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"^Illinois 3wl Medical ournal
July 1974 Volume 146 No. 1
Health scien universi
JUL 3 1 74‘
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CIRCULa,
IAL JOURNAL OF THE IS STATE MEDICAL SOCIETY
Our 75th Year
JETD. JAN 2 5
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President’s page. ...12
HEALTH SCIENCES LIBRARY
UNIVERS,TY OF MARYLAN0 BALTIMORE
When parenteral analgesia is no longer required, Empirin Compound with Codeine usually provides the relief needed.
Empirin Compound with Codeine is effective for visceral as well as soft tissue pain— provides an antitussive bonus in addition to its prompt, predictable analgesia.
€ prescribing convenience:
up to 5 refills in 6 months, at your discretion (unless restricted by state law) ; by telephone order in many states.
Empirin Compound with Codeine No. 3, codeine phosphate* 32.4 mg. (gr. V2); No. 4, codeine phosphate* 64.8 mg. (gr. 1). ^Warning- may be habit-forming. Each tablet also contains.- aspirin gr. 3V2, phenacetin gr. 2V2, caffeine gr. V2.
&
Wellcome
Burroughs Wellcome Co.
Research Triangle Park North Carolina 27709
Healing nicely, but it still
HURTS
EMPIRIN
COMPOUN
C CODEIN
#3, codeine phosphate* (32.4 mg.) gr. Vz\ #4, codeine phosphate* (64.8 mg.) gr. 1
New Medical Trustees Elected to Board of Illinois Medical Service
Five medical trustees, including two new mem- bers, were elected to the Board of Trustees of Illi- nois Medical Service at the annual meeting held June 11 at Blue Cross and Blue Shield headquarters in Chicago. Medical trustees reelected to new terms of office were: Dr. Joseph R. Mallory, Mattoon; Dr.
V. P. Siegel, East St. Louis; and Dr. Leo P. A. Sweeney, Chicago. The new medical trustees are Dr. George Shimkus of Aurora, and Dr. Thomas
W. Samuels, Jr., Decatur.
Dr. Shimkus is board certified in obstetrics and gynecology, his full time specialty. He is a member of the senior staffs of St. Joseph Mercy Hospital and Copley Hospital in Aurora. A member of the American College of Obstetricians and Gynecolo- gists and the American Medical Association, he is a delegate to the Illinois State Medical Society from Kane County.
Dr. Thomas W. Samuels, Jr. is a general surgeon, board certified and in solo practice. He is a staff
member of both Decatur-Macon Hospital and St. Mary’s Hospital in Decatur and President of the medical staff of Decatur Memorial Hospital. Dr. Samuels is also a member of the American College of Surgeons and American Medical Association.
Medical trustees in addition to the new mem- bers and those reelected are: Dr. H. Close Hessel- tine, Chicago; Dr. Franz Steinitz, Chicago; Dr. William De Hollander, Springfield; Dr. Alexander Ruggie, Skokie; and Dr. Robert Stepto, Chicago.
Ten medical trustees and nine public trustees serve on the Blue Shield Board. Public trustees include: Henry B. Anderson, Chicago; Howard Builta, Minonk; Dr. Frederick L. Eihl, Moline; Dr. O. Kenneth Johnson, Chicago; Emil J. Koe, Park Ridge; George E. Tapling, Chicago; Robert Agnes, Bensenville; Weir C. Swanson, Arlington Heights; and Mathew P. Cicero, Rockford.
Officers of the corporation are: Dr. H. Close Hesseltine, Chairman of the Board; Dr. V. P. Siegel, Vice Chairman; Mr. Robert M. Redinger, President; Dr. Alexander Ruggie, Secretary; and Mr. George E. Tapling, Treasurer.
!!
Highlights of Annual Report ....
Record Levels of Corporate Operations., Service Improvements for ’74 Emphasized
Record operating levels were achieved by the Illinois Blue Cross and Blue Shield Plans in 1973, Robert M. Redinger, Chief Executive Officer, stated in his message in the 1973 annual corporate report published recently. Commenting on operations, he noted that approximately 4 U million claims were paid by the Plans under both private and govern- ment programs during the year, representing an 11 percent increase over 1972, with the total dollar volume of business approaching $1 billion.
Other highlights of operations and programs cited were:
( 1 ) Membership in the Illinois Blue Cross Plan reached a total of 3.2 million persons in 1973, and Blue Shield membership increased 9 percent to a high of 2.9 million.
(2) Programs in which the Plans are primarily involved in the health care delivery field include: Containment of health care costs; development of Health Maintenance Organizations; introduction of new coverages; cooperation with consumer interests and community affairs.
(3) Because of the tremendous growth in the number of insured persons and the changes occur- ring in health care delivery in the past few years, considerable stress has been placed on the Plan’s internal operations that require attention. Service improvement is, therefore, the number one objec- tive of both corporations in 1974.
“By determining where service improvements are needed and how these improvements can best be achieved, we can assure our members of pro- gress in this area in 1974”, Mr. Redinger emphasized.
(This report is a service to the physicians of Illinois)
ASK BLUE SHIELD . . . ABOUT MEDICARE
ACCEPTING ASSIGNMENT OF MEDICARE BENEFITS
When a physician and his patient agree to the assignment method of billing for Medicare services, the patient conveys his right to payment of benefits to the physician. Under the assignment of benefits the physician agrees to accept the reasonable charge as determined by Part B Medicare as pay- ment in full for services or items he furnishes, and that he will not bill the patient for any charges disallowed as “more than the allowable charge”.
The patient is responsible for 20% of the allowable charges (20% coinsurance), any amount applied to the Part B deductible, and any charge for services disallowed as non-covered. The Part B carrier will pay 80% of the reasonable charge over and above the $60 deductible.
Each year a new Part B deductible must be met by the patient. Effective January 1, 1973 the amount of the deductible was increased to $60. Even though a person is not eligible for Medicare for the entire year, the full deductible must be met. A “carry-over” provision in the regulations, how- ever, applies to covered expenses incurred in the months of October, November and December. Any covered expenses incurred in those months which are applied to the deductible for that year will also be applied toward the deductible for the following year.
If a patient, for example, had no medical ex- penses for the year 1973 until the month of October and then incurred covered expenses of $60 during the next three months, these expenses will satisfy the deductible for 1973 and 1974. As another ex- ample, a patient may incur expenses of $20 prior to October and another $40 in November and December. The $40 will be applied toward the 1974 deductible, as well as the remaining 1973 deductible.
The “carry-over” rule was established to help the beneficiary who might otherwise have to meet the entire deductible twice in a comparatively short period of time.
Before payment can be made, the claim form, SSA 1490, Request for Medicare Payment must be completed, including the signature of the patient and the physician on every assignment claim. Item #12 on the claim form (Assignment of patient’s bill) must show whether the physician and patient agreed to the assignment. The box “I accept as- signment” must be checked, otherwise payment will be made to the patient.
The patient’s signature must appear on the SSA 1490 Request for Medicare Payment form except under the following circumstances:
(1) When the patient is a Public Aid recipient he is not required to sign the form. The Public Aid number of the patient is noted on line 5, and on the patient’s signature line the wording “Public Aid Patient” is either stamped or written by the physician or his office assistant.
(2) When a patient is unable to sign the claim form because of a mental or physical condition, the patient’s name is shown on line 6 of the form, followed by the word “by” and the signature and address of the relative or approved representative explaining his relationship to the patient. A state- ment is also needed explaining why the patient was unable to sign the request.
(3) If a person cannot write his name, he may sign with the mark (X) on the signature line, but the name and address of a witness must also appear on the line.
( 4 ) When a patient is deceased and the physician accepts assignment, line 6 may be completed by the physician indicating “Patient is deceased”.
(5) A physician treating a patient over an ex- tended period, who agrees to accept assignment, may obtain the patient’s consent to assignment of unpaid bills for an anticipated period of treat- ment by having the patient sign a statement as follows :
“I request that payment under the Medical In- surance Program be made directly to Dr
on any unpaid bills for the services furnished me
by that physician during the period to
” The period should extend no longer
than the close of the calendar year, and the state- ment should be attached to the original claim and be submitted in the usual manner. On subsequent claims, the physician should indicate: “This is a continuation of a course of treatment for which the patient’s assignment was previously obtained.” This statement should appear in the signature box.
When the physician accepts assignment for a recipient of Public Aid the SSA 1490 form should be completed in triplicate. Send the first copy of the SSA 1490 to your Medicare carrier, and the second copy to the Illinois Department of Public Aid, Medical Administration, 425 South Fourth Street, Springfield, Illinois, 62762. The third copy should be kept in your files.
Medicare will allow 80 percent of the reasonable charge after the annual $60 Part B deductible has been satisfied. A copy of the Explanation of Medi- care Benefits (EOMB) indicating payment or non- payment will be sent to the Public Aid office. Public Aid will match this EOMB with their copy of the SSA 1490 and adjudicate the claim to make payment under the provision of the Public Aid law.
(This report is a service to the physicians of Illinois)
Illinois Medical Journal
JULY, 1974 Vol. 146, No. 1 CONTENTS
Special Articles
19 Guidelines in the Selection of a Weight Control Program or Product
23 Abstracts of the Board of Trustees Action
33 Categorization of Hospital Emergency Medical Capabilities in Illinois:
A Statewide Experience
David R. Boyd, M.D.C.M., Winifred Anri Pizzano, B.A.,
Patricia A. Silverstone, B.A.Ed. and Teresa L. Romano, B.S.N.
President’s Page
12 A Challenge— Not An Invitation
Fredric D. Lake, M.D.
Clinical Articles
25 Swimming Instruction for Pre-School Children
Eugene F. Diamond, M.D.
28 The Cholesterol Hypothesis and the Coronary Primary Prevention Trial
Philip A. Hahak, M.D., Helmut G. Schrott, M.D. and William E. Connor, M.D.
31 Rupture of the Heart— Report of a Case with One Week Survival
Arnaldo G. Carvalho, M.D., F.A.C.C.
47 The Changing Role of Neonatal Nursing
Charlyn Slade, R.N., B.S.N.
Surgical Grand Rounds
39 Hemangiosarcoma of Breast
John M. Beal, M.D.
(Contents continued overleaf)
for July, 1974
5
CONTENTS (continued)
Features
38 Clinics for Crippled Children
42 View Box
43 New Pharmaceutical Products
45 EKG of the Month
51 Doctor’s News
53 Editorial
54 Pulse of the Doctor’s Wife
56 ISMS Guide to Continuing Medical
Education
63 Physician Recruitment
65 Obituaries
(Cover by Jane E. Bushwaller)
Staff
Editor Theodore R. Van Dellen, M.D.
Managing editor Richard A. Ott
Assistant editor Joyce Gallagher
Executive administrator Roger N. White
PUBLICATIONS COMMITTEE
Jacob E. Reisch, M.D., Springfield, Chairman Eugene T. Hoban, M.D., Oak Park A. Edward Livingston, M.D., Bloomington James A. McDonald, M.D., Geneva Warren W. Young, M.D., Crete
Contributor in Surgery: John M. Beal, M.D., Chicago Contributor in Medical Progress: Harvey Kravitz, M.D., Skokie Contributor in Maternal Death Studies:
Robert Hartman, M.D., Jacksonville Contributor in Pediatric Perplexities: Ruth A. Seeler, M.D., Chicago Contributor in Radiology: Leon Love, M.D., Maywood Contributor in Cardiology: John R. Tobin, M.D., Maywood
ILLINOIS STATE MEDICAL SOCIETY
360 N. Michigan Ave., Chicago, 60601
OFFICERS
Fredric D. Lake, M.D., President 1041 Michigan Ave., Evanston 60202 J. M. Ingalls, M.D., President-Elect 502 Shaw, Paris 61944 Harold A. Sofield, M.D., 1st Vice-President 715 Lake Street, Oak Park 60301 Robert Hartman, M.D., 2nd Vice-President J515A W. Walnut Street, Jacksonville 62650 Jacob E. Reisch, M.D., Secretary-Treasurer 1129 S. 2nd St., Springfield 62704
HOUSE OF DELEGATES
Andrew J. Brislen, M.D., Speaker of the House 6060 S. Drexel Blvd., Chicago 60637 James A. McDonald, M.D., Vice-Speaker 13 S. 2nd St., Geneva 60134
TRUSTEES
1st District: 1977, Joseph L. Bordenave, M.D., 1665 South Street, Geneva 60134 2nd District: 1977, Allan L. Goslin, M.D. 712 N. Bloomington, Streator 61364 3rd District: 1976, David S. Fox, M.D. 20829 Greenwood Center Ct., Olympia Fields 60461 3rd District: 1976, Robert T. Fox, M.D. 2136 Robin Crest, Glenview 60025 3rd District: 1975, Eugene T. Hoban, M.D.
6429 North Ave., Oak Park 60302 3rd District: 1975, Joseph Skom, M.D. 707 Fairbanks Ct., Chicago 60611 3rd District: 1977, William M. Lees, M.D. 6518 North Nokomis, Lincolnwood 60646 3rd District: 1977, George Shropshear, M.D.
1525 E. 53rd St., Chicago 60615 3rd District: 1977, Philip G. Thomsen, M.D.
13826 Lincoln Ave., Dolton 60419 3rd District: 1976, Frederick E. Weiss, M.D.
15643 Lincoln, Harvey 60426 3rd District: 1975, Warren Young, M.D.
3450 Haweswood Dr., Crete 60417 4th District: 1976, Fred Z. White, M.D. 723 N. 2nd St., Chillicothe 61523 5th District: 1976, A. Edward Livingston, M.D.
326 Fairway Dr., Bloomington 61701 6th District: 1975, Mather Pfeiffenberger, M.D.
State and Wall Sts., Alton 62002 7th District: 1976, Arthur F. Goodyear, M.D.
142 E. Prairie, Decatur 62523 8th District: 1976, Eugene P. Johnson, M.D.
P.O. Box 68, Casey 62420 9th District: 1975, Warren D. Tuttle, M.D.
203 N. Vine St., Harrisburg 62946 10th District: 1975, Herbert Dexheimer, M.D.
301 S. Illinois, Belleville 62220 11th District: 1977, Ross Hutchison, M.D. 126 E. Ninth St., Gibson City 60936 Trustee-At-Large: Willard C. Scrivner, M.D.
6600 West Main, Belleville 62223 Chairman of the Board: Joseph L. Bordenave, M.D.
1665 South Street, Geneva 60134
Microfilm copies of current as well as some back issues of the Illinois Medical Jour- nal may be purchased from Xerox University Microfilm, 300 North Zeeb Road, Ann Arbor, Mich. 48106.
Contents of 1MJ are listed in the Current Contents/ Clinical Practice.
Published by the Illinois State Medical Society, 360 N. Michigan Ave., Chicago, 111. 60601 (312-782-1654) Copyright, 1974. The Illinois State Medical Society.
Subscription $8.00 per year, in advance, postage prepaid, for the United States, Cuba, Puerto Rico, Philippine Islands and Mexico. $10.00 per year for all foreign countries included in the Universal Postal Union. Canada $8.50. U.S. Single current copies available at $1.00 ($1.10 by mail), back issues $1.50.
Second class postage paid at Chicago, 111. When moving please notify Journal office of new address including old mailing label with notification, if possible. POSTMASTER: Send notice on form No. 3579 to Illinois State Medical Society, 360 N. Michigan Ave., Chicago, 111. 60601.
Pharmaceutical advertising must be approved by the ISMS Publications Committee. Other advertising accepted after review by Publications Committee or Board of Trustees. All copy or plates must reach the Journal office by the fifteenth of the month preceding publication. Rates furnished upon request.
Original articles will be considered for publication with the understanding that they are contributed only to the Illinois Medical Journal. The ISMS denies responsibility for opinions and statements expressed by authors or in excerpts, other than editorial or allied views or statements which reflect the authoritative action of the ISMS or of reports on official actions, policies or positions. Views expressed by authors do not necessarily represent those of the Society; any connection with official policies is coincidental.
cannibal stomach
*Fordtran, J. S., and Collyns, J. A. H.: Antacid Pharmacology in Duodenal Ulcer: Effect of Antacids on Postcibal Gastric Acidity and Peptic Activity, New England J. Med. 274:921-927 (April 28) 1966.
add Pro-Banthine
Helps to relieve pain without risk of patient drug dependency.
add Pro-Banthine
Reduces gastric secretory volume and total resting and free acid without the caloric, digestive, and social problems occasioned uent eating.
by
Pro-Banthine
Pro-Banthine slows intestinal motility to enhance and prolong the action of antacids. The action of Pro-Banthine lasts 4 to 6 hours.
Searle & Co.
San Juan, Puerto Rico 00936
Address medical inquiries to: G. D. Searle & Co. Medical Department, Box 5110, Chicago, III. 60681
SEARLE
3
ilij ' 0
2 1
iK
» I
5
usually get better patient response.
occur as well as mydriasis and blurred vision. In addition the following adverse reactions have been reported: nervousness, drowsiness, dizziness, i insomnia, headache, loss of the sense of taste, nausea, vomiting, constipa- tion, impotence and allergic dermatitis.
Dosage and Administration: The recommended daily dosage for adult oral therapy is one 15-mg. tablet with meals and two at bedtime. Subse- quent adjustment to the patient's requirements and tolerance must be made.
Pro-Banthine P. A. — Each tablet of Pro-Banthine RA. (propantheline bromide) contains 30 mg. of the drug in the form of sustained-release or
timed-release beads; on ingestion about half of the drug is released within an hour and the remainder continuously as earlier increments are metab- olized. Thus the result is even, high-level anticholinergic activity main- tained all day and all night in most patients with only two tablets daily. Some patients may require one tablet every eight hours.
The contraindications and precautions applicable to Pro-Banthine 15 mg. should be observed.
How Supplied: Pro-Banthine is supplied as tablets of 15 and 7.5 mg., as prolonged-acting tablets of 30 mg. and, for parenteral use, as serum- type vials of 30 mg.
389
President’s Page
A Challenge- —
Not An Invitation
pilllllililllllllllilliilllliiiiillllliliilllliilllillllllll
All too frequently I hear the complaint that the state medical society “does not represent me.” This tune is sung by physicians who have made no effort to be represented. Often they have not par- |
ticipated nor made the least effort to become involved in the af- |
fairs of their county society or ISMS. They have permitted their “representatives” to be chosen for them by others. g
Also heard — all too often — is the complaint that a small clique runs the show. If true, this is so only because the body politic — the 1
grass roots — permits this to happen by abdicating its rights —
1 especially the electoral franchise. 1
The privilege of authoring this page has befallen me not because I had the right “school tie” nor because I was a member of the “power bloc” — I have neither of these qualifications. I hold my office because within the “halls of medicine” I have dared to address the issues and to speak my piece. g
In my previous message on this page, I invited the membership to make known to the House Select Committee its views on the problems besetting the society, and to offer any suggestions on its governance, organization and operations. I pointed out that this is your opportunity to participate in restructuring ISMS and eliminating J
its troubles. 1
I have received some disconcerting feedback from this invitation.
There are physicians who predict that the Select Committee will lay a sterile egg. To them I suggest that the Committee can fail only if you, the members of ISMS, let it fail. The recommendations of this committee will be reported at the House of Delegates in April, 1975. g
What those recommendations will be depends upon you. g
The action of your delegates will determine the success or failure 1
of this monumental effort. If you ordain the needed changes, your |
delegates dare not ignore you.
Submit comments to Committee Chairman and ISMS President-Elect J. M. Ingalls, M.D., g
502 Shaiu Avenue, Paris, III. 619II .
illllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllM
12
Illinois Medical Journal
Guidelines in the Selection of A Weight Control Program or Product
At its recent meeting, the ISMS Board of Trustees approved the “Guidelines In the Selection of A Weight Control Program or Product.” These “Guidelines” were produced to inform patients what to look for when selecting a weight reduc- tion regimen. Copies of the “Guidelines” are available for distribution to patients or for display in physicians offices; contact: ISMS headquarters, 360 N. Michigan Ave., Chicago, 60601.
1. CONSULT a physician to make sure the program or product is safe for you. Most diets, drugs, exercises, and products are de- signed for people in good physical condition. It is imperative to have a doctor’s approval BEFORE BEGINNING potentially danger- ous weight control procedures or products.
2. BE WARY of deceptive advertising. NO SINGLE ITEM CAN OFFER GUARAN- TEED RESULTS.
S. KNOW what “medical supervision” means. Programs which do not have a physician, licensed to practice medicine in all of its branches, on the premises at all times, are not medically supervised.
4. SEE a physician regularly while participat- ing in a weight control program or using a reducing product. Such check-ups will insure that the program or item is not deleterious to your health.
5. FIND out if drugs are to be used in a weight reduction program. If so, medical supervi- sion is essential.
6. BEWARE of any drug used for weight con- trol which has not been approved by your physician. Drugs like Human Chorionic
Gonadotropin (H.C.G.) are considered ex- perimental, and are not F.D.A. approved for weight control. To determine the status of a particular drug, consult your physician.
7. CHECK diet regimens with a physician or local health department to insure that they meet the nutritional requirements necessary to maintain good health.
8. REMEMBER, exercise should accompany any weight loss for increasing energy output and toning tissues and muscles. However, exercise alone is inadequate for losing weight, and could be harmful if not properly supervised or structured to meet your limita- tions.
9. BE WARY of special drugs, fad diets, or mechanical reducers which guarantee dram- atic losses in weight. Any sudden change in weight is potentially hazardous. Body wrap- pings, in particular, should be discouraged. These can be dangerous, and may cause severe circulation ailments.
10. REMEMBER, the “secret” of weight con- trol is a “RETRAINING” of eating habits. This will help maintain the weight you lose. Any program which fails to do this is inade- quate. M
for July, 1974
19
Dalmane
(flurazepam HCI)
Distinctiveness that begins with the benzodiazepine
structure
Distinctive sleep potential in the flurazepam HCI molecule
Dalmane (flurazepam HCI) is a distinctive
sleep medication— a benzodiazepine specifically indicated for insomnia. It is not a barbiturate or methaqualone, nor is it related chemically to any other available chjChpn(c2h5)2 hypnotic.
In the most rigorous course of clinical evaluation ever accorded a sleep medication in the sleep research laboratory, Dalmane has repeatedly been shown effective in helping patients fall asleep promptly, stay asleep and sleep longer.1'7
2 HCI
20
Illinois Medical Journal
Abstracts of Board Actions
June 1-2, 1974 Chicago
These abstracts are published so that members of the Illinois State Medical Society may keep advised of the actions of the Board of Trustees. It covers only major actions and is not intended as a detailed report. Full minutes of the meetings are available upon any member’s request to the headquarters office of the ISMS.
1974 Annual Meeting
The Board of Trustees agreed that ISMS would underwrite up to $11,500 of def- icit incurred by the scientific program planned in conjunction with the 1975 Midwest Clinical Conference and the annual meeting of ISMS. The agreement is contingent upon a uniform accounting system being developed by the treasurers of ISMS and the Chicago Medical Society. The subsidy was necessitated by the decision to discontinue technical and scientific exhibits.
TAP Institute
The Executive Committee was authorized to decide if ISMS should co-sponsor a "Trustee-Administrator-Physician" TAP Institute to be conducted in October by the Joint Commission of Accreditation Hospitals. If the Executive Committee judges the institute's program content to be contrary to ISMS policy, partici- pation will be declined.
Outlook Sanatorium
The Board approved and forwarded to the Champaign County Medical Society a report presented by an ISMS physician committee following its inspection of the Outlook Sanatorium in Champaign. The report refuted adverse findings of the Illinois Department of Public Health Tuberculosis Advisory Committee. The Board authorized the Champaign Medical Society to release the ISMS report to the press.
Benevolence Fund
All applicants for benevolence and annual renewals of aid will be screened by the appropriate district trustee, who may call upon the county medical so- ciety or its auxiliary for assistance in checking eligibility.
Amendments to Emergency Medical Treatment Act
In a followup to previous action, the Board approved ISMS introduction of amendments to the Emergency Medical Treatment Act in the current session of the legislature.
National Blood Program
Endorsement of the American Blood Commission Plan was approved by the Board and the Department of Health, Education and Welfare was notified.
Resolution on Family Practice
The Board withheld approval of a resolution asking the General Assembly to re- quire medical schools to report their progress in developing and expanding fam- ily practice departments. Further action will depend on the position taken by the Illinois Academy of Family Physicians on this matter.
PSRO Ad Campaign
Following a progress report on the campaign to inform the public of the dele- terious effects of PSRO, the Board directed that a sample "Confidentiality" en- velope stuffer be mailed to all ISMS members with an order blank on which addi- tional copies may be requested.
In a related action, the Board instructed the AMA delegation to support in the
( Continued on page 58)
for July , 1974
23
.
Kefzol
cefazolin sodium
Ampoules, equivalent to 1 Gm. of cefazolin
Additional information available to the profession on request.
Eli Lilly and Company Indianapolis, Indiana 46206 400380
24
Illinois Medical Journal
Swimming Instruction for Pre-School Children
By Eugene F. Diamond, M.D. /Maywood
Accidents are the leading cause of death be- tween one and four years of age and drowning is the number three cause of fatal accidents in this age group. About 15% of all fatal accidents between ages one and four years are due to drowning. The circumstances of these drownings are shown in Figures 1 - 4.
The American Academy of Pediatrics is, there- fore, concerned about the 2,500 deaths each year due to drowning, including the over 800 infants under four years of age who drown. We do not wish to delay the learning of water skills for so long as to be teaching swimming only to a few survivors.
On the other hand, we are aware that one of the unfortunate characteristics of this modern era is excessive adult intrusion into juvenile recreation. Particularly in suburbia, inappro- priate pressures tend to be brought on immature children to develop all kinds of skills at a rate not in keeping with orderly process of neuro-
EUGENE F. DIAMOND, M.D., is Pro- fessor of Clinical Pediatrics at Loyola University Stritch School of Medicine. Dr. Diamond served residency programs in internal medicine and pediatrics. He is the author of numerous scientific publications. An active member of the American Academy of Pediatrics, Dr. Diamond is presently the Chairman of their Joint Committee on Physical Fitness.
Figure 1
muscular development and maturation. The laudable efforts of Little League baseball, Pop Warner football, and pee-wee hockey to broaden the base of juvenile sports participation are often frustrated, if not negated, by over-zealous parents looking for vicarious gratification.
It was against this background of dilemma and mixed emotions that the Joint Committee on Physical Fitness, Recreation and Sports went about the development of an official statement
for July, 1974
25
per Cent of Drownlngs*
35.1
Relative Frequency of Drownlngs by Temperature of Water
Figure 2
Figure 3
Relative Frequency of Drownlngs by Swimming Ability
Figure 4
on Swimming Instruction for Infants. The text of the statement is as follows:
Swimming Instruction For Infants
Children less than three years old are most vulnerable to drowning, and organized attempts to reduce the toll are indicated.
Swimming instruction, heretofore, has concen- trated on school age children. Recent efforts have been focused on teaching young children to swim, even during the first year of life. It may be pos- sible to teach very young infants to swim and keep their heads above water, but it is question- able whether or not an infant can truly be taught water safety and proper reaction to an emergency. Parents can develop a false sense of security if they know that their young infant can swim a few strokes.
Additional problems are associated with admis- sion of infants to public pools. Incontinent infants in pools certainly pose an aesthetic problem, and it is difficult to maintain the effectiveness of chlor- ination. In addition, infants with age-specific immunity handicaps would be subject to sig- nificant exposures to enteroviruses, adenoviruses, and other potentially dangerous microorganisms in dosages not likely to be found under con- trolled home conditions.
Considerations involved in the use of swimming as a form of ‘‘patterning” are not of sufficiently established benefit to be weighed as factors in favor of early pool training.
It is not recommended that large-scale programs he undertaken to teach swimming to children under the age of three years.
However, it is recommended that efforts to reduce the incidence of drowning in children under three years of age should concentrate on three measures of proven effectiveness:
1 . More adequate fencing and other protective measures to exclude infants from pool areas or areas of excavation.
2. The assurance of constant parental or other adult supervision for all non-swimmers in swimming areas.
3. The use of flotation jackets for all non- swimmers close to bodies of water or in boats.
The Academy of Pediatrics is represented on the Council for National Cooperation in Aquat- ics. At the November, 1971, meeting of the council, our representative with representatives from YWCA, YMCA, American Red Cross, Boys Clubs of America, The United States Office of Education and representatives from The Schools of Physical Education at Purdue and Yale Uni- versities developed the following statement on the subject of pre-school swimming:
Because certain considerations affecting a child’s learning and safety require a degree of develop- ment not attained by most children before they are three years old, the Council for National Cooperation in Aquatics recommends that the
26
Illinois Medical Journal
minimum age for organized swimming instruction be set at age three. It is imperative that parents be made to realize that even though pre-schoolers may learn to swim, no young child, particularly the pre-schooler, can ever be considered “water safe” and must be carefully supervised when in or around water.
Guiding Principles
For organized pre-school swimming programs, CNCA recommends the following guiding prin- ciples:
1 . Pertinent health information about pre- existing conditions which would affect a child’s ability to participate in the activities should be obtained from the parents before a child is accepted into an organized swim- ming program.
2. Swimming instruction of pre-school children requires a staff of sufficient number to pro- vide a very low ratio of instructors or aides to children. This requirement may be met by using parents and other volunteer aides working directly under professionally com- petent leaders.
3. Parents involvement in and understanding of the program is essential. Their orienta- tion should include:
(a) Complete understanding of program objectives.
(b) A clear picture of the skills that can be developed by the young child as well as the realization of his limitations.
(c) Their responsibility in supplementing and enhancing the role of the instruc- tor.
(d) Accepting their role in the supervision of the pre-school child any time the child is near water.
4. Orientation of the child to facilitate adjust- ment to the total physical environment should precede the first class experience.
5. The learning of skills of the young child is directly related to active participation in the instructional programs and to frequency of practice; the retention of skills is dependent upon reinforcement through frequent op- portunity to participate.
G. The water temperature usually found in multiple-use indoor pools (in the range of 78-82°) is acceptable for most children in this age group, provided that the teaching procedures include continuing vigorous ac- tivity.
7. Suitable flotation devices when used in a controlled teaching situation help promote safer participation and can enhance learning.
It is entirely appropriate to begin instructional programs after infancy in the three-seven year age group. Our main reluctance is to recommend organized programs for those under three years of age, and we recognize that individuals will still wish to undertake instructions for their own infants. We recognize that there is some disagree- ment as to whether or not it is possible to accommodate chlorination to the increased con- tamination incurred by allowing incontinent
infants to swim. The increased susceptibility of infants to enterovirus and adenovirus infection is a real problem and not reducible by any program of pool antisepsis. The alleged benefits of infant swimming programs as “patterning” or “sensitivity” sessions are highly controversial. If there are benefits, they are as readily attain- able on land as in water.
The American Red Cross estimates that there are 90 million non-swimmers in this country. Efforts to reduce this number are entirely ap- propriate to the prevention of death by drown- ing. Swimming instruction programs will be most successful, however, when they take realistic account of the realities of growth and develop- ment.
The techniques of swimming instructions are beyond the scope of this presentation. It is important to emphasize, however, that all rules of child guidance are not suspended by the desire to teach a child to swim. The initial skills usually taught are breath control, prone float, and dog paddle. When dealing with young- er children, it is probably true that one is likely to encounter a smaller percentage of students who have a pathological fear of water. It also is probably true that fears of water are not always reconciled by persuasion or logical ex- planation of hazards and safeguards. There is, however, an inclination to circumvent the need for explanation and education in the younger age groups. Because of the instructor’s obvious superiority in size and strength, there is a temp- tation to resort to compulsion and intimidation. All of us have seen the dramatic change which can come over a young child through even a brief successful experience in the water. In order to bring about this important initial achieve- ment, it may be necessary to resort to firmness, pressure and even coercion at times as long as the pervading background is one of gentleness and sympathy. All programs of swimming in- struction which include, as basic instructional techniques, throwing children into the water or holding children under water will be viewed askance by pediatricians. Those who contend that such techniques are necessary and innocuous will have to support their view points with prospective studies and objective psychological data. Retrospective claims, short-term observa- tions, and disclaimers based on prestige and ex- perience will not necessarily be admissable. Neither will it be possible to justify every technique of instruction on the basis of overall success of a program in teaching children how to swim.
(Continued on page 61)
for July, 1974
27
The Cholesterol Hypothesis and the Coronary Primary Prevention Trial
By Philip A. Habak, M.D., Helmut G. Schrott, M.D., and William E. Connor, M.D./Iowa City, Ia.
Heart disease is presently the leading cause of death in the United States, ranking well above cancer, accidents and infections. In 1967, 54.1% of all deaths were due to cardiovascular disease and approximately 626,000 deaths from atherosclerotic and degenerative heart disease were reported during the same year.1 In men be- tween 40-59 years of age, the death rate is even greater, reaching about 8 per 1000 per year.
Among the various coronary risk factors, the level of serum cholesterol has attracted much in- terest recently. The Framingham heart study2 and other studies have clearly identified the level of serum cholesterol as a major risk factor for atherosclerotic coronary heart disease. Further- more, the relationship between an elevated serum cholesterol and atherosclerosis is supported by the discovery that in several species of animals atherosclerotic lesions can be produced by high cholesterol, high saturated fat diets3-4 and by the experiments of Taylor et al5 who were able to induce fatal myocardial infarctions in Rhesus monkeys fed a high cholesterol diet.
More recently, Armstrong, et al6 reported that regression of arterial plaques occurred in mon- keys when a low cholesterol diet was subsequent- ly introduced suggesting that at least in that species, the process may be reversible. In man, however, regression of the disease has not been observed and whether measures to reduce serum cholesterol are effective in preventing coronary heart disease is still open to question. Most studies of the efficacy of dietary or drug treat- ment were secondary prevention trials in that patients with documented coronary heart dis- ease were entered into treatment programs and observed for varying lengths of time. For exam- ple, the Oslo diet heart study included 412 men one to two years post myocardial infarction who were randomly allocated into diet treatment and
The authors are from the Lipid Research Clinic, Cardiovascular Division of Department of Internal Medicine at The University of Iowa College of Medicine, Iowa City, la.
control groups.7 After five years, the diet treat- ment group had signicantly fewer myocardial in- farctions. However, the difference in the death rate was not statistically significant. In England, a similar study involved 395 persons who were divided into diet treatment and control groups.9 The treatment group had fewer coronary events but the difference was not statistically significant. Actually, the treatment group had slightly more cardiovascular deaths. Diet studies such as these are not convincing because of small numbers, reliance on soft end points, and use of subjects with advanced coronary heart disease. If high risk groups had been selected, i.e. hypercholes- terolemic men, and entered into the different treatment groups before the development of coronary heart disease, the results might have been different.
The Coronary Primary Prevention Trial is well under way in several Lipid Research Clinics throughout the country. It is a centrally coor- dinated, randomized, double blind primary pre- vention study using patients with type II hy- perlipoproteinemia (hypercholesterolemia) and designed to substantiate the lipid hypothesis and the efficacy of intervention. The patients admitted into the study will have an elevated serum cho- lesterol level mainly secondary to an increase in the concentration of low density or beta-lipopro- teins. These lipoproteins contain a greater pro- portion of cholesterol than the other lipoproteiq fractions and there is a high correlation between their concentration and the incidence of athero- matous disease both in animals and in man.10 Beta-lipoproteins are synthesized by the liver and gut and their serum concentration depends on the balance between synthesis and degradation. The role of dietary cholesterol, fat content and the ratio between polyunsaturated and saturated fats in the genesis of atherosclerotic vascular dis- ease may be related to alterations in the concen- tration of the beta-lipoproteins in the plasma.
Physicians in western Illinois, within a 50 mile radius from the Quad-Cities will have the oppor-
28
Illinois Medical Journal
tunity to play a substantial role in this unique and important cooperative study. Thus, the se- lection and referral of patients to the Lipid Re- search Clinic in Iowa City is primarily depen- dent on the active participation of interested physicians in practice in their respective com- munities.
The Lipid Research Clinics
The Lipid Metabolism Branch of the National Heart and Lung Institute was created in Decem- ber, 1970. A network of continent-wide Lipid Research Clinics located in 12 universities in the United States and Canada was established. Their major objectives included the performance of studies on the prevalence and natural history of the hyperlipoproteinemias and a primary pre- vention trial on patients with hypercholesterole- mia.
The University of Iowa is among the institu- tions which were approved to participate in this major research goal and to host a Lipid Research Clinic. The Iowa Lipid Research Clinic staff will offer consultation and assistance to all physicians encountering management problems in patients with disorders of lipid metabolism. The Lipid Core Laboratory of the Clinic has been standard- ized according to the Lipid Standardization Lab- oratory of the Communicable Disease Center in Atlanta, Ga. The University of Iowa Lipid Lab- oratory will be available as a reference for the standardization of other laboratories which per- form various blood lipid studies and would pro- vide assistance to any clinical laboratory wishing information regarding specific technical prob- lems in the lipid field. The protocol for the pri- mary prevention trial, also known as the Lipid Research Clinics Type II Coronary Primary Pre- vention Trial, was approved by the Lipid Re- search Clinics Directorate in November, 1972.
The Primary Prevention Trial Protocol11
I. Patient Population
A minimum of 300 men per clinic, 35-59 years of age, will be enrolled in the project. These men will have hypercholesterolemia (type II hyper- lipoproteinemia) and thus are coronary prone individuals. Type II hyperlipoproteinemia is characterized by elevated levels of serum choles- terol, beta-lipoproteins and a clear fasting serum. It is sometimes associated with tendon nodules (xanthoma tendinosa) , xanthelasma, and (less frequently) skin xanthomas of the tuberous type. Frequently it is an hereditary disorder, trans-
mitted as a simple Mendelian dominant trait, but may also occur in part secondary to a cholesterol- fat rich diet, hypothyroidism, nephrosis, dyspro- teinemias or obstructive liver disease. The pa- tients referred to the prevention study should be healthy men having no angina pectoris, his- tory of a myocardial infarction, coronary insuf- ficiency or heart failure as well as severe hyper- tension. Patients with diabetes mellitus, other endocrine disorders and diseases limiting life expectancy to less than five years also are not eligible for the sutdy. In addition, they should not be receiving any of the following medica- tions: estrogens or androgens, thyroid, corticos- teroids, anticoagulants, quinidine, procainamide or digitalis,
II. Recruitment
The enrollment of 300 men with type II hyper- lipoproteinemia between the ages of 35 and 59 years into the study will require the screening of a much larger population that may amount to 10,000 subjects. Western Illinois and Eastern Iowa physicians will play a central role in iden- tifying and referring these patients. Candidates for this program should have cholesterol levels greater than 285 mg%. We would like to stress the fact that the referring physician remains the primary physician for the patient, with the Lipid Research Clinic staff serving only as consultants in the special area. The referring physician will be furnished a copy of the initial medical eval- uation, the cardiovascular workup and the re- sults of all screening tests as well as reports of subsequent examinations.
It also should be mentioned that all patients referred to the study stand to benefit. These are some of the advantages to the participants: 1) general medical workup: 2) lipid and cardiovas- cular workup; 3) all patients will receive dietary counseling; and 4) there are no costs to the patient. Furthermore, since there is a familial preponderance of hypercholesterolemia, family members including siblings and children also may indirectly benefit.
III. Preliminary Evaluation
All patients will undergo an initial evaluation which will be spread over five monthly visits. The study will be explained to the patients in- dividually and their consent will be obtained. The initial screening process will include testing for diabetes mellitus and for disorders of the thyroid, liver and kidneys as well as a complete cardiovascular evaluation. Thus, in addition to a complete history and physical examination, some of the visits will include a blood lipid pro- file, blood counts and blood chemistry, an elec-
for July, 1974
29
trocardiogram as well as a treadmill exercise test. All laboratory results obtained in the initial period will be communicated to the patient’s pri- mary physician and only those individuals who successfully complete this screening program, the most coronary prone men, will be eligible for the treatment phase of the study.
IV. The Treatment Phase of the Study
At Visit 2, the patients will be placed on a cholesterol modified diet. This diet is best de- scribed as a prudent diet. It is expected to pro- duce some reduction in the serum cholesterol level. At Visit 5, following completion of the preliminary workup, the patient is randomly al- located to one of two treatment groups: the diet and placebo group or the diet and Cholesty- ramine group. Cholestyramine is a bile acid sequestrant which is expected to achieve an average reduction in serum cholesterol of about 20%. The drug has been used at the University of Iowa and elsewhere for eight years and has been found to be remarkably free of serious side effects. Cholestyramine was approved by the Food and Drug Administration on August 6, 1973.
If we can conclusively establish that lowering the cholesterol level can prevent premature coronary heart disease, then the time and effort expended to vigorously treat high risk patients will be worthwhile. Because such a study is im- portant from a personal and family point of view as well as from a national standpoint, it is. nec- essary to eliminate bias in the conduct of the investigation which might mitigate against the results. Accordingly, neither the patient nor the physician seeing him in the Lipid Research Clin- ic will know whether drug or placebo is being dispensed. The patient’s lipid levels in the treat- ment phase are mailed to a Central Patient Reg- istry located in Chapel Hill, North Carolina, and will not be known to either the clinic physicians or the patient’s primary physician. The patient’s physician also will be requested to refrain from ordering blood cholesterol determinations on pa- tients enrolled in the project to avoid unblind- ing the study. Should it become important for medical care, the information on a certain pa- tient’s lipid studies or treatment can be obtained from the local Lipid Research Clinic.
V. Follow-Up Phase
During the follow-up period, which is expected to last five to seven years, the subjects will be seen in the Lipid Research Clinic at two month intervals for blood lipid determinations and screening for side effects. A more extensive out- patient evaluation will be performed every six months and a stress electrocardiogram will be
obtained once a year.
VI. End Points
Primary end points in the study are a definite non-fatal myocardial infarction or a definite atherosclerotic heart disease death (fatal myo- cardial infarction, sudden death). Other response variables include different forms of arterial athe- rosclerotic disease; arterial peripheral vascular disease and cerebral vascular disease are consid- ered here.
VII. Safety and Data Monitoring Board
A Safety and Data Monitoring Board will re- view all the data accumulated during the study. The board may recommend changes in the de- sign of the study or its premature termination on the basis of toxicity data or whenever a sig- nificant difference in end points is found between the control and the treated group. At the end of the follow-up period, based on the findings and conclusions gathered, appropriate treatment of patients in the study will be recommended.
How to Refer Patients
Interested physicians can refer potential can- didates for this program by writing or calling the Iowa Lipid Research Clinic at S-228 West- lawn, Iowa City, Iowa 52242; telephone number 319-356-2095. Physicians in Southern Illinois may wish to refer their patients to Dr. Gustav Schon- feld or Dr. Joseph Witztum at the St. Louis Lipid Research Clinic, Washington University School of Medicine, Box 8046, 4566 Scott Avenue, St. Louis, Missouri 63130; telephone number 314- 454-3461. ◄
References
1. Vital Statistics of the United States, 1967, Volume II, Mortality, Part A, National Center for Health Statistics, U.S. Dept, of Health, Education and Wel- fare, Public Health Service, U.S. Government Printing Office, Washington, D.C., 1969.
2. Dawber, T. R., Moor, F. E. and Mann, G. V.: “Coro- nary Heart Disease in the Framingham Study.” Arner. J. Pub. Health (Suppl) 47:4-24, 1957.
3. Anitschkow, N. N.: A History of Experimentation on Arterial Atherosclerosis in Animals, Cowdry’s Arteriosclerosis. Second edition, edited by H. T. Blumenthal, Springfield, 111., C. C. Thomas, 1967, pp. 21-44.
4. Roberts, J. C. Jr., Straus, R.: (Editors) Comparative Atherosclerosis. New York, Harper and Rowe, Hoeber Med. Division, 1965.
5. Taylor, L. B., Cox, G. E., Counts, M., and Yogi, N.: “Fatal Myocardial Infarction in Rhesus Monkeys with Diet-Induced Hypercholesterolemia.” Circulation 20, 975, 1959. (Abstract)
6. Armstrong, M. L., Warner, E. D., and Connor, W. E.: “Regression of Coronary Atheromatosis in Rhesus Monkeys.” Circ. Res. 27:59-67, 1970.
(Continued on page 61)
30
Illinois Medical Journal
health sciences LJBRAM
UNIVERSITY of MARYLAND!
Baltimore
Rupture of the Heart
Report of a Case With One Week Survival
By Arnaldo G. Carvalho, M.D., F.A.C.C./Springfield
Because of the marked progress made during the last few years in the prompt recognition and treatment of arrhythmias in patients with acute myocardial in- farction, most deaths in coronary care units today are the result of congestive heart failure, shock or rupture of the heart.
The incidence of cardiac rupture is between 4 and 13% of fatal cases.1 Recently attention has been focused on certain characteristic electrocardiographic patterns that occur in cardiac rupture. Mogensen et al2 reported seven patients with rup- ture and tamponade whose electrocardiograms were monitored during the terminal event: all had abrupt onset of bradycardia, initially of sinus origin and then nodal. Meurs et al3 reported 8 patients who had slowing of sinus rhythm followed by nodal rhythm.
The present report deals with the electrocardiographic findings in a patient with rupture of the heart; the case was unusual because the patient survived for several days following the initial manifestations of cardiac rupture.
Case Report
A 67-year-old female, was admitted to Saint Johns Hospital on 9/9/72 with chest pain radi- ating to the left arm. She gave a history of angina for 8-10 years with crescendo angina for one month prior to admission. Chest pain recurred over the next several days requiring the admin- istration of opiates. At 4 p.m. of 9/12 she com- plained of chest pain on inspiration. At 9:05 a.m. of 9/13, while she was sitting in bed and a phy- sician was listening to her lungs, she suddenly became unconscious; no blood pressure or pulse could be obtained. Monitor strips at that time and during the next 40 minutes showed alternat- ing A-V dissociation, sinus tachycardia and A-V block. (Fig. 1)
Resuscitative measures including an attempt at pericardiocentesis were carried out and cir- culation was restored. Over the next several hours administration of levaterenol was necessary in order to maintain the blood pressure. Her condi- tion continued to improve, however, and ad- ministration of levarterenol was discontinued at 9 p.m.
ARNALDO GOMES CARVALHO, M.D., is Chief, Cardio-Vascular Department, St. John's Hospital, Springfield and is Clinical Associate Professor, Southern Illinois University School of Medicine. Dr. Carvalho is a Fellow, American College of Cardiology and certified by the American Board of Cardiovascular Diseases.
During the next several days she had ventric- ular ectopic beats which were controlled with Lidocaine. On 9/19 at 9:15 p.m. she had ven- tricular tachycardia followed by bradycardia and cardiac arrest. (Fig. 2)
Post-mortem examination showed the pericar- dial sac to be distended by 250 cc of semi-clottecl blood, mostly adherent to the inferior surface of the heart. The heart weighed 320 gm. An exten- sive transmural myocardial infarction involved most of the inferior left ventricular wall. At ap- proximately the mid-point of the infarcted area a probe patent small area of dissection through the necrotic muscle was demonstrable; adherent clots were found around and external to this zone.
Discussion
This case illustrates some of the features com- monly associated with cardiac rupture, which is more common in women4 (6.9% of fatal myo- cardial infarction vs. 3.8% in men) and usually occurs in the seventh decade or later.1 Hyper- tension is present in a large percentage of pa- tients.
The concept that cardiac rupture can be diag- nosed only in the moribund patient or at autopsy probably is not true today. Van Tassel’s1 data suggest that rupture of the heart may be clin- ically evident for a sufficient period of time prior to death to permit the diagnosis to be made. Biorck et al5 made the clinical diagnosis in eight
for July, 1974
31
Figure 1. Note atrial premature beats (9:05) s;nus tachycardia (9:15), A.-V. dissociation (9:45), Mobitz type IA-V block (9:45).
A-V — atrio-ventricular
patients on the basis of a sudden circulatory arrest in association with sustained QRS con- figuration for some minutes. Meurs3 and Mogen- sen2 suggest that bradycardia wotdd be present in all such patients. The number of patients reported is rather small, however, and at this time it cannot be said with certainty that brady- cardia is a sine qua non for the clinical diagnosis of myocardial rupture. It was not present in our patient.
It might be argued that rupture did not occur on 9/13 but rather just prior to death on 9/19. This is unlikely for several reasons. In patients dying from myocardial infarction, sinus rhythm is not often found at the time of circulatory arrest. In Biorck’s series of 529 patients with acute myocardial infarction there was one false positive diagnosis. In our patient the presence of markedly adherent clots to the walls of the path- way formed by the tear and the appearance of semi-clotted blood also suggest that the clinical fundings on 9/13 were related to the rupture. It
certainly is possible that clots may seal the per- foration after only a small amount of blood has leaked into the pericardial sac, as is the case in false aneurysm of the left ventricle.
What practical conclusions can be derived from this report? Since rupture of the myocardium will certainly lead to death, prompt surgical inter- vention is mandatory when the condition is di- agnosed, despite the dismal results obtained thus far in four cases6-7 reported in the literature. On the other hand, if persistent sinus mechanism with circulatory arrest is found in a significant number of other conditions complicating myo cardial infarction, such as sudden pump failure, surgical intervention with the purpose of reliev- ing hemopericardium could have disastrous con- sequences.
It is hoped that the report of this case will stimulate study and report of other conditions which might give a false positive diagnosis of myocardial rupture.
Summary
A case of myocardial rupture secondary to acute myocardial infarction is reported. The pa- tient survived for about six days following pre- sumed rupture. The electrocardiographic findings are discussed.
Recognition of such complication might lead to prompt surgical intervention:
• Electrocardiogram in myocardial rupture
• Myocardial infarction, complications
• Myocardial rupture
• Heart rupture •<
32
Illinois Medical Journal
Categorization Of Hospital Emergency Medical Capabilities in Illinois:
A Statewide Experience
By David R. Boyd, M.D.C.M., Winifred Ann Pizzano, B.A., Patricia A. Silverstone, B.A.Ed. and Teresa L. Romano, B.S.N.
The categorization of hospital capabilities to render effective emergency medical treatment has been a subject of increasing interest to the en- tire health community. It is anticipated that the concept of categorization of hospital emer- gency capabilities will be an essential and effec- tive step in the process of improving emergency medical care across the nation. Of national scope, this concept involves the effectiveness of utiliza- tion of emergency personnel and facilities, with appropriate attention to such elements as quality of care, cost, community acceptance, and the applicability of categorization to urban and rural areas.1
The categorization process has taken dif- ferent forms in several areas across the nation. This variance may be an effective way to re- spond to the charge of the American Medical Association (AMA) Conference recommenda- tions and guidelines for “The Categorization of Hospital Emergency Capabilities.”2 The AMA guidelines, established in 1971, concluded with a strong recommendation for field testing with secondary modified guidelines to be developed later, based on the wisdom of experience.
The State of Illinois has, over the past three years, gained considerable experience and achieved apparent success in the implementation of a hospital categorization program. The de-
DAVID R. BOYD, M.D.C.M., is Chief of the Division of Emer- gency Medical Services and Highway Safety, Illinois Depart- ment of Public Health, and Assistant Professor of Surgery, The Abraham Lincoln School of Medicine of the University of Illinois College of Medicine. WINIFRED ANN PIZZANO, B.A., is the Assistant of the Division Chief, Division of Emergency Medical Services and Highway Safety, Illinois Department of Public Health. PATRICIA A. SILVERSTONE, B.A. Ed., is a former Special Assistant for Health Planning and Public Education, Division of Emergency Medical Services and Highway Safety, Illinois Department of Public Health. TERESA L. ROMANO, B.S.N. , is Operations Director for the Division of Emergency Medical Services and Highway Safety, Illinois Department of Public Health.
velopment of a trauma care system in 1 971 ,3’4 and the initiation of an effort to further expand this program into a Total Emergency Medical Services System,5'6 involved initially a functional categorization of selected “Trauma Center Hos- pitals” for a specific patient group— the critically injured— and has been extended to include 261 acute care hospitals for all aspects of emergency medical care. The first Areawide EMS Plan with categorization of hospital emergency capability in Illinois was reported in this Journal by For- kosh.7 The general approach reported in this article was further refined and amplified to become a teaching model for the entire state.
At the time of this writing, the Trauma Pro- gram and hospital net are essentially complete and the first years’ experience with planning, coordinating, and implementing of all Illinois general hospitals into some 40 areawide EMS plans in compliance with the Illinois Categoriza- tion Law (PA 76-1858) has been accomplished. Further areawide planning and implementation of a wide spectrum of EMS activities is now in progress throughout the state, utilizing and further supporting this categorized and planned areawide approach to the delivery of emergency medical services.
A chronological and programmatic narrative of the Illinois experience is the subject of this report.
General Principles
Categorization of hospital emergency capa- bility to comply with bureaucratic regulations or restrictive legislative mandates will not, of itself, improve the quality of emergency medical care. Categorization of hospital emergency medi- cal care must be done in relationship to patient needs, community capability, and improved re- sources utilization. These efforts must be stylized to meet the needs of specific emergency patients
for July , 1974
33
which will significantly effect improvement in overall medical care. In Illinois, the planning process emphasized this important issue and required an assessment of the primary care capabilities and available transfer mechanisms of the following six clinical patient groups in each areawide plan: trauma, cardiac (acute coronary) , high-risk infant, poison control, drug overdose and alcohol detoxification, and psy- chiatric emergencies.
The statewide categorization program in Illi- nois was based on the premise of presenting the potential benefits to emergency medical patients, physicians, nurses, allied health workers, and hospitals. Initial awareness of the issues and problems of categorization had previously been encountered with the functional categoriza- tion of some 45 Trauma Centers across the state during the preceding year. The Trauma Pro- gram was a successful learning model and was effective in emphasizing the beneficial aspects of hospital categorization and areawide planning to an entire statewide health community.
Categorization in Illinois has allowed for hospitals to self-categorize their capability, pro- vided that this self-categorization was consistent with effective areawide EMS planning. Hospitals then had to plan with contiguous hospitals in a geographic area, with no deletion of less favored hospitals being allowed. To perform this, each hospital in an areawide plan had to designate one administrator, one physician, and one nurse for membership on the Categorization Commit- tee to develop the areawide plan (Figure 1) . An “area” for EMS planning was geographically described to meet functional needs of emer- gency medical patients. These coincided fairly well with existing and developing Comprehen- sive Health Planning “B” planning regions and subregions: in fact, they are a leading geographic determinant in this and future planning efforts.
To facilitate planning for the development of a “systems approach” to emergency medical care, the Illinois Department of Public Health, Division of Emergency Medical Services and Highway Safety was identified as the govern- mental lead agency with overall initiating re- sponsibility.
Illinois has utilized non-ranking terminology for its hospital categorization program. By Illi- nois law, hospitals are now classified for the provision of Comprehensive, Basic or Standby emergency medical care.8 Trauma Center hos- pitals have been designated as Regional, Area- wide, Local, and “Special” Regional. A func-
tional comparison of these titles and the AMA categorization is shown in Table I. As future experience and the real potential of these ef- forts is gained, a closer approximation to the AMA (or as modified) categorization is anti- cipated.
TABLE I
HOSPITAL CATEGORIZATION SCHEME
|
Illinois Law PA 76-1858 |
Illinois Trauma Program |
AMA Guideline Recommendations |
|
Regional |
I |
|
|
Comprehensive 24 Hour M.D. Subspecialties |
Areawide |
II |
|
Basic 24 Hour M.D. |
Local |
III |
|
Standby 24 Hour R.N. |
IV |
In order to be acceptable, every emergency medical plan must have and now has the fol- lowing: a strict geographic definition of the area of responsibility, working relationships between the area hospitals, and a systems description of the six clinical patient groups as listed above.
In a similar fashion, each plan includes the other essential EMS subsystems of communica- tions, transportation, professional training and education, public education, program monitor- ing, and evaluation. These activities are now being instituted, and area plans are being inte- grated into one of nine regional EMS service systems. The Illinois concept and definition of a medical “region” involves total medical compe- tence for all routine as well as the most special emergency medical problems. Only very special or unique emergency medical problems (spinal cord, extensive burn, hyperbaric treatment, etc.) need to be removed from a medical “region.”
The Illinois Experience
In 1969, the Illinois legislature passed en- abling legislation which allowed hospitals to self-categorize and to participate in an area- wide plan for the delivery of emergency medical services. This permissive law was implemented in only one area of Illinois (St. Francis Hospital, Peoria, and Eureka Hospital, Eureka) . In July of 1971, the Illinois Trauma Program became operational. This program was not based upon a specific law; however, it resulted in the initial development of a system for the delivery of
34
Illinois Medical Journal
emergency medical services based on areawide and regional medical planning. This program aimed at the identification and functional cate- gorization of 50 hospital Trauma Centers de- dicated to the care of the critically injured patient. The functional hospital categories of trauma care (Regional, Areawide, and Local) were necessarily selective to provide well-identi- fied access points to the emergency care essential to the life-threatened accident victim.
The success of the Illinois Trauma Program has been due, in part, to the classification of treatment centers based on a hospital’s care capability and the distribution of selected trauma patients by the seriousness of their injuries. In this system, patients are secpientially transported to more advanced centers for specialized inten- sive trauma care as the patients’ clinical needs are identified. This basic areawide triage of trauma patients has been shown to result in better care for the critically injured.9 It is the general impression that trauma patient care is now improving in all Trauma Centers and that prehospital (primary) transportation and inter- hospital (secondary) transporation also are improving statewide. In fact, prehospital mobile intensive care is now being considered by most of the larger communities in Illinois.
Based on the apparent success of the initial Trauma Program in effecting inter-hospital co- operation and areawide planning, the Illinois Hospital Licensing Board subsequently ruled that the permissive categorization law passed in 1969 be made mandatory as of July 1, 1975. This law provides that all hospitals with emer- gency rooms must participate cooperatively in an areawide plan to provide medical emergency services on a community and areawide basis.
Areawide Hospital
Emergency Service Plan Development
The Division of Emergency Medical Services and Highway Safety assumed the responsibility of initiating the planning process at the local level, and served as a resource (professional, technical, staffing and consultation) to the local EMS planning committees. In addition, the Di- vision continues to serve as a liaison between the local planning committees/councils, the Illinois Division of Health Facilities ( Hospital Licensing) , and Comprehensive Health Plan- ning Agencies.
Distributed in December, 1972, were guide- lines, Areaivide Emergency Services: A Manual for the Illinois Plan for a Comprehensive Emer-
gency Care System. This manual includes the Emergency Planning Law (PA 76-1858), a de- scription of a systems approach to the delivery of emergency services, discussions of the EMS subsystems, and an identification of the planning steps required to comply with PA 76-1858. The manual was developed in “loose leaf” form and modeled after the AMA guidelines to allow for midcourse corrections based on experiences gained in field operation.
Although the Illinois law requires a com- prehensive plan for “emergency medical ser- vices” including all EMS subsystems, emphasis was placed on hospital categorization and the development of a basic regionalized medical emergency system utilizing current resources and building on the existing Trauma Program’s ini- tial structure and functional components further systems designs were planned for acute coronary, high-risk infant, poisoning drug overdose and alcohol detoxification, and psychiatric problems.
The Planning Process
To initiate this planning process, the Division of Emergency Medical Services and Highway Safety held a series of 14 regional workshops across the state to provide technical and profes- sional assistance to local planning groups. All appropriate health providers in each geographic service area were invited to attend and partic- ipate. At the workshops, representatives from the Illinois Hospital Association, local (“B”) and state (“A”) Comprehensive Health Plan- ning Agencies, Illinois Nurses Association, and Illinois State Medical Society participated with local area physicians, nurses, hospital adminis- trators, ambidance operators, etc., to initiate and develop their areawide EMS plans.
Defined Geographic Area
All area acute care general hospitals with emergency rooms or departments met to become part of an Areawide Hospital Emergency Service Plan. Each plan required a specifically defined geographic service area. Participation by pro- fessional representatives from contiguous and interdependent areas were along the lines of established state, regional, and subregional de- signs.
The Illinois Department of Public Health and the Hospital Licensing Board interpreted the regulations (PA 76-1858) so that in the rural Illinois each geographic area would be approxi- mately 25 mlies in radius around a “comprehen- sive” or “basic” emergency room. This approach
for July, 1974
35
has been effective in downstate Illinois, and follows closely the previous Trauma Center area planning and hospital designations.
Within the Chicago metropolitan area, the Illinois Department of Public Health recognized the 12 functioning Comprehensive Health Plan- ning “B” suborganizations established on pre- vious service areas and planning agency rela- tionships. These 12 planning agencies all related to the Chicago area Emergency Service Commis- sion for overall planning, inter-area considera- tions, and primary plan review. This EMS Com- mission was recognized by the Comprehensive Health Planning “A” Agency as the responsible plan review group for emergency services in the Chicago metropolitan area.
There are, at the present time, some 40 area- wide hospital emergency service plans function- ing with continuous EMS planning. All of these plans essentially include at least one designated Trauma Center as the basic or comprehensive emergency hospital providing 24-hour physician coverage. This hospital Trauma Center is, in many areas, the focal point for ongoing EMS activities.
Illinois Hospital Emergency Facility Categorization Guidelines
Categories of emergency services have been established which allow hospitals to identify and declare the level of emergency services appro- priate to their resources. In Illinois, every hos- pital with an emergency room must provide emergency services in one of the three classifica- tions: Comprehensive, Basic, or Standby. The essential elements of these emergency service classifications are capsulized in Table 2.
The American Medical Association presently endorses four emergency department/room cate- gories.2 The Illinois experience over the past year has shown that the identification of at least three levels of hospital emergency cate- gorization allows for the successful initial devel- opment of comprehensive areawide emergency medical planning. Within the three categories listed above, many hospitals will vary in their present overall capability. It is anticipated that more uniformity among categorized hospitals using existing or modified categorization stan- dards will occur with time.
In Illinois, all hospitals, irrespective of their category of emergency services, must have ade- quate provision for rendering immediate first aid, emergency care, and life support to persons requiring such treatment on arrival at the hos- pital. In each areawide plan there must be,
TABLE II
OUTLINE OF EMERGENCY SERVICE CLASSIFICATIONS
Comprehensive Emergency Treatment Servces
1. Illinois licensed physician in the emergency room 24 hours a day.
2. Specialties of medicine, surgery, obstetrics, and pediatrics on call, and available within minutes, 24 hours a day.
3. Additional subspecialties on call and available within minutes, 24 hours a day.
4. Laboratory and X-ray departments staffed 24 hours a day.
5. Pharmacy on call within minutes, 24 hours a day.
Basic Emergency Treatment Services
1. Illinois licensed physician in the emergency room 24 hours a day.
2. Specialties of medicine, surgery, obstetrics, and pediatrics on call, and available within minutes, 24 hours a day.
3. Laboratory, X-ray, and pharmacy departments on call within minutes.
Standby Emergency Treatment Services
1. Registered nurse available at all times.
2. Illinois licensed physician on call at all times.
by law, at least one “comprehensive” or “basic” designated emergency room. Once a defined geo- graphic area is determined, the self-categoriza- tions of each of the participating facilities may be readjusted as necessary to meet areawide needs. With the development of EMS planning and categorization, there has been an increase in 24 hour physician coverage in downstate Illinois.6 Hospital physician coverage in the Chicago area has remained relatively constant and area plans are now being further supported by a citywide ambulance ordinance that directs ambulances with critical patients to compre- hensive emergency hospitals.
Review and Approval of Areawide Emergency Service Plans
The 40 areawide hospital emergency service plans were developed after the regional work- shops were held across the state, and staff person- nel and trauma coordinators served as consul- tants to local planning groups, clarifying what was required and how to further identify avail- able resources. All plans were submitted to ap- propriate local Comprehensive Health Planning agencies for review and comment. They were then passed to the Illinois Department of Public Health and further reviewed by the Division of Emergency Medical Services and Highway
36
Illinois Medical Journal
EMS PLANNING ORGANIZATION
Figure 1. The Emergency Medical Services Council and Emergency Medical Services Committee and Subcom- mittee structure adapted to local EMS areawide planning. Program initiation and legal authority are impart- ed through the Hospital Categorization Subcommittee.
Safety for professional and technical adeqnacy. The Emergency Service Advisory Committee of the Hospital Licensing Board made final review before the plans were submitted to the Director of the Illinois Department of Public Health for approval. During the first year (1973) all plans received “conditional approval,” and after some 90 days, finalizing progress reports were resub- mitted to the Illinois Dapertment of Public Health.
The local Emergency Medical Service Com- mittee is responsible for the development, im- plementation, and ongoing evaluation of each areawide emergency service plan. The required minimum membership of this committee is a physician, a nurse, and an administration repre- sentative from each participating hospital. In addition to the EMS committees, active sub- committees have since been formed for com- munications, transportation, professional train- ing and education, public education, and pro- gram evaluation (see Figure 1) .
Future Expectations of Areawitle Planning Process
The progress made over the past year in areawide emergency service planning in Illinois
has surpassed expectations. The task of develop- ing coordinated and upgraded emergency ser- vices on a community and areawide basis has been initiated. The local planning authority for the medical plan has been identified as the Emergency Service Council, usually under the Comprehensive Health Planning “B” Agency.
As each EMS planning council/committee further develops its plan, more ancillary emer- gency service personnel are becoming involved. EMS Councils are being integrated into the local Comprehensive Health Planning “B” Agency activities. The Council itself is made up of health providers and consumers and is functioning as the overall advisory body to the specific area subcommittees on categorization, communications, transportation, professional training and education, and public education.
Public Awareness
All public education subcommittees are now working on programs to inform their respective communities of the necessity for hospital cate- gorization and areawide EMS planning. This public education effort will soon be expanded to inform the public and to gain support for improvements in communciations (“911”), am-
for July, 1974
37
bulance services, and a wide variety of other essential emergency medical services. The Illinois Division of the American Trauma Society is assisting in these public education efforts, and state medical, nursing, and hospital associations are being asked to lend support. State and local health departments will be utilized to provide professional and material support to local emergency medical services efforts now gaining considerable momentum across Illinois.
Summary
Categorization is only the first, and most im- portant, of the necessary steps to a true regional EMS systems implementation. The goal of this approach must be the continual upgrading of trauma and emergency medical capability across the community. This approach can produce other benefits including better cost effectiveness and improved resource utilization in those com- munities which are unnecessarily duplicating their efforts, monies, and medical manpower.
By defining the problem for critically injured patients, and by categorizing hospital emergency capabilities for this group, significant progress has been realized in Illinois, where a total hos- pital emergency categorization effort has been accomplished. This program was facilitated by the statewide experience gained in the trauma categorization model. All areawide plans were based on self-categorization of each participating hospital and consistent with area EMS deficien- cies and strengths. Each area plan has attempted to initiate a “systems approach” to the six iden- tified major clinical patient groups. Equipment
purchases and other financial allocations were then made to support these local EMS plans.
A major task of public education lies ahead for Illinois. One enthusiastic individual, agency, or association will not solve this massive health problem. It will require a consortium of all interested health professionals and agencies working together rather than in competition. These participants will need to realize that individual efforts must be consistent with an overall program of improving areawide and regional emergency medical services. ^
References
1 . American Hospital Association: Categorization of Hos- pital Emergency Services. Report of a Conference. Chi- cago, American Hospital Association, 1973.
2. American Medical Association: Recommendations of the Conference on the Guidelines for the Categorization of Hospital Emergency Capabilities. Chicago, American Medical Association, 1971.
3. Boyd, D. R., Mains, K. D., and Flashner, B. A.: “Status Report: Illinois Statewide Trauma Care System,” IMJ, 141:56-62, January, 1972.
4. “A Symposium on the Illinois Trauma Program: A Systems Approach to the Care of the Critically In- jured.” J. Trauma, 13:275-320, April, 1973.
5. Boyd, D. R.: “A Preview: A Total Emergency Service System for Illinois,” IMJ, 142:486-488, November, 1972.
6. Boyd, D. R. and Pizzano, W. A.: “Illinois Emergency Medical Service System Status Report II (July, 1973),” IMJ, 144:210-216, 256, September, 1973.
7. Forkosh, D. S.: “A Plan for the Organization of Emer- gency Services on Chicago’s North Side,” IMJ, 142:209- 212, September, 1972.
8. Illinois Public Act 76-1858, signed October, 1966, Springfield, Illinois.
9. Boyd, D. R., Mains, K. D., and Flashner, B. A.: “A Systems Approach to Statewide Emergency Medical Care,” J. Trauma, 13:276-284, April, 1973.
Clinics for Crippled Children Listed for August
Twenty-five clinics for Illinois’ physically handicapped children have been scheduled for August by the University of Illinois, Division of Services for Crippled Children. The Division will conduct 17 general clinics providing diag- nostic orthopedic, pediatric, speech and hearing examina- tion along with medical social and nursing services. There will be six special clinics for children with cardiac con- ditions, and two for children with cerebral palsy. Any private physician may refer to or bring to a convenient clinic any child or children for whom he may want ex- amination or consultative services.
August
August
August
August
August
August
August
August
August
August
August
August
August
August
August
1 Rockford— Rockford Memorial Hospital 1 Lake County Cardiac— Victory Memorial Hos- pital
6 Belleville— St. Elizabeth’s Hospital
7 Carlinville— Carlinville Area Hospital
7 Springfield Pediatric-Neurology-Diocesan Center
7 Hinsdale— Hinsdale Sanitarium
8 Sterling— Sterling Community Hospital 8 Springfield— St. John’s Hospital
8 Kankakee— St. Mary’s Hospital
9 Chicago Heights Cardiac— St. James Hospital
12 Peoria Cardiac— St. Francis Children’s Hospital
13 Peoria— St. Francis Children’s Hospital
13 East St. Louis— Christian Welfare Hospital
14 Champaign-Urbana— McKinley Hospital
15 Bloomington— Mennonite Hospital
August 15 Elmhurst Cardiac— Memorial Hospital of Du- Page County
August 20 East St. Louis— Christian Welfare Hospital August 20 Rock Island— Moline Public Hospital August 21 Chicago Heights— St. James Hospital August 23 Evanston— St. Francis Hospital August 23 Chicago Heights Cardiac— St. James Hospital August 26 Peoria Cardiac— St. Francis Children’s Hospital August 27 Peoria— St. Francis Children’s Hospital August 28 Springfield Pediatric-Neurology— Diocesan Cen- ter
August 28 Aurora— St. Joseph Mercy Hospital
The Division of Services for Crippled Children is the official state agency established to provide medical, sur- gical, corrective and other services and facilities for diag- nosis, hospitalization and after-care for children with crippling conditions or who are suffering from conditions that may lead to crippling.
In carrying on its program, the Division works coop- eratively with local medical societies, hospitals, the Illi- nois Children’s Hospital-School, civic and fraternal clubs, visiting nurse association, local social and welfare agencies, local chapters of the National Foundation and other in- terested groups. In all cases the work of the Division is intended to extend and supplement, not supplant activi- ties of other agencies, either public or private, state or local, carried on in behalf of crippled children.
38
Illinois Medical Journal
- §||i
surgical grand rounds
Edited By John M. Beal, M.D
Surgical Grand Rounds are held weekly on Tuesday at 5:00 p.m. in the Offield Auditorium of the Passavant Pavilion. Patient presentations from North- western Memorial and the Veterans Administration Research Hospitals form the basis of the discussions. This case report was part of the Surgical Grand Rounds of December 4, 1953.
Hemangiosarcoma of Breast
Dr. Mitchell Grasseschi: Two cases will be pre- sented briefly. First, a 59-year-old Black woman was admitted to Wesley Pavilion November, 1973, with a mass in her left breast. In December 1972, she had a mass removed from the left breast at another hospital. She was told that this was a benign tumor. Two months later, she noticed tenderness in the same breast and a recurrence of a firm mass. There was no change observed until four weeks prior to admission when she noticed marked increase in the size of the mass associated with warmth and dis- coloration of the skin of the breast. Past history is significant only in that she breast fed her child and noted that the left breast was deficient in milk compared to the right.
Physical examination at the time of admission was unremarkable except for a large mass in the inferior lateral portion of the left breast, described by the initial examiners to be ap- proximately the size of a grapefruit. Blueish discoloration of the skin over the mass was noted associated with increased warmth. Admis- sion blood count, urinalysis and chest X-ray were negative.
A needle biopsy was performed the day after admission and reported as hemangiosarcoma. A liver scan showed a suspicious defect in the left lobe of the liver. An X-ray skeletal survey was negative. Mammograms were obtained. A simple mastectomy was performed November 9, 1973. Her post operative course was uncomplicated.
The second case: A 22-year-old white woman was admitted December, 1967, with a small, fairly movable non-tender nodule in the left breast, and a larger tender mass in the right
breast. Biopsy of both masses was performed. The lesion in the left breast mass was reported to be fibroadenoma. The right breast mass was found to be a hemangiosarcoma. In January, 1968, a right simple mastectomy was performed. She was well until July, 1969, when she noted a nodule in her scalp in the occipital region. This was excised and microscopic examination revealed metastatic hemangiosarcoma. She de- veloped numerous subcutaneous recurrences and she was admitted for radiation therapy in Jan- uary, 1970. At that time she had subcutaneous metastasis in the scalp, neck, left axilla and recurrence in the mastectomy scar. After colbalt therapy, she was well until April, 1970, where more subcutaneous nretastases appeared. Chemo- therapy was started with cytoxan and Metho- trexate. A variety of chemotherapeutic agents were used without demonstrable benefit.
In October, 1970, she was found to have a pelvic mass. She was admitted a month later with severe abdominal pain. She was taken to the operating room and was found to have hemangiosarcoma metastatic to both ovaries, with hemorrhage and necrosis of the ovaries and 700 cc. of blood in the peritoneal cavity. A bilateral oophorectomy was performed. The liver was reported to be normal at laparotomy, but the spleen was thought to be enlarged. She recovered from this procedure but developed some weak- ness in her legs. She subsequently became para- plegic and died.
Dr. Hector Battifora: The excised breast from the first patient, the 59-year-old woman, con- sisted of several confluent masses of hemorrhagic, somewhat necrotic tumor with very poorly cir- cumscribed margins. The tumor contained large
for July , 1974
79
Figure 1. H & E stained section from tumor #1. Cavernous vascular spaces as well as more solid areas are shown,
Figure 2. H & E stained section from tumor #2. Hyperchromatic endothelial cells line irregular vas- cular spaces. Innocent appearance of tumor is be- trayed hv it’s true malignant potential as evidenced hy later development of disseminated metastases.
Figure 3. Electron micrograph from Case 1. Pleo- morphic endothelial cells are shown lining a capillary.
blood filled lakes. A superficial examination with the microscope might lead us to believe that we are dealing with a cavernous hemangi- oma which is a mistake not infrequently made by the inexperienced. However, I think that even at low power, one can notice that there are grapelike clusters of cells hanging from the endothelial surface seemingly due to a local excess of cells. This strongly militates against a diagnosis of simple hemangioma. On higher magnification, one can see that the endothelial cells pile up on each other. In addition, there are pleomorphic, occasionally bizarre endothelial cells. There were also solid areas of growth in which the capillaries were very inconspicuous. (Figure 1) Changes of this type are enough to warrant a diagnosis of henrangiosarcoma re- gardless of the tissue source. This is particularly true of breast lesions since hemangioma is a distinct rarity in the breast. One should be very cautious about accepting, prima facie, a diagnosis of hemangioma of the breast. In our experience, angiosarcoma is a more common tumor than hemangioma of the breast.
The second case, the younger patient, had a diffuse enlargement of the breast, a biopsy revealed a similar appearance to the previous case. (Figure 2)
Electron microscopy was done in both cases revealing that the tumor cells maintained fea- tures typical of endothelial cells. (Figure 3) .
Dr. Mitchell Grasseschi: A review of the litera- ture reveals how rare this tumor is. There have been only 43 cases reported from 1907 to the present. The terms hemangiosarcoma, hemangio- blastoma, metastasizing hemangioma and angio- sarcoma are synonymous terms. Schmidt (1887) is credited with the earliest reported hemangio- sarcomas of the breast and described tumors of the breast which metastasized without involving the lymph nodes. In 1907, Borman reported a case of metastasizing hemangioma which was histologically benign; however, the patient died 2(4 years later from multiple metastases.
From the clinical standpoint, this tumor is very rare. It is most frequent among young women in the second to third decade of life. The age range of the 43 reported patients was from 15-82 years with half being 26 years or younger. Some have suggested that these tumors may be hormone related. Five of the reported cases were pregnant at the time of discovery of the tumor. The tumor is usually painless, rapidly growing and of short duration. The average sur
40
Illinois Medical Jownal
vival after diagnosis is approximately 2i4 years. Among the reported cases, only two patients survived more than five years, one for seven years and one for fourteen years. Hemangio- sarcoma has been said to have the worst prog- nosis of all breast tumors. The tumor usually presents as a deep mass. Occasionally when it is superficial, there is bluish discoloration of breast. Often there is a reported history of trauma. Seven cases were thought initially to be a hematoma and were treated expectantly. Hemangiosarcoma tends to occur slightly more often in the right breast than in the left, al- though carcinoma is found slightly more in the left breast. They metastasize primarily to the lungs, skin, the subcutaneous tissue and the bones and rarely to the lymph nodes. Histo- logically, these tumors are deceptively benign in appearance. Fourteen of the reported cases ini- tially had a diagnosis of benign hemangioma. As Dr. Battifora mentioned, benign hemangio- mas are even more rare than are hemangio- sarcomas.
There does not seem to be any effective treat- ment for this problem. Simple mastectomy seems to be adequate when the disease is advanced. It is interesting to note that of the two patients that did survive five years, both had the initial diagnosis of malignant hemangiosarcoma and both had radical mastectomy.
Dr. Peter Rosi: There is little to be added to
the discussion by Dr. Grasseschi. From a review of the literature, the most frequently performed operation was either a radical or a simple mastec- tomy, although wide segmental resections of small tumors and subcutaneous mastectomies have been reported. The value of post operative irradiation has not been established; however, Ackerman reported one patient in whom the breast angiosarcoma was completely destroyed by X-ray irradiation.
The course of the disease is probably not influenced by the surgical procedure, but most likely by the biological behavior of the tumor. Histologic studies have shown that the greater the number of dividing cells per high power field, the poorer the prognosis.
The present prevailing management of angio- sarcoma of the breast is a simple mastectomy with microscopic examination of the edges of the resected specimen for residual malignancy. Although the value of post operative irradiation and chemotherapy has not been determined, they may be, nevertheless, advisable. One of the characteristics of hemangiosarcoma of the breast has been a high rate of recurrence at the opera- tive site.
Reference
1. Gulesserian, H. P. and Lawton, R. L.: “Angiosarcoma
of the Breast.” Cancer , 24:1021, 1969.
Professional
protection
CONTINUOUSLY
CHICAGO AREA OFFICE:
T. J. Pandak, J. C. Kunches, L. R. Gannon, and W. G. Prangle, Representatives 815 Commerce Drive, Suite 102, Oak Brook, Illinois 60521 (312) 325-7314
SPRINGFIELD OFFICE: W. J. Nattermann, Representative 426Vi South Fifth Street, Springfield 62701 (217)544-2251
for July, 1974
41
The patient is a 42-year-old white female with the chief complaint of recurring attacks and of right upper quadrant pain. Physical examination revealed tenderness in the right upper quadrant, pallor and a prominent spleen. Laboratory work revealed a congenital hemolytic anemia.
What’s your diagnosis?
1. Carcinoma of the lung
2. Extramedullary Hematopoiesis
3. Neurofibroma
4. Duplication of the Esophagus
(Answer on page 44)
42
Illinois Medical Journal
new
For detailed information regarding indications, dosage, contraindications and adverse reactions; refer to the man- ufacturer’s package insert or brochure.
Single Chemicals— Drugs not previously known, includ- ing new salts.
Duplicate Single Drugs— Drugs marketed by more than one manufacturer.
Combination Products— Drugs consisting of two or more active ingredients.
New Dosage Forms— Of a previously introduced product.
The following new drugs have been marketed:
SINGLE CHEMICALS
ULCOLAX
Manufacturer: Nonproprietary Name: Indications:
Dosage:
Supplied:
Laxative o.t.c.
Ulmer Pharmacal
Bisacodyl
Constipation
Two to three tablets, taken at bedtime or before breakfast, chil- dren over 6 one tablet.
Tablets, 5 mg.
DOWPEN VK
Manufacturer: Nonproprietary Name:
Indications:
Contraindications:
Dosage:
Supplied:
Penicillin Deriv. Rx
Dow Pharmaceutical Phenoxymethyl Penicillin Potas- sium
Infections due to penicillin G sensitive organisms Hypersensitivity to penicillin See package insert Tablets, 250 and 500 mg.
INTROPIN
Manufacturer: Nonproprietary Name: Indications:
Contraindications:
Dosage:
Supplied:
Adrenergic Rx
Arnar-Stone Laboratories Dopamine HC1
Hemodynamic imbalances pres- ent in shock produced by a vari- ety of causes.
Pheochromocytoma
Follow instructions in package
insert
Ampules, 5cc. cc/40 mg.
NICOLAR
Manufacturer: Nonproprietary Name: Indications:
Contraindications:
Precautions:
Dosage:
Supplied:
Cholesterol Reducing Agent Rx
Armour Pharmaceutical Comp. Niacin
Hypercholesterolemia and hyper- betalipoproteinemia Hepatic dysfunction or acute peptic ulcer.
See package insert Two to 4 tablets daily Tablets, 500 mg.
QIDAMP
Manufacturer:
Nonproprietary Name: Indications:
Contraindications:
Dosage:
Supplied:
Semisynthetic Penicillin Rx Mallinckrodt Pharmaceutical Prod. Div.
Ampicillin triliydrate Susceptible infections caused by Gram-negative and Gram-posi- tive organisms.
Hypersensitivity to penicillin See package insert Capsules, 250 and 500 mg. am- picillin ecj. Powder f. oral sus- pension—125 and 250 mg/5cc reconstituted
HYTINIC
Manufacturer: Nonproprietary Name: Indications:
Dosage:
Su pplied:
Hematinic o.t.c.
Hyrex-Key Pharmaceuticals Polysaccharide iron complex Iron deficiency anemia Capsules— one to two tablets daily
Elixir— Adults, one to tw'o tea- spoonfuls daily
Children, 6-12 one teaspoonful daily; 2-6 i/, teaspoonful daily; under 2 14 teaspoonsful daily Capsules, 150 mg. elemental iron Elixir, 5 cc/100 mg. elemental iron, alcohol 10%
METRETON OPIITH. SOL
Manufacturer: Nonproprietary Name: Indications:
Contraindications:
Dosage:
Supplied:
Eye preparation Rx
Schering Corporation Prednisolone sod. phosphate Steroid-responsive inflammatory conditions of the eye.
Superficial herpes simplex kera- titis, viral infections of the cor- nea and conjunctiva. Tubercu- losis of the eye and fungal diseases of the ocular or auricu- lar structures.
Duration varies with type of lesion. Eye: One to 2 drops every hour during the day and every two hours during the night. Re- duce dosage as progress occurs. Ear: Initial dose 3 to 4 drops 2 to 3 times daily, reduce grad- ually.
Dropper bottle, 5cc/0.5%
for July, 1974
47
COMBINATION PRODUCTS
Supplied:
Capsules
AMCILL-GC
Manufacturer:
Composition:
Indications:
Contraindications:
Precautions:
Dosage:
Supplied:
Penicillin Deriv. Rx
Parke-Davis
Dry powder for reconstitution Ampicillin trihydrate eq. 3.5 Gm Probenecid 1 .0 Gm
Uncomplicated gonorrhea Hypersensitivity to penicillin or probenecid
Do not use in patients with blood dyscrasias, uric acid kid- ney stones or during acute attack of gout.
Single dose administration Bottles containing dry powder mixture.
POXY COMPOUND 65 Analgesic, Non-narcotic Rx
Manufacturer: Sutcliff & Case
Composition:
Indications:
Contraindications:
Precautions:
Dosage:
Supplied:
mg.
Propoxyphene HC1 65
Aspirin 227
Phenacetin 162
Caffeine 32-5
Relief of mild to moderate pain Do not use in children, use with circumspection in pregnancy. Tolerance has been reported in some patients
One capsule three to four times daily.
Capsules
ENEMEEZ
Manufacturer:
Composition:
Indications:
Supplied:
Enema o.t.c.
Armour Pharmaceutical Comp. 100 cc. contain
Sod. biphosphate 16 Gm
Sod. phosphate 6 Gm
Cleansing enema Bottles, 4i/2 fl. oz.
KEY-PLEX Capsules
Manufacturer:
Composition:
Indications:
Dosage:
Vitamins and Minerals o.t.c. Hyrex-Key Pharmaceuticals
mg.
Ascorbic acid 300
Niacinamide 50
Thiamine mononitrate 15
d-Calcium Pantothenate 10 Riboflavin 10
Pyridoxine HC1 5
Magnesium sulfate 70
Zinc sulfate 80
Vitamin and mineral deficiencies. One capsule daily with meals; in severe deficiencies three cap- sules.
PRETTS
Manufacturer:
Composition:
Indications:
Dosage:
Supplied:
|
Antiobesity |
|
|
Preparation |
o.t.c. |
|
Marion Laboratories |
|
|
Alginic acid |
200 mg. |
|
Sod. carboxymethyl- |
|
|
cellulose |
100 mg. |
|
Sod. bicarbonate |
70 mg. |
Adjunct use in diet control Chew 2 to 4 tablets, followed by a full glass of water, 30 minutes before meals and at bedtime. Tablets
NEW DOSAGE FORMS
ZARONTIN Syrup
Manufacturer: Nonproprietary Name: Indications: Contraindications: Dosage:
Supplied:
Anticonvulsant Rx
Parke-Davis Ethosuximide Petit mal epilepsy Hypersensitivity to succinimides Children 3 to 6 years— one tea- spoonful daily; Over 6 years— two teaspoonfuls daily Syrup, 5cc/250 mg. M
View Box
(Continued from page 42)
DIAGNOSIS: Extramedullary Hematopoiesis — This is a rare condition which should be born in mind in any case of a paravertebral mass in a patient with severe anemia, with or without splenomegaly, hepatomegly and gall stones from hemolysis (Figure 1). Extramedullary hemato- poiesis occurs as a compensatory phenomenon in various diseases in which there is inadequate production or excessive destruction of blood cells; extramedullary sites include the liver, spleen, kidney, hila, thymus, adrenal, appendix, lymph nodes, dura mater, the broad ligaments, prostate, sciatic nerve, breast, and the paraverte- bral areas of the thorax.
The majority of cases are associated with
congenital hemolytic anemia. It has also been found in thalassemia and sickle cell anemia.
The characteristic roentgenographic finding is of multiple masses, smooth or lobulated in con- tour and of homogenous density, situated in the paravertebral regions, either unilaterally or bi- laterally. A presumptive diagnosis usually can be made when this roentgenographic finding is present in patients with severe anemia and splenomegaly.
The presence of extramedullary hematopoiesis within the thorax usually occasions no symptoms, although paraplegia has been reported in one case. **
44
Illinois Medical Journal
John R. Tobin, M.D., M.S., Rimgaudas, Nemickas, M.D., Patrick J. Scanlon, M.D., John F. Moran, M.S., M.D., James V. Talano, M.D., Sarah Johnson, M.D. and Rolf M. Gunnar, M.D., M.S./Section of Cardiology, Loyola University Stritch School of Medicine
A 49-year-old female was admitted to the psychiatric service with diagnosis of manic-depressive psychosis. She had been on chlorpromazine (Thorazine) , thioridazine (Mellaril) and lithium carbonate 300 mg t.i.cl. In recreational ther- apy she fell unconscious and was found to be pulseless. Resuscitative effort was successful. Rhythm strip taken is shown.
Questions:
1. The rhythm strip demonstrates:
A. Frequent non-conducted premature atrial beats.
B. Second degree A-V heart block (Mobitz
type I).
C. Severe sinus arrhythmia.
D. Sinoatrial block.
E. None of the above.
2, The treatment of choice is:
A. Electrocardiographic monitoring.
B. Insertion of a temporary transvenous pacemaker.
C. Determination of blood lithium level.
D. Stopping all medications possible.
E. All of the above.
(Answer on page 61)
for July, 1974
45
The Changing Role of Neonatal Nursing
By Charlyn Slade, R.N., B.S.N./Park Ridge
new nursing role has been created in the area of perinatal medicine, and with it the capacity to save many infants’ lives. Specially trained nurses are essential to every neonatal unit. The nursing role in the High-Risk Nursery has changed considerably; the old feelings of doing virtually nothing for premature infants except feeding and changing diapers have changed. The attitude of “don’t handle them and the good ones will survive” is certainly outdated; now nursing takes an active part in the care of these critically ill infants. The nurse is no longer the physician’s handmaiden; she is a colleague in this setting. In the High-Risk Nursery, assuming proper medical supervision, the difference between success and failure is the difference between excellent and mediocre nursing care.
The high-risk nurse must have certain per- sonal attributes. Very important is her optimism about various therapeutic efforts despite an ap- parently dismal outlook. The nurse who feels it fruitless to try and save a tiny infant on a respirator does not belong in the unit. Calmness and composure are essential, since emergency situations are frequent and a calm confident atmosphere is most reassuring. The nurse also must know not only what to do, but have the desire to know why it is done. The nurse no longer just follows doctors’ orders; she must be able to assess problems and initiate or pre- pare for the treatment program while awaiting the doctors’ instructions and she must anticipate his needs. If she functions in this way, the time saved may mean the life of an infant.
The nurse must develop a special feeling for babies and generate this feeling to others. This feeling consists of an inspiration by, and dedica- tion to, the challenges of the care of newborn infants. Caring for babies is not routine. Babies are fascinating and exciting; they also are in- volved and complex. They are not good inform- ants so the nurse becomes their interpreter. She senses their needs and relays this information to the physician.
The Nurse’s Role
What exactly is the role of the high-risk nurse? Upon receiving an infant to her unit, the nurse
CHARLYN SLADE, R.N., B.S.N., is
Head Nurse, High Risk Nursery at Lutheran General Hospital, Park Ridge.
should scrutinize the maternal record with par- ticular attention to the length of the first and second stages of labor, type of delivery, the anal- gesia and anesthesia, the time of rupture of mem- branes and the Apgar scores. She shoidd note whether any special resuscitative measures were needed in the delivery room. All of these things will have some bearing on the infant’s adjust- ment to extrauterine life. The nurse learns to anticipate certain types of behavior from differ- ent complications of labor and delivery.
On admission to the nursery the infant is weighed, as all fluids, medications and treatments are based on weight. Providing the infant is breathing and in no immediate danger of a car- dio-respiratory arrest, the next priority is regula- tion of temperature. This is done in several ways. First, the infant is placed on servo control; a probe is placed on the infant’s abdomen and the infant then regulates the temperature of the in- cubator. Second, a heating coil may be placed in i he oxygen humidifier. Then, the infant may be placed on a K-pad. Finally, and most important, when working with the infant, always work through the portholes. If the nurse does not set the example of protecting the infant’s warmth, it is cpiite likely that no one else will.
As a member of the team that cares for the in- fant, the nurse’s initial assessment should include evaluation of general appearance, activity and vital signs. Signs of trauma such as cephalhema- toma, forcep marks, abrasions or lacerations should be noted. Muscle tone is important. Hy- potonia may be a result of drug depression or cerebral asphyxia or peripheral nerve damage.
*Presented in part at the “Post Graduate Program in Neonatology for Nurses” at Children’s Memorial Hospital, November 9, 1972.
16
Illinois Medical Journal
Hypertonia may be a result of cerebral anoxia or tetany secondary to hypocalcemia. The nurse must be familiar with the normal to recognize the abnormal. All of these observations are of utmost importance, especially for later compari- son.
Since it is the nurse who handles the infant around-the-clock, she is in a position to note subtle changes. A nurse’s expertise in the care of newborn patients requires an understanding of the abnormalities of intrauterine growth patterns as they relate to gestational age. An infant’s course in the nursery is in large measure deter- mined by these factors; the illnesses that develop postnatally are often peculiar to a particular type of aberrant intrauterine growth pattern. The nurse must be adept at assessing gestational age by using physical and neurological findings. With this skill and a knowledge of maternal factors, the nurse can readily recognize a large number of high-risk infants and plan their management accordingly. For example: infants of diabetic mothers are usually large babies even though they are premature. A 3300-gm infant born after a 34-week gestation may have all the problems of prematurity, such as respiratory distress syn- drome. On the other hand a term infant weigh- ing 1500-gm reflects different in utero problems such as placental insufficiency or intrauterine in- fection; the trained nurse will be on the alert for certain symptoms, such as those of hypogly- cemia, which could lead to faster diagnosis and treatment.
The nurse today must be skilled in resuscita- tive procedures and be able to recognize quickly an infant who is in trouble and respond quickly and efficiently. She should be skilled in use of the arnbu bag and mask. Often the nurse makes the first discovery of serious respiratory dysfunc- tion, and she should be able to ascertain that therapy is proceeding effectively and without jeopardy to the infant. The observations of respiratory status made by the nurse are of ut- most importance. She should note the infant’s color, depth and quality of respirations. Is the infant grunting, flaring, retracting? Is his chest symmetrical? Are good breath sounds heard? The nurse must be familiar with the various respira- tors used in a neonatal unit. She should know when and why an infant goes on a respirator. Once an infant is on a respirator, the nurse must watch him even more carefully. Frequent suc- tioning and observation of the infant are essen- tial; the endotracheal tube must be kept patent. The nurses’ observations will help the physician
in deciding when to wean the infant off the respirator.
Another indication of respiratory status is acid- base balance. An understanding of acid-base dis- turbances is essential if the nurse is to correlate laboratory data with the clinical course of her infants and thus assess their progress accurately. This is a part of giving full care contributing to diagnosis. Appreciation of the rationale of ap- propriate therapy is indispensable if the nurse is to participate intelligently in its administra- tion. Blood gases are routinely done on all in- fants receiving oxygen therapy. If high concentra- tions of oxygen over an extended period of time are necessary, the infant will usually have an arterial catheter in place. The ambient oxygen concentration should be monitored continuously with an electronic analyzer. Charting of the in- fant’s appearance and the oxygen concentration are essential.
Electronic monitoring has greatly facilitated the detection of cardiovascular and respiratory difficulties. These instruments are intended for use by skillful personnel; they assist the nurse but are not intended to replace her. Severe diffi- culty can be detected in the earliest stages by an alert nurse who notes cyanosis even though unin- terrupted respirations and heart rate have not yet tripped alarms of monitors. The nurses’ ob- servations lead to action, which in turn reflect the quality of care received by the infant.
Importance of Feeding
Nutrition is of utmost importance to the sick infant. Early feeding minimizes the dangers of hypoglycemia, hyperbilirubinemia and excess catabolism. Providing the infant can tolerate it, oral feedings are started as early as 3-6 hours of age. Small quantities of sterile water are offered first. The tiny or feeble premature soon demon- strates whether or not he can take in by his own efforts sufficient food upon which to gain weight. Inability to do so or the appearance of cyanosis during early attempts at feeding calls for insti- tution of gavage feedings. We prefer to use a size 3 1/9 French indwelling catheter because these sick infants often are in such a delicate respira- tory balance that the act of passing the gavage tube may induce apnea, cyanosis or bradycardia.
The observations made by the nurse at feeding time are of utmost importance. She needs to recognize how the infant acts before the feeding— is he awake, active and making sucking motions? Does he eat eagerly or does he seem fatigued? The first signs of illness can often be detected
(Continued on page 50)
jor July, 1974
47
there a need
for a drug compendium?
■ rlri \a
Adrugcompend of the type I envisii would fill a definite need for the prac ing physician. Su( compendium wc give him all 1 information n< essary for us a drug intelligently, and it woulc
do so in a clear, concise, con- venient, objective and balancec fashion.
Government Health Official
Henry E. Simmons, M.D. Deputy Assistant Secretary for Health
What a Compendium Should Contain
I believe the compendium should inform the doctor what c drug will do, when he should us, for what type of patient, for howi long, in what dose, what benefitl his patient is likely to obtain, th< j risks involved, and cross-reactit] with other drugs.
based on the package insert ant i have the same legal status. In fc , a complete compendium with c<\
might even eliminate the neces i
A drug compendium, or preferably compendia, should, believe, be private, not federal, sponsorship. They should conta1 comprehensive listings of drug? available for prescribing. They should be single, legibly printec volumes of reasonable size, up- dated quarterly or semiannually and completely revised every y«
Dialogue
Function of a Compendium
A compendium should fur nish the following information c drugs in the followingorder: ind tions for use, side effects, advei drug reactions, contraindicatioi drug interactions, drug dosage the dosage forms marketed. Dr| prices should not be included b cause they vary so widely and change rapidly.
No compendium should si forth drugs of choice or discuss relative efficacy. Such questior must be left for the practicing p sician to decide, whether on the basis of the medical literature, own clinical experience, advice colleagues, information supplie by manufacturers, and so on.
Nor should a compendiun undertake to educate the docto how to use drugs. Rather, it mu be a reference source designed marily to refresh his memory a: drugs he may not use regularly
! package insert in many in- :es. This would constitute a a.antial saving for the manu- rer.
By a complete compendium, not mean a volume of prohibi- s ize. You don’t need a book r ribing 25,000 products with lormous amount of repetition, ter, drugs should be arranged • ass. Mutually applicable infor- nn would be provided, along brief discussions pinpointing rences in specific drugs of iclass. Listings would be cross- 1, :ed in a useful way.
ir Available Documents as lies of Information
Existing references such as land the AMA Drug Evaluation i bviously useful but they are >nplete. Either they are not ii-referenced by generic name
!lo not group drugs with simi- laracteristics, or they do not I the available and legally
( eted drugs. And some of ! omitted may be very useful.
lid in no way imply control over
!iractitioner’s prerogatives.
Another Compendium?
A practicable, single-volume tpendium cannot, nor is it cssary to, include all drugs on market today. From my prac- of internal medicine for some fears, my experience as a con- iint, and as a faculty member 3ur or five medical schools, I i d estimate that a doctor uses 30 to 35 drugs regularly. The
)l Physicians’ Desk Reference, ientally, contained about 0 entries.
As to whether there should be deral compendium, in my opin- as stated earlier, the answer is —there should not be one. The >osal assumes that existing .pendia are inadequate. We’re sure of that at all. Whatever its ejections, the present drug rmation system in the U.S. is i, multifaceted, pluralistic and nsive. Good compendia exist, ell as other ample sources on l therapy, ranging from journal ature through AMA Drug Evalu- 'i to company materials. Not hysicians may use such "ces as often or as well as they Jld, but that is the fault of the i, not of the sources.
In any event, rather than pro-
On the other hand, drugs made by more than one supplier, tetracy- cline for example, may be fully described a dozen times in the same book.
While perhaps PDR could be rearranged and cross-indexed with generics included, and while the AMA Drug Evaluation might also be modified and expanded, I am not sure that the end result would have all the attributes required for a useful compendium. At the same time, you would run the risk of amassing a voluminous and un- wieldy tome.
Should Editorial Comments Accompany the Listings?
Subjective judgments, in my opinion, have no place in a com- pendium. However, if there is sub- stantial evidence based on a sound body of science concerning rela- tive efficacy of several drugs, cer- tainly that information should be included. The committee of experts compiling and editing a particular section would also have to assess
and indicate instances where a meaningful difference between drugs is pertinent.
Sponsorship, Compilation and Editing
Producing a book like this would undoubtedly be difficult and demanding. It would obviously take a great deal of talent and exper- tise, and would require a varied and experienced group, ranging from writers and editors to highly skilled clinicians and pharmacolo- gists. Style, format and clarity of language would play an important part in determining the usefulness of the book. And it should be up- dated periodically and completely revised annually.
I have no opinion whether the government or the private sector should sponsorand/or finance the compendium. What is most im- portant is that the compendium be an authoritative, objective and useful source of information for the doctor to have at hand as a ready reference.
duce another book, it makes much more sense to work on improving existing compendia, and perhaps they could, as knowledge ad- vances, include more accumulated clinical data and experience, and more information on drug interac- tions and adverse reactions.
Implications of a Federal Compendium
Take a hard look at the impli- cations of a federal compendium.
It would have the force of law, vir- tually dictating what drugs to use and how to use them. In effect, it would be a regulatory document with legal or quasi-legal status, posing medical/ legal problems similar to those the doctor may now encounter if and when he de- parts from the provisions of the package insert. A compendium under federal aegis would tend to restrict decisions on drug therapy to one orthodox level — a most dangerous trend for medicine.
New Compendium — A Medical Option
I detect no ground swell of initiative or support whatsoever for a federal compendium — or, for that matter, for a new compendium of any type. A 1969 PMA survey conducted by Opinion Research Corporation found that only 15 per
cent of those physicians inter- viewed felt a new compendium was needed. And a iarge majority did not favor the involvement of the federal government if one were to be created, preferring instead a nongovernmental consortium.
Even if we come to a time when the medical profession itself optsfora new kind of compendium, it should be handled and financed, ideally, outside both government and industry. Final review and edi- torial authority could be delegated, say, to specialty bodies and medi- cal societies— but above all, not the government.
Surely the health care system in the United States has far more vital matters to consider than the extensive cost and effort that would have to go into the prepara- tion and maintenance of a new, monolithic compendium, and especially one bearing the impri- matur of the federal government.
Opinion & Dialogue
What is your opinion, doctor? We would welcome your comments.
The Pharmaceutical Manufacturers Association 1155 Fifteenth Street, N.W. Washington, D.C. 20005
The Changing Role of Neonatal Nursing
(Continued from page 47)
by the nurse at feeding: they include gastric residual from previous feed, abdominal disten- tion, vomiting, refusing to feed, lethargy or cyanosis with feedings. Since the nurse is with the infant around-the-clock, she can make these observations more readily than anyone else.
In the very small or ill infant, early feeding is best accomplished by the intravenous route. Fluid and electrolyte balance are very important to the neonate. Usually no parenteral electrolytes are necessary for the first 24-48 hours. The nurse should know the fluid requirements of infants. Regulation of IV’s is done with an infusion pump. We use both the Holter and Ivac. The pump insures a constant flow and prevents over- hydration of the infant, providing a trained nurse is regulating it. The nurse has a large re- sponsibility to making sure that the IV— whether in an umbilical vessel or peripheral one— remains patent and functiontal. This may be the infant’s life-line. In the very small babies even a small in- filtrate of IV fluid into subcutaneous tissue may cause sloughing which could lead to infection. The nurse must, therefore, check the site of in- fusion frequently.
The nurse is also involved in the transport of infants to her center. Responsibility for that in- fant begins when the infant is accepted. The nurse needs to get a full report from the refer- ring hospital and also inform them what to send with the infant. Some hospitals send trained nurses out to pick up the infant. Everything should be set up so that once the infant arrives treatment can begin immediately.
Another major role of the nurse is working with parents. The old concept of not letting parents in the nursery and just allowing them to look through glass windows is obsolete. Parents should be encouraged to come into the nursery and to do as much for their infant as possible,
even if this means just touching the infant through the portholes of the isolette. The nurse must realize that this is somewhat of a shock to parents; their baby is not the normal one they expected. The many wires attached to the infant, and equipment surrounding the infant may frighten the mother, and she may be under- standably unable to focus on her infant. An hon- est simple explanation of what is going on with her infant is often reassuring to the mother. As the infant progresses, it is important to teach the mother to care for her infant and to en- courage her to become a part of the team.
The nurse also may be involved in a follow-up clinic. Nurses take pride in seeing the later prod- ucts of the tiny patients they cared for in earlier months. Much can be gained from the follow-up of these high-risk infants.
What about the high-risk nurse of the future? She will continue to grow professionally along with the high-risk nurseries and neonatologists. She will learn new skills including endotracheal intubation. Nurses will continue to be involved in the actual transport of infants and will assume increasing responsibility in this area. The nurse is now an integral part of the “High-Risk Team.” Now doctors and nurses work together to give each infant the best possible chance for a mean- ingful existence. ◄
Bibliography
1. Babson, S. G., and Benson, R. C.: Management of High-Risk Pregnancy and Intensive Care of the Ne- onate, 2nd ed., St. Louis, 1971, C. V. Mosby Co.
2. Korones, S. B.: High-Risk Newborn Infants— The
Basis for Intensive Nursing Care, St. Louis, 1972, C. V. Mosby Co.
3. Minott, W.: “Nurses Key Functions in Operation of Intensive Special-Care Nursery.” Hospital Topics, 65- 67, Nov., 1971.
4. Silverman, W. A.: Dunham’s Premature Infants, 1955, Paul B. Hoeber, Inc.
It's a Two-Way Street
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50
Illinois Medical Journal
7) actin' &
Dr. Jirka Wins Two-Year Term As AM A Trustee
Frank J. Jirka, Jr., M.D., River Forest, was elected to a two-year term as an AMA Trustee during the closing session of the Annual AMA Convention held in Chicago, June 23-27.
Dr. Jirka, a urologist, is an ISMS Past President; delegate to the AMA; and former ISMS Trustee.
Eleven candidates vied for the six positions available on the AMA Board of Trustees.
Also during the AMA meeting, the American Association of Medical Society Executives met at its’ annual meeting and elected David Meister, Jr., Peoria to the Board of Directors.
Mr. Meister is the county executive for Peoria and Tazwell counties. He has served the counties for many years and is active on the AAMSE committees for continuing education.
CME WORKSHOPS PLANNED FOR THIS FALL-Continuing Medical Education work- shops will be held October 4-6, 1974, in Chicago and St. Louis. Objectives of the workshops are to learn (1) effective methods for involving colleagues in planning and conducting in-hospital CME programs; (2) group tech- niques for problem-solving; and (3) methods for analyzing the learning needs of hospital colleagues.
The workshops are planned by the Illinois Council on Continuing Medi- cal Education Committee on CME Workshops. The content and approach for the workshop are based on a survey of Illinois hospital CME planners. Fourteen hours of AMA Category I credit may be earned.
For full details, write: Illinois Council on Continuing Medical Education, 360 N. Michigan Ave., Chicago, 60601.
U. OF I. GETS APPROVAL FOR HOSPITAL— The Illinois Board of Higher Education re- cently approved the University of Illinois’ plans to construct a $60 million university hospital on the West Side of Chicago.
The proposed hospital would replace the existing 500-bed university hospital. The project also needs the approval of the General Assembly.
PHYSICIANS IN THE NEWS— Robert A. Miller, M.D., pediatric cardiologist, has been ap- pointed Chairman of the Department of Pediatrics of Cook County Hos- pital, Chicago.
William F. Hejna, M.D., Dean, Rush Medical College and Vice President for Medical Affairs at Rush-Presbvterian-St Luke’s Medical Center, has been elected President of the State of Illinois Council of Medical Deans.
The new Dean of the Abraham Lincoln School of Medicine, University of Illinois College of Medicine, is Bernard Sigel, M.D. Dr. Sigel, presently Dean of the Medical College of Pennsylvania, will assume his new position September 1.
Dr. Jirka
for July, 1974
51
ISMS Trustee Warren Tuttle, M.D., Harrisburg, was one of the five University of Illinois College of Medicine graduates to receive Alumni of the Year Awards. Dr. Tuttle was cited for his service to medical organiza- tions.
J. Philip Ambuel, M.D., is the new Medical Director of Ambulatory Services at The Children’s Memorial Hospital, Chicago.
Lloyd M. Nyhus, M.D., Professor and Head of the Department of Sur- gery, Abraham Lincoln School of Medicine, University of Illinois, Chicago, was recently installed as President of the Society for Surgery of the Alimentary Tract.
Beg your pardon— last month’s Doctor’s News cited Joseph L. Bordenave, M.D., as a recent recipient of a Masters degree in education. This was in error, as Dean Bordeaux, M.D., Peoria, earned this post graduate degree from Bradley University.
ISMS Past President Thomsen Honored For 40 Years of Service
In commemoration of 40 years of medical practice, over 800 patients, relatives, associates and friends in general gathered May 31, 1974, to honor Philip G. Thomsen, M.D., Dolton, at a testimonial dinner.
In attendance were Congressman Edward Der- winski, former Governor Ogilvie, State Rep. Tom Miller and officials of several south suburban com- munities as well as the staffs of clinics and hospitals. Congratulatory wires were received from many who could not attend. Both Vice President Gerald Ford and President Nixon sent letters of congratulations.
Dr. Thomsen has been very active in organized medicine having served as President of the Illinois State Medical Society and President of the Illinois Foundation for Medical Care. He presently serves as ISMS Trustee from the Third District.
Dr. Baranov Mr. Stagl
Lester J. Baranov, M.D., Honored
The physicians of Bethesda Hospital, Chicago, paid tribute to Lester J. Baranov, M.D., at a gala State of Israel Bond testimonial dinner last month. Dr. Baranov was cited for his devoted support of Israel’s economic development through the State of Israel Bond campaign and for his dedication as a physician.
Guest speaker at the affair was Robert Mayer Evans, foreign correspondent and former Moscow Bureau Chief for CBS news.
Dr. Baranov, a graduate of the Chicago Medical School, was appointed National Surgeon by the Jew- ish War Veterans of America in 1970.
New Head Named For McGaw Medical Center of NU
John M. Stagl, President of Northwestern Memorial Hospital, has been named Executive Vice President of the McGaw Medical Center of Northwestern Uni- versity. The position became vacant upon the recent death of Ray E. Brown.
Mr. Stagl is a former Trustee of the Illinois Hos- pital Association, and is Secretary of the Illinois Regional Medical Program and Trustee of the Ameri- can Hospital Association.
52
Illinois Medical Journal
Editorials
Angina Pectoris
Angina pectoris, a well-known cardiac symp- tom, is usually ascribed to myocardial ischemia secondary to coronary atherosclerosis. Although one or more of the coronary arteries is narrowed or obstructed, it functions properly so long as the individual is resting or calm. It is during exercise, excitement or, perhaps, following a heavy meal that the blood flow is not adequate. One victim in five goes on to develop coronary thrombosis or myocardial infarction.
The chest pain or feeling of pressure, constric- tion, or tightness may last seconds or minutes. Nitroglycerin usually brings relief to victims who have only one or two attacks a day. Those with frequent attacks or nocturnal angina should have coronary angiography and aortocoronary bypass surgery. As a rule, the more severe the angina, the better the surgical prospects. Surgical inter- vention is not recommended when only one ves- sel is diseased. Angiography requires considerable skill and should be done by technicians and sur- geons who do several of these operations every week. Selecting patients for saphenous bypass surgery is not simple. Furthermore several years must elapse before long-term results can be eval- uated. Not all bypass grafts remain open. In fact, 15 to 30% of these close. The operative mortality averages six per cent.
The medical treatment of ordinary angina in- cludes nitroglycerin, which not only relieves pain, but is an excellent drug to prevent predictable pain (after meals, or during unpleasant discus- sions and sexual intercourse) . Longer-acting drugs, such as isosorbide dinitrate (Isordil) , ery- thrityl tetranitrate (Cardilate) or pentaerythritol tetranitrate (Peritrate) also may be helpful. Propranolol (Inderal) is useful because it lessens the oxygen needs of the cardiac muscle. Walking a distance shorter than that required to induce pain has a favorable effect on the cardiac con- traction.
Upper abdominal disorders such as hiatal her- nia, peptic ulcer, gallbladder disease, recurrent pancreatic edema often initiate anginal pain at rest in those who also have exertion angina. Re- flexes from the abdomen can be very strong and correcting the culprit may be most helpful. The wearing of an abdominal support has long been forgotten, but it may lessen angina in an obese individual.
There are many variations of angina pectoris. Much has been written on the Prinzmetal variant and with the development of bypass surgery for coronary artery disease, the identification of pa- tients with Prinzmetal angina pectoris became more than just acedemic interest. However, iden- tification is not easy because there is no precise correlation between the clinical picture of Prinz- metal angina and the Underlying anatomy.
Prinzmetal and his group described the variant as 1) Chest pain begins most commonly at rest (often during deep dreamless sleep) or with or- dinary activity and not with exertion. 2) During episodes of pain, there is transitory ST eleva- tion on the electrocardiogram which is otherwise normal at rest. 3) Exercise tests are frequently negative. 4) A focal lesion is found in a single vessel only. 5) During pain, arrhythmias, such as ventricular tachycardia or conduction disorders are frequently noted. 6) Myocardial infarction often occurs in the area of the heart correspond- ing to the ST segment elevation. 7) Finally, there is no subsequent serum enzyme elevation.
There is little coronary atherosclerosis, mini- mal plaquing with no areas of narrowing greater than 20%, or entirely normal coronary arteries. Perhaps the coronary artery spasms are respon- sible for the distress. In fact, well-defined spasms have been observed during angiography. Chest pain also has been brought on or aggravated by
(Continued on page 62)
for July , 1974
53
As I Saw It In Springfield
One persistent thought emerged during and after the ISMS LEGISLATION DAY in Spring- field, and it overwhelms every other impression and expression from the day: WE MUST BE- COME INVOLVED! And it is imperative that we convince our physician husbands to take the time not only to be informed but to let their voices be heard LOUD AND CLEAR IN GOV- ERNMENT!
Yes, I’m well aware how busy they are and that they must take care of the sick and wounded first . . . but bills are being enacted every ses- sion that limit their effectiveness in practicing medicine. These new laws tend to add more and more paper work plus more restrictions on the “art of medicine.”
Listening to the governor, I thought to my- self “He really doesn’t understand the practice of medicine nor does he realize what is being done to medicine through all the limitations being imposed on physicians through bureau- cies.”
Each speaker, even though some were elo- quent, made the picture even more clear! POLI-
TICS IS NOT SOMETHING WE CAN LEAVE TO THE PROFESSIONAL POLITICIANS. We as doctors’ wives must take an active interest and do something to encourage good legislation. We can be effective! It is so easy to excuse our lack of action because we are busy . . . but we no longer can afford to neglect our responsibility.
Won’t you please read the ISMS Action Report and On the Legislative Scene ? They are sent to you without charge. If you are not already re- ceiving them, write the ISMS office to put you on the mailing list. NOW, after you read the issues currently before the legislature. DO WRITE YOUR REPRESENTATIVES AND SENATORS TO EXPRESS YOUR VIEWS. Let them know how you feel, how you want them to represent you! They do read their mail and letters are effective. When it comes time to vote, support those who are friends of medicine and who can best represent us and do what is right for our state and our nation.
Millie Vickery, President-Elect WA/ISMS
District Meetings
|
September |
10 |
District 4 |
Rock Island |
Place to be announced |
|
September |
17 |
District 5 & 6 |
Pekin |
Pekin Country Club |
|
September |
19 |
District 1 & 2 |
Elgin |
Holiday Inn |
|
September |
27 |
District 11 |
Joliet |
Place to be announced |
5J
Illinois Medical Journal
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T he Womans Auxiliary to the Illinois State Medical Society are selling these “Mouth-to-Mouth Resuscitation' plaques. Inquiries in obtaining these plaques should be directed to: Mrs. Paul E. Wochos, WA/ISMS Safety Chairman, 349 S. Elmwood Lane, Plum Grove Estates, Palatine, III. 60067.
for July, 1974
55
ISMS Guide to Continuing Medical Education
Compiled for Illinois physicians by the ILLINOIS COUNCIL ON CONTINUING MEDICAL EDUCATION 360 No. Michigan Ave. • Chicago, IL 60601 • (312) 782-1654
CONTINUING
Items for this Calendar must be received 90 days prior to the event. Those received earlier may appear in up to three monthly issues.
If your organization’s CME activities are not listed— please contact us. To avoid possible conflicts, you’re invited also to consult our pie of future events.
WARNING! Items for this Calendar come from many sources, often far in advance of the publication date. Some- times, cancellations or changes in date, place or time occur too late to be corrected before publication. You are urged to contact the sponsoring organization to confirm information given below.
AUGUST
Emergency Care
EMERGENCY MEDICAL CARE
For: All physicians. August 12-16, 1974; Wisconsin Cntr., Madison, Wis. Sponsor, contact: Univ. of Wis- consin, Dept, of Continuing Med. Educ., 610 N. Wal- nut St., Madison, Wl 53706.
Family Medicine
SPECIALTY REVIEW COURSE FOR FAMILY MEDICINE For: Family Physicians. lOVi-day course, August 12- 23, 1974, Chicago. Hrs. of Instr.: 98. CME Credit: AMA Category 1. Fee: $300. Reg. Limit: 150. Spon- sor, contact: Cook County Grad. Sch. of Med., 707 S. Wood St., Chicago, IL 60612.
General Interest
PAS & MAP TUTORIAL SESSION For: Physicians, Hosp. Admin., Allied Health. August 7-8, 1974, Ann Arbor, Mich. Hrs. of Instr.: 12. CME Credit: AMA Category 1. Fee: $110 (1-4 persons, if at least 2 physicians). Reg. Limit: 75. Sponsor, con- tact: Commission on Professional & Hosp. Activities, 1968 Green Rd., Ann Arbor, Ml 48105.
Orthopaedics
SPECIALTY REVIEW COURSE IN ORTHOPAEDICS
For: Specialists. 6>/2-day course, August 25-31, 1974, Chicago. Hrs. of Instr.: 60. CME Credit: AMA Cate- gory 1. Fee: $200. Reg. Limit: 60. Sponsor, con- tact: Cook County Grad. Sch. of Med., 707 S. Wood St., Chicago, IL 60612.
Psychiatry
WINNEBAGO SYMPOSIUM FOR GENERAL PRACTITIONERS
For: Family Physicians. August 22, 1974, The Pioneer Inn, Oshkosh, Wis. Hrs. of Instr.: 6. CME Credit: AMA Category 1. Fee: $15. Reg. Limit: 60. Sponsor, contact: Winnebago State Hospital, Box H, Winnebago, Wl 54985.
Sports Medicine
SPORTS MEDICINE
For: Family Physicians, Allied Health. One-day work- shop, August 28, 1974, Indianapolis. Hrs. of Instr.: 7. CME Credit: AMA Category 1. Sponsor, contact: Mr. John Roscoe, Program Co-ord., Indiana Univ. Sch. of Med., 1100 W. Michigan St., Indianapolis, IN
SEPTEMBER
Alcoholism
ALCOHOLISM
For: All Physicians, Allied Health. Weekly medical education seminar, Sept. 24, 1974, 11:30 AM, Me- morial Hospital of DuPage County, Elmhurst, III. Speaker: Herbert Neuhaus, M.D., Dept, of Public Health Hosp , Chicago. Hrs. of Instr.: 1. CME Credit: AMA Category 1. Sponsor, contact: John H. Huss, M.D., DME, Memorial Hospital of DuPage County! Avon Rd. & Schiller St., Elmhurst, IL 60126
Anesthesiology
CLINICAL ANESTHESIA PRACTICE— COURSE I
For: All Physicians. 1-month course, Sept. 30-0ct. 29, 1974, Chicago. Hrs. of Instr.: 176 approx. CME Credit: AMA Category 1 Fee: $400. Sponsor, contact: Cook County Grad. Sch. of Med., 707 S. Wood St., Chicago, IL 60612.
Cardiology
CARDIOVASCULAR DISEASES
For: All physicians. Lecture, group discussion, Sept. 13, 10 AM, S.R. Forkosh Hospital; Sept. 13, 6 PM. Lincolnwood Hyatt House; Sept. 14, 10 AM, Bethany Methodist Hospital. Speaker: G. T. Gau, M.D., Mayo Clinic. CME Credit: 5 hrs. AMA Category 1. Fee: $10 (non-staff, for dinner) Reg. Deadline: Sept. 9, 1974. Sponsor: FAB3-CME. Contact: Mr. S. Plotner, S. R. Forkosh Hospital, 2544 W. Montrose, Chicago, IL 60618; (312) 267-2200.
INTERNATIONAL SYMPOSIUM ON EPIDEMIOLOGY OF HYPERTENSION
For: All Physicians, Epidemiologists. 3 day symposium, Sept. 18-20, 1974, Sheraton-Blackstone Hotel, Chi- cago. Fee: $150 ($75 students). Sponsor, contact: Helen Heck, Chicago Heart Association, 22 W. Madison St., Chicago, IL 60602.
INTERMEDIATE CARDIOLOGY
For: All Physicians. 41/2-day course, Sept. 23-27, 1974, Chicago. Hrs. of Instr.: 32 approx. CME Cred- it: AMA Category 1. Fee: $175. Sponsor, contact: Cook County Grad. Sch. of Med., 707 S. Wood St., Chicago, IL 60612.
ECHOCARDIOGRAPHY WORKSHOP
For: Specialists. 4-day course, Sept. 30-Oct. 3, 1974, Indianapolis. Hrs. of Instr.: 28 CME Credit: AMA Category 1. Reg. Limit: 50. Sponsor, contact: Mr. John Roscoe, Program Co-ord., Indiana Univ. Sch. of Med., 1100 W. Michigan, Indianapolis 46202.
Family Medicine
FIFTH FAMILY MEDICINE REVIEW
For: Family Physicians, Osteopaths. Symposium, Sept. 15-21, 1974, Univ. of Kentucky Medical Cntr., Lex- ington, Ky. CME Credit: 50 hrs. AAFP; 50 hrs. AMA Category 1. Fee: $195. Reg. Limit: 250. Sponsor, contact: Ofc. of Cont. Educ., College of Med., Univ. of Kentucky, Lexington, KY 40506.
Gastroenterology
UPPER GASTROINTESTINAL ENDOSCOPY
For: Specialists. 2-week course, Sept. 9-20, 1974, Chicago. Hrs. of Instr.: 40 approx. CME Credit: AMA Category 1. Fee: $350. Sponsor, contact: Cook County Grad. Sch. Med., 707 S. Wood St., Chicago 60612.
FIBEROPTIC COLONOSCOPY
For: All Physicians. 3-day course, Sept. 11-13, 1974, Chicago. Hrs. of Instr.: 21 approx. CME Credit: AMA Category 1. Fee: $250. Sponsor, contact: Cook County Grad. Sch. Med., 707 S. Wood St., Chicago 60612.
FIBEROPTIC ESOPHAGOGASTRIC ENDOSCOPY
For: Specialists. 3-day course, Sept. 16-18, 1974, Chicago. Hrs. of Instr.: 20 approx. CME Credit: AMA Category 1. Fee: $250 Sponsor, contact: Cook County Grad. Sch. Med., 707 S. Wood St., Chicago 60612.
Internal Medicine
REVIEW COURSE IN RHEUMATOLOGY
For: Family Physicians. 1-week course. Sept. 9-13, 1974, Chicago. Hrs. of Instr.: 35 approx. CME Cred- it: AMA Category 1. Fee: $200. Sponsor, contact: Cook County Grad. Sch. of Med., 707 S. Wood St., Chi- cago, IL 60612.
REVIEW COURSE IN PULMONARY
For: Family Physicians. 1-week course, Sept. 9-13, 1974, Chicago. Hrs. of InStr.: 35 approx. CME Cred- it: AMA Category 1. Fee: $200. Sponsor, contact: Cook County Grad. Sch. of Med., 707 S. Wood St., Chicago, IL 60612.
RECENT CONCEPTS IN DIABETIC MANAGEMENT
For: All Physicians, Allied Health. Weekly medical education seminar, Sept. 10, 1974, 11:30 AM, Me- morial Hospital of DuPage County, Elmhurst, III. Speaker: Ann M. Lawrence, M.D., Univ. of Chicago. Hrs. of Instr.: 1. CME Credit: AMA Category 1. Sponsor, contact: John H. Huss, M.D., DME, Me- morial Hospital of DuPage County, Avon Rd &
Schiller St. , Elmhurst, IL 60126.
ENDOCRINOLOGY
For: Internists. 3-day course, Sept. 11-13, 1974,
Hilton Hotel, Indianapolis. HrS. of Instr.: 18. CME Credit: AMA Category 1. Sponsor, contact: American Coll. Physicians, 4200 Pine St., Philadelphia 19104.
REVIEW COURSE IN HEMATOLOGY
For: Family Physicians. 1-week course, Sept. 30-0ct. 4, 1974, Chicago. Hrs. of Instr.: 35 approx. CME
Credit: AMA Category 1 Fee: $200. Sponsor, con-
tact: Cook County G'rad. Sch. of Med., 707 S. Wood St., Chicago, IL 60612.
REVIEW COURSE IN INFECTIOUS DISEASES
For: Family Physicians. 1-week course, Sept. 30-0ct. 4, 1974, Chicago. Hrs. of Instr.: 35 approx. CMiE
Credit: AMA Category 1. Fee: $200. Sponsor, con-
tact: Cook County Grad. Sch. of Med., 707 S. Wood St., Chicago, IL 60612.
REVIEW COURSE IN NEPHROLOGY
For: Family Physicians. 1-week course, Sept. 30-0ct. 4, 1974, Chicago. Hrs. of InStr.: 35 approx. CME
Credit: AMA Category 1. Fee: $200. Sponsor, contact:
Cook County Grad Sch. of Med., 707 S. Wood St.. Chicago, IL 60612.
Neurology
SPECIALTY REVIEW IN NEUROLOGY- PART II, CLINICAL
For: All Physicians. 1-week course, Sept. 9-13, 1974, Chicago. Hrs. of Instr.: 44 approx. CME Credit: AMA Category 1. Fee: $200. Sponsor, contact: Cook County Grad. Sch. Med., 707 S. Wood St., Chicago 60612.
Obstetrics /Gynecology
BASIC GYNECOLOGY
For: All Physicians. 1 week course, Sept. 16-20, 1974, Chicago Hrs. of Instr.: 35 approx. CME Credit: AMA Category 1 Fee: $200. Sponsor, contact: Cook County Grad. Sch. Med., 707 S. Wood St., Chicago 60612.
GYNECOLOGICAL LAPAROSCOPY
For: Specialists, l week course, Sept. 23-27, 1974, Chicago. Hrs. of Instr.: 15 approx. CME Credit: AMA Category 1. Fee: $250. Sponsor, contact: Cook County Grad. Sch. Med., 707 S. Wood St., Chicago 60612.
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Illinois Medical Journal
Occupational Medicine
34TH CONGRESS ON OCCUPATIONAL HEALTH
For: Industrial Physicians, Nurses, & Safety Engineers. Symposium-workshop, Sept. 9-10, 1974, Marriott Mo- tor Hotel, Chicago. CME Credit: 12 hrs. AMA Cate- gory 1. Fee: $20. Sponsor, contact: Henry F. Howe, M.D., AMA Dept, of Environmental, Public, & Oc- cupational Health, 535 N. Dearborn St., Chicago, IL 60610. Co-sponsor: Nat’l. Institute for Occupational Safety & Health, U.S. Dept, of HEW.
Ophthalmology
OPHTHALMOLOGY
For: All Physicians. 2-day seminar, Sept. 6-7, 1974, Wisconsin Center, Madison, Wis. Sponsor, contact: Dept, of Cont. Med. Educ., Univ. of Wisconsin Med. Sch., 610 Walnut St., Madison, Wl 53706.
Pediatrics
COMPREHENSIVE CHILDHOOD TRAUMA SYMPOSIUM
For: All Physicians. 2-day symposium, Sept. 11-12, 1974, Stouffer's Inn, Indianapolis. Hrs. of Instr.: 14. CME Credit: AMA Category 1. Sponsor, contact: Mr John Roscoe, Program Co-ord., Indiana Univ. Sch. of Med., 1100 W. Michigan St., Indianapolis, IN 46202.
PROBLEMS IN PEDIATRIC UROLOGY MANAGEMENT For: All Physicians. One-day workshop, Sept. 25, 1974, Indianapolis. Hrs. of Instr.: 7. CME Credit: AMA Category 1. Sponsor, contact: Mr John Roscoe, Program Co-ord., Indiana Univ. Sch. of Med., 1100 W. Michigan St., Indianapolis, IN 46202.
Plastic Surgery
REVIEW COURSE IN PLASTIC SURGERY For: Plastic Surgeons. 3-day lecture series, Sept. 3- 5, 1974, McGaw Med. Cntr., Northwestern Univ., Chicago. Hrs. of Instr.: 18V&. Fee: $200. Reg. Dead- line: luly 31, 1974. Sponsor: Dept, of Surgery,
Northwestern Univ. Med. Sch. Contact: D. A. Ker- nahan, M.D., Childrens Memorial Hospital, 2300 Chil- drens Plaza, Chicago, IL 60614.
MANAGEMENT OF INDUSTRIAL INJURIES OF THE HAND
For: Family Physicians, Plastic Surgeons. Symposium, Sept. 14, 1974, Barnes Hospital, St. Louis. Sponsor, contact: Paul M. Weeks, M.D., Director, Milliken Hand Rehab. Cntr., 907 Wohl Clinic, 4960 Audubon Ave., St. Louis, MO 63110. Co-sponsor: Washington Univ. Sch. of Med.
Psychiatry
CURRENT & FUTURE PERSPECTIVES IN TREATMENT OF ALCOHOLISM
For: All Physicians. Lecture, Sept. 13, 1974, 7:30
PM, Forest Hosp. Professional Cntr., Des Plaines, III.
Speaker: R J. Catanzaro, M.D., The Palm Beach Institute, Florida. Fee: $15 ($5 students). Sponsor, contact: Forest Hospital, 555 Wilson Lane, Des
Plaines, IL 60016; (312) 827-8811, ext. 362.
Radiology
GAMMA SCINTILLATION CAMERA WORKSHOP
For: Specialists. 3-day workshop, Sept. 5-7, 1974.
Indianapolis. Hrs. of Instr.: 21. CME Credit: AMA Category 1. Reg. Limit: 30. Sponsor, contact: Mr. John Roscoe, Program Co-ord., Indiana Univ. Sch. of Med., 1100 W. Michigan St., Indianapolis, IN 46202.
Surgery
MANAGEMENT OF COMPLICATIONS IN SURGERY
For: All Physicians. 4-day course, Sept. 16-19, 1974, Chicago. Hrs. of Instr.: 28 approx. CME Credit: AMA Category 1. Fee: $175. Sponsor, contact: Cook County Grad. Sch. Med., 707 S. Wood St., Chicago 60612.
UPPER MIDWEST REVIEW OF GASTROENTEROLOGY
For: All Physicians.. ll/2-day lecture & discussion, Sept. 21-22, 1974, Pfister Hotel, Milwaukee. CME Credit: 10 hrs. AAFP. Fee: $125. Sponsor, contact: The Medical College of Wisconsin, c/o A. T. Fin- negan, Course Coord., 561 N. 15th St. , Milwaukee, Wl 53233.
FLUID & ELECTROLYTE MANAGEMENT
For: All Physicians. 1-week course, Sept. 23-27, 1974. Chicago. Hrs. of Inst.: 30 approx. CME Credit: AMA Category 1. Fee: $200. Sponsor, contact: Cook County Grad. Sch. Med., 707 S Wood St., Chicago 60612.
BRONCHOSCOPY
For: Specialists. 1-week course, Sept. 23-27, 1974. Chicago. Hrs. of Inst.: 20 approx. CME Credit: AMA Category 1. Fee: $200. Sponsor, contact: Cook County Grad. Sch. Med., 707 S. Wood St., Chicago 60612.
DISEASES OF ESOPHAGUS, STOMACH & DUODENUM For: All Physicians. 3-day course, Sept 26-28. 1974, Chicago. Hrs. of Instr.: 20 approx. CME Credit: AMA Category 1. Fee: $125. Sponsor, contact: Cook County Grad. Sch. Med., 707 S. Wood St., Chicago 60612.
SPECIALTY REVIEW IN GEN. SURGERY— PART I
For: Surgeons. 2-week course, Sept. 30-Oct. 11,
1974, Chicago. Hrs. of Instr.: 94 approx. CME Credit: AMA Category 1. Fee: $350. Sponsor, contact: Cook County Grad. Sch. of Med., 707 S. Wood St., Chi- cago, IL 60612.
OCTOBER
Anesthesiology
COURSE III— EKG FOR ANESTHESIOLOGISTS
For: Anesthesiologists. 1-week course, Oct. 28-Nov. 1, 1974, Chicago. CME Credit: 35 hrs. (approx.) AMA Category 1. Fee: $200. Reg. Limit: 35. Sponsor, contact: Cook County Grad. Sch. of Med., 707 S. Wood St., Chicago, IL 60612.
Cancer
20TH FALL CANCER CONFERENCE For: All Physicians. Vi-day conference, Oct. 5, 1974, University of Wisconsin Hospital, Madison. Fee: $5. Sponsor, contact: Dept, of Cont. Med. Educ , Univ. of Wisconsin, 610 N. Walnut St., Madison, Wl 53706.
TUMORS OF URINARY TRACT
For: All Physicians. Symposium, Oct. 16, 1974,
Ruth Lake Country Club, Hinsdale, III. CME Credit:
3 hrs. AMA Category 1. Reg. Deadline: Oct. 14, 1974. Sponsor, contact: DuPage County Medical Soc., 646 Roosevelt Rd., Glen Ellyn, IL 60137; (312) 469-7773.
Cardiovascular
BASIC ELECTROCARDIOGRAPHY
For: Family Physicians. 1-week course, Oct. 28-Nov. 1, 1974, Chicago. CME Credit: 35 hrs. (approx.) AMA Category 1. Fee: $200. Reg. Limit: 35. Sponsor, contact: Cook County Grad. Sch. of Med., 707 S. Wood St., Chicago, IL 60612.
Dermatology
BASIC DERMATOLOGY
For: Family Physicians. 1-week course, Oct. 14-18, 1974, Chicago. CME Credit: 30 hrs. (approx.) AMA Category 1. Fee: $175. Reg. Limit: 30. Sponsor, contact: Cook County Grad. Sch. of Med., 707 S. Wood St., Chicago, IL 60612.
Family Medicine
FIFTH FAMILY MEDICINE REVIEW
For: Family Physicians, Osteopaths, Symposium, Oct. 6-12, 1974, Univ. of Kentucky Medical Cntr., Lexing- ton, Ky. CME Credit: 50 hrs. AAFP; 50 hrs. AMA Category 1. Fee: $195. Reg. Limit: 250. Sponsor, contact: Ofc. of Cont. Educ., College of Med., Univ. of Kentucky, Lexington, KY 40506.
General Interest
NEWER CONCEPTS OF THE CLINICAL PHARMACIST
For: All Physicians & Allied Health. Weekly seminar,
Oct. 1, 1974, 11:30 AM, Memorial Hospital of Du-
Page Co., Elmhurst, III. CME Credit: 1 hr. AMA Category 1. Sponsor, contact: John H. Huss, M.D., DME, Memorial Hospital of DuPage Co., Avon Rd. & Schiller St., Elmhurst, IL 60126; (312) 833-1400.
THE OTHER DOCTOR IN YOUR PRIVATE PRACTICE
For: All Physicians & Allied Health. Weekly seminar,
Oct. 8, 1974, 11:30 AM, Memorial Hospital of Du-
Page Co., Elmhurst, III. CME Credit: 1 hr. AMA Category 1. Sponsor, contact: lohn H. Huss, M.D., DME, Memorial Hospital of DuPage Co., Avon Rd. & Schiller St., Elmhurst, IL 60126; (312) 833-1400.
General Interest /CME Methods
INTRODUCTION TO CME TECHNIQUE
For: Hospital and other CME program planners. Two identical workshops held simultaneously, Oct. 4-6, 1974, Marriott Inn, St. Louis and Oak Brook Hyatt House, Oak Brook, III. CME Credit: 14 hrs. AMA Category 1 (plus 4 hrs. extra on completion of post- workshop assignment). Fee: $125. Reg. Limit; Dead- line: 20 each; Sept. 20, 1974. Sponsor, contact: Illinois Council on Cont. Med. Educ., 360 N. Michi- gan Ave., Chicago, IL 60601.
Geriatrics
GERIATRICS— IN-DEPTH VIEW
For: All Physicians. 3-day conference, Oct. 24-26, 1974, Wisconsin Cntr., Univ. of Wisconsin, Madison. Fee: $70. Sponsor, contact: Dept, of Cont. Med. Educ., Univ. of Wisconsin, 610 N. Walnut St., Madison, Wl 53706.
Neurology
3RD ANNUAL CHILD NEUROLOGY SOCIETY MEETING
For: Pediatric Neurologists. Annual meeting, Oct.
10-12, 1974, Hilton Hotel, Madison, Wis. Sponsor, contact: Child Neurology Society, Box 486 Mayo, 412 Southeast Union, Minneapolis, Minn. 55455.
Obstetrics-Gynecology
SPECIALTY REVIEW IN OB-GYN
For: Specialists. 2-week course, Oct. 28-Nov. 8, 1974, Chicago. CME Credit: 86 hrs. (approx.) AMA Category 1. Fee: $350. Reg. Limit: 85. Sponsor, contact: Cook County Grad. Sch. of Med., 707 S. Wood St., Chicago, IL 60612.
Orthopaedics
MANAGEMENT OF COMMON FRACTURES
For: Family Physicians. 1-week course, Oct. 28-Nov. 1, 1974, Chicago. CME Credit: 30 hrs. (approx.) AMA Category 1. Fee: $200. Reg. Limit: 30. Sponsor, contact: Cook County Grad. Sch. of Med., 707 S. Wood St., Chicago, IL 60612.
Otolaryngology
OTOLARYNGOLOGY WORKSHOP
For: Family Physicians. Seminar, Oct. 30, 1974,
Indianapolis. CME Credit: 7 hrs. AMA Category 1. Sponsor, contact: Mr. John Roscoe, Program Coord., Indiana Univ. Sch. of Med., 1100 W. Michigan St., Indianapolis, IN 46202.
Pediatrics
MANAGEMENT OF PEDIATRIC HEART DISEASE
For: All Physicians. 3-day course, Oct. 30-Nov. 1, 1974, Chicago. CME Credit: 21 hrs. (approx.) AMA Category 1. Fee: $100. Reg. Limit: 45. Sponsor, contact: Cook County Grad. Sch. of Med., 707 S. Wood St., Chicago, IL 60612.
Psychiatry
PSYCHIATRY FOR THE MEDICAL PRACTITIONER
For: All Physicians. 4-day course, Oct. 7'-10, 1974, Chicago. CME Credit: 24 hrs. (approx.) AMA Cate- gory 1. Fee: $175. Reg. Limit: 80. Sponsor, con- tact: Cook County Grad. Sch. of Med., 707 S. Wood St., Chicago, IL 60612.
CURRENT & FUTURE PERSPECTIVES IN DRUG ABUSE
For: All Physicians. Lecture, Oct. 16, 1974, 7:30 PM, Forest Hospital Professional Cntr., Des Plaines, III. Speaker: P. G. Bourne, M.D., Special Action Ofc. for Drug Abuse Prevention, Washington, D.C. Fee: $15 ($5 students). Sponsor, contact: Forest Hospital, 555 Wilson Lane, Des Plaines, IL 60016; (312) 827-8811, ext. 362.
PSYCHOPHARMACOLOGY
For: Family Physicians, Specialists. Seminar, Oct. 16, 1974, Indiana Univ. N.W. Campus, Merrillville, Ind. CME Credit: 6 hrs. AMA Category 1 Sponsor, con- tact: Mr, John Roscoe, Program Coord., Indiana
Univ. Sch. of Med., 1100 W. Michigan St., India- napolis, IN 46202
PSYCHIATRY FOR THE ADOLESCENT
For: All Physicians. Lecture, group discussion, Oct. 23, 1974, 10 AM, Bethany Methodist Hosp.; Oct. 23, 6 PM, Lincolnwood Hyatt House; Oct. 24, 10 AM, Belmont Hosp. Speaker: Beverley Mead, M.D., Dept, of Psychiatry, Creighton Univ. Sch. of Med. CME Credit: 5 hrs. AMA Category 1. Fee: $10 (non- staff, for dinner). Reg. Deadline: Oct. 18, 1974. Sponsor: FAB3-CME. Contact: Mr. D. Larson, Bethany Methodist Hosp., 5025 N. Paulina, Chicago, IL 60640; (312) 271-9040.
Radiology
DIAGNOSTIC RADIOLOGY
For: Family Physicians. 1-week course, Oct. 7-11, 1974, Chicago. CME Credit: 35 hrs. (approx.) AMA Category 1. Fee: $200. Reg. Limit: 25. Sponsor, contact: Cook County Grad. Sch. of Med., 707 S. Wood St., Chicago, IL 60612.
Surgery
PRE & POSTOPERATIVE CARE OF PATIENTS
For: Surgeons, Surgical Specialists. 4-day course, Oct. 29-Nov. 1, 1974, Chicago. CME Credit: 32 hrs. (approx.) AMA Category 1. Fee: $175. Reg. Limit: 80. Sponsor, contact: Cook County Grad. Sch. of Med., 707 S. Wood St., Chicago, IL 60612.
Urology
SPECIALTY REVIEW— UROLOGY
For: Specialists. 3V2-day course, Oct. 2-5, 1974, Chicago. CME Credit: 30 hrs. (approx.) AMA Cate- gory 1. Fee: $150. Sponsor, contact: Cook County Grad. Sch. Med., 707 S. Wood St., Chicago 60612.
for July, 1974
57
Abstracts of the Board
( Continued from page 23)
AMA House those resolutions which favor repeal of PSRO and are consistent with the position taken by the ISMS House of Delegates in this matter.
Support Anesthesiologists
The Board agreed to support the position of the Illinois Society of Anesthe- siologists in the matter of licensing requirements for Ambulatory Surgical Treatment Centers. The following was approved: "A licensed physician, or a cer- tified registered nurse anesthetist medically directed by a licensed physi- cian, who has privileges to administer or direct the administration of anes- thesia in a hospital accredited by the Joint Commission on Accreditation of Hospitals, shall be present for the administration of anesthetics and recovery of patients. The approved program for the facility shall include policies re- garding the provision of anesthesia services."
Council and Committee Appointments
In the future, county societies will be invited to submit nominations for ISMS council and committee appointments. Until now, only off icers and trustees have been asked for nominations, with the Board as a whole approving the slate of each council and committee. Letters of appointment for 1974-75 committees are in the mail.
Membership Recruitment
The Board commended the Public Relations Council for its recognition of the importance of internal communications with members, but referred back to the council its membership recruitment campaign plan. The Board said that some parts of the program required further study regarding feasibility.
Recognition of SIMA 1 OOth Anniversary
ISMS will present an appropriate plaque to the Southern Illinois Medical As- sociation in honor of SIMA's 100th anniversary.
MEDICHEK
As a follow-up to Resolution 74M-25, which called for clarification and mod- ification of MEDICHEK regulations, the Governmental Health Program Reimburse- ment Committee informed the Board it had met with representatives of the Illi- nois Departments of Public Health and Public Aid to discuss the four parts of the resolution.
A. Because federal regulations mandate the implementation of MEDICHEK throughout the country, the Board recognized the impracticality of requiring its annual approval by county medical societies.
B. The committee reported that the federal MEDICHEK program could not be under the "direct control of the peer review and ethical relations committees of the local county medical society," as specified in the resolution but that state officials welcomed review and comment from these sources. The Board in- structed the committee to seek a stronger commitment from state officials and continue its dialogue with them in this area.
C. The committee's recommendation that physicians be encouraged to charge usual and customary fees for services under MEDICHEK was approved by the Board , and the committee was instructed to obtain a firm commitment from the Department of Public Aid that the present maximum fee schedule would be reviewed and ad- justed accordingly at the end of six months.
D. It was reported that the pilot projects referred to in the resolution were already operating and no further action needed.
In a related action, the Board commended Joel Edelman, Director of the Depart- ment of Public Aid, for his efforts to keep confidential the record of IDPA pay- ments to individual physicians preventing such data from being sensational- ized in the public press.
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Illinois Medical Journal
Problems of Pharmaceutical Industry
The Board directed the Executive Committee to assign to an appropriate ISMS committee the problem of bureaucratic intervention in the pharmaceutical in- dustry and to study generic vs. brand name prescribing with a view toward de- veloping a position for ISMS to take in this matter.
Peer Review Appeals
A question involving the right of insurance carriers to utilize the ISMS peer review process was resolved by referring to the following bylaws statement: "Any party to the proceedings considering himself aggrieved by the findings and recommendations of the (local) committee shall have the right to appeal through the component society to the Illinois State -Medical Society."
Psychotherapy Definition
In keeping with House Action, the Board approved and referred to the Policy Committee the following definition:
Medical Psychotherapy is a medical procedure for the treatment of mental and physical ailments or illness. It involves verbal or non-verbal communi- cations with the patient, and always includes continuing medical diagnostic evaluation and drug management as indicated. Medical psychotherapy may be performed only by a physician licensed to practice medicine in all of its branches, who has had training in psychiatric medicine.
Mental Health Department Budget
At the request of the Council on Mental Health and Addiction, the Board di- rected the Governmental Affairs Council to take appropriate action toward in- creasing the Illinois Department of Mental Health budget so that $5 million would be available for the purchase of care for mental treatment in licensed private psychiatric facilities.
Proposed Mental Health Department Rules
ISMS will object to the Mental Health Department's proposed Rule 12.09, which outlines the procedure to be followed for administering psychotropic drugs in state facilities. The department will be asked to delay implementation until the council has had an opportunity to review and comment on proposed rules.
Revision of Mental Health Code
Noting the need for physician guidance in the proposed revision of the Illi- nois Mental Health Code, the Board will urge ISMS members to send their sugges- tions for code changes to the state medical society for forwarding to the Revi- sion Committee.
Other Legislation
On recommendation of the Medical Legal Council, the Board rescinded its pre- vious endorsement of HB 751, the Clinical Research Act, because of amendments and changes being contemplated by the legislature. ISMS will now oppose the bill in its present form and referred the matter back to the Medical Legal Coun- cil to develop appropriate amendments.
The Board also referred to the Governmental Affairs Council a recommendation that ISMS support HB 2571, which would amend the Controlled Substances Acts, and HB 2826, which would create a Dangerous Drug Commission.
The Board also:
Will not endorse HB 2225, the Comprehensive Health Service Act unless ap- propriately amended ;
Not support proposed legislation rescinding exemption, for religious beliefs, from mandatory immunizations and other mandatory medical procedures ;
Oppose HB 2217, which would create a new class of crimes related to controlled substances ;
Referred to the Executive Committee a recommendation to oppose HB 2710, which
for July, 1974
59
would require legislative approval for the closing or reducing of programs in state mental hospitals.
Oppose HB 1412, Nursing Practice Act amendment, until the Joint Practice Com- mittee has taken a position on it:
Support HB 2757, the Health Professional Student Loan Program, if ISMS amend- ments are accepted by the sponsor;
Vigorously oppose SB 1500, which would grant permanent limited licenses to hospital permit physicians under certain conditions.
Plan for Perinafal Health
On recommendation of the Council on Environmental and Community Health, the Board endorsed the final version of a Plan for Perinatal Health in Illinois. The council stated that implementation of the plan will result in improved care for both the high-risk mother and high-risk infant.
Proposed Rules for Sodium, Nitrate and Nitrite Content in Drinking Water Supplies
The Board endorsed the Illinois Environmental Protection Agency's proposed rules for sodium, nitrate and nitrite content in drinking water supplies. The new standards update present Illinois standards and bring them into line with federal guidelines.
Health Care Delivery Problems in Spanish-Speaking Communities
The Board approved a recommendation of the Council on Social and Medical Ser- vices that ISMS, in collaboration with local medical societies, explore the pos- sibility of sponsoring conferences for health care providers and agencies lo- cated in predominantly Spanish-speaking neighborhoods.
Guidelines for Weight Reduction Programs
As a follow-up to approving a position statement on the use of human chorionic gonadotropin in weight reduction, the Board endorsed a set of "Guidelines in the Selection of a Weight Reduction Program." The guidelines are to be submitted to the Illinois Osteopathic Association for its consideration and possible co- sponsorship, since there are osteopaths being employed by weight clinics.
The Board also agreed that the guidelines be given wide public distribution via the mass media, that they be reproduced on appropriate-sized cards for distri- bution to patients in physicians' offices and other health facilities, that they be made available to the AMA Council on Foods and Nutrition, and that the ISMS work with the Illinois Department of Public Health in exploring the need for regulating weight control businesses in Illinois. (Guidelines appear on page 19. )
Professional Liability in Patient Care
The Medical Legal Council was authorized to begin development of a revised version of the "Physician's Liability in Patient Care" booklet, with produc- tion costs allocated from the council ' s budget. Legal counsel will review ma- terials before they are published.
Special Advisory Committee to IDPH
A proposal to develop a special Legislative Advisory Committee to Illinois Public Health Director Joyce Lashof has been referred to the Executive Com- mittee, which will consult with the Illinois Hospital Association and others interested in establishing this committee. The Governmental Affairs Council recommended to the Board that existing ISMS councils and committees be utilized rather than another advisory committee.
Legislative Seminar
The Public Affairs Committee will sponsor a Legislative Seminar September 20- 22 at Chateau Louise in Dundee. Invitations will be mailed to 3,500 physicians and spouses on the mailing list for On the Legislative Scene. Information group discussions on the legislative process are planned, with legislators serving as faculty and physicians as students. ■<
60
Illinois Medical Journal
Swimming Instructions for Pre-School Children
(Continued from page 27)
Pediatricians do not claim to be experts on swimming or swimming instruction, but they will justifiably claim to be experts on child development. They also will claim a better perspective, a broader view of the child in the longitudinal consequences of various pressures and influences on his emotional integrity. We are a success oriented society with ever-decreasing ability to delay the gratification of success. The child’s best interests must always be paramount in all programs aimed at making him perform or excel. ^
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Swimming Safety
As the outdoor swimming season approaches, the safety experts predict with certainty that some thousands of Americans will drown in the coming summer months.
They will drown in swimming pools, in lakes and streams, at ocean beaches. Some will drown while in for a refreshing dip and others will fall out of boats and off docks and piers.
Many, if not most, of these drownings need not happen.
The American Medical Association offers some basic safety rules that can help to avoid a tragic water accidents.
• Learn to swim and to relax in the water.
• Never swim alone.
• Do not swim when overly tired or when the water is extremely cold.
• Do not overestimate your ability and endurance.
• Swim at protected pools or beaches under the supervision of a trained lifeguard.
• If a boat overturns, stay with it and don’t try to swim a long distance to shore.
• Never dive into water of unknown depth.
• Try new activities, such as water skiing or scuba diving, only after learning the skills from qualified instructors.
Many families will do most of their swimming this season in private pools, in their own backyards or in those of a friend or neighbor. There also are some special safety precautions for private pools.
• Make certain the pool is kept clean and the water chemically purified.
• Walk, don’t run, about the pool. Horseplay is dangerous.
• Fence the pool and keep the gate locked to keep out small children.
• Keep handy rescue equipment, such as long poles and ring bouys.
• Keep bottles and glasses away from the concrete or metal pool deck.
EKG of the Month
( Continued from page 45)
Answers: 7. D. 2. E. The rhythm strip shows SA block with short pauses. These should not be con- tused with non-conducted premature atrial beats followed by an incomplete compensatory pause. No premature p waves can be seen. During monitoring long pauses were documented that probably produced the syncope. Other mecha- nism in patient on thioridazine and chlorproma- zine is ventricular tachycardia and fibrillation. This was not seen. Serum lithium level was 2.5 mEq/L (therapeutic range 0.5 to 1.5 mEq/L) . Patient refused pacemaker. Isoproterenol was started.
Patient improved and SA block disappeared with decreasing lithium levels only to reappear when drug was restarted. Most frequent causes of SA block include drug toxicity (digitalis, quanidine, and potassium salts) , acute myocar- ditis, and myocardial ischemia. Since our patient had no other cause for the black, but had high lithium levels, the possibility of lithium induced SA block is raised. ■<
COOK COUNTY Graduate School of Medicine
CONTINUING EDUCATION COURSES STARTING DATES, 1974
SPECIALTY REVIEW FOR FAMILY PRACTICE, August 12 SPECIALTY REVIEW IN ORTHOPAEDICS, August 25 SPECIALTY REVIEW COURSES IN PULMONARY & RHEUMATOLOGY, September 9
SPECIALTY REVIEW COURSES IN HEMATOLOGY. INFECTIOUS DISEASES & NEPHROLOGY, Sept. 30 SPECIALTY REVIEW IN SURGERY, PART I, Sept. 30 SPECIALTY REVIEW IN OBSTETRICS & GYNECOLOGY, Oct. 28 SPECIALTY REVIEW IN MEDICINE, RECERTIFYING, Oct. 14 SPECIAL COURSE IN GYNECOLOGIC PATHOLOGY, Oct. 14 MANAGEMENT OF COMPLICATIONS IN SURGERY, 4 Days, Sept. 16 MANAGEMENT OF COMMON FRACTURES, One Week, Oct. 28 FLUIDS & ELECTROLYTES, One Week. Sept. 23 BASIC GYNECOLOGY, One Week, September 16 BASIC ELECTROCARDIOGRAPHY, One Week, Oct. 28 INTERMEDIATE CARDIOLOGY, September 23 NEUROLOGY, PART II, CLINICAL, One Week, September 9 PSYCHIATRY FOR THE MEDICAL PRACTITIONER. 4 Days, Oct. 7 STATE & NATIONAL BOARD REVIEW, Basic & Clinical,
Oct. 14 & 20
Information concerning numerous other continuation courses available upon request.
Address:
REGISTRAR. 707 South Wood Street, Chicago, Illinois 60612
for July, 1974
61
The Cholesterol Hypothesis and the Coronary Primary Prevention
( Continued from page 30)
7. Leren, P.: "The Effect of Plasma Cholesterol Lower- ing Diet in Male Survivors of Myocardial Infarction.” Acta Med. Scand. Suppl. 466:48-92, 1966.
8. Leren, P.: “The Oslo Diet-Heart Study. Eleven-Year Report.” Circulation 40:935-942, 1970.
9. ‘‘Report of a Research Committee to the Medical Re- search Council: Controlled Trial of Soya-Bean Oil in Myocardial Infarction,” Lancet, 11:693-699, 1968.
10. Olson, R. E.: Prevention and Control of Chronic Dis- ease: 1. “Cardiovascular Disease— With Particular
Attention to Atherosclerosis.” Amer. J. Pub. Health 49:1120-1128, 1959.
11. Protocol for the Lipid Research Clinics Type II Coro- nary Primary Prevention Trial. April, 1973.
EDITORIAL : Angina Pectoris
(Continued from page 53)
such drugs as guanethedine, alpha-methyldopa, and propranolol. The spasms may respond to nitroglycerin.
Spasm appears to be the logical cause but not all cardiologists consider this a satisfactory ex- planation. In addition, there is no standard remedy, except when medical therapy is not ef- fective, a surgical approach should be attempted. Various methods have been tried. Those with no significant coronary disease as shown on the angiograph do well on nitroglycerin and sub- lingual isosorbide.
T. R. Van Dellen, M.D.
Editor
References
1. “Prinzmetal Variant of Angina Pectoris.’, Editorials, JAMA 228:3 (April 15) 1974.
2. “Prinzmetal Variant Angina Covers a Wide Spectrum.” Internal Medicine Neivs (April 1) 1974.
LOW-COST GROUP INSURANCE ANOTHER
THE GROUP DISABILITY PLAN • Provides up to $300.00 weekly in the event of disability caused by Accident or Sickness. • Special Guaranteed renewal feature. • Protect your income and security.
BUSINESS OVERHEAD EXPENSE PLAN • Pays your office overhead expense when disability strikes. • Premiums are Tax Deductible. • Pays in Addition to the Disability Plan Benefits.
THE FAMILY MAJOR MEDICAL EXPENSE PLAN • In or out of Hospital Benefits up to $25,000.00 per Disability. • Up to $100.00 Gross Daily Hospital Room and Board available. • Subject to choice of deductible and 80% coinsurance.
9933 N. Lawler Avenue Skokie, Illinois 60076 Phone:312-679-1000
ISMS MEMBERSHIP PRIVILEGE
Central Illinois Service Office: 849 Forest Lane — Petersburg, III. 62675 • phone 217-632-7220
Wayne J. Hubbert, District Manager
62
Illinois Medical Journal
Physician Recruitment Program
In an effort to reduce the number of towns in Illinois needing physicians, the Physician Recruitment Program and the Doctor’s Job Fair, are publishing synopses in the Journal.
Physicians who are seeking a place to practice or who know of any out-of-state physicians seeking an Illinois residence are
asked to notify the Program.
Any areas wishing to be listed should contact: Mrs. E. Duffy, Physician Recruitment Program, ISMS, 360 North Michigan Ave., Chicago, 60601.
ALEDO: Mercer County, 17,000 population, needs addi- tional family physicians. 4 active physicians at present. General acute hospital in Aledo. High quality medical care economically rewarding. Thirty miles from met- ropolitan quad-city area. Good small community for family living. Contact: Shirley Lindberg or Monty McClellan, M.D., 308 NW Fourth Street, Aledo, 61231, 309/582-5156. (10)
BLOOMINGTON: General Practitioners, Internists, Pediatricians and a Surgeon needed to help establish a multi-specialty clinic in a new Erdman Building. Corporate practice with all the usual benefits. Contact: Paul G. Theobald, M.D., #1 Medical Hills Dr., Bloom- ington, 61701, 309/828-6051. (10)
CHAMPAIGN: Private hospital expanding and build- ing new 110 bed facility. We are seeking a General Surgeon, Internist and Family Practitioner. Minimum guarantee offered. Contact: Donald L. Francis, Ex- ecutive Director, Cole Hospital, Inc., 809 W. Church Street, Champaign, 61820; (217) 356-3788. (8)
CHARLESTON: Small midwestern University Health Service serving 8,000 students, 4% day week; no after hours or weekends. Perfect for post-retirement. Five weeks vacation and one week for medical meetings. Life insurance, health insurance, and University Re- tirement System. Contact: Director, Health Service, Eastern Illinois University, Charleston, 61920, (217) 581-3013. (10)
CHENOA: Rural area, 100 miles south of Chicago on 1-55. Looking for one or two physicians to do family practice. Hospital facilities nearby. Financial assistance and office space can be arranged. Contact: R. J. Walk- er, National Bank of Chenoa, Chenoa, 61726, 815-945- 2311. (10)
CHICAGO: Private young multispecialty group seeks General Practitioners or Medical Specialist. University affiliation available. Spanish speaking M.D. welcomed. Contact: Dr. Finley W. Brown or Dr. Gonzalo Ruiz, 3109 W. Armitage, Chicago, 60647, 312-276-8811. (7)
CHICAGO: Generalist or Internist wanted for full- time practice in welfare neighborhood. New office, unlimited financial opportunity. For details contact: Mrs. Grescio, Dr. G. Mizock Office, 6201 N. California, Chicago 60645. 312-642-1094 (8)
CHICAGO & SUBURBS: Privately owned multi- specialty clinic, 40-48 hour week. Day and/or night work. Contact: Joseph Lentini, Garfield Medical Cen- ter. (312) 624-4200 or (312) 427-3343. (8)
CHICAGO: Board Certified or eligible, Internal Medi- cine, Illinois Registration. Medical Center, providing preventive and therapeutic medical care with other specialists and diagnostic services on premises. Ad- ministrative Ability an Asset, Salary Open, Commen- surate with background and experience. Call Collect: William A. Hutchison, M.D., Union Medical Center, 1657 West Adams, Chicago, 60612, (312) 829-1134. (10)
CREVE COEUR: M.D. URGENTLY NEEDED as an
associate in a very active practice in the Peoria area, hospitals. Present M.D. wishes to retire soon and is Family or General Practice within six miles of three hospitals. Present MD. wishes to retire soon and is concerned with his patients. Financial arrangements and over-all needs negotiable. Only those seriously interested in private practice call collect 309-699-8022 or 309-699-5525 or write William Long, M.D., Creve Coeur, 111, 60601. (2)
DEKALB: Northern Illinois University Health Service needs Internist; General Practitioner; and Gynecol- ogist or practitioner with wide experience in gyne- cology and family planning. Reduced paper work, better hours, inquiring patients, new health care de- livery systems, and University atmosphere provide interest. Illinois license required. Equal Opportunity Employer. Write L. W. Akers, M.D., Director. NIU Health Service, DeKalb 60115. (10)
FLORA: Population 6,000, Patient- drawing area larger. G. P., Internist, Pediatrician. Group or solo. Office space can be arranged to suit your needs. Unusually well-equipped small hospital with excellent lab and X-ray facilities and ICU. Nearby specialty consultants. Fine school system and availability of homes. For information contact: Administrator, Clay County Hos- pital, Flora, 62839, 618-662-2131. (10)
GENESEO: Family Practice; Ped., Ob-Gyn, Int. Medi- cine who will also do General Practice. Population 7,000 serving area 30,000 on Interstate 80, 2% hrs. from Chicago, 25 miles from Quad-Cities metropolitan areas, over 300,000. Safe, ideal, small city living, 110 bed ultra-modern hospital, excellent schools, recrea- tional facilities. Hospital has just completed construc- tion of two new modern doctor’s offices on hospital property which are available immediately. Guarantee monthly gross income. Clement G. McNamara, 210 W. Elk St., Geneseo, 61254. Call collect (309) 944-6431. (10)
HARVARD: Population 5,200, estimated trading area 20,000. Three physicians at present, previously five. Center of rapidly growing and financially sound area.
for July, 1914
63
65 miles northwest of Chicago, 30 miles east of Rock- ford. Contact: J. M. Holcomb, Harvard Com. Hosp.. Grant & McKinley Sts., Harvard, 60033. (10)
JERSEYVILLE: population 8000. Trade area: 19,000. County medical society very anxious for additional physicians to locate here. 9 practicing physicians at present. Jersey Community Hospital located here; 54 beds. 20 miles from Alton. Office space available. Financial assistance available. German-Irish com- munity. 14 protestant & catholic churches. Grade & high schools including parochial. 20 miles from South- ern 111. U., Country Club with golf course. 1 hour to St. Louis. Contact: William B. Watts, Administrator — 508 W. Pine St., Jerseyville, 62052. Phone: (618)
498-2133. (8)
LEXINGTON: Population 1700. Just 15 minutes away from Bloomington. Office facilities available. Great need for a doctor in the community. Lucrative prac- tice waiting. All recreational facilities nearby. Con- tact: Michael Payne, Association of Commerce and Industry of McLean County, 210 South East Street, Bloomington, 61701, (309) 829-6344. (8)
LIBERTYVILLE — Thirty-Five miles northwest of Chi- cago. Population 12,000 — serving 40,000. Group practice of Family Physicians. Affiliated with a 175 bed hospi- tal. Corporation benefits. Salary guarantee. Beautiful country for lake sports. Contact: Dr. Mark Fields, 716 S. Milwaukee Rd„ Libertyville 60048, 312-362-1390. (10)
METROPOLIS: Physicians wanted. Complete office facilities. Financial assistance available. Modern, well equipped hospital serving tri-county area in scenic southern Illinois. Contact: Charles Russell, Adminis- trator, Massac Memorial Hospital, Metropolis, 62960, (618) 524-2176. (10)
MONMOUTH: Services area population 30,000. Open- ing for Family Practice and OB-GYN. Modern well- equipped hospital — 141 beds. Near Highways 1-74 & 1-80. Daily rail to Chicago. Flight service available. Safe place to raise family. Near medical school, liberal arts college. Contact: Roger E. Gurholt, 1000 W. Harlem Ave.. Monmouth, 61462. 309-734-3141. (10)
PAXTON: Population 5400. Service area population 20,000. Two hours from Chicago; thirty minutes from Champaign-Urbana. This area needs another MD to share two physician clinic with a general surgeon. Free rent, office help offered. Contact: Dr. M. Y. Que, or Harry Dubets, Administrator, Paxton Community- Hospital, 651 E. Pells St., Paxton 60957, 217-379-2387. (8)
PEMBROKE TOWNSHIP: Population 6,000. Opening in new medical facility. Seventeen miles east of Kankakee and 60 miles south of Chicago. Financial assistance available. Contact: Andrew J. Hargrett, 135 West Court Street, Kankakee 60901. AC 815-939- 7304. (8)
PITTSFIELD: Need family practitioners and sur- geons interested in locating in rural community area. Population 4100; area 18,000. Excellent opportunity
for someone wanting to practice in a rural community. Located between Jacksonville and Quincy, on High- way 54 and 36. Contact Dr. T. C. Bunting, Illini Community Hospital, Pittsfield 62363. AC 217-285-2141 or 217-285-2113. (12)
QUINCY: OBG, Ind. Med., Fam. Prac., Ortho., Derm., GU to join 18-man clinic. Large modern clinic, many benefits, two well-equipped hospitals. Excellent schools, cultural, recreational advantages. Good family city. Above average earnings. Write or call collect: Mr. Judson C. Green, Quincy Clinic, 1400 Maine St., Quincy, 217-222-6550. (8)
RANSOM: General Practice — free rent and use of modern equipment and brick building for one year. Brick building consists of doctors’s, nurses, recep- tionist’s offices, large reception room, laboratory and office and (2) treatment rooms. 80 miles southwest of Chicago, RTE 170, St. Mary’s Hospital Staff, Streator Practices Reaches A 25 mile radius. Contact Mrs. Delmar Jones; Phone 815-586-4229. (8)
ROCHELLE: Population 10,000. General Practitioners, Internist-Cardiologist. Group or solo practice. Located 75 miles West of Chicago, near new medical school and university. $2,000,000 addition, 1971. Ultra-mod- ern, 70-bed hospital; new offices adjacent. Excellent schools, recreation. Visit at our expense. Contact: Robert Knapp, Rochelle Community Hospital, Rochelle 61068, 815-562-2181. (8)
SAVANNA: Pediatrician, Internist, or General Prac- titioner. Illinois community of 5,000 population on Mississippi River. 40-bed open staff hospital; excep- tional recreational facilities; excellent schools and churches of all denominations. Option to practice alone or in partnership. Contact: William J. Dayton, 202 Mead.owview Knoll, Savanna, 61074, 815-273-2755. (10)
SHELBYVILLE : Population 6,000 — drawing population 22,000. New eight man medical ctr. recently opened and attached to 100 bed hospital. Object to secure a medical practice group. Central location within com- muting distane of Springfield — 60 miles, Decatur 35 miles & St. Louis 115 miles. Located on large lake rec- reational area. Contact: John Snyder, Shelby County Memorial Hospital, 1st & Cedar Sts., Shelbyville, 62565, 217-774-3961. (10)
STREATOR: Internist, Family Physician, Pediatrician, Surgeon, and Orthopedic Surgeon needed to join 11 physician multispecialty group in community of 20,000 with new clinic across from new hospital, excellent practicing facilities for energetic physicians, full insurane benefits, guaranteed income; teaching opportunities. Contact: C. T. Hawkins, M.D., Streator Medical Clinic, S.C., 104 Sixth St., Streator, 61364, 815-672-0511. (8)
WHEATON: Pediatrician (s) to join unique medical office condominum. College town 25 miles west of Chi- cago. Practice arrangements flexible. Rapid practice expansion assured for right individual (s). Contact: Douglas B. Mains, M.D., Mona Kea Professional Park, 393 Schmale Road, Wheaton, 312-665-9777. (7)
64
Illinois Medical Journal
Obituaries
““Berg, Edward Paul, Chicago, died May 5, at the age of 82. He had been a general practitioner, surgeon; he was a graduate of the Chicago Medical School in 1916. Dr. Berg also had practiced medicine for more than 50 years.
“Baumann, Milton C., Springfield, died March 21 at the age of 63. He graduated from the University of Illinois in 1937. He was affiliated with the Department of Psy- chiatry and Neurology at the Baumann Clinic.
“Coombs, Robert, Chicago, died May 29 at the age of 73. He graduated from Rush Medical School in 1925. Dr. Coombs was a former instructor in surgery at the Re- search Educational Hospital and a lecturer in surgery at the Grant Hospital Training School for Nurses. He also was a member of the attending staff at Grant Hospital for 47 years. Dr. Coombs was the grandson of Dr. Jacob Frank, world famous Chicago surgeon of the early 1900’s.
“Davidson, Woodram W., Centralia, died June 4, at the age of 62. He graduated from the University of Illinois in 1948.
“Eshbaugh, Dorothy E., Chicago, died June 1, at the age of 56. She graduated from the Womens Medical School of Pennsylvania in 1942. Dr. Eshbaugh was as- sistant director of pathology at Michael Reese Medical Center and a professor and consultant on the staff of Chicago Medical College. Previous to serving at Michael Reese Hospital, she had served on the pathology staff at Rush-Presbyterian-St. Lukes Medical Center.
“Garcia, F. D., Florida, died April 29, at the age of 80, He graduate from the Chicago Medical School in 1923.
““Gorov, Ida Ruth, Chicago, died December 30, at the age of 80. She graduated from the Chicago Medical School in 1917. Dr. Gorov also has practiced medicine for more than 50 years.
“Gough, J. A., Florida, died May 14, at the age of 79. He graduated from Rush Medical College in 1922. Dr. Gough was an Obstetrician and Gynecologist for more than 35 years. He was to have been honored May 15 by the Presbyterian-St. Lukes Hospital on the 50th anni- versary of his enrollment on its staff, where he became an emertius member of the staff 16 years ago.
“Gurvey, Julius A., Chicago, died May 9, at the age of 69. He was Medical Director for the Wilson Sporting Goods Co. and Steel Supply Division of the United States Steel Corp. Dr. Gurvey also was a staff member of St. Elizabeth’s Hospital. He was a 1929 graduate of the University of Illinois.
“Hickerson, R. G. Sr., Galesburg, died June 5, at the age of 66. He graduated from the LTniversity of Illinois in 1933.
“Jones, Alexander J., Springfield, died April 3, at the age of 73. He graduated from the LTniversity of Edinburgh, Scotland in 1928.
“Lodato, Victor, Chicago Heights, died May 24, at the age of 62. He graduated from the Chicago Medical School in 1941. Dr. Lodato was an associate of the Boulevard Medical S.C., in Chicago Heights. He was also a staff member of St. James Hospital for more than 30 years and also a past president of the hospital.
““Matthies, Mabel, Arizona, died March 26, at the age of 91. She graduated from the Dearborn Medical School in 1907. Dr. Matthies practiced medicine for more than 50 years.
“O’Malley Sr., Francis X., Chicago, died June 2, at the age of 77. He had been a physician and a staff member of St. Joseph’s Hospital.
“Rudder, Ralph C., Arizona, died May 15, at the age of 69. He graduated from the Chicago Medical School in 1945.
“Sass, Louis A., Oaklawn, died May 22, at the age of 60. He graduated from Rush Medical School in 1939. Dr. Sass was a past president of the staff at Evangelical Hospital. He was also past president of Christ Com- munity and associate professor of medicine at Rush Medical School.
““Van Alyea, O. E., Winnetka, died May 5, at the age of 87. He had been a well known otolaryngologist, best known for his international text books on nasal sinuses. Dr. Van Alyea joined the faculty of the LTniversity of Illinois College of Medicine as an assistant in otolaryn- gology in 1929 and became Clinical Professor of oto- loryngology in 1941. When he retired in 1957, he was honored with emeritus status. He continued his interest in education and research.
“Watt, Lucille, Chicago, died June 3, at the age of 78. She received her Medical degree from Rush Medical College in 1943. Dr. Watt served on the staff of Billings, Presbyterian and Passavant Hospitals, where she was di- rector of anesthesia from 1959 until she retired in 1964.
“Wittier, Marie H., Arkansas, a former resident of Elm- hurst, died March 25 at the age of 64. She graduated from the Washington University School of Medicine, St. Louis, Mo., in 1937.
° Denotes member of ISMS 00 Denotes member of 50-Year Club of ISMS
for July, 1974
65
CLASSIFIED ADVERTISING
Positions & Practice Opportunities
IMMEDIATE FAMILY PRACTICE OPENING-in two man clinic. Liberty- ville, Illinois, 35 miles northwest of Chicago. Initial salary and early partnership. Busy practice in small suburban town. Call collect— Dr. Lawrence C. Day (312) 362-1447.
WANTED: OB-GYN, SURGEON and INTERNIST for nine man group. Thirty miles southwest of Chicago, excellent hospital, housing and schools. $30,000 guarantee first year. Write to Box Number 782, c/o Illinois Medical Journal, 360 N. Michigan Ave., Chicago, Illinois 60601.
ATTENTION PHYSICIANS! CHICAGO MEDICAL CENTERS-Welfare area in need of physicians. Please contact: Mr. Robert Fields (312) 236-2555.
GENERAL INTERNISTS and GENERALISTS: For growing sub-sections of 45 man medical department, including allergists, psychiatrists, neurologists, all sub-specialties and expanding primary care section. Multispecialty group of 120. Large patient population and area re- ferral. Functioning HMO. Generous salary and fringe benefits. Peace- ful setting near Wisconsin vacationland and cities. Good schools, cultural advantages. Junior College. Educational and research pro- grams. Liberal schedules, little practice pressure. New Clinic and hospital developing. Write or call J. L. Struthers, M.D., Marshfield Clinic, Marshfield, Wisconsin 54449.
FAMILY PRACTITIONERS— Expanding 880 bed multiple facility medi- cal center in Chicago is seeking family practitioners (individual or groups) to join the staff of its family practice oriented facility— 230 bed hospital located on the near West Side. The hospital will provide an office and furnish equipment to establish private practice at a mutually agreeable site in the nearby community— no investment by physicians required— and guarantee annual private practice income to a $36,000 minimum for one to five years (negotiable). Send Curric- ulum Vitae to Box 825, c/o Illinois Medical Journal, 360 N. Michigan Avenue, Chicago, Illinois 60601.
OZAUKEE COUNTY NEEDS Family Practitioners, Orthopedist, and Pediatricians to provide health care for over 55,000 affluent people. St. Alphonsus Hospital, located in the center of Ozaukee County, is an orderly, modern facility ready to provide acute hospital care. Office space is available here and in nearby cities and villages. Contact George A. Seidenstricker at St. Alphonsus Hospital, 743 North Montgomery Street, Port Washington, Wisconsin 53074. Phone 414-284-5511.
P.S. Spend the day with us so we can show you and your family everything . . . schools, shops, homes, parks.
Immediate opening for Ob-Gyn, Internal Medicine, and Orthopedic specialties to establish successful practice with 14-man multi-specialty group. Excellent group benefits; pension plan; modern clinic facili- ties; progressive community with excellent educational system includ- ing two colleges; city population 35,000; good recreational facilities; each specialty must be board eligible or certified. Contact: Business Manager, The Manitowoc Clinic, 601 Reed Avenue, Manitowoc, Wis- consin 54220.
A BETTER PLACE TO PRACTICE MEDICINE: Enioy practicing medicine in a warm climate, and with the friendly people in Wichita Falls, Texas. Our brand new 55,000 square foot clinic building has new offices and examining rooms ready for specialists in Internal Medi- cine, Family Practice, and Diagnostic Radiology. We are a multi- specialty group located in a city of 100,000 people in North Central Texas— close to everything— but away from big city problems. Call collect Dr. Preston McCall at (817) 766-3551, at 501 Midwestar Parkway, East, Wichita Falls, Texas 76302.
ANESTHESIOLOGIST— Immediate opening with fully-accredited mod- ern trauma center hospital in progressive and growing community. Excellent guarantee. Contact Administration, St. Joseph's Hospital, Bloomington, Illinois 61701, (309) 662-3311.
Positions & Practice Opportunities (Con’t)
PRACTICE and OFFICE AVAILABLE, about August 1, 1974, in a growing central Illinois town. Size 10,000, local hospital 75 beds, and 6 area nursing homes. Principally GP, OB, Geriatrics & in- dustrial practice. Price Negotiable. Present location 35 years. In- come 50,000-75,000. Reason for moving, health and age. Write: Box 831, c/o Illinois Medical Journal, 360 N. Michigan Ave., Chicago, IL 60601.
FAMILY PHYSICIANS OR GENERAL INTERNISTS - NEW MEDICAL CENTER, COUNTRYSIDE-LAGRANGE: Area fujl or part time excellent arrangement regarding benefits 100,000 insurance (life), malpractice. Car credit card + practice pre-paid. Also H.M.O. Some Fee for service. Hal Halihan, Co-Administrator, Countryside Health Care Center, Inc. 6160 W. Joliet Rd., Countryside, Illinois 60525.
Well-established, prosperous North-Michigan Avenue, Chicago In- ternist practice available because of sudden death. Sub-specialties in Electrical Cardiography and Allergy. Especially able and loyal staff and equipment also available. Financial information and further detail furnished promptly to interested parties. Contact Richard W. Burke, Attorney, 3220 Prudential Plaza, Chicago, Illinois 60601, (312) 944-2400.
MEDICAL DIRECTOR for permanent, fulltime position with a neigh- borhood health center at the University of Illinois Hospital and Medi- cal School. Academic appointment, excellent salary and fringe bene- fits. Opportunity for innovative medical care research in systems and manpower. Student and community education programs. Work with inner city population adjacent to the Medical Center complex. ILLI- NOIS LICENSE REQUIRED. Available now. Salary, rank open. Con- tact Edward A. Lichter, M.D., Prof. & Head, Dept. Prev. Med. & Commu. Hlth., P.O. Box 6998, Chicago, III. 60680. Phone, 312-996- 7630. The University of Illinois is an Affirmative Action-Equal Op- portunity Employer and encourages applications from members of minority groups and women.
Full Time Physician for Outpatient Department of Prepaid Health Plan. Five day 40-hr. week. No on call. Located in Central Illinois. New modern facility. Salary open. Tax shelter available. Contact administrator, Wabash Memorial Hospital Assn., 360 E. Grand, Decatur, III. 62525. Telephone: (217) 429-5246.
GENERALIST for full time position in university health service; 40-hr. week, no on-call responsibilities; excellent community of 75,000, three local hospitals. Salary negotiable with liberal fringe benefits including 30-day vacation and retirement plan. Illinois license. Write or call: Margaret M. Torrey, M.D., Illinois State University, Normal, Illinois 61761. Phone (309) 438-8655.
WHY FIGHT PSRO's, HMO's, AND ILLINOIS PUBLIC AID? Join us- minimal records, short hours, 5 weeks vacation, and 1 week medical meetings. Illinois University Retirement System, Health Insurance, and Life Insurance. Beginning salary $25,000 and negotiable. Call or contact Director, Health Service, EIU, Charleston, Illinois. Phone 217-581-3013.
INTERNIST; PRIMARY CARE PHYSICIAN; GYNECOLOGIST. Internist
to serve as Director of Clinical Medicine; must have residency. Gynecologist must have residency or be a practitioner with ex- tensive experience in office gynecology and family planning ser- vices. All three must be interested in college students, new health care delivery systems, preventive medicine, health educa- tion, as well as clinic work. Salary dependent on qualifications; Illinois license required. Good fringe benefits, good geographical location. Health service has excellent modern facilities, well- developed x-ray and laboratory departments, etc. Equal Opportunity Employer. L. W. Akers, M.D., Director, University Health Service, Northern Illinois University, DeKalb, Illinois 60115.
66
Illinois Medical Journal
BLUE SHIELD
D
Ll\
FOR
New Blue Shield Payment Vouchers Ready August 30 for FEP Members
The inaugural phase of the new payment system utilizing the 2-part Blue Shield Payment Voucher will begin on August 30 for members of the Fed- eral Employees Program.
As the system is further implemented, it will phase-out the traditional method of Blue Shield payments to physicians with multiple checks for individual types of services, and substitute the 8/2" x 11" computerized payment voucher that com- bines the physician’s check with patient records by date of payment. Each of five sections of the voucher form — patient records and check — are per- forated for detaching from the form.
Checks will cover up to four patients and include as many as five services per patient. In each patient record portion, data blocks include the patient’s name, age, patient number, group number and
member ID number, case number and total amount paid for services in the upper part; and check number, payment date, type of service, service date, place of treatment, amount billed to Blue Shield, portion not covered by Blue Shield, payment amount and payment type in the lower portion of each statement.
The amount of the check to the physician is the total amount paid for each patient’s covered ser- vices. When payment is made to the physician, a copy of the patient’s statement portion of the voucher is sent to the subscriber as an explanation of benefits paid.
Place of treatment, type of service and payment type are coded by numbers and explanations are given on the reverse side of the voucher.
Payments under the new system will be made weekly by Blue Shield rather than daily and sub- stantial savings are anticipated through the reduc- tion in number of checks issued, with less handling and postage.
Fall Workshops for Medical Assistants
The first meeting in the fall series of workshops for medical assistants scheduled by the Blue Shield Plan of Illinois Medical Service will be held September 4 at Pheasant Run Inn, St. Charles. Workshops for medical assistants in Will-Grundy counties, Lake and DuPage will follow in Septem- ber and meetings for those in Cook County will be held at Plan headquarters during the month of October.
Invitational letters have been sent to physicians’ offices in counties outside of Cook to the attention of the medical assistant. Letters to medical assistants in Cook County are scheduled to be mailed Sep- tember 1.
All workshops in the fall schedule will be day- time meetings of morning and afternoon sessions. For those unable to attend morning meetings, the program is repeated in the afternoon. Morning workshops will be held from 9:00 AM to 11:30 AM, with registration beginning at 8:30 AM. After- noon programs begin at 1:30 PM, following 1:00 PM registration, and end at 4:00 PM. Compli- mentary luncheons will not be served during the fall programs but coffee “breaks” will be held during the morning and afternoon meetings.
Workshop programs will be conducted by mem-
bers of the staff of the Professional Relations De- partment and include discussions on the two-part Blue Shield payment voucher on notification of membership benefits paid; changes in benefits in Blue Shield contracts; claim filing procedures; the Blue Shield Reciprocity Program and State of Illinois Group Insurance Program. To provide as much discussion time as possible, participating medical assistants will be assigned to groups of approximately 25, with a member of the Profes- sional Relations staff serving as instructor. Special attention will be given to the newly-employed assistant.
Workshops for medical assistants in Cook County will be conducted in the auditorium of the Blue Cross and Blue Shield headquarters building at 233 North Michigan Avenue, Chicago. The sched- ule includes workshops every Wednesday and Thursday, beginning October 2 and ending October 31, except Wednesday, October 16. Morning and afternoon workshop hours and registration times are the same as for the meetings outside Cook County:
September Schedule Blue Shield Workshops
Wednesday, Sept. 4 Pheasant Run Inn St. Charles
Wednesday, Sept. 11 Holiday Inn South Joliet
Wednesday, Sept. 18 Sheraton-Waukegan Waukegan
Wednesday, Sept. 25 ' Ramada Inn Hinsdale
(This report is a service to the physicians of Illinois)
ASK BLUE SHIELD . . . ABOUT MEDICARE
Optional Payment Method for Patients on Maintenance Dialysis; Training Payment for Self-Dialysis Patients
Summary of New Instructions — Part I
Instructions issued recently by the Department of Health, Education and Welfare to Part B Medi- care carriers advised that physicians may elect to receive payment from Medicare on a direct monthlij charge basis as an alternative payment method for services to patients on maintenance dialysis.
Another new provision of the program allows physicians conducting patient training in self- dialysis to be reimbursed on a fat fee basis of $500 (begun on and after July 1, 1974), per patient (subject to the Part B deductible and coinsurance) upon completion of the training course. If the course is not completed, payment will be made proportionate to the amount of time spent in train- ing the patient.
Services include assessment of the patient’s home environment; direction of and participation in the training process; counseling and training of family members; and the review of training progress.
Determination of Monthly Payments
If a physician elects the monthly payment meth- od of furnishing services to patients on mainte- nance dialysis, or for home dialysis, he bills Medi- care monthly on the regular SSA-1490 Request for Medicare Payment form and receives his payment charge based on the following determinations and conversion factors:
The monthly payment total is based on the cal- culated average prevailing charge for internists’ follow-up office visits in areas served by the carrier, based on 1973 charge data, multiplied by the con- version factor of 20 for maintenance dialysis pa- tients and 14 for those on home dialysis.
Elements of Monthly Method
(1) Payment may be made to either the physi- cian who accepts assignment or the beneficiary when assignment is not accepted. In either case payment is subject to the usual Part B deductible and coinsurance.
(2) Physicians may elect the new method or continue to be reimbursed under the current method.
(3) A physician may change the method of re- imbursement by giving the carrier written notifica- tion 60 days prior to termination of the agreement.
(4) When a physician elects the monthly method he also accepts certain other conditions contained in the coverage and billing procedure.
(5) The physician who elects the alternate method ( or the beneficiary in non-assignment cases) will be reimbursed on a basis that reflects variations in charges, since the conversion factor
represents a frequency of services provided to maintenance dialysis patients and also includes specialized type of care provided when necessary by nephrologists. Charge screens for services are also reviewed and adjusted annually by the carrier and new methods of therapy evaluated as the pro- gram acquires experience.
(6) As a requirement of treatment in a facility, when a physician elects the monthly reimburse- ment method for furnishing dialysis services all physicians in the facility attending renal disease patients must agree to the payment method. A copy of the agreement must also be on file at the facility and with the carrier.
Services Covered
( 1 ) Services during maintenance dialysis for stabilized patients are covered, whether supervisory or direct, in uncomplicated or complicated dialysis sessions. Examples would be a routine predialysis examination or attendance during a dialysis treat- ment when a patient had a serious ailment such as pulmonary edema.
(2) Office visits are covered for routine evalua- tion of patient progress or for treatment of renal disease complications; also evaluation of diagnostic tests and procedures.
(3) Services rendered by the attending physi- cian in the course of an office visit are covered. The primary purpose is routine monitoring or follow-up of complications of dialysis including prescribing therapy for illnesses unrelated to renal disease, but not exceeding the normal number of physician-patient contacts anticipated during the course of dialysis sessions or visits for treatment of renal complications.
Summary Continued in Sept. Issue
The new instructions on renal dialysis treat- ment and payment options issued to Part A intermediaries and Part B Medicare carriers are published at the request of the Department of Health, Education and Welfare. The summary of instructions in the August and September issues of Illinois Medical Journal is intended as information on the program to the general medical community. Specific details may be obtained from the appropriate service area in- termediaries and carriers. (Blue Shield for Part B in Cook County).
Part II to be published in September issue of “Ask Blue Shield About Medicare”, will conclude the summary with instructions on Dialysis Maintenance Services Not Covered; Conditions for Electing the Optional Method of Payment and the Monthly Payment Option to Patients on Self-Dialysis at Home or in a Facility.
(This report is a service to the physicians of Illinois)
Illinois Medical Journal
AUGUST, 1974 Vol. 146, No. 2 CONTENTS
Special Articles
91 The Heroin Problem: Some Strategic Aspects
Edward C. Senay, M.D. and Richard J. Weinberg , B.A.
96 Alcoholism— A General Hospital Meets the Challange
James West, M.D.
124
125
Personnel Development For the Illinois Emergency Medical Services System R. R. Hannas, M.D.
Illinois Emergency Medical Service System Status Report III (July, 1974) Winifred A. Pizzano, B.A., Teresa L. Romano, B.S.N.,
John C. Nance, HMC, USN(FLT RES) and David R. Boyd, M.D.C.M.
Clinical Articles
101 Sensitivity Tests on Individual Human Cancers to Pick
Active Drug Therapy
Frances E. Knock, Ph.D., M.D., Raymond M. Galt, M.D.,
Y. T. Oester, M.D. and Robert Sylvester, B.S.
105 Deafness and Acupuncture
Max Sadove, M.D., Koji Okazaki, O.M.D., Sang Ik Kim, M.D., Man H. Lee, O.M.D., Tak Ho Liu, M.D., O.M.D.
Ill Pediatric Perplexities: Meandering Catheter
Vivian J. Harris, M.D.
President’s Page
78 Consider the Alternative
Fredric D. Lake, M.D.
(Contents continued overleaf)
for August, 1974
73
CONTENTS (continued)
Features
100 New Pharmaceutical Specialties
117 Practice Management
121 Doctor’s News
130 Editorials
133 EKG of the Month
134 ISMS Guide to Continuing Medical Education
137 View Box
137 Clinics for Crippled Children
138 Pulse of the Doctor’s Wife
140 Housestaff News
141 Physician Recruitment Program
143 Obituaries
Staff
Editor Theodore R. Van Dellen, M.D.
Managing editor Richard A. Ott
Assistant editor Joyce Gallagher
Executive administrator Roger N. White
(Cover by Mike Abeam)
PUBLICATIONS COMMITTEE
Jacob E. Reisch, M.D., Springfield, Chairman Eugene T. Hoban, M.D., Oak Park A. Edward Livingston, M.D., Bloomington James A. McDonald, M.D., Geneva Warren W. Young, M.D., Crete
Contributor in Surgery: John M. Beal, M.D., Chicago Contributor in Medical Progress: Harvey Kravitz, M.D., Skokie Contributor in Maternal Death Studies:
Robert Hartman, M.D., Jacksonville Contributor in Pediatric Perplexities: Ruth A. Seeler, M.D., Chicago Contributor in Radiology: Leon Love, M.D., Maywood Contributor in Cardiology: John R. Tobin, M.D., Maywood
ILLINOIS STATE MEDICAL SOCIETY
360 N. Michigan Ave., Chicago, 60601
OFFICERS
Fredric D. Lake, M.D., President 1041 Michigan Ave., Evanston 60202 J. M. Ingalls, M.D., President-Elect 502 Shaw, Paris 61944 Harold A. Sofield, M.D., 1st Vice-President 715 Lake Street, Oak Park 60301 Robert Hartman, M.D., 2nd Vice-President 1515A W. Walnut Street, Jacksonville 62650 Jacob E. Reisch, M.D., Secretary-Treasurer 1129 S. 2nd St., Springfield 62704
HOUSE OF DELEGATES
Andrew J. Brislen, M.D., Speaker of the House 6060 S. Drexel Blvd., Chicago 60637 James A. McDonald, M.D., Vice-Speaker 13 S. 2nd St., Geneva 60134
TRUSTEES
1st District: 1977, Joseph L. Bordenave, M.D.
1665 South Street, Geneva 60134 2nd District: 1977, Allan L. Goslin, M.D. 712 N. Bloomington, Streator 61364 3rd District: 1976, David S. Fox, M.D. 20829 Greenwood Center Ct., Olympia Fields 60461 3rd District: 1976, Robert T. Fox, M.D. 2136 Robin Crest, Glenview 60025 3rd District: 1975, Eugene T. Hoban, M.D.
6429 North Ave., Oak Park 60302 3rd District: 1975, Joseph Skom, M.D. 707 Fairbanks Ct., Chicago 60611 3rd District: 1977, William M. Lees, M.D. 6518 North Nokomis, Lincolnwood 60646 3rd District: 1977, George Shropshear, M.D.
1525 E. 53rd St., Chicago 60615 3rd District: 1977, Philip G. Thomsen, M.D.
13826 Lincoln Ave., Dolton 60419 3rd District: 1976, Frederick E. Weiss, M.D.
15643 Lincoln, Harvey 60426 3rd District: 1975, Warren Young, M.D.
3450 Haweswood Dr., Crete 60417 4th District: 1976, Fred Z. White, M.D. 723 N. 2nd St., Chillicothe 61523 5th District: 1976, A. Edward Livingston, M.D.
326 Fairway Dr., Bloomington 61701 6th District: 1975, Mather Pfeiffenberger, M.D.
State and Wall Sts., Alton 62002 7th District: 1976, Arthur F. Goodyear, M.D.
142 E. Prairie, Decatur 62523 8tli District: 1976, Eugene P. Johnson, M.D.
P.O. Box 68, Casey 62420 9th District: 1975, Warren D. Tuttle, M.D.
203 N. Vine St., Harrisburg 62946 10th District: 1975, Herbert Dexheimer, M.D.
301 S. Illinois, Belleville 62220 11th District: 1977, Ross Hutchison, M.D. 126 E. Ninth St., Gibson City 60936 Trustee-At-Large: Willard C. Scrivner, M.D.
6600 West Main, Belleville 62223 Chairman of the Board: Joseph L. Bordenave, M.D.
1665 South Street, Geneva 60134
Microfilm copies of current as well as some back issues of the Illinois Medical Jour- nal may be purchased from Xerox University Microfilm, 300 North Zeeb Road, Ann Arbor, Mich. 48106.
Contents of 1MJ are listed in the Current Contents/ Clinical Practice.
Published by the Illinois State Medical Society, 360 N. Michigan Ave., Chicago, 111. 60601 (312-782-1654) Copyright, 1974. The Illinois State Medical Society.
Subscription $8.00 per year, in advance, postage prepaid, for the United States, Cuba, Puerto Rico, Philippine Islands and Mexico. $10.00 per year for all foreign countries included in the Universal Postal Union. Canada $8.50. U.S. Single current copies available at $1.00 ($1.10 by mail), back issues $1.50.
Second class postage paid at Chicago, 111. When moving please notify Journal office of new address including old mailing label with notification, if possible. POSTMASTER: Send notice on form No. 3579 to Illinois State Medical Society, 360 N. Michigan Ave., Chicago, 111. 60601.
Pharmaceutical advertising must be approved by the ISMS Publications Committee. Other advertising accepted after review by Publications Committee or Board of Trustees. All copy or plates must reach the Journal office by the fifteenth of the month preceding publication. Rates furnished upon request.
Original articles will be considered for publication with the understanding that they are contributed only to the Illinois Medical Journal. The ISMS denies responsibility for opinions and statements expressed by authors or in excerpts, other than editorial or allied views or statements which reflect the authoritative action of the ISMS or of reports on official actions, policies or positions. Views expressed by authors do not necessarily represent those of the Society; any connection with official policies is coincidental.
cannibal stomach
*Fordtran, J. S., and Collyns, J. A. H.: Antacid Pharmacology in Duodenal Ulcer: Effect of Antacids on Postcibal Gastric Acidity and Peptic Activity, New England J. Med. 274:921-927 (April 28) 1966.
add Pro-Banthlne
Helps to relieve pain without risk of patient drug dependency.
add Pro-Banthine
Reduces gastric secretory volume and total resting and free acid without the caloric, digestive, and social problems occasioned by eating.
Pro-Banthlne
slows intestinal motility to enhance and prolong the action of antacids. The action of Pro-Banthlne lasts 4 to 6 hours.
Searle & Co.
San Juan, Puerto Rico 00936
Address medical inquiries to: G. D. Searle & Co. Medical Department, Box 5110, Chicago, III. 60680
SEARLE
usually get better patient response.
occur as well as mydriasis and blurred vision. In addition the following adverse reactions have been reported: nervousness, drowsiness, dizziness, insomnia, headache, loss of the sense of taste, nausea, vomiting, constipa- tion, impotence and allergic dermatitis.
Dosage and Administration: The recommended daily dosage for adult oral therapy is one 15-mg. tablet with meals and two at bedtime. Subse- quent adjustment to the patient’s requirements and tolerance must be made.
Pro-Banthine P.A. — Each tablet of Pro-Banthine PA. (propantheline bromide) contains 30 mg. of the drug in the form of sustained-release or
timed-release beads: on ingestion about half of the drug is released within an hour and the remainder continuously as earlier increments are metab- olized. Thus the result is even, high-level anticholinergic activity main- tained all day and all night in most patients with only two tablets daily. Some patients may require one tablet every eight hours.
The contraindications and precautions applicable to Pro-Banthine 15 mg. should be observed.
How Supplied: Pro-Banthlne is supplied as tablets of 15 and 7.5 mg., as prolonged-acting tablets of 30 mg. and, for parenteral use, as serum- type vials of 30 mg.
389
President’s Page
Consider The Alternative
IIIMllil
Despite what you read in opinion polls, doctor, not everyone loves you.
This observation reflects the gravest problem facing medicine to- day: Poor public relations.
By public relations I am not referring to the relations engineered or contrived on Madison Avenue, but to the day-to-day relationship between you, your patients and your community.
While public opinion polls indicate your patients may still worship the ground upon which you walk, many of those patients bear con- siderable antagonism toward your colleagues and toward the pro- fession at large. And, your colleagues’ patients hold similar views of you and the rest of the medical fraternity.
Moreover, your patients’ rosy view of you is not monochromatic. While you may be respected as an astute clinician, a great diag- nostician or a skilled surgeon, the image is often blurred by tinges of indifference, callousness, arrogance and greed.
Realistically, we must accept the fact that the kindly physician of yore — confidante and advisor as well as healer, always available to aid and comfort — has necessarily faded into oblivion in the wake of a scientific explosion in medicine and the parallel development of specialization. However, we cannot justify the shortcomings with which we are identified. The major complaints lodged against us are that we are not available when needed, keep our patients wait- ing, tolerate inefficient and inhospitable aides, are indifferent, over- charge, fail to communicate, and keep aloof from community involve- ment.
The freguency and volume of these charges attest to the deplor- able state of our public relations — the root problem confronting our profession. A barrage of press releases and angry denials will not solve it. If it is to be resolved, each physician must recognize the validity of the public’s complaints, examine his methods and atti- tudes, and