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Satcher’s
message of prevention
In visit to Yale, surgeon general
cites public health challenges
Human behavior, according to
Surgeon General David Satcher, M.D., Ph.D., is the most important
factor in the public health challenges facing the nation. In
conversations with students and in a speech to library associates
this spring, Satcher said that smoking, poor nutrition and physical
inactivity are responsible for hundreds of thousands of deaths
each year. Half of all deaths derive from nine behaviors, he
said in his keynote address, “Toward a Balanced Community
Health System: Opportunities and Challenges,” delivered
March 24 at the 51st annual meeting of the Associates of the
Cushing/Whitney Medical Library. And medicine expends a disproportionate
amount of its resources on treatment of late-stage disease rather
than health promotion and disease prevention, he said.
Treatment, he pointed out, fails
to reach all social groups and classes equally. “We have
the most sophisticated health care system in the world,”
he said. “Yet there are tremendous disparities on the basis
of race and ethnicity. An African-American baby born in this
country is two times as likely to die in the first year of life
as a majority baby.”
Over lunch he took questions
from medical, public health and nursing students who had traveled
abroad on research fellowships or spent time working in inner-city
hospitals and homeless shelters. What, asked Kebba Jobarteh,
did Satcher think about controversial AZT trials designed to
reduce vertical transmission of HIV in the Third World? “We
were criticized by people I respect a lot,” answered Satcher,
who, as director of the Centers for Disease Control and Prevention,
endorsed the trials that used placebos in a control group. The
study found that use of AZT could reduce the spread of AIDS from
pregnant mother to child, even if the first dose is administered
during labor. “That controversial study is saving thousands
of lives every day,” Satcher said.
Did he foresee, asked Rachel
Lovins, any changes in the nation’s health insurance system? “There
is no way we are going to control costs as long as we focus on treatment of patients
after they are sick,” he said. “There is not enough incentive for health
promotion and disease prevention.” Satcher expressed hope that frustration
with the current system would pave the way for his balanced approach.
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Yale
delegation brings high-tech care to remote corner of Peru
Two Yale plastic
surgeons traveled to the Peruvian Amazon in March, where they
performed about 80 operations for people in need of corrective
surgery. John A. Persing, M.D., chief of the section of plastic
surgery, and Joseph Shin, M.D., HS ’97, assistant professor
of plastic surgery, went as part of Interplast, an agency that
sends doctors around the world to do charitable work. Their trip
to Iquitos, Peru, a port on the Amazon accessible only by air
or water, was sponsored by the Ronald McDonald House. Interplast
was founded in 1965 by Yale alumnus Donald R. Laub, M.D. ’60,
HS ’63, now at Stanford University.
The surgeons
each spent a week in Iquitos, part of a team of 16 people that
included nurses, an obstetrician-gynecologist and a pediatrician.
Of the 80 operations Persing and Shin performed, most were for
cleft lip and palates. They also operated on burn patients and
removed a tumor on the nose of a 90-year-old woman. “We
try to serve the needs of the local population,” said Shin,
“although the emphasis is on cleft palates and congenital
malformations.” This was Shin’s second trip on behalf
of Interplast and Persing’s fifth since 1993.
As part of
their program they are following up on their patients’ recoveries via information
sent by local doctors on the Internet. Two Web sites, http:// www.wiredMD.com
and http:// yalesurgery.med.yale.edu, carry the information. Part of the doctors’
mission is to provide training to local physicians, both during their visit and
afterwards over the Internet. “The initial goal,” says Persing, “is
to provide service for people who would not be able to afford care. The secondary
goal is to magnify our effect by teaching local surgeons how to do the work.”
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Telemedicine
proves its mettle
on Mt. Everest
In May 1998, a team of Yale physicians
trekked to the slopes of Mt. Everest to provide medical support
for climbers and to conduct research on the body’s response
to high altitude and thin air. They brought along equipment to
record how fast climbers’ hearts pumped and how well their
lungs worked in those extreme conditions on the world’s
highest mountain.
At the core of the expedition
was a system to transmit that information from climbers high
on the mountain to the expedition’s makeshift medical center
at the Everest Base Camp at 17,500 feet, and then around the
globe to New Haven.
This spring, a second Yale team
returned to Everest to continue the work of that first expedition
and quickly found an opportunity to prove the value of telemedicine
in an emergency. On May 14, as physicians on the mountain were
beginning their daily videoconference with colleagues in New
Haven, a climber stumbled into the medical tent, wheezing and
coughing. The climber had reached Everest Camp Four, at 26,000
feet above sea level, before turning back with breathing difficulties
that worsened even as he descended into the fuller air of lower
altitudes.
Tests showed that his blood oxygen
was low and that little air was moving through the lower part
of his lungs. Suspecting either pneumonia or the potentially
fatal condition known as high-altitude pulmonary edema, his physicians
used the expedition’s electronic network to consult in real
time with their colleagues in New Haven. They sent ultrasound
images of the climber’s lungs, along with digitized blood
smears and sputum samples, to Yale for further analysis, and
the diagnosis of pneumonia was confirmed. The clinical data traveled
the 15,000 miles in an instant — by satellite from Base
Camp to a relay station in Malaysia, then to the United States
and onto Yale via the Internet.
After two days of antibiotics,
oxygen and an IV to treat dehydration, the climber left the medical
tent. “He was able to walk down to lower altitudes, where
he continued to improve,” said Richard Satava, M.D., of
the Commercial Space Center for Medical Informatics and Technology
at Yale, which was responsible for the expedition. Yale’s
partners in the expedition were the Explorers Club and Millennium
Healthcare Solutions Inc. Olympus America was a major sponsor
of the expedition. Ronald C. Merrell, M.D., former chair of surgery,
was the driving force behind the school’s telemedicine efforts.
The consultation that spanned
an ocean and two continents proved the viability of the communications
technology, which is being developed for the National Aeronautics
and Space Administration. “We are hoping that the success
of this year will be enough to encourage NASA to put some of
these things on the space station and the mission to Mars,”
Satava said.
The expedition’s research
also expanded knowledge of the effects of hypoxia on the cardiovascular
system. Previous studies concentrated on the pulmonary system,
Satava said. “We now have specific measurements about how
the heart and blood vessels adapt to low oxygen,” he said.
Last year’s lesson was that
a telemedicine station in remote terrain could transmit to a
medical center thousands of miles away, said Peter Angood, M.D.,
program director for the Yale Surgical Critical Care program,
and a member of the support team at Yale. But during that first
expedition the technology was not always successful. Personal
status monitors, designed to measure climbers’ temperature,
heart rate, breathing and location, often failed to transmit
the information to Base Camp. This year climbers successfully
repositioned repeaters, the line-of-sight devices that transmit
data from the climbers’ monitors to Base Camp. Upgraded
personal status monitors proved better able to transmit data
to Base Camp than last year. On May 12 three climbers wore them
on a trek to Camp One at 21,000 feet, while the Yale support
team monitored them in real time.
Physicians on the team again
opened a clinic at Base Camp, where they treated routine high-altitude
ailments — headaches, insomnia and gastrointestinal disorders
— as well as medical emergencies such as frostbite and physical
injuries. The expedition team included a resident in ophthalmology
who conducted research into the effects of high altitude on sight.
“Surprisingly,” said Angood, “there is very little
good research on what happens to the eyes in high altitude. With
the pressure changes the contours of the eyeball itself change.”
On May 18, M. Bruce Shields, M.D., chair of ophthalmology and
visual science, consulted with the resident, Jennifer Grin, M.D.,
on a case of retinal hemorrhage. A video fundoscopic exam had
revealed the hemorrhaging, and Shields also identified venous
congestion in the retina.
In addition to caring for sick
and injured climbers, the team’s physicians conducted regular
tests on a core group of seven climbers. Every other day the
climbers went through a 90-minute exam that measured, among other
things, cardiac output, oxygen saturation, mental and visual
acuity and cognitive functions. The tests started before the
team members left the United States so their physiological measurements
at sea level could be compared with readings in the mountains.
The team’s medical devices included a small camera that
fits under the tongue and reveals how small blood vessels change
shape and caliber.
The next step in the project
is, Satava said, “up in the air.” An expedition to
Everest, or another remote site, depends on the results of this
year’s research and the availability of corporate support.
“There are other environments that similar concepts and
ideas could be tested out on,” Angood said. “It doesn’t
have to be Everest.” |
