If you have recently been admitted to a hospital, chances are that you were not seen by your primary care physician in the hospital, but admitted by and cared for by a Hospitalist - a physician trained in and focused primarily on hospital medicine and care management.  This change in the relationship between patient and personal physician in the inpatient setting raises many questions in the minds of patients who may not be aware of, or understand, the rationale for their primary care physician turning their hospital care over to a Hospitalist.

Anita Dhople, MD, FACP, is a board certified internist specializing in Hospitalist Medicine. She is a graduate of Satellite High School, received her BS in Human Nutrition, and then went on to medical school at the University of Florida on a full scholarship. She completed her Internal Medicine residency at the University of Virginia in Charlottesville. After residency, she worked at a Community Health Center in Albany, Georgia and then started a Hospitalist program at Phoebe Putney Memorial Hospital. Dr. Dhople then moved to Atlanta where she was in private practice with the Piedmont Physicians Group. In July 2008, with her husband Rick and two kids in tow, she moved back to her hometown to be closer to her family. She is currently the Medical Director of the Health First Hospitalist Program at Holmes Regional Medical Center. When she is not seeing patients or chasing kids, she enjoys playing tennis, running marathons, participating in triathlons, and experimenting in the kitchen.

Space Coast Medicine & Healthy Living welcomes Dr. Anita Dhople, a board certified internist specializing in Hospitalist Medicine and Medical Director of he Hospitalist Program at Holmes Regional Medical Center to address questions about hospital medicine and hospitalists, and the changes in the way patients in the hospital are now being managed compared to how they were traditionally managed in the past.

SCM&HL: What exactly does "Hospital Medicine" mean?
DR. DHOPLE: Hospital medicine is the discipline concerned with the general medical care of hospitalized patients.  Hospitalist activities may include patient care, teaching, research and leadership related to hospital care.  Hospital medicine, like emergency medicine, is a specialty organized around a site of care (the hospital), rather than an organ (like cardiology), a disease (like oncology), or a patient's age (like pediatrics).  Hospital medicine is the fastest growing medical specialty in the United States. Demand for this specialty was initially fueled by managed care efforts to bolster efficiency, cut costs, and improve care. Today, patients admitted to the hospital tend to be more severely ill.  Certain conditions that once required hospitalization are now handled on an outpatient basis; also, older people are in the hospital with chronic age-related illnesses.  Hospital-based doctors can better attend to such patients, respond to their problems and navigate hospitals' increasingly complex systems.

SCM&HL: What is a "Hospitalist?"
DR. DHOPLE: The term "Hospitalist" is relatively new, first introduced in 1996 by  Drs. R.M. Wachter and L. Goldman to describe physicians who devote most of their professional time and focus to the care of hospitalized patients.   The term may be new to the general public, but, in the medical profession, "Hospitalist" has been a recognized and accepted term that has been around for over a decade.  It is estimated that there are about 20,000 Hospitalists across the United States now.  In general, Hospitalists do not have an outpatient office practice.  Their work is solely dedicated to caring for patients in the hospital.  Most Hospitalists are trained in internal medicine, meaning they are trained to diagnose and treat diseases in adults.  At Holmes Regional Medical Center, every Hospitalist is board certified in Internal Medicine.

SCM&HL: What is the driving force behind the Hospitalist movement?
DR. DHOPLE: There are many factors that are driving the Hospitalist movement.  These factors include patient safety, efficiency, physician availability, cost effectiveness and the need for more specialized and coordinated care for hospitalized patients.

SCM&HL: Why are physicians referring patients to a Hospitalist for hospital care?
DR. DHOPLE: By referring patients to a Hospitalist, your primary care doctor can spend more time being available to patients in the office.  For many primary care doctors, this means that they can avoid the delays and distractions in the office brought about by unpredictable demands in the hospital.  Hospitalists stay at the hospital all the time.  So your primary care doctor can be more focused on providing care in his or her office with fewer delays and interruptions.  Your primary doctor will be able to devote more time to keeping you and your family healthy.

SCM&HL: How does the Hospitalist know about me?
DR. DHOPLE: Your Hospitalist physician will spend time learning about you.  At the time of your admission, he or she will speak with your primary care physician who will communicate as much information about your medical history as possible. They will review any past medical records that you may have at the hospital and will gather information from you and your family. Your Hospitalist physician will use all this information to help them provide you the best possible medical care.

SCM&HL: What are the benefits of being cared for by Hospitalists?
DR. DHOPLE: By focusing on care in the hospital, your Hospitalist is more available to you than a doctor who has a busy schedule in an office.  A Hospitalist can more easily respond to unexpected problems while you are in the hospital, and can be more available for communication with you and your family.   They are also available to answer nurses' questions and simply to deal with problems as they arise.  Hospitalists also coordinate the care of patients in the hospital and serve as "captain of the ship." Hospitalists organize the communication between different doctors caring for a patient.  They serve as a point of contact for other doctors and nurses for questions, updates, and delineating a comprehensive plan of care.  Because Hospitalists are in the hospital most of the time, they are able to track down test results and order necessary follow-up tests promptly.  This is in contrast to the traditional setting where your primary care doctor may come to the hospital the next day to follow up on tests and take the necessary step at that time.  And since the Hospitalist's office is the hospital, they become very familiar with the hospital's policies and activities.  Many Hospitalists are involved in hospital committees and assist in improving important areas such as patient safety, medical error reduction, effective communication between physicians and staff, and cost effective patient care.

SCM&HL: What does it feel like to be cared for by a Hospitalist?
DR. DHOPLE: From a patient perspective, there really is not much of a difference than if you were cared for by your primary care physician.  Ideally, your primary care doctor in the outpatient setting will explain to his patients that he works with hospitalists to provide hospital care. Whether you are told about the Hospitalist model in advance of the hospitalization or by the hospitalist at the time of admission, it is critical that certain messages are clear:

• The Hospitalist is around the ward throughout the day, a level of access that primary care doctors aren't able to replicate
  The Hospitalist and primary care doctors work as colleagues and partners, communicating at the time of admission and discharge, at the very least, to be sure that no "information is dropped" at the time of transitions
• Although the Hospitalist system does require an inpatient-outpatient discontinuity, the presence of a Hospitalist improves the continuity of hospital care; for example, the Hospitalist can act as an orchestra conductor, coordinating the care when the patient is being evaluated by multiple hospital specialists
• The primary care doctor remains the care provider after the patient leaves the hospital

HOSPITALISTS, such as Dr. Raymond Giammanco of Cape Canaveral Hospital (pictured above), can improve hospital efficiency by facilitating movement of patients through the system. There are presently over 22,000 practicing hospitalists in the United States.

SCM&HL: I'm a patient; How should I interact with a Hospitalist?
DR. DHOPLE: First of all, don't be surprised if your hospital physician is, in fact, a Hospitalist. Having read this, you hopefully understand what a Hospitalist is, how they are trained, and why they are there instead of your regular doctor. But this person is a stranger to you, and it is reasonable to have questions and concerns.

Speak up. Ask the Hospitalist how he or she will communicate with your regular doctor to ensure that there are no fumbled handoffs. Inquire about his or her background - where did she go to medical school and do her residency. Make a connection - ask how she likes being a Hospitalist. Tell the Hospitalist about any preferences you have or special needs - not just your medical history, but any unusual reactions you have to certain medicines, or that you get very anxious in tight places (like MRI scanners), or that you want the Hospitalist to update your son in Philly on your condition each day.

SCM&HL: When will the Hospitalist see me?
DR. DHOPLE: If you come to the hospital through the Emergency Department (ED) and it is determined that you should be admitted, a Hospitalist will examine you while you are still in the ED.  If you are admitted directly to the hospital from your physician's office, a Hospitalist will examine you in your room shortly after you arrive.  The Hospitalist will visit you each day while you are in the hospital and often more than once during the day.  They are also available to come back and talk to you when your family arrives so that they can also answer any questions that your family members may have.

SCM&HL: Who will care for me once I am discharged from the hospital?
DR. DHOPLE: When you are discharged from the hospital, the hospitalist who cared for you will send detailed records to your primary care physician that clearly chronicle your hospitalization and further treatment needs, and facilitate arrangements for follow-up.  The Hospitalist will provide you with any needed prescriptions when you leave the hospital.  The Hospitalist will also let you know when you should see your primary care doctor. You are an important partner in your care.  The more you understand about your illness and treatment, the better you can help prevent complications.  Don't be afraid to ask questions or clarify something you do not understand.

SCM&HL: Why did you decide to become a Hospitalist?
DR. DHOPLE: There are many reasons. I like the fact that no day is ever the same. I like the acute setting of the hospital, particularly the satisfaction of managing the most difficult cases and seeing patients leave the hospital in better condition than when they arrived. That is truly a rewarding experience.  I also enjoy being able to build relationships with patients and their families because the hospital is my second home.  And because I get to work in every unit and with every specialty in the hospital, I'm constantly kept on my toes as to the most up-to-date treatment options for complex diseases.   Finally, it allows me to interact with a lot of different people on staff, including nurses, respiratory therapists, social workers, etc.  It's a very collegial working environment.

SCM&HL: What do you enjoy most about your role as a Hospitalist?
DR. DHOPLE: I love solving problems for a patient. I also love how the relationship builds. You introduce yourself to a patient and their family as a Hospitalist and they're thinking, "Who the heck are you?" For a few seconds, it's like meeting someone on a blind date. But by the time they are discharged, you have forged a mutually valuable and rewarding relationship, and they are thanking you.  So it's a courtship at a rapid pace.

Related posts:

1. ‘Hospitalists’ Coined To describe New Specialists
2. Editor’s Note
3. MacDonald Twins Both Specialize in Occupational Medicine

With Joe Sunday RPM, RN, Assistant Fire Chief, EMS Division, Melbourne Fire Department

Americans make more than 200 million calls to 911 every year to summon the police, the fire department or an ambulance. In a medical crisis, some people panic and call unnecessarily, while others postpone getting help because they're not sure if the symptoms are serious enough.

Space Coast Medicine & Healthy Living is delighted to welcome Joe Sunday RPM, RN, the Assistant Fire Chief, EMS Division, Melbourne Fire Department to address questions that will help our readers better understand how to most effectively use our emergency response systems.

Joe Sunday RPM, RN is the Assistant Fire Chief, EMS Division, of the Melbourne Fire Department. He has 30 years experience in the fire service and started with the Rockledge Fire Department in 1980. Joe then moved to Brevard County Fire Department in 1981, and was hired by the Melbourne Fire Department in 1984. His career with the MFD began as a Firefighter, and he was subsequently promoted to Driver/Engineer, Lieutenant and then to Assistant Fire Chief supervising the Emergency Medical Services Division. In addition to being a paramedic, Joe has 14 years experience as a registered nurse specializing in cardiac telemetry, and also in special procedures.

SCM&HL: Let's talk about emergency medical response (911). What are the most common medical problems that precipitate a 911 call?
Assist. Chief Sunday: The most common 911 calls for medical problems include: heart problems, shortness of breath, stroke/possible stroke, falls at home, and accidents.  Unfortunately, falls at home are very common and can have devastating consequences, so the fire department is planning some education on fall prevention in the home.

SCM&HL: For what types of health issues should someone call 911 immediately?
Assist. Chief Sunday: You should call 911 immediately if the symptoms you are experiencing will potentially threaten your life.  Uncontrolled bleeding, difficulty breathing, chest pain that doesn't subside with rest, serious burns, and severe allergic reactions (throat closing, hives) are some examples of when you should not hesitate to call 911.  An example for children would be a child having seizures, or experiencing choking.  Call 911 right away.

SCM&HL: Why is it important to call 911 immediately for these particular conditions?
Assist. Chief Sunday: By calling 911, you are bringing medical treatment to your location.  With heart attacks, we say, "Time is Muscle" meaning that the sooner treatment begins, the better your outcome in preventing serious heart damage. For strokes, "Time is Brain."  Swift treatment for strokes can help prevent damage to your brain.  If your doctor has told you that you are at risk for heart attack or stroke, inform your family about what symptoms to look for in case you are not able to call 911 yourself.

SCM&HL: Should I call my doctor before I call 911?
Assist. Chief Sunday: It really depends on the symptoms.  If your symptoms or illness are not severe or life threatening, you may want to call your doctor.  However, if you are experiencing symptoms that may lead to a heart attack, stroke or other serious illness, call 911 first which will assure that help is on its way.  The paramedics will assess you and rapidly evaluate whether more advanced care is needed urgently.

SCM&HL: What should I do before the paramedics arrive at my home?  Is there anything my family should do before the paramedics arrive?
Assist. Chief Sunday: First of all, everyone should remain calm.  If you are having chest pain or difficulty breathing, stop any activity and rest in a comfortable position. If you are having difficulty breathing and already use oxygen intermittently, keep the oxygen on while waiting for the paramedics. Administer any first aid as appropriate, e.g. apply pressure for active bleeding, keep the person still if a bone fracture is suspected, etc. If the person is unconscious and there is someone trained in CPR, cardiopulmonary resuscitation, start the ABC's checking for Airway, Breathing and Circulation (pulse). Make sure there is access to the home (door is unlocked).  If there is a person available, send them to wait outside to direct the paramedics to the correct location. If you have pets, secure them in a room for your safety, for the pet's safety, and for the safety of the firefighters/paramedics. Pets may react to the stress of an emergency.  They may try to run away, or they may become aggressive and protective of the owner, not allowing the paramedics to approach the person needing assistance.  Also, it's a good idea for everyone to check their home, mailbox, curb, etc. to assure that your house number is easily visible from the street.  Police or fire must be able to find your home quickly to prevent wasting time trying to locate you in an emergency.

SCM&HL: What if I live in a gated community?  How will the paramedics be able to enter the gates?
Assist. Chief Sunday: The fire department has a list of gate codes. Most Homeowner's Associations have provided the Fire Department with their gate information.  Also, some gates respond to our sirens and will open automatically. Don't worry. The gates will not hinder our response to an emergency.

SCM&HL: If I have a chronic health condition such as diabetes, what should I have prepared in case I have to call 911?  What information will the paramedics want to know?
Assist. Chief Sunday: You should have a list of your medications, and the list should include the medication names, dose, and how many times taken per day.  The paramedics will also want to know when you took your last dose of medication.  They will ask about your symptoms: when did they start, how severe are they, etc. Other important information is your past medical history, allergies to medications, and any other information that might be pertinent to your condition. Using the "Vial of Life" consolidates this information for the paramedics.

SCM&HL: What is a Vial of Life?  Where can I get one?
Assist. Chief Sunday: The Vial of Life is a pill bottle that contains your medical information on one folded piece of paper inside the bottle. Follow the instructions inside the vial, completing the information in pencil so you may update it as your condition or medications change. Keep the vial in the refrigerator, and place the stickers included in the vial on the front of the refrigerator and also on your front door.  These stickers alert the paramedics to look for your vial in the refrigerator. If you would like a Vial of Life, stop by any Melbourne Fire Department station.

“If you are not sure about your condition it’s always best to call 911. The paramedics can assess your condition, and begin treatment immediately if necessary. For the best outcome, early treatment is essential.”

SCM&HL: I've heard people talk about putting "ICE" on my cell phone? What does "ICE" mean?
Assist. Chief Sunday: ICE stands for In Case of Emergency.  This is your emergency contact person. Enter ICE into your cell phone's address book with the name and phone number of your emergency contact.  If necessary, the paramedics can use your cell phone to call your emergency contact person.

SCM&HL:When the paramedics arrive at my home, what will they do?
Assist. Chief Sunday: Our job is to assess your condition, and stabilize you on the scene for transport to the hospital for advanced care. We will start with assessing your ABC's- Airway, Breathing and Circulation.  We also want to know what events led up to the call to 911.

SCM&HL: When someone calls 911, there seems to be a lot of people who show up.  Why do so many people respond to my 911 call?
Assist. Chief Sunday: Depending on the situation, the police may also respond for an emergency medical call. For a "routine" call, one squad consisting of 2 emergency personnel and the ambulance transport crew of 2-3 people respond.  In Brevard County, Brevard Fire Rescue has the contract for all emergency ambulance transports in the county. For example, if you live in Melbourne, Melbourne Fire Rescue is your first responder coming to your home and initiating treatment on you.  Then, Brevard Fire Rescue will transport you to the hospital.  If your condition is life threatening, such as cardiac arrest, multiple people are needed to assist with stabilizing the patient.  Extra personnel, other squads or engines will be called in to help with administering any vital, life-saving treatments. More hands are needed when providing advanced life support.

SCM&HL: What kind of treatments can the paramedics do?
Assist. Chief Sunday: Paramedics receive advanced training to perform a variety of treatments. These treatments support your vital functions until you arrive at the hospital for more advanced care. Paramedics can start intravenous lines (IVs), administer IV medications, defibrillate  (which helps regulate your heart rhythm), apply an external pacemaker to keep your heart rate steady, insert a tube into your windpipe to support breathing, immobilize bone fractures, treat bleeding, etc.

SCM&HL: Do the paramedics work under the supervision of a doctor?
Assist. Chief Sunday: Yes, we have a Medical Director, Dr. John McPherson, who works closely with the Melbourne Fire Department to assure that our paramedics follow the most up-to-date protocols and procedures.  Dr. McPherson practices both as an Emergency Medicine Specialist at Holmes Regional Medical Center, and also as a critical care Intensivist for Health First's eICU.  Melbourne Fire Department's paramedic protocols are state approved and reviewed every 2 years by the Space Coast Fire Chief's Association EMS Subcommittee, which is comprised of 5 local Medical Directors and the EMS Chiefs.  Our paramedics have ongoing training to assure their skills are up-to-date with the latest medical advances.

SCM&HL: What hospital will they take me to?
Assist. Chief Sunday: The hospital you are transported to depends on your condition.  For example, if you are in an accident and meet criteria as a trauma patient, then you would be taken to the closest trauma center. In Brevard and Indian River Counties, Holmes Regional Medical Center is the state-approved trauma center.  Children needing a trauma center will be taken to Orlando for treatment, as will patients of any age with severe burns.

SCM&HL: May I request which hospital the ambulance will take me to?

Assist. Chief Sunday: We would like to take you to the closest appropriate hospital so your treatment can be continued as soon as possible.  But if your condition allows it, we try to accommodate requests for a certain hospital. Your safety is always our first concern.

SCM&HL: May I refuse to be taken to a hospital?
Assist. Chief Sunday: Yes, any person who is competent may refuse treatment.  However, we will explain to you the risks involved if you refuse treatment, and will strongly encourage you to be treated.

SCM&HL: When do the paramedics call for a helicopter transport rather than an ambulance?
Assist. Chief Sunday: A helicopter is typically called in to transport you when you meet two criteria. First, your medical condition must be extremely serious (life threatening) and meet the guidelines for trauma.  Examples of these conditions are severe injuries from any type of accident, an auto accident where it takes a long time to free you from the car, severe burns, etc. Secondly, your location must be such that it is quicker to fly you to the trauma center rather than take you by ambulance. In Brevard County, Holmes Regional Medical Center is the trauma hospital, and if your location is within a five-mile radius of the hospital, it is quicker to take you by ambulance than to call in First Flight. We call this five-mile radius a "no-fly zone." If a child is involved in an accident and meets trauma criteria, usually the child will be transported by helicopter to the pediatric trauma center in Orlando.

SCM&HL: Can my family ride in the ambulance with me to the hospital?
Assist. Chief Sunday: Yes, a family member may ride in the ambulance with you. The family member must ride in the front of the ambulance wearing a seat belt for their safety. When a child is being transported, it helps to have a parent ride along to keep the child calm.

SCM&HL: What should I do if I am not sure if I should call 911 or not?
Assist. Chief Sunday: If you are not sure, it is always better to call 911.  The paramedics can assess your condition, and begin treatment immediately if necessary. You don't want to wait until your condition deteriorates.  For the best outcome, early treatment is essential.

SCM&HL: In addition to emergency medical calls, what other types of calls does the fire department respond to?
Assist. Chief Sunday: The fire department responds to a variety of emergency calls including fires, car accidents, other accidents such as falls, fire alarms, hazardous materials (gas spills, chemical leaks, etc.), police assistance, and citizen assistance.  Fires can include house or business fires, car fires, boat fires, or brush fires. The fire department also does extensive planning for disasters, not just hurricanes that are the most common type of disaster in Florida, but also for Mass Casualty Incidents (MCI).  MCIs can range from a medical type disaster, such as the avian (bird) flu, to disasters such as an airplane crash.

SCM&HL: Are there any new and exciting treatments in the field of emergency response?
Assist. Chief Sunday: Melbourne Fire Department was the first in the county to use the AutoPulse, a device that performs automated CPR, cardiopulmonary resuscitation. The AutoPulse is a circumferential CPR device, meaning that it circles a person's chest and provides consistent, good quality chest compressions during CPR. Research has shown that not only does it improve the survival rate for the patient, but it also never gets tired, and prevents back injuries to the firefighters.  Every fire station in Melbourne has an AutoPulse, and we were able to purchase most of these with monies from a federal grant. A new treatment in the planning stages is hypothermic therapy. In this therapy, the paramedics would induce cooling of the body with the goal of lowering the body's metabolic rate.  Cooling the body lowers the tissues need for oxygen and may help save organs and tissues while treatment takes place. It is an exciting new therapy that research is showing improves survival rates and also quality of life.  Protocols are being developed for the paramedics to implement in the field.

SCM&HL: Is there anything else the public should know about emergency response?
Assist. Chief Sunday: We are always here when you need us, 24 hours a day, 7 days a week.  Our firefighters and paramedics are highly trained to provide you the best care possible. We are proud and happy to serve our community. n

Related posts:

1. Know When You Should Go the Emergency Room
2. Hero Nurse Honored by Melbourne Fire Department
3. Emergency Medicine: Prevention is Key

A DAY AT THE BEACH: SpaceCoastMedicine.com Editor-In-Chief Dr. Jim Palermo, far left above, was joined by nursing executives from Brevard and Indian River Counties at the Cocoa Beach Pier for an upbeat roundtable discussion of their profession. With Dr. Palermo are (left to right) Karie Ryan, Palm Bay Community Hospital; Mary Ellen Shannon, Wuesthoff Medical Center - Melbourne; Coleen Bailey, Sebastian River Medical Center; Chuck McGlothlin, Wuesthoff Medical Center - Rockledge; Edwin Loftin, Parrish Medical Center; Lisa Cox, Sebastian River Medical Center; Bonnie Rudolph, Holmes Regional Medical Center; and Jan McCoy, Cape Canaveral Hospital.

What are the challenges facing the local nursing community today? We sat down with nursing leaders at hospitals located from Titusville to Sebastian, Florida and found a group excited about the opportunities within their profession.

Participating in our roundtable discussion were Edwin Loftin, RN, MBA, FACHE, Vice President, Nursing, Parrish Medical Center; Jan McCoy, MSN, RN, CNAA, Vice President, Patient Care Services/Chief Nursing Officer, Cape Canaveral Hospital; Mary Ellen Shannon, RN, MSM, Vice President, Nursing Services, Wuesthoff Medical Center - Melbourne; Chuck McGlothlin, RN, Nurse Manager, Wuesthoff Medical Center - Rockledge; Bonnie Rudolph, RN, MS, Vice President/Chief Nursing Officer, Holmes Regional Medical Center; Karie Ryan, RN, MS, Director of Nursing, Palm Bay Community Hospital; and from Sebastian River Medical Center, Director of Quality Coleen Bailey, RN, MA and Nursing Director Lisa Cox, RN. Asking the questions were spacecoastmedicine.com writer Catherine Harwood and Editor-in-Chief Jim Palermo, MD.

EDWIN LOFTIN RN, MBA, FACHE, Vice President, Nursing Parrish Medical Center

SCM&HL: Reflect on why you became a nurse and what role you see nurses playing in today’s healthcare system.

• Jan: It sounds hokey, but it was truly a calling for me. The difference I see from literally 40 years ago and today is that before it was very much task oriented to where we have evolved today to literally the critical thinking required and a much, much higher level of performance that we’re expecting from our nurses. It’s a totally different world today and it’s very exciting.
• Mary Ellen: I may be the dinosaur here but in the 1960s you were either an airline stewardess, a teacher, a nurse or a homemaker.
• Jan: You’re not the dinosaur.
• Bonnie: You’re in good company. We’re right here with you. (Laughter)
• Mary Ellen: Going to nursing school for three years was $1,000 and so I chose to go that track, but once I got into it, like Jan said you just feel it, there’s just something that’s there. There were no ICUs (Intensive Care Units) at that time. You didn’t even wear gloves for a procedure back then.
• Edwin: I went off to school to be an engineer in the late 70s, early 80s and was unsuccessful at that. Came home and took a summer job and through hands on experiences with patients the awakening occurred and I knew that the calling was there. I did the typical guy thing first and thought of that other profession (being a doctor) and from my perspective, seeing who was at the bedside 24/7 — who was the hub of the wheel? And it’s nursing. Nursing has changed dramatically in the past 10 years, but at the same time the roots are still there. The key nursing skills and assessment of wholistic care — body, mind, spirit, soul — are still there and nursing staff are more than ever the hub of communication between the physician, the patient, and the other support services that we have.

MARY ELLEN SHANNON RN, MSM, Vice President, Nursing Services Wuesthoff Medical Center, Melbourne

SCM&HL: Studies show that 75 percent of nurses in Brevard County (Florida) are over age 40. What about the generational issues in nursing and the balancing act as you try to attract new, younger nurses while keeping the experienced ones in the profession as long as possible? For example, there’s the trend toward working three, 12-hour long shifts, which appeals to some, but not all nurses.

• Bonnie: This is going to be our challenge. At Holmes we put up the Heart Center. Our nurses in there walk an average of nine miles a day and somebody 55 years old, working three 12s, we’re going to kill ‘em. So we’re having a whole different thought process. We’re offering four-hour shifts. We have what we call Care Shift where they can go in and bid on extra shifts and we’ve made some of those four hours. We’re looking at places where they can job share and do all kinds of different things because you can’t count on 12-hour shifts, (which were) a convenience for management.
• Jan: It takes real flexibility. Before we’ve been relatively rigid with our policies and procedures and how things had to be done and we can’t really keep going that way. We’ve got to be flexible.
• Karie: We have to also give tools to the management teams to be able to adjust how they manage different generations. The younger ones love the 12-hour shifts, but at the same time they want their personal life and you really can’t expect that they’re going to work overtime. So if we offer the eight and the four (hour shifts) to some of our more experienced nurses we get the benefit of having that experience and they can mentor the younger, less experienced nurses. The 22-year olds going into nursing aren’t doing it for the money. Most of them have chosen it because it’s a calling and we need to nurture and develop that desire.
• Mary Ellen: It’s very difficult to understand why some of the experienced nurses are harder on the young ones coming in rather than helping nurture them. The only way we can be successful is to have the more experienced ones help the younger ones along. Nurses can be critical of each other and so we have to change the mindset of some.
• Coleen: Part of the challenge today is to get people to go into nursing. So we work with the schools, even marketing to high schools to get them to come to the hospitals and work with them while they’re younger as far as getting them involved in health care.
• Edwin: What everybody’s saying is what everybody in the nursing profession is feeling. It’s not about nursing. It’s about the patients in the community we’re serving and who is going to be in the multiple roles required to serve them. It’s just as much an issue with support and diagnostic technicians as it is with medical staff. I see it not as problem, but as an opportunity to change health care entirely and truly bring the village together. If you look at the Native American population and other cultures and who took care of each other and it was the multiple generations working together. We have that alive in our healthcare facilities.

COLEEN BAILEY RN, MA, Director of Quality Sebastian River Medical Center

CHUCK McGLOTHLIN RN, Nurse Manager Wuesthoff Medical Center, Melbourne

SCM&HL: Retention of experienced nurses is something you’ve all said was important. It’s not just money that keeps people happy at their job so what are some issues as you address the employee satisfaction component of retaining nurses?

• Jan: I think one of the most important things that I hear them asking is they want to be heard. They want to have an influence on how they care for their patients. Policies can tend to put barriers in that process. We need to listen to them and try to respond. What can we be doing to make their work easier? One of the things that we’ve got to do, going back to your question on the aging of nurses, is to find ways to be more efficient — to find ways they don’t have to walk so many miles a day, to take the care back to the bedside instead of down the hall, around the corner in the storage room and we need to be proactive about that — decentralize the care back to the bedside.
• Ed: We have to make sure we have a collegial approach to patient care and that we have partnerships with the medical community, nursing and other support services. For our organization it means getting rid of the term satisfaction. For us the key word is engagement. If we have engaged care partners — if we have an engaged community, that’s where the loyalty comes from.
• Karie: The more that an organization can support interdisciplinary cooperation and collaboration and not just say it, but support the relationship between the nurse and the other disciplines that really does engage the associate more.
• Mary Ellen: Staffing ratios (the number of patients per nurse) is also one the biggest factors because you want to be in a safe environment. Nurses don’t mind working hard and long (shifts), but they want to be able to say they did a good job. If you work short, day after day and think there were 10 things I should have gotten done that I did not, that’s when you begin the burn out. So appropriate staffing and an appropriate skill mix needs to be there.

Dr. Jim Palermo, MD, SpaceCoastMedicine.com Editor-In-Chief

SCM&HL: (Dr. Palermo): As a surgeon when I saw patients in the hospital, I maybe visited with them 10 minutes a day, but it was the nurse who was caring for them that other 23 hours and 50 minutes. Comment on the evolving relationships with physicians and the collaborative team approach.

• Lisa: Our physicians are very supportive of our nursing staff and the whole staff. We actually have nursing representation on the physician peer review board. I think from our standpoint, it’s important that our patients see us interacting with physicians.
• Bonnie: Speaking for Holmes we have over 600 doctors. It’s difficult. I think back to the 80s when I worked in pediatrics for years. I knew every pediatrician. I knew their style. I knew what they were going to order. I was right on it. I think some of that’s still there in the specialty areas where you have a captive doctor audience. But I think we’ve become so complex in our care that we’ve become fragmented and it’s harder to be a team.
• Jan: What I have seen is the fragmentation of the medical care and when you’ve got five or six or seven physicians working with one patient and that nurse is trying to pull all those pieces together because that is the key role of the RN. She is the person who oversees the care and you’re trying to meet the needs of all those doctors and then trying to blend that into one collaborative approach (to the patient’s care) is almost impossible.
• Bonnie: We’re figuring out how much the bedside nurse can do and putting things in place to help her. We have clinical charge nurses and other folks that augment the nurse’s role. There’s a new role coming out called the Clinical Nurse Leader. Karie has someone at Palm Bay getting a master’s degree to become a Clinical Nurse Leader. It’s envisioned that they have a select population of people they look after, 10 or 15 (patients) and they do all that coordination. The doctors and the social worker, have they been in? Has the patient been out of bed? Simple little things that the bedside nurse, when you really look at what they have to do, how much can they coordinate in a day? This Clinical Nurse Leader is something I think we’re going to see more of in nursing.
• Mary Ellen: Where I worked previously it was similar in role, but we actually employed an ARNP (Advanced Registered Nurse Practitioner) on the medical floor. They were able to come in, look at labs in the morning, deal with a simple issue such as a laxative or antibiotic. We had a lot of resistance early from the physicians, but in the end it turned out the physicians really did rely on those individuals. This person actually dictated the patient discharge and that was very pleasing to the physician because that was one less task they had to do. They came to depend on these people, in fact from resistance to insisting we have one on each floor.
• Karie: If we look hopefully in 5 or 10 years where we will have the Hospitalist (a physician who sees only hospital inpatients) and the clinical nurse leader assisting the bedside RN, you really will get back to that total collaboration of care. The clinical nurse leader is really showing a lot of impact on patient satisfaction because the patient knows there’s one person who’s coordinating that care.

LISA COX RN, Nursing Director Sebastian River Medical Center

KARIE RYAN RN, MS, Director of Nursing Palm Bay Community Hospital

SCM&HL: How do you stay current with the ever-changing clinical skills and care guidelines?

• Jan: Education is critical. There is an element of personal responsibility and a nurse must assume that personal responsibility for their own education, but we also need to make available either internally or through support, for the nurse to attend appropriate conferences and seminars. There’s a lot they can do now online. One of the satisfiers for nurses is support for growth and development.
• Edwin: It’s also very critical that no matter what size facility, and I use Parrish as an example as a small community hospital, we’ve got to create the environment of learning through teaching clinical staff how to be researchers. Create that level of energy and enthusiasm at discovering the research that’s demonstrated an improvement in outcomes.
• Coleen: In addition to staying up on current research, the clinical ladder is very important. The nurse is encouraged to further their education formally, but also so they can progress through the steps and promotion levels for nurses in your facility.
• Bonnie: If you’ve ever seen how physicians learn through grand rounds in medical school, we’ve started clinical nursing grand rounds at Holmes. We assigned each nursing area a date, which means that they do a presentation about something from their unit. They take it seriously and they want to be good. What we found is that sometimes doctors even come. To sit in nursing grand rounds and see three surgeons in the back of the room is really exciting. That’s such support for the nurses. We need to do more of that. We talk about how busy we are, but we can’t forget the things that challenge our staffs. I think that’s my biggest thing is how do we keep these people engaged and wanting to come to work?

CATHERINE HARWOOD Writer & Moderator SpaceCoastMedicine.com

SCM&HL: We have two men at this table, but in the nursing profession, 95 percent of nurses are women.  Talk about the role for men in nursing.

• Edwin: In my first managerial role in an Emergency Department, the medical director (a doctor) was a female. She and I would go in at the same time and I learned never to do that because with the older population, she’d ask the assessment questions and the patient would look at me and give the answers. Yes, there are still some misconceptions, but it’s not just in nursing, in other professions in the medical community the gender issues are there.
• Chuck: From my point of view I think we need to do more education in the community. My wife’s a school counselor and she’s in a middle school and the kids don’t talk about nursing. We need to get the word out that it’s a really interesting and  very challenging profession. There are just a magnitude of opportunities out there for everyone, but there are still the stereotypes within nursing and we have to get away from them.

SCM&HL: (Dr. Palermo): It’s so important that we let fourth, fifth and sixth graders know that nursing is a career to consider. You all mentioned the critical thinking component of nursing and that’s something we have to make clear, that the national expectations of safe patient health care, especially hospital-based health care, are really on the shoulders of nurses.

• Jan: Nursing is a profession, but we have not overcome the image of the handmaiden to the doctor. We’ve got to somehow bring that image to that level of critical thinking.
• Edwin: The direction that national issues are pushing us in — it’s not about the nurse making the decision or the physician making the decision. It’s about the care I receive as a patient. Be consistent, be a team and provide me good healthcare. So as we get messages out to advance our profession, we can’t do that at the expense of any other profession.

BONNIE RUDOLPH RN, MS, Vice President/Chief Nursing Officer Holmes Regional Medical

SCM&HL: What do you see as the opportunities for cooperation among your facilities at the local level?

• Bonnie: I did case management at Holmes for about 15 years and I love Wuesthoff. I’d get on the phone and say can you take this patient? We work together.
• Jan: We do have a task force right now about the Baker Act (mental health related) patients and another program that we worked on was standardizing the armbands and that’s a safety issue for patients. So if that orange armband means you’re a fall risk at my hospital, it means fall risk at the other hospitals as well.
• Karie: We have nurses who work at least at two of the facilities if not more. You don’t want that nurse to hide that they’re working somewhere else. You want to know that. Typically they have one primary work place and the other they’re working per diem and that’s fine.
• Bonnie: Let’s talk about the emergency rooms. In the old days, we diverted (patients from Holmes), you guys (Wuesthoff) would go crazy and Ed you felt it coming north. Now we don’t divert because somebody else is going to be effected. We’ve come a long way on looking at the whole picture. I think it’s exciting to work together.

BONNIE RUDOLPH RN, MS, Vice President/Chief Nursing Officer Holmes Regional Medical

SCM&HL: Finally, what are some out-of-the-box ideas or just something you’ve tried as you lead the nursing teams at your facilities?

• Jan: One thing we do at Health First that I think has been a great recruitment and retention program is our specialty certification pay. It does take extra work. It takes extra education. They have to test to achieve it. If they do receive that then we pay additional each hour. It retains then in the organization and it moves them to that higher level of practice.
• Karie: We’re looking at what you do with a newly graduated nurse when they  first come into the hospital and bridging that gap. My educator is also the one who’s going to school to be a clinical nurse leader. She’s really taken those graduate nurses and made that experience very individualized to the nurse based on what their future goals are as well as sending them to work in different areas. Every single one of them at the end of that 12-week (orientation) really felt like they were a part of the family and I think that is how we’re going to retain nurses in hospitals.
• Edwin: That’s important. Over the past two years, of all the graduate nurses we’ve brought in, and we’ve brought in many, we’ve had a 98 percent retention ratio.
• Mary Ellen: As far as retention goes, and it’s not just nursing but the entire facility, again it comes down to the work environment and the feeling that you’re valued and appreciated and I think part of it is just the celebration aspect. Such as we have a birthday party once a month where everybody who has a birthday gets together with the CEO and the CNO and the head of HR. You get to know people on a different level.
• Coleen: We have luncheons with the CEO for new staff over the past 90 days. What are the things they really like so far? What are some of the barriers they’ve had to overcome? It helps us know each other better. It helps create that culture that we’re all a team together.
• Jan: It’s still one of the most wonderful opportunities to be able to help other people. That’s what it comes down to.
• Bonnie: And I think most of us who have been in it for so long, wouldn’t do anything else. As frustrated as we get and as disillusioned at times, I can’t see myself doing anything else.

CLICK HERE FOR RELATED STORY

SANDY QUINLAN spent 15 years as a medical secretary in Melbourne, Florida before cutting back to part-time so she could attend nursing school. Quinlan chose from three local nursing school options: The University of Central Florida, Keiser University and Brevard Community College.

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3. STEMI ALERT: A Race Against Time

DR. MICHELLE HENDERSON, MD is a board certified orthopedic surgeon at Cape Canaveral Hospital in Cocoa Beach, Florida. She specializes in hip and knee surgery. A native of Michigan, she attended Michigan State University College of Human Medicine. She practiced in Michigan for 10 freezing years before she came to her senses and moved to Florida four years ago. An avid sports enthusiast (running, biking, surfing, scuba, hunting, fishing, yoga. kiteboarding), she takes personal as well as professional interest in the aging athlete.Chester, PA and has been with Health First for 14 years.

‘BOOMERITIS’

BABY BOOMERS are not like their parents or grandparents.  Being tired or suffering from a little bit of pain is not accepted as a natural part of aging.  “Boomers” are driven by higher expectations for healthy living and the means to be able to attain a healthier life style.

The good news is that more of us will be active and enjoying our later years.  But to meet the health challenges that come with that, we will need a greater focus on wellness and prevention, and new approaches to care delivery.

The demographics of the United States patient base are rapidly changing along with the population as a whole. The average age of the population continues to increase as baby boomers enter their 50s and 60s.  Members of the post World War II era, born between 1945 and 1965, baby boomers represent the largest group of health care consumers in the country.

Physical activity is a critical, yet often neglected, part of staying healthy as we age. At least 30 minutes of moderate physical activity five times per week is recommended.  Joint pain from arthritis is the most common condition that prevents participation in physical activity.  Almost half of the “Boomers” will live with arthritis with that number peaking at over 26 million by 2020.

Space Coast Medicine and Healthy Living is delighted to welcome Dr. Michelle Henderson, Board Certified Orthopedic Surgeon, to address non-surgical management of the inevitable “Boomeritis” that is or will be inflicting a significant and very influential segment of our society.

SCM&HL: What is arthritis?

Dr. Henderson: Arthritis is a degenerative condition of bones and joints characterized by joint pain, stiffness and swelling.  There are several kinds of arthritis, the most common being osteoarthritis.  Osteoarthritis is deterioration of, or wearing out of the cartilage and bone.  Causes are aging, genetics, obesity, and trauma.  In the early stages of arthritis, pain starts with activity, and can be relieved by rest.  As arthritis progresses, pain may also occur at rest or when trying to sleep.

SCM&HL: The older I get, I feel stiffer and less limber.  Is that arthritis?  Can anything be done?

Dr. Henderson: As we age, our tendons, ligaments, and muscles become less flexible, causing decreased range of motion in our joints.  Arthritis can cause loss of range of motion and stiffness.  Regular exercise, especially stretching and balance can help maintain flexibility and decrease the symptoms of stiffness.  Yoga can increase flexibility, maintain or improve balance, improve strength, and is weight bearing, thus providing an excellent all around exercise.

Buy a DVD and do yoga or exercises at home.  Water aerobics and swimming help maintain flexibility, and are well tolerated by most patients with arthritis, as the water helps unload the weight from joints, thus causing less stress.  Go to a local gym.  Keep moving.  A stiff arthritic joint is more painful than a mobile joint.  Try different kinds of exercise until you find one that doesn’t hurt, and stick with it.

SCM&HL: I love to run, but my knees hurt.  How can I keep running?

Dr. Henderson: Running shoes are very important.  The rule of thumb is to replace running shoes every 500 miles.  Buy good quality shoes with arch supports and well padded soles.  Try running on soft surfaces, trails or a tread mill instead of concrete.  Softer surfaces are more forgiving and less traumatic.  Alternate running with other exercise such as biking, elliptical trainer, or swimming.

Anti-inflammatories such as aspirin, Aleve, Ibuprophen, or tylenol arthritis, can help with pain and swelling associated with arthritis.  Side effects such as ulcers, kidney or liver problems can occur, so take them sparingly, with food and a large glass of water.

Consider glucosamine and chondroitin supplements.  They are cartilage building blocks that can help prevent the progression of arthritis.  As we age, our bodies stop making glucosamine and chondroitin.  Supplements are available over the counter.  It’s like taking a vitamin for your cartilage.  Some patients get improvement of pain, too

SCM&HL: What can I do for hip pain?

Dr. Henderson: The three main causes of hip pain are arthritis, trochanteric bursitis, and sciatica or pinched nerves.  Arthritis pain usually hurts in the groin, in the middle of where your hip bends.  Sometimes the pain radiates toward the inside of your knee.  Glucosamine and chondroitin supplements, anti-inflammatories such as Aleve and Ibuprophen, and tylenol can help.  If your pain is severe using a cane in the opposite hand may help.

Trochanteric bursitis hurts near the bony prominence on the side of your hip, the spot you lay on when you are laying on your side.  The pain is aggravated by hip flexion and getting out of a car or chair.   Ice or heat can help.  Stretching exercises with your hip and knee bent 90 degrees and pushing you knee toward the opposite hip can help.  Physical therapy with ultrasound treatment may help.  Cortisone injections can be helpful if stretching and anti-inflammatories don’t help.

The third cause of hip pain can be due to a pinched nerve in your back or pelvis.  Symptoms are pain in the buttocks that radiates down the back of the leg to the knee (sciatica) or to the calf or foot (Pinched nerve in you back).  Back pain may or may not be associated with the pain in the buttocks or leg.  Exercise to stretch and strengthen the back and abdomen, as well as improving the posture, can help.  Aleve, Ibuprophen, or tylenol are good medications to start with.

SCM&HL: I am losing motion in my shoulder and it hurts.  I can’t get my hand behind my back.  Do I have arthritis?

Dr. Henderson: Arthritis can cause loss of motion in shoulders.  A grinding sensation can often be felt and heard as the cartilage wears out.  Mechanical blocks to movement are due to bone spurs and the flattening of the humeral head, the ball portion of the shoulder.  Treatment includes anti-inflammatories, glucosamine and chondroitin, cortisone injections, and, as a last resort, surgery to clean out or to replace the joint.

Adhesive capsulitis, or “frozen shoulder”, is another cause of a stiff painful shoulder.  Middle-aged, fair skinned females and diabetics are most commonly affected.  The layers of skin, fascia, muscles, tendons, ligaments and joint capsules get stuck together with adhesions, similar to a rusty hinge.

IRIS DAVIS says exercise “helps you with aches and pains, and it makes you stronger.” Davis is pictured here training at Parrish Health & Fitness in Titusville, Florida.

The adhesions can be broken with stretching, stretching, stretching.  Physical therapy can help guide the exercises and provide stretching passively by the therapist manipulating the joint. Anti-inflammatory medications can help, too.

SCM&HL: What are the “rooster comb” injections for arthritis?

Dr. Henderson: Cartilage is made of collagen fibers woven together like a sponge.   The holes in the sponge are filled in with a thick fluid called hyaluronic acid, or HA.  HA gives the cartilage more resilience and makes it more resistant to compressive forces.  As we age, the collagen fibers wear out and flake off, the start of arthritis.

The HA then leaks out of the cartilage, making it less spongy and less of a shock absorber.  HA production by your body decreases with age.  HA injections help replace what is lost.  Through unknown processes, HA helps relieve arthritis pain.  It does not stop the progression of arthritis, but can ease up the symptoms.  HA used in these injections are produced from rooster combs, which are made up of a lot of cartilage.

SCM&HL: It is encouraging to know that there are a variety of effective non-surgical treatments for arthritis.  Any concluding suggestions for us “Boomers?”

Dr Henderson: Those affected with arthritis pain need to work with their doctors in order to find the best arthritis pain treatment regimen.  Most cases of arthritis can be managed with medications, physical therapy and other non-surgical approaches as described.

Although the hierarchy of treatment plans for arthritis requires that more simple and conservative steps be tried and exhausted before surgical consideration, there are a variety of surgical procedures that are very effective and can render tremendous pain relief for patients suffering from more severe arthritis refractory to non-surgical treatment.

CLICK HERE FOR RELATED STORY

YOU CAN HEAR the pride in her voice when Ruthie Porter says, “I’m keeping up with the younger generation.

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2. Osteoarthritis Also Known as “Wear and Tear” Form of Arthritis.
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DR. IVY M. CHONG has worked in the area of developmental disabilities and autism for the past 12 years. Her research interests focus on language acquisition, skill acquisition, and the assessment and treatment of problem behavior. A Board Certified Behavior Analyst, Dr. Chong is a Licensed Psychologist in the state of Michigan where she spent the last four years supervising an outpatient treatment program for preschoolers diagnosed with ASDs in metro-Detroit. Dr. Chong has substantial clinical experience in supervising intensive treatment programs for children diagnosed with autism and related disabilities, and training students at the graduate and undergraduate level. Dr. Chong has taught courses in Applied Behavior Analysis at Oakland University, which prepares her well for similar teaching responsibilities at Florida Tech. Born and raised in Winnipeg, Canada, Dr. Chong was delighted to re-locate to sunny Florida to serve as the Program Director for the Scott Center for Autism Treatment, which will officially open its doors in a brand new 18,000 square foot building in this summer.

CASES OF AUTISM are soaring at an alarming rate. Just in Central Florida, about 20,000 residents are thought to have autism spectrum disorders, with more than 4,000 cases in Brevard County alone. Though much is being invested in finding a possible genetic link, the cause is unknown. Thus there is no cure, but early diagnosis and intervention are proving to help young people with autism spectrum disorders and their families.

Psychologists at the Florida Tech School of Psychology offer assessment and treatment in their temporary center on Country Club Road.  Diagnostic services are available from birth to age 12 through Counseling and Psychological Services (CPS), also located on campus and the university has broken ground for the Scott Center for Autism Treatment on Babcock Street.

To be finished this year, the center is part of a $5 million project that will serve children, adolescents and adults with these disorders in the counties of East Central Florida.  The location in East Central Florida is within a three-hour drive of all of Florida’s major population centers (e.g., Orlando, Tampa, Jacksonville, Ft. Lauderdale, and Miami), helping to ensure access to state-of the-art services for thousands of families and individuals.

The university also offers free monthly workshops on campus for parents, educators and professionals who deal with autism. Last October, the School of Psychology held its second annual Autism Conference: The Many Faces of Autism.

At that conference, College of Psychology and Liberal Arts Dean Dr. Mary Beth Kenkel announced the results of a new survey commissioned by the school: First National Public Opinion Survey: Americans’ Knowledge and Understanding of Autism. The results provide a place to start in helping to educate and inform about the nature of the disorders, about interventions, and the likely and unlikely causes of autism.

Space Coast Medicine and Healthy Living is delighted to welcome Dr. Ivy Chong, (Ph.D., BCBA) Program Director of the Florida Tech Scott Center for Autism Treatment as she addresses frequently asked questions and misconceptions about autism.

SCM&HL: What is autism and what is meant by autism spectrum disorders?

Dr. Chong: Autism is a neurological disorder that is first diagnosed in early childhood and results in impairments across three core areas: social skills, communication skills, and a restricted repertoire of activities and interests. In addition, many individuals with autism have mental retardation and may exhibit self-injurious, stereotypical, and /or aggressive behaviors. Autism occurs on a spectrum, and related disabilities include Rett’s Disorder, Childhood Disintegrative Disorder, and Asperger’s Syndrome. Distinctive characteristics are associated with each disorder.

SCM&HL: How many babies born in the U.S. today are affected by autism? Are boys and girls affected equally?

Dr. Chong: Until recently, autism was thought to be rare. However, it is now thought to be much more common, and is currently diagnosed in about one in every 150 births. Autism is now the fastest growing developmental disability with a 10% to 17% annual growth rate.  Further, boys are more often affected than girls, with four boys diagnosed to every girl.

SCM&HL: What are some of the early behaviors to observe?

Dr. Chong: Early indicators of autism may include, but are not limited to: impaired nonverbal behaviors such as eye gaze and facial expression directed to others, lack of social/emotional mutual action and reaction, delayed language without attempt to compensate via gesture, impaired pragmatic language, stereotyped/repetitive or idiosyncratic language, lack of pretend play, repetitive motor mannerisms, inflexible adherence to routines/rituals, and preoccupation with parts of objects.

AUTISM IS A BRAIN DEVELOPMENT DISORDER that is characterized by impaired social interaction and communication, and restricted and repetitive behavior, all starting before a child is three years old. Autism affects many parts of the brain; how this occurs is not understood. Parents usually notice signs in the first two years of their child’s life. Early behavioral or cognitive intervention can help children gain self-care, social, and communication skills.

SCM&HL: What are some problem behaviors that may be observed?

Dr. Chong: Common problem behaviors may include: looking away, non-responding, non-compliance, self-stimulatory behaviors such as rocking, mouthing objects, falling to the floor, running from adults, climbing on tables, counters, bookcases, screaming, yelling, loud noises, crying, tantrums (combination of behaviors), property destruction, and self-injurious behaviors.

SCM&HL: How early should intervention take place and what should it consist of?

Dr. Chong: Intensive intervention should start as early as possible. Treatment should ideally start by age two to three and more recently there has been promising work done with infants. The best programs should involve at least 20 - 25 hours per week of one-on-one therapy with the therapists trained in Behavior Analysis (ABA) and overseen by a Board Certified Behavior Analyst. Behavioral treatment focuses on language, self-help and appropriate social interaction. A large emphasis is also placed on reducing problem behaviors, such as those mentioned above.

SCM&HL: What is known about the cause of autism? What is the biological evidence that a child is autistic?

Dr. Chong: Unfortunately, the etiology of autism is still largely unknown.

SCM&HL: What is known about the connection between early vaccinations and autism?

Dr. Chong: Scientists say there is no evidence linking vaccines and autism.  More than a dozen studies have been conducted internationally indicating the lack of relation between autism and the vaccine, but the lingering apprehension is leading to fewer parents having their children vaccinated.  With fewer vaccinations, cases of the disease are increasing. The New York Times reported in August that measles cases in the first seven months of 2008 grew at the fastest rate in more than a decade. Cases in Britain, Switzerland, Israel and Italy are said to be soaring. Indeed, confusion may stem from the fact that the cause of autism is unknown.  The evidence does not support withholding necessary vaccines from infants and children based on a concern that vaccines cause autism.

There is no scientic evidence linking autism to childhood vaccines.

SCM&HL: What resources does Florida Tech offer in diagnosing and treating autism?

Dr. Chong: Florida Tech aims to be a comprehensive, multi-faceted, community based service providing high quality affordable services to children and their families in Central Florida and the state.  Currently, services include diagnosis for children birth through 12 years.  Intensive one-to-one treatment is provided for children aged 2 to 6.  Additionally, social skills training in the format of small group instruction is provided for children aged 2 to 12.  A new group will be developed for young adolescents aged 13 – 15 beginning in January of 2009.  Finally, counseling is also being provided individually and for families (through Counseling and Psychological Services or CPS).

CASES OF AUTISM are soaring at an alarming rate nationally, with more than 4,000 cases in Brevard County alone. Though much is being invested in finding a possible genetic link, the cause is unknown. Thus there is no cure, but early diagnosis and intervention are proving to help young people with autism spectrum disorders and their families.

SCM&HL: What are some of the highlights from the first national public opinion survey about Americans’ knowledge and understanding of autism, 2008?

Dr. Chong: Much information was generated from the survey.  A few key highlights are:

• More than 80 percent of survey respondents say every state should have an early intervention program for children from birth to age three. An even larger percentage (83%) thought that finding a cure for autism should be a national priority.
• Nearly one quarter (24%) of respondents said that because vaccines may cause autism it was safer not to have children vaccinated at all. Another 19% were not sure. The Centers for Disease Control says “evidence from several studies examining trends in vaccine use and changes in autism frequency does not support such an association.”
• About eight of ten (82%) respondents know that autistic people of all ages can benefit from treatment and 77 percent say behavioral therapists are integral to the successful treatment of people with autism. An additional 73 percent believe behavior therapies are the most effective way to get autistic individuals to maximize their capabilities.
• About four of ten (39%) survey respondents know a person with autism. They had a better understanding of the disorder, except for its cause, than those who do not know someone with autism. Those who know someone with autism are more likely (21% vs. 17%) to believe the disorder was caused by a preservative once found in childhood vaccines.

Related posts:

1. Scott Center at Florida Tech Probing the Mysteries of Autism
2. Do Vaccines Cause Autism?
3. Florida Tech To Host Autism Conference

THE NUMBER of people diagnosed with diabetes in North America has increased substantially over the past two decades. In 2008 there were about 24 million people with diabetes in the United States alone, but 5.7 million of those don’t even know it because they remain undiagnosed. Another 57 million people are estimated to have hereditary, physical and/or life-style influences that make them susceptible to developing diabetes. Affecting men and women of all ages and ethnic groups, diabetes is newly diagnosed in nearly 1 million people each year.

VINCENT MARINO, MD, is a graduate of Cocoa Beach High School in Florida and the University of South Florida in Tampa. Dr. Marino attended medical school at the American University of the Caribbean and completed his family practice residency at East Tennessee State University. Returning to Brevard County to open his own office in 1984, Dr. Marino is board certified in Family Practice. You can contact Dr. Marino at his office in Cocoa Beach at 321-868-7170. He continues to see patients in his office, and rounding on personal patients daily at Cape Canaveral Hospital.

SCM&HL welcomes Dr. Vincent Marino to address frequently asked questions related to diabetes, a condition that the Centers for Disease Control has described as an epidemic that costs 132 billion U.S. healthcare dollars every year.

SCM&HL: What is diabetes?

DR, MARINO: Diabetes mellitus is a chronic condition in which a gland called the pancreas does not secrete adequate insulin to meet a person’s needs. This results in blood sugars (glucose) that are higher than normal. Cells in the body break down glucose in order to provide energy for movement, growth, and repair. The hormone insulin is responsible for regulating glucose levels in the blood. Abnormally high levels of glucose can damage the small and large blood vessels, leading to diabetic blindness, kidney disease, poor circulation and possibly amputations of limbs, stroke, and heart disease.

SCM&HL: Are there different types of diabetes?

DR. MARINO: There are three different types of diabetes.
• Type 1 diabetes is usually (but not always) diagnosed in children and young adults and was formerly known as juvenile-onset. The pancreas stops producing insulin in type 1, therefore daily insulin injections are necessary.
• Type 2 diabetes is usually (but not always) diagnosed in adults over the age of 45, and is the most common type. In type 2 diabetes, either the person is not making enough insulin, or the body is resistant to insulin and cannot use it properly. There are a variety of treatments for type 2 diabetes, including diet and exercise, pills and/or insulin.
• Gestational diabetes occurs during pregnancy: 2-4 percent of all pregnant women have gestational diabetes. If a woman has gestational diabetes, she has about a 40 percent chance of having type 2 diabetes later in her life.

SCM&HL: How would I know if I had diabetes?

DR. MARINO: As many as 50 percent of persons with type 2 diabetes are unaware that they have the disease. For this reason, it is particularly important to pay attention to the signs and symptoms of diabetes and its risk factors.  Some of the signs of either type 1 or type 2 diabetes are:

• Being very thirsty
• Urinating often
• Feeling very hungry or tired
• Losing or gaining weight without trying
• Having sores that heal slowly
• Having dry, itchy skin
• Losing the feeling in your feet or having tingling in your feet
• Having blurry eyesight

Symptoms of type 1 diabetes often develop over a short period of time. In type 2 diabetes, symptoms develop more slowly, and many people with diabetes do not experience any symptoms at all. If you are regularly having any of these signs and symptoms, you should visit your doctor and have blood drawn. Diabetes can be diagnosed with a simple lab test. If a fasting blood sugar test is greater than or equal to126, you may have diabetes. The test should be repeated to confirm. Two fasting blood sugar tests with results greater than or equal to 126 is positive for the diagnosis of diabetes.

SCM&HL: What factors increase my risk of getting diabetes?

DR. MARINO: Although researchers don’t fully understand why some persons get diabetes and others don’t, it is clear that certain factors increase your risk. You are at risk for having diabetes if:

• Your mother, father, sister, or brother has diabetes;
• You are African American, Hispanic American/Latino, American Indian, Native Alaskan, Asian American, or Pacific Islander;
• You have high blood pressure and low good cholesterol/high triglycerides
• You have a history of diabetes during pregnancy (gestational diabetes) or gave birth to a baby weighing more than nine pounds at birth;
• You are overweight or obese;
• You are inactive or have a sedentary lifestyle; or
• You are older than 45 years of age.

If you have one or more of these risk factors, even if you are experiencing no symptoms, your doctor may want to test you for diabetes.

SCM&HL: How does the doctor test for diabetes?

DR. MARINO: Although the amount of glucose in your blood varies depending on when and what you eat, the range should be relatively narrow. In general, your blood sugar is highest after you eat and lowest after you have not eaten for 8-10 hours. After fasting all night, most persons have blood glucose levels between 70 and 110 milligrams of glucose per deciliter of blood (mg/dL). After eating a large meal, a person’s blood sugar will rise, but generally not above 140 mg/dL. People with untreated diabetes will have higher blood sugars after fasting and after eating.

To check if you have diabetes, your doctor will test your blood sugar levels. The results of these tests and other clinical findings will be used to decide if you have diabetes and what type. Doctors cannot diagnose diabetes on the basis of one single test. Instead, they will perform two or more glucose tests before confirming your diagnosis. The most common tests to measure glucose are the fasting plasma glucose test, the random blood sugar test, and the oral glucose tolerance test.

• Fasting plasma glucose test. Most experts recommend using a fasting plasma glucose test to diagnose diabetes. Before taking this test, you cannot eat anything for 8 to 10 hours. Blood will be drawn from a vein in your arm and sent to a laboratory for testing. If your fasting blood glucose is 126 mg/dL or higher, your doctor will probably diagnose you with diabetes.
• Random blood sugar test. Many cases of diabetes are found during routine physical exams when blood is drawn for other tests. Since you don’t necessarily fast before these physical exams, you may have just eaten and your blood sugar may be high. Even so, it shouldn’t be higher than 200 mg/dL. If your random blood glucose is higher than 200 mg/dL, your doctor will probably suspect diabetes and may want to give you a fasting plasma glucose test.
• Oral glucose tolerance test. In this test, a person consumes a drink containing glucose dissolved in water. Blood is then drawn in timed intervals over a three-hour period. If plasma glucose levels rise more than expected, the person is diagnosed with diabetes. This test is often used to check pregnant women for gestational diabetes. It is rarely used to diagnose diabetes in other patients, because it is cumbersome and time-consuming.

SCM&HL: How can I reduce my chance of getting diabetes?
DR. MARINO: A recent study funded by the Federal government of 3,234 persons at high risk for diabetes showed that diet and exercise can sharply lower the risk of getting type 2 diabetes.

The Diabetes Prevention Program (DPP) was a major clinical study of ways to prevent or delay diabetes in persons at high risk for type 2 diabetes. Patients were overweight and had higher than normal levels of blood glucose, called impaired glucose tolerance. Both conditions are strong risk factors for type 2 diabetes.

Because of the high risk among some minority groups, about half of the DPP participants were African American, American Indian, Asian American, Pacific Islander, or Hispanic.

PEOPLE WITH DIABETES have the same nutritional needs as anyone else. Along with exercise and medications (insulin or oral diabetes pills), nutrition is important for good diabetes control. By eating well-balanced meals in the correct amounts, you can keep your blood glucose level as close to normal (non-diabetes level) as possible. Diabetes nutrition focuses on healthy foods. But you can eat sweets once in a while without feeling guilty or interfering with your blood sugar control. The key to diabetes nutrition is moderation.

The DPP compared two methods for preventing diabetes: (1) an intensive program of healthy eating and exercise and (2) the use of metformin, a diabetes drug. Persons who engaged in moderate physical activity for about 30 minutes a day, followed a low-fat and low-calorie diet, and lost 5 to 7 percent of their body weight (or about 12 pounds for someone who weighs 200 pounds) cut their risk of getting type 2 diabetes by about one half (58%). Those persons receiving metformin reduced their risk by one third (31%).

SCM&HL: Why are so many children being diagnosed with Type 2 diabetes?

DR. MARINO: The incidence of obesity in young children, adolescents and teens has increased dramatically over the years. In addition, activity levels have decreased. Anyone who is overweight and sedentary is at greater risk for developing diabetes.

SCM&HL: If I have diabetes do I have to go on a special diet?

DR. MARINO: Actually, the diet recommended for people with diabetes is a healthy diet for everyone!  It includes food from all major food groups with emphasis on eating less fat, incorporating more vegetables and fruit.  The diet also recommends that you consume whole grain products to increase fiber intake.  You are not required to buy “special” foods.  This is an approach, which would be endorsed by most dieticians.  I personally take a different approach with my patients though.  I have no large study to back my reasoning, it is simply based on my own personal observations with my patients over the years.  My approach is “my approach”, which may be different than other physicians.  The approach I like, is to ask them to try the South Beach Diet.  It has a 3 phase approach.  I ultimately would like to see all my patients, and that includes myself, to limit carbohydrates to 100 to 120 grams a day.  It isn’t hard to do once you get into the rhythm of the right food selections.

SCM&HL: What exercise would you recommend for our older diabetic readers?

DR. MARINO: I totally believe in the “10,000 Steps A Day Program”.  Pedometers can be purchased starting at $10.  Programming these devices is not hard and after using them for 2 to 3 weeks they can be reprogrammed very accurately.  2,000 steps is one mile.  Put your Pedometer on first thing in the morning and go, go, go.  It’s funny but in my busy day, I may do 4000 steps from the time I step out of bed to 5 p.m..  That means I am 6000 short, or I have to walk 3 miles.  Once at a local restaurant I noticed a waitress wearing one, and I asked her how many steps she did in a day.  She stated that a normal day for her was 20,000 steps.  I have to add she was thin.    The deficit mileage can be done either out side, at your fitness center or in any of the large malls.  Unfortunately, sometimes both my patients and I suffer from the “out of sight out of mind” concept of exercise.  The pedometer heightens awareness, puts your progress in plain site and challenges you to go the extra distance every day you use it.

SCM&HL: If I start taking insulin, can I ever stop?

DR. MARINO: If you have type 1 diabetes the answer is no. You must take insulin every day for the rest of your life. For type 2 diabetes, insulin may be temporarily added for some situations to adequately control your blood sugars. If normal blood sugar control is achieved without insulin, it may be discontinued. However, we now know that the normal progression of type 2 diabetes is to require more medications and insulin over time.

SCM&HL: If I am diagnosed with diabetes, will I have to go on disability?

DR. MARINO: Absolutely not! Current treatments allow people to lead completely normal lives. It is, of course, important for individuals with diabetes to be proactively involved in good healthcare practices.  In fact, many professional athletes have diabetes, and with balanced diet, medication and activity management compete at the highest levels.

SCM&HL: Which type of diabetes is worse?

DR. MARINO: Type 1 and type 2 diabetes, if uncontrolled, are equally bad. Although there is no cure for diabetes yet, early detection and daily treatment are imperative to control blood sugar and help prevent diabetes-related complications. There are excellent treatment options for both types of diabetes. If you suspect that you might have diabetes, get checked!

FOR MORE INFORMATION About Diabetes, Click on These Web Sites:

• Diabetes.org/about-diabetes.jsp
• CDC.gov/DIABETES/consumer/index.htm
• Diabetes.webmd.com/default.htm

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JOHN STERN was in his Satellite Beach, Florida home getting ready to go out. While brushing his teeth at about 10 a.m. that Monday morning, his left side began to go numb.

John Stern

His left leg gave way and he sank to the floor. Stern, 79, was familiar with stroke symptoms, so he knew he needed to get help fast. But his frozen left leg was trapped under his right leg, and he was also hampered by health problems including his chronic obstructive pulmonary disease.

It took about an hour for Stern, who lives alone, to drag himself six feet to the telephone on his night table. When he finally got there, he used the telephone cord to pull the telephone to the floor. He tried calling 911, but in his confused state he was dialing 119, he later learned. He kept getting busy signals.

Finally he called a trusted neighbor who has a key to his house. She called 911 and then came over to be with Stern until the emergency medical personnel arrived. “After that, my memory becomes blurry as to what was going on,” says Stern, who doesn’t suffer from the common stroke precursors of high blood pressure and cholesterol.

Stern learned he was transported to Holmes Regional Medical Center and received by the stroke team, which is lead by Dr. Bhuvaneswari Dandapani, MD, a neurologist. He was given a CAT scan, which showed he had suffered a stroke brought on by a blood clot, and then received a thrombolytic, a clot-busting drug.

The thrombolytic, which is able to quickly help reverse stroke symptoms in many patients, was given to Stern just within the three-hour window in which it is effective and safe to administer. Stern quickly began to recover and was able to check out of the hospital by Thursday because he had family members who could support and care for him until he fully recovered.

“Dr. D calls me her ‘miracle man.’ I feel very blessed to have gotten to the hospital and been diagnosed in time thanks to the quick work of the emergency personnel and hospital staff,” Stern says.

Without the drug it could have taken Stern months or years to recover lost functioning on his left side. As it was, he used a walker for a few hours after returning home, then worked with Beachside Therapy to strengthen his muscles. “I still do my exercises each day, but I’m essentially fine,” Stern says.

Immediate Recognition of Numbness Critical for Soucy's Survival

BERT SOUCY had just finished having a meeting with his boss at Mercedes Homes in Suntree, Florida when he began to feel numb on his left side. So Soucy, now 66, backtracked and told his boss that he’d better drive himself to the hospital because he felt like he might be having a stroke. Soucy called his wife, Betty, and asked her to meet him along the way.

Bert Soucy

“In retrospect it probably wasn’t the smartest thing to drive myself rather than calling 911,” Soucy says because he could have collapsed before getting to his car or had a wreck on the way to the hospital.

Soucy met up with his wife at the 7-Eleven several blocks from his work and she drove him to Wuestoff Medical Center in Melbourne. There the stroke team determined Soucy’s stroke was caused by bleeding in his brain rather than a clot, so he wasn’t a candidate for a thrombolytic, a clot-busting drug.

Because no quick treatment for a hemorrhagic stroke is generally available, and because a new experimental drug is under clinical trials at Holmes Regional Medical Center, the Wuestoff team gave Soucy the option of taking part in the Holmes study.  The study is being led by Dr. Bo Dandapani, MD., a neurologist.

“I knew there were no guarantees but that participating offered me the chance of a better outcome, so I agreed,” Soucy says. Soucy was transferred down to the hospital via ambulance.

Because the scientific study was double blind, Soucy did not know if he would receive a placebo or the drug. He believes he did receive the drug, however, because his stroke symptoms quickly abated. “Because lasting damage is typical from a hemorrhagic stroke I have to think the drug is what made the difference,” says Soucy, whose stroke was brought on by brain defects he was born with.

After the stroke Soucy did suffer from minor seizures on his left side but now takes a medication that got those under control. His neurologist, Dr. Scott Gold, M.D. continues to monitor his condition. “I haven’t had any seizures in months,” say Soucy, now retired.

Soucy believes his story would have been far different if he had ignored those first symptoms of numbness on his left side. It could have led to death or permanent disability. “My dad had a stroke. It was a rude awakening of what can happen to you at any time,” Soucy says.

CLICK HERE FOR RELATED STORY

Q&A With Dr. Bo Dandapani: EVERY 53 SECONDS, someone in the United States suffers a stroke and 70 percent of these occur in people over the age of 65. Stroke is the third leading cause of death in the US and one of the leading causes of long term disability.

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EVERY 53 SECONDS, someone in the United States suffers a stroke and 70 percent of these occur in people over the age of 65. Stroke is the third leading cause of death in the US and one of the leading causes of long term disability. The burden of stroke affects the patient, family and society, and recovery is often a lifetime challenge.

DR. BO DANDAPANI completed medical school in India and then did research in Parkinson’s disease at the University of Miami, followed by her residency in Neurology and Fellowship in Stroke and Cerebrovascular diseases. She was on the faculty of the Cleveland Clinic in Fort Lauderdale for six years until she joined Melbourne Internal Medicine Associates in Melbourne, Florida.

A stroke occurs when a blocked or burst vessel interrupts blood flow to the brain. This can cause a variety of symptoms including disruption of neurological function leading to paralysis, inability to speak, visual loss, cognitive dysfunction and some times personality changes.  These disabilities impair daily function, loss of job and independence, and some require long-term care.

Space Coast Medicine & Healthy Living is delighted to have the opportunity to talk with neurologist and nationally recognized stroke expert, Dr. Bhuvaneswari “Bo” Dandapani, about this prevalent and potentially devastating condition, and the importance of rapid recognition of symptoms and timely treatment.

SCM&HL: Dr. Dandapani, with the development of new, more effective treatment in recent years, there seems to be an increasing awareness in the public and media about stroke. Can you comment on this?

DR. DANDAPANI: Until recently there was little to offer stroke victims.  However, the availability of clot busting medicine (t-PA), offers selected stroke patients a better chance of survival and reduced disability.  This therapy can only be offered within the first three hours of the onset of stroke symptoms.  In order to receive t-PA, patients manifesting stroke symptoms must get to the hospital within three hours. “Time is brain!” The best way to do this is by calling 911!

Awareness of, and rapid response, to stroke symptoms is the most important message to convey to the public.  Unfortunately, a decision made by a patient or family member not to seek immediate medical help could cost a life or result in a life with disability.  That is why it is so critical that patients and families know and recognize the warning signs and symptoms of stroke.

SCM&HL: What are the warning signs? How can the lay public recognize and remember these signs, and understand complex medical terms that are used to describe them?

DR. DANDAPANI: It is easy to remember the warning signs if you can remember the term ‘FAST.’

• F: Face numbness or weakness, especially one side of your body;
• A: Arm numbness or weakness, especially one side of body;
• S: Speech slurred or difficulty speaking or understanding;
• T: Time to call 911.

Also, a bystander can recognize a stroke by asking four simple questions:

• • Ask the individual to SMILE. A crooked smile is a concern.
• • Ask the person to speak a simple sentence.
• • Ask him or her to raise both arms.
• • Ask the person to stick out their tongue.  A crooked tongue that goes to one side or the other is a concern.
• • Time is of the Essence

SCM&HL: What is a TIA?  This is a term frequently used associated with stroke.   Is a TIA the same as a stroke or different?

DR. DANDAPANI: TIA is Transient Ischemic Attack. The patient suffers the same symptoms as we discussed before, but symptoms are transient and go away resulting in no residual deficit.  Hence, people tend to ignore the symptoms. However, a TIA is a very serious warning sign that suggests underlying disease and a high risk for stroke.  Over 50 percent of patients with TIA suffer damage to the brain cells as evidenced on  MRI scan.  Fortunately, when patients present with TIA, it gives them and us an opportunity to identify the cause and risk factors and thus, with treatment, prevent a devastating stroke.

SCM&HL: What is the optimum way to heighten public awareness of stroke?   Have you personally seen any increase in stroke awareness in our community?

DR. DANDAPANI: The American Stroke Association and National Stroke Association along with the National Institute of Neurological Diseases and Stroke have made great strides in the past several years in improving public awareness. Media announcements, public service announcements and educational programs sponsored by pharmaceutical companies and individual hospitals have helped promote the message.  Not-for-profit organizations like churches and ministries are promoting the awareness among their congregations, and, in some areas of the country, school programs have developed educational curriculum that addresses the fundamentals of CPR and promotes the awareness of both cardiac and stroke symptoms.

As far as our community, I can tell you that the message is slowly but steadily reaching our population at risk.  Emergency Medical Systems are bringing patients to the emergency room in a timely fashion to obtain early and rapid treatment.  For example in 2002, we gave thrombolytic therapy to two patients with stroke.  Now in 2007, 34 early stroke patients were treated with the brain and life saving “clot-buster.” It is a significant increase, but we have a long way to go, in my opinion.

SCM&HL: That is an impressive increase.   What, other than public awareness, do you think has lead to that increase?

A STROKE is the sudden damage or death of cells in a localized area of the brain due to inadequate blood flow. A stroke occurs when blood flow is interrupted causing oxygen starvation. A hemorrhage or thrombosis in the main arteries of the brain can cause the oxygen starvation.

DR. DANDAPANI: It could not have been made possible without the participation of medical personnel and hospital systems across the Space Coast.  Even if the patients present for care in a timely fashion, we would not be able to help them if we were not ready and equipped for it. National expectations are that hospitals have systems and programs in place to provide specialized stroke care. A whole paradigm shift in stroke care has been taking place.

SCM&HL: Is that what the “primary stroke center” concept is all about?

DR. DANDAPANI: That is precisely what I was getting to. When the “clot-buster” t-PA was originally approved for use in acute stroke patients, we were not organized into a coordinated unit focused on stroke care.  When I mean “we,” it includes the Emergency Medical Services (EMS), Emergency Department, ancillary departments like Radiology and Laboratory, physicians and nurses.  It took a monumental effort to make all these folks understand the concept of “Time is brain.”  Then came the challenge of getting evaluations and tests done in a timely manner, followed by focused engagement of physicians and nurses specially trained to be able to administer t-PA to eligible patients. Thus the concept of Stroke Center was born.  In a Stroke Center, all the “stars are aligned” so to speak to administer t-pa to patients in a rapid and timely fashion.

Stroke care does not end with t-PA. To be able to identify the cause of stroke, prevent and treat complications, initiate rehabilitation and promote risk factor education takes a multidisciplinary team effort.  Every member in this continuum of care has to do their part in a dedicated manner to give the patient the best outcome possible and highest probability of avoiding another stroke. This is what is done in a Stroke Center. The standards of care have now been defined by various groups and organizations and the Joint Commission for Accreditation of Hospitals is now certifying hospitals based on their ability to provide stroke care adhering to high performance standards.

SCM&HL: Are you saying that a hospital, which is a stroke center, can provide optimal stroke care for all stroke patients?

DR. DANDAPANI: Certainly not. Different strokes for different folks…a Primary Stroke Center can take care of patients with acute stroke, administer thrombolysis, provide initial care and rehabilitation for selected stroke patients. Although a good number of stroke patients fall within this category, some patients require a different and higher level of care.

SCM&HL: Interesting comment...“Different Strokes for different folks.” What exactly do you mean by that?  There are several types of strokes?

DR. DANDAPANI: Yes.  Primarily strokes are caused either by blocked blood supply called ischemic strokes and strokes that are caused by bleeding in the brain called hemorrhagic strokes.  Both types can present similar symptoms of weakness, numbness, speech problems etc.  Only ischemic strokes can be treated with t-PA, as we mentioned earlier.

Hemorrhagic strokes are caused by bleeding into the brain from burst aneurysms or uncontrolled high blood pressure.  Treatment of hemorrhagic stroke requires different specialists like neurosurgeons who perform surgeries to remove blood clots, and interventional neuroradiologists who are trained to place coils and stents in the brain blood vessels to stop focal bleeding.  Centers that provide these types of treatments are called Neurovascular Centers or Interventional Centers.

SCM&HL: Do we have any Neurovascular Centers in our county?

DR. DANDAPANI: We have several Primary Stroke Centers in Brevard County. In fact, every hospital is a certified Primary Stroke Center.  We currently do not have a Neurovascular center in Brevard.

SCM&HL: You talked earlier about prevention of stroke.  Looking at the disabilities and disruptions to life caused by stroke, one would think that if we have a choice, we ought to be able to prevent a stroke…don’t you think?

DR. DANDAPANI: Absolutely, without a doubt!  There are still a lot of medical professionals who use the term “CVA” or cerebrovascular accident.  Stroke is not an accident!  Stroke is preventable by controlling risk factors. In fact, studies indicate that 80 percent of  strokes are preventable. Although stroke treatment is improving by early intervention, PREVENTION IS STILL BETTER.  Prevention of stroke includes identifying and treating conditions such as diabetes, obesity, hypertension and high cholesterol, all of which contribute to increased risk for stroke.

All the risk factors for stroke are also risk factors for heart disease, still the #1 killer in the U.S.  Patients with stroke or TIA are at high risk of having a heart attack within a few years.  Therefore, by preventing and addressing risk factors for stroke, we are also addressing our heart health.

SCM&HL: Your dedication to systematic stroke management and commitment to your patients is obvious from the passion in your responses.   Please sum up your message for our readers.

DR. DANDAPANI: Stroke is a devastating disease. Stroke disables and destroys patients and their lives. Stroke prevention starts early. Early intervention in stroke centers with dedicated multidisciplinary teams results in markedly improved outcomes. If you are having symptoms of stroke, call 911.

CLICK HERE FOR RELATED STORY

John Stern

JOHN STERN was in his Satellite Beach, Florida home getting ready to go out. While brushing his teeth at about 10 a.m. that Monday morning, his left side began to go numb.

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INFECTIONS CAUSED by a bacteria called Methicillin-Resistant Stahylococcus Aureus (MRSA) have recently commanded considerable attention in the media, and you’ve more than likely heard the recent news that potentially deadly, drug-resistant staph infections are on the rise.  A study published in The Journal of the American Medical Association (JAMA) reported that MRSA infections, both in and out of hospitals, are more common than experts once thought.

JENNIE WILLIAMS, RN, received her Bachelors Degree in Nursing in 1974 from Roberts Wesleyan College in North Chili, NY; her Masters in Health Service Administration from St. Francis University in 2003; and obtained certification in Infection Control in 2005. She has spent the past 31 years at Wuesthoff, working in the ICU, Med/Surg, Hemodialysis, Recovery Room, education, and since 2003, as the Infection Prevention Control Coordinator. In February of this year she was elected to the Florida Professionals in Infection Control (FPIC) Board, a non-profit organization dedicated to promoting infection prevention and control through education, networking, and consultation.

More than 90,000 Americans get potentially deadly infections each year from this drug-resistant staph “superbug,” according to the Centers for Disease Control and Prevention (CDC) in Atlanta, which reported the findings in the Oct. 17 issue of JAMA.

Although MRSA is making headlines, it’s not a new infection.  The first case was reported in 1968. The difference now is that MRSA is affecting more people outside of hospitals. MRSA used to be seen only in those with weakened immune systems, such as chronically ill people who’d been hospitalized for a long time or had surgery, those receiving long courses of antibiotic therapy, or people living in long-term care facilities like nursing homes or prisons.

However, a growing number of otherwise healthy people who are not considered at risk for MRSA are getting the infection. Up to 15-20 percent of reported MRSA infections are now considered to be community-associated MRSA (CA-MRSA), which means that the infection occurred in people without documented health care risk factors.

Because CA-MRSA infections are occurring more frequently in school environments and child-care settings, our Q and A is focused on answering the burning questions that parents have related to minimizing the risk of MRSA and keeping their children safe.

Space Coast Medicine & Healthy Living welcomes Jennie Williams, RN, MHSA, Infection Control Coordinator at Wuesthoff Health Systems, to address the important aspects of CA-MRSA to help our readers understand how to manage an infection as well as prevent one.

SCM&HL: What is MRSA?
Ms. Williams: MRSA stands for Methicillin resistant Staphylococcus aureus. It means the germ Staphylococcus aureus has become resistant to the antibiotic methicillin and some, but not all, of the commonly used antibiotics.

SCM&HL: Where does MRSA live?
Ms. Williams: MRSA can be found anywhere on the human body, but typically is found living on the skin (including some wounds) or in the nose of approximately one- third of all healthy people. The majority of people who carry the staph are unaware of it, as it does not cause them any harm.

SCM&HL: What type of infections does MRSA cause?
Ms. Williams: Most CA-MRSA infections are skin infections that may appear as pustules or boils which often are red, swollen, painful, or have pus or other drainage. These skin infections commonly occur at sites of visible skin trauma, such as cuts and abrasions, and areas of the body covered by hair (e.g., back of neck, groin, buttock, armpit, beard area of men).

SCM&HL: How are these infections typically treated?
Ms. Williams: Almost all MRSA skin infections can be effectively treated by drainage of pus with or without antibiotics. More serious infections, such as pneumonia, bloodstream infections, or bone infections, are very rare in healthy people who get MRSA skin infections.

SCM&HL: How is MRSA transmitted?
Ms. Williams: MRSA is usually transmitted by direct skin-to-skin contact or contact with shared items or surfaces that have come into contact with someone else’s infection (e.g., towels, used bandages).

SCM&HL: In what settings do MRSA skin infections occur?
Ms. Williams: MRSA skin infections can occur anywhere, however some settings have factors that make it easier for MRSA to be transmitted. These factors, referred to as the 5 C’s, are as follows: Crowding, frequent skin-to-skin Contact, Compromised skin (i.e., cuts or abrasions), Contaminated items and surfaces, and lack of Cleanliness. Schools nationwide are reporting outbreaks of Staphylococcus aureus skin infections.  Most of these infections are being spread in school gyms and locker rooms as athletes with minor cuts and abrasions share equipment.  Other common locations include, dormitories, military barracks, correctional facilities, and daycare centers.

SCM&HL: What steps can be taken by families and schools to reduce the risk of CA-MRSA infection?
Ms. Williams: Encourage students to clean their hands frequently. Enforce hand hygiene with soap and water or alcohol-based hand sanitizers (if available) before eating and after using the bathroom.

• Parents, if your child is mature enough to use it properly, tuck a small container of hand sanitizer in your child’s book bag.
• Educators, install dispensers of hand sanitizer inside each classroom. Students should not have to get a hall pass and leave the classroom to clean their hands.
• Warn students not to share gym clothes, towels and other personal items. MRSA bacteria can live on fabrics and hard surfaces for up to 90 days.
• Shower immediately after participating in exercise. Warn students against sharing bars of soap. If possible, use only pump dispensers.
• Educators, ensure that all shared sports equipment (wrestling mats, baseball gloves, gymnastics equipment, etc.) and locker room facilities such as benches are cleaned with detergents, which must remain on the surfaces for at least three minutes. Quick spraying and wiping is not effective.
• Educators, make sure that when a student gets a cut or abrasion on the playground or in class, it is cleaned immediately by someone whose hands are also clean, and covered with a clean dry bandage until healed. Classrooms should have a first-aid kit or ready access to a school nurse.
• School authorities should consider antimicrobial coatings for sports equipment and other high-touch surfaces as well as washable keyboards for computers.
• School authorities should periodically have surfaces in the gym and classrooms tested in order to know the extent of MRSA contamination.
• Athletes, gym teachers and coaches should be given extra awareness tools to reduce their heightened risk of MSRA exposure.

SCM&HL: Should schools close because of a MRSA infection?
Ms. Williams: The decision to close a school for any communicable disease should be made by school officials in consultation with local and/or state public health officials. However, in most cases, it is not necessary to close schools because of a MRSA infection in a student. It is important to note that MRSA transmission can be prevented by simple measures such as hand hygiene and covering infections.

SCM&HL: Should the school be closed to be cleaned or disinfected when a MRSA infection occurs?
Ms. Williams: It is not necessary to close schools to “disinfect” them when MRSA infections occur. MRSA skin infections are transmitted primarily by skin-to-skin contact, and contact with surfaces that have come into contact with someone else’s infection.  When MRSA skin infections occur, cleaning and disinfection should be performed on surfaces that are likely to contact uncovered or poorly covered infections.  The afore mentioned practices and precautions, and cleaning surfaces with detergent-based cleaners or Environmental Protection Agency (EPA)-registered disinfectants should be adequate to minimize MRSA in the environment and protect the general student population.

SCM&HL: Should the entire school community be notified of every MRSA infection?
Ms. Williams: It is not necessary to inform the entire school community about a single MRSA infection. When a MRSA infection occurs within the school population, the school nurse and school physician should determine, based on their medical judgment, whether some or all students, parents and staff should be notified. The Brevard County Health Department does not recommend a letter be sent for each and every MRSA infection a school might have. In the case of an outbreak involving multiple children, consideration should be given to sending a letter to the families of the class.

SCM&HL: Should the school be notified by parents if their child has a MRSA infection?
Ms. Williams:  In this age of confidential health information, there is no hard and fast rule about disclosure of any medical condition.  However, it is best to consult with your school about its policy for notification of skin infections.

SCM&HL: Should students with MRSA skin infections be excluded from attending school?
Ms. Williams: According to the Brevard School Board’s policy, if a child has a lesion that has been established by a physician to be an infectious risk to others, he/she should not come to school.  However, unless directed by a physician, students with MRSA infections should not be excluded from attending school.  Exclusion from school and sports activities should be reserved for those with draining wounds that cannot be covered and contained with a clean, dry bandage and for those who, for whatever reason, cannot maintain good personal hygiene.

SCM&HL: What advise would you give to someone with a MRSA skin infection to prevent spreading it to others?
Ms. Williams: Like the afore mentioned suggestions for students in the school environment, the same general principles apply:

• Try your best to keep the wound covered at all times. Keep wounds that are draining or have pus covered with clean, dry bandages until healed.
• Follow your healthcare provider’s instructions in detail regarding your antibiotic dose and duration, and on proper care of the wound. Pus from infected wounds can contain staph, including MRSA, so keeping the infection covered will help prevent the spread to others.
• Bandages and tape can be discarded with the regular trash.
• Clean your hands frequently. You, your family, and others in close contact should wash their hands frequently with soap and water or use an alcohol-based hand sanitizer, especially after changing the bandage or touching the infected wound.
• Avoid sharing personal items, such as towels, washcloths, razors, clothing, or uniforms, that may have had contact with the infected wound or bandage.
• Diligent washing of soiled sheets, towels, and clothes with hot water and laundry detergent is imperative. Use a dryer on the hot setting to dry clothes completely.

SCM&HL: Any final pearls?
Ms. Williams: Be vigilant about washing your hands frequently and encourage those around you to do the same.

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IN THE UNITED STATES, an estimated 25.9 million men (23.9 percent) and 20.7 million women (18.1 percent) are smokers. Tobacco use is the leading preventable cause of death in the United States, causing more than 438,000 deaths each year, according to the U.S. Centers for Disease Control and Prevention (CDC).

• 60,372 die from cancer.
• 131,503 die from cardiovascular disease.
• 102,632 die from respiratory disease.

MR. JIM KENDIG is the Chairman of the Tobacco Free Hospitals Task Force; and Vice President of Safety, Security, Courier and Parking Services for Health First. He has worked on several successful hospital based integration projects including emergency codes, patient wrist bands, birth announcements and others. He holds a Bachelor’s and Master’s Degree from West Chester University, WestChester, PA and has been with Health First for 15 years.

If this isn’t enough, in 2004, the CDC issued an advisory warning people with a heart condition or those predisposed to heart disease to avoid all indoor environments where smoking is allowed. As little as 30 minutes of exposure to secondhand smoke can cause an immediate heart attack.  Smoking-attributable direct medical expenditures in the United States during 1998 were $75 billion.

Between 1997 and 2001 the average annual costs of smoking-attributable productivity losses in the United States were $92.5 billion. This does not include expenses due to cigarette-caused burns or secondhand smoke deaths.  Sixty-nine (69) percent of Americans report smoking is not allowed in work areas (indoor public/common areas, such as, lobbies, restrooms and lunch rooms) and 61 percent report smoking is not allowed in the home.

Since November 20, 2008 all of the Brevard healthcare systems have gone “tobacco free.”  Wuesthoff Health System’s Wuesthoff  Medical Center Rockledge and Wuesthoff  Medical Center Melbourne; Parrish Medical Center; and Health First’s Cape Canaveral Hospital, Holmes Regional Medical Center and Palm Bay Community Hospital, and their respective ancillary healthcare locations are included in this initiative which prohibits tobacco use both inside the buildings as well as on the outdoor grounds and parking areas.

The healthcare systems have partnered with the Brevard County Health Department and Prevent of Brevard as well as the American Cancer Society, the American Heart Association and the American Red Cross to take advantage of the tools that are in place to make this initiative a success.

Space Coast Medicine and Healthy Living is delighted to welcome Jim Kendig, Vice President of Safety, Security, Courier and Parking Services for Health First and Chairman of the Brevard Tobacco Free Hospitals Task Force to address questions about the “Smoke Out” as it relates to patients, visitors and healthcare employees.

SCM&HL: What does “tobacco-free” campus mean?

Mr. Kendig: Since November 20, 2008, smoking and the use of tobacco products (includes but is not limited to cigarettes, cigars, chewing tobacco, snuff and pipe smoking) have not permitted by anyone on the campuses of all three healthcare systems, any system-owned/leased properties, or in system-owned/leased vehicles.

SCM&HL: Why are the Brevard healthcare systems going tobacco-free?

Mr. Kendig: As the major providers of health care in the community, we are collectively committed to leading by example and creating a healthy environment for our patients, visitors, employees and volunteers who are on our campuses. This initiative sets a positive example in the community, reduces chronic exposure to second-hand smoke‚ reduces odors from smoking in its environments and supports those who are trying to quit.

Studies have shown that it is more likely that a person will have a successful quit attempt if their employer enacts a tobacco-free policy. A tobacco-free workplace is consistent with the mission of all healthcare institutions, in that it works to improve the overall health of the community that it serves. It is especially important for hospitals to promote tobacco-free campuses, since tobacco is the leading cause of preventable death in the United States.  For example, patients who smoke regularly before surgery have twice the risk of wound infection, smoking retards wound healing, a smoker’s bones take nearly twice as long to heal as a non-smoker’s, secondhand smoke contains over 4,000 chemicals of which 50 are known carcinogens, among other reasons.

SCM&HL: Are other hospitals moving to a strict tobacco-free environment?

Mr. Kendig: Yes. We are not alone nor breaking new ground. There is a growing trend among hospitals nationwide to become completely tobacco-free and eliminate designated smoking areas.  Approximately 1,100 hospitals and health systems have already moved forward with a tobacco free program and, in fact, Orlando based hospitals will be tobacco free in July 2008. The Brevard Tobacco Free Hospitals Task Force, in an attempt to demonstrate tobacco-free as the healthy model for all aspects of our community, has also engaged other county organizations, including local colleges, to seriously consider the benefits and rationale of going tobacco-free.

SCM&HL: To whom does the policy apply?

Mr. Kendig: All persons, including employees, volunteers, students, patients, visitors, vendors, contractors and others who work in or visit hospital/healthcare service buildings, parking lots and grounds.

SCM&HL: Where on the campus does the tobacco-free policy apply? Is smoking allowed inside cars?

Mr. Kendig: Tobacco use is prohibited on all areas of the campuses, inside and outside, including inside cars that are parked on hospital property.

SCM&HL: Isn’t smoking a personal legal right?

Mr. Kendig: We are not asking employees, visitors and patients to quit using tobacco products but to refrain from using tobacco products while visiting or working within our healthcare facilities.  While we recognize that individuals have choices‚ we want to encourage the best choices for a healthy life, and send as strong a message as possible to our patients‚ employees and the community that smoking and using tobacco is inconsistent with good health.

SCM&HL: How will visitors and patients be notified?

Mr. Kendig: The “Smoke Out” policy change has already been publicized in local media, and the healthcare systems have developed several teams to address each topical area such as  clinical needs for patients, support for our employees, and addressing visitor and customer compliance over the next seven months before implementation. Extensive signage is in place by, and various other methods of communication will be used to ensure that visitors and patients are aware of the policy.

SCM&HL: Why can’t we have smoking huts that are designated outdoor locations?

Mr. Kendig: Smoking and secondhand smoke are known health hazards.  As health care systems, we are committed not just to healing illness, but also to promoting wellness.  Allowing smoking on our campuses, even in designated areas, is not consistent with this commitment.  We do not want our patients, visitors and employees to be exposed to secondhand smoke while on our campuses.

SCM&HL: What kind of support is being offered to employees and visitors?

Mr. Kendig: To support hospital based employees and visitors, hospital gift shops will sell over the counter smoking cessation aids. As part of this policy change, Brevard based health systems will be providing information on tobacco cessation and treatment programs to their staff, patients and the general community.

SCM&HL: We are encouraged by the collaborative effort on this initiative by Brevard’s three healthcare systems.  Any last comments?

Mr. Kendig: We realize that the scope and magnitude of this project is significant.  It is clear that our success is dependent on all three healthcare systems’ belief in a tobacco-free work environment, especially in the healthcare setting and as an integral element of our collective missions to the community, as the right thing to do.

For information concerning smoking cessation programs please call the Florida Quitline at 1-877-U-CAN-NOW (1-877-822-6669).

Related posts:

1. Brevard Healthcare Systems Ban Smoking On Campuses
2. Brevard Healthcare Forum, FIT Hosts Healthcare Summit
3. Brevard Tobacco Initiative Promotes Cessation with ‘5 As’

If you’ve ever been on a diet you know the challenges in controlling your weight. Government research indicates that about two-thirds of adults in the United States are overweight, with half of those people considered obese. Obesity translates into unhealthy side effects, including diabetes, heart disease and a 10 to 50 percent higher risk of death from all causes compared with healthy weight individuals. As the obesity problem has grown in the U.S., so has the number of people turning to weight loss or bariatric surgery, with two popular choices being Gastric Bypass and the Lap-Band® procedure.

Dr. Fusco is a graduate of The Johns Hopkins University and New York Medical College and received residency training in general surgery from Keesler Air Force Base Medical Center. After fellowship training in critical care from Vanderbilt University, Dr. Fusco began a practice in general surgery with an emphasis in laparoscopic surgery in 1994.

Gastric Bypass has been around the longest and is the best known. During this in-patient operation, surgeons make the stomach smaller, which results in an early feeling of fullness and allows food to bypass part of the small intestine so fewer calories are absorbed. Patients leave the hospital within two to four days and the weight loss can be dramatic within the first year. It’s a very difficult operation to reverse.

In 2001, the FDA approved the Lap-Band as a reversible, surgical weight loss option that’s primarily done on an outpatient basis. Using minimally invasive laparoscopic surgery through tiny incisions, the surgeon places a band around the stomach that’s then tightened to make the stomach smaller. Tiny meals then “hang up” in the smaller stomach pouch long enough for the person to feel full before food passes normally through the intact digestive system. Weight loss results are similar to gastric bypass, but may be slower, with the optimum weight reached in the second year following the procedure.

Because the Lap-Band is relatively new on the scene, SCM&HL talked with Melbourne surgeon Mark Fusco, MD about what’s become one of the fastest growing weight loss surgeries. He’s a board-certified general surgeon with Melbourne Internal Medical Associates (MIMA) who specializes in laparoscopic surgical techniques. In 2003, he began performing Lap-Band procedures as the medical director of the Lifeshape Advanced Bariatrics Center of Florida, a cooperative venture with Melbourne Same-Day Surgery Center. Since then Dr. Fusco has performed close to 400 Lap-Band cases and works with the product’s manufacturer, Allergan, to train other surgeons in the Lap-Band operation.

SCM&HL: When would someone be a candidate for weight loss surgery?
Dr. Fusco: This is for people who have serious medical weight issues — not for cosmetic weight problems. Surgery is an option for people who have a Body Mass Index over 35 and associated medical problems or over 40 without medical problems. (BMI is a standard index of weight adjusted for an individual’s height.) That roughly correlates to someone who, depending on height, is 60 to 100 pounds overweight. You have five times the risk of heart disease and diabetes if you’re obese at age 50. Since we’re doing this for health, what we’re trying to achieve is enough weight loss so we get health benefits. My patients have all tried a tremendous number of things to get their weight under control without success, and a lot of times there’s an event that may finally spark them into action, such as a new diagnosis of diabetes.

SCM&HL: Why do the majority of your patients choose the Lap-Band over other options?
Dr. Fusco: My patients gravitate toward the Lap-Band because of the increased safety involved. It’s done on an outpatient basis so they can go home and return to work quicker. It’s a tool to help with hunger control. The thing that distinguishes Lapband over the gastric bypass is that the intestines are not divided or re-routed, which decreases the risk of there being leaks or nutritional malabsorption issues. The long-term benefit of Lap-Band over traditional bypass is the band is adjustable so it’s just tight enough that people have some hang up of food in their pouch to help the hunger control, but not so tight that they can’t eat good solid, healthy food. That adjustability is really a key element because it gives you the ability to customize it for every patient and change it as needed. If the patients have any significant issues that require them to have a little better nutrition, for example if they get pregnant, or have to have another kind of surgery, or if they get cancer and need to have chemotherapy — the fact that the band is adjustable gives us the ability to deflate it and allow them to take in more nutrition if they should need it, which is a very nice safety valve.

SCM&HL: How do you adjust it after surgery?
Dr. Fusco: It’s strictly an office procedure. The band includes a saline-filled balloon that adjusts how tight it is. We sew an access port to the very bottom part of the belly and it’s under the skin, so all you see is a little bump. We put in or remove saline fluid using a very fine needle with no need for anesthesia. The first few weeks after surgery they’re on a healing diet and at week three they have a follow up appointment to advance their diet to a more normalized diet. Then at week six we start the process of adjusting the band to get the right tightness. We have an open door policy about making adjustments.

SCM&HL: Explain a little more about the post surgical diet and the weight loss people can expect.
Dr. Fusco: Patients will eat two to four, four-ounce meals a day, which is roughly the same size meals as what someone can eat after gastric bypass. If the band is properly adjusted then that amount of food makes them feel satisfied. If the band is too loose, that four ounces drops out of the pouch too quickly and they have increased hunger. In addition to a properly adjusted band, what foods you eat also play a role. You can imagine that if you drink four ounces of soup that leaves the pouch almost immediately, you don’t get as good of hunger control as if you had three ounces of chicken and one ounce of broccoli.

Because health risks start to go up with a BMI above 27 or 28, we set out as a goal to get a patient’s BMI below 30. A good percentage of excess weight loss is considered to be 50 percent.  It has been my experience that the average percent excess weight loss after three years is 53 percent, which has proved to be very satisfactory. If someone’s initial BMI is 50 they have a five times normal risk of premature death. So even if you get the BMI down to 40, which some might say is not a great weight loss, you’ve gotten down to two and a half times the risk of premature death using outpatient surgery that had minimal risk.

SCM&HL: This involves a major lifestyle change so how do you support Lap-Band candidates before and after surgery?
Dr. Fusco: When they contact our office, they’ll be sent an introductory packet and asked to attend a two to three hour patient information seminar where we talk about obesity and the different treatment options. We usually have from two to four of our past patients talk about why they had surgery, what it was like, how their life has changed afterwards and then we answer questions they may have and discuss insurance issues. Those people who want to go forward are required to have a detailed consultation with our dietitian, an evaluation with our psychologist or, if they’re already working with a mental health professional, an evaluation with their own, plus a pre-operative evaluation with their primary care doctor. They meet with our after-care coordinator who is in control of all the support care issues afterwards. They get a pre-operative anthesthesia evaluation and only after all that is done do they come see me. We want to be sure they’re prepared to make every aspect of the changes they need to make. Exercise is very important for maintenance of weight loss, so we emphasize that in our pre and post-operative teaching.

Post surgery, once we’re into the band adjustment process, we have the patient come for a three-month follow up dietitian appointment, we ask them to come in for monthly weight checks and see me yearly after surgery. We have monthly, in-person support groups. Last July, after discovering the majority of our patients use the Internet, we also started something we call the Weight Goal Portal. It’s their Internet home page which interfaces with our weight loss database so it tells them what their last weight was, how much they’ve lost, when they’re due for their next weigh in, or it will flash that they’re overdue.

SCM&HL: What about the costs? Are insurance companies covering weight loss surgery?
Dr. Fusco: There was a backlash in the beginning primarily due to the complications and costs some people experienced from gastric bypass surgery. There’s powerful medical data that shows the benefits. When we started, insurance coverage was minimal, but now little by little, more and more insurance companies are seeing the benefits and seeing better outcomes and with the Lap-Band there are fewer complications so fewer insurance companies are excluding coverage for bariatric surgery. Medicare now approves the Lap-Band and weight loss surgery in general when it’s medically indicated.

Since many patients still may be self-funded we’ve developed a package price for the Lap-Band of $16,750, which includes all routine follow up care for the first year. (Editor’s note: That compares to a $26,000 average cost for Gastric Bypass which requires a two to four-day hospital stay.)

SCM&HL: What about the risks?
Dr. Fusco: There are the traditional risks of any surgery, including the risk of bleeding, infection and blood clots. Then risks for the band itself are that it could slip out of place and not work properly so we’d have to do another surgery. That happens about four percent of the time. The little access port that goes underneath the skin could have problems and if that happens that would take another small operation to change out the port.

The 30-day mortality rate for having Lap-Band surgery, in other words the risk of being dead from any cause in the first 30 days after surgery, is about 1 in 2000 people, which is about one-tenth of the most commonly quoted number for gastric bypass. So it’s about 10 times safer than gastric bypass. But I always stress in the pre-surgical seminar that we have to take even the small risk seriously when making the decision. If you look at people’s chance of being around five years after the surgery, they had an 89 percent reduction in mortality compared to people the same weight and age who did not have weight loss surgery. The most dangerous thing someone could do is stay morbidly obese.

FOR MORE INFORMATION on the Lap-Band and LifeShape Advanced Bariatrics Center of Florida call 321.728.7553 or visit www.LifeShape.net

Related posts:

1. LIFESHAPE Receives LAP-BAND Accreditation
2. Lapband Procedure Changes Steenhoff’s Life
3. Lap Band Procedure is Life Saving for Blair, Morgan