Category: Uncategorized

By David Doolittle

Originally published on Texas Medical Association’s website.

As the number of COVID-19 cases in Texas and around the country grows, what steps should your clinic take to ensure the safety of your staff and patients?

The Texas Medical Association COVID-19 Task Force has published a “Frequently Asked Questions” that answers many of the questions you might have about caring for people who have been exposed to the virus.

Among the questions answered:

• What do you tell your patients when they call?
• What steps should your clinic take to prevent COVID-19 exposure?
• How should your staff safely care for a patient who has a potential case of COVID-19?
• Should you tell a patient with a potential case of COVID-19 not to come to your clinic?

The FAQ is based on guidance from the Centers for Disease Control and Prevention (CDC), the Department of State Health Services (DSHS), and other health organizations.

As of Friday, 39 cases have been confirmed in Texas, mostly in the state’s largest metropolitan areas, according to the DSHS tracker for Texas COVID-19 cases.

You can find the latest news, resources, and government guidance on the coronavirus outbreak by visiting TMA’s COVID-19 Resource Center regularly.

The Texas Medical Association, in conjunction with the Texas Department of State Health Services, has scheduled a critical conference call with Texas physicians next week. Answer your home phone at 7 pm CT, Tuesday, March 10, to take part in TMA’s Tele-Town Hall Meeting on COVID-19.

This is an opportunity get information to proactively protect your practice as COVID-19 continues to spread throughout Texas. Key discussion topics will include working with local/regional health department and how to counsel your patients. TMA President David Fleeger, MD, will moderate the hour-long event, and a number of specialists will participate in the discussion.

Potential speakers include the following:

• John Hellerstedt, MD, DSHS commissioner

• Wendy Chung MD, chief epidemiologist, Dallas County Department of Health and Human Services, and current chair of TMA’s Council on Science and Public Health

• Jennifer Shuford, MD, DSHS infectious disease medical officer

• E. Linda Villarreal, MD, chair of the TMA Board of Trustees

• TMA staff experts

Not only is this an opportunity to learn more about a critical topic, but participants also have the opportunity to earn one hour of CME credit for education in medical ethics and/or professional responsibility.

Click here to find out more information about this event.

Click here to access TMA’s online COVID-19 Resource Center.

“For every thousand hacking at the leaves of evil, there is one striking at the root.” –Henry David Thoreau

by Tom Black, MD

Publications Committee Chair Dr. Hujefa Vora will be taking a temporary break from his committee duties. In his stead, members of the committee will continue to contribute to the Last Word. Dr. Robert Bunata will serve as Interim Chair.

As a recent session of the American College of Surgeons was ending, the words of Ray Magliozzi came to my mind, “Well, it’s happened again—you’ve squandered another perfectly good hour . . .” The subject of the session had been “Firearm Injuries,” and the take-away message was, of course, the need for gun control. As I waited to file out of the auditorium, Thoreau’s words rang in my ears, and I wondered how many more fruitless discussions we must endure, hacking at the leaves of the issue, before someone begins striking at the root?

When a question arises that can’t easily be answered, it’s often because the wrong question is being asked. Maybe that’s why we have repeatedly and consistently failed to resolve the conundrum of firearm injuries. 

In the well-known parable of the six blind men and the elephant, each of the men describes the elephant differently. Although none of the men were incorrect, none had defined the entirety of the elephant itself. Similarly, there are so many aspects to the problem of firearm injuries that until we begin discussing them as disparate entities with different causes and remedies, we will continue to be enticed into advocating only the lowest common denominator—the supernatural disappearance of all firearms.

In this era of frenetic 24-hour news, consumers expect the “quick fix” and the “one size fits all” solution so they can move their attention expeditiously onward to the next crisis. In the world of reality, within which some—perhaps even most—of us live, the usually reliable Occam’s law of parsimony is simply unrealistic when applied to this multi-faceted issue. It’s simply so much easier to demand the confiscation of all firearms than it is to analyze the root causes of firearm violence and address them as the distinct and unique issues that they are. 

I would be among the last to suggest looking to Hollywood as a moral North Star, but occasionally a pearl of wisdom is unexpectedly heard from the silver screen. In the 1953 movie “Shane,” the heroic title character expresses the following: 

“A gun is a tool, Marian; no better or no worse than any other tool: an axe, a shovel or anything. A gun is as good or as bad as the man using it.”

These are words from a by-gone era that would never be heard today in the same medium, but are they not true?

Let’s analyze the problem of firearm violence as if it were a medical condition. All rashes are not treated in the same manner, nor are all cases of shock or of diarrhea or of headache. Does treating a fever address the cause of the illness? I submit that firearm violence is a symptom or expression of societal disease, not a disease itself, and treating it without addressing the root cause makes as little sense as treating pneumonia with acetaminophen alone.  

Viewing firearm violence as a symptom of disease, the list of differential diagnoses would include the following:

• Suicide:
• genetic or acquired mental disorders; drug abuse; acute                       psychological states such as trauma or loss; cultural, familial, and social situations.

• Homicide:
• hate, greed, lust, desire for control, mental disorders, emotional                        agitation, impaired judgment due to substance abuse. 

• Unintentional injuries:
• inadequate gun education, carelessness, improper storage.

Would anyone suggest, aside from the impractical proposition of decreeing the disappearance of all firearms, that the solution to each of these issues is anywhere near the same? In some cases, controlling access to firearms is indeed the best solution, but to mandate it as a panacea is as inappropriate as treating every case of arterial hypotension with epinephrine alone.

Assume for a moment that all guns vanished instantaneously into thin air. Would the despair and depression that leads one to commit suicide be simultaneously cured? Would the hatred and greed that result in homicide abruptly disappear? Would everyone prone to foolish and reckless behavior suddenly become wise? 

Factors contributing to intentional violence are numerous, pervasive, and so entrenched in our culture that it is not hard to see why we have chosen to focus our attention on the utopian and inherently impossible objective of eliminating guns. Such factors must certainly include the ubiquitous and desensitizing violence portrayed in movies, television shows, video games, music lyrics, and music videos; illegal drugs; rampant materialism; the lack of self-esteem due to a hedonistic obsession with personal appearance; the rise of secularism and the decline of religion; and the general decline of ethical behavior toward others. Regarding unintentional injuries. Ah—there’s an area in which we might actually be able to make some inroads, such as mandating trigger locks and education regarding the handling of firearms. But in the overall incidence of gun violence, unintentional injuries are but a drop in the bucket.

Firearm violence is a symptom, not a disease. It’s a common pathway by which various deeply rooted maladies of society are expressed. Only when we begin seeing firearm violence as a symptom can we begin the arduous task of diagnosing and appropriately treating underlying societal diseases. Meanwhile we must halt the irrational, perpetually unproductive, and divisive demand to cure a variety of diseases by treating their common symptom. 

We seem to have three choices: continue the Sisyphean efforts to eliminate all firearms; begin tackling the overwhelming issues that contribute to firearm violence; or resign ourselves to the future we have created.

The real question is, does society have the resolve to identify and remedy the roots of societal disease, or would we prefer to continue hacking at the leaves?

“When a question arises that can’t easily be answered, it’s often because the wrong question is being asked.”

Hearing Wellness Exposition – 2nd Edition   |   by Shirley A. Molenich, MD

As you are probably aware, Sertoma and Hearing Loss Association of America have joined together to do a series of programs on hearing loss for the general public for the past two years. Our third program will be on March 28, 2020, at the Tarrant County Medical Society from 9am to 1pm, with registration beginning at 8:30am.

In my last article I mentioned three of our speakers – Jed Grisel, MD (ENT), Terri Jo Edwards, AuD, and Marylyn Koler, MS, CCCA, AuD. At this event, we will discuss how the brain and ear work together, give new information on prevention/treatment, and review modern research. We are also going to discuss tinnitus, which is a difficult disease both in terms of cause and treatment. 

There is a great deal of research going on in the area of hearing disorders. More information is becoming available about many chronic health issues that play a role in hearing loss. There is significant new knowledge about genetic causes of hearing loss with over 140 related gene mutations identified. With these gene mutilations identified, basic scientific research has discovered the specific biological changes that occur, yielding information which may open up the avenue for treating hearing loss. There also continues to be increasing development of technical assistance.

There is a clear need for audiologists and physicians to work together to care for patients by identifying hearing loss issues earlier, which can lead to better results for patients. Basically, when auditory hair cells are damaged, neurons in the brain will atrophy axons along with the synapses, leading to hearing loss. This means that if a person gets hearing aids, they will require regeneration of the axons with new synapses. There are areas of research now on the theories of cognitive function and hearing.

We will discuss opportunities to help the hearing impaired with school, education, and vocational rehabilitation of hearing impairment, and new technology. 

“There is a clear need for audiologists and physicians to work together to care for patients by identifying hearing loss issues earlier.”

This will be our first program in which tinnitus is discussed. There has been research conducted by the National Center for Rehabilitative Auditory Research at the V.A. Portland Health Care System in Oregon, which was founded in 1997. Tinnitus has been one of their major areas of research. Basically, tinnitus is the experience of hearing sound (such as ringing or buzzing) without an external source. Part of the problem has been that tinnitus is a chronic condition without an existing reliable treatment. There are many protocols that have been tried, i.e. nutritional, pharmacological, surgical, deep brain transcranial electrical stimulation, sound, and transcranial magnetic stimulation, among others. The one treatment concept using sound therapy is Tinnitus Retraining Therapy, which has been the gold standard in coping with but not curing tinnitus. This technology works because the brain becomes habituated to it, so the tinnitus is no longer perceived as a negative and disruptive experience.  

We want to continue to educate the public about hearing disease and to reinforce new ideas and treatment options that are coming soon. We appreciate the help of the Tarrant County Medical Society in this endeavor. 

Sources 
Reviewing Tinnitus Research as an Educator, Veteran and Parent.
Oman Rodriguez – Hearing Health Foundation. Fall 2019, pp.26-28.
Tackling Tinnitus
James A. Henry, Ph.D – Hearing Health Foundation. Fall 2018, pp. 10-12.

Texas’ 10-day rule regarding life support works to prevent harm.

by Stuart Pickell, MD, FACP, FAAP

We have monitored the scenario surrounding infant Tinslee Lewis at Cook Children’s Medical Center for the last two months as it has moved the issue of the Texas Advance Directives Act in general, and the 10-day rule in particular, back onto the front burner.

While we agree with the Fort Worth Star-Telegram Editorial Board’s assertion that the law is imperfect, we do not agree that extending the 10-day period that hospitals have to find an alternative facility is the solution.

As technology has advanced, so have the options available to treat critically ill patients. For many patients, aggressive medical intervention is a life-saving bridge until their bodies can recover. But there is a point at which no amount of medical intervention will help. In fact, it may hurt.

For the last 40 years, healthcare facilities have increasingly relied upon ethics committees to aid them with the unenviable task of examining clinical situations in which medical technology contributes to a moral conundrum with no good options. The typical ethics committee consists of an interdisciplinary team of healthcare workers. The members are often employees of the institution but the panels also usually include community members who have no official relationship with the facility.

Families rarely insist on aggressive treatment that the medical team believes is non-beneficial or even harmful, but when they do, either party may request a formal hearing before the ethics committee. The committee’s objective is to hear the concerns of both and discern the ethical thing to do for the patient. If the panel decides to withdraw aggressive interventions that the family wants continued, the facility may invoke the advance directives law.

Texas’ law leverages the expertise of healthcare and ethics professionals to promote a deliberative process at the bedside, carefully considering the family’s desires for treatment in light of the medical realities to discern the best treatment options available for the patient. As medical professionals we have an imperative to honor our patients’ treatment desires.

While we sympathize with the Lewis family, their desire to continue aggressive interventions does not give them — or anyone — the right to demand treatment that violates the norms of the medical profession, the caregivers’ moral integrity or the long-standing ethical precept of “do no harm.”

Much of the criticism of the directives law focuses on the section that allows a health-care facility to discontinue life-sustaining treatment 10 days after giving written notice. During this time, the treating facility and the family seek to identify another facility willing to assume care. Despite opponents’ claims, 10 days is long enough.

Every case that gets to the point of invoking the law has been thoroughly vetted by the medical team in consultation with the family. When it becomes clear that an impasse is imminent, the search for an alternative facility begins, usually weeks before any formal hearing of the ethics committee.

The law allows a judge to grant an extension if more time makes it likely that another facility would be willing to accept the patient. It’s rare for a medical team elsewhere to disagree that care is futile. Even so, judges often grant extensions, especially in high profile cases.

But many families have not dealt with the gravity of their loved one’s condition, a reality they can no longer ignore once the 10-day rule is invoked. Extending the 10-day period will not lessen their grief or increase the likelihood of finding a facility willing to assume the patient’s care.

The Texas Advance Directives Act is imperfect, but this law, including the 10-day rule, is better than what we had before: actively dying patients with no hope of recovery subjected to indefinite pain and suffering because well-meaning loved ones were unwilling to let them go.

A longer waiting period will not bring hope to a hopeless situation; it will only prolong suffering. So, while we strongly advocate for initiatives to improve the health and well-being of Texans, extending the 10-day rule is not one of them.

Stuart Pickell, MD is chairman of the TCMS Ethics Consortium, a group that seeks to ensure the application of ethical principles in health care. He wrote this piece on the group’s behalf. Dr. Pickell is a member of Cook Children’s Medical Center’s ethics committee; this piece does not necessarily reflect that committee’s views.

This article was originally printed in the Fort Worth Star-Telegram.
Reprinted with permission.

by Paul K. Harral, Fort Worth Business Press

Tom Roger’s dedication to his patients is legendary. In a 58-year career, he has always put his patients at the center of his focus, says nominator Stuart D. Flynn, MD, the founding dean of the TCU and UNTHSC School of Medicine.

“In addition, Tom has served as a mentor to countless TCU pre-medical students who have observed his skills and compassionate practice of medicine,” Flynn said.

Rogers graduated from TCU with a degree in biology in 1957 and earned his medical degree from the University of Texas Southwestern Medical Center in Dallas.

He lettered in baseball at TCU and was inducted into TCU’s Letterman’s Hall of Fame in 1999.

Rogers has received the Gold-Headed Cane Award from both the Tarrant County Medical Society and the Cook Children’s Physician Network, a mark of respect physician to physician dating to the 18th century.

“When the winds of uncertainty and disruption swirled in the 1990s, Dr. Tom Rogers came to the president and CEO of Cook Children’s, Mr. Russ Tolman, with a new idea,” Flynn said.

“He suggested that the Cook Physician Network move quickly to harness the loyalty and influence of the pediatricians in town as an essential part of the network. In a few months the first primary care groups had joined, and Dr. Rogers became the first chairman of the board. His foresight set precedent which has made the network an integral part of the Cook Children’s system.”

He served in multiple roles in local medical associations and organizations but Rogers was and is active in the community outside medicine.

He chaired the Fort Worth ISD’s Citizen’s Advisory Committee on Desegregation in 1990 and the Citizens Advisory Committee for Facilities Improvement Program in 1985, that passed and implemented a hugh bond issue.

“The committee supervised projects for the next years and these came in under budget and completed on time,” Rogers noted.

Other community service includes the Fort Worth Heart Association, the United Way, the March of Dimes, the Lena Pope Home, the Fort Worth Opera Association, the Fort Worth Symphony Orchestra, First United Methodist Church, a variety of roles at TCU, the Child Study Center, the Parenting Center and Schola Cantorum of Texas, where he was president of the board and a member of the chorus for 20 years.

Asked if there was a specific person who influenced his decision to become a physician, Rogers said he came from a non-medical family “so I really had no background to rely on.  I just admired the medical profession.”

That “non-medical family” part ended with him. He and his wife Joan started their own family tradition with a son, a daughter, a son-in-law and a daughter-in-law in practice. And now there are two grandsons in medical school.

“I think each of us looks for two primary ingredients in our health-care providers: First, we want someone who is competent, who will make the correct diagnosis and masterfully handle the ‘science’ of medicine. Second, and equally as important, we look for someone with the communications skills and compassion, a person who truly cares about us as human beings,” Flynn said. “Tom is the epitome of both. He is a personal Health Care Hero to many in Fort Worth.”

Q & A

Q Why do you do what you do?
A I’m a physician. I do it because I love helping people with my skills.

Q What inspires you during the tough times?
A My family, especially my wife. 

Q What’s your best advice for people wanting to enter the health care profession?
A Be willing to work hard and always put the patient first. 

Q If you could make one change that would improve health care for everyone, what would it be?
A In a dream world, be able to disregard cost.

Q Is there something else that we wouldn’t have known to ask?
A What I miss most in retirement is the daily connection with my families.  I am getting into sleeping until 7:30.

This article was originally published in The Fort Worth Business Press. Reprinted with permission.

by Norm Tremblay, MD

There it was staring me in the face . . . retirement. I wanted to stay useful to mankind and not just wander off into a blank horizon. I happened to befriend a fishing buddy Mike Emerson in the Fort Worth fly fishing club, and he encouraged me to look into an organization called Reel Recovery. 

What I discovered was a story that began with four avid fly fishermen on an outing in Colorado in 2003. One of them was dealing with a brain tumor. At the end of the day, he remarked that he enjoyed the day thoroughly and didn’t think of his cancer for the first time in six months! From this sprouted an organization that has spread to 21 states and New Zealand. 

I have successfully survived five different types of cancer and therefore had motivation to get involved. There were retreats that involved participants, fishing buddies, and staff personnel. I remarked to Mike that I was an “expert” fly fisherman and could start as a buddy, at which point he promptly put me in my place and made me start as a participant at a retreat in Oklahoma coordinated by Marty Weaver (a veteran of three military branches and a really neat guy). 

There we were . . .15 guys tough on the outside and terrified on the inside . . . all strangers. Half of us were “forced” to attend by spouses or other family members. Marty Deschner, a clinical psychologist from Dallas, began a series of six “Courageous Conversations.” We were instructed to speak from the heart and given the option to answer a series of initially benign questions such as our first car and fishing experience. The questions became more serious, involving our individual dealings with cancer. 

What followed was an amazing experience where these men, many for the first time, opened up and often broke down. We bonded with and supported each other and received support from our individual fishing buddies and staff members. Two of the highlights of the retreat were the vest ceremony (vests signed by past retreat participants from all over the country, some still fighting the battle and others gone away but still alive in the signatures) and the closing ceremony where final thoughts were shared among participants, buddies, and staff, and tearful farewells were absorbed into our memories. 

Since then, I have further engrossed myself as a buddy, medical director, assistant to my dear wife Cathy who is photographer at several retreats, and retreat coordinator. I was a buddy to a fine gentleman who was at the final stages of his battle. He was too weak to fish, so we spent two days enjoying the outdoors and discussing the afterlife and other metaphysical topics. It was his first time out of the house in six months, and his wife was eternally grateful for the three-day break from having to administer his medications every three hours. 

Mike and I were manning a Reel Recovery booth last year at Troutfest near New Braunsfels when a mother and her 23-year-old son inquired about the organization. The young man had recently been diagnosed with an aggressive form of cancer. I could see in his eyes that he was just beginning to deal with this and encouraged him to attend a retreat. He signed up for the Navasota retreat, and his 22-year-old brother who had a good basic knowledge of fly fishing signed up as his fishing buddy. They both displayed tremendous courage and enjoyment throughout the retreat, caught the biggest bass, and showed us heartwarming gratitude that persisted through his family after his passing away three months later. The toughest ones are the most rewarding.

Reel Recovery exists in 21 states and New Zealand, and there are plans to expand to Canada and Australia. There are only three paid positions in the United States, and more than 600 volunteers (88 percent of donations go directly to these guys!). In Texas, we run six retreats each year in the spring and fall. Two are at Arrowhead Camp near Glen Rose, two at Camp Capers near San Antonio (one is for veterans with cancer), and two at Camp Allen near Houston. All expenses except transportation to and from the retreat are covered, and we try to carpool somehow when transportation is an issue. 

We raise funds through donations as a 501(c) (3), and we have an annual live and silent auction scheduled this year on Wednesday, May 13th, 2020, at the Firestone and Robertson Distilling Corporation (“Whiskey Ranch”). You can get involved in many ways: refer your oncology patients to our website (see below) to sign up for a retreat and help them sign the medical release form shortly before the retreat; be a participant if you qualify (it’s an unforgettable experience); donate through our website( see below) or come to our annual auction (the auction items are cool!); volunteer as a staff member or buddy; buy some gear at our website (see below); you can even tie flies for warm water fishing since we are in constant need of flies. Above all, spread the word about us. We have no advertising budget so we depend on word of mouth.

Our website is reelrecovery.org. For questions you can call me at
(817) 271-5482 or email me at
tremblay.reelrecovery@gmail.com. You can also contact Mike Emerson, our State Coordinator at 817-8947832 or at his email emerson.reelrecovery@gmail.com. 

Thanks for staying awake through this and catch a world record dose of good health! 

“There we were… 15 guys tough on the outside and terrified on the inside.”