The Pulse April 2008 by ACOEP

The PULSE

Osteopathic Emergency Medicine Quarterly VOLUME XXXIII NO. 2

April 2008

“Who is Paying for American Health Care?” Presidential Viewpoints Peter A. Bell, D.O., FACOEP In my Winter ’08 comments, I emphasized the need for all of our members to engage in the process of health policy formulation. We hold one of the few degrees most respected by the public and have the earning power that wields influence within our society. As emergency physicians, we are the safety net of American health care. We are obligated to speak on behalf of our patients, and our profession. Our objective must be a friendlier, faster, and more cost effective delivery of comprehensive, universal, health care. While we best know the emergent nature of health care, we must take the higher ground in our opinions. Demonstrating an understanding of each stakeholders’ viewpoint and thinking holistically, we place ourselves in a position of leadership. I regularly review health policy reports, survey results, and governmental statistics. While I am cautious when relying on any one report or statistic as absolute fact, there is much to be learned from the trends. It is reported that our percentage of Gross Domestic Product (GDP) spent on health care has doubled from 1970 to 2000 (7.2% to 14.5%). This translates into $75 billion or $356 per person in 1970, to $1.4 trillion or $4,950 per person in 2000. In addition, economists have long argued that our economy cannot tolerate greater than 15% of the GDP spent on health care, and yet

we now stand greater than 16%! In 2007, the growth in the U.S. population coupled with increased spending exceeded $2.2 trillion in health care dollars (approximately $7500 per person). The economists have also predicted that based on the trends of the past 37 years, we can expect our health care spending to exceed 20% of the GDP by 2017. Unfortunately, the predicated trends of the past twenty years have correlated very closely with the measured trends. It appears that the economists have found a reliable forecasting model. http://www.census.gov/prod/2007pubs/ 08abstract/pop.pdf http://www.kff.org/ insurance/upload/7692.pdf Where do our health care dollars come from? Public programs make up about 45% of all health care dollars while private health insurance is approximately 35%. The remaining 20% comes from a variety of sources such as charities, self-pay, trusts etc. Here is where the double jeopardy argument is made. The public programs are fueled by our tax dollars. In 2006, the Internal Revenue Service collected $2.2 Trillion in taxes net of refunds. Approximately 45% came from taxation on individuals ($990 Billion). That same year, approximately 5% of U.S. households reported making greater than $154K. (What was your reported household income in 2006?) This 5% of tax payers represented approximately 60% of the total individual tax collection ($594 Billion). Reality? As a highly compensated professionals, we are paying for our own health insurance coverage and the lion share of the public supported health insurance programs. http://en.wikipedia.org/wiki/

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Internal_Revenue_Service. It behooves all of us to get involved! So how are our health care dollars being spent? Again reports vary, but for point of discussion, I will simplify the numbers. About 1% of the U.S. population consumes 20%, 5% consumes 50%, and 20% consumes 80%. Between 27-30% of all Medicare dollars are spent in the last year of life. While only God knows when life will end, we as health care practitioners have the skill sets and experience to reasonably predict the end. Instead of spending resources on futile care, a viable solution may be Hospice. (This has been shown to produce savings of 25-40%.) http://64.85.16.230/ educate/content/elements/expendituresforeolcare.html Another solution is greater emphasis on preventative health care and health maintenance. This is not only consistent with Osteopathic philosophy, but in alignment with AOA President Ajluni’s theme of ‘Fit for Life’. Multiple studies have demonstrated substantial cost savings, an increase in the quality of life, and a decrease in episodic care with the application of preventative medicine. http://www. pmri.org/?p=nwr Any approach to reshaping our health care system, must consider current trends, new ideas, and physician expertise. Similar to the economists who have predicated our health care expenditures, we must predict patient outcomes using the best evidence based medicine and gestalt. We can not afford to pay for all things for all people when a negative outcome is most likely. This concept alone will require a change continued on page 4

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Editorial Drew Koch, D.O., FACOEP, Editor

The Art of Communication The Encarta Dictionary defines communication as: 1. The exchange of information between people by speaking, writing or using a common system of signs or behavior; 2. A spoken or written message; 3. Act of communicating the communicating of information; 4. Rapport a sense of mutual understanding and sympathy; and 5. Access a means of access and communication. We are constantly communicating with patients and patients’ families and friends, nurses, secretaries, technicians, prehospital personnel, primary care providers, midlevel providers, emergency medicine colleagues, members of the medical staff, the hospital administration and anyone else who is involved in patient care or directing the emergency department. This initial communication is accomplished by many means including: direct, verbal communication e.g. patient history is obtained either from the patient, family, friends, prehospital providers, nurses and/or care takers; indirectly by written records e.g. transfer sheets from nursing homes, old records, and trip sheets from the prehospital personnel; and/or from phone conversations with the primary care providers, other physicians who are involved in the patient’s

care, the visiting nurse who evaluated the patient initially or the hospice worker or home aide who referred the patient to the emergency department. Even though all this information is available to us when we (the emergency medicine physician or midlevel provider) evaluate the patient, many times we do not have a “clue” to why the patient is in the emergency department. Many times the information is incomplete or conflicting especially with patients who are unable to provide an adequate history i.e. patients who are confused, who present with mental status changes, dementia, psychotic patients, intoxicated patients, pediatric patients and those who are in extremis. Conversely, the majority of patients and patient’s families are able to communicate a succinct reason for the emergency department visit. After evaluating the patient and either treating and releasing the patient or working the patient up is where the communication between the physician and patient becomes an integral part of the evaluation. After the history and physical is obtained, I discuss my findings with the patient and the patient’s family and either discharge the patient or continue the work up to attempt to find out what is wrong with the patient. On both occasions I explain what I found and what I am going to do and why I am doing this test or treatment and ask if there are any questions. I advise the patient how long it will take to

obtain the results and that I will return after the additional testing and /or treatment is obtained and will review the results with the patient and then make a disposition. Obviously, this scenario is not how I work up every patient because on occasion the laboratory and diagnostic studies are available when I evaluate the patient and on extremely busy days I do not have the luxury of spending as much time with a patient as I would prefer. After going through the above scenario with the patient and making a disposition after discussing the results of their studies, and on many occasions giving them copies of their studies, and answering all the patient’s and their families questions, I am invariably reminded by the nurses that the patient and their family wants to know what is going on. At this point, I am frustrated because I felt I spent time with the patient and explained what I found or did not find and what the plan was whether it was discharge or admission. I then question myself and ask if I am an effective communicator? Even though I spend the majority of my day communicating with others either in person, by phone or email maybe I am not able to express myself succinctly. If I am the cause of poor communication then I need to spend more time with the patient and the family and to find a better way is assess if the patient really comprehended what was told them.

Table of Contents Presidential Viewpoints, Peter A. Bell, D.O., FACOEP . . 1

Medical Update Update . . . . . . . . . . . . . . . . . . . . . . . . 11

Editorial, Drew Koch, D.O., FACOEP . . . . . . . . . . . . . . 3

From the Pediatric Files – PANDAS . . . . . . . . . . . . . . . 15

Executive Director’s Desk . . . . . . . . . . . . . . . . . . . . . . . . 5

Guest Column, Wayne Jones, D.O., FACOEP . . . . . . . . 17

AOBEM Important Dates . . . . . . . . . . . . . . . . . . . . . . . 6

Working Toward Wellness – Sleeping Habits . . . . . . . . . 19

ACOEP Member Database. . . . . . . . . . . . . . . . . . . . . . . 7

Emergency Department Ethics . . . . . . . . . . . . . . . . . . . 21

Governmental Affairs . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

CME Calendar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

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The Pulse – An Osteopathic Emergency Medicine Quarterly 142 E. Ontario St., Suite 1250 Chicago, IL 60611 312-587-3709 / 800-521-3709 Editorial Staff Drew A. Koch, D.O., FACOEP, Editor Wayne Jones, D.O., FACOEP, Asst. Editor Peter A. Bell, D.O., FACOEP Gary Bonfante, D.O., FACOEP Duane Siberski, D.O., FACOEP Janice Wachtler, Executive Director Communications Subcommittee Drew A. Koch, D.O., FACOEP, Chair Wayne Jones, D.O., FACOEP, Vice Chair Gary Bonfante, D.O., FACOEP, Advisor James Bonner, D.O., FACOEP, Advertising Bobby Johnson, Jr., D.O., FACOEP William Kokx, D.O., FACOEP Annette Mann, D.O., FACOEP The PULSE is a copyrighted quarterly publication distributed at no cost by the ACOEP to its Members, libraries of Colleges of Osteopathic Emergency, sponsors, and liaison agencies by the National Office of ACOEP. The Pulse and ACOEP accept no responsibility for statements made by contributors or advertisers. Display and classified advertising are accepted. Display advertisements should be submitted as camera-ready, pdf, or jpg formats in black and white art only. Classified advertising must be submitted as typed copy, specifying the size, and number of issues in which the copy should be displayed. The name, address, telephone numbers and email address of the submitting party must accompany advertising copy. Advertisers will be billed for ads prior to the publication of their advertisements and payments will be due within 30 days of the issuance of the invoice. The deadline for submission of articles and advertising is the first day of the month preceding publication, i.e., December 1, March 1, June 1, and September 1. ACOEP and its Editorial Board reserve the right to decline advertising and articles for any issue.

Presidential Viewpoints, continued from page 1 in culture and laws to protect both the patient from a system that could seek to inappropriately curtail costs, and a plaintiff seeking compensation for an inaccurate prognosis. So how do you get involved in the dialogue? The easiest approach is signing up for a program like GOAL that alerts you to important federal legislation. GOAL allows you to sign on to letters and notifies your federal legislators of your concerns. Most of this takes only a few minutes and can be done electronically. http://www.capwiz. com/aoa-aoia/home Getting to know your congressperson and senator is a great idea. Most of them have local offices, and make regular appointments (when in town) with their constitu-

Editorial, continued from page 3 Invariably the patient is frustrated by lack of a specific diagnosis and wants to know what is wrong with them. I explain to the patient that the emergency department is not the place to find out what caused their symptoms but to determine if there is a life threatening emergency, if the symptoms warrant admission to further evaluate the etiology or if the patient can be discharged to home to follow up with their primary care physician and continue an outpatient work up. I realize that is not what the patient wants to hear and that the patient wants immediate gratification and does not understand the emergency department’s role. Many times the patient has been seen by their primary care physician for the same compliant or was referred to the emergency department by their

ents. In fact, you are more likely to get time and exposure if you setup an appointment at the local office. Finally, twice a year the AOA sponsors DO Day on the Hill in Washington DC. This one day event starts with a morning briefing on a few key issues, followed by group visits to your legislators. The next DO Day on the Hill is Thursday April 24th. I will be there with many of our ACOEP Board members and encourage you to join us. It is a great way to get involved, and is a great opportunity to network with your fellow physicians. https://www. do-online.org/index.cfm?PageID=adv_mai n&au=D&SubPageID=doday

primary care provider or specialist for an evaluation and work up. The patient is under the impression that by coming to the emergency department and getting a work up that we are going to determine the etiology of their symptoms. As emergency physicians part of our job is to communicate and educate not only the patients but also the medical community and the community at large to what is the function of the emergency department. Also, we need to re-evaluate the way we communicate and make sure that the patient really understands what we said to them. Just because we spent time with them does not mean that they understood what was communicated.

The PULSE and ACOEP do not assume any responsibility for consequences or response to an advertisement. All articles and artwork remain the property of the PULSE and will not be returned. Subscriptions to The PULSE are available to non-ACOEP members or other organizations at a rate of $50 per year. © ACOEP 2007 - All Rights Reserved. Articles may not be reproduced without the expressed written approval of the ACOEP and the author.

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Executive Directors Desk Janice Wachtler

Post 9-1-1

Are we treating patients correctly? Much like the scenes from the bombing of Pearl Harbor in 1940 were burned into the memories of members of the Greatest Generation, so too are the scenes that flashed across television and computer screens on September 11, 2001 for this generation of Americans. We saw on that day and the days that followed the devastation and destruction that rescue workers, EMS, Firefighters and civilians faced as they tried in vain to rescue people trapped in the twin towers. Likewise we saw scenes of workers and visitors alike running to escape the plumes of dust and debris that showered the blocks around the scene as the towers fell. We suffered through agonizing weeks of pictures as people searched for loved ones, and then we stopped and much of the Nation’s populace got on with their lives. New Yorkers had to live with this for many more months and this is where my article begins. On that day, much like any other day, workers flooded downtown Manhattan, just as they do in any major metropolitan area, and much like these Mecca’s of business throughout the U.S. and the world, many of these workers live within miles of their offices. Where better to participate in a city’s culture? But as these people in New York returned to those apartments, condos and homes in or near downtown, they were faced with other realities. Many couldn’t stay in their homes because the dust and debris penetrated heating and air conditioning units, some debris entered through open windows left open to enjoy the September breezes and sweet smells of autumn. Many were allowed to return only briefly to retrieve pets, prescriptions and belongings

so that cleaning personnel could clean up the debris that now filled their homes. This was the same for visitors in hotels near the site; they too, were affected by the caustic dust and debris. And what of those rescue workers? What about the EMT’s and firefighters who were slogging through the debris to find that one survivor or the bodies of the fallen comrades? What about the physicians and nurses who were there treating the injured? Everyone was exposed in varying degrees to this dust. As people removed themselves from the central area of Manhattan, and went on to live and potentially work in other cities and states, and as tourists returned to their hometowns, they all left with microscopic pieces of dust lodged in their lungs. Studies have found that dust around the World Trade Centers location was a mix of chemicals pulverized into microscopic dust particles. Included in the mix were pulverized bits of “plaster, paint, foam, glass fibers and fragments, fiberglass, cement, vermiculite (used as a fire retardant), chrysotile, asbestos, polycyclic aromatic hydrocarbons (PAHs), polychlorinated dibenzodioxins, polychlorinated dibenxofulrans, barium silicon, arsenic cotton fibers and lint, tarry and charred wood, rubber, paper and plastic1.” Additionally the plume of dust that blew over the site included “benzine, chromium, beryllium, phosphorus, nickel, carbon monoxide, silver, selenium, cadmium, vanadium, thallium, osmium, zinc, mercury, sulfuric acid, and lead.2” Now, more than six years after that event, people are developing health problems from their exposure, and they are presenting in hometowns across America, not only in New York City. The question is are we prepared to deal with these exposures? Would you suspect a 40-year-old person presenting in Oklahoma City with severe anemia and high lead levels as having been exposed to the dust in New

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York or even, suspect that an office worker in Chicago as having mesothelioma if he or she presented in your emergency room? Would you question someone to find out if he or she were in or near the World Trade Centers on that particular day? My questions are these: Should we put exposure questions, specific to 9-11 on forms completed by patients presenting to emergency departments throughout the U.S.? Should you, as emergency physicians, ask patients presenting with unexpected symptoms caused by exposure to this wide range of chemicals if they were in New York at this time? And, would these questions be of any use to you in diagnosis? In our mobile society today people no longer can be expected to stay in one area their entire lifetime. To expect physicians in New York or New Jersey to only encounter diseases related to inhalation of carcinogenic material from the World Trade Center fallout is narrow minded. People of all ages were affected on that day; they will move throughout the strata of society over the next years, some may retire, some may start families, will this exposure cause illnesses down the line, we may never know completely, but it would behoove us as medical practitioners to include this scenario in potential examinations, especially if they are unsuspected and out of character. 1 The 9/11 Cover-Up, Discover Magazine, October 2007 2 Ibid

The old days will never be again, even as a man will never again be a child. — Dakota Indian Proverb

Important Dates for Board Certification / Recertification The AOBEM has supplied us with these dates in 2008 for anyone involved in the certification / recertification process during the calendar year of 2008. Please mark your calendars. January 1

COLA 5 available

February 1

Application deadline for Formal Re-Certification Exam (FRCE)

February 4

CAQ Emergency Medical Services Examination

March 1

Submission of Part III (clinical) examination in emergency medicine

March 26

Part I Examination â&#x20AC;&#x201C; Computerized Exam

June 1

Application deadline for Part II (oral) examination in emergency medicine

June 9 & 10

Formal Re-Certification Exam (FRCE) â&#x20AC;&#x201C; Philadelphia, PA

September 1

Application deadline for entry into the certification process of emergency medicine

September 14 -15

Part II Oral Examinations in Emergency Medicine, Philadelphia, Pennsylvania

November 1

Application deadline for CAQ Medical Toxicology

November 9 & 10

Part II Oral Examinations in Emergency Medicine, Chicago, Illinois

December 1

Submission of Part III (clinical) examination in emergency medicine

December 31

COLA 3 expires

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Member Update Amanda J. Lundeen Membership Coordinator

ACOEP Member Database —Live! On January 17th, the ACOEP web-based database was “officially” in business on the ACOEP website (www.acoep.org). At this time, it is temporarily housed in the “What’s New” section on the home page to allow members easy access to entering and updating their member information. The new database will provide

members with the opportunity to login and update their demographic and training information. A series of new functionalities will be added throughout the next few months with a completion date for full functionality by the end of May 2008. After the functionalities are implemented, you will then have the ability to

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pay your membership dues on-line, register for an ACOEP event and make donations to FOEM, Resident and Student Chapters. It is important that you visit the ACOEP website before the end of May and create a username and password for the database. After you have created this, you will have the opportunity to update your demographic information and most importantly, include an email address. This will facilitate email messages to arrive in you home or work electronic mailbox announcing events and important information from the ACOEP. When you visit the website you will notice that the home page has been redesigned to make it a more user-friendly navigational site. Added to the site have been pull-down tabs for each headline subject at the top of the page as well as two newly added sections, Governmental Affairs and Career Center. We are very excited to have these changes and the database available to our members and encourage all of you to visit regularly. If you have any questions about the new items and the database, please contact me at 1-800-521-3709 or at mandylundeen@acoep.org and I will be happy to help.

I remind myself every morning: Nothing I say this day will teach me anything. So, if I'm going to learn, I must do it by listening. — Larry King

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Governmental Affairs Raul J. Garcia-Rodriguez, D.O., FACOEP Chairman Greetings from the beautiful Pacific Northwest. Our College keeps growing and we have more involvement from emergency physicians in our profession than ever before. The changes in Healthcare are imminent and the time is perfect for all of us emergency physicians to get involved and help guide its future. As we get ready to say good-bye to winter and look forward to our convention in Scottsdale in March, issues in our nation’s capital keep heating up and will continue through the election cycle. Agenda for the 110th Congress The Bureau on Federal Health Programs has specified issues that our profession will concentrate in during the 110th Congress. These are: 1. Reform and enhance physician payment policies 2. Ensure appropriate funding for Osteopathic Graduate Medical Education 3. Enhance the quality of the Health Care Delivery System and improve patient safety. 4. Reform the Medical Liability System. 5. Promote and protect physician’s ability to care for patients. 6. Increase access to and coverage of health care services. 7. Reduce the administrative and regulatory burden placed on physicians. 8. Improve the Health to the public 9. Promote the advancement of technology in the Health Care System 10. Monitor efforts aimed at Comprehensive Health System Reform 11. Improve financing of Osteopathic Medical Education for Osteopathic Medical Students

12. Ensure the inclusion of Osteopathic Medicine in all Health Care Delivery System and Medical Policy-Making Bodies 13. Ensure the inclusion of Osteopathic Medicine in the future physician workforce 14. Seek funding for Osteopathic Research From the Government Affairs Corner In our opinion…

expressed or shown an interest in being a little less restrictive on this issue if elected President. The Balance Budget Act of 1997 restricts the ability for our profession to fulfill the overwhelming need for new residency slots in some parts of our country. The profession will work very diligently to eliminate this restriction and others that impede the advancement of our cause. Dr. DeMarco, the AOA’s President Elect has expressed that he will dedicate his year to postgraduate education.

Hot topics Medical Liability Reform Medicare Physician Payments At some point, someone is going to come up with a reform of the Medicare physician payment formula, specifically, the repeal of the sustainable growth rate formula. Unfortunately, it has not happened yet. This is still one of our profession’s priorities. Every year, we run before the year is over to stop the next cut of our payments. This year, however, the cut is only postponed until June and not December as in previous years. Physicians are the only Medicare providers that are subjected to the flawed SGR formula. We must continue to stop any further cuts and replace the SGR formula with one that lets Medicare beneficiaries access to physician services. Again, this change carries a high price tag along with it (Billions). It is, however, something that must be done and both parties are aware and agree to some extend. We will work hard to ensure that physician quality-reporting, pay for performance, and utilization review programs for Medicare payments are fair for our physicians. Graduate Medical Education Graduate Medical Education will certainly become a hot issue shortly. Luckily for all of us in either side of the isle, all of the front-runners for the White House have

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After trying to pass Medical Liability Reform for so many years, this will take a back seat. Most of the Democratic leaders strongly oppose reforms set forth on previous years and highly supported by the AOA and ACOEP such as capitation on non-economic damages. If there is any bill introduced on this issue it will be to reform medical liability through reviewing and changing current laws involving medical liability insurance companies but not touching upon any restrictions on lawyers or law suits vs. physicians. This will definitely not sit well with the republicans in Congress that stand for free enterprise and will not want to place restrictions in insurance agencies. Washington Update Senate Bill 2499 This bill passed just before the end of the year and encompassed a few issues pertinent to us: 1. Physician Payment - Prevented the scheduled 10.1% cut in Medicare physician reimbursements. Now there is a 0.5% increase through June 30, 2008. Warning about this…As of July 1st, we are scheduled to take the 10.1% cut. Let’s be proactive about attacking this issue early this spring. 2. State Children’s Health Insurance Program- Extends funding through March 31, 2009. Warning about this… This falls

short of what we tried to accomplish but we will continue to work on this. Health Information Technology HR 2406 HR 3800 Both bills explore integrating information technology into the Health Care system. We will be monitoring to make sure that our patient’s privacy and physician’s abilities are not hindered. National Health Service Corp HR 2915 This bill would reauthorized the NHSC scholarship and loan forgiveness program previously expired in 2006 and increase the budget of these programs by double the previous amount to $300 million per year. Trauma Care The Senate had appropriated $3 million for trauma systems development through the Labor HHS Education bill. The money was dropped from the bill to ensure other budget constraints. We will continue to support new funding in this area.

Emergency Medical Services for Children The President’s budget FY 2008 calls for a $19.8 million reduction. The Wakefield Act (HR 2464/ S 60) is being introduced to reauthorize those monies. We will continue to monitor and support. Indian Health Services HR 1328/ S 1200 While supportive of Indian Health, some of the language in these bills concedes that health care professionals be exempt from the licensing requirements of the State in which the Tribal Health Program performs services as long as they are licensed in any State. This is permissible for physicians because our licensing requirements are the same in every state but not the case for non-physicians. For more up to date issues, please visit our Web Site. OTHER ANNOUNCEMENTS Scottsdale in March For the first time in years, your Government

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Affairs committee is sponsoring a luncheon on the Wednesday of the convention. Mark your calendars! We have great guest speakers that will certainly help each of us get an up to date perspective on our future and on the future of Healthcare. It is also a great opportunity to get acquainted with the members of your Government Affairs Committee and express your feelings in what we should be doing for you. DO Day on the Hill in April (Washington, D.C.) Thursday, April 24th Come see the Cherry Blossom in DC. See a few of your DO friends from all over the country that you have not seen. Go to the Capitol Hill Brewery for lunch…but most importantly, COME REPRESENT YOUR COLLEGE AND YOUR PROFESSION. Meet your Senator and your Congressman and tell them exactly how you want the future of medicine to go. For all those of you that have never been there, it’s a great fun and fulfilling day.

Medical Update Steven J. Pariillo, D.O. FACOEP

Kawasaki Disease Although not much has changed in the past decade regarding Kawasaki disease, the recent emphasis on incomplete cases warrants an update on this serious pediatric illness. As you know, Kawasaki disease (KD) is a febrile illness of childhood manifesting as a self-limited acute vasculitic syndrome of unknown etiology. Several years after the original 1967 description, fatalities occurred in Japan among children younger than 2 years. The fatalities occurred when patients were improving or had recovered. Postmortem examinations revealed complete thrombotic occlusion of coronary artery aneurysms with a myocardial infarction (MI) as the immediate cause of death. It soon became evident that, when studied by echocardiography (ECHO), 20-25% of untreated children developed cardiovascular sequelae ranging from asymptomatic coronary artery ecstasies or aneurysm formation to giant coronary artery aneurysms with thrombosis, MI, and sudden death. Even today, 15-25% of untreated patients develop coronary artery aneurysms. (The increase from older quotes of 5% is largely based on revised echocardiographic criteria for aneurismal dilatation). The syndrome has now surpassed rheumatic fever as the leading cause of pediatric acquired heart disease in the United States. The etiology is unknown, although many suspect an infectious etiology. Many now believe that there are many factors that are capable of triggering a final common pathway that results in immune activation. Epidemics occur primarily in the late winter and spring with 3-year intervals. KD is most commonly observed in children from the middle and upper-middle classes. The estimated number of children hospitalized annually in the United States is about 3000, though there were more than 4000 admissions in 2006, some of which were incomplete cases.

Coronary artery aneurysms present the only significant long-term problem. Even acute MI has been reported secondary to true coronary artery obstruction. Subsets of patients in whom the risk of aneurysm is increased include those who have fever for more than 2 weeks, who have recurrence of fever after an afebrile period of at least 48 hours, are males, and/ or who have cardiomegaly. The biggest single risk factor is age younger than 1 year. Laboratory values that may help predict a greater likelihood of aneurysm development include hematocrit <35%, thrombocytopenia (<350,000), elevated CRP, albumin < 3.5g/dL, and WBC > 12,000. Researchers are beginning to look at the possibility that patients with aneurysms may have an increased risk of premature coronary atherosclerotic disease. The disease is slightly more common in males than in females. Peak prevalence is in children aged 18-24 months. Infants aged 6 months or younger may have maternal antibody protection, but "incomplete" cases have even been reported in that age group. Most children present in the emergency department because of parental concern of a prolonged fever. Diagnosis requires fever of at least 5 days duration (though many believe that the diagnosis can be made earlier in otherwise classic presentations). Parents may note that the fever began abruptly. Antibiotic therapy may have been initiated for other diagnoses, but fever persists. The affected child is usually more irritable than would be expected by the degree of fever. The diagnosis of classic Kawasaki disease requires fever (> 39) of at least 5 days duration and the presence of four of the following: o Extremities changes (erythema, edema, desquamation). o Bulbar conjunctivitis (not associated with exudates) o Polymorphous rash (not vesicular) o Cervical lymphadenopathy (usually

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>1.5 cm and unilateral; the least common of all clinical features in US cases) o Changes in the lips and oral cavity (pharyngeal erythema, dry/fissured or swollen lips, strawberry tongue) o Other clinical features of the disease may include urethritis, orchitis, arthritis/arthralgia, abdominal pain, vomiting/diarrhea, sterile pyuria, hepatitis, and gallbladder distention. The current literature emphasis is on incomplete cases. The features are typical, just not present in the numbers required for fully manifested cases. Most authors, then, suggest using the term “incomplete” rather than “atypical” Kawasaki disease. In this setting, usually in children younger than 6 months of age, fever plus only 3 features establishes the diagnosis. Since treatment is safe and effective and since failure to diagnose may have a significant negative impact on outcome, everyone agrees that it is best to be aggressive in suspecting KD and starting treatment. Both the American Academy of Pediatrics and the AHA suggest that when fever plus 2 or 3 of the typical features are present for 5 days or more, and patient characteristics suggest possible KD, a CRP and ESR should be done. If CRP is <3mg/ dL and ESR is <40, the child is followed and actions taken as appropriate. If CRP is greater than or equal to 3mg/dL and ESR is greater than or equal to 40, additional lab studies can help solidify the diagnosis. Those labs include albumin < 3gm, anemia for age, elevated ALT, platelets > 450,000 (after 7 days), WBC > 12,000 and presence of pyuria Three or more positive supplemental lab criteria should make the diagnosis. The child should have an echocardiogram and be treated. If there are fewer than three positive supplemental lab criteria, cardiac echo should be performed. If negative but fever persists, a repeat echo may be done. If the echo is negative and the fever abates, KD is unlikely.

If the echo is positive, the child is treated for KD. Three phases occur, but only the acute phase impacts the ED. This phase lasts one to two weeks. During this phase, the temperature is elevated (>104°F), the child is irritable, conjunctivitis and rash are present, tongue and oral mucosa become red and cracked and the hands and feet develop the erythema and edema that cause the child to refuse to walk. (*Note that this finding may be the last to develop. Lack of extremity findings may cause consideration of incomplete Kawasaki disease). Cardiac complications noted in this stage include myocarditis and pericarditis. There is a small group that does not respond to therapy. Recrudescence is defined as fever beyond the 36-hour mark from completion of the 12-hour IVIG infusion. Assuming that the diagnosis is correct, most authors suggest a second dose of IVIG. No specific laboratory test exists; however, certain abnormalities coincide with various stages. A normochromic anemia is observed in the acute stage along with a moderate to alarmingly elevated WBC count with a left shift. Many of the acute phase reactant markers, such as the ESR and CRP level are elevated. An echocardiogram is the study of choice to demonstrate coronary artery aneurysms in both complete and suspected incomplete cases. A chest radiograph should be obtained to assess baseline findings and to confirm clinical suspicion of congestive heart failure. An electrocardiogram (ECG) indicates the presence of various conduction abnormalities. Additionally, children with the syndrome may suffer acute infarction. CT has been used to diagnose coronary artery abnormalities, but that is not likely to happen in the ED. A select group may require cardiac catheterization, coronary artery bypass grafting or cardiac transplantation. The medical management of Kawasaki disease primarily involves the use of gamma globulin. Some have suggested that aspirin is no longer needed, but most clinicians still use high-dose aspirin for a variable period of time, followed by lower dose aspirin for its anti-platelet effects. Some controversy exists about the ideal timing to begin gamma-globulin, but that

is not an issue that concerns emergency physicians. It is given most often from days 5-7. Despite some literature to the contrary, there is currently no indication for corticosteroids. Ibuprofen antagonizes aspirin's anti-platelet activity and should be avoided. Vaccination against influenza and Varicella must be assured because these children will be taking aspirin. In summary, Kawasaki disease is not rare. While most cases are fully manifested, the danger lies in not suspecting ACOEP/ThePulse_Location – and therefore not diagnosing and treating – incomplete cases. We need to be liberal

in our application of the criteria. When in doubt, suspect, test, consult and treat.

"A child's life is like a piece of paper on which every person leaves a mark." — Chinese Proverb 4/9/07

11:30 AM

Page 1

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From the Pediatric Case Files... Mary E. Young, D.O. Anita W. Eisenhart, D.O., FACOEP, FACEP Maricopa Integrated Health Systems Emergency Medicine Residency Pediatric Emergency Department

Post-Streptococcal Neuropsychiatric Disorder Introduction Streptococcal infections are linked to a variety of autoimmune diseases; most commonly associated is rheumatic fever. However, these infections are also the cause of a large spectrum of central nervous system pathology such as sydenham’s chorea, tourette syndrome, pediatric autoimmune neuropsychiatric disorder associated with Streptococcus (PANDAS) as well as a host of less well described emotional disorders such as depression, attention deficit hyperactivity disorder (ADHD), anxiety and oppositional disorder2. Case Presentation A nine-year-old boy presented to the pediatric emergency department (PED) describing a prohibitive fear of pain or choking therefore precluding him from swallowing solid food. According to the boy’s mother, he had refused to eat any solid foods since a recent episode of culture positive group A Streptococcal pharyngitis that began 13 days prior to this presentation. Since that time, the boy consumed liquids and soft foods, without any difficulty or pain, but refused to eat solid food secondary to a fear that it might hurt or that he might choke. The boy’s mother also described other odd behaviors that started since his sore throat, such as difficulty dressing with excessive attention to detail when buttoning his shirt. His mother continued that in order to get him off to school on time, she would have to button his shirt, as his buttoning and unbuttoning rituals were taking too long. The patient had never previously exhibited any such difficulties prior to the throat infection. The boy had no previous past medical history or any history of behavioral, psychological, or neurological abnormali-

ties. His family history included anxiety in his mother (treated with alprazolam) and low functioning autism in his younger brother. His medication was limited to the erythromycin he was prescribed for his pharyngitis (penicillin allergic). Physical Exam revealed a well nourished, well hydrated boy who was in no obvious distress. His throat exam included clear oropharynx free from erythema, swelling or exudates. His trachea was midline and he had no stridor. There was no lymphadenopathy. Observing the boy’s behavior, he did

express a seemingly irrational fear that he would choke if he attempted to swallow food. He swallowed Jell-O without any difficulty, pain or choking. When asked to eat a bite of a sandwich, the boy chewed a very small piece for several minutes, ruminating until it was nearly liquid, painstakingly picking seeds from the bread out of his mouth with his fingers. He was picking imaginary pieces from his lips in a tic-like fashion, while keeping his mouth closed. He found the smallest of particles in his water, and would refuse to drink because of the crumbs (even after his mother assured

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him they were his crumbs.) In the eyes of these emergency physicians, his behavior mirrored that of obsessive-compulsive disorder (OCD). In the PED both a complete blood count and a comprehensive metabolic screen were within normal limits. The mother was instructed to continue encouraging oral intake of both liquids and solids and to follow up in the pediatric clinic. The follow up revealed little change in behavior from previous. The mother believed the child to be doing better, however he was still not eating solid foods. He was, however, staying well nourished with breakfast supplement drinks. Further follow up two weeks later was recommended, however, he has not returned to our clinic system since. Discussion PANDAS is a disorder, described initially as OCD in immediate temporal relationship to group A-beta-hemolytic Streptococcus4. There are five criteria used to diagnose PANDAS; 1) presence of OCD and/or tics, 2) pre-pubertal onset, 3) episodic course with abrupt onset and dramatic exacerbations, 4) association with group A Streptococcal infections and 5) association with neurological abnormalities such as adventitious movements, motor hyperactivity and choreiform movement1. In addition, there appears to be a genetic component to PANDAS.

Many children with the disease also have close relatives with OCD, anxiety and other psychiatric conditions2. The most commonly accepted hypothesis regarding the cause of PANDAS is that of molecular mimicry2. There are many structural similarities between the streptococcal antigen and self-antigen. These structural similarities result in antibodies, which were initially made to attack the bacteria, but attack the brain as well. The most common site of attack is the basal ganglia4. Due to the general characteristic of PANDAS waxing and waning, it has been hypothesized that the inflammation caused by the attack causes symptoms, rather than actual irreversible degeneration2. In our case the boy met the majority of criteria for PANDAS. He is a prepubescent boy with a very clear temporal relationship between the Streptococcus pharyngitis and obsessive-compulsive symptoms, which suggests PANDAS. The boy also had a family history of psychiatric disorders. We are yet unable to solidify the diagnosis of PANDAS, however, as one of the criteria is an episodic course and the diagnosis can only be made over a period of time. PANDAS is a disease process that should be considered for any child with new onset obsessive-compulsive behaviors. While it is not recommended that every child with new onset psychiatric disease be

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screened for Streptococcus infection, a careful history and physical should be obtained in order to assess the need for throat cultures or antistreptolysin O (ASO) titers. Treatment is largely experimental. Some children respond to immunosuppressive therapies such as intravenous immunoglobin and plasma exchange. Others have been treated with selective serotonin reuptake inhibitors (SSRIâ&#x20AC;&#x2122;s) and behavior modification therapy with success. 1. Chmelik E, Awadalla N, Hadi S, et al. Varied Presentation of PANDAS: A Case Series. Clin Pediatr. 2004;43:379-382 2. Dale R. Post-streptococcal Autoimmune Disorders of the Central Nervous System Developmental Medicine and Child Neurology. 2005;47:785-791. 3. Mell L, Davis R, Owens D. Association Between Streptococcal Infection and Obsessive-Compulsive Disorder, Touretteâ&#x20AC;&#x2122;s Syndrome, and Tic Disorder. Pediatrics 2005;116:56-60 4. Pavone P, Parano E, Rizzo R, et. al. Autoimmune Neuropsychiatric Disorders Associated With Streptococcal Infection: Sydenham Chorea, PANDAS, and PANDAS Variants. Journal of Child Neurology 21;9:727-736 5. Swedo S, Leonard H and Rapoport J. The Pediatric Autoimmune Neuropsychiatric Disorders Associated With Streptococcal Infection (PANDAS) Subgroup: Separating Fact From Fiction. Pediatrics 2004;113:907911 6. Walker KG, Lawrenson J, Wilmshurst JM. Neuropsychiatric movement disorders following streptococcal infection. Developmental Medicine and Child Neurology. 2005;47:771-775

Guest Column Wayne Jones, D.O., FACOEP

Satisfaction I always thought I was an advocate for customer satisfaction. Make the customer happy, improve your “satisfaction score”, maybe improve throughput while you’re at it and everyone is happy. Nurses dance through the halls, physicians’ call daily looking for a job and administrators take you out to lunch. I even presented a lecture dealing with customer satisfaction. I think what I really was referring to was patient advocacy, assuming that it was customer satisfaction. OK, I’m wrong. Take for example the last customer who called to complain. She was bitter over the way my physician addressed her

boyfriend. She would never return if this was the way patients would be treated. “Sit down”, was my physician's initial conversation. “She was like a Nazi, like Hitler”, said my “customer”. I apologized. “I will speak with the physician and get back to you”, I replied. “Oh, I think it was because my boyfriend was going through the cabinets in the room when she came in”, replied the voice on the phone. “Why” was my innocent reply, “I think I told him to look for a pillow. I think.” Her voice trailed off. It reminds me of a line delivered by Henry Blake on an episode of MASH; there are certain rules about a war and rule number

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one is young men die. And rule number two is doctors can't change rule number one. Exchange “young men die” for “patients complain.” I have been following recent articles and letters to the editor in emergency medicine periodicals. I am hearing a lot of frustration out there. I hate to say it but I believe I am beginning to suffer a similar fate. Not only are we expected to provide an ever increasingly complex style of medicine, but now we must “serve” the customer. At a recent Grand Rounds, a colleague of mine likened modern medicine to Chinese take out. We are expected to meet their expectations, provide services that are requested and make it timely and convenient. I believe this is where we fall down. We have done it to ourselves. As a society in medicine, we fought for expanded clinical abilities, expanded imaging services, timely lab and better facilities. We became competent, respected, immortalized on TV, and yes… convenient. Convenient for people with busy lives, attendings who wish to clear their offices of troublesome patients and even the hospital. Yes, they love us. We admit more than sixty percent of all inpatients, we serve as a holding area and we trouble shoot ever changing volumes and acuity with little fanfare. When we ask for help, it is met with an almost inquisitive look. “You want what?” “But you never needed help before.” They are stumped, bewildered, and aghast. “Can you show me a study justifying this request”, they will say. They display true shock and ah. So what is our defense? I believe it is returning to our core value systems. Be honest, practice proper medicine and be an advocate for patients. Be the educator… the dad. Have perseverance and do not be discouraged. I believe we hold the power to change the system, but like any disease, we need to recognize the symptoms. It is an indolent disease process, but now that I can see it, I can begin to recover. I think I will create a tee shirt that says “I Survived Satisfaction”.

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Working Toward Wellness Anthony Jennings, D.O., FACOEP

Wellness: Sleeping Habits As Emergency physicians, most all of us work some nights. A few work dedicated nights ... and God Bless You! For most of us however, we work a mixture of days, evenings, and nights. This puts strain on our bodies as we try to maintain some semblance of a nocturnal / diurnal schedule. There are a few strategies that can be incorporated to make the transition a more acceptable one. Following a night shift, you should go home and to bed as soon as possible. I frequently find myself staying in the hospital to take care of a few things or to attend a meeting (not good). I can even recall my bad habits as a “younger indestructible physician” when I would even exercise or play golf after a night shift. I could go home and sleep without difficulty back then. Youth will carry you for a long time. As you get older things really do change. Sleep may become difficult even under the best of circumstances. Even sleep medication may not work if your habits interfere. So leave your shift and head straight to home with the idea of sleep first. The drive home should be one that sets the sleep mood. Put the sunglasses on and avoid the bright sunlight. Dracula was right on with the Ray-Bans! Bright light will serve as a stimulus to wake you up. Avoid the light. The opposite holds true

Emergency Physicians Wanted

for the night work environment that should be bright to ensure alertness and productivity. Thermal control is also important as you drive. A cool environment is best. The body will drop the core temperature as we sleep by a degree or two. Getting in the sleep temperature range and staying there will promote quality sleep. Just don’t fall asleep before you get home! The home sleep environment is crucial to quality sleep. I have a “sleep room” in our basement. It has one window with light darkening shades which make it instant night. I like the basement for its other virtues. It is quiet, dark, and cool. The addition of background noise (a noise machine) makes it optimal for me to sleep. For those who do not have a basement option, darkening the windows with light blocking shades will help. If you can get used to them, earplugs limit the sound stimulus above and beyond the noise machine. What we eat and drink also affects our sleep. Avoid drinking a lot of fluid prior to going to bed for the obvious reasons. Eating a large meal may lead to poor sleep secondary to reflux and bloating, and avoid caffeine prior to sleep. Caffeine affects everyone differently. Knowing your body and how it handles caffeine is very important. Just say no to the day shift even if they did bring in the gourmet coffee for everyone at shift

change! Alcohol is also something that may have a negative impact on your sleep. The night shift at the county hospital where I previously worked held “morning services” conducted by two of our very entertaining and beloved security guards at a saloon next to the hospital. Scrambled eggs, and a couple of beers, before going home was the routine. It was always a good time but probably not the best prescription for sleep. Not only will alcohol interfere with REM sleep, it will interrupt your sleep when you need to empty your bladder. Self-preservation of our sleep is crucial to us. Our sleep impacts our health, our families, our interactions with coworkers, and our patient care. Our profession is by nature not a 9 to 5 gig. You can optimize to some degree the quality of your sleep by attention to your habits. Next quarter we will look at medication enhancement of sleep. “Working Towards Wellness“ is a new feature in The Pulse and will feature articles geared toward assisting emergency physicians and their hectic lifestyles. If you would like to contribute to this column or to this publication please send your article to the Editor at the ACOEP. Longer articles may be sent to the ACOEP on CD-ROM or by email.

Preferred Emergency Specialists, Inc. seeks board eligible/board certified emergency physicians for full-time or part-time positions for two low-volume emergency departments in Southeast Indiana (between Indianapolis, IN and Cincinnati, OH). Package for full-time attendings includes pay scale of $100/hour plus retirement, healthcare and malpractice insurance benefits. Package for part-time attendings includes pay scale of $95/hour plus malpractice coverage. For information contact: I. Brady Husky, D.O., FACOEP, Preferred Emergency Specialists, Inc. at 937-743-9474 or Fax CV and contact information to 937-743-9475

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Emergency Department Ethics Bernard Heilicser, D.O., MS, FACEP, FACOEP

What Would You Do? The following case was submitted by Tim Hall, PA-C, a practicing physician assistant in Illinois. A 19 year-old female is separated from her husband. It appears the estranged husband forced his wife into his car at gunpoint after stalking her. He sexually assaults her. The victim then escapes from the car when the police locate them. The assailant subsequently sustains a self-inflicted gunshot wound to his head. He is transported to one hospital, and then transferred to a Level I trauma center, unresponsive and near death. The victim is taken to another hospital.

The dilemma: 1. Can the victim’s physician request the trauma center to obtain lab for HIV, RPR, etc., from the assailant without consent? He is still in police custody as a suspect. Is there any regulatory violation (i.e. HIPPA)?

Please send us your thoughts and ideas. (Fax 1-708-915-2743) Every attempt will be made to publish them when we review this case in the next Pulse. If you have any cases in your practice that you would like to present or have reviewed in The Pulse, please fax them to us.

2. With death of the assailant imminent, what about organ donation? With the victim technically still married, can she donate any organs when the police are done with him? What other options would she have? What would you do?

May 2 – 3

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September 12 – 13 Oral Board Review Sheraton Four Points Hotel Chicago, IL 10 Category 1A Credit

CME Calendar

2008

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October 26 – 30

Scientific Seminar Caesar’s Palace Las Vegas, NV 23 – 25 Category 1A Credits

2009 January 7 – 11 Emergency Medicine: An Intense Review Westin River North Chicago, IL 42 Category 1A Credits February TBD Program Directors Workshop Hilton Marco Island Resort Marco Island, FL TBD

COLA Essentials Hilton Marco Island Resort Marco Island, FL

April 14 – 18 Spring Seminar Hyatt Regency Grand Cypress Orlando, FL

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