Friday, December 16, 2016
By: Chef John Hall with Post Office Pies
• 1 pint cooked angel hair pasta
• ¼ cup small diced yellow squash
• ¼ cup small dice zucchini
• 4 cherry tomatoes, quartered
• 2 tbsp capers, drained and rinsed
• 1 tbsp fresh chopped Italian parsley
• 2 cloves minced garlic
• 1 tbsp canola oil
• 1 tbsp EVOO
• 1/8 cup shredded pecorino romano
• Kosher salt and fresh cracked pepper to taste
1. In a sautee pan, cook garlic in canola oil over medium-high heat until golden brown
2. Add squash and zucchini, cook until squash softens but still has slight crunch
3. Add tomatoes, capers , pasta, and parsley. Toss in sautee pan until hot throughout pasta
4. Season with salt and pepper
5. Pour pasta dish into bowl, drizzle with EVOO, and garnish with pecorino romano
Thursday, December 15, 2016
By: Michael D. Smith, MD
Would it be nice to have the option of undergoing anesthesia or being offered the “wide awake” alternative similar to when you are having a dental procedure? As a new hand and upper extremity surgeon, I often meet patients that for one reason or another would like to have surgery to correct their problem but are nervous about or don’t want to undergo anesthesia. Some patients have difficulty in arranging for a ride to pick them up after they had undergone the sedation or others believe they are too “high risk” to undergo anesthesia secondary to a significant cardiac or pulmonary co-morbidity. For these patients, I have begun to offer the possibility to have their surgery done under Wide Awake, Local Anesthesia with No Tourniquet or WALANT as it’s known within the hand surgery community. This technique can be used for a variety of hand surgeries such as carpal tunnel syndrome, trigger finger and excisions of mucous cysts.
WALANT utilizes 1% lidocaine with 1:100,000 epinephrine buffered with 8.4% sodium bicarbonate to provide both local anesthesia to the hand or digit and to also provide hemostasis. This allows the surgeon to avoid using a tourniquet, which is often the most painful aspect of the surgery for patients that are having a procedure done under light sedation.
For years, medical students have been taught to never inject lidocaine with epinephrine into the fingers for fear of causing irreversible ischemia and digit necrosis. The familiar adage of no epinephrine into “fingers, nose, penis and toes” was well ingrained into my head by the time I had graduated from medical school in 2010. Dr. Don Lalonde, a hand surgeon from New Brunswick, Canada, has published his results of over 2000 cases using epinephrine in the finger and has been at the forefront of debunking this commonly held myth. Dr. Lalonde has also published his research into the myth and there is evidence that origin of the myth stems from the use of procaine (Novocaine) in the early 1900’s before the introduction of lidocaine in 1948. Procaine started with a pH of 3.6 and became more acidic as it sat on the shelf. It is highly likely the reports of digit necrosis after “epinephrine” injection in the early 1900’s were actually cases of highly acidic procaine causing the digit necrosis.
Dr. Lalonde has a new adage, “If the fingertip is pink before the lidocaine with epinephrine, it will be pink after the lidocaine with epinephrine.” In addition, there is a reversal agent, phentolamine that can reverse the hemostatic effects of epinephrine injections within an hour or two.
Some of the advantages of WALANT hand surgery include:
●Little to no pre-operative testing, as the only two medications being administered are lidocaine and epinephrine.
●Patients are able to drive themselves home, as they have had no sedation or anesthesia.
●Patients do not need to fast or change medication schedules before the procedure; which is especially helpful in my diabetic patients.
●Patients do not need to endure a tourniquet, even for five minutes.
In my practice, patients are sometimes nervous about being awake during their surgery, but oftentimes they find that the worry about “being awake” is much worse than the reality. In truth, I find the opportunity to talk with my patients during their surgery is a great avenue to build my relationship with the patient, but also to reiterate the post-operative protocol I would like for them to follow. I think most of my patients that have undergone WALANT would agree that it made their surgical experience simpler and more enjoyable.
Michael D. Smith, MD
Hand and Upper Extremity Surgeon
Southlake Orthopaedics Sports Medicine and Spine Center, PC
Friday, December 9, 2016
Physicians Giving Back: All in the Family with the Smiths
By: Lori M. Quiller Communications Director, Medical Association of the State of Alabama
LINEVILLE – The City of Lineville is a small, rural community of about 2,500 residents in Clay County. At the heart of the community lies Lineville Clinic, home of the Smith family medical practice.
Patriarch George Smith Sr., M.D., graduated from Howard College with a Bachelor’s degree in Pharmacy and worked for three years with Eli Lilly as a pharmaceutical representative, but something was missing.
“I felt like I could do more than I was doing as a pharmaceutical rep, so I applied to medical school,” Dr. Smith said. “My wife and I really wanted to come back to Lineville, but I wanted to come back here as a doctor. I’m a fourth generation Smith. My great grandfather helped settle the area. This is home.”
In 1966, Dr. Smith came back to Lineville and bought his practice from a physician who wanted to focus more on nursing homes than private medicine. His first day in his new practice was July 1, 1966 – the first day of Medicare.
“I got this survey asking what my office fee was, and I answered truthfully. It was $4, and that stuck with me for another 10 or 12 years because they wouldn’t let me change it. When I first started out it was $2. Can you imagine if I hadn’t changed it?” Dr. Smith laughed.
Since then, Dr. Smith has seen not only his community grow, but also his practice. In 1986, his son, Buddy Smith, M.D., joined the practice.
“I grew up going on house calls with Daddy, carrying his doctor’s bag. He did a lot of house calls in the 60s and 70s, and I was impressed with how people treated my father, how he was respected by his patients and the community. There’s a reason why he’s Dr. Smith and I’m Dr. Buddy. There’s only one Dr. Smith. He’s a legend,” Dr. Buddy said.
Dr. Buddy said one of the things that has contributed to the longevity of the practice, given that it is not affiliated with a large hospital or company, is its reputation largely due to his father. With patients willing to drive up to 50 miles to visit the clinic, and some patients who have been with the clinic since the beginning, there’s something to be said for small town reputations.
“In a small town, everyone knows you,” Dr. Buddy said, “so it’s important to remember why we’re here. We have patients who come a long way to see us because of our reputation. The patients are the reason why we’ve been in practice here for so long. We never forget why we’re here.”
And, that’s just one of the reasons why Dr. Buddy’s daughter, Ashley Smith Lane, M.D., joined the practice in October 2016. Dr. Smith’s Lineville Clinic officially became a family affair with three generations of physicians practicing under the same roof.
“I grew up here and already knew a lot of the people,” Dr. Lane said. “This is a great, established practice, and having these two, amazing mentors during a time when medicine is changing so quickly definitely makes being a young practicing physician a bit easier.”
Dr. Lane said she was prepared for a bit of inconvenience after finishing her residency in Huntsville, where tapping into the medical pool for specialty consults was as easy as picking up a phone. But, her heart was calling her back to Lineville…back to her home.
“Being a young doctor today is already complicated by all the changing rules and regulations, but add in being in a rural setting makes it more complicated because we don’t have the ease of getting our patients to the proper specialists as quickly as we would like,” Dr. Lane explained. “Coming from my residency in Huntsville where all the specialists were pretty much right there at our fingertips to a rural situation that allowed me to be a more well-rounded family doctor…it’s fulfilling and challenging all at the same time. I knew in residency I wanted to come back home, and I knew I would need these skills when I came back here. I loved my time in Huntsville, but this is home.”
Part of what Dr. Lane said she loves about practicing with her father and grandfather is the true partnership she has in the practice.
“It’s been a lot of fun working with both my father and grandfather – it’s actually pretty cool! Of course I’m learning a lot from them, but they also let me do my own thing and be myself. That means a lot, too, to allow me to be myself in the practice as a partner,” she said.
Together, the trio face the challenges of medicine together.
“We have to balance the demands of a health care system with a rural small business. And, everything is more difficult when you’re in a rural setting from communication to referrals to transportation…it’s all challenging,” Dr. Buddy explained. “The biggest challenge is to incorporate all the changes in medicine, such as MACRA, MIPS, advanced payment models, quality incentives, into an independent practice in a rural setting when none of them necessarily translate to my situation. These new rules are written for large practices with large IT departments, not small practices or independent practices like ours. It’s a huge challenge to try to meet these guidelines when you don’t have these resources. It takes more and more of my time away from patient care to do these other things. I would say now it’s 50/50 split between sitting at a computer and sitting with a patient. It’s about equal when we should be caring for our patients more than working computers.”
Another change? Alabama’s prescription drug abuse problem. It’s an issue Dr. Buddy was willing to tackle as one of the architects of the Medical Association’s Opioid Prescribing education course.
“We could see the need was growing because of the lack of prescribing education among our physicians. It was a need that had to be addressed, so we created the Opioid Prescribing Course,” Dr. Buddy said. “Doctors were closing their doors and quitting their practices because of what they were seeing happen in their communities. We needed to find a way to educate our doctors so they could keep their doors open and understand how to prescribe these medications effectively and efficiently. I think we have been successful in educating physicians about the dangers of opioids, but I’m not so sure if we’ve been as successful about continuing to practice pain management. It’s scary out there, but it’s rewarding if done correctly.”
With all the changes in medicine throughout the years, from Medicare to electronic records, Dr. Smith said looking back, he would not have done things any differently.
“I’ve been so happy to do what I do for all these years. It was never about the money. It was always about our patients. I’m sure I could have done better somewhere else, but that’s not why we do what we do, is it? It’s been very rewarding. You know you’ve done some good, and that’s the main thing. I’ve done what I call ‘rounds at the Pig’ at the local Piggly Wiggly where someone might stop me and ask about this or that. I still enjoy stopping to chat,” he laughed.
When Dr. Smith opened the doors of the clinic in 1966, he never expected having three generations of his family practicing medicine under the same shingle, but he can’t hide the smile when you mention his son and granddaughter.
“It’s special,” he said. “I know how rare this kind of thing is, especially for two physicians to choose family medicine and to come back home to a rural practice in a small town…that’s very special.”
Wednesday, December 7, 2016
By: Lindsesy Allumbaugh
Two winters ago, Kevin Glandon faced a prognosis of an amputation of his left leg due to poor circulation from peripheral artery disease. Kevin is married with three children and works in the nuclear power industry as a principal engineer. This role requires routine travel to the plant sites and walking in the field. “A good part of my jobs requires me to be mobile,” he says.
Arterial disease also affects Kevin’s heart. At the age of 48, stents were placed in his heart arteries because of severe cholesterol build up. Unfortunately, his stents did not remain open, and over a 4 year period he underwent multiple stenting procedures to improve the blood flow to his heart. Ultimately, at age 52, Kevin required bypass surgery.
Concurrently, Kevin was suffering from leg pain as the cholesterol build up in his legs progressed. “In my late thirties, I started having cramps in my left calf,” says Kevin. “Over the years, exercise became a significant challenge because of the poor circulation in my legs.” Similar to what took place in his heart, multiple stents were placed in the arteries of his legs, but these stents failed to stay open. He thus underwent bypass surgery on his left leg to improve the blood flow to his lower leg and foot. It lasted seven months. Doctors then attempted a second bypass, but it only lasted four days. He was then told there was no other option to improve the flow to his left leg, and he would likely need an amputation.
In a final effort to save Kevin’s leg, his primary Cardiologist consulted Christopher Huff, M.D., an Interventional Cardiologist at CVA and Brookwood Baptist Medical Center who specializes in complex peripheral arterial disease and amputation prevention. Dr. Huff reviewed Kevin’s medical record and scheduled a procedure with Kevin for the following day. “Dr. Huff worked for six hours cleaning out the blockage,” says Kevin. “I was awake the whole time and was just in awe of him. He stuck in there with me and worked tirelessly until he and his team restored blood flow back to my natural artery in my lower leg and foot.”
“Without Dr. Huff, I would have lost my leg and it would have been an incredible impact to me and my family,” says Kevin. “I’m blown away by his dedication to my care and the knowledge he brought to the table.” Since the procedure, Kevin sees Dr. Huff for periodic assessments to see how impacted the blood flow is and if needed, Dr. Huff goes into the artery to clean it back out. “I don’t have muscle cramping now and I’m able to walk,” he says.
Kevin is so grateful for what Dr. Huff has done for him and he wants to share his story with others that might be going through the same situation as he did two years ago. “Dr. Huff has said there are so many amputations happening because of PAD and it could have been me,” he says. “Listen to your body. Prevention is the key for something like this. Dr. Huff could help save limbs for people in a situation like mine.
“I can’t say enough about his skills, capability and dedication for his craft,” says Kevin. “Talk about a blessing, Dr. Huff is mine.”
MONTGOMERY – The Medical Association of the State of Alabama applauds the nomination of U.S. Rep. Tom Price for secretary of the U.S. Department of Health and Human Services.
“Congressman Price is a strong advocate for preserving the patient-physician relationship, which includes fighting for patients’ rights as well as preserving physician autonomy,” said Medical Association President David Herrick, M.D. “Dr. Price has worked with our Medical Association leadership for many years on the national level to deregulate medicine and ease the administrative burdens placed on physicians. We feel that as a physician, Dr. Price understands firsthand what the health care system needs to get back on track so our physicians can focus more on treating their patients and less on red tape.”
For nearly 20 years, Dr. Price worked in private practice as an orthopaedic surgeon. Before coming to Washington he returned to Emory University School of Medicine as an Assistant Professor and Medical Director of the Orthopedic Clinic at Grady Memorial Hospital in Atlanta, teaching resident doctors in training. He received his Bachelor and Doctor of Medicine degrees from the University of Michigan and completed his Orthopaedic Surgery residency at Emory University.
Should Dr. Price be confirmed as secretary of the U.S. Department of Health and Human Services, he would be the first physician to serve in that position since 1989 and the third physician in the 63-year history of the department. The Medical Association strongly feels physician leadership of HHS and in the President’s Cabinet would provide the necessary perspective that has been lacking in the health care decisions of our country.
Tuesday, December 6, 2016
By: Bruce Korf, M.D., Ph.D.
UAB Professor and Chair, Department of Genetics
Birmingham pediatricians now have expanded options for easily accessing genetic expertise and testing, with the recent opening of a genetics clinic at Children’s of Alabama.
For physicians, it’s important to consider when to refer a patient for genetic evaluation, especially for those patients who were unsuccessfully evaluated in the past.
Most pediatricians have experience in recognizing children with congenital malformations, intellectual disability or developmental delay that may have a genetic component. When those patients receive a diagnosis, parents have at least a minimum understanding of what is happening with their child, how best to manage that child, and whether it may occur in their other children.
Unfortunately, in the past a large percentage of patients went undiagnosed, even with an evaluation, putting the parents of young children on a seemingly endless quest to decide how best to manage their child’s medical conditions.
A great deal has changed relatively recently, however, and new tools, including microarray and genome sequencing, are available, which means we have the ability to achieve diagnoses that were not available to us before. So if you have been following a patient with medical issues that you suspect are genetic in origin, and that patient has not had genomic sequencing, it is likely time to refer them to a clinic for retesting.
One of the new tools available to us is microarray testing, which gives us the ability to make a definitive diagnosis at much higher rates than we could expect just a few years ago. Older tools would enable us to see the big picture, much like a satellite picture of the earth. Today’s tools are more like the Google Earth app, allowing us to zoom down to street level, so we can see detail on the genome that was previously impossible.
Genome sequencing is another tool that has improved our ability to diagnose. The cost for the test is dropping dramatically. Once costing $100 million per run, the test and analysis are now in the $6,000 to $7,000 range. While that is still a lot of money, compared to the cost of other medical tests it is actually fairly reasonable.
Microarray can be expected to pick up the genetic cause of 15 to 20 percent of autism spectrum disorder cases. Genome sequencing can pinpoint a diagnosis in about 30 percent of cases of children with intellectual disability, autism spectrum disorder, or congenital anomalies. Putting the two tests together means we can expect a definitive diagnosis in 50 percent of the cases presented to us. Considering that even five years ago we could only expect to diagnose about 5 percent, that’s a tremendous step forward in a very short time.
At one time, a genetic diagnosis relied on the physician’s ability to predetermine the underlying problem in order to test for that particular disorder. Today, we are able to diagnose based on the tests, even finding conditions so rare that no physician would have considered testing for them in the past.
And when a diagnosis still eludes us initially, we can now share results and experience with other geneticists around the world, enabling us to establish a diagnosis we may not have been able to make alone. In short, the tools we have at our disposal now have never been more powerful, so if you are a pediatrician following a patient and have been unsuccessful getting a diagnosis in the past, it is worth taking a second look now. Of course, putting a name to a disorder is only part of the battle. The next step is knowing how to treat a patient’s condition, and we have made progress in that area as well. Certainly, we can’t say we are able to treat every condition we see, but once we figure out which gene underlies the condition, we then begin to ask why the change in the gene causes the problems it does. And we are gradually figuring that out and identifying drugs that improve quality of life.
With such dramatic and rapid developments in the field of genetics, there are many implications to be considered as we move forward. There is increasing discussion that perhaps everyone should have their genome sequenced, as the cost goes down and the feasibility of the testing goes up. This emerging area will have to be addressed carefully. Between 1 to 3 percent of people whose genes are sequenced will discover a condition they did not realize they had or were at risk for, and virtually everyone can learn how their body manages specific medications or can become aware of risk factors for common diseases. But there are also questions about what options exist to manage these risks once they are known. We will have to proceed carefully in light of our increasing technological abilities.
For patients with known medical problems that can be addressed with genetic evaluation, however, there are ample reasons to make referrals and try to determine a diagnosis that can improve quality of life for the patient and their family.
We have a new clinic integrated into Children’s, with access to parking and other specialists, making genetic evaluation more convenient for parents than ever before. In addition to our Children’s clinic, we have a prenatal diagnosis program through OB/GYN and maternal fetal medicine at UAB, and our newest clinic at Kirklin Clinic for adults.
If you have questions about referring a patient to one of our Birmingham area clinics, please call (205) 934-4983 to discuss.