The Pulse- Spring 2019 by ACOEP

SPRING 2019

UPDATE

PEDIATRIC FEVER

CONCUSSION RECOVERY TIME FOR TEEN GIRL ATHLETES IS TWICE AS LONG AS IT IS FOR BOYS PG 14

DIAGNOSIS CONCUSSION: A PERSONAL STORY PG 15

PARENTING IS EASY PG 17

The Pulse VOLUME XLI No. 2

TABLE OF CONTENTS EDITORIAL STAFF Timothy Cheslock, DO, FACOEP, Editor Wayne Jones, DO, FACOEP-D, Assistant Editor Tanner Gronowski, DO, Associate Editor Justin Grill, DO John C. Prestosh, DO, FACOEP-D Christine F. Giesa, DO, FACOEP-D Erin Sernoffsky, Editor Janice Wachtler, Executive Director Gabi Crowley, Senior Media Coordinator EDITORIAL COMMITTEE Timothy Cheslock, DO, FACOEP, Chair Justin Grill, DO John C. Prestosh, DO, FACOEP-D Roseanna Roundtree. DO, FACOEP Kaitlin Bowers, DO Tanner Gronowski, DO Dominic Williams, DO Erin Sernoffsky, Director, Media Services

Have You Seen the FOEM Research Network? Calling all researchers and research sites! The FOEM Research Network is a state-of-the art, easy-to-use website that connects researchers and research sites for easily accessible multicenter studies! Users can search by research topic, location, and more to help get their finger on the pulse of the most cutting-edge research in EM.

Find us at frn.foem.org!

The Pulse is a copyrighted quarterly publication distributed at no cost by ACOEP to its Members, Colleges of Osteopathic Medicine, sponsors, exhibitors, and liaison associations recognized by the national offices of ACOEP. The Pulse and ACOEP accept no responsibility for the statements made by authors, contributors, and/ or advertisers in this publication; nor do they accept responsibility for consequences or response to an advertisement. All articles and artwork remain the property of The Pulse and will not be returned. Display and print advertisements are accepted by the publication through ACOEP, 142 East Ontario Street, Chicago, IL 60611, (312) 587-3709 or electronically at marketing@acoep.org. Please contact ACOEP for the specific rates, due dates, and print specifications. Deadlines for the submission of articles are as follows: January issue due date is November 15; April issue due date is February 15; July issue due date is May 15; October issue due date is August 15. Advertisement due dates can be found by downloading ACOEP's media kit at www.acoep.org/advertising. ACOEP and the Editorial Board of The Pulse reserve the right to decline advertising and articles for any issue. ©ACOEP 2019 – All rights reserved. Articles may not be reproduced without the expressed, written approval of ACOEP and the author. ACOEP is a registered trademark of the American College of Osteopathic Emergency Physicians.

PRESIDENTIAL VIEWPOINTS Christine Giesa, DO, FACOEP-D

THE EDITOR'S DESK Erin Sernoffsky, Director, Media Services

EXECUTIVE DIRECTOR’S DESK Janice Wachtler, BAE, CBA

THE ON-DECK CIRCLE Robert Suter, DO, MHA, FACOEP-D

WHAT’S NEW IN PEDIATRIC FEVER? Robert E. Suter, DO, MHA, FAAEM, FACEP, FACOEP-D, FIFEM

CONCUSSION RECOVERY TIME FOR TEEN GIRL ATHLETES IS TWICE AS LONG AS IT IS FOR BOYS AOA STAFF

DIAGNOSIS CONCUSSION: A PERSONAL STORY Annika Giesa, Spring-Ford High School and Christine Giesa, DO, FACOEP-D

PARENTING IS EASY Bradley Chappell, DO, MHA, FACOEP

ACOEP’S COMMITTEE FOR WOMEN IN EMERGENCY MEDICINE UPDATE Nicole Vigh, DO, MPH

WHY I BELONG TO ACOEP G. Joseph Beirne, DO, FACOEP-D, Secretary, ACOEP Board of Directors

RSO UPDATE! Dominic Williams, DO, University of Maryland

DEFINING SCHOLARLY ACTIVITY IN 2019 Bradley Chappell, DO, MHA, FACOEP

EQUAL ACCEPTANCE OF COMLEX-USA AND USMLE IN RESIDENCY Melissa D. Turner, MS, Associate Vice President for Strategy, Quality & Communications, National Board of Osteopathic Medical Examiners

ETHICS IN EMERGENCY MEDICINE: WHAT WOULD YOU DO? Bernard Heilicser, DO, MS, FACEP, FACOEP-D

he ACOEP 40th anniversary celebration and Scientific Assembly in Chicago were big successes. Following the close of Scientific Assembly, things start to ramp down until the New Year. The president usually spends the last week in November in the ACOEP office making committee appointments and meeting with the auditors, but sometimes we need to take time and stop to smell the roses. This year I took a few hours and I visited the Christkindlmarket in Daley Plaza. The Christkindlmarket is a German Christmas festival with traditional German cuisine and many booths filled with holiday items and handmade crafts from Germany. The most notable are wood carvings from the Erzgebirge. This was physician wellness at its best! In my report to the membership in Chicago, I reported on outof-network balance billing for emergency care. A bipartisan group of senators, led by Senator Cassidy (R-LA), has been working on this issue since last summer. The ACA defines patient cost-sharing as deductibles, along with co-pays and coinsurance; however, for emergency care, cost-sharing is defined only as co-pays and coinsurance and does not include deductibles. Insurers thus have an incentive to keep EM physician groups out-of-network since patients will be required to pay more of their bill out-of-pocket before the insurance takes over due to the higher deductible.

PRESIDENTIAL VIEWPOINTS

THE EDITOR’S DESK

Christine Giesa, DO, FACOEP

Erin Sernoffsky, Director, Media Services

PRESIDENTIAL UPDATE

WHAT A DIFFERENCE A DECADE MAKES

IN THE NOW FAST-PACED WORLD OF MEDICINE, WE DO NOT HAVE TIME TO SIT AND TALK. ACOEP CONFERENCES ARE THE PLACE WHERE WE CAN SOCIALIZE AND NETWORK WITH COLLEAGUES WHO SHARE OUR STRUGGLES.” In January, I participated in a meeting with experts from a diverse group of practices at the ACEP headquarters in Washington. The purpose of the meeting was to reach a consensus on the minimum billing standard for emergency medicine that would serve as the base in negotiations with Senator Cassidy the next day. The group also felt there should be provisions for patient protection included in the bill such as the use of plain language in insurance contracts, and that in emergency situations outof-network deductibles be the same as in network deductibles. We have also been working hard to further add value to your ACOEP membership. We may be a smaller organization, but we provide all members with the opportunity for a growth track in education, research, or governance. Be aware that other EM organizations would be happy for us join them, but those organizations will not provide the opportunities that ACOEP provides to our members. As a member of ACOEP, it does not take years for you to get appointed to a committee or hope that someone recommends you as a speaker. All you need to do is express an interest for a committee appointment, schedule a new

speaker audition, or self-nominate to the Board of Directors. The Board of Directors has called for a Membership Task Force, a group of staff members and representatives from the Board of Directors, the New Physicians in Practice group, and the RSO, to launch a membership campaign to attract emergency physicians and residents, as well as ancillary emergency personnel. The Task Force began meeting in January, and through a series of conference calls will develop a report that will be presented to the Board of Directors in April. When was the last time that you left the ED during a shift and went to the cafeteria to get your lunch? Better yet when was the last time that you actually sat and ate in your hospital’s cafeteria? Do you even know the location or combination to the physician lounge? Long gone are the days when physicians ate and socialized with one another. In the now fast-paced world of medicine, we do not have time to sit and talk. ACOEP conferences are the place where we can socialize and network with colleagues who share our struggles. Membership and camaraderie in ACOEP assist

n January I celebrated 10 years as part of the ACOEP team and, being a sentimental person, I’ve spent quite a bit of time reflecting on how much ACOEP has changed in those years. In our quest to keep ACOEP moving forward, it’s tempting to take for granted the incredible strides we’ve taken in recent years as we look for new ways to grow and undertake new initiatives. It’s easy to look at the changing landscape of medicine in this country and feel worried about the future.

IT’S NEVER BEEN MORE IMPORTANT TO TAKE A MOMENT AND REFLECT ON HOW FAR WE’VE COME OVER THE YEARS...” It’s never been more important to take a moment and reflect on how far we’ve come over the years and take pride in the community we are a part of. Ten years may not be a long time in the lifecycle of this organization, but it is an honor to be part of this exciting chapter of ACOEP’s history.

When I was hired our staff expanded from four full-time employees to six, and today I sat in on a staff meeting with our team of 13. In 2009 we didn’t have email marketing, a social media presence, or a designer for The Pulse.

ACOEP is now proudly dually accredited to provide both AOA and AMA CME credit.

I remember the first time we broke 1,000 attendees at Scientific Assembly and now we assume we’ll top that number.

Not only have we introduced hands-on learning, breakout lectures, and tracks at conferences, but the 2019 Spring Seminar featured two days of interactive workshops and opportunities to have more fun with events like a movie night, wine tasting, and a mixology demo.

We have blown the dust off of Written Board Prep and now offer energizing, fast-paced lectures and interactive review sessions.

FOEM has aligned with WestJEM to improve access to the publication for our members and created the FOEM Research Network connecting researchers and studies across the country. The FOEM 5K and the Legacy Gala have become annual staples at our events.

Our kickoff party for the 2018 Scientific Assembly took over Chicago’s House of Blues with a live band. The year before we invaded Jimmy Buffett’s Margaritaville in Las Vegas.

Our diverse faculty is made up of nationally renowned experts and top-tier keynote speakers.

We launched the RSO.

We’ve hosted Student Symposiums throughout the year.

We established the Committee for Women in Emergency Medicine, empowering talented women through networking, CME tracks, and social events.

We created the Digital Classroom, providing more opportunities and content for learners.

We partnered with HippoEM to create an exclusive opportunity for resident members to excel.

ACOEPearls launched as a new video series featuring our best speakers. The EMS Committee puts on lecture tracks and this past fall worked with the City of Chicago to create the unparalleled Mass Casualty Incident Training.

We’ve developed onsite programs, created mobile sites, and streamlined CME attestation processes to make conference experiences more enjoyable!

CONTIN U ED ON PG 7

THE PULSE APRIL 2019

APRIL 2019 THE PULSE

n Greek mythology, Pandora was created by the gods as retribution to mankind for Prometheus’ theft of fire. This beautiful woman was presented to Epimetheus, Prometheus’ brother, to be his wife. Epimetheus accepted Pandora, even though he was warned not to accept gifts from the gods. He found her too difficult, too curious for a woman, and thus her curiosity caused her to open a box the gods had given her, releasing all the illness and bad things to the world while locking hope inside.

EXECUTIVE DIRECTOR’S DESK

THE ON-DECK CIRCLE

Janice Wachtler, BAE, CBA

Robert Suter, DO, MHA, FACOEP-D

PANDORA’S BOX

THE BEST PART OF THE JOB

Some of these illnesses were prejudice and hate and, unfortunately, while we thought by 2019 these were things of the past, instead they seem to have taken on a life of their own.

“Isn’t it true that osteopathic students are trained in inferior schools then MDs, so we can’t take them into clinical clerkships without extra malpractice insurance?”

Prejudice doesn’t have a base in anything real. It mostly appears when misinformation is spread through ignorance about a topic or person. You may be familiar with many of the prejudices that our society faces, but what about prejudices regarding our profession?

This sentence was stated in a podcast last December by a reputable group, and listened to by most students seeking to enter the Match and gain entrance to our now combined programs. The host also stated that ACGME emergency programs are less likely to select DOs because of questionable training.

YOU MAY BE FAMILIAR WITH MANY OF THE PREJUDICES THAT OUR SOCIETY FACES, BUT WHAT ABOUT PREJUDICES REGARDING OUR PROFESSION?”

To anyone who may have heard this, I urge you to recognize that osteopathic schools produce quality physicians, just as any other medical school does. And to students, my advice is to be proud of your background and training. It’s time we recognize that the initials after a physician’s name are equivalent, and quality education and learning lies not solely with the individual but the person and program that trains them. While Pandora may have made the mistake of opening her box long ago, a graver mistake would be to allow these biases to exist today, without speaking to them and setting the record straight.

THE PULSE APRIL 2019

he theme of this issue of The Pulse is pediatrics. We recognize it as a subspecialty, but it is one that most emergency physicians practice every day. As a group we have a seemingly complex relationship with the emergency care of children.

A HUNDRED YEARS FROM NOW, IT WILL NOT MATTER WHAT KIND OF CAR I DROVE, WHAT KIND OF HOUSE I LIVED IN, HOW MUCH MONEY I HAD IN THE BANK...BUT THE WORLD MAY BE A BETTER PLACE BECAUSE I MADE A DIFFERENCE IN THE LIFE OF A CHILD.”

Children constitute over 35 million ED visits per year in the U.S. and they are overwhelmingly seen by emergency physicians who are generalists - general emergency physicians (GEMs). Only a small percentage of these tens of millions of kids are seen by pediatric emergency medicine subspecialists (PEMs). Yet somehow there is regular and ongoing concern expressed by some in the media and elsewhere that GEMs are not qualified to see children.

as “the adult doctor” is to quip “aren’t we all adults here?” which normally makes the point that the terminology is insensitive and inaccurate.

As someone credentialed at two children’s hospitals for the past 20 years – in spite of having missed the deadline to become PEM certified due to my ignorance of my eligibility to take the pediatric emergency medicine boards – I am a little perplexed by anyone invested in the PEM vs. GEM concern. Unfortunately, without realizing it, some in the PEM take the argument over the top by referring to GEMs as “adult doctors,” as if GEMs are a subspecialty of internal medicine trained and credentialed only to see adults. Frankly, this shorthand would be offensive if they fully believed it; my normal response to being referred to

FOREST WITCHCRAFT

Most children in the U.S. do not live within 30 minutes of a children’s hospital, and less than 10% of general hospital EDs have enough volume to support a dedicated PEM. The geographic and economic reality is that it will never be possible for the majority of kids to be seen by a PEM. So, what is the point of the conflict? I was a resident in San Antonio where there was no children’s hospital in town. Our faculty, including those double boarded in EM and pediatrics, admonished us that, “you have to be better at pediatrics than any pediatrician because you are seeing kids when their lives are on the line.” We took that to heart, and as a result I have always relished the opportunity to take care of sick kids. Since I was a resident the number of PEM fellowships has grown exponentially, which is a good thing, but I wonder if as a result some GEMs feel more insecure about taking care of sick kids? I hope not.

The keys to being comfortable taking care of any category of patient are always knowledge and attitude, followed by experience and repetition. There are only a handful of hospitals where you can avoid seeing children in your practice, so, unless you are at one of these, the solution is not to be fearful, it is to keep studying and practicing. Compared to most general pediatricians, you really are the expert at taking care of sick kids—be proud of that. Make no excuses when it comes to taking care of kids. Our youngest patients deserve it. ACOEP members are overwhelmingly GEMs (in more ways than one) and, there is no doubt about it, none of us should be happy to be called an “adult” emergency physician. Pediatric emergency physicians who respect us do not use that terminology. True advocates for children understand the necessity of the partnership between PEMs and GEMs to make sure that all children get timely, quality emergency care. Let’s make the world a better place by working together, GEMs and PEMs, to make a difference in the lives of our youngest patients.

APRIL 2019 THE PULSE

“PRESIDENTIAL U PDATE” CONTIN U ED FROM PG 3

In January I attended the AOA LEAD Conference in Las Vegas. Marc Goodman, the author of Cyber Crimes, was the keynote speaker. He stated that there are several causes of cybercrimes, such as not updating software, using the same password for multiple accounts, and/or basing one’s password on personal information (birthdays, names of children, or names of pets). The largest area of cybercrime is electronic health records. Many organizations have had their records hacked or held for ransom. Many hackers are selling patient records to pharmaceutical companies that can target patients for drugs that they might need. On the black market, the cost of a credit card is only $2,000, but a hacker can get $20,000 for the sale of a medical record.

us in maintaining healthy bonds with our colleagues, and are how we will maintain our osteopathic identity. At the October Membership Meeting I reported that, through the support of WestJEM, ACOEP is now able to provide our members with new opportunities for publication in two peer-reviewed journals – the ACOEP EM CPC Case Edition (with pub-med numbers) and the FOEM Abstract Competition. The submission formats for the CPC Case Competition and the Abstract Competition were considerably different than the required formats used by WestJEM for publication. FOEM has now changed their formats so they are more closely in line with WestJEM’s, thus decreasing the amount of work required to submit these scholarly activities for publication. Please take advantage of all of the scholarly activities offered by FOEM.

In March Dr. Suter and I attended the AOA Midyear Meeting in Naples,

Florida. There were eight resolutions for discussion. If you would like to review those resolutions, I will refer you to the “AOA Midyear Business Meeting 2019” on the AOA website. A major resolution passed by the AOA at the Midyear Meeting was the institution of two pathways for board certification. Candidate diplomats will have the opportunity to choose to take a core exam in their specialty that includes osteopathic principles, thereby resulting in osteopathic board certification in their specialty. Or they may choose to take only a core exam in their specialty, thereby resulting in board certification in their specialty only. The reason for this change is to provide all osteopathic physicians, regardless of whether their residency program has osteopathic recognition, with an opportunity to choose AOA board certification. These two pathways to board certification are also open to MD candidates. The ACOEP’s Women’s Council received a $400 grant from FOEM in order to take on a community service outreach with a local Girl Scout troop at Spring Seminar. They will make rag blankets to donate to the Path 2 Freedom, a restorative service for women who have been victims of sex trafficking.

ER ST G I AY ! E R OD T

Orlando



Also in: Boston

May 17 - 19 

Seattle



Chicago

Keep your practice on the leading-edge! theairwaysite.com or 866-924-7929

2019

SAVE THE DATE NOVEMBER 2 - 6, 2019 JW MARRIOTT • AUSTIN, TX

ACOEP will soon have a new address! The office will be moving to the 5th floor in the AOA building. ACOEP no longer requires the amount of space that we currently have as several of our staff members work remotely and only travel into the office periodically. In moving our office to the 5th floor, we will decrease our footprint by 2/3, which will also significantly decrease our rent. This will help us retain our fiscal integrity by offsetting financial losses incurred by new AOA policies that have impacted all of the specialty colleges.

Stay tuned at acoep.org for more information. 7

THE PULSE APRIL 2019

WHAT’S NEW IN

PEDIATRIC FEVER? By Robert E. Suter, DO, MHA, FAAEM, FACEP, FACOEP-D, FIFEM With special thanks to William Bickell, MD, for his assistance

s emergency physicians, we are all well aware that fever is among the most common complaints of infants and children presenting to the emergency department. For those of us who have been in practice for a long time, we know that our approach to fever has changed significantly over the past three decades. For example, reflex testing has been replaced with selective testing for many of our youngest patients. Others may be aware of current research seeking to make selective testing an option down to 21 days. So, what is state of the art for pediatric fever in 2019 and what can we expect in the future? In contrast to often panicked parents, we know that fever represents a normal physiologic response with a role in fighting and overcoming infections. The challenge is differentiating the vast majority who will have an uneventful course from the few who have serious infections.

PEDIATRIC FEVER: EVOLUTION The evaluation and management of the febrile child continues to evolve in response to the changes in epidemiology brought about by the introduction of new vaccines. The focus on bacterial infection remains, although some viral agents (HSV, RSV) are also important pathogens. Most research was conducted prior to the introduction of the Haemophilus influenzae type b (HiB) vaccine and Streptococcus pneumoniae vaccine, which unfortunately makes some of the best studies irrelevant to today’s pediatric population. While newer research exists, this reality combined with concerns about the impact

THE PULSE APRIL 2019

of non-vaccination have complicated metaanalysis and expert consensus, delaying updates in Practice Guidelines. It has long been recognized that, just as children are not little adults, infants are not little children, and this is especially true when it comes to fever. Infants in the first few months of life have decreased opsonin activity, macrophage function, and neutrophil activity. Common pathogens vary by age group, and the patient’s physical and behavioral response to illness varies with their age. Prospective clinical research has long substantiated age grouping as the proper approach to pediatric fever, but evolution of research cut-offs over the years combined with variable rates of non-vaccination have complicated meta-analysis and recommendations and will likely continue to do so. Most recent risk of serious bacterial infection (SBI) is felt to be approximately 13% in 0-28 days, 9% in 29-56 days, and 7% in 57-90 days. That said, the astute physician recognizes that no age cutoff is absolute. An important thing to remember is that if an infant was born pre-term you must calculate adjusted gestational age prior to applying guidelines. When calculating gestational age use 40 weeks (not 38) to define term - so a baby born at 32 weeks would be Birth Age minus 8 weeks = Gestational Age. In many cases this will push your otherwise reassuringly older infant back into the neonatal sepsis guidelines.

APRIL 2019 THE PULSE

Most febrile ( > 100.4°F/38°C) children 0-36 months with fever without obvious source have viral infections, but it is crucial to note that the presence of viral infection does not exclude SBI, so infants with viral infections still need an appropriate SBI work up for their age.

Prior to the advent of H. flu and pneumococcal vaccines, Pediatric Fever research focused on subgroups less than 36 months old and so there is very little in the way of evidence to provide guidelines above age 3 years. In the past 25 years the upper cut-off of studies has evolved to 24 months, making “two the new three.” Similarly, in the first three months of life during the same period the cut-off has evolved from 90 to 60 (or 56) days. Recently, researchers have been pushing against the 0-28 day cut-off as well. So, where are we? Three large, older prospective studies (Baker et al in NEJM, Baskin et al and Dagen et al, both in Journal of Peds) focused on children < 90 days all found an increase in serious bacterial infections missed in infants 1 to 28 days requiring sepsis evaluation – strong evidence for age cutoff between the first and second months of life. So, it is a Level A recommendation that infants between 1 and 28 days old with a fever over 100.4°F (38°C) should be presumed to have a serious bacterial infection and treated accordingly. This recommendation has survived unchanged in spite of all of the new vaccinations, although a move is underfoot by the PECARN investigators to push the cutoff back to 21 days, with the second of three studies needed to validate published in February 2019. The research being done in this area is not yet validated, and so while of interest should not change your practice until the third study has been completed and published with positive results.

THE PULSE APRIL 2019

FOR NOW THE BOTTOM LINE REMAINS Nothing in the literature supports avoiding a full sepsis workup in a febrile neonate (< 28 days with temperature > 100.5°F/38°C)! BLOOD CULTURE AND A CBC PLUS/MINUS CRP AND PRO CALCITONIN HERPES SIMPLEX (HSV) TESTING URINALYSIS AND URINE CULTURE CHEST X-RAY LUMBAR PUNCTURE IV ANTIBIOTICS AND ADMISSION

ANTIBIOTICS AMPICILLIN UP TO AGE 6-8 WEEKS 400MG/KG/ DAY IV DIVIDED Q 8-12HR PLUS GENTAMYCIN 4-5 MG/KG/24-48HR OR CEFOTAXIME - 50MG/KG Q 8-12HR AND HAVE LOW THRESHOLD TO ADD ACYCLOVIR - 20MG/KG Q 8HR Ampicillin is necessary because cephalosporin’s have poor coverage against Listeria. Interestingly, the recommendation for Cefotaxime over Ceftriaxone 50-100 mg/kg is based on a concern of it displacing bilirubin from protein although most experts feel this is likely a cephalosporin class effect.

When developing recommendations for patients over 28 days, over the past 20 years studies have preferentially looked at children under age 2 and 2 months (56 or 60 days.) As a result, vaccinated children 57-90 days (> 2 months) are increasingly being managed in the same group as those > 3 months rather than their classically younger cohort. With regard to children over one month old, we know that the various Pediatric Observation scales (Philadelphia, Boston, Yale) fail in infants aged 1 to 2 months and this has not been altered by newer vaccinations that are given at two months. So, what are the risks of serious bacterial infection (SBI) in infants aged 29-90 days in the post-vaccine era? A 2015 study > 5000 infants (Greenhow et al Pediatr Infect Dis J 3024;33:624-628) found a rate of SBI to be 13% in Neonates, 9% in infants 29-56 days, and 7% in infants 57-90 days. Bacterial meningitis was found in 0.9%, Bacteremia in 2%, and UTI in 17.9%. Based on this and other studies, the current incidence of occult bacteremia in this group is now estimated to be 0.004-2%, with 92% of occult infections being UTI. Uniform consensus is that the evidence shows that the incidence of serious bacterial infections and especially occult bacteremia has decreased significantly due to vaccination patterns, but only 58% of infants with bacteremia or bacterial meningitis appeared ill (Pantell et al Management and outcomes of care of fever in early infancy JAMA 2004:291:1203-10).

Children over 2 months with temp > 39°C (102.2°F) can be treated selectively. Blood work may be unnecessary if the baby has had at least one pneumovax/HiB and is clearly unnecessary if the child has had three pneumococcal immunizations. If a CBC is obtained, order blood culture if the WBC > 15,000, and consider giving empiric ceftriaxone. Currently there is not high-grade evidence that CRP or Procalcitonin alone can provide sufficient sensitivity/specificity to guide treatment, but his may change with future investigations, and so if ordered positive results should not be ignored (Kupperman et al Acad Emerg Med 2015;22(S1):S4).

WHAT ABOUT PNEUMONIA? We know that seven percent of all febrile children aged younger than 2 years with temperature greater than 38°C (100.4°F) will have pneumonia, with the majority being of viral etiology. Multiple studies have examined the use of the chest radiograph younger than 3 months without respiratory symptoms. Meta-analysis of these studies, a combined group of 361 febrile (> 38.0°C [> 100.4°F]) infants, shows all of those with pneumonia on chest radiographs as determined by 2 or more radiologists had one or more of the following findings: • Tachypnea more than 50 breaths/min Rales

• Coryza

• Rhonchi

• Nasal flaring

• Retractions

• Cough

MOST COMMON POST-VACCINE ERA BACTERIAL PATHOGENS IN 1-3 MONTHS 60% E. COLI 18% GROUP B STREP 6% 2%

STAPH AUREUS OTHERS: STREP PNEUMO, SALMONELLA, ENTEROCOCUS, KLEBSIELLA

Of 256 infants with one or more of these finding, 85 (33.2%) had positive chest radiograph for pneumonia, so it is a Level B recommendation to obtain a chest radiograph in febrile children younger than 3 (or possibly 2) months with evidence of acute respiratory illness. A chest radiograph may not be needed in febrile children aged 1-2 months with temperature less than 39°C (102.2°F) without clinical evidence of acute pulmonary disease. A chest radiograph is usually not indicated in febrile children aged older than 2 months with temperature less than 39°C (102.2°F) without

clear clinical evidence of acute pulmonary disease. As hinted at previously, a bigger issue is determining which children are at risk for urinary tract infection. Classic signs of urinary tract infection may be present but are difficult to recognize in young children. Symptoms are generally nonspecific and include fever (most common), vomiting, diarrhea, irritability, or poor feeding. None of these have high sensitivity or specificity. A change in the urinary voiding pattern of a young child is suggestive of UTI. CONTIN U ED ON PG 27

• Grunting • Stridor

• Wheezing

APRIL 2019 THE PULSE

WRITTEN BOARD P R E P

FAST PACE. HIGH YIELD. IT’S NOT YOUR AVERAGE REVIEW.

CONCUSSION RECOVERY TIME FOR TEEN GIRL ATHLETES IS TWICE AS LONG AS IT IS FOR BOYS

JUNE 17 - 21 ––– Aloft Chicago Mag Mile 243 E Ontario Street, Chicago, IL (312) 429-6600 www.acoep.org/boardreviews –––

This article was originally published by the AOA on the blog, The DO. Visit www.thedo.osteopathic.org

By AOA STAFF

Written Board Prep: An Intense Review

THIS YEAR’S REFORMATTED REVIEW GETS YOU: • Updated lecture format for a faster pace • Special focus on high-yield topics • 40+ hours of AOA Category 1A CME Credit • Access to our exclusive online site containing lecture outlines, slides, and speaker handouts

* Limit one time use

disparity in concussion recovery times between male and female adolescent athletes is the subject of an October article in The Journal of American Osteopathic Association. The article’s findings have been covered by CBS News. The root of the difference, researchers found, may be linked to pre-existing conditions that are more prevalent in girls, including depression, anxiety and migraines. Concussions may exacerbate these pre-existing conditions, according to a consensus statement from the 5th International Conference on Concussion. In a study of 110 male and 102 female athletes, ages 11 to 18, with first-time concussion diagnosis, the median for the duration of symptoms for boys was 11 days, compared to 28 days for girls. The data also showed that 75 percent of symptoms resolved for boys within three weeks, compared to only 42 percent of girls.

• Visual stimulus review • Real-time direct access to ask faculty questions and receive clarification • Interactive lunch reviews

...SO, IF I ASK A PATIENT WHETHER THEY HAVE ONE OF THESE CONDITIONS, THEY’RE LIKELY TO SAY ‘NO’.”

Researchers noted that the overlap of symptoms makes it imperative that physicians be skilled at eliciting patient history to understand the scope of factors that might hinder or delay recovery. “Often in this age range, issues like migraines, depression and anxiety have not yet been diagnosed,” said John Neidecker, DO, a sports concussion specialist in Raleigh, North Carolina. “So, if I ask a patient whether they have one of these conditions, they’re likely to say ‘No’. But when I ask about their experiences, I get a much clearer picture.” Dr. Neidecker gives an example of a patient with no history of migraines who admitted experiencing weekly headaches prior to the head injury. She thought the headaches were normal, but in fact the patient was suffering from migraines. He uses a similar approach to uncovering anxiety, mental stress and depression, and says diagnosis is tricky because adolescence is inherently emotional and stressful. To better understand the patient, he recommends asking young athletes whether they are hard on themselves or feel bad about not performing their best. CONTIN U ED ON PG 28

ACOEP is accredited by the AOA to provide osteopathic continuing medical education for physicians. APRIL 2019 THE PULSE

DIAGNOSIS CONCUSSION:

A PERSONAL STORY By Annika Giesa, Spring-Ford High School and Christine Giesa, DO, FACOEP-D

t was October 12th, a cool Thursday night spent in the school parking lot for marching band practice. We were focused on learning the moves for the last 30 seconds of our show with the color guard for the Homecoming game that Saturday. The practice went as it always did, then we moved on to learn the next page. We were told to take eight counts forward to our next spot. Before those eight counts I was doing well in school, in the best physical shape of my life, and excited about the homecoming dance. After those eight counts, everything changed. We finished our move and stopped. I was in my spot standing still like I was supposed to. As the guard finished their backwards flag spin, a 6’4” girl hit me on the right side of my forehead with a metal flag pole. In that moment, I dropped to my knees while everyone stood still as they were supposed to. The band director ran out to me and helped me to the curb to sit down. I sat out for 20 minutes and went back in to march. Everyone thought I was fine. The next day I was exhausted and fell asleep at the pep rally, but it had been a really long week. Saturday, I went to practice, marched in the homecoming parade, and then went to the game. After the parade I was shaking. I drank a bottle of Gatorade and went to the game. I sat through the first half and then went to warm up for the halftime show. Right before we were about to go on I was shaking again and I felt nauseous. I stood up, and I fell over. I told

NEXT THING I KNEW, I WAS SPIRALING DOWN AND IN A WORSE PLACE THAN EVER.”

THE PULSE APRIL 2019

the head chaperone that I could not perform. I don’t remember exactly what happened next, but I do know that I went to the emergency room and missed the dance. Two days later, I went to a sports medicine doctor and was told that I would have to be out of school and marching band for at least a week. After a few days, I had surprisingly improved and was cleared to return to school and band early. I took it slow, but in a few days I was quickly back to my normal routine. I continued in physical therapy, but I slowly began to slip backwards. Next thing I knew, I was spiraling down and in a worse place than ever. During this time, I had flown to Denver for my mom’s inauguration as President of ACOEP, and I don’t remember much of that trip. Six weeks after the accident, I hit absolute rock bottom. I constantly felt sick. I never wanted to eat. I couldn’t make decisions. I was angry and upset all the time. I was sent to rehab. I was doing speech therapy to help with my cognitive deficiencies and vestibular therapy to work on balance and coordination. Slowly with the help of rehab, I began to improve. My improvement became steadier, and I began to feel closer and closer to normal. The concussion lasted three months, much of which I cannot remember. It also left me with an excessive amount of school work that was not completed until September almost a year later. In the end, it left me with a new found perspective on life. Every day I wake up knowing that I am very fortunate. This event has made me stronger. I now have a better work ethic. I learned how to recover from a life altering injury and to cope with large problems. Most of all, I learned not to take the little things for granted like memories, abilities, and opportunities.

A PHYSICIAN’S PERSPECTIVE A concussion is a mild traumatic brain injury that usually results from a blow to the head. It is common in individuals who participate in contact sports, and teenagers tend to be more commonly affected. As emergency physicians we know how to diagnose a concussion, but we do not see the prolonged circuitous path that many patients experience. Some symptoms may develop weeks after the injury, and can include difficulty in concentration or memory, sensitivity to light or noise, and emotional lability or personality changes. Emotional lability may become evident as the patient becomes frustrated trying to cope with their deficiencies. As a parent, there is nothing more frightening than looking into the eyes of your once bright and engaging teenager and seeing an empty stare with an expressionless face. The teenage author was very much aware that she was “broken,” and she became very angry. The anger dissipated as she made progress with recovery. A concussion should not be taken lightly. Teenagers today play on highly competitive teams with high-stakes performances. Athletes need to be encouraged to inform their coach and parents when a head injury occurs and not hide it. I advise parents to take any head injury seriously, no matter how trivial it may initially appear. Athletes who sustain a head injury should be fully evaluated by sports medicine or a concussion specialist and should follow the recommended protocols for return to play. Parents should not override these protocols and allow their child to resume play early. Allow your athlete the time to heal. A much more serious injury with more severe symptoms and prolonged recovery can occur if the athlete sustains a second impact injury while still recuperating from the first. Athletes who engage in contact sports should have baseline ImPACT testing performed prior to the start of each season to serve as a baseline in case he/she sustains a head injury. Following recovery from a head injury, an athlete should always have ImPACT testing repeated to ensure that they have returned to normal or to establish the athlete’s “new normal.”

APRIL 2019 THE PULSE

NEARLY FIVE CHILDREN DIE EACH DAY FROM ABUSE

PARENTING IS EASY By Bradley Chappell, DO, MHA, FACOEP

“P

arenting is easy.” Famous last words of someone without kids! Children are amazing – endless curiosity, imaginative thinking, and overall bundles of joy. My wife and I got married straight out of college and will be celebrating our 16th anniversary this year. We waited until after residency to have children, but were surrounded by wonderful families with lots of kids throughout that time. We would even occasionally babysit our friends’ kids so they could have an adult night out. Our first child was amazing – the type that lures you into thinking you can handle a second one. He slept through the night at one month old and continues to eat anything we feed him. Queue baby number two, who did not sleep longer that 45 minutes for five months and still takes excessive amounts of time to eat most meals.

Parenting, although rewarding, is also very challenging and exhausting. It can be frustrating, time-consuming, stressful, and overwhelming – pushing people to unimaginable actions. Fresh from the headlines two weeks ago: a two-yearold was thrown from a balcony (thankfully only sustaining a leg fracture) while police found a 6-month-old inside the home who was unable to be resuscitated. According to news reports, neighbors did not suspect abuse in the home as the couple was described as nice without apparent problems.1 A few days later, we treated an infant who died from non-accidental head trauma. EMS was called because the baby was

50%

72%

80%

CHILD FATALITIES ARE LESS THAN ONE YEARS OLD

CHILD FATALITIES ARE LESS THAN THREE YEARS OLD

CHILD FATALITIES INVOLVE A PARENT

Department of Health and Human Services 2

encouraged by social media such as Blue Whale and Momo challenges, and shows like “13 Reasons Why.” However, the official Child Protective Services data suggests significant underreporting as less than 1% of children were confirmed victims of maltreatment in 2011. The author noted, “When it’s 12.5% of parents [involved in maltreatment], this isn’t psychopaths, this isn’t drug addicts. A lot of these folks are in dire straits financially and certainly have their ups and downs, like we all do.”3

not acting normally, which can happen after enough impact to result in a skull fracture. Our ED has a separate pediatric ED where we see more than 27,000 kids a year. With this volume, it is easy to get consumed with the minutia of birth history, vaccination schedule, fracture versus ossification center, Tylenol for routine fever, or extensive Kawasaki disease workup, and antibiotics now or watchful waiting. Among all these medical concerns, we must be ever mindful to look for the subtle signs of child abuse. The sad fact is a medical provider has recently evaluated many children who die from abuse, and there were missed opportunities for potential life-saving intervention. Some frightening statistics from the Department of Health and Human Services: nearly five children die each day from abuse; 50% of deaths are less than one year old and 72% are less than three years old; and 80% of child fatalities involve a parent.2 A 2014 article in JAMA Pediatrics suggests one in eight children will experience maltreatment (neglect, physical, sexual, or emotional abuse) by age 18. There was a racial and ethnic skew with African American children at highest risk at 20%, Hispanic 13%, Caucasian 11%, and Asian 4%. Children who experience abuse have a higher frequency of medical issues, increased criminal behavior, and a five-fold risk of suicide, often

So that leaves it to us in the ED to provide an additional line of defense for these vulnerable patients. A few simple tips to assist in recognizing and evaluating potential abuse: • Have the patient exposed – do not compromise a head-to-toe skin assessment for the sake of modesty. • When age appropriate, sit down and talk to the child (alone or with a social work or child-life specialist). Children tell imaginative tales, but they often do not hide the truth. • Be concerned when stories change, are inconsistent, match verbatim as if rehearsed, or do not mirror the injury pattern.4 • Know your rough pediatric milestones: 4 months – roll; 6 months – sit; 9 months – crawl/stand; 12-18 months – walk. In residency, I cared for a twomonth-old that “rolled off the bed” with resultant ICH. • Bruising. As a father of two young and very active kids (soccer, Taekwondo, non-stop tackling, wrestling, or jumping off things they aren’t supposed to), scrapes and bruises are a way of life. The kids know where the peroxide and Neosporin are, and nearly all injuries can be cured by a Batman Band-Aid. However, bruises to the ear, neck, cheek, eyelid, and torso, as well as patterned bruises such as pinch marks, handprints, loops, or bites, must be investigated. • Burns. Circumferential or patterned burns are rarely accidental. • Fractures. Fractures without a reasonable explanation require further evaluation. Review the medical record for multiple fractures (remember, the incidence of osteogenesis imperfect is exceedingly rare, about 1 in 20k patients).5 Keep in mind that a spiral fracture of the tibia is common with minor trauma in kids less than three years old (toddler’s fracture).

When there is concern about abuse, make your staff aware so there are no patient elopements. Notify social work, child protective services, and the local police per your hospital protocol. Talk to the parents about your concerns – most parents, although annoyed by the delay and inconvenience, will be understanding of your duty as a mandated reporter and will appreciate your concern in trying to protect their children. I get very concerned when parents get defensive and demand to leave. Your job is to initiate the investigation, not to make any ultimate determinations. When there are signs of abuse, broaden your workup to include a complete skeletal survey with consideration for CTs depending on age and injury pattern – CBC/ INR for bruising, LFTs (AST>80 concerning) and UA (RBC>50/hpf) for abdominal trauma, and ophthalmology consultation if you are not able to perform a good retinal exam.6 Be vigilant, look for warning signs, and take the extra few minutes to be a hero for the innocent child who is depending on you to intervene and potentially save their life.

1. https://www.nbclosangeles.com/news/local/Upland-Baby-Balcony-Tossed-Critical-Loma-Linda-506398281.html 2. Child Maltreatment 2017. Published: January 2019. An office of the Administration for Children & Families, a division of U.S. Department of Health & Human Services. This report presents national data about child abuse and neglect known to child protective services agencies in the United States during federal fiscal year 2016. Retrieved from: https://www.acf.hhs.gov/sites/default/files/cb/cm2017.pdf 3. https://jamanetwork.com/journals/jamapediatrics/fullarticle/1876686 4. https://americanspcc.org/physical-child-abuse/ 5. https://www.uptodate.com/contents/osteogenesis-imperfecta-clinical-features-and-diagnosis 6. http://pemsource.org/wp-content/uploads/2017/09/Suspected-Child-Abuse-and-Neglect.pdf

THE PULSE APRIL 2019

APRIL 2019 THE PULSE

ACOEP’S COMMITTEE FOR

WOMEN IN EMERGENCY MEDICINE UPDATE By Nicole Vigh, DO, MPH

COEP’s Committee for Women in Emergency Medicine is proud to have continued our women’s lecture track at Spring Seminar in Bonita Springs, Florida. We had a dynamic lineup of lectures scheduled and were honored to have Dr. Jaime Hope come back to ACOEP this year. She has captured our attention speaking on imposter syndrome and teaching us how to be resilient in a stressful work environment. This year she spoke on “Reframing Our Mindset.” We were also thrilled to welcome Dr. Sandy Simons who presented on “Beyond #MeToo; Women’s Bias Against Women and How to Overcome it in Your ED.” We were also excited to have Dr. Gita Pensa join us who presented on “Dealing with Stressors of Physician Litigation.” All conference attendees were encouraged to attend these lectures! On Wednesday, April 10th, we held a committee meeting during which we discussed important topics, including some potential endeavors that our organization can collaborate on with other national women’s emergency medicine organizations such as FemInEM and ACEP.

THE PULSE APRIL 2019

Wednesday evening we hosted a philanthropic social event with the local Girl Scouts Troops where we made tie blankets to donate to the Path 2 Freedom organization. The organization serves the needs of child victims of human trafficking by providing safe environments and long-term programs for recovery. The event was an incredible opportunity to mingle with other female professionals in emergency medicine, as well as a great chance to bring together the women of ACOEP and the young ladies of the local Girl Scouts troop, all while benefiting an organization which serves an important cause! Lastly, we are extremely excited to share that the Women’s Committee will be partnering with the Breast Cancer Research Foundation (BCRF) to support breast cancer awareness, treatment, and research! As part of our collaboration we will be selling products including scarves, t-shirts, tote bags, and mugs. All the proceeds will benefit BCRF, a nonprofit organization committed to achieving prevention and a cure for breast cancer by providing funding for the world’s most promising cancer research including advances in tumor biology, genetics, prevention, and treatment. BCRF is the highest-rated breast cancer organization in the world, and we are very proud to partner with them. Follow us on Facebook to stay informed about ACOEP’s Committee for Women in Emergency Medicine, our Spring Seminar events, and purchase some ACOEP swag to support breast cancer awareness!

RICHARD LOGUE, MD, FACEP

Featured Southern Opportunities

■

Citrus Memorial Hospital Tampa Bay, FL

■

Hunter's Creek ER Orlando, FL

■

Kendall Regional Medical Center Miami, FL

■

Ocala Regional Medical Center Ocala, FL

■

Port St. Lucie Medical Center Port St. Lucie, FL

■

Regional Medical Center Bayonet Point Tampa Bay, FL

Medical Director Opportunities

■

Northwest Medical Center Ft. Lauderdale, FL

■

Mt. Juliet Freestanding ED Nashville, TN

877.226.6059 MakeAChange@evhc.net

WHY I BELONG TO ACOEP By G. Joseph Beirne, DO, FACOEP-D, Secretary, ACOEP Board of Directors

ince the Scientific Assembly in October I have given much thought to the question, “why do I belong to ACOEP?” Nurses in my department ask me what ACOEP is about. I have had physicians on staff at our hospital ask me what ACOEP is about. My answer to anyone who asks me is this, “ACOEP is an organization that represents osteopathic emergency physicians, produces quality CME programs, and gives every physician in the College the opportunity to be a part of that success.” But in all honesty, the real answer lies deeper within. When I graduated residency in 2001, I was excited for the future. I attended ACOEP’s Oral Board Review in 2002 and felt it prepared me very well for the oral exam, and I couldn’t wait to attend my first conference. In April of 2003, I attended Spring Seminar in Scottsdale. I knew nobody, yet I was welcomed with open arms. I met many future board members and presidents of the College and soaked up every piece of information and advice they gave me. Jan and the office staff were so friendly and welcoming. The CME program was fantastic and being in Arizona in April, well that was hard to beat! Over the years, the conferences grew bigger and better. People I met at the first conference became close friends, and we watched our

AFTER A FEW YEARS I REALIZED THIS ORGANIZATION WASN’T JUST FOR CME, IT WAS A FAMILY.” 21

THE PULSE APRIL 2019

children grow up together. Each conference became more like a family event; something you just couldn’t wait to attend. After a few years I realized this organization wasn’t just for CME, it was a family. A family that continued to grow and mature, a family that shared joy, happiness, sadness, and death; but we shared it all together. I went from being a participant, to becoming a contributor to the student CD lecture series, then becoming a member of the EMS committee. The more involved I became with the organization, the more I wanted to contribute. Tom Brabson, who became president of ACOEP in 2008, asked me to take over the EMS committee in 2009. At first the thought of being the committee chair was overwhelming. I had never taken on this type of responsibility. Tom talked to me and reassured me I was capable of being the committee chair. I accepted the appointment and began a six year journey as the chair of EMS. Over that time span, I met the best group of physicians one could ever hope to work with, and who now are close friends—Steve Vetrano, Duane Siberski, Stephanie Davis, and Kevin Loeb to name but a few. Without these friends, the EMS committee would never have had the success we enjoyed to this date. Again, the concept of ACOEP being a family was ever-present in all of my work on EMS. I was elected to the Board of Directors at the 2014 Scientific Assembly, and then reelected in 2016. During this time, I have come to see first-hand the intricacies of how a national organization representing emergency physicians functions. I have always viewed our organization as a family. We are not as big as ACEP, that is true, but our members know one another. We are not “member IDs” in the database – we are

WE ARE A FAMILY AND A TEAM. OUR SUCCESS IS DIRECTLY RELATED TO EACH AND EVERY ONE OF YOU.”

all unique physicians who each have our own story about why we chose emergency medicine and why we chose osteopathic medicine. I had the pleasure of being asked to speak to the RSO at the 2017 Scientific Assembly in Denver during their leadership forum. This was an informal discussion about their expectations after graduation and how to solidify their careers. One of the points I made, which I am very passionate about, was this: “Each of you are unique. Each one of you in this room who chose to become an osteopathic physician have your own story. Your story is how you will represent this profession, how you will make your own contribution to medicine. Let your story define who you are and be proud of what you have done.” I also gave them one other piece of advice: give back to the organization. Give back by sharing your experiences and

expertise for the next generation of physicians. After my years of being in ACOEP, I truly feel that, because of our family environment, I have been able to become part of the leadership of this College. I do not think I would have had these opportunities in ACEP. Being part of the leadership of our organization has provided me with a tremendous sense of pride in what we have accomplished and how we will continue to be leaders in the field of emergency medicine. None of this would be possible without the support of the “family,” namely our members and office staff of ACOEP. We are a family and a team. Our success is directly related to each and every one of you. Our story continues to grow each day, and that is why we will succeed. So, why do I belong to ACOEP? It’s a great family to belong to. Come with us and find out why. Be a part of the best team in emergency medicine!

APRIL 2019 THE PULSE

ACOEP’s NEW Resident Education Membership! The only membership that brings you free access to Hippo EM! A $479 value! Talk to your program director today about joining our family.

RSO UPDATE!

Resident Education Membership - $165 • Exclusive membership to Hippo EM Board Review Resident Package, including access to on-demand video education, over 1,200 practice questions, and Hippo EM • Podcasts and detailed performance data • January In-Service and July Assessment exams

By Dominic Williams, DO, RSO President

hange is inevitable – as individuals, as communities, and as a profession. We within the Resident and Student Organization are no exception. In the light of the merging of both allopathic and osteopathic residencies to one single ACGME match this coming year, our roles and responsibilities are evolving. We are now tasked with helping our osteopathic student chapters navigate the new world of a single accreditation system. Furthermore, we must not lose our relevance to the osteopathic residents representing our profession throughout the most competitive and prestigious allopathic programs in the nation.

WE CAN’T BE AFRAID OF CHANGE. YOU MAY FEEL VERY SECURE IN THE POND THAT YOU ARE IN, BUT IF YOU NEVER VENTURE OUT OF IT, YOU WILL NEVER KNOW THAT THERE IS SUCH A THING AS AN OCEAN, A SEA.” C. JOYBELL C.

The RSO is recognized by other organizations as having an important role in the future of the house of emergency medicine. We are invited to participate with them at a national level and have earned our seat at the table with exceptional events at their conferences. Through FOEM and our online platform The Fast Track, we continue to offer students and residents an opportunity to share with the world their investigations into the future of emergency medicine, and the care we offer our patients. Our student events provide exceptional experiences for those exploring the field we are so proud of and inspire many students to pursue our specialty as their own. Our world is expanding and our pond is becoming an ocean. Our board represents our future. Allopathic physicians working alongside osteopathic physicians to build a better world for our patients, our students, and ourselves. We invite you to supplement our efforts by engaging the students and residents you meet, and we thank you for your continued support.

• Access to the new interactive FOEM Research Network • An online subscription to the Western Journal of Emergency Medicine • Discounted rates for residents to ACOEP conferences • Access to ACOEP’s exclusive membership benefits • Invitation to join ACOEP’s mentorship program • Entry to networking events • Access to ACOEP’s Digital Classroom

Classic Membership - $30 • Discounted rates for residents to ACOEP conferences • Access to ACOEP’s exclusive membership benefits • Access to ACOEP’s Digital Classroom

Residents Register today by logging into www.acoep-rso.org and signing up.

Program Directors & Coordinators Email Sonya Stephens at SStephens@acoep.org and be sure to include your program name as well as a roster of residents, their graduation year, and an email address. 23

THE PULSE APRIL 2019

DEFINING SCHOLARLY ACTIVITY IN 2019 By Bradley Chappell, DO, MHA, FACOEP

THANK YOU TO EVERYONE WHO JOINED US AT SPRING SEMINAR AND MADE IT SUCH A SUCCESS! Check our Facebook page for pictures, ACOEPearls, and more! See you in Austin!  @ACOEP.official

e are all educators – informing nurses why we are managing the patient in a certain manner, telling anxious parents how much Tylenol to give, and instructing patients and families on expectations and return precautions prior to discharge. Some of us choose to give back as an instructor at medical schools, others take medical students under their wings, while others dedicate their careers to education as residency faculty. I would not be where I am today without the encouragement and mentorship of a few exceptional EM physicians, to whom I am forever indebted. In the era of the Single Accreditation System, scholarly activity is redefined in comparison to the former AOA requirements. Per ACGME guidelines, faculty have the following options to participate:

PEER REVIEWED ARTICLES

NON-PEER REVIEWED ARTICLES

Published in journals indexed in PubMed, including original contributions of knowledge published in journals listed in Thomson Reuters (formerly ISI), Web of Knowledge, MEDLINE®, or the Med Ed PORTAL.

Online venues; abstracts, editorials, and letters to the editor submitted to peer-reviewed journals; journal submissions not meeting the peer-review requirements; and the creation of educational videos, DVDs, and podcasts (FOAMed).

TEXTBOOKS/CHAPTERS

PRESENTATION AT LOCAL/REGIONAL/ NATIONAL ORGANIZATIONS

Includes participation as editor, section editor, or chapter author.

COMMITTEE LEADERSHIP Elected or appointed positions in nationally recognized organizations.

EDITORIAL SERVICES Includes serving as an editor, editorial board member, reviewer, or content expert. Serving as an abstract reviewer or grant reviewer also qualifies.

Encompasses invited presentations, such as abstracts (posters), expert panel discussions, serving as a forum leader, Grand Rounds at an outside institution, and non-EM grand rounds presentations within your institution. This does NOT include teaching courses such as ACLS, PALS, or ATLS.

GRANTS

Can only be satisfied by receipt of a grant.1

As noted in a recent communication from AOA President William Mayo, DO, as well as an article in the Journal of the American Osteopathic Association by AOA Vice President, Certifying Board Services Daniel Williams, AOA board certification, although evolving, is here to stay.2 As a board certified emergency medicine physician, you are uniquely qualified to give back. As a content expert, two excellent opportunities to earn scholarly activity are serving as an AOBEM Oral Board Examiner or Item Writer. CONTIN U ED ON PG 28

APRIL 2019 THE PULSE

“WHAT’S N EW IN PEDIATRIC FEVER?” CONTIN U ED FROM PG 12

Prevalence of a UTI in young children aged 2 months to 2 years with no identifiable source for fever on history physical examination is 3% to 7%. Girls younger than 1 year (6.5%) are two times as likely as boys (3.3%). For girls aged between 1 to 2 years the rate increases to 8.1%, while for boys it decreases to 1.9%. Uncircumcised boys are at an increased risk according to a study of febrile, especially infants aged younger than 8 weeks with whom they found a urinary tract infection prevalence rate of 12.4%. Another study found a prevalence rate of 8% in uncircumcised and 1.2% in circumcised male infants aged younger than 1 year. Clinical decision, based on large study (Gorlich et al, Archives of Pediatric and Adolescent Medicine) to identify children at very low risk looking at 5 variables in females aged 2 to 24 months, found: 1. Temperature of > 39°C (102.2°F) 2. Fever for 2 days or more 3. White race 4. Age younger than 1 year 5. Absence of another potential source of fever The presence of 2 or more of these risk factors had a sensitivity of 95% and specificity of 31% for detecting urinary tract infection. Therefore, females with 1 or none of these risk factors are at low risk for UTI. Because of fewer numbers in male infants, clinical risk factors are harder to identify. In one study, all boys with urinary tract infections had at least 1 of the following risk factors: 1. Age younger than 6 months 2. Uncircumcised 3. Absence of another potential source of fever It is important to make the diagnosis of UTI because there are serious long term complications of UTI in young

children. An estimated 75% of children younger than five years with UTI have upper tract disease or pyelonephritis, which results in renal scarring in 27% to 64% of these children. Renal scarring causes 10% to 20% risk of hypertension and ultimately 10% risk of end-stage renal disease. Unfortunately, a problem at some community hospitals is the method for obtaining urine for urinalysis and culture in these patients, where nursing staff continue to use bag collection or “clean catch.” Bag-collection method causes an increased risk of contamination with peri urethral flora, with false-positive results ranging from 12% to 83%. Assuming a 5% prevalence rate of urinary tract infections in young children and a high false-positive rate (specificity 70%), this results in a positive urine culture from a bag specimen to be a false positive 85% of the time. Even “clean-catch” sample contamination rates range to 29%. This is why all children’s hospitals use invasive urine collection methods, and you should too. Urethral catheterization is less prone to contamination and is the method of choice for obtaining urine samples in ill or septic-appearing children. It has higher sensitivity (95%) and specificity (99%). The risk of introducing infection by the urethral catheterization method has not been well defined, but expert consensus is that the risk is very low. Percutaneous bladder aspiration is advocated by some as the method to obtain the truest urine, and it is the criterion standard in research comparing the sensitivity and specificity of other methods of urine collection. It may be the only method in a young male infant with severe phimosis. That said, it is used routinely in only a handful of centers. Technical expertise is required and success rates vary from 23% to 90%

As many as 10% to 50% of infants with urinary tract infections documented by positive urine culture, can have a false-negative urinalysis. Because of the significant sequelae, urine cultures are recommended by many in children younger than 2 years. While in adults a positive dip urinalysis is nitrate positive, this is an inappropriate standard in young children. Nitrite is formed by metabolism of urinary nitrates by pathogens, especially gram-negative enteric bacteria. Nitrite conversion requires extensive exposure of bacteria to the urine that may not occur in young infants who retain urine in the bladder for shorter periods of time. This gives it high specificity or truepositive results, and lower sensitivity or true-negative results. Leukocyte esterase detects WBCs in urine and has higher sensitivity or true negative results, but lower specificity or true-positive results. Meta-analysis of urine dipstick studies showed a true-positive rate of 88% and false positive rate of 7% for urinary tract infection. If the results of both tests are positive, the specificity is 96% (i.e. the false positive rate is less than 4%). As a result, it is a Level Recommendation to use any of the following to diagnose UTI in the febrile 2-24 month old: Leukocyte Esterase, Nitrate, WBC>5, or gram stain. Further, a urine culture should be obtained in a child aged younger than 2 years when starting antibiotics and/or consider doing so. To this point, we have been discussing vaccinated children. It is a Level B recommendation that preantibiotic era recommendations be followed for children 29-90 days with fever > 39°C (102.2°F) or children 90 days to 3 years without a source. These are to obtain a CBC and blood culture, in addition to any indicated UA and/or CXR, and consider empiric antibiotic therapy for a WBC count

of 15,000/mm3 or greater and ensure close follow-up. The most common empiric antibiotics have been Ceftriaxone 50mg/kg IM and Amoxicillin 45mg/kg/day. What about older infants and children? Are there guidelines for them? Not really. These children should be evaluated selectively based on history and physical findings, remembering that toxic appearing children of any age should have a full sepsis work up. Traditional WBC counts are usually not helpful in excluding bacteremia by other organisms in HiB and PCV vaccinated children and are more likely to lead to unnecessary testing and treatment. Evaluation and management of febrile children over 6 months who have had as few as one HiB and Pneumovax can be guided by symptoms and clinical acumen alone and need not include any reflex blood testing or imaging other than urinalysis.

Further, there is no combination of clinical assessment and diagnostic testing that will successfully identify all children with serious infection at the time of initial presentation. Therefore, the importance of timely reassessment cannot be overemphasized. One caveat to this in all children is the response to antipyretic medication. There is overwhelming evidence that ill children who appear better after acetaminophen or ibuprofen need to be managed in accordance with their initial presentation. (Level A Recommendation) A response to antipyretic medication does not change the likelihood of a child having serious bacterial infection and should not be used for clinical decision making. In spite of herd immunity, clinicians should continue to manage unvaccinated children of all ages, including neonates, in accordance with traditional teaching and age

“CONCUSSION RECOVERY TIM E FOR TEEN GIRL ATH LETES IS TWICE AS LONG AS IT IS FOR BOYS” CONTIN U ED FROM PG 13

“DEFINING SCHOLARLY ACTIVITY IN 2019” CONTIN U ED FROM PG 26

Patients with Type A personality traits typically have a baseline level of stress about the need to perform and become more stressed when they cannot, Dr. Neidecker explained. Losing the physical outlet of sport for managing their stress compounds the issue during the recovery period.

AOBEM Oral Board Examiner: currently in Chicago, but potential alternate locations coming in the near future; must have 3 years of postgraduate experience and be a DO (with AOBEM or ABEM certification) or MD (with AOBEM certification).

“It can really become a vicious cycle for some of these kids,” said Dr. Neidecker. “Uncovering and addressing any underlying conditions gets them back on the field faster and ultimately helps them be healthier and happier in the future.”

AOBEM Item Writer: no travel required; DO or MD with AOBEM or ABEM certification. Can still be in fellowship.

appropriate blood, urine, CSF, and radiograph tests. Regarding vaccinated infants and children, the evidence supports the selective work up of febrile infants who have had at least one (1) HiB and PCV13 immunization. Traditional WBC counts are usually not helpful in excluding bacteremia by other organisms in HiB and PCV7 or PCV13 vaccinated children and are more likely to lead to unnecessary testing and treatment. Evaluation and management of febrile children over 2 months who have had at least one HiB and PCV7 or PCV13 can be guided by symptoms and clinical acumen alone need not include any reflex blood testing or imaging. Exception is a very low threshold for urinalysis and culture in boys less than one year and girls less than two years old. Occult UTI should replace occult bacteremia as the major concern of emergency physicians evaluating vaccinated febrile children.

Additionally, you can get involved in the leadership of one of the many ACOEP committees. There are a large variety of options catering to physicians of all interests and career stages: CME, Practice Management, New Physicians in Practice, Education (GME, UGME, PD, Fellowship, Research), Member Services, Bylaws, Media Services, Awards, and EMS. For additional information, see: https://acoep.org/main/about-acoep/ committees/

Email aobem@osteopathic.org for additional information. 1. Frequently Asked Questions: Emergency Medicine Review Committee for Emergency Medicine, ACGME. https://www.acgme.org/Portals/0/PDFs/FAQ/110_emergency_medicine_FAQs_2017-07-01.pdf Accessed 3/13/19. 2. The Evolution of Osteopathic Board Certification, JAOA. https://jaoa.org/article.aspx?articleid=2728378 Accessed 3/14/19.

THE PULSE APRIL 2019

APRIL 2019 THE PULSE

Bernard Heilicser, DO, MS, FACEP, FACOEP-D

EQUAL ACCEPTANCE OF COMLEX-USA AND USMLE IN RESIDENCY By Melissa D. Turner, MS, Associate Vice President for Strategy, Quality & Communications, National Board of Osteopathic Medical Examiners

n light of the move to a single accreditation system, the American Medical Association adopted policy in November 2018 to promote equal acceptance of the USMLE and COMLEXUSA for all US residency programs. Led by both DO and MD student interest groups, the AMA policy is supported by national organizations involved in medical education, training, and regulation, and aims to reduce the burden of many DO students who feel compelled to take USMLE exams, in addition to COMLEX-USA which is required of all DO students for graduation and licensure. DO applicants are increasingly selected for residency by emergency medicine programs, and a high percentage of DO applicants take and submit USMLE scores while applying to emergency medicine programs. The AMA is working with stakeholder organizations, including the Association of American Medical Colleges, the Accreditation Council for Graduate Medical Education, the American Osteopathic Association and the National Board of Osteopathic Medical Examiners, to educate residency program directors on how to interpret and use COMLEX-USA scores and promote higher utilization of COMLEX-USA for residency program matches in light of the single accreditation system for graduate medical education.

What Would You Do?

As a physician-owned group, we protect each other.

Ethics in Emergency Medicine

The following ethical dilemma was submitted via email by ACOEP member Elise Zahn, DO, of Tampa, Florida. I wanted to suggest an ethics question on patients in the ED whose ETOH level is checked and then want to leave. Medicolegally the level should be under 0.08, the legal limit, unless they have someone to sign them out.

At US Acute Care Solutions, we understand that the possibility of medical malpractice lawsuits can weigh heavily on your mind. With every full-time physician becoming an owner in our group, we have the power to reduce risk and protect our own. In fact, our continuing education and risk management programs cut lawsuits to less than half the national average. If a case is ever brought against you, we’ll have your back with our legendary Litigation Stress Support Team and the best medical malpractice insurance. It’s one more reason to weigh the importance of physician ownership. It matters.

Patients are frequently homeless or intoxicated in public and brought in by EMS or the police. The ED wants the patients discharged ASAP but I’m not comfortable discharging to home or to the streets when their alcohol level is above the legal limit. We had a patient recently discharged alone who walked in the street and came back to the ED two hours later as a trauma victim. This dilemma is unfortunately common and very frustrating. We feel a need to “move the room,” yet we are faced with the need to do what we should be doing for this human being.

Discover the benefits of physician ownership and check out career opportunities at USACS.com.

How does one reconcile this dilemma? Do we discharge the patient to the streets; after all, he will either sleep it off or return to the department after consuming more alcohol? Do we force him to stay in the department until his alcohol level is below the legal limit, even if this requires restraints? Or, do we look the other way as the patient walks out having absconded without our knowledge? What would you do? Please visit www.acoep.org/newsroom and share your thoughts on this case.

If you have any cases that you would like to present or be reviewed in The Pulse, please email them to us at esernoffsky@acoep.org. Thank you.

Own your future now. Visit USACS.com

or call Darrin Grella at 800-828-0898. dgrella@usacs.com

THE PULSE APRIL 2019

142 E. Ontario Street Suite 1500 Chicago, Illinois 60611