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Haitian Earthquake Disaster Relief 

January 12, 2010 

West Virginia’s PhysiciansRespond with 

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Serving your practice 

WVU is committed to partnership with West Virginia physicians. 

One way we can help your patients is by providing advanced specialty 

programs that make it possible for you to refer to an in-state medical center. 

Call 1-800-WVA-MARS to consult with any WVU specialist. 

Pediatric Orthopaedics 

John P. Lubicky, MD, FAAOS, FAAP 

Dr. John P. Lubicky is a pediatric orthopaedic surgeon with a special emphasis on the 

treatment of spinal deformities, tumors, trauma, and infections. Dr. Lubicky is a 

member of Spinal Deformity Study Group, a select group of international spinal 

surgeons studying many aspects of spinal surgery in both children and adults. 

Dr. Lubicky is head of the Pediatric Orthopaedics Section at WVU and is board 

certified in orthopaedic surgery. 

Information and appointments: 304-598-4830 

Laryngology 

Jason McChesney, MD 

Dr. Jason McChesney is a laryngologist with expertise in treating voice and swallowing 

problems. In addition to treating vocal cord paralysis, professional hoarseness, and 

nodules of the vocal cord, Dr. McChesney offers in-office treatment for patients with 

laryngeal papillomas, performed under local anesthesia. 

Dr. McChesney is a member of the American Academy of Otolaryngology. 

Information and appointments: 304-598-4825 

MARS 800 982-6277 • wvuhealth.com

Continuing Medical Education 

Opportunities at CAMC Health Education 

and Research Institute 

The CAMC Health Education and Research Institute is dedicated to improving health through 

research, education and community health development. The Institute’s Education Division 

offers live conferences, seminars, workshops, teleconferences and on-site programs to health care 

professionals. The CAMC Institute’s CME program is accredited by the Accreditation Council for 

Continuing Medical Education to sponsor continuing medical education for physicians. The CAMC 

Institute designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit(s). 

Physicians should only claim credit commensurate with the extent of their participation in the 

activity. For more information on these and future programs provided by the Institute, please call 

(304) 388-9960 or fax (304) 388-9966. 

SEMInARS 

6th Annual Advanced Geriatrics 

Educator Skills Certification 

Program (AGES) 

Friday through Sunday 

March 26-28 

Bridgeport Conference Center 

Bridgeport, WV 

2010 Oncology Symposium for 

the Primary Care Physician 

Friday, April 30 

Charleston Marriott Town 

Center 

Charleston, WV 

Osteopathic Medicine 

Symposium 

Thursday and Friday 

May 13-14 

Robert C. Byrd Health Sciences 

Center of WVU-Charleston 

Division 


Dental Implant Conference 

Friday, March 12 

Charleston Marriott Town 

Center 


Newborn Day Conference 

Thursday and Friday 

April 22-23 

Embassy Suites 


LIfE SuppORt tRAInIng 

Log on to our web site to 

register at 

www.camcinstitute.org 

Advanced Cardiovascular Life 

Support (ACLS) – Provider 

March 10, 22; April 21, 28 

Advanced Cardiovascular Life 

Support (ACLS) – Renewal 

March 8, 9, 24; April 15, 16, 19 

Basic Life Support (BLS) – 

Provider 

March 2, 16, 30; April 13, 27 

Pediatric Advanced Life Support 

(PALS) - Renewal 

March 17; April 5 

Pediatric Advanced Life Support 

(PALS) – Provider 

March 2; April 6 

CME OnLInE pROgRAMS/ 

ARCHIvEd guESt LECtuRE 

pROgRAMS 

Log-on to our web site at 

www.camcinstitute.org 

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contents 

March/April 2010, Volume 106, No. 2 

features 

4 President’s Message 

8 Our Editor Speaks 

30 General News—Our Physician’s Efforts in Haiti 

38 Marshall University Joan C. Edwards School 

of Medicine News 

40 2010 Resolution Committee Report 

42 Robert C. Byrd Health Sciences Center of 

West Virginia University News 

43 West Virginia School of Osteopathic 

Medicine News 

44 Bureau for Public Health News 

50 2010 Annual Business Meeting Highlights 

52 Physician Practice Advocate News 

54 Obituaries 

55 New Members 

56 West Virginia Medical Insurance Agency News 

58 WESPAC Contributors 

59 Classified Ads 

In this issue… 

Scientific Articles 

12 Growing Skull Fracture in a 5-month Old Child: A 

Case Report 

18 Bouveret Syndrome: A Case Report 

23 Admissions to the State Hospital: A One Year Study 

32 A New Technique for the Primary Percutaneous 

Endoscopic Realignment of a Complete 

Urethral Injury 

Special section 

A Decade of Health Promotion 

West Virginia Medical Foundation Highlights pg. 45 

Excellence in Medicine Awards pg. 49 

CMOM Certification 

 

call for papers 

 

1st class—April 16, April 17, 

April 23 and April 24—pg. 36 

Substance Abuse in 

West Virginia—pg. 10 

60 Manuscript Guidelines/Advertisers 

Editor 

F. Thomas Sporck, MD, FACS 

Charleston 

Managing Editor/Director of Communications 

Angela L. Lanham, Charleston 

Executive Director 

Evan H. Jenkins, Huntington 

Associate Editors 

James D. Felsen, MD, MPH, Charleston 

Douglas L. Jones, MD, White Sulphur Springs 

Steven J. Jubelirer, MD, Charleston 

Roberto Kusminsky, MD, MPH, FACS, Charleston 

Robert J. Marshall, MD, Huntington 

David Z. Morgan, MD, Morgantown 

Martha D. Mullett, MD, Morgantown 

Louis C. Palmer, MD, Clarksburg 

The West Virginia Medical Journal is published bimonthly by the West Virginia State Medical Association, 4307 MacCorkle Ave., SE, Charleston, WV 

25304, under the direction of the Publication Committee. The views expressed in the Journal are those of the individual authors and do not necessarily 

reflect the policies or opinions of the Journal’s editor, associate editors, the WVSMA and affiliate organizations and their staff. 

WVSMA Info: PO Box 4106, Charleston, WV 25364 

1-800-257-4747 or 304-925-0342

President’s Message 

“An American Tale — The Little Truck 

That Said It Can!” 

(Health Care’s Shifting Universe) 

It was an old story of the little 

truck that said it can, and did it 

redux in Massachussets! Burl Ives 

sings of the saga of the little engine 

whose mantra was, “I think I can, 

I think I can,” and finally did. 

The recent win of Republican 

Scott Brown over the Democratic 

candidate, State Attorney General 

Martha Coakley was one of the most 

improbable electoral victories in 

recent U.S. history. He won with fifty 

two percent (52%) of the vote while 

Miss Coakley garnered forty-seven 

percent (47%). The GOP victory 

means Democrats will hold only 59 

seats in the senate and this creates 

a major obstacle in completing 

healthcare reform in its present form, 

as Brown has said he would vote 

against healthcare reform legislation. 

As the Democratic leaders are 

scrambling to save healthcare reform 

legislation, what are the possible 

scenarios that could occur 

Scenario 1 – Full steam ahead. 

Abandon the White House and 

Democratic congressional leadership, 

abandon the House-Senate 

negotiations and work out differences 

between the two bills. Instead they 

push House Democrats to approve 

the Senate bill as is. However, it is 

not clear whether the House votes are 

there to pass it. This causes significant 

political risks for the Democrats 

as they would appear to be acting 

against mounting public opinion. 

Scenario 2 – Find a new 60th 

vote in the Senate. President Obama 

has been on the phone regularly 

with Senator Olympia Snowe (R- 

Maine), who voted reform out of 

the Senate Finance but withheld her 

vote on the Senate floor. Anything 

is possible, but he is unlikely to 

bring Snowe back on board. 

Scenario 3 – Alternatively 

Democrats could choose to slow down 

the legislative train and reopen debate 

on healthcare reform. The likely 

result is either no legislation on 

healthcare reform during 2010 or 

a significantly trimmer package— 

nothing close to universal coverage. 

Earlier Conchita and I visited 

the Capitol. Driving by the river, 

several times, I found that the view 

of the river even from the same 

vantage point changes every time. 

It was then I remembered that it 

was not a novel idea, Heraclitus 

2,600 years ago dipped his toes 

in a river in Greece and instantly 

understood that change itself is the 

only unchanging reality. He realized 

that he could never, as hard as he 

might try or as much as he might 

like – step into the same river again. 

Change and innovation will 

come despite our attempt at stalling 

and standing firm. Flexibility is 

the ongoing practice of moving 

with life. So let’s move on. 

With healthcare reform in limbo, 

we need to focus on the repeal of 

the Sustained Growth Rate Budget 

Neutrality enacted in 1997. Congress 

wins again, as it has side-stepped a 

permanent SGR fix by kicking the 

can down the road until March 1— 

the shortest distance on record. 

The deferral appeared as 

an amendment to a defense 

appropriations bill signed into law 

by President Obama December 

19, 2009. To gain a sense of the 

recurring nightmare this annual 

stopgap has become for us, consider 

that in 2005 the deficit was $48.6 

billion or a 3.3% cut. By 2009 it has 

ballooned to $245 billion or 21.2% 

in Medicare and Tricare (insurance 

provider for our military and their 

families) payments to providers. 

Unless another deferral takes 

place, West Virginia physicians will 

face an across-the-board Medicare 

reimbursement cut of 21%, with more 

cuts likely to follow over the next 

few years due to a flawed payment 

formula, the Sustainable Growth 

Rate or SGR. This formula was put in 

place by Congress over a decade ago 

and both Democrats and Republicans 

agree it needs fixed, and the time 

to fix it is now. At least seven times 

in as many years, Congress has 

stepped in at the last minute with a 

temporary fix to limit reimbursement 

cuts. Each time, however, it causes 

future cuts to grow larger and, once 

again, we are facing a 21 percent cut. 

We should be concerned that 

Medicare cuts will further erode 

seniors’ access and choice of 

 

West Virginia Medical Journal

physician as we already have one of 

the worst patient-physician ratios in 

the country. Congress needs to fix the 

formula once and for all so patients 

can be assured of continued access 

to care and choice of physician. 

West Virginia is one of twenty-one 

states and the District of Columbia 

that made the American Medical 

Association’s “Access Hot Spots” list, 

which highlights areas where patients 

already face problems getting patient 

care, and the problem will get worse 

unless Congress repeals the broken 

Medicare physician payment formula. 

With nearly one in five West 

Virginians covered by Medicare, we 

have the largest proportion of 

population on Medicare of any state. 

Access problems for West Virginia 

seniors are very pronounced, with 

only 13 practicing physicians per 1,000 

Medicare beneficiaries, which is one of 

the nation’s worst, and 29 percent of 

seniors on Medicare living below 150 

percent of the federal poverty level. 

In addition, 44 percent of West 

Virginia’s practicing physicians 

are over 50 years old, an age at 

which surveys have shown many 

physicians consider limiting 

their patient care activities. 

Let me be clear: West Virginia 

physicians want to care for seniors 

and military patients—but we cannot 

keep the doors open to all patients 

when the government does not cover 

the cost of providing that care. These 

cuts will make a bad situation worse 

for seniors and military families. 

Previous momentum spurred 

hope that healthcare reform would 

encompass a permanent fix to the 

SGR, and the first House draft bill 

included an SGR restructuring. This 

provision was scrapped after the 

Congressional Budget Office (CBO) 

analysis indicated that it would add 

$245 billion to the bills’ final cost. 

In any scenario, the rising antigovernment 

spending sentiment will 

pressure the President to initiate a 

serious bipartisan effort at deficit 

reduction in 2010. When Washington 

looks at deficit reduction— 

Medicare providers—look out! 

The House bill would have 

postponed the insolvency date of the 

hospital trust fund by five years; the 

Senate bill by ten years and if the big 

bill fails, we are back to insolvency by 

2016-2017, physicians and hospitals 

would still face reimbursement perils. 

What do health policy experts 

debate Where should reform go 

Their viewpoints articulate the 

clashing philosophies that underlie 

the current deadlock in Washington. 

Stuart Butler, of the right-wing 

Heritage Foundation, points out 

that even small reforms could have 

large unintended consequences. For 

example, he notes that the Office 

of Personnel Management (OPM) 

now administers the Federal Health 

Employees Benefit Program like 

a large private employer, without 

laying a strong regulatory hand on 

the health plans that compete for 

government workers’ business. If 

the provision in the Senate bill that 

would let OPM supervise a menu of 

plans for individuals and small firms 

were passed on its own, he suggests, 

the OPM would take a much harder 

line with the plans, which would 

eventually come to resemble the 

public option much reviled by the 

right. Butler concludes that Congress 

is better off doing nothing until every 

last possibility has been puzzled out. 

John Goodman, another Republican 

policy maven, does not favor any of 

the Democratic ideas, either. While he 

agrees with ultra-liberal Paul Krugman 

(shudder) that the proposed insurance 

reforms would fail if they were 

adopted incrementally, he proposes 

replacing them with a raft of ideas 

derived from the consumer-driven 

healthcare concept he’s associated 

with. Just as in consumer-driven 

health plans with health savings 

accounts, these ideas revolve around 

having each person insure themselves 

against their own personal risk, rather 

than spreading the risk across the 

sick and the healthy, the old and the 

young. This reflects the Republican 

thinking of every-person-for-himselfor 

herself—non redistributive 

philosophy, but it’s hard to see how 

it would help expand coverage or 

reduce health costs, except by denying 

care to those who need it the most. 

Joseph Antos, a less conservative 

thinker at the American Enterprise 

Institute, also acknowledges that a 

slimmer bill is unlikely because of 

the interconnectedness of the issues 

involved. “One cannot simply pluck 

a few provisions out of the bill 

and expect to have legislation that 

achieves ambitious goals,” he points 

out. But he thinks that the current 

legislation over reaches and that 

Congress should focus on incremental 

reforms to achieve targeted goals. 

For example, he would change 

the way Medicare reimburses 

providers (an approach that is 

promoted in the current bill), and he 

would cap the federal contribution 

to Medicaid programs (an idea the 

states would be ecstatic about). 

He would replace the individual 

mandate to buy insurance with a 

system in which those who maintained 

lifetime coverage would have 

lower premiums than those who 

interrupted their coverage or tried 

to buy insurance only when they 

got sick. Antos maintains that this 

would be the best way to persuade 

everyone to buy insurance. 

Finally, there’s Henry Aaron of 

the liberal Brookings Institution, who 

insists that the only way forward is 

to pass the current legislation, using 

the budget reconciliation maneuver 

to “fix” the Senate bill that the House 

would have to pass. “The start-over, 

do-it-in pieces strategy is an invitation 

to time-wasting failure,” he states, 

pointing out that each piece would 

need to attract 60 votes in a Senate 

where the Democrats now have 

only 59 at best. Moreover, Aaron 

points out, a “reform lite” package 

that expanded coverage to a smaller 

group would not work: “It is not 

possible to institute serious insurance 

market reforms without assuring a 

balanced pool of enrollees. It is not 

March/April 2010 | Vol. 106

possible to mandate coverage. It is 

not politically correct to institute 

serious insurance market reforms 

without assuring a balanced pool of 

enrollees. It is not possible to mandate 

Back in West 

Virginia, we 

have just 

concluded 

the WVSMA 

Mid-Winter 

Business 

Meeting, 

and those 

who were in 

attendance enjoyed 

and benefitted from the Physician 

Practice Conference. Certainly, 

Barbara Good has chosen very well. 

Rose Moore’s Management Tips for 

a Successful Practice are up to date 

and necessary. The RAC update 

is timely and much needed. Pam 

Harvit’s, Office Protocol and Etiquette 

garnered the most number of pearls. 

I can still remember Sister 

Janet Marie who taught us on the 

deportment of young men with 

good breeding. There’s considerably 

more than hype to the contemporary 

concern about courtesy, manners 

and style. Such concerns have a 

long and venerable history. The 

oldest book in the world, is a dusty 

Egyptian papyrus, containing advice 

coverage without providing subsidies 

to make insurance affordable to 

low and moderate income people. 

And it is not possible to prevent 

subsidies from boosting deficits 

from an Egyptian father to his son 

on polite conduct. The Proverbs of 

Solomon provide shrewd and pithy 

counsel on personal conduct, but 

Shakespeare dispenses literature’s 

most unforgettable tips on good 

Manners—when in Hamlet–Polonius 

declares to his departing son— 

“Give every man thy 

ear but few thy voice, 

Take each man’s censure, 

but reserve thy judgement, 

Costly thy habits as thy purse can buy, 

But not expressed in 

fancy; rich not gaudy; 

For the apparel oft proclaims the man, 

And they in France of the 

best rank and stations 

Are of a most select and 

generous chief in that. 

Neither a borrower nor a lender be, 

For loan oft loses both itself and friend. 

And borrowing dulls the 

edge of husbandry. 

This above all; to thine 

own self be true, 

And it must follow, as 

the night the day, 

Thou canst not then be 

false to any man.” 

~ My offering— HCR Haiku ~ 

unless one is prepared to boost 

taxes or cut other spending, which 

reform opponents have consistently 

refused to do and which would 

certainly require sixty Senate votes.” 

One such classic I must tell you of 

is “The Book of the Courtier,” published 

in 1528 by Baldassare Castiglione, 

during the height of the Renaissance. 

Indeed he was a man of impeccable 

manners, a “courtier” who learned 

the art of chivalry at the court of the 

Duke of Urbino in Northern Italy, 

and he coined the word sprezzatura, 

an almost untranslatable word 

whose nearest English equivalent 

is – “unstudied nonchalance,” 

the ability to show a cool lack 

of concern when the going gets 

sticky. Certainly in my estimation, 

President Obama lacks sprezzatura!! 

My father who would have been 

100 years old in January said it best— 

“A man must be like tea—grow 

stronger in hot water.” 

Everywhere we turn, there’s 

sad news – the sad state of the 

economy, SGR and impending 

Medicare cuts, Haiti. 

Yearning to feel hopeful 

I try to catch a glimpse of 

hope wherever I can. 

Healthcare REFORM HAIKU 2009 

Healthcare REFORM NOW 

DIFFICULT NECESSARY 

COMPLEX, NE! EXPENSIVE! 

(Traditional haiku consist of seventeen 

ons (syllables), in three lines of metrical 

phrases of five syllables, first line tumbling 

into seven syllables, second line and finally 

finishing in five syllables in the third line. 

Healthcare REFORM HAIKU 2010 

Healthcare REFORM WHEN 

NECESSARY, DIFFICULT 

RETHINK, CHANGE, LATER 

SENRYU STYLE—Senryu is a poem that is written 

in a similar form and emphasizes irony, satire, 

humor and human foibles rather than the seasons. 

Carlos C. Jimenez, MD 

WVSMA President 

 


What’s Good for Them Is Good for You. 

UniCare. 

Why UniCare 

For You: 

 

 

 

 

And for Them: 

 

 

 

 

 

 

1-888-611-9958 

 

 

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Our Editor Speaks 

Massachusetts Miracle 

Once again the founding fathers’ 

confidence in Divine Providence has 

been justified. Just days after our last 

issue went to press a miracle occurred 

in Massachusetts. This bluest of 

the blue states elected a hitherto 

unknown Republican moderate 

by the name of Scott Brown to the 

Senate seat recently vacated by the 

death of Ted Kennedy. This one small 

election has restored some semblance 

of balance to the Senate. The Obama 

healthcare express has at least been 

removed to a siding if not parked in 

the roundhouse for a total overhaul. 

I had always been of the 

understanding that Massachusetts 

was controlled by a strong 

democratic majority. That, after all, 

is what the media has been telling 

us lo these many years. In the 

post election analysis a somewhat 

different picture crystallized. 

Independents comprise 52% of 

the Massachusetts electorate with 

37% Democrats and the remainder 

Republicans. Very different from 

what we have been led to believe. 

At this moment there is 

discussion of putting healthcare 

back on the table as early as next 

week. there is talk of this effort 

being transparent and bipartisan. 

I’ll believe that when I see it. 

Hopefully, they will first 

decide whether medical care is 

a right or a privilege. Only after 

that has been settled can they 

legitimately move forward with 

any kind of system reform. 

Before they can do anything else 

however, the flawed SGR formula 

must once again be dealt with by 

March first. Once again this will 

have to be a short term fix only to 

be dealt with again in a few months. 

We need a permanent fix and soon! 

Hopefully the fall elections will 

bring even greater balance to both 

houses. We have good candidates in 

all three of our districts this year. 

Here’s hoping the promises of 

transparency and bipartisanship 

truly come to fruition. 

F. Thomas Sporck, MD 

Editor, WV Medical Journal 

 


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C a l l f o r P a p e r s 

Theme: Substance Abuse in West Virginia 

Topics of interest may include, but are 

not limited to: 

• Prescription Drug Abuse/Misuse 

• ‘Doctor Shopping’ 

• Pain Management 

• Prescription Drug Diversion 

• Evidence-based Practices 

• Epidemiological/Evaluation/Research 

• Prevention, Early Intervention, 

Treatment, and Recovery 

• End-of-Life Care 

• Prescriber Training and Education 

DEADLINE: April 5, 2010 

Submissions must include 1) cover letter (include 

corresponding author’s email address), 2) manuscript 

(double‐spaced), 3) short biography for each author, 

4) three questions and answers pertaining 

to the manuscript and, 5) a paragraph 

stating the objectives of the paper to 

Angie Lanham, Managing Editor, 

WV Medical Journal, PO Box 4106, 

Charleston, WV 25364 or email to: 

angie@wvsma.com. All figures, 

photos, and tables 

must be submitted 

separately as .jpg, 

.tif or .pdf files. 

Scientific 

articles should 

be prepared 

in accordance 

with the “Uniform 

Requirements 

for Submission 

of Manuscripts to 

Biomedical Journals.” Please go 

to www.icmje.org for complete 

details. For additional requirements, 

see, Manuscript Guidelines on 

the last page of the Journal.

Scientific Articles 

Growing Skull Fracture in a 5-month Old Child: 

A Case Report 12 

Bouveret Syndrome: A Case Report 18 

Admissions to the State Hospital: A One Year Study 23 

A New Technique for the Primary Percutaneous 

Endoscopic Realignment of a Complete 

Urethral Injury 32 

March/April 2010 | Vol. 106 11

Scientific Article | 

Growing Skull Fracture in a 5-Month Old Child: 

A Case Report 

Michael Yu, MD 

Neurology Resident, Ohio State 

University Hospital Columbus, OH 

John H. Schmidt, III, MD 

Clinical Professor of Neurosurgery, West 

Virginia University Charleston Division 


Brooke A. Trenton, MD 

Pediatrics Resident, Georgetown 

University Hospital, Washington, D.C. 

Nicholas W. Sheets, MPH 

Medical Student First Year, West Virginia 

University, Morgantown, WV 

Abstract 

Growing skull fractures are a rare 

complication of linear skull fractures in 

children. The authors report a case of a 

growing skull fracture in a 5-month-old 

patient with a review of the literature. CT 

and MRI scans revealed a growing skull 

fracture with complication of 

leptomeningeal cyst formation. Surgical 

removal of the cyst, duraplasty and 

cranial reconstruction were performed. 

Follow up showed that the patient was 

stable neurologically and had improving 

left upper extremity weakness. 

Introduction 

More than 600,000 children 

are evaluated in the emergency 

department each year following blunt 

head trauma and approximately 

95,000 have intracranial injuries 11 . 

A study of 278 pediatric patients 

presenting with head trauma 

revealed a 29% incidence of skull 

fracture in patients less than 12 

months and 4% in children aged 13- 

24 months. 6 Growing skull fractures 

are a rare complication of linear 

skull fractures and occur almost 

exclusively in children less than 

three years of age. 16 These fractures 

are characterized by a laceration 

in the dura that enlarges with time 

to produce a cranial defect. It is 

important to identify and treat this 

condition due to the progressive 

nature of the widening fracture. This 

is associated with brain herniation 

and progressive neurologic deficit. 2, 

10, 19, 20, 22 

We present a case of a 5- 

month old male who presented 

with a skull fracture resulting from 

a motor vehicle collision. Three 

weeks later, follow up imaging 

revealed a growing skull fracture 

in the right parietal region. 

Case Report 

A previously healthy 18-week 

old male infant was transferred to 

Charleston Area Medical Center 

(CAMC) after being involved in a 

motor vehicle collision in which he 

was an unrestrained passenger. At 

the scene he was unconscious and 

was intubated. He had superficial 

abrasions over his face and bilateral 

periorbital ecchymoses. He had 

marked edema over the right 

parietal aspect of his scalp. Cranial 

nerve testing revealed small but 

reactive pupils. He was able to 

withdraw to pain and flail his right 

upper extremity. He exhibited no 

withdrawal to painful stimulus with 

his left upper extremity. His deep 

tendon reflexes were decreased 

throughout. A CT Scan preformed 

on the day of admission revealed 

a significant contusion in the 

frontoparietal region with evidence 

of a linear skull fracture (Figure 1). 

Twelve days after admission 

the patient exhibited increased 

irritability and a subgaleal fluid 

collection. A repeat CT scan revealed 

a comminuted fracture involving the 

left parietal bone as well as a fracture 

involving the right parietal skull. A 

large defect at the site of the right 

parietal skull fracture was noted 

with evidence of external cerebral 

herniation into the subgaleal space. 

MRI confirmed the presence of a 

significant dural rent with formation 

of a leptomeningeal cyst (Figure 2). 

Definitive surgical address was 

delayed until cerebral edema had 

resolved. At three weeks post 

injury the patient underwent a 

right parietal craniotomy, dural 

Figure 1. 

Initial cranial CT scans: brain (left) and bone (right) windows showing widened skull 

fracture (arrows). 

12 West Virginia Medical Journal

| Scientific Article 

Figure 2. 

MRI scans axial (left) and coronal (right) showing leptomeningeal cyst formation 

(arrows) 

exposure, dural repair and cranial 

reconstruction (Figures 3-6). 

The postoperative course was 

uneventful and he was discharged 

home. At his two week post-operative 

follow-up visit the patient was 

stable neurologically and exhibited 

mild residual weakness in his left 

upper extremity. A post-op CT scan 

demonstrated encephalomalacia in 

the right posterior parietal region, 

dilation of the third and lateral 

ventricles, and calcification in the 

right subdural region (Figure 7). 

At his four-month-post-operative 

follow up, the weakness in his left 

upper extremity was resolving with 

physical therapy. The patient was 

progressing well, and was discharged 

from the neurosurgical service. 

Discussion 

The complication of 

leptomeningeal cyst formation 

following linear skull fractures 

in young children, though rare, 

has been identified since the 

nineteenth century beginning with 

John Howship’s report in 1816. 17 

Most of the data and observations 

contributing to the hypotheses of 

the pathophysiology have been 

reported in the 20th century. Dyke 

used the term leptomeningeal cyst in 

1937 to describe an enlarging cystic 

structure at the site of a skull fracture 

with erosion of the bone edges and 

diastasis of the fracture line. 3 In 1953 

Taveras and Ransohoff concluded 

that the leptomeningeal cyst was 

formed by a ball valve mechanism at 

the dural rent. They deduced through 

their own surgical experience that 

leptomeningeal cysts arise from 

the sequestration of cerebrospinal 

fluid (CSF) within arachnoid tissue 

at the fracture site. 21 This theory 

has since been refuted by repeated 

observation that the contents of these 

expanding masses are composed 

solely of brain matter without a 

cystic component. Rosenthal et al. 

conducted an experiment in which 

India ink injected into the CSF 

circulation failed to accumulate in 

the cyst thus providing evidence 

against the ball-valve mechanism. 19 

Finally Pia and Tonnis described the 

growing skull fracture of childhood 

to include patients with cysts or 

cerebral herniation in the fracture. 17 

A triad of signs strongly 

associated with the development 

of leptomeningeal cysts has been 

described including isolated 

swelling, neurological symptoms 

Figure 3. 

Right parietal skull exposed showing widening linear fracture and underlying cerebral 

contusion (arrow). 



Figure 4. 

Dura exposed following craniotomy showing dural laceration and separation (arrows) and cerebral contusion. 

Figure 5. 

Dura repaired with allograft. 

Figure 6. 

Bone flap repositioned following reconstruction using absorbable 

bone fixation plates. 



Figure 7. 

CT scans six weeks after injury showing encephalomalacia right hemisphere and 

enlarged ventricle (left) and healing fracture (right). 

(most commonly hemiparesis, 

quadriparesis, and seizure activity), 

and diastasis of the fracture greater 

than 4 mm. 2, 10, 19, 20,22 Physical exam 

usually reveals a cranial defect with a 

bulging, pulsatile mass. 2, 5, 21, 10 On rare 

occasions the lesions were depressed 

rather than bulging. 16 Radiographs 

taken after the development of the 

leptomeningeal cyst commonly reveal 

a widening fracture with margins that 

have become smooth and elongated. 21 

Also commonly seen are ipsilateral 

ventricular dilation and cystic mass 

8, 10, 15 

or cerebral tissue herniation. 

Elevated ICP has been 

implicated in the development 

of leptomeningeal cysts. Lateral 

ventricle enlargement is invariably 

noted ipsilateral to the lesion, and 

there have been a few reported cases 

in which placement of shunts have 

prevented further growth. 14 However, 

MRI studies have not provided 

evidence of transependymal flow 

or mass effect to support the role 

of intracranial hypertension. 16 

Instead current theory holds that 

the development of the herniation 

is secondary to the normal pressure 

dynamics of the developing brain 

and lack of ossification of the infant 

skull; the dilation of the ventricle 

forms as a result of the herniation. 16 

Observation has revealed necrosis 

of brain tissue deep to the lesion 

and degeneration at the edges of 

the defect. The surface damage is 

thought to result from the interface 

of the now unprotected brain 

parenchyma with the uneven bony 

surface of the fracture and friction 

along these surfaces caused by the 

physiologic pulsations of the brain. 7 

The deeper damage may be the 

result of interference with blood 

supply after the development of a 

pressure cone that forms between 

the lateral ventricle and the skull. 25 

Much of the literature supports 

the notion that this kind of lesion, 

if left untreated will enlarge to a 

maximal point and remain stable 

throughout adulthood without 

further emergence or worsening of 

neurological status. 1,17,18,24 However, 

there have been reports of untreated 

cases which continue to worsen 

even into adulthood. 12 It is believed 

that hemorrhages may occur within 

the cystic lesion which leads to 

further enlargement and pressure 

build-up, thus new neurological 

complaints can emerge. 12 These 

patients have been reported to 

complain of local pain, discomfort, 

giddiness, or headache dependant 

on body position resembling greatly 

the “syndrome of the trephined.” 4 

Surgical repair commonly involves 

dural repair and cranioplasty. 2,5,20 

Craniotomy should extend far 

beyond the edges of the fracture; 

some reports recommend the 

craniotomy flap should be twice 

the area of the bony defect. 7,12 The 

rationale for removal of such a large 

portion of the skull in some literature 

is based on the observation that the 

dural defect extends far beyond the 

sclerotic edges of bone. 16 This finding 

is confirmed in our case (Figure 4). It 

is imperative that the dura be closed 

in this procedure for persistence of 

an opening is associated with a high 

recurrence of the leptomeningeal 

cyst. 16 Ventriculoperitoneal shunting 

has been advocated when the dura 

cannot be closed, in advanced and 

recurrent cases, or cases complicated 

by hydrocephalus. 9,13,25 Debridement 

of gliotic brain and granulation 

tissue is recommended. 23 

Conclusion 

Growing skull fractures are a rare 

but treatable complication of skull 

fractures and should be considered 

when there is radiographic evidence 

of pediatric skull fractures. This 

report details a case of a growing 

skull fracture developing after 

a traumatic head injury and 

demonstrates the techniques of 

surgical correction. Diagnosis is 

straightforward, based on a history 

of head and subsequent progressive 

development of neurological 

symptoms and a pulsatile mass over 

the skull fracture. Treatment consists 

of cerebral debridement, removal of 

the cyst, duraplasty, and cranioplasty 

to prevent enlargement of this 

lesion and further brain damage. 

Abbreviations 

CT – Computed Tomography 

MRI – Magnetic Resonance Imaging 

CAMC – Charleston Area Medical Center 

CSF- Cerebrospinal Fluid 

ICP - Intracranial Pressure 



Acknowledgements 

Special thanks to Dr. Mary 

Emmett, PhD from CAMC Health 

Education and Research Institute. 

References 

1. Addy DP. Expanding skull fracture of 

childhood. BMJ. 1973;4:338-339 

2. Arseni C, Ciurea AV. Clinicotheraputic 

aspects in the growing skull fracture: a 

review of the literature. Child’s Brain. 

1981;8:161-172 

3. Dyke CG. The roentgen ray diagnosis of 

disease of the skull and intracranial 

contents. In: Golden W (ed): Diagnostic 

Roentgenology. Baltimore, MD: Williams 

and Wilkins; 1938;1-34. 

4. Fodstad H, Love JA, Ekstedt J, Friden H, 

Liliequist B. Effect of cranioplasty on 

cerebrospinal fluid hydrodynamics in 

patients with syndrome of the trephined. 

Acta Neurochirurgica. 1984; 70:21-30. 

5. Goldstein FP, Rosenthal SAE, Garancis 

JC, Larson SJ, Brackett CE Jr. Varieties of 

growing skull fractures in childhood. J 

Neurosurg. 1970; 3:25-28. 

6. Gruskin KD, Schutzman SA. Head trauma 

in children younger than 2 years. Are there 

predictors for complications Arch Pediatr 

Adolesc Med. 1999;153:15-20. 

7. Iplikcioğlu AC, Kökes F, Bayar A, Buharali 

Z. Leptomeningeal cyst. Neurosurgery 

1990;27:1027-1028. 

8. Ito M, Miwa T, Onodera Y. Growing skull 

fracture of childhood with reference to the 

importance of the brain injury and its 

pathogenic consideration. Childs Brain. 

1977;3:116-126. 

9. Kashiwagi S, Abiko S, Aoki H: Growing 

skull fracture in childhood: A recurrent case 

treated by shunt operation. Surg Neurol 

1986;26:63-66. 

10. Kingsley D, Till K, Hoare R. Growing 

fractures of the skull. J Neurol Neurosurg 

Psychiatry. 1978;41:312-318. 

11. Krauss JF, Black MA, Hessol N, Ley P, 

Rokaw W, Sullivan C, Bowers S, Knowlton 

S, Marshall L. The incidence of acute brain 

injury and serious impairment in a defined 

population. Am. J. Epidemiol. 

1984;119:186-201. 

12. Kutlay M, Demircan N, Akin ON, Basekim 

C. Untreated growing cranial fractures 

detected in late stage. Neurosurgery. 

1998;43:72-77 

13. Leibrock LG, Skultety FM, Pierson E, 

Connolly D. Growing skull fractures. Nebra 

State Med. J. 1982;67:235-238 

14. Lye RH, Occleshaw J, Dutton J. Growing 

fracture of the skull and the role of CT case 

report. J Neurosurg. 1981;55:470-472 

15. Matson DD: Leptomeningeal cyst. in: 

Matson DD (ed): Neurosurgery of Infancy 

and Childhood. Springfield, Illinois: 

Thomas;1969, pp 304-311 

16. Muhonen MG, Piper JG, Menezes AH. 

Pathogenesis and treatment of growing 

skull fractures. Surg Neurol. 1995;43:367- 

373. 

17. Pia HW, Tonnis W. Dle wacbsende 

schadelfraktur des kindesalters. Zentralbl 

Neurochir. 1953;13:1-23. 

18. Ramamurthi B, Kalyanaraman S. Rational 

for surgery in growing fractures of the skull. 

J Neurosurg. 1970;32:427-430. 

19. Rosenthal SAE, Grieshop J, Freeman LM. 

Experimental observations on enlarging 

skull fractures. J Neurosurg. 1970;32:431- 

434. 

20. Scarfo GB, Mariottini A, Tomaccini D, 

Palma L. Growing skull fractures: 

progressive evolution of brain damage and 

effectiveness of surgical treatment. Childs 

Nerv Syst. 1989;5:163-167. 

21. Taveras J, Ransohoff J. Leptomeningeal 

cysts of the brain following trauma with 

erosion of the skull: a study of seven cases 

treated by surgery. J Neurosurg. 1953;10: 

233-234. 

22. Thompson JB, Mason TH, Haines GL, 

Cassidy RJ. Surgical management of 

diastatic linear skull fractures in infants. J 

Neurosurg. 1973;39:493-497. 

23. Tomita T. Growing skull fractures of 

childhood. In: Wilkins HR, Rengachary SS, 

(ed) Neurosurgery. New York: McGraw- 

Hill; 1996:2757-2761. 

24. Vas CJ, Winn JM. Growing skull fractures. 

Dev Med Child Neurol. 1966;8:735-740. 

25. Winston K, Beatty RM, Fischer EG. 

Consequences of dural defects acquired in 

infancy. J Neursurg. 1983;59:839-846. 

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Bouveret Syndrome: A Case Report 

Daniel Rossi, DO 

PGY-5 Surgical Resident 

West Virginia University 

Uzer Khan, MD 

PGY-1 Surgical Resident 


Stephen McNatt, MD 

Associate Professor 

Wake Forest University 

Richard Vaughan, MD 

Professor and Chairman 

Department of Surgery 


Abstract 

Bouveret syndrome is characterized 

by the migration of a gallstone through a 

cholecystenteric fistula into the proximal 

duodenum resulting in gastric outlet 

obstruction. Bouveret syndrome is a rare 

phenomenon that most commonly occurs 

in females and the elderly. 

A 79-year-old female presented with 

symptoms of gastric outlet obstruction 

and was diagnosed with Bouveret 

syndrome. This report describes the 

symptoms, diagnosis, and management 

of Bouveret syndrome, as well as its 

prevalence and differentiation from 

gallstone ileus. 

Patients with Bouveret syndrome 

present with varied, non-specific 

symptoms that may include emesis, 

abdominal pain, anorexia, and abdominal 

distention. Computed tomography 

remains the diagnostic modality of choice. 

Although different techniques are 

reported, surgical intervention is almost 

always required in the treatment of 

Bouveret syndrome. 

Introduction 

Gallstone disease is an ailment of 

the gastrointestinal tract afflicting 

approximately 6.3 million men and 

14.2 million women in the United 

States annually. It has a prevalence 

of approximately 10% in the Western 

Hemisphere. 1 Despite the large 

number of individuals living with 

this entity, only 20-30% develop 

symptoms from their gallstones. 

Biliary colic, which includes 

abrupt epigastric pain that reaches 

maximum intensity in 60 minutes and 

gradually resolves over 2-6 hours, 

is the most common presentation in 

those who develop symptoms. Acute 

cholecystitis, gallstone pancreatitis, 

and acute cholangitis are also 

known sequelae of cholelithiasis. 

Less common presentations and 

complications include the Mirizzi 

syndrome, cholecystocholedochal 

fistula, and gallstone ileus. 2 

Gallstone ileus is an important, 

although rare, cause of mechanical 

intestinal obstruction with 

intermittent signs of nausea, 

vomiting, and abdominal pain. 

Migration of a gallstone through a 

cholecystenteric fistula to the distal 

ileum leads to impaction of the 

stone and subsequent symptoms 

of intestinal obstruction. Although 

gallstone ileus is a cause of only 1- 

4% of intestinal obstructions in the 

general population, the incidence 

increases in the elderly accounting 

for 25% of nonstrangulated small 

bowel obstructions. 3 Females are 

affected up to six times more often 

than males which is related to the 

cholestatic effects of the female 

sex hormonal melieu. 4 The site of 

obstruction is most commonly the 

terminal ileum (50-70%), where the 

small bowel is at its narrowest. Less 

common locations of impaction 

include the distal jejunum (9%), 

the colon (4%), the rectum (4%), 

and the duodenum (1-3%). 3 

Bouveret syndrome, in contrast to 

gallstone ileus, is characterized by 

the cephalad or proximal migration 

of a gallstone into the duodenum 

resulting in a persistent gastric 

outlet obstruction as originally 

described by the French surgeon 

Leon Bouveret in 1896. 2,3,5,6,14 Bouveret 

syndrome accounts for 1-3% of 

duodenal obstruction cases. 3 As 

in gallstone ileus, there is a higher 

incidence of the disease in women 

than in men, 4 with a female-tomale 

sex ratio of 1.86. It is also a 

disease of the elderly with a mean 

age of 74.1 ± 11.1 (SD) years. 15 

Case Report 

A 79-year-old Caucasian female 

presented to our institution in 

transfer with a one-week history 

of intractable vomiting. Emesis 

occurred one-two hours after eating, 

however anorexia was denied. 

She denied fever, chills, or rigors, 

but experienced mild dyspnea 

with exertion. Her past medical 

history was significant for type II 

diabetes mellitus, hypertension, 

morbid obesity, congestive 

heart failure, and chronic renal 

insufficiency. Her past surgical 

history consisted of a hysterectomy. 

A focused physical examination 

elicited a soft, non-distended 

abdomen with minimal tenderness 

throughout, but with no 

obvious peritoneal signs. Chest 

auscultation revealed audible 

heart sounds with regular heart 

rate but occasional ectopy. 

Laboratory testing revealed 

a hypochloremic, hypokalemic 

metabolic alkalosis, deranged 

liver function tests, chronic renal 

insufficiency, mild malnutrition, as 

well as a urinary tract infection. 

During the course of admission, 

her liver and canalicular enzymes 

and renal function gradually 

improved. Her electrolyte imbalance 

was resolved with standard therapy. 

An abdominal ultrasound of the 

right upper quadrant on day two 

of admission showed multiple 

gallstones in a contracted gallbladder 

with chronic wall thickening and 

a common bile duct measuring 

2.1 mm in diameter. A CT scan of 

the abdomen and pelvis showed 

gallstone-induced inflammatory 

changes about the duodenum 

consistent with duodenitis as well 

as the presence of pneumobilia 



Figure 1. 

Axial CT scan image 

Figure 2. 

Coronal CT scan image 

(Figure 1). A 4-5 cm calcified mass 

was present in what appeared to 

be a fluid-filled sac-like structure 

invaginating into the duodenum 

and concern was raised for the 

presence of a gallstone within 

the duodenum (Figure 2). After 

preoperative optimization, the 

patient, on day five of admission, 

underwent esophagoduodenoscopy 

and exploratory laparotomy. Intraoperatively, 

the patient was found to 

have a phlegmon in her right upper 

quadrant involving the gallbladder, 

liver, duodenum, and omentum. 

An endoscope was passed into 

the esophagus and stomach, and 

the findings were unremarkable. 

However, a large gallstone could 

be easily visualized just distal to 

the pylorus, situated in the distal 

duodenal bulb and the first and 

second portions of the duodenum 

(Figure 3). The stone was palpable 

and visible through the pylorus, 

and an anterior gastrotomy was 

performed in the antrum. Following 

an unsuccessful attempt to withdraw 

the stone through the pylorus with 

stone-grasping forceps, the stone 

was crushed and retrieved in piecemeal 

fashion. Upon relieving the 

obstruction, a cholecystoduodenal 

fistula was palpated and also 

visualized via the endoscope. The 

endoscope was used to confirm the 

relief of the duodenal obstruction 

by passing it into the 3rd and 

4th portions of the duodenum 

(Figure 4). Cholecystectomy and 

cholecystoduodenal fistula closure 

were not performed due to presence 

of the phlegmon. The gastrotomy 

was then closed in two layers. 

The patient’s post-operative 

was uncomplicated, and she 

was discharged to home on 

post-operative day eight. 

Discussion 

Bouveret syndrome is considered 

a distinct clinical entity from 

gallstone ileus due to the proximal 

site of the obstructing stone. 

Proximal obstruction is due to a 

large obstructing stone, generally 

measuring 2.5 cm or more. The 

presence of multiple smaller 

gallstones, however, has also been 

associated with duodenal obstruction 

especially in the presence of strictures 

or edema leading to a narrowing of 

the lumen of the duodenum. 16 The 

size of the obstructing gallstone 

in our case, 5cm, is one of the 

largest in reported literature. 15 

The clinical features of Bouveret 

syndrome can be varied and nonspecific; 

however, certain complaints 

tend to recur. Nausea and vomiting, 

abdominal pain, hematemesis, 

recent weight loss and anorexia 

are the most common presenting 

features of the syndrome. Abdominal 

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Figure 3. 

EGD image of 

gallstone located 

within the proximal 

duodenum. 

Figure 4. 

EGD image of 

unobstructed distal 

duodenum 

tenderness, signs of dehydration, 

abdominal distension, and pyrexia 

are the most common findings on 

physical examination. 15 These signs 

and symptoms are all suggestive 

of an upper gastrointestinal 

obstructive pathology but none are 

specific for Bouveret syndrome. 

Nonspecific symptoms make it 

necessary to use imaging modalities 

to assist in making a correct 

diagnosis. Plain abdominal flat and 

upright x-rays are still useful in the 

diagnosis of an intestinal obstruction. 

The confirmation of a diagnosis 

of Bouveret syndrome using plain 

abdominal films is dependent on 

the observation of Rigler’s tetrad 

as delineated in his 1941 article 17 

(Table 1). The classic “Rigler’s triad” 

comprising the first three signs 

is seen in only 30-35% of cases. 18 

However, up to 50% of abdominal 

radiographs may contain two of 

the classic three signs which would 

increase the index of suspicion for 

a gallstone ileus significantly. 3,18 

In a series of 64 cases of Bouveret 

syndrome in which abdominal 

radiographs were conducted, Cappell 

and Davis reported the discovery 

of pneumobilia in 39%, a dilated 

stomach in 23%, and dilated loops 

of bowel in 14% of cases. An ectopic 

stone in the region of the gallbladder 

is also visualized in 21-38% of 

cases. 7,15 An upper GI series may 

assist with the delineation of the 

cause of gastric outlet obstruction. 

The most common findings 

include a filling defect or mass in 

the duodenum, a gallstone in the 

duodenum, duodenal or pyloric 

obstruction, cholecystoduodenal 

fistula, and pneumobilia. 15 

Diagnostic ultrasound scans 

usually depict what is known as a 

“double-arch sign” which can arouse 

suspicion particularly if pneumobilia 

is seen as well. 19 Nevertheless, 

sonographic visualization can be 

difficult if the gallbladder is collapsed 

or air-filled. In these situations, a 

gallstone in the duodenum would 

require significant amounts of 

fluid surrounding the stone in 

the antro-duodenal lumen for 

adequate visualization. Otherwise, 

an orthotopic gallstone in the 

gallbladder becomes a significant 

differential diagnosis. 20 Ripolles et 

al conducted a study to compare the 

accuracy of ultrasonography to plain 

abdominal films in the detection 

of Rigler’s triad. They discovered 

that ultrasound was superior in the 

detection of pneumobilia and ectopic 

gallstones but somewhat inferior in 

the detection of bowel obstruction. 

However, they discovered that when 

combined with a plain abdominal 

X-ray, clinicians were able to 

make at least a probable diagnosis 

(visualization of only an ectopic stone 

or only pneumobilia and intestinal 

obstruction) in 96% of cases. It should 

be noted, however, that pneumobilia 

was detected in 22 of 23 cases. This 

increases the utility of the ultrasound 

since pneumobilia, unlike ectopic 

gallstones, has very few causes 

aside from gallstone ileus once prior 

biliary surgery has been ruled out. 

Ectopic stones will be visualized in 

exactly the same manner as bezoars 

on ultrasonography.8 The efficacy 

of ultrasonography as a tool is also 

dependent on the skill of the user. In 

another series of 40 cases of Bouveret 

syndrome, pneumobilia was 

visualized in less than half. 15 Even in 

the case of a definitively diagnostic 

plain film, ultrasonography will 

assist the surgeon in locating 

the stone as well as provide 

information on other stones that 

may be present in the GI tract. 8 

Difficulties with ultrasonography 

can arise, however, in the presence 

of excessive intestinal gas. 

Because of the relative lack of 

specificity with plain abdominal 

radiographs and ultrasound for a 

bilioenteric fistula, one should also 

remain cognizant of other common 

causes of pneumobilia (Table 2). 

In the absence of these conditions, 

pneumobilia is highly suggestive of 

a bilioenteric fistula. 21 Because of the 

limitations of plain radiographs, CT 

scans have become routine in the 

evaluation of intestinal obstruction 

and almost every other disease 

process involving the abdomen. 

CT scanning is particularly helpful 

in these situations. 22 Diagnosis is 

also superior with this modality 

as all three signs of Rigler’s triad 

are depicted 77.78% of the time. 23 

Pneumobilia is visualized in 60%, 

gallstones in 50%, and duodenal 

or gastric distension in 33% of 

cases of Bouveret syndrome. 15 

Gastroscopy is useful in 

identifying the obstructing gallstone 

in up to 69% of cases. In the 

remainder of patients, an obstructing 

gallstone would not be appreciated 

due to the possibility of being deeply 

embedded within the mucosa. In 

these cases a high suspicion should be 

maintained for a gallstone if the mass 

is hard, convex, smooth, non-friable, 

and non-fleshy. 15 The visualization of 

a gallstone on gastroscopy appears to 

be the only significant differentiating 

factor between the gastric outlet 

obstruction of Bouveret syndrome 

and the jejunoileal obstruction 

of the classic gallstone ileus. 

The management of Bouveret 

syndrome is similar to the paradigm 

established for gallstone ileus. 

Definitive therapy remains surgery 15 , 

while endoscopy and lithotripsy 

may be reserved as options for 

those unable to tolerate invasive 

procedures and for recurrent 

gallstone ileus. 13,15,26 No consensus 

exists for the most appropriate 

surgical intervention. Pavlidis et 

al promote a one-stage procedure 



in low-risk patients involving 

enterolithotomy or gastrotomy with 

removal of the obstructing gallstone 

followed by a cholecystectomy and 

fistula closure during the same 

procedure. 11 This combination, in 

comparison to enterolithotomy or 

gastrolithotomy alone, is thought 

to preclude the development of 

a recurrent obstructive event, 

cholecystitis, or cholangitis. The 

risk of developing a carcinoma is 

also eliminated, as is the need for 

a second operation. The significant 

disadvantage, however, is the 

associated morbidity and mortality 

that develops in significantly ill 

patients. A review of a 1001 cases 

of gallstone ileus by Reisner et al. 

noted a mortality rate of 16.7% in 

the one-stage procedure group 

compared to 11.7% in the group 

undergoing enterolithotomy alone 

for the treatment of gallstone ileus. 3 

Cholecystectomy can not entirely 

prevent a recurrence of symptoms 

because obstruction may occur from 

stones in the common bile duct 

migrating into the small intestine, 

or from those which have already 

advanced into the small intestine, 

but were unnoticed during surgery. 

High-risk patients are 

recommended to undergo a twostage 

procedure with enterolithotomy 

alone and cholecystectomy at a 

second stage only if symptomatic 

stones remain. A patient may be 

considered higher risk if an ASA 

class of 3 or 4 is identified and/or 

hypotension is diagnosed during 

pre-operative evaluation. 12 Recurrent 

gallstone ileus is a significant 

problem. The overall recurrence 

has been shown to be 4.7%, with 

57% of the recurrences occurring 

within the first six months after 

surgery. Symptomatic biliary tract 

disease has also been shown to 

develop in 15% of patients who do 

not undergo cholecystectomy. 

A one-stage procedure has 

exhibited a greater number of early 

post-operative complications as well 

as a higher mortality rate. 3,24 Studies 

have also reported no difference 

in outcomes with enterolithotomy 

alone in both low- and high-risk 

patients. The reported mortality 

rates associated with the one-stage 

procedure may be artificially low 

due to a selection bias in favor of 

performing one-stage procedures 

in healthier, lower-risk patients. 

No significant complications were 

observed secondary to the remnant 

fistula. 12,24 A one-stage operation 

is recommended in patients who 

can tolerate the extended operative 

time (an average of 70 minutes in 

the enterolithotomy alone group 

versus 178 minutes in the one-stage 

procedure group 12 ) and possibly in 

patients with gall bladder necrosis or 

empyema. 24 In patients undergoing 

enterolithotomy alone, many of the 

remnant fistulae have been shown 

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to close spontaneously if the cystic 

duct remains patent and residual 

gallstones are not present. 3 A second 

stage cholecystectomy, however, 

can be offered to patients who have 

persistent biliary symptoms and 

who have a higher life expectancy. 

Laparoscopic approaches to 

relieve the obstruction have also 

been described to be safe. 25 In our 

case a laparotomy was performed 

with a gastrotomy once the large 

stone was confirmed to be in the 

duodenum. Neither closure of the 

cholecystoduodenal fistula nor 

cholecystectomy was performed. 

The recurrence rate for gallstone 

ileus is significant, with more than 

half of the recurrences occurring 

within the first six months after 

surgery. This underscores the 

importance of interval follow-up. 

Due to the unhealthy status of most 

of the individuals presenting with 

this disease (86% of this patient 

population have been shown to 

belong to an ASA class of 3 or 4) 10 , 

the mortality rate of 4.5%- 25% is 

five to ten times higher than with 

all other nonmalignant causes of 

mechanical small bowel obstruction. 3 

Therefore, it must be stressed that 

these patients need to be adequately 

prepared for their operation with 

correction of electrolyte abnormalities 

and treatment of co-morbid 

conditions. A one-stage procedure 

consisting of enterolithotomy alone 

is recommended in this generally 

high-risk population due to the 

low risk of disease recurrence and 

the increased morbidity associated 

with staged surgical therapy. 

Conclusion 

Our patient had several comorbidities 

and electrolyte 

derangement on presentation. 

Due to the complex nature of the 

patient’s active and past medical 

problems, she was resuscitated prior 

to surgery and electrolyte imbalances 

were corrected. Following cardiac 

evaluation, the patient underwent 

a semi-elective enterolithotomy 

procedure that was uncomplicated. 

As depicted in this case, the nonemergent 

setting and relative stability 

of most patients with Bouveret 

syndrome necessitates the adequate 

preparation of the patient for 

surgery. Since the majority of these 

patients are elderly and likely to have 

multiple comorbidities, thorough 

preparation, we believe, will result in 

decreased morbidity and mortality. 

Nevertheless, half of all cases of 

gallstone ileus/Bouveret syndrome 

are diagnosed during laparotomy. 

A high index of suspicion should, 

therefore, be maintained to ensure 

early diagnosis and effective 

treatment of this otherwise rare 

and potentially fatal condition. 3 

Table 1. Rigler’s Triad 

Partial or complete intestinal obstructions 

Pneumobilia or contrast in the biliary tree 

Visualization of ectopic gallstone in the 

bowel 

Change in position of previously observed 

stone 

* In 1978 Blathazar and Schecter described a 

fifth sign: Two air fluid levels in the right upper 

quadrant on an abdominal X-ray due to air in 

the gallbladder. 

Table 2. Causes of Pneumobilia 27 

Spontaneous biliary-enteric fistula 

Surgical anastomosis - Whipple’s procedure, 

choledochojejunostomy 

Incompetent sphincter of Oddi 

ERCP with papillosphincterotomy or surgical 

transduodenal sphincteroplasty 

Emphysematous cholecystitis 

Trauma 

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gallstone disease: Mirizzi syndrome, 

cholecystocholedochal fistula and gallstone ileus. 

Am J Gastroenterol 2002; 97: 249-254 

3. Reisner RM, Cohen JR. Gallstone ileus: a 

review of 1001 reported cases. Am Surg 1994; 

60: 441-446 

4. Bateson MC. Gallbladder disease and 

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5. Geron N, Hazzan D, Shiloni E. Bouveret’s 

Syndrome as a Rare Complication of 

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6. Sakarya A, Erhan M Y, Aydede H, Kara E, Ozkol 

M, Ilkgul O, Ozsoy Y. Gallstone ileus presenting 

as gastric outlet obstruction (Bouveret’s 

Syndrome): a case report. Acta Chir Belg 2006; 

106:438-40 

7. Riesser JF, Vicas B. Gallstone impacted in the 

duodenal cap. 1952; 58:401-4 

8. Ripolles T, Miguel-Dasit A, Errando J, et al. 

Gallstone ileus: increased diagnostic sensitivity by 

combining plain film and ultrasound. Abdom 

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9. Yu CY, Lin CC, Shyu RY, et al. Value of CT in the 

diagnosis and management of gallstone ileus. 

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12. Tan YM, Wong WK, Ooi LL. A comparison of two 

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cause of gastric outlet obstruction. Digestion 

2007; 75:17-9 

14. Bouveret L. Stenose du pylore, adherent a la 

vesicule calculeuse. Rev Med 1896; 16:1-16 

15. Cappell MS, Davis M, Characterization of 

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of 128 cases. Am J Gastroenterol 2006; 

101:2139-2146 

16. Lowe AS, Stephenson S, Kay CL, et al. Duodenal 

obstruction by gallstones (Bouveret’s syndrome): a 

review of the literature. Endoscopy 2005; 37:82-87 

17. Rigler L, Borman C, Noble J. Gallstone 

obstruction: pathogenesis and reontgen 

manifestations. JAMA 1941; 117:1753 

18. Balthazar EJ, Schechter LS. Air in gallbladder: a 

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19. Saez-Garmendia F, Lopez-Ruiz JA, Martinez 

Alvarez A, et al. Bouveret syndrome: new cause of 

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Admissions to the State Hospital: A One-Year Study 

Cheryl A. France, M.D. 

Assistant Professor, WVU Department of 

Behavioral Medicine, Geriatric 

Subspecialist 

William R. Sharpe, Jr. Hospital 

Neil L. Mogge, Ph.D. 

Professor, WVU Department of 

Behavioral Medicine, Director of 

Psychology 

William R. Sharpe, Jr. Hospital 

Abstract 

Admission to one of the state 

hospitals in West Virginia is gained 

through a legal proceeding which is 

initiated on a county level. It was 

hypothesized that involuntary psychiatric 

admission patterns from the Sharpe 

Hospital catchment area do not have a 

direct correlation with county population. 

Methods: Sharpe Hospital admissions 

data for a one year period were collected 

and demographic data from counties 

within the hospital catchment area was 

obtained for comparison. 

Results: Involuntary psychiatric 

admissions from the Sharpe Hospital 

catchment area do not correlate directly 

with county population, supporting the 

hypothesis that factors besides county 

population explain differences in 

admission patterns. Socioeconomic 

status, diversion of admissions to other 

hospitals and proximity to the state 

hospital do not fully explain the 

differences. 

Conclusion: Rates of admission were 

found to vary widely from counties in the 

Sharpe Hospital catchment area. Local 

evaluation and treatment variables and 

patient-specific factors such as diagnosis, 

comorbid substance dependence, and 

psychiatric history warrant further study to 

guide planning 

Introduction 

There are at present, two inpatient 

acute care mental health facilities 

operated by the West Virginia Dept of 

Health and Human Resources with a 

total of 240 beds to serve the mentally 

ill population of West Virginia. Each 

hospital has a designated catchment 

area with corresponding Community 

Mental Health Centers. William 

R. Sharpe, Jr. Hospital is a 150 bed 

facility located in Lewis County 

that serves 42 of West Virginia’s 55 

counties. Mildred Mitchell Bateman 

Hospital in Huntington has 90 beds 

and admits patients from 13 counties. 

All admissions to the hospital are 

involuntary, either through civil 

commitment or, in the case of 

forensic patients, through court 

order via the judicial system. Civilly 

committed patients are admitted 

along catchment area lines with few 

exceptions. Forensic patients from 

the entire state are initially admitted 

to the forensic program at Sharpe. 

The procedure by which an 

involuntary psychiatric admission 

occurs is outlined in West Virginia 

Code Chapter 27 1 ; in summary, the 

process begins with application 

in the community, examination 

by a licensed physician or mental 

health professional designated by 

the area mental health center, and 

a mental hygiene hearing at the 

county level. If “probable cause” is 

found that the person is mentally 

ill or addicted and dangerous, then 

an order is entered for placement 

at a mental health facility. 

Since 2002 the census at Sharpe 

Hospital has nearly consistently 

been above its designed capacity 

of 150 patients. When this is the 

case, attempts are made to divert 

admissions to non-DHHR inpatient 

facilities willing to accept involuntary 

patients. The inpatient stay for 

these patients is funded by the 

state. It was evident from casual 

observation at Sharpe Hospital 

that more admissions came from 

some counties than others. The 

authors chose to quantify these 

observations and to study other 

variables related to admissions in 

an attempt to determine current 

admission patterns and to consider 

best practices to respond on a 

hospital level. However, since 

each patient is admitted through 

a county-level process, analysis of 

Sharpe Hospital admission patterns 

in light of variables within the 

catchment area counties would be 

important for state level planning 

for psychiatric treatment. Various 

patient-specific (e.g. poverty 

and diagnosis) and external (e.g. 

population and proximity to 

hospital) factors have been shown to 

positively predict rates of psychiatric 

admission 2 and recent data reveals 

a trend toward increasing forensic 

patient populations. 3 Additionally, 

admission to a public mental health 

facility and involuntary admission 

both have been associated with 

greater severity of illness 4 and low 

socioeconomic status and service 

quality at the local level. 5 Our initial 

analysis considered Sharpe Hospital 

catchment area demographic data to 

test the hypothesis that the number 

of involuntary admissions at Sharpe 

from each county does not directly 

correlate with the population of the 

county but is also impacted by other 

variables; therefore, rates are not 

constant across the catchment area. 

Methods 

The research project was approved 

by the William R. Sharpe, Jr. 

Hospital Research Committee. The 

database of information relating to 

admission numbers, counties from 

which referrals came, legal status, 

and diversions to other hospitals 

was obtained from archival sources, 

with the cooperation of Sharpe’s 

Health Information Management 

and Admissions personnel. All 

admissions from April 1, 2007 

through March 31, 2008 were studied. 

The data was transferred into S.P.S.S. 

(Statistical Package for the Social 

Sciences, Version 10, 2004, SPSS Inc.) 

and analyzed. Data was subsequently 

entered into Microsoft Office Excel 

2003 (Copyright 1985-2003 Microsoft 

Corporation) for calculation of 

rates, rank sorting and graphing. 

Population data was obtained from 

the United States Census Bureau 6 

for calculation of rates per 100,000 

population in each county. 



tABlE 1: SUMMArY OF SHArPE HOSPItAl ADMISSIONS AND COUNtY DEMOGrAPHIC DAtA 

COUNtY 

2007 

POPUlAtION 

Sharpe Admissions 

total 

Sharpe Admissions 

forensic 

Percent Sharpe 

Admissions 

rate Sharpe 

Admissions * 

Sharpe 

Diversions 

Percent Sharpe 

Diversions 

rate Sharpe 

Diversions * 

total Involuntary 

Admissions 

Percent 

Involuntary 

Admissions 

rate Involuntary 

Admissions * 

2007 Poverty 

Estimate All Ages 

2007 Poverty 

rate * 

2007 Median 

Household 

Income 

Barbour County 15,532 13 2 1.5% 83.70 6 0.5% 38.63 19 1.0% 122.33 3,476 22,380 28,826 

Berkeley County 99,734 18 5 2.1% 18.05 11 1.0% 11.03 29 1.5% 29.08 9,936 9,963 52,566 

Braxton County 14,639 11 0 1.3% 75.14 2 0.2% 13.66 13 0.7% 88.80 3,137 21,429 31,616 

Brooke County 23,661 9 0 1.1% 38.04 6 0.5% 25.36 15 0.8% 63.40 2,777 11,737 39,601 

Calhoun County 7,201 11 0 1.3% 152.76 1 0.1% 13.89 12 0.6% 166.64 1,582 21,969 27,791 

Doddridge County 7,262 5 1 0.6% 68.85 0 0.0% 0.00 5 0.3% 68.85 1,264 17,406 34,145 

Fayette County 46,334 8 2 1.0% 17.27 13 1.2% 28.06 21 1.1% 45.32 10,584 22,843 30,312 

Gilmer County 6,907 5 0 0.6% 72.39 0 0.0% 0.00 5 0.3% 72.39 1,467 21,239 34,355 

Grant County 11,925 6 0 0.7% 50.31 2 0.2% 16.77 8 0.4% 67.09 1,746 14,642 36,361 

Greenbrier County 34,586 30 1 3.6% 86.74 16 1.5% 46.26 46 2.4% 133.00 6,066 17,539 33,163 

Hampshire County 22,577 7 1 0.8% 31.01 1 0.1% 4.43 8 0.4% 35.43 3,606 15,972 36,217 

Hancock County 30,189 5 0 0.6% 16.56 10 0.9% 33.12 15 0.8% 49.69 3,779 12,518 39,378 

Hardy County 13,661 6 3 0.7% 43.92 5 0.5% 36.60 11 0.6% 80.52 1,737 12,715 37,336 

Harrison County 68,309 71 4 8.5% 103.94 34 3.1% 49.77 105 5.4% 153.71 12,585 18,424 38,063 

Jackson County 28,223 21 0 2.5% 74.41 24 2.2% 85.04 45 2.3% 159.44 4,363 15,459 40,978 

Jefferson County 50,832 7 1 0.8% 13.77 5 0.5% 9.84 12 0.6% 23.61 4,099 8,064 61,219 

Lewis County 17,145 19 1 2.3% 110.82 12 1.1% 69.99 31 1.6% 180.81 3,152 18,384 34,223 

Marion County 56,728 55 1 6.5% 96.95 54 4.9% 95.19 109 5.6% 192.14 7,854 13,845 38,000 

Marshall County 33,148 16 1 1.9% 48.27 87 7.9% 262.46 103 5.3% 310.73 8,856 26,717 33,804 

Mineral County 26,722 8 0 1.0% 29.94 5 0.5% 18.71 13 0.7% 48.65 4,056 15,179 35,929 

Monongalia County 87,516 50 3 6.0% 57.13 142 13.0% 162.26 192 9.9% 219.39 13,101 14,970 40,889 

Monroe County 13,537 4 1 0.5% 29.55 5 0.5% 36.94 9 0.5% 66.48 1,992 14,715 35,034 

Morgan County 16,351 0 0 0.0% 0.00 0 0.0% 0.00 0 0.0% 0.00 1,762 10,776 44,162 

Nicholas County 26,160 14 1 1.7% 53.52 13 1.2% 49.69 27 1.4% 103.21 4,898 18,723 38,813 

Ohio County 44,398 35 6 4.2% 78.83 217 19.8% 488.76 252 13.0% 567.59 7,121 16,039 38,757 

Pendleton County 7,650 9 1 1.1% 117.65 3 0.3% 39.22 12 0.6% 156.86 1,027 13,425 36,019 

Pleasants County 7,183 5 0 0.6% 69.61 2 0.2% 27.84 7 0.4% 97.45 923 12,850 40,539 

Pocahontas County 8,571 7 0 0.8% 81.67 20 1.8% 233.35 27 1.4% 315.02 1,296 15,121 31,832 

Preston County 30,254 27 1 3.2% 89.24 19 1.7% 62.80 46 2.4% 152.05 4,927 16,285 35,567 

Raleigh County 79,170 53 8 6.3% 66.94 111 10.1% 140.20 164 8.5% 207.15 12,610 15,928 37,261 

Randolph County 28,292 18 2 2.1% 63.62 6 0.5% 21.21 24 1.2% 84.83 5,096 18,012 33,472 

Ritchie County 10,371 7 0 0.8% 67.50 2 0.2% 19.28 9 0.5% 86.78 1,752 16,893 34,329 

Roane County 15,295 2 0 0.2% 13.08 7 0.6% 45.77 9 0.5% 58.84 3,445 22,524 30,175 

Summers County 13,202 7 0 0.8% 53.02 4 0.4% 30.30 11 0.6% 83.32 2,860 21,663 27,021 

Taylor County 16,117 26 0 3.1% 161.32 28 2.6% 173.73 54 2.8% 335.05 2,801 17,379 34,804 

Tucker County 6,868 6 0 0.7% 87.36 5 0.5% 72.80 11 0.6% 160.16 1,102 16,045 32,755 

Tyler County 8,952 12 0 1.4% 134.05 6 0.5% 67.02 18 0.9% 201.07 1,655 18,487 35,271 

Upshur County 23,508 15 2 1.8% 63.81 7 0.6% 29.78 22 1.1% 93.59 4,510 19,185 34,687 

Webster County 9,435 6 0 0.7% 63.59 2 0.2% 21.20 8 0.4% 84.79 2,351 24,918 27,521 

Wetzel County 16,432 11 1 1.3% 66.94 56 5.1% 340.80 67 3.5% 407.74 2,667 16,231 36,397 

Wirt County 5,809 4 0 0.5% 68.86 0 0.0% 0.00 4 0.2% 68.86 1,078 18,557 36,850 

Wood County 86,088 145 2 17.3% 168.43 142 13.0% 164.95 287 14.8% 333.38 13,842 16,079 39,910 

Out of State N/A 12 1 1.4% N/A 0 0.0% N/A N/A N/A N/A N/A N/A N/A 

Bateman Catchment 

Area N/A 34 21 4.0% N/A 5 0.5% N/A N/A N/A N/A N/A N/A N/A 

Sharpe Catchment 

Area 1,176,474 794 51 94.5% 67.49 1,091 99.5% 92.73 1,885 97.4% 160.22 188,938 16,060 36,332 

tOtAl ^ 840 73 100.0% 1,096 100.0% 1,936 100.0% 

 

 



Results 

During the year of this study, 

there were 840 admissions to Sharpe 

Hospital. Overall, 794, or 94.5%, of 

all involuntary admissions were 

from within Sharpe’s catchment 

area, 34, or 4%, were from Bateman’s 

catchment area and 12, or 1.4%, were 

from out of state. Seventy-three, or 

8.7%, of the 840 admissions were 

court-ordered forensic patients, with 

22, or 30.1%, of these coming from 

outside of Sharpe’s catchment area. 

Our hypothesis that involuntary 

hospitalizations do not directly 

correlate with county population 

was supported by the data. Rates of 

admission to Sharpe range from 0 to 

168 with a mean of 69. Wood County, 

with the third largest population, 

had the highest rate of admission 

and admitted 145 (17.3%) of the 

overall total, more than double that 

of any other county. Taylor, Calhoun, 

Tyler and Pendleton Counties follow 

Wood County in rate of admissions; 

but in that their populations are 

small, their actual impact on 

Sharpe admissions is limited. In 

contrast to Wood County, the most 

populous county in the Sharpe 

catchment area, Berkeley County, 

had only 18 admissions, ranking 

it 37 out the 42 counties in rate. 

The number of patients from 

Sharpe’s catchment area diverted to 

other facilities and not admitted to 

the state hospital was also considered 

as a potentially confounding variable 

so this data was analyzed. There 

were ten hospitals that admitted 

patients under probable cause status 

as diversions; more patients were 

actually diverted than admitted 

to the state hospital. Most of the 

diversion hospitals accept primarily 

(or almost exclusively in some 

cases) patients from their own or 

nearby counties. As can be seen from 

Table 1, several counties diverted 

more patients than they admitted; 

there are diversion hospitals in 

these counties or very nearby. 

The county rates of total 

involuntary admissions either to 

Sharpe or a diversion hospital were 

calculated as these rates actually 

reflect state-funded psychiatric 

admissions from the catchment 

area. These rates differ substantially 

for some counties from the rates of 

admission to Sharpe Hospital and 

range from 0 to 568. For example, 

Ohio County, the 9th most populous 

county, located in the Northern 

Panhandle, had 217 diversions with 

only 35 Sharpe Hospital admissions 

and had the highest rate of diversion 

as well as total involuntary admission 

in the catchment area. It should be 

noted that the local mental health 

center is located adjacent to a 

general hospital with an inpatient 

psychiatric unit; the majority of 

commitments from this catchment 

area were admitted to this unit. 

The three very populous counties 

in the Eastern Panhandle, Morgan, 

Jefferson, and Berkeley, had the 

lowest total rates of admission. 

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Graphical representation by 

scatterplot of the relationship 

between both Sharpe admissions 

and total involuntary admissions 

(Chart 1) tends to be positive overall; 

however, covariance is not linear 

over the entire range of values, 

the small number of admissions 

from some counties and the broad 

range of rates preclude statistically 

valid correlation analyses. 

To further explore the disparity 

between admission numbers 

from various counties in Sharpe’s 

catchment area, the United States 

Census Bureau data regarding 

poverty level and estimated 

household income for 2007 was also 

obtained 7 . Rates of poverty were 

calculated based on population for 

the 42 counties in the catchment area. 

To assess the relationship between 

involuntary admission rates, poverty 

rates, and median income, correlation 

coefficients were calculated. This 

relationship is graphically illustrated 

in Charts 2 and 3. The correlations 

between involuntary admission 

rates and median income (r= -0.10) 

and rate of poverty (r=0.12) were 

reflective of no relationship. 

Proximity to the state hospital 

also appears to have a limited 

correlation with admission rates to 

Sharpe Hospital. Lewis County, the 

location of Sharpe Hospital, ranked 

sixth in rate. Wood County, first in 

rate, is approximately an hour and 

three quarters drive from Sharpe. 

Most of the counties with low rates of 

admission to Sharpe (e.g. the Eastern 

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Panhandle) are at a considerable 

distance from Sharpe, but Spencer 

in Roane County is only fifty miles 

from Weston and is second to last 

in rate of admissions. Though all 

adult patients in West Virginia 

involuntarily hospitalized through 

the mental hygiene process come 

to the state hospital or an in-state 

diversion hospital, it is possible that 

lower rates are found, especially 

in border counties, due to patient 

evaluation and hospitalization 

at an out of state facility. 

Discussion 

The finding that variation in 

admission rates across the catchment 

area is not explained by differences 

in population, socioeconomic status, 

or proximity to the state hospital 

is consistent with prior studies. 5 

Local mental health center staff 

may reasonably make the case for 

commitment with the mental hygiene 

commissioner if a patient is poor 

with inadequate housing, living in 

a remote area with limited access 

to outpatient treatment, and has no 

other access to hospitalization due 

to having no payer source. Study 

of individual characteristics of 

patients referred for evaluation at 

West Virginia mental health centers 

and subsequently involuntarily 

hospitalized may elucidate some 

correlative factors. It has certainly 

been demonstrated that the needs of 

remote rural patient populations pose 

unique challenges when attempts are 

made to provide ethical and adequate 

mental health care. 8 However, there 

has also been evidence to indicate 

that non-clinical, non-patient 

factors are even more likely to 

play significant role in involuntary 

treatment decisions. 9 Lorant’s Belgian 

study determined that lack of a less 

restrictive alternative was the most 

crucial factor driving the decision 

for involuntary treatment; more 

than patient refusal, dangerousness, 

diagnosis, housing status, or other 

factors. 10 His findings are consistent 

with studies done in the United 

States. 11,12 In Lorant’s study, more 

than half of those referred for 

evaluation were not committed. All 

of the evaluations were performed 

by psychiatrists at a teaching hospital 

psychiatric emergency room, a 

notable difference which may 

have impacted outcomes 13 ; in West 

Virginia, a mental health center nonphysician 

is usually the evaluator. 

Medical clearance, if it occurs, is done 

after the hearing. If the symptoms 

warranting commitment are found 

to be secondary to a medical etiology 

or intoxication, the patient may 

still be involuntarily psychiatrically 

hospitalized since probable cause has 

already been found, unless a medical 

condition, once discovered, justifies 

acute medical hospitalization. Our 

study was limited to patients who 



were involuntarily hospitalized; 

so the rate of patients evaluated 

and not committed in each county 

is unknown. We are currently 

collecting data for further study 

on patients admitted to Sharpe 

Hospital with medical conditions 

necessitating transfer to an 

acute care medical hospital. 

The level and type of outpatient 

services, which were not examined 

for this study, vary greatly between 

mental health centers and may 

contribute to the differences in 

involuntary admission rates. 

Local operational norms, level of 

professional accountability for 

assessment decisions, organizational 

culture and support in decisions to 

care for a patient in the community, 

perceptions of conditions at the 

state hospital, and whether or 

not involuntary hospitalization is 

considered a “last resort” option all 

have been shown to influence the 

compulsory admission threshold. 9,14 

Similarly, the impact of statefinanced 

diversion admissions on 

readiness to petition for involuntary 

treatment is unknown. In theory, it 

is beneficial to the patient and their 

family, the diversion hospital with 

open bed space, and the Sheriff’s 

Department transporting personnel 

to keep the treatment local. For 

a patient who wants and needs 

treatment but has limited resources 

for receiving inpatient or outpatient 

services, it may seem more justifiable 

to make the case for involuntary 

treatment even when a patient is 

actually willing to receive it and 

may have presented to the diverting 

hospital requesting it. As legislative 

decisions are made to address 

overcrowding at state psychiatric 

facilities, the following issues 

warrant consideration: data suggests 

a positive correlation between 

rates of compulsory admission 

and number of psychiatric beds 13 , 

transfers of patients to state funded 

treatment may be economicallymotivated, 

especially if there is no 

incentive to provide treatment in 

another setting 15 , and increasing 

inpatient beds without developing 

comprehensive outpatient treatment 

(which is also costly) to care for 

discharged patients 16,17 , may only 

serve to increase state hospital use by 

those who are already high users 18 

or the number of long stay patients 

awaiting an appropriate placement. 

Conclusion 

Rates of admission to Sharpe 

Hospital and overall involuntary 

admission rates vary by county in 

the Sharpe Hospital catchment area. 

Further study of local evaluation and 



treatment variables as well as patient 

specific factors such as diagnosis, 

co morbid substance dependence, 

and psychiatric hospitalization 

history and length of stay is 

warranted to guide mental health 

planning and funding allocation. 

References 

1. West Virginia Legislature West Virginia 

Code Chapter 27. Mentally ill persons. 

http://www.legis.state.wv.us/WVCODE/ 

Code.cfmchap=27&art=1. Accessed 

December 30, 2008. 

2. Almog M Curtis S, Copeland A, Congdon, P, 

Geographical variation in acute psychiatric 

admissions within New York City 1990– 

2000: growing inequalities in service use 

Soc Sci Med. 2004;59(2):361-376. 

3. Manderscheid RW, Atay JE, Crider RA, 

Changing trends in state psychiatric 

hospital use from 2002 to 2005. Psychiatr 

Serv. 2009; 60(1):29-34. 

4. Hugo M, Comparative efficiency ratings 

between public and private acute inpatient 

facilities. Aust N Z J Psychiatry. 

2000;34(4):651–657. 

5. Bindman J, Tighe J, Thornicroft G, Leese 

M, Poverty, poor services, and compulsory 

psychiatric admission in England, Soc 

Psychiatry Psychiatric Epidemiol, 

2002;37(7):341-345. 

6. County-level Population Data for West 

Virginia. http://ers.usda.gov/Data/ 

Population/PopList.aspTheState=WV%2 

CWest+Virginia. Accessed October 2, 

2008. 

7. U.S. Census Bureau, Small Area 

Estimates Branch. 2007 Poverty and 

Median Income Estimates-Counties. 

http://www.census.gov/did/www/saipe/ 

downloads/estmod07/est07ALL.xls. 

Accessed December 23, 2008. 

8. Weiss Roberts L, Battaglia J, Epstein R S, 

Frontier ethics: mental health care needs 

and ethical dilemmas in rural communities. 

Psychiatr Serv. 1999;50(4):97-503. 

9. Quirk A, Lelliott P, Audini B, Buston K, Nonclinical 

and extra-legal influences on 

decisions about compulsory admission to 

psychiatric hospital. J Ment Health. 

2003;12(2):119-130. 

10. Lorant V, Depuydt C, Gillain B, Guillet A, 

Dubois V, Involuntary commitment in 

psychiatric care: what drives the decision 

Soc Psychiatry Psychiatr Epidemiol. 

2007;42(5):360–365. 

11. Lincoln A, Psychiatric emergency room 

decision-making, social control and the 

‘undeserving sick’. Sociol Health Illn. 

2006;28:54–75. 

12. Segal S, Laurie T, Segal M, Factors in the 

use of coercive retention in civil 

commitment evaluations in psychiatric 

emergency services. Psychiatr Ser. 

2001;52(4):514–520. 

13. deStephano A, Ducci G, Involuntary 

admission and compulsory treatment in 

Europe. Int J Ment Health. 2008(1);37:10-21. 

14. Encandela JA, Korr W, Lidz CW, Mulvey 

EP, Slawinski T, Discretionary use of 

involuntary commitment by case managers 

of mental health clients: a case study of 

divergent views. Clin Soc Work J. 

1999;27(4):397-411. 

15. Schlesinger M, Dorwart R, Hoover C, 

Epstein S, The determinants of dumping: a 

national study of economically motivated 

transfers involving mental health care. 

Health Serv Res. 1997;32(5):561-590. 

16. Bond G, Drake R, Mueser K, Latimer E, 

Assertive community treatment for people 

with severe mental illness: critical 

ingredients and impact on patients. Dis 

Manag Health Outcomes. 2001;9(3):11-159. 

17. Joy CB, Adams CE, Rice K, Crisis 

intervention for people with severe mental 

illnesses. Cochrane Database Syst Rev. 

2006;4(3):CD001087. 

18. Semke J, Kamara S, Hendryx M, Stegner 

B, State mental hospitals in Washington 

state in an era of policy change. Adm 

Policy Ment Health. 2001;20(1):51-65. 

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General | NEWS 

Reprinted with Permission from The Dominion Post, Jan 20, 2010 

Doctors head to Haiti 

BY CASSIE SHANER 

Dr. Dave Fogarty had planned 

to go to Haiti in March. But 

after last week’s earthquake, he 

decided to leave a little sooner. 

“It’s a different type of trip now,” 

Fogarty said. “It’s totally changed.” 

Fogarty, a Morgantown plastic 

surgeon, has been to Haiti several 

times before for Interplast WV, the 

local chapter of a national organization 

that provides reconstructive surgery 

for children in developing countries. 

Fogarty and six other Morgantown 

health care providers are heading to Haiti 

this week to help treat earthquake victims 

at Hospital de Bienfaisance in Pignon. 

Fogarty is leaving at about 5 this 

evening. He be drive a UHaul truck 

loaded with about 2 tons of medical 

supplies to Miami, where he will meet up 

with the rest of the medical team Friday. 

A C-130 Coast Guard plane will 

then fly them to Port-au-Prince, 

and a helicopter will take them to 

Pignon, which is about 12 hours 

from Haiti’s capital — by ground. 

Trauma patients are being 

taken to the hospital by helicopter 

for treatment, Fogarty said. 

The team should arrive at the 

hospital Saturday, and they expect 

to be there for at least a month. 

“They need us,” Fogarty said, 

explaining why he wanted to go. 

“The need is overwhelming. It’s 

unbelievable. They say it’s worse than 

the tsunami, hundreds of thousands 

of bodies lying in the streets.” 

Many of the victims need urgent 

medical care, Fogarty said. Without 

it, their wounds could become 

infected, and in some cases, deadly. 

The supplies Fogarty is taking 

will help. Fogarty initially planned to 

haul about 2,000 pounds of supplies, 

but local hospitals, community 

groups and individuals provided 

additional items and donations. 

“They’ve really come out of the 

woodwork,” Fogarty said, who is 

still seeking donations. “There’s 

really been a community outpouring 

to help us. We’re going to be taking 

about 4,000 pounds of supplies.” 

The Cheat Lake Rotary Club 

collected money at its Tuesday 

meeting, raising about $1,040. 

Charter member Gary Cobun knew 

Fogarty and was familiar with his work in 

Haiti. He contacted Fogarty on Monday 

to see what Rotary could do to help. 

“He said they needed money for 

medical supplies,” Cobun said. “We just 

thought that would be the quickest way 

to make it happen. ... We wanted him to 

know that the community’s behind him.” 

Charlotte Stewart, of Care Partners 

Home Health, took up a collection for the 

team’s trip at work Tuesday. She’s raised 

$100 so far, and she hopes other home 

health care providers will follow her lead. 

“We’re challenging others to meet that 

or go beyond it,” Stewart said. “We’re just 

trying to get people to contribute to Dr. 

Fogarty and Interplast’s work in Haiti.” 

Fogarty got involved with 

Interplast while he was training at 

Stanford University, more than 30 

years ago. Since then, he’s taken 97 

trips to 25 different countries. 

He founded Interplast WV when 

he moved to Morgantown in 1980. 

Members of the local chapter have been 

to Ecuador, Peru and other countries to 

Dr. David Fogarty tapes a box of medical supplies to 

add to the growing shipment on his front porch he will 

take to aid earthquake victims in Haiti. 

treat burns, as well as cleft palates and 

other congenital deformities. They’ve 

been working in Haiti for about six years. 

Lucille Pierce, a WVU Hospitals 

operating room nurse, has worked with 

Dr. Fogarty and Interplast for 25 years. 

She’s been to Haiti four times before, 

and she’s going again this week. 

“You look at all the pictures 

of devastation, and it pulls at 

your heartstrings,” Pierce said. 

“You feel that you have gifts to 

give. ... I want to go do that.” 

Fogarty is already planning a 

follow-up trip to Haiti in April. He 

said the medical team he takes will 

likely include a mix of specialties, 

but it will depend on the needs 

identified during this week’s trip. 

TO CONTRIBUTE 

send donations to 

Interplast WV/Project 

Haiti, Dr. Dave Fogarty 

228 S. Walnut St., 

Morgantown, WV 26501. 

Bob Gay/The Dominion Post 


Member Physicians Answer the Call 

BY ANGIE LANHAM 

It was the last Saturday before 

their departure to Fort Liberté, Haiti. 

Volunteers were busy removing 

medications from their original 

boxed packages into small, zip 

lock bags, each requiring a label. 

Packed suitcases lined the walls 

of the fellowship hall at the First 

Presbyterian Church of South 

Charleston. More suitcases awaited 

the tireless efforts of volunteers 

taking inventory of medications and 

medical supply bags. A scale is used 

to weigh each suitcase. Volunteers 

must adhere to a 50 pound weight 

limit: 40 pounds for medical supplies 

and 10 pounds for personal items. 

Every suitcase contains a variety of 

medications in small quantities to 

insure ample supplies in the event of 

lost luggage or delays upon arrival. 

Dr. Richard Hayes and his 

wife Lora, RN, help coordinate 

groups of medical mission teams 

from this region for the Friends of 

Fort Liberté relief organization, a 

nonprofit group based in Elkins, WV. 

They have traveled with medical 

mission teams to Haiti since 2000. 

The Friends of Fort Liberté was 

formed in 1975 by Architect J.D. 

King and Pastor Andre Jean. Since 

Danis Pierre of Haiti poses with Lora Hayes, RN and 

her husband Dr. Richard Hayes. 

that time, a church, orphanage, 

school, and medical clinic have 

been built. Generators were 

purchased to provide electricity 

for lights, ceiling fans and pumps 

for a water system at the center. 

This time, nine physicians, eight 

nurses, one pharmacist and two 

medical technicians form this trip’s 

medical team. Several nonmedical 

support staff will undergird the 

group’s efforts to bring relief to the 

people of Haiti. Team members 

volunteer their time and expertise, 

obtain the necessary vaccinations and 

pay their own traveling expenses. 

The earthquake that struck Haiti 

on January 12, 2010, has left over one 

million people homeless. More than 

2,000 refugees from Port-au-Prince 

have traveled to Fort Liberté seeking 

medical care, food, water and shelter. 

The team will treat victims 

for medical conditions ranging 

from anemia, TB, malnutrition 

and parasites. Infections from 

injuries sustained as a result of the 

earthquake, as well as post-op care 

for those who have been treated 

for injuries is expected to be high. 

The West Virginia State Medical 

Association (WVSMA) is proud to 

have members of the Association 

give selflessly to those in need. The 

Fort Liberté team is one of many 

groups which include WVSMA 

member physicians including, 

Dr. Richard Hayes, Dr. Rafael 

Gomez, and Dr. Doug Carnutte. 

Others include orthopedic teams 

working in Milo, Haiti, through the 

CRUDEM Foundation, including 

Dr. William Sale, Dr. Ken Wright, 

and Dr. Richard Sibley. During 

Volunteers working together to package much needed 

medications for the trip to Haiti. 

the last CRUDEM team trip, 

approximately 400 patients were 

treated for various injuries requiring 

orthopedic specialists. Dr. David 

Fogarty led a group to Haiti in 

early February (see opposite page). 

Another group of orthopedists led 

by Dr. Peter Lukowski will leave for 

Haiti in late March. There are many 

physician groups that hale from West 

Virginia, who have given or will give 

of their time and talents. The timehonored 

tradition of service marks 

West Virginians and its physicians 

as leaders of compassionate care 

in our state and the world over. 

For more information about 

the Friends of Fort Liberté, 

contact Bonnie Woodrum 

at 304.636.3082 (home), 

304.614.0903 (cell), or email: 

bwoodrum@meert.net, or go to 

www.haitifriends.com 



A Case Study of a New Technique for the Primary Percutaneous 

Endoscopic Realignment of a Complete Urethral Injury 

Faith Payne, DO, PGY3 

Charleston Area Medical Center 

Julio Davalos, MD 

Urology Center of Charleston 

Abstract 

The male urethra is vulnerable to 

injury with multisystem trauma, especially 

those that include pelvic fractures. 

Controversy exists regarding the optimal 

time to repair urethral injuries and 

different modalities exist for their 

treatment. We report the first documented 

case of percutaneous endoscopic 

realignment of a urethra using a previous 

cystostomy site that has been dilated 

using a balloon dilator. 

Case Report 

A 40-year-old male presents as 

a priority two trauma to CAMC 

General Hospital via HealthNet 

Aeromedical. The patient was 

rescued from Nicholas County after 

he lost control of his vehicle on a 

patch of ice. He struck a tree and was 

found unconscious on the scene. The 

patient was hemodynamically stable 

during prehospital intervention. He 

was given IV fluids, placed in full 

cervical and spinal immobilization, 

and was transferred to the trauma 

bay in stable condition. Upon arrival 

he denied any recollection of the 

accident. The patient complained of 

a headache and pain in his left hip, 

left pelvis, left arm, and left chest. 

Vital signs were stable. Physical 

exam revealed an obvious left hip 

deformity. There was difficulty 

passing the foley catheter and at 

that time a retrograde urethrogram 

was done. This demonstrated 

complete transection of the urethra 

with extravasation of contrast both 

above and below the urogenital 

diaphragm. Trauma radiographic 

images were obtained and revealed 

other injuries including disruption 

of the diaphragm with abdominal 

contents displaced superiorly, left 

rib fractures with pneumothorax, 

pelvic fracture with hematoma, 

and a large hematoma anterior 

and superior to urinary bladder. 

Consultants were notified. The 

patient underwent exploratory 

laparotomy and a suprapubic 

catheter was placed at that time. 

After a few days the patient was then 

given treatment options of delayed 

repair and open urethroplasty 

or percutaneous endoscopic 

urethral realignment. He decided 

to undergo primary percutaneous 

endoscopic urethral realignment. 

Discussion 

Urethral disruption injuries 

typically occur in conjunction with 

multisystem trauma from vehicular 

accidents, falls, or industrial 

accidents. Pubic diastasis, localized 

pubic rami fractures, or more 

complex pelvic fractures may be 

associated with urethral disruption. 

“Straddle fractures” involving all 

four pubic rami, open fractures, and 

fractures resulting in both vertical 

and rotational pelvic instability are 

associated with the highest risk of 

urologic injury. There are three types 

of urethral disruptions; a type one 

injury occurs when the posterior 

urethra is stretched and elongated 

but intact. A type two injury is a 

disruption of the urethra above 

the urogenital diaphragm (UGD) 

in the prostatic urethra with the 

membranous urethra intact. Lastly, 

a type three injury is disruption 

of the membranous urethra with 

extension into the bulbous urethra 

and/or disruption of the UGD; i.e. 

complete tear. 1 Because the posterior 

urethra is fixed at both the urogenital 

diaphragm and the puboprostatic 

ligaments, the bulbomembranous 

junction is more vulnerable to 

injury during pelvic fracture. 2,3 

Immediate suprapubic tube 

placement remains the standard 

of care. 4 This is best accomplished 

through a small infraumbilical 

incision, which allows inspection 

and repair of the bladder and proper 

placement of a large-bore catheter 

at the bladder dome. An attempt 

at primary realignment of the 

distraction with a urethral catheter 

is reasonable in stable patients, 

either acutely or within several 

days of injury. 5 Often a simple 

technique consisting of passage of a 

coudé catheter antegrade through a 

cystotomy, then tying it to another 

that can then be drawn back into 

the bladder is effective. A variety 

of more elaborate approaches have 

been described. If primary urethral 

realignment is unsuccessful then the 

suprapubic catheter is placed and 

the patient will eventually undergo 

an open urethroplasty. The urethral 

catheter is then removed after 4 to 

6 weeks. Most patients will develop 

posterior urethral stenosis therefore 

the suprapubic catheter is kept in 

place. The suprapubic catheter is 

removed once the patient is voiding 

through the urethra with success. 2 

Realignment may not prevent 

symptomatic stenosis; however it 

may ease the difficulty of an open 

posterior urethroplasty by bringing 

the prostate and urethra closer. 

We prefer to do a primary 

realignment using a percutaneous 

endoscopic approach. It has been our 

experience that the comorbities of 

urethral stricture and incontinence is 

decreased with primary realignment. 

This is a case report of a complete 

urethral tear and the repair using 

a technique that has not been 

previously described. Percutaneous 

endoscopic access is achieved 

through the previous cystostomy 

site. This is dilated using a balloon 



Figure 1. 

Percutaneous access via a previous cystostomy site. 

than before. Percutaneous primary 

realignment using a balloon dilated 

cystostomy site has not been 

previously documented. It is our 

opinion than primary realignment 

decreases the comorbidities 

associated with this injury and this 

is the optimal technique for primary 

realignment. In our experience, 

this decreases comorbidities and 

the need for future operations. 

dilator. Flexible cystoscopy and 

flexible urethroscopy is performed 

and a guidewire is placed antegrade. 

Realignment is achieved proximally 

and distally, using guide wires. 

Once the guide wire is in place, the 

urethra is then re-approximated by 

sliding the foley catheter over the 

guide wires. The injured urethral 

segment will then heal over the 

foley. The realignment is confirmed 

with a cystogram (Figure 1). 

Conclusions 

Urethral injuries secondary to 

trauma are more common today 

Acknowledgements 

Special thanks to Holly 

Blackwood, RN from CAMC Health 

Education and Research Institute. 

References 

1. Rosenstein DI, Alsikafi NF. Diagnosis and 

Classification of Urethral Injuries. Urologic 

Clinics of North America. 2006. (33):73-85, 

vi-vii 

2. http://radiographics.rsnajnls.org/cgi/ 

reprint/23/4/951.pdf (referenced 7-9-08) 

3. Wein AJ, Kacoussi LR, Novick AC, Partin 

AW, and Peters CA. Campbell-Walsh 

Urology 9th Edition Saunders/Elsevier. 

Philadelphia, PA. 2007. 879-903 

4. Maull K, Sochatello CR, Ernst CB. The 

deep perineal laceration–an injury 

frequently associated with open pelvic 

fractures–a need for aggressive surgical 

management. J Trauma. 1977; 685-696. 

5. Sandler CM, Harris JH, Corriere JN, et al. 

Posterior urethral injuries after pelvic 

fractures. AJR 1981;137:1233. 

6. Kusminsky RE, Shbeek I, Makos G, 

Boland JP. Blunt pelvic-perineal injuries: an 

expanded role for the diverting colostomy. 

Dis Colon Rectum. 1982;25:787-790. 

OFFICE MANAGERS ASSOCIATION 

OF HEALTHCARE PROVIDERS, INC. 

www.officemanagersassociation.com 

OFFICE MANAGERS ASSOCIATION 

OF HEALTHCARE PROVIDERS, INC. 

www.officemanagersassociation.com 

We invite you to join our organization which consists of members 

We invite you to join our organization which consists who manage of the members daily business who of healthcare manage providers. the daily business of 

We invite you to join our organization which Our objectives consists of are members to promote educational opportunities, professional knowledge 

healthcare providers. who Our manage objectives the daily business are of to healthcare promote providers. and educational to provide channels opportunities, of communication to professional office knowledge 

managers in all areas of healthcare. We currently have 

and to Our provide objectives are channels to promote educational of communication opportunities, professional to office knowledge 

eleven managers chapters in West in Virginia. all areas of healthcare. 

and to provide channels of communication to office 

managers We in all currently areas of healthcare. have Weeleven currently Visit us have chapters in West Virginia. 

on our website for more information or contact 

eleven chapters in West Virginia. Donna Zahn (President) at 740-283-4770 ext. 105 or 

Visit us on our website for more information or contact: Toni Charlton Tammy Mitchell – President (Membership) at 304-670-7197 at 304-324-2703. or Donna Lee - State VP 

Visit us on our website for more information or contact 

Membership at 276-322-5732. 

Donna Zahn (President) at 740-283-4770 ext. 105 or 

Tammy Mitchell (Membership) at 304-324-2703. 


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10 

10. Give your fax machine a rest. 

Top 10 Reasons to Provide Your Email Address to the WVSMA 

9. Impress the kids with your use of e-mail. 

8. Save trees and “go green:’ 

7. Increase your personal comfort with technology. 

6. Get information in a quick-read, timesaving format. 

5. Share news with staff just by clicking Forward. 

4. Help the WVSMA maximize your dues dollars. 

3. Know what your colleagues know at the same time they know it. 

2. Protect your patients with access to immediate updates from the CDC and other healthcare bulletins. 

AND the TOP reason to ensure the WVSMA has your e-mail address: 

1. Learn news of importance to physicians as soon as it is available. 

To make sure you, like your colleagues, are getting e-mail news and bulletins of importance to West Virginia 

physicians, send an e-mail message to mona@wvsma.com. If your e-mail has changed, or whenever it changes, 

make sure you send your new address to the WVSMA.

You Asked and the WVSMA Delivered! 

In response to requests by physicians and office managers, the WVSMA is excited to 

announce that we will be offering a Certified Medical Office Manager course in April 2010! 

The WVSMA, in partnership with the Practice Management Institute, 

will offer the four-day Certified Medical Office Manager (CMOM) class, 

which will teach experienced staff proven strategies to lead the medical 

practice to increased productivity and efficiency. 

In today’s healthcare environment, more physicians are seeking certified 

professionals capable of understanding the newest business and 

regulatory issues. Becoming a Certified Medical Office Manager is 

more than just a title; it demonstrates that a manager has additional 

skills and knowledge to better guard the practice against risks, increase 

the practice’s revenue, and most importantly lead the practice to the 

ultimate goal—that of providing better healthcare for the patients. 

Angie Linville, Office Manager for a large West Virginia medical practice, 

traveled out of state several years ago to take the course and become 

a Certified Medical Office Manager. Her previous employer, Dr. Kiran 

Patel, recognizing the importance of obtaining and maintaining the certification, 

sent Angie to North Carolina for the classes. Angie has high 

praise for the CMOM course and the certification. 

The inaugural CMOM course will take place in Charleston for two days 

during two different weeks in order to minimize office downtime. Participants 

will be able to “try out” their newly learned skills during the week 

in between classes. The course is scheduled for Friday, April 16 and 

Saturday, April 17 from 9:00 AM – 4:00 PM, and then again on Friday, 

April 23 and Saturday, April 24. The certification exam will be given on 

April 24. Participants must attend all four sessions. 

1st class will be held on - 

these dates 

April 16 – April 17 

April 23 – April 24 

9am - 4pm 

Sign in 15 minutes prior to program 

The tuition for the class is $799.00, which includes program manuals, 

workbooks, and the exam. WVSMA physicians and staff may attend for 

$699.00. The clinical faculty for the first class will be Practice Management 

Specialist Rose Moore. 

The class size will be limited, so please contact Barbara Good 

(304-925-0342, ext. 11) or (Barbara@wvsma.com) as soon as 

possible to express your interest in the course. Additional details will 

be forthcoming. 

The WVSMA is proud to be the exclusive West Virginia partner for the 

CMOM certification. 


deliver exceptional patient service. 

Financial Management 

• Developing and maintaining 

a budget 

• Forecasting and revenue projecting 

• Revenue and cost accounting 

• Presented Financial control by: 

Managed Care and the Medical Practice 

• Types of managed care plans 

and how to select the right ones 

• Terminating the patient/physician 

relationship 

• Medical record keeping 

• Time management and delegation 

Upcoming Seminar for Medical Office Personnel 

Personnel Management 

• Job descriptions and training 

• Maintaining valued employees 

• Effective communication 

• Terminating $699 for employees WVSMA 

Physician Members 

• Dealing with 

and 

difficult 

Staff! 

employees 

• Unique employee relations issues 

Sign-in begins 15 minutes prior to program 

Certified Medical Office Manager (CMOM) 

Cancellation Policy: A full refund less $20.00 processing 

fee, if cancellation is received 7+ days prior 

Hosted to program by: start date. A 50% refund if cancellation 

is 6 days to 48 hours prior to start date. No refund if 

cancellation is less than 48 hours in advance. Upon 

registration, custom materials are printed, refreshments 

are ordered and seating is reserved. Due to 

this, PMI strictly adheres to this policy. 

Join NetworkPMI, an exciting, new community for medical office professionals. Details at network.pmiMD.com 

This program is recommended for experienced 

medical office managers 

• Evaluating contracts 

REGISTRATION FORM Upcoming 

who want to • 

Seminar 

Organizing the Fee 

for PARTICIPANT Medical 

Service 

INFORMATION Office Personnel 

take Please their keep skills a copy to the for next your records. level. Learn to initiate 

policies and protocols that will • MCO coordinator Registrant 1________________________________________________ 

practice 

improve, 

PROGRAM 

protect 

INFORMATION 

and stabilize the financial • Physician utilization Registrant committee 2*_______________________________________________ 

April 16, 17, 23 

security April 16, 17, 23 & 24, 2010 (Prgm # 15422-0516) 

Certified of the practice. More physicians Medical Office Registrant 3* Manager _______________________________________________ 

West Virginia State Medical Association 

& 24, 

(CMOM) 

• Utilization control techniques 

need Certified Office Managers who understand 

4307 the Presented MacCorkle newest by: business Avenue, and SE regulatory • HIPAA compliance issues 

Hosted by: 

• OIG compliance program guidance 

2010 

Additional registrants may be listed on a separate sheet 

issues. *If you are registering two or more participants, or if you are PMI-Certified, 

Charleston, Certified WV Medical 25364 Office Managers 


help guard the practice against risks, and Practice Administration please call for discount information. 

$699 for WVSMA 

4307 MacCorkle Avenue, SE 

motivate employees to improve productivity • Improving employee Practice relations Name ____________________________________________ 

9:00 a.m. to 4:00 p.m. each day 

Physician Members 


and increase revenue. Find out how to analyze 

• Operations management Address __________________________________________________ 

(Sign-in 

managed 

begins 

care 

15 

contracts, 

minutes prior 

stay 

to 

in 

program) 

compliance 

with OSHA, OIG, and HIPAA, and 

and Staff! 

• Facility management 

City/State/Zip _____________________________________________ 

9:00 a.m. to 4:00 p.m. 

REGISTRATION METHOD 

• Risk management 

deliver exceptional patient service. 

Phone (____)________________ Sign-in Fax begins (____)____________________ 

15 minutes prior to program 


Mail with payment to: 

This program is recommended for experienced 

4307 medical Management MacCorkle office managers Avenue, Charleston, who want to WV 25364 •• Medical Organizing record the keeping Fee PAYMENT for Service INFORMATION 

• relationship Evaluating contracts E-mail: __________________________________________________ 

Karie Sharpe, West Virginia State Medical Association, 

Financial 

• Developing Fax or Call and with maintaining 

take their skills to the next 

Credit 

level. 

Card: 

Learn 

(304) 

to 

925-0345 

initiate 

• Forecasting Phone: 

• Time 

practice 

management and delegation 

a budget 

Select form of Payment: q VISA q MasterCard q AmEx 

policies 

(800) and and 

257-4747 revenue protocols projecting that will Personnel • MCO Management 

coordinator 



q Check (Payable to West Virginia State Medical Association) 

improve, • Revenue protect and cost and accounting stabilize the financial • • Job Physician descriptions utilization and training committee 

Email: karie@wvsma.com 

Card No.: ______________________________________________ 

to program April start date. 16, A 50% 17, refund 23 if cancellation 

security • Financial of control the practice. More physicians • Maintaining valued employees 

• Utilization control techniques 

is 6 days to 48 hours prior to start date. No refund if 

• Effective communication 

need Certified Office Managers who understand 

the newest business and regulatory 

Cardholder Name: ______________________________________ 

Total Amount: ___________________ cancellation is less & Exp. than 24, 48 Date:_____________ 

2010 hours in advance. Upon 

Managed PROGRAM Care FEE/DISCOUNT and the Medical POLICIES Practice •• Terminating 

OIG compliance 

employees 

program guidance 



Registration • Types of Fee: managed Fee: $799. $799. WVSMA care $699 plans Members for WVSMA and Staff Members $699. •• Dealing HIPAA Includes and with compliance Staff. difficult issues employees 

instructional Includes issues. and how Certified instructional materials. to select Medical the materials. right Office ones Managers • Unique employee relations Cardholder issues Signature:____________________________________ 

this, West PMI Virginia strictly adheres State to Medical this policy. Association 


REGISTRATION FORM 

4307 MacCorkle Avenue, SE 


help guard the practice against risks, and 

motivate employees to improve productivity 

and increase revenue. Find out how to ana- 

PARTICIPANT INFORMATION 

Please Financial lyze keep managed a Management 

copy care for your contracts, records. stay in compliance 

Developing with INFORMATION 

OSHA, and maintaining OIG, and a budget HIPAA, and • Risk management • Improving employee relations 

• Facility management 

Registrant Practice Administration 

1________________________________________________ 

9:00 a.m. to 4:00 p.m. 

PROGRAM • 

Registrant 2*_______________________________________________ 

April • deliver Forecasting 16, exceptional 17, 23 and & revenue 24, patient 2010 projecting service. (Prgm # 15422-0516) 

Sign-in begins 15 minutes prior to program 


• Operations management 

• Revenue and cost accounting 

Registrant • Facility management 

3* _______________________________________________ 


relationship 

• Financial control 

• Risk management Additional registrants may be listed on a separate sheet 

4307 Financial MacCorkle Management Avenue, SE 

• Medical record keeping 

*If • Terminating you are registering the patient/physician two or more participants, relationship or if you are PMI-Certified, 

Charleston, Managed • Developing Care WV and 25364 

the maintaining Medical Practice 

• Time management please • and Medical delegation call for record discount keeping information. 

• Types 

a budget 

of managed care plans and how to select the right ones 

Practice • Time management Name ____________________________________________ 

and delegation 

• Evaluating contracts 

9:00 • a.m. Forecasting to 4:00 and p.m. revenue each day projecting Personnel Management 



• Organizing the Fee for Service practice 

Address Personnel __________________________________________________ 

Management 

(Sign-in begins 15 minutes prior to program) 

• MCO • Revenue coordinator and cost accounting 

• Job descriptions and 

City/State/Zip • Job training descriptions _____________________________________________ 

and training 

to program start date. A 50% refund if cancellation 

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March/April 2010 | Vol. 106 37 

April 16, 17, 23 & 24, 2010 (Prgm # 15422-0516) 

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Marshall University Joan C. Edwards School of Medicine | NEWS 

Marshall Providers Tackle Haiti Devastation 

Young Malechi 

made his own 

tide-turning 

contribution. 

STAT blood 

transfusions took 48 

hours … a bicycle 

pump became surgical 

equipment… eyes 

and hands replaced 

nonexistent x‐rays 

… and pro baseball 

players pinch-hit as 

transport orderlies. 

Marshall’s 

faculty, staff and 

medical student who 

traveled to earthquake-devastated 

Haiti in January in connection 

with church aid groups found the 

resilient people inspiring, their 

needs beyond imagination, and 

improvisation and teamwork core 

components of delivering care. 

Chairs of family medicine, internal 

medicine and orthopedic surgery 

were among several Marshall 

faculty members providing aid. 

“We all had a personal moral 

feeling that we needed to step 

up,” Dr. Kevin Yingling told 

the Charleston Daily Mail. 

He and several others already 

are planning return trips. 

Five days after the Jan. 12 

earthquake, fourth-year medical 

student Stephen Shaffer had 

rearranged his schedule to add a fourweek 

international health elective 

there, and he and Dr. John Walden 

were on their way to Good Samaritan 

Hospital on the border of Haiti and 

the Dominican Republic. Walden 

primarily performed triage, while 

Shaffer teamed up with a generalist 

physician to change dressings, 

set bones and cast fractures. 

“All of us have something to learn 

about responding to a disaster with 

total devastation and the ensuing 

chaos,” Walden said, adding that 

the military comes the closest 

to providing the structure and 

services needed in that situation. 

He was impressed during his 

week there by the ability of people 

from all over the world and from 

all walks of life – from military 

personnel to physicians and even 

professional baseball players—to 

coalesce into teams and deliver 

services under adverse conditions. 

“Everyone pretty darn quickly 

adapted to the fact that there 

was little to do with, but they 

managed to do it,” he said. 

Back in Huntington, Dr. Ali 

Oliashirazi was working with Gov. 

Joe Manchin to get a team of 22 

Huntington physicians and other 

providers, together with some 

3,000 pounds of equipment and 

supplies, to a hospital near Portau-Prince 

that needed a medical 

team the last week of January. The 

team had four surgeons available to 

keep the hospital’s two operating 

rooms open around the clock 

for the week they were there. 

“You would think they planned 

it for a month, but it came together 

in about 24 hours,” Gov. Manchin 

said. He arranged for them to travel 

to Port-au-Prince on a jet funded 

by Pittsburgh philanthropist Jim 

Bouchard, Esmark and Highmark 

Blue Cross Blue Shield. Despite 

the needed U.S. government 

approvals—complicated by the fact 

the group was taking the largest 

legal narcotic shipment ever made 

to Haiti – the team of physicians and 

Days after the quake, triage chipped away at the chaos. 

A bicycle pump became an essential piece of surgical 

equipment. 

support staff was airborne Jan. 24. 

Although the team had 

an important edge because it 

included both equipment and the 

support staff necessary back up 

the physicians, Dr. Oliashirazi 

said some barriers were great. 

“From a medical standpoint, our 

biggest challenges included lack of 

basic equipment, including crutches, 

lack of a full spectrum of antibiotics, 

lack of adequate laboratory support 

(we could ONLY obtain a CBC), 

inability to obtain any microbiology 

or cultures, and unavailability of x- 

ray in any form,” he said. “We were 

diagnosing fractures by palpating 

the limbs and reducing fractures 

based on whether the limb looked 

A team from Marshall, Cabell Huntington Hospital and 

elsewhere treated hundreds of people and created a 

system to assist providers who would follow. 


Marshall University Joan C. Edwards School of Medicine | NEWS (continued) 

‘right’ or not. We had two patients 

with a hemoglobin of 4 and 6; our 

STAT blood transfusion order took 

48 hours to get to our hospital.” 

With hundreds of Haitians 

seeking care the first day, a 

critical need was to create a basic 

structure and patient charts. 

Seeing patients who had been 

treated elsewhere and had no medical 

records was particularly difficult, 

Dr. Oliashirazi said. Patients with 

long arm casts, for example, often 

had no idea where the fractures 

were, whether there were wounds 

that needed to be evaluated, or 

how long the cast was to remain. 

“The dilemma was, do we take 

the entire cast off and re-evaluate 

for fracture and wounds in a setting 

where we did not have adequate cast 

material, or leave things be,” he said. 

“Probably half the time, we did take 

everything off to reevaluate. To help 

with these issues, we wrote the date 

of injury, type of fracture, any wound 

issues, tentative treatment plan both 

ON THE CAST and on a prescription 

given to the patient, in case they 

did not return back to our facility. 

We, of course, also made charts 

for the patients at our hospital.” 

In retrospect, Dr. Walden 

remembers from the earliest days 

the toughness of patients who out of 

necessity underwent major surgical 

procedures without the “luxury” of 

general anesthesia and painkillers, 

which simply weren’t available; he 

sees overwhelming future needs 

for rehabilitation, for meeting the 

needs of amputees, and for restoring 

infrastructure as basic as safe water. 

Dr. Oliashirazi recalls the myriad 

infections from wounds washed with 

well water, and Haitians who insisted 

on sharing with others despite their 

own privations. Stephen Shaffer 

remembers panic-stricken patients 

jumping out of second-floor hospital 

windows during an aftershock, and 

the difference made by the spirit and 

courage of one young boy whose 

broken femur was being treated 

using an external fixator (x-fix). 

“Many of the patients we have left 

have x-fixes,” the medical student 

wrote that night. “One important 

part of their recovery (and avoiding 

other complications) is physical 

therapy and basically getting them to 

walk. It is painful. It is scary. No one 

would do it. That is, until Malechi 

decided he was going to walk. He 

opened his own walker, staggered 

to his feet, and began walking up 

and down the front of the orphanage 

showing people they didn’t have 

to be afraid. Most of us cried. 

“Most of our patients are 

walking now. One brave little boy 

made an incredible difference.” 

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Report of the Resolutions Committee— 

January 30, 2010 

Your Committee on Resolutions has carefully considered 

the Resolutions offered in the First Session of the 

House of Delegates on Saturday, January 30, 2010. 

We are happy to report that a number of interested physicians 

appeared at the meeting of the Committee on Saturday 

and discussed in detail the Resolutions pending before 

the Committee. 

The cooperation of those physicians present was most 

helpful to the Committee in reaching decisions and we express 

appreciation to those who took the time to attend the 

opening hearing. 

Mr. Speaker, your Committee assures the members of 

the Association that the one and only consideration that 

has guided the Committee in its deliberations has been the 

criteria as to whether each of the resolutions was or would 

be in the best interest of the entire medical profession in 

West Virginia in giving its patients the best of care. 

Mr. Speaker, your Committee considered Resolution 1, 

pertaining to Variation in Community Cost and Quality of 

Medical Care. 

Mr. Speaker, your Committee recommends that Resolution 

1 not be adopted and that the following substitute 

Resolution 1 be adopted: 

RESOLVED, that the West Virginia State Medical Association 

call upon the American Medical Association in their 

studies (and related actions) regarding the variation in the 

cost and quality of medical care within different communities 

include consideration of the unique organizational and 

community cultural, economic, geographical, legal, social, 

resource, and related factors that significantly contribute 

to the variation and the cost of medical care within such 

communicates; 


call upon the American Medical Association when 

considering enhanced centralized reimbursement incentives 

and performance improvement techniques directed 

at physicians designed to improve the quality and cost effectiveness 

of care delivery within an individual community, 

to also weigh the potential that such measures may 

significantly disrupt, increase the cost of, and/or compromise 

care; 


call upon the American Medical Association in 

such studies and actions consider activities that may be 

required by the public within each individual community 

in order to improve significantly the quality and cost-effectiveness 

of medical care and avoid undesirable unintended 

consequences, as well as the incentives and activities that 

would motivate the public within each community to work 

with their physicians and others to promote such positive 

improvements. 

Mr. Speaker, your Committee moves the adoption of 

substitute Resolution 1. 


pertaining to Coordinated Communications. 

Mr. Speaker, your Committee recommends that the following 



continue efforts to coordinate the sharing of information 

and fostering communications between all physicians 

and Medical Specialty Societies. 


Resolution 2. 


pertaining to Communication of Resolutions. 





implement an effective and efficient method of 

distributing Resolutions to all Delegates and Alternate 

Delegates prior to the Annual Business Meeting. 




pertaining to Commercial Support. 


4 be referred to the Executive Committee for review 

and consideration with instructions that the Executive 


Committee report its findings to the next meeting of the 

House of Delegates. 

Mr. Speaker, your Committee moves the referral of Resolution 

4. 


pertaining to Medical Record Confidentiality. 


5 be referred to the Executive Committee for review 

and consideration with instructions that the Executive 

Committee report its findings to the next meeting of the 

House of Delegates. 

Mr. Speaker, your Committee moves the referral of Resolution 

5. 


pertaining to Federal Health System Reform. 





continue to advocate support for legislation that 

protects the sacred relationship between patients and their 

physicians in making healthcare decisions without interference; 

promote affordable health insurance coverage for 

all through a choice of plans that guarantees portability 

and eliminates denials for pre-existing conditions; and 

encourages greater personal responsibility for prevention 

and wellness on the part of all citizens; 


express its belief and serious concern that the 

health system reform bills approved by the US House or 

US Senate awaiting final reconciliation before Congress in 

January, 2010, as designed are financially unsustainable 

because they expand Medicaid eligibility and “back-load” 

new spending with government levied new user fees and 

new taxes to cover expanded coverage and benefits; 


oppose legislation that impose punitive provisions 

that target government calculated resource use outliers; 


oppose legislation that grants authority to governmental 

bureaucracies to make significant future Medicare 

payment cuts through the new CMS Innovation Center 

and the new Independent Medicare Commission; 

RESOLVED, that the WVSMA opposes restrictions that 

curtail physician-owned hospitals; 

RESOLVED, that any health care reform legislation is 

incomplete without substantive medical liability reform; 

and, 

RESOLVED, that the House of Delegates supports the 

efforts and authority of the West Virginia State Medical 

Association’s Executive Committee and Council in expressing 

the position of the West Virginia State Medical 

Association, based upon our principles of reform on the 

health system reform actions being taken by Congress and 

the President. 




pertaining to West Virginias’ Access to All Effective Tobacco 

Cessation Treatments. 

Mr. Speaker, your Committee recommends that the following 



support the efforts to have all tobacco cessation 

pharmaceutical products be a covered benefit by all state 

payors. 


Resolution 7. 

Mr. Speaker, we wish to thank the members of the 

WVSMA who appeared before the Committee for their 

participation, patience, enthusiasm, wisdom, endurance, 

and time devoted to the study of the resolutions. 

In addition to me, as Chairman, the appointed members 

of the Committee who participated in these deliberations 

were: 

John Schmidt III, MD, Chair 

Charles Whitaker, MD 

John Holloway, MD 

R. Austin Wallace, MD 

MaryAnn Cater, DO 

Stephen Sebert, MD 

Joseph Reed, MD 

James Felsen, MD 

David Avery, MD 

Joseph Selby, MD 

Michael Stitely, MD 

Elizabeth Spangler, MD 

WVSMA Staff 

Evan Jenkins, Executive Director 

Karie Sharp 

Respectfully submitted, 

John H. Schmidt III, MD, Council Chair 

March/April 2010 | Vol. 106 

1

Robert C. Byrd Health Sciences Center of West Virginia University | NEWS 

WVU Heart Institute Opens in New Location 

The West Virginia University 

Heart Institute has expanded 

and consolidated its outpatient 

services at new space off campus 

to meet the growing demand 

for heart care. Patients can now 

receive care at the Heart Institute’s 

new location at Morgantown’s 

Suncrest Towne Center. 

The new location, less than a mile 

from the Robert C. Byrd Health 

Sciences Center, opened Monday, 

Feb. 1. WVU cardiologists, cardiac 

surgeons, physician assistants, 

nurses, technologists and others 

are seeing patients in a state-of-theart, 

outpatient diagnostic center. 

These specialists address a 

multitude of cardiac concerns for 

their patients through diagnostic 

procedures such as vascular imaging, 

EKG, chest X-rays and more. 

“Instead of having to go to 

many different areas – the lab 

in one building, the doctor’s 

office in another – our one-stop 

shop makes outpatient cardiac 

care more convenient for the 

patient,” WVU Heart Institute 

Administrator Wayne Cochran said. 

Located in the red brick building 

near Damon’s Grill, the WVU Heart 

Institute occupies the second floor 

and some of the first floor – a total 

of approximately 16,000 square 

feet. It includes a new larger area 

for cardiac rehabilitation, with 

showers and locker rooms. 

Cochran said planning for the 

new $3-million facility – a joint effort 

between West Virginia University 

Hospitals and University Health 

Associates – began about two 

years ago with patient needs at the 

forefront of their concept and design. 

For more than 30 years, the 

WVU heart team has performed 

open-heart surgery and has 

provided intervention, management 

and rehabilitation for cardiac 

patients with a full range of 

heart problems – from congenital 

heart issues to heart attacks. 

With the new facility and its 

additional space and manpower, 

even more people can be served, 

according to WVU Heart Institute 

Director Robert Beto, M.D. 

Beto said there’s a need for 

expanding outpatient services, 

because the success of new 

technology that fixes cardiac 

problems more rapidly creates 

shortened hospital stays. 

“We see larger volumes of 

outpatients and have more noninvasive 

testing,” he said. 

Heart surgery and catheterization 

procedures will still be performed 

at Ruby Memorial Hospital, 

but all pre-testing will be done 

at the new location first. 

The Institute has a 24-hour cardiac 

call center, with only one number for 

patients and referring physicians. 

The Institute has satellite 

and outreach locations in 

Elkins and Fairmont. 

Cochran said they will add an 

additional 25 employees (nurses, 

medical assistants, technologists 

and financial counselors) to the 

current 12 to staff the new facility 

WVUH Sleep Evaluation Center Receives Accreditation 

WVU Hospitals’ Sleep Evaluation 

Center has been fully accredited 

by the American Academy of 

Sleep Medicine (AASM). 

AASM accreditation is the gold 

standard by which the medical 

community and the public can 

evaluate the services provided by 

a sleep center or laboratory. The 

accreditation is valid for five years. 

To be accredited by the AASM, 

a sleep center or lab must display 

and maintain proficiency in 

testing procedures and policies, 

patient safety and follow-up, and 

physician and staff training. 

The Sleep Evaluation Center, 

the largest in the area, is among 

14 accredited centers in the 

state, providing services that 

identify and treat sleep-related 

disorders. The state-of-the-art 

facility is located at Ridgeview 

Business Park in Morgantown. 

It opened in August 2008. 

“We offer testing and treatment 

for all types of sleep disorders,” John 

Young, M.D., WVU neuropsychiatrist 

and medical director of the center. 

said. “Some common disorders 

include snoring, sleep apnea, 

restless legs syndrome and 

excessive daytime sleepiness.” 

The six-bed center treats 

about 1,200 adult and 

pediatric patients a year. 

Individuals experiencing 

sleep disorders need a referral 

from their physician to be seen 

at the Sleep Evaluation Center. 

For more information, see www. 

health.wvu.edu/services/sleepevaluation-center/index.aspx. 


West Virginia School of Osteopathic Medicine | NEWS 

Dr. John Manchin Appointed to WVSOM Board of Governors 

Farmington, WV 

physician Dr. John 

Manchin II, D.O., has 

been appointed to the 

Board of Governors 

of the West Virginia 

School of Osteopathic 

Manchin 

Medicine (WVSOM). 

Dr. Manchin, a graduate in WVSOM’s 

first class in 1978, is an active 

member of the WVSOM Alumni 

Association. His appointment was 

made by Governor Joe Manchin III. 

“We are thrilled to learn of the 

Governor’s appointment of Dr. 

Manchin to our Board of Governors,” 

WVSOM president Richard Rafes, 

J.D., Ph.D. said. “He has been 

supportive of our institution’s 

mission. He is knowledgeable 

about our institution and is an 

active alumnus. We look forward to 

working with him as he assumes this 

important position as a member of 

our Board of Governors,” Rafes said. 

Each public university and 

college in West Virginia is supervised 

by a Board of Governors (BOG). 

Each BOG consists of three elected 

representatives – one each from the 

faculty, classified employees and 

student body – along with nine lay 

members who are appointed by 

the Governor. BOGs are charged 

with determining, controlling, 

supervising and managing the 

financial, business and education 

policies and affairs of the state 

institution of higher education under 

its jurisdiction, as well as developing 

a master plan for the institution. 

“I am delighted to welcome 

John Manchin, D.O., a member of 

WVSOM’s first graduating class, to 

the Board of Governors,” WVSOM 

BOG chairman Rodney Fink, D.O., 

said. “There is no one better qualified 

or more dedicated to the School than 

Dr. Manchin, of Farmington, W.Va. 

He has dedicated his life to service 

for West Virginia and he will be an 

extraordinary leader on the Board of 

Governors. Welcome home, John.” 

The keynote speaker at the 

School’s annual White Coat 

Ceremony and Convocation in 

September, Dr. Manchin has 

been in family practice in rural 

West Virginia for over 30 years. 

He opened the Manchin Clinic in 

Farmington in 1979. In the summer 

of 2008, he extended his medical 

services to Fairmont at the Manchin 

Clinic South. Manchin and his 

son, John Manchin III, are partners 

in the clinic, and his daughters 

– Angela and Christina – also work 

there as physician assistants. 

Dr. Manchin received a Bachelor of 

Science degree in Biology from West 

Virginia University in Morgantown. 

He is Board Certified in Family 

Medicine and is past president of 

the Board of Trustees of the West 

Virginia Society of Osteopathic 

Medicine and remains a current 

board member. He enjoys traveling, 

golfing, reading and spending time 

with family and friends. He also 

has his private pilot’s license. 

WVSOM Faculty Member Nominated for State Teaching Award 

A WVSOM 

faculty member has 

been nominated for 

the West Virginia 

2009 Professor of 

the Year award. 

Judith Maloney, 

Maloney 

Ph.D., associate 

professor of Biomedical Science, 

is among five finalists for the 

Professor of the Year awarded by the 

Faculty Merit Foundation of West 

Virginia. The Foundation selects 

a Professor of the Year annually 

from nominees submitted by West 

Virginia colleges and universities. 

On March 3, the finalists will be 

honored at a Governor’s Mansion 

reception followed by dinner at the 

Culture Center in Charleston. The 

2009 Professor of the Year will be 

announced during the dinner. 

The Faculty Merit Foundation was 

created in 1984 to provide a means 

to recognize and reward innovation 

and creativity among the faculties of 

West Virginia’s public and private 

colleges and universities. Through 

the Professor of the Year program, 

the outstanding achievements of 

those individuals are brought to 

the attention of the general public. 

A $10,000 cash award and 

trophy is given to the candidate 

selected as Professor of the Year, 

with smaller awards to the other 

finalists. The four other finalists 

are: Carolyn Peludo Atkins, Ph.D., 

speech pathology and audiology 

professor, West Virginia University; 

Robert Scott Beard, Ph.D., music 

professor, Shepherd University; 

Bonita Lawrence, Ph.D., mathematics 

professor, Marshall University; and 

Brian W. Moudry, Ph.D., math, 

physics and computer science 

professor, Davis & Elkins College. 

March/April, 2010, Vol. 106 43

Bureau for Public Health | NEWS 

Healthcare Associated Infection (HAI) Prevention— 

Join the Campaign! 

In February 2009, an outbreak 

of pneumonia and invasive 

Streptococcus pneumoniae was 

reported in a West Virginia nursing 

home resulting in as many as 11 

deaths. In May 2009, an outbreak 

of invasive Staphylococcus aureus 

was identified in association with 

an outpatient clinical practice. An 

outbreak of hepatitis B was identified 

in November 2009 in association 

with a large dental clinic. Like all 

healthcare associated outbreaks, 

these outbreaks were costly in lost 

revenue, patient health and provider 

peace of mind. We invite you to 

join the campaign against these 

devastating preventable infections. 

Fortunately, 2009 also brought 

much-needed attention to prevention. 

The United States Congress 

mandated that all states develop a 

healthcare associated infections (HAI) 

plan. The Centers for Disease Control 

and Prevention allocated stimulus 

funding to the West Virginia Bureau 

for Public Health to support plan 

development and implementation. 

The West Virginia plan was 

developed with the assistance of a 

multidisciplinary advisory group. 

Membership included infectious 

disease physicians, hospital 

infection preventionists, the West 

Virginia Hospital Association, 

third party payors, West Virginia 

Medical Institute, the West 

Virginia Health Care Association, 

the West Virginia Health Care 

Authority, and other stakeholders. 

In deliberations throughout the fall 

of 2009, this group put together a 

plan of action for West Virginia. 

Key objectives in the plan include: 

1. Maintain the statewide HAI 

multidisciplinary advisory group to 

advise the Bureau for Public Health 

on prevention goals and objectives. 

2. Choose two HAI prevention 

targets for the state, among: central 

line-associated bloodstream 

infections; Clostridium difficile 

infections; catheter-associated 

urinary tract infections; methicillin 

resistant Staphylococcus aureus; 

surgical site infections; and 

ventilator-associated pneumonias. 

Evidence-based guidelines for 

preventing these infections were 

recently published by the Society 

for Hospital Epidemiology of 

America (SHEA) and Infectious 

Disease Society of America (IDSA). 

See: http://www.shea-online. 

org/about/compendium.cfm. 

3. Improve coordination among 

state agencies such as the Office 

of Health Facility Licensure 

and Certification; the medical, 

osteopathic, dental, pharmacy 

and nursing licensing boards; and 

the Office of Epidemiology and 

Prevention Services for management 

of healthcare associated outbreaks 

and infection control breaches. 

4. Improve healthcare associated 

outbreak reporting and investigation. 

Epidemiologists with the Bureau 

for Public Health will receive 

additional training in healthcare 

epidemiology during 2010. A rule 

change mandating healthcare 

associated outbreak reporting will 

likely be introduced in 2012. 

5. Enhance investigation 

protocols for hepatitis B and C to 

improve detection of healthcare 

associated infections. 

6. Support and expand 

reporting of healthcare associated 

infections to the West Virginia 

Health Care Authority. 

7. Encourage statewide 

implementation of SHEA and IDSA 

guidelines for preventing HAIs. 

8. Establish a plan to offer training 

in HAI surveillance, prevention 

and control. Training is needed for 

hospital infection preventionists, 

physicians, office staff and others. 

9. Perform a needs assessment 

during 2010. An annual needs 

assessment is envisioned to 

assure that nascent efforts to 

improve infection prevention are 

appropriately targeted to the needs of 

West Virginia hospitals and clinics. 

10. Develop and implement 

a communications plan. West 

Virginia’s HAI plan will be posted 

to the Division of Infectious Disease 

Epidemiology website. The medical, 

osteopathic, nursing, dental and 

pharmacy boards will be notified to 

alert licensed professionals about the 

plan. The Bureau for Public Health 

will be discussing the plan directly 

with the West Virginia Association 

of Professionals in Infection Control 

(APICWV), and other stakeholders. 

If all goes well, you should be 

hearing about prevention of 

healthcare associated infections from 

your licensing board and your local 

hospital. Please join the campaign 

against healthcare associated 

infections. Educate yourself about 

SHEA/IDSA evidence-based 

recommendations. Talk to the 

infection preventionist at your local 

hospital and ask how you can help. 

Educate your office staff. Infection 

prevention is a team sport with 

benefits for your patients, your staff 

and you. 

Danae Bixler, MD, MPH 

Director, Division of Infectious 

Disease Epidemiology 

Jim Kaplan, MD 

Chief Medical Examiner 


A Decade 

of Health Promotion

A D E C A D E o f H E A 

 

 

 

 

 

 

 

Partnering with the West 

Virginia Chapter of the American 

Academy of Family Physicians, 

the Foundation helped to train 

more than 750 physicians, nurses 

and other health care providers in 

the Clinical Practice Guidelines 

“Treating Tobacco Use and 

Dependence.” 

The Foundation led the effort to produce the first single topic 

issue of the West Virginia Medical Journal. The entire edition of 

the Jan/Feb 2001 West Virginia Medical Journal was devoted to 

the disease, devastation and death caused by tobacco. 

 

Through a contract with the West Virginia Bureau for 

Public Health’s Division of Tobacco Prevention, the 

Foundation’s staff facilitated the 

planning and implementation of 

a two-day statewide conference 

related to tobacco prevention and 

cessation initiatives. 

The Foundation hosted its first 

preventive medicine conference 

“Healthy West Virginia Summit 

2003: Preventing Chronic Illness” 

May 2-4 at Stonewall Resort. The 

conference participants enhanced 

their skills in: 

assessing the need for counseling and behavior 

change among borderline, overweight and obese 

patients, 

discussing weight issues with patients, 

creating a behavior change plan with their 

patients or accessing available resources, 

establishing a systematic approach to encourage 

and support the consistent and effective 

identif ication and treatment of tobacco users, and 

understanding behavioral interventions and 

environmental and policy interventions to increase 

physical activity. 

Another single topic issue of the West Virginia Medical 

Journal was produced focusing on preventing obesity through 

increased physical activity and good nutrition. The issue 

included a message to West Virginia physicians from former 

U.S. Surgeon General David Satcher, MD, PhD. 

 

Under the Leadership of Foundation Board Member Wayne 

Spiggle, MD, the Foundation convened a group of more than 

20 stakeholders to discuss ways to streamline the process and 

improve patients’ ability to receive prescriptions through various 

prescription assistance programs. The group explored the feasibility 

of establishing a statewide central fill pharmacy. This group’s 

efforts lead the way for West Virginia Rx, a program that provides 

prescription drugs at no cost to patients who are uninsured, 

between the ages of 18 and 65. 

 

 

The Foundation spearheaded the establishment of the Partnership 

for a Healthy West Virginia (Healthywv.com) that includes 

representatives from education, health care, business, government 

and non-profit organizations to develop a bold three-year plan to 

address obesity in the state. The group’s policy recommendations 

were included in the Healthy West 

Virginia Act of 2005. With the 

Partnership, the Foundation hosted 

the 2006 Healthy West Virginia 

Summit that brought together more 

than 250 individuals to develop 

strategies to address obesity in the 

state. Facilitated by West Virginia 

Medical Foundation, the Partnership 

receives support from the Claude W. 

Benedum Foundation. 

Members of the Partnership include 

the Claude W. Benedum Foundation, 

MAMSI, Mountain State Blue Cross/Blue Shield, Partnership 

of African American Churches, Wellness Councils of America, 

West Virginia Chamber of Commerce, West Virginia Department 

of Education, West Virginia Department of Health and Human 

Resources, West Virginia Hospital Association, West Virginia 

Legislature, West Virginia Primary Care Network, West Virginia 

State Medical Association, Wheeling Health Right and the 

Wellness Council of West Virginia.

L T H P R O M O T I O N 

 

 

As part of the Partnership for a Healthy 

West Virginia and the West Virginia 

Medical Foundation’s “Know Your 

Numbers” educational program, posters 

and brochures were distributed to 

physician offices and community health 

centers. This effort includes information 

about the healthy range for key risk 

factors such as cholesterol, triglycerides, 

blood pressure, blood glucose and body 

mass index. The intent of the effort is to 

enable individuals to take responsibility 

for their health by taking action to reduce 

their chances of developing heart disease, diabetes and many 

other illnesses. Funding for this project has been provided by the 

Claude W. Benedum Foundation. 

 

 

The Foundation was awarded a 

two-year $168,000 grant from the 

Physicians’ Foundation for Health 

Systems Excellence to establish the 

Center for Electronic Health Best 

Practices. The Foundation conducted 

a statewide health information 

technology needs assessment, hosted 

a two-day conference June 15-16, 

2007 titled “Improving Patient 

Care through Health Information 

Technology” and produced a special 

issue of the West Virginia Medical Journal on health technology. 

In addition, the Foundation’s web page, wvsma.com/foundation, 

provides resources to aid in the adoption and implementation of 

health technology. Also, the Foundation hosted the “Advancing 

Excellence in Health care and Health Information Technology” 

Conference October 15-16, 2009 at Stonewall Resort. This 

conference provided an update on key health care reform issues 

including technology’s role in driving health system improvement, 

how to access federal stimulus funds for health information 

technology, health IT in small and rural communities, progress in 

creating a health information exchange and technology’s role in 

making your practice a medical home. 

 

 

The West Virginia Medical Foundation joined with several partners 

to help implement the Alzheimer’s Outreach and Registry Program at 

the Blanchette Rockefeller Neurosciences Institute (BRNI) at West 

Virginia University. This initiative brings together the Foundation, the 

West Virginia Bureau of Senior Services, the Alzheimer’s Association, 

West Virginia Chapter and the Blanchette Rockefeller Neurosciences 

Institute. The aim of the initiative is to reach every physician and other 

health care providers to improve the diagnosis, 

treatment, and support for the more than 44,000 

Alzheimer’s disease patients and their 85,000 

caregivers in West Virginia. 

The initiative has three components: 

a. A continuing medical education course 

to keep physicians informed and proactive 

in the latest diagnostic techniques and 

treatments available for Alzheimer’s disease; 

b. A continuing medical education program 

to connect the medical community, and 

through them caregivers, with local resources 

to better link treatment and care; and 

c. The first-ever West Virginia Alzheimer’s 

Disease Registry to collect data on patients 

and the disease in order to better inform state 

allocation of resources and to help guide BRNI research. 

 

In 2010, the West Virginia Medical Foundation announced the 

creation of the Excellence in Medicine Awards. The awards 

recognize the efforts of West Virginia physicians who are 

dedicated to the Foundation’s mission: To improve the health 

of all West Virginians by promoting health education, leadership 

and research; encouraging healthy lifestyles and enhancing access to 

quality health care. 

 

The Foundation’s Chief Executive Officer, Helen 

Matheny, has been invited to present at national 

meetings including: 

American Medical Association’s State Legislative 

Strategy Conference, January 2007, La Quinta, CA 

Progress in Preventing Childhood Obesity: Focus 

on Communities: Institute of Medicine Regional 

Symposium, in collaboration with the Healthcare Georgia 

Foundation and supported by The Robert Wood Johnson 

Foundation, October 2005, Atlanta, GA 

American Medical Association’s “Call to Action: National Summit 

on Obesity”, October 2005, Chicago, IL.

L T H P R O M O T I O N 

 

 

As part of the Partnership for a Healthy 

West Virginia and the West Virginia 

Medical Foundation’s “Know Your 

Numbers” educational program, posters 

and brochures were distributed to 

physician offices and community health 

centers. This effort includes information 

about the healthy range for key risk 

factors such as cholesterol, triglycerides, 

blood pressure, blood glucose and body 

mass index. The intent of the effort is to 

enable individuals to take responsibility 

for their health by taking action to reduce 

their chances of developing heart disease, diabetes and many 

other illnesses. Funding for this project has been provided by the 

Claude W. Benedum Foundation. 

 

 

The Foundation was awarded a 

two-year $168,000 grant from the 

Physicians’ Foundation for Health 

Systems Excellence to establish the 

Center for Electronic Health Best 

Practices. The Foundation conducted 

a statewide health information 

technology needs assessment, hosted 

a two-day conference June 15-16, 

2007 titled “Improving Patient 

Care through Health Information 

Technology” and produced a special 

issue of the West Virginia Medical Journal on health technology. 

In addition, the Foundation’s web page, wvsma.com/foundation, 

provides resources to aid in the adoption and implementation of 

health technology. Also, the Foundation hosted the “Advancing 

Excellence in Health care and Health Information Technology” 

Conference October 15-16, 2009 at Stonewall Resort. This 

conference provided an update on key health care reform issues 

including technology’s role in driving health system improvement, 

how to access federal stimulus funds for health information 

technology, health IT in small and rural communities, progress in 

creating a health information exchange and technology’s role in 

making your practice a medical home. 

 

 

The West Virginia Medical Foundation joined with several partners 

to help implement the Alzheimer’s Outreach and Registry Program at 

the Blanchette Rockefeller Neurosciences Institute (BRNI) at West 

Virginia University. This initiative brings together the Foundation, the 

West Virginia Bureau of Senior Services, the Alzheimer’s Association, 

West Virginia Chapter and the Blanchette Rockefeller Neurosciences 

Institute. The aim of the initiative is to reach every physician and other 

health care providers to improve the diagnosis, 

treatment, and support for the more than 44,000 

Alzheimer’s disease patients and their 85,000 

caregivers in West Virginia. 

The initiative has three components: 

a. A continuing medical education course 

to keep physicians informed and proactive 

in the latest diagnostic techniques and 

treatments available for Alzheimer’s disease; 

b. A continuing medical education program 

to connect the medical community, and 

through them caregivers, with local resources 

to better link treatment and care; and 

c. The first-ever West Virginia Alzheimer’s 

Disease Registry to collect data on patients 

and the disease in order to better inform state 

allocation of resources and to help guide BRNI research. 

 

In 2010, the West Virginia Medical Foundation announced the 

creation of the Excellence in Medicine Awards. The awards 

recognize the efforts of West Virginia physicians who are 

dedicated to the Foundation’s mission: To improve the health 

of all West Virginians by promoting health education, leadership 

and research; encouraging healthy lifestyles and enhancing access to 

quality health care. 

 

The Foundation’s Chief Executive Officer, Helen 

Matheny, has been invited to present at national 

meetings including: 

American Medical Association’s State Legislative 

Strategy Conference, January 2007, La Quinta, CA 

Progress in Preventing Childhood Obesity: Focus 

on Communities: Institute of Medicine Regional 

Symposium, in collaboration with the Healthcare Georgia 

Foundation and supported by The Robert Wood Johnson 

Foundation, October 2005, Atlanta, GA 

American Medical Association’s “Call to Action: National Summit 

on Obesity”, October 2005, Chicago, IL.

In celebration of the West Virginia State Medical Association’s contribution to the health of 

West Virginians through the West Virginia Medical Foundation, the Foundation announces the 

creation of the prestigious “Excellence in Medicine Awards” that recognize outstanding efforts 

by members of the West Virginia State Medical Association who help the Foundation fulfill its 

mission: To improve the health of all West Virginians by promoting health education, leadership and research; 

encouraging healthy lifestyles and enhancing access to quality healthcare. 

Each year the Foundation will honor a select group of physicians who exemplify the medical 

profession’s highest values: commitment to service, community involvement, altruism and 

leadership in the medical profession. The Foundation is accepting nominations for the 2010 

Excellence in Medicine Awards including: 

Excellence in Medicine for Enhancing Access to Quality Healthcare 

Presented to the physician who has demonstrated extraordinary interest and efforts toward 

improving access to healthcare or reducing health care disparities in West Virginia. 

Excellence in Medicine for Leadership in Public Health 

Presented to the physician who has made a real difference in creating and nurturing a caring 

health promotion and disease prevention environment. Efforts may be related to reducing 

tobacco use, promoting healthy lifestyles, providing leadership in community health or 

public health policy advocacy. 

Excellence in Medicine for a Lifetime of Distinguished Service 

The award recognizes a West Virginia physician who throughout his or her career has 

exemplified the medical profession’s highest values: commitment to service, community 

involvement, altruism and leadership in the medical profession. The individual must have 

practiced medicine for at least 25 years. 

The awards will be presented at a black tie optional dinner on Friday, August 27, 2010 at 

the West Virginia State Medical Association’s Healthcare Summit at The Greenbrier. 

Each award is accompanied by a $500 contribution to the charitable medical organization 

of the recipient’s choice. The nomination form and additional information is available at 

wvsma.com/foundation. The nomination form must be received at the West 

Virginia Medical Foundation no later than 5 p.m. on Wednesday, March 31st. 

Please call Helen Matheny at 1-800-257-4747 ext. 13 if you have any questions. We thank 

you for your interest and look forward to receiving your nominations.

2010 Annual Business Meeting Highlights 

Dr. Jimenez, WVSMA President, presides over the the 2010 House 

of Delegates meeting. 

Amy Tolliver, Government Relations Specialist shares this year’s 

WVSMA legislative policy priorities as well as a briefing on Federal 

health system reform. 

Drs. Sherri Young, Adam Breinig, Richard Rashid and Tony Majestro listen 

intently to the discussion on healthcare policies.. 

David Rader, President of the WV Mutual Insurance Co. and WVU 

medical student, Josh Cusick-Lewis in attendance at the 2010 WVSMA 

Legislative Agenda meeting. 

Speaker of the House, Dr. David Avery, leads this year’s 

assembly. 

50 West Virginia Medical Journal 

Commissioner Cline discusses the 2009 

5% Medical Malpractice Market Share 

Report at the West Virginia Medical 

Insurance Agency client meeting at 

the invitation of Steve Brown, Agency 

Manager. 

Michael Stitlely, MD gives a brief report of the 

activities of the Perinatal Partnership.

WVU vs. Louisville Watch Party 

This year’s Annual Business Meeting was well attended, despite the snowy weather and ominous forecast 

(see photo, bottom right). 

The WVSMA House of Delegate members attended an early morning meeting including reports on 

nominations, resolutions, full reports from the West Virginia Medical Insurance Agency and West Virginia 

Medical Foundation. Delegates debated and engaged one another during the Legislative Agenda 

and Federal Health System Reform briefing. All of this was followed by a relaxing, casual lunch which 

included a game watching party. Of course, the viewing of the WVU vs. Louisville game and WVU victory 

added to the pleasure and success of the afternoon. 


1

Physician Practice Advocate | NEWS 

2010 Mid-Winter Conference Highlights 

The WVSMA’s recent Physician 

Practice Conference, held in 

conjunction with the Mid-Winter 

Conference, provided an exciting 

day of education for attendees. 

Physicians, administrators and 

other office personnel received the 

latest updates about the CPT coding 

changes for the New Year, as well 

as utilization and reimbursement 

updates that payors have made for 

2010. Attendees learned effective 

strategies for improving their 

medical practices from Practice 

Management expert Rose Moore and 

Protocol Consultant Pam Harvit. 

During the afternoon payor 

workshop, Patsy Hardy, Secretary 

of the Department of Health and 

Human Resources, and Nancy 

Atkins, Commissioner of the 

Bureau for Medical Services, 

joined the attendees and gave an 

overview of changes at Medicaid. 

Dr. James Lee, of Connolly 

Consulting, the RAC (Recovery 

Audit Contractor) for Region C, 

provided guidance as to the status 

of the RAC’s activities in West 

Virginia. Judging from the reaction 

of conference attendees, there still 

appear to be many questions about 

the RAC and how it will affect 

medical practices. Since the RAC 

activity in WV as of this date has 

been fairly minimal, it would seem 

a good time to review some of 

the information about the RAC. 

As a review, Congress created the 

recovery audit contractors (RAC) 

program to help the Centers for 

Medicare and Medicaid Services 

(CMS) identify improper payments 

made by Medicare. The RAC 

contractors are private entities that 

are retained by the government to 

identify and recoup overpayments 

made to physicians and other 

healthcare providers, as well as to 

identify and return underpayments. 

First created as a demonstration 

program, the RAC was subsequently 

expanded as a permanent nationwide 

program. The Tax Relief and Health 

Care Act of 2006 (TRHCA) authorized 

permanent RACs by January of 

2010. The RAC program focuses 

on traditional Medicare Fee for 

Services and does not audit Medicare 

managed care plans. The RACs 

review claims on a post-payment 

basis and are paid a contingency 

fee for each inappropriate payment 

identified and recovered. It is 

important to note that the RAC 

will check for “excluded” (claims 

that were previously reviewed by 

another entity) before a claim is 

selected for audit. Also, the RAC 

will not pursue overpayments of less 

than $10.00 nor will they identify 

underpayments of less than $1.00. 

There are limits to how far 

back a RAC may audit claims. 

Only claims which were paid as of 

October 1, 2007, and forward may 

be reviewed. In addition, the claim 

may not be audited more than three 

years past the claim paid date. 

The RACs are also limited as to 

how many charts they may request 

per physician. For a solo practitioner, 

the RAC may only request 10 medical 

records every 45 days per NPI. For a 


partnership of 2-5 practitioners, the 

limit is 20 medical records every 45 

days per NPI. For small groups (6-15), 

the limit is 30 every 45 days per NPI, 

and large groups (16+ practitioners) 

may have 50 medical records 

requested every 45 days per NPI. 

If the RAC finds an overpayment, 

physicians have a number of options 

to return any monies. You may 

pay by check, allow withholding 

from future payments, or request 

an extended payment plan. If the 

overpayment is questioned by the 

physician, he/she may file an appeal. 

It is advisable to pay back the money 

before appealing, since interest must 

be paid on any outstanding monies if 

the physician should lose the appeal. 

Physicians can prepare and ensure 

that they are ready for the RAC in 

several ways. They can conduct an 

internal assessment to identify if they 

are in compliance with Medicare 

rules and if not, they can identify 

corrective actions to implement for 

compliance. Also, all practices should 

have a contact person for the RAC 

and send the contact person’s name 

and address to Connolly Healthcare. 

For more information about 

the RAC, you may visit Connolly 

Healthcare at their website 

www.connollyhealthcare, or contact 

them at 866-360-2507. You may 

also obtain additional information 

from the CMS website, www. 

cms.hhs.gov/RAC/. For a quick 

response, RAC questions may be 

addressed to RAC@cms.hhs.gov. 

I hope this information is helpful 

as you and your practice prepare 

for the RAC implementation. 

Barbara Good 

WVSMA Physician Practice Advocate 


3

Obituaries 

The WVSMA remembers 

our esteemed colleagues… 

C. Vincent Townsend, MD 

C. Vincent Townsend, M.D., 

husband of Sara H. Townsend, Huxley 

Hall, Old Mill Road, Martinsburg, 

died on Saturday, Dec. 19, 2009, at 

the Winchester Medical Center. He 

was the son of C. William and Roxie 

Mae Townsend of Martinsburg. 

He was of the Baptist faith. 

He is survived by his wife and 

three sons, C. Vincent Jr. and wife, 

Julie; Gary Miles Townsend, M.D., 

J.D.; and Robin Wade Townsend, 

D.V.M. and wife, Janet. He is also 

survived by his dear grandchildren, 

C. Vincent III, Carson Hunter, Sage 

Noel, Sarah Bucko, Austin Hux, Troy 

Kearney and Amber Dawn Townsend. 

He was preceded in death by 

his parents, Clarence William 

and Roxie Mae Townsend. 

He was a graduate of Martinsburg 

High School; Potomac State College, 

Keyser; West Virginia University, 

Morgantown; and the Medical 

College of Virginia, Richmond, Va. 

He was president of Sigma Chi 

fraternity at WVU and a member 

of Phi Beta Pi at MCV. He served 

as a Medical Officer at Portsmouth 

Naval Hospital and aboard the 

USS Adirondack AGC 15. 

He was active in many facets of his 

hometown community in addition 

to his private practice of internal 

medicine for 40 years. Over the years, 

he was president of Kings Daughters 

Hospital and City Hospital staff, 

Eastern Panhandle Medical Society, 

Eastern Panhandle Heart Association, 

Rotary Club of Martinsburg, Junior 

Board of Trade, Exhausted Roosters, 

Eastern Panhandle Shrine Club, 

Burke Street School PTA and the 

Medical College of Virginia Valley 

Chapter and West Virginia Chapter. 

He was a member of the General 

Adam Stephen Chapter of the Sons of 

the American Revolution, Fraternal 

Order of Elks, Lodge 778, the Henry 

Kyd Douglas camp of the Sons of 

Confederate Veterans and Berkeley 

Post 14 American Legion; Voiture 

Local 1356 of La Societe des Quaante 

Hommes et Huit Chevaux. He was 

also a trustee and past master of 

Robert White Lodge #67 AF & AM in 

Martinsburg and Past Grand Master of 

the Grand Lodge of West Virginia AF & 

AM. He was a member of the Palestine 

Commandery, R.A.M., the Scottish Rite 

32nd and the Royal Order of Jesters. 

He had been medical director of 

paramedics for Eastern West Virginia, 

medical director of civil defense and 

medical director of Regions 8 and 

9 Emergency Medical Services, for 

which the office building was named 

the C. Vincent Townsend, M.D. 

Building. He was chosen from the 

EMS regions for the 2001 state Samuel 

W. Channel Award and received the 

1999-2000 Rural Health Physician 

of the Year award from the West 

Virginia State Medical Association. 

He was a past director of the local 

Chamber of Commerce, past director 

of the West Virginia Heart Association, 

past director of Old National Bank 

and One Valley Bank and a director 

Emeritus of Branch Banking and Trust. 

Memorials may be sent to the Dr. C. 

Vincent Townsend Scholarship Fund, 

Shepherd University Foundation, 

P.O. Box 3210, Shepherdstown, 

WV 25443-3210; or Robert White 

Lodge #67 AF & AM, 1007 W. King 

St., Martinsburg, WV 25401. 

William D. McLean, MD 

Dr. William D. McLean, 

80, of Beckley passed away 

Thursday, Nov. 19, 2009. 

Born Dec. 10, 1928, in Beckley, he 

was the son of the late David Waddell 

and Margaret McTaggart McLean. 

Dr. McLean graduated from 

Hampten-Sydney College and received 

his medical degree from the University 

of Virginia. He served his internship 

at Cook County Hospital in Chicago. 

Following his return to Beckley, he 

practiced dermatology for forty-four 

years before retiring in 2006. He 

served his country as a member of the 

10th Special Forces Group. He was a 

member of the Beckley Presbyterian 

Church and a former member of 

the Black Knight Country Club. He 

was preceded in death by his wife 

Lois Clements McLean in 2008. 

He is survived by his three sons: 

John David McLean and wife Mary 

Ann of N. Smithfield, R.I., Paul 

Joseph McLean of Claremont, Calif., 

Marc Andrew McLean and wife 

Danielle of Boynton Beach, Fla.; 

grandchildren: Madeline, Jimmy and 

William McLean; and his brother 

Robert McLean of Beckley. 

The family requests memorial 

contributions be made to the Beckley 

Area Foundation, 129 Main St., 

Suite 203, Beckley, WV 25801. 


| New Members 

We would like to welcome the following physicians and medical students to the WVSMA: 

Cabell County Medical Society 

Mark Akers, MD 

Amanda Bennett MD 

Doreen Griswold, MD 

Catherine Slemp, MD 

Eastern Panhandle Medical Society 

Lawrence Shombert, MD 

Kanawha County Medical Society 

Joshua Bradford, DO 

Joseph Conroy, MD 

Sancar Eke,MD 

Darren Harris, MD] 

Julie McCallister, MD 

Patrick Stone, MD 

Marion County Medical Society 

David McClure,MD 

Monongalia County Medical Society 

Kiran Bandaru,MD 

Steven Bauer, MD 

Christopher Colenda,MD 

Ahmed El-Haddad,MD 

Kymberly Gyure, MD 

Sayed Hamadani, MD 

Mark Johnson, MD 

Manie Juneja, MD 

Ahmed Kandeel,MD 

Fawad Khan, MD 

Hollynn Larrabee, MD 

Jason McChesney, MD 

Kassandra Milam, DO 

John Nguyen,MD 

Ward Paine, MD 

Rubayat Rahman, MD 

Mohamad Salkini,MD 

Kathryn Skitarelic,MD 

Joel Yednock, MD 

Mary Ann Zakutney, MD 

Parkersburg Academy of Medicine 

Michael Holtgrewe, MD 

Raleigh County Medical Society 

Anna Corbin, MD 

Suresh Thomas, MD 

Tug Valley Medical Society 

Leo Pajarillo, MD 

Tygart Valley Medical Society 

Donald Fleming, MD 

Please direct all membership inquiries to: Mona Thevenin, WVSMA Membership Director 

What’s behind 

quality healthcare in 

rural West Virginia 

For nearly ten years, the Center for Rural Health 

Development’s Loan Fund has worked to assist 

healthcare providers throughout West Virginia by 

providing affordable loans at reasonable terms 

and conditions to address facility, equipment, and 

technology needs. 

AffORDABLE LOAns 

fOR fACILITIEs, 

EquIpmEnT AnD 

TECHnOLOgy 

Whether you’re a dentist, physician, health center 

or a hospital, contact Robert Dearing, CFO/ 

Loan Fund Manager today to learn more about 

our commitment to help you to meet your capital 

financing needs. 

Center for Rural Health Development, Inc. 

3465B Teays Valley Road 

Hurricane, WV 25526 

(304) 397-4071 

robert.dearing@wvruralhealth.org 

Equal Opportunity Lender 


WV Medical Insurance Agency | NEWS 

This and That 

As we commence the new year, a reflection on what occurred in 2009 and some thoughts on 

2010 are appropriate. What did we see in 2009, and what will happen in 2010. The West Virginia 

Medical Insurance Agency provides valuable services for its clients and we expect to continue 

to do so in the future. The following represents a picture of “This” (2009) and “That” (2010). 

2009 Cost Savings 

Premium Savings 

Since becoming operational in 2004, the 

West Virginia Medical Insurance 

Agency has determined that it has 

provided a premium savings to new 

business accounts at least 40% of the 

time, due to the efforts of the Agency. 

In 2009, this result was achieved for 

75% of the applicable new business 

accounts written by the Agency. 

CARE/Risk Management 

Premium Credits 

In 2009, clients of the West Virginia 

Medical Insurance Agency achieved 

an average of 8.1% CARE/Risk 

Management premium credits from 

the West Virginia Mutual Insurance 

Company. This is due to our efforts, 

in addition to the Mutual’s, to keep 

our clients informed of the need 

for premium credits and how they 

can achieve these discounts. 

Premium Financing 

In 2009, the West Virginia 

Medical Insurance Agency arranged 

premium financing for 51 clients of 

the West Virginia Mutual Insurance 

Company. In each of these cases or 

100% of the time, the West Virginia 

Medical Insurance Agency financed 

its clients’ premiums at lower 

interest rates than those offered 

by the Company. This resulted 

in lower finance charges to “our” 

clients and savings of approximately 

13.7% from the financing charges 

of the Company’s offer. 

Physicians are our only clients. 

As a subsidiary of the West Virginia 

State Medical Association, our goal is 

to “help” our clients. Cost savings is 

one way we can achieve that result. 

Further, the commissions we receive on 

your business go to the West Virginia 

State Medical Association to assist and 

enhance the services of the Association. 

Doing business with the Association’s 

insurance agency, the West Virginia 

Medical Insurance Agency, provides 

an indirect return to our clients. While 

our goal is to help you – your goal 

should also be to help yourself. 

2010 Activities 

Businesskillers 

The West Virginia Medical 

Insurance Agency has joined with 

The Hartford to present workshops to 

discuss how to avoid the six mistakes 

that can destroy your business (your 

medical practice) and your future. 

Twenty-nine physicians (and their 

family members) attended our first 

presentation on Saturday, January 30th, 

at the Charleston Marriott. Physicians 

learned how to prepare themselves 

and their business (medical practice) 

for the future. Our businesskillers 

team is made up of Graham Reger, 

life, health, and disability insurance; 

George Webb, investment advisor 

and retirement planning, and Bruce 

Stout, attorney for estate planning 

and trust and estate administration. 

To have a workshop presented in 

your area, call Steve Brown, Agency 

Manager, at 1-800-257-4747 ext 22 

(or locally at 304-925-0342 ext 22). 

Crime Loss Identified as 

Emergency Risk in 2010 

The Global Risks 2010 report 

presented at the World Economic 

Forum contains many trends including 

those related to crime (insurance) 

loss. Not only did the report identify 

a troubled economy’s influence on 

crime loss potential, but a recent 

article in the Wall Street Journal noted 

the same link. The economy-crime 

correlation seems logical and insurance 

industry numbers bear this out. 

A clear trend emerges when 

fidelity and burglary/theft insurance 

industry statistics from 1966 to 2008 are 

compared to unemployment statistics 

as published by the Bureau of Labor 

Statistics from 1960 through 2009. 

It is evident that with each peak in 

unemployment, there are one or two 

subsequent peaks in fidelity losses. 

Major writers of crime coverage 

estimate that half of all commercial 

entities are either uninsured or grossly 

underinsured for crime losses. 

The West Virginia Medical 

Insurance Agency represents The 

Hartford, one of the top 5 writers of 


WV Medical Insurance Agency | NEWS Continued 

fidelity and crime/theft coverages: 

let us review your coverage for 

employee dishonesty and other 

crimes. Call Steve Brown, agency 

manager, at 1-800-257-4747 ext 22 

(or locally at 304-925-0342 ext 22). 

Was 2009 the Softest Market 

Ever; What About 2010 

Prospects for 2010 do not look 

much different from 2009, buyers 

of commercial insurance should 

expect continued soft pricing. 

Estimates for industry capitalization 

predict that policyholder surplus 

will grow and in the absence of 

major catastrophes, will result in loss 

ratios improving slightly. This will 

generally increase carrier appetite for 

risk. Add to that the prospects for a 

modest or slow economic recovery 

and demand will likely remain 

weak with rating bases like property 

values, payrolls, and business receipts 

growing only slowly if at all. 

What does this mean To the benefit 

of the purchasers of insurance, it may 

be a good time to shop your coverages. 

This could be the softest market ever. 

The West Virginia Medical Insurance 

Agency can offer you a wide array 

of coverages and welcomes the 

opportunity to evaluate your insurance 

needs with quality products and 

competitive pricing. Call Steve Brown, 

Agency Manager, at 1-800-257-4747 ext 

22 (or locally at 304-925-0342 ext 22). 

Congratulations … 

West Virginia Insurance Commissioner Becomes President of National 

Association of Insurance Commissioners 

Jane Cline has recently assumed 

a position of honor to the State 

of West Virginia. Commissioner 

Cline has become President of the 

National Association of Insurance 

Commissioners during the NAIC 

Winter National Meeting in San 

Francisco. This is an honor not 

only for Commissioner Cline but also the State of West 

Virginia. Commissioner Cline came into office during a 

very trying time, specially relative to medical professional 

liability insurance, and worked diligently to provide the 

necessary documentation and verification information 

that assisted our legislature to create and pass medical 

professional liability tort reform in 2001 and 2003. She 

has worked tirelessly since to regulate this aspect of the 

insurance industry including the formation, licensure 

and conduct of the West Virginia Mutual Insurance 

Company. She has also been readily available to the 

WVSMA and WVMIA during her time in office and has 

always been willing to participate in our client meetings. 

We appreciate her services to the medical community. 

Commissioner Cline has served our state well 

and we extend to her our congratulations and best 

wishes in her year as President of the NAIC. 

Pictured above at the Agency’s client meeting at the WVSMA 2007 Healthcare Summit: 

David Rader, President, West Virginia Mutual Insurance Co., Jane Cline. Commissioner, 

West Virginia Insurance Commission, Steve Roberts, President, West Virginia Chamber of 

Commerce and Steve Brown, Agency Manager, West Virginia Medical Insurance Agency. 


7

WESPAC Contributors | 

2010 WESPAC Contributors 

The WVSMA would like to thank the following physicians, residents, medical students and Alliance 

members for their recent contributions to WESPAC. These contributions were received as of February 18, 2010: 

Chairman’s Club ($1000) 

Patrick P. Dugan, MD 

Extra Miler ($500) 

David A. Bowman, MD 

James L. Comerci, MD 

Michael A. Kelly, MD 

Michael A. Stewart, MD 

Dollar-A-Day ($365) 

Greenbrier D. Almond, MD 

Edward F. Arnett, MD 

D’Ann E. Duesterhoeft, MD 

Michael O. Fidler, MD 

William L. Harris, MD 

Sushil K. Mehrotra, MD 

Stephen R. Powell, MD 

L. Blair Thrush, MD 

John A. Wade, Jr., MD 

Campaigner Plus (> $100) 

Finbar G. Powderly, MD 

Richard A. Rashid, MD 

Diane E. Shafer, MD 

Campaigner ($100) 

Moutassem B. Ayoubi, MD 

Patsy P. Cipoletti, MD 

James D. Felsen, MD 

Joby Joseph, MD 

Ignacio H. Luna, Jr, MD 

Harry A. Marinakis, MD 

Stephen K. Milroy, MD 

Wayne Spiggle, MD 

Wilfredo A. Tiu, MD 

Byron L. Van Pelt, MD 

Ophas Vongxaiburana, MD 

WESPAC is the West Virginia State Medical Association’s bipartisan political action committee. We work 

throughout the year with elected officials to make sure they understand the many facets of our healthcare 

system. 

WESPAC’s goal is to organize the physician community into a powerful voice for quality healthcare in West 

Virginia. We seek to preserve the vital relationship between you and your patients by educating our legislators about issues important to our members. 

WESPAC contributions provide critical support for our endorsed candidates. Your contribution can make the difference between a pro- physician/patient 

candidate winning or losing. 

For information about making a contribution to WESPAC, please call Amy Tolliver at (304) 925-0342, ext. 25 

WESPAC Board Members 

2009-2010 

STATE AT-LARGE - 2 SEATS 

Phillip R. Stevens, MD, Chairman 

M. Tony Kelly, MD 

WVSMA COUNCIL REPRESENTATIVE - 1 SEAT 

F. Tom Sporck, MD, Secretary 

FIRST CONGRESSIONAL DISTRICT - 2 SEATS 

Ken Nanners, MD 

David W. Avery, MD 

SECOND CONGRESSIONAL DISTRICT - 2 SEATS 

John Wade, MD 

Other seat vacant 

THIRD CONGRESSIONAL DISTRICT - 2 SEATS 

Ahmed D. Faheem, MD 

Ron Stollings, MD 

ALLIANCE REPRESENTATIVE - 1 SEAT 

Terry Waxman 

DIRECTOR 

Amy N. Tolliver, MS, Treasurer 


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Manuscript Guidelines 

Thanks To Our Advertisers! 

Originality: All scientific and special topic 

manuscripts for the West Virginia Medical Journal will 

not be considered for publication if they have already 

been published or are described in a manuscript 

submitted or accepted for publication elsewhere. All 

scientific articles should be prepared in accordance 

with the “Uniform Requirements for Submission of 

Manuscripts to Biomedical Journals.” Please go to 

www.icmje.org for complete details. 

Authors: A cover letter from the corresponding 

author should be submitted with the manuscript. All 

persons listed as authors should have participated 

sufficiently in the work to take public responsibility for 

the concept. 

Format: All articles may be submitted by email or on 

CD. Microsoft Word is preferred, but other programs 

are acceptable. All tables or figures should be 

created separately from the body of the manuscript 

as .tif, .jpg or .pdf files in a high resolution format with 

corresponding file names such as, Table 1, Figure 1, 

etc. Legends should be included for all tables and 

figures. 

References: References should be prepared in 

accordance to the “American Medical Association 

Manual of Style.” These instructions for authors are 

available online at www.jama.com. 

Photographs: Please submit high resolution digital 

files with an image size of 300 dpi at 100% of size. 

This high resolution size must be equal to 2.5” by 2.5” 

minimum size. Low resolution photos may be 

rejected or print with poor quality. 

Note to authors: The WV Medical Journal inside pages 

traditionally print in black and white. If authors wish to 

have photos and figures printed in color, there is a 

$1,000 charge per article to help defray the printing 

costs to the Association. Please indicate your preference 

when submitting an article. If your article is accepted for 

publication, you will be invoiced for the charges in 

advance of publication. 

Please address articles and cover letter to the editor at 

this address only: 

F. Thomas Sporck, M.D., F.A.C.S. 

Editor 

West Virginia Medical Journal 

P.O. Box 4106 


or email your article with cover letter to: 

Angela L. Lanham, Managing Editor 

angie@wvsma.com 

Alpha Financial Solutions.................................................59 

CAMC Health Ed. and Research Institute..........................1 

Center for Rural Health Development Loan Fund............55 

Chapman Printing Co........................Inside Back Cover, 59 

CPR Solutions Group, Inc..................................................2 

Cleveland Clinic.................................................................9 

Ear, Nose & Throat Assoc. of Charleston, Inc..................37 

Flaherty Sensabaugh & Bonasso PLLC..........................29 

HIMG................................................................................53 

Kee C. Lee, MD...............................................................26 

Madison Medical, PLLC...................................................59 

Marshall University Tobacco Cessation Provider Training.....35 

Marshall University Pregnancy & Smoking Courses........17 

McLain Surgical Supply...................................................59 

Mountain State Vital Care................................................25 

Office Managers Association............................................33 

Physician’s Business Office.............................................39 

Stationers, Inc..................................................................59 

Suttle & Stalnaker............................................................21 

Unicare...............................................................................7 

West Virginia Mutual Insurance Co................... Back Cover 

West Virginia University......................... Inside Front Cover 

Advertising Policy 

The WVSMA reserves the right to deny advertising space to any individual, 

company, group or association whose products or services interfere with 

the mission, objectives, endorsement agreement(s) and/or any contractual 

obligations of the WVSMA. The WVSMA, in its sole discretion, retains the 

right to decline any submitted advertisement or to discontinue publishing any 

advertisement previously accepted. The Journal does not accept paid political 

advertisements. 

The fact that an advertisement for a product, service, or company appears 

in the Journal is not a guarantee by the WVSMA of the product, service or 

company or the claims made for the product in such advertising. The WVSMA 

reserves the right to enter into endorsements, sponsorship and/or marketing 

agreements that may limit the placement of advertisements for certain 

products or services. 

Subscription Rates: 

$60 a year in the United States 

$100 a year in foreign countries 

$10 per single copy 

POSTMASTER: Send address changes to the West Virginia 

Medical Journal, P.O. Box 4106, Charleston, WV 25364. 

Periodical postage paid at Charleston, WV. 

USPS 676 740 ISSN 0043 - 3284 

Claims for back issues should be made within six months after 

publication. Microfilm editions beginning with the 1972 volume are 

available from University Microfilms International, 300 N. Zeeb Rd., 

Ann Arbor, MI 48106. 

©2009, West Virginia State Medical Association 


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97576 Cov_SeptOct09.indd 3 9/8/09 11:33 AM

West Virginia Medical Journal 

P.O. Box 4106 


www.wvsma.com 

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