The Pulse - January 2017 by ACOEP

JANUARY 2017

IN THIS ISSUE: Would You do it Again? - Pg 7 MInd Over Gray Matter - Pg 11 ACEOPâ&#x20AC;&#x2122;s 2016 Scientific Conference - Pg 17 Updates in EM Literature - Pg 30

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

Continuing to Determine Our Future (Page 3)

Mark your calendar for

ACOEP’s Spring Seminar!

April 18-22, 2017 NEW LOCATION!

HIGHLIGHTS INCLUDE:

Bonita Springs, FL

• COLA Review

Ft. Myers Coast

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

OVER 30 HOURS OF CME CREDIT

• Expanded breakout lectures • New tracks and events

Visit www.acoep.org for more details!

The Pulse VOLUME XXXVIII No. 1 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.

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 Would You do it Again?.............................................................................................................................7 Duane D. Siberski, D.O., FACOEP, FACEP Introducing ACOEP’s Emergency Resident and Student Organization...............9 Tim Bikman, OMS-IV, John Downing, DO ACOEP - RC President’s Report.......................................................................................................10 Kaitlin Bowers, DO

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Mind Over Grey Matter..............................................................................................................................11 Frank Gabrin, DO

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Look How Far We Have Come.........................................................................................................16 Theresa M Campo DNP, FNP-C, ENP-BC, FAANP, Mary Jo Cerepani DNP, FNP-BC, CEN

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.

ACOEP Welcomes Three New Staff Members to the Team!...................................15 Gabi Crowley

ACOEP’s 2016 Scientific Assembly................................................................................................ 17 Gabi Crowley The Foundation Spotlight........................................................................................................................19 Ethics in Emergency Medicine: What Would You Do?..................................................23 Bernard Heilicser, D.O., M.S., FACEP, FACOEP-D 2nd Annual Meeting of ACOEP’s Council for Women in Emergency Medicine.................................................................................................................................24 Kaya Smith Medical Monitors for Weight Loss and Improving Health............................................27 Janice Wachtler, BAE, CBA New Physicians in Practice (NPIP) Update..............................................................................28 Nicole Ottens, DO, FACOEP Literature Update: Winter 2017..........................................................................................................30 John Ashurst DO, MSc, Steve Sherick MD

Continuing to Determine Our Future Look to the future because that is where you will spend the rest of your life. — George Burns

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

COEP recently concluded a very successful Scientific Assembly in San Francisco, California. Many thanks go to all ACOEP staff members for their part in helping create this event. I also wish to thank the CME Committee for their hard work and diligence in putting this educational event together. Each speaker and participant in the track events also deserve kudos. Through the generosity of our sponsors, we could present special functions throughout the week. All of these individuals help our College provide cutting-edge presentations in emergency medicine. However, there is another group that needs to be recognized—the attendees. It is their presence that continues to identify our College’s presentations as one of the premier offerings in continuing education. As ACOEP continues its efforts to obtain full ACCME accreditation, which will be forthcoming, we will strive to provide our members with first-rate educational events. This is just one facet that makes our future look bright. We have recently seen a drastic change in the political events of the United States.

Many question the future direction our country will take. There is definitely a division of perspectives the citizens of our country share; however, all must unite behind the new government leaders if we are to succeed in the coming years. The unification of thoughts and perspectives is also true in the delivery of healthcare in our country especially concerning emergency care and treatment. The “House of Emergency Medicine” needs to combine the talents of all emergency medicine providers as we move into the future. The issues facing us are many and complex: advocacy for patients, diversity in our organizations, balanced billing, the issue of opiate abuse, and health insurance for everyone. The American College of Osteopathic Emergency Physicians is well aware of these issues. We are partnering with other emergency medicine organizations to determine how to best present a unified voice to address the problems we face. However, there are concerns facing our specialty that ACOEP is actively seeking answers on our own. One such concern is the inclusion of MDs in our College. As you may be aware, ACOEP has amended its Bylaws to open our College’s membership. As the Single Accreditation System continues to move forward, it is reasonable to believe that MD students will join AOA recognized residencies. It is incumbent for our College to actively seek those residents

as well as all MD emergency medicine residents to become members of our College. Of course, it must be said that our goal is to welcome all DO emergency medicine residents as members. We aspire to be the home for all emergency medicine physicians, residents, and students that have an avid interest in our specialty. Our quest for ACOEP to be all-inclusive for emergency medicine providers does not end there. We believe there is a vital role in the delivery of emergency care in our country that is practiced by nurse practitioners, physician assistants, and those physicians who are not board certified in EM but have substantial experience working in emergency departments. These individuals are many and should be recognized. We realize there is a national shortage of EM physicians and the aforementioned groups are essential in filling that gap. All of us have worked with these professionals and understand that they provide quality care for our patients. ACOEP will be extending an invitation to these providers and believe they will strengthen our college as we meet their professional needs. There are no tea leaves to be read. There is no looking glass to the future. The future of ACOEP will be decided by the direction and actions we take today. Continued on Page 23

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Reflect, Reorganize, Renew! could provide vital clues that you are overstressed or need a well-deserved reset.

The Editor's Desk Timothy Cheslock, DO, FACOEP

t’s hard to believe this is the start of another new year. It seems time moves faster and faster. The world is rushing by and if you do not take a moment to pause and reflect on your own situations, what you perceive as your life and legacy may just be steaming on ahead of you unchecked. Social media is a constant barrage of stories about physician burnout, suicide and distress. The challenges that we as emergency physicians face takes a toll on every aspect of our lives. It affects our relationships with colleagues and staff on a daily basis. It also has a direct impact on members of our family. How we engage at work and at home and how we live our lives is a true reflection of our overall wellness and satisfaction with our current personal situation. Are you satisfied with your current situation at work and at home? Are you feeling fulfilled personally and professionally? It is often difficult to recognize the toll our profession takes on our lives and our wellbeing, due to gradual change. Most often though, others recognize the change before we do. Involving your family and friends in taking a personal inventory of your situation

The new year is the perfect time to reflect on your recent past. If your results are satisfying and everything is bliss, congratulations! You have what we all envy. If the results of your reflection are less than completely gratifying, use this as an opportunity to reorganize your life. Maybe you need to be more involved in your work, having your opinions taken into account. This may be the perfect opportunity to seek out additional responsibilities in your department. Taking on committee assignments or projects that reflect your special interests within the scope of your daily practice or on a larger scale within the organization, can provide you with job satisfaction and feelings of fulfillment that you are missing. Some of you may be feeling overwhelmed with the daily rigors of the profession. Take this time to determine if you are working too much. Could you shuffle your schedule to better accommodate more personal and family time? Balance in your life is essential to a long and healthy career. Everyone feels the pressures of paying the bills and keeping up with the lifestyle. Many times these things aren’t as important as making sure you see your children in the school play and being present for the big moments that you just can’t recreate. Everyone knows deep down what is important to them. Only with an honest, unbiased reflection can you determine what is right for you. Aligning your priorities and making sure that each is relegated a sufficient

portion of your time will help to get things back on track in your life. A sufficient work/life balance enhances your overall productivity ensuring that no single aspect of your life has been short changed. We all have aspirations for our career and our families, it is only with a grounded plan that we can satisfy all the demands placed upon us. After a thoughtful reflection and reorganization of your current situation, it is time to renew your personal commitment. Renewing your commitment to yourself first and foremost is vital. Taking care of yourself and making sure that you are satisfied with your career and personal life will ensure your success in all parts of your life. Addressing your health, through proper rest, exercise, and nutrition will keep you strong for the challenges that you face daily. Next, renew your commitment to your family. Without their support, everything else in life becomes a challenge. They will see you through thick and thin. It is important to nourish this relationship at all costs. Finally, renew your commitment to your profession. You have endured years of training, Preparation, and the daily rigors of a career that at times can appear thankless and stress filled. Renewing the commitment to why you first chose this profession, will reinvigorate your commitment to the profession. therefore hopefully reigniting the flame to keep you going for this new year. Here is to each and every one of you for a healthy and prosperous 2017. Happy New Year!

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New Year’s Resolutions I tend to have a good outlook on the next year, hoping the world will somehow change and all the bad and evil things we do to one another will stop, if only for an hour. Executive Director's Desk Janice Wachtler, BAE, CBA

s we flip that calendar page from December to January and welcome in that miraculous new year that will somehow wipe out all the sins of the previous year, we all make ourselves promises of what we will achieve within the next twelve months. In my case, my checklist stays pretty much the same: lose weight (nope), meet Prince Charming (that has never happened), and look at the world with clear and focused eyes and try not to judge. I always have a good outlook on the next year, hoping the world will somehow change and all the bad and evil things we do to one another will stop, if only for an hour. While that usually doesn’t happen, I do try not to judge people. So if I were to make a New Year’s wish for 2017, these are things I hope to achieve this year: Be more caring: A few years ago, as I walked up Michigan Avenue, a woman my age asked for money for lunch. I was heading into Walgreens and said, “when I come out” and went into the store to buy something. When I came out, I walked up to the woman and asked her to join me for lunch at a nearby McDonald’s. To my surprise, she said sure. That began

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an 18-month friendship with Doris, whom I met almost every Tuesday for lunch at McDonald’s. I learned that she was younger than I was and had been laid off from her job at Stroger Hospital, and even though she really didn’t need the money, she wanted to be with people instead of locked inside of her house with a disabled brother and elderly mother. We traded little birthday gifts, a scarf I’d crocheted, a pin she made from old buttons, and then one Tuesday she told me she was going back to work. That was the last I saw of her. But I remember her and think we shared something special for those 18 months. I’d like to do that again. Sharing: This is something we should do on a regular basis. Tell your story to a younger person; your experience, trials and tribulations lest they be forgotten in what you are today. I remember that good old ‘glass ceiling,’ and wishing I had had a really big hammer to break through it. I remember being passed over for promotions and awards simply because I was a woman and ‘women didn’t belong in the corner office making difficult decisions,’ or being told ‘I was single with no children so I didn’t need that raise.’ I also remember coming to ACOEP and was told to take over and do whatever

I wanted. I was dumbfounded that I was allowed to rip through things and make wholesale changes, but the Board believed in me and I found my home, and hopefully, have done well. I hope to continue sharing my stories with you. Giving: It’s important for all of us to put our hands in our pockets or wallets and give our fair share to a cause. Whatever you believe in, you should support. Since graduation from UIC, I’ve pledged funds to the National Wildlife Federation. At first it was $20 a year and then it grew as I could afford more. Now, I also support wildlife refuges for tigers and elephants, as these majestic animals lose their natural habitats. I also give to food banks and services for the homeless. I also give to FOEM, to support research in emergency medicine and finding the osteopathic connection there. If I could make a worldwide set of resolutions this is what I’d wish for the world to: 1. Take a chill pill – look for the good in each other and not the bad. 2. End the violence that plagues all populations from the smallest town to the large city; all lives matter. Continued on Page 14

The Unique Impact of the Opioid Epidemic on Women There has been an exponential increase in the use and abuse of prescription pain killers by women and in subsequent deaths. The On-Deck Circle Christine Giesa, DO, FACOEP-D, President-Elect

n September I accepted an invitation from Sylvia Burwell, Secretary of the Department of Health and Human Services, to attend the Office on Womenâ&#x20AC;&#x2122;s Health National Meeting for Opioid Use, Abuse, and Overdose in Women. It was a little intimidating, as I was one of the few physicians in attendance. I was not sure what to expect at this meeting, but as an emergency physician I felt confident in my knowledge about the severity of the opioid epidemic, its impact on society, and how to treat overdose patients. As physicians, we are familiar with the staggering statistics regarding the increase in prescription opioid use, misuse, and overdoses. Nearly every week there is an article or podcast that discusses the widespread American epidemic. Most of us would be hard-pressed to remember a shift in which we did not see at least one acute overdose patient. Those patients are men and women, and we typically treat them equally. But do we always? Should we? By the time the opening session of the meeting concluded, I was acutely aware of how little I knew about the unique impact that the opioid epidemic has had on women.

From 1999 to 2010, deaths due to overdose from prescription pain killers increased 400% among women compared to an increase of 237% among men. Women are more likely to be treated for chronic pain than men. Women also use prescription opioid medications at higher dosages and for longer periods of time than men. Physiologic differences cause women to become more physically dependent on opioids. Women can become dependent on opioids after taking smaller dosages and for shorter periods time than men. Women are also more sensitive to cravings and thus act to satisfy them. Whereas women tend to misuse prescription opioids, men tend to use heroin. Recently, however, there has been sharp rise in heroin use among women. Studies have shown that women are more likely to be introduced to heroin by a significant other. Men are more likely to be introduced to the use of elicit substances by friends. It is not unusual for women to use drugs or to increase their use due to coercion from an intimate partner. Women who are unable to inject themselves with heroin are at the mercy of their partners. They are frequently injected by their male partner only after he has injected himself, thus putting them at risk for

contracting hepatitis and HIV. More women than men cite traumatic childhood events as causative factors in starting to use abusive substances. Traumatic events could include physical or sexual abuse, growing up in a home with domestic violence, emotional abuse, neglect, substance abuse among family members, and/or living in a home where a family member was incarcerated. I was surprised to learn that women are less likely to be given Naloxone than men, when found unresponsive by EMS. I found this concept incomprehensible and contrary to our practice in the emergency department. There is, however, a growing body of evidence revealing that women are less likely to be given Naloxone when found unresponsive by EMS. The reasons for this are varied. Women are more likely to suffer from chronic pain and consequently can be on high doses of opioids, which can cause respiratory depression and altered levels of consciousness. EMS may not consider that a womanâ&#x20AC;&#x2122;s depressed level of consciousness could be due to opioid abuse or overdose. Women are frequently found unresponsive in their home and without evidence of injection Continued on Page 10

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Would You do it Again? By Duane D. Siberski, D.O., FACOEP, FACEP

phrase, a question, a retrospective approach. Any way I view those words, I can’t help but notice how many people ask me this regarding medicine. It is easy to answer this question when it is directed at a recent meal, a movie, a vacation or other short-lived activity. I know I can always eat again, stay awake in a dark room with visual bubblegum projecting on a screen, or spend hours sprayed down with sunblock that repels UV radiation and attaches grains of sand to my skin. But when asked whether I would choose to become an emergency physician again, I find my answers are spun for the person asking the question. So now I ask myself, “hey Duane, would you do it again? You know…medicine…emergency medicine…Osteopathic Emergency Medicine…would you do it again?” Emergency medicine. A specialty recognized by other medical specialists for the challenges encountered. “I did ER during my internship, anyone can do it.” A specialty that has always been recognized by our patients. “When are you going to get your own practice, honey?” A specialty recognized by our patients for our critical thinking ability. “I was looking on Google and I have Fibromyalgia, can I get a Percocet prescription?” A specialty that has always been recognized by hospital administration as the entry point for patients. “You guys in the ER have always been a money loser for the hospital, can’t you do better?” A specialty glamourized on television for our ability to save the life of the trauma surgeon after a limb severing helicopter accident and just as quickly move to the nearest supply closet for a 45-second tryst with a

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co-worker before the commercial break. Let me see what I’d do.

way early. I’ll have time for fun classes later on.

How far back in the process does one have to rewind to get to the starting point on the road to medicine? I speak with junior high school Boy Scouts at meetings who have no clue what they want for lunch, much less what to do with the rest of their lives. Too far back. Seniors in high school, that should be a reasonable starting point, all that prep to prepare to find a college must be a good starting point. I am surely convinced that current high school students, at least the ones our son is hanging with, are better prepared for college than I can recall ever being. Multiple visits with the guidance counselor, interview workshops, statement writing practice, SAT and ACT prep classes and financial presentations. Where was that in the 70’s? Well, I got in the first time without it. I do not think it will fly this time. If I am going to do it again, I am going to have to groom and prep myself for college. Good looks only go so far and having looked in the mirror recently, I will go with the groom and prep for the extra points.

Where do I want to go to college? What’s close, cheap, has a good football team, and will get me on track for med school? Penn State, that’s a good idea to start. Blue and white, that’s the majority of my wardrobe. That’ll work for me, won’t it? Let me dig in this pile on the corner of the desk, college acceptance rates, freshman retention rates, and four-year graduation rates, professional placement ranking, college visitation schedules for October with preference for the high school seniors, college website addresses, scholarship application, loan applications, college open house save-the-date mailer cards…this kid doesn’t throw anything out. Excel-like spreadsheets with columns of Get In, Get in with Scholarship Money Maybe, Get in with Scholarship Money Definite, Reach School, Needs Personal Statement, No Personal Statement, SAT/ACT. I had fewer choices picking options on my last truck. This college choice thing is not so simple anymore.

Since I am here at the high school level, I guess I should look at some of my courses. Our son’s high school course selection catalog is still here, nothing gets thrown out or filed away in his room, just stacked on, under or near the desk. Hmmm, CP, Honors or AP….where are the fun courses? No woodshop, print shop, metal shop, chorus, photography or art class! Dual-enrollment at Penn State or Alvernia University with credits transferrable to other educational facilities. I guess I will be getting some of those freshman courses out of the

College, some would say “the best six years of my life.” Who are these people living the life of a researcher? When did Kaplan become a frequently bantered name? Multiple meetings with guidance counselors. I remember my guidance counselor, but one for your major, your other major and the preprofessional program sounds like another grooming team. Adding to the resume writing service, personal statement editing service, interview skills practice sessions, and the system resembles how the business schools have been prepping their folks to enter their industry. I see that

I will be doing more than just studying and getting good grades. Am I a multifaceted, socially connected, electronic media savvy, well-educated candidate to apply to medical school? How could this have ever been done in the past without cell phones, the web, Skype, laptops, tablets, e-books, schedule alerts, and more? Weren’t libraries, textbooks, lecture halls, payphones, and little black calendar books sufficient? Evidently not, I’ll have to learn to text quicker. Medical school should be an easy choice. I had fun in Maine, I’ll apply there again. But there are a few more places to look at now. Ok, I’ll look at PCOM again. What do you mean there are two? Next thing they will tell me is that Lake Erie is in Florida and Arizona is considered Midwest. What is this about the combined programs, multiple degrees, virtual classrooms, international study, US News and World Report ranking list, research tracks? I was good with an anatomy lab, a lecture hall, 35mm slide tray lectures, a library, note service, and a black leather bag with a stethoscope, BP cuff, otoscope/ophthalmoscope, tuning forks, tongue depressors, and a pen. I guess I can add a laptop, cellphone, ultrasound, double-jointed thumbs to

The great unknown looms over my choice though. text at 438 MPH, and a debt to rival a McMansion mortgage. Indentured servant mandatory commitment, otherwise known as internship and residency are the last steps in my journey. Oh joy, the fun of a “block” of 12 hour nights which translates to 49 straight calendar days of 15-18 hour nights. Sleep deprivation psychosis is always better the second time around. Residency could have been three years without that intern year but that transition was occurring anyway. Read Rosen’s three volumes, sleep on Tintinelli as a pillow to get wisdom by osmosis, offservice rotations with a real attending, pre-tending shifts, moonlighting, real money, light at the end of the tunnel, look for a job and sign a contract that looks good. I’m going to have to try to follow the laws now and limit my work to 80 hours a week. Just imagine all the great cases I’ll miss with mandatory time off and capped services. I’ll use that extra time to read more since the basic information in medicine has at least doubled and every book in my library

now fits on a tablet. I will get doubleduty out of that tablet to do my EMR with fingers blurring over a keyboard. I could go faster but the hospital’s Starbucks is closed at night, no espresso for you. I will expand my vocabulary to include customer satisfaction, risk management, debt consolidation and exit strategy. The great unknown looms over my choice though. Single accreditation pathway will open residencies up to all medical school graduates. Length of training is either three or four years. How do I choose? Get out a year early and start real work or do a program for four years with additional training to add to my skill set? Which certifying boards do I take? Which ones can I take? Since I am training under a single accreditation pathway, with folks who have no vowels in the abbreviation of their degree, how will I be different? Dentists have two different degrees and a single training pathway. There may be something that differentiates between the degrees, but Continued on Page 28

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Introducing ACOEP’s Emergency Resident and Student Organization Tim Bikman, OMS-IV Past President, ACOEP-Student Chapter WVSOM

John Downing, DO Past President, ACOEP-Resident Chapter Midwestern University Department of Emergency Medicine

leadership roles will continue to be elected by their peers and will serve an important role in the Emergency Resident and Student Organization as well as their main ACOEP Committees.

s the outgoing Presidents of our respective ACOEP Chapters, we are excited to announce the new ACOEP Emergency Resident and Student Organization! This joint venture, combining ACOEP’s Student and Resident Chapters, was the culmination of planning over the past year to strengthen our organizational leadership. These changes further promote the highest quality resources, events, and education to our student and resident membership. These organizations have come a long way since their foundation, growing in both size and responsibility.

An exciting addition for the organization is the introduction of the Congress of Residents and Students. This Congress will be made up of one member from each program and school. They will be elected by their peers to represent their program or chapter and provide governance to the Executive Board through a Congress of Residents and Students.

The creation of this new organization will streamline the planning and execution of our various activities, creating a more collaborative approach to resident and student events and education. We envision a cooperative and shared executive council made up of our strong student and resident members. Committee members will continue to play a key role in the organization. Positions will be available for the Conference, Publications, Research, GME, and Constitution and Bylaws Committees. These key active

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The creation of this new organization will streamline the planning and execution of our various activities, creating a more collaborative approach to resident and student events and education. The current executive boards are currently working on the timelines for the complete roll out, and we hope to have the new organization completed in time for ACOEP’s 2017 Scientific

Assembly. Please be on the lookout for our new logo, social media pages, and other important updates on these exciting changes!

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ACOEP - RC Presidentâ&#x20AC;&#x2122;s Report Kaitlin Bowers, DO ACOEP Resident Chapter President ACOEP Board of Directors

s the newly-elected Resident Chapter President, I would like to thank my fellow residents and the College for their continued support. I am excited to have the opportunity to serve my colleagues in

"On Deck Circle" continued from page 6 paraphernalia lying around, whereas men are more commonly found in public with evidence of illicit drug use. EMS providers also need to be aware that the historic stereotype of a heroin overdose victim as a young male is no longer valid. Heroin and opioid overdose should be considered in any person who is found with a depressed mental status, regardless of age, socioeconomic status, or gender. In general, there is a paucity of substance abuse treatment centers to meet the growing demand. Women who seek substance abuse treatment have unique needs. Women are more likely than men to have co-existing psychiatric disorders, such as major depression, anxiety, or PTSD. It is thus imperative that women be screened for these underlying disorders when they seek

this capacity! I am also very lucky to have such a great team of officers behind me that are already working hard to provide our membership with the highest quality offerings for the upcoming year. We have a lot to live up to, as this past conference in San Francisco was one of the largest turnouts of residents in many years. We had approximately 175 residents in attendance, representing over 30 programs. We look forward to developing new and exciting programming to continue to get more residents involved. We are very excited to announce the new Emergency Resident and Student Organization. This is an exciting time for the resident and student leadership as we

treatment for their substance abuse. Failure to screen for and treat these underlying disorders will result in an unsuccessful recovery plan. Women, by nature, are caregivers, and define themselves based on the relationships in their lives. Often, they do not seek treatment or fail to complete treatment because they are unable to participate and manage their caregiving responsibilities at the same time. Women with children face additional barriers to treatment. They may lack safe and affordable housing, which they must obtain before they can gain access to a treatment program. They worry about what will happen to their children if they seek treatment, because admitting to substance abuse may lead to loss of custody. A future consideration would be a family-centered treatment model.

continue to strengthen our partnership and transition to becoming one organization. We have always had similar goals and offerings for our memberships however, by working together as one, we hope to streamline our processes while continuing to provide our members the best opportunities possible. Finally, I would like to invite our resident members to join us for our offerings at ACOEPâ&#x20AC;&#x2122;s Spring Seminar in Bonita Springs, April 17-22nd, 2017. We will offer our Critical Care Ultrasound lab, FOEM research competitions, Mini Mock Oral Board Prep, targeted lectures, and a keynote speaker. We hope to see you all there this spring!

In this treatment model, the immediate family is placed in safe housing and receives both clinical and community support services. This helps the woman and her family deal with the drug abuse and achieve recovery. In summary, it is important to recognize that the opioid and drug abuse epidemic is real. There has been an exponential increase in the use and abuse of prescription pain killers by women and in subsequent deaths. The stereotypic face of the heroin user has changed dramatically. Opioid overdose must be considered in any patient with a depressed mental status, regardless of age, socioeconomic status, or gender.

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Mind Over Grey Matter Frank Gabrin, DO

was giving sign out after the end of my night shift when the doctor who was relieving me began to tell me about her shift the day before. Tears streamed down her cheek as she shared the story of the 35-year-old man who had metastatic cancer all throughout his brain. She’d made the diagnosis, but she couldn’t bring herself to face him with the news. The sadness overwhelmed her. She’d given the diagnosis to his mom. It was the best she could do. Today she was still feeling badly for him. This deeply troubled her. She told me she just couldn’t let herself cry in the room with him. Yet, here she was still feeling empathy for him. He could have been her brother, her boyfriend or her neighbor. Cancer can happen to any of us. I know all too well, cancer happened to me, twice! I started to cry with her. I was feeling empathy for him too. How awful! How devastating! I began to wonder how long this young vibrant woman, who just happens to be a great emergency physician, would carry this patient around with her? How long would she feel sad for him? How long would she remember that she wasn’t able to face him with the news? How long would she feel bad because of this encounter? It’s encounters like these that contribute to our development of compassion fatigue. Think about it, we could see a case like this every shift we work. If we work three shifts a week, in a month we would be carrying around a dozen patients with us, feeling sad, feeling bad for them and their situation. Who could

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handle all that grief? It’s just too much! We were never taught how to handle our emotions in these cases. This is why we get stuck with the compassion fatigue that our empathy for our unfortunate patients causes us. It’s no wonder our compassion fatigue quickly turns into burnout.

an increase of 10%. At the same time, the rate of professional burnout seen in the general population has remained the same at 28%. These statistics should alarm each and every one of us. From the most recent study, the medical specialties affected the most and from highest to lowest are as follows:

Burnout is a crisis in all of medicine From the groundbreaking work that Dr. Tait Shanafelt and his colleagues are doing at the Mayo Clinic, and from the yearly Medscape surveys, it’s clear that doctors suffer professional burnout at a rate almost twice what is seen in the general population. In Dr. Shanafelt’s first study in 2011, 45.5% of physicians had at least one symptom of burnout. That percentage rose to 52.4% in his 2014 study. That’s

• Critical Care- 53% • Emergency Medicine- 52% • Family Medicine-50% • Internal Medicine- 50% • General Surgery-50% • Infectious Disease-50% • Radiology-49% • Ob/Gyn-49% • Neurology-49% • Urology-48% As emergency physicians, we are essentially leading the pack in burnout.

To think is to practice brain chemistry. -Deepak Chopra

Over half of this country’s board certified emergency physicians, [52%], are already suffering emotionally. Burnout is a very real problem for all of us. Each year, the effects of burnout can become so overwhelming, that for roughly 300 to 400 of us, suicide has become the only way out. At this moment, six out of 100 physicians, suffering from burnout, are contemplating suicide. We enter medical school with amazing psychological profiles (students begin medical school with superior mental health profiles relative to graduates entering other fields). Yet, shortly after we finish medical school, residency, and a few years of practicing medicine, we begin to succumb to the emotional dysfunction of professional burnout. This is a very steep and quick downhill slide in our overall emotional health. These studies and surveys are showing us that this phenomena is unique to our industry, and it’s destroying our careers and our lives. Interestingly, research shows that as physicians, we still have generally high degrees of satisfaction with our career choices, yet we exhibit large amounts of dissatisfaction with work-life balance, as well as alarming levels of medical burnout. Why is this happening to us? No one knows for sure. I can tell you from my own personal experience with burnout left untreated, it does not allow us to feel happy, engaged or fully alive. It’s bad enough that medical burnout robs us of our ability to enjoy our careers (in which we’ve invested so much) but it doesn’t stop there, eventually we can no longer enjoy our lives.

Many think the fact that one in two US physicians has symptoms of burnout implies the origins of this problem are rooted in the environment and care delivery system, rather than in the personal characteristics of a few susceptible individuals. But, does it?

moment by moment awareness of our thoughts, feelings, bodily sensations and surrounding environment. Mindfulness also involves acceptance, meaning that we pay attention to our thoughts and feelings without judging them— without believing, for instance, that there’s a “right” or a “wrong” way to think or feel in a given moment.” -Greater Good Science Center A mind is a terrible thing to waste.

Let’s think about this for a moment. Burnout happens in all specialties and all care delivery environments: plastic surgery, general pediatrics, radiology, urology and even pathology! These specialties are very dissimilar. Burnout happens in the office, the hospital, the clinic, the emergency room, the delivery room, and the operating room. These environments are not the same either.

What were we taught in medical school that could stop my colleague from facing her young patient and delivering the news that he has metastatic brain cancer? Remember she could not bear the thought of crying in the room, and she clearly knew she would! She was crying when she told me about the case, but at least it was not in the room, at the bedside, or in front of her patient.

Maybe, just maybe, the root cause of our emotional dysfunction isn’t in our environment or clinical situation, but rather something that is deeply internalized within each of us. After all, physicians are a diverse group of people, but the one thing we all have in common is that we graduated from medical school.

We were taught, in no uncertain terms, there is no greater sin in medicine than getting too close and involved with our patients. We were taught it’s imperative we keep a safe professional distance, that we stay clinical, and most importantly, detached.

What could have been implanted within all of our psyches during those four years of medical school that could result in our universal emotional dysfunction? The clue to answering this question lies in looking at what has been shown to diminish the effects of medical burnout. Looking at the research, it’s a short list of options that have statistically shown some positive effects; taking more than two weeks of vacation a year offers a mild effect and volunteering outside the hospital, in our off time, offers a moderate effect. But it’s in the one that offers the biggest effect, mindfulness or mindfulness based stress reduction training, that I believe we find the answer. “Mindfulness means maintaining a

We were warned not to connect or to get close or friendly with our patients because this connection will remove our objectivity, cloud our judgment, and make it impossible for us to make good clinical decisions. We were taught to believe that not connecting would make us better doctors and that feeling the pain of our patients would consume and destroy us. Keeping our professional distance is the seed planted in our psyches during medical school that no longer serves us and is the root cause of compassion fatigue and burnout in all of medicine today. This is the reason doctors are suffering. This is the reason that my colleague is carrying that 35-year-old man with metastatic brain cancer around with her

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and why she cries each time she thinks about him. This is the reason six out of a 100 of us are contemplating suicide.

ourselves from our collective suffering (from burnout), is to step into, and stay in an energetic connection with our patient.

Science is now showing us our bodies are not wired to work this detached way, especially if we want to care for others. This is because care, just like love, can only be experienced in connection to another. Care requires a connection to the one you are caring for. We can’t care if we don’t connect. This flies in the face of what we were taught about not connecting to our patients in medical school.

When we’re mindful of our connection and we deliver the diagnosis, or the awful news, we will witness their pain wash over their body and register on their face. Automatically, and quite naturally, we will begin to feel within ourselves, the exact same emotions, and quite possibly the same physical sensations our patient is already feeling. This is because deep underneath our cognitive awareness, our hyper-vigilant survival based MNS (Mirror Neuron System which is buried deep in our brain stem, connected to our lambic system and our amygdala) forces us to mimic within our own bodies all of the facial expressions and body language that is happening right in front of us within our patient.

Dr. Henri Nouen teaches us that the word care comes from the Greek word “kara,” which means, “to lament, to grieve, to experience sorrow, or to cry out with”. He goes on to show us that all of us, without exception, “are uncomfortable with an invitation to enter in someone’s pain before doing something about it.” But the essence of care doesn’t lie in doing something about the pain—it lies in entering into it, freely and wholeheartedly. He teaches us that “the friend who can be silent with us in a moment of despair or confusion, who can stay with us in an hour of grief and bereavement, who can tolerate not knowing, not healing, not curing...that is the friend who cares.” Care is actually rooted in the human condition itself. None of us are immune from facing pain, suffering, disappointment, regrets and death. We’re all merely mortal and stage four terminal brain cancer could happen to any one of us. When we come to the ER because we’re sick, injured or just overwhelmed by life, we do not necessarily believe we will find a solution for our problem, or a cure for what ails us, but we all expect to find someone who cares that we’re suffering. If we’re mindful about what is going on in ourselves, especially in cases where there is no solution, it becomes easy to see that we can no longer buy into medicine’s big lie, and stay disconnected from our patients and their grief. We can see that the only way to release

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This process, which in the context of the patient encounter, has been labeled affective empathy, is unconscious and almost instantaneous, and there is nothing we can do to stop it. This can actually hurt and it can be emotionally overwhelming, and we may begin to cry, especially if our patient is sobbing, but feeling the pain of our patients so intensely, as if it were our own, will not consume and destroy us, like we were taught in medical school. This is why my colleague could not deliver the diagnosis to her patient with metastatic brain cancer. She, like you and I, was taught that feeling this sort of pain, would overwhelm her and that she would lose her objectivity, that it would essentially steal her ability to make good clinical decisions from her, that she would in effect become a bad doctor. Nothing could be further from the truth! It’s here in this painful place, where we feel our patient’s pain as if it were our own, when we’re mindfully engaged in the process with our patients, that the natural empathetic process will unfold organically and we will enter the next phase of the process, called cognitive empathy. It’s in this next step that the pain

we’re feeling lessens a little and we begin to wonder, as we move from the level of our brain stems to our prefrontal and frontal cortexes, what it must be like to be in their shoes. By allowing our curiosity to wonder what it’s like for them, we naturally begin to move away from that painful empathetic place and into the next natural phase of the caring process, compassion. Compassion is the feeling that arises within us when we’re confronted with another’s suffering and feel motivated to relieve it. We just wish that things were better for them. Research shows when we begin to feel compassion, our heart rate slows down, oxytocin, dopamine and other positive neurotransmitters start to be elaborated in our frontal cortex and the centers and nuclei that register pleasure begin to light up. As we begin to feel better and these neuro-chemicals wash over the gray matter in our frontal and pre-frontal cortexes, we become more tolerant, open and trusting and are better able to see the interconnectedness between people and situations. We begin to see more possibilities and become more receptive to novel solutions. At the same time, our patient’s MNS causes our patient to mimic what is happening for us and our patient begins to feel what we’re feeling. It’s when we speak or act from this place of heightened compassion that we can truly make a difference for our patient and ourselves, and we both feel better. Practicing mindfulness while practicing medicine allows us to see that compassion cannot fatigue. Compassion enlarges and augments us as doctors, healers and people. It’s when we get stuck in the place of affective empathy, each time we avoid delivering a devastating diagnosis because of what we were taught in medical school, that we over time, with each new patient, start to experience empathetic overload. No one can hold all that grief and pain and expect to be healthy emotionally. This is why we succumb to burnout. This is why we can’t enjoy our careers or our lives, and this is

why six out of 100 of us are thinking about suicide as the only way out right now. Only when we begin to mindfully practice medicine and allow this caring process to unfold naturally, without being afraid, can we know for sure that what we say and do, matters.

By walking these steps in connection with our patients, we begin our own journey home, back from burnout, to a wholesome and emotionally healthy experience of life itself. Until next time, go care, make a difference and change (y)our world.

“Executive Director’s Desk” continued from page 5 3. Stop the political bickering and make a government that works for all people. 4. End the religious wars taking place around the globe. Put religion in your back pocket, don’t just look at people and judge them because they believe in doctrine that’s not the same as yours—see number 1. 5. Build a world that can feed its people; where ideas are accepted and not something to be afraid of; where the air and water are clean and healthcare is practiced in a fair and equitable way. Happy New Year, my friends. Wishing you a wonderful year, filled with what is important to you and yours.

Dr. Carol Rivers’ Written Board Review New Eighth Edition January 2017

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THE PULSE | JANUARY 2017

ACOEP Welcomes Three New Staff Members to the Team! Gabi Crowley

COEP is very excited to welcome three new staff members to the team, Kefáh Spreitzer, Tyescia “Ty” Jackson, and Lindsey Roden.

Kefáh Spreitzer joined ACOEP in August as the College’s Educational Specialist. She was born and raised in New York City, but graduated from Earlham College in Indiana with a degree in Theater Arts and Peace Studies, and went on to receive her master’s in education from Roosevelt University in Chicago. Before joining the team, she worked in educational programming, administration and teaching for almost 10 years. “ACOEP is so excited to add Kefáh to the Education Department, as she has a great wealth of knowledge in a variety of aspects when it comes to education,” ACOEP’s Director of Education Services, Kristen Kennedy said. Kefáh’s role includes working with ACOEP’s Student and Resident Chapters, as well as growing educational initiatives for the College through testing and other educational activities. “I am excited to wear many hats by assisting the Educational Services Department with a variety of programs and goals,” Kefáh said. In her spare time Kefáh enjoys cooking with friends, and freelances from time to time as a director and producer in both Chicago and New York.

Ty Jackson, who will be taking on the role of Manager of Continuing Medical Education, is a Chicago native, and comes to ACOEP with much experience in nonprofit medical education, having worked with the American Medical Technologists, Emergency Nurses Association, and the American Academy of Pediatrics. “I am excited about bringing my experience to a new position and working with a new group of medical professionals. The ACOEP is growing at such a fast pace and the opportunities are endless, so I am looking forward to contributing to its continued success,” Ty said. Ty’s position includes ensuring that all educational activities are conducted in compliance with the standards set forth by ACOEP’s accrediting organizations. She also plans to focus on obtaining ACCME accreditation status for ACOEP. “We are very fortunate and excited to welcome Ty to the team, and are confident that she is going to take our CME offerings to the next level,” Kennedy said. When not at work, Ty enjoys going to concerts, movies, museums and festivals. And with a passion for dance, thinks she

could have been a back-up dancer for Beyoncé and Janet Jackson in a previous life. She also enjoys spending quality time with her seven nieces and nephews. Lindsey Roden, will assume the position of ACOEP’s Coordinator for Resident and Student Organizations. She graduated from Spelman College in Atlanta, Georgia, with a Bachelor of Arts in Women Studies with a Health Concentration and Public Health minor, before returning to her hometown of Chicago, where she most recently received her master’s degree in Public Health from DePaul University. “Lindsey is an excellent addition to our staff. We knew immediately that she understood the student/resident perspective,” ACOEP Executive Director, Jan Wachtler said. Previously, Lindsey has worked for health organizations including Chicago Department of Public Health, Optima Rx, and The Greater Humboldt Park Diabetes Empowerment Center. “I’m excited to get in this position and learn more about ACOEP, the team, the work that goes into my role and shaping it, and how ACOEP helps emergency Continued on Page 23

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Look How Far We Have Come

The American Academy of Emergency Nurse Practitioners Theresa M Campo DNP, FNP-C, ENP-BC, FAANP Mary Jo Cerepani DNP, FNP-BC, CEN

n 2014 a core group of nurse practitioner leaders founded and launched The American Academy of Emergency Nurse Practitioners (AAENP to “promote high quality, evidence-based practice for NPs providing emergency care for patients of all ages and acuities in collaboration with an interdisciplinary team.” Since then, AAENP has grown and flourished and continues to change the landscape of emergency nurse practitioner (ENP) practice in the United States. Since its inception, AAENP continues to work in collaboration with nursing, physician, and physician assistant organizations such as AANP, ENA, ACOEP, ACEP, and SEMPAto improve patient care in the emergency care setting. In the past two years AAENP has increased its membership to over 500 members and continues to grow. AAENP not only welcomes nurse practitioners, but also nurse practitioner students, registered nurses, physician assistants, and physician members through affiliate membership. The organization offers continuing education, member discounts, legislative updates, an annual conference, regional meetings, as well as a subscription to its sponsored journal Advanced Emergency Nursing Journal.

ENPs face many challenges in the US, including academic education at the population focus level, varying state regulations, credentialing, restrictions,

intensive emergency care education, competency, and standards of practice. These challenges have been seriously met by AAENP, and our leadership has developed many initiatives to help ENPs navigate each issue. Initiatives include facilitating and disseminating a comprehensive and clear understanding of the ENP role to assist to those hiring ENPs, state and national boards of nursing,

examination, scope and standards for ENP practice, solidifying relationships with interdisciplinary organizations by participating in annual and biannual conferences and continuing education opportunities. There is currently one method to board certification through the American Nurses Credentialing Center (ANCC) and a board certification examination will be launched January 2017. This year at the 3rd General Assembly, AAENP provided interesting educational topics such as an orthopedic workshop with a highly interactive session covering specific exam techniques, and high-risk injuries with radiology interpretation of extremities and splinting techniques. Other session titles included RVUs and the Art of Compensation, Diagnostic and Therapeutic Medical Imaging, The Fussy Neonate, Pain Management, and much more.

academic and continuing education accreditation bodies, as well as graduate NP educational organizations (i.e. national organization of nurse practitioner faculties – NONPF). Other critical work includes standardized educational curricula, updating core competencies, and furthering ENP science.

All of these initiatives are being carefully evaluated and expanded on a regular basis with constant oversight and consideration of the needs of not only ENPs, but our health care colleagues. Emergency nurse practitioners work in concert with physicians, physician assistants, nurses, and other health care professionals to provide high quality patient care with knowledge, dedication, and care.

Specifically, the past year has brought the ENP specialty certification by

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ACOEP’s 2016 Scientific Assembly A Look Back on a Successful Conference! By Gabi Crowley

COEP’s Scientific Assembly took place this year in San Francisco, CA, and was a runaway success! With attendance numbers over 1,200 registrants, this year’s conference welcomed DOs, MDs, NPs, PAs and RNs. Scientific Assembly’s Kickoff Party was a grand slam, thanks to Island Medical Management, who sponsored the event at AT&T Stadium, where attendees, friends, and families witnessed the Chicago Cubs win the World Series on the park’s jumbotron. Scientific Assembly provided more learning opportunities than ever before, kicking off the week with pre-conference tracks including, ACOEP’s first-ever Active Shooter Scenario Training course, Basic and Advanced Emergency Ultrasound courses, Advanced EKG and Airway courses, and an EMS Directors Track. ACOEP President John Prestosh, DO, FACOEP-D, took the stage Thursday morning to officially welcome all attendees before this year’s keynote speaker, David Schriger, ME, MPH. Outside of the lecture halls and breakout sessions, attendees mingled with colleagues while visiting the Expo Hall, along with conversing with Scientific Assembly faculty in both the Conversation Hub and Ask the Expert stations. Various Student and Resident Chapter events took place throughout the week along with sponsored social and networking events. At the annual Membership Meeting, three new Board members

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were sworn in including Stephanie Davis, DO, FACOEP, Juan Acosta, DO, MD, FACOEP-D, Nicole Ottens, DO, FACOEP, along with ACOEP Resident Chapter’s new President, Kaitlin Bowers, DO. Case competition winners and FOEM donors were recognized at this year’s Chinatown-themed FOEM Legacy Gala. Authentic Chinese food was served and entertainment was provided by Chinese dragon dancers and a harpist. After the paddle call, attendees closed out the night by showing off their best moves on the dancefloor…we’re looking at you Dr. Prestosh! The 3rd annual Women’s Council Luncheon took place on Friday, November 7th and drew in over 30 powerful and driven women. President-Elect Chris Giesa, DO, FACOEP gave a warm welcome and Beth Longenecker, DO, FACEOP was awarded the Willoughby Award named after ACOEP’s first-ever female President Paula DeJesus, DO, FACOEP. As the week came to a close, many attendees didn’t forget to practice worklife balance and explored the city, taking advantage of the vintage fire truck and chocolate tours that the ACOEP staff helped organize. We’d like to thank everyone who attended this year’s Scientific Assembly, its success would not have been possible without all of you. We hope to see you in Bonita Springs, FL this spring for Spring Seminar, April 18-22!

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The Foundation Spotlight

The Foundation for Osteopathic Emergency Medicine hosted several events at ACOEP’s Scientific Assembly this November. The week started off with the FOEM Resident Research Competitions. The posters, papers, oral abstracts, and CPCs were better quality than ever, highlighting the work of residents from across the country. Congratulations to the 2016 winners! Be sure to read the 2016 winning abstracts on page 32.

Research Paper Competition

CPC Faculty Discussant Winners

Sponsored by

1st Place Joshua Spicer, DO Henry Ford Allegiance Health, Jackson, MI

P 1st Place Lauren Segal, DO Aria Health, Philadelphia, PA 2nd Place Kathryn Yates, DO Metro Health Hospital, Wyoming, MI 3rd Place Priyanka Kailash, OMS-IV Campbell University SOM, Lillington, NC

2nd Place Kristin Shnowski, DO Metro Health Hospital, Wyoming, MI 3rd Place Scott Taylor, DO Conemaugh Memorial Medical Center, Johnstown, PA Next on the docket was the highlight of the week, the 2016 FOEM Legacy Gala presented by US Acute Care Solutions. This year’s theme was a taste of Chinatown, as guests were transported into an enchanted setting that delighted them all.

Thank you to the 2016 FOEM Legacy Gala Honorees.

FOEM Pinnacle Award Presented to donors with a lifetime level of $25,000 and above Juan Acosta, DO, MS, FACOEP-D, FACEP

FOEM President’s Circle Award Presented to donors with a lifetime level of $10,000 and above Fahim Shan Ahmed, DO, MS, FACOEP, FACEP Gary Bonfante, DO, FACOEP Janice Wachtler, BAE, CBA

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WHAT MORE COULD YOU WANT?

FOEM BEACON | JULY 2016

APPLY TODAY! eddocs.com/careers

Victor J. Scali, D.O., FACOEP-D Jeremy Selley, D.O., FACOEP and Victoria Selley, D.O., FACOEP Bryan D. Staffin, D.O., FACOEP-D Robert E. Suter, D.O., MHA, FACOEP, FACEP, FIFEM James Turner, D.O., FACOEP and Sherry Turner, D.O., FACOEP Janice Wachtler, BAE, CBA Shelly Zimmerman, D.O., FACOEP, FACEP

FOEM Sustainers

Attendees at the 6th Annual FOEM Legacy Gala enjoyed a memorable evening.

FOEM Pillar Award

FOEM 500 Club

Presented to donors with a lifetime level of $5,000 and above G. Joseph Beirne, DO, FACOEP, FACEP Bernadette Brandon, DO, FACOEP Gregory Christiansen, DO, FACOEP-D Christine Giesa, DO, FACOEP-D Steven Hollosi, DO, FACOEP Donald Phillips, DO, FACOEP-D, FACEP, FAAEM

Presented to donors with an annual donation of $500 and above Juan F. Acosta, D.O., M.S., FACOEP-D F. Shan Ahmed, D.O., M.S., FACOEP, FACEP Michael Allswede, D.O. John Ashurst, D.O. G. Joseph Beirne, D.O., FACOEP, FACEP Gary Bonfante, D.O., FACOEP Bernadette P. Brandon, D.O., FACOEP Timothy J. Cheslock, D.O., FACOEP Jack B. Field, D.O. Christine F. Giesa, D.O., FACOEP Justin Grill, DO Christopher M. Gooch, D.O., FACOEP Drew A. Koch, D.O. FACOEP-D Joseph J. Kuchinski, D.O., FACOEP-D David Lawrence Levy, D.O., FACOEP Brandon Lewis, D.O., FACOEP, FACEP Beth A. Longenecker, D.O., FACOEP Mark A. Mitchell, D.O., FACOEP-D, FACEP Donald Phillips, DO, FACOEP-D, FACEP, FAAEM

FOEM Partner Award Presented to donors with a lifetime level of $2,500 and above Michael Allswede, DO John Ashurst, DO Aimee Blagovich, DO Timothy Cheslock, DO, FACOEP David Levy, DO, FACOEP

Presented to sustained monthly donations of $50 or more Juan F. Acosta, D.O., M.S., FACOEP-D F. Shan Ahmed, D.O., M.S., FACOEP, FACEP Michael Allswede, D.O. G. Joseph Beirne, D.O., FACOEP, FACEP Jack B. Field, D.O. Christine F. Giesa, D.O., FACOEP Christopher M. Gooch, D.O., FACOEP Joseph J. Kuchinski, D.O., FACOEP-D Brandon Lewis, D.O., FACOEP, FACEP Mark A. Mitchell, D.O., FACOEP-D, FACEP Thomas Mucci, D.O., FACOEP-D Jeremy Selley, D.O., FACEOP and Victoria Selley, D.O., FACOEP James Turner, D.O., FACOEP and Sherry Turner, D.O., FACOEP

FOEM Research Flame Award Presented to the ACOEP Residency Program with the highest average score for research papers Charleston Area Medical Center Charleston, WV

FOEM 100% Program Challenge Presented to the ACOEP Residency Program with the most donations per resident in 2016 Ohio Valley Medical Center Wheeling, WV

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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 ambulance EMS coordinator. “A couple of months ago we had a call at our local nursing home. We were called for an unresponsive person. Upon arrival, the crew was handed paperwork for the patient and continued to work on the patient. The crew packaged patient and moved them to the ambulance with ALS care and contact/transported to the hospital. Our patient did not make it and the doctor made the call. My next shift started with no problem. I then overheard someone saying that a nursing home had given the wrong paperwork to an ambulance crew and the hospital had no idea that this had happened at the time of transport. The hospital then had called the patient’s family. The hospital used the paperwork that we had given them. We found out the family arrived at the hospital and the staff had taken family members to see the deceased. The family was very upset upon realizing that this was not their mother. I then realized that this was our call on our last shift. I proceeded to advise my Shift Commander and Chief of the situation. We were never notified in an official capacity. I contacted the hospital and

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the nursing home that this situation had occurred. Furthermore, we had already sent a bill to the family. Now not only do we look like idiots, but the hospital really looks bad, as well. After contacting the nursing home, staff had said that they would handle the problem with both families. My Chief wants us to write a supplemental on this call. I had told the Chief that I don’t believe I should do this. This was the paperwork that we were handed by the nursing staff and at the time that’s all we could do. I did say that I could write on our letterhead and attach information of what had happened to the report, but I can’t change the report. Also, the nursing staff had said that they were going to cover whatever expense had occurred on our end and to submit a bill to the nursing home. The problem we have is that we still don’t have the proper name on this patient. The staff at the nursing home said that they would give us this information and we then could bill accordingly. I am not concerned about the bill. I am concerned about proper documentation. Do we just attach a letter to this form for our own knowledge, or do we submit a supplemental? What should we do?” What would you do? Please send your thoughts and ideas to ThePulse@acoep.org. Every attempt will be made to publish them when we review this dilemma in the next issue of The Pulse. What advice would you give? Attach information or formal documented chart addendum? If you have any cases that you would like to present or be reviewed in The Pulse, please email them to us ThePulse@acoep.org. Thank you.

“Future ” continued from page 3 Although we do react to what is currently happening in our healthcare environment, we cannot stop there because if reaction is our only action, we will soon be lost. We need to be proactive and take the necessary steps to maintain not only relevance in emergency medicine but be a leader in our specialty. The Board of Directors met in Florida less than a year ago to implement a new strategic plan and we have already set that plan in action. However, as pertinent as this plan is, we need to reset our goals in a fluid fashion. Changes in the healthcare system are rapidly occurring and it is imperative that we are ahead of those changes. I believe that ACOEP will meet the challenges facing our profession. I do not say this out of wishful thinking. Our Board of Directors has a goal for our College and is striving to ensure that plan is translated into a working reality to make our future successful. However, we cannot do this alone. We need the continued support of all our members. We encourage everyone to get involved with the issues facing emergency medicine. We would appreciate hearing your thoughts and ideas on how ACOEP should have more input within our specialty. Our College is moving forward ensuring our future to be relevant and bright. I ask every member of ACOEP to help us attain that goal.

“Welcome” continued from page 15 physicians enhance their craft and the impact it has on their careers and development,” Lindsey said. Outside of work, Lindsey loves traveling and spending time with her family and friends. She also enjoys movies, trying new restaurants, working out, taking pottery classes, and tea time. ACOEP is very excited to have Kefah, Ty and Lindsey as part of the team! We look forward to having them on board to continue the growth and success of the College.

2nd Annual Meeting of ACOEP’s Council for Women in Emergency Medicine Kaya Smith, Student Member

COEP’s Council for Women in Emergency Medicine held their second annual luncheon on October 5th in San Francisco, CA, during the Scientific Assembly events. President-Elect Christine Giesa, DO, FACOEP, welcomed us to the Council and presented our mission statement, “Inspiring, mentoring, leading and shaping the future of women in emergency medicine.” Open to all conference attendees, the Council welcomed board members, attendings, residents, and students alike.

Alexis LaPietra, DO, the luncheon’s keynote speaker, was honored with the Innovative Practice Award at the Fellowship Ceremony for her accomplishments on the Alternative to Opioids (ALTO) program at St. Joseph’s Regional Medical Center in Paterson, New Jersey earlier in the week. While Dr. LaPietra worked tirelessly on the ALTO program, she is not defined by it. She addressed the dichotomy of being an emergency physician, a mother, a wife and a woman all wrapped in one, and advised all in the room, with fellow groans and laughter of agreement, that juggling all of those roles at once can sometimes be impossible,

of identifying and empowering women leaders in the field of emergency medicine and encouraged all present to be involved.

Dr. Ottens and Dr. Giesa along with Gabi Crowley, ACOEP’s Digital Media Coordinator, have been working hard on creating a social media presence, introducing conversation topics, and keeping members connected and up to date with current events. Find more information on Facebook at www.facebook.com/ACOEP-Councilfor-Women-in-Energency-Medicine. This page features weekly discussion topics and articles, encouraging Council mem bers to engage with each other throughout changes, we the year.

Paula Willoughby DeJesus, DO, FACOEP, the first As the future of emergency medicine female President are reminded to continually be supportive of the many of ACOEP, honored amazing, intelligent, tireless, and outstanding heroines. As the future Beth Longenecker, DO, FACOEP, of emergency as the first-ever medicine changes, recipient of the we are reminded heartbreaking, and discouraging, but Willoughby Award, recognizing true to continually be supportive of the each day you can strive to be great in leaders in emergency medicine. Dr. many amazing, intelligent, tireless, and one. She takes pride in doing what she Longenecker, Program Director for outstanding heroines. As emergency can with each day and having faith in the Emergency Medicine Residency physicians, residents, students, nurses, what inspires her to be better. Program at Mount Sinai Medical Center practitioners and staff of all kinds, we ACOEP faculty member and Oral Board are the women of emergency medicine, As Dr. Giesa transitions into her new examiner, exemplifies leadership, and we run the world. position as ACOEP’s Board President, inspiring and educating both men and the Council looks to new leadership in women in emergency medicine. In her Nicky Ottens, DO, FACOEP. Dr. Ottens acceptance speech, Dr. Longenecker is very excited to lead the Council, and acknowledged her peers, who have was supported by an outpouring of been inspiring women in her career, welcome and support at the end of the many of whom were in attendance, and meeting. She reminded us of our vision offered encouragement to be uplifting to others.

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Join the Foundation for Osteopathic Emergency Medicine at the 2017 ACOEP Spring Seminar in Bonita Springs, Fl!

5K & 1-Mile DO DASH Wednesday, April 19, 2017 5:45 pm – 6:45 pm

Get the blood flowing for a good cause! All conference attendees and their families/ guests – from walkers and novice runners to seasoned marathoners – are welcome to join the FOEM 5K Run for Research and one-mile DO-Dash!

BEFORE 3/18/17

REGISTRATION

AFTER 3/18/17

5K rate for attending physicians

$60

$75

5K rate for students, residents & family

$30

$40

FOEM 1-Mile DO Dash (all)

$20

$25

Registration includes t-shirt. Your shirt size is guaranteed if you sign up by March 18!

For more information or to register for an event, please contact Stephanie Whitmer at swhitmer@foem.org, or register online at acoep.org/spring.

FOEM Case Study Poster Competition Wednesday, April 19, 2017 from 2:00 – 5:00 pm

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The Foundation for Osteopathic Emergency Medicine (FOEM) is proud to present the annual Case Study Poster Competition, in which students and residents present interesting or unique cases that have presented at their hospital. Winners receive certificates, cash prizes, and recognition in FOEM publications throughout the year. The deadline for submission of applications and abstracts is January 31, 2017.

“Would you ” continued from page 8

I don’t notice it when the drill is in my molar. I have developed a practice style not unlike that of my MD colleagues. We both sit down to listen to the patient, we both touch our patients, we both care about our patients, we both nod to affirm their concerns and we both pay homage

patients looking at my scrub top and saying, “Oh good, you’re a DO.” They know and expect something that I am presumed to possess. I had best fulfill their expectations. Would I do it again? Yes, I would.

Throughout the process there will need to be gutchecks to verify I will be an osteopathic emergency physician and just not a generic emergency physician. I had better not rely on my good looks. to the Press-Ganey imp. I do use that skill set of OMM, occasionally. Did it take some education of the credentialing committee, the fiscal department and the patients? Yes, but I have also noted

technologies. Residencies hone the skills to produce providers ready to enter the career challenges of emergency medicine. Throughout the process there will need to be gut-checks to verify I will be an osteopathic emergency physician and just not a generic emergency physician. I had better not rely on my good looks.

However, I would be entering a pool with candidates who start from high school better prepared and informed for their college career. Their medical schools utilize proven educational methods and

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Medical Monitors for Weight Loss and Improving Health Janice Wachtler, BAE, CBA

k, I could have told you that the gadgets we all seem to be wearing don’t help much. Sure, it’s great to see how far you walk in a day and to monitor your sleep patterns, how much water you drink and just about everything else; but I could have told the American public they really didn’t help do much. During the six months I wore my device I was diligent to enter water intake, I checked to see how much I’d walked in a day and, unfortunately, how little sleep I was getting. But the only weight I lost was 1.5 lbs. I spoke with the doctor, who told me that unless I severely limited calories while exercising, my weight would stay the same. Frustrated, I sold it on eBay.

What I’ve learned is the data is fine, but no habits are changed unless you want to change them.

I think what I’ve learned is the data is fine, but no habits are changed unless you want to change them. And then you have to stick to your guns, make the changes you have to make and be true to yourself. We’ve seen this over and over as we look for cures for baldness, to lose weight, or cure wrinkles. If you do something more than you’re currently doing it, it will help,

but you can’t stop there. Some things are genetically predisposed and that’s that. So, if someone wants to throw money my way, on the presumptive ability of anything to lose weight for you; hey, I’m ready to be a test subject and will probably be able to tell you if it works or not.

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

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

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

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New Physicians in Practice (NPIP) Update Nicole Ottens, DO, FACOEP

hank you to those everyone who attended the New Physicians in Practice events at ACOEP’s Scientific Assembly in San Francisco on November 3rd. We were thrilled to welcome more than 70 registrants and a standing room-only crowd for the NPIP track. Christopher Colbert, DO, FACOEP, Kevin Klauer, DO William Fraser, DO, Alan Janssen, DO and Mr. McNeff from Legally Mine, LLC provided great lectures and helpful information for those who are new in practice. Attendees also received an updated New Physicians in Practice membership guide, and an expandable folding file to keep paperwork and certification information organized.

WE WANT TO YOU TO BE INVOLVED! We need your help! If you are interested in serving on this committee, please contact us. We are looking for senior residents, or those in the first few years of practice, who would be willing to get involved in this growing and thriving committee. There are positions available for conference planning, publications and marketing, and mentorship. Please send all inquiries to Gina Schmidt at gschmidt@acoep.org. And lastly, follow us on social media. Like our Facebook page at www.facebook.com/acoepnp and share it with others so you can keep up-to-date on the latest NPIP happenings.

Important 2017 Dates Looking ahead to 2017, here are some events to keep on your radar screen:

January 5-6, 2017 ACOEP’s Oral Board Review

March 2017 ACOEP Fellowship applications are due; AOBEM Oral Boards

April 18-22, 2017 ACOEP’s Spring Seminar

If you were unable to attend, this membership guide provides great information about the timeline of the events from senior year of residency through the first five years after graduation, through board certification, continued medical education, COLAs and more. You can find a copy at www.acoep.org/npip, or contact Gina Schmidt at ACOEP (gschmidt@acoep. org) to request a hard copy. ACOEP’s Spring Seminar is April 18-22, 2017 at the Hyatt Regency Coconut Springs Resort in Bonita Springs Florida, we anticipate having another poolside party, as well as Oral Board Review prep. Details will be coming soon, watch your emails and the next edition of The Pulse for more information.

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Assistant/Associate Residency Program Director Emergency Medicine Core Faculty Pediatric Emergency Medicine Faculty Community-Based Site Opportunity

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, on-campus fitness center, day care, credit union and so much more! For your health, Hershey Medical Center is a smoke-free campus. Applicants must have graduated from an accredited Emergency Medicine Residency Program and be board eligible or board certified by ABEM or AOBEM. We seek candidates with strong interpersonal skills and the ability to work collaboratively within diverse academic and clinical environments. 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 Hershey Medical Center, Mail Code A590, P.O. Box 850, 90 Hope Drive, Hershey PA 17033-0850, Email: hpeffley@hmc.psu.edu OR apply online at www.pennstatehersheycareers.com/EDPhysicians

The 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.

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Literature Update Winter 2017 John Ashurst DO, MSc Steve Sherick MD Kingman Regional Medical Center, Kingman, Arizona

Public Usage of AEDs Improve Survivability and Neurologic Outcomes

Syncope and Pulmonary Embolism: Is there a Relation?

Article: Kitamura T, Kiyohara K, Sakai T et al. Public-access defibrillation and out of hospital cardiac arrest in Japan. N Engl J Med 2016, 375: 1649 â&#x20AC;&#x201C; 1659.

Article: Prandoni P, Lensing AW, Prins MH et al. Prevalence of pulmonary embolism among patients hospitalized for syncope. N Engl J Med 2016; 375(16) 1524 â&#x20AC;&#x201C; 1531.

What we know: Early cardiac defibrillation in those with a shockable rhythm in out of hospital cardiac arrest is proven to improve survival.

What we know: For those with syncope, there is no defined research to determine who needs imaging to rule pulmonary embolism as the cause of their syncope.

Article Review: Using a national registry, investigators examined the outcomes of those who had ventricular fibrillation from 2005 to 2013 that was either witnessed by bystanders or treated by bystanders or emergency medical services and transferred to the hospital. The primary outcome of the study was survival with a favorable neurologic at one month. A total of 43,762 patients were examined with 10.3% receiving public access AED defibrillation. Over the years studied, the amount of public access to AEDs increased 39 fold while the amount of patients receiving public access defibrillation increased from 1.1% to 16.5% (p<0.001). 38.5% of patients receiving public access defibrillation had favorable neurologic outcomes at one month as compared to 18.2% of those that did not receive public access defibrillation.

Article: This study was a cross sectional study to determine the prevalence of pulmonary embolism in those hospitalized with their first episode of syncope. Admitted patients underwent testing for pulmonary embolism based upon the Wells score and D-dimer assay. A total of 560 patients were included in the final analysis and 58.9% had pulmonary embolism ruled out based upon Wells score and D-dimer assay. Pulmonary embolism was detected in 42.2% of the remaining patients and 17.3% of the entire cohort. In those without a definite cause of syncope 25.4% had a pulmonary embolism and 12.7% of those with an alternative cause of syncope also had a pulmonary embolism.

Commentary: Based upon the study, public access AEDs appear to not only improve survivability but also neurologic preservation in those with out-of-hospital cardiac arrest. However, baseline characteristics differed amongst the two groups and may have led to an effect. Further research should be conducted in this area before healthcare policies are changed.

Commentary: For those being admitted for their first episode of syncope, pulmonary embolism should be suspected and clinical decision-making, including the Wells score and D-dimer testing, may be warranted. Should EM Physicians Give Naloxone on Discharge to Those Who Overdose on Opiates? Article: Kestler A, Buxton J, Meckling G et al. Factors associated with participation in an

emergency department-based take-home Naloxone program for at risk opioid users. Ann of Emerg Med. Epub ahead of Print. What we know: The United States is facing an opioid epidemic of growing proportions and deaths related to opiate overdoses can be preventable. Article Review: In an urban emergency department, a survey was completed by patients aged 16 years or older who were found to be a high opioid overdose risk. The survey consisted of demographics, previous opioid overdose experiences and awareness and opinions in regards to Naloxone. The primary outcome of the survey was acceptance of take home Naloxone while secondary outcomes were to analyze characteristics that would lend supportive of take home Naloxone. A total of 83.4% of those approached completed the survey and 74.6% had admitted to using injection drugs. In this group, 60.7% admitted to overdosing on opiates and only 15.4% had received a takehome Naloxone pack at discharge. The majority of those surveyed would accept a Naloxone take-home pack and multivariate analysis showed that witnessing others overdose, concern about overdosing, injection drug use, and being female was associated with acceptance of the Naloxone take home pack. Commentary: Opiate addiction is much like any other disease and those that are inflicted are worried about their outcomes. The study shows a striking lack of takehome Naloxone being given to those who have overdosed on opiates but there is room for improvement. The majority of those surveyed would be willing to accept take-home Naloxone if only the physician would prescribe it.

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2016 Scientific Assembly Winning Abstracts 1st Place Research Paper Electrocardiographic Manifestations and Clinical Outcomes of Severe Hyperkalemia: Can the Electrocardiogram Risk Stratify for Short Term Adverse Events? Brian Lehnhof, DO; Andrew Bergeson DO; Shayla N.M. Durfey, BSc; Kristina McAteer, MD; Justin Valiquet, DO; Nicole Durfey, MD Department of Emergency Medicine, Kent Hospital, Warwick, RI; Affiliate of University of New England College of Osteopathic Medicine Medical School, Biddeford, Maine (Bergeson, Durfey N, Lehnhof, McAteer, Valiquet) and The Warren Alpert Medical School of Brown University, Providence, RI (Durfey SNM) Disclaimers and Disclosures: No financial support was received for the conducting of this project. Electrocardiographic Manifestations and Clinical Outcomes of Severe Hyperkalemia: Can the Electrocardiogram Risk Stratify for Short Term Adverse Events? Brian Lehnhof, DO; Andrew Bergeson DO; Shayla Durfey, BSc; Kristina McAteer, MD; Justin Valiquet, DO; Nicole Durfey, MD Kent Hospital, Department of Emergency Medicine. University of New England College of Osteopathic Medicine Introduction: Without any preceding signs or symptoms, severe

hyperkalemia may lead to lethal cardiac dysrhythmias.1,2 As a patient’s potassium rises, standard teaching describes sequential appearance of classic electrocardiographic (ECG) abnormalities. 3,4 However this has been challenged by findings that a significant proportion of patients with hyperkalemia do not have these abnormalities. More information is needed to know how to use the ECG most effectively in the management of these critically ill patients.

rhythm, and treatment for hyperkalemia prior to obtaining the ECG and laboratory sample.

Objectives: The objective of this study is to determine the frequency of ECG changes in patients with severe hyperkalemia and the correlation between hyperkalemic ECG changes and short-term adverse events.

Results: Of the 188 included episodes of severe hyperkalemia, 134 episodes (71%, 95% CI: 58.6-71.5%) had hyperkalemic ECG abnormality. QRS prolongation (43%, 95%CI: 36.7-50.8%) and peaked T waves (30%, 95% CI: 24.137.2%) occurred most commonly. PR prolongation (15%, 95% CI: 10.5-20.7%) and bradycardia of less than 50 bpm (11%, 95% CI: 7.4%-16.5%) were also noted. All patients who had an adverse event within 6 hours (n=28, 15%) had a preceding ECG that demonstrated hyperkalemic abnormality (100%, 95% CI: 85.7-100%). There was no statistically significant correlation between peaked T waves and short-term adverse events (OR 0.73, 95%CI: 0.29-1.84). QRS prolongation (OR 6.11, 95%CI 2.35-15.92), junctional rhythm (OR 25.24, 95%CI 7.24-88), and bradycardia of less than 50 bpm (OR 60.27, 95%CI 17.28-210.18) were all associated with an increased likelihood of short-term adverse event.

Methods: This retrospective cohort study included 188 episodes of severe hyperkalemia (K+ ≥ 6.5 mEq/L) in emergency department and hospitalized patients at a suburban 350-bed community hospital. The study received institutional review board approval from Kent Hospital, with a waiver of informed consent. The presence or absence of ECG findings of hyperkalemia and adverse clinical outcomes were reported. Odds ratios were calculated to evaluate the association between specific hyperkalemic ECG abnormalities and short-term adverse events. Included cases had a documented serum or plasma K+ of ≥6.5 mEq/L and an ECG performed within one hour before or after the laboratory draw. Exclusion criteria included laboratory notation of a hemolyzed sample, platelet count ≥ 500 x 109 platelets/L, paced

There were no interventions conducted in this retrospective chart review. The primary outcome measure was the presence or absence of ECG findings of hyperkalemia. The secondary outcome measures were adverse clinical outcomes within 6 hours.

Conclusion: The ECG does not reliably demonstrate hyperkalemic abnormalities in patients with severe hyperkalemia. While short-term adverse events were uncommon, all were preceded by an

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s d e fi i s s a l C M E O F EM O F e h t g Introducin s! d e fi i s s a l C h c r a e s e R

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ECG that demonstrated hyperkalemic abnormality. An increased likelihood of short-term adverse events was found in hyperkalemic patients with QRS prolongation, bradycardia of less than 50bpm, and/or junctional rhythm.

1st Place Poster Title: Incidence of Delayed Intracranial Hemorrhage in Patients Taking Warfarin that Sustain Head Trauma Authors: Lauren Segal, DO, Brian Collins, DO, Maricel Dela Cruz, DO, Michael Baier, DO, and Scott Plasner, DO Aria-Jefferson Health, Philadelphia, PA Abstract: Introduction: With an aging United States population, individuals taking anticoagulant medications are common, particularly those using Warfarin. A large proportion of the elderly and those in lower socioeconomic classes utilize Warfarin due to its affordability. Emergency medicine physicians are challenged in treating these patients after they sustain head trauma. Of particular interest is the incidence of delayed intracranial hemorrhage in patients with head trauma while on Warfarin. To date, there is limited data on this matter. Objective: The objective of this study was to determine the incidence of delayed intracranial hemorrhage in individuals taking warfarin. It is hypothesized that the incidence of delayed intracranial hemorrhage in this specific population is low. As a result, this data can potentially prevent unnecessary admissions to the hospital, decrease radiation, and reduce costs. Methods: A retrospective observational study was conducted by medical record review from January 2009 to January 2012 at a Level II community trauma center, Aria Health

Torresdale in Philadelphia, Pennsylvania. The Aria Health IRB approved this study. Participants included individuals admitted to the trauma service that were taking Warfarin, suffered blunt head trauma, and had an initially negative CT Brain and were admitted for a follow up CT. Patients had to be 18 years or older to be eligible. There were no interventions performed, as this was a retrospective analysis. Results/Main Outcome: The primary outcome of this study was to determine the incidence of delayed intracranial hemorrhage in patients sustaining blunt head trauma while anticoagulated on Warfarin from 2009 to 2012. In this chart review study, there were several thousand patients admitted to the trauma service during the time span of interest. Of those, there were 73 who were admitted to the trauma service and satisfied this studyâ&#x20AC;&#x2122;s inclusion criteria. There were a multitude of blunt traumatic mechanisms of injury, including but not limited to, accidental falls, assaults, and MVCs. These patients were anticoagulated on warfarin for a variety of reasons, most commonly for atrial fibrillation. In this cohort, there were three patients who had an initial negative CT Brain that developed an intracranial hemorrhage seen on 6-hour follow-up CT scan. The remaining 70 patients had negative imaging on a 6-hour follow-up CT Brain. Conclusion: There is a risk of delayed intracranial hemorrhage in individuals using warfarin. Three out of 73 (4%) were found to have delayed ICH. However, none of them had significant clinical change or required intervention. This may indicate that monitoring of clinical status is more appropriate than scheduled repeat imaging for all. On a systems-wide scale, this has the potential to decrease spending on imaging and reduce radiation to our patient population.

1st Place Oral Abstract Identification of Cerebellar Stroke in the Emergency Department: A Retrospective Approach Study Objectives: Our aim was to evaluate 5 years of patient records to assess how often cerebellar strokes (CS) were diagnosed or missed, and potential factors causing this. Methods: Five years of patient records were utilized to retrospectively ascertain all patients who were diagnosed with an ischemic cerebellar event with an associated diagnosis of ataxia, dizziness, imbalance, or vertigo after an ED visit. Records were evaluated for the presence of recent ED visits with similar complaints. Trends in data were followed; such as repeat visits, ED diagnosis, physician examination documentation for ambulation or ataxia, and imaging results. Results: 98 patients had a diagnosis of stroke with an associated complaint of dizziness or vertigo. 20 patients had a diagnosed (CS). Only 9 patients had any physician documentation in the physical exam/medical decision making discussing or recording attempted ambulation or signs of ataxia. All 20 patients had CT non-contrast imaging performed in the emergency department. 5 CT scans were positive for (CS). 15 patients had an MRI performed during their inpatient stay and 13 were positive for a (CS). 4 patients were diagnosed clinically by neurology after a negative CT. 6 patients were given a final diagnosis of (CS) in the ED. The remaining 14 patients were diagnosed during their inpatient stay. Conclusion: Few (CS) are presenting repeatedly for a final diagnosis, and few are diagnosed in the ED. Most are diagnosed during their inpatient stay after a neurology consultation. The majority of physicians are not documenting ambulation, evaluation of gait, or signs of ataxia. Finally, CT scan is not helpful in making the diagnosis.

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