HAWAIIMEDICAL

JOURNALApril 1996 Volume 55, No. 4 ISSN: 0017-8594

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HAWAIIMEDICAL

JOURNAL(USPS 237-640)

Published monthly by theHawaii Medical Association

Incorporated in 1856 under the Monarchy1360 South Beretania, Second Floor

Honolulu. Hawaii 96814Phone (808) 536-7702: Fax (808) 528-2376

EditorsEditor: Norman Goldstein MD

News Editor: Henry N. Yokoyama MDContributing Editor: Russell T. Stodd MD

Editorial BoardVincent S. Aoki MD, Benjamin W. Berg MD,

John Breinich, Theresa Danao MD,Satoru Izutsu PhD, James Lumeng MD,

Douglas G. Massey MD, Irwin J. Schatz MD,Myron E. Shirasu MD, Frank L. Tabrah MD,

Kim M. Thorbum MD

Journal StaffBusiness Manager: Becky Kendro

Copy Editor: Jan EstiokoEditorial Assistant: Carol Uyeda

OfficersPresident: Carl W. Lehman MD

President-elect: JoIm S. Spangler MDSecretary: Roger T. Kimura MD

Treasurer: Leonard R. Howard MDPast President: Frederick C. Holschuh MD

County PresidentsHawaii: Emest Bade MD

Honolulu: Patricia Lanoie Blanchette MDMaui: Madhup Joshi MD

West Hawaii: Theresa Smith MDKauai: Timothy Crane MD

Advertising RepresentativesHawaii Professional Media Group

3036-A Kahaloa DriveHonolulu, Hawaii 96822

Phone (8081 988-6478Fax (808) 988-2785

The Journal cannot beheld responsible foropinions expressed inpapers. discussion, communications or advertisements. The advertising policy of ihe HawaliMedicalfournal is governed by iherules of the Council on Drugs of the American Medical Association. Thenght is reservediorejecimaterial submitted foreditorialor advertising colantns. The Haicail Medical Journal ILSPS237641(1 is published monthly by the Hawaii Medical Association(ISSN (1017-8594). 136(1 South Beretania Street. Second Floor.Honolulo, Hawaii 96814.

Postmaster: Send address changes to the Hawaii MedicalJourval. 13611 South Beretania Street. Second Floor. Honolulu,Hawaii 96814. Second-class postage paid at Honolulu. Hawaii.

Noitmember subscriptions are $25. Copyright 1995 by theHawaii Medical Association. Printed in the U.S.

Contents

EditorialNorman Goldstein MD 64

HMA President’s MessageCarl W Lehman MD 64

Medical School HotlineBeatriz L Rodriguez MD, PhD, J. David Curb MD, MPH, Helen Petrovitch MD,Kamai H. Masakj MD 66

Early Experience with Inhaled Nitric Oxide for the Treatment ofInfants and Children with Pulmonary HypertensionDavid Easa MD, Daniel T Murai MD, Brian Oka RRT Marshall Dressel MD,Paula Vanderfora’ MD, Susan Pelke RN, and Venkataraman Balaraman MBBS 67

Shrinking the Western Pacific: Psychiatric Training forMedical Students from MicronesiaDykes M. Young MD and David Bernstein MD 70

Council HighlightsRoger T. Kimura MD, Secretary 72

Classified Notices 73

The WeathervaneRussell I Stodd MD 74

Cover art and descriptive text by Dietrich Varez, Volcano, Hawaii.All rights reserved by the artist.

Depicted here is a medicinal kahuna or doctor. Also shown are a few of the plantshe might have used: awa, ki, and sugarcane or ko.

Kahuna Lapaau

National HIV Telephone Consultation Service

The National HIV Telephone Consultation Service, “Warmline” (800-933-3413) based at San Francisco General Hospital provides free HIV clinicalinformation and case consultation to health care providers. The Warmlinefaculty includes physicians, clinical pharmacists, and nurse practitioners whohave extensive experience treating patients with HIV disease. Warmline consultants are available to answer questions between 7:30 am and 5:00 pmPST. A 24-hour voice mail system is available at other times.

The Warmline is funded by the Health Resources and Services Administration, the AIDS Education and Training Centers, and the American Academyof Family Physicians.

\

HAWAII MEDICAL JOURNAL, VOL 55, APRIL1996

63

Editorial HMA President’s Message

Norman Goldstein MD

Very special issues coming up

Our September issue of the Journal will be compiled by guest editorFlorence Chinn MD. Florence retired from her internal medicinepractice and as a medical consultant for the Hawaii Health CareAdministration Division—but she is busier than ever! She serves onthe Hawaii State Violence Prevention Coordinating Council and isco-chair of the Hawaii Medical Association Domestic ViolencePrevention Committee. Look for the special issue on DomesticViolence.

Death with Dignity will be our special issue in November, editedby past president of the Hawaii Medical Association, Fred C.Holschuh MD. This issue promises to be one of our most stimulating, thought-provoking issues ever. We already have manuscriptsfrom local and national authorities in the field.

We welcome Letters to the Editor on these subjects as well asothers, even before the publication of the issues.

Specifically, ifyou presently care for terminally ill patients or planto do so. We would like to hear from you. Write or fax me.

1128 Smith StreetHonolulu, HI 96817(808) 523-6842

Carl W. Lehman MD

Why should medical doctors or osteopathic physicians belongto the Hawaii Medical Association?

Each year, physicians must reaffirm their commitment to organizedmedicine: joining the HMA lets us speak with one voice thatrepresents a force in our community striving not only to uphold andprotect our profession but also to set the standards, to be theadvocate, to carry forth the visions our training and experience haveprovided. Paying dues to a professional organization must bej udgedby standards different from those when buying material items.Rather than analyzing how much a member saves or benefits fromthe amount of dues paid each year, one must look at what made itpossible for us to attain our medical education and practice ourprofession as well as the contributions made to society.

Some of us have little knowledge about the achievements andaccomplishments made on behalf of our profession by the medicalassociation. I want to thank Becky Kendro for helping me collatethis list of HMA accomplishments.

This year marks the 20-year anniversary of bold and innovativelegislation passed to address tort reform issues. As a key player ona community-wide Malpractice Commission, HMA physicians led

the way in seeking legislation to set standards ofinformed consent, added an ad dainnum clauseto the law, established the Medical Claim Conciliation Panels to review all medical torts priorto entry into the courts, amended the MedicalPractice Act to define more clearly grounds forlicensure actions, and required reporting of adverse peer review actions to the Board of Medical Examiners. An umbrella insurance fund wascreated in an effort to reduce professional liability insurance premiums although this was laterrepealed.

This legislation has been of considerableimportance to physicians as well as to thosefiling tort cases. The MCCP panels have beenvery successful in settling or dismissing malpractice cases prior to entry into a costly courtsystem. Throughout the years, nearly 75% of allcases have been resolved at the panel level. Thefact that the panels have been able to continueoperations for the past 20 years speaks well forthe dedication of the administrators, physiciansand attornies who serve on the panels.

Workers’ Compensation.—Nearly 30years ago, the HMA introduced legislation guaranteeing injured workers the right to choosetheir own physician. Legislation requiring anannual adjustment in the schedule based on theConsumer Price Index was achieved by legislation fostered by the association. As changes inthe Workers’ Comp program occur, the HMAwill continue to be involved.

Medicaid.—The HMA has devoted manyhours and resources to the Hawaii Medicaid

HAWAII MEDICAL JOURNAL. VOL 55, APRIL 1996

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64

program. Freedom to choose a physician, an equitable reimbursement for services rendered, and various experimental programs toencourage early medical encounters have all been fostered by theHMA. When the program shifted to QUEST, HMA continued toexpress concerns regarding quality of care, access to care, and otherissues related to managed care.

Continuing Medical Education.—The HMA became theagency in Hawaii responsible for surveying and accrediting Hawaiihospitals and other institutions to enable them to offer Category 1CME programs that conform to national standards. HMA hassponsored its own annual CME program for physicians, a traditionwhich has been upheld since the early l900s.

Malpractice Insurance.—When professional liability insurance carriers left the state in the early l980s, HMA was againinvolved in exploring various options for its members. After firstconsidering the formation of its own physician company, theassociation attracted the Medical Insurance Exchange of Californiato enter Hawaii. The relationship with Hawaii physicians has beenoutstanding.

• Legislation.—This column is much too limited to list all of thelegislative action that has been achieved since statehood. Lawsabout peer review committee immunity, living wills, immunity forgood samaritans, child protection laws, emergency medical services, the establishment of the school health program, physician-patient privileged communication, and many others have all beenfostered by l-{MA. HMA’s legislative staff monitors the nearly4,000 bills introduced annually.

No space is being devoted to the issues we have prevented fromhappening: they too form a lengthy list. It is somewhat similar topreventing disease by immunizations—as long as we prevent thedisease, we sometimes forget or question the importance.

Many nonmembers benefit from the efforts of the HMA. However, without support from all medical doctors and osteopaths, ourpower and activities are limited. Our profession needs all of oursupport. Send in your dues today or request a membership application if you have not already joined.

HAWAS MEOWAL JOURNAL, VOL 55, APR01996

Medicine in TransitionHPPA — Managed care by physicians for physicians offering will be available soon.

Complete form for information,

Hawaii Pacific Physicians Association (HPPA), a for-profitcorporation, represents an alliance of the Hawaii MedicalAssociation and the Pacific Medical Administrative Group.Recognizing the radical changes in the health care deliverysystem, this organization has formed to provide what it believes is a positive response to changes taking place in themedical marketplace. HPPA’s mission will be to carry outcast-effective, quality health care for Hawaii and the Pacific basin.

As chairman of this organization, I must give credit to theoriginating members and directors who spent many hoursand much more in developing and implementing this concept of a for-profit statewide physicians network.

health care is in transition, HPPA believes physicians mustdirect these changes and physicians must take the lead inidentifying solutions for the future, developing strategies foraccomplishing them, and finally communicating with physicians the success of their efforts.

I please fill out the form below and mail orfax itto HPPA.

HPPA

NameBernard Fang MD, Vice Chair, HPPAClifford Chang MD, President, PMAG, Director

Carl Lehman MD, President, HMA, DirectorJohn H.S. Kim MD, Director HPPARoger Kimura MD, Director HPPA

Allan Kunimoto MD, Director HPPAJames Lumeng MD, Director HPPA

Dudley Seto MD, Director, HPPAMyron Shirasu MD, Director, HPPA

Degree Type of practice -

Specialty

Location of practice

Mailing address

The physician-directed model will provide an alternative tocurrent managed care plans. The goals are to preserve theexcellence of health care in Hawal, to maintain care for ourpatients, to maintain an organization controlled and drivenby physicians, to develop a statewide provider network, toprovide effective quality assurance and utilization reviewamong physicians, to carry out responsible peer review, toeffect changes in physician’s practice patterns when appropriate, and to reward risk-sharing appropriately.

HPPA will aim to provide cost-effective, quality care whilepreserving the patient-physician relationship and maintainingaccess to care. Medicine is in transition and the delivery of

Solo

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Employed Self-employed.

I Andrew Don MD, (‘hairmnan1360 S. BeretanW Street. Second Floor. Honolulu. HI 96814

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* Please note this article is not an offer to sell securities or to join HPP4,and the request for the information does not denote aims’ obligation

01 c()lltlfl it,nent /‘ronl you or from 1-IPPA.

65

Medical School Hotline

The Role of Epidemiology in Medical Education

Beatriz L. Rodriguez MD, PhD, J. David Curb MD,

MPH, Helen Petrovitch MD, Kamal H. Masaki MD

The multiple disciplines that contribute to the knowledge about

health and disease can be categorized into three areas: clinical

medicine, bench science, and population-based medicine. Popula

tion medicine, in contrast to clinical medicine, is focused on the

community as opposed to individuals. Epidemiology is the disci

pline that provides population medicine with a systematic approach

to study the patterns of occurrence of disease and delivery of

medical care.’ Originally epidemiology was concerned with provid

ing the methodology for the study of population epidemics. Today

it has a broader scope—the study of health and disease in human

populations. Some of these topics include chronic and acute ill

nesses, health care utilization,2and molecular epidemiology. Infor

mation derived from epidemiologic studies is utilized to design

programs for prevention and control of disease.”3Although the importance of epidemiology and its role in preven

tive medicine is increasingly being recognized by the medical

community and the public, its role in medical education needs to be

emphasized. Medical students and residents often lack the motiva

tion to study epidemiology because they think of it as a peripheral

discipline in medicine that may not be directly relevant to clinical

practice.4However, clinical medicine, bench science and population medi

cine are highly interrelated. Physicians often use information de

rived from epidemiologic studies in practice. The age, sex, occupa

tion, behavioral characteristics of a patient, and the knowledge

about the prevalence of a disease in the community must be

considered when making a diagnosis. In the same manner, the

accuracy of individual diagnoses made by clinicians and the com

pleteness with which reportable diseases are made known to health

authorities are essential in the assessment of occurrence of disease

in a community.’ Nobody would expect to understand a disease

without the knowledge of its clinical findings and pathology.

However, many physicians have little knowledge about another

important aspect, the study of disease in relation to populations.5

Cardiovascular diseases provide an example of the importance of

epidemiology and prevention. Since 1960, there has been a decline

of nearly 50% on the rates of cardiovascular disease mortality in the

United States. Most data suggest that primary prevention played a

Divisions of Clinical Epidemiologyand Geriatnc MedicineJohn A. Burns School of MedicineUniversity of Hawaii, Manoa

significant role in this decline. During these years, the prevalence of

cigarette smoking and blood cholesterol levels have decreased and

blood pressure is also better controlled.6These trends are greatly

influenced by the interaction of the medical practitioner with each

of his or her patients. In many cases, the impact of these life-style

changes promoted by physicians may have only a moderate impact

on the health of a particular individual however, when these

changes occur in many individuals, they can have a major impact on

health at the population level. Thus, it is essential that medical

students understand the importance of their role in the promotion of

health in their communities.After completing formal medical training, most physicians de

pend on conferences and medical journals to learn about advances

in medicine and for making treatment decisions in individual cases.

Evidence-based medicine, decision analysis, and clinical decision

making are rooted in the use of epidemiologic methods and prin

ciples. Epidemiologic methods have specific techniques for data

collection, analyses and interpretation of results, and jargon of

technical terms. Therefore, it is crucial that physicians have a basic

understanding of the principles of epidemiology prior to completing

their training. Physicians must be able to evaluate critically the

medical literature in order to judge the strengths and limitations of

data on which they will base clinical decisions. In general, medical

students and residents are interested in the content of epidemiologic

studies and their application to clinical settings. However, an

understanding of the methods used to conduct the studies is neces

sary to determine if the conclusions of the study are valid.

Critical review ofjournal articles can be used to motivate physi

cians in training to learn epidemiology.4Often, fellows and aca

demic physicians who have not had training in research methods

develop clinical studies without seeking appropriate advice. Thus,

these projects encounter problems with funding and the publication

of manuscripts. These studies are often based on good ideas, and

would yield valuable results if appropriate methods were used.5

Two years ago, the John A. Bums School of Medicine at the

University of Hawaii at Manoa formed the Division of Clinical

Epidemiology within the Department of Medicine. This division,

which works closely with the Division of Geriatric Medicine,

conducts large epidemiologic research studies funded by the Na

tional Institutes of Health including: the Honolulu Heart Program,

the Honolulu-Asia Aging Study, the Women’s Health Initiative

(Women’s Health Hawaii), Genetic Determinants of High Blood

Pressure (SAPPHIRe), and a study on Macronutrients and Blood

Pressure (INTERMAP Hawaii) among others. Geriatric Medicine

and General Medicine fellows at the University of Hawaii Depart

ment of Medicine attend a weekly course on research methods

conducted by the Divisions of Clinical Epidemiology and Geriatric

Medicine. Many of these fellows have had the opportunity of being

directly involved in some of these important investigations and are

learning research methods from this experience. It may be consid

ered beneficial to expand this program to include all medical

students and residents in schools of medicine.

References:1. Mausner JS. Kramer S. Epidemiology, an introductory text. WB Saunders Co: 1985, 1-21.

2. Kleinbaum DO, Kupper LL, Morgenstern H. Epidemiologic Research, Principles and Quantitative

Methods. Van Nostrand Reinhold Company; 1982, 2-15.

3. Lilienteld AM, Lilienfeld DE. Foundations of Epidemiology. Oxford University Press; 1980, 3-20.

4. Grufferman 5, Kimm SY, Maile MC. Teaching epidemiology in medical schools: A workable model. Am

J Epidemiol.1 984:120:203-209.5. Rose G, Barker DJP. Epidemiology for the uninitiated. British MedJ. London, 1986.

6. Pearsson TA, Chqui MH, Luepker RV, Oberman A, Winston M,eds. Primer in Preventive Cardiology,

American Head Association. Dallas, Texas: 1994.

HAWAu MEDICAL JOURNAL, VOL 55, APRiL 1996

66

Early Experience with Inhaled NitricOxide for the Treatment of Infants andChildren with Pulmonary Hypertension

David Easa MD, Daniel I. Murai MD, Brian Oka ART, Marshall Dressel MD,Paula Vanderford MD, Susan Pelke AN, and Venkataraman Balaraman MBBS

When nitric oxide (NO), an endogenous regulatorof smooth muscletone, is administered by inhalation, it acts as a selective pulmonaryvasodilator, This report details the treatment with inhaled NO of thefirst 11 patients in Hawaii.

IntroductionThis report describes the development of the inhaled nitric oxide

(NO) program and our initial experience with NO for pulmonaryhypertension at Kapiolani Medical Center for Women and Children(KIVICWC). NO, a clear, colorless gas,’ is a component of the air webreathe as measured in parts per billion (ppb).23 It also is found inhigher concentrations of parts per thousand (ppt) in cigarettesmoke.4 In higher concentrations, NO is toxic and capable ofcausing acute pulmonary injury and death.5 Furthermore, in thepresence of oxygen, NO combines to form nitrogen dioxide (NO9),another toxic gas.6 The Environmental Protection Agency set theupper limit of exposure to NO and NO., at 25 ppm and 5 ppm,respectively.7

Over the last few years, NO has been identified as the endothehum-derived relaxing factor (EDRF).8This factor facilitates smoothmuscle relaxation9 and is an endogenous regulator of smoothmuscle tone.’°’1 In the vascular endothelium, NO is synthesizedfrom the amino acid L—arginine,’° and readily diffuses into adjacentsmooth muscle cells where it activates guanylate cyclase to formcyclic guanosine monophosphate (cGMP).’° cGMP mediates smoothmuscle relaxation by complex intracellular mechanisms.

This understanding of the role of NO in smooth muscle relaxationled to its clinical use as a therapy for patients with pulmonaryhypertension. ‘i” It was determined that inhaled NO could reducepulmonary vasoconstriction and shunt fraction, thereby improvingoxygenation in these patients.’ ‘It also was found that inhaled NO isa selective pulmonary vasodilator. As NO diffuses through thesmooth muscle cell into the blood vessel, it rapidly combines with

Departments ot Pediatrics and Respiratory CareKapiolani Medical Center for Women and Children;Department of Pediatdcs, Tripler Army Medical CenterHonolulu, Hawaii

Address correspondence to:David Easa MDKapiolani Medical Center for Women and Children1319 Punahou Street, Honolulu, HI 96826Phone: (808) 973-8670, FAX: (808) 949-4232

hemoglobin to form methemoglobin;’°’5free NO does not circulatein, and therefore does not affect, the systemic circulation.’2

As of 1994, it has been estimated that more than 1,000 patientshave been treated with inhaled NO worldwide. Subsequently, theuse of inhaled NO in infants and children with pulmonary hypertension has

MethodsAfter review of the literature, consultation with national experts

and personal experience at Massachusetts General Hospital by oneof the authors (B 0), the Department of Neonatology at KMCWCbegan the process of developing an NO therapy program for infantsand children. The Food and Drug Administration approved ourInvestigational New Drug application for the rescue use of NO ininfants and children with documented pulmonary hypertension andsystemic hypoxemia. The protocol then was approved by ourmedical center’s Institutional Review Board. In addition, separateanimal studies were carried out to gain experience with NO administration before subjecting human infants to this new form oftherapy. The following equipment and supplies were necessary(Fig 1).

Nitric oxide.—Nitric oxide is mixed with nitrogen (N2)as an inertdiluent at a concentration of 800 ppm.

Blender and connections—Levels of NO concentration wereadjusted using a blender connected with oxygen. The concentrationof NO was measured by electrochemical analysis in parts permillion.

Fig 1.—Basic nitric oxide (NO) delivery system using a double blendertechniqueand NO analyzer, modified for a time-cycled, pressure-limited infant ventilator.Reprinted with permission.2’

HAWAII MEDICAL JOURNAL, JOL 55. APRIL199667

Pulmonox electrochemical analyzer.—Electrochemical analy

sis was used for all NO and nitrogen dioxide measurements(Pulmonox II, Pulmonox Research and Development Corp, Alberta,

Canada).Exhalation scavenging device.—The exhalation block of the

ventilator was enclosed by a custom-made plastic bottle connected

to the wall vacuum set at -100 cmH2O.NO, analysis verification was

performed around this scavenging system with a Drager NO,

chemical analyzer.Ventilators.—NO was utilized only with conventional ventila

tors (Sechrist Infant Ventilator, Sechrist Industries, Anaheim, Cali

fornia; Servo 900C Ventilator, Siemens-Elema, Sweden).Methemoglobin analyzer.—Methemoglobin levels were ana

lyzed utilizing a co-oximeter (2500 Series, Ciba Corning, Medfield,

Massachusetts) at 1, 2 and 4 hours after initiation of NO, then every

6 to 8 hours until stable while on 40 ppm. When NO was weaned

to <40 ppm, methemoglobin levels were followed every 12 hours.

Eligibility criteria.—To receive NO, patients were required to

meet the following criteria: 1) 34 weeks of gestation for infants;2) evidence of pulmonary hypertension by systemic hypoxemia

(AaDO2 600 torr or PaO, 70 ton in FiO, 1.0 on two arterial blood

gases 30 minutes apart) with echocardiographic confirmation of

pulmonary hypertension; 3) poor response to conventional or high

frequency ventilation with mean airway pressure >12 cmH2O; 4)

increasing inotropic drug support; and 5) informed parental con

sent. We excluded infants with inoperable life-threatening anoma

lies. Common diagnostic categories included meconium aspiration

syndrome, pneumonia and sepsis, diaphragmatic hernia, acuterespiratory distress syndrome (ARDS), and postoperative patients

with congenital heart disease.Procedures.—Infants were placed on the conventional ventilator

with the NO blender attached. We frequently attempted to use

respiratory alkalosis therapy (pH 7.6 and PaCO, 20 ton) toensure adequate lung expansion and improve the chances for

response to NO therapy during NO insufflation.We used an initial dose of 40 ppm to 80 ppm. This dose allowed

the clinician to immediately differentiate between responders and

non-responders. Response was defined in an infant as a twofold

increase in PaO2.Failure to respond to NO therapy is an important

determination and could be criteria to transfer the infant for extra-

corporeal membrane oxygenation (ECMO) therapy.Determination of response to NO was usually made in the first 30

minutes after initiation. If the patient was a responder, small

decreases iii NO concentrations were made in proportion to the

extent of the increase in PaO, >150 ton. The reductions were as

small as 5 ppm to as great as 20 ppm at any one time. The goal was

to lower the NO concentrations as quickly as possible to 5 to 6 ppm

to reduce the risk of methemoglobin or NO, toxicity.6’°’ Accord

ingly, NO was preferentially weaned before attempting any reduc

tion in oxygen or ventilator settings.Non-ventilator conventional management continued during NO

therapy and included minimal stimulation, medications such as

fentanyl, Versed and pancuronium, pulmonary physiotherapy and

suctioning. We maintained mean arterial pressures between 60

mmHg to 75 mmHg with varying combinations of dopamine,

dobutamine, and amrinone and with fluid boluses.

ResultsOf the 11 patients treated with NO to date, one was admitted to the

pediatric intensive care unit; the others were neonates admitted to

the neonatal intensive care unit. Two of these infants were trans

ferred from other hospitals (Kaiser Medical Center, Tripler Army

Medical Center) for NO therapy; two were transferred from other

islands for treatment of congenital heart disease and diaphragmatic

hernia; the remaining patients were born at KMCWC.Seven of the II patients responded to NO therapy, with a mean

increase in PaO, of 166 ton within 12 hours after NO was started.

One infant, whose PaO, did not respond dramatically or consistently

to NO, was considered a responder because his condition stabilizedand he became easier to manage once NO was begun. NO was

administered for an average of 105 hours (range 1 to 469 hours). The

baseline methemoglobin level was <2% in all but one infant, whose

initial level after beginning NO at 60 ppm was 4.3. However, thislevel rapidly decreased to 1.1 within one hour after reducing the NO

to 40 ppm. Otherwise, the maximum methemoglobin level recorded

during therapy was 2.6. Platelet counts were normal or near normal.Four patients did not respond to NO therapy. The first

nonresponding infant had meconium aspiration syndrome and poorcardiac contractility, both factors known to decrease the success ofNO therapy. This infant survived after transport to the Mainland for

ECMO. Another nonresponding infant in retrospect was thought tohave more pulmonary than pulmonary-vascular disease. The last

nonresponding infant had congenital diaphragmatic hernia and died

of that primary diagnosis. The only older child treated with NO was

a three-year old who was critically ill with ARDS and pre-existing

central nervous system disease. He was treated with NO for only one

hour after not responding to conventional therapy. He did not

respond to NO and died of his other diagnoses.A summary of treatment and outcome information is shown in

Table 1; the average oxygenation index (0!) is plotted before andafter NO therapy in the responding and nonresponding infants inFigure 2.

Table 1.—Nitric Oxide Treatment and Outcome Data

Pt Birth Diagnoses Treatment Maximum Pa02 Outcome

No Weight Duration Dose Pre/PostNO

1 2840 MAS 2 hr 80 54/34 ECMOsurvived

2 2650 MAS/pneumothorax 122 hr 40 73/297 survivedanatomicbrainanomaly

3 3020 coarctation 469 hr 20 65/365 survived-seizuredisorder

4 4600 pneumonia/DIC 76 hr 60 38/216 survived

5 3 yo ARDS 1 hr 80 46/45 died

6 2790 MAS/pneumonia 112 hr 40 53/120 survived

7 3731 MAS/blood 170 hr 52 90/270 survived

aspiration/pneumonia

8 3365 MAS/pneumothora 72 hr 40 43/1 72 survived

pneumonia

9 3722 MAS/pneumonia 4 hr 60 82/84 survived

10 3099 CDH l4hr 80 48/42 died

11 3610 MAS/pneumonia 114 hr 40 67/150 survived

NO, nitric oxide; MAS, meconium aspiration syndrome: ECMO, extracorporeal membrane

oxygenation; DIC, disseminated intravascular coagulopathy; ARDS, acute respiratory

distress syndrome; CDH, congenital diaphragmatic hernia.

HAWAII MEDICAL JOURNAL, VOL 55, APRIL 1996

68

DiscussionAlthough anecdotal, we are encouraged that NO contributed

significantly to the survival and recovery of these critically illinfants who were not responding to conventional therapies. Randomized, controlled trials comparing NO to conventional therapywill be needed to definitively prove the value of NO therapy; suchtrials are currently being conducted in other centers. However, it isclear from anecdotal experience from other tertiary centers aroundthe country that there is significant variability in response to NOtherapy from center to center.

At this point in our experience, several observations suggest thereare important factors enhancing the success ofNO therapy. The fourmost important factors associated with a good response include:high systemic arterial pressures (means of> 60 mmHg); adequatelung volume as evaluated by frequent chest x-rays; normal cardiaccontractility; and maintenance of respiratory alkalosis with pH 7.6and PaCO, 20 torr.

When the above factors were controlled, the lability in oxygenation was dramatically reduced, especially during attempts to weanthe infant from ventilator support. Lability in oxygenation is ofconcern since it indicates the presence of pulmonary vasospasmwhich could lead to severe hypoxemia, acidosis, and death. Previously, systemic vasodilators such as tolazoline were used in anattempt to reduce this lability.’8However, these drugs frequentlydilated both pulmonary and systemic vascular beds resulting insystemic hypotension and further instability.’9Because inhaled NOis inactivated by immediately combining with hemoglobin afterdiffusing into the systemic circulation,’°”5 it acts as a selectivepulmonary vasodilator. Neither systemic hypotension nor labilityof oxygenation was observed in infants responding to NO treatment.Thus, any deterioration during weaning attempts was easily reversed by returning to baseline conditions. Finally, this stability inoxygenation should promote future confidence in the treatment ofthese infants, knowing that the use of NO allows for more forgivingclinical management.

Until the benefits of this therapy are proved in randomized trialsand adequate followup studies, we believe the most importantconsideration in the use of NO is safety.’°”2° should be used inthe lowest concentration possible in order to avoid any potentialtoxic effects.2°

In summary, we have presented the background knowledge andprocess that led to our use of this experimental therapeutic gas. Our

initial experience with NO therapy has been encouraging, and weanticipate greater success with more experience. Furthermore, wespeculate that future uses for inhaled NO therapy will be found otherthan those characterized strictly by pulmonary hypertension. Thesemay include such conditions as bronchopulmonary dysplasia, chroniclung disease, viral and bacterial pneumonia, respiratory distresssyndrome, and ARDS. Oxygenation in these disorders may improve from the reduction in shunt fraction seen with the use of thisselective pulmonary vasodilator.2°

AcknowledgmentsWe thank Kapiolani Medical Center for Women and Children for

support with equipment purchases and the Respiratory Care andNeonatal Intensive Care Unit nursing staff for their expertise inimplementing this program.

AddendumSince submission of this paper, we have treated an additional 19

infants with NO. Thirteen of the last 15 treated infants responded toNO; the only infant who died had pulmonary hypertension complicated by diaphragmatic hernia. We believe that the improvedresponse and survival were due to the beneficial effects of a learningcurve. Furthermore, we credit the improvement in results to theliberal use of fluids to expand blood volume, pressors to maintainblood pressure, exogenous surfactant to reverse surfactant dysfunction, and diuretics after the initial period of stabilization to reducepulmonary congestion. Finally, our current approach is to begin NOat 20 ppm and increase to 40 ppm only when necessary.

References1. Austin AT. The chemistry of the higher oxides of nitrogen as related to the manufacture, storage and

administration of nitrous oxide, BritJAnaesth. 1967; 39:345-350.2. Hugod C. Effect ot exposure 1043 ppm nitric oxide and 3.6 ppm nitrogen dioxide on rabbit lung. lntArch

Occup Environ Health. 1979; 42:159-167.3. Gerlach H, Pappert D, Lewandowski K, Rossaint ft Falke KJ. Long-term inhalation with evaluated low

doses of nitric oxide torselective improvement in oxygenation in patients with adult respiratory distresssyndrome. Intensive Care Med. 1993; 1 9:443-449.

4. Norman V, Keith CH. Nitrogen oxides in tobacco smoke. Nature. 1965, 205:915-916.5. Clutton-BrockJ. Twocases of poisoning bycontaminafion of nitrous oxide with higherosides of nitrogen

during anaesthesia. BritJAnaesth. 1967; 39:388-392.6. Samet JM. Utell MJ. The risk of nitrogen dioxide: What have we learned from epidemiological and

clinical studies? Toxicol md Health. 1990; 6:247-262.7. U.S. Dept. of Health and Human Services. NIOSH recommendations foroccupational safety and health

standards 1988. MMWR Moth Mortal Wkly Rep. 1988; 37(S-7):1 -29.8. Palmer RMJ, Ferrige AG, Moncada S. Nitric oxide release accounts for the biological activity of

endothelium-derived relaxing factor. Nature. 1987; 327:524-526.9. Furchgott RF, Zawadzki JV. The obligatory role of endothelial cells in the relaxation of arterial smooth

muscle by acetylcholine. Nature. 1980; 288:373-376.10. Anggard E. Nitric oxide: Mediator, murderer, and medicine. Larrcet. 1994; 343:1199-1206.11. Zapol WM. Rimar 5, Gillis N, Marietta M, Bosken CH. Nitnc oxide and the lung. Am J Respir Crlf Care

Med. 1994; 149:1375-1380.12. Pepke-Zaba J, Higenbottam ‘1W, Dinh-Xuan AT, Stone 0, Wallwork J. Inhaled nitric oxide as a cause

of selective pulmonary vasodilation in pulmonary hypertension. Lancet. 1991; 338:1173-1174.13. KinsellaJP, Neish SR, Shatter E, Abman SH. Low-dose inhalational nitric oxide in persistent pulmonary

hypertension of the newbom. Lancef. 1992; 340:819-820.14. Roberts JD, Polaner DM, Lang P, Zapol WM. Inhaled nitric oxide in persistent pulmonary hypertension

of the newborn. Lancet. 1992; 340:818-819.15. Gibson OH, Roughton FJW. The kinetics and equilibria of the reactions of nitric oxide with sheep

haemoglobin. J Physiol. 1957; 136:507-526.16. Kinsella JP, Neish SR, l’ DD, Shatter E, Abman SH. Clinical responses to prolonged treatment of

persistent pulmonary hypertension of the newborn with low doses of inhaled nitric oxide. J Pediatr.1993; 123:103-108.

17. Abman SH, Griebel JL, Parker DK, Schmidt JM, Swanton D, Kinsella JP. Acute effects of inhaled nitricoxide in children with severe hypoxemic respiratory failure. J Pediatr. 1994; 124:881-888.

18. Walsh-Sukys MC. Persistent pulmonary hypertension of the newborn. Clin Perinatol. 1993; 20:127-143.

19. Kulik ‘Id, LockJE. Pulmonary vasodilatortherapy in persistent pulmonary hypertension of the newborn.Clin Perinatol. 1984: 11:693-702.

20. Rossaint R, Gerlach H, Falke Sd. Inhalation of nitric oxide—a new approach in severe ARDS. EurJAnaesthesiol. 1994; 11:43-51.

21. Wessel DL, Adatia I, Thompson JE, Hickey PR. Delivery and monitoring of inhaled nitric oxide inpatients with pulmonary hypertension. Crit Care Med. 1994; 22:930-938.

Fig 2.—Oxygenation Index (01) values in 7 responding and 4 nonrespondingpatients to inhaled nitric oxide. Values represent mean ± standard deviation. 01= (Mean airway pressure x FlO, x 100)/Pa02.

70 - Non Responders—0— Responders

60

50

40

aC

130

0

24

TIme (hrs)

.1 0 1

Stwt NO

4

HAWAS MEDICAL JOURNAL, VOL 55, APRiL1996

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Shrinking the Western Pacific:Psychiatric Training for Medical

Students from MicronesiaDykes M. Young MD and David Bernstein MD

In 1989 the Hawaii State Hospital became the primary site for clinicalteaching of psychiatry to students of the Pacific Basin Medical

Officer TraThing Program, a program designed to train clinicians forthe western Pacific. The psychiatry clerkship was developed toprovide practical training in psychiatry to clinicians who willpracticein Micronesia. Challenges encountered by the educators, includingtranscultural issues, are discussed. Interventions found to be effective in resolving these challenges are described.

The RegionThe termMicronesia was originally a cultural designation. How

ever, since the region is inhabited by eight sufficiently diversecultural groups, the term, as a cultural designation, has little meaning. Today the term is used to refer to a geographic area in thewestern Pacific that covers three million square miles of ocean withan area of habitable dry land half the size of Rhode Island. About175,000 people call one of the 2,200 islands ofMicronesia home andreside in one of the four newly created political entities: Belau,Federated States of Micronesia (FSM), Republic of the MarshallIslands, or the Commonwealth of the Northern Marianas.’

At the end of World War II Micronesia came under the jointtrusteeship of the United States and the United Nations. In 1986 theFSM entered into “Free Association” with the U.S.2

Historical BackgroundSince the close of World War II many efforts were undertaken to

supply physicians to the Pacific Island nations.For the most partthese efforts were unsuccessful and the shortage of physicians in thearea continued. Of all the attempts to supply physicians to theregion, the Pacific Basin Medical Officer Training Program(PBMOTP) has been the most successful.

John A, Burns School ot MedicineThe University of Hawaii1356 Lusitana StreetHonolulu, Hawaii 96813

In 1986 the John A. Burns School of Medicine of the Universityof Hawaii (JABSOM) contracted to design and administer a program that would train enough physicians to meet the needs of theU.S.-associated islands of Micronesia. The first class of 23 studentsentered the five year program, based in Pohnpei in January 1987.The program features early introduction to the clinical setting, withbasic sciences integrated over five years. Medical officers initiallyreceived training in psychiatry in Guam. When the Guam facilityclosed, arrangements were made for the students to receive theirpsychiatric training at Hawaii State Hospital (HSH), a psychiatrichospital affiliated with the University of Hawaii.

Overview of the Psychiatry ClerkshipTwo PBMOTP students at a time come to HSH for a six week

psychiatry clerkship. During the rotation the students are housed onthe hospital grounds. The students follow assigned patients. Didactics in psychopathology, psychopharmacology, and child psychiatry are provided by JABSOM faculty. The students attend andparticipate in ward rounds, therapy groups and meetings ofAlcoholics Anonymous. They visit a community mental health clinic andtreat patients on an emergency psychiatric service.

The cultural diversity of the patient population at HSH offers anexceptional opportunity for training for the PBMOTP students whomay treat culturally diverse patient populations when they return toMicronesia.

Specific ChallengesThe islands of Micronesia have few of the distractions of urban

life compared to the island of Oahu, the site of HSH. On some

Pohnpei Public Health Department.

HAWAII MEDICAL JOURNAL, VOL 55, APRIL 1996

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Micronesian atolls there are no automobiles or bicycles. When theyarrive on Oahu some students are distracted by the urban setting andneglect their studies. The clerkship director has found it helpful toallow the students ample time to take advantage of the culturallyenriching opportunities that Honolulu has to offer.

The psychiatry training of students in the PBMOTP poses specificproblems for the educators. Investigators have documented differences between U.S. and non-U.S. physicians in their attitudestoward mental illness.3 The Micronesian students seem to have agreater tolerance for psychopathology than the North Americanstudents. For example, the PBMOTP students are less likely thantheir North American colleagues to perceive auditory hallucinations or loosened association as abnormal. Perhaps this differencebetween North American and Micronesian students is because thesepsychotic symptoms can result in less impairment in Micronesia,where the economy is based largely on fishing or subsistencefarming, than in North America, where the economy is currency-based.

In order to provide the students with training that is culturallyrelevant to the patients that the medical officers will treat, thepreceptors work toward raising the students’ awareness of theWestern medical model of mental illness, but not necessarily towardhaving the students embrace these Western models. None of thecurrent educators has had any clinical experience with psychiatricpatients in Micronesia. An effort has been made to learn from thestudents the kinds of psychiatric problems common to Micronesia.Review of the available literature on psychopathology in Micronesiahas been helpful in tailoring training to meet the needs of the medicalofficers. For example: an unusually high focus of psychotic disorders in Belau has been described.4Educators attempt to provideespecially intensive training in the treatment of psychosis to students who intend to practice in Belau.

The students in the PBMOTP show a passive learning style ascompared to the North American students. They ask few questionsand are hesitant to participate in case discussions even when they areencouraged to do so. The JABSOM faculty has found that patienceand positive reinforcement result in the students taking a moreactive role.

The psychiatric formulary in Micronesia is limited to threeneuroleptics (haloperidol. chlorpromazine, and fluphenazine), threetricyclic antidepressants: carbamazepine, lithium, and diazepam.Many patients at HSH are treated with newer atypical antipsychoticsand serotonin-specific antidepressants. Familiarity with these newer

medications is of little practical value when the students return toMicronesia. The educators make an effort to teach the students howto treat patients with the agents that are available in Micronesia.

Even more challenging to the Micronesian medical officer is thecurrent lack of facilities in Micronesia for measuring serum lithiumlevels. During the clerkship an effort is made to train students to besensitive to the clinical manifestations of early lithium toxicityrather than to rely on serum measurements.

Investigators have reported high rates of suicide in Micronesia.5The PBMOTP students corroborate these reports, especially foradolescent and young men. For this reason considerable effort isinvested in teaching the students how to assess for suicide risk.Rates for alcoholism also are reported to be high in Micronesia. Notsurprisingly, some of the PBMOTP students themselves may havesuffered from alcohol abuse or dependence during their training. Aneffort is made to familiarize the PBMOTP students with chemicaldependency treatment programs at HS H. Though 12-step programsare the mainstay of chemical dependency treatment at HSH, onlyone student has been aware of the existence of an AlcoholicsAnonymous group meeting in Pohnpei. Some of the medical officerstudents have expressed interest in advocating for the developmentof more chemical dependency treatment programs in Micronesiawhen they return.

DiscussionThe PBMOTP has almost reached its original goal of training 80

physicians for Micronesia and is scheduled to come to a close in1996. The psychiatry rotation at HSH has been an enriching experience for both faculty and students. Despite the unique challengesof the clerkship arrangement discussed above, the program issuccessful in providing psychiatric training to medical studentsfrom Micronesia. The authors hope that other students and medicaleducators will benefit from these experiences of the PBMOTPpsychiatry clerkship.

References1 Ashby G, ed. Micronesian Customs and Bellets, Revised ed. Eugene, Oregon: Rainy Day Press, 1983.2. Ashby G, ed. Pohnpe An Island Argosy. Revised ed. Kolonia, Pohnpei; Rainy Day Press. 1983.3, Fernandez-PoI B, Juthani N, Feiner J, Bluestone H. Attitudes of foreign medical graduates toward

mental illness, Academic Psychiatry. 1989;13:39-43.4. Dale PW. Prevalence of schizophrenia in the Pacific sland populations of Micronesia. J Psychiatr Res.

1981; 16:103-11.5. Rubinstein DH: Suicidal behavior n Micronesia. In: Peng KL, Tseng W, (eds): Suicidal Behavior in the

Asia-Pacific Region. Kent Ridge, Singapore: Singapore University Press. 1992:199-230.

UH Pediatric Professor Dr Rudolfo Rudoy with medical officer students on thepediatric ward of Pohnpei Hospital.

Medical officer students participated in the revival of the Pacific BasinMedical Association last year.

HAWAII MEDICAL JOURNAL, VOL 55, APRIL199671

Council HighlightsMarch 1, 1996

Roger T. Kimura MD

The HMA Council was called to order by HMA President CarlLehman MD at 5:31 p.m.

Present: Officers: J. Spangler, President-elect; R. Kimura, Secretary; L. Howard, Treasurer; F. Holschuh, Immediate Past President;AMA Delegates: C. Kam, R. Stodd, AMA Alternate Delegate: A.Kunimoto; Speaker: H.K.W. Chinn; Vice-Speaker and HonoluluCounty President: P. Blanchette; Component Society Presidents: E.Bade, Hawaii; T. Smith, West Hawaii; Councilors: D. Canete, P.Chinn, P. DeMare, C. Fukino, R. Hollison, M. Shirasu, K. Thorburn,R. Wong, W. Young, J. Betwee, B. Shitamoto, P. Kim, C. Kadooka,A. Bairos; Past Presidents: W. Chang, W. Dang, A. Don, G. Goto, S.Wallach; Young Physician Delegate: C. Goto; HMA Alliance: S.Robinson.

HMA Staff: J. Won, B. Kendro, N. Jones, L. Tong, J. Estioko, P.Kawamoto, A. Rogness-recording secretary.

Minutes: The minutes of the February 2 meeting were approved ascirculated.

Dr Lehman reported: (1) that the Communications Commissioner, Dr Howard, will investigate the possibility of video conferenceand telephone conferences of HMA meetings; (2) he attended theChaminade’s Presidential Inauguration; (3) he visited Kauai CountyMedical Society to speak about HMA; (4) he met with the Governorwho signed a proclamation for Doctors’ Day on March 30; (5) heattended the Hawaiian Open which was sponsored by First HawaiianBank; (6) that Dr Roger Kimura and other physicians did a wonderfuljob at the Great Aloha Health and Fitness Expo; (7) he met with a fewresident physicians to activate the Resident Physician Section; 8) thatmeals for committee meetings are to help physicians get through thehour and they are welcome to eat what is served or eat on their ownafter the meeting. (9) The Executive Committee voted to oppose a billproposing a 4% tax on mutual benefit societies.

The HMA Alliance reported: (1) that they are working on aproject called Stop America’s Violence Everywhere and will belooking for donations; (2) they are selling a cookbook called Just Whatthe Doctor Ordered which will support the Parkinson’s SupportGroup and the Children’s Advocacy Center; (3) they are helping tosell books authored by Dr Ruth and Senator Matsuura at $8 a book or$50 for 8 books; (4) the Alliance will produce the talent portion of theDistinguished Medical Reporting Awards. They are encouragingphysicians to buy a table for the DMRA.

For Action• A motion was passed by Council to approve the Public Relations

DMRA budget. Any profit from the event will be equally dividedbetween the HMA and the HMA Alliance.

• A motion was passed by Council to support the concept ofregional boards where community hospitals are situated.

• Council approved the Annual Meeting Committee’s recommendations one to five on the financial aspects of the meeting. The banquetfee will be $62.50. The travel costs for exhibit booth installers need tobe reviewed.

Council also approved the committee’s recommendation No 6that HMA sports events be open only to registered attendees of theHMA Annual Meeting.

A motion was passed by Council to change the name of the

Sunday seminar to The George H. Mills, MD Symposium with asubtitle that can be changed annually.

• Council approved the Annual Meeting Ad hoc Committee’srecommendation that the HMA Annual Meeting/Arrangements Committee proceed with planning of the 1997 Annual Meeting under thecurrent structure until the results of a proposed membership survey arereceived and reviewed.

• A motion was passed to support the concept of restoring thefunding for general assistance as a basic public health issue.

Component Society ReportsMaui.—Dr Shitamoto reported that Maui County will meet next

week.Kauai.—No report.West Hawaii.—Dr Smith reported that a county meeting on the

changing health care scene in Hawaii will be held.Hawaii.—Dr Bade had no report.Honolulu.—Dr Blanchette reported that there are several county

meetings in the planning process. She showed Council the first issueof Hawaii Medical News and thanked Jan Estioko for her assistance.To improve the contents of the newsletter, please contact Jan witharticles, etc.

For InformationLegislative.—Dr Howard reported that: (1) the Peer Review bill

was held in the Senate Judiciary Committee; (2) the Informed ConsentBill was also held by the Senate Judiciary Committee. The Houserevision was never heard by the House Judiciary Committee; (3)Immunity for hospitals or health care organizations who contributemedical data information to the Hawaii Health Information CouncilInc is likely to pass; (4) a surrogate medical decision maker bill whichallows family members or partners to serve as the surrogate decisionmaker; passed out of Senate and will go to the House.

Dr Kam reported on the Workers’ Compensation Administrationbill that calls for a managed care system for Workers’ Comp. HMAgave testimony in favor of alternate ways ofproviding health care. Theprogress of the bill will be monitored.

SHPDA.—Dr Holschuh introduced Marilyn Matsunaga, actingadministrator for SHPDA. She is interested in cutting red tape andstreamlining. In the last few months a test case was done to see howfast the agency can process a standard CON application. It was donein two months. She is hoping to implement this as the standard for theagency. She looks at SHPDA as one place where community grassroots people can have access to providers in a fair and consistentlyformal atmosphere. Some physicians at Council did not agree with herand she will be forwarded a copy of the Florida review which says thatSHPDA allows the formation of cartels, etc.

Credential Verification Service (CVS).—Dr Lehman reportedthe CVS Committee is working on options. A phone conference isplanned for March 5 with CIVS. The CVS Board will also address thecontrol of data.

Hawaii Health Foundation.—Dr Shintani is forming a group andwas funded S300,000 to study the diets of Hawaiians and healthproblems in Hawaii.

The meeting was adjourned at 8 pm.

HAWAII MEDICAL JOURNAL, VOL 55, APRIL 1996

72

Classified Notices

To place a classified notice:HMA members—Please send a signed and typewrittenad to the HMA office. As a benefit of membership, HMAmembers may place a complimentary one-time classifiedad in HMJas space is available.Nonmembers.—Please call 536-7702 for a nonmemberform. Rates are $1.50 a word with a minimum of 20 wordsor $30. Not commissionable. Payment must accompanywritten order.

Office Space

Medical Arts BIdg.—250 sq ft to 997 sq ft office spaceavail. Pharmacy, x-ray lab; Clinical Laboratories ofHawaii on-site. Call Chrissy Young (S), 524-2666.Pearl City Business Plaza.—Long leases; 680+ sq ft;24 hr security; free tenant/customer pkg; availablenow; call 531-3526 Gifford.Fully furnished medical office space for rent.—Full/partial days. Opportunity to participate in clinicaltrials with established clinical research institute. Excellent Kakaako location in newly renovated building.Laboratory, x-ray, nuclear medicine on site. Additionalphysician support, including medical billing. Call 592-2639.

Position Available

Lahaina, Maui, Hawaii.—B/C/BE FP Well-establishedmulti-specialty group. Ambulatory care, minimal call.Position available summer 1996. Send CV to Dr Gilbert, 130 Prison St, Lahaina, HI 96761.

Locum Tenens

Radiologist.—Available on short notice for bourntenens. Full or part time, any island. (808) 875-9794.

For Sale

For sale.— ASSI microsurgical instruments, md forceps, needleholders, scissors, etc. in metal case anddemagnetizer. Never used. Paid $1400. Asking $600.Keeler magnifying loupe. Never used. Pd $1000. Asking $500. Phone 988-6449 (evenings).

Practice For Sale

Medical office available.— Ala Moana Building. Willconsider all offers. Call (808) 955-6666.Beautiful rural Hawaii.— Southpoint area of the BigIsland. Solo family practice. Mostly outpatient. ERcoverage available. Flexible terms, (808) 929-9827.

Office to Share

Office to share.— Physician has space to share.Flexible arrangements. Kahala Mall, Office Tower.Call 735-7681.

Announcements

Grand Opening.— Waikiki Gallery at the Aston ParkShore Hotel, 2586 Kalakaua Aye, Opening art exhibitLouis PohI and Juanita Kenda.* A portion of sale toHMA members supports HMA. For more info call (808)922-7701.

The Most Essential Part of This Office SystemMay Be Dan. Or Ed. Or Helen.

A warranty is only as good asthe people who stand behindit. At Servco Office Systems,our people are ypir mostimportant resource.

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JOURNAL, VOL 55, APRIL199673

The Weathervane Russell T. Stodd MD

Repentance is not so much remorse for what wasdone as fear of the consequences.

Rarely does the federal government file criminal antitrust charges againsthealth care professionals, but it happened for only the second time in 50years. The Justice Department proceeded successfully against the LakeCounty (Texas) Optometric Society charging that the group conspired toraise, fix, and stabilize the price of eye exams. The defendant pleaded guiltyand agreed to pay a fine of S75,000 and the group has since disbanded. TheTexas Optometric Association (Lake County was once a member) has takenno position on the case.

We hate the people we love because they are theonly ones who can hurt us.

An H TV-positive man was hospitalized in a Florida hospital and was to betransferred to a hospital in Alabama. Because travel could not be arrangedby ambulance, the patient’s brother came from Mississippi to provide thetransportation, but he did not know that his brother had AIDS. In transit aheparin lock was dislodged from the patient’s arm, and fluid from the locksite contacted the brother’s hands where he had multiple scratches from arecent fishing trip. Now the brother is HIV positive, and he brought suitagainst the Florida hospital. The Florida Supreme Court ruled that thecomplaint was not a claim for medical malpractice, and it was disallowed.

We are inclined to judge ourselves by our ideas;others by their acts.

W. Andres Harris MD, an ophthalmologist in Salem, Oregon, has againdemonstrated that one man can make a difference. After learning that theU.S. Army was developing laser weapons that cause permanent blindness,Dr Harris wrote letters and articles calling public attention to improper useof this remarkable tool. Serving on the Board of Directors of Physicians forSocial Responsibility, Dr Harris prodded the Board into forcing the Pentagon to abandon plans to spend $17 million to develop and purchase 75 of thehigh-tech weapons. Now, both the Department of Defense and the UnitedNations have adopted policy banning the use of lasers specifically designedto blind enemy forces.

You can fool all the people all of the time if theadvertising is right and the budget is big enough.

About 12 years ago a prescient observer stated that radial keratotomywould not generate much market pressure because it required no majorpiece of technical equipment, and therefore no major industrial investment.With laser surgery, the opposite picture prevails as the media is planted withnews stories. multiple educational symposia are offered, and daily mailersarrive promoting participation in an income-generating laser project. Tensof millions of dollars have been invested in the manufacture and certification of exotic lasers for PRK and cosmetic surgery,and the medical/industrial complex must be rewardedfor risking their capital.

Hurry, Hurry, Hurry! Ladies andgentlemen, step right up and get...

The excimer laser photorefractive keratectomy(PRK) promoters have arrived in Hawaii. One planoffers, with just a $250 annual contribution, thesurgeon can enjoy the privilege of referring his or herpatient for laser refractive surgery which will beperformed by the chosen ones. In return, the operating surgeon will kick back 40% of the laser fee, for“pre and post-op care.” PT. Barnum lives!

A man’s dying is more the survivors’affair than his own.

Dr Gerald Klooster, Sr, a retired obstetrician, hasdeveloped Alzheimer’s disease. A psychiatric cx-

amination of the patient’s cognitive capacity revealed “severely impairedwith a score of 2 out of 30,” including inability to identify a wristwatch ordescribe how it was used, or to identify the month, year or location of thetest. According to Dr Jack Kevorkian’s attorney, the patient, in companywith his wife, provided a notarized statement that he was mentally competent and declared “that he does not want to go through the throes ofAlzheimer’s.” Dr K’s attorney, Geoffrey Fieger, added that the “rest of thefamily is very supportive, except for one son (Dr Gerald Klooster. Jr, DO)who wants to declare his father mentally incompetent.” In fact, Dr Klooster,Sr, has three other sophisticated, adult offspring, who have said only thatthey were against assisted suicide. Right-to-die activists claim that the caseillustrated why we must have legalized euthanasia with strictly enforcedsafeguards, but opponents claim there is no way to protect the patient fromoverzealous friends or family members who wish them to exert their rightto die with dignity. Meanwhile, Dr Kevorkian has opted out and wants nopart of the family dispute.

God is love, but get it in writing.“Be careful out there,” goes a current parting phrase, and with good

reason. In this era of defining informed consent, who are your friends, CYA,etc, it turns out that the HMOs are providing heavy financial support for theGOP, with not so much being spent on Democrats. Just two years ago in1994, 12 of the largest HMOs contributed 60% of their campaign dollars tothe Democrats, but in 1995, that number dropped to 25%, with 75% toRepublicans, a dramatic reversal. The reason is simply that Republicanplans for overhauling Medicare could result in doubling the number ofbeneficiaries in HMOs over the next seven years, and that would amount toabout $85 billion in new business for the merchants ofmanaged care. Don’tforget the Golden Rule of the 1990s.

There were giants in the earth in those days.Forgotten in the heat of Congressional jabberwocky is the fact that

President Harry S. Truman in 1947 recommended term limits of 12 years forall Congresspersons (and the incumbents didn’t like it then either).

Addenda+ HMO premiums are up, medical service is more restricted, but CEOs

of HMOs average income is more than double the CEO nationalaverage.

+ Ski injuries have increased 300% since 1985.+ A professor is one who talks in someone else’s sleep.

Aloha and keep the faith—rts.

CHUN & RUDY

Attorneys at LawREPRESENTING HAWAII’S DOCTORS

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HAWAII MEDIcALJ0uRNAL VOL 55, APRIL 1996

74

Insurancefrom MIECMakesGood Sense

Physician owned and directedPhysicians started MIEC in 1975 when commercialcarriers refused to insure professional liability orprohibitively raised rates.

No sales and marketing staffMIEC doesn’t pay sales commissions. We don’t have amarketing staff. Our operating expenses are lower. Ourfull attention and financial obligation is to ourpolicyholders: to defend them, to advise them aboutpreventing claims, and to answer their questions onpractice liabilities, including managed care.

Lower premiums, dividendsMIEC has maintained the same rates for Hawaiiphysicians for the past five years. When claimsexperience is better than expected, MIEC also grantsdividend credits. In 1996, these credits will once againreduce out-of-pocket malpractice insurance costs ofrenewing Hawaii policyholders an average of 40%.

MIEC, your best long-term answerto malpractice insurance.

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