Sombrero November 2014

Sombrero
Pima County Medical Society

Home Medical Society of the 17th United States Surgeon-General
NOVEMBER 2014
Ebola = donations
Dr. G. Mason Garcias
direct-pay way

Valley Fever Awareness Week
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SOMBRERO November 2014
Sombrero
Pima County Medical
Society Officers
Official Publication of the Pima County Medical Society
Michael Connolly, DO
Michael Dean, MD
Howard Eisenberg, MD
Afshin Emami, MD
Randall Fehr, MD
Alton Hallum, MD
Evan Kligman, MD
Kevin Moynahan, MD
Soheila Nouri, MD
Wayne Peate, MD
Scott Weiss, MD
Leslie Willingham, MD
Gustavo Ortega, MD (Resident)
Snehal Patel, DO (Resident)
Joanna Holstein, DO (Resident)
Jeffrey Brown (Student)
Jamie Fleming (Student)
President
Timothy Marshall, MD
President-Elect
Melissa Levine, MD
Vice President
Steve Cohen, MD
Secretary-Treasurer
Guruprasad Raju, MD
Past-President
Charles Katzenberg, MD
PCMS Board of Directors

Eric Barrett, MD
Diana Benenati, MD
Neil Clements, MD
Executive Director
Bill Fearneyhough
Phone: 795-7985
Fax: 323-9559
E-mail: billf 5199@gmail.com
Editor
Stuart Faxon
Phone: 883-0408
E-mail: tjjackal@comcast.net
Please do not submit PDFs as editorial copy.
Advertising
Phone: 795-7985
Fax: 323-9559
E-mail: dcarey5199@gmail.com
Art Director
Alene Randklev, Commercial Printers, Inc.
Phone: 623-4775
Fax: 622-8321
E-mail: alene@cptucson.com
Spectacular Views
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Members at Large
At Large ArMA Board
R. Screven Farmer, MD
Donald Green, MD
Veronica Pimienta, MD
Pima Directors to ArMA

Timothy C. Fagan, MD
Timothy Marshall, MD
Board of Mediation
Timothy Fagan, MD
Thomas Griffin, MD
George Makol, MD
Mark Mecikalski, MD
Edward Schwager, MD
Delegates to AMA
William J. Mangold, MD
Thomas H. Hicks, MD
Gary Figge, MD (alternate)
Arizona Medical
Association Officers
Thomas Rothe, MD
immediate past-president
Michael F. Hamant, MD
secretary
Printing
Commercial Printers, Inc.
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Publisher
Pima County Medical Society
5199 E. Farness Dr., Tucson, AZ 85712
Phone: (520) 795-7985
Fax: (520) 323-9559
Website: pimamedicalsociety.org
SOMBRERO (ISSN 0279-909X) is published monthly

except bimonthly June/July and August/September by the
Pima County Medical Society, 5199 E. Farness, Tucson,
Ariz. 85712. Annual subscription price is $30. Periodicals
paid at Tucson, AZ. POSTMASTER: Send address
changes to Pima County Medical Society, 5199 E. Farness
Drive, Tucson, Arizona 85712-2134. Opinions expressed
are those of the individuals and do not necessarily represent the opinions or policies of the publisher or the PCMS
Board of Directors, Executive Officers or the members at
large, nor does any product or service advertised carry the
endorsement of the society unless expressly stated. Paid
advertisements are accepted subject to the approval of the
Board of Directors, which retains the right to reject any
advertising submitted. Copyright 2014, Pima County
Medical Society. All rights reserved. Reproduction in
whole or in part without permission is prohibited.
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3
Inside
5 Letters: Public Health Committee urges
Correction
donations to Medicins Sans Frontieres.
6 Milestones: Whats up with doctors Hutchinson,

Ruben, Tretbar, Power, and Scully.
In our October Milestones item about Desert Sun Gastroenterology,

we mis-identified Dr. Craig Gross as Cross. We apologize for the typo.
8 Membership: Dr. G. Mason Garcias cardiology
On the Cover
10 In Memoriam: Longtime Tucson pediatrician Dr.

Sandra M. Smith died in July.
Dr. Hal Travelin Tretbar, PCMSs unofficial official photographer,

recalls that he and his wife, Dorothy, were heading east on Broadway late on an August afternoon when the stormy clouds looked like
they would develop some color at sunset. So they headed to Saguaro
National Park East for a potential photo-op.
the direct-pay way.
12 PCMS News: Working on licensing; Ebola
We stopped at Freeman Road and climbed a small hill to look back

at the light on the Catalinas, Dr. Tretbar said. The soft, slanting
light was illuminating the backside of the front range, giving a sense
of depth that is not apparent in harsh midday sunlight.
awareness; AZ in NVDRS.
17 Valley Fever: FDA fast-tracks NikZ; VF

Awareness Week events.
19 Bioethics: A hospice case vignette by Dr. David

Jaskar.
22 Time Capsule: Rains notwithstanding, TMC
works to bring back history.
24 Makols Call: Dr. Makol gives himself a good

talking-to about the future.
26 CME: Credits locally and out-of-town.
This image was taken at 6:09 p.m. with a Nikon D7000 with the 1805mm 3.5/5.6 lens set at 105mm. Exposure was 1/400th second at
f5.6 at ISO of 250, normal program and matrix metering. The flash
was not fired. I used the faster shutter speed because the camera
was hand-held and I was using the longest focal length.
Because of how a digital image is recorded, almost all photos need
some tweaking to get the desired result. In Photoshop Elements 9,
I adjusted the contrast and removed most of the blue haze by using
the Hue/Saturation setting. I clicked the Master button and chose
blue to partially desaturate it. The final step was to sharpen the image
with the unsharp maskwhich would be another long explanation!
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4
Leers
An open letter:
The fight against Ebola
To the Editor:
As I write on Oct. 9, the number of Ebola cases in Africa is around
7,000; half of the victims have died.
By the time you read this, these numbers will be significantly
higher. This unprecedented outbreak is mostly limited to Sierra
Leone, Guinea, and Liberia, but cases were also reported in
Nigeria, and now we have had a case in the US.
This outbreak represents a grave threat to the stability of those
countries, and in this age of global travel, all countries are at risk. The
usual resources such as the World Health Organization, United
Nations, NGOs and the countries themselves, are severely challenged
regarding personnel and material resources to fight this disease.
Most supplies necessary to control this epidemic are neither
esoteric nor costlygowns, gloves, masks, eye shields,
disinfectant, IV solutions, surgical caps, etc. In addition, a major
educational effort is needed in order to contain the disease, and
there are cultural barriers in West Africa to contend with. The
worlds response has been sluggish until recently. The best hope
for control is acting now, while the disease is relatively localized.
In recognition of the importance of fighting Ebola, the Public
Health Committee of the Pima County Medical Society voted
unanimously on on Oct. 9, 2014 that PCMS should encourage
donations to Doctors Without Borders (Medecins Sans Frontieres)
to help in the battle against Ebola. The PCMS Board of Directors
has endorsed this position.
Doctors Without Borders has assumed the lions share of
responsibility, putting essential medical personnel and
equipment on the front lines, and they desperately need
additional funding and support. The Public Health Committee
knows they are reputable, reliable and dedicated, and the Ebola
outbreak is the greatest health crises they currently face.
We encourage Society members and all others to give donations
to: www.doctorswithoutborders.org. These donations can be
earmarked for the Ebola outbreak. We have confidence that
these funds will be used wisely.
Sincerely, Norman Epstein, M.D
on behalf of the PCMS Public Health Committee n
STARonSthe
Save that date!
The date is April 18,

2015, and the reason is the
return of Stars on the
Avenue!
Pima County
Medical Society
So thats SOTA, April, 18,
2015, 7 p.m. at St. Philips
Plaza, Campbell at River,
4280 N. Campbell Ave.
We will have more information monthly as the
time nears!
ve
bell A
Camp
AVENUE
PRESENTED BY THE
Milestones
Dr. Scully elected

VP of TheWestern
Thomas B. Scully, M.D.,
F.A.A.N.S., neurosurgeon with
Northwest NeuroSpecialists,
was recently elected vicepresident of the Western
Neurological Society. The
Western is considered the
premier neurosurgical society in
the Western U.S. and Canada.
Membership is by invitation
only. Dr. Scully has been an
active member since 2005.
He has previously served as
membership chairman on the
Scientific Program Committee, and is also current Bylaws chairman.
Dr. Scully came to Tucson in 1994 and has been in private practice
since. He has been a PCMS member since relocating to Tucson,
and he has previously served as a PCMS Board member. His
neurosurgical practice includes general neurosurgery with an
interest in cervical spine and minimally invasive procedures.
Comings, goings at Camp

Lowell Medical Specialists
Jerry Hutchinson, Jr., D.O. and Shivani S. Ruben, M.D. are the
latest additions to the IM practice Camp Lowell Medical
Specialists, where they join PCMS members Timothy Fagan,
M.D., Daniel Graybill, M.D., Ob-Gyn Laurene Goll, M.D. and
dermatologist Mireille (Mimi) Algazi, M.D.
Dr. Hutchinson, a PCMS member since 2007, takes over the
practice of the retired Donald Leiberman, M.D. Also, were told
that Jenora Jolly, M.D. has left the practice to raise her new baby.
Dr. Hutchinson is a 1985
graduate of ATSU College of
Osteopathic Medicine in
Kirksville, Mo. He did his IM
internship and residency at
Tucson General Hospital. He is
a Fellow of the American
College of Osteopathic
Internists, and just finished a
two-year term chairing the
Tucson Osteopathic Medical
Foundation Board of Directors.
Dr. Hutchinson has practiced
ambulatory and hospital-based
internal medicine. He has been
involved with Resident education as a clinical preceptor instructor
through the various schools and training hospitals serving Tucson.
6
Dr. Ruben earned her

undergraduate degree at the
University of California at
Berkeley, and her M.D. in 2011
at St. Georges University, St.
Georges, Grenada, where she
also earned a masters in public
health. She finished her IM
residency this year at
University of ArizonaSouth
Campus.
Dr. Ruben is a member of the
American College of Physicians,
through which she has
presented several posters and
publications. Her clinical focus is on IM and preventive medicine.
She joined PCMS as a Resident in February 2014.
With his new association Dr. Hutchinson moves from hospitalist to
his roots in primary care. Though Camp Lowell Medical Specialists
physicians are part of Arizona Community Physicians (ACP), Dr.
Hutchinson is as community as one can get. In 1989 he joined in
practice on 1st Avenue with his father, family practitioner Jerry
Hutchinson, D.O., who died in 1994. The younger physician did
primary IM for outpatients, and did consultation services until 2003.
Being a solo practioner at that time in Tucson, Dr. Hutchinson
said, it was difficult to bring new primary care providers into
town. I would not have left primary care if I did not have the
advantages of being in a group practice.
Closing the practice in 2003, Dr. Hutchinson did primary care, IM
and hospital coverage with the Southern Arizona Veterans
Administration hospital. I always had a significant component of
hospital medicine in my practice, he said. In the 1990s the
hospitalist movement was getting off the ground. It grew out of
mattters of time and efficiency. As a hospitalist you give up the
administrative duties and personel issues, he said, because
youre either employed by the hospital or by a group that the
hospital hires. You just do in-house hospital coverage for
admitted patients.
Dr. Hutchinson was a hospitalist from 2007 to this year, working
longest at TMC with the group AIMArizona Inpatient Medicine,
and later with Cogent Healthcare at Carondelet St. Josephs
Hospital.
The disadvantagescertainly not to disparage hospitalists or
hospital medicineare that you seldom take a patient through
the healthcare process, Dr. Hutchinson said. You are part of a
team, doing patient care in shifts. When I practiced solo, I always
followed the patient through hospital stays.
In hospital medicine, You also tend not to have a standard
working schedule, he said. You end up working any shift that
needs covering, since a hospital runs 24 hours a day.
In primary care you get to intercede at an earlier point, interrupt
the process of disease, and avoid the crisis-driven intervention.
You also get to know people and follow through, which is a lot
more enjoyable and interesting. I feel that I can make a bigger
impact in primary care than as a hospitalist.
Dr. Tretbar honored

by alma mater
andM.D. 56, will be one those honored with a dinner and a

special ceremony to unveil the plaques. He is being recognized as
a rheumatologist for advanced treatments of arthritis, and for
teachingat the University of Arizona Arthritis Center.
He has also been involved in management of medical
organizations and chaired the board of Intergroup for 10 years.
He was co-founder of the UA Section of Rheumatology, and
started the Arthritis Clinic at the Southern Arizona VA hospital.
Dr. Power chairs TOMF Board

Deborah Jane Power, D.O. is
the new chairman of the
Tucson Osteopathic Medical
Foundation Board of Trustees.
Dr. Power is a San Pedro, Calif,
native and has been practicing
medicine in Arizona for more
than a decade. She will serve
as chairman until September
2016. She was elected to the
TOMF Board of Trustees in
2004. She has been a member
of the Steering Committee for
the Southwestern Conference
on Medicine since 2000, and
has chaired it since 2010.
Alas, poor Yorick! I knew him, Horatio; a fellow of infinite jest,

of most excellent fancy. O.K., Dr. Hal Tretbar did not play
Hamlet, Prince of Denmark, but in 1952 he did play a very
convincing freshman at University of Kansas Medical School
(Photo courtesy himself).
Harold C. Tretbar, M.D., F.A.C.P., F.A.C.R., longtime photographer/

writer in these pages, says he was a good medical student at
Kansas University Medical School, from which he graduated in 1956.
He practiced in Tucson from June 1965 at The Tucson Clinic and
served as president of the 36-physician practice. He retired in July
1998 from Thomas-Davis Medical Centers after a merger.
He served as a captain in the U.S. Army Medical Corps in Germany
1958-61 in charge of a seven-physician dispensary for Combat
Command A, 3rd Armored Division. He was a Fellow for four years
at the Cleveland Clinic to get his boards in IM and rheumatology.
He was PCMS Physician of the Year in 1998, was awarded as an
Outstanding Physician-Rheumatologist and Friend by the Arizona
State Rheumatology Association, climbed 19,350-foot Mount
Kilimanjaro on his 65th birthday, and served as president of the
Southern Arizona Region Porcshe Club of America, but now even
all that aint all.
Each year graduates of Southwestern College in Winfield, Kan. are
nominated for induction intothe Southwestern College Natural
Science Hall of Fame. This year the three who have been selected
have all gone on to get M.D. degrees from the University of Kansas
School of Medicine. On Nov. 6 Dr. Tretbar, B.A. chemistry 52
Dr. Power was principal investigator for two Juvenile Idiopathic

Arthritis (JIA) clinical trials, has participated as an investigator in
more than 70 clinical trials, and has presented both nationally
and internationally. She practices at Catalina Pointe Arthritis &
Rheumatology Specialists, 7520 N. Oracle Rd., Tucson.
Dr. Power earned her Bachelor of Science in Kinesiology from
UCLA, and an M.S. in Exercise and Sport Sciences at The University
of Arizona. She earned her D.O. in 1997 at Kirksville College of
Osteopathic Medicine, Kirksville, Mo., and interned at Midwestern
University/Arizona Graduate Medical Education Consortium at
Tucson General Hospital.
In 2002 she completed her rheumatology fellowship at The
University of Arizona, where she still has a faculty appointment.
She continues to provide rheumatology consultation services for
UAMC Diamond Childrens.
Dr. Power has a special interest in pediatric rheumatology, and is
one of the few rheumatologists in the state with this expertise. In
addition to caring for children with juvenile idiopathic arthritis,
(formerly called juvenile rheumatoid arthritis), she specializes in
the care of children with systemic lupus erythematosus, vasculitis,
dermatomyositis and spondylarthropathies. In addition to seeing
children and adolescents at Catalina Pointe, she continues to see
patients at the Childrens Clinics for Rehabilitative Services,
affiliated with TMC, three afternoons per month.
TOMF was founded in 1986 after the sale of Tucson General
Hospital. It uses an endowment as an operating foundation to
provide medical education, including scholarships and the
Southwestern Conference on Medicine, as well as programs that
aid public health in Southern Arizona. Executive director is Steve
Nash, former PCMS executive director.
n
7
Membership
Story and Photos by Dennis Carey
Cardiology the direct-pay way
his truly is a labor of love, cardiologist G. Mason Garcia,

M.D. said. I dont think you could pay me any amount of
money to change what I am doing, and now we are doing it.
Dr. Garcia has practiced in Tucson 20 years, but as he opened his
new practice, Sunrise Cardiology at 2380 N. Ferguson Ave., it was
to do healthcare from the heart as much as to it.
Sunrise Cardiology opened its doors July 7 as the only direct
pay cardiology practice in Tucson. As a direct pay practice,
Sunrise has opted out of partnering with any insurance
companiesprivate or public. It also means no relationship with
a large medical group or medical management company. It is not
part of any physician network.
Patients are a given two-page document explaining what direct
pay means and how much office visits, procedures, and services
cost. Patients with insurance coverage are welcome, but patients
must send any invoices to their own insurance company for
reimbursement. Patients on government-funded plans such as
Medicare and Medicaid, and supplemental plans associated with
those plans such as AARP plans, will not be reimbursed. Patients
on those plans are given an opt-out contract that explains in
Michigan fan much?!? Dr. G. Mason Garcia in whats left of his
detail. Private commercial plans may reimburse patients
office
after the flag ate it.
BUZZING
anywhere
TI from 20 to 80 percent.
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RING
BUZZ
TINNITUS
BUZZING
RING
HUMM
RINGING
HUMMINGGING
RIN
Your patients
deserve the
best hearing
care possible
ING
HUMM
USG
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IN
IN
BUZ
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N
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We offer
comprehensive
tinnitus
consultations.
TINNITUS
RINGING
TINNITUS
HUMMINGDr. Garcia admits that direct pay may not be a

RINGING good fit for everyone, but can be affordable
BUZZING
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Learn more about why we are a
R
preferred audiologistplease visit our website: www.arizonahearing.com
We are preferred providers
on most insurance plans.
520.742.2845
7574 N La Cholla Blvd Tucson
520.742.2845
6969 E Sunrise Dr, Ste 203 Tucson
520.648.3277
Helping you hear your best.
512 E Whitehouse Canyon Rd, Ste 196

Green Valley
Janis Gasch, Au.D.
Doctor of Audiology, Founding Director
We are very transparent about what we

charge and what it means to their insurance
coverage, Dr. Garcia said. We dont want
any surprises in the care we give, or whats on
the bill.
for many patients when they examine the

out-of-pocket responsibility on many
commercial insurance plans. Deductibles,
co-insurance and co-payments may be as
much or more than what his patients will pay.
Some price examples for office visits are:

$500 for a first-time patient office visit
consultation. This will include the
consultation and any diagnostic testing such
as EKG, treadmill stress tests,
echocardiograms; $395 for a one-time visit
per year, new patient emergency visit, or new
patient home visit. Added procedures for the
one-time visits could be added on.
Memberships are also offered, to be inclusive
of two consultation visits per year, diagnostic
procedures, home visits, and emergency
visits. Individual memberships are $70 per
month or $720 if paid in full in advance.
Family memberships are $42 per month or
$500 if paid in full in advance.
Garcia, M.D. and Lawrence Garcia, M.D. are cardiologists in

Tucson and Phoenix. His sister Mariali Garcia, M.D. is an
endocrinologist in Tucson.
Every week it seems like there is something new with healthcare,
Dr. Garcia said. Direct-pay does not mean we dont have to deal
with the changes, but I can practice the way I think it should be.
I can take my time and be thorough by not having to see a lot of
patients every day. I am accessible to my patients. If something
happens, they can come in or call and I will do what I can. I can
be me, and not have to be a company doctor and say what
somebody else wants me to say, or do what somebody else
wants me to do.
Dr. G. Mason Garcia and his wife, Kayla, office coordinator and
respiratory therapist, welcome patients to Sunrise Cardiology,
Tucsons only direct-pay cardiology practice.
I decided to do it this way because it comes down to patient care

first, and not dealing with the red tape of any insurance plans,
Dr. Garcia said. I spend a minimum of 30 minutes and a
maximum of one-hour with each patient. I could not do that
being part of a large group or insurance network.
Early reviews have all been positive. Most of Dr. Garcias patients
have been with him before, but about 10 percent are new. He
also has not worked out all the kinks about doing procedures at
hospitals. He said he thought he had it worked out, but there are
still a few wrinkles.
Since I dont plan to charge for the procedures I do, I think I will
have it cleared up sooner than later, he said. I will visit my
patients for no charge, but if anyone has to have a procedure
done at a hospital, I am referring them to one of my colleagues.
I think I have an excellent relationship with many Tucson
physicians and other cardiologists. I just have to work out a few
business details, but I am confident I will be able to do
procedures at hospitals.
Dr. Garcia does have experience working in the now-standard

healthcare system: He started his career in 1995 with Desert
Cardiology following graduation from the medical school of the
Autonomous University of the City of Juarez, Mexico. He did
residencies in IM and cardiology at Advocate Christ Hospital and
Medical Center in Oak Lawn, Ill.
In 1998 he started Vascular Institute of Southern Arizona with
Jolyon Schilling, M.D., Brenda Peart, M.D., and the recently
retired Michael Lavor, M.D. That practice is now part of
Carondelet Health Network.
Dr. Garcia is the only physician at Sunrise Cardiology, but his staff
has plenty of experience. Practice Manager Lisa Taylor has 21
years of healthcare administrative experience, and Office
Coordinator Kayla Garcia is a licensed respiratory therapistand
Dr. Garcias wife.
Thats the entire staff, Dr. Garcia said. Without the paperwork,
we have eliminated the need for a large office staff. Since we
dont work with insurance companies, we dont have to get
authorizations for procedures. That also means we only do
procedures that are necessary. Our patients feel confident that if
I recommend something, they need it. We arent under any
pressure to generate revenue for another employer or entity.
Kayla Garcia added, The biggest chunk of paperwork is the new
patient medical history that is about eight pages. Healthcare has
gotten so bogged down with forms and protocols. As a direct-pay
practice, we dont have to deal with that.
Dr. Garcia is from a decidedly medical family. His cardiologist
father, Hector L. Garcia, was PCMS Physician of the Year in 2003.
He has practiced in Tucson for 50 years and has become
legendary for his housecalls. Dr. Garcias brothers, Hector F.
Dr. Garcias waiting room promotes a relaxing atmosphere.
Dr. Garcia also knows his colleagues are keeping an eye on him,
and on other direct-pay practices that are starting around Tucson.
There are no immediate plans to add another physician to
Sunrise, but he wants to be able to continue his policy of
extended patient visits and open access. If the practice is
successful, that will probably mean adding to his staff.
We have to get back to caring for the patient first, he said. It
feels like patient care is becoming the last thing on the list of
things to do. I know I could make more money as an employee of
a large group, or as part of an insurance network. But this is the
way I thought healthcare should be done, with transparency, and
with patients having access to their physicians.
n
In Memoriam
By Stuart Faxon
Sandra M. Smith, M.D.

1943-2014
Editors note: We apologize for missing this obituary that should
have appeared in our August-September issue.
ongtime Tucson pediatrician Sandra Mildred Smith, M.D.

died July 7 at her home in Tucson. She was 70.
Dr. Smith, a PCMS member 1974-1988, was a compassionate

pediatric physician, devoted friend, avid reader, and talented
athlete, her family told the Arizona Daily Star.
Sandra Mildred Smith was born was born Sept. 28, 1943 in
Oxford, Miss. And graduated from Arkansas High School in
Texarkana, Ark. She went to the University of Mississippi as a
National Merit Scholar and majored in liberal arts. She then went
to Duke University School of Medicine, where she earned her
M.D. in 1967. That year she also served as a ward physician John
Umstead State Mental Hospital.
She did her internship at Duke University Medical Center,
Durham, N.C., and her residency at St. Louis (Mo.) Childrens
Hospital. In 1973-74 she had a Fellowship as a Robert Wood
Johnson Scholar at the Duke departments of Community Health
Sciences, and Pediatrics. She was a diplomate of the National
Now youre
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Dr. Sandra M. Smith in 1981.
Board of Medical Examiners and a Fellow of the American

Academy of Pediatrics.
At The Tucson Clinic she practiced with doctors William N.
Neubauer, Ronald P. Spark, Gary L. Henderson. E. Luis Aguilar, and
Christopher T. Maloney. In 1985 she relocated to St. Marys
Medical Park on West St. Marys Road
She spent her professional career caring for children in Tucson,
Colorado, and California, the family told the paper, and as a
volunteer physician in El Salvador, Saudi Arabia, Brazil, Sri Lanka
and a Cambodian refugee camp following the Vietnam War. She
upheld the highest intellectual and ethical standards throughout
her challenging career and was a staunch advocate for her
patients and their needs.
As an athlete, Sandra was a fierce competitor whether at
softball, soccer, rugby, touch football, charades, jeopardy, or
backgammon, and a masterful bridge player. She routinely
tackled New York Times crossword puzzles and the acrostic, in
pen, and completed them using her razor-sharp intellect.
Her door was always open to friends who gathered in her home to
play games or watch football, and, if you were lucky, you got to
sample her wonderful Southern cooking. When [people were] in
need, the welfare of others was paramount to Sandra. Support, love,
and laughter came naturally to her. She also loved her cats, Maggie
and Elvis. She leaves behind a large circle of living and devoted
friends who will mess her generosity and unique spirit immensely.
ROC #278632
10
Her brother David Smith, M.D., and sister Leslie Measel survive
her. A celebration of Sandraa life was given Aug. 2 at Jane and
Carolyns home. Memorial donations may be made to Hearts
That Purr, Box 36418, Tucson 85740.

n
11
PCMS News
AMB resumes new licenses

The Arizona Medical Board in October approved a motion to
resume issuing new licenses.
At issue was an opinion issued by Attorney General Tom Horne
interpreting the fingerprinting law in such a way that effectively
brought new licenses issuances to a halt.
advance of license renewal notices. Additionally, there are

specific instructions that must be followed by your fingerprinting
technician, and finally, keeping a fingerprint card on file prior to
submission could expose individuals to potential fraud breaches.
Are we ready for Ebola?

By Jane M. Orient, M.D.
PCMS Public Health Committee
The Arizona Medical Association, working with support of PCMS

and the Maricopa County Medical Society, with backing of the
Arizona Hospital and Healthcare Association, took leadership in
remedying the situation.
Ebola is here, and the most rudimentary public health

precautions were ignored in a prominent Dallas hospital,
even though an infectious disease specialist there thought his
hospital was ready (Business Insider, Oct 4, 2014, http://www.
businessinsidercom/r-us-nurses-say-they-are-unprepared-tohandle-ebola-patients-2014-10 ).
ArMAs attorneys did extensive legal research and analysis in a

short timeframe to issue what became a compelling legal opinion
countering that of the AG. Efforts received strong support from the
Arizona Legislature leadership, and from Gov. Jan Brewers office.
The intake nurse obtained a history that the patient came from
Liberia, where a deadly epidemic is raging, but the message
didnt get to the doctor who discharged the patient on
antibiotics. The doctor, apparently, did not take a history himself.
AMBs action Sept. 8 applies to issuing of new licenses. Renewal

licenses were not impacted. Please be certain to closely follow
AMBs instructions for renewing your licenses.
A travel and exposure history is crucial in a patient with

symptoms that could be Ebola (or a lot of other common
conditions such as influenza). These include fever, headache,
abdominal pain, nausea and vomiting, muscle aches, and
sometimes a macular rash.
For those of you directly involved with any of the applicants

impacted, the licensing board has posted the following language
on their website, based on the adopted motion proposed by
PCMS and AMB Board member Dr. Screven Farmer:
The Arizona Medical Board met [Sept. 8] and voted to resume
processing and issuing initial licenses effective immediately to
applicants meeting all statutory requirements for licensure, with
the exception of the FBI criminal background check. These
applicants will be issued an Arizona medical license on a provisional
basis with the following stipulations: requiring applicants to sign a
notarized attestation that there are no undisclosed criminal
convictions in other states or countries; requiring applicants to
submit a signed statement acknowledging that failure to disclose
such information will result in discipline and/or revocation of
licensure; additionally, requiring applicants to undergo a third party
background check by an entity other than the FBI.The board staff is
in the process of investigating and determining the entity that will
conduct the criminal background check. Applicants granted a
license under these terms and conditions are subject to additional
processing once the Board receives approval to obtain criminal
background checks from the FBI.
When renewing a license:
1) In its first renewal notice following implementation of the
requirement, AMB mistakenly informed renewal licensees that
they must complete their fingerprinting at the local police or
sheriffs office. Fingerprinting at a law enforcement agency is NOT
required by law, and many local police departments no longer offer
this as a public service. PCMS has compiled a list of fingerprinting
services in the city. A mobile service is also available.
2) AMB has issued specific instructions for submitting their preprinted fingerprint card sent with your renewal packet. If you
adhere to the instructions issued, and submit your renewal
packet on time, you will be deemed in compliance. AMB has
posted the instructions on their website.
3) We have been asked if physicians might complete the
fingerprinting process before their renewal packet arrives, and
we advise against doing so. AMB is issuing its own pre-printed
fingerprint cards, and are not accepting any FD-258 cards in
12
Patients with possible exposure to Ebola need to be isolated at

once. Notify the public health department so that specific testing
can be done. Personnel need to be trained in advance, notified,
and provided with adequate protective gear. Contaminated items
must be disposed of properly, and the area cleaned meticulously
with an effective disinfectant such as bleach. Remember that
viruses have remained infective for six days on surfaces. Print out
and have available CDC guidelines for these precautions (http://
www.cdc.gov/vhf/ebola/hcp/index.html), but check frequently
for updates. CDC has changed guidelines, and more stringent
precautions may be appropriate.
Be sure that your office has, at a minimum, an adequate supply of
gloves, safety goggles or face shields, and N-95 masks. If there is
to be more than minimal contact with an Ebola infected patient
or body fluids, fluid-resistant gowns are needed. All protective
equipment must be removed without touching the outer,
contaminated surface.
Be aware that an aerosol loaded with pathogenic organisms is
generated by flushing a toilet. When Ebola patients were treated
at Emory, water was disinfected for 10 minutes before flushing.
River conference fills up fast

Tucson Hospitals Medical Education Program Inc.s 5th Bi-Annual
Colorado River Medical Conference travels down the Colorado
River through the Grand Canyon June 27-July 3, 2015 for a grand
event along with learning.
The trip is mildly strenuous, Dr. Richard Dale said, potentially
dangerous from large rapids, but extremely fun and educational.
This year the places booked quickly and we only have five left.
I need a commitment from 23 persons in order to schedule a
medical/dental conference for 12-14 Category 1 CME credits. The
conference is sponsored by THMEP. Deadline for commitment is fast
approaching, so please call Dr. Richard Dale at 721.8505 or e-mail
rdale9136@aol.com as soon as possible regarding your interest.
Significant others and children (8 and older) are invited. We leave
Lees Ferry Saturday, June 27, 2015 at 8 a.m. and return to Lees
Ferry Friday, July 3. The price will be approximately $2,500 per

person (not payable to THMEP) for the full trip, plus the
registration fee (payable to THMEP), exclusive of one nights
lodging at Marble Canyon.
This will be a trip of a lifetime, Dr. Dale said. We can carpool,
etc. Again, if you are interested, or for further information or
questions, contact me at 721.8505 or e-mail rdale9136@aol.com.
PCMSA Holiday Luncheon is

Dec. 10
The Mobile Meals Holiday Luncheon of the Pima County Medical
Society Alliance will have a Black & White Party theme when it
is given Dec. 10 at Flemings Steakhouse & Wine Bar, 6360 N.
Campbell Ave., 11 a.m.-1 p.m.
Major owner-to-be visits

local Carondelet hospitals
CAKE OF AGES
Associate members Dr. J. Wright Cortner, 91, right, and Dr.
John Wilson, 97, cut the cake and cut up Oct. 14 at an informal
celebration of 110 years of the medical society. Between them is
Dr. Jim Klein, Pima County Medical Foundation chairman.
Seated on left is PCMS Associate Director Dennis Carey.
(Jeremy Snavely photo).
Representatives from Dallas-based Tenet Healthcare Corp. were

in Tucson last month in anticipation of a joint deal to operate
Carondelet Health Network, Stephanie Innes reported in the
Arizona Daily Star.
For-profit Tenet signed a letter of intent on July 22 to own and
operate the nonprofit chain of Southern Arizona Catholic
hospitals in a partnership with California-based Dignity Health
and Missouri-based Ascension. Ascension, which is the current
owner, would retain a minority interest, officials said when they
announced the deal.
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Tenet was onsite at Carondelet facilities at different times in

September to participate in due-diligence activities, Carondelet
spokeswoman Lisa Contreras said.
Network officials successfully met an Aug. 15 deadline for
submitting all requested due-diligence materials, according to a
Sept. 10 memo to employees from network Chief Executive
Officer James K. Beckmann.
Beckmanns memo says the letter of intent is an exclusive, nonbinding agreement that allows all sides to enter a period of due
diligence and announces to others that we are negotiating
exclusively with our potential partners.
Beckmann wrotes that Tenet and Dignity are now reviewing
thousands of documents provided to them so they can learn as
much as possible about Carondelet. He also provided employees
with an answer to questions about the deal. It is appropriate to
explain that: We are very early in the process, but we are excited
about the possibility of coming together with Tenet and Dignity,
the memo says.
WALK WITH A DOC

Gonzalo Celis, M.D. presented an Obesity and Diabetes
program at the September PCMS Walk With a Doc event. Events
are given on second Saturdays monthly at Rillito River Park.
PCMS seeks physicians interested in presenting the events next
year, so if you are interested, call Dennis Carey at 795.7985 or
e-mail dcarey5199@gmail.com (Dennis Carey photo).
Lynn Polonski, M.D.
4021 E. Sunrise Dr.

Ste. 121
Tucson, Arizona 85718
Phone: (520) 576-5110
Fax: (520) 529-7165
At the time the letter of intent was announced, the news release
said Tenet would be the majority partner with management
responsibility for all three of Carondelets Southern Arizona
hospitals. Officials have not said whether the partnership will
be for-profit or nonprofit. The news release also said the
agreement would maintain Carondelets identity, heritage,
and Catholic sponsorship.
Carondelet Health Network has a workforce of about 3,500
and is the second-largest local health system behind the
University of Arizona Health Network, which operates two local
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hospitals. The UA Health Network is in the midst of negotiating a

sale to the nonprofit Phoenix-based Banner Health, one of the
countrys largest health systems.
Both the Banner and the Tenet-Dignity deals would connect
local hospitals with larger regional health systems, consistent
with a national trend of hospital supersizing with consolidations,
mergers and acquisitions.
In Arizona, Dignity Health already operates four Phoenix-area
hospitals. Dignity Health in Arizona also includes imaging centers,
clinics, specialty hospitals, urgent-care centers, an insurance
provider, an accountable care organization and other clinical
partnerships.
Arizona to track violent deaths

The ASU Center for Violence Prevention and Community Safety
reported in September that Arizona will track violent deaths in an
effort to prevent suicides and homicides.
PCMS Public Health Committee members Dr. Paul Gee and Dr. Randall
Friese will serve on the advisory committee to the ASU Center.
The Center will begin gathering and analyzing data on murders and
suicides in Arizona for the National Violent Death Reporting System.
The data will help state and local officials better understand when
and how violent deaths occur by linking information from law
enforcement, medical examiners, vital statistics, and crime
laboratories. The collected data will help public health practitioners
and violence prevention professionals develop prevention and
intervention strategies to reduce violent deaths in Arizona.
Law enforcement tracks the number and manner of murders in

Arizona, and health officials do the same for suicides, but no one
is looking at the bigger picture, says Charles Katz, Watts Family
Director of the ASU Center for Violence Prevention and
Community Safety. This allows us to get a better idea of whats
going on and why.
Working in close collaboration with the ADHS, Dignity Health St.
Josephs Hospital & Medical Center, medical examiners, law
enforcement agencies, and injury prevention specialists, the
Center will examine violent deaths as both crime and public
health concerns. The system will diagnose the scope, nature and
source of particular characteristics contributing to violent deaths
in Arizona, which will in turn inform prevention efforts.
We had 1,070 suicides in Arizona in 2012 and 358 murders, says
David Choate, Center associate director. Having all the facts
about the violent deaths that occur in Arizona will help identify
the right prevention efforts to save peoples lives.
Arizona will be one of 32 states collecting data for the National
Violent Death Reporting System, run by the Centers for Disease
Control and Prevention. The first report is expected to be issued
next year.
The ASU Center for Violence Prevention and Community
Safety is a research unit of the College of Public Programs at
Arizona State University. It conducts use-inspired research that
advances scholarly knowledge and practical application of
explanations and solutions to the causes and correlates of
crime, to reduce violence, and improve the quality of life of
our community.
15
PCOA: Family caregivers

key for older adults
Family caregivers are key to helping older adults continues to live
safely and comfortably in their homes, thus reducing the need for
costly institutional care, says Adina Wingate, marketing/PR
director for the Pima Council On Aging.
However, it comes with a substantial cost to the caregivers, she
said. They may experience stress, physical strain, competing
demands, and financial hardship. Because of the many risks
associated with family caregiving, it is now viewed as an
important health concern.
Many studies have shown that family caregivers often feel
chronically stressed, and this has a negative impact on their
mental and physical health. Support groups can relieve some of
this stress by promoting social connection, normalizing the
emotions and tensions caregivers often feel, and by providing a
place where caregivers can share their experiences and learn
from one another.
PCOA offers multiple Caregiver Support Groups throughout
Tucson and the surrounding area, including Oro Valley and Green
Valley. The groups typically meet once or twice a month and are
facilitated by a skilled professional.
Caregivers can also benefit from taking the Caregiver Training
classes PCOA offers in conjunction with Luminaria Home Care.
The classes are provided to family caregivers as two four-hour
workshops and cover numerous aspects of caregiving, including
The Faces of Casa are the
Dr. Ann Marie Chiasson

Associate Medical Director
infection control, stress management, nutrition, fall prevention,

dementia, personal care, use of a gait belt, proper body
mechanics, and more. Both the caregiver and the care recipient
benefit from these classes as the caregiver learns skills that
increase his or her confidence and effectiveness.
If you notice that one of your patients, or your patients
caregiver, is experiencing stress related to caregiving, encourage
them to call PCOA at 790.7262 for information about Caregiver
Support Groups and Caregiver Training Classes.
The Breast Center,

InformedDNA team up
Patients at higher risk for genetic cancer can benefit from the
Hereditary Risk Assessment Program at The Breast Center at
Carondelet St. Marys Hospital, which recently announced that it
is collaborating with genetic services specialist InformedDNA to
provide risk assessment and genetic counseling.
Approximately 12 percent of women in the U.S. will develop
breast cancer, according to the American Cancer Society. Thats
more than 30,000 in Tucson alone, 2,500 of whom are estimated
to have a genetic risk factor for cancer. The breast centers
collaboration is in response to this growing concern.
The program helps identify those at higher risk for cancer
before diagnosisand helps patients make informed decisions
about their medical care. Genetic risk assessments are usually
done after a patient has been diagnosed with cancer, which can
be too late. The Breast Center at St. Marys is
providing risk assessments before diagnosis,
offering them to all patients who receive a
screening mammogram. Patients do not pay
more for the risk assessment at The Breast
Center, whether the patient is insured (the
co-pay does not increase) or uninsured and
paying out of pocket.
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The gold standard of care for a person at

high risk for cancer is having genetics experts
on an integrated care team, especially if he or
she is considering genetic testing, said David
Nixon, InformedDNA CEO. InformedDNAs
national network of genetics specialists
delivers services via phone and online,
making it easier and faster for facilities like
The Breast Center at Carondelet St. Marys to
provide the best care possible.
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to direct patient care in most major genetics
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seeking to better understand genomic
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n
Valley Fever
Cocci drug gets FDA

fast-track
s Dr. John Galgiani says, Its our disease, right up from

our Tucson and Phoenix dirt. The fungus that causes
coccidioidomycosis becomes airborne when soil is disturbed. In
susceptible people and animals, infection occurs when a fungal
spore is inhaled.
Every year in Arizona 20,000 people are diagnosed with it, and
160 die from it. And we still cant cure it.
Dr. Galgiani directs the UA Valley Fever Center
for Excellence, and the university reports that
it received word in October that a potentially
curative anti-VF drug has been given a boost
in its development by the U.S. Food and Drug
Administration.
fungus, which grows in soils in areas of low rainfall, high summer

temperatures, and moderate winter temperatures. The fungal
spores become airborne when the soil is disturbed by winds,
construction, farming, and other activities.
An estimated 150,000 infections occur each year in the
Southwest. About one-third of these result in a self-limited,
possibly lengthy, respiratory illness. However in a small
percentage, cocci is more serious and potentially lethal.
QIDP designation also provides access to priority review of
marketing applications and eligibility for fast-track designation. This
extended market exclusivity makes our Nikkomycin-Z effort much
more attractive to investors, a major goal of the GAIN act, said David
Larwood, CEO of Valley Fever Solutions. This brings us much closer
to our dream of commercializing this promising compound.
We know Tucson. We are Tucson.

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The UofAs request has been granted to

designate nikkomycin Z (NikZ) as a qualifying
infectious disease product (QIDP). NikZ is an
antifungal drug that the UA has been helping
to move into clinical trials and eventually to
help patients. The UA has licensed
development rights to Valley Fever Solutions,
Inc. (VFS), a small start-up business in Tucson.
legal services for Southern Arizona since 1969.
Getting a QIDP designation is huge for our

program, said Dr. Galgiani, leader for the
NikZ development team and CMO of the VF
center. It makes NikZ much more attractive
to investors because of the added protection
and other benefits that come with this
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serious and hard-to-treat bacterial and fungal
infections. Cocci is one such infection that
currently has no cure. QIDP designation for a
drug adds an additional five years of market
exclusivity, which means that the company
that brings the drug into clinical use is
protected from competitors for that period.
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This is especially valuable for NikZ development because it is an old drug and most of its
patent protection already has expired, Dr.
Galgiani said. This protection is on top of
seven additional years of exclusivity that
were granted to NikZ when it was designated
an orphan drug, or one that is used for a
relatively uncommon disease such as cocci.
Although cocci is very common in Arizona, it
almost never occurs outside the Southwest.
Primarily a disease of the lungs in the
Southwestern U.S. and Northwestern Mexico,
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NikZ is the first of a new class of antifungal drugs that attack the
formation of chitin, a major component of the fungal cell wall, the
UofA reported. Given to mice with the cocci fungus, NikZ seems to
cure the infection. The drugs development was started in the
1990s by a small company in California, but was halted when the
business failed. The NikZ program was inactive until it was
acquired by the university in 2005 and clinical trials were restarted.
Between the UA and VFS, more than $12 million dollars has been
raised in research grants from the National Institutes of Health,
the FDA and from philanthropic donations, chiefly from the J.T. Tai
& Company Foundation in New York City. In September VFS was
awarded a $1.7 million small business grant from the NIH to
resume clinical trials to treat VF pneumonia patients. NIH is also
helping to manufacture the NikZ that will be used in this clinical
trial, scheduled to start in late 2015.
Valley Fever Awareness Week

Nov. 8-16
The University of Arizona Valley Fever Center for Excellencewill
host free events in Tucson and Phoenix for the public and health
professionals in observance of the 12th annualValley Fever
Awareness Week, Nov. 8-16.
Gov. Jan Brewer proclaimed the week in recognition of the
outstanding treatment and research conducted by the Valley
Fever Center for Excellence at the University of Arizona, its new
clinical center at St. Josephs Hospital in Phoenix, and for the
advances in Valley Fever education and public health by the
Arizona Department of Health Services.
The Seventh Annual Public Forum on Valley Fever will be Sunday
Nov. 9, 1-4 p.m. at the UA BIO5 Institute, Room 103, 1657 E.
Helen St., Tucson. The free forum features UA experts:
Kenneth Ramos,. M.D., Ph.D., PharmB, associate vice-president
for precision health sciences at the AHSCenter and professor of
medicine in the UA Department of Medicine, Division of
Pulmonary, Allergy, Critical Care and Sleep Medicine, on
Precision Health: A Bold Initiative at the Arizona Health
Sciences Center.
Dr. Galgiani will speak on Precision Health in Valley Fever
Does Ancestry Matter?
Zaid Shehab, M.D., professor of pediatrics and pathology and
section chief, Division of Pediatric Infectious Diseases, UA
Department of Pediatrics, will speak on Valley Fever in Kids.
Lisa Shubitz, D.V.M., associate research professor, Department of
Veterinary Science and Microbiology, UA School of Animal and
Comparative Biomedical Sciences, will speak on A Valley Fever
Vaccine for Dogs.
Valley Fever 101, a free event for the public, will be Tuesday Nov.
4, 9-11 a.m. at Banner Del E. Webb Medical Center, 14502 W.
Meeker Blvd., Sun City West, and features presentations by Dr.
Galgiani and others.
Primary care physicians are invited to attend a free conference,
Coccidioidomycosis (Valley Fever) for the Primary Care Physician,
Saturday Nov. 8, 8 a.m.-noon, at Banner Good Samaritan Medical
Center Amphitheater, 1111 E. McDowell, Phoenix. CME credits
are available.
To register for these events, or for more information, please
visit the Valley Fever Center for Excellence website, www.vfce.
arizona.edu .
n
Bioethics
A hospice case vignette

By Dr. David Jaskar
he PCMS Bioethics Committee presents this clinical case to

illustrate how physicians can help patients manage common
end-of-life symptoms while in hospice. While this case presentation
focuses on the physicians role, hospice care is a multi-disciplinary
group with crucial roles played by many disciplines.
Central to patient care in hospice is a coordinated care team
comprised of a physician, R.N. case manager, social worker,
chaplain, home health aide, bereavement counselor, a
thoroughly-trained volunteer and after-hours R.N., and on-call
physician. A hospice patient is usually treated in his place of
residence, with cohesive and collaborative visiting and on-call
medical attention. Although the hospice team does not remain
with the patient around-the-clock, hospice staff is always available
to promptly manage symptoms that arise at any time of day.
This case vignette involves a 55-year-old male with metastatic
non-small-cell lung cancer. He has metastases to the anterior ribs,
scapula, and clavicle. A comorbidity included severe chronic
obstructive pulmonary disease. The patients prognosis was six
months or less as determined by his oncologist, so she
recommended that the patient consider hospice care.
On admission to hospice, the patient was on 2 L/min of oxygen per
nasal cannula as needed for sleep and exercise. He had been taking
low-dose hydrocodone/acetaminophen (Vicodin) 5/325mg about
five to six times per day. The patient rated the pain in his chest and
upper back as ranging between 4 and 7 out of a possible 10.
Upon admission, the opiate analgesic was changed to plain
oxycodone (immediate release) with a range of 10-20 mg every
four hours as needed for pain. This regimen reduces the risk of
hepatoxicity that might occur if acetaminophen were to be taken
in larger doses (exceeding 3 grams in the elderly or 4 grams in
younger usersassuming no alcohol consumption).
After several days of taking immediate release oxycodone it was
determined that he needed approximately 60-100mg of
oxycodone in a 24-hour period to manage his pain. Thus a long
acting oxycodone formulation, Oxycontin, was started at 30mg
every 12 hours while the pm short-acting oxycodone was
continued. The patient was now taking 60mg daily of long acting
Oxycontin and supplementing with three or four breakthrough
doses of oxycodone lOmg per 24 hours. If more than just a few
breakthrough doses were required, then the long-acting opiate
would be increased.
After a few weeks, the patients back pain became much more
severe and dexamethasone (Decadron) was added for bone pain
(4mg twice per day). This provided transient pain control.
However, after a period of time his pain again worsened more
dramatically and an X-ray revealed a pathologic T4 fracture; of
note, there were no neurological deficits. The patient was then
sent to radiation oncology and given a one-time dose of palliative
radiation to the involved area. The patients pain improved over a
period of weeks and dexamethasone was tapered and

discontinued.
The patients symptoms continued to evolve as he became
increasingly short of breath. His 2L/min of oxygen was
incrementally increased to 5 L/m and ultimately an Oxymizer
high-flow oxygen delivery system was added to further increase
the delivery of oxygen to 8 L/min.
After several weeks, the patients shortness of breath increased
more dramatically, his sputum became purulent, and he
developed generalized wheezes with localized left lower lobe
rhonchi. For the presumed pneumonia, we prescribed doxycycline
100mg twice per day for 10 days and steroids were again added in
the form of dexathasone 4mg daily. Albuterol/ipratroprium
nebulizer treatments were administered four times per day.
Later in the course of his illness, morphine was also given via
nebulizer treatments for control of air hunger and shortness of
breaththe data on the effectiveness of nebulized opioids
compared to saline in this situation are equivocal, but in our
experience some patients seem to benefit significantly, and even
placebos can be very effective in pain and dyspnea.
A few weeks after the episode of pneumonia, the patients pain
again became much more severe and was not well controlled
with escalating doses of oral analgesics. Additionally, he had
increasing abdominal girth with palpable liver enlargement.
Patient was therefore admitted to the inpatient hospice unit
where he was started on parenteral (subcutaneous) doses of
opiates, in this case hydromorphone (Dilaudid) which is less
dependent on liver function than is morphine. Subcutaneous
hydromorphone was titrated up to patient comfort, ultimately
settling at 4mg per hour continuously via a pump with boluses of
2mg every 30 minutes as needed. With the patients pain now
well controlled he was again sent home where he was cared for
by his elderly mother.
At home he developed significant ascites from liver metastases.
The ascites was significant in that it caused discomfort as well as a
significant increase in dyspnea. He was then sent to outpatient
interventional radiology where a paracentesis was done with
relief of symptoms. He needed one more paracentesis before he
decided the discomfort from ascites was less than that of
undergoing the procedure.
After the dexamethasone had been weaned off, the patient
developed significant fatigue and depression and a course of
methylphenidate (Ritalin) at 5mg and later 10mg was started,
with improvement in fatigue and depression at institution and
escalation of dosage. Parenthetically the methylphenidate was
used because it has a much quicker onset of action and better
efficacy when compared to an SSRI.
Constipation was an ongoing issue throughout the course of his
care while on hospice. On admission, he was started on
scheduled docusate with sennasides (Senna-S) at 2 tablets twice
a day with additional laxatives such as magnesium citrate or
bisacodyl (Dulcolax) suppositories as necessary. At one point the
patient was given an injection of .methylnaltrexone (Relistor)
12mg to counter the constipating effects of opioids by blocking
the mu receptor in the bowel (while leaving the CNS action of the
opioid uninhibited, thus minimizing the impact on pain control
19
while countering the peripheral side effects of the opioid). The

patient had a large bowel movement within a few hours of
receiving the methylnalotrexone.
The patients status continued to worsen and he became
confused (delirious) with increasingly short of breath, inability to
swallow, and severe pain that required very frequent dose
adjustments in his subcutaneous hydromorphone infusion. The
patients mother was no longer able to care for him at home and
he was therefore re-admitted to the inpatient hospice unit for
control of his symptoms.
Treatment was expanded to include parenteral lorazepam
(Ativan) for anxiety, as well as haloperidol (Haldol)which was
used not only to help control his severe confusion but also for
treatment of nausea. His symptoms were well-controlled with
this regimen and he gradually became less responsive. The
medications were titrated to keep patient comfortable but not to
intentionally suppress respirations or hasten death. He died
peacefully three days after his re-admission to the inpatient unit.
The patients family was very satisfied with his care during the
course of his illness. It must be noted that control of pain and
end-of-life symptoms have been demonstrated to not only
improve the patients comfort, but also the duration of their life
in instances of lung cancer.
Gerontologist Dr. David Jaskar is medical director of Casa de la Luz
Hospice, Tucson. He chairs the PCMS Bioethics Committee, which
includes Ann Marie Chiasson, M.D.; social worker Dale Johnson;
Steven Ketchel, M.D.; Cynthia Miley, M.D.; Kenneth Sandock,
M.D.; and David Siegel, M.D.
n
20
&
Balance
Dizziness
SUPPORT GROUP
Hosted by
Date & Time:
Tuesday,
November 11th,
2014
3:30 PM
Space is limited. RSVP today
by calling 520-795-8777.
Carlson Ear Nose &

Throat Associates
Location:
3172 N. Swan Road Tucson, AZ 85712

Join us for free informational and educational
meetings to learn more about your symptoms of
dizziness, lightheadedness, vertigo, imbalance,
and associated concerns. The support group will
meet on the second Tuesday of each month at our
Swan Road office location. Meet other individuals
who are experiencing similar symptoms and
circumstances. A variety of topics will be discussed
throughout the year including: What is Vertigo?
Anatomy and Physiology of the ear. Proper
Diagnosis of symptoms. Treatment options.
Meeting are facilitated by:
Amanda Kester, Au.D., CCC-A, FAAA

Doctor of Audiology
To learn more about the Dizziness & Balance Disorder Support Group,
hosted by Carlson Ear Nose & Throat Associates, please call 520-795-8777 today.
21
Time Capsule
Patio Building from 1928 gets makeover

in TMC campus upgrade
Story and photos by Tucson Medical Center
ucson Medical Center is marking its

70thanniversary this year,
commemorating the day its first patient
was admitted, on Nov. 9, 1944. But its root
extend back long before that.
The historic Patio Building is being
restored, harkening back to its construction
in 1928 when it was meant to serve as the
Institute of Research and Diagnostic Clinic
for the Desert Sanatorium.
Before TMC was born, the Desert San
served as a TB treatment center and as a
healthy retreat for those seeking the
benefits of dry desert air and abundant
sunshine. The San, a cluster of buildings
out in the desert northeast of Tucson,
faded in popularity through the Great
Depression and World War II. In 1943,
owner Anna Erickson donated the property
as the foundation for a community-run
In the Patio Building project, the adobe mud
surface is removed to assess the structural brick
repairs needed. Then adobe mud is re-applied
according to historical processes. Helical piers are
installed at critical points under the foundation to
help alleviate settling fractures. Other repairs
include replacing much of the rotted wood lintels
and porch beams; replacing the hand-troweled
porch concrete walk with a new hand-troweled
one; and re-roofing almost half the existing roof.
Two non-functional copper domes will be
installed to restore the original appearance of the
domes on the two east corners of the building.
hospitalTMCthat began admitting

patients in 1944.
Today, this significant building from the
Sans early days still stands at the TMC
entrance at Beverly and Grant. Designed by
architect Roy Place with later renovations
byHenry Jaastad, the Patio Building
perpetuates the Hopi-inspired motif used in
the Sanatoriums first buildings, including
the use of battered walls and parapets and
wood- beam details.
The U-shaped building features a central
patio surrounded by a covered arcade
graced with hand-hewn beams and
columns. Finished with a smooth stucco
finish, the building has walls constructed of
brick, floor and roof slabs of concrete, and
support beams of steel. At the eastern
corners of the building are two towers that
22
which it shall hereafter acquire under this agreement any building

which shall exceed one storey in height.
That agreement only lasted a couple of years, as it became void
upon Mrs. Ericksons death in February 1961. Yet the agreement cast
a shadow for many years as the hospital considered and rejected
several high-rise concepts.
After extensive preparation work by TMC in 2006 and 2007, the
Tucson City Council unanimously approved a Planned Area
Development plan that now governs how vertical construction could
take place on the TMC campus.
The Patio Building not long after its opening with an Open House
given in January 1929.
Today, TMC has upgraded its grounds and facilities with new roads
and walkways, plus larger patient care areas. TMC now celebrates 70
years of patient care with a new four-storey skyscraper that
houses sophisticated surgical and patient care services.
n
once housed specialty research equipment,

designed to enable treatments using the rays
of the sun. Copper domes atop the towers
protected the equipment at both corners.
Now in 2014, one of the final phases of a sevenyear, $250 million campus improvement project
is the Patio Building renovation. The new
Orthopaedic and Surgical Tower is the
centerpiece of the project, which also has
included new roads, parking areas, walkways,
and expanded Pediatric and Mother/Baby units.
The historic Erickson Building, once home to
the Desert Sans owners, has already been
restored. Work on the Patio Building is
expected to last until the end of the year.
Speaking of buildings, what about that
decree that kept TMC a singlestoreyhospital for so long?
It became a local truism that TMC was
prohibited by code, deed, or law from building
any structures taller than one storey. There
was a whiff of truth to the tale, but the
stipulation about building height expired more
than half a century ago.
The one-storey story dates from when the
Desert Sanatorium was founded as health
retreat Dr. Bernard Wyatt in the 1920s. The San
was transferred to financial backers Alfred and
Anna Erickson in 1927, and the Ericksons built a
home on the site as their winter retreat from
New York City.
After her husbands death, Anna Erickson held
the Desert San until 1943, by which time the
Depression and World War II had left the
facility no longer viable. She donated it to
become a community hospital, and continued
living part of the year in the Erickson home on
campus.
Years later, the specification of the low-level
concept for the hospital finally appears in
TMCs 1959 deed to the medical office park
across Grant Road [home to PCMS since
1981]. The deed reflects Anna Ericksons
desire for unobstructed views, stating that
TMC hereby agrees with Erickson that it will
not during her lifetime erect on any of the land
23
Makols Call
Quit? Why, Ive barely begun!

By Dr. George J. Makol
his month I would like to

write about something that
I know little or nothing about. I
can hear you saying, Doesnt
he do that every month?
On his way home he stopped by my clinic to have a cup of coffee

with me during my break, and I was glad that he finally left
because I was nervous the whole time he was going to collapse
again. A story like that does not really inspire one to call it quits.
But there are forces that do push a physician in that direction.
But this is different. I am talking

about the great unknown, the
modern mystery, a concept that
never really existed except in
very recent history. Most people
do not know how to do it, do not
know how to start it, how long it
is supposed to last, and if they
should do it in the first place.
I have a friend who lives in the Midwest, a 55-year-old

cardiovascular surgeon. He told me recently that he would like to
retire in the next year or two. Yesterday I heard from a local
patient that his excellent 62-year-old internist is leaving active
practice in one more month. These are both tragic losses for the
medical field.
I am talking about retirement.

Up until the last 100 years or so, retirement was not really an
issue for most people. You simply got up in the morning, worked
until it was dark to feed your family, went to sleep, and then
awoke and did the same thing repeatedly until you died. When
Social Security was instituted in the 1930s, the average person
died by age 65, so that was the age they set for people to start
receiving benefits. You can see that politicians have not changed
much in the past nine decades.
Lifespans have changed, however, and today one can expect to
live into her or his (more often her) late 80s, according to life
insurance tables. Despite that, 65 seems to have stuck as a
retirement age. We as physicians dont really get into our
careers until we are at least 30, so quitting at 65 leaves a relatively
short career, considering it takes you 30 years to get started.
And what happens when a doctor does retire? Is he no longer a
healer, a physician, and counselor to his fellow man? Do his
relatives no longer ask him questions that are totally out of his
field, such as asking an immunologist about complex Ob/Gyn
situations? Will your patients, when they see you on the street,
no longer say, Bugs Bunny-like, Whats up, Doc? and revert to
Mister or Madam? Perish the thought!
And if someone collapses right in front of you, do you yell
Somebody call a doctor!?
I remember a lady friend of mine telling the story of one
Saturday when she was worshiping at temple. A woman in front
of her suddenly collapsed to the floor, and someone yelled, Is
there a doctor in the house? So many doctors rushed forward to
help that they had to make them all step back so the lady could
get some fresh air!
When I was an intern, I was standing in line at the pharmacy
behind a fortyish gentleman who had just left a cardiology clinic
with a relatively clean bill of health. He collapsed in front of me in
ventricular tachycardia. I started CPR and called a Code Blue. We
had to shock him 12 times over the next 30 minutes, but
amazingly he walked out the hospital on his own two weeks later.
24
Im sure that fighting with insurance company clerks over what is

medically necessary; asking a nurse practitioner in Michigan if its
O.K. to order a CT scan on your Tucson patient; or sometimes
feeling like you are in the employment of an insurer who sets
your pay, all were factors in those two docs quitting so early.
Medicine is the only field in the U.S. in which price fixing is
allowed and universally followed, from Medicare on down
through monopolistic insurers. It is hard to deny these
discouraging truths, although I recently did a column highlighting
the great and inspiring things about being a physician, and I still
see things mostly that way.
The biggest question of all is, what does a doctor, one of the most
productive persons on the planet, do when there is nobody to
cure? I suppose there is always golf, but I for one have never been
an acolyte of this sport. In fact, I inadvertently skipped the class in
med school one afternoon where they introduced golf, country
club living, and Mercedes-Benz driving. That is why I do not play
golf, why I drive a Ford or Chevy, and why the closest Ive come to
Country Club is building an office a couple blocks from there. I
could never see the sense of hitting a ball and then going to chase
it. At least in tennis somebody has the decency to hit the ball
back to you. Even in football when you kick the ball in one
direction, 11 men bring it back to you, even if their intention is to
run you over and into the dirt.
Technology, however may have come to the rescue according to
the new issue of Forbes. The Stuart Golf X9 Follow ($3,000 at
stewartgolf.com) is a roving contraption that holds your golf bag
and connects via Bluetooth to a transponder, so that bag will
follow you around the course. I suppose if you put the
transponder in the lounge at the end of the 18 holes, the bag
would just go right there carrying a small flask of your favorite
spirit. You could avoid the heat, the walking and the sweating and
just meet your golf bag there in the first place.
I dont know about each of you, but I do not intend to retire any
time soon. I will keep going as long as I am healthy and there are
patients that appreciate what you and I door perhaps until they
perfect holographic chase-free video golf.
Sombrero columnist George J. Makol, M.D., a PCMS member
since 1980, STILL practices with Alvernon Allergy and Asthma,
2902 E. Grant Rd.
n
25
CME
Local CME from Pima County

Medical Foundation
PCMF schedules CMEvents for its Tuesday Evening Speaker series.
Dinner is served at 6:30 p.m. presentation follows at 7.
Nov. 11: Newer Anticoagulants and their Role in A-Fib, DVT, and
Pulmonary Embolism presented by Timothy Fagan, M.D.
November
Nov. 14-15: The Primary Care Refresher and Update: Cardiology
& Pulmonary and Critical Care Medicine presented by Med
Study, 8 a.m.-12 p.m. daily at Delano Las Vegas at Mandaly Bay,
3940 S. Las Vegas Blvd., Las Vegas, Nev.; phone 1800.841.0547.
Accreditation: Receive 12 hours morning lecture from top
presenters + 100 free online Q&As for up to 37 CME credits, plus
bonus one-year subscription to MedStudy Heart Sounds.
Email:customerservice@medstudy.com
Register at http://www.medstudy.com/CME-course.html
Website:www.medstudy.com
MedStudy produces study/review materials that target the
professional development of physicians at every stage of their
careers, aiming to bring our innovative approach to medical
education to a growing audience of medical professionals.
Nov. 15: Mayo Clinic Arizona sponsors Thoracic Oncology for the
Non-Oncologist: Family Practitioners, Internists, Pulmonologists
& Surgeons at Mayo Clinic Education Center, 5777 E. Mayo Blvd.,
Phoenix 85054.
CME credits: 6.25 AMA PRA Category 1; 6.25 AOA; AAFP pending.
Website:
http://www.mayo.edu/cme/internal-medicine-andsubspecialties-2014s429
Contact: CME Dept., Mayo Clinic Scottsdale, 13400 E. Shea Blvd.,
Scottsdale 85259; phone 480.301.4580; fax 480.301.8323. mca.
cme@mayo.edu http://www.mayo.edu/cme
Course focuses on recent developments in comprehensive care
of patients with malignancies of the chest. Faculty will provide
info on lung cancer, mesothelioma, and esophageal cancer.
Attendees will learn about the latest recommendations for lung
cancer screening and about causes, prognosis, and treatment for
thoracic malignancies. Important clinical advances including
surgical, medical, radiation, and supportive techniques will be
presented.
January 2015
Jan. 9: The Association of American Physicians and Surgeons
presents a workshop and an update in New Orleans, with hotel
and meeting location to be announced. The 21st Thrive, Not Just
Survive Workshop is 1-6 p.m., and Politics and Your Practice is 6
p.m.-9 p.m.
26
Build a healthy, independent practice, AAPS says. You can

break out of the third-party payment straitjacket before
healthcare reform puts you to work for big insurance or the
government. After the workshop, stay for dinner and updates on
physician-led initiatives in D.C. and nationwide to protect patientcentered medicine.
CME accreditation through New Mexico Medical Society and
Rehoboth McKinley Christian Health Care Services is up to 4.75
hours Category 1. Online signup and more info is at www.
AAPSonline.org/neworleans .
Jan. 23: Clinical and Multidiscplinary Hematology and Oncology
2015: The 12th Annual Review is at the Westin Kierland Resort,
6902 E. Greenway Pkwy., Scottsdale 85254. CME credits pending.
Course targets hematologists, oncologists, NPs, RNs, PAs, and all
interested in comprehensive update of diagnosis and treatment of
hematologic and oncologic disorders. Course presents new
disease classification, treatments, and challenging cases in key
hematologic diseases (dysproteinemias, acute and chronic
leukemias, lymphomas), key solid tumors (breast, thoracic, GI, GU),
and overlap topics of supportive, ancillary and diagnostic care.
Includes breakout sessions for one-on-one interaction with faculty.
Website: http://www.mayo.edu/cme/hematology-and-oncology
Contact: Lilia Murray, Mayo School of Continuous Professional
Development, 13400 E. Shea Blvd., Scottsdale 85259; phone
480.301.4580; fax 480.301.8323.
mca.cme@mayo.edu http://www.mayo.edu/cme
February 2015
Feb. 5-7: The Mayo Clinic Third Annual Collaborative Update in
Minimially Invasive Gynecologic Surgery is at the Fairmont
Princess Scottsdale, 7575 E. Princess Drive, Scottsdale 85255,
sponsored by Mayo, Harvard Medical School and Cleveland Clinic.
Phone 1800.344.4758 or 480.585.4848.
Accreditation: 9.75 AMA PRA Category 1; 19.75 AOA Category
2-A; ACOG assigns 19 cognate credits.
Course is designed to provide practical update on minimally
invasive gynecologic surgery by offering tips and wisdom-pearls
for practicing gynecologists. Topics include laparoscopic, vaginal,
and robotic surgical procedures for endometriosis, pelvic pain,
fibroids, urogynecology, and other conditions. Hysterectomies,
myomectomies, and excision of endometriosis will be discussed.
Goal is to maximize practical take-home value for participants.
Mayo faculty and guest faculty from Harvard and Cleveland Clinic
will provide information in lectures, video presentations, and
unedited pre-recorded surgeries.
Website: http://www.mayo.edu/cme/surgical-specialties2015s978
Members Classifieds
MEDICAL EQUIPMENT FOR SALE:
GYNEMED Colposcope. Good condition made by Medtronics with Japanese lenses,
no camera, $500.00 obo. MILEX Western Portable Office Suctions Machine. HandsFree pedal and variable speed with gauge. Good Condition. $50.00. Interested
parties should e-mail: houseofmontrose@msn.com.
Radiology Ltd. is pleased to share a new quantitative

brain image analysis tool called NeuroQuant, which
brings accurate and fully automated advanced MRI
capabilities to you and your loved ones.
NeuroQuant is useful in the evaluation of patients from
ages 18 to 95, providing critical information used in the
assessment of neurological conditions such as:
Alzheimers Disease
Epilepsy
Multiple Sclerosis
Traumatic Brain Injury
Now featuring NeuroQuant Brain Image Analysis
To learn more about NeuroQuant, visit our website at www.radltd.com. Please consult with
your health care provider to determine if NeuroQuant would be appropriate for you.
27
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(602) 956-5276
(800) 352-0402
www.mica-insurance.com
28

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Sombrero

Pima County Medical Society

Valley Fever Awareness Week

Get the ultimate bundle

Choose the Internet package

More than 20 professional

(520) 300-5267 | coxbusiness.com

SOMBRERO November 2014

Official Publication of the Pima County Medical Society

PCMS Board of Directors

Enjoy spectacular Catalina & Rincon Mountain

SOMBRERO November 2014

At Large ArMA Board

Pima Directors to ArMA

SOMBRERO (ISSN 0279-909X) is published monthly

in a private enclave. Home backs to lush desert.

Madeline is Your Connection to

donations to Medicins Sans Frontieres.

6 Milestones: Whats up with doctors Hutchinson,

In our October Milestones item about Desert Sun Gastroenterology,

8 Membership: Dr. G. Mason Garcias cardiology

10 In Memoriam: Longtime Tucson pediatrician Dr.

Dr. Hal Travelin Tretbar, PCMSs unofficial official photographer,

the direct-pay way.

12 PCMS News: Working on licensing; Ebola

We stopped at Freeman Road and climbed a small hill to look back

17 Valley Fever: FDA fast-tracks NikZ; VF

19 Bioethics: A hospice case vignette by Dr. David

24 Makols Call: Dr. Makol gives himself a good

26 CME: Credits locally and out-of-town.

WE ANSWER FOR YOU!

Message Delivery via Pagers

24 Hours 7 Days A Week

PIMA COUNTY MEDICAL

SOMBRERO November 2014

Save that date!

The date is April 18,

SOMBRERO November 2014

Dr. Scully elected

Comings, goings at Camp

Dr. Ruben earned her

Dr. Tretbar honored

andM.D. 56, will be one those honored with a dinner and a

Dr. Power chairs TOMF Board

Alas, poor Yorick! I knew him, Horatio; a fellow of infinite jest,

Harold C. Tretbar, M.D., F.A.C.P., F.A.C.R., longtime photographer/

Dr. Power was principal investigator for two Juvenile Idiopathic

Cardiology the direct-pay way

his truly is a labor of love, cardiologist G. Mason Garcia,

HUMMINGDr. Garcia admits that direct pay may not be a

7574 N La Cholla Blvd Tucson

6969 E Sunrise Dr, Ste 203 Tucson

Helping you hear your best.

512 E Whitehouse Canyon Rd, Ste 196

We are very transparent about what we

for many patients when they examine the

Some price examples for office visits are:

Garcia, M.D. and Lawrence Garcia, M.D. are cardiologists in

I decided to do it this way because it comes down to patient care

Dr. Garcia does have experience working in the now-standard