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A BI-WEEKLY PUBLICATION FROM THE CEDARS-SINAI CHIEF OF STAFF June 6, 2014 | Archived Issues

Meetings and Events


Grand Rounds

Click here to view upcoming grand rounds.


Upcoming CME Conferences

Click below to view a complete list of all scheduled Continuing Medical Education conferences.

CME Newsletter - June 2014 (PDF)


Milestones

Do you know of a significant event in the life of a medical staff member? Please let us know, and we'll post these milestones in Medical Staff Pulse. Also, feel free to submit comments on milestones, and we'll post the comments in the next issue. Click here to email us your milestones and comments.

Click the "Read more" link to see this issue's milestones.

» Read more

CS-Link Tip: a Big Weekend

System Will Shut Down June 7 From 1-5 a.m.

The weekend of June 7 will have three significant CS-Link™ events: CS-Link will be upgraded, the Alaris Pump integration with CS-Link will go live, and Anesthesia will begin using the CS-Link anesthesia module for the Laboring Epidural workflow.

» Read more

ED, Discharged Patients to Get My CS-Link Access

Cedars-Sinai is continuing its efforts to meet and prepare for the meaningful use requirements across the health system and provide more patient-centered care. As part of our efforts to reach these goals, Cedars-Sinai Health System will be extending My CS-Link™ access to patients who visit the Emergency Department or are discharged from the hospital starting on Saturday, June 7, 2014.

» Read more

Cal MediConnect and Changes for the Dual Eligible

Insurance plan changes are happening for seniors and people with disabilities who are dually eligible for both Medicare and Medi-Cal. This patient population is often referred to as "dual eligible" or "medi-medi."

» Read more

Morgenstern Debaters to Tackle Robotics

Event Opens Cedars-Sinai's First Founders Day

Robotics in medicine is the subject of this year's Dr. Leon Morgenstern Great Debates in Clinical Medicine Resident Competition. Kicking off the first Cedars-Sinai Founders Day, the debate will convene for its 11th year on Friday, June 6, at 8 a.m. in Harvey Morse Auditorium.



» Read more

Update on Shortages of Nitroglycerin Inj, Metronidazole Inj

Cedars-Sinai is experiencing an ongoing shortage of nitroglycerin inj. The shortage of commercial, premade nitroglycerin 50 mg/250 mL infusion bottles has resolved. Premade nitroglycerin 50 mg/250 mL infusion bottles will be restocked in 4 North Saperstein and 6 Saperstein at standard par levels. Also, because of an ongoing shortage of metronidazole inj, an automatic substitution has been implemented.

» Read more

Shattering the Taboo Against Discussing Death

Southern California Healthcare Providers Come Together at Cedars-Sinai to Launch Joint Effort to Improve End-of-Life Care

If there is such a thing as a "good death," it's more likely to happen in the Los Angeles region in the near future, now that nearly a dozen major healthcare providers have joined forces to promote more compassionate end-of-life care. This was the consensus among healthcare and religious leaders who spoke during a conference at Cedars-Sinai on May 22.

» Read more

Taking the Hurt out of Healing

Inpatient Pain Service Helps MDs Ease their Patients' Pain

Because patients experience and deal with pain in their own individual ways, physicians may find that what works for one patient is not effective for another. Enter the Inpatient Pain Service, a pain management program at Cedars-Sinai that focuses not only on acute perioperative pain management, but also on chronic pain and cancer pain among inpatients.

» Read more

Drugs Show Progress Against Fatal Lung Disease

Researchers in separate clinical trials found two drugs slow the progression of idiopathic pulmonary fibrosis, a fatal lung disease with no effective treatment or cure, and for which there is currently no therapy approved by the federal Food and Drug Administration.

» Read more

Fireworks, Sand 'N' Snore Are on the Horizon

Summer has a couple of treats in store for medical staff members and their families: the Independence Day celebration at the Hollywood Bowl on July 3, and the Sand 'N' Snore sleepover on Sept. 5.
 

» Read more

CSF Leak Surgery Gets Woman Back on Her Feet

Unable to stand or sit upright without an excruciating headache, a New Mexico woman came to Cedars-Sinai, where Wouter Schievink, MD, surgically repaired a tear in the lining around her spinal cord.
 

» Read more

CS-Link Tip: a Big Weekend

System Will Shut Down June 7 From 1-5 a.m.

The weekend of June 7 will have three significant CS-Link™ events:

  • CS-Link will be upgraded across all modules to Version 2012, including the foundation for ICD-10, which will display expanded code sets (also known as Clinical Readiness).
  • The Alaris Pump integration with CS-Link will go live in phases throughout the day on Saturday, June 7.
  • Anesthesia will begin using the CS-Link anesthesia module for the Laboring Epidural workflow.

A command center to support the changes will be set up in rooms ECC A-C and will be available for two weeks. The command center phone number is 310-248-6600.

This upgrade will require a downtime. CS-Link users will need to log off of the system and follow downtime procedures on June 7 from 1 a.m. until about 5 a.m. In addition, no SmartPhrases can be created or edited through June 7.

The command center will have details of the Alaris Pump integration.

Please visit CS-Link Central and review training materials so you are ready to enjoy the new functionality and increase your efficiency.

You can schedule physician efficiency training at your office by emailing Alex Bram at alex.bram@cshs.org or Lisa Masson, MD, at lisa.masson@cshs.org.

Click here for more CS-Link training updates for physicians.

Previously in Medical Staff Pulse:

CS-Link Upgrade Set for June 7 (May 23, 2014)

ED, Discharged Patients to Get My CS-Link Access

Dear Colleagues,

Cedars-Sinai is continuing its efforts to meet and prepare for the meaningful use requirements across the health system and provide more patient-centered care. As part of our efforts to reach these goals, Cedars-Sinai Health System will be extending My CS-Link™ access to patients who visit the Emergency Department or are discharged from the hospital starting on Saturday, June 7, 2014.

The impact of this is that patients who are discharged from the inpatient or ED setting will be given a My CS-Link enrollment letter that will allow them to access parts of their medical information through My CS-Link. These My CS-Link enrollment instructions will automatically print as part of the after visit summary (AVS) for all patients who are not already a registered My CS-Link user. Patients who establish a My CS-Link account will have access to portions of their medical information pertaining to their inpatient or ED admission. A summary of the information available in My CS-Link is outlined below.

  • Patients who are discharged will have access to information from their admission, including:
    • Inpatient and ED AVS — the same AVS information that is currently printed and handed to the patient at the time of discharge.
    • Health summary information (e.g., active problem list, active medication list, allergies, immunizations, etc.).
  • In addition to any results from laboratory tests ordered in the ambulatory setting, patients will also have access to their inpatient laboratory test results through My CS-Link. Results from laboratory tests ordered in the inpatient and ED setting will be automatically released to a patient's My CS-Link account 24 hours after the patient is discharged. The automatic release of inpatient and ED test results will apply to the same laboratory tests as it does in the ambulatory setting. This means that auto-release will not apply to certain sensitive laboratory results or those for which electronic release is regulated by statute: HIV antibody test, presence of antigens indicating a hepatitis infection, drug abuse or pathology revealing a malignancy.

Benefits for the patient include immediate access to clinical data to facilitate care after discharge and remote access to health summary information. As with any change, this represents a new paradigm in sharing information with patients, but it is an important step in providing safer, patient-centered care. We thank you in advance for your support of this initiative.

For further information, please visit CSLinkCentral.org. If you have any specific questions, please reach out to Shaun Miller, MD, (310-423-8759, shaun.miller@cshs.org) or Lisa Masson, MD, (310-779-1651, lisa.masson@cshs.org).

Richard V. Riggs, MD, Chief Medical Information Officer
Christopher S. Ng, MD, Chief of Staff

Cal MediConnect and Changes for the Dual Eligible

Insurance plan changes are happening for seniors and people with disabilities who are dually eligible for both Medicare and Medi-Cal. This patient population is often referred to as "dual eligible" or "medi-medi."

The biggest change is the launch of a pilot program in California called Cal MediConnect. All dual-eligible patients are receiving notices about this program. Eight counties are included in the Cal MediConnect pilot program: Los Angeles, Orange, San Bernardino, Riverside, San Diego, Alameda, San Mateo and Santa Clara counties.

At this point, Cedars-Sinai is not participating in the Cal MediConnect program. Patients who want to keep coverage for Cedars-Sinai must opt out of Cal MediConnect. By opting out of the program, they will keep the same fee-for-service Medicare benefits, but likely will need to sign up for a Medi-Cal managed health plan, if not already enrolled in one. The Medi-Cal managed care plan will be responsible for covering Medi-Cal benefits, long-term support services and coordinating with Medicare for deductibles and coinsurance.

Cedars-Sinai is in discussions with various payers regarding participation in Cal MediConnect. We will update you if any changes occur.

We have launched several communication vehicles to assist in explaining the options for this important patient population. Among them:

  • Telephone number operated by Cedars-Sinai where beneficiaries can have their questions answered as they relate to keeping coverage for Cedars-Sinai care. (The number is 844-CS-MEDIS (844-276-3347) and is staffed 24 hours a day, seven days a week with translation services available.)
  • Website that includes information on important dates, a glossary of terms, and frequently asked questions at cedars-sinai.edu/duals.
  • Handout that details beneficiaries' options, important dates and instructions to select coverage (translations available for offices and departments upon request).

Changes for Patients With Both Medicare and Medi-Cal (PDF)

  • Handout that explains the Health Plan Choice Form in plain language. At this point, we have only included instructions for how to opt out as Cedars-Sinai is not currently participating in the Cal MediConnect program. (The California Department of Health Care Services is mailing the form to eligible beneficiaries.)

Completing Your Health Plan Choice Form (PDF)

For your information, PDFs of both handouts referenced above are attached to this email. If you are interested in distributing these handouts to your patients, please contact marketing at marketing@cshs.org.

If you have any questions about these insurance plan changes or the Cal MediConnect program, please email duals@cshs.org.

Morgenstern Debaters to Tackle Robotics

Heidi Reich, MD

Ryan Spurrier, MD

Robotics in medicine is the subject of this year's Dr. Leon Morgenstern Great Debates in Clinical Medicine Resident Competition.

The debate will convene for its 11th year on Friday, June 6, at 8 a.m. in Harvey Morse Auditorium. The topic will be "Robotics — Medicine or Marketing? Progress or Promotion?" Heidi Reich, MD, will argue that robotics is a medical advance. Ryan Spurrier, MD, will argue that robotics is medical marketing.

The debate will anchor the inaugural Cedars-Sinai Founders Day (see story below).

For more information about the debate, contact Leo Gordon, MD, at leo.gordon@cshs.org.

To see coverage of last year's debate, click here.

Morgenstern Debate - June 6 (PDF)


Founders Day Coming Up June 6

In 1976, a fleet of ambulances made a ceremonial procession, carrying Cedars-Sinai patients to the medical center's new location.

Cedars-Sinai will celebrate its inaugural Founders Day on Friday, June 6. The occasion will be an annual observance of the day in 1976 that Cedars-Sinai first opened in its present location.

Founders Day events will include:

  • 8 a.m.: Dr. Leon Morgenstern Great Debates in Clinical Medicine Resident Competition, Harvey Morse Auditorium.
  • Noon: "June 6, 1976 — You Were There," a presentation on the new Cedars-Sinai's opening day, Harvey Morse Auditorium. The presentation will include a panel discussion featuring four people who started working at Cedars-Sinai in 1976 or earlier — Glenn D. Braunstein, MD, vice president, Clinical Innovation; Linda Burnes Bolton, DrPH, RN, FAAN, vice president and chief nursing officer; Ilean Smith, DTR, administrative coordinator, Food and Nutrition Services; and Steve Simons, MD, medical director, Medical Affairs for Quality/Performance Improvement. Lunch will be provided.
  • All day: Preview of a new Historical Conservancy exhibit on Cedars-Sinai's past. The exhibit will be in the corridor outside the Medical Library. The collection of books, documents and artifacts traces the founding and development of Cedars-Sinai over the past century.

Founders Day - June 6 (PDF)

Previously in Medical Staff Pulse:

Cedars-Sinai Celebrates Its Beginnings (May 23, 2014)

New Exhibit Will Display Cedars-Sinai's History (Nov. 22, 2013)

Update on Shortages of Nitroglycerin Inj, Metronidazole Inj

Cedars-Sinai is experiencing an ongoing shortage of nitroglycerin inj. The shortage of commercial, premade nitroglycerin 50 mg/250 mL infusion bottles has resolved. Premade nitroglycerin 50 mg/250 mL infusion bottles will be restocked in 4 North Saperstein and 6 Saperstein at standard par levels. New nitroglycerin infusion orders will be processed as written.

Nitroglycerin 5mg/ml x 10ml vials remain unavailable. At this time, we cannot accommodate custom nitroglycerin infusion (i.e., nitroglycerin infusion in normal saline or different concentrations).

Metronidazole Inj Shortage

Cedars-Sinai also is experiencing an ongoing shortage of metronidazole inj. To conserve the remaining supply, the following automatic substitution has been implemented.

Medication OrderedAutomatic Substitution
Metronidazole injMetronidazole PO, same dose and frequency if patient is able to tolerate orals except when used for treatment of brain abscess, meningitis, anaerobic bacteremia, severe complicated C. difficile infection

This plan was approved by the Antimicrobial Use Review Committee and the Pharmacy and Therapeutics Committee.

Shattering the Taboo Against Discussing Death

Panelists at the conference pointed out that the failure to do advance care planning and have conversations about end-of-life care before a health crisis leads to costly medical treatments that may involve greater burdens than benefits for patients.

Southern California Healthcare Providers Come Together at Cedars-Sinai to Launch Joint Effort to Improve End-of-Life Care

If there is such a thing as a "good death," it's more likely to happen in the Los Angeles region in the near future, now that nearly a dozen major healthcare providers have joined forces to promote more compassionate end-of-life care.

This was the consensus among healthcare and religious leaders who spoke during a conference at Cedars-Sinai on May 22. The event at Harvey Morse Auditorium, titled "Better Planning, Better Care: Promoting Dignity, Reducing Suffering at End of Life," was the first to be sponsored by a recently formed coalition called the Los Angeles Advance Care Planning Group.

Jonas Green, MD, MPH, associate medical director of Clinical Effectiveness for the Cedars-Sinai Medical Network, said conference participants are working toward a day "when no Angeleno dies with family, loved ones and healthcare providers uncertain as to that person's preferences regarding goals of care."

It's the first such effort in a large metropolitan area.

The main order of business was to issue a joint set of recommendations on how to ensure that the care patients receive as they approach the end of life reflects their values and goals, and avoids treatments that can do more harm than good. But this gathering of about 135 people also provided a forum for frank dialogue about the challenge of bringing about change in a culture in which the subject of death remains largely taboo.

As several panelists pointed out, the failure to do advance care planning and have conversations about end-of-life care before a health crisis leads to costly medical treatments — about a quarter of Medicare expenditures go toward care in the last year of life — that may involve greater burdens than benefits for patients.

The coalition of healthcare providers has set out to change this with guidelines that aim to make advance care planning a standard part of medical care.

"We aim to shatter the taboo surrounding discussions of death, and thereby make today the first step toward a day when no Angeleno dies with family, loved ones and healthcare providers uncertain as to that person's preferences regarding goals of care," said Jonas Green, MD, MPH, associate medical director of Clinical Effectiveness for the Cedars-Sinai Medical Network.

Conference participants heard a powerful message from the patient and family perspective from keynote speaker Katy Butler. The journalist and author of the 2013 memoir "Knocking on Heaven's Door: The Path to a Better Way of Death," told them the taboo surrounding end-of-life discussions has "created an epidemic of unnecessary suffering on the way to death."

Guidelines for End-of-Life Care

The end-of-life care guidelines developed by the Los Angeles Advance Care Planning Group reflect consensus among nearly a dozen private and public healthcare institutions that collectively care for more than 5 million Southern Californians, about half the population of Los Angeles County. The guidelines call for doctors and medical systems to:

  • Encourage all patients to engage in advance care planning, and make this approach standard so providers can deliver appropriate care that reflects each patient's values and preferences
  • Facilitate timely access to palliative care and other support services such as hospice care for patients with chronic and progressive illnesses
  • Advise patients about the potential benefits and drawbacks of medical treatments, and whether such care can deprive individuals of a peaceful death
  • Engage in "shared decision-making" with patients to reach conclusions about what constitutes optimal care in particular situations

Butler shared the story of how her father "lived into a time where he had no reason to live." A pacemaker kept his heart going for years after the effects of a stroke and dementia deprived him of the ability to have a meaningful quality of life.

"We don't like to say there comes a point for many people when living stops being a blessing and becomes a curse, and this can be compounded by medical treatments designed to maximize longevity that actually destroy the remaining quality of life," she said. "The medical profession has not succeeded in making sure we are managing our technologies for the service of deep human values."

Butler called it a "harsh kindness" for healthcare providers to initiate conversations about end-of-life care with patients before they face a health crisis that could make it impossible for them to speak for themselves.

"People in Los Angeles can experience a good death as a result of you being here today, as a result of you having the moral courage to start these conversations early," she said.

Glenn D. Braunstein, MD, vice president of Clinical Innovation at Cedars-Sinai and one of the leaders of the Los Angeles Advance Care Planning Group, called the conference a "historic moment" for healthcare in the Los Angeles region.

"We all came together to announce and support a common set of recommendations to help physicians reduce suffering and promote dignity for dying patients. Los Angeles is the first large urban city in the U.S. to do this," he said. "There was a tremendous amount of positive energy at the conference, and we anticipate that this collaborative effort will have a significant impact on the quality of end-of-life care in this region."

The Los Angeles Advance Care Planning Group includes the following institutions: Cedars-Sinai, HealthCare Partners Medical Group and Affiliated Physicians, Huntington Hospital in Pasadena, Kaiser Permanente Southern California, Keck Medical Center of USC, LAC+USC Medical Center, MemorialCare Health System, Olive View-UCLA Medical Center, Providence Little Company of Mary Medical Center Torrance, Providence TrinityCare Hospice and the UCLA Health System. The group issued a joint statement defining optimal end-of-life care (see PDF link below).

In her keynote speech, author Katy Butler said the taboo surrounding end-of-life discussions has "created an epidemic of unnecessary suffering on the way to death."

Jason Weiner, senior rabbi and manager of the Cedars-Sinai Spiritual Care Department, moderated a panel discussion that featured faith leaders from across the religious spectrum, including Buddhism, Catholicism, Christianity, Islam and Judaism. They talked about how they are encouraging their congregations to do advance care planning and have conversations about their wishes, and also shared their views on what it means to have a "good death."

"A good death has everything to do with how we live. I don't know how you get to a good death without living a good life," said the Rev. Care Crawford of Bel Air Presbyterian Church. Others linked a "good death" to having a sense of peace, having healthcare providers and caregivers you trust, being free of pain and knowing you are not alone.

Braunstein noted that plans for the coming year include collaborations among the healthcare providers in the coalition and religious organizations, to help them help their congregants do advance care planning.

There also will be collaboration among the healthcare organizations, which will come together for a second conference next year to report on what they have accomplished. The 2015 conference will be hosted by UCLA, and Neil Wenger, MD, MPH, director of the UCLA Healthcare Ethics Center, ended this year's event with a call to action.

"This group is extraordinary, and our job is extraordinary," he said. "What I take away from these panel discussions is that we can generate a different community standard. Our job over the next year is to go out and build on this beginning."

Advance Care Planning Group Statement (PDF)

Taking the Hurt out of Healing

Bahman Shamloo, MD, associate director of the Inpatient Pain Service, (left) speaks with Charles Louy, PhD, MD, MBA, medical director of the service.

Inpatient Pain Service Helps MDs Ease their Patients' Pain

More than 30,000 surgeries will be performed at Cedars-Sinai this year. Virtually all of them will require some form of pain management.

Because patients experience and deal with pain in their own individual ways, physicians may find that what works for one patient is not effective for another.

Enter the Inpatient Pain Service, a pain management program at Cedars-Sinai that focuses not only on acute perioperative pain management, but also on chronic pain and cancer pain among inpatients. The service is available as a 24/7 hospital resource with night on-call coverage by attending physicians, nurse practitioners and rotating fellows and residents. To reach the service, call 310-423-5870.

Under the supervision of Charles Louy, PhD, MD, MBA, medical director, Bahman Shamloo, MD, associate director, and Peachy Hain, MSN, RN, director of Medical, Surgical and Rehabilitation Services, the Inpatient Pain Service team consists of five pain board-certified nurse practitioners who work closely with patients, family members and the patients' physician team to conduct a comprehensive assessment of their pain.

This assessment includes psychological factors, patient expectations and history of substance dependence and abuse. It is used to formulate an individualized, evidence-based approach to pain management.

"Pain management is becoming increasingly complex. We are seeing greater numbers of patients who are taking high doses of pain medications at home, and typically these patients experience more pain because their tolerance is so high," Louy said. "In addition, people who suffer from chronic pain usually have pain in more than one site, so one problem leads to another."

"At the other end of the spectrum are patients who suffer with cancer pain, and we work closely with their oncologist to help manage their pain," Louy said. "Our current group of nurse practitioners has extensive backgrounds in critical care, family medicine, cancer pain and crisis management. Our team of providers collaborates with other services, such as Addiction Medicine, Hospice and Supportive Care Medicine, to provide a multidisciplinary approach to pain management."

Patients most appropriate for referral to the pain service include those who are or have:

  • Postoperative opioid tolerant and may benefit from a multimodal approach
  • Postoperative opioid-naïve
  • Severe intolerance or allergies to opioids
  • Airway problems including sleep apnea
  • Morbidly obese
  • Altered mental status
  • Complicated pain management histories, including those with intrathecal pain pumps and spinal cord stimulators
  • An acute exacerbation of chronic pain, requiring an interventional procedure
  • Cancer pain
  • Acute trauma pain, needing epidural and peripheral nerve catheters
  • Post-dural puncture (spinal) headaches and may require an epidural blood patch
  • Pediatric or neonatal patients needing pain management

For more information or to request consults, please call the Inpatient Pain Service at 310-423-5870.

Drugs Show Progress Against Fatal Lung Disease

Researchers in separate clinical trials found two drugs slow the progression of idiopathic pulmonary fibrosis (IPF), a fatal lung disease with no effective treatment or cure, and for which there is currently no therapy approved by the federal Food and Drug Administration.

Paul W. Noble, MD, chair of the Cedars-Sinai Department of Medicine and director of the Women's Guild Lung Institute, is the senior author of the multicenter study that found that the investigational drug pirfenidone significantly slowed the loss of lung function and reduced the risk of death. Pirfenidone was developed by InterMune Inc. and in 2011 was approved by the European Union for the treatment of idiopathic pulmonary fibrosis.

The findings of the ASCEND drug trial were published online by the New England Journal of Medicine and were presented last month at the International Conference of the American Thoracic Society in San Diego. "What we discovered about the anti-inflammatory and anti-fibrotic properties of pirfenidone offers help and encouragement to so many patients suffering from this relentless disease that robs them of breath and life," Noble said.

Idiopathic pulmonary fibrosis causes thickening and scarring in the regions of the lungs where oxygen gets to the blood, leaving patients with shortness of breath, a chronic cough and extreme fatigue. Most patients die within two to five years of diagnosis.

"Not only did pirfenidone prevent the loss of lung function and preserve the distance patients could walk, but during the study, the risk of death was reduced by a remarkable 48 percent in those taking the drug when compared with those who received placebo," Noble said. "The findings were so strong that an early access program has been initiated to provide patients with pirfenidone while the process of obtaining FDA approval is undertaken. Cedars-Sinai will be participating in this program under the direction of Dr. Jeremy Falk and the Advanced Lung Disease Program."

Noble also was a co-author of a second study testing the efficacy and safety of the multikinase inhibitor nintedanib on patients with idiopathic pulmonary fibrosis. Nintedanib also is being studied in lung cancer.

"In our research, we found that nintedanib could also slow the loss of lung function in patients with idiopathic pulmonary fibrosis," Noble said. "It is a second dose of good news for our patients because nintedanib not only slowed the progression of the disease, but it tended to reduce acute exacerbations of the disease, while tending to preserve the quality of life of the study patients receiving the drug."

Findings of the nintedanib study also were published online by the New England Journal of Medicine.

Noble is a paid consultant of InterMune Inc. and Boehringer-Ingelheim for his work on the steering committees of the two clinical trials. Cedars-Sinai was not among the medical centers participating in this multicenter study of the drug's efficacy in treating idiopathic pulmonary fibrosis.

"These IPF drug therapy findings by Dr. Noble and his colleagues exemplify the dedication and hard work required to find treatments for a group of patients who have so few therapeutic options because there have been no drugs approved by the Food and Drug Administration specifically targeted for treating this fatal disease," said Shlomo Melmed, MD, senior vice president of Academic Affairs and dean of the medical faculty at Cedars-Sinai.

Fireworks, Sand 'N' Snore Are on the Horizon

Summer has a couple of treats in store for medical staff members and their families.

Hollywood Bowl Fireworks — July 3

Celebrate Independence Day at the Hollywood Bowl with fireworks and music by the Hollywood Bowl Orchestra, along with Steve Martin and the Steep Canyon Rangers, featuring Edie Brickell.

The event on Thursday, July 3, is open to Cedars-Sinai physicians and their immediate family members. Cost is $130 per adult and $65 per child 3-11 years of age.  

Valet and Lower Terrace parking passes also are available.

To see coverage of the 2013 celebration, click here.

A photo from last year's Independence Day event at the Hollywood Bowl

Sand 'N' Snore — Sept. 5

The dinner, sleepover and breakfast starts Friday, Sept. 5, at the Jonathan Beach Club in Santa Monica. Those who don't want to sleep on the sand are welcome to enjoy dinner and the evening with colleagues and their families. There's a limit of one tent per physician.

Tickets for the whole event are $60 per adult and $45 for each child under age 12. Tickets for Friday's dinner only are $50 per adult and $25 for each child younger than 12.

A photo from the 2013 Sand 'N' Snore

To see coverage of the 2013 event, click here.

To reserve a place for either event, call Cheryl Verne, in the office of Marjorie Santore Besson, at 310-423-2681.

CSF Leak Surgery Gets Woman Back on Her Feet

After a successful surgery at Cedars-Sinai, Elizabeth Johnson returned to her home near Santa Fe, New Mexico, and is working to rebuild the muscle mass she lost while she was incapacitated with a leak of cerebrospinal fluid.

When Elizabeth "Beth" Johnson stood up from working at her computer last Oct. 28, she noticed "a kind of funny feeling" in the back of her neck. By Nov. 2, the sensation had become an excruciating headache that came on whenever she tried to stand or sit upright.

Her symptoms and MRIs suggested that a hole had developed in the dura, the lining around her spinal cord. With the loss of cerebrospinal fluid — which circulates around the brain and spinal cord — her brain shifted and sagged away from her skull when she tried to stand, causing severe positional headaches and leading to periods of confusion.

After two attempts at another neurosurgical center failed to patch the hole, Johnson, who lives near Santa Fe, New Mexico, came to Cedars-Sinai, where Wouter Schievink, MD, director of the Microvascular Neurosurgery Program in the Department of Neurosurgery, surgically repaired the tear.

Elizabeth Johnson and her neurosurgeon, Wouter Schievink, MD, after successful repair of a cerebrospinal fluid leak

Schievink, one of the world's most experienced neurosurgeons for this diagnosis, said Johnson's tear was extensive but no larger than many he has treated. It was, however, located on the front side of her spinal cord, making surgical access more challenging and the repair procedure more delicate.

When Johnson — who describes herself as a fast-moving, quick-thinking Type A, personality — first felt the strange sensation in her neck, she didn't slow down. But as symptoms got worse, she wondered if she should go to an urgent care center. Friends surmised she was just stressed out and recommended therapeutic massage. But by Nov. 5, no longer able to sit or stand without pain, she saw her primary care physician, who immediately sent her for MRIs that showed she had spontaneous intracranial hypotension. A defect in the dura had opened, allowing spinal fluid to leak.

Two days later, Johnson was flown by air ambulance to a neurosurgical center, where doctors used injections of her own blood to try to seal the tear, the first line of treatment for most leaks. Although she was discharged Nov. 15, Johnson and her partner of 14 years, Charlotte "Char" Schnepf, quickly realized the blood patches hadn't held.

"When I called the doctors, they said to come back and have a third blood patch. They said sometimes people need 10 of them. But this didn't make sense to me," said Johnson, manager of a family compound and a life transitions coach.

At the suggestion of a client and friend who had found Schievink's name online, Johnson called Cedars-Sinai; Schnepf wrote a letter, collected copies of the original MRIs and shipped them overnight to Schievink.

"He looked at my MRIs and called me the next day," said Johnson, who was flown by air ambulance to Los Angeles on Monday, Dec. 2. She met Schievink that afternoon and began undergoing a series of diagnostic procedures. They confirmed the defect's location at the front of the spine and showed a calcium deposit on a disc, which may have contributed to the tear.

But working from the back to shave down the calcification and repair the lining at the front of the spinal canal is not straightforward. The spine's large, drum-shaped bones — called vertebral bodies — are stacked on the front side of the spinal canal, separated by discs, which act as cushions. Each vertebral body has a hard, bony structure called a pedicle, which consists of two parts that form the sides of the spinal canal and connect the large bones to the smaller ones in back. The entire structure protects the spinal cord, nerves and nerve roots that carry electrical signals to and from the rest of the body.

"We removed a piece of bone from the back part of the spinal canal and took out half of one of the pedicles. By removing half of a pedicle, I could rotate the spinal cord away from where the tear was, which gave me enough room to work. I closed the tear with four sutures, which I'm confident will provide a strong and permanent repair," Schievink said.

"We always use advanced technology to frequently monitor the spinal cord — before and after each suture is placed," he said. "When her last suture was in place, the monitor detected a reduced signal to her right leg, and she woke up with some weakness in that leg, which resolved overnight. But she had considerable weakness resulting from weeks spent incapacitated. That kind of generalized deconditioning doesn't improve immediately, and she would need a course of physical therapy to really get back on her feet."

As usual after such a surgery, Johnson remained quiet and flat in bed for a day. She sat up in a chair on Dec. 8 — for the first time of any duration since early November — and was able to walk with a walker the next day.

She didn't need the walker for long, and an MRI three days after surgery confirmed the obvious: The leak was stopped, and fluid was steadily returning to its normal level. The typically active patient — Johnson likes to ride a bike and participate in yoga — is working hard to rebuild the muscle mass she lost, and she continues to regain the mental quickness she had.

"I have said to Dr. Schievink repeatedly, 'I couldn't stand. I couldn't sit. And my brain was being totally compromised,'" Johnson said. "'You saved my life. I am so grateful.'"

Elizabeth Johnson (right) walks with her partner, Charlotte "Char" Schnepf. Before her spinal surgery at Cedars-Sinai, Johnson was unable to stand without pain.