Patricia Estrada | Family Medicine
One of my toughest cases
The Mysterious Pain in a Knee
Doctors in family practice treat a wide array of problems on a day-to-day basis. From rashes and yearly physicals to diabetes and bone fractures, every day brings something new. For more than 22 years, local families have turned to Dr. Patricia Estrada for medical care. “I love the thought of preventative health for a variety of different ages,” says Estrada, whose patients’ ages range from 18 to 101. “I like the fact that you address the whole person’s physical and emotional needs.”
Though not wanting to be a doctor until she was in college (she wanted to be an archeologist when she was little), Estrada grew up with physicians in the family. Her father was a psychiatrist, and her grandfather was an OB-GYN in the relitively small country of Columbia. “He rode his horse to deliver babies,” she says. That small-town atmosphere trained her well for her current job.
Many of Estrada’s original patients continue to seek treatment from her, even as she takes on new generations of patients. “It’s funny; some patients will tell me, ‘You’ve been my doctor for like 30 years!’ and it makes me feel old,” she says, adding, “I haven’t even been in practice that long!”
Twenty years ago, a 14-year-old, whose mother and grandmother were also patients of Estrada’s, visited complaining of pain in her knee. After an examination, Estrada gave her some anti-inflammatory medication and scheduled a follow-up for two weeks later. When the pain continued, she did an X-ray revealing an osteosarcoma, a malignant tumor, which had developed in her femur (thigh) bone.
“I feared an amputation,” she says. “During my training, I had seen osteosarcomas and that was the treatment.
Chemo and surgery, at that time, were still new treatments.” Estrada then referred the patient to Dr. Kleinschmidt at West Jefferson Memorial Hospital who referred her to Dr. Yu and Dr. Heinrich of Children’s Hospital. The team of doctors saved her leg through chemotherapy and surgery, leaving only a scar as evidence of the tumor. Estrada stayed in close contact with Dr. Kleinschmidt and the family throughout the process.
“I feel very lucky to be in this town because I have a small-town, traditional family practice but the specialists here are superb,” she says. “One of the key things as a family doctor is knowing who to refer your patients to. I think each primary doctor develops their A-team. If I had lived in a little town in the middle of nowhere, this would have been very difficult to achieve.”
Over the years, Dr. Estrada continued treating the patient. A couple years ago, the patient began talking to Estrada about changing careers. “She came to me and said ‘I think there is something more,’” she says. So, at 34, the patient quit her lucrative career and is now studying to be a nurse. “I encouraged her. She will make a great nurse.”
“As family doctor, often the toughest cases are cases that have both devastating medical and emotional aspects,” Estrada says. “I feel blessed to form close relationships with my patients. Sometimes very hard things happen to your health. It’s a very difficult time for yourself and your family. How you face it and the support that you have makes all the difference in the world to your outcome. I will go to bat for my patients.”
4701 Westbank Expressway, Suite 7, Marrero
22 years in practice
MD from University of Missouri – 1986
Residency at University of Texas
Medical Branch at Galveston – 1989
Native of Columbia, Mo.
Ricardo Sorensen | Allergy and Immunology
One of my toughest cases
Campaigning for Early “Bubble Boy” Disease Screening
uring the 1970s, David Vetter grabbed national attention as the “Boy in the Plastic Bubble.” He was forced to live in a sterile environment from birth at a children’s hospital in Texas until he died at the age of 12, still waiting for a cure for his severe combined immunodeficiency. SCID is a severe, early-onset form of primary immunodeficiency (PI) disease, a condition that weakens the immune system that appears in more than 20 different forms.
“Fortunately those diseases are not very frequent, but they are more frequent then what is recognized and diagnosed,” says Dr. Ricardo Sorensen. “If recognized early, they can be cured.”
Sorensen is leading the charge for Louisiana to require neonatal screening for T-cell deficiencies – or “bubble boy diseases.” As a pediatrician specializing in immunology, he sees newborns and may even treat before birth. They are referred to him after many hospital stays and doctor visits for symptoms including repeated infections, failure to thrive, lack of weight gain and chronic diarrhea. These usually indicate a PI disease.
“When a child arrives already with so many infections and is malnourished, treatment becomes very difficult,” he says. “We try bone marrow treatment, but the success rate under those conditions is not very good. It’s tough because if those patients are recognized before they get ill – if you were to find out they have the gene defect that will make them ill eventually – then you can treat them before they become ill. That can be done by neonatal screenings. If treated, they can have a normal life.”
In May of 2010, U.S. Secretary of Health and Human Services Kathleen Sebelius officially added SCID to the Recommended Uniform Screening Panel. The Louisiana State legislature followed, passing a bill to include this disease in the mandatory neonatal screening panel. A year later, due to lack of money, the program was stopped.
“My toughest case is to receive one of these kids where you realize that if they had been diagnosed earlier, the outcome would have been very different,” Sorensen says. “That motivates me to keep talking about these diseases.
If you can change the outcome of these tragedies for these families, you are obliged to do it, aren’t you?”
Sorensen now is working on two goals. The first is to increase education by helping local physicians become aware of how to recognize and diagnose this condition. “Frequently, these are not identified because there is a lack of information about them,” he says. “Newborn screenings for some diseases are an idea. General education about the existence of these disease and getting people to think about them should be done anyhow.”
Sorensen discussed PI diseases with a former classmate, now an allergist, who claimed that in 40 years of practice, he had never treated a patient that had been diagnosed with a PI disease. After learning more, the allergist was able to identify 20 adult patients who had in fact suffered from PI disease.
Sorensen acts as president for the Latin American Society for Immunodeficiencies and works closing with the Jeffrey Modell Foundation out of New York. The foundation was formed in 1987 by Vicki and Fred Modell in memory of their son, who died at 15 from complications of PI. New Orleans is home to one of seven Jeffrey Modell Diagnostic Centers in the country.
Along with colleague Dr. Kenneth Paris, Sorensen also coordinates the Jeffrey Modell Continuing Education Course in Primary Immunodeficiencies, a yearly course in New Orleans for general practitioners to help them learn to recognize PI symptoms. He invites the best immunologists from around the country, and occasionally the world, to speak and “offer the best advice possible.”
Sorensen’s second goal is to bring back PI testing to all Louisiana hospitals. Louisiana has sent a grant proposal to the Centers for Disease Control and Prevention for additional funding, which will be decided in September. “We did the effort of becoming the fifth state to start the screenings, and we showed that we can do it,” he says. “If someone gives us the money, Louisiana is ready to do it.”
36 years in practice
MD from University of Chile – 1964
Native of Chile
Asif Anwar | Cardiology | Tulane Medical Center
One of my toughest cases
Diagnosis for a Colleague
ardiac diseases are not only fascinating by their complexity but also by the incredible and tremendous progress science has made in the last decades for their diagnosis and treatment,” says cardiologist Dr. Asif Anwar.
“However, still much has to be done for treating cardiovascular diseases which are still the number one killer in our western societies.” In fact, every 25 seconds, someone in the country will have a coronary event, and about one every minute will die from it, according to a recent study by the American Heart Association.
Treating cardiac disease can be difficult, especially when the case involves a friend with a potentially deadly diagnosis. Three months ago, Anwar’s toughest case began when a 56-year-old colleague told him that he started running after gaining 20 pounds over five years of inactivity, the result of a heavy workload. He sought treatment after noticing occasional palpitations (an abnormal heartbeat), after a run. He had already seen another physician and had a normal cardiac ultrasound and an electrocardiogram. The patient said he never passed out or had any chest pain. “He attributed the problem to the fact that he was totally ‘out of shape,’” Anwar says.
But due to the fact that his colleague was having these very fast heartbeats for only moderate exercise, Anwar decided to pursue the case a bit further. He began by talking with him and taking his medical history.
“Taking the patient’s history in length is one of the most important components of a correct diagnosis,” Anwar says. “Paying attention to every detail is crucial even though it is very time-consuming in a busy clinic and, nowadays, more and more difficult. History, simple baseline tests such as blood pressure, blood analysis, EKG, chest X-ray and eventually a cardiac ultrasound can diagnose – up to 90 percent of times – the right ailment.”
The discussion revealed that 10 years prior, the patient has been diagnosed – and considered cured – from pulmonary sarcoidosis, a benign inflammatory disease. He had been implanted with a subcutaneous defibrillator.
Suspecting a link between the old condition and the new symptoms, Anwar did more tests, including a cardiac magnetic resonance revealing a “small, unusual localized area in the wall of the left heart ventricle compatible with inflammatory reaction.”
With one piece of the puzzle, testing continued with a treadmill stress test, which the patient passed, and readings from a Holter monitor, a portable device for continuously monitoring heart activity. One of the readings revealed an episode of 200 heartbeats per minutes for two minutes. “This arrhythmia was a ventricular tachycardia, a dangerous arrhythmia which most of the time can lead to a sudden cardiac death,” he says. Follow-up electrophysiology testing, placing catheters in the heart and recording the electrical activity confirmed an irritable heart.
“Figuring out the right diagnosis was not the end of the problem, though,” Anwar says. “This cardiac disease is rare and limited scientific evidence exists on the most appropriate treatment.” After discussions, Anwar and the patient decided on cortisone therapy to decrease cardiac inflammation. “Since then, the patient has had no problems,” he says. “He is leading a normal life and even managed to loose weight with a special training program.”
But during the four-week process, Anwar admits it wasn’t the rarity of the case that proved to be the most difficult, but rather the relationship with a colleague and friend and now, patient.
“Treating colleagues you do work with everyday is always tricky,” Anwar says. “They have similar medical knowledge, and over time we become close friends. Therefore you tend to explain and spend much more time giving evidence of the severity of their disease than in usual patients. Because of these potential difficulties, various medical societies recommend not to be the primary physician of its own family members, for example. I found taking charge of this issue difficult.”
27 years in practice
M.D. in Geneva, Switzerland – 1984
Cardiology Fellowship at Emory
University – 1992
Invasive Cardiology Fellowship at Inselspital in Bern, Switzerland – 2002
Native of Geneva, Switzerland
Craig W. Maumus | Psychiatry
One of my toughest cases
Diagnosing and Treating Dysthymia
s a budding psychiatrist in private practice more than 30 years ago, eager to get his foot in the door and pay his bills, Dr. Craig Maumus accepted a case from an attorney in a neighboring state. The case was to analyze and treat a man in his 20s who had been arrested for pulling down the clothes of a little girl in a grocery store.
“At this point in my young career I had little experience with the legal system and no experience at all in dealing with pedophilia,” he says. The attorney went on to express that psychiatric treatment would help stop the young man from going down the wrong path in life and help get a lighter sentence if convicted.
“I told the attorney that any treatment would have to be intense and long-term and that there was no medication specific for pedophilia and no quick fix,” he says. “I would have to evaluate his client first, of course, before I could make any recommendations, but that some intense inpatient treatment would likely be required, followed by lengthy outpatient psychotherapy.”
The parents of the patient agreed to have their son hospitalized under Maumus’ care for an extended period of time.
Once he began treatment, Maumus discovered that he was incredibly immature for his age and had never really dated. He never mentioned any specific talents or interests. “He was neither mentally retarded nor was he functioning in the borderline IQ range,” Maumus says. “He did understand that he had a serious problem with the law, but I’m not sure if he ever felt that his behavior was that unacceptable.”
Maumus continued to treat him by interviewing his parents and conversing with colleagues. “Not having Internet resources like we do today, I spent quite a number of evenings after work at the Tulane medical library downtown making Photostat copies of any germane journal articles that I could find,” he says.
The patient was discovered to have dysthymia, a chronic, low-grade depression, and Maumus prescribed him anti-depressants. He also tried to engage him through insight-orientated psychotherapy and cognitive restructuring techniques, to no avail.
Frustrated, Maumus turned to Dr. Chet Scrignar to help him with behavior modification therapy. “We decided to use the technique of conditioned behavior in which my patient’s erotic feelings for little girls would be paired with a noxious agent, in this case some foul-smelling liquid in a bottle. The goal was to extinguish the pleasurable thoughts by associating them with horrible smells.”
In the therapy sessions, Maumus would show “stimulus” photos of little girls that the patient had cut out from a catalogue. Once the patient acknowledged his interest, Maumus would have him smell unpleasant odor to immediately kill his erotic thoughts.
Over time, the patient said he no longer had any interest in little girls. He returned home to face trial with a vial of the foul-smelling liquid to use if the wrong thoughts started again. Maumus was called to testify on behalf of the defense about his treatments but did acknowledge that there wasn’t a cure for pedophilia and more intense treatment would be required. “I had to admit that my prognosis was not very optimistic,” he says.
The patient was eventually convicted, though as the years passed, the internal debate of doing his job as a psychiatrist versus helping someone receive reduced or no prison time remained.
“I felt my patient did indeed have some real psychological problems that caused him to have these inappropriate feelings for little girls, and I knew that medication and conventional talk therapy were not going to cure him, nor even likely cause much improvement, if that is the proper word to be used here,” Maumus says. “But I felt in my heart that my efforts at behavior modification might cause some positive behavioral changes, if nothing else. If only he would never touch another young girl or if he were able to form some sort of a relationship with a woman his age, then I could declare some sort of success.
“On the other hand,” he continues. “I was troubled by the thought of being an agent in possibly saving someone guilty of a crime from the full weight of the law, which was exactly what the defense attorney was trying to do. By trying to help my patient, I knowingly was going to be used to this end. But, regardless, I felt I had done what I could to help my patient get better, which I felt was my duty. I told myself that I could not be responsible for how my help was used in the legal system.”
St. John VA Outpatient Clinic
35 Years in Practice
B.S. from Tulane – 1968
M.D. from Tulane – 1972
Native of New Orleans
Lisa Bazett-Matabele | Gynecologic Oncology | Ochsner Health System
One of my toughest cases
Saving the Uterus
very year, about 71,500 women in the United States are diagnosed with gynecologic cancer – that’s 10 percent of all new cancers in women. “It’s a small percentage of all the cancers women suffer from, but we’re seeing it everyday,” says Dr. Lisa Bazzett-Matabele. “We get patients referred in from a wide geographic area. Patients come to us from the Gulf Coast to the bayou, all the way from Lake Charles and Baton Rouge.”
Bazzett-Matabele decided to go into the specialty during her residency. “I went into obstetrics and gynecology because I wanted to take care of young, healthy patients, but as I went into my training, I realized I wanted more of a challenge, although there’s a lot to do in obstetrics and gynecology. I became a lot more interested in the surgical aspect of the field and in doing intensive care rotations with more complicated, sicker patients. That’s really what gynecologic oncology is about.”
Working in the field, she sees numerous forms of the disease. Cervical cancer is more common in younger patients while other diagnoses (ovarian, uterine, vaginal and vulvar cancers) are often seen in post-menopausal women.
She recalls a case of a 20-something with cervical cancer from early in her career. At the time, the standard of care was a radical hysterectomy. “I sat down, like I did with everyone, and went over what the standard treatment would be,” she says. “She sat there listening to everything I had to say very politely, and when I was done, she said, ‘Well, I heard about this other procedure.’”
The patient was speaking of a procedure that was popular in Europe and Canada that removes the cervix, but leaves the uterus, preserving the ability to have children. The patient was engaged to be married and worried about not having children. Unfamiliar with the procedure, besides what she had read about it in medical journals, Bazzett-Matabele agreed to consider the operation.
“I told her, ‘You do your homework and look up whatever you can find about it, because I want you to understand if this is truly a valid option for cervical cancer. I’m going to do the same thing, and we’ll come back in a week to discuss what we find,’” she says.
During the week, Bazzett-Matabele discovered there were a few hospitals in the United States doing this procedure routinely. After talking with those doctors and doing more research, she agreed to do the procedure. “The procedure wasn’t something totally out of what we were used to doing. We knew the techniques. It’s just kind of putting nuances on what we already do. The most important thing was not compromising the chance of curing her cancer,” she says.
Assisted by a colleague, she performed the surgery successfully. “It was exciting for us,” she says. “This is something we can do now for cervical cancer.” A year later she went to her patient’s wedding. Bazzett-Matabele lost contact with her patient after Hurricane Katrina and doesn’t know if she’s had any kids, but “she certainly has the ability to have children,” she adds. Almost 10 years later, the procedure has replaced the hysterectomy as the standard of care nationally. “Had she not brought that to me the way she did, I probably wouldn’t have started doing that procedure for maybe a couple more years down the road.”
In the future, Bazzett-Matabele plans on moving to Africa with her photographer husband to help improve the quality of women’s health. “It’s always been my dream since I went into medicine before even knowing what specialty I was going into,” she says. Cervical cancer and complications during pregnancy and birth are leading causes of death in women in developing countries. “There’s so much need for women’s health care there. I will be doing gynecologic oncology, but there are other, more basic issues that are killing women there. I hope to be doing teaching and training to get more people out on the ground doing these procedures and test so less women will die of such mundane things.”
11 years in practice
M.D. from Wayne State University – 1993
Residency at Wayne State University – 1997
Fellowship at University of Louisville – 2000
Native of Traverse City, Mich.