The Pulse- October 2016 by ACOEP

OCTOBER 2016

IN THIS ISSUE: Are You Sharing the Osteopathic Story? - Pg 3 Unintended Consequences in the Emergency Department - Pg 6 Get Ready for the 2016 Scientific Assembly! - Pg 17 Updates in EM Literature - Pg

Presidential Viewpoints | John C. Prestosh, DO, FACOEP-D

A Story Waiting to Be Heard (Page 3)

The Pulse VOLUME XXXVII No. 4 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 Editorial Committee Timothy Cheslock, DO, FACOEP, Chair Wayne Jones, DO, FACOEP-D, Vice Chair Drew A. Koch, DO, MBA, FACOEP-D, Board Liaison John C. Prestosh, DO, FACOEP-D Stephen Vetrano, DO, FACOEP John Ashurst, DO John Downing, DO Tanner Gronowski, DO Erin Sernoffsky, Director, Communications The Pulse is a copyrighted quarterly publication distributed at no cost by the ACOEP to its Members, Colleges of Osteopathic Medicine, sponsors, exhibitors and liaison associations recognized by the national offices of the 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. Advertisements due dates can be found by downloading ACOEP's media kit at www.acoep. org/advertising. The ACOEP and the Editorial Board of The Pulse reserve the right to decline advertising and articles for any issue. ©ACOEP 2016 – All rights reserved. Articles may not be reproduced without the expressed, written approval of the ACOEP and the author. ACOEP is a registered trademark of the American College of Osteopathic Emergency Physicians.

TABLE OF CONTENTS Presidential Viewpoints..............................................................................................................................3 John C. Prestosh, DO, FACOEP-D The Editor's Desk............................................................................................................................................4 Timothy Cheslock, DO, FACOEP Executive Director's Desk........................................................................................................................5 Janice Wachtler, BAE, CBA The On-Deck Circle......................................................................................................................................6 Christine Giesa, DO, FACOEP-D Fighting Back Against the Opioid Epidemic...............................................................................7 Erin Sernoffsky Single Accreditation Update................................................................................................................12 Confronting Fear with Action...............................................................................................................13 Erin Sernoffsky ACOEP Council for Women in Emergency Medicine.......................................................16 Christine Giesa, DO, FACOEP ACOEP’s Scientific Assembly Bringing More than Ever Before!............................. 17 Member News................................................................................................................................................. 18 Ethics in Emergency Medicine: What Would You Do?...................................................19 Bernard Heilicser, D.O., M.S., FACEP, FACOEP-D New Physicians in Practice: Helping You Get the Most Out of Your New Career...........................................................................................................20 Nicky Ottens, DO, FACOEP Osteopathic Continuous Certification in Emergency Medicine: What is That?..................................................................................................................................................23 Donald Phillips, DO, FAAEM, FACEP, FACOEP-D Literature Update Fall 2016 ................................................................................................................29 Amanda Ellis, DO and John Ashurst DO, MSc

A Story Waiting to Be Heard Do you want to know a secret? — The Beatles, 1963

the side to wait for someone to come and check the questionable bag.

Presidential Viewpoints John C. Prestosh, DO, FACOEP-D

steopathic physicians have a story to tell; we also have an audience waiting to hear our “osteopathic” story. We should be prepared to share this information with as many individuals as possible. I believe we would be surprised with the outcomes of many of these conversations. I want to share the events of a chance meeting I recently had with a complete stranger. I was given an opportunity to discuss osteopathic medicine at a time when such a discussion was not really on my mind. My wife and I were leaving Chicago having attended the AOA Board of Trustees and House of Delegates meeting this past July. We had entered the TSA PreCheck line at O’Hare Airport when unexpected events unfolded. My wife was in front of me and had no problems passing through security. However, I had an uncomfortable feeling when I saw my over-the-shoulder bag receiving more scrutiny in the x-ray machine than I thought necessary. Sure enough, my bag was removed from the conveyor belt and a brusque voice barked, “Who belongs to this bag?” I immediately replied that it was mine. I was then ordered to move to

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Several minutes passed until another unsmiling TSA agent approached me, took my bag, and instructed me to follow her. I must admit I was perplexed as to why my bag was receiving extra attention. I then realized I had not removed my laptop computer from the bag and immediately reported this fact to the TSA agent. She stared at me and stated rather blandly, “No, that is not the reason.” She opened my carry-on and quickly pointed to a rectangular cardboard box at the bottom of the bag. “That’s the problem. What’s in the box?” I almost laughed out

loud but managed to only maintain an outward grin when I saw the “problem.” I told her I was a physician and had the occasion to visit my home office while attending medical meetings in Chicago. I added that I had received new business cards while at the office and the box contained my cards. She asked me to open the box and remove a card so she could examine it. I gave her a card and was surprised that she did not just give the card a cursory look but actually spent time reading it. I was not expecting her next two questions. “What is ACOEP? And what does osteopathic mean?” As I was about to answer her, she turned to me and quickly added, “Are you a real doctor?” Continued on Page22

Tragedy and Triumph In recent weeks I continue to wonder how ready is my hospital to handle a potential situation as this?

The Editor's Desk Timothy Cheslock, DO, FACOEP

t has been almost four months since the horrific events unfolded at a nightclub in Orlando. A lone gunman entered The Pulse nightclub and began shooting indiscriminately with an assault rifle into the crowd. 49 people lost their lives and many other were critically injured. The city once known for its famous tourist destinations, the home of Mickey Mouse, and my current hometown was now known across the world as yet another statistic on gun violence and terrorism. While I do not work at the hospital facility where the victims were transported, the constant media coverage, televised interviews, and stories from friends and colleagues much closer to the event than myself painted a picture of unimaginable sights, things that most people outside of those in a militarized combat zone could never imagine. In the days to follow stories emerged of harrowing efforts by police and first responders to breech the club and rescue the injured, free those being held at gunpoint and subdue an unknown assailant. In addition, the sight of utter devastation, bodies piled upon each other, and a blood covered floor. The constant barrage of media replays were overwhelming.

As an emergency physician, my initial thoughts went to the safety of those engaged in the operations, their wellbeing and their families. Next, the staff of the two facilities who received the wounded. How were they coping with such a surge of patients? Did they have the resources they needed to handle the onslaught? It was the early morning hours on a weekend. Itâ&#x20AC;&#x2122;s a lot different than the middle of the day with fully staffed operations. Their skill and adrenaline would carry them through the initial triage and treatment; but how would they handle the stress and the true carnage they were forced to witness and ultimately be a part of trying to undo? The emergency department and the trauma team of the Orlando Regional Medical Center did nothing short of the impossible. They performed countless surgeries and treated over 50 patients that night that rolled through their doors over a two hour period. Just imagine that! 50 patients, all with traumatic injuries in two hours. Thatâ&#x20AC;&#x2122;s more patients than most facilities see in a shift with all comers. This was not a just a few patients with serious injuries. All of the injured suffered wounds from a high powered assault rifle. The implications and the extent of injuries much more devastating than normal small caliber fire arms that routinely present to the local trauma facility. Operating rooms were stressed to the max, blood supplies being coordinated from a large area due to the sheer volumes required for resuscitation. All seemed grim. Out of the casualties brought in that day, nine died almost immediately from injuries too severe to survive. All the others made

it through surgery, and as of this writing only one remains hospitalized. What a miracle! Despite the miraculous efforts of all the staff, first responders and police, the events of that night in early June were a tragedy not soon to be forgotten What is the triumph you may wonder? It is difficult to find any good in a situation as this, but the actions and efforts of the residents, businesses, and entire Orlando community from the time of the event forward has been outstanding. The local community came together as never before. The fact that the shooting happened at a gay nightclub immediately stirred the media into a frenzy. Was this a hate crime, a terror attack, or some other incident that could be spun to highlight hatred and intolerance? The fact that it was being used by certain outlets to stir those suggestions should be ashamed. It was an assault on our community! Those that are our neighbors, co-workers and friends were directly affected by this tragedy should not be singled out because of their orientation. What began as an effort to highlight a typically discriminated against group turned into something entirely different. The Orlando community embraced the LGBT community with an outpouring of love and support like never before! From the county and city government officials, to church groups and civic organizations, it seemed that the entire community was holding each other up. Assistance centers sprung up, lines to donate blood stretched around city blocks. In the days following the event, one blood drive Continued on Page19

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So Let Us Begin Anew... These young men and women will be our pioneers; they will integrate programs unfamiliar with the tenets of osteopathic medicine much as those physicians who came before them, but they will do this in a system that will be without prejudice. Executive Director's Desk Janice Wachtler, BAE, CBA

n 1960, John F. Kennedy used those words to welcome in a new era of government, one not plagued by world wars, or conflicts; one that would usher in a new era of understanding. As I read those words I found similarities between that era and the changes being incorporated into medicine, so let me quote JFK. “So let us begin anew, remembering on both sides that civility is not a sign of weakness, and sincerity is always subject to proof. Let us never negotiate out of fear. But let us never fear to negotiate.

California; embraced the growth of our profession, the establishment and growth of emergency medicine and the ACOEP; and sometimes fear the unknown future of our College. Over the past decades, we have proven our similarities and celebrated our differences, we have reached across the chasm that separates DOs and MDs to bring the best education to our residents and physicians, members and non-members alike. But now is a time where we really do have to begin anew, and this is why.

“Let both sides seek to invoke the wonders of science instead of its terrors. Together let us explore the stars, conquer the deserts, eradicate disease, tap the ocean depths, and encourage the arts and sciences.”

In 2016, the osteopathic profession will have its first class matriculating into residency programs universally accredited by one agency representing medicine in America. This class will bear the burden of many osteopathic physicians before them, of proving they are equal to their MD counterparts. They will be the standard bearers of the osteopathic profession and the group to ensure the osteopathic profession continues.

These words, spoken over 55 years ago, opened a new frontier for the United States; they will also usher a new frontier for osteopathic medicine. In the past, we have seen the battles for equality in

These young men and women will be our pioneers; they will integrate programs unfamiliar with the tenets of osteopathic medicine much as those physicians who came before them, but

“Let both sides explore what problems unite us instead of belaboring those problems which divide us...“

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they will do this in a system that will be without prejudice. They will not need to prove the equivalency of training or degree and so we begin anew. It will be up to our young physicians to remember the past and hold tight onto agencies that supported them. They will revel in the new freedom given to them by the system; but they will need to embrace new things and learn from experiences that will make or break the osteopathic profession. “...we observe today not a victory of party, but a celebration of freedom— symbolizing an end, as well as a beginning —signifying renewal, as well as change...” And so I call upon you, the young physicians, residents, and students to maintain your identity as DOs, use your individual strengths taught to you by your osteopathic education and stand before your peers and say “I AM A DO; I AM A PHYSICIAN; AND I AM A MEMBER OF THE AMERICAN COLLEGE OF OSTEOPATHIC EMERGENCY PHYSICIANS.”

i-ii – Inaugural Address, John F. Kennedy, January 20, 1961

Unintended Consequences T hings do not always turn out as we expect. Often times our intentions are laudable, but when acted upon, unanticipated consequences arise. The On-Deck Circle Christine Giesa, DO, FACOEP-D, President-Elect

hings do not always turn out as we expect. Often times our intentions are laudable, but when acted upon, unanticipated consequences arise. Two examples of unintended consequences currently getting a lot of attention are prescription opioid abuse stemming from chronic pain management, and in the osteopathic world, the single accreditation system.

and required institutions to provide a pain assessment for all patients. There has also been increasing institutional emphasis placed on the HCAHPS Survey and patient satisfaction scores which includes questions addressing how well a patientâ&#x20AC;&#x2122;s pain was managed. In many instances, these scores are linked to physician bonuses and continued employment. (Note: The Joint Commission removed pain assessment

from its standards in 2009.) Opioids, originally reserved for the treatment of acute and end-of-life pain, were advocated for the treatment of chronic pain, on the belief that they were safe and their more liberal use would provide significant pain relief. Not understanding how to best treat chronic pain, it was recommended Continued on Page 28

Prescription Opioids No one would dispute that relief of pain is a moral expectation and that healthcare providers have a professional responsibility to effectively treat their patientâ&#x20AC;&#x2122;s pain. Patients with chronic pain can be difficult to evaluate and treat in the emergency department. What makes chronic pain especially difficult to manage is the lack of objective means to assess and quantitate the degree of pain that a patient is experiencing. Over the past three decades, there has been a movement for healthcare providers to improve their pain assessment and management. In 2000, the Joint Commission integrated pain assessment and management into its standards

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Fighting Back Against the Opioid Epidemic By Erin Sernoffsky

s an emergency physician, you have no doubt seen the direct effects of the opioid epidemic in communities across the United States. You know the stats—that drug overdose is the leading cause of accidental death in this country; 1.9 million people are dependent on prescription opioids, and 2014 saw 19,000 deaths related to prescription pain relievers. While the majority of prescriptions for opioids don’t come from the ED, often times emergency departments are the first exposure many people have to opiates. In the face of the constant struggle with the epidemic, and in the midst of the daily chaos of the ED, it can be difficult to see any viable paths to make a difference in the ongoing fight. Alexis LaPietra, DO, has made it her mission to fight back against the rising tide of opioid overdoses. Working with her team at St. Joseph’s Regional Medical Center in Paterson, New Jersey, LaPietra spent a year developing the ground-breaking Alternatives to Opioid (ALTO) Program, a comprehensive approach to helping patients in extreme pain that doesn’t automatically default to prescribing opioids. “Our goal in the ED is to break the pain cycle,” said Dr. LaPietra in a recent interview. “It’s unrealistic to completely alleviate pain, but we can make pain tolerable. Once we reach that point, it’s much easier to maintain pain management at home.” In her work, Dr. LaPietra identified specific areas of pain management

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that can effectively be treated through non-opioid modalities and medication including trigger point injections, nitrous oxide, and ultrasound guided nerve blocks. Current ALTO protocols call for intravenous lidocaine in the treatment of kidney stones; oral and topical pain medications and trigger point injections have proven very effective in treating lower back pain; ultrasound guided nerve blocks are used first in treating extremity fractures. There are still instances when opioids have a place in emergency pain management. “We aren’t anti-opioid,” said Dr. LaPietra. “If alternatives aren’t effective, we will still prescribe opioids, we just don’t want to do this reflexively.” Pain as a result of cancer, intra-abdominal pathology, and significant trauma are all areas in which opioid use is appropriate. In these cases, Dr. LaPietra urges physicians and nurses to take extra time with patients to educate them on the serious side effects of the drugs, and to make them aware of the risks. All of the protocols and practices outlined in ALTO are evidence-based, developed after extensive research and the results are promising. At St. Joe’s, patient satisfaction is higher and they have seen no increase in the number of return patients, a fact that Dr. LaPietra credits first to treating the cause of the pain rather than the pain itself, and to working with patients to control their pain. System-wide support of ALTO has expanded the program’s reach and efficacy throughout the community. The ED partnered with St. Joseph’s Healthcare System Opioid Overdose Prevention and

Naloxone Distribution Program to educate friends and family members of highrisk individuals about prescription opioid abuse. This program provides a Naloxone kit to be kept in the home and trains friends and family to recognize an overdose and to respond appropriately. Additionally, the St. Joseph’s Departments of Family Medicine, Chronic Pain Management, PM&R, and Psychiatry have all adopted the principles of the ALTO program. The protocols set forth by the ALTO program are easily adaptable to any ED across the country, depending on the level of administrative support. “The biggest hurdle for any EM physician is to get buy in from administration so that they have the support to implement,” says Dr. LaPietra. “There will be protocol and policy changes, but there will also be significant education for the physician and the entire team during this massive culture change.” However, Dr. LaPietra and her team feel that the facts speak

for themselves, that evidence-based treatments and a results-oriented plan are powerful tools of persuasion in setting these changes in motion. Resistance of staff is another potential roadblock to rolling out similar plans, particularly when physician time is the only major cost. Dr. LaPietra cautions, “It can also be hard to train doctors to try something new when they are unsure of results. Physicians may champion these ideas, but it can be a slow go, but don’t get discouraged. The results are compelling and when you implement these modalities and protocols there are really beautiful results and patients are satisfied.” Treating the Whole Person The core of ALTO’s success is a foundation of treating the patient rather than the pain. This is a perfect example of a core tenant of osteopathic training put into practical use, and Dr. LaPietra credits much of the success of this program to her training as an osteopathic physician. “Going through the osteopathic curriculum there was always a focus on the person and appreciating intervention and how that may affect the person as a whole,” she says. “You have to appreciate that the whole person is functioning with other issues besides their pain. The pain may not always be organic, so you have to sit down, take time, touch your patient. I really appreciate the osteopathic principle of touching the patient, sympathize, empathize, sit eyelevel. I advocate for a full exam of the back, palpating and mapping out pain, if you can identify trigger points we have an intervention that works wonders.” Treating the whole person goes beyond treatment modalities, and while prevention is of upmost importance, it is also critical to offer support services to patients who are already struggling with addiction. A key pillar of ALTO is an emphasis on mental health and addiction support.

I really appreciate the osteopathic principle of touching the patient, sympathize, empathize, sit eye-level. I advocate for a full exam of the back, palpating and mapping out pain, if you can identify trigger points we have an intervention that works wonders. One such successful partnership is with Eva’s Village, a local community group that offers outpatient addiction treatment and recovery services. Every patient who is treated for an overdose also meets with a peer counselor from Eva’s Village, this is a person who has experienced addiction and worked through rehab. The goal is to encourage patients to go directly from discharge to Eva’s Village to enroll in a treatment program. These peer counselors have a significantly higher capture rate than physician, social workers, nurses or other medical professionals presenting the same information. Dr. LaPietra is adamant that working collaboratively with these patients is as important as any treatment they receive. “It can be very frightening, and it’s important for us to be sympathetic and gentle as we work with people who are

already stigmatized and marginalized. Addiction is a disease. These people are in the shadows and are pushed to the side of society and they don’t have much. For a white coat to walk in the room and lecture them isn’t effective, but to have someone come in and be on their level allows for a significant amount of comfort. We need to embrace them and treat them like human beings who have a disease.” The opioid epidemic has devastated families and communities across the country, and a multifaceted attack is necessary in fighting back. The ALTO Program is striking a blow at the epidemic, focusing on prevention through alternative and often times more effective pain management treatments; access to recovery services; and a major cultural shift in our relationship to opioids.

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CLINICAL APPLICATIONS OF THE ALTOSM PROGRAM Headache/ • Migraine • • •

Extremity Fracture or Dislocation

• Nitrous oxide + Intranasal Ketamine Set- up for block • Ultrasound Guided Regional Anesthesia

Musculoskeletal Pain

• • • •

Lumbar • Radiculopathy • • • •

Renal Colic

Metoclopramide, Ketorolac, IV fluids, Sumatriptan If <50% relief then, Magnesium, Valproic Acid, Dexamethasone If <50% relief then, Haldol If <50% relief then, OBSERVATION with neuro consult

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Ibuprofen + Acetaminophen Lidocaine or Diclofenac Patches Cyclobenzaprine or Valium Trigger Point or other soft tissue injection

Ibuprofen + Acetaminophen Cyclobenzaprine or Diazepam Gabapentin Lidocaine patch Ketamine

• Toradol + Tylenol + IVF • Cardiac Lidocaine 1.5 mg/kg IV, max 200 mg

The 6th Annual FOEM Legacy Gala: Dinner and Awards Ceremony

he Foundation for Osteopathic Emergency Medicine’s 6th Annual Legacy Gala, presented by US Acute Care Solutions, is right around the corner. Join us as we celebrate this year’s honorees with a taste of San Francisco’s Chinatown, complete with exciting live entertainment, regional beers, delicious Chinese cuisine, and beautiful décor. “I am so excited for this year’s event,” says FOEM Executive Director, Stephanie Whitmer. “There are some really fun live performances to surprise our guests, delicious signature cocktails, as well as a beautifully decorated environment to enjoy the company of your peers. More than anything I’m excited for the chance to celebrate everything we’ve accomplished this year with so much generous support.” The evening begins with a reception in the Hilton’s Cityscape, a stunning room with an incomparable 360-degree view

The Legacy Gala honors all of the generous individuals who have supported FOEM’s mission and enabled us to provide medical supplies for a medical mission trip, continue the success of FOEM’s national research competitions, and fund a research project that will examine the costs and satisfaction of the Single Pathway transition. Purchase individual tickets for $250, student/resident tickets for $150, or consider reserving a table for 10 attendees for $2,000. Visit www.acoep.org/scientific for links to purchase your tickets.

of San Francisco. After enjoying delicious hors d’oeuvres and an open bar, guests will proceed to the main event. Cross a virtual coy pond and find yourself transported into San Francisco’s historic Chinatown. From there, enjoy a lovely meal and engaging awards ceremony before dancing the night away.

Be sure to buy your tickets before October 31st to avoid the on-site price increase. FOEM would also like to thank our Presenting Corporate Sponsor, US Acute Care Solutions, as well as our friends EmCare and Florida Emergency Physicians for helping make the 6th Annual FOEM Legacy Gala possible.

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Visit Us at

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EMA, headquartered in Manhattan Beach, CA, is a premier provider of physician and practice management services for 20+ Emergency Departments that treat over 700,000 patients each year. For more information, please visit us at: www.ema.us

Single Accreditation Update

ver the past weeks and months, changes and clarification have come to the ACOEP from many directions on many different issues Reimbursement: In June AOA and the Centers for Medicare and Medicaid Services (CMS) clarified that they will pay for all training required for certification. If your program is three years in length, it will be reimbursed for three years of training, and residents will only be eligible for ABEM certification. If your program is four years in length with an osteopathic emphasis, the program will be reimbursed for four years of training and residents will be eligible for AOBEM and ABEM certification. If your program is a four-year program, without osteopathic emphasis, reimbursement is for 3.5 years and the resident is eligible for AOBEM and ABEM certification. Osteopathic Emphasis Statement: In June, AOA developed a statement

for Osteopathic Emphasis in emergency medicine, that can be used when applying for a four-year program. “Trainees must learn to incorporate an osteopathic structural examination and osteopathic manipulative treatment into the care of the emergency department patient, when appropriate. This requires first developing an understanding of the initial assessment of the patient (triage), followed by routine emergency care, taking into consideration the osteopathic philosophy as well as the osteopathic approach to structure and function. Osteopathic skills are skills that are built upon each other, similar to milestone achievements, a trainee must have achieved a certain level of competence to be able to safely, reliably, and exponentially incorporate the osteopathic techniques.”

Application Assistance: In July, AOA set up a hotline for assistance in applying for the osteopathic emphasis application, which many applicants have found onerous at best. We were informed that Franklin Medio, Ph.D., is one of the consultants. Dr. Medio was a speaker at last year’s Program Directors/CORD Meeting in Nashville. He will be available to answer questions and this service is not meant to do the application, just provide assistance. Membership: At the July AOA Board of Trustees, ACOEP’s request to admit MDs into its membership was approved. A new copy of the Bylaws is now up on the website at http://acoep.org/main/ about-acoep/policies-bylaws-minutes.

Trainees must learn to incorporate an osteopathic structural examination and osteopathic manipulative treatment into the care of the emergency department patient, when appropriate.

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Confronting Fear with Action ACOEP brings an Active Shooter Scenario Training Course to the 2016 Scientific Assembly Erin Sernoffsky

ass shooting events are a terrifying reality in our culture. From Sandy Hook, to San Bernadino, to Orlando, the American public seems to be perpetually waiting for news to break of the next tragedy. According to an FBI study, an average of 16.4 active shooter events happened annually from 2007-2013, a marked increase from a previous study which found 6.4 incidents annually from 2000-2006. In another comprehensive study by the FBI, from 2014-2015 there were 40 active shooter incidents in 26 states. 92 civilians were killed in these events, and 139 were wounded. The same study states that, “in six incidents, citizens successfully acted to end the shooting.” The study goes on to detail the locations of these harrowing events. Fifteen took place in areas of commerce— pedestrian streets, malls, and other stores. Six tragically occurred in schools. Two active shooter events took place in healthcare facilities. Emergency physicians are prepared to care for the victims in such an event, but what happens when the violence forces its way into the emergency department? When metal detectors and security guards aren’t sufficient to contain a threat? What will you do if you,

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your patients, and your colleagues find yourselves in the crosshairs? Are you prepared? ACOEP is working to improve readiness in emergency departments across the country, beginning with an intensive Active Shooter Preparedness

Track at the 2016 Scientific Assembly. This track is a CME-eligible course unlike any that ACOEP has offered before. A combination of didactic lectures and hands-on training make this course a lifesaving tool in creating safe emergency departments, and it empowers the entire medical team to rise above a culture of fear.

ACOEP’s EMS Committee has been spearheading this project, working diligently to design a track that addresses a wide range of concerns in the case of an active shooter. Along with their team of experts, Stephanie Davis, DO, and Sasha Rihter, DO, have created a customized experience that ranges from violence prevention, to tactical medicine, to institutional responses, legal implications, and real-world scenarios, culminating in practicing techniques that can be used in hallways, open rooms, and rescue and extraction situations. “Attendees can expect to learn a variety of different things from this course ranging from example strategies and plans, to handson training exercises,” said Dr. Davis, who also serves as the Co-Chair of ACOEP’s EMS Committee. “Health care facilities (HCF) are affected in more than one way in an active shooter incident, whether it be a threat at the HCF which requires training of staff to respond, or a local incident and responding to the care of the injured; and supporting the critical actions of THREAT: threat suppression, hemorrhage control, rapid extrication, assessment by medical providers and transport to definitive care. A preplanned, integrated response is required

A pre-planned, integrated response is required in order to maximize effectiveness and improve the survivability of those injured in such attacks, but also those who find themselves at the heart of the incident. in order to maximize effectiveness and improve the survivability of those injured in such attacks, but also those who find themselves at the heart of the incident.”

review of specific cases. A psychologist will also present in regards to resilience training, burnout avoidance, coping strategies and de-briefing planning.

The day begins with an overview of preattack behavior and violence protections, where attendees learn to recognize the potential for workplace violence indicators and find ways to take action to prevent the potential for violence. The next step is a review of tactics including deciding when and how to run, hide or fight, followed by an exploration of tactical medicine. Attendees will also explore the legal implications of events like these, including patient abandonment, and a

However, not everything can be learned from a lecture. Hands-on training and drills teach practical techniques for barricading to keep medical staff and patients safe. Every ED is different and the skills and techniques needed vary from hospital to hospital. These drills will also cover specific goals and objectives targeted to protect different settings— large suburban, small community centers, rural departments, and more.

At the end of the course, attendees will walk away with the tools to create an action plan to implement at their own hospital. “I believe there’s a growing concern that shootings at vulnerable sites are getting more frequent,” says Dr. Rihter. “EDs are often the front doors to hospitals and that makes EM professionals the first line of defense. However you choose to act, I think it’s important to know some strategies and practice handling such scenarios.” If current trends persist, active shooter situations will continue to grow in the coming years. The best way to combat fear is with preparation. ACOEP’s Active Shooter Preparedness Track gives emergency physicians the information and practice they need, empowering them to stay safe, protect patients, and minimize the horrifying damage done by active shooters.

ITEM WRITERS WANTED! As the RISE Committee transitions into the Committee on Board Prep in Emergency Medicine (BPEM) ACOEP is recruiting members who can serve as item writers for the new practice exam.

Writers Commit to: • Attending a one-time training session (online) • Writing ten exam questions and answer explanations on an assigned topic for both the spring and fall • Review questions written by other committee members

Benefits of Being an Item Writer: • Receive ACOEP and ACGME scholarly activity • Faculty development through the workshop • Recognition as a national committee member To be considered for membership, please contact Kristen Kennedy at the ACOEP, kkennedy@acoep.org or 312-445-5708. Upon inquiry, you will be asked to include your most current CV, as well as write and submit five audition questions and answer explanations based on a preassigned topic, which the committee will then review to determine eligibility.

ACOEP’S ACTIVE SHOOTER TRACK November 1, 2016 San Francisco, CA Visit www.acoep.org/ scientific to register Space is limited and preregistration is required!

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Save the Date!

November 3, 2016, 7:00pm â&#x20AC;¢ San Francisco, California

Presented By

Friends

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ACOEP Council for Women in Emergency Medicine Christine Giesa, DO, FACOEP

here are several new and exciting updates regarding the ACOEP Council for Women in Emergency Medicine. Gabi Crowley, our new Digital Media Coordinator, launched a Facebook page for The Council, giving our members a chance to connect with one another, share perspective, and network. Be sure to find and “like” us! The Council’s annual luncheon will be on Friday November 5, 2016 from 12:30-2:30pm at the Hilton Union Square in San Francisco, featuring keynote speaker Alexis LaPietra, DO. Dr. LaPietra completed a pain management fellowship and she spearheaded the Alternatives to Opioids (ALTO) program at St. Joseph’s Regional Medical Center in Paterson, New Jersey. She has created treatment protocols using non-opioid therapies for the treatment of headaches, kidney

MISSION STATEMENT:

Inspiring. Mentoring. Leading. Shaping the future of women in emergency medicine. VISION STATEMENT:

To identify and empower women leaders in the field of emergency medicine. FIND US ON FACEBOOK! www.facebook.com/ACOEP-Council-for-Women-in-Emergency-Medicine

stones, low back pain, musculoskeletal pain, and fractures/dislocations. The first-ever recipient of the Willoughby Award will be named at this year’s Scientific Assembly. The Willoughby Award is named in honor

of Paula Willoughby DeJesus, DO. Dr. DeJesus has the distinguished honor of being the first female President of ACOEP and has truly exemplified a commitment and excellence to emergency medicine and the ACOEP.

ACOEP 2016 Board Elections! At its meeting in April, the ACOEP Board identified six physicians for the 2016 slate of candidates for the three positions available on the Board.

VOTE 2016

ACOEP active members can visit www.acoep.org/voting to read candidate bios and watch videos of the candidates introducing themselves. There is also a link to cast your vote online. Online voting will be open until October 25th. Attendees of ACOEP’s Scientific Assembly will be able to vote onsite on Thursday, November 1st until 3:00pm.

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ACOEP’s Scientific Assembly Bringing More than Ever Before!

s an emergency physician, your actions can directly impact your medical practice, community, and especially the patients who look to you in times of duress. It’s crucial to stay current with techniques and research to provide the best possible care. With this commitment to leadership, service, and quality medical care, ACOEP’s 2016 Scientific Assembly is bigger, more exciting, and immersive than ever before. Returning to San Francisco, the 2016 flagship event has more to offer than ever before, from didactic sessions lead by a world-class faculty, to advanced skills labs, and networking opportunities, you will grow as a professional and a leader. We expanded our preconference tracks to include more opportunities to delve deep into the topics that are the most important to you. This year ACOEP’s EMS committee unveils the Active Shooter Scenario Training, a hands-on course detailing strategies to keep yourself, your colleagues, and your patients safe in the tragic event of an active shooter situation. Also new this year is the Advanced EKG Course, pushing you past the basics to get the most out of this life-saving technology. We have two levels of an Emergency Ultrasound Track, giving you the skills you need to maximize a vital, bed-side tool. You can also master your skills in Airway Management, an advanced lab where you can practice the latest maneuvers and technology.

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s an emergency physician, your actions can directly A impact your medical practice, community, and especially the patients who look to you in times of duress.

All of these are before the main didactic sessions even kick off!

NEW AT ACOEP’S 2016 SCIENTIFIC ASSEMBLY! • Active Shooter Scenario Training • Advanced Airway Course • Advanced EKG Course • Tachy Track: 7 Minute Lecture Series • Complimentary Professional Head Shot Photos • Conversation Hub • Twitter Q&A with Participating Faculty • Resident and New Physicians in Practice Happy Hour

RETURNING BY POPULAR DEMAND! • Meeting of the ACOEP Council for Women in Emergency Medicine • FOEM Competitions • New Physicians in Practice Track • Specialized Student and Resident Programs • 16 Unique Lecture Tracks • Session IV of the Faculty Development Track • EMS Directors Track • Basic and Advanced Ultrasound Course

This year ACOEP’s Council for Women in Emergency Medicine meets again for a networking luncheon, featuring the pioneering Alexis LaPietra, DO. FOEM competitions, a networking happy hour for New Physicians in Practice and ACOEP’s Resident Chapter, and Session IV of the Faculty Development Track all offer opportunities to customize your experience. We’ve also expanded our breakout lecture series to include more topics, giving you the chance to customize your experience and learn more about the important issues facing your practice. We’re also proud to introduce the Tachy Track, a CME-eligible series that harnesses all of the pace of the ED and brings it to the lecture hall. 7-minute lectures presented back-to-back, all distill the information down the most important points, keeping you on your toes and informed.

Member News

Congratulations to Col. William “Bill” Bograkos, DO, MA, FACOEP, FACOFP who was recently elected as the President of the American Osteopathic Academy of Addition Medicine. Dr.Bograkos, who has long been heavily involved with ACOEP as a faculty member, and member of numerous committees, is the first emergency physician to serve in this role.

Did we mention the kickoff party at Major League Baseball’s AT&T Park? Shuttles will take attendees and their guests to and from the ballpark for a great night out and a chance to have fun with old friends and new. And of course, the 6th Annual FOEM Legacy Gala: Dinner and Awards Ceremony is the centerpiece of a busy week. Bringing all the culture and excitement of San Francisco’s own Chinatown to you, the Legacy Gala is a wonderful opportunity to honor the driven individuals who have made an incredible impact on medicine in this country. Please remember, ticket price increases on site, so buy your tickets now at www.acoep.org/scientific.

ACOEP’s Past President Gregory Christiansen, DO, M.Ed, FACOEP-D has recently been named the Dean of the College of Osteopathic Medicine at Des Moines University. Dr. Christiansenofficially moves into this role on December 1st. ACOEP’s members are always doing incredible things! Let us know what you’ve been up to and see yourself featured in our Members in the News section!

There’s so much to experience at the 2016 Scientific Assembly, we hope to see you there!

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What Would You Do? Ethics in Emergency Medicine

Bernard Heilicser, DO, MS, FACEP, FACOEP-D In this issue of The Pulse we will review the dilemma presented in the July, 2016 issue, referred to us by an Emergency Department EMS Coordinator. The question posed is whether a behavioral health patient, that has been petitioned and certified, and is being transferred from an ED to another facility, should always be restrained. Her concern was the need for such restraints if the patient is calm and cooperative. Unfortunately, our EMS Coordinator’s hospital administration has demanded restraints on all such transfers. The EMS system within which the hospital and municipal and private EMS services function has a policy that states, “restraints are to be used only when necessary in situations when the patient is potentially violent and is exhibiting behavior that is dangerous to self and others.” What Would You Do? It is certainly understandable to want to cover the hospital’s potential liability in the event something bad happens. However, what ethical rights does the patient have? One could interpret the certification of the patient as a

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declaration that the patient has lost their rights in this situation, but, should this apply to every patient? Of course, the dangerous patient needs to be restrained. We all know the problems we face in the ED with the progression of sitter, to physical, to chemical restraints (the people who make those rules have never been in a room with a pissed off 300-pound psych patient). However, the 80-year-old grandmother with dementia who is smiling and content does not need to be tied down. This may be frightening and cruel. So, I would maintain that logic should prevail. A principled ethical approach to each patient is appropriate. Scene safety is paramount, but, kindness and compassion have a place in the decision. The Pulse reader Mark Mitchell, DO, FACOEP-D, FACEP, emailed his own take on the circumstances. He writes, “The ‘mandate’ that all involuntary psychiatric patients must be transferred with physical restraints is one that I cannot advocate for. Per EMTALA, it is the responsibility of the transferring physician to ensure that the patient is transferred safely. That does not mean that every patient needs to be placed in restraints. Of course there will be those that can’t be safely transferred without restraints, but that decision should be made by the transferring physician. I bet that same hospital administrator doesn’t want us to admit every patient that presents to the ED with chest pain for fear of missing one patient with an atypical presentation. Common sense must be used.” If you have any cases that you would like to present or be reviewed in The Pulse, please email them to us ThePulse@acoep.org. Thank you.

“Tragedy ” continued from page 4 collected over 700 units of blood in an eight-hour period. The entire community was touched. Memorial services for the victims, candle light vigils, prayer services all helped to cope with the emotional toll of the events that had gripped our city. It was a turning point for the City of Orlando. Monetary funds to help the victims’ families and those affected by injury collected millions of dollars in a matter of days. In the days and weeks that have followed, the constant media attention has dwindled but the support and cohesiveness of the community has continued. In recent weeks I continue to wonder how ready is my hospital to handle a potential situation as this? Do we need to update our disaster plan? How would we handle an active shooter event at or near our hospital? How do I make a difference in the effort to educate the public on the dangers of firearms? Can I be a more vocal advocate for sensible gun control measures? As I come up with a personal plan to move forward on some of these issues, I rally in the fact that I am part of such a great community where love and support for everyone shines bright and keeps us truly #OrlandoStrong! As part of the fall Scientific Assembly in San Francisco, we will present an Active Shooter Scenario Training Course. This is a new and unique offering includes lectures and workshop activities to help prepare you for the unthinkable possibility of being involved in a situation such as this. I strongly encourage you to check it out and make it a part of your agenda!

New Physicians in Practice: Helping You Get the Most Out of Your New Career Nicky Ottens, DO, FACOEP

ongratulations to the 2016 residency graduates! You did it! Finally, your training is over and you are officially an attending! What an accomplishment! We celebrate with you! While there is relief, joy, excitement, and a small amount of bittersweet feelings of leaving the academic nest you’ve been a part of for so many years, there is also some inevitable worry and fear of what lies ahead. You may experience many questions—from debt repayment to retirement planning, contract negotiation to leadership development, asset protection to staying out of the courtroom, CME hours to “what the heck is a COLA,” board certification to becoming a fellow, and many more. The New Physicians in Practice Committee is meant to be the resource to help support you through this transition and to answer all of these questions and more. This group is specifically geared towards those who are in their final year of residency or have been out in practice five years or less. We know exactly how it feels to be in your shoes and had similar questions and concerns. You can read through some of the more common ones in our Membership Guide or on the ACOEP website. For all those social media fans, you can also find us on Facebook. The easiest way to get plugged in and earn some of those required CME hours is to attend our NPIP Lecture Track on Thursday, November 3rd in San Francisco at ACOEP’s Scientific Assembly. This track is jam packed

with non-science lectures to address those life lesson lectures of being a new attending: • Our first lecturer is the award winning speaker Christopher Colbert, DO. This kickoff lecture will address some of those transitional issues when going from resident to attending. He will highlight some of the professional responsibilities and requirements that change, laying out a timeline for your certifications and addressing the common questions we all have. • Next up will be the famous Kevin Klauer, DO who will review the high-risk topics in EM and help us to avoid the pitfalls that could cost us our brand new licenses. • Following that is William Fraser, DO who will help us sort out how to achieve the ideal work/life balance. He will give us some perspective and pearls on enjoying the life we’ve worked so hard to achieve. • Next, as the Chair of the AOBEM Board of Directors and a residency Program Director himself, Alan Janssen, DO,

knows a thing or two about working with residents. He will share his knowledge and tips to make the transition from student to teacher a bit smoother. • And finally, the CEO of Legally Mine, Daniel McNeff, will give us some necessary and impartial advice on protecting our assets. This non-CME lecture will start those important conversations about securing our financial future and tricks of the trade for securing our assets from potential litigation. Tips on taxes and investment portfolio options will also be tackled. Also, save the date for a Resident and New Physician Happy Hour complete with free drinks on Wednesday, November 2nd from 3:30-5:00pm. During this time, recruiters will be available exclusively for this special group to wander about to collect details and swag on all of the various job opportunities available to you. We know this is a stressful time of change for you, but we want to be there to help you through it every step of the way. We hope to see you in San Fran and hope you’ll join us for CME and a wellearned toast of celebration!

ou may experience many questions—from debt Y repayment to retirement planning, contract negotiation to leadership development, asset protection to staying out of the courtroom, CME hours to “what the heck is a COLA,” board certification to becoming a fellow, and many more.

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Fall Research Competitions FOEM Research Study Poster Competition

Sponsored by WEDNESDAY, NOVEMBER 2, 2016 7:30 am – 11:00 am

This annual competition takes place during the ACOEP Scientific Assembly and is open to residents and students that have completed a research project and would like to present it as a poster summarizing their findings.

FOEM Clinical Pathological Case Competition (CPC) WEDNESDAY, NOVEMBER 2, 2016 7:30 am – 3:30 pm

This exciting annual competition pits residents against faculty in diagnosing a difficult case. It takes place during the ACOEP Scientific Assembly. Residents submit the case without final diagnosis, and the faculty member is given one month to develop a diagnosis. Both residents and faculty submit PowerPoint presentations. Each program must have a resident and faculty member in order to participate.

FOEM Oral Abstract Competition WEDNESDAY, NOVEMBER 2, 2016 12:00 pm – 2:00 pm

FOEM Resident Research Paper Competition Sponsored by WEDNESDAY, NOVEMBER 2, 2016 2:00 pm – 3:30 pm

This is FOEM’s most prestigious event. Participants submit their full research papers for review by a panel of physician experts. The panel identifies the top 5 papers prior to conference, and the winning resident-authors face off to determine the top 3 winners.

The deadline to apply to the Foundation’s Fall Research Competitions is July 2016 31, 2016. Apply now at www.foem.org 21 THE PULSE | OCTOBER

“Story” continued from page 3 Well, there I was, in the midst of a busy international airport with my wife waiting for me, being asked multiple questions by a TSA agent. Should I politely say, “yes,“ I am a real doctor and move along, or should I provide this inquisitive individual with informative answers regarding my profession? My response was, “I am a real doctor. I am an osteopathic emergency medicine physician.” She gave me a look that reflected a complete lack of knowledge of osteopathic physicians. I explained I was a DO, not an MD, and practiced holistic medicine. I continued to explain that osteopathic physicians are concerned with the physical, mental, spiritual, and emotional aspects of our patients. We are not concerned with just the physical complaint our patients have but make every endeavor to determine the root cause of our patient’s problem. I must admit her next question completely shocked me. She asked, “May I have your business card and would you be my doctor?” I explained I would be more than happy to care for her if she was ever a patient in St. Luke’s University Hospital’s Emergency Room in Bethlehem, Pennsylvania. She smiled and said that would probably never happen as she did little traveling. She then asked if she could keep my card and contact me if she ever needed emergency care. She wanted to know if I could direct her to a local DO in Chicago. Wow! I was excited by this chance meeting. The osteopathic profession gained another future patient after a five-minute conversation. Will I receive a call from this TSA agent? I honestly don’t know the answer; however, I know I will not be shocked if she does contact me. She appeared very sincere to understand how a DO is different, and her attention during my explanation was riveting. Osteopathic physicians care for many

patients and interact with many people on a daily basis. We have multiple opportunities every day to share our philosophy and practice of medicine. Do we do this or do we keep osteopathic medicine a secret? We need to openly express our story and explain the tenets of the Osteopathic philosophy and practice. We need to impress upon individuals that everyone can benefit from the judicious use of manipulative therapy. We need to DO it! Well, this is my story of how one individual learned about osteopathic medicine and physicians. Was this a unique situation? You bet it was! I was completely caught off guard by this opportunity to explain who I was and what I represented while being checked by a TSA agent for possessing a potentially suspicious bag. However, that brief encounter in a most unlikely setting, may possibly change the future healthcare for that individual. I hope that TSA agent will also tell others about our interaction. We need to share our story to one person at a time. Perhaps those individuals will then spread our story to others. We, as osteopathic physicians, have the opportunity to spread the news of who we are and what we do. Will you tell our story to someone who is waiting to hear this information? Do you want them to know a secret? Osteopathic Medicine. We can evaluate their responses and answer questions on how we are different. We need to assimilate educational information into our message and then mentor others regarding our profession. The environment of healthcare is rapidly changing and like it or not, we physicians, are in the middle of it. We must create a sense of stability in the midst of what is transpiring. Physicians need to be vocal and take action to provide a proper direction the practice of medicine must travel. This in itself is but one reason attending DO Day is vitally important for the future of medicine, our voices definitely need to be heard by our lawmakers that day. If we fail to provide

a road map of where to go, rest assured the government, insurance companies, or both will dictate how to practice our specialty. We, as practicing physicians, need to remember why we do what we do. We were at one time, energized and enthusiastic students, desiring to be human sponges, to learn everything in medicine. As years progress, we understand our education is a daily learning process and we will never know everything. It is relatively easy to get caught up in governmental issues, insurance concerns, RVUs, best practice models, and reimbursement policies. All of these items have a role in our daily practice, but none of these concerns should overrule our basic premise of doing what we do…taking care of our patients with enthusiasm. I believe our patients should never be referred to as consumers or users. If those terms become common everyday usage, I honestly believe we will lose integrity within the patient-physician relationship. Well, this now brings me back to the question, “Am I still enthused about what I do in medicine?” My answer is yes! The day that answer changes, is the day I should stop caring for patients. I admit that being around students has aided in keeping my answer positive. Their enthusiasm does radiate and is contagious. I consider myself fortunate my present position in ACOEP allows me to interact with students on a continual basis. How about you? Has the practice of medicine become a hum-drum daily existence, or are you still excited about what you do? Think back to the beginning of your medical career and remember the energy you exhibited. Think about why you entered the Osteopathic profession. I hope that when you reflect upon your early career, you will remember the zest you displayed. I hope you can continue with that enthusiasm and share it with every patient who relies upon your care.

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Osteopathic Continuous Certification in Emergency Medicine: What is That? Donald Phillips, DO, FAAEM, FACEP, FACOEP-D Board Secretary – American Osteopathic Board of Emergency Medicine Medical Director Excel ER – Weatherford and Keller, TX

he following is a brief overview of the American Osteopathic Board of Emergency Medicine (AOBEM) and its processes as well as an explanation of several significant changes. History: The first certification examination in emergency medicine was given in 1980. The activities of the AOBEM increased over the years. The re-certification process was established in 1994, and all certificates issued after January 1, 1994, are time-dated, for a ten-year period. The AOBEM, as with all osteopathic specialty boards, is part of the AOA, and ultimately answers to the AOA Board of Trustees (BOT). This is unlike American Board of Medical Specialties (ABMS) member boards which operate independently.. All AOA specialty boards operate under the auspices of the Bureau of Osteopathic Specialists (BOS) which has numerous committees that ensure certification processes are as similar as possible across all boards. The BOS provides a higher level of oversight through its appeals process to ensure accountability of each board to its candidates and diplomates. The BOT may also hear appeals after an appeal is heard by the BOS. The Board of Directors for each osteopathic board is comprised of volunteer physicians who are in active specialty practice. A simplistic comparison between the

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specialty colleges and the boards are that the specialty colleges are independent corporations but provide input into the education standards through the AOA’s Bureau of Education (BOE) and until the Single GME Accreditation System is fully implemented, provide- accreditation standards and site surveys of training programs. The specialty boards report through the BOS establish specialty certification standards and ultimately certification is granted by the AOA BOT, not the individual boards.

diverse patient populations. 5. Systems Based Practice: Demonstrate awareness of and responsibility to larger context and ability to use system resources to provide optimal care (e.g., coordinating care across multiple specialties, professions, or sites). 6. Practice-Based Learning and Improvement: Able to investigate and evaluate their – care of patients, collect scientific evidence and improve their practice of medicine.

The AOBEM Certification Process The AOBEM accomplishes its mission to protect the public through the certification process in emergency medicine by measuring performance in six core competencies. 1. Patient Care: Provide care that is compassionate, appropriate, and effective treatment. 2. Medical Knowledge: Demonstrate knowledge of established and evolving diagnostics and treatments 3. Interpersonal and Communication Skills: Demonstrate skills that result in effective information gathering and communication with patients, their families, and professional associates. 4. Professionalism: Demonstrate a commitment to carrying out professional responsibilities, adhering to the AOA Code of Ethics, and sensitivity to

All examinations and OCC components are designed to measure and validate at least one of these core competencies. Initially, AOBEM certification was accomplished through a three-step process. This consisted of a written examination (Part I), an oral examination (Part II), and a site visit by a board member (Part III) who observed the candidate’s practice and graded their care of patients and charting (a process to evaluate a microcosm of all six core competencies). As the number of candidates increased it became logistically impossible to perform site visits with each candidate. As an alternative, a review of twenty patient charts was instituted. The candidate selected the charts for review. Applicants who began the certification process after September 2013 no longer must complete Part III. Candidates that began the process prior to this date must still complete all three Parts. AOA and BOS have always had rules that state that

a candidate must complete the process under the rules in place when they first applied. Osteopathic Continuous Certification (OCC) In 2003, AOBEM presented a plan to the BOS, which was approved to begin the Continuous Osteopathic Learning Assessments (COLA). Each year, the board appoints a committee to take a portion of its Table of Specificity (TOS), which is divided into eight sections, and find the most relevant new literature in these areas along with any “landmark” articles regardless of the portion of the TOS that they may fall into. The ten most significant articles are then selected, and a forty question examination developed. The committee is charged with identifying articles from easily accessed sources (Medscape, journals which diplomates likely already receive such as Annals of Emergency Medicine, and other journals which should be easy to access from local medical libraries and/or online). COLA requirements were phased in over several years. Initially, diplomates applying to recertify were required to complete only one COLA. Currently, diplomates must take eight COLAs and pass six to be eligible to sit for the recertification examination. Within the next few years, they will be required to take and pass eight. In 2008, the AOA Board of Trustees approved the recommendation of the BOS to implement an Osteopathic Continuous Certification (OCC) process. All Certifying Boards were mandated to be fully operational and compliant with all OCC components by January 2013. The certification process for Emergency Medicine has evolved dramatically since

its creation in 1980. What began as a one-time assessment to obtain a lifetime certificate has evolved into a lifelong learning assessment and continuous certification. Every certificate issued by AOBEM since 1994 is valid for ten years and expires on December 31 of the tenth year. In order to maintain the validity of the certificate for another ten years, the diplomate must participate in the OCC process. Specialized residency training and initial board certification established initial standards for performance, but do not assure maintenance of proficiency over a practice lifetime. Regulatory agencies, health maintenance organizations, and the public require reassurance and documentation of continual professional development and education by physicians. OCC is a professional response to the need for public accountability and transparency. AOBEM believes high standards for certified emergency physicians lead to better health care for emergency patients. The principles behind OCC are designed to assure that the highest standards of

The AOBEM accomplishes its mission to protect the public through the certification process in emergency medicine by measuring performance in six core competencies.

patient care are practiced and maintained; and to assure patients, physicians, and other stakeholders that physicians are being continually assessed, resulting in continually improving patient care. This is congruent with AOBEM’s mission to protect the public by ensuring the excellence of osteopathic emergency physicians. The Joint Commission strongly encourages hospitals to measure the six core competencies of their medical staff every two years as part of the credentialing process. In the future, the OCC program may help fulfill Joint Commission requirements. Some pay-for-performance models reward physicians for ongoing performance evaluation and evidence of involvement in improvement. The AOBEM OCC process offers physicians a program to keep skills and knowledge current in a rapidly changing field. It also responds to the healthcare consumers who demand evidence of a physician’s ongoing excellence in the field of emergency medicine. The AOBEM OCC process is designed to document that emergency physicians certified by AOBEM are maintaining the skills and knowledge necessary to provide quality patient care. This program gives diplomates the opportunity to demonstrate to peers, patients, and

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the general public a commitment to lifelong learning and improvement in their practice of Emergency Medicine. OCC acknowledges that diplomates have already demonstrated a commitment to excellence by becoming certified and builds upon this. OCC incorporates six core competencies, as defined by the AOA, into an evaluation process by which emergency physicians can document their ongoing commitment to excellent patient care. The Five Part Process of AOBEM OCC (see http://aobem.org/OCC_main.shtml) 1. Professional Status: Emergency physicians must hold a valid, unrestricted, and unqualified medical license in the states where they practice or in any one state if in active military practice. (Core Competency #4) 2. Continuous Osteopathic Learning Assessment (COLA): A COLA module involves reading assigned articles from the literature and then completing an online examination concerning those articles. The list of assigned articles and applications for the examination are posted on the AOBEM website. The articles cover the entire AOBEM Table of Specificity over an eight-year cycle (Core Competency #2), as well as articles covering physician communication skills, cultural competency, physician interpersonal skills, (core competency #3) and systems based practice (Core Competency #5). A new COLA module is available each year. In order to be eligible for the Cognitive Assessment (CA), a diplomate must take a minimum of 8 COLA modules within a 10-year cycle. Additionally, the diplomate must receive a passing score on at least 6 of the COLA modules. Taking and passing 6 COLA modules will not satisfy the requirement, as the physician must have attempted at least 8 COLA modules. Beginning in 2012 (those diplomates who will be taking the

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CA in 2020), diplomates must take and PASS at least 8 COLA modules. Each COLA module is considered “current” and available online for three years only. Diplomates who have not remained current on the COLA articles may take modules that are older than three years, but at a higher price; thus, it is important that physicians keep current with each of the modules. Candidates have an initial three opportunities to successfully pass a COLA module. If unsuccessful after these initial three attempts, the candidate may pay the COLA fee again. She/he then has another three opportunities to pass the module. Diplomates who fail to meet the COLA requirements for the cognitive assessment (CA), will not be permitted to take the CA. They must then re-enter the certification process and complete it in its entirety (parts 1 and 2 of the primary certification process). These diplomates would maintain their current certification until it expires; however, to become “re-certified” the physician must re-enter and complete the entire primary certification process. If their certification expires during this time, they may not use the phrase “board certified” to describe their professional status until they have completed the certification process. 3. Cognitive Assessment (CA): The entire Table of Specificity and its core content will be covered in the CA. Diplomates are required to take this examination every ten years to maintain Osteopathic Continuous Certification. The examination consists of a computer based multiple choice examination (core competencies # 1 and #2). It should be noted that diplomates may take the CA as early as three years prior to the expiration of their certificate and up to three years after their certification expires. If the certification has expired, they may not describe themselves as “board

certified” until they have completed the process successfully. Failure to successfully complete the CA will require the physician to re-enter the certification process in its entirety (Part I and Part II). 4. Practice Performance: Beginning in 2013, diplomates will need to perform a practice assessment as a part of the Osteopathic Continuous Certification. It will be performed twice in a tenyear recertification cycle as noted in the practice performance document. This component of OCC consists of a process whereby the clinician assesses the quality of his/her care provided by comparing it to that of peers and national benchmarks. This process promotes improved care through application of “best evidence” and consensus recommendations. The completed Practice Performance Form must be submitted to AOBEM once in years 1 - 5 and once in years 6 10 of the diplomat’s certification cycle. No charts - need to be submitted. The process consists of four steps as outlined below: Step 1: To initiate the process, identify a target area for clinical improvement. The target area may be a disease entity, a clinical care issue, or an access-tocare issue (e.g., through-put or leftbefore-treatment). The target area requires a population or clinical issue that is measurable for improvement and has recognized comparison data available. The clinician will need to choose appropriate data points as measures of quality. (Diplomates are advised to review pre-approved projects that are listed on the attestation form at http://aobem.org/ practiceperformance.shtml) Step 2: Collect and review data points from 10 patient charts from the targeted area of study. The clinician may choose patient charts from his/ her practice group, but a minimum of three charts must be his/her own patient encounters.

Step 3: The data points from the ten charts are then compared to evidence- based guidelines or expert consensus statements or comparable peer data. Interpretation and analysis of the data points can then be used to identify areas for improvement. Step 4: Next, develop and implement a practice performance improvement program. This plan may include an educational piece, personal reminders, or a change in process (e.g., adding the NEXUS criteria for cervical spine imaging to the electronic medical record, in order to avoid unnecessary radiation in trauma patients). Step 5: After implementation of the process improvement plan, review at least ten new charts of the targeted area of improvement. Again, at least three must be the clinician’s charts. Measure and analyze the data, and then evaluate for improvement.

Those physicians not involved in clinical practice must complete the “AOBEM Recertification Non-Clinical Form.” These physicians are still required to complete the Practice Performance Module, and their status will be reported to the AOA as “AOBEM Certified: Non-Clinical”. Additionally, there is a patient communication and satisfaction component which must be completed once during each tenyear recertification cycle. Emergency physicians are increasingly judged by their ability to communicate with patients, and assessment of communication skills has become a major tool as a measure of overall excellence. Diplomates may make use of any satisfaction surveys or methods their departments or hospitals currently employ, so long as the required AOBEM parameters are included and measured. AOBEM can supply a version of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Clinician

and Group Survey Reporting Kit (version 2008) to those diplomates not currently participating in an eligible satisfaction survey program. There is an online attestation form at http://aobem.org/patient_overview. shtml (Both of these measure core competency #6) 5. Continuous AOA Membership: Diplomates must also maintain continuous membership in good standing in the American Osteopathic Association. AOA membership insures that a physician meets the AOA’s Continuing Medical Education (CME) requirements for certification and adheres to the AOA Code of Ethics. (Core Competency #4) AOBEM diplomates are required to obtain 150 hrs of CME (50 of which must be in the specialty of emergency medicine) every three years. (core competencies #2 and 6) This is tracked by the AOA CME division on a rotating three-year basis. Beginning in 2016, diplomates are no longer required to complete an oral examination for recertification. Since the core competencies this component measured are now being measured by the other components of OCC, it was felt to be duplicative and onerous. AOBEM also realizes that component 4 can be measured with data that is already being collected at a physician’s practice, AOBEM offered to allow that data. Considering that emergency medicine is a system of practice and in most cases changes to address problems affect the entire group, pooled data for these components is allowed as long as at least 30% of the patient charts reviewed belong to the diplomate. This is also in recognition that physicians who work in low volume EDs (critical access hospitals, etc.) may have difficulty collecting data if forced to evaluate their own charts only. This also allows diplomates to perform this component without a cost in most cases.

Conclusion: Th e Am e ri ca n Osteopathic Board of Emergency Medicine, the AOA Bureau of Osteopathic Specialists, and the AOA Board of Trustees have attempted to construct well thought out processes in planning OCC activities for diplomates that answer the calls of the public, third party payers, oversight agencies, and most importantly, patients. Every effort has been made to make the requirements easy to achieve, provide value to an individual physician’s needs and practice, and are cost effective. The BOT and the BOS have repeatedly emphasized that these requirements should be adaptable to change in order to meet the changes in practice over time. The AOBEM is open to suggestions for improvement. Some examples of these changes include: dropping the part III (chart reviews) from the initial certification phase, eliminating the oral examination from the recertification, and allowing pooled data for the practice performance assessment. It is only through participation by volunteer physicians, in our processes and utilizing a model of practicing physicians certifying practicing physicians that we feel we are able to meet the needs of our diplomates and achieve our ultimate goal of “protecting the public through the certification of excellence in emergency medicine.” Please feel free to contact us with any questions. Written communication is preferred. American Osteopathic Board Emergency Medicine - AOBEM

c/o Jennifer Hausman, MPA Certification Director 142 E. Ontario, Chicago, IL 60611 Phone: (312) 202-8293 Fax: (312) 202-8402 Email: AOBEM@osteopathic.org Donald Phillips, DO, FACOEP-Dist , FAAEM, FACEP Executive Physician Director - AOBEM phillipsdo@yahoo.com

THE PULSE | OCTOBER 2016

OUR PHYSICIANS LOVE WORKING IN TEXARKANA! CHRISTUS St. Michael Health System • 60,000 annual ED volume • Award-winning hospital in a beautiful setting with excellent specialty backup • Challenging mix of trauma, critical care, pediatrics, and general medicine • Scribes and NP/PA support • Physician-owned group offering great benefits • Tort reform and no state income tax!

FOEM BEACON | JULY 2016

(512) 610-0315 lisa@eddocs.com

Unintended ” continued from page 6 that physicians use escalating dosages of opioids, similar to the end of life guidelines, in an attempt to provide pain relief. There also was a general trend of prescribing opioids more liberally for the treatment of acute pain. As a result, opioid prescriptions skyrocketed and the sales of opioid analgesics quadrupled between 1999 and 2010. 1 Unintended consequences of efforts to better address patient pain include an increase in prescription opioid drug abuse and a significant rise in unintentional drug overdoses and deaths since the late 1990s. Reported overdose deaths involving opioid analgesics increased from 4,030 in 1999 to 14,800 in 2008. Currently, deaths from opioid analgesics are significantly greater than those from cocaine and heroin combined.1 Despite our best efforts to treat pain, the most recent report of the Institute of Medicine (IOM), Relieving Pain in America, declared that healthcare providers have not done as well as possible in the area of pain management. Sadly, there are still many patients whose pain is poorly controlled, and there is now an epidemic of opioid abuse and overdoses from the liberal use of opioids. The Single Accreditation System (SAS) In July 2015, the American Osteopathic Association (AOA) and the Accreditation Council for Graduate Medical Education (ACGME) began the transition to a single accreditation system (SAS) for graduate medical education. From the onset of this endeavor, it was anticipated that once osteopathic programs were accredited by the ACGME, they would continue to provide osteopathic education and would seek osteopathic recognition. It was also anticipated that the graduates from osteopathic-focused programs would continue to pursue osteopathic board certification.

a single accreditation system, AOA board certification will continue to be available to DOs trained through either AOA- or ACGME-accredited residency programs. In addition, the market for AOA certification will expand to include MDs interested in osteopathic training opportunities through ACGME.” - AOA President Boyd Buser, DO (July 25, 2016, The DO)

The SAS poses a unique conundrum for emergency medicine. The osteopathic emergency medicine residencies are four years, whereas the majority of the ACGME residences are only three years. The AOBEM currently requires four years of postgraduate training prior to taking the osteopathic board certification exam. If our residencies adopt the ACGME model of three years of training or once they are accredited by ACGME do not seek osteopathic recognition, then osteopathic residents in those programs will not have the opportunity to take the osteopathic boards.

Not all unintended consequences are negative. The SAS will allow graduates of the colleges of osteopathic medicine to seek and complete their residency and fellowship training in ACGMEaccredited programs. The SAS could potentially have a positive impact on some of the ACGME training programs. There are a small number of the ACGME emergency medicine residencies that are four-year programs, and CMS only reimburses the hospital for 3.5 years of their training. If these fouryear ACGME residencies were to seek and achieve osteopathic recognition, then they could be reimbursed for all four years of training. This also would allow their residents to have the choice to take the AOBEM board certification exam. Also with the SAS, ACGME programs have been invited to learn about osteopathic medicine and to seek osteopathic training opportunities, thereby spreading the philosophy and practice of osteopathic medicine.

Citation An unanticipated consequence of the SAS is that many institutions are forcing our residency programs to accept the three-year ACGME training model. According to the current AOBEM board certification requirements, residents from the three-year training programs would not be eligible to take the osteopathic board certification exam and would instead be forced to take the ABMS exam. This unintended consequence could also have a domino effect. Not only would we lose a large number of physicians who would not be permitted to take the osteopathic boards, but the osteopathic programs that were forced to adopt the three-year ACGME training model, may not see a value in maintaining their osteopathic identity and choose not to pursue osteopathic recognition. We could potentially lose an entire generation of young osteopathic emergency physicians.

1. American College of Emergency Physicians. Clinical

policy:

Critical

issues

the

prescribing of opioids for adult patients in the emergency department. Ann Emerg Med. 2012;60:499.525.

“During and after the transition to

THE PULSE | OCTOBER 2016

Literature Update Fall 2016 Amanda Ellis DO and John Ashurst DO, MSc Duke Lifepoint Conemaugh Memorial Medical Center

Title: Sex-related differences in emergency department renal colic management: Females have fewer CT scans but similar outcomes Article: Innes GD, Scheuermeyer F, Law M, et al. Sex-Related Differences in emergency department renal colic management: females have fewer CT scans but similar outcomes. Academic Emergency Medicine. 2016 June 30; Epub ahead of print. What we know: Research studies have noted a gender difference between numerous facets of medicine. Article Review: This study was a retrospective multi-center cohort study that used administrative data and chart reviews to determine the type of imaging modality those with renal colic undergo. Over a one-year period a total of 1111 females and 1993 males were included in the study. Males were more likely to have a CT (68.9% vs 58.5%; 95% CI 6.8, 14) and females were more likely to have an ultrasound (20.8% vs 9.6%; 95% CI, 8.4, 13.9). Males, however, were more likely to be hospitalized at day 7 as compared to females (3.3% difference) Commentary: Although there are many studies demonstrating gender differences in medical management, this study shows a gender difference in the diagnostic modality for the work up of renal colic. A broad take home point from this study is that the US is underutilized for the diagnosis of renal colic indeterminate of gender.

THE PULSE | OCTOBER 2016

Title: Amiodarone or lidocaine or placebo for cardiac arrest Article: Sanfilippo F, Corredor C, Santonocito C, et al. Amiodarone or lidocaine for cardiac arrest: A systematic review and meta-analysis. Resuscitation. 2016; 107: 31 â&#x20AC;&#x201C; 37. What we know: Previous studies have shown that amiodarone, lidocaine, and placebo have been equivalent for outof-hospital survival rates for cardiac arrest. However, these studies have been underpowered and further data was needed. Article review: A meta-analysis including randomized clinical trials using amiodraone vs lidocaine vs placebo were analyzed based on the primary outcome of survival at hospital admission and discharge in out-of-hospital cardiac arrest patients. A secondary analysis was completed on non-RCT as well. No difference was found for survival at hospital admission (p=0.40) or discharge (p=0.56) for amiodarone or lidocaine. Survival at hospital admission was higher both for amiodarone (p<0.0001) and lidocaine (secondary analysis, p=0.0005) as compared with placebo. However, there was no statistical difference between amiodarone, lidocaine or placebo with respect to hospital discharge. Commentary: Survival to hospital admission shows improvement if amiodarone or lidocaine is used in outof-hospital cardiac arrest. However, no difference is noted in long term survival when you compare amiodarone, lidocaine or placebo.

Title: Prescription Drug Monitoring Programs and the impact on physician prescribing practices. Article: Prescription Bao Y, Pan Y, Taylor A et al. Drug Monitoring Programs Are Associated with Sustained Reductions in Opioid Prescribing By Physicians. Health Affairs. 2016; 35(6):1045-1051. What We Know: Prescription pain relievers were responsible for almost 19,000 deaths in 2014 and have been labeled as one of the newest epidemics that we face in medicine. Article Review: This study reviewed practice patterns of prescribing schedule II or higher analgesics from a national survey of physician practices over a 10-year period. Over this time period, the implementation of state prescription drug monitoring programs was launched. In the first year, there was more than a 30% reduction in the prescription rate of schedule II narcotic analgesics. This same reduction was maintained over the next two years of the monitoring program. Commentary: Due to the potential abuse liability, having a monitoring system that can aide prescribers in providing the appropriate analgesic medication for a patient with concerns for misuse is invaluable. The study showed that with the implementation of a state-run drug monitoring program, prescribers were less likely to prescribe schedule II narcotics.

Title: Immediate total-body CT scanning versus conventional imaging and selective CT scanning in patients with severe trauma (REACT-2): a randomized controlled trial. Article: Sierink J, Treskes K, Edwards MJ, et al. Immediate total-body CT scanning versus conventional imaging and selective CT scanning in patients with severe trauma (REACT-2): a randomized controlled trial. Lancet. 2016; 388(10045): 673 â&#x20AC;&#x201C; 683. What we know: Current literature

suggests that total body computer tomography offers a survival benefit for trauma patients. Article Review: This multicenter randomized controlled trial aimed to assess the effect of total-body CT scanning compared with selective CT imaging on in-hospital mortality in patients with trauma. Over a four-year period, there was no difference found for in-hospital mortality between the groups (p=0.92). Upon subgroup analysis, no difference was found for in-hospital mortality in those with poly-trauma or traumatic brain

injuries (p=0.46 and p=0.31). Commentary: It is customary in patients who present to the ED with significant traumatic injuries to undergo wholebody CT imaging. This study suggests that selective radiographic imaging may be just as effective in the treatment of the trauma patient. Further studies to determine secondary outcomes such as morbidity should be undertaken before widespread implementation.

THE PULSE | OCTOBER 2016

Assistant/Associate Residency Program Director

The Emergency Medicine Department at Penn State Milton S. Hershey Medical Center seeks energetic, highly motivated and talented physicians to join our Penn State Hershey family. Opportunities exist in both teaching and community hospital sites. This is an excellent opportunity from both an academic and a clinical perspective.

Emergency Medicine Core Faculty

As one of Pennsylvania’s busiest Emergency Departments with 26+ physicians treating over 70,000 patients annually, Penn State Hershey is a Magnet® healthcare organization and the only Level 1 Adult and Level 1 Pediatric Trauma Center in PA with state-of-the-art resuscitation/trauma bays, incorporated Pediatric Emergency Department and Observation Unit, along with our Life Lion Flight Critical Care and Ground EMS Division.

Pediatric Emergency Medicine Faculty

For additional information, please contact: Susan B. Promes, Professor and Chair, Department of Emergency Medicine, c/o Heather Peffley, Physician Recruiter, Penn State Hershey Medical Center, Mail Code A590, P.O. Box 850, 90 Hope Drive, Hershey PA 17033-0850, Email: hpeffley@hmc.psu.edu

We offer salaries commensurate with qualifications, relocation assistance, physician incentive program and a CME allowance. Our comprehensive benefit package includes health insurance, education assistance, retirement options, on-campus fitness center, day care, credit union and so much more! For your health, Hershey Medical Center is a smoke-free campus. Applicants must have graduated from an accredited Emergency Medicine Residency Program and be board eligible or board certified by ABEM or AOBEM. We seek candidates with strong interpersonal skills and the ability to work collaboratively within diverse academic and clinical environments.

The Penn State Milton S. Hershey Medical Center is committed to affirmative action, equal opportunity and the diversity of its workforce. Equal Opportunity Employer – Minorities/Women/Protected Veterans/Disabled.

THE PULSE | OCTOBER 2016

Mark yourfor calendar

ACOEP’s Upcoming Spring Seminar!

April 18-22, 2017 NEW LOCATION!

HIGHLIGHTS INCLUDE:

Bonita Springs, FL

• COLA Review

Ft. Myers Coast

• A mix of CME activity and time to relax on your own • FOEM 5K & 1 Mile DO Dash

OVER 30 HOURS OF CME CREDIT

• Expanded breakout lectures • New tracks and events

Visit www.acoep.org for more details!

THE PULSE | OCTOBER 2016

TAB COPY GOES HERE

ON SALE NOW!

November 1 - 5, 2016 Hilton Union Square, San Francisco, CA

ACOEP’s flagship conference brings you more than ever before. Highlights include: • Advanced Airway Course • Active Shooter Training • Advanced EKG Course • FOEM Legacy Gala: Dinner & Awards Ceremony

• Specialized Tracks in Critical Care, Pain Management, and Wellness • Meeting of ACOEP’s Council for Women in Emergency Medicine • 1-on-1 Access to Expert Speakers

Visit www.acoep.org/scientific to register and for more information. Paramount Sponsor

Prime Sponsor

Supporting Sponsor

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THE PULSE | OCTOBER 2016

ACOEP INFORMATION

ACOEP Staff Listing Here is the complete staff listing of the American College of Osteopathic Emergency Physicians who work hard to bring you cutting edge educational events like ACOEPâ&#x20AC;&#x2122;s Scientific Assembly.

EXECUTIVE

EDUCATION

Executive Director Janice Wachtler, BAE, CBA Direct Line: (312) 445-5705 Email: janwachtler@acoep.org

Director of Education Services Kristen Kennedy, M.Ed. Direct Line: (312) 445-5708 Email: kkennedy@acoep.org

Director of Affiliate Management Stephanie Whitmer, MNA Direct Line: (312) 445-5712 Email: swhitmer@acoep.org

Educational Specialist Kefah Spreitzer Direct Line: (312)445.5702 Email: KSpreitzer@acoep.org

Executive Assistant Geri Phifer Direct Line: (312) 445-5700 Email: gphifer@acoep.org

EVENTS Director of Events & Strategic Initiatives Adam Levy Direct Line: (312) 445-5710 Email: alevy@acoep.org

Manager, Meetings & Events Lorelei N. Crabb Direct Line: (312) 445-5707 Email: lcrabb@acoep.org

142 E. Ontario Street, Suite 1500 Chicago, Illinois 60611 Phone: 312.587.3709 | Fax: 312.587.9951 | www.acoep.org

MEMBER SERVICES Director of Membership Sonya Stephens Direct Line: (312) 445-5704 Email: sstephens@acoep.org

Senior Coordinator, Data Management Gina Schmidt Direct Line: (312) 445-5701 Email: gschmidt@acoep.org

MEDIA SERVICES Director, Communications Erin Sernoffsky Direct Line: (312) 445-5709 Email: esernoffsky@acoep.org

Digital Media Coordinator Gabi Crowley Direct Line: (312) 445-5715 Email: gcrowley@acoep.org

THE PULSE | OCTOBER 2016

Presorted Standard U.S. Postage

PAID

Chicago, IL Permit No. 2177

142 E. Ontario Street Suite 1500 Chicago, Illinois 60611

Ownership matters.

Never back down when it comes to ownership. At US Acute Care Solutions, we whole-heartedly believe that physician ownership empowers us to deliver the best patient care and the best solutions for our hospital partners. Every USACS physician becomes an owner in our group, no buy-in. To secure a future where patient care is always first, weâ&#x20AC;&#x2122;ve aligned with partners who share our vision and passion, becoming one of the largest, fastest growing, physician-owned and led groups in the country. Secure your future and the future of patient care. Ownership matters, join USACS.

Own your future now. Visit usacs.com or call Darrin Grella at 800-828-0898. dgrella@usacs.com

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