Read Now - Sentara
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Read Now - Sentara
SPECIAL HEART AND VASCULAR EDITION healthQuest W I N T E R 2 0 15 BACK From the Brink Local Coach Survives Life-Threatening Emergency PAGE 8 president’s message H Matters of the Heart eart disease is the leading cause of death in our country and accounts for nearly one of every four deaths. Men and women are both affected, and more than 700,000 Americans will suffer a heart attack in 2015 alone. While these numbers may seem staggering for our nation, we can’t forget that our community isn’t exempt from being a part of the equation. This is not something we can ignore. It’s likely you know someone who has suffered from a cardiac event or is at risk for developing heart disease, or maybe you have experienced an event yourself. It’s important we remain aware of the risks that are present and work to keep ourselves and our loved ones educated, too. At Sentara RMH, our mission is to improve health every day. As just one way to deliver on our mission, we are dedicating this special Heart Month issue of HealthQuest to all things heart and vascular. Prevention is always good medicine, and understanding your risk for heart disease is an important first step in maintaining your health. Inside this issue you can read about the Sentara RMH Heart Check program (page 20), which provides a risk assessment, as well as health coaching, to help you avoid heart disease. When facing a medical emergency such as stroke or heart attack, quick action is imperative for ensuring the best possible outcome. On page 8 you will read how, at the start of the 2014 football season, longtime Turner Ashby coach Charlie Newman survived a serious medical emergency, thanks to the quick thinking and skilled intervention of local EMS providers, the Sentara RMH Emergency Department, and our cardiothoracic surgeon and his team. And on page 19 you will read how Sentara RMH is able to provide some of the best care in the country for heart attack patients due, once again, to skilled EMS providers working closely with our Emergency Department and Heart and Vascular Center. Jim Krauss President, Finally, we can all make a significant difference in our own personal health and Sentara RMH Medical Center reduce our cardiac risk by adopting healthier lifestyle habits. Including more MediterraCorporate Vice President, nean meal options (page 33) is just one example of how we can make small changes that Sentara Healthcare add up to a big difference for our health. At Sentara RMH, providing cardiac care has always been one of our top priorities. Thanks to the hard work of our medical staff and the dedicated teamwork that takes place day in and day out, we continue to grow and evolve our heart care services, as we provide minimally invasive surgical options for patients and introduce new technologies previously not available in our community. No matter where you are in your health journey, I want to thank you, from the bottom of my heart, for trusting Sentara RMH with your healthcare needs. The members of this community are what make us tick, and we sincerely value your confidence and continued support. Sincerely, Jim Krauss President, Sentara RMH Medical Center contents WINTER 2015 14 8 features 3 Sentara RMH Achieves Magnet Recognition 8 Back From the Brink Local Coach Survives LifeThreatening Emergency 14 Not Just a Man’s Disease Women and Heart Disease 15 Heart Disease in Hiding Microvascular Angina in Women 17 Heart Attack? Time is Muscle 17 26 Mended Hearts Support and Education for Heart Patients 30 All Heart Minimally Invasive Heart Surgery 19 Superior Heart Care Sentara RMH “Goes Platinum” 26 healthQuest A health lifestyle publication by Sentara RMH Medical Center 2010 Health Campus Drive, Harrisonburg, VA 22801 Sentara.com A D M I N I S T R AT I O N President | Jim Krauss 20 Senior Vice President, Sentara RMH Medical Center; President, Sentara RMH Medical Group | John A. McGowan, MD Senior Vice President, Clinical Effectiveness | Dale Carroll, MD, MPH Chief Financial Officer, Sentara Blue Ridge Region | J. Michael Burris departments IFC President’s Letter 4 Ask the Doctor Enlarged Heart, Effects of Smoking on the Heart and Blood Vessels 6 Physician’s Perspective Treating Atrial Fibrillation 20 For Your Health Improve Your Heart IQ With Heart Check 21 Sobre Su Salud Senior Vice President, Operations | Richard Haushalter Vice President, Acute Care Services; Chief Nurse Executive | Donna Hahn 37 Medical Staff Update Vice President, Business Development, Sentara Blue Ridge Region | Ronald J. Cottrell Sentara RMH Welcomes New Healthcare Professionals Vice President, Human Resources, Sentara Blue Ridge Region | Mark Zimmerman 40 RMH Foundation Funding Compassionate Care Vice President, Information Services | Michael J. Rozmus 42 Friends of the RMH Foundation Gifts Received June 1–Nov. 23, 2014 BOARD OF DIRECTORS Ann E. C. Homan, Chair | Howard P. Kern, President and COO, Sentara, Vice Chair | Alden L. Hostetter, MD, Secretary | Devon C. Anders | A. Jerry Benson, PhD | David L. Bernd, CEO, Sentara | Joseph D. Funkhouser II | Terry M. Gilliland, MD, Senior Vice President and CMO, Sentara | James E. Hartman 52 Jim Bishop Amazing Love Never Quits Executive Editor | Michael J. Cordell Mejore el CI de su corazón con Heart Check Managing Editor | Neil Mowbray Design and Production | Picante Creative Photographers | Luca E. DiCecco, Tommy Thompson 22 Telestroke Technology Contributing Designer | Marc Borzelleca Diagnosing Stroke From a Distance CONTRIBUTING WRITERS Luanne Austin | Jim Bishop | Karen Doss Bowman | Christina Kunkle | Lisa V. Mahenthiran | Neil Mowbray | Robert VerNooy, MD 28 Living with Synergy Follow Your Heart to a Path With Purpose 33 Nutrition Mediterranean Diet for (Heart) Health 22 © Copyright 2015 by Sentara RMH Medical Center. No part of this publication may be reproduced or transmitted in any form or by any means without written permission from Sentara RMH Medical Center. Articles in this publication are written by professional journalists who strive to present reliable, up-to-date health information. However, personal decisions regarding health, finance, exercise and other matters should be made only after consultation with the reader’s physician or professional adviser. All editorial rights reserved. Opinions expressed herein are not necessarily those of Sentara RMH Medical Center. Models are used for illustrative purposes only. Please email comments or questions to rmh_rmhhealthquest@sentara.com or call 540-564-7205. 6 Sentara RMH Achieves Magnet® Recognition for Nursing Excellence Rare Recognition Signifies Top-Notch Experience For Patients And Families S entara RMH Medical Center has achieved the Magnet Recognition Program® designation from the American Nurses Credentialing Center (ANCC). Magnet® designation is granted to approximately 7 percent of U.S. hospitals and recognizes sustained excellence in nursing care. “This designation validates our superior quality of nursing and the positive impact it has on our patients and their families,” says Donna Hahn, chief nurse executive for Sentara RMH. “For members of our community, this means they can feel confident that when they come to Sentara RMH they will receive the best possible care available.” A Magnet hospital is one that has met the specific standards set forth by ANCC. These standards define the highest quality of nursing practice and patient care. “When we began our Journey to Magnet Excellence® in 2010, I am not sure any of us understood how the process would help transform the culture and the continued improvements that we now see as part of what we do here everyday,” says Hahn. Research shows there are clear benefits to patients and their families who receive care at Magnet facilities, including confidence in caregivers and positive outcomes. The designation is awarded for four years, during which time the ANCC monitors facilities to ensure high standards of care remain intact. “We are so proud of our team and their continued commitment to provide high quality, patient-centered care to our community,” says Hahn. A conference room full of nurses, clinicians and administrators erupts in cheers and confetti Dec. 19, 2014, as Sentara RMH staff are informed that the hospital has achieved Magnet® recognition for nursing excellence. Sentara.com 3 ask the doctor healthQuest Q: What causes an enlarged heart? Is it life-threatening? Can it be treated? D iagnosis of an enlarged heart is usually made on a chest X-ray when the left and right sides of the heart are farther apart than normal. Such an enlargement is typically due to one of the condition’s three main causes: William Lee, M.D. 1. The patient has a normalsized heart, but fluid has collected around the heart (pericardial effusion). 2. The patient has a very thickened heart muscle (left ventricular hypertrophy). 3. The patient has one or more dilated heart chambers, which is usually due to heart failure. Fluid collection A VERY THICKENED HEART MUSCLE around the heart IS USUALLY CAUSED BY EITHER HIGH could be the result of an infection—most BLOOD PRESSURE OR A RARE a viral infecPARTICULAR HEREDITARY CONDITION.” often tion—although the spread of cancer, trauma or other causes are also possible. Treatment for this condition involves treating the cause of the fluid buildup. A very thickened heart muscle is usually caused by either high blood pressure or a rare particular hereditary condition. In the case of high blood pressure, aggressive treatment is of utmost importance. Should the patient have the rare hereditary condition, a cardiologist should be consulted and involved in the patient’s care. A dilated heart due to heart failure can have numerous causes, including hardening of the arteries 4 healthQuest | Winter 2015 leading to heart attacks; high blood pressure; or a cardiomyopathy (disease of the heart tissue), which can be caused by viruses, alcohol abuse, certain drugs including chemotherapy, or genetic factors. Inflammation in the heart can also cause an enlarged heart, as can birth defects, heart valve troubles and even metabolic issues such as thyroid disease. Treatment involves identifying and focusing on a patient’s specific problem. All patients with an enlarged heart should avoid smoking, limit the amount of salt in their diet, exercise regularly, and avoid excessive use of caffeine or alcohol. They should also monitor their blood pressure and see their physician regularly. Depending on the root problem, certain cases of enlarged heart can be treated and even reversed. Some episodes can be life-threatening, but there are excellent medications for treating congestive heart failure, high blood pressure and coronary artery disease. William Lee, M.D., is a cardiologist on staff with Harrisonburg Medical Associates. He joined the Sentara RMH medical staff in 1980. What effects does smoking have on the heart and blood vessels? T he link between smoking and cancer is well known, but cancer is just one of smoking’s many dangers. Smoking is one of the most harmful things a person can do to the body, causing damage to nearly Gregory Montgomery, M.D. every organ. According to the National Institutes of Health, smoking is responsible for one out of every five deaths in the United States and is the leading cause of preventable deaths. The chemicals in tobacco smoke directly affect the blood cells, heart tissues and arteries. Carbon monoxide, for example, reduces the amount of oxygen the red blood cells can carry, forcing the heart to work harder to meet the body’s oxygen needs. Carbon monoxide also can increase the buildup of plaque inside the arteries, which over time can lead to atherosclerosis, or hardening of the arteries. The result may be a heart attack; stroke; or peripheral artery disease (PAD), a lower-leg condition that can make walking painful. Nicotine, a highly addictive chemical in tobacco, constricts the blood vessels and increases blood pressure and heart rate, forcing the heart to work harder. Nicotine can also contribute to atherosclerosis. Cadmium, another chemical in tobacco smoke, can damage the inner lining of the arteries. And the benzene and formaldehyde produced by smoking can lead to leukemia, or cancer of the blood, as well as other forms of cancer. Hydrogen cyanide, a fast-acting chemical in tobacco that interferes with the body’s ability to use oxygen, causes considerable damage to the heart and blood vessels, as well as the brain. Because both the heart and brain require a great amount of oxygen for normal functioning, hydrogen cyanide is particularly harmful to both organs. In addition to its negative effects on the body’s organs, smoking lowers the blood level of HDL (“good cholesterol”) and raises the blood levels of LDL (“bad cholesterol”) and triglycerides (fat). Over time, low HDL, high LDL and high triglycerides can lead to plaque buildup in the arteries, increasing the risk of heart attack, stroke and PAD. Smoking’s harmful effects THE CHEMICALS IN TOBACCO aren’t limited to heavy smokers, moreover, and there’s no such thing SMOKE DIRECTLY AFFECT as a safe level of tobacco use. Even THE BLOOD CELLS, HEART people who smoke once or twice a TISSUES AND ARTERIES.” day, or only occasionally, cause damage to their heart, blood vessels and other organs. If you’re having trouble quitting smoking, be sure to speak with your healthcare provider about ways to kick the tobacco habit. Gregory Montgomery, M.D., is a vascular sur- geon on staff with Valley Vascular Associates in Harrisonburg. He joined the Sentara RMH medical staff in 1985. ■ Want to Kick the Smoking Habit? Get Off Your Butt: Smokeless for Life In six group sessions, learn about nicotine addiction, identify smoking triggers, create a plan for quitting and develop healthy alternatives to using tobacco. This is a free class, taught by Erica Rollins, a tobacco treatment specialist with Sentara RMH Community Health. • Meets Mondays and Wednesdays beginning April 6, 7-8 p.m. • Cecil F. Gilkerson Community Activities Center, 305 S. Dogwood Drive, Harrisonburg • For more information, call 540-433-4421. To register, call 1-800-SENTARA (736-8272). Sentara.com 5 physician’s perspective Treating AFib: Restoring the Heart’s Natural Rhythm Atrial fibrillation, also known as AFib or AF, is an irregular cardiac rhythm caused by unorganized electrical activity in the atria, the upper chambers of the heart. Currently more than 2.4 million people in the United States have AFib, the most commonly diagnosed heart rhythm problem. Factors that can increase the risk of developing AFib include obesity, untreated sleep apnea, uncontrolled high blood pressure, overactive thyroid disease, excessive intake of alcohol or other stimulants, chronic heart or lung disease, recent serious illness or surgery, and aging. 6 healthQuest | Winter 2015 I n a normal heart rhythm, the atria beat in coordination with the ventricles, the lower heart chambers responsible for most of the heart’s pumping action. During an AFib episode, however, the atrial muscle quivers in a very fast and disorganized manner, rather than contracting in sync with the ventricles. This can lead to a variety of symptoms, ranging in seriousness from the minimal to the disabling, depending largely on how fast and irregularly the atrial impulses are causing the ventricles to contract. If the lower chambers are activated too quickly or too irregularly, the patient may experience unpleasant palpitations, chest discomfort, lightheadedness, shortness of breath, fatigue, or even partial or complete fainting. In addition, AFib is linked to an increased risk of stroke, which can occur if a blood clot forms in the atria due to sluggish blood flow during an AFib episode. Risk factors associated with increased chance of stroke with AFib include congestive heart failure, high blood pressure, age greater than 65 (the risk is even higher in patients older than 75), diabetes, history of a prior stroke, existing vascular disease and female gender. With the presence of one or more of these predictors, an anticoagulant or “blood-thinner” medication should be considered to help decrease the risk of stroke. Otherwise, at most a daily aspirin—and perhaps no stroke prevention treatment at all—may be indicated. The good news is that doctors today have more options to help people with AFib, and those options are safer and more effective than at any time in the past. In many patients, AFib may come and go transiently, but the condition can also persist, sometimes requiring medicines or the administration of an electrical shock under sedation to restore the heart’s normal rhythm. In some cases, AFib may become chronic or permanent, calling for further treatment. For those requiring longer-term treatment, physicians employ two main strategies. One approach, making use of medications to control the heart rhythm during an AFib episode, is often considered for those with mild symptoms. While these medications do help some patients, they can be associated with significant risks and side effects and may not be very effective over the long term. The other strategy, commonly used with patients who have frequent AFib symptoms and have not been helped by medication, is to attempt to maintain normal heart rhythm over a longer time frame through a well-established catheter-based surgical treatment known as ablation. While ablation does carry some rare risks, the procedure and its associated technology continue to evolve, leading to improvements in the technique’s safety and effectiveness. Clinical studies have shown that AFib ablation has a better success rate than medicine-based treatment, decreasing or eliminating symptoms and improving quality of life for the majority of patients. The Sentara RMH Heart and Vascular Center offers safe, effective cardiac ablation procedures to correct atrial fibrillation and other heart rhythm problems. If you think you may have heart rhythm problems, be sure to talk to your healthcare provider. ■ ■ Robert VerNooy, M.D., an electrophysiologist on the cardiology staff of Harrisonburg Medical Associates, joined the Sentara RMH medical team in 2010. Sentara.com 7 Back From the Brink Local High School Coach Survives Life-Threatening Medical Emergency | By Luanne Austin Before Sept. 12, 2014, Charlie Newman, the longtime head football coach at Turner Ashby High School in Bridgewater, had never heard of an aortic dissection. By the time that day was over, however, the condition, in which a tear occurs in the major artery transporting blood out of the heart, would forever change his outlook on life. Fortunately for Newman, a confluence of quick thinking, top-notch healthcare services and more than a bit of good fortune would help him pull through this often fatal emergency. Charlie Newman Sentara.com 9 Coach Charlie Newman doing what he loves most. 10 N ewman was coaching during the second quarter of a Friday night football game at Turner Ashby, when he felt a flutter, then a sharp pain, in the left side of his chest. Suddenly dizzy, he made his way over to the sideline bench and sat down, in obvious distress. “I thought I was having a heart attack,” recalls Newman, 55. Heather Fincham, Turner Ashby’s athletic trainer, noticed Newman’s behavior and rushed to his side to evaluate his condition. She asked him about his pain but, strangely, couldn’t detect any pulse. “Then his face started drooping, so I thought it might be a stroke,” says Fincham. “He had chest pain but was showing stroke symptoms. I didn’t know what it was—just that it was bad. I knew we had to get him out of there quickly.” Fortunately for Newman, the Bridgewater Rescue Squad happened to be parked at the end of the field, as part of safety precautions taken during all Turner Ashby home football games. Fincham called them over to assist. By this time Newman’s wife, Robyn, had come down from the bleachers to see what was happening. After her husband was loaded into the ambulance, she climbed in, along with two EMTs and a medic who healthQuest | Winter 2015 had been watching the game. And before leaving the parking lot, the ambulance crew met up with another medic and an EMT-Enhanced who were on call. Newman had a strong response team taking care of him. For his part, Newman doesn’t remember much about the ambulance ride, but he does recall that Robyn was holding his hand. “She said over and over, ‘Stay with us, babe, stay with us. We’re almost there,’” Newman says. “At one point she said, ‘Look at me,’ but I couldn’t see her. All I saw was white, and I thought, ‘This is that white light you see before you die.’” Even remembering this moment brings tears to Newman’s eyes. “I thought about my kids and … ‘oh, gosh, this is really serious,’” he adds. “I didn’t know what was wrong. I hoped that I would wake up.” “Then I heard Robyn say, ‘We’re here at the ER.’” Ready and Waiting During Newman’s ambulance ride, the Sentara RMH Emergency Department (ED) had been alerted that a presumed stroke patient was coming in, which sets a protocol in motion to treat the patient as quickly as possible. “When I saw he was a young, athletic guy, it didn’t make sense that he would have an ischemic stroke,” says “I thought I was having a heart attack.” Christina Johnson, M.D., the ED physician who attended to Newman. “Then I asked if he was having any chest pains.” Although he was very sick, Newman replied with a definite “Yes.” “His case didn’t add up,” Dr. Johnson says. The chest pains and low blood pressure were not signs of stroke. Suspecting an aortic dissection, she added a chest CT scan to the brain CT order. And due to the seriousness of Newman’s condition, Dr. Johnson accompanied him to the scanning room and saw the problem right away as the image appeared on the technician’s screen. “I could see the dissection—it was so big,” she recalls. “As soon as I saw that I thought, ‘We’ve got to get him to the operating room.’” In the past, Sentara RMH typically would have transferred a case like Newman’s to a Level I trauma center, so Dr. Johnson promptly called for a medevac helicopter. But neurohospitalist Daniel Chehebar, D.O., intervened; he knew the hospital’s new cardiothoracic surgeon, Jerome McDonald, M.D., had the expertise to operate on Newman. Dr. Chehebar consulted with Dr. McDonald, who—in another stroke of luck for Newman—was already at the hospital. “That,” says Dr. Johnson, “was the best-case scenario—to save time.” Time of the Essence After hearing a brief explanation of Newman’s condition, Dr. McDonald rushed to the ED, where he checked the patient and updated Robyn, now accompanied by her two adult children, on Charlie’s condition. By that time, the medevac helicopter had arrived to take Newman to another facility. Dr. McDonald told Robyn the time had come to make a decision regarding her husband’s treatment. “He told me that time was of the essence,” says Robyn. “He said, ‘I know aortas, I have seen this before, I have worked on aortic dissections before.’” The Newmans agreed that Dr. McDonald should perform the surgery at Sentara RMH. State-of-the-Art Surgery Dr. McDonald describes an aortic dissection as “like wet plywood.” In such a case, the walls of the aorta come off in layers, and the blood travels between those layers. When he first examined Newman, the patient had no blood flow to his head and neck, he could not move his left side, he was blind, and his blood pressure was dangerously low. “He was profoundly sick when he arrived,” Dr. McDonald notes. “He was dying.” In fact, Dr. McDonald wasn’t sure Newman would live long enough to get the surgery started. Meet Dr. Jerome McDonald Jerome McDonald, M.D., cardiothoracic surgeon at Sentara RMH since late 2013, is very familiar with aortic dissections. Before coming to Harrisonburg, he worked for six years with Stockton Cardiothoracic Surgical Medical Group and was medical director of the Surgical ICU and Post-Cardiac Surgical Ward at St. Joseph’s Medical Center, both facilities in Stockton, California. While serving in the U.S. Army, Dr. McDonald was chief of cardiothoracic surgery at Madigan Army Medical Center from 2004 to 2007 and chief of surgery for the 47th Combat Support Hospital from 2003 to 2004. He graduated from the University of Pennsylvania School of Medicine, completed his internship and residency at Madigan Army Medical Center, and completed his cardiothoracic surgery fellowship at Washington University’s Barnes-Jewish Hospital. Since 2004, Dr. McDonald also has served as assistant professor at Uniformed Services University of the Health Sciences in Washington, District of Columbia. He also is a fellow of the American College of Surgeons. Sentara.com 11 leaving the high school, were, “Who won the game?” “When he asked about the game, we knew mentally he was OK,” Robyn says. “Then he asked about the tailgating we had planned to do at the JMU game that day. We all started crying.” Charlie and Robyn at home 12 With the decision made to treat Newman at Sentara RMH, the surgery team quickly moved to cool his body to 64.4 degrees Fahrenheit, which decreases metabolic activity, heart rate and oxygen consumption, and then drained his blood. According to Dr. McDonald, the brain can tolerate this state for up to 60 minutes, while the body can endure it for longer. Fortunately, thanks to his surgeon’s skilled technique, Newman’s procedure took only 19 minutes, during which Dr. McDonald cut out a section of the ascending aorta and replaced it with a polymer-based Dacron tube. Following the procedure, warming Newman’s body took about an hour—twice as long as the presurgery cool-down period. “When a patient has bad blood flow to the brain, it’s in their best interest to keep them cool for a while after surgery and warm them up gradually,” Dr. McDonald says. “We left Charlie a little cold afterward because it improves the neurological outcome.” At 6 a.m. on Saturday the doctor and his staff went home, as did Newman’s wife and children. When Robyn called the nurses’ desk at 8 a.m., she found out her husband had already opened his eyes. “So we went in,” she says with a smile, “and he was still alive.” To Robyn’s amazement, Charlie’s first words to her, with no memory of what had transpired since healthQuest | Winter 2015 “Phenomenal” Treatment Newman’s family members weren’t the only ones surprised at how well Charlie’s brain was functioning. Dr. Chehebar plied Newman with a variety of questions designed to detect subtle problems but found no major issues of concern. “He’s in great shape,” says Dr. Chehebar, attributing a large part of Newman’s neurologic recovery to his high level of fitness. “He eats well and exercises, so he has a better chance of bouncing back.” Dr. McDonald is also pleased with Newman’s recovery. “He was much sicker than most aortic dissections I’ve seen,” Dr. McDonald notes. “He was blind and unable to move half his body, and there was hardly any blood pressure. Clearly he was in a world of trouble.” The day after Newman’s surgery, nurses at Sentara RMH got him out of bed to stand, and then he began walking. Each day during his recovery he walked farther up and down the hospital hallways. When Dr. Johnson visited Newman a few days after the emergency, she found him “sitting up in bed with his laptop, watching the football game he’d missed,” she says. Robyn calls the treatment her husband received during his week at Sentara RMH “phenomenal.” “The nurses, Dr. McDonald, his assistant … all showed so much compassion and caring,” she adds. Friends thronged to visit Newman at the hospital, but the coach needed to rest, so the staff put a procedure in place whereby the family gave an access code to only a limited number of visitors. “I felt bad I couldn’t see everyone, even people I’m close to,” Newman says. A New Perspective on Life Newman was released home on a Friday, one week after the aortic dissection. But he didn’t stay there long. That same day he went to Turner Ashby High School, where his football team was boarding the bus to their next game. “I wanted the kids to know I was OK,” he says. During his recovery period, he and Robyn would walk the perimeter of their 3/4-acre yard. Then he began doing laps, telling Robyn he wanted to do it on his own (although she admits to watching him through the window, to ensure his safety). Then he started walking across the large field in back of their house. Now Newman walks for about 50 minutes a day, four days per week, and has three sessions of cardiac rehab a week at the Sentara RMH Heart and Vascular Center. “I feel stronger every day,” he says. In November, Newman went back to coaching at Turner Ashby part time. Heather Fincham, glad to see her co-worker back on the job, remarked on all the things that came together in his favor during the emergency. “If it was going to happen, it was the right time and place to happen,” Fincham notes. “I was there, the rescue squad was there. Everything was lined up for him to live.” Newman does not take his survival for granted. He has joined aorticwarriors.com, a website for survivors of aortic dissection, and he now has a deeper appreciation for life and the people around him. And since his surgery, he has received many letters and cards from people telling him how he has touched their lives. “Now I know I’ve left a mark on people,” Newman says. “If I had passed on, I wouldn’t have known.” After Charlie’s surgery, the Newman family sent this card to the hospital. AORTA What is Aortic Dissection? The aorta is the largest blood vessel in the body. It carries oxygenated blood out of the heart, and the vessels that branch off the aorta carry blood to all parts of the body. An aortic dissection occurs when the inner layer of the aorta tears, allowing blood to flow between the inner and outer layers. This causes the layers to dissect, or separate—a serious condition that typically results in decreased blood flow to the organs. If the outer wall of the aorta ruptures, the result is often death. Aortic dissection is fairly uncommon, occurring most often in men between ages 50 and 70. Known risk factors include age; uncontrolled high blood pressure; atherosclerosis (“hardening of the arteries”); a pre-existing aneurysm or weakened spot in the aorta; and, rarely, receiving a blunt, powerful blow to the chest. Certain connective tissue and inflammatory disorders also may increase a person’s risk. In many cases, the exact cause is unknown. Typical symptoms include sudden, intense pain in the chest or upper back; shortness of breath; loss of consciousness; and stroke-like symptoms such as weakness or paralysis of one side of the body, loss of vision, or difficulty speaking. A person experiencing any of these symptoms should call 911 immediately. Early diagnosis and treatment of aortic dissection increase a person’s chance of surviving. Sentara.com 13 Not Just a ‘Man’s Disease’ Sentara RMH Caregivers Work to Highlight the Heavy Toll Heart Disease Takes on Women C BY KAREN DOSS BOWMAN ontrary to popular perception, men aren’t the only ones who should be concerned with developing heart disease. In fact, since 1984, more women than men in the United States have died from heart disease, according to the American Heart Association (AHA). “Heart disease is really prevalent among women, making it a major public health issue,” says Brad Rash, M.D., a cardiologist with Harrisonburg Medical Associates and the Sentara RMH medical staff who specializes in women’s heart health. “We need to promote education and awareness, so that women know the signs of and risk factors for heart disease.” Despite its widespread impact on women’s health, heart disease continues to be one of the most underrepresented, undertreated and misdiagnosed medical conditions for women, according to the AHA. One reason for the disconnect may be that heart disease often presents itself differently in women than in men. While many women do experience the “classic” symptoms of heart disease—chest pressure, pain radiating to the left arm, shortness of breath, lightheadedness— many others experience only less obvious symptoms, including back pain, jaw pain, nausea and fatigue. “Sometimes women simply feel like something’s wrong, but they can’t put their finger on it,” says Dr. Rash. “We don’t know all the reasons why some women experience different symptoms than men do, but women in general need to have a better understanding of the signs of heart disease—that’s key to saving more lives.” Dr. Rash notes that women who seek medical care for heart attack symptoms may undergo testing that shows no blockages in their main coronary arteries. 14 healthQuest | Winter 2015 But even with clear main coronary arteries, blockages may still exist in the smaller arteries. When these smaller vessels become diseased, they often don’t allow for adequate blood flow to the heart—particularly during times of exertion. To detect and diagnose this potentially dangerous condition, known as microvascular dysfunction, the Sentara RMH Heart and Vascular Center offers coronary reactivity testing in its catheterization lab. “This condition was something the medical community had very little understanding of until recent advances over the past decade,” Dr. Rash notes. “We called it ‘cardiac syndrome X’ because we had no clue what was causing it, but now we’re much more familiar with how that disease process works, and we’re more effective at detecting and treating the problem.” Startling Statistics About Heart Disease in Women • Heart disease accounts for one-third of deaths among women during a given year. • More women die of heart disease annually than from all types of cancer combined. • Heart disease kills eight times more women than breast cancer yearly. • 43 million U.S. women currently have some form of heart disease. • 90 percent of U.S. women have one or more of the risk factors for heart disease. (Source: American Heart Association, “Go Red for Women” website) WHEN IN DOUBT, CALL 911 According to the American Heart Association’s “Go Red for Women” website, women who are experiencing symptoms of a heart attack are less likely to call 911 for themselves than for someone else. If you’re experiencing these symptoms—even if you’re uncertain or if the symptoms are not severe—call 911 immediately. Dismissing the symptoms could delay lifesaving treatment. Heart Disease in Hiding BY KAREN DOSS BOWMAN Microvascular Angina Affects More Women Than Men M ore than a decade ago, Janice Monger of Port Republic began experiencing chest pain and shortness of breath while walking. Her family doctor ordered stress testing and heart catheterization, but those tests revealed no blockages in the coronary arteries, failing to yield a clear treatment plan for Monger. And while she managed her condition with medications for several years, her symptoms continued to come and go. “It got to the point where I couldn’t even walk out in my yard and back to my house without experiencing severe chest pain,” says Monger, 64. “The pain would start in my back and move into my chest, and I couldn’t breathe.” In January 2013, cardiologist Brad Rash, M.D., diagnosed Monger with microvascular angina, a condition that affects the microscopic blood vessels within the heart muscle. These smaller vessels are quite different from the larger coronary arteries, which lie over top of the heart itself and are often responsible for heart attacks, Dr. Rash explains. When these microscopic vessels don’t dilate properly, blood flow to the heart is inhibited. “Janice was continuing to complain of chest pain that would become worse with exertion and get better with rest,” Dr. Rash recalls. “That’s typical of angina.” Women are more likely than men to have microvascular angina, though researchers still don’t understand why. Over the past decade, however, the medical community has gained a greater understanding of this condition, and researchers currently are engaged in studies to find better ways to diagnose and treat it, accordSentara.com 15 Take Care of Your Heart Health Your primary care doctor or cardiologist can evaluate your risk factors and customize a plan of care to help you manage those risks. Here are some steps you can take now: Stop smoking. If you smoke, quitting can be difficult. Ask your doctor about the many smoking-cessation options that can help you kick the habit. ing to Dr. Rash. Though some stress tests and other diagnostics may detect the abnormality, many patients are diagnosed with microvascular angina only after other possible conditions are ruled out. For patients like Monger, Dr. Rash says the treatment plan generally focuses on managing symptoms and modifying risk factors such as high blood pressure and cholesterol. “Women with microvascular angina tend to have more heart attacks and strokes than women who do not have this condition,” Dr. Rash explains. “It’s important to diagnose this condition, because those patients need to be treated aggressively. They can still have chest pain, even when a cardiac catheterization shows normal-appearing coronary arteries. So if their symptoms continue, despite the absence of blockages in the coronary arteries, consideration should be given for a diagnosis of—and treatment for—microvascular disease.” Know Your Risks The risk factors for heart disease, which are the same for women and men, include: • • • • • • • High cholesterol High blood pressure Smoking A family history of heart disease Diabetes Obesity A sedentary lifestyle Specific to women: • History of pre-eclampsia • History of gestational diabetes • Early menopause 16 healthQuest | Winter 2015 Reduce stress. Find positive ways to manage your stress, including meditation, reading a favorite book, taking a walk or visiting a friend. Get plenty of exercise. The American Heart Association recommends a half-hour of moderate aerobic activity at least five days a week, along with moderate- to high-intensity musclestrengthening exercises two days per week. Eat healthy. Doctors often recommend a Mediterranean-style diet, which emphasizes fruits, vegetables, whole grains, nuts and legumes, and olive oil—while limiting meats and sweets. The Women’s Heart Program at Sentara RMH The Women’s Heart Program, directed by cardiologist Brad Rash, M.D., emphasizes the importance of early diagnosis and treatment of heart disease in women. The program offers screening appointments that include an EKG (electrocardiogram), a complete review of medical history and a physical exam. Indications for a consultation include: • Concern about risk factors and desire for a closer evaluation • Symptoms that are of concern, despite negative diagnostic tests • Multiple risk factors, including nontraditional risk factors such as pre-eclampsia, gestational diabetes or connective tissue disease Physician referral is not necessary. To schedule an appointment, call Harrisonburg Medical Associates at 540-434-0559 or 800-296-0559. With Heart Attack, Time is Muscle It’s an established fact that coronary heart disease is the No. 1 killer of men and women in the United States. But much of the disability and mortality associated with heart disease could be limited if people having heart attacks would seek medical help sooner, according to interventional cardiologist Stewart Pollock, M.D., of Harrisonburg Medical Associates. “The longer you wait, the more heart tissue dies,” he says. Like all parts of the body, the heart needs an uninterrupted supply of blood to provide oxygen to its cells and tissues through the coronary arteries, Dr. Pollock explains. But people with coronary artery disease have a waxy substance inside their coronary arteries called plaque, which builds up over time and hardens. If an accumulation of plaque happens to rupture, a blood clot can form at the rupture site, blocking the artery. B Y N E I L M O W B R AY Sentara.com 17 “The longer you wait, the more heart tissue dies” “With a heart attack the coronary artery is closed,” Dr. Pollock says. “A blood clot forms on the plaque, and blood flow is diminished or lost beyond that point. So the heart muscle—the cells and tissue—that depends on the oxygen from that blood flow is no longer receiving the oxygen, and the tissue starts to die.” Not all the oxygen-deprived heart cells die at once. Dr. Pollock describes a “wave of infarction”—tissue death from lack of oxygen—that starts with the cells deep inside the heart and works its way outward. “The heart cells begin to die very quickly,” he continues, “within the first 15 to 20 minutes 18 healthQuest | Winter 2015 after onset of chest pain. People experience the chest pain or other symptoms because the cells are dying. The death of those cells progresses for about 12 hours.” Persons having a heart attack may experience “classic” symptoms, including pain or pressure under the breast bone that may radiate down the left arm or into the neck, jaw or back; sweating; and shortness of breath. Some patients—particularly women—may have less obvious symptoms, such as feeling unusually tired, especially for several days, or feeling dizzy, lightheaded or nauseated. So how do you know if what you’re experiencing is a heart attack? “Often you don’t know for sure,” Dr. Pollock says. “It’s often difficult even for physicians to know, which is why we have to run multiple tests on some patients.” And that’s exactly why reacting quickly to heart symptoms is so crucial. During a heart attack, time is, in a very real sense, proportional to loss of heart muscle. “By the time the patient gets to the hospital, he or she is going to have some heart damage, but it may still be quite minimal if the patient responds quickly to his or her heart symptoms and seeks medical attention immediately,” Dr. Pollock explains. Once caregivers have determined that a patient is indeed having a heart attack, an interventional cardiologist can open the blocked coronary artery with balloon and stent procedures in the Sentara RMH cardiac catheterization lab. The goal of treatment is to restore blood flow to the heart tissue and limit the infarct, the area of heart cells that are dying from lack of oxygen. “The take-home message is: if you think you’re having a heart attack, call 911 immediately, and then, as an added measure, take one adult dose of aspirin,” adds Dr. Pollock. “Those simple steps will help you maximize your chance for a good outcome.” Superior Heart Care Sentara RMH Medical Center “Goes Platinum” for Second Consecutive Year For the second year in a row, Sentara RMH has received the American College of Cardiology’s ACTION Registry®—GWTG™ (Get With the Guidelines) Platinum Award for providing superior care to heart attack patients. I n evaluating Sentara RMH for award consideration, the ACTION Registry looks at the treatment of all patients who were seen for heart attack in the previous year at the hospital, says Linwood Williams, cardiac operations manager for the Sentara RMH Heart and Vascular Center. The Platinum Award is the highest level of award granted by the registry. “The registry looks at the patient’s entire stay at the hospital—how long the patient was here, whether the proper medications were given before and after discharge, and whether the patient received appropriate education to help him or her remain well,” says Williams. One of the most important measures the registry considers is door-to-balloon time. This refers to the amount of time it takes to get a patient suffering a STEMI, the most serious kind of heart attack, from the ambulance; through the Emergency Department (ED); and into the catheterization lab, where the blocked coronary artery is opened in a procedure known as balloon angioplasty. The National College of Cardiology and the American Heart Association have set a goal of 90 minutes or less from door to balloon. The Sentara RMH average door-to-balloon time is 46 minutes, while the national average is 59.2 minutes, Williams says. The Action Registry also looks at an institution’s mortality rate after intervention—that is, the number of heart attack patients who go on to die after having their blocked coronary artery opened. The risk-adjusted 90th percentile for all U.S. hospitals is 3.37 percent, whereas Sentara RMH’s rate is considerably better, at 0.98 percent. Lifesaving Collaboration Sentara RMH is able to accomplish these impressive results because of a close collaboration among the hospital’s ED and cardiac catheterization lab and the area’s emergency medical service (EMS) providers. “It would not be possible at all without those three components working well together,” Williams says. In 2009, Sentara RMH donated 16 portable 12-lead EKG (electrocardiogram) cardiac monitors to local EMS squads that didn’t already have them, to ensure that each area’s emergency vehicle was equipped with this lifesaving device. An initial diagnostic tool that checks heart rhythm, the monitor can help EMS providers determine if a patient is having a heart attack. In such cases, the EMS squad alerts the Sentara RMH ED staff. “The EMS providers are an integral part of the team because they make accurate assessments in the field and transmit EKGs to the ED, so we can alert the STEMI team to be on standby when the patient arrives,” says Marcus Almarode, nurse director of the Sentara RMH ED. “Those 12-lead EKGs play a huge role in this; they’re priceless when it comes to saving lives.” Helping People is the Point ED Medical Director Robert Marble, M.D., notes that the significance of being recognized by the ACTION Registry isn’t in the honor of receiving the award. “What’s important is that we’re being officially recognized for the high level of care we provide our heart patients,” he says. “The bottom line,” adds Williams, “is that if you’re having a heart attack—even a serious one like a STEMI—and you come to Sentara RMH, you’re going to receive care here that is as good as you would get anywhere.” Sentara.com 19 for your health Are You Smart About Your Heart? Improve your heart IQ with Heart Check, a personalized, one-on-one screening and health coaching program designed to help you learn about your risk of developing heart disease and what you can do about it. What Makes Heart Check Different? The Sentara RMH Heart Check program provides a unique dual approach of personalized cardiovascular disease risk assessments and meaningful health coaching. In addition to gaining awareness about your personal risk factors for heart disease, you will also be guided and encouraged to make optimal health decisions for your future. How Does Heart Check Work? After scheduling your appointment, you’ll have some lab work completed, and the results will be sent to the heart health navigator, who is a cardiac nurse and integrative health coach certified by Duke Integrative Medicine. During your appointment, the heart health navigator will help you identify your cardiovascular disease risks by using standardized biomeasurements and a lifestyle assessment. Other tests and advanced screenings may be suggested based on your results. A copy of your risk profile, along with your lab results, will be provided to you and can be forwarded to your healthcare provider. Taking Heart Check to the Next Level A new addition to the Heart Check program is health coaching, which is offered as an optional follow-up to your Heart Check appointment. If you would like more help in setting goals, staying motivated and maintaining healthy lifestyle changes, health coaching is a good next step. How Much Does Heart Check Cost? Heart Check and all follow-up coaching appointments are $50 each. ■ Schedule a Heart Check Today! To schedule an appointment, call Sentara RMH Patient Scheduling at 540-689-6000. You will receive a brief assessment questionnaire and a form for your blood work after registering. Heart Check appointments are held at the Sentara RMH Funkhouser Women’s Center. Appointments are available to both men and women. 20 healthQuest | Winter 2015 Why Should I Schedule a Heart Check Appointment? • Cardiovascular disease is the leading cause of death in American women and men. • Among both women and men, cardiovascular disease causes more deaths than all forms of cancer combined. • Women’s heart attack symptoms are different from men’s. Often these symptoms are not recognized and go undiagnosed. • For many men, the first sign of cardiovascular disease is a heart attack. • Cardiovascular disease is the primary cause of premature, permanent disability among the U.S. workforce. • The estimated average amount of life lost due to a heart attack is 14.2 years. sobre su salud ¿Toma decisiones inteligentes con respecto a su corazón? Mejore el CI de su corazón con Heart Check, un programa personalizado de detección personal y asesoría de salud para ayudarle a saber el riesgo que corre de desarrollar enfermedades cardíacas y lo que puede hacer al respecto. ¿Qué es lo que hace a Heart Check diferente? Llevando a Heart Check al siguiente nivel El programa Sentara RMH Heart Check proporciona un enfoque dual único de las evaluaciones personalizadas de riesgos de enfermedades cardiovasculares y asesoramiento de salud significativo. Además de estar más consciente de sus factores de riesgo personales de desarrollar enfermedades cardíacas; también se le guiará y animará a tomar decisiones de salud óptimas para su futuro. Un nuevo complemento del programa Heart Check es la asesoría de salud que se ofrece como un seguimiento opcional a su cita de Heart Check. Si desea obtener más ayuda para proponerse metas, estar motivado y mantener cambios de estilo de vida saludables, el asesoramiento de salud es el siguiente paso. ¿Cómo funciona el programa Heart Check? Después de haber programado su cita, completará un análisis de laboratorio y los resultados se enviarán a el navegador de salud cardíaca, que es un asistente cardíaco y un asesor de salud integral certificado por Duke. Durante su cita, el navegador de salud cardíaca le ayudará a identificar sus riesgos de desarrollar una enfermedad cardiovascular por medio de biomedidas estandarizadas y una evaluación de su estilo de vida. Se pueden recomendar otras pruebas y exámenes de detección avanzados basado en sus resultados. Se le proporcionará una copia de su perfil de riesgo, junto con sus resultados de laboratorio lo que puede ser enviado a su proveedor de atención médica. ¡Programe una cita para Heart Check hoy! Cuando llame para programar su cita puede pedir un interprete si lo necesita. Para programar, llame a programación de citas para pacientes de Sentara RMH al 540-689-6000. Usted recibirá un cuestionario de evaluación breve y un formulario para su análisis de sangre después de la inscripción. Las citas para Heart Check se llevan a cabo en el Sentara RMH Funkhouser Women’s Center (Centro para mujeres Funkhouser de Sentara RMH.) Las citas están disponibles para hombres y mujeres. ¿Qué precio tiene Heart Check? Heart Check y todas las citas de seguimiento para asesoría cuestan $50 cada una. ■ ¿Por qué debo programar una cita para Heart Check? • Las enfermedades cardiovasculares son la causa principal de muerte en hombres y mujeres estadounidenses. • Las enfermedades cardiovasculares causan más muertes entre hombres y mujeres que todas las formas de cáncer juntas. • Los síntomas de ataque al corazón de la mujer son diferentes al de los hombres. Con frecuencia, estos síntomas no son reconocidos y no son diagnosticados. • Para muchos hombres, el primer signo de enfermedad cardiovascular es un ataque al corazón. • Las enfermedades cardiovasculares son la principal causa de discapacidad prematura permanente entre la fuerza laboral de los Estados Unidos. • El promedio estimado de años de vida perdidos debido a un ataque al corazón es de 14.2 años. Sentara.com 21 DIAGNOSIS DISTANCE FROM A By Luanne Austin Telestroke Technology Ensures Patients Receive Quick Treatment When James Garrett’s left side went numb in early November 2014, he suspected he was having another stroke. Soon he was on his way from his home in Franklin, West Virginia, to Sentara RMH. Within moments of his arrival at the hospital, Garrett was examined by a neurologist—but this was different from any exam he’d ever had before. The neurohospitalist, Daniel Chehebar, D.O., did his assessment by way of stroke telemedicine, also known as telestroke. “It threw me a curve at first,” says Garrett, 77, but he soon felt comfortable talking with Dr. Chehebar through an Internet connection. Using telestroke, neurologists (physicians with advanced training in the nervous system) remotely evaluate people who have had strokes, then make diagnoses and treatment recommendations to emergency medicine physicians on site with the patients. The physicians communicate using digital video cameras, microphones and speakers, Internet telecommunications, 22 healthQuest | Winter 2015 Know the Signs and Symptoms of Stroke Sudden numbness or weakness of the face, arm or leg Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, or loss of balance or coordination Sudden severe headache with no known cause Sudden confusion or trouble understanding Emergency Department physician Dr. Nazir Adam, left, and nurse Justin Brenneis with the telestroke unit. With stroke, time is brain tissue! If you think you may be having a stroke, or if you think someone else is, call 911 immediately. Sentara.com 23 robotic telepresence, and other technology. A prompt neurological evaluation means patients can receive the “clot-busting drug” t-PA, or tissue plasminogen activator, in time to reduce their risk of disability and death resulting from stroke. The target time for administering the drug is within one hour of the stroke’s onset. Available Around the Clock In September 2014, after receiving telestroke training, the Sentara RMH neurologists and Emergency Department (ED) staff were ready to do a dry run using the new system for diagnosis. The telestroke hardware includes a dedicated computer mounted on a table with wheels, so it can be moved quickly and easily to a patient’s exam room. “The telestroke allows us to call a neurologist at home from the computer here,” says Carlissa Lam, RN, clinical nurse specialist. Each of the hospital’s four neurologists has a dedicated computer at home to use for this purpose. Video cameras on the telestroke computers allow the physician and patient to see each other, and the physician can control the hospital camera’s position from home to better examine the patient. Microphones and speakers also allow them to talk with each other. The neurologist works with the ED physician and nurses to assess the patient, looking for the telltale signs of a stroke: slurred speech, drooping face, and weakness in an arm or leg. The ED staff acts as the neurologist’s hands. At home, the neurologist receives the patient’s lab results; checks the CT scan; and, if necessary, places an order with the hospital pharmacy for t-PA. “The idea is to get patients evaluated sooner to see if they qualify for the clot-busting drug,” Lam says. “Every minute we can save, we’re saving brain cells. That’s our goal.” Lower Your Stroke Risk Eat plenty of fruits, vegetables and foods high in fiber, and avoid saturated fats. Control your weight. Get 30 minutes of physical activity most days of the week. Don’t smoke. Drink alcohol in moderation, if at all. Have your blood pressure and cholesterol checked regularly. Keep your blood sugar under control if you have diabetes. 24 healthQuest | Winter 2015 A Time-Saving Role in Modern Medicine Dr. Chehebar first used the telestroke technology in September, late at night. Right from home he performed an assessment, put in the orders for the needed drugs, and communicated with the ED physicians and pharmacy. Then he went to the hospital. “I still wanted to see the patient,” says Dr. Chehebar. “It wasn’t necessary—more just peace of mind for me. I hadn’t used the telestroke system before.” The telestroke diagnosis enabled the patient to receive the clot-busting drug 20-25 minutes sooner than he would have without the telestroke. “It doesn’t seem like a long time, but 2 million neurons a minute die with a stroke,” adds Dr. Chehebar, who lives 15-20 minutes from Sentara RMH. “Stroke is such a time-sensitive condition. Literally, every minute counts.” For every 15 minutes of time saved before administering the clot-busting drug, the difference in improvements can be charted, says Dr. Chehebar. So those 20-25 minutes saved can have a big impact on a patient’s outcome. Dr. Chehebar admits the telestroke assessment is different from being physically present with a patient. “I can’t touch the patient to feel for the tremor, for the little nuances you can evaluate, and I couldn’t listen to his heart,” he says. But telemedicine does have a certain place in modern medical treatment, Dr. Chehebar explains. “With the NIH stroke scale and the welltrained ED docs and nurses on the other end, we can decide with confidence to recommend the t-PA,” he says. Dr. Chehebar was pleased that Garrett interacted so well with him by way of the telestroke system. However, it turned out the patient did not qualify for the clot-busting drug. During his assessment, Dr. Chehebar discovered Garrett was already on a strong regimen of blood-thinning drugs due to previous heart attacks and stroke. “The first line of treatment was not available, so I was able to talk over the telestroke computer with the patient and his family about what we were going to do,” recalls Dr. Chehebar. “I was glad to be able to respond to the patient’s situation quickly.” Sentara RMH Welcomes First Neurohospitalist F or seven years, neurologist Daniel Chehebar, D.O., was on call at the hospital’s Emergency Department (ED) every two to three weeks. If a stroke patient arrived in the ED, Dr. Chehebar would drop everything to rush to the hospital. “When it happens, you have to say to the patient in your office, ‘Sorry, I’ve got to go,’ and you schedule another visit later,” he says. This fall, Dr. Chehebar Dr. Dan Chehebar became Sentara RMH’s first neurohospitalist, one of the inpatient care specialists on staff at the hospital. He works every other week—on call 24/7—which allows the other three neurologists in Harrisonburg to be on call less often, so they can spend more time in their own offices. A recent trend in health care, the neurohospitalist model offers many advantages to physicians and patients. According to the American Academy of Neurology website, neurohospitalists are now present in both academic and community settings across the United States. Better for Patients Having a neurohospitalist in the ED when a stroke patient arrives ensures quicker diagnosis and treatment, which translates to better survival and recovery rates. Particularly in stroke situations, time is of the essence—the clot-busting drug t-PA is most effective when administered within one hour of the stroke’s onset. Dr. Chehebar deals mainly with strokes and seizures, but in the hospital, he says, “critically ill people in intensive care can be subject to neurological problems, such as after a heart attack or renal damage. Patients may seem confused or mixed up, so the attending physician may ask me to come figure out what’s going on.” Dr. Chehebar believes it’s essential for him to spend adequate time with patients. “Neurology is different from, say, orthopedics, in the sense that it may not have definite physical symptoms,” he explains. “If someone falls down and comes into the office complaining of pain, the orthopedist can do a focused physical exam; order an X-ray; and often make a quick, accurate diagnosis. “With neurology, however, with a condition like multiple sclerosis, a patient may report fatigue, headaches and insomnia, so there’s more to check for,” he says. “You have to listen and ask a lot of questions. It takes a bit of digging.” Sentara.com 25 Revived Mended Hearts Chapter Provides Support and Education for Heart Patients and Caregivers Hopeful Hearts BY KAREN DOSS BOWMAN For Dennis Ragan of New Market, the heart attack he experienced in 1995 was truly a wake-up call. At the time, Ragan was overweight and a smoker who rarely exercised, and he had a history of heart disease in his family. After having double bypass surgery to treat his condition, Ragan says he was “hungry” for information about how to make healthier lifestyle choices. Dennis and Stephanie Ragan have been actively involved with Mended Hearts since the mid-1990s. 26 healthQuest | Winter 2015 “I wanted to learn everything—from what I could eat that would be heart healthy and also taste good, to what kinds of exercises would be most beneficial,” says Ragan, now 69. Ragan and his wife, Stephanie, found support, encouragement and hope through Mended Hearts, a national and community-based nonprofit organization with more than 300 chapters across the country. The group meets monthly to offer education and emotional support to heart disease patients, as well as their families and caregivers. “We’re walking, talking examples of life after heart surgery or a heart event,” shares Ragan, a charter member of the original Mended Hearts chapter that was active at Sentara RMH from 1998 to 2010. “Life is still good.” Today the Ragans are encouraging others living with heart disease to join a new chapter of Mended Hearts that recently began at Sentara RMH. The Harrisonburg group, a satellite of the Winchester chapter, held its first meeting in October. Peer-to-Peer Care Mended Hearts is the nation’s oldest peer-to-peer cardiac support group, providing heart disease patients and their loved ones a safe place to talk about lifestyle changes and offering support to cope with depression and achieve recovery. Following his triple bypass surgery in April 2014, Tracy Baughman, 52, of Harrisonburg, sought the support of other patients. Baughman, whose blockages were discovered as the result of an abnormal electrocardiogram and stress test, knew his family history of heart attacks meant he was at higher risk for heart disease. He attended the October Mended Hearts meeting after seeing an ad in the Daily News-Record. “I wanted someone to talk to who had gone through a similar situation,” Baughman says. “You can talk about what you’re feeling and find out if that’s normal, or learn from others how they dealt with certain situations.” Baughman was the first member to join the revived Mended Hearts group and is looking forward to being involved with the local organization. The Importance of Education While emotional support is vital to healing, Mended Hearts also educates heart disease patients about their condition and how to stay healthy. Cardiothoracic surgeon Jerome McDonald, M.D., FACS, fully supports the newly revived Mended Hearts chapter. The support group can help “normalize the experience,” he says, particularly for patients who are experiencing depression. “Mended Hearts can really offer hope for people facing distressing and overwhelming circumstances,” he adds. Caring Visits An important component of Mended Hearts is the visiting program, staffed by local chapter members who are trained and accredited by the national organization to visit new heart patients and their families in the hospital. These visiting volunteers can be recognized easily in the hospital by their red vests. New heart patients are typically concerned about how their lives will change and how quickly Tracy Baughman is the first member to join the revived Mended Hearts group at Sentara RMH. they will heal, says Ragan, who was an officer of the original local chapter and also served at the national level, including time on the national board of directors. “Patients want to know what’s normal in recovery and when they should call or visit their doctor,” he says. “So these visits can really help. We get them to talk about their experiences, and that’s often cathartic. Once they start talking, we share our experiences to keep the conversation going.” Ragan’s wife, Stephanie, also a charter member and officer of the original chapter, points out that families face many challenges as they prepare to take a new heart patient home. Following her husband’s heart attack, she worried that he might have another cardiac episode. She was also concerned about his recovery and dietary needs, and the psychological effects of his experience. “As a caregiver, you don’t know what to expect,” she says. “But with Mended Hearts you don’t have to face it alone.” ■ YOU’RE INVITED! Heart patients and their family members are invited to attend the monthly meetings of the Sentara RMH Mended Hearts satellite chapter. For more information, contact Tom Rice of the Sentara RMH Heart and Vascular Center at 540-689-1839 or thrice@sentara.com. Sentara.com 27 living with synergy FOLLOW YOUR HEART TO A Path of Purpose Are Mondays coming too often and Fridays not often enough? Do you feel you’re not as good a fit for your current job as you once were, but are unsure about what other kinds of work you could do? Are you stuck spinning your wheels but getting nowhere, wondering if others know something you don’t? Perhaps you’ve dreamed of starting a business, but you’re too busy just getting through each day to see how you could turn your passion into reality. I f any of the above scenarios fits you, I invite you to stop going through the motions and answer a couple of tough questions: • Areyoudoingwhatyouwanttodoorwhatyou think you should do? • Doyoulikeandrespectwhoyouareinyourwork? Many of us may have chosen a career based on family expectations, advice from teachers, or areas of study in which we performed well. But for some people, none of these influences is necessarily the best basis upon which to build a life. In his book “The 7 Habits of Highly Effective People,” author Stephen Covey writes: “Most people spend their whole lives climbing the ladder of success only to realize, when they get to the top, the ladder has been leaning against the wrong wall.” 28 healthQuest | Winter 2015 Sadly, we can be very successful at a given profession but never really satisfied by it. Who we are is much more than what we’re good at, and success without fulfillment can be toxic over time. The happiness we desire and deserve comes only when we live in alignment with our core values. Luckily, a radical career change isn’t always required for you to live more purposefully. The following tips can help you get to the heart of what really matters, find a deeper connection to the work you already do and add a fresh twist to what you think is possible. 1. Take 100 percent responsibility. YOU are in charge on this one. YOU get to define for yourself what will make you happy—not your friends, not your family, not the latest trends. Listening to our Inner Wisdom When you’re tempted to blame others or complain about your circumstances, state out loud: “I take full accountability for my own happiness and fulfillment.” 2. Be honest. Come clean on what you do— and don’t—feel passionate about. “Your time is limited, so don’t waste it living someone else’s life. Don’t be trapped by dogma—which is living with the results of other people’s thinking. Don’t let the noise of others’ opinions drown out your own inner voice. And most importantly, have the courage to follow your own heart and intuition. They somehow already know what you truly want to become. Everything else is secondary.” —Steve Jobs Does something you’re involved with now feel more like an obligation? Let go of any attachment to what you think your ideal life should look like; release the unnecessary roles and responsibilities that are draining you dry. 3. Get fresh perspective. Wake up! What are you waiting for? If you think you have forever to get around to that “thing” you want to do, think again. Take nothing for granted; live NOW. This moment is the only one you can do anything about. If today were your last day, what would you wish you had done with your life? Write it all out in a “bucket list” and share it with someone close to you. Ask that person to hold you accountable for crossing something off your list regularly, and celebrate like crazy each time you make one happen! 4. Reframe the idea of perfection. Unrealistic expectations often will sabotage our best efforts at change—so will guilt over past mistakes, regret about missed opportunities and the habit of comparing your “worst” to everyone else’s “best.” Watch out for thoughts like these: • “IfIcan’tdoitperfectly,whytryatall?” • “Imissedmychancetodevelopmytalent.” • “OtherpeoplearebetterormoreskilledthanI; I have nothing special to offer.” If you catch yourself thinking this way, STOP! BREATHE! Then FLIP the thought to one that’s more empowering, such as: • “It’snevertoolatetolearnnewthings.” • “NoonecanfulfillmymissionbetterthanIcan.” 5. Use your struggles. There’s nothing in your past that you can’t use to help you move forward. Every experience you’ve had, especially the challenges and struggles, can help you get clear about why you’re here and how you’re meant to serve. With this resilient mindset, we don’t just survive in spite of setbacks; we intentionally thrive because of them. If there is a higher purpose for the tough times you’ve been through, what would it be? We teach best what we need to learn ourselves. Sharing your story could have a powerful effect on others. 6. Listen to your “heart messages.” Learn to say YES to what your heart really wants. Is there any place in your life right now where you have that “gut instinct” about what to do next? Moments of intuition are blessings about the directions we need to take in our lives, but we can miss the quiet whispers of spirit unless we make an intentional effort to be mindful and listen. Set your timer for five minutes. Go to a quiet place. Close your eyes and place your left hand over your heart. Take a few deep breaths and say the following out loud: “What do you really, really, really want me to know?” Give yourself space to just listen. Repeat the question if you get distracted. You’ll continue to receive answers, so pay attention to flashes of insight, creative ideas and inspirations, and things that you hear and see. Trust that these answers are authentic to you and a reflection of your true calling. The world can be happier and healthier because of the contribution you are here to make. Whether it’s taking up a creative hobby, volunteering for a cause you’re committed to, writing a book or mastering a soul-centered project, my greatest wish is that you follow your heart and claim your true calling—with no excuses or apologies! ■ ■ Christina Kunkle, R.N., is a CTAcertified life and wellness coach. To learn more, visit her website at www.synergylifeandwellnesscoaching.com or call 540-746-5206. Sentara.com 29 All HEART Harrisonburg Man Undergoes Newly Available, Minimally Invasive Heart Surgery For the past 12 years, Don Myers has been an avid mall walker, trekking a distance of two miles, five days a week, inside Harrisonburg’s Valley Mall. The physical activity has been a boost to his overall health, so he was puzzled when last winter he began experiencing chest pain and shortness of breath. Still, he didn’t tell anyone. By Karen Doss Bowman 30 healthQuest | Winter 2015 “I didn’t want to worry my family, and I just thought [the chest pain] would go away.” “I didn’t want to worry my family, and I just thought it would go away,” says Myers, 71, a Harrisonburg resident who retired in 2006 from Myers Ford in Elkton, the car dealership his family owns. “I didn’t think it was anything to be concerned about.” After two weeks of persistent chest pain, however, Myers finally confided in his two walking partners—one of them a nurse—who were adamant that he seek medical attention that very day. Myers called his primary care doctor, who advised him to go to the hospital immediately. At the Sentara RMH Heart and Vascular Center, Myers, who has no previous history of heart problems, underwent a stress test that revealed a blockage of the left anterior descending coronary artery, the most important vessel for supplying blood to the heart. Because of the obstruction, the heart wasn’t receiving adequate blood flow. A subsequent evaluation in the catheterization lab showed that the blockage, because of its location, could not be treated with a stent, a small wire tube designed to keep an obstructed artery open. Myers was told he would need coronary artery bypass grafting (CABG) to create a new pathway for blood to flow to the heart. Because he needed grafting for just one artery, he was a candidate for minimally invasive CABG, a procedure that requires just a small, two-inch incision and can be performed with the heart beating. New Technique, Big Benefits Sentara RMH began offering the new procedure in fall 2013 when Jerome McDonald, M.D., FACS, joined the hospital’s medical staff. Dr. McDonald is a cardiothoracic surgeon with specialized expertise in minimally invasive surgery for the heart and chest area, including the lungs. He also is one of a small number of cardiothoracic surgeons in the country who perform minimally invasive aortic valve replacement. Prior to Dr. McDonald’s arrival at Sentara RMH, patients had to go out of the area for these procedures. Dr. McDonald, who serves as medical director of the Sentara RMH cardiothoracic surgery program, explains that the minimally invasive CABG procedure offers a faster recovery time and leaves a less-visible scar than traditional open-heart surgery. The traditional approach requires a large, eightinch to 10-inch incision and is performed while the patient is connected to a heart-lung machine to keep blood circulating through the body. The recovery period for traditional open-heart surgery can be six weeks or longer. However, the minimally invasive procedure isn’t an option for the majority of Dr. McDonald’s patients, he says. Those who need more than one or two bypass grafts, or those who have had previous heart surgeries or who have other health conditions, are not candidates for the technique. Sentara.com 31 “The care I received was excellent. Everybody was really attentive to my needs and went out of their way to be helpful.” “Most patients we do heart surgery on need quadruple bypasses,” says Dr. McDonald. “But the minimally invasive approach is an excellent option for those who need only one or two bypass grafts in certain segments of the heart. There’s essentially no bleeding with this procedure. Patients are less likely to have complications, so they can go home sooner, experience a quicker recovery and get back to their normal activities.” Getting Back on his Feet Just two weeks after his surgery, Myers began rigorous cardiac rehab at Sentara RMH, during which he worked out on the treadmill, the NuStep and a stationary bicycle. His recovery wasn’t easy, but Myers credits the medical team as a large motivating factor for him. “Cardiac rehab was no picnic—they really put me through the paces,” he recalls, laughing. “But I really have no complaints. They were doing their job and took good care of me.” Myers also was pleased with the care and attention he received from Dr. McDonald and the nurses and other medical staff at the Sentara RMH Heart and Vascular Center. Since completing his rehab, Myers has resumed his normal activities, including walking two miles daily, five days a week, at the mall. He believes his walking habit may have helped speed up his recovery. “I was back on my feet right away and didn’t feel weak,” says Myers. “The care I received was excellent. Everybody was really attentive to my needs and went out of their way to be helpful. They made the experience as pleasant as possible, and that does make you feel better.” Reassuring Other Heart Patients Myers works with front-desk staff in the Heart and Vascular Center. 32 healthQuest | Winter 2015 Myers has been a Sentara RMH volunteer since 2007, following in the footsteps of both his parents: John, now deceased, and Rachel Myers. As a volunteer at the front desk of the Heart and Vascular Center, Myers says he now understands firsthand patients’ concerns about heart disease and tries to use his own experiences to help ease patients’ anxieties. “I enjoy meeting people coming in with heart concerns,” he says. “Many times, they’re tense and anxious. I hope I can put them at ease by helping them through the registration process or getting them a wheelchair or whatever else they might need. Now I can relate to what these patients are going through.” He does have one specific piece of advice for others who may be experiencing symptoms of heart problems: See your doctor. “If you have any reason to believe you’re having heart trouble, don’t put it off like I did; get it checked out,” Myers suggests. “It could have been much worse for me. I’m thankful my walking partners urged me to see a doctor.” ■ nutrition For Your (Heart) Health, Go Mediterranean! Widely recognized as the model for healthy eating, the Mediterranean diet is associated with a low risk for developing many chronic diseases such as high blood pressure, heart disease, Type 2 diabetes and obesity. BY LISA V. MAHENTHIRAN, M.S., R.D., SENTARA RMH FOOD AND NUTRITION SERVICES The healthful characteristics of the Mediterranean diet include: • Anabundanceoffruits,vegetables,whole grains, nuts, seeds and beans that are minimally processed, seasonally fresh and locally grown • Oliveoilasthemajorsourceofdietaryfat • Lowtomoderateamountsofdairyproducts (mainly cheese and yogurt) • Nomorethanfoureggsperweek • Moderateconsumptionofseafoodorfish (at least twice per week) • Less-frequentconsumptionofredmeat (several times a month) Sentara.com 33 nutrition Simple Steps to Help you go Mediterranean ■ Always eat breakfast. Fruits and whole grains are fiber-rich and will keep you full for hours. Possible breakfast items include granola, yogurt and fruit, or whole grain toast with half a mashed avocado. ■ Eat plenty of vegetables, preferably grown locally. Fill half your plate with vegetables for lunch and dinner. Include salads, greens, soups and stews, oven-roasted or grilled vegetables, vegetable-laden pizzas, and plates of sliced fresh tomatoes drizzled with olive oil and topped with feta cheese. ■ Go vegetarian at least one night a week. Make vegetarian meals using beans, lentils, whole grains and vegetables. Add herbs and spices to increase flavor. ■ Replace refined grains. Instead of white bread, pasta or rice, use whole-wheat bread, brown rice and whole-wheat pasta. Try recipes that use the whole grains barley, bulgur and couscous. ■ Use dairy products in moderation. Eat plain or Greek yogurt and small amounts of a variety of cheeses. ■ Use very little red meat. To lower saturated fat, replace red meat with skinless chicken, turkey, fish, eggs, beans and nuts. Limit portion sizes of red meat to 3-4 ounces. ■ Eat fish or seafood twice a week. Fatty fish like salmon, tuna, herring and sardines are rich in omega-3 fatty acids, which help keep your heart healthy. ■ Experiment with herbs and spices. Use these instead of salt to flavor food. ■ Use healthy fats in meals. Extra-virgin olive oil, nuts, peanuts, sunflower seeds, olives and avocados are sources of healthy fats. Replace margarine and butter with canola oil or olive oil for cooking. A high-quality extra-virgin olive oil seasoned with balsamic vinegar is delicious for dipping bread. ■ Don’t forget desert! Eat a wide variety of fresh fruits. Save sweets like ice cream, cookies, and other items high in sugar and fat for special occasions and celebrations. ■ Drink water. The Mediterranean diet is high in fiber, and the body needs sufficient water for the fiber to work properly. • Lowtomoderateamountsofwine,generally with meals (optional) The Mediterranean diet is a plant-based diet that’s high in fiber and unsaturated fat and low in saturated fat. It doesn’t consist of one type of food, but a combination of foods that work together to maintain good health. As an added bonus, this dietary pattern also recognizes the importance of social ties—enjoying meals with family and friends—and being physically active. What are the Health Benefits? Research over several decades has consistently shown that the Mediterranean diet plays an important role in preventing and slowing the development of many common chronic diseases. • Heart disease and stroke: The Mediterranean diet is heart-protective because it’s low in trans fats, saturated fats and cholesterol. • Type2diabetes: Healthy food choices, combined with regular physical activity and not smoking, can help decrease the risk of developing diabetes. The Mediterranean diet is rich in healthy food options such as whole grains, fruits and vegetables. It is also linked to better blood glucose control in people who are newly diagnosed with diabetes and in those who are overweight or obese. Continued on page 36 34 healthQuest | Winter 2015 Diet: A Four-Letter Word Say “diet,” and many people think immediately of restrictions and limitations. But not so with the Mediterranean diet! It’s not really a “diet” in the way people generally use the term. Rather than dietary restrictions, think of the Mediterranean diet as a way of life you will adapt to help you lose weight and stay healthy. It’s the healthy eating pattern of people who live in olive-growing regions like Greece, Italy, Portugal, Spain and some North African countries. RECIP ES Herb Baked Fish (serves 4) 1 pound of fresh halibut, cod or salmon 2 teaspoons olive oil 1 teaspoon dried thyme ¼ cup grated Parmesan cheese Preheat the oven to 425°F. Place fish in a flat baking dish, skin side down. Rub both sides with olive oil. Sprinkle top with thyme and cheese. Bake for 10 minutes or until the fish flakes easily. Fresh Vegetable Wrap (serves 1) 1 whole-grain wrap 2 tablespoons hummus (any flavor) ½ cup chopped romaine lettuce or baby spinach 2 tablespoons diced walnuts 1 small red pepper, seeded and sliced Place the wrap on a flat surface. Spread the hummus evenly over the wrap, leaving about a half-inch of space around the edge. Add lettuce, walnuts and pepper. Wrap tightly, tucking in the edges. Wrap in aluminum foil for lunchtime transport. Sentara.com 35 Lentil Soup (serves 4) This soup can be made with any kind of lentils. For a protein boost, serve each portion topped with a diced hard-cooked egg. 2 tablespoons extra-virgin olive oil 1 large onion, chopped 1 stalk celery, chopped 1 garlic clove, minced 2 teaspoons ground cumin 2 tablespoons tomato paste 1 quart vegetable or chicken stock 1 cup lentils Juice of 1 lemon Salt and pepper Crumbled feta cheese for garnish Heat the olive oil in a large pot. Add the onion, celery and garlic; sauté for 2 minutes. Add the cumin and cook, stirring continuously, for one minute longer. Add the tomato paste, stir until smooth, and add the stock and lentils. Bring just to a boil; reduce the heat; and simmer partially covered for 20 minutes, or until the lentils are very soft. Add 1 cup of water if the soup seems too thick. Puree in batches in a food processor or blender, return to the pot, and stir in the lemon juice. Season with salt and pepper. Serve garnished with feta cheese. • Obesity: It’s a well-known fact that obesity increases the risk of developing many chronic diseases. Dietary patterns that are high in red and processed meats, high-fat dairy products, sugar-containing beverages, sweets, desserts, and refined grains are associated with an increased risk for obesity and heart disease. In contrast, the Mediterranean diet is linked to decreased risk for obesity because it is nutrient-dense and high in fiber and water, which helps you feel full after eating and keeps you from eating long after you’re already full. People on similar dietary patterns tend to lose weight safely with more long-term benefits and without feeling restricted or deprived. • Cancer: Researchers have found links between a person’s overall dietary pattern and the development of some forms of cancer. The Mediterranean diet consists of food choices that are rich in fiber, antioxidants, and other nutrients associated with an overall lower risk for cancer. The Mediterranean diet also may help prevent osteoporosis and Alzheimer’s disease. The healthiness of the Mediterranean diet continues to be supported by new studies that appear regularly in leading scientific journals. ■ Want to Learn More? Visit Mediterranean Diet & Pyramid/Oldways, available at oldwayspt.org/resources/heritage-pyramids/mediterranean-diet-pyramid 36 healthQuest | Winter 2015 medical staff update The following professionals have recently joined the Sentara RMH medical staff. We welcome them to Sentara RMH and the community. Do you need a physician referral or need to contact a physician? Call our free contact center, Sentara RMH Healthsource, at 1-800-SENTARA. Rebecca L. Botticelli, M.D. Family medicine Valley Family & Elder Care Medical School: Medical College of Virginia, Richmond Residency: Fairfax Family Practice Residency Program, Virginia Commonwealth University, Fairfax Clinical Interests: End-of-life care Personal Interests: Zumba, needlework, traveling, spending time with family Heather N. Camp, DNP Allied health Harrisonburg Medical Associates Graduate Schools: James Madison University, Harrisonburg (MSN); University of Alabama, Tuscaloosa (doctor of nursing practice) Clinical Interests: Gastroenterology Personal Interests: Travel, crafting, reading Amanda L. Gerber, M.D. Pediatrics Bluestone Pediatrics Medical School: Michigan State University College of Human Medicine, East Lansing Residency: Children’s Hospital of Richmond Clinical Interests: Weight problems, behavioral health Personal Interests: Cooking, swimming, hiking, family time Anthony O. Isedeh, M.D. Internal medicine Sentara RMH Hospitalists Medical School: Ross University School of Medicine, Edison, N.J. Residency: Newark Beth Israel Medical Center, Newark, N.J. Personal Interests: Reading, traveling, tennis and golf Nirmal B. Khandoobhai, M.D. Internal medicine Sentara RMH Hospitalists Medical School: Eastern Virginia Medical School, Norfolk Residency: Wake Forest University Baptist Medical Center, Winston-Salem, N.C. Clinical Interests: Hospital medicine Personal Interests: Electronics, biking, hiking Veronica Kheyfets, M.D. Hematology/oncology Hematology Oncology Associates Medical School: Albert Einstein College of Medicine, Bronx, N.Y. Residency: North Shore University Hospital, Manhasset, N.Y. Fellowship: Montefiore Medical Center, Bronx, N.Y. (hematology/oncology) Clinical Interests: Malignant hematology, breast cancer, colorectal cancer, prostate cancer Personal Interests: Gardening, traveling, spending time with family and friends Ryan McKenzie, M.D. Internal medicine Sentara RMH Hospitalists Medical School: Medical University of the Americas, St. Kitts and Nevis Residency: Carilion Clinic–Virginia Tech Carilion, Roanoke Personal Interests: Mountain biking, tennis, fun with family more » Sentara.com 37 medical staff update Chad D. Moorman, DPM, CPed Podiatry Hess Orthopaedics & Sports Medicine, Harrisonburg Medical School: Temple University School of Podiatric Medicine, Philadelphia, Pa. Residency: Temple University Hospital, Philadelphia, Pa. Clinical Interests: Trauma and sports medicine of the foot and ankle Personal Interests: Soccer, cooking, and spending time with his wife and children Georgios Psarros, M.D. Internal medicine Sentara RMH Hospitalists Medical School: University of Athens Medical School, Athens, Greece Residency: Albany Medical Center, Albany, N.Y. Fellowship: University of Michigan Hospitals Health, Ann Arbor (infectious diseases) Clinical Interests: Infectious disease Personal Interests: Soccer, swimming, spending time with his two sons David E. Muscan, N.P. Allied health Harrisonburg Medical Associates Graduate School: James Madison University, Harrisonburg Clinical Interests: Heart failure Personal Interests: Family, public speaking, musical performance Sudhir R. Rao, M.D. Pain management North American Spine & Pain Center Medical School: St. George’s University School of Medicine, Grenada, West Indies Residency: Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, N.Y. (anesthesiology) Fellowship: Mount Sinai School of Medicine, New York, N.Y. (interventional pain management) Clinical Interests: Spinal cord stimulation, chronic neuropathic pain, chronic regional pain syndrome, health and wellness Personal Interests: Travel and running Li Ouyang, M.D. Internal medicine Sentara RMH Hospitalists Medical School: Central South University, Hunan, China Residency: Kingsbrook Jewish Medical Center, Brooklyn, N.Y. Clinical Interests: Diabetes, pulmonary medicine Personal Interests: Reading, cooking, shopping Beth Poore-Bowman, N.P. Allied health Harrisonburg Medical Associates Graduate School: Virginia Commonwealth University, Richmond Clinical Interests: Heart failure, heart disease prevention, electrophysiology Personal Interests: Reading, knitting, hiking, travel, cooking 38 healthQuest | Winter 2015 Sarah C. Rhinehart, N.P. Allied health Sentara RMH Valley Behavioral Medicine Graduate School: Virginia Commonwealth University, Richmond Clinical Interests: Schizophrenia, underserved population Personal Interests: Gardening, biking, hiking, spending time with her dog Melissa K. Sikes, FNP-C Allied health Harrisonburg ENT Graduate School: University of Virginia, Charlottesville Certification: Family nurse practitioner Clinical Interests: Otolaryngology Personal Interests: Crafting, outdoor adventures, spending time with family Alexandria A. (AlexAnn) Westlake, CNM Allied health Shenandoah Women’s HealthCare Graduate School: Oregon Health & Science University, Portland Clinical Interests: Women’s health, pregnancy, preconception care, contraception, postpartum care Personal Interests: Trail running and hiking with her family, friends and dog; cooking; gardening Jason P. Wilson, P.A. Allied Health Harrisonburg Emergency Physicians Graduate School: James Madison University, Harrisonburg Clinical Interests: Emergency medicine Personal Interests: Camping, kayaking and archery Kimberly St. Jean, M.D. Hospice and palliative care Sentara RMH Hospice and Palliative Care Medical School: Drexel University College of Medicine, Philadelphia, Pa. Residency: University of Illinois at Chicago (internal medicine) Fellowship: Med Star Washington Hospital Center/Capital Caring, Washington, D.C. (hospice and palliative medicine) Personal Interests: Travel, college football, music Constance N. Wenger, P.A.-C Allied health Harrisonburg Medical Associates Graduate School: James Madison University, Harrisonburg Clinical Interests: Nephrology, inflammatory process, biofilms Personal Interests: Kayaking, gardening, travel Sentara.com 39 RMH foundation Funding Compassionate Care By Karen Doss Bowman B “We hope our gift will contribute to better care all around.” 40 healthQuest | Winter 2015 Grateful Patient Supports Advanced Education for Sentara RMH Nurses ill Bedall understands firsthand the impact caring nurses can make on a patient’s experience at Sentara RMH. During each of the three times he’s been hospitalized— most recently in December 2013 after an episode of atrial fibrillation, or irregular heartbeat—Bedall has been impressed with the level of care and compassion delivered by the hospital’s nurses. Not only did they bring him his medications and monitor his progress, they also offered reassurance to him and his wife, Gerry, during their times of uncertainty. “Everyone on the medical team provided excellent care, but I was especially impressed with the nurses,” says Bedall, who worked for 40 years as a financial planner in Harrisonburg before retiring 14 years ago. “They really did a great job taking care of me. They were at or near the bedside 24/7.” As an expression of gratitude for the care they received, the Bedalls recently made a generous contribution to support the Sentara RMH Institute for Nursing Excellence and Innovation. The institute provides scholarship support to nurses seeking to advance their nursing education. Sentara RMH has set a goal of having at least 80 percent of its registered nurses trained at the baccalaureate level or higher by 2020. Support from grateful patients like Bedall, who also made a substantial gift to the Sentara RMH Heart and Vascular Center, is crucial to strengthening the hospital’s delivery of nursing care. “Bill and Gerry’s generosity to the RMH Foundation has made a tremendous impact on the care our patients receive,” says Cory Davies, executive director of the Foundation. “Their earlier gift helped fund advanced technology that enables our Heart and Vascular Center to provide the latest, most advanced treatments to patients. And their most recent support invests in the training and education of our nurses. It’s a gift that keeps on giving, because the nurses who benefit pay it forward as they provide higher-quality care to their patients.” Bill and Gerry Bedall, of Harrisonburg, give to the RMH Foundation because of the compassionate care they have received at Sentara RMH. As health care becomes increasingly complex, ongoing professional development for nurses is essential, especially as the current shortage of experienced nurses continues to grow. The Harrisonburg community is not immune to this predicament, says Davies, so the institute is putting into place strategies to develop and support new nursing graduates and to retain experienced clinicians. “Sentara RMH is committed to ‘grow our own’ expert nurses through formal education, professional development and specialty certification,” Davies adds. “We want to continue the hospital’s long-standing commitment to nursing excellence.” The institute also seeks to improve patient care by supporting original research and the application of evidence-based best practices in patient care. As nursing knowledge and practice continue to advance, the quality of the care delivered at Sentara RMH will be enhanced by nurses who contribute to that scholarly work and pursue methods for applying it at the bedside each day. “When you’re in the hospital, the nurses are the people on the medical team who are with you the most, day and night,” notes Bedall. “So having nurses who can recognize when something is going wrong, even when the doctor isn’t nearby, is very important. That’s why we wanted to support nursing scholarships. If I’m in the hospital bed, I want the assurance that the person who’s by my bedside, taking care of me hour by hour, is as well trained as can be.” For many nurses with families to support, committing to an educational program can be challenging. The Bedalls hope their gift will help ease the burden for working nurses and encourage them in their pursuit of professional development. “I have three sisters who are nurses, and I know what they go through to further their education,” Gerry says. “We hope our gift will contribute to better care all around.” ■ Sentara.com 41 friends OF THE RMH FOUNDATION Gifts Received June 1–Nov. 23, 2014 Sentara RMH Medical Center is grateful to have the support of generous community members. We express this gratitude and recognize the contributions our donors make through the President’s Forum, the William Leake Society and the 1910 Cornerstone Club. These exclusive giving circles are our way to honor our most generous partners who show they care about having the best medical services available in our community. Thank you for your support! Totals represent cumulative amounts given in 2014. President’s Forum $100,000 and above The Fred O. Funkhouser Charitable Foundation Inc. Harrisonburg Emergency Physicians, PLC $25,000–$99,999 Warren L. and Lillian C. Braun Garner H. and Mae Frances Downey Fidelity Charitable Gift Fund Zanette and Howard Hahn Jerry and Becky Morris Karl D. and Barbara B. Stoltzfus $5,000–$24,999 Jerry R. and Kathleen L. Andes Bill and Gerry Bedall Eddie R. and Catherine Coffey Dynamic Aviation Group Inc. Farmers and Merchants Bank Harry F. and Margaret M. Flippo Foundation given through The Community Foundation of Harrisonburg and Rockingham County Orden L. and Reba Harman Dr. Alden L. and Louise Otto Hostetter Herman and Janet Mason Families given through The Community Foundation of Harrisonburg and Rockingham County Packaging Corporation of America (PCA) Rockingham Cooperative 42 healthQuest | Winter 2015 Rotary Club of New Market Charitable Fund The Merck Foundation Theta Iota Chapter of Alpha Phi, JMU Lynn and Diane Trobaugh N. Paige and Ann C. Will William Leake Society $1,000–$4,999 Active Network Drs. Frank J. and Jean-Marie P. Barch Larry and Natalie Beiler Blackwell Engineering, PLC Blue Ridge Aviation Blue Ridge Bank Bob Wade Auto World J. Michael and Dianne H. Burris Dr. William F. and Susan Cale Piers Carey William B. Sr. and Phyllis W. Carper Dr. Dale A. Carroll and Merrily McGowan Paul and Sherry Cline George L. Curran III Brownie M. Driver Gladys A. Driver Friends of Valley Charities M. C. and Lori Gravely Asa and Kathleen Graves given through The Community Foundation of Harrisonburg and Rockingham County Elizabeth Harnsberger Trust Katherine A. Harrison Harrisonburg Department of Parks and Recreation Richard and Julie Haushalter Dr. Charles H. and Mary Henderson International Student Association Joe Bowman Auto Plaza Richard and Mona Johnson Mary Elizabeth Kite Estate Jim and Vicki Krauss Mary Louise Leake John and Kathy Lubkowski Janet L. Macarthur Linda T. and James R. McIntyre Jr. T. Carter Jr. and Connie G. Melton Jim and Pat Messner N2 Hair Salon Garry and Nancy Nichols George and Ann Pace Heidi D. Rafferty, M.D. Deborah Y. Ritchie Rocktown Sports Performance, LLC E. John III and Carol H. Rosenberger Michael and Susan Rozmus Martha Coupe Schneider Bob and Mary Sease and Family given through The Community Foundation of Harrisonburg and Rockingham County Shenandoah University Mary C. and James R. Sherman Helen W. Shickel Sigma Phi Epsilon Ed and Zizi Sipe Audrey L. Smith Lisa H. Spruhan Ethel S. Strite Estate Debra D. Thompson Turner Ashby High School Student Athletes and Athletic Program Dr. Robert M. Underwood United Way of Greater Augusta Inc. Nancy Hopkins Voorhees 1910 Cornerstone Club $100–$999 Accuwrite Forms and Systems Inc. Robert L. and Karma C. Adams Isobel B. Ailles Corina Albert Clarence C. and Helen M. Allen Donald V. Allen Franklin L. Allman Jr. Marcus B. Almarode James R. Alpine Social Security Retirees Richard and Johanna Anderson Margaret B. Arbogast C. Dennis Armentrout Eldon W. and Sandra P. Armstrong Isabel Baez Lloyd C. and Theresa G. Bailey Sandra G. Baker Cynthia M. Banks Joyce I. Barb Edgar L. Barnard Jr. John G. Barr Stephen S. Sr. and Mattie Wacker Barranco Charles and Janet Batten Richard A. Baugh Jennifer B. Baugher Sheila R. Baugher Walstene A. Bazzle W. William and Elizabeth A. Beckmeier James T. Sr. and Barbara R. Begoon George W. Bell Thomas L. Bellamy David L. Bernd Kenneth G. and Linda R. Berry Lois E. Berry Richard and Sandy Berthelsen and Family Dr. Thomas and Faythe E. Bertsch Beta Alpha Psi—James Madison University Donna K. Blank Patricia Blankenbicker Debra H. Bontrager Jane H. Bowles Gail M. Bowman James O. and Sylvia K. Bowman Larry O. and Paula C. Bowman Auburn A. and Ruth D. Boyers Joyce A. Bracken Robert N. Branson Angela M. Breeden Craig L. Breeden Teresa A. Breeden Rosemary O. Brenner Lisa Bricker Jeb W. Brittle Carol J. Brooks Candace R. Brown Dr. and Mrs. Donald R. Brown, DDS H. Kent Brown Larry E. Brown Harold D. and Fay K. Brubaker J. Allen and Erma R. Brubaker Lynn and Becky Brubaker Nellie V. Brubaker Rebecca M. Brubaker Jennifer M. Bryant Katharine C. Buckner Henry F. and Catherine S. Buhl Jane S. Burgess Amy E. Burke Christine W. Burner Gregory G. and Pollyanna A. Bush Matthew S. and Carrie C. Bynaker Howard E. Sr. and Anne G. L. Byrd Nancy E. Camp Charles T. Campbell Jay L. Campbell Eleanor F. Canter Robert P. and Marilyn R. Carroll Thomas F. and Janice R. Carroll Harry W. Cash Stephanie M. Cave Stephen and Gretchen Cessna Kathryn L. Cheeks Sheri Lee Childs Lee E. Clapper Sr. Hope R. Clatterbuck Holly B. Clem Brenda J. Cline Ralph W. Cline David R. B. and Christine Collins CommonWealth One Thomas F. Constable Jr. Dana Corriere Mary Cox Timothy S. Craddock Christy L. Crawford Gloria M. Crump Rosalie W. Cumings, Todd Cummings, Timothy Cummings, Shannon Angelotti Dale L. and Sandra S. Cupp Loretta Sue Custer Claudette E. Dalton Maria D’Antonio Daniel A. and Megan R. Davis Diane C. Davis Irene Morris Davis Kenneth G. and Gayle L. Davis Lowell R. and Alta A. Davis Michael W. and Debra I. Davis Melissa G. Dawson Ingrid De Sanctis Debbie L. Dean Mensel and Linda Dean Mickey Dean Debra K. Deavers Ben and Betty DeGraff Patricia C. Dickens Gary and Marie Dickenson Donald B. Dillon Anita F. Dove Betty B. Dove Dr. Aubrey Jr. and Elizabeth Drewry DuPont Community Rita K. Durbin Elizabeth V. Early Jessica C. Edwards Mary C. Eger Ronald D. and Diane Elliott Ronald W. Elliott Harold C. Eskey Dr. James D. and Sheila D. Evans Everence Teresa D. Evick Sarah L. Fagan Patricia C. Farrell Greg and Regina Felton Hal C. and Saundra Sue Ferguson Jean L. Fifer Dr. Denis E. Finnegan Elwood and Madge Fisher Theodore J. and Shelly B. Fisher Amy E. (Libbi) Fitzgerald Audrey G. Fitzwater Jennifer L. Fitzwater Norman V. and Patsy M. Fitzwater Edgar A. Flora Samuel H. and Lillie Ann Flora William M. and Grace A. Florence Cheryl B. Floyd Virginia R. Foltz Jeffery Ford Michael A. and Tracy S. Fornadel Susan M. Foster Clarence L. Fox Dennis B. and Joan E. Fox Dr. Fred L. and Gail P. Fox Loretta G. Frantz Freehill Hogan & Mahar, LLP Friendship Industries Inc. David and Rachel Frye Margaret S. Frye Curtis W. Funkhouser Sr. Joseph K. II and Sallie Funkhouser Samuel F. Funkhouser Thomas N. and Susan S. Gallaher Ruby B. Gallalee Ruth K. Garber Silvia Garcia-Romero Norma J. Gardner Sandra Gardner Tracey A. Gentry Royce O. Gibson Sara E. Gingerich M. Andreé Gitchell Harry and Pat Glenn Gregory and Carolyn Gochenour Saieda A. and Richard M. Godfrey Paige Webb Godoy Edwin L. and Esther B. Good Janene O. Good Bobby W. Gooden II Barbara Graves Mary S. Gray Gerald D. Greene Janis L. Gregg Benjamin W. Greider Jamey C. Groff John F. and Joann Grubbs Daryl D. Gum Donna S. Hahn Trenna M. Haislop Herman W. and Rosemary G. Hale Josh P. and Chassidy S. Hale Jean S. Hamill Donald L. and Jacqueline S. Hamilton Kevin and Kimberly Landis-Hamner Helen S. Harman Rebecca S. Harrell Pamela M. Harris Vivian Harrison Harrisonburg First Presbyterian Church—Presbyterian Women Doris L. Harsh Kenneth T. Haskell III Brenda J. Hedrick Debra Hedrick Nancy R. Heisey Donald F. Heishman Krista A. Heishman John E. and Judith N. Henneberger Denise A. Hensley Frederick R. Hepner Roger E. Herring and Family Mary E. Hershey Patricia A. Herudek James A. and Donna J. Herzig Regina L. Hester Darin C. Hevener Kenneth and Lillian Hilbert Emily Hill James H. and Lois Hinegardner John and Lou Holsten Robert E. and Betty W. Hoover J. Faye Hoover-Thomas Richard K. and Laurel J. Horst Dwight and Carolyn Houff Michael L. and Rose Ann Houliston Martha F. Hounchell Catherine J. Houser Harold E. Huber William R. and Sandra E. Hudelson Charlinda W. Huffman James E. and Theresa A. Huffman Brenda J. Hull Glen C. and Virginia Ann Hulvey Robert W. Hussey Ethel W. Iverson JMU Strikeout Cancer Drive David S. and Judi Jackson and Family Jeffrey A. Jackson Charlene A. Jacob Yvonne G. Jarrels Shelvy M. Jenkins Rebecca S. Jessie Sharon L. Johnson Sam P. Jr. and Sue L. Jones William Y. and Janet S. Joseph Sherry Joyner Susan K. Justice Robin D. and Leslie T. Keith Ken Copeland Family Dentistry, PLC Robert O. and Janice M. Kenney Bonnie F. Keppel Howard P. Kern, FACHE Daniel B. Keyes Charles S. and Nelsie M. Kiracofe Gleen D. and Lena R. Kite Linda D. Kite Teresa M. Kite Jo Ann P. Kline Orrin M. Jr. and Jane C. Kline Amos D. and Anna G. Knicely James E. and Amanda M. Knicely Katherine H. Knicely Kerry Knight Betty Jane Knighton Betty M. Kniss Carlene Knupp Rachel L. Knupp Joyce W. Kuhns Carolyn R. Lam Deanna D. Lam Patricia M. Lam C. Stephen and Cynthia H. Lamb Arnold L. and Elaine H. Lambert Gina L. Lambert Tina M. Lambert Dana Landacre David R. and Sarah Landis Stephanie S. Laos Bill and Joan Layman David A. and Anna Layman Jerry O. and Daisy D. Leake Robert and Nancy Lee Rita A. Lehman Robert J. and Carolyn J. 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Powell Honor Gifts Jared and Margaret Alexander Russell E. and Lillian C. Huffman George and Mary Anderson Jack, Jane, Jonathan and Daniel Yokum Lynn Ellen Black Ellen T. Wilhite Cindy and Ted Bryan Darlene L. Newman Tammy Crawford Larry D. and Barbara B. Horne Vada T. May Lareth L. May Janice McArdle Rebecca H. Powell Connie McDonald Robert F. and Nancy D. Scully Mary Mongold Bryan A. and Loretha J. Bland Dr. Brian E. Robinson Sam P. Jr. and Sue L. Jones Robert L. and Virginia C. Layman Nell C. Wright Dr. Timothy Short Dr. Gary L. and Marcia E. Tyeryar Caroline Spiers Sharon S. McLaughlin The MDs, NPs and staff of the Sentara RMH Funkhouser Women’s Center Dr. Susan Conaty-Buck, DNP, FNP-C Ken Thomas Fred B. and Carolyn B. Pence R. Jan Thompson Lucile H. Vaughn All Those Who Need Help Norma L. Greenleaf Dr. Christine M. Urbanski Roberta (Robbie) and Robert K. Wilkins Tara Vetting Nancy L. East Dr. Mary Helen Witt Robbie J. Zirkle Dr. Gene L. Yoder Mr. and Mrs. Johnny L. Thompson Dr. Paul Yoder Daryl D. Gum Martha Sutton Dr. Abraham Davis Jr. Nora Dofflemyer Hubert and Judy Roop Mae Frances Downey Garner H. Downey Wallace S. Erdman, Father Michael R. and Adina E. Bailey Kenneth W. Fletcher Kenneth W. and Shelbia J. Fletcher To the Glory of God Sara Davis Dr. Stephen E. Godshall Shirley Hupp Jodi Marie Gooden Bobby W. Gooden II Arlene Gutshall Jeanette L. Jamison Robert and Ambi Hahn Bernard Tabatznik Team Hamntonality Colin Mantell Kay Harrison J. Michael and Dianne H. Burris Susan Harrison John S. and Jo Anne Hensley Leroy Harsh Doris L. Harsh Terry G. and Vickie G. Slaubaugh Todd and Amy Slaubaugh Hospice Volunteers Dana Landacre Phyllis Hughes Wayne L. and Ann Payne Long A Gift That Pays Income for Life? A charitable gift annuity, in addition to helping improve and enhance the care our patients receive, can also provide income back to you. For example, a 78-year-old individual would receive the following benefits for a $10,000 gift annuity: • A6.4percent*return($640annually)fortherestofhisorherlife, partly tax free • Anincometaxdeduction • Aneffectiverateofreturnupto9.2percent*aftertaxbenefits • Advancingourmissiontoimprovehealthandpromotewell-being *Rates depend on age and whether the annuity is for one or two lives Many of our friends have found this option to be one of the more satisfying ways to make a gift. To receive the “Giving Through Gift Annuities” pamphlet without cost or obligation, please complete and return the form below: Name: ______________________________________________________________________________ Address: ____________________________________________________________________________ City: ________________________________________________________________________________ State: _______________________________________ Zip: __________________________________ Mail to: Cory Davies, Executive Director, RMH Foundation 2010 Health Campus Drive, Harrisonburg, VA 22801 540-564-7225 Sentara.com 51 Jim Bishop Amazing Love H ow does one put into words one of the most powerful forces in the universe? Love is marvelous, amazing, a many-splendored thing. Yet, I find myself declaring, “I love seafood. I love warm, sunny days on the beach. I love celebrating holidays. I love getting affirmations on email. I love music of the 1950s. I love getting my monthly annuity check.” Then I realize these are merely commodities about which I’ve come to have strong feelings. But do they deserve the term “love”? The abiding principle here should be: love people, use things. It’s all too easy to venerate material objects that don’t return our affection while feeling insensitive toward our fellow human beings who deserve our kindness. We’re supposed to love everyone, but is that humanly possible? Can I honestly say that I love everyone? I am grateful for having been raised in a setting where love was shown in numerous ways. My parents not only modeled love but also verbalized it often to my siblings and me. If we’ve experienced love at critical stages of our development, we should in turn be better equipped to share the same with others. Love has two sides that almost 52 healthQuest | Winter 2015 NEVER QUITS seem to be opposing poles. It’s tough yet tender—tough when we need to forgive one who has wronged us, tender when we feel compassion toward one in need. Perhaps just as important as lovingly offering forgiveness is the other necessary component: letting go of the wrongdoing. We love—excuse me, like—to hang on to the memory even after the wrong has been righted. A wise person once stated, “When you bury the hatchet, don’t mark the spot.” Love doesn’t remain stagnant, but it can wither and fade if we fail to cultivate and nourish it in both word and deed. We keep discovering what it means for love to deepen and flourish. It may be through a painful, life-shattering experience when you hang in there with someone who has wrongfully used you. Or it could result from being the recipient of another’s heartfelt action toward you. In I Corinthians 13, the “love chapter,” the Apostle Paul declares that “love never fails.” I take this to mean that love never gives up, regardless of how difficult situations become. Only love can turn an enemy into a friend. This is true of relationships between individuals and between groups with opposing ideologies. I keep returning to the basic question: What is love? A few propositions: • Loveisakindwordinplaceofone spoken in haste or anger, patience in a mile-long waiting line, listening instead of always talking or insisting on having the final word. • Loveisrespondingtothewide-eyed innocence of children, and respecting and encouraging them. • Loveisagentle,caringtouch;ahearty hug; a tender kiss. • Loveisvisitingashut-in,givingfinancial gifts with gratitude, contributing time and energy to worthy causes, giving a flower to someone “just because.” • Loveisrejoicingwiththosewhorejoice and weeping with those who weep. • Loveisquietingoneselfbeforethe Creator, being still and knowing that God is already there. Again, to paraphrase St. Paul: “To sum up, there are three things that will never quit: faith, hope and love.” My heartfelt prayer is that each of us will grow in the greatest of these—love. ■ Jim Bishop is retired after 40 years as public information officer at Eastern Mennonite University. He can be contacted at jimanna. bishop@gmail.com. ● Heart Check A heart disease screening and health coaching program for men and women The Heart Check program provides personalized cardiovascular disease risk assessments and meaningful health coaching. You will not only gain awareness about your personal risk factors for heart disease, you will also be guided and encouraged to make optimal health decisions for your future. Sentara.com ou! y o t t f i Our g ! f f o % 0 5 e k a T le to schedu . t” s e u Q $25 Health o code “ pointment for only ll. m o r p e s U ap ces are fu rt Check when spa r o 5 1 your Hea 0 ule. 30, 2 ed 0 to sch 0 0 6 9 -68 Call 540 s April Offer end Rockingham Memorial Hospital 2010 Health Campus Drive Harrisonburg, Virginia 22801 NON-PROFIT U.S. POSTAGE PAID PERMIT NO. 19 BURLINGTON, VT Sentara.com Change service requested I came to Dr. Cucé desperate for help. “ Since my surgery, I can walk without pain and am finally getting my life back.” —Kathy, double hip replacement Get back to the life you love. Call 689-5500 today; no referral needed. SENTARA RMH ORTHOPEDICS AND SPORTS MEDICINE Sentara.com
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