V': t' Digitized by the Internet Archive in 2016 ) https://archive.org/details/journaloftenness8311tenn Vol. 83, No. 1 • January, 1990 T0ZIZ aw ' 9 J oniT -4 I ^ a ■4S 9U99JS S TIT AJBjqiq aouaiog qu9m:iJ^d9a sx^T^^S -T 0-86 6 lournol of the mCDICAl AlfOCIATIOn r ^ HEALTH SCIENCES LIBRARY UNIVERSITY OF MARYLAND BALTIMORE JAN 30 1990 SECU NOT TO CIRC. ; V y p TENNESSEE MEDICAL ASSOCIATION 155th Annual Meeting April 4-7, 1990 Hyatt Regency Hotel Knoxville, Tennessee Let us cut you a deal! THE TMA MEDICAL PLAN For a limited time only, we will reward you for allowing us to quote the TMA Medical Plan for your firm. Our sales representative will deliver with the quotation a valuable " Parker Pocket Knife." (Sorry, just one per firm.) This specially designed Medical Plan offers unique benefits at Competitive Rates!!! How it Works For Deductible Options: • $100.00 • $250.00 • $500.00 • $1,000.00 Plan pays 80% of the first $5,000 of eligible expenses in the calendar year. Member pays 20%. Plan pays 1 00% of the eligible expenses in a calendar year up to a maximum of $1 ,000,000. The Special Plan Benefits • 100% Special Out-Patient Surgical Benefit • 100% of First $300. - Special Out-Patient Accidental Injury Benefit • $5.00 Per 90 Day Supply - Special Maintenance Prescription Drug Plan • Up to 10% Discount on your portion of the Flospital Bill at many hospitals statewide • Special Surviving Dependent Benefit For A Quotation, Call Your Representative: Administered by: THE TMA ASSOCIATION INSURANCE AGENCY, INC. RONNIE McCLISTER, CLU, ChFC GORDON LOWE, CLU The TMA Association Insurance .Agency, Inc. 822 McCallie Avenue P.O. Box 1109 Chattanooga, TN 37401 1-800-347-1108 Local 267-0915 WE LOOK FORWARD TO HEARING FROM YOU! 1060 (8-88) jeumol of Hie lenne//ee mecNccil o//ockiliofi Vol. 83, No. 1 January, 1990 OFFICE OF PUBLICATION 1 12 Louise Ave., Nashville, 37203 (615) 327-1451 EDITOR John B. Thomison, M.D. 230 25th Ave. North Nashville, 37203 BUSINESS MANAGER L Hadley Williams MANAGING EDITOR Jean Wishnick TMA OFFICERS PRESIDENT William O. Miller, M.D. 939 Emerald Ave. Knoxville, 37917 PRESIDENT-ELECT Hamel B. Eason, M.D. 4628 Peppertree Lane Memphis, 38117 CHAIRMAN, BOARD OF TRUSTEES James T. Craig, Jr., M.D. 616 W. Forest Jackson, 38301 TMA EXECUTIVE STAFF EXECUTIVE DIRECTOR L. Hadley Williams ASSOCIATE EXECUTIVE DIRECTOR Donald H. Alexander DIRECTOR OF STUDENT EDUCATION FUND AND HEALTH SERVICES William V. Wallace DIRECTOR OF EDUCATION AND MEETING SERVICES John H. Grant Jr. DIRECTOR OF GOVERNMENTAL AND LEGISLATIVE AFFAIRS Charles W. Cato II EXECUTIVE ASSISTANT Mark Greene DIRECTOR OF COMMUNICATIONS Russell E. Miller Jr. STAFF ATTORNEY Dennis Lord Journal of the Tennessee Medical Association ISSN 0040-3318 Published monthly under the direction of the Board of Trustees for and by members of the Tennessee Medical Association, a nonprofit organization with a definite membership for scientific and educational purposes. Devoted to the interests of the medical profession of Tennessee. This Association does not officially endorse opinions presented in various papers published herein. Advertisers must conform to policies and regulations established by the Board of Trustees of the Tennessee Medical Association. Subscriptions (nonmembers) $20 per year for US, $26 for Canada and foreign. Single copy $2.50. Payment of Tennessee Medical Association membership dues includes the subscription price of this Journal. Copyright 1990, Tennessee Medical Association. All material subject to this copyright appearing in the Journal may be photocopied for non- commercial scientific or educational use only. Second Class postage paid at Nashville, TN. POSTMASTER: Send address changes to Journal of the Tennessee Medical Association, 1 1 2 Louise Ave. , Nashville, TN 37203. coiiicnl/ Original Contributions 9 Medical Grand Rounds and Prescribed Credit by the American Academy of Family Physicians — Raymond Massengill, Jr., Ed.D.; Leo Harvill, Ph.D. 11 Remote Metastases From Uveal Melanoma — Timothy Powers, M.D.; Rodolfo Laucirica, M.D.; Sandra Brooks, M.D.; Sophie Leopold, MRS, CT (ASCP); Michael Whitson, M.D., James Earn urn, M.D. 15 Cutaneous Alternaria Infection in a Patient on Chronic Corticoste- roids— Richard M. Sneeringer, M.D.; David W. Haas, M.D. 18 Colonoscopic Removal of a Gallstone Obstructing the Sigmoid Co- lon— Shauna R. Roberts, M.D.; Cindy Chang, M.D.; Todd Chapman, M.D.; Paul G. Koontz, Jr., M.D.; Gerald O. Early, M.D. Regular Features 20 Trauma Rounds — Recognition of the Subtle Signs of Child Abuse 22 Vanderbilt Morning Report — A Case of Cyanosis Without Hypoxemia; A Case of Syncope in the Church Choir 24 Health and Environment Report — Disposal of Infectious Wastes in Sanitary Landfills 25 Medicolegal Junction — Reach for the Moon: The TMA-TBA Code of Cooperation 27 Loss Prevention Case of the Month — Help Needed — Not Called For TMA Organizational 40 Highlights of the TMA Board of Trustees Meeting — October 15, 1989 43 IMPACT Members — 1989 President’s Page 31 Emotions and Perceptions in a Postop Waiting Room Editorials 32 A Time for Hope— A Time for Danger 34 CME for Credit 35 Looking Back — and Forth Departments 37 in Memoriam 38 New Members 38 Personal News 38 PRA Recipients 39 Announcements 48 Continuing Medical Education Opportunities 51 Placement Service 52 Information for Authors 52 Advertisers in this Issue 3 YOCON’ YOHIMBINE HCI Description: Yohimbine is a 3a-15a-20B-17a-hydroxy Yohimbine-16a-car- boxylic acid methyl ester. The alkaloid is found in Rubaceae and related trees. Also in Rauwolfia Serpentina (L) Benth. Yohimbine is an indolalkylamine alkaloid with chemical similarity to reserpine. It is a crystalline powder, odorless. Each compressed tablet contains (1/12 gr.) 5.4 mg of Yohimbine Hydrochloride. Action: Yohimbine blocks presynaptic alpha-2 adrenergic receptors Its action on peripheral blood vessels resembles that of reserpine, though it is weaker and of short duration. Yohimbine's peripheral autonomic nervous system effect is to increase parasympathetic (cholinergic) and decrease sympathetic (adrenergic) activity. It is to be noted that in male sexual performance, erection is linked to cholinergic activity and to alpha-2 ad- renergic blockade which may theoretically result in increased penile inflow, decreased penile outflow or both. Yohimbine exerts a stimulating action on the mood and may increase anxiety. Such actions have not been adequately studied or related to dosage although they appear to require high doses of the drug Yohimbine has a mild anti-diuretic action, probably via stimulation of hypothalmic centers and release of posterior pituitary hormone. Reportedly, Yohimbine exerts no significant influence on cardiac stimula- tion and other effects mediated by B-adrenergic receptors, its effect on blood pressure, if any, would be to lower it; however no adequate studies are at hand to quantitate this effect in terms of Yohimbine dosage, indications: Yocon^ is indicated as a sympathicolytic and mydriatric. It may have activity as an aphrodisiac. Contraindications: Renal diseases, and patient's sensitive to the drug. In view of the limited and inadequate information at hand, no precise tabulation can be offered of additional contraindications. Warning; Generally, this drug is not proposed for use in females and certainly must not be used during pregnancy. Neither is this drug proposed for use in pediatric, geriatric or cardio-renal patients with gastric or duodenal ulcer history. Nor should it be used in conjunction with mood-modifying drugs such as antidepressants, or in psychiatric patients in general. Adverse Reactions; Yohimbine readily penetrates the (CNS) and produces a complex pattern of responses in lower doses than required to produce periph- eral a-adreneigic blockade. These include, anti-diuresis, a general picture of central excitation including elevation of blood pressure and heart rate, in- creased motor activity, irritability and tremor. Sweating, nausea and vomiting are common after parenteral administration of the drug.i '2 Also dizziness, headache, skin flushing reported when used orally. '' ■3 Dosaga and Adminlstaation; Experimental dosage reported in treatment of erectile impotence. ^ 'S '* 1 tablet (5.4 mg) 3 times a day, to adult males taken orally. Occasional side effects reported with this dosage are nausea, dizziness or nervousness. In the event of side effects dosage to be reduced to Va tablet 3 times a day, followed by gradual increases to 1 tablet 3 times a day. Reported therapy not more than 10 weeks.3 How ^ppiiod: Oral tablets of Yocon® 1/12 gr. 5.4 mg in 2. bottles of 100’s NDC 53159-001-01 and 1000’s NDC 53159-001-10. References: 1. A. Morales et al., New England Journal of Medi- cine: 1221 . November 12, 1981 . Goodman, Gilman — The Pharmacological basis of Therapeutics 6th ed., p. 176-188. McMillan December Rev. 1/85. 3. Weekly Urological Clinical letter, 27:2, July 4, 1983. 4. A. Morales et al. , The Journal of Urology 1 28; 45-47, 1982. Rev. 1/85 AVAILABLE EXCLUSIVELY FROM PALISADES PHARMACEUTICALS, INC. 219 County Road Tenafly, New Jersey 07670 (201) 569-8502 1-800-237-9083 4 Each capsule contains 5 mg chlordiazepoxide HCLand 2.5 mg clidinium bromide. Please consult complete prescribing information, a summary of which follows: * Indications: Based on a review of this drug by the National Academy of Sciences— National Research Council and/or other information, FDA has classified the indications as follows: "Possibly” effective: as adjunctive therapy in the treatment of peptic ulcer and in the treatment of the irritable bowel syndrome (irritable colon, spastic colon, mucous colitis) and acute enterocolitis. Final classification of the less-than-effective indicabons requires further investigation. Contraindications: Glaucoma; prostatic hypertrophy, benign bladder neck obstruction; hypersensitivity to chlordiazepoxide HCI and/or clidinium Br. Warnings: Caution patients about possible combined effects with alcohol and other CNS depressants, and against hazardous occupations requiring complete mental alertness (e g., operating machinery, driving). Usage in Pregnanof: Use of minor tranquilizers during first trimester should almost always be avoided because of increased risk of congeni- tal malformations as suggested in several studies. Consider possibility of pregnancy when instituting therapy. Advise patients to discuss therapy if they intend to or do become pregnant. As with aU anticholinergics, inhibition of lactation may occur. Withdrawal symptoms of the barbiturate type have occurred after discontinuation of benzodiazepines (see Drug Abuse and Dependence). Precautions: In elderly and debilitated, limit dosage to smallest effective amount to preclude ataxia, oversedation, confusion (no more than 2 capsules/day initially; increase gradually as needed and tolerated) . Though generally not recommended, if combination therapy with other psychotropics seems indicated, carefully con- sider pharmacology of agents, particularly potentiating drugs such as MAO inhib- itors, phenothiazines. Observe usual precautions in presence of impaired renal or hepatic function. Paradoxical reactions reported in psychiatric patients. Employ usual precautions in treating anxiety states with evidence of impending depres- sion; suicidal tendencies may be present and protective measures necessary. Variable effects on blood coagulation reported very rarely in patients receiving the drug and oral anticoagulants; causal relationship not established. Inform patients to consult physician before increasing dose or abruptly discontinuing this drug. Adverse Reactions: No side effects or manifestations not seen with either com- pound alone reported with Librax. When chlordiazepoxide HCI is used alone, drowsiness, ataxia, confusion may occur, especially in elderly and debilitated; avoidable in most cases by proper dosage adjustment, but also occasionally observed at lower dosage ranges. Syncope reported in a few instances. Also encountered; isolated instances of skin eruptions, edema, minor menstrual irreg- ularities, nausea and constipation, extrapyramidal symptoms, increased and decreased libido— aU infrequent, generally controUed with dosage reduction; changes in EEG patterns may appear during and after treatment; blood dyscrasias (including agranulocytosis), jaundice, hepatic dysfunction reported occasionaUy with chlordiazepoxide HCI, making periodic blood counts and liver function tests advisable during protracted therapy. Adverse effects reported with Librax typical of antichohnergic agents, i.e., dryness of mouth, blurring of vision, urinary hesi- tancy, constipation. Constipation has occurred most often when Librax therapy is combined with other spasmolytics and/or low residue diets. Drug Abuse and Dependence: Withdrawal symptoms similar to those noted with barbiturates and alcohol have occurred foUowing abrupt discontinuance of chlor- diazepoxide; more severe seen after excessive doses over extended periods; milder after taking continuously at therapeutic levels for several months. After extended therapy, avoid abrupt discontinuation and taper dosage. Carefully supervise addiction-prone individuals because of predisposition to habituation and dependence. Roche Products P.t 0288 Roche Products Inc. Manati, Puerto Rico 00701 joufMlof Hie lenntt//ee mcdkol <i//e€iolion Vol. 83, No. Q- February, 1990 OFFICE OF PUBLICATION 1 12 Louise Ave., Nashville, 37203 (615) 327-1451 EDITOR John B. Thomison, M.D. 230 25th Ave. North Nashville, 37203 BUSINESS MANAGER L. Hadley Williams MANAGING EDITOR Jean Wishnick TMA OFFICERS PRESIDENT William O. Miller, M.D. 939 Emerald Ave. Knoxville, 37917 PRESIDENT-ELECT Hamel B. Eason, M.D. 4628 Peppertree Lane Memphis, 38117 CHAIRMAN, BOARD OF TRUSTEES James T. Craig, Jr., M.D. 616 W. Forest Jackson, 38301 TMA EXECUTIVE STAFF EXECUTIVE DIRECTOR L. Hadley Williams ASSOCIATE EXECUTIVE DIRECTOR Donald H. Alexander DIRECTOR OF STUDENT EDUCATION FUND AND HEALTH SERVICES William V. Wallace DIRECTOR OF EDUCATION AND MEETING SERVICES John H. Grant Jr. DIRECTOR OF GOVERNMENTAL AND LEGISLATIVE AFFAIRS Charles W. Cato II EXECUTIVE ASSISTANT Mark Greene DIRECTOR OF COMMUNICATIONS Russell E. Miller Jr. EXECUTIVE ASSISTANT Marty Vaughn Journal of the Tennessee Medical Association ISSN 0040-3318 Published monthly under the direction of the Board of Trustees for and by members of the Tennessee Medical Association, a nonprofit organization with a definite membership for scientific and educational purposes. Devoted to the interests of the medical profession of Tennessee. This Associotion does not officially endorse opinions presented in various papers published herein. Advertisers must conform to policies and regulations established by the Board of Trustees of the Tennessee Medical Association. Subscriptions (nonmembers) $20 per year for US, $26 for Canada and foreign. Single copy $2.50. Payment of Tennessee Medical Association membership dues includes the subscription price of this Journal. Copyright 1990, Tennessee Medical Association. All moterial subject to this copyright appearing in the Journal may be photocopied for non- commercial scientific or educotional use only. Second Class postage paid at Nashville, TN. POSTMASTER: Send address changes to Journal of the Tennessee Medical Association, 1 12 Louise Ave., Nashville, TN 37203. content/ Original Contributions 63 Paramedic and Emergency Medical Technician Ciinicai Encounter Management System for Tennessee — Paul S. Auerbach, M.D., M.S.M. 71 The Foul Smelling, Removable Tonsillar Concretion; A Poorly Ap- preciated Manifestation of Colonization With Actinomyces — Abra- ham Verghese, M.D.; Cedric Fernando, M.D.; Donna Roberson, B.S.; Constantino Diaz, M.D.; James Farnum, M.D. Regular Features 74 Trauma Rounds — Trauma in Pregnancy 77 Radiology Case of the Month — CT Scan of the Abdomen in the Eval- uation of Splenic Infarction 79 Vanderbilt Morning Report — A Fatal Case of Hiccups; A Case of Goodpasture’s Disease and Interstitial Pulmonary Infiltrates 82 Health and Environment Report — Tuberculosis in Tennessee: Cur- rent Trends and Program Update 84 Loss Prevention Case of the Month — Continuing Supervision of Staff — A Necessity Special Features 85 Minutes of the Tennessee State Board of Medical Examiners Meet- ings— August 23, 1989 and October 11, 1989 86 Minutes of the Tennessee State Board of Medical Examiners Meet- ings— October 3-4, 1989 President’s Page 93 Looking for a Silver Lining Editorials 94 Solidarity 96 All Junked Up: Out It Goes WIGART 97 Tender — Legal, Not Non-Tough Departments 98 In Memoriam 98 New Members 99 Personal News 99 PRA Recipients 99 Announcements 102 Continuing Medical Education Opportunities 105 Placement Service 106 Information for Authors 106 Advertisers in this Issue 57 PHYSICIANS • Monthly Stipend for Physicians in training leading to qualification as General/Orthopedic/Neurosurgeon or anesthesiologist. • Loan repayment of up to $20,000 for Board eligible General/Orthopedic surgeons and anesthesiologists. • Flexible drilling options. • CME opportunities. Promotion Opportunities *Prestige For graduates of AM A approved Medical Schools 1-800-443-6419 NAVAL RESERVE You are Tomorrow. You are the Navy. 58 JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION joumol of Ihc lenne//ee flMclkol o/zockilieA Vol. 83, No. 3 March, 1990 OFFICE OF PUBLICATION 1 12 Louise Ave., Nashville, 37203 (615) 327-1451 EDITOR John B. Thomison, M.D. 230 25th Ave. North Nashville, 37203 BUSINESS MANAGER L. Hadley Williams MANAGING EDITOR Jean Wishnick TMA OFFICERS PRESIDENT William O. Miller, M.D. 939 Emerald Ave. Knoxville, 379 1 7 PRESIDENT-ELECT Hamel B. Eason, M.D. 4628 Peppertree Lane Memphis, 38117 CHAIRMAN, BOARD OF TRUSTEES James T. Craig, Jr., M.D. 6 1 6 W. Forest Jackson, 38301 TMA EXECUTIVE STAFF EXECUTIVE DIRECTOR L. Hadley Williams ASSOCIATE EXECUTIVE DIRECTOR Donald H. Alexander DIRECTOR OF STUDENT EDUCATION FUND AND HEALTH SERVICES William V. Wallace DIRECTOR OF EDUCATION AND MEETING SERVICES John H. Grant Jr. DIRECTOR OF GOVERNMENTAL AND LEGISLATIVE AFFAIRS Charles W. Cato II EXECUTIVE ASSISTANT Mark Greene DIRECTOR OF COMMUNICATIONS Russell E. Miller Jr. EXECUTIVE ASSISTANT Marty Vaughn Journal of the Tennessee Medical Association ISSN 0040-3318 Published monthly under the direction of the Board of Trustees tor and by members of the Tennessee Medical Association, a nonprofit organization with a definite membership for scientific and educational purposes. Devoted to the interests of the medical profession of Tennessee. This Association does not officially endorse opinions presented in various papers published herein. Advertisers must conform to policies and regulations established by the Board of Trustees of the Tennessee Medical Association. Subscriptions (nonmembers) $20 per year for US, $26 for Canada and foreign. Single copy $2.50. Payment of Tennessee Medical Association membership dues includes the subscription price of this Journal. Copyright 1990, Tennessee Medical Association. All material subject to this copyright appearing in the Journal may be photocopied for non- commercial scientific or educational use only. Second Class postage paid at Nashville, TN. POSTMASTER: Send address changes to Journal of the Tennessee Medical Association, 1 12 Louise Ave., Nashville, TN 37203. coAicnl/ Original Contributions 119 Rapid Management of Intracranial Hypertension To Reverse Trans- tentorial Herniation — Usa Verderber, B.A.; Robert Maciunas, M.D.; John Morris, M.D. 124 Diagnosis of Acoustic Neuroma By Magnetic Resonance Imag- ing— Raymond Massengill, Jr., Ed.D.; William Johnstone, M.D.; Jeffrey Robbins, M.D. AMA 1989 Interim Meeting Reports 128 Strengthening the American Medical Association — Fiscal Respon- sibility and Oversight 130 Address of the AMA Executive Vice President — James H. Sam- mons, M.D. 132 Address of the Chairman of the AMA Board of Trustees — John J. Ring, M.D. Regular Features 134 Trauma Rounds — Inverse Ratio Ventilation for Posttraumatic Respira- tory Failure 136 Vanderbilt Morning Report — Fever and Foot Drop in a 61 -Year-Old; A Case of Abdominal Pain and Diarrhea 138 Health and Environment Report — Adolescent Pregnancy in Tennessee 140 Loss Prevention Case of the Month — I Thought I Saw That Report President’s Page 145 Growing Pains Editorials 146 Money, Money Everywhere 147 The Use and Abuse of Power 149 Rewriting History; A Corregendum Departments 149 In Memoriam 150 New Members 150 PRA Recipients 151 Personal News 151 Announcements 154 Continuing Medical Education Opportunities 159 Placement Service 160 Information for Authors 160 Advertisers in this Issue 1 1 1 PUT YOUR MEDICAL CAREER IN FLIGHT. Discover the thrill of fly- ing, the end of office overhead and the enjoy- ment of a general prac- tice as an Air Force flight surgeon. Talk to an Air Force medical program manager about the tremendous benefits of being an Air Force medi- cal officer: • Quality lifestyle, quali- ty practice • 30 days vacation with pay per year • Support of skilled professionals • Non-contributing retirement plan if qualified Discover how to take flight as an Air Force flight surgeon. Talk to the Air Force medical team today. Call USAF Health Professions (800) 423-USAF Toll-Free joUfMlI of HlC tennc//ee inmlkol <i//eckilien Vol. 83, No. 4 April, 1990 OFFICE OF PUBLICATION 1 12 Louise Ave., Nashville, 37203 (613) 327-1431 EDITOR John B. Thomison, M.D. 230 23th Ave. North Nashville, 37203 BUSINESS MANAGER L. Hadley Williams MANAGING EDITOR Jean Wishnick TMA OFFICERS PRESIDENT William O. Miller, M.D. 939 Emerald Ave. Knoxville, 3791 7 PRESIDENT-ELECT Hamel B. Eason, M.D. 4628 Peppertree Lane Memphis, 38117 CHAIRMAN, BOARD OF TRUSTEES James T. Craig, Jr., M.D. 616 W. Forest Jackson, 38301 TMA EXECUTIVE STAFF EXECUTIVE DIRECTOR L. Hadley Williams ASSOCIATE EXECUTIVE DIRECTOR Donald H. Alexander DIRECTOR OF STUDENT EDUCATION FUND AND HEALTH SERVICES William V. Wallace DIRECTOR OF EDUCATION AND MEETING SERVICES John H. Grant Jr. DIRECTOR OF GOVERNMENTAL AND LEGISLATIVE AFFAIRS Charles W. Cato II EXECUTIVE ASSISTANT Mark Greene DIRECTOR OF COMMUNICATIONS Russell E. Miller Jr. EXECUTIVE ASSISTANT Marty Vaughn Journal of the Tennessee Medical Association ISSN 0040-3318 Published monthly under the direction of the Board of Trustees for and by members of the Tennessee Medical Association, a nonprofit organization with a definite membership for scientific and educational purposes. Devoted to the interests of the medical profession of Tennessee. This Association does not officially endorse opinions presented in various papers published herein. Advertisers must conform to policies and regulations established by the Board of Trustees of the Tennessee Medical Association. Subscriptions (nonmembers) $20 per year for US, $26 for Canada and foreign. Single copy $2.50. Payment of Tennessee Medical Association membership dues includes the subscription price of this Journal. Copyright 1990, Tennessee Medical Association. All material subject to this copyright appearing in the Journal may be photocopied for non- commercial scientific or educational use only. Second Class postage paid at Nashville, TN. POSTMASTER: Send address changes to Journal of the Tennessee Medical Association, 1 12 Louise Ave., Nashville, TN 37203. COflIttAl/ Original Contributions 169 On the Role of Alcohol in Nonvehicular Unintentional injuries Among Adolescents — Ian R. H. Rockett, Ph.D., M.P.H.; Sandra L. Putnam, Ph.D. 174 Obstetrics and Obstetrical Care Providers in Rural East Tennes- see— Mark A. Clapp, M.D. Special Features 179 Special Item — The Birth, Childhood and Early Adolescence of SVMIC — William H. Edwards, M.D. 186 Special Communication — Physician’s Recognition Award — Arthur Osteen, Ph.D. Regular Features 189 Radiology Case of the Month 190 Vanderbilt Morning Report — Pericarditis Following Antiarrhythmic Therapy; A Case of Peripheral Neuropathy and Hepatitis 192 Health and Environment Report — Results of Immunization Surveys 194 Loss Prevention Case of the Month — A Missed Opportunity? TMA Organizational 200 The New President — Hamel B. Eason, M.D. 209 Highlights of the TMA Board of Trustees Meeting — January 13-14, 1990 President’s Page 1 99 In Media Res Editorials 202 The Appearance of Evil 203 Everybody’s Talkin’ at Me Departments 205 In Memoriam 205 New Members 207 Personal News 207 PRA Recipients 208 Announcements 211 Continuing Medical Education Opportunities 215 Placement Service 216 Information for Authors 216 Advertisers in this Issue 165 9L173 THE UNITED STATES ARMY RESERVE HEALTH CARE PROFESSIONALS BONUS TEST PROGRAM $10,000 - $20,000 - $30,000 The 1989 National Defense Authorization Act requires that the Department of Defense conduct a test to determine the effectiveness of a recruitment bonus to attract health care professionals to the Selective Reserve of the Army. The Bonus Test Program is scheduled to begin on or about August 1, 1989 and will be offered to physicians in the following specialties: ANESTHESIOLOGY ORTHOPAEDIC SURGERY and GENERAL SURGERY (Including selected subspecialties) Applicants must be board certified or meet all requirements for board candidacy in one of the above specialties. BONUS ELIGIBILITY: In addition to meeting all criteria for appointment as a medical corps officer in the US Army Reserve, Bonus Test applicants must be civilians and if prior service, discharged before 28 April 1989. BONUS AMOUNTS: The test will offer $10,000 bonus for each year of affiliation with the Selected Reserve of the Army, up to a maximum of 3 years. Physicians must choose 1 , 2, or 3 years of affiliation at time of application. Bonuses will be paid annually at the beginning of each year of agreed affiliation. TEST PARAMETERS: The design of the test stipulates that bonuses be offered in certain geographic areas. To qualify, applicants must reside within those areas at the time of accession. TO FULLY DETERMINE YOUR ELIGIBILITY FOR THIS PROGRAM PLEASE CONTACT: ARMY RESERVE HEALTH CARE TEAM 3606 AUSTIN PEAY, SUITE 313, MEMPHIS, TN 38128-3755 OR CALL: (901) 388-9876 or 9877 COLLECT jeumolof the lenne//ee fflccNcol <i//eckilioA Vol. 83, No. 5 May, 1990 OFFICE OF PUBLICATION 1 12 Louise Ave., Nashville, 37203 (615) 327-1451 EDITOR John B. Thomison, M.D. 230 25th Ave. North Nashville, 37203 BUSINESS MANAGER L. Hadley Williams MANAGING EDITOR Jean Wishnick TMA OFFICERS PRESIDENT Hamel B. Eason, M.D. 8673 Classic Dr. Germantown, 38138 PRESIDENT-ELECT Howard L. Salyer, M.D. 1 900 Patterson Nashville, 37203 CHAIRMAN, BOARD OF TRUSTEES Rex A. Amonette, M.D. 1 455 Union Ave. Memphis, 38104 TMA EXECUTIVE STAFF EXECUTIVE DIRECTOR L. Hadley Williams ASSOCIATE EXECUTIVE DIRECTOR Donald H. Alexander DIRECTOR OF STUDENT EDUCATION FUND AND HEALTH SERVICES William V. Wallace DIRECTOR OF EDUCATION AND MEETING SERVICES John H. Grant Jr. DIRECTOR OF GOVERNMENTAL AND LEGISLATIVE AFFAIRS Charles W. Cato II EXECUTIVE ASSISTANT Mark Greene DIRECTOR OF COMMUNICATIONS Russell E. Miller Jr. EXECUTIVE ASSISTANT Marty Vaughn STAFF ATTORNEY Marc Overlook Journal of the Tennessee Medical Association ISSN 0040-3318 Published monthly under the direction of the Board of Trustees for and by members of the Tennessee Medical Association, a nonprofit organization with a definite membership for scientific and educational purposes. Devoted to the interests of the medical profession of Tennessee. This Association does not officially endorse opinions presented in various papers published herein. Advertisers must conform to policies and regulations established by the Board of Trustees of the Tennessee Medical Association. Subscriptions (nonmembers) $20 per year for US, $26 for Canada and foreign. Single copy $2.50. Payment of Tennessee Medical Association membership dues includes the subscription price of this Journol. Copyright 1990, Tennessee Medical Association. All material subject to this copyright appearing in the Journal may be photocopied for non- commercial scientific or educational use only. Second Class postage paid at Nashville, TN. POSTMASTER: Send address changes to Journal of the Tennessee Medical Association, 1 12 Louise Ave., TM '(79m coAlenI/ Original Contributions 225 Nonneoplastic Paraganglionic Tissue in the Gallbladder Wall — Edward C. McDonald, M.D. 227 Primary Adenocarcinoma of the Vagina Apparently Originating From Cloacal Remnant — Nirmala B. Upadhyaya, M.D., M.P.H.; Pleas R. Co- pas, M.D.; Paul B. Googe, M.D.; Thomas W. McDonald, M.D.; D. Doug- las Wilson, M.D. 230 Condyloma Acuminata in Men: The Role of the Urologist — L. Dean Knoll, M.D.; William L. Furlow, M.D.; Ralph C. Benson, Jr., M.D. 233 Ataxic Hemiparesis Secondary to Paradoxic Embolization — Curtis M. Sauer, M.D. AMA 1989 Interim Meeting Report 235 Address of the AMA President — Alan R. Nelson, M.D. Regular Features 239 Vanderbilt Morning Report — A Case of Rash and Digital Necrosis; Flank Pain Complicating Atrial Fibrillation 242 Trauma Rounds — Ureteropelvic Junction Avulsion Following Blunt Ab- dominal Trauma 244 Health and Environment Report — Incentive Programs Attract Physicians 246 Loss Prevention Case of the Month — A “Cut ” in the Dark Special Features 262 Minutes of the Tennessee State Board of Medical Examiners Meet- ings— November 14 and 15, 1989 President’s Page 251 TMA — Down and Out? Editorials 252 The Blandishments of Frugality, or The Great Gored Herd 254 Home Plate 255 Spacing Out Departments 257 In Memoriam 257 PRA Recipients 258 New Members 258 Personal News 258 Announcements 260 Continuing Medical Education Opportunities 267 Placement Service 268 Information for Authors 268 Advertisers in this Issue 221 PHYSICIANS • Monthly Stipend for Physicians in training leading to qualification as General/Orthopedic/Neurosurgeon or anesthesiologist. • Loan repayment of up to $20,000 for Board eligible General/Orthopedic surgeons and anesthesiologists. • Flexible drilling options. • CME opportunities. *Promotion Opportunities *Prestige For graduates of AM A approved Medical Schools 1-800-443-6419 NAVAL RESERVE You are Tomorrow. You are the Navy. 222 JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION Jeumolof Hw lennc//ee hmcNoiI Q/zockiHen Vol. 83, No. 7 July, 1990 OFFICE OF PUBLICATION 1 12 Louise Ave., Nashville, 37203 (615) 327-1451 EDITOR John B. Thomison, M.D. 230 25th Ave. North Nashville, 37203 BUSINESS MANAGER L. Hadley Williams MANAGING EDITOR Jean Wishnick TMA OFFICERS PRESIDENT Hamel B. Eason, M.D. 8673 Classic Dr. Germantown, 38138 PRESIDENT-ELECT Howard L. Salyer, M.D. 1 900 Patterson Nashville, 37203 CHAIRMAN, BOARD OF TRUSTEES Rex A. Amonette, M.D. 1 455 Union Ave. Memphis, 38104 TMA EXECUTIVE STAFF EXECUTIVE DIRECTOR L. Hadley Williams ASSOCIATE EXECUTIVE DIRECTOR Donald H. Alexander DIRECTOR OF STUDENT EDUCATION FUND AND HEALTH SERVICES William V. Wallace DIRECTOR OF EDUCATION AND MEETING SERVICES John H. Grant Jr. DIRECTOR OF GOVERNMENTAL AND LEGISLATIVE AFFAIRS Charles W. Cato II EXECUTIVE ASSISTANT Mark Greene DIRECTOR OF COMMUNICATIONS Russell E. Miller Jr. EXECUTIVE ASSISTANT Marty Vaughn STAFF ATTORNEY Marc Overlock Journal of the Tennessee Medical Association ISSN 0040-3318 Published monthly under the direction of the Board of Trustees tor and by members of the Tennessee Medical Association, a nonprofit organization with a definite membership tor scientific and educational purposes. Devoted to the interests of the medical profession of Tennessee. This Association does not officially endorse opinions presented in various papers published herein. Advertisers must conform to policies and regulations established by the Board of Trustees of the Tennessee Medical Association. Subscriptions (nonmembers) $20 per year for US, $26 for Canada and foreign. Single copy $2.60. Payment of Tennessee Medical Association membership dues includes the subscription price of this Journal. Copyright 1990, Tennessee Medical Association. All material subject to this copyright appearing in the Journal may be photocopied for non- commercial scientific or educational use only. Second Class postage paid at Nashville, TN. POSTMASTER: Send address changes to Journal of the Tennessee Medical Association, 1 12 Louise Ave., Nashville, TN 37203. coAicnl/ Original Contributions 339 The Pattern of HIV Infection in a Southern State and City: A Model for the Outpatient Clinic — Stephen B. Palte, M.B.Ch.B.; Danny J. Lancaster, M.D.; Stephen T. Miller, M.D.; Robert E. Morrison, M.D.; Lor- etta Bobo, M.D. 344 Adolescents’ Knowledge of AIDS: A Pilot Study in Northeast Ten- nessee— James Granger, M.D.; Russell West, Ph.D.; Harold Nara- more, M.D.; David Snow, M.D.; Helen Clark, ACS14/ 347 Central Retinal Vein Occlusion in a Heart Transpiant Patient: A Case Report — Joseph C. Keller, M.D.; John E. Linn, M.D. Regular Features 349 Trauma Rounds — High Level Positive End Expiratory Pressure in a Trauma Patient With Adult Respiratory Distress Syndrome 352 Vanderbilt Morning Report — Sudden, Profound Weakness and Thy- rotoxicosis: A Case of Bacteremia and a Hepatic Lesion 354 Heaith and Environment Report — AIDS Surveillance in Tennessee: A Report of Trends, 1982-1989 356 The Juris Doctor — AIDS; The Legal Ramifications of Nonconsensual, Mandatory Testing 358 Loss Prevention Case of the Month — It’s Not My Fault, It’s HIS Special Features 370 Minutes of the Tennessee State Board of Medicai Examiners Meet- ings— Jan. 16-17, 1990; Feb. 3-4, 1990 TMA Organizational 372 Officers and Committee Members 1990-1991 376 Component Society Officers 1990-1991 377 Insurance Plans Sponsored by TMA President’s Page 361 Brothers By Process Editorials 362 Responsibility in Government 363 Earth Day 365 Impatience, or, The Belie of the Baitic Departments 367 In Memoriam 367 New Members 367 PRA Recipients 368 Personal News 368 Announcements 379 Continuing Medical Education Opportunities 383 Placement Service 384 Information for Authors 384 Advertisers in this Issue 335 GENERAL SURCERYTAKES ON NEW MEANING IN THE ARMY RESERVE. When you take time to serve with the Army Reserve, we’ll make sure it’s time well spent. For a minimum amount of time, the Reserve will make sure you get a maximum amount of experience you probably won’t find in your civilian practice. First and foremost, you’ll be an Army officer with all the privileges and benefits which that entails. Also, service in the Reserve affords you an opportunity to work with dedicated, top profes- sionals from all across the country, as well as attend important medical conferences and even continue your education. Serving as a general surgeon in the Army Reserve is an adventure waiting to happen. And because your time is important, we can be very flexible about how and when you participate. For more information about Army Reserve medicine, contact one of our experienced Army Reserve Medical Counselors. They can arrange for you to talk to an Army Reserve physician and visit a Reserve Center or medical facility. Call or write: ARMY RESERVE HEALTH CARE TEAM 3606 Austin Peay, Suite 313 Memphis, TN 38128-3755 (^) 388-9876 / 9727 BE ALL YOU CAN BV ARMY RESERVE jouf Aol of Hie ICAAe//ee mecHccil o/zockilioA Vol. 83, No. 8 August, 1990 OFFICE OF PUBLICATION 1 12 Louise Ave., Nashville, 37203 (615) 327-1451 EDITOR John B. Thomison, M.D. 230 25th Ave. North Nashville, 37203 BUSINESS MANAGER L. Hadley Williams MANAGING EDITOR Jean Wishnick TMA OFFICERS PRESIDENT Hamel B. Eason, M.D. 8673 Classic Dr. Germantown, 38138 PRESIDENT-ELECT Howard L. Salyer, M.D. 1 900 Patterson Nashville, 37203 CHAIRMAN, BOARD OF TRUSTEES Rex A. Amonette, M.D. 1 455 Union Ave. Memphis, 38104 TMA EXECUTIVE STAFF EXECUTIVE DIRECTOR L. Hadley Williams ASSOCIATE EXECUTIVE DIRECTOR Donald H. Alexander DIRECTOR OF STUDENT EDUCATION FUND AND HEALTH SERVICES William V. Wallace DIRECTOR OF EDUCATION AND MEETING SERVICES John H. Grant Jr. DIRECTOR OF GOVERNMENTAL AND LEGISLATIVE AFFAIRS Charles W. Cato II EXECUTIVE ASSISTANT Mark Greene DIRECTOR OF COMMUNICATIONS Russell E. Miller Jr. EXECUTIVE ASSISTANT Marty Vaughn STAFF ATTORNEY Marc Overlock Journal of the Tennessee Medical Association ISSN 0040-3318 Published monthly under the direction of the Boord of Trustees for and by members of the Tennessee Medical Association, a nonprofit organization with a definite membership for scientific and educotionol purposes. Devoted to the interests of the medicol profession of Tennessee. This Association does not officially endorse opinions presented in vorious papers published herein. Advertisers must conform to policies and regulations established by the Board of Trustees of the Tennessee Medical Association. Subscriptions (nonmembers) $20 per year for US, $26 for Canada and foreign. Single copy $2.50. Payment of Tennessee Medical Association membership dues includes the subscription price of this Journal. Copyright 1990, Tennessee Medical Association. All material subject to this copyright appearing in the Journal may be photocopied for non- commercial scientific or educational use only. Second Class postage paid at Nashville, TN. POSTMASTER: Send address changes to Journal of the Tennessee Medical Association, 1 1 2 Louise Ave. , Nashville, TN 37203. conicnl/ Original Contributions 393 Sinusoidal Fetal Heart Rate Pattern With Vasa Previa — Pickens A. Gantt, M.D.; Joseph S. Bird, Jr., M.D.; Gary W. Randall, Ph.D. 395 Risk Stratification of the Post-Infarction Patient — Fred L. Haley, M.D. Regular Features 400 Vanderbilt Morning Report — Cystic Brain Lesions in a Haitian Man 402 Trauma Rounds — Laryngotracheal Transection 404 The Juris Doctor — The New Medical Records Act Amendment 405 Loss Prevention Case of the Month — There Ain’t No Justice 406 Health and Environment Report — Tennessee Medical Home Project Special Features 409 Special Item — Expressing Concern for the Patient Without Admitting Legal Liability — James G. Frierson, J.D. 412 Special Item — Health Access America — The AMA Proposal to Improve Access to Affordable Quality Health Care 414 Special Communication — HIV Infection Documentation for Disabil- ity— Howard Carpenter TMA 1990 Annual Meeting Reports 428 Report of the Committee on Legislation President’s Page 421 BIG D little r period Editorials 422 Power From the People, or, People Power-less 424 Make the Punishment Fit the Crime Departments 425 In Memoriam 425 New Members 425 Announcements 426 PRA Recipients 431 Continuing Medical Education Opportunities 435 Placement Service 436 Information for Authors 436 Advertisers in this Issue andchairn^, Department of Pedialrics, and Dianne Mnrpty, M.D., pediatric infectious disease specialist, pose with MARMA (Mother to Rapid Medical Ass ' Pe&tric Center’s kanaamo mascot. Drs. Moore and Murphy are only two of the many pediatric specialists available for consultation through the TCC. At The University of Tennessee Medical Center, our pediatric specialists, from endocrinologists to nephrologists, recognize and strive to meet thi special health care needs of children. That is one reason we have created the Tennessee Consultation Center (TCC), a fast, no-cost, physician-to physician consultation service that puts the valuable knowledge of our many pediatric specialists at your fingertips. To use the TCC service, simply choose the medical or dental specialist with whom you wish to speak from the Directory of Consultants. (If yc do not have a directory, call 1-800-442-8862, and we’ll mail one to you.) Then dial our toll-free number anytime Monday through Friday from 8 a.m. to 6 p.m., or c^ 594-8862 if you are inside Knox County. When the TCC operator answers, give her your name, location and telephom number, and she will connect you with the colleague or service you have requested. In addition to general consultation, TCC can supply you with laboratory results, patient information and informa- tion on continuing medical or dental education programs. When you need to know what we know about kids, call TCC. The call and the service are available at no cost. Tennessee Consultation Center 1-800-442-8861 UNIVERSITY OF TENNESSEE r^ALCENTER AT KNOXVILLE The University of Tennessee Medical Center at Knoxville is an academic medical ricity blending the best of the art and science of medicine. Since 1956, the Medical Center has provided compassionate patient care in a state-of-the-art setting, comprehensive training for tomorrow’s health rpgparrh Jourool of the lenne//ce medkol o/zockilion Vol. 83, No. 9 September, 1990 OFFICE OF PUBLICATION 1 12 Louise Ave., Nashville, 37203 (615) 327-1451 EDITOR John B. Thomison, M.D. 230 25th Ave. North Nashville, 37203 BUSINESS MANAGER L. Hadley Williams MANAGING EDITOR Jean Wishnick TMA OFFICERS PRESIDENT Hamel B. Eason, M.D. 8673 Classic Dr. Memphis, 38125 PRESIDENT-ELECT Howard L. Salyer, M.D. 1 900 Patterson Nashville, 37203 CHAIRMAN, BOARD OF TRUSTEES Rex A. Amonette, M.D. 1455 Union Ave. Memphis, 38104 TMA EXECUTIVE STAFF EXECUTIVE DIRECTOR L. Hadley Williams ASSOCIATE EXECUTIVE DIRECTOR Donald H. Alexander DIRECTOR OF STUDENT EDUCATION FUND AND HEALTH SERVICES William V. Wallace DIRECTOR OF EDUCATION AND MEETING SERVICES John H. Grant Jr. DIRECTOR OF GOVERNMENTAL AND LEGISLATIVE AFFAIRS Charles W. Cato II EXECUTIVE ASSISTANT Mark Greene DIRECTOR OF COMMUNICATIONS Russell E. Miller Jr. EXECUTIVE ASSISTANT Marty Vaughn STAFF ATTORNEY Marc Over lock Journal of the Tennessee Medical Association ISSN 0040-3318 Published monthly under the direction of the Board of Trustees for and by members of the Tennessee Medical Association, o nonprofit organization with a definite membership for scientific and educational purposes. Devoted to the interests of the medical profession of Tennessee. This Association does not officially endorse opinions presented in various papers published herein. Advertisers must conform to policies and regulations established by the Board of Trustees of the Tennessee Medical Association. Subscriptions (nonmembers) $20 per year for US, $26 for Canada and foreign. Single copy $2.50. Payment of Tennessee Medical Association membership dues includes the subscription price of this Journal. Copyright 1990, Tennessee Medical Association. All material subject to this copyright appearing in the Journal may be photocopied for non- commercial scientific or educational use only. Second Class postage paid at Nashville, TN. POSTMASTER; Send address changes to Journal of the Tennessee Medical Association, 1 12 Louise Ave. Nashville, TN 37203. cenlcnU Original Contributions 443 AV Nodal Reentrant Tachycardia — Jerry Williams, M.D., Ahmed A. Khan, M.D. 447 Infant Botulism in Tennessee — M. Dianne Murphy, M.D.; Sharon Lail, M.D. TMA 1990 Annual Meeting Report 450 Report of the Tennessee Deiegation to the American Medicai Association Regular Features 455 Medical Grand Rounds — A Brief History of Pneumonia 462 Trauma Rounds — Blunt Intestinal Trauma 463 Vanderbilt Morning Report — A Case of Headache and Amnesia; Hy- pokalemia and Weight Loss in a Young Woman 466 Health and Environment Report — Blacks and High Blood Pressure 468 Loss Prevention Case of the Month — The Loser Finally Wins Special Features 478 Minutes of the Tennessee State Board of Medical Examiners Meet- ing— March 20-21, 1990 President’s Page 471 Obscenities Abound Editorials 472 Stars in My Eyes 473 RHK, 1898-1990: RIP 474 The Burden of the Burdensome Burden Departments 475 In Memoriam 476 New Members 476 PRA Recipients 477 Personai News 477 Announcements 480 Continuing Medical Education Opportunities 485 Placement Service 486 Information for Authors 486 Advertisers in this issue 441 GENERAL SURCERYTAKES ON NEW MEANING IN THE ARMY RESERVE. When you take time to serve with the Army Reserve, we’ll make sure it’s time well spent. For a minimum amount of time, the Reserve will make sure you get a maximum amount of experience you probably won’t find in your civilian practice. First and foremost, you’ll be an Army officer with all the privileges and benefits which that entails. Also, service in the Reserve affords you an opportunity to work with dedicated, top profes- sionals from all across the country, as well as attend important medical conferences and even continue your education. Serving as a general surgeon in the Army Reserve is an adventure waiting to happen. And because your time is important, we can be very flexible about how and when you participate. For more information about Army Reserve medicine, contact one of our experienced Army Reserve Medical Counselors. They can arrange for you to talk to an Army Reserve physician and visit a Reserve Center or medical facility. Call or write: ARMY RESERVE HEALTH CARE TEAM 3606 Austin Peay, Suite 313 Memphis, TN 38128-3755 (901) 388-9876 / 9727 BE ALL YOU CAN BV ARMY RESERVE jouinol of Ihc lenne//ee iMclkol Qz/eckilion Vol. 83, No. 10 October, 1990 OFFICE OF PUBLICATION 1 12 Louise Ave., Nashville, 37203 (615) 327-1451 EDITOR John B. Thomison, M.D. 230 25th Ave. North Nashville, 37203 BUSINESS MANAGER L. Hadley Williams MANAGING EDITOR Jeon Wishnick TMA OFFICERS PRESIDENT Hamel B. Eason, M.D. 8673 Classic Dr. Memphis, 38125 PRESIDENT-ELECT Howard L. Salyer, M.D. 1 900 Patterson Nashville, 37203 CHAIRMAN, BOARD OF TRUSTEES Rex A. Amonette, M.D. 1 455 Union Ave. Memphis, 38104 TMA EXECUTIVE STAFF EXECUTIVE DIRECTOR L. Hadley Williams ASSOCIATE EXECUTIVE DIRECTOR Donald H. Alexander DIRECTOR OF STUDENT EDUCATION FUND AND HEALTH SERVICES William V. Wallace DIRECTOR OF EDUCATION AND MEETING SERVICES John H. Grant Jr. DIRECTOR OF GOVERNMENTAL AND LEGISLATIVE AFFAIRS Charles W. Cato II EXECUTIVE ASSISTANT Mark Greene DIRECTOR OF COMMUNICATIONS Russell E. Miller Jr. EXECUTIVE ASSISTANT Marty Vaughn STAFF ATTORNEY Marc Overlock Journal of the Tennessee Medical Association ISSN 0040-3318 Published monthly under the direction of the Board of Trustees tor and by members of the Tennessee Medical Association, a nonprofit organization with a definite membership for scientific and educational purposes. Devoted to the interests of the medical profession of Tennessee. This Association does not officially endorse opinions presented in various papers published herein. Advertisers must conform to policies ond regulations established by the Board of Trustees of the Tennessee Medical Association. Subscriptions (nonmembers) $20 per year for US, $26 for Canada and foreign. Single copy $2.50. Payment of Tennessee Medical Association membership dues includes the subscription price of this Journal. Copyright 1990, Tennessee Medical Associotion. All material subject to this copyright appearing in the Journal may be photocopied for non- commercial scientific or educational use only. Second Class postage paid at Nashville, TN. POSTMASTER: Send address changes to Journal of the Tennessee Medical Association, 1 1 2 Louise Ave. . Noshville, TN 37203. conleni/ Original Contributions 499 Vasa Previa — Michael C. Good, M.D.; Pleas R. Copas, M.D.; Gary E. Kleinman, M.D.; Michael R. Caudle, M.D. 502 More Than 17,000 Transurethral Prostatic Resections (TURs): Some of the Things I Have Learned — Oscar Carter, M.D. Regular Features 508 Trauma Rounds — Traumatic Lung Cyst 510 Vanderbilt Morning Report — An Unusual Case of Ventricular Tachy- cardia; A Case of Refractory Hypotension 512 Health and Environment Report — Communicable Disease Reporting; Why? Special Features 515 Special Communication — Durable Powers of Attorney for Health Care Decisions: Understanding the Latest Malpractice Risk — David E. Fowler 518 Minutes of the Tennessee State Board of Medical Examiners Meet- ings—May 14-16, 1990; July 17-18, 1990 TMA 1990 Annual Meeting Report 531 Report of the Committee on Communications and Public Service TMA Organizational 533 Highlights of the TMA Board of Trustees Meeting — July 14-15, 1990 President’s Page 523 Tennessee Healthcare Exchange 90s Editorials 524 Rockin’ the Boat: A Footnote on History 526 Compared to What? Departments 528 In Memoriam 528 New Members 528 Personal News 528 PRA Recipients 529 Announcements 534 Continuing Medical Education Opportunities 539 Placement Service 540 Instructions for Authors 540 Advertisers in this Issue 493 Let SEAKO Highlight Your Practice . . . with PMS PLUS SEAKO’s Practice Management System provides a state-of-the-art automated solution that allows your practice to: INCREASE CASHFLOW: Simplifies statements that eliminate confusion Electronic claims for better accuracy and quicker claims return Automatic accounts receivable tracking for collecting on-time payments SAVE TIME AND MONEY: Automates routine tasks which reduces work load Patient inquiries, billing, statements, and insurance processing are completely automated Automates patient recall which enhances follow up care and marketing efforts GAIN CONTROL: Produces medical and business reports to help analyze your practice Provides a revenue report by day, month and year- to-date which allows analysis comparison to determine future trends Organizes reports for effectiveness in everyday management PMS PLUS FEATURES: Automated Billing Automated Insurance Processing Automated Medical Records Management Reports Practice Marketing Word Processing PMS PLUS SUPPORT: Toll-Free Hotlines Classroom and On-Site Training Advanced Education Beeper Service Program Enhancements 90-day Unlimited Training Top-of-the-line Hardware; IBM OR NEC Seako offers you complete security. Being a wholly-owned subsidiary of CSC gives SEAKO the backing and resources of a billion dollar company. You can be sure we will be here today and tomorrow. SEAKO, INC. A Wholly-Owned Subsidiary of Computer Sciences Corporation 517 Beacon Parkway West Birmingham, Alabama 35209 For more information about highlighting your practice with PMS PLUS call: (205) 945-8200 In FL (904) 730-3822 494 JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION JoufAol of Hie l«nne//ce m«(lk<il ci/zeckilion Vol. 83, No. 1 1 November, 1990 OFFICE OF PUBLICATION 1 12 Louise Ave., Nashville, 37203 (615) 327-1451 EDITOR John B. Thomison, M.D. 230 25th Ave. North Nashville, 37203 BUSINESS MANAGER L, Hadley Williams MANAGING EDITOR Jean Wishnick TMA OFFICERS PRESIDENT Hamel B. Eason, M.D. 8673 Classic Dr. Memphis, 38125 PRESIDENT-ELECT Howard L. Salyer, M.D. 1 900 Patterson Nashville, 37203 CHAIRMAN, BOARD OF TRUSTEES Rex A, Amonette, M.D. 1 455 Union Ave. Memphis, 38104 TMA EXECUTIVE STAFF EXECUTIVE DIRECTOR L. Hadley Williams ASSOCIATE EXECUTIVE DIRECTOR Donald H. Alexander DIRECTOR OF STUDENT EDUCATION FUND AND HEALTH SERVICES William V. Wallace DIRECTOR OF EDUCATION AND MEETING SERVICES John H. Grant Jr. DIRECTOR OF GOVERNMENTAL AND LEGISLATIVE AFFAIRS Charles W. Cato II EXECUTIVE ASSISTANT Mark Greene DIRECTOR OF COMMUNICATIONS Russell E. Miller Jr. EXECUTIVE ASSISTANT Marty Vaughn STAFF ATTORNEY Marc Overlock Journal of the Tennessee Medical Association ISSN 0040-3318 Published monthly under the direction of the Board of Trustees for and by members of the Tennessee Medical Association, a nonprofit organization with a definite membership for scientific and educational purposes. Devoted to the interests of the medical profession of Tennessee. This Association does not officially endorse opinions presented in various papers published herein. Advertisers must conform to policies and regulations established by the Board of Trustees of the Tennessee Medical Association. Subscriptions (nonmembers) $20 per year for US, $26 for Canada and foreign. Single copy $2.50. Payment of Tennessee Medical Association membership dues includes the subscription price of this Journal. Copyright 1990, Tennessee Medical Association. All material subject to this copyright appearing in the Journal may be photocopied for non- commercial scientific or educational use only. Second Class postage paid at Nashville, TN. POSTMASTER: Send address changes to Journal of the Tennessee Medical Association, 1 1 2 Louise Ave. Nashville, TN 37203. cenlcnU Original Contributions 549 Lower Extremity Revascularization by Percutaneous Atherec- tomy— Edward M. Priest, M.D.; Douglas A. Waldo, M.D. 552 Tissue Characterization of a Parathyroid Adenoma: Sonographic- Pathologic Correlation — Jack Dempsey, M.D.; Jay Brooks, M.D.; Randall L. Scott, M.D. Regular Features 557 Trauma Rounds — Large Diameter Impalement 559 Radiology Case of the Month 561 Vanderbilt Morning Report — An Unusual Cause of Heart Failure; An Unusual Cause of Solitary Pulmonary Nodule 563 The Juris Doctor — The Privilege of Peer Review 566 Health and Environment Report — Tennessee’s Regulation of Lead in Drinking Water 568 Loss Prevention Case of the Month — Fragmented Evaluation AMA 1990 Annual Meeting Report 571 Address of the AMA President — The Business at Hand and the Chal- lenges Ahead — Alan R. Nelson, M.D. TMA 1990 Annual Meeting Reports 574 Report of the Committee on Governmental Medical Services 576 Report of the Committee on Hospitals President’s Page 579 When Prowess Outstrips Prudence — Muddy Water Editorials 580 Pretentiousness 582 The Girls from Ipanema Departments 584 Mail Box — AIDS Issue Response 585 In Memoriam 585 PRA Recipients 586 New Members 586 Personal News 586 Announcements 588 Continuing Medical Education Opportunities 593 Placement Service 594 Information for Authors 594 Advertisers in this issue 545 Charles M. Cooper, M.D. Morgan E. Scott, M.D. Neil P. Dubner, M.D. Arthur E. Kelley, M.D. Basil E. Roebuck, M.D. Don L. Weston, M.D. Orren LeRoyce Royal, M.D. G. Paul Hlusko, M.D. D. Wilfred Abse, M.D. Ronald L. Myers, M.D. Hal G.GiUespie, M.D. Greek poet Theocritus said it. The eleven men who comprise the Active Medical Staff of Saint Albans Hospital practice it. Every day. They combine years of study and experience to bring patients the best available care for emo- tional and psychological troubles. Their special interests cover the broadest spectrum of psychiatric treatment, resulting in both adult and adoles- cent programs for chemical dependency, eating disorders, phobias and anxieties, and pain management. Our doctors lead a large group of professionals and volunteers who make compassion and expert care a way of life. Saint Albans. Today and for the past 74 years we are concerned, above all, with your peace of mind. 2 Saint Albans np l^hiatric Hospital Radford, Vireinia fZOSf 639-2481 jouf AOl of HlC lenne//ce fflcdkol o//o€iolien Vol. 83, No. 12 December, 1990 OFFICE OF PUBLICATION 1 12 Louise Ave., Nashville, 37203 (615) 327-1451 EDITOR John B. Thomison, M.D. 230 25th Ave. North Nashville, 37203 BUSINESS MANAGER L Hadley Williams MANAGING EDITOR Jeon Wishnick TMA OFFICERS PRESIDENT Hamel B. Eason, M.D. 8673 Classic Dr. Memphis, 38125 PRESIDENT-ELECT Howard L. Salyer, M.D. 1 900 Patterson Nashville, 37203 CHAIRMAN, BOARD OF TRUSTEES Rex A. Amonette, M.D. 1 455 Union Ave. Memphis, 38104 TMA EXECUTIVE STAFF EXECUTIVE DIRECTOR L. Hadley Williams ASSOCIATE EXECUTIVE DIRECTOR Donald H. Alexander DIRECTOR OF STUDENT EDUCATION FUND AND HEALTH SERVICES William V. Wallace DIRECTOR OF EDUCATION AND MEETING SERVICES John H. Grant Jr. DIRECTOR OF GOVERNMENTAL AND LEGISLATIVE AFFAIRS Charles W. Cato II EXECUTIVE ASSISTANT Mark Greene DIRECTOR OF COMMUNICATIONS Russell E. Miller Jr. EXECUTIVE ASSISTANT Marty Vaughn STAFF AHORNEY Marc Overlock Journal of the Tennessee Medical Association ISSN 0040-3318 Published monthly under the direction of the Boord of Trustees for and by members of the Tennessee Medical Association, a nonprofit organization with a definite membership for scientific and educational purposes. Devoted to the interests of the medical profession of Tennessee. This Association does not officially endorse opinions presented in various papers published herein. Advertisers must conform to policies and regulations established by the Board of Trustees of the Tennessee Medical Association. Subscriptions (nonmembers) $20 per year for US, $26 for Canada and foreign. Single copy $2.50. Payment of Tennessee Medical Association membership dues includes the subscription price of this Journal. Copyright 1990, Tennessee Medical Association. All material subject to this copyright appearing in the Journal may be photocopied for non- commercial scientific or educational use only. Second Class postage paid at Nashville, TN. POSTMASTER: Send address changes to Journal of the Tennessee Medical Association, 1 12 Louise Ave., Nashville, TN 37203. conlcAl/ Original Contributions 603 Infective Endocarditis Due to the CDC Group M6 Bacillus — Richard C. Rose, III, M.D.; Allan M. Grossman, M.D.; James kV. Giles, M.D. 605 Tuberculous Epididymo-orchitis and Granulomatous Prostatitis Mimicking Neoplasia — AH Jaffar, M.D.; Jay B. Mehta, M.D.; James H. Godfrey, M.D. Regular Features 608 Vanderbilt Morning Report — Lung Nodules in a Heart Transplant Patient 609 Health and Environment Report — The Trauma Care System in Tennessee 610 Loss Prevention Case of the Month — Parameters’ in the Emergency Room Special Features 613 Minutes of the Tennessee State Board of Medical Examiners Meet- ing— Sept. 18-19, 1990 TMA Organizational 623 1990 Membership Roster 644 Index to Volume 83 President’s Page 617 Oh No, I’m on Call This Christmas Editorials 618 Those Xmas Catalogs 619 Scene and Be Seen Departments 620 New Members 621 In Memoriam 621 PRA Recipients 621 Personal News 621 Announcements 622 Continuing Medical Education Opportunities 651 Placement Service 652 Information for Authors 652 Advertisers in this Issue 599 PUT YOUR MEDICAL CAREER IN FLIGHT. Discover the thrill of fly- ing, the end of office overhead and the enjoy- ment of a general prac- tice as an Air Force flight surgeon. Talk to an Air Force medical program manager about the tremendous benefits of being an Air Force medi- cal officer: • Quality lifestyle, quali- ty practice • 30 days vacation with pay per year • Support of skilled professionals • Non-contributing retirement plan if qualified Discover how to take flight as an Air Force flight surgeon. Talk to the Air Force medical team today. Call USAF Health Professions (800) 423-USAF Toll-Free jouMolef the tennez/ce mecNccil o//ockiHon OWNED AND PUBUSHED BY THE ASSOGATION JANUARY, 1990 VOL. 83, NO. 1 Medical Grand Rounds and Prescribed Credit by the American Academy of Family Physicians RAYMOND MASSENGILL, JR., Ed.D. and LEO HARVILL, Ph.D. Medical grand rounds take on various formats at the various medical centers. The programs at Bristol Regional Medical Center, which is one of the teaching hospitals of the East Tennessee State University, James H. Quillen College of Medicine, usually consist of a 50-minute lecture followed by a 10-minute question and answ^er pe- riod. The programs for grand rounds are devel- oped by a committee composed of an internist, two surgeons, a family physician, and a medical educator.^ See editorial comment in this issue. Medical grand rounds have been conducted at Bristol Regional Medical Center for the past 12 years and credit hours in Category 1 of the Phy- sician’s Recognition Award of the American Medical Association have been provided. Since July 1986, these programs have also been re- From the James H. Quillen College of Medicine, East Tennessee State University, Bristol. Dr. Massengill is director of Medical Education. Reprint requests to Bristol Regional Medical Center. Bristol, TN 37620 (Dr. Massengill). viewed and accepted for prescribed credit by the American Academy of Family Physicians (AAFP). The present study deals with what im- pact this change has made on family physician attendance, as well as continuing education cred- it and other educational considerations. Method In April 1989, a questionnaire was mailed to 11 family physicians, four of them full-time fac- ulty and seven in private practice, who attend rounds along with a cover letter that indicated that since July 1986, the grand rounds programs had been reviewed and accepted for prescribed credit by the AAFP, and in order to help deter- mine if this procedure should be continued it would be helpful if they would complete the questionnaire shown in Fig. 1. Results Ten physicians (91%) of the 11 responded. Two (20%) of the physicians indicated their at- tendance at rounds was dependent upon the fact that prescribed credit could be obtained, while eight (80%) stated their attendance was not dependent upon this. One of the eight did write that although JANUARY, 1990 9 FIGURE 1 QUESTIONNAIRE 1. Does your attendance depend upon whether the medical grand rounds programs that have been conducted at Bris- tol Regional Medical Center have been reviewed and ac- cepted for 1 prescribed credit hour by the American Acad- emy of Family Physicians? Yes No 2. Since grand rounds programs have been reviewed and are accepted for prescribed credit have you been more in- clined to attend? Yes No 3. Since medical grand rounds are available for prescribed credit at your local hospital and medical center have you obtained more continuing medical education credit than when they were not available? Yes No 4. From July 1, 1987 through June 30, 1988 a total of 47 grand rounds programs were presented. Out of this total how many would you estimate you attended? 40 or more 30-39 20-29 10-19 less than 10 5. In your opinion should one of the responsibilities of the community hospital and medical center be to conduct medical grand rounds that are approved for continuing medical education credit by the American Academy of Family Physicians? Yes No 6. Of the medical grand rounds programs that you have attend- ed how many would you estimate have been appropriate for both the internist as well as the family practitioner? 0-25% 26%-50% 51%-75% 76%-100% he did check no for this first question that he would be very disappointed not to continue to have rounds approved for prescribed credit. Another one, who gave a negative response, wrote that she hoped the programs would continue to be approved for AAFP credit (prescribed). Eight (80%) indicated that since the programs now offered prescribed credit they had been more inclined to attend, while two (20%) reported this was not an influencing factor. Eight (80%) indicated they had obtained more continuing medical education credit since rounds were available for prescribed credit at the local hospital and medical center, while one (10%) in- dicated this had not influenced him, and another did not answer this question. Three (30%) of the physicians indicated they attended 40 or more of the programs from July 1, 1987 through June 30, 1988, one (10%) at- 10 tended between 30-39, four (40%) between 20- 29 and two (20%) between 10-19. All 10 (100%) respondents felt that one of the responsibilities of the community hospital and medical center was to conduct medical grand rounds that are approved for continuing medical education credit by the AAFP. Eight (80%) estimated that 76% to 100% of the programs they had attended were appropri- ate for both the internist and the family practi- tioner, while two (20%) estimated 51% to 75%. Because of the small numbers involved in the study, it can do no more than establish a trend. Discussion Continuing medical education credit may be desired for many reasons, such as for continued membership in state medical societies, maintain- ing hospital privileges, requirement for malprac- tice self-insurance plans, re-registration of a li- cense to practice medicine,'^ and to keep abreast of the latest developments in medicine. The medical grand rounds programs that are presented at Bristol Regional Medical Center are based on the needs that have been identified in the hospital and those the grand rounds commit- tee considers important to bring a new or ad- vanced medical concept to the attention of the faculty and staff. Speakers for the medical grand rounds are either members of the medical school faculty or hospital staff or guest professors.^ It seems clear that the respondents to the ques- tionnaire believe that the grand rounds pre- sentations and the prescribed credit for them are meeting their needs. This is evidenced by the influ- ence prescribed credit has had on their attendance, by their expressions of attendance, and by the ex- pressed appropriateness of the presentations. Family physicians appear to be benefiting from both the availability of medical ground rounds and the availability of prescribed credit from the AAFP. REFERENCES 1. Ram MD, Thompson JS, Kilner JF, et al: A good death; medical ethics grand rounds. Hosp Pracf 21:31-50, 1986. 2. Kossmann CE, Watanabe A. Nunn SL: Medical grand rounds. CABG; Have the indications changed? J Tenn Med Assoc 78:219-223, 1985. 3. Massengill RM, Culp JS, Derden PJ: Grand rounds. J Med Ed 63:503, 1988. 4. Ayers J: Continuing medical education fact sheet. Chicago, American Medical Association, July, 1987, p 1. JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION Remote Metastases From Uveal Melanoma TIMOTHY POWERS, M.D.; RODOLFO LAUCIRICA, M.D.; SANDRA BROOKS, M.D.; SOPHIE LEOPOLD, MHS, CT (ASCP); MICHAEL WHITSON, M.D.; and JAMES FARNUM, M.D. Malignant melanoma is the most common in- traocular neoplasm. It can readily metastasize to the liver as well as other sites. Although most metastasize within five to ten years, metastases 20 to 25 years after the primary diagnosis have been reported. We report two cases of uveal melanoma that metastasized over 15 years after initial diagnosis. In neither case was a diagnosis of malignant melanoma entertained until cyto- logic materials were obtained. We present the cytologic and histologic specimens and review the natural history, prognostic indicators, treatment, and current recommendations for initial evalua- tion and follow-up. We emphasize the need to consider metastatic disease in the patient who has had a previous uveal melanoma regardless of how temporally distant the diagnosis was made. Case Reports Case 1. A 65-year-old white man with a two-week history of abdominal distension reported a 40-lb weight loss over the previous three months, but a 10-lb weight gain over the two weeks prior to admission. A history of enucleation of the right eye for melanoma was noted but not further explored. Phys- ical examination showed bitemporal wasting and a right eye prosthesis. Abdominal examination revealed a protuberant abdomen with a liver span of 14 cm, palpable 3 cm below the right costal margin. Prothrombin time was 9.2 seconds, al- bumin 3.3 gm/dl, total bilirubin 0.4 mg/dl, alkaline phospha- tase 95 U/L, SGPT 25 U/L, SCOT 11 U/L, and the LDH was greater than 600 U/L. Ultrasound of the abdomen re- vealed extensive liver metastases and probable renal metas- tases. Liver-spleen scan demonstrated hepatic enlargement with multiple large filling defects in the left and right lobes of the liver. Abdominal paracentesis was performed and showed abundant single malignant tumor cells, diagnosed as malignant melanoma. Subsequent Chiba fine needle aspira- tion (FNA) of the liver demonstrated metastatic malignant melanoma with positive S-100 immunoperoxidase stains. The patient was started on chemotherapy with carmustine (BCNU), dacarbazine (DTIC), cis-platinum, and tamoxifen. His course was complicated by pulmonary edema and respi- ratory failure, and he died. Request for autopsy was denied. From the Departments of Medicine (Dr. Powers) and Pathology, James H. Quillen College of Medicine, and Mountain Home Veterans Administration Medical Center, East Tennessee State University, Johnson City. Reprint requests to Department of Pathology, James H. Quillen College of Medicine, East Tennessee State University, P.Q. Box 19540A, Johnson City, TN 37614 (Dr. Farnum). Case 2. A 72-year-old white woman with several weeks history of lethargy, weakness, and anorexia had had idi- opathic thrombocytopenic purpura (ITP) treated with high- dose prednisone, and enucleation of the left eye 19 years be- fore admission for malignant uveal melanoma. Physical ex- amination revealed a distended, tender abdomen with a fluid wave and a periumbilical mass. Glucose was 863 mg/dl, BUN 31 mg/dl, creatinine 1.8 mg/dl, LDH 2,067 U/L, alkaline phosphatase 226 U/L, SGOT 208 U/L, SGPT 202 U/L, total bilirubin 0.2 mg/dl, CA-125 935 U/ml (normal less than 35), and a CEA of 2.7 ng/ml (normal 0 to 3). CT scan of the abdomen showed ascites, focal lesions within the liver, mul- tiple peritoneal and mesenteric implants, and masses at the distal portion of the stomach and the pancreas. Cytology of the peritoneal fluid was negative. Chiba FNA of the abdom- Figure 1. Low-power photomicrograph of 1970 enucleation speci- men, showing uveal melanoma elevating, but not involving, the intact retina (hematoxylin-eosin, x125). 1 1 JANUARY, 1990 UVEAL MELANOMA METASTASES/Powers inal mass with CT guidance revealed malignant melanoma. The patient and family declined treatment other than suppor- tive care. The patient’s condition deteriorated over the course of several weeks with progressive edema and ascites, and he died. Request for autopsy was denied. Histologic Findings Each tumor consisted of a black, nodular sub- retinal mass that measured approximately 1.0 cm in greatest dimension; no transscleral or optic nerve involvement was identified. Microscopic examination revealed similar histologic features in both cases. The tumor filled the choroidal space, and elevated but did not involve the reti- na (Fig. 1). Both spindle and epithelioid cells were found, arranged in fascicles and sheets (Fig. 2). Coarse granular to fine dusty melanin cyto- plasmic pigment was readily identified within some cells. Many of the malignant cells possessed large, ovoid, hyperchromatic to vesicular nuclei and prominent eosinophilic macronucleoli. FNA of the liver in case 1 yielded diagnostic cellular material (Fig. 3). The malignant cells were pleomorphic and lacked well-defined cellu- lar cohesiveness. The cells contained large, ec- centrically located nuclei, giant macronucleoli, and prominent cytoplasmic granularity. An FNA cell block preparation of the abdominal mass in case 2 (Fig. 4) displayed histologic and cytologic epithelioid features similar to those found in the original uveal tumor. Discussion Uveal melanoma is the most common primary intraocular tumor. This disease has special signif- icance to the ophthalmologist as the only prima- ry intraocular process in adults that can be fatal. ^ It also has significance to the primary care phy- sician who will follow the patient after diagnosis, as this tumor has a high incidence of metastasis and requires long-term follow-up. The epidemiology and risk factors associated with uveal melanoma are diverse and multifac- torial. This uncommon tumor has an annual age- adjusted incidence of 0.7 per 100,000.^ It is rare in childhood,^ with the median age at diagnosis being 55 years. In contrast to other cancers the incidence begins to level off after 70 years of age."* Uveal melanoma is slightly more common in men, with an interesting left-sided excess in men and a right-sided excess in women. ^ Caucasians have a greater than eight-fold risk over blacks in the United States, while there has never been a case 12 reported in American Indians.^ Sunlight expo- sure is now considered an important risk factor, and brown-eyed individuals have been shown to be more protected than blue-eyed individuals. Complexion and hair color are not important risk factors.^ Familial cases are rare.^'p^^^’ The only specific occupational exposure linked to uveal melanoma is welding.^ There have been cluster- ings of cases in jobs with chemical exposure, but no causative agent has been positively identi- fied.^ There is suggestive evidence that trauma and inflammation of the eye have a role in the conversion of a benign pigmented lesion into a malignant melanoma. Chemicals known to in- duce ocular melanomas in animals include nickel subsulfide, platinum, methyeholanthrene, ethionine, N-2-fluorenylacetamide, and radium. Viruses have been used to induce uveal mela- noma in animal models.^ Once the diagnosis of uveal melanoma is made, several factors influence prognosis. The Callender classification is the traditional method of classifying the histologic type of uveal mela- noma, and has definite prognostic implications. According to this classification, there are six var- iations in histologic type: spindle A, spindle B, fascicular, epithelioid, mixed, and necrotic. Spin- dle A tumors are composed primarily of spindle Figure 2. Medium-power photomicrograph of original tumor (1971 enucleation of uveal melanoma) showing spindle and epithelioid cells arranged in fascicles and sheets, cytoplasmic melanin pigment (cen- ter), occasional mitoses, and pleomorphic nuclei with macronucleoli (hematoxylin-eosin, x250). JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION A cells (small spindled nuclei without distinct nu- cleoli and indistinct cytoplasm) and make up 5% of all uveal melanomas. Five-year mortality has previously been thought to be 5%, but Zimmerman* has shown that these tumors do not metastasize and therefore behave as nevi. Spindle B tumors are composed primarily of spindle B cells (prominent spindled nuclei with distinct nucleoli and indistinct cytoplasm) and comprise 33% of uveal melanomas. They have a 14% five-year mortality. A fascicular tumor is characterized by a palisading arrangement of cells, and can be made up of spindle A or spindle B cells. The fascicular pattern accounts for 6% of uveal melanomas, which have a 14% five-year mortality. Epithelioid tumors consist almost ex- clusively of large oval or round epithelioid cells. This cell type comprises 3% of uveal melanomas and has a 69% five-year mortality. A mixed cell type of tumor is one of variable combinations of spindle and epithelioid cells; it comprises 45% of uveal melanomas and has a 51% five-year mor- tality. A necrotic uveal melanoma is one with abundant necrosis, such that the tumor cell type cannot be identified. It comprises 8% of uveal melanomas and has a 51% five-year mortality. Although the Callender classification is widely accepted, the problem of intraobserver variabili- ty has stimulated interest in the development of Figure 3. High-power photomicrograph of liver FNA smear (case 1) showing metastatic uveal melanoma with pleomorphic, discohesive cells, macronucleoli, and granular cytoplasmic melanin pigment (he- matoxylin-eosin, x500). a more reproducible tumor classification system. Recently, a more quantitative method of assess- ing cell type has been described in which epithe- lioid cells are counted per high power field and the nucleolar area of tumor cells is measured by image analysis. The inverse standard deviation of nucleolar area is calculated. A high number of epithelioid cells per high power field and a low value for the inverse standard deviation of nu- cleolar area is associated with poor prognosis. A major prognostic factor is tumor size, diame- ter being the single most important clinical and pathologic prognostic factor. Good prognosis is generally expected with tumors less than 10 mm in diameter, and a poor prognosis with tumors larger than 10 mm in diameter. Other ominous factors include scleral extension, high mitotic ac- tivity, increasing age, increased height of tumor, excessive tumor pigmentation, and compromised integrity of Bruch’s membrane. Discussion of metastatic uveal melanoma has previously focused on metastasis occurring many years after the primary diagnosis. Recently, how- ever, the incidence of metastasis at the time of primary diagnosis has been an area of controver- sy. Though this incidence has been previously thought low, estimated at 1% to 3%,^'^ Albert and associates'^ suggested in 1981 that this incidence had been underestimated. They suggested that if full metastatic workups had been done on all pa- tients, a higher incidence of metastases would have been found. A recent unpublished account Figure 4. Cell block preparation of abdominal mass FNA (case 2) showing a sheet of pleomorphic, malignant cells with prominent cy- toplasm (HMB-45 immunoperoxidase positive), interpreted as meta- static uveal melanoma (hematoxylin-eosin, x 500). JANUARY, 1990 13 UVEAL MELANOMA METASTASES/Powers reported a metastatic incidence as high as 12% at time of primary diagnosis.'^ Metastases are most common to the liver. Other sites include stomach, subcutaneous tissues, spine, lungs, and lymph nodes. Tumor rarely metastasizes to a sec- ond site in the same eye or to the fellow eye. Metastases are believed to be due to tumor in- vasion of blood vessel walls, but tumor cells have been seen circulating in the blood of patients without evidence of metastases. The average on- set of a metastatic focus is 37 months, but it can be as long as 20 to 25 years. There has been one report of a metastatic focus occurring 42 years after primary diagnosis.*’ Because of the strong predilection for the liver, a search for metastases should begin there. Some studies have suggested that liver scans have low yield in patients without overt evidence of metastases and with normal liver enzymes.** However, because of the recent controversy regarding the incidence of metasta- ses at the time of primary diagnosis, prudence may dictate management of patients as per Al- bert’s recommendations. A conservative surgical philosophy has recent- ly evolved in the treatment of uveal melanoma. Traditionally, enucleation has been the standard treatment, but over the last few years enuclea- tion has been reassessed and other forms of treatment have been studied. Zimmerman*'* ^** has shown that the incidence of death rises sharply after enucleation and that two-thirds of deaths after enucleation can be attributed to surgical dissemination of tumor cells. Other investigators dispute the interpretation of Zimmerman’s find- ings. This controversy has stimulated the devel- opment of other treatment modalities. Appropri- ate treatment can be approached by evaluating the size and elevation of the tumor. For large tumors (over 15 mm in diameter and 5 mm in elevation) there is general agreement that enu- cleation is the treatment of choice. Small tumors (less than 10 mm in diameter and 2 mm in ele- vation) are managed much more conservatively. There is accumulating evidence that the risk in observing small tumors is low, and small tumors that are asymptomatic and small tumors in elder- ly patients are frequently managed by observa- tion only. Certainly if the diagnosis is equivocal (melanoma vs nevus), the tumor should be man- aged only by close observation. Progression or rapid growth and vision impairment can be treat- ed with radiation treatment or enucleation. 14 Treatment of medium-sized tumors (10 mm to 15 mm in diameter and 2 mm to 5 mm in elevation) is more controversial, and much more individual consideration is required, as there is less consen- sus on the management of this size of tumor. Other treatment modalities such as xenon arc photocoagulation, cryotherapy, and local full- thickness eyewall resection are not commonly used.* Recently the use of the high energy argon laser has shown promise in animal models.^* Conclusions Clinical prosnostic factors of uveal melanoma in order of greatest significance are tumor size, histologic type, scleral extension, and mitotic ac- tivity. The ophthalmic pathologist has a pivotal role in gross and microscopic examination of the eye. / Acknowledgments Figure 2 is courtesy of Robert Baker, M.D., Lexington, KY. The authors gratefully acknowledge the secretarial assist- ance of Martha Potts and photographic expertise of Medical Media Production Service, VAMC. REFERENCES 1. Weiss JS. Albert DM: Intraocular melanoma, in DeVita VT. Heilman S, Rosenberg SA (eds): Cancer. Principles and Practice of Oncology, ed. 2. Phila- delphia, JB Lippincott, 1985, pp 1423-1436. 2. Young JL, Percy CL, Asire AJ, et al; Cancer incidence and mortality in the United States, 1973-1977. Cancer Inst Moriogr 57:1-187, 1981. 3. Barr CC, McLean IW, Zimmerman LE: Uveal melanoma in children and adolescents. Arch Ophthalmol 99:2133-2136, 1981. 4. Raivio I: Uveal melanoma in Finland: an epidemiological, clinical, histo- logical and prognostic study. Acta Ophthalmol 133 (suppl): 3-63, 1977. 5. Scotto J, Fraumeni JF, Lee JAH: Melanomas of the eye and other non- cutaneous sites. J Natl Cancer Inst 56:489-491, 1976, 6. Bettman JW: Eye disease among American Indians of the Southwest. I. Overall analysis. Arch Ophthalmol 88:263-268, 1971. 7. Tucker MA, Shields JA, Hartge P. Sunlight exposure as a risk factor for intraocular malignant melanoma. N Engl J Med 313:789-792, 1985. 8. Yanoff M, Fine BS: Ocular melanotic tumors, in Ocular Pathology: A Test and Atlas, ed 3. Philadelphia, JB Lippincott, 1989, p 657. 9. Albert DM, Paliafito CA, Fulton AB, et al: Increased incidence of cho- roidal malignant melanoma occurring in a single population of chemical workers. Am J Ophthalmol 89:323-337, 1980. 10. Reese AB: Tumors of the Eve. ed 3. New York, Harper and Row, 1976, pp 193-196. 11. Shields JA: Tumors of the uveal tract, in Duane TD (ed): Clinical Oph- thalmology. Philadelphia, JB Lippincott, 1988, pp 3-6, 12. Seddon JM, Polivogianis L, Hsieh C: Death from uveal melanoma: num- ber of epithelioid cells and inverse SD of nucleolar area as prognostic factors. Arch Ophthalmol 105:801-806, 1987. 13. Shammas HF, Blodi FC: Prognostic factors in choroidal and ciliary body melanomas. Arch Ophthalmol 95:63-69. 1977. 14. Graham BJ, Duane TD: Meetings, conferences, symposia: report of ocu- lar melanoma task force. Am J Ophthalmol 90:728-733, 1981. 15. Albert DM. Wagoner MD. Smith ME: Are metastatic evaluations indi- cated before enucleation of ocular melanoma? Am J Ophthalmol 90:429-432, 1981. 16. Frederic DR, Chan DH, Ljung BM: Solitary intraocular lymphoma as an initial presentation of widespread disease. Arch Ophthalmol 107:395-397, 1989. 17. Shields JA, Augsburger JJ. Donoso LA, et al: Hepatic metastasis and orbital recurrence of uveal melanoma after 42 years. Am J Ophthalmol 100:666- 668, 1985. 18. Miller TR, Gomez-Moreiras JJ, Smith ME: The value of liver scintigra- phy in choroidal melanoma. Arch Ophthalmol 97:1875-1876, 1979. 19. Zimmerman LE, McLean IW. Foster WD: Does enucleation of the eye containing malignant melanoma prevent or accelerate the dissemination of tumor cells? Br J Ophthalmol 62:420. 1973, 20. Zimmerman LE. McLean IW: An evaluation of enucleation in the man- agement of uveal melanoma. Am J Ophthalmol 87:471. 1979. 21. Jaffe GJ, Mieler WF. Burke JM, et al: Photoablation of ocular mela- noma with a high-powered argon endolaser. Arch Ophthalmol 107:113-118, 1989. JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION Cutaneous Alternaria Infection in a Patient on Chronic Corticosteroids RICHARD M. SNEERINGER, M.D. and DAVID W. HAAS, M.D. Alternaria is a saprophytic soil fungus found widely in nature. Although it is classified with pathogenic fungi such as Aspergillus, Blasto- myces, and Histoplasma in the class Hyphomy- cetes, it only rarely causes disease in man. Syn- dromes described have included cutaneous infectiond'"* osteomyelitis^ pulmonary granu- lomad peritonitis,' nasal septal infection in a pa- tient with acquired immunodeficiency syndrome (AIDS),® and spore-induced bronchial asthma and hypersensitivity pneumonitis.^ We describe a case of severe cutaneous alternariosis in a patient on chronic systemic steroid therapy. A review of the pertinent literature follows. Case Report A 70-year-old white man was admitted to the Nashville Veterans Administration Medical Center with a two-day his- tory of nausea, coffee ground emesis, dehydration, and dys- pnea. He had previously been admitted numerous times for chronic obstructive lung disease, and had received oral pred- nisone therapy (at least 10 mg daily) for the preceding three years. Medications on admission included prednisone 30 mg twice a day as well as digoxin, furosemide, enalapril, theo- phylline, and inhaled isoetharine. Oral trimethoprim-sulfa- methoxazole had been started five days earlier. Physical ex- amination was remarkable for a temperature of 98.6° F with expiratory wheezes over both lungs. His skin and abdomen were normal. Laboratory studies revealed a blood urea nitro- gen of 68 mg/dl, creatinine 8.6 mg/dl, WBC count 17,600/cu mm and hematocrit 41%. Following further work-up the diagnosis of sulfa-induced interstitial nephritis was made. His renal dysfunction im- proved with discontinuation of the trimethoprim-sulfame- thoxazole. Esophagogastroduodenoscopy (EGD) with biopsy performed the day after admission revealed severe distal esophagitis. Special stains were consistent with herpes sim- plex. His gastrointestinal symptoms improved with intrave- nous acyclovir. On the third hospital day his right forearm was noted to be diffusely erythematous, and by the following From the Departments of Internal Medicine (Dr. Sneeringer) and Infectious Diseases (Dr. Haas), Vanderbilt University Medical Cen- ter, Nashville. Reprint requests to Division of Infectious Diseases. Vanderbilt University Medical Center, C-3210 Medical Center North, Nashville, TN 37232 (Dr. Haas). day developed ecchymotic areas and several hemorrhagic bullae. Initially this was thought to be a chemical cellulitis, possibly due to extravasation of radiocontrast material given two days before, but similar lesions soon appeared on the left forearm. Silver stains of a skin biopsy revealed branching, septate hyphae (Fig. 1). Treatment was begun with ampho- tericin B, 20 mg every other day, topical silvadene, and whirlpool therapy. The lesions progressed to full thickness sloughing of the skin of both upper extremities (Fig. 2). On the fifth day culture of the skin biopsy specimen grew pure growth of a fungus with conidial characteristics of Alternaria (Fig. 3). The patient's course was complicated by culture-negative sepsis, for which broad-spectrum antimicrobial therapy was begun. He subsequently developed refractory bronchospasm, gastrointestinal bleeding, and hypotension. In accord with the family’s wishes, aggressive resuscitation was not attempted. The patient died on the 20th hospital day. Autopsy revealed bacterial bronchopneumonia, centrilobular emphysema, gas- tric ulcerations, esophagitis, adrenal atrophy, and acute my- ocardial infarction. No evidence of disseminated alternariosis was found. Discussion Cutaneous alternariosis was first described in 1933 by Borsock^ following a splinter wound to the hand of a normal host. Subsequently, Yu^° found that Alternaria often colonized normal skin. In 1976, Farmer and Pedersen first identified pri- Figure 1. Patient's right forearm on hospital day 8. JANUARY, 1990 15 Figure 2. Skin biopsy demonstrating branching, septate hyphae (ar- row) in the subdermal tissue (Gomori-methenamine silver stain, X 1,200). mary (nontraumatic) cutaneous alternariosis in immunocompromised hosts. ^ ^ In the interim an increasing number of such cases have been re- ported. Vivianb reviewed 33 cases reported prior to 1981, 19 of whom were immunocompromised, six had renal transplants, five Cushing’s syn- drome, four hematologic malignancies, and one each discoid lupus, topical steroid use, and pri- mary pulmonary hypertension. An additional pa- tient was receiving chronic systemic steroid ther- apy similar to our patient. The clinical features of cutaneous alternariosis seen in our patient are consistent with those de- scribed elsewhere. Single or multiple erythema- tous papulonodular lesions with later formation of hemorrhagic bullae and ulceration are typical. Early lesions may resemble Mycobacterium mar- inum infection, but unlike mycobacteria, Alter- naria species do not grow on Lowenstein-Jen- sen’s medium. The clinical diagnosis of alternariosis is com- plicated by Alternaria’s being a frequent contam- inant encountered in the laboratory, especially when samples are obtained from potentially col- onized surfaces such as skin or mucous mem- branes. It grows rapidly on Sabourand agar, forming dark grey to grey-green colonies that lat- er turn black with a white rim.^^ When grown in vitro, ovoid conidia with multiple transverse, longitudinal, and oblique septa (also called dic- tyoconidia) are formed from conidiophores (Fig. 3). Definitive diagnosis of invasive skin infection requires PAS or methenamine silver stain to identify hyphal elements and vesicular bodies in Figure 3. Alternaria conidia with characteristic multiple transverse (large arrow) and a single oblique (small arrow) septum (cotton phenol blue stain, X 1,200). the dermal or hypodermal tissues, often associ- ated with microabscesses, a granulomatous infil- trate, or visualization of the organism within macrophages or neutrophils.^ Reports on the treatment of Alternaria with an- timycotic agents are few. Mardh and Hallberg^ tested six stains of Alternaria in vitro and found them all to be susceptible to 10 |JLg/ml of clotrima- zole, natamycin and nystatin. Ketoconazole was ineffective in the treatment of a cutaneous infec- tion.^^ An AIDS patient with invasive nasal alter- nariosis was cured by excision of his nasal septum with administration of 1 gm of amphotericin B. Notably, this patient acquired his infection while receiving ketoconazole for candidiasis.® While it is impossible to make definitive recommendations based upon the limited published experience, early excision of involved tissues when feasible, with concurrent local and/or systemic antimycotic ther- apy, is a reasonable approach. Summary We have presented a case of invasive cuta- neous alternariosis in a patient receiving chronic oral steroid therapy. Alternaria must be consid- ered in the differential diagnosis of any progres- sive cutaneous infection in an immunocompro- 16 JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION CUTANEOUS ALTERNARIA INFECTION/Sneeringer mised patient. Invasive maneuvers are often needed to confirm the diagnosis. Given the rarity of cases and lack of controlled clinical trials, firm therapeutic guidelines are not available. Clini- cians are likely to encounter more such cases as the population of immunocompromised hosts grows. r ^ REFERENCES 1. Farmer SG, Komorowski RA: Cutaneous microabscess formation from Alternaria alternata. Am J Clin Pathol 66:565-569. 1976. 2. Pedersen NB. Mardh P-A, Hallberg T, et al: Cutaneous alternariosis. Br J Dermatol 94:201-209, 1976. 3. Borsock ME: Skin infection due to Alternaria tenuis. Can Med Assoc J 39:479. 1933. 4. Viviani MA, Tortorano AM, Laria G, et al: Two new cases of cutaneous alternariosis with a review of the literature. Mycopathologia 96:3-12, 1986. 5. Garau J, Diamond RD. Lagrotteria LB. et al: Alternaria osteomyelitis. Ann Intern Med 86:747-748. 1977. 6. Lobritz RW, Roberts TH, Marraro RV, et al: Granulomatous pulmonary disease secondary to Alternaria. JAMA 241:596-597. 1979. 7. Reiss-Levy E, Clingan P: Peritonitis caused by Alternaria alternata. Med J Aust 2:44, 1981. 8. Wiest PM, Weise K, Jacobs MR, et al: Alternaria infection in a patient with acquired immunodeficiency syndrome: case report and review of invasive Alternaria infections. Rev Infect Dis 9:799-803, 1987. 9. Schlueter DP, Pink JN. Hensley GT: Wood-pulp worker's disease: a hy- persensitivity pneumonitis caused by Alternaria. Ann Intern Med 77:907-914. 1972. 10. Yu H: Studies on fungi of normal skin. Acta Derm 60:126. 1965. 11. Mardh P-A, Hallberg T: Alternaria alternata as a cause of opportunistic fungal infections in man. Scand J Inf Dis 16 (suppl): 36-40. 1978. 12. Del Palacio HA, Conde-Zurita JM. Reyes PS. et al: A case of Alternaria alternata infection of the knee. Clin Exp Dermatol 8:641-646, 1983. JANUARY, 1990 17 Colonoscopic Removal of a Gallstone Obstructing the Sigmoid Colon SHAUNA R. ROBERTS, M.D.; CINDY CHANG, M.D.; TODD CHAPMAN, M.D.; PAUL G. KOONTZ, JR., M.D.; and GERALD L. EARLY, M.D. Introduction Biliary-enteric fistula occurs in up to 5% of all patients who have gallstones; cystic duct obstruc- tion, cholecystitis, and multiple episodes of ad- jacent tissue inflammation usually precede fistula formation. As many as 21% of patients who de- velop a biliary enteric fistula will have clinical evidence of gallstone ileus. The majority will pass their gallstones, but once obstruction takes place, passage of the stone almost never occurs. ‘ * Gallstone ileus is the cause of mechanical small bowel obstruction in up to 4% of the general population. The typical patient is an elderly woman with multiple medical problems and a history of gallstones. Most patients have several days of crampy abdominal pain, vomiting, and intermittent obstipation due to “tumbling” of the stone. (The gallstone typically causes intermit- tent obstruction as it moves distally to its final impaction point.) The clinical picture of small bowel obstruction is usually present, since the il- eocecal valve is the most common site of gall- stone impaction. Other sites of involvement in order of frequency are mid-ileum, jejunum, stomach, duodenum, and colon; approximately 5% of gallstone ileus cases involve obstruction of the colon. Courvoisier*^ described the first case of a gall- stone obstructing the colon in 1890. Since then, approximately 60 cases have been reported, most of them at a site of a preexisting narrowing. Pri- mary small bowel obstruction may be absent if the stone reaches the colon directly by fistula formation, if a stone is small enough to pass through the small bowel but not an area of dis- eased colon, or if a stone enlarges in the colon From the Department of Surgery, University of Missouri-Kansas City, and St. Luke’s Hospital, Kansas City, Mo, Reprint requests to Department of Surgery, University of Tennes- see College of Medicine, 956 Court Ave., Memphis, TN 38163 (Dr. Roberts). 18 (by fecal concretions or inspissation with other stones). The diagnosis of gallstone ileus is suspected preoperatively in 45% to 55% of cases.^ ^ ^^ Ra- diopaque gallstones are appreciable on abdomi- nal films in about 66% of patients, and there- fore a plain abdominal film that shows bowel obstruction and migration of a preexisting gall- stone out of the right upper quadrant suggests the diagnosis of gallstone ileus. Pneumobilia may be present in up to 71% of cases, but may be difficult to appreciate. About 90% of suspected cases of duodenocolic fistula may be diagnosed by barium enema. Case Report An 85-year-old white woman gave a 12-day history of progressive abdominal distension and obstipation after hav- ing earlier experienced recurrent bouts of severe indigestion and abdominal discomfort which had subsequently resolved. The patient had a history of peptic ulcer disease and choleli- thiasis without known cholecystitis. Her primary care physi- cian performed an upper gastrointestinal series, which showed a large calcification in the left lower quadrant similar to that previously seen in the gallbladder (Fig. 1). Significant elec- trolyte and acid-based disturbances were present, and fluid and electrolyte resuscitation were performed. Sigmoidoscopy revealed a large stone impacted in the mid- sigmoid region. Partial fragmentation of the distal portion of the stone was achieved with the polypectomy snare, but the patient did not pass the stone and had further evidence of bowel distension within a few hours. On a second colonos- copic procedure, the papillotomy balloon was manipulated beyond the largest fragment of the stone (4 cm), which was then gently withdrawn into the distal sigmoid colon; the stone was encircled with the polypectomy snare and gradually with- drawn. Except for diverticulosis, there was no other apparent intraluminal pathology. The patient subsequently regained normal bowel function. Nine months later, with the patient in good general con- dition, elective cholecystectomy was performed without com- plications. Discussion Many aspects of the management of gallstone ileus remain controversial, particularly as to whether or not the operative intervention should be staged, using the initial procedure only to re- JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION lieve the obstruction and close the fistulad The mortality rate has been in the 13% to 20% range for single-stage or two-stage therapy. At lapa- rotomy the entire intestinal tract should be care- fully examined for other stones, as multiple stones large enough to obstruct the intestine are present in about 13% of cases. Gallbladder carci- noma occurs in as many as 15% of patients with a biliary enteric fistula, ^ as compared to 0.8% of all patients who have cholecystectomies.^^ Ideally, the fistula should be closed, chole- cystectomy performed, and the common duct evaluated. This case of gallstone ileus is particularly in- teresting because the gallstone obstructed the sigmoid colon, and the colonic obstruction was relieved nonoperatively in this very ill patient who Figure 1. The arrow in the patient's left lower quadrant points to a calcification previously seen in the right upper quadrant. was extremely frail due to age and other medical problems. Although endoscopic retrieval of gall- stones from the stomach has been reported, we are not aware of other reports of endoscopic gallstone extraction from the sigmoid colon. The condition of the patient may require that the initial procedure consist only of relief of the bowel obstruction. If there is no evidence of common duct obstruction, cholecystectomy and fistula closure can be performed as a “second op- eration.” Indications for cholecystectomy and fistula repair are continuing symptoms, remain- ing gallstones, nonfunctioning gallbladder, and a patent biliary-enteric fistula.^ Summary For the patient with a single gallstone ob- structing the colon, this technique offers non- operative relief of the obstruction, allowing de- finitive operative therapy to be accomplished at a later time on a more elective basis. The patient should be carefully observed during the interval for intervening recurrent gallstone ileus, r ^ REFERENCES 1. Glenn F, Reed C, Grafe W: Biliary enteric fistula. Surg Gvnecol Obstet 153:527-531. 1981. 2. Hricak H, Vander Molen R: Duodenocolic fistula with gallstone ileus. Am J Gastroenterol 69:711-715. 1978. 3. Kurtz R. Heimann T. Kurtz A: Gallstone ileus: a diagnostic problem. Am J Surg 146:314-317. 1983. 4. Buetow G. Glaubitz J, Crampton R: Recurrent gallstone ileus. Surgery 54:716-724. 1963. 5. Milsom J, MacKeigan J: Gallstone obstruction of the colon: report of two cases and review of management. Dis Colon Rectum 28:367-370, 1985. 6. Cooperman A. Dickson R. ReMine W: Changing concepts in the surgical treatment of gallstone ileus: a review of 15 cases with emphasis on diagnosis and treatment. Ann Surg 167:377-383, 1968. 7. Kurtz R, Heimann T, Beck R. et al: Patterns of treatment of gallstone ileus over a 45-year period. Am J Gastroenterol 80:95-98, 1985. 8. Pryor J: Gallstone obstruction of sigmoid colon with particular reference to aetology. Br J Surg 47:259-260, 1959. 9. Ramanujam P, Shabeeb N. Silver J: Unusual manifestations of gallstone migration into the gastrointestinal tract. South Med J 76:30-32, 1983. 10. Phillips D. Doran J: Obstruction of the colon by a giant gallstone. Br J Hosp Med 36:444, 1986. 11. van Hillo M, van der Vliet J, Weggers T, et al: Gallstone obstruction of the intestine: an analysis of ten patients and a review of the literature. Surgery 101:273-276, 1987. 12. Bedogni G. Contini S, Meinero M, et al: Pyloro-duodenal obstruction due to a biliary stone (Bouveret’s syndrome) managed by endoscopic extraction. Gastrointest Endosc 31:36-38, 1985. 13. Shocket E, Evans J, Jonas S: Cholecysto-duodenocolic fistula with gall- stone ileus. Arch Surg 101:523-526, 1970. 14. Kreel L: Gallstone ileus. Postgrad Med J 61:511-512, 1985. 15. Tomescu O, Levien D. Mahoney W, et al: Surgical options in the treat- ment of gallstone ileus. Contemp Surg 25:11-15, 1984. 16. Berliner S, Burson L: One-stage repair for cholecyst-duodenal fistula and gallstone ileus. Arch Surg 90:313-316, 1965. JANUARY, 1990 19 Trauma Rounds Recognition of the Subtle Signs of Child Abuse R. LESLIE MILES, M.D. and R. PHILLIP BURNS, M.D. Millions of children are seen every year in pediatric emergency rooms across the nation with traumatic in- juries ranging from minor burns and bruises to serious intra-abdominal and intracranial pathology.' Approxi- mately 1 million of these children will have been the victims of physical abuse or neglect, representing a 1.6% prevalence rate in the population of children un- der 18 years of age.^ Because these victims of nonac- cidental trauma are seen not only by pediatricians but by emergency room physicians and surgeons, and be- cause children are often unwilling or unable to give an adequate history, it is important for the physician to be cognizant of the historical discrepancies and the physical signs and symptoms that should raise one’s index of suspicion for child abuse. We present a case of child abuse and briefly outline the historical and physical factors that will alert the physician to possible abuse. Case Report A 29-month-old black boy was admitted to the emergency room of T. C. Thompson Children’s Hospital in Chattanooga by his stepfather, who stated the child apparently had fallen from the upper level of a bunk bed while he was away from home (the child was unattended), and that the child was un- conscious when he returned. On further questioning, the man admitted he was not actually married to the patient’s mother, and that he had been arrested on another charge. On physical examination the patient’s blood pressure was 128/78 mm Hg, pulse 128/min, and respirations 36/min. He had multiple bruises and abrasions on both sides of his face. Pupils were small and sluggishly reactive, and both eyes were deviated downward. The abdomen was distended, but non- tender and with normal bowel sounds, and a large abrasion was noted in the right lower quadrant. The child responded purposefully to pain on the left side, but demonstrated very little movement in his right upper or lower extremities. The toes of his left foot had several discrete, old-appearing burn marks. Laboratory examination revealed a hematocrit of 25.6%, an MCV of 72 cup,, and gross hematuria on urinaly- sis. The patient was admitted to the pediatric intensive care unit, where an intracranial pressure monitor was placed and a phenobarbital coma induced. The patient remained in in- tensive care 21 days, during which time he experienced re- current episodes of elevated intracranial pressure, treated with osmotic diuresis and hyperventilation. The patient was dis- charged on disability income with daily physical therapy. From the Department of Surgery, University of Tennessee Col- lege of Medicine, Chattanooga Unit. 20 Discussion Over the course of the last three decades the Amer- ican public has become increasingly aware of the prob- lem of child abuse. Physicians, of course, are most often responsible for recognizing the subtle clinical signs asso- ciated with this problem, and often have difficulty in doing so since the history, usually given by the parents, is invariably inaccurate.^ The physician should always have the question, “Could this be abuse?” in the back of his mind as he assesses the injured child, and should repeatedly request clarification and amplification as the parent or child relates the history of the event. A discrepancy between the history of the trauma and the degree of physical injury will often exist, leading the physician to doubt the verity of the history and requiring the physician to rely much more heavily on clinical signs in assessing the child. The time sequence is important to note in the history. Often the reported time of injury does not correlate with obvious age of injury or the seeking of medical advice, and the history may include repeated trauma with the child having been seen in a number of different emergency rooms. The parents of abused children often respond inappropriately or do not comply at all with medical advice. Another salient feature to note in the history is age, since toddlers more often sustain intra-abdominal in- juries from physical abuse, while internal injuries in school age children are usually the result of contact sports, a fall onto bicycle handlebars, or traffic acci- dents.^ Information on the child’s birth and medical history as well as the mother’s pregnancy provides im- portant insight into her attitude about the child. ^ Social history is also important in identifying other factors that may be associated with child abuse: socio- economic status, parental divorce, illegitimacy, physi- cal and mental defects in the child, and teen pregnan- cy, all of which are seen with increased frequency in the abused child and his family. In addition, those children who are perceived as different, or actually are different, or actually are different in terms of physical or behavioral characteristics (such as the fussy, irrita- ble, hyperactive child or the child with congenital mal- formation, developmental disability or mental retar- dation) are at higher risk of abuse than the normal child. JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION On physical examination, the early signs that should alert the child’s physician to possible abuse are neglect and malnutrition. The earliest signs of actual physical abuse are usually soft tissue injuries, with certain pat- terns and locations of injury being characteristic. These injuries are seen about the head, perioral, perianal, and genital regions, with bruising being the most com- mon manifestation. Often they will be of a bizarre na- ture, such as bites, rope marks, or cigarette burns, and often are in different stages of resolution, indicating multiple episodes of battering and abuse. ^ Another frequently encountered problem is long bone fracture, especially in children under 3 years of age."* These fractures are usually several days old and inadequately explained by the parents. The three most common fractures are humeral, femoral, and rib, with the types of fractures suggestive of jerking or twisting forces. Of course multiple fractures, especially in the toddler, provide even stronger evidence that the inju- ries are nonaccidental. ^ Cranial trauma is the most frequent cause of mor- bidity and death in abused children. Many of these injuries, especially the more serious intracranial inju- ries, are difficult to distinguish from accidental injuries as the manifestations of both are similar. ^ Some of the more common cranial trauma injuries seen are alopecia due to hair pulling, skull fracture, and subdural hematoma. Abusive alopecia is usually diffuse, while complex depressed or diastatic fractures, retinal hemorrhages, and associated findings of abuse make the diagnosis of nonaccidental skull fracture more likely. Subdural hematoma is rarely seen except in in- stances of inflicted injury. Kravitz demonstrated in a study of 330 accidental falls only one infant who sus- tained a subdural hematoma, while Billmire and Myers found that 95% of life-threatening head injuries were the result of child abuse. ^ In summary, the problem of child abuse is charac- terized by denial on the part of the perpetrators. Be- cause they cannot be relied upon to provide an accu- rate history, the physician must approach possible cases of child abuse with a high degree of suspicion and a firm grounding in signs and symptoms commonly as- sociated with child abuse. If child abuse is suspected, the physician must act as an advocate for the child by reporting his findings to the proper authorities to en- sure that the child’s well-being and possibly the child’s life will be protected after the child leaves the physi- cian’s care. / REFERENCES 1. Ledbetter DJ. et al: Diagnostic and surgical implications of child abuse. Arch Surg 123:1101-1105, 1988. 2. Reece RM. Grodin MA: Recognition of nonaccidental injury. Pediatr Clin North Am 32:41-60, 1985. 3. O'Neill JA, et al: Patterns of injury in the battered child syndrome. J Trauma 13:332-339, 1973. 4. Adyanced Trauma Life Support Student Manual. American College of Surgeons Committee on Trauma, 1984, pp 172-173. 5. Billmire ME, Myers PA: Serious head injury in infants: accident or abuse? Pediatrics 75:340-342, 1985. Odds Are Against You... . , . when you take a chance on disability without disability insurance. A disability can strike without warning. In fact, you are three times more likely to be disabled this year than to die!* You can protect your ability to practice medicine through the Tennessee Medical Association’s plan of disability coverage. Fill out, clip and return the coupon below. We will send you information on a disability plan that’s a sure winner. Or, call us toll tree at 1-800-347-1109. 'Journal of the Amencan Society ot Chartered Lite Underv^riters. Vol VIII. No 1 (Based on persons between the ages of ^2 and ~2) Yes, send me information on TMAs non- cancellable disability insurance plan. Name Date of Birth Spouse Date of Birth Firm name Address City- State Smoker yes CIl no (ZI Zip Spouse yes Cl no C Mail to Plan Administrator The TMA Association Insurance Agency, Inc. P.O. Box 1109, Chattanooga, TN 37401 Sponsored by the Tennessee Medical Association! JANUARY, 1990 Vanderbilt Morning Report A Case of Cyanosis Without Hypoxemia Case Report A 24-year-old man entered the emergency room com- plaining of dizziness, nausea, and mild dyspnea after having inhaled several “poppers” (amyl nitrite). His past medical history was unremarkable. On physical examination, he was afebrile, his respiratory rate was 24/min, and his heart rate was 140/min. He was distinctly cyanotic and remained so de- spite supplemental oxygen. An arterial blood gas on 5 L/min oxygen showed pH 7.38, PCO2 39 mm Hg, POi 183 mm Hg. His methemoglobin level was 22% (normal < 3%). The re- mainder of his laboratory data was normal. He was sympto- matically improved after several hours of observation and subsequently was discharged. Discussion Methemoglobin is a derivative of hemoglobin in which the iron has been oxidized from the normal (reduced) ferrous (Fe++) state to the ferric (Fe+ + + ) state. Methemoglobin does not transport oxygen, and it has an intense dark blue color which causes clinically apparent cyanosis at concentrations of 15% or greater.’ Spontaneous formation of methemoglobin occurs slowly in vivo. There are several active metabolic processes that reduce methemoglobin back to hemoglobin^; the most active is dependent on reduced nicotinamide-adenine dinucleotide (NADH) and uti- lizes cytochrome bj as the physiologic electron carrier. Other biochemical systems are capable of reducing methemoglobin to hemoglobin but do so in vivo at much slower rates than the NADH-cytochrome sys- tem. One such pathway is an NAD-phosphate de- pendent (NADP-dependent) system which plays little physiologic role in reduction of methemoglobin be- cause an artificial electron carrier, such as methylene blue, is required. However, this enzymatic system is the major pathway by which methylene blue acceler- ates reduction of methemoglobin. The system also re- quires that reduced NADP (NADPH) be generated by the pentose phosphate pathway, the first step of which is catalyzed by glucose-6-phosphate dehydrogenase (G6PD). Methemoglobinemia may be congenital or ac- quired. Congenital methemoglobinemia may occur either as a result of an abnormality in the hemoglobin molecule (hemoglobin M) or as a result of a biochem- ical deficiency in the normal cellular protective mech- anisms. Acquired methemoglobinemia results from exposure to various drugs and chemicals.’’ Neonates are Prepared by Thomas E. Ducker, M.D., medical resident, and William F. Fleet, IIF M.D., Hugh J. Morgan chief medical resident, Vanderbilt University Hospital, Nashville. 22 particularly sensitive to induction of methemoglobine- mia. Agents capable of inducing methemoglobinemia include the aniline dyes, antimalarials, chlorates, cop- per sulfate, dapsone, local anesthetics, naphthalene, nitrites^ and nitrates (including sodium nitrite, amyl nitrite, butyl nitrite, nitroglycerin, nitroprusside, and silver nitrate), nitrobenzene, PAS, phenacetin, phen- azopyridine, and sulfonamides. Cases of fatal met- hemoglobinemia due to recreational use of inhaled ni- trites have been reported. ^ Symptoms of methemoglobinemia are dependent on the concentration of methemoglobin. At concentra- tions of 15% to 20%, cyanosis and “chocolate brown” blood are apparent. Concentrations of 20% to 45% are associated with dyspnea, fatigue, lethargy, head- ache, and dizziness. Progressive CNS depression oc- curs at concentrations of 45% to 55%, and concentra- tions greater than 70% are associated with a high mortality rate. The diagnosis of methemoglobinemia should be suspected in patients who present with cy- anosis in the absence of respiratory distress and in those whose cyanosis fails to correct with 100% oxygen administration. The diagnosis of methemoglobinemia is suggested by the failure of blood to become bright red on exposure to oxygen. Blood with 10% or greater methemoglobin leaves a characteristic dark red-brown stain on filter paper. The diagnosis may be confirmed by direct measurement of the methemoglobin level. Specific therapy for methemoglobinemia should be given to those with methemoglobin concentrations greater than 40% and to those in whom the methe- moglobin level is rapidly rising. Treatment consists of administration of intravenous methylene blue (tetra- methylthionine chloride) in a dose of 0.1 to 0.2 cc/kg of a 1% solution (1 to 2 mg/kg) over five minutes. Methylene blue activates the NADPH-methemoglobin reductase system but is ineffective if the patient has G6PD deficiency. In severely affected patients and in those suffering from chlorate poisoning (in whom methylene blue is ineffective), exchange transfusion should be considered. REFERENCES 1. Jaffe ER: Methemoglobinemia in the differential diagnosis of cyanosis. Hasp Practice 20:92-110, December 1985. 2. Jaffe ER: Methaemoglobinaemia. Clin Hematol 10:99-122, 1981. 3. Hall AH. Kulig KW. Rumack BH: Drug- and chemical-induced methae- moglobinaemia. Clinical features and management. Med Toxicol 1:253-260, 1986. 4. Walley T, Flanagan M: Nitrite-induced methaemoglobinemia. Postgrad Med J 63:643, 1987. 5. O Toole JB III, Robbins GB, Dixon DS: Ingestion of isobutyl nitrite, a recreational chemical of abuse, causing fatal methemoglobinemia. J Forensic Sci 32:1811-1812, 1957. JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION A Case of Syncope in the Church Choir Case Report A 78-year-old man was admitted after experiencing syn- cope while singing in his church choir. Before losing con- sciousness, he noted light-headedness and “skipped heart beats”; he regained consciousness quickly. He had experi- enced three similar episodes over the previous two years, each time while singing in the choir. Past medical history was re- markable only for mild coronary artery disease demonstrated by cardiac catheterization in 1980. Medications included pro- pranolol, isosorbide dinitrate, and quinidine gluconate, which he took for suppression of PVCs. At admission, the blood pressure w'as 100/50 mm Hg in both arms. There were no carotid bruits and no jugular ven- ous distension. Cardiac rhythm was regular with a rate of 68/ min and no murmur or gallop. Neurologic examination w'as normal. Laboratory findings and EKG were unremarkable. Continuous cardiac monitoring showed no significant dys- rhythmia, and serial cardiac enzyme determinations revealed no evidence of myocardial infarction; echocardiogram was normal. When carotid sinus massage was performed with minimal pressure on the right carotid artery, high degree AV block with marked bradycardia and hypotension developed (Fig. 1); formal electrophysiologic testing confirmed these findings. Premedication with atropine before carotid sinus massage prevented bradycardia and hypotension. It was pos- tulated that the combination of wearing a necktie and per- forming the valsalva maneuver while singing stimulated the hypersensitive carotid sinus. Subsequently, a ventricular de- mand pacemaker was placed for treatment of hypersensitive carotid sinus. Discussion Carotid sinus hypersensitivity is not a common cause of syncope, but it should always be considered in the differential diagnosis of recurrent syncope.' Two ma- jor types of this syndrome have been described. In cardio-inhibitory hypersensitivity' asystole or marked bradycardia results from carotid sinus stimulation. The cardio-inhibitory response is mediated by vagal action on the sinoatrial and AV nodes and can be abolished with atropine. Vasodepressor hypersensitivity- causes a significant drop in arterial blood pressure (5=50 mm Hg, or 5=30 mm Hg if symptomatic) in the absence of a change in heart rate. The response is not abolished by atropine. This type of carotid sinus hypersensitivity is much less common than cardio-inhibitory hypersen- sitivity. The two types may coexist. Patients who have demonstrable carotid sinus hy- persensitivity may have additional causes for their syn- cope. A drop in cerebral perfusion due to atheroscle- rotic carotid artery disease may occasionally mimic carotid sinus hypersensitivity. Carotid sinus hypersensitivity is more frequent in the elderly; intrinsic conduction system disease is probably not the major underlying cause of this syn- drome (although there is debate about thisj.^"* Predis- Prepared by Anthony L. Thomas, M.D., medical resident, and William F. Fleet, III, M.D., Hugh J. Morgan chief medical resident, Vanderbilt University Hospital, Nashville. Figure 1. Continuous rhythm strip during light pressure (indicated by up arrow) on the right carotid sinus. During this maneuver, the patient developed marked sinus bradycardia and AV block, resulting in symptomatic hypotension. The abnormalities resolved after discontin- uing carotid sinus massage (indicated by down arrow). posing factors include diabetes, hypertension, ather- osclerotic vascular disease, and local abnormalities near the carotid sinus, such as scars or lymph nodes. There appears to be a significant correlation between carotid sinus hypersensitivity and the presence of significant coronary artery disease. ^ Precipitating factors are activities that stimulate the sensitive carotid sinus, including turning the head, shaving, and coughing. Many patients do not recall any specific precipitating factor. Various drugs (including digoxin, alpha-methyldopa, clonidine, and beta block- ers) may exacerbate the symptoms. The diagnosis of carotid sinus hypersensitivity is made by the demonstration of an abnormal response to carotid sinus massage. This maneuver should be performed only with continuous cardiac monitoring of the supine patient and after listening for carotid bruits. Complications of carotid sinus massage are rare but include stroke, asystole, and ventricular arrhythmias. In patients with the cardio-inhibitory type of hyper- sensitivity, carotid sinus massage should be repeated after pretreatment with 1 mg of atropine.^ If carotid sinus massage continues to cause hypotension in the absence of bradycardia, an element of vasodepressor response is also present. Therapy for carotid hypersensitivity includes: dis- continuing drugs that exacerbate the abnormality, an- ticholinergic and sympathomimetic drugs, denervation of the carotid sinus, and, most commonly, insertion of a ventricular pacemaker. Atrial pacing is often ineffec- tive. Symptoms due to the vasodepressor response may respond to a combination of ephedrine and propranolol’ or to a DVI pacer. Occasionally, these patients may require denervation of the carotid sinus. CZIP REFERENCES 1. Coplan NL. Schweitzer P: Carotid sinus hypersensitivity. Case report and review of the literature. Am J Med 77;561, 1984. 2. Almquist A, et al: Carotid sinus hypersensitivity: evaluation of the vaso- depressor component. Circulation 71:927-936. 1985. 3. Davies AB. Stephens MR. Davies AG: Carotid sinus hypersensitivity in patients presenting with syncope. Br Heart J 42:583-586. 1979. 4. Leatham A: Carotid sinus syncope (ed). Br Heart J 47:409-410. 1982. 5. Brown KA. Maloney JD, Smith HC. et al: Carotid sinus reflex in patients undergoing coronary angiography: relationship of degree and location of coronary artery disease to response to carotid sinus massage. Circulation 62:697-704, 1980. 6. Walter PF. Crawley SI. Domey ER: Carotid sinus hypersensitivity and syncope. Am J Cardiol 42:396-403. 1978. 7. Keating EC, Burks JM. Calder JR: Mixed carotid sinus hypersensitivity: successful therapy with pacing, ephedrine, and propranolol. PACE 8:356-359. 1985. JANUARY, 1990 23 Health and Environment Report Disposal of Infectious Wastes in Sanitary Landfills SARAH H. SELL, M.D. In 1988, after lengthy regulatory deliberations, a revised policy was announced for the disposal of infec- tious wastes in sanitary landfills. The current policy was developed by the combined infectious waste rule- making efforts of the divisions of Solid Waste Man- agement, Health Care Facilities, and Air Pollution Control of the Tennessee Department of Health and Environment. For regulatory purposes the Department has de- fined “infectious wastes” to mean wastes which con- tain pathogens with sufficient virulence and quantity so that exposure to the waste by a susceptible host could result in an infectious disease. The following are to be considered infectious wastes; isolation wastes, cultures and stocks of infectious agents and associated biologicals, human blood and blood products, pathological wastes, contamined sharp objects, contaminated animal carcasses, body parts or bedding, and facility-specified infectious wastes. It is recommended that all infectious wastes be in- cinerated, steam sterilized, or otherwise rendered noninfectious prior to disposal in sanitary landfills. However, the Division of Solid Waste Management will permit some infectious wastes to be landfilled provid- ed certain precautions and limitations are strictly en- forced. The following restrictions apply: ® Sharp objects must be securely packaged in puncture-proof packaging. • Cultures and stocks of infectious agents and as- sociated biologicals must be rendered noninfectious (e.g., autoclaved). Once properly treated, most such wastes may be approved for normal solid waste dis- posal. • Human blood and blood products and other body fluids may not be landfilled. This restriction applies to bulk liquids or wastes containing substantive amounts of free liquids; it does not, however, apply to blood- contaminated materials such as emptied blood bags, “dirty” linens, or bandages. • Recognizable human organs and body parts may not be landfilled. From the Tennessee Department of Health and Environment, Nashville, Dr. Sell is director of the TDHE Environmental Epide- miology Program. 24 Infectious wastes must be managed at the landfill according to these minimal operating restrictions; • Infectious wastes must be transported to the landfill separately from other solid wastes and in se- curely tied plastic bags or other leak-proof containers. • Either the landfill operator must obtain advance notice before receiving a shipment of infectious waste, or a routine delivery schedule must be established, so that the operator will have time to prepare to receive the waste. • The landfill operator must confine unloading and disposal operations to a specific area, separate from the normal working face, prepared to assure proper disposal with minimal complications. • By the end of the operating day, the landfill op- erator shall have applied at least one foot of cover ma- terial over the waste and shall have compacted the emplaced cover material. There should be no compac- tion of uncovered infectious waste. It should be noted that this policy does not obligate the Division of Solid Waste Management to allow the disposal of any infectious waste in any landfill. The granting of approval for disposal of any special waste in a landfill is a case-by-case determination made at the division field office level based on several factors. That approval should be denied or revoked if the field office manager has reason to believe that the above requirements will not be or are not being met. Also, it should be noted that the approval does not obligate any landfill operator to accept infectious waste for dis- posal. He may refuse to accept the waste or may im- pose additional conditions on the infectious waste gen- erator. This policy covers not only wastes generated by hospitals and nursing homes, but also by clinics, phy- sicians’ offices, dental offices, veterinary offices and other generators of infectious waste. Physicians and other generators of infectious waste should give high priority to establishing office or clinic procedures to take care of their wastes in an acceptable manner. Sharp object disposal poses specific problems. In addition to being “infected” after use, these instru- (Continued on page 26) JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION Medicolegal Junction Reach for the Moon: The TMA-TBA Code of Cooperation DENNIS LORD TMA Staff Attorney I was 17 years old and living in Athens, Greece. The city set up about 20 television sets in the square near our house so everyone could watch, and hundreds of people gathered around, riveted to the screens. When the lunar module touched down, a great cheer went up from the crowd. Man had landed on the moon. What an accomplishment! The impossible had been done! What a cooperative effort! It was 1969. That same year accolades must have been ex- pressed right here in Tennessee. Certainly they were for the lunar landing. But another major event also occurred in 1969. The Tennessee Medical Association (TMA) and the Tennessee Bar Association (TBA) hammered out their mutual Code of Cooperation. Now, that was an accomplishment! That was a coop- erative effort. Nothing is impossible! But that was 20 years ago, and so in June 1989 committees of the TMA and TBA sat down to revise and update the Code. Thomas Ballard, M.D., who participated on both occasions, said it wasn’t as diffi- cult this time. In fact, the revision process went quite smoothly for a number of reasons, not the least of which is that several sections of the Nashville Acade- my of Medicine-Nashville Bar Association Code of Cooperation (promulgated in 1988) were adopted. For that, we owe the two Nashville associations sincere thanks. Another reason is that the basic framework already existed, taken from the 1969 Code, and in fact much of the language remains the same. But the most exciting reason that the 1990 revision went so well is expressed in two words — communica- tion and cooperation. A committee from each organi- zation sat down together and talked things out in an atmosphere of mutual respect, patience, and sincerity. There was give and take on both sides, and genuine interest in understanding each other’s position. Ulti- mately, that’s what our Code is all about. Code History The first TMA-TBA Code of Cooperation, a four- page pamphlet, was published in 1957, covering inter- relationship, preliminary conferences, records and re- ports, expert witness fee, court attendance, and administration of the Code. Under the heading entitled “Inter-Relationship,” was the following: There should at all times be complete cooperation be- tween the physician and the lawyer, each assuming his proper responsibility, and recognizing that each profession has the duty to develop an enlightened and tolerant understanding of the other. That is still the point, but it has taken several more pages to cover the same material in the 1990 revision. Times have changed. The only other revision of the Code was in 1969, when it expanded to 13 pages. Coverage was expand- ed to include such topics as testimony by deposition, and compensation, items that were mentioned in the 1957 Code, but not developed. The 1969 Code also offered a suggested form of authorization to be completed by the patient/client, al- lowing the physician to furnish medical reports to the attorney. Finally, the 1957 and the 1969 Codes called for the establishment of a 12-member committee (six from each profession) to administer the Code, and the 1969 Code introduced a grievance procedure to be carried out by the administration committee. Though apparently the Administration/Grievance Committee has never been implemented, it is to be hoped that TMA and TBA will overcome that hurdle this time and utilize the committee to everyone’s ad- vantage. The Next Step The Apollo Space Program placed several more men on the moon after that first “giant step” by Neil Arm- strong in 1969. TMA and TBA face a similar challenge now, which is to carry out the spirit of our mutual Code of Cooperation by improving communication and cooperation between the two professions. That is easier said than done. After all, we are each caught up in our own world with our own professional priorities, which don’t always overlap conveniently. The committee members who worked on the 1990 Code JANUARY, 1990 25 were quick to realize that. The most fervent sentiment expressed at their first meeting last year was that both associations must take steps to get the Code to every attorney and physician in the state. We must let peo- ple know that the Code exists — not to be administered as binding rules of conduct, but instead to be used as suggested guidelines to foster cooperation between the professions. A look at the conclusion of the Code (first articu- lated in 1969 and revised in 1990) provides an appro- priate summary for members of our professions to consider. Each profession is obligated by its own stature to respect and honor the calling of the other. One who has chosen to be a physician or an attorney and has been found competent to be such by appropriate authorities is vested with high re- sponsibilities and privileges to enable him to serve the public with honor, with dignity, and with effectiveness. These stand- ards of practice are intended as a guide to the attainment of the best in interprofessional conduct and practice. The interests of the patient/client are primary. Physicians and attorneys should communicate with each other on behalf of those interests. This Code should be used as a primary instrument to facilitate this communication. . . . It is hoped that every physician and attorney practicing in Tennessee will abide by the spirit as well as the letter of the principles. You should be receiving your copy of the 1990 TMA-TBA Code of Cooperation soon. When you do, take a few minutes and look it over. Consider it. Use it. It’s a matter of courtesy between two professions and between individuals. r ^ NOTICE Your copy of the 1990 TMA-TBA Code of Coopera- tion is being mailed to TMA members along with an updated Physicians' Guide to Tennessee Law. The Physicians’ Guide is current through the 1989 session of the Tennessee General Assembly. It should be used as an educational tool. For specific situations, how- ever, consult your personal attorney. Health and Environment Report . . . (Continued from page 24) ments pose a danger to others who encounter the sharp portions. There have been complaints by garbage han- dlers who have been injured. In addition, there exists a possibility of injury to both adults and children who may pick up used needles and blades around dump- sters where the instruments have fallen out of insecure containers, such as plastic bags. Physicians are urged to review procedures for in- fectious waste disposal and make necessary modifica- tions to comply with the present rules. For further information, feel free to call: Mr. Tom Tiesler, Director, Division of Solid Waste Manage- ment, Tennessee Department of Health & Environ- ment; phone (615) 741-3424. MOVING? Send Us Your Address j Please notify us six weeks in advance ! Old Address { Name j Address j City State Zip j New Address ! Address [ City State Zip j Effective Date of New Address j Send to; TMA, 112 Louise Ave . Nashville, TN 37203 j I I 26 JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION Loss Prevention Case of the Month Help Needed — Not Called For J. KELLEY AVERY, M.D. Case Report In 1983, our patient was 36 years old and already had had a long history of pelvic pain. When the patient was age 28, an operation disclosed endometriosis. Prior to the second surgical procedure, the patient again complained of proges- sively severe pelvic pain, particularly during the menses, and the examiner noted irregular enlargement of the uterus con- sistent with fibroids. The right adnexa had been found to be thickened, tender, and at times to contain what appeared to be a large and tender follicle cyst. The patient underwent a total abdominal hysterectomy with a right salpingo-oophorectomy. Extremely dense pelvic adhesions were commented upon in the operative note, but the operation went well and convalescence was uneventful. In 1988, at age 41, our patient developed increasing pain in the pelvis, particularly on the left, and on examination was found to have a left ovarian cyst, confirmed by ultrasound; the patient was admitted to the hospital for a left salpingo- oophorectomy. Except for the pelvic examination, which showed the en- larged left adnexa, which was tender and relatively fixed, the preoperative laboratory work and physical examination were within normal limits. The operative note referred repeatedly to “dense adhesions.” There was no operative note that in- dicated that an attempt was made to skeletonize the left ure- ter, but in discussion with the surgeon after the fact, he stat- ed that attempt was made but proved to be impossible due to the severe dense, generalized adhesions. The surgeon proceeded with the operation, and almost immediately after surgery the patient began to complain of inordinate pain in the left lower abdomen and in the left flank. The diagnosis of a transsected and ligated ureter on the left was made within five days of the operation. One attempt was made to surgically repair the lesion, but this proved to be unsuccessful. On the second attempt a successful repair of the ureter was accomplished. Dr. Avery is chairman of the Loss Prevention Committee. State Volunteer Mutual Insurance Company, Brentwood, and medical di- rector for Ambulatory/Outpatient Services, St. Thomas Hospital, Nashville. The patient had been in the hospital for a number of weeks, she had had three operations, and she had lost her job. In a subsequent lawsuit, defense proved next to impos- sible, and a six-figure settlement was necessary. Loss Prevention Comments A thorough review of the record and examination of both the doctor and the patient indicated that there was no problem with the informed consent process. There had been an adequate description of the surgery and its risks and benefits, and specific reference had been made to the rather significant danger of injury to adjacent structures. In fact, a videotape had been shown in the doctor’s office that spoke directly of in- juries to the urinary tract, including the ligation of a ureter that this patient experienced. Although the consent proved to be adequate within an acceptable standard, there were other severe defi- ciencies in this patient’s management. Experts who reviewed the record were critical be- cause once the surgeon found that he was not able to skeletonize the ureter because of adhesions, there was no mention of the possibility of calling in a urologist to catheterize the ureters from below so they could be easily identified in the pelvis. Experts were also critical of there being no attempt by the gynecologist to call in a more experienced col- league and ask for assistance at the table. This oc- curred in a medical center of such size that this kind of consultation would have been both possible and de- sirable. Again, the very important point must be made that even when informed consent is adequate and appro- priate, quality considerations in the delivery of care are paramount in the assessment of potential liability on the part of the physician. f— TENNESSEE MEDICAL ASSOCIATION 155TH ANNUAL MEETING April 4-7, 1990 Hyatt Regency Hotel, Knoxville JANUARY, 1990 27 The Tennesee Medical Association Gold MasterCard® Simply stated, it is the only credit card you will ever need. The Tennesee Medical Association Gold MasterCard® Card offers you a higher line of credit — up to $15,000. Fast, responsive, accurate serv'ice that includes One-Hour Processing for Credit Line Increase Requests and 24-Hour Toll-Free Customer Service. The convenience of cash access up to your available credit line — at over 150,000 locations worldwide including 23,000 automated teller machines. And of course, value. The Tennesee, Medical Association Gold MasterCard is issued free of an annual fee for the first year.t Each year thereafter, you pay just $30. And, because you travel more than most . . . The Tennesee Medical Association Gold MasterCard offers you more travel-related benefits and services than any other premium credit card. Services that include: MasterAssist"“ — a network of emergency medical and legal aid for when you are more than 100 that you can have the best . . . miles from home, a 24-Hour Toll- Free Travelers’ Message Center, Travel Accidental Death and Dismemberment Insurance —up to $1,000,000, No Liability for Lost or Stolen Card, Emergency Card Replacement and much more. All this, and the recognition you deserve. The Tennesee Medical Association Gold MasterCard bears the endorsement of our association. Every time you use it, you will be recognized as a Tennesee Medical Association member. Call 1-800-847-7378 to request your card. Be sure to use the priority code BGHM when calling! Or, just complete and return the attached application to: MBNA, P.O. Box 15464, Wilmington, DE 19850. Certain restrictions apply to these and other benefits as described in the benefits brochure that will accompany your Premium Access Checks®. MasterCard® is a federally registered Service mark of MasterCard International, Inc. MBNA® is a federally registered Servige mark of Maryland Bank. N.A . a subsidiary of MNC Financial. Inc VFQI ' 3pply for the Tennesee Medical Association I L^l3« Gold MasterCard® account with credit lines up to $15,000, and all other benefits described in this advertisement. I understand if I do not qualify for the Gold MasterCard, this request constitutes my application for the Silver MasterCard. t (Note: This is not an application for a corporate account.) (Please Print) NAME ADDRESS CITY STATE ZIP HOME PHONE I I BUS. PHONE I I ARE YOU; □ Renting □ Own □ Buying Monthly Payment S SOCIAL SECURITY # DATE OF BIRTH EMPLOYER,. NAME OF BUSINESS POSITION YEARS THERE ANNUAL SALARY $ OTHER INCOME" $ .SOURCE 'lAlimony, child support, or separate maintenance income need not be revealed if you do not wish it considered as a basis of repayment.) MOTHER'S MAIDEN NAME IFor use when you request special action taken on your account) CURRENT CREDIT CARD ACCOUNTS My MasterCard®/VlSA® Account *> is My American Express® Account is Previous address IPlease complete if at current address less than 3 years.) CITY . . STATE ZIP PREVIOUS EMPLOYER lif less than 3 yrs.l YEARS THERE I have read this entire application, agree to its terms, and certify the information is correct APPLICANT SIGNATURE Date (Seal) If you wish an additional card issued to a co-applicant over 18 years of age, complete the information below. CO-APPLICANT NAME RELATIONSHIP EMPLOYER SOCIAL SECURITY « .YEARS THERE POSITION ANNUAL . SALARY $ OTHER INCOME S . WORK PHONE I * (Alimony, child support, or separate maintenance income need not be revealed if you do not wish it considered as a basis of repayment I I have read this entire application and agree to its terms, and understand that I will jointly and severally liable for all charges on the account. CO-APPLICANT SIGNATURE be Date (Seal) I (we) authorize MBNA® to investigate any facts, or obtain and exchange reports regarding this application or resulting account with credit reporting agencies and others. Upon request I (we) will be informed of each agency’s name and address. tThe ANNUAL PERCENTAGE RATE IS 15 9% for that portion of the average daily balance (subject to FINANCE CHARGES) up to $3,500 and is 14.9% for that portion of the average daily balance (subject to FINANCE CHARGES) greater than $3,500. The ANNUAL FEE for the Gold MasterCard is $30. The ANNUAL FEE for the Silver MasterCard is $20. GRACE PERIOD; You will not be assessed a FINANCE CHARGE on purchases if you pay the New Balance Total each month by the Payment Due Date 125 days after the closing date) If this amount is not paid, FINANCE CHARGES accrue from the date of transaction Cash Advances bear FINANCE CHARGES from the date of transaction OTHER CHARGES; You will be charged an overlimit fee of $15 if your New Balance Total on your billing date is more than 1 5% over your credit limit. You will be charged a late fee of $15 if you fail to make required payment within 15 days after the Payment Due Date You will be charged a return check fee of $15 if a check submitted as payment is returned for any reason. This offer is not available in BGHM 04-560 01-253 Emotions and Perceptions in a Postop Waiting Room Let me share with you some impressions of what the parents of a patient go through as they wait in a surgical waiting room, and the anxieties and emotions of the presurgical admission process. It was good for me to see, feel, and share the loss of control of time and the flow of events and activities that occur once one gets into the system of a hospital. You become utterly dependent for information on volunteers, nurses, orderlies and the multiple levels of hospital personnel with whom you come in contact. These people have specific jobs to do at specific times, and the patient’s progression through the system can make your existence in this journey comfortable, reassuring, miserable, anxious, or angry — the total range of emotions; these are all dependent on a smile, a kind word, a sense of urgency or a sense of boredom, or whether or not the individual may have had a prior confrontation with his employer or fellow employee. You, as a waiting member of the family, have all your antennae out to read all the emotions that may be in the air. Yes, no matter what your level of education or emotional stability, you are anxious to have anyone at any level reassure you and say it is going to be all right. After the interminable wait for things to get started, you have been sitting with your own thoughts as to why you are there, and realizing no one knows the depth of your concern and no one is aware of the depth of your care, concern, and worry; your wait comes to an end and your loved one leaves you for the operating suite in the care of the nurse or orderly. You look at the faces of those who are still waiting, and during the time you have waited in silence or not with those others, you have developed a small sense of camaraderie. In their eyes you see a look of “Is it going to be all right, or what am I assured is the outcome?" You find yourself seeking a word of assurance that all is going to be well even from the surgical attendant wheeling the gurney. Now sitting in the waiting room, with its subdued conversation, you begin to consciously or uncon- sciously scan the faces of those around you, trying to plumb the emotions in their faces and at the same time think of your own anxieties. You try to compare their problems with yours, or their degree of pain or need as compared to yours. As you sit trying to find something to consume your time, or more accurately your level of concentration, you are acutely sensitive to the range of emotions you perceive. You find that you are overhearing the telephone messages that are being sent to the hospital personnel or volunteers, and try to read them. Once again, for what seems like an eternity, during which time you have been through the full range of emotions, from anxiety, sorrow, desperation, despondence, fear, and anger, to hope, thank- fulness, and gratitude. Then a visit through either telephone or in person, your physician brings things into sharp focus, and then this phase of your contact with the health care system comes to a close. As I have sat through this experience, I have become aware of how my emotions have been on a rollercoaster, and to what extent my state of mind may have been a function of those support people of the hospital with whom I have been in contact. We as physicians, and I particularly as a surgeon, should be ever alert to how much these support people have been directing the families of our pa- tients. I also became aware of how necessary is the job that they do, and how deserving this whole cadre of people are of our thanks and gratitude for their support of our patients’ families. William O. Miller jouf AOl o^ Ihc tennez/ec mccNccil cizzockiHon PUBLISHED MONTHLY DEVOTED TO THE INTERESTS OF THE MEDICAL PROFESSION OF TENNESSEE OFFICE OF PUBLICATION: 112 LOUISE AVENUE, NASHVILLE, TN 37203 JOHN B. THOMISON, M.D., EDITOR ADDISON B. SCOVILLE, JR., M.D., ASSOCIATE EDITOR JEAN WISHNICK, MANAGING EDITOR Acceptance for mailing at special rate of postage provided for in Section 1 103, Act of October 3, 1917, authorized July 15, 1932 Copyright for protection against republication. Journals of the American Medical Association and of other state medical associations may feel free to quote from this Journal whenever they desire merely giving credit to this publication. Address papers, discussions and scientific matter tO: John B Thomison, M.D., Editor 230 25th Ave. North, Nashville, TN 37203 Address organizational matters to L. Hadley Williams, Executive Director, 1 12 Louise Avenue, Nashville, TN 37203 COMMITTEE ON SCIENTIFIC AFFAIRS OSCAR M. McCALLUM, M.D , Chairman, Henderson SIDNEY L, BICKNELL, M.D., Jockson FREDERICK D. SLAUGHTER, M.D., Bristol WINSTON P. CAINE, JR., M.D., Chattanoogo FRANCIS W, GLUCK, JR., M.D., Nashville JOHN B. THOMISON, M.D., Nashville, Ex-Officio JANUARY, 1990 cdHoriol/ A Time of Hope — A Time of Danger . . An’ de walls come a’tum-bulin’ down.” (To the tune of “Joshua fit de battle ob Jericho”) Who’d a thunk it? Nobody, that’s who. There they were — East German Communist workmen (or workers, I be- lieve we are supposed to call them now) hacking away a few days ago at The Wall that had cut Berlin in two for 28 years; and on top of The Wall — literally in Berlin and figuratively from the North Sea to Czechoslovakia — ordinary East German citizens were chipping away to help. As of right now, Checkpoint Charlie is no more, the Brandenburg Gate is open, and the old Glien- icke Bridge once again links West Berlin with Potsdam. There are indications, disclaimers from East German officialdom notwithstanding, that its new name. Unity Bridge, may soon mean Unity Bridge. It hasn’t been a week since the officials began once again allowing freedom of travel be- tween the two countries; but take down The Wall? Never! Now, they say, so The Wall is down; so what? Unification next? Never! No, never — well, hard- ly ever; at least, not in your lifetime (cf. above). There is a reason, though, that this time the dis- claimer may have some weight. The reason is that it has the backing of Mr. Gorbachev, and Mr. Bush is not going to do anything to rock the Communist boat. East Germany is a satellite of the Soviet Union, and despite glasnost and all that stuff, a unified Germany would likely be neu- tral— and strong. And who wants it? Well, for one thing, apparently a lot of Ger- mans on both sides of The Wall do — not their leaders, but folks like you and me, the ones who started the ruckus in the first place by their de- termination to either escape the system or change it. So far they, both those who have left and those who have stayed, appear to have been successful at changing it. So far. Who else apparently doesn’t want a unified Germany is the West German youth. They have grown up with two Germanies — one an affluent one and the other a poor relation, and a distant one at that. They see East Germans flooding into their country for no better reason than to get a car or their own house sooner than they could get it at home — reasons these youngsters see as not good enough; at the same time, they are causing housing shortages and labor problems for West Germans. The young West Germans do not view the other Germany with the nostalgia of their elders, but as only another foreign country in which they have no stake. In truth, that may be the single greatest hurdle for unification to cross, since the country will after all soon be theirs all by themselves. Last spring the world watched in wonder as multiplied thousands of Chinese, most of them young, were allowed to demonstrate unchal- lenged in Tiananmen Square in Beijing, demand- JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION ing a voice in the nation’s affairs — in short, de- mocracy. The People’s Army slowly gathered, but kept their distance, and seemed sympathetic to- ward the students. But as voices became progres- sively more strident in their demands for even greater reforms and concessions, and the leaders felt their security threatened, the soldiers were ordered to break it up, and they did. The Army of the People slaughtered the People whose army they were supposed to be — mostly the young, bright ones, to the extent that it will take a gen- eration or more for China to recover. In a special TV program about the Wall of Iron — the army — all of the youthful soldiers in- terviewed waxed eloquent over the great honor that had been accorded them by allowing them to bear arms for the motherland. Every able- bodied Chinese man must serve in the military, and a lot of women do, too. They all are imbued with the necessity for discipline; they do as they are told, even to gunning down, crushing, and incinerating their countrymen for no better rea- son than that it was so ordered, ostensibly as being necessary to their country’s continued well- being. What appeared to be a stable, peaceful, peaceable situation suddenly curdled, and the world was aghast. The system of government that only shortly before had been dismissed as obso- lete, moribund, and in its terminal stages had suddenly arisen phoenix-like from its ashes to crush its detractors. Presently there is unbridled euphoria through- out Germany, and the euphoria has spread like a plague to Washington, depriving many of our leaders of their reason. Communism, they opine, is obsolete, moribund, and in its terminal stages. The situation ought to remind any person with his wits about him of Yogi Berra’s observation that it is deja vu all over again. Time after time, we have read of happy Germans trooping across the border in both directions, passing “stony- faced” or “unsmiling” East German border guards. It seems to me that should tell us some- thing. It should tell us even more, I think, than that Hans Modrow, the new East German Prime Minister, has been charged by the Politburo with putting together a leadership that will pull the nation back from the brink and restore faith in the party. What it should tell us is that East Ger- man soldiers, like soldiers almost everywhere else (China, the Soviet Union, and yes, the United States, included), mostly do as they are told. It is at best impolitic and at worst dangerous, if not fatal, not to. In a major address in Tokyo, an address that received wide coverage in the British and Japa- nese press, but which inexplicably and I think unconscionably was never mentioned either in the press or on television in the United States, Mrs. Margaret Thatcher, the British Prime Minister, warned that times of instability, such as the pres- ent situation in Eastern Europe, are times of great danger, and that it would be foolish in the ex- treme for the West to drop its guard; she said further that under no circumstances should nu- clear disarmament be even considered. Such a message is unpopular in Washington, and it ap- pears that Washington may be about to be fool- ish in the extreme, a posture to which it is cer- tainly no stranger. After all, Mr. Gorbachev wants it, and we must do everything we can, we are told (even, one fears, to laying down our country and our very lives on the altar), to as- sure Mr. Gorbachev’s success. Ever since our two countries began cultural exchanges a number of years ago, and travel to the Soviet Union became possible, it has become apparent that the Russians are nice, attractive, intelligent people, people who would make fine next-door neighbors — people, in short, just like us. Too, Mr. Gorbachev is a charismatic, per- suasive leader. But we need to keep in mind that Russian and Soviet are not synonymous. Mr. Gorbachev is both. The Soviet is a hard-line Communist elite who are strongly committed to the notion that not only is Communism not dead, but that it will ultimately bury the Western de- mocracies, just as Mr. Khrushchev prophesied it would and Mr. Lenin insisted it should. The So- viet Union today is perilously close to bankrupt- cy, taken there by its massive military and de- fense buildup. Unlike the United States, it has a well-nigh impenetrable radar net. It suits Mr. Gorbachev’s purposes, and those of the Supreme Soviet, to play footsie with the West to gain breathing room. It is equally important to remember that Mr. Gorbachev is not alone the Supreme Soviet. He has played his cards well, but there are other powerful Communists in the Soviet Union who are waiting for him to stumble, which is, of course, the source of Washington’s anxiety. East Germany may be a testing ground, and the Bush administration has so far not given evidence of any leadership. Mr. Gorbachev has. A lot is going to happen between the moment of this writing and your reading it. Voices for reform are be- coming strident in East Germany. One must JANUARY, 1990 33 wonder if it is to become Tiananmen Square all over again. We shall have to wait and see, but one hopes our own leadership will have consid- ered that possibility. Likely nothing will be al- lowed to cause discord before the summit meet- ing in Malta on Dec. 2; but after that? Mrs. Thatcher is by far the leading authority in the world in such matters. Mr. Roosevelt told Mr. Churchill at Yalta not to worry about Stalin; he could handle Old Joe. And so, as everyone knows, he did. We seem to be retracing our steps, but this time we are likely to get mired up over our heads, and you know what happens when that happens. What Mrs. Thatcher has done in effect is to remind the West that when they see the Greeks talking sweet and bearing gifts, they had better be extra cautious. The Trojans weren’t, and look what happened to them. Characteristic of the thought processes of our leadership is that their response would almost certainly be that the Greeks today are pretty harmless. So what’s the problem? Well, the problem as I see it is that Mrs. Thatcher and I see a world that is a whole lot more unstable than the one Mr. Bush and Mr. Secretary Baker apparently see, which is one in which they can handle Mr. Gorbachev, so not to worry. Since that is so, this seems at least as good a time as any, and maybe a better time than lat- er, which may not happen (it is right now Nov. 14), to wish you a Happy New Year. By the time this gets to you, most of us will know one way or another whether or not it happened. Just think: this time we get to change two digits in our de- piction of the year. The last Nineties were the Gay ones (used in the classic sense); what will these Nineties be? Next decade the whole shootin’ match will roll over in what is generally referred to as the Turn of the Century, except that this time it will also be the Turn of the Millennium. That has hap- pened only once before since the time of Christ, and at the moment I think I’d like to stick around to watch. On the other hand, when that time comes there might be a more attractive alterna- tive. Only God knows, and he ain’t tellin’. So Happy 1990. Too bad it can’t be something more poetic than just an old number — like the Year of the Bush, or maybe the Year of the Dragon; could be maybe even the Year of the Hammer and Sickle. Better the first than either of the last. Time magazine will no doubt let you know, but it tells you only after it’s over, and by then it’s too late; when it’s over, it’s over. One must hope, 34 though, or at least I think one must hope, that it won’t all be over — unless it’s time for the start of the Millennium, or whatever else it is, if any- thing, you are expecting when it’s all over except for that. J.B.T. CME for Credit When in 1969 I was launched by Tom Nesbitt, then Speaker of TMA’s House of Delegates, upon my career in continuing medical education (CME) as a member of the newly formed TMA Committee on CME, of which I became chair- man two years later, the CME effort was just getting cranked up nationwide under the aus- pices of the AM A. That spasm was in response to a U.S. presidential blue-ribbon commission report purporting to show that doctors were an ignorant bunch who were disinterested in keep- ing up with what was going on in the world of medicine, and since that was not in their pa- tients’ best interests, somebody had to make them. Just who that somebody ought to be has never been fully clarified, but a variety of bodies in various areas, both geographic and specialty, have taken that task upon themselves. Since I have editorialized at length and on numerous oc- casions on that subject in the ensuing two dec- ades, I’ll not go further into detail here. The prime mover in all of this was the AMA, who had just begun work on the Physician’s Rec- ognition Award (PRA) for CME, and was begin- ning work on an accreditation program so that state medical societies could accredit organiza- tions and institutions in their own state to mount CME programs that would be approved for Cat- egory 1 credit toward the AMA PRA. Thanks to the foresight of the TMA Board of Trustees in moving ahead with a CME effort, TMA’s CME Committee was the second in the nation to be approved for accrediting its state programs. There were a lot of conferences in those days for establishing ground rules and procedures and so on, and at those conferences one of the prime topics for conversation was “the carrot or the stick” — was the doctor rewarded for obtaining CME, or was he punished for not? That debate is still going on in specialty societies, state hous- es, and hospitals, some opting for one and some the other. In Tennessee we have been fortunate JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION that the legislature has never seen fit to get into the act. Since hospital privileges are tied almost universally to fulfilling some CME requirement, I guess the legislature has not felt the need to, and some states that have had such requirements have now rescinded them. Throughout the debate I have stoutly main- tained that the doctor who failed to refurbish his attic rather frequently was an anomaly, amount- ing to no more than perhaps 5% of the physician population, a rather widely accepted figure for medical incorrigibles, since for as long as there has been any sort of medical organization at all, doctors have always attended medical meetings; in fact, that was the reason for establishing med- ical societies in the first place. Doctors read jour- nals, and they consult with their colleagues daily, both formally and in hospital corridors, which may in the long run be the most effective learn- ing experience of all. I have maintained all along that with few exceptions my colleagues were ea- ger to learn, so that the whole organized CME accreditation effort was nothing but window dressing to assuage a public misperception. Imagine my chagrin, then, when I received a paper, published in this issue of the Journal, in- dicating that as many as 80% of a group of doc- tors tied their education to credit. The study is such a small one, involving only 11 family prac- titioners, of whom ten responded, happily mak- ing for nice round numbers, that my initial reac- tion was not to publish it, since the findings have no statistical validity. What the study does clear- ly indicate, though, is that whereas the figure may not be as high as 80%, it would, with a larger sample, still be substantial. So as to establish itself as a true specialty, dis- tinct from general practice, the American Acad- emy of Family Physicians early in its existence established stringent training and CME require- ments, with provision for periodic reaccredita- tion by its specialty board. It is therefore not sur- prising, and indeed to be expected, that all of the family practitioners surveyed would consider it an obligation of their hospital to furnish them CME that would be accreditable by their board. That is not an unreasonable expectation. I was taken aback, though, that 20% indicated that they would not attend a program that was not so ac- credited. I would have thought sheer curiosity would have drawn better than that. The other 60% said they would be less likely to attend. What those statistics, weak though they are, say to me is that a substantial number of those doctors have better things to do than be educat- ed. To be fair, it may be that they believe the educational opportunity is not all that great, and maybe it isn’t; I’ve been to a lot myself where it was not worth my time, but I didn’t know it be- forehand. Then again, maybe they do. As an ad- vocate of the carrot, though, the carrot being the educational experience itself, I must say my ar- gument is weakened thereby. I suspect that this is neither a local phenome- non nor one confined to a family practice; I very much fear that it is instead just one more hair in the mole on the nose of the monster that the Washington Frankenstein has made of medicine. I also am very much afraid that we shall have to wait until, as Kipling observed, earth’s last pic- ture is painted and the tubes are twisted and dried before we will be able again to paint the thing as we see it for the God of things as they are. J.B.T. Looking Back — and Forth In fourteen hundred and ninety-two Columbus sailed the ocean blue. So went the little mnemonic that helped us first-graders remember the date of the discovery of America by Christopher Columbus, and even though it has now transpired that others had been here before him, they had no press agent and left no significant mark to indicate that they laid claim to the land. In any case, Columbus’ contribution has been remembered for half a millenium, lack- ing three years; there aren’t very many that hold up nearly so long. Maintaining interest depends upon perceived importance. Take, for example, the American Revolution, which is one of the few events schoolchildren re- member these days (and from some of the polls, one has to wonder about the ubiquitousness of even that knowledge). I’m talking now about American schoolchildren (or perhaps it would be more proper to say schoolchildren in the United States of America — in fact, I know it would, be- cause most Canadians, who are American also, do not remember it fondly, and in fact choose to forget it. Brazilians are American, too, who like- ly don’t consider it at all. It rankles those folks no end, certainly not without justification, that we have appropriated the term American. Even JANUARY, 1990 35 Nordamericano, as we are called south of the border, will not do it, either, as both Mexicans and Canadians fit that description. At the same time, rule those out and I have no suggestions. But I digress). The English, on the other hand, understandably choose not to celebrate, though they, I thought magnanimously, did help us cel- ebrate our Bicentennial. That war was sort of England’s Vietnam — unpopular at home, fought a long way off, in a wilderness where it was im- possible to distinguish friend from foe (they did have a lot of friends here who thought the revolt an abomination), and with a foe who didn’t fight fair. Instead of the thrill of victory, the agony of defeat. Or take Bastille Day in France. Like our Bi- centennial celebration, theirs was as much a commercial venture as a patriotic gesture, only in their case it was more so, since the dissenters in that revolution were homegrown, and not on some other continent. Though it made a great show on television, the attendees at the celebra- tion thought it something less than wonderful, the only thing wonderful about it being the magni- tude of the overcrowding of Paris and the traffic jams (except that their monumental traffic jams are something to pray fervently not to be a part of on even normal occasions). Many of the French consider their revolution to have been only the swapping of an oppressive monarchy for the reign of terror of a virtual anarchy in which most of the intellectuals lost their heads (literal- ly). Robespierre has been branded by some as the inventor of terror, which, though he was a master, is patently absurd, the Chinese having already been at it for at least a couple of millen- ia. The difference in their revolution and ours is that whereas ours eventuated in the founding of a new nation, the result of theirs was only anoth- er shifting of power, albeit a significant one, in a nation already ancient. When I was growing up. Armistice Day, Nov. 11, 1918, was one of the days we celebrated. In the first place, World War I had initiated a heal- ing process in our North-South rift, which up un- til then had been still fresh in most southern minds. (Since the downtrodden are slow to for- get, it of course stayed pretty much that way in the South for 20 or so more years, until the real mixing of our population came about in World War II, and wounds of the present took the place of the old ones.) Who now remembers World War I? If it weren’t for the vast array of TV net- works having to fill up all that air time, nobody 36 would. World War II memories are confined to a few of us fading relics; and as for the Spanish- American War — say which? Armistice Day is now Veterans’ Day, to honor all our veterans — and why not? If we clung to all the old days of re- membrance, the calendar would be even a whole lot more cluttered than it already is. Unless such days of remembrance become embedded in our national tradition as holidays, and mercifully few do, sooner or later they drop out. If they continue to be held as of some im- portance, they are resurrected at intervals, usu- ally for a while in quarter and then half century lots; we are presently at station one for the land- ing of a man on the moon, and station two for the opening gun of World War II. Both were sig- nificant events for the world, since the former expands our horizons, and fallout from the latter could terminate them, given just a little push from the right (read wrong) direction. We will, I guess, teeter forevermore on the brink of that disaster, given the ease of its accomplishment and the reachable depths of human depravity. Mankind is at the point in advanced technology where it doesn’t take much; his spiritual advancement is still, shall we say, generously, tenuous. If we can avoid that cataclysmic horizon crunch, for my money Aug. 25, 1989 was zero anniversary for a millenial celebration at least equal to Columbus Day. In 1492 it was known, on fairly reputable authority, that if one went far enough east, one would come eventually to Ca- thay. It was a long, hard trip, and dangerous; caravans would set out and often never be heard from again. Furthermore, it took years to know whether they would or would not ever be heard from again. That can be hard on insurance com- panies, not to mention the beloveds. Columbus, being a sailor, thought it would be neat if you (speaking generically) could make the short hop by boat to the far side and get east by going west. He had heard that the Phoenicians had been around the world; the cognoscenti said forget it. The earth is flat, they said; you’ll only fall off the edge into unthinkable, even unimaginable, hor- rors, they said. He didn’t get any encouragement from the Spanish throne, either, which was where the money was. So he went to Portugal, where he found in the persons of Ferdinand and Isabel- la kindred imaginative, adventurous spirits (of course, all they would have to commit to it was money). Their Majesties grub-staked Columbus to three little bitty craft laughingly referred to as ships, the Pinta, the Nina, and the Santa Maria, JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION in which he sailed off on a journey that was a lot more than he had bargained for, finally coming to some islands he called the West Indies, be- cause they were just off India, only they weren’t. In 1976 two robotic spacecraft. Voyager 1 and Voyager 2, set out for parts known, but just barely. The space program had gone to Con- gress, hat in hand, for them, and been rebuffed. Don’cha know there’s a war on, man (in the best manner of King Phillip — who was the one in the long run who gained the most from Columbus’ venture, Spain being the real sea power — only chicken)? Congress finally relented, and the probes were airborne, or maybe more accurate- ly, spaceborne. After problems with its joints, and some other problems with hearing and seeing in its early days (perhaps I should say “her,” since that’s how the space lab people refer to her). Voyager 2 performed so well and was still going so strong at the end of her assignment, that her bosses reprogrammed her toward the far cor- ners, and then some, and told her, “Go, Baby!” and she did. On Saturday, Aug. 26, after sending back spectacular photographs of Neptune, the farthest corner of our solar system, and its moon Triton, Baby, having already explored Saturn and Jupiter with wondrously detailed photography, headed out to sea. Though she will be returning all sorts of data to the lab for possibly years to come, we shan’t be seeing any more pictures from her, since so far as we know there’ll not be any- thing to be seeing pictures of — so far as we know. But then, what do we know? What we know of the universe out past Neptune is infinitesimal by any acceptable standards. Until now, man’s relationship with the uni- verse for more than a few hundred miles away, and excepting our own star, has been confined to receiving signals, essentially light, and generally weak ones, at that. At last we have answered back with something more tangible than radio waves. Barring a chance disastrous encounter. Voyager 2 will be out there forever, speeding away from us at an ever-increasing velocity, and out of reach of the sun’s gravitational attraction; any chance for any such encounter is vanishingly small, given the vastness of interstellar space. Why did Baby go? Well, despite all the ready answers, who really knows why? The most per- vasive commentary on the signals she sent from Neptune was that our very imagination is too limited. So many of Voyager’s findings are out- side the realm of possibility, given our present understanding of physical laws. Voyager has raised more questions about the universe than she has answered. Despite all of that, the probe is allowing us to answer unanswerable questions about our own small piece of ground. There are clearly other reasons to explore space than “be- cause it’s there” (assuming that something that isn’t can be somewhere). Exploration requires personal risk, but man- kind has never been short on adventurous spirits. Exploration also requires money, though, and those with the money have been considerably less enthusiastic. There are, as with horses and their back ends, a lot fewer Ferdinands and Isabellas than Phillips around. One hopes that when it comes to supporting the space program. Con- gress does not take the approach of Phillip that there are too many other things we need to be spending the money on. (Some of the more ex- pensive of those things could be mitigated by making space ventures a cooperative rather than a competitive effort.) If the King Phillip line of reasoning had pre- vailed, what we now call the United States of America would not have the opportunity to cel- ebrate anything on the fourth of July, or on any other day, for that matter. The Indians would still have the hemisphere all to themselves, and “voy- ager” would be just someone sailing around the Mediterranean, and possibly, with luck, all the way up to Ireland. J.B.T. fncmofkim Lee F. Cayce, age 74. Died November 7, 1989. Grad- uate of Washington University School of Medicine in St. Louis. Member of Nashville Academy of Medicine. Hiram Crutchfield, age 29. Died November 15, 1989. Graduate of University of Tennessee College of Med- icine. Member of Knoxville Academy of Medicine. John H. Saffold, age 76. Died October 23, 1989. Graduate of University of Tennessee College of Med- icine. Member of Knoxville Academy of Medicine. John Lanier Wyatt, age 73. Died November 1, 1989. Graduate of University of Tennessee College of Med- icine. Member of Nashville Academy of Medicine. JANUARY, 1990 37 ncul member/ The Journal takes this opportunity to welcome these new members to the Tennessee Medical Association. BENTON-HUMPHREYS COUNTY MEDICAL SOCIETY Mark Warren Anderson, M.D., Waverly BLOUNT COUNTY MEDICAL SOCIETY Daniel E. Brewer, M.D., Maryville Edward F. Brown, M.D., Maryville Don J. Lapenas, M.D., Maryville BRADLEY COUNTY MEDICAL SOCIETY William E. Buchner, Jr., M.D., Cleveland Balram L. Chhajwani, M.D., Cleveland Stephen W. Jackson, M.D., Cleveland FENTRESS COUNTY MEDICAL SOCIETY Leonard Carroll, M.D., Jamestown MAURY COUNTY MEDICAL SOCIETY Charles R. Harmiith, III, M.D., Columbia Chet H. Jameson, III, M.D., Columbia TMA Members Receive AMA Physician's Recognition Award The following TMA members qualified for the AMA Physician’s Recognition Award during October 1989. This list, supplied by the AMA, does not include members who reside in other states. Physicians can receive the PRA certificate valid for one, two, or three years. For the one- year award, physicians report 50 hours of con- tinuing medical education, including 20 hours of Category 1; for the two-year award, physicians report 100 hours of CME, including 40 hours of Category 1; for the three-year award, physicians report 150 hours of CME, 60 of which are Cat- egory 1. Jack R. Baker, M.D., Nashville Elijah G. Cline, M.D., LaFollette David N. Collins, M.D., Chattanooga Larry C. Collins, M.D., Cleveland Richard J. Davis, M.D., Nashville Mark P. Freeman, M.D., Nashville Monica A. L. Gefter, M.D., Chattanooga Francis W. Gluck, Jr., M.D., Nashville Vernon Hutton, Jr., M.D., Nashville Denis M. O’ Day, M.D., Nashville James S. Powers, M.D., Nashville Douglas R. Shanklin, M.D., Memphis Rena M. Thomison, M.D., Nashville C. Richard Treadway, M.D., Nashville 38 John A. Maloof, III, M.D., Columbia John O. Simmons, M.D., Columbia Anthony L. Smith, M.D., Columbia ROANE-ANDERSON COUNTY MEDICAL SOCIETY Pamela Bridgeman, M.D., Oak Ridge SMITH COUNTY MEDICAL SOCIETY Roger Duke, M.D., Carthage SULLIVAN COUNTY MEDICAL SOCIETY Matthew W. Wood, Jr., M.D., Bristol SUMNER COUNTY MEDICAL SOCIETY Wade Davidson, M.D., Hendersonville WASHINGTON-UNICOI-JOHNSON COUNTY MEDICAL ASSOCIATION Brian P. Donovan, M.D., Johnson City Marcia E. Mathes, M.D., Johnson City David B. Welch, M.D., Johnson City George B. Winton, M.D., Johnson City WILLIAMSON COUNTY MEDICAL SOCIETY Laura E. Higgins, M.D., Franklin WILSON COUNTY MEDICAL SOCIETY Ernest E. Sullivent, M.D., Watertown Steven L. Watkins, M.D., Lebanon pCf/OACll iiw/ Luthur A. Beazley, M.D., Donelson, has received the Pediatrician of the Year Award from the Tennessee chapter of the American Academy of Pediatrics. John M. Flexner, M.D., Nashville, has been elected president of the Tennessee Division of the American Cancer Society. James T. Jackson, M.D., Dickson, has been named Physician of the Year by the Tennessee Academy of Family Physicians. William T. Mathes, M.D., Johnson City, has received the Milligan College 1989 Distinguished Alumnus Award. The following TMA members have been certified as diplomates of the American Board of Family Practice: Robert F. Baker, M.D., Sparta; Karl B. Rhea, Jr., M.D., Somerville. The Mid-South Foundation for Medical Care, Inc., Tennessee’s Peer Review Organization, has an- nounced that James A. Mann, M.D., Memphis, will succeed Kenneth Phelps, Jr., M.D., Lewisburg, as chairman of the Board. Dr. Phelps will become vice- chairman. JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION announcement/ CALENDAR OF MEETINGS NATIONAL American Academy of Orthopaedic Sur- geons— Hilton, New Orleans American Orthopaedic Foot and Ankle So- ciety— Convention Center. New Orleans Pan-Pacific Surgical Association — Hyatt Regency, Waikoloa Island, Hawaii Society of Toxicology — Fontainebleau, Miami Beach American Society for Dermatologic Sur- gery— Maui Westin, Maui, Hawaii American College of Psychiatrists — Wynd- ham. Palm Springs, Calif. American Association for Geriatric Psychia- try— Meridien Hotel, San Diego American College of Utilization Review Physicians — Airport Hilton. Atlanta Central Surgical Association — Drake Hotel, Chicago U.S. and Canadian Academy of Patholo- gy— Sheraton, Boston American Institute of Ultrasound in Medi- cine— Hilton, New Orleans 17th Annual Critical Care Medicine Course (sponsored by Univ. of Oklahoma) — Holi- day Inn Airport West, Oklahoma City Association for Academic Psychiatry — Stouffer Madison, Seattle U.S. Pharmacopeial Convention — Capital Hilton, Washington, D C. International Anesthesia Research Soci- ety— Sheraton Waikiki Hotel, Honolulu, Hawaii American College of Cardiology — Hilton, New Orleans American Society of Neuroradiology — Wes- tin Century Plaza, Los Angeles American Society of Clinical Pharmacology and Therapeutics — Marriott Moscone Cen- ter, San Francisco Society for Adolescent Medicine — Hilton Hotel and Towers, Atlanta American Academy of Allergy and Immu- nology— Baltimore American Society of Clinical Hypnosis — Sheraton World, Orlando American Society of Clinical Pathologists — San Francisco Hilton Square College of American Pathologists — San Francisco Hilton Square American Society of Regional Anesthesia — Peabody, Orlando American Burn Association — Golden Nug- get, Las Vegas March 28- April 1 American Society of Contemporary Ophthal- mology— Hyatt, Phoenix March 28-April 1 Mid-American Orthopaedic Association — Marriott’s Grand Hotel, Point Clear, Ala. STATE Feb. 24-25 Tennessee Society of Anesthesiologists, An- nual Meeting — Opryland Hotel. Nashville. JANUARY, 1990 Picture Your Family... . . . without you in the picture. Could they continue the lifestyle they now enjoy.^ What about the house . . . the car . . . the kids’ education.-' That’s why there’s LOW COST LIFE INSURANCE AVAILABLE to you and your sjxjuse through the Tennessee Medical Association. Fill out, clip and return the coupon below. We will send you details on a picture perfect TMA sponsored plan of life coverage. Or, call us toll free at 1-800-347-1109. Yes, send me a quote on the Low Cost Life Coverage. Amount Name Date of Birch Sp>ouse Dace of Birth Firm name Address City State Zip Smoker yes (U no CD Spouse yes IZl no Cd Mail to Plan Administrator The TMA Association Insurance Agency, Inc. P.O. Box 1 109, Chattanooga, TN 37401 Sponsored by the Tennessee Medical Association! Feb. 8-13 Feb. 11 Feb. 11-16 Feb. 12-16 Feb. 13-18 Feb. 14-18 Feb. 17-19 Feb. 24 March 1-3 March 3-9 March 4-8 March 4-9 March 7-10 March 8-10 March 9-13 March 18-22 March 18-23 March 21-23 March 22-25 March 23-28 March 23-28 March 24-29 March 24-29 March 25-28 March 27-30 Highlights of the TMA Board of Trustees Meeting October 15, 1989 The following is a summary of the major actions taken by the Board of Trustees of the Tennessee Medical Association at its regular fourth quarter meeting in Nashville, October 15. TMA Association Insurance Agency, Inc. THE BOARD: Received a detailed report from George C. Knox, Jr., vice-president of the TMA Association Insurance Agency, Inc., regarding the TMA Group Health Insurance Plan. Medical Practice Committee Received a status report from the Medical Practice Committee on the imple- mentation of Resolution 18-89 (Guidelines for Third Party Queries Regarding Subscriber Patients). Headquarters Building Update Received a report from the Executive Director on efforts to locate a suitable property site for the construction of a new TMA headquarters office building. The Board also reviewed a feasibility study report from Carl Storey Company and Adkisson, Harrison & Rick Architects, Inc. The Board authorized the Executive Director to negotiate for the purchase of the property reviewed in the feasibility study. Sexual Addiction Received a report from legal staff on the development of recommendations for the appropriate handling of problems arising from the sexual addiction of phy- sicians. The Board authorized the Medical Director of the TMA Impaired Physician Program to work as a consultant with the Board of Medical Exam- iners on problems related to the sexual addiction of physicians. Committee on Scientific Affairs Received a report from the Committee on Scientific Affairs regarding the eli- gibility of medical specialty societies for holding meetings in conjunction with the 1990 TMA Annual Meeting. Twenty-one organizations were granted meet- ing space and program assistance for the 1990 Annual Meeting. Interprofessional Liaison Committee Received a report on the Sept. 24, 1989 joint meeting of the TMA Interprofes- sional Liaison Committee and the Interprofessional Relations Committee of the Tennessee Pharmacists Association. Both committees are working to im- plement TMA Resolutions 2-89 (Out-of-State Pharmacies), 3-89 (Prescription Time Limit) and 5-89 (Outlawing Anorectic Drugs in Tennessee). Public Relations Program Authorized the use of funds from the CARE Program membership dues as- sessment for staff and other expenses. Authorized the Executive Director to employ an additional staff person. Rural and Community Health Committee Received a report on the twenty-seventh Rural Health Conference, held on Oct. 4 in Columbia and on Oct. 5 in Milan. HIV Infection and AIDS Committee Referred back to the Committee on HIV Infection and AIDS proposed Res- olution 20-89 (HIV Testing for Protection of Health Care Workers); declined to authorize funding for the publication of an AIDS manual for Tennessee physicians until other sources have been investigated. Continuing Medical Education Approved a recommendation by the Continuing Medical Education Commit- tee to survey Tennessee hospitals on their current CME activities. Mid-South Foundation for Medical Care Received a report from Dr. Otis Warr, III, Medical Director of the Mid-South Foundation for Medical Care, on the PRO sanction process, quality assurance, emergency surgical procedures, duplicate physician license numbers and small area analysis. 40 JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION Impaired Physician Program Renewed the contract for the Medical Director of the TMA Impaired Physi- cian Program. Appointed Dr. William Cloud, Board of Medical Examiners, to serve on the Impaired Physician Committee. Coalition on Smoking or Health Appointed Dr. David Jarvis to serve as TMA’s representative on the Tennes- see Coalition on Smoking or Health. PADS/Triplicate Prescriptions Reaffirmed TMA’s opposition to triplicate prescriptions through a letter to Governor Ned McWherter. Sports Medicine Committee Appointed Dr. Dwight R. Wade, Jr., Knoxville, and Dr. Thomas J. Limbird, Nashville, to the Sports Medicine Committee. Medical Laboratory Board Agreed to nominate the following physicians for appointment by the Governor to the Medical Laboratory Board (formerly the Laboratory Advisory Commit- tee): Four-year term position: Drs. Augustus L. Middleton, Jackson; Francis S. Jones, Knoxville; Terry T. Francisco, Memphis. Two-year term position: Drs. David R. Yates, Donelson; Rodger P. Lewis, Union City; Jerome H. Abramson, Chattanooga. / ^ 1-800-234-STONE imilTRIPSV r ^ n CutOutThis Number And You Could Be Removing A Future Need For Gallstone Surgery. Use this number to call Alabama Lithotripsy Services, and offer your patients an alternative to gallbladder surgery. Alabama Lithotri^ Services, a group of leading Alabama hospitals, has been chosen by Medstone International, Inc. to participate in the evaluation of a lithotripter to treat gallstones with shock waves. The hospitals include The Baptist Medical Outers of Birmiwham (Montclair and Princeton), DCH Regional Medical Outer in Tuscaloosa and Huntsville Hospital. The procedure has been successfully used since 1980 in the treatment of kidney stones. Biliary lithotripsy uses ultrasound to pinpoint the location of the gallstones. Spark-gap generated shock waves shatter the gall- stones, reducing them to small particles that can pass from the gallbladder or can be dissolved by prescribed medication. Lithotripsy offers patients a much shorter hospital stay, a faster recovery period than surgery, and involves less surgical risk. For additional information or to find out about a particular patient’s eligibility, clip out and call the number above. Gallstone Lithotripsy with the Medstone Lithotripter has been approved by the Food and Drug Administration for investigational use. JANUARY, 1990 41 PHYSICIANS • Monthly Stipend for Physicians in training leading to qualification as General/Orthopedic/Neurosurgeon or anesthesiologist. • Loan repayment of up to $20,000 for Board eligible General/Orthopedic surgeons and anesthesiologists. • Flexible drilling options. • CME opportunities. *Promotion Opportunities *Prestige For graduates of AM A approved Medical Schools 1-800-443-6419 NAVAL RESERVE You are Tomorrow. You are the Navy. 42 JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION IMPACT Members— 1989 As Chairman of the Board of IMPACT (Indepen- dent Medicine’s Political Action Committee — Tennes- see), I am pleased to present the following list of IMPACT members for 1989 as of November 15. Al- most 1,500 TMA members have recognized the impor- tance of united participation in the political process by contributing to IMPACT this year. This represents ap- proximately 25% of the total TMA membership and is a substantially higher level of participation than ever before. To those of you whose names are included on the list below, please accept my sincere thanks. You can be assured that legislators do pay attention to those who help them get elected and stay in office. To the extent that organized medicine is successful in working with the members of the 96th General As- sembly and the soon to be elected members of the 97th General Assembly, those of you who are IMPACT contributors will be due a great deal of the credit for that success. If you do not find your name on this list, our rec- ords do not reflect that you were a member of IMPACT for 1989. Memberships are now being ac- cepted for 1990. Annual dues are $150 for sustaining membership. TMA’s future legislative success depends on our continued participation in the political process. Your contribution will be much appreciated and will be put to good use. Robert Kirkpatrick. M.D. Chairman IMPACT Board of Directors ABELL, JAMES E ADAMS, CARL E ADAMS, JOHN W JR ADAMS, ROBERT RALPH ADAMS, WESLEY F ADAMS, WM MILTON JR ADCOCK, FRANK JOHN III ADKINS, ROBT BENTON AGUIRRE, DENNIS MANUAL AHLER, ALBERT JULIAN AIKEN, MARC A AKIN, HOBART E AKINS, CHARLES D AL-ABDULLA, ABDUL-SAHIB M ALEXANDER, CLYDE VINSON ALEXANDER, CLYDE W JR ALFORD, ROBERT H ALFORD, WM CUTTER JR ALI, MAYSOON SHOCAIR ALI, SUBHI DAWUD ALLEN, BILLY JASON ALLEN, CHAS EDWARD ALLEN, GEORGE S III ALLEN, JAMES LESTER ALLEN, L DIANNE ALLEN, VERNE ELWOOD ALLEY, EDMOND LYNN ALLISON, JACK R ALPER, CHAS H AMADOR, JOSE GARCIA JR AMBROSE, PAUL SEABROOK AMBROSIA, JOHN M AMONETTE, REX ALLEN ANAND, VEENA ANAND, VIRENDER ANDERSON, ALLEN F ANDERSON, EDWARD EUGENE ANDERSON, EDWIN B JR ANDERSON, JOE PAT ANDREWS, DOUGLAS EUGENE ANDREWS, SUSAN T ANTONUCCI , RICHARD A ARCHIE, DAVID S ARKIN, CHAS RICHARD ARNOLD, COLEMAN LEE ARNOLD, EDWARD STANLEY ARNOLD, HENRY GRADY JR ARNOLD, IRA L ARONOFF, PHILIP MELVIN ATKINS, JERRY FRANKLIN ATKINSON, RICHARD AGARD ATWOOD, JOHN WESLEY ATWOOD, SUE C AVERETT, STEPHEN L AVERY, JAMES KELLEY AVERY, ROBERT BRUCE AVERY, SHIRLEY BANNISTER BACHMAN, HARRY WILSON JR BACKUS, ELIZABETH MAUREEN BACON, STUART PETER BAER, HARRY BAGBY, RICHARD A JR BAGGETT, HENRY W BAILEY, ALLAN H BAILEY, JOS C BAKER, PAUL D JR BAKER, RICHARD DUDLEY BALES, DONALD W BALL, CHARLES A BALLARD, THOS K BALLINGTON, KAREN LOUISE BANKS, SAML LOUIS BANKS, WOODRUFF A JR BARCLAY, LEE ROY BARD, RALPH M BARD, SHIRLEY A BARHAM, HARVEY HAYWOOD BARNARD, VAUGHN N JR BARNES, DAVID R BARNES, JAMES WALTER JR BARNETT, ROBT BURTON BARRON, FREDDIE T BARRY, FREDERICK JAMES BASHAW, ROBERT BASKIN, REED CARL BAYLOSIS, ROBERTO B BEALE, HOBART H BEALS, JOE DUNCAN BEAMER, WILSON C BEASLEY, ALFRED DURANT BEASLEY, JIMMIE L BEASLEY, ROBERT ALAN BEATTY, BRIAN CRAIG BEATY, JAMES HAROLD JR BEAZLEY, LUTHUR BEAZLEY, WILLIAM COOPER BECHTEL, JACK T JR BECK, LARSON DALE BEELER, T CRAIG BELL, JOHN L BELL, RICHARD BRYAN BELL, W KEN BELL, WILLIAM M BELLOMY, BRUCE B BENNING, THOMAS R BERGLUND, ROBERT K BERRIE, WARREN R BETHURUM, ALVA JEFFERSON BHAT, NARAYANA B BICKNELL, SIDNEY LANE BIGBEE, WALLACE BURNS BILBREY, RICHARD LEE BINDER, SAML S BINGHAM, TERRY M BIRDWELL, DAVID ALLEN BIRDWELL, JOEL STANLEY BISE, STANLEY L BISHOP, CALVIN R BISHOP, MICHAEL ROBT BLACK, WILLIAM D BLACKWELL, CAROLYN FISER BLANTON, FRANK S JR BLANTON, MARVIN A III BLEVINS, MELVIN LEE BLOCK, CLEMENT H JR BLOUNT, HENRY C JR BLYTHE, JOS ALFRED III BOAZ, LONNIE ROY JR BOBO, ROBT THOMPSON BOLIN, MARION G BOLTON, TRAVIS LEON BONE, GEORGE BONE, ROBERT CARVER BOOKOUT, MARK WILLIAM BOOTH, GLENN H JR BORN, MARK L BORTHWICK, THOMAS R BOURLAND, ROBT LEON JR BOURLAND, WM LANDESS BOWERS, ROBT EUGENE BOXELL, JOHN FREDERICK BOYD, ALLEN STREET JR BOYE, HARRY GEORGE BOZEMAN, CHARLES H II BRABSON, LEONARD ALLISON BRACKIN, HENRY B JR BRADLEY, DONALD HUGHES BRADSHAW, JAMES C JR BRAKEFIELD, JAMES MARION BRANSON, AUBRA DAVID BRANTLEY, RICHARD GREEN BRAREN, H VICTOR BRASFIELD, JIM C BRATTON, CHRIS H BREWER, RANDALL J BRIMI, JOHN BENJ BRIMMER, ROBERT A II BRINNER, RICHARD A BRITT, JAMES CLYDE BROADSTONE, PAUL A BROCK, HOWARD THOS JR BROGLIO, ANTHONY LEE BRONSTEIN, MAURY W BROTHERS, JOHN CUNNINGHAM BROWN, GERON JR BROWN, LLOYD TYNTE BRUEGGEMAN, MICHAEL BRUNO, JOHN III BRUNT, CHAS HAL BRYAN, DAVID BRYAN, JOHN MILTON BRYANT, JOHN FRANK BRYANT, MAX VINCENT BUCHANAN, RICHARD DURR BUCHANAN, ROBT NORMAN JR BUCKLEY, MADISON H JR BUCKSPAN, GLENN S BUCY, GUY STEVEN BUKEAVICH, ALFRED PETER BURKHART, JAMES M BURKHART, JOHN H BURKHART, JOHN MCLAIN BURKHART, PATRICK H BURKHART, WILLIAM L BURNES, JAMES EDMOND BURNETT, LONNIE S BURNS, GERALD ROBT BURNS, RANDEL PHILLIP BUTLER, ARDEN JONES JR BUTTERWORTH, JACKSON JR BUTTERWORTH, JOE S BYRD, JACK CADENA-CUCTA, GUILLERMO CALDWELL, EDWARD PRICHARD CALDWELL, RONALD DAVID CALLAWAY, JAMES MILLER CALLAWAY, JAMES J CALVERT, DAVID CAMERON, ROBT LYNN CAMPBELL, EARL ROY JR CANALE, DEE JAMES CANCELLARO, LOUIS A CANNON, JESSE J 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LAWRENCE MONTENEGRO, FRANKLIN MONTGOMERY, CHAS ALEXANDER MONTGOMERY, JOHN LEE JR MONTGOMERY, ROBERT N 45 MONTGOMERY, TONY JOHNSON MOORE, JOHN H III MOORE, JOHN T JR MOORE, JOHN DAVID JR MOORE, KENNETH LYNN MOORE, ROBERT SAYLOR MOORE, W R MORAN, HOUSTON MORENO, FRANCISCO G MORGAN, STEVEN W MORGAN, TOMMY E MORGAN, TRAVIS EUGENE MORISY, LEE RICHARD MORRIS, STEVEN ALLEN MORRISON, LARRY BURT MORSE, WM HAL MOSRIE, AZETT JIMMIE MOSS, JOHN PALMER MOUKHEIBIR, NABIL W MOUNGER, EMERSON JAY MOYERS, JAMES RICHARD MUKHERJI, BARUNDITYA MULLINS, W MICHAEL MUMFORD, MARK S MURPHY, CYNTHIA DABNEY MURPHY, PATRICK J MURPHY, WM MONT MURRAY, R SMITH MURRAY, ROBERT C JR MUSE, WM S SR MUSE, WM SCOTT JR MUTHS, FREDERICK A MUTTER, MITCHELL L MYERS, WM STANLEY NAGALLA, LAKSHMAN R NAGEL, LAWRENCE S NEAL, GARY W NEBLETT, JOHN W NEHLAWI , MOHAMMED M NELSON, JOHN R JR NELSON, MARK L NELSON, ROGER T NEMEC, DEWEY G NERY-MANALO, NORA NESBITT, THOMAS E JR NESBITT, TOM EDWARD NEUMANN, JOHN E SR NEWTON, NICHOLAS NOE, HORACE NORMAN NORMAN, WARREN T NORTON, DOUGLAS EDWARD NOWAKOWSKI, JAMES F NOXON, ELVIN B NUNNERY, JAMES A O’BRIEN, PATRICK O’NEAL, DAVID MEDFORD ODOM, ALAN C OGLE, EVELYN M' OLAECHEA, REINALDO A ORCUTT, THOS WM ORDONEZ, J ENRIQUE OSSOFF, ROBERT H OUTLAN, JOHN EDWARD OUTLAN, WILLIAM F OVERFIELD, RONALD EDWIN OVERHOLT, BERGEIN F OVERHOLT, ROBERT MARION OWEN, J DAVID OWEN, WM KENDRICK OZAWA, T TED PACK, RONALD LYNN PAGE, GENE RUFFNER PAGE, ROY C PALMER, ROBERT E IV PALMIERI, GENARO MIGUEL PARK, IH KOO PARRIS, WINSTON CLIVE VIC PARROTT, JAMES A PARSONS, PAUL D PASIPANYODA, ALPHONSE PASS, LAWRENCE J PATE, JAMES W PATEL, PRAVIN PATTON, ROBT CARROLL PAYNE, STANLEY ROSS PEARSON, JAMES M PEARSON, JOHN G PEARSON, RANDALL E PEARSON, RICHARD MCQUISTON PEAVYHOUSE, JOEL Q PECACHE, CONCHITA T PEDIGO, THURMAN LEE PEDIGO, WILLIAM J PEELER, HARRY LEE PEELER, MOLLY M PENDERGRASS, HENRY P PENNINGTON, THOS G PENNY, RICHARD M PERALES, MARIA ISABEL PEREZ, MARTIN ALLEN PERLMUTTER, MARTIN I PERRIN, MILLARD FOY PERRY, FRANK A JR PERRY, MALCOLM 0 PETERSON, MARVIN DEAN PETRILLA, DIANE L PETROCHKO, NICHOLAS PETTY, ALBERT M PETTY, CATHY ELLEN PEYTON, RICHARD R PHILLIPS, JAMES CURTIS PICKENS, DAVID R JR PIERCE, E HARRIS PIERCE, EDGAR H JR PIERCE, IRA S PIERCE, TRUETT H PINSON, E LOUISE PITCOCK, JAMES ALLISON PLACE, JAMES G PODGORSKI, GARY THOMAS POEHLEIN, RICHARD POMERANCE, GLENN NOEL POOL, MICHAEL L PORCH, PHILLIP P JR PORTER, F RAYMOND PORTER, NATHAN F PORTERA, CHARLES ANTHONY PORTERFIELD, JAMES G PORTIS, BILL SCOTT POSMAN, CLIFFORD L POTDAR, ANILKUMAR S POWELL, JOHN MANLEY POWELL, R PAGE POWERS, LAURA B PRESUTTI, HENRY J PRIBOR, HUGH C PRICE, JAMES ALFRED JR PRICE, JOHN DUNCAN PRINCE, MARK D PRITCHER, G MARK PURYEAR, THOS RICHARD QUARLES, JAMES RICHARD QUARLES, WILL G JR QUINN, ROBERT S RABON, RANDAL J RAGSDALE, JAMES HOWARD RAINES, EDWIN ALLEN RAJASHEKARAIAH , K M RALSTON, FRED JR RAMER, WARREN CARLTON JR RANKIN, DAVID M RAPER, CHAS ALLEN RAY, JONATHAN H RAYNE, FREDERICK S REARDON, PETER REATH, DAVID B REAVES, JOHN ANDREW REDDEN, R ALLEN REDDICK, LOVETT P REECE, RICHARD R REED, PAUL EMORY REGACHO, CONCEPCION A REGESTER, ROLLAND F JR REID, MICHAEL L REID, WILLIAM STUART REYNOLDS, JOHN ROBT RHEA, KARL BYINGTON RHEAR, R WAYNE RICCIARDI, JAMES EDWARD RICE, RONNIE NEAL RICHARDS, AUBREY THOS RICHARDS, BRUCE EARLE RICHARDS, SHERRIE ANDERSON RICHARDSON, ELBERT GREER RICHMOND, JAMES P JR RICKS, PHILLIP M RIDLEY, ROBERT WENDELL RIES, WILLIAM RUSSELL RISSLING, DELORIS E ROBERSON, TRAVIS HUBERT ROBINETTE, CHARLES L JR ROBINSON, FRANKLIN P III ROBINSON, JOHN EDWARD JR ROBINSON, WM ALLISON II ROBISON, LOWELL BENJ JR ROCHESTER, JOHN CRAWFORD ROJAS, NORBERTO ROSENBLUM, HOWARD H ROSENSWEIG, JACOB ROUTON, WILLIAM ROBERT ROWE, WM EDWARD ROYAL, JAMES RICHARD RUCH, WALTER ALLWEIN JR RUDD, J DANIEL RUIZ, DAVID E RUSHING, VAN RUSSELL, HENRY P RUSSELL, WM LEE RUTHERFORD, RICHARD T RUTLEDGE, JONES FLANAGAN RYLANDS, JOHN CRAIG SACKS, EUGENE I SACKS, HAROLD SAMUEL SADLER, ROBT NEIL SAFLEY, CHAS FRANKLIN JR SALYER, HOWARD LEE SAMAHA, JOSEPH K SAMPLES, RANDALL GARY SAMPSON, LOUIS SAMS, JOSIAH B SANDERS, CLARENCE RAMEY SANDERS, HARVEY STANFORD SANES, GILMORE M JR SANNER, ROBERT F SARGENT, JEFFREY DALE SATTERFIELD, WM T JR SAUTER, ROBERT F SAVAGE, H BRYANT SAWYERS, JOHN L SCHATZ, MARY L SCHLAMP, ALLEN LEE SCHLEIFER, GROVER F III SCHMITS, G MICHAEL SCHNEIDER, RICHARD PAUL SCHOETTLE, TIMOTHY P SCHULTZ, RICHARD L SCHWISOW, DONAVON SCOTT, AUGUSTUS BARNETT SCOTT, DANIEL J JR SCOTT, JOHN CHRISTOPHER SCOTT, JOS MANSON SCRUGGS, JERRY L SEALS, JAMES L SELL, SARAH HAMILTON SEMMER, JOHN R SENDELE, DEBORAH D SENDELE, ROBERT L SERRELL, PAUL BURT SESHUL, MICHAEL BOYD SETTLE, CHARLES SIDNEY SEWELL, DAVID H SEXTON, RICHARD CARR JR SHACKLEFORD, ELBERT C SHAH, JAYRAJ C SHAPIRO, MARVIN LOUIS SHAW, JAMES WILLIAM SHAW, JOHN L JR SHEA, JOHN JOS JR SHEA, MARTIN COYLE JR SHELTON, ALVIN DILLARD SHELTON, GEO WASHINGTON SHELTON, THOMAS B SHENOUDA, ADEL NEMR SHERIDAN, WILLIAM F JR SHIPLEY, THURMAN SHMERLING, ABRAM CARL SHOEMAKER, KENNETH E SHUCK, EDWIN H III SHUCK, EDWIN H JR SHULL, HARRISON J SHURLEY, WILLIAM R II SIDKY-AFIFI, MAHMOUD SIEGEL, JEROME SEYMOUR SIKES, J GREGORY SIKES, JAMES C SILER, RITA ANNE SIMMONS, STEPHEN P SIMONTON, RALPH W JR SINER, JOHN ROBERT SLAGLE, DAVID J SLAUGHTER, FREDERICK D SMALLEY, J BRYAN JR SMITH, ARCHIBALD Y III SMITH, C GRAY SMITH, EUGENE BAXTER SMITH, GARY D SMITH, JACK CALVIN SMITH, JOE S SMITH, KENNETH DALE SMITH, LANGDON G SMITH, LOUIS A SMITH, MICHAEL G SMITH, O KAY JR SMITH, RICHARD S SMITH, ROBT LLOYD SMITH, ROBT JOS SMITH, SAMUEL A SMITH, STEVEN M SMITH, THOMAS ANDERSON SMITH, WILLIAM DAVID SMITH, WM N SNYDER, ROBT BRUCE SOLOMITO, VINCENT LEE SOLOMON, DALE E SON, CHOON DUCK SOTERES, PETE SPIROS SPALDING, ALANSON R SPEAR, JOHN MICHAEL SPENGLER, DAN M SPIGEL, STUART CHAS SPIOTTA, EUGENE JOS SPIVEY, OSCAR SMITH SPRAY, PAUL ELLSWORTH SPRUILL, JAMES HENRY JR SRINIVAS, NAVEEN ST CLAIR, DAVID SMITH STAFFORD, FLORENCE E STAGGS, STEPHEN MICHAEL STALEY, HOMER LEE STALEY, JOHN R JR STALLWORTH, WM PARK STANLEY, DAVID GRANVILLE STAPPENBECK, RICHARD F STARNES, DANIEL L STEIN, ROBT ELLIOT STEPHENS, JOSEPH W STEPHENS, RAJ K STEVENS, FRANK W JR STEVENS, GEO MILLER III STIMPSON, CHARLES L STOCKTON, DAVID L STONE, HARRY ALFRED STONE, JAMES PATTERSON STRADER, LORENZO D STRANG, ROBT TUDOR STRIKER, WM KENDALL STRIPLING, JACK CLEMENTS STROUD, MARY E THOMPSON STROUP, STEVEN L STUBBLEFIELD, CARL THOS STUBBS, HAL SESSION STUMB, PAUL RUST SUGGS, CHAS L JR SULKOWSKI, VIKTOR P SULLIVAN, JAMES N SULLIVAN, MICHAEL JUDE SUMMAR, ALVIN JONAH SUMMITT, ROBERT LAYMAN SUNDAHL, C GERALD SWAN, LAWRENCE CARL SWINDLE, JAMES TYLER SYDNOR, ELMER W TABOR, OWEN BRITT TALTON, BROOKS M JR TANENBAUM, MARK HARRIS TANTIHACHAI, SITHIPOL TATE, HARRY T TATE, STEVEN M TAYLOR, DEAN GATES TAYLOR, HERBERT A III TAYLOR, JOHN CHARLES TAYLOR, KENNETH M TAYLOR, OWEN C TAYLOR, WM WOOD JR TEJWANI, INDURANI A TEMPLETON, THOMAS S 46 JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION TEPPER, BERNARD TERRY, WILLIAM F TESCHAN, PAUL ERHARD THOMAS, HENRY LEWIS THOMAS, JAMES LOUIS THOMISON, JOHN B JR THOMISON, JOHN B THOMISON, RENA M THOMPSON, BRYAN BROOKS THOMPSON, JOHN K THOMPSON, JOHN ROBT JR THOMPSON, PAUL C THOMPSON, THOS REECE THOW, GEORGE BRUCE THRELKELD, WM CLEAGE THUR DE KOOS, PAUL THURMAN, GRAFTON H THURMAN, STEPHEN S TITTLE, JOE EVAN TOBAN, M MOATAZ TODD, M ALFRED TOLHURST, GEORGE F TOMICHEK, RICHARD C TONKIN, ALLEN K TOOMS, ROBT EDWIN TOSH, ROBT H TOYOHARA, HIROSHI TRABUE, ANTHONY E TRAVIS, LAWRENCE WARREN TRAYLOR, THOMAS REID TRENT, BILLY CARL TUCKER, ROBT TAYLOR JR TURNBULL, JAMES MCJANNETT TURNER, BRUCE IRWIN TURNER, GORDON H JR TURNER, HARRISON D TURNER, JAN LEWIS TURNER, SHELBY OSCAR TYRER, AUSTIN ROY JR UPCHURCH, D THOMAS VALENTINE, FRED M JR VANCE, MINNIE RATLIFF VANDERGRIFF, WM LOWELL VANDEVENDER, FRANK KARL VANDIVER, CLAYTON J JR VANHOOYDONK, JOHN E VANN, HAROLD FRANCIS VARNER, C FERRELL JR VEGORS, ROBERT A VERHEECK, KENNETH VICK, GEORGE W VICKERS, MARVIN HABER JR VILLENEUVE, VICTOR VINSON, HAROLD WALLACE WADE, DWIGHT ROBT JR WADE, W BURKE WADLINGTON, WM B WALKER, FRANCES CAROLYN WALKER, PARKS W JR WALL, JAMES WHELAND WALLACE, SIDNEY L WALLIS, DONALD EDWIN WALSH, JOHN THOMAS WALTERS, WILLIAM J WARE, ROBT EDWIN WARMBROD, JAMES G JR WARNER, JOHN J WATERHOUSE, GEORGE WATERS, CLYDE C JR WATLINGTON, JOSEPH T WATSON, DAVID THEODORE WATSON, DONALD C WATSON, HORACE EUGENE WATTS, DAVID REED WEBER, ALVIN JULIAN III WEBER, BILL CARL WEBSTER, RAYMOND HARRIS WEBSTER, ROLAND MARION WEBSTER, THOS MOORE WEEMS, THOS DOYLE WEIGHT, GLEN R WEINBERG, JANE RUTH WELDON, THOMAS DARRELL WELLES, EDWARD HUNTER III WESLEY, RALPH E WESLEY, RAYMOND WESTERFIELD, LARRY H WHEELER, ARVILLE VANCE WHITE, CHARLES WESLEY WHITE, JAMES HAROLD JR WHITE, JERALD WAYNE WHITE, LAMAR ARTHUR WHITE, ROBERT F WHITE, WILLIAM OTIS WHITMORE, MARK ALLAN WHITSON, MICHAEL L WIEGAND, CLIFFORD F WIESMAN, H JAMES WIKE, SIDNEY ALFRED WILBURN, CHARLES D WILEY, WM ARTHUR JR WILKENS, CHAS HENRY WILLIAMS, DAVID B WILLIAMS, JAMES LARRY WILLIAMS, JOHN O JR WILLIAMS, MELBORNE A WILLIAMS, OLIN OLIS WILLIAMS, PAUL HERBERT WILLIAMS, RICHARD LARRY WILLIAMS, ROBERT HENRY WILLIAMS, THOS WOLFORD WILLIAMS, WAYNE PATRICK WILLIAMSON, JAMES STEPHEN WILLIARD, KENNY F WILLIFORD, WILLIAM N WILLIS, ROBERT A WILLOUGHBY, JOS LEEPER WILSON, ARTHUR JAMES DAVID D DAVID M EARL K G DEAN JAMES PHILLIP RAYMOND EDWARD STEPHEN K , VOLKER GERT MICHAEL JON WITHERINGTON, JOHN M WITT, PETER C WITTKE, PAUL EDWARD WOFFORD, CHAS PARKER WOLFE, JAMES W LAWRENCE KENNETH WAYNE HARVEY , CHARLES T III , SARA BURGIN HENRY GEORGE H GEORGE W II WOOD, ROBT HANCOCK JR WOOD, THOS OVAL WOOD, WILLIAM G WOODALL, JESSE C JR WOODCOCK, CLARENCE C JR WOODFIN, MOSE CLARKE JR WOODFIN, MOSE CLARKE WOODS, ESSIE J WORDEN, JAMES P WORTHINGTON, JULIAN MACK WORTHINGTON, WILLIAM B WRAY, TAYLOR M WRIGHT, ELLEN PAYNE WRIGHT, GLENN E WYCHE, DONALD B WYCHE, MARY YARBRO, HAROLD R YARBROUGH, ROBERT R YARBROUGH, SCOTT YIUM, JACKSON JOE YORK, DOUGLAS CLIFTON YOUMANS, WM TINSLEY YOUNG, GEO G YOUNG, LARRY CRESTON YOUNG, RICHARD WILSON JR YOUNG, ROBT ROGER JR YOUNG, RUTH T YOUNG, WM MCKINNEY YOUNGER, ROBERT E III ZIMMERMAN, CARL WAYNE ZIRKLE, GEO ANDREW JR ZIRKLE, JOHN W ZIRKLE, PETER KEVIN One Button Management With a Macintosh® computer and MediMoc® software from IthCore Communications, managing your practice is os easy ushing a button. MediMac has the functions you need to p^^rofits including electronic claims, scheduling and general ledger. For office automation that is simply the best, rail today. WILSON, WILSON, WILSON, WILSON, WILSON, WILSON, WILSON, WINKLER, WINSOR, WOLFE, WOLFE, WOMACK, WOMACK, WOOD, WOOD, WOOD, Melrose Electronics Inc. 509 5th Avenue South Nashville. TN 37203 INTRODUCES THE "PROFESSIONAL COMMUNICATIONS PACKAGE" Finally a Communications Package, specifically designed for the Medical Profession, putting information within your reach ANYTIME you need it. For more information Call 615-254-5861 Ask for the Medical Package We feature Motorola Pagers JANUARY, 1990 47 TUM coAliniii AQ mcclkcil . cducotioft oppofHmiMc/ The continuing tnedical education accreditation program oj the TMA has full approval hy the Accreditation Council for Continuing Medical Education. An accredited institution or organization may designate for Category I credit toward the AMA Physician's Recognition Award those CME activities that meet appropriate guidelines. If you wish information as to how your hospital tnay receive accreditation, write: Director of Continuing Medical Education, Tennessee Medical Associa- tion, 1 12 Louise Ave., Nashville, TN 37203. IMPORTANT NOTICE Published in this section are all educational opportunities which come to our attention which might be of interest to our membership. As some of these are very long, full year schedules, and others are detailed descrip- tions of courses, in order to conserve space, most of them will be pub- lished in only one issue of the Journal. MEHARRY MEDICAL COLLEGE Extended Continuing Education Program Arrangements have been made with many services and departments in the medical school to allow practicing physi- cians to participate in the service’s activities tor a period of one day to one week. This program provides an opportunity lor physicians to study in depth for a specified period. The schedule of activities is individualized in response to the phy- sician’s request by the participating department, The experi- ence includes conferences, ward rounds, audiovisual mate- rials and coritact with patients, residents and faculty . Fee: $75 per day or $275 per five-day week of educational experience including lunch and parking at Meharry Medical College. Credit: AMA Category I of the Physician’s Recog- nition Award, AAFP, and Continuing Education Units from Meharry Medical College. Application: For information con- tact Flenry A. Moses, Ph.D., Director of Continuing Educa- tion, Meharry Medical College, 1005 D.B. Todd Blvd., Nashville, TN 37208, Tel. (615) 327-6235. IN TENNESSEE VANDERBILT UNIVERSITY MEDICAL CENTER Clinical Training Program The doctor and faculty plan an individualized program to meet the physician’s practice needs. This may include contact with patients, participation in clinical rounds and diagnostic procedures, interaction with faculty and housestaff, access to the Medical Center Library and other learning resources, and other benefits of a preceptorship. AMA Category 1 or AAFP prescribed credit is possible. Physicians must be licensed and be in active practice with evidence of liability coverage. Ongoing Rounds and Conferences Arrangements can be made for licensed practicing physi- cians to attend for credit. Special Conferences/Seminars Detailed brochures for the following courses are avail- able. In some cases, registration numbers are limited. Feb. 3-9 Feb. 13-17 Feb. 10-16 March 19-23 Practical Aspects of Diagnostic Radiology/ Medical Imaging III — Snowmass Village, Colo. Contemporary Issues in Chronic Pain Man- agement, International Pain Control Con- ference— Cancun, Mexico 4th Annual Advances in Infertility and Re- productive Endocrinology — Snowmass Vil- lage, Colo. The Spine, Current Concepts — Wailea, Maui, Hawaii For information contact Division of Continuing Medical Education, Vanderbilt University School of Medicine, CCC- 5326 MCN, Nashville, TN 37232, Tel. (615) 322-4030. UNIVERSITY OF TENNESSEE Continuing Education Schedule Memphis Feb. 8-10 Feb. 24-25 March 10-16 March 28- April 1 May 3-4 Prostate Cancer Radiology Seminar 23rd Annual Review Course for the Family Physician Critical Care Medicine Conference — Hot Springs, Ark. Update ’90 March 22-24 May 24-26 June 14-16 June 20-22 Aug. 27-29 Sept. 13-15 Knoxville 13th Annual Family Practice Update and Review 5th Annual Smoky Mountains Infectious Disease Conference — Gatlinburg 35th Great Smoky Mountains Seminar — Gatlinburg 96th Annual Upper Cumberland Medical Society Meeting — Fall Creek Falls Resort Inn, Pikeville 12th Annual Obstetric Office Ultrasound Workshop 6th Annual Regional Vascular Conference Chattanooga Feb. 17-24 Topics in Medicine — Maui, Hawaii April 17-21 Infectious Diseases — St. Thomas, Virgin Islands May 3-4 Emergency Medicine May 30-June 3 Family Medicine Review For information contact Mrs. Jean Taylor Bryan, Office of Continuing Medical Education, University of Tennessee, 800 Madison Ave., Memphis, TN 38163, Tel. (901) 528-5547. JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION jouf nol of Hic |CAAC//Ce mccHcol Q/zociolioA OWNED AND PUBUSHED BY THE ASSOCIATION FEBRUARY, 1990 VOL. 83, NO. 2 Paramedic and Emergency Medical Technician Clinical Encounter Management System for Tennessee PAUL S. AUERBACH, M.D., M.S.M. Introduction This paper discusses the design and implemen- tation of a management control system to moni- tor the activities of paramedics and emergency medical technicians (EMTs) during clinical en- counters within Tennessee. The presentation is organized into sections as follows: Background, The Proposed New System, Intended Use of Data, Cost/Benefit Analysis, Implementation Is- sues, Remaining Problems and Recommended Solutions, Discussion, and Conclusions. Background The provision of prehospital emergency med- ical care has undergone a considerable transition in the last 20 years. Prior to the Korean and Vietnam Wars, most communities were served by a combination of volunteer providers that includ- ed firefighters, law enforcement personnel, and ambulance attendants. In many cases, the local ambulance was affiliated with the mortuary. Be- cause it was not yet clearly recognized that rapid From the Division of Emergency Medicine, Vanderbilt University Medical Center, Nashville. Reprint requests to Room 1367 Emergency, Vanderbilt University Hospital, Nashville, TN 37232 (Dr. Auerbach). transport was an important element of the out- come of injured victims or persons suffering my- ocardial infarction, support of rudimentary train- ing and equipment was assigned low priority in most municipal and state budgets, and received no federal regulatory or fiscal attention. Clinical investigations regarding mobile pre- hospital coronary care in Europe and the United States, combined with experiences in rapid trans- port to definitive trauma care accumulated by the military during the Vietnam War, focused atten- tion on the benefits of rapid response and early intervention. “Medics” evolved into “paramed- ics” and “emergency medical technicians,” and were increasingly delegated responsibilities to di- agnose and intervene in complex disease situa- tions. The “load and go” philosophies of the late 1950s and early 1960s were abandoned for more sophisticated protocols that mandated patient as- sessment, preliminary diagnosis, treatment, and transport. Prehospital personnel became physi- cian extenders, and rudimentary standards of care were promulgated. In the late 1970s and early 1980s there was a logarithmic proliferation of paramedical services, and a full-fledged industry emerged. It is now unusual to find a nonrural FEBRUARY, 1990 63 TENNESSEE EMS SYSTEM/Auerbach community in the United States with an ambu- lance service staffed by persons having less than HMT status. Historical Problems. The design and develop- ment of prehospital provider systems in this country have been largely unplanned. Rather, the growth has occurred with discontinuity and in re- sponse to trends in emergency care (e.g., heli- copter transport for victims of trauma) or at the insistence of the providers. Although paramedics and EMTs are legally considered physician ex- tenders, operating in many instances under the license of physician advisors (Medical Directors), surprisingly little input in system design has orig- inated from the physician sector (“medical con- trol”). There are many reasons offered for this, but the most probable include: (1) Inadequate time: most physicians who agree to accept the additional supervisory activities tend to be those who are already operating under a full clinical and/or administrative load; (2) Lack of under- standing or inadequate training: nonemergency physicians do not receive formal education re- garding prehospital care and therefore are unfa- miliar with activities that occur “in the field”; (3) Poor cooperation: many physicians who are as- signed responsibility for prehospital programs in fact do not fully approve of the concept and are thus noncontributory; (4) Lack of incentive: there is rarely remuneration for physicians who are in- volved as local or regional Medical Directors; (5) Failure to appreciate the value of physician input: misconceptions (overestimation) regarding the level of expertise and judgmental capabilities of paramedics and EMTs; (6) Failure to appreciate the implications of inadequate medical control: loss of cost-benefit analysis, underreporting of inci- dents, incomplete discipline and reward systems, promotional bias, disheveled media image, etc.; and (7) Inconsistent state legal requirements for physician medical control. Absence of refined management and monitor- ing systems follows directly from insufficient medical control. Unmotivated physician assign- ees and ambulance service directors without pre- vious scientific or practical clinical experience (e.g., beyond simple logistics of scheduling and vehicle repair) would not reasonably have been expected to anticipate the rapid evolution of pre- hospital intervention into a vital and accountable component of medical care. Therefore, it is not 64 surprising that inadequate consideration has been given to reporting and management control. Paralleling promotion of prehospital care has been an intense movement to quality assurance in medicine. This encompasses many different concerns, but largely reflects propriety, adequa- cy, effectiveness, and cost of care. The ethical issues of rationing and social conflict aside, the public has developed a minimum expectation of information, including treatment options, choice of provider, and itemization of procedures, out- comes, and justification of expenses. The medi- cal litigation craze has contributed “defensive medicine.” These considerations arose first in the most sophisticated medical setting (e.g., inten- sive care unit, operating room), and have now filtered down to the entry points into the health care system (e.g., ambulance service, emergency department). Therefore, all players are held re- sponsible in this era of accountability, and com- mon sense holds that documentation and analysis are crucial in efforts to manage systems, improve performance, and unfortunately, mount an oc- casional defense. A final issue is reimbursement for prehospital care, which has not yet been equitably integrated into the health care payment system. In most sys- tems, actual costs have nothing to do with setting reimbursement rates for ambulance services. Al- though most state legislatures have enacted laws establishing emergency medical services (EMS) programs within state health departments, federal grants and revenue sharing have not kept pace with the proliferation and intensity of services rendered, and Medicare financial intermediaries are operat- ing under inflexible fiscal constraints. Current reimbursement for prehospital care from Medicare is based on past charge profiles, and is now ap- proximately 30% of total cost in Tennessee. The remainder of costs is passed on to local taxpayers. Increased prehospital accounting will be necessary to provide the statistics upon which the Health Care Financing Administration can act to reform Medi- care, which is the single largest purchaser of am- bulance services. The Tennessee Experience. Tennessee is not unique in any of these regards. The Division of EMS of the Bureau of Manpower and Facilities (BMF) resides within the Tennessee Department of Health and Environment (TDHE). EMS is charged with licensure/certification responsibili- ties for health professionals (including training programs), health care facilities, emergency JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION medical services, and associated planning activi- ties. There are approximately 150 emergency medical (e.g., ambulance) services, 600 vehicles, 22 aircraft, and 5,000 licensed EMTs/paramedics in Tennessee. It is the responsibility of EMS to license the services, vehicles, and health profes- sionals, and to monitorl regulate emergency health care delivery to the public. Aircraft are regulated in part by EMS and in part by the appropriate aviation authorities. EMS is regulated by a 13- member EMS Board, which is appointed by the Governor, and consists of representative physi- cians, nurses, paramedics/EMTs, and hospital administrators. Statewide, there are approximately 400,000 yearly patient encounters, including nursing home transfers. As of April 1987, no management control sys- tem existed to monitor and regulate prehospital health care delivery to the public. Patient en- counters were documented at the local level by the completion of handwritten “run reports,” the content of which varied for each service. Many were predominately in a narrative format, with as much space devoted to acquisition of billing data as to clinical data. Requirements for com- pletion varied statewide, and it was not uncom- mon for forms to be left incomplete, particularly during busy periods. Statistical trend analysis was rarely achieved, and there was no reliable state- wide data base upon which to evaluate prehos- pital clinical care. Central (state) evaluation of clinical care was “achieved” by individual patient care audits (approximately 200 [.005%] annual- ly); notably, these were not performed by the same individual, nor were they correlated. It is accurate to state that meaningful information concerning EMS in Tennessee was not available. The Proposed New System To address the absence of a management con- trol system, in April 1987, EMS proposed the development of an “EMS Quality Assurance System.” The justification document stated: The EMS Quality Assurance System will provide the means to collect (information), analyze the report(ed) rele- vant patient care information and thus give the department the means to insure that minimum patient care standards are met. . . . The ambulance quality assurance system will provide de- tailed information on response to emergency requests, quali- fications of responding personnel, condition of patients, ser- vices rendered to patients, conditions at the scene of the emergency and disposition of the patient. The detailed infor- mation will provide accurate statistics to the regulators of emergency medical services, to the services themselves, and to personnel in medical facilities who are charged with pa- tient care. . . . There are several direct and indirect benefits. The first is the elimination of current requirement for EMS field staff to do annual patient care records audits. These are done pri- marily to determine compliance with each service's license category. The elimination of 1,200 man hours of work an- nually will save the state about $18,000 in staff time. . . . A more important benefit is that the reports generated by this system will help local governments decide how to better spend portions of their EMS budgets. By focusing on patient care needs, some funds for patient care material will be spent more effectively. Further, the provision of complete patient care information will make the state and individual agencies much more competitive in seeking federal EMS grant and research funds. . . . These changes will lead to the ultimate benefit, which is improved care to decrease patient mortality and morbidity. State EMS laws have been enacted to improve emergency patient care. The Quality Assurance System will finally pro- duce information to gauge patient care, treatment and out- come, determine compliance with accepted treatment proto- cols and to provide information to justify changes and improvements as necessary. Preliminary Design. Because of TDHE policy, the initial system design was performed internal- ly by EMS to integrate with existing mainframe computer support for information systems. After consideration of existing technology, it was de- cided to construct a system that would: acquire input data from a completed form via optical scanner; perform edits for data validation; gen- erate monthly statistical reports by service, coun- ty, region and statewide using personal computer hardware (quarterly, yearly and ad hoc reports to be produced on the mainframe report gener- ator); format data for storage and external inter- face; and provide communication capability for remote sites. Final Design. A vendor was chosen by a mul- ti-step sealed bidding process. The vendor met with EMS to design the run report (“EMS En- counter”) form. After the initial design, the form was circulated to selected paramedics, EMTs, ambulance service directors, trauma surgeons and emergency physicians to gather additional sug- gestions. The sheets are configured for optical scanning and can be completed in pen or pencil. An additional sheet is tailored to the individual ambulance service and used to allow a narrative to provide billing information and additional facts about the encounter. The optical scanner is pro- grammed to reject incomplete forms based upon specified critical data points required for comple- tion. FEBRUARY, 1990 65 TENNESSEE EMS SYSTEM/Auerbach Intended Use of Data The data are to be compiled and reported in such a way as to yield specific statistics about the operations and performance of the state and re- gional EMS systems, ambulance services, and in- dividual health care providers. Cross tabulation can conceivably allow correlation of diverse dafa points not previously available to a reviewer, such as weather conditions at the time of an ambu- lance accident, types of injuries associated with prolonged attempts to initiate an intravenous line in the field, and a particular paramedic’s number of successful/unsuccessful endotracheal intuba- tion attempts in a year. EMS data support or refute the benefits of prehospital intervention. It is absolutely impera- tive to bring scientific methods of evaluation to the proliferation of devices and drugs that have been introduced into the armamentarium of par- amedics and EMTs. There must be a system to provide surveillance over new technology and to accept or reject all modes of therapy. It is com- mon sense that cost-benefit or cost-effectiveness analysis of interventions is impossible in the ab- sence of systematic tabulation of costs, proce- dures, and results. The records can be used to facilitate record- keeping necessary to complete individual recer- tification requirements and to renew licenses for ambulances and services. In addition, they can identify performance trends that do not meet ex- pectations, and facilitate continuing education and retraining, or in unusual circumstances, discipli- nary measures. Individual records serve as doc- umentation in the event of malpractice litigation. The records can indicate which regions or services are substandard in comparison to the rest of the system, and thus might benefit from en- hanced training efforts or remedial educational programs. Local concentrations of unique partic- ular clinical settings might provide impetus for revised protocols, and would suggest the need for tailored training and recertification programs. Given the paucity of federal grant money available for prehospital care research and dem- onstration projects, it is reasonable to assume that grant proposals will not be considered from agencies that cannot demonstrate the ability to collect meaningful data. Implementation of the run report system renders Tennessee competitive for federal funding. Finally, clinical encounter documentation is the cornerstone of a newly implemented trauma care system in Tennessee that requires strict data col- lection in the prehospital setting, at the trauma center, and at the rehabilitation facility. Funding Estimated costs for the first year are $51,000 for hardware, software and 15,000 forms, and $32,500 for personnel (total $83,500). Estimated annual costs for the next two years are $35,000 for forms, $39,000 for personnel, and $6,000 for report preparation (total $80, 000/year). Funding for the first (pilot) year of the pro- gram was provided by reallocation to EMS of $65,000 granted through Section 402 of the High- way Safety Act (National Highway Traffic Safety Administration [NHTSA]). The remaining finan- cial support was appropriated from discretionary funds of the EMS Director. It is predicted, but not guaranteed, that NHTSA money will be made available to sup- port the program in future years. In addition, the EMS Director plans to request of the Commis- sioner of TDHE permission to introduce legisla- tion to approve additional fees for ambulance permits and licensure, and increased penalty fees for ambulance services. Implementation Issues Reactions of the EMS Personnel. In the devel- opment stages, the first reactions of the provid- ers were adversarial, consisting of complaints about the additional paperwork and resentment at the supervisory component. The implementa- tion of compulsory record-keeping was viewed as inordinately bureaucratic, without justification in a system that was not seen to be malfunctioning. The paramedics/EMTs complained that they op- erated under conditions of maximal stress and that the new management control system would not address their major concerns about the work environment. Ambulance service directors were concerned that the collection of billing data would be com- promised and did not feel responsible for any of the costs associated with the new system. An un- dercurrent of resentment was tied to a percep- tion of the process as additional surveillance with a disciplinary motive (“big brother” image). Because of the initial emotional response and concern about noncompliance, public and am- bulance service presentations were restructured to emphasize the benefits that the system would 66 JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION offer to field personnel, including individual par- amedic/EMT skills analysis and procedure suc- cess ratios (improved performance), patient out- comes (clinical research potential), case documentation (malpractice litigation defense), case mix (continuing education and recertifica- tion), and activity and payor mix (service finan- cial support). The accountability issue was por- trayed as a necessary component from legal and professional status perspectives, integral to pre- hospital care’s ascendance into the formal health care system. Currently, most of the paramedics/ EMTs understand the logic behind the system, but are not emotionally committed to its success. Training. To identify the obvious remediable problems with the data collection system, a pilot program was initiated in autumn of 1988. EMS provided in-service lectures to all paramedics/ EMTs involved in the pilot program, which in- cluded distribution of videotapes and EMS En- counter Form Instruction Manuals. A Reference Manual to the data base and reporting package software was developed for EMS and the sub- agencies that might wish to manipulate their seg- ments of the data. The encounter data collection system is now a mandatory component of the EMS curriculum taught in accredited training programs in Tennessee. Compliance. In early observations of the pilot program, it became clear that the system was constrained by the completeness and accuracy of I the data recorded. In a pilot introduction (15,000 forms) of the new encounter form, 1,500 of the first 4,000 sheets were returned because of mis- ! takes, the most common being multiple marks in 1 areas of the form that require a single mark. At ; this early date, it is therefore not possible to de- termine the absolute veracity of the data. Remaining Problems and Recommended Solutions Problem No. 1 There is no clearly defined system of rewards ii (incentives) for the individual health care provid- \ er, whose accurate input is the cornerstone of the system. Expectations of record completion do not have an equally explicit reward/punishment menu. In addition, the system may fail to capture ex- traordinary (good) performances that are not identified with the data measurements. Without a system of rewards, the control system can eas- ily be construed to be of punitive intent. Possible Solutions 1. Individual rewards might include monetary and/or public recognition for high percentage faultless completion of records, for consistent high clinical performance and for identification of problems within the management control system. Ambulance service rewards might include allo- cation of resources to areas of clinical need (e.g., placement of a training ambulance, grants for purchase of equipment), compensation for re- search participation and public recognition for improved performance (e.g., response times, trauma outcomes). The financial costs of such re- wards should be included in the budget for the system. 2. To increase the motivation of the individu- al paramedics/EMTs, the state should provide each paramedic/EMT with a summary of his ac- tivity for the first year of the encounter data col- lection. This should include a comparison with an average activity profile for a Tennessee par- amedic/EMT. Subsequent years’ individual sum- maries should be provided by the local ambul- ance services as they come on-line with hardware. 3. Specific outstanding achievement awards should be offered for extraordinary acts of res- cue, resuscitation, and consistency of perfor- mance. The nominees for consistency should be supported by information tallied from the en- counter report system. 4. The system should not be used overtly to identify individual inadequate performances that merit punishment; this would serve as a disincen- tive to the provider with respect to honest data entry and might encourage frank cover-ups. A better approach would be to identify trends of negative performance variances with regard to key variables (e.g., response time, survival fol- lowing cardiac arrest) in a region and approach such discoveries with support-based solutions to problems. Problem No. 2 There is no clearly defined process for detec- tion or discipline vis-a-vis falsification of data or noncompliance. Possible Solutions 1. Detection: a standard number of patient encounter forms should be compared to emer- gency department records to verify that clinical FEBRUARY, 1990 67 TENNESSEE EMS SYSTEM/Auerbach information is complete and accurate. Any ser- vice that shows a dramatic improvement in per- formance between quarterly reports should be the focus of an intense audit. 2. Discipline: deliberate falsification or failure to complete a record should lead to an explicitly delineated disciplinary process that involves sus- pension of the individual (or service director) pending verification, a hearing before the EMS Board, and penalties that include decertification and a monetary fine. Problem No. 3 There are no concrete action plans for meas- ures to correct performance or clinical variances identified by the system. Possible Solution After the first year analysis of data, the most troublesome variances should initiate appropri- ate remedial responses. For instance, if it is found that a particular paramedic has an unacceptably low success rate for endotracheal intubation, he should be retrained and observed in the field un- til performance is up to national standards. An- other example would be the observation that a particular ambulance service has response times that exceed an acceptable figure with regard to cardiac arrest or trauma victims. In such case, the situation should be investigated to uncover mitigating circumstances or for specific changes that could remedy the deficiency. Problem No. 4 The cost-benefit analysis for justification of the system is weak. In the development, there was strong rhetoric for the moral and legal issues in- volved with data collection, but little demonstra- tion of cost-benefit. Many of the proposed ben- efits, such as a life saved, are intangible or extraordinarily difficult to value. “Quality of care” can be approached only through outcome studies, and even then with enormous difficulty. Possible Solutions 1. Quantify the modifications of practice based upon the data collection that will result in cost savings. This will be necessary to justify the sys- tem to county Health Commissioners (cost-shift- ing) and to the state Commissioner of Health (guaranteed funding renewal). 2. Perform annual analysis of costs and third 68 party reimbursement, focusing on Medicare. Publish the data and provide it to action commit- tees and agencies attempting to promote Medi- care reform. 3. Produce a document that provides compel- ling medicolegal justification for the system. Problem No. 5 There is no guaranteed source of funding for this system beyond the first year. The agreement to continue utilization of NHTSA money is in- formal. EMS budgets must be approved annually and are subject to both legislative and adminis- trative cutbacks. The Commissioner of Health is newly appointed and has not been familiarized with the activities of EMS. The EMS Director proposes a cost-shifting strategy to have the local ambulance services pay for the forms and cus- tomized reports. In addition, there is no pro- posed funding for correction of deficiencies un- covered by the system. It is highly likely that problems will be encountered that will require additional training, personnel, and equipment. Possible Solutions 1. The Commissioner of Health must be edu- cated with regard to the functions of EMS, de- velopment of the management control system, and the implications of its continuation/discon- tinuation. Ideally, he should become a champion of the system. Funding for the program should be budgeted and guaranteed for a minimum 10-year period through the TDHE, pending annual sys- tem performance reviews. Conditional money should be budgeted for remedial action based upon data analysis. 2. It is going to be a real problem to shift costs to the counties. Local funding of the system should be windfall-only strategy for the initial five years of operation. If the long-run plan is to shift the paper/reporting costs to the provider agen- cies, this should be agreed upon well in advance, to allow financial planning and avoid hostility. A 50% local cost-shifting strategy should be accept- ed in the long run. Problem No. 6 Generation of reports is time-consuming and costly to state EMS. In the pilot program, it re- quired 20 minutes to print a single service report. Each data collection requires a minimum of six reports for interpretation. With 150 services (of which 100 provide primary emergency services) requesting monthly reports, the time commit- JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION ment is 3,600 hours of printing time, approxi- mately one-tenth of which must be attended (360 man hours). Possible Solutions 1. Distribute the software package for analy- sis to each ambulance service (cost $400 each). Adhere to a relational data base format. In this way, each service can generate its own custom- ized reports from diskettes supplied by state EMS. All services will be required to purchase a personal computer for this operation. 2. Limit state reports to quarterly, semian- nual and annual. Charge a fee for nonroutine analyses to individual ambulance services. 3. Make the reports to individual ambulance services easy to interpret. Provide only informa- tion directed at the specific ambulance service and numbers for comparison based upon the region and entire system. Whenever possible, include graphic interpretation of performance and trends. Problem No. 7 There is no long-range plan for modification of the system. Possible Solutions 1. Interactive menu-driven programs for re- port generation using remote portable computer terminals for direct electronic transmission to a central computer have been developed for law enforcement. In all likelihood, this technology will have medical applications. Such programs would eliminate completion of forms and perhaps strengthen the directive aspect of data collection. These systems and others should be considered as possible next logical steps in the automation process. The ultimate goal would be a paperless system in the field. 2. This is the problem of lowest priority, but should be addressed after the first 18 months of full operation. Technology upgrades should prompt early and thorough capital budgeting. Discussion In a generic sense, a management control sys- tem that operates in the cost-benefit mode takes into consideration the key elements of goal con- gruence, motivation criteria, effort, performance evaluation, and rewards. Each element offers the opportunity for design choices and the overall structure can be used as a framework from which to hang the components and spot any structural weaknesses. Accordingly, it is possible to reflect upon the components of the Tennessee EMS management control system. It is apparent that goal congruence remains to be established, a task rendered more difficult by strong aversion to su- pervision that has traditionally resided in the cul- ture of prehospital care. Furthermore, the soon- er the control system is recognized to generate a favorable change within the EMS system, the more rapid will be the acceptance of the system. A quick win is mandatory. The paramedic and emergency medical tech- nician clinical encounter management system is a control process that begins to structure bureau- cratic components into a strong medical culture. It originated from a condition of sparse record- keeping and lack of surveillance, which was per- ceived as lack of control. The major proponents of the system relied upon health care accounta- bility issues to garner support for the system. The imprecisions of hospital-based medicine are mag- nified in the uncontrolled environment of the paramedic/EMT. Because many interventions are of reputed, rather than documented, efficacy, the strategies of clinical behavior are more intuitive than many scientific medical minds would prefer. This huddles under the umbrella of difficulty in defining certain acceptable ranges of behavior. In order to modify existing clinical protocols, it is first necessary to determine what is impor- tant, a task that can only be accomplished within a tight management control system. For in- stance, the ability to “dollarize” benefits would be exemplified in the elimination of a training module based on data that indicates that a par- ticular clinical condition is never encountered. Obviously, risk/cost/benefit analysis is impossible without data acquisition. While standards of functional performance (e.g., response time and delivery of the patient to the appropriate facility) and clinical care are, for the most part, uniform in the prehospital community, the new management system codi- fies the specifics and requires documentation of accomplishments. Favorable outcome variances may well identify regions that have developed solutions to performance problems that plague poorer performers. Third party payors (e.g., insurance compa- nies) and redistribution programs such as Medi- care and Medicaid will continue to under-reim- burse for ambulance services as long as the providers cannot provide organized documenta- tion of need and enhanced support for individual claims. On the flip side, it is not reasonable to FEBRUARY, 1990 69 TENNESSEE EMS SYSTEM/Auerbach expect the payors to blindly accept increasing costs without data that support the cost details and benefits of specific interventions. An obvious deficiency in a system of this sort is the general inability to include ultimate diag- nosis and outcome. It would be an administrative nightmare to require reporting by every emer- gency department and hospital of clinical care, diagnosis, and outcome for each patient deliv- ered by ambulance. However, it is a reasonable expectation to be able to abstract necessary data from medical records in order to investigate var- iances or to complete clinical investigations that originate in the prehospital setting. Because there is knowledge about the desirability of actions, but outcome measurement is difficult, specific ac- tions and observations comprise the data set. The data collection method itself encourages complete evaluation of victims and serves as a checklist to jostle the memory of the clinician. For instance, one can easily imagine a scenario where in the course of a complicated resuscita- tion, the provider forgets to complete the mental status examination. Because completion of the form requires making note of the key compo- nents of such an examination, the rescuer is re- minded to obtain the appropriate clinical infor- mation. In the recording of drugs and procedures, it serves as a reminder of the treatment options. However, because of space limitations, the en- counter form cannot follow a clinical protocol format; therefore, there is no mitigating effect upon training requirements. The potential educational component of the control system is largely in the data analysis and dissemination of reports to the individual provid- ers and ambulance services. This is the weakest component of the system as it now stands, be- cause there is no precedent for this type of feed- back in Tennessee. The approach to modifica- tion of prehospital care has been largely crisis intervention following an incident or public dis- closure of inadequacy, or delayed adaptation to impending national standards, rather than ad- justment based upon intense local and regional observation. The new system offers a new oppor- tunity for internal comparisons and differential allocation of resources. Importantly, this in- cludes correlations of program training and pre- hiring capabilities of staff with measured per- formance. Data entry is subject to manipulation, but this is no more of a problem here than in any other clinical situation. Objectivity and precision are subservient to honesty; the paramedic/EMT ethic is advertised as being as noble as that of doctor- ing or nursing, so one would hope that the data would be valid. However, if the system is viewed by the providers as punitive, the natural tenden- cy may be to falsify or “shade” the information. In Tennessee, field supervision has been infor- mal, and this new system might easily have an initial deleterious effect on morale. There is am- ple opportunity for resentment to be magnified, particularly by low performers. At the other ex- treme, high achievers may be aggravated by ac- tivities that they feel are peripheral to the provi- sion of high-quality clinical care. The greater the degree of positive feedback and future develop- mental input that can be provided by line provid- ers, the less the expected dissension. As previously mentioned, ambulance services are constrained in hiring with regard to calibre of personnel (educational level attained, previous experience, motivation) by reimbursement and geographic location. More rigorous selection of paramedics/EMTs would require higher pay scales (cost), which is in most cases not feasible. There- fore, a high-performance standard ethic must ap- peal to the lowest common educational denomi- nator, which most often represents a high school education and paramedic/EMT training. The prehospital system is characterized by an ex- treme pyramid; there are few promotions and these are largely based on seniority rather than performance (which has heretofore been difficult to measure). Accordingly, accurate participation in the encounter system must be packaged as an integral performance measure in and of itself. Conclusions Design and implementation of a management control system for the clinical encounters of par- amedics and EMTs in Tennessee was long over- due. The intuitive need for program develop- ment that dominated the regulatory process will not sustain the program in perpetuity. The data must demonstrate a favorable cost/benefit rela- tionship to make a case for continued funding. The underlying premise of valid data acquisition is highly dependent upon the evolution of goal congruence between the Division of EMS, am- bulance services, and individual providers. r 70 JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION The Foul- Smelling, Removable Tonsillar Concretion: A Poorly Appreciated Manifestation of Colonization With Actinomyces ABRAHAM VERONESE, M.D.; CEDRIC FERNANDO, M.D.; DONNA ROBERSON, B.S.; CONSTANTINO DIAZ, M.D.; and JAMES FARNUM, M.D. Introduction Actinomyces is a well-known inhabitant of the oral cavity,* frequently demonstrable in surgical- ly removed tonsillar tissue. Less well known is the fact that Actinomyces can be an integral part of concretions in the tonsillar crypts; these con- cretions can achieve dimensions that render them visible to the naked eye.*'* Patients may com- plain of a foreign body sensation and frequently remove these concretions manually.^ Although some physicians — perhaps from personal experience — are familiar with this syn- drome, many are not, and may be inclined to re- gard with skepticism the patient who reaches into his throat and extracts a foul-smelling concre- tion. One of us (C.F.) saw several cases in succes- sion and convinced the rest of the existence of this syndrome. The paucity of descriptions of this condition, aside from the older otolaryngology literature, prompted this report. Case Reports Case 1. A 16-year-old girl had a three-month history of intermittent sore throat and a complaint of “something stuck in the left side of my throat.” She claimed to be able to ex- tract from her tonsil, using her finger, a yellowish, foul-smell- ing, solid material. Her symptoms would abate for a variable period of time, only to recur coincidental with the reappear- ance of the yellow concretion on the tonsil. She had had re- current pharyngitis, and her tonsils were chronically en- larged. Examination showed a mildly erythematous pharynx From the Departments of Medicine (Drs. Verghese, Roberson, Diaz), Family Practice (Dr. Fernando), and Pathology (Dr. Farnum), Veterans Administration Medical Center and East Tennessee State University, Johnson City. Reprint requests to Department of Medicine, James H. Quillen College of Medicine, East Tennessee State University, P.O. Box 21160A, Johnson City, TN 37614 (Dr. Verghese). with a discrete, yellow, well-circumscribed concretion pro- jecting from the surface of the tonsil. A commercial rapid streptococcal screen was negative. The concretion was readily extracted (by the patient) and confirmed to resemble the ma- terial she periodically removed. It was firm, yellow, and foul smelling (Fig. 1). She was treated with 2.4 million units of procaine penicillin intramuscularly and then given 2 gm/day of penicillin V orally for two weeks. Her symptoms had not recurred after three months. Case 2. A 14-year-old girl had a sore throat and tender- ness in the right side of her throat for one week, unaccom- panied by fever, chills, cough, or sputum production. A solid yellow concretion nestled behind the right tonsillar pillar and was extracted as in the previous case. A streptococcal rapid screen was negative. The concretion was similar to that de- scribed in case 1 and was submitted for histopathologic ex- amination. The patient was treated with 2.4 million units of procaine penicillin intramuscularly, followed by 2 gm/day of penicillin V orally for two weeks. She has experienced sev- eral recurrences. Figure 1. Intraoral view of right tonsillar crypt with embedded yellow concretion (4x3x3 mm). FEBRUARY, 1990 71 Figure 2. {Left) Large sulfur granule (ray-fungus) with peripheral radial filamentous hyphae (GMS stain, x 125). (Right) High-power photomicro- graph of sulfur granule showing black, intertwined filamentous hyphae of Actinomyces (GMS stain, x800). Pathology Hematoxylin and eosin stains of the tonsillar concretions revealed the features of a typical “sulfur granule,” with outer filamentous hyphae that varied from dark blue to purple staining and indistinct morphology, and an inner amorphous, pink material without obvious filamentous struc- ture. The periodic acid-Schiff (PAS) stain showed distinct filamentous hyphae, most pronounced at the periphery of the granule. The Grocott me- thenamine silver (GMS) stain revealed distinct and diffuse black filamentous and coccoid ele- ments, most pronounced at the peripheral por- tion of the granule, but with distinct morphologic features in the central areas as well (Fig. 2). The tissue Gram stain was disappointing in that there was variable and minimal staining of Gram-posi- tive elements, restricted to the coccoid forms. However, a smear of the crushed tonsillar con- cretion showed Gram-positive, long, filamentous hyphae with marked beading and background Figure 3. (Left) Smear from extracted sulfur granule with darkly stained, variable, filamentous hyphae (GMS stain, x 1,250). (Right) Original smear of right tonsillar concretion revealing Gram-positive, beaded filamentous hyphae and coccoid elements of Actinomyces (Gram stain, X 1,250). 72 JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION coccoid elements (Fig. 3, right). The GMS stain of the smeared preparation showed black, dis- tinct, filamentous hyphae with less conspicuous coccoid forms (Fig. 3, left). The staining charac- teristics of tissue and smear are consistent and characteristic of Actinomyces species. A Kin- youn acid-fast stain was negative on tissue and smear, which is usually the case with Actino- myces, with some exceptions.^ Neither specimen was submitted for culture. Discussion As early as 1896, Ruge^ described granules of Actinomyces in tonsillar crypts. Lord,® in 1910, demonstrated Actinomyces-Wke, organisms from tonsillar crypts but did not confirm their pres- ence by culture. Emmons, ^ in 1938, performed sections on freshly removed tonsils and described “cheesy, subspherical, or lobulated masses from microscopical size up to 2 or 3 mm in diameter” in the tonsillar crypts. The typical hyphae of Ac- tinomyces were found in 37% of these granules, and confirmed by culture in approximately a third of these cases. Other studies have recovered Ac- tinomyces in 16% of tonsillar material removed at tonsillectomy^ and 40% of tonsils removed at autopsy.^ A more recent study by Maher et al,-* who noted the presence of Actinomyces species in 30% of 227 tonsils removed for chronic tonsillitis, pro- vided some clinical information to correlate with the presence of tonsillar concretions. He noted that “most of the cases with positive cultures and histopathologic evidence of Actinomyces, com- plained of similar symptoms, viz, fetor oris, a sensation of foreign body in the throat, a dull ache of the tonsils immediately relieved by the expulsion of the debris from the crypts, and a constant fear of the yellowish spots that persisted in the tonsils even in quiescent periods.” The majority of the 227 patients had previously re- ceived repeated antibiotic treatment for sore throats. Actinomyces is said to affect the lymphatic system infrequently^ and it is customary to re- gard Actinomyces granules in the tonsils as rep- resenting colonization. However, the symptoms in both our patients as well as the patients de- scribed by Maher^ suggest the association with chronic tonsillitis may be more than coincidental. Tonsillar crypts can become distended with col- lections of cellular debris, inspissated secretions, and bacterial colonies, including Actinomyces, resulting in the formation of a “crypt cast.” True tonsilloliths that are calcified and have reached an unusually large size have been described. The chronically diseased tonsil may promote coloni- zation with Actinomyces and the formation of these concretions; it is also conceivable that such colonization could be a cause of chronic tonsilli- tis. In either case, the granules can reach suffi- cient size to act as a foreign body and be symp- tomatic; obstruction of a salivary duct by an Actinomyces concretion has also been de- scribed. The propensity of thoracic actinomy- cosis to involve a dependent segment of the lung has suggested that aspiration is the key pathoge- netic mechanism in this disease. Aspiration of concretions the size we recovered from our pa- tients could produce bronchial obstruction and atelectasis, and create appropriate conditions for anaerobic growth. Introspective (and dexterous) patients, as well as observant physicians, will continue to recog- nize tonsillar concretions, some of which will contain Actinomyces. Mechanical removal seems to afford some relief of the “foreign body sensa- tion”; the role of antibiotic treatment is uncer- tain at this time. Prospective case-control studies will be needed to ascertain the frequency, symp- tomatology, and clinical significance of tonsillar concretions. r ^ Acknowledgments: We are grateful to the participants of the weekly Tri-Cit- ies Infectious Diseases Rounds for encouragement in prepar- ing this report and to Doug Allen and Mark Howze R.B.P. for photography. REFERENCES 1. Emmons CW': The isolation of Actinomyces bovis from tonsillar granules. PubI Health Rep (Wash) 53:1967-1975. 1938. 2. Gruner OPN: Actinomyces in tonsillar tissue; a histological study of ton- sillectomy material. Acta Path Microbiol Scand 76:239-244. 1969. 3. Gruner OPN: Actinomyces in tonsillar tissue: a histological study of an autopsy material. Acta Path Microbiol Scand 79:77-78, 1971. 4. Maher A. Bassiouny A. Bucci TJ. et al: Tonsillomycosis: a myco-histo- pathological study. J Laryngol Otol 96:231-232, 1982. 5. Robboy SJ, Vickery AL Jr: Tinctorial and morphologic properties distin- guishing actinomycosis and nocardiosis. N Engl J Med 282:593-596. 1970. 6. Hotchi M, Schwarz J: Characterization of antinomycotic granules by ar- chitecture and staining methods. Arch Pathol 93:392-400. 1972. 7. Ruge H: Uber Acrmomycei-ahnliche gebilde in den tonsillen. Z Klin Med 30:529-537. 1896. 8. Lord TF: The etiology of actinomycosis. JAMA 55:1261-1263, 1910. 9. Cope Z: Actinomycosis. New York. Oxford Medical Publications. Oxford University Press. 1938, p. 248. 10. Osborn GR: Tonsillolith. Aust Dent J 19:284, 1974. 11. Soderlund G; Die speichelsteinkranheit und ihr verhalten zu der primar- en und duktogenen speicheldrusenaktinomykose. Acta Chir Scand 63 (suppl 9). 1927. 12. McQuariie DG. Hall WH: Actinomycosis of the lung and chest wall. Surgery 64:905-911. 1968, 13. Drabick JJ, Looney DJ: Actinomycotic tonsillitis with expectoration of sulfur granules (letter). N Engl J Med 320:599, 1989. FEBRUARY, 1990 73 Trauma Rounds Trauma in Pregnancy ROBERT B. LEE, M.D.; JAMES H. WUDEL, M.D.; and JOHN A. MORRIS, JR., M.D. Introduction Injury is the most frequent cause of death in the female population 35 years and younger. Most preg- nancies occur in this age group. The exact incidence of trauma in pregnancy is difficult to assess, but the incidence of major trauma requiring hospitalization is thought to be about 4 per 1,000 admissions.' Minor trauma occurs more frequently in pregnant women and increases in frequency from the first to third trimes- ters. Mortality in maternal trauma ranges from 7.2%- to 24%.’ Case Report A 27-year-old woman with a known 27-week intrauterine pregnancy was an unbelted passenger in a motor vehicle ac- cident. She was awake, alert, and hemodynamically stable upon presentation to a local emergency department. Initial evaluation revealed both multiple rib fractures and multiple extremity fractures. She was transferred to a tertiary care center for further evaluation. Upon arrival, examination revealed a young woman in moderate distress with a pulse of 100/min, blood pressure of 114/90 mm Hg, and respirations of 22 to 25/min. Evaluation revealed a left flail chest with underlying pulmonary contu- sion, a left hip dislocation with acetabular fracture, fracture of the left olecranon, fracture of the left humerus and radius, and multiple finger fractures. Her abdomen was soft without tenderness, and bimanual examination was consistent with a 27-week intrauterine pregnancy without vaginal discharge. Pelvic sonography confirmed a 27-week intrauterine pregnan- cy, a fetal heart rate of 120 to 130/min, and no evidence of abruptio placentae. Surgical stabilization of her fractures was accomplished with continuous fetal monitoring and magnesium sulfate in- fusion for tocolysis. Intraoperative amniocentesis was unre- markable, and no fetal distress was noted throughout the case. Upon the patient’s return to the surgical intensive care unit, there was marked fetal bradycardia with a rate of 50/min, and emergency cesarean section was performed. A 22-gm infant with Apgars of 0, 0, and 0 was delivered, but it subsequently expired in the neonatal unit. The mother was discharged home on the 18th postoperative day. Physiology of Pregnancy Pregnancy produces profound changes in anatomy and in cardiovascular, respiratory, gastrointestinal, renal and endocrine physiology. From the Division of Trauma, Section of Surgical Sciences, Van- derbilt University School of Medicine, Nashville. 74 Anatomy: The uterus is intrapelvic until the 12th week of pregnancy, reaching its maximum height at 36 weeks. As it rises out of the bony pelvis, the uterus and its contents become more vulnerable to injury. The myometrium becomes thinner in the later stages of pregnancy at the same time the fetal head becomes fixed in the pelvis. There is a marked increase in uter- ine artery size and uterine vein capacitance. The uter- us becomes increasingly vulnerable to injury as preg- nancy progresses. Cardiovascular Physiology: Plasma volume increas- es at the 10th week and reaches a peak 50% above normal by the 34th week. Plasma volume exceeds the red cell mass, resulting in a relative anemia (average hematocrit = 35%) and decreased blood viscosity’; a relative leukocytosis also occurs. With increasing uter- ine size, the diaphragm becomes elevated; its excur- sion is decreased, and functional residual capacity de- creases, but vital capacity remains unchanged. Tidal volume and respiratory rate increase. Evaluation, Resuscitation, and Management Although mother and fetus are inseparable, man- agement of the mother takes priority. Prognosis for the fetus after major injury is poor during the first and second trimesters but improves during the third trimester. Maternal shock is associated with 80% fetal mortality.’ Thus, efforts to save the mother become also the most appropriate treatment of the fetus. With a few exceptions, early resuscitation and management of the pregnant woman should be identical to that of the nonpregnant one. Priorities remain unchanged. Significant maternal hemorrhage may occur before the blood pressure falls (30% to 35% reduction in blood volume may occur while blood pressure remains normal). This puts the infant at risk, because blood flow is shunted away from the placenta to the mother’s vital organs. The catecholamine response to shock causes uterine artery vasoconstriction, further reduc- ing uterine blood flow by as much as 10% to 20%.’ Therefore, the fetus may be in shock while the mother is not. Mild maternal hypoxemia has a profound effect on the fetus. Normally the fetal blood has low oxygen content to augment the maternal fetal oxygen gradient JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION extraction by the placenta. When the mother becomes hypoxemic, the fetus has no oxygen reserve and quick- ly becomes acidotic. On arrival in the emergency department, standard advanced trauma life support measures should be in- stituted. The airway is checked for patency, and sup- plemental oxygen delivered to prevent fetal hypox- emia. Breathing is evaluated, remembering the pregnant woman normally breathes 20 to 24 times per minute and has a respiratory alkalosis. Intravenous in- fusion through a large bore needle is started. If the patient is supine, she should be logrolled to the left with the right hip elevated; this will decrease uterine compression of the inferior vena cava and may in- crease cardiac output by 30%. If simple repositioning of the patient and rapid fluid resuscitation fail to pro- duce an adequate perfusion pressure, inflation of the MAST trousers may be considered. Only the leg com- partments should be inflated; inflation of the abdomi- nal portion is strongly contraindicated. In addition to the routine trauma physical exami- nation, the uterus should be palpated to determine tenderness and muscle tone. A tender, hypertonic uterus suggests placental separation. A vaginal specu- lum examination should be performed to check for cervical dilatation, amniotic fluid, or gross blood. If the patient has no evidence of blood in the vagi- na or the uterus, yet appears to be in hemorrhagic shock, diagnostic peritoneal lavage may be consid- ered. The lavage should be performed superior to the enlarged uterus by an open technique. Parameters for a positive tap are the same as in the nonpregnant woman. Radiologic and laboratory studies should proceed simultaneously with evaluation and resuscitation. There is obvious concern about radiation injury to the fetus, but the risk of congenital defect is low' when exposure is less than 10 rads; risk becomes significantly in- creased above 15 rads. Initial films, including chest x-ray (1 millirad), cervical spine (less than 0.5 milli- rads), lumbrosacral spine (721 millirads), and pelvis (210 millirads) can be performed well below these lev- els. The fetus should be shielded when possible.-”' Laboratory evaluation is essential, giving special at- tention to coagulation studies. Placental injury and separation causes release of thromboplastin, while uterine injury releases plasminogen activator, so that consumption coagulopathy and fibrinolysis may oc- cur.^ Fibrinogen levels are the most sensitive indicator of coagulopathy. Since Rh sensitization may occur in Rh-negative mothers, titers should be checked and Rhogam given when indicated. If fetal-maternal hem- orrhage and blood mixing is suspected, the Kleihauer- Betke test will determine the number of fetal cells in the maternal circulation and guide the physician in de- termining the amount of anti-D globulin to be admin- istered. All Rh-negative women should receive at least one vial.^ Blood for electrolyte determinations and full CBC should also be drawn. Once the primary and secondary assessment has been completed and the patient stabilized, uterine sonography and fetal monitoring should be performed. Ultrasound is a sensitive indicator of gestational age, presentation, amniotic fluid volume, and fetal move- ment, and may demonstrate intra-abdominal bleeding. It may also reveal congenital malformations, fetal fractures, placental characteristics, and the presence of abruptio placentae. Fetal/uterine monitoring should be instituted as soon as practicable. A hypertonic, contractile uterus sug- gests placental disruption, late decelerations suggest fetal hypoxia, and variable decelerations suggest cord compression. Prolonged fetal hypoxia produces aci- dosis and loss of fetal heart rate variability with a baseline tachycardia (> 160/min). When the fetus is severely compromised, a sustained bradycardia (less than 120/min) and wandering baseline results. Re- member that fetal distress may be an occult sign of maternal distress. It is our practice to monitor the pregnant mother sustaining major trauma for at least 24 hours. Established indications for laparotomy, thoracot- omy, or craniotomy should be observed irrespective of the fetus. Spinal column fracture may require stabili- zation rather than casting due to possible uterine growth retardation. It should be kept in mind that pa- tients with pelvic fractures have significant blood loss due to the pregnant woman’s increased pelvic vascu- lature. Also there is increased risk of fetal skull frac- ture with maternal pelvic fracture. Risk of uterine in- jury increases with length of gestation. Hysterectomy is rarely indicated, as uterine rupture is rare and can be repaired primarily. Premature labor is a common sequela of injury, and may be caused by small placental separation, uterine contusion, membrane ischemia, or membrane rupture. Magnesium sulfate is the first drug of choice for ar- resting labor. Ritadine hydrochloride is the second choice, but may lead to hemodynamic instability and pulmonary edema. When the fetus has been severely compromised, and intrauterine death occurs, labor usually ensues within 48 hours. With fetal demise, careful observation for evidence of disseminated intra- vascular coagulation (DIG) should begin. Surgery on behalf of the fetus, for example cesare- an delivery, should be considered only when the mother is stable and at minimal risk. Intrauterine death is not an indication for cesarean section; spontaneous abor- tion usually occurs within 48 hours. Indications for ce- sarean section include fetal distress, placental separa- tion, uterine rupture, or fetal malpresentation during premature labor. An unstable pelvis or lumbosacral fracture is sometimes an indication for cesarean sec- tion. Refractory coagulopathy due to placental sepa- ration is a rare indication for hysterectomy. Laparot- omy for management of other injuries does not necessitate cesarean section unless intraoperative fetal distress occurs or unless exposure of the pelvic vascu- FEBRUARY, 1990 75 lature. sigmoid colon, or bladder is compromised. When the uterus is injured and the fetus is mature, cesarean section may be indicated, but if the fetus is immature, myometrial repair is recommended without delivery. Decision to deliver the fetus should be based on the consideration of whether the fetus is at greater risk of dying from intrauterine hypoxia or prematurity. Delivery before 28 weeks is associated with a 50% mortality. If the mother dies, the fetus may have a chance. The elapsed time between maternal death and delivery correlates with neonatal survival. If the infant can be delivered within 15 minutes, survival is possible.^ At least 150 to 200 postmortem deliveries are reported in the literature with successful outcome.^ Comatose, neurologically devastated mothers have also been sus- tained to allow fetal maturation and eventual delivery. Judgment regarding cesarean section must be indivi- dualized, and in general the uterus is best left undis- turbed whether the fetus is alive or dead. r ^ Conclusions The injured pregnant woman presents the unique challenge of evaluating and caring for two inseparable lives. Appropriate management requires a team of physicians, including emergency physicians, trauma surgeons, obstetricians, and pediatricians. Under- standing the anatomic and physiologic changes that occur in pregnancy is essential for proper evaluation. In general, the best treatment for the mother consti- tutes the best treatment for the fetus. REFERENCES 1. Lavin JP. Polaskv SS: Abdominal trauma during pregnancy. Clin Perinatal l(l;423-437. 1983. 2. Crosby WM. Costilac JP: Safety of lap belt restraint for pregnant victims of automobile accidents. N Engl J Med 284:632-636. 1977. 3. Rothenberger D, Quattlebaum FW. Perry JF. et al: Blunt maternal trau- ma: a review of 103 cases. J Trauma 18:173-179. 1988. 4. Flaycock C: Trauma in Pregnancy. Littleton. Mass, PSG Publishing Com- pany, Inc, 1985. 5. Neufeld JDG, Moore EF, Marx JA, et al: Trauma in pregnancy. Emerg Med Clin North Am 5:623-640. 1987. 6. Lagrew D, Masterson BJ: Common Problems in Trauma. Chicago. Year Book Medical Publishers, Inc, 1987. pp 319-327. 7. Maull KI, et al: Injury to the female reproductive system, in Mattox KL (ed): Trauma. New York, Appleton and Lange, 1988, pp 553-560, MOVING? Send Us Your Address j Please notify us six weeks In advance. ’ Old Address • Name • Address | City State Zip ' New Address ' Address [ City State Zip j Effective Date of New Address j Send to: TMA, 112 Louise Ave., Nashville, TN 37203 [ I I YOCON' YOHIMBINE HCI Description: Yohimbine is a 3a-15a-20B-17a-hydroxy Yohimbine-16a-car- boxylic acid methyl ester. The alkaloid is found in Rubaceae and related trees . Also in Rauwolfia Serpentina (L) Benth. Yohimbine is an indolalkylamine alkaloid with chemical similarity to reserpine. It is a crystalline powder, odorless. Each compressed tablet contains (1/12 gr.) 5,4 mg of Yohimbine Hydrochloride. Action: Yohimbine blocks presynaptic alpha-2 adrenergic receptors. Its action on peripheral blood vessels resembles that of reserpine, though it is weaker and of short duration. Yohimbine’s peripheral autonomic nervous system effect is to increase parasympathetic (cholinergic) and decrease sympathetic (adrenergic) activity. It is to be noted that in male sexual performance, erection is linked to cholinergic activity and to alpha-2 ad- renergic blockade which may theoretically result in increased penile inflow, decreased penile outflow or both. Yohimbine exerts a stimulating action on the mood and may increase anxiety. Such actions have not been adequately studied or related to dosage although they appear to require high doses of the drug. Yohimbine has a mild anti-diuretic action, probably via stimulation of hypothalmic centers and release of posterior pituitary hormone. Reportedly, Yohimbine exerts no significant influence on cardiac stimula- tion and other effects mediated by B-adrenergic receptors, its effect on blood pressure, if any, would be to lower it; however no adequate studies are at hand to quantitate this effect in terms of Yohimbine dosage, indications: Yocon® is indicated as a sympathicolytic and mydriatric. it may have activity as an aphrodisiac. Contraindi^tions: Renal diseases, and patient's sensitive to the drug. In view of the limited and inadequate information at hand, no precise tabulation can be offered of additional contraindications. Warning: Generally, this drug is not proposed for use in females and certainly must not be used during pregnancy. Neither is this drug proposed for use in pediatric, geriatric or cardio-renal patients with gastric or duodenal ulcer history. Nor should it be used in conjunction with mood-modifying drugs such as antidepressants, or in psychiatric patients in general. Adverse Reactions: Yohimbine readily penetrates the (CNS) and produces a complex pattern of responses in lower doses than required to produce periph- eral a-adrenergic blockade. These include, anti-diuresis, a general picture of centra! excitation including elevation of blood pressure and heart rate, in- creased motor activity, irritability and tremor. Sweating, nausea and vomiting are common after parenteral administration of the drug.'' 2 Also dizziness, headache, skin flushing reported when used orally. ^ -3 Dosage and Adminisb^tion: Experimental dosage reported in treatment of erectile impotence. ' 1 tablet (5.4 mg) 3 times a day, to adult males taken orally. Occasional side effects reported with this dosage are nausea, dizziness or nervousness. In the event of side effects dosage to be reducedto Vi tablets times a day, follow®! by gradual increases to 1 tablet 3 times a day. Reported therapy not more than 10 weeks.3 How Applied: Oral tablets of Yocon® 1/12 gr. 5.4 mg in bottles of 100’s NDC 53159-001-01 and 1000’s I 53159-001-10. Roforences: 1. A.4^orales et al.. New England Journal of Medi- cine: 1221 . November 12, 1981 . 2. Goodman, Gilman — The Phamiacological basis of Therapeutics 6th ed., p. 176-188. McMillan December Rev. 1/85. 3. Weekly Urologies Clinical letter, 27:2, July 4, 1983. 4. A. Morates et al . , The Journal of Urology 1 28; 45-47, 1982. Rev. 1/85 AVAILABLE EXCLUSIVELY FROM PALISADES PHARMACEUTICALS, INC. 219 County Road Tenafly, New Jersey 07670 (201) 569-8502 1-800-237-9083 76 Radiology Case of the Month CT Scan of the Abdomen in the Evaluation of Splenic Infarction R. DANIEL MERRICK, M.D.; JAYANT B. MEHTA, DON DONAHUE, M.D.; and MARK YOUNG, M.D. Introduction Splenic infarction' needs to be included in the dif- ferential diagnosis of acute abdominal pain, since its radiographic diagnosis^-^ could prevent unnecessary surgical intervention in about 80%^ of cases of splenic infarction. Jaroch et ab summarized the natural history of splenic infarction. Their guidelines help the internist and the surgeon in patient management, especially in the decision regarding surgical intervention. Balcar et ah summarized the computer tomography (CT) varia- tions of splenic infarction and described the evolution of splenic infarction by using an animal model, induc- ing splenic infarctions in dogs and studying changes in CT of the spleen sequentially. We report the case of a patient with a typical nat- ural history, but with markedly prolonged evolution of her splenic infarction as shown by CT. Case Report A 72-year-old white woman entered the emergency room with the complaint of left lower quadrant abdominal pain for six days. The pain was sharp, and radiated to the left side of her neck. There was no associated nausea, vomiting, fever, shaking chills, diarrhea, constipation, or change in urine or stool color or character, and there was no suggestion of a cardiac source as the cause of the pain. The pain was neither exacerbated nor relieved by food intake, and was not posi- tional. Past medical problems w'ere hypertension, congestive heart failure, history of blood transfusion (reason unknown), and radioactive iodine treatment for a thyroid mass. The patient's blood pressure w'as 140/70 mm Hg without orthostatic changes. Her temperature orally was 98.6°F, pulse 100/min and regular, and respirations nonlabored with a rate of 20/min. She appeared in acute distress and was holding her abdomen. Examination of the lungs and heart was normal except for a 2/6 systolic ejection murmur. Her abdomen was protuberant with diminished bowel sounds, hepatospleno- megaly, left lower quadrant pain on palpation, and moderate diffuse tenderness with rebound. The remainder of her ex- amination was normal and there was no clinical evidence of bacterial endocarditis. From the Department of Medicine, James H. Quillen College of Medicine, East Tennessee State University, Johnson City. M.D.; JAMES COWAN, M.D.; Serum electrolytes, blood urea nitrogen, creatinine, cal- cium, and amylase w^ere all normal, and the complete blood count W'as w'ithin normal limits except for a mild microcytic, hypochromic anemia. Chest x-ray and flat and upright x-rays of the abdomen w'ere normal. An arterial blood gas analysis with the patient breathing room air revealed a pH of 7.44. PaC02 of 38 mm Hg and a Pa02 of 62 mm Hg. A CT scan of the abdomen revealed a low- density area laterally in the spleen. The patient was treated with bed rest, and given intrave- nous fluids, oxygen, and analgesics. Her pain continued dur- ing her admission, but steadily decreased to where she w'as able to tolerate it with minimal oral analgesics. Her temper- ature and hemoglobin remained stable throughout the admis- sion. Surgical intervention w'as unnecessary, and she was dis- charged ten days after admission in stable condition. Serial CT scans of the abdomen done over the course of four months confirmed the diagnosis by showing the expected radiograph- ic changes in spleen size and contour. Discussion There are multiple causes of splenic infarction, the most common being embolization, often with infec- tious endocarditis; hematologic disease, usually sickle hemoglobinopathy, is the next most frequent cause. Jaroch et ab found that patients under the age of 40 most often had hematologic disease and those older had had an embolic event. The etiology of our pa- tient’s splenic infarction was never determined, the case in roughly 3%^ of patients. Left upper quadrant abdominal pain is the principal presenting symptom, though 30%^ to 90%^ of patients will have no symptoms at all. Our patient’s symptoms were rather prolonged but she was managed medically because her pain was well controlled with minimal an- algesia and she had no significant sequelae of the in- farction. The conservative management included an- algesia, hydration, and supplemental oxygen. Significant complications requiring other measures, not present here, include hemorrhage, hypersplenism, ab- scess, massive splenic enlargement, or recurrent epi- sodes of splenic infarction. Splenectomy is often done in such cases. The mortality rate for medical manage- ment of complicated cases of splenic infarction in one review was 43%.^ FEBRUARY, 1990 77 Figure 1. The shorter arrow points to a wedge-shaped area of de- creased signal intensity with its apex toward the hilum of the spleen. The longer arrow shows normal spleen signal intensity. Diagnostic procedures used in the diagnosis of splenic infarction consist of CT, liver/spleen radio- nuclide scan, ultrasonography of the spleen, and an- giography, CT and liver/spleen radionuclide scan being the best methods. The final diagnosis in our case was based on the clinical presentation and the findings from the CT scan of the abdomen (Fig. 1). Surgical inter- vention was not necessary because of the classic radi- ographic findings. This diagnosis was supported by a liver/spleen scan. The wedge-shaped defect with the apex towards the hilum of the spleen (Fig. 1) is typical of splenic infarction. Dakar’s animal model would have projected radiographic resolution in 15 to 28 days. A second scan one month later was unchanged, but a third scan after four months (Fig. 2) finally showed the ex- pected radiographic resolution, i.e., atrophy and Figure 2. The arrow points to the shrunken, notched spleen. The size and contour changes are expected with resolution of the infarct. notching of the splenic contours. The cause of the slow resolution of this patient’s splenic infarction is unclear; whether it indicates the fallibility of using animal models, an unusual cause of the splenic infarction, or recurrent (yet silent) splenic infarctions with delayed healing, is unknown. Nonetheless, radiographic dem- onstration of resolution of the process greatly reduces the likelihood of neoplasm. r ^ REFERENCES 1. Sleisenger M, Fordtran JS (eds): Gastrointestinal Disease, ed 4. Philadel- phia. W. B. Saunders Co, 1989. pp 243-249. 2. Balcar I, Seltzer SE, Davis S. et al: CT patterns of splenic infarction: a clinical and experimental study. Radiology 151:723-729, 1984: 3. O’Keefe JH, Holmes DR, Hartzell VS, et al: Thromboembolic splenic infarction. Mavo Clin Proc 61:967-972, 1986. 4.. Piekarski J, Federle MP, Moss AA, et al: Computed tomography of the spleen. Radiology 135:683-689, 1980. 5. Haft JI. Altieri J. Smith LG. et al: Computed tomography of the abdomen m the diagnosis of splenic emboli. Arch Intern Med 148:193-197, 1988. 6. Jaroch MT, Broughan TA, Hermann RE: The natural history of splenic infarction. Surgery 100:743-749, 1986. APRIL 1990 . Sunday Monday Tuesday Wednesday Thursday Friday Saturday | 1 2 3 4 5 6 7 TMA 1 55th ANNUAL MEETING Hyatt Regency Hotel — Knoxville 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 NOTES 78 JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION Vanderbilt Morning Report A Fatal Case of Hiccups Case Report A 46-year-old man was evaluated at a hospital emergency room for confusion, agitation, and acidosis. He had been well until earlier that day w'hen he drank approximately 1 ounce of oil of wintergreen in an attempt to suppress persistent hic- cups. He experienced no immediate effects, but over the next several hours he became progressively confused and agitated. Upon admission to the emergency room, an arterial blood gas showed a pH of 7.39, a PcOj of 23 mm Hg, and a P02 of 103 mm Hg. The serum bicarbonate was 14 mmol/L, with an anion gap of 23. Serum glucose and the remainder of the electrolytes were normal. The salicylate level was 102 mg/dl (toxic ^ 40 mg/dl). He was treated with activated charcoal and alkaline diuresis, but serial salicylate levels continued to rise and his acidosis worsened. He w'as given 150 mEq so- dium bicarbonate intravenously and transferred to Vanderbilt University Hospital, where the pH was 7.51, PcOj 15 mm Hg, PO2 84 mm Hg, and the salicylate level 128 mg/dl. Chest radiograph demonstrated normal cardiac silhouette with pul- monary edema. Soon after transfer, respiratory arrest oc- curred, for which tracheal intubation was performed, but he developed asystole, and though he initially responded to re- suscitative measures, he subsequently failed to respond, and was pronounced dead approximately 17 hours after ingesting the oil of wintergreen. Discussion Methyl salicylate is a rare cause of salicylate poi- soning. It is available as a concentrated liquid (oil of wintergreen) and in various topical preparations. One teaspoon of oil of wintergreen contains 5 gm of sali- cylate.' Lethal dosage in children may be as small as 4 cc, while a lethal dose in adults is usually around 30 cc. Other factors contributing to the risk of methyl sa- licylate poisoning include its pleasant odor, its availa- bility without prescription, the lack of appreciation by the public of its potential toxicity, the lack of appro- priate warnings on packages, and the possibility of toxicity when topical preparations are applied to large areas of skin.^ Methyl salicylate is quickly hydrolyzed in the liver to free salicylate.^ Acute toxicity of methyl salicylate appears to be identical to that of sodium salicylate. The pharmacokinetics of salicylate metabolism switch from first order to zero order kinetics with large doses because of saturation of conjugation mechanisms. Prepared by William F. Fleet, III, M.D.. Hugh J. Morgan chief medical resident, and Patrick J. Morello, M.D., medical resident. Vanderbilt Medical Center, Nashville. Therefore, toxic doses of salicylates have a longer half- life than that of therapeutic doses. The renal excretion of salicylate becomes important with large doses, and it is dependent on urine pH; there is a much greater excretion of salicylate in alkaline than in acidic urine. Ingestion of 150 to 300 mg/kg of salicylate usually results in only mild to moderate toxicity; doses of 300 to 500 mg/kg usually cause serious toxicity, while dos- es of 500 mg/kg or more are potentially lethal. Nau- sea, vomiting, tinnitus, and disorientation are common early symptoms of salicylate poisoning. Respiratory al- kalosis is a direct effect of salicylate on the respiratory center of the brain. Metabolic acidosis results from uncoupling of oxidative phosphorylation and inhibi- tion of enzymes of the Krebs cycle, causing accumu- lation of pyruvic acid and lactic acid. Increased pe- ripheral utilization of glucose stimulates lipid metabolism with formation of ketone bodies.-* The un- coupling of oxidative phosphorylation increases the metabolic rate, with resultant hyperpyrexia and dia- phoresis. Fluid loss can be substantial because of hy- perventilation, diaphoresis, fever, emesis, and renal excretion. Hyponatremia, hypernatremia, hypokale- mia, hypoglycemia, hypocalcemia, and hypouricemia have all been described. Central nervous system symptoms may dominate the clinical picture in severe intoxication, and may be the underlying cause of death. ^ These symptoms include lethargy, confusion, delirium, seizures, and coma. Cerebral hypoglycemia may play a pathophysiologic role in these abnormalities, and may occur despite normal peripheral glucose levels.^ Cerebral edema and hemorrhage may occur. * Other clinical manifestations of salicylate toxicity include reversible liver damage, impairment of vitamin K-dependent clotting factors, renal tubular damage, cardiovascular collapse, and noncardiogenic pulmonary edema.' Diagnosis of salicylate intoxication is made by measuring the blood level of salicylate. Levels ob- tained sooner than six hours after ingestion are still in the absorption-distribution phase and cannot be used to predict severity of poisoning. ■* In massive overdoses, salicylate levels may rise for as long as 24 hours after ingestion. The Done nomogram** is useful for estimat- ing the severity of salicylate toxicity. Initial management of salicylate poisoning should include gastric emptying and administration of char- FEBRUARY, 1990 79 coal. Electrolyte abnormalities and metabolic acidosis should be corrected, and intravenous glucose is indi- cated in most cases. Appropriate fluid is important for maintaining urine output and renal excretion of sali- cylate; alkalinization of the urine will significantly in- crease renal excretion. Acetazolamide should not be used. Hemodialysis and charcoal hemoperfusion are both effective in increasing salicylate clearance.'' Spe- cific indications for hemodialysis in cases of salicylate poisoning include renal insufficiency, heart failure, in- tractable acidosis, severe fluid and/or electrolyte ab- normalities, salicylate levels greater than 100 mg/dl, and severe CNS symptoms. REFERENCES 1. Howrie DL. Moriarty R, Breit R: Candy flavoring as a source of salicylate poisoning. Pedfatr/ci 75:869-871 . 1985. 2. Davies MG, Briffa DV. Greaves MW: Systemic toxicity from topically applied salicylic acid. Br Med J 278:661, 1979. .1. Davison C. Zimmerman EF. Smith PK: On the metabolism and toxicity of methyl salicylate. J Pharmacol Exp Ther 132:2(17-211. 1961. 4. Temple AR; Acute and chronic effects of aspirin toxicity and their treat- ment Arch Intern Med 141:364-369, 1981. 5. Hill JB: Salicylate intoxication. N Engl J Med 288:1110-1113, 1973. 6. McGuigan MA: A two-year review of salicylate deaths in Ontario. Arch Intern Med 147:510-512. 1987. 7. Heffner JE. Sahn S: Salicylate-induced pulmonary edema. Ann Intern Med 95:405-409, 1981. 8. Done AK: Salicylate intoxication: significance of measurements of salicy- late in blood in cases of acute ingestion. Pediatrics 26:803-807, 1960. 9. Winchester JF, Gelfand MC. Helliwell M, et al: Extracorporeal treatment of salicylate or acetaminophen poisoning: is there a role? Arch Intern Med 141:370- 374, 1981. A Case of Goodpasture’s Disease and Interstitial Pulmonary Infiltrates Case Report A 23-year-old white man was admitted in June 1989 for evaluation of malaise and fever. He was well until January 1989 when he noted slight cough and blood-streaked sputum. He was treated with erythromycin for bronchitis but did not improve. He again sought medical attention in March 1989 for hematuria, and was diagnosed as having a urinary tract infection, for which he was treated with trimethoprim-sulfa- methoxazole. Hemoptysis, fatigue, and dyspnea on exertion all increased over the next several weeks, prompting him to seek further medical attention. Evaluation at that time re- vealed bilateral pulmonary infiltrates on chest x-ray, hemat- ocrit of 13%, and creatinine of 5.5 mg/dl. A preliminary di- agnosis of Goodpasture’s disease was confirmed by kidney biopsy, which revealed intense linear staining (4-f ) for IgG and 1 + irregular C3 staining of the basement membrane. Antiglomerular basement membrane antibody (anti-GBM) titer was 1:50. He was subsequently treated with plasmapher- esis 11 times, and with prednisone and cyclophosphamide; his anti-GBM titer fell to zero. He was continued on daily pred- nisone and cyclophosphamide and maintained on hemodi- alysis via a subclavian catheter (hemocath). He did well until June 26, when he was admitted with malaise and fever to 102° F. He denied cough, sputum, dys- pnea, dysuria, diarrhea, or pharyngitis. Physical examination revealeiJ blood pressure of 130/70 mm Hg, pulse 90/min, res- piratory rate 16/min, and temperature 99° F. HEENT exam- ination was unremarkable. Neck was supple without adeno- pathy. Lungs were clear to auscultation. Cardiac examination revealed a 1/6 systolic murm.ur, unchanged from previous ex- aminations. The rest of the physical examination was normal except for erythema and tenderness of the site of the subcla- vian hemocath. Laboratory examination showed a BUN of 46 mg/dl, creatinine of 4.4 mg/dl, and phosphorus of 7.2 mg/ Prepared by R. Stokes Peebles, M.D., chief medical resident, Nashville Veterans Administration Medical Center. 80 dl. The WBC count was 500/cu mm (differential not ob- tained), and hematocrit was 25%. Chest radiograph revealed no infiltrate or effusion. The hemocath was removed and the patient was empirically treated with vancomycin, ceftazidime, and gentamicin; prednisone taper was begun, and cyclophos- phamide was stopped. Initial blood and urine cultures were negative. He re- mained febrile, but two days into his hospitalization, he de- veloped diarrhea. Stool for culture, ova and parasites, and Clostridium difficile toxin were negative. Treatment with oral metronidazole and parenteral amphotericin B was started. He remained neutropenic until the tenth hospital day, when his WBC count was 2,120/cu mm, with 77% neutrophils, but fe- ver continued. Metronidazole and ceftazidime were discon- tinued, and aztreonam was given instead. His WBC count continued to rise, but fever continued, and on the I6th hos- pital day the patient became dyspneic, tachypneic, and hy- poxic (Pa02 71 mm Hg on two liters of oxygen by nasal can- ula). His hematocrit was 17%. Chest radiograph revealed bilateral interstitial infiltrates present diffusely throughout both lungs. He was transferred to the intensive care unit, where bronchoscopy and bronchoalveolar lavage yielded Pneumo- cystis carinii (PCP). All other stains and cultures were nega- tive, and there was no evidence for reactivation of Goodpas- ture’s disease as a cause of his acute illness. HIV antibody was negative. The patient was treated with intravenous tri- methoprim (8 mg/kg/day) and sulfamethoxazole (40 mg/kg/ day) for 23 days with improvement of symptoms and defer- vescence. He was discharged from the hospital and is doing well. Discussion This case illustrates several important points. With the emergence of the acquireid immunotJeficiency syn- drome and the high prevalence of PCP infections in this patient population, it is important to remember that other immunosuppressed states also can predis- JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION pose to Pneumocystis infection.' Impoverished living conditions and malnutrition led to Pneumocystis pneu- monia in central Europe just after World War II. Now, with common use of cytotoxic drugs in organ trans- plants and antineoplastic therapy, iatrogenic immuno- suppression is recognized as predisposing to this po- tentially lethal disease.^ Thus, Pneumocystis infection must be considered whenever pneumonia accompanies immunosuppression. Another important aspect of this patient’s care is that the diagnosis was made by bronchoalveolar la- vage. This procedure has been reported to have a high degree of sensitivity in making the diagnosis of Pneu- mocystis infection (up to 95%) and is safer than trans- bronchial biopsy or open lung biopsy. ^ Immunoflu- orescence stains with monoclonal antibodies have been reported to have a sensitivity as high as 92% using spu- tum, and may be the noninvasive test of the future. REFERENCES 1. Burke BA. Good RA: Pneumocystis carinii infection. Medicine 52;23-51. 1973. 2. Rifkind D. Starzl TE. Marchino TL. et al: Transplantation pneumonia. JAMA 189:808. 1964. 3. Golden JA. Hollander H. Stulbarg MS. et al: Bronchoalveolar lavage as the exclusive diagnostic modality for Pneumocystis carinii pneumonia. A pros- pective study amone patients with acquired immunodeficiency syndrome. Chest 90:18-22. 1986. 4. Kovacs JA. Ng VL. Cohen E, et al: Diagnosis of Pneumocystis carinii pneumonia: improved detection in sputum with use of monoclonal antibodies. .V EnglJ Med 318:589-593. 1988. NORTH AMERICAN TRANSPLANT COORDINATORS ORGANIZATION Announces An ORGAN DONATION Information and Referral HOTLINE for Physicians and Health Care Professionals DIAL 800/24-DONOR Day or Night To refer a potential postmortem organ donor or to secure information concerning donation and procurement of organs for transplantation — or call your regional organ procurement program FEBRUARY, 1990 Odds Are Against You... . . . when you cake a chance on disability without disability insurance. A disability can strike without w'arning. In fact, you arc three times more likely to be disabled this year than to die!* You can protect your ability to practice medicine through the Tennessee Medical Association’s plan of disability coverage. Fill out, clip and return the coupon below. We will send you information on a disability plan that’s a sure winner. Or, call us toll free at 1-800-347-1109. ’‘Journal of the Amcntan So«.ien ut Chartenni Lite I ndtrwnrcrs. Vol Vlll. X»: 1 iBascd mi persons between the ages of ^2 and Yes, send me information on TMA’s non- cancellable disability insurance plan. Name Date of Birth Spouse Date of Birth Firm name Address City State Smoker yes Cl no Q Zip Spouse yes C no C Mail to Plan Administrator The TMA Association Insurance Agency, Inc. P.O. Box 1109, Chattanooga, TN 37401 Sponsored by the Tennessee Medical Association! Health and Environment Report Tuberculosis in Tennessee: Current Trends and Program Update JAYANT B. MEHTA, M.D. and KERRY W. GATELEY, M.D., M.P.H. The current chemotherapeutic regimen for tuber- culosis (TB) is a triumph of modern medical science. Not only can the disease be cured with a 97% success rate, but it also can be prevented by isoniazid (INH) prophylaxis.' - Nevertheless, in spite of the availability of curative medicines. TB continues to remain a na- tional problem. Although during the early years of this decade the incidence of TB was declining in Tennessee at an average annual rate of approximately 3.5%, in 1987 there were 609 new cases reported in Tennessee, which represents a 2% increase over the 1986 total of 597 cases. In 1988, 620 cases were reported, a 1.8% increase over 1987. Compared with that of the rest of the nation, Ten- nessee's TB rate is high. In 1987 the Tennessee case rate of 12.4 per 100,000 ranked tenth in the United States; the 1988 rate was slightly higher at 12.5, but national rankings were not available at this writing. The eradication of TB, particularly in our growing geriatric population, remains an elusive goal in Ten- nessee and most of the nation. Tremendous efforts and progress are being made in the realm of early diagno- sis of TB. leading to reductions in death rates and pre- venting transmission. Eleven of Tennessee’s 95 coun ties did not report a single case of TB in 1988, and one county has not reported a case in the past five years. The distribution of reported cases by race and sex has continued virtually unchanged for the past several years. About 70% of the 620 cases reported in 1988 occurred in whites, but on the other hand, the case rate of 21.4 per 100,000 observed among blacks is more than twice as high as that for whites (10.6 per 100,000); 71.8% of new cases were in male subjects. The inci- dence of TB in the elderly is high, the case rate for persons over 65 being 54.8 per 100,000. Although TB is thought of as a pulmonary disease, Mycobacterium tuberculosis can infect other sites as well.-* Extrapulmonary TB comprised 13% of the cases report- ed in 1987 and 16.8% in 1988. The rate of extrapulmon- ary TB has remained fairly constant over the past sev- eral years, and the recent historical decline in TB largely has been due to the decreases in pulmionary disease. As a result, extrapulmonary TB has come to represent a From the Division of Tuberculosis Control, Tennessee Depart- ment of Health and Environment. Nashville. 82 proportionally expanded fraction of total TB cases. At this point, it is natural to wonder why the steady decline in TB case rates has reversed. Several factors have been proposed, and these will be explored brief- ly. Although there is no standard definition, and their true numbers are not known, it is estimated that at least 4,000 homeless persons were living in Tennessee during 1987. Twenty-four cases of TB were reported among this group in 1987, for an estimated case rate of 600 per 100,000. Fourteen such cases were reported in 1988 (350 per 100,000, using the 1987 population estimate). Although the homeless comprise a heter- ogenous population, and these estimates are of uncer- tain accuracy, this alarmingly high rate certainly sug- gests that this cluster of people could be contributing to the new increase of TB. The introduction of TB into nursing homes, pris- ons, or other institutionalized populations poses a spe- cial risk to persons living or working in these facili- ties.'' Despite recommendations for routine TB screening, 16 nursing home residents and 14 persons in jail or in prison developed TB in 1988. Case rates for these groups are as much as ten times those of the general population. Furthermore, many such persons may be released to their communities, where they can spread their infection to others. The well-publicized AIDS epidemic has raised con- cern that lung disease due to M. tuberculosis and other mycobacteria would increase."’ Nationally, this fear is well founded. Preliminary data in Tennessee suggest there were at least four cases of concomitant AIDS and TB in 1987, and three in 1988. Solid data as to the concurrence of HIV positivity and TB are lacking. TB is one of the few potentially treatable diseases that afflict these immunocompromised patients. In the present day, most cases of TB represent a failure in prevention. TB is spread by persons with TB who were, in turn, infected by someone else with the disease. Treatment is available, and infected persons can be effectively prevented from developing active, in- fectious disease by the use of appropriate drug regimens. Thus, if all cases of infectious TB were treated ade- quately and promptly, and all eligible infected persons were treated prophylactically, TB could be eliminated. The TB prevention recommendations of the Divi- sion of Tuberculosis Control are consistent with the JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION TABLE 1 RECOMMENDATIONS FOR ISONIAZID PROPHYLAXIS*’ ^ 1. Household contacts, both tuberculin negative (especially children) and tuberculin positive (risk during first year after discovery of the index case about 1 in 30). 2. Recent converters of any age (annual risk about 1 in 20). 3. Persons with previously known tuberculosis, now inactive, who have not had adequate chemotherapy (annual risk about 1 in 75). 4. Positive tuberculin reactors with abnormal pulmonary findings in the chest x-ray (annual risk about 1 in 125). 5. Positive tuberculin reactors under the age of 35 years. Although very young children and teenagers are at the highest risk, all re- actors in this age group will be at a lifetime risk. 6. Positive tuberculin reactors in the special clinical situations noted below. (The risk varies and applies only while the special situation exists.) Special Clinical Situation, in which a person with a positive tuber- culin test is in increased danger of activation or reactivation of tuberculosis due to: Adrenal corticold or immunosuppressive therapy After gastrectomy Reticuloendothelial disease such as leukemia or Hodgkin’s disease Severe diabetes Silicosis Children with a positive tuberculin reaction who develop measles or whooping cough Weight loss for any cause Positive HIV test and/or AIDS Chronic renal insufficiency Heroin addicts 'Important to note that isoniazid can be prescribed for a period of 6 months instead of 9 or 12 months as recommended in the past. This short duration will be effective only if the compliance is adequate. guidelines promulgated by the American Lung Asso- ciation and the American Thoracic Society. These are summarized in Table 1. The Division of Tuberculosis Control provides well- organized services for all stages of TB control. It is our pleasure and our purpose to assist clinicians in com- batting TB, and information on these services may be obtained from the Division. Although it sometimes seems that the eradication of TB in Tennessee is an idle dream, continuing co- operative efforts by private physicians and health de- partment personnel will reduce TB in this state. Early diagnosis, prompt and effective therapy, and enthu- siastic preventive efforts are still the cornerstones of the TB elimination effort. r ^ REFERENCES 1. Treatment of tuberculosis and TB infection in adults and children: Joint statement of the American Thoracic Society and the Centers for Disease Control. Am Rev Respir Dis 134:355-363, 1986. 2. Comstock GW: Prevention of tuberculosis among tuberculin reactors: maximizing benefits, minimizing risks. JAMA 256:2729-2730, 1986. 3. Farer LS: The current status of tuberculosis control efforts. Am Rev Res- pir Dis 134 (suppl):402-423. 1986. 4. Tuberculosis— United States 1985. MMWR 35:699-703, 1986. 5. Stead WW, Lofgren JP, Warren BA. et al: Tuberculosis as an endemic and nosocomial infection among the elderly in nursing homes. A' Engl J Med 312:1483-1486, 1985. 6. A strategic plan for the elimination of tuberculosis in the United States. MMWR 38 (suppl), April 21, 1989. FEBRUARY, 1990 Your Health Depends On... . . . your medical insurance coverage. But don’t wait until you file a claim to test your coverage. With today’s rising health care costs, you can’t afford not to find out more about TMA’s medical insurance plan for physicians. Fill out, clip and return the coupon below. We will send you information on a medical insurance plan that’s the right prescription for your pocketbook. Or, call us toll free at 1-800-347-1109. Yes, send me information on TMA’s medical insurance plan. Name Firm name Phone # Address City Mail to Plan Administrator The TMA Association Insurance Agency, Inc. P.O. Box 1109, Chattanooga, TN 37401 Sponsored by the Tennessee Medical Association! Loss Prevention Case of the Month Continuing Supervision of Staff — A Necessity J. KELLEY AVERY, M.D. Case Report Our patient, a 58-year-o!d woman, had a modified radical mastectomy on the right eight years earlier because of breast cancer. She had been treated according to standard protocol, and following the surgery had had chemotherapy and radia- tion. She had done so well postoperatively that after the five years following the initial treatment had lapsed, her attending physician elected to see her annually. At the eight-year annual checkup, the patient complained of a rather severe pain in the upper back and chest, which had begun only two or three weeks before. A physical ex- amination did not reveal any significant abnormality. The mastectomy scar was examined thoroughly and a chest x-ray showed no evidence of lung pathology. Some symptomatic treatment was prescribed, and the patient was asked to re- turn within a month if the pain continued. The patient’s pain became worse, and she did not wait a month to return, but returned to her primary care physician within two weeks. At this point the patient was sent to the operating surgeon for further evaluation. Again, the physical examination showed no significant findings. It included a very thorough examination of the chest wall and axilla. Again, a routine chest x-ray was unremarka- ble. Because the patient’s pain had gotten decidedly worse in the two weeks that intervened between her visit to her pri- mary care physician and the appointment with her surgeon, a CT scan and a bone scan were ordered. Both showed evi- dence of metastatic disease in the upper thoracic spine and in the right clavicle. Since the patient was having no neurologic symptoms ex- cept for the local pain, it was elected to treat her with chem- otherapy to begin with, to be followed by radiation. She re- sponded clinically to a course of chemotherapy with a marked reduction in pain, and the radiation therapy was to follow at an appropriate time after the completion of chemotherapy. The lesions were evaluated and the radiation protocol was established, and the patient was to return at stated intervals until she had completed the radiation protocol. The patient followed the protocol precisely, and after completing all of the radiation, despite significant radiation sickness she did well for a very short time. The patient began to complain of some numbness and weakness in her lower extremities. This rapidly progressed to involve the upper extremities, and she soon became quadri- plegic, with only minimal function in the upper extremities, and a diagnosis of transverse myelitis due to radiation was made. In reviewing the entire protocol for treatment, it was found that inadequate shielding had been used in the actual delivery of radiation to the prescribed sites on this patient’s body. The same shielding had been used with every treatment, and was Dr. Avery is chairman of the Loss Prevention Committee, State Volunteer Mutual Insurance Company, Brentwood, and medical di- rector for Ambulatory/Outpatient Services, St. Thomas Hospital, Nashville. 84 considered by all involved in the case, including the attending physician, to be the cause of the patient’s disease. A six-fig- ure settlement was negotiated. Loss Prevention Comments Catastrophes of this type do not occur often, but they do occur, and when they do they most often are due to a tragic mistake. There have been cases where the programming of the therapy unit had been at fault, and even though the appropriate dosage and length of time had been entered into the machine, due to the programming error the patient received much more radiation than had been intended. This did not appear to be the problem in this case. There have been cases where the supervision of the technical people involved with actually delivering the treatment has been at fault. Instructions that were less than precise, and failure to monitor with each treat- ment what the technician was actually doing may have played a part here. Calibration of the machine has been a problem in some previous cases, but in this case that was not sus- pected. Here we have a situation where everybody involved admitted that inappropriate shielding had been used. It was not done because nobody knew what was ap- propriate; it was simply because those responsible for setting up the machine for the treatments did not at- tend to their responsibilities adequately. You may say that this kind of tragic error will occur despite all our efforts to prevent it. Perhaps that is true. However, if this happens to one of your patients, perhaps the pain of high malpractice insurance premi- ums will be the least pain you will have to endure. The much greater pain will be the memory of the damaged patient. Had this particular event gone to a jury, it was feared that the degree of negligence would be such that punitive damage would have been called for. To repeat, when one is involved in delivering this type of therapy, there simply must be precise calibra- tion of the machine to be used, appropriate program- ming of the prescribed dosage and time into the unit, and close supervision of technical people. It appeared to be the last that produced this very tragic injury. JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION Minutes of the Tennessee State Board of Medical Examiners Meetings August 23, 1989 Members Present: Duane C. Budd, M.D., President William W. Cloud, M.D., Secretary Oscar M. McCallum, M.D. Members Absent: Edgar L. Scott, M.D. Chris Blevins, M.D. This was a special meeting called to consider a Summary Suspension of Owen C. Bell, M.D. Violations: (1) Malpractice (performing complex and extensive surgical procedures with questionable indi- cations, in an outpatient setting, and failure to provide adequate follow-up). (2) Operating an unlicensed am- bulatory surgery center. Action: (1) The license of Owen C. Bell, M.D., is Summarily Suspended. (2) The Suspension shall re- main in effect until a hearing is held before the Board of Medical Examiners. October 11, 1989 Members Present: Duane C. Budd, M.D., President William W. Cloud, M.D., Secretary Edgar L. Scott, Jr., M.D. Members Absent: Oscar M. McCallum, M.D. Chris Blevins, M.D. This was a special called meeting to consider some items regarding the Summarv Suspension of Owen C. Bell, M.D. The meeting was called to order at 2:00 pm, by Duane C. Budd, M.D., president. Petition for Stay of an Order of the administrative law judge issued on October 6, 1989. The Order in- cluded: (1) The State’s complaint against Respondent Bell is DISMISSED WITH PREJUDICE. (2) The State is ORDERED to immediately return all the cre- dentials that have been Summarily Suspended from the respondent. (3) The proposed hearing scheduled for October 11, 1989, being rendered moot by this Order, is hereby cancelled. After hearing evidence by Mary Johnston, Attor- ney, Office of General Counsel, and by Larry Levine, Attorney for Dr. Bell, the Board unanimously voted to grant the Petition for Stay of the Order. Therefore, the Summary Suspension is still in effect. Petition for Stay of the Summary Suspension filed by Mr. Levine, Attorney for Dr. Bell: After hearing evidence by Mary Johnston and Larry Levine, which included testimony by Dr. Owen Bell, the Board unanimously voted to deny the Petition for Stay of the Summary Suspension. Appeal of an Initial Order of the administrative law judge regarding an Order issued on August 21, 1989, concerning this case: The Board decided not to act on this matter. Both the attorney for the State and the administra- tive law judge have filed petitions in Chancery Court to settle these legal matters. The hearing for Dr. Bell before the Board is ten- tatively scheduled for November 14-16, 1989. There being no further business, the meeting ad- journed at 4:00 pm. FEBRUARY, 1990 85 Minutes of the Tennessee State Board of Medical Examiners Meetings October 3 and 4, 1989 Members Present: Duane C. Budd, M.D., President William W. Cloud, M.D., Secretary Edgar L. Scott, Ji., M.D. Oscar M. McCallum, M.D. Chris Blevins, M.D. The meeting was called to order at 8:30 am, by Duane C. Budd, M.D., president. The minutes from the July 11, 1989 and August 23, 1989 Board meetings; the Conference Call meeting of August 31, 1989; and the Rulemaking Hearing of Sep- tember 1, 1989 were approved as submitted. Applications Reciprocity applications were approved for Drs. Holvor W. Ashley, Charles E. Farmer, Eugene V. Grace, Swatantra B. Kodali, Robert Lorenzo, Stead- man A. Mason, David G. Newman, Stephen H. Royal, Charles R. Sharpe, and Ernest E. Sullivent. Approval was deferred until receipt of additional information for Drs. Carmen L. J. Haynes and Robert G. Peden. No action was taken on the following applications due to the fact that the applicants were not present; Drs. James A. Moseley, Carl Reed, and Richard Sundling. The reciprocity application for Dr. James H. Thomas, Jr. was denied due to the fact that he did not receive the passing score on FLEX which is required in Ten- nessee for licensure. The reinstatement application was approved for Dr. Walter D. Harris. Approval for licensure was granted for the following who had passed the June, 1989 FLEX examination; Drs. Kendall H. Boyd, Mohammed B. Khan, and Olayinka O. Onadeko. Licensure was de- nied to Dr. Marvin E. McElroy who has passed FLEX, because he had not completed a continuous three-year residency. He graduated from one of the Caribbean schools that Tennessee requires three years of U.S. postgraduate training. Approval was deferred for Dr. Osama A. Ramsey since he was not present. Hearings Licensee: Herbert Ray Evers, M.D. Violations: (1) Gross malpractice. (2) License pre- viously revoked by state of Alabama. Action: Default hearing. License revoked. Licensee: James F. Albritten, M.D. Violations: (1) Substance abuse and addiction (Tal- win and Nubain). (2) Violation of the intent and pur- pose of the Board’s previous Order regarding sub- 86 stance abuse, thereby impairing his ability to safely practice medicine. Action: (1) License placed on probation for mini- mum of three years and maximum of five years. (2) Enter into a new contract with the TMA Impaired Physician Program (five years). (3) Continue after- care, including unannounced urinalyses. Licensee: Howard L. Burley, Jr., M.D. Violation: Respondent had his license to practice medicine suspended in the state of Michigan due to chemical dependency. He has entered into a treatment program and obtained their advocacy. He is now pre- pared to accept conditional relicensure for a proba- tionary period from this Board. He was previously li- censed in Tennessee on June 23, 1988. Action: (1) License reinstated with probation for a minimum of three years and maximum of five years. (2) Contract with TMA Impaired Physician Program (five years). (3) Aftercare program with unannounced urinalyses. (4) Respondent’s DEA certificate for pre- scribing Schedule II drugs has been previously surren- dered, and he shall not reapply for Schedule II privi- leges without permission of the Board. May use Schedule III, IV, and V privileges only on in-patients in his in-house employment. Licensee: Richard G. Hofmeister, M.D. Violation: Dispensing, prescribing, or otherwise distributing controlled substances, not in the course of professional practice, or for a legitimate medical pur- pose. Action: Board accepted an Agreed Order as fol- lows: The respondent has retired from the practice of medicine, is not licensed to practice medicine in Ten- nessee, and shall not reapply for licensure. Licensee: Donald R. Spencer, M.D. Violation: Convicted in U.S. District Court for the western district of Tennessee on October 2, 1987 for the offense of filing false tax returns. He was sen- tenced to one year’s incarceration on six counts, to run concurrently. He was given a suspended sentence on one count and placed on probation for five years. He served a period of incarceration at the federal mini- mum security prison in Big Spring, Texas, from De- cember 1987 through September 1988. Action: Board accepted an Agreed Order as fol- lows: (1) Probation by the Board for three years. (2) Carry out terms of his federal probation. (3) Appear JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION before the Board at the end of his probationary period to show cause why his license should be reinstated in full. Licensee: Charles A. Heffington, M.D. Violations: (1) Inappropriately prescribing narcot- ics and controlled substances. (2) Wrongfully possess- ing codeine and oxycodone during 1982 and 1983, and being convicted therefore before a General Court Martial of the U.S. Navy. (3) Unlawful touching of females serving in the U.S. Navy in 1982. (4) Render- ing medical treatment in such a manner as to consti- tute gross negligence, ignorance, or incompetence. (5) After discharge, respondent returned to Tennessee and was granted hospital privileges by Lewis County Hos- pital. Notice of Charges was filed by the Board and his license was Summarily Suspended on May 20, 1985. The respondent’s counsel accepted the State’s offer to settle the Summary Suspension by agreement that the respondent would not utilize the hospital privileges granted him, pending a due process hearing. The hearing was never held, and the respondent has re- frained from utilizing any hospital privileges. The re- spondent sought help through the TMA Impaired Physician Program in 1985 and obtained the advocacy of Dr. David Dodd. The Bureau of Investigations of the Department of Health and Environment under- took an investigation of the respondent in 1988. Action: After hearing testimony from the Bureau of Investigations and Dr. David Dodd, the Board ac- cepted an Agreed Order as follows: (1) Respondent’s license is limited to general practice. (2) Respondent may participate in surgery, except for any open or- thopedic surgery, only under direct supervision of a licensed physician. (3) Respondent may participate in surgery under the supervision of Virender Anand, M.D., with the specific purpose of showing compe- tence to the Board in a future meeting, not less than six months from this Order of the Board. (4) Re- spondent may seek hospital privileges necessary to ad- mit patients consistent with items 2 and 3, above. (5) Respondent will produce a current report from Dr. David Dodd of the TMA Impaired Physician Program when he reappears before the Board. Licensee: Glenn J. Williams, M.D. Violations: (1) Violation of an Order of the Board. (2) Habitual intoxication and misuse of drugs. (3) Dis- pensing, prescribing, or otherwise distributing con- trolled substances, not in the course of professional practice. Action: (1) Probation for two years — must appear before Board at end of two years. (2) DEA Schedule II privileges suspended for two years — must reappear before Board at end of two years for evaluation prior to having Schedule II privileges reinstated. (3) Main- tain aftercare contract with TMA Impaired Physician Program. Licensee: Tuckey Hayes, Jr., M.D. Violations: (1) Unprofessional conduct. (2) Gross malpractice. (3) Engaging in the practice of medicine when mentally or physically unable to safely do so. Action: The Board accepted an Agreed Order as follows: (1) The respondent pleads no contest to the allegations in the Notice of Charges. (2) The respon- dent agrees to retire from the practice of medicine, and he shall not reapply for his license. Licensee: Reuben P. Morris, M.D. Violations: (1) Unprofessional, dishonorable, or unethical conduct. (2) Dispensing, prescribing, or oth- erwise distributing any controlled substance or any other drug, not in the course of professional practice. Action: An Agreed Order was presented. The Board did not accept the Order. This matter will be considered at a later date. Licensee: George R. McEIroy, M.D. Action: An Agreed Order was presented. The Board did not accept the Order. The attorneys are to try to work out an agreement that the Board can ac- cept. Licensee: Neil J. Kellman, M.D. Violations: (1) Respondent has prescribed Sched- uled drugs to patients he knew were addicts in an at- tempt to treat their addiction on an outpatient basis. (2) Inappropriate prescribing of Scheduled drugs to an inordinate number of his patients over a period of years. Action: The Board accepted the following Agreed Order: (1) DEA certificate is revoked. (2) Respondent will no longer practice obstetrics unless and until he appears before the Board and obtains permission to resume his obstetrical practice. (3) Probation for three years. (4) Respondent must take postgraduate training and sit for the SPEX examination in June 1990. With- in one year he must present evidence of a satisfactory grade on the SPEX examination. (5) Must reappear before the Board before probation is lifted. Summary Suspensions Licensee: Andrew H. Cheng, M.D. Violations: (1) The respondent has engaged in such abusive and excessive dispensing and prescribing of drugs that he has flagrantly disregarded the health, safety, and welfare of his patients. (2) The respondent is grossly negligent and incompetent in his practice of medicine. (3) Upon review of a drug audit, patient records, and hospital records. Dr. Howard R. Fore- man, the Board’s medical consultant, recommended Summary Suspension. Action: (1) The license of Andrew H. Cheng, M.D., to practice medicine is Summarily Suspended. (2) The Suspension shall remain in effect until a hearing is held before the Board. Licensee: Shed H. Caffey, M.D. Violations: (1) The respondent has exhibited un- professional conduct on a number of occasions. (2) The respondent has demonstrated ignorance and gross malpractice in the course of his medical practice. Action: (1) The license of Shed H. Caffey, M.D., to practice medicine is Summarily Suspended. (2) The Suspension shall remain in effect until a hearing is held before the Board. (3) The Board recommends that the respondent secure a physical and psychiatric examina- tion prior to the hearing. FEBRUARY, 1990 87 Petitions for Reinstatement Licensee: Jack Woodside, M.D. Violation: Inappropriate prescribing. Action: Since Dr. Woodside plans to enter a family practice residency program, the following decision was made by the Board: (1) His license will not be rein- stated. (2) He will be licensed by exemption in the usual manner when the head of the residency program requests same. (3) He will maintain his contract with the TMA Impaired Physician Program and shall not write prescriptions for Schedule II drugs. Licensee: Norman Saliba, M.D. Violation: The respondent’s license was suspended on May 7, 1987. Action: The respondent’s license is returned to the respondent under the following conditions: (1) The re- spondent shall not prescribe or dispense Schedule II drugs for a period of two years. (2) Maintain his con- tract with the Impaired Physician Program and adhere to the terms of his aftercare contract. Licensee: James Alfred Bryan, M.D. Violations: (1) The respondent has exhibited char- acteristics indicative of mental instability and/or chem- ical dependency as evidenced by inappropriate pre- scribing of Schedule II drugs, irrational reasons for prescribing Schedule II drugs, and by pleading guilty to a charge of shoplifting. (2) The respondent’s license was Summarily Suspended on January 24, 1989. Action: The Board accepted the following Agreed Order. (1) May prescribe and dispense noncontrolled substances. (2) Shall not prescribe Schedule II or III controlled substances for five years. (3) Shall enter into a five-year contract with the TMA Impaired Physician Program. (4) Probation for five years — must reappear before the Board for an evaluation at the end of five years. (5) The Summary Suspension is hereby set aside subject to the above restrictions. Licensee: Frank Page, M.D. Violation: Respondent is on work-release from fed- eral prison after serving time for violation of federal drug laws. He is under contract with the Illinois Im- paired Physician Program. Action: Respondent’s license is reinstated with the following restrictions: (1) Dr. David Dodd will moni- tor his progress in his rehabilitation program and com- municate with the Illinois Impaired Physician Program regarding same. (2) Dr. Page will not reapply for his DEA certificate until the Board grants him permission to do so. (3) Probation for five years and must come before the Board before applying for renewal of his license. (4) Must petition the Board at the end of five years prior to his probation being lifted. Licensee: Gardner Dixon, M.D. Action: The Board voted to allow Dr. Dixon to ap- ply for his DEA certificate which removes the last re- striction from his license. Licensee: Guillermo T. Minnharr, M.D. Violation: None. The respondent’s reciprocity ap- plication was denied on October 3, 1989 due to a low 88 score on FLEX. The respondent requested a hearing. Action: Petition for licensure by reciprocity through waiver of rules is denied. Other Business Confirmation of Policy on Residents from Other States in Tennessee Programs Requiring Exemption Status — The Board voted to require advance requests for exemption status of residents who are in residency programs in other states but come to Tennessee to participate in a Tennessee program for a period of time. Mrs. Blair was directed to send a notice to each of the medical schools concerning this requirement. Prescription Writing — Mr. Floyd Ferrell, Director, Board of Pharmacy, had requested to appear before the Board to discuss the prescription writing practices in physicians’ offices, especially in regard to physician assistants and nurses. Mr. Ferrell was at this Board meeting and this subject was discussed at length. It was suggested to Mr. Ferrell that if he knew of any of these licensees who were violating the law concerning this, he should turn this information over to our In- vestigation Division. It was also suggested that maybe an article could be written by Mr. Ferrell which could be run in the TMA Journal or Newsletter and other newsletters reminding the physicians and others the acceptable procedures for writing and issuing prescrip- tions. The Board voted to hold a Rulemaking Hearing concerning promulgating rules for amphetamine and amphetamine-like substances. We will try to hold this in December or January. After holding a Rulemaking Hearing concerning re- newal fees and listening to recommendations from Ed Johnston, Assistant Director, Bureau of Manpower and Facilities, the Board voted to approve a renewal fee of $40 plus the $5 state regulatory fee per year for all professions under the umbrella of the Board of Medi- cal Examiners which includes medical doctors, athletic trainers, respiratory care practitioners and physician assistants. The ones renewing on a biennial basis would pay $90 and the ones on an annual basis would pay $45. The Board wishes to review the figures in another year prior to voting to continue this. There being no further business, the meeting ad- journed. ^ REWARD A rewarding experience awaits those phy- sicians who plan to attend the Tennessee Medical Association’s 155th Annual Meet- ing— April 4-7, 1990, at the Hyatt Regency Hotel in Knoxville. Mark your calendar NOW so you won’t miss out. JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION pfc/idcfilV pQ9C. Looking for a Silver Lining I am trying to prepare this President’s Page in December and trying to think positive. My mind runs through the documents I am receiving on my desk from Equicor with its Personal Physician Identification number, its rules and regulations on what will and will not be accepted, and documentation on how the Gramm-Rudman will affect my billing. I am aware of the con- stant impacts I am having on my private practice. As I then try to assimilate those pressures, my morning paper reassures me that the cost of medical care can be laid at the feet of the physician. Then on the newscast I hear about the investigation of Medicare and Medicaid fraud cases, and can look on the corner of my desk and see correspondence from SVMIC of cases that need to be reviewed for possible malpractice litigation. With such tangible evidence of non-patient-care activities very visible before my eyes, I am also reminded of how the changing relationship of the physician-patient activity seems to be more evident than ever before, of how there seems to be in- creasing impersonality of interchanges between me and my patients, and of how the innerposition of third party seems to be more and more evident — this is not only with third party payers, but with hospital employees who are helping us with Quality Assurance and Utilization Review. This set me to struggling to find a silver lining. I am aware of the quantum leap in advances not only in surgical skills and technology, with all the new instrumentation that I see in surgery, the Laser Lab, the Special Procedure Lab, but also in the biomedical advances that allow patient control, better anesthesia, better diabetic control by the patient, and the merit of new technologies, machines and gadgets as I walk through the intensive care areas of the hospital. I am also aware of the tremendous advances in therapeutic technique of nutrition, new antibiotics, and oncologic therapy. In addition, there is the repetitive communication within the hospital and the entire medical system having to do with computerization, telephone hookups with computers, and even FAX machines. I am aware also of the explosion of medical subspe- cialists such that as the state of the art knowledge comes available, there are these individuals who can interpret and use all the new techniques and data. The physical health care system has become enormous. I am caught up by two conflicting emotions — despair because of the in- trusion that I have mentioned, and elation with the new tools that we have to help our patients. My obvious frustration is somewhat allayed by that realization, and my hope that medicine, which survived the culture shock from Hippocrates to Semmelweiss and Lister, can survive the mammon, whether it be third party or personal. Is it a time to return to basics? JOUfIKlI of Ihc teAne//ee mccHcol o//ockilioA PUBLISHED MONTHLY DEVOTED TO THE INTERESTS OF THE MEDICAL PROFESSION OF TENNESSEE OFFICE OF PUBLICATION: 112 LOUISE AVENUE, NASHVILLE, TN 37203 JOHN B, THOMISON, M.D., EDITOR ADDISON B. SCOVILLE, JR., M.D., ASSOCIATE EDITOR JEAN WISHNICK, MANAGING EDITOR Acceptance for mailing at special rate of postage provided for in Section 1 103, Act of October 3, 1917, authorized July 15, 1932 Copyright for protection against republication. Journals of the American Medical Association and of other state medical associations may feel free to quote from this Journal whenever they desire merely giving credit to this publication. Address papers, discussions and scientific matter to: John B. Thomison, M.D., Editor 230 25th Ave, North, Nashville, TN 37203 Address organizational matters to L Hadley Williams, Executive Director, 1 12 Louise Avenue, Nashville, TN 37203 COMMITTEE ON SCIENTIFIC AFFAIRS OSCAR M. McCALLUM, M,D., Chairman, Henderson SIDNEY L, BICKNELL, M.D,, Jackson FREDERICK D. SLAUGHTER, M.D., Bristol WINSTON P. CAINE, JR , M.D., Chattanooga FRANCIS W, GLUCK, JR., M D,, Nashville JOHN B. THOMISON, M.D,, Nashville, Ex-Officio FEBRUARY, 1990 ccPilofiol/ Solidarity I’ll bet when you saw this title you thought this was going to be about Poland or some such. It’s not about Poland, but it is about some such. Solidarity in Poland has accomplished a lot be- cause as it turns out it is appropriately named. Had it not been, it wouldn’t have. Communism isn’t, and it hasn’t. Both imply all for one and one for all, but in practice there are patent dif- ferences between the two approaches. The showpiece of the Deutsche Demokra- tische Republik (DDR), known familiarly as East Germany, as in fact is the case with all of the iron curtain countries, is their athletes; the most recent star in their crown is Katherina Witt, the world champion figure skater and Olympic gold medalist. Unlike some of her fellow athletes, who skipped out on being given the opportunity, Fraulein Witt has been big on singing the praises of both the system and the country. It has be- come apparent during the past few weeks that there is not wholehearted approbation of the fraulein’s publicly expressed views. It is not pos- sible for me to tell you what her own private views are. My own are that there is more than an outside chance that her private and public views might deviate more than somewhat, since she is a bright girl. On the other hand, the sys- tem has unquestionably been good to her, and a lot of other people who are just as bright have been deluded about the system. The problem in the DDR at the moment is lack of solidarity. Communism is on the run, but is busily mending its fences under the leadership of Mr. Egon Krentz, who, unlike some of his elders, was bright enough to know that the Chinese solution to unfriendly gatherings would not work in Leipzig, if for no better reason than that it would be unacceptable to his neighbors, whom he is trying his best to cultivate. Maybe he suspected, too, that given enough rope the op- position just might hang itself, which it seems to be in a fair way of doing. The trouble in his op- position stems from the movement’s origins in ideology without pragmatism. If one is going to start a revolution, one had better know where he is going — not just sometime, but right now. The intelligentsia in the DDR, as in China, started all the uproar, even though it is popularly fueled, and they constitute the leadership, such as it is. It has a good idea about the sometime, but its now is in bad disarray; there are probably about half as many notions about what should happen next as there are people in the fray. The reason there are not just as many is that the other half haven’t gotten around yet to giving it any thought. The situation appears to me to be a paradigm of American medicine, or maybe vice versa. I recognize that by the time you read this the whole situation in Germany, and in fact in the whole Eastern bloc, may have changed substantially, or even completely, but it is unlikely the situation in American medicine will have, and I am com- paring it with East Germany at Thanksgiving- time, in the Year of Our Lord 1989. 94 JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION In the first place, it is unclear to me how it is that American medicine can be regarded as an entity, even though I refer to it that way myself. It is very difficult to get two doctors to agree on anything, as had become perfectly clear to me long before I became involved in organized med- icine. A lot of members have a lot of ideas about how things ought to be done, and they are very free with their advice. But how many of them do you think will help you effect the changes they propose? Not many. They also object mightily to paying dues sufficient to hire it done. The big- gest majority in the House of Medicine compris- es those who will advise you not on how things ought to be done, but on how they ought not to be done. The corollary to that is that the way such dissidents usually say they ought not to be done is the way they are being done. Being beset on all sides as we are, one would think doctors would have the good sense to unite against the common enemy, though considering our history that might be expecting too much. The situation is made even more difficult in that the enemy is sometimes hard to define in more than general terms, such as “the government” or “the feds” or “the bureaucracy.” Indeed, it sometimes seems it might be more accurately de- fined as each other. One usually finds that if he (or whatever his practice entity is) is in compli- ance with HCFA he is out of compliance with the JCAHO, and vice versa, or else with the Federal Trade Commission, or both. Taken to- gether, those constitute what at least I mean by the common enemy. Instead of taking a united approach, though, various entities within medi- cine are in the habit of going off half cocked and making their own deals, thereby weakening the whole fabric of medicine, while at the same time seldom serving themselves well; in many in- stances it is, in fact, counterproductive. The various houses of delegates are micro- cosms of their constituencies. When their constit- uents are specialists they tend to have more un- animity than those in the federation, sharing as they do more of the same concerns; notwith- standing that, though, even the speciality society members frequently have major divergences of opinion, and have been known to squabble among themselves. In the House of Delegates of the AMA and those of the federation, those di- vergences are multiplied by as many times as there are specialty societies within them, the po- litical parties and special interest groups repre- sented there, such as, only for starters, women. minorities, and foreign medical graduates, and whatever else you can think of that divides the general population. What frequently is over- looked is that before doctors were doctors, they were people, and that and their consequent bias- es were not changed by the MD degree. There are frequently major differences of opinion even as to how a patient with a particular disease should be treated, and those differences can sometimes generate considerable animosity, some of it lasting. Because doctors are people, they often be- come actively involved in all sorts of social is- sues, many of them highly emotionally charged. Also because they are people, in such instances doctors may become emotionally involved, too, and may lose their objectivity. One such issue that comes to mind is the matter of abortion. Despite the involvement of doctors as the instru- ments of abortion, abortion is neither a medical nor a legal issue. Whether or not abortions can be performed and under what circumstances is a social issue, and as such is for society to decide. The way society makes its wishes known is through the ballot box, which is a secret place. Not every- body will, of course, agree about that, either. Another hot issue presently in this state, and others, too, is the matter of corporal punishment in the schools. That also is not a medical issue unless it involves child abuse. If it does, there are criminal statutes that apply in such instances. I recognize that there are those, among them some doctors, notably pediatricians, who consider any corporal punishment of children child abuse by definition, and they are entitled to their opinion. Used in the way the rules specify, however, cor- poral punishment is a corrective measure, and is no more a medical problem than imprisonment is. (Don’t tell me; I know. You don’t agree.) There are sufficient issues dividing medicine that have to do directly with medicine and the practice thereof, and therefore are properly the business of the House of Delegates, no matter how much one may wish it otherwise. Whatever things are problems of society divide society, and therefore are likely to divide medicine, as well. Such divisiveness obscures, and these days is par- ticularly harmful to, medicine’s primary objec- tive, which is taking care of our patients. The House of Delegates of TMA took note of this last April when it tabled indefinitely both a pro- abortion and an anti-abortion resolution as not being the proper business of the House. Individ- uals and organizations submitting resolutions to FEBRUARY, 1990 95 the House, or those requesting that the TMA back legislation, should consider carefully wheth- er or not the issue is really a medical one; if it is not, the House of Delegates is not the proper forum for it. It can only lead to bloodshed, and the blood is more likely than not to be your blood. That 1 can stand, but even worse, it will unquestionably be medicine’s blood. That is a luxury none of us can afford. J.B.T. All Junked Up: Out it Goes WIGART I have a standing vendetta against junk mail, of which I, like you, receive many pounds a week. Unlike you, though, I receive multiplied addi- tional pounds through the Journal office, stuff that its senders don’t consider junk, but which for my purposes are. There is a problem there, though, even though the material is screened be- fore any of it makes it to my office, which is a few blocks from the Journal's. Though the ne- cessity for the survivors to be transported re- duces them semiautomatically to a minimum, they are nevertheless still legion. What’s more, many of them are of more than passing interest, and make it into one of the stacks on my desk or credenza or the floor in front of or beside them — stacks of things to look at when I get a round tuit (WIGART). Since there aren’t many round tuits around, WIGART turns out in most cases to be never. Consequently, when the stack reaches an unstable height, it finds its way en bloc into you know what. By that time most of it is of no consequence, anyhow. Despite all this, my real problem is not with what all of us speak of as junk. We all know what that is, and where it is ultimately destined for; even its senders know, and just hope some of it gets our attention before it gets there. My prob- lem is with the junk that is not junk, but which nevertheless by necessity suffers the real junk’s fate. For starters, each week I get (and I’ll prob- ably leave out some) JAMA, AM News, Science, the New England Journal, Medical World News, and Science News; I also get a couple of financial advisories. Each morning I get, besides the daily local rags, the Wall Street Journal, with which I spend breakfast, and often longer. Not counting this Journal and the Southern Medical Journal, 96 both of which I nurture with TLC, and which it goes without saying I save bound, each of the four national pathology organizations to which I belong publishes at least one journal, and the AMA publishes the Archives, which I receive as a membership benefit. There are several other first-class pathology journals that for reasons that sometimes escape me I subscribe to. Then there’s the Scientific American and a dozen or so assort- ed nonmedical publications, not to mention all of the other state medical journals, to which the Jour- nal receives reciprocal copies (and which merciful- ly stack up in the Journal office and not here). Even practicing tear and toss, which I do on everything but my particular aforementioned pets, gridlock set in years ago, and is perpetual and aggressive, even considering that I periodically sweep vast piles of unperused periodicals into the trash bin just so I can continue functioning. I long ago gave up worrying about what I miss by doing that. I comfort myself by the realization that even if I hadn’t missed whatever it was I missed, I probably wouldn’t remember it anyway, since there is spillover of the information gridlock into my higher centers, which, to use a colloquialism, are bad backed up. I complained recently to a neurologist colleague that I thought I was getting Alzheimer’s disease, to which he responded, not so; it is, he said, just that there is too much in- formation going in. I have begun thinking of it as an impaction of words leading to constipation of the brain. In a speech before the National Press Club the other day. Lech Walesa, founder of Polish Solidarity, commented that in Poland they write a lot, but read a lot less; they suffer, he said, from too many editors. I understand. Po- land is far from unique in that respect. Occasionally an issue of some publication comes along that I feel I simply must spend some time with WIGART. Such a one was a fairly re- cent issue of Science that contains a symposium on frontiers in biology entitled “The Cell Cycle.” In the process of tearing and tossing I happened upon a letter to the editor that put the whole matter of overload in perspective, and the per- spective it put it in was anything but comforting, despite its reassurance that my dilemma is shared not only by every other individual — at least by every other person who cares — but by corriputers as well. The writer maintains that “our data-col- lecting technologies have not only outstripped our cognitive abilities but also the computerized management systems we have created to help us deal with the information.” As an example, he JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION cites the Landsat earth surveillance system, which in its 17 years of operation has accumulated far more data than can even be archived properly, let alone analyzed. Air controllers and pilots contend that so overwhelmed is the aircraft con- trol system already that FAA proposals to re- quire aircraft to submit altitudes in addition to all the other data they already transmit would di- minish rather than enhance air safety. The Three Mile Island accident is said to have resulted from a deficiency of information about previous accidents that likely would have al- lowed the operators to avoid core meltdown, combined with overload of the control room op- erators by such a deluge of system monitoring data that they were able to act upon it. That sounds familiar. In our hospital parking garage is a large sign proclaiming that “this garage is con- tinuously monitored at all times for your safety.” There is indeed a bank of television monitors, probably three for each level, along a wall of the small booth at the garage entrance that doubles as a toll booth. The operator sits looking out to- ward incoming traffic, his back toward the mon- itors; he is obviously and necessarily oblivious to them. Seldom in all my comings and goings over the several years the garage has existed have I noted any attention at all being paid the moni- tors. In fairness to the operator, it couldn’t be expected that he would. As presently constitut- ed, the system is overloaded, and the notion that it confers safety is a delusion. Even if a moles- tation were detected, it is my impression that whatever help would be forthcoming would be too little and too late. The author of the letter to the editor contin- ues by observing that technology often advances out of step with law, ethics, and economic feasi- bility, and that they should be developed in har- mony with one another so they are regarded as equally important. I certainly agree; that way one might come to feel more secure in our parking garage, in airplanes, or around the nuclear reac- tors of the world, pursuing our discussion in the previous paragraph. I have a feeling, too, that data from seismographs and weather observation might, with better processing, do a more credit- able job of predicting earthquakes and forecast- ing of where hurricanes will actually come ashore; I don’t know that, understand, but I would al- most bet on it. I really don’t spend a whole lot of time con- cerning myself with such things; like the Califor- nians or those living along our shores, I just go on doing what I have to do or want to do, and pretend such hazards don’t exist, or at least that they won’t — not can’t, but won’t — happen here. I really am much more concerned about being buried alive under an avalanche of paper, 99% of which is not only unnecessary, but an actual intrusion. My real problem is finding the 1% that isn’t, to which anyone who has visited my office can attest. Someday I’ll get that done, WIGART. (Just throwing the stuff away takes a lot of time. And anyhow, I might toss something I couldn’t bear to part with, something that the moment it was gone I would need desperately.) By that time it likely won’t matter. Maybe I should pay more attention to a gnawing suspi- cion I have that none of it really matters now, either. I will, WIGART. J.B.T. Tender — Legal, Not Non-Tough Some years back the United States issued a coin that was to replace, at least substantially, the good ol’ greenback. The coin was the Susan B. Anthony dollar; it bombed. It bombed not because of any male chauvinism or any arcane motives on anybody’s part. It bombed simply be- cause it was the wrong size and shape. How would one, for instance, put an octagonal quart- er-sized piece of change into a dollar slot? It gave casino owners the willies. But not just casino owners. How would you fancy reaching into your jeans for a dollar and encounter that sort of un- familiar object, one with corners, yet. It gave other folks the willies because quarter slots would accept the coin, and (obviously) not give you change. It’s enough to give a body asterognosis. It did, and so it bombed. It was not a bad idea, actually, as the coins don’t wear out and have to be replaced periodically, as the dollar bills do. But not having dollar bills was not popular. How would the car-park know you weren’t slipping him a slug, for instance? In case you have need of eight million or so, you can find them, I under- stand, at the Denver mint. Do you ever look at the coins in your pock- et— I mean look at the coins in your pocket — or more properly the coins you had in your pocket before you took them out — or those you get in change, more than just to see if the change is correct? That is accomplished at a glance, taking into account size, shape, and color, but generally FEBRUARY, 1990 97 not design. Witness to that is that on both sides of the Canadian border, quarters and dimes of the two countries intermingle unobstructed, even in vending machines, since they are the same size and shape, and vending machines aren’t interest- ed in design. Are you? Unless you are a coin collector. I’ll bet you can’t tell me what is on the two sides of every one of our coins. In the first place, there are several different things on each denomina- tion, depending on when they were minted. Some collectors search out silver coins, which are be- coming very scarce, none having been minted ex- cept for special occasions for 25 years. Looking for them was more popular in the heyday of hot silver in the last decade, but not much anymore. Pennies aren’t useful nowadays for anything but sales tax and chewing-gum balls. And remember when they used to be made of zinc? Probably not, most of you. That was a wartime accom- modation; it was not popular — just necessary. Monkeying with our legal tender generally makes the natives restless. On the other hand, I was party to a discussion the other day on this sub- ject in which most conceded that we have the world’s ugliest currency; another party to the dis- cussion was a Canadian who admires theirs. Either way, who cares, so long as it spends? Ob- viously somebody. Know something? The Treasury Department is about to complete a new many-million dollar mint out West, and soon the United States of America will be printing out there multicolored dollar (and other) bills just, or almost just, like the funny-money our neighbors have. It’s a fact. They say the change is to prevent counterfeiting. Indeed. There is also talk again of replacing the dollar bill with a coin, obviously for some other reason. Know something else? Congress doesn’t have very much to do these days. How do I know that? A great many more than half of the members of both houses find the designs that appear on our coins boring. Imagine. Those congressmen and senators have so little to do otherwise that they have sponsored a bill in their respective houses of Congress to change those designs, which are, they say, worse than just being boring, not con- sonant with our Constitution. Alas! Just think of that. Is it not marvelous, and is it not also com- forting, to know that our future is safely in the hands of such innovative and concerned lawmak- ers, who, when the ship of state is sailing so smoothly that there are no weighty matters to 98 occupy them, can gravitate so unerringly to other critical issues that demand immediate attention? Having considering that, again Alas, and also Alack! J.B.T. in mcmoficim Robert T. Barrett, age 47. Died December 16, 1989. Graduate of University of Tennessee College of Medi- cine. Member of Montgomery County Medical Society. George Henderson Brown, age 83. Died February 10, 1989. Graduate of Yale University School of Medicine. Member of Washington-Unicoi-Johnson County Med- ical Association. Joseph S. Henderson, Jr., age 61. Died December 16, 1989. Graduate of University of Tennessee College of Medicine. Member of Blount County Medical Society. Hugh Milby Alexander Smith, Jr., age 80. Died Novem- ber 27, 1989. Graduate of University of Tennessee Col- lege of Medicine. Member of Memphis-Shelby County Medical Society. ncul meml3>er/ The Journal takes this opportunity to welcome these new members to the Tennessee Medical Association. BLOUNT COUNTY MEDICAL SOCIETY Ernest Russell Gibson, M.D., Maryville Marye Lois McCroskey, M.D., Maryville Randall D. Towne, M.D., Maryville CONSOLIDATED MEDICAL ASSEMBLY OF WEST TENNESSEE Alan Carter DeJarnatt, M.D., Jackson Randy Fly, M.D., Jackson Jimmy Dale McCauley, M.D., Jackson Frances E. Pritchard, M.D., Jackson CUMBERLAND COUNTY MEDICAL SOCIETY John Branson Sherrill, M.D., Crossville FENTRESS COUNTY MEDICAL SOCIETY Keith M. Kimbrell, M.D., Jamestown HENRY COUNTY MEDICAL SOCIETY James W. McGee, M. D. , Paris LAKEWAY MEDICAL SOCIETY Steven D. Payne, M.D., Morristown JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION MAURY COUNTY MEDICAL SOCIETY Linda P. Monroe, M.D., Columbia McMINN COUNTY MEDICAL SOCIETY Kimberly T. Breeden, M.D., Athens WASHINGTON-UNICOI-JOHNSON COUNTY MEDICAL ASSOCIATION John L. Holbrook, M.D., Johnson City David N. Walters, M.D., Mountain Home Marcus G. Williams, M.D., Johnson City pcf/onol neui/ C. Eugene Jabbour, M.D., Memphis, has been elected to the Board of Governors of the American College of Surgeons. Claude Raymond Webb, M.D., Ripley, has been awarded the Meritorious Service Award for Medical Staff Members by the Tennessee Hospital Association. Dr. Webb was cited for his service to Baptist Memorial Hospital Lauderdale and community residents during the past 39 years. The following TMA members have been elected Fel- lows of the American College of Surgeons: Henry Rus- sell, M.D., Franklin; Sithipol Tantihachai, M.D., Dayton. TMA Members Receive AMA Physician’s Recognition Award The following TMA members qualified for the AMA Physician’s Recognition Award during November 1989. This list, supplied by the AMA, does not include members who reside in other states. Physicians can receive the PRA certificate valid for one, tw'o, or three years. For the one- year award, physicians report 50 hours of con- tinuing medical education, including 20 hours of Category 1; for the two-year award, physicians report 100 hours of CME, including 40 hours of Category 1; for the three-year award, physicians report 150 hours of CME, 60 of which are Cat- egory 1. Charles H. Bozeman, M.D., Sevierville Thomas A. Codings, M.D., Greeneville Thomas W. Conway, M.D., Newport Joseph H. Fishbein, M.D., Nashville Robert L. Haley, Jr., M.D., Nashville Charles W. Hawkins, M.D., Chattanooga Benjamin A. Moeller, Jr., M.D., Memphis Hugo C. Pribor, M.D., Nashville Jesse O. Quillian, M.D., Chattanooga Clarence R. Sanders, M.D., Gallatin Charles L. Stunpson, M.D., Shelbyville Robert T. Tucker, Jr., M.D., Jackson Alvin J. Weber, HI, M.D., Memphis Melborne A. Williams, M.D., Nashville Joseph L. Willoughby, M.D., Franklin onnouncemcnl/ CALENDAR OF MEETINGS NATIONAL March 24-29 American Society of Clinical Pathologists — San Francisco Hilton Square March 24-29 College of American Pathologists — San Francisco Hilton Square March 25-28 American Society of Regional Anesthesia — Peabody. Orlando March 27-30 American Burn Association — Golden Nug- get, Las Vegas March 28- April 1 American Society of Contemporary Ophthal- molo2V — Hvatt, Phoenix March 7-10 Association for Academic Psychiatry — Stouffer Madison. Seattle March 28-April I Mid- American Orthopaedic Association — Marriott's Grand Hotel, Point Clear, Ala. March 8-10 U.S. Pharmacopeial Convention — Capital Hilton, Washington. D.C. April 1-5 American Association of Pathologists — Hyatt, Washington, D.C. March 9-13 International Anesthesia Research Soci- ety— Sheraton Waikiki Hotel. Honolulu, April 1-5 American Physiological Society — Hyatt Re- gency. Washington, D.C. Hawaii April 2-6 American Society for Pharmacology and March 18-22 American College of Cardiology — Hilton. New Orleans Experimental Therapeutics — Washington. D.C. March 18-23 American Society of Neuroradiology — Wes- tin Century Plaza, Los Angeles April 3-7 American Association of Orthopaedic Med- icine— Howard Johnson’s. Boston March 21-23 American Society of Clinical Pharmacology and Therapeutics — Marriott Moscone Cen- ter, San Francisco April 4-6 American Group Practice Association — Hvatt Regencv Capitol Hill. Washington, d'c. March 22-25 Society for Adolescent Medicine — Hilton Hotel and Towers, Atlanta April 5-7 American Surgical Association — Shoreham, Washington, D.C. March 23-28 American Academy of Allergy and Immu- nology— Baltimore April 7 American College of Utilization Review- Physicians — Marriott, Richmond, Va. March 23-28 American Society of Clinical Hypnosis — Sheraton World. Orlando April 14-18 American Fracture Association — The Pointe at Squaw Peak, Phoenix FEBRUARY, 1990 99 April 17-19 National Managed Health Care Congress Program — World Trade Center, Boston April 18-22 Society for Pediatric Radiology — Westin, Cincinnati April 19-22 American College of Preventive Medicine — Westin Peachtree Plaza, Atlanta April 21-25 American Radium Society — Registry Re- sort, Scottsdale, Ariz. April 25-29 American Medical Society on Alcoholism and Drug Dependencies — Hyatt Regency, Phoenix, Ariz. April 26-28 Eastern Allergy Conference — Bal Harbour, Fla. April 26-29 American College of Physicians — Fairmont, Chicago April 28 American Rhinologic Society — Palm Beach, Fla. April 28-May 4 American College of Occupational Medi- cine— Westin, Houston April 29-May 4 American Society of Colon and Rectal Sur- geons— Adam’s Mark. St. Louis April 30-May 4 American Society for Head and Neck Sur- gery— The Breakers, Palm Beach, Fla. STATE April 4-7 Tennessee Medical Association. 155th An- nual Meeting — Hyatt Regency Hotel, Knoxville April 5-7 American Society for Laser Medicine — Op- ryland Hotel, Nashville April 28-May 3 American Association of Neurological Sur- geons— Opryland Hotel, Nashville Marty Vaughn Appointed TMA Executive Assistant Tennessee Medical Association Executive Director L. Hadley Williams has announced the appointment of Marty Vaughn as Executive Assistant. Vaughn, 27, is a native of Nashville and holds a bachelor of science de- gree in public relations from Middle Tennessee State University accompanied by minors in English and busi- ness administration. Mr. Vaughn joins TMA having served as an editor with American General Life & Accident Insurance Company since 1986. Prior to his graduation in 1985, he served as an assistant in the Sports Information De- partment at MTSU. CORRECTION An error occurred in the article entitled “Toxic Met- hemoglobinemia,” published in the November issue of the Journal (82:581-583, 1989). On page 581, in the Case Report, in the initial blood gas, the initial PCO2 was 27.9 mm Hg. We regret any confusion this may have caused. 1-800-234-STONE 'lunn lITIIiTRIPSV r n r ^ Cut Out Thds Number And You Could Be Removing A Future Need For Gallstone Surgery. Use this number to call Alabama Lithotripsy Services, and offer your patients an alternative to gallbladder surgery. Alabama Lithotripsy Services, a group of leading Alabama hospitals, has been chosen by Medstone International, Inc., to participate in the evaluation of a lithotripter to treat gallstones with shocL waves. The hospitals include The Baptist Medical Centers of Birmingham (Montclair and Princeton), DCH Regional Medical Center in tocaloosa and Huntsville Hospital. The procedure has been successfully used since 1980 in the treatment of kidney stones. Biliary lithotripsy uses ultrasound to pinpoint the location of the gallstones. Spark-gap generated shock waves shatter the gall- stones, reducing them to smaO particles that can pass from the gallbladder or can be dissolved by prescribed medicatioa Lithotripsy offers patients a much shorter hospital stay, a faster recovery period than surgery, and involves less surgical risk. For additional information or to find out about a particular patient’s eligibility, clip out and call the number above. Gallstone Lithotripsy with the Medstone Lithotripter has been approved by the Food and Drug Administration for mvestigational use. 100 JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION jeuf iKil of Hie lcAfie//ee mcdkol <i//o€kilieA OWNED AND PUBUSHED BY THE ASSOCIATION MARCH, 1990 VOL. 83, NO. 3 Rapid Management of Intracranial Hypertension To Reverse Transtentorial Herniation LISA VERDERBER, B.A.; ROBERT MACIUNAS, M.D.; and JOHN MORRIS, M.D. Injuries are the leading cause of death in the United States for those between the ages of 1 and 44 years, accounting for 1 of 12 deaths.’ For those between 15 and 24 years, 79% of all deaths are due to injury. Brain injury accounts for about 40% of the overall injury death rate. Of those who survive brain injury, only about 30% are able to return to their previous level of employment. ^ Cerebral edema, commonly associated with severe head injury, is a vasogenic edema due to transvascular leakage of solutes into the extracel- lular space. 3 Vasculature that has been injured by trauma cannot restrict the flow of proteins and solutes. Expanding lesions in the head, especially those associated with edema, displace adjacent brain tissue, causing displacement and compres- sion of neighboring structures. Shifts may result in midline or caudal displacement. The situation of the high pressure area determines the nature From the Department of Neurosurgery, Vanderbilt University Medical Center, Nashville. Ms. Verderber is a fourth year medical student. Reprint requests to Department of Neurosurgery, c/o R. Maciu- nas, M.D., Vanderbilt University Medical Center, T-4224 MCN, Nashville, TN 37232 (Ms. Verderber). of the herniation. Patients with raised intracran- ial pressure have a higher mortality rate, and an uncontrolled intracranial pressure above 25 mm Hg is thought to be incompatible with functional recovery. Early aggressive treatment of intra- cranial pressure elevation has been found to re- duce mortality without increasing the number of severely disabled.^ Report of a Case An 18-year-old w'hite woman, an unrestrained passenger involved in a motor vehicle accident, was initially alert but talking nonsensically; her pupils were equal, reactive, and 2 mm in diameter. She became unresponsive at the scene, and her right pupil dilated to 6 mm and became nonreactive. She was transported via helicopter to the Vanderbilt University Medical Center emergency room where she was in hemody- namically stable condition, with a blood pressure of 124/84 mm Hg, pulse 87/min, and respiratory rate 10/min and la- bored. She was combative and unresponsive to command. Her right pupil was 6 mm and fixed, and her left pupil 5 mm and sluggishly reactive. She had roving eye movements. Corneal reflexes were present bilaterally. Her face was symmetrical, and she had a positive gag reflex. She moved all four extrem- ities purposefully to pain. Biceps, triceps, and patellar reflex- es were 2+ bilaterally. Ankle jerks and Babinsky reflexes were not assessed because of bilateral open ankle fractures. Glasgow Coma Scale score was 8. Aggressive medical management was instituted. After the cervical spine was assessed, she was endotracheally intubated and hyperventilated to maintain a PaC02 between 25 and 30 MARCH, 1990 119 Figure 1. Head CT scan, taken on admission, demonstrates uncal herniation and “skim” subdural hematoma. mm Hg. A Foley catheter was placed, and she was given a 50-gm bolus of mannitol intravenously, with prompt diuresis. Decadron was not given. CT scan of the head showed edema throughout the right cerebral parenchyma, causing compression of the right lateral ventricle, and right subfalcine and transtentorial uncal her- niation. A “skim” subdural hematoma of less thickness than of the skull was present over the right temporal lobe (Fig. 1). Immediately after the scan was completed the patient opened her eyes and grabbed at her endotracheal tube. She became alert, responsive, and able to follow commands; her pupils were equal and reactive to light. Motor examination revealed 5/5 upper extremity strength bilaterally, with lower extremity strength 4/5 bilaterally; there was decreased range of motion in her legs and toes, and decreased sensation to light touch on the dorsal and plantar surfaces of both feet. Sensation was otherwise intact to light touch, pin prick, and vibration sense. A lumbar CT scan revealed a burst fracture of L-1 with multiple bony fragments projecting posteriorly within the spinal canal, causing less than 40% canal compro- mise. It was the impression of the orthopedic surgeons that this injury was stable and did not require immediate de- compression or stabilization. She remained in neurologically stable condition through- out the remainder of her hospital course. She was weaned from hyperventilation over the course of two days, and was extubated without incident on the third hospital day. Fluid restriction with monitoring of serum electrolytes and osmo- larity was instituted, and she was weaned from mannitol ther- apy over the course of three days. Aspirin and sedating med- ications were withheld, acetominephen and codeine being used for pain control. A head CT scan on the second hospital day showed a marked decrease in cerebral edema, with de- compression of the ventricles and basilar cisterns. There was marked decrease in midline shift, without evidence of transtentorial herniation, and the “skim” subdural hematoma over the right temporal lobe had somewhat diminished in size (Fig. 2). 120 After stabilization of her neurologic status she underwent transpedicular decompression of the lumbar spine and Har- rington rod instrumentation with an iliac crest bone graft for her L-1 burst fracture (Fig. 3). Both orthopedic and neuro- surgical teams were involved in the procedure. Postoperative scans showed good alignment and decompression of the spin- al canal. She was discharged home for physical therapy with mild recent memory deficits and deficits in spatial orienta- tion. Her neurologic deficits have cleared since discharge, and she is now ambulatory. Discussion Compliance is defined as the ability of the in- tracranial cavity to absorb an increase in volume without a significant increase in pressure; it is a time-dependent function. As compliance de- creases a smaller increment of volume is needed to produce an increase in pressure. With trauma the decrease may be attributed to an increase of brain mass due to edema, or to increased blood volume due to a loss in vascular tone. Reversal of these conditions will increase compliance. Fig- ure 4 demonstrates the pressure volume relation- ship of the compliance curve. As intracranial pressure rises, one of the three major components of the skull — brain parenchy- ma, blood, or cerebrospinal fluid — must leave the skull to compensate. Transtentorial herniation of the mesial temporal lobe as a result of increased intracranial pressure was first described as a pathologic entity in 1920. ^ The hallmark of trans- JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION Figure 2. Repeat head CT scan demonstrates reversal of uncal herniation and decrease in size of “skim” subdural hematoma. tentorial herniation is dilation of the ipsilateral pupil due to injury to the third cranial nerve. Possible etiologies for third nerve dysfunction with transtentorial herniation include damage to the nerve as the result of direct pressure from the herniating brain, and ischemia of the nerve or the midbrain produced by compression of the posterior cerebral artery. Hemiparesis is also seen in transtentorial her- niation and may be either contralateral or ipsilat- eral. The likely etiology is compression of the ip- silateral cerebral peduncle to produce contralateral hemiparesis. Falsely localizing ipsi- lateral paralysis can be encountered when the entire brainstem is shifted en bloc by the herniat- ing uncus to compress the contralateral peduncle with the tentorium producing a Kernohan’s notch. ^ In the terminal stages of herniation, de- formation of the midbrain may produce decere- brate rigidity. The last of the cardinal signs in transtentorial herniation is a change in the level of conscious- ness progressing to coma. The reticular activat- ing system of the midbrain serves to maintain consciousness. Compression of the midbrain, or a decrease in its blood supply due to herniation, threatens consciousness. The Glasgow Coma Scale was developed in 1974 as a rating scale that assesses eye opening, best verbal response, and best motor response to predict outcome of injury^ (Table 1). A score of 8 or less out of 15 consti- tutes a severe head injury. Of severely head in- jured cases admitted to the hospital, between 40% and 50% die.® Care of the patient with a head injury must begin immediately after trauma with rapid resus- citation at the accident site. Airway and breath- ing must be immediately assessed. For a coma- tose patient, intubation with hyperventilation is Figure 3. Lumbar CT scan demonstrating L-1 burst fracture. AAARCH, 1990 121 Figure 4. Curve B represents the pressure-volume relationship of compliance. indicated. External hemorrhage must be con- trolled, and any hypotension reversed. Adequate intravenous access is critical. With acute head in- jury with clinical signs indicating increased intra- cranial pressure and herniation, the goal of treat- ment is to promptly normalize the intracranial pressure and reverse the intracranial shift, while maintaining cerebral perfusion. Cerebral perfu- sion pressure is defined as the systemic mean ar- terial blood pressure minus the intracranial pres- sure. The pressure may be relieved by reducing the volume of any of the intracranial components. Hyperventilation is one of the most effective means of controlling increased intracranial pres- sure. It exerts its effect by constricting cerebral vessels to reduce cerebral blood flow and vol- ume. Cerebral blood flow decreases by 2% per mm Hg change in PaC02.^ The peak effect of hy- perventilation occurs within 2 to 30 minutes. The PaC02 should be maintained at 25 to 30 mm Hg. If Paco2 decreases to less than 20 mm Hg, blood flow may not be sufficient to support brain me- tabolism. Hyperosmolar agents are used to set up an osmotic gradient to drive water from the brain to plasma, and also to inhibit cerebrospinal fluid production. Mannitol is commonly used, and is dosed at 1 to 2 gm/kg body weight. Serum os- molarity is monitored to guide therapy. An os- motic gradient of only 10 mosm/L is effective in reducing intracranial pressure. Since serum os- molarity of 350 mosm/L can cause coma and death, mannitol administration is inadvisable at levels greater than 320 mosm/L. Fluid restriction 122 is commonly used in coordination with hyper- osmolar therapy. Electrolytes must be monitored to prevent dehydration and hypernatremia due to osmotic diuresis. Barbiturate coma is occa- sionally used if intracranial hypertension is diffi- cult to control. Pentobarbital sodium is given in- travenously at a dose of 3 to 5 mg/kg in divided doses to reach a concentration of 2.5 to 4.0 mg/ dl. Intracranial pressure is maintained at less than 15 mm Hg, and cerebral perfusion pressure is maintained at greater than 50 mm Hg. Barbitu- rates decrease cerebral metabolism, cerebral blood flow and volume, and intracranial pres- sure. Arterial hypotension is a potential side ef- fect, and can usually be controlled with concur- rent administrations of intravenous pressor agents such as dopamine. The CT scan can be used to diagnose in- creased intracranial pressure. The most reliable sign is effacement of the third ventricle and peri- mesencephalic cisterns. The CT scan, however, does not give any indication of the level of the pressure. Intracranial pressure monitoring can ensure adequate cerebral perfusion pressure by giving accurate values for intracranial pressure. Monitoring is appropriate for any head injury patient who is comatose on arrival to the emer- gency room and remains comatose. Steroids have also been used in the past to de- crease intracranial pressure. Recent studies, ^ however, have not shown evidence of effective- I ness. High dose dexamethasone was found to ! have no more beneficial effect than placebo on . intracranial pressure, and it may increase the risk ^ TABLE 1 THE GLASGOW COMA SCALE Modality Response fr Score I Eye opening Spontaneous 4 To Speech 3 To Pain 2 None 1 Best verbal response Oriented 5 Confused 4 Inappropriate words 3 Incomprehensible sounds 2 None 1 Best motor response Obeys commands 6 Localizes pain 5 Flexion withdrawal 4 Abnormal flexion 3 Abnormal extension 2 None 1 Total response 15 JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 4 of infection. Sedatives are withheld because of their dilatory effect on vasculature and their in- terference with the neurologic examination. An- esthetics given to patients with underlying hypo- volemia may result in hypotension and further insult, and paralyzing agents should be used with caution during mechanical ventilation since they make neurologic examination impossible to per- form. Vercuronium (Norcuron) is recommended over pancuronium (Pavulon) because of its shorter half-life. Aspirin is withheld to guard against any predisposition to intracranial hemor- rhage. The above case demonstrates the importance of rapid treatment of the patient with a head in- jury. The patient was rapidly moved from the in- jury site by helicopter to a trauma center, and was stabilized by a systematic approach. Hyper- ventilation and hyperosmolar therapy with fluid restriction were begun after a clinical diagnosis of intracranial hypertension was made. A multi- disciplinary team of trauma surgeons, orthopedic surgeons, and neuorosurgeons was used to eval- uate her injuries. After less than one hour of hy- perventilation and hyperosmolar therapy, her- niation was relieved as evidenced by equal and reactive pupils. The patient remained neurologi- cally stable throughout the remainder of her hos- pital course. REFERENCES 1. Baker SP, O'Neil B, Karpf RS; The Injury Fact Book. Lexington, Mass. DC Heath and Co, 1984, pp 7-17. 2. Miller JD (ed): Northfields Surgery of the Central Nervous System, ed 2. Edinburgh. Blackwell Scientific Publishing. 1987, p 191 . 3. Popp AJ, Bourke RS: Pathophysiology of head injury, in Wilkins RH. Rengachary SS (eds): Neurosurgery. New York. McGraw-Hill, 1985, pp 1536- 1543. 4. Saul TG, Ducker TB: Effect of intracranial pressure monitoring and ag- gressive treatment on mortality in severe head injury. J Neurosurg 56:498-503. 1982. 5. Meyer A: Herniation of the brain. Arch Neurol Psychiatry 4:387-400, 1920. 6. Kernohan JW. Woltman HW: Incisura of the crus due to contralateral brain tumor. Arch Neurol Psychiatr 21:274-287. 1929. 7. Teasedale G. Jennett B: Assessment of coma and impaired consciousness. A practical scale. Lancet 2:81-84, 1974. 8. Miller JD, Jones PA: The work of a regional head injury service. Lancet 1:1141. 1985. 9. Reivich M: Arterial PCO2 and cerebral hemodvriamics. Am J Physiol 206:25- 35. 1964. 10. Rottenberg DA, Hurwitz BJ. Posner JB: The effect of oral glycerol on intracranial pressure in man. Neurology 27:600-608. 1977. 11. Braakman R, Schouten HJA. Blaauw-Van Dishoek M, et al: Megadose steroids in severe head injury, results of a prospective double-blind clinical trial. J Neurosurg 58:326-330. 1983. APRIL 1990 Sunday Monday Tuesday Wednesday Thursday Friday 1 Saturday I 1 2 3 4 5 6 7 TMA 155th ANNUAL MEETING Hyatt Regency Hotel — Knoxville 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 NOTES i 1 MARCH, 1990 123 Diagnosis of Acoustic Neuroma By Magnetic Resonance Imaging RAYMOND MASSENGILL, JR., Ed.D.; WILLIAM JOHNSTONE, M.D.; and JEFFREY ROBBINS, M.D. “The acoustic neuroma represents between one and two percent of all intracranial tumors. These are histologically benign, and may occur in any portion of the auditory nerve . . . With increas- ing growth there may be involvement of the fa- cial nerve with ensuing paralysis, and an increas- ing disequilibrium from involvement of the vestibular nerve. In the past, Bekesy audiometry has assisted the otologist and audiologist in determining the site of the lesion. 2 It has been pointed out that “re- cent investigations have shown that such tumors are not associated with uniform audiometric pat- terns as was formerly believed, particularly at early stages.”^ A team approach utilizing neuro- logic, audiologic, and radiographic information can be most useful in the diagnosis of these tu- mors.' This paper focuses on the radiologic eval- uation of the acoustic neuroma. Radiologic Evaluation The radiologic evaluation of patients with symptoms referable to a potential posterior fossa lesion is now initiated with magnetic resonance imaging (MRI) of the posterior fossa and supra- tentorial structures, which is both quicker and relatively less invasive than CT air cisternogra- phy. Its sensitivity is well demonstrated to be greater than that of CT in detecting pathologic lesions'*; further, the absence of bone streak ar- tifact, found in CT, certainly improves the over- all soft tissue detail. This is true both with intra- axial and extra-axial lesions. More recently the widespread availability of a standard MR contrast agent (Gadolinium-DTPA) has further increased the sensitivity for the de- tection of abnormal enhancement in normal-sized From the James H. Quillen College of Medicine, East Tennessee State University, Bristol. Reprint requests to Bristol Regional Medical Center, Bristol, TN 37620 (Dr. Massengill). 124 cranial nerves. The standard advantages of MR also include the availability of multiple planes of view and the lack of ionizing radiation. Figures 1-4 show aspects of the radiologic evaluation for the acoustic neuroma. These figures dramatically demonstrate the diagnostic supremacy of MRI even over the sophisticated CT scan. Comment Traditional training has taught us that patients with unilateral sensorineural hearing loss, unilat- eral tinnitus, or unexplained dizziness or vertigo, or combinations thereof, were deemed acoustic neuroma suspects. As such, they were deserving of neuro-otologic physical examination, audio- vestibular testing, and standard radiologic views of the internal auditory canals. If after such test- ing, acoustic neuroma suspicions remained high, diagnosticians turned to further radiologic eval- uations to confirm or refute one’s clinical con- cerns. In the late 1960s and early 1970s, the hypocy- cloidial polytomographic examination of the in- ternal auditory canal was probably the most fre- quently employed study, and for its time offered a modest probability of diagnostic success with absence of risk and minimal expenditure; it was, however, far from definitive. The ultimate study of this era was the posterior fossa myelogram,^ which was indeed invasive and with definite mor- bidity, but it was the only technique with the ability to demonstrate small intracanalicular tu- mors. Pneumoencephalography and arteriog- raphy were ancillary procedures less frequently employed. As we entered the 1980s, CT rapidly usurped the role of being the preeminent radio- logic diagnostic modality. The basic study was and remains the high-resolution CT of the internal auditory canals using extended scale and “bone algorithm” techniques.^ To obtain greater defi- nition and increased accuracy of diagnosis, infu- sion studies of the cerebellopontine cisterns and JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION Figure 1. A 10-mm thick CT image of the brain at the level of the internal auditory canal. Arrow points to the area of nonvisualized acoustic neuroma. Notice the multiple artifacts from the torcula and from the petrous bones. Figure 2. Unenhanced Ti-weighted axial image at the same level as the CT image. The arrow demonstrates the acoustic neuroma which has a lower signal intensity than the adjacent pons and cerebellum. Figure 3. Axial Ti-weighted MR study following the administration of intravenous Gadolinium-DTPA. Figure 4. Coronal Ti-weighted MR study at the level of the internal auditory canal, again following intravenous Gadolinium-DTPA. The distortion of the midbrain and the inferior extent of the acoustic neu- roma are well demonstrated. AAARCH, 1990 125 ACOUSTIC NEUROMA/Massengill gaseous or opaque cisternography were often added to the basic CT study. The CT scan and its several variations represented a noteworthy refinement and significant advance in our ability to locate earlier, smaller and relatively occult neuromas. CT scanning was indeed a sophisticat- ed diagnostic tool, and it was the best we had until the appearance and availability of clinical MRI. It may be said as a fair assessment of cur- rent sentiment that the MRI performed with thin and contiguous sections has replaced CT as the study of choice for the diagnosis of acoustic neu- romas.^ The overwhelming attribute of MRI is its ability to diagnose tumors of almost any size without ionizing radiation, in a noninvasive man- ner, with multiplanar display. A negative MRI study is our most reliable reassurance that an acoustic neuroma is not present. r ^ REFERENCES 1. Travis LE: Handbook of Speech Pathology and Audiology. New York, Appleton-Century-Crofts, 1971. 2. Newby HA: Audiology, ed 2. New York, Appleton-Century-Crofts, 1964. 3. Wolstenholme GEW, Knight J: Sensorineural Hearing Loss. London, J & A Churchill, 1970. 4. Lee BCP. Kneeland JB, Deck MDF, et al: Posterior fossa lesions: mag- netic resonance imaging. Radiology 153:137-143, 1984. 5. Curati WL, Graif M, Kingsley DP, et al: Acoustic neuromas: Gadolinium- DTPA enhancement in MR imaging. Radiology 158:447-451, 1986. 6. Breger RK, Papke RA, Pojunas KW, et al: Benign extra-axial tumors: contrast enhancement with Gd-DTPA. Radiology 163:427-429, 1987. 7. Gates GA: Interpretation of Diagnostic Tests for Acoustic Neuroma. American Academy of Ophthalmology and Otolaryngology, 1976. 8. Valvassori GE: Cerebellopontine angle tumors. Otolaryngol Clin North Am 21:337-348, 1988. HELP FOR IMPAIRED PHYSICIANS Through its Committee on Impaired Physicians, TMA helps doctors who are suffer- ing from alcoholism and drug addiction. The thrust of the program is rehabilitative, not punitive. The Committee is composed of physicians who have special expertise in these areas, some from personal experience. Effective treatment for these illnesses is achieved most easily when the disease is detected early and family, friends, and associates are urged to avoid misguided sympathy which enables the condition to deteriorate. HELP US TO HELP Call the TMA Impaired Physician Program (615) 327-2711; outside Nashville call collect. Phone service available around the clock. 126 JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION FAMILY PRACTICE. A REWARDING EXPERIENCE IN ARMYMEDKINE. The Army has more soh diers with families than ever before. So when you join the Army Medical Team as a Fam- ily Practitioner, expect to spend most of your time serv- ing not only soldiers, but their spouses and children, too. What s more, vou won’t have to worry about the paperwork, malpractice insurance pre- miums, or the costs incurred in running a private practice. Expect to work in a highly challenging and varied environment. Working with a team of highly trained profes- sionals, you can receive assignments almost anywhere in the United States; the Army offers the largest svstem of comprehensive health care in the nation. Familv Practice positions are also available overseas, in Germany and Korea. The benefits package available to Army Family Practitioners is quite attractive. You’ll receive 30 days paid vacation, opportunities to continue edm cation and conduct research, a chance to travel, and reasonable work hours. All in all, your Army Familv Practice will be a rewarding experience. Not only for you, but for Army families, too. Talk to your Army Medical Depart' ment Counselor for more information. ARMY MEDICINE MID-MEMPHIS TOWER BUILDING 1407 UNION AVENUE. SUITE 702 MEMPHIS. TN 38104 CALL COLLECT: (901 ) 725-585 1 ARMY MEDICINE. BE AUYOU CAN BE. MARCH, 1990 127 AM A 1989 Interim Meeting Report Strengthening the American Medical Association — Fiscal Responsibility and Oversight Background. At each meeting of the Board of Trustees, the Finance Committee reviews the financial statements, investment reports, membership of the Association and receives an economic status forecast. In addition, the AMA has employed outside auditors who annually provide the Board with an analysis of AMA finances and financial transactions to assure that financial policies and procedures are being followed and that controls are adequate. The Finance Commit- tee reports its findings and recommendations to the full Board. Similar information is provided to Refer- ence Committee F of the House of Delegates quar- terly. See editorial comment in this issue. The AMA received an inquiry from Chicago media on Oct. 16, 1989, concerning certain AMA financial matters. AMA staff began an investigation of the mat- ters. One of those financial matters concerned a 1987 payment by the AMA to Whalen M. Strobhar, then AMA Chief Operating Officer. Strobhar had informed John E. Turner of AMA Advisors on Oct. 15, 1987, that money from his Executive Variable Benefit Plan (EVBP) money market investment had been trans- ferred into the stock market and demanded that it be returned to the money market fund. The EVBP was a deferred compensation plan available to senior AMA executives which has since been terminated. Strobhar contended that the AMA had made an error in the transfer and that he deserved to be made whole for losses he incurred in the stock market decline. Be- cause transfers were only allowed at month’s end, Strobhar, with Turner’s support for the claim of error, sought and received approval from Executive Vice President James H. Sammons, M.D., for a mid-month This is AMA Board of Trustees Report QQ, submitted to the House of Delegates at its Interim Meeting in Hawaii in December 1989. 128 transfer and reimbursement for his losses based upon the claim of AMA error. Strobhar was reimbursed $353,826 and the Board of Trustees was not informed of the transaction. The results of the staff investigation of this inci- dent, including facts contradicting Strobhar’s claims, were presented via conference call to the Board of Trustees by the Executive Vice President and the General Counsel on Oct. 26, 1989. On Oct. 27, 1989, Strobhar resigned, saying he would repay the $353,826 with interest. On Oct. 28, 1989 an article about the Strobhar matter appeared in the Chicago Sun-Times. Strobhar has not yet repaid the funds. This event focused the collective and very substan- tial concern of the Board on the adequacy of the AMA’s fiscal policies, audit procedures and reports, financial information regularly available to the Board, and specific events reflecting AMA financial transac- tions. Board Actions. On Oct. 28, 1989, the Board re- tained the firm of Jenner & Block as independent le- gal counsel, directing that an independent investiga- tion be conducted and a report made to the Board concerning reimbursement from the AMA Reserve Funds to the EVBP account of Whalen M. Strobhar for losses incurred during the period Oct. 1 through Oct. 20, 1987. The Chairman also called a special meeting of the Board. Jenner & Block began its inves- tigation the following morning. A special meeting of the Board was conducted on Nov. 2, 1989, at which time an interim confidential report of the independent legal counsel was presented to the Board. The Board authorized Jenner & Block to continue its investigation and to review all financial information it deemed appropriate. Further, the Board authorized Jenner & Block to retain the services of outside accountants and to undertake comprehensive reviews of the financial controls of the AMA, the structure, functions and information systems needed by the Board and its committees, and the relationships between the EVP and the Board of Trustees and its committees. JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION Background. A Nov. 19, 1989, Sun-Times article disclosed the fact of a loan authorized by Dr. Sam- mons to a deputy executive vice president, Richard A. Noffke, for the purchase by Noffke of a home. The AMA secured the loan with a mortgage on the home. After Noffke’s termination by the AMA, he failed to pay the loan as required and the AMA foreclosed on the loan. The Board was not informed of the loan or the foreclosure litigation. Board Actions. The Board directed a broad expan- sion of Jenner & Block’s investigation into the finan- cial affairs of the Association, including the matter of the AMA loan to Richard Noffke. On Nov. 20, 1989, the Board directed that the EVP enter into no financial arrangements or dealings on behalf of the Association with any employee or former employee where the arrangement is extraordinary in nature or involving a substantial amount of funds without express consent of the Chairman. The Board met in executive session Nov. 29, 1989, and received Jenner & Block’s report on its investiga- tion of the Strobhar and Noffke matters, its conclu- sions, and recommendations. The Board intends to maintain the confidential and privileged nature of that report. In summary, the Board finds that: • The AMA personnel actions accepting the resig- nations of Whalen M. Strobhar as President of AMA Services, Inc. and John E. Turner as Executive Vice President of AMA Advisors were appropriate. • Dr. Sammons authorized the transfer of AMA Reserve Funds to the EVBP account of Whalen M. Strobhar and authorized a loan of AMA funds to Richard A. Noffke. • In engaging in financial transactions of this mag- nitude, the EVP acted within the scope of his author- ity existing at the time of his actions. In doing so, however, in both instances the EVP failed to follow the usual fiscal policies and procedures in existence and known to him at the time of his actions. The EVP failed to assure that an internal investigation into the Strobhar EVBP error was undertaken in 1987. The EVP also failed to communicate both of these extraor- dinary financial decisions to the Board of Trustees. The following actions have been taken by the Board to assure the continued exercise of its fiduciary re- sponsibilities: • Jenner & Block will continue its broad investi- gation and expand it as they recommend and the Board deems necessary, and will report to the Board. • AMA General Counsel has been directed to con- tinue to take all appropriate action necessary to re- cover any and all funds due the AMA. It is unlikely that there will be full recovery of funds lost from the Noffke transaction. • To strengthen Board oversight of the Association and to define limitations of EVP authority, there will be a restructuring of Board committees to include: A Finance Committee with broad authority to review and monitor the fiscal policies, procedures, and finances of the Association. An Audit Committee to review and monitor the auditing activities of the Association. A Compensation Committee to review performance and authorize the compensation of senior staff. • The Board directed that new outside auditors be retained for 1990. • The Board recognized the strong leadership of and contributions to the Association by Dr. James H. Sammons since he became EVP in 1974. • To improve the operation of the AMA, the Board will formulate and institute specifically defined limits upon the authority of the EVP in respect to monetary, compensation, and health policy matters to conform to the exercise of the Board’s fiduciary responsibilities. • All expenditures, unless otherwise budgeted, in excess of $100,000 shall be approved by the Chairman of the Board. • AMA policies on providing loans to employees shall be evaluated and defined by the Board. • The Board reaffirmed the value of the present activity of Reference Committee F, a special reference committee of the House of Delegates meeting quart- erly with the Finance Committee, to maintain uniform financial communication as previously directed by the House. Noting that Dr. Sammons had previously planned to retire from his position as Executive Vice President and leave the employment of the AMA on March 31, 1991, when his current contract expires, the Board ac- cepted his decision. To assure an orderly transition in administrative leadership, a search process will imme- diately begin to identify a successor for the position of AMA Executive Vice President. The Board will continue the development and re- finement of these policies and will report the findings of its continuing investigation and its further actions to the House at the 1990 Annual Meeting. At the conclu- sion of the investigation, the Board will provide a full accounting to the House of Delegates. r ^ MOVING? Send Us Your Address Please notify us six weeks in advance. Old Address Name Address City State Zip New Address Address City State Zip Effective Date of New Address Send to: TMA, 112 Louise Ave.. Nashville, TN 37203 I AAARCH, 1990 129 kM 1989 Interim Meeting Report Address of the AMA Executive Vice President JAMES H. SAMMONS, M.D. For over 30 years now I have been in this House in one way or another. I sat out there with you for the first 15 of those years in various positions, and I have been sitting over there next to a series of chairmen as your Executive Vice President for the last 15 years. I have enjoyed every minute of it. I can truthfully say that the AMA has been my life. We have a lot of work to get done this week, so I am going to be very brief. But I would ask you to indulge me some deeply felt personal observations. I would like to discuss three things in these re- marks— the American health care system, the Ameri- can Medical Association, and myself. I would like those of you who may have doubts to be reassured in all three areas. See editorial comment in this issue. Let’s take the most important issue first — the American health care system. Make no mistake about it, we are right to defend our system. Here in the United States we provide the highest level of medical care known anywhere in the world. To put it very sim- ply, we save lives that would be lost anywhere else. So as we seek to strengthen our system’s ability to meet the nation’s cost and access expectations, and we must do that with all of our creative energies, we must also never lose sight of the system’s basic value, its basic quality. And we must be sure that Americans do not just take it for granted. . . . Now let me say something about the AMA, and I’ll borrow from Mark Twain. Reports of the demise of the AMA influence are highly premature. We, the AMA, are easy to criticize because we are a big American institution that has wielded great power, and we are operating in a climate that is hostile to anything This address was delivered to the AMA House of Delegates at its Interim Meeting in Hawaii in December 1989. 130 that is perceived to benefit physicians. But I assure you we are still the dominant player in health care pol- itics and health care education in this country. We may not like the package of Medicare reforms that has just been passed but it would have been a heck of a lot worse without the AMA. The compromise that passed Congress, no matter what you are told, does not in- clude the punitive expenditure targets that were origi- nally proposed. It does not include mandatory assign- ment, and it does not turn physicians into employees of the government. AMA lobbying, including the or- ganized grass roots support from physicians all over this country — counties, states, specialty societies — that’s what made the difference. Washington insiders recognize that difference in our effectiveness. It was just a year ago that an inside Washington political journal — The Washington Report on Medicine and Health — said this, and I quote: “Things may be splintered in the hinterlands, but in Washington, AMA still enjoys a decided advantage. Smaller groups have their own agendas and lobbyists, but AMA is the big dog in the policy-influencing block.” In a poll of congressional staffers this year, a leading political pollster found that the AMA is again considered, and I quote: “one of the top five organi- zations most effective in achieving legislative goals.” We have to be realistic about all this, and it is tough when you have to measure your victories in terms of the “worse things that might have happened.” But that is the environment we are living in now. At some point we hope to turn that around. I believe the pendulum will swing back. Don’t give up. And take heart in the fact that AMA influence is felt outside of the Washington beltway in ways that may be even more important. Another story in the paper last week — this one the lead story on the front page of the New York Times — told of the break- through discovery that certain vitamins can help pre- vent birth defects. And, as is frequently the case, in the second paragraph of the story it was noted that the discovery had been reported in an article in the Jour- nal of the American Medical Association. This kind of medical education is provided by AMA every week of every year. JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION Now and of least importance, let me talk about me. One of our Chicago papers has reported within the last month on two AMA incidents, both of which in- volve payments to key AMA employees which I au- thorized without informing the Board. The first in- volved an act of what we now believe may have been deception by a former trusted AMA executive. The other payment was a short-term loan secured by prop- erty requested by a senior executive who needed to relocate. The manner in which I carried out these decisions was wrong. I want to make it absolutely, perfectly clear that these decisions were mine alone. I accept the re- sponsibility for the errors and the changes that are needed to prevent their recurrence. I deeply regret the distress and concern that this has caused. I endorse the creation of the new Board committees outlined in Re- port QQ and the closer communication and control they will provide. I know many of you have questions that you do not yet consider have been answered. I will be available in Reference Committee F for as long as it lasts to answer all the questions you choose to put to me to the very best of my ability and the best of my knowledge. In retrospect, I clearly recognize that I failed to fol-