Frank McDougall: American Hospital Association’s 2009 “Grassroots Champion”Page 7

The Lebed Program: Breast Cancer survivors dance and prance their way to healthPage 3

SPecial FeatureGuest Author, P.J. O’Rourke, shares his experience with cancer, health care and les-sons learned. Page 4

Despite suffering a stroke at birth that left him with permanent weakness on the left side of his body, peripheral vision loss, and febrile (fever-induced) seizures during the first few years of his life—there was no denying that David Martin was a very bright child.

“David always wanted to join in whenever we’d sit down to do homework with his two sis-ters,” recalls David’s mom, Ann. “He would read with them, and he loved answering math ques-tions. I never worried about him getting picked on at school because he was so funny and witty, the kind of kid who would be the class clown.”

Losing ControlBut as David approached 2nd grade, that all began to change. “The seizures started happen-ing more frequently, and the medication he had been taking became less effective,” explains Ann.

“There was a point where we literally had to carry him from place to place or hold on to the back of his shirt when he was walking because he was having ‘drop seizures,’ where his whole body would just go limp and he’d collapse,” she adds.

“All of those seizures were taxing on his body,” remembers Ann’s sister, Donna. “Here was a big, strapping kid who weighed 74 pounds in 2nd grade, who over time lost all interest in eating and eventually went down to 52 pounds. It was heart-wrenching to watch him deteriorate like that, and to see how emotionally trying it was on Ann, her husband, and the kids.”

Trial and ErrorBut then Donna heard about Richard Morse, MD, and the pediatric epilepsy program at Chil-dren’s Hospital at Dartmouth (CHaD), consid-

ered one of the top programs in the country. “As soon as we got in to see Dr. Morse, he

did an EEG and admitted David because he was in status,” says Ann. “From the beginning, we were very impressed with Dr. Morse, his nurse Deb, and the whole team at CHaD, not just because of their expertise but also because they were so caring.”

“The EEG led to a number of follow-up

studies—including advanced imaging, monitor-ing and localizing techniques—which helped us to determine that David had a severe form of epilepsy that was the result of a brain mal-formation (on one side of his brain) rather than the cerebral palsy diagnosis that he had received as a baby,” says Dr. Morse, who serves as Sec-tion Chief of Pediatric Neurology at CHaD. “We suspected early on that the best option of treatment might be surgery,

GettingDavidBack

When Every Minute Counts…

(Continued on pg. 2)

While sobering, it was the kind of feedback that Nathaniel Niles, MD, and his colleagues knew they needed to hear. About two years ago Dr. Niles, an inter-ventional cardiologist at Dart-mouth-Hitchcock Medical Center (DHMC), had begun present-ing the idea of setting up a rapid transfer process that would allow STEMI (ST Elevation Myocardial Infarction) patients to bypass the local emergency departments (EDs) and be transported directly to DHMC’s Catheterization Labora-tory.

“STEMIs represent the classic form of heart attack where a coro-nary artery has completely clotted off. A STEMI patient is best treated with an intervention such as angio-

plasty to open up the vessel as soon as possible,” explains Niles. “In the past, STEMI patients would typi-cally receive thrombolytics (clot busters) as their primary treatment, but these drugs can fail and they carry some significant risks. Most rescue squads now have 12-lead EKG capacity which allows them to make the STEMI diagnosis in the field, notify us, and administer pre-hospital care. If the transport can be made rapidly enough, we can achieve a better outcome by avoid-ing thrombolytics and bringing the patient directly to the Cath Lab to open the artery.”

But when Niles talked with Rick Marasa, MD, who runs the ED at Springfield Hospital and provides medical control for the rescue

squads in his area, Niles initially felt some resistance. “Dr. Marasa said that he’d be happy to consider doing it, but wasn’t sure that we could pro-vide a fast enough ‘door-to-balloon’ (D2B) at our end—which measures the time between when the patient arrives at DHMC’s door and when we actually open the artery,” says Niles. “The ‘gold’ standard is 90 minutes or less. At the time, we weren’t consistently achieving that. I told him we’d work on it and get back to him.”

Evidence-Based ApproachNiles had created a patient regis-try in 2001 for collecting detailed data on STEMI cases coming into DHMC. This now became an essential tool (Continued on pg. 2)

Now that he is seizure-free, David Martin can once again enjoy activities like reading and playing outside with his friends.

DHMC interventional cardiologist Nathanial Niles, II, MD, is leading a regional effort that’s helping to save lives and improve the care of heart attack patients.

Volume Eight, Number Three Summer 2009

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“too often, people try to ignore their symptoms...precious time is wasted and they’re not receiving that first stage of treatment that could actually help start their healing.”

Sheila Conley, RN

Thanks to a collaborative and highly-specialized treatment approach led by Richard Morse, MD (above center), Section Chief of Pediatric Neurology at CHaD, David Martin has been seizure-free for two years and medication-free for the last year. Left, David plays soccer with his sister, Sarah. Right, David gets a hug from his mom, Ann.

STEMI (from page 1)

DAVID (from page 1)

but we wanted to see if we could first get his seizures under control through medication.”

For more than a year, Morse tried different combinations, working up to five medications at once. “We finally got it where you couldn’t physically see them happening to him, but they were still going on inside his brain,” recalls Ann. “And he hated taking the medi-cations. He was like a zombie—he had no recall, so he was unable to really learn in school.”

Weighing the RisksEven before the medications proved ineffective, Morse began discussing David’s case with his colleagues in the epilepsy program and sought input from pediatric neurosurgeon Ann-

Christine Duhaime, MD. “At CHaD, we have an unusually

fruitful and collaborative relationship between the specialties,” says Duhaime, Program Director for Pediatric Neu-rosurgery at CHaD. “One of the nice things about our program is that Dr. Morse’s interests and my interests are very well-aligned. In cases like David’s, we make the decision to start talking about surgery early on. That allows us to carefully weigh all of the potential benefits and risks and present them to the family, who are really the most important part of the equation.”

But initially, Ann was resistant to the idea. “My first thought was, ‘No; I’d rather have him with me and deal with the seizures than face the pos-sibility of death,’” she says. “But both

Donna and Dr. Morse kept remind-ing me that we needed to think about David’s quality of life, too. As he approached puberty, there was also the risk that his seizures would get worse and spread to the ‘good’ side of his brain. I finally agreed to it because of the confidence that I had in Dr. Morse and Dr. Duhaime. I knew they had David’s best interest at heart.”

Restoring HopeIn May of 2007, David underwent a hemispherectomy procedure. “It involves using computerized image guidance to disconnect, rather than remove, most of the damaged or mal-formed hemisphere (where the seizures come from) so that the abnormal sig-nals can’t spread to the ‘good’ side of the

brain or body,” explains Duhaime, one of the few pediatric neurosurgeons in the country to do this type of surgery.

“It’s been a fantastic result,” says Morse. “David has been seizure-free since the operation, he’s maintained the strength and motor skills he had pre-operatively on his weak side, and he recently celebrated one year of being off all of his medications.”

To his family’s delight, not only has David’s spark returned, he’s mak-ing great strides in school. “He just mastered his multiplication tables up to 12, which he’s very proud about,” says Ann. “We’ve got our David back. I can’t say enough about Dr. Morse, Dr. Duhaime, and the team at CHaD. Thanks to them—he has a chance, he has a life, and he has a future.”

for process improvement in attaining two main objec-tives: to reduce door-to-balloon times to less than 90 minutes in 75 percent of STEMI cases, and to design a pre-hospital triage system for providing timely angio-plasty to STEMI patients in DHMC’s referring area.

To help them achieve these goals, Niles and his colleagues obtained support from DHMC senior management and formed a multidisciplinary group—with representatives from Cardiology, Emergency Medicine, EMS, Communications, CCU, Cardiac Cath Lab, DHMC administration and Quality Management—that was expanded to include local rescue squads and referring hospital ED representatives.

“We brought together the right people to make pretty substantial changes in our process of care, and they’ve done a fantastic job,” says Niles. “We want to acknowledge the organizational support of Evelyn Schlosser, RN, from the New England Alliance of Hos-pitals and Tammy Anderson, RN, from the Cath Lab.”

“One of the most important things we did was to join the American Heart Association’s D2B Alli-ance and adopt a number of their proven strategies for reducing D2B time,” says Sheila Conley, RN, a Quality Improvement Associate in the Department of Cardiology, who serves as project coordinator. “These included streamlining the activations to the Cath Lab, mobilizing the Cath Lab team in 30 minutes, provid-ing prompt data feedback, and allowing Emergency Medical Services (EMS) squads to activate the Cath Lab directly. Essentially, better teamwork.”

“One huge benefit out of the STEMI project is the immediate feedback that we receive on each case that tells us how well we did against a set of criteria that we use to measure our performance,” says Mike Hinsley, a paramedic who leads the EMS squad in Hanover. “This helps us with our quality assurance and improvement, our training, and it also reiterates the fact that the pre-hospital care provider is very much a part of the team with Dartmouth-Hitchcock.”

Framework for SuccessThese collective efforts have led to some impressive results. “Over the past year, we’ve been able to reduce our door-to-balloon time to 90 minutes or less in 77 percent of our cases,” says Niles. “Our median door-to-balloon time has dropped from 126 minutes to about 65 minutes—the national average D2B time is 118 minutes. Moreover, our transfer protocols have enabled us to offer this approach to significantly more patients who would have been taken to local EDs and received thrombolytics in the past. Our mortality rate with this approach has consistently been about 40 percent lower than predicted with standard thrombolytic treatment. We hope it will be lower still with shorter D2B times.”

“I’ve been a medical director now for over 20 years, and I know how hard it is to implement these

kinds of changes,” says Dr. Marasa. “The job that Nat Niles and everyone at Dart-mouth have done is remarkable—they’ve made real believers out of us. We’ve already had several patients from our hospital that have met the criteria for get-ting to the Cath Lab immediately and it’s worked out extremely well. I should also add that, even for the patients that don’t meet this criteria, the support we get from Cardiology at Dartmouth is fabulous.”

“What I’m most enthusiastic about is that, together, we’ve been able to create a regional net-work—comprising 20 hospitals and 40 EMS agen-cies—that provides a very high level of care for this condition,” says Niles. “And we’ve built a framework for continued improvement in the future.”

Bringing the ER to You

You’ve probably heard of the classic symp-toms of a heart attack. They include intense chest pressure or pain that often radiates to the jaw or left arm, and is frequently accom-panied by nausea and profuse sweating.

What should you do if you’re experiencing symptoms like these? “Call 911 and chew an aspirin,” says Sheila Conley, RN, a nurse in DHMC’s Department of Cardiology. “Too often, people try to ignore their symptoms, and then they ask a family member or friend to drive them to the hospital. Meanwhile, precious time is wasted and they’re not receiving that first stage of treatment that could actually help start their healing.”

“By calling EMS, you’re effectively bringing the ER to you,” explains Nathaniel Niles, II, MD, an interventional cardiologist at DHMC.

“Most rescue squads now have 12-lead EKG capac-ity, which allows them to make the diagnosis in the field and administer pre-hospital care. The data is show-ing that people who follow this path of treatment have the shortest times to medical inter-ventions such as angioplasty, which can lead to a better outcome.”

www.dhmc.org Skylight 2

it’s a sunny WeDnesDay afternoon in April, the kind of day that holds promise and tends to put Northern New Englanders in a good mood. But inside Dartmouth-Hitchcock Medical Center’s (DHMC) Rehabilitation Medicine gym, another kind of celebration is underway.

A spirited group of 10 women ranging in age from their 40s to 80s—who share the common bond of being breast cancer survivors—have been partici-pating in their weekly Lebed class, exercising to songs like, “Honey, Honey” from the movie soundtrack of Mama Mia. As the session winds down, they hold hands in a circle and recite a mantra that includes the words above. A moment later they begin to cheer and take turns giving hugs to Lois Winkler.

Tending to Minds and Spirits“I just finished my radiation treatments,” explains Winkler, smiling. “This class has been great, both in terms of the encouragement you receive and also just the benefits of moving your body. When you’re going through treatments, you don’t feel that great physically. This makes you feel better.”

Pam Gile, who introduced Winkler to the class last fall while they were both going through chemo,

agrees. “It gives you something to look forward to,” she says. “It’s a very supportive group and that has really helped, especially in this first year of having been diagnosed, to see that there’s a long-term future.”

For founding member Ruth Cioffredi, the class also provides a sense of empowerment. “When you’re diagnosed with breast cancer and you’re going through treatment, it’s easy to feel like you have no control,” says Cioffredi. “This is some-thing that we can do for ourselves that contributes to our medical care and our sense of well-being.”

Thriving After Breast CancerDeveloped a number of years ago by Sherry Lebed to help her mom recover from breast cancer, the Lebed Method is now recognized nationally as an effective therapeutic exercise and movement-to-music program that helps reduce the common side effects of treatment and surgery for breast cancer.

“Women who’ve had mastectomies or lumpec-tomies with lymph node resections and/or axil-lary radiation treatments are at a higher risk for lymphedema (chronic swelling of the hand, arm or chest), which can lead to an infection,” explains Terry Cioffredi (Ruth’s sister-in-law), a physical

therapist at DHMC who is certified to teach the Lebed Method and is also a certified lymphedema therapist. “Studies are showing that regular exercise not only helps women better tolerate their treat-ments, it can improve their mortality.”

“We do a variety of things in the class that help women to regain and maintain range of motion, address balance issues, decrease pain, and increase energy,” says Jasmin Bihler, a physical therapist at DHMC who carries the same certifications as Ciof-fredi. “We try to make it a very relaxed and fun atmosphere—it’s something that any woman can do and do at her own pace. We’d like people to know that it’s available and that they’re welcome to bring a friend or family member along, if they’d like.”

Thanks to the generosity of Rehabilitation Medicine, which pays for Cioffredi and Bihler’s time and provides the space, the Lebed class is currently being offered free, as a pilot study, each Wednesday at 11:30 to 12:30 (except during the summer months). “We’d love to find long-term funding for the class,” says Ruth Cioffredi. “It’s making such a difference in our lives.”

For more information, please contact Terry Ciof-fredi or Jasmin Bihler at 650-5978.

Celebrating life“May I be safe and free from danger; may I be healthy and free from pain; may I be happy; and may I live with ease…”

After Breast Cancer

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P.J. O’Rourke is back enjoying his life as writer, journalist, and America’s leading political satirist due, in part, to the expertise and care of Drs. Marc Pipas and Bassem Zaki, and DHMC staff.

The SicknessUnto Health

I wasn’t able to play the role to its full tragical effect anyway. Fortunately, the kind of cancer I had was highly treatable. Unfortunately, it was highly ridicu-lous. It’s not every time you get diagnosed with cancer and it makes you laugh. I’d had a hemorrhoid opera-tion. Two days later the colorectal surgeon called. “I’m sorry to tell you,” he said, “your hemorrhoid was malignant.”

“Malignant hemorrhoid?” I said. “There’s no such thing as a malignant hemorrhoid.”

“In almost every case you’d be right,” the surgeon said, and paused in a moment of sympathetic hesita-tion and of unintentional comic timing. “But ...”

I wanted to argue. “Malignant hemorrhoid” is Rush Limbaugh radio talk. “Malignant hemorrhoids” is a Dave Barry rock band. I wanted to argue, but I had to get treated.

Going from the metaphysical to the all-too-physi-cal makes for gratitude to God. You have immediate access to the top specialist in the field when you pray. (Do polytheists have difficulties with this?) At least I had the good fortune to live part-time in Washington, D.C.—a city full of flaccid old guys like myself who spend their time blowing smoke out of you-know-where and being full of you-know-what and sitting on their duffs. Consequently, the town is full of medical expertise about the body part in question.

It turns out what I had was skin cancer, squamous cell carcinoma. Practically every melanin-deficient (let alone Irish) person who spends time in the sun gets

this if he or she lives long enough. “I call it ‘adult acne’ when it turns up on the face or arms,” the oncologist said. But why it occasionally turns up where it turned up on me is something of a medical mystery. I mean, I was naked a lot in the 1960s but not that naked.

There’s a considerable loss of dignity involved in trading the awe-inspiring fear of death for the perspi-ration-inducing fear of treatment. There are hells on earth. Until a generation ago the cure for anal cancer was a colostomy. Doctors have gotten over that. Most of the time. Now, with God’s grace, the cure is radia-tion and chemotherapy.

Would I have to go to some purgatorial place for this? To Sloan-Kettering in New York, a city I detest? Or out to the Mayo Clinic, although I have a phobia about hospitals named after sandwich toppings? “No,” the oncologist said. “The treatment protocol is stan-dardized and is successfully used everywhere.”

I named my local New Hampshire hospital (which doubles as a large animal veterinary clinic).

“Almost everywhere,” the oncologist said.I asked about the Dartmouth-Hitchcock Medical

Center, seventy miles from home but still on the planet New Hampshire. Dr. Marc Pipas at Dartmouth-Hitch-cock’s Norris Cotton Cancer Center came strongly recommended. Dr. Pipas is an avid bird hunter and an advocate of reintroducing the prairie chicken to the Eastern seaboard. So he and I had something to talk about in addition to my behind. I’d need radiation therapy every day for six weeks. (Every day, that is, Monday through Friday—the Radiology Department has to play golf, too.) And I would undergo two four-day stints of around-the-clock chemotherapy, carrying a fanny pack of poisonous chemicals to be pumped into my body through a surgically implanted medi-port. (Dr. Pipas convinced the Infusions Department to install this on the left side of my chest so that it wouldn’t interfere with mounting a gun.)

In theory I could get my radiation treatments elsewhere, within easy commuting distance. But it’s worthwhile to find out what a doctor himself would do if he had your medical problem. And he probably thinks he does. Several doctor friends have told me you can’t get through medical school without being convinced that you have every disease in the textbooks including elephantitis, beriberi, and Guinea worm infestation. Dr. Pipas immediately said that, for anal cancer, he’d go to radiologist Dr. Bassem Zaki.

Dr. Zaki is a Coptic Christian who immigrated from Egypt in his late teens. He and I talked about

Middle Eastern politics, which, as far as I’m con-cerned, is the second most interesting blood sport after upland-game shooting.

Dartmouth-Hitchcock Medical Center is a spar-kling edifice, full of light and air and surprisingly good art for a non-profit institution. The architectural style is higgledy-piggledy 1980s modern—2 million square feet, every one of which is between you and where you have an appointment. Finding your way around is a trial run for Alzheimer’s but a small price to pay for the pleasant surroundings. Even the food in the cafeteria is good. Various scientific studies have shown that patients recover better and faster in cheerful envi-ronments. Duh.

The staff at DHMC is also cheerful, but not too cheerful. They don’t make you feel like a small child at the receiving end of an over-ambitious pre-school cur-riculum. Perhaps they know better because DHMC is a teaching hospital. The Dartmouth Medical School is the fourth-oldest in the nation, founded in 1797. DHMC is venerable as well as modern. But not too venerable. They don’t use leeches.

Being at a teaching hospital puts a patient in a com-fortable equilibrium with the institution. People are expecting to learn something from you, not just do something to you. But let’s not push the idea of equal-ity too far. There’s a current notion that you should

by p.J. o’rourkeA malignant hemorrhoid has a lot to teach about cancer, U.S. health care, and the

need to slow down.

Last year I wrote an essay about being told I had cancer and the deep metaphysical questions this raised, such as, “Is God a nice guy?” and “Will my bird dog go to heaven, or do I flush the quail of paradise with seraphim, cheru-bim, and putti?” But after a while diagnosis wears off. It’s time for an intermission in the self-dramatization of “I Have a Life-Threatening Disease.”

www.dhmc.org Skylight 4

“take charge of your disease.” No thanks, I’m busy. I’ve got cancer.

I’m willing to face having cancer. I’m not willing to face having cancer with homework. I promised Dr. Pipas and Dr. Zaki that I wouldn’t show up with sheaves of printouts from the Internet containing everything on Wikipedia about malignancies. They each laughed with detectable notes of relief. (Although I suspect my wife has made her way into the health blog ether. Fish oil pills, raw kelp, and other untoward substances have been showing up on the dinner plates since I was diagnosed.)

Dr. Pipas and Dr. Zaki combined had something like half a century of medical experience. God wants us to have faith in what we can’t see. Therefore He certainly wants us to have faith in what we can. I could see the diplomas on the doctor office walls.

“I’ve got cancer” is more than an excuse for rational ignorance about medicine. It’s an excuse for everything. From niece’s wedding to daughter’s piano recital to IRS audit, you’re off the hook. I tried the excuse on the Pope. I couldn’t go to mass because of the effect that germ-swapping, Vatican II “Sign of Peace” handshakes could have on my radiation-weak-ened immune system. I continued to employ cancer as an alibi until last week when an exasperated spouse finally shouted, “You’re curable! You can too put your dirty dishes in the sink!”

The radiation treatments weren’t bad—twenty minutes positioned on a machine in a humiliating posture. Most of me was exposed and the nurses were embarrassingly pretty. But it’s interesting, the connec-tion that physical modesty has with physical vanity. Once past sixty you can reasonably abandon both. This was one of the life lessons with which having cancer abounds.

I hate life lessons. Consider all the I-hope-you’ve-learned-your-lesson experiences: skinned knees, high school romances, wrecked family cars, flunked college courses, horrible hang-overs, failed marriages. I tell my children, “Avoid life lessons. The more important the lesson, the more you should avoid it.”

The chemotherapy was worse than the radiation. The pump in the fanny pack of poisonous chemi-cals made a whining whirr every minute or so—not frequently enough to get used to and too frequently to let me sleep. A long plastic tube that attached the fanny pack to my medi-port allowed me to bury the pump and its noise in a mound of pillows. But then I’d forget that I was connected. As with all attempts to forget one’s troubles, I was courting disaster. I’d get up in the middle of the night to go to the bathroom and be yanked back to the mattress by the tubing. The fanny pack came with a bag of protective cloth-ing and instructions for dealing with chemical spills. According to these instructions I was supposed to do, by myself, what the entire U.S. government had done during the national anthrax panic.

The cumulative effects of the treatments were unpleasant. The loss of my previously full, thick head of ungreyed hair met with no sympathy from my age cohort of males. I developed fatigue, mouth sores, and a rash around my loins as if I’d been dressed in nothing but hip boots and an Eisenhower jacket and turned on a spit in a tanning salon.

Suffering makes us question God. My question was, what evolutionary purpose does the itch serve? Indeed, an itch may be an argument for intelligent design. Maybe we itch not for biological purposes but to give us a moral lesson about surrendering to our strongest passions. I had the strongest passion to scratch certain parts of my body. If, however, I had scratched these parts of my body near a school or playground I would have been sent to jail.

Dr. Pipas, Dr. Zaki, and the Dartmouth-Hitchcock staff were attentive to my complaints and gave me generous doses of things to turn complaints into complaisance. But I was nagged by a concern about the quality of my medical care. Was it too good? I’m well-insured and passably affluent. I asked Jason Aldous, Dartmouth-Hitchcock’s Media Relations Manager, “What if I weren’t?” “We’re a charitable institution,” Aldous said. “No one will ever be refused

care here. On the other hand, we have to keep the lights on. We do try to find any possible means of payment—government programs, private insurance, et cetera.”

The hospital has a whole department devoted to that. “In about 60 percent of cases,” Aldous said, “peo-ple who think they aren’t eligible for any assistance actu-ally are.” Then there are the people who have income but no savings or assets. Discounts are provided and payment plans worked out. Failing all else, treatment is simply given free—$63 million worth in 2007.

I asked Aldous about who gets what treatment from which doctor. Do your means affect the hospi-tal’s ways?

“The doctors,” he said, “don’t know how—or if—you’re paying.”

What Jason Aldous told me seemed true from what I could see of the hospital’s patients, a cross-section of Yankees, flinty and otherwise. The Norris Cotton Cancer Center alone treats more than five thousand people a year. And we were all amiable in the wait-ing rooms. Any time someone new came in and sat down he or she was tacitly invited to spend about three minutes telling everyone what was wrong. Then the conversation was expected to return to general top-ics. The general topic of choice during the summer of 2008 was how the Democrats would destroy the private health care system that was saving our lives. When medicine was socialized we’d have to sit in wait-ing rooms forever, if we lived. (The exception to the three-minute rule was for a child patient. Then there was unlimited interest and upbeat chat.)

In my case at least, the amiability had something to do with pain-killing drugs, of which I was on plenty. Opiates are a blessing—and a revela-tion. Now when I see people on skid rows nodding in doorways I am forced to question myself. Have they, maybe, chosen a reasonable response to their condi-tion in life? Being addicted to drugs is doubtless a bad plan for the future, but having cancer also lets you off the hook about taking long-term views.

I’m sure that various holy martyrs and pious ascet-ics will disagree but I saw no point to adding suffering to my suffering. And I can’t say I had a sign from God that I should, at least not if God was speaking though my old friend Greg Grip.

Greg was batching it in a cottage on Lake Mas-coma, fifteen minutes from Dartmouth-Hitchcock. He’s divorced and his college-age daughter was away at a summer job. “I’m not saying you can stay at the cottage while you get treated,” Greg said. “I’m saying I

will be deeply offended if you don’t.”Dr. Zaki arranged my radiation treatments, late on

Monday afternoons and early on Friday mornings. My wife and children were spared self-pitiful weekday grousing. And I missed them, so I was on good behav-ior over weekends.

Greg is a splendid Weber grill cook. Charcoal fires produce carcinogens, but the chemotherapy had that covered. Dr. Pipas said I could have one measured Scotch each evening. But he failed to specify the mea-sure. I think the pint is a fine old measure, although the liter is more up-to-date.

I couldn’t tolerate the sun, but Greg’s cottage is on the southwest shore of Mascoma. The patio was in shade all afternoon. I read a lot, mostly histories of World War II concerning the Russian front. Everyone on the Russian front in World War II was having it worse than I was.

Tony Snow, the former Bush administration press secretary, wrote an essay about dying from colon can-cer. Tony said that the sense of mortality promoted “the ability to sit back and appreciate the wonder of every created thing.” Every created thing put on a wonderful show for me at Lake Mascoma. A family of mergansers with six ducklings was living under the dock. A pair of mallards had taken up residence in the shrubbery. Beavers swam up and down the lake. I don’t know why—Mascoma has a concrete dam. There were bird sightings—hawks, turkey vultures, kingfishers, a bald eagle, even an extremely wayward pelican. A hummingbird visited the patio every evening. Skinny-dipping sightings were also made at a nature reserve across the lake. Water skiers and jet ski riders took amusing falls. Not to engage in the pathetic fallacy, but the weather itself was kind and cool. Greg’s pointer, Weezy, slept on my bed each night, though this may have had less to do with doggie compassion than the fact that Greg won’t let her sleep on his. Weezy’s dulcet snoring drowned out the chemo fanny pack pump.

I’m doing fine now. Anal cancer can be invasive, but mine seems to have had a wimpy EU-style foreign policy. The cancer is gone, as far as can be told. I still have a colonoscopy to worry about and a CAT scan to dread and six-month check-ups to fret over. I’ll be okay. Or I won’t. Or I’ll go through it all again.

Last summer was not the worst summer of my life—loving family, kind friends, skilled and consider-ate care, a big warm dog in the bed. The worst summer of my life was forty years ago when I was young and healthy and didn’t have a care in the world. But there was this girl, and a novel that refused to write itself, and anomie, and angst, and weltschmerz ... Nothing brings us closer to God than age and illness. I only hope the Almighty doesn’t mind having nothing but sick old people around.

P.J.’s newest book “Driving Like Crazy: Thirty Years of Vehicular Hell-bending” is now available in bookstores.

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Advanced Heart Failure and Cardiomyopathy Program team members: Alan T. Kono, MD, (lead cardiologist), Virginia Beggs, ARNP, Margaret Sullivan, ARNP, Sherry Duveneck, RN, Kathryn Kaminski, RN, KC Wright, LD, Jeannette K. Champagne, and Ann Hopkins

Advancing theVision for Health

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When hank anD lynn hopeman moved to New Hampshire from North Carolina, the site they chose for their new home was atop a granite ledge. “It’s not going anywhere,” says Hank Hopeman of the house they moved into last year.

It’s an apt metaphor for this cou-ple, who have quickly made them-selves at home in the Granite State. The Hopemans wasted no time in reaching out to Dartmouth-Hitch-cock Medical Center (DHMC) to learn how they could support the Transforming Medicine Campaign.

The result is a generous gift that will launch a new health promo-tion initiative that integrates and builds upon an array of existing disease prevention programs across DHMC and Norris Cotton Can-cer Center. Seed funding commit-ted by the Hopemans will provide an initial three years of salary sup-port for a Director of Community Education and Prevention, as well as programmatic support.

The new program will be based in the Cancer Center, but will work across the medical center to strengthen interdisciplinary con-nections among existing preven-tion programs—such as those relating to cancer and cancer screening, childhood obesity, and tobacco use—and to plan and implement new programs. Its work will focus on developing effective programs both within the clinical setting and throughout the region, by building strong community partnerships. The program will work closely with the new Center for Population Health at The Dartmouth Insti-tute for Health Policy and Clinical Practice to evaluate the success of its efforts.

“I know that it’s difficult to fund programs like this that don’t generate income,” says Hank Hopeman, who serves on the Board of Visitors of Wake Forest University Baptist Medical Center near their former home in Win-ston-Salem, NC. “The way our healthcare system is set up, doc-tors don’t get paid for preventing illness. Lynn and I really like the

idea of trying to raise the health standard of people in this area, rather than just curing illness once it’s been identified.”

The new program is a direct out-growth of Dartmouth-Hitchcock’s bold vision of “achieving the health-iest population possible,” a commit-ment to going beyond medicine’s standard emphasis on treatment to proactively preventing disease and promoting healthy living.

“We’re so grateful to the Hopemans for their interest in advancing awareness of prevention strategies for high-impact diseases like cancer,” says Mark Israel, MD, director of Norris Cotton Cancer Center. “The Hopemans’ visionary gift will stimulate new evidence-based prevention programs and help us establish models for enhancing healthy behaviors in the communities we serve.”

The Hopemans are equally excited about the opportunity to promote health and wellness in the region. “It would be nice for people to be able to live rewarding lives without having to deal with illness,” says Lynn Hopeman. “This looked like a great opportunity. I can see potential for this program to develop into something more. We don’t know where this is going to go, but we think it’s a good beginning.”

Adds Hank Hopeman, “You can’t get to the finish line unless you start.”

in november 2008, the Dart-mouth-Hitchcock Medical Center (DHMC) Heart Failure and Cardio-myopathy Program co-sponsored its first heart transplant clinic in col-laboration with one of its healthcare partners, Tufts Medical Center in Bos-ton. DHMC patients with advanced cardiac disease who had received transplants or mechanical heart assist devices as well as possible transplant candidates, were evaluated by trans-plant specialists from both institutions. This unique clinic will be offered four times a year, providing improved patient access to the most advanced treatment without the need to travel to Boston.

It was another milestone for the Advanced Heart Failure and Car-diomyopathy Program, which was instituted in 2004, led by cardiologist Alan T. Kono, MD. By developing a patient-centered, multidisciplinary team of health professions, the pro-gram serves a broad population of patients from a large regional area. Since that time, the program has pro-vided a level of care for patients with the most serious types of heart disease that was previously unavailable in the central New Hampshire and Vermont region. Heart failure, a serious cardiac condition that carries a high morbidity and mortality rate, is also the number one discharge diagnosis among elderly patients in our country.

As a prototype of chronic disease management, the program’s mission is to provide compassionate care while delivering optimal use of evidence-based treatments (which are often underutilized in this population) to improve patient functional status and

outcomes and hopefully reduce urgent emergency room visits or hospitaliza-tions. By providing patient education and self monitoring techniques, easy access to the heart failure medical staff and follow-up appointments, support groups, and coordination of care, the program has been organized around a patient-centered focus. The Heart Failure program was also involved in a DHMC regional pay for perfor-mance project sponsored by Centers for Medicare and Medicaid Services (CMS) to improve performance and enhance quality of care for Medicare recipients.

A multidisciplinary team, address-ing inpatient heart failure quality of care, re-engineered the process for hospitalized patients. “By making an early or accurate diagnosis, identifying high-risk patients, delivering appropri-ate therapies, and by doing pro-active phone intervention and seeing patients as soon as possible, we have lowered readmission rates from 20 to 25 per-cent to 12 to 15 percent,” says Dr. Kono, medical director of the Heart Failure Program.

Kono is a strong believer in a mul-tidisciplinary approach to treatment. Every morning the Heart Failure team—comprised of Kono, two nurse practitioners, two nurse care managers, and a nutritionist as well as admin-istrative support secretaries—meets to discuss patient status and clinical updates, including patients need-ing urgent care or intervention, and develop a plan for the day. “The team functions at a very human level so we can provide a human connection to our patients,” says Kono.

These meetings (Continued on pg. 8) Hank and Lynn Hopeman

the hopemans’ visionary gift will stimulate new evidence-based prevention programs and help us establish models for enhancing healthy behaviors in the communities we serve.”Mark Israel, MD, Director of Norris Cotton Cancer Center

M i S S i O np o s s i b l e

Heart Team Improves the Quality of Patient Care

www.dhmc.org Skylight 6

if frank mcDougall, Dart-mouth-Hitchcock Medical Center’s (DHMC) Vice President for Gov-ernment Relations, had a nickel for every time he’s shuttled between Lebanon, Concord, and Washing-ton, D.C., he might be able to solve the biggest challenge he faces today: the looming prospect of drastic Med-icaid cuts to DHMC. But following the money—and carefully cultivating the relationships necessary to keep it flowing—are his forte.

The American Hospital Associa-tion (AHA) certainly thinks so. On

April 28, the AHA flew McDougall back to Wash-ington to honor him with a 2009 “Grassroots Cham-pion” award. Each state chapter of the organization nominates one winner per year. Hospitals throughout New Hampshire agreed

that McDougall’s work on issues such as Medicaid reimbursements has benefited medical centers large and small—no small task in these hard economic times.

McDougall’s lobbying skills have been more important than ever, given Governor Lynch’s approval of a $10 million reduction in Medicaid payments to DHMC over the next two years. With an opportunity to reverse that shortfall coming through the federal stimulus package, one of McDougall’s top priorities has been making sure that the money

earmarked for Medicaid doesn’t go to other programs—and urging the governor and legislature to recon-sider that $10 million cut.

Thanks to a grassroots advocacy effort led by McDougall and his team, the NH House of Represen-tatives passed a State Budget that restores $7 million of this funding to the Children’s Hospital at Dartmouth (CHaD) over the two year budget cycle. It also includes an amend-ment that directs the Department of Health and Human Services to create a Medicaid classification for CHaD that differentiates rates to “reflect the uniqueness and intensity of pediatric services provided and the need to pre-serve the availability of such services to the Medicaid population.”

“Now it’s on to the Senate,” says McDougall. “We’ll be working hard to be sure that the Senate Budget concurs as closely as possible with

the House Budget with regard to reversing the CHaD cuts and includ-ing the CHaD amendment.”

The New Hampshire Hospital Association (NHHA), the group of 26 hospitals that nominated McDou-gall for the “Grassroots Champion” award, applauded McDougall’s creative approach to bringing the leg-islative and healthcare worlds closer together. One example of that out-reach is “Project Medical Education,” in which public officials and other opinion leaders spend a day working alongside medical residents to see the excellent care New Hampshire hospi-tals provide their patients.

“I accepted the award on behalf of our entire team,” McDougall said. “I’m lucky to work with such a tal-ented group. We have a lot of work to do, but if we stick together and con-tinue to broaden our political base, I think we can accomplish even more.”

DHMC Leader Named as AHA’s Grassroots Champion

One nIGHT

last winter, on the eve of

opening Dartmouth-Hitchcock

Medical Center’s (DHMC)

new dedicated endovascular

surgery suite, vascular

surgeon Mark Fillinger,

MD, paused to reflect on a

milestone moment.

“I was doing the last run-

through, making sure that

everything was in position and

operational,” recalls Dr. Fillinger.

“I remember thinking that we

had first proposed the suite a

decade ago and that reaching

our goal was the culmination

of a lot of work on the part of

a lot of people. It would have

been really neat to have had

everyone there—but we would

have needed an auditorium to

accommodate them all!”

As a result of these efforts, the medical center now has one of the most advanced endovascular surgery suites found anywhere. “With its unique design and state-of-the-art imaging capa-bilities, this suite is enhancing our ability to do procedures that are only done in literally a handful of places around the country, and not even that many places in the entire world,” he says.

Repairing Damaged Blood VesselsEndovascular surgery is a form of minimally-invasive surgery that is designed to access different regions of the body through major blood ves-sels. “The technique allows us to make just a puncture or a very small incision through an area like the groin, and then remotely position a device from within the blood vessel to repair the diseased or injured artery,” explains Fillinger. “So, the trauma on the body is dramatically less and the recovery time much faster than it would be otherwise.”

This can prove critical for patients who have sustained vascular trauma or who have advanced vascular disease—which commonly includes atheroscle-rosis (narrowing of the arteries) and aneurysms (when a vessel wall bulges out due to weakness)—and are consid-ered too high risk for open surgery.

“The primary types of procedures that we do involve either putting in a stent that pushes open a narrowed artery, or a stent graft, which is used to reline and strengthen a weakened vessel,” he says. “Everything else falls around those two basic strategies.”

Meeting Highly-Specialized NeedsStill, there are certain kinds of com-plex procedures that require a unique set of capabilities. “Aortic aneurysm repairs are a good example,” says Fillinger. “They require a very large device (relatively speaking) and often we need to do a combined open and endovascular procedure to get access to the vessel. It’s still far less invasive than a full-blown open procedure, but it requires some of the surgical light-ing, suction, and other equipment that operating rooms have, but that typical interventional suites don’t.”

“Generally speaking, rooms that are designed for open surgery are very poor at doing imaging, and rooms that are designed purely for imaging are very poor at doing open surgery,” he adds. “This room is designed to do it all, and do it very well. In fact, the more complex a procedure is, the more important this room is.”

And with its video routing capabili-ties and ability to combine advanced multi-modality imaging, the suite gives medical teams a more complete picture of what they’re working on during

procedures. “We can do a less inva-sive repair on a higher percentage of patients,” explains Fillinger. “It allows us to see structures more clearly, to treat patients with less dye and radiation, and to complete procedures in less time with hopefully better outcomes.”

Wave of the FutureThe new suite will also help to support a top-notch training environment for tomorrow’s vascular surgeons.

“We want to train people using the most advanced techniques and tech-nologies possible, so that when they go off to work in other large academic centers they can bring the experience and knowledge they need to continue pushing the field forward,” says Fill-inger, who directs DHMC’s vascular surgery training programs.

“A lot of what is considered state-of-the-art now is going to become standard, not just in our field, but in many areas of surgery, as we continue to develop less invasive ways to treat patients,” he adds. “One of the things that makes the vascular surgery pro-gram here special is that we’re on the leading edge of these changes.”

DHMC now has one of the most advanced endovascular surgery suites found anywhere. “Basically, it allows us to do a less invasive repair on a higher percentage of patients,” explains Mark Fillinger, MD (pictured above).

Staying on the Cutting Edge of Vascular Surgery

7

dhmc mission:

We advance health through research,

education, clinical practice and community partnerships, providing each person the best care, in the right place, at the right time, every time.

about dhmc:Dartmouth-Hitchcock Medical Center in-cludes Mary Hitchcock Memorial Hospital, a member of the New England Alliance for Health; Dartmouth Medical School, the state’s only medical school; Dart-mouth-Hitchcock Clinic, a multi-specialty academic group practice; and Veterans Affairs Medical Center in Vermont, which provides a rich educational environment for doctors in training.

Skylight is published quarterly by the Office of Public Affairs and Marketing.Phone: (603) 653-1910

Please address comments to:“Skylight Editor” via e-mail at: CreativeServices@blitz.hitchcock.orgor by mail to:Dartmouth-Hitchcock Medical CenterOne Medical Center Dr., Lebanon, NH 03756

Editor: E. Senteio

Contributing Editor: Sandra Adams

Contributors: Tim Dean, Susanna French, Elaine Gottlieb, Guest author, P.J. O’Rourke

Photographer: Mark Washburn unless otherwise noted.

Design and Illustration: David Jenne

Who, What, When & Where

dhmc mission:

We advance health through research,

education, clinical practice and community partnerships, providing each person the best care, in the right place, at the right time, every time.

about dhmc:Dartmouth-Hitchcock Medical Center in-cludes Mary Hitchcock Memorial Hospital, a member of the New England Alliance for Health; Dartmouth Medical School, the state’s only medical school; Dart-mouth-Hitchcock Clinic, a multi-specialty academic group practice; and Veterans Affairs Medical Center in Vermont, which provides a rich educational environment for doctors in training.

Skylight is published quarterly by the Office of Public Affairs and Marketing.Phone: (603) 653-1910

Please address comments to:“Skylight Editor” via e-mail at: CreativeServices@blitz.hitchcock.orgor by mail to:Dartmouth-Hitchcock Medical CenterOne Medical Center Dr., Lebanon, NH 03756

Editor: E. Senteio

Contributing Editor: Sandra Adams

Contributors: Tim Dean, Susanna French, Elaine Gottlieb, Kate Villars, Guest author, P.J. O’Rourke

Photographer: Mark Washburn unless otherwise noted.

Design and Illustration: David Jenne

Exhibits by DHMC physicians, Clifford Belden, MD, as lead author, David Pastel, MD, Benoit Gosselin, MD, Joseph Paydarfar, MD, and Candice Black, DO, took top honors at the 47th Annual Meeting of the American Society of Neuroradiology, in Vancou-ver, BC. “Hypopharynx: Patterns of Cancer Spread,” received the Magna Cum Laude award, and was the only “Magna” awarded at the conference, which included approximately 67 sci-entific exhibits. “Hypopharynx: Detailed Imaging anatomy with Clinical and Pathologic Correlation,” received the Summa Cum Laude award—the only exhibit to be awarded with the presti-gious title. Together, the two exhibits provided a detailed demonstration by

CT and MR images of the hypopharynx and described distinctive patterns in the spread of hypopharyngeal tumors.

Researchers at Dartmouth-Hitchcock Medical Center investigated the use of a new florescence-guided tech-nique during glioma resection surgery. David Roberts, MD, Section Chief of Neurosurgery, presented the results during the American Association of Neurological Surgeons Annual Meet-ing in May. Dr. Roberts commented, “It can be very difficult for a surgeon to visually distinguish tumor tissue from normal brain. This new tech-nique “color codes” the tumor to be removed, and shows great promise for enabling more complete resection of

a tumor and preservation of surround-ing normal tissue and critical brain functions.”

Dale Collins, MD, MS, will as-sume the duties of Section of Plastic Surgery effective June 1. Collins will remain actively engaged in the Clinical Transformation Project and Informat-ics Program. She is also involved in integrating shared decision making into practice and will continue in her role as the director of the Center for Informed Choice at The Dartmouth Institute. In addition, she serves on multiple local and national committees, has numer-ous funded grants and is an elected member of the Board of Governors and the Board of Trustees.

4th Annual CHaD Half Marathon & RelaySaturday, August 29 Be a Hero—

come and help us break a World

Record! Also: 5K Walk and 1 Mile

Family Fun Course. All activities start

from the Dartmouth Green in Hanover.

For details, visit www.CHaDHalf.org.

Bone Marrow Drive & Information Session

Tuesday, September 15 Everyone

is invited to participate or learn more

about being a donor at our Bone Mar-

row Drive from 12-7 p.m. at the Blood

Donor Program Office on Level 2 at

DHMC. For details: (800) 639-6918 or

cancer.dartmouth.edu/

CHaD Seacoast ClassicThursday, October 15 Enjoy the

majestic beauty of New Hampshire’s

peak foliage season at the second

annual CHaD Seacoast Classic golf

tournament at The Oaks, in Somer-

sworth. Registration begins at 7:30

a.m. Shotgun start at 9 a.m. All pro-

ceeds benefit CHaD. For details: www.

chadseacoastclassic.com or contact

Toby Trudel at (603) 629-1862 or toby.

trudel@hitchcock.org.

Coping with Parkinson’sSaturday, October 17 For people

with Parkinson’s and their care part-

ners. Grappone Conference Center,

Concord, NH, 9 a.m.-2:30 p.m. Talks

will focus on caregiving with love and

the role of the brain and behavior in

Parkinson’s disease. Enjoy a fun after-

noon presentation about the use of

service dogs. Registration is $15 per

person and is required by October

9. For details or to register, call (603)

650-5280, e-mail apda@hitchcock.org,

or visit dhmc.org/goto/parkinson.

help team members under-stand all clinic patients and develop individualized treat-ment plans. But treatment is only effective if patients fol-low their treatment regimens so “we help newly diagnosed patients understand and take care of their disease. It is well-established that the main rea-sons for patient readmissions are when they discontinue their medications, don’t fol-low dietary recommendations and can’t identify symptoms of wors-ening heart failure,” says Virginia L. Beggs, heart failure nurse practitioner.

After patients receive outpatient or inpatient treatment, nurse care manag-ers follow up with home visits, coordi-nate with primary care physicians and/or phone contact (“telemanagement”), and facilitate connections with resources for financial or medication assistance. “We have very strong care manage-ment that will be in touch with patients as often or as little as they need,” says Beggs. “Furthermore, we recognize that patients need to have appropriate nutritional counseling by experienced dietitians to ensure successful self man-agement and pro-active care.”

Providing care by phone is particu-larly important in treating a rural pop-ulation. Because the program serves a broad geographical area, many patients need assistance without having to come

for an urgent evaluation or utilizing an emergency room for non-urgent care. Some of the services the care managers offer are: telephone triage, assessment of financial resources and social supports, referrals and informa-tion regarding appropriate community resources, health coaching, facilitation of changes in therapies, and coordina-tion of care with specialty providers and support groups. Often reassurance of the patient, as well as family under-standing of their disease and treatment plan, is a key element in their health maintenance. “Patients and families have reported how much they appreci-ate being able to speak with a person directly and how it makes them feel less alone in their disease,” says nurse care manager Sherry Duveneck, RN.

The advanced treatments avail-able at DHMC not only improve patient lives but sometimes save them.

Patients may be candidates for implantable devices, such as specialized pacemakers or ventricular assist devices, which provide electrical or mechanical cardiac sup-port for patients awaiting transplants. The program is on the forefront of provid-ing care for chemotherapy-induced cardiomyopathy, a potential complication of cancer therapy, which is just starting to receive greater

attention and treatment. Research protocols also allow patients the opportunity to participate in newer therapies. The latest advances in heart failure care are presented at the pro-gram’s annual Heart Failure Sympo-sium, which brings in leading heart failure specialists to the region and is always well attended by regional nurs-ing and physician staff.

Working as part of a dedicated team focused on disease management through evidence based therapies and patient outcomes, while promoting health maintenance, is very fulfilling say the care managers. In the coming years, Kono and the team would like to continue to offer more professional education and show that “this kind of disease management can work for pri-mary care practices and smaller institu-tions and can lead to tangible outcome improvement.”

HEART TEAM (from page 6)

Every morning the team meets to discuss patient status, clinical updates and needed interventions.

the transforming meDicine campaign is approaching its $250 million goal, with gifts and pledges now surpassing $236 million. Dartmouth-Hitchcock’s vision of achiev-ing the healthiest population possible is generating excitement and strong sup-port from donors. Recent commitments to the Cam-paign include $2 million to be directed to The Dart-mouth Institute’s new Cen-ter for Population Health. Led by Dr. Elliott Fisher, this new initiative seeks to identify prevention strate-gies that produce measur-

able reductions in the rate of disease and quantifi-able improvements in the region’s health. Another recent gift commitment will significantly advance DHMC’s prevention programming (see story,

page 6).Unrestricted giving to

the Dartmouth-Hitchcock Annual Fund (DHAF) also plays a vital role in advanc-ing DHMC’s commitment to providing each person with the best care, in the right place, at the right time, every time. By their very nature, unrestricted gifts target high priority areas because

they offer the flexibility to be used in support of criti-cal needs and opportunities not funded by other means. In the current economic climate, as DHMC’s budget is constrained by increasing numbers of patients seeking charitable care, shrinking Medicaid funding, and reduc-

tions in income from endow-ments, the unrestricted support of patients and com-munity members is essential.

DHMC has set an ambi-tious target of $930,000 for DHAF for the July 1, 2009 – June 30, 2010 fis-cal year.

Other gifts to the Transforming Medicine

Campaign are investing in the facilities, people, and programs that will drive discovery and collabora-tion, accelerate medical advances, and bring new hope to patients. To learn more, please visit www.transmed.dartmouth.edu.

C A m pA i g nU p d AT e

Take Note

www.dhmc.org Skylight 8