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Dartmouth Medical School Dartmouth-Hitchcock Medical Center

Letters

IIf there's a pattern in the letters in this issue, it has to be "fortuity." What are the chances, for example, that a longtime faculty member who landed in the ER in a tiny town in the mountains of Colorado would be cared for by a DMS alumnus? Or that the first Dartmouth team to arrive in Haiti after its magnitude 7.0 earthquake would immediately run into a residency alum? Or that a Dartmouth College alum's wife would stumble upon a 1962 magazine article just as our Spring issue arrived, containing a feature on a subject very similar to the 48-year-old clipping? Luckily for the rest of our readers, all three took the time to share word of these coincidences. And a number of other readers wrote in, too.

We're always glad to hear from readers about matters pertaining to medicine at Dartmouth or to the contents of past issues of Dartmouth Medicine. Letters to the editor may be sent to DartMed@Dartmouth.edu. Letters may be edited for clarity, length, or the appropriateness of the subject matter.

Crowing about a DMS "product"
Imagine this scenario: This past February, on a skiing trip in Colorado, I began feeling ill our first evening above 5,000 feet. Things seemed to be getting worse, and I eventually found myself in the Emergency Room of St. Anthony Summit Medical Center in Frisco, Colo.

The care was both prompt and excellent, and soon it became clear that I was having a bout of altitude sickness. After a moment or two, a robust, friendly doctor came into my cubicle, looked at my chart and then at me, and blurted, "I know you—you're Harte Crow, you're from Dartmouth."

It turned out the physician staffing the St. Anthony ER that evening was Marshall Denkinger, DMS '87. I'll admit that I don't know how our paths had crossed in the past, nor do I know much about Marshall's career since DMS, but I was more than glad to find him at the helm that evening.

It's clear from my experience that DMS has good reason to be proud of this product—a competent, direct, and efficient physician. So if you find yourself in need of medical care in Summit County, Colorado, don't hesitate to seek it at St. Anthony—maybe you'll be as lucky as I was and run into Marshall Denkinger.

Harte C. Crow, M.D.
Etna, N.H.

Crow, a professor of radiology, has been at Dartmouth since 1971.

Magnitude of relief effort
I was very pleased to read "Dartmouth commits to the earthquake relief effort in Haiti" in the Spring issue of Dartmouth Medicine.

I was a member of a team of emergency physicians and nurses from Stanford that traveled to Haiti under the auspices of the International Medical Corps. When Dartmouth's Dr. Jim Geiling and the DHMC nurses arrived at the University Hospital in Port-au-Prince, we were struggling to manage all the critically injured and ill victims with very limited resources.

The Dartmouth team jumped in to establish a tented "ICU" (they were given possession of the few oxygen bottles), and Jim volunteered to help out with other critical-care patients and postoperative patients and with the general organization of the compound.

In my role as lead physician coordinating the activities of all the nongovernmental organizations, hospital administrators, university volunteers, and military and other entities attempting to establish a functional medical center, I can say in all honesty that the magnitude and quality of the effort, fortitude, and compassion demonstrated by the Dartmouth clinicians were not exceeded by any other group. The Big Green contingent accepted a tough assignment and then stepped up big time.

This collection of poems about the emotions of medicine prompted praise from a couple of readers and a pair of incredible but true patient stories from another.

It was our great privilege to work alongside Dr. Geiling and company. One can only hope that world leaders bring similar collaboration, work ethic, and generosity to building a sustainable Haiti.

Paul S. Auerbach, M.D.
DHMC Housestaff '77-78
Los Altos, Calif.

Paean to the poems
I want to compliment you on your magazine for its content, art, news—everything. I have been a reader for 10 years, ever since my first DHMC surgery by Dr. Michael Mayor. At first I used to just scan the magazine for news of Dr. Mayor or Dr. Barth (a later surgeon, for my breast cancer). I remember when Dr. Barth received an award for being a compassionate surgeon!

The most recent issue I read cover to cover. I especially enjoyed the poetry in "Through the Clouds", and I cut out the article titled "Working Wonders" to send to my psychiatrist son. I'm looking forward to the next issue.

Barbara Goss
Underhill, Vt.

Two compliments, one quibble
I enjoyed the Spring 2010 Editor's Note about C.P. Snow. Snow is an old favorite of mine. His novels about life at Cambridge seem not to be read much anymore, but The Two Cultures has survived. It's a great essay, although I think it's a little much to think that all scientists should know the sonnets of Shakespeare and all humanists should know the second law of thermodynamics. The discussion reminds me of the French philosophes who used mathematical formulas to "prove" that science was "just another social construct."

I also enjoyed the poetry in the same issue. I couldn't help but wonder how you identify the people who write poetry for the magazine. Do they just pop up on your doorstep or do you seek them out?

I do have one small quibble: In paragraph 2 of the article titled "A new factor in bladder cancer risk", I think that "irritable" should be replaced by "inflammatory." But Dartmouth Medicine is in good company, for the Wall Street Journal recently published a correction about an article on Crohn's disease, noting that the writer should have called it an inflammatory bowel disease, not an irritable bowel syndrome.

Harvey Mandell, M.D.
DMS '48
Norwich, Conn.

We appreciate both Mandell's kind words and his sharp eye. He is correct—our article, too, should have referred to inflammatory bowel disease (IBD). There is such a thing as irritable bowel syndrome (IBS), but it is a different condition. IBS does not cause inflammation, whereas IBD, as its name suggests, does. We are . . . um, irritated with ourselves for confusing the two.

As to the poems that we publish, they come our way by a variety of means. Some we seek out, and some find their way to us.

A fish story (quite literally)
"You can't faint, you're lying down." Those words in one of the poems in the Spring issue of Dartmouth Medicine triggered a memory so powerful I couldn't resist sharing it.

In my early days of family practice, in the 1950s, I met a young woman by prearrangement in my office after hours. She needed a premarital test. At that time in New Hampshire, one needed a Wassermann test, for syphilis, to get married. You had to use a kit provided by the state and mail the blood back to the state. What some people, including some doctors, didn't know was that a positive Wassermann was not a barrier to the union as long as both parties were warned of the possibility of syphilis.

This patient and I were the only souls in the building, which perhaps wasn't wise. The Wassermann kit was a test tube with a large, #18 needle attached. Barbaric! The young woman warned me that she was afraid of needles and fainted at the mere thought of one. I uttered the same words that were in the poem: "You can't faint, you're lying down." I believed everything I'd been taught in those early years.

So I stuck her with that big needle and luckily hit a vein the first time. But as the tube was filling up, my supine patient turned gray, her eyes rolled up, and she proceeded to have a grand mal seizure before my horrified eyes. I removed the tube of blood, put her in the Trendelenburg position—flat on her back, with her feet higher than her head—and protected her tongue and airway as I pondered the likelihood of a malpractice suit. Eventually, her color returned, she made "where am I?" noises, and she came to. She toddled off into the night having no idea what had happened but glad to have the blood test done.

Not long after that, another young woman came to my office and told me that she had gone to her regular family doctor for a Wassermann, and he'd told her it had come back positive, that she had syphilis, and that he could not sign her certificate. She left in a huff, I guess looked in the Yellow Pages, and gave me a try. I remember her saying, "You may believe me or not, but I am a guaranteed 100% virgin, and I don't have syphilis."

I said, "Cool down. There are other reasons for a positive Wassermann." I don't remember them all now, but they included tapeworm. In my workup, I asked for a stool specimen and was surprised when it came back positive in a big way for the fish tapeworm—to which people who eat raw or undercooked fish are susceptible. After a quick session with the books and a call to Hitchcock, I put her in the hospital, inserted a nasogastric tube, and poured in a bottle of oleoresin of aspidium, which our small-town druggist happened to have. In a day or so, she grossed out the nursing staff by delivering about 30 feet of tapeworm into a bed pan. All I cared about was that the head was included. Nothing like that had been seen before in our small hospital and, as far as I know, still hasn't been seen since.

It did wonders for my reputation. She, her eventual husband, and, still later, their children, as well as all her friends and family became devoted patients. It turns out that, for cultural reasons, she ate a lot of raw white fish.

I still won't touch sushi. And I never again told supine patients they couldn't faint.

Jerome Nolan, M.D.
DHMC Housestaff '52-54
Wilmington, N.C.

Wonder of wonders
My wife, Joan, and I very much appreciate receiving Dartmouth Medicine. The Spring issue was of special interest to us—specifically, the article titled "Working Wonders," on the Psychiatric Research Center's supported employment program—as we are both Jungian analysts, Joan having trained in Zurich and I in San Francisco.

The issue's arrival happened to coincide with Joan's discovery of a 1962 article from a publication called The American Weekly. The article was about the town of Gheel in Belgium and its citizens' longtime efforts to help those suffering from psychological difficulties. This article was among Joan's mother's papers and letters, which she has recently forwarded to the Schlesinger Library at Radcliffe.

This feature, about a program that helps those with severe mental illnesses succeed in real-world jobs, resonated with a couple of readers who are psychiatrists.

During World War II, Joan's parents lived in Europe, where her father headed the U.S. Office of Strategic Services in Berne. He consulted with Carl Jung on several occasions about the psychological, cultural, and sociological implications of German and Italian tactics.

The article that Joan's mother saved describes a town where "anyplace else in the world, one person in ten . . . would be locked up in a padded cell. But in Gheel, for five centuries by written record (and almost as long before that by town legend), . . . victims of mental illness are welcomed into the [town's] little brick homes, . . . where they live and work as loved members of the family." The Belgian government paid those who took in patients, and the "unqualified acceptance transforms les malades, disheveled and often violent when they arrive, into normal-seeming human beings."

The underlying premise of this very humane initiative in Gheel sounds strikingly similar to that of the Dartmouth program. So we were most interested to learn about the Dartmouth effort just as Joan happened upon the article that her mother had saved 48 years ago.

John Talley, M.D.
Dartmouth College '50
Santa Fe, N.M.

Counterfeit counterpoint
Unfortunately, your article "A high-tech solution to drug counterfeiting" uses "fake" and "counterfeit" interchangeably. They do not mean the same thing. [The article described a technique developed by a Dartmouth graduate student to use cell phones to protect patients in developing countries from counterfeit drugs—a problem that is very serious in some parts of the world, because counterfeit drugs often contain toxic fillers.]

A fake pharmaceutical is one that does not do what it is supposed to do because it lacks the active ingredient claimed on its label. Generally, it is not efficacious for the prescribed use and may be harmful (the special case of placebos withstanding).

A counterfeit pharmaceutical is one whose maker has no license to manufacture or market. Typically this is because the maker has violated the legal right of the pharmaceutical company that holds the rights to manufacture or market the drug.

Think of a counterfeit drug as being like a counterfeit CD of, say, Microsoft Office. A counterfeit drug may be otherwise identical to the legitimate drug and work just as well. It may have more or less of the active ingredient, just as legitimate pharmaceuticals may.

Counterfeit pharmaceuticals are mostly a problem for Big Pharma in preserving their franchise against competition, such as knockoffs from India. They are not a problem for consumers.

Fake pharmaceuticals are a problem for consumers in the way the article mentions or because they may not contain a sufficient amount, or any amount, of the active chemical, thereby causing harm from nontreatment or undertreatment.

Big Pharma goes to considerable lengths to block counterfeiting of their products, just as Microsoft does. But Big Pharma is far less concerned about fake pharmaceuticals, mostly because they are a problem only for consumers in developing countries who cannot afford legitimate pharmaceuticals anyway.

The solution that the Dartmouth student devised seems to envision a populace wealthier than those that typically inhabit developing countries—ones that can afford cell phones and text messaging services. If they could afford those, then sellers of fake drugs might not find a ready market of desperate people. The solution is to compel big pharmaceutical companies to provide necessary drugs free to those who cannot afford them, rather than to devise high-tech workarounds that assume the right of these companies to maintain their exploitative business practices.

Tom Shillock
Portland, Ore.

We offered Ashifi Gogo, the student who developed the anticounterfeiting technology, an opportunity to respond to these comments. He wrote: "I just returned from speaking at the Fifth Global Forum on Pharmaceutical Anticounterfeiting. The distinction between 'fake' and 'counterfeit' is not one that is widely acknowledged by industry experts. Largely, fake is seen as equivalent to counterfeit in the pharmaceutical anticounterfeiting world. What the letter-writer refers to as 'fake' is actually known as 'substandard,' and substandard pharmaceuticals are a large problem in several countries.

"Thus a fake or counterfeit drug is one that masquerades as the real drug but does not have the same active ingredient(s), potency, product quality, or approval for sale as the genuine medication. A substandard drug is one that's made by a legitimate manufacturer that lacks good quality control processes or isn't skilled in good manufacturing practices. These are two very different situations. Experts largely see the problem of fake/counterfeit drugs as an example of the larger problem of substandard drugs. Every fake drug is substandard, but not every substandard drug is fake."

And regarding Shillock's observation about the availability of cell phones in the developing world, Gogo wrote: "The cell phone is now ubiquitous in Africa. It only takes one trip to the continent to realize how widely available mobile communications have become, providing the backbone upon which solutions such as the one described in the article can be deployed. For those who can't make the trip, a Google search shows that Nairobi, Kenya, sends more text messages than New York City."

Wait, wait . . . tell me more
I happened to stumble on the article "Blood draw waiting times drop dramatically" in the Spring issue of Dartmouth Medicine.

I have been researching the improvement of lab wait times and patient flow at our hospital and would like to know more about the project at Dartmouth-Hitchcock. I am curious to know, for example, how your lab collected the data on average wait times, if there is a relationship between the wait time and the time of day the patient arrives, and if you factored into your calculations the time it takes to get a patient registered.

Actually, your entire magazine was quite fascinating. Excellent job!

Mona Adan
Toronto, Ontario

It is not always possible for the subjects of articles in Dartmouth Medicine to respond to individual queries. But we're always glad to pass along questions such as these, so if readers are interested in more information on a matter we've covered, feel free to give us a try.

A long-distance acquaintance
I am always glad to receive my copy of Dartmouth Medicine even though my connection with DHMC is at present somewhat tenuous. A few years ago, I had a very successful carotid operation by your magnificent vascular surgeon Dr. Robert Zwolak. I then used to return to Hanover periodically for a recheck of my artery. But now my vision makes it well-nigh impossible to drive 300 miles.

But I enjoy keeping up my acquaintance with a fine medical center through your very informative magazine.

Donald R. Hart, Jr.
Salisbury, Conn.

Moved by the magazine
I have not read Dartmouth Medicine in depth in the past but started to read the Spring issue and have not been able to put it down.

I'd love you to add my son—a DMS '99 and '99-05 DHMC resident—to your mailing list. I know he is quite busy because of that fantastic medical education he received, but it will keep him in touch with colleagues and with what's happening at DMS. I asked him if he receives the magazine, and he said he does not. I told him there was an article in the Spring issue about one of his best friends, Dr. Philip Goodney. Thanks so much.

Keith Thomas
Chester, N.J.

We assured Thomas that, as an alum, his son should automatically receive Dartmouth Medicine. But it turns out that after a recent move, his son was apparently too focused on his patients (not a bad thing!) to let DMS know his new address, so that's why he had not been receiving the magazine (or any other DMS mail). So a reminder to all alums, or their perhaps slightly less-busy parents, to let us (either the magazine or the alumni office) know whenever you move.

Touched by the care
I very much enjoy your magazine and would like to be on your mailing list.

In January 2002, my grandson was born three months early at DHMC. Ashton weighed 1 lb., 15 oz. Thanks to the doctors and nurses in the Neonatal Intensive Care Unit, Ashton today is a happy, healthy, active 8-year-old.

In December 2008, DHMC gave my son-in-law a new lease on life. Danny desperately needed a kidney. It was an answer to our prayers when a donor was found immediately. My daughter-in-law (Ashton's mom, in fact) was a match. Not only are Danny and Samatha no blood relation, but they are of different ethnic backgrounds. What are the chances of that happening?! Today both Danny and Samatha are doing great, thanks to the transplant team and the doctors and nurses at DHMC.

We are so blessed to have DHMC located here in the Upper Valley.

Velma Lord
Cornish, N.H.

Inspired by the insights
I have in front of me the Spring 2008 issue of Dartmouth Medicine. It was given to me because I am an admirer of the poetry of Jane Kenyon and Donald Hall. Your cover story about them, with its excellent photographs by Jon Gilbert Fox and text by Susan Salter Reynolds, is truly comforting and inspirational.

Your entire magazine is exceptional. I'd like very much to be on your mailing list.

Patricia L. Walker
Bloomfield, Conn.


If you'd like to offer feedback about this article, we'd welcome getting your comments at DartMed@Dartmouth.edu.

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