The Pulse July 2012 by ACOEP

JULY 2012 VOLUME XXXVII NO. 3

Presidential Viewpoints

Gregory M. Christiansen, D.O., M.Ed., FACOEP

Frequently Asked Questions Controversy for Emergency Medicine

There should be a Frequently Asked Questions section at our fingertips for the answers we all seek. Today’s apps don’t have all the answers and Siri® is neutral on most issues. There just isn’t an existential temple on a high mountain waiting for your trepid expedition. Answer.com can help you with Harry Potter’s fictional world of knowing the limitations of a muggle.1 According to the experts muggles don’t have any magical powers to change the world. Other sites like AllExperts. com can help you fix your broken air conditioner to clear the air, but they can’t help you navigate the changing health care environment?2 If you ascribe to an existential view point, then your medical profession isn’t about working a shift, it is about helping you create a career to serve your patients. Creating a career is partly why ACOEP exists. We as fellow members of ACOEP are committed to excellence in emergency care as the cornerstone for osteopathic emergency physicians. Through a variety of tools including continuing medical education and advocacy efforts among others, we

help each other focus on how we can better serve our most important priority, our patients. Allow me offer a candid discussion on the vitriol, but passionate, commentary which occurred during an informational report on Maintenance of Licensure (MOL) by the Secretary of the AOBEM, Dr. Mark Stone during the ACOEP Spring Seminar in Scottsdale, Arizona. As an aside, knowing Dr. Stone for many years, he is an absolute advocate and selfless supporter of our patients and our practice rights. We could not ask for a better, more diligent and impartial leader in these challenging times. I am personally thankful for his tireless work on the AOBEM Board of Trustees. Regarding the MOL issue, although I wasn’t present to hear the actual comments, I was apprised of the unprofessional nature of the criticism which reflected poorly on our society as a whole. I am also aware of the bravery of one member who attempted to speak the truth on the issue. In the end the truth will prevail and any action taken on an issue needs to be based in the principle of truth. I am not going to engage in arbitrating the arguments, but I did find it most interesting and refreshing to learn that there is passion among us. I was equally relieved to know that our members are interested in the issues and want to have a dialogue. What I hope to accomplish in this article is to offer you a means to channel that passion into thoughtful and purposeful action. Opinion is very important because it recognizes the paradox of our situations

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and forces us to reconcile the discourse. Just look at our current world economy as an example. Stimulus spending has long been held as the answer to reviving growth by the dominant political party. However, 3 years later MSNBC hosted three European economists in late May of this year who lamented that after all of their efforts to avert a worsening crash in their respective country’s economies with stimulus spending, the only hope they have of not breaking up the euro-zone was through painful spending cuts. How agonizing was that realization? Opinion and discourse foster learning by recognizing another view point. Be mindful that information, especially new revelations in thinking, can be sensitive to those you may not understand or have considered another perspective. Dialogue should be offered in a civil and professional manner. With that being said, the passionate comment on MOL hit on a topic many find irksome. The MOL topic serves as the backdrop of the euphemistic frequently asked question list. Why do we have to engage in MOL? That is a great question and if we examine it based on the evidence then one would wonder why all of the personal effort in terms of time and money are we being forced to do MOL? I am not going to speak for the AOBEM but rather speak to the larger issue of why do you belong to an advocacy organization like ACOEP? Do you know why MOL even exists? If you are disgruntled about this narrow issue of continued on page 6

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Editorial Committee: Drew A. Koch, DO, FACOEP-D, Chair Wayne Jones, DO, FACOEP, Vice Chair Julia Alpin, DO David Bohorquez, DO Gregory M. Christiansen, DO, M.Ed., FACOEP Joseph Dougherty, DO, FACOEP Anthony Jennings, DO, FACOEP William Kokx, DO, FACOEP Annette Mann, DO, FACOEP Mark A. Mitchell, DO, FACOEP Erin Sernoffsky Brian Thommen The PULSE is a copyrighted quarterly publication distributed at no cost by the ACOEP to its Members, library of Colleges of Osteopathic Medicine, sponsors, exhibitors and liaison associations recognized by the national offices of the ACOEP. The PULSE and ACOEP accepts 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 Norcom, Inc., Advertising/Production Department, PO Box 2566 Northbrook, IL 60065 ∙ 847-948-7762 or electronically at theteam@norcomdesign.com. Please contact Norcom for the specific rates and print specifications for both color and black and white print ads. Deadlines for the submission of articles and advertisements are the first day of the month preceding the date of publication, i.e., December 1; March 1, June 1, and September 1. The ACOEP and the Editorial Board of the PULSE reserve the right to decline advertising and articles for any issue. ©ACOEP 2012 – All rights reserved. Articles may not be reproduced without the expressed, written approval of the ACOEP and the author.

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THE

The Pulse Editorial Staff: Drew A. Koch, DO, FACOEP-D, Editor Wayne Jones, DO, FACOEP, Assist. Editor Gregory M. Christiansen, DO, M.Ed., FACOEP Mark A. Mitchell, DO, FACOEP Erin Sernoffsky, Communication Manager Janice Wachtler, Executive Director

O S T E O PAT H I C

EMERGENCY MEDICINE

Q U A RT E R LY

Table of Contents

Presidential Viewpoints . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Gregory M. Christiansen, D.O., M.Ed., FACOEP The Editors's Desk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Drew A. Koch, DO, FACEOP-D Executive Director's Desk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Janice Wachtler, BA, CBA A Look Back . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Erin Sernoffsky What Would You Do? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Bernard Heilicser, D.O., MS, FACEP, FACOEP In My Opinion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Wayne T. Jones, D.O., FACOEP New Advanced ED Ultrasound Course . . . . . . . . . . . . . . . . . . 11 Erin Sernoffsky ACOEP Resident Chapter Elections . . . . . . . . . . . . . . . . . . . . 12 Osteopathic Continous Certification . . . . . . . . . . . . . . . . . . . . 13 Mark Stone DO, FACOEP, Secretary, AOBEM FOEM: 5K Run for Research . . . . . . . . . . . . . . . . . . . . . . . . . 14 Residency Spotlight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 FOEM: Competitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 ACOEP Residency Schedule . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Frome the Pediatric Case Files . . . . . . . . . . . . . . . . . . . . . . . . . 23 Phyllis A. Cowan, MS 3 Anita W. Eisenhart, DO, FACOEP, FACEP Board of Directors Nominees . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Scientific Assembly Agenda . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 The Journey to Fellowship . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Gary Bonfante, DO, FACOEP,Chair, Fellowship Committee Visual Stimulus Competition . . . . . . . . . . . . . . . . . . . . . . . . . . 33

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The Editors's Desk

Drew A. Koch, DO, FACEOP-D

What is the truth? Every patient that we see in the emergency department provides us with a history and we perform a physical examination. Those two acts encompass a medical screening exam. Upon completion of the exam, we have three choices. We can decide to do a further work-up, waiting for more diagnostic testing before making a decision; we can treat the patient based upon our history and physical, or, based on the same, we can discharge the patient home. In every case, history is paramount to the outcome of the patient encounter. But there often lurks a question: Is the patient truthful in relating that history? Do they have an acute medical emergency that requires emergency medical attention? Or, is there an ulterior motive behind their visit? These latter cases, if distasteful to write about, are not so unusual. This is the patient who is requesting a work note because he did not go to work for non-medical reasons; this is the so-called “professional patient” who presents to the ED to obtain drugs. Every provider is familiar with the frequent untruths told about drug prescription abuse, alcohol consumption or compliance with medications. Less personally blameworthy (though not less frustrating to clinical factfinding) is the patient who believes himself to be telling the truth… and is not. The truth of the patient’s stated history is one thing; the history, after all, is necessarily “subjective.” What about the truth of the physical exam? This is the “objective” part of the medical screening exam. Vital signs, heart tones, visualization of tympanic membranes are subject to accuracy, but not to questions of veracity. Here, one would think we would worry less about “truth”. Yet, it is in the realm of

the physical exam – not the patient history – that I have fielded several difficult patient complaints in the last month. In having to evaluate the truth of those complaints, I have found myself both strategicallyminded about proof, and philosophicallyminded about the nature of truth. One of the most difficult aspects of emergency medicine is answering patient complaints. But those that are most difficult are the complaints that accuse the physician, student, intern, resident, nurse practitioner or physician assistant of inappropriate behavior. The specifics of the alleged inappropriate behavior are two: 1. The provider did not exam me 2. The provider touched me “inappropriately.” Both of these accusations have the potential of involving a medical staff code of conduct, police report and an inquiry into the State licensing board. The first accusation involves the provider being accused of fraud, specifically, billing for a Service that was not performed. A confirmed case of this could subject the provider to civil or criminal penalties or be banned from Medicare and Medicaid participation, which would make the provider unemployable. The second accusation could lead to criminal charges filed against the provider, a report to the state licensing board and a code of conduct or medical staff bylaws violation. What do you do when both the complainant and the accused provider are credible? Whom do you believe? Who is telling the truth and who is lying? Or, to return to our philosophers, is it rather a conception (or misconception, depending on your perspective) on of what is appropriate and inappropriate, what is a complete medical exam and what is not? Certainly, health care professionals will have a different perspective on these questions than others. Just as certainly, it is the responsibility of the provider and staff – within reason – to help ameliorate patient discomfort. When confronted with a situation of alleged wrongdoing by the

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provider, however, and the facts themselves are in question, an administrator is left with a “he said, she said” scenario. Without independent verification of the facts, it is difficult to resolve the complaint. Where, then, might we find such independent verification? I propose two solutions to the problem. The first solution would be the use of ED Scribes. The scribe is a documenter and a record-keeper; she is also a constant shadow to the patient. The utilization of scribes 24/7 365 days per year would provide a witness to collaborate the patient encounter. Chaperones are another option, currently used when providers perform GU exams of a patient of the opposite sex. Any ED staff member of the same sex as the patient can be a chaperone. Have you ever tried to find assistance in a room when the ED is busy? Chaperones are not always available and to hire a chaperone assigned to each provider would be cost-prohibitive. Scribes can serve a double function, as chaperones as well as record-keepers, and constant witnesses the patient-provider interaction. The use of a scribe service is not universal in all emergency departments, secondary to costs and/or resistance by the providers to use them. The second solution would be employing a virtual witness: having a video camera in every patient room. This would provide independent corroboration of the emergency department visit. The use of video cameras is not without policy questions. HIPPA regulations would have to be followed, and policy questions answered, such as: who would have access to the video and under what circumstances would they be viewed? How would they be stored and by whom? Would the videos be used to monitor patient behavior, or the behavior of medical staff, or both? There would have to be policies in place that address the above concerns and attain HIPPA compliance, at minimum. But the creation of such policies is not impossibly out of reach. Video surveillance is already continued on page 5

Executive Director's Desk Janice Wachtler, BA, CBA

Is Anyone Listening? This was a question that appeared on one of the Member Surveys that was returned to the ACOEP in 1995. The member lamented that he or she was tired of the ACOEP’s unresponsiveness to its members. They stated that the ACOEP did little for its member and served its Board of Directors more than it did its members. Needless to say, as Executive Director, this was a devastating comment and I thought about it often during the ensuing years. After that we made a concerted effort, not only to listen to our members’ comments, but to act on them. Over the years, I think we’ve listened and learned from our members as we instituted changes that benefitted ease of travel to and from sites; negotiated for rates that allowed our members to stay at venues that were four

and five star resorts at prices that would benefit them. We shortened or lengthened meetings to provide the maximum CME opportunities to those who needed them; moved from airport locations to downtown sites to allow our members access to dinner venues and nightlife. We have provided access to the internet and Wi-Fi as technology warranted, and basically we listened and continue to do so. In terms of our Board, we opened most of our sessions to the members should they wish to sit in on the reports and nonconfidential actions. We sought outside nominations and mechanisms for selfnomination for Committee and Board positions, and we made our Board Members accessible via email and in person. But now I ask you: are you listening to us and hearing what we need from you? Throughout the last years, we have asked you to step up for Committee and Board nominations and have presented interested parties the opportunity to sign up for interviews with the Nominations Committee for consideration for placement on future Board ballots. We had two people

Editorial (continued from page 4)

of fraud or inappropriate behavior. These accusations can be career-ending for the provider and publicly damaging to the hospital. At the same time, we must protect our patients from providers who practice criminal or unethical behavior. When I mentioned the idea of video in patient rooms to various physicians and P.A.s on my staff, the reaction was almost disbelief. To apply such surveillance to the patient-provider interaction seemed out of line, to say the least. In an earlier time, maybe it would be. In today's practice of medicine, however, video-documentation may be the closest we can get to the truth.

utilized in many ICUs and Psychiatric units, and the legal and administrative examples set. As a staunch advocate for patients’ rights and for providers and nurses to practice without administrative interference, the thought of either entity being violated made me reluctant to endorse videos in the emergency department. However, the inability to resolve patient complaints with independent verification of both complainants and providers has led me to advocate for what at first seemed a radical proposal: the use of video in every patient room of the emergency department. We have to be vigilant in protecting our providers if they are wrongly accused

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in two years sign up for this opportunity. We have asked people to step forward to be considered for nomination to Committees of the ACOEP and AOA and although the number of these has increased it has not surpassed our needs as a College. So what do we need to do to get you to listen to us? The art of listening is not a one-way street and listening does not always mean hearing or understanding. Many times groups like associations hear and understand comments, but don’t necessarily care to make the changes needed. I’d like to say that this is a limited problem, but it’s not, I think it’s a national epidemic. Government doesn’t listen to citizens; schools don’t listen to parents; parents don’t listen to children and children don’t listen to teachers. It all rolls downhill and while we are all connected and although we are world-class texters and emailers, we don’t communicate well with each other on an intrinsic basis. So maybe we should all ask ourselves if we listen. If you do, you will be surprised at what you hear and learn.

Congratulations to the winners of the 2012 Student Case Competition! 1st Place: Jessica Smolar 2nd Place: Holly Ringhauser 3rd Place: Sung M. Cho Look for Jessica Smolar’s winning case in the next issue of The Pulse!

continued from page 1 MOL then what have you done to educate yourself to make the system better? These are very tough questions so let us see if we can have a dialogue and seek solutions. Like a clinical question, I would pose the debate of MOL in a similar format as a journal club. Before coming to the debate, the discussants have to know the issue before engaging in a meaningful discussion. Ideally, since there are two opinions, it would have been very entertaining and informative to have two college members argue their positions in a point / counterpoint format in The Pulse. Alas, another opportunity missed… so let us move on and drill down to the crux of the issue. Is there evidence to support MOL or any certification effort? If I am going to spend the time and effort to complete MOL then I want to know if it will help me in my career and ultimately help my patients. The simple answer is yes. In a powerful 1993 study almost 19,000 patients cared for by 3760 physicians were analyzed for various factors that affected their outcome in acute myocardial infarction (AMI). The study even compared osteopathic certification with allopathic certification and arrived at the same conclusion. Board certified physicians had a 15% reduction in mortality regardless of the type of license. The extrapolated data suggested care from Board certified physicians would have resulted in 325 fewer deaths.3 This landmark study provided validity to the credential of Board certification. The aforementioned study didn’t really address MOL. So is there any other evidence to suggest MOL specifically will help my career and my patients? Again the answer is yes. In a meta-analysis of quality of care outcomes from 1966-2004, 52% of evaluations reported decreasing performance in relation to increasing years of experience. Some outcomes had marginal variability, but the study proved the there is a decay in knowledge and a progression in advances in medical care. Physicians who do not remain up to date had worse quality of care indicators.4 Brennan likewise reviewed the Institute of Medicine’s report on a system’s based approach to quality improvement in his 2004 JAMA article. He summarized the theory with the evidence to determine the relationships on outcomes. He found patient safety was improved when ‘problem solving behaviors’ were part of the culture. These habits correlated to

the same behaviors needed to achieve board certification. He also reviewed the Gallup Poll which demonstrated MOL was highly valued by the public. He concluded that evidence based measures for quality improvement should be part of a physician’s recurrent certification status.5 I hope I have provided a basis for why MOL is important. What I haven’t addressed are the political issues which have been a concern for the physician trade organizations. Transparency of the evidence is paramount to ensure there is validity and reproducibility in a regulation. Otherwise the regulation impedes growth and becomes a punitive means to extract fines or penalties from the participant. It is important for the Federation of State Medical Boards (FSMB) and the American Board of Medical Specialists (ABMS) to demonstrate validity to their decision which ultimately results in mandates passed through the AOA and AOBEM. If the renewal process becomes too cumbersome to navigate the bureaucracy, or becomes a self-serving source of revenue for its affiliates or in the words of Inspector General Levinson, supports ‘competency assurance’ to contractors to avoid being ‘soft on physicians’, then the process is not transparent but rather politically motivated. In my opinion then the system should be re-evaluated or challenged to maintain integrity to the process. It is no longer about career development nor patient safety but rather an issue of control. Here is an example of my concerns. Sheldon Horowitz of the American Board of Medical Specialties provided a brief entitled, ‘American Board of Medical Specialties: Aligning Maintenance of Certification with Meaningful Use.’ This document allows ABMS to align with the potentially controversial aspects of the Department of Health & Human services (HHS) Meaningful Use objectives through MOL. In case you were not aware, Meaningful Use is the term used by the Center for Medicare and Medicaid Services (CMS) to describe the 20 point incentivized payment system for a certified Electronic Health Record (EHR) Program. Dr. Horowitz’s argument mixes valid points such as learning as a continuum with potential political concerns such as the insurance mandate that would result in a single payer platform and thus completely control the emergency medicine practice and reimbursement environment. The proposal goes a step further in having the CMS Physician Reporting Quality Initiative

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(PQRI) data merge with MOL. For many physicians, health information technology (HIT) is still an expensive, cumbersome and contentious issue due to the negative impact on their services. Additionally, historical blunders from CMS’ decisions to ban propofol from the emergency department or require antibiotics within four hours for pneumonia care in order to receive reimbursement are recent reminders of the problems associated with a dominant agency. Do we want our license to be held in review with these metrics? As a further example, the new rules requiring patient satisfaction surveys as a metric for payment while working in a mandated environment is fraught with problems. What a crazy position to be forced into. Give the patient the Percocet or medical marijuana to save yourself on the survey so you can renew your license. Just as crazy is the notion that giving the patient the drugs they seek may also kill them. The patient in turn would be prevented from participation in the survey. Only the government could create such a controversial scenario in the name of good government. Shouldn’t we test these rules before imposing high stakes mandates upon them? Incidentally, don’t expect state licensing board to make much of a fuss regarding the federal government take over of the renewal process. There will be the almighty dollar waived at the state boards to persuade support of the system just like the Department of Educational mandates for broccoli in school lunch programs… yuk! Enough pontification and I have already made the argument for MOL. In moving forward, let us put it into perspective. MOL is supposed to focus on physician competence while enhancing patient safety. However, physician competence is rarely a significant factor at the state licensing level. The Ohio State Board is one of the state boards that tracks certified versus non-certified physicians. On a yearly basis only 0.8% (do you mean <1% or 8%? ) of physicians were subjected to any state board action and of these only about 0.04% were related to performance. The reasons cited included mental health/ retirement, wrong site procedures or history of substandard care. Most state board actions were for personality or behavioral infractions including alcohol and drug abuse or fraud.6 In reviewing all of the arguments for and against MOL, in my opinion there is a benefit to MOL but it has it limits. To take it out of context and expect results that cannot be achieved will

only mean increased cost & burden as a result of the regulation. This will likewise create more physician frustration. This brings me full circle to the point of the article. Passion for an issue is important. Communicating that passion in a professional manner requires some strategic restraint, knowledge on the issue and persistence to effect change. Collectively, we had a failure of all three opportunities to excel. I believe we can do better. First we have to accept where we are on the issues. If we haven’t asked the right questions, then it will be hard to seek the right solutions. We need to educate ourselves and be honest with ourselves. The ACOEP has opportunities for our members to channel the creative and motivated fervor to benefit all concerned. Truthfully many opportunities have passed by without significant membership input. If you are passionate about the issue then participate in educating and creating a meaningful agenda. The issue of MOL is only the tip of the iceberg. The Affordable Care Act (ACA) is the most farreaching law of our professional careers. It fundamentally will change our practices. Many members are still unaware of what is going to happen to their own profession. The Supreme Court will rule on the ACA in late June. No matter what the outcome there is still a need to decrease the cost of healthcare and provide care for an ever increasing population with an insufficient work force. How will you address the coming changes? Are you going to sit idly by and not advocate for your patients and your practice? Have you participated at DO day, the Patient and Physician Advocacy (PAPA) Committee or contributed to OPAC or a political campaign? I can tell you only 3% of DOs supported OPAC. Less than 15 ACOEP members participated in the meet and greet with the honorable Congressman Joe Heck at the Spring Seminar. Few were educated about Congressman Heck’s direct intervention to preserve your practice rights as a DO. Less 10 ACOEP members participated in DO day. The PAPA committee has been begging for participation for years. It is the one place where you can directly get involved in policy decisions, regulatory concerns and government mandates like the MOL issue. The successful Emergency Medicine Action fund (EMAF) was a result of ACOEP’s action to get involved to stem the tide of over-regulation. These opportunities for improvement need to come from you the member through the

committee system if we are to continue to be successful. Don’t let the opportunity pass you by. It may be fitting to top off a controversy with a quote from Peter McWilliams who said, “If you are not actively involved in getting what you want, you really didn’t want it.” Please take the opportunity any way you can and make a difference. An organization can only be as strong as it members who make up the organization. I would challenge you to help us get stronger. References: • http://www.answers.com/ h t t p : / / e n . a l l e x p e r t s . c o m / q / Fi r s t Aid-995/2012/5/hypothetical-case-novel. htm

Patients After Acute Myocardial Infarction. Academic Medicine: Journal of the Association of American Medical Colleges. 2001 October; 76(10) Supplement: S21S23 • Systematic Review: The Relationship between Clinical Experience and Quality of Health Care. Annals of Internal Medicine. 2005 February; 142 (4): 260-273 • The Role of Physician Specialty Board Certification Status in the Quality Movement. Journal of the American Medical Association (JAMA). 2004 September; 292(9): 1038-1043.

• Physician Board Certification and the Care and Outcomes of Elderly Patients with Acute Myocardial Infarction. Journal of General Internal Medicine. 2006 March; 21(3): 238–244.

• American Board of Medical Specialties: Aligning Maintenance of Certification with Meaningful Use National Press Club briefing on meaningful use of health IT, August 5, 2010. http://healthaffairs.org/ blog/2010/08/05/amer-board-of-medspecialties-aligning-maintenance-ofcertification-and-meaningful-use/ accessed May 2012.

• The Certification Status of Generalist Physicians and the Mortality of Their

• h t t p : / / w w w . m e d . o h i o . g o v / professionals-mfal.htm. accessed May 2012

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A Look Back ACOEP 1975-1979 Erin Sernoffsky Communication Manager In December 1975, a small item appeared on page 106 of DO Magazine reading, “A committee has been recognized by the AOA to pursue the formation of the American College of Osteopathic Emergency Physicians. Any interested parties should contact B.D. Horton, D.O.” One year later, a fledgling ACOEP hosted its first CME seminar in Cleveland, elected the inaugural Board, and was well on its way to becoming the respected national organization it is today. The past decade has been a time of tremendous change for ACOEP. Not only has the College begun hosting independent conferences, but membership, committee participation, and registration numbers have all sky-rocketed. The number of staff members has more than doubled and the College is represented in print publications, e-newsletters, social media and more. ACOEP is bigger than ever and still growing.

At times such as these, it is important to take a look back, to learn from the forerunners of this association and understand their dedication, determination and creativity. It is vital for any healthy organization to understand the foundation upon which it is built. In this way, ACOEP will be able to continue in its dedication to providing education for physicians. In 1976, 28 men made up ACOEP’s roster of charter members. By 1977, ACOEP attracted 200 physicians from across the country to its annual meeting, and was authorized to award 17 hours of 1A CME credit to the attendees: ACOEP was growing. To get this organization off the ground, it would take an incredible amount of vision, determination and leadership, and the first Board had no lack of that. Specifically, this zeal was found in Dr. Horton, the first President of the ACOEP Board of Directors. Dr. Horton and his

counterparts saw the need for increased attention to Emergency medicine, for specialized care, and for a support network for the physicians serving in this capacity. They recognized that Americans at large we receiving substandard care. “People are asking for something new in primary care,” Dr. Horton wrote in a 1978 ACOEP newsletter. “Slowly evolving are physicians alert to the specific problems found in medical and surgical emergencies and are honestly responding to the real shortcomings of primary care today. These are some of the same physicians who are reassessing the teaching responsibilities of the medical, house, nursing staffs, paramedics and EMTs.” The visionaries who made up the first ACOEP Board understood that there was a genuine healthcare crisis facing the American people and were determined to change the system. As they studied the problems at hand, the tools at their disposal, and the goals that would benefit the entire country, the Board coined the term, “emergentology.” They defined emergentology as “what emergency patients want and rightfully deserve (i.e., the properly trained emergency [professional], skillfully applying his talents encompassing the Osteopathic Principles of Practice and rendering to the needs of the acutely ill).” Their vision would benefit both patients and practitioners by codifying and expanding standards of care, and increasing the educational opportunities, growth potential, and support network for physicians. They recognized the unique influence that physicians could wield. They looked to themselves and their colleagues to create a solution for a problem and knew that in order to train better doctors continued on page 9

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What Would You Do? Bernard Heilicser, D.O., MS, FACEP, FACOEP In this issue of The Pulse, we will review the case presented by an Emergency Department nurse in April 2012, regarding a 13 year-old female who called 911 because she has a sore throat.

You are medical control. What would you do?

We should first separate transport from ED treatment. The patient has a mild complaint. Nevertheless, she should be transported by EMS to the hospital. If a clinical situation requiring EMS intervention was present, EMS should act on the child’s behalf and treat. Otherwise, routine transport is appropriate. There may be extenuating circumstances surrounding the call that may not be clarified until ED evaluation. Is the child in jeopardy? Is she attempting to leave an abusive environment? Is she being neglected? These problems my not be readily apparent.

This situation may be troublesome for EMS and the base station. Treatment of minors seems to always cause a dilemma. However, a logical approach will simplify our nurse’s concern.

Treatment is not in question. If medical intervention is indicated , we do it. Lack of parental consent, or not present, should never deter a child’s best interest. This would apply for EMS and the ED.

A Look Back (continued from page 8)

handling emergencies, from grease fires to cardiopulmonary resuscitation. In an interview, Dr. Becher said, “People can die from choking on food or from a heart attack in a crowded restaurant simply because no one knows what to do. These deaths are preventable if people do the right thing, and we want to train restaurant employees in proper first aid techniques.” Although the College’s first educational meetings were well-received, they knew that it would not be enough if they did not build the foundation for long-term, sustained growth. “Beginnings are easy,” wrote Dr. Horton, “and ideas are often free flowing only to settle into pleasant conversations on lateral moves and seemingly insurmountable hurdles. Moderately motivated individuals disguise vocal play for commitment and can leave an idea in limbo, curtail its delivery, or force a miscarriage…There is plenty of room for anyone willing to share ideas and

When EMS arrived, there was no family present and they could not be reached. Consequently, there is no consent for treatment or transport of this minor patient. Should EMS transport this patient?

who worked in the emergency departments they must recruit leaders from among the talented pool of physicians already practicing in this new specialty. They established regional coordinators to work with hospitals and physicians in their geographic areas, and developed seven committees, all dedicated to perennially important topics, such as Education, Teaching Hospitals, Membership, Credentials and Ethic. The pioneer members of ACOEP worked far and wide to support physicians and patients. In 1979 Dr. Gerald Reynolds became the first DO resident in an emergency medicine residency program at the Hospital of Pennsylvania College of Osteopathic Medicine. Also at PCOM, Dr. John Becher established an initiative to train restaurant workers in

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When the patient reaches the ED, we can decide if we can wait for consent or immediately treat. A simple sore throat can wait for parental consent. However, if the child is in pain or has a serious medical problem, we should assume protective custody and treat. When a minor calls 911 they cannot give consent not to be transported, so we have an affirmative obligation to be their advocate and care for them. If you have any cases in your practice that you would like to present or have reviewed in The Pulse, please fax them to us at 708-915-2743. Thank you.

hard work so that we may attend to the business at hand: acute medicine.” In the intervening years between then and now, ACOEP has consistently grown: opportunities for Continued Medical Education have expanded; the depth and breadth of conference speakers has continued to evolve; committees serve an ever-increasing number of special interest groups; students and residents have found mentors in ACOEP members. The foundation built by Dr. Horton and his colleagues has given rise to advocacy, education, and, most importantly, lifesaving care in the emergency department.

In My Opinion

Wayne T. Jones, D.O., FACOEP Assistant Editor

Five Monkeys in a Cage I know this will be the second edition in a row that I tell you a story, however the following was an experiment published in 1967 by G. R. Stephenson, Cultural Acquisition of a Specific Learned Response Among Rhesus Monkeys. Five monkeys are placed in a cage with a ladder leading up to a banana hung from a rope. One monkey climbs the ladder and attempts to remove the banana. Just prior to the monkey grabbing the banana, a researcher squirts all the monkeys with cold water. As the monkeys again attempt to obtain the banana, they are all doused again. With the next attempt, a behavior change is noted. The next time one of the monkeys attempts to climb the ladder, another pulls him away, as the rest posture, preparing for the cold water bath. The ladder, banana and water system are removed from the cage. One of the original monkeys is replaced with a new monkey, not aware of the experiment and attempts to remove the banana. The remaining monkeys are aggressive toward the newest member. Of course, the new fellow has no idea why. Another experienced monkey is removed and another novice monkey is introduced. The same behavior is noted. Sequentially, all five of the original monkeys are replaced with monkeys who have never experienced the dousing. Interestingly, none of these

monkeys have any knowledge of the consequences of removing the banana, but all treat newcomers with aggression. So, what can we learn from this? Obviously, if you see a ladder leading up to a banana, just leave the banana alone. More seriously, it speaks to how we learn to love, hate, and do what we do and never question why. We have many behaviors and beliefs that there is no good rationale for. Where did prejudice come from? Why are you a Democrat? Why do they tell me to count to three? Is “see one, do one, teach one” the way to learn? Or how about, “This looks like a student case.” We are not only speaking to how we treat each other, but the bigger picture in how we perform everyday tasks. This also speaks to why we hate to change. Medicine is considered a noble tradition and does, in fact, carry with it many behaviors none of us question (or wish to change). I suspect much of medicine is the practice of avoiding the banana. Ask any physician which patients should be seen first when rounding each morning. I suspect, most will tell you, the most critical; those in the ICU. Ask them why and they will probably tell you that is the way it has always been done. When pressed harder, I am certain they will come up

with some reasons, all of which support their reasoning, but do not support a true “reason”. In fact, if you start rounding on the medical floor, discharge patients, move to the step down, then into the ICU, the forward flow of patients will happen in a more timely manner. This way, nursing has more time to discharge the medical patients so transfers from the Unit can occur more timely. I suspect your hospital would accommodate more ICU admissions this way. We just do what others have done and understand that this is what should be done. “We have always done it this way.” That is a hard rebuttal to overcome. On the other hand, “we already tried that.” It takes a lot of energy to turn that ship. But, if you want to make change, you need to press for a better answer. I suspect many organizations, medical floors, and yes, even emergency departments have succumbed to this pitfall. I have felt pressured in medical staff meetings to agree with the majority. Deep down I knew it was the wrong decision. I felt pummeled. Yet, I have been able to turn some ships. I challenge each of you to look at every decision and action differently; either to make a better personal decision or, at least, to understand why someone else made the decision they did. Remember, they may have been beaten by a group of monkeys.

Don’t Miss Out on Your Chance to Give Back!

Experience is an invaluable teacher. Use your experience and expertise to make a difference in the future of emergency medicine by serving as a Mentor!

The ACOEP Mentor Program is an informal, informative initiative that pairs experienced physicians with aspiring students, helping novices in the field to navigate the challenges of emergency medicine!

Details can be found on the ACOEP website, or by calling Jaclyn Ronovsky, Member Services Assistant, at 312.445.5702.

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New Advanced ED Ultrasound Course at the 2012 Scientific Assembly

Erin Sernoffsky

Planning for A C O E P ’s 2012 Scientific Assembly is well underway, with incredible speakers, spirited competitions, glamorous galas, and much more. Among the many offerings, ACOEP is proud to announce that Teresa Wu, MD has once again joined the faculty of experts and will be presenting two sessions of an interactive emergency ultrasound course. Dr. Wu and her team will guide participants through an interactive,

hands-on lesson that focuses on the use of emergency ultrasonography to minimize risks and improve patient care. This four hour session will explore critical diagnoses using emergency cardiac ultrasonography; ways to perform and interpret ocular and musculoskeletal ultrasonography at the bedside; and utilization of ultrasound guidance during complicated emergency procedures. Both sessions take place on Saturday, October 13th, first from 8am-noon, the second from 1pm-5pm. The $150 registration fee includes 4 hours of 1A CME credit, refreshments and plenty of opportunity for hand-on practice. Space in each session is limited to 35 participants. This course is sure to sell out quickly, so interested attendees are encouraged to

register right away! Dr. Wu is a graduate of Johns Hopkins School of Medicine and completed her residency training, ultrasound fellowship and administrative fellowship at Stanford University School of Medicine. Dr. Wu is the Associate Program Director for the Emergency Medicine Residency Program and the Director of Ultrasound Simulations Programs and Fellowships at the Maricopa Medical Center. She is also an Associate Professor in Emergency Medicine at the University of Arizona College of Medicine in Phoenix. Dr. Wu is a renowned speaker, researcher, educator, and has published prolifically on ultrasound and simulation based training.

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ACOEP Resident Chapter Governing Board Elections EXECUTIVE OFFICER POSITION DUTIES These executive positions are elected individually in a trickle down process. Each executive officer is expected to be at both conventions as well as each conference call in the interim, otherwise is subject to dismissal. PRESIDENT • Oversees all Resident Chapter functions/activities • Attends board meetings as the Resident Representative • ACOEP Committee to attend: Board of Directors VICE PRESIDENT • Assists in any duties that need tended to • Coordinates conference planning • ACOEP Committee to attend: UGME SECRETARY • Responsible for submissions to all publications • Creates the minutes at all Resident Chapter functions • ACOEP Committee to attend: Publications TREASURER • Creates and submits the annual budget • Arranges travel reimbursement for officers and members • Organizes fundraising • ACOEP Committee to attend: Finance COMMITTEE MEMBER DUTIES These 8 positions are selected from the body at large and are voted concurrently on one ballot. Once elected, these 8 people will be assigned by the President to one of the following sub-committees according to their interests and personal strengths (committees subject to change based on current needs). Each committee member is expected to be at both conventions as well as each conference call in the interim, otherwise is subject to dismissal.

• Conference Committee (2) o Programming (lectures, social events, clinics) o PR (sponsorship, marketing and welcome gifts) o ACOEP Committee to attend: CME • PR/Communications o Fast Track/Pulse o Conference Flyers o ACOEP Committee to attend: Publications • Members Services o Benefits o Student Chapter Liaison o ACOEP Committee to attend: Members Services • Graduate Medical Education o fellowship opportunities, job opportunities, professional development o graduation requirements o ACOEP Committee to attend: EMS, practice management • Information Technology (IT) o Website, podcasts, program database, online resources o ACOEP Committee to attend: UGME • Research o Promotion of competitions o ACOEP Committee to attend: Research, FOEM • Political Action o Constitution and Bylaws, DO Day on the Hill, elections o ACOEP Committee to attend: Government Affairs ELECTION RULES RUNNING FOR OFFICE • Must be a member, in good standing, of an ACOEP/AOA approved Osteopathic Emergency Medicine Residency Program • Residents interested in running should submit a 1-2 paragraph

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description of their specific interest in running as well as a picture to Kade Rasmussen (krodeo85@gmail. com) by Friday, August 31st, 2012 • Last minute applicants are accepted but will not have the opportunity to be included in the publications that go out to the members prior to voting • Only executive position applicants are allowed to have a PowerPoint presentation o All presentations must be submitted to above email or brought in person by 8am on day of elections (10/13/12) • Presentations for executive positions will be no more than 3 minutes • Presentations for committee positions will be no more than 2 minutes VOTING • Each program present at fall conference selects 1 official representative • Each program gets 1 vote per executive officer position and 8 votes for the committee positions • The 8 committee positions are voted concurrently on one ballot • The ACOEP-RC Past President is the official tie breaker should it be required (See ACOEP Resident Chapter Constitution and Bylaws for more information)

Osteopatic Continuous Certification Mark Stone DO, FACOEP Secretary, AOBEM Osteopathic Continuous Certification (OCC) - OCC embodies the principles of lifelong learning and continuous improvement designed for the benefit of the public and the profession. Its goal is to continually set the standards of excellence in all fields of medicine by focusing on the six core competencies integral to quality medical care: medical knowledge, patient care, interpersonal/communication skills, professionalism, practice based learning and improvement, and systemsbased practice. These competencies were established by the American Osteopathic Association (AOA), and all its osteopathic medical specialties, including the American Osteopathic Board of Emergency Medicine (AOBEM). The History of OCC – In 2008, the American Osteopathic Association (AOA) Board of Trustees approved the recommendation of the Bureau of Osteopathic Specialists (BOS) to implement an Osteopathic Continuous Certification (OCC) process. All certifying boards are mandated to be fully operational and compliant with all OCC components by January 2013. The parameters of certification in Emergency Medicine have changed dramatically since the founding of AOBEM in 1980. What began as a one-time assessment to obtain a lifetime certificate has evolved into a lifelong learning assessment and continuous certification. Every certificate issued by AOBEM since 1992 is valid for 10 years and expires on December 31 of the tenth year. To maintain the validity of the certificate for another 10 years, the certified emergency medicine physicians (diplomat) must complete the OCC process. The Value of OCC - Specialized residency training and initial board certification established initial standards for performance, but did not assure maintenance of proficiency over a lifetime of practice. Regulatory agencies, health maintenance organizations, and the medical community require reassurance and documentation of continual professional development and education by physicians. AOBEM believes high standards for certified emergency

physicians lead to better health care for emergency patients. The principles behind OCC are designed to assure that the highest standards of patient care are practiced and maintained and to assure patients, physicians, and other stakeholders that physicians are being continually assessed and continually improve patient care outcomes. This is congruent with AOBEM’s mission to protect the public by ensuring the excellence of osteopathic emergency physicians. The Federation of State Medical Licensing Boards (FSMB) recently approved language that would allow OCC participation to serve as a proxy for statebased requirements for Maintenance of Licensure (MOL). The Joint Commission strongly encourages hospitals to measure the six core competencies of their medical staff every two years as part of the credentialing process. In the future, the OCC program may help fulfill Joint Commission requirements during hospital accreditation visits and some pay-forperformance models reward physicians for ongoing performance evaluation and evidence of involvement in improvement processes. The emergency medicine OCC process developed by the AOBEM offers physicians a program that will assist them in maintaining their skills and a mechanism to provide current knowledge in a rapidly changing field. It also responds to the healthcare consumers who demand evidence of a physician’s ongoing excellence in the field of Emergency Medicine. OCC Components -The AOBEM’s OCC process is designed to document that AOA/ AOBEM certified emergency physicians are maintaining the skills and knowledge necessary to provide quality patient care. The program gives diplomats the opportunity to demonstrate to peers, patients and the general public a commitment to lifelong learning and improvement in their practice of Emergency Medicine. Much as basic or initial certification indicates that a physician has met the basic six core competencies during his or her training; OCC acknowledges that the certified physician participates in an

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active and ongoing process of lifelong learning and exhibits the interest and understanding that this knowledge leads to better patient outcomes. This process increases the physician’s value in today’s medical marketplace and enhances his or her worth to their employer and to the patient community that they serve. The initial Core Competencies adopted by the AOA are stated in the first paragraph of this article and the specific Core Competencies for emergency medicine appear in the Basic Standards for Residency Training in Emergency Medicine that are on the ACOEP’s website. A brochure on OCC can be downloaded from the AOA at http://www.osteopathic. org/inside-aoa/development/aoa-boardcertification/Documents/OCC-brochure. pdf The Four Part Process of OCC in Emergency Medicine consists of (1) Professional Status: Emergency physicians must hold a valid, unrestricted and unqualified medical license in the states where they practice or in any one state if in active military practice. Diplomats must also maintain continuous membership in good standing in the American Osteopathic Association. Such membership insures that a physician meets the AOA’s Continuing Medical Education (CME) requirements for certification and adheres to the AOA Code of Ethics. (2) Continuous Osteopathic Learning Assessment (COLA): The COLA module process involves reading assigned articles from the current literature and completing an on-line examination concerning information gleaned from the articles. The list of assigned articles and applications for the examination are posted on the AOBEM website (www.aobem.org/continuous. html). The articles will cover the entire Emergency Medicine Table of Specificity over an 8 year cycle. A new COLA module is available each year. COLA modules must be completed successfully by each physician to enter continued on page 22

FOEM 5K Run for Research

At 5:30 in the morning on Wednesday, April 11, 2012, the Foundation for Osteopathic Emergency Medicine hosted its first ever 5K "Run for Research" fundraiser in Scottsdale, AZ. With over 70 supporters (50 of which actually woke up and ran!) the event was incredibly successful and a great opportunity to bond

in a fun new way. Thank you to all who came out! Find FOEM on facebook for photos of the event! Congratulations to John Sillery, D.O. of Chattanooga, TN for taking first place with a time of 17 minutes, 37 seconds!!! The hotel staff was so amazed by his speed, they deemed him "the

antelope." Great job, Dr. Sillery! Special thanks to Kasandra Botti, D.O. of Boalsburg, PA for raising the most money for the fundraiser. Even her six-year-old daughter Michal Ann donated her Easter money for the cause! Thank you so much for setting such a wonderful example, Dr. Botti!

FOEM 5K Case Study Poster Competition On the afternoon of the run, FOEM also held its annual Case Study Poster Competition which boasted 53 talented presenters. The competition is an excellent way for residents (and some ambitious students as well!) to showcase their presentation skills while providing the audience with an insight into a unique or interesting case that presented in their hospital. It was a wonderful experience for both the presenters and the audience as we spent the afternoon learning together. Thank you to all who attended! Please check out the July issue of The Pulse to read the winning abstracts.

CONGRATULATIONS TO OUR WINNERS

1st Place: Sarah Whyte, D.O. from Kent Hospital for her presentation on Lisinopril Induced Angioedema Requiring Emergent Cricothyrotomy. 2nd Place: Blessit George, D.O. from St. Joseph's Regional Medical Center for her presentation on An Atypical Presentation of Alcoholic Ketoacidosis in the Alcohol Naïve Patient. 3rd Place: Svetlana Zakharchenko, D.O. from St. Barnabas Hospital for her presentation on A Case of New York City Heat Wave Induced Hyperthermia in a 44 Year-old Female with Substance Abuse History.

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SPECIAL THANKS TO OUR JUDGES!!! Curt Cackovick, D.O. Martin Dunsky, D.O., FACOEP Judy Knoll, D.O., FACOEP Beth Longenecker, D.O. Jerry Milas, D.O. Valerie Pollard, D.O. Carol Rahter, D.O. Arnold Schiller, D.O. John Weilbacker, D.O., FACOEP

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Residency Spotlight ACOEP is happy to continue its spotlight on the excellent resident programs available today! Sparrow/MSU EM Residency-Lancing 1215 E. Michigan Avenue Lansing, MI 48912 Hospital Information: Type: University affiliated community Trauma Level: I Number of Hospital Beds: 700 Number of ED Beds: 62 EM Program Information: Phone: (517) 364-2583 Website: www.emlansing.org Total Number of EM Residents: 4-5 per year Residents to Attending Ratio Working Clinically: 1-2:1 Accepts Medical Student Rotations? Yes, contact program for further details. EM Program Curriculum: PGY 1: See Website PGY 2: See Website PGY 3: See Website PGY 4: See Website EM Program Application Information: Dates applications are accepted: October Prefers COMLEX (required); can also have USMLE Interview Dates: October-December Letters of Recommendations: Must have EM letter St. Barnabas Hospital 4422 Third Ave Bronx, NY 10457 Hospital Information: Type: Urban Community Trauma Level: I Number of Hospital Beds: 450 Number of ED Beds: 50 EM Program Information: Phone: (718) 960-6103 Website: www.sbhemresidency.com Total Number of EM Residents: 52 EM Residents, 10 EM/IM, 10 EM/FP Residents to Attending Ratio Working

Clinically: 3-4:1 Accepts Medical Student Rotations? Yes, contact program for further details. EM Program Curriculum: PGY 1: IM/NF, EM, Peds EM, Surg, IM, OB/GYN, ICU, Trauma, VAC PGY 2: EM, Ortho, Neuro, US, ICU, Peds EM, Anes, Trauma, EMS, VAC PGY 3: EM, EMS, Selective, Peds EM, Admin/Research, Trauma, Tox, ICU, VAC PGY 4: EM, Cardio, Elective, US, Ortho, Optho, PICU, Peds EM EM Program Application Information: Dates applications are accepted: Start August 1st Prefers COMLEX Interview Dates: September-December Letters of Recommendations: 3, at least one EM OU-HCOM/Doctors Hospital 5100 West Broad Street Columbus, OH 43228 Hospital Information: Type: Community Trauma Level: N/A; application process to become Level III Number of Hospital Beds: 262 licensed, 150 operational Number of ED Beds: 50 EM Program Information: Phone: (614) 544-2780 Website: www.ohiohealth.com/ medicaleducationdoctors Total Number of EM Residents: In order from PGY 1-4: 6, 9, 10, 8 Residents to Attending Ratio Working Clinically: 1:2 Accepts Medical Student Rotations? Yes, please contact program for further details. EM Program Curriculum: PGY 1: EM, Peds, IM, Critical Care, General Surgery, Ortho, Surgery Elective, OB/GYN, Paid leave PGY 2: EM, Peds EM, Critical Care, Pulmonology, Cardio, Neuro, Anesthesia, Ophthalmology, Paid Leave PGY 3: EM, Peds EM, Emergency Ultrasound, Tox, Trauma, Surgical Intensive Care, Ortho, Elective,

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Paid Leave PGY 4: EM, Peds EM, Admin EM, EMS, Medicine Selective, Elective, Paid Leave EM Program Application Information: Dates applications are accepted: October 1st Deadline Prefers COMLEX Interview Dates: Thursdays from mid-September to first week of December Letters of Recommendations: 3 St. Vincent Hospital St. Vincent Osteopathic Emergency Medicine Residency 2314 Sassafras St., 3rd Floor Erie, PA 16502 Hospital Information: Type: Urban Trauma Level: N/A Number of Hospital Beds: 430 Number of ED Beds: 23 EM Program Information: Phone: (800) 730-3003; (814) 452-5100 Website: www.saintvincenthealth.com Total Number of EM Residents: 16 Residents to Attending Ratio Working Clinically: 4:7 Accepts Medical Student Rotations? Yes, contact program for further details. EM Program Curriculum: PGY 1: EM, Peds Ophthalmology, Medicine, OB, Peds, Surgery, ENT PGY 2: EM, EMS, Infectious Diseases, Ortho, Radiology, Anesthesia, Tox, Elective PGY 3: EM, Peds ER, Adult Trauma, Elective PGY 4: EM, Surgical ICU, CCU, Elective, Research/Admin EM Program Application Information: Dates applications are accepted: JulyDecember Prefers COMLEX Interview Dates: September-December Letters of Recommendations: 2, prefer 1 Emergency Physician

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LEARN MORE ABOUT FOEM’S ANNUAL COMPETITIONS! FOEM Case Poster Competition: This annual competition takes place during the ACOEP Spring Seminar and is open to students and residents that experienced an interesting case that took p lace in their hospital. o o o

DEADLINE F OR APPLICATION: January 31 DEADLINE F OR POWERPOINT: March 31 Top 3 posters are a warded $500, $250, and $125 respectively.

FOEM/MedExcel Research Poster Competition: This annual competition takes place during the ACOEP Scientific Assembly and is open to s tudents and residents that have completed a research project and would like to present it as a poster summarizing their findings. o o o

DEADLINE F OR APPLICATION: July 31 DEADLINE F OR POWERPOINT: September 30 Top 3 posters are a warded $500, $250, and $125 respectively.

FOEM/Schumacher Group Clinical Pathological Case Competition (CPC): This exciting annual competition pits residents against faculty in diagnosing a difficult case. It takes place during the ACOEP Scientific Assembly. Residents submit the case without final d iagnosis, and the faculty member is given a few weeks to develop a diagnosis. Both residents and faculty submit PowerPoint presentations. Each program must have a resident and faculty member in order to participate. o o o o

DEADLINE F OR APPLICATION: July 31 DEADLINE F OR POWERPOINT: September 30 Fee: $100 per program, per case submitted Top 3 presentations are a warded $500, $250, and $125 respectively for both residents and faculty members.

…continued on back….

FOEM/EmCare Oral Abstract Competition: This competition is the same as the Research Poster Competition, but instead of a poster, the s tudent or resident must create a PowerPoint slideshow to present d uring the ACOEP S cientific Assembly. o o o

DEADLINE F OR APPLICATION: July 31 DEADLINE F OR POWERPOINT: September 30 Top 3 presentations are a warded $500, $250, and $125 respectively.

FOEM/EMP Resident Research Paper Competition: Participants submit their research papers (already required to complete residency training) for review by a panel of p hysician experts. The panel identifies the top 3 papers and the resident-‐authors present their findings a t the Annual FOEM/EMP Research Competition that is held during the ACOEP Scientific Assembly. o

DEADLINE F OR APPLICATION/SUBMISSION OF PAPER: July 31 o FOEM will give up to $3500 annually for the best research papers. Typically the top 3 papers get $2000, $1000, and $500 respectively, but FOEM reserves the right to withhold funds if quality work is not submitted.

For more information, please contact:

Stephanie Whitmer Executive Secretary 142 E. Ontario Suite 1500 Chicago, IL 60611 312-‐445-‐5700 swhitmer@foem.org

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continued from page 13 the next step, the Formal Re-Certification Examination (FRCE). Currently, the physician must take all 8 modules during a ten-year period and successfully pass 6 of the modules. Beginning this year (2012) that requirement will change for any physician certified in 2010 or later. These physicians will be required to take and pass all 8 modules during the ten-year period of certification. Physicians should remember these facts regarding COLA modules: first, they are each available on line for three calendar years; so it’s important to stay current. Next, physicians enrolling in any COLA module have three opportunities to take and pass the on-line examination; after three unsuccessful attempts the physician will have to re-enroll in the process and pay the fee again, at which time he or she will have three more chances to pass the examination. Certified physicians failing to meet the requirements outlined above will not be allowed to participate in the next step of the OCC process and will not be eligible to take the FRCE. If you do not meet this requirement you will be required to begin the certification process all over again, taking Part I, Part II and Part III of the primary certification process. If that happens, the physician would maintain his or her current certification status until is expires. (3) Formal Re-Certification Examination (FRCE): Certified physicians are required to take this examination every 10 years to maintain Osteopathic Continuous Certification. The examination covers knowledge areas contained in the entire Emergency Medicine Table of Specificity. The testing process consists of a computerbased multiple choice examination (Core Competencies #1 and #2), as well as an oral examination (Core Competencies #1, 2, 3, and 4). Certified physicians who meet the criteria for this examination may take the FRCE as early as 2 years prior to the expiration of their certificate. (4) Practice Performance: Beginning in 2013, all certified emergency physicians will need to perform a practice assessment

as a part of the Osteopathic Continuous Certification process. It will be performed twice in a ten-year recertification cycle as noted in the practice performance document. This component of Continuous Certification consists of the practicing clinician to assess the quality of his or her patient care by comparing it to that of their peers and nationally set benchmarks. This process promotes improved care through application of "best evidence" and consensus recommendations. Practice Performance must be completed twice every 10 year recertification cycle. (Is this correct? In third line you say twice in 10 years) The completed Practice Performance Form must be submitted with the individual's OCC application to be credentialed for the recertification exams. No charts will need to be submitted and the process consists of 4 steps as outlined below: • Step 1: To initiate the process, identify a target area for clinical improvement. The target area may be a disease entity, a clinical care issue, or an access-to-care issue (e.g., through-put or left-before-treatment). The target area requires a population or clinical issue that is measurable for improvement and has recognized comparison data available. The clinician will need to choose appropriate data points as measures of quality. • Step 2: Collect and review data points from 10 patient charts from the targeted area of study. The clinician may choose patient charts from his/ her practice group, but a minimum of 3 charts must be his/her own patient encounters. • Step 3: The data points from the 10 charts are then compared to evidence based guidelines or expert consensus statements or comparable peer data. Interpretation and analysis of the data points can then be used to identify areas for improvement. Next, develop and implement a practice performance improvement program. This plan may include an educational piece, personal reminders, or a change in process (e.g., adding the NEXUS criteria for cervical spine imaging to the electronic medical record, in order to avoid unnecessary radiation in trauma patients). • Step 4: After implementation of

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the process improvement plan, review at least 10 new charts of the targeted area of improvement. Measure and analyze the data, and then evaluate for improvement. Physicians not clinically practicing emergency medicine will still need to participate in the OCC process. To do this they must complete the "AOBEM Recertification Non-Clinical Form." These physicians will not be required to complete the Practice Performance Module, and their status will be reported to the AOA as "AOBEM Certified: Non-Clinical". If a physician classified as AOBEM Certified: Non-Clinical returns to active practice, they will be required to submit 20 patient charts for review (following the same format/guidelines as Part III of the primary certification process) within one year of their return to active clinical practice. There is also a patient communication and satisfaction component which must be completed once during the ten-year recertification cycle. Emergency physicians are increasingly judged by their ability to communicate with patients, and communication skills have become a major assessment tool as a measure of overall excellence. Diplomats may make use of any satisfaction surveys or methods their departments or hospitals currently employ, so long as the required parameters are included and measured. AOBEM can supply a version of the CAHPS Clinician and Group Survey Reporting Kit (version 2008) to those diplomats not currently participating in an eligible satisfaction survey program. In summary, while many physicians believe this process to be unnecessary physicians must understand that for too long, the credentialing process has involved a one-stage certification process after which time there was no national requirement for the maintenance and continuation of medical knowledge. Osteopathic Continuous Certification and Maintenance of Certification (MOC) on the allopathic side is the medical professions response to the need for public accountability and transparency. This process claims the right to oversee the field of certification and clinical expertise by physician-run national organizations and not governmental agencies. If we are to be the masters of our own fate, we must bite the bullet and police our own practice and physicians.

From The Pediatric Case Files…

14-Year-Old Boy With Chest Pain Phyllis A. Cowan, MS 3 Anita W. Eisenhart, DO, FACOEP, FACEP This case report was a collaborative effort created by the ACOEP Mentor Program between practicing physicians and medical students. Introduction Children often present to Emergency Departments with a complaint of chest pain. The usual differential includes asthma/respiratory difficulty, trauma, gastro-esophageal reflux, sprain/strain, dysrhythmias, or other infectious etiologies.

normal) and a 12-lead electrocardiogram (ECG) (figure 1). The cardiogram showed 1 mm ST elevations inferiorly with reciprocal ST depressions anteriorly. This was a significant change compared to his old ECG’s from past episodes of chest pain (figure 2).

We present a case of a 14-year-old previously healthy boy who had chest pain that woke him out of sleep.

A bedside troponin was 27.71 ng/mL. IV was established, oxygen, aspirin and nitropaste and morphine administered.

Case A 14-year old boy presented to a pediatric tertiary care emergency department (ED) in the pre-dawn morning with chest pain. It started 2 hours prior and woke him from sleep. It was described as a “strong heartbeat” and was associated with vomiting. Upon presentation, the pain was mild, but constant.

The CBC, complete metabolic panel, UA and an 11-point toxicology screen were all normal. The laboratory troponin was 68. 4 ng/mL, and the creatine kinase was 1,503 U/L with a CK-MB of 128.7 ng/ mL (relative index 12.2%).

His only past medical history was anxiety disorder, which presented as chest pain twice to the ED and twice to his primary care adolescent medicine physician. Each episode was worked up and deemed noncardiac. He described this episode as “… nothing like [his] anxiety attacks.” Upon presentation, he was ambulatory, fully conversant, calm and in no acute distress. He was a tall trim young man. HR 76 bpm, BP 129/73 mmHg, RR 16 bpm, T 36.4oC, 100% (RA). HEENT was unremarkable (normal palate). Neck was supple, without abnormality. Chest was clear, good breath sounds. Heart was regular, without murmur, ectopy, or rubs. Abdomen was soft, non-tender, normal organ size, no mass. Extremities had excellent pulses and capillary refill. Neurologic exam was unremarkable. No skin lesions. Initial laboratory evaluation included a portable chest radiograph (which was

The nitro-paste was changed to a nitroglycerin drip and a pediatric cardiology consultation initiated. While waiting for transfer to another tertiary care pediatric hospital (with interventional pediatric cardiology), a bedside echocardiogram was obtained, and read as normal. At the time of transfer, his pain had improved and he remained hemodynamically stable. Hospital Course His pain initially resolved with decreasing cardiac enzymes. Later that first day, his chest pain returned and enzymes again elevated. He had one episode of transient hemodynamically stable ventricular tachycardia. He was medicated with oral atenolol and ibuprofen. His pain and his enzymes improved during his five-day hospital stay and he was diagnosed with myopericarditis. Follow up A pediatric cardiologist saw the child at five months follow-up. He seemed to have resolution. His follow-up ECG was

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improved (figure 3). atenolol.

He remained on

Discussion As in adults, chest pain in children can have many etiologies1. The vast majority of pediatric cases are found to be of noncardiac origin. Behind idiopathic diagnoses, musculoskeletal dysfunctions are the most common. Other common diagnoses include asthma, pleuritis, pneumothorax, and similar respiratory disorders, anxiety and other psychogenic presentations, gastro-esophageal reflux and gastritis, and congenital diseases with pulmonary complications (cystic fibrosis and sickle cell disease). The possibility of occult trauma should always be considered. While cardiac etiologies are less common, the differential remains broad. These include: myocarditis/pericarditis, drug abuse, exposure to cardiotoxins, and congenital cardiac malformations (Marfan’s, Turner’s, Ehlers-Danlos, and familial dyslipidemias). Autoimmune disorders also enter the differential, such as Kawasaki’s or Lupus. Further considerations include mechanical or pathogenic manifestations of neoplasms such as lymphomas, or pediatric pheochromocytoma, in which only 64% of pediatric patients present with classical hypertension2. Myopericarditis may come from any number of infectious or noninfectious sources3, including but not limited to: viruses, bacteria, spirochetes, mycotic organisms, protozoans, helminthes, cardiotoxins, radiation, systemic and

continued on page 24

continued from page 23 autoimmune disorders, or even certain hypersensitivities. Pathogenesis usually includes some measure of cardiac injury. Presentation may be of an ill or well-appearing child4, course may be acute or chronic, and outcomes range from self-limited with complete resolution (as in this case) to fatal5. Conclusion In the absence of dysrhythmias, myopericarditis may not be the first thing that comes to mind with pediatric chest pain. Fortunately, a minimally invasive work-up is sufficient to either rule out serious cardiac or pulmonary etiology or alert the practitioner that a closer look is warranted. This would include a good history and physical, ECG and chest radiograph.

In our case, the ECG triggered the appropriate actions, including cardiac enzymes, protective pharmacology, and a cardiology consult. As in adults, cardiac enzymes are considered reliable markers of myocardial injury. Here, the recurrence of elevated cardiac enzymes supported the diagnosis of myopericarditis, whereas a myocardial infarction would likely have a single peak in enzymes6.

Waltham, MA, 2012. 4. Hoyer MH, Fischer DR. Acute myocarditis stimulating myocardial infarction in a child. Pediatrics 1991 87;2:250-253 5. English RF, Janosky JE, Ettedgui JA, Webber SA. Outcomes for children with acute myocarditis. Cardiol Young. 2004;14(5):488 6. Lane JR, Ben-Shachar G. Myocardial infarction in healthy adolescents. Pediatrics 2007;120;e938

References 1. Geggel RL, Endom EE. Approach to chest pain in children. In: UpToDate, Wiley II JF (Ed), Waltham, MA, 2012. 2. Young Jr. WF. Pheochromocytoma in children. In: UpToDate, Hoppin AG (Ed), Waltham, MA, 2012. 3. Allan CK, Fulton DR. Clinical manifestations and diagnosis of myocarditis in children. In: UpToDate, Kim MS (Ed),

Pediatric Figure 1: Initial ECG with chest pain. Note the ST elevations inferiorly and the reciprocal ST depressions anteriorly

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Pediatric Figure 2: Baseline ECG taken 22 months prior to this presentation.

Pediatric Figure 3: Six month follow-up ECG.

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Board of Director Nominees The nominees for this year’s elections for the Board of Directors are listed below in alphabetical order so that you may familiarize yourself with the candidates. Elections will be held later in the summer and you will receive more information on voting with your dues renewal forms. This information can also be found on the ACOEP website. Thank you very much! Gregory J. (“Joe”) Beirne, D.O., FACOEP, FACEP

Gregory J. (“Joe”) Beirne, D.O., FACOEP, FACEP, is a graduate of the Chicago College of Osteopathic Medicine and of Des Peres Hospital Emergency Medicine residency program where he served as Core Faculty in its emergency medicine department. Since 2003, he has worked as an attending physician at Missouri Baptist Medical Center in St. Louis, where he is the Director of EMS Education. He is also Medical Director for four fire departments in St. Louis and for St. Louis Community College-EMS Programs. Dr. Beirne has been fellowed by ACEP and ACOEP and is a member of the Emergency Medical Service Committee, where he has served as Chair since 2009. In this role, he is active in WADEM as the ACOEP liaison and has been a frequent lecturer to the Resident and Student Chapters. He has served in many roles in EMS, including his pre-medical career as a paramedic and shift supervisor for a hospital-based EMS system. He is active in emergency medical services in the St. Louis area and has is a frequent lecturer with research interests including Prehospital Cardiocerebral Resuscitation, Prehospital Therapeutic Hypothermia, and Prehospital Treatment of Atrial Fibrillation. I appreciate the opportunity to speak to the members of our fine college and ask for your support as I seek a position on the ACOEP Board of Directors. My goal is to represent the interests of all of you, attending, resident and student members.

I’m involved at several levels supporting emergency medicine as not only the “safety net” of our healthcare system, but working to demonstrate to the public, as well as our government, that ED physicians truly are the vital link in any healthcare model. Our student and resident members are the future of our organization. Each and every one of these young physicians are potential leaders and my goal is to help cultivate an environment of mentorship as they begin their professional careers. Thank you for this opportunity; I appreciate your vote and pledge to continue my hard work to maintain ACOEP’s status as the best specialty college in the AOA.

Drew Koch, DO, FACOEP

Dr. Drew Koch is a second generation D.O. and has long wanted to give back to the field. In twenty-five years of practice as a board-certified and residency-trained Osteopathic Emergency physician, Koch has done just that. Dr. Koch has taken on positions of increasing responsibility within Osteopathic Emergency Medicine, and in clinical, educational and administration capacities. Dr. Koch has been an active member of ACOEP since 1987. He is a public face of ACOEP, both as a member and current Chairman of the Communications Committee and as contributing Editor of The Pulse, ACOEP’s quarterly with a circulation reaching more than 3000. He has served as Chair of ACOEP’s Fellowship Committee from 1998-2011. He has also served on the EMS Committee, Member

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Relations Committee and Nominations Committee, where he currently serves as Vice Chair. Dr. Koch has been recognized by ACOEP for his accomplishments in Emergency Medicine. He was awarded the Meritorious Service Award in 2003 and the Robert D. Aranosian, DO, FACOEP, Excellence in Emergency Medical Service Award, in 2010. Dr. Koch is the working Medical Director of the Emergency Department and the two Urgent Care Centers at Cayuga Medical Center, an affiliate of Cornell Weill Medical College based in Ithaca, NY. Dr. Koch serves as Clinical Instructor in Emergency Medicine for Weill. He serves as the hospital’s Chairman of the Peer Review Committee, as well as Second VP of the Medical Staff. He is the Medical Director of four ALS agencies and of sixteen BLS agencies, and Medical Director of Tompkins County EMS. Koch also serves on the Central New York Regional Emergency Medical Advisory Committee. Dr.Koch is most proud of his wife Sandy and his four sons: Drews, Joe, Mikey and John.

John C. Prestosh, D.O., FACOEP

I would like to take this opportunity to thank the members of the ACOEP for electing me to the Board of Directors for the past two terms. I have thoroughly enjoyed this position and would appreciate your vote for a third term. I would like to give back to the college what I have learned based on the experiences of my two terms

and also continue to advocate both for patients and osteopathic physicians. I have been an emergency medicine physician for 33 years and appreciate the art of our specialty. I have an avid interest in academics and teaching students, and when our hospital started an emergency medicine residency, I served as a site director prior to becoming program director. One of the most rewarding moments of my teaching career was receiving the Benjamin A. Field, D.O., FACOEP, Mentor of the Year Award. I have participated in many roles as a Board Member. I have visited medical schools and met with students, presented clinical lectures, and hosted question and answer sessions regarding ACOEP. I am involved in several ACOEP committees: Undergraduate Medical Education, Nominations and Fellowship, Program Directors, Finance, and Executive. I served as the Chair of the Resident In-Service Examination (RISE) and am presently the Board Liaison for Program Directors, Fellowship, Bylaws, and Practice Management. I am also presently serving as the Secretary of the Board. I am actively involved with researching the ACGME Impact Statements as they relate to osteopathic graduating residents participating in ACGME sponsored fellowships and osteopathic physicians acting as core faculty in ACGME programs. While representing our Board, I have contacted allopathic physicians involved in education to request that they voice their disapproval of these impact statements. Leaders from ACEP, AAEM, and CORD have responded and written letters to the ACGME supporting the ACOEP’s concerns. I have been involved with “DO Day on the Hill” and believe the voice of the ACOEP needs to be represented at this national function. We can make a difference by sharing our concerns, opinions, and beliefs with policy makers. I am honored to have been a part of our leadership group and hope the membership believes I have positively contributed to the ACOEP Board and college.

Dr Mark Rosenberg, DO, MBA, FACEP, FACOEP-D

Dr Mark Rosenberg, DO, MBA, FACEP, FACOEP-D is Chair of Emergency Medicine at St Joseph's Healthcare System, and Chief of Geriatric Emergency Medicine and Palliative Medicine. Here he helped create a residency program and oversees the care of more than 130,000 patients each year. He is instrumental in developing several Emergency Medicine Fellowship programs including, EMS/ Disaster, Emergency Bedside Ultrasound, Administrative Management and the new Pediatric Emergency Medicine Fellowship. Dr. Rosenberg has championed many innovative programs including: • ED based Resuscitation Center of Excellence • Geriatric Emergency Department Emergency Department based Palliative Care Program • Physician Incentive Plan • Physician Triage and Front End Patient flow management A PCOM graduate, he is board certified in Emergency Medicine by AOBEM and ABEM, as well as Hospice and Palliative Medicine by ABEM. He received his MBA in Medical Management and studied Physician Compensation Strategies. He started Evergreen Emergency Solutions, a small EM practice group in Northern NJ. Dr. Rosenberg is Chairman of the Geriatric Emergency Medicine Section of ACEP; Chairman and Founder of the ACEP’s Palliative Medicine Section; Council Member for ACEP; Chairman of ACOPE’s Practice Management Committee; Board of Director of NJACEP. Dr. Rosenberg serves on Emergency Practice Management Committee for ACEP where he has helped developed several policies and white papers. He has been a consultant to NQF regarding Palliative Medicine and worked with American Geriatric Society to promote the Emergency Department as the hub of Geriatric Care for unscheduled urgencies.

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He has published in many journals and currently has three textbook chapters accepted for publication on Physician Compensation Models, Geriatric Emergency Department Development, Emergency Department Palliative Medicine. Dr. Rosenberg has unique experience that will be beneficial to the ACOEP Boar d. He has developed one of the nation’s first geriatric emergency departments, and ED-based palliative medicine programs. When asked, how being on the Board of ACOEP would help his career, he answered, "this is an interesting question. The fact that I was nominated is an honor. I am at a point in my career that it is not about me, it is about what I can give back to my profession. I would be honored to serve".

Duane D. Siberski, D.O., FACOEP

Duane D. Siberski, D.O., FACOEP is a 1992 graduate of the University of New England College of Osteopathic Medicine who completed his training in emergency medicine at the Chicago Osteopathic Hospital in 1996. Since then he has served in the capacity of an attending physician in the Department of Emergency Medicine at the Reading Hospital and Medical Center in Reading, Pennsylvania, where he is also the EMS Director. Dr. Siberski also serves his community as an instructor in ACLS, BTLS, PALS, ATLS and BCLS. Dr. Siberski is certified and recertified in emergency medicine by the AOBEM and has served the osteopathic emergency medicine community as a Board Member of the ACOEP from 2008 through 2011 where he served as a Liaison to the Resident Chapter and Member Services Committee. Prior to his term on the ACOEP Board, he served the College as Chair of the Member Services Committee and Liaison to ACEP; continued on page 28

continued from page 27 a member of the EMS Committee and Advisor to the national Student Chapters. Dr. Siberski is also a Fellow of ACEP and ACOEP. Dr. Siberski is a frequent lecturer on emergency medicine topics at national, regional and local venues including the ACOEP Scientific Assembly, the American Heart Association and UNECOM. If elected to the Board of Directors of the ACOEP, it is his desire to represent the needs of the emergency physician working in a community institution to the Board. This position will assist in balancing out the Board by providing the voice of a member who is not an academician or administrator.

James M. Turner, D.O., FACOEP

James M. Turner, D.O., FACOEP – As a three-year member of the Board of Directors, I have been highly involved in the operations of the College, participating in all of its activities. During this time, every vote I have cast has been preceded by the thought, “What would the membership want?” I have served in a number of roles, including as Treasurer of the College. I feel a great deal of responsibility to the membership and view the administration and management of the budget as essential for our success. I have also served as a member of the Committee on Graduate Medical Education where I am currently the Liaison to the Board of Directors. As a member of this Committee, I have become acutely aware of the issues presented to all clinical faculty and administrators of medical education programs and this has served me well in my previous role as Program Director to the emergency medicine residency in Charleston. As the Associate Dean of Clinical Sciences at William Carey University

College of Osteopathic Medicine, it is my duty to direct the curriculum for all clinical courses in the medical school curriculum (including clinical rotations). I am also responsible for the simulation laboratory, continuing medical education, and graduate medical education development. I have had several other positions throughout my career including Chair of Emergency Services at three facilities simultaneously, was an EMS director, and served as a Chief of Staff, and a member of the Board of Directors of a hospital. I was President of the Tennessee Osteopathic Medical Association, served on the RISE committee, and on many state and local committees. I have been a member of the Evaluators Registry, Bureau of Professional Education of the American Osteopathic Association and was as an ACOEP residency inspector until my election to the Board. I have been honored to serve the ACOEP Membership and would be honored to continue to. Whether elected or not, I will continue to be active in this organization. I consider this as I have other experiences in my life as invaluable lessons and I look forward to serving your needs and interests in the future.

Douglas P. Webster, DO, FACOEP-D

Dr. Webster is a graduate of the Chicago College of Osteopathic Medicine, and completed his Emergency Medicine residency there in 1990. He continued as a faculty member at CCOM for the next eleven years, eventually rising to the rank of Associate Professor and Chair of the Department of Emergency Medicine. Dr. Webster has served as Medical Director of the Emergency Department at numerous institutions, including a Level I Trauma Center. He is a former Chair of the Illinois Medical Disciplinary Board, and a Fellow of the Federation of State Medical Boards.

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As a longstanding member of ACOEP, Dr. Webster has been a lecturer at several conferences and for the Written Board Review Course, a co-funder of the Oral Board Review Course and Moderator for the Oral Abstracts Presentation. He has been an invited speaker at the Loyola University Neiswanger Institute for Bioethics and Health Policy, and the University of Southern California, and is the author of a number of scientific papers in the areas of physics and medicine. Dr. Webster is presently Executive Vice President for EmCare, Inc., and recently completed AOBEM recertification in Emergency Medicine. He also serves as a Board Member for the Foundation for Osteopathic Emergency Medicine and the Fibromuscular Dysplasia Society of America.

Agenda for the 2012 Scientific Assembly! Please note that this schedule is tentative subject to change.

Didactics in Detail Monday, October 15 7:30 am 8:30 am 9:30 am 10:30 am 11:30 am 12:30 pm 1:30 pm 3:00 pm 4:00 pm

Keynote Address Rick Bukata, MD The Geriatric ED: The Time is Now Before We are Old Mark Rosenberg, DO, FACOEP-D Emergency Department Palliative Care Mark Rosenberg, DO, FACOEP-D Getting Better, Faster than the Other Guy: How to Astonish our Patients, Staff and Medical Staff Jay Kaplan, MD Lunch (on your own) Practicing Excellence: How to Make More Money and Feel Better at the End of Your Day Jay Kaplan, MD Important Papers from the Recent Literature Kevin Klauer, DO, EDJ & Rick Bukata, MD Abdominal Pain in the Elderly Diane Birnbaumer, MD TIAs: Myths and Controversies Diane Birnbaumer, MD

Tuesday, October 16 7:30 am Deadly Headache Disasters You Can't Miss Michael Epter, DO 8:30 am Diagnostic Radiation- When We've Gone Too Farâ&#x20AC;Ś Tom Green, DO, FACOEP 9:30 am Bedside Teaching in the ED: Really?

10:30 am 11:30 am 1:00 pm 2:00 pm 3:00 pm 4:00 pm

Michael Epter, DO Aortic Disasters - Don't Miss It! Tom Green, DO, FACOEP Lunch (on your own) Traumatic Brain Injury: Beyond the Guidelines Andy Jagoda, MD Newer Drugs of Abuse Heath Joliff, DO Seizure Management in the ED Andy Jagoda, MD Toxicology for the Non-Toxicologist Heath Joliff, DO

Wednesday, October 17 8:00 am 9:00 am 10:00 am 11:00 am 12:00 pm 1:00 pm 2:00 pm 3:00 pm 4:00 pm

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New Opportunities to Improve Cardiopulmonary Resuscitation Benjamin Abella, MD Pediatric Literature Review: What you need to know Maureen McCollough, MD Therapeutic Hypothermia After Cardiac Arrest Benjamin Abella, MD Trauma Update: 2012 Stathis Poulakidas, DO Lunch (on your own) Pediatric Fever: 2012 - In the Era of Contemporary Immunizations Maureen McCollough, MD Burn Update: What We Need to Know in the ED Stathis Poulakidas, DO Critical EKG Pearls I Fred Abrahamian, DO Critical EKG Pearls II Fred Abrahamian, DO

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The Journey To Fellowship Gary Bonfante, DO, FACOEP Chair, Fellowship Committee Have you attended the Scientific Assembly in the fall and watched as a bunch of familiar faces go walking by all dressed in black robes, with green, blue and white colored hoods hanging from their necks? Where are they headed? Those smiling and laughing faces are off to induct the most recently minted Fellows of our College. It’s an exciting, energy-filled event, especially for those being inducted. I recall my induction ceremony with pictures and congratulations. It was like a graduation! Hard work was being recognized and the realization of how much more one could continue to contribute was palpable. So how does one become a Fellow or a Distinguished Fellow? Is there a hazing process? A Fear Factor type event? Dancing with celebrity guest stars? Nope. It’s more difficult! “What?” you might say. “How could that be?” Well, because the way I see it, to become a Fellow, you have to do all your schooling, your residency, and your time as an attending. Then you give of yourself, usually gratis, for countless hours helping others and working to advance the specialty. Oh, and you have to do it well. You just make it look easy. The specific requirements and applications are available on the ACOEP web site under “Member Center” and then “Levels of Membership.” The deadline for all applications is on March 1 of each year. For either honorary titles, you must be nominated by a current Fellow. Fellowship requires continuous membership of five years prior to application (including years

as a resident member) and Distinguished Fellowship requires having been a Fellow for at least ten years. During this time, you must attend and sign in at least two membership meetings. Attendance at two ACOEP CME events in the last five years is also required. Residents can accumulate this time during your training. Nominees must also be board certified by either AOBEM or ABEM. Then it’s time to list all that hard work you’ve been doing. Instead of creating a list of the criteria Please refer to the web site and the applications for a complete list of the criteria. Please remember to submit all paperwork requested as incomplete applications cannot be processed and may be deferred. At the Spring Seminar, the Fellowship Committee will make approval or deferment of the candidates and then submits the lists of inductees to the Board for final approval. When listing your achievements, consider for a moment if the item is truly worth including. While most applications contain significant involvement, occasionally a minor involvement is cited. For example, teaching an ACLS class for paramedics once or twice is not really EMS teaching, nor is giving lectures to medical students a “significant contribution” to the specialty, even if it was a really good lecture. If I look at my application and see that I didn’t truly meet all the requirements, I would consider this an opportunity to become more involved in the specific areas mentioned.

Nominators can be a significant asset by articulating your accomplishments. This is particularly true for application for Distinguished Fellow. Maybe what you humbly list as “giving lectures” is actually the development of a curriculum along with noteworthy research to show outcomes on the teaching. It is important for the committee to fully understand why exactly the individual should be considered for either title. What makes them shine as a member of our specialty? A one to two page recommendation is sufficient to highlight qualifications On occasion an application may be deferred. This typically occurs because clarification is needed or the requirements are not met. In the event of a deferment, applicants will be notified and then have until the next year’s deadline to submit additional supporting information. If the office does not receive that information by the deadline, the application is withdrawn and the candidate would have to be re-nominated. Finally, there is a fee once approved which covers your robe, hood, award and all other recognition from the College that comes along with the title. It is not recommended that you wear your robe on rounds in the ED, but hey, it’s a personal choice! But do wear it to induction ceremonies. Hopefully, we will see you on the stage at an upcoming fall meeting. I will be looking forward to your Fellowship - we promise not to make you sing your favorite tune or eat any worms!

Members in the News! Congratulations to Mark Cichon, DO, FACOEP, newly appointed Chair of the Department of Emergency Medicine at Loyola University Medical Center, Maywood. Dr. Cichon was formerly the Director of the Division of Emergency Medicine in the Department of Surgery. [Source: Crain’s Chicago Business, April 30, 2012] Do you have news to share? An interesting idea for an article? E-mail Esernoffsky@acoep.org to be included in The Pulse!

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ACOEP Announces Visual Stimulus Competition ACOEP is continuing to develop an electronic database of educational visual stimuli for use at the Intense Review and Oral Board Review courses. The database will also be made available to ACOEP members. We encourage you to participate in this new competition, which will take place during the 2012 Scientific Assembly in Denver. Just by submitting your original visual stimuli to the Visual Stimulus Competition you could win prizes of $500, $250 and $125 for the top three submissions. This work will also be considered a scholarly activity for those participating in resident education. All content will be controlled by the College through the Continuing Medical Education Committee. Photographs of patients, EKGs, radiographic studies or other visual stimuli demonstrating classic or unique findings will be used to enhance the education of the practioning emergency physician, and then be added to a developing web-based database for the general membership to access for their own review. Visual Stimulus Competition Format Only original visual stimuli will be considered for presentation, this includes photographs of patients, EKGs,

radiographic studies or other visual stimuli demonstrating classic or unique findings that will enhance the education of the practioning emergency physician. A minimum of two different photographs should be submitted for each individual case. Please submit digital JPEG image by an email attachment (resolution of at least 640 x 480) to:

Brian Thommen: bthommen@acoep.org AND Victor Almieda: almeidavic@aol. com and be sure to mark them “ATTN: Visual Stimulus Competition.” Each submission must be a case review with containing the following elements: 1) chief complaint, 2) history of present illness, 3) focused physical exam, 4) pertinent laboratory data, 5) two questions asking the student to identify the diagnosis or pertinent finding(s). The case review must be typed on a single 8.5” x 11” page document in Microsoft Word® for Windows. On a separate page, please list the answer(s) and brief discussion of the case, including an explanation of any key features or aspects. This two-page document will be mounted adjacent to the

photographs on the 2’ x 2’ board. The case review will be limited to 250 words. Submissions will be selected based on their educational merit, relevance to emergency medicine, quality of the photograph and the case history. Accepted submissions will be notified via email and will be instructed when to set-up and dismantle their case. Patients, patient identifiers and hospital specific information should be appropriately concealed. If accepted for display, ACOEP reserves the right to edit the submitted case. Participants must attest that written consent and release has been obtained for all photographs, with the exception of isolated diagnostic studies such as EKGs, radiographs, etc. Authors will be responsible for bringing their photograph(s) and case review (2 pages with case review and answer) to the Scientific Assembly. Authors of all photos submitted by July 30, 2012, will receive a notification of acceptance or rejection by August 30, 2012. *Submission Form on page 18

Congratulations! The winner of the 2012 Bruce D. Horton, D.O., FACOEP, Lifetime Achievement Award is Peter Bell. This award is given to a member of ACOEP who had made contributions to the College and emergency medicine through his or her actions, dedication and deeds over his or her career. Dr. Bell was chosen based on his role as inaugural director of the Emergency Medicine Residency at Doctors Hospital/OhioHealth, consistent service to the ACOEP as a long time Board and Committee member, Editor of The Pulse, and for his leadership role at the Ohio University Heritage College of Osteopathic Medicine and Centers for Osteopathic Research and Education. Mary Jo Hughes, DO, FACOEP-D, is the recipient of the 2012 Benjamin A Field Award, which is awarded to an ACOEP member or member of the emergency medicine community who had made contributions to teaching emergency physicians, residents and students. Dr. Hughes, a graduate of Michigan State University, has served as an educator, department chair, researcher, lecturer, and leader in the field for three decades. Congratulations, Dr.Hughes!

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ACOEP VISUAL STIMULUS SUBMISSION FORM Submission Deadline: July 30, 2012 Affiliated Institution: First Name: Last Name: Degree (DO/MD): Address: City: State: Zip: Phone: Fax: E-mail:

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Disclosure of Relationships: List any financial or conflicting relationships you may have with submission of this material: �

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I have the following disclosure to make: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________

Submission: Submission of a signed form indicates agreement and conformity with all visual stimuli instructions and constitutes a commitment by the author(s) to present the visual stimulus at the Scientific Assembly and not profit from its presentation. Author’s Signature: ___________________________________________________________ Affirmation Statement: I affirm that written consent and release of responsibility was granted by the patient prior to the submission of photographs. Author’s Signature: ____________________________________________________________ Return the visual stimulus, disclosure and word document electronically to: ACOEP Visual Stimulus Competition American College of Emergency Physicians 142 Ontario Street, Suite 1500 Chicago, IL 60611- 5722 Phone: (800) 521-3709 bthommen@acoep.org

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