Docs in Black
At the vanguard of tactical medicine,
life-saving "SWAT Docs" like Nelson Tang are poised
Nelson Tang dresses in black for a reason: If he’s
called into a nighttime sniper situation, he’ll
blend in with the shadows. “We try not to carry
bright, shiny objects,” he says, flashing the
glint of a steel surgical tool. “Something like
this can get you killed. You’re lit up in a field
somewhere. You’d be the first target.” Increasingly,
explains Tang, makers of instruments intended for “tactical
medicine” tailor the devices for the “light
discipline” so valued by police SWAT teams—all-black
stethoscopes, scissors and scalpels. “Stealth
is an important consideration,” says Tang.
As a physician who heads up special operations for
emergency medicine at Johns Hopkins, Tang occupies
a unique place in tactical medicine’s vanguard.
With armed violence on the rise, emergency responders
have sought ways to combine firepower with quick life-saving
skills, prompting SWAT teams to include physicians
when responding to hostile incidents. Hopkins has emerged
as a leader in this new approach, hosting a modern
training center on the Mt. Washington campus where
physicians and police groups at every level of government
can share skill sets.
After completing his medical residency at Hopkins
and joining the medical faculty in 1997, Tang found
himself serving part time with Presidential Secret
Service units by 1999. The war on terror then spawned
the Department of Homeland Security, which selected
Hopkins as one of its key centers two years ago. Hopkins
is now one of the nation’s only academic medical
centers to specialize in tactical medicine, with five
faculty members and two full-time paramedics.
Taking their cues from combat medicine, tactical physicians
don protective gear and deploy with “entry teams” made
up of four to six people. The only distinction for
the team’s physician—always the last to
enter any hot spot—is that the doctor carries
a medical “go bag” instead of a weapon.
Traditionally, physicians or paramedics would wait
at a mobile unit some distance from the danger zone
until given the “all-clear” signal from
police. The lag time inevitably raises the risk of
losing lives to blood loss. Skilled SWAT docs are on
the scene instantaneously—potentially shrinking
the long-revered “golden hour” of trauma
medicine to mere seconds.
When Tang needs to travel light he favors the “M-9” go
bag, which contains “all the immediate essentials,” he
says. These include packets of powder designed to quickly
stanch bleeding on multiple victims—a terrific
asset in cases where the injured can’t be moved, “as
in a barricade situation,” he explains. The
bag is also equipped with a small skin-stapling kit
for closing wounds, along with the basic items for
restoring fluid levels via IV lines.
Though Tang has donned his gear countless times, he
has not yet been exposed to an active shooting case.
Yet you get the sense he’d keep his cool under
fire. “I’ve had a lifelong interest in
law enforcement,” he says. “My best friend
is now a police officer.... Maybe this bridges the
A Silence Not So Golden
Why do surgeons keep mum about needle-stick injuries?
Martin Makary thinks silence has worsened a threat
to the health of surgical residents, so he’s
publicly declaring his latest study results: Nearly
all surgeons accidentally stick themselves with sharp
instruments during their first five years of training.
Most don’t report the incidents, even when they
know the patients carry blood-borne infections such
as HIV and hepatitis.
The numbers from Makary’s new study, which appeared
in the June 28 New England Journal of Medicine, make
it starkly clear. Ninety-nine percent of the 699 surgical
residents reported injuries that included either needle
sticks or skin breaches from other instruments. About
51 percent did not formally report the incidents. Of
those who remained silent, 53 percent were working
on patients with high risk for potentially fatal infections.
The national tally for needle stick injuries among
all health care workers is estimated at 800,000 annually.
Why the hush? Makary, a general surgeon here who led
the study, found that it stems from multiple sources.
The reporting system is riddled with obstacles. They’re
likely unaware that quick responses really work (nearly
100 percent effective in preventing HIV). Some
worry it will harm their careers. And, Makary
believes, the culture of surgery can condition its
practitioners to keep their patient responsibilities
first, even above the need to care for themselves.
As to surgical trainees’ worries over how the
incidents can affect their careers, Makary says he’s
working on that. At Hopkins, at least, more of the
senior surgeons have become vocally open about their
own needle-stick incidents. One of the most effective
new preventions for under-reporting, according to Makary,
is to encourage all practitioners to speak up, a principle
embodied in the department’s recently instituted
briefing and debriefing tool. At the end of a procedure,
all those present are asked if anyone has suffered
an injury. If so, they are told to call the Hospital’s
needle-stick hotline, 5-STIX.
“We don’t want to create another patient,” says
“Iron Man” Cal Ripken Jr.’s entry
into Baseball’s Hall of Fame wasn’t the
only thing Baltimoreans had to celebrate this summer.
The same month that Ripken and his famous “streak” were
fêted in Cooperstown, Johns Hopkins Hospital
celebrated a streak of a different kind. For the 17th
year in a row, U.S.News & World Report ranked
Hopkins at the top of its “Best Hospitals” Honor
The magazine ranked Hopkins #1 in otolaryngology,
gynecology, rheumatology, and urology; #2 in geriatrics,
neurology and neurosurgery, ophthalmology, and psychiatry;
and #3 in endocrinology and the treatment of cancer,
digestive disorders, and respiratory disorders.
U.S. News bases its results on a national survey of
board-certified specialty physicians, along with analysis
of a long list of objective indicators—everything
from death rates to the availability of advanced services
such as robotic surgery. While geriatrics reappeared
this year after a year’s absence, pediatrics
ratings were temporarily dropped.
A Royal Gift of Tower-ing Impact
"Above and beyond" patient services
paved the way for the UAE’s generosity.
left, Ronald Peterson, Edward
Miller and William Brody presenting
a rendering of the cardiovascular
and critical care tower to Crown
Prince Sheikh Mohammed bin Zayed
al Nahyan in Abu Dhabi on April
artist’s rendering of the
cardiovascular and critical care
Months after the United Arab Emirates endowed Johns
Hopkins Medicine with a momentous contribution that
catapulted the hospital’s $1.2 billion redevelopment
plan toward reality, the confetti is still flying.
The gift, one of the most significant Hopkins has
received to date, will help fund a 913,000-square-foot
cardiovascular and critical care tower that will be
named for Sheikh Zayed bin Sultan Al Nahyan, who formed
the UAE in 1971 and ruled it until his death in 2004.
To fête the employees who made the historic
gift possible, Hopkins leaders planned a pull-out-the-stops
celebration for September 6.
JHM International’s above-and-beyond patient
services team is known around the hospital—and
the world—for its personalized attention to everything
from appointment scheduling and financial planning
to interpreting and arranging travel.
The team has tailored care for patients from the UAE
since at least 1988. And when it comes to opinion leaders
such as the royal family, “the service expectations
are above and beyond any standard,” explains
Raffaella Molteni, director of international patient
services. “Our coordinators work day and night,
weekends included, to manage and facilitate any possible
The first large-scale visit was in 2005, when a high-ranking
royal arrived for surgery with an entourage of more
than 70 people. Since then, similar groups have returned
each year for care ranging from orthopedic surgery
to dermatology consults.
The preparations begin months in advance, says Wafik
Gobrial, who orchestrates the often two-month-long
events. Schedulers arrange back-to-back appointments
for as many as 30 family members. On Marburg, facilities
experts upgrade the private suites with new TVs and
familiar satellite channels, laptops, artwork, curtains
and Oriental rugs. The team hires additional help—private
duty nurses and interpreters among them. Everyone from
kitchen staff and housekeeping to nurses and medical
staff are briefed on cultural do’s and don’ts. “Our
team knows that all will go well,” says Gobrial. “It
But Hopkins’ ties to the UAE extend far beyond
treating patients. Mohan Chellappa, vice president
for global strategy, has also nurtured a business relationship
with Abu Dhabi’s health authority. Last year,
Chellappa’s work culminated in Hopkins’ 10-year
contract to manage Tawam Hospital, the UAE’s
most prestigious tertiary care facility (see “Desert
Bloom,” p. 30).
“The whole relationship has grown from strength
to strength,” says Harris Benny, CEO of JHM International. “Due
to the ties between the Abu Dhabi health authority
and the royal family, a strong link with the head of
the health authority gave us the right audience with
Sheikh Mohammed [Abu Dhabi’s crown prince].”
All of this led directly to that day in April when
Sheikh Khalifa bin Zayed Al Nahyan, the UAE’s
president, offered his gift to a coterie from Hopkins
during a whirlwind, 17-hour visit to the southern shore
of the Persian Gulf.
“This was purely a gift to honor a great man, a gift with no political
agenda and no strings attached,” says Steven Rum, head of development
for Hopkins Medicine.
Health System President Ronald Peterson likens the
UAE to the “Switzerland of the Middle East” because
it is open, is tolerant of all religions, and maintains
good relations with its neighbors and the United States.
“It’s a smaller world now,” says Peterson. “For over
a decade we’ve extended care to the royal family and others from the
UAE. This is their way of giving back.”
Hazards of Change: Part Deux
With letters continuing to come
in, we figured it was time to sit down with Dean
Edward Miller to explore more fully the comments
he made in last
winter’s “Post-Op” about
the School’s new Genes to Society curriculum,
set to roll out in 2009. Joining the conversation
was the curriculum’s chief architect, Vice
Dean for Education David Nichols.
Dean Miller, one line in
your column in particular has seemed to stir the
most consternation: “Our
students choose us because they hope to learn bench-to-bedside
treatment for complex diseases rather than serving
as family practitioners in community hospitals.” Many
took this to be a knock against Hopkins grads who’ve
chosen family practice as the focus of their medical
Miller: I firmly believe that
prospective medical students look at this place for
its reputation and the fact that it has research.
The NIH has invested—and
we have invested—billions of dollars in the side
of medicine called discovery.
Now, what students do once
they get here is totally up to them. We’ve got students in family practice,
emergency medicine and everything under the sun. But
I believe we get a subset of students who pick us for
a different reason than they might pick a state school.
Their purpose is to train physicians for the state.
That’s not our mission. It never has been.
I’m not putting down anybody who goes [to those
schools]. I’m just saying this place was built
for a different reason. Would you agree, David?
Nichols: I agree. I would add
that a [major reason] students come here is the quality
of the faculty. The faculty’s outstanding characteristic is that
in any individual discipline, including primary care
types of disciplines, there is at least one—and
usually several—world leaders in the field.
What about students interested in pursuing family
medicine in particular. Would you advise them not to
come to Hopkins?
Miller: No! I think it’s just the opposite.
I think if somebody came here in family medicine, they
would probably look at certain aspects [of the field] that
need to be improved. Hopefully, we’re training
students so that they can look at what they’re
doing not just by rote but, rather, what can they do
to advance the field.
Nichols: That’s what
the new curriculum is about in many ways. It begins
with the premise that primary care, just like all
specialties, will evolve at a very rapid pace. The
Genes to Society curriculum is designed to prepare
our graduates for the evolution, which will really
differentiate the types of primary care that are
There will be the rote approach—the protocol-driven
primary care for relatively standard problems. One
of our suppositions is that that kind of care will
probably devolve to nurses or other types of providers
because physicians are expensive for the delivery of
that kind of care in the United States.
So how do you see the primary
will need] to differentiate themselves from what nursing
and other providers do. They must understand the uniqueness
of the patient, the atypical presentation, the disease
that is not following the routine scheme and may get
the patient into very severe trouble unless the atypicality
The sources of uniqueness come,
of course, from genotype, from population biology,
from environmental factors. Those are some of the emphases
of the new curriculum. We believe that our graduates
will be leaders in primary care, leaders in their communities,
leaders in health policy, leaders in Washington D.C.
pulling away from primary care at all.
One reader wrote: “A true ‘genes-to-society’ curriculum
would produce graduates choosing careers from bench
research to community-based family medicine.” From
what you’ve been saying, it sounds as if neither
of you would disagree?
Understanding what the health issues
are in populations and then particularizing it to individuals
within the population—that’s what Genes to Society
is all about. We were working very closely with Bloomberg
School of Public Health faculty to bring that to
Prevention is another huge
priority. The point of understanding the genotype
and the environment is to prevent disease, ultimately,
and that’s what
primary care physicians are in the business of doing.
But you can’t do it only by protocol because
everybody’s genotype is different.
Is it safe to say that primary care, in fact, will
be an essential component of the new curriculum?
Nichols: Yes, that’s true. The curriculum includes
a yearlong primary care clinic experience in the first
year that will be directed by our Johns Hopkins Community
Physicians group. Students will join a practice and
follow a group of patients for a year. The purpose
is for the students to experience the evolution and
chronicity of disease as it plays out in patients’ lives.
They’ll also see it from the practice’s
perspective. What does it take to run a practice? What
does the insurance cost? How do the patient and physician
communicate best with one another?
Dr. Miller, you’ve expressed some anxiety about
how Hopkins’ new curriculum will be received
by the accrediting bodies, noting “we could face
difficulty in embracing standards not like other schools’.”
Miller: Outside accrediting
agencies must have some standard metrics that apply
to everybody. We didn’t
design the curriculum around their metrics. We designed
our own curriculum. We hope their metrics will fairly
evaluate our new curriculum.
Nichols: The accrediting bodies
have signaled a very intense interest. They were
just here and that’s
what they wanted to talk about the most, at least with
me. It’s, What are you doing with the curriculum
and when can we know? We have to deliver reports to
them going forward on what our curriculum is going
to look like and how it’s going to roll out.
So we’ll be setting
the standard nationally?
Nichols: We hope we are.
Miller: When you’re in these positions, you’re
always a target in some ways. Only time will tell whether
we’ve picked the right model and are doing the
When Hopkins opened the hospital
in 1889, and the school in 1893, I don’t think there was immediate reaction
that this was the greatest thing since sliced bread,
but by 1910 with the Flexner Report, within 17 years,
it was clear that [Hopkins had been right and] things
had to change. You’re not going to turn a switch
one day and say, you’ve got it right.
Interview by Sue De Pasquale
The Latest Big Fish Story
Wherein the "Dear Abby" of radiology earns the approbation
of his peers.
|>Standing, l to r: Robert De Jong Jr., David Bluemke, Jim Philbin, Dean Wong and Katarzyna Macura. Seated, l to r: Nagi Khouri, Elliot Fishman and Richard Wahl.
Dear Fish: How does it feel
to be rated the top radiologist in the country by readers of Medical Imaging magazine?
ANSWER: “What you’ve
really won is recognition that you represent a whole bunch of people and a
whole lot of excellence. For the technologists and my associates, when you
win, they win also.”
So replies Elliot Fishman, the Department of Radiology’s director of
diagnostic imaging and body CT, and the man behind the “Ask the Fish” column
on www.ctisus.com, the remarkably popular medical imaging Web site that he
created eight years ago.
Fishman’s honor, along with accolades bestowed by the magazine on seven
other Hopkins radiologists, led to the entire department being recognized by
the mag as tops in the nation.
The other honorees ranked as among the top 10 in their fields were David
professor of radiology and medicine and clinical director of MRI; Richard
professor of radiology and oncology and director of the Division of Nuclear
Medicine/PET; Dean Wong, professor of radiology, psychiatry and environmental
health; Nagi Khouri, associate professor of radiology and oncology and director
of breast imaging; Katarzyna Macura, assistant professor of radiology; James
Philbin, director of imaging informatics; and M. Robert De
Jong Jr., radiology
technical manager of ultrasound.
Fishman pioneered the development of 3-D medical imaging—initially with
Pixar, the computer manufacturing firm that was a spin-off of LucasFilms and
now is better known for the wizardry behind such computer-animated movies as
Toy Story and Ratatouille.
In addition to advancing the field of 3-D imaging, Fishman remains the moving
force behind www.ctisus.com (as in CT-is-Us, a parody of the popular toy store
chain). The site was the first of its kind to use podcasting, and now also
employs vodcasting—Fishman lectures via the Internet that use slides,
videos or animations.
One of the site’s most popular features, “Ask the Fish,” takes
its title from his childhood nickname. Fishman answers every radiology question
personally or relays replies from colleagues, whom he credits.
“It’s kind of a ‘Dear Abby’ for medical radiology
stuff,” Fishman says.
ALS' Key Adversary
A visionary neuroscientist seeks clues to the miscues of the central nervous system.
Jeffrey Rothstein is driven to find a cure for Lou Gehrig’s disease—the
cruel, always fatal neurological disease (officially known as amyotrophic lateral
sclerosis, or ALS) that strikes down people in their prime.
If anyone can do it, Rothstein’s the one. In the early 1990s, his pathbreaking
studies of the neuro-transmitter glutamate translated into riluzole, the first—and
still the only—drug on the market for slowing progression of ALS.
Rothstein has also had a major impact on changing the ALS research process
around the globe. Frustrated by what he considered its slow, piecemeal pace,
he launched the Packard Center for ALS Research at Hopkins seven years ago.
He’s guided the center’s expeditious distribution of $12 million
in grants to researchers around the world, giving top scientists well-defined
goals and requiring them to share their findings.
Within the center, Rothstein oversees the efforts of some two dozen postdoctoral
fellows and neurology residents whose work has helped define ALS research.
Their work also sheds new light on the common paths of the major diseases of
the nervous system—from Alzheimer’s to brain cancer.
Paralleling his ALS work, Rothstein studies the very proteins that control
central nervous system communication—glutamate transporters. Controlling
the activity of these proteins can prevent serious damage to the brain and
For his remarkable vision, leadership and achievement, Rothstein (residency,
1989) was awarded the School of Medicine’s Distinguished Medical Alumnus
Award, presented in May.
“Jeff is one of the finest investigators in disease-
oriented neuroscience today,” says John Griffin, director of Hopkins’ Brain
Science Institute. “He’s one of its best ambassadors.”
Neil A. Grauer
More Alpha Docs
Charles Balch, professor of
surgery and oncology, and deputy director of the
Institute for Clinical and Translational Research,
has received the American Society of Clinical Oncology’s
Special Recognition Award for his contributions to
the fields of melanoma and breast cancer, his extensive
service to the ASCO and his influence in the oncology
Roger Blumenthal, professor
of medicine and director of the Ciccarone Center
for the Prevention of Heart Disease, has been named
one of Men’s Health magazine’s
Peter Burger, professor of pathology, oncology and
neurosurgery, has received the Distinguished Pathologist
Award from the United States-Canadian Academy of Pathology.
Vinay Chaudry, professor, vice-chair and director
of the neurology outpatient center, has been elected
as a director of the board of the American Academy
Nancy Craig, professor of molecular biology and genetics,
has been elected a fellow of the American Academy of
Arts and Sciences.
J. Raymond DePaulo Jr., professor and director of
the Department of Psychiatry and Behavioral Sciences,
has received the 2007 Research Award from the American
Foundation for Suicide Prevention.
Rebecca Elon, associate professor
of geriatrics, has been named Clinician of the Year
by the American Geriatrics Society.
David Hellmann, vice dean and director of the Department
of Medicine at Johns Hopkins Bayview Medical Center,
has been elected to the American Board of Internal
Medicine Foundation. The ABIM works to advance medical
professionalism and physician leadership in quality
assessment and improvement.
J. Brooks Jackson, professor
and director of pathology, has received the Herman
and Gertrude Silver Award from the Children’s
Hospital of Philadelphia for his internationally
renowned work in preventing the transmission of HIV
from infected mothers to their newborns.
Gabor Kelen, professor and director of the Department
of Emergency Medicine, has received the 2007 Leadership
Award from the Society for Academic Emergency Medicine.
Trish Perl, associate professor of medicine and director
of hospital epidemiology and infection control, has
become president of the Society for Healthcare Epidemiology.
Neil Powe, professor of medicine and director of the
Welch Center for Prevention, Epidemiology and Clinical
Research, has been named the 2007 Distinguished Educator
by the National Association of Clinical Research Training.
Solomon Snyder, distinguished service professor of
neuroscience, pharmacology and psychiatry, has been
honored with the 2007 Albany Medical Center Prize in
Medicine and Biomedical Research, the largest financial
prize in medicine in the United States. Snyder, recognized
for his pioneering work on how proteins on cell surfaces
enable cells to communicate with each other, shares
the $500,000 prize with Robert Lefkowitz of Duke and
Ronald Evans of the Salk Institute, who made independent
discoveries about how cells communicate with their
Glenn Treisman, associate professor of psychiatry
and behavioral sciences, has received the William C.
Menninger Memorial Award from the American College
of Physicians for his contributions to medicine and
Levi Watkins, professor of cardiac surgery and associate
dean for postdoctoral affairs, has received the Southern
Christian Leadership Conference Health Award.
Mike Weisfeldt, the William
Osler Professor of Medicine and director of the Department
of Medicine, has received the American College of
Physicians’ John Phillips
Memorial Award for Outstanding Work in Clinical Medicine.