The Pulse- Summer 2017 by ACOEP

JULY 2017

Z. DoggMD to Headline ACOEP’s 2017 Scientific Assembly

IN THIS ISSUE: 2017 Scientific Assembly Preview Pg 11 Recipient of the US Army’s 2016 Mologne Award Pg 15 Vote in the 2017 ACOEP Board Elections! Pg 19 Presidential Viewpoints | John C. Prestosh, DO, FACOEP-D

Shaping the Future of Emergency Medicine (Page 3)

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The Pulse VOLUME XXXI No. 3 Editorial Staff Timothy Cheslock, DO, FACOEP, Editor Wayne Jones, DO, FACOEP-D, Assistant Editor Tanner Gronowski, DO, Associate Editor Drew A. Koch, DO, MBA, FACOEP-D, Board Liaison John C. Prestosh, DO, FACOEP-D Christine F. Giesa, DO, FACOEP-D Erin Sernoffsky, Editor Janice Wachtler, Executive Director Gabi Crowley, Digital Media Coordinator Editorial Committee Timothy Cheslock, DO, FACOEP, Chair Wayne Jones, DO, FACOEP-D, Vice Chair Drew A. Koch, DO, MBA, FACOEP-D, Board Liaison John C. Prestosh, DO, FACOEP-D Stephen Vetrano, DO, FACOEP John Ashurst, DO John Downing, DO Tanner Gronowski, DO Erin Sernoffsky, Director, Communications The Pulse is a copyrighted quarterly publication distributed at no cost by the ACOEP to its Members, Colleges of Osteopathic Medicine, sponsors, exhibitors and liaison associations recognized by the national offices of the ACOEP. The Pulse and ACOEP accept no responsibility for the statements made by authors, contributors and/ or advertisers in this publication; nor do they accept responsibility for consequences or response to an advertisement. All articles and artwork remain the property of The Pulse and will not be returned. Display and print advertisements are accepted by the publication through ACOEP, 142 East Ontario Street, Chicago, IL 60611, (312) 587-3709 or electronically at marketing@acoep.org. Please contact ACOEP for the specific rates, due dates, and print specifications. Deadlines for the submission of articles are as follows: January issue due date is November 15; April issue due date is February 15; July issue due date is May 15; October issue due date is August 15. Advertisements due dates can be found by downloading ACOEP's media kit at www.acoep. org/advertising. The ACOEP and the Editorial Board of The Pulse reserve the right to decline advertising and articles for any issue. ©ACOEP 2017 – All rights reserved. Articles may not be reproduced without the expressed, written approval of the ACOEP and the author. ACOEP is a registered trademark of the American College of Osteopathic Emergency Physicians.

TABLE OF CONTENTS Presidential Viewpoints..............................................................................................................................3 John C. Prestosh, DO, FACOEP-D The Editor's Desk............................................................................................................................................4 Timothy Cheslock, DO, FACOEP Executive Director's Desk........................................................................................................................5 Janice Wachtler, BAE, CBA The On-Deck Circle......................................................................................................................................6 Christine Giesa, DO, FACOEP-D ACOEP- RC President’s Report..........................................................................................................8 Kaitlin Bowers, DO Z. DoggMD to Headline ACOEP’s 2017 Scientific Assembly........................................9 Erin Sernoffsky Join Us In Denver For ACOEP’s 2017 Scientific Assembly!...........................................11 Gabi Crowley, ACOEP Staff Starting an Ultrasound Program in the Community Setting......................................... 13 Jay Kugler, DO ACOEP Board Member is the Recipient of the US Army’s 2016 Mologne Award...................................................................................................... 17 Ken Holder Osteopathic Emergency Physicians Participate in Operation Gotham Shield 2017..........................................................................................................19 Stephen J. Vetrano DO, FACOEP, EMT Vote in the 2017 ACOEP Board Elections!................................................................................21 ACOEP Member Bill Bograkos Bridges the Divide from the Emergency Department to Addiction Medicine..........................................................24 Erin Sernoffsky New Physicians In Practice (NPIP)................................................................................................. 26 Nicky Ottens, DO, FACOEP Literature Review: Spring 2017..........................................................................................................28 John Ashurst DO, MSc and Amanda Ellis DO Ethics in Emergency Medicine: What Would You Do?....................................................30 Bernard Heilicser, D.O., M.S., FACEP, FACOEP-D Foundation Focus.........................................................................................................................................31 Sherry Turner, DO, FACOEP

Shaping the Future of Emergency Medicine Do not go where the path may lead, go instead where there is no path and leave a trail. — Ralph Waldo Emerson the above listed challenges diminish the face to face time we desire and need to have with our patients!

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

recently had the privilege to be part of a discussion panel at the Emergency Department Practice Management Association’s annual convention held this past May in San Diego, California. The hour-long discussion featured many pertinent questions and thoughts on how the practice of emergency medicine will look in the future. The first question asked of the panel participants was, “What are the biggest challenges facing the specialty today?” As you can imagine many answers were immediately offered such as insurance companies dictating physician reimbursement; hospital administrators demanding faster emergency department patient throughput; reliance on PressGaney reports as a true reflection of physician care; the electronic medical record; rising costs of medical care, renewal of “merit badges” every few years. There were more challenges offered, but I believe one can plainly see that many obstacles present themselves to emergency medicine physicians. What is the common thread among these barriers facing our specialty? They all take away from the primary reason we chose emergency medicine as our profession—to care for our patients. All

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I certainly agree with each of the above listed challenges facing our specialty. However, I opened my part of the discussion with the statement that we, the physicians, are our own worst adversary. I must admit that my utterance was met with some amazement and questioning looks from the audience. However, I believe my analysis is accurate. Too often physicians merely accept what is presented to them as “that’s the way it is, so do it.” We then incorporate the new edict into our practice as best we can. Is this correct? Is this how we should be acting? Should we speak up if we believe something pushed upon us is not going to improve patient care? All physicians must answer those questions for themselves. I believe physicians have not had enough input into how patient care should be provided. We have not pushed back when demands are made upon us that we know will hinder proper care for our patients. Emergency medicine is still a young specialty in medicine but no one can devalue the importance we have in patient care. Where else can one find immediate care 24/7/365? The lights never go out; the doors never close. Insurance, no insurance—neither will impact the fact that a patient will be seen! Emergency medicine physicians have a unique ability in making split-second decisions that have bearing on patient

outcomes. We relish that ability. We enjoy making a positive difference in a patient’s well-being very quickly. However, our specialty is also different is other ways. We typically know our schedules 1-2 months into the future and can make plans for time-off. That does help provide stability and resilience to do what we do when working in the department. A recent survey of physicians showed that the majority of EM physicians are quite satisfied with what they do on a daily basis. This report is good news, but I believe it leads to internal contentment of the “here and now,” but can hinder the vision of where our specialty may be headed. I believe it is incumbent for every EM physician to speak out when they sense change is not for the betterment of patient care. I realize the House of Emergency Medicine is composed of many groups and each group has leadership that is very active in dealing with the many challenges facing our specialty. These leaders work on behalf of their associations. However, each group may have 4-12 individuals speaking on behalf of patient care. That is a limited number of voices. What would happen if even half of all the members of the House of Emergency Medicine groups were joining their voices speaking out against the challenges confronting our specialty? There would be thousands of voices sharing the same message which would certainly attract the attention of those pushing their will upon us! Continued on Page 8

Resiliency in the Profession The stress and challenges of our profession have the potential to affect our physical and mental health along with our emotional well-being. The Editor's Desk Timothy Cheslock, DO, FACOEP

he emergency medicine profession is known for its high-stress environment— always there, always ready. We serve a diverse population, caring from those in crisis and those who need someone to listen to them. The constant demand of meeting the needs of those we serve takes a heavy toll on us. When the shift is over and the day is done, the coping mechanisms we utilize come in many forms. We all experience breaking points and at time we may choose vice over virtue with the mechanisms we use to cope. It is essential to maintain a well-rounded lifestyle allowing us to remain positive and resilient. We must consciously remain aware of how the trials and tribulations we experience effect our daily routines. Recognition of what makes us unique as both individuals and emergency physicians helps us to enhance our resilience and grow within our profession and fostering relationships important to us. Maintaining healthy relationships with our spouses, children, family members, and friends contributes a large part to who we are. We rely on those relationships to advance our lives. Providing for our families, watching

them grow, and being there for special events is part of why we do what we do. Let’s face it, our job is important but our family is equally important. Creating strong relationships with friends and colleagues is unparalleled in its value. Our colleagues best understand what we do working alongside us daily. A robust support group of family, friends, and colleagues helps us cope with the daily challenges we encounter. We must also focus on our needs as an individual. Our health is just as important as maintaining a healthy work life balance. Taking time to devote to exercise, healthy eating, and rest helps us to stay healthy and continue to serve those whom we care for. We often preach this information to our patients. Isn’t it time we take our own advice? One remaining crucial part of our resilience as emergency providers is our spiritual health. This may take on a variety of meaning depending on one’s beliefs. To some it is attending a house of worship regularly. To others it is taking time for peaceful meditation to clear the mind, reaching that inner peace which is often elusive. For others, it may mean something very different. Whatever your faith, beliefs, or practices it is important to recognize how they influence your daily routine and practice. I believe it is important to take the steps necessary to incorporate your spirituality into practice.

Thus, creating an actively engaged provider eager to meet the high standard of care expected from our patients. As I sit to write this article, I am watching the first anniversary memorial service of the Orlando Pulse tragedy which occurred on June 12, 2015. The events which unfolded that morning challenged the community like never before. The loss of life and severity of injury encountered by emergency responders and personnel that day underscores our need for resilience as emergency physicians. The stress and challenges of our profession have the potential to affect our physical and mental health along with our emotional well-being. It is encouraging and enlightening how the Orlando community has come together to support all those involved, from those who lost loved ones, to the emergency responders, law enforcement community, and the entire region that was effected by this act of violence. I encourage each of you to take stock of your resilience inventory. If you feel resiliency is one of your strong attributes, I commend you for being the wellbalanced physician so many of us aspire to be. If you have identified challenges, I encourage you to develop a plan to make positive change and work toward a more wholesome you!

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Did a Symptom, a Scale, a Solution, and a Paragraph Fuel Today’s Opiate Problem? Executive Director's Desk

What may render someone with extreme pain, may only be a slight pain to someone else.

Janice Wachtler, BAE, CBA

ain ... it has always been there and always will be, but the way it is treated changed drastically with the development of a pain scale. For years, pain was treated with analgesics, the ‘take two aspirins and call me in the morning’ approach. Pain was almost always palpated to determine the severity and with the development of better and different medications, treated individually. In the 1940’s, a physician team at Cornell introduced the first device to detect and measure pain. The Dolorimeter detected pain by focusing a light on a section of skin that was blackened and found that when the skin was heated to certain degrees it produced several different pain levels. This led to the development of the Hardy-Wolff-Goodell Scale with 10 levels or degrees of pain. The only problem—their results were not always reproducible. But that didn’t stop the researchers, who knew that pain was a definite and physical sign and should not be shelved by physicians who thought that pain was only in people’s heads. And so, research continued throughout the latter part of

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the 20th century on how to best treat pain.

lie about pain levels? And, where did opioids come from?

What they learned is that people have varying degrees of pain and that pain is individualized. What may render someone with extreme pain, may only be a slight pain to someone else. Pain tolerance was subjective, so to treat all patients with narcotics wasn’t always necessary. But they knew that pain was real and could, in some cases, inhibit patient wellness.

Well, vacations are time for reading, and what I read was that a short letter to the editor of the New England Journal of Medicine in 1980 may have somehow given physicians a false sense of security in prescribing these powerful drugs. The letter stated that when opioids were prescribed for chronic pain to nearly 40,000 patients at a Boston hospital, only four became addicted.

Other physicians developed different mechanisms for assessing pain, this was to ask their patients to rate their pain on a specific scale, “0” none, “1” slight, “2” moderate, “3” good, “4” complete. This has morphed into the pain scale now seen in most hospital rooms with different emojis for no pain to total pain.

If I was a doctor in 1980, I would have thought, “gee whiz, this is a panacea for pain control and with that kind of data, this is an easy decision!” But it wasn’t.

As someone who has a pain tolerance of a moose, and practically must be dead to acknowledge pain, I wondered how we got to the point today, where so many people are given heavy-duty drugs for pain, and why doctors are so ready to write scripts for narcotics. Is it because they are too busy to properly assess pain? Or is it because people

What was worse is that the letter, sent with no substantive citations, was cited over 600 times in articles published between 1980 and now. In 72% of the articles, the letter was cited as evidence that addiction was rare in patients treated with opioids. In over 80% of the articles authors failed to note that patients in the study were hospitalized. So, for more than 40 years, American physicians were supplied with articles Continued on Page 32

The Ghost Within team, and you suddenly have clarity of thought? Aha!—and all the pieces fall together to make the diagnosis. We are grateful for those moments, both for our patients and for our ego.

The On-Deck Circle Christine Giesa, DO, FACOEP-D, President-Elect

riter’s block. We’ve all been there. What to write for the July issue of The Pulse? With the deadline quickly approaching and still no spark of genius, I reached back to the tactics of my academic days of yore. I went to the basement, and I cleaned the felt on the pool table. I connected my iPhone to a Bluetooth speaker (Oh, how technology has changed!), and I pulled up my Billy Joel playlist. I took my stick in hand and started to shoot pool. As I quietly shot, the neurons in the deep recesses of my brain were hard at work behind the scenes. Eventually, I found myself in a “New York State of Mind,” and the idea started the flow. Our subconscious brain can be our greatest friend or our worst enemy. The intricate synapses in our brain allow us to make analytical decisions and to recall happy memories. The subconscious synapses give us our “Aha” moments. Sometimes in patient care we know that the patient is sick, but we are not able to put our finger on the correct diagnosis. Have you ever been in the process of signing a patient out to the medical

We all strive to provide our patients with the best care, but sometimes we miss the mark (or fear we do). Perhaps there is a diagnosis that we failed to consider, a diagnostic study we misinterpreted, or a treatment that we didn’t think to provide. While in REM sleep, the neurons deep in our brain are hard at work reviewing our activities and decisions from the day. The same synapses that give us that thrilling aha moments are also responsible for conjuring the “ghosts” that wake us from sleep in a cold sweat. This has happened to all of us. If it hasn’t, I have some bad news—it’s going to happen. These realizations, or “ghosts,” are powerful and they affect us deeply. They envelop us in a fear like we have never experienced before, and this fear reaches into the deepest recesses of our being. Once a ghost has been awakened, it can be hard to think of anything else. Why is it that we automatically doubt ourselves and believe that we have made a horrible mistake? What gives the ghost such power over our minds? As physicians, we are taught that we cannot make mistakes. We never want to be responsible for harming anyone, and I think that the consequences of a potential mistake terrify us. We spend a tremendous amount of energy actively trying to suppress these overpowering ghosts. I have found that as the hours and days pass, these permeating thoughts become less intense and eventually become buried.

Or are they? In my personal experience, each time a new ghost arises, the mental and emotional trauma caused by the old ghosts arise along with it, and the next thing I know it’s night of the living dead.

Our “ghosts” have a lot to teach us. When dealing with our ghosts of patient care, it is important to realize that we are not alone. All physicians have faced their own ghosts. There is no easy fix. You cannot simply call Ghostbusters. Our “ghosts” have a lot to teach us. It is important that we deal with them effectively and do not merely suppress them. You may never be able to ascertain whether or not you actually made a mistake, but the first step to recovery is to admit that you have been emotionally traumatized by the possibility. Friends and spouses can be very supportive; however, they have never experienced the degree of anguish that we endure. I have found that discussing the situation with a trusted colleague can be very beneficial and may assist in the healing process. If you are unusually paralyzed by one of these events, I recommend talking with a professional. It is not a sign of weakness, it may be a necessity, and no one will think less of you.

Visit www.acoep.org/news for links to resources to help if you find yourself becoming overwhelmed by the ghosts in your mind.

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Save the Date November 4-8, 2017 Hyatt Regency, Denver, Colorado Save the Date for ACOEP’s Flagship Conference Don’t miss out on: • Keynote speaker Zubin Damania, MD, aka ZDogg • Kickoff Party in downtown Denver presented by Island Medical Management • Expanded Tachy Track • Customizable experience through breakout lecture series • Pre-Conference Tracks including: Wilderness Medicine, Resuscitation, Advanced Ultrasound, Advanced Airway • 7th Annual FOEM Legacy Gala: Dinner and Awards Ceremony presented by US Acute Care Solutions • …and much more!

Visit www.acoep.org/scientific for more information!

ACOEP - RC President’s Report Kaitlin Bowers, DO ACOEP Resident Chapter President ACOEP Board of Directors

ummer for the Resident Chapter is always a busy time! Between graduation and new interns starting there is tons of excitement.

This summer our resident family will grow more than normal as we combine forces with the Student Chapter to form the new Resident and Student Organization (RSO). By working more closely with the students, we hope to continue to improve our conferences and provide our membership with high“Shaping” continued from page 3 When physicians in small community hospitals, urban centers, and large academic institutions make their voices heard, I believe we have the ability to make changes. These would be changes offered by physicians to improve the delivery of care to our patients. We need to get involved in hospital committees to shape our future and to ensure we are delivering the best possible care to our patients. Physicians need to contact their local congressional representatives when important healthcare issues are being considered. Our representatives are appreciative when physicians contact them with information regarding healthcare. Yes, these acts will add to your already busy schedules but the importance of individual involvement will directly affect our future healthcare system. I would like to reflect on one specific example of how physicians are being confronted with unnecessary burdens— the perceived necessity of continuing renewal of “merit badges” (ACLS, ATLS, PALS, BLS). Hospitals and organizations

quality lectures, hands-on experiences, and networking opportunities. In addition to an awesome conference agenda, we are very excited about our new RSO website that is set to go live at the end of the summer. Our hope is that our new site will serve as a user-friendly information hub for residents and students alike. As if that wasn’t already enough, the Fast Track team has big plans to debut their new interactive web platform. With so many new and exciting changes be sure to like our Facebook and Twitter

are promoting the importance of constant renewal in these categories, but the House of Emergency Medicine has taken a strong stand against this issue. The Coalition to Oppose Medical Merit Badges has been formed. The organizations represented in this coalition are the American Academy of Emergency Medicine, the American Academy of Emergency Medicine Resident/Student Association, the Association of Academic Chairs of Emergency Medicine, the American College of Osteopathic Emergency Physicians, the American Osteopathic Board of Emergency Medicine, the American Board of Emergency Medicine, the American College of Emergency Physicians, the Council of Residency Directors, the Emergency Medicine Residents Association, and the Society for Academic Emergency Medicine. All these organizations firmly uphold that certification in emergency medicine overrides completing merit badge renewals. EM certification requires boardcertified physicians to be competent in all the merit badge categories. Although this coalition has been newly created, it

pages to stay up to date on the latest happenings. As always, we want to thank you for your continued support of the resident chapter. We truly appreciate everything the college has done to help us get to this point.

is very active in moving forward to stop the merit badge movement. However, all the listed groups need the assistance of their general memberships. We need all physicians to join this cause. I believe that if every member of the House of Emergency Medicine voices support for this cause, the merit badge matter will be put to rest. Who is going to shape the future of emergency medicine? Will it be the large insurance companies? Will it be the government? Will it be physicians actually working in our specialty? I believe that answer will be shortly forthcoming. It is not too difficult to see where the answer lies if physicians do nothing but accept what is presented to them. I do not believe it is too late for us to be the determining movement to shape emergency medicine. We all need to be motivated to be involved and make a difference in the delivery of healthcare. If we will not be the primary force to determine our existence, you can be sure someone else is waiting to shape our future.

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Z. DoggMD to Headline ACOEP’s 2017 Scientific Assembly Keynote speaker mixes humor with heart By Erin Sernoffsky

With a trademark mix of swagger, humor, and honesty, Z.DoggMD simultaneously commiserates with overworked doctors, takes issue with the healthcare system, and expresses genuine care and concern for patients trapped in medical quicksand. Graduate of UC Berkeley and University of California San Francisco Medical School, Z.Dogg MD, whose real name is Zubin Damania, found himself a newly graduated internist and nearly at his breaking point. And so in 2010 he turned to humor and music, two constants in his life.

It’s like my 10th readmission Not the sharpest clinician But I thought a CHF patient Oughta eat Kentucky Fried Chicken Sole caregiver’s the son I’m like, so what he’s 1 There’s a freakin’ PICC in All he had to do was manage the pump Clad in scrubs, furry white coat, and sunglasses, the headliner for ACOEP’s 2017 Scientific Assembly, Z.DoggMD, croons, dances, and cracks jokes all while shining a light on hospital readmissions, something plaguing EDs across the country.

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It’s just one more readmission No love from the Joint Commission Cause my 1-day prednisone taper’s Probably why her colon’s now missin’ D/c creatinine 1 Now it’s 7 point something It’s the freakin’ weekend Who’m I gonna get to place a Quinton?

“The starting point was burnout,” he said. “This was a cry for help and a means to re-connect with my inner ‘creative’ side while trying to make a difference in our messed up system.” He began making parody music videos as a means of relieving stress and connecting with his fellow doctors; and over one million views later, he hasn’t looked back. His musical parodies use songs from every part of the musical spectrum; from Garth Brooks’ Friends in Low Places, to You’re Welcome from Disney’s Moana, and Eminem’s Lose Yourself where he deals directly with end of life care.

This was a cry for help and a means to re-connect with my inner ‘creative’ side while trying to make a difference in our messed up system.

We are thrilled to welcome Dr. Damania to Scientific Assembly! Z.Dogg MD brings a fresh perspective to the issues we all face on a daily basis. I’m looking forward to the conversations he is bound to spark; only through openness to new ideas can we hope to challenge stagnation in healthcare and create the change we need. John C. Prestosh, DO, FACOEP-D, ACOEP Board President

His videos take in everything from the opioid epidemic, to physician burnout, and while they keep audiences laughing they never lose sight of the human cost of the problems in healthcare. His work has expanded to include daily podcasts, the Incident Report (a series of live videos), and Force Friday videos in which he dons a Darth Vader mask. His work takes direct aim at a broad range of issues including healthcare inequity, the treatment of nurses, and his ongoing disdain for Dr. Oz. He has also become an acclaimed speaker, gaining increased notoriety for a 2013 TEDMED Talk, “Are Zombie Doctors Taking Over America?” With so much fodder for parody readily available, Dr. Damania remains positive and committed to his calling as a doctor. “Traveling around the country speaking and performing, I meet lots of people across the spectrum on the front lines of

health care. They are really excited about real change, change that builds what I call Health 3.0— repersonalized medicine that promotes real outcomes and is driven by clinician leadership, with a focus on teamwork and preventative medicine. These folks have me convinced that positive change and a real movement is possible and in fact inevitable.” Much of the power for this change lies in the hands of physicians, especially emergency physicians, who are often caught between strict regulations and an unending barrage of patients in need. The resulting burnout and depression is a very real danger to physicians personally and to the patients they treat. Dr. Damania has strong recommendations to overcome this. “Focus on compassion (love in the face of suffering) over empathy (feeling others’ pain),” he councils. “Compassion is scalable and inexhaustible and allows you to show concern in words and action

for both patients and colleagues and the broader system as a whole. Empathy is exhausting, leads to poor decisions and bias, has a narrow focus, and burns us out, particularly in the ED.” Z.DoggMD’s mission is to use humor to highlight deeply important issues facing healthcare in America. He champions a patient-centric healthcare system which considers the needs of both patients and providers. ACOEP is proud to welcome Dr. Damania and his trademark combination of entertainment and real-world problem solving to the 2017 Scientific Assembly in Denver. He’ll kick off the event as the keynote speaker in his talk, “Healthcare, Remixed.”

Want to see Z.Dogg’s videos for yourself? Visit www.acoep.org/news for links to his music, lectures and more!

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Join Us In Denver For ACOEP’s 2017 Scientific Assembly! Gabi Crowley, ACOEP Staff

With the planning for Scientific Assembly starting soon after the previous year’s conference is complete, a lot of time and effort goes into making sure the event runs smoothly. “We meet about two times in Chicago for a few days to plan, brainstorm on topics based on curriculum needs and feedback, choose speakers, and complete a boat load of CME paperwork. Then we execute the plan,” he said.

rom Boston, to Orlando, to San Francisco, over the years ACOEP has taken its annual fall conference, Scientific Assembly across the country, and this year we’re heading to Denver, CO, November 4-8th. Scientific Assembly’s 2017 keynote speaker, ZDOGG MD, new preconference tracks, including a resuscitation course led by Dr. Haney Mallemat, MD, FAAEM, and multiple new track lectures, are just a few of the many highlights that attendees can look forward to this fall, according to Scientific Assembly’s Course Chair, Nilesh Patel, DO, FACOEP.

Dr. Patel admits a lot of hard work and time goes into creating a successful event, but in the end, it’s quite rewarding to see it all come to life. “It’s fun to plan the Scientific Assembly. With clinical and administrative tasks, it is a lot of work but the enjoyment of planning it makes it worth it. And seeing the conference succeed makes it worth it as well,” he said. Caring for the critically ill, learning how to stay well having a career in EM, utilizing FOAMed, and updates in various medical

specialties, are just a some of the topics that Dr. Patel hopes attendees will master. “You are hearing from high quality speakers and educators, some of the best in EM,” he said. “Our conference is a success of the growth of the college, as well as the attendees that foster the excitement at the conference. Have fun, get to as many lectures and events as you can!” ACOEP’s 2017 Scientific Assembly also plans to offer more opportunities to earn CME credit, a new and improved resident career fair, well-known EM speakers including Salim Rezaie and David Talan, a re-vamped expo hall, and various physician wellness activities.

Visit www.acoep.org/scientific for more details. We hope to see you in Denver this fall!

Dr. Patel also credits the overall “vibe” of the conference as a large component of its success. “ACOEP is a close-knit group and you tend to see new and old friends at every conference. It’s a big family that comes together to learn from the best in emergency medicine,” Dr. Patel said.

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Starting an Ultrasound Program in the Community Setting Challenges and Solutions By Jay Kugler, DO

mergency ultrasound (EUS)/ Point of Care (POC) ultrasound is fast becoming a necessity in all Emergency departments (ED). Training in EUS/POC ultrasound is now a requirement for all Emergency residency programs and is an area of rapid growth in emergency medicine. Integration of ultrasound in our daily practice is the future of emergency medicine. POC ultrasound is a skill that can be mastered by emergency physicians. The AOA, AMA, ACOEP and ACEP all recognize that POC ultrasound is an obtainable skill that can be utilized in a safe manner. The technology is improving, making it easier and less expensive to train. It is easier than ever to convince your hospital to purchase the equipment you need to do the job. Many community EDs do not have 24 hour comprehensive ultrasound available to them. Ultrasound allows physicians to rapidly assess, diagnose problems and make decisions for better care of their patients. It improves patient safety, when performing procedures, such as central line placements, abscess drainage and nerve blocks. It allows us to manage undifferentiated shock, chest pain and dyspnea with more accuracy. Critical decisions can be made without waiting for a comprehensive study. We can visualize what we have previously, only heard, felt or suspected. Working without ultrasound is like practicing with our eyes closed.

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Working without ultrasound is like practicing with our eyes closed. What I have mentioned is not new or foreign to most ED physicians. There have been various articles on the topic and the use of ultrasound in the ED is supported by the literature. So, why am I writing this article? The simple reason is to address an education gap for community ED physicians. We generally practice in departments with less staff and may not have 24hr ultrasound available. In many cases, we have the ultrasound equipment, but do not have the education and confidence to use EUS/POC ultrasound. I am an ED physician in practice for more than 15 years. During my residency, ultrasound in the ED was new and mostly limited to FAST exams. None of my mentors had any significant formal training in POC ultrasound. And, for the most part our SonoSiteâ&#x201E;˘ S-Fast machine was mostly used as a coat rack. To be fair, there were limited ED uses of ultrasound at the time. And, it was not required training for ED residencies. Over the years, attended conferences and learned to do a FAST exam, looked at the heart during a code and preform line placement with ultrasound guidance. But, for the most part, that was it. I suspect this story is common among ED physicians, working at community hospitals.

Currently, most EUS/POC ultrasound training and usage is at university centers or large EDs with residency programs. They have dedicated time for education and can hire experts in ultrasound to train their students. Collecting cases under ACEP/ACOEP guidelines is easier. And there is more opportunity to practice scanning than community EDs. Bigger programs usually have storage solutions for their images and have robust QI processes. In contrast, community EDs may not have the dedicated time and support to properly train seasoned ED physicians. Most ED physicians recognize the need to be properly trained in EUS/POC ultrasound. And, we also acknowledge the need to be trained to a common standard. Unfortunately, this is not happening fast enough in the community setting. For a variety of reasons, including lack of training, time constraints, availability of equipment and other obstacles, we are falling behind. In the near future, emergency physicians will be expected to use ultrasound in our daily practice. It is already required for central line placement and FAST exams in Trauma. Currently, in many community EDs, EUS/POC ultrasound is either not being used at all or only infrequently. In

addition, ultrasound studies may not be properly stored or reviewed. Decisions are being made based on inadequate or incomplete studies. This is a dangerous way for ED physicians to practice from a medical and legal prospective. Proper education affords us the opportunities to learn new techniques and skills. In addition, it will allow us to bill for the work we are doing. What are some of the challenges and barriers to regularly performing EUS/ POC ultrasound in the ED? 1. Time It takes significant time to learn and feel comfortable with our skills. 2. Money Equipment and training are expensive for already strained budgets. 3. Training requirements can be overwhelming There are many areas to study and the minimum requirements may seem impossible to achieve. 4. Length of stay measures Initially, it takes more time to perform ultrasound studies and this can add to length of stay.

5. Productivity The increased time you spend, with ultrasound studies, may initially decrease your productivity. This will improve with experience. 6. Storage of Studies When we perform an ultrasound study, where do we keep the images? HIPAA compliant storage must be permanent, convenient and accessible. So, how will the community ED physician get the proper training? Most of us cannot leave practice for a year and leave or move our families. Traditional ultrasound fellowships are too comprehensive, too long and are not a practical for the community ED physicians. We need the training, but must find an alternative pathway. Community ED physicians need a more streamlined and focused educational program. We do not need to learn every study available, but need to be great at what we do. Good news is, it is not necessary for ED physicians to drop everything to complete an ultrasound fellowship. We can obtain the needed training and skills by other methods. ACOEP and ACEP both recognize the need to train

community ED physicians who are in practice and have created novel pathways for the needed training. There are now mini-fellowships (1-2 weeks), self-directed training options and online courses. Whatever method we use to obtain the training, we must maintain the highest quality, lest we risk harming our patients and having other specialties dismiss our capabilities. How do we begin the learning process without breaking the bank and further complicating our busy lives? Start with a good introductory course. These are roughly 16 hour courses designed to learn the basics of ultrasound physics, uses of ultrasound and hands-on practice with the transducers. ACOEP also offers ultrasound labs at both Scientific Assembly and Spring Seminar which have been incredibly popular. Then, I suggest going online. YouTube and other online sources have thousands of free ultrasound instructional videos. I also suggest ultrasound blogs and podcasts to further your education. The challenges for training any ED physician in EUS/POC ultrasound are similar, but are highlighted in the community setting. From my experience, it is difficult to motivate community ED physicians. They will need commit additional time and resources, to their busy lives. Community ED physicians usually do not have protected educational time or a formal training programs to rely on. Most

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of the available providers, at a given time are either working, sleeping, recovering from a shift, attending a meeting, or are otherwise unavailable to attend formal training sessions. And, unless they see an immediate need for the skill, other priorities will get in the way. Proper EUS/POC training needs to be made convenient, attainable, affordable, and, most importantly recognized as a critical skill for all ED physicians. This training can be achieved, but we must recognize the obstacles and alter the training methods for the community ED physician.

ACOEP PRESENTS

ZDOGGMD

This is what I suggest: 1. Pick a champion. The most motivated and influential ED physician needs to lead the program. Ideally this person is fellowship trained.

HEALTHCARE, REMIXED

a. The champion must want to do the job. They need to be the ambassador to the other providers, nursing staff and administration.

11/06/17

b. They need to advocate for the necessary training, equipment and software. They will need be armed with data to convince the administration to provide the funds for EUS/POC ultrasound. This is easier than it sounds. c. The champion must make sure their medical group and/or leadership recognize the importance of a robust EUS/POC ultrasound program. They will need their active support to push past any obstacles. d. This person will need protected time to administer the program, train others and manage the QI process. This will need to include financial compensation for their time.

e. They will need to work one-on-one with their colleagues before, during and/or after shifts, to help them in real time, to obtain studies and identify opportunities to use ultrasound.

2. Pick only two or three critical needs

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AC O EP â&#x20AC;&#x2122;S SCIEN T IFIC A S SEMBLY HYATT DENVER CONVENTION CENTER

for EUS/POC Ultrasound in your ED (E-FAST, vascular access, aorta, etc.) and focus training on ONLY those areas.

4. Identify those who are most interested in EUS/POC ultrasound training (Surveys work well).

a. Do not overwhelm your colleagues with too many things to learn.

a. Those in need of training and have strong interest, should be trained first.

b. Help trainees gather the required studies for billing. Focus only the 2-3 selected studies. Other topics could be taught, as soon as everyone (or most) are proficient in the initial training areas. It will get easier to teach other skills as over time.

5. Set up hands-on training sessions after regularly scheduled meetings and in small groups on a regular basis.

6. Set up a committee of interested physicians to formalize your ED standards and training.

c. Keep training simple and frequent.

3. Identify the different skill levels in your group. Some may need only minimal training while others will need more. a. Document which physicians are already trained in EUS and identify their areas of proficiency.

7. Find a storage solution. You will need to work with the hospital IT for HIPAA compliant storage. I recommend Q-path, but a thumb drive and an encrypted viewer will work. 8. Insist that all scans done are saved and stored for review. Continued on Page 28

Fall Research Competitions FOEM Research Study Poster Competition

Sponsored by SUNDAY, NOVEMBER 5, 2017 7:30 am – 11:00 am

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

FOEM Clinical Pathological Case Competition (CPC) SUNDAY, NOVEMBER 5, 2017 7:30 am – 3:30 pm

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

FOEM Oral Abstract Competition SUNDAY, NOVEMBER 5, 2017 12:00 pm – 2:00 pm

This annual competition takes place during ACOEP's Scientific Assembly and is open to residents and students that have completed a research project and would like to present it as a PowerPoint presentation (multiple slides, not a poster) summarizing their findings.

FOEM Resident Research Paper Competition Sponsored by SUNDAY, NOVEMBER 5, 2017 2:00 pm – 3:30 pm

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

The deadline to apply to the Foundation’s Fall Research Competitions is July 31, 2017. Apply now at www.foem.org

ACOEP Board Member is the Recipient of the US Army’s 2016 Mologne Award By Ken Holder USARCENT Public Affairs

AMP AS SAYLIYAH, Qatar – Col. Robert Suter, commander, 3rd Medical Command (Deployment Support) Forward, U.S. Army Central, received the prestigious Major General Lewis Aspey Mologne Award recently in a ceremony held at Camp As Sayliyah, Qatar. The Army surgeon general selected Suter to receive the award. It is given annually to one Active and one Reserve Medical Corps officer who the selection board feels best emulates Mologne by exhibiting a balance between outstanding leadership in military medicine and leadership in academics on a national level. “It is an incredible honor and a humbling experience to be selected to receive this award,” said Suter. “Being respected as both an officer and as an academic is something that I think all military medicine professionals strive for.”

I’ve always tried to be the best I could at both, understanding that through balance, I’d be the most effective officer I could be for the Army. could at both, understanding that through balance, I’d be the most effective officer I could be for the Army.”

Suter, who entered the Army in August 1978 on a four-year ROTC scholarship, said maintaining a balance between being an effective military leader and a professor is like having two distinct professions.

Suter was commissioned into the Medical Service Corps and his first assignments included leading an ambulance platoon and serving as the services officer of a field hospital.

“Oftentimes in our profession you’ll see people that are very strong doctors, some of the best in the world, but they might not be well versed and grounded in military leadership and vice versa,” said Suter. “I’ve always tried to be the best I

Suter then applied and was accepted to medical school. After graduating with a Doctor of Osteopathic Medicine degree, he was assigned to the Emergency Medicine Residency at Brooke Army Medical Center, Fort Sam Houston,

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Texas. Upon completion of that program he served as Chief, Department of Emergency Medicine and Acute Care, Dwight D. Eisenhower Army Medical Center at Fort Gordon, Georgia. In 1995 he transitioned into the Army Reserves as an individual mobilization augmentee in the Department of Military and Emergency Medicine at Uniformed Services University, a position from which he participated in a number of special liaison positions in educational and doctrinal development on behalf of USU and the Acting Secretary of Defense for Health Affairs. He ultimately served

for Emergency Medicine in 2006. He is a subject matter expert in healthcare quality, emergency services management, organization, health policy, and clinical topics with a significant role in international medical diplomacy and medical education in nations on every continent in conjunction with entities including the World Health Organization.

as the senior Army operational medicine educator and course director. While assigned to USU he also mobilized multiple times to fill critical assignments in support of Operations Enduring Freedom, Noble Eagle, and Iraqi Freedom, including Level I and II operations support of the 1st Cavalry and 3rd Infantry Divisions in Iraq, where he worked closely with the Iraqi army, Iraqi national police, and U.S. State Department, and Level III clinical support at Landstuhl Regional Medical Center, Germany. Suter commanded the 94th Combat Support Hospital from 2011-2014 overseeing the deployment of the 94th CSH (-) to Afghanistan, where they performed with such readiness and distinction that the unit was selected out of rotation for two subsequent overseas deployments.

overall theater responsibility for medical logistics and force health protection, and responsibility for health services support of Operations Freedom’s Sentinel, Spartan Shield and contingency support of Operation Inherent Resolve. In addition to his primary assignment, he is the Surgeon Generals Emergency Medicine Consultant (USAR) and a professor of military and emergency medicine at USU. Suter’s civilian career includes serving on the board of directors of a number of emergency medicine and EMS organizations over the past 20 years, including serving as president of the 33,000 member American College of Emergency Physicians in 2004-05, and president of the International Federation

Upon accepting command of the 3d MC (DS) Forward he left his position as vice president, Quality and Health IT for the American Heart Association, where he led global efforts to improve cardiovascular and stroke care in over 2,500 hospitals in the U.S. and over 200 internationally, and retains a civilian position as Professor of Emergency Medicine at the University of Texas-Southwestern Medical School in Dallas, Texas. Suter said this award is important not only to him but to young officers on their way up. “This award is named for Major General Mologne who was a member of the West Point Class of 1954 and the USMA Student Clinic is named after him; he was one of the first West Point graduates to achieve multi-star rank in the medical corps and he is buried at Arlington National Cemetery. He didn’t make a decision to be successful as a Soldier or as an academic or as a physician. He simply chose to be successful.”

Following an assignment in the 807th MDSC Headquarters as the operational medical consultant, Suter took command of the 2nd Medical Brigade during its Army Contingency Force designation period, and successfully transitioned it back into the training cycle. In 2016 he assumed command of the 3d MC (DS) Forward, which is now deployed and serving as the U.S. Army Central Theater Medical Command with

THE PULSE | JULY 2017

Osteopathic Emergency Physicians Participate in Operation Gotham Shield 2017 By Stephen J. Vetrano DO, FACOEP, EMT

10-kiloton improvised nuclear device is detonated on the New Jersey side of the Holland Tunnel. Thousands have been killed and injured. Chaos reigns as the wounded seek help and shelter. Not a newspaper headline, or the focus of the latest Michael Bay movie, this scenario was part of Operation Gotham Shield 2017, a FEMA tabletop exercise now in its second year. One of three such trainings on the East Coast, the program helps first responders from various groups learn how to how to assess, treat and evacuate victims during a potential nuclear attack in the New York City area. The NJ office of EMS and the NJ EMS Task Force, a state sponsored umbrella organization that coordinates large scale responses throughout NJ, held a functional exercise on this date as a spinoff of the FEMA exercise.

was on scene as well. Assisting Vetrano and Letizia were Kenneth Lavelle, MD NR-P, a long-standing NJ EMS Task Force Physician; and Herman Morchell, MD, Medical Director of the Mobile Satellite Emergency Department. The role of the physicians is to staff both the field hospital and the MSED as needed. With Dr. Morchell on scene, Doctors Vetrano, Letizia and Lavelle would staff the triage and treatment areas of the field hospital, as established by Acting Medical Operations Manager William Castagno, EMT-P. The field hospital is a Western Shelter tent system that, when fully assembled, can hold cots for 100 patients. Supplies for the field hospital come from the Mass Care Response Units that are hosted by agencies throughout New Jersey.

The mission of the New Jersey EMS Task Force was to establish decontamination areas as well a formal field hospital where victims would be triaged and treated. Stephen Vetrano, DO, FACOEP, EMT, and Matt Letizia DO both participated in this training, taking on leadership roles in the simulation.

The Mobile Satellite Emergency Department, or MSED, is an 18-wheeler trailer which can expand out to the sides, creating an 8-bed ER, complete with mini lab, portable x-ray machine, and pharmacy. The MSED system is supported by cargo trucks of supplies, a field communications unit, and an incident support vehicle. One of three identical units, sponsored by a consortium of New Jersey hospitals was used for the training.

Dr. Vetrano, Medical Director of the New Jersey EMS Task Force and chair of ACOEP’s EMS Committee was on the scene to coordinate the physician field response. Dr. Letizia, Medical Director of Elizabeth Fire and EMS, a participating New Jersey EMS Task Force agency,

Weather conditions prohibited the air medical helicopters from participating and so the drill proceeded with casualty evacuation done by ground assets. Ambulance Strike Teams were requested from throughout New Jersey, and New Jersey activated an Emergency

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Management Assistance Compact requesting strike teams from Pennsylvania and Connecticut, whose states both sent assets. The highlight of the day was the arrival of 21 medical ambulance buses from throughout New Jersey and New York. Each of these ambulance busses can transport 20 patients on stretchers, more if patients are ambulatory. EMS Task Force Logistics personnel were able to set up a generator that would power the MABs so that they would not have to run off their own engines. Essentially, one engine ran the electrical supply for 21 vehicles. The day ended with two lectures. The first was a brief presentation from the Bergen County Office of Emergency Management Drone Program. The second was a lecture on radiation injuries and response by Dan Januseski, MS, RSO, DABR, EMT; a Radiation Safety Officer and state certified EMT. The NJ EMS Task Force continues to demonstrate its commitment to the citizens and guests of New Jersey by participating in such highly specialized training. Many states have sought to copy the idea of a coordinating agency for specialized EMS resources. “Participating in NJ EMS Task Force events, both drills and real-world, have been some of the most rewarding experiences of my career,” Vetrano said. “Many people go on medical missions throughout the world. This agency allows me to participate in a similar fashion in my own state.”

2017 WEDNESDAY, APRIL 19, 2017 2:00 PM – 5:00 PM

FOEM CASE STUDY POSTER COMPETITION Save the Date Monday, November 6, 2017 • Denver, Colorado

CALUSA E-H

Celebrate a year of achievement, commitment, and progress progress at at the the 2017 2017 FOEM FOEM Legacy Legacy Gala: Gala Dinner and Awards Ceremony. Tickets available soon!

Presented By

THE PULSE | JULY 2017

Vote in the 2017 ACOEP Board Elections! By Ken Holder USARCENT Public Affairs

lection season is once again upon us as ACOEP members are invited to select peers to serve as the guiding body for ACOEP. Not only can active members read the bios here, you are invited to visit the ACOEP website to view videos of Board candidates and view voting instructions. John W. Graneto, DO, FACOEP-D is a 1986 graduate of Ohio University, College of Osteopathic Medicine, completed residencies in emergency medicine and pediatrics at the Midwestern University/ Chicago College of Osteopathic Medicine. A true educator, Dr. Graneto has a Master’s Degree in Education from the University of Cincinnati as well as a Certificate in Health. He is also a graduate of the Costin Institute, Scholars Program for Academic Medical Educators from MWU/CCOM. Dr. Graneto is the Associate Dean for Clinical Education and GME at Kansas City University - College of Osteopathic Medicine, where he is also a professor of emergency medicine and pediatrics. Prior to relocating to Kansas City, Dr. Graneto was involved in the predoctoral, and postdoctoral education at CCOM’s Emergency Medicine Program. Noted for his devotion to education, Dr. Graneto received the Benjamin A. Field, DO, Mentor of the Year Award from the ACOEP in 2012. He has been a

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member of the Committee on Graduate Medical Education, where he served as chair for several years, as well as a noted speaker in many emergency medicine and pediatric conferences. At CCOM Dr.Graneto developed the Master Faculty Series Program to develop a more robust faculty development initiative for clinicians. Justin Grill, DO, FACOEP is a 2007 graduate of Michigan State University College of Osteopathic Medicine who has two master’s degrees in Healthcare Administration and Education in the Health Professions. He completed his residency in emergency medicine at Oakwood Health System in Dearborn/ Trenton, Michigan. Dr. Grill is the Director of Medical Education/Designated Institutional Official at Mercy Health in Muskegon, Michigan where he also serves as Assistant Program Director of its emergency medicine residency. Dr. Grill has been a member of the Emergency Medicine Aptitude and Assessment Testing Committee since 2013 which develops and operates the in-service examination for emergency medicine. He is also member of the Committee on CME responsible for the development of continuing medical education programs for the ACOEP.

Brandon J. Lewis, DO, MBA, FACOEP is a 2002 graduate of the Texas College of Osteopathic Medicine who completed his Emergency Medicine residency at Lehigh Valley Hospital in Pennsylvania. Dr. Lewis served in the U.S. Air National Guard for 10 years as a flight surgeon and was activated several times including a deployment to Iraq in 2007. Dr. Lewis was a partner and Board Member of Emergency Service Partners until 2017 when E.S.P. joined as a founding partner with U.S. Acute Care Solutions. He is currently a physician owner, Southwest Region Clinical Governance Board member, and Regional Vice President with U.S. Acute Care Solutions. Dr. Lewis currently practices at CHI St. Joseph Regional Medical Center, a 310 bed, Level II trauma center in Bryan, Texas. He served as Medical Director and Chair of Emergency Services of the 60,000 patient per year department from 2009 to 2017. Under his direction, the E.D., in cooperation with other departments, earned the hospital national recognition seven consecutive years for excellence in stroke and cardiac care. The facility was designated as a certified stroke center and selected by CMS to serve as a test site for Comprehensive Stroke designation for community hospitals. His facility achieved cycle V Chest Pain Center Accreditation and increased its trauma designation from Level III to Level II. He oversaw the consolidation of regional EMS services under a single medical director for

better standardization and cooperation and implemented a successful clinical research program in the Emergency Department. He has received awards from Trauma Region-N Regional Area Council and St Joseph Regional for his service and achievements. Dr. Lewis has served as Vice President of Medical Affairs for St. Joseph Health System since 2013. Dr. Lewis began his administrative career serving in a Medical Director role at a 7000-volume critical access hospital, and later, at a hospital affiliated freestanding E.D. seeing 12,000 patients per year. Dr. Lewis has been an active member of the ACOEP since joining as a student in 1998 and has served as President of both the Student and Resident Chapters. As a current Board Member, he participated in site visits at residency and student chapters on behalf of the ACOEP. Robert E. (Bob) Suter, D.O., MHA, FACOEP-D, FIFEM is a two-term member of the ACOEP Board of Directors who in July is returning from a Middle East deployment on as a Colonel in the US Army Reserve where he served as the Commander of the medical and healthcare forces in the 13 nation CENTCOM region. When home in the US he practices emergency medicine in a variety of settings from small rural hospitals to major academic medical centers as a Professor of Emergency Medicine. He is a Past President of the American College of Emergency Physicians and the International Federation for Emergency Medicine. He received his bachelor’s degree from Washington University in St. Louis, and received his DO and MHA degrees from Des Moines University in Des Moines, Iowa and a Masters in strategic studies from the Army War College.

He was the physician Co-Chair of the federal project EMS Agenda for the Future published in 1995. On the Board of ACOEP, he has worked hard to mentor osteopathic students, residents, and physicians across the US, always available for as a coach or mentor. Dr. Suter was the first osteopathic physician to serve in an officer position in the ACEP, serving as secretary-treasurer, and President in 2004-05. He was also the first osteopathic physician on the Board of the International Federation for Emergency Medicine, and served as its President in 2006. Before deploying, Bob was Vice President of Quality and Health IT for the American Heart Association, and a Professor in the Department of Emergency Medicine at UT Southwestern in Dallas. In addition to being recognized as an expert clinician he is also the author of scores of studies, papers, and textbook chapters in emergency medicine, and has given hundreds of presentations worldwide, especially in the areas of Evidenced-Based Practice, EMS, Practice Management, Quality and Health Policy. Bob has practiced in nearly every imaginable health care practice setting, and has extensive experience in operations and administration, including as a managing partner in a regional emergency medicine group and as the COO of a 15 hospital multispecialty group of over 200 providers. As a Colonel in the U.S. Army Reserve who has served in Iraq and Afghanistan with the 1st Cavalry and 3rd Infantry Divisions. He is the Reserve Consultant to the Surgeon General for Emergency Medicine, and has commanded the 94th Combat Support Hospital, the 2d Medical Brigade, and the 3rd Medical Command-Forward.

Frank Veer, DO, FACOEP is a graduate of Midwestern University AZCOM, and completed his EM residency at Freeman Health System in Missouri. He has been married to Tami for over 15 years and they have three little boys. Dr Veer is currently the medical director of the ED at Freeman Neosho Hospital, was an EM residency Program Director for 10 years, and has been the medical director of the local tactical EMS team. His varied roles and experiences in Emergency Medicine will help him serve the college during these times of challenge and change.” John Dery, DO FACOEP, FACEP, FAWM is an Associate Clinical Professor of Emergency Medicine at both Michigan State University College of Human Medicine and Osteopathic Medicine. He also serves as the Associate Medical Director and attending physician at Sparrow Health System’s Main and St. Lawrence Campuses. Dr. Dery received his medical degree from Midwestern University’s Chicago College of Osteopathic Medicine in 2004 and completed his Emergency Medicine residency training at Michigan State University, Lansing Campus in 2008. He has been active at the national level in the ACOEP serving as the Student and Residency chapter President and in the AOA serving on the Board of Trustees and as the President of the Council of New Practicing Physicians. Dr. Dery currently serves as the Director of Critical Care Transport and EMS Liaison at Sparrow Health Systems and Medical Team Leader with multiple law enforcement agency S.W.A.T. teams in the Mid-Michigan area. He is a graduate of the International School of Tactical Medicine and completed his Basic and Advanced Tactical Officer training in 2014. He enjoys lecturing on a variety of topics, SCUBA diving, skydiving, technical climbing, travelling on his motorcycle and being outdoors with his family.

THE PULSE | JULY 2017

Register Today for ACOEP’s Oral Board and Written Board Prep Prepare for the upcoming Oral Board and Written Board exams during ACOEP’s prep courses this August. Courses will take place at The Westin Chicago River North in downtown Chicago, Illinois.

Oral Board Review: Midwest

ACOEP’s Written Board Prep

August 5-6, 2017

August 7-11, 2017

Our two-day workshop features an orientation and examination overview, visual stimulus review, and a full day of mock testing sessions with board-certified examiners and case developed to mimic the actual exam.

An intense five-day review course, covering every aspect of the exam through in-depth didactic lectures, lively Q&As, visual stimulus reviews and informal interaction with the course faculty.

Earn up to 10 hours of AOA Category 1A CME credit.

Earn up to 42 hours of 1A CME Credit.

Visit www.acoep.org to register.

ACOEP Member Bill Bograkos Bridges the Divide from the Emergency Department to Addiction Medicine By Erin Sernoffsky

dds are, you’ve seen Bill Bograkos, MA, DO FACOEP, FACOFP around. Be it as an ACOEP faculty member, active committee chair, or board member. Or perhaps you have seen him at another conference. He has lectured around the world; has had a distinguished military career; has worked tirelessly to advance the mission of the World Association of Disaster Emergency Medicine. The indefatigable Dr. Bograkos is involved with American College of Osteopathic Family Physician’s Public Health Committee, has championed causes for America’s veterans and was appointed to the American Osteopathic Association Bureau on Scientific Affairs & Public Health. Recently, Dr. Bograkos became the Board Chair of the American Osteopathic Academy of Addiction Medicine. Emergency medicine physicians often find themselves at the front line of dealing with the struggles of addiction; creating a partnership between doctors in the ED and those who specialize in combating with addiction is a crucial step in gaining a foothold against addiction. Especially in battling the opioid epidemic, it has never been more important to give ED physicians the tools they need to strike a serious blow against addiction. Dr. Bograkos’s unique career path gives him an important perspective on the intersection of emergency medicine and addiction medicine.

“During my EM career I have picked up the phone and called AA for people in crisis,” says Dr. Bograkos. “50% of trauma patients have alcohol on board. 40% of motor vehicle fatalities (dead in the golden hour) have alcohol on board. Emergency Medicine physicians are a vital part of psychiatric emergency services.” In the chaos of the moment it can be difficult for emergency physicians to handle the responsibility of addiction care, however strong partnerships between the ED and other specialties can help. “It behooves us to develop stronger relationships with our partners in psychiatry and addiction medicine,” Dr. Bagrakos advises. “We need to know who to call and when to call. We also need to develop stronger more resilient communities and Psychiatric Emergency Services. Ideally, our ACOEP residency programs would be involved with Addiction Medicine Centers of Excellence. We are the frontline in ‘the war on drugs’ and ‘the opiate epidemic.’” Drugs have struck a major blow throughout the country, however emergency medicine physicians, particularly DOs, are in a unique position to fight back. “Emergency medicine physicians are very capable of diagnosing and stabilizing acute intoxication and delirium,” says Dr. Bograkos. “The addition of a yearly presentation on SBIRT will improve our clinical skills. [As A.T. still says,] ‘to find health should be the object

of the doctor. Anyone can find disease.’ We are physicians not technicians. This is the difference a DO makes.” Building strong ties with colleagues in other specialties can create a strong front in fighting against these epidemics, and with ACOEP’s active members such as Dr. Bograkos, there are some strong weapons in the arsenal. “I have taught chemical and biological preparedness for 25 years now and believe the only way to contain and control an epidemic is through coalitions of dedicated stakeholders,” says Dr. Bograkos. “The World Health Organization refers to bioterrorism as a ‘deliberate epidemic.’ The current drug epidemic is a deliberate epidemic and a significant point source is transnational organized crime. Our prescribing habits and treatment of pain in the emergency room can always improve… Emergency medicine and addiction medicine physicians would benefit from coming together in the pursuit of an operational plan. We don’t need a Task Force. We need to share best practices and lessons learned. We need to walk our talk, communicate, coordinate, and cooperate. We are living in the disaster zone and have seen the casualties.”

For more words of wisdom from Dr. Bograkos, and for references on dealing with addiction medicine, visit www.acoep.org/new

THE PULSE | JULY 2017

CHALLENGE YOURSELF AS A U.S. ARMY EMERGENCY MEDICINE PHYSICIAN.

As part of the U.S. Army health care team, you can make a real difference treating the immediate medical needs of Soldiers and their families while also growing in your career: • You’ll work with the most advanced emergency technology and have the opportunity to experience a variety of settings. • You’ll develop as a leader, learn from the best and have the ability to make quality patient care your main focus. • You’ll receive excellent benefits such as special pay, as well as the potential for continuing education and career specialty options.

To learn more about joining the U.S. Army health care team, visit healthcare.goarmy.com/gx07, e-mail usarmy.knox.usarec.list.9c2d@mail.mil or call 847-541-7326.

New Physicians in Practice Spring 2017 Nicky Ottens, DO New Physicians in Practice, ACOEP Board Liaison

n behalf of the New Physicians in Practice (N PI P) Com m ittee, cong ratulations to graduating residents! Your hard work has paid off and now you are ready to transition from resident to attending. This is such an exciting and nerve-wracking time in your career. We are here to help you with that transition. Whether you have questions about contract negotiations, liability insurance, loan repayments or maintaining your newly minted license, we have answers and are here to help you every step of the way! Feel free to contact us directly through ACOEP or browse the website where you will find helpful information, including our membership guide that answers lots of questions directed at those who are in their final years of residency or first five years in practice. We had a nice time gathering poolside at ACOEP’s Spring Seminar in Fort Myers, Florida. We welcomed approximately 25 attendees at our social outing and enjoyed answering questions about what it’s like to be newly out in practice and getting to know each other. As we look ahead to the Denver, you can expect more exciting things including a NPIP educational track. Keep watching The Pulse and ACOEP’s website as well as our Facebook page for the New Physicians in Practice for more details. Hope to see you there!

There are a lot of changes coming down the pipeline, especially with the combined match and movement towards a single GME accreditation system. There are a lot of changes coming down the pipeline, especially with the combined match and movement towards a single GME accreditation system. As those changes occur, we will be sure to keep you updated. For now, as of 2018, the AOA annual dues will no longer be a requirement to maintain board certification. More details can be found at their website at www.Osteopathic.org. Also, testing dates for the AOBEM have made quite a change. For 2017, the Written Board testing date is in September. Therefore, a resident can no longer take the exam while still a resident and must graduate first and take it three months after graduation. This applicant would then not be able to apply for Oral Boards until July 2018, to sit for the Oral Boards in November 2018 or into 2019. For 2018, things will be similar to how they were in 2016. Written Boards will take place in May 2018. You can then apply for Oral Boards in July 2018 and take them in November of 2018 or in 2019. With regards to the recertification process, all board certifying groups will be combining and have been tasked with coming up

with an alternative to the current 10 year recert exam. This exam will most likely change in formatting and will likely be g-oing away. Replacement for it is still being discussed. The AOBEM will be sending out a survey to get your input. Please take advantage of this opportunity to help guide what our futures look like, it isn’t often that we get the opportunity to actually play a role in the board certification process! Stay up to date on the latest changes at their website. ACOEP is here to hep in preparing to take these exams whenever you are able to take them. The upcoming Written Board Prep and Oral Board Review has been moved to August in Chicago to accommodate these changes. With a transition into a single accreditation system, change is inevitable. The New Physicians in Practice Committee is working hard to keep you up to date as these changes take place! And we could use your help- if you are interested in serving on this committee and staying active in the ACOEP, please let us know!

THE PULSE | JULY 2017

Emergency Medicine Opportunities in Texas • • • • • •

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Literature Update Spring 2017 John Ashurst DO, MSc and Amanda Ellis DO

Did Manny Get It Wrong: An Update On Early Goal Directed Therapy

practice and possibly make adjustments to their standard of care.

Donâ&#x20AC;&#x2122;t hold the Epinephrine in the Elderly with Anaphylaxis

Article: The PRISM Investigators. Early, goal directed therapy for septic shock: A patient-level meta-analysis. NEJM. Epub ahead of print.

Does Metabolic Resuscitation Work in Sepsis?

Article: Kawano T et al. Epinephrine use in older patients with anaphylaxis: Clinical outcomes and cardiovascular complications. Resuscitation. Epub ahead of print.

What We Know: In 2001 Rivers and his colleagues developed a means of treating sepsis called Early Goal Directed Therapy (EGDT) that was widely accepted in the medical community due to its reduction of mortality in those with septic shock. However, recent trials have shown EGDT is no better than the standard of care. Article Review: This was a prospective meta-analysis of patients enrolled in the ProCESS, ARISE and ProMISE trials with a goal to use the pooled data to primarily determine the 90 day mortality of EGDT compared to usual care. The investigators also sought to determine the clinical and economic outcomes of EGDT versus usual care. A total of 138 hospitals across seven countries enrolled 3723 patients and found that 90 day mortality was similar for usual care and EGDT (25.4% vs 24.9%; 95% confidence 0.82 to 1.14; P=0.68). Secondary analysis found that EGDT was associated with longer stays in the intensive care unit, receipt of cardiovascular support and overall total cost as compared to usual care. Commentary: According to the PRISM trial, EGDT does not reduce mortality at 90 days and increases total resource allocation in those with septic shock. Based upon this new data, physicians and administrators should review how they

Article: Marik PE, Khangoora V, Rivera R et al. Hydrocortisone, vitamin C, and thiamine for the treatment of severe sepsis and septic shock: A retrospective before/ after study. Chest. Epub ahead of print. What We Know: A significant amount of time and funding has gone into resuscitative efforts for sepsis but only a handful of studies have looked to determine if metabolic resuscitation improves outcomes. Article Review: This was a retrospective before and after study that sought to determine if hydrocortisone 50 mg every six hours for seven days, vitamin C 1.5 grams every six hours for four days and thiamine 200 mg every 12 hours had an impact on hospital survival in those with sepsis. A total of 47 patents were included in both the treatment and control groups and had no difference in baseline characteristics. Hospital mortality was 8.5% in the treatment group and 40.4% in the control group. Vasopressors were also weaned off on average 36.6 hours earlier in the treatment group (p<0.001). Commentary: Although this article shows promise it is limited by study design. A randomized clinical trial needs to be completed in order to determine the true effects of treatment. However, when all interventions have been exhausted; this treatment method seems to be a safe and reasonable treatment method to employ.

What We Know: The use of epinephrine in treating anaphylaxis in the elderly is relatively low. Reluctance is thought to stem from concerns for cardiovascular complications when epinephrine is given to the older populations. However, anaphylaxis is a serious emergency which requires prompt treatment. Article Review: In this retrospective cohort study, two urban EDs compared the frequency of epinephrine administration and subsequent cardiac complications in patients 50 years and older with younger counterparts. Overall 492 patient charts were reviewed that met criteria for anaphylaxis. Patients 50 years and older were less likely to receive epinephrine (36.1 % vs 60.5%). When older patients did receive epinephrine, they were more likely to receive an excessive dose (15.9% vs 0.9%). Older patients were also more likely to experience cardiovascular complications than their younger counterparts (9.1% vs 0.4%). Finally, the cardiovascular complications resulted mostly from epinephrine that was delivered intravenously as opposed to intra-muscularly. Commentary: Despite the small data set, it does appear that appropriately dosed epinephrine given IM is safe in elderly patients. The caveat however,

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

The Emergency Medicine Department at Penn State Health Milton S. Hershey Medical Center seeks energetic, highly motivated and talented physicians to join our Penn State Hershey family. Opportunities exist in both teaching and community hospital sites. This is an excellent opportunity from both an academic and a clinical perspective. As one of Pennsylvania’s busiest Emergency Departments treating over 75,000 patients annually, Hershey Medical Center is a Magnet® healthcare organization and the only Level 1 Adult and Level 1 Pediatric Trauma Center in PA with state-of-the-art resuscitation/trauma bays, incorporated Pediatric Emergency Department and Observation Unit, along with our Life Lion Flight Critical Care and Ground EMS Division. We offer salaries commensurate with qualifications, sign-on bonus, relocation assistance, physician incentive program and a CME allowance. Our comprehensive benefit package includes health insurance, education assistance, retirement options, oncampus fitness center, day care, credit union and so much more! For your health, Hershey Medical Center is a smoke-free campus. Applicants must have graduated from an accredited Emergency Medicine Residency Program and be board eligible or board certified by ABEM or AOBEM. We seek candidates with strong interpersonal skills and the ability to work collaboratively within diverse academic and clinical environments. Observation experience is a plus. FOR ADDITIONAL INFORMATION, PLEASE CONTACT: Susan B. Promes, Professor and Chair, Department of Emergency Medicine, c/o Heather Peffley, Physician Recruiter, Penn State Health Milton S. Hershey Medical Center, 500 University Drive, PO Box 855 Mail Code A595, Hershey PA 17033, Email: hpeffley@pennstatehealth.psu.edu OR apply online at: http://hmc.pennstatehealth.org/careers/physicians Penn State Health Milton S. Hershey Medical Center is committed to affirmative action, equal opportunity, and the diversity of its workforce. Equal Opportunity Employer – Minorities/Women/Protected Veterans/Disabled.

is that all-cardiovascular complications occurred in patients between 41-58 years old. Further studies to confirm or refute the treatment trend and identifying the subset at risk for cardiovascular complications would be of great benefit.

Low Dose Ketorolac is Effective in Treating Acute Pain in the Emergency Department. Article: Motov, Sergey et al. Comparison Of Intravenous Ketorolac At Three SingleDose Regimens For Treating Acute Pain In The Emergency Department: A Randomized Controlled Trial. Ann of Emerg Med. Epub ahead of print. What we Know: Chronic and acute pain is a frequent complaint in the ED. For many years pain was addressed and treated with a myriad of analgesics including opiates. However, patient dependence and the opiate epidemic has led to the need to evaluate other treatment options. Ketorolac is frequently used in the ED as a safe and effective intravenous NSAID. Previous practice supported using ketorolac dosages that were above its analgesic ceiling. Such dosing raises concern for adverse effects without providing additional analgesia.

different doses of ketorolac (10, 15, 30 mg) in patients who presented to the ED with moderate to severe pain. The primary outcome was measuring pain reduction at 30 minutes however multiple pain scores were recorded from 0 minutes up to 120 minutes. A total of 240 subjects were enrolled and reduction in pain scores at 30 minutes from baseline was statistically significant across all dosing regimens. However, there was no statistical difference noted in pain score between each dosing regimen. Adverse effects included dizziness, nausea and headache but there was not a relationship between dose and adverse effect. Commentary: The use of ketorolac in treating moderate to severe pain in the ED setting appears to show no difference between 10, 15 or 30 mg dosing. This study shows promise as ketorolac has the advantage of providing pain control without the potential for abuse or misuse. The study is limited however in addressing long-term adverse effects as the study did not follow patients after 120 minutes. Additional studies are required to further elucidate if adverse effects are dose-dependent.

Article review: This was a randomized double-blind trial looking at three

â&#x20AC;&#x153;Ultrasoundâ&#x20AC;? continued from page 13 9. Train staff and colleagues to keep the equipment in working order and clean. 10. Help motivate your group to see the need for EUS. Here are 5 quick talking points to get their attention.

a. Improved patient safety.

b. More accurate and faster diagnoses.

c. Faster throughput (As they use ultrasound more).

d. Billing opportunities.

e. Improved marketability of their skills (If they leave their current job).

11. Keep a positive attitude and try to say focused. EUS/POC ultrasound training in the community hospital is challenging on many levels. However, it can be done. And, now is the time to start. The future of Emergency Medicine is here.

What Would You Do? Ethics in Emergency Medicine

Bernard Heilicser, DO, MS, FACEP, FACOEP-D The following ethical dilemma was referred to us by a municipal EMS system paramedic. His ambulance was en route to the closest hospital with a patient suspected of having a cerebrovascular accident. The ambulance was forced to stop at a train crossing while a train was passing through. While waiting, a person from a car also trained began banging on the ambulance window screaming for help for his brother not breathing. What should the two-person EMS crew do? Where is the priority? How would you triage this situation? What options exist? As medical control, what would you do?

Join the discussion! Visit www.acoep.org/news to share your thoughts on this controversial case. If you have any cases that you would like to present or be reviewed in The Pulse, please email them to us at ThePulse@acoep.org. Thank you.

THE PULSE | JULY 2017

Foundation Focus By Sherry Turner, DO, FACOEP

he Foundation for Osteopathic Emergency M ed ici ne was thrilled to be a part of the 2017 ACOEP Spring Seminar. Always striving to improve the quality of events, the FOEM Board took the recommendations of the ACOEP Resident and Student Organization and completely revamped the format of the Case Study Poster Competition. Formerly dark lecturestyle presentations were reimagined as brightly-lit simultaneous pods of digital presentations happening throughout the room. Attendees enjoyed healthy snacks and cold beverages as they collected 3 hours of CME, and participants enjoyed having four experienced judges provide valuable and specific feedback on their work. It is safe to say this new format will be adopted for the Research Study Poster Competition in the Fall! The winners of the 2017 Case Study Poster Competition are:

1st Place: Shane Sergent, DO Conemaugh Memorial Medical Center A Shade of Supplement Toxicity

2nd Place: Alexis Cates, DO Albert Einstein Healthcare Network A Case of Burning Throat Pain

3rd Place: Aadil Vora, OMS-III NOVA Southeastern University COM Don’t Skip Leg Day, Bro Directly following the Poster Competition, FOEM was pleased to bring back its 5K Run for Research for another successful year! Runners received their classic dry-fit race t-shirts as well as a

THE PULSE | JULY 2017

full buffet of delicious snacks, sponsored by ACOEP. This year’s race took place on scenic Coconut Road, and the weather could not have been more perfect for a run. The winners of the 2017 FOEM 5K Run for Research are:

1st Place Men’s: John Sillery, DO 1st Place Women’s: Andrea Carson 2nd Place Men’s: Matthew Brunetti 2nd Place Women’s: Gabriel Forbes 3rd Place Men’s: Timothy Bikman

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3rd Place Women’s: Hala Ashraf Last, but not least, FOEM held its first ever telethon in support of its mission on May 23. FOEM Day was a full-day event that consisted of ACOEP staff and FOEM Board members calling over 3000 ACOEP members to tell them what FOEM has been doing and request their support. First time donors learned that FOEM funds global mission trips, puts on amazing research competitions, has a multi-center research network, and is currently funding a study to track the costs and satisfaction levels associated with the ACGME transition. The event successfully raised over $8,000 and many first-time donors learned what FOEM is all about!

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A Shade of Supplement Toxicity Shane Sergent, DO Conemaugh Memorial Medical Center Johnstown, PA

Case Description: 53 y.o. male presented following a brief syncopal episode while standing at a checkout line. Patient states that he felt lightheaded preceding event. Bystanders reported the episode as brief with no preceding signs or symptoms. Patient states that he only had tea today since he was fasting. Patient denied any medical history but states he takes Aspirin once in a while for the “heart benefits.” He denies any other associated symptoms or modifying factors. When further questioned he confirms that he takes silver supplements since 2011, which he self produces combining silver rods and electric currents. Patient reports he carefully produces this silver chloride supplement at home as a immune

system boost to stop viruses. Patient states that he was initially taking 150 ppm a silver 3 times a day, but recently he decreased his dose to approximately 20 ppm 3 times a day. Vitals at arrival were a temperature 39.1 degrees C, respiratory rate 16, heart rate 100 bmp, BP 140/92, and SpO2 95% RA. Physical exam demonstrated argyria most profound in sun exposed areas. Poison control was consulted regarding suspected silver toxicity and had no recommendations. Pertinent ED labs included normal MI units, TSH/T4, INR/ PTT/PT, acetaminophen and salicylate levels, Hb 12.8, WBC 9.1, pH 7.49, pCO2 30, pO2 67, GFR 37, Cr 1.9, AST 48 ALT 52. No acute findings were noted on CT head or EKG. Chest Xray found left lower lobe pneumonia. Patient was provided Rocephin 1 gram IV, NS 2 liters, Tylenol 1 gram PO, Td 0.5 ml IM for sepsis and acute kidney injury. Patient was admitted for sepsis, left lower lobe pneumonia, acute kidney injury, and suspected silver toxicity. Pending labs returned as a silver serum level of 131 (ref. 0.0-14), normal urine drug screen, no growth on blood or urine culture, and normal EF on ECHO. Patients urinalysis found RBC 11-20, granular casts, trace ketones, large blood, and protein 30. His Cr and GFR improved to

1.4 and 53 respectively following fluids. Patient signed out AMA following course of Ceftin inpatient. Patients fever and underlying sepsis were secondary to pneumonia identified on chest x-ray, which may have been a result of damage associated with chronic silver inhalation. His acute kidney injury was most likely associated with the silver supplement, which was exacerbated by a mild level of dehydration. While the patient was not aware of any underlying skin changes, it was quite evident on physical exam. This was caused by the chronic consumption and irreversible deposition of silver. More importantly, the patient did not initially provide any history of supplement use when asked about medications. This case highlights the need to address supplement use and further denotes the need of regulation of such substances by the FDA given there potential life threatening effects. Although extremely rare, documented silver toxicity cases cause a wide variety of toxic effects to the liver, kidney, eyes, skin, respiratory, and blood cells. This case highlights a rare and unique case of silver supplement toxicity with associated argyria.

“Did a Symptom” continued from page 5 and information that allayed their fears about opioids in articles published by numerous medical sources, substantiated by a short, five sentence letter that appeared in a prestigious medical journal with no references or research published to verify these claims.

References: 1. Hardy, JD, Wolff, HG, Goodell, H, Pain

Pain and Symptom Management, Vol 29, No. 1,

Sensations and Reactions, Williams and

January 2005.

Wilkins, Baltimore, 1952. 5. Marchione, M, How 1 paragraph fueled 2. The Problem of Pain, Time magazine, July

opioid epidemic – Medical journal notes how

30, 1956.

industry used 1980 letter. Chicago Tribune, June 3, 2016.

So, could a five-sentence statement published in a medical publication fuel an epidemic—well stranger things have happened—but it certainly brings this to a new level, doesn’t it?

3. Keele, KD, The pain chart, Lancet 1948:26-8.

6. Leung, PTM, Macdonald, EM, Stanbrook, MB, Dhalla, IA, Juurlink, DN, A 1980 Letter on

4. Noble, B, Clark, D, Meldrum, M, Have,

the Risk of Opioid Addiction, New England

H t, Seymour, J, Winslow, M, Paz, S, The

Journal of Medicine, 2017; 376:2194-2195,

Measurement of Pain, 1945 – 2000, Journal of

June 1, 2017.

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A Case of Burning Throat Pain Alexis L. Cates, DO1 Theo Leriotis, DO1 Joseph Herres, DO1 Albert Einstein Medical Center, Philadelphia, PA

Introduction: Throat pain is a common complaint in an emergency department (ED). The related diagnoses are varied, from simple gastro-esophageal reflux (GERD) to catastrophic aortic dissection. This case highlights the importance of pertinent patient history and frequent reassessments in order to recognize the latter. Case Description: A 58-year-old female presented to the ED reporting burning throat pain after eating a spicy dinner approximately one hour prior to arrival. She expressed concern for a possible allergic reaction to seafood. She described intermittent mid-chest pain, radiating to the left jaw and epigastrium, associated with water brash. She denied dyspnea or other systemic complaints. Medical history included hypertension, cerebral aneurysm status post intravascular coiling in 2012, which the patient stated presented as jaw pain. She reported occasional ethanol use, regular tobacco abuse and no illicit drug use. On exam, she was severely hypertensive. She appeared significantly uncomfortable and grasped at her neck, describing a burning sensation. Physical exam was otherwise unremarkable. At this point, the differential diagnosis was wide: GERD, esophageal injury, Boerhaave’s

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syndrome, carotid artery dissection or aneurysm, coronary artery syndrome, hypertensive emergency, mediastinitis, aortic dissection. Laboratory studies were unremarkable. An EKG was normal save for T-wave inversions in V4/V5. A chest radiograph demonstrated a mildly uncoiled, slightly prominent aorta with an anterior mediastinal mass. While awaiting head/ neck CT angiography (CTA), the patient’s course acutely changed when she was in a sudden panic, complaining of right lower extremity cramping and feelings of paralysis. She remained severely hypertensive despite labetolol and had persistent chest discomfort despite aluminum hydroxide, morphine and anxiolytic. Peripheral pulses, motor and sensation of right lower extremity were then diminished. An emergent CTA revealed a type A aortic dissection. Immediate consultation to cardiothoracic surgery and vascular surgery was obtained. Subsequent CTA of the chest/ abdomen/pelvis revealed renal and iliac involvement causing an acute ischemic limb.

and previous cerebral aneurysm, as was the case in this patient, increase the risk of aortic dissection. The patient’s chief complaint was related to possible allergic reaction to seafood; however, she had no specific symptoms alluding to such. The constellation of symptoms appeared to be related to GERD; however, the presentation changed throughout her visit. This prompted us to hasten the CTA study, thus concluding a final diagnosis of type A aortic dissection.

References 1. Alter SM, Skin BE, and Allegra JR. Diagnosis of Aortic Dissection in Emergency Department Patients is Rare. Western Journal of Emergency Medicine. 2015. Sep: 16(5) 629631. 2. Chua J, Ibrahim I, Neo X et al.: Acute aortic dissection in the ED: risk factors and predictors for missed diagnosis. Am J Emerg Med 30: 1622, 2012. 3. Johnson GA, Prince LA. Aortic Dissection and Related Aortic Syndromes. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler

Labetolol and nitroprusside infusions were initiated; however, the patient’s mental status progressively deteriorated. She underwent emergent operative repair with aortic graft and a coronary artery bypass grafting, as well as exploration of bilateral femoral arteries, which led to bilateral lower extremity fasciotomies. Despite heroic care, withdrawal of care occurred after approximately one week due to persistent multi-organ failure. Discussion: Aortic dissection is a rare and challenging emergency with a high mortality. The diagnosis is unsuspected by physicians in over 50% of the clinical presentations and occurs without classic chest pain in up to 20% of the cases. In some, an expanding aorta may compress nerve structures causing dysphagia, hoarseness or sore throat. Factors such as hypertension, smoking, drug abuse, dyslipidemia, connective tissue disorders,

GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. New York, NY: McGraw-Hill; 2016. http:// accessmedicine.mhmedical.com/content. aspx?bookid=1658&sectionid=109429195. Accessed January 02, 2017. 4. Ramanath VS, Oh JK, Sundt TM, Eagle KA. Acute Aortic Syndromes and Thoracic Aortic Aneurysm. Mayo Clinic Proceedings. 2009;84(5):465-481.

“Don’t Skip Leg Day, Bro” A Case of Unprecedented Exertional Rhabdomyolysis without Acute Kidney Injury Aadil Vora, OMS-III Nova Southeastern University College of Osteopathic Medicine, FL Ayesha Hussein, MD Director of Emergency Medicine, Palmetto General Hospital, FL Introduction: A young male complaining of dark urine following strenuous exercise is characteristic to Exertional Rhabdomyolysis. Creatine Phosphokinase (CPK) values typically peak at 25,000 IU/L in 24 hours.1 However, we present the case of a typical Exertional Rhabdomyolysis patient who’s CPK rose to an atypical 545,000 IU/L 48 hours after he tried squatting at the gym. Case Report: A 19 year old male with no past medical history presented to the ED complaining of red, foul smelling urine and lower extremity soreness after squatting 135 pounds two days prior. He was afebrile with a heart rate of 93 bpm, blood pressure of 130/80 mmHg and weight of 130 Lb. He denied medications, illicit substances (UDS confirmed), recent illness, remarkable family history and trauma. The patient was slim, with tenderness to palpation of bilateral quadriceps. CPK was 37,000 IU/L, ALT was 266 U/L and AST was 2371 U/L. BUN and Creatinine were normal. Dipstick UA showed proteinuria and hematuria. EKG showed normal sinus rhythm. The patient was diagnosed with Exertional Rhabdomyolysis; 0.9%

NS was started at 250 mL/hr and he was admitted to telemetry. Repeat CPK level taken on admission had spiked to 545,000 IU/L. Inpatient, he received a Bicarbonate Drip and D5W 300mL/hr. He never developed Acute Kidney Injury (AKI). Further workup of hepatitis panel, thyroid studies, coagulation panel and autoantibody titers were negative. The patient was discharged 8 days later with a CPK of 1,396 IU/L.

production. Our patient’s good outcome was likely due to his healthy kidneys, early recognition, aggressive hydration and the avoidance of opioid analgesics. This case also reminds us of the great prognosis of rhabdomyolysis, even when extreme, in young healthy patients. References 1. Rhabdomyolysis: an evaluation of 475 hospitalized patients. Melli G, Chaudhry V, Cornblath DR Medicine (Baltimore).

Discussion: This case, reports the highest CPK level secondary to Exertional Rhabdomyolysis without AKI in the literature.2 Rhabdomyolysis is diagnosed when CPK surpasses 5 times the normal limit; this patient peaked at 500 times the normal limit. 7 Furthermore, it is astonishing that this patient’s unprecedented CPK did not cause common comorbidities of rhabdomyolysis such as arrhythmias, compartment syndrome or AKI, of which a 30-50% of patients develop.8

2005;84(6):377. 2. Khan, Asif. “Lose 500,000 Creatine Phosphokinase With a 2-Hour Workout: A Case Report on Rhabdomyolysis in a Novice Athlete.” World Journal Nephrology and Urology 5.3 (2016): 54-57. Web. 25 Jan. 2017. 3. Effects of Analgesic and Anesthetic Medications on Lower Urinary Tract Function Sammy E. Elsamra, MD; Pamela Ellsworth, MD, FAAP, FACS Urology Nursing. 2012;32(2):60-67. 4. Chen CY, Lin YR, Zhao LL, Yang WC, Chang

The incidence of Rhabdomyolysis is well documented, with trauma and infection as leading causes and exertion relatively rare.4 This patient’s markedly high CPK value suggests an underlying metabolic disorder, such as a McArdle’s, which has been reported to cause extremely elevated CPK in teenagers.5 However, patients tend to have multiple occurrences of rhabdomyolysis, and for this patient, it was his first time.6

YJ, Wu HP. Clinical factors in predicting acute renal failure caused by rhabdomyolysis in the ED. American Journal of Emergency Medicine. 2013;31(7):1062-1066 5. “Glycogen storage disease type V Genetics Home Reference.” U.S. National Library of Medicine. National Institutes of Health, n.d. Web. 25 Jan. 2017. 6. Lofberg M, Jankala H, Paetau A, Harkonen M, Somer H. Metabolic causes of recurrent

One other case of Exertional Rhabdomyolysis with a peak CPK of 500,000 IU/L was reported, and it too was in a young male who attempted heavy weight-lifting. 2 However, that patient developed Stage 3 Renal Failure after being administered morphine. Morphine is known to cause urinary retention due to impaired sensation of urinary urgency and increased tone of the urinary sphincter, which could have exacerbated his pre-renal obstruction by creating a post-renal obstruction. 3 Our patient did not receive morphine, and may have therefore not developed any renal injury. His only complaint was copious urine

rhabdomyolysis. Acta Neurol Scand. 1998;98(4):268-275. 7. Mougios, Vassilis. “Reference intervals for serum creatine kinase in athletes.” British Journal of Sports Medicine. BMJ Group, Oct. 2007. Web. 29 Jan. 2017. 8. Keltz, E., Khan, F. Y., & Mann, G. (2014). Rhabdomyolysis. The role of diagnostic and prognostic factors. Muscle, Ligaments and Tendon Journal, 3(4), 303–312. Retrieved from www.ncbi.nlm.nih.gov/pmc/articles/ PMC3940504/#b106-303-312

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