Commentary

In a recent column entitled “To the limit,” I tried to make the case that the negative consequences of permissive parenting are numerous enough to warrant the attention of primary care pediatricians and family physicians. The evidence linking atypical sensory adaptation, behavior difficulties, sleep deprivation, and obesity to a permissive parenting style is just beginning to appear in the literature, but the numbers are in sync with the anecdotal observations of many experienced pediatricians like me. In that previous column, I offered to provide a more nuanced discussion of when and how clinicians might address the issue of permissive parenting with families in their practices.

First, let me make it clear that I don’t consider parenting style to be a topic that needs to occur on the checklist of every patient at every health maintenance visit. You already are overburdened with the demands of experts who have lobbied to have their favorite hot button issues included in your 15 minutes of face-to-face time with your young patients.

ChamilleWhite/Thinkstock

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

In a recent column entitled “To the limit,” I tried to make the case that the negative consequences of permissive parenting are numerous enough to warrant the attention of primary care pediatricians and family physicians. The evidence linking atypical sensory adaptation, behavior difficulties, sleep deprivation, and obesity to a permissive parenting style is just beginning to appear in the literature, but the numbers are in sync with the anecdotal observations of many experienced pediatricians like me. In that previous column, I offered to provide a more nuanced discussion of when and how clinicians might address the issue of permissive parenting with families in their practices.

First, let me make it clear that I don’t consider parenting style to be a topic that needs to occur on the checklist of every patient at every health maintenance visit. You already are overburdened with the demands of experts who have lobbied to have their favorite hot button issues included in your 15 minutes of face-to-face time with your young patients.

ChamilleWhite/Thinkstock

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

In a recent column entitled “To the limit,” I tried to make the case that the negative consequences of permissive parenting are numerous enough to warrant the attention of primary care pediatricians and family physicians. The evidence linking atypical sensory adaptation, behavior difficulties, sleep deprivation, and obesity to a permissive parenting style is just beginning to appear in the literature, but the numbers are in sync with the anecdotal observations of many experienced pediatricians like me. In that previous column, I offered to provide a more nuanced discussion of when and how clinicians might address the issue of permissive parenting with families in their practices.

First, let me make it clear that I don’t consider parenting style to be a topic that needs to occur on the checklist of every patient at every health maintenance visit. You already are overburdened with the demands of experts who have lobbied to have their favorite hot button issues included in your 15 minutes of face-to-face time with your young patients.

ChamilleWhite/Thinkstock

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

Do you believe that children whose parents can make and enforce rules are more likely to thrive than those children whose parents are hesitant to set limits? If you don’t see limit setting as a critical function of parenting, you and I are not only marching to different drummers, we aren’t even in the same parade.

You may be tempted to write me off as just another old school ranter because I believe that limit setting is one of the cornerstones of parenting. But, let’s look at some of the evidence. There are several studies demonstrating that children whose parents set bedtimes get more sleep. One recent survey also found that teenagers who got more sleep as a result of enforced bedtimes functioned better in school (Sleep. 2011 Jun 1;34[6]:797-800).

©iStockphoto

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

Do you believe that children whose parents can make and enforce rules are more likely to thrive than those children whose parents are hesitant to set limits? If you don’t see limit setting as a critical function of parenting, you and I are not only marching to different drummers, we aren’t even in the same parade.

You may be tempted to write me off as just another old school ranter because I believe that limit setting is one of the cornerstones of parenting. But, let’s look at some of the evidence. There are several studies demonstrating that children whose parents set bedtimes get more sleep. One recent survey also found that teenagers who got more sleep as a result of enforced bedtimes functioned better in school (Sleep. 2011 Jun 1;34[6]:797-800).

©iStockphoto

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

Do you believe that children whose parents can make and enforce rules are more likely to thrive than those children whose parents are hesitant to set limits? If you don’t see limit setting as a critical function of parenting, you and I are not only marching to different drummers, we aren’t even in the same parade.

You may be tempted to write me off as just another old school ranter because I believe that limit setting is one of the cornerstones of parenting. But, let’s look at some of the evidence. There are several studies demonstrating that children whose parents set bedtimes get more sleep. One recent survey also found that teenagers who got more sleep as a result of enforced bedtimes functioned better in school (Sleep. 2011 Jun 1;34[6]:797-800).

©iStockphoto

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

When tasked with outlining updated therapy regimens for rosacea, specific patient vignettes come to mind.

A 53-year-old male golfer presents with years of central facial flushing, prominent telangiectases, erythema, and scattered pink papules. He attempted various over-the-counter topical products indicated for acne, such as salicylic acid scrub and benzoyl peroxide cream, with no improvement and much irritation. Recently, his wife has been helping him apply redness-concealing makeup in the morning and over-the-counter hydrocortisone cream in the evening, which has been slightly helpful.

This patient’s rosacea could conceivably be labeled under the papulopustular rosacea subtype; however, the conventional categories are fluid with subtype overlap and imprecise diagnostic criteria. He also seemed to display features of the erythematotelangiectatic subtype, perhaps with underlying photodamage as well as steroid rebound erythema and/or atrophy.¹ Nevertheless, it is a common presentation, and certain baseline tenets should be applied. First, all steroid products and irritants (eg, benzoyl peroxide and salicylic acid ingredients, any scrub vehicle) should be discontinued. Education about avoidance of triggers (ie, sun, heat, spicy food, alcohol, stress is paramount. Because barrier inadequacy is a recent insight into rosacea pathogenesis, mild syndet- or lipid-free cleansers, daily sunscreen, and evening emollients dictate baseline skin care, as does meticulous situation-specific sun protection.^2,3 The papular component and immediate erythema in and around the papules can be managed topically (prior to sunscreen or emollient application) with metronidazole gel or cream up to twice daily, ivermectin cream once daily, or azelaic acid gel or foam up to twice daily. Oral doxycycline 40 mg (delayed release) on an empty stomach or 50 mg (immediate release) with food to avert antimicrobial dosing and antibiotic resistance also could be considered if topical therapy is inadequate or irritating, though gastrointestinal comorbidities with rosacea also should be delineated before initiating oral antibiotics.^4-6 (Management of this patient’s nonlesional fixed erythema, telangiectases, and flushing is discussed after the next vignette.)

What if a woman presented in a similar fashion as above, only without papules? Her family physician prescribed metronidazole gel twice daily for years with no improvement in flushing, redness, or telangiectases.

Background erythema in rosacea often is persistent with trigger-specific intensification, with or without episodic facial flushing; undoubtedly, these symptoms can be difficult to compartmentalize depending on the clarity of the patient’s history and frequency of clinic visits. The aforementioned baseline skin care and sun-protection regimen applies, and newer topical agents such as α-adrenergics (daily oxymetazoline cream or brimonidine gel) may be considered for persistent erythema; however, irritant potential and rebound erythema are common.^7-9 Topical therapies such as metronidazole gel, as in this case, are inadequate for persistent background erythema or flushing. Persistent erythema and telangiectases can be reduced with pulsed dye laser or intense pulsed light modalities, particularly following conservative management of acute inflammation.⁵ Episodic flushing is poorly controlled with the above tactics, but anecdotally, topical or oral α-adrenergics or oral nonselective beta-blockers could be considered; the latter is also applicable to migraine therapy, which is perhaps comorbid with rosacea.^5,10

A 35-year-old Hispanic woman states that the scalp, forehead, and cheeks have been flaky, pink, and pruritic for years. She saw several aestheticians for it and the admixed “acne” on the face, receiving salicylic acid chemical peels with no improvement and much dyspigmentation.

Although underreported, the commingling of rosacea with seborrheic dermatitis is common, perhaps with mutual Demodex mite overpopulation, assigning topical therapies to its management such as daily ivermectin cream or steroid-sparing pimecrolimus cream for inflammatory papules and scaly regions of the face and scalp.^11-13 Further, this case exemplifies the increasing incidence and awareness of rosacea in darker skin types, along with its postinflammatory pigmentary perturbations, which necessitate repeated education about barrier control and sun protection.¹⁴

A 72-year-old male farmer presents with his wife whoinsists that his nose has been increasing in size for years; she procures a prior driver’s license photograph as proof. She also notes that he has been snoring at night and having more trouble breathing while working outdoors. The patient had not noticed.

Phymatous rosacea may exist as an additional feature of any rosacea subtype or as a singular finding, presenting as actively inflamed, fibrotic/noninflamed, or both. Management, particularly if inflamed, involves baseline gentle skin care and sun protection, avoidance of rosacea triggers, and implementation of oral therapy such as doxycycline or isotretinoin. Many cases, particularly those with a fibrotic component, warrant surgical methods such as fractionated CO₂ laser or Shaw scalpel surgical sculpting. These cases frequently demonstrate varying degrees of airway compromise, validating surgery as a legitimate medical, not merely cosmetic, presentation.^5,15

Final Thoughts

The Table, constructed as a concise therapy compendium by the ROSacea COnsensus (ROSCO) international panel of dermatologists and ophthalmologists, outlines data-driven and expert experience-based therapies for rosacea.⁵ This panel asserts that phenotypical features, not rigid subtypes, oblige patient-specific treatment schema. Also, as these cases outline, an evolving understanding of rosacea’s multifaceted pathogenesis, assorted presentations, and frequent pitfalls in daily skin care and initial management require individualized care.

When tasked with outlining updated therapy regimens for rosacea, specific patient vignettes come to mind.

A 53-year-old male golfer presents with years of central facial flushing, prominent telangiectases, erythema, and scattered pink papules. He attempted various over-the-counter topical products indicated for acne, such as salicylic acid scrub and benzoyl peroxide cream, with no improvement and much irritation. Recently, his wife has been helping him apply redness-concealing makeup in the morning and over-the-counter hydrocortisone cream in the evening, which has been slightly helpful.

This patient’s rosacea could conceivably be labeled under the papulopustular rosacea subtype; however, the conventional categories are fluid with subtype overlap and imprecise diagnostic criteria. He also seemed to display features of the erythematotelangiectatic subtype, perhaps with underlying photodamage as well as steroid rebound erythema and/or atrophy.¹ Nevertheless, it is a common presentation, and certain baseline tenets should be applied. First, all steroid products and irritants (eg, benzoyl peroxide and salicylic acid ingredients, any scrub vehicle) should be discontinued. Education about avoidance of triggers (ie, sun, heat, spicy food, alcohol, stress is paramount. Because barrier inadequacy is a recent insight into rosacea pathogenesis, mild syndet- or lipid-free cleansers, daily sunscreen, and evening emollients dictate baseline skin care, as does meticulous situation-specific sun protection.^2,3 The papular component and immediate erythema in and around the papules can be managed topically (prior to sunscreen or emollient application) with metronidazole gel or cream up to twice daily, ivermectin cream once daily, or azelaic acid gel or foam up to twice daily. Oral doxycycline 40 mg (delayed release) on an empty stomach or 50 mg (immediate release) with food to avert antimicrobial dosing and antibiotic resistance also could be considered if topical therapy is inadequate or irritating, though gastrointestinal comorbidities with rosacea also should be delineated before initiating oral antibiotics.^4-6 (Management of this patient’s nonlesional fixed erythema, telangiectases, and flushing is discussed after the next vignette.)

What if a woman presented in a similar fashion as above, only without papules? Her family physician prescribed metronidazole gel twice daily for years with no improvement in flushing, redness, or telangiectases.

Background erythema in rosacea often is persistent with trigger-specific intensification, with or without episodic facial flushing; undoubtedly, these symptoms can be difficult to compartmentalize depending on the clarity of the patient’s history and frequency of clinic visits. The aforementioned baseline skin care and sun-protection regimen applies, and newer topical agents such as α-adrenergics (daily oxymetazoline cream or brimonidine gel) may be considered for persistent erythema; however, irritant potential and rebound erythema are common.^7-9 Topical therapies such as metronidazole gel, as in this case, are inadequate for persistent background erythema or flushing. Persistent erythema and telangiectases can be reduced with pulsed dye laser or intense pulsed light modalities, particularly following conservative management of acute inflammation.⁵ Episodic flushing is poorly controlled with the above tactics, but anecdotally, topical or oral α-adrenergics or oral nonselective beta-blockers could be considered; the latter is also applicable to migraine therapy, which is perhaps comorbid with rosacea.^5,10

A 35-year-old Hispanic woman states that the scalp, forehead, and cheeks have been flaky, pink, and pruritic for years. She saw several aestheticians for it and the admixed “acne” on the face, receiving salicylic acid chemical peels with no improvement and much dyspigmentation.

Although underreported, the commingling of rosacea with seborrheic dermatitis is common, perhaps with mutual Demodex mite overpopulation, assigning topical therapies to its management such as daily ivermectin cream or steroid-sparing pimecrolimus cream for inflammatory papules and scaly regions of the face and scalp.^11-13 Further, this case exemplifies the increasing incidence and awareness of rosacea in darker skin types, along with its postinflammatory pigmentary perturbations, which necessitate repeated education about barrier control and sun protection.¹⁴

A 72-year-old male farmer presents with his wife whoinsists that his nose has been increasing in size for years; she procures a prior driver’s license photograph as proof. She also notes that he has been snoring at night and having more trouble breathing while working outdoors. The patient had not noticed.

Phymatous rosacea may exist as an additional feature of any rosacea subtype or as a singular finding, presenting as actively inflamed, fibrotic/noninflamed, or both. Management, particularly if inflamed, involves baseline gentle skin care and sun protection, avoidance of rosacea triggers, and implementation of oral therapy such as doxycycline or isotretinoin. Many cases, particularly those with a fibrotic component, warrant surgical methods such as fractionated CO₂ laser or Shaw scalpel surgical sculpting. These cases frequently demonstrate varying degrees of airway compromise, validating surgery as a legitimate medical, not merely cosmetic, presentation.^5,15

Final Thoughts

The Table, constructed as a concise therapy compendium by the ROSacea COnsensus (ROSCO) international panel of dermatologists and ophthalmologists, outlines data-driven and expert experience-based therapies for rosacea.⁵ This panel asserts that phenotypical features, not rigid subtypes, oblige patient-specific treatment schema. Also, as these cases outline, an evolving understanding of rosacea’s multifaceted pathogenesis, assorted presentations, and frequent pitfalls in daily skin care and initial management require individualized care.

When tasked with outlining updated therapy regimens for rosacea, specific patient vignettes come to mind.

A 53-year-old male golfer presents with years of central facial flushing, prominent telangiectases, erythema, and scattered pink papules. He attempted various over-the-counter topical products indicated for acne, such as salicylic acid scrub and benzoyl peroxide cream, with no improvement and much irritation. Recently, his wife has been helping him apply redness-concealing makeup in the morning and over-the-counter hydrocortisone cream in the evening, which has been slightly helpful.

This patient’s rosacea could conceivably be labeled under the papulopustular rosacea subtype; however, the conventional categories are fluid with subtype overlap and imprecise diagnostic criteria. He also seemed to display features of the erythematotelangiectatic subtype, perhaps with underlying photodamage as well as steroid rebound erythema and/or atrophy.¹ Nevertheless, it is a common presentation, and certain baseline tenets should be applied. First, all steroid products and irritants (eg, benzoyl peroxide and salicylic acid ingredients, any scrub vehicle) should be discontinued. Education about avoidance of triggers (ie, sun, heat, spicy food, alcohol, stress is paramount. Because barrier inadequacy is a recent insight into rosacea pathogenesis, mild syndet- or lipid-free cleansers, daily sunscreen, and evening emollients dictate baseline skin care, as does meticulous situation-specific sun protection.^2,3 The papular component and immediate erythema in and around the papules can be managed topically (prior to sunscreen or emollient application) with metronidazole gel or cream up to twice daily, ivermectin cream once daily, or azelaic acid gel or foam up to twice daily. Oral doxycycline 40 mg (delayed release) on an empty stomach or 50 mg (immediate release) with food to avert antimicrobial dosing and antibiotic resistance also could be considered if topical therapy is inadequate or irritating, though gastrointestinal comorbidities with rosacea also should be delineated before initiating oral antibiotics.^4-6 (Management of this patient’s nonlesional fixed erythema, telangiectases, and flushing is discussed after the next vignette.)

What if a woman presented in a similar fashion as above, only without papules? Her family physician prescribed metronidazole gel twice daily for years with no improvement in flushing, redness, or telangiectases.

Background erythema in rosacea often is persistent with trigger-specific intensification, with or without episodic facial flushing; undoubtedly, these symptoms can be difficult to compartmentalize depending on the clarity of the patient’s history and frequency of clinic visits. The aforementioned baseline skin care and sun-protection regimen applies, and newer topical agents such as α-adrenergics (daily oxymetazoline cream or brimonidine gel) may be considered for persistent erythema; however, irritant potential and rebound erythema are common.^7-9 Topical therapies such as metronidazole gel, as in this case, are inadequate for persistent background erythema or flushing. Persistent erythema and telangiectases can be reduced with pulsed dye laser or intense pulsed light modalities, particularly following conservative management of acute inflammation.⁵ Episodic flushing is poorly controlled with the above tactics, but anecdotally, topical or oral α-adrenergics or oral nonselective beta-blockers could be considered; the latter is also applicable to migraine therapy, which is perhaps comorbid with rosacea.^5,10

A 35-year-old Hispanic woman states that the scalp, forehead, and cheeks have been flaky, pink, and pruritic for years. She saw several aestheticians for it and the admixed “acne” on the face, receiving salicylic acid chemical peels with no improvement and much dyspigmentation.

Although underreported, the commingling of rosacea with seborrheic dermatitis is common, perhaps with mutual Demodex mite overpopulation, assigning topical therapies to its management such as daily ivermectin cream or steroid-sparing pimecrolimus cream for inflammatory papules and scaly regions of the face and scalp.^11-13 Further, this case exemplifies the increasing incidence and awareness of rosacea in darker skin types, along with its postinflammatory pigmentary perturbations, which necessitate repeated education about barrier control and sun protection.¹⁴

A 72-year-old male farmer presents with his wife whoinsists that his nose has been increasing in size for years; she procures a prior driver’s license photograph as proof. She also notes that he has been snoring at night and having more trouble breathing while working outdoors. The patient had not noticed.

Phymatous rosacea may exist as an additional feature of any rosacea subtype or as a singular finding, presenting as actively inflamed, fibrotic/noninflamed, or both. Management, particularly if inflamed, involves baseline gentle skin care and sun protection, avoidance of rosacea triggers, and implementation of oral therapy such as doxycycline or isotretinoin. Many cases, particularly those with a fibrotic component, warrant surgical methods such as fractionated CO₂ laser or Shaw scalpel surgical sculpting. These cases frequently demonstrate varying degrees of airway compromise, validating surgery as a legitimate medical, not merely cosmetic, presentation.^5,15

Final Thoughts

The Table, constructed as a concise therapy compendium by the ROSacea COnsensus (ROSCO) international panel of dermatologists and ophthalmologists, outlines data-driven and expert experience-based therapies for rosacea.⁵ This panel asserts that phenotypical features, not rigid subtypes, oblige patient-specific treatment schema. Also, as these cases outline, an evolving understanding of rosacea’s multifaceted pathogenesis, assorted presentations, and frequent pitfalls in daily skin care and initial management require individualized care.

In Emergency Medicine this month and next, Drs. Tom Scalea (See “The Golden Hourglass,” EM, April 2007), Ashley Menne, Daniel Haase, and Jay Menaker of the University of Maryland’s R Adams Cowley Shock Trauma Center paint a detailed picture of the changing landscape of trauma care over the past two decades.

In his introduction, Dr. Scalea writes “Certainly, the most important change has been the ‘graying’ of trauma patients…[whose evaluation and care] may involve a number of diagnostic tests in the ED…”, and whose care must include dealing with comorbidities, and a large number of medications that might interact with the analgesics, sedatives, and anti-seizure meds needed to treat trauma. These considerations have led many Level I trauma centers to add advanced patient age as an independent determinant for both trauma activations and subsequent ICU admissions, and to include “geriatric” consultants in the initial management. 

The aging trauma patient, however, is not the only factor responsible for major changes in the management of serious trauma, as the Shock Trauma group describes the current difficulties in attempting to rapidly reverse the anticoagulation effects of the novel oral anticoagulants (NOACs) that are increasingly being prescribed instead of warfarin to manage the thromboembolic complications of atrial fibrillation, valve replacement, venous thrombosis, and pulmonary embolism in both younger and older patients. They also explain a major change in thinking regarding the optimal degree of blood pressure control in favor of “permissive hypotension” as part of “damage control resuscitation,” and in the amount and types of volume replacement, optimal blood component ratios for transfusion, monitoring, and faster and less invasive endovascular repair techniques for hemostasis. The authors also note the persistent and rising incidence of penetrating trauma from gunshot and knife wounds. 

But the increasing percentages of elderly trauma victims requiring care for devastating falls and low-speed vehicular injuries in even the busiest “knife and gun club” trauma centers mandate the attention of all health care providers. In recent months, much space in this and other journals has been devoted to the health care issues of the elderly (see “Recognizing and Managing Elder Abuse in the Emergency Department,” and “Elder Abuse: A New Old Problem,” EM, May 2017) that necessitate significantly increased resources and provider time and effort now, and for at least the first half of the 21st century.

The main reason for this seismic demographic shift, dubbed by some “the silver tsunami”, is the aging post World War II “baby boomer” generation that has commanded center stage in western society throughout their development since the late 1940s. As a member of that generation, I often wonder how subsequent generations such as “Gen X” and “Millennials” view this phenomenon. Do they resent the attention, resources, and expenditures now demanded by baby boomers? If so, there is an important lesson to be learned from the changes in trauma care described in the following pages: virtually every measure now employed to enhance recovery of an elderly trauma victim will benefit younger trauma victims, as well. At most, some of the measures may not be absolutely necessary because younger adults have greater functional reserve and are more likely to survive less precise management, even if their posttraumatic courses are longer and more difficult. But younger trauma victims with comorbidities can also benefit from a more inclusive team approach from the start, as well as measures such as permissive hypotension, vascular stents and less invasive endovascular approaches, more precise blood component replacement, more accurate monitoring, and a better approach to anticoagulation and its reversal.

Faster and better quality survival of all trauma victims—including, but not limited to, the elderly—will free up needed and expensive resources for other patients and trauma victims, including those who continue to butt heads, drive two and four wheel vehicles at excessive speeds, and engage in trauma of an “interpersonal nature.” 

In Emergency Medicine this month and next, Drs. Tom Scalea (See “The Golden Hourglass,” EM, April 2007), Ashley Menne, Daniel Haase, and Jay Menaker of the University of Maryland’s R Adams Cowley Shock Trauma Center paint a detailed picture of the changing landscape of trauma care over the past two decades.

In his introduction, Dr. Scalea writes “Certainly, the most important change has been the ‘graying’ of trauma patients…[whose evaluation and care] may involve a number of diagnostic tests in the ED…”, and whose care must include dealing with comorbidities, and a large number of medications that might interact with the analgesics, sedatives, and anti-seizure meds needed to treat trauma. These considerations have led many Level I trauma centers to add advanced patient age as an independent determinant for both trauma activations and subsequent ICU admissions, and to include “geriatric” consultants in the initial management. 

The aging trauma patient, however, is not the only factor responsible for major changes in the management of serious trauma, as the Shock Trauma group describes the current difficulties in attempting to rapidly reverse the anticoagulation effects of the novel oral anticoagulants (NOACs) that are increasingly being prescribed instead of warfarin to manage the thromboembolic complications of atrial fibrillation, valve replacement, venous thrombosis, and pulmonary embolism in both younger and older patients. They also explain a major change in thinking regarding the optimal degree of blood pressure control in favor of “permissive hypotension” as part of “damage control resuscitation,” and in the amount and types of volume replacement, optimal blood component ratios for transfusion, monitoring, and faster and less invasive endovascular repair techniques for hemostasis. The authors also note the persistent and rising incidence of penetrating trauma from gunshot and knife wounds. 

But the increasing percentages of elderly trauma victims requiring care for devastating falls and low-speed vehicular injuries in even the busiest “knife and gun club” trauma centers mandate the attention of all health care providers. In recent months, much space in this and other journals has been devoted to the health care issues of the elderly (see “Recognizing and Managing Elder Abuse in the Emergency Department,” and “Elder Abuse: A New Old Problem,” EM, May 2017) that necessitate significantly increased resources and provider time and effort now, and for at least the first half of the 21st century.

The main reason for this seismic demographic shift, dubbed by some “the silver tsunami”, is the aging post World War II “baby boomer” generation that has commanded center stage in western society throughout their development since the late 1940s. As a member of that generation, I often wonder how subsequent generations such as “Gen X” and “Millennials” view this phenomenon. Do they resent the attention, resources, and expenditures now demanded by baby boomers? If so, there is an important lesson to be learned from the changes in trauma care described in the following pages: virtually every measure now employed to enhance recovery of an elderly trauma victim will benefit younger trauma victims, as well. At most, some of the measures may not be absolutely necessary because younger adults have greater functional reserve and are more likely to survive less precise management, even if their posttraumatic courses are longer and more difficult. But younger trauma victims with comorbidities can also benefit from a more inclusive team approach from the start, as well as measures such as permissive hypotension, vascular stents and less invasive endovascular approaches, more precise blood component replacement, more accurate monitoring, and a better approach to anticoagulation and its reversal.

Faster and better quality survival of all trauma victims—including, but not limited to, the elderly—will free up needed and expensive resources for other patients and trauma victims, including those who continue to butt heads, drive two and four wheel vehicles at excessive speeds, and engage in trauma of an “interpersonal nature.” 

In Emergency Medicine this month and next, Drs. Tom Scalea (See “The Golden Hourglass,” EM, April 2007), Ashley Menne, Daniel Haase, and Jay Menaker of the University of Maryland’s R Adams Cowley Shock Trauma Center paint a detailed picture of the changing landscape of trauma care over the past two decades.

In his introduction, Dr. Scalea writes “Certainly, the most important change has been the ‘graying’ of trauma patients…[whose evaluation and care] may involve a number of diagnostic tests in the ED…”, and whose care must include dealing with comorbidities, and a large number of medications that might interact with the analgesics, sedatives, and anti-seizure meds needed to treat trauma. These considerations have led many Level I trauma centers to add advanced patient age as an independent determinant for both trauma activations and subsequent ICU admissions, and to include “geriatric” consultants in the initial management. 

The aging trauma patient, however, is not the only factor responsible for major changes in the management of serious trauma, as the Shock Trauma group describes the current difficulties in attempting to rapidly reverse the anticoagulation effects of the novel oral anticoagulants (NOACs) that are increasingly being prescribed instead of warfarin to manage the thromboembolic complications of atrial fibrillation, valve replacement, venous thrombosis, and pulmonary embolism in both younger and older patients. They also explain a major change in thinking regarding the optimal degree of blood pressure control in favor of “permissive hypotension” as part of “damage control resuscitation,” and in the amount and types of volume replacement, optimal blood component ratios for transfusion, monitoring, and faster and less invasive endovascular repair techniques for hemostasis. The authors also note the persistent and rising incidence of penetrating trauma from gunshot and knife wounds. 

But the increasing percentages of elderly trauma victims requiring care for devastating falls and low-speed vehicular injuries in even the busiest “knife and gun club” trauma centers mandate the attention of all health care providers. In recent months, much space in this and other journals has been devoted to the health care issues of the elderly (see “Recognizing and Managing Elder Abuse in the Emergency Department,” and “Elder Abuse: A New Old Problem,” EM, May 2017) that necessitate significantly increased resources and provider time and effort now, and for at least the first half of the 21st century.

The main reason for this seismic demographic shift, dubbed by some “the silver tsunami”, is the aging post World War II “baby boomer” generation that has commanded center stage in western society throughout their development since the late 1940s. As a member of that generation, I often wonder how subsequent generations such as “Gen X” and “Millennials” view this phenomenon. Do they resent the attention, resources, and expenditures now demanded by baby boomers? If so, there is an important lesson to be learned from the changes in trauma care described in the following pages: virtually every measure now employed to enhance recovery of an elderly trauma victim will benefit younger trauma victims, as well. At most, some of the measures may not be absolutely necessary because younger adults have greater functional reserve and are more likely to survive less precise management, even if their posttraumatic courses are longer and more difficult. But younger trauma victims with comorbidities can also benefit from a more inclusive team approach from the start, as well as measures such as permissive hypotension, vascular stents and less invasive endovascular approaches, more precise blood component replacement, more accurate monitoring, and a better approach to anticoagulation and its reversal.

Faster and better quality survival of all trauma victims—including, but not limited to, the elderly—will free up needed and expensive resources for other patients and trauma victims, including those who continue to butt heads, drive two and four wheel vehicles at excessive speeds, and engage in trauma of an “interpersonal nature.” 

Warren R. Kadrmas, MD, COL, MC, USAF

November 6, 1969-May 8, 2014

Matthew T. Provencher, MD, CAPT, MC, USNR, and John M. Tokish, MD

A Selfless Leader and Former Head of Air Force Orthopedics

In 2014, we tragically lost a true friend, outstanding clinician, great family man, and incredible human being. As one of the preeminent sports orthopedists in the military, Dr. Kadrmas was beloved by all and heralded for his many selfless contributions to military musculoskeletal medicine and injury prevention. He was known for his humble nature and steadfast integrity, and served as an exemplary role model whom we all aspired to emulate. We all remember our time with Warren fondly, and he left us all with lasting memories to cherish and countless stories sure to regale.

Warren Kadrmas was born in 1969 in Vermillion, South Dakota and grew up in Sheridan, Wyoming. Dr. Kadrmas graduated with distinction from both the US Air Force Academy in 1992 and Duke University School of Medicine in 1996. He then went on to complete his residency in 2003 at the Hospital for Special Surgery (HSS) in New York City and was recognized with the Jean C. McDaniel Outstanding Resident Award. He began his Air Force orthopedic career at Wilford Hall Ambulatory Surgical Center on the grounds of Lackland Air Force Base in San Antonio, Texas as part of the 59th Medical Wing. Warren was deployed and served as 1 of 5 people on the mobile-field surgical team assigned to the 379th Expeditionary Medical Group. Subsequently, he returned to HSS, where he excelled in sports medicine and shoulder service subspecialty training.

After his fellowship, Warren returned to San Antonio to continue his work as a top military sports surgeon, serving as a mentor, educator, and leader for all of Air Force orthopedics. During this time he served several tours overseas, becoming an invaluable member of the 332nd Expeditionary Medical Group operating out of the Air Force Theater Hospital at Balad Air Base, Iraq. Warren served as the Program Director of the Orthopedic Residency Program at Wilford Hall Ambulatory Surgical Center. He held the position of Head of Orthopedics for the Air Force as Orthopedic Surgery Consultant to the Air Force Surgeon General for 5 years, a role that entailed coordinating all orthopedic assets for the Global War on Terror for the Air Force. Selfless to a fault, he would never ask anything of anyone that he had not done himself. He completed 6 deployments away from family, loved ones, and work in San Antonio.

A true innovator and visionary, Warren was a pioneer in the integration of high-caliber hip arthroscopy, as well as cutting-edge shoulder and knee care for our active-duty military personnel. He was a prominent member of the American Orthopaedic Society for Sports Medicine (AOSSM) and Arthroscopy Association of North America, and was in line to be the incoming President of the Society of Military Orthopaedic Surgeons, after having previously served as the society’s 2nd Vice President. He was selected for and was scheduled to participate in the AOSSM Traveling Fellowship touring Asia just prior to his untimely accident.

One of Warren’s favorite quotes was on the topic of leading from behind. Nelson Mandela said, “It is better to lead from behind and to put others in front, especially when you celebrate victory when nice things occur. You take the front line when there is danger. Then people will appreciate your leadership.” Warren was the embodiment of this quote. He led from the front, and by example, in times of danger to inspire those he led. But he also honed the skill of leading from behind, with quiet self-sacrifice, to celebrate the success of those he led. His tireless dedication was prominent in all the facets of his life, whether as a father, son, brother, surgeon, educator, mentor, or friend. We miss him dearly, and try to embody his spirit by living our lives through what he taught us all.

Brian Allgood, MD, COL

1960-2007

Dean Taylor, MD

An Exemplary Selfless Leader in Orthopedics and Medicine

When people ask me what effective, ethical healthcare leadership looks like, I think of Brian Allgood. Brian was the epitome of leadership. He led quietly, by example and selflessly–always putting the interests of patients and those on his team ahead of his own.

Brian was a 1982 graduate of the United States Military Academy at West Point, and received a Doctor of Medicine degree from the University of Oklahoma. He completed his orthopedic training at Brooke Army Medical Center in San Antonio. I first met Brian in 1994 when he was practicing as an orthopedic surgeon at Womack Army Medical Center at Ft. Bragg, North Carolina, where he also served at the Division Surgeon for the 82nd Airborne Division. At the time, I was extremely impressed with Brian’s outstanding orthopedic skills, and his unwavering commitment to leadership in orthopedics, military medicine, and medicine.

Brian’s role as the 82nd Airborne Division Surgeon was on the leadership track in Army medicine, a track that many of us who enjoyed and were good at patient care shunned because it was structured to limit the amount of time an administrative leader could spend in patient care. Brian was certainly a skilled orthopedic surgeon who loved caring for patients; however, he was courageous enough to put his responsibility to military medicine and the medical profession ahead of his own clinical interests. He realized that he could provide exceptional leadership that would benefit many instead of only those in his sphere of care. And what an exceptional leader he was!

From 2002 to 2004, I saw firsthand Brian’s extraordinary leadership when he served as the hospital commander of Keller Army Community Hospital at West Point. He was the best hospital commander I worked with during my 11 years at West Point. I saw the sacrifices he made for the rest of us. He gave up something he loved–orthopedic surgery–so that he could effectively lead our hospital. While we operated, he occasionally would look longingly through the operating room (OR) windows. When we saw him, we would invite him to scrub in, much to his delight. He would also show up in other services’ ORs and the hospital’s clinics, staying connected to patients and patient care. This patient-centeredness contributed significantly to the beloved leader he was.

Brian’s final assignment was in 2006 as the Command Surgeon of Multi-National Forces, the highest-ranking medical officer in Iraq. On January 20, 2007, Brian Allgood—on the verge of promotion to brigadier general and on the fast track to Surgeon General of the Army—was killed along with 11 other American service members when their helicopter was shot down.

In his life, Brian was an exemplary leader. After his death, he lives on in our memories as an example to which we should all aspire–an ethical, selfless leader who cared for all patients, always striving to do the right thing.

LCpl Benjamin Whetstone Schmidt

1987-2011

David R. Schmidt, MD

A Fallen Hero’s Legacy

On September 11, 2011, LCpl Benjamin Whetstone Schmidt posted on his Facebook page, “I guess you can use today as a reason for us to be here in Afghanistan. Just know I am fighting for myself, but most of all for my friends and family who read this. Everyone, it’s an honor to be your ambassador.”

Benjamin was a Marine Scout Sniper on his second tour to Afghanistan, this time voluntarily. Not one member of his platoon had combat experience. He felt called to lead, to be with his boys. During his first deployment to Afghanistan he was awarded the Navy/USMC Achievement Medal with Valor for his action in combat.

Less than a month later, on October 6, 2011, he was killed while on patrol in Helmand Province. Even now, 6 years after his death, his comrades continue to hail his virtues as a leader, a friend, a patriot, and an inspiration. He was also a fine athlete and a courageous, energetic young man with bold plans for his future.

Other than his family, few knew what Benjamin would inspire in his death. He left $200,000 of his life insurance to establish a scholarship in the History Department at his beloved Texas Christian University (TCU). With a matching gift from his father, orthopedic surgeon David R. Schmidt, MD, and stepmom Teresa, the scholarship provides annual funding for a graduate student. Asked why he chose to support graduate students, Benjamin replied with his signature humor and wisdom, “I wouldn’t invest in a freshman like myself.” Benjamin had spent 2 years at TCU prior to enlisting in the Marine Corps, and intended to return to TCU to complete his undergraduate and graduate degrees.

Certainly not many young men at age 24 years, prior to going to war, have the foresight to envision and implement a legacy bigger than themselves, with the promise of influencing generations into the future. For his actions, Benjamin was a finalist for a Congressional Medal of Honor Society “Citizen Service Before Self” award.

David and Teresa Schmidt subsequently raised $1 million dollars to endow the LCpl Benjamin W. Schmidt Professor of War, Conflict and Society. It is truly inspirational to know that a young man’s selfless vision and his friends’ and family’s support could produce such a lasting legacy.

Warren R. Kadrmas, MD, COL, MC, USAF

November 6, 1969-May 8, 2014

Matthew T. Provencher, MD, CAPT, MC, USNR, and John M. Tokish, MD

A Selfless Leader and Former Head of Air Force Orthopedics

In 2014, we tragically lost a true friend, outstanding clinician, great family man, and incredible human being. As one of the preeminent sports orthopedists in the military, Dr. Kadrmas was beloved by all and heralded for his many selfless contributions to military musculoskeletal medicine and injury prevention. He was known for his humble nature and steadfast integrity, and served as an exemplary role model whom we all aspired to emulate. We all remember our time with Warren fondly, and he left us all with lasting memories to cherish and countless stories sure to regale.

Warren Kadrmas was born in 1969 in Vermillion, South Dakota and grew up in Sheridan, Wyoming. Dr. Kadrmas graduated with distinction from both the US Air Force Academy in 1992 and Duke University School of Medicine in 1996. He then went on to complete his residency in 2003 at the Hospital for Special Surgery (HSS) in New York City and was recognized with the Jean C. McDaniel Outstanding Resident Award. He began his Air Force orthopedic career at Wilford Hall Ambulatory Surgical Center on the grounds of Lackland Air Force Base in San Antonio, Texas as part of the 59th Medical Wing. Warren was deployed and served as 1 of 5 people on the mobile-field surgical team assigned to the 379th Expeditionary Medical Group. Subsequently, he returned to HSS, where he excelled in sports medicine and shoulder service subspecialty training.

After his fellowship, Warren returned to San Antonio to continue his work as a top military sports surgeon, serving as a mentor, educator, and leader for all of Air Force orthopedics. During this time he served several tours overseas, becoming an invaluable member of the 332nd Expeditionary Medical Group operating out of the Air Force Theater Hospital at Balad Air Base, Iraq. Warren served as the Program Director of the Orthopedic Residency Program at Wilford Hall Ambulatory Surgical Center. He held the position of Head of Orthopedics for the Air Force as Orthopedic Surgery Consultant to the Air Force Surgeon General for 5 years, a role that entailed coordinating all orthopedic assets for the Global War on Terror for the Air Force. Selfless to a fault, he would never ask anything of anyone that he had not done himself. He completed 6 deployments away from family, loved ones, and work in San Antonio.

A true innovator and visionary, Warren was a pioneer in the integration of high-caliber hip arthroscopy, as well as cutting-edge shoulder and knee care for our active-duty military personnel. He was a prominent member of the American Orthopaedic Society for Sports Medicine (AOSSM) and Arthroscopy Association of North America, and was in line to be the incoming President of the Society of Military Orthopaedic Surgeons, after having previously served as the society’s 2nd Vice President. He was selected for and was scheduled to participate in the AOSSM Traveling Fellowship touring Asia just prior to his untimely accident.

One of Warren’s favorite quotes was on the topic of leading from behind. Nelson Mandela said, “It is better to lead from behind and to put others in front, especially when you celebrate victory when nice things occur. You take the front line when there is danger. Then people will appreciate your leadership.” Warren was the embodiment of this quote. He led from the front, and by example, in times of danger to inspire those he led. But he also honed the skill of leading from behind, with quiet self-sacrifice, to celebrate the success of those he led. His tireless dedication was prominent in all the facets of his life, whether as a father, son, brother, surgeon, educator, mentor, or friend. We miss him dearly, and try to embody his spirit by living our lives through what he taught us all.

Brian Allgood, MD, COL

1960-2007

Dean Taylor, MD

An Exemplary Selfless Leader in Orthopedics and Medicine

When people ask me what effective, ethical healthcare leadership looks like, I think of Brian Allgood. Brian was the epitome of leadership. He led quietly, by example and selflessly–always putting the interests of patients and those on his team ahead of his own.

Brian was a 1982 graduate of the United States Military Academy at West Point, and received a Doctor of Medicine degree from the University of Oklahoma. He completed his orthopedic training at Brooke Army Medical Center in San Antonio. I first met Brian in 1994 when he was practicing as an orthopedic surgeon at Womack Army Medical Center at Ft. Bragg, North Carolina, where he also served at the Division Surgeon for the 82nd Airborne Division. At the time, I was extremely impressed with Brian’s outstanding orthopedic skills, and his unwavering commitment to leadership in orthopedics, military medicine, and medicine.

Brian’s role as the 82nd Airborne Division Surgeon was on the leadership track in Army medicine, a track that many of us who enjoyed and were good at patient care shunned because it was structured to limit the amount of time an administrative leader could spend in patient care. Brian was certainly a skilled orthopedic surgeon who loved caring for patients; however, he was courageous enough to put his responsibility to military medicine and the medical profession ahead of his own clinical interests. He realized that he could provide exceptional leadership that would benefit many instead of only those in his sphere of care. And what an exceptional leader he was!

From 2002 to 2004, I saw firsthand Brian’s extraordinary leadership when he served as the hospital commander of Keller Army Community Hospital at West Point. He was the best hospital commander I worked with during my 11 years at West Point. I saw the sacrifices he made for the rest of us. He gave up something he loved–orthopedic surgery–so that he could effectively lead our hospital. While we operated, he occasionally would look longingly through the operating room (OR) windows. When we saw him, we would invite him to scrub in, much to his delight. He would also show up in other services’ ORs and the hospital’s clinics, staying connected to patients and patient care. This patient-centeredness contributed significantly to the beloved leader he was.

Brian’s final assignment was in 2006 as the Command Surgeon of Multi-National Forces, the highest-ranking medical officer in Iraq. On January 20, 2007, Brian Allgood—on the verge of promotion to brigadier general and on the fast track to Surgeon General of the Army—was killed along with 11 other American service members when their helicopter was shot down.

In his life, Brian was an exemplary leader. After his death, he lives on in our memories as an example to which we should all aspire–an ethical, selfless leader who cared for all patients, always striving to do the right thing.

LCpl Benjamin Whetstone Schmidt

1987-2011

David R. Schmidt, MD

A Fallen Hero’s Legacy

On September 11, 2011, LCpl Benjamin Whetstone Schmidt posted on his Facebook page, “I guess you can use today as a reason for us to be here in Afghanistan. Just know I am fighting for myself, but most of all for my friends and family who read this. Everyone, it’s an honor to be your ambassador.”

Benjamin was a Marine Scout Sniper on his second tour to Afghanistan, this time voluntarily. Not one member of his platoon had combat experience. He felt called to lead, to be with his boys. During his first deployment to Afghanistan he was awarded the Navy/USMC Achievement Medal with Valor for his action in combat.

Less than a month later, on October 6, 2011, he was killed while on patrol in Helmand Province. Even now, 6 years after his death, his comrades continue to hail his virtues as a leader, a friend, a patriot, and an inspiration. He was also a fine athlete and a courageous, energetic young man with bold plans for his future.

Other than his family, few knew what Benjamin would inspire in his death. He left $200,000 of his life insurance to establish a scholarship in the History Department at his beloved Texas Christian University (TCU). With a matching gift from his father, orthopedic surgeon David R. Schmidt, MD, and stepmom Teresa, the scholarship provides annual funding for a graduate student. Asked why he chose to support graduate students, Benjamin replied with his signature humor and wisdom, “I wouldn’t invest in a freshman like myself.” Benjamin had spent 2 years at TCU prior to enlisting in the Marine Corps, and intended to return to TCU to complete his undergraduate and graduate degrees.

Certainly not many young men at age 24 years, prior to going to war, have the foresight to envision and implement a legacy bigger than themselves, with the promise of influencing generations into the future. For his actions, Benjamin was a finalist for a Congressional Medal of Honor Society “Citizen Service Before Self” award.

David and Teresa Schmidt subsequently raised $1 million dollars to endow the LCpl Benjamin W. Schmidt Professor of War, Conflict and Society. It is truly inspirational to know that a young man’s selfless vision and his friends’ and family’s support could produce such a lasting legacy.

Warren R. Kadrmas, MD, COL, MC, USAF

November 6, 1969-May 8, 2014

Matthew T. Provencher, MD, CAPT, MC, USNR, and John M. Tokish, MD

A Selfless Leader and Former Head of Air Force Orthopedics

In 2014, we tragically lost a true friend, outstanding clinician, great family man, and incredible human being. As one of the preeminent sports orthopedists in the military, Dr. Kadrmas was beloved by all and heralded for his many selfless contributions to military musculoskeletal medicine and injury prevention. He was known for his humble nature and steadfast integrity, and served as an exemplary role model whom we all aspired to emulate. We all remember our time with Warren fondly, and he left us all with lasting memories to cherish and countless stories sure to regale.

Warren Kadrmas was born in 1969 in Vermillion, South Dakota and grew up in Sheridan, Wyoming. Dr. Kadrmas graduated with distinction from both the US Air Force Academy in 1992 and Duke University School of Medicine in 1996. He then went on to complete his residency in 2003 at the Hospital for Special Surgery (HSS) in New York City and was recognized with the Jean C. McDaniel Outstanding Resident Award. He began his Air Force orthopedic career at Wilford Hall Ambulatory Surgical Center on the grounds of Lackland Air Force Base in San Antonio, Texas as part of the 59th Medical Wing. Warren was deployed and served as 1 of 5 people on the mobile-field surgical team assigned to the 379th Expeditionary Medical Group. Subsequently, he returned to HSS, where he excelled in sports medicine and shoulder service subspecialty training.

After his fellowship, Warren returned to San Antonio to continue his work as a top military sports surgeon, serving as a mentor, educator, and leader for all of Air Force orthopedics. During this time he served several tours overseas, becoming an invaluable member of the 332nd Expeditionary Medical Group operating out of the Air Force Theater Hospital at Balad Air Base, Iraq. Warren served as the Program Director of the Orthopedic Residency Program at Wilford Hall Ambulatory Surgical Center. He held the position of Head of Orthopedics for the Air Force as Orthopedic Surgery Consultant to the Air Force Surgeon General for 5 years, a role that entailed coordinating all orthopedic assets for the Global War on Terror for the Air Force. Selfless to a fault, he would never ask anything of anyone that he had not done himself. He completed 6 deployments away from family, loved ones, and work in San Antonio.

A true innovator and visionary, Warren was a pioneer in the integration of high-caliber hip arthroscopy, as well as cutting-edge shoulder and knee care for our active-duty military personnel. He was a prominent member of the American Orthopaedic Society for Sports Medicine (AOSSM) and Arthroscopy Association of North America, and was in line to be the incoming President of the Society of Military Orthopaedic Surgeons, after having previously served as the society’s 2nd Vice President. He was selected for and was scheduled to participate in the AOSSM Traveling Fellowship touring Asia just prior to his untimely accident.

One of Warren’s favorite quotes was on the topic of leading from behind. Nelson Mandela said, “It is better to lead from behind and to put others in front, especially when you celebrate victory when nice things occur. You take the front line when there is danger. Then people will appreciate your leadership.” Warren was the embodiment of this quote. He led from the front, and by example, in times of danger to inspire those he led. But he also honed the skill of leading from behind, with quiet self-sacrifice, to celebrate the success of those he led. His tireless dedication was prominent in all the facets of his life, whether as a father, son, brother, surgeon, educator, mentor, or friend. We miss him dearly, and try to embody his spirit by living our lives through what he taught us all.

Brian Allgood, MD, COL

1960-2007

Dean Taylor, MD

An Exemplary Selfless Leader in Orthopedics and Medicine

When people ask me what effective, ethical healthcare leadership looks like, I think of Brian Allgood. Brian was the epitome of leadership. He led quietly, by example and selflessly–always putting the interests of patients and those on his team ahead of his own.

Brian was a 1982 graduate of the United States Military Academy at West Point, and received a Doctor of Medicine degree from the University of Oklahoma. He completed his orthopedic training at Brooke Army Medical Center in San Antonio. I first met Brian in 1994 when he was practicing as an orthopedic surgeon at Womack Army Medical Center at Ft. Bragg, North Carolina, where he also served at the Division Surgeon for the 82nd Airborne Division. At the time, I was extremely impressed with Brian’s outstanding orthopedic skills, and his unwavering commitment to leadership in orthopedics, military medicine, and medicine.

Brian’s role as the 82nd Airborne Division Surgeon was on the leadership track in Army medicine, a track that many of us who enjoyed and were good at patient care shunned because it was structured to limit the amount of time an administrative leader could spend in patient care. Brian was certainly a skilled orthopedic surgeon who loved caring for patients; however, he was courageous enough to put his responsibility to military medicine and the medical profession ahead of his own clinical interests. He realized that he could provide exceptional leadership that would benefit many instead of only those in his sphere of care. And what an exceptional leader he was!

From 2002 to 2004, I saw firsthand Brian’s extraordinary leadership when he served as the hospital commander of Keller Army Community Hospital at West Point. He was the best hospital commander I worked with during my 11 years at West Point. I saw the sacrifices he made for the rest of us. He gave up something he loved–orthopedic surgery–so that he could effectively lead our hospital. While we operated, he occasionally would look longingly through the operating room (OR) windows. When we saw him, we would invite him to scrub in, much to his delight. He would also show up in other services’ ORs and the hospital’s clinics, staying connected to patients and patient care. This patient-centeredness contributed significantly to the beloved leader he was.

Brian’s final assignment was in 2006 as the Command Surgeon of Multi-National Forces, the highest-ranking medical officer in Iraq. On January 20, 2007, Brian Allgood—on the verge of promotion to brigadier general and on the fast track to Surgeon General of the Army—was killed along with 11 other American service members when their helicopter was shot down.

In his life, Brian was an exemplary leader. After his death, he lives on in our memories as an example to which we should all aspire–an ethical, selfless leader who cared for all patients, always striving to do the right thing.

LCpl Benjamin Whetstone Schmidt

1987-2011

David R. Schmidt, MD

A Fallen Hero’s Legacy

On September 11, 2011, LCpl Benjamin Whetstone Schmidt posted on his Facebook page, “I guess you can use today as a reason for us to be here in Afghanistan. Just know I am fighting for myself, but most of all for my friends and family who read this. Everyone, it’s an honor to be your ambassador.”

Benjamin was a Marine Scout Sniper on his second tour to Afghanistan, this time voluntarily. Not one member of his platoon had combat experience. He felt called to lead, to be with his boys. During his first deployment to Afghanistan he was awarded the Navy/USMC Achievement Medal with Valor for his action in combat.

Less than a month later, on October 6, 2011, he was killed while on patrol in Helmand Province. Even now, 6 years after his death, his comrades continue to hail his virtues as a leader, a friend, a patriot, and an inspiration. He was also a fine athlete and a courageous, energetic young man with bold plans for his future.

Other than his family, few knew what Benjamin would inspire in his death. He left $200,000 of his life insurance to establish a scholarship in the History Department at his beloved Texas Christian University (TCU). With a matching gift from his father, orthopedic surgeon David R. Schmidt, MD, and stepmom Teresa, the scholarship provides annual funding for a graduate student. Asked why he chose to support graduate students, Benjamin replied with his signature humor and wisdom, “I wouldn’t invest in a freshman like myself.” Benjamin had spent 2 years at TCU prior to enlisting in the Marine Corps, and intended to return to TCU to complete his undergraduate and graduate degrees.

Certainly not many young men at age 24 years, prior to going to war, have the foresight to envision and implement a legacy bigger than themselves, with the promise of influencing generations into the future. For his actions, Benjamin was a finalist for a Congressional Medal of Honor Society “Citizen Service Before Self” award.

David and Teresa Schmidt subsequently raised $1 million dollars to endow the LCpl Benjamin W. Schmidt Professor of War, Conflict and Society. It is truly inspirational to know that a young man’s selfless vision and his friends’ and family’s support could produce such a lasting legacy.

This Memorial Day, with all that is taking place in the world, it was hard not to think about the brave men and women who have sacrificed so much to preserve our freedom. They are away from their families, sometimes for years at a time, and they operate in the most dangerous places in the world. A safe return is not guaranteed. I am thankful for these intrepid men and women whose sacrifices and commitment to their country allow me to live comfortably at home with my family and practice orthopedic surgery.

A few years ago, my wife and I traveled to Normandy and visited the American cemetery. It was a moving experience that I will never forget. We then toured Pointe du Hoc, the elevated peninsula separating Omaha and Utah beach and the location of German gun emplacements covering both beaches. The bunkers, and even the craters from the bombs, are still there. Army Rangers were tasked with launching an amphibious assault on the beach and then scaling the 100-foot cliffs using grappling hooks, ropes, and ladders. Once at the top, they faced a heavily fortified German force that was dug in. Looking down at the beach and out over the ocean from above, I thought of the troops who landed there and the impossible task they faced. Despite the overwhelming odds stacked against them, the Rangers took Pointe du Hoc in 25 minutes and then repelled multiple counterattacks with their backs against the cliff. In my opinion, it’s one of the greatest testaments to the incredible determination and ability of our military personnel.

Speaking of incredible ability, AJO would like to recognize our military orthopedists. They are often deployed in combat zones and provide the best of care for our soldiers while working in the most stressful of conditions, and doing it all on a government salary. In their spare time, they’ve contributed so much to the orthopedic literature, authoring numerous landmark articles.

In this issue, AJO looks at classic military injuries: shoulder instability, stress fractures, and multi-ligamentous knee injuries. Provencher and colleagues authored a comprehensive review of instability with current guidelines for determining surgical approach. DeBerardino shows our readers how to take a military approach to multi-ligament and complex knee injuries, and Owens and colleagues provide a guide to the diagnosis and treatment of stress injuries to bone.

We also take a moment to recognize 3 members of our military orthopedic family whose lives were tragically cut short. Warren R. Kadrmas, Brian Allgood, and Benjamin Whetstone Schmidt’s memorials are included on the following pages. Benjamin Whetstone Schmidt, son of orthopedist David R. Schmidt from San Antonio, was a Marine Sniper killed in action in Afghanistan after volunteering for a second tour. After his death, the LCpl Benjamin Whetstone Schmidt Endowed Professorship in History was created at the Texas Christian University. Contributions can be made in his memory at www.heartofpurple.com.

As Independence Day is celebrated, AJO is pleased to present “Military Orthopedics” to honor our troops and the military doctors who support them. As you read this issue, take a moment to reflect on the freedoms you enjoy because America is truly the Home of the Brave.

Am J Orthop. 2017;46(4):166. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.

This Memorial Day, with all that is taking place in the world, it was hard not to think about the brave men and women who have sacrificed so much to preserve our freedom. They are away from their families, sometimes for years at a time, and they operate in the most dangerous places in the world. A safe return is not guaranteed. I am thankful for these intrepid men and women whose sacrifices and commitment to their country allow me to live comfortably at home with my family and practice orthopedic surgery.

A few years ago, my wife and I traveled to Normandy and visited the American cemetery. It was a moving experience that I will never forget. We then toured Pointe du Hoc, the elevated peninsula separating Omaha and Utah beach and the location of German gun emplacements covering both beaches. The bunkers, and even the craters from the bombs, are still there. Army Rangers were tasked with launching an amphibious assault on the beach and then scaling the 100-foot cliffs using grappling hooks, ropes, and ladders. Once at the top, they faced a heavily fortified German force that was dug in. Looking down at the beach and out over the ocean from above, I thought of the troops who landed there and the impossible task they faced. Despite the overwhelming odds stacked against them, the Rangers took Pointe du Hoc in 25 minutes and then repelled multiple counterattacks with their backs against the cliff. In my opinion, it’s one of the greatest testaments to the incredible determination and ability of our military personnel.

Speaking of incredible ability, AJO would like to recognize our military orthopedists. They are often deployed in combat zones and provide the best of care for our soldiers while working in the most stressful of conditions, and doing it all on a government salary. In their spare time, they’ve contributed so much to the orthopedic literature, authoring numerous landmark articles.

In this issue, AJO looks at classic military injuries: shoulder instability, stress fractures, and multi-ligamentous knee injuries. Provencher and colleagues authored a comprehensive review of instability with current guidelines for determining surgical approach. DeBerardino shows our readers how to take a military approach to multi-ligament and complex knee injuries, and Owens and colleagues provide a guide to the diagnosis and treatment of stress injuries to bone.

We also take a moment to recognize 3 members of our military orthopedic family whose lives were tragically cut short. Warren R. Kadrmas, Brian Allgood, and Benjamin Whetstone Schmidt’s memorials are included on the following pages. Benjamin Whetstone Schmidt, son of orthopedist David R. Schmidt from San Antonio, was a Marine Sniper killed in action in Afghanistan after volunteering for a second tour. After his death, the LCpl Benjamin Whetstone Schmidt Endowed Professorship in History was created at the Texas Christian University. Contributions can be made in his memory at www.heartofpurple.com.

As Independence Day is celebrated, AJO is pleased to present “Military Orthopedics” to honor our troops and the military doctors who support them. As you read this issue, take a moment to reflect on the freedoms you enjoy because America is truly the Home of the Brave.

Am J Orthop. 2017;46(4):166. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.

This Memorial Day, with all that is taking place in the world, it was hard not to think about the brave men and women who have sacrificed so much to preserve our freedom. They are away from their families, sometimes for years at a time, and they operate in the most dangerous places in the world. A safe return is not guaranteed. I am thankful for these intrepid men and women whose sacrifices and commitment to their country allow me to live comfortably at home with my family and practice orthopedic surgery.

A few years ago, my wife and I traveled to Normandy and visited the American cemetery. It was a moving experience that I will never forget. We then toured Pointe du Hoc, the elevated peninsula separating Omaha and Utah beach and the location of German gun emplacements covering both beaches. The bunkers, and even the craters from the bombs, are still there. Army Rangers were tasked with launching an amphibious assault on the beach and then scaling the 100-foot cliffs using grappling hooks, ropes, and ladders. Once at the top, they faced a heavily fortified German force that was dug in. Looking down at the beach and out over the ocean from above, I thought of the troops who landed there and the impossible task they faced. Despite the overwhelming odds stacked against them, the Rangers took Pointe du Hoc in 25 minutes and then repelled multiple counterattacks with their backs against the cliff. In my opinion, it’s one of the greatest testaments to the incredible determination and ability of our military personnel.

Speaking of incredible ability, AJO would like to recognize our military orthopedists. They are often deployed in combat zones and provide the best of care for our soldiers while working in the most stressful of conditions, and doing it all on a government salary. In their spare time, they’ve contributed so much to the orthopedic literature, authoring numerous landmark articles.

In this issue, AJO looks at classic military injuries: shoulder instability, stress fractures, and multi-ligamentous knee injuries. Provencher and colleagues authored a comprehensive review of instability with current guidelines for determining surgical approach. DeBerardino shows our readers how to take a military approach to multi-ligament and complex knee injuries, and Owens and colleagues provide a guide to the diagnosis and treatment of stress injuries to bone.

We also take a moment to recognize 3 members of our military orthopedic family whose lives were tragically cut short. Warren R. Kadrmas, Brian Allgood, and Benjamin Whetstone Schmidt’s memorials are included on the following pages. Benjamin Whetstone Schmidt, son of orthopedist David R. Schmidt from San Antonio, was a Marine Sniper killed in action in Afghanistan after volunteering for a second tour. After his death, the LCpl Benjamin Whetstone Schmidt Endowed Professorship in History was created at the Texas Christian University. Contributions can be made in his memory at www.heartofpurple.com.

As Independence Day is celebrated, AJO is pleased to present “Military Orthopedics” to honor our troops and the military doctors who support them. As you read this issue, take a moment to reflect on the freedoms you enjoy because America is truly the Home of the Brave.

Am J Orthop. 2017;46(4):166. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.

In the article, “When can infants and children benefit from probiotics?” (J Fam Pract. 2016;65:789-794), Dassow et al recommended probiotics as a therapeutic tool for reducing abdominal pain associated with pediatric irritable bowel syndrome (IBS). There are several types of functional disorders in childhood with related abdominal pain, the most common of which are IBS and functional abdominal pain (FAP).^1,2

Several recent randomized placebo-controlled trials—one of which I led—have shown that Lactobacillus reuteri DSM 17938 is a beneficial treatment for FAP in children.^3-5 When compared with placebo, this probiotic agent significantly reduced the frequency and intensity of FAP in children.

Family physicians should consider this probiotic microorganism as a potential therapeutic tool for IBS, as well as childhood FAP.

Zvi Weizman, MD
Beer-Sheva, Israel

In the article, “When can infants and children benefit from probiotics?” (J Fam Pract. 2016;65:789-794), Dassow et al recommended probiotics as a therapeutic tool for reducing abdominal pain associated with pediatric irritable bowel syndrome (IBS). There are several types of functional disorders in childhood with related abdominal pain, the most common of which are IBS and functional abdominal pain (FAP).^1,2

Several recent randomized placebo-controlled trials—one of which I led—have shown that Lactobacillus reuteri DSM 17938 is a beneficial treatment for FAP in children.^3-5 When compared with placebo, this probiotic agent significantly reduced the frequency and intensity of FAP in children.

Family physicians should consider this probiotic microorganism as a potential therapeutic tool for IBS, as well as childhood FAP.

Zvi Weizman, MD
Beer-Sheva, Israel

In the article, “When can infants and children benefit from probiotics?” (J Fam Pract. 2016;65:789-794), Dassow et al recommended probiotics as a therapeutic tool for reducing abdominal pain associated with pediatric irritable bowel syndrome (IBS). There are several types of functional disorders in childhood with related abdominal pain, the most common of which are IBS and functional abdominal pain (FAP).^1,2

Several recent randomized placebo-controlled trials—one of which I led—have shown that Lactobacillus reuteri DSM 17938 is a beneficial treatment for FAP in children.^3-5 When compared with placebo, this probiotic agent significantly reduced the frequency and intensity of FAP in children.

Family physicians should consider this probiotic microorganism as a potential therapeutic tool for IBS, as well as childhood FAP.

Zvi Weizman, MD
Beer-Sheva, Israel

In the article by Smith et al, “ ‘Cold turkey’ works best for smoking cessation” (J Fam Pract. 2017;66:174-176), the authors highlighted a study by Lindson-Hawley et al showing that abrupt cessation was associated with higher quit rates than gradual cessation.¹

While I agree with Smith et al’s assessment of abrupt cessation for patients in the preparation and action stages of change as created by DiClemente and Prochaska,² most clinical patients are in the pre-contemplative and contemplative stages of change. A bias of the study was that all recruited participants were willing to quit within 2 weeks.

A systematic review by the same authors (Lindson-Hawley et al) compared gradual reduction of smoking with abrupt cessation and found comparable quit rates.³ Smith et al commented that the reason for this conclusion was limitations in the studies, including differences in patient populations, outcome definitions, and types of interventions.

Because a large subset of clinical patients are in the pre-contemplative and contemplative stages of change, I believe gradual cessation remains an important technique to use while patients transition their beliefs.

Jeff Ebel, DO
Toledo, Ohio

Author’s response:

I appreciate Dr. Ebel’s input and perspective. My co-authors and I acknowledge that the previous systematic review noted comparable quit rates, but there were significant limitations to the studies, which Dr. Ebel noted. The highlight from the 2016 randomized, controlled trial by Lindson-Hawley et al is that patients are more likely to quit from abrupt cessation, even if they initially prefer gradual cessation. As Dr. Ebel notes (and we highlighted in the PURL), our role as family physicians is to inform patients of the data, but support them in whatever method of cessation they choose.

Dustin K. Smith, DO
Jacksonville, Fla.

In the article by Smith et al, “ ‘Cold turkey’ works best for smoking cessation” (J Fam Pract. 2017;66:174-176), the authors highlighted a study by Lindson-Hawley et al showing that abrupt cessation was associated with higher quit rates than gradual cessation.¹

While I agree with Smith et al’s assessment of abrupt cessation for patients in the preparation and action stages of change as created by DiClemente and Prochaska,² most clinical patients are in the pre-contemplative and contemplative stages of change. A bias of the study was that all recruited participants were willing to quit within 2 weeks.

A systematic review by the same authors (Lindson-Hawley et al) compared gradual reduction of smoking with abrupt cessation and found comparable quit rates.³ Smith et al commented that the reason for this conclusion was limitations in the studies, including differences in patient populations, outcome definitions, and types of interventions.

Because a large subset of clinical patients are in the pre-contemplative and contemplative stages of change, I believe gradual cessation remains an important technique to use while patients transition their beliefs.

Jeff Ebel, DO
Toledo, Ohio

Author’s response:

I appreciate Dr. Ebel’s input and perspective. My co-authors and I acknowledge that the previous systematic review noted comparable quit rates, but there were significant limitations to the studies, which Dr. Ebel noted. The highlight from the 2016 randomized, controlled trial by Lindson-Hawley et al is that patients are more likely to quit from abrupt cessation, even if they initially prefer gradual cessation. As Dr. Ebel notes (and we highlighted in the PURL), our role as family physicians is to inform patients of the data, but support them in whatever method of cessation they choose.

Dustin K. Smith, DO
Jacksonville, Fla.

In the article by Smith et al, “ ‘Cold turkey’ works best for smoking cessation” (J Fam Pract. 2017;66:174-176), the authors highlighted a study by Lindson-Hawley et al showing that abrupt cessation was associated with higher quit rates than gradual cessation.¹

While I agree with Smith et al’s assessment of abrupt cessation for patients in the preparation and action stages of change as created by DiClemente and Prochaska,² most clinical patients are in the pre-contemplative and contemplative stages of change. A bias of the study was that all recruited participants were willing to quit within 2 weeks.

A systematic review by the same authors (Lindson-Hawley et al) compared gradual reduction of smoking with abrupt cessation and found comparable quit rates.³ Smith et al commented that the reason for this conclusion was limitations in the studies, including differences in patient populations, outcome definitions, and types of interventions.

Because a large subset of clinical patients are in the pre-contemplative and contemplative stages of change, I believe gradual cessation remains an important technique to use while patients transition their beliefs.

Jeff Ebel, DO
Toledo, Ohio

Author’s response:

I appreciate Dr. Ebel’s input and perspective. My co-authors and I acknowledge that the previous systematic review noted comparable quit rates, but there were significant limitations to the studies, which Dr. Ebel noted. The highlight from the 2016 randomized, controlled trial by Lindson-Hawley et al is that patients are more likely to quit from abrupt cessation, even if they initially prefer gradual cessation. As Dr. Ebel notes (and we highlighted in the PURL), our role as family physicians is to inform patients of the data, but support them in whatever method of cessation they choose.

Dustin K. Smith, DO
Jacksonville, Fla.

Drugs are valuable when they effectively relieve symptoms or prevent illness, but we all know they are double-edged swords when it comes to cost, adverse effects, and drug interactions. This “downside” is not lost on older Americans—especially when you consider that more than a third of Americans, ages 62 to 85 years, take 5 or more prescription medications daily.¹

Too often patients take prescription drugs that they either don’t need or that are harming them. That’s where deprescribing comes in. As this month’s feature article by McGrath and colleagues explains, deprescribing is the process of reducing or stopping unnecessary prescription medications.

The power of deprescribing. About a decade ago, a geriatrician/family physician friend of mine took over as medical director of a 160-bed nursing home. He lamented that the average number of prescription medications taken by the patients in the nursing home was 9.5. He and his team went to work deprescribing, and one year later, the average number of prescription medications per patient was 5.3. As far as he and the nursing staff could tell, the patients were doing just fine and were more alert and functional.

With a blood pressure consistently around 105/50 mm Hg, it was an easy decision to stop one of the patient’s 3 antihypertensive medications.

Another specialist, another Rx. In clinic, I saw a 54-year-old woman with the chief complaint of chronic, dry cough for which she had been on a specialist pilgrimage. A GI specialist prescribed omeprazole, an ENT physician prescribed fluticasone nasal spray and cetirizine, and a pulmonologist added an inhaled corticosteroid to the mix. (I’m not making this up!) I reviewed her medication list carefully and noted she had been placed on amitriptyline for insomnia shortly before the cough began. I was suspicious because the properties of anticholinergics can contribute to a cough. At my suggestion, she agreed to stop the amitriptyline (and endure some sleeplessness). Two weeks later, she returned with no cough. Over the next month, she stopped all 4 other medications, and the cough did not return.

Today in the office, a 64-year-old man complained of lightheadedness and fatigue and told me his blood pressure on home monitoring was consistently around 105/50 mm Hg. In addition to taking 3 antihypertensive medications, I discovered he had been prescribed doxazosin—an alpha blocker, which also lowers blood pressure—for symptoms of benign prostatic hypertrophy. It was an easy decision to stop one of his 3 antihypertensive medications.

I’m certain that you, too, have stories of successful deprescribing. Let’s remain alert to the problem of polypharmacy, keep meticulous medication lists, and deprescribe whenever it makes good sense. Doing so is essential to our roles as family physicians.

Drugs are valuable when they effectively relieve symptoms or prevent illness, but we all know they are double-edged swords when it comes to cost, adverse effects, and drug interactions. This “downside” is not lost on older Americans—especially when you consider that more than a third of Americans, ages 62 to 85 years, take 5 or more prescription medications daily.¹

Too often patients take prescription drugs that they either don’t need or that are harming them. That’s where deprescribing comes in. As this month’s feature article by McGrath and colleagues explains, deprescribing is the process of reducing or stopping unnecessary prescription medications.

The power of deprescribing. About a decade ago, a geriatrician/family physician friend of mine took over as medical director of a 160-bed nursing home. He lamented that the average number of prescription medications taken by the patients in the nursing home was 9.5. He and his team went to work deprescribing, and one year later, the average number of prescription medications per patient was 5.3. As far as he and the nursing staff could tell, the patients were doing just fine and were more alert and functional.

With a blood pressure consistently around 105/50 mm Hg, it was an easy decision to stop one of the patient’s 3 antihypertensive medications.

Another specialist, another Rx. In clinic, I saw a 54-year-old woman with the chief complaint of chronic, dry cough for which she had been on a specialist pilgrimage. A GI specialist prescribed omeprazole, an ENT physician prescribed fluticasone nasal spray and cetirizine, and a pulmonologist added an inhaled corticosteroid to the mix. (I’m not making this up!) I reviewed her medication list carefully and noted she had been placed on amitriptyline for insomnia shortly before the cough began. I was suspicious because the properties of anticholinergics can contribute to a cough. At my suggestion, she agreed to stop the amitriptyline (and endure some sleeplessness). Two weeks later, she returned with no cough. Over the next month, she stopped all 4 other medications, and the cough did not return.

Today in the office, a 64-year-old man complained of lightheadedness and fatigue and told me his blood pressure on home monitoring was consistently around 105/50 mm Hg. In addition to taking 3 antihypertensive medications, I discovered he had been prescribed doxazosin—an alpha blocker, which also lowers blood pressure—for symptoms of benign prostatic hypertrophy. It was an easy decision to stop one of his 3 antihypertensive medications.

I’m certain that you, too, have stories of successful deprescribing. Let’s remain alert to the problem of polypharmacy, keep meticulous medication lists, and deprescribe whenever it makes good sense. Doing so is essential to our roles as family physicians.

Drugs are valuable when they effectively relieve symptoms or prevent illness, but we all know they are double-edged swords when it comes to cost, adverse effects, and drug interactions. This “downside” is not lost on older Americans—especially when you consider that more than a third of Americans, ages 62 to 85 years, take 5 or more prescription medications daily.¹

Too often patients take prescription drugs that they either don’t need or that are harming them. That’s where deprescribing comes in. As this month’s feature article by McGrath and colleagues explains, deprescribing is the process of reducing or stopping unnecessary prescription medications.

The power of deprescribing. About a decade ago, a geriatrician/family physician friend of mine took over as medical director of a 160-bed nursing home. He lamented that the average number of prescription medications taken by the patients in the nursing home was 9.5. He and his team went to work deprescribing, and one year later, the average number of prescription medications per patient was 5.3. As far as he and the nursing staff could tell, the patients were doing just fine and were more alert and functional.

With a blood pressure consistently around 105/50 mm Hg, it was an easy decision to stop one of the patient’s 3 antihypertensive medications.

Another specialist, another Rx. In clinic, I saw a 54-year-old woman with the chief complaint of chronic, dry cough for which she had been on a specialist pilgrimage. A GI specialist prescribed omeprazole, an ENT physician prescribed fluticasone nasal spray and cetirizine, and a pulmonologist added an inhaled corticosteroid to the mix. (I’m not making this up!) I reviewed her medication list carefully and noted she had been placed on amitriptyline for insomnia shortly before the cough began. I was suspicious because the properties of anticholinergics can contribute to a cough. At my suggestion, she agreed to stop the amitriptyline (and endure some sleeplessness). Two weeks later, she returned with no cough. Over the next month, she stopped all 4 other medications, and the cough did not return.

Today in the office, a 64-year-old man complained of lightheadedness and fatigue and told me his blood pressure on home monitoring was consistently around 105/50 mm Hg. In addition to taking 3 antihypertensive medications, I discovered he had been prescribed doxazosin—an alpha blocker, which also lowers blood pressure—for symptoms of benign prostatic hypertrophy. It was an easy decision to stop one of his 3 antihypertensive medications.

I’m certain that you, too, have stories of successful deprescribing. Let’s remain alert to the problem of polypharmacy, keep meticulous medication lists, and deprescribe whenever it makes good sense. Doing so is essential to our roles as family physicians.