annual budget for the Department of Education). It’s easy to see that the situation is out of hand. Studies have been saying the same for more than a decade. The heart of the issue lies, in my mind, in statistics more like this: Even when a person has an advance directive, there is only a 25 percent chance that his or her physician will know about it1. I could cite plenty more, but the truth is that physicians are not having sufficient conversations with their patients about what they want the end of their lives to look like. When we do have this talk, we get statistics like this one: A large-scale study of cancer patients found that costs were a third less for patients who had end-of-life discussions. There will, of course, be those who would argue that there is no price one could put on extending an individual’s life by a month. But I believe that statement misses the point: The reality is that many people near the end of life know it, and so do we, their doctors. It’s

how and when we present the choices available that is making all the difference. Our job as physicians is to preserve life. But let us make no mistake, in the future we will be judged for ignoring that we have, for many, extended the length of our stay on this Earth but reduced the quality of that stay. The truth is that most of us don’t want to spend our last moments amongst strangers, instrumented or tubed; we want to be at home with our loved ones. We don’t need surveys or statistics to tell us that. It may be a complicated time to die, but the basics are still the same. Most dying patients and their families just want to feel at least partly in control. However, it seems that they also want someone to guide them in making decisions, and they are begging for physicians to fill that role. Just as in reading an X-ray or initiating a workup, we all need a road map, a standard process. Eventually a national guideline will be created, but in the meantime we should all develop a personal algorithm that we follow in initiating conversations with people regarding their wishes for end-of-life care. It may even be that a good start only needs two goals. The first would be to initiate the end-of-life conversation with anyone over the age of 75. The second might be to always have the discussion earlier if a person’s disease state predicted fewer than 10 years’ survival. Of course the difficult part follows: What happens after the conversation has been started? There are resources to help: http://www.eperc.mcw.edu/EPERC, http://www.deathwithdignity.org/end-of-life-resources. However, I think that like any other conversation we have in medicine, it’s practice that will really ease the process – practice, and lots of patience. I fully expect my grandparents to have no idea what CPR and intubation are, or what they signify. They will have lots of questions. But I also know that when the conversation is over, they will feel more empowered and hopefully more at ease with their own ability to make such complex decisions. Ultimately, I hope I will be returning their love and teaching. I hope I’ll be showing them that the world really is as stable and consistent as they taught me it was. LM References: 1. FRONTLINE® (2010, November 10). “Facts & Figures.” pbs.org. Retrieved October 17, 2013 from www.pbs.org/ wgbh/pages/frontline/facing-death/facts-and-figures/. 2. CBSNews (2010, December 3). “The Cost of Dying.” cbsnews.com. Retrieved October 17, 2013 from www.cbsnews.com/8301-18560_162-5711689.html. Note: Ben Rogers is a fourth-year medical student at the University of Louisville. He is currently interviewing for internal medicine residency programs. December 2013

A monthly feature written by the students of U of L Medical School

Ben Rogers

Students’ Lounge

The Conversation With My Grandparents

25

O

n September 7, 2012 Marty Rosen gave the restaurant a 4-star review in a special to the CourierJournal, and on June 23, 2013 Louisville Magazine readers voted La Coop as Louisville’s best new restaurant. My purpose is not to rewrite either of these but simply to bring the restaurant to the attention of those of our readers who may have decided that the NULU scene, especially the restaurants at the east end of Market Street, is not for them. The restaurant is - as the word bistro translates - small and unpretentious with a truly French flair. Located on the first floor of the Green Building at 732 East Market, it replaced 732 Social and seats 34 to 40 people, so reservations are strongly recommended. (Reservations are also confirmed by the staff on the appropriate date.) Walk-ins are encouraged and a well stocked and gleaming bar provides a comfortable place to sit and wait for tables to become available. Our reservation for a party of four was for 6 p.m. on a Saturday evening. We parked at no charge in the well paved and lit parking lot adjacent to the building. Our guests had no difficulty with on-street parking. One couple was dining when we entered and shortly after our arrival the restaurant started to fill up. In less that 30 minutes the tables were full and there was an energy and a buzz that I enjoyed. It was not difficult to hold a conversation in spite of the proximity of other diners. This apparently is an improvement over the echo chamber effect that was a problem in the previous restaurant. My husband had heard that dinner portions were small and advised us all to consider appetizers (Hors D’oeuvres) prior to our main courses (Plats Principaux). This was another myth busted. Two of us ordered the crab cake appetizers and were amazed to (each) receive two piping hot, generously sized cakes full of flaky fresh crab meat. They were accompanied by a small, attractive bed of greens and a house made garnish. The gentlemen each ordered escargots, again piping hot, tender and flavorful. Apparently the garlic butter enhanced with gruyère cheese was out of this world and a substantial amount of extra bread was ordered so that not a drop would be wasted. We were all beginning to wonder how we would handle our main courses. The cassoulet and coq au vin were perfectly cooked and very substantial, and the steak frites were delicious. This was true eating for enjoyment and we took our time savoring the distinctive dishes. Only two of us had wine by the glass. The choices were very satisfactory and very French. The full list of alcoholic beverages is quite amazing for a restaurant of this size. It is a tribute to master sommelier Brett Davis, also one of owners. The

wine list alone is lengthy ranging from Champagne through a multitude of reds, whites, rosés to sweet dessert wines. All are listed by region, vintage and cépage (type of grape). The bar at La Coop then lists all other alcoholic beverages available. Daily there are created three “vins maison.” These consist of a red, a white and a rosé wine each fortified with grape brandy and infused with seasonal fruit flavors. A list of “kirs,” the traditional mix of white or sparkling wines with fruit liqueurs, is extensive and innovative. The full list of liqueurs is Eurocentric and includes three types of Pastis and also Absinthe. Beers are either French or Belgian with the exception of the first on the list - Roi de Bières petite, aka Bud Light classic Yankee Lager. The list of spirits is a global one. It struck me that if conversation were to lag during dinner at La Coop there is more than enough on the wine and bar list to generate all manner of interesting topics. Finally there was the question of dessert. Two of our intrepid group selected Tarte au Pommes à la mode (apple pie with ice cream - caramel sea salt) and Crèpe du Jour. This latter was the traditional barely sweetened thin batter crèpe garnished with apples, raisins and crème fraiche (sour cream). My only disappointment was that I could not obtain a decaf cappuchino. (Come to think of it, I would never expect a decaffeinated espresso drink in France so tip of the hat for authenticity.) Throughout the evening our service was impeccable and with a ratio of 1:2 wait staff to tables there was a smooth, efficient and yet very comfortable rhythm maintained - at least during the almost two hour period that we were there. The owners, Steven and Michael Ton, Chip Hamm and Brett Davis have realized their vision and with the high standard of culinary authenticity established by their excellent chef, Bobby Benjamin, most recently of the Seelbach’s Oakroom, the end result is for Louisvillians and out-of-towners alike to enjoy. Pricing is moderate; ambience is fun, French, intimate; noise level is acceptable. Given that the restaurant fills up very quickly, I doubt that it is much noisier at 11 p.m. than it was at 7:30 p.m. One downside is that the restaurant is no longer open for lunch. Dinner hours are: Tues-Thurs 5:30 p.m. to 10:30 p.m.: Fri-Sat 5:30 p.m.-11:30 p.m.; Bar opens at 5 p.m. On Tuesday , Wednesday and Thursday each week there are Prix Fixe dinners. Details are readily available on the website www.coopbistro.com, as is the entire menu and beverage listings together with other newsworthy items. Go. Enjoy. L

M

Note: Dr. Amin is a retired diagnostic radiologist.

RESTAURANT REVIEW La Coop Bistro à Vins 732 East Market Street Louisville KY 40205 502 410 2888 www.coopbistro.com

Reviewed by

Elizabeth A. Amin, MD December 2013

27

28

LOUISVILLE MEDICINE

Physicians in Print Anderson RJ, Dunki-Jacobs E, Callender GG, Burnett N, Scoggins CR, McMasters KM, Martin RC 2nd. Clinical evaluation of somatostatin use in pancreatic resections: Clinical efficacy or limited benefit? Surgery. 2013 Oct;154(4):755-60. PubMed PMID: 24074412. Barnett RE, Keskey RC, Linsky PL, Byam J, Mathis TJ, Cheadle WG. Tension-free Open Mesh Cooper’s Ligament Repair for Femoral Hernia. Am Surg. 2013 Sep;79(9):952-3. PubMed PMID: 24069997. Couceiro J, Sanders S, Cobb M, Manon-Matos Y, Banegas R. Retiform hemangioendothelioma of the finger: a case report. Hand Surg. 2013;18(3):439-41 .PubMed PMID: 24156596. Fowler JF Jr, Eichenfield LF, Elias PM, Horowitz P, McLeod RP. The chemistry of skin cleansers: an overview for clinicians. Semin Cutan Med Surg. 2013 Jun;32(2 Suppl 2):S25-7. PubMed PMID: 24156155. Fowler JF Jr. Routine skin care as prophylaxis and treatment. Semin Cutan Med Surg. 2013 Jun;32(2 Suppl 2):S15. PubMed PMID: 24156152. Gump WC, Mutchnick IS, Moriarty TM. Complications associated with molding helmet herapy for positional plagiocephaly: a review. Neurosurg Focus. 2013 Oct;35(4):E3. PubMed PMID: 24079782. Kowalski WJ, Dur O, Wang Y, Patrick MJ, Tinney JP, Keller BB, Pekkan K. Critical transitions in early embryonic aortic arch patterning and hemodynamics. PLoS ONE. 2013;8(3):e60271. PubMed PMID: 23555940.

Nguyen MD, Tinney JP, Yuan F, Roussel TJ, El-Baz A, Giridharan G, Keller BB, Sethu P. Cardiac cell culture model as a left ventricular mimic for cardiac tissue generation. Anal Chem. 2013 Sep 17;85(18):8773-9. PubMed PMID: 23952579. Shields LB, Kadner R, Vitaz TW, Spalding AC. Concurrent bevacizumab and temozolomide alter the patterns of failure in radiation treatment of glioblastoma multiforme. Radiat Oncol. 2013 Apr 25;8(1):101. PubMed PMID: 23618500 Spalding AC, Hawkins DS, Donaldson SS, Anderson JR, Lyden E, Laurie F, Wolden SL, Arndt CA, Michalski JM. The effect of radiation timing on patients with high-risk features of parameningeal rhabdomyosarcoma: an analysis of IRS-IV and D9803. Int J Radiat Oncol Biol Phys. 2013 Nov 1;87(3):512-6. PubMed PMID: 24074925. Ye F, Yuan FP, Li X, Cooper N, Tinney JP, Keller BB. Gene expression profiles in engineered cardiac tissues respond to mechanical loading and inhibition of tyrosine kinases. Physiol Records. 2013 Oct 2. LM 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 Ellen Hale by fax (502-736-6339) or email ([email protected]).

Kowalski WJ, Teslovich NK, Menon PG, Tinney JP, Keller BB, Pekkan K. Left atrial ligation alters intracardiac flow patterns and the biomechanical landscape in the chick embryo. Dev Dynamics. 2013 (in press). Larson GM. Presidential address for the Central Surgical Association: March 15, 2013: Practice of surgery in the next decade: The future is still bright. Surgery. 2013 Oct;154(4):64954. PubMed PMID: 24074403. Lee JJ, Huang J, England CG, McNally LR, Frieboes HB. Predictive modeling of in vivo response to gemcitabine in pancreatic cancer. PLoS Comput Biol. 2013 Sep;9(9):e1003231. Epub 2013 Sep 19. PubMed PMID: 24068909.

December 2013

29

The Test Drive

Kenneth C. Henderson, MD

A

mericans are reported to have a love affair with the automobile. I believe that I should qualify as a third-generation car lover. My affair started with a 1948 Jeep and has resulted in a lifetime of driving, collecting and restoring exotic cars. I have never driven or owned a Ferrari. I have never been interested in garage queens or cars that required expensive scheduled maintenance unrelated to use or mileage. I have recently retired for what I sincerely trust is the third and final time. I have tried several times to make out my bucket list to exclude automobiles; however, the list always seems to include a Ferrari. I accompany my charming and delightful wife, Kathy, to Chicago twice each year for shopping. My rewards are good company, walking exercise, fine dining and wine. In recent years, I have added a visit to an exotic car dealership on Rush Street just off North 30

LOUISVILLE MEDICINE

Michigan Drive near the Water Tower. It is a new car dealership for Bentleys and Lamborghinis. The dealership usually has other nearly new exotics in the showroom as well. However, on our most recent trip, a Ferrari was not represented. My wife is a cosmetics executive and has had the Chicago market over the years with two different companies. She loves the old Marshall Field’s store, and we always have lunch there in the seventh-floor Walnut Room. The food is still good, and the wine is even better. After splitting a bottle of wine for lunch, we left State Street walking to North Michigan Avenue. I lobbied for and won my second trip by my favorite dealership to inquire about the availability of a Ferrari. I did not plan to leave town without seeing a Ferrari. On arriving at the dealership, we were greeted by a nicely dressed salesman and soon by the man I recognized as the owner. He was smartly dressed in a European suit fashionably cut one size too small. He immediately asked, “Were you just in here yesterday? Are you the doctor from Louisville?” I answered “yes” to both questions,

but said I had not seen a Ferrari as yet. My wife and I were offered seats. He next opened a bottle of Champagne, and we all had two quick glasses. While he opened the second bottle, his salesman was showing my wife on the computer screen the various used Ferraris available in the warehouse. She selected her favorite, a nice red one, to be delivered to the dealership by its valet service. Of course, she was the first to insist that I drive the car.

enjoyed the distinct, magnificent exhaust sound of the Ferrari, but the panic caused by the onrushing street was magnified in the tunnel. By now, I had sweated through my white shirt and the underarms of my red sweater. Somehow, the trip back seemed less fearful and eventful, even though I continued to be terrified and bombarded by sound and motion. He continued to direct me the way the tower would talk in a stunned and bloodied pilot.

The selected car turned out to be a nearly new 2007 Ferrari 599 GTB that listed new for $275,000. It was a very well-optioned unit sporting ceramic brakes and a carbon fiber interior. It was also equipped with the paddle shifting automatic/manual transmission. It was a V12 front engine model boasting 620 horsepower. My wife, the young Indian salesman and the owner all insisted that I drive the car. I reported that I never drove my own car when I came to Chicago and would not like to drive this very powerful Ferrari on Michigan Avenue. I asked the salesman to simply take me for a spin, and I would be happy. He said that I must at least drive it around the block. He agreed to accompany me around the block in case I should require his assistance. It was a warm day, and I had already removed my jacket. I was beginning the cool sweat of excitement beneath my shirt and sweater.

Suddenly, he said, “We are here,” and I woke up and realized that the terror was over. I cannot recall the exact route we took back from Lake Shore Drive to the dealership on Rush Street. I could not believe we had safely made it. I did not even recognize the dealership building. I think I remember saying that I did not want to park the car since I did not know where it belonged. I suppose that he said that he could take it from here and would park it on the street. I can recall that he said, “We never allow or trust customers to park the cars.” He apparently did not seem to know that he had just taken a test drive with a blind man who had unsuspectingly drunk Champagne. When we walked in, Kathy was still drinking it and was casually talking with the owner. They were examining and discussing a designer handbag that he had purchased that morning for his wife. She did comment to me that she was puzzled that she’d seen me walk away from the building, instead of toward it, when I got out of the car. I just stared at her.

After starting the engine and a quick lesson on the art of paddle shifting, we were off. The first stop clearly indicated we were not destined to just go around the block, but were leaving Rush Street for North Michigan Avenue. The next two blocks were filled with cars, two large horse-drawn carriages and people coming into the street taking pictures of the red Ferrari as we inched along. We turned north on North Michigan Avenue but were stopped in mid-turn by cars and people, well after the light had turned red. Sometime in the midst of this horn-blowing, people swearing at an old man driving a new red Ferrari, and my anxiety and confusion, I suddenly realized that I did not have my contact lenses on my legally blind eyes. I have had three eye surgeries, cannot be corrected with regular lenses, and wear special hard/soft contacts that provide functional daytime vision. I generally do not wear my contacts when we are shopping for ladies’ clothing. My first fear reaction was to pull the Ferrari over, but there was no place to go, and my young copilot was already yelling for me to get it ON to beat the next light. In spite of my blind terror, I suddenly remembered from our walking that at the top of North Michigan Avenue that three street choices were coming at me. He had already picked the central tunnel that led to Lake Shore Drive and was rolling down the windows so that we could hear the 620 HP V12 engine exhaust roar. He yelled “Get on it!” again as we entered the tunnel and fishtailed down the incline into relative darkness. I cannot recall how many other cars were in the long tunnel. Next, he directed me into traffic as we merged onto Lake Shore Drive. After a couple of miles in the horrid blur of its traffic, he directed me off to the right, and we took the tunnel back to the left. I should have

The owner next introduced me to his young son and, in the same breath, said that the Ferrari 599 was the only Ferrari for me and that I could own it, delivered today, for $169,000. We thanked him. As we walked two blocks back to the Park Hyatt Hotel, I explained to Kathy that I had not had my contacts in for the test drive. I had left them with her in my coat, safely in their case. She exclaimed in disbelief. After she escorted me back to the hotel, I switched to my favorite Kentucky bourbon. This time it was a drink that was truly deserved. Undaunted, Kathy continued shopping for two more hours, while I collected myself in our hotel room. The search for my bucket list Ferrari – that work of art – continues. LM Note: Dr. Henderson is a clinical professor at the University of Louisville School of Medicine, Department of Pediatrics.

December 2013

31

WE WELCOME YOU GLMS

would like to welcome and congratulate the following physicians who have been elected by Judicial Council as provisional members. During the next 30 days, GLMS members have the

right to submit written comments pertinent to these new members. All comments received will be forwarded to Judicial Council for review. Provisional membership shall last for a period of two years or until the member’s first hospital reappointment. Provisional members shall become full members upon completion of this time period and favorable review by Judicial Council. LM

Candidates Elected to Provisional Active Membership Azadi, Ali (20539) Taraneh Yeganeh 401 E Chestnut St Ste 410, 40202 271-5999 Obstetrics/Gynecology 12 Shaheed Beheshti Med U 99

Hart, Anna (31528) Andrew Hart 4000 Kresge Way, 40207 502-897-8100 Internal Medicine 11 Weill Cornell Medical College 06

Johnson, Robert Ryan (32403) Krista R. Johnson 9070 Dixie Hwy Ste 6, 40258 502-271-3236 Family Medicine LECOM 05

Moyer, Sarah (32352) James Moyer 215 Central Ave Ste 100, 40208 502-588-8720 Family Medicine Temple U 10

Stone, Thomas William (31659) Leslie Stone 120 N Eagle Creek Dr Ste 500 Lexington KY, 40509 859-263-3900 Ophthalmology 01,12 State U of New York 95

32

LOUISVILLE MEDICINE

“When it comes to Meaningful Use, athenahealth did all the legwork… and then they made it easy for me to do.” –Dr. Reavis Eubanks

This is how Dr. Eubanks

got paid for Meaningful Use.

A

fter practicing medicine 35 years, Dr. Reavis Eubanks knew it was time for an EHR. As a solo physician, he needed an easy transition and an effective way to begin earning up to $44,000 in Medicare incentive payments. athenahealth helped Dr. Eubanks go from paper to payment in just six months. With guidance every step of the way and proven, cloud-based services.  Best in KLAS EHR*  Free coaching and attestation

 Seamless clinical workflow  Guaranteed Medicare payments**

85% of eligible athenhealth providers attested to Stage 1 Meaningful Use. And we’re ready for Stage 2.

Visit athenahealth.com/LLS or call 800.981.5085 *ambulatory segment for practices with 11-75 physicians ** If you don’t receive the Federal Stimulus reimbursement dollars for the first year you qualify, we will credit you 100% of your EHR service fees for up to six months until you do. This offer applies to HITECH Act Medicare reimbursement payments only. Additional terms, conditions, and limitations apply.

Cloud-based practice management, EHR and care coordination services

NortoN orthopaedic care welcomes Joseph W. Greene, M.D. Joseph w. Greene, m.d., is an orthopaedic surgeon with a special interest in sports injuries, partial and total knee replacement, complex knee reconstruction and orthopaedic trauma. he earned his medical degree from the University of louisville, where he also completed his residency training in orthopaedic surgery. he then completed a fellowship in adult joint reconstruction and sports medicine at the insall scott Kelly institute in New York city.

dr. Greene sees patients at Norton orthopaedic specialists on the Norton Brownsboro hospital and Norton suburban hospital campuses.

For more information or to refer a patient to dr. Greene, call Norton orthopaedic specialists at (502) 394-6341.

Joseph W. Greene, M.D. orthopaedic surgeon

NO BELLS HERE Mary G. Barry, MD

I

Louisville Medicine Editor [email protected]

n twenty minutes it would be 1985, and I was standing in the MEC at Grady, surveying the wreckage. For holidays at Grady we housestaff were on the religious schedule: the Jews and Hindus very kindly took Christmas (we had a whole four days off!) and we Christian types returned the favor for New Year’s. David Akin had traded with me; his parting words were, “If you’re kissing at midnight at Grady, I want to be the first to hear about it.”

tonight, “ I told him, “but the ambulance brought her in unconscious and her heart keeps going into a real fast rhythm but so far when we work on her, she comes back around. What can you tell me about your Pauletta – has she fainted or had heart troubles before?”

But I was eyeing no one as a possible kisser. I had hurried into a Heart Room that was knee deep in rhythm strips. As the admitting intern for GI, Renal, Neuro, and Oncology, I had just been called to work up a 19 year old girl who kept trying to die before I could even speak to her. She was intubated and being watched warily by a nurse and the RT, who was bagging her. She looked pale and sick and young; her mascara had run down her cheeks and her fingers were almost purple, while her nails were bright pink. Martin, my resident for the night, was huddled over her EKG with a heart guy I did not know, but who had a beautiful Nigerian accent. Martin said, “Mary this kid is 19 and was Found Down and keeps going into Atrial Flutter 1:1 and we shock her out of it, go see if her Mom is here that’s all we got from EMS.” I looked at her name again (wondering why isn’t the nice Cardiology intern doing this job - why me Miss Subspecialty? Sure seems like a heart patient) but went out to the triage/ waiting room. We hated doing that - everybody said Doctor! Doctor! I’ll just take a minute Doctor! – we felt exposed out there.

My heart sank. “ I don’t know, yet – I wish I could tell you that but she only just got here – she’s never been sick? Has she looked well lately? Looks kind of thin.”

“Anybody here for Pauletta?” I asked, and a stumpy little man stood up. “My granddaughter,” he said, and I shook his hand and took him back inside the door. “I don’t know what you know about her

He said, “She was sposed to work tonight till 9 and then had a date and she has never been sick a day in her life. Is she gonna be ok?”

“No, she never eats more’n a bite, never has, she’s a good girl, she works and tryin’ to save up and get her a car. They called me up to her job and said some man found her out in the lot and then her date showed up and he was just - well, we just don’t know what, that’s all.” He was a talker. That was good, but I hated to see how distressed he was. “How long she been living with you?” “Just a couple months, her parents, they joined up missionaries and she did not want to go, she’s my stepdaughter’s but I always took a shine to her so I said ok.” I nodded. “Anybody in her family got any heart problems – like pacemakers, things like that?” He didn’t know. He just knew she was an awful good girl, so I said I’d be back after while, go check on her, and touched his arm a moment and left. Back in the Heart Room they were putting in a pacemaker and a chest tube. I looked at Martin in alarm and he said, “We couldn’t bag her and we stuck her chest and air came out and you should see her Xray,”

and I looked at the light box and swore. Her whole chest was whited out with something, her heart was as big as a gourd, and the only good lung was way up high on the right. I got around to her left side and listened for air but heard only my own breathing; nothing moving in her lung at all. I felt for a pulse; she had a good femoral, still about 150. But she had a hard mass above it, had to be something like sarcoma, hard as a rock and as big as a lemon. “Martin, did you all feel this?” I asked. “Well - she’s admitted to Onc, isn’t she?” I glared at him. He lifted his hands and said, “Look - she’s got more of those on her chest wall and she might not make it upstairs. I’m sorry you missed the tubing part, thanks for talking to the family. You get them back here, get her No-Code, get her settled, I got to go admit three more, call me.” I said Fine. Her nurse and I got her quick straightened up, and I went back to her grandpa. “Mr. Gordon,” I said, “you can come see her now but I have real bad news for you – what she has is real bad.” He shrank a bit and I took his arm. “Come back here with me and let’s see her,” and (continued on page 40)

Speak Your Mind 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. 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. December 2013

35

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 three of their posts with Louisville Medicine readers.

Breathe In……and Exhale Neagum Patel, MD

T

here is not a mystery here, just wanted to share a case I had that at least for the first time since the start of 2nd year, I was scared and against the ropes…… Woman, 42 y/o with history of asthma/ COPD (she smokes too - I suppose she is allowed to have both) presents in extremis (at 10 p.m., evening shift #3 in a row and needless to say my counterpart and I for the past 3 days have been getting WORKED). Had albuterol treatment, got nasally intubated by EMS, presents to Room 9, difficult to bag, SATS in the 80s. I go full force, no messing around: albuterol, Mag 2 grams IV, Epi 0.5 mg subq, Solumedrol 125 mg IV and went ahead with dose of Ketamine 100 mg IV as the patient was hypoxic and in extremis, but nonetheless awake during this whole experience and why not?? Ketamine is a sedative and bronchodilator right?…. Bagging becomes a little easier, SATs are 95%, patient appears better, CXR is R main stem, withdraw, reshoot my chest, tube is good. Paged MICU, Done Right? “Dr. Patel, can you go speak to the family?” “Yes, but of course.” (Although at that time I’m thinking, Sir I could use a minute myself ya know??? That followed by internal expletives.) I talk to the family, let them know things have calmed down, she is intubated and we appear to be heading in the right direction. “Dr. Patel to Room 9 Please,” on the overhead. I return to find my patient satting back in the 80s, RT’s telling me she is impossible to bag. Check my trachea, it’s midline, shoot a quick chest to check for a pneumo, its rotated but everything appears to be shifted to the Left. Yell for pneumodarts and reshoot my chest, I have lung markings all the way down bilaterally, nothing appears to be shifted at this time. I’ve got nothing. SATs now in the 70s and falling. I order another dose of Epi, another dose of ketamine, and go with propofol drip (another lovely Bronchodilator). Patient is agitated, fighting the tube and bagging. She calms down, SAT’s improve, try to put her on the vent, but peak airway pressures are too high, vent won’t support it. Fine, vecuronium 10mg to aid in tolerating the vent - we’re gonna be at a happy place now right?

Attending and one of the three RT’s want to re-intubate, change out the nasal: let’s switch it, maybe it’s kinked, may be too small. Oh fantastic, because this woman with the short neck, and tight lungs, desats in seconds, is just the type of patient I want to exchange a nasal tube on. We first think, we’ll let’s look and see if we can pass a Bougie past our tube that’s already in place. Neither the attending nor I find success. We can get it to the glottis but there just isn’t enough room. Ok fine, glydescope is in. I have great visualization (after I grabbed the tooth I knocked out OOPS). We say alright let’s just do this. We pull the nasal airway, place the 8.0 tube without much issue (Thank You Sweet Baby Jesus.) Try the vent, NOTHING. Peak airway pressures are STILL too high. By this time Dr. Jason Mann arrives (Pulm Fellow), says it’s either OR for inhalational therapy or ECMO. Patient went to the OR for 4 hours on isoflurane inhalation therapy and subsequently was able to be placed on the vent. Now that’s a win folks (except for the tooth, small casualty in the battle, which by the way came out when the Yankauer of all things nudged it). Talking with Dr. Mann later he commended me for all that I had done without hesitation, didn’t have much to add because once you’re at that point you’re just praying something would work. Epi drip/Ketamine drip were other ideas. Bougie nasally and then standard intubation was another great idea in case I had failed in exchanging the tube I at least had the option of nasally intubating over it. In looking through this on Rosens they didn’t have much to add to be honest. They make some anecdotal remarks about ECMO and Isoflurane ironically but not more than a small blurb - I’ll open the floor for discussion, criticisms, comments. Whew. LM Note: Dr. Patel is a second-year resident in Emergency Medicine at the University of Louisville.

Wrong. Patient still can’t be put on the vent. By this time MICU is down there, the upper level asks me, “well did you give dsk;ajf;akfs” I don’t know exactly what he said as I stopped listening immediately because I gave everything and 30 seconds later he was dumbfounded as well; told him to call his Fellow because this is beyond us. Meanwhile the lovely RT is tiring out because she has been bagging this whole time a patient who really doesn’t bag well. December 2013

37

From the Blogosphere Pelvic Mass!!

Robert Vichich, MD

24

year old Hispanic female with no past medical history comes in from Planned Parenthood with a pelvic mass that has been expanding for the past 14 months. Today she states that she was having significant amount of LLQ pain along with nausea and vomiting. She denies any fevers chills, constipation diarrhea, urinary difficulty, vaginal bleeding or discharge-No past medical or surgical history; never been pregnant; no meds or allergies Normal vitals; Normal physical other than scant white vaginal discharge and a large firm mass on the left side of the cervix and left adnexa. You would feel the mass as well on abdominal exam. Normal labs ( CBC, CMP, UA, lipase, HcG, KOH, wet prep) Ct of the abdomen and pelvis shows this: (images to the right) What is that going on in the pelvis? Ct read as a Dermoid cyst (teratoma)- and yes it was read as fat, hair, teeth. So what do we do with it? Ob was consulted as it was the middle of the night and

scheduled the patient to return to clinic in the am and scheduled her to have it taken out within the week. Dermoid cyst is a cystic teratoma that contain mature skin, hair, sweat glands, fat, bone, nails, teeth. Because it contains mature tissue it is commonly benign but you can have a malignant version, typically coming from squamous cell carcinoma. It does increase the risk of torsion. Surgery is required. LM Note: Dr. Vichich is a third-year resident in Emergency Medicine at the University of Louisville.

“Shortness of Breath” Benjamin Favier, MD

M

an, 35 y.o. presents with Shortness of Breath, looks very uncomfortable and reports symptoms have been gradually getting worse. Exam shows thin patient with slightly decreased breath sounds on the right, Tachypneic and tachycardic. Due to recent visit for similar symptoms and complex medical history he was initially ordered a CT chest. We were called by Radiology regarding tension pneumothorax with shift of the mediastinum to the left. Patient returned to ED bed. Still tachycardic, borderline hypotensive, and starting to develop some hypoxia in the low 90’s. Chest XR obtained after CT. Needle decompression right mid-clavicular line 2-3 intercostal space as bridge to chest tube. Vitals and hypoxia improved slightly. Surgery placed right sided chest tube with resolution of pneumothorax. Follow-up CXR showed good placement. Patient was admitted. Learning points from a true emergency: 1) Trust your Physical Exam! If breath sounds are decreased or absent, there is probably a reason. Keep your suspicion high! 2) Needle Decompression is an option for unstable patients or simply place a chest tube. 38

LOUISVILLE MEDICINE

3) Chest XR is fast and should be second if patient is stable. 4) DON’T skip to CT. I think it important to learn from others’ mistakes. While sometimes we know we will get a CT and it will be faster just to order it alone, there are reasons we must follow the protocol – like this one. 5) Be available for procedures. Although I wasn’t the first one to evaluate the patient I offered to do the needle decompression and the attending let me do it. 6) Be on high alert when at Jewish! Had a different level of awareness there – now I know, I won’t forget this one for a while. Good cases come in everywhere. LM

Note: Dr. Favier is a second-year resident in Emergency Medicine at the University of Louisville.

business card gallery

CR

Canfield Realty Group Steve Canfield P: (502) 245-4428 C: (502) 649-5687 [email protected]

11802 Brinley Ave., Suite 201 Louisville, KY 40243 www.canfielddevelopment.com

December 2013

39

Advertisers’ Index Athena Health

33

www.athenahealth.com Avery Custom Exteriors

1, 39 16 26 IFC 28

8

www.murphypaincenter.com

6

Practice Administrative Systems

39

ProNational Insurance

10

Republic Bank & Trust Co

23

Retina Associates of Kentucky / Louisville

14

www.retinaky.com IBC

www.merkelykendrick.com Murphy Pain Center

PNC

www.republicbank.com

www.glms.org Merkley Kendrick Jewelers

36

www.proassurance.com 4

www.magmutual.com Medical Society Employment Services

Physicians Medical Center

www.pasmedicalbilling.com

www.painstopshere.org MAG Mutual Insurance Co.

OBC

pnc.com/cashflowinsight

www.kentuckyonehealth.org Kentuckiana Pain Specialists

The Pain Institute

www.pmcindiana.com

www.hallrender.com Kentucky One Health

34

www.thepaininstitute.com

www.elmcroftseniorliving.com Hall Render Killian Heath & Lyman

Norton Orthopaedic Care www.nortonhealthcare.org

www.canfielddevelopment.com Elmcroft

19

www.niai.com 39

www.averycustomexteriors.com Canfield Development

National Insurance Agency

Semonin (Joyce St Clair)

39

www. JoyceStClair.semonin.com 12

State Volunteer Mutual Insurance Co

2

www.svmic.com

Doctors’ Lounge

40

(continued from page 35)

how far away were her parents.

told him about the tube and what to expect, and then I told him that we thought she had a bone cancer that had spread to her chest, and was making her heart misbehave. I stood there with him and he smoothed her hair and held her hand for awhile, and I told him we could only make her comfortable, and if he wanted anybody else to come see her they should, because it would be wrong to keep her alive on machines for a long time even if we could – because we could tell already that the cancer had spread too far. All this I told him in little doses, letting him think in between, and I finished my exam as we spoke. Then I asked him about

He said, “They’re in Africa and they won’t come home, they don’t hold with doctors.”

LOUISVILLE MEDICINE

Suddenly it was all too clear. She probably had never been to the doctor, just soldiered on alone. Her little grandpa had not asked her any questions; he’d been glad just to have her. I said, ‘Then you and I will take care of her, we can give her some morphine tonight, and you can get anybody you like to come sit with you, and in the morning maybe we will take this tube out and see if she can breathe enough to talk to you some, but I won’t let her suffer.”

He said ok, and I shook his hand some more, but then I had to apologize and go: to get all that done and answer my beeper and then go admit the next one, and the next, and so on. It was not a Happy New Year. 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.

oyster perpetua l d ate jus t ii

rolex

oyster perpetual and datejust are trademarks.

Greater Louisville Medical Society 101 WEST CHESTNUT STREET LOUISVILLE, KY 40202

PRSRT STD U.S. POSTAGE PAID LOUISVILLE, KY PERMIT NO. 6

DISTINCTION. EXCELLENCE. SKILL. The physicians at The Pain Institute are Board-Certified Anesthesiologists who are all Fellowship-Trained and Board-Certified in Pain Management. They use knowledge, experience and state-of-the-art medical technology to provide relief to patients who suffer from debilitating pain related conditions. 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