Summer 2012

 
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66th Annual Mtg

VOS 66th Annual Meeting
May 3-5, 2013
Mandarin Oriental Hotel
WashinGton, DC




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Topper

Orthopaedic Volunteers Put Kids First

By  Billy Andrews, MD

volunteersI am a member of an organization called Kids First, a group of 23 surgeons, anesthesiologists, and nurses who, for 20 years, have treated children with orthopaedic problems in South and Central America. We have worked in Colombia, Brazil, Guatemala, El Salvador, the Dominican Republic, and Mexico. Our current site is San Miguel de Allende, in central Mexico, and on June 9 we made our eighth surgical trip to San Miguel.

kids1
 
kids2

Ours is a turn-key operation as we own all of our surgical equipment and have three surgical teams, five anesthesiologists and anesthetists, and a staff of pre- and post- operative nurses.  We also ship all of our durable goods, OR packs, casting materials, etc., about six weeks prior to our arrival, so we need nothing from the local government other than a place to work. We have worked as a unit for 20 years, but live throughout the country – Tennessee, Virginia, New York, Connecticut, Ohio, Maine, and Florida.

kids3This was a typical trip, in that we arrived Saturday afternoon, screened approximately 150 children on Sunday, and operated Monday through Friday.  We performed 149 cases. Two of the surgeons also run a pre-operative screening clinic in February, and one runs a post-operative clinic in August. We write a brief operative note with post-operative instructions in Spanish on the children’s casts so if a child doesn’t return to the post-operative clinic any healthcare provider will know how to treat him/her.

Many of you followed along during our most recent trip via the Kids First Blog.  If you missed it or would like to learn more, please visit:  http://kidsfirstortho.wordpress.com/

_________________

In Memoriam - Frank C. McCue, MD

By Robert S. Franco, MD

Frank McCue

From left, A. Bobby Chhabra, MD, 2010 VOS President, presents Frank McCue, MD with the 2009 VOS Career Award.

It is with great sadness that I must share with you that Dr. Frank C. McCue, III, our leader, role model and dear friend, passed away peacefully on Sunday afternoon, July 8, 2012.

In Harvey Araton's book, When the Garden Was Eden: Clyde, the Captain,
Dollar Bill, and the Glory Days of the New York Knicks, Bill Bradley is
quoted as saying, "In life, it's very difficult to get to the mountaintop,
because one day leads to another and leads to another day. There are small
wins and losses in the process. But in sports, what you can do as a team,
with your fans feeling part of it, is to show what's possible for human beings
to achieve if they work together, if they care about each other. Winning the
title gave resolution to people who didn't have much resolution in lives, at a time when resolution was something they really needed."

Doc gave us all the resolution that we needed. And last June 8, his team gathered in Charlottesville - many present in person and thousands in spirit.

Dr. McCue suffered a heart attack on May 13, but due to the dedication of his wife, he returned home to Old Farm Road on June 4, following a three week hospital and rehabilitation stay. After much concern about whether he could attend the McCue Society weekend, Doc rallied. Not only did he attend, he beamed throughout and closed Thursday night's party. We want to thank everyone who helped make the special night possible, including Gary Hazelrigg, Becky Davis, Mike Stroud and Sue Saliba. Thanks also go to Sierra Bellows for her help with the newsletters.

Dr. James R. Andrews gave an eloquent and heartfelt keynote speech and sat next to Doc at his table. To the outside world, Dr. Andrews is an icon, but sitting next to Doc, he was simply Doc's 1972 Fellow. Doc said, "I am so glad Jim came home to visit."

In his inimitable fashion, Dr. Andrew's speech described Doc's tireless work ethic and his incredible dedication to the practice of medicine and the University. It was through this process of always reaching out and giving that Doc touched thousands of lives. As Dr. Andrews emphasized, Doc became our leader through his actions. He demonstrated to us that sacrifice and working together can accomplish great results. To a standing ovation, Dr. Andrews saluted "The Chief," Dr. Frank McCue.

In conversations a year ago with a donor who wanted to make a gift to honor Dr. McCue, Doc specifically asked that the donor direct his gift to the Athletic Training Department. The care and training of athletes was, as always, most important to him. At Doc's direction, The Frank C. McCue Athletic Training Department Fund was created. In lieu of flowers, his family suggests that if you wish to make a donation, please send it directly to: The UVA Fund/McCue Athletic Training Department Fund, P.O. Box 400314, Charlottesville, VA 22904

Doc will continue to motivate us and provide us with a sense of purpose. His legacy will continue to bring us together. Doc, we thank and love you.

_________________

Medical Care at the Ironman
World Championship in Hawaii

By T. K. Miller, MD

Every October, the population of the village Kailua-Kona on the Big Island of Hawaii expands exponentially with participants, families, and support staff of the Ironman World Championship. Often unrecognized is the parallel expansion of medical expertise on the island as a massive volunteer medical staff makes an annual migration to provide event medical care. Under the direction of longtime medical director Bob Laird, MD, return volunteers have included the Medical Director for the International Triathlon Union (ITU), the Medical Director of the Rock and Roll marathon series, the Past President of ACSM, and the Past Chair of Cardiology of Duke University. Other volunteers come from the annual “Sports Medicine in Conjunction with the Ironman” educational course. While the Big Island has an excellent core of medical service, with over 1,800 participants in the 140.6 mile competition, the potential volume of athletes requiring care could easily overwhelm the transport and hospital services on the island. This allows, in fact requires, a level of flexibility and creativeness in providing emergency and sports medicine services associated with race day medical care. Cargo vans are converted into roving ambulances (staffed with a nurse, driver and physician and supplies for wound care, basic fracture stabilization, IVs and transport); the medical tent at the finish line is constructed as a “mini” ER with space for 60+ cots, 20 observation (aka “weak and dizzy”) spaces, computer-based registration of each athlete that will enter and leave, onsite lab and real-time communication with a command center constructed just for the event.
 
I have had the opportunity to work as part of the medical staff covering this event and have been fortunate to make this “pilgrimage” as one of the charge physicians in the finish line medical tent for the past two decades. It’s been a welcome break in the middle of football season and one of the few occasions where “medicine” is the more important component of my SportsMedicine practice. What follows is the “typical” race day medical coverage.

The athletes begin to arrive at the area in front of the King Kam Hotel at about 4:30 am with anticipation of the 7:00 am race start. At the same time, the blank space under an adjacent circus tent (constructed a few days prior and with supplies delivered on pallets the day prior) begins a conversion to a field ER. From the carpet covering the sand to every cot that needs to be assembled and set up, IV hangers and prepped IV bags, supply tables, crash cart, check in station, communication hub, and warming station for chicken broth (surprising for a race contested in 90-100 degree conditions but invaluable for late night finishers and hyponatremia care), the entire set-up occurs race morning.

Prior to race start, the usual “band aid brigade” shows up at the small triage area. With race start, the complexion of services changes.  A small area of the tent is set up for early emergent services. Ocular injuries from the rugby scrum that is race start and sea sickness during the swim are not uncommon. Asthma attacks, near drowning, shoulder dislocations, broken fingers and toes and even a quadriceps tear have been seen in years past, as has a past pro winner’s “asthma attack” that later required pacemaker / defibrillator. Once the last swim finisher is on the bike course, a relative calm allows completion of the finish line medical area construction.

From the bike course, a few athletes are transported for dehydration.  Bike misadventures require transport to the small hospital in Waimea for fracture care (the Island’s spring warm-up to Ironman saw three hospital transports for fracture care, including a hip fracture). Lesser injuries are transported to finish medical for care or triage.

Around five hours after race start, the pros have come through the bike/run transition. With this first real break in the race, a number of athletes who have hung on to complete the bike portion will drop out and require medical care. Using wheeled military stretcher carriers, they will be transported from a triage area to the medical tent for definitive care. After completing 112 miles on the bike, the remaining athletes head out for a marathon through town and the lava fields.

At 8:03:56, after the race start, the first pro finishes and the steady stream of athletes into the tent begins.  Some are transported immediately from the finish, some make it to the tent under their own power, some “bounce back” after post-race celebrations finding that they didn’t finish as well off as they thought. For most of the pros, the tent is a place to recover away from the crowd. For some (pro and age grouper), failure to respond to limited IVs, worsening whole body cramps, disorientation, and hyperreflexia indicate hyponatremia and merit ER transport. Each year, as finish times drop and athlete conditioning and training improves, the surge of athletes into medical moves earlier and is more compressed.  This leads to a three to four hour time of controlled chaos in the medical tent. Improved conditioning and understanding of how to compete at this distance also translates to quicker recovery with less intervention. Monitoring of heart rate, made simpler by the number of athletes wearing heart monitors, is the best indicator of medical status;  in this population, a heart rate of 70-80 after a few minutes of observation is tachycardic. As compared to the idea of “IVs for everyone,” the concept of reduced immediate intervention and allowing “nature to take its course” and allow the body to equilibrate has led to the concept of “if they don’t recover quickly and with minimal fluids (1-2 liters of IVF), something bad is going on”. The broad spectrum of volunteer clinical expertise (nothing is more comforting than  having a cardiologist, cardiac surgery anesthesiologist, several ER docs, a GI specialist and ER and anesthesia nurses on staff) and years of work in the tent allow most care to be provided in the tent as opposed to ER transport. While hyponatremia is the most common (and much better recognized) reason for transport, pulmonary distress, chest pain and even bowel infarcts have been seen.

After dark, the number of participants on the course dwindles and the count of “how many are left” begins. An estimated 20% of the field will require evaluation and care in the medical area (down from 25-30% in years past) but only a handful will require ER transport and only two end up in hospital overnight. As the numbers dwindle, portions of the tent are closed and supplies packed up. At midnight, 17 hours after race start, the course is officially closed. The last medical stragglers come in over the next 30-45 minutes and the tent closes down to a small care area of a half dozen beds. One athlete exceeds the “time and fluid” limit, and is clearly going to require extended observation; they travel to the Kona hospital. A repeat customer from years past gets up under their own power and leaves with family. After this, the medical staff disassembles and packs the “ER”.  By 2:30 am, aside from supplies on pallets and the tent overhead, there is no indication of the last 20 hours of work. Dr. Bob loads the 02 tanks in his truck and heads home. Tomorrow (actually later today), supplies are shipped back to the warehouse, the tent comes down, care records and supply use will be reviewed, ER transports require follow up and inventory and planning for the next year begins.