The Fast Track - Spring 2015

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The Fast Track The Fast Track

An Emergency Medicine Publication

Spring 2015 Issue

50

Politics & Policy Issue

states create one nation, searching for a health care solution!

Pg 16

MEDICAL CLEARANCE

Pg 08

AOA/ACGME MERGER

Pg 12

THE STUDENT SYMPOSIUM

Pg 22

TRICKS OF THE TRADE

Pg 11

DO “Snow” Day on the Hill!

COMBAT MEDIC

A glimpse at the life of military health

Careful how you clear patients!

What’s the deal?

Did you go?

Get that scalp lac back together!

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Letter from the Editor

The Track The Fast Fast Track Editors-in-Chief Fall 2014

Tanner Gronowski, DO Veronica Coppersmith, DO Chris Swyers, OMS-III Ariel Sindel, OMS-III

M

atch day! The climax of medical school, full of emotions good and bad for all who have been involved in your medical training. The upcoming residents are hopefully stoked for

where they will continue their training, and the new program directors optimistically excited for the new class they’ll be training for the next few years. Families, friends, and spouses also filled with emotion to learn where you will be living for the next chapter of your life. Hopefully match

Ros

But for the current residents match day is a reminder that another year has been put behind

Andy Little, DO Drew Kalnow, DO Jeremy Lacocque, OMS-IV Danielle Turrin, DO Erin Sernoffsky John Casey, DO

Pre

day was in everyone’s favor and all new residents are happy, as you all deserve the best after 4 years of hard work in medical school!

Editors

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us; we are another year further in our training and that much closer to the finish line.

Closer

Me

to attending hours for attending paychecks, but with that comes attending responsibility. We are one step closer to those sick patients being ours alone: septic shock, apneic babies, coding pregnant patients, whatever your personal worst nightmare patient is. It is not far in the future

Tric

when we will be making those tough medical decisions on our own, without an attending to talk through if we want to push TPA, when to call the code, or if the faker should get another scan. It is fast approaching when we will be doing procedures without the bail-out option of

Sin

an attending on that tough intubation, impossible central line, or non-reducible hip refractory

RC Board Members

Andy Little, DO President Joe Sorber, DO Vice President Drew Kalnow, DO Treasurer Tanner Gronowski, DO Secretary Veronica Coppersmith, DO Gina Moffa, DO Allison Remo, DO John Downing, DO Patrick Cary, DO Chase Ungs, DO Danielle Turrin, DO Daniel Engleberg, DO Steven Brandon, DO Past President

SC Board Members Cameron Meyer Sasha Rihter Timothy Bikman Jeffery Weeks Deborah Rogers Michael Fucci Ariel Sindel Chris Swyers Chris Falslev Michelle Kinghorn Bryant Gray Kaitlin Fries

President Vice President Treasurer Secretary

to every variance of Captain Morgan positioning you can think of. It’s not that this scares me, because I know we’re all getting great training, but rather makes me want to take full advantage

Pol

of the free consult, advice, and guidance sessions my attendings offer me daily.

I told my program director the other day that I wanted to be a resident forever (he offered

Ma

to continue failing me because having a PGY-35 sounds like it’d be pretty beneficial for the hospital). Although he was kidding (I hope), I was only half joking when I said this; although we

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work a bunch, bringing true meaning to the term “resident” of the hospital, and our paychecks are fractions of what they one day will be, I feel truly lucky to have an Emergency Medicine residency spot and am in no rush to leave it. We are granted for a few years the luxury of time

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designed for learning, 4 years of protected educational time with pretty fantastic teachers giving us private tutoring sessions all day at work. The residency buddies we have in emergency medicine are hands down the best to be going through this journey with and make every day

AC

tolerable if not enjoyable. So stop counting the days to your “attending salary” and instead enjoy the next few years you have, learn as much as you can, and have a great time doing it. Enjoy your treasured EM residency spot – we’re all lucky to have one. With that, biggest congrats to all

Hea

the new EM residents, let’s all make the most of it!

AP

Veronica Coppersmith, DO FAWM St Luke’s University Health Network Editor, The Fast Track Publication, ACOEP

Past President

Printing of this issue sponsored by:

DO

Interested in contributing?

Let us know: FastTrack@ACOEP.org

Res

Pul

page Cover photo courtesy of Tanner Gronowski

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r have

CONTENTS

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Presidential Messages...............................04

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Rosh Review ..................................................06

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Closer

20

THE MERGER

by The AOA President

Medically Cleared .......................................08

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uture

Tricks of the Trade ......................................11

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other

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Single GME System.....................................12

ctory

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Political Advocacy.......................................13 Master of the Airway .................................14

14

GHANA MASTER THEDO by FrederickOF Davis, AIRWAY

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Combat Medic ..............................................16

hecks

dicine time

Human Trafficking.......................................18

giving

gency

y day

ACOEP Student Symposium .................22

enjoy

Enjoy to all

Health System Comparison ...................24 A Promise to Peru .......................................26

19

ACOEP STUDENT SYMPOSIUM

30

RESIDENCY SPOTLIGHT Kingman

DO Day Photos .............................................28 Residency Spotlight....................................30 Pulse Crossover Article .............................32

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The Fast Track Spring 2015

PRESIDENTIAL MESSAGE –

P

T

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Resident Chapter

o all our members, a BIG hello from ALL of your Resident Chapter Officers. We want to first congratulate our 4th year Student Chapter members who recently matched!

Whether you took part in the osteopathic or allopathic match or even matched outside of emergency medicine, your life is one step closer to the goal you set out for four years ago. That is something to be pumped about! For those of you who did match into one of the 300+ osteopathic EM residency spots we welcome you to the Resident Chapter family, and hope we can be a resource for you throughout your training.

As spring time is upon us, it is also a time to congratulate our new Chief Residents! We wish the 70+ of you well in your endeavours over the next year as you make your mark and to try to leave a legacy for residents to come. In this vein, I would like to address each of you. In my years as a medical professional (resident, student, ED tech, and unit secretary), as an athlete, and as a member of a large family I have learned a few things about legacy and how leadership is directly tied to these. Over this time I have had the opportunity to attend many meetings, conferences, small group discussions, and other activities on learning to be a better leader I’ve came across one truth. Being a leader is about being a good example.

Whether in the way you interact with faculty, hospital administrators, co-residents, or nursing staff, your example will be the first and probably last thing people remember about you. With that thought I leave you with one of my favorite poems of all time, and hope it inspires you to improve.

S

C A W

Best Regards, Andy Little, DO ACOEP National Resident Chapter President Doctors Hospital Emergency Medicine

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W a re to a p re p th a ta s h s

U a to to to y

“I’d rather see a sermon than hear one any day; I’d rather one should walk with me than merely tell the way.

The eye’s a better pupil and more willing than the ear, Fine counsel is confusing, but example’s always clear; And the best of all preachers are the men who live their creeds, For to see good put in action is what everybody needs.

I soon can learn to do it if you’ll let me see it done; I can watch your hands in action, but your tongue too fast may run.

And the lecture you deliver may be very wise and true, But I’d rather get my lessons by observing what you do; For I might misunderstand you and the high advice you give, But there’s no misunderstanding how you act and how you live.”

- Edgar Guest

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The Fast Track

PRESIDENTIAL MESSAGE –

Spring 2015

Student Chapter

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n behalf of the Student Chapter, I would like to congratulate all of the students that recently matched. Hopefully everyone was able to match into a program that fits them well. Match Day and the days surrounding the match because medical students to experience a unique battery of emotions, including anxiety, doubt, happiness, fear, and excitement. These emotions are felt not only by 4th year medical students, but also by all medical students alike. We all feel the fear of the ominous day of reckoning.

While this time of the year can be stressful, it offers us all a chance to reflect on where we are and what we need to do to reach our destination. For some, this time is a chance to realize that there is more they can do to improve their resume. For others, it’s a chance to rededicate themselves to becoming a better person. With the right perspective, both approaches can be one in the same. It is true that besides doing well in school, residency programs want to see you get involved in leadership, participate in service projects, do research, attend conferences, and have hobbies. But why? These extra activities show programs two things about a student. First, this student is capable of managing many things simultaneously? Second, and most importantly, this student is striving to become a better person? By participating in activities that make us work harder, serve others, and take us out of our comfort zones, we are forced to grow. Leadership and other types of service teach us to put others first. Research helps us understand how things work and how we can make things better. Attending conferences increases our knowledge and our skills. Hobbies teach us healthy ways to cope with stress.

Understand that Match Day is coming. Study hard. Take advantage of the time you have and participate in activities that force you to become a better person. If you are struggling to find these opportunities, start by talking to those that have gotten to where you want to go. Ask them what additional activities helped them along the way. Make it a priority to attend conferences and find ways to serve others. The harder you work on improving yourself, the more prepared you will be for what lies ahead.

Sincerely, Cameron Meyer OMS-III ACOEP National Student Chapter President West Virginia School of Osteopathic Medicine

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The Fast Track Spring 2015

Emergency Medicine Review with 1) Which of the following patients mandates reporting to health authorities in all 50 states or to federal officials?

A) A 33-year-old man who was involved in a motor vehicle collision and is found to have a blood alcohol level of 300 g/dL B) A 45-year-old man who sustained a gunshot wound to his leg C) A 79-year-old man with tuberculosis D) An 8-year-old girl who was bit on her face by the neighbor’s dog

Find more questions like these by visiting roshreview.com

2) The Emergency Medical Treatment and Active Labor Law of 1986, or EM TALA, requires hospitals to provide which of the following?

A) Care to all patients B) Interpreters for all patients in a timely manner C) Screening exam, competent ED physicians and appropriate stabilization D) Screening exam, stabilization process, appropriate transfer process 3) A 29-year-old male is brought to the ED for a gunshot wound to the right chest. He is diagnosed with a right-sided hemopneumothorax. Tube thoracostomy is subsequently performed with immediate drainage of 250 cc of blood. The nurse connects the chest tube to a commercial suction device, and a chest radiograph is performed that confirms proper placement.

You note an absence of respiratory fluctuation of the fluid level in the drainage tube. A repeat chest Xray shows the right-sided hemopneumothorax remains. Which of the following is true regarding this finding?

A) An air leak is present B) The lung is still collapsed C) There is a blockage of the drainage tube D) This is an expected finding 4) Which of the following patients is the best candidate for an ED thoracotomy?

A) A 35-year-old woman with a gunshot wound to the left chest with no vital signs noted in the field, but has a return of spontaneous circulation with a BP of 110/60 mm Hg after 5 minutes of CPR and 2 L of normal saline B) A 39-year-old man with a stab wound to the left chest presenting with HR 135, BP 70/palp, and left chest crepitus C) A 40-year-old woman who was in a high-speed MVC, with loss of vital signs en route to the ED D) A 45-year-old woman with a stab wound to her chest, with loss of vital signs 5 minutes into the initial resuscitation

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FOR Find your Rosh Review Answers at the end of the issue 3/10/15 10:57 PM

The Fast Track

Spring 2015

The Edge: Spring Seminar 2015

Resident Conference

Marriott Harbor Beach Fort Lauderdale, FL - April 7-9, 2015 Tuesday April 7th 5:00-6:30pm

Confernence Welcome Reception

Wednesday April 8th 8:30-8:55am 9:00am-12:00pm 1:00-5:00pm 6:00 pm 7:00pm

Conference Welcome Ultrasound in the Crashing Patient presented by EMP FOEM Case Competition FOEM 5K Night Out wth EMP

Thursday April 9th 9:00am-12:00pm 9:00am 10:00am 11:00am 7:00pm

Junior Resident Boot Camp presented by Infinity Research Primer Crucial Conversations Teach The Teacher Night Out with Team Health

FOR MORE INFORMATION AND TO REGISTER: WWW.ACOEP.ORG issue The Fast Track - Spring 15 Draft 11 - TB.indd 7

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The Fast Track Spring 2015

MEDICALLY CLEARED? William Sullivan, DO, JD Attending physician, St. Margaret’s Hospital, Spring Valley, IL Sullivan Law Office, Frankfort, IL

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29-year-old patient with a history of psychiatric problems sprains her ankle walking near a ditch. A month later, she is admitted to the hospital because she has trouble walking up stairs. During her hospitalization, she has an EKG, lab tests and other radiology testing. She was discharged, but still in pain and walking on crutches. A week after being discharged, she went back to the hospital for knee and ankle pain. X-rays were normal. She was discharged but refused to leave. So an ambulance took her to a second hospital. There, ultrasound of both legs was negative for blood clots. She was homeless, so she was given a list of shelters.

She returned the following morning complaining of abdominal pain and was discharged four hours later, but refused to sign discharge papers. She was wheeled in a wheelchair to the hospital exit then told the security guard that she couldn’t even stand up. She was re-examined by a doctor in the emergency department and then discharged into police custody. A police officer was heard on a hospital surveillance video telling a fire chief that the hospital staff thought the patient was a “drug seeker.”

We’ve all seen patients who complain of vague or changing symptoms despite normal evaluations in the emergency department. Many times we find there is some secondary gain involved, whether it is a work note, a prescription, or even as a means to get out of jail. Sometimes we’ll get a request to “medically clear” the patient - for example, when a patient is released to police custody, when a patient is being transferred to a psychiatric facility, or when a patient goes back to work.

That’s where the plot in this case takes a twist.

The treating emergency physician created a “Fit for Confinement” report for the police officer before the patient was discharged. With that report in hand, the police wheeled the patient out of the hospital in handcuffs, placed her in a police car, and took her to jail. When she arrived at jail, she told the officers that she couldn’t get out of the police car, so they dragged her by her arms into the police station and laid her on the concrete floor of a jail cell.

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A few hours later, she was dead.

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The Fast Track

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Spring 2015

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Medical clearance is not as simple as it may seem.

An autopsy showed that the patient died from pulmonary emboli and had blood clots in both of her legs.

The Police Chief tried to cast some of the blame for the bad outcome on the emergency physician, telling the newspapers that “A lot of times people don’t want to stay in jail and will claim to be sick. We depend on medical officials to tell us they’re OK.” The medical providers and the hospitals that cared for the patient were later sued over her death.

What can we learn from this case?

First, while the emergency department may see its share of “drug seekers,” we need to be careful in establishing a reasonable basis for the label before we use it. Just as we don’t label all patients with chest pain as “heart attacks” without further investigation we shouldn’t label all patients with pain as having some ulterior motive to obtain controlled substances without evaluating the patient’s complaints. In this patient’s

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Better wording for medical clearence

case, the patient may have exhibited some characteristics of drug-seeking behavior, but she also stated that she couldn’t move her legs and that she couldn’t walk -complaints not usually associated with receiving pain medications.

Second, we should consider what we mean when we write “medically cleared” on any discharge form, whether it is for psychiatric patients, for incarcerated patients, or for a work release. Rather than using the blanket statement that a patient is “medically cleared,” which can be subject to interpretation, we could make the limitations of an emergency department more evident.

Better wording for a “medical clearance” form might contain language such as the following:

“The patient was evaluated in an emergency department and has no manifestations of an emergency medical condition at this time.

However, the patient should be re-evaluated if symptoms worsen, if new symptoms develop, or if problems occur. Emergency medical evaluations do not take the place of regular medical care.”

“The patient was evaluated in an emergency department and has no manifestations of an emergency medical condition at this time.

However, the patient should be reevaluated if symptoms worsen, if new symptoms develop, or if problems occur. Emergency medical evaluations do not take the place of regular medical care.”

Dr. Sullivan is an attending physician at St. Margaret’s Hospital in Spring Valley, IL and has a private law practice in Frankfort, IL that focuses upon legal issues related to medical practice. He lectures frequently on medicolegal issues.

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Junior Resident The Fast Track

Spring 2015

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Tricks of the Trade

Spring 2015

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The Fast Track

By Veronica Coppersmith, DO @ St. Lukes Hospital

Scalp Lacerations More staple guns, fewer tears - If you have a child who is not going to do well with getting

staples put in their head (or anyone who doesn’t seem like they’re going to like that for that matter), and it looks like the wound is only going to need two staples, you can use the trick that beauticians have been using for years to get earings in kids! Use two staple guns and have two providers, each putting staples in at the same time. By the time the kid realizes that it hurts, the wound will be closed!

Lube Hair Style - If you have a scalp wound that requires sutures, but the hair keeps getting

in the wound, use either petroleum jelly or sterile lube to “style” the hair away from the laceration.

This leaves you a clean working space to fix the wound without hair in the way.

Hair Apposition Technique (HAT)

- Most scalp wounds come with some handy intact hairs surrounding the wound. You can use these hairs to approximate the wound using HAT. After copious irrigation to clean the wound and ensuring that no foreign bodies are left in the wound, separate the hair on either side of the wound. Pick up several strands of hair from one side and twist them together to form a strand (this can be done with gloved hands or with hemostats for better dexterity and tighter grasp). Do the same thing on the other side so you have two twisted strands of hair. Then twist them together a full 360-degree turn around each other and they interlock. You will note that the wound is now approximated; apply a drop of tissue adhesive on the X of the crossed hairs and hold until dry. You may do this on multiple sites if the wound is a long laceration. Advise the patient to avoid getting the wound wet for 24-48 hours, and that in 7-10 days the glue will fall off on it’s own and the hair ties will unravel revealing a healed wound.

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The Fast Track

Single GME ssssssssSystem

The Spring 2015

By: Robert S. Juhasz, DO, AOA President

Rapid growth in osteopathic medicine has fostered an integration of DO and MD training in recent years. Of nearly 5,000 DO graduates seeking residencies in 2014, 45% entered ACGME programs. In academic medical centers and clinics across the country, MDs and DOs are already accustomed to working side-by-side. The upcoming transition to the single GME accreditation system responds to the dynamic growth and interest in osteopathic medicine, but more importantly it ensures broad access to training for all current and future physicians.

Quality and expanded access to GME for all postgraduate physicians remain our overarching goals and have been the major focus areas for all stakeholders working behind the scenes to prepare for the transition period, which begins on July 1, 2015.

When fully implemented in July 2020, the new system will allow graduates of osteopathic and allopathic medical schools to complete their residency and/or fellowship education in ACGME-accredited programs and demonstrate achievement of common milestones and competencies. Currently, the ACGME and AOA maintain separate accreditation systems for allopathic and osteopathic educational programs. The first steps to integrate the two systems into one system have now begun.

A shared desire to align GME structures and standards to improve public health drove this historic undertaking.

Work since announcement of the transition has focused on preparation and education. In September, the AOA and ACGME hosted a collaborative webinar with the American Hospital Association to share information on the single GME system with hospital CEOs who have osteopathic GME programs. Three educational sessions are planned to keep program directors and medical educators aware of steps they must take to prepare for the transition and encourage them to retain an osteopathic focus in their current programs.

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The AOA and the American Association of Colleges of Osteopathic Medicine (AACOM) have also taken strides to ensure that osteopathic physicians have a strong role within ACGME governance. In October 2014, the Osteopathic Principles Committee was appointed and began its work to develop standards. DOs were also nominated to serve on all ACGME Residency Review Committees that oversee specialties with osteopathic-focused programs. These are

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Robert S. Juhasz, DO, an AOA board-certified internist, is the AOA’s 2014-15 president. Dr. Juhasz serves as president of Cleveland Clinic’s South Pointe Hospital in Warrensville Heights, Ohio. He is an associate clinical professor of medicine at the Ohio University Heritage College of Osteopathic Medicine and assistant clinical professor at the Cleveland Clinic’s Lerner College of Medicine at Case Western University.

critical steps toward ensuring the continued recognition and promulgation of osteopathic postdoctoral training programs within the ACGME system.

The AOA and AACOM became ACGME member organizations on January 1, joining existing ACGME member organizations: the American Medical Association, American Hospital Association, Association of American Medical Colleges, American Board of Medical Specialties and Council of Medical Specialty Societies.

There are four osteopathic physicians who were recently appointed to the ACGME Board of Directors: AOA nominees Karen J. Nichols, DO, and David Forstein, DO; and colleagues Gary Slick, DO, and Clinton Adams, DO, who were nominated

by AACOM. As next steps, the ACGME will hire an osteopathic physician to serve as senior vice president to oversee osteopathic-focused programs. This is a unique opportunity to lead postdoctoral medical training into a new realm built upon strong collaboration on both sides of the “aisle” to create a new system that ensures quality for all physicians and their patients.

The AOA strongly believes the public will benefit from a single system to evaluate the effectiveness of GME programs for producing competent physicians. Standardizing requirements for accrediting the training programs for all physicians in the U.S. is an important step in strengthening the postdoctoral education process and ensuring that the next generation of physicians is equipped to deliver quality health services to patients. Through osteopathic-focused residency programs, the new GME accreditation system will recognize the unique principles and practices of the osteopathic medical profession and its contributions to health care in the U.S.

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The Fast Track

Spring 2015

Political

Healthcare policy has always been on the minds of providers, insurance companies and a small portion of the general public. Since the beginning of the Obama administration, it has been at the forefront of government proceedings, and now virtually every citizen has a stance on the current status of our healthcare system.

This is good because virtually every citizen is impacted, in one way or another, by changes in healthcare policy. As physicians and future physicians, we are impacted even more than the “Average Joe’. We have a responsibility to ourselves and our patients to be informed about current issues and play an active role in policymaking. Additionally, relatively recent changes in the national political environment have resulted in greater importance of grassroots advocacy [1]. We can and should use this to our advantage.

Busy schedules combined with the ever-changing whirlwind of democracy makes it difficult to keep up with the issues. Fortunately, there are a number of ways to stay informed. Most specialty colleges and medical organizations have a section of their website dedicated to current policy issues. There are also private blogs and social media accounts devoted to keeping followers up to date with healthcare policy. Settings on mobile news apps can be helpful in filtering articles and receiving updates. One particularly convenient resource is the American Medical Association’s Advocacy Update newsletter, available online [2]. With so many options, resources can be experimented with to find one or two favorites.

Once we are aware of the issues, the next steps are to determine a stance and make the stance known.

Determining a stance is usually a passive process that occurs naturally while exploring the facts, but making opinions known is more of an active process. A lot of people do not know where to start. “Who cares what I think?’, “Who would I even talk to?’, and “How can I get in contact with the right people?’ are common questions. The American Osteopathic Association has an excellent webpage, including an Advocacy Handbook, designed specifically for those with an osteopathic background looking to influence healthcare policymaking [1,3]. It is helpful for the newbie and the veteran alike. There are even sections designed just for students. There are a variety of ways to be an advocate, ranging from talking about the issue with friends, to writing letters, to meeting with policymakers in person. D.O. Day on Capitol Hill is just one opportunity for the latter.

Increased participation in policymaking is incredibly beneficial to physicians and future physicians. We have the opportunity to influence our own futures. Recurrent themes in healthcare policy include cost of medical education, availability of training and changes in delivery of care. These issues all directly affect us, so nobody should care more about them. The more people who choose to make their voice heard, the louder the collective voice, and the greater the chance of success. Whatever the opinion on specific issues, make it known! We live in a world where it is not uncommon know let the world know everything about breakfast. Surely we can tell the world about how we want to improve healthcare.

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The Fast Track Spring 2015

Master of the Airway An editorial on the benefits of VL

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By Drew Kalnow, DO, EMT-P Doctors Hospital, Columbus, OH

ou stand in the resus bay, at the head of the bed, ready to take charge of a crashing patients airway.

EMS had just alerted the ED that they are enroute with a critical patient in respiratory failure and they were unable to secure the patients airway. As they arrive, it’s clear the patient is in distress and not breathing well, if at all. You take a few deep breaths and now you are ready to be an airway master. But how will you do it?

In emergency medicine, we are the masters of the airway! Of course anesthesia tries to lay claim to this title and they are good, really good, but they also cheat.

The anesthesiologist gets to use their airway skills in a controlled setting, on a pre-assessed patient that is not trying to die in front of

IN EMERGENCY MEDICINE, WE ARE THE MASTERS OF THE AIRWAY! them. While this is a bit simplified, in the ED, we don’t have these luxuries. When we intubate, we are doing it on a patient that needs that tube now, probably just ate a chili cheeseburger and we are lucky if we know a medical history.

So, with the odds already stacked against us, how are we going to get the tube? page 14

In my ED, and many around the

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country, we have two options to intubate. First, is the tried and true direct laryngoscopy (DL). It uses nearly 100 year old technology to displace the tongue and lift the oropharynx in order to directly visualize the larynx. This is how anesthesia typically intubates and how the majority of EM physicians learned as well.

Then there is the newcomer, video laryngoscopy (VL). This approach uses the aid of a small video camera at the tip of the laryngoscope blade transmitted to screen to visualize the larynx and pass the endotracheal tube.

Some of the VL devices can be used like a DL blade as well and other can only used via video.

Before I go any further and potentially ruffle a few feathers, let me say that I used to be a DL guy. Before going to medical school and becoming an EM resident, I was a paramedic. I have been slightly o b s e s s e d with airway Even a poor view with VL gives management good information a n d

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intubations from the time I first put my hand on a l a r y n g o s co p e.

When I started my medical training as a paramedic, VL was just starting to hit the market and hadn’t made it to any ABC’s start with AIRWAY! of the departments I worked at. I became proficient at DL and was the Video Laryngoscopy the standard? o d d b a l l that really liked the Miller blade. I still intubate using DL on occasion and feel comfortable with both a Mac and Miller blade. But, despite my initial resistance to VL, I am now a card carrying, band beating convert to the world of video.

the problem is that the airway is not a series of straight, nonalignable lines, but rather a curve.

VL allows you to follow the curve and visualize without having to try and align the unalignable.

VL is easier to learn: Plain and simple, when studying resident ability to intubate, the learning curve for VL is much better than for DL. The initial success rate using VL is nearly 90% after just 25 intubations, a number that is obtainable in the first year of training. For DL, the initial success rate is less than 70% at 25 attempts and it takes over 100 intubations to reach proficiency.

Now, I am not so naive as to think VL is the end of DL but in my opinion, it is superior and should be the go to tool for airways in the ED. Any ED physician knows you have to have a backup plan when performing any intubation, this is where DL and other tools such as the bougie come into play.

Follow the curve: The entire concept of DL is to align the three airway axes to provide direct visualization of the vocal cords,

If you want to read and watch more on this topic, or hear from the other side of the argument, please check out my sources.

Spring 2015

The Fast Track

VL makes you better at DL: Crazy but true, using VL actually makes you better at DL intubation. So in the off chance you are faced with having to use DL, all of those VL intubations will have payed off.

VL is better for the difficult airway: In several recent studies, VL has been shown to improve first pass intubation in the difficult airway.

We also know that we are not good predictors of who is going to be a difficult airway. As far as I am concerned, all intubations in the ED need to be approached as difficult, it’s a bonus if they turn out not to be.

VL allows others to see the intubation: This is huge! The resus room is a high stress environment and a difficult airway turns up the heat even more. Using VL allows other in the room (your attending, another resident, respiratory Here is my argument therapist, etc) to see what you are for why VL should be doing. When you get the tube, the your first choice when room knows it and you can feel intubating in the ED. the tension release.

Screen view of the cords

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VL is how I master the airway.

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The Fast Track Spring 2015

LIFE OF A COMBAT MEDIC I Ariel Sindel, OMS-III KCUMB-COM

t was a late summer night. My unit was returning from a patrol to one of its outposts when we were suddenly flagged down in the middle of the road. A man told us his wife fell off the cliffside.

Without thinking, we jumped into action, turned on our lights, put on headlamps and looked for her from the road. One of us could hear or see her, so I looked at my commander and said I would climb down the side of the cliff on foot and find her. I put on my Medic’s Combat Vest, filled with tourniquets, bandages, and other crucial emergency supplies, and went over the ledge and started a slow descent down the cliffside.

The grade was steep, but I slowly made my way down the cliff, calling out for her to answer me. Above me I could see more and more lights as battalion command and civilian emergency services started to arrive. I finally heard a faint voice, and after 20 meters of descending, I finally found her. I made a quick assessment, feeling for bleeding, not trying to move her. I called up for a neck brace to secure her cervical spine and then started prepping her for an evacuation. The patient was leaning on a big boulder with her legs so close to the edge of the cliff that I found myself straining to keep my balance as I prepped her..

As I calmed her down, an evac team with a stretcher attached to a vehicle above arrived, and we carefully put her on the stretcher and lifted her to safety.

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With more and more students applying for the Health Professionals Scholarship Program (HPSP) and going into Military Medicine, I thought I would give my perspective on life as a Combat Medic in the Israeli Defense Forces. In

the IDF, the Combat Medic plays a crucial role in not only being the general health personnel on a base or outpost but also must be able to go out on patrols and missions and be ready to apply emergency medical support to injured soldiers with a wide array of trauma situations. Training starts with combat boot camp, a four-month training camp that all combat soldiers go through. After learning how to operate as a soldier, one then goes to the Combat Medic’s Course, another 4 months of intensive medical training. At this course, soldiers learn about a wide variety of illnesses, pathology, behavioral health, and trauma. They also learn basic physiology, basic treatments for minor illnesses, how to manage mass casualty situations, and how to assist a Paramedic or the battalion doctor with intubations, tracheotomies, and chest tubes. After the 4 months of Combat Medic training, you rejoin your unit for advanced training; and after 1 year of total training, you are put on the front lines.

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atrol n in side. ghts, f us aid I put ges, edge

The Fast Track

After I completed my training, I joined the unit in my battalion called the “Ta’gad”.

This platoon provided medical support for the battalion as a whole (there are also individual medics who are assigned to combat platoons). My platoon consisted of the Battalion doctor, the Battalion paramedic, the Chief Medic, and several other medics. We medics perfomed several functions, including monitoring the health of all the battalion (vs. just a platoon, as platoon medics do), providing access to the Batallion doctor when needed, going on patrols and missions with the soldiers (for immediate medical support), inspecting the platoon medics, and monitoring the kitchen for any health or safety concerns. At times of war, my unit stays at Battalion HQ and sets up a triage center for injured soldiers. Another function of my unit was to respond to EMS calls for civilians when our unit was closer than the EMS services of Magen David Adom.

At y unit was on alert 24/7 and could respond within minutes of a call. For the next year of my life, with the exception of 1 weekend a month, I would be in a perpetual state of readiness, waiting for the phone to ring, or I would be out on a patrol or mission, ready to assist if needed.

A day in the life of a Combat Medic starts with inspection, where we check all the equipment on our Humvee ambulance, as well as our personal equipment. We then go to monitor the morning patrol.

After breakfast, we review our roles in different scenarios with the paramedic

or doctor. In the afternoon, we clean, relax, go to one transport soldiers to the doctor, and afterwards get ready for the night patrol. I would have dinner, and around 10pm I would go on a night patrol that generally lasted anywhere from two to five hours. In general, one medic stays behind and rotates with the other soldiers in guarding the base.

After the night patrol, I went home and got whatever sleep I could before repeating the process the next day.

In the cases of soldier injuries, we would do what we could to stabilize the patient and then either drive the patient to a nearby hospital or call in air support.

In Israel, a patrol is generally no more than two hours by ambulance from the nearest hospital. As such, we are trained, as EMS in the United States is, to be able to stabilize the patient enough for transport and then to move as fast as possible to a nearby hospital. I have experienced combat where that must be done under fire, but you are trained to act as a soldier first and then as a medic.

The medical forces of the IDF are an integral part of the Emergency Services of the State of Israel. They must be ready to respond when needed to provide medical assistance to not just the soldiers, but also to any injured civilians. We work with the State’s EMS system to provide services to hard to reach areas and be to respond faster to emergencies.

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The Fast Track Spring 2015

The Fight Against Human Trafficking

BY Charles F. Ebersbacher, OMS-I, OUHCOM

I

t is estimated that nearly 27 million people worldwide are enslaved today, which is twice the amount of slaves as there were during the Atlantic Slave Trade (1). These men, women, and children are enslaved in the form of human trafficking (HT). According to the United Nations Office of the High Commissioner for Human Rights, HT is defined as the recruitment, transportation, transfer, harboring or receipt of people by the threat or use of kidnapping, force, fraud, deception or coercion, or by the giving or receiving of unlawful payments or benefits to achieve the consent of a person having control over another person, and for the purpose of sexual exploitation or forced labor (2, 3). HT, or modern day slavery, is an industry that generates $7-10 billion annually for traffickers (4, 5). The monetary value of a human has declined from $40,000 in 1850 to $100 today, causing an explosion of the industry, making it the second largest illegal market behind arms trading and ahead of drugs (1). HT is not only prevalent globally but also takes place in the United States. It is estimated that 18,000 men, women, and children are trafficked from other countries into the US and an additional thousands of citizens are trafficked every year (5). Persons at risk to be targeted include homeless youth and undocumented immigrants that are forced into manual labor in hotels, restaurants, nail salons, agriculture, construction, and factory work (1, 2, 4).

How does human trafficking happen?

Traffickers lure their victims with the promise of high paying jobs that often do not play out but leave the victim with no other option. Romantic relationships that start off with gifts, compliments, and physical and sexual intimacy, with promises of a better lifestyle, fast money, and unrealistic luxuries quickly transform into exploitation. The trafficker uses controlling techniques such as physical and mental abuse, sexual assault, confiscation of identification and earned money, and removal from society. Traffickers turn promises of better lifestyles and loving relationships into violence, threats, lies, debt, bondage, and other forms of coercion to force victims into commercial sex and forced labor (6). Before victims know what is happening, they are trapped in a cycle of forced labor or sex and have no way of removing themselves. They become codependent on the trafficker as the victim is without money, shelter, or identification. Sex trafficking victims are expected to meet a financial quota seven days a week of $500-$1000 a day, which equates to sexual encounters with around six to ten men (6). Commercial sex is often disguised as fake massage spas, online escort services, residential brothels, or in public on city streets, in truck stops, strip clubs, hotels and motels. Forced labor is usually manual labor in hotels, restaurants, nail salons, agriculture, construction, and factory work that is done over long hours for little compensation if any. Escaped victims end up on the streets where people rarely believe their stories or are willing to help. It’s not hard to walk past a homeless person and assume they are mentally ill or have an addiction. However, it is possible that they have been a victim of human trafficking and cannot turn anywhere for help. Escaped victims commonly return to involuntary servitude, as they have no other options and are left without food, shelter, money, or identification upon escaping.

18,000 [people] are trafficked... into the US... every year.

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o other better such as fickers cion to forced ent on ficking 0 a day, cial sex othels, d labor uction, scaped meless human o other

Spring 2015

The Fast Track

It is also possible that victims do not know any other lifestyle.

Young children or immigrants may believe that the forced conditions they are working in are what life is supposed to be like. People who come from nothing will appreciate someone who gives them food, money, and shelter. However, they do not realize that their human rights are being violated and it is therefore society’s responsibility to recognize these atrocities and rescue these individuals. HCWs have an opportunity to help victims of trafficking because they often turn to medical treatment due to horrible working conditions and sexually transmitted infections.

Role as health care worker (HCW) It is estimated that twenty eight to fifty percent of human trafficking victims, while in captivity, encounter a healthcare worker and are not recognized (4, 7). Trafficking survivors have said they visited small, private healthcare facilities as well as large medical centers to be treated commonly for respiratory illness, systemic bodily injuries, or STIs (8). Traffickers usually bring victims for medical care only when symptoms prevent them from performing their forced tasks. It is hard to believe that victims would not inform HCWs of what is happening to them but as mentioned above, they may be too scared of their captor or deportation, may not know any better, think no one will believe them, or feel they need the job. During an encounter with a victim and HCWs, most paperwork is completed and communication is done by the trafficker (4). Victims can often be limited by a language barrier. Health care for victims is most commonly paid for in cash by the trafficker and then added to the victim’s debt.

Human trafficking has numerous aspects, and therefore patients can present with a variety of conditions, making a common presentation difficult to describe. For any HCW focusing on the patient as a whole, it is vital to not overlook signs of HT. Medical care may be the only commodity a trafficker cannot provide and must seek outside help. Therefore, HCWs are presented with a small window of opportunity to rescue the victims of involuntary servitude. It is important for health care workers to use common

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sense and instincts about a situation. Is the patient being elusive and deferring most questions to someone that brought them in? Victims are often brought in together and are said to be relatives. A HCW must ask themselves, do they look alike and does the story makes sense? If some suspicions arise, ask the patient if anyone is hurting them or if they are being coerced into something against their will such as sexual intercourse or labor. Other important questions include “Are you safe in your home or workplace,” and “Do you owe your employer money?”

Below is an outline of red flags that indicate human trafficking and questions that should be asked upon recognizing some red flags.

Red flags (1, 5, 9): A patient who: Is accompanied by someone who seems to be controlling and may act as a translator Does not have appropriate identification or documentation, or who is not allowed to handle the identification or documentation Lacks knowledge of his/her whereabouts Shows signs of neglect or abuse Has a discrepancy between history provided and clinical findings Is unusually fearful or submissive Has recently entered the US from Asia, Eastern Europe, or Latin America

Questions to ask upon noticing red flags(1, 9): Where do you live?

Where do you work? What hours do you work? When you are not working can you come and go as you please?

Are you free to quit your job and get a different job?

Have you or family members been threatened or mistreated by your employer?

Have you ever been forced to do work that you did not want to do?

Have you ever been forced to have sex?

Has anyone lied to you about the type of work you were to do?

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The Fast Track Spring 2015

Consider this example from AWHONN Lifelines(5): A 28-year-old woman, gravida 1, para 1 presents to a clinic for a 28-week prenatal visit. She is from Mexico, has no legal documents and speaks only Spanish. An interpreter, assigned by the health care facility, is present for the interview and examination. The patient has only one prior prenatal visit, which was at 13 weeks, and she has lost 10 pounds since that visit.

During the course of the visit, she is advised that laboratory work will be drawn and that she would need to return for administration of prophylactic RhoGAM, as per clinic protocol. The patient responds that she can’t return for the follow-up because of her work schedule. Further questioning reveals that she works seven days a week, in 12-hour shifts, in a restaurant owned by her “sponsor.” Her meals consist of leftovers in the restaurant, which are usually available at the end of her workday.

She has very little money, as “most of her pay” goes to her “sponsor” for rent and living expenses. She refuses to meet with a public health nurse at home or work because she fears being sent back to Mexico if her sponsor finds out she is pregnant. This woman is a victim of human trafficking within the U.S. Using the criteria above, this patient has numerous red flags including language barriers, having no legal documentation, malnourishment, delay in seeking healthcare, excessive work hours, and fear of deportation. The HCW followed the correct procedure of obtaining an interpreter and asking questions such as why she cannot come back for her appointments and why she will not meet with a public health nurse at home or work. After the red flags are noticed, the HCW should not

let the patient leave and call the National Human Trafficking Resource Center (NHTRC) at 1-888-373-7888 and report the incident. The NHTC can help confirm the patient is being trafficked and initiate the appropriate resources to emancipate and rehabilitate the victim.

HCWs have a rare chance of interacting with victims while under the control of their traffickers. Therefore, doctors’ offices, hospitals, and the emergency department are on the frontlines of preventing the perpetuation of HT. However, HCWs are responsible for protecting and helping patients and responsibility for stopping HT does not start and end with recognizing victims. The steps in fighting HT are listed below and can be summarized to prevention, recognition, education, and support.

E R

Basics steps to fight human trafficking as a HCW(1):

Become better informed Share knowledge and passion with other Support organizations that combat HT Be a wise consumer and buy from fair trade companies Practice medicine vigilantly Provide volunteer services for victims of HT Disseminate and educate through research and publishing

Human trafficking is a direct violation of human rights and a great injustice. It is important that those in healthcare become informed and share their knowledge with others. As an educated team, it is possible that healthcare workers can guide victims of human trafficking to freedom.

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Elevate your knowlege, rock the inservice exam and blow away the boards! www.roshreview.com The Fast Track - Spring 15 Draft 11 - TB.indd 21

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The Fast Track Spring 2015

Kaitlin Fries, OMS-IV, OU-HCOM ACOEP-SC Immediate Past President

The first ever ACOEP REGIONAL STUDENT SYMPOSIUM

O

n Saturday, February 21, 2015, over 80 students, representing 14 different osteopathic schools, traveled to Columbus, Ohio to attend the first annual ACOEP Regional Student Symposium.

The event - held at Doctors Hospital in Columbus, Ohio - featured local ACOEP mentors, five area residency programs and a keynote address by ACOEP President Dr. Mark Mitchell.

The goal of the symposium, developed by the student and resident chapters, was to provide students with the benefits of attending a national conference while remaining close to home.

The morning kicked off with our popular rapid-fire lecture series given by local members of the college’s Regional Mentorship Program. Lecture topics included trauma, pediatrics, provider wellness, and how to write a personal statement.

ACOEP President, Dr. Mark Mitchell, rounded out the morning with his keynote address to the students.

Students had the opportunity to learn about regional residency programs during an interactive lunchtime resident’s panel. Five programs were represented on the residency panel, including Doctor’s Hospital, Adena Regional Medical Center, St. John’s Medical Center, Ohio Valley Medical Center, and Charleston Area Medical Center.

The panel allowed students to get a glimpse into what each program looks for in a future resident, learn tips on how to be a competitive emergency medicine applicant, and gain advice on how to navigate the audition and match process.

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Spring 2015

Caption for imge goes here

The Fast Track

M The afternoon consisted of a skills lab titled, “Basic EM Skills Students Should Know�. This two-hour lab had five skills stations, each run by a participating residency program.

Students had the opportunity to learn about lumbar punctures, ENT complaints, laceration repair, direct and video laryngoscopy, and ultrasound. For first and second year students, the skills lab was a great opportunity to get an introduction to the hands-on aspects of Emergency Medicine.

For the third years, it served as a chance to become more familiar with basic skills before their upcoming audition rotations.

Overall, the event functioned as a great platform for students at all levels of medical education to learn more about emergency medicine as a specialty. While there were some familiar faces, many students commented that this was their

first ACOEP event and they quickly added that it won’t be their last! The student chapter board realizes that there are many barriers preventing students from attending our national conferences.

Many osteopathic schools have strict guidelines for excusing students from daily requirements, making attending two conferences a year difficult. For others, the financial implications of traveling to conferences pose the problem. The Regional Student Symposium was designed to alleviate this problem for our student members. The student chapter board hopes that by setting up more of these oneday events across the country, we will be able to reach out to more students and continue to share our passion for Emergency Medicine.

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The Fast Track Spring 2015

International Health System Comparison:

Are we really that bad?

Joshua Enyart, DO Lehigh Valley Health Network

1.

These are interesting times to be training or entering the workforce as a healthcare provider in the U.S. Much has changed in recent years with the rollout of the Affordable Care Act, and the debate over the future of our system still rages on. Change was inevitable given that despite uncontrolled escalation of costs, many still went without care and our outcomes remained poor when compared to other modern industrialized nations. The fact is, that though there have been some recent improvements in access to care and efforts for cost containment, the most recent data suggests there is still a lot of ground to be made up in terms of having a healthy population on par with that of these other industrialized countries. Though much of the focus up to now has been on remodeling the healthcare system itself, I propose that any changes focusing exclusively on healthcare delivery are going to be insufficient and that greater emphasis needs to be placed on the social policies with which we can help alleviate the factors that lead to poor health to begin with. To illustrate this point, I offer the first part of an old parable:

2.

THE STORY OF THE RIVER

Once upon a time there was a small village on the edge of a river. The people there were good and life in the village was good. One day a villager noticed a baby floating down the river. The villager quickly swam out to save the baby from drowning. The next day this same villager noticed two babies in the river. He called for help, and both babies were rescued from the swift waters. And the following day four babies were seen caught in the turbulent current. And then eight, then more, and still more!

The villagers organized themselves quickly, setting up watchtowers and training teams of swimmers who could resist the swift waters and rescue babies. Rescue squads were soon working 24 hours a day. And each day the number of helpless babies floating down the river increased. The villagers organized themselves efficiently. The rescue squads were now snatching many children each day. While not all the babies, now very numerous, could be saved, the villagers felt they were doing well to save as many as they could each day. Indeed, the village priest blessed them in their good work. And life in the village continued on that basis. . .

3.

Healthcare in the U.S. is like that village. We continue to dedicate massive resources to fixing an ever growing problem with seemingly inexplicable origins but eventually, despite our best efforts it becomes impossible to get all the babies out of the river. Fortunately we are not just a village, but a modern country, amongst many other modern countries who also have to deal with the health of their populations. And being in the technological age, we have a fair bit of easily accessible data to use to compare ourselves and to help come up with solutions. Lets take a look at exactly where we stand.

In a recent update of The Commonwealth Fund’s International Health Comparison, which compares the systems of 11 industrialized nations, there are two key areas where we are head and shoulders above others.

(1) The bad news is that these two areas are average spending on health per capita ($8,508 vs next highest of $5700 in Norway) and total health spending as a percentage of GDP (17.7% vs next highest of 12% in The Netherlands).(2) In spite of this, we still rank at or near the bottom in regards to access, efficiency, equity and healthy lives. That said, we actually do fairly well in overall quality metrics, falling right in the middle, and specifically are above average when it comes to effectiveness of care, preventive care and patient centeredness.(1) So why, then are we next to last in healthy life expectancy at age 60, and dead last amongst these countries in terms of mortality amenable to healthcare, and infant mortality? This last one is of particular interest as it is considered a good benchmark for the overall state of a countries level of health and socioeconomic development.(3,4) Worldwide, we actually rank 34th, 2 spots above Cuba.(5,6) The 5 countries with lowest infant mortality rates are: Singapore, Iceland, Japan, Sweden and Finland.(5,6) What are these places doing that is different?

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The Fast Track

Spring 2015

s cros ns a e o i t a m lic s, er so app ear , howev t system l c e t es or l at gi m upp apo nfan extr litical re social s down i of life) o t s lt k ing d po ne i o nt h e fficu e di ures an seen. O es. Brea (first m relativ b n t i s l a s i r e d t c u b o e e n c i t I r u n er e dl s arat lities ca rdic co natal pe , and th ls regar p s i o d a s o a n e the e ne mon nt r i e vidu n th com seen in at in th her cou ed indi nifest i related a t s th is tag to m see ith o r ly a mic this va n icula data we n par w larly ad s begin uggest ioecono t r a i s p c ce y yo talit uall g sim eren ce to lower so ween t mor S. is act mparin The diff eviden f o b k e . o s se U. en c ocation there i gst tho r the lin we can the h w n fo 7) nd ty cl ing pari graphi eriod a lity amo idence comes,( ta mak o v a t p a e e t l d u r g a t o o n at he h han of eon xcess m ignifica r healt ew t ective t ving n k t s s s o e y a po ha eff to po he ng not ies m less en t rg o i rely and enti .(10) Giv status disparit stem is ique in por t fo lifies us s re ged cial h sy an’t is un emp s t at anta how so ur healt he U.S. merican gain ex e who c the v d a t dis see sure gh o ur ther, 7% of A ccess, a as thos m e a l a te d i n to a hou s e e w m beg ear as t ally is. F e and 3 rrier to o h rre a p ag tu outc by whic best co who are it ap ps it ac h cover 1) This b health e s r ic -64, a l .( ob lt eral the met seem t ged 40 00. For 0, co s t per h rsal hea v o o t n 0,0 ,00 e ch ue ing ts a univ care d impact ive dow ors whi or adul 2 per 10 per 100 t h r F 4 3 y t c . . ) d l t 1 7 (7 fa y ty, hea inequi a te l key ncome. es are 2 ber is 6 pover who o m l i t a w l n i i t i T m n a u soc are i o n . i o n a n d r t a l i t y r t h a t n u s l i v i n g te r t h a h i s rd c the nat , o ic ea at rt n r n c o m o g f a i affo u t s f s s p e ed ca on e te ho his m u e s i t r b l t d a d a a a ined e i e n 5 he alth ates, d school lacks a hich is h e r i n te r t w s e T ) h 9 with e gradu a high mong b poor w uintile.( myriad se thing h c g q st o A h the e su colle with ju rease.8 as fair t income lex wit ’t do becaus ea n p e c t h o s t s n m ar ed eal tho efold i n nd g h e u b t co is an sitio eir h e hi FK , w rd, a o re a th epor t th lth in th re no d hrase J y are ha ills. This we tran ps r a e a ap w sk ta 3 0 % p o o r h e i m p a c t to p a r a u s e t h e s a n d s ho nd in le e list i c his i c u u i e g T o m B t r . i r b m . f s e a s g t l o o h c n cu g en bu to r oeco ing fac e easy, t of our litical fo o gainin bottom r, more i c o t s e r s t ly ie d po ey a tual alth nch e be m th tr ibu con ause th sure th tudy an ch by i ove fro ng a he run, ac he s i n c g t i v ea be ore ard we m visit e lon o ha ls m goa r thy of m ing for w is how gards t k, in th Let’s re n is . re wo m ov I thi g so s. Th s in from bound nation lus, and by doin u rn rs and pop ode olla “But where of m ductive hcare d er: r iv pro e healt are all these the s av a b l e o f babies comin par g

4.

from? Let’s org anize a team to head upstream to fi nd out who’s throwin g all of these babie s into the river in th e first place!”

5.

To answer the question posed in the title, “are we really that bad?” I don’t think so, at least not in our healthcare delivery.

We do well in quality measures, but fall way behind in terms of access and equity. Those who are well off in this country can expect health on par with anyone else in the world of similar status, but the poor outcomes disporpotionately represented by disadvantaged individuals more than offsets this. These aren’t problems that can be fixed within the walls of hospitals and doctors offices, but as providers we remain on the front lines and frequently deal with the consequences of such failures. As such, we have a unique perspective and it’s essential that more of us begin to realize that social change can be an effective tool for improving health on a larger scale. To reduce the burden on those of us down the river, it’s time we get more people working upstream.

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The Fast Track Spring 2015

A PROMISE TO PERU

Frederick Davis, DO, MPH Dr. Davis is an attending physician at North Shore Long Island Jewish Medical Center in New Hyde Park, NY. He completed an International EM Fellowship and now practices medicine here and abroad.

P

eru offers a beautiful backdrop of mountains and vast terrain, but within there lies a part of the population that has little to no access to medical care. People living on mountain tops are removed from community access, while others might not have the financial means or even medical support to seek care. One group, A Promise to Peru, is trying to change this.

With about 29.5 million inhabitants, Peru is the fifth most populous country in South America. There is a wide range of diversity in Peru and while the majority of the population speaks Spanish, there are several other languages that are spoken in the country. 13.2% of the population speaks Quechua. About 45% of the population is considered indigenous and where they live often has reduced access to food, water, shelter, and basic health care needs.

A Promise to Peru, Inc., has been providing care to these areas, with an annual cataract surgical and medical missions to the remote villages of the Sacred Valley of Peru and other regions in need. Organizers for this group have arranged for an annual mission to provide medical care to areas around the Sacred Valley of Peru. The medical care includes eye exams, cataract surgeries, and routine diagnostic services and treatments. To aid in this cause, a number of health professions volunteer from across the U.S. Those professions represented include physicians in Ophthalmology, Emergency Medicine, Pediatrics, Internal Medicine, OB/Gyn, as well as students in optometry, pharmacology and public health.

These professionals and students come to volunteer their time to provide care for these remote populations. page 26

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Prior to arrival, the group works with the local healthcare community to identify patients who would benefit most from cataract surgery. The surgical mission focuses on cataract surgeries since many of these procedures can be performed each day with lasting effects for the patient. The medical side of the mission sets up shop in various areas around the Sacred Valley, ranging from local schools to remote mountain tops to bring the care to the people in the areas like Ccotohuincho, Ccotataqui, and Calca. Here physicians evaluate patients and offer basic treatment as well as diagnostic studies, like ultrasound, urinalysis, and pregnancy tests In some remote areas, the team worked with members of the Peruvian Health Ministry who were able to provide point of care testing for Syphilis and HIV, as well as vaccinations and shoes for children. The optometrists with the mission were able to do eye exams on the people and, in many cases, provide them with donated prescription glasses or sunglasses.

Wherever the medical clinic was set up, there were many patients seeking care. The diversity of symptoms these patients presented with ranged from headaches, weakness, difficulty walking, cough, abdominal pain, skin problems, back and shoulder pain, urinary symptoms, vaginal complaints, and vision disturbances.

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Together, the groups were able to see hundreds of patents daily and provide medical care for adults and children.

Patients were given medications, health education on back exercises and hand hygiene, dental care, and more During the most recent mission, around 1,650 patients were evaluated and treated.

This number includes eye exams, where 1,000 pairs of prescription glasses and sunglasses were dispensed, around 50 various ultrasounds for various pathologies that were performed, 85 eye surgeries, and various other treatment, education, and medication dispensary.

A Promise To Peru has also recently been working with those from Friends

New England, who promotes education and sustainable development projects world-wide.

With a hand-in-hand philosophy, FNE works with impoverished communities to identify pressing needs, network with local and international organizations, facilitate collaboration, and empower individuals to actively participate within their communities.

Those in developing countries often find it hard to get access to care, be a lack of providers or poor access. The works of A Promise to Peru is helping to bridge that gap with their service in Peru. They are helping provide surgical and medical care to a population that lacks such overwhelming access. You can find out

A Promise to Peru, Inc. provides an annual cataract surgical and medical mission to the remote villages of the Sacred Valley of Peru and other regions in need. Physicians and other health professionals from across the U.S. along with medical, optometry, pharmacology and public health students and undergraduate students volunteer their time toward this effort For more information, or to donate to this cause, please visit: http://apromisetoperu.com

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Residency Spotlight

Kingman Regional Medical Center – Kingman, AZ –

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Size: 16 EM residents Total ED visits per year: ~45,000 Hospital size: 235 beds

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K l A l o t s t o m a t T a E r t ( n o

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What is unique about your program?

Kingman Regional Medical Center is located in the Mojave Desert of northwest Arizona. and is classically known for being located on Route 66. With a catchment area of approximately 77,000 people including the Hualapai Reservation, there is a broad spectrum of pathology that presents to the Emergency Department. A multitude of outdoor activities including hunting, mountain biking, and ATV riding as well as passage of Interstate 40 contribute to a relative large proportion of trauma.

The only residency programs at KRMC are EM and Family Medicine making the EM residents unopposed for all necessary resuscitations and procedures. Proximity to Las Vegas (100 mi NW) and Phoenix (200 mi SE) allow for transfer of patients needing a higher level of care and excellent out-rotations.

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What do you do outside the hospital?

The majority of residents enjoy the abundant outdoor activities including hiking, biking, camping, golfing, and boating. Weekend getaways to Las Vegas, the Grand Canyon, Sedona, and Flagstaff allow for frequent escapes.

What three words describe your residency?

Busy, Collegial, Laidback

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The Fast Track Spring 2015

The Pulse Crossover Article the PULSE | APRIL 2015

Reflective Moments – Musing Thoughts four-year emergency medicine residency. I truly believe the fourth year is extremely beneficial in enhancing the education of residents and preparing them to practice in our healthcare system. I am not saying three year programs do not prepare excellent physicians; however, it is obvious to me that more training cannot hurt, but can only help all residents!

also stated they could prepare and present a single clinical presentation which would give them the necessary AOA credit for their ACGME training year. As I was completing this article, I discovered that there is a resolution by the AOA which will even remove this requirement as the Single Accreditation Pathway becomes a reality.

Although I maintain that four years is the most beneficial length of training, I believe this may be the time for ACOEP to consider promoting the establishment of a three year training program for Osteopathic emergency medicine.

As I previously stated, I, and the majority of Osteopathic emergency medicine residency program directors, favor a four year program.

However, will the government have the funds to continue future financial backing for that “extra” year of education? It is obvious that the

failing to prepare, you "By are preparing to fail. " – Benjamin Franklin

The On-Deck Circle John C. Prestosh, DO, FACOEP, President-Elect

F

or this edition of The Pulse I would like to express thoughts that have been on my mind for some time. Of primary importance, I want the readers to understand that these are my personal views and do not reflect those of ACOEP or any other individual. If nothing else, I hope all readers would have an opinion on these issues and that this will serve as a spark for further conversation.

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I have been in agreement with the AOA and ACGME merger to create the Single Accreditation Pathway for residency training.

I believe it is a win-win situation for students and residents. With this new system in place, all residents graduating from accredited Osteopathic training programs will have access to fellowship training if they so desire. It is clear that our Osteopathic graduates would not have this opportunity if the AOA did not agree to the merger. What does concern me, as an Osteopathic program director, is the long-range viability of our Osteopathic training programs.

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The two main questions that persist are: will Osteopathic training programs continue to “recruit” extremely qualified Osteopathic students with this merger? And will our length of residency training eventually hinder our existence? I have always been a proponent of a

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I, like all Osteopathic program directors, have just completed another interview season. I was surprised by the high number of candidates who applied to my program.

My concern regarding the ability to “recruit” candidates in the future was partially assuaged. I interviewed many Osteopathic students who seemed genuinely interested in the Osteopathic emergency medicine residency, only to have them contact me and state that they were dropping out of the AOA match and pursuing the ACGME match.

I responded and asked them if they were willing to explain their decision. I informed those particular candidates I was not prying but wanted to know if there was something that was lacking with either with my program or the AOA match.

Several applicants responded and there was indeed a common answer: the “extra” year of training.

It was obvious to me these soon to be graduating Osteopathic medical students believed they could learn a sufficient amount of emergency medicine in a three year ACGME program.

They

government places an extraordinary amount of funding into graduate medical education. Will this financial backing continue? This would not only apply to Osteopathic programs but all four year ACGME training programs. With the AOA and ACGME merger taking place, there will be an almost equal split between three and four year emergency medicine training programs! If there are insufficient funds for Continued ononPage Continued Page35 12

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1) ANSWER: C. All states require hospitals to report certain events or illnesses to local public health authorities.

The intent is to prevent the spread of communicable diseases, protect citizens from disease and violence, and prosecute criminal acts. In each instance, the state statute overrides patients’ rights of confidentiality. The statutes typically also provide physicians with immunity from civil liability or criminal prosecution if the reporting is done in good faith. Typical communicable diseases that must be reported to the federal government include those of epidemiological concern such as sexually transmitted infections and highly communicable illnesses such as tuberculosis, hepatitis, pertussis, and recently MRSA. Some, but not all, states require that physicians report drivers in motor vehicle collisions while intoxicated (A).

Most, but not all, states mandate the reporting of injuries from a deadly weapon (B)—stab or gunshot wounds.

Most, but not all, states require reporting of animal bites (D), particularly dog and cat bites

Spring 2015

Review Answers

The Fast Track

One Step Further: Is child abuse a reportable event?

Yes, all states require the reporting of suspected or confirmed child abuse or neglect.

2)ANSWER: D. Explanation: The Emergency Medical Treatment and Active Labor Act (EMTALA), a section of the Consolidated Omnibus Labor Act of 1985 (COBRA), also known as the “anti-dumping” statute, governs how emergency physicians must triage, register, examine, provide workup, treat or stabilize, discharge or transfer, utilize hospital resources, and involve medical staff expertise when caring for patients presenting to the ED. EMTALA specifies that any person who comes to an ED requesting examination or treatment must be provided with an appropriate medical screening examination (MSE). If the MSE does not reveal an emergency medical condition, further care of that patient is not controlled by EMTALA, so the law’s provisions governing stabilizing treatment, transfer of the patient, or involvement of on-call physicians no longer apply (A). EMTALA does not require interpreters (B) for patients. EMTALA does not stipulate the competency (C) of ED physicians.

One Step Further: Does EMTALA apply to patients with private insurance? Yes, it applies to all patients, regardless of the type of insurance.

3) ANSWER: C. There are 2 essential components to all drainage systems: a one-way valve to allow air or fluid to drain out of the pleural space without allowing air back into the cavity, and a suction mechanism to increase the rate of drainage. This is accomplished with a 2-chamber system. When the tube is functioning properly, the height of the fluid level in the drainage tube fluctuates with the respiratory cycle. An absence of respiratory fluctuation or a decrease in drainage implies that the system is blocked or the lung is fully expanded. Thoracostomy tubes draining fluid are prone to blockage.

Current commercial drainage systems additionally contain air leak chambers. Bubbling in this 3rd chamber indicates presence of an air leak (A), signaling either that air is leaking into the drainage system itself (usually from a loose tube connection) or the presence of persistent air inside the pleural space. The expected finding (D) is for the height of the fluid level in the drainage tube to fluctuate with the respiratory cycle. There should be respiratory fluctuation of the drainage tube if the lung is still not fully re-expanded (B).

One Step Further: What complication is possible from clamping a chest tube? If an intrathroacic air leak is present, a tension pneumothorax can develop.

4) ANSWER: D. The main goals of ED thoracotomy are to relieve cardiac tamponade, support cardiac function with open massage, aortic cross-clamping, internal cardiac defibrillation, or to control cardiac, pulmonary, or great vessel hemorrhage. Although it is tempting to perform an ED thoracotomy on all traumatic arrest patients presenting to the ED, there are clear indications for ED thoracotomy.

Patient (A) has a serious injury and likely sustained significant blood loss. Given that she has a return of spontaneous circulation and a normal blood pressure, she is not a candidate for an ED thoracotomy. Patient (B) requires emergent intervention and likely a chest tube, but he is not a candidate for an ED thoracotomy because he has a blood pressure of 70 mm Hg systolic. Patient (C) sustained a blunt trauma and had a loss of vital signs en route to the ED. Some clinicians may elect to perform an ED thoracotomy on this patient if the transport time is minimal from the time that the patient lost vital signs. However, the loss of vital signs in the setting of blunt trauma has a very poor prognosis, and it is very rare that these patients survive.

One Step Further: Which nerve is at risk of being severed during an ED thoracotomy?

Phrenic nerve.

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References videolaryngoscopy compared to direct laryngoscopy.

Human Trafficking 1.O’Callaghan MG. The health care professional as a modern abolitionist. The Permanente journal.

2012;16(2):67-9. PubMed PMID: 22745622; PubMed Central PMCID: PMC3383168.

2.Chisolm-Straker M, Richardson LD, Cossio T. Combating slavery in the 21st century: the role of emergency medicine. Journal of health care for the poor and underserved. 2012;23(3):980-7. doi: 10.1353/ hpu.2012.0091. PubMed PMID: 24212151.

3.United Nations. Available from: http://www.ohchr.org/ EN/Pages/WelcomePage.aspx.

4.Baldwin SB, Eisenman DP, Sayles JN, Ryan G, Chuang KS. Identification of human trafficking victims in health care settings. Health and human rights. 2011;13(1):E3649. PubMed PMID: 22772961.

5.Spear DL. Human trafficking. A health care perspective.

AWHONN lifelines / Association of Women’s Health, Obstetric and Neonatal Nurses. 2004;8(4):314-21.

PubMed PMID: 15484995.

6.Polaris Project [11-24-14]. Available from: http:// www.polarisproject.org/human-trafficking/overview.

7.Grace AM, Lippert S, Collins K, Pineda N, Tolani A, Walker R, Jeong M, Trounce MB, Graham-Lamberts C, Bersamin M, Martinez J, Dotzler J, Vanek J, Storfer-Isser A, Chamberlain LJ, Horwitz SM. Educating Health Care Professionals on Human Trafficking. Pediatric emergency care. 2014. doi: 10.1097/PEC.0000000000000287.

PubMed PMID: 25407038.

8.Siva N. Stopping traffic. Lancet. 2010;376(9758):20578. doi: 10.1016/S0140-6736(10)62283-0. PubMed PMID: 21187276.

9.Barrows J, Finger R. Human trafficking and the healthcare professional. Southern medical journal.

2008;101(5):521-4. doi: 10.1097/SMJ.0b013e31816c017d.

PubMed PMID: 18414161.

Master of the Airway 1. Carley, S. JC: Did Video kill the Laryngoscope star?

Here comes the evidence. St.Emlyn’s website. July 6, 2013. Accessed February 25, 2015.

2. Deverill, J. DL Terminated. LITFL website. http:// lifeinthefastlane.com/dl-terminated/ February 24, 2015.

Accessed February 24, 2015.

3. De Jong A, Molinari N, Conseil M, Coisel Y, Pouzeratte Y, Belafia F, Jung B, Chanques G, Jaber S. Video laryngoscopy versus direct laryngoscopy for orotracheal intubation in the intensive care unit: a systematic review and meta-analysis.Intensive Care Med. 2014 May;40(5):629-39. doi: 10.1007/s00134-014-3236-5.

Epub 2014 Feb 21.

4. Mosier JM, Stolz U, Chiu S, Sakles JC. Difficult airway management in the emergency department: GlideScope

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J Emerg Med. 2012 Jun;42(6):629-34. doi: 10.1016/j. jemermed.2011.06.007. Epub 2011 Sep 10.

5. Podcast 94 – Has Video Laryngoscopy Killed the Direct Laryngoscope? EmCrit website. http://emcrit. org/podcasts/has-video-laryngoscopy-killed-the-dlstar/ March3, 2013. Accessed February 24, 2015.

6. Sakles JC, Mosier J, Patanwala AE, Dicken J. Learning curves for direct laryngoscopy and GlideScope® video laryngoscopy in an emergency medicine residency.

West J Emerg Med. 2014 Nov;15(7):930-7. doi: 10.5811/ westjem.2014.9.23691. Epub 2014 Oct 29.

7. Sakles JC, Patanwala AE, Mosier JM, Dicken JM. Comparison of video laryngoscopy to direct laryngoscopy for intubation of patients with difficult airway characteristics in the emergency department.

Intern Emerg Med. 2014. Feb;9(1):93-8. doi: 10.1007/ s11739-013-0995-x. Epub 2013 Sep 4.

Healthcare Comparison 1. Davis, Stremekis, Squires, Shoen: Mirror Mirror On The Wall: How the U.S. Healthcare System Compares Internationally. The Commonwealth Fund, New York, 2014.

2. Health: United States, 2013, With special feature on prescription drugs. National Center for Health Statistics Hyattsville MD, 2014.

3. MacDorman, Mathews: The challenge of infant mortality: have we reached a plateau? Public Health Rep, 124 (5): 670– 680, 2009.

4. Gortmaker, Wise: The first injustice: socioeconomic disparities, health services technology, and infant mortality.

Annu Rev Sociol 23: 147–170, 1997.

5. World Population Prospects: 2011 revision. United Nations, Department of Economic and Social Affairs Population Division, New York 2012.

6. CIA – The World Factbook: Infant Mortality Rate.

Archived from the original on December 18, 2012.

Retrieved Feb 12, 2015.

7. Wilkinson, Marmot. Social determinants of Health: The Solid Facts. World Health Organization, Copenhagen Denmark 2003.

8. Health: United States, 2007, With chartbook on trends in the health of americans. National Center for Health Statistics, Hyatsville MD, 2008.

9. Braveman, Egerter: Overcoming obstacles to health: Report from the Robert Wood Johnson foundation to the commission to build a healthier america. Robert Wood Johnson foundtion, Princeton NJ, 2008.

10. Chen, Oster, Williams. Why is Infant Mortality higher in the U.S. Than Europe? Working paper, National Bureau of Economic Research, Cambridge MA, 2014

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Parma, Ohio EM Physician Opportunities

Full and part time positions available for excellent board certified, residency trained emergency medicine physicians at UH Parma Medical Center.

Parma is one of northeast Ohio's top three living destinations for young professionals, and we recently recognized by Businessweek Magazine as one of the best places in Ohio to raise children.

About the ED: Annual Volume of 41,000 36 Hours of Physician Coverage 36 Hours of Independent Midlevel Coverage 39 Bed Emergency Department Stroke & Chest Pain Center Pursuing Level III Trauma Center Status Located 11 miles from Downtown Cleveland Our competitive package includes: Signing Bonus; 401k w. Match; Malpractice w. Tail; Paid Life Insurance; Long & Short Disability; HSA Contribution; Family Health, Dental, Vision Plan To learn more about this opportunity, or others within our organization, please contact Erin Waggoner at ewaggoner@4Mdocs.com Reach us by phone at (888) 758-3999 or visit us online at www.4MDOCS.com.

reimbursement of medical education, how many hospitals will continue to maintain four year programs?

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The Fast Track

The Graduate Medical Education Committee of ACOEP is a very hard working and well organized group. They seriously evaluate our training standards and are always seeking to make recommendations that will strengthen our programs. I believe they have done outstanding work, and I commend them for their diligence.

Times are changing and Osteopathic programs will be challenged to prove why we should continue to exist.

I personally believe now is the time to begin serious discussion and planning for a three year “Osteopathic focused” emergency medicine residency. We certainly need to maintain our Osteopathic roots to prove that, in a true sense, our training programs are distinct and different.

If we cannot maintain our unique identity, what is our purpose? I strongly believe we need to promote osteopathic principles not only in our academic sessions but also in the day-to-day clinical environment. Is this difficult to do in the setting of an emergency department? Yes it is, but not impossible.

The Single Accreditation Pathway is here to stay, and it is the road we, as a profession, have decided to travel. We must ensure that even though we are traveling in the same direction, Osteopathic training programs are not traveling on an accessory road but are on the main route. It is my opinion that the extra year may ultimately be a burden to our programs.

I look forward to all our Osteopathic emergency medicine programs continuing to excel in training young physicians in the art of our specialty. What we have accomplished with our past training has had enormous beneficial effects on today’s healthcare. We will continue to provide excellent training for our residents, and we can provide this in a three year program. I sense that with this change in our program training length, we will not have future applicants vanish from the list of potential candidates for our Osteopathic programs.

These are my thoughts, my reflections, and my musings. One may say that I am looking through a glass that is “half-empty.” I would prefer to think that I am visualizing the present scenario through a glass that is “half-full” with the hope to soon be realizing I am looking through a glass that is “completely full.”

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Fringe benefits.

As an EM physician, you work hard.

We get it. We’re emergency medicine physicians just like you. We know that you need downtime to relax, spend time with family and friends, and pursue your passions outside the ED. And because EMP is 100% owned and managed by emergency medicine physicians, we have the power to create the lives and careers we want.

Our excellent benefits include more than signing bonuses, they include priceless fringe benefits. Create the life you’ve always dreamed of – join EMP.

Catch more benefits at emp.com/benefits or call Ann Benson at 800-828-0898. abenson@emp.com

ACOEP Resident and Student Chapter 142 East Ontario Street Suite 1500 Chicago, Illinois 60611 Phone: 312.587.3709 Fax: 312.587.9951 E-mail: fasttrack@acoep.org

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Opportunities from New York to Hawaii.

AZ, CA, CT, HI, IL, MI, NH, NV, NY, NC, OH, OK, PA, RI, WV

Follow us on

@ ACOEPSC @ ACOEPRC @ facebook.com/acoepsc @ facebook.com/acoeprc 3/10/15 10:58 PM