The Pulse- Winter 2019 by ACOEP

WINTER 2019

AN ALL-NEW EVENT:

REIMAGINING ACOEP’S SPRING SEMINAR

MEMBER RESEARCH

MASS CASUALTY INCIDENT AND THE MODERN HOSPITAL PG 11

ACOEP’S COMMITTEE FOR WOMEN IN EMERGENCY MEDICINE UPDATE PG 19

CONGRATULATIONS TO ACOEP’S 2018-2019 BOARD MEMBERS! PG 22

The Pulse VOLUME XLI No. 1

TABLE OF CONTENTS EDITORIAL STAFF Timothy Cheslock, DO, FACOEP, Editor Wayne Jones, DO, FACOEP-D, Assistant Editor Tanner Gronowski, DO, Associate Editor Drew A. Koch, DO, MBA, FACOEP-D, Board Liaison 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 Drew A. Koch, DO, MBA, FACOEP-D, Board Liaison 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 REPORT Christine Giesa, DO, FACOEP-D

THE EDITOR'S DESK Timothy Cheslock, DO, FACOEP

EXECUTIVE DIRECTOR’S DESK Janice Wachtler

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

GUN VIOLENCE: IMPLICATIONS FOR EMERGENCY DEPARTMENTS AND PUBLIC HEALTH Stephanie Davis, DO, FACOEP

MASS CASUALTY INCIDENT AND THE MODERN HOSPITAL: A ROLE FOR EMERGENCY MEDICINE TO LEAD THE DEBATE Michael Allswede, DO

GOING BIG IN THE SECOND CITY Jenna Sopko, Sr. Events and Media Associate, ACOEP Staff

AN ALL-NEW EVENT: REIMAGINING ACOEP’S SPRING SEMINAR Gabi Crowley, Sr. Media Coordinator, ACOEP Staff

ACOEP’S COMMITTEE FOR WOMEN IN EMERGENCY MEDICINE UPDATE Teagan Lucas, DO

CONGRATULATIONS TO ACOEP’S 2018-2019 BOARD MEMBERS! Gabi Crowley, Sr. Media Coordinator, ACOEP Staff

RSO SYMPOSIUM RETURNS TO DOCTORS HOSPITAL Clairisse Hafey

RSO UPDATE! Dominic Williams, DO, University of Maryland

FOEM FOCUS Stephanie Welter, MNA, CFRE, Executive Director, FOEM

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

his is the first edition of The Pulse for the new year. I hope that all of the members of our ACOEP family were able to spend valuable and memorable time with their own families. ACOEP and the Board of Directors have been keeping busy with many projects. ACOEP joined with the American College of Addiction Medicine and 84 other organizations co-signing a letter on “Opioid Awareness,” urging Congress to introduce legislation that addresses a comprehensive approach to the opioid overdose epidemic in terms of substance use prevention, addiction treatment, and recovery support services. ACOEP co-signed a letter sponsored by the AOA urging the

PRESIDENTIAL VIEWPOINTS

THE EDITOR’S DESK

Christine Giesa, DO, FACOEP

Timothy Cheslock, DO, FACOEP

PRESIDENTIAL UPDATE

THE CHALLENGES OF A NEW YEAR FOR HEALTHCARE IN AMERICA

Senate to preserve the Substance Use Disorder (SUD) Workforce Loan Repayment. The legislation offers student loan repayment for physicians and other health care professionals who agree to work as SUD treatment professionals in areas most in need of their services. The SUD legislation was passed by the House. In October, ACEP instituted a new multiorganizational taskforce to examine and propose a scope of practice for Advanced Practice Providers (APPs). Gregory “Joe” Beirne, DO, will represent ACOEP. ACOEP continues to advocate against independent practice rights for APPs. A letter was sent to Representative Theresa Gavarone from Ohio urging her to withdrawal HR726 in the interest of patient safety.

Similar letters were sent to Senator Rafferty and Representative Kampf in Pennsylvania urging them not to support SB25 and HR100. The AOA Washington office brought to our attention a draft by Senator Cassidy – “Protecting Patients from Surprise Medical Billing.” This Bill addresses protecting patients from surprise medical bills after they are treated in emergency situations or receive care from an out-ofnetwork provider. This dichotomy forces insurance providers to pay for emergency visits at out-of-network costs. To recoup their losses, the insurance companies re-bill their customer the difference between in-network care and out-of-network care. ACOEP’s Practice Advocacy Committee is currently drafting a statement in support of this bill. Through the support of WestJEM, ACOEP will be able to provide our members with new opportunities for publication in two peer-reviewed journals – the ACOEP EM-CPC Case edition and the FOEM Abstract edition. The EM-CPC Case edition will consist of approximately 20-25 cases published in an electronic journal with PubMed numbers. All of the abstracts presented at the FOEM Abstract Competition will be published in a peer-reviewed electronic journal. These new electronic publications have been secured to help our faculty meet the ACGME scholarly activity requirements and will ensure that these competitions remain relevant as we move into the future. CONTIN U ED ON PG 7

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ith each New Year comes the prospect of change. Resolutions to have a better outlook on any number of things, from personal health and fitness to career goals and time management, abound. The same goes for our government. As we ring in 2019, we will see a new Congress and a shift of power to the Democrats in the House of Representatives and a wider margin for Republicans in the Senate. We continue to have an Executive Branch that is mired in investigations, that has no clear path forward on many issues. What will this mean for healthcare in America? It is anyone’s guess where we will end up. As emergency physicians, we need to stay keenly aware of the needs of our patients and how to best advocate for those entrusted to our care. With the close of 2018, there are many issues that we as a College need to keep abreast of to ensure our interests and those of our patients are protected. One of the most significant ongoing issues is the Affordable Care Act (ACA) and the recent ruling by a Texas district court that the law is unconstitutional. The ongoing appeals and court battles are likely to drag on through 2019. The first of two areas affecting both our patients and us as providers is the potential loss of coverage for possibly millions of patients. Second, because of several changes already put forth by the current administration, there are many new policies available on the market that do not provide the protections the ACA intended.

Most importantly, we must continue to seek out coverage that is fair and reasonable for Emergency Services. We as a College need to advocate for these protections so that our patients need not fear going to the Emergency Department to later be denied coverage for their visit. As physicians, we also need to make sure that we will be appropriately reimbursed for our care based on charges that are fair and reasonable. There are many other issues that continue to evolve in the healthcare arena that will be shaped by the agenda of a new Congress. Items to keep tabs on include proposals for a single-payer healthcare system, the opioid crisis, acts of violence and mass shootings across the country,

legislature as well. One of the larger issues at the state level to keep tabs on is the expansion of the scope of practice issues for advanced practice providers. Many states are seeing challenges to existing law and a push toward greater independence for these providers. As emergency physicians, we need to make sure that protections remain in place to keep our patients safe. We need to be sure that their relationship with advanced practice providers is one that is based on cooperative support and supervision, not blind independence for the sake of cost savings. Individual states expansion of Medicaid programs may again be an issue as the governors of many states have flipped parties and the need for coverage continues to grow.

HEALTHCARE ON THE NATIONAL LEVEL IS NOT THE ONLY PLACE WE NEED TO BE VIGILANT. EACH STATE WILL ALSO BE GOING THROUGH A SIGNIFICANT RESHAPING OF THEIR LEGISLATURE AS WELL.” and many others. During the first part of the year we should see what the agenda is shaping up to look like. It will also be interesting to see if there is any hope of bipartisan cooperation on issues moving forward. Healthcare on the national level is not the only place we need to be vigilant. Each state will also be going through a significant reshaping of their

How willing they will be to embrace expansion where it’s needed? That remains to be seen. Reimbursement rates for Medicaid are a never-ending battle as well, given the ability of the states to set rates for care and the many managed care Medicaid programs currently in existence. My challenge to you for the New Year is to get involved. Become informed on the issues and get to know your CONTIN U ED ON PG 7

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first witnessed what a gunshot could do when I was seven. It was a time of innocence and adventure, but it was a time when I learned how harmful one person with a gun could be. So, let me tell you my story. I grew up in Chicago, where we would have been classified today as lower middle class. The only difference was that my family had a summer house in rural, southeastern Wisconsin which we visited every weekend from Easter to Labor Day, and where we spent the summer. The area was great for swimming and bike riding – just being a kid. My dad would leave for work in Chicago every Monday morning, work throughout the week - staying at our apartment in the city - and return after work on Friday. When he was gone there was no car and the closest phone was located two doors away. Communications were by letter, which he wrote my Mom every night and mailed every morning, a routine she mirrored. This was during the Cold War, and my Dad was always nervous about leaving us alone. He made sure that everyone knew how to shoot his rifle, just in case. The rifle was housed with a bullet ready to be loaded above our 10” television, within handy reach of the door and in full view of any invader. Despite knowing, in theory, how to use my Dad’s rifle, the kickback just about knocked me on my rear end

EXECUTIVE DIRECTOR’S DESK

THE ON-DECK CIRCLE

Janice Wachtler, BAE, CBA

Robert Suter, DO, MHA, FACOEP-D

DADDY SAID...

A TRADITION OF EFFECTIVE ADVOCACY

I FIRST WITNESSED WHAT A GUNSHOT COULD DO WHEN I WAS SEVEN.” with every shot fired. We would have a target lesson once or twice each year, with a paper target nailed onto a board leaning against our shed. After each lesson, Dad would say, “Remember, people kill people. Guns only do what you want them to do. If you’re threatened, fire. If not, the gun is not a toy.” In the summer of 1961, my friend Ross got a BB gun for his birthday, and, of course, a group of us went hunting – for what, I don’t know. All I remember is a feral cat named Herman, who was one of many that roamed the area and made our yard and house his during the summer and weekends, did not return home for dinner. Mom put us to bed, and about 11 p.m. we heard this terribly yowling coming from our patio. Turning on the light, we saw Herman on our patio, bloody and crying. Mom scooped the cat up and began heating water, placing the cat gently on a bath towel on our kitchen table, as Herman meowed pitifully. She searched and washed his bloody, matted hair as my sister went to retrieve my Dad’s razor, which she used to gently shaved around the wound. She pushed on his skin and a BB popped out. She looked at me with disgust and continued to probe the wound as the cat mumbled and grumbled on the table. Afterward, she

poured the contents of a bottle of peroxide (her go-to medicine) on the wound, heated a needle and tied four little stitches across the wound. That night Herman slept in my arms as my Mom covered us up on the chaise lounge, hoping the cat would be alive the next day. Remarkably, he was. He looked a little rough around the edges, sort of like he had a hard night at the catnip bar. Slowly over the next few days he was up and walking, although never leaving our yard. When my Dad came out that next weekend, he took me over to Ross’s house and met quietly with Ross’s father. We both sat nervously on the front porch waiting for what we knew would follow. But after uttering several sentences littered with my Dad’s favorite swear words, we got off easy with a lecture that ended with, “Guns aren’t toys.” A few weeks later, Ross’s BB gun was in the trash after his little brother shot himself in the foot. So, that’s my gun story. Dad’s gun was in our house until 2006 when we felt it was time for it go to its own happy hunting ground with the police department gun return program. If we fast-forward to today, guns and gun violence are everywhere in the news. There are opinions from every

or many emergency physicians, advocacy and public health seem to be as distant and unrelated to our specialty as anything could be. After all, what does public health have to do with cardiac resuscitation, trauma care, or the high stakes, highpressure procedures that we perform?

have constantly striven to increase the treatments and cures in our armamentarium, together, with basic scientists and other professionals, we have simultaneously worked hard at implementing ways to prevent disease at the population and individual level. These efforts are well known.

Others, most likely those heavily involved in EMS, know that from a policy perspective, emergency medicine and EMS are considered to be the intersection of public safety, healthcare, and, wait for it…. public health. We all know that our primary role in public safety is to be “the safety net” and that means that we get to do lots of cool things when the other systems fail. But sometimes we need to remind ourselves as professionals that is not what we should aspire to do. As the frustratingly un-attributable “deep thought” phrase that I have quoted on this page tells us, the mark of a true professional should be their constant efforts to decrease or eliminate the need for their services. It is easier for us to see this when we widen our aperture beyond our beloved emergency medicine to the level of medicine. While physicians

The Osteopathic profession since day one has had a strong philosophical stance on public health, including what is now taken for granted as the traditional sense - the revolutionary concept that we now call wellness. A.T. Still said, “to find health should be the object of the doctor.” Our philosophic underpinnings should urge us to promote wellness and health activities to our patients to the greatest extent possible. Of course, working in very busy emergency departments, it is sometimes difficult to figure out when we are going to eat or use the facilities, let alone do anything other than address our patients’ immediate needs. Our first goal is making sure that when our patient “falls”, they land safely in the middle of the public health and healthcare safety net and are assisted in order to swiftly

THE GOAL OF ANY TRUE PROFESSION SHOULD BE TO ELIMINATE THE REASON FOR ITS EXISTENCE.” UNKNOWN

resume their lives. These are great, feel-good moments, but as true professionals we need to reserve at least a twinge of regret that we are not doing more to prevent our patients from falling in the first place. Frankly, this is why it is so important to support ACOEP and your community public health efforts. Most of us really don’t have the ability to promote health and wellness in our normal work environment, so we need to look for opportunities to do so in other venues. For those who are passionate or especially interested, you can do this in many ways through countless community organizations. For others who may feel exhausted by working too many shifts while trying to balance family and friend relationships and activities, your professional “out” is your support of ACOEP and our many public health and advocacy efforts, usually in partnership with other organizations. For those of you involved in our public health and wellness activities, I salute you. For others who have the energy and motivation to help us in these areas going forward, I want to hear from you. Regardless, we will put you to work on behalf of the ACOEP and all of our members. We are the healthcare professionals who valiantly struggle to deal with the failure of the rest of the healthcare systems. It is though our membership and support of ACOEP that we strive to end these failures and complete ourselves as true professionals. Hope to see you at Spring Seminar!

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“PRESIDENTIAL U PDATE” CONTIN U ED FROM PG 3

ACOEP is offering a Resident Education Package. The cost of the package is $165 per resident and includes full access to HippoEM, the January In-Service Exam and July Assessment Exam, resident member rates at conference, a free exhibit table at the Residency Fair and a space to interview potential resident candidates, access to the FOEM Research Network, a subscription to WestJEM, and ACOEP Membership. If you are a program director and you are paying more than $165 per resident subscription to HippoEM, then I suggest that you contact ACOEP. Residents may also purchase the resident educational package on an individual basis. The Board has also established a Membership Task Force. ACOEP is a member-driven organization. Our main sources of revenue come from our CME programs and membership

dues. The Task Force will develop a campaign to attract new members and provide incentives to current members to maintain their membership, with a goal to increase our membership by 10%. ACOEP may be a smaller organization, but with its size comes many advantages. Our members are never made to feel like just a number or another face in the crowd. True to our DO heritage, ACOEP’s staff and leadership offer service with a personal touch. We provide ALL members with the opportunity to pursue a growth track: whether it be in research, committee work, education, or leadership. ACOEP is a stabilizing entity in our quickly-changing medical world. The Board has also asked the Fellowship Committee to review the current application process and requirements for fellowship and distinguished fellow. The intent is to make the overall process more

New informational items on the horizon include the addition of the LLSA Seminar and the 2019 Spring Seminar. The LLSA seminar will be similar to the COLA Seminar. Please note that the dates of Spring Seminar will be April 8-12, 2019, in Bonita Springs, Florida. As President, I represent the ACOEP at many events. My upcoming travels include the AOA LEAD conference in Las Vegas January 24-25; the AOA Midyear Meeting in Naples, Florida February 27-28th; and the RSO Strategic Planning Session April 6-7 in Bonita Springs Florida followed by the Spring Seminar.

“DADDY SAID...” CONTIN U ED FROM PG 5

elected officials. Be a voice and advocate for your profession and your patients. The only way to effect change is if we get involved. As a College, we will do our best to keep you informed on crucial legislation and policies that affect our profession. But it will be our collective efforts that will drive the change that we seek. Do not hesitate to contact the ACOEP office with your legislative items. We will continue to assist in keeping the members of our College informed about important happenings in the healthcare arena and advocating on your behalf for the profession and our patients. Here’s to a successful and prosperous 2019!

side, but the results of gun violence making news today aren’t caused by BB guns or hunting rifles – they are military grade weaponry. These bullets don’t cause a simple gunshot wound, but maximum damage. They shatter bone, rip apart organs, and create massive tissue damage. Physicians see this every day in the ED.

syndrome sweeping across our nation. We need to look at the gun ownership and perhaps limit the type of weapons that can be purchased legally; the mental status of mass shooters; the ways guns get into the hands of people bent on destruction; and the lasting damage caused by the bullets that tear apart lives as well as flesh.

The NRA recently told doctors to “stay in their own lane” when they published information on the wounds being seen in EDs across America. The problem with this statement is that the lane we are in needs to be a shared lane, where health and political concerns and ideology on both sides needs to drive.

Without comprehensive knowledge of the multiple facets of this problem, we can’t even begin a non-emotional discussion. Yes, it’s our right as Americans to own guns to protect ourselves from invaders and provide food for our families – these rights are provided in our Constitution. But do you really think that the Founding Fathers ever fathomed hunting with an UZI? I don’t think so.

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Save the Date! April 8-12, 2019 Join us at the 2019 Spring Seminar in beautiful Bonita Springs, Florida!

“TH E CHALLENGES OF A N EW YEAR FOR H EALTHCARE IN AM ERICA “ CONTIN U ED FROM PG 4

Gun violence needs to be put under a national microscope; one that looks at every facet that makes up the

streamlined and to include those physicians who may no longer be practicing EM, such as deans or associate deans at the COMs, but who remain actively engaged in the college.

Featuring three incredible keynote speakers:

Richard Cantor, MD

Amal Mattu, MD

The American College of Osteopathic Emergency Physicians (ACOEP) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. ACOEP is accredited by the AOA to provide osteopathic continuing medical education for physicians.

Tarlan Hedayati, MD

ACOEP IS NOW DUALLY ACCREDITED! ACOEP is now accredited by the American Osteopathic Association (AOA) and the Accreditation Council for Continuing Medical Education (ACCME) to provide CME credits to physicians!

nger. Frustration. Empathy. Heartwrenching sadness.

These are just a few of the emotional responses felt at the end of 2018 after the NRA made a comment asking physicians to “stay in their own lane” when it comes to gun violence. Physicians, not just emergency physicians, were outraged. So, now the question is:

WHERE ARE WE, AND WHAT ARE WE DOING ABOUT GUN VIOLENCE?” As emergency physicians, we treat not only the physical injuries, consequences, and aftermath of gun violence, but we also treat the emotional response – effects that often last long after the physical wounds have healed. This approach has led to a dialogue between those who may differ with respect to their views on the benefits of firearm ownership and personal liberty, even when they agree upon the critical importance of reducing injuries and deaths related to firearms.

GUN VIOLENCE: IMPLICATIONS FOR EMERGENCY

DEPARTMENTS AND PUBLIC HEALTH By Stephanie Davis, DO, FACOEP

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More than 35,000 people in the US are killed in firearm related deaths every year. The number of firearm injuries is simply unknown. With mass casualty incidents on the rise and over 308 active shooter incidents in 2018, it is time to say enough is enough. As physicians, and particularly emergency physicians, we deal with the implications on a daily basis, over and over. Gun violence has escalated into a public health crisis, affecting not only physicians but innocent bystanders and the general public. The effects of gun violence weigh heavily on emergency departments and emergency physicians. The emotional, mental, and physical stress of caring for those injured, or worse, killed, by gun violence is extreme.

Each and every one of us has an incident of a patient who suffered at the hands of gun violence, and who stays in our minds ever since. Here’s one of mine:

about how to stay safe in high-risk situations. We, more than anyone, see the effects of the gun violence epidemic. We, more than anyone, treat its aftermath.

A few years ago, working in a small rural emergency department, a young 20 -year-old male walked in complaining of being hit in the face with shrapnel. He later began complaining of neck pain. I immediately placed him in a C-collar and sent him to CT. The radiologists then called me within minutes, asking, “Is this patient alive and breathing?”

We train for such mass casualty incidents, knowing that it’s not a matter of if, but when, an active shooter incident or MCI will occur in our area. Oftentimes, the implications to physicians are worsened by our lack of ability to intervene to make a difference. As physicians our battle is not with gun rights, but with gun violence. We’re here to maintain the framework that gun violence is a public health issue, and to focus on common interests over partisan positions. The implications against physicians and the patients we care for – that’s our focus.

What was thought to be shrapnel was a bullet sitting 1mm in front of this young man’s brainstem. He was set up for intubation, which proved to be difficult, and I life-flighted him to the nearest trauma facility. A young man with high hopes of going into the military, his life was forever changed after that day. He was one of the lucky ones though; he survived. But I remember discussing the critical nature of his injuries with his parents, and the possibility of his death. Seeing his family cry, looking at me with the little bits of ounces of hope they could muster…these are the moments that we keep with us as physicians. We feel vulnerable and frustrated as we sit with a patient or their family feeling the pain and anguish of an injury or the loss of life. Frequently, as emergency physicians, we deliver the brutal news of the loss of a loved family member from a gun. We bear witness to family grief, the stunned tears, the angry shouts, and— worse—the quiet silence. We clean up from the aftermath of a failed trauma resuscitation. We attempt to treat the permanent physical and psychological scars borne by survivors of firearm injury, and the guilt of those who felt they could have stopped it. Daily, we talk to our patients about their grief, their safety, their healing; and we talk

History gives us strong reason to believe that this epidemic of gun violence can easily be addressed without starting a political battle, or even threatening the Second Amendment. For example, we can allow the medical and scientific community to use its collective wisdom to conduct large-scale research on how to best address this epidemic. This has worked before in the past; take a look at how we created positive change on automobile collisions. The number of automobile deaths have been decreased without ever having to stop any cars from being on the road, thanks to devoted time and research. Gun violence would require similar research and funding, and would hopefully have just as positive of a result on the public at large. I believe the NRA is sadly mistaken when they asked doctors to, “stay in their own lane.” This is our lane, and it’s our turn to have a say in the gun violence epidemic in America.

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MASS CASUALTY INCIDENT AND THE MODERN HOSPITAL: A ROLE FOR EMERGENCY MEDICINE TO LEAD THE DEBATE By Michael Allswede, DO

hile the US homicide rate has decreased over the last 40 years1 , mass casualty incidents (MCI) have unfortunately become increasingly common2 . Whether the event is a barricaded gunman, a rogue motor vehicle, or the use of explosives, a common feature of any MCI is that existing medical capacity is rapidly overwhelmed in the early phases of the event. A primary MCI challenge is the rate at which victims needing life-saving resources are generated by the event. This rate may be termed the “event velocity.” The medical response to an MCI is not only the triage of existing resources to primary life saving but also the rapid development of “surge capacity.” Lessening the gap between event velocity and surge capacity development is the primary problem to solve. While the bulk of experience with MCIs is military, the growth of civilian MCI frequency has exposed several key weaknesses in the civilian system: • Civilian hospitals have minimal “surge capacity” because, to remain economically viable, personnel and supplies are scaled to be nearly 100% utilized on a “normal day” volume. • Because of critical shortages, Crisis Standards of Care3 commonly occur in MCIs but are neither taught nor openly discussed in the commercial medico-legal context.

Another previously unappreciated weakness in modern medical facilities is the lack of scalability of electronic information systems (EIS). Hospital electronic information systems such as registration, computerized physician order entry (CPOE), blood bank, radiology, and electronic health record (EHR) systems are designed to capture and track patient information used for billing, documentation, and other purposes, but were not designed to be rapidly scalable. The failure to rapidly register victims causes a cascade of failures, including: • The inability to track patient locations. • The inability to create EHR to document findings. • The inability to utilize CPOE systems. • The inability to give results of lab and radiology studies to the patient. These structural weaknesses cause “brittle” failures in the normal operating systems of civilian hospitals during an MCI. A brittle failure refers to the collapse of a needed functionality due to the inability of the system to adapt to the event velocity. A modern hospital EIS is particularly at risk for brittle failures.

MCI CONSENSUS STATEMENT PROPOSAL • An MCI consensus statement, authored by leading emergency and trauma physicians involved in the recent spate of MCI events; directed at identifying common areas of improvement for civilian hospitals is in the public interest. • An MCI consensus statement process used to compile empirical data and experience from recent events will better characterize critical system failures. • The data-driven characterization of common system failures may generate a solution set and/or identify needed areas of research to improve civilian hospital performance during MCI events. • An MCI consensus statement of this sort would inform the planning of multiple Federal agencies to include: the National Disaster Medical System (NDMS), The Department of Homeland Security (DHS), The Agency for Healthcare Research and Quality (AHRQ), and the Hospital Resources and Services Administration (HRSA) to set funding priorities and identify needed regulatory changes to address this public health threat. • Without data, the planning for these high-acuity, lowfrequency MCIs will be guided by supposition. While in any single location, these events will hopefully remain low frequency, nationally they represent a new public health threat.

1 Homicide in the US Known to Law Enforcement, 2011, Erica L. Smith and Alexia Cooper, Ph.D., US Dept of Justice, Office of Justice Programs Bureau of Justice Statistics, NCJ243035 December 2013, pg 3-4 2 US Mass Shootings Becoming More Frequent-And More Deadly, The Guardian US edition, Mona Chalabi, Dec 2 2015, 18:46EST https://www.theguardian.com/us-news/2015/dec/02/mass-shootings-in-america-numbers-more-frequent-more-deadly 3 Crisis Standards of Care Volume 4: Hospitals, https://www.phe.gov/coi/Pages/cscvol4.aspx

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GOING BIG IN THE SECOND CITY By Jenna Sopko, Sr. Events and Media Associate, ACOEP Staff

or ACOEP’s 40th year, we celebrated our annual Scientific Assembly in our hometown of Chicago, IL! Throughout the week-long conference, attendees took part in exciting hands-on labs, listened to top-notch speakers, and enjoyed time with colleagues and friends. We kicked off the conference with a preconference day featuring our first-ever Mass Casualty Incident Simulation, where we partnered with the Chicago Fire and Police Departments, as well as Chicago’s Office of Emergency Management and Communications off-site at a Chicago Fire training facility. Students volunteered as patients with various injuries and complications, while residents and attendings were given a limited number of supplies and medications to treat the influx of patients. With the help of Chicago’s Fire and Police Departments, participants also were faced with the challenges of outside forces in the ED, including balancing patient care, answering questions from police and fire personnel, treating patients carrying concealed weapons, and working while police dogs searched and secured the area. After the event, all attendees gathered to discuss what went smoothly, as well as what areas needed improvement during the simulation, and learned how to best approach and treat patients if ever faced with a mass casualty incident. Back at the conference, other attendees participated in our new, sold-out Comprehensive Critical Care workshop and Practical Ultrasound for the Emergency Room Physician lab. The Comprehensive Critical Care course was a highly interactive workshop that focused on airway, pediatric, and OB/GYN emergencies. With ultrasound as a leading technology in the ED, the

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Practical Ultrasound course taught attendees how to utilize ultrasound in their daily practices to diagnose patients more efficiently. To celebrate our 40th, we began the celebration with our annual Scientific Assembly Kick-Off Party at the Chicago House of Blues. Attendees enjoyed food, beverages, and musical entertainment by one of Chicago’s favorite bands, Rod Tuffcurls & The Bench Press. Attendees danced the night away and kept the energy going the next day at ACOEP’s birthday party, where conference attendees enjoyed cake and shared memories of past years as members. ACOEP wants to give a special thank you to Dr. Michael Stalteri for using his musical talents to accompany the College in playing “Happy Birthday” on his saxophone! The 2018 Scientific Assembly featured amazing speakers that discussed hot topics across emergency medicine. One of the biggest hot topic lectures was presented by Dr. Alexis LaPietra, who discussed the opioid epidemic in the United States and the new procedures and tactics to combat this issue. Dr. Kevin Klauer gave a fantastic lecture on risk management in the ED, and Dr. Salim Rezaie was able to start a great conversation regarding the flu. If you would like to hear more about what they discussed, you can go on to www.facebook.com/ACOEP.official to view their ACOEPearls short video lectures. ACOEP’s Resident Student Organization had one of its biggest years yet at the 2018 Scientific Assembly. With over 300 attendees, students and residents were able to network with top speakers and mentors in the medical field and take part in hands-on labs while continuing to grow their love for emergency medicine. Dr. George Willis

gave an insightful and inspiring keynote address for the RSO on their first day of conference, and RSO attendees were able to compete in an airway obstacle course, a dental workshop, and a guided IV workshop. In addition to participating in these labs, they listened to faculty and peers present lectures and research materials on crucial issues in the ED. FOEM kicked off their annual Research Poster & Paper Competitions, Clinical Pathological Case Competition, and Oral Abstract Competition on Monday, October 22. Residents and attendings presented their research and findings on various topics, including substance abuse, sepsis, BRASH syndrome, and pediatric trauma. The 2018 FOEM Legacy Gala was a roaring good time for all who attended the 1920’s-themed bash! Attendees were greeted by a swing band and dancers to kick off the party. Thank you to everyone who supported FOEM at this year’s gala, including the evening’s sponsor, Envision. The 2018 Scientific Assembly was a success all around! We hope you had a great time learning and connecting with colleagues and friends. ACOEP is thrilled to be returning to Bonita Springs, FL for the 2019 Spring Seminar! Be sure to check out the new and improved interactive format for the week at acoep.org/spring. Thank you for all your continued support of ACOEP, and we look forward to seeing you again in a few months!

1,000 attendees up to 48 CME hours offered over 20 different tracks 74 speakers 7 labs 285 RSO Members over

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CARDIOLOGY Learners will practice identifying subtle arrhythmias and ischemic mimickers. Additionally, this track will highlight the signs of ischemia that EM physicians should be aware of.

AN ALL-NEW EVENT:

OSTEOPATHIC MANIPULATIVE MEDICINE (OMM) AND REIMBURSEMENT

REIMAGINING ACOEP’S SPRING SEMINAR By Gabi Crowley, Sr. Media Coordinator, ACOEP Staff

s emergency physicians you chose your career path and specialty, and now ACOEP’s Spring Seminar allows you to do the same.

This conference mixes a little of the old and a little of the new. Beginning and ending with lectures on hot topics in EM and the latest cutting-edge medicine, the first two days and the last day will be familiar to long-time attendees. Sandwiched between these days, however, ACOEP is trying something new—two days of deep dives into the topics of your choice. On the third and fourth day of the conference attendees can pick two immersive tracks that best suit their needs. Each track starts off with two hours of lectures, followed by two hours of hands-on practice. “Learning the important information from engaging faculty in a lecture is a great way to get the basics of a topic,” says course chair Christopher Colbert, DO, “but we all know that putting this information into practice is the best way to really hone new skills and improve.”

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WHERE TO STAY ACOEP HAS RESERVED A ROOM RATE OF $279 PER NIGHT AT THE HYATT REGENCY COCONUT POINT RESORT AND SPA UNTIL MARCH 15TH, 2019, OR UNTIL THE ROOM BLOCK SELLS OUT.

This track is ideal for the physician seeking to incorporate or increase the use of OMM as an effective treatment option for a wide variety of ED complaints, and will also teach attendees how to optimize their reimbursement for the services they provide. During the OMM portion, learners will determine which patients will derive the greatest benefit from OMM, and which specific techniques should be applied. During the second part of the track, physicians will evaluate the potential billing implications of incorporating OMM into practice and will learn how to chart smarter and realize optimal reimbursement for their services, including OMM, Critical Care, HighYield Procedures, EKG / Cardiac Monitor Interpretations, Foundational E/M Encounters and more.

PEDIATRICS In this track we will provide cognitive techniques for the identification and management of common pediatric conditions such as rashes and infections. Additionally, antibiotic stewardship and the incorporation of diagnostic ultrasound in the workup of pediatric abdominal pain will be discussed. Because space is limited in each “ED-Venture” session, you must choose your two “ED-Venture” topics upon registering online ahead of the conference.

LEARNING THE IMPORTANT INFORMATION FROM ENGAGING FACULTY IN A LECTURE IS A GREAT WAY TO GET THE BASICS OF A TOPIC, BUT WE ALL KNOW THAT PUTTING THIS INFORMATION INTO PRACTICE IS THE BEST WAY TO REALLY HONE NEW SKILLS AND IMPROVE.” COURSE CHAIR, CHRISTOPHER COLBERT, DO, FACOEP

MORE WAYS TO LEARN! In addition to Spring Seminar’s new format, attendees can register for various add-on workshops and tracks at additional costs, including the Advanced Airway Workshop, Critical Care Workshop, ABEM Lifelong Learning Assessment, and the 2019 COLA Review. In the Advanced Airway Workshop, attendees can expect to learn and explore varying technological intubation modalities for the treatment of patients with difficult airways in the ED. “Advanced Airway has always been a popular topic for us,” says Colbert, “and Critical Care was a huge success at Scientific Assembly, so we made the decision to expand.” The Critical Care Workshop topics will include bleeding disorders, shock management, volume replacement and the utilization of bedside ultrasound to improve management, assessment, and treatment of patients in the ED, and attendees will explore the evidence-based best practices

and clinical recommendations for the care of the critically ill patient. Those that register for the ABEM Lifelong Learning and SelfAssessment or the 2019 COLA Review can expect the courses to prepare them with the tools they need to pass each exam. “We’ve constructed both courses to provide attendees with the proper knowledge and confidence needed in order to ace the actual exams,” says Kefah Spreitzer, ACOEP’s Educational Program Specialist. “In each separate course, attendees will review topics and articles to each given exam.” And with hours of learning comes some much needed down time! This year, we’ve added a few extra FREE events and activities to the week’s agenda that help contribute to your work-life balance, and we’ve made sure there’s something there for the entire family. Check them out on the following page!

CONTIN U ED ON PG 17

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FOOD PREP TIPS WITH A FOURDIAMOND CHEF Ever wonder what you could be doing better in the kitchen? Hoping to prep food faster and easier? ACOEP has arranged a brief, free demo with the Hyatt Chef to showcase skills and answer questions.

CRAFT COCKTAIL-MAKING WORKSHOP After a day filled with learning, you deserve to unwind with a drink! We’ll have a brief workshop with the Hotel Drink Specialist to learn about and create a special beverage. Cheers!

RICHARD LOGUE, MD, FACEP

WINE TASTING

Featured Academic Opportunities

Calling all Oenophiles! While we aren’t in the foothills of Central California, you can still join the hotel’s Wine Director to sample various types of wine and ask questions.

Osceola Regional Medical Center Orlando, FL

■ ■

MOVIE NIGHT ACOEP invites attendees and their families to join us for a projected movie night!

“BRING YOUR FAMILY TO WORK” DAY If you’ve ever wanted to bring your family to work, we’ve got you covered! We’ll have various stations and areas set up to showcase parts of the ED with interactive experiences for all ages. As a family-friendly organization, it’s important to ACOEP that you get to share the work you do as an EP with your own family.

FOR MORE INFORMATION ABOUT SPRING SEMINAR, PLEASE VISIT ACOEP.ORG/SPRING. WE LOOK FORWARD TO SEEING YOU IN FLORIDA IN A FEW MONTHS!

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Ultrasound Fellowship Director

Oak Hill Hospital Tampa Bay, FL ER REGIST T O D AY

■ ■ ■ ■

Associate Program Director Ultrasound Director Core Faculty PEM Faculty

San Diego, March 29 - 31  Boston, April 26 - 28 Orlando, May 17 - 19  Seattle, September 13 - 15 Chicago, October 4 - 6

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

Residency Program Director

877.226.6059 success@evhc.net

ACOEP’S COMMITTEE FOR

WOMEN IN EMERGENCY MEDICINE UPDATE By Teagan Lucas, DO

ince the ACOEP’s Women’s Committee has become an official committee, we have been working hard to establish our lecture track as a permanent and popular fixture in the Scientific Assembly and Spring Seminar schedules. This fall, Drs. Nicole Ottens, Jamie Hope, Jeanette Wolfe, and Romie Mushtaq gave powerful talks with a shared message: we have made strides in women’s equality, but we still have a ways to go. They shared ample research that verifies our current position is still behind men, especially in terms of financial discrepancies and underrepresentation in leadership positions.

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As a committee, we were compelled by data like this, as well as personal and public events, to write a position statement on gender equality for female emergency medicine physicians. We have a responsibility and opportunity to support our female physicians within the college and to create the change we want to see in the field of medicine in general. In order to achieve equality for female physicians, we have recognized that it is necessary to develop skills in leadership, advocacy, conflict management, and wellness as well as develop educational courses and policy.

In order to shrink the gaps and achieve the goals we hope to, we must be well trained. The confidence gap is a major area of concern. There is a difference in how men and women express and feel confident. Men tend to overestimate their abilities and performance while women underestimate both, even though they may be more qualified for a position. To gain confidence and raise our voices a little louder against the competition, we have proposed two resolutions on women’s leadership training and equal representation on committees, councils, and task forces within ACOEP. The ACOEP Board of Directors approved the position statement that follows and the two resolutions. They have put the momentous support of our College behind us, as a committee and as female physicians, to help shape the field for future emergency physicians. As those before us have pushed the envelope of their time, we have now set a new bar for the younger generation of female physicians, and have built a ladder for them to reach it.

The American College of Osteopathic Emergency Medicine (ACOEP) supports the rights of female physicians practicing in the specialty of Emergency Medicine to receive equal: 1. Leadership opportunities and promotions based on their abilities, talents, and qualifications. 2. Consideration when assigning shifts, patients, or other responsibilities within the department. 3. Compensation as their male colleagues working the same shifts with the same responsibilities. 4. Opportunities when assigning grand round topics, mentoring opportunities, and other teaching assignments.

IN ORDER TO SHRINK THE GAPS AND ACHIEVE THE GOALS WE HOPE TO, WE MUST BE WELL TRAINED.” JANUARY 2019 THE PULSE

WE LOOK FORWARD TO SEEING WHAT GREAT THINGS OUR BOARD MEMBERS WILL DO THIS YEAR AND BEYOND!”

CONGRATULATIONS TO

ACOEP’S 2018-2019 BOARD MEMBERS! By Gabi Crowley, Sr. Media Coordinator, ACOEP Staff

rom coast to coast, ACOEP takes pride in having a representative cross-section of physicians throughout the United States. The Board of Directors values perspective from physicians serving in a variety of locations— from rural emergency departments to big city trauma centers. ACOEP Board members hail from 10 states across the country and represent 11 different hospital systems. Our board includes a wide range of expertise; including educators such as Dr. John Graneto who is the Associate Dean for Clinical Education and GME at Kansas City University; College of Osteopathic Medicine, President-Elect Robert Suter, DO; Tim Cheslock, DO, who currently serves in the armed forces; and Greg Beirne, DO, who stays true to his EMS roots by working with local fire, EMS, and public safety units. We are proud to have seven female physicians serving on the Board, including the College’s second female President, Dr. Christine F. Giesa.

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And with the growth of ACOEP’s Council for Women in Emergency Medicine, we look forward to continuing to break ceilings and pave the way for women in emergency medicine to thrive in leadership roles. The 2018 Board elections welcomed two new Board members and one returning member to the 2018-2019 Board of Directors. New this year are Jennifer Axelband, DO, and Megan Koenig, DO, MBA, FACOEP, with Tim Cheslock, DO, FACOEP returning for his second term. “I’m thrilled to work with Dr. Axelband and Dr. Koenig,” says ACOEP Board President Christine Giesa. “I have known them both for a long time and having their experience and expertise will help to propel ACOEP forward. Dr. Cheslock has done an excellent job as our treasurer and I am happy he is continuing his tenure. Congratulations to all three of you!” Get to know our newest Board members!

JENNIFER AXELBAND, DO Since 2005, Dr. Jennifer Axelband has been practicing as both an EM physician and an intensivist in Bethlehem, PA. Dr. Axelband credits ACOEP as being an integral part of her growth and achievements as an osteopathic physician and is ready to “pay it forward.” As a new graduate of emergency medicine and critical care, Dr. Axelband sought guidance from a few board members on how to pursue recognition of osteopathic EM physicians as intensive care physicians. Because of the support the ACOEP Board provided, new EM/CC graduates are becoming certified and hired for positions in both disciplines. She has had the opportunity to become involved with committees and speak at conferences for ACOEP, is a strong supporter of education, and values her role as a clinical physician educator for medical students, residents, and now fellows.

MEGAN KOENIG, DO, MBA, FACOEP Throughout her time as a member of ACOEP, Dr. Megan Koenig has served on both the Student and Resident Chapter Boards, is currently the Chair for the New Physicians in Practice Committee, and a member of the CME Committee. She is currently an emergency physician in Alamosa, CO, and will soon be relocating to Indiana. Her passion within the College lies in mentorship towards the younger members, as well as improving the quality of conference programming. She looks forward to the opportunity to be a part of the Board again during such a pivotal time as we transition towards the single accreditation system, as she feels “new physician” representation would be a great asset to the current team.

TIM CHESLOCK, DO, FACOEP Having been a member of ACOEP for over 15 years, Dr. Tim Cheslock currently serves as the Board’s Treasurer, the Media Services Committee chair, and is a past President of ACOEP’s Resident Chapter. He also serves as a member of the AOA’s Committee on Continuing Medical Education. Dr. Cheslock currently works for the Florida Emergency Physicians of Team Health. He is chairman of the Department of Emergency Medicine, Assistant Facility Medical Director, and an attending physician at Florida Hospital Waterman in Tavares, Florida. He has been a member of the Army National Guard for 20 years, serving a tour in Afghanistan. He completed the Army Command and General Staff College and continues to serve as a Lieutenant Colonel in a medical support battalion for the Florida Army National Guard.

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RSO UPDATE! By Dominic Williams, DO, University of Maryland

RSO SYMPOSIUM RETURNS TO DOCTORS HOSPITAL By Clairisse Hafey

he ACOEP RSO Winter Symposium took place at Doctors Hospital in Columbus, OH, on December 1, 2018. Upon arrival, students enjoyed breakfast and coffee, as well as some fun freebies provided by Doctors Hospital and Adena Health residencies. The first lecture of the day captivated the student audience with a live trauma demonstration by Doctors Hospital residents, which demonstrated the importance of obtaining an accurate primary and secondary trauma survey. The rest of the morning enlightened students with other trauma lectures focused on abdominal, chest, head and neck, ultrasound, and resuscitation principles from various experts in the field. Lunch was provided, and third and fourth years had the opportunity to ask residency program directors from Doctors Hospital, The Ohio State University, and Adena Health questions regarding

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EM audition rotations, as well as about the residency application and interview process. The rest of the afternoon was dedicated to hands-on skills lab activities such as airway management, FAST exam, central line placement, and trauma survey in the simulation lab, as well as medical trivia. Student feedback was mostly positive and suggestions for improvement were communicated to the RSO board via surveys at the end of the day. The results of the survey suggested that the symposium should provide more caffeine, certain location preferences, and more residency programs during lunch breaks. We will impart our due diligence to improve on these areas for the next symposium. Please remember that most of the residency program exposure will be available at our Spring Seminar and Scientific Assembly, so we hope that you plan to attend!

t’s been another busy year for the ACOEPRSO. If you haven’t had the opportunity to attend our events over the last 12 months, then you’ve been missing out. Whether it be a fireside chat with an experienced EM physician about the importance of technology in the setting of continuing education, or an airway melee intubation time trial, the feedback was overwhelmingly positive. The competition was fierce, so, if you think you can intubate with the best of them, then don’t miss the next popular competition! If the cold weather this winter is getting you down, why not warm yourself up with a trip to Bonita Springs, FL? Our RSO events will be on the 9th of April. If you’re reading this, then you absolutely must enter one of the research competitions. Not only are there prizes to be won and bragging rights to be had, but these events add legitimate research experience to your resume. Check out www.foem.org/pages/research for more details.

If you’re reading this and you’re currently a practicing or training emergency medicine physician, then congratulations! Can you think of anyone that helped you achieve that goal? If so, why not pass on the favor to one of our aspiring RSO student members. Please contact me at RSOPresident@acoep.org to be matched with a student hoping to follow in your footsteps. Students, emergency medicine is a spectacular field full of unique opportunities. Find out more about becoming a physician in our specialty by reviewing our website and getting an idea of your pathway to success. If you’re not a member already – what are you waiting for? Visit www.acoep-rso.org to learn more. We appreciate you taking the time to become part of the RSO family. Please feel free to reach out to us about how we can better provide for your needs, what you’d like to see in the future, and what you loved about the past.

MAKE ACOEP YOUR CME HOME We are proud to announce, ACOEP is dually accredited! The American College of Osteopathic Emergency Physicians (ACOEP) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. ACOEP is accredited by the AOA to provide osteopathic continuing medical education for physicians.

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FOEM FOCUS

he 2018 Scientific Assembly was a success, including all of the events hosted by FOEM! The week started off with the FOEM Resident Research Competitions. The posters, papers, oral abstracts, and CPCs were fun and educational to watch, and the winning abstracts are listed on the following pages. The highlight of this year’s Scientific Assembly was the 2018 FOEM Legacy Gala. This year’s theme was the Roaring 20s, and guests came out dressed in style and raised a significant amount of money for FOEM! Congratulations to the winners of the FOEM competitions! FOEM has partnered with WestJEM to publish as many abstracts as possible from our events, so don’t miss out on your chance to get published in the spring!

CONGRATULATIONS AND THANK YOU TO THE 2018 FOEM LEGACY GALA HONOREES! FOEM JOSEPH AND FLORENCE WACHTLER SPIRIT AWARD RESEARCH PAPER COMPETITION SPONSORED BY First Place: Michael Tranovich, DO, Ohio Valley Medical Center Overnight Radiology Interpretation Discrepancies Between Emergency Physicians and Radiologists in a Community Hospital Emergency Department Second Place: Evan Montanye, DO, St. Vincent Health Center Effect of Prehospital Blood Draws on Length of Stay for Chest Pain Patients in the Emergency Department Third Place: Jordan LaFave, DO, Good Samaritan Hospital Medical Center Incidence of Clostridium Difficile Infection After Sepsis Protocol Antibiotics

RESEARCH POSTER COMPETITION First Place: Rachel Fiemen, MD, Lehigh Valley Hospital and Health Network Reducing Substance Use by an Emergency Department Intervention Second Place: Olga Lembersky, DO, St. Vincent Hospital Emergency Department Post-Intubation Sedation Rates and Patient Characteristics Utilizing a National Airway Registry Third Place: Adam Heinemann, DO, Ohio Valley Medical Center Sepsis Protocols and Point of Care Testing: Do They Help?

ORAL ABSTRACT COMPETITION First Place: Christen Kegarise, DO, Sparrow/MSU EM Residency The Safety of Tranexamic Acid in Pediatric Trauma Second Place: Kyle Fratta, BS, Johns Hopkins University Assessing EMS Provider Use of a Novel Pediatric Triage Protocol

By Stephanie Welter, MNA, CFRE, Executive Director, FOEM

Third Place: Stefan Meyering, DO, MSUCOM/Lakeland Approach to formalized Ultrasound Credentialing

CLINICAL PATHOLOGICAL CASE COMPETITION First Place Resident: Christen Kegarise, DO, Sparrow/MSU EM Residency A Tense Man With Tremors Second Place Resident: Jessica Zahn, DO, University of Illinois Chicago A Tale of Two Cities Third Place Resident: Gregory Tanquary, DO, MBA, from Doctors Hospital BRASH Syndrome First Place Faculty (TIE): Nilesh Patel, DO, St. Joseph’s University Medical Center and Shana Ross, DO, University of Illinois Chicago Second Place Faculty: Osman Abassi, DO, Inspira Health Network Third Place Faculty: Nancy Weber, DO, Lehigh Valley Health Network

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Presented to donors with a lifetime level of $50,000 and above Juan Acosta, DO, FACOEP-D

FOEM PINNACLE AWARD

Presented to donors with a lifetime level of $25,000 and above Janice Wachtler, BAE, CBA

FOEM JUAN ACOSTA AWARD

Presented to donors with a lifetime level of $15,000 and above Jack Field, DO, FACOEP Gary Bonfante DO, FACOEP-D

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

What Would You Do? Ethics in Emergency Medicine

In this issue of The Pulse we will review the dilemma presented in the October 2018 issue, referred to us by a local fire chief. The problem involved an elderly patient with dementia who has a history of wandering off from her condominium. Her daughter is her power of attorney for health care and has requested, through the 911 CAD system, that if the patient is found wandering around and family not available, she be transported to the ED for evaluation.

FOEM PRESIDENT’S CIRCLE AWARD

Well, as expected, the patient wandered off, had contact with a police officer, and an ambulance was dispatched to the scene. The patient was fully alert and oriented. She refused care and was transported back to her condominium and stayed with a neighbor.

FOEM PILLAR AWARD

The family was not pleased, complained to the police commander, and it was related back to our fire chief. The fire chief told the commander that if the patient is conscious and oriented and refusing transport, we could not justify taking her to the ED without consent from the power of attorney for health care. The fire chief looked for guidance.

Presented to donors with a lifetime level of $10,000 and above Christine Giesa, DO, FACOEP-D William Lynch, Jr Shelly Zimmerman, DO, FACOEP

Presented to donors with a lifetime level of $5,000 and above Michael Allswede, DO Timothy Cheslock, DO, FACOEP Otto Sabando, DO, FACOEP

FOEM PARTNER AWARD

Presented to donors with a lifetime level of $2,500 and above Thomas Boyle, DO, FACOEP Terry Carr, DO, FACOEP Stephanie Davis, DO, FACOEP Thomas Green, DO, FACOEP-D Thomas Mucci, DO, FACOEP-D James, Walker, DO, FACOEP Christopher Zabbo, DO, FACOEP

FOEM RESEARCH FLAME AWARD

Presented to the ACOEP Residency Program with the highest average score for research papers Inspira Health Network, Vineland, NJ

This situation is not uncommon. There are frequent misconceptions about advance directives. The power of attorney for health care is a wonderful document, and we should all consider appointing an agent. However, it only comes into play when the patient lacks decision-making capacity. It does not supersede the individual’s autonomous rights. If our wandering patient is decisional and has not been declared incompetent by a judge and a guardian appointed, she has autonomous rights. Of course, we must be very careful in judging her realistic capabilities, and advocate for her safety, if necessary.

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.

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1ST PLACE RESEARCH PAPER ABSTRACT OVERNIGHT RADIOLOGY INTERPRETATION DISCREPANCIES BETWEEN EMERGENCY PHYSICIANS AND RADIOLOGISTS IN A COMMUNITY HOSPITAL EMERGENCY DEPARTMENT Michael J. Tranovich, DO Christopher Gooch, DO Joseph Dougherty, DO Ohio Valley Medical Center, Wheeling, WV

BACKGROUND

SETTING

In many hospitals, off-hours Emergency Department (ED) radiographs are not read by a radiologist until the following morning and are instead interpreted by the emergency physician (EP) at the time of service. Studies have found conflicting results regarding the radiographic interpretation discrepancies between EPs and trained radiologists.

Community hospital ED with residency program.

OBJECTIVE

MAIN OUTCOME MEASURES

To identify the number of radiologic interpretation discrepancies between EPs and radiologists in a community ED setting. Also, to determine the frequency and nature of treatment changing discrepancies in order to determine if plain radiographs can be accurately interpreted by EPs without immediate radiologist interpretation.

METHODS Using a preexisting logbook of radiologic discrepancies as well as our institutions’ PACS system, all off-hours interpretation discrepancies between January 2012 and January 2015 were reviewed and recorded in a de-identified fashion. The type of radiograph obtained was recorded for each patient. Discrepancy grades were recorded based on a preexisting 1-4 scale defined in the institution’s protocol log-book as Grade 1 (no further action needed); Grade 2 (call to the patient, floor, or pharmacy for followup, oral antibiotic, etc); Grade 3 (return to ED for further treatment, eg. fracture not splinted); or Grade 4 (return to ED for serious risk, eg. pneumothorax, bowel obstruction). The total number of radiographs formally interpreted by EPs during the prescribed time-frame was also recorded in order to determine overall agreement between EPs and radiologists.

DESIGN Retrospective cohort study; IRB approved.

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PATIENTS General ED patients having plain radiographic studies interpreted by EPs without immediate radiologist interpretation between 1/2012 and 1/2015. 16,111 EP reads were recorded with 1,044 discrepancies.

Agreement in radiology reads between EPs and radiologists.

RESULTS There were 1,044 discrepancies out of 16,111 EP reads, indicating 93.5% agreement. Patients averaged 48.4 ± 25.0 years and 53.3% were female. 24.9% were over-calls by EPs. The majority of discrepancies were minor with 75.8% Grade 1 and 22.3% Grade 2. Only 1.7% were Grade 3 which required a return to the ED for further treatment. A small number of discrepancies, 0.2%, were Grade 4. Grade 4 discrepancies accounted for 2 of the 16111 total reads, equivalent to 0.01%. A slight disagreement in finding between EP and radiologist accounted for 8.2% of discrepancies. Of the x-ray findings not appreciated by the EP, 22.9% were possible or definite infiltrates on chest x-ray, 16.6% possible or definite fractures, 15.6% lung nodules, 0.3% pneumothorax.

CONCLUSION Results suggest that plain radiographic studies can be interpreted by EPs with a very low incidence of clinically significant discrepancies when compared to the radiologist interpretation. Due to rare though significant discrepancies, radiologist interpretation should be performed when available. Further studies are needed to determine the generalizability of this study to EDs with differing volume, patient population, acuity, and physician training.

1ST PLACE POSTER ABSTRACT

REDUCING SUBSTANCE USE BY AN EMERGENCY DEPARTMENT INTERVENTION INTRODUCTION/BACKGROUND Rachel E. Fiemen, MD Matthew D. Marschall, DO Smeet R. Bhimani, DO Derek J. Fikse, DO Ryan A. Anderson, DO Paige Roth, MSW LSW CRS Jennifer Stephens, DO Manuel F. Colon, BS Kevin R. Weaver, DO David M. Richardson, MD David B. Burmeister, DO Marna Rayl Greenberg, DO, MPH Robert D. Cannon, DO

Substance use and misuse are prevalent in emergency department (ED) populations. While tobacco and alcohol use concerns have been reported, more recently attention has been brought to the opioid crisis in the United States.

OBJECTIVE We set out to determine substance use reduction rates after a brief emergency department (ED) intervention for patients with tobacco, alcohol, street drug, and/or misuse of potentially addictive prescription medication use.

METHODS In this pilot prospective study, we approached a convenience sample of subjects in two emergency departments in Northeastern Pennsylvania during scheduled provider times. One site was a large tertiary care Level 1 Trauma Center, while the other was a smaller community hospital. To be eligible to participate, subjects had to be 18 years or older, have the capacity to answer survey questions and participate in the program interventions, not be critically ill, and be willing to participate in the intervention program. In addition, participating subjects must have been willing to admit to unhealthy use of one or more of the following: tobacco products, alcohol, street drugs, or addictive prescription drugs. If all inclusion criteria were met, subjects received a structured survey and intervention tool that was previously validated, a brief intervention based on motivational interviewing, and referral to treatment. The intervention was carried out by

either a medical student, Emergency Medicine (EM) Resident, or an Addiction Recovery Specialist (a licensed social worker, and certified recovery specialist with lived substance use disorder experience). Phone follow-up was used to determine current substance utilization by the patient was ascertained.

RESULTS A total number of 105 patients received an intervention regarding tobacco usage, 54 people received an intervention regarding alcohol usage, and 32 received an intervention for drugs. At follow-up, of the 105 patients in the tobacco category, 16 (15%) had stopped smoking, 51 (48.6%) patients reported a decrease in the amount of tobacco they used (decrease in the absolute amount of cigarettes used per day), and 32 (30.5%) had attempted to quit. Of the 54 patients in the alcohol category, 40 (74.1%) patients reported either a decrease in the number of days per week of drinking or a decrease in the number of drinks had per day. Of the 32 patients in the drug use category, 25 (78.1%) patients reported a decrease in usage since the intervention.

CONCLUSIONS In this pilot study involving medical students and EM residents at multiple EDs, we found that a brief intervention targeted at patients with unhealthy tobacco, alcohol, and drug use resulted in overall decreased substance use. A more robust study, with a larger patient sample size and longer-term outcomes, is indicated.

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1ST PLACE ORAL ABSTRACT

THE SAFETY OF TRANEXAMIC ACID IN PEDIATRIC TRAUMA Christen Kegarise, DO

INTRODUCTION Pediatric trauma prevention and management have been an area of ongoing investigation since 2013 when the Center for Disease Prevention stated that trauma is the leading cause of mortality in the Pediatric population. Hemorrhage control has been particularly studied since it is a potentially preventable complication and one of the main causes of death. Tranexamic Acid (TXA) has been studied as a key treatment for Pediatric trauma patients suspected of suffering from a hemorrhage. A study published by the Military demonstrated benefits of utilizing TXA in reducing mortality and blood transfusions in children suffering from trauma in the combat setting.

PURPOSE To confirm the safety profile of TXA in Pediatric trauma patients with a secondary outcome of a decreased need for blood transfusions.

METHOD A matched case-controlled, retrospective study analyzing all Pediatric trauma patients less than 16 years old that received TXA using Injury Severity Score (ISS) to a control group prior to the beginning the use of TXA in our institution. Study population from a community-based Level One trauma center with a dedicated Pediatric Emergency Department.

RESULTS There were 61 patients reviewed. There were thirty from prior to TXA and thirty-one with TXA.

The mean age of the pre-TXA groups was 10.578 years (range 1.97-15.04 years), and for the TXA group the mean age was 10.554 years (range 1.91-14.98). There were 11 females (6 in TXA and 5 in pre-TXA) and 50 males (25 in each of the groups). There were two mortalities in the TXA group and five in the pre-TXA. The mean hemoglobin in the pre-TXA was 12.73 grams (SD 1.46, range 10.2-15.4) and in the TXA group was 12.09 grams (SD 1.83, range 7.7-15.6). The mean hemoglobin on day 2 in the pre-TXA was 11.78 grams (SD 1.84, range 7.4-14.4) and in the TXA group was 10.66 grams (SD 1.71, range 7.4-14.10). The mean change in hemoglobin in the pre-TXA group was 0.56 grams (SD 0.92), and in the TXA group was 1.01 grams (SD 1.19). The majority of both groups had a decrease in the hemoglobin when comparing day 1 to day 2 of admission. Two patients of the pre-TXA group and four of the TXA group required blood transfusions. There were no significant age or gender differences between comparison groups.

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CONCLUSIONS This is the first community hospital-based study comparing TXA to pre-TXA in Pediatric trauma patients. While the study population is small, we did not discover a significant difference between the TXA and pre-TXA groups, which is encouraging. Further studies will need a larger patient population to have a more accurate measurement of mortality and transfusion requirements in TXA and non-TXA Pediatric trauma patients.

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