Saturday, December 20, 2014

The Amazing Story of Nicki Imber

Read my latest blog on "Times Of Israel" on the artist and sculptor Nicky Imber - An awe-inspiring story of one man's determination to live life to the fullest.

Go to The TIMES OF ISRAEL----- BLOG PAGE----- under "Search"---- Steven Shalot & read and enjoy! 

Wednesday, December 10, 2014

Blogger for THE TIMES OF ISRAEL

My Blog for The Times Of Israel - the largest English language Israeli Internet publication, focuses on topics of Jewish and Israeli culture, historical figures and events, and also spiritual topics and current events. To view them, go to the site "TimesofIsrael.com" and click the link for "Blogs" and search for "Steven G. Shalot"

Sunday, February 17, 2013

OPIATE USE AND DEPENDENCE


Opiate Dependence and Withdrawal - 
The Covert Killer

     Without even realizing it's happening, people of the Boomer generation can find themselves in a situation of physical dependence and addiction to opiates. The reason is that as we advance in years, we are more prone to chronic and debilitating injuries. Let's  face it, looking sharp and aging gracefully has its price. Today, Boomers are more active than any other generation of people over 50. We run races, play tennis, bike, mountain climb, and spend our time in places like HOME DEPOT, where we buy stuff to engage in exhaustive repairs of our homes. All of these activities, of which I've only named but a few, combined with aging bodies, are too often a recipe for trouble - sprains, strains, breaks, and chronic injuries are our rewards. Sometimes we wear them like badges of honor. In a large number of cases, they lead to painful disabilities and recoveries. 

    Let’s take chronic low-back pain as our example: The spongy, donut shaped structures between our vertebrae, our discs, provide cushion and bounce to us as we perform our daily activities. As we age, they tend to lose water and naturally compress. Sometimes, an injury like a fall, sports injury, or an accident cause the vertebrae to compress the spinal nerves which go out to the body. This compression, right at the beginning of the nerve, called the nerve Root, is called a radiculopathy - an exceedingly painful condition. It shows itself mostly by a

PICTURE OF SPINAL NERVE COMPRESSION -
Fig 1. 
This shows a spinal compression in the neck region, a bulging disc causes a pressure on the nerve roots coming out of the spinal cord, and a narrowing of the cord itself. 
chronic, dull, back pain; unremitting and miserable to anyone that's had it. It can lead also to numbness of the areas of the body supplied by the nerve, or even paralysis if untreated. In severe cases, surgery is required in which the disc is removed, and the vertebral bones are fused to remove the pressure. Sometimes, a simple movement like cleaning oneself during toileting can cause a sudden, vicious acute pain requiring a trip to the ER or the neurologist, who will usually prescribe a skeletal muscle relaxant like VALIUM (diazepm), or FLEXERIL (cyclobenzaprine), along with the narcotics which the patient is already on from the orthopod or the physiatrist. 

       Sometimes people may be in so much pain that they will tend to over medicate, which can lead to a lethal chemical cocktail for the unwary subject. 
Today we will look at the case of a patient who has a nerve compression problem due to an accident, with a collapse of the vertebrae and a narrowing of the opening for the nerve. They are in severe, chronic, low-back pain, and their physician elects to treat their problem of pain with narcotics - a mixture of a long-acting one like OXYCONTIN(R) long-acting), and something like MORPHINE SULFATE, immediate-release tablets for sudden or “breakthrough pain.” Along with the medication, the patient will also undergo physical therapy 3 times weekly. 
     But first, in order to get an idea of how narcotics work in the body, there are some terms we will become familiar with: tolerance, dependence, addiction. Narcotics are really very devilish drugs because as a person becomes “used to” the pain-relieving benefits of the drug, the adverse effects of the drug like respiratory depression, and slowing of the heart rate also occur when the person increases their dosage. This is what is meant by a “tolerance” developing - you need increasing amounts of the drug to feel pain relief, and more to hurt you. Unfortunately, there comes a point where those bad effects take over, and taking more narcotics will kill you. Dependence goes right alongside of tolerance; a person who becomes tolerant to a larger dose of, say, OXYCONTIN(R), is also physically dependent on the drug as well - if they suddenly stop taking it, there will be withdrawal symptoms, which are most unpleasant!, after about 24 hours. 

How Narcotics Work In The Brain


FIG 2. The two pathways through which Narcotic Opiates work in the Brain -
From the source of Pain to the Spinal Cord via the Peripheral Nervous System, and
then in the Brain, where the Pain response is altered; in other words:
"The Pain is still there, but who cares?"  

      When someone is in withdrawal from an opiate narcotic, they will feel anxious, have sweating, chills, a runny nose. Later on, muscle contractions become apparent - they may have to keep stretching and contracting their arms or legs, and feel pressure in the chest. It’s also possible to have a heart attack as well! (Remember Jamie Lee Foxx in the Ray Charles movie?) Someone in withdrawal like this is VERY sick, and should be in an emergency room, or under a physician’s care directly. Giving a person the narcotic they have become tolerant of and dependent on, will immediately stop the withdrawal. 
      There are other ways of stopping withdrawal which I will introduce soon, other than "cold turkey." Is  a person undergoing narcotic withdrawal addicted to the drug, or are they a “drug addict?” The answer is not necessarily. Being dependent on these drugs when someone is taking them for legitimate medical reasons can be a stigma, and something that people may elect to hide from family, friends, employers and even insurance companies. This is unfortunate and more public education is needed on the subject (Like this blog!).
     Someone who takes OXYCONTIN(R) for constant, unremitting back pain, and in high doses, does not seek or take the drug for the euphoria or “the high” it produces. They don’t seek phony prescriptions, or seek to obtain the drug from illicit sources - That . . . in most definitions, this maladaptive behavior, constitutes a drug addict. So, there is a big difference between our pain patient, who is physically dependent on OXYCONTIN(R) and Morphine, and a drug addict, who is chasing the euphoriant effect of the drug.  The addict has become tolerant to the euphoria, and will often die of an overdosage while “chasing the high.” This is the case with Heroin, an illegal street drug, as well as the prescription narcotic opiate drugs, like the OXYCONTIN(R), PERCOCET(R) or the Morphine. 
     Our patient has been taking the OXYCONTIN(R) and a fast-acting very potent narcotic for "breakthrough pain" called FENTANYL lozenges on a stick, a relatively new product that dissolves slowly when held between the cheek and the gums, releasing the drug in fruit-flavored varieties for different strengths. Originally, this product, also sold under the brand name ACTIQ(R), was developed to treat the chronic pain of terminal cancer, but lately has been used for chronic back and neck pain of a severe variety as well. 
     So, its been 5 years that our patient has been on steadily increasing doses of both drugs, (tolerance and dependence can develop in as little as 2 weeks!)and they've really outlived their usefulness; increasing the doses would be dangerous for both drugs, and the doctor isn't sure they are working any longer to provide adequate pain relief - something else will have to be decided upon by both doctor and patient that would be acceptable. There are other modalities to use such as Physical Therapy, non-steroidal anti inflammatory drugs NSAIDS, such as CELEBREX(R), NAPROSYN(R), or the newer drugs that work on the nervous system like LYRICA(R) or NEURONTIN(R)
     
     Also, our patient has developed a problem of considerable tooth decay from the lozenges, and has developed low testosterone, and Type II Diabetes, which have been linked to chronic use of narcotics. So how does he come off the narcotics? Cold Turkey is a rather rough and dangerous way to come off these drugs as we have seen. METHADONE, with various manufacturers is an alternative, but again, there is a stigma associated with HEROIN addiction. Today, there is a safe, rapid, and relatively painless way to get off these drugs safely and permanently, on an out-patient basis, and no stigma attached. I will discuss that method soon, in my next installment of "BOOMER HEALTH."   
     
     

Sunday, April 24, 2011

JUST HOW SECURE ARE YOUR MEDICAL RECORDS???

JUST HOW SECURE ARE YOUR ELECTRONIC MEDICAL RECORDS??

Studies show Doctors lag behind rest of the country in Internet security issues.

By

Steven G. Shalot, R.Ph., D.P.M.

“Editor At Large”

The real danger is the gradual erosion of individual liberties through the automation, integration, and interconnection of many small, separate record-keeping systems, each of which alone may seem innocuous, even benevolent, and wholly justifiable.

-----U.S. Privacy Protection Study Commission, 1977

The EHR Issue from different perspectives . . .

We’ve got our noses to the grindstone, and are working hard to start off the second decade of the twenty first century. Somehow, despite all the naysayers and “talking heads” on cable news networks that predict dire consequences for the healthcare system, especially since the lack of confidence in Obamacare, we’re doing okay here in our little world of podiatry. Our future outlook is good - the number of DPM’s is expected to grow between 7 and 9% over the next 10 years, and our Net income, (which in 2009, was listed at $150,000.00 by Forbes) continues to contribute to the placement of podiatry on Forbes magazine’s “top 25 jobs” list. According to the APMA, “The Bureau of Labor Statistics suggests that until 2014, we can expect job growth of about 16% in podiatric medicine.”

Being the savvy doctors we are, a good number of us have electronic patient records and order prescriptions electronically. However, as great as all of this is, it is not without some foibles. Thieves abound, who are all too eager to get their hands on your records, and exploit the information they can get from them.

Back in 2002, John Hultman, D.P.M., Podiatry Management magazine’s practice management “guru,” said in an issue of PM News, that “it is interesting that patients and doctors feel less secure with digital records than they do with paper.” Eight years later Dr. Hultman’s words still ring true, and there is much good reason to be uncertain about keeping health records digitally. It used to be that medical information theft could be measured in tens of thousands. In 2010, that number has jumped to over 275,000 cases, according to Privacy Rights Clearing House, www.privacyrights.org.

Fraud from these thefts, in other words actual damage being done as opposed to just having records reported as stolen, has gone from 3% in 2008 to over 7% in 2009 – which is a 112% increase, according to Nicole Lewis of Information Week. Is this an unknown, or an unspoken fraud scheme? Hardly, because celebrities such as Britney Spears, Farrah Fawcett, and Maria Shriver, have all had data breeches of health care information.

“As opposed to stealing a driver’s license or a credit card, data gleaned from personal health records provides a wealth of information that helps criminals commit multiple crimes,” this, according to James Van Dyke, President of Javelin Strategy and Research, a Pleasanton, California-based marketing firm. Some of these include making payments from stolen credit card numbers, and ordering and reselling medical equipment with stolen insurance numbers. Compared to stealing a credit card, Van Dyke says that stolen medical information can be used to commit crimes for an average of 320 days, as opposed to around 80 days for credit card or bank information. In addition, it takes more than twice the time to detect fraud from medical information, than from other types of identity theft. His prediction is that as medical providers increase their use of EMR’s, the incidents of fraud will increase; at an astronomical rate.

From the cradle to the grave

With new security measures in place against fraud, credit cards are not the hottest commodity trading in the Identity Theft market place. The number one spot has been taken over by EMR’s and EHR’s. These two are NOT interchangeable. Electronic Health Records, or EHR’s, are more likely to be stored and maintained by patients, as compared to EMR’s, which are more often physician or hospital-generated. Credit cards just aren’t profitable anymore, according to the New York Times. In 2005, a typical stolen VISA card went for about $100.00, and today, the same card on the Black Market will go for maybe $6.00 to as little as $0.40.

With EMR’s you get a lot more than just a number. According to David Bailey, in the March, 2010 edition of Redspin Labs, an identity sold for $14 to $18. With an EMR you get all the information like name, address, date of birth, social security number, prescription history, medical history, and maybe even a driver’s license with a photo. Being targeted here by the thieves is not just identity but the medical information contained within them. A single hospital would retain this information for every patient that ever checked in, and that is all that an identity thief would need. Patients with recent birth or death events are the perfect candidates for identity theft because usually no one is checking on their records. In other words, people are targets right from the cradle to the grave. Hospitals usually keep all their paper patient records in the basement, as they are converted to digital information. Security is very lax here, and this is the point at which most of these records are stolen.

Now the thieves are starting to sell the actual medical and health information. Retail pharmacies were among the first to digitize patient records for the purpose of insurance billing. The insurance companies usually provided the software for these transactions. Knowledgeable thieves have hacked into systems and have held tremendous amounts of patient records hostage for large sums of money. In October of 2008, an attacker notified Express Scripts, a major national processor of prescriptions and insurance information that “millions of client records would be released to the public” if a large ransom weren’t paid. In a similar incident in April of 2009, an attacker hijacked the Virginia Prescription Monitoring web site, and posted a message demanding a $10 million dollar ransom. Just who is buying this health information? People desperate for medical care who look to acquire stolen medical records to assume an identity in order to get badly needed treatment. This trend is only on the increase. The World Privacy Forum, notes an increase in medical identity theft, from 86,168 in 2001 to 255,565 in 2005. The types of crimes that can come with this type of larceny are simply beyond the imagination – everything from tonsillectomies and bunion surgeries to heart transplants.

A Ghoulish Crime

It may seem like something out of a James Bond novel, and in many respects it is; all the ingredients for terrific fiction are there, except that this one is real. We have a staid brownstone serving as a quaint English medical clinic in a respectable London neighborhood, British doctors and patients, and international smugglers and thieves! It all began back in 2008, when the Harley Street medical clinic in London started to convert all of their medical records in the basement into digital form. They subcontracted out the job to a British firm who in turn sub-subcontracted out the job to another “English firm” which turned out to be two young Indian “entrepreneurs” from Mumbai, India. An investigative British journalist contacted the two men in an Internet chat room pretending to be a marketing executive looking to buy medical charts in order to sell devices, drugs, etc., to different patients. Such leads, according to industry insiders could really be “gold mines.” Some of the charts were being offered for as little as 4 British Pounds each.

A patient whose records were among those stolen from the clinic called the act “one step up from grave robbing.” The point to be learned by this episode is that a lack of security at the points of transfer of these records from one party to another resulted in a leak of information.

Asked to comment on examples of medical information thievery like the type that occurred at the Harley Street Clinic in London, Pam Dixon, a spokesperson for World Privacy Forum had this to say:

People desperate for medical care are looking more and more at the Black Market for an insurance identity to file fraudulent claims, thus they get the care they seek, but which is otherwise denied through more standard channels.

In April of 2010, stolen U.S. health records were found on a computer server in Malaysia operated by an international organized crime syndicate. The server compromised the medical and health information of thousands of U.S, citizens. But as we’ve seen earlier, it isn’t just health information at risk. According to Ms. Dixon: “Medical records are really like a ‘Platinum Card’ for organized crime, which can rake in millions of dollars from false billings.” Also, “information generated from these false claims entered into a patient’s EMR, can pose life-threatening risks to patients,” she added.

EHR’s Quantum Leap Despite Risks

A recent survey by a firm near Chicago called Healthcare Information & Management Systems Society (HIMSS), concluded that most hospitals in the U.S. spend less than 3% of their Internet Technology (IT) budget on security. Lisa Gallagher, the senior director for Privacy and Security at HIMSS calls this figure “inadequate,” an understatement at the least. Even though we can see that the risks associated with EMR’s and a paperless “utopia” of medical practice are great, it is doubtful if the momentum can be stopped, in fact, far from it. It seems that the inertia favors an inexorable climb to complete digitalization, on both a clinical level, and on the financial. Indeed, the case for digitalization is quite compelling, and for all of the right reasons. For our geographic illustration of this point, we will go to New England.

Boston, MA was a leader in the American Revolution, and it appears as though they are reluctant to give up that role in the “Paperless Revolution” in healthcare. Partners Healthcare is a very large corporation that operates several Boston area hospitals, and they have already turned their sights to the future. Keeping this in mind, let’s look at some background first: Physicians are under a great deal of pressure to digitize records and “get on board,” yet there is a tremendous dichotomy between doctors and hospitals in this regard. Both the New England Journal of Medicine and Partners did their own surveys, and they came out with similar results comparing doctors and hospitals in terms of who was making faster progress in digitizing their health records. They found that less than 17% - 20% of the nations 700,000 doctors are using Electronic Healthcare Systems (EHR’s), yet most of the nation’s largest hospitals have already deployed electronic health record systems.

Financial incentives despite downturn:

(Did someone say ‘Stimulus Package?’)

Compared with these largest and well-known large hospital centers across the country, the second survey dealt with smaller, non-federal hospitals, and stated that 1.5% of these have a comprehensive electronic filing system in place. Whatever survey(s) one looks at, it seems pretty clear that there is much growing to be done. But still, the lingering question is why are doctors in practice reluctant to change over to complete Electronic Systems? One obvious answer is comfort. The old adage that there is safety in doing things the way that they’ve always been done seems to have a foothold. Doctors are just reluctant to change; no matter what common sense or surveys suggest. In medical school we learned to chart a certain way, fill out forms ad infinitum, and write out our prescriptions. Charting, paper charting, that is, is very hard to say goodbye to; but it MUST be gone. The continued use of paper records places physicians at a high risk for medical mistakes, ill-informed treatment decisions and unnecessary tests because hospitals and doctors don’t have easy access to information about recent tests, health histories and other important data.

Yet the fact remains that we are still in the midst of a vast economic downturn. So while many hospitals are trying to catch up, and have taken initial steps with automation, they still have not adopted comprehensive systems. A study by Symantec Corp., the large Internet security company, on the challenges that hospitals face as they make the move to electronic records says that:

“High costs, the difficulty of changing the clinical culture from a paper-based workflow, and the economic situation (resulting in reduced budgets, layoffs, a drop in patients, and difficulties in getting credit) have all impeded caregivers’ ability to invest in new systems.”

However, observers on Capitol Hill believe that the reluctance to embrace EHR’s could dissolve soon as a result of the stimulus package and healthcare reform. Programs such as the inclusion of podiatrists in the EHR Medicare incentive make it very difficult not to participate. In fact, there are penalties for not participating. Last year’s stimulus legislation produces looming financial implications – The $787 billion package, officially known as the American Recovery and Reinvestment Act (ARRA), sets aside more than $20 BILLION in direct incentives to individual doctor practices, hospitals, and other healthcare organizations that show they are making “meaningful use” of EHR’s; which is translated to mean that medical data can readily be exchanged between interested healthcare providers. In fact, some analysts place this number at $36 billion. The major efforts to reform healthcare have focused on improving the quality of patient care, and reducing costs through information technology.

At risk are incentive payments of as much as $64,000.00 for a physician practice and millions of dollars for hospitals, depending on their size. In 2015, penalties for non-compliance will start, when physicians and hospitals that treat Medicare patients will see a reduction in fee reimbursements if they aren’t complying with ‘meaningful use’ requirements.

Now we come back to Partners Healthcare in Boston. Because of the tremendous amounts of money involved as well as governmental penalties, they are not leaving it up to the individual doctors in their system to convert to EHR’s. They take a rather atypical approach of mandating that its physicians use EHR’s. There are some interesting incentives. For instance, Huntington Memorial Hospital is helping its doctors go digital by giving them a free e-prescribing system for their offices. Beth Israel Deaconess Medical Center and Inova Health System are offering their physicians subsidized EHR systems.

Security must equal or surpass technology

These different healthcare organizations may go about using different approaches, but the goal is still the same: to assist the independent practices with which they work to make the complicated and expensive transition to EHR’s. Still, the nagging issue of having technological security keep pace with the items they are supposed to protect is there. The safety and security of EHR’s is an evolving science. A good part of the protection of these records, i.e., prevention of both the illicit possession of, and illicit alteration of them, has to do with security at the places these software programs are installed, and later used.

A bigger problem that exists in hospitals, but not so much in private offices has to do with a hospital purchasing laptops, desktops, mobile devices and such. The more “gateways” there are of entry into a system, the greater is the likelihood of theft or compromise. So, when you purchase hardware for your office you must make sure that the proper control exists over who will be doing data entry, and exactly “what” they will be entering. A basic principle is that EHR data entry should be incremental – information can never be removed or altered from the record, only added. Basically, NO unauthorized persons should ever have access to your office system. Keeping some type of paper “sign-in log” next to your pieces of computer hardware and iPads and “smart phones,” etc., if you have them in your office would be a good idea. This would give you a decent measure of control over both WHO is entering data, WHEN it is being entered, and lastly WHAT is being entered. It may seem redundant and silly, but just the fact that a log exists and is sitting there on the counter or in the employee break room can be a deterrent to fraudulent activity.

Industry standards for security of EHR’s are needed

Of course, under the health IT provisions of the federal stimulus package, all entities that handle protected health information must comply with HIPAA (Health Insurance Portability and Accountability Act) security and privacy regulations. In addition, the HIPAA rules extend to things like when patient information can be used for marketing purposes. The new law also increases penalties for non-compliance, rules pertaining to business associates, and it also allows for more vigorous enforcement.

Every office or hospital may have a different system in place, but there are “General Principles” for managing EHR’s, that ought to be universal in order to set an industry standard that makes safety and security a cornerstone of their existence (These will be listed below). To be really good at protecting patient’s and physician’s privacies, the developers, and later the users of EHR’s have to be several steps ahead of the criminals who would pirate this information and profit by it. This is no easy task, and the scope of such activity and planning is beyond the scope of this article. In fact, the literature is teeming with the security concerns of the entire “electronic alphabet:” EHR’s, EMR’s, even EPR’s!!! The users of and the creators of these systems must be aware of one fact: Without sufficient attention to security and privacy, the virtues of EHR’s can quickly become vices.

In your office, by paying attention to these aforementioned four general principles of working with Electronic Health Records, you can play a significant role in the reduction of data theft. They are: Confidentiality, Control, Integrity, and Legal Value. Pretty much, they are self-explanatory, and you can adapt them to your practice setting. The last principle, Legal Value, refers to the governing HIPAA rules with regards to commercial use of patient information. For example, using your data to identify diabetic patients for the purposes of marketing by a drug or shoe manufacturer. Your responsibility is to see that the patient is not exploited in any way.

The second principle deserves some mention here: Control. In your office, depending on the number of assistants you have working for you, you should NOT give blanket permission for everyone to access patient information. YOU will have to set the guidelines for data entry, security and financial information. Remember, the financial and billing data in your EMR should be guarded with the same diligence as the clinical information. It is not prudent, nor is it safe for everyone to know about Mrs. Jones’ payment schedule, which includes her VISA Card number, etc.,

We’ve seen how electronic medical records and charting are here to stay and the promises for the bright future they bring. The less occupation we have with the more mundane aspects of our practices, the more time and energy we can spend tending to what we love – relieving the sufferings of the foot sore public. Still, we must be vigilant and guard the privacy of the patients that come to us for treatment. As “captains of our ships,” as dependence on paper becomes less and less, we set the tone for the smooth sailing of our practices. After all, we cannot afford not to.

I would like to acknowledge the following individuals, and sources for assistance in acquiring the information contained in this article:

Nicole Lewis - Information Week

James Van Dyke – Javelin Strategy and Research, Pleasanton, California

John Hultman – quoted in PM News Archives, 2002

Maryanne Kolbasuk-McGee - Information Week ~ Analytics section

David Bailey – Redspin Labs Blog

Pam Dixon – spokesperson, World Privacy Forum

Lisa Gallagher – Healthcare Information & Management Systems Society (HIMSS)

Dr. Shalot is a former Senior Editor of Podiatry Management Magazine,(Kane Comm), and today is a freelance Health and Medical writer interested in a variety of issues pertaining to Practice Management. A trained pharmacist, he is also a specialist in the application of pharmaceutical science to clinical practice. He can be reached at “Scribbler30@gmail.com”

Sunday, April 18, 2010

Podiatrists who responded on Sept. 11th

Baptism by Fire

Podiatrists who dealt with the September 11th attacks.

By Steven G. Shalot, D.P.M. Dr. Shalot is a Senior Editor of Podiatry Management magazine.



There's a terrace in a high-rise apartment building in Forest Hills, NY. The building is about 4 miles from the heart of midtown Manhattan in the outer borough of Queens. It's a beautiful late-summer morning with blue skies and perfect visibility. Down below, the street traffic appears almost normal, the breaking news from the city barely noticeable amidst the hustle of the morning commute. It isn't until you gaze from the terrace, across the expanse of Queens into Manhattan, that you realize something is terribly, horribly, out of place. Later that evening, and into the wee hours of the next morning, these thoughts come from the terrace:


"It is just after 3 a.m. here in New York City, and I simply can't sleep. Looking out the window of my bedroom on the 17th floor, there is an unobstructed view of the Manhattan skyline. I search again for the once familiar sight of the two tall white buildings that marked the lower end of the skyscraper-filled island. All I see are some eerie searchlights of the rescue crews. "Like everyone else, I have been in shock all day, particularly since I witnessed in real-time the morbid views of the second plane hitting the World Trade Center and the sequential collapse of both towers.


"The gamut of emotions runs from shock, fear, sadness, to anger. Barely one-half century after the Holocaust, despite all our technological advances, man remains uncivilized. "The realization sets in that the terrorists who committed this crime could have and still could set off a nuclear bomb, killing millions. The safety and security we have taken for granted in America is and never will be the same."

The writer of these words and the occupant of that terrace apartment in Forest Hills, NY is Editor-In-Chief Barry Block of Podiatry Management magazine. For him, like so many of us, the events of Sept. 11th changed the way we live our lives, and ponder our futures.

There were many heroes who rose to the challenge of that day, and some who gave their lives in trying to save others. Among them were New York City firefighters,police officers, emergency services workers, and ordinary citizens. As podiatrists, we too can be proud of our own on that and the days that followed.

Three podiatrists have their practices in and around Ground Zero, and were able to give Podiatry Management some unique and candid pictures of the events as they unfolded. We can read and understand the words, but not even begin to grasp the emotions.

John Zboinski is an attending at NYU Downtown Hospital, formerly known as Beekman Downtown. He was seeing patients in his office, which is a few blocks from Ground Zero. "The first report that day was from a patient who stated a plane had hit the World Trade Center, but to what extent we had no idea," according to Zboinski. Just a few minutes later he felt the building begin to shake and heard what sounded like a rumble. More patients kept running in and saying that an airliner, and then a second airliner, had hit the WTC.

People everywhere were getting upset. Soon they were visited by the chief of medicine who asked all physicians to report to the hospital, and told them that there was a disaster and that their services would be required. Dr. Zboinski is with a group of orthopedic surgeons, Seaport Orthopedic Associates, and soon all of them found themselves in the emergency room "to do what we had to do."


A Hollywood Movie Scene



There was, outside the hospital on Beekman street, a major flow of pedestrians coming from the WTC area. "It was like crossing a river of people," Dr. Zboinski said. Some were injured, helping others, covered in soot, others not injured, but all walking or running to get away from the immediate area. Frantically, police and firemen were trying to keep people moving, imploring them to stay calm, and scanning the throngs of pedestrians for the more seriously injured among them.


Outside the hospital, Dr. Zboinski turned, looked around and up and saw "multiple floors of the twin towers just burning away." At that point, said Zboinski, "I knew we were in for a long haul. It was like a scene from a movie, where one would expect to see a Bruce Willis or Steven Segal come running in to save everybody. I saw people running for their lives and these famous buildings just burning away. It was the last thing I wanted to see on a beautiful Tuesday morning, especially in the United States."

"So I reported to the emergency room from my clinic, and things were already in place, people were coming in, it was just a high volume of

patients coming. I just rolled up my sleeves and went to work," Zboinski said. Initially, they set up the cafeteria as a triage/treatment area for the ambulatory patients. Dr. Zboinksi and his colleagues handled numerous ankle sprains/fractures, and foot fractures. At one point they began to do a lot of suturing of lower extremity wounds, as well as on other parts of the body. "We basically functioned under the Chief of Orthopedics, Ronald Krinick, and the chief of surgery, Howard Beaton. We assisted whatever way we could," said Zboinski.


Bad Air


There is a little courtyard outside the hospital cafeteria, which is surrounded by the four walls of the hospital. Dr. Zboinksi and colleagues were preparing to put patients out in that area for more space. However, as the Towers collapsed, this cloud of dust began coming over the hospital itself, and the sky kept getting darker and darker, "until you couldn't even see across the courtyard. We ended up having to put duct tape around the doors and windows to prevent the dust from coming in. It was just like night," Dr. Zboinski said.


Dr. Zboinski's car was in the hospital lot outside, and it was completely covered with dust and debris. "Our problem," according to Zboinski, "was that we really didn't know what was happening outside of the hospital - we lost phones, lost electric, lost cable TV. We were completely under emergency power." He has no recollection of when that happened, only that he and his team worked non-stop throughout the day, and that he would probably spend the night in the hospital, which he did.


Then, about 7:00 p.m., some excitement. A report came in that a field amputation was required down at Ground Zero. A firefighter or rescue worker was supposed to have had his legs pinned, and they were going to do an amputation of both legs. So, a surgical team was hastily put together which included Dr.Zboinski. They were taken by police vehicles down to Ground Zero, with supplies which included battery operated saws from the operating room, to perform the expected procedure.


"We waited and waited for a patient who never showed up. Apparently, they were able to get him out, or they managed to so something, but our services were not required," according to Dr. Zboinski. That night, they didn't get back to the hospital until midnight. That first evening at Ground Zero was the first chance to see the devastation and what happened at the trade center. "The dust was so horrible and intense, that we constantly wore surgical masks. I'm still coughing from all the dust. We wore caps and surgical goggles for eye protection. I still can't put everything I saw into words," Dr. Zboinski said.

Then, there were the memorable patients and experiences to capture for a moment and show our profession at it's best: The girl's name was Debbie, and she had bilateral open tib-fib fractures. She had a left heel avulsion, where most of her calcaneus was ripped out. In addition, she had both major portions of her gluteal muscles torn away - all from falling debris. She was in the operating room for about eight hours that first day.


Another woman was brought into the emergency room, having an asthma attack and in a state of panic. Dr. Zboinski recognized her as a patient from the hospital clinic and went over to her. As soon as she started talking to him, a familiar person, her panic and asthma subsided somewhat and she was able to undergo treatment.

"It was just like being in a M.A.S.H. unit. We did, I am very proud to say, adapt to that role very well. My residents performed in a fantastic manner - they pitched right in," said Dr. Zboinski. In addition, three other podiatry attendings affiliated with Downtown hospital managed to get to the emergency room from offices uptown. They were Drs. Joe Fox, Richard Frankel, and Stuart Mogul. All three identified themselves as physicians from the hospital, and were brought by police escort right to the emergency room.


"24/7"


Stuart Kitton, D.P.M., has his private practice just a few blocks from Ground Zero. The twin towers of the WTC were an imposing and magnificent sight, and were really the heart and soul of the area. Many of Dr. Kitton's patients worked in the financial district and at the WTC - he lost some of them in the disaster. During the first few minutes of the bombing, Dr. Kitton had presence of mind to step outside his office, and photograph events as they happened.


One particular photograph, shown here, seems to capture the essence of what Sept. 11th was all about. On the right side of the photo you see green foliage against a perfect, blue, late summer morning sky. On the left hand side, you see the dramatic image of one of the Towers on fire, moments before the collapse. There is a contrast here, a conflict. It is, as if, the picture demands to be split down the middle - the two halves simply don't belong together on the same page. Yet, the two images present in the same photo remind us of the theme of that day: senseless violence tearing into the fabric of our peace, security, and everything we hold beautiful and admirable about our culture. So, perhaps the photo should stand as it is.


Dr. Kitton volunteers his services from time to time at St. Paul's church, also pictured, where a 24 hr/7 day emergency foot clinic was set up for the rescue workers and firemen by Dr. Nancy Clark, of NYCPM's surgical faculty. He does the best he can, and hopes that some day, things will return to normal in his part of town, and his practice will return. Alfred Garofalo, D.P.M. graduated NYCPM in 1992, and is the chief of the podiatry service of Gouverneur Hospital in Manhattan, also very close to the WTC. He gave this account of that morning's events:


"We were in the office, talking with the attendings, and we heard a loud explosion. We ran to one of our windows and we saw one of the WTC towers on fire. We are on the fifth floor and we have a view of about 40 floors of the WTC. We saw it on fire, no one knew exactly what had happened at the time, and we went back into the office, trying to get some information. We found out that a plane had crashed into the WTC, and then we heard another loud explosion. Looking out the window, we saw the second tower on fire.


"One of my residents saw the second plane hit. He was coming out of the train station which was about two blocks away, and he felt this tremendous amount of heat, and he looked up, saw one tower on fire, and was staring at the scene when he saw the second plane approach and crash into the building. After the two buildings were on fire, we were still trying to figure out what we were going to do with the institution, because they called an emergency staff meeting.


"One of my attendings had taken out a pair of binoculars, and right in front of our eyes the tower collapsed. We could actually see an individual leaping from one of the windows of the building as debris was falling down on him. He just disappeared in a puff of smoke. It made me sorry I had the binoculars - I didn't need to see that."


"We waited around the hospital, because being part of the Health and Hospitals Corporation, all of the institutions were put on alert, because there may be survivors or wounded coming out. So, we waited and every hour we had an updated meeting. We had a couple of firemen come in, police officers, but no survivors. At around 5:00 p.m., they called another meeting and told us we could leave because everybody was being taken to Bellevue at that time.

"I then decided to go down to the site and volunteer with a couple of my residents to see what we could do. We got down there about 6:00 p.m., and it was still very chaotic. It was not in control like it is now with the State Troopers and the Army National Guard. We were told to go to Stuyvesant High School, which was being set up as a triage center. By the time we entered Stuyvesant high school, they were closing it down because they decided there was no need for it. They decided to move it closer to Ground Zero. Instead they told us to go the American Express building which was across the street from the WTC. By the time we got

there, they started bringing in the body bags because they had set up a temporary morgue there.


"... I remember seeing a lot of images I don't want to remember, like the wounded, the dead. There was a large section of the WTC that was over on its side, almost like a ship where they were climbing on top of it and peeking into the windows that weren't there, to see if there were any survivors there. Of course, there weren't any. We stayed in the back, by a firehouse where they set up a triage center for the firemen. We stayed there for about two or three hours, and then we all decided to leave at about 2 or 3 in the morning.


"The next day we decided to go back again after work around 5:00 p.m. It was a little more difficult getting in, but once we showed our ID they let us right through to Ground Zero again, and they let us through again to the fire station which was being used for triage. After about two hours of waiting around, one of my residents just said 'let's go up front and help,' so that's what we did. We helped dig for about five or six hours, assisted the firemen, etc.."


"The next day we went back and did the same thing till about 3:30 in the morning. We took off Thursday, I went back alone on Friday, and on Saturday I came down with about two of my friends. By that time, they moved a lot of debris out of the area, so the only thing left were remains that were just too heavy to pick up and move. At that time they weren't really letting a lot of the non-professionals up there because it was getting dangerous. We stayed back, with the firemen, and a couple of more days passed."


The rescue efforts and the subsequent care given to the volunteers and city workers during this immense tragedy was truly a team effort in which podiatry played, and still is playing an integral part. The selfless devotion shown by Drs. Garofalo and Zyboinski, as well as attendings and residents, are typical of the best of our profession. Perhaps the mood is best summed up by Dr. Zyboinski: "I realized from this experience how quickly your life can change in a matter of moments - and that all the training and all the time you put into medicine, it all comes back to you, and no matter what the situation, there is always something to do, and always some help you can give."