Docs in Black

At the vanguard of tactical medicine, life-saving "SWAT Docs" like Nelson Tang are poised for peril.

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 gap.” 

Ramsey Flynn

> Dr. Martin Makary

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 Makary.

Ramsey Flynn

Sweet 17

“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 Roll.

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.

> From 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 30. > An artist’s rendering of the cardiovascular and critical care tower

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 need.”

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 has to.”

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.” 

Lindsay Roylance

STRAIGHT TALK

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.

>Miller and 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 careers.

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 delivered.

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 care physician’s role changing?

Nichols: [They 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 is understood.

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. We’re not 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?

Nichols: There is commonality.

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 life.

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 right thing.

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

ALPHA DOCS

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 Bluemke, professor of radiology and medicine and clinical director of MRI; Richard Wahl, 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.

Neil A. Grauer

ALS' Key Adversary

A visionary neuroscientist seeks clues to the miscues of the central nervous system.

> Rothstein in the lab

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 spinal cord.

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 community.

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 top cardiologists
for 2007.

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 of Neurology.

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 environment.

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 psychiatry.

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.