The Pulse January 2005

The PULSE

Osteopathic Emergency Medicine Quarterly VOLUME XXX NO. 1

JANUARY 2005

Presidential Viewpoints

Paula Willoughby DeJesus, D.O., FACOEP We have returned home from San Francisco and have already settled back into our daily routine. We begin to mentally make that transition even before we pack and board the plane.

Our thoughts drift home to where we left off. Where we were so quickly trying to tie up the loose ends when we were mentally transitioning to the work of our meetings in San Francisco. We move seamlessly between both paradigms.

Just like our home ACOEP is that constant you can come back to no matter how long you have been away. It is that constant that you count on year after year.

It is also dynamic. It is alive and responsive to the needs of today. Our challenge and our charge are to hold onto those constants while we pave the road ahead.

At home we have a social responsibility to our family and community. From the time we are a child we know we are to say please and thank you. We know we are to help our neighbors. We learn that we will grow up and make the world better by how we live our life. At ACOEP we have that same socio-professional responsibility to our life's work, emergency medicine.

We are drawn together as members of this College. We are accountable to one and another not only to uphold the profession but shape it, guide it and yes, hold onto those constants that ground us. We are responsible to advocate for ourselves and our patients to make health care better by how we practice our profession. As mem-

bers and Fellows of this College we build and contribute to the profession each in our own way.

Over the next two years I would like us to focus on strengthening our infrastructure to prepare us for the future.

The broader the base the taller the tower.

The base of this organization is clearly the member. We are the building blocks.

Our job as a Board, then is to lead this organization by setting an agenda that focuses on the direction and vision of the members. The members, the building blocks that build the base and hold up the tower. Over the next two years the focus will be on the following: • We will revise the constitution to update its definitions of the offices and relationships.

• We will establish specific criteria within the constitution on how new committees, subcommittees and/or sections will be created.

• The Office of President-elect will staff all AOA resolutions with the Executive Committee before the House of Delegates and keep College members abreast of those that are pertinent to emergency medicine.

• The Office of the Secretary will become directly responsible to oversee all of our liaisons to assure the message of the College to these groups is clearly articulated and the ACOEP members filling these rolls are prepared.

• New Board members will have an orientation program and the Board Reference manual will be revised.

• The Officers of the Board will develop and conduct a structured program for all Committee Chairs to outline their responsibilities, orient them to ACOEP process and provide them with the tools to make

their Committee more productive and alive between our meetings.

• I will increase regular communications with the Board members and the Executive Committee.

• Committee Chair and Vice-Chair positions will be filled from the membership.

All Committees will continue to have specifically assigned Vice-Chairs, Board member liaisons and an office staff member to better assure their productivity throughout the year.

• The Student and Resident Chapters will each have an assigned Committee of member mentors. These Resident and Student Chapter Mentor Committee members will assist the Chapters in learning organizational process and guidance in project development. Their Board liaison will take on a more critical role in preparing them for their leadership responsibility as they assume their positions on the ACOEP Board.

• We will bridge alliances that properly position ACOEP in the medical and social community.

We will continue to build the firm foundation that has been established by Dr. Scali and his predecessors. I encourage each and every one of you to step forward, be an ACOEP building block.

Become involved and engaged in shaping your life's work.

I have the privilege of announcing the Committee Chairs for the coming two years. They have distinguished themselves by taking that step and advocating for us through their commitment in leading their Committee's work. They deserve our grateful thanks and congratulations!

You can have it all, right in the palm of your hands.

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Editorial

Drew Koch, D.O., FACOEP, Editor

Changing of the Guard The Pulse has undergone many changes under the stewardship of Dr. Peter A. Bell.

These include: a name change from the ACOEP Newsletter to The Pulse, format changes, content improvement, appearance enhancement, and other improvements that enhanced the ACOEP member publication. The Publications Committee has grown and developed into the Communication Committee and includes not only written material, but other media and electronic forms of communication. Now, the time has come for further change as Dr. Bell steps down as Editor of The Pulse. His leadership and guidance transformed the ACOEP quarterly newsletter from an uninspiring newsletter to a professional publication enjoyed by the membership. Dr Bell will continue to serve on the Communications Committee as he assumes his new role as President-Elect of our College.

The College has also changed since I started attending the annual Spring and Fall Conferences in the early 1990's. The hierarchy of the College was closed. Committee membership was limited, and decision making was retained by a coterie of members. Myself and others attempted membership on various committees, but were denied. The late Benjamin Field, D.O. opened the College to the members

by allowing members on committees. ACOEP embarked on its journey to become a college for the members during Dr. Field's presidency.

This transformation carried over through the presidencies of Dr. Ted Spevack and Dr. Joe Kuchinski, who replaced Board members as committee chairs with members of the College, Dr. Vic Scali and now Dr. Paula Willoughby DeJesus, with her open recruitment of members for committees. With the recent deaths of Dr. Field and Dr. Robert Aranosian, the retirement of Dr. Ben Chlapek from ACOEP's Board of Directors and the shift of Dr. John Becher from ACOEP Board of Directors to ABOEM's Board, ACOEP has been thrust into a new era. This new era however, is guided by the exemplary wisdom and leadership of the previous Board Members who governed ACOEP from its infancy. Their leadership was invaluable and will be sorely missed by the college.

With the changing of the guard and term limits for the Board of Directors, it is incumbent upon you, the members, to become involved in ACOEP. For ACOEP to be truly a College of its members, your participation is essential. The College's strength is in its members and their level of involvement. If you are not a member of a committee, please consider participating in a committee!

If interested in committee involvement, contact Paula Willoughby DeJesus at ACOEP. Committee involvement serves two purposes: first, it involves the member in the College; and secondly, it develops the next generation of leaders for the College.

Historically, The Pulse has solicited the membership for “volunteers” to write articles in the quarterly newsletter. This approach has had mixed results, and is no longer viable!! The Communication Committee has now resorted to capitalism to recruit articles from its members.

The Committee has proposed two different financial incentives to secure new articles for publication in The Pulse. The first involves offering free tuition at the Spring Conference (current a value of $450). This is accomplished by the member submitting 8 articles over 2 years, 6 of which are published in The Pulse.

The second incentive involves lecturers at the Spring and Scientific Seminars who received the highest and second highest evaluations. If these lecturers submit 1000 word abstracts of their lecture to be published in The Pulse, they will receive a cash reward equivalent to their honorarium. This is currently equivalent to $250.

The Communication Committee is looking for new members to serve on three subcommittees. The first subcommittee will be responsible to develop articles and recruit authors. The second subcommittee will solicit advertisers for The Pulse. Finally, the third subcommittee requires a computer savvy individual to work with Jan Wachtler on the ACOEP website. If interested please contact ACOEP. As ACOEP approaches its 30th year, its appearance has dramatically been altered.

ACOEP is no longer governed by a small group of members, but is truly governed and represented by its membership. Thank you for your participation in the College.

Position Available Looking for a better career destination? Make your next stop Frankford Hospitals of the Jefferson Health System.® The Frankford Health Care System’s three premier locations have proudly served the communities of Philadelphia and Bucks Counties in Pennsylvania for 100 years.

Ever evolving and with an ED patient volume approaching 100,000 per year for all three campuses, we include a Level II Trauma Center, systemwide digital and comprehensive cardiac services including EPS and stat interventional cath labs.

Emergency Physicians As an integral member of our ED, we seek physicians with Board certification or eligibility in emergency medicine. You must be qualified and licensed to practice without restrictions in Pennsylvania and registered with the DEA. 8, 10 and 12 hour shifts available. As a member of the Frankford Health Care System, you will enjoy partnering with an exceptional professional team.

We offer a Sign-on Bonus, competitive salary and comprehensive benefits package. Send your resume to: Human Resources, Frankford Hospital, Knights and Red Lion Roads, Philadelphia, PA 19114; E-mail: dprincipe@fhcs.org; Fax to 215-612-4073. www.FrankfordHospitals.org EOE

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Editorial Staff Drew A. Koch, D.O., FACOEP, Editor Paula Willoughby DeJesus, D.O., FACOEP Peter A. Bell, D.O., FACOEP Bobby Johnson, Jr., D.O. Janice A. Wachtler, Executive Director Publications Committee Drew A. Koch, D.O., FACOEP, Editor & Chair Peter A. Bell, D.O., FACOEP, Advisor Bobby Johnson, Jr., D.O., Vice Chair/ Assistant Editor The PULSE is published quarterly (January, April, July, and October) and distributed at no cost by the ACOEP to Members and libraries of Colleges of Osteopathic Medicine by the National Office of ACOEP. The Pulse and ACOEP accept no responsibility for statements made by contributors or advertisers.

Display and classified advertising are accepted. Display advertisements should be submitted as camera-ready, pdf, or jpg formats in black and /white art only.

Classified advertising must be submitted as typed copy, specifying the size, and number of issues in which the copy should be displayed. The name, address, telephone numbers and E-mail address of the submitting party must accompany advertising copy.

Advertisers will be billed for ads following the publication of their advertisements and payments will be due within 30 days of the issuance of the invoice.

The deadline for submission of advertising is the first of the month preceding publication, i.e., December 1, March 1, June 1, and September 1. The deadline for article submission is November 15, February 15, May 15, and August 15. ACOEP and the Editor reserve the right to decline advertising and articles for any issue.

The PULSE and ACOEP do not assume any responsibility for consequences or response to an advertisement. All articles and artwork remain the property of the Pulse and will not be returned.

Subscriptions to the Pulse are available to non-ACOEP members or other organizations at a rate of $50 per year.

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FOEM Update The Foundation for Osteopathic Emergency Medicine is pleased to announce the unveiling of its new web site www.foem.org.

The site features information about the Foundation and provides visitors with access to the applications for FOEM awards and grants and the opportunity to download forms to make pledges or donate to the Foundation. Please visit this new site.

Board Positions. The Foundation is soliciting the names of physicians, corporate leaders, and has non-physician researchers who may be interested in serving on the Foundation’s Board of Trustees. The Board will be expanding to 12 members this year and 6 positions available. Three, 3-year positions are available for existing positions. Positions for terms of 1, 2 and 3 years will also be available.

The Board of Trustees meets twice yearly and are responsibility to create policy, grants and direct the operation of the Foundation. They decide distribution and disbursement of grant allotments.

Interested candidates should contact Jan Wachtler, Executive Director, in writing, regarding their desire to be considered for a Board position. A current curriculum vita must accompany the request for consideration. Requests should be received by March 1, 2005. Terms begin on January 1.

Letters and CV’s may be sent to: Jan Wachtler, Executive Director, FOEM, 142 E. Ontario St., #1250, Chicago, IL 60611. You may fax information to: 312-587-9951 or e-mail it to janwachtler@acoep.org

January 6 – 11 Emergency Medicine: An Intense Review Embassy Suites, Chicago, Lake Shore Chicago, Illinois 40 hours

2005

THE PULSE–AN OSTEOPATHIC EMERGENCY MEDICINE QUARTERLY 142 E. Ontario St., Suite 1250 Chicago, IL 60611 312-587-3709/800-521-3709

February 6 – 9 Program Directors Workshop Marco Island Beach Resort, Marco Island, Florida 8 – 10 hours 9 – 12 Core Essentials Marco Island Beach Resort, Marco Island, Florida 25 hours March / April 29 – 2 Spring Seminar Sheraton Wild Horse Pass, Phoenix, Arizona 25 hours October 22 – 27 Scientific Seminar Orange County Convention Center, Orlando, Florida 25 hours

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Executive Director’s Desk Janice Wachtler

The Art of Listening It's hard to know if we have a hearing deficit or are deficient in our ability to listen to what is being said. This manifests in several ways throughout our lives. You may first notice this deficit in conversations with your family. Often you hear, '”Just what don't you understand? I only told you about this three times in the last two weeks!” Heavy sighs, rolling eyes, and body language suggesting extreme frustration usually follows this. Then you notice that you are having a hard time understanding what is being said in a lecture or an educational conversation. You know you hear what the person is saying but the information is just not sinking in.

We often then consult friends saying things like; do you think I have a hearing deficit? Or even go to the point of consulting a hearing specialist and getting an audiogram. Often there is noting wrong with your hearing, it's your ability to listen.

Why do we have this deficit? Well, it could be that we are inundated with noise on a daily basis. How often do we turn on the radio or TV to create “white noise” to cover up other noise so we can work undisturbed? How often do we turn up the TV to block the sound of a nagging spouse or roommate? It's an easy thing to do. But do we often “tune out” on important things we need to hear? I think so.

Here is a story that you may find interesting.

Recently, my best friend, moved back to the Chicago area, unfortunately she had to develop new relationships with physicians in the area in a hurry. Her first encounter with a health care professional was through an emergency room visit. She presented with severe back pain, generalized around her one kidney. She presented

the emergency physician with a copy of her medical record since she had no local physician at the time. The physician, took a urine sample, and ran several blood tests.

The emergency nurse questioned her about large bruising that appeared on her leg.

She explained that she had been developing pinpoint (petechial) bruising that would mass into these large bruises. The nurse looked at her, nodded and began to ask her about domestic abuse. The bruising was shown to the doctor, he too, asked about domestic abuse.

She continued to tell them of other symptoms that she had been having since last year. She told them she had lived in a rural area with free-roaming deer; she told them about being bitten by a “deer fly” and told them about mouth ulcers (coxsackie) that had developed several times over the summer. They never asked her about Lyme's Disease.

She gave them her medication and told them about severe migraine headaches, joint pain, and severe swelling of the joints of her hands. They never ran anything more than a CBC. Finally, they admitted her because the tests indicated she was passing a kidney stone.

Over the next week she visited a family physician assigned to her case at the hospital. He too, was concerned about the violent aspect of the bruising that appeared on her legs. She explained that they just appear, she didn't know why or how. He ran blood tests and then told her husband, that she may be a overdosing on OTC pain killers, ibuprofen, Tylenol®, Excedrin®, and aspirin and may have issues dealing with pain.

When she told me this whole scenario, I was concerned. I have been familiar with her litany of problems for almost 20 years.

She had severe headaches; gastrointestinal upsets, strange rashes and each had been treated by a family physician or internist as separate occurrences. We talked for a long time. She was upset that no one could tell her what was going on, and I was upset

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that no one was looking at her as a whole patient. Could these be related? I didn't know. I threw out some suggestions, the first going to a woman internist, because in my life, women doctors seem to listen better and as a woman could relate better to me as a patient. I also suggested that they do some thorough blood work, maybe she had lupus or neuro-myalgia.

A few days later, she called and said she had gone to a new doctor, a woman.

She had an hour-long appointment where she went through her whole file, medications, and symptoms. She ran a battery of blood tests (16 of them) and made an appointment for her to see a neurologist.

The neurologist looked at the results of those blood tests, ordered some more, and an MRI. He said he thought she might have lupus or some other autoimmune disease. Both doctors agreed that she needed to see a hematologist because her platelet count was over 400. The hematologist just informed her that it wasn't a blood disease, but most likely an autoimmune disease or chronic inflammation.

Although we still remain in the dark about her condition, wouldn't it have been nice if the emergency physician had listened to her whole story? If the family physician would have recognized the litany of complaints and recommended a specialist? Instead, both physicians looked but did not listen to this patient.

Did they have a listening deficit? Do you?

For the many readers who responded to my story about my cat, Max and his health problems that were masked by other things, I have to let you know that Max passed away in early November, a victim of his continuing battle with stomatitis. He was 16 1/2. I thank you all for your concern it was very appreciated.

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ACOEP Bulletin Board This is a new feature in The Pulse to provide members with notices on upcoming events within the College and its Foundation.

If you have any notices you would like posted on the Bulletin Board, please contact the ACOEP Office.

• Speakers in need of an audience may wish to be considered by the CME Committee for a slot at an upcoming CME meeting.

To be considered, please send your CV and a cover letter informing the CME Committee of your interests and topics you feel that you can speak on. The CME Committee will review anyone submitting information quarterly and will contact the potential speaker of available slots.

• Do you want to serve on an ACOEP Committee? If you do, see the article on Committee appointments and let us know what committee you would like to be considered for. Committee appointments are made annually. Please send your CV and cover letter listing the Committee you would be most interested in serving on. You can send information to Paula Willoughby DeJesus, D.O., President at President@acoep.org or to Jan Wachtler, Executive Director at janwachtler@acoep.org.

• Are you interested in being considered for a Board position? Active members who are interested in running for a position on the ACOEP Board of Directors should send an introductory letter and CV to the Nominating Committee of the College by March 1.

Board members are required to attend 2 to 3 meetings of the Board (as scheduled) and to act as a liaison to ACOEP committees.

Board members are paid for their attendance at meetings and receive a Perdiem, travel and lodging. Letters and CV should be sent to the Nominating Committee, c/o Victor J. Scali, D.O., FACOEP, Chair, ACOEP 142 E. Ontario Street, Suite 1250, Chicago, IL 60611.

• Are you a frustrated author, just waiting to have something published in a national forum, if you are then you need to contact us.

The Pulse is seeking authors to contribute regular columns on emergency medicine topics. If you commit to present 8 publishable articles over a two-year period, we are willing to pay your admission to an Spring Seminar, currently a value of $450. Please contact Drew Koch, D.O., FACOEP, Editor at Editor@acoep.org or Jan Wachtler.

• Before you submit your Fellow application, please remember the following: The deadline is March 1, 2005, applications received after March 1 will be deferred until 2006. You must meet all the criteria for meeting attendance and Board Certification before your application is processed. Also, with the change in the Constitution and Bylaws, changes have been put in place for Fellowship in the College. These changes mostly apply to the area concerning high professional standing that may be met by two of the following items: (1) Publication of scientific articles or reference materials in the field of Emergency Medicine, in nationally peer-reviewed periodicals; (2) Past or present member of an ACOEP Committee; (3) Past or present member of the Board of Directors of the ACOEP; (4) Faculty appointment in Emergency Medicine at a College of Osteopathic Medicine or College of Medicine accredited by the AOA or AMA, respectively, and (5) Active involvement in the leadership and education of Emergency Medical Services, including but not limited to: (a) EMT and paramedic training; (b) Working as a Medical Director of a Community EMS System; (c) Participation in local disaster planning and implementation, and (d) Direct supervision of training physicians and residents in on-line medical command.

• 2005 Neonatal Resuscitation Program - Research Grant and Young Investigator Award - Call for Applications. The American Academy of Pediatrics (AAP) Neonatal Resuscitation Program (NRP) Steering Committee and the Section of Perinatal Pediatricians are pleased to announce the availability of the 2005 Neonatal Resuscitation Program Research Grant and the NRP Young Investigator Award. The awards are designed to support basic science, clinical, or epidemiological research pertaining to the broad area of neonatal resuscitation.

Physicians-in-training or individuals within four years of completing fellowship training are eligible for up to $10,000 through the NRP Young Investigator Award.

Any health care professional with an interest in neonatal resuscitation can submit a proposal for up to $25,000 through the NRP Research Grant Program.

Researchers from Canadian and U.S. institutions are invited to apply.

Potential applicants should submit an intent application to the NRP Steering Committee by Friday, May 6, 2005. All intents will be reviewed and the committee will ask a select group to submit full proposals. Those selected to submit a full proposal will receive the formal application by Friday, July 1, 2005. Completed applications will be due on Friday, September 2, 2005.

To obtain the NRP Research Grant or NRP Young Investigator Award Program Guidelines and the Intent for Application, please contact: American Academy of Pediatrics, Division of Life Support Programs, 800/433-9016, extension 4798 or go to www.aap. org/nrp and select the science tab.

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ACOEP Committee Chairs Announced Paula Willoughby DeJesus, D.O., FACOEP, President of the ACOEP has announced her appointments for Chairs and Vice Chairs for each of the College's Committees. Committee chair and vice chairs have been given the authority to recruit up to 8 members per committee and the names of the appointees will be submitted to the ACOEP in midJanuary. All committee members will be required to attend at least one meeting of the committee each year and to participate in any activities the committee may conduct by mail or online.

CME Committee Anita Eisenhart, D.O., FACOEP, Chair Beth Longenecker, D.O., FACOEP Vice Chair Steven Parrillo, D.O., FACOEP, Board Liaison Subcommittees •Administrative Aspects of EM John Graneto, D.O., FACOEP, Chair Brian Robb, D.O., FACOEP, Vice Chair •COLA Essentials Beth Longenecker, D.O., FACOEP, Chair Nicole Lang, D.O., Vice Chair •EMS Review Wayne Jones, D.O., FACOEP, Chair Paula Lange, D.O., FACOEP, Vice Chair •Intense Review Donald Sefcik, D.O., FACOEP, Chair John Weilbacker, D.O., FACOEP, Vice Chair •OMM Education (Ad Hoc) Terrance Mulligan, D.O., Chair Anita Eisenhart, D.O., FACOEP, Vice Chair •Oral Board Review Scott Morrison, D.O., FACOEP, Chair Bobby Johnson, Jr., D.O., Vice Chair •Scientific Seminar Gary Bonfante, D.O., FACOEP, Chair William Frasier, D.O., FACOEP, Vice Chair •Spring Seminar Christine Giesa, D.O., FACOEP, Chair Brian Robb, D.O., FACOEP, Vice Chair •Toxicology Review Dean Olsen, D.O., Chair Steven Aks, D.O., FACOEP, Vice Chair Communications Drew Koch, D.O., FACOEP, Chair / Editor Bobby Johnson, Jr., D.O., Vice Chair / Assistant Editor Fred G. Wenger, Jr., D.O., FACOEP, Board Liaison Constitution and Bylaws John W. Becher, D.O., FACOEP, Chair Sandra Schwemmer, D.O., FACOEP, Vice Chair Peter A. Bell, D.O., FACOEP, Board Liaison

Emergency Medical Services Wayne Jones, D.O., FACOEP, Chair Scott Morrison, D.O., FACOEP, Vice Chair Thomas Brabson, D.O., FACOEP, Board Liaison Domestic Preparedness Subcommittee William Bograkos, D.O., FACOEP, Chair Joseph Heck, D.O., FACOEP, Vice Chair Fellowship Drew A. Koch, D.O., FACOEP, Chair Elaine Lombardi-Wilk, D.O., FACOEP, Vice Chair Gregory Christiansen, D.O., FACOEP, Board Liaison Geriatric Emergency Medicine (Ad Hoc) Kristyna Paradis, D.O., Chair Joseph Dougherty, D.O., FACOEP, Vice Chair Victor J. Scali, D.O., FACOEP, Board Liaison Graduate Medical Education Alan Janssen, D.O., FACOEP, Chair Victor Almeida, D.O., FACOEP, Vice Chair Gregory Christiansen, D.O., FACOEP, Board Liaison

Practice Management Bernard Heilicser, D.O., FACOEP, Chair William McConnell, D.O., FACOEP, Vice Chair Mark Mitchell, D.O., FACOEP, Board Liaison Program Directors Alexander Rosenau, D.O., FACOEP, Chair David Lang, D.O., FACOEP, Vice Chair Paula DeJesus, D.O., FACOEP, Board Liaison Inservice Examination John Prestosh, D.O., FACOEP, Chair Gary Bonfante, D.O., FACOEP, Vice Chair Research Juan Acosta, D.O., FACOEP, Chair Beth Longenecker, D.O., FACOEP, Vice Chair Victor J. Scali, D.O., FACOEP, Board Liaison Academic Awards Michael Morgenstern, D.O., Ph.D., FACOEP, Chair Mark Foppe, D.O., FACOEP, Vice Chair Resident Chapter Advisors David Lang, D.O., FACOEP Valerie Kemsuzian, D.O., FACOEP Peter A. Bell, D.O., FACOEP, Board Liaison

Government Affairs Raul Garcia, D.O., FACOEP, Chair Joseph J. Kuchinski, D.O., FACOEP, Board Liaison

Student Chapter Advisors Duane Siberski, D.O., FACOEP Michael Oster, D.O., FACOEP Mark Mitchell, D.O., FACOEP, Board Liaison

International Emergency Medicine (Ad Hoc) Terrance Mulligan, D.O., Chair Edward Cho, D.O., Vice Chair Joe A. Nelson, D.O., FACOEP, Board Liaison

Undergraduate Medical Education Howard Friedland, D.O., FACOEP, Chair James Shuler, D.O., FACOEP, Vice Chair Anthony Jennings, D.O., FACOEP, Board Liaison

Membership and Credentials Murry Sturkie, D.O., FACOEP, Chair Michael Ward, D.O., Vice Chair Douglas Hill, D.O., FACOEP, Board Liaison Pediatric Emergency Medicine (Ad Hoc) Anita Eisenhart, D.O., FACOEP, Chair Mario Cosenza, D.O., Vice Chair Fred G. Wenger, Jr., D.O., FACOEP, Board Liaison

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National Liaisons Thomas Brabson, D.O., FACOEP, Board Coordinator ACEP: Duane Siberski, D.O., FACOEP AOBEM: Thomas Brabson, D.O., FACOEP Paula Willoughby DeJesus, D.O., FACOEP CECBEMS: Scott Morrison, D.O., FACOEP CoAEMSP: Joe A. Nelson, D.O., FACOEP NAEMSE: Juan Acosta, D.O., FACOEP

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Ethics in Emergency Medicine Bernard Heilicser, D.O., FACOEP

What Would You Do? In the October 2004 issue of The Pulse, we reviewed the following difficult issue in Emergency Medical Services.

This dilemma developed when an ambulance was dispatched to a “fall victim.” En route to this call, the ambulance came upon a just-occurring motorcycle crash with the victim lying in the street with a crowd surrounding him. Traffic was placing everyone in danger. The ambulance elected to stop, block traffic, and attend to this patient. The second ambulance, dispatched to the crash, was instructed to proceed to the first patient, the fall victim. Was this appropriate? Was this ethical?

We received the following response: A very interest scenario! With no vital signs or additional information, this becomes a difficult triage. So, the squad personnel must assume all things are equal. Both patients should have been categorized with “life threatening” insults. Given this case, the correct decision was made by EMS control. If both patients were in extremis, being “on scene” for a fatal collision would certainly over-ride a decision to drive to another patient. IF the squad had continued on its course and found a patient unsalvageable, they could have lost both patients. The ability to render life-saving procedures on the spot (again, no further information on the extent of injuries being available) was paramount. I believe the correct decision was made.

Doug Harmon, D.O. Staff Attending Grandview Medical Center, Dayton, OH We thank Dr. Harmon for his insight.

This was a very stressful situation for the paramedics. The first ambulance was essentially dedicated to the first patient

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(fall victim). No additional information was available regarding the status of this person, e.g., vital signs, or condition.

What if a cardiac arrest had precipitated the fall? By deferring the EMS response to the second ambulance, would this now demonstrate abandonment? There was a legal obligation for them to respond to this patient, as dispatched.

However, we have a critically injured crash victim with six bystanders precariously located in the middle of an intersection. The traffic was certainly endangering all of them. The potential for sever critically injured patients now existed. Is there a greater obligation to the one patient and six potential patients? If this were viewed as a mass casualty incident waiting to happen, then an argument for the greatest good would have priority and validate the first ambulance's actions. In a disaster situation, we initially triage and assort need.

We do not necessarily treat the first patient encountered.

The paramedic who made the decision to stop stated he was concerned the “ . . . if we passed this accident that more people were in danger of being struck by cars passing the scene at high speeds. It was getting dark and visibility was low.” He acknowledged, “. . . We could have been sued for delay of care for the first gentleman.” However, he concluded, “Although neglect of the second situation would be harder to prove in court, I would have a difficult time dealing with the fact that someone was hurt or killed because I didn't act. Morally and ethically could I deal with the result of someone being killed if I didn't react to the situation, I don't think so.”

What Would You Do? What happened? Fortunately, the fall victim had minor shoulder injuries. But, what if . . .? There is no wrong answer to this dilemma. This situation represents a classic conflict between the legal and the ethical. The bottom line is you must follow

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your instincts and judgment, and let's hope you were right!

If you have any cases in your practice that you would like to present or have reviewed in The Pulse, please send them to us.

You may reach Dr. Heilicser at 708-915-6900 or by fax at 708-915-2743, or through the ACOEP Office at 312-5873709 or 800-5213709.

POSITION AVAILABLE Pennsylvania, Erie - Currently seeking an energetic BC/BE Emergency Physician to join our 13 member hospital-based group. Saint Vincent Health Center is a 413-bed tertiary care hospital with yearly patient volumes of 35,000, with 47 hours of physician coverage daily plus 6 hours of midlevel coverage. Physicians currently see less than 2 patients per hour. Osteopathic Emergency Medicine Residency established in 2004. Majority of physicians have at least 10 years ED experience.

Excellent compensation/incentive package with full benefits. Ideal candidate will have ultrasound and research experience. Erie, Pennsylvania's fourth largest city, is a scenic lakefront community with exceptional recreational, educational and cultural opportunities. Erie is an excellent place in which to live and Saint Vincent Health Center provides a superb environment in which to practice Emergency Medicine. Contact: Sue McCreary, (814) 452-7822, FAX: (814) 455-1524, email smccrear@svhs.org.

Reports to the Membership The following reports were presented to the ACOEP Membership at its meeting in San Francisco, California on November 7, 2004.

President Victor J. Scali, D.O., FACOEP During the past two years, it has been an honor and a privilege to serve the membership and Board of Directors as President of this College. However, it is time to “pass the torch�, that time-honored democratic tradition in which one president transfers the leadership of the present administration to the incoming president. I would like to thank the members of the Board of Directors and its Officers for their hard work, expertise, and personal guidance and advice during the last two years of my presidency. Their individual leadership has insured the future growth of this College. Presidents come and go, but our Executive Director, Jan Wachtler, is the constant whose leadership and management skills on a daily basis keep our College on a steady forward course. Without her organizational skills and her dedicated office staff, ACOEP would not be the leader and service organization we have become. Thank you so much! However, the backbone of this non-profit corporation with a million dollar budget will continue to depend upon its Committee Chairs and Members. We all know that the behind the closed doors of these committee meetings progress and direction are born. I commend the many committee members and chairs for their dedication, hard work and contribution to our recent growth as a specialty college.

Within the last sixteen months of my term as president, we have sadly seen the tragic passing of two leaders of our College, Dr. Robert Aranosian and Dr. Benjamin Field, two individuals so influential in the strategic growth of our College that their leadership ability cannot merely be replaced, only mirrored. Their example will endure as the quality leadership standard for future presidents to continuously strive to achieve. Although, those of us who were privileged and fortunate to have been their friend and colleague over many years will miss them dearly, their legacy will live on and continue to be the benchmark our College will be measured by in the future.

As I critically review the progress of my presidential agenda, we have made significant progress and in the process left much work to

be done. The quality of our CME is becoming well known nationally as espoused by the recent request by Ohio ACEP to explore the possibility of collaboration between our organizations to include conferences, board review courses, and publications.

We have made great progress with respect to raising the bar on resident research education and production within our growing number of residency programs thanks to the work of the Research, GME, and Program Directors' committees. Through a FOEM grant, the Internet based Resident Research Education Program will become a reality ahead of the projected 2005 implementation date. The Research Consortium has evolved under the auspices of the Foundation as a tool to enhance research participation by residency sites and non teaching hospital centers. The Consortium is currently updating its database of participating members. Pharmaceutical companies and contract research organizations queried to date have expressed a great interest in accessing the comprehensive databases of potential sites for national multi-center drug and device trials through FOEM web page access.

With respect to a humanitarian initiative by our College, we have established a close partnership with The International Center to Heal our Children based at Children's National Medical Center (CNMC), whose mission is to help foster, promote, and maintain the emotional health of our Children who are traumatized psychologically by acts of terrorism, interpersonal violence and natural disasters. On August 4th, 2004, ten College members from across the country attended an Instructor Trainer/ Provider initial training course at CNMC taught by the ICHOC Executive Director Dr. Joshi and Program Manager Ms. Shulamit Lewin.

Resource material for training school teachers was introduced critiqued and modifications were suggested, as well as the content for the next training session. We anticipate two annual training sessions as we approach our ultimate goal of an advanced pediatric emotional life support course (PELS) involving instructors and providers similar to the PALS train the trainer/ provider paradigm during the next three years accelerated by funding from a grant we are co-writing during this 2004-05 EMSC grant cycle. In addition, our new partnership with Emergency Medical Services for Children (EMSC) has provided valuable national network-

The PULSE JANUARY 2005

ing and grant opportunities as ACOEP proudly sits with the 19 most influential organizations in emergency care of children in this country that includes ACEP, ATS, CDC, AAP, NAEMSP, and ENA. I am currently writing an EMSC targeted grant proposal sponsored by ACOEP involving the development of an evidence-based core curriculum in pediatric emergency medicine that will upgrade the present emergency medicine residency training standards and will reflect core competencies and future standards of care. Our Ad Hoc Committee on Pediatric Emergency Medicine will drive this grant initiative and provide expertise.

Finally, I am proud to announce a partnership with the Centers for Disease Control (CDC) and ACOEP during the last year that continues to grow through liaison with our EMS Committee. Dr. Sherlita Amler, with the division of mass casualty preparedness has addressed our Committee in the spring 2004 meeting in Arizona as we further synchronize our organizations in the event of potential future terrorist acts. At the invitation of Dr. Amler, Bill Bograkos and I were guests at the expense of CDC in June 2004 to make a presentation representing the ACOEP and its potential to help the CDC respond to mass casualty situation s and fine tune the response. At the conclusion of the meeting it was agreed that ACOEP and the CDC would along with ACEP develop a four hour residency training module to be incorporated in all allopathic and osteopathic emergency medicine training programs to include the following one hour POWERPoint lectures: Counterterrorism, Explosives and Incendiary Devices, Lessons learned abroad, and Needs Assessments.

As a Past President, I look forward to continuing my service to our College in a new challenge as I assume the presidency of the Foundation. I also look forward to serving our new President, Dr. Paula Willoughby DeJesus, in any capacity that I may support her leadership and mission. I am confident her immense talent and leadership skills will take our College to the next level of national influence and leadership. With the collective talent in this College to support her, I see this as not a challenge but our next significant achievement.

Again, thank you for allowing me the honor to serve you, the members, of this College as President during the last two years. As always, may I respectfully wish you and your

13

families great health, happiness and continued success.

President - elect Paula J. Willoughby, DO, FACOEP AOA BOARD OF TRUSTIES House of Delegates There were hundreds of resolutions before the AOA House of Delegates at July's business meeting this year. Dr. Scali, Ms. Wachtler and myself staffed the resolutions prior to the meeting. Those resolutions that could impact the members of our College as we practice are summarized below.

EDUCATION • Aggressively petition Congress to reinstate tax laws allowing deductions for student loans regardless when the loan was incurred.

• Revision of EM Core Competencies.

• The development of a joint match. Referred to COPT for further discussion.

• Develop strategies to streamline approval of Osteopathic and ACGME internship and residencies. Resolution withdrawn after discussion.

CREDENTIALS • Expedite the processing of returning ACGME trained osteopathic physicians from all ACGME residency programs. Resolution withdrawn after discussion.

• Revision of the Handbook of the Bureau of Osteopathic Specialists to allow osteopathic physicians certified through an approved Board of the American Board of Medical Specialists with COPT approval to enter AOA certification process.

• Modification of re-entry of ACGME trained osteopathic physicians to have candidate apply directly to specialty college and not require retroactive training approval but verify training. Resolution withdrawn after discussion.

CLINICAL PRACTICE • Broaden efforts to address the crisis of medical liability reform.

• Expulsion of members from the AOA will be reported to the National Practitioner Data Bank.

• Support positions that osteopathic physicians acting as expert witnesses, peer reviewers and/or medical directors practice clinically.

Resolution referred back to Committee.

• Discourage the use of the term “provider” to describe physicians.

• Oppose specific mandatory topic requirements for CME. • Healthcare Facilities Accreditation now requires policies on the mechanism of man-

16

agement of medical emergencies in hospital non-ED settings on and off the hospital campus.

• Encourage hospitals to provide non-latex alternatives in areas of patient care.

• Position Paper considering placebos inappropriate in the treatment of pain for end-of-life care.

• Encourage physicians to utilize multiple programs available to provide patients with free or reduced cost medications.

• Advocate for the removal of restrictive drug formularies.

• Support legislative and regulatory efforts that require a physician/patient relationship (including direct physical examination) prior to prescribing and/or dispensing medications via the Internet. Resolution deleted, superseded by previously adopted resolution.

• Determined it is ethical for an osteopathic physician to charge administrative fees as long as the patient is informed of the fees in advance and is not in violation of contracts or state statutes.

PUBLIC HEALTH • Support public awareness efforts related to organ donation, convenient identification programs and ethical distribution of organs to patients most qualified to receive them.

Resolution deleted, superseded by previously adopted resolution.

• Support efforts of the US Department of Health and Human Services to develop and foster programs that prevent domestic violence.

• Support strategies for public education and use of safe storage of firearms.

• Endorses State and Federal legislation to control the consumption and purchase of alcohol by individuals less than 21 years of age.

Urges alcohol and abuse treatment programs be given a high national priority.

• Adopt the policy that except in the case of protecting the public from imminent harm, no adverse action be taken against a physician based on a claim of physician impairment without suitable due process.

• Support programs for risk identification, prevention and treatment of suicide in children.

Resolution deleted, superseded by previously adopted resolution.

respect to the revenue streams, it was noted that we have experienced approximately 4% per year attrition rate over the past couple of years.

This past year we also saw that all CME courses generated less revenue than budgeted. One course on toxicology was not presented and the Committee discussed whether it would be beneficial to partner with other agencies on some other organizations on the presentation of smaller meetings.

Treasurer Thomas Brabson, D.O., FACOEP Budget Review - FY 2003 2004

Staff Activities. During this period the staff has discussed and enacted a plan to assign each staff person to several committees to be the “Staff Liaison” for the named committees. This will provide each Committee with a regular staff person by which the chair and vice chair can plan meetings, conference calls and activities know-

The Finance Committee met and reviewed the FY 2003-2004 tentative year-end figures.

Each section was reviewed and discussed. With

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FY 2004-2005 The proposed budget was reviewed by each line item. After adjusting a few of the entries, the following recommendations were discussed to reduce any possible budget deficits in future years. A budget of $ 1,192,764.63 was approved by the Board for this current fiscal year.

Executive Director Janice Wachtler This report reflects the activities of the Office of the American College of Osteopathic Emergency Physicians from May through October 2004.

Membership. Current membership numbers are: 1916 total membership; 1415 Active or Active/Charter Members (73.8%); 14 ActiveExempt Members (.7%); 5 Retired Members (.2%); 11 Life Members (.5%); 453 Resident Members (23.6), and 15 Intern Members (.7%).

There are also currently 602 students registered as ACOEP members.

Member Benefits. During the past several months, the staff has met with several different vendors to provide services to the ACOEP members. These have included auto rental companies and a bank/mortgage company.

Washington Mutual has approached us to offer potential mortgage services to our members at a fixed closing costs saving members money on these variable fees. After a hopeful meeting, we were informed in late September that our membership was not sufficient for these services, however, the company planned on visiting us again after the first of the year as they begin marketing a benefit package on banking and savings plans.

Guest Column

Steven J. Parrillo, D.O., FACOEP

Remember That Patient You Saw...?

The nightmare begins!

Sooner or later, it is likely that you will receive an envelope from an attorney marked “Personal & Confidential”. Sit down, take a deep breath and pray it was sent to you accidentally. It wasn't. Take another breath. Open the letter. Remember that you have a legal obligation to respond to the summons. If you don't respond within a specified time frame, there will a “default judgment with prejudice” entered against you by the Court. That time frame varies by state and county jurisdiction. The case is lost, you cannot bring up the case or counter-sue in the future and the judgment amount will be decided without your input.

As you know, the vast majority of such cases are settled. That may seem unfair, but after you hear this talk, you will probably be happy to see the suit go away.

Having recently faced a suit that went all the way to trial, (and that ended with a verdict for the plaintiff), I plan to share my experiences with you. Yours may not be identical, but the sequence of events here is fairly typical.

Remember that four things must be proven and be part of the letter you receive. Plaintiff's counsel must prove that you had a duty to treat, that you breached that duty in some way, that an injury occurred and that the breach caused that injury (proximate cause).

In an effort to take some of the mystery out of the process, here's the sequence that begins once the plaintiff's attorney has decided to pursue the case: • The complaint • Pretrial motions • Discovery / Interrogatories • Deposition - very broad questioning • Settlement negotiations • The Trial • Jury selection • Judge's initial charge to the jury • Opening statements • Plaintiff's case • Defendant's case • Closing statements • Judge's discussion with counsel about points of charge • Points of Charge • Judge's charge to the jury • Deliberations • Verdict

• Judgment • The payout • Structured vs. single payment In the months (and perhaps years) before a case goes to trial, you will meet with your attorney several times. In the first meeting, he/she will bring you up to date on the status of the case. The accusations against you will need to be answered in writing. They get submitted to the plaintiff's counsel. He/she must now decide whether to proceed with the case.

Interrogatories come later.

The time frame between your answers to those questions and the next phase will likely be many months. When you hear from your attorney, it will probably be to schedule a time for the deposition. Both sides need to be flexible on the choice of date. At this point, contact is still “friendly”. The comments below are based on my experience beginning with the first time I heard the word “defendant” attached to my name.

How about settling? You may think you are absolutely in the right. However, some types of cases are likely to be lost regardless of facts because they are so inflammatory (death of a child for example). Today, juries are composed of lay people who identify more with the plaintiff, are aware of the Institute of Medicine report on errors and are generally mad at doctors.

Some believe that all doctors are rich anyway, or have insurance that will cover them.

Attempts to settle are pretty standard. They begin very early on and may continue right up till the bitter end. There are several reasons why settlement doesn't occur, but they generally involve plaintiff's belief that he/she can get more. The better malpractice policies include language giving you the ability to help decide if you will settle. Cheaper policies don't give you that option.

Remember, whether you settle or lose a judgment, anytime money is paid out on your behalf, your name is entered into the National Practitioner Data Bank. The exception would be if you used your own money to settle. ➣ Get counsel you and the hospital trust I work for a healthcare network that is self-

The PULSE JANUARY 2005

insured for professional liability (malpractice) coverage for its physicians, employees and hospitals. The network's in-house attorneys assigned defense counsel. My attorney was one my hospital had used many times before and trusted. He told me then that his track record was pretty good. I did talk to hospital counsel and felt comfortable with their choice.

If there had been a conflict of interest between my position and that of the hospital, separate counsel would have been assigned to represent me alone. Perhaps in your case your commercial insurer will assign counsel to defend you. Even then, you may not have much say in the matter, as most insurance carriers have lists of approved attorneys that they deal with.

In my case, plaintiff's counsel refused to settle, partly because the Pennsylvania Catastrophe Loss Fund refused to cooperate in settlement negotiations. The “CAT Fund” is a state run entity that provides a secondary layer of insurance coverage. Once the decision was made to go to trial I met with my defense counsel to plan the trial strategy. Our first meeting served to familiarize me with the sequence of trial events, the role of expert witnesses, judge and jury. My work schedule prevented me from being when the jury was selected; however, the defendant physician is usually encouraged to be there. The jury needs to know that this lawsuit is important to you. Your daily presence can convey that.

You will likely spend a great deal of time with your attorney prior to trial. You need to be comfortable with his/her skills and questioning techniques. Your attorney will also be able to prepare you for the type of questions the plaintiff's counsel will ask and the manner in which he/she asks them. ➣ Get to know your counsel In my case, the associate attorney who reviewed the records, medical articles and books, chose the expert witnesses and prepared me for my deposition was part of the defense team, but was not the partner who actually defended me at trial. The partner, associate and often a paralegal work closely together to craft the defense. Actually, the associate who began to research my defense left the firm. The case was then assigned to another associate to complete the pre-trial preparations. I spent much more

11

time with them as we prepared the case, than I did with the partner who actually tried the case. When it came time for trial, the partner was completely immersed in the case and was a truly effective advocate.

Prepare carefully for the deposition Know the case cold.

Since your primary area of concern is the ED record, review it meticulously, including nursing notes, triage notes, all time records, report of diagnostic studies, consultants' reports etc.

Don't contact anyone else involved in the case.

If you happen to meet an RN, resident or consultant who participated, don't discuss the case.

Plaintiff's counsel will ask you if you have spoken to anyone else. If you have, that conversation becomes admissible as evidence. ➣

Anticipate questions You may or may not be able to do this in all cases, but some can be expected. “Did you speak to anyone about the case”? “Had you seen cases like this before? How about since then”? These questions are basically designed to intimidate the physician, give the jury the

impression that this incident was so momentous that the entire hospital was talking about it, and that the patient's problem was so common that the diagnosis you made and / or treatment you provided were obviously wrong. Many of the questions will relate specifically to the content of the record. Your deposition and trial testimony is not a memory test; the original medical record should always be there for you to refer to. Some will (legitimately) be intended to clarify what you wrote, explain abbreviations etc. Think before you answer and word your answers carefully. Give your attorney a chance to object before you speak.

Plaintiff's counsel will ask about “authoritative” texts you use. There are none. They are old and outdated, authors are chosen for reasons that may have nothing to do with expertise etc. If you state that Rosen's is authoritative, you will be held to the standard of every word in that book.

If you have a CV, know what it contains.

Plaintiff's counsel will. Know the standard of care for the case involved and be prepared to

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state how you met that standard. Remember that the standard of care is the sum of your training and experience plus research. It changes! There is also a difference between the optimal situation and the real world. The “expert” hired by the plaintiff cannot know what went on in your department at the time you saw the plaintiff.

Maintain composure (at trial, too) There will not be a judge or jury at the deposition, but maintenance of composure serves a few functions. From my standpoint, the best thing it did was serve notice to plaintiff's counsel that I was not going to be rattled. (He will try). It also serves as practice for the trial when it is even more important. (More on being confident below).

At the deposition, plaintiff's counsel may try to intimidate you by standing over you. There is no rule preventing you from joining him in the upright position. Don't let him win by intimidation!

Review your deposition meticulously. Change anything you don't like (wording, inaccuracies).

The deposition is part of pre-trial activity. If your plaintiff's attorney is anything like the one I faced, he/she will refer frequently to that deposition and will know it cold. I don't even recall how many times at trial he asked me about something I said during the deposition.

He then had me turn back to the page where I had signed off on any changes I had made and pointed out that I had not requested that change be made. He was, in essence, telling the jury that I was trying to change my testimony.

I have no idea if they believed me or him. Some I thought were picayune, minor and irrelevant, but if I could go back in time and change or reword some of my statements, I would. ➣

➣ Help in your own defense This may seem like a given, but I understand that some physicians leave everything to the lawyers, believing that the matter is out of their hands. I respectfully disagree.

No matter how medically knowledgeable your attorney is, he/she is not a doctor (at least not usually). Your input is important and may be critical. Explain why you did what you did.

Clarify terms, issues, extenuating circumstances etc. Every case is different, and an ED case is likely to be very different from others your attorney may have tried in the past.

Read every expert report and comment on those opinions to your defense counsel. If plaintiff's expert is published (many are), read what he/she has written. Pick it apart if there are inconsistencies between what the expert says on

Remember That Patient You Saw? Continued on page 20

12

The PULSE JANUARY 2005

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ing that the staff liaison has some knowledge of the committee's past activities and history.

Staff Liaisons will create and maintain minutes and reports for the meetings and will be able to periodically transmit messages to the members to keep them abreast of items of interest to the committees. Assignments are as follows: Membership and Credentials; Undergraduate Medical Education; Program Directors (as assistant) - Julie Evans Governmental Affairs; Continuing Medical Education - Katie Cavarretta EMS; OMM in Emergency Medicine (Ad Hoc); International Emergency Medicine (Ad Hoc); Student Chapter - Barbara Guerra Graduate Medical Education; Program Directors; Research; Resident Chapter Pediatric Emergency Medicine (Ad Hoc); Publications - Janice Wachtler Assignments may change if ad hoc committees are made permanent committees and as staff ages. Assignments were made based on the staff person's interaction with issues for the committees and responsibilities to these areas.

During this period of time, the staff has conducted several site reviews of potential meeting sites for 2006, 2007, and 2008 Intense Reviews, Core Essentials and Program Director sites. We have also completed several educational documents, including drafts of a revised inspection manual, and new combined standards for family and emergency medicine.

I thank you for your continued support of our staff.

Affiliated Agencies ACOEP-Student Chapter Nicole Ottens, President What a wonderful year this has been for the ACOEP-Student Chapter. We have had a tremendous year filled with growth and improvement and are excited about where we are going.

This year our three basic goals were: (1) to refine our organization, (2) to improve our level of respect within our profession and nationally, and (3) to take on more responsibility. Not only have we met those goals, but also through the efforts of many hardworking and dedicated people, we have exceeded our greatest expectations.

As part of our efforts to refine the Student Chapter, we reassessed the Chapter's wants and students' needs. We also made use of the motivated students who wanted to become more involved. In an attempt to be more efficient, we expanded positions in our organization, to include a PR Committee and Convention Committee. The Convention Committee CoChairs made sure that this convention was geared toward the interests and needs of the students. They recruited lecturers, sought pharmaceutical support, marketed events to students and added an additional day of lectures.

In tandem with these efforts, the PR Committee Co-Chairs have promoted the ACOEP-SC, by working with our Communications Officer they have developed brochures for marketing, coordinated a raffle/fundraiser at the ACOEP Spring Seminar, developed a scrub shirt fundraiser for convention, and have worked with local chapters and the ACOEP-SC Vice-President plan site visits by the ACOEP-SC officers. Combined with their efforts, the assistance of ACOEP and generous physicians, we have increased our budget by over $4,000.00 this year. Extra financial support has allowed us to increase our public relations, and triple the amount of funding to local chapters allowing them to send students to this convention. We have also proposed a revision of our Constitution and Bylaws to allow them to more appropriately reflect the mission of our organization.

port of this notion, the ACOEP-SC has worked in collaboration with Dr. Mark Foppe and the Osteopathic Medical Explorers Program (OMEP) to mentor high school students interested in medicine. Our OMEP Committee Chair has worked to help local ER clubs set up OMEP posts and have meetings for students.

This provides an opportunity to give back, while spreading the word about osteopathic medicine. To better service our members, we have created convention packets to provide them with up-to-date information. We've continued to use generic ACOEP-SC email addresses to maintain continuity of our contact information from year to year. Additionally, we have worked with Edward Via Virginia College of Osteopathic Medicine's ER Club to help them make contact with the ACOEP and assist them in establishing their new chapter. Finally, we have worked with the ACOEP Undergraduate Medical Education Committee to increase student awareness and participation in the Student Case Competition. The winning student case presentation was awarded with a free trip to the AOA Convention.

The ACOEP-SC has also made strides to be more respected as a professional organization.

To do so, we have increased our participation in national osteopathic events, attending AOA activities like D.O. Day on the Hill, the House of Delegates, and we had 6 of 10 Board members in attendance at the ACOEP Spring Seminar.

We have increased the quality and content of our national newsletter, The Emergent. Two years ago, it was one page, plain paper and without photos. Thanks to the ACOEP-SC Secretary, our latest edition is eight pages, glossy and full of photos. It now resembles our parent organizations' newsletter, The Pulse. And finally, we drafted and passed a resolution to sit on the ACOEP Board of Directors to allow us to have a more active role in our profession.

The ACOEP Board accepted this resolution in April and we now have a non-voting position on the Board. We feel this position will further enhance the relationship between the students and the physicians.

As you can see, our students have been very active this year. Their enthusiasm is contagious and their work ethic is remarkable. The phrase “Many hands lighten the load� has rung true for me this year. The ACOEP-SC could not have come this far if it weren't for the many hands helping along the way. I would like to thank those who have dedicated so much to this organization. First and foremost, to the officers and board members of the ACOEP-SC- thank you for your diligence and positive energy. You have truly taken us to a new level this year. I admire your hard work and dedication. You've made my job incredibly easy. To Dr. Scali, Dr. DeJesus, and the ACOEP Board, thanks for your support and overwhelming acceptance of our involvement. We look forward to even more interaction the in years to come. To Jan Wachtler, Barb Guerra, and the ACOEP staff - we cannot even begin to thank you for your dedication to us!

You've helped us every step of the way. Thanks for your support!! To Dr. Kuchinski, Dr. Oster, and Dr. Mitchell thanks for making the ACOEP Spring Seminar safer and more fruitful! Please join us at this meeting and see how many students have benefited from your efforts! And to all those who have bought raffle tickets, scrub tops or just donated money- thank you!!! We GREATLY appreciate your financial contributions! Thanks!!

As any association grows, it has a responsibility to its members and the community. In sup-

We are always looking for more students and doctors to get involved with our great group! If

The PULSE JANUARY 2005

17

you are interested, come to our meetings, stop by the ACOEP booth, ask us directly or reach us on the web at www.acoep.org! We've love for you to join us! Thanks again!

Foundation for Osteopathic Emergency Medicine Joseph J. Kuchinski, D.O., FACOEP, President As President of the Foundation for Osteopathic Emergency Medicine, I am happy to report to the Board of Directors and the Membership of the American College of Osteopathic Emergency Physicians that your philanthropic arm is alive and well.

Donations to the Foundation have dipped a bit during the last year, however we currently have collected over $250,000 in donations over the past 5 years. During that time we have supported resident research through the Annual Resident Paper Competitions and have distributed grant awards to the ACOEP to support is on-line resident research education project and to support one grant request.

During this year, the Foundation began a marketing campaign. The first step was to work on our image and with that came the redesigning of our logo and stationary as well as the creation of a website. You can view our website at foem. org. The website features all of our grant documents as well as information about contributions. Due to security concerns we are not currently able to take on-line donations, however, this will be implemented during the next calendar year. We have also developed a new marketing brochure that has been on display at the ACOEP booth and outside the meetings.

During the next month, the grant handbook will be revised and redesigned for distribution to all residency programs (osteopathic and allopathic) and any one interested is participating in research. This new document will also be featured on the website.

We have also created our own credit card processing mechanism and for those of you who donated to the Foundation after September 1st, you will have noted that your credit card donations were acknowledged through an e-mail and followed up with a letter from our office formally acknowledging the donation.

During the next calendar year our focus will shift to external marketing through the development of a newsletter for the Foundation. We anticipate that this will be developed in the first quarter of 2005 and will feature research results

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from this meeting.

We'd like to personally thank those physicians and residents who have contributed this year and hope to continue to promote osteopathic research in emergency medicine for years to come through your continued support of the Foundation through your tax-deductible pledges and contributions.

Liaison Organizations American Osteopathic Board of Emergency Medicine Bryan Staffin, D.O., FACOEP, Secretary On behalf of the American Osteopathic Board of Emergency Medicine, I would like to thank you for providing AOBEM the opportunity to update you on its activities.

AOBEM has been active this year with the implementation of the new process of Continuous Certification in Emergency Medicine (CCEM).

As is expected with change, numerous questions have been forwarded to AOBEM by its diplomats regarding CCEM. While these questions have been answered promptly, it is expected that many questions remain. AOBEM wishes to thank the ACOEP Board of Directors for allowing AOBEM the opportunity to address these issues at the upcoming ACOEP general membership meeting.

process was offered this past June 2004. 70 candidates participated in the exam. 67 candidates passed the exam for a pass / failure rate of 95.7 %. A separate report has been forwarded to the ACOEP's Executive Director indicating the pass / failure rate by osteopathic emergency medicine program.

Part III The clinical component of the primary certification process is currently ongoing.

The candidates that successfully complete this final component of the primary certification process will be recommended for certification

by AOBEM to the Bureau of Osteopathic Specialists (BOS) this coming January 2005.

With the BOS's approval, the candidates will then be presented to the AOA's Board of Trustees (BOT) in February 2005 for certification in emergency medicine. Upon the approval of the BOT, the candidates will be granted certification in emergency medicine by the AOA. Recertification In 2003, 42 diplomats participated in the recertification process. 18 diplomats elected to participate in the written recertification exam.

18 diplomats passed the exam for a 100 % pass / fail rate. 24 diplomats elected to participate in the oral recertification exam. 22 diplomats passed for a 91.6 % pass / fail rate.

The body of our report is as follows.

AOBEM Examinations 1. Primary Certification in Emergency Medicine 2. Continuous Certification in Emergency Medicine 3. Certification of Added Qualifications Primary Certification in Emergency Medicine Part I The written portion of the primary certification process was offered this past February. 167 candidates participated in the exam. 130 candidates passed the exam for a pass / failure rate of 77.8 %. A separate report has been forwarded to the ACOEP's Executive Director indicating the pass / fail rate by osteopathic emergency medicine program with the intent that this information will be shared with the ACOEP's Graduate Medical Education Committee.

Part II The oral component of the primary certification

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The successful 40 diplomats were recommended to the BOS for recertification this past January 2004. After the BOS's approval, the diplomats were presented for recertification to the BOT in February 2004. Upon the BOT's approval, these 40 candidates were granted 10-year recertification certificates in emergency medicine by the AOA. 30 diplomats are scheduled to take the Formal Recertification Exam (FRCE) this coming November 13, 2004. This will be the first offering of the FRCE since the initiation of the new process of Continuous Certification in Emergency Medicine (CCEM) this past January 1, 2004. Upon their successful completion of this exam, they will be presented to the BOS in January 2005 for recertification by the AOA. As of November 1, 2004, there are 1,274 diplomats certified in emergency medicine by the AOA. Continuous Certification in Emergency Medicine

As of January 1, 2004, the episodic recertification process ended. The diplomat receiving a certificate in year 2004 will be immediately eligible to participate in CCEM in its entirety culminating in the year 2014 when the diplomat can elect to recertify by participating in the Formal Recertification Examination (FRCE).

Diplomats with certificates that expire prior to 2014 will be phased into the CCEM process (see attachments) if they desire to recertify.

CCEM consists of four components over the 10-year period of continuous certification. The components are as follows: 1. Evidence of Professional Status 2. Evidence of Practice Status 3. Evidence of Participation in Lifelong Learning 4. Demonstration of Practice Performance and Cognitive Knowledge The professional status component is fulfilled by providing evidence of an unrestricted, unqualified license to practice medicine. The practice status component is fulfilled by providing evidence of the active practice of emergency medicine or its related activities. The third component is fulfilled by the participation in and successful completion of the required number of Continuous Osteopathic Learning Assessments (COLA). The fourth component is fulfilled by the successful completion of the FRCE. COLA's COLA 1 came online this past January 2004.

As of October 18, 2004, 111 diplomats have registered for the COLA. The diplomats that have successfully passed the COLA will receive CME via the ACOEP. Each COLA module is a 40 item web-based exam covering a portion of the core content of emergency medicine (see attachment). References and suggested readings for each COLA are available at AOBEM's website aobem.org. The exam is an untimed, unproctered exam. The exam is intended to be taken at the convenience of the physician at his own computer. The COLA will assist the physician in their review of a specified area of the core content.

Each COLA will be online for two years. The diplomat has three opportunities to pass an individual COLA though, given the fact that the exam is untimed and unproctered, it would be unlikely that the three attempts would be required.

greatly appreciated as we navigate this new age of technology and web-based education.

FRCE The fourth component of CCEM is the one-day FRCE. The FRCE consists of an abbreviated written exam and an abbreviated oral exam.

These written and oral components are different then the Part I and Part II components of the primary certification process. They are designed to assess a recertifying diplomat's cognitive knowledge and practice performance.

The FRCE's will be offered in November. The application deadline for the FRCE is August 1 of the year the diplomat intends to take the FRCE. The application is available at the AOBEM website if the diplomat wishes to recertify.

Diplomats with certificates that expire in 2004 and 2005 have been notified by AOBEM of the FRCE's availability. In 2005, diplomats with certificates that expire in 2005 and 2006 will receive notification of the FRCE's availability.

Certification of Added Qualifications The CAQ in EMS exam was offered this past February. Two diplomats participated in the exam. One diplomat passed the exam. AOBEM recommended a CAQ for the candidate at the June BOS meeting.

The next offering of a CAQ in EMS will be in 2006. The deadline for application is December 1, 2005.

The next offering of the CAQ in Medical Toxicology will be in February 2005. The deadline for application is December 1, 2004.

A conjoint examination committee under the direction of the BOS administers the CAQ in Sports Medicine. AOBEM has participated in the conjoint examination process since its inception in 1996. The examination is given yearly at the AOA convention.

The Future AOBEM is continuing to search for new modalities that will assist it in accomplishing its directives regarding certification in emergency medicine. If a new modality is found that maintains the integrity of the certification process, assures the quality of the certification process and is respectful of the physician's time and financial commitments, AOBEM will change to that modality. As always, the suggestions and comments of the ACOEP and its members are

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In closing, AOBEM is appreciative of the support it receives from the ACOEP. The mutual cooperation and support the two organizations provide to osteopathic emergency medicine will ensure a future of excellence.

Certificate Expiration Date 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

# COLA's attempted 0 0 1 2 3 4 5 6 7 8 8 8

#COLA's passed 0 0 1 2 3 3 4 5 6 6 6 6

National Association of EMS Educators Paula Willoughby DeJesus, DO, FACOEP Meeting: Scientific Symposium and Membership, September 7 - 12, 2004 YEAR

Core Content Areas Covered

2004

Thoracic / Respiratory Disorders; Immune System Disorders; Musculoskeletal (non-traumatic) Disorders Nervous System Disorders; Toxicological Disorders Traumatic Disorders; Cutaneous Disorders Psycho-behavioral Disorders; Systemic Infectious Disease; Pediatric Disorders; Clinical Pharmacology Procedures & Skills integral to the practice of EM; Environmental Disorders Cardiovascular Disorders; Hematological Disorders Abdominal and Gastrointestinal Disorders; Obstetrics and Disorders of Pregnancy; Administrative Aspects of EM; EMS / Disaster Medicine HEENT Disorders; Endocrine, Metabolic, and Nutritional Disorders; Renal and Urogenital Disorders

2005 2006 2007

2008

2009 2010

2011

Reports to the Membership Continued on page 23

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Remember That Patient You Saw? Continued from page 12 the stand and what he/she has written. Read everything relevant you can and provide ammunition to your side. If something is portrayed as “standard of care” but isn't, provide counsel with literature that supports your case. I even read some of the papers cited in the bibliography of one expert witness, several of which expressed difference of opinion with that expert.

It was gratifying to see him squirm a bit when my counsel mentioned that disagreement during his cross-exam.

Once on the stand, during both direct and cross-examination, make sure that the jury understands why you did what you did. They are, after all, laypeople with very little knowledge of medicine. It is likely that plaintiff's counsel will try to get you to answer “yes” or “no” to most questions, when it may not be possible to do so. My counsel was able to get the judge (who seemed very fair) to allow me to make some explanation.

Your attorney will probably think of this, but look for reasons to have the jury consider contributory negligence. For example, if there was a bad outcome due to negligence, look for ways to let the jury know that the plaintiff was partly responsible. - didn't return as recommended, didn't take prescribed medicine etc. Once the verdict is decided, the jury may declare that the plaintiff was __% responsible.

The judgment amount will, therefore, be lowered by that percentage. ➣ Be at jury selection.

I mentioned above that you should try to be at jury selection. That whole process is a science unto itself. For you, it means possibly having some input into the choices. I was not able to be there and had to trust my very experienced counsel. ➣ Be careful what you read.

You will, no doubt, want to read up on your case. The literature may or may not support your position. You will be asked what you have read and challenged on it. If you read, be sure to read everything you can, or you will be accused of reading only the information that supports your position.

Plaintiff's counsel had a copy of Tintinalli and Rosen on the desk during the trial. Sometimes they are for purposes of intimidation. However, Plaintiff's lawyers will spend a great deal of time trying to find some obscure reference in a textbook generally considered authoritative, which exactly contradicts your diagnostic reasoning or the technique you used. Plaintiff's attorney actually showed me portions of the texts that he had highlighted during his own reading.

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Try to find an EP as your expert who really is an expert.

Different jurisdictions have different standards for accepting or qualifying a witness as an expert, but the standards are often quite low.

It is not unusual to find that Plaintiff's lawyers have asked a general practitioner to testify against a surgeon, or a general surgeon who stopped practicing 15 years ago to testify against a neurosurgeon. Many defense attorneys jokingly refer to these physicians as “a doc in a box”; turn the handle and they will pop up with whatever answer you want. More troubling are the practicing physicians whose sole interest is the money they can earn as an expert witness (several hundred dollars an hour for reviewing records and writing a report, then several thousand for testifying at trial). ➣

Your defense counsel will likely ask you to identify a physician in your specialty that you respect. Perhaps a lecturer you saw at a conference or an extensively published physician. It is best not to put forth the name someone who knows you well even if he/she is the Chair of Emergency Medicine at a respected teaching hospital. He will appear biased in your favor.

Try to identify someone who you only know by professional reputation. Your defense counsel will then approach that physician to see if they are interested in performing a defense review of the case and the care at issue.

In some states (but not Pennsylvania), only an ED physician can testify against you. In some states, if you are a DO, only another DO can testify.

Your expert will face some tough grilling by plaintiff's counsel. Whoever you ask should ideally really be an expert in the area of question.

Your attorney will no doubt have a list of experts they can contact, but there is no reason why you can't suggest someone. I was surprised to find out that both sides knew a great deal about the testimony experience of all experts. All were asked on the stand how much they were paid for their services. Both sides did their best to make the jury aware of the experts' motivation for coming to Philadelphia.

Once on the stand, counsel will try to pick apart his/her opinion. Experienced experts are prepared for that and maintain their composure very effectively. He/she will do a much better job for you if truly expert. Some “experts” are little more than being very good at being an expert witness. They may be very good at presenting their testimony, but a good attorney will make the jury see them as being purely mercenary. ➣ The judge makes a difference.

The first judge assigned to hear my case was

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replaced for reasons unknown. My counsel was happy with that. The first had a reputation for being less than decisive, while the second was a former criminal lawyer with a reputation for being decisive and fair. He listened to every word. Most of his rulings actually made sense to me, though I didn't always like them. The direction of the proceedings may be a function of how your judge operates. ➣ The jurisdiction matters.

Philadelphia is notorious for very large judgments. For that reason, plaintiff's counsel is much less favorably disposed to settle. As a matter of fact, effective January 1, 2003 a Pennsylvania case must be tried in the county in which the alleged malpractice took place. ➣ Select carefully whom you will ask to sit through the trial.

The trial is a painful experience not only for you, but also for those who love you. I had a mental picture of my wife being ejected from the room because she wouldn't have been able to listen to someone accuse me of being incompetent. A good friend offered to be there for me as moral support, but I declined the offer rather than disrupt another life. Whatever you do, do it with a great deal of thought.

Prepare your colleagues for the time you will be away.

The length of the trial, of course, is variable. It is critical that you get your colleagues to cover you. You need to give all your attention to the trial. Besides, if you are like many, you will have some question about your own competence.

That is baggage best left outside the work environment. It might even be wise to plan for a few days off after the trial is over. ➣

Connect with the jury (need to know you are not prejudiced, cocky etc.)

Dress the part of the professional. Make eye contact with the jury and address them when you answer questions. Let your attorney know that there may be times when he will need to ask the judge to give you some latitude in explanations. Plaintiff's counsel actually tried to imply that I would have treated my patient differently had he not been poor and African American. The jury may not have approved of my medical care, but I did not let them buy that lie. ➣

➣ Be at the trial everyday.

I was very surprised to hear that some physicians choose not to be present during the trial.

You should be there. The jury needs to see that you are interested in what is happening. After my trial, counsel informed hospital attorneys that I had been there and active in my defense.

(I think they need to hear that, especially when jury finds for the plaintiff).

➣ Be confident but not cocky.

Try not to roll your eyes when the Plaintiff's lawyer asks what you consider a stupid question.

Try not to sound superior or elitist. Plaintiff's lawyers will often purposely misstate the name of a procedure or how it is performed, hoping you will smugly point out their error. It is fine to correct them when they make a misstatement, but do it politely. Another tactic is for the Plaintiff's lawyer to speak in an overly aggressive or condescending manner to you - do not react by going for the jugular. Again, be polite, but firm.

Presumably in an attempt to make the jury think I was incompetent, plaintiff's counsel did his best to make me look bad. Assuming you don't think you did anything wrong, a confident attitude and demeanor helps the jury get the idea that you believe in yourself and that you did what you thought was best for the patient. Cockiness, on the other hand, makes an enemy of the jury. (Although it didn't happen in my trial, I hear that there are times when either side's legal team alienates the jury with such cockiness). Remember, they are usually working people who “connect” more with the plaintiff's plight than yours. (Some say that only those who can't get out of jury duty actually serve). ➣ Look at the jury Get the question from the attorney, then look at the jury and address them. ➣ Be honest.

Your best defense is a thoroughly documented ED record. If something in the chart stirs your recall of something, say so (if asked). If you don't recall something, say so. Never give in to the temptation to lie or bend the truth.

Plaintiff's attorneys don't get wealthy by being stupid. They may (and will) try to distort the truth, but unless you let them, they can't change the truth. There were several times when I had answered a question only to be asked the same one in a different way a bit later.

If you stick to the truth, your answer will be the same. It was small consolation, but I did have the opportunity to tell counsel that I was not going to change what I had said earlier.

Remember, too, that if you would do something differently now that you are aware of all the facts, it is OK to say so. It would be a mistake to adhere stubbornly to the idea that what you did was right when you now believe it was in error. Be careful how you say this. ➣ Consider your answers.

In both deposition and trial testimony, there are right ways and wrong ways to answer questions.

Give truthful answers, but be brief. One-word answers are best.

During the deposition, it

is best to be short and to the point in your responses - it is not your responsibility or in your best interest to teach Plaintiff's counsel the art of medicine. This often goes against the grain for physicians accustomed to teaching residents or educating their patients. During the deposition, Plaintiff's counsel wants you to be verbose, so they can try to find something you said to use against you. On the other hand, during crossexamination at trial Plaintiff's counsel wants to box you in and give you little opportunity to explain your position to the jury. That's when they will demand yes or no answers. You will be able to get your position across during direct and re-direct examination by your own attorney. Let your attorney decide when you should elaborate on your answers.

Beware of leading questions. I grimaced and mentally prepared myself every time plaintiff's counsel started by saying “You would agree with me, would you not, Doctor…”.

“I don't know” and “I don't remember” are acceptable (and even good) answers if that happens to be the case.

Stress favorable facts, but don't exaggerate the truth.

Pause before every answer, giving your attorney time to object. If he/she stands to object, stop talking. (By the way, only in Hollywood does an attorney give a reason for his/her objection.

The judge anticipates the objection and should know the basis for each one).

A cardinal rule of questioning is never to ask one to which you don't know the answer.

Plaintiff's counsel expects a particular answer every time he opens his mouth. Deny him that satisfaction if you can.

Beware of hypothetical questions. You can't know what would happen in a given “what if ” scenario, but you do know what happened with your case.

I have listed a few “dirty tricks”-type questions at the end of this syllabus. They appeared in a Medical Economics article in 2001. ➣ If you disagree with your defense, speak up!

It only occurred in a kidding way with my defense team, but if it appears that they plan to do something with which you disagree, say so and tell your team why. It is, after all, your defense. ➣ Some plaintiff's counsels are worse than others.

My counsel told me I'd gotten off easy. Some attorneys are much more aggressive. It is likely that your own counsel will know something about the style the other will bring into the courtroom.

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When my trial was over, opposing counsel came up to me with his hand out and that “no hard feelings” look on his face. Yes, I shook his hand, but I couldn't help but wonder if he'd have done the same if the verdict was for me. ➣ Points of Charge Just before the jury begins deliberations, the judge will charge the jury. He/she will read a series of legal points to help clarify in the jurors' minds what they must do and how they must do it in keeping with the law. Both sides get to discuss what charges go the jury. ➣ Plaintiff's Counsel “Dirty Tricks” • Twisted words • Using the deposition as a weapon • Harassing the expert(s) • Leading and other unfair questions (see below) • Using a good chart against you • Using the discharge instructions as a weapon • Playing one doctor against another (This is a favorite, because doctors get defensive and start pointing fingers and begin to imply that they would have done differently “if only I had known all the facts”). ➣ Be mentally prepared for the aftermath of the trial.

I mentioned above that you will, no doubt, question your own abilities when you hear an attorney portray you as incompetent or uncaring. You may return to work expecting that your colleagues will look down at you because you “lost”. You may wonder if they can attack your assets. You may even fear that the hospital will terminate you.

The realities, at least for me, were different. For the first few days I was a bit more defensive in my care of patients, but I soon got back into my normal rhythm. That may or may not be what happens to you.

Your colleagues will almost certainly recognize that the next case may be theirs and that losing the case isn't the same as being a weak link.

In the vast majority of cases, the judgment will be covered by your malpractice carrier.

Although it varies by state, the plaintiff does not usually have access to your personal assets.

In Pennsylvania the plaintiff can go after personal assets, but that rarely happens.

It is unlikely that you will be fired as long as you cooperate with your defense team. My legal team sent a letter to the administration confirming that I had been present from the start and had been cooperative. ➣ Sneaky Questions Allan E. File faced a suit some time ago and listed his suggestions for answering specific types of “sneaky lawyer questions”. The attorney

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who helped defend him (successfully) helped him write the article. The article is worth reading. You can go to a few websites for this and related legal articles. The sites are: www.rmf.harvard.edu/publications (Harvard's Risk Management Forum), www.findarticles.com/m3229 (where I found the “sneaky questions”; www.forensic-pshych. com (medical-legal articles) and www.ucalgary.ca (University of Calgary overview of malpractice suits and the legal requirements of plaintiff and defendant.

Here are those question types: • The compound or multiple part question - Ask for the question to be rephrased, one question at a time.

• The double negative question - Restate it in your own terms to be sure you understand.

• The leading question - As I mentioned above, the attorney wants you to answer in a specific way. Tell him/her why you can't do that.

• The damaging supposition / allegation -

Especially when you are tired, the attorney may try to sneak in with such a scenario. Ask him/her to repeat the question slowly, then ask for a break.

• Rapid-fire question - Don't let the attorney set the pace. Finish answering one before allowing him to ask another.

• The argumentative question - If you disagree with what he/she says, speak up. State the facts.

• The paraphrase - If the attorney “reminds” you of something you said and it doesn't sound accurate, ask for clarification.

• The “authoritative guideline” tactic - Remind the jury that clinical guidelines are just that.

Tell them, too, that those guidelines never take into consideration the circumstances surrounding the case and that guidelines change as new information comes to light. Explain why you deviated from a guideline.

• Speculation - Don't allow him/her to trick you into guessing what you would do in a hypo-

thetical situation. Tell the jury you can't do that because in the absence of facts, you would only be guessing.

• The “Isn't it possible, Doctor” trick - Be firm in your answer. If you don't think what he/she is suggesting is possible, say so. If not, consider this a theoretical situation.

• I love this one. Dr. File calls this the “Detective Colombo gambit”. Remember when that cigar-smoking detective would act like he was leaving, then turned around and said “Just a few more questions, then we're done?” He is probably not “almost done” but would like you to drop your guard.

Foundation Forum Victor J. Scali, D.O., FACOEP Foundation President The Foundation Forum is a new feature in The Pulse to provide updates and information to the membership of the American College of Osteopathic Emergency Physicians on the activities of the Foundation for Osteopathic Emergency Medicine (FOEM). As you may know, the Foundation was formed in 1998 with the vision to be the philanthropic arm of the ACOEP with its emphasis on supporting research and education in emergency medicine done by osteopathic physicians or completed at osteopathic institutions. Initially funded by a grant from the ACOEP, the Foundation has annually continued to grow its financial base through the generous support of pledges donated by a growing number of college members. However, this single revenue stream at the current level of giving is not enough to ensure a future endowment that will fund research for future generations of osteopathic emergency physicians. Future foundation financial growth and stability will depend heavily on corporate and institutional support, bequests, as well as increasing the growing number of individual contributions from our College.

Over the past year, the Foundation has increased its visibility through its new web site (www.foem.org) that showcases the Foundation's mission and vision. I invite you to visit the site and welcome your suggestions to make it even better. Our grant applications and contribution forms have been posted for easy downloading. We have revamped the Foundation's promotional materials and had hoped to distribute grants during the 2005 year. However, during this past fiscal year, FOEM, for the first time, fell $10,000 short of its yearly goal and now must regretfully take drastic steps to curb spending and increase revenue. Even though the Foundation has received requests for grants from three osteopathic physicians, because of our shortfall, FOEM has decided to declare a moratorium on grant distribution during the 2005 year to insure future financial growth and stability. Be assured this measure is not a sign of weakness, the Foundation is alive, well, and growing with a total worth of over $250,000, garnered in just 6 years from its inception. During the next year, FOEM will continue to fund the awards for paper, poster, abstract, and CPC competitions at the annual scientific seminar.

During 2005, FOEM will also be embarking on an intensive capital campaign to increase our visibility and support among corporate sponsors, institutions, and individual donors. You will be kept informed of the Foundation's progress and this campaign in future columns. The future of research in our profession will depend on the success of this critical fund-raising activity.

The Foundation wishes to thank its present group of donors who have supported us through regular donations throughout the years, and we hope they will continue to do so at even a higher level of giving. If you are not a current contributor to FOEM as a new member of ACOEP, the Foundation asks you pick up the torch of research and become a supporter of the Foundation. You can do this in several ways. You can make a pledge to support the Foundation throughout the year through tax-deductible donations periodically charged to your charge card or you can make a one-time tax-deductible donation. The FOEM Board of Trustees is expanding its membership in 2005 and invites those college members interested in being nominated for a position on the FOEM Board to contact Jan Wachtler or me at 312-587-1765.

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Reports to the Membership Continued from page 19 The meeting was held in Hollywood California and once again demonstrated record attendance.

The sessions continue to have full participation.

The group is progressing on establishing itself fiscally and by numbers. There are multiple active committees. Membership increased by over 500 to 2697. It was voted to increase dues by $15 from the current $65 fee. They will offer a reduced fee of only a $5 increase if the member agrees to accept all correspondence electronically.

The Association continues to actively participate in the development of the implementation of EMS Education Agenda for the Future with the National Highway Traffic and Safety Administration (NHTSA). The Scope of Practice, which has been lead by the State EMS Coordinators and regulators, is released.

NAEMSE will take the lead on the Educational Standards section will follow. If you are interested in participating submit your letter of intent, CV and 2 letters of recommendation to the Association.

The Association will continue to strengthen partnerships with the Brain Trauma Foundation, law enforcement, Department of Justice, International Association of Fire Chiefs and others. They are seeking to establish relationships with Aero-medical Transport Conference, Rural EMS and Trauma Technical Association Center and the AHA. They are working on the development of a pediatric disaster-planning curriculum. The Association is looking for groups to host their EMS Educators Conference.

The State of EMS Education Research Project (SEERP) has been released and can be found on the NAEMSE web site. It found most EMS educators were satisfied with their positions and will continue in their role. Most educators felt challenged by testing and assessment skill performance and evaluation of students.

National Registry Emergency Medical Technicians Paula Willoughby DeJesus, DO, FACOEP

mittees, the Executive Committee, Standards and Examination, Data Utilization and Information Technology, Community Relations and Nominations.

develop needs assessment tools to determine the direction the Committee should precede in the establishment of a pediatric emergency medicine fellowship and CAQ.

The Registry has officially certified its one millionth NREMT, a paramedic from Midland, Texas. The office renovations are complete, including the technology upgrades. Staff will now be added to keep up with the increased workload. Florida is the latest addition with them adopting the EMT-B exam as their State examination. They are continuing to move forward with computer adaptive testing and have released the RFP. There has been a decrease in the EMT-B pass rate. Airway subset of questions most commonly where they have seen increased deficits.

The Committee developed four survey tools.

The first will be directed at program directors to determine the percentage of pediatric cases seen in emergency departments at training institution. This was handed out on sight to the Program Directors Committee and responses were requested by December 1.

There was discussion related to NREMT recognizing programmed courses. It was felt they would continue to require CPR and ACLS. There was uncertainty if other courses would be recognized. They will discuss this with CECBEMS and state representatives and finalize a position.

The Registry will participate in the continued implementation of the NHTSA's EMS Education Agenda for the future. They have been asked to be an ex-officio member of the National EMS Certification element as opposed to other EMS organizations having full participation because they are a national certification organization. The Scope of Practice document is being circulated for discussion.

NREMT has paid fees to be a member of the EMS Advocates group. Mr. Brown, Executive Director, and other Board members verbalized concerns related to NREMT participating in lobbyist group and those they could not represent their members as other organizations because of the different relationship NREMT has with its members. They agreed that NREMT would not have the Advocates group authorization as supporting any particular position but would monitor activity only.

Ad Hoc Committee on Pediatric Emergency Medicine Anita Eisenhart, D.O., FACOEP, Chair

Meeting: Board of Directors, June 9, 2004 The semiannual Board of Directors meeting took place in Chicago with the usual broad discipline involvement. Participants include ACEP, NAEMSP, NAEMSD, NCSEMSTC, AAA, IAFC, NHTSA, ACS, AHA, military representatives and others. There are five com-

At its previous meetings, the Committee approved its Mission Statement and began to

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The second survey tool is directed recent graduates from residency programs and will determine if recent graduates felt that they had sufficient exposure to pediatrics during their training and to determine interest levels in creating a pediatric emergency medicine fellowship and ultimately a Certificate of Added Qualifications (CAQ) in pediatric emergency medicine.

The third survey tool is directed to current residents in training to determine their interest levels in these areas among this section of the membership.

The fourth and final survey would be directed at the general, active membership of ACOEP and would determine the number of pediatric cases seen, various required pediatric merit badge courses, and the interest level of this group of active emergency medicine physicians.

The schedule for distribution will be completed by the beginning of February and survey compilation should be completed by the Spring meeting of the Committee.

Emergency Medical Services William Bograkos, D.O., FACOEP The Committee received updates from liaison representatives for CDC; USSOCOM and CECBEMS. The Committee discussed the continued low attendance at the Tactical EMS meeting, and suggested options of informing other specialty physicians of upcoming Tactical EMS meetings, including advertising in The D.O. magazine to attract physicians from other specialty areas who may wish to attend as members.

To assist the Committee in dealing with the broadening scope of Emergency Medical Services, the Committee discussed forming several new subcommittees whose focus would be narrower than general EMS. The suggested subcommittee would deal with domestic pre-

23

paredness. The subcommittee's focus will be only on issues of homeland security and will be meet prior to the full meeting of the EMS Committee and submit a written report to the EMS Committee for incorporation into its agenda.

As far as future CME venues, the Committee recommended that the Fall 2005 Scientific Seminar and the 2006 Spring Seminar be utilized as a venue for Tactical EMS focus on Research projects. Suggestions will be forwarded to the CME Committee and the EMS Committee for research projects.

The Committee discussed the factor of EMTs practicing Rapid Sequence Intubation. The Committee will review the NASP position paper on RSI, and forward their comments via email

by December 1st. to NITSA. Communications Committee Drew Koch, D.O., FACOEP, Chair The Committee met on Saturday, November 6, 2004 and discussed several issues pertinent to the College's publication, The Pulse, and its website.

The Committee discussed the development of several subcommittees to take charge of the development of articles, recruitment of authors and advertiser recruitment. Discussion centered on the recruitment of authors who will make the commitment to produce several articles over the period of 2 years. Some of the incentives discussed were the inclusion of article publication in The Pulse, as criteria for Fellowship within in the College, and the development of financial incentives.

The Committee made a motion to request that all committee chairs be required to submit 4 to 6 articles for publication over their term as chair of ACOEP committees. The articles would not have to be written by the chair, but could be done by members of the Committee and submitted through the Chair to the Editor.

Additionally, the Committee moved to offer College members the ability to submit 8 articles over the period of 2 years in which 6 must be approved for publication. If a minimum of six are accepted for publication, the member would be granted free tuition to the next Spring Seminar after the submission of the sixth article.

The Committee moved that lecturers receiving the highest evaluation during the Spring and

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Scientific Seminar be informed that their lectures were judged to be the highest rated in the seminar and are being given the opportunity to increase their honorarium by $250 for the submission of a 1,000 word abstract of their lecture.

This would have no fiscal impact, as monies would be taken from the Executive Director's Discretionary Funds.

The Committee stated that it would ask the Program Directors Committee if they would develop a series of abstracts on the articles utilized for the COLA preparation. This would be discussed further with the Communications Committee after consideration by the Program Directors Committee.

Continuing Medical Education Anita Eisenhart, D.O., FACOEP, Chair The Committee heard an updates on all meetings scheduled for 2005 including the Intense Review, COLA Essentials, Scientific Seminar and the Spring Seminar. All programs appeared to be well established and organized for presentation on their projected schedules.

Several programs had to undergo changes because of illnesses and deaths within the ranks of our speakers. These holes are being filled, but some concern was presented with the last minute changes, especially in light of these unexpected cancellations.

Due to continuing escalation of costs of printing, the Finance Committee recommended that all seminar material be distributed on CD-ROM beginning with the COLA Essentials course in February. Material will be submitted according to the guidelines but registrants will be informed that information will no longer be on paper and that CD-ROMs will be sent out to them approximately 2 weeks prior to the Seminar. A number of PC stations will be set up at meeting sites for those on-site registrants who wish to print the material at their own expense. This pilot program will be monitored and information submitted to the Finance and CME Committees for possible continuation in the fall of 2005.

The Committee heard an update on the progress of the revamped Oral Board Review. The Oral Board Review is being planned for late April or early May in Chicago and also during the AOA Convention. The Committee discussed and accepted the changes made to the Oral Board Review format.

The Committee heard an update on the prog-

The PULSE JANUARY 2005

ress of the Scientific Seminar 2005. A joint session is scheduled with the American College of Neurology and Psychiatry. The Keynote speaker will be Daryl Beehler. The Committee discussed ideas for the 2006 Scientific Seminar.

The Committee was introduced to a new Subcommittee, the OMM Education Subcommittee. The Subcommittees goals will be to offer training courses, lectures at ACOEP's bi-annual meetings, which will serve as refresher courses for students and residents, as well as provide lectures and CD - ROM materials to answer questions on OMM billing and coding questions. The Subcommittee will also provide clinical scenarios and how - to guidelines.

The Committee discussed ways to increase meeting revenues and decrease spending and speaker expenses. The Committee discussed the possibility of having speakers commit to 3 hours lecture time for $250. The Committee decided to revisit this issue at a later date. In order to help defray printing costs, the Finance Committee has recommended that all future CME syllabi with the exception of the Intense Review are in a CD - ROM format. The Committee discussed this recommendation and agreed with the Finance Committee's recommendation.

The Committee discussed the possibility of moving COLA Essentials to San Diego for 2006. The Committee agreed and decided to have the COLA Essentials 2006 at the Hilton La Jolla Torrey Pines Resort.

The Committee discussed the possibility of having COLA Essentials 2007 in Park City, Utah or Banff, Canada. The Committee decided to research going out of the country further and revisit this issue at a later date.

The Committee discussed having an Emergency Airway Course with a course coordinator of Gregory Christiansen. The Committee decided the course would be held in Washington, D.C. in August 2005. The course would be limited to 40 participants.

OMM Subcommittee of CME Terrence Mulligan, D.O., FACOEP, Chair The Subcommittee met for the first time and developed the following mission statement to

direct future actions: The Subcommittee on OMM Education of CME will exist to promote OMM in acute care setting; to promote training in osteopathic emergency residency programs, to promote resources for training practice in evaluation and billing.

The Subcommittee determined the purpose would be to develop a training course for students and residents to utilize their OMM techniques in the acute setting.

The Subcommittee suggested the training course to consist of possible two-hour block workshops offered once a year, which includes hands on practical session.

The Subcommittee recommended that resource material would be available to attending physicians teaching OMM to students and residents.

This would include manipulation guidelines as part of assessment in treatment, possible lecture series and hands on teaching from attending physicians.

Governmental Affairs Joseph Kuchinski, D.O., FACOEP, Acting Chair The Committee reviewed the lobbying activities for DO Day on the Hill in September 2004.

The September program was very successful and the 2005 DO Day on the Hill has been scheduled for April 14, 2005.

The Committee urged everyone to take action and contact their state constituents for action on issues pertinent to PLI and healthcare reform.

The Committee discussed the numerous ways to develop relationships with State and Federal level liaisons.

The Committee discussed issues being dealt with for the 109th Congress Meeting, which will begin on January 28th, 2005. Also discussed were issues of workforce shortage, including nurses, technicians, and physicians, board certification in Florida, with BCEM, and AAPS, and the importance of having national standards and credentials for D.O.'s Graduate Medical Education Jerry R. Balentine, D.O., FACOEP, Chair The Committee reviewed revisions of two training standards and recommended that they be reviewed further by committee members with input directed back to the Executive Director for finalization at its meeting in February, 2005.

The Committee reviewed 3 continuing pro-

grams. Recommendations were made regarding these programs and will be reported to the American Osteopathic Association's PTRC in January.

It also accepted two hospital's answers to the deficiencies noted in previous inspections.

The Committee reviewed several proposed residency programs. Recommendations were made regarding these programs and will be reported to the American Osteopathic Association's PTRC in January.

The Committee reviewed 12 requests for advanced standing. Recommendations were made regarding these programs and will be reported to the American Osteopathic Association's PTRC in January.

Two new program directors were recognized at established programs.

Membership Murry Sturkie, D.O., FACOEP, Acting Chair The Committee reviewed the current benefits of Membership in ACOEP which, are car rentals discounts; airline travel discounts; travel assistance; financial planning; and member tuition discounts to determine what more could be developed. Suggestions included pre-taxed salary withdrawal for payments of tuition and dues, discounts at major chains and computer vendors. The Committee discussed investigating the cost to put COLA articles on CD ROM either as a member benefit or at a cost to the members.

The Committee also reviewed candidates for life membership Practice Management Thomas Brabson, D.O., FACOEP, Acting Chair The Committee discussed the creation of a Pre EMS Diversion policy. The purpose of the policy would give hospitals a plan to prevent going on diversion and if a hospital does go on diversion what to do once on diversion.

The Committee also discussed creating a policy to deal with “Frequent Flyers� but decided it should be a hospital policy instead of a national policy.

The Committee also discussed creating a policy for the Management of patients with Transient Ischemic Attack. The Committee is going to do more work on this matter and discuss it at the

The PULSE JANUARY 2005

next Spring Seminar.

The Committee also discussed accepting the ACEP policy on Acute Stroke Management and decided to table the discussion until more studies are done to either support or not support this treatment.

The Committee also discussed Policy number 7 the Public Access to Automated External Defibrillators (AED), which was, passes by the Board of Directors at the Spring Seminar.

Research Alan R. Janssen, D.O., FACOEP, Chair The Committee met on Saturday, November 6, 2004 and discussed several issues pertinent to the research within the College and the Foundation for Osteopathic Emergency Medicine.

The Committee received a report on the research modules that are currently being developed with KCOM to allow core faculty and PGY-3 and PGY-4 residents to gain training in research prior to the end of the 2004-05 training year.

The modules will be reviewed once more to determine if all the anomalies were removed and would then be implemented for general training use after January 1, 2005.

The Committee also received a report from the Administrator of the Consortium for Research in Emergency Medicine (CREM) concerning the development of the database which will be housed on the Foundation's website and used to attract pharmaceutical companies and others seeking multi-centered research opportunities.

To date, there are 7 training institutions that have sent in information and the Foundation will be contacting the remaining 32 training institutions to determine their interest level. It is the hope of the Foundation that we will have all programs join in this effort.

The Committee was also utilized as a review committee for three grants submitted to the Foundation for Osteopathic Medicine. The Committee requested that several changes be made to the review process to enable them to review the submitted grants either online or via email to avoid costly shipping, and to submit its evaluations via a secured link on the Foundation's website. This process would be revamped within the next 8 weeks and be available for use during the next grant cycle.

Reports to the Membership Continued on next page

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Student Chapter Update

Reports to the Membership

The 2003-2004 school year brought with it great success to the American College of Osteopathic Emergency Physicians - Student Chapter (ACOEPSC). The Student Chapter activities at the recent San Francisco convention was the capstone to a wonderful year as we more than quadrupled our attendance to events from the previous year. The newly elected Student Chapter officers are excited to continue the success of the Student Chapter into the 2004-2005 school year.

The last year brought with it much needed change to the Student Chapter as we set out to refine our organization, to improve our level of respect within our profession and nationally, and to take on more responsibility. These goals were reached and in most instances far exceeded expectations. The committee changes allowed us to focus a large part of our efforts into the advertising and planning of convention activities. “If you plan for it, they will come,” is the phrase the Convention and Public Relations committees took to heart last year. As a result, our Student Chapter members were better informed about the activities we organized and there was outstanding attendance at those activities.

This year, we plan on continuing our success with the changes we made and making additional goals for the next year. Once again, the Convention and Public Relations committees will be in full force over the next year to bring as many if not double the amount of student to the upcoming ACOEP and AOA Conventions in the next year to Arizona in April and Florida in October, respectfully.

One very important aspect of the Student Chapter is to provide information to the schools for use in their individual clubs for recruitment and informational purposes. This year the Student Chapter has multiple ways to increase the individual chapter awareness of the ACOEP-SC. The first aspect is to provide the schools with recruitment welcome packets. These welcome packets will include copies of The Emergent and The Pulse, tri-fold brochure, and other practical emergency medicine

The Foundation representatives asked the Committee for its input on several aspects of grant review and its answers would be taken back to the Foundation and reported to the Committee at its next meeting.

Jeremy K. Selley, President

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information. The second aspect is to provide as much information as possible about the Student Chapter on the website in an easy to read format and have an additional area for an “update your chapter information” section. The website has been under construction for the last year, but will soon be up and running. The use of the website over the next year will more effectively increase our Student Chapter communication. The third aspect would be to organize school luncheon visits with a Student Chapter board member and possibly an ACOEP board member or a physician involved with the ACOEP. These school visits would increase the awareness of what the Student Chapter does for its members along with providing insight about Emergency Medicine. If you are interested in helping the Student Chapter conduct these visits to a school in your area, please contact me at acoepsc_pres@hotmail.com.

The ACOEP has generously offered the Student Chapter multiple positions on its thirteen committees. This is an excellent opportunity for the student chapter members to provide a voice into the professional organization they eventually will become a part of. Additionally, the Student Chapter president has the privilege to serve on the ACOEP Executive Board as a non-voting member. This board member position will allow more rapid communication between the ACOEP and ACOEP-SC, collaboration of ideas, and promote and validate the importance of student representation within national organizations.

Thank you to ACOEP and its members for its continued support of the Student Chapter. Without your support we could not function effectively to serve our members.

Continued from page 25

Undergraduate Medical Education Anthony Jennings, D.O., FACOEP, Chair Nicole Ottens, SC-President, updated the committee on the accomplishments of the Student Chapter for the past several months.

The Committee discussed identifying mentors for the Students who are interested in emergency medicine. On the 2004 - 2005 membership renewal form there was a box that you can check asking physicians if they are interested in becoming a mentor. So far we have about 100 physicians interested.

The Committee also discussed letting the Student Chapter know that there are physicians who are interested in mentoring and matching them with physicians. The Committee also discussed having a mechanism for evaluating mentors. The Committee will also create a guide to help physicians know how to mentor students at different levels of there learning.

The Committee also discussed the Student Lecture Series. They have approximately 30 lectures including Trauma, EKG, Stroke, Sexual Assault, Toxicology, Chest Pain, Airway Management. The Committee would like to have a mechanism for physicians to manipulate the content of the lectures so the user can make changes to the lecture.

The Committee also discussed the Student Case Presentation, this year John Dery won with his case “The Trouble with John Doe” he will present his case on Tuesday November 9, 2004.

The Committee also decided to dispense with the Student Case Competition that is due to the lack of interest by the Students.

The Committee also discussed giving a Resident a position on the committee.

The PULSE JANUARY 2005

Nathaniel Sherman, MD Chairman, PHCS Diversity Committee PHCS physician since 1991

Doug Finefrock, DO Candidate for PHCS Leadership Program PHCS physician since 2003

Joan Kolodzik, MD PHCS Director of Education Past PHCS Board Chair PHCS physician since 1989

Steve Yamaguchi, MD ED Medical Director Mercy Hospital-Fairfield PHCS physician since 1998

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