New Specialties and Subspecialties There Is No “Refresh” Button in Life

A QUARTERLY PUBLICATION OF THE POTTER-RANDALL COUNTY MEDICAL SOCIETY Winter 2019 | VOL 30 | NO. 1

New Specialties and Subspecialties There is no “refresh” button in life.

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* Effective 8/1/2019, TMA Insurance Trust is able to provide participants with a premium credit of 25% that will be applied to their billing invoices, effectively decreasing the amount of their premium payments by 25%. This complimentary premium credit is provided at the sole discretion of TMA Insurance Trust, is not guaranteed for future years, and will be subject to periodic review and evaluation. TMA Member Long Term Disability Plan and TMA Member Business Overhead Expense Plan is issued by The Prudential Insurance Company of America, Newark, NJ. The Booklet-certificate contains all details, including any policy exclusions, limitations and restrictions, which may apply. Contract Series 83500. 1023626-00001-00

4 PANHANDLE HEALTH WINTER 2019 WINTER 2019 | VOL 30 | NO. 1 CONTENTS New Specialties and Subspecialties

6 Editor’s Message: New Specialties and Subspecialties 27 Spotlight: Pediatric Emergency Medicine (PEM) by Steve Urban, MD by Schyler Z. Grodman, MD

7 Alliance News 29 Clinical Cardiac Electrophysiology by Ashley Troutman, President by Ismaile S. H. Abdalla, MD, PhD, FACC, FHRS

8 Executive Director’s Message 31 Hospice and Palliative Care Training by Cindy Barnard by Susan Meikle, MD 9 Robotic Surgery 33 The Evolution of HIV Care by LaJohn B. Quigley, MD by Scott Milton, MD 12 Obesity in the Panhandle of Texas by Bleu Schniederjan, MD, FACS, FASMBS; 35 Case Report: Incidental Right-Sided Aortic Arch with Bo Neichoy, MD, FACS; Daren Peterson, MD, FACS Aberrant Left Subclavian Artery 15 The Current State of Geriatric Psychiatry in the U.S. David P. Foley, MBA; Alyssa R. Byrd, BS; by Luke Bacon MBA, MS4, Allison S. Gracey, BS; Chandralekha Ashengari, MD Ravindra M. Bharadwaj (Dr. Ravi) MD, MPH 36 Patient Information: 18 Geriatric Oncology Nonalcoholic Fatty Liver Disease – NAFLD by Helayna Abraham, MS4, Tarek Naguib, MD, MBA, FACP Ravindra M. Bharadwaj (Dr. Ravi) MD, MPH 37 Health News 21 Female Pelvic Medicine and Reconstructive Surgery by Tarek Naguib, MD, MBA, FACP by Paul Tullar, MD 38 Spotlight on New Members 23 Space Medicine: A New Specialty for a New Age by Rouzbeh K. Kordestani, MD, MPH

POTTER-RANDALL COUNTY PANHANDLE HEALTH MEDICAL SOCIETY EDITORIAL BOARD Executive Committee Walter Bridges, MD, Editor Daniel Hendrick, MD, President Neil Veggeberg, MD, President-Elect Tarek Naguib, MD | Rouzbeh Kordestani, MD Gerad Troutman, MD, Secretary/Treasurer TMA Delegates: Paul Tullar, MD | Tracy Crnic, MD Ryan Rush, MD • Rodney B. Young, MD Scott Milton, MD | Ravi Bharadwaj, MD Gerad Troutman, MD • Evelyn Sbar, MD Robert Gerald, MD • Daniel Hendrick, MD Copy Editor: Steve Urban, MD

On The Cover: Winter Cardinal by Marsha Clements PANHANDLE HEALTH is published quarterly by the Potter-Randall County Medical Society, (806) 355-6854. Subscription price is $12.00 per year. POSTMAN: Send address changes to PANHANDLE HEALTH, 1721 Hagy, Amarillo, Texas 79106. ISSN 2162-7142 Views expressed in this publication are those of the author and do not necessarily reﬂect opinions of the Potter-Randall County Medical Society. Reproduction of any contents without prior written approval of the publisher is strictly prohibited. Publication of advertisement in PANHANDLE HEALTH does not constitute endorsement or approval by the Potter-Randall County Medical Society or its members. PANHANDLE HEALTH reserves the right to reject any advertisement. PHOTOCOMPOSITION AND PRINTING BY CENVEO. WINTER 2019 PANHANDLE HEALTH 5 Editor’s Message: New Specialties and Subspecialties

by Steve Urban, MD

his issue of Panhandle Health Some more recently approved spe- specialty. We have produced 23,000 psy- Taddresses new specialties and sub- cialties include interventional radiology chiatrists and neurologists (they share a specialties in the medical field. Some have (2017) and laboratory genetics and genom- certifying board) and 11,000 surgeons. been around for a while but have not per- ics (2019). Among the subspecialties, sev- The smallest number of specialists (I’m not meated the Panhandle area (e.g. pediat- eral have been approved by the ABMS counting subspecialists here) include tho- ric emergency medicine, approved as a quite recently; for instance, sports medi- racic surgeons (984), colorectal surgeons subspecialty in 1991). Others have been cine was approved in 2003, sleep medicine (860) and, glowing off there in the distance, around a bit longer (e.g. hospice and pal- in 2006, and pain medicine in 2014. The nuclear medicine practitioners (621). liative care, since 2006), while female pel- newest subspecialties include addiction vic medicine and reconstructive surgery medicine (2015), micrographic dermato- I must admit to having some res- was approved only in 2011. Some topics, logical surgery (also 2015) and neurocriti- ervations about this process of grind- such as bariatric surgery, are interesting cal care (2018). In 2017, the ABMS created ing medical practice into finer and finer niche areas where training requirements a new category termed Focused Practice pieces. Statistics demonstrate that medi- and full certification exams have yet to be Designation, which recognizes doctors who cal systems based around the primary established. have built a niche of expertise for them- care physician—ideally, one who carefully selves through practice and continuing edu- assesses the patient and refers only when The American Board of Medical cation. One example Is hospital medicine, necessary--produces slightly superior Specialties was established in 1933 (the designed for the many hospitalists who did outcomes at significantly reduced cost. I name was a little different then) to cre- general internal medicine or family medi- regret the increasing rarity of the primary ate standards for certain specialized cine residency (i.e., no additional training doc who embraces the role as captain of disciplines (dermatology, ob/gyn, ENT, in hospital medicine) but who demonstrate the ship and refers for specialized proce- and ophthalmology). These areas were expertise as a hospitalist through and hours dures or the occasional perplexing case. felt to require specialized skills or exper- of CME credits and years of inpatient Few PCPs now contribute to the care of tise in limited areas that the general- practice. Another interesting new area of their patients during hospitalization; the ist physician might not master. Within Focused Practice is advanced emergency modern PCP has become a traffic cop for a few years, specialization in areas such medicine ultrasonography. referrals. Unless we see a dramatic change as general surgery, internal medicine, in the way the American medical system pediatrics were included. Now, each spe- Almost half a million practitioners is structured and remunerated, however, cialty or subspecialty establishes its own are now board certified. The largest num- the unending subspecialization of medi- standards, usually involving require- ber are internists (including the medicine is here to stay. With robust certifica- ments for residency or fellowship train- cal subspecialties) at around 240,000. tion, we can at least have some assurance ing, certifying exam, and maintenance of Pediatricians are next at 105,000, with that our minutely pulverized medical certification. Although board certifica- family medicine practitioners at 91,000. delivery system is peopled with rigorously tion is optional and is not required for Perhaps not surprisingly, the most exclu- trained and well recertified specialists and licensure to practice medicine in most sive club is colorectal surgery, with only subspecialists. states or in some hospitals, certification 2,400 certified practitioners. Over the past does indicate that the practitioner has, 10 years, the ABMS has certified more at the very least, completed the specified internists (75,000), family doctors (33,000) requirements. and pediatricians (31,000) than any other Our Next Issue Of Panhandle Health POTTER RANDALL COUNTY MEDICAL SOCIETY (PRCMS) OFFERS HELP TO TROUBLED PHYSICIANS Features: If you, or a physician you know, are struggling with addiction, depression or burnout and are unsure what to do or whom to contact, the Potter-Randall County Medical Highlights of Society is here to help. We offer face-to-face confidential sessions with the PRCMS Physician Health and Wellness Committee, made up of your physician peers who know and understand recovery. Please don’t struggle alone when help is a phone call or the last five an email away. Whether you are calling for yourself, your practice partner, or as a family member of a physician, contact Cindy Barnard, PRCMS Executive Director, at years 806-355-6854 or [email protected]. Membership in PRCMS is not required.

6 PANHANDLE HEALTH WINTER 2019 Potter-Randall Alliance NEWS by Ashley Troutman, President

November 2019 Michelle Agostini and Christine Cox please send me an email at potterrandal- In September, the Potter-Randall for helping plan the Fall Couples & [email protected]. We have opportuni- County Medical Alliance, Society and Ladies Social in September and October. ties to suit many types of personalities… Circle of Friends hosted the Fall Couples Weather has not been on our side this family events, socials, community out- Social at the beautiful home of Dr. and year, with rain and snow, but these ladies reach and advocacy. Mrs. Assadour Assadourian. It was great put together lots of hard work to make Sincerely, getting to know new faces and catching sure our events ran smoothly. A huge Ashley Troutman-PRCMA President up with old friends. We hope you enjoyed thank you to Dr. and Mrs. Assadourian www.potterrandallalliance.com the evening and will attend another one for hosting the Fall Couples Social. The of our events in 2020. food and drink were delicious and without your generosity we would not have It’s time to renew membership for had the opportunity to have fellowship 2019 PRCMA Board 2020! There are three options for paying with friends and colleagues. dues: President: 1. Go online to www.texmedalliance. Ashley Troutman VOLUNTEER OPPORTUNITIES org (look for blue button in the The Alliance needs your help to make upper-right corner of website; President-Elect: a difference in our local community for click on “Renew” if you’re a 2020! We are currently seeking volunteers Sofia Balderamos current member and want to to provide meals to the Ronald McDonald renew your membership) House in 2020. This is a great way to give Treasurer: families peace of mind and allow them to Lara Assadourian 2. Call TMA Knowledge Center at unwind without the stress of cooking or (800) 880-7955 with credit card expense of going out while their child is Secretary: information hospitalized here in Amarillo. We need Elisa Hemmerich only 11 volunteers for 2020 who are will- 3. Mail an application or mailed ing to commit to sending a restaurant invoice with payment to the Publicity: catered meal for typically 10-15 people address indicated on the form. Mackenzie Sigler on the 2nd Tuesday of the month. This can If you are not already a member, be as simple as pizza delivery or a fam- please consider joining. Membership: ily meal pack from United. If interested, Olga Tolscik please send an email to potterrandal- The Alliance is a great organization for [email protected]. developing lifelong friendships, building Past President: a network of colleagues, and finding a Kristen Atkins support system that understands the In addition, if you are interested in unique challenges of life in a medical helping plan and execute events in 2020, family. If you are a physician, the spouse of a physician, resident physician or medical student, you can also join this dynamic organization that advocates on behalf of medicine.

Please check Facebook and email for a list of upcoming events. www.potterrandallalliance.com

SHOUTOUTS Thank you Elisa Hemmerich and Mackenzie Sigler for providing meals to the Ronald McDonald House in September and October. Thank you WINTER 2019 PANHANDLE HEALTH 7 Executive Director’s Message by Cindy Barnard, Executive Director

It may be news to many of us, but Executive Committee 2019: Board of Censors: there exist many medical subspecialties President Elect: Neil Veggeberg, M.D. Evelyn Sbar, M.D. unfamiliar to you and me! From Allergy Tarek Naguib, M.D. (A) and Anesthesiology (AN) to Urology Secretary/Treasurer: William Holland, M.D. (U), i.e. from A to U (if a Z specialty or Gerad Troutman, M.D. Gerad Troutman, M.D. subspecialty exists, I don’t know of it!), Neil Veggeberg, M.D. a physician’s choices are anything but TMA Delegates: Lisa Veggeberg, M.D. limited when it comes to medical spe- Rodney B. Young, M.D. cialties and subspecialties. It is fairly Daniel Hendrick, M.D. Alliance President: obvious that a subspecialty is a narrow Rouzbeh Kordestani, M.D. Ashley Troutman field within a specialty such as Pediatric Robert Gerald, M.D. Ophthalmology (PO), a subspecialty Gerad Troutman, M.D. Committee Chairmen: within the specialty of Ophthalmology Ryan Rush, M.D. Mitch Jones, M.D. and Richard McKay, (OPH). These advanced fields of medi- M.D. – Retired Physicians cal expertise require 1-2 years of post- TMA Alternate Delegates: Tarek Naguib, M.D. Nathan Goldstein, M.D. – Mediations residency training or a fellowship “in Neil Veggeberg, M.D. a recognized program” and often end Walter Bridges, M.D. – Panhandle William Holland, M.D. Health Editor with an exam and further certification. Evelyn Sbar, M.D. Some of the more common subspe- Michael Paston, M.D. Robin Martinez, M.D. – Physician cialties exist within Cardiology (CD), Health & Wellness Internal Medicine (IM), and Emergency Medicine (EM). Another thank you goes to the 2019 ued financial support and generosity. Panhandle Health Editorial Board, led by Their commitment is absolutely essen- The need for subspecialties has Dr. Walter Bridges, Editor, and Dr. Scott tial to the success of all our events. They increased as medical research and tech- Milton, Associate Editor. Other Editorial are Amarillo National Bank, Baptist nology have become infinitely more Board members are Tracy Crnic, M.D., Community Services, Neely, Craig & complicated. For example, the American Tarek Naguib, M.D., Steve Urban, M.D., Walton Insurance Agency, Texas Medical Academy of Orthopedic Surgeons Rouzbeh Kordestani, M.D., Paul Tullar, Association Insurance Trust, Texas (ORS) states that approximately 2500 M.D. and Ravi Bharadwaj, M.D. Medical Liability Trust, Happy State Orthopedic Surgeons (ORS) are Board Bank, Cenveo Amarillo, Daryl Curtis, Certified in Orthopedic Sports Medicine A final thank you goes to our 2019 CLU, CHFC, and Physicians Financial (OSM), and another 2000 are Board “Circle of Friends” for their contin- Partners. Certified in Hand Surgery (HS). These diverse subspecialties indicate a physician with a unique body of education and In Memoriam knowledge in his or her field who is able to care for a patient with a unique illness. We highlight some of these subspecialties Hollis Hands, M.D. in this Winter issue of Panhandle Health. Obstetrician and Gynecologist,

As the year ends, I want to thank the died on January 22, 2019 2019 Board of Directors for their service at the age of 90. and dedication to our Society. Under the He was a member of the leadership of our President, Dr. Daniel Potter-Randall County Hendrick, 2019 has been an exceptional Medical Society for 58 years. year. The following physicians deserve a big thank you for their support as well: 8 PANHANDLE HEALTH WINTER 2019 Robotic Surgery by LaJohn B. Quigley, MD, FACS

Surgery is a fundamental tool of ther- ment surgeries (1,2). These early robots Concepts in immersive telerobotic apy in our healthcare system. Robotic contributed to the development of more surgery began their development with surgery now plays an integral role in the advanced and current robotic systems. the military. Scientists envisioned the improvement of surgical care. Advances application of telecommunication and in technology have led to better patient “AESOP, look up.” “AESOP, zoom robotic technology to allow a surgeon outcomes and shorter stays in the hospi- in.” As I looked around the room I could to operate on a wounded soldier from a tal. Surgical robots have been developed to see no one responding, but the cam- workstation at a remote location. Newly facilitate minimally invasive surgical tech- era did exactly what the attending said. developed technology was taken from the niques and to assist surgeons performing As I scrubbed in with a new attending, I battlefield and incorporated into the field advanced surgical procedures which oth- noticed a small machine attached to the of medicine. erwise would not be possible with tradi- operating table. I had never seen this tional open or laparoscopic techniques. device before, and it was very impressive. Developed by Akhil Madhani, “Black Approved in 1994, AESOP (Automatic Falcon” was the first teleoperated surgical History of robotic surgery Endoscopic System for Optimal instrument for minimally invasive sur- Robotic surgery is one of the most Positioning) was the first robot approved gery. The robot was able to be manipu- advanced forms of Minimally Invasive by the FDA for surgical procedures of lated from a remote location using a hand Surgery. Application of robotic technol- the abdomen. Controlled by voice com- piece. The success of AESOP as an assis- ogy to surgical robotics started approxi- mands, the device can be connected to tive device, combined with the potential mately 20 years ago. A robot is defined the operating room table and holds the clinical applications of the “Black Falcon”, as a mechanical device that can be pro- laparoscopic camera. AESOP is capable of resulted in commercial interest in robotic grammed to carry out instructions and doing exactly what is commanded, with surgical applications. In 1995, Intuitive perform complicated tasks usually done steadiness and precision. The ability of Surgical Inc. bought the patent for “Black by people. The first robot to imitate the surgeon to control the camera was a Falcon” which led to the development of human movements of the jaw, arms, and major technological advancement, allow- da Vinci Robotic Surgical System (Figure neck was designed by Leonardo da Vinci ing the surgical assistant to be replaced by 1). First used in 1997 to perform lapa- in 1495 and named the Metal-Plated a robot. Later generations have 7 degrees roscopic cholecystectomy in Brussels, Warrior. This served as inspiration to forward motion to mimic the human Gianello Torianno, who created a robotic hand. | continued on page 10 mandolin-playing lady in 1540. Invented by Jacquet-Droz in 1772, “The Writer” was a programmable wheel designed to write whatever the user desired, replicat- ing tasks previously only performed by humans (1).

Surgical robots can be either passive or active. Autonomous (passive) robots, such as Probot©, perform a sequence of movements which are typically pre- programmed. Active robots involve a surgeon directly moving the surgical instruments intraoperatively. The surgeon feels as though he or she is within the operative field. Puma 560© was a robot used to perform neurosurgical biopsies in 1985. In 1988, a transurethral resection of the prostate was performed using the same technology. ROBODOC© was designed to machine the femur with greater precision in hip replace- Figure 1 WINTER 2019 PANHANDLE HEALTH 9 Belgium, the da Vinci Surgical System is a however, does have limitations. Poor bulkiness of the device, risk of mechanical robotically controlled endoscopic instru- ergonomics can lead to surgeon fatigue or failure, lack of haptics (tactile feedback), ment controlled by a surgeon at a remote joint strain. Additional surgical training increased cost and operating room time location. The operating surgeon controls is required for more advanced techniques can all limit the implementation robotic 2 or 3 arms to manipulate the instru- such as laparoscopic suturing, knot surgery. Operative time is typically lon- ment and an additional arm to control tying, complex dissection, and stapling. ger, particularly when the surgeon is in the video endoscope. An infrared sensor Robotic assisted laparoscopy allows a sur- the early stages of training. detects the surgeon’s head position to geon to perform more complex maneu- trigger the activation of the robotic arms. vers and has features to help overcome The lack of haptics (tactile feedback) is The system has been approved by the US poor ergonomics and surgeon fatigue. one of the more challenging adjustments Food and Drug Administration for uro- Conventional laparoscopy provides two- with robotic surgery. As the surgeon, you logic, general laparoscopic, gynecologic, dimensional imaging of the operative cannot feel resistance of the tissues. One and general non-cardiovascular thoracic field, whereas the robotic system affords must use experience from previous sur- surgical procedures in adults and children a three-dimensional view of the surgical gical laparoscopic cases and visual cues since 2000. field. With telerobotic systems, surgeon to accommodate. Ensuring that knots fatigue is minimized by use of a console are tied down adequately and avoiding My first encounter with the da Vinci which allows the surgeon to sit com- excessive tension on tissue can be quite Surgical System occurred in 2013 dur- fortably. If the patient is obese, there is challenging and require many hours of ing my fellowship in Minimally Invasive more torque placed on the instruments experience with the robotic platform. and Bariatric Surgery. Minimally Invasive which may lead to fracture of smaller Training and Education and Bariatric Surgery fellowship is an caliber instruments such as the laparo- Surgical training has remained more intensive one-year fellowship focused scopes. “Endowrist” technology with the or less unchanged for several decades. on less invasive approaches for surgi- da Vinci system allows wrist-like move- Surgeons in training gain operative expe- cal procedures. Approximately 60% of ments to facilitate suturing and complex rience through supervised training on the year is spent on training for bariat- maneuvers (Figure 2). Conventional rigid real patients. Training and credentialing ric procedures, and the remainder of the laparoscopic instruments only allow four standards have not yet been established time focuses on minimally invasive tech- degrees of freedom. Robotic systems pro- for robotic surgeons. Training programs niques (laparoscopic and endoscopic) for vide seven degrees of motion and allow are becoming more readily available general surgery cases. Fellowship is not the ratio of motion of the surgeon’s hand through many surgical residency and fel- required to perform laparoscopic and to that of the robotic arms (motion scal- lowship programs, although proficiency endoscopic procedures, but the fellow- ing), as well as the speed at which the with robotic systems is neither standard- ship allows a newly trained surgeon to instruments move, to be modified. become even more facile with minimally ized nor required. With the help of da invasive techniques. Laparoscopic surgery Vinci Surgical Systems, a surgeon can can be very difficult technically. In order obtain the education and skills neces- to perform certain surgical maneuvers, I sary to implement robotic surgery into noticed myself standing on one foot and his or her practice. Several online mod- performing balancing acts as if I were a ules are required to obtain a certificate of ballerina. Operating on obese patients training. Prior to live cases, the surgeon can be even more difficult due to body has the opportunity to implement early habitus and inability to reach the opposite training with a pig lab. Typically, a new side of the abdomen. Although fellow- robotic surgeon is mentored during his ship significantly improved my technical or her initial cases. The number of men- laparoscopic skills, I often found myself tored procedures varies from institution physically and mentally exhausted at the to institution. The surgical learning curve end of the day. In an observational study, depends on the total number of proce- 8 to 12% of surgeons reported pain and dures performed and the time interval numbness in their wrist, arms, or shoul- between procedures. Experts agree that ders after performing conventional lapa- a surgeon should be competent in per- roscopic gastrointestinal surgery (3). forming a procedure via laparotomy prior to advancing to the robotic approach. Advantages of robotic surgery During my fellowship training, my expe- Laparoscopy has several established rience with the robotic platform began advantages over conventional open sur- Figure 2 with hiatal hernia repair via Nissen fun- gery including shorter length of stay, doplication for management of chronic more rapid recovery, decreased mor- Although robotic surgical systems GERD, a challenging and at times techni- bidity, and improved aesthetics of the have many advantages over conventional cally difficult procedure to perform lapa- incisions. Conventional laparoscopy, laparoscopy, they do have limitations. The roscopically. With full range of motion

10 PANHANDLE HEALTH WINTER 2019 of my wrist and the surgical instruments paring outcomes and complication rates shorter recovery times. Since the initial provided by the robotic system, however, for robotic versus laparoscopic Roux- phase of robotic procedures in gynecol- I was able to perform all tasks necessary en-Y gastric bypass, robotic Roux-en-Y ogy and urology, the robotic platform has with efficiency. Immediately, I could see gastric bypass resulted in similar compli- been expanded to include colorectal, head the utility of this laparoscopic adjunct. cation rates with a trend towards shorter and neck, gastrointestinal, and bariatric length of stay in the robotic group. surgery. Benefits to the surgeon through In review of studies of robot-assisted Although operative times were longer in improved optics and ergonomics may laparoscopic hysterectomy, 15-70 cases the robotic group, they tend to decrease lead to better surgical performance and were required to achieve an operative following the initial robotic cases, prob- thus improved outcomes for patients. time of approximately 2 hours (4). A simi- ably secondary to a more favorable learn- Robotic systems have been proven to lar series of 113 robot-assisted procedures ing curve for robotic Roux-en-Y gastric be safe and have resulted in improved performed by surgeons with advanced bypass. patient satisfaction and quality of care. laparoscopic skills found that blood loss, operative time, and set-up time improved Cost-effectiveness Bibliography until approximate 50 cases and then sta- Robot-assisted surgery is associated 1. Dharia SP, Falcone T. Robotics in bilized (5). Virtual training (robotic simu- with high capital and operating costs. reproductive surgery. Fertil Steril. lation) in robotic surgery involves virtual Obtaining a new da Vinci robotic system 2005;84(1). reality stimulators and soft tissue models costs between $750,000 to $1.9 million, that re-create the texture of human tissue, depending on the system. Each instru- 2. Valero R, Ko YH, Chauhan S, thus allowing trainees to acquire surgical ment costs between $2200 and $3200; sur- Schatloff O, et al. Robotic surgery: skills safely and without interaction with gical instruments must be replaced after history and teaching impact. Acta an actual patient. The latest stimulators 10 uses. Cost effectiveness can be affected Urol Esp. 2011: 35(9):540-545. allow the surgeon to perform an entire by operating room time and the number operation with use of the complete instru- of surgical instruments used. Additional 3. Berguer R, Forkey DL, Smith WD. ment panel, all through stimulation alone. costs include equipment, maintenance, Ergonomic problems associated with and set-up time. In the preliminary stages laparoscopic surgery. Surg Endosc General surgery has become a spe- of the surgeon’s training, costs can be 1999; 13:466. cialty with rapid growth in robotic uti- quite high due to the need for additional 4. Kho RM, Hilger WS, Hentz JG, et lization. The robotic platform is being instruments as well as extended length al. Robotic hysterectomy technique used more often for hernia, foregut, of operating time. By reducing the num- and initial outcomes. Am J Obstet colorectal, and bariatric procedures. In ber of instruments utilized and eliminat- Gynecol. 2007; 197:113.e1. my practice as a bariatric surgeon, I have ing the need for advanced laparoscopic implemented robotics for the majority instruments such as surgical tackers, 5. Lenihan JP Jr, Kovanda C, Seshadri- of my surgical procedures. This allows surgeons are able to perform common Kreaden U. What is the learning complex surgical patients to undergo procedures (cholecystectomy, inguinal curve for robotic assisted gynecologic minimally invasive procedures with short hernia) which are cost neutral. surgery? J Minim Invasive Gynecol. length of stay, less pain, and fewer com- 2008; 15:589. plications. Weight at the time of surgery Conclusion for a bariatric patient can range from just Robot-assisted surgery offers ben- 6. Faust RA. Robotics in Surgery. New over 200 pounds to well over 500 pounds. efits to patient via minimally invasive York. Nova Science Publishers; 2007. Once the robot is docked, there is mini- approaches which could lead to reduced mal discernable difference felt physically blood loss, reduction in blood transfu- 7. Long E, Kew F. Patient satisfaction when operating on this unique patient sion, reduced postoperative pain, shorter with robotic surgery. J Robot Surg population. In a retrospective study com- hospital stays, fewer complications, and 2018 493-499.

WINTER 2019 PANHANDLE HEALTH 11 Obesity in the Panhandle of Texas by Bleu Schniederjan, MD, FACS, FASMBS; Bo Neichoy, MD, FACS; Daren Peterson, MD, FACS

n 1990, obese adults made up less than in 1990 and 21.7% in the year 2000. This weight loss. Sustained weight loss includes I15% of the population in most U.S. number continues to rise at a linear rate intense education involving nutritional states. By 2010, 36 states had obesity rates and has not plateaued. Obesity in the counseling, exercise counseling, psy- of 25% or higher, and 12 of those had obe- Texas Panhandle was 33.4% in 2016 and chological counseling, behavior modi- sity rates of 30% or higher. Today, nation- is obviously a major concern for our fications, stress management, and sleep wide, roughly two out of three U.S. adults local health care providers. Over 12% of management. The treatment involves an are overweight or obese and one out of Texans have diabetes, and this rate con- individualized approach for each patient thirteen is considered morbidly obese. tinues to increase. Many of the current with a basic foundation in the above Even more alarming, the prevalence of health issues related to weight include stated modalities followed by escalation overweight and obesity in children and type II diabetes, obstructive sleep apnea, of treatment for certain patients who do adolescents is on the rise, and youth are coronary artery disease, hypertension, not respond. Additional treatments could becoming overweight and obese at earlier and arthritis of the hip, knees, and back. involve short-term weight loss medica- ages. One out of six children and adoles- In addition, obesity has been linked to tions, weight loss endoscopy procedures, cents ages 2 to 19 is obese, and one out of an increase in multiple types of can- and lastly bariatric surgery. The most three is overweight or obese. Early obesity cers. Currently the American Medical important aspect for durable weight loss not only increases the likelihood of adult Association has recognized obesity as appears to be the behavioral changes obesity, it also increases the risk of heart a chronic disease for which there is no related to nutrition and fitness. Of course, disease in adulthood, as well as the preva- cure. Over 95% of patients fail tradi- this is often the most difficult of post bar- lence of weight-related risk factors for tional commercial diet programs. This iatric lifestyle changes for a patient to cardiovascular disease, hypertension, and does not mean that patients cannot lose fully integrate into their regular routine. diabetes. From a financial standpoint, an weight, but they ultimately regain weight obese person in the United States incurs over time. Losing weight in a sustainable Panhandle Weight Loss Center an average of $1,429 more in medical and durable fashion would address these (PWLC) has put together a multidisci- expenses annually. Approximately $147 medical issues at the root cause and bring plinary team to help tackle the epidemic billion is spent in added medical expenses about meaningful life change to our col- of obesity. There is a noticeable and inten- per year within the United States. This lective patient population. tional difference the patient will observe number is expected to increase by when first setting foot in our office. Our approximately $1.24 billion per year until We anticipate that, over the next goal is to treat patients who are anywhere the year 2030. 25 to 50 years, there will be significant from 30 lbs. to 500 lbs. overweight with advancements in the treatment of obe- compassionate and individualized care. The obesity rate in Texas is an sity. Currently the best approach is a mul- Their tour begins with an initial weight astounding 34.8%. Compare this to 10.7% tifaceted, multidisciplinary approach to loss consult with one of our three physicians. This is designed to tailor the remainder of their care with a patient’s weight loss needs and goals. This is fol- In Memoriam lowed by a series of tests to understand the physiology behind their weight struggles and includes metabolic testing, body William Price Hale, M.D. composition scans, and cardio-metabolic Otolarynlogist, analysis. A Resting Metabolic Rate (RMR) died on August 7, 2019 study is a test which measures a patient’s C02 production and compares the results at the age of 85. to similar age matched patients to get He was a member of the a picture of their overall metabolism. Potter-Randall County Patients also undergo body composi- Medical Society for 57 years. tion analysis to evaluate percent body fat and lean muscle mass compositions. The PNOE is a cardio-metabolic analysis that 12 PANHANDLE HEALTH WINTER 2019 provides our Health Coach the most com- what “eating right” looks like. Similarly, with preventing future weight regain. prehensive and insightful health assess- most patients with weight issues have Patients are required to see a psycholo- ment, allowing us to develop an accurate never exercised on a regular schedule gist and are given the opportunity to deal and customized nutrition and workout and don’t even know where to begin nor with aspects related to emotional eating plan for each patient. Patients then begin do they have any desire to go to a gym. and stress management. working with our team, which includes a For these reasons, we have brought the dietitian for nutritional counseling. Health Coaching model into our prac- Our group works together as a cohe- tice to educate patients about appropriate sive and comprehensive team to imple- While goal caloric intake is estimated, nutrition and fitness. We recognize that ment a unique weight-loss strategy for a more detailed look at macronutrient patients did not develop the habits that each patient. This may include the use of composition of food intake is undertaken resulted in their weight struggles over- short-term weight-loss medications, and/ in relation to carbohydrates, fats, and night and similarly will not develop new or newer weight loss medical devices, protein. The standard USDA food pyra- patterns and routines overnight. As noted as well as bariatric surgery. Surgery has mid published many years ago is thought previously, the PNOE system allows us to become the most effective weight-loss tool to contribute to the rise in obesity in measure whether patients are fat adap- for patients who need to lose 50 pounds America as it emphasized a high carbo- tive or carb dependent, allowing us to or more. The procedures utilized today hydrate and low fat diet. Our approach tailor exercise and nutrition to focus on have changed significantly over the past 2 is evidence-based and designed to help appropriate weight loss and long-term decades. These operations are more effec- lower patients’ intake of processed car- maintenance. Our personal trainer is not tive and have a dramatically improved bohydrates to blunt the effects of excess only certified by the National Association safety profile. At PWLC, we currently insulin levels and to restore hormonal of Sports Medicine (NASM) but also as a offer the laparoscopic sleeve gastrectomy balance. We have recognized that telling Primal Health Coach. She helps develop and the laparoscopic duodenal switch. patients to “eat right” and “start exercis- behavior modifications related to seden- The sleeve gastrectomy involves ing” does not work. Our society is con- tary lifestyle and poor food choices. We reducing the size of the stomach from are also using innovative approaches to stantly fed a plethora of information the size of a football down to the size of that is directly contradictory to a healthy stress management, sleep management, lifestyle, and patients simply don’t know and overall hormone management to aid | continued on page 14

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Purpose Panhandle Health strives to promote the health and welfare of the Web sites: URL of the site and the date the information was accessed. residents of Amarillo and the Texas Panhandle through the publication of Other sources: Enough information must be included so that the source can practical informative papers on topics of general interest to most physicians while EHLGHQWL¿HGDQGUHWULHYHG,IQRWSRVVLEOHWKHLQIRUPDWLRQIRUVRXUFHVKRXOGEH maintaining editorial integrity and newsworthiness. included parenthetically in the text. Spectrum The Journal seeks a wide range of review articles and original ,OOXVWUDWLRQV,OOXVWUDWLRQVVKRXOGEHEODFNDQGZKLWHRQO\ZLWKFRPSOHWHVHQWHQFH observations addressing clinical and non-clinical, social and public health, aspects legend. as they relate to the advancement of the state of health in the Texas Panhandle. Pertinent letters to the editor, news submissions, and obituaries listings are Previously Published Material Short verbatim quotations in the text may be accepted pending editorial review. The Editorial Board accepts or rejects used without permission but should be quoted exactly with source credited. submissions based on merit, appropriateness, and space availability. Otherwise, permission should be obtained in writing from the publishers and authors for publishing extensive textual material that was previously published. Submission process Material should be e-mailed to the editor at prcms@ suddenlinkmail.com or mail a hard copy to Cindy Barnard, PRCMS, 1721 Hagy, Editing Accepted manuscripts are edited in accordance with the American Amarillo, TX 79106. A recent photograph of the author (optional) and a curriculum Medical Association Manual of Style. vitae or a biographical summary are also to be submitted. Letters Letters will be published at the discretion of the editor and editorial board. &RQÀLFWRI,QWHUHVW$XWKRUVPXVWGLVFORVHDQ\FRQÀLFWRILQWHUHVWWKDWPD\H[LVW 7KHOHQJWKVKRXOGEHZLWKLQZRUGV5HIHUHQFHVVKRXOGQRWH[FHHG¿YH$OO in relation to their submissions. letters are subject to editing and abridgment. Journal Articles Manuscripts should be double-spaced with ample margins. Text News News should be e-mailed [email protected] or mailed to Cindy should be narrative with complete sentences and logical subheadings. The word Barnard, PRCMS, 1721 Hagy, Amarillo, TX 79106. count accepted is generally 1200 to 1500 words. Review articles and original Obituaries Listings of deceased members of PRCMS with highlights of their contributions should be accompanied by an abstract of no more than 150 words. contributions are published when adequate information is available. 5HIHUHQFHV5HIHUHQFHVWRVFLHQWL¿FSXEOLFDWLRQVVKRXOGEHOLVWHGLQQXPHULFDO Copyright Copyrights are reserved. Written permission from the editor must be order at the end of the article with reference numbers placed in parentheses at obtained before reproducing material published in Panhandle Health whether in appropriate points in text. The minimum acceptable data include: part or in whole. Journals: Authors, article title, journal, year volume, issue number, inclusive 3RLQWRI9LHZ Opinions published in any article, statement, or advertisement pages. are the responsibility of the author and shall not be construed by any means to Books: Author, title, place of publication, publisher, year. represent those of the editors or the medical society.

WINTER 2019 PANHANDLE HEALTH 13 a banana. While the restrictive nature counseling to each patient’s unique meta- road forward for these patients is not easy of the procedure is important, research bolic make up. Further, we have recog- and requires a huge team with significant demonstrates that an even more impor- nized that the number on a scale is not a resources to help change patients’ lives. tant manipulation of hormones is at precise measurement of health but should In the end, we have thousands of patients play with this procedure. When the lat- be supplemented by measures of percent who will testify that little else is more eral aspect of the stomach is removed, body fat, stress levels, regular exercise, rewarding than achieving meaningful circulating hormones like ghrelin and healthy eating, hormone balance, and weight loss and renewed health. Nothing leptin are substantially reduced. These adequate sleep. Old habits do not change in life of true value is obtained without hormones are responsible for appetite overnight, and we realize it takes time, effort. stimulation as well as manipulation of accountability, and health coaching to our internal “set point”. The “set point reprogram each patient’s daily habits and The current training for Bariatric sur- theory” essentially states there is a geneti- routines. Truly astonishing, however, is gery involves a 5 year general surgery res- cally imprinted “set point” within each the transformation a patient experiences idency followed by a 1 year fellowship in one of us which drives our body’s compo- when most, if not all, of their medical Bariatric surgery. Below, I will discuss a sition to a given level. Decreasing in the issues related to obesity are dramatically little bit about the surgeons at Panhandle relative amounts of these circulating hor- improved if not completely reversed. The Weight Loss Center. mones, as occurs with surgery, is thought to reduce this “set point” to allow patients to more easily achieve and maintain their goal body composition. Patients on average can expect to lose approximately 65% of their excess body fat within the first 12-18 months. Over 60% of patients with Type II diabetes will go into complete remission, totally eliminating their need for hyperglycemic medications.

The most effective operation for weight loss is the laparoscopic duode- Bleu Schniederjan, MD, Bo Neichoy, MD, FACS Daren Peterson, MD, FACS, FASMBS Dr. Neichoy obtained FACS nal switch. This procedure is ideal for Dr. Schniederjan is a his medical degree the Dr. Peterson is Texas patients who need to lose in excess of 100 graduate of the University University of Texas in Tech SOM graduate lbs and/or have poorly controlled Type II of Texas Medical Branch Houston and completed who also completed his diabetes. This surgery begins by remov- in Galveston who his surgical training at the surgery training at the ing about 2/3 of the stomach, reshaping completed his surgery University of Florida. University of Florida. it into the sleeve gastrectomy, and then training at Baylor bypassing roughly half of the small intes- University Medical tine. Patients can expect to lose up to 90% Center in Dallas and the of their excess body fat over a two-year Cleveland Clinic. period. Similar to the sleeve gastrectomy, the duodenal switch has been shown to result in remission of Type II diabetes in over 90% of patients.

There are no “quick fixes” when it comes to the treatment of obesity, and we are emphatic about counseling patients that surgery is not a cure. Strategies for working with this disease are becoming more complex, and we are realizing there is not a “one size fits all” approach. The genetic makeup of each patient ascribes a unique metabolism and metabolic efficiency, which responds differently to certain nutritional and exercise protocols. In the future, we see genetic testing as a way Panhandle Weight Loss Center Staff to specifically tailor fitness and nutritional 14 PANHANDLE HEALTH WINTER 2019 The Current State of Geriatric Psychiatry in the U.S. by Luke Bacon MBA, MS4, Ravindra M. Bharadwaj (Dr. Ravi) MD, MPH

geriatric psychiatrist is a physician developing mental illness, such as reduced Board of Psychiatry and Neurology Awith special training in the diag- mobility, chronic pain, frailty, bereave- (ABPN) administered the first certifi- nosis and treatment of mental disorders ment, and elder abuse (19). One national cation examination in 1991. By 2015, in older adults, who often have special study published in 2015 found that in 3,329 certifications had been awarded in physical, emotional, and social needs the past year 11.4% of elderly adults had Geriatric Psychiatry (2). To become certi- (1). In recent years there has been grow- experienced an anxiety disorder, 6.8% fied, applicants must already be certified ing recognition that the geriatric popula- had experienced a mood disorder, and in general psychiatry, have passed ABPN’s tion possesses unique characteristics and 3.8% had met criteria for a substance use Geriatric Psychiatry computer-adminis- mental health needs (3), fueling a greater disorder (10). Another study attempted tered examination, and have completed demand for physicians with specific to describe how many older adults 55 and one year of an ACGME-accredited fel- expertise in this field (4). older sought mental health services. It lowship in Geriatric Psychiatry (14). found that 53% of these individuals with Interest in psychiatric fellowship pro- Much attention has been given one of the disorders described above per- grams has historically been low when in recent years to the growing short- ceived a need for help, 41% received some compared to interest in fellowships for age of primary care physicians in the form of mental health services, but only non-psychiatry specialties, and Geriatric United States (5,6), as well as to a rapidly 15.7% saw a specialty mental health pro- Psychiatry is no exception. The number increasing geriatric population that has fessional (11). been predicted to grow to about 72 mil- of Geriatric Psychiatry fellows, as well as lion Americans age 65 or older by 2030 Efforts to meet the current men- fellowship programs, has been steadily (from about 40 million in 2010) (7). These tal health needs in the U.S. will likely be decreasing over the past 10-15 years. patients often have particular healthcare difficult, as even general psychiatrists In 2001/2002, there were 94 fellows in needs, which will likely contribute to an are in increasingly short supply relative training as compared to 72 fellows in increase in both the number of people to national needs (6). As of 2017, 77% 2006/2007. Over the same period, the on Medicare and in Medicare spending of US counties were already experienc- proportion of filled fellowship positions (8). Mental health will be an especially ing a severe shortage of general psychia- dropped from 61% to 48%. In 2007, 67% important consideration in this popula- trists (9). Calls for more geriatric mental of training programs had two or fewer tion, with 10.1 to 14.4 million Americans health specialists are not a recent devel- first-year fellows and 16% had none (15). aged 65 or older expected to meet criteria opment, however. In the 2003 President’s As of 2017, there were about 60-65 fel- for a mental health or substance use dis- Commission on Mental Health lows per year, and fewer than half posi- order by 2030. Millions of baby boomers Subcommittee on Older Adults, it was tions were being filled each year (2). will have difficulty obtaining behavioral stated that, “at the current rate of grad- A survey of residents and fellows health treatments unless there is a con- uating approximately 80 new geriatric attending American Association of certed effort to boost the number of pro- psychiatrists each year and an estimated Geriatric Psychiatry (AAGP) meetings viders able to supply geriatric behavioral 3% attrition, there will be approximately between 2000-2002 found that the major- health care, according to a 2012 report 2,640 geriatric psychiatrists by the year ity first became interested in geriatric psy- from the Institute of Medicine (7). 2030 or one per 5,682 older adults with a chiatry during their PGY1 and/or PGY2

psychiatric disorder” (13). In Texas, there years. The greatest influencers on devel- Older adults experience the same are currently three training programs for oping this interest were “specific teacher mood disorders found in the general Geriatric Psychiatry: UT Southwestern attributes, training experiences, personal population, though at different rates in in Dallas, Baylor College of Medicine experiences with seniors, and characteris- some cases. Other issues, like dementia, in Houston, and TTU Health Sciences tics unique to geriatric psychiatry, such as are almost exclusively seen in the geriat- Center in El Paso. TTUHSC is also plan- the medical, neuropsychiatric, and mul- ric population. The most common issues ning on starting a general psychiatry resi- tifactorial nature of the field” (16). Other facing this age group are depression and dency in Amarillo in the coming years. surveys conducted among Canadian psy- dementia, which affect 7% and 5% of chiatry residents have reported similar those aged 60 and older, respectively. With regard to formal recognition, findings (17, 18). Some factors highly associated with older Geriatric Psychiatry is a relatively new adults may place them at greater risk for subspecialty for which the American | continued on page 16 WINTER 2019 PANHANDLE HEALTH 15 Given the present environment for of the geriatric behavioral health Rockville, MD. https://www.ahrq. geriatrics and psychiatry, it’s surprising workforce. Psychiatr Serv. 2012: gov/research/findings/nhqrdr/ how little visibility the future of geriatric 63(8): 841-842. doi:10.1176 nhqdr17/index.html psychiatry in the U.S. is receiving. It’s also somewhat unclear why there isn’t more 5. Petterson SM, Liaw WR, Phillips RL 13. Bartels SJ. Improving the United interest in Geriatric Psychiatry training Jr, Rabin DL, Meyers DS, Bazemore States’ system of care for older adults programs or greater attention to geriat- AW. Projecting US primary care with mental illness: findings and ric mental health in general psychiatric physician workforce needs: 2010- recommendations for The President’s training and other primary care special- 2025. Ann Fam Med. 2012;10:503- New Freedom Commission on ties. Like most things, the truth is that 509. Mental Health. 2003. Am J Geri it’s probably due to a multitude of factors Psychiatry. 2003; 1(5): 486–497. 6. KFF’s State Health Facts. Bureau of relating to the economic and workforce doi:10.1176 Health Workforce, Health Resources environment, as well as general attitudes and Services Administration 14. Information for Applicants: Initial toward geriatric medicine. Increasing the (HRSA), U.S. Department of Health Certification for Geriatric Psychiatry. supply of fellowship-trained Geriatric & Human Services, Designated American Board of Psychiatry and Psychiatrists will certainly be important Health Professional Shortage Neurology, 2014. in order to respond to increased demand Areas Statistics: Designated HPSA for older adult mental health services. 15. Bragg EJ, Warshaw GA, van der Quarterly Summary, as of December However, there are likely also opportu- Willik O, et al. National Survey of 31, 2018. nities to accomplish this via greater geri- Geriatric Psychiatry Fellowship atric psychiatry-related training among 7. Blazer D, Le M, Maslow K, Eden J. Programs: comparing findings in non-psychiatrists and advanced practice The mental health and substance use 2006/07 and 2001/02 From the providers. What’s clear is that current workforce for older adults: In whose American Geriatrics Society and needs are not being met and that the pres- hands? 2012 : National Academies Association of Directors of Geriatric ent state of the field will likely worsen if Press. Academic Programs’ Geriatrics novel solutions to increase education sur- Workforce Policy Studies Center. rounding mental health in older adults 8. Cubanski J, et al. The rising cost of Am J Geri Psychiatry.2012; 20 (2): are not explored, among psychiatrists and living longer: analysis of medicare 69–178. doi:10.1097 non-psychiatrists alike. spending by age for beneficiaries in traditional Medicare - methodology.” 16. Lieff SJ, Tolomiczenko GS, Dunn References The Henry J. Kaiser Family LB. Effect of training and other Foundation. 11 May 2017. influences on the development of 1. “Careers in Geriatric Psychiatry.” career interest in geriatric psychiatry. American Association for Geriatric 9. The Psychiatric Shortage: Causes Amer J Geri Psychiatry.2003; 11 (3): Psychiatry, www.aagponline.org/ and Solutions. National Council for 300–308. doi:10.1097 index.php?src=gendocs&ref=Careers Behavioral Health, 2017. GeriatricPsychiatry&category=Main. 17. Rej S, Laliberte V, Rapoport MJ, et al. 10. Reynolds K, et al. Prevalence of What makes residents interested in 2. Juul D, Colenda CC, Lyness JM, psychiatric disorders in U.S. older geriatric psychiatry? a pan-Canadian et al. Subspecialty training and adults: findings from a nationally online survey of psychiatry residents. certification in geriatric psychiatry: representative survey. World Amer J Geri Psychiatry. 2015; 23 (7): a 25-year overview. The American Psychiatry. 2015; 14 (1): 74–81. 735–743. doi:10.1016 Journal of Geriatric Psychiatry. doi:10.1002/wps.20193. 2017; 25 (5): 445–453. doi:10.1016/j. 18. Reichenfeld HF. What factors jagp.2016.12.018. 11. Mackenzie CS, Pagura J, Sareen J. contribute to senior psychiatry Correlates of perceived need for residents’ interest in geriatric 3. Reifler BV, Colenda CC, Juul D. and use of mental health services psychiatry? Can J Psych. 2001; 46 (4): Geriatric psychiatry. In: Aminoff by older adults in the Collaborative 373–374., doi:10.1177 MJ, Faulkner LR, eds. The American Psychiatric Epidemiology Surveys. Board of Psychiatry and Neurology: Am J Geri Psychiatry. 2010; 18(1200: 19. Mental Health of Older Adults. Looking Back and Moving Ahead. 1103–1115. doi:10.1097 World Health Organization, World Washington, DC: American Health Organization, www.who. Psychiatric Publishing, 2012:135– 12. 2017 National Healthcare Quality int/news-room/fact-sheets/detail/ 141. and Disparities Report. Content mental-health-of-older-adults. last reviewed July 2019. Agency for 4. IOM report highlights inadequacies Healthcare Research and Quality,

16 PANHANDLE HEALTH WINTER 2019 Scott Alan Steve Ryan Martin VanOngevalle Seabourn Monroe

Steve Kayla Greg Valerie Bowen Carpenter Graham De la Fuente Making Bill David Jim Latimer Jones Bryan

David Erin Chris Yolando Davis Viermann Morris Castillo

Jeff J. Pat Joby Shelly Geoff Irwin Hickman Mills Kearns Phemister Amarillo Gary Courtney Todd Wells Evans Wetsel

Jennifer Mikel Bill Alisa Currie Williamson Holland Scott

Tucker Lee HAPPY

Rian Clinton Member FDIC 3rd happybank.com Best Bank in Texas Debbie Ryan and the 26th Best Bank in the USA! Loyless Evans Geriatric Oncology by Helayna Abraham, MS4; Hena Tewari, MD; Ravindra M. Bharadwaj (Dr. Ravi), MD, MPH

ecently, the concept of “Geriatric that the best cancer treatment for the Society of Geriatric Oncology (SIOG) ROncology” has received more atten- older population may not be the same as has created a task force to review geri- tion in the oncology community. Cancer in the younger population (3-5). atric oncology literature and to make treatment in the elderly population is recommendations. The National challenged by suboptimal outcomes, The aging process can cause sig- Comprehensive Cancer Network many of which can be reduced with bet- nificant changes in physiology such as (NCCN) has published guidelines for ter personalized care that factors human decreased kidney function, lung compli- older adult oncology. The first textbook physiology and sets appropriate goals ance, cardiac function and bone marrow for geriatric oncology was published in for the individual based on the physi- cellularity. These factors alone can ham- 1992 by Lodovico Balducci et al. cal, social and mental health needs. Due per the recovery from the cancer; how- to the increase in the aging population, ever, lifestyle factors such as poor dietary In 2017 the University of Rochester oncologists are treating more patients in habits, inadequate exercise, and social published a survey of current Hemato- their 70’s and 80’s with curative intent. circumstances also adversely impact out- Oncology fellows and reported that The prevalence of cancer in the geriatric comes. Healthier older patients recover 84% of fellows perceive geriatric oncol- population is on the rise due to higher better compared with frail ones; there- ogy as an important issue, whereas only age-specific incidence of cancers (1). fore, it is important to identify and cat- 25% had access to a geriatric oncology The current cancer rate is higher in the egorize the older individuals with cancer clinic, and 53% had no lectures in geriat- Amarillo Metro Statistical Area com- based on their potential to withstand ric oncology (6). pared with that of the state of Texas rate cancer therapy and to recover. This (474 versus 415 per 100,000 of popula- goal can be achieved through the use of Realizing the need for geriatric con- tion). Similarly, the age adjusted cancer Geriatric Assessment (GA) and making cepts in cancer patients, ASCO with incidence rate in the 65 year and older it an integral part of cancer management support from the John A. Hartford population is higher in Potter County in the older population. Foundation started pilot programs compared to Texas in general (2,012 ver- of 3-4 yrs. of geriatric oncology at 10 sus 1,812 per 100,000 of population) (2). Geriatric Oncology Status: In 1983 institutions (Table 1). At present there the National Cancer Institute (NCI) con- are 8 fellowship programs that provide Because information regarding spe- ducted first symposium related to cancer combined 3-4 years fellowship pro- cific treatments in the aging population care in older patients. Subsequently the gram of geriatric- oncology (Table 2) is lacking, these patients are often treated American Society of Clinical Oncology (7). ACGME also requires that fellows the same way as their younger counter- (ASCO) has played an important role in be able to provide care to older cancer part. However, the nature of cancer and promoting Geriatric Oncology. ASCO patients (8). treatment outcomes may be significantly has also supported oncology fellow- different in an older population. The ships and faculty development in field Understanding Geriatric Oncology: medical community is now recognizing of geriatric oncology. The International A core effort in the field of geriatric oncology is establishing a comprehen- Name Current Status sive geriatric assessment which aims to Boston Medical Center Active address the issue of physiologic versus chronologic age. Chronologic age often Duke University Medical Center Active fails to consider physiologic and func- Johns Hopkins University Non-Active tional status of older adults, thus disre- Northwestern University Non-Active garding important information needed University of California, Los Angeles Active to guide cancer treatment. In contrast, University of Chicago Active physiologic age reflects the body’s abil- University of Colorado Health Sciences Center Non-Active ity to maintain homeostasis which affects the body’s ability to stave off organ dam- University of Michigan Non-Active age despite physiologic stressors, such University of Rochester Active as cancer and its treatment. Several bio- University of Texas Non-Active markers that correlate to physiologic age Table 1: Recipients of the ASCO-Hartford Foundation Geriatrics/ have been noted but have limited clini- Oncology Training Program Development Grant cal application due to their quantitative variation. Thus, the current mainstay in 18 PANHANDLE HEALTH WINTER 2019 evaluation of physiologic age remains those in the non-elderly. They consider tion needed to make an appropriate the geriatric assessment (GA), a multi- the biomolecular properties of the can- plan of care for many elderly cancer dimensional tool that evaluates several cer and the stage of the disease to deter- patients (11). This exemplifies the need domains, including physical function, mine the ability of treatment to prolong for a more comprehensive approach to cognition, nutrition, co-morbidities, psy- survival, preserve quality of life, and, in addressing diagnosis and treatment in chological status, and social support (9). some cases, provide a cure. Conversely, this particular population. The field of In addition to other tools, this assess- predicting cancer toxicity relies more on geriatric oncology focuses on provid- ment should ultimately guide clinicians physiologic age. Geriatric oncologists ing education to physicians, nurses, and in estimating life expectancy, evaluat- have developed additional tools that use other healthcare workers to maintain ing cancer treatment benefit, predict- components of the geriatric assessment a high standard of care for the elderly ing treatment toxicity, and recognizing to estimate the risk of chemotherapy population, integrate geriatric evaluation patient preferences to provide personal- toxicity. A commonly used tool, Cancer into oncology decision making, develop ized care to elderly cancer patients. and Aging Research Group (CARG), and validate easy screening tools, and aims to stratify patients into three broad improve research to optimize treatment Estimating the overall life expec- categories: low risk, intermediate risk, of the growing elderly population with tancy of the patient, vis-a-vis the risk and high risk of chemotherapy toxicity cancer. of cancer related morbidity and mor- based on properties of the cancer being tality during such time, helps to guide treated, in addition to patient specific Geriatric Oncology at Amarillo: decision making and can prevent both characteristics. Another of these tools, Texas Tech HSC Amarillo, with help over and underreating patients. The life Chemotherapy Risk Assessment Scale from the Don and Sybil Harrington expectancy tables that have historically for High Age Patients (CRASH), assesses Foundation and the Mary E. Bivins been used to estimate prognosis simply risk of toxicity based on specific chemo- Foundation, has established a program consider epidemiological data and fail therapy regimens in conjunction with of geriatric oncology with an aim to to consider co-morbid conditions and the functional, nutritional, and men- benefit the community through educa- functional status. As a result, efforts have tal status of the patient (4). Other tools tion, screening and care to older cancer been made to design a tool that includes focus on determining the morbidity and patients. TTUHSC’s Comprehensive information from the geriatric assess- mortality of surgical treatment of cancer. Geriatric Oncology Clinic (CGOC) ment to develop non-disease specific is staffed with a geriatrician, a dieti- prognostic indices to more accurately Finally, the clinician should consider cian, a pharmacist and a social worker predict all-cause mortality in elderly the treatment goals of the patient. Goals to actively collaborate with area cancer patients (9). A widely used tool to assess of treatment in older patients tend to providers. The clinic thoroughly evalu- life expectancy is e-Prognosis. Based on shift from prolonging survival to main- ates geriatric issues, chemo-toxicity risks, a systematic review of the literature, the taining independent function and a good medications, nutritional status, and tool establishes a repository of prognos- quality of life (4). As in all disciplines in frailty issues of the patients and makes tic indices to help guide clinicians in medicine, the geriatric oncologist con- recommendations to the cancer treating forming a prognosis (10). siders the patient’s perspective and moti- physicians. This clinic is unique as all vations in formulating a treatment plan. the services can be provided under one After estimating the overall life roof. This clinic also provides services expectancy of the patient and weighing A systematic review revealed a modi- to indigent patients who lack financial this against the risk of cancer related fication of treatment plan in one third resources. The program focuses on care- morbidity and mortality, an assessment of patients who underwent the geriatric giver education through symposia, grand of the benefits versus toxicities of can- assessment, suggesting that the typical cer treatments helps to further guide patient encounter lacks vital informa- | continued on page 20 the decision to proceed with treatment. Tools for estimating the benefits of treatment in the elderly are comparable to In Memoriam 1 University of North Carolina 2 Thomas Jefferson University 3 Boston Medical Center Harve Daniel Pearson, M.D. 4 Duke University Medical Center Anesthesiologist, 5 Yale University died on May 28, 2019 6 University of California, Los Angeles at the age of 78. 7 University of Rochester He was a member of the 8 Moffitt Cancer Center, Tampa Potter-Randall County Table 2: Current Geriatric-Oncology Medical Society for 43 years. Programs

WINTER 2019 PANHANDLE HEALTH 19 rounds and workshops. As a part of its study in first-line chemotherapy 7. Geriatric Oncology Resources. prevention program, this center also for metastatic colorectal cancer ASCO. conducts comprehensive biennial cancer in elderly patients. J Clin Oncol. 8. ACGME. ACGME Program screening events. 2013;31(11):1464-1470. Requirements for Graduate Medical 4. Freyer G, Geay JF, Touzet S, et al. Education in Hematology and In conclusion, we can say that geriat- Comprehensive geriatric assessment Medical Oncology (Subspecialty of ric oncology is an expending field with a predicts tolerance to chemotherapy Internal Medicine). 2019:20-21. focus on an interdisciplinary approach and survival in elderly patients 9. Soto-Perez-de-Celis E, Li D, to older cancer patients. Efforts are with advanced ovarian carcinoma: Yuan Y, Lau YM, Hurria A. being taken to integrate geriatric oncol- a GINECO study. Ann Oncol. Functional versus chronological ogy principals in the training of medi- 2005;16(11):1795-1800. age: geriatric assessments to cal oncologists as well as other related guide decision making in older 5. Balducci L, Extermann M. subspecialists. patients with cancer. Lancet Oncol. Management of cancer in the 2018;19(6):e305-e316. doi: 310.1016/ References: older person: a practical approach. S1470-2045(1018)30348-30346. Epub 1. Shih YC, Hurria A. Preparing for an Oncologist. 2000;5(3):224-237. 32018 Jun 30341. epidemic: cancer care in an aging 6. Maggiore RJ, Dale W, Hurria 10. ePrognosis. population. Am Soc Clin Oncol Educ A, et al. Hematology-Oncology Book. 2014:133-137. 11. Hamaker ME, Te Molder M, Thielen fellows’ training in geriatrics N, van Munster BC, Schiphorst AH, 2. Texas Cancer Registry. Texas and geriatric oncology: findings van Huis LH. The effect of a geriatric Cancer Registry. Accessed from an American Society of evaluation on treatment decisions 01/02/2018. Clinical Oncology-Sponsored and outcome for older cancer 3. Aparicio T, Jouve JL, Teillet L, national survey. J Oncol Pract. patients - A systematic review. J et al. Geriatric factors predict 2017;13(11):e900-e908. doi: Geriatr Oncol. 2018;9(5):430-440. chemotherapy feasibility: ancillary 910.1200/JOP.2017.022111. Epub doi: 410.1016/j.jgo.2018.1003.1014. results of FFCD 2001-02 phase III 022017 Aug 022124. Epub 2018 Apr 1017.

Amarillo National Bank · Baptist Community Services Neely, Craig & Walton Insurance Agency Texas Medical Association Insurance Trust Texas Medical Liability Trust · Happy State Bank Daryl Curtis, CLU, CHFC - Physicians Financial Partners Cenveo Amarillo · Leslie Massey Farmers Insurance Agency Boxwell Brothers Funeral Home Be a part of the circle. In 2006, Potter Randall resources to assist the physician in the business of County Medical Society introduced the Circle of medicine so their practice of medicine can improve. Friends, a program designed with the business This program has proven to be a valuable of medicine in mind. Members of the Circle of resource of services such as liability insurance, Friends are companies that pay an annual fee to accounting, banking and much more. This year, we participate in Medical Society events. Their ﬁnancial hope to expand the Circle to include services the commitment allows PRCMS to provide quality physician may use in his or her personal life. Through programs throughout the year, such as the Annual this program, we can invite businesses serving Meeting, Doctors Day, Resident Reception, Family physicians to support the Society and increase their Fall Festival, Retired Physicians Lunch and Women visibility among its members. Corporate support in Medicine. In return, these companies are invited to contributes to the Society’s ability to advocate and attend these events and discuss with the physicians care for physicians and patients in Potter and Randall the beneﬁts that their companies offer a physicians Counties. practice. The Medical Society thanks all of its supporters as We are grateful for the support of these it offers new opportunities to its membership.If your organizations and anticipate another great year of business is interested in being a part of our Circle of serving the needs of our members. The purpose for Friends, please contact Cindy Barnard at 355-6854 Circle of Friends is to provide a valuable base of or e-mail [email protected].

20 PANHANDLE HEALTH WINTER 2019 Female Pelvic Medicine and Reconstructive Surgery by Paul Tullar, MD

emale pelvic medicine and recon- ABMS in 2011. The first board certifica- The field of FPMRS started out as a Fstructive surgeons (FPMRS) special- tion exam was administered in 2012 and clinic for basic incontinence run by Dr. ize in the care of women with pelvic floor the first accredited fellowships emerged Jack Robertson, an attending at Harbor disorders, lower urinary tract dysfunc- in 2013. The specialty is a result of the General Hospital in Torrance, CA in tion, and complex benign pelvic disor- confluence of three medical societies: the mid-1960s. At the time, a young ders. Pelvic floor dysfunction can take the American UroGynecologic Society Dr. Don Ostergard was a second-year place due to stress on the tissue during (AUGS), Society of Gynecologic Surgeons resident at the program. The first fellow- parturition, connective tissue disease, (SGS) and Society of Urodynamics ship in Urogynecology was later started genetics, menopause, repetitive heavy lift- Female Pelvic Medicine Urogenital by Dr. Ostergard at Harbor General. In ing or pushing, and repetitive strenuous Reconstruction (SUFU). It is a joint the 1970s, interest in the management activity. Although management of these of incontinence in women was growing effort between the American Board of problems can be straightforward and eas- among gynecologists. Obstetrics and Gynecology (ABOG) and ily managed by the general gynecologist, the American Board of Urology (ABU). the occurrence of complex and refractory In 1974, Dr. Paul Hodgkinson was In 2015, the first FPMRS oral boards cases is common enough that subspe- performing urodynamics at Henry were given. Though the specialty is quite cialty care has proved to be necessary. Ford in Detroit, and Drs. Robertson new in terms of accreditation, the story and Ostergard went to watch and bring FPMRS is one of the more recent of its origins was almost 40 years in the specialties, having been accepted by the making. | continued on page 22

WINTER 2019 PANHANDLE HEALTH 21 back the technique to their institutions. Since then, the field has grown ropubic urethropexy, periurethral injec- The next year, during his sabbatical, Dr. steadily, currently with 64 accred- tions, chemodenervation, posterior Ostergard began a literature review of the ited programs in the United States. tibial nerve stimulation (PTNS), and field which led to evaluating the need for Applications are submitted via ERAS sacral neuromodulation. Surgical man- an organization focused on the study of for accredited programs in May, and agement of pelvic organ prolapse includes female incontinence. He visited with Dr. the NRMP fellowship match for FPMRS colpopexy, uterine suspension, hyster- Stuart Stanton, a London based gyne- takes place in August. New fellows start ectomy, laparoscopic procedures (with cologist, Drs. Rud and Asmussusen, two on July 1st of the following year. and without robotic assistance), vaginal gynecologists in Oslo, and Dr. Tanagho, procedures including hysterectomy, col- a urologist from San Francisco, all leaders There are currently three different pocleisis, colpopexy (intra and extraperi- in the field at the time. Soon afterward, variations in fellowship format. Some toneal approaches), and removal of pelvic programs accept only urology trained Drs. Roberston and Ostergard began mesh. offering postgraduate training courses applicants, others only gynecology can- in the evaluation of female incontinence didates, but most accept both. Some Other urinary procedures that FPMRS with international leaders in the field. combined programs, which accept appli- fellows are trained in include repair of Two years later, in 1979, the Gynecologic cants from both fields, accept urology vesicovaginal, rectovaginal, and ure- Urology Society (GUS) was formed versus gyn fellows in alternate years, throvaginal fistulae, urethral diverticu- by Drs. Robertson, Ostergard, Jansen, while others run parallel tracks, where lectomy, ureteroneocystotomy, ureteral Wiggins, and Fuller. In 1980, the first sci- urology and gyn programs function in stent placement, retrograde pyelography, entific meeting was held in New Orleans. parallel with varying degrees of interac- urethrolysis, urinary diversion, construc- tion. Then there are truly integrated pro- tion of neovagina, and anal sphincter The name was eventually changed grams, where all trainees complete the laceration repair. Although generalists to Urogynecology after the name same training and didactic courses. The can perform many of these procedures, change was suggested by Dr. Ingelman- current trend is moving toward com- once the patient has moved onto third Sundberg, a professor of OB/GYN bining the two sides to develop a more line treatment modalities or have a recur- in Stockholm, Sweden in 1980. The uniform training experience and skill set rence or complication, a referral would be change was later promoted by Dr. representative of the field. appropriate. Shingleton, president of the GUS in 1982. In 1986, the name of the society In order to be eligible to sit for the Most major cities have access to a fel- was officially changed to the American subspecialty board, the fellowship is 2 lowship trained FPMRS surgeon. Patients Urogynecologic Society (AUGS). In years long for those who complete train- benefit from referral when primary treating in urology, and three years for those 1989, then president of AUGS, Dr. ment modalities have been ineffective, from gynecology, though a growing num- Thiede, asked ABOG to consider creden- and/or their disease processes are com- ber of programs are 3 years in length tialing the Urogynecologic fellowships. plex in the nature requiring advanced regardless of the specialty of origin. In 1992, AUGS and SGS made a presen- diagnostics or major reconstruction. To Specific information about fellowships in tation to the ABOG board of directors find a physician in your area, you can go FPMRS can be found at AUGS.org and to educate them about the specialty. In to www.voicesforpfd.org. This page is SUFUorg.com. 1993, at an ABOG meeting, the leader- maintained by AUGS. SUFU.org main- ship from AUGS, who represented the Some commonly treated problems tains a list of graduates from accredited non-surgical side of urogynecology, and where FPMRS physicians can assist the FPMRS programs, and AUGS.org main- Society for Gynecologic Surgeons (SGS), generalist are: urinary or fecal inconti- tains a membership directory. who were already training people in nence, urinary retention, overactive blad- complex vaginal surgery, were invited by References: der, neurogenic bladder, pelvic organ ABOG to discuss formalized training in 1) American Urogynecologic society prolapse/descent of the bladder, uterus, the field. At that meeting they were able websites: AUGS.org vagina, and/or rectum, and fistula care to unite both sides of the specialty, both (rectovaginal, urethrovaginal, and vesico- surgical and non-surgical, and ABOG 2) Society for Urodynamics, Female vaginal). FPMRS physicians also interpret was willing to study whether the field had Pelvic Medicine and Urogenital complex urodynamic studies. enough breadth to warrant its own sub- Reconstruction website: sufuorg.com specialty again. The name was changed Fellowship trained FPMRS physicians 3) Society of Gynecologic Surgeons to Urogynecology and Reconstructive are expected to be proficient at perform- website: sgsonline.org Pelvic Surgery, to fully incorporate both ing surgeries for the management of aspects of the field. In 1995, both ABOG incontinence, pelvic organ prolapse, and 4) NRMP fellowship match and ABU agreed there was enough sub- other complex surgeries on the urinary information: www.nrmp.org stance to warrant a formalized subspe- system. cialty. Learning objectives and guidelines 5) ERA 2020 Fellowship application were then drawn up and the first accred- Surgeries for the management of timeline: students-residents.aamc. ited program in Indianapolis, Indiana incontinence include: sling procedures org/training-residency-fellowship/ was instituted. (placement, revision, and removal), ret- article/eras-fellowship-timeline/ 22 PANHANDLE HEALTH WINTER 2019 Space Medicine: A New Specialty for a New Age by Rouzbeh K. Kordestani, MD, MPH

What is Space Medicine and what is its to foster a good and safe working culture son’s physiology that may place them focus? between the crews and their equipment in at risk. These include insults such as As abstract as it may sound, space the harshness of altitude of air or space in radiation exposure, microgravity, blind- medicine or aerospace medicine is con- the setting of new environmental insults. ness, decompression sickness, and pos- cerned with the maintenance of the sible barotrauma. These environmental History of Space Medicine health, safety and maximal performance changes in turn have health ramifications The field of space medicine is thought of individuals/persons in the air and in in decreased immune system function, to have begun in the late 1940s, follow- space. As can be reasoned, life and func- increased infection rates, fatigue, balance ing the end of World War II. It started tion in air and space present the medical issues, and long-term sleep deprivation. professional with new challenges, as there with Dr. Hubertus Strughold. As many are significant new terrains and envi- German scientists were liberated and Radiation Exposure ronments that may affect the patient’s/ were subsequently brought to the U.S., to Radiation exposure and its long-term pilot’s well-being. The environmental help with the advancement of technolo- effects are only now being understood. challenges that are possible with space gies here, Strughold was brought into the Astronauts and flight personnel are and space travel can include micrograv- U.S. He was a German physician and an exposed to much higher rates of radia- ity, radiation exposure, gravity forces, accomplished physiologist. Following his tion effects of the sun and the stars. These and hypoxic conditions to name only a arrival, he started his career in the U.S. radiation effects can have long-term few. The human body’s response to these at the School of Aviation Medicine (now health effects. NASA now recognizes that new environmental challenges can only better known as the U.S. Air Force School radiation exposure to personnel in space be estimated. Since original data in these of Aerospace Medicine (USAFSAM). can be 600X the radiation effects noted settings is hard to come by and the expo- He was given the title of Professor of on Earth. The true effects of long-term sure in these environments can at times Space Medicine for his knowledge of the damage have not yet been ascertained. be deadly, the field is mired in experimen- physiology of humans in non-terrestrial However, a dramatically increased rate of tal science and cross specialty training. settings. Most of the early ideas and None of the traditional fields of medicine hypotheses for physiology in space origi- cataracts and blindness has been noted in or surgery or their subsequent sub-spe- nated with Strughold. the astronaut population. Most regard it cialties address the specific issues faced by as a known fact and do not discuss it. The engineers, flight surgeons, military pilots The New Settings/Environmental Russian astronauts/cosmonauts who have or astronauts. To that end, the field of air/ Challenges the longest exposure rates in space of all space medicine is a combination of multi- In space, astronauts and flight per- human flight personal have uniformally ple other specialties with the focus on the sonnel are faced with new environmen- shown progressive cataracts. Other long- clinical and the (health) support of crews tal challenges, far different from anything term radiation damage is only now being and crew members during their missions that they may have encountered on Earth. noted and catalogued. and during their scientific explorations. These can present themselves as external The focus of the practitioners in turn is hazards or as internal changes in a per- | continued on page 26 PROUD TO SERVE THE HEALTHCARE INDUSTRY IN THE TEXAS PANHANDLE

WINTER 2019 PANHANDLE HEALTH 23 Happy Holidays from the Potter-Randall County Medical Society Active Members

Anthony Agostini, D.O. Ken M. Brantley, M.D. Samuel J. Cunningham, M.D. Jon L. Haddad, M.D. Syed Ahmed, M.D. Victor L. Bravo, M.D. Albert Cura, M.D. Paul G. Hakim, M.D. Hassan Ahmed, M.D. Walter Bridges, M.D. Tully J. Currie, M.D. James D. Hale, M.D. Brendan C. Albracht, D.O. David E. Brister, M.D. Bejan J. Daneshfar, M.D. Michael Jay Hall, M.D. Douglas A. Albracht, D.O. Bart A. Britten, M.D. Bahraum Daniel Daneshfar, M.D. Victor V. Hands, M.D. Muhammed Farhan Ali, M.D. Charles D. Brooks, M.D. Michael E. Daniel, M.D. John P. Harvey, M.D. Julie Allman, M.D. Gary L. Brown, M.D. Nicole Davey-Ranasinghe, M.D. Yohey Hashimoto, M.D. James R. Allman, M.D. James D. Bryan, M.D. John L. David, Jr., M.D. Raj Hashmi, M.D. Refugio Alvarez, M.D. Bill F. Byrd, M.D. Prakash K. Desai, M.D. Jason Hemmerich, M.D. John L. Andrew, M.D. Agustin Cabrera-Santamaria, M.D. Yagnesh Desai, M.D. Daniel J, Hendrick, M.D. Carin C. Appel, M.D. Jon L. Caldwell, M.D. Pablo R. Diaz-Esquivel, M.D. Hillary Hendrick, M.D. Antonio V. Aragon, M.D. Griseld Camacho, M.D. Javier Dieguez, M.D. Marc Henson, M.D. Gary L. Aragon, M.D. Richard Campin, M.D. Nam Do, M.D. Hector N. Hernandez, M.D. Branch T. Archer, M.D. J. Taylor Carlisle, M.D. Amber Dobler-Dixon, M.D. Pedro R. Hernandez-Lattuf, M.D. Estelle Archer, M.D. Roberto B. Carrasco, M.D. C. Anne Doughtie, M.D. Randy Hines, M.D. Richard K. Archer, Jr., M.D. Londa G. Carrasco, M.D. Chuck A. Duke, M.D. Bradley A. Hiser, M.D. Lova T. Arenivas, M.D. Debora E. Carrizo, M.D. Keith Dyer, M.D. William M. Holland, D.O.. Cesar J. Arias, M.D. Ricardo J. Carrizo, M.D. John P. Dzik, D.O. Shane Holloway, M.D. Brent Artho, M.D. Kade Carthel, M.D. R. Todd Ellington, M.D. Heather Holmes, M.D. Assadour Assadourian, M.D. Rhodesia A. Castillo, M.D. Aaron Elliott, M.D. Andrew Hoot, M.D. Mohammed Bahaa Aldeen, M.D. Harry J. Cazzola, M.D. Bret D. Errington, M.D. R. Cullen Hopkins, M.D. April A. Bailey, M.D. John Richard Chandler, M.D. W. Vance Esler, M.D. Luzma M. Houseal, M.D. Teresa E. Baker, M.D. David L. Chastain, M.D. Thahir Farzan, M.D. Debbie P. Hoving, M.D. Christi A. Baker, M.D. David M. Childress, M.D. Randall Felder, M.D. Melburn K. Huebner, M.D. William Banister, M.D. Amanda R. Christian, M.D. Craig Fichlander, M.D. James M. Hurly, M.D. Kuldip S. Banwait, M.D. Alfred A. Chu, M.D. Rex A. Fletcher, M.D. Dennis A. Ice, M.D. George Barnett, M.D. Crandon F. Clark, M.D. Ronald W. Ford, M.D. Esther O. Iheukwumere, M.D. Eva Bashover, M.D. Kathleen A. Clark, M.D. Leonardo Forero, M.D. Marc David Irwin, M.D. Scott Bass, M.D. Summer Clark, M.D. Jeffrey L. Foster, D.O. Chance L. Irwin, M.D. Perry E. Bassett, M.D. David B. Clarke, M.D. Dudley E. Freeman, III, M.D. Mouin M. Jaber, M.D. Andrew W. Bauer, M.D. Kelly E. Clements, M.D. J. Brett Gentry, M.D. Ali Jaffar, M.D. Jesus R. Benitez, M.D. Elaine R. Cook, M.D. Robert E. Gerald, M.D. Michael D. Jenkins, M.D. Mike Preston Berry, Jr., M.D. Stanley D. Cook, M.D. James E. Gibbs, M.D. Paul Jew, M.D. Ravindra Bharadwaj, M.D. Tyler N. Cooper, M.D. Milton A. Giron, M.D. Thomas L. Johnson, M.D. Chand Bhasker, M.D. Dena Cornelius, M.D. Steven Goettsche, D.O. Jack C. Johnston, M.D. William C. Biggs, M.D. S. Lane Cox, M.D. Adan Gonzalez, M.D. Jason K. Jones, M.D. Keith D. Bjork, M.D. Dhana Cox, M.D. Anuradha S. Gopalachar, M.D. Robert P. Kauffman, M.D. Kathryn Bonds, M.D. Eric Cox, M.D. Robert D. Gross, M.D. Alan W. Keister, M.D. William H. Bordelon, M.D. Robert N. Crabtree, M.D. Jill Gulizia, M.D. Chad M. Kennedy, M.D. David Brabham, D.O. Eric Crandall, M.D. Christopher Gulley, M.D. Richard C. Khu, M.D. Ako D. Bradford, M.D. Tracy C. Crnic, M.D. John Gwozdz, M.D. Richard G. Kibbey, III, M.D. Todd W. Bradshaw, M.D. Reagan L. Crossnoe, M.D. Rolf Habersang, M.D. Joshua Kilgore, M.D. 24 PANHANDLE HEALTH WINTER 2019 Samuel Kirkendall, M.D. Sean M. Milligan, M.D. Nandkishore Raghuram, M.D. Robert H. Stroud, M.D. Patrick J. Kirkland, M.D. Jennifer Milner, M.D. Ron K. Rankin, M.D. Anthony Stuart, M.D. John W. Klein, M.D. J. Scott Milton, M.D. Anita Ravipati, M.D. Sivaram Sudhakar, M.D. Rouzbeh Kordestani, M.D. Timothy S. Mooring, M.D. Arunava D. Ray, M.D. Jan Swan, M.D. Michael O. LaGrone, M.D. Marc Moreau, M.D. Srini B. Reddy, M.D. Andrew B. Tatah, M.D. Michael J. Lamanteer, M.D. Stacie S. Morgan, M.D. James F. Reid, M.D. Victor M. Taylor, M.D. Angela B. Lampkin, M.D. R. Thane Morgan, M.D. Mark Wayne Richardson, M.D. C. Sloan Teeple, M.D. David C. Langley, M.D. Darrell Morgan, M.D. Kevin J. Rickwartz, M.D. Hagos Tekeste, M.D. Michael A. Lary, M.D. Sergio E. Muniz, M.D. Ferdinand R. Rico, M.D. Hena Tewari, M.D. Abby S. Leake, M.D. Amanda D. Murdock, M.D. Timothy (Toby) M. Risko, M.D. Abdul S. Thannoun, M.D. Benjamin J. Leeah, M.D. Richard G. Murray, M.D. Robert H. Ritter, M.D. Ira Lee Thomas, M.D. James Lemert, M.D. John W. Murrell, M.D. Ernesto Rivera, M.D. Margaret Thurmond-Anderle, M.D. Douglas E. Lewis, D.O. Brian S. Murrell, M.D. Larry C. Roberts, M.D. Stephen T. Tidwell, D.O. Brian S. Lindstrom, M.D. Tarek H. Naguib, M.D. Jeri K. Rose, D.O. Robert M. Todd, M.D. Lisa Longhofer, M.D. Rajesh Nambiar, M.D. J. Avery Rush, M.D. Lance L. Trahern, M.D. Jerod Lunsford, M.D. Muhammad H. Nazim, M.D. James A. Rush, M.D. Amit K. Trehan, M.D. James E. Lusby, M.D. Suresh Neelagaru, M.D. Sloan W. Rush, M.D. Lewis C. Lyons, M.D. Susan L. Neese, M.D. Ryan B. Rush, M.D. Salil K. Trehan, M.D. Lyudmyla Lysenko, M.D. Bo T. Neichoy, M.D. Constantine K. Saadeh, M.D. Amanda Trout, D.O. Taghreed N. Maaytah, M.D. Stephen R. Neumann, M.D. Armando Salcido, Jr., M.D. Elijah S. Trout, D.O.. Georges M. Maliha, M.D. Wesley Nickens, M.D. Thomas Sames, M.D. Gerad Troutman, M.D. Gerald Malkuch, M.D. Lyle J. Noordhoek, M.D. Raj Saralaya, M.D. Keelie Tucker, M.D. James “Brian” Malone, D.O. Steven K. Norris, M.D. Shilpa R. Saralaya, M.D. Praveen K. Tumula, M.D. Michael Manderson, M.D. Joshua D. North, M.D. Ruby Saulog, M.D. Matthew Turney, M.D. Reg C. Martin, M.D. D. Izi Obokhare, M.D. Evelyn D. Sbar, M.D. David L. Tyson, M.D. Lance Martin, M.D. Joel C. Osborn, M.D. Alan D. Sbar, M.D. Stephen J. Usala, M.D. Joaquin Martinez-Arraras, M.D. S. Carl Paetzold, M.D. Matthew C. Scalapino, M.D. Martin Uszynski, M.D. Sambasiva Rao Marupudi, M.D. Paul F. Pan, M.D. Lawrence A. Schaeffer, M.D. Julito P. Uy, M.D. Gregorio Matos-Serrano, M.D. James R. Parker, M.D. Daniel L. Schneider, M.D. Bradley B. Veazey, M.D. Dorian R. Matzen, D.O. Michael J. Paston, M.D. Brian Schneider, M.D. Lisa E. Veggeberg, M.D. Gregory May, M.D. Virgil A. Pate, M.D. Matthew B. Schniederjan, M.D. Neil Veggeberg, M.D. Elise May, M.D. Shrestha Patel, D.O. Jason Schocker, M.D. Meganne Walsh, M.D. Farley E. Mba, M.D. Srinivas Pathapati, M.D. Janet Schwartzenberg, M.D. Bang Wan, M.D. Larence McAfee, M.D. Steven Patton, M.D. Rebecca Scott, M.D. Kimberly Waugh, M.D. Rebecca Archer McCarthy, M.D. Wayne C. Paullus III, M.D. Michael D. Sennett, M.D. Wyatt Weinheimer, M.D. Edward M. McCarthy, M.D. Wayne S. Paullus Jr., M.D. Rakesh Shah, M.D. Cody J. Welch, M.D. C. Alan McCarty, M.D. David M. Pearson, M.D. Kaylee J. Shepherd, M.D. Carmen M. Werner, M.D. Allan McCorkle, M.D. Darren L. Peterson, M.D. Isaac Siew, M.D. David M. Wilhelm, M.D. James Scott McCown, M.D. Ruth Pilco-Jaber, M.D. J. Brian Sims, M.D. Jamie L. Wilkerson, M.D. James M. McKenny, M.D. Robert L. Pinkston, M.D. Harnoor Singh, M.D. Sheryl L. Williams, M.D. Dianne S. McKenzie, M.D. Robert T. Pinson, D.O. Monte L. Slatton, M.D. Jacob Williams, M.D. John P. McKinley, M.D. Mary Ann Piskun, M.D. Aubrey Smith, M.D. Kathryn E. McNeil, M.D. Carlos A. Plata, M.D. Earl C. Smith, M.D. Anwar C. Wilson, M.D. David G. McNeir, M.D. Fred Dean Poage, D.O. Kent K. Sorajja, M.D. Susan T. Wingo, M.D. Shari Medford, M.D. Amber M. Price, M.D. D. Gary Soya, M.D. Sara Woodward Dyrstad, M.D. Clyde Meeks, M.D. Liana H. Proffer, M.D. C. V. Sreenivasan, M.D. Kishan Yalamanchili, M.D. Rahul C. Mehta, M.D. Patrick J. Proffer, M.D. James Stafford, M.D. Bindu Yalamanchili, M.D. Nilay V Mehta, M.D. Paul L. Proffer, M.D. Amy L. Stark, M.D. John M. Young, M.D. Daniel J. Merki, M.D. Brian Pruitt, M.D. Mark E. Stevens, M.D. Rodney B. Young, M.D. Thomas E. Merriman, M.D. Bradden R. Pyron, M.D. Randy L. Stewart, M.D. J. Edward Ysasaga, M.D. Scott D. Miller, M.D. LaJohn Quigley, M.D. Grace L. Stringfellow, M.D. Lawrence P. Zarian, M.D. WINTER 2019 PANHANDLE HEALTH 25 | continued from page 23

Decompression sickness and soon develop fatigue. To treat this, they plete 2-year program and is the only one barotrauma are often treated with sleeping medica- considered a true “fellowship” program. In space and in high altitude flight, tions. Adding to the fatigue is the actual pilots and/or astronauts are exposed to loss of muscle mass and bone density in The three civilian programs are increased positive pressure of gases. The their bodies. Astronauts are routinely located at Wayne State University, the positive pressure can do tremendous forced to exercise 2-3 hours a day simply University of Texas Medical Branch at damage to organ systems and body parts. to keep their muscle tone at a baseline. Galveston, and the already mentioned This is especially true of the lungs, heart, As for bone loss, a 3-4-month space trip program at the Mayo Clinic. The two mil- the gastrointestinal tract, the eyes and the causes enough bone redistribution that it itary programs are located at the Wright- ears. Barotrauma and possible decom- will take an average of 2-3 years to recu- Patterson Air Force Base in Ohio and the Naval Aerospace Medical Institute in pression sickness can present with symp- perate and be at the same bone density Pensacola, Florida. toms such as chest pain, muscle fatigue, level(s). Vibration therapy and additional lightheadedness, dizziness, tingling, medication routines are now used as pos- Each program has individual strengths numbness, and generalized body aches sible methods to treat these losses while and weaknesses. However, their core cur- and pains. These are known symptoms in space. riculum holds to the essentials of pre- and can be treated. ventative medicine and the guidelines The newest and most concern- as advocated by the American Board of In space and in high altitude condi- ing finding is that astronauts, especially Preventative Medicine (ABPM). tions, since the pilots and astronauts are after long-term trips, have significant exposed to these harsh conditions and are changes in mental ability. In 2012, stud- Certification(s) at risk for barotrauma and the possible ies from NASA showed that spaceflight The field of aerospace medicine is still resulting decompression sickness, they might in fact accelerate the onset of brain considered a part of the ABPM. The cer- are routinely treated with oxygen to cor- atrophy as seen in disease processes like tification process and the maintenance rect these maladies. In short doses, these Alzheimer’s. Because of these earlier find- of certification in Aerospace Medicine is interventions themselves can cause prob- ings, MRI studies are being completed processed through the ABPM. Both the lems. Long-term exposure to pure oxy- on all flight personnel at NASA. Initial Aerospace Medical Association and the gen is known to cause health problems. details confirm that astronauts who are American Society of Aerospace Medicine These environmental exposures and their exposed to longer journeys and longer Specialists work through the channels of treatments have not been studied long stays at the space stations have greater the ABPM. term. Concerns about such exposure in brain changes. Additional studies are cur- long-term flight/journeys have particu- rently pending. Conclusions lar ramifications especially in light of the Space travel and space medicine go upcoming Mars missions. Immune system changes and the hand in hand. As we venture into the increased rates of infection beyond and leave Earth to seek adventure Brain, heart and body changes For some time now, NASA has noted and science in the worlds that surround In space, most astronauts suffer from that astronauts in space have a decreased us, we are faced with the fragility of our cardiac arrythmias. Studies show that immune system response. The exact own bodies. Studies and experiments in some cases the arrythmias are related nature and degree of the immune com- show that we have to make adjustments to pre-existing conditions. The stresses promise has not been well established. for space travel. Data from the ISS and of space travel and the environmental Coincidentally, multiple research proj- NASA shows that space and space travel changes however seem to cause arryth- ects in the International Space Station are truly harsh and need to be respected. mias to occur far more often in pilots and (ISS) have also found that bacteria and astronauts exposed to the harsh condi- viruses have increased survival and viru- As we study our astronauts and our pilots, we gain tremendous new knowl- tions of space and at the increased alti- lence in space. Studies at the ISS have edge of what we need to survive in the tudes in flight. NASA is further studying shown that bacteria such as Salmonella harsh environments out there. For us to this common occurrence. and Enterobacter actually are more viru- survive and to endure the next step in our lent and more resistant to antibiotics in evolution, we must be able to decipher the Along with cardiac changes, the the environment of the space station and data and to go forward not with fear but most common noted physical finding in space. This series of findings is concern- with knowledge. In this way, aerospace astronauts and pilots is fatigue. It is well ing since it may show increased adapt- medicine is a true opportunity. By using documented that astronauts and pilots ability of organisms other than human in facts and knowledge we have gained, have altered circadian rhythms. This in the space environment. This continues to we can plan well and adjust accordingly turn has effects on their sleep patterns. be a key area of study and concern. Test pilots exhibit this in some cases. to the needs for our future. In this way, Most often this is seen in astronauts Schools available for training aerospace medicine is not only an up and since they are exposed to completely There are five (5) active programs with coming field, it is a needed tool for our abnormal sunrise and sunset sched- training in Aerospace Medicine. Three are survival in the decades and centuries to ules. Astronauts are noted to sleep in civilian based and two are military based. come. 2-3-hour cycles. With this in mind, they Of the five, only one (Mayo) has a com- 26 PANHANDLE HEALTH WINTER 2019 Spotlight: Pediatric Emergency Medicine (PEM) by Schyler Z. Grodman, MD

ew things are more terrifying than a lies often turn towards emergency rooms One major issue with having general Fchild who cannot breathe: to watch for immediate care. The problem with emergency medicine practitioners treat- them claw, fight, and struggle for every this decision is that, across the United ing children is the lack of specialization single breath, to see their throat tight- States, 90% of children are cared for in and comfort, and thus the over-reliance ening up, to watch the muscles in their Emergency Departments not connected upon their ability to simply admit any chest retracting, and to see that, despite to children’s hospitals, which are staffed “questionable” pediatric case instead of their best efforts, they are fighting a bat- by emergency medicine physicians, and managing it from the ER. More often tle they seem destined to lose. This sight not pediatricians. The unfortunate conse- than not, there is a concern among not is all too familiar throughout the Texas quence? Children with bronchiolitis may just emergency medicine physicians, Panhandle region, as well as the United but also Emergency Department nurses, be given treatments designed for those States as a whole, from the fall through to be uncomfortable handling the com- with asthma, or visa versa. Children with winter months, as respiratory viruses plexities of children in an emergency a viral infection may be given unneces- send legions of children into emergency room and to simply admit every unsure sary antibiotics which do not address departments with cough, congestion, and pediatric case to the hospital, whether difficulty breathing. In particular, asthma the issue, and may in fact result in the clinically warranted or not. This is fine and bronchiolitis, two distinct diseases subsequent development of a bacterial during the spring and summer, when impacting two different age ranges of infection that is now resistant to antibi- average pediatric inpatient censuses are children, are a parent’s worst nightmare otics. Namely, the issue is that, in most relatively low. The problem arises dur- and account for the majority of pediatric instances, the doctor treating a child with ing the months where respiratory com- complaints during those months. During an emergency is not, in fact, given com- these times of crisis, children and fami- prehensive training in pediatrics. | continued on page 28

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WINTER 2019 PANHANDLE HEALTH 27 plaints are more prevalent, and a greater PEM fellowship programs in the United comprehensive care of patients rather number of children are brought to emer- States. Those trained in PEM are qualified than being spread too thin. gency rooms with difficulty breathing. It to treat children in any emergency depart- is at these times that the greatest vigilance ment in the United States, whether it be When a child has a heart problem, in care and resource utilization must be the pediatric emergency room of a chil- they go to a pediatric cardiologist. When they have a stomach disorder, they see a practiced; if every single child is simply dren’s hospital, an emergency room in pediatric gastroenterologist. When a child admitted, then the inpatient floor will conjunction with a general hospital (such has an emergency, shouldn’t they be able become full of children who may not have as Northwest or BSA), or any free-stand- to see a doctor who is specially trained required admission and could have been ing emergency room. These physicians to address the emergencies of children? managed adequately in the emergency are specially trained to handle pediatric Additionally, wouldn’t it be of great ben- room. In Amarillo alone, a city with a emergencies in terms of diagnosis, man- efit for the physician seeing children in notable patient population of children agement, and procedures. Additionally, such acute settings to not only be able with chronic special healthcare needs, given the need to manage neonates, many to recognize a sick child, but also the what are we supposed to tell the mother fellowship programs have their trainees vast spectrum of healthy children who, of a child in a sickle cell crisis when there spend time rotating through Neonatal though they may have chronic condi- are not enough beds or nurses for us to Intensive Care Units (NICUs) so that they tions (cerebral palsy, congenital cardiac treat their child’s life-threatening emer- may provide emergent, life-saving care conditions, colostomy bags, epilepsy, and gency upstairs, because we are too busy to early term or preterm infants, such as many more), may not require immediate with children who simply required a few respiratory support or even intubation admission to an inpatient service? breathing treatments or a bolus of saline, (which is technically very different, espe- and are instead taking up that space? It’s cially when comparing the intubation of There is a saying that is used many an incredibly difficult question to answer; an adult with the intubation of the much times in Pediatrics: children are not just let us at least help the Panhandle region smaller airway of a child or infant). small adults. PEM addresses the problem by ensuring that the gatekeepers to the of trying to merely apply adult medicine to children in terms of simply using pediatric inpatient floors are themselves How would this impact the Panhandle “smaller doses.” The problems facing chil- trained in pediatrics. region? Having pediatricians in the emergency rooms of Amarillo would help dren, medical or otherwise, are vastly dif- To address this issue, there is an ensure that only those children who abso- ferent from those facing adults. We have entire sub-specialty within pediatrics that lutely must be admitted to the hospital separate training routes for physicians deals solely with these cases: Pediatric are admitted. These children, and their who treat adults versus those who treat Emergency Medicine (PEM). First offi- families, might be spared the financial, children; we have pediatricians, pediat- cially certified as a sub-specialty of pedi- time, and emotional cost of unnecessary ric surgeons, pediatric cardiologists, etc. In the most trying of times for families, atrics in 1990, PEM focuses on the care of admissions. The system as a whole would when there is the most chaos, the most acutely ill or injured children. Fellowships more efficiently tend to the needs of all uncertainty, the most tension, why should can be done after completion of either a children, and not have those who desper- the Panhandle region not seek to address pediatric or emergency medicine resi- ately require admission be turned away, the emergent needs of children differently dency; those applying from Pediatrics or be delayed in receiving the special- than the crises of adults? enter a 3-year fellowship, while those ized care that they need. The number of applying from an Emergency Medicine hospital-acquired complications or infec- 3 Year Programs Nationwide: 52 residency can complete a fellowship in 2 tions could be reduced. The time of hos- 3 Year Programs in Texas: 3 years. There are currently more than 70 pital house staff could be directed towards (UT-Austin, UT-Houston, UT-Southwestern) 2 Year Programs Nationwide: 25 2 Year Programs in Texas: 1 In Memoriam (UT-Houston)

Emergency Medicine Resident Morgan Hoy McCaleb, M.D. Positions: 50/50 filled in 2018. Family Physician, Pediatric Resident Positions: 146/146 died on June 3, 2019 filled in 2018. at the age of 88. Applications Open: June. He was a member of the Programs Receive Applications: July. Potter-Randall County Application Season: September – Medical Society for 18 years. November. ERAS Match: December Examinations: Biennially (even years). 28 PANHANDLE HEALTH WINTER 2019 Clinical Cardiac Electrophysiology by Ismaile S. H. Abdalla, MD, PhD, FACC, FHRS

linical cardiac electrophysiology tion or hemodynamically compromising Electrophysiologists work closely C(also referred to as arrhythmia ser- ventricular tachycardia), whereas others with other cardiologists and cardiac sur- vices or electrophysiology) is a subspe- are dangerous because of the clinical set- geons to assist or guide therapy for heart cialty of cardiology that is concerned with ting (e.g. atrial fibrillation with rapid ven- rhythm disturbances (cardiac arrhyth- the evaluation and treatment of cardiac tricular response in patients with severe mias). In doing that, one of the tools rhythm disorders. Cardiologists with coronary artery disease or with manifest they use is the EPS. An Invasive EPS expertise in this area are usually referred accessory pathway or preexcitation syn- involves introducing multipolar catheter to as electrophysiologists. drome—WPW syndrome--with capabil- electrodes into the venous system (and ity of rapid conduction of the very fast sometimes the arterial system) and posi- The training required to become an atrial rate leading to ventricular fibrilla- tioning the electrodes at various intracar- electrophysiologist is lengthy and entails tion). Some arrhythmias, such as prema- diac sites to record or to stimulate cardiac seven to eight years after medical school ture ventricular complexes (PVCs), may electrical activities. The heart is stimu- (in the U.S.). Physicians must complete be highly symptomatic but not be associ- lated from portions of the atria or ven- three years of internal medicine residency ated with adverse outcome, whereas other tricles and from other sites as needed (e.g. and three years of clinical cardiology fel- patients with atrial fibrillation may have near the accessory pathway in WPW). lowship, before enrolling in an accredited no symptoms at all but may still be at sig- Such studies are performed diagnostically electrophysiology fellowship program nificant risk of stroke. to provide information about the type of for at least two years. During fellowship the clinical rhythm disorder and insight training, future electrophysiologists will Evaluation of patients with cardiac rhythm disorders begins with a careful into its electrophysiological mechanism, be trained on all aspects of diagnosing which will guide the treatment. The and treating various cardiac rhythm dis- history and physical examination, and should usually progress from the sim- remainder of this article will focus on the orders, as well as evaluation of patients invasive EPS. with fainting disorders and those who plest to the most complex tests, from the least invasive and safest to the most inva- suffer from palpitations. Also, they will Durrer et al in Amsterdam and sive and risky, and from the least expen- be trained on all aspects of device man- Coumel and his associates in Paris inde- sive out of hospital evaluations to those agement of cardiac arrhythmias includ- that require hospitalization and complex pendently developed the technique of ing pacemakers, cardiac defibrillator costly procedures. At times, depending Programed Electrical stimulation of the implants, and cardiac resynchronization on the clinical situation and patient’s pre- heart in 1967. This began the first decade devices (used to treat certain patients with sentation, the physician may choose to of Clinical Cardiac Electrophysiology. congestive heart failure). In addition to proceed directly to a high risk, expensive The early years of electrophysiology in that, in certain programs they learn to procedure, such as Electrophysiologic man were dominated by descriptive work explant pacemaker and defibrillator leads. Study (EPS), before getting noninvasive exploring the presence and timing of His Once they successfully complete their electrocardiographic monitoring. | continued on page 30 fellowship program, fellows become eligible to sit for the examination to become Board Certified in Clinical Cardiac Electrophysiology. They are subject to the American Board of Internal Medicine Panhandle Area Physician (ABIM) rules and regulations for maintenance of certification; currently recertifi- cation is required every 10 years. Rosters are on sale for In the management of patients with cardiac rhythm disorders, the electrophysiologist must evaluate and treat the whole patient, not just the rhythm dis- $10.00 order. Some arrhythmias are life threatening to the patient irrespective of the clinical situation (e.g. ventricular fibrilla- WINTER 2019 PANHANDLE HEALTH 29 Bundle activation (and that of a few other The other major thrust of the last who would benefit from an implantable intracardiac sites) in a variety of sponta- 2-3 decades has been the use of cath- cardioverter-defibrillator. neously occurring physiologic and patho- eter ablation techniques to treat, and in In summary, EPS can be helpful logic states. A quantum leap occurred, many cases to cure, cardiac arrhythmias. in patients who have sinus node dys- however, when the techniques of pro- Focal ablation of the area of the myocar- function, AV nodal dysfunction, intra- gramed stimulation were combined with dium involved in the tachyarrhythmia, ventricular conduction disturbance, intracardiac recording by Wellens in the using radiofrequency energy, is now the treatment of choice for patients with a tachyarrhythmias, unexplained syn- Netherlands. Use of these techniques sub- variety of supraventricular tachycardias cope, near syncope and palpitations. sequently furthered our understanding of including AV nodal reentry tachycar- Therapeutically, EPS have been very suc- the functional components of the AV spe- dia (AVNRT), atrio- ventricular recip- cessful in treating and curing a variety of cialized conduction system, including the rocating tachycardia (AVRT) utilizing cardiac arrhythmias. Research continues refractory period of the atrium, the AV a manifest or concealed accessory path- particularly in the area of catheter abla- node, the His Bundle and the ventricles. way, focal or reentrant atrial tachycar- tion of atrial fibrillation where, although dia, atrial flutter, ventricular tachycardia many patients undergoing this proce- This led to the development and the in normal heart and in certain patients dure enjoy a high percentage of suc- use of EPS as a tool for treating arrhyth- with coronary artery disease and previous cess with the first procedure, some of mias. The ability to reproducibly ini- myocardial infarction. Recently, radiofre- them will require a second ablation. If tiate and terminate arrhythmias by quency ablation has become important the pace of advancement of the past half programmed atrial and ventricular stim- in the management of certain patients century continues, these and other com- ulation led to the development of serial with atrial fibrillation. Finally, EPS has plicated rhythm problems will be more drug testing to assess the efficacy of anti- been used prognostically to identify successfully and easily treated by clinical arrhythmic drugs. patients at risk of Sudden Cardiac Death electrophysiologists. Happy Holidays from the Potter-Randall County Medical Society Retired Members

Ismaile Abdalla, M.D. Thomas D. Easley, M.D. Jake Lennard, M.D. Miguel A. Rios, M.D. Walter Allison, M.D. William East, M.D. Sien H. Lie, M.D. Pablo Rodriguez, M.D. John J. Alpar, M.D. John Ellis, M.D. Robin Martinez, M.D. James F. Rogers, M.D. Masoud Alzeerah, M.D. Roberto Estevez, M.D. James W. Mason, M.D. Michael G. Ryan, M.D. Leora R. Andrew, M.D. Don Leon Fong, M.D. Nazre Mawla, M.D. Martin Schneider, M.D. William A. Anthony, M.D. Richard Franklin, M.D. Vicente F. Maza, M.D. Richard K. Archer, M.D. W. Glenn Friesen, M.D. Richard F. McKay, M.D. Charles W. Seward, M.D. G. Emily Archer, M.D. Nona D. Fulton, M.D. John Milton, M.D. H. Wayne Smith, M.D. Bill Barnhill, M.D. Nathan Goldstein III, M.D. Carroll T. Moore, M.D. Rush Snyder, M.D. Richard H. Bechtol, M.D. Cesar Guerra, M.D. C. Tom Nichols, M.D. James Spurlock, M.D. David F. Beggs, M.D. James E. Hamous, M.D. Robert W. Paige, M.D. Bob L. Stafford, M.D. Howard Berg, M.D. Ann Harral, M.D. Suryakant J. Patel, M.D. Andrew Stenhouse, M.D. Gayle H. Bickers, M.D. Robert J. Hays, M.D. Vinod S. Patel, M.D. Robert Taylor, M.D. Andrew Brooker, M.D. James Hefner, M.D. Phillip Periman, M.D. Turner Caldwell III, M.D. Charles K. Hendrick, M.D. Dennis Plummer, M.D. Victoria Thompson, M.D. Dennis L. Canon, M.D. Thomas J. Hickman, M.D. Gary Polk, M.D. Paul E. Tullar, M.D. Arturo Carrillo, M.D. Richard High, M.D. Randel E. Posey, M.D. Steve Urban, M.D. David G. Carruth, M.D. J. Franklin Howell, Jr., M.D. Donald Pratt, M.D. Aniceta V. Velky, M.D. R. Lowell Chafﬁn, M.D. Douglass Hyde, M.D. William Price, M.D. Jack Waller, M.D. Pam Chandler, M.D. Robert Jackson, M.D. Loralu Raburn, M.D. Bruce Weinberger, M.D. John Coscia, M.D. Richard L. Jennings, M.D. Holley W. Reed, M.D. Michael Westmoreland, M.D. Robert E. Cotton, M.D. Kenneth H. Johnston, M.D. Leslie E. Reese, M.D. R. H. Cox, M.D. W. Mitchell Jones, M.D. Harvey Mac Richey III, D.O. Charles Wike, M.D. Hugh Bob Currie, M.D. John Kaczmarek, M.D. Joan Riker, M.D. Michael D. Williams, M.D. Edwin L. Dodson, M.D. Keith D. Kartchner, M.D. Charles Rimmer, M.D. Geoffrey Wright, M.D.

30 PANHANDLE HEALTH WINTER 2019 Hospice and Palliative Care Training

by Susan Meikle, MD

eople with serious illness have pri- ment of pain and other problems, physi- ied tools such as the Memorial Delirium Porities besides simply prolonging cal, psychological, and spiritual.” Hospice Assessment Scale or the Mini-Cog®. their lives,” writes Dr. Atul Gawande in and palliative care encompasses the inter- Being Mortal. “If your problem is fixable, disciplinary evaluation and treatment of Advance care planning is another we know just what to do. But if it’s not? physical, emotional, spiritual and social important component of the pallia- The fact that we have had no adequate realms. The hospice and palliative care tive care evaluation and treatment plan. answers to this question is troubling and physician is trained in the skillful man- Advance care planning is the process of has caused callousness, inhumanity, and agement of distressing physical symp- communication between the patient, the extraordinary suffering.” toms, alleviating psychological distress, family or health care proxy, and medical providing support for evolving sense of staff in prospectively identifying a surro- Chronic illnesses and cancer are now identity, enhancing relationships, and, gate decision maker, clarifying treatment the leading causes of death in industrial- finally, setting achievable goals. preferences, and developing individualized countries. 78% of the US population ized goals of care near and up to end of lives past their 65th birthday, and more A comprehensive palliative care life. The primary goals of the palliative than ¾ will have cancer, stroke, heart dis- assessment is the basis for treatment. care evaluation are to enhance education ease, obstructive lung disease or demen- The palliative care assessment includes about illness (including prognosis and tia. Most cancer patients are in their 60’s clinical assessment, social history, func- outcomes), to define key priorities in end- to 70’s. This shift in the aging of the pop- tional status, and mental status exam as of-life care, and to develop a care plan ulation and increase in chronic, severe well as a review of the medical records. that addresses these issues. Advance care disease with life-limiting impact has led Symptom burden is assessed often by the planning is important to help patients to the development of the subspecialty Edmonton Symptom Assessment Scale find hope and meaning in life, to help Hospice and Palliative Care. (ESAS), which is a ten-point numeric achieve a sense of spiritual peace, and to scale that measures average intensity strengthen relationships with loved ones Suffering has been deconstructed by over previous 24 hours for symptoms of (Fast Facts #162, Advance Care Planning the medical establishment. Debilitation pain, fatigue, nausea, depression, anxiety, in Chronic Illness). and the dying process occur contempo- drowsiness, appetite, feeling of wellbeing, rarily over months to years instead of shortness of breath and sleep. Two addi- Referrals to palliative care services days to weeks as in the past. This cre- tional items have recently been added: are available to help patients at any time ates a situation where suffering occurs. spiritual pain and financial distress (The in the cancer trajectory, whether that be Suffering is an all-encompassing effect MD Anderson Supportive and Palliative during active treatment, palliative treat- on the patient. Medicine has focused on Care Handbook, Fifth Edition 2015, pp. ment, or hospice (6 months or less life pain as the sole representative of suffering 166). In addition to physical symptoms, expectancy). Other life-limiting diseases because it is quickly assessed and is acces- palliative care physicians often carry are also be eligible for palliative care ser- sible. However, this has created a false out decisional capacity testing with var- | continued on page 32 sense of control, equating relief of pain with alleviation of suffering. This dis- tances patients from providers by avoiding other equally important dimensions. In Memoriam Dying has become the final stage of psy- chosocial development.

In 1990 The World Health Richard D. Chandler, D.O. Organization identified Palliative Care Family Physician, as a specialty. In 2002, the WHO defined died on June 10, 2019 palliative care as “an approach that at the age of 85. improves the quality of life of patients and their families facing the problems He was a member of the associated with life threatening illnesses, Potter-Randall County through the prevention and relief of suf- Medical Society for 6 years. fering by means of early identification and impeccable assessment and treat- WINTER 2019 PANHANDLE HEALTH 31 vices including end-stage renal disease, ogy, family medicine, pediatrics, neurol- ing from direct patient care in a variety COPD, late stage heart failure, dementia, ogy, and psychiatry, among others. The of settings to administrative roles with or stroke. Palliative care can be deliv- one-year palliative care fellowship supple- less patient care contact. This field also ered in the hospital, emergency room, ments the base residency, and its com- provides expanding opportunities for long term care facility and office setting. pletion allows for dual certification. The research. Palliative care outpatient clin- Palliative care in the last six months of fellowship typically includes inpatient, ics and new models of concurrent care life is hospice care, and programs often outpatient, long term care, home hospice, delivery will further expand the diversity deliver both palliative care and hospice and pediatric rotations. During the inpa- of this career. care in the home setting. Both adults and tient rotation, it would be common to see children can be offered palliative care. patients in the emergency department, in In summary, subspecialists in Hospice Compassionate palliative care works best the intensive care unit, and on the wards. and Palliative care offer specialized medi- when there is a team approach, usually Fellows are educated on breaking bad cal care to patients with incurable disease, including physicians, nurses, social work- news, pain management, delirium, and from pediatric to geriatric age groups, in ers, and other professionals. other symptoms associated with life-lim- both inpatient and outpatient settings. iting diseases and dying. This one-year fellowship focuses skills The American Medical Association states that Hospice and Palliative medi- Board certification is achieved by acquired during the base residency (e.g. cine is a new and a rapidly growing field. passing the biannual exam. Board certi- internal medicine, family medicine) onto One of 10 residency programs must be fication in the primary specialty must be the care of appropriate patients, and the completed before electing to spend an maintained in order to remain board eli- physician so trained achieves dual certi- additional year undergoing specialized gible for hospice and palliative medicine. fication. This focused training in symp- hospice and palliative medicine train- Many possible career routes can be cho- tom control, spiritual care and end-of-life ing. Elegible primary specialty programs sen after completing formal training in preparation allows these practitioners to include internal medicine, surgery, hospice and palliative medicine. Palliative manage transitions and to alleviate suffer- obstetrics and gynecology, anesthesiol- medicine careers cover a spectrum rang- ing for all of our eligible patients. Happy Holidays from the Potter-Randall County Medical Society Resident Members Kerolos Abdelmalek, M.D. “Jade” Dharmarpandi, M.D. John Kimbuqwe, M.D. Sameer Prakash, D.O. Mais Abdou, M.D. Tram Dinh, M.D. Fasiha Klair, M.D. Rebecca Ramdhan, M.D. Kholud Alarji, M.D. Daniyah Elagi, M.D. Lauren Knight, M.D. Nicoleta Rus, M.D. Aparna Alavalapadu, M.D. Nahla Elzubeir, M.D. Anders Leverton, M.D. Tarek Shihab, M.D. Ikha Al-Azzawi, M.D. Nolan Farmer, D.O. Joe Lin, D.O. Ghassan Sindi, M.D. Ibraheem Algarni, M.D. David Fields, M.D. Tasai Lo, M.D. Khaled Alhbshi, M.D. Antonio Flores, D.O. Taylor Maguire, M.D. Aesha Singh, M.D. Hamsa Aljumaili, M.D. Marie Fouad, M.D. Tarek Mansi, M.D. Moutasim Souliman, M.D. Abdulelah Almutairi, M.D. Matthew Goldﬁnger, D.O. Abdullah Masud, M.D. Kinsley Stepka, D.O. Farah Alsaati, M.D. Martha Gonzalez, D.O. Michael “Drew” McBrayer, M.D. Cystal Stewart, M.D. Muath Alsharif, M.D. Schyler Grodman, M.D. Ephrem Melese, M.D. Leland Stoddard, III, M.D. Muhammad Amin, M.D. Anita Gupta, M.D. Nooraldin Merza, M.D. Talal Talal, M.D. Dalya Aqel, D.O. Natasha Gupta, D.O. Assad Mohammedzein, M.D. Nibras Talib Mamury, M.D. Shyla Arismendez, M.D. Wagas Hafeez, M.D. Nandar Mon, M.D. Turki Tallab, M.D. Chandralekha Ashangari, M.D. Jacob Hall, M.D. Asisha Mozumder, M.D. William Baladron Guerra, M.D. Ahmad Hallak, M.D. Faiza Mubeen, M.D. Gabrielle Tardier, M.D. Abigail Batson, M.D. Randa Hazam, M.D. Lusine Nahapetyan, M.D. Matthew Thigpen, M.D. Lynn “Kevin” Benson, M.D. Brian Hokeness, M.D. Mithra Lakshmi Narasimhan, M.D. Rachel Thomas, M.D. Oluwatosin”Tosin” Bewaji, M.D. Katlyn Hoover, M.D. Montana O’Dell, M.D. Olusola Komolafe Tjani, M.D. Elspeth Bittle, M.D. Sheikh Islam, M.D. Nneka Okeke, M.D. John Mark Tohlen, M.D. Solomon Boagale, M.D. Llya Ivanskiy, M.D. Nkechi Okotcha, M.D. James “Jim” Walter, M.D. Victoria Bzik, M.D. Apurva Jain, M.D. Ayobami Olanrewaju, M.D. Jonathan Werner, M.D. Divya Cheruku, M.D. Anuja Kamat, M.D. Lenah Omer, M.D. Rasmey Chhin, D.O. Preetha Kandaswamy, M.D. Koley”Chance” Pack, M.D. Shaun Wesley, M.D. Eliza Contreras, M.D. Deepika Kaushal, D.O. Hirva Pandya, M.D. Justin Williams, M.D. Steven Cummings, M.D. Muhammad Khan, M.D. Joshua Penniman, M.D. Christina Young, M.D. Dhara Dave, M.D. Audrey Kim, M.D. Lindsay Porter, M.D. Hina Yousuf, M.D.

32 PANHANDLE HEALTH WINTER 2019 The Evolution of HIV Care by Scott Milton, MD

he HIV epidemic began around 1980 advanced disease requiring long hos- invented. While these drugs remain very Twhen healthy young gay men devel- pitalizations and expensive treatment expensive they are highly cost-effective oped a rare pneumonia termed pneumo- protocols with generally poor outcomes. by allowing these individuals to maintain cystis. These individuals also developed Antiretroviral therapy was limited and their health and productivity. Further, the rare cancer Kaposi’s sarcoma. This the drugs were expensive; many believed the risk of transmission is much reduced new syndrome, called the Acquired that two or three drug regimens would when an individual is receiving effective Immune Deficiency Syndrome or AIDS, bankrupt the health care system. If indi- therapy, which further reduces the bur- was found later to be caused by a novel viduals were diagnosed prior to becoming den of this disease on our society. virus. Despite this discovery, testing for ill it was a common practice to withhold As the HIV epidemic evolved over acquisition of the virus was not avail- antiretroviral therapy and monitor their this time, the individuals and treatment able until 1985. I entered medical school parameters over time. However, as the team also evolved and began to include in Houston Texas in the fall of 1985 and clinical regimens for any retroviral drugs individuals who did not obtain training clearly remember a large open room became established and as combination filled with young men on ventilators through an infectious disease fellowship. pill therapy became commonplace, which The specialty of infectious diseases has dying from this pneumonia. I also recall improved compliance, the nature of HIV around this time the Houston newspapers been recognized by the American Board care and where and when it was delivered of Internal Medicine since the early 1970’s reporting that the city of Houston would began to change. By the mid to late 1990s build a 5000 bed hospital designated as a distinct subspecialty with a certifica- the regimens were good enough that most tion exam. Infectious diseases is a broad just for AIDS patients. The response to people with HIV could avoid hospital- the epidemic was clearly an unprepared field, and no discipline of medicine is ization. It also became clear that patients spared. I believe this is why I’ve been able and desperate attempt to grapple with placed on treatment as soon as they were the enormous burden on the healthcare to meet most practitioners on staff at our diagnosed had improved outcomes over hospitals. Infectious diseases also touches system. time. HIV care became almost exclusively many other medical disciplines such as AZT or zidovudine was the first drug an outpatient disease. Ironically a com- public health and global health that are that was shown to be effective against mon complaint of our internal medicine beyond the scope of a traditional hospital the HIV virus. This was developed in the residents is the lack of experience caring setting. The breadth of knowledge in this mid-1980s. It wasn’t until the late 1980s for HIV patients. This is truly a testimony field is illustrated when the content cat- and early 1990s when multiple drug regi- to the great advances in HIV care and mens were found to be more effective that specifically to the drugs that have been | continued on page 34 using one drug alone. A new class of antiretroviral drugs called protease inhibitors were invented in early 1990s, with saqui- 100 % Membership navir being the first commercially avail- Thanks to the group practices* whose entire physician staff are able drug. The highly potent integrase members of Potter Randall County Medical Society and TMA. inhibitors became available in 2007 with raltegravir. These are the most important Amarillo Emergency Physicians class of drugs in use today and are essen- Amarillo Family Physicians Clinic tially the backbone of therapy. Amarillo Heart Group • Amarillo Urology Therefore, in my career, HIV has Cardiology Center of Amarillo gone from an untreatable fatal infection High Plains Radiological Association to a highly treatable (although incur- Panhandle Eye Group able) disease that can be managed over Texas Oncology time much like any other chronic medical condition. Initially, HIV was almost Women’s Healthcare Associates exclusively treated in the hospital. Most Amarillo Anesthesia Consultants clinically- based internal medicine pro- Texas Tech/Dept. of Surgery grams and infectious disease fellowships were overwhelmed with the HIV *those groups of seven or more epidemic. Almost all HIV patients had WINTER 2019 PANHANDLE HEALTH 33 egories for certification are reviewed from an important but relatively small subset. practitioners, physician assistants, and the ABIM website. These include: bacte- Further, the practices of many infectious pharmacists. The HIV specialist is avail- rial disease 27%, HIV 15%, antimicrobial disease doctors are focused on other spe- able to clinical providers while the HIV therapy 9%, viral diseases 7%, travel and cific aspects of infectious diseases such as expert is offered to nonpracticing clini- tropical medicine 5%, fungi 5%, immu- transplant medicine, ICU medicine, or cians. The HIV pharmacist is available nocompromised host (non-HIV infected) even global medicine. In fact, HIV care to eligible HIV-specialized pharmacists. 5%, vaccinations 4%, infection control is best delivered by those to practice this This entity offers a core curriculum which and prevention 5%, general internal med- exclusively. is a web-based learning resource cover- icine, critical care, and surgery 15%. ing both the basics of HIV care as well as Within the American Board of the latest advances in care. The core cur- Internal Medicine is the HIVMA, an Competency in HIV care has always riculum is designed to assist providers organization of medical professionals been incorporated in the curriculum new to the field as well as those with expe- who practice HIV medicine. This entity of the infectious diseases fellowship. rience. The program is produced by the serves those who were trained through an Infectious diseases fellowships are usu- American Academy of HIV Medicine and ally a minimum of two years. A year of infectious diseases fellowship and a residency in internal medicine after medical is supported by unrestricted grants from research often is added to training pro- Gilead Sciences and Viiv Health. grams with significant research oppor- school. There are many clinicians and scientists who only care for HIV infected tunities. HIV training usually includes In summary, just as the HIV epi- patients. The HIVMA website also offers managing an inpatient service as well as demic has evolved so has the care and an HIV provider directory. There are an outpatient clinic. Over the two or three the individuals trained to treat HIV. videos and clinical practice guidelines as year fellowship, trainees manage compli- Traditionally, HIV care was mastered well as resources and links to professional cated medical issues unique to HIV inpa- through an infectious disease fellowship development and other subjects useful to tient care and deal with social barriers with prior training in internal medicine. those researching HIV or caring for HIV that prohibit optimal care. The outpatient The American Academy a HIV medicine infected patients. care experience many times involves a has evolved separately from the American comprehensive approach to patient care Another alternative that has evolved Board of Internal Medicine and offers with social services, psychiatric and medi- separately is the American Academy of its own credentialing to individuals not cal care all offered under the same roof. HIV Medicine. This professional orga- formally trained with an infectious dis- Trainees can gain competency by working nization supports HIV practitioners to ease fellowship. Further, this entity offers in each setting. Thus, individuals who are promote quality care for all Americans accreditation to individuals other than fellowship trained in Infectious Diseases living with HIV. Credentialing is offered physicians including nurse practitioners, are broadly trained with HIV care being not only to physicians but also to nurse physician assistants and pharmacists.

Yes, I Would Like To Contribute To The Potter-Randall County Medical Society Endowment Fund The endowment fund was established in 1981 to promote the advancement of general education in medical science in Potter and Randall counties through discussion groups, forums, panel lectures, and similar programs. It is the hope of the society that, through the endowment fund, the work of our physicians will be continued by increased public awareness and understanding of the advances in medical science. We are happy to accept memorials and/or honorariums. Notiﬁcation of gift is sent immediately. Amount remains conﬁdential. Your contribution is tax deductible. Please make checks payable to Potter-Randall County Medical Society, and send to PRCMS, 1721 Hagy, Amarillo, Texas 79106. Enclosed is my contribution of $ ______Print Name ______Address ______City ______State ______Zip ______My gift is in memory of ______My gift is in honor of ______Please send acknowledgement of this gift to: Name ______Address ______City ______State ______Zip ______

34 PANHANDLE HEALTH WINTER 2019 CASE REPORT Incidental Right-Sided Aortic Arch with Aberrant Left Subclavian Artery David P. Foley, MBA; Alyssa R. Byrd, BS; Allison S. Gracey, BS; Chandralekha Ashengari, MD Texas Tech Health Sciences Center Department of Internal Medicine, Amarillo, Texas, USA

Introduction: Discussion: should recognize common features of this Right-sided aortic arch (RAA) is com- Aortic malformation beginning in syndrome such as abnormal facies and monly asymptomatic and found inci- the 4th through 7th weeks of embryonic hypocalcemia. dentally on radiographs. This case report development is responsible for RAA. Literature provides many examples aims to distinguish the types of RAA, Normal development begins with two of unwarranted surgeries and tests con- clarify the alternative management plans, arches, followed by involution of the ducted on asymptomatic RAA. The and assess for common cardiovascular right. In RAA, the right side of the dou- authors hope that accurate identification comorbidities. ble arch persists while the left involutes. RAA occurs in 0.05% of the general pop- of RAA and its types will prevent these Case: ulation and is associated with many vas- unnecessary interventions. A 71 year old white female with a past cular anomalies (1). The most common References: medical history of COPD, renal disease, of these, vascular ring, is a failure of left 1. Nair KKM, Ganapathi S, Inamdar S, atherosclerosis, hypertension, and atrial ductus arteriosus (LDA) involution which Gopalakrishnan A, Kapilamoorthy fibrillation presented to the ER with vom- may compress the trachea and esophagus. TR, Valaparambil A. Incidentally iting and diarrhea. The patient was afe- Although associated with 22q11 deletion detected right aortic arch with brile, hypotensive (79/40), and reported a syndrome, RAA is not typically related to mirror image branching in a patient cough. She was given 2L NS. Thoracic CT genetic abnormalities. Current literature with rheumatic calcific mitral valve showed an isolated pulmonary nodule. has not yet established a definitive etiol- disease. Natl Med J India. 2018 Jan- Type II RAA (Figure 1) was also noted. ogy (2). Feb;31(1):22-23. doi: 10.4103/0970- 258X.243408. PubMed PMID: She denied dysphagia, dyspnea, angina, RAA is classified by the branching 30348918. claudication, syncope, edema, and a fam- pattern of arch vessels: mirror type [I], ily history of medical conditions. aberrant left subclavian (LSCA) [II], and 2. Evans WN, Acherman RJ, Berthoty isolation of the LSCA [III]. Type I is the D, Mayman GA, Ciccolo ML, presence of left innominate, right com- Carrillo SA, Restrepo H. Right aortic mon carotid, and right subclavian arter- arch with situs solitus. Congenit ies. It is associated with left pulmonary Heart Dis. 2018 Jul;13(4):624-627. doi: 10.1111/chd.12623. Epub 2018 artery (LPA) stenosis/isolation. In type Jul 22. PubMed PMID: 30033669. II, the LSCA exits the left dorsal aortic root leading to increased risk for vascular 3. Shuford WH, Sybers RG, Edwards rings. Type III is characterized by an iso- FK. The three types of right aortic lated LSCA connected to the LPA by the arch. Am J Roentgenol Radium Ther LDA and presents with absent left upper Nucl Med. 1970 May;109(1):67-74. extremity pulse (3). PubMed PMID: 5442127. Figure 1: Axial CT shows RAA with Recognizing RAA type is important 4. Hastreiter AR, D’Cruz IA, Cantez aberrant left subclavian originating for determining management and pre- T, Namin EP, Licata R. Right-sided from dilated dorsal aortic root (white dicting complications. In asymptomatic aorta. I. Occurrence of right aortic arrow). patients with Types I or III, no further arch in various types of congenital management is needed. All patients heart disease. II. Right aortic Surgical history included carotid with Type II RAA or RAA concomitant arch, right descending aorta, and endarterectomy, appendectomy, and with atherosclerosis should be screened associated anomalies. Br Heart J. 1966 Nov;28(6):722-39. Review. hysterectomy. Medications included ami- via Doppler ultrasonography for carotid PubMed PMID: 5332779; PubMed odarone, amlodipine, aspirin, clopidogrel, and subclavian artery stenosis (4). While Central PMCID: PMC490086. metoprolol, omeprazole, prednisone, and providers should be aware of the poten- simvastatin. Physical examination was tial sequelae of RAA’s associated vascular 5. Stewart JR, Kincaid OW, Titus unremarkable. Urine demonstrated mild malformations, management is limited to JL. Right aortic arch: plain film acute kidney failure. Fluid resuscitation symptomatic treatment such as surgical diagnosis and significance. Am J was given, and blood pressure improved. correction of compressing vascular rings Roentgenol Radium Ther Nucl Med. She was discharged and instructed to fol- (5). Patients with RAA have increased risk 1966 Jun;97(2):377-89. PubMed low up for evaluation of the lung nodule. of comorbid 22q11 deletions. Physicians PMID: 5944202. WINTER 2019 PANHANDLE HEALTH 35 PATIENT INFORMATION Nonalcoholic Fatty Liver Disease – NAFLD by Tarek Naguib, MD, MBA, FACP

What is Nonalcoholic Fatty Liver? How Do I Suspect Having Nonalcoholic lipids, blood glucose, and blood pressure Nonalcoholic Fatty Liver Disease Fatty Liver? all have been used with success to con- (NAFLD) describes fatty accumulation If you are obese you have a higher risk trol the condition. Liver biopsy has been and inflammation in liver cells from any of NAFLD. Metabolic syndrome puts you used to characterize suspected severe liver cause other than alcohol use. This can at high risk to develop NAFLD. Metabolic involvement in order to define the exact progress to severe liver failure over time. syndrome is a condition of overweight, cause. high blood pressure, poor response to What is the Cause of Nonalcoholic Fatty What is Liver Biopsy? Liver? insulin, and high blood lipids (fat). Liver biopsy means obtaining a small Exact causes are not well known, but How Do Doctors Diagnose piece of the liver, usually using a needle obesity is a risk factor for the condition. with no need to use surgery. The needle Nonalcoholic Fatty Liver? is inserted through the skin into the liver Why Nonalcoholic Fatty Liver? Blood work for liver functions, liver using ultrasound or CT guidance. NAFLD has the potential to advance ultrasound, and CT scan have all been to a condition called nonalcoholic steato- used in order to diagnose NAFLD. For more information: National Insti- hepatitis (NASH), which is an advanced tute of Diabetes and Digestive and Kidney What is the Plan to Manage accumulation of fat in the liver causing Dieases. fibrosis and scarring of the liver. This fur- Nonalcoholic Fatty Liver? ther leads to cirrhosis and liver failure. Increase of physical activity, weight www.niddk.nih.gov/health-information/ Severe cirrhosis can lead to death. loss through better diet, control of blood liver-disease/nafld-nash

UPCOMING EVENTS 2020

TMA TMA Fall Conference Winter Conference Sept. 11-12 Jan. 24-25 Hyatt Lost Pines Hyatt Regency Austin Area, TX Austin Area, TX TexMed 2020 AMA House of Delegates Interim Meeting May 1-2 Fort Worth Convention Center Nov. 14-17 and Omni Fort Worth Manchester Grand Hyatt Fort Worth, TX San Diego, CA AMA House of Delegates Annual Meeting TMA Advocacy Retreat June 6-10 Dec. 4-5 Hyatt Regency Omni Barton Creek Chicago, IL Austin, TX

36 PANHANDLE HEALTH WINTER 2019 HEALTH NEWS by Tarek Naguib, MD, MBA, FACP

Opioids in Texas in 2017 Tex Med screening pregnant women for asymp- as tamoxifen, raloxifene, or aromatase (11/19) – There were 1,458 overdose tomatic bacteriuria using urine culture (B inhibitors, in women who are at increased deaths in Texas involving opioids and 53 recommendation). risk of breast cancer and low risk of medi- opioid prescriptions per 100 people (less cation side effects (B recommendation). than national average of 58). New Nasal Glucagon for Low Sugar This applies to women 35 years or older JAMA (9/19) – The first non-injectable who are without symptoms. Texas Sues Opioid Maker Tex Med glucagon therapy for treating severe (11/19) – Texas attorney general hypoglycemia has received FDA approval. Counseling Doctors! JAMA (10/19) – announced a suit against Johnson & The intranasal powder is called Baqsimi Physicians reported less burnout and Johnson for “misrepresentation” to Texas and is used for severe hypoglycemia in emotional exhaustion after receiving Medicaid program about their fentanyl diabetics aged 4 years or older. short-term professional coaching according to a pilot trial. After 5 months of opioid drug to doctors. Oklahoma won a being counseled (on average 3.5 hours a $572 million judgment against the drug A Pill for Women at Risk of Breast month), doctors reported 50% less emo- maker in a similar law suit. Cancer JAMA (9/19) – USPSTF recommends that clinicians offer to pre- tional exhaustion compared to doctors scribe risk-reducing medications, such who were not counseled. Marijuana Use on the Rise JAMA (10/19) – Marijuana continues to be the most widely used illicit drug in the United States, with 15.9% of people aged 12 years or older reporting that they had used it in the past year. Federal government still considers the drug illicit even though many states have legalized it.

Preexposure Prophylaxis for HIV JAMA (11/19) – A new combination drug called Descovy (emtricitabine and tenofovir alafenamide) was approved by FDA for men and transgender women who have sex with men. It is taken daily to prevent catching HIV from high risk behavior. Cisgender women (non-transgender women) were not tested. Descovy is safer than its predecessor Truvada in terms of kidney side effects.

Drug Costs in the US JAMA (10/19) – The Drug costs in the US have increased more than three fold in the last 20 years. Three of every 10 report not taking their medicines due to cost!

Pregnancy Related Death in the US JAMA (10/19) – About 28% of deaths in relation to pregnancy in the US are shared equally among hemorrhage and cardiovascular conditions. Approximately 70% of these deaths are preventable!

USPSTF Recommends Urine Screen in Pregnancy JAMA (9/19) – The US Preventive Services Task Force (USPSTF) has updated its recommendations for WINTER 2019 PANHANDLE HEALTH 37 Spotlight on New Members

Board of Censors Report: HANSEN, NATHAN, M.D. The following were approved for membership on January 15, 2019: GENERAL SURGERY (GS) 1400 S. Coulter, Amarillo TX. REGULAR MEMBERSHIP: Graduated from Pennsylvania State University, Milton S. Hershey Medical Center, Hershey PA HERNANDEZ, HECTOR, M.D. 2007. Residency at Pennsylvania State University, Hershey PA 2007-2012. OTOLARYNGOLOGY (OTO) HASHIMOTO, YOHEY, M.D. 3501 Soncy #140, Amarillo TX 79119. GENERAL SURGERY/COLON/RECTAL SURGERY (GS/CRS) Graduated from University of Pennsylvania School of Medicine, Philadelphia PA 1990. Internship 1400 S. Coulter, Amarillo. and Residency at Hospital of the University of Pennsylvania, Philadelphia PA 1990 -1995. Graduated from Yokohama City University, Yokohama, Kanagaw 2005. Internship and Residency TRANSFER MEMBERSHIP: at Allegheny General Hospital, Pittsburgh PA 2012-2016. Fellowship at New York-Presbyterian/ Weill Cornell Medical Center, New York NY 2016-2017 (Critical Care). CRABTREE, ROBERT N., M.D. ANESTHESIOLOGY//PAIN MANAHGEMENT (AN/APM) HOLMES, HEATHER M.D. 6819 Plum Creek Drive, Amarillo TX 79124. OBSTETRICS/GYNECOLOGY - (OBG) Transfer from Dallas County Medical Society 1400 Coulter, Amarillo TX 79106. Graduated from Texas Tech University Health Science Center, Lubbock TX 1987. Internship and Rejoined. Graduated from University of Texas Medical Branch, Galveston TX 1998. Internship and Residency, Dallas TX 1987-1991. Residency at Texas University Health Science Center, Amarillo TX 1998-2002. Residency/Post Grad at University of Texas Southwestern, Dallas TX 2002-2005 (Maternal & Fetal Medicine, MFM). PEARSON, DAVID M., M.D. FAMILY MEDICINE (FM) MALKUCH, GERALD, M.D. 1400 S. Coulter, Ste. 5100, Amarillo TX 79106. ANESTHESIOLOGY (AN) Transfer from Galveston County Medical Society 2201 Civic Circle, #503, Amarillo TX. Graduated from University of Texas Medical Branch, Galveston TX 2014. Internship and Residency Rejoined. Graduated from Texas Tech University Health Science Center, Lubbock TX 1999. at Texas Tech Health Science Center, Amarillo TX 2014-2018. Internship and Residency at Scott & White Memorial Hospital, Temple TX 1999-2003. POAGE, FREDERICK DEAN, D.O. MARTIN, LANCE, M.D. FAMILY MEDICINE (FM) FAMILY MEDICINE (FM) 1400 S. Coulter, Ste. 5100, Amarillo TX 79106. 1215 S. Coulter, Amarillo. Transfer from Galveston County Medical Society. Graduated from Texas Tech University Health Science Center, Lubbock TX 2010. Residency at Graduated from University of North Texas Health Science Center, Texas College of Osteopathy Texas Tech University Health Science Center, Lubbock TX 2010-2013. Medicine, Fort Worth TX 2014. Internship and Residency at Texas Tech University Health Science NAZIM, MUHAMMAD H., M.D. Center, Amarillo TX 2014-2018. GENERAL SURGERY (GS) 1400 Coulter, Amarillo TX. Board of Censors Report: Graduated from Aga Khan Medical College, Aga Khan University, Karachi, Pakistan 2003. The following were approved for membership on March 19, 2019: Internship and Residency at West Virginia University, Morgantown WV, 2005-2010. Fellowship at REGULAR MEMBERSHIP: Indiana University, Indianapolis IN 2010-2011 (Burn and Reconstructive Surgery). AHMED, HASSAN, M.D. PATTON, STEVEN, M.D. GENERAL SURGERY/THORACIC SURGERY (GS/TS) ANESTHESIOLOGY (AN) 1400 S. Coulter, Amarillo TX. 2201 Civic Circle, #503, Amarillo TX. Graduated from University of Gezira, FAC of MED, Wad Medani, Sudan 2002. Internship and Rejoined. University of Texas Medical Branch, Galveston TX 1990. Internship at University of Residency at Texas Tech Health Science Center, ending 2017. Texas Medical Branch, Galveston TX 1990-1991. Residency at Texas Tech University Health Science Center, Lubbock TX 1991-1994. ARTHO, BRENT, M.D. ANESTHESIOLOGY (AN) PYRON, BRADDEN REX, M.D. 2201 Civic Circle, #503, Amarillo TX. INTERNAL MEDICINE (IM) Graduated from Texas Tech University Health Science Center, Lubbock TX 2004. 1600 Wallace, Amarillo TX. Graduated from Universite Auto de Guadalajara, FAC DE MED, Guadalajara, Jalisco MX 2001. BARAJAS, JORGE, M.D. Internship at University of Texas Health Science Center, San Antonio TX, 2003-2004. Residency ANESTHESIOLOGY (AN) at William Beaumont Army Medical Center, El Paso TX 2007-2010. 2201 Civic Circle, #503, Amarillo TX. Graduated from Universite Del Bravo, Reynosa, Tamaulipas, MX 1998. Residency at MFPRP- QUIGLEY, LAJOHN, M.D. UTHSC, McAllen TX 2001-2004. BARIATRIC SURGERY/GENERAL SURGERY (BRS/GS) 1400 S. Coulter, Amarillo TX. CAMPIN, RICHARD C., M.D. Graduated from Texas Tech University Health Science Center, Lubbock TX 2007. Residency at RADIOLOGY, DIAGNOSTIC (DR) Texas Tech University Health Science Center, Lubbock TX 2007-2013. Fellowship at Greenville 1901 Medi Park Dr., #2050, Amarillo TX. Health System, Greenville SC 2013-2014 (Minimally Invasive and Bariatric Surgery). Graduated from Dartmouth Medical School 1999. Residency and Fellowship at Boston Children’s RICO, FERDINAND R., M.D. Hospital, Boston MA ending 2009. SURGERY/TRAUMA (TRS) CORNELIUS, DENA, M.D. 1400 S. Coulter, Amarillo TX ANESTHESIOLOGY (AN) Graduated from University of Santo Tomas, Manila 1985. Internship at Harlem Hospital, New 2201 Civic Circle, #503, Amarillo TX. York NY 2001-2002. Residency at Our Lady of Mercy Medical Center, Bronx NY 2002-2004. Rejoined. Graduated from University of Texas, Houston, TX 2000. Internship at Kansas University, Residency at University of Rochester Medical Center, Rochester NY 2006-2008. Fellowship at Wichita KS 2000-2001. Residency at University of Texas, Houston TX 2001-2004. University of Rochester Medical Center, Rochester NY 2005-2006 (Surgical Critical Care.) GOETTSCHE, STEVEN, D.O. SBAR, ALAN D., M.D. ANESTHESIOLOGY (AN) GENERAL SURGERY (GS) 2201 Civic Circle, #503, Amarillo TX. 1400 Coulter, Amarillo TX. Graduated from Des Moines University of Osteopathic Health Science, Des Moines, IA 1990. Graduated from George Washington University School of Medicine & Health Science, Washington Residency at University of Iowa, Iowa City IA (1991-1994. DC 1996. Residency at US Army San Antonio, San Antonio TX (General Surgery) 1996-2002.

38 PANHANDLE HEALTH WINTER 2019 Spotlight on New Members

SCHNEIDER, BRIAN, M.D. DANESHFAR, BAHRAWN (DANIEL), M.D., GENERAL SURGERY (GS) GENERAL SURGERY/VASCULARY SURGERY (GS/VS) 1400 S. Coulter, Amarillo TX 79106. TRANSFER FROM HUTCHINSTON/HANSFORD COUNTY MEDICAL SOCIETY Graduated from University of Texas Medical Branch, Galveston TX 2000. Internship and Residency 2 Care Circle, Amarillo TX 79124 at Wayne State University/DMC, Detroit MI 2000-2005. Graduated from Texas Tech University Health Science Center, Lubbock TX. 2006. Internship at University of Arkansas, Little Rock AR, 2006-2007. Residency at Virginia Tech-Carilion Clinic, Roanoke STARK, AMY L., M.D. VA, 2007-2013. Fellowship at Baylor University, Dallas TX 2013-2015 (Vascular Surgery). PSYCHIATRY (P) 1400 Wallace, Amarillo TX. RETIRED: Graduated from Texas Tech University Health Science Center, Lubbock TX 2013. Residency at Mayo Clinic, Rochester MN 2013-2017. Fellowship at Yale University School of Medicine, New GARY POLK, M.D. Haven CT 2017-2018 (Addiction Psychiatry). PULMONARY DISEASE/SLEEP MEDICINE (PUD/SM). 3507 Edgewood, Amarillo TX 79109 STUART, ANTHONY, M.D. ANESTHESIOLOGY (AN) Board of Censors Report: 2201 Civic Circle, #503, Amarillo TX. The following were approved for membership on July 16, 2019: Graduated from University of Texas/Houston, Houston TX 1990. Internship and Residency at REGULAR MEMBERSHIP: Texas A & M College of Medicine, Temple TX 1991- 1994. CLARK, SUMMER, M.D. TRAHERN, LANCE L., M.D. DERMATOLOGY (D) ANESTHESIOLOGY (AN) 1611 Wallace Blvd., Proffer Surgical Association, Amarillo TX 79106. 2201 Civic Circle, #503, Amarillo TX. Graduated from University of Oklahoma College of Medicine, Oklahoma City OK 2014. Internship Rejoined. Graduated from University of Kansas Medical School, Kansas City KS 2001. Internship and Residency at University of Oklahoma Health Sciences Center, Oklahoma City OK 2014-2018. and Residency at University of Texas/Houston, Houston TX 2001-2005. Fellowship (Micrographic Surgery and Dermatologic Oncology), Vanderbilt University, Nashville TN 2018-2019. WILLIAMS, JACOB, M.D. ANESTHESIOLOGY (AN) TRANSFER MEMBERSHIP: 2201 Civic Circle, #503, Amarillo TX. Graduated from University of Texas Medical School/Houston, Houston TX 2010. Residency at WOODWARD DYRSTAD, SARA, M.D. UTMB, Galveston TX 2010-2014. DIAGNOSTIC RADIOLOGY (DR) Transfer from Ector County Medical Society 1000 S. Coulter, #100, Amarillo TX 79106. TRANSFER MEMBERSHIP: Graduated from Southern Illinois University School of Medicine, Springﬁeld IL 2007. Internship and Residency at Washington University School of Medicine, St. Louis MO 2008-2012. Fellowship NICKENS, WESLEY, M.D. (Breast Imaging) at Washington University School of Medicine, St. Louis MO 2012-2013. FAMILY MEDICINE (FM) 4514 Cornell, Suite B, Amarillo TX Board of Censors Report: Transfer from Greenbelt County Medical Society. The following were approved for membership on September 17, 2019: Graduated from Texas Tech University Health Science Center, Lubbock TX 2006. Residency at Texas Tech University Health Science Center, Lubbock TX 2006-2009. REGULAR MEMBERSHIP: Board of Censors Report: McKENNY, JAMES R., M.D. The following were approved for membership on May 21, 2019: AN (ANESTHESIOLOGY) P.O. Box 51793, Amarillo TX 79159. REGULAR MEMBERSHIP: Graduated from Texas Tech University Health Sciences Center, Lubbock TX 2013. Residency at University of Texas Health Science Center, San Antonio TX 2013-2017. FELDER, RANDALL, M.D. ANESTHESIOLOGY (AN) (rejoined) MILNER, JENNIFER, M.D. 1501 S. Coulter, Amarillo TX 79106 (Lone Star Anesthesiology Consultants) PD (PEDIATRICS) Graduated from Texas Tech University Health Science Center, Lubbock TX, 1985. Internship at 1411 Amarillo Boulevard E., (JO Wyatt), Amarillo TX 79106. University of Oklahoma, Oklahoma City OK, 1985-1986. Residency at University of Oklahoma, Rejoined PRCMS. Graduated from Texas Tech University Health Sciences Center. Lubbock TX Oklahoma City OK, 1986-1989. 2008. Residency at Texas Tech University Health Sciences Center, Lubbock T 2008-2911. JOHNSTON, JACK C., M.D. KEELIE TUCKER, M.D. ORTHOPEDIC SURGERY (ORS) OBG (OBSTETRICS & GYNECOLOGY) 6010 Amarillo Blvd W., Dept 112, Amarillo TX 79106 (VA) 1301 S. Coulter, #300, Amarillo TX. Graduated from Boston University School of Medicine, Boston, MA 1992. Internship at Jacobi Graduated from Texas Tech University Health Sciences Center, Lubbock TX 2007. Residency at Hospital, Bronx NY. 1992-1993 (GS). Residency at Monteﬁori Medical School, Bronx NY, 1993- Texas Tech University Health Sciences Center, Amarillo TX 2007-2011. 1997 (ORS). Fellowship at Long Beach Memorial, Long Beach CA, 1997-1998. (OSM). RETIRED MEMBERSHIP: TRANSFER MEMBERSHIP: BARNHILL, BILL S., M.D. BASHOVER, EVA, M.D. ORS/OSM – (LIFE) PATHOLOGY (PTH) TRANSFER FROM HARRIS COUNTY MEDICAL SOCIETY EAST, WILLIAM ROBERT, M.D. P.O. Box 51525, Amarillo TX 79159 D – (LIFE) Graduated from American University of the Caribbean School of Medicine, Cupecoy Saint Maarten, LIE, SIEN, M.D. 2012. Residency at Case Western Reserve University, Cleveland OH, 2012-2016 (Combined OBG –(LIFE) Anatomic and Clinical Pathology). Fellowship at MD Anderson Cancer Center, Houston TX, 2016- 2017 (Surgical Pathology). Fellowship at MD Anderson Cancer Center, Houston TX 2017-2018 WRIGHT, GEOFFREY, M.D. (Cytopathology). OTO – (LIFE).

WINTER 2019 PANHANDLE HEALTH 39 Are You Connected With TMA? Follow, like, tweet, and engage with us on social media.

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40 PANHANDLE HEALTH WINTER 2019 PROFESSIONAL CARDS

Cardiology Dermatology Internal Medicine AMARILLO HEART GROUP PALO DURO Mouin M. Jaber, MD Joaquin Martinez-Arraras, MD DERMATOLOGY, PLLC Board Certified in Internal Medicine Marc Moreau, MD Larry C. Roberts, MD 3504 N.E. 24th Prakash K. Desai, MD M.A., F.A.A.D. Amarillo, TX 79107 Jon Luigi Haddad, MD Diplomat of the (806) 381-1732 • Fax (806) 381-0748 D. Gary Soya, MD American Board of Dermatology ______Agustin Cabrera-Santamaria, MD 2005 N. 2nd Ave., Ste.D AMARILLO DIAGNOSTIC CLINIC Arunava D. Ray, MD Canyon, Texas 79015 6700 W. Ninth A. Alan Chu, MD (806)510-3376 Fax: (806)510-3379 Amarillo, TX 79106 Rajesh Nambiar, MD www.paloduroderm.com (806) 358-0200 Muhammed Ali, MD Gastroenterology 1901 Port Lane Hearing Daniel A. Beggs, MD Amarillo, TX 79106-2430 PHYSICIANS HEARING CENTER R. Todd Ellington, MD (806) 358-4596 • 1-800-355-5858 Royce A. Armstrong, Au.D., CCC-A James E. Lusby, MD www.amarilloheartgroup.com 3501 S. Soncy Road #140 Thomas L. Johnson, MD Amarillo, TX William Shear, MD Dermatology (806) 352-6901 • Fax (806) 352-2245 Infectious Disease J. Taylor Carlisle, MD HIGH PLAINS DERMATOLOGY Internal Medicine CENTER, P.A. Hospice/Palliative Holly Mitchell, MD Scott D. Miller, MD Medicine Joanna Wilson, DO Jason K. Jones, MD KINDRED HOSPICE Adrian Pay, DO Christi A. Baker, MD Eric Cox, MD Neurology 4302 Wolflin Ave. Board Certified in Douglas Lewis, DO Near I-40 & Western Hospice & Palliative Care Sean Milligan, MD (806) 355-9866 3232 Hobbs Road Nuclear Medicine Fax (806) 355-4004 Amarillo, TX 79109 Bill F. Byrd, MD 806-372-7696 (ofc) Pulmonary Diseases Attention: 800-572-6365 (toll free) Timothy S. Mooring, MD, D, ABSM 806-372-2825 (Fax) Javier Dieguez, MD Mark Sigler, MD Active Members of www.kindredhospice.com Rheumatology Potter-Randall County Internal Medicine Ming Chen, MD, Ph.D Sleep Disorders Medical Society Ruth Pilco-Jaber, MD Timothy S. Mooring, MD, D, ABSM Board Certified in Internal Medicine Gary R. Polk, MD, D, ABSM Annual Membership 3501 Soncy Road, Suite 131 Physician Extenders fees for 2020 Amarillo, TX 79119 Tiffany Randle, RN, MSN, FNP-C (806) 467-9111 • Fax (806) 467-9333 William A. Ledford, RN, MSN, FNP-C are due and payable Cindy Anderson, RN, MSN, FNP-C Kyla Beedy, RN, MSN, FNP-C by January 1, 2020 Ashley Quillin, RN, MSN, FNP-C

WINTER 2019 PANHANDLE HEALTH 41 PROFESSIONAL CARDS

Neurosurgery Obstetrics & Obstetrics & S.W. NEURO SCIENCE Gynecology Gynecology & SPINE CENTER PANHANDLE OBSTETRICS TEXAS TECH UNIVERSITY Bret D. Errington, MD & GYNECOLOGY HEALTH SCIENCES CENTER Board Certified by the American Board Dudley E. Freeman, MD DEPARTMENT OF of Neurological Surgery - Cranial and Gregory A. May, MD OBSTETRICS AND GYNECOLOGY Spinal Neurosurgery Cullen Hopkins, MD Amarillo Campus 7120 W. 9th Jamie Wilkerson, MD 1400 Coulter • 414-9650 www.ttuhsc.edu/amarillo/som/ob Amarillo, TX 79106 Brian Lindstrom, MD Obstetrics & Gynecology (806) 463-2251 • Fax: (806) 463-2252 Sarah Bergeron, RNC, WHNP Hena Tewari, MD ______Brenna Payne, RNC, WHNP Teresa E. Baker, MD 7620 Wallace Blvd. J. Brett Gentry, MD George Barnett, MD Amarillo, TX 79124 Neurological & Spinal Surgery Stephen J. Griffin, MD (806) 359-5468 • Fax (806) 358-1162 Board Certified - American Board Paul Tullar, MD ______of Neurological Surgery Mary G. Bridges, MD WOMEN’S HEALTHCARE Haylee DeVries, PA-C Wayne S. Paullus, MD ASSOCIATES, P.L.L.C. Chad Winchester, MSN, WHNP Neurological & Spinal Surgery Carin C. Appel, MD Renee Gray, MSN, WHNP Board Certified - American Board of Katy Bonds, MD Gynecologic Surgery Neurological Surgery Rhodesia A. Castillo, MD Hena Tewari, MD David L. Chastain, MD Teresa E. Baker, MD Wayne “CP” Paullus III, MD Jill A. Gulizia, MD George Barnett, MD Neurological & Spinal Surgery Clyde A. Meeks, MD Stephen J. Griffin, MD Board Certified - American Board Amanda Murdock, MD Robert P. Kauffman, MD of Neurological Surgery Keelie R. Tucker, MD Mary G. Bridges, MD Brenna Melugin, APRN, FNP, BC Menopausal Management Brad Hiser, MD Brooke Hillard, APRN, FNP, BC Robert P. Kauffman, MD Board Certified by the American Board 1301 Coulter, Suite 300 Reproductive Medicine & Infertility of Neurological Surgery Amarillo, TX 79106 Pediatric Gynecology #11 Medical Drive Gynecologic Ultrasound (806) 355-6330 • Fax (806) 351-0950 Amarillo, TX 79106 Robert P. Kauffman, MD whaonline.net (806) 353-6400 • (800) 358-2662 Maternal Fetal Medicine www.swneuro.com Obstetric Ultrasound ______Heather J. Holmes, MD www.ttuhsc.edu/amarillo/ William M. Banister, MD patient/obgyn/ultrasound 3101 Hobbs, #202 Genetic Counseling Amarillo, TX 79109 Heather Wheeler, RN (806) 279-1183 • Fax: (806) 350-7693 Breast Diseases and Surgery Most Insurance Accepted Mary G. Bridges, MD Including Medicare Diplomat - the American Board of Neurological Surgery

42 PANHANDLE HEALTH WINTER 2019 PROFESSIONAL CARDS

Oncology Ophthalmology Orthopaedic BSA HARRINGTON PANHANDLE EYE GROUP (Con’t) Surgery CANCER CENTER C. Alan McCarty, MD Michael O. LaGrone, MD Reconstructive Spine Surgery, Scoliosis, Medical Oncology/Hematology Comprehensive Ophthalmology, Pediatric Orthopaedics Board Certiﬁed Brian Pruitt, MD Cataract Surgery 1600 Coulter, Bldg. B Anita Ravipati, MD 7411 Wallace Blvd. Amarillo, TX 79106 Milan Patel, MD Amarillo, TX 79106 (806) 354-2529 • Fax (806) 354 2956 Javed Shinwari, MD (806) 351-1177 • (800) 782-6393 www.scoliosismd.com Paul Zorsky, MD ______W. John W. Murrell, MD Radiation Oncology James R. Parker, MD Comprehensive Ophthalmology, Daniel Arsenault, MD Board Certiﬁed Cataract & Oculoplastic Specializing in Sports Medicine Jaime Zusman, MD Reconstructive Eyelid Surgery & Total Joint Replacement 1500 Wallace Blvd., 7411 Wallace Blvd. 7000 W. 9th Ave. Amarillo, TX 79106 Amarillo, TX 79106 Amarillo, TX 79106 (806) 212-4673 • Fax (806) 354-5888 (806) 351-1177 • (800) 782-6393 (806) 350-2663 • Fax (806) 350-2664 www.harringtoncc.org J. Avery Rush, MD Otolaryngology Ophthalmology Cataract & Refractive Surgery (ent) Sloan W. Rush, MD PANHANDLE EYE GROUP, L.L.P. PANHANDLE EAR, NOSE & THROAT Cornea, Cataract & Refractive Surgery Specializing in the Diseases 3501 South Soncy Road, Ste. 140 7308 Fleming Ave. & Surgery of the Eye Amarillo, TX 79119-6405 Amarillo, TX 79106 (806) 355-5625 Fax (806) 352-2245 www.paneye.com (806) 353-0125 • (800) 225-3937 Stacie Morgan, MD Amber Dobler-Dixon, MD Amber Price, MD Bruce L. Weinberger, MD Glaucoma Laser & Surgery Hector Hernandez, MD 700 Quail Creek Dr. Amarillo: 7411 Wallace Blvd. Rachel Botkin, APRN, FNP-C Amarillo, TX 79124 (806) 350-1100 • (866) 567-0948 (806) 353-6691 • (800) 637-2287 Robert E. Gerald, MD Pain Management/ Retired Comprehensive Ophthalmology, Treatment 7308 Fleming Ave. J. Edward Ysasaga, MD AMARILLO PAIN ASSOCIATES Amarillo, TX 79106 Antonio V. Aragon, II, MD Thomas E. Merriman, MD (806) 359-7603 • (800) 283-8018 Ryan Rush, MD 1901 Medi Park Place John W. Klein, MD Diseases & Surgery of the Retina, Suite 2002 Amarillo, TX 79106 Comprehensive Ophthalmology, Vitreous, & Macula (806) 353-4699 • Fax (806) 353-4551 7411 Wallace Blvd. Cataract Surgery ______Amarillo, TX 79106 13 Care Circle ADVANCED PAIN CARE (806) 351-1870 • (888) 404-1870 Amarillo, TX 79124 Victor M. Taylor, MD (806) 353-2323 • Fax (806) 351-2323 7910 SW 34th (888) 393-7488 (806) 352-7431 • Fax (806) 352-2374 Amanda Trout, DO Michael Balderamos, MD 1901 Medi-Park Dr. Bldg. C, Ste. 2 Amarillo, TX 79106 WINTER 2019 PANHANDLE HEALTH 43 PROFESSIONAL CARDS

Pain Management/ Radiology Senior Living Treatment HIGH PLAINS RADIOLOGICAL THE CRAIG INTERVENTIONAL PAIN ASSOCIATION Senior Living MANAGEMENT 1901 Medi Park, Suite 2050 5500 S.W. 9th Avenue Brian S. Murrell Amarillo, TX 79106 Amarillo, TX 4104 SW 33rd Ave., Suite 200 (806) 355-3352 • Fax (806) 355-5367 (806) 352-7244 Amarillo, TX 79109 John Andrew, MD craigseniorliving.com (806) 803-9671 • Fax (806) 803-9674 Gary Aragon, MD Branch Archer, MD Surgery Plastic & Richard Archer, MD AMARILLO SURGICAL GROUP Reconstructive April Bailey, MD Surgery 6 Medical Drive Charles Brooks, MD Amarillo, Texas 79106 Mary Ann Piskun, MD Richard Campin, MD (806) 212-6604 Fax (806) 212-0355 Board Certiﬁed by the American Crandon Clark, MD Michael Lary, MD Board of Plastic Surgery Stanley Cook, MD General Surgery Member of the American Tully J. Currie, MD John McKinley, MD Society of Plastic Surgery Michael Daniel, MD General Surgery Reconstructive Surgery of the Breast Aaron Elliott, MD David Langley, MD 500 Quail Creek Dr., Ste. B Paul Hakim, MD General / Vascular Surgery Amarillo, TX 79124 Michael Hall, MD Shane Holloway, MD (806) 358-8731 • Fax (806) 358-8837 Arouj Hashmi, MD Surgical Oncolory / General Surgery www.drpiskun.com Richard Khu, MD Chance Irwin, MD ______Rahul Mehta, MD General / Vascular Surgery Patrick Proffer, MD, F.A.C.S. Paul Pan, MD Reconstructive Surgery of Breast & Body Samuel Kirkendall, MD Robert Pinkston, MD Board Certiﬁed by General Surgery Matthew Scalapino, MD The American Board of Plastic Surgery Erica Wheat, MD Rakesh R. Shah, MD Member of the American General Surgery Elijah Trout, DO Society of Plastic Surgery Chris Kolze, MD Martin Uszynski, MD 1611 Wallace General Surgery Kimberly Waugh, MD (806) 352-1185 • Fax (806) 352-4987 Lawrence Zarian, MD www.drproffer.com

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Cliff Craig, CPCU, CIC (806) 376-6301 WINTER 2019 PANHANDLE HEALTH 47 [email protected] PRESORTED STANDARD US POSTAGE PAID AMARILLO, TX PERMIT NO. 247 A QUARTERLY PUBLICATION OF THE POTTER-RANDALL COUNTY MEDICAL SOCIETY 1721 HAGY AMARILLO, TEXAS 79106