2013: A Year in Review
It has been an extraordinary year of change in healthcare, both nationally and locally, and not all of it has been comfortable. As Washington struggled with the Affordable Care Act, doctors in our region were working to implement or optimize EHR systems, gear up for ICD-10, and continue to make a living in an increasingly competitive environment. We here at MED have been working to follow these trends and issues, while managing our own move into digital technology, as we shine a spotlight on extraordinary people, programs and institutions on the Great Plains. Following are excerpts and top stories from the pages of MED in 2013.
"Once, I had this case...": The Stories We Could Tell
It is said that everyone has a story to tell and it may be even truer for those in the medical field. By its very nature, the unique role of physicians brings them into close and sometimes intense contact with a wide swath of humanity. We invited several area physicians to share some of their most memorable practice experiences and notable cases and brought them to readers in their own words.
Jeff Murray, MD, Gastroenterologist, Sanford: “I remember a patient with a bleeding ulcer. I did an emergency endoscopy to treat it. When we were finally able to bring him back in, even though this looked great, we decided to do a biopsy anyway. I’m not really sure why we did, but it turned out to be a signet ring cell cancer, which is uniformly lethal. Here is a guy who just about didn’t even come back. And even though it looked healed, we still took a biopsy. This patient had two thirds of his stomach removed and he’s doing great. Was it luck? Could have been. But you just know that there was more to it. Something intangible. If your eyes are open wide enough, you recognize that. And then you recognize that this is a pretty cool field to be in.”
Kelly McCaul, MD, Transplant Hematologist, Avera: “One patient that stands out for me had a high grade myelodysplastic syndrome (MDS). No one really had a lot to offer at the time. So she developed acute myeloid leukemia (AML) and eventually was referred back to me. At the time, the median survival with what she had would have been 3 or 4 months. So we really scrambled to get her into an NCI trial that could offer her something. She became the first person in the state to get on this new drug, called Vidaza. Now, ten years later, she has a perfectly normal blood count.”
This story launched MED’s “Case By Case” column, a forum for discussing notable or unusual cases.
News Flash: Rapid City Regional Hospital unveils $2.8 million renovation of its Medical Imaging Department
News Flash: Mercy Medical Center dedicates new state-of-the-art robotic operating suite
News Flash: Sanford becomes first in the region to use the world’s smallest microscope during endoscopies.
Neurocritical Care at Sanford Health
Rare Subspecialty Provides Critical Interventions that Save Lives and Promote Recovery
Neurocritical Care is the critical care of patients with injuries or acute conditions of the brain or spinal cord. Brain trauma as well as stroke, subarachnoid hemorrhage, intracranial hemorrhage, subdural hematomas, seizures, spinal cord trauma, status epilepticus, and encephalitis all fall under the auspices of Neurocritical Care. It has evolved in recent years from a segment of Intensive Care to its own subspecialty, with its own society, journal, research studies, and growing number of practitioners.
“If it is something in your head, we will take care of it,” says Larry Burris, DO, who, along with his partner Charles Miller, MD, is now one of the 400 or so board certified Neurocritical Intensivists in the country.
Vital to Neurocritical Care’s emergence as its own specialty area is the improved ability to monitor certain parameters such as intracranial swelling, brain blood pressure, and neurooxygenation. One of the life-saving interventions made possible by improved monitoring is decompressive craniectomy during which a portion of the skull – sometimes as large as a hand – is removed and carefully preserved at -60° C while the patient’s potentially brain-damaging inflammation diminishes.
“Novel application of acceptable techniques allows us to go beyond standard therapies and give our patients a better fighting chance when it comes to these really terrible injuries,” says Dr. Miller.
Another one of those acceptable but not highly-publicized techniques is therapeutic hypothermia, a method of lowering a patient’s body to a therapeutic temperature of 91° F in an effort to prevent ischemic injury to already-damaged tissues.
In addition to Drs. Miller and Burris, Sanford’s Neurocritical Care tem includes a vascular neurologist and the state’s only interventional neurologist.
News Flash: Spearfish Regional Hospital is verified as a Level III Trauma Center by the American College of Surgeons.
News Flash: Brookings Health System becomes the third in South Dakota to use robotic technology in its OR.
The Center for Family Medicine
Putting Training into Practice
The Center for Family Medicine’s 16 faculty providers include 12 family physicians, a clinical psychologist, a licensed nutritionist, a PharmD and a geriatric nurse practitioner. The CFM-based Sioux Falls Family Medicine residency program, which has graduated nearly 300 residents and provides care for thousands of local patients, is jointly sponsored by Avera McKennan and Sanford Health Hospitals and is affiliated with the University of South Dakota Sanford School of Medicine.
Because residents play such an integral role in the practice, CFM incorporates their cutting-edge new knowledge into its patient care model while the graduates themselves are learning the practical application of that knowledge.
“Our mission is to train family physicians for South Dakota and other areas in the upper Midwest, which has a lot of rural and frontier areas, so they have to be pretty broadly trained,” explains David Brechtelsbauer, MD, a board-certified family physician and geriatrician who has worked and taught at the Center for Family Medicine since 1985.
Accredited in 1973, the Sioux Falls Family Medicine Program is one of the oldest of its kind in the country. The program size has recently expanded to 9 with the result that, at any given time, about 27 residents are working in the practice.
The diverse patient makeup at CFM means that the clinics doctors are more likely to encounter patients with rare or unusual conditions. “For instance, it would be unusual to see elephantiasis in a town the size of Sioux Falls, but we have seen it,” says Dr. B. “This is why it is a culturally and intellectually stimulating environment for teaching and learning.”
News Flash: Avera McKennan Hospital & University Health Center is named a Top 100 Hospital by Truven Health Analytics.
News Flash: Sanford Gynecologic Oncologist Maria Bell, MD, completes her 1000th robotic surgery at Sanford Health.
Going the Distance
Local Physicians Travel to Serve
Every year, teams of American doctors, dentists and other healthcare professionals clear their schedules and pack their bags for some of the world’s poorest and most remote places. Their mission: to improve the lives and futures of underserved and vulnerable people around the globe by providing medical, dental, and surgical care, medicines, equipment, instruction and support. While their ranks are not large, their service-driven hearts invariably are. For this month’s Cover Story, we spoke with three area physicians who have embraced the joys and considerable challenges of medical mission work.
Craig Hedges, MD, Ear Nose & Throat
Although he has served in Honduras, Russia, Africa, Mexico and Cuba since 1994, teaching and training and bringing equipment, Dr. Craig Hedges’ first love is Vietnam, where he has served on 18 mission trips in 19 years. “When I first went, they were taking safety razors and breaking them into two pieces and holding the broken piece with a hemostat in order to make an incision,” says Hedges. “The things that we do and see on a day-to-day basis in Sioux Falls – cancers and nasal polyps and perforated ear drums and chronic infections – were the exact things they wanted to learn.”
Paul Amundson, MD, Family Medicine
Working through the South Dakota Synod of the ELCA, Dr. Paul Amundson has travelled to Nicaragua 10 of the last 12 years. “We drive through dried out creek beds to get to villages of 10 to 15 families where we set up a clinic in whatever structure is available. For some, we are the first physicians they have ever seen,” he says. Parasites, malnutrition, and the increasing availability of cheap packaged foods and soft drinks are major health problems in the country.
Greg Schultz, MD, Vascular Surgery
Two years ago, Dr. Greg Schultz travelled to Gracias, Honduras, one of more than 50 sites around the world where the Luke Society provides support to indigenous mission-minded physicians. “On our first day, we probably saw 50 to 60 cases and they all came in with obvious medical problems… gallbladders, hernias, cancer,” say Dr. Schultz. “These people travel for 6 to 10 hours on bumps roads, have major operations, and get up and leave the next day. And they are so gracious and so happy about it.”
You can find a list of organizations that provide service opportunities for medical professionals at www.MidwestMedicalEdition.com.
News Flash: Heart specialists at both Sioux Falls Heart Hospitals begin offering a minimally invasive treatment for chronic total occlusion.
News Flash: Sioux Falls Infectious Disease specialist Wendell Hoffman, MD, receives the CDC’s annual Childhood Immunization Champion award.
News Flash: Iowa Health System changes its name to UnityPoint Health.
Medical Homes on the Prairie
A New Structure for Care Delivery
According to the NCQA, the national certifying body for what they term Patient-Centered Medical Homes, a Medical Home is a primary care setting that “facilities partnerships” between patients and providers and one in which “care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.”
Or as Laurie Jensen, Director of Clinic operations at Sanford Luverne Clinic, itself a certified Medical Home for more than a year, explains it, “It is about achieving a team, including the patient, the doctor, the RN health coach, the family, etc., that works together to optimize care.”
“This is not a program, but a philosophy of how we manage care.”
Chad Markham, VP for Clinic and Network Development at UnityPoint St. Luke’s in Sioux City, puts it even more succinctly: “It’s about setting up a network of people to make sure that no one falls through the cracks.” UnityPoint St. Luke’s new Sunnybrook Medical Plaza in Morningside, includes a primary care clinic designed – both physically and logistically – entirely around the Medical Home model of care coordination. Under the Medical Home model, the sickest and most time-consuming patients are funneled into a system to connect them with needed support services without clogging up the works or throwing off the schedule.
“We know that a healthy population uses less of the more costly healthcare things,” says Amy Slevin, RN, Director of Clinical Program Development at Mercy Medical Center in Sioux City. “So you want to keep your healthy patients as healthy as you can, and your chronically ill patients in the management category so that they don’t progress into the more expensive category.”
News Flash: Avera Heart Hospital is first in the region to offer the PEVAR procedure for repairing abdominal aortic aneurysm (AAA).
News Flash: UnityPoint Health-St. Luke’s unveils new Siemens Definition AS 64 CT scanner, which can reduce radiation exposure.
Gain Without Pain
Ergonomics in the Medical Workplace
Medicine can be a risky profession.
According to the CDC’s National Institute for Occupational Safety and Health, healthcare workers experience musculoskeletal disorders at a rate exceeding that of working in construction, mining and manufacturing. In addition to lifting and positioning increasingly heavy patients, many of these injuries occur as a result of being forced to spend many hours working in awkward positions. 
“We do our procedures standing, often in non-ergonomic positions, trying to focus on small movements of our fingertips while the rest of the body is frozen,” says Sanford Interventional Cardiologist Adam Stys. The awkward stance is exacerbated by the fact that international cardiology procedures are performed while wearing a heavy lead apron to protect against radiation exposure. So it’s no surprise that Dr. Stys and his colleagues at Sanford have gladly embraced the advantages of robotic technology. With robotic assistance, the surgeon can manipulate wires and catheters from a seated position behind a radiation-safe console.
“Once I switched to robotics, my injuries went away,” agrees gynecologic oncologist Maria Bell, MD, who developed upper back and shoulder issues after she began performing laparoscopic procedures more than 8 years ago. “Ergonomically, that was not a great transition. I absolutely believe that I will be able to operate longer because of robotics than I would have been able to otherwise.”
Installing robotic systems is not the only way area hospitals are attempting to make life easier and more comfortable for physicians. Hospital administrators say even lower-tech improvements, like ergonomic stools and adjustable computer monitors, can make a big difference over the long haul. “
News Flash: St. Luke’s Sunnybrook Medical Plaza Opens in Sioux City
News Flash: Sioux Falls Specialty Hospital joins a Johns Hopkins research study on best hospital practices.
News Flash: Sanford Aberdeen cardiologist Puneet Sharma, MD, completes record 68-minute ‘door to balloon’ heart attack treatment using vascular robot.
Managing the Maze
By now it is a term with which every American healthcare provider is intimately familiar. Some would say all too familiar. But when the words “meaningful use” first entered our vocabulary as part of the American Recovery Reinvestment Act of 2009 as a way to bring medical care into the digital information age, they were, for many providers, a source of anxiety, confusion, and even fear.
“We fully anticipated that there would be fear, challenges, blockades and barriers with meaningful use,” says Holly Arends, Clinical Program Manager with HealthPOINT. “You’re talking about a change in workflow and a major disruption in business.”
“This has been a tremendous amount of work for everyone – providers, security teams, clinical informatics, nurses, IT departments – everyone,” agrees Hailey Schepp, Sanford Health’s Director of Meaningful Use. “It is so easy to get overwhelmed with the details of meaningful use, but we have to remember that this initiative really is about the patient and improving the patient care experience.”
Arends says South Dakota is in the top 10 states nationwide in adoption of electronic health records, with more than 53 percent of the state’s providers having a ‘live’ EHR system. Providers who have not attested to at least one year of the two-year Stage I meaningful use process by September 30, 2014 (which means they had to have started the process this September) will see a 1% reduction in reimbursements beginning in 2015, and an additional 1/% reduction every year thereafter until they “catch up”.
News Flash: Avera McKennan Hospital announces plans to open an outpatient dialysis center on its Sioux Falls campus.
News Flash: Mercy Medical Center in Sioux City starts construction on a $16.8 million ICU renovation and MRI project.
Most MED articles come from the suggestions of area healthcare professional. If you know of a physician, program, or institution that you think is worthy of coverage in MED, write to us at Alex@MidwestMedicalEdition.com.
 “Preventing Back Injuries in Health Care Settings”, September 22nd, 2008, NIOSH Science Blog