The Pulse Summer 2023

SUPPORTING THE ORGANIZATION, SUPPORTING YOURSELF:

Physician Wellness & Meeting Attendance

SCIENTIFIC ASSEMBLY HIGHLIGHTS

URGENT CALL TO ACTION PG 4

MORAL INJURY TO MORAL RECOVERY PG 12

THE IMPACT OF WELLNESS

NOW THE REAL WORK BEGINS PG 16

EDITORIAL STAFF

Timothy Cheslock, DO, FACOEP, Editor

Victoria Selley, DO, FACOEP, Assistant Editor

Mary Kate de Leon, Marketing & Communications

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TABLE OF CONTENTS

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PRESIDENT’S REPORT

Timothy Cheslock DO, FACOEP

THE ON-DECK CIRCLE

Brandon Lewis, DO, MBA, FACOEP, FACEP

EXECUTIVE DIRECTOR’S DESK

DeAnna McNett, CAE

RSO UPDATE

Stefanie Herfurth, PGY-2, Resident Publications Chair

Kayla Shorten, PGY-1, Student Publications Chair

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WELLNESS COMMITTEE UPDATE

Matthew Keeler, DO, Vice Chair

SUPPORT MEDICARE PAYMENT SYSTEM REFORM

Jeremy Selley, DO, FACOEP

WOMEN’S COMMITTEE UPDATE

Nicole Vigh-Runz DO, MPH, Public Relations Chair

LAUREL ROAD PARTNERSHIP

MORAL INJURY TO MORAL RECOVERY

William L. Bograkos, MA, DO,FAOAAM, FACOEP, FACOFP, Past President AOAAM

LESSONS FROM THE STAR THROWER

Contributed by our partners at The Whole Physician

NOW THE REAL WORK BEGINS

Susan M. Mastellone , DO, FACOEP

AN ACCIDENTAL MEDICAL HOLIDAY

Jeremy Selley, DO, FACOEP

SCIENTIFIC ASSEMBLY HIGHLIGHTS

WHAT WOULD YOU DO? ETHICS IN EMERGENCY MEDICINE

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

Amembership, our Scientific Assembly is less than 4 weeks away. Our flagship CME event of the year is coming soon to Washington DC from August 11-15 , and I look forward to gathering with colleagues and friends for a great event. Our CME planning committee has worked hard to put together an outstanding roster of speakers and our staff has been planning additional activities to make this both educational and fun! Washington DC is host to many opportunities for sightseeing as our nation’s capitol and also institutions such as the Smithsonian Museums making for a great trip not only for education but family fun as well.

As we approach our meeting this year I have been made aware that our current registration numbers are very low. This is surely in part due to the change from our typical October time frame. Unfortunately, due to previously negotiated contracts and conflicts with other meetings the date change was felt necessary to allow our members opportunity to come to Scientific Assembly unimpeded by other meeting conflicts and scheduling issues. Your participation in this meeting is vital to its success and the success of the organization. When we plan

URGENT CALL TO ACTION

for these twice a year large events there is a lot at stake. We base our planning on historical attendance so that we can assure adequate accommodations for our members. Unfortunately, when we do not hit our targets for attendance the organization as a whole suffers. We are contracted for a large hotel block at our conference venue. When we miss our targets, the organization still has to pay for attrition as a result of low attendance. As it stands currently, the college will be dealt a devastating blow that will impact our activities going forward into the future unless you come through and attend the meeting.

ACOEP has always prided itself on being a close-knit family. I am calling on that family to come home and register for our meeting and attend the event! We are currently offering discounts on registration and various opportunities for single day attendance rates if you cannot attend the entire

meeting. See the offers on page 21 to register for the in-person meeting, but more importantly reserve your hotel room at the host hotel. The hotel block has closed but your reservation can still be counted toward our contracted rooms. Now more than ever we need your support in order to keep our college a thriving and viable organization. Your presence and participation go a long way to making this happen. If you have been hesitating about coming or on the fence for whatever reason, I ask that you commit to the event and help us make it the best meeting ever!

Should you have questions or need additional information, please contact the office at info@acoep.org or click the links below for more information. I look forward to seeing you soon! –•–

...YOUR PARTICIPATION IN THIS MEETING IS VITAL TO ITS SUCCESS AND THE SUCCESS OF THE ORGANIZATION.”

They say that if the groundhog pokes his head out on Feb 2nd and sees his shadow, that there will be 6 more weeks of winter. I don’t know if there are any other rodent traditions that portend the change from Summer to Fall, but I do know that in 2023, at least in some ways, the Fall will come early. Due to a contractual obligation that existed pre-COVID and a difficult convergence of dates, The ACOEP will hold its 2023 “Fall” Scientific Seminar in Washington, DC at the Washington Hilton Hotel August 11-15th (Summer time!!).

While this is certainly a change of pace in terms of timing, and certainly brings other conflicts into play (last-minute summer vacations, kids starting school-related extra-curriculars) it offers us the opportunity to visit the Capital city at a slower time of year. There are still many outdoor events ongoing, such as outdoor concerts and movies, and sporting events from Major League Baseball to Major League Soccer. This of course is in addition to the many museums and monuments to tour. My personal favorite is a night tour of the monuments ending at the Iwo Jima Memorial from which you can look back toward the National Mall and see the Lincoln Memorial, Washington

THIS YEAR FALL IS COMING EARLY

Monument, and the Capitol Building lighting up the vista.

All of these remind us of the many contributions made by those in the past to make our country what it is today and inspires confidence in me that the current and future generations will continue to make us even better.

Similarly, one of the great joys I get from attending our ACOEP events is reminiscing with old acquaintances. Remembering our formative years as physicians and those who came before us who pioneered our specialty, built the support structures that helped us as Osteopathic emergency physicians to be fully embraced in the world of medicine and to set the stage for us to practice as we do today. Further, it gives me the opportunity to meet with the brightest and best of our specialty and to learn and grow professionally from them. Osteopathic Emergency Physicians such as Andy Little, who is growing the voice of Osteopathic Emergency Medicine through social media and the “EM Over Easy” Podcast and Chris Colbert, a dynamic leader teaching and organizing on the academic lecture circuit in Emergency Medicine teach and inspire me. These, and a full panel of exciting speakers, will

help me to grow professionally and to be a better physician for the patients that I see.

Finally, I am always excited to have the opportunity to meet with the next generation, our students and residents. I remember so many in the previous generation who extended a hand to me in mentorship and encouragement that ultimately led me to many of the opportunities I have had in my career. I am privileged to be able to offer that same encouragement and opportunity to those coming up in our ranks. These younger folks give me new energy and assure me that the world of Osteopathic Emergency Medicine will continue to evolve to be smarter and more impactful to patients year by year.

To me, the ACOEP is so much more than learning and getting my CME credit. It is the opportunity to see and be refreshed by my friends and colleagues and to be reminded that I am privileged to be part of a very special community. If you haven’t already signed up for the Scientific Seminar, I highly encourage you to take advantage of this, and every opportunity to reconnect with your ACOEP family and the small community of which you are a part of! Hope to see you in DC!! –•–

Brandon Lewis, DO, MBA, FACOEP, FACEP

EXECUTIVE DIRECTOR’S DESK

DeAnna McNett, CAE Executive Director

SEE YOU IN WASHINGTON, DC!

Dear Members,

I hope this issue of The Pulse finds you well. As the Executive Director of the American College of Osteopathic Emergency Physicians (ACOEP), I am pleased to provide updates about our upcoming Scientific Assembly conference. The purpose of this article is to keep you informed and encourage you to register for this important event.

Our upcoming Scientific Assembly conference will be held on August 11-15, 2023, at the Washington Hilton in Washington, DC . This conference will provide members with the opportunity to connect with other professionals, learn about the latest advances in the field, and share their own research and experiences.

The conference will feature several sessions, workshops, and networking events, covering a broad range of topics in osteopathic emergency medicine. Some of the highlights include interactive skills labs, informative lectures, and poster presentations. Attendees will have the opportunity to receive CME credits, network with their colleagues, as well as participate in our FOEM competitions.

We are delighted to offer members a discount for conference registration in this final week before the event kicks off. You will find special rates for physicians, associates, residents, and students for in-person registration on page 21 . Keep an eye out for email and social media announcements about these final promotional offers.

As a member of ACOEP, attending this conference is crucial to your professional and personal development. It provides you with an opportunity to learn from leading experts, network with peers across the country, and stay up-to-date with the latest developments in osteopathic emergency medicine. Therefore, I strongly encourage you to register now to take advantage of our current promos and pricing and secure your spot.

Thank you for your continued support and participation in ACOEP. We are committed to providing you with valuable resources and opportunities for professional development. As always, I am looking for feedback from YOU! You are the reason ACOEP is here, to support you in your practice as your professional society. Is there a benefit we should add? An issue we should address? Something we should change? Or something you love? Let me know! Scan the QR code for surveys to let me know what ACOEP can do for you. Or simply email me at deanna@affinity-strategies.com.

I look forward to seeing all of you at the upcoming Scientific Assembly conference and continuing our work together.

Sincerely,

DeAnna McNett, CAE ACOEP Executive Director

RSO FAST TRACK

RSO’s Publication and Social Media Chairs Stefanie Herfurth (PGY-2) and Kayla Shorten (PGY-1) are working hard to promote The Fast Track, a way for our organization to more readily allow students and residents to become officially published online. The Fast Track has been around for 12 years now and is a great, lowstress way to boost your CV and applications. It is also an excellent avenue to share educational cases and improve the practice of emergency medicine. We accept case reports and studies, research/ literature reviews, opinion-based pieces, and more. Submitting your article to us is as easy as filling out a form that can be found on the RSO website. We will communicate with you about edits to be made, and once these have been reviewed and accepted, the article is sent to our ACOEP operations manager for final review and publication online. It’s as simple as that! –•–

Selley’s Social Club

As we get closer to seeing each other in DC- keep your mind open to fun events happening! Below are listed events within the conference that you definitely want to attend! I also included a few other options in case you are looking to book some fun outside the conference and museums!

DC Activities

• There are multiple tours you can book to see the Monuments- I suggest an evening one for the cooler temperatures and the lighting is beautiful at night at all the monuments.

• Silver Spring International Food and Craft Festival August 13 at Veterans Plaza.

• Try Iron Gate. Located in Dupont Circle. Iron Gate is one of Washington D.C.’s oldest restaurants. It features menus with locally sourced Greek and Italian fare with items that change seasonally, so there’s always a surprise on the menu!

• Experience a Candlelight Concert!

• Explore with a Mystery Picnic!! A totally unique way to experience Washington DC. You pick an area to explore, sign up. Get clues on your phone to solve with specific locations to see along the way. Enjoy food at various stops, then finally a picnic in a special location set up for you at the last spot! You can do this as a couple, a family or with a group of friends! Currently they have picnics to explore Georgetown and Alexandria.

• Interested in a food tour? There are several Walking food tours in the Georgetown area, the U Street Food, History and Street Art tour and there is also a Washington DC Premier Brunch Cruise with bottomless Mimosas!

Scientific Assembly Events

Saturday August 12

Welcome Reception

7:00 PM – 9:00 PM at Int’l Terrace

Sunday August 13

ACOEP Awards Ceremony & Fellow

Reception

6:00 PM – 8:30 PM at Int’l Ballroom East

Monday August 14

Wine & Cheese w/ Exhibitors

6:30 PM – 7:30 PM at Columbia

ACOEP Night Out! - Movie Theater

8:00 PM – 10:00 PM at TBD

ACOEP Night Out! - Escape Room

8:00 PM – 10:00 PM at Escape Room DC Midtown

ACOEP RSO BOARD

Stefanie Herfurth, PGY-2, Resident Publications Chair

Kayla Shorten, PGY-1, Student Publications Chair

WELLNESS COMMITTEE UPDATE

FINDING SERVICE TO IMPROVE WELLNESS

Personal wellness is not just influenced by taking care of oneself. In large part, our interactions with others influence our personal well-being and by engaging in acts of service and giving back to others, one can positively enhance their personal wellness. By integrating service into our lives, we not only contribute to the wellbeing of others but also experience a positive impact on our own physical, mental, and emotional health. Here are a few fundamental components that are easy to grasp, to enhance personal wellness by focusing on others.

Physical health is foundational to health and wellness. Engaging in service often involves physical activities. Focusing and incorporating others into these activities can often lead to positive personal change. A few examples are volunteering at community events, charity runs, neighborhood or community environmental cleanups. To make things even easier, most healthcare and hospital institutions have organizations that focus on health-related causes to increase awareness for healthy habits and to inspire personal lifestyle changes.

Secondly, service work often provides an immediate positive mental and emotional change. Minding to one’s mental and

emotional health may be the most important aspect of wellbeing. One that is often overlooked by many. Mentorship opportunities can provide a profound sense of fulfillment and purpose, directly improving mental and emotional health. Helping others through mentoring can be stress alleviating, provide affirmation of life and career choices, and deliver a sense of community. Mentorship connections should be focused on connections through volunteering. Which starts with the assumption that no one is present for themselves. This established assumption improves social connections, promotes inclusivity, and enhances selfesteem.

Appreciation and gratitude can be powerful tools for selfimprovement. Appreciation naturally leads to exposure of individuals to diverse experiences and challenges. By diversifying our experience in life, one may gain a greater understanding of their own privileges and sense of gratitude. When focused gratitude and appreciation are given, there is an immediate improvement in a level of contentment, resilience for work, and a more positive outlook on work and life balance. The easiest way to gain appreciation from others is to provide focused appreciation from yourself.

Finally, connecting with people is a necessary part of everyday life. Everyday life often dictates who and how those interactions occur and in a confined manner. Finding that connection in as a method of service can unlock a foundational piece of personal wellness that you may have not experienced before. You may be surprised to learn a new skill set in the process, develop deep social connections, and help alleviate the pressure of everyday life in the ED.

Matthew Keeler, DO Vice Chair

ACOEP WELLNESS COMMITTEE

CHECK OUT ACOEP’S DIGITAL CLASSROOM WHEN YOU NEED ON-DEMAND CME CREDITS

SUPPORT MEDICARE PAYMENT SYSTEM REFORM

Why are we still talking about congress and physician reimbursement? If you remember back in 2015 congress finally passed a “fix” called the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) that fixed the Sustainable Growth Rate (SGR) that required 17 yearly fixes from 1998 to 2015 when the MACRA was passed. This MACRA is what Center for Medicaid Services (CMS) uses to calculate the Physician Fee Schedule (PFS). MACRA was supposed to streamline multiple quality programs under the new Merit Based Incentive Payment System (MIPS) and give bonus payments for participation in eligible alternative payment models (APMs). In 2020 the No Surprises Act (NSA) was signed into law that allows for physician/groups to charge for their cost sharing amount. This is calculated based on the median in-network amount for similar plans and services in that geographic area

called the qualified payment amount (QPA). This has been the most recent legal battle you might have heard about where plans have been refusing to pay ER bills altogether or not considering all the factors in the payment because of flawed interpretation.

H.R. 2474 Raul Ruiz, M.D. (D-CA 25th) introduced (4/3/23) this bill modifies the PFS to be based off a single conversion factor and provides an update that is equal to the annual percentage increase in the MEI beginning in 2024.

The Medicare Economic Index (MEI) measures the average annual price change for inputs of physician services or practice cost of inflation.

This bill hasn’t moved yet, so ACEP was encouraging you to contact your representatives to sign onto a bipartisan letter to house leadership led by Drs. Ami Bera, M.D. (D-CA 6th) and

Larry Bucshon, M.D. (R-IN 8th) urging leadership to make Medicare payment system reform a priority this year.

Please sign up for ACEP 911 Grassroots Network updates if you do not already as it updates you with issues like this and will send you an email with a link that takes 30 seconds to fill out a few times per year. If you do not have the time to attend D.O. on the Hill or ACEP LAC, or similar, please at the very least send your representatives emails urging their support when required. Jeffrey Davis also does a weekly regulatory blog through McDermott Consulting that you can sign up for as well.–•–

Digital Classroom Link

WOMEN’S COMMITTEE UPDATE

WOMEN’S COMMITTEE WELCOMES DR. NGUYEN

The ACOEP Women’s Committee invites you all to join us for the 2023 ACOEP Scientific Assembly taking place August 11th- 15th at The Washington Hilton in Washington DC. We will be holding our Committee Meeting Friday, August 11th, at 3:00 pm , all members are welcome to join! We are actively recruiting new members as well, medical students, resident physicians, and attending physicians are all welcome to join!

We are excited to be hosting our Women’s Committee Luncheon on Sunday, August 13th, 12:00 pm – 2:00 pm . We are honored to be welcoming our speaker Dr. Theresa Nguyen, MD. Dr. Nguyen attended medical school at Sidney Kimmel Medical College – Thomas Jefferson University in Philadelphia, Pennsylvania. She completed her emergency medicine residency training at Cristiana Care Hospital in Newark, Delaware. Dr. Nguyen completed a significant amount of fieldwork internationally, including in Haiti, Peru, Guatemala, Dominican Republic and Vietnam. Through her experience in global health she obtained her Certificate of Knowledge in Clinical Tropical Medicine and Travelers Health in 2014. She is now an Associate

Professor of Emergency Medicine and the Director of the Center for Community and Global Health at Loyola University Medical Center in Maywood, Illinois. Dr. Nguyen has developed a strong interest in providing access to care for the homeless population. In January 2020, she co-founded the Loyola Street Medicine program. This program is dedicated to providing medical care and social outreach to the homeless population. Its mission includes addressing the unique psychosocial and health care needs among the homeless population, preventing unnecessary emergency department visits, and minimizing health care expenditures. In 2022, Dr. Nguyen was named the Loyola Medicine Spirit of Dr. Martin Luther King Jr. awardee for her leadership in co-founding the Loyola Street Medicine program. Her other interests include teaching ultrasound in resource- limited settings, addressing language barriers, increasing awareness and education surrounding human trafficking as well as international EM development. We are honored to have Dr. Nguyen join us for our luncheon where she will be speaking on “Understanding and Caring for the Homeless Population.” During this presentation Dr. Nguyen

will address some common myths related to individuals experiencing homelessness, help us to understand the challenges and health disparities that are unique to this patient population as well as discuss how we, as emergency medicine providers can better advocate for this patient population, as the emergency department is often the only healthcare that these individuals have access to. We are looking forward to learning more about street medicine from Dr. Nguyen.

We hope to see you all in Washington, DC for our exciting events. Remember to follow our Facebook Page, ACOEP Committee for Women in Emergency Medicine to stay up to date on all of our events!

ACOEP WOMEN’S COMMITTEE Nicole Vigh-Runz DO, MPH Public Relations Chair

All credit products are subject to approval.

IMPORTANT INFORMATION: The U.S. Department of Education recently announced a student loan debt relief plan which includes forgiveness of up to $10,000 for qualifying federal student loans and up to $20,000 for qualifying Pell Grant recipients. For more information, please read the announcement. Please note that if you refinance qualifying federal student loans with Laurel Road, you may no longer be eligible for certain benefits or programs and waive your right to future benefits or programs offered on those loans. Examples of benefits or programs you may not receive include, but are not limited to, student loan debt relief or public service loan forgiveness, repayment options such as Income Based Repayment or Pay As You Earn, or COVID-19 relief benefits such as a 0% interest rate, suspension of payments or loan forgiveness. Please carefully consider your options when refinancing federal student loans and consult StudentAid.gov for the most current information.

1. ACOEP members get a $50.00 discount on an annual program membership with GradFin (“Offer”). The discount will be applied on the current annual membership fee of $249.00 and will automatically apply at checkout. This Offer is only available to current ACOEP members, is non-transferable and cannot be applied to previous membership purchase(s). This Offer cannot be redeemed for cash or combined with other offers and is subject to cancellation at any time and without notice.

2. To qualify for PSLF, you must be employed by a U.S. federal, state,

service); work full-time for that agency or organization; have Direct Loans (or consolidate other federal student loans into a Direct Loan); repay your loans under an income-driven repayment plan; and make 120 qualifying payments. For full program requirements, visit www.studentaid.gov/manage-loans/forgiveness-cancellation/public-service.

MORAL INJURY TO MORAL RECOVERY

By Bill Bograkos , MA, DO, FAOAAM, FACOEP, FACOFP, COL MC FS COL (retired)

By

Bill Bograkos , MA, DO, FAOAAM, FACOEP, FACOFP, COL MC FS COL (retired), deployed on 9/11 and cared for traumatized troops until 2019. After retiring from military medicine he spent seven years on the Trauma-Recovery Service, Psychiatry Continuity Service, Walter Reed National Military Medical Center, Bethesda, MD, USA.

While his ER days are in the past, he now serves with the New Hampshire state Veterans Suicide Prevention Committee and holds teaching appointments @ www. USUHS.edu in the departments of “Military & Emergency Medicine” and “Physical Medicine & Rehabilitation”.

My name is Bill Bograkos, and I am a retired military physician. I became a member of the ACOEP in 1993, and have spent the last seven years serving as a consultant on Trauma Recovery, Psychiatry Continuity Service, at Walter Reed National Military Medical Center in Bethesda, Maryland. Prior to that, I cared for Service Members with severe traumatic brain injuries. My career extends from emergency medicine to rehabilitation medicine.

It has been almost 40 years since living and training in New York City. Thank you to all First Responders and First Receivers for your service. You certainly are fighting the good fight, and finding the “good trouble”. Hope you are all keeping the faith in yourselves, and in something greater than yourselves.

I survived medical training in New York City, so the military sent me to the “Survival” school at Fairchild, AFB, Spokane, WA, USA. During the 1980s, USAF SERE (Survive, Evade, Resist, Escape) Instructor cadre were survivors of POW internment camps in Vietnam. These survivors taught “so others may live”. Teaching others to survive kept them alive. There were other Veterans living in the Cascades alone, like many Veterans across the country in isolation. The darkness of

isolation never allows growth in a survivor’s recovery. Trauma recovery like Disaster Recovery, requires communication, cooperation, coordination, and collaboration with others. Victims isolate. Survivors engage.

Trauma- and StressorRelated Disorders are discussed in the DSM 5.(1) Criteria for Post-Traumatic Stress Disorder (PTSD 309.81) includes A) exposure to a traumatic event, B) intrusive symptoms (while awake or asleep), C) avoidance of reminders or known triggers, D) negative alterations of cognition and mood, E) alteration in arousal, changes in the autonomic nervous system including sleep disturbances, F) duration of psychological pain of more than thirty days, G) the disturbance causes distress or impairment (disorder), H) the disturbance is not attributable to substance use disorder (“Addiction is a brain disease”) (2), or another medical condition. More than 50-60% of people with PTSD abuse substances. Mood disorders are common co-occurring disorders in both PTSD and traumatic brain injury. Traumatic experiences may have involved feeling helpless and hopeless while witnessing others die.

When we experience chest pain, our brains guide us to the Emergency Room.

When we experience a traumatic brain injury, a toxic brain injury, or psychological trauma, we depend on others to help us find our way. When we experience a moral injury, we may repress and depress, or we may choose to connect and communicate with ship “mates”, “battle buddies”, or our “wing man”, within civilian or military communities.

Moral injury is a profound violation of a person’s core moral identity. Guilt, shame, and betrayal are hallmark reactions to moral injury. (3) In healthcare and warfare, experiences may be related to life and death triage, resource allocation, policies felt as betrayal, or dysfunctional leadership. The combination of PTSD and moral injury is associated with greater PTSD, greater depressive symptomatology, and greater suicidal thoughts and attempts. PTSD is largely fear based where shame and guilt drive moral injury. Betrayal by peers, mentors, or leaders, or a failure to live up to one’s own moral standards are hallmarks of moral injury.

A moral injury feels like an unrepairable hole in your soul. Imagine

how Major (Dr) Andrew Taylor Still felt after returning home from the horror of war and again after he lost his family to infectious disease. He did recover and he did develop Osteopathy for the world.

Moral injury requires repair of injured bio-psycho-social-spiritual structure and function. The path to Moral Recovery involves connecting with others before you drown in guilt and shame. Recovery involves education and self-forgiveness before drowning in self-harm and self-sabotage. Recovery involves grabbing on to that life line thrown from ships. Your mates navigate and sail on these ships and these ships are friendship, mentorship, and leadership.

In Disaster Medicine the stronger Development phase always follows the Recovery phase. Development is often difficult to envision from the darkness of moral injury. Sometimes we require light and guidance from others. Leaders and mentors serve as stakeholders in the development of junior physicians. Our friends, mentors, and leaders may need a lifeline connection with professionals outside of their own comfort levels or safe zones. Trauma is complex and not all trauma bleeds.

Moral injury is not a disorder or disease. It is a sign of mental and moral health in caring for trauma survivors. The injured need assistance in rejoining life and repairing “self”. One suggestion is sharing your story with those you trust and supporting others with your own active listening skills. Prosocial behavior is a form of restitution and a method of healing. Recovery involves cleaning house, helping others, trusting, and serving something greater than yourself. The past is gone forever. Recovery and development involve lifelong learning from our pasts and the experiences of others. Isolation leads to impairment. Stay engaged and stay safe. –•–

References:

1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013.

2. National Institutes on Drug Abuse. http://www.drugabuse.gov (accessed October 2, 2020).

3. U.S. Department of Veterans Affairs. PTSD: National Center for PTSD. http://www.ptsd.va.gov (accessed October 2, 2020).

Bill & Rex

a now retired Marine canine

LESSONS FROM THE STAR THROWER

Article Contributed By The Whole Physician

In 1969, Loren Eiseley published a collection of essays in a book called The Unexpected Universe. In it, there was one essay called The Star Thrower. It’s been adapted into various forms, but essentially it goes like this:

An old man goes down to the seashore. He sees a little boy picking up starfish, one by one, and throwing them back into the ocean. As he approaches, he asks the child what he’s doing. The child tells him he’s saving starfish- the tide is going out, it’s a hot day and they’ll dry out and die otherwise.

The old man scoffs a little. He points out that there are thousands of starfish along the miles and miles of coastline. The boy can’t possibly think he can make a difference!

The little boy quietly leans down, picks up another starfish and throws it in the ocean. Then he turns to the man and says, “ I made a difference for this one .”

We know the waiting rooms are overcrowded. We know staffing is short. It seems like you’re up against insurmountable odds. And you’re right - if it were only up to you.

But you’re a piece in the bigger puzzle. It’s NOT only up to you. Your only job is to pay attention to the “starfish” you can help at this moment. And when you’re finished for the day - celebrate a job well done. The world is a little better because you’re in it. And for the “starfish” you helped, it meant the entire world.

It’s imperative to make the good you’re doing sustainable and to be satisfied with your little piece of the puzzle. Please recharge your batteries and take care of yourself first. There will always be more starfish, but there is only one you. Are we going to cure physician burnout and dissatisfaction overnight? Absolutely not. But every single time one of you has a moment of clarity, sighs a sigh of relief, or holds your head a little higher at the end of your shift, then maybe YOU were the one helped today! –•–

Coaching is a highly effective tool that has been used in highlevel corporate positions and professional sports for years. It takes intelligent people from feeling unfulfilled in their lives to feeling envigorated and hopeful. Multiple randomized controlled trials have shown statistically significant results in wellbeing for physicians.

Choose between:

Self-guided 12-week video lecture course

Private 1:1 coaching sessions with a coach who is also a physician Both for greater progress

We are 3 EM doctors, so expect results STAT. Think of this as work-life resuscitation. With over 50 years combined working in busy ERs, we understand your situation. We've been there. Let us teach you the tools you need to thrive.

Laura Cazier, MD

Amanda Dinsmore, MD Kendra Morrison, DO

By Susan M. Mastellone , DO, FACOEP

After 23 years of fast paced, controlled chaos in the emergency department I decided to retire with a new mission in mind. I have served in various clinical settings during my career from inner city to rural farm community. The common theme has always been the people. Yes, of course I mean the patients, but also my colleagues. I spent 10 years with the residency of the University of Maryland Emergency Medicine teaching young, amazing minds. It was in that role I realized how important it was to teach them to care for their patients, not just treat them. I graduated from KCOM, now A T Still University, in 1995. In 2000 I finished my emergency medicine residency from St. Barnabas Hospital in the Bronx, NY.

NOW THE REAL WORK BEGINS

By Susan M. Mastellone, DO, FACOEP

COMLEX exams passed? Check.

Emergency Medicine residency complete? Done!

Successful employment? Affirmative!

Board certification? Yup!

That should be everything, right? Not even the tip of the iceberg. Now the real work begins.

In 2000, when I graduated from my residency at St Barnabas Hospital in the Bronx, I was sure I was ready to save the world. Twenty-three years later, I have realized all the ways I was not prepared to care for my patients. The elements missing from my training could not be found in any textbook, nor were they tested on any exam.

What I was never taught was the art of humanity. Sure, I observed my brilliant attendings in residency perform amazing acts of intelligence and caring, but it was the side act, if you will. It wasn’t what I focused on, and perhaps understandably so. There was so much to learn, and humanity didn’t make the reading list.

I spent the first 15 years of my career in Baltimore, with the

last ten years working at Mercy Medical Center. During my time there, I had the privilege of participating in the education of EM residents from the University of Maryland. Mercy was an outside rotation for them, away from the mothership. At Mercy, we were able to work more closely, virtually one on one, and I loved it. It was during my time with the residents that I found myself mothering them. Our chairman nicknamed me Mama Bear, and I wore that moniker with pride.

Slowly but surely, I was spending more time just talking to my patients, trying to be a good example for the residents. But I noticed it changed me in the process. I guess you might call it maturity, but something, some force, was preparing me for the future.

In 2015, we migrated to Florida. This time, my “resident children” were my scribes. Such an amazing group of motivated young people. I felt obligated to remain a good example. However, I started to see the change in medicine that I feared: less time with patients, more time with my computer.

In 2021, I got a taste of reality... as a patient. Headed

into a shift on a sunny Saturday in May, I knew something was wrong. I managed to get myself into the building and asked the staff to check me in to be seen. Forty-eight hours later, I heard words I never expected: “You have a brain tumor.” You hear the words, but then again you don’t. Certainly, they didn’t mean to tell me that. Maybe there was a mistake, I thought to myself.

Since that time, I have been to the operating room, undergone radiation, and completed two rounds of chemotherapy. I was quickly turned into a patient,

and I really wanted someone to talk to me, just talk to me. I’m still waiting, but now, two years later, I’m taking matters into my own hands. I am going to be the change I want to see in medicine.

As a result of my new mission, I started a blog called “But if you did know, what would you say?” Initially, it was purely for me, therapeutic if you will. However, I realized there might be a greater good that could be achieved from these words, so I’ve decided to share them.–•–

CHECK OUT SUSAN’S BLOG

ACOEP DOCMATTER COMMUNITY

The ACOEP family has a great place to collaborate and learn. We want to encourage the use of the ACOEP DocMatter Community. The platform, accessible only to ACOEP members, is designed to harness the global connectivity of the internet and make it easier than ever to broaden peer learning.

Join a discussion or start one of your own. Recent topics of conversation have included new COVID-19 infections in fully vaccinated healthcare workers and compensation for frontline workers. The Pulse column “What Would You Do? Ethics in Emergency Medicine” from Bernard Heilicser, DO, MS, FACEP, FACOEP-D will also now be featured in the DocMatter Community. Log in and tell us how you would handle this issue’s dilemma. To access the Community please visit DocMatter.com/ACOEP.

AN ACCIDENTAL MEDICAL HOLIDAY

THE BEGINNING OF A PASSION TO CARE FOR THOSE IN HONDURAS

Jeremy Selley, DO, FACOEP

ED providers are so alike. We work very hard taking care of too many patients. We often spend more time coordinating social nonemergent issues than patients’ physical issues. Our workload is HUGE, our support and self-care suffer.

I have learned to welcome the break from the chaos of the ED. I was introduced to international medicine in 2016 when my wife and a local nurse in North Carolina decided that I would join her mission team to Honduras. Being voluntold can end in disaster, but in this instance, it was quite the opposite. I could have never guessed that my introduction to the Carolina Honduras Health Foundation (CHHF) would become my new passion.

I had always wanted to do some medical mission work, but years went by before opportunity met great timing. I had seen our local church take religious trips across the globe and watched medical teams help in Haiti and Guatemala. Unfortunately, I always found just the right excuse not to sign up. There was never anyone going on a trip that I knew… it wasn’t the right time… I’d be gone too long… the fee seemed too much. Isn’t it easy to find reasons to avoid something that is appealing but scary? In July 2017, I finally took

the leap and made my first trip to Honduras. I was nervous. It wasn’t my first time out of the country with a passport, but it was my first time on a medical mission to a third world country. I had no idea what to expect. I had served in the US Navy and had even went to Jordan, Kuwait, Dubai and Bahrain. I could not pinpoint why Honduras made me nervous, but it did. I even wrote a goodbye note to my wife and kids and placed it in the gun safe before leaving!

Once I arrived, things appeared just simple. My journey became more about experiencing the beautiful culture of the country and less about my fears. I found everything to be scaled down and less affluent. The people were all very friendly and welcoming. In some of the more populated areas I found a shanty next to a brand-new Pizza Hut. Many simple block homes did not have stucco, but the windows had bars and razor wire on top of their fences.

The trip from the airport in San Pedro Sula to the clinic in Limón took a full day. Two half days of driving with a one-night sleepover in La Ceiba where I was first introduced to Honduran fruit. The fruit. I could talk about it for hours (and crave it every day)! The fruit is absolutely amazing. Pineapple from Honduras is on a different level.

Coupled with fresh coconut juice, that pineapple can make one hell of a Piña Colada. The fruit and fajitas that we had at the hotel the first night are truly what foodie dreams are made of.

Once at the clinic in Limón, after settling into our rooms, we all gathered onto the porch. Lined with weather beaten wood rocking chairs, overlooking the ocean through dozens of coconut palms trees, there was an aura of solitude. It was such a contrast from the chaos I had expected to find. The CHHF staff greeted us and we were introduced to Bexa and Elda, the two local cooks that would make us our food over the next 5 days, helping to cement my love for Honduran food and coffee. Both only speak Spanish, but the language of good food transcends any language barrier. It also provides the needed energy to face the long, busy days of clinics I was about to experience.

During four days of clinics, our team of 13 provided primary care to over 400 patients at the main clinic and two clinics in remote locations. The need for medical care was great, but there was such a huge difference from patients I typically saw in the ED. The patients I saw, many walking miles for their visit, were happy to see me. Every single one was happy, gracious, and thankful. When was the last time you were able to say that about a week of patient care?

Remote villages were an exciting part of the experience. Just getting there on an old yellow school bus on unpaved, rocky roads was interesting. The dust was overwhelming at times. At one point we were forced to push past a heard of cows to continue our drive. It’s certainly

a reminder that we were not in the United States.

The children were so happy and playful. They comprised about 50% of the patients seen during the week. One young boy really touched my heart. Darlin was a 4-year-old who could barely walk the day I met him. He sustained a traumatic brain injury from an auto accident in 2017. He needed to see a neurosurgeon in San Pedro to have a skull plate placed to cover his brain from his previous craniotomy. He needed to have his extraocular muscles corrected to fix his strabismus and he needed physical and occupational rehab. His parents did not know where to begin. They also did not have the money to provide for this medical care. It was heartbreaking. CHHF helps to coordinate and pay for referral specialist care for patients similar to Darlin that come to our clinic. Watching a young girl receive a leg prosthesis and walk for the first time, post traumatic leg amputation, with tears of joy streaming down her face, erasing two years of depression, is another example.

The villages served by the mission team are almost two hours from a hospital that does not even provide linen sheets or medication. If a patient finds transportation, they don’t have the financial resources to pay. No one in Honduras goes to the ED for small issues like patients do in the USA. During my week, I saw a lot of kids with sniffles and coughs. There were adults with chronic HTN and DM. Unlike at the government clinics and hospitals in Honduras, all CHHF clinics provide medications for free. The teams pay for and bring what they will use with them, and then some. There is always an

ongoing and revolving pharmacy supply of a full formulary that CHHF coordinates.

After the clinic days we reverse and make the 2-day trek back to the airport, sometimes with a day to decompress before making the long journey home. Uniformly, on the plane ride home, everyone starts to plan their trip for the following year, hoping they can make their schedule work. Before your feet touch the ground, you miss everything about Honduras. Because at this point, you have fallen in love with the country, people, food and most importantly the mission!

If you are like my wife, after her first trip, you will sit on the plane ride home, tearful, as the emotions overwhelm you and as you recant what an amazing experience from both a clinical and humanistic side. A medical mission team experience is difficult to explain, but it will change your life forever. My wife, my friends, and I are proof that you can fall in love with missions. As an added bonus, you have created new friends on your team, have new CHHF staff family members in Honduras, and have lasting memories, group chats and Facebook friends to last the rest of your life!

CHHF medical mission teams go 18 times a year. There is always room for you. Put the stress of working in the ED aside for one solid week. Serve under resourced villages full of people who are generous and grateful.

For more information, you can visit www.chhf.org or email us at contact@chhf.org. Take the first step and inquire today. I promise it will renew your spirit and refresh your energy. –•–

Jeremy Selley, DO, FACOEP, is a native of Nibley, Utah. He graduated from Utah State University with a B.S. and then went to Kirksville College of Osteopathic Medicine for his D.O. Jeremy met his wife, Victoria H. Selley, D.O., in medical school and they then attended Emergency Medicine Residency at Lehigh Valley Health Network. After residency, Dr. Selley served 4 years in the US Navy and was deployed on the 24th Marine Expeditionary Unit in 2012. In 2014, Dr. Selley joined USACS full time and has been with the company since. In 2018, Drs. Selley moved from NC to FL and started work with AdventHealth Sebring. Dr. Selley began working with Carolina Honduras Health Foundation in 2017 and serves on their Board of Directors. He travels to Honduras yearly to help treat patients. Dr Selley chairs the ACOEP Practice Advocacy Committee and works with Florida College of Emergency Physicians to increase advocacy awareness.

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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 Spring, 2023 issue regarding the 72-yearold male patient who presented with a hip fracture.

The patient resided in a nursing home and had a fall injury sustaining a left hip fracture. He did have a medical history of hypercholesterolemia and schizoaffective disorder. He was a full code status.

The ethical dilemma related to the patient refusing surgery in the context of the significant mortality if surgery was not performed.

The patient was a Ward of the State, but did manifest intermittent decision-making capacity. Should we accept his refusal?

As a start, we should determine if there are any advance directives. There were none.

The patient is a Ward of the State and has a State Guardian. That individual is empowered to make all medical decisions on the patient’s behalf. Although, the patient does have what appears to be intermittent decision capability, the fact that he has been declared incompetent by the court and a State Guardian has been appointed, renders his decision unacceptable and we must turn to the State Guardian. The Guardian has indicated that he will consent for the surgery and this should be accepted by his medical providers. This decision has been based on the risk versus benefit of the circumstances and certainly this would point towards the patient having the surgery.

WHAT HAPPENED?

The patient did have hip surgery and was subsequently discharged to a nursing home. Please visit the ACOEP DocMatter forum and share your thoughts on this case.

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