The Pulse- Winter 2018 by ACOEP

JANUARY 2018

TECH AND INNOVATION IN EM

PRESIDENTIAL VIEWPOINTS

A PRESIDENTIAL INTRODUCTION PG 3

TECHNOLOGY AND EMERGENCY CARE PG 9

SUPPORTING RESPONSIBLE USE â&#x20AC;&#x201C; THE CASE FOR SOCIAL MEDIA PG 25

The Pulse VOLUME XXXVIII No. 5

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

2018

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

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.

ACOEP’s Spring Seminar Heads West! April 3- April 7, 2018 Loews Coronado Bay • San Diego, CA Visit acoep.org/spring for more information and to register.

The Pulse and ACOEP accept no responsibility for the statements made by authors, contributors and/ or advertisers in this publication; nor do they accept responsibility for consequences or response to an advertisement. All articles and artwork remain the property of The Pulse and will not be returned. Display and print advertisements are accepted by the publication through ACOEP, 142 East Ontario Street, Chicago, IL 60611, (312) 587-3709 or electronically at marketing@acoep.org. Please contact ACOEP for the specific rates, due dates, and print specifications. Deadlines for the submission of articles are as follows: January issue due date is November 15; April issue due date is February 15; July issue due date is May 15; October issue due date is August 15. Advertisements due dates can be found by downloading ACOEP's media kit at www. acoep.org/advertising. The ACOEP and the Editorial Board of The Pulse reserve the right to decline advertising and articles for any issue. ©ACOEP 2017 – All rights reserved. Articles may not be reproduced without the expressed, written approval of the ACOEP and the author. ACOEP is a registered trademark of the American College of Osteopathic Emergency Physicians.

TABLE OF CONTENTS 3

PRESIDENTIAL VIEWPOINTS Christine Giesa, DO, FACOEP-D

THE EDITOR'S DESK Timothy Cheslock, DO, FACOEP

EXECUTIVE DIRECTOR’S DESK Janice Wachtler

ON DECK CIRCLE Robert Suter, DO, MHA, FACOEP-D

TECHNOLOGY AND EMERGENCY CARE: WHAT HAVE WE GAINED? WHAT HAVE WE LOST? Frank Gabrin, DO

SUPPORTING RESPONSIBLE USE – THE CASE FOR SOCIAL MEDIA Christina Powell, OMS-III

FROM TV SUPER HEROES, TO ED SUPER HEROES Gabi Crowley. ACOEP Staff and Erin Sernoffsky, ACOEP Staff

RE-INVENTING THE ED DISCHARGE CALLBACK WITH TELEMEDICINE Benjamin Busch, DO, FACOEP, Adam Ash, DO, FACEP, Alexander Chiu, MD, MBA

ONE COMPANY SET TO DISRUPT THE TELEMEDICINE INDUSTRY Allison Price

NEW APP STREAMLINES TRACKING FOR PRACTITIONERS Erin Sernoffsky, Director, Media Services

HIRO DRONE SAVES THE DAY IN REMOTE MOUNTAIN RESCUES Erin Sernoffsky, ACOEP Staff

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2017 SCIENTIFIC ASSEMBLY IS ONE FOR THE RECORD BOOKS

ACOEP WOMEN’S COUNCIL PULSE UPDATE Nicky Ottens, DO, FACOEP Women’s Council Chair

JOIN ACOEP IN THE SUNSHINE STATE FOR THE 2018 SPRING SEMINAR!

FOEM FOCUS

want to thank the Board of Directors and the members of the College for the trust and confidence that you have placed in me. I have the distinguished honor to be the 2nd woman to become president of the American College of Osteopathic Emergency Physicians, and I am the 1st mother to become president. Allow me to share a little insight into what makes me who I am. My grand mom was the stabilizing force in my life. She kept me out of trouble, taught me to say “please” and “thank you,” and to respect my elders. She also taught me that if I did not have anything nice to say that I should not say anything at all. I have an unswerving sense of righteousness. I will always do the right thing even if it gets me in trouble, and trust me it has! I tend to put the needs of others before my own. I am committed to those things that I hold dear—my family and friends, my faith, my practice of emergency medicine, and the American College of Osteopathic Emergency Physicians. There are two German words that I would like to share with you—arbeit and dienst. “Arbeit” means work. “Dienst” means service. They are two very different words that refer to one’s work. However, the distinction is rather simple, and it has nothing to do with performing manual labor. The distinction comes with the type of work that is performed. “Arbeit” is work which is task-oriented. “Dienst” entails providing one’s service to people. This is the perspective I

THE PULSE JANUARY 2018

PRESIDENTIAL VIEWPOINTS

THE EDITOR’S DESK

Christine Giesa, DO, FACOEP

Timothy Cheslock, DO, FACOEP

A PRESIDENTIAL INTRODUCTION

TECHNOLOGY: FRIEND OR FOE?

take to the emergency department every day. I do not go to work in the emergency department, but rather I provide my “dienst,” or services, to the patients. As president, I bring this same concept of “dienst” to the College. I am here to serve you, the membership, and ACOEP. There has been a lot of angst surrounding our programs since we began the transition to the Single Accreditation System (SAS). Angst is the perfect word to describe how we in emergency medicine have been impacted by the transition. The word angst does not simply mean worry. Angst is a worry that is encompassed by trepidation. In a perfect world, all our programs would successfully transition to the SAS. In a perfect world, all DOs would take the AOBEM certification exam. But, emergency medicine is not a perfect world. A significant number of our residency programs have either chosen to follow the ACGME three-year training model, or were forced to do so by their hospital administration. Graduates from three-year training programs will not be eligible to receive board certification through AOBEM, and this will result in the loss of a very large number of DOs. This is quite troublesome to ACOEP, because ACOEP values all osteopathic emergency physicians. To us, it does not matter if you are from a three-year or a four-year residency program. It does not matter which board certification exam you take. What is important is that our residents receive excellent training and become board certified in emergency medicine.

I DO NOT GO TO WORK IN THE EMERGENCY DEPARTMENT, BUT RATHER I PROVIDE MY “DIENST,” OR SERVICES, TO THE PATIENTS” ACOEP does support osteopathic recognition, but it is not required for membership. Osteopathic recognition is not what defines us. We in emergency medicine already know who we are. We are osteopathic emergency physicians. And the bond that unites all of us, regardless of our training or board certification, is ACOEP. The American College of Osteopathic Emergency Physicians is an organization with personal touch. At our conferences you are not a nameless face in the crowd waiting to be processed by convention employees. ACOEP staff is here to greet you and give you conference materials. The staff makes every effort to get to know you and address you by name. If you have a question a staff member cannot answer, you are not told to go and ask Sonya. Instead, CONTINUED ON PAGE 16

he focus of our current issue is on technology in medicine. There are a variety of articles looking at this from both a positive and maybe not so positive view. We face the reality that technology is here to stay. Despite our frustrations and challenges we continue to care for our patients and often don’t think twice about the technology behind the care until either the computers go down or someone is delivering you a report on which boxes you didn’t check off last month. Here is my view on the subject. I hope you enjoy it and maybe even connect with it on some level. There is no question that CPOE and EMR has changed the practice of medicine. Depending on who you talk to, it was both a savior and a curse. While some of us still long for the days of T sheets and paper orders, we are now forced to document in an often cumbersome EMR typically set up for the bean counters, creating a lengthy dissertation for each patient encounter. These documents never

read smoothly and sound more like staccato notes in a robotic computerized voice than a note that tells a story. We have adapted through the addition of medical scribes to help us navigate the technology of today and make us more efficient as we strive to have face-time with patients rather than be buried with our nose in a computer. IT personnel, abstractors, and billing personnel hailed their arrival. Finally, an easier way to generate statistics and rate our providers on their IT prowess. Let’s see if they can work their way out of this one! Challenges of implementation and focus on metrics have forced us into power plans for major diagnosis categories such as sepsis, stroke, COPD, and MI. These plans include all the “essential items” required to meet quality metrics so that we do not lose out on the funding provided for caring for those diagnosis and meeting quality standards. Bonus payment also seems to be an overwhelming reason to make sure those boxes get

WE CONTINUE TO CARE FOR OUR PATIENTS AND OFTEN DON’T THINK TWICE ABOUT THE TECHNOLOGY BEHIND THE CARE UNTIL EITHER THE COMPUTERS GO DOWN OR SOMEONE IS DELIVERING YOU A REPORT ON WHICH BOXES YOU DIDN’T CHECK OFF LAST MONTH.”

checked as well. The complication is that these power plans are meant to address a very specific diagnosis. When was the last time you treated a patient that had one unique issue? Maybe they presented with dyspnea that later turned out to be CHF superimposed on an NSTEMI with underlying COPD. Which order set do we choose? Pick the wrong one and now you are on the naughty list, because either you picked wrong when you walked in the room, or heaven forbid you piecemealed a set of orders and none of the stuff you did for the patient is credited to you because it wasn’t ordered via a power plan, even though the patient has improved clinically, received all the appropriate care and is being discharged in better health than they came to you in. You need to stay in your lane or you get a penalty. Chart abstractors and quality personnel function in a black and white world. Medicine is not black and white. When you ask why the process cannot be streamlined for functionality or why you can’t get credit for the triage EKG that was entered as a single test you are told, we can’t do that. The patient still received the appropriate test or maybe not. They said the word, “chest pain,” so we now chase this diagnosis which may ultimately have nothing to do with a cardiac etiology, but we must meet our metric so an EKG on everyone that mumbles the word is our goal. How much over utilization of resources goes into completing a CONTINUED ON PAGE 28

JANUARY 2018 THE PULSE

ach day we judge people on their ability to do a task successfully or efficiently—that’s what competency is all about, right? But is competence enough in today’s or tomorrow’s society? When I taught school, competence allowed you to promote a student from one grade to another, excellence allowed you a double-promote or place a student in an honors class. Competence was for those who were adequate at what they did, excellence was for over-achievers. But in today’s education, we see so many systems, including medical schools, that are built on the competence system—if you are competent to do a task you move onto the next lesson—but is competent good enough? Would you want a competent teacher teaching your kids? Or a competent doctor taking care of your family? I don’t know; and I don’t think the system knows either. Recently in an issue of Medical Regulation, a publication of Federation of State Medical Boards, there was an article on the topic of how to determine competency and which method was best to judge this. What they found was surprising. Whether it was judging competence of a jurist, veterinarian, or doctor, testing wasn’t always a good indicator—why? Because some people do well in a testing situation and others don’t. The current models are based on three systems: Continuing Education,

EXECUTIVE DIRECTOR’S DESK

THE ON-DECK CIRCLE

Janice Wachtler

Robert Suter, DO, MHA, FACOEP-D

JUDGING COMPETENCE

ACOEP’S KODAK MOMENT

Educational Portfolios, and Peer-toPeer Learning. Continuing Education (CE) allows professionals to attend any given course provided by an accredited source and then either sit for certification in their specialty or recertify after gathering sufficient Continuing Education Units (CEUs). An Educational Portfolio system, provides diplomats with specific courses and specific testing modules associated with them. A Peer-To-Peer Systems that involved learning, observation, and evaluation. Despite the system used, most failed to

WHETHER IT WAS JUDGING COMPETENCE OF A JURIST, VETERINARIAN, OR DOCTOR, TESTING WASN’T ALWAYS A GOOD INDICATOR— WHY? BECAUSE SOME PEOPLE DO WELL IN A TESTING SITUATION AND OTHERS DON’T.”

truly deem the participant competent in their practice, although the Educational Portfolio with testing modules associated with learning seemed to be able to identify areas needing improvement more readily than the others; none provided a true definition of competence in the fields with which they were associated with. What the certifying bodies learned was that once someone was certified or credentialed in their specialty, they received pushback from their constituents on the system based on evidenced-based learning. It didn’t matter if you could show competence in a procedure repeated over a time; it was level of ability could be maintained after a period, when the procedure was not done, e.g., practice makes perfect. So, what’s the takeaway? Adult learners learn differently from younger learners. Continuing education should have testing modules attached to them, testing competence after learning, competence after doing and maybe, competence after 90 to 120 days after learning. So, do you want to be excellent or competent doctors? Would you prefer CME that had testing modules attached with them which tested your ability to learn and utilized what you’ve learned over a 60 or 90-day period? Let us know! References: Austin, Z BScPhm; Gregory, P.A.M, MLS. Journal of Medical Regulations, vol.103, 3, page 22-34.

t is apropos that my first column as the new President-Elect of ACOEP is in an edition of The Pulse dedicated to “technology and innovation.” Because as the best-selling author notes, technologic advances can drive unsettling changes, and as osteopathic emergency physicians we are already coming to terms with a lot of other changes in our world. When innovations occur in the clinical arena, usually they improve patient care so as emergency physicians we ultimately embrace them. The stressful parts are often getting our hospitals to buy the new tools and then learning how to use them and incorporate them into our practice. Think bedside ultrasound. At the same time, we live in an health policy environment where the funding for everything we do for our patients is debated and at risk on a regular basis. Regardless of where you stand in the debate, the political back and forth and the disjointed nature of the payment system should unsettle all of us regardless of how distant we may be from the business aspects of our practice.

In these respects, we have no more stressors than our MD colleagues, but they are enough. Unfortunately, amid all the above, we are simultaneously involved in the changes in the GME system that have recently shaken the osteopathic profession. What will the impact of the Single Pathway be on our students and residents? On the hospitals that have been most supportive of us? What will be the second order effects of this change on the osteopathic profession and our institutions? How does our family of osteopathic emergency physicians mitigate any negatives, take advantage of any opportunities, and thrive together going forward? There is no question that there is a lot of anxiety about the answers to these questions. That is a good thing. It means we understand the stakes, we are paying attention, we care about what the future holds. So how do we turn this energy into our desired outcome? As Abraham Lincoln said, “the best way to predict your future is to create it.” Most of us are old enough to remember the fall of the Kodak Company from one of the most successful and well-known corporations in the world into bankruptcy. This resulted from its failure to recognize the significance and respond strategically to digital photography,

WE HUMANS HAVE A LOVE-HATE RELATIONSHIP WITH OUR TECHNOLOGY. WE LOVE EACH NEW ADVANCE AND WE HATE HOW FAST OUR WORLD IS CHANGING... “ DANIEL H. WILSON, AUTHOR OF ROBOPOCALYPSE which ironically its engineers invented. This failure is now a textbook example of failure to adapt to disruption and the point at which organizations need to adapt referred to as the “Kodak Moment” in a nod to the company’s long running ad campaign. To find an example of successful adaption we need only to look at Apple, now the most highly valued company in the world. Apple didn’t invent any of the machines that made Apple a household name, it just made them infinitely better. Apple didn’t invent the personal computers, but rather the intuitive icon-based interfaces in models with such style CONTINUED ON PAGE 8

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JANUARY 2018 THE PULSE

NEW PHYSICIANS IN PRACTICE

MAJOR CHANGES WILL AFFECT YOUR BOARD CERTIFICATION As we make the transition towards a Single Accreditation System, the American Osteopathic Board of Emergency Medicine (AOBEM) continues to adapt the certification process to eliminate outdated requirements and develop a more efficient and relevant process.

Initial Board Certification Process Over the last few years there have been changes to the testing calendar based on feedback from residency program directors who stated there wasn’t enough time between the annual RISE Exam and the Written Board Exam. As a result, the 2018 Written Boards will be moved to May, allowing physicians to sit for this exam while still in residency.

Osteopathic Continuous Certification (OCS) Process Historically, there have been five parts that encompassed the AOBEM board recertification process. The term parts has been eliminated and now the four sections have been given the following titles, with the changes as outlined below: I. Professional Status, previously known as Part I • Physicians will be required to complete 150 hours of CME in the three-year period, 60 of which need to be emergency medicine specific. Previously, only 50 EM hours were required. • These 60 hours can be made up of any level of CME, they no longer need to be level one or two. • These hours no longer need to be Osteopathic specific CME for national certification, however, individual state rules may vary. II. COLA, previously known as Part II •

There are no changes to the COLA process

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III. Cognitive Assessment Exam, previously known as Part III •

Currently the same 150-question computer based exam; however, the exam questions have been updated to reflect the new Table of Specifications. These changes are based on a recent survey of EM physicians to better align the questions with real world EM content.

IV. Practice Performance Assessment, previously known as Part IV •

You are no longer required to submit patient satisfaction survey responses as a part of this section

V. Continuous College Membership, no longer a section •

Physicians will no longer be required to have AOA membership

Each section has many more details, only recent changes are highlighted above. For a complete listing of each section please reference our NPIP Membership Guide or the AOBEM website.

Moving Forward In response to an AOA initiative to find a more efficient and appropriate way to continuously assess physicians, AOBEM will be eliminating the 10-year Cognitive Assessment Exam, also known as the “recert exam.” AOBEM is currently working to determine how exactly this process will be implemented, but the current thought is that it will be an annual 45-question online exam replacing both the COLA and the Cognitive Assessment Exam. This will likely be implemented in 2019. Until AOBEM releases more details, it is best for all physicians to continue to follow the current process, and keep up with all the requirements as currently written.

ACOEP-RSO PRESIDENT AND DIRECTOR OF STUDENT AFFAIRS REPORT Dhimitri Nikolla, DO, PGY-3 ACOEP-RSO President AHN Saint Vincent Hospital

Christina Powel, OMS-3 ACOEP-RSO Director of Student Affairs LECOM – Bradenton

he ACOEP Resident Student Organization (RSO) has taken over a year to form and now we have elected our first RSO Board of Directors! We believe that this leaner board makes us more task-specific in pursuing our mission: to support the continuing education, osteopathic philosophy, and career development of emergency medicine residents and students worldwide.

While events specific to residents and students remain at conference, it was moving to see over 400 residents and students partake in the dedicated RSO events at the 2017 Scientific Assembly. We have watched our students become residents and our residents become young physicians, and we have contemplated how we can, as an organization, support this growth. Our student events remain a popular and vital source of exposure to emergency medicine for our student members. The enthusiasm seen by over 250 students participating in the airway workshop at Scientific Assembly was invigorating, as well as the positive evaluations from the Student Leadership Academy!

As for residents, they have spoken and we have listened! Residents in the past requested more competitions and bigger name speakers. The airway competition got heated, and ZDoggMD’s dedicated lecture to the RSO to rave reviews! Lastly, the RSO website is up and running, and in addition to publishing our quarterly edition of The Fast Track, we have begun posting articles weekly on the website blog. Articles can now be viewed and shared individually on social media expanding our readership. Beginning next fall, The Fast Track Anthology will be printed consisting of the best articles from the year, in part determined by the number of views and shares each article generates on the blog. Best articles from selected categories such as best review article, case report, or opinion piece, will receive prizes and recognition at next year’s Scientific Assembly! It is an exciting time to be part of the RSO, and we are looking forward to watching the RSO grow!

CONTINUED FROM PAGE 6

and user-centered design that no one remembers the functional awkward clunkers that came as the first wave of the disruption. Likewise, the iPod and iPhone were not the first handhelds or the iPad the first tablet, but the design improvements made them the new standards. Along the way Apple found itself struggling to find a consistently profitable source of revenue, trying and failing to market everything from digital cameras, to portable CD players, to TV appliances; it ditched these product lines when it realized that they were distracting from their core focus.

Ironically, our current challenges are arguably the result of the rest of medicine evolving to embrace many of the reforms and approaches “invented” by our original engineer, A.T. Still. Regardless, our ACOEP Board of Directors recognizes the events surrounding the Single Pathway make this our organizational “Kodak Moment.” Like Apple, we will focus on our core strengths and attributes to best serve you, our members, and we will succeed. Our members and staff are ACOEP’s biggest strength. Over the next few years and beyond we absolutely

want and need you to be a part of our successful navigation of the environment to create the future that we want. Our journey will be as transparent as possible, and we value your contributions, and will keep you in the loop. As a member of ACOEP since 1986, the opportunity to serve as your President-Elect in such a challenging time is an incredible and humbling honor. Thank you for your confidence and support. Together we will develop a shared vision of success, and together we will achieve it.

JANUARY 2018 THE PULSE

TECHNOLOGY AND EMERGENCY CARE:

The patients I treated during this time hardly ever complained. They were appreciative for what we did for them. The ER was full of gifts from our patients at every holiday. Most Sundays somebody brought us baked goods from their kitchen. If our patients saw us in the hospital when they were following up with their regular doctors or getting outpatient testing, they stopped to shake our hands or hug us, and thank us again for all we did for them.

WHAT HAVE WE GAINED? WHAT HAVE WE LOST? By Frank Gabrin, DO

love our technology, I can’t imagine practicing emergency medicine without it. But, back in 1986, that’s exactly what I did on my very first shift in the ED as an attending physician. 31 years ago, registration had the only computer terminal in the ED. They had dot matrix printers that generated stickers, our one-page ED Chart and the patient’s armband. There was no internet, no cell phones, no EMR. The blood pressure cuffs were on wheels. Our manometers and thermometers were filled with mercury. Bedside monitors were rare. There was no ultrasound, CT scan, MRI, or PET scanners, just X-Ray and fluoroscopy. I loved using fluoroscopy to remove metal or glass foreign bodies from hands and feet—all the hair on my hands fell off. My only source of reference material were the books I carried in a gym bag to work each shift because if I left them in the ED they’d disappear. I had a giant notebook filled with stuff I had to look up all the time. We didn’t have thrombolytics, clot busters or stints. Diagnosing a kidney stone required a six-hour IVP. We had heparin and coumadin. We had a few different antibiotics and some were really

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difficult to use like gentamicin and tobramycin. We didn’t have “biologics” or “immune therapies.” Most of the chemotherapy we were using was so harsh, our patients suffered horrible complications. We didn’t have half the laboratory tests we do now. We relied more on nuclear medicine tests like a VQ Scan to rule out PE. We often had to use our working diagnosis without being able to prove it. We were really good at gathering historical and clinical information and relied heavily on our hands and physical exam findings. We spent quite a bit of time at the bedside conversing with our patients and their families. We did more procedures. We did LP’s without a cat scan first. We diagnosed and treated DVT with our hands and admitted the patient to the hospital for a venogram during normal business hours. We paid more attention to what we heard with our stethoscopes and what our patients said to us to paint a clinical picture that would support our working diagnosis. When our patients came to the ED having a heart attack, we didn’t have troponins. We’d repeat the EKG over and over again. We’d give aspirin and start a nitro drip. We’d sit at our patient’s bedside closely watching the

monitor for arrhythmias or st-changes that might indicate worsening ischemia or maybe a decrease in the amount of ST elevation. We’d do everything we could to make them pain free. We’d listen to their heart over and over again to see if they were developing a murmur. We’d listen to their lungs for rales and watch for JVD. Often, our patients were frightened by the amount of attention we were giving to them and they’d ask, “Doc, am I gonna be alright?” We’d assure them that they were getting the best of care and we were hoping for the best possible outcome. Often they’d ask us to pray with them, to their god of choice, and we did. We’d hold their hand and tell them everything would be ok. But we knew their cardiac muscle was dying and that they were going to end up with a low ejection fraction and probably suffer from CHF for the rest of their days. We knew if they survived they’d be in the ED over and over again because of what happened to the function of their heart as a result of their heart attack. If they suffered a stroke, there was absolutely nothing we could do but make them comfortable and document their neurological deficits over and over again.

I was proud and happy to be an EM doctor then. None of us were burned out. None of us talked about compassion fatigue. We did however share our warm and fuzzy success stories with each other whenever we could. Looking back, I see how this was some of the best care I delivered in my whole career. Today, because of all our advanced technology, my practice is very different. When we do it exactly right it can make a huge difference in our patients’ outcome. This is awesome. But it also creates a serious reality for all of us practicing emergency medicine today. For example, today with significant head trauma, we no longer do thorough neurological exams and observe the

patient, repeating the neuro exam over and over again. We don’t teach our patients and their loved ones how to do the significant parts of the neuro exam at home. We don’t interact with them hourly for several hours and then we tell them to go home, and watch their family member for the next 24 to 48 hours. Now we spend only a few minutes at the bedside, order the CT scan and if it’s negative, which it almost always is, we discharge them. This is usually a much less satisfying experience for the family and the patient. They go home happy the CT was negative, but they don’t feel they received the care they expected from their doctor. This often leads to a patient complaint. “I got a bill for hundreds of dollars and the doctor didn’t even spend five minutes with me. That doctor didn’t care.” The same sort of thing happens with abdominal pain. In the days before CT, we held off on pain meds and did repeated serial abdominal exams and observed the patient to see if rebound or peritoneal signs were developing. We interacted with concern and attention. We repeated their vital signs to see if they were developing a fever. We worked with simple labs and meticulous repeated physical exams

and overall assessment of what was developing during their ED stay. Today the CT scan makes for a much different patient experience. Most often the scan is non-diagnostic and instead of seeing us, getting serial exams, or us teaching their family member where to push and what would be alarming and a reason to return, they see us briefly at discharge and we tell them we don’t know exactly what is wrong, but it’s safe for them to go home. Most patients feel frustrated with this. Mostly because they don’t feel our care. We no longer spend so much time at the patient’s bedside. Things move so very quickly, it’s amazing. We all do it several times a day every day. We work against the clock but our work is no longer at the bedside. We say, “hello, your EKG shows that you are having a heart attack. How bad is your pain? I am making arrangements to get you to the cath lab so that Dr. Heart can find the blockage of your artery and open the vessel and place a stint so that you won’t have any damage to your heart.” We disappear. We activate the cath lab, and in roughly 30 minutes from

MY ONLY SOURCE OF REFERENCE MATERIAL WERE THE BOOKS I CARRIED IN A GYM BAG TO WORK EACH SHIFT BECAUSE IF I LEFT THEM IN THE ED THEY’D DISAPPEAR.” JANUARY 2018 THE PULSE

THE WAY OUR NEUROANATOMICAL HARDWARE IS DESIGNED, THE ONLY WAY TO TAKE CONTROL OF THIS EMOTIONALLY NEGATIVE STATE IS TO ASK THE QUESTION, “WHAT WOULD IT BE LIKE IF I WERE IN THEIR SHOES?” triage they are moving. The vessel is opened, heart damage is avoided, the patient does well and goes home. Then they get our bill. “What? I never even saw the ED doctor!” We just did the miraculous and took full advantage of all of our technology. Spectacular compared to what we did back in the day, but our patients are left feeling flat. When they complain to us in real time, we often hear at some point in the conversation: “Yeah, but you are a doctor, you are supposed to care.” Today’s medicine is amazing, and I love all this technology, but it has come at the expense of our interpersonal interactions which have become brief and strictly clinical and professional. What does this mean to most of us? Research shows that 64% of us are suffering from compassion fatigue and professional burnout. We feel exhausted, like no matter what we do, it doesn’t matter, it’s never enough,

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are feeling. It runs under our conscious awareness and it’s impossible for us to shut it down. Science calls it affective empathy. Real time MRI scanners show us that all the centers in our prefrontal cortex that register pain light up in this state. The neurotransmitters that are elaborated are all negative and they drain us, deplete us, rob us of our happiness and our wellbeing. Affective empathy is suffering. Who among us is at their best when they’re suffering? Science is learning that what we’ve called compassion fatigue is, in reality, a super-negative state of being, where our empathetic centers are overloaded and overwhelmed from constant exposure to our patients who are frightened, anxious, in pain or overwhelmed. Each patient we see activates our own suffering centers repeatedly. All of this happens automatically and unconsciously when our brainstem, basal ganglia and amygdala is presented with the information from our five senses. The way our neuroanatomical hardware is designed, the only way to take control of this emotionally negative state is to ask the question, “What would it be like if I were in their shoes?” Simply asking this question moves the experience into our prefrontal cortex where our thoughts are in control. Science calls this cognitive empathy. and emotionally, we’ve become disconnected and isolated. This is why 30 years into my emergency medicine career, I am taking full advantage of the latest research which shows that mindfulness is the number one modality that can reverse or erase burnout in all physicians across all specialties. Medicine is both an art and a science. Our technology is all scientific. The art of medicine involves all that is uniquely human in both ourselves and our patients. Practicing the art of medicine requires us to connect emotionally with our patients and their families. It is what defines the doctor patient relationship. Mindfulness is a method that is extremely reliable, allowing us to blend the art and the science. Through mindfulness, I am able to be fully engaged in the process, embrace our new technology, and most importantly, connect emotionally

to my patients and their families in healthy, extremely positive ways. This is how I am able to love what I am doing again. The power mindfulness lies within the design of our own neuroanatomy. When practiced effectively, this method uses our neuroanatomy as it was designed to be used, and we connect to the cure for our own compassion fatigue and burnout. Compassion fatigue is a misnomer. What we’re really experiencing is empathetic overload. Compassion and empathy are not the same. Empathy for the most part is automatic. It arises from deep within our brain stem and our amygdala whenever we see another human who is sick, injured, in pain or suffering. It’s rooted in our primal neuroanatomy to ensure survival of the species and survival of the self. Empathy is defined as a state of shared suffering where we automatically feel what our patients

When we sit in this state and allow ourselves to feel our patients’ pain as if it were our own while remaining connected with them, our primal neuroanatomy will naturally move us into the self-healing state of compassion. If we stay in compassion long enough, all our negative centers that register empathy and shared suffering down-regulate and cease to be active. Neurobiology and real-time MRI scans tell us that compassion is an incredibly wholesome state that enhances all of our human capacities and abilities. The neurotransmitters that are released by the centers in our prefrontal cortex have very positive effects on the rest of our brain. A mix of dopamine, serotonin, oxytocin, neuropeptide X, glutamate, GABA, endorphins, endogenous opiate peptides and endocanninaboids start to wash our brains clean of distractions and stressors. The centers in our brain that are involved with pleasure are activated. Everything a human can be or do is augmented by these neurotransmitters of compassion. Our physical strength is enhanced, our spatial perception gets better, our ability to calculate and diagnose is sharpened, and our immune system is strengthened. When we feel compassion, we feel at peace, we feel happy, and the experience is incredibly pleasurable on a visceral level. If we are at the bedside and we are connected to our

patients or their family members, they can sense or feel our compassion and care, and this makes all the difference in the world for them, and for us. Just feeling compassion is powerful enough to have an effect, even before we say or do anything compassionate. The great news is that we can use mindfulness to train ourselves to enter the state of compassion whenever we want to. The method for using mindfulness to activate our primal neuroanatomy is this six step mindful process: 1. Get fully present 2. Connect to your patient 3. Focus on your patient and consciously make their needs your priority 4. Move beyond the affective empathy by asking the question, what, “What would it be like for me to walk in their shoes?” This will move you into cognitive empathy where you take control of the emotional situation. Allow yourself to stay in the connection until you’ve activated the next step. 5. Compassion: Feel your own desire for things to be better for them; for them to feel better, their pain to lessen, their fear to dissipate, their anguish or despair to soften. Stay in this place for a little while, don’t speak or do anything. Just allow your compassion to fill your brain and your body completely. 6. Action: Say or do something compassionate. Now you can move on to the practical physical matters that will help make your patients situation better or at least more tolerable. Incorporating mindfulness into your practice of medicine doesn’t add much time and feels incredibly good. You will no longer feel stressed and drained. You will feel empowered and so will your patient. I know deep in every fiber of my being that compassion can’t fatigue, and compassion fatigue doesn’t really exist. Mindfulness is the ultimate method for the emergency physician to use the uniquely human hardware, our neurobiology, our neuroanatomy, and our neurotransmitters, to take control of our emotions and our feelings while using them to help others. This is the holy grail in the fight against professional burnout. I have found no better way to accomplish this than moving through the six-step process to deliver true, authentic and genuine care and generating compassion for our patients and their families right at the beside. This is our cure. Physician heal thyself! Make a difference and change (y)our world.

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SUPPORTING RESPONSIBLE USE

THE CASE FOR SOCIAL MEDIA By Christina Powell, OMS-III LECOM – Bradenton Director of Student Affairs, ACOEP-RSO

hether you partake in the social media trend or not, it would be difficult to deny its increasing relevance to professionals. Its use in health care has been a debated topic, mainly because physicians are bound by ethical and professional obligations and oaths that extend beyond the department. There are serious implications of the misuse of social media, but it should not outweigh the benefits applied to our daily practice of medicine or in collaboration with our colleagues around the nation. As medical professionals, let’s support and encourage responsible use of social media. While the informality of a Twitter profile may lead one to an untimely rant of a sensitive subject, we should instruct and advise proper use of the medium to maximize its benefit for our educational and social advancement, while minimizing the negative concerns that we face in many other areas of our practice, besides the internet. Everything can be used for good or evil, let’s consider the implications of our online activities in order to maximize the good. CONCERN 1:

Bridging the gap between a professional and personal account Should you have two profiles—a professional account and a personal account? Are you feeling compelled to accept a friend request on Facebook from a professional contact that you’d rather not introduce to your private life? There’s two ways to tackle this concern. First, you can implement a selective content strategy—where you only post carefully considered content. You scrutinize everything and only project an image of professionalism, or maximize posts to maintain the reputation that you have with coworkers. The major annoyance here is that it is an inauthentic use of social media. In a field like emergency medicine, where personality is key, it makes social media very dry and sterile. Instead (option two), a more specialized strategy should be implemented, where you don’t need to have multiple accounts to keep certain people close and others more detached. Facebook has a feature called a Friend Lists, allowing a user to section off Facebook friends into specific lists that you have created. For example, you can make a family list, a patient list, or a professional list. Content can be posted specifically to one of those lists, so the other lists aren’t privy to that post. This allows an individual to maintain their profile authentically, without jeopardizing their reputation. However, as the next concern points out, nothing posted online is completely private—be mindful of that.

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THERE ARE SO MANY CURRENT USES OF SOCIAL MEDIA FOR LIFELONG LEARNING, IT JUST TAKES AN INFORMED PROFESSIONAL TO KNOW HOW TO LIMIT THE CONCERNS AND MAXIMIZE THE BENEFIT SOCIAL MEDIA CAN HAVE ON OUR INDUSTRY.” C O N C E R N 2:

Patient Privacy Medical professionals have an absolute obligation to patient privacy. This is an especially sensitive topic when health care moves to a social media platform. Refrain from posting identifiable patient information or patient history regardless of practice location. Online platforms care little regarding point of origin, and good stories travel fast. If you have any concern that you are supplying too many details, do not post any. Your Facebook story can survive without one amazing patient encounter; publicizing a personal trial for a patient over a public platform could not only be damaging to your career, but most importantly, damaging for that patient. Consider that privacy is not absolute. If you have both a personal and professional account, professionalism needs to extend to both. CONCERN 3:

Your Own Privacy Routinely monitor your own personal identifying information to ensure its accuracy. Most importantly, review

that what you want visible to the public is visible—and what you want private, is removed. An angry patient online can become a fiasco in person if you demonstrate too much personal information on the Internet. As stated prior, privacy is not absolute. CONCERN 4:

Maintain a High Standard Refrain from using profanity, discriminatory remarks about patients, population groups, or other healthcare workers. Maintain your professionalism online as well as in person. As in the personal encounter with a patient, physicians must maintain the appropriate boundaries with patients online. Although these points seem like ‘no-brainers’, we all know that person that posts rants that are all too unfiltered. This all said, social media is a useful tool. While these concerns should be given proper attention, they should not deter an individual from promoting the use of social media in medicine. Instead of shying away from an area

that could lead to a poor outcome, equip yourself and your colleagues with the insight necessary to convert that resource into a useful tool. And that is exactly what social media is—a useful tool.

Know the Social Media Platforms Each social media platform has a specific niche. Pay attention to the purpose of that platform so that you can maximize its use in your professional development and minimize the drawbacks presented.

LinkedIn Think Online Resume LinkedIn expands your professional network by making contacts with individuals in your field and industry of interest. It is used by recruiters, hiring managers, and professionals. The site has sections where you can input your specific skills and professional experience which can be “endorsed” by others in your network.

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CONTINUED FROM PAGE 3

Facebook Personal but Can be Used Professionally Traditionally many of us use Facebook as a way to stay in contact with our friends and family; however, the website’s use as a public forum for businesses, organizations, groups, and events has been gaining popularity. “Share” and “Like” company pages related to your interests—maybe that program you want to be hired by, or that journal you spend hours reading for continued education. Find out who else “Likes” that company and add them to your network. There are many new applications such as the social jobs partnership app that combines the employment databases of US.jobs, monster, Jobvite, BranchOut, and WORK4LABS all in one. Facebook can be a way to expand your professional education and employment opportunities.

Twitter Online Presence for Users Twitter “tweets” are indexed by Google—which means that you can make a name for yourself on the internet by establishing an online presence. Maybe you aren’t in it for the exposure—you can silently stay up to date on what’s new in the field, within seconds of checking your account. Unlike Facebook or LinkedIn, Twitter allows you to follow many people online without requiring an invitation or acceptance from fellow users. Easily follow residency programs, attendings, scholarly journals, or health care leaders without having to know them personally. Your Twitter account can not only be a mechanism of networking and identity in a sea of emergency medicine professionals, but you can create an individually tailored and curated profile of medical information, freely available at any time. There are some key Twitter users that consistently tweet links to high-yield

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content or relevant journal articles. You can be kept informed in 140-characters or less!

Social Media’s Use in Emergency Medicine: The #FOAMed Movement What is FOAMed? FOAM is a dynamic online display of ideas, clinical skills, novel research, and educational pearls posted for the community to view online and apply in their practice. FOAMed stands for Free Open Access Medical (FOAM) Education. It is a collection of evolving and collaborative educational resources in critical care and emergency medicine that is constantly updated, keeping you quickly up to date in a moment’s notice. Limited on time reviewing all the new journal articles in between ED shifts? FOAMed can keep us up to date; its free, and accessible to anyone, anywhere, and anytime. The #FOAMed hashtag brings all the posted education together for ease of access and visibility. This is a great use of your Twitter account, and individuals who make #FOAMed tweets maximize the use of social media as an educational tool. The beauty of FOAMed resides in the global interactions surrounding the new information presented on social media. The open discussion and scholarly discourse that occurs is independent of platform or media; it includes blogs, podcasts, tweets, Google hangouts, online videos, Facebook groups, etc. Social media also allows for optimized searches. Relocate a current publication faster on Twitter than on Pubmed! There are so many current uses of social media for lifelong learning, it just takes an informed professional to know how to limit the concerns and maximize the benefit social media can have on our industry.

RENOWNED #FOAMED TWITTER ACCOUNTS TO FOLLOW: The Bottom Line @WICSBottomLine Academic Life in EM @ALIEMteam FOAMcast @FOAMpodcast FOAM Highlights @FOAM_Highlights EM Res Podcast @BobStuntz Radiopaedia.org @Radiopaedia Steve Carroll, DO @embasic Haney Mallemat @CriticalCareNow Rob Cooney, MD, MEd @EMEducator BoringEM @BoringEM Rob Bryant @robjbryant13 Tessa Davis @TessaRDavis Teresa Chan @TChanMD The EMCrit Crew @Emcrit FOAMed on MEDucation @med_FOAMed ACOEP @ACOEP If you have any questions, feel free to reach out to the ACOEP marketing team with questions on how to get started using social media for your professional and educational development.

Sonya is brought to you. That’s a personal touch! ACOEP is unique in that it is family-oriented. Family members are invited to our receptions, and our social events appropriate for guests of all ages. We all have our conference friends that we look forward to seeing each year, and there are family bonds that develop among our members. With the help of FaceTime, I watched my daughter’s induction into the National Honor Society during the break at one of the COLA seminars. I was standing in a remote section of the hallway. As I watched the ceremony on my iPad, a small group began to gather around and watched it with me. I was truly touched! The kinship in this college is amazing! You will not experience this in many other organizations. In the past decade our conferences have grown and expanded exponentially. The appearance and content of Scientific Assembly has changed dramatically. There are breakout sessions and rapid fire talks. This year we are introduced the “In Case You Missed It” series which is an encore presentation of key lectures that you may have missed. The level of excellence that the educational content has reached is outstanding, and we have you, the members of this College, to thank. You are the driving force behind the college. In order for ACOEP to continue to provide excellent quality CME, I ask for your continued support and membership. As emergency physicians, we are required to attend CME conferences, but the entire department cannot all go to ACEP. Somebody needs to stay behind and cover the ED. We need to introduce our colleagues to the great CME conferences ACOEP offers. During my presidency, I pledge to bring at least one of my colleagues to either Scientific Assembly or Spring Seminar. I challenge all of you to bring a colleague, and introduce them to our unique and awesome educational experience. “We can’t control the wind, but we can always adjust our sails.” I found this message in my fortune cookie

last year, and I kept it specifically for my inauguration speech. I think this message is very applicable to our current situation. Despite our transition to the SAS, ACOEP will continue to remain strong and viable. We have a strategic plan to move us into the future, and that plan does not include being assimilated by a larger entity. With our new bylaws, we are now able to open our membership to MDs. We are also offering membership to nurse practitioners and physician assistants. ACOEP has entered into a formal relationship with the American Academy of Emergency Nurse Practitioners (AAENP), and we are currently in talks with the Society of Emergency Medicine Physician Assistants (SEMPA) who recently approached us asking to form an alliance. There were 1,200 professionals registered for Scientific Assembly including 440 residents and students. The Resident Student Organization (RSO) is an amazing group of young physicians, and when these young doctors complete their training, they become the New Physicians in Practice group (NPIP). These young people are the future leadership of this College, and our future is very bright. In the spring, I crashed a causal meeting of the editorial staff of the Fast Track. They were discussing the launch of a new digital platform with a blog format for The Fast Track. In what probably seemed like an eternity to them, they patiently explained the format to me. I was so excited with this new blog format. We so needed to add blog capability to The Pulse. Little did I know that Erin already had this in the works. The new blog platform premiered in the July edition of The Pulse. This is the type of relationship that I expect to have with the RSO and the membership. The Board of Directors can lead from above and steer our course, but we need the next generation of leaders to guide us and help promote the future of American College of Osteopathic Emergency Physicians.

A special shout out to the residents. Residents you are not the middle child. You are an asset to the College. The Board of Directors wants to make sure that the College is meeting your expectations and providing you with extraordinary experiences to help you successfully start your career. You need to let us know how we can help. As president, I am here to serve you, the members of our College. I have a close friend who has always been there as far back as I can remember. I may be a few months older, but she possessed more wisdom than I could ever hope to have. A few years ago, I was in the midst of my board recertification exam, and I was starting to come unglued before the oral exam. She said “Chris, you have nothing to worry about. Emergency medicine is in your bones. You got this!” She was right. Emergency medicine is in my bones. And it’s in your bones too. We got this!

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JANUARY 2018 THE PULSE

FROM TV SUPER HEROES,

TO ED SUPER HEROES How Virtual Reality is Helping Save Lives One Headset at a Time

By Gabi Crowley, ACOEP Staff Erin Sernoffsky, ACOEP Staff

emand for excellent doctors has never been higher, and increasingly the medical community has turned to hightech, yet easy-to-use tools to train doctors on high-pressure scenarios. Virtual reality, or VR, is filling this need with new products such as VR Trauma Simulation created by Josh Sherman, MD, and Todd Chang, MD. VR Trauma Simulation is an interactive virtual reality technology designed to train and teach physicians how to treat patients in emergency medical

extremely immersive by nature of VR (3D, 360 degrees of immersion),” Dr. Sherman said.

situations by using hands-on, 3-D virtual reality. Previously used in interactive and advanced video game systems, this technology enables a physician to virtually explore “patients” by slipping on a headset programmed with specific trauma scenarios. These life-like scenarios go so far as to include details such as having virtual paramedics, techs, nurses, and even frantic family members of the patient “on-site,” exactly how a real-life situation may be. Sherman and Chang sought to bridge some gaps created by more traditional training methods such as mannequin (MBS) and screen-based (SBS) simulation. While MBS training includes the act of physical touch, which is ideal for life-like training purposes, it demands a large amount of human resources to properly operate, including a large space and team to run the simulation. And although SBS is more portable and standardized, it has proved to be distracting and has unrealistic menus that are not fully immersive. Virtual reality medical simulations have great potential to solve many of the issues of MBS and SBS, while providing life-like training for trauma situations. “Virtual reality medical simulations require minimal space (3x3 feet in one’s home office, residency lounge, etc.), minimal human resources (eventually just the user), are extremely standardized and asynchronous, do not have any menus, and are

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After his wife introduced him to the Oculus Dreamdeck, a type of virtual reality technology, Dr. Sherman realized the immense potential VR holds for emergency medicine training, and began to explore simulation methods for medical training scenarios. Along with his colleague Todd Chang, MD, a well-known simulation expert, the two set out to create medical training modules using VR. They won a grant for the development of the project and have not looked back.

WE ENVISION A DOCTOR IN NEW YORK BEING ABLE TO PRACTICE RESUSCITATION WITH A NURSE IN LOS ANGELES, A PHARMACIST IN ENGLAND, AND A RESPIRATORY THERAPIST IN AFRICA.”

Sherman and Chang led a team of experts in creating the simulation scenarios and many layers of branch chain diagrams that can easily be followed by non-medical tech teams. The team collaborated with global experts in the field including leading VR companies, tech experts, and coding and artificial intelligence specialists. After many rounds of testing and finding opportunities for improvement in the VR experiences, Dr. Sherman and Dr. Chang successfully introduced two VR medical simulation modules to the medical world. “One of the things that impresses me the most is the amazing feedback we have been getting from both brand-new residents, as well as emergency physicians that have been practicing for many years,” Dr. Sherman said. “Trainees and attendings alike catch on very quickly, and the technology has not been challenging to get the hang of.” When it comes to the question of whether or not virtual reality has made an impact in real-life medical situations, Dr. Sherman’s answer is a definite, “yes.” “I had a resident tell me that after she went through the [virtual reality] seizure module, the next week a patient she was managing on the floor had a seizure, and she felt more prepared to take care of that infant,” he said. And not only does VR benefit healthcare providers, but also patients. “As we go to more and more conferences, we are seeing how the utility of VR in healthcare is growing. For example,

therapeutic escape and therapeutic desensitization for patients, to 3D visualization, surgery planning, and simulation training for providers,” he said. Looking ahead, Dr. Sherman believes the future of virtual reality is bright. He has high hopes for its continued improvement and success, including gaze tracking, which is often difficult to teach, and the improvement in teaching teamwork and communication by different medical professionals all around the world.

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RE-INVENTING THE ED DISCHARGE CALLBACK

WITH TELEMEDICINE By Benjamin Busch, DO, FACOEP Adam Ash, DO, FACEP Alexander Chiu, MD, MBA

“We envision a doctor in New York being able to practice resuscitation with a nurse in Los Angeles, a pharmacist in England, and a respiratory therapist in Africa,” he said. Dr. Sherman also has plans for VR to help the medical community in teaching and assessing cultural competency, with abilities to change skin color and culture. “We can change the environment in which the trainee of the provider must practice. The potential for training and assessment in the medical field is endless. I hope that more VR companies and leaders in the industry realize this, and place their resources and powers in the right place, so we can continue to make VR for Good!” Dr. Sherman would like to thank the following people for

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their assistance for making this one-of-a-kind project possible: Jordan McCollum, Parisa Sabeti Zagat, James Hairston, Ashley Woolheater and teams at Oculus, a division of Facebook; Trevor Hollinger , Anita Schmidt, Brian Benson and all the great doctors and nurses and ancillary staff at Children’s Hospital Los Angeles; Randy Osborn and Rik Shorten and team at Bioflight VR; Shauna Heller of Claypark VR; Devi Koli , Tom Dolby and team at AI Solve Limited. And the biggest thanks goes to my colleague and friend Dr. Todd Chang.

ischarge follow-up phone calls made to patients after emergency department visits are quite common. These programs are initiated for a variety of reasons, including patient satisfaction, quality improvement, patient education, or to follow-up unresulted tests. Patient satisfaction scores increase as much 30% when patients receive follow-up phone calls1. Additionally, because improving patient satisfaction is shown to reduce the risk of medical malpractice lawsuits2, discharge callbacks also serve as an excellent risk mitigation tool. For a number of reasons, many patients are non-compliant with discharge instructions. Misunderstanding a treatment plan can result in failure to take prescribed medications, missed follow-up appointments, redundant testing, and persistent or worsening symptoms. This “communication gap” greatly affects the quality of care experienced after an emergency department visit. Callbacks serve as a safety net, giving providers another chance to ensure these patients are properly treated and followed-up. Although many emergency departments now utilize callback programs, they can be cumbersome to staff and typically require additional financial resources. Programs vary from hospital to hospital, and there is no standard of care with regard to

expectations or measuring improved outcomes. The expansion of real-time video telemedicine over the past decade has allowed for the re-design of discharge follow-up programs. Telemedicine programs are becoming more financially feasible because of parity laws set into place in 2016 that require private payers to pay equal amounts for both in-person and telemedicine visits for certain diagnoses and complaints. A new company, Airvisits, partners with hospitals to perform patient callbacks to all discharged patients. The Airvisit telemedicine follow-up service provides an improved method of post discharge patient care with a billable, faceto-face provider interaction. Airvisits has been implemented at a number of sites in New Jersey and New York with great success. All follow up appointments and multidisciplinary consultations are made within the local health care system. This serves to increase outpatient resource utilization, improve communication, and ease access to multi-specialty patient care within a healthcare system. The new Healthy You patient engagement software helps to close the communication gap by electronically sending educational videos and recommended mHealth resources to patients once they’re discharged from the emergency department. This helps to maintain quality patient care after a clinical visit, and improve patient understanding and treatment compliance with multimedia resources. Furthermore, these tools help to facilitate intervention when a patient’s condition seems to be worsening. Initial results are encouraging, and improvements in patient satisfaction scores and patient retention and clearly evident. 1. Guss DA, Gray S, Castillo EM. The impact of patient telephone call after discharge on likelihood to recommend in an academic emergency department J Emerg med. 2014 Apr;46(4):560-6 2. Hickson GB, et al. Patient complaints and malpractice risk. JAMA 2002 Jun 12, 287(22):2951-7

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ONE COMPANY SET TO DISRUPT THE TELEMEDICINE INDUSTRY

t a rural office outside of Richmond, Virginia, a small team of physicians and entrepreneurs is working hard to change the face of telemedicine. There is a certain buzz at this office and the excitement felt here is palpable. “We believe that all people around the world can—and will—have access to quality healthcare, where and when they need it,” says Adam Hardage, CEO of Remote Health Solutions (RHS). “Today we’re making that belief a reality through our technology and a relentless drive to expand global access to remote medicine.” It’s 5:30 in the morning and Hardage is already at work, strategizing with RHS Chief Medical Officer Dr. Jonathan Baugh on several company initiatives. “This is a really exciting time for the company and the future of telemedicine,” says Dr. Baugh. “We have just come to market with a ground-breaking FDA-cleared device that allows us to put a patient and a Doctor in direct contact almost anywhere on the planet. More than just another tablet, our ‘Virtual Exam Room’ allows me to not only video conference with a patient 10,000 miles away, but also to conduct remote diagnostics like 12-lead ECG and complete vital signs.” “Where it gets really exciting for the EMS system here in the US is its ability to shorten door-to-needle and door-to-balloon times for stroke and STEMI patients,” says Dr. Baugh. “With the VER employed in the back of an ambulance or on a Life Flight helicopter, we can see the patient in real time and make the call to go ahead and activate the Cath Lab or ready the TPA, all prior to the patient’s arrival. Or, in the case of rural areas, we can direct the ambulance or helicopter to bypass a lower level

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saves money,” says Hardage. “In the case of the airlines, we’re currently working with a major US air carrier to change the way in-flight medical emergencies are handled. Right now it’s a game of ‘telephone’ between the patient, the flight attendant, the Captain, and a ground call center. All of that’s about to change. Moreover, when it comes to the airlines, we can demonstrate a return on investment in less than three years. Then the VER has paid for itself and begins making money for the airline by decreasing the rate of preventable aircraft diverts.”

By Allison Price

medical facility in order to go directly to a regional receiving facility that has higher level capabilities and equipment.” I’m shown the VER in a variety of configurations for different use scenarios and must admit it seems impressive. There is a clinical cart version, a field-hardened version for medics, a more robust rolling clinic for use in remote villages or disaster areas. “The real game changer here is that all we need is a 3G connection anywhere on the planet and we can conduct a clinical quality exam or one of our Doctors can direct care,” says Dr. Baugh. Nodding in agreement, Hardage adds, “I don’t think there’s another company out there who can do what this platform can over 3G. What’s more, the VER is cleared for patient self-use, meaning we don’t even need to have a medical professional on the ground to hook the patient up… they can do it themselves and be connected directly to the Doctor. That is hugely beneficial in remote and austere environments or even with our national community paramedicine efforts.” What about HIPAA compliance? Dr. Baugh nods, saying, “the VER is not only HIPAA compliant but it also syncs to Electronic Medical Records through a cyber secure cloud. A really interesting aspect for the insurance companies as telemedicine laws change is that the system also includes Doctor’s notes and ICD codes, so it can become a billable event in many cases.” Hardage points to a bright yellow pelican case. “These are our maritime and airline versions,” he says. Wait, airline? “Yes, absolutely. Whether on an airplane, an oil platform, or ship at sea; the VER has almost unlimited utility across a range of industries. Not only does it add value but it also

Sounds terrific, but what about the billions of people around the world who live in underserved areas or those people who don’t have access to any healthcare at all? Hardage nods, saying, “Great question. We’re currently working with a major university and their grant system to deploy these into remote villages and underserved areas in Central America and Africa.” Dr. Baugh comments, “When it comes to the fight against infectious diseases like Ebola and Smallpox, everyone involved quickly sees how these devices can also protect the care givers who themselves are at risk for infection.” “We’re also working with one of our partners to establish a network of clinics in the Middle East,” says Hardage. “Imagine that for the first time, 2 million refugees in Jordan could have access to a US BoardCertified network of Physicians…or that you could go to a clinic in the West Bank and see a US Doctor! Incredible,” he says, shaking his head in amazement. Dr. Baugh nods in agreement. “The applications really are almost limitless.”

THE REAL GAME CHANGER HERE IS THAT ALL WE NEED IS A 3G CONNECTION ANYWHERE ON THE PLANET AND WE CAN CONDUCT A CLINICAL QUALITY EXAM OR ONE OF OUR DOCTORS CAN DIRECT CARE”

Visit www.acoep.org/newsroom or links to learn more about Remote Health Solutions and other telemedicine innovations.

With the time for our interview up, one thing is certain; the energy, excitement, and pulse felt at the RHS office is tangible. This is a company that seems clearly intent on moving the telemedicine industry forward in a variety of big ways.

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NEW APP STREAMLINES TRACKING FOR PRACTITIONERS By Erin Sernoffsky Director, Media Services

lectronic medical records. Procedure tracking for certification and privilege. Validation of work done by residents, nurse practitioners, and physician assistants. Credentialing. The number of boxes healthcare providers must check daily has grown exponentially, as has the amount of self-tracking, forms, and requirements. Of all the electronic documentation required in healthcare, almost no system is created with the sole purpose of making practitioners’ lives easier. Until now. Enter Jack and James Hilton, twin brothers and selfprofessed “techies.” The two earned pre-med degrees and had been accepted into medical school when they took a risk and changed course. Their grandfather encouraged their entrepreneurial spirit, and the two decided to focus on tech startups instead.

departments in particular,” says James. “Every clinician I meet has the same priority: quality care. They all want the same thing and that’s where Clusio fits in.” Clusio is an app designed to help physicians, residents, Pas, and NPs easily track procedures. The free, HIPAAcompliant app is intentionally simple, creating a tool where a provider can get in and out without needless hunting around. As a provider leaves the patient’s bedside, they

simply open the app, enter the name of the procedure, and move on to the next task in the ED. When the time comes to recertify or apply for new privileges, Clusio is a simple way to see exactly what was accomplished and when.

TECHNOLOGY HAS PERMANENTLY CHANGED HEALTHCARE. WHILE SOME OF THESE CHANGES ARE UNDOUBTEDLY POSITIVE, IT IS CLEAR MANY HAVE ADDED COMPLEXITY AND CONFUSION THAT DETRACTS FROM PATIENT CARE.”

Furthermore, when a supervising physician’s approval is required, residents, NP, and PAs can simply select their supervising physician who then approves the entry in real-time, saving time and frustration. Clusio is not meant to take the place of EMRs, or add another requirement to already over taxed physicians. “Healthcare was underserved in software for a long time and now we see it being overserved,” says James. However, almost none of this software was created with the intention of making the lives of clinicians better. The Clusio team’s focus is on support rather than another obligation. “Clusio is, at its core, augmentative. Clinicians tell us what their problem is and we use our technical know-how to solve their problem”

Hospital systems can also benefit from Clusio. Administrations that register have access to a dashboard that tracks providers’ entries, allowing systems to see what procedures are being used, how often, and have powerful data to help create positive change. Already this data has been beneficial, for example during the recent shooting tragedy in Las Vegas, practitioners were still using Clusio. This data can be vital for improving care in mass casualty situations. Technology has permanently changed healthcare. While some of these changes are undoubtedly positive, it is clear many have added complexity and confusion that detracts from patient care. Tools like Clusio exist to help providers cut through some of the confusion to better focus on the patients in front of them.

The Hiltons were eventually approached by Scott Mateosky, an emergency medicine physician assistant with a 20-year career in the military. Mateosky was looking for a simple way to track procedures in real-time, eliminating cumbersome spreadsheets, pen and paper lists, and the process of struggling to remember and verify procedures days and weeks later. The Hiltons consulted with emergency medicine physicians and other professionals, including their mother, an ICU director for over 30 years, and quickly realized that Mateosky’s struggle was universal. “This is a big problem for all hospitals but emergency

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HiRO DRONE SAVES THE DAY IN REMOTE MOUNTAIN RESCUES By Erin Sernoffsky, ACOEP Staff

’s a bird! It’s a plane! It’s a telemedical drone equipped with holographic technology delivering emergency physicians and lifesaving medical supplies to aid in remote mountain rescue! Health Integrated Rescue Operations, otherwise known as HiRO, is the brainchild of Italo Subbarao, DO, Senior Associate Dean at William Carey University College of Osteopathic Medicine, and Guy Paul Cooper Jr., DO. The two began work on the system in response to the devastation caused by an EF-4 tornado in Hattiesburg, Mississippi in 2013. Dr. Subbarao previewed his drone at the 2017 Scientific Assembly, an ideal location for attendees to learn about the latest developments in life-saving innovations applied to mountain rescue. “There are significant challenges in getting lifesaving treatment to victims in a mountain rescue situation, particularly when first responders can’t get there quickly,” said Dr. Subbarao, in a statement. “Our goal, as osteopathic physicians, is to bridge that delay by delivering rapid treatment directly to the victims, using remote physicians to instruct anyone on site.” HiRO, currently being tested in support of the Mississippi Department of Emergency Management, Homeland Security, the National Guard, and NATO, is designed to reach victims

in remote or devastated areas. A Microsoft HoloLens headset is operated by a physician in a remote location, giving them the opportunity to treat multiple victims. The remote physician can also unlock various bins containing medicine which bystanders can then access and administer with assistance from the physician through video guidance. Finally, an integrated health medical record provides easy patient monitoring. “We focused on making sure our interface and medical kits are intuitive for both the remote physician and the person at the scene. Safety and simplicity are top priorities because we’re working to saves lives in very high-stress situations,” said Dr. Cooper. “The HiRO telemedical drone provides immediate access to a physician through a wireless video connection. When the portable critical care kit arrives, the doctor appears on a touchscreen display to direct medical treatment. Additionally, vital supplies such as a heated blanket, tents, and food and water can be delivered to victims.” This device also allows a person at the scene to maintain contact with the physician even when moving away from the drone through smart glasses. These glasses also provide holographic technology, meaning the physician can see the disaster, while the aid workers on the scene remain hands-free. Once field tests are complete, the team predicts that the HiRO drone will be ready for market in 2018.

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

If you have any cases that you would like to present or be reviewed in The Pulse, please email them to us at esernoffsky@acoep.org. Thank you.

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JANUARY 2018 THE PULSE

Join the Foundation for Osteopathic Emergency Medicine at ACOEP’s 2018 Spring Seminar in San Diego, CA!

CONTINUED FROM PAGE 4

power plan for a diagnosis that turns out not to be even close to the real diagnosis that included the utterance of chest pain?

5K &

1-MILE

DO DASH WEDNESDAY, APRIL 4, 2018 • 5:30 - 6:30 PM Run in the sun! Take in the beautiful sights of San Diego as you run with old and new friends for a great cause. All conference attendees and their guests – from walkers to seasoned marathoners – are welcome to join the FOEM 5K Run for Research and one-mile DO-Dash!

REGISTRATION

BEFORE 3/1/18

AFTER 3/1/18

Attending Physicians (5K run)

$60

$75

Students, Residents, and Family

$30

$40

FOEM 1-Mile DO Dash

$20

$25

FOEM Case Study Poster Competition Wednesday, April 4, 2018 from 2:00 – 5:00 pm

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Along with student and residents, this year the Foundation for Osteopathic Emergency Medicine (FOEM) is excited to welcome attendings with interesting or unique cases that have presented at their hospital to participate in this year’s Case Study Poster Competition. Students and residents can win cash prizes, attendings are eligible to earn scholarly activity, and all winners will receive certificates and recognition in FOEM publications throughout the year. The deadline for submission of applications and abstracts is January 31, 2018.

CPOE was supposed to make a provider more efficient and provide a higher level of consistent care, but it has not even come close. It has increased the cost of health care by demanding essential elements that may or may not contribute to better outcomes for patient care. It has also added to the cost of healthcare, with the addition of scribes and numerous others to data crunch the massive amounts of information produced. It tries to fit every encounter into a nice fixed plan of care. It attempts to standardize care. This is all well and good if the system did that. So now, instead of making clinical decisions that support rapid and efficient care we are left to hunt and peck for power plans that once open, look like Pandora’s box. Choices for x, y, and z. Clinical decision support links, hard stops and more. And remember folks, that is just to order the tests. Now we either must enter our clinical exam into the record or converse with a scribe who makes the magic happen and generates a visit note that includes a plethora of items to meet the mark. Finite times for onset of symptoms. How did the patient know? Well, it was exactly 7:10 pm. We were just watching Jeopardy and hit the first commercial break, so I know Alex always takes the first round break at 7:10pm. Ok, Mrs. Smith very good! But was the network running 2 minutes off that night? I’m not sure. The craziness of the system can sometimes be overwhelming. My lighthearted and maybe comical approach to this is not meant to be all pessimistic. There has been some good from all of this. We have saved lots of trees in not needing the reams of paper to document our encounters. Theoretically, it is easier to determine

if your chart is complete with the wonderful audit tools available to you. And maybe, the patient did benefit slightly by having that allergy alert fire for a medication that they forgot they were allergic to, but was recorded in their chart, saving them a potential adverse reaction. I’m sure there are

many other good examples of how we have benefited from technology in our department, but you must look hard and really convince yourself that it is all worth it.

ER REGIST ! Y A D O T

World-class airway education in 5 amazing cities! Boston, April 20 - 22  Denver, May 4 - 6 Baltimore, Sept. 21 - 23  New Orleans, Oct. 26 - 28 San Francisco, Nov. 9 - 11

Keep your practice on the leading-edge! Hands-on course emphasizing assessment and decision-making to help you manage any emergency airway! Register at theairwaysite.com or 866-924-7929

JANUARY 2018 THE PULSE

2017 SCIENTIFIC ASSEMBLY IS ONE FOR THE RECORD BOOKS

1222 ATTENDEES

400

STUDENTS AND

OVER

RESIDENTS

SPE AKERS 16 SPECIALIZED

TRACKS

4 LABS

Any way you crunch the numbers, ACOEP’s 2017 Scientific Assembly was one for the record books! Whether you came for the legendary ZDogg, to test your skills in a sell-out hands-on lab, to learn about mountain rescue in the field, to learn from the best in emergency medicine, or to catch up with old friends, ACOEP’s members and guests made this year’s conference bigger, more dynamic, and more fun than ever before. Thanks to the tireless efforts of Course Chair Nilesh Patel, DO, FACOEP, and his dedicated team, the Denver event surpassed anything ACOEP has yet offered, while still maintaining the friendly, family-feel that makes ACOEP unique. Believe it or not, plans are already well underway for the 2018 Scientific Assembly which takes over ACOEP’s home turf: Chicago! The Windy City conference will feature even more opportunities to learn, grow, and have fun.

$80,000 RAISED FOR FOEM

2nd WOMAN PRESIDENT

OF ACOEP

1 ZDOGGMD

But first, Spring Seminar!

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JANUARY 2018 THE PULSE

ACOEP WOMEN’S COUNCIL PULSE UPDATE By Nicky Ottens, DO, FACOEP Women’s Council Chair

JOIN ACOEP

IN THE SUNSHINE STATE FOR THE 2018 SPRING SEMINAR!

unshine. Ocean views. Hands-on skills labs, CME, and professional development! ACOEP’s Spring Seminar must be around the corner, this time in Coronado, California, April 3-7, 2018. Join us at the Loews Coronado Bay Resort overlooking San Diego for a week of learning, and of course, leisure! Along with an impressive mix of leading emergency medicine professionals as part of the conference’s faculty, we are proud to welcome two phenomenal keynote speakers. Creator and editor-in-chief of the Core EM Project, Anand K. Swaminathan, MD, MPH brings a unique perspective to the event. ACOEP and FOEM regulars will be thrilled to see Director of Graduate Medical Education at Merit Health Wesley, Sherry Turner, DO, FACOEP as one of the 2018 headliners. The 2018 Spring Seminar will include more breakout tracks, hands-on workshops including cardiology, toxicology, critical care, infectious diseases, and many more. Didactic lectures, COLA review, FOEM competitions and more will challenge and invigorate all attendees. Here at ACOEP, we acknowledge the countless hours you spend working day in and day out. That’s why at Spring Seminar, we believe in work/life balance. We strive to not only make it a priority to provide superior continued medical education throughout the week, but also allow attendees the chance to catch their breath and escape from the hustle and bustle of a busy day in the ED. With events including the annual Kickoff Party, meeting of the Council for Women in Emergency Medicine, FOEM 5K and DO-Dash, New Physicians in Practice Social, and sponsored nights out for the RSO, Spring Seminar perfectly balances

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interesting science, with the chance to relax and have fun. A five-minute walk to the beach, the Loews Coronado Bay Resort will be your home away from home for the week! With five restaurants and lounges, three heated pools, one of the highest rated spas in Southern California, and activities including watersports and bike rentals, the Loews Coronado Bay Resort is perfect for the whole family! The hotel is also just a short distance away from kid-friendly attractions including SeaWorld, the San Diego Zoo/Safari Park, LEGOLAND, Living Coast Discovery Center, Coronado Ferry Landing, and Balboa Park. And with onsite childcare available, parents can even enjoy a night out on the town!

SPRING SEMINAR PERFECTLY BALANCES INTERESTING SCIENCE, WITH THE CHANCE TO RELAX AND HAVE FUN.”

Please visit www.acoep.org/spring to for more information and to register today. We hope to see you in April!

n November 7th the ACOEP Women’s Council hosted their annual luncheon at ACOEP’s Scientific Assembly. With over 75 attendees at the Women’s Luncheon this event sold out twice over! Attendees had the opportunity to meet with some amazing women leaders in our profession, including the Dr. Chris Giesa our new President of ACOEP. We were also honored to host Dr. Paula Willoughby DeJesus, first female President of ACOEP, multiple program directors, department chairs, an associate dean, four female Board of Directors members, and multiple ACOEP committee members and chairs. It was an incredible time of fellowship and support to the women in the room. Dr. Patsy McNeil of USACS who sponsored the luncheon, provided a lecture on women in leadership positions. Dr. Giesa addressed the group and our Willoughby Award Winner, Dr. Sandra Schwemmer, provided insight into her career path and pioneering accomplishments. Finally, Dr. K Kay Moody spoke to the group about women and wellness in their career path. After the luncheon, those interested in serving on the Women’s Council met and discussed the educational track for Spring Seminar, lecture topics, and connections and continuing partnerships with Physician Mom’s Group (PMG), FemInEM and other national women’s groups. We were delighted to have two lectures on topics relevant to women at the Scientific Assembly in Denver. Dr. Hala Sabry, founder of Physician Mom’s Group (PMG) lectured on Balancing Family and EM Careers and Gender Disparities in Clinical Care.

We are looking forward to the educational track in the spring as way to provide more lectures related to women in medicine. Preliminary plans are for a half-day lecture track at the Spring Seminar in San Diego, California. We will also host a social event, and council meetings during our time in San Diego. If you are interested in being a lecturer for us, please let us know. Women represent 40% of the workforce in emergency medicine. And yet, our respective representation in leadership positions does not match that percentage. When we look at some of the leading organizations in emergency medicine, the percentage of board positions held by women are not where they need to be: ACEP Board of Directors 20%, ACEP Chapter Presidencies 19%, AAEM Board of Directors 18%, EMCARE Exec and Regional leadership 9%, US Acute Care Solutions 13%, CEP is 10%, Team Health 8%. At the ACOEP Board of Directors we have 30%, but there is more work to be done. We want more women on our Board and we want more women involved in and chairing committees. And of course, we want you involved in the Women’s Council. Looking ahead, we will meet next by teleconference in January. We are working toward transitioning the Women’s Council into a fully functional committee and plan to have a drafted proposal to the Board of Directors and ByLaws Committee in the next fiscal year. If you are interested in being more involved, we would love your help! Please contact us!

JANUARY 2018 THE PULSE

FOEM FOCUS

Lakeland Healthcare in St. Joseph, MI 3rd Place: Kaitlyn Bowers, DO from Ohio Health Doctors Hospital in Columbus, OH Congratulations and thank you to the 2018 FOEM Legacy Gala Honorees!

FOEM Joseph and Florence Wachtler Spirit Award Presented to donors with a lifetime level of $50,000 and above Jim Turner, DO, FACOEP-D and Sherry Turner, DO, FACOEP

The 2017 Scientific Assembly was a success, including all of the events hosted by FOEM! The week started off with the FOEM Resident Research Competitions. The posters, papers, oral abstracts, and CPCs were fun and educational to watch, and the winning abstracts are listed on the following page.*

FOEM President’s Circle Award Presented to donors with a lifetime level of $10,000 and above John Ashurst, DO Jack B. Field, D.O. Mark A. Mitchell, DO, FACOEP-D, FACEP

The show stopping event of this year’s Scientific Assembly was the 2017 FOEM Legacy Gala presented by US Acute Care Solutions. This year’s theme was Chocolate and Champagne, and an aerial artist poured champagne for guests who indulged in chocolate and champagne food pairings, and dance the night away. FOEM also hosted its first-ever silent auction, and every single trip package—from Alaska to Greece—was purchased by our excited guests! Most importantly, the crowd came together to raise funds to further the Foundation’s mission, resulting in over $80,000.00!

Research Paper Competition sponsored by WestJEM

Research Poster Competition 1st Place: Andrew Rudin, DO from Orange Regional Medical Center in Middletown, NY 2nd Place: Andy Leubitz, DO from Ohio University Heritage COM in Athens, OH

1st Place: Kate Hughes, DO from University of Arizona Department of Emergency Medicine in Tucson, AZ 2nd Place: Joshua Bowers, DO from Adena Regional Medical Center in Chillicothe, OH 3rd Place: Martin Gagne, DO from Good Samaritan Hospital Medical Center in West Islip, NY

3rd Place: Brent Mok, DO from St. John Macomb-Oakland Hospital in Warren, MI

Victor J. Scali, DO, FACOEP-D

FOEM Pillar Award Presented to donors with a lifetime level of $5,000 and above Aimee Blagovich, DO Judith M. Knoll, DO, FACOEP Brandon Lewis, DO, FACOEP, FACEP

Oral Abstract Competition 1st Place: Patrick Hughes, DO from Florida Atlantic University in Boca Raton, FL

Jeremy Kent Selley, DO, FACOEP and Victoria Hutto Selley, DO, FACOEP

2nd Place: Kathleen Clark, DO from

Clinical Pathological Case Competition 1st Place Resident: Michael Tranovich, DO from Ohio Valley Medical Center in Wheeling, WV 1st Place Faculty: Curt Cackovic, DO from St. Josephs Regional Medical Center in Paterson, NJ 2nd Place Resident: Ryan Anderson, DO from Lehigh Valley Health Network in Bethlehem, PA 2nd Place Faculty: Italo Subbarao, DO from Merit Health Wesley in Hattiesburg, MS 3rd Place Resident: Katrina D’Amore, DO from St. Joseph’s Regional Medical Center in Paterson, NJ 3rd Place Faculty: Jason Becker from Einstein Medical Center in Philadelphia, PA

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JANUARY 2018 THE PULSE

FOEM Partner Award Presented to donors with a lifetime level of $2,500 and above Kelly Klocek, DO, FACOEP and Patrick Klocek, DO, FACOEP Otto Sabando, DO, FACOEP, FACEP Abdulrahman Qabazard, DO, FACOEP

FOEM 500 Club Presented to donors with an annual donation of $500 and above Juan F. Acosta, DO, M.S., FACOEP-D Fahim Shan Ahmed, DO, M.S., FACOEP, FACEP John Ashurst, DO Aimee Blagovich, DO Gary Bonfante, DO, FACOEP Timothy J. Cheslock, DO, FACOEP Jack B. Field, DO Gregory R. Frailey, DO, FACOEP Christine F. Giesa, DO, FACOEP Thomas E. Green, DO, MPH, FACOEP, FACEP Steven D. Hollosi, DO, FACOEP Drew A. Koch, DO FACOEP-D

Jack B. Field, DO Christopher Michael Gooch, DO, FACOEP

Joseph J. Kuchinski, DO, FACOEP-D

Thomas E. Green, DO, MPH, FACOEP, FACEP

Brandon Lewis, DO, FACOEP, FACEP

Joe Kissinger, CASE

Beth A. Longenecker, DO, FACOEP

Joseph J. Kuchinski, DO, FACOEP-D

William Lynch

Brandon Lewis, DO, FACOEP, FACEP

Mark A. Mitchell, DO, FACOEP-D, FACEP

Thomas J. Mucci, DO, FACOEP-D

Victor J. Scali, DO, FACOEP-D

Jeremy Kent Selley, DO, FACOEP and Victoria Hutto Selley, DO, FACOEP

Jeremy Kent Selley, DO, FACOEP and Victoria Hutto Selley, DO, FACOEP Megan A. Stobart-Gallagher, DO James Turner, DO, FACOEP and Sherry Turner, DO, FACOEP

Megan A. Stobart-Gallagher, DO James Turner, DO, FACOEP and Sherry Turner, DO, FACOEP

Jan Wachtler, BAE, CBA

FOEM Research Flame Award

FOEM Sustainers

Presented to the ACOEP Residency Program with the highest average score for research papers

Presented to sustained monthly donations of $50 or more Juan F. Acosta, DO, M.S., FACOEP-D Fahim Shan Ahmed, DO, M.S., FACOEP, FACEP John Ashurst, DO Aimee Blagovich, DO Gary Bonfante, DO, FACOEP

Timothy J. Cheslock, DO, FACOEP

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Integris Southwest Medical Center – Oklahoma City, OK

FOEM 100% Program Challenge Presented to the ACOEP Residency Program with the most donations per resident in 2016 1st Place: Ohio Valley Medical Center Wheeling, WV

2nd Place: Merit Health Wesley Hattiesburg, MS

angiograms were evaluated to receive lower dose imaging or no imaging.

*Winning Abstracts

1 Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan

METHODS: This was a retrospective cohort investigation of women aged 18-29 years seen in the emergency department of 5 regional hospitals from May 1, 2015-April 30, 2016 for suspected acute pulmonary embolism. The investigation was approved by the institutional review boards of all participating centers.

2 Department of Emergency Medicine, Banner Health-University of Arizona, Tucson, Arizona

RESULTS: Computed tomographic

1st Place Research Paper CT Pulmonary Angiography in Young Women Paul D. Stein, MD1, Fadi Matta, MD1, Kate E. Hughes, DO2, Mary J. Hughes, DO1

ABSTRACT BACKGROUND: Young women are a group of patients at particularly high risk of radiationinduced cancer.1-3 Recommendations have been made to reduce exposure to radiation from diagnostic imaging,3, 7-11 but the constraints of practice in emergency departments (ED) has limited application of such recommendations.12

OBJECTIVE: To determine whether young women in the emergency department who received computed tomographic (CT) pulmonary

pulmonary angiograms were obtained in 379 young women. Pulmonary embolism was diagnosed by CT angiography in 2.1%. A Wells probability score could be calculated in 11.9%. D-dimer was obtained in 46.2% and a chest radiograph was obtained in 41.7%. Among patients with a normal chest radiograph, 3.9% had a lung scan. Venous ultrasound of the lower extremities was obtained in 6 of 151(4.0%) with an elevated D-dimer and negative CT angiogram. Among the young women who received CT angiograms, 53 were pregnant. In 15.1% of pregnant women, a Wells clinical probability score could be

calculated from the medical record and the score indicated “unlikely” in 11.3%. D-dimer was obtained in 30.2%, chest radiograph in 22.6%, lung scan in 11.3%, and venous ultrasound of the lower extremities in 0% with an elevated D-dimer.

CONCLUSION: Young women and pregnant women often receive CT pulmonary angiograms for suspected acute pulmonary embolism without an objective clinical assessment, measurement of D-dimer, chest radiograph, lung scintiscan or venous ultrasound, which would eliminate the need for CT pulmonary angiography in many instances. 1st Place Poster Title Blood Cultures in the ED - Are they worth the time and money? Investigators Andrew S. Rudin, DO Blessit George-Varghese, DO

Specific Aims/Purpose The government insists on two blood cultures from patients that meet sepsis criteria while in the emergency department and prior to the initiation of antibiotics. With a cost of over $400 per patient, and millions of patients meeting sepsis criteria annually, is this money well spent or do we need a more precise criteria for patients requiring blood culture? Scientific Rationale and Significance Studies have looked at the need for blood cultures in pneumonia and two studies retrospectively reviewed total blood culture yield. One [1] had 1.4% true positive blood cultures with only 0.18% affecting patient management. The other [2] yielded 5% true positives with 1.6% (18 patients) affecting patient management. As of January 1, 2014, CMS and JCAHO no longer require blood cultures for non-ICU patients as a core measure in pneumonia cases. Can we do the same with sepsis and limit the blood cultures for those patients who meet the criteria for “septic shock”?

Research Design and Methods We conducted a retrospective analysis of blood cultures drawn in the ED over a 3 year period and review how many of these prove to have positive culture results. We reviewed the cases to see if the positive cultures proved to be an integral part of the treatment and care of the patient. Study Population: The population consisted of emergency room patients meeting the criteria for sepsis across the GHVHS hospitals from January 1, 2014 to December 31. 2016. Subject Identification/Recruitment: Patient were identified only by their medical record number without any identifying data included in the research data. For those patients with positive blood cultures a chart review was undertaken to determine if the blood culture results lead to a change in patient antibiotic management. Main outcome measures: Positive blood cultures drawn within the emergency department that are then used during the patients hospital stay for differentiation of treatment. Results: We reviewed over 60,000 blood cultures drawn January 1, 2014 to December 31. 2016 and found that less than 600 patients had their therapy adjusted based on the blood cultures drawn in the emergency department.

Patrick G. Hughes, DO1 Kate E. Hughes, DO2 Rami A. Ahmed, DO MHPE3 1 Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 2 Michigan State University, E. Lansing, MI 3 Department of Medical Education, Summa Health System, Akron, OH

Background: Communication errors are the leading cause of preventable patient harm in medicine. The purpose of this study is to describe a relatively well-established, yet not welldescribed, teaching technique that blindfolds the team leader. Methods: A resident physician is provided a blindfold and positioned facing away from the resuscitation team. The team members surrounding the patient announce their names and role. They can only execute orders directed to them by name. The team leader can ask questions about the monitor, however, the team member must describe the appearance of the rhythm in laymanâ&#x20AC;&#x2122;s terms. The team leader must remember to switch out chest compressors, ask a team member to start bagging, have another team member insert an

advanced airway, and interpret the potentially changing rhythm. Results: A 15-item survey was administered to every blindfolded code team leader (N=27) after the completion of their code resuscitation. Our results show 100% of residents agree/strongly agree that this knowledge could be transferred to the clinical setting. The majority of residents (81.5%) strongly agreed the blindfolded code training exercise was more challenging than typical code training exercises. Most residents (81.5%) strongly agreed the blindfolded code training allowed them to use the critical thinking skills acquired throughout residency. Nearly all residents (88.9%) strongly agreed that blindfold code training made them better utilize closed loop communication in comparison to typical code training to ensure task performance and/or completion.

Take a career step in the right direction.

Conclusion: Learners overwhelmingly found the blindfolded code training as a challenging and beneficial exercise to improve communication during resuscitations.

At US Acute Care Solutions, we believe family life is just as important as a robust career. As the largest physician-owned group in the country, weâ&#x20AC;&#x2122;re empowered to deliver both. How? We keep leadership in the hands of physicians by making

Conclusion: Our results mimic those found during the pneumonia studies and bring to the forefront the discussion of necessity for a change to Systemic Inflammatory Response Syndrome (SIRS) CMS requirements for appropriate treatment.

every full-time physician in our group an owner. The result? Benefits like our ground-breaking parental leave policy for families. Take the first step. Visit USACS.com and discover how you can have it all.

1st Place Oral Abstract I can literally do this blindfolded: The blindfolded code training simulation exercise

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

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