The Pulse April 2010

April 2010 VOLUME XXXV NO. 2

Presidential Viewpoints Thomas A. Brabson, D.O., MBA, FACOEP, President

I hope that as you are reading this edition of The PULSE you are not only well but also warm. For most of us this has been a record-breaking winter that we are sure to remember for many years. As I am typing my article, the Philadelphia area is experiencing another snow shower. Almost the entire country had experienced record breaking low temperatures and snow.

Record numbers of power outages and flooding were a result of the devastating winter. The good news though is that the winter is now behind us and we can look forward to a great spring season.

We thank everyone that overcame their respective weather related challenges this past winter in order to keep your emergency department operational and able to serve the people in need of your services. The personal sacrifice you have demonstrated for your profession should be recognized, respected and appreciated.

On a warmer note, your Board of Directors and Executive Director participated in a strategic planning meeting

January 28-30 at Marco Island, Florida.

The meeting was facilitated by Robert Harris, CAE who is an expert in strategic planning services. The purpose of the meeting was to evaluate the components of our prior strategic plan and make any necessary adjustments that would enhance our College and enable it to continue to prosper and grow. We had many collegial and productive sessions which analyzed where we have been as a College and what we aspire to become in the near and distant future. The discussion highlights centered on the areas of growth, leadership, diversification, and communication.

At the core of any non-profit organization are its Mission, Vision, and Value statements.

These three statements help to create the framework upon which the organization is built. They also create an internal and external image of the organization. They help to tell ourselves and others who we are as a College and what is our purpose for existing as an organization. They also help to guide our future decisions both as College leaders and as members.

The mission is a broadly defined statement of purpose and distinctiveness.

It underscores the uniqueness of the organization and identifies its scope of operations in terms of service and market.

It also must be stable and enduring to keep the organization focused. Our mission statement has endured with a few word changes that did not change the essence of the statement. Our mission statement is: The American College of Osteopathic Emergency Physicians (ACOEP) advocates quality emergency medical care and promotes the advancement of osteopathic principles.

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The vision is an expression of hope. Truly effective visions exemplify the characteristics including: idealism, uniqueness, and thinking for the future. Just as with the mission, the focus of the vision is on distinctiveness. The vision is formulated with an appreciation of the past history of an organization, perception of opportunities for the organization, and an understanding of the organizations strategic ability to take advantage of these opportunities. Our vision statement is: The American College of Osteopathic Emergency Physicians (ACOEP) will be the leading professional organization in emergency medicine actively promoting osteopathic principles.

The core values are the fundamental principles that make people and organizations unique. Often, discussions of organizational values relate to ethical behavior and socially responsible decisionmaking. Values may be specific to a particular organization. They help guide the behavior of the organizational leaders and members. Unlike the mission statement, these may change over time. It is important that they be communicated throughout an organization. The Core values that will guide the ACOEP are: 1. Quality emergency care is a fundamental right.

2. There is a body of knowledge unique to emergency medicine.

3. Emergency medicine is best practiced

by Board certified emergency physicians.

4. The osteopathic emergency physician has a lead role in defining, evaluating, and improving health. continued on page 20

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The PULSE April 2010

THE

The Pulse An Osteopathic Emergency Medicine Quarterly 142 E. Ontario St., Suite 1500 Chicago, IL 60611-5277

PULSE O s t eop a t h i c

Editorial Staff: Drew A. Koch, DO, FACOEP, Editor Wayne Jones, DO, FACOEP, Assist. Editor Thomas Brabson, DO, MBA, FACOEP Anthony Jennings, DO, FACOEP Janice Wachtler, Executive Director Editorial Committee: Drew A. Koch, DO, FACOEP, Chair Wayne Jones, D.O., FACOEP, Vice Chair David Bohorquez, DO Thomas Brabson, DO, FACOEP Joseph Dougherty, DO, FACOEP Anthony Jennings, DO, FACOEP William Kokx, DO, FACOEP Annette Mann, DO, FACOEP Brian Wiboon, DO Janice Wachtler, CBA The PULSE is a copyrighted quarterly publication distributed at no cost by the ACOEP to its Members, library of Colleges of Osteopathic Medicine, sponsors, exhibitors and liaison associations recognized by the national offices of the ACOEP. The PULSE and ACOEP accepts no responsibility for the statements made by authors, contributors and/ or advertisers in this publication; nor do they accept responsibility for consequences or response to an advertisement. All articles and artwork remain the property of the PULSE and will not be returned.

Display and print advertisements are accepted by the publication through Norcom, Inc., Advertising/Production Department, PO Box 2566 Northbrook, IL 60065 ∙ 847948-7762 or electronically at theteam@norcomdesign.com. Please contact Norcom for the specific rates and print specifications for both color and black and white print ads.

Deadlines for the submission of articles and advertisements are the first day of the month preceding the date of publication, i.e., December 1; March 1, June 1, and September 1. The ACOEP and the Editorial Board of the PULSE reserve the right to decline advertising and articles for any issue. ©ACOEP 2009 – All rights reserved.

Articles may not be reproduced without the expressed, written approval of the ACOEP and the author.

Emergency

Me d i c i n e

Q ua r t e r ly

Table of Contents Presidential Viewpoints . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Thomas A. Brabson, DO, MBA, FACOEP Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Drew Koch, DO, FACOEP Executive Director's Desk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Janice Wachtler, BA, CBA Scientific Assembly Program Announced . . . . . . . . . . . . . . . . . . 6 WADEM Update . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 William Bograkos, D.O., FACOEP 2009 Student Case Comeptition Winner . . . . . . . . . . . . . . . . . . 8 FOEM: 2010 Foundation Plans Unfold . . . . . . . . . . . . . . . . . . 12 FOEM: 2009 Research Paper Winners . . . . . . . . . . . . . . . . . . . 13 FOEM: 2009 Contributions . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Calendar of Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 The On Deck Circle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Anthony W. Jennings, DO, FACOEP Osteopathic Residencies on the Cutting Edge . . . . . . . . . . . . . . 21 Tim Cheslock, DO Resident Chapter President In My Opinion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Wayne Jones, D.O., FACOEP Emergency Department Ethics . . . . . . . . . . . . . . . . . . . . . . . . . 23 Bernard Heilicser, D.O., MS, FACEP, FACOEP On the Wild Side . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 James Shuler, D.O., MA, FACOEP Resident Chapter Update . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Members in the News . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

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

Acute Exacerbation of Chronic Pain in the Emergency Department

Every day that I work in the emergency department there is at least one patient who is dubbed a “drug seeker and who was just here the other day,” by the nursing staff, registration and the tech/clerical staff. The patient is labeled by the emergency department staff before he/she is seen by a provider. The questions I must ask myself before I enter the room are: 1). is this patient suffering from an acute exacerbation of chronic pain; 2). is this patient exhibiting drug seeking behavior and; 3). how am I going to treat or not treat this patient. EMTALA requires that every patient who presents to the emergency department must have a medical screening examination and stabilization.

If the medical screening exam reveals that the patient does not have an acute problem, are you obligated to treat the patient, and by refusing to care for a known drug seeker and are you risking an EMTALA violation?

The Joint Commission requires that each and every patient has a right to the assessment and management of pain. Hospitals must develop policies and procedures which address the organization’s expectations of pain management in support of their mission and philosophy of care.

Physicians are concerned about possible legal, regulatory, licensing or other third party sanctions related to the prescription of controlled substances. Controlled substances include: narcotic analgesia, sedative-hypnotics and stimulants. The leading cause of physician investigations and sanctions by state licensing boards are over prescribing controlled substances. It is estimated by the DEA that the street value of controlled substances is only second to the value of cocaine but greater than the street value of marijuana and heroin.

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Pain is defined from the International Association for the Study of Pain as: an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain can be described as acute pain syndromes such as sprains, trauma or fractures. The second type of pain can be described as neuropathic pain that is found with radiculopathy or peripheral neuropathy. The third type of pain involves a malfunction in the central nervous system pathway found with fibromyalgia, phantom pain or psychiatric problems.

Pain can also be delineated by time.

Acute pain is defined as pain that is 0 to 2 weeks in duration. Sub acute pain lasts from 2 week to 3 months; whereas chronic pain is grater than 3 months in duration.

Acute pain tends to be the result nociceptive stimulation due to musculoskeletal injury compared with chronic pain which is most often associated with supratentorial processing of neuropathic stimuli.

The prominent physical signs of autonomic nervous system dysfunction that relate to acute pain are: tachycardia, hypertension, diaphoresis, mydriasis and pallor.

Chronic pain is absent of physiological signs as the patient adapts to continual pain scenario.

One of the reasons that people seek health care and present to the emergency department is pain. Many health care providers have difficulty evaluating pain. Pain can be masked by stoic behavior, exaggerated by hysteria or disguised by co-existent psychological problems. It is often difficult to differentiate behaviors of patients driven by pain from those with other motives.

Most people who complain of pain do not seek a euphoric state but a relief from disabling or unbearable discomfort. However, among those individuals with legitimate pain are individuals who seek drugs to cope with addictions or provide them with illicit incomes.

The forces behind drug seeking and

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abuse are addiction, pseudo-addiction, tolerance and physical dependency. Addiction is wrongly equated with physical dependency and tolerance. Pseudo-addiction is a complicated phenomenon that often goes unnoticed. Abuse refers to using drugs in a manner other than what the prescribing physician intended. This may include using the drugs recreationally, in increased amounts, with increased frequency for different indications and with different routes of administration. Addiction is a psychological dependence or craving for drugs that cumulates with loss of control and compulsivity. Pseudo-addiction is a behavioral manifestation of inadequate pain control. The unrelieved pain leads to anxiety and distress. These individuals try to procure more drugs because their pain is unrelieved and they have the fear of running out of their medications. Tolerance is the need for increased drug dosage to produce the same effect or level of previously experienced analgesia. This is not always obvious and does not signal an addiction. Physical dependence is defined as a state of adaptation that is manifested by a drug class withdraw syndrome produced by abrupt cessation, rapid dose reduction and/or the administration of an antagonist.

Dependency is not the same as psychological problem of addiction but may occur with both addiction and pseudo-addiction.

Drug seeking behaviors are common place in the emergency department. Many physicians have faced patients with multiple alleged allergies to narcotics and other medications who request a medication that the physician never would have initially thought of prescribing, whose medications were stolen and who become angry, threatening and agitated upon refusal to refill the stolen prescription-Emergency Medicine Reports, January 3, 2005. continued on page 18

Executive Directors Desk Janice Wachtler, BA, CBA

Educating the Patient and Family This article about family and friendship; the importance of physician/ patient communication is and, most of all just how important it is to educate not only the patient but the patient’s family on healthcare conditions, side-effects of medication and medical procedures.

You see, this friendship has spanned my entire lifetime and started almost from birth. I was born 16 days before my cousin Jeanie, throughout our childhood we were close friends, however as we grew up we periodically lost touch with each other, each time we reconnected it was as if only a day had passed and we picked up from where we left off. We reconnected most recently after my Dad died and have remained close since then, “speaking” to each other almost daily by email and on the phone for several hours each month until January 2010. At that time, we spoke briefly and emailed several times but then agreed to speak around my birthday in early February, however, when I didn’t hear from her I emailed and received no answer, so I assumed that she too had gotten busy and would get back to me. However, 8 days after my birthday and 7 days before hers she was found dead in her home after suffering a stroke.

Could her death been avoided, who knows, but there were symptoms that her immediate family missed; signs that were subtle and others that were not so subtle.

Signs that she saw and articulated to her physician and others; symptoms that were so in your face that older people could have detected had they had in person contact with her, but only her children were nearby, all other relatives lived out of state. But let’s go back to the beginning.

Last October, I received an email stating

that my cousin thought she had Cushing’s Disease after she entered her litany of symptoms into WebMD.© She had, in the past 18 months developed diabetes, high blood pressure, weight gain (around her mid section), bruising, and now osteoporosis and lethargy. She was tired of being “sick” all the time. You see, years before she had gone on disability after being diagnosed with a rare stomach disorder that had prevented her from working with either bouts of vomiting or diarrhea.

She went to the doctor and underwent numerous tests and an MRI to verify that she did indeed have Cushing’s Disease and a tumor on her Pituitary gland. She then underwent surgery in mid-November. As late as the end of December she still had had no relief from her symptoms, but was told by her physician that these symptoms would last for about a year as her body dumped the excessive cortosol that it had produced over the years.

As she was recovering she noticed that she was beginning to slur her words. The doctor told her not to worry that it often happened after the nasal surgery. She voiced her concern over and over to me during December and I encouraged her to talk to her doctor or go to the ED to check things out. During mid-January her emails lessened and my travel schedule sped up.

Our last communication was a promise to talk when I got home on February 2.

After her death, on February 9th, I spoke with her daughter, who related to me that during the last two weeks of January, her mother’s behavior became strange. She was often confused, losing things, locking herself out of her house, writing bizarre notes at home to remind herself to do things. She had headaches, and her voice was slurring more and more. She had contacted her doctor and made an appointment for early February; it was an appointment she never went to.

What if the physician in my cousin’s case

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had gone that extra mile to inform her family of the side effects of surgery; or even the signs and symptoms of potential problems?

Would it have driven her and or her children to take her into the ED? What everyone forgets is that information sometimes doesn’t get related to caregivers or in the case of many older patients, family and friends they speak to. Physicians generally have a good rapport with their patients but know little of their situation once they leave the office or ED. Does the patient live alone? Do they have a support network of family and friends that will check on their well-being at least once daily following major surgery? Does the patient know the signs and symptoms of infection or stroke? Do their caregivers?

When I had surgery a few years ago, my surgeon came into my hospital room for the five days following my surgery and called my home daily for the first three days I was home. He would speak only with me, asking me very pointed questions; was I experiencing bleeding, did I have a fever or headache, was the incision red or swollen? Even the hospital network called once a week for several weeks to check on me.

Now I ask was this atypical behavior or was it good follow-up?

Should all hospitals and physicians follow up with patients who have undergone major surgery? Should the ED follow up patients who are released and sent home after a fall, break, or trauma? Should hospitals be charged with routine follow up calls just to check on the patient?

And what of educating the patient’s family or support network of danger signs?

Should physicians be doing more patient and public education on the danger of postprocedure infection and stroke? These silent killers take so many people’s lives annually, and yet so many people are unaware of its signs and dangers. continued on page 18

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Scientific Assembly Program Announced This fall, ACOEP will meet concurrently with the AOA in San Francisco for the Unified Osteopathic Convention. The ACOEP Scientific Assembly will be held October 24 – 28 at the Hilton in downtown Union Square, while the AOA convention will be held at the Mascone Convention Center in San Francisco over the same dates.

We are proud to announce that this year’s program will feature several prominent, nationally recognized speakers. Topics of focus include critical care, administration, trauma, and literature review. Below are just a few of our featured presenters:

Kenneth Butler, D.O., FACEP, FAAEM - Dr. Butler is Associate Professor of the Division of Emergency Medicine at the University of Maryland School of Medicine in Baltimore, Maryland as well as the Associate Residency Director for the Division of Emergency Medicine Residency Program at the University of Maryland School of Medicine. Dr. Butler will be lecturing on ocular emergencies.

Jonathan Davis, MD, FACEP, FAAEM Dr. Davis is the Associate Program Director for the Georgetown University/Washington Hospital Center EM Residency Program in Washington, D.C. Dr. Davis received his medical degree from the University of Maryland, and completed his EM train-

ing at the Stanford University Program in Palo Alto, California. He has published and lectured on various EM clinical topics, including allergic emergencies, male genitourinary emergencies, and hematologic emergencies. He currently holds the title of Associate Professor of Emergency Medicine at Georgetown University School of Medicine. Dr. Davis will be lecturing on allergic emergencies.

Amal Mattu, M.D. - Dr. Mattu completed his emergency medicine residency at Thomas Jefferson University Hospital in Philadelphia, after which he completed a teaching fellowship with a special focus on emergency cardiology. Since joining the faculty at the University of Maryland in 1996, he has received more than a dozen teaching awards including national teaching awards from the American College of Emergency Physicians and the American Academy of Emergency Medicine. Dr. Mattu has also authored or edited 5 books pertaining to emergency cardiology, electrocardiography, and high-risk emergency medicine. Dr. Mattu is currently Associate Professor and Residency Director in Emergency Medicine at the University of Maryland. Dr. Mattu will be lecturing on modern management of acute decompensated CHF as well as doing a literature review of emergency cardiology

articles.

Noelle Rotondo, D.O. - Dr. Rotondo is a 1994 graduate of the Philadelphia College of Osteopathic Medicine. She completed her internship training at Community General Osteopathic Hospital in Harrisburg before starting her EM residency at York Hospital in 1995. Dr. Rotondo is currently medical student clerkship director at York Hospital, PA, while also being involved with the EM residency. She is on the PaACEP Board of Directors, Co-director of the PaACEP Emergency Medicine Board review course, and an examiner for the PaACEP oral board review courses. Dr. Rotondo has published numerous articles on OB/GYN emergencies for the Merck Manual of Patient Symptoms and has published the "Approach to the Trauma Patient" for The Merck Manual.

She has written review articles and board review questions on Obstetric Emergencies for the peer-reviewed journal Hospital Physician. Dr. Rotondo will be lecturing on trauma in pregnancy and 3rd trimester Obgyn emergencies.

Please visit www.acoep.org for program details and registration information.

We look forward to seeing you in San Francisco!

That Human Touch

Over the past few months, we have received several calls asking why the ACOEP no longer has the “personal” answering mechanism we did before we moved. Well, we’ll have to blame technology. After researching the newer telephone technologies all of them featured the automatic answering as the central service. So building our “tree” added several layers to the prompts, members can always type in the last name of the desired staff person, or go through the tree to Member Services, Executive Office; IT, or Meetings and Conventions. You can also dial each member of the staff, if you know their extension.

To help you this directory will appear in the next several issues of The Pulse as well as be present on our website as it is redesigned.

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Member Services (1) Brittani Eckhart (1)

Executive Assistant Extension 5701 Direct Line: 312-445-5701

Mandy Lundeen (2)

Director of Member Services Extension 5704 Direct Line: 312-445-5704

Executive Director/Executive Office (3) Janice Wachtler (1)

Executive Director Extension 5705 Direct Line: 312-445-5705

Stephanie Whitmer (2) Executive Assistant Extension 5700 Direct Line: 312-445-5700

Meetings and Conventions (2)

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Erin Moore (1)

Executive Assistant Extension 5709 Direct Line: 312-445-5709

Kristin Wattonville (2)

Director of Meetings and Conventions Extension 5710 Direct Line: 312-445-5710

Information Technology (4) Brian Thommen (1)

Executive Director Extension 5703 Direct Line: 312-445-5705

Foundation for Osteopathic Emergency Medicine (FOEM) (4) Stephanie Whitmer (1)

Executive Secretary Extension 5712 Direct Line: 312-587-1765

WADEM Update

William Bograkos, D.O., FACOEP At the Scientific Assembly, the ACOEP Board gave approval to pursue the development of a section within the World Association for Disaster and Emergency Medicine – WADEM. Under the leadership of WADEM Board member William Bograkos, DO, FACOEP, a group met and wrote tentative mission and vision statements for what we plan to call the “Osteopathic Section of the WADEM”.

This action follows the Board approval for the ACOEP to be an Affiliate Member of WADEM. That took place after the Spring meeting. A brief summary of that action appears in a previous edition of the Pulse.

Mission Statement – The mission of the “Osteopathic Section of the WADEM” is to pursue academic excellence in international disaster preparedness, response, recovery, development, prevention and mitigation.

Vision – To expand the role of the Osteopathic physician in Global Health and Humanitarian Assistance So why has the College decided to make this move? The intent is to have a way for all osteopathic physicians in the US and abroad – regardless of specialty - to interface with like-minded people around the world. Many of our members already are heavily involved in disaster prepared-

ness and response. For many, that is at the local level. For others it involves deployment on DMATs, USAR teams. For others it means lending a hand abroad when disasters strike. Emergency Medicine is the discipline that should continue to lead the way in this critically important area. To that end, the College submitted a proposal to the AOA for a fellowship in Disaster Medicine.

If you are a DO and a member of WADEM, we need to know. A section requires a minimum of 10 members, but we would like many more than that. If you do not belong to WADEM and have an interest in disaster medicine, consider joining. Since the College is an Affiliate, the yearly dues are only $120. There will be no other financial commitment. From our Mission and Vision statements you can see that we will have an educational focus.

This interface with WADEM will help us to liaison with world experts and should open doors for interested residents to obtain EMS and disaster medicine rotations in parts of the world they might otherwise never experience.

Osteopathic physicians will have a way to meet In te n si ve

and talk with world experts. We may be able to collaborate in research that has never before been feasible. WADEM works closely with the World Health Organization.

Once we have enough interest from College members, we will write bylaws and distribute drafts to section members for discussion, review and approval. Officers will probably be appointed initially from the group that met in Boston, but future leaders will be elected from the membership.

Once the Section is established, leadership will notify the AOA and solicit interest from other DOs. If you are interested or would like more information, contact Bill Bograkos at irisbo@comcast.net or Steve Parrillo at parrills@einstein.edu. You may apply for WADEM membership by going to www.wadem.org.

We are excited about this new venture.

Please join us!

™

Im m er si on E xp er ie n ce

On the Event Horizon 33rd PIAA Annual Meeting Protecting Patients, Reducing Risk: New Liability Challenges in 2010 and Beyond May 12 – 15, 2010 Sheraton Chicago Hotel and Towers Chicago IL Register on line at www.piaa.us and click on 2010 Event Registration link on home page

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Congratulations on a life saved!”

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April 16 - 18, Seattle

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Prepare yourself for your next difficult airway as you master state-of-the-art techniques, devices and algorithms.

Register at www.theairwaysite.com or (866) 924-7929

Evidence-based. Comprehensive. Expert Faculty.

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Hyperosmolar Hyperglycemic State in the Emergency Room Joshua D. Green, OMS, Nova Southeastern University College of Osteopathic Medicine

2009 Student Case Competition Winner Introduction: Hyperosmolar Hyperglycemic State (HHS) is a life-threatening condition characterized by extremely high blood glucose and serum osmolarity in the absence of ketoacidosis. While similar to diabetic ketoacidosis (DKA), the other major complication of uncontrolled hyperglycemia, the progression of HHS is much more insidious, so that by the time patients typically present their condition is much more severe and leads to greater mortality. [1-3] HHS most commonly occurs in patients with type 2 diabetes, but a significant number have never been diagnosed with diabetes. [1-4] As the prevalence of diabetes dramatically increases, HHS is becoming an increasingly common community-based emergency.

This case involves a patient who presented too late to correct the physiological imbalance in time. The previous day he had adamantly refused to go to the emergency room.

Case Report: CHIEF COMPLAINT: Unresponsiveness HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old white male who was transferred to the Medical Center emergency department from a smaller outlying emergency room with GI bleeding, hypotension, and altered mental status.

He had been diagnosed with diabetes mellitus at the medical center in 2004 after undergoing CABG, and was managed by an endocrinologist until 2005. According to the family he no longer required medication and did not obtain any other medical follow-up except for yearly visits to his cardiologist for cholesterol checks.

The patient’s wife reports that he had no appetite for the past 3 days after eating oysters. Yesterday, he started having some emesis while his wife was at work. She tried to get him to go to the Emergency Room and he refused. He had further emesis during the night and when his wife came home at lunchtime today he was

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minimally responsive. He appeared to be unable to move his arms or legs and was “thick-tongued”. His nail beds were said to be blue. His wife called the paramedics.

He had been intubated at some point and reportedly had vomited blood, though it is not clear if this was prior to intubation.

Labs were still pending at the time of transfer and have now returned demonstrating that his blood sugar there was 976. Sodium was 126, with Potassium 4.3. His C02 was only 16. White Count was 11,900.

PAST MEDICAL HISTORY 1. Multi-vessel coronary artery disease.

2. Status post myocardial infarction.

3. Unstable angina.

4. History of Guillain-Bare syndrome.

5. Type 2 diabetes mellitus.

6. Hx of cigarette smoking, 12 pack years—quit in 2004, PAST SURGICAL HISTORY 1. Coronary artery bypass grafting in 2004 ALLERGIES: NKA MEDICATIONS: 1. Ecotrin 325 mg daily.

2. Colace 100 mg p.o. b.i.d.

3. Lipitor 30 mg q h.s.

REVIEW OF SYSTEMS Obtained from his wife at bedside.

GENERAL: Had seemed ill for 3 days with no appetite, no known fever, chills, or diaphoresis.

HEENT: Wears reading glasses, no vision changes.

CV: CABG in 2004. No subsequent chest pain, palpitations or syncope.

RESP: occasional cough, no SOB, wheezing or painful breathing.

GI: Little to no oral intake x 3 days, intermittent vomiting since yesterday, hematemesis today, no known diarrhea or hematochezia, previously taking Miralax for chronic constipation.

GU: Frequent urination x 1 week, no known painful urination, hematuria x 2 days NEURO: Had lost voluntary use of arms

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and legs x 5 hours, unable to speak clearly.

Previously had experienced occasional tingling of feet, occasional headaches, no seizures or tremor.

MUSCULOSKELETAL: No joint or muscle pain, no swelling, fully ambulatory.

SKIN: No rashes or lesions noticed.

ALLERGIC: No seasonal rhinitis. No food allergies ENDOCRINE: diagnosed with diabetes in the past, not medicated, no known thyroid disease.

PSYCHIATRIC: Some confusion yesterday, no depression, anxiety, mood swings or suicidal ideation.

PE VITAL SIGNS: BP: 114/74 HR: 156 RR: 20 T: 96°F O² sat: 84% GENERAL: Intubated, unconscious elderly white male.

HEENT: Normocephalic, atraumatic, nonicteric, eyes closed, PERRL, mild conjuctival edema, dry oral mucosa and tongue, some trace blood around ET tube.

NECK: Supple, no thyromegaly, no adenopathy, no carotid bruits.

CV: Sinus tachycardia, no murmurs, no S3.

LUNGS: Intubated, some mild course breath sounds, no crackles or wheezing.

ABDOMEN: no masses, diminished bowel sounds, no pulsatile mass.

EXTREMITIES: Without clubbing, cyanosis, edema, LE pulses detectable by Doppler only.

NEUROLOGICAL: GCS score of 8, Localizes pain UE’s, slight movement to pain LE’s DTR’s decreased at Achilles.

SKIN: Poor turgor, no acanthosis nigricans, vitiligo, rash, or non-healed lesions.

See Lab Data Table A, page 10.

EKG: Sinus tachycardia Blood Cultures, on Antibiotics: No growth DIAGNOSTIC IMPRESSION: 1. Hyperosmolar Nonketotic Coma 2. Possible slight ketoacidosis as well.

PLAN: 1. Aggressive replacement of IV fluids, potassium, as needed, and insulin.

2. Consult Endocrine to see the patient and help assist with the management of this.

3. Complete Vent support at the present time, and 02 protocols.

4. Hold Lovenox because of the apparent bleeding, and will check an H/H every six hours. If there is obvious gross bleeding, or his hematocrit falls further, will get Gastroenterology to see him. Will use TED stockings as DVT prophylaxis 5. Protonix IV for history of bleeding.

6. Levaquin and Zosyn for broad-spectrum coverage of possible underlying infection.

7. Rule out myocardial infarction with cardiac isoenzymes.

DISPOSITION AND HOSPITAL COURSE: The patient had received several liters of IV fluid resuscitation in the Emergency Department. He was taken to the Intensive Care Unit and there became bradycardic and asystolic. He was treated with ACLS protocol, and eventually after 20 to 25 minutes the team recaptured a rhythm, pulse and blood pressure. He was maintained on Levophed, Dopamine and wide open fluids. It was found that when his fluids were reduced to 2 L/hour his blood pressure dropped significantly. He remained hypotensive with minimal urine output and was increasingly acidotic, receiving several amps of bicarbonate during the night. His blood sugars were managed with insulin drip.

The following day he was very edematous, volume overloaded, and had borderline PAO2. Despite correction of his electrolytes and glucose he never woke up. There was concern that he might have had some anoxic brain injury during the arrest. This was shared with the family, who stated that he never wanted to be on a ventilator or life support, and indeed he was massively swollen and edematous. The decision was made to stop his pressors. Within 15 minutes his blood pressure dropped out and he became bradycardic and asystolic. He was declared deceased shortly thereafter. The family was in attendance.

Discussion: This case demonstrates a characteristic progression of Hyperosmolar Hyperglycemic State (HHS), a medical emergency. Although the condition is also traditionally known as Hyperosmolar

Nonketotic Coma, the more comprehensive nomenclature has been adapted by the American Diabetes Association because only a minority of patients is comatose on presentation. [1-4] While this case introduced a prototypical patient illustrating the full course of the condition, not all HHS patients are elderly diabetics presenting with altered mental status. This same emergency department had seen several other presentations of HHS recently. There had been a 20 year old type 1 diabetic, a 61 year old woman who presented with tingling in her left hand, and multiple patients that presented with abdominal pain who were discovered to be suffering from HHS. There had also been a patient triaged lowacuity, who just didn’t “feel right” who, fortunately, was properly diagnosed and admitted for treatment of HHS. Not all of these patients had previously been diagnosed as diabetic.

In 2007 it was estimated that of the 23.6 million people with diabetes in the United States, 5.7 million were undiagnosed. [5] The progression of DKA is more rapid and thus easier to identify and reverse.

In contrast, the slow and subtle nature of HHS has potential to create medicolegal complications. A standard scenario is an undiagnosed diabetic that presents with mild constitutional complaints, often to a primary care office, who is sent home without testing serum glucose. The disease slowly progresses, and several days later the patient ends up presenting to the emergency room in critical condition.

Etiology: Although most patients have a history of type 2 diabetes mellitus, a myriad of factors have been reported to cause HHS in patients who have never been diagnosed with diabetes. [6,7] While an identifiable precipitating factor is evident in around half of all cases of HHS there is still much that remains uncertain about the inciting factors. Poor glycemic control whether from noncompliance or undiagnosed diabetes is a frequent underlying factor. The most common stressor is infection such as UTI, pneumonia, or bacteremia. [1,3,8] Other common triggers are myocardial infarction, cerebrovascular accident, surgery, and drugs.

Many drugs have been implicated as a cause of HHS including steroids, anticonvulsants, diuretics, and atypical antipsychotics. [1, 9, 10] Uncommon triggers are numerous. Cases

The PULSE april 2010

have been reported conditions ranging from Grave’s disease to acute lymphocytic leukemia. [11,12]

On the other side of the coin, in many instances the underlying causes are not always clearly identified, as this case demonstrates. Emergent lifesaving treatment clouded some retrospective diagnosis. The patient exhibited probable rhabdomyolysis, increased amylase, and BNP. It is unknown if these preceded the development of HHS and treatment or were complications of it.

The significance of having eaten oysters 3 days prior cannot be determined. Blood cultures were not done before IV antibiotics were given so an infection cannot be ruled out. The level of underlying cardiac pathology is unknown because the family did not want an autopsy and the patient did not seek routine medical care.

Epidemiology: Specific population data for HHS is lacking. However DKA was responsible for 115,000 hospital admissions in 2003. [13] The incidence of HHS is estimated less than 1 case per 1000 per year, compared with DKA estimated to occur at a rate of 4.6 to 8 cases per 1000 per year. [14] While HHS accounts for fewer admissions than DKA, the mortality is higher, with estimates ranging from 10-50% [2,4,10] Pathogenesis: Precipitating event Hyperglycemia Glucosuria→Volume loss Hyperosmolarity ↓ Altered mental status, decreased GFR ↓ Coma, death

This flow diagram summarizes the basic progression of HHS. Dehydration from sustained diuresis is the basic pathological mechanism. In HHS the course is more insidious than DKA, developing over days or wee ks.

Like DKA, HHS is initiated by a precipitating stressor that impairs glucose metabolism by decreasing pancreatic beta cell function and increasing glucogenic stress hormones like glucagon, catecholimines and cortisol.[1,3,8] These hormones mobilize the body’s energy stores and release

9

glucose into the blood stream. As the blood and decreased oral intake. [1-4,17] Weakness sugar rises the glucose receptors in the and malaise are also common. Eventually kidney become saturated allowing glucose signs and symptoms of extreme dehydrato be released in the urine. Water osmoti- tion may surface such as nausea, vomiting, cally follows the sugar resulting in hypovolemia and dehydration.

As dehydration progresses, the LABORATORY AND ANCILLARY DATA: kidneys work to preserve volResult Name Results Units ume and the GFR slows even in Protein, Total 4.6 L the presence of extremely high Albumin 2.0 L osmolarity. Serum glucose conCalcium 6.8 L Bilirubin, Total 0.8 tinues to rise as urine production Alk Phos 139 H stops. The extreme dehydration AST (SGOT) 74 H that results may be accompanied ALT (SGPT) 49 Creatinine 2.90 H by hypokalemia, azotemia and BUN 31 H hypo or hypernatremia. [1-4, 7, 15] Sodium 126 L Profound dehydration and the Potassium 4.0 accompanying metabolic changes Chloride 99 Carbon Dioxide 16 LL lead to a change in mental staGlucose 973 HH tus. Mortality is not necessarily BUN/Cr Ratio 10.7 from dehydration and electrolyte Anion Gap 16.7 GFR, Calculat 22 imbalance but rather an increased Osmolality Calc.

323 susceptibility to comorbid illness.

blurred vision, muscle cramps, abdominal and chest pain. There is increased susceptibility to rhabdomyolysis. Pulse will increase with increased dehydration in an attempt

gm/dL gm/dL mg/dL mg/dL units/L units/L units/L mg/dL mg/dL mEq/L mEq/L mEq/L mEq/L mg/dL mL/min/ mOsm/kg

Reference Range

6.0-8.5 3.2-5.0 8.5-10.5 0.2-1.2 42-121 10-42 10-60 0.5-1.2 6-22 135-145 3.6-5.0 100-110 25-31 70-115 6.0-20.0 6.0-20.0 1.73 m2 273-304

[1]

It is assumed that in HHS patients there is just enough insulin and insulin sensitivity to prevent ketoacidosis, while not enough to promote glucose uptake into cells. [2] This is reasonable as it has been demonstrated that the serum insulin concentration needed to allow glucose utilization is roughly ten times the concentration needed to prevent ketolysis. [16]

It should be noted that features of both HHS and DKA can be present simultaneously. The two conditions can be thought of as two ends of a spectrum of insulin utilization in hyperglycemic crises.

Clinical Presentation: The classic HHS patient is an elderly individual with type 2 diabetes mellitus. The condition commonly progresses to altered mental status by the time of presentation.

This can range from mild confusion to coma. [1,7,8,14] Focal neurological deficits can also occur, mimicking stroke, seizure and other neurological pathology. A history will likely reveal days to weeks of polyuria, weight loss,

10

CBC White Blood Cells Red Blood Cells Hemoglobin Hematocrit MCV MCH MCHC RDW Platelets Acetone, Serum Ketones, Serum Negative

10.4 H 5.18 16.6 49.8 96.2 32.1 33.4 14.4 258

X10-3/uL X10-6/uL gm/dL % fL pg gm/dL % X10-3/uL

4.5-10.0 4.40-5.90 13.0-18.0 39.8-52.2 80.0-97.0 26.0-34.0 31.0-36.0 11.5-14.5 150-450

Negative

Amylase

406 H

units/L

25-125

Cardiac Panel Myoclobin CKMB Troponin-I BNP

>500.0 H 2.4 <0.05 223.0 H

ng/mL ng/mL ng/mL pg/mL

0-170 0.3-4.3 0.00-0.15 0-100

Urinanalyis--Catheter Protein Glucose Ketone Bilirubin Blood Leuk Esterase Nitrite Urobilinogen Bacteria Mucous Spermatozoa WBCs RBCs

1+ A 4+ A 1+ A NEG TRACE A NEG NEG NORMAL FEW A PRESENT A PRESENT A 3 <1

/hpf /hpf

NEG NEG NEG NEG NEG NEG NEG NORMAL NONE NONE NONE 0-5 0-3

Amylase: Lipase:

406 22

units/L units/L

25-125 22-51

The PULSE April 2010

Leu/Ul

to maintain blood pressure. Physical exam may also reveal poor tissue turgor, sunken eyeballs, and decreased deep tendon reflexes. [2,8] Diagnosis: HHS is initially suspected when a metabolic panel or finger stick returns a severely elevated blood glucose. This immediately focuses the differential to DKA or HHS. HHS is characterized by extremely high blood glucose (>600 mg/dL but can exceed 1000 mg/dL), high serum osmolarity (>320 mOsm/kg), and the absence of ketoacidosis (serum bicarbonate >15 mEq/L and ketones not present in the blood). [1-4, 6-8] see Table 1 below.

The workup for HHS includes a search for underlying causes, as well as complications, and will often include: Urine Analysis: Will show glucosuria, red cells, and perhaps some ketones. Bacteria and WBC’s may indicate urinary tract infection.

Cardiac panel: May show elevated myoglobin in rhabdomyolysis. May point towards myocardial infarction or CHF as underlying illness.

Blood and Urine Cultures: May indicate bacterial infection and direct targeted antibiotic therapy.

CBC: May show mildly elevated white cells or evidence of infection.

Metabolic Profile: Sodium may be increased or decreased, though total body sodium is usually normal. Potassium may be decreased, though this is more characteristic of DKA. Liver enzymes may be elevated.

Amylase and Lipase: May be mildly elevated, or markedly so, indicating possible pancreatitis.

Treatment: 1. Aggressive rehydration 2. Insulin drip 3. Correction of potassium and other

electrolytes 4. Identify and treat underlying cause

and complications.

Vigorous hydration with normal saline is the first step. Once fluid replacement is underway an IV bolus of 0.15 U per kg of insulin should be given. A drip of 0.1 U per kg is then used until glucose measures less than 300. Any potassium deficit should be corrected when urine output is reestablished. Throughout the whole process the laboratory values must be carefully monitored and total sodium and free water should be calculated and corrected accordingly. [1-3,14,7]

The diagnosis of HHS prompts an urgent search for an underlying cause as soon as emergent treatment has been initiated. History and laboratory data may direct further treatment if other pathology is identified.

It is important to monitor the patient for complications such as vascular occlusions (e.g., mesenteric artery occlusion, low-flow syndrome, and disseminated intravascular coagulopathy), cardiac arrhythmias, rhabdomyolysis, and cerebral edema. [17] Finally, physicians should take steps to prevent future episodes through patient education and instruction.

Summary: HHS is a major acute complication of diabetes, that while not as well studied or popularized as DKA, is relatively common in the emergency room. The case presented was representative of a typical patient illustrating the full course of the condition.

However, HHS is known to present at any age and has an unpredictable variety of precipitating causes. In many cases it is the first presentation of diabetes. While the workup, diagnosis, and treatment are similar to that of DKA, HHS is a much more insidious disease that is more difficult to reverse by the time of presentation.

References: 1.Kitabchi, Abbas E et al. (2006) Hyperglycemic crises in diabetes mellitus: diabetic ketoacidosis and hyperglycemic hyperosmolar state Endocrinol Metab Clin

Table 1 – Common Diagnostic Criteria of Hyperosmolar Hyperglycemic State

Serum glucose >600 mg/dL

Serum Osmolarity >320 mOsm/kg

Serum Bicarbonate >15 mEq/L

Serum Ketones negative to trace

The PULSE april 2010

North Am, 35:725-51Z3 2.Stoner, GD (2005) Hyperosmolar hyperglycemic state. American Family Physician, 71(9):1723–1730.

3. Ennis, ED, Stahl, EJ, Kreisberg, RA. (1994) The hyperosmolar hyperglycemic syndrome. Diabetes Review, 2:115.

4. Yared Z, Chiasson JL (2003) Ketoacidosis and the hyperosmolar hyperglycemic state in adult diabetic patients. Diagnosis and treatment. Minerva Medica, 94(6):409-18.

5. National Diabetes Information Clearing House (2007) National Institute of Health.

National Diabetes Statistics, 2007, p.4 6. Powers, A C. (2008) Diabetes Mellitus.

Harrison’s Principles of Internal Medicine. 17th ed. New York, NY: McGraw-Hill; 2285.

7. Gray M, Mehler P S. (2003) Hypersomolar Nonketotic Coma. In Critical Care Secrets Third Edition, Elsevier Health Sciences.

New York. 279-282 8. Kitabchi AE, et al. (2004) Hyperglycemic crises in diabetes. Diabetes Care; 27(Suppl 1) S95.

9. Shin, Baekhyo, and Joseph, S (1977) Hyperglycemic Hyperosmolar Nonketotic Coma Following Diazoxide, Anesthesia and Operation. Journal of Anesthesia and Analgesia; 56:506-508 10. Campanella LM, Lartey R, Shih R. (2009) Severe hyperglycemic hyperosmolar non-ketotic coma in a nondiabetic patient receiving aripiprazole. Annals of Emergency Medicine, 53(2):264-6 11. Moon, Sung Won et al. (2006) A case of hyperglycemic hyperosmolar state associated with Graves' hyperthyroidism: a case report Jounal of Korean Medical Science, 21:765-7 12. Venkatraman R, et. al. (2005) Hyperglycemic hyperosmolar nonketotic syndrome in a child with acute lymphoblastic leukemia undergoing induction chemotherapy: case report. Journal of Pediatric Hematology and Oncology, 27(4):234-5 13. Centers for Disease Control (2005) Division of Diabetes Translations: National Diabetes Surveillance System DKA as firstlisted diagnosis for hospitalization. Atlanta, GA: U.S. 14. Chiasson J, et al. (2003) Diagnosis and treatment of diabetic ketoacidosis and the hyperglycemic hyperosmolar state. Canadian Medical Association Journal,168:859-866. continued on page 18

11

• A FOUNDATION DEDICATED TO RESEARCH IN OSTEOPATHIC EMERGENCY MEDICINE

Juan Acosta, D.O., MS, FACOEP, President, FOEM

2010 Foundation Plans Unfold In my last update, I wrote about working with Program Directors to devise a means for FOEM to help support the research mission of residency training. Since then I have contacted Program Directors and reached out to their research faculty where available.

One means of supporting residency research that I’ve discovered at the suggestion of Joseph Flynn, D.O., Research Director at Mt. Clemens Regional Medical Center, is an online course provided by Michigan State University. It consists of 20 modules that vary in length, but most are less than 20 minutes, and encompass the requisite core research skills including Developing a Research Question, Evaluating Medical Literature, Identifying Research Variables, several modules on Statistics and Ethics and concluding with an Introduction to Writing a Publishable Manuscript.

The content of the modules is excellent; each includes references and a post quiz for the resident’s use. I am currently gathering feedback on the relevance of the course from residency programs and also working with Michigan State University to negotiate a discounted fee for the residencies’ use of the course. The Foundation hopes to defray the cost for participation further by providing additional funds to each residency that is interested in subscribing to the course.

More details will follow as participation is assessed and costs are finalized.

In other news, the FOEM Board joined with that of ACOEP to engage in strategic

12

planning on Marco Island at the end of January, 2010. We are appreciative of the opportunity provided by ACOEP to use the services of its consultant, Bob Harris, CAE. The FOEM Board drafted a plan that streamlined its thinking about forward movement into its second decade. To implement its mission “to encourage emergency medicine physicians to conduct research and to increase awareness of medical research in the osteopathic profession” the Board is pursuing four goals: Research Grants, Awards and Education, Resources and Funding, Communications and Governance and Management. During the planning session, within each goal it began to develop a 2-year course of action for achieving its mission. FOEM plans to complete its strategic plan in the first half of 2010. You will learn more about it as the Board develops strategies and tactics in the coming months.

The first Spring Seminar Case Study Poster Competition is rapidly approaching.

Over 20 exciting entries have been received and we look forward to a lively competition on Thursday, April 8, 2010 from 1 to 5 p.m. in Scottsdale, Arizona. Plan to

come and sit in on the presentations. If you are interested in judging the competition, please contact Carolyn Swallow at cswallow@foem.org.

As I mentioned in an earlier column, last year in Boston, FOEM decided to separate the Case Study and Research Poster Competitions, in part to satisfy residents’ requests. The Research Poster Competition remains in the Fall Scientific Assembly.

Those of you already thinking about presenting a Research Poster at the Scientific Assembly in San Francisco should remember that poster abstracts are due July 1, 2010.

And finally, thanks to all who contributed to the Foundation in 2009, especially those who responded to our Thanksgiving Appeal. Like everyone on a budget these days, we are finding that funds are tight.

Just as we are trying to provide more, like the proposed assistance to residency programs highlighted in the first part of this column, we are finding we have less to work with. An extra gift from you at this time means a lot and would be greatly appreciated.

Calling All Board Certified Emergency Physicians Looking for an opportunity to get scholarly activity? Looking for a way to gain CME?

ACOEP needs Board Certified Emergency Physicians to act as examiners for its Oral Board Review Course on Saturday, October 23rd in San Francisco.

Attendees participate in simulated sessions, with an examiner presenting cases developed to mimic the Part II Oral Board Examination. Examiners will receive one-night hotel accommodations, as well as $150 stipend and a travel stipend. Each examiner is also eligible for 11 hours of 1A CME credit.

If you are interested in participating as an examiner, please contact Erin Moore at 312-445-5709/800-521-3709 x 5709 or via email at erinmoore@acoep.org

The PULSE April 2010

• A FOUNDATION DEDICATED TO RESEARCH IN OSTEOPATHIC EMERGENCY MEDICINE

2009 Research Paper Winners from Two Residencies It’s not too early to be thinking about submitting research papers for consideration for the 2010 FOEM/EMP Research Paper Competition. The deadline is July 15, 2010. Papers should be submitted to FOEM, 142 E, Ontario St., Ste. 1500, Chicago, IL 60611 or via email to swhitmer@foem.org. Consult your Program Director for the application form.

Emergency Medicine Physicians (EMP) has been a long-term sponsor of this competition. We are grateful for their sponsorship of the monetary awards provided and related costs.

In 2009 the Research Award Luncheon, was hosted by Juan Acosta, M.S., D.O. FACOEP, President of FOEM, on October 2nd and featured presentations by the First, Second and Third Place winners.

Each year Osteopathic Physicians Residents in accredited residency programs are encouraged to present their research papers to the Foundation for this competition. Submitted papers are distributed to the Research Evaluation Sub-committee of the Joint ACOEP/FOEM Research Committee. This committee, consisting of physicians, review blinded papers for their content and validity. In 2009, eighteen papers were submitted for consideration.

Below are abstracts of the three winning papers.

First Place Winner

Comparison of the cardio-toxic effects of reacemic albuterol vs levalbuterol in treatment of acute airflow obstruction.

Author: Tameesh Husain, D.O. Abstract This randomized, single blinded study at a 450 bed community teaching hospital compared the cardiotoxic effects of nebulized levalbuterol (xopenex™) and nebulized racemic albuterol in the treatment of acute airflow obstruction.

Background: Racemic albuterol has long been the treatment of broncho-constriction in the hospital setting. It has been formulated as a 1:1 racemic mixture of the R- and S-isomers. The therapeutic activity of albuterol is due entirely to the R-isomer, whereas a 450 came on the market and is a formulation containing only the R-isomer of albuterol. Since xopenex™ has been out, the common prescribing patterns at our institution are to order xopenex™ for patients whose baseline HR is elevated.

The reason being, xopenex™ is only the R-isomer and is thought to induce less trachycardia than albuterol. It is not clear if xopenex™ causes less clinically significant tachycardia than albuterol in hospitalized patients with asthma or COPD. Objective: The aim of the study was to evaluate the cardiotoxic effects of racemic albuterol and levalbuterol in hospitalized patients with acute airflow obstruction Methods: This prospective, randomized, single-blind study was conducted in all the ICUs (Medical, surgical, cardiac and neuro) and the cardiac step-down unit at a 450- bed teaching hospital. Patients were eligible for enrollment if they were 18 years or older and required β2-adrenergic-receptor therapy every 4-6 hours for respiratory function. Patients were randomized to one of three groups. Group 1 received albuterol 2.5 mg which was alternated with levalbuterol 0.63 mg every 4-6 hours. Group 2 received levalbuterol 0.63 mg and was alternated with albuterol 2.5mg every 4-6 hours.

Group 3 received levalbuterol 1.25 mg alternating with albuterol 2.5 mg every 4-6 hours. Heart rate was recorded from the continuous electrocardiogram monitor just prior to the dose of study drug and than 15 minutes after the dose was completed.

Patients were also asked if they felt better or experienced any shakiness after the treatment.

Results: Of the 70 patients completing 878 treatments in this study the average base-

The PULSE april 2010

line HR was 91.7 (SD=1.43). The mean change in heart rate from pre-treatment (µ=87.5) to post treatment (µ=88.2) was 0.8 (SD=5.1). Change in heart rate did not differ significantly based on the group of randomization (p=0.45) or treatment drug (p=0.29) Conclusion: The study suggests that there is no clinically significant increase in heart rate when prescribing xopenex™ over albuterol. Racemic albuterol is well tolerated and compares favorably to xopenex™ in its cardiotoxic profile when it went head-tohead in all three treatment groups.

Program Director: Alan R. Janssen, D.O., FACOEP Genesys Regional Medical Center Grand Blanc, MI Second Place Winner

High frequency users of the Emergency Department: A descriptive study.

Author: Captain Kamal S. Kalsi, D.O. BACKGROUND: It is well established that emergency department (ED) utilization has been rising in recent years, with a 26% increase in the number of visits between 1993 and 2003 . Furthermore, the majority of EDs reported that they were at or over capacity for at least 50% of the time in 2003 . In an effort to decrease ED crowding and health care costs, frequent users of ED services have been targeted for interventions because of the presumption that their use of the ED may be “inappropriate.” There seem to be varying perceptions among ED physicians about what defines a high frequency user (HFU), their use of the ED, and their medical and social needs. A better understanding of the characteristics of HFUs will help in addressing the needs of this patient population, and is a critical step before enacting policies targeted at modifying their utilization. We

13

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sought to identify high frequency users of the emergency department and determine the characteristics of these patients at our urban, tertiary-care hospital.

METHODS: We retrospectively reviewed all ED visits from patients aged 18 years or older from April 1st, 2007 through March 31st, 2008 in order to identify HFUs of our academic, urban facility. Individuals with 12 or more visits during this one-year period were considered HFUs, and those patients with less than 12 visits per year were considered non-high frequency users (NFUs). Using descriptive statistics, we compared these two groups. Histograms and unpaired student T tests were utilized to investigate the age distribution of this cohort. A Chi-square analysis was then used to compare the two groups with respect to age, sex, race, disposition and mode of arrival. We identified and compared the 10 most common diagnoses for both groups.

RESULTS: Our analysis identified a total of 61,630 adult visits for the one year study period. The HFU cohort was comprised of 85 individuals who were responsible for 1,527 , or 2.5% of the total, adult visits.

Our HFU population is predominantly male (62%) as compared to the NFU population (44%) (p<0.0001). The mean ages for the HFU and NFU groups were calculated to be 44.6 and 43.7 years, respectively. Despite similar mean ages, a 2-tailed T-test analysis revealed a significant difference (p<0.02) in age distribution between these two groups. Although we did find significant differences in racial distribution amongst the two groups, there was a high percentage of patients categorized as “other”, 25% and 34% for HFUs and NFUs respectively, limiting the interpretation of this data. There were no significant differences noted in admission rates. We did note, however, a lower discharge rate in HFUs, 65% versus 72%. We also noted a higher rate of patients leaving against medical advice (AMA), 2% versus 1%, and leaving without treatment (LWT), 8% versus 5%, in HFUs and NFUs respectively.

In terms of mode of arrival, the HFU is

14

less likely to walk in (p<0.001), and more likely to arrive by BLS (p<0.001). The two groups did not, however, statistically differ in their ALS, police and other modes of arrival. The top three diagnoses in NFUs are musculoskeletal pain, abdominal emergencies, and chest pain. The prevalence of these diagnoses is similar in HFUs; however, asthma, alcohol intoxication, and psychiatric disorders are more common than chest pain in the HFU cohort. Although back pain is a prevalent diagnosis in both groups, alcohol intoxication, drug abuse, seizure and COPD exacerbations are unique to the HFU top ten diagnoses list. Similarly, kidney stones, vaginal bleeding, URI, and laceration are unique to the NFU top ten diagnoses list.

CONCLUSIONS: We sought to identify and characterize a subgroup of ED patients classified as high frequency users, and compare them against the general, non-high frequency user, ED population. The HFUs are predominantly male, older and there are significant differences between these groups in terms of age distribution, race, disposition, and modes of arrival. HFUs and NFUs have a similar prevalence of musculoskeletal pain, abdominal emergencies and chest pain; however, HFUs have a higher prevalence of asthma, alcohol/ substance abuse, and psychiatric disorders.

The HFUs at our facility are a heterogeneous group with similar rates of arrival by ALS and admission rates when compared with the NFU population. Hence, the high frequency users who were previously thought to over-utilize the ED may share similar acuity as the general, NFU ED population. In order to better meet the needs of our HFU population, we will need a thorough understanding of their characteristics. These patients clearly have unique needs that require greater investigation and a multi-disciplinary strategy for improved coordination of care.

Program Director: Otto Sabando, D.O., FACOEP St. Joseph’s Regional Medical Center Paterson, NJ

The PULSE April 2010

Third Place Winner

Patient analysis as a function of mode of arrival to the Emergency Department.

Author: Tamara Moise, D.O. BACKGROUND: Descriptive emergency medical services (EMS) studies have provided the health care community a better understanding of their EMS populations, and have been essential in making informed decisions with regard to the management of EMS systems. In this study, we sought to describe several characteristics of our patients based on their modes of arrival to the emergency department (ED). We hope that this information will help tailor our EMS services to meet the changing needs of our growing patient population.

METHODS: This was a retrospective study that was conducted at St. Joseph’s Regional Medical Center in New Jersey, a 651-bed academic tertiary medical center located in an urban setting. From our hospital database, we obtained patient visit information for all visits by patients 21 years or older, from April 1, 2007 through March 31, 2008. We excluded records: for patients who were under age 21, that were grossly incomplete, which represented duplicated charts, and for visits with an unknown mode of arrival. We identified and characterized patients who arrived by four different means: Advanced Life Support (ALS), Basic Life Support (BLS), on their own (Walk-In), and via police (Police). We studied patient age, sex, disposition, floor assignment, race, arrival date and time.

Chi-square and Unpaired Student T-tests were used to analyze these characteristics.

A p-value of less than 0.05 was used to indicate statistical significance.

RESULTS: Of 92,574 total records, 8337 were excluded. 7,428 of these excluded records were pediatric patients whose age was measured in months, and so were erroneously categorized as adults during data collection. Age histograms created for all four groups revealed bell-curves that skewed to the right; however, the Police

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• A FOUNDATION DEDICATED TO RESEARCH IN OSTEOPATHIC EMERGENCY MEDICINE

mode of arrival had the sharpest decline in older patients. As compared to Walk-In, we found the following: ALS had a significantly higher mean age, Police a significantly lower mean age, and no difference in BLS. There were significantly fewer females in ALS, BLS and Police. ALS and BLS groups had statistically higher rates of admission, 54.6%, 29.9%, respectively, as compared to Walk-In, 20.9%; p < 0.0001 for both comparisons. There were no differences in admission rates between the Police (17.6%) and Walk-In groups. When compared to Walk-In, all other groups had similar rates of patients who left against medical advice.

ALS patients were significantly less likely to leave the ED without treatment, or without being seen (2.6% vs. 7.6%), p < 0.0001.

ALS, BLS and Police had a significantly higher ED mortality rates. For patients

who were admitted, floor assignments were similar for Walk-In and BLS groups, telemetry and medical floors comprised 2/3 of each group’s assignments. ALS patients had the highest incidence of intensive care unit admissions (30.2%), followed by Police patients (15.3%). Police had the highest percent of psychiatric admissions (20.0%) and OB/GYN admissions (5.9%). Patient volume by month of year revealed a gradual increase in volume every month for all groups except for Police. There was a sharp increase in Police visits around January 2008, when we acquired a new contract to treat local jail prisoners. Finally, with respect to time of day, all groups showed the lowest patient volume around 5:00 AM and a peak in volume around 12:00 PM. CONCLUSIONS: We identified several differences in patients arriving to the ED by

ALS, BLS, and Police as compared to WalkIn. ALS patients tend to be older, have higher admission and ED mortality rates, and tend to be admitted to higher acuity floors. BLS patients are similar in age, and in floor assignments, but also have higher admission and ED mortality rates. Patients arriving by Police are younger, mostly male, have similar admission rates, but have greater ICU, OB/GYN, and Psychiatric admission rates. All patients have similar peak and trough arrival times. This study sheds light on many trends that can guide us in further developing our EMS system.

Program Director: Otto Sabando, D.O., FACOEP St. Joseph’s Regional Medical Center Paterson, NJ

Thanks to our 2009 contributors who have given their support to FOEM when it has been needed the most!

2009 Contributions

$7500 and Above EMCare Emergency Medicine Physicians (EMP) Schumacher Group

$2,500 - $7,499 Joseph J. Kuchinski, D.O., FACOEP Sherry Turner, D.O. NORCOM, Inc.

$1000 - $2,499 Joseph J. Calabro, D.O., FACOEP Anita W. Eisenhart, D.O., FACOEP MedExcel, USA

$500 to $999 Gary Bonfante, D.O., FACOEP

Thomas Mucci, D.O., FACOEP-Dist Bruce Whitman, D.O., FACOEP $250 to $499 Juan Acosta, D.O., FACOEP Sheldon Bender Thomas Brabson, DO, MBA, FACOEP Mark Foppe, D.O., FACOEP Stephen G. Kaiser, D.O., FACOEP Peter Kaplan Drew A. Koch, D.O., FACOEP Beth Longnecker, D.O., FACOEP David T. Malicke, D.O., FACOEP Michael D. Passafaro, D.O. Jon-Pierre Pazevic, D.O., FACOEP John C. Prestosh, D.O., FACOEP Abdulraham Qabazard, DO, FACOEP Janice Wachtler James S. Walker, D.O., FACOEP Gary Willyerd, D.O., FACOEP-Dist

The PULSE april 2010

Valerie Woodmansee, D.O., FACOEP

$100-$249 Anthony Affatato, D.O., FACOEP Mary Lynn Arvantis, D.O., FACOEP Mark Banas, D.O. John W. Becher, D.O., FACOEP-Dist Gregory J. Beirne, D.O. FACOEP Victoria Camba, D.O. Gregory Christiansen, D.O., FACOEP Duane Corsi, D.O., FACOEP Kenneth Doroski, D.O., FACOEP Stephen Dubos, D.O. Donald Findlay, D.O Greg Frailey, D.O., FACOEP Christine F. Giesa, D.O., FACOEP Gregory Gray, D.O. Anthony Guarracino, D. O., FACOEP Regina Hammock, D.O. John Herrick, D.O.

15

• A FOUNDATION DEDICATED TO RESEARCH IN OSTEOPATHIC EMERGENCY MEDICINE

• A FOUNDATION DEDICATED TO RESEARCH IN OSTEOPATHIC EMERGENCY MEDICINE

Douglas M. Hill, D.O., FACOEP Anthony Jennings, D.O., FACOEP Risty Kalivas, D.O., FACOEP Bryan Kane, M.D. Michael Kelly, D.O. Jay Kugler, D.O., FACOEP Johanna R. Leuchter, D.O. Brandon Lewis, D.O., FACOEP Mary-Lin Magarelli, D.O., FACOEP Ned A. Magen, D.O. William E. McConnell, D.O., FACOEP David L, McKelway, D.O. Mark A. Mitchell, D.O., FACOEP Steven J. Parrillo, D.O., FACOEP Carol Rahter, D.O. Abdulrahman Raja, D.O., FACOEP Brian J. Robb, D.O., FACOEP Mark S. Rosenberg, D.O., FACOEP Michael P. Ruggiero, D.O. Alfred Sacchetti, M.D. Jeffrey A. Sendi, D.O. Regina Sexton, D.O. Michael E. Sheehy, D.O., FACOEP Duane D. Siberski, D.O., FACOEP Purabi Mehta Simon, D.O. Jessica Sop, D.O. Theodore Spevack, DO, FACOEP-Dist Murry B. Sturkie, D.O., FACOEP Robert Suter, D.O., FACOEP Harrison Tong, D.O. James Turner, D.O., FACOEP John A. Tyrrell, D.O. Kevin Weaver, D.O. Stacy Williams, D.O., FACOEP Thomas Wills, D.O., FACOEP Jennifer Bantley Wilson, DO, FACOEP Kristy Ziontz, D.O.

Under $100 Andrew C. Allison, D.O., FACOEP Louis Allocco, D.O. Victor Almeida, D.O., FACOEP Daniel Anderson, D.O. Daniel Angeli, D.O., FACOEP Michael Philip Applewhite, D.O. Michael Baker, D.O. Clyde Banner, D.O. Charles D. Black, D.O.

16

Paul A. Blackburn, D.O., FACOEP Brian S. Blaustein, D.O., FACOEP Melinda L. Boye-Nolan, D.O. Wallace M. Broadbent, D.O. Terry L. Carr, D.O. Christopher J. Case, D.O. Tania Castro, D.O. Lawrence Cherish, D.O. Allen W. Cherson, D.O. Mark E. Chicon, D.O., FACOEP-Dist Rodney Cox, D.O. Melissa Cusumano, D.O. Mario D’Alessandro, Jr., D.O. John Ditchman, D.O. Jean Emmanuel Dorce, D.O. Craig Dues, D.O., FACOEP Ronald Dupler, D.O., FACOEP Robert M. Duvoisin, D.O. Michael C. Eastman, D.O. Trudie J. Ellenberger, D.O. Randy A. Engelman, D.O. Robert Esposito, D.O. Armand Eusanio, D.O. James P. Farinosi, D.O. Mark L. Fennema, D.O., FACOEP Clifford J. Fields, D.O. Jon Finch, D.O. Bryan T. Fitzgerald, D.O., FACOEP Chip Fowlkes, D.O. Jean-Claude Frank, D.O Kevin Franks, D.O. J. Gregory Frappier, D.O., FACOEP Michelle Gebhard, D.O. Jeffrey A. Giese, D.O. Richard Giovannini, D.O. Bernadette B. Gniadecki, D.O. Edward E. Goetten, D.O. Sheryl L. Gottlieb, D.O. David T. Grinbergs, D.O. Gregory J. Hall, D.O. Karl Harnish, D.O. Bernard Heilicser, D.O., FACOEP Ralph Charles Hess, D.O. James Hildebrandt, D.O. Michael Hohlastos, D.O. Timothy Holt, D.O. Raymond G. Hughes, D.O., FACOEP Anwar Hussain, D.O. Jody Johnson, D.O.

The PULSE April 2010

Donald Gregory Jones, D.O. George M. Kaiser, D.O. Laura Kasper, D.O. Kenneth R. Keller, D.O. Thomas E. Klie, D.O. William Kokx, D.O., FACOEP Henry Landsgaard, D.O. Paula Lange, D.O., FACOEP Aaron Love, D.O. Rose Mack, D.O. Mary Malcolm, D. O. James T. Massimilian, D.O., FACOEP John McCarthy, D.O. Maureen McCarville, D.O. James L. McMullen, D.O., FACOEP Shawn Minor, D.O. Alicia A. Morales, D.O. Javier Morales, D.O., FACOEP Arlene F. Mrozowski, D.O., FACOEP Joe A. Nelson, D.O., FACOEP Jeri Norman, D.O. Paul Numsen, D.O. Julia Ann Obrien, D.O. William E. Osborn, D.O. Dana F. Parsons, D.O., FACOEP Celine Paulus, D.O. Donald G. Phillips, D.O., FACOEP Amy Poholski, D.O., FACOEP Christopher M. Posey, D.O., FACOEP Karen H. Rickert, D.O. William D. Ross, D.O. Brandon Russell, D.O. Henry R. Schuitema, D.O., FACOEP Tamara Scott, D.O. John R. Scranton, D.O., FACOEP Donald J. Sefcik, D.O., FACOEP James Shuler, D.O., MS, FACOEP Steven Shy, D.O. Brian S. Silverman, D.O., FACOEP Glenn F. Suacillo, D.O., FACOEP Michael Summerfield, D.O. Steven Talbot, D.O. Brandon T. Thomas, D.O. Michael F. Todd, D.O., FACOEP Dinesh Verma, D.O. Stephen J. Vetrano, D.O. Jared Wolfert, D.O.

calendar of events AmericAn college

of

o s t e o p At h i c e m e r g e n c y m e d i c i n e The American College of Osteopathic Emergency Physicians (ACOEP) exists to support quality emergency medical care, promote interests of osteopathic emergency physicians, support development and implementation of osteopathic emergency medical education, and advance the philosophy and practice of osteopathic medicine through a system of quality and cost effective healthcare in a distinct, unified profession.

2009

2011

Scientific Assembly

Emergency Medicine: An Intense Review

September 29 - October 3, 2009 Westin Copley Place Boston, MA

January 5 - 10, 2011 Westin River North Chicago, IL

Oral Board Review

Program Directors Workshop

October 23 - 24, 2009 Four Points Sheraton Chicago, IL

January 30 - February 1, 2011 Hilton Marco Island Marco Island, FL

2010 Emergency Medicine: An Intense Review January 6 - 11, 2010 Westin River North Chicago, IL

Spring Seminar April 26 - 30, 2011 Marriott Harbor Beach Fort Lauderdale, FL Scientific Assembly

ACOEP Board of Directors Retreat January 28 - 29, 2010 Hilton Marco Island Beach Resort Marco Island, FL Program Directors Meeting January 31 - February 2, 2010 Hilton Marco Island Beach Resort Marco Island, FL Spring Seminar

October 11 - 15, 2011 Encore at Wynn Las Vegas Las Vegas, NV

The Building Block of osTeopaThic emergency medicine

April 6 - 10, 2010 Westin Kierland Resort Scottsdale, AZ AOA United Osteopathic Convention October 24 - 28, 2010 San Francisco, CA

The PULSE april 2010 Please note that these dates and locations are subject to change.

142 E. Ontario Street Suite 1500 Chicago, Illinois 60611 www.acoep.org 17 (800) 521-3709

Student Paper, continued from page 11

Editorial, continued from page 4

Executive Directors Desk, continued from page 5

15. Crandall J (2007) Nonketotic Hyperosmolar Syndrome. Retrieved Jan 23, 2009 from The Merck Manuals Online Medical Library, http://www.merck.com/ mmpe/sec12/ch158/ch158d.html 16. Zierler, KL, Rabinowitz, D. (1964) Effect of very small concentrations of insulin on forearm metabolism. Persistence of its action on potassium and free fatty acids without its effect on glucose. Journal of Clinical Investigation; 43:950 17. Fishbein, HA, Palumbo, PJ. (1995) Acute metabolic complications in diabetes.

In: Diabetes in America National Diabetes Data Group, National Institute of Health, p. 283

The question arises do we treat the patient who presents with an acute exacerbation of chronic pain who presents to the emergency department. The answer is not so straight forward and creates a contradiction for the physician. As physicians we are compassionate individuals who want to relieve our patients of their pain, anxiety or any other discomforts that brought them to the emergency department. This must be weighed against the fear of creating an addiction, of being investigated by law enforcement or licensing authorities and of being duped by the drug seeking patient.

The next edition of the Pulse will continue with this topic of An Acute Exacerbation of Chronic Pain. It will explore what constitutes a drug seeking patient, oligoanalgesia and the treatment options available to the emergency medicine physician.

These articles are taken from a lecture that I presented on The Management of the Narcotic Dependent Patient in the Emergency Department.

So this is for Jeannie, and my request that all of you remember the importance of educating not only the patient, but their families and even though you are busy, take a few minutes to follow up with that patient who leaves your emergency department with a phone call just to see if they are doing well. It may not mean a lot to you, but to patients it could mean a lot and could be a call that prevents a death. If only the physician she visited had called when she missed her appointment; if only her family was aware that these were symptoms worth worrying about, if only . . .

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combined with stability – a place where individual

Pennsylvania: Brandywine Hospital - Coatesville Chestnut Hill Hospital - Philadelphia Lewistown Hospital – Lewistown Lower Bucks Hospital – Bristol St. Joseph’s Medical Center – Reading Wilkes-Barre General Hospital – Wilkes-Barre

potential is recognized and supported.

North Carolina: Onslow Memorial Hospital – Jacksonville

with your lifestyle and goals.

As a physician with an affiliated region of a leading national company, you have flexibility and freedom

Call Julia at 800.848.3721, Ext. 7, or send an email to jromano@teamhealth.com

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0210 THE ACEP ad.indd 1

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2/2/2010 12:48:21 PM

The PULSE April 2010

KENT HOSPITAL

Warwick, Rhode Island

Hyperbaric Medicine Fellowship Department of Emergency Medicine and Wound Recovery and Hyperbaric Medicine Center Accepting applications for 2010-2011 academic year ➼ AOA approved Fellowship leading to CAQ eligibility in Undersea & Hyperbaric Medicine (one of only two such programs in the US) ➼ 12 month curriculum ➼ Clinical monoplace chamber training ➼ Clinical multiplace chamber training ➼ Clinical wound care training ➼ Diving medicine training ➼ Emergency Dive program (joint Emergency Medicine-Wound Center program) ➼ Clinical research opportunities available ➼ Academic faculty certified in Undersea & Hyperbaric Medicine ➼ Certified Referral center for the Divers Alert Network (DAN) Kent Hospital, a major teaching affiliate of the University of New England College of Osteopathic Medicine, is a 24 hour per day hyperbaric medicine referral center for southern New England. Our hyperbaric unit is the busiest in New England.

We are now accepting applications for our Hyperbaric Medicine Fellowship for the 2010-2011 academic year. The fellowship consists of a one year curriculum with a clinical focus on wound care, dive medicine, and hyperbarics. Applicants must be osteopathic physicians who have completed an AOA- approved residency.

For a fellowship application or more information, please contact: Ms. Shannon Vacha Office of Graduate Medical Education Kent Hospital 455 Toll Gate Road, Warwick, RI 02886 (401) 737-7010, Ext. 5641 svacha@kentri.org

The PULSE april 2010

19

The On Deck Circle Anthony W. Jennings, D.O., FACOEP President-elect Welcome to spring! After this cold, wet, snow blinding winter we have deserved a break.

We certainly had a taste of winter for all of the states. Even the southern contingent was not spared this year! Fortunately for most of us we did not suffer the predicted battering of the flu which was predicted.

But again it “ain’t over . . . just yet.”

Hopefully we will continue to dodge the flu this year.

This winter has been difficult on other fronts with disasters occurring abroad. We

have watched once again as human tragedy played out and pondered how things could have been improved. It is difficult to watch these scenarios play out. As compassionate healthcare providers we wish we could do more to help. I think we have improved with each of the disasters over the last few years but we still have a long way to go.

This past winter, the ACOEP held a retreat at Marco Island to validate who we are, what we are doing, and what direction we are going. The meeting was a success as Dr Brabson has commented. We as

your leadership look to implement the ideas generated by this session over the next several years to deliver to you an organization which serves and meets your needs.

My activities over the winter months were interrupted by illness. I will miss you at the spring meeting but hope to be fine tuned and ready to go by July. The days are getting better for me now and hopefully it will not be long until I am back to self.

My best wishes to you all and have a great spring!

Presidential Viewpoints, continued from page 1

and guide productive changes. We have also begun to develop metrics to better evaluate the changes that we implement. We will evaluate our committee structure and better define what is necessary for the business of the College and determine what structure would better serve fostering special interest groups in the College. The topic areas for each category are: 1. Membership – Recruitment and Retention, Students and Residents, Member Forums, Benefits and Services, and Leadership Development.

2. Advocacy – Government Relations, Physician-Patient Relations, AOBEM, Allied Healthcare Organizations, and Staffing.

3. Awareness and Marketing – Technology Application, College Publishing, Collaborative Efforts with Other Organizations.

4. Education and Knowledge – Marketing and Outreach, Graduate

Medical Education, On-Line Education, Conferences, FOEM, Speaker Bureau, and Bookstore.

5. Organizational Performance – Performance Measures, Diversify Revenue Sources, Professional Staffing, Governance and Leadership, and Committee Structure.

I hope that this summary of our recent strategic planning meeting demonstrates to you that our Board, Executive Director, and College staff has a solid plan which will be used to further develop the ACOEP. I would like to publicly thank each of the members of the ACOEP Board of Directors, Jan, and Bob Harris for their dedication and devotion to creating the great strategic plan that we were able to produce. I also want to remind each of our members that we invite and encourage you to be an active participant in our College. I continue to be concerned that we have much

5. The osteopathic emergency physician has the responsibility to assume a lead role in promoting the principles of osteopathic medicine.

6. ACOEP supports the constituents of osteopathic emergency medicine.

7. Osteopathic emergency physicians should demonstrate professionalism.

The Board also discussed strategic goals for the College. Our prior goals were reviewed with a critical analysis of the successes, failures, and areas that were either in process or for some reason incomplete. We decided to take our list of goals and incorporate them into 5 categories. The five categories are: Membership, Advocacy, Awareness and Marketing, Education and Knowledge, and Organizational Performance. The topic areas of each category will be used to evaluate our current operational structure

Opportunity

When one door closes, another opens; but we often look so long and so regretfully upon the closed door that we do not see the one which has opened for us.

20

~Alexander Graham Bell, Inventor

The PULSE April 2010

Osteopathic Residencies on the Cutting Edge: Training for the Real World Tim Cheslock, DO Resident Chapter President It is a question I often hear from medical students on rotations or at meetings-- Do you think your training is good enough to make it in the real world when youâ&#x20AC;&#x2122;re finished? Another version may be something like, you didn't train in a level 1 facility, except for 2 months, and do you feel you had adequate exposure to trauma? I could go on and recite 10 or more versions of similar questions that show the concern among medical students about the quality of Osteopathic EM programs for one reason or another. Most, if not all, of the questions arise because they are simply misinformed about what the real world of EM is about or because someone has given them bad information to begin with. Discussions about ED volumes and numbers of cases seen during a shift seem to dominate conversations about what makes a certain EM residency worth its salt. Reinforcing the myth that the only way to get the best training is to go to an institution where the volumes are astronomical and there is an association with a large academic institution. It tends to put most residents and faculty on the defensive from the get-go.

Especially when their program doesn't have the stellar stats that everyone is looking for.

Imagine my surprise when I recently picked up one of the other circulating EM newsletters and found a topic very similar to this.

But instead of touting their huge volumes and stellar academics, the article's authors related what we have been preaching for years - that this environment isn't EM in the real world. The real world consists of community ED's with much smaller volumes and not so unique circumstances, where a cath lab is not available 24/7 and there is

no in house neurosurgeon; a place where you may need to push TPA for an MI or reduce an elbow dislocation. You have to respond to in house codes, because there is no house staff. Consultants are not readily available to make all the tough calls. The authors pretty much came out and stated that the current system does residents training in these locations a huge injustice in not preparing them to work in this type of environment, that is by far more common a job setting than the high volume, level 1 facilities where they trained. They go on to say how inefficient large institutions are on so many levels from patient throughput, to dealing with patient satisfaction issues and the psychosocial dilemmas of the day.

I sat back and was dumbfounded. What's even more dĂŠjĂ -vu is that I made a similar statement at our recent Board of Director's retreat when discussing how we market our residencies to students. I went back to my notes and there it was- "We train residents to practice EM in the real world."

Osteopathic EM residencies number far fewer in total number than allopathic programs, but looking at them collectively an interesting pattern comes to pass. At least half of our training programs are in facilities with annual ED volumes between 30,000 and 60,000 visits per year. The other half has volumes greater than that, but many are total volumes distributed over several hospitals within a healthcare system.

Typically Osteopathic EM programs are found in institutions where there are only a few other post graduate residencies, so the competition for procedures and hands on management is not a concerning issue.

While many of our programs are not in

isolated small hospitals, they are closer to the community setting that many of our graduates will migrate to once they complete their training. Even though this is the case, the numbers of patients we see, the procedures we record and the challenges we face are just as complicated as those who train in a much larger institution. Could it be that for once Osteopathic EM training will be recognized as being at the forefront of the next great trend in EM training? Will reading this type of statement from our Allopathic counterparts makes Osteopathic students realize what a true benefit it is to train in our programs, rather than trying to go outside the match? Will it drive home the point that we really do know what we are talking about when we tout the benefits of smaller institutions? Only time will tell. Is our training better than theirs? Not really. Is it more realistic of the challenges you will face as an attending physician?

Definitely!

What I can say personally is that the training I have received thus far has been stellar and I feel that my knowledge base and procedural skills could hold their own when put up against a graduate from any allopathic EM program. I am proud to be an Osteopathic Emergency Physician and will do my best to continue to help grow the profession and encourage continued development of new programs in community settings where our impact will be most felt and have the greatest impact of newly minted EM physicians so that they are prepared to function in the Real World of Emergency Medicine.

On Responsibility . . .

You cannot help men permanently by doing for them what they could and should do for themselves.

~Abraham Lincoln, 16th President

The PULSE april 2010

21

In My Opinion Wayne T. Jones, D.O., FACOEP

The Case of Creeping Determinism

OK, last time we spoke I introduced you to the theory of creeping determinism. If you recall, this is a theory, which describes how we rationalize outcomes and events. Society has used it to rationalize the outcome of wars (i.e. it was because Bush attacked Iraq) and why sex offenders do what they do (bad parents).

Remember, I warned you. Medicine needs to prevent utilizing such whimsical theory as a prediction model for disease outcomes. See In My Opinion: Do we create studies to prove our experiences? (The Pulse, January 2010, Volume XXXV 1, pg 15) Well, it is happening, and I bet few people realize how many times they have seen creeping determinism. Society has become so accustomed to its use that we just accept the process. The nightly news with Dan Rather uses it all the time. In fact, I use it in day-to-day conversation. Events need to make sense, so we try to tell the most reasonable story.

I received a forwarded news article from my local Department of Health, “Is appendicitis a viral disease?” by HT Media Limited, an international news organization. HT was sighting a recent article in the Archives of Surgery, Association of Viral Infection and Appendicitis. The article housed tables and graphs dicing the incidence of influenza and appendicitis from 1970 to 2006. The article’s conclusion, although wordy and soft in its approach, stated there was a “significant cointegration between the annual incidence rates of influenza and nonperforated appendicitis”.

What?

So, I pulled the article. Figure 1 on page 64 contains a graph trending influenza and appendicitis. Appendicitis follows a continuous downward trend since 1970 while influenza is not as well trended. I am not sure I can swallow this conclusion. I am certain, though, that I can use creeping determinism to make up some of my own hypotheses.

22

Sugar consumption averaged 114 pounds per capita in 1967. This number has risen to 142 pounds of sugar for each American annually. Now, this may take some data splitting, but maybe appendicitis can be prevented if we consume more sugar. The trended data for both sugar consumption and the diminishing incidence of appendicitis appear similar.

OK, don’t like that one. Here is another. Over the past 20 years there has been a dramatic rise in obesity. We eat more and exercise less. The CDC reports that very few states had obesity rates above 10% in 1985 while those same states now have obesity rates approaching 35%. My hypothesis is that obesity bestows protection from appendicitis since the drop in appendicitis mirrors the rise in obesity over the same time period. If we expand on this, I bet that if you eat more sugar and gain a lot of weight, you may never suffer from appendicitis. No? Try this one.

Studies indicate that the average global surface temperature has increased by approximately 1.0°F over the last century.

This is the largest increase in surface temperature in the last 1,000 years and scientists are predicting an even greater increase over this century. This warming is largely attributed to the increase of greenhouse gases (primarily carbon dioxide and methane) in the Earth's upper atmosphere caused by human burning of fossil fuels, industrial, farming, deforestation activities and bovine flatulence. This trend also mirrors the decline in appendicitis… and yes… it fits our model. In fact, if we continue to eat more sugar and steak (remember we need to continue creating the bovine flatulence), we will be warmer, fatter and less inclined to fall prey to appendicitis. What? Still skeptical? Ok, one more. God, this is fun.

The stock market has had its ups and downs over the past few years, but on the average, we have seen a steady increase in stock returns over the past several decades.

The PULSE April 2010

Following in this trend, we as Americans have lived more and more prosperous lifestyles. Things are good now. In fact, things are so good we are seeing less appendicitis.

Face it… we eat more sugar, grow flatulent cattle, get fat, raise the earths temperature and are blessed with less appendicitis. I think I am going to publish this.

Get Involved with ACOEP Have you ever wanted to make your voice heard?

Here’s your chance to get involved in Committees, Special Interest Groups and the Board of Directors of the ACOEP. If you are interested, send your CV and a cover letter, by fax, email or regular mail letting us know.

Submit information to: Anthony Jennings, D.O., FACOEP, President-elect ACOEP 142 E. Ontario Street Suite 1500 Chicago, IL 60611 312-587-9951 (fax) swhitmer@acoep.org Nominations for 2011 are being reviewed now for members, chairs and even potential candidates for positions on the Board of Directors for terms beginning in the fall of 2011 – 2013. Board & Chair candidates must fellows of the College, Committee members must be members of the College and in all cases you must be committed to attend the Committee meetings and to participate in the activities and assignments of the Committees.

Nominations will be accepted through October 1, 2010.

Information received after that date will be delayed until 2011 cycle.

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

Ethics in Emergency Medicine: What Would You Do? The following ethical dilemma was raised during a recent FEMA Medical Specialist Class.

A difficult rescue operation is being undertaken at a structural collapse. An urban search and rescue team has located 3 victims in the rubble. This has been a rather prolonged operation and we are a few days into the rescue attempt. All the victims are awake, but clearly hypothermic, dehydrated and suffering probable crush syndrome from entrapment.

The first victim is a few feet in front of the other two and is blocking access to them.

Victim 1 will not be able to be extracted without an above the knee amputation.

Additionally, the other two victims cannot be accessed without extraction of Victim 1.

Victims 2 and 3 do not appear to require amputation for removal.

When informed of the life saving need to amputate, Victim 1 states he will not allow this to occur, and would rather die intact.

Repeated discussion is unsuccessful in dissuading this refusal. Victim 1 fully understands his refusal will surely result in his death. Tragically, this refusal will prevent probable successful extraction of Victims 2 and 3, resulting in their deaths.

The PULSE april 2010

Does Victim 1 have the right to refuse his own life saving procedure, and does he have the right to have this decision result in the death of others?

You have worked days to get to these victims, risking your life and those of your task force.

What would you do?

Please send your thoughts and ideas to (fax 708-915-2743). Every attempt will be made to publish them when we review this case in the next Pulse.

23

On the Wild Side James Shuler, D.O.,MS, FACOEP, FAWM

Medical Support of Endurance Events Are you the type of person who likes to participate in multi-day walks, rides, other events—or do you perhaps enjoy providing medical support for those who do? I certainly do. I know that through my lectures to the ACOEP, I’ve harped on this before, as I’m an ER doc who has been participating in and providing medical event support for benefit walks and rides for years. I absolutely love it. Whether you want to participate or provide support, I have learned a few things that can enhance your experience, enabling you (and others!) to enjoy the event much more while avoiding many of the troubles that lie on the rocky road.

When I am the medical director of an event, I find that a brief preliminary discussion with all of the participants is worthwhile. On the first three-day walk I participated in, nearly five percent of the participants required intravenous hydration and medications at some point during the event. Although all of the nutrition and electrolyte requirements were readily available, participants weren’t educated about what they needed to do to keep themselves happy and healthy along the way. It didn't take long for me to see a pattern of errors emerge, errors that easily could have been avoided. Since that first walk, I’ve made it a priority to speak to all the participants before the event begins, and the results have been outstanding. In the past ten years, I’ve been the medical director of thirty plus such events and only two participants have required any intravenous intervention on the walks since participant “education” has been given.

As an aside, I can’t stress enough that this “education” must be done in a humorous way that “captivates” the audience.

I use examples of where “failures” happened, most winding-up in the Emergency Department with some near-fatalities.

Truly, this hits a “home-run” with the audience.

One of the first issues I address with participants is that of adequate hydration.

24

Adequate hydration is easy to monitor through the output of the participant’s urine. Many of those enrolled fail to realize that their increased respiratory rate and increased perspiration will cause them to lose valuable fluids. A complicating factor is that with physical exertion, the heart rate also increases. This leads to a natural increase in the amount of blood presented to the kidneys, which have no choice but to filter. Subsequently, urine output is increased, leading to further fluid loss. Since participants judge their urine output to be normal—or even increased—they may erroneously assume that they’re hydrating their bodies adequately. However, frequent urination is not on its own a reliable indicator of hydration. A better measure is the color of the urine. An adequately-hydrated participant should urinate quite frequently, and the color should be a very light clearyellow.

When it comes to electrolytes, research has shown the body has an uncanny ability to take what it needs from the environment. A fascinating study explored what happened when participants ingested colorcoded salt tablets, where the color of the tablet corresponded with the strength of the tablet. Though the participants didn’t know the strength of the tablets, their bodies figured it out pretty quickly. In only twenty-four hours, participants learned—or rather their bodies learned—how to adapt their behavior to maintain an adequate salt balance based on their experience with the colored tablets. This study also suggests that if a wide variety of electrolyte and nutrient replacement items are provided, the body will take in what is needed. Again, however, participants need to be educated about the availability and importance of such health aids. Otherwise—excuse the pun—the participants and their bodies will be left high and dry.

Another fascinating study has shown that during endurance events, one of the most common ailments is water toxicity. What’s

The PULSE April 2010

tricky about this is that the symptoms of water toxicity closely mimic the symptoms of heat-related illness, “clouding” your treatment regimen. During an event I was involved in many years ago, patients having the typical symptoms of heat-related illness that were given 2L of intravenous normal saline and two rounds of nausea medications. If this treatment failed to address their symptoms, they were sent to the local emergency department. There, under my care, they received another liter of intravenous normal saline and further anti-nausea medication. If this treatment regimen failed to respond, blood work was subsequently sent to the lab. Of the thirty patients treated that day, ten had a metabolic panel checked, and of these ten, every single person demonstrated hyponatremia ranging from 110 to 128 mEq per liter. One patient was so low she even presented in status-epilepticus. She was in critical condition; room-air saturations were in the 70’s, chest X-ray showed a complete “white-out” and her head CT showed dramatic swelling.

What does this tell us? That none of these patients had "heat-related" illness; instead, they were all "water-toxic." Lack of education proved near-fatal.

Because endurance events have become so popular, science has had a real chance to study the athlete very thoroughly, although it is still lacking in some of the most basic science. Some of the things scientists have found are astounding. For instance, fluid loss through sweat varies greatly even between similar athletes performing at similar events under the same conditions.

Losses can be anywhere from minimal to literally gallons a day, at a rate approaching a gallon an hour! Electrolyte loss can be just as unpredictable. To further complicate things, several studies have shown that even the amount of fluids and electrolytes lost by a single individual will vary greatly from day to day at similar events. Ugh! Given so much uncertainty, how can we figure out what the heck to do?

On the Wild Side continued from on page 24 Simple: Listen to Mom… Mothers tell their children, “Listen to your body.” And according to the studies, these moms are right. If carbohydrates are what you “feel” you need, then eat them.

If the fruit looks good, eat it. How about a pretzel? Potato chips? A PB & J? If it looks good, eat it. The take-away lesson for those planning endurance events is to have “everything” available at regular stations.

As for how to space out these stations, it comes down to this: If a participant feels the need for a drink or a snack, it should be

there. Generally for “walkers,” offer water at every 1.5 miles with full sustenance at every 3 miles. And for “riders,” triple that, meaning water every 4-5 miles and a “fullstop” with all “whistles and bells” at every 10 miles.

To date, there is scant literature supporting the importance of participant education and adequate provisions during multi-day walks, rides, and other similar events. My own experience tells me without a doubt that addressing these issues will dramatically reduce emergency department referrals.

That said, an excellent study that will be published soon in the Wilderness Medical Society’s Journal, did a retrospective review

of five years of The Register’s Annual Great Bike Ride Across Iowa (RAGBRAI). In that study a clear line of heat-related issues dramatically increased when the ambient temperature rose above 80ºF. Consequently event supporters need to keep that number in mind.

In my next note I will talk about what type of injuries to expect during events like these, as well as what kind of “medical kit” you should take with you, based on the event’s locale. Until then, keep getting out there and having fun—and help the other participants do the same!

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Resident Chapter Update

by Tim Cheslock, DO Resident Chapter President

I hope everyone is enjoying Spring!

As we move forward to the end of another training year, many are preparing to move on to their first real job as new attending physicians. You have been down a long road and finally can see the light at the end of the tunnel. In the same breath we say welcome to a brand new class of residents who matched just a few short weeks ago and will be starting in July. It seems like the cycle moves so quickly, and yet at other times it seems there is no end in sight.

The resident chapter leadership held a Conference Call in February to review the Spring Seminar Agenda and make preparations for the Fall Scientific Assembly. Every year the participation in both meetings has been increasing by significant numbers. We expect an even larger resident turn out in Scottsdale this year with the addition of the Research Poster Competition. While

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Spring Seminar is traditionally more of a working week for the resident chapter leaders who attend committee meetings and other board functions, it is also a time to sit in on some great lectures and have some fun as well! We have also used the Spring Seminar as an opportunity to work with the Student Chapter on several activities. A Resident Panel Discussion, Student Jeopardy Competition and collaborative social events all increase our interaction with the students and hopefully provide some sound advice, mentorship and friendship that will continue to motivate them as they pursue a goal of becoming EM residents.

The Resident Board will be having a strategic planning session during our meeting in Scottsdale to come up with a plan for the next few years. Given the limited time frame we have to work with, this will be

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a challenge, but something that needs to be done. Our collective goals will involve developing a framework and direction of focus for the residency chapter over the next two years. I'm sure we will be incorporating some of the items that were developed as part of the ACOEP's Strategic Plan during the January Board Retreat as well.

I would like to thank the ACOEP Board and members of the college for their continued support of the resident chapter activities!

What would you like to see the Resident Chapter do for you? All Osteopathic EM residents have a representation in the Chapter. Feel free to email me and share your thoughts. You can reach me at tim.cheslock@gmail.com. I look forward to seeing many of you in Scottsdale!

Members in the News Donald Phillips, D.O., FACOEP was named to the Emergency Medical Services Advisory Council for the State of Texas by Governor Perry last January. Dr. Phillips resides in Weatherford (TX) and is emergency medical director of Brazos Emergency PhysiciansEmCare and EMS medical director for LifeCare (Parker County) EMS, Everman EMS, and Azle Fire/EMS. He is a member of the American and Texas colleges of Emergency Physicians, American College of Osteopathic Emergency Physicians, as well as the National Association of EMS Physicians. He is also a volunteer tactical physician for the Weatherford/Parker County Special Operations Group, and a past member of the Frisco Volunteer Fire Department and Ambulance Corps. Phillips received his emergency medical technician certification at Baylor University Medical Center, paramedic certification from Henderson County Junior College, a bachelorâ&#x20AC;&#x2122;s degree from Texas Christian University, and a doctorate of osteopathic medicine from the University of North Texas Health Sciences Center. He is appointed for a term to expire Jan. 1, 2012.

Would you like to announce something happening in your professional career?

If so, contact Mandy Lundeen, Director of Member Services at mandylundeen@acoep.org, in the subject line list Member News and we will pass it onto the Editorial Board for review.

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