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an online version of the magazine Winter 2005
Circling the Dome
Alan Heldman looks forward to the day when all his patients have private rooms as up to the minute as the cath lab.
Alan Heldman looks forward to the day when all his patients have private rooms as up to the minute as the cath lab.


New Beat, All Heart

Not that Alan Heldman worries about getting the job done. His clinical Grand Central Station—the Cardiovascular Diagnostic Laboratory—already has just about every bell and whistle the interventional cardiologist could wish for. But that doesn't mean Heldman, who helped create drug-carrying stents to keep coronary arteries open, can't see a lot of room for improvement. One example? “So much of cardiology is image-based,” he says, “and what we need is to have these images digitally archived so we can view all of them wherever we are.”

As treatment for heart disease has gone increasingly high-tech, the Hospital's geography has often forced each new piece of imaging equipment or laboratory advance to sprout up wherever it could find space, sometimes floors away from each other. That problem should disappear by 2008, when the specialty will have its own planned community—the Johns Hopkins Heart Institute, slated to occupy several floors in the new Cardiovascular and Critical Care Tower.

“A lot of what we're doing now or will do in the future requires the cooperation of physicians across many disciplines—surgery, cardiac surgery, interventional radiology, cardiology, pediatrics,” says Rick Lange, chief of clinical cardiology. “But we're so isolated now that to bring that collaborative effort together for the patient is very difficult to do.”

Besides creating sorely needed proximities, the new center also is being designed to beef up efficiency and flexibility. Operating rooms may house CT or MRI that can be used to immediately assess the results of surgery. ORs will be able to convert to cath labs or vice versa, depending on future needs. Equipment and walls will be movable. And patient rooms will be outfitted with plasma screens where X-ray, laboratory or cardiac cath results can be called up to discuss with patients and families.

“It's a way to bring the technology that sits in radiology, cardiology, surgery and the laboratory directly into the patient's room,” says Lange. “It's way cool.”

So substantial is the Heart Institute that it's got its own board of governors. Led by Art Modell, former majority owner of the Baltimore Ravens, the board includes more than two dozen high-profile volunteers. Modell, who also joined the Hopkins Medicine board of trustees this year, served for 22 years as a trustee for the Cleveland Clinic. Board members will be involved in marketing the Institute, but their biggest job will be fund raising.

“If history is our guide,” says Modell, who has himself suffered two heart attacks and a stroke, “there's every reason to expect that the Johns Hopkins Heart Institute will achieve the success we're all waiting for.”

Mary Ellen Miller

Tune in for Treatment

Alexander Nason is out to prove that a picture can be worth a thousand miles.
> Alexander Nason is out to prove that a picture can be worth a thousand miles.

Telemedicine, says Alexander Nason, needs to be experienced, not talked about. Two minutes later, he's established simultaneous live connections with hospitals in Cork , Dublin and Belfast , Ireland . The Irish network, which links 29 pediatric centers, is the world's first national telemedicine system, and doctors on the network call in from 2,500 miles away to consult face to face with Hopkins specialists.

This new method for providing long-distance, top-notch medical care, industry experts predict, will play a major role in our economy as consumers and insurers demand more cost-efficient medical care. Nason, an international senior manager for business development here, has made it his personal mission to awaken faculty physicians to what they can do with the dumbfounding technology—everything from simple consultations to seemingly far-fetched telesurgery for patients on the other side of the world (or presumably in space). The middle ground encompasses radiology consults via home computers, lectures broadcast in real time by satellite, home health care by videophone, centralized intensive-care monitoring and travel-free prison health.

Clinicians here are using some of these opportunities, but not enough or as cohesively as Nason would like. With his help, Johns Hopkins International has made telemedicine a routine part of its operations, and now he wants the new Office of Telemedicine he heads to become the clearinghouse for divisions all over the Hospital to establish their own programs.

In monthly meetings, Nason brings together a small band of believers that includes people like Bill Ruby, the infectious disease specialist who videoconferences HIV care to Maryland's prison population, and Louis Kavoussi, the urologist who has performed robotic telesurgeries on patients in places like Rome and Singapore and even conducts hospital rounds with a remote-controlled robot.

With them spreading the word, more faculty are showing up in Nason's office to propose projects: An otolaryngologist wants to use videoconferencing to do speech rehab on patients recovering from throat surgery; infectious disease specialist Bob Bollinger is sending clinical expertise out to health care workers in nations devastated by AIDS; a psychiatry staffer is teaching therapists in rural Maine to evaluate her clients.

“The possibilities are almost unlimited,” Nason says. “And once a project is in place, it becomes a habit instead of a special event.”

Rosemary Hutzler

A Whale of an Exam

At the Aquarium, Comparative Medicine postdocs Tim Cooper and Brian Simons.
> At the Aquarium, Comparative Medicine postdocs Tim Cooper and Brian Simons.

Scientists at the National Aquarium in Baltimore have been running a successful dolphin breeding program for years, but when they unexpectedly found 4-month-old Bridgit dead in the Marine Mammal Pavilion—the second dolphin calf they'd lost within a few months—they were mystified. For help, though, they knew exactly where to turn: the postdoctoral fellows in Hopkins' Department of Comparative Medicine, who've not only been determining causes of death in the Aquarium's marine mammals since the Inner Harbor attraction opened in 1981, but who've also been conducting the postmortem exams called necropsies on every animal that's died at the Baltimore Zoo in the last 20 years.

More than 100 veterinarians, many now department chairs and leaders in academia and industry in the United States , Canada and Europe, have trained in the Hopkins program. Today, Comparative Medicine can boast of having examined one of the greatest variety of species—from elephants and whales to tarantulas and snakes—of any such department in North America.

“By understanding how animal diseases are caused, we gain a better understanding of human disease,” says Christine Zink, professor of comparative medicine and Hopkins ' chief liaison with the Zoo and the Aquarium. “That's what comparative medicine is all about.”

The postdocs use confocal micros-copy and other technology that's not generally available at zoos and aquariums to figure out what's going on at the molecular level. Among the diseases they're currently investigating are a disorder in giraffes that resembles HIV, and a herpes virus, discovered here by a postdoc about six years ago, that's killing elephants worldwide. Bridgit's affliction was far more common—she had pneumonia. The other Aquarium dolphin, a 10-day-old male, had bacterial meningitis.

Now, at the Aquarium's request, Hopkins vets will do necropsies on all its animals, including reptiles, birds and furry mammals. The Aquarium is preparing to open an Australia exhibit, so it looks like Comparative Medicine will be adding to its list of examined species crocodiles, flying foxes and blue-tongued skinks (a type of lizard, in case you're wondering).


Anne Bennett Swingle

ABX Rules

It's a “must have,” extolled the technology editor of Pharmacy Practice News, reviewing Hopkins ' Antibiotic Treatment Guide for handheld computers in the August 2004 issue. The easily navigated application—known to aficionados as the ABX Guide—already has more than 240,000 registered users, including clinicians and other health care workers, who rely on it for quick, accurate information on some 150 infectious diseases, 170 drugs and 75 pathogens. Developed here several years ago (the editor in chief is Infectious Diseases Chief John Bartlett), the ABX Guide also helps practitioners wade through the estimated 1,500 antibiotic treatment guidelines that government agencies and medical organizations have developed over the years. Best of all, it's free. Check it out at www.hopkins-abxguide.org.

Anne Bennett Swingle

Meet-Less Fridays

Back-to-back, dawn-to-dusk meetings have been controlling the lives of Hopkins leaders. “If there's a problem,” says Chip Davis, executive director of the Center for Innovation in Quality Patient Care, “we have a meeting.” But for Ed Miller, meetings were the problem. “I'd ask people why they weren't paying more attention to patient safety,” says the dean, “and the answer invariably was, they didn't have time; they were always in meetings. And I kept thinking, That's just wrong.”

To help everyone stay on track, this fall Miller and Hospital President Ron Peterson recommended to all clinical chiefs, nursing directors and administrators that no multidepartmental meetings be held on Fridays and that all meetings be limited to 45 minutes. The point, says Davis , is that “people can use that time in their departments to focus on safety and quality. Folks aren't here because they want to sit in meetings, but because they want to contribute to the care of patients.”

Patrick Gilbert

No Free Lunch

It's hardly been a secret that drug manufacturers employ an army of “detailers” who fan out with a single goal: to convince prescribers that their company's products rock. And their targets aren't only private-practice physicians: For years, you could drop in on any hospital unit and find a sales rep waiting to buttonhole someone or setting up an industry-sponsored meal in the break room. But now Hopkins has joined the growing trend to clamp down on this freewheeling relationship between the pharmaceutical industry and health care professionals.

“In too many cases, the behavior of drug sales reps around the institution was getting out of hand,” says Beryl Rosenstein, vice president for medical affairs. “It was time to come up with a comprehensive policy that brought some control over this activity.”

So last spring, a group representing the medical staff, nursing, pharmacy and the ethics committee hammered out new rules. Now, the flood of pens, notepads, key chains and free food is gone. All gifts, in fact, are banned unless they're directly related to patient care or have educational benefit, such as medical books or journals. House staff, medical students and nurses are no longer being subjected to unrestricted pharma marketing. And clinical departments, not the drug companies, are the ones choosing the topics and speakers for company-underwritten educational sessions.

Although some here wanted to completely banish the 200 sales reps who visit Hopkins on behalf of 76 drug companies, “we felt that wasn't entirely in our best interest because we are a teaching institution,” says Rosenstein. In a controlled setting, he adds, the reps can provide a worthwhile educational experience.

Patrick Gilbert

And So To Baltimore

Not leaving home without Willy and Liberty? Priceless.
> Not leaving home without Willy and Liberty? Priceless.

Professorial types may come endowed with brains, but, make no mistake, they get just as stressed as the next guy about changing cities. Pathologist Cory Brayton, who arrived at Hopkins in December from Baylor College of Medicine to become director of mouse phenotyping, says she went through weeks of turmoil, mainly because she had to find space for her horses, Willy and Liberty . “It's so much harder with two.” Still, Baltimore is a much easier place to live now, Brayton says, than when she first saw it in the 1980s.

Donlin Long, who came to Hopkins in 1973 to become director of neurosurgery, seconds that. “ Baltimore ? It was a terrible place,” he says. “You can't look at this city now and think what it was like then. The riots of east Baltimore had been four years earlier, but there were still lots of burned buildings. Garbage in the streets, rats running around, packs of wild dogs roaming the streets.

“And none of the new Hopkins buildings were here,” Long adds. “The great Johns Hopkins Hospital had the worst physical plant I'd ever seen. What's more, I came as a clinical chief and never had a contract. I talked with the dean, we shook hands, and that was the extent of the agreement. The so-called dowry that clinical chiefs now receive, there was nothing like that. What you had was an opportunity to be here.”

Thirty years later, that's still what did it for Peter McDonnell, Wilmer Eye Institute's latest director. At 46, McDonnell made his fourth cross-country move from UC Irvine to take his job—which he doesn't think is that unusual. Academics move every three and a half to four years, according to his real estate agent.

“But my wife said if I decide to move again, she and the children are going to miss me,” McDonnell admits. He's not planning on going anywhere, though. “There's not a better job in my field.”

One age group seems unfailingly to applaud the move east, according to Julie Freischlag, who left UCLA to head Surgery here. “My kid never knew there was such a thing as a snow day. We showed up during the hugest blizzard in years, and he couldn't believe he was getting out of school.”


Sarah Richardson

Infection Patrol

It's long been virtual dogma that a certain number of hospitalized patients will inevitably acquire a bloodstream infection. Patients in intensive care units are especially vulnerable. Not only are their immune systems already working overtime, but they usually need to have a catheter inserted in a large vein so they can be given fluids and medication—a procedure that can easily introduce unfriendly microbes. Of the 250,000 bloodstream infections that annually occur in the United States, nearly a third are in ICUs, increasing mortality by 12 percent to 25 percent and costing up to $40,000 per episode.

Yet, in the last two years here, infection levels in several ICUs have plunged so low they're almost off the charts, dropping from an annual high of 235 to around 24. Both the Weinberg ICU and the surgical ICU recently celebrated one year without a single infection. And on the medical ICU, the historically high numbers shot down to one.

The turnaround—one of the institution's most significant patient safety achievements to date—is no accident. It's the result of single-minded determination and a protocol consisting of meticulously documented interventions, such as requiring everyone involved in central line insertions to wear sterile gowns, masks and caps and to use large sterile patient drapes around the insertion site. Special carts now corral all needed supplies, and checklists much like those pilots use before take-off ensure that no protocol steps are bypassed. The Hospital's Department of Epidemiology and Infection Control also created a Web-based tutorial that's mandatory for everyone who inserts central lines.

The result? In the first year of the program, the estimated impact was 14 lives saved—not to mention 448 hospital days and $2,240,000.

Patrick Gilbert

The Shoe View

Before they ever arrive at the School of Medicine , students hear about the dangers of the surrounding neighborhood. Yet on two fall afternoons, fully 25 percent of first-year medical students headed into the McElderry Park neighborhood of East Baltimore with Glenn Ross, a community activist who spoke to the Physician and Society course.

The goal, says M.D./Ph.D. student David Dowdy, who helped organize the outing, is to help students feel comfortable going into the community if they want to get involved.

For the most part, the tour was sobering, as students trekked along streets lined with boarded-up buildings. But amid the blight, they also found the cheery playground at Tench Tilghman Elementary School , and the Amazing Port Street Project, where vacant lots now blossom with gardens, totem poles and a labyrinth. Surveyed later, nearly all the students said the experience made them interested in volunteering in the neighborhood. “And lots of people there are doing really great things,” says Dowdy, “even if at first glance, things look desperate.”

Anne Bennett Swingle

Stepping Down, Not Standing Still


Pat Walsh: Prostate cancer's nemesis.
> Pat Walsh: Prostate cancer's nemesis.

Patrick Walsh, urologist in chief for the last 30 years, may be handing over the reins to one of his own trainees, urologist and scientist Alan Partin. But he's not going anywhere. That's why the recent daylong symposium on prostate cancer research and the black-tie dinner that followed didn't mark Walsh's retirement. Instead, it paid homage to him and his wife, award-winning interior designer Peg Walsh, who has created such stupendous Hopkins interiors as the Wilmer Library and public areas in the two Hopkins buildings that form Green Spring Station.

Although Walsh joked about going from “Who's Who” to “Who's He,” his reputation is secure. His nerve-sparing radical prostatectomy, an operation he devised and has refined over the last 20 years in more than 3,000 men, now is known worldwide as the “Walsh procedure.” It's the only form of treatment for localized prostate cancer that has been shown to prolong life. Meanwhile, the major urology textbook, for which Walsh has been senior editor for the last 25 years, has been renamed the Campbell-Walsh Textbook of Urology. “I'm at the top of my game,” he says.

In fact, Walsh just put out a free DVD for surgeons. You're not going to find this one on the shelves at Blockbuster, and the title may not exactly roll off the tongue, but “Nerve-Sparing Radical Retropubic Prostatectomy” leaves no doubt how the star urologist has come close to conquering the two most-feared side effects of prostate surgery: impotence and incontinence. With funding provided by a grateful patient, the DVD demonstrates in 105 step-by-step minutes the sequence and instruments Walsh uses in the eponymous operation. Some 40,000 copies of the DVD have already gone out to members of the world's top urological societies, and another 15,000 are on hand for urologists who request one (http://urology.jhu.edu ).

 Medical School Reformer
 Icons and Fundraisers
 In Spite of All Odds
 Circling the Dome
 Medical Rounds
 Annals of Hopkins
 Learning Curve
Johns Hopkins Medicine

© The Johns Hopkins University 2005