The Pulse- Fall 2017 by ACOEP

OCTOBER 2017

THE

COLLABORATION ISSUE

PRESIDENTIAL VIEWPOINTS

OUR JOURNEY CONTINUES FORWARD PG 3

HOW INTERPROFESSIONAL TRAINING IS CHANGING HEALTHCARE PG 7

INTRAPROFESSIONAL ALLIANCES—WHO’S GOT YOUR BACK? PG 11

ARE YOU READY TO TAKE THE LEAP? We’re here to propel you forward.

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The Pulse VOLUME XXXVIII 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 Gabi Crowley, Digital Media Coordinator EDITORIAL COMMITTEE Timothy Cheslock, DO, FACOEP, Chair Drew A. Koch, DO, MBA, FACOEP-D, Board Liaison John C. Prestosh, DO, FACOEP-D Stephen Vetrano, DO, FACOEP Kaitlin Bowers, DO Tanner Gronowski, DO Dominic Williams, OMS-IV Erin Sernoffsky, Director, Media Services

go.cep.com/ChooseJoy 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.

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TABLE OF CONTENTS 3

PRESIDENTIAL VIEWPOINTS John C. Prestosh, DO, FACOEP-D

THE EDITOR'S DESK Timothy Cheslock, DO, FACOEP

ON DECK CIRCLE Christine Giesa, DO, FACOEP-D

HOW INTERPROFESSIONAL TRAINING IS CHANGING HEALTHCARE Samuel Wood, OMS III

INTRAPROFESSIONAL ALLIANCES - WHO’S GOT YOUR BACK? Elda G. Ramirez, PhD, RN, FNP-BC, ENP-C, FAANP, FAEN

BUILDING BRIDGES BETWEEN ACOEP AND AAENP John Prestosh DO, FACOEP-D Theresa M Campo, DNP, FNP-C, ENP-BC, FAANP

DELIBERATE EPIDEMICS William Bograkos, MA, DO, FACOEP, FACOFP, President AOAAM

EMS: PART OF THE ED TEAM Rose Anna Roantree, DO, FACOEP

WHAT YOU ALWAYS WANTED TO KNOW ABOUT EMPAS Michelle Parker, Executive Director, Society of Emergency Medicine Physician Assistants (SEMPA)

ACOEP’S 2017 SCIENTIFIC ASSEMBLY Erin Sernoffsky, Director, Media Services

ROUNDING THE FIRST CURVE ON THE RACE TO EMS 3.0 Matt Zavadasky, President-Elect of National Association of Emergency Medical Technicians

ACOEP MEMBER SPOTLIGHT: REGINA HAMMOCK, DO Gabi Crowley, ACOEP Digital Media Coordinator

ADDICTION: NOT ABOUT KNOWING BETTER Stephen Kavalkovich

DO YOU KNOW FOEM? Stephanie Whitmer, MNA, FOEM Executive Director

ACOEP’S COUNCIL FOR WOMEN IN EMERGENCY MEDICINE EXPANDS AT SCIENTIFIC ASSEMBLY Nicky Ottens, DO, FACOEP, ACOEP Board of Trustees, Women’s Council Chair

THE LOVE AFFAIR Marina Shpilko, DO

s I write my final article for the Presidential Viewpoint, I want to take this opportunity to thank the American College of Osteopathic Emergency Physicians Board of Directors, committee chairs, office staff, and the membership for their never-ending support and help over the past two years. It has been an honor and a privilege to serve as your President and be the representative face of our College. I have enjoyed traveling on behalf of ACOEP to voice our thoughts and opinions on various issues with colleagues of the House of Emergency Medicine. ACOEP has gained equal standing and respect throughout the world of emergency medicine. I look forward to our continued efforts in constructing beneficial policies regarding the delivery of quality healthcare to our patients. In previous articles, I have written about the proud heritage of ACOEP and the importance of emergency medicine physicians getting involved and expressing their concerns regarding patient care.

PRESIDENTIAL VIEWPOINTS

THE EDITOR’S DESK

John C. Prestosh, DO, FACOEP-D

Timothy Cheslock, DO, FACOEP

OUR JOURNEY CONTINUES FORWARD

MEDICAL STAFF OPPORTUNITIES ABOUND

As I have traveled throughout the United States, it has become evident that more physicians want to have an active impact when patient care issues are raised. As individual physicians unite to add their voices to their respective organizations, the House of Emergency Medicine continues to grow stronger and be a leader in healthcare delivery. ACOEP has fostered closer relationships with the American College of Emergency Physicians (ACEP), the International Federation for Emergency Medicine (IFEM), the Society for Academic Emergency Medicine (SAEM), the Association of Academic Chairs in Emergency Medicine (AACEM), the Emergency Department Practice Management Association (EDPMA), the American Academy of Emergency Nurse Practitioners (AAENP), and other organizations related to emergency healthcare. I believe these relationships are vital going forward for ACOEP to maintain visibility, sustainability, and relevance. These organizations represent hundreds of thousands of members and patients. We all continue to speak with one voice to ensure appropriate healthcare policies are enacted. The Single Accreditation System (SAS) is in full-stride and the majority of our emergency medicine programs have made their decisions regarding this venture. The Center for Medicare and Medicaid Services (CMS) has notified the American

STILL AROUND THE CORNER THERE MAY WAIT, A NEW ROAD, OR A SECRET GATE.” J.R.R. TOLKIEN Osteopathic Association that four year AOA accredited programs will continue to receive 100% funding for the entire training period. However, that message has apparently not been received with open arms by all institutions hosting our training programs. There is a significant number of AOA programs that have opted (or possibly have been forced) to change their emergency medicine residency to a three-year model. This is problematic for the Osteopathic profession as graduates from three year programs will not be eligible to receive certification through the American Osteopathic Board of Emergency Medicine (AOBEM). This matter has not gone unnoticed by the AOA. Conversations among the AOA, ACOEP, and AOBEM are ongoing as to what can possibly be done to alleviate losing many graduating residents from being AOBEM certified. Our College has been active to adapt its identity to remain relevant in these changing times in the medical profession. I have previously CONTINUED ON PAGE 7

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n this issue of The Pulse we will focus on building strong partnerships within healthcare networks. These opportunities are multi-leveled, occurring locally and nationally as you will read throughout this edition. One area I would like to share with our readership is the value of contributing to partnerships with your own medical staff at your institution. While this may be seen as a foregone conclusion for many, I believe that there is value in highlighting the importance of not only participating in medical staff endeavors, but also taking a leading role in creating an environment where your contributions add value and strength to the organization in which you practice every day. Many opportunities exist in your primary facilities to become involved. These include ED representation on committees that deal with common complaint driven diagnosis to include sepsis, STEMI, trauma, or any of a variety of issues within the hospital that are benchmarked or metric driven priorities for the hospital. Most of these endeavors are tracked from the time the patient presents to the emergency department. ED physician buy-in and participation is crucial to their success. The contributions to such committees cannot be understated. The majority of order sets and initial treatment are driven by us. It is preferable to be a part of the decision making process than to have it thrust upon without the opportunity for feedback. This may be a selfish reason to get involved, but you will be much happier with a process that you

helped develop and guide. In addition to gaining exposure to various processes throughout the hospital, your participation in committees and other forums will elevate your visibility within the hospital and your status as a proponent of change. These are all highly sought-after qualities for anyone seeking to grow their role within the ED or hospital leadership. For many, committee work is a precursor to being asked to participate in roles of greater responsibility within the hospital. This may include medical staff leadership, serving on a board for the hospital foundation, or a variety of other opportunities within the organization and/or community. If this all sounds like a lot of work, it can be. Do not be discouraged; opportunities like this do not come without reward. In addition

IT IS PREFERABLE TO BE A PART OF THE DECISION MAKING PROCESS THAN TO HAVE IT THRUST UPON WITHOUT THE OPPORTUNITY FOR FEEDBACK.”

to recognition by your colleagues, director, and hospital leadership, there is also opportunity for additional skills development and training for yourself. Many healthcare institutions have recognized the need to develop their physicians and medical staff’s leadership skills. Leadership training courses, fellowships in healthcare management and numerous other seminars sponsored by healthcare institutions and many of the large staffing groups are becoming more commonplace. The only price for admission to many of these is taking the initiative to become involved and expressing desire to be part of the process. The true value to the provider is often not obvious. If you were to seek out these types of courses on your own they may cost tens of thousands of dollars. The skills which you walk away with provide a wealth of new knowledge. Opportunities to network with colleagues and many other leaders, both within the healthcare industry and other outside organizations, are incredibly valuable. If you desire to someday advance your career in healthcare management, whether as a practicing EM provider or making the jump into the administrative spectrum of healthcare, these opportunities can pave the way to success. I would encourage all of you to seek opportunities where you can make a difference within your workplace and accept the challenge of getting involved!

OCTOBER 2017 THE PULSE

THE ON-DECK CIRCLE

Christine Giesa, DO, FACOEP-D

ometimes missing a deadline can be beneficial. My delay in writing for this issue was rewarded with a new topic that recently hit the news and social media: Iceland’s announcement that they are “on pace to eliminate Down Syndrome.” This made me reflect on a recent patient. He is an older gentleman, a widower, whose adult son still lives at home. I have seen these two gentlemen before. The son works in the family hardware store, and the two of them spend their days and evenings together. After dinner, it is their habit to enjoy one or two Manhattans while watching their favorite TV shows. In the ED, the son was very attentive to his father. He straightened out his blankets and readjusted the back of his bed. He asked simple, yet pertinent questions about his father’s condition. It was obvious that these two men were best of friends. Oh, did I forget to mention that the son has Down Syndrome? Since the introduction of prenatal screening tests in 2000, there has been a significant decrease in the number of babies born with Down Syndrome around the world, but few countries have come as close as Iceland to eradicating Down Syndrome births. The prenatal screening test is a combination test that utilizes ultrasound, blood tests, and the mother’s age to determine the odds of whether the fetus will have a chromosomal abnormality, the most common of which is trisomy 21 (Down Syndrome). All expectant mothers are

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offered prenatal screening tests, but it is optional to have the test performed. In Iceland, approximately 85% of women choose to have screening tests performed. If the screening test determines an increased likelihood that the fetus has Down Syndrome, the woman is counseled and is given two options: either to carry the fetus to term or to terminate the pregnancy. Nearly 100% choose to abort the pregnancy. The estimated termination rate for Down Syndrome in the U.S. is 67%; 77% in France, 90% in Great Britain, and 98% in Denmark. Iceland currently averages one to two babies born with Down Syndrome per year. These babies were determined by screening to be very low risk for chromosomal abnormalities. As you can see, the screening test is not perfect. If screenings can produce a false negative, they also produce false positives, and it raises the question whether “normal” fetuses have been unintentionally aborted. The most bothersome comment that I read came from a physician in Iceland who explained that they do not consider these abortions to be murder. Rather, they look at them as a “thing that was ended.” They contend that they ended a possible life that may have had a huge complication, and they prevented suffering for both the child and family. Icelanders are quite proud that they are “on pace to eliminate Down Syndrome,” and promote their perfect society. Why do they feel so motivated to eliminate these

“undesirable” human beings from society? I am sure that my patient would not have given up one day that his son was in his life. Families that I know with a special child with Down Syndrome feel that they have been blessed. Today, several countries are on pace to eliminate Down Syndrome. Tomorrow, the decision could be made to terminate fetuses that are genetically prone to develop unsightly obesity, psychiatric disorders, alcoholism, or cancer. Where does it end?

TOMORROW, THE DECISION COULD BE MADE TO TERMINATE FETUSES THAT ARE GENETICALLY PRONE TO DEVELOP UNSIGHTLY OBESITY, PSYCHIATRIC DISORDERS, ALCOHOLISM, OR CANCER. WHERE DOES IT END?”

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RSO

Dominic Williams Director of Student Affairs

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Kaitlin Bowers RSO President

Resid e

NEWS FROM THE RSO

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ON PACE TO ELIMINATE…

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f O st e o p a t h i c E

his year has been a time of major change for the resident and student leadership. As many of you may know, we have combined forces to form the new Resident Student Organization. By working together as one we hope to streamline our processes and have more time to provide our members with the most exciting and educational emergency medicine experiences we can offer.

This year’s RSO kickoff at Scientific Assembly in Denver promises to be an unmissable event. From airway competitions, to one-on-one time with the ACOEP keynote speaker, to career advice from the student level to that of a senior resident, this very special conference promises to provide ample opportunity to instill the confidence residents and students need to take the next step on their personal emergency medicine journey.

For those of you who haven’t checked out our new website, www.acoep-rso.org, what are you waiting for? One of the biggest improvements is the new blog format of our RSO publication, The Fast Track. This digital platform allows for more immediate connection and feedback with our readership. In the dynamic world of emergency medicine we don’t have the luxury to sit back and wait. We are excited to begin to introduce real-time interaction on articles and events addressed by our authors. We will even be tracking which articles get the most #FOAMed love to print in a new annual anthology.

With all these great new changes, we have to take the time to thank the College for being behind us every step of the way! We are so grateful for the support of the parent chapter in helping us promote this new venture. The residents and students are well aware of the interest and support that the attending physicians show in us as both individuals but also the future of the College as a whole. Your willingness to stand behind our endeavors is what allows us to face the future with certainty. We hope to see you all in Denver!

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mentioned that at our Strategic Planning Session in January 2016, the Board of Directors addressed issues concerning the future of ACOEP. We have enacted changes that will soon be evident as our new Bylaws are issued. We will be opening ACOEP membership to physicians with MD degrees. This is an enormous change for us; however, I believe a necessary and forward-thinking process. We should welcome all physicians who practice holistic medicine consistent with our Osteopathic philosophy. We also want to open membership to nurse practitioners and physician assistants. I believe that most of our DO members work closely with NPs and PAs and it makes sense to invite these professionals into our College. I know our Board of Directors

will continue to monitor the rapidly changing issues and act upon them when the need arises. In closing, I would be remiss to not single out several individuals who have been extremely significant in my journey through Emergency Medicine and the ACOEP. I want to thank Joseph Stella, D.O., my mentor and a great friend who was instrumental in my entering emergency medicine. A big thank you goes to Mark Mitchell, D.O., for his guidance and lending an ear when discussing pertinent ACOEP issues these past two years. Another thank you goes to Jan Wachtler, our Executive Director, a close friend who has been very supportive of my presidential initiatives. The last thank you goes to an individual who

is my best friend, my wife Jeri. I thank her for her continuous support not only during my presidential term but throughout my entire medical career. It has been her patience and understanding for more than 45 years that has made my journey most memorable. Thank you Jeri; I could not have done it without you! I believe the future of the American College of Osteopathic Physicians can be as bright as we wish it to be. As we continue to embrace our Osteopathic heritage and practice our philosophy of caring for our patient’s mind, body and spirit, other organizations and futures patients will seek us. I look forward, with great anticipation, to see where the ACOEP will go.

OCTOBER 2017 THE PULSE

HOW INTERPROFESSIONAL TRAINING IS CHANGING HEALTHCARE An inside look at the University of New England College of Osteopathic Medicine’s collaborative approach to education By Samuel Wood, OMS III

my was clearly dying. Each of her legs had swollen to nearly four times their normal size, a consequence of the renal failure that was ending her life. She sat slumped in her wheelchair, and her eyes surveyed the scene unfolding before her. A nurse practitioner, medical assistant, case manager, social worker, nursing student, and med student all huddled in her tiny onebedroom apartment.

As the recently appointed third-year medical student, I was focusing on the basics, like trying to not trip over anything or sweat through my undershirt. I offered to take her blood pressure, but her arms were so large, her circulation so compromised, that I could only manage a systolic estimate using a weak radial pulse. It was 90, slightly above her average. This moment represented a series of firsts: my first rotation, my first in-home visit, and my first real exposure to the power of interprofessional healthcare. As a student at the University of New England College of Osteopathic Medicine, I was participating in an Enhanced Interprofessional Education Community Health Rotation (IPE CHR), which was partially funded by a grant from the Josiah Macy Jr. Foundation, through UNE’s Center for Excellence in Health Innovation and the Care for the Underserved Pathway. My mission was to take the knowledge and training we received during the didactic portion of our schooling, and apply it to the clinical world, with a particular emphasis on how different health providers work together to provide comprehensive care. My assigned location, Nasson Health Care, is a federally qualified health center in Maine that focuses on the underserved and uninsured. This facility houses a medical team, behavioral health, social work, dentistry, public health, and more. Further, they provide Medically Assisted Treatment for current and recovering

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addicts, particularly those struggling with opioid abuse. Throughout my four weeks, I was able to experience and participate in nearly all aspects of Nasson’s mission, and the system they are currently implementing serves as a prime example of the power of teamwork in healthcare. This is most clearly demonstrated by tracing the visit of a new patient I worked with named Judy. Judy is a struggling, uninsured addict who has hit the end of her rope. Normally under these circumstances, Judy’s default option is to go to the ER, which adds to the congestion of the department, and often fails to solve her complex issues. But this time, she went to the local police department looking for help, who then referred her to Nasson. After checking in at the front desk,

Judy’s first stop is with behavioral health. Rather than feeling pelted by complex medical questions at the very beginning, the behavioral health team focuses on getting her basic history, and really tries to dig in to learn the story of what brought her in. Next, a medical assistant enters to get her vitals, current medications, and a more detailed medical history. They are the front line, and lay the foundation for the provider, which saves precious time. Next, the provider enters. With the framework set, and the basic medical history complete, they can focus on Judy’s next steps: namely the assessment, plan, and most appropriate medical management. Following the visit, the power of an integrated network really kicks in. Judy can be referred to an intensive outpatient program to follow her progress, to social work for help with her payments and transportation,

WITHOUT ANY HESITATION, OUR CASE MANAGER POKES HER HEAD INTO THE BATHROOM, TAKES A QUICK LOOK AROUND, AND TURNS BACK TO HER. ‘WE CAN HELP WITH THAT,’ SHE SAYS WITH A SMILE.” OCTOBER 2017 THE PULSE

{ Job Opportunities } or to the dental clinic to assess her oral health. Judy walked in helpless, alone, and without any resources. Roughly one hour later, she emerged with confidence, a plan, and a team to help her implement it. Whether she sticks to it or not is her decision, but the pieces are now in place. At face value, the system is perfect. But we are human beings, and human beings are not perfect, our health is not perfect, and our healthcare is not perfect. But the idea is perfect. Health is intricate, unique, and ever-changing. It is physical, emotional, and spiritual. Therefore, it follows that the systems charged with preserving health should follow the same protocols. They

should be multifactorial, adaptable, and incorporate as many aspects of wellness as possible. At Nasson, every single member of the team plays an integral role, and the system would not survive if any piece was missing. It works, and their patients say it works. I only hope political leaders and other medical institutions work to incorporate, adapt, and optimize the model, because as time is telling us, our definition of health is changing, and our healthcare system needs to change with it. Back with Amy in the one-bedroom apartment, the medical assistant finishes drawing blood, medications are confirmed, and the visit is nearly complete. But before we leave, Amy makes a brief mention that she’s

frustrated that she can’t get into her shower to wash her hair, which leaves her feeling dirty. Without any hesitation, our case manager pokes her head into the bathroom, takes a quick look around, and turns back to her. “We can help with that,” she says with a smile.

ASSISTANT MEDICAL DIRECTOR PEDIATRIC EMERGENCY MEDICINE LEADERSHIP OPPORTUNITIES ASSOC PROGRAM DIRECTOR VICE CHAIR, RESEARCH EMERGENCY MEDICINE RESEARCHER POSITIONS

Visit www.acoep.org/ newsroom for an interview with UNE COM’s Dora Anne Mills, MD, MPH, FAAP, Vice President for Clinical Affairs, Director Center for Health Innovation and Interim Vice President for Research.

The Emergency Medicine Department at Penn State Health 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. As one of Pennsylvania’s busiest Emergency Departments treating over 75,000 patients annually, Hershey Medical Center 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. We offer salaries commensurate with qualifications, sign-on bonus, relocation assistance, physician incentive program and a CME allowance. Our comprehensive benefit package includes health insurance, education assistance, retirement options, oncampus 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. Observation experience is a plus. FOR ADDITIONAL INFORMATION, PLEASE CONTACT: Susan B. Promes, Professor and Chair, Department of Emergency Medicine, c/o Heather Peffley, Physician Recruiter, Penn State Health Milton S. Hershey Medical Center, 500 University Drive, PO Box 855 Mail Code A595, Hershey PA 17033, Email: hpeffley@pennstatehealth.psu.edu 9

OR apply online at: http://hmc.pennstatehealth.org/careers/physicians THE PULSE OCTOBER 2017 Penn State Health 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.

INTRAPROFESSIONAL ALLIANCES

WHO’S GOT YOUR BACK?

By Elda G. Ramirez PhD, RN, FNP-BC, ENP-C, FAANP, FAEN

t was summertime in Texas. The emergency department (ED) was bursting at the seams. The pediatric area in this Level III had its share of lacerations and falls from bicycles—until we got the 4-year-old little girl. She had been playing in the driveway when her uncle got in his truck on his way to the grocery store and accidentally ran her over. The paramedics were so hopeful. They recited the history, exam and triumphantly claimed a large bore peripheral intravenous catheter in the left antecubital! Her vital signs were blood pressure of 130/78, pulse of 130, respiratory rate of 30 and pulse oximetry of 94 percent on room air. She was answering questions in her native tongue of Spanish. The dance began…The emergency medicine attending and I, a nurse practitioner, began our assessment. The nurses were whirling around us in synchronicity drawing labs, securing lines and doing their own assessment. Respiratory therapy, patient care technicians moved in rhythm alongside. It was like a beautifully rehearsed waltz. Then we saw the tire mark. All of us just stopped for that one moment in time and each of us instinctively understood. Our pace grew more rapid, we called for the central line kit, intubation setup. We knew. I was the Spanish speaker assigned to tell that beautiful baby girl that she was a good girl and she was going to go to sleep for a little while—it was okay. She looked at me with huge tear-filled eyes and nodded acceptance. I can see her face looking up at me even now. The attending intubated, I secured a femoral line (early 2000’s), nurses were setting up blood for rapid infusion, respiratory therapy was setting up the vent, and the techs were running labs. The flight crew arrived within what seemed like a nanosecond, and we were sending her to the big hospital. On the way out the door—she coded. We lost

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her in an instant. The tire mark was right over her abdomen and she had complete derangement of her abdominal cavity and rupture of her diaphragm. All of us, including the flight crew, had a moment of silence. My attending and I went into the back hallway and hugged each other while we cried. We had to talk to the family now. The screams of anguish were piercing. Through the screams and tears all of our “team” had to move on. We had an ED to run. My purpose in writing this story is to focus on the “team” the interprofessional lattice that is woven among those of us who provide care in an ED. Who we are and how we sync is no secret. Teams are often defined by their size, purpose, goals, skills, approach and accountability (Katzenbach & Smith, 2015). The world health organization describes the events that result in an organized, purposeful interprofessional activity, “happens when multiple health workers from different professional backgrounds work together with patients, families, caregivers and communities to deliver the highest quality of care.” However, these definitions are generic and don’t define the dynamics associated with emergency care teams. In our world, the attending is the team leader, they set the confidence, speed and mood of the department. The triage nurse has tremendous power over all of us since that nurse has to make aggressive decisions based on assessment skills and experience with the multitudes of potential illnesses that are lurking under the somewhat stable vital signs and half-truths the patients claim. The charge nurse is the conductor of the orchestra. This position eases flow and breaks bottle necks while maintaining the intraprofessional

IT WAS LIKE A BEAUTIFULLY REHEARSED WALTZ. THEN WE SAW THE TIRE MARK. ALL OF US JUST STOPPED FOR THAT ONE MOMENT IN TIME AND EACH OF US INSTINCTIVELY UNDERSTOOD.” communication active. The primary nurses in the main ED and critical care/shock rooms are constantly in motion drawing labs, putting in IV’s and working in tandem with the provider, patient and family on a plan and implementation of care. Patient care techs, respiratory therapist, social work, security guards, the business office are all part of this intricate animated world where the team influences people’s lives forever. Nurse practitioners (NP) and Physician Assistants (PA) are an instrumental part of the emergency team.

NPs have been providing care to patients and their families since the mid 1960’s around the time the first residency programs for emergency medicine physicians became established. We have partnered with our emergency medicine physicians for over 50 years. Our roots began to fill critical workforce gaps in whatever area we were most needed— pediatrics, emergency and trauma care, and family practice. We remain providers with varied skills, knowledge and competencies. Because of this, our scope of practice can be misinterpreted. Physician Assistants have a more easily understood set of competencies and scope or practice. PAs certify as generalists and are authorized to practice within the scope of their delegating physician collaborators. This also allows them to practice within the emergency care team. They train within the medical model. Nurse practitioners are educated within a nursing model which is inclusive of the patient’s personal experience and within the context of their families and communities. This allows the NP to

contribute in a different way as part of the emergency care team. Contemporary NP educational preparation can be challenging to understand. Emergency department census data demonstrates that the emergency NP must be prepared to provide care to patients of all ages which is the foundation of the family NP curriculum. However, emergency care requires that family NPs be additionally educated in prioritization, triage, acute resuscitation and management or patients across the care continuum. An NPs scope of practice is based on their educational preparation. Certification provides validation of educationally obtained competencies. In practice, NPs and PAs assume similar roles; however, licensure and regulation of PA and NP scope of practice varies based on state statues. Currently, NPs have been granted full unrestricted scope of practice in 24 states. Full, unrestricted scope of practice allows greater patient access to primary care providers and reduces physician liability and unnecessary medical record oversight. This frees physicians

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in community settings to see more patient’s further increasing access. However, independent, unrestricted scope of practice does not change how NPs practice within the emergency care setting. The essence of emergency care demands a team based approach. Even in critical access settings NPs practice within a team based care connecting to their physician colleagues using telemedicine technology. Our physician colleagues have asked how “independent practice” impacts the collaborative nature of emergency care practice. The American Academy of Emergency Nurse Practitioners stand firm that our scope and our role is to provide team based care to optimize patient outcomes, access and safety. Emergency NP practice is rooted in collaboration with our physician colleagues regardless of state statutes. It is the nature of emergency care to “dance” and practice in partnership. Who has your back? In my close to three decades of working in the ED as an NP I have experienced both aberrations and miracles in context to teams. Again—teams are often defined by their size, purpose, goals, skills, approach and accountability (Katzenbach & Smith, 2015). I can concede that the teams that I am and have been a part of that made miracles were the ones that did not base their purpose on each individual’s accolades but measured their worth by patient outcomes. The teams that did not point fingers on those horrible days that things went wrong. The teams that were blind to rank yet valued knowledge and maintained accountability in the worst of times. A team is only as strong as its newest member and yes—we have their back! The Wisdom of Teams, Creating the High-Performance Organization Harvard Business School Publishing, 60 Harvard Way, Boston, Massachusetts 02163. First eBook Edition: Oct 2015 ISBN: 978-1-6336-9107-0. Health Professions Networks Nursing and Midwifery Office. Framework for action on interprofessional education and collaborative practice. Geneva, Switzerland: World Health Organization, 2010.

ITEM WRITERS WANTED! Earn CME. Earn scholarly activity and faculty development. Get involved on the ground floor of an impactful national committee. Make a difference in the training of new emergency medicine physicians. All while you’re at ACOEP’s Scientific Assembly!

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BETWEEN ACOEP AND AAENP

The Emergency Medicine Aptitude Assessment Test (EMAAT) Committee is recruiting new members to serve as item writers for our resident in-service and July Assessment Exams. Join the committee for an Item Writer Workshop at Scientific Assembly in Denver on Sunday, November 5th from 7:30-9am. Current writers and interested members alike are invited to attend this workshop that provides writers a chance to refine their question writing and editing skills, learn more about the functions of the EMAAT committee as well as the benefits of joining. Best of all, CME credit is available for attending this workshop! “The EMAAT workshop is a great way to demystify question writing,” says Jill Uberti, chair of the committee. “We will walk you through what makes a good question, how to write it clearly and accurately, and the best ways to edit. You’ll leave the workshop with all of the tools you need and the confidence to contribute to this important work and you will help create better, more prepared doctors.” Involvement in this committee is vital, but not arduous. Members commit to: • Attending a training session (available online or at a conference) • Writing two cycles of 10 exam questions and answer explanations on an assigned topic area each year • Reviewing and editing questions written by fellow committee members each cycle

By John Prestosh, DO, FACOEP-D and Theresa M Campo, DNP, FNP-C, ENP-BC, FAANP

he American College of Osteopathic Physicians has entered into a formal relationship with the American Academy of Nurse Practitioners (AAENP). Our Board of Directors voted unanimously to join with AAENP as we realize this organization has a significant impact on the delivery of emergency healthcare. A majority of ACOEP members work with nurse practitioners in their departments on a daily basis and our board feels that entering such an agreement will help both ACOEP and AAENP to better understand the focus and scope of practice of both groups. This affiliation is not only groundbreaking in emergency medicine, but will exemplify collaboration, teamwork, advocacy, and moving into the future together providing high quality care to our patients.

The goal of the affiliation is to facilitate real-time communication between the organizations, work together to enhance practice, and support each other professionally and organizationally. Collaboration and affiliation will foster mutual benefits of education, advocacy, and financial benefits to all members. Dr. Pretosh is representing ACOEP at the AAENP Leadership Conference in Washington DC October 27-29, 2017 and Dr. Campo is representing AAENP at the upcoming ACOEP Scientific Assembly. Both will be presenting topics at the conferences. A major component of this partnership is to place a representative on each board. Dr. Theresa Campo will represent AAENP on the ACOEP board and Dr. Prestosh will serve as the ACOEP representative to AAENP. Both will initially have a non-voting status on each board, however, this understanding will be reviewed in the near future and the hope of both organizations is to have a full vote on each other’s board of directors. This is a positive step forward for both organizations and to having a very close working relationship with the nurse practitioners.

While working on this committee you will also be a part of a team that will support and help through any questions, and balance you workload. With dedicated ACOEP staff to help coordinate, item writers will have a great experience. If you are interested in attending this workshop, or would like to learn more about becoming an Item Writer, please contact kspreitzer@ acoep.org or 312-445-5702. Upon inquiry, you will be asked to include your most current CV, as well as write and submit five audition questions and the answer explanation based on a preassigned topic which the committee will then review to determine eligibility. If you have any questions about the application process, Kefah is more than happy to help direct you. Visit www.acoep.org/newsroom for more information and an interview with Jill Uberti!

BUILDING BRIDGES

DID YOU KNOW THAT ACOEP IS APPLYING TO OFFER CREDIT TO NPS AT SCIENTIFIC ASSEMBLY?

Invite your NP colleagues to join us in Denver!

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DELIBERATE EPIDEMICS Addiction medicine, emergency medicine, and the complexities of the opioid epidemic.

By William Bograkos, MA, DO, FACOEP, FACOFP President AOAAM

mergency medicine physicians see the plague of drug abuse every day, in every state, across the United States of America, and there is always conversation about containing and treating this epidemic. In my own career, I have seen one case of brucellosis, one case of tularemia, and one case of anthrax. Substance Use Disorder (SUD) is not an infectious disease, however, SUD requires exposure. In my mind, the current drug abuse disaster is a “deliberate epidemic,” with criminals serving as carriers, vectors, and point sources. Prescribing patterns, big pharma, and criminal diversion, all contribute to this plague. Physicians are challenged by pain patients, patient satisfaction surveys, and citizens having greater access to illicit drugs than access to dedicated, educated, addiction medicine clinicians. The public expects the medical community to cure the demand for drugs and expects law enforcement (LE) to fix the supply. I first came across the term “deliberate epidemics” while working for the Pentagon in the Black Sea Region. The World Health Organization utilized the term in preparing for bioterrorism events and worked with INTERPOL on the global stage as collaboration between global public health and global law enforcement is essential in containing and controlling pandemics. In 1972, I received my draft card after

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President Nixon declared “the war on drugs.” Today our nation utilizes public health terms such as “opiate epidemic” in seeking to balance efforts within public health, military, and law enforcement missions. Public health operations require common language across multiple disciplines. When communities are challenged with a deliberate epidemic it behooves them to discuss and develop a course of action. States do have bioterrorism plans within their emergency operation centers, and within their state public health offices. I suggest we utilize the simple framework of passive surveillance, active surveillance, and seek to contain and control the epidemics. Basic public health operational plans begin with phase zero (passive surveillance). We are beyond phase zero and beyond phase one (active surveillance). We are living in the phase two (contain and control) environment, but we often lack the ability, and appropriate funding to bridge interdisciplinary silos. Phase two requires a dedicated coalition of interdisciplinary stakeholders (law enforcement, public health, emergency medicine, hospitals, businesses, and others). We cannot and should not wait for a national response framework or plan. Tactical Emergency Medical Support (TEMS) has been a home to many of our ACOEP physicians. Let’s remind ourselves of all the LE deployments responding to calls related to drug and alcohol use and abuse. Let’s remind ourselves of criminal behavior with intent to distribute. Addiction is a brain disease, and criminals supply the substances in this neurocognitive disorder. I recommend we join forces across our academic silos, engage subject matter experts in our SAMSHA Regions, and explore “the operational plan”. The SAMSHA Regions share the same geographic area of responsibility (AOR) as our FEMA Regions. The AOR is shared but our languages and cultures often differ. Dynamic community development and resilience is more about the planning than about that static plan in the binder

JUST SAY NO” STOPS THE DIALOGUE. LET’S ADDRESS THIS CHRONIC DELIBERATE EPIDEMIC AS FIRST LINE ACTION-ORIENTED PHYSICIANS.” community came together to form a working group addressing these issues. The Executive Director of the Coalitions of Physicians Educators for Substance Use Disorders brought together leaders in the emergency medicine community to tackle these issues. And I believe we should keep the movement going and share best practices and lessons learned across all ten SAMSHA Regions. Let’s introduce the next generation of physicians to the concept of coalitions. “Just say no” stops the dialogue. Let’s address this chronic deliberate epidemic as first line action-oriented physicians. The drug disaster is a clear and present danger. Drugs of abuse are a global public health threat. Substance use, misuse, and abuse are clear and present dangers to individuals, families, and communities. ACOEP has always provided leadership in addressing the difference a DO makes. Our students are currently engaged in dialogue across academic silos and benefit from the leadership and mentorship that our educators provide. Communication, collaboration, and coordination strengthen coalitions. Emergency medicine and addiction medicine specialties cannot contain and control the epidemic alone. We need to surge the number of educated physicians and advocates. I recommend we invest in the neuroplasticity of the next generation of Osteopathic physicians as we develop opportunities for dialogue with state and SAMSHA / FEMA regional stakeholders. Rx HOPE.

This past August, the SAMSHA V Region meeting took place in Chicago, where select leaders in the medical

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EMS:

EMS PROVIDERS ARE AS MUCH A PART OF MY TREATMENT TEAM AS THE ED NURSE, TECH, SECRETARY, RADIOLOGY, LAB ETC. SO, WHY DON’T MORE OF OUR ED COLLEAGUES FEEL THE SAME WAY?”

PART OF THE ED TEAM By Rose Anna Roantree, DO, FACOEP

paramedic rushes a pale 24-year old Hispanic male into the trauma bay of the local emergency department. A team of emergency physicians, nurses, and techs, notified of the patient’s impending arrival by the same medic, quiets down and listens carefully as he gives a detailed report, including the fact that the patient was stabbed four times in the chest during a robbery which occurred hours earlier, tried to walk home, and finally collapsed on the stairs to his apartment, complaining of shortness of breath. During the brief ride to the hospital EMS has stripped the patient and assessed him for other wounds, started an IV, and monitored his vital signs. As the team moves the patient onto the ED gurney, one physician begins a physical exam, as a nurse puts the patient on a monitor, and another physician puts an ultrasound probe on the patient’s chest, concerned about the history the paramedic gives—several stab wounds to the chest hours earlier, initially fine, but now with worsening shortness of breath. The first ultrasound image is startling—cardiac tamponade is obvious. There is no time to obtain further images as the patient closes his eyes and the monitor shows asystole. A quick decision is made to perform a thoracotomy, the pericardium is incised, and a stab wound to the right ventricle is found and repaired. Just as quickly, the patient regains pulses, goes to the OR, and is sitting up in bed eating a sandwich the next day. He is discharged home from the hospital four days later.

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This happened in my hospital. This happened to me. And this is exactly how it happened. In my shop, we have an excellent rapport with our EMS, paramedics and EMT’s alike. They are a part of our team. On occasions such as this one, that relationship means the difference between life and death. Now think about where you work—do you have this kind of relationship with your pre-hospital crews? Do you trust the reports they give? Are they thorough? Do you give them the time and attention they deserve to deliver the information you need to take care of this patient? Many times, unfortunately, the answer to these questions is “no,” for a variety of reasons. For one thing, many emergency physicians, although inarguably experts in emergency medical care, don’t know much about EMS in general and their own pre-hospital system specifically. I have encountered many a physician unfamiliar with the difference between an EMT and a paramedic, the difference between BLS and ALS. Although usually easily referenced via printed handbook or regional website, many also have limited knowledge of the protocols or scope of practice of EMS in their area. In a recent blog entry for the National Association of EMS Physicians, Clayton Kazan, the medical director for the Los Angeles County Fire Department, highlighted this issue. Said Dr. Kazan, “EMS providers are as much a part of my treatment team as the ED nurse, tech, secretary, radiology, lab etc. So, why don’t more of our ED colleagues feel the same way? Why don’t more of them take an active part in understanding the basics of the local EMS system in which they practice: scope of practice, treatment protocols, destination criteria, etc?”

Emergency physicians need to read and understand the local and state protocols under which their patients are treated, and approach EMS providers when they come in with a patient, for a detailed report. Often critical information is offered which is not given by the family, skilled nursing facility paperwork, or hastily written run report. If the issue is an inaccurate or incomplete report from the EMS provider, this must be addressed by the emergency physician. Ask for more information from the EMS team. Yes, they probably did check the blood glucose, search under the bed for pill bottles, or try that left antecubital for an IV—just ask. Communication is, after all, the key to most inter-provider relationships in medicine, and it’s no different between EMS and emergency physicians. This is emphasized in a recent study by Goldberg et al in Prehospital Emergency Care, “Quantitative Analysis of the Content of EMS Handoff of Critically Ill and Injured Patients to the Emergency Department.” This study, like ones before it, showed poor quality handoff from EMS to ED providers. The issues cited include a perceived lack of attention, divided attention, or lack of active listening on the part of ED providers receiving the patient, as

well as a feeling by ED providers that the information given by EMS during handoff is lacking. A thorough and accurate handoff, given to a receptive ED team who is actively listening, is vital to patient care and safety. Bedside (or more like hallway or ambulance bay) education is also more valuable than you might think— like any of us, EMS providers are always learning, and will listen to what an emergency physician has to say regarding atrial fibrillation, or spinal immobilization, or whatever the case is, as long as any criticism is constructive and not destructive. Insightful feedback is important for EMS education and the care of future patients. If you’d like to deliver a message to a wider audience, give an EMS lecture or do a call audit at your hospital or local EMS agency. It’s always appreciated, and everyone will benefit from the extra interaction. Improved emergency physician knowledge of protocols, effective

communication during handoff, and increased EMS provider education by emergency physicians will all improve patient care and the relationship between emergency providers and EMS, making EMS a real part of the emergency department team. So the next time a paramedic brings you a patient, give him a moment to catch his breath, as he has likely just had to intubate a vomiting patient while lying on his belly in a dark alley, or had to carry a morbidly obese patient down eight flights of stairs—and then listen to what he has to say. It could save a patient’s life.

For links to the study and blog mentioned, visit www.acoep.org/newsroom. Share your thoughts on how EMS and physicians can work better together!

ACOEP PRESENTS

ZDOGGMD

HEALTHCARE, REMIXED

11/06/17

AC O EP ’S S CI ENT IFIC A S SEMBLY HYATT DENVER CONVENTION CENTER

OCTOBER 2017 THE PULSE

WHAT YOU ALWAYS WANTED TO KNOW ABOUT EMPAS,

• Internal medicine • Obstetrics and gynecology • Pediatrics • Psychiatry Many programs offer elective rotations so graduates may finish with additional emergency medicine experience.

BUT WERE AFRAID TO ASK

PA postgraduate programs—often referred to as PA residencies or fellowships—are optional, but becoming increasing desirable for graduating PAs. Similar in structure to physician residencies, PA postgraduate programs are 12-18 months of specialized emergency medicine training and are usually affiliated with a physician emergency medicine residency. The majority of the time is spent in the ED but depending on the program there are also off-service rotations in anesthesia, critical care, trauma, ultrasound, pediatric emergency medicine, EMS, burns, toxicology and more.

By Michelle Parker, Executive Director, Society of Emergency Medicine Physician Assistants (SEMPA)

erhaps you’ve worked alongside PAs in your ED for years, or maybe you’ve never worked a single shift with one. Whatever your level of experience may be in working with an emergency medicine physician assistant (EMPA), you probably have had questions, such as “What is their training?”, “How do we onboard them?”, “Will they have a positive impact in the ED?”, and the most common question, “How the heck do I utilize them?”

Most PA postgraduate programs also incorporate weekly didactic conference, which includes lectures, simulation lab, journal club, morbidity and mortality conference, and other academic activities similar to physician emergency medicine residency training. In many programs, the PA residents train alongside physician residents.

We’re here to help navigate you through these burning questions, and get you and your EMPAs on the way to working together in providing quality patient care.

A Brief History Born out of the need for increased access to medical care due to a shortage of primary care physicians, the physician assistant (PA) profession was established in 1965 when Dr. Eugene A. Stead, Jr., of Duke University helped start the first PA program. Seeking to take advantage of the experience with the military emergency care medical system, Dr. Stead called upon four highly trained and skilled Navy Hospital Corpsmen. These men went on to become the first PAs in the United States. The newly formed PA profession received the support of the medical community and led to the founding of the American Academy of Physician Assistants (AAPA) in 1968, which was made up of the members of the Duke University program graduates. In 1974, the National Commission on Certification of Physician Assistants (NCCPA) was established, and by 1980 there were 42 accredited PA programs and approximately 9,000 certified PAs. Today, there are 225 accredited PA programs and more than 115,000 certified PAs. From the start of the profession, PAs practiced in the field of emergency medicine, though their role was limited in

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scope. But, as the demand for emergency care started to increase and the shortage of emergency physicians began to take hold, the role of the emergency medicine PA started to change. In as recent as the last seven to 10 years, EMPAs have experienced a dramatic shift in how they are utilized in the ED. Once limited to Fast Track, now EMPAs practice in all areas of the specialty, including prehospital patient care, triage and the main ED. Today’s EMPA often sees medium to high-acuity patients and carries a high patient load. Furthermore, they can be found in all practice settings. Whether it be a trauma center, suburban or urban setting, teaching hospital, or rural ED, EMPAs are there on the frontlines working hand in hand with emergency medicine physicians and other providers to serve the millions of patients that walk through the doors of EDs nationwide and around the world. To help support PAs in emergency medicine, the Society of Emergency Medicine Physician Assistants (SEMPA) was established in 1990 by a group of former postgraduate residency-trained EMPAs. Today, SEMPA continues to serve as the definitive source for EMPA practice guidelines, education, advocacy and support.

Physician Assistant Training There are currently 225 PA programs across the country. Most of these programs are an average of 26 months in length and require the same prerequisite courses as does a medical school. Applicants are required to have completed at least two years of college courses in basic and behavioral sciences, with prerequisites in anatomy, biology, chemistry, microbiology and physiology. Most programs also require prior experience in health care that includes direct patient care, such as an EMT, paramedic, medic, hospital corpsman or RN, as examples. The majority of the PA programs offer a Master’s degree.

To help standardize PA postgraduate training, SEMPA developed the Emergency Medicine Physician Assistant Postgraduate Training Program Standards. The goal of the standards is to help create consistent and expected outcomes for those employing the EMPAs in the program as well as those graduating the program.

Onboarding EMPAs Getting your newly hired EMPA up to speed and ready to practice on the floor can be daunting, but it doesn’t have to be. There are many things you can do to ensure the success of both the EMPA and ED.

PA education is based on the medical model and is extensive in scope. The training consists of didactic instruction (anatomy, physiology, pharmacology, pathophysiology, microbiology, physical diagnosis, and more) and clinical rotations, with the requirement of more than 2,000 hours of clinical rotations in:

One important aspect to keep in mind is that onboarding an EMPA is an investment, particularly if he or she is a new graduate. New EMPAs need more guidance, supervision, education and opportunities to gain experience than a more seasoned EMPA. The onboarding for the new PAs should include ongoing didactic education that specifically focuses on emergency medicine, and hands-on skills training can be quite beneficial. Physicians should also be prepared to provide newly graduated PAs with more detailed, deliberate guidance and supervision.

• Emergency medicine • Family medicine • General surgery

Scheduling for an onboarding PA should also be taken into consideration. Newly graduated PAs should not be scheduled as the only PA in the ED or during peak times until they gain

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more experience. But even PAs who have been practicing emergency medicine for some time will need onboarding into what is a new ED—and new policies, processes and procedures—for them. Both should be added to the schedule as an “extra person” for a predetermined number of orientation shifts. Establishing a clear scope of practice is also vital. Early on, the emergency medicine physician should outline the EMPA’s scope of practice for that ED based on state laws, hospital policies and the PA’s level of experience. It’s also a good idea to develop an onboarding plan to help gauge and monitor the progress of the EMPA’s integration into the ED. EMPAs should be allowed to practice at the top of their license for maximal efficiency, taking into account adequate onboarding and experience. Having a Chief/Lead PA within the ED to help the medical director oversee PA operations and act as a liaison between the PAs and physicians can be quite valuable. Whether you’ve hired a new EMPA or a seasoned veteran, ultimately, having a culture within the ED that is supportive of EMPAs can make the biggest difference in ensuring a positive experience for everyone.

Utilization of EMPAs Appropriate use of EMPAs can help an ED become more efficient and cost-effective. As previously mentioned, in the last decade, EMPAs have seen a paradigm shift in scope of practice. Today’s EMPA can be found treating simple pediatric fever and upper respiratory infections all the way to more complex conditions, such as diabetic ketoacidosis, acute coronary syndrome and trauma patients. EMPAs have also become involved in administrative roles. They serve as chief or lead PAs, assistant medical directors, EMS coordinators, and on hospital committees. They can also be found in academic medical centers working alongside and teaching PA students, medical students and physician residents. EMPAs are also researchers, which is why SEMPA established a joint research grant with the Emergency Medicine Foundation. A 2017 SEMPA Practice Survey illustrates current trends in EMPA practice. Eighty-seven percent (87%) of respondents indicated that they work in the main ED. Fifty-five percent (55%) reported that the highest degree of severity that they routinely see is emergency severity index (ESI) level 2-3 and thirty-nine percent (39%) reported seeing ESI 1-2 routinely. And while advanced procedures varied by frequency, the survey did find respondents performing airway management, advanced wound management, lumbar puncture, and

ultrasound guided procedures, along with several other procedures.

Impact of Utilizing EMPAs The benefits to using PAs in the ED are numerous.

GIVEN THAT EMPAS ARE TRAINED IN THE MEDICAL MODEL, LIKE PHYSICIANS, THEY BRING A LIKEMINDED APPROACH WHEN EVALUATING AND TREATING PATIENTS.”

Given that EMPAs are trained in the medical model, like physicians, they bring a like-minded approach when evaluating and treating patients. EMPAs value the PA-physician team approach to patient care so the ability to collaborate makes the partnership successful. And, given the roles and patient load an EMPA can take on, EMPAs are cost-effective. The addition of EMPAs can improve flow within an ED, as demonstrated in a study by Ducharme et al, which looked at six Canadian EDs.1 The study found that the use of EMPAs resulted in patients who were 1.6 times more likely to be seen within established wait time benchmarks. Length of stay was also 30.3% lower when EMPAs were involved. Patients are consistently satisfied with the care they receive by EMPAs, a valuable quality to physician groups and hospitals.2 In a survey of 1,000 emergency physicians, most felt that PA staffing may increase patient satisfaction, decrease wait times, and improve patient communication, thus decreasing malpractice risk.3 The Doctors Company, the nation’s largest physician-owned malpractice insurer, has compiled data from 2001-2010 showing that emergency medicine only accounts for 6% of all claims brought against PAs.4 Finally, EMPAs are being utilized to staff geographic areas that have challenges recruiting emergency physicians. Some models have an emergency physician working with a team of EMPAs and some have the EMPA working solo in critical access hospitals with physician consultation available. In an era where there are simply not enough emergency physicians along with financial constraints, EMPAs can supplement the emergency care workforce to provide safe, quality patient care.

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, 2017 issue, regarding the situation where an EMS crew was en route to a hospital with a suspected cerebrovascular accident patient. The ambulance was delayed at a railroad crossing waiting for the train to pass through. While waiting, a person from a car, also trained, began banging on the ambulance window screaming for help for his brother who was not breathing. As medical control, what would you do? This situation really has no definitive solution. Of course, a second ambulance should immediately be requested. The paramedics can both stay, dedicated to their current patient. Or, they can split and have one paramedic stay and one evaluate the new potential apneic patient. What if they train clears while the second patient is being evaluated, and perhaps CPR is initiated? What if CPR is in progress and the CVA patient crashes and requires resuscitation? There is no clear win. One would make a point and say Ambulance One is legally dedicated to their patient, and Patient Two will just have to wait for Ambulance Two. This may preclude abandonment, but, may also put the paramedics in jeopardy of a violent response from the relative shouting for help. Also, how do you ethically justify not treating an apneic patient right next to you? And, would it be abandonment to start treatment on patient two, then the train clears. Ambulance Two has a prolonged response time. Do you leave Patient Two to transport Patient One? The CVA patient had a last known well time of two hours, further putting pressure on the crew for an expedited transport to the hospital. This is essentially an untenable situation. What happened? The crew decided to have one medic evaluate Patient Two. Fortunately, he was having an asthma attack and was breathing. Also, fortuitously, Ambulance Two arrived as the train cleared. This allowed Ambulance One to depart for the hospital without delay, and Ambulance Two to treat and transport Patient Two. We have all been in the most difficult position of deciding which patient gets treated first—two or more gunshot victims, multiple patients from a mass casualty incident. However, the situation discussed has us already treating a patient, with another now presenting. Perhaps our conscience may be the determinant. I would look forward to other opinions. Please visit www.acoep.org/newsroom and share your thoughts on this case.

Resources Below are some articles regarding the utilization of EMPAs you might find helpful. Tips for Collaborating with Advanced Practice Providers www.acepnow.com/article/tips-forcollaborating-with-advanced-practiceproviders/?singlepage=1 PA Training and Supervision: A Conversation with SEMPA Leadership (link to http://epmonthly.com/article/ pa-training-and-supervision/ Myth v. Fact: The Truth Behind Common PA Misconceptions http://epmonthly.com/article/factv-fiction-the-truth-behind-a-fewcommon-empa-misconceptions/ PA Training and Oversight: A Model Worth Copying? http://epmonthly.com/article/ pa-training-oversight-model-worthcopying/ SEMPA (www.sempa.org) and AAPA (www.aapa.org) are also great resources. If you require any assistance with your EMPA program, or have questions about EMPAs feel free to contact SEMPA at sempa@sempa.org.

References 1. Ducharme J, Alder RJ, Pelletier J, Tepper J. The impact on patient flow after the integration of nurse practitioners and physician assistants in 6 Ontario emergency departments. CJEM. 2009;11(5):455-461. 2. Counselman FL, Graffeo CA, Hill JT. Patient Satisfaction with Physician Assistants (PAs) in an ED Fast Track. Am J Emerg Med. 2000;18(6):661665. 3. Gifford A, Hyde M, Stoehr JD. PAs in the ED: Do physicians think they increase the malpractice risk? JAAPA. 2011;24(6):36-38. 4. The Doctors Company. Mid-level Practitioner Liability: Preventive Action and Loss Reduction Plan. http://www.thedoctors.com/ecm/groups/ public/@tdc/@web/@kc/@patientsafety/ documents/article/con_id_005897.pdf. Accessed August 22, 2018.

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. 21

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OCTOBER 2017 THE PULSE

ACOEP’S 2017 SCIENTIFIC ASSEMBLY:

MORE FOR YOU, MADE FOR YOU By Erin Sernoffsky, Director, Media Services

t the heart of ACOEP are our members. You are the engine that drives the College forward, firmly establishing ACOEP as a cornerstone in emergency medicine. For proof of this, look no further than the 2017 Scientific Assembly! Over recent years this conference has expanded at an unprecedented rate. From the creation of an app that gives up-to-the minute information and easy access to lecture materials, to the specialized breakout tracks allowing for a customized learning experience, Scientific Assembly has grown by leaps and bounds. At ACOEP we are a tight-knit community, and changes and improvements that we make are based on the feedback given onsite and through course evaluations. You help us to create a road map, directing where the conference goes and how we expand. This year, there are more updates and improvements than ever before, specifically made to give our members what they want in a conference experience.

THIS YEAR WE’RE INTRODUCING THE IN CASE YOU MISSED IT SERIES, AN ENCORE PRESENTATION OF SELECTED SPEAKERS ALLOWING YOU TO CATCH ALL THE IMPORTANT SESSIONS YOU DON’T WANT TO MISS.”

More CME Please! Let’s face it, you come to Scientific Assembly to learn and to hone your skills, but you also come to meet ever-present CME requirements. This year Scientific Assembly didactic sessions begin a half day early! Now, on Sunday, November 5th you have your choice of attending CME-eligible FOEM Competitions, hands-on labs, or getting a jumpstart on lectures.

ICYMI Ends FOMO “Fear of missing out,” AKA FOMO, has infiltrated Scientific Assembly. The breakout lectures have been a runaway success in recent years, however the caliber of our faculty is so strong that oftentimes attendees are frustrated that they can’t hear everyone. This year we’re introducing the In Case You Missed It series, an encore presentation of selected speakers allowing you to catch all the important sessions you don’t want to miss.

Play Hard

Labs, Labs, and More Labs ACOEP’s sell-out skills labs have become increasingly popular and we are thrilled to offer

two new ones! The Advanced Resuscitation Workshop will immerse you in a combination of lecture and hands-on experience, taught by renowned experts in resuscitation. Led by Haney Mallemat, MD, Mimi Lu MD, Jon Greenwood, MD and Sean Quinn, DO. This workshop offers four hours of CME, and is limited to 30 total physicians to keep a small instructor-learner ratio intact. What better way to embrace being in the Wild West than with the new Wilderness Medicine Track? This intensive workshop kicks off with four hours of interactive lecture, followed by four hours of putting what you learned into practice in the great Rocky Mountains. Space is limited!

Meet You at the Hub In the center of the expo hall you’ll find The Hub, a special location for demonstrations and exciting information. Keep hearing people talk about Twitter but not sure what the fuss is about? RSO representatives will be on hand to get you started, connecting you with the latest EM information. See demos in breakthrough virtual reality technology, and so much more. Grab your coffee and get to The Hub!

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At ACOEP we pride ourselves on how well we know our members and one thing we know for sure is that you play as hard as you work. So for this year’s Kickoff Party, we’re taking over the entire Punch Bowl Social Denver! Unlimited food and drinks are a given, but you can also take on your friends in free bowling, air hockey, foosball and other games. If that’s not enough, we’re also bringing in a mechanical bull! The cowboy or cowgirl who stays on longest will win a prize! And if it somehow goes badly for you, at least we know there’s a doctor in the house! Throughout the conference we’ll also bring you live music, comfortable lounge areas, and great food and drinks. For the many mothers in attendance our mother’s lounge offers a comfortable place to nurse or pump, or maybe have a call to the kids back home. These are just some of the advances we’re making with ACOEP’s Scientific Assembly. We can’t wait to see you in Denver where the entire experience is designed with your needs in mind.

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EMS has, and always will be, the community’s ultimate healthcare safety net, when all else fails, pressing three digits on a phone brings medical help to the caller. EMS will also always have a role transporting medically fragile patients from one facility to another. However, the advent of Healthcare 3.0 is seeking additional roles for EMS, roles that meet three main goals; improve the patient’s experience of care, improve the health of the population and reduce healthcare costs. These goals are often referred to as the Triple Aim® developed by the Institute for Healthcare Improvement (IHI). Services provided as part of EMS 3.0 are designed to effectively navigate patients needing urgent or unscheduled care through the healthcare system to ensure they receive the right care, in the right place, at the right time. EMS 3.0 agencies fill gaps in patient care, preventing new or recurrent medical episodes to reduce ambulance transports, emergency department visits, hospital admissions and readmissions. The effectiveness of the programs is rooted in collaboration. EMS 3.0 agencies help break down siloes in healthcare delivery models by coordinating and collaborating with a variety of community healthcare providers and agencies to deliver a broad spectrum of patient-centered preventive,

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THE ADVENT OF HEALTHCARE 3.0 IS SEEKING ADDITIONAL ROLES FOR EMS, ROLES THAT MEET THREE MAIN GOALS; IMPROVE THE PATIENT’S EXPERIENCE OF CARE, IMPROVE THE HEALTH OF THE POPULATION AND REDUCE HEALTHCARE COSTS.” primary, specialty, and/or rehabilitative care outside of medical facilities. The expanded roles most commonly being undertaken by EMS systems operating in the 3.0 environment include the following:

24/7 emergency medical dispatch (911)

Post-discharge follow up, preventive care

Chronic disease management and support

Rapid response, medical assessment and treatment

Patient Urgent cardiac, stroke, trauma, mass casualty/disaster care

Nurse Triage This typically involves the use of specially trained nurses as part of the 9-1-1 call taking process for low to no acuity 9-1-1 calls. Nurses use their training, along with decision support tools to help callers find more appropriate outcomes for their call as opposed to an ambulance to an ED. For example, a mom calling 9-1-1 for a child with an ear ache and low-grade fever could get an appointment with a pediatric clinic, or even self-care at home with follow-up pediatrician appointment the next morning. EMS systems such as MedStar, Mesa Fire and Medical, REMSA, Salt Lake City Fire and King County, Washington are using 9-1-1 Nurse Triage. Some agencies are using nurses in their communications center to both receive calls and make outbound calls to follow-up on high risk patients. The nurses and help assure patients are safe at home, have and keep medical appointments, or answer any questions patients may have. Northwell Health Center for EMS in Syosset, NY is doing that type of program.

Alternative transportation or referral to community health or social services resources

Emergent | U r g ent

But what exactly is EMS 3.0?

Nurse advice

Lower costs

The current version of America’s healthcare system has been described by many policy think tanks and economists as entering “Healthcare 3.0”1,2. Concurrent with this third major shift in healthcare, it is logical, perhaps even essential, that EMS is transforming into its third major revision, “EMS 3.0”.

Our nation’s healthcare system is transforming from a “fee-for-service” model to a patient-centered, and value and outcomes-based model, referred to as Healthcare 3.0. EMS can be a part of Healthcare 3.0 only if it undergoes its own transformation by expanding services and demonstrating value. EMS 3.0 includes…

pa Better tient hea lth

pon hearing the term “3.0”, many people think of software release versions with the general understanding that “3.0” is newer and better than “2.0”, and that likely there will be a “4.0” even newer and better version at some point in the future.

EMS 3.0 Preventive | Navig atio n

ROUNDING THE FIRST CURVE ON THE RACE TO EMS 3.0

By Matt Zavadasky, President-Elect of National Association of Emergency Medical Technicians

Emergency and critical care transport

EMS is uniquely positioned to support our nation’s healthcare transformation by assessing and navigating patients to the right care, in the right place at the right time. Let’s move our profession to EMS 3.0.

Serving our nation’s EMS practitioners

OCTOBER 2017 THE PULSE

ACOEP MEMBER SPOTLIGHT

Post Discharge Follow-Up Care EMS personnel are being used in a growing number of communities to follow-up with patients and assure a safe transition from the hospital to the home. Crews complete one or two post discharge visits things like in-home safety and fall risk assessments, medication inventories, and a review of all discharge instructions while the patient is at home and in a way that the patient may be better able to comprehend the instructions. EMS agencies such as Procare Integrated Health and Transport in Baltimore, MedEx Ambulance in Chicago, and Albuquerque Ambulance are operating these types of programs. Taking that concept a step further, a growing number of agencies are enrolling patients in 30-day post discharge readmission prevention programs, conducting a series of follow-up visits and even 9-1-1 intervention and redirection if the patient calls 9-1-1. MedStar Mobile Healthcare, REMSA, Mesa Fire and Medical and several other agencies are doing these types of interventions.

Chronic Disease Management and Support Some patients need assistance managing chronic diseases or behavioral health issues. Because EMS is available 24/7/365, numerous EMS systems have formal partnerships with hospitals, home health agencies, hospice agencies and payers to help these patients during a longer enrollment. Specially trained paramedics make routine home visits and are available for any episodic needs these patients may have. The goals of these programs are to help the patient use their patient centered medical homes more effectively and prevent unnecessary 9-1-1, emergency department and inpatient hospital use. REMSA, Northwell, Mesa Fire and Medical, McKinney (TX) Fire Department, and San Diego Fire are examples of operating programs for this intervention.

Ambulance Transport Alternatives

Although still a relatively new component of ACOEP, the NPIP has quickly become one of the fastestgrowing and most popular aspects of Scientific Assembly. Last year, NPIP lectures were standing room only. This year’s track will focus on non-medical, real life lectures exploring issues that challenge your wallet, your practice, and your personal life. This year, the NPIP Lecture Track is jam-packed with topics specifically geared to those first, challenging years out of residency. This year the NPIP is proud to offer:

Keeping Yourself Out of the Courtroom Kevin Klauer, DO, award-winning keynote speaker, reviews real-life, highrisk cases and how you can avoid them in your own practice.

Payment Alternatives

Mark Fogg, JD is a lawyer who has specialized in EM cases throughout his career. He will cover the anatomy of a lawsuit and what you need to know from the moment you get served to final verdict.

As you can see, the EMS 3.0 transformation is already out of the gate with many agencies capitalizing on the changing healthcare dynamics test alternate service delivery and economic models. For more information on EMS 3.0, including useful links and references visit www. acoep.org/newsroom 1. https://www2.deloitte.com/content/dam/Deloitte/sg/Documents/risk/risk-sea-healthcare-3.0healthcare-for-the-new-normal.pdf 2. https://home.kpmg.com/xx/en/home/insights/2015/04/unlocking-the-value-of-big-data.html

AT SCIENTIFIC ASSEMBLY ON TUESDAY, NOVEMBER 7TH, 2017!

A few EMS systems are operating under protocols that train paramedics to do enhanced assessments in the field on 9-1-1 calls and allows these paramedics to offer low-acuity patients the option of being transported to destinations other than emergency departments. These programs are in operation at REMSA, and three sites in California as part of the California Community Paramedic Pilot Projects (Carlsbad Fire, San Diego Fire, and Glendale Fire).

Since 1965, EMS has been paid based on a transport model, we are suppliers of transportation, and as such, are typically only paid to transport patients requiring medically necessary ambulance transport. Some 3.0 payers are realizing that if they keep paying EMS only to transport, then generally, that is what we are going to do. Payers in Fort Worth, Missouri and Reno are getting ready to test economic models for EMS that decouple the payment from transport. These models could be a payment for the response, regardless of transport or not, payment for transport to alternative destinations, or even population-based capitated per member per month rates that incentivize the EMS agency to not even have to respond to calls.

THE PULSE OCTOBER 2017

REGINA HAMMOCK, DO

NEW PHYSICIANS IN PRACTICE TRACK

So You Have Been Served, Now What?

Tax Strategy for the New Physician Greg Papineau, CPA is an accountant who works specifically with physicians and will teach you the steps to start financial freedom and decrease the amount you pay in taxes early in your career.

More Money in Your Pocket Travis Ulmer, MD is a top executive in USACS and will provide tips to improve your charting to maximize your reimbursement and ultimately the check you bring home.

lthough women make up over one-third of the physician workforce, it’s all too common they’ve faced gender discrimination at some point in their career. Emergency Medicine Residency Program Director at NYC Health + Hospitals/Coney Island, Regina Hammock, DO, knows firsthand the challenges women in emergency medicine face every day.

“She is a truly fabulous woman who has accomplished three lifetimes in her one, with no sign of slowing down. She taught me that people do not aim at low targets, so keep on doing what you do, and expect backlash, especially if you do it extremely well,” she said.

“Preconceived notions and prejudices have been the cause of many obstacles. I’ve found that closed minds produce closed doors. In order to develop more possibilities in career and life, you have to find ways to open those minds first, then the doors can follow,” she said.

“Time is the one resource that you cannot make more of, so learn how to work with what you have,” she said.

Dr. Hammock suggests a strong network of support and mentors when it comes to climbing the ladder to success. “Fortunately, there are many good, objective people out there willing to give a chance to people like me. Find them, develop them, and you can find your way through (or around, in some cases) those closed doors,” she said. The fight for gender equality in emergency medicine doesn’t end at the caretaker level, and often presents greater issues with treatment and care of patients. A topic of which Dr. Hammock believes needs to be discussed more often.

When it comes to maintaining a healthy work-life balance, Dr. Hammock is a big proponent of time management and developing an efficient and reasonable schedule for yourself and your work.

Admitting that she lives by the popular quote, “Do what you love, and you’ll never work a day in your life,” Dr. Hammock says it’s still possible to burn out, especially in a career that is so time consuming. Traveling, practicing yoga, enjoying movies and music, and spending time with family and friends are just a few of the things that she surrounds herself with while taking a break from the ED. “I do things that are not my job when I feel I’ve had enough of it. It can be difficult to disengage from work, but you have to

WOMEN’S HEALTHCARE AND THEIR RIGHTS IN GENERAL ARE UNDER SIEGE BY POLITICIANS WHO DO NOT REPRESENT US, BUT ARE DETERMINING THE QUALITY OF OUR LIVES.”

“Heart attacks, along with many other ailments, present differently between the sexes, and symptoms are often either ignored in women, or are dismissed as being imaginary, hormonal, or mood swings,” she said. And with the future of women’s healthcare resting heavily on our country’s current political leaders, Dr. Hammock believes this topic needs to continue to be challenged for the sake of every woman’s well-being. “Women’s healthcare and their rights in general are under siege by politicians who do not represent us, but are determining the quality of our lives. Why should this be, when we represent the majority of the population? Let’s talk some more about that,” she said. Dr.Hammock’s mother, who mastered multiple careers as a teacher, an attorney, and a bureau chief, on top of being a mom, serves as a source of guidance and inspiration.

do it, or you can be consumed. Too much of anything, even a good thing, is not good,” she said. At the end of the day, Dr. Hammock stresses the importance of being humble and kind, regardless of your position, and to simply enjoy the journey and path of your career. “Take your work seriously, but don’t take yourself that seriously. If you are doing this because you enjoy it, then enjoy the privilege of doing it.” To learn more about Dr. Hammock’s career in emergency medicine, visit http://acoep.org/newsroom.

By Gabi Crowley, ACOEP Digital Media Coordinator

OCTOBER 2017 THE PULSE

ADDICTION: NOT ABOUT KNOWING BETTER By Stephen Kavalkovich

spent most of my adult life as an advanced life support paramedic serving multiple urban and suburban areas in the New Jersey metro area. A vast majority of the emergencies I responded to were overdoses, especially in recent years. I would say that the compound effect of the greater availability of opiod medications, increase in life stress, and other socioeconomic factors have created this epidemic that plagues our society today. However, I am not here to debate what caused this global problem, or if addiction is really a disease. My greater concern is you, the healthcare provider. Since you have spent years studying to secure a place as a licensed physician, do you know better than to fall into the trap of addiction? Now, I do not claim to have had nearly the amount of training that you do. However, I do know that as a human being, we are all fundamentally the same. Everything that we are made of still essentially has the same function on a physical level. We still have the same stresses of life, whether we are an acclaimed surgeon or a homeless war veteran on a park bench. Our basic needs must be met in order to obtain personal homeostasis. The circumstances may be different, but the ways that we sometimes react as humans are rather universal. I saw hundreds of overdoses

THE PULSE OCTOBER 2017

throughout my career as a prehospital provider. In fact, we used to carry Narcan in our pockets due the frequency of its use. I used to work with partners who would complain and show little compassion for these poor souls who we sometimes would revive multiple times in a shift. Little did these colleagues know that I was sliding down the same slippery slope as these people found themselves in. But I knew better, right? Now, I was in a position where I knew that I could not talk about my situation due to fear of retribution, career loss, and judgement. It’s not secret that the stigma within our society surrounding addiction is glaring. However, it remains even more concentrated amongst our colleagues. I began a downward spiral, sinking further into isolation because I didn’t feel safe to open up about it. The shame and guilt that I already carried was crippling, hearing the criticism form my fellows certainly wasn’t going to help.

SINCE YOU HAVE SPENT YEARS STUDYING TO SECURE A PLACE AS A LICENSED PHYSICIAN, DO YOU KNOW BETTER THAN TO FALL INTO THE TRAP OF ADDICTION?

2018 ACOEP’s Spring Seminar Heads West! April 3- April 7, 2018 • Loews Coronado Bay • San Diego, CA

I had all of the proper training surrounding dangerous substances and the consequences of abuse. The reality of seeing it up close every day should have served as a warning from stepping foot on the road of addiction. The fear of incarceration, dereliction, and career loss should’ve stopped it. Yet, I still wound up on the living room floor of my parent’s house, pulseless and cyanotic from an overdose. A former coworker had to inject Narcan to revive me. I lost my marriage, career, and life in the end. But, I knew better right? As medical professionals, you know that there are countless factors that can lead to full blown addiction. Perhaps a sports injury was the starting point. Maybe the vicious cycle of being exposed to trauma and heartbreak every day led you

to use alcohol to cope. Eventually it became a requirement to just get out of bed in the morning. What about a sexual abuse during childhood left you in so much pain that Benzodiazapines seemed to calm the anxiety when the memories came flooding in. We can go on for hundreds of pages about the origins of one’s addictive behaviors. However, I want to open you up to the reality of what lies beneath your white coat. Human behavior is predictable and universal, regardless of pedigree or profession. It can happen to anyone of you. I had to lose my medical credentials to be able to freely share my experience. I became a fullblown heroin addict, which became a financial decision. Narcotic painkillers on the street were $30 a pill versus a bag of heroin for $7.

My brain was already chemically dependent and all rational thinking went out the window. Some say it’s a choice. I agree. Everything that man has ever done began with a choice. However, I certainly didn’t daydream as a child of loss, addiction, and institutions. I didn’t fantasize of divorce, loss of my family, and financial ruin. It can happen to anyone. Even a person with twenty letters after their name can drown. Nonetheless, do we blame a drowning man for getting caught in the rip current? For links to Stephen’s website and podcast, visit www.acoep.org/ newsroom.

OCTOBER 2017 THE PULSE

DO YOU KNOW

FOEM? By Stephanie Whitmer, MNA FOEM Executive Director

ou know that FOEM is your Foundation. You know that it is the non-profit arm of ACOEP and it hosts annual competitions, providing a platform and a spotlight for the best up-andcoming emergency medicine physicians. You know that the Legacy Gala is the best party of the year. But do you really know FOEM?

THE FOEM RESEARCH NETWORK IS AN INDISPENSABLE RESOURCE, DRIVING COLLABORATION AND ALLOWING SMALL OR RURAL HOSPITALS TO WORK WITH OTHER RESIDENCY PROGRAMS TO GATHER QUALITY DATA.”

2017

In recent years the Foundation has grown so drastically, expanding its reach and influence, you may not know everything FOEM is doing, and the opportunities you can take advantage of. So, let me walk you through a few groundbreaking resources FOEM is working on. The FOEM Research Network (FRN) is an indispensable resource, driving collaboration and allowing small or rural hospitals to work with other residency programs to gather quality data. The FRN, still in its early phases, will unite institutions and simplifying the ability to secure funding from pharmaceutical or device manufacturing pilot studies. Now partnering with ACOEP’s Resident and Student Organization, FOEM is revamping the online application process, focusing on applicant’s needs, and making it easier than ever to produce quality research even while short-staffed. FOEM is also in the process of changing its grant funding to align with suggestions made by the applicants. We no longer serve just osteopathic emergency physicians, but the entire emergency medicine community. Our new Grant Handbook, which will be available in 2018, will showcase innovative ways to secure funding for technological advancements, global mission trips, industry-related research and so much more. Currently, FOEM is funding a project investigating the cost, satisfaction levels, and quality associated with adopting a new accreditation paradigm. The results of this study have far-reaching implications into the efficacy of the new training model and will provide valuable insight into successes as well as areas in need of improvement. FOEM is also restructuring its research competitions in response to a changing system. All five competitions now offer a separate faculty track to provide much-needed scholarly activity. We showcase posters in digital pods, allowing us to accept over 100 submissions per competition so no one gets left behind. A new research publication is in development that will need authors, editors, and an Editorial Board, all of which qualify for scholarly activity. We are listening and responding to your needs, and will continue to be your support and resource throughout your career. There is so much more that FOEM is doing and we invite you to get involved and find out all that we have to offer. Join us at the upcoming Champagne and Chocolate Legacy Gala. Meet FOEM Board members and staff at Scientific Assembly. Find out how you can make a difference when you utilize the resources of your Foundation.

Champagne & Chocolate Gala Monday, November 6, 2017 Celebrate a year of achievement, commitment, and progress at the 2017 FOEM Legacy Gala Dinner and Awards Ceremony. Attendees will indulge in a decadent chocolate & champagne pairing as part of our evening of fine dining and recognition of our peers. Visit acoep.org/scientific to purchase tickets.