Current Issue
Spring 2014
BMM Current Issue
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Letter from the Dean
Big News for Little Patients
Brown’s affiliated hospitals provide outstanding care for the citizens of Rhode Island and beyond. An excellent example is Women & Infants Hospital, one of the busiest obstetrical and gynecological hospitals in the  country. A state-of-the-art Neonatal Intensive Care Unit (NICU) has just opened there, as described in the cover story of this issue of Brown Medicine.

The new chair of Obstetrics and Gynecology, Dr. Joanna Cain, recruited from the University of Oregon in 2008, is a nationally recognized leader who in her first year has already brought to Brown outstanding leaders in several specialties of obstetrics and gynecology. She and Dr. Jim Padbury, chief of neonatal medicine, oversee a team that provides the most up-to-date care available for infants who are premature or have serious medical conditions. Women & Infants CEO Connie Howes, the board, and the staff should be congratulated on the new NICU—a wonderful achievement.

My wife, Rena, and I recently had the first-year class of Alpert Medical School at our house for a backyard reception. The members of this class come from 25 states, Washington, DC, Canada, and Pakistan. Harvard is the second-most represented undergraduate institution after Brown. The students have arrived via different paths, including the PLME (Brown’s eight-year combined degree program) and postbaccalaureate (premed programs at Johns Hopkins, Bryn Mawr, Goucher, and Columbia) routes. Many have come after years in the pursuit of other careers. For example, the class includes a lawyer, a former writer for Seinfeld, an Army paratrooper, a graduate of Dillard University (President Simmons’ alma mater) who spent a year in Madagascar and earned two masters degrees, and a Navy veteran who served on a nuclear submarine. This diverse class brings tremendous talent to Alpert Medical School, Brown University, and Rhode Island.

It is a privilege to serve as their dean.  You can read more about why they have chosen to pursue medicine in this issue.

Letter from the Editor
Years ago I had a friend whose son had been born prematurely.I first met him as a wiry, bright,energetic 8-year-old. My son,several years younger, had weighed seven pounds at birth,and it was hard for me to imagine just how profoundly small this other child had been.

“Five hundred grams,” my friend said.“Like a big steak.”

It’s a bit of a commonplace to say that as your children get bigger, so do the problems you’ll have to deal with. Extremely premature babies turn that saying on its head. They seem impossibly small—a 24-weeker can fit in the palm of your hand—but right from the start their challenges are as immense as their bodies are tiny. As Vicki Forman wrote in This Lovely Life, her excellent memoir of having premature twins, to a certain extent these infants are “bodies to preserve, a collection of levels (sugar,oxygen, blood pressure, respiration) to manage.” They risk brain hemorrhages, life-threatening infections, blindness, and, later, cerebral palsy, learning disabilities, and a multitude of other complications.

The cover story in this issue focuses on the latest in neonatology as manifested in Women & Infants Hospital’s state-of-the-art neonatal intensive care unit, or NICU. The field is complex and fascinating, and the article introduces many important questions we have yet to explore—about why there are now more than half a million premature births each year in this country, about the toll the experience takes on parents, about cost, outcomes, and quality of life. There is, after all, more to life than survival. But for the preemies and families who end up at Women & Infants, a great NICU is a good place to start.

Letters to the Editor
Adrenaline Junkie
As I read Kris Cambra’s article “Expect the Unexpected,” (Brown Medicine, Winter 2009) my mind was flooded with thoughts of my own experiences as an emergency physician and the challenges that we continue to face. In 1979, I knew upon graduation from Brown Med that the emergency department (ED) was the place for me. I had completed two month-long rotations in the ED at Rhode Island Hospital and I loved to “hang out” in The Miriam Hospital ED. There was something about the pace, mobilization, and call to action when that “bad case” came through the door that appealed to my adrenaline needs. Although expressing interest in  completing a residency in Emergency Medicine, I was strongly discouraged by some advisors that it was a field without academic credibility.

My internal residency training in New York City was excellent, but I was most fulfilled when working in the hectic and sometimes chaotic environments of the inner city EDs. I felt that I was reaching people at their
greatest point of need. I did not envision myself treating chronic diseases in a doctor’s office somewhere. So after some additional training in trauma, I took an attending position in the ED at Harlem Hospital, where I
remain to date.

The early years in the Harlem ED were a fairly stark contrast to my experiences in the Rhode Island hospitals.
The Harlem community was ensconced in the midst of a crack cocaine epidemic and major trauma was regular daily occurrence. Penetrating trauma (gun shot wounds and stabbings) were a fairly rare occurrence even at Rhode Island Hospital. At Harlem, it was unusual not to see three or more of these victims daily. I recall a midnight shift where we received seven gunshot and two stabbing victims between the hours of midnight and 9 a.m. Patients with bacterial endocarditis, active tuberculosis, and all manifestations and complications of HIV disease were regular presentations in our ED.

I was also struck with the apparent lack of primary care access for many of my patients. Many used the ED for minor problems, medication refills, and many other conditions that clearly could and should have been managed in primary care settings. As a medical student at Brown, I was often admonished to call the patient’s PCP after my evaluation in the ED. At Harlem, ED patients generally did not have or could not identify a primary care provider. We attempted to provide good discharge planning with appointments to our on campus or community clinics, but 70 percent of the time, patients were “no shows.” The real tragedies occurred when so many of these patients returned to the ED with catastrophic presentations of stroke, acute coronary events, end-stage renal disease, etc., because their risk conditions were not managed appropriately.

Harlem and similar communities in NYC have changed considerably over the last 30 years. There is now million dollar housing in Harlem and gentrification in the area is remarkable. We are still challenged with a hard core group of patients who struggle with alcohol and drug addiction, poverty, homelessness, violence and, for some, mistrust of the medical establishment. At Harlem, close to 90 percent of the inpatient admissions still come through the ED. Similar to the Brown hospitals we are an academic department with a home at the medical school (Columbia University College of Physicians and Surgeons). Residents, PAs, and other medical personnel train at our hospital. Harlem hospital has alsobeen a training site for military medicalcorpsmen to provide experience in managing “war-type injuries.”

As my Brown colleagues expressedso well, we pride ourselves on being able to handle any situation that may come through the door of our emergency departments. No one gets turned away even if their condition is not of anemergency nature. During periods of economic downturn, stress and even reports of “swine flu,” the volume in EDs tends to increase. Although I have“matured” considerably over the last 28 years, I still work several evening and night shifts clinically to take care of patients and fulfill my diminished but still present adrenaline needs.

Reynold L. Trowers, FACEP ’75 MD’79
Director, Emergency Department, Harlem Hospital Center

Nice Work
The spring issue of Brown Medicine was a pleasure to read—and to look at. The layout and graphics were easy on the eye and added positively to the variety of articles in the issue. Your cover story on Darwin (“A Shropshire Lad”), with its several contributors, was a highlight.

Keep up the great effort!

Rick Marshall ’71, P’10

More Primary Care, Stat
I was pleased to see the mention of the Rhode Island Area Health Education Center (RI AHEC) in the most recent issue of Brown Medicine (Spring 2009).

The article on the patient-centered medical home was especially pertinent to the work of the RI AHEC 
Program and its three affiliated centers operating in Rhode Island’s medically underserved communities, and to that of many of the AHEC programs in 52 medical schools, two nursing schools, and 220 community-based centers in 48 states.

I was also delighted to see a number of other Alpert Medical School initiatives and student and faculty profiles that had direct and indirect connections to RI AHEC. Each of these, in some fashion, supports the recruitment, retention, and continuing education of the primary health care workforce, particularly increasing access to quality health care for underserved populations. The National AHEC Program has a nearly 40-year history of influencing health policy and practice, and RI AHEC is proud to be one of the links between academic programs and local communities working to improve health outcomes and the supply, distribution,
and diversity of the primary health care workforce.

Robert M. Trachtenberg, MS
Associate Director, RI AHEC Program
Teaching Associate in Family Medicine, Alpert Medical School
President, National AHEC Organization

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