The Pulse January 2007

The PULSE

Osteopathic Emergency Medicine Quarterly VOLUME XXXIi NO. 1

January 2007

New President 2006-2008

Peter A. Bell, D.O., FACOEP

The PULSE january 2007

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The PULSE january 2007

Presidential Viewpoints Peter A. Bell, D.O., FACOEP With each new President comes an opportunity to change. Ideally, this change reflects the desires of the members and is congruent with the mission of the organization. Over the past 6 months, I have sought to identify key issues that meet these criteria. These issues needed to be contemporary, doable and deliverable, and lead to the future success of our organization.

Coupled with this process was the continuity of leadership on the board, committees, and effectiveness of the support staff. A process of evaluation with feedback was developed to better determine where our strengths and weaknesses were.

Realignment of people and positions was then instituted. It is my desire to have each employee or member performing those duties in which they have the most expertise and most desire. While there are limits to how many members can chair a committee in any given cycle, I have sought to balance the enthusiasm of the members with the needs of the college. I also recognize that this is an ongoing process, and does not easily fit into a 2-year presidential term.

For this reason, it was Dr DeJesus’ intent (and mine) to change no more than one third of our committee chairs in any given year (similar to Board of Director terms).

The office staff is also going through changes. We are in transition in both job descriptions and people. We engaged two outside Human Resource experts to assist us in the process. I also appointed a member at large to represent the interests of the membership in this process. Ultimately, we hope to have a more highly effective, highly efficient staff that is able to meet the members’ needs.

In April, July, and October I met face-to-face with the office staff, board members, and committee chairs to discuss the 2006-2008 Presidential Objectives.

I also spent hours on the phone and corresponding by e-mail. The following list is not all inclusive of what we will accomplish, but gives us direction for what we strive to accomplish. It is my belief that it is 90% achievable with 10% being stretch goals. It is consistent with our strategic plan and in alignment with our mission statement. The details will be discussed with the responsible committees, and progress monitored. For the most part, the objective list has always been an integral part of any presidency, but by sharing it with the membership; I hope to clarify the path we are taking.

2006-2008 Objectives 1) Members participation

a) Membership required for each AOA EM resident

b) Each AOA EM residency is required to send a resident repre-

sentative to each biannual meeting c) Every AOA EM resident must attend one ACOEP conference and membership meeting once during their 3 years of residency

d) Every core faculty member must be an Active member of ACOEP

e) Every AOA EM residency is required to enter the CPC/ POSTER competition

f) Fellows are required to participate in one membership meeting per year in order to maintain fellowship

g) Pursue Bureau of Osteopathic Specialty Societies initiative for required membership in a specialty college if you belong to AOA

h) Establish recurrent theme in publications; “the member is our building block”

i) Become the second largest specialty society in the AOA 2) Leadership

a) Future leaders

i) Institution of progressive committee appointments

ii) New board members developed from committee chairs annual evaluation process for iii) Board members iv) Committee chairs v) Committee members vi) Executive director vii) Office staff

b) Effective strategy for appointment of members to AOA committees

Table of Contents New President 2006-2008, Peter A. Bell . . . . . . . . . . . . 1

Not Exactly EMS History . . . . . . . . . . . . . . . . . . . . . . . 18

Presidential Viewpoints . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Guest Article,

Continuing Medical Education Calendar . . . . . . . . . . . . . 4

William M. Kokx, D.O., FACOEP, FACEP . . . . . . . . . . 19

Editorial, Drew Koch, D.O., FACOEP . . . . . . . . . . . . . . 5

Resident Chapter Update . . . . . . . . . . . . . . . . . . . . . . . 20

Executive Director’s Desk . . . . . . . . . . . . . . . . . . . . . . . . 7

Guest Article,

ACOEP Members Elect New Board Members . . . . . . . . 9

Beth A. Longenecker, D.O., FACOEP, FACEP . . . . . . . 21

Money Talk - Gifting Away Your Assets . . . . . . . . . . . . 15

What's Happening . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Guest Article, Zafar Shamoon, D.O. . . . . . . . . . . . . . . . 17 The PULSE january 2007

THE PULSE–AN OSTEOPATHIC EMERGENCY MEDICINE QUARTERLY 142 E. Ontario St., Suite 1250 Chicago, IL 60611 312-587-3709/800-521-3709 Editorial Staff Drew A. Koch, D.O., FACOEP, Editor Peter A. Bell, D.O., FACOEP Fred G. Wenger, Jr., D.O., FACOEP Bobby Johnson, Jr., D.O., FACOEP Janice A. Wachtler, Executive Director Publications Committee Drew A. Koch, D.O., FACOEP, Editor & Chair Fred G. Wenger, Jr., D.O., FACOEP, Advisor Bobby Johnson, Jr., D.O., FACOEP, Vice Chair/ Asst. Editor James Bonner, D.O., FACOEP Annette Brunetti, D.O., FACOEP Randall A. Howell, D.O., FACOEP William Kokx, D.O., FACOEP 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.

Presidential Viewpoints, continued from page 3

3) Advocacy

a) Regular political advocacy through AOA i) 100% board member participation in OPAC

ii) Board representation at

Bureau of State Government

Affairs iii) Board representation at Federal Health Council iv) 50% of board members participate in annual DO Day on the Hill

b) Annual board member visits to EM Clubs and Residencies

c) AOA actively seeks the advice, collaboration, and expertise of ACOEP 4) Education

a) Publication of an OPP curriculum for EM residents

b) Two year calendar of educational offerings available on the website 5) Finance

a) Draft budget requests are submitted to the finance committee by the spring meeting of each year

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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b) Final budget for the next fiscal year is completed by mid-July

c) Appointment of a member-at-large on the finance committee that demonstrates superior expertise in financial management 6) Benefits

a) Agreement with other Emergency Medicine organization(s) to provide additional benefits i) Publications

b) Interactive website with searchable data base

c) Advanced level of fellowship

Many of these items are already in progress, and will occur in the immediate future. Some are in their infancy. Some members will cheer when reading this list, noting that the time has finally come.

Others might feel less enthusiasm. These objectives are about the balance between the member and the organization. I need your support. I need your confidence in our process. I need you to engage in our college, for you the member are our building blocks, our future.

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

Empty Nest ACOEP recently held its 2006 Fall Seminar in conjunction with the AOA Convention in Las Vegas, Nevada.

The College has held its fall CME program at the annual AOA Convention since its first CME in the late 1970’s and is poised to continue this relationship through 2012.

The projected specialty college calendar does not include the fall convention dates or locations for the years 2008 and 2011. The word on the street is the AOA is going to be at the Las Vegas Venetian Resort Hotel Casino in 2008. So, what does the location of the AOA Convention have to do with ACOEP and its fall CME? Depending on who is queried, a lot. Is ACOEP sprouting its wings and leaving the AOA Convention and going out on its own?

The course evaluation at the Fall Conference this year asked the question: Would you continue to attend the fall conference if it was held at a different location than the AOA Convention? Is our College ready to make the plunge and separate its fall CME from the annual AOA Convention?

This thought and possibility has merit and needs to be explored and hopefully acted upon by the College. The opinion of some members of the College is that the College has been treated like a child since its infancy and now needs to spread its wings. We should not sever our ties and communication to our parent organization but we need to become independent and focus on the needs and concerns of our members.

Does the AOA Convention benefit the rank and file members or the speciality colleges? Neither, on the surface it appears that the AOA Convention benefits the AOA and not the speciality colleges and the members of the AOA. The cost, location,

and hotel selection are egregious. The registration costs appear excessive and include: not only the tuition costs but the cost of a ticket to the AOA President’s Reception, Alumni Luncheon and specialty reception.

The registration should only include the cost of tuition of the CME and the other tickets should be ala carte. Guest registration should only be for the events that the guest desires to attend.

If my memory serves me right I, have attended the AOA Convention since 1992 in San Diego, California sans the 2001 convention. My biggest gripe is the cost and selection of the hotels for the Convention. I always felt that the AOA’s size and potential economic windfall to the host city should reflect a better price for the members. It appears that the AOA is more interested in obtaining free rooms for itself and its dignitaries! The host hotels selected by the AOA in conjunction with the AOA Convention are not always aesthetically appealing and frugal. For instance, the Las Vegas Hilton might appeal to a Star Trek® aficionado but to anyone else it is an old, tired hotel!!

With so many luxurious hotels available and affordable in the heart of the Strip with convention centers, it gets old and unappealing to keep returning to the Las Vegas Hilton and the Las Vegas Convention Center.

I avoid AOA host hotels because of the high cost of the room and when I bring my family the hotels are not kid friendly. The last AOA sanctioned hotel I stayed at was in San Francisco and the stay was marred by a labor dispute at the hotel.

With ACOEP being the second largest specialty college in the AOA, one would hope that ACOEP would be able to secure a prime location in the host convention center but this is not always the case. At the San Francisco convention in 2004, the Orlando Convention in 2005 and the recent Convention in Las Vegas had ACOEP occupying space that was inconspicuous and out of the way. Because of our size and loyalty

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to the AOA, we should have been afforded better locations at the last three conventions.

Moving the Fall CME to another location and/or time is something that ACOEP should consider. Our Fall CME could be held simultaneous in the same city as the AOA but at a different locale than the AOA. We may choose to hold our Fall CME at a different time and location than the AOA. In my opinion, ACOEP does a superb job of selecting locations and hotels that are affordable and family oriented.

The hotels chosen are not always the cheapest price but if you compare the room rate obtained by ACOEP to the actual room rate a significant discount is obtained. The location is conducive to meetings and leisure activities. ACOEP should be applauded for its efforts in obtaining quality CME at affordable rates. ACOEP should continue providing quality affordable CME and is handcuffed and thwarted by the AOA when ACOEP holds its Fall Convention in conjunction the AOA annual Convention.

Other specialty colleges including the Anesthesiologists; Internists; Obstetricians and Gynecologists; Ophthalmologists and Otolaryngologists; Orthopedic Surgeons, and Surgeons hold their meetings and CME at different locations and times than the AOA Convention and are still held in high regard by the AOA. This is evident by the fact that the past president of the AOA was an ophthalmologist and the president-elect is an orthopedic surgeon.

It is probably too late to change our venue for the 2007 fall convention but it is the right time to change our 2008 fall convention to a new location and time.

The College needs to do what is in the best interests of its members and continue providing value-added CME. If the College is to continue providing excellent CME programs in the Fall, it has to do it on its own. Now is the time to spread our wings and leave the nest!!

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Executive Directors Desk Janice Wachtler

Google Medicine Growing up when I did, the people in my section of the Baby Boomers were known mostly for their political stances and were referred to as Hippies, the Love Generation, or even the Pepsi Generation. If I were to classify people who are in their twenties now, I think I would refer to them as the Google Generation.

Why? Basically, because they are the first generation to grow up with a computer in their lives from birth onward. They are totally comfortable with the Internet, and seem not to be upset by the thought of your personal information being in cyberspace.

Whether this is good or bad, or just the wave of the future, I can’t say but they also have ushered in a new form of medicine.

Now, we all have the ability to access information on the Internet. We all have access to some search engine by which we can look up symptoms, medications, and get a good handle on your condition of choice. We also are barraged by television advertisements on everything from sleep aids to sexual performance medications. We can go online to pharmaceutical companies to join PPA and order our medications from overseas if necessary. But the scariest thing, I think, is that we are all becoming our own physicians and we practice, Google Medicine.

The internet provides us with access to so much information that the consumer can literally, surf the net until he, or she finds a disease du jour that meets all their symptoms on any given day.

Recently, a friend of mine was depressed; previously she was treated for everything from MS to a brain tumor because she had fluctuating symptoms. At one time, she was even considered a drugseeking patient by an emergency physician.

But now, having undergone a severe bout

with kidney stones, she was told that she had so many stones that she would need to have kidney surgery because there was no way these stones, numbering in the area of 50+ would migrate through her ureter and out of her body. Doctors had been treating her as a middle aged woman going through menopause, even though she had gone through menopause in her early 40’s.

They prescribed estrogen, painkillers, and so forth, but what could make her truly 100%? They didn’t know.

During a conversation, we talked about how depressed she was with this prognosis and she decided to Google depression sites, and found that she met most of the symptoms listed on a psychiatric society’s site, as being Clinically Depressed. Armed with this information, she presented her research to her family physician, who was surprised that she had never spoken to him about this and referred her to a psychiatrist who is now working with the family physician to work on the whole patient. In this case, use of the Internet and Google, proved to be to the advantage of both the physician and patient. But what do you do if a patient self-diagnoses and comes up with the wrong diagnosis, do you take his or her word or do you conduct your own evaluation?

As I was listening to the radio on the way to work, and a physician who routinely appears as a guest on the show, stated how frustrated he was with people coming into his office after “googling” a disease and insisting they had “X” disease.

He felt that his personal diagnostic skills were being challenged because not only did the patient make up his or her mind as to what disease they had, but they also had a medication selected for use in treating their symptoms. He claimed that he was frustrated because the patients argued that they did not need diagnostic tests or even a physical exam because they “knew” what they had. He presented a rationale as to why patients should not solely rely on “Google” or “Web MD” as their sole source for medical information stat-

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ing that their physician has spent numerous years studying and identifying symptoms and matching those symptoms with appropriate diagnosis and selecting appropriate drug therapies to either cure the disease or to treat the symptoms and aid in patient healing.

I don’t know if you, as an emergency physician, would have the same type of interactions with a patient, but you may have interactions with patients who treat themselves after conducting a Google-search and self-diagnosing and self-prescribing.

How would your patient encounter evolve, if this patient has already gained a mind-set as to what condition they have? Are they speaking from true knowledge or information gleaned from the Internet? Are they taking prescription drugs, obtained through physician prescription or obtained from an Internet site, or are they taking supplements that are unregulated whose side effects are wide ranging and unknown?

As we become more of an Internet savvy population, will this ultimately remove physician interaction with patients?

Will it replace medical practitioners all together? Or will we learn to utilize the computer to enhance medical practice and diagnostics? Will medicine lose the human factor altogether?

I think the most logical approach to medicine in this new age of computers with medical knowledge not being confined to medical practitioners is seen in the original Star Trek® television series. It depicted a well-trained physician who worked with his diagnostic bed and his hand-held “scanner” utilizing the computerized diagnostics in addition to his all-too-human instincts and training to diagnose and treat the patients he encountered. Perhaps that is the only way we will all “live long and prosper” in this futuristic view of medicine.

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ACOEP Members Elect New Board Members There was an air of change at the Membership Meeting in October 2006, besides the fact that the ACOEP was changing officers and inaugurating a new president, but the format of the meeting itself changed. The Membership Meeting each fall will feature the inaugurating new Board members and Presidents at the end of this meeting.

This year, the ACOEP acknowledged the past service of former Board members as well as those who are retiring from the Board. Lisa J. DeWitt, D.O. was recognized for past service to the Board and Mark Mitchell, D.O., FACOEP, Victor J. Scali, D.O., FACOEP, and Fred G. Wenger, Jr., D.O., FACOEP were recognized for their service to the Board as they retired from Board service after this meeting. The Membership also recognized physicians for their service to the College. Among these was Theodore A. Spevack, D.O., who was the recipient of the Bruce D. Horton, D.O., FACOEP Lifetime Achievement Award; Mark A. Mitchell, D.O., FACOEP, who was the recipient of the Benjamin A. Field, D.O., FACOEP, Mentor of the Year Award, and William Bograkos, D.O., FACOEP, who received the Robert D. Aranosian, D.O., FACOEP, Excellence in EMS Award. Members also recognized emergency physicians for their membership in the Association by granting Life Membership to Sandra Schwemmer, D.O., FACOEP, and recognizing non-emergency physicians by granting Honorary Membership to Philip Shettle, D.O., Past President of AOA, and Shawn Martin, Director of the AOA’s Washington Office.

The College also inaugurated a new President; the College’s 15th, with the swearing in of Peter A. Bell, D.O., FACOEP. The Membership elected four members to the College’s Board of Directors for three-year terms. Those elected were William Bograkos, D.O., FACOEP; Gary Bonfante, D.O., FACOEP; Thomas Brabson, D.O., FACOEP and John Prestosh, D.O., FACOEP. Also joining the Board are Joshua Morrison, Student Chapter President, and Christine Perry, D.O., Resident Chapter President.

Following the meeting, the College Board elected new officers, electing Thomas Brabson, D.O., FACOEP to the office of President-elect; Anthony Jennings, D.O., FACOEP to the office of Secretary, and Gregory Christiansen, D.O., FACOEP to the office of Treasurer.

Members also adopted the revised Bylaws that will be submitted to AOA for final adoption. When in effect, the elections for Board members will switch from an in-person vote to allowing all Active Members to vote for Board members. As we move toward the new elections, information will be sent to members on the process and date for the elections.

Dr. Willoughby DeJesus recognized for her service as 14th President.

Mark Mitchell receiving Field Mentor of the Year award.

Victor Scali receiving recognition for past Board Service.

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Photos continue on next page

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Philip Shettle, D.O. receives Honorary Membership from Dr. Willoughby DeJesus.

William Bograkos receiving Aranosian Excellence in EMS Award.

Peter Bell addresses Membership as President.

Theodore A. Spevack receiving Horton Lifetime Achievement Award.

Shawn Martin receives Honorary Membership from Dr. Scali.

Peter A. Bell taking oath.

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Courtesy of AOA

AstraZeneca

is pleased to support the

American College of Osteopathic Emergency Physicians AstraZeneca is one of the world’s leading healthcare companies, providing innovative, effective medicines for serious medical conditions.

Skilled research is at the heart of our continuing success and we spend more than $2.7 billion each year on the discovery and development of new and improved medicines.

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With US headquarters based in Wilmington, Delaware, we are committed to maintaining a flow of new products around the world which protect and improve human health and quality of life.

www.astrazeneca-us.com Š 2002 AstraZeneca Pharmaceuticals LP

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research and development organization With 100 years of combined experience, scientists at AstraZeneca have discovered and developed several of today’s leading prescription medicines—pharmaceuticals that contribute to a higher quality of life for millions of patients and to a better health economy worldwide.

Based in Sweden, AstraZeneca’s R&D organization is international in scope and comprised of approximately 10,000 researchers. Through its own resources and through collaboration with dozens of universities and strategic alliances with numerous research and biotechnology companies, AstraZeneca has broad access to advanced technologies in biomedical research, including genomics, bio informatics, chemical libraries, high throughput screening and product delivery systems.

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AstraZeneca is a major international research

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leading in the community and the workplace patient assistance program AstraZeneca is acutely aware of the growing costs of healthcare in the United States. The AstraZeneca Foundation Patient Assistance Program (PAP) (formerly the Zeneca Pharmaceuticals Foundation Patient Assistance Program), which has been in existence since 1978, and the

In addition to its products and research and development efforts, AstraZeneca provides health education information, support services and health guidance to millions of Americans through public awareness campaigns including: • National Breast Cancer Awareness Month • Prostate Cancer Awareness Month • Capitol Hill Briefing Program with Asthma and Allergy Foundation of America (AAFA) • National Alliance for the Mentally Ill (NAMI) Helpline Online

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free of charge to patients who cannot afford them and who do not have insurance or other programs that can provide the product. Currently there are more than 250,000 patients enrolled in these programs. Over the past year, AstraZeneca donated medicines valued at over $250 million to indigent patients across the United States and Puerto Rico.

National Headache Foundation • Clinical Outcomes Research Initiative (CORI) with the American Society for Gastrointestinal Endoscopy • Nationwide Asthma Screening Program with the American College of Allergy, Asthma and Immunology (ACAAI) • Human Medicine Symposium Series with the Minority Health Institute While AstraZeneca is committed to educating the public, the business’s commitment to its own employees is equally important. AstraZeneca offers onsite breast, prostate, colorectal and skin cancer screenings as well as preventive health programs for employees in all of our therapeutic areas.

www.astrazeneca-us.com © 2002 AstraZeneca Pharmaceuticals LP

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Money Talk Monica H. Masters, Financial Advisor, Smith Barney

Gifting Away Assets During Your Lifetime Gifting Away Assets During Your Lifetime

Like many of us, you may want to provide for your family’s financial future.

At the same time, you may want to decrease the size of your estate to reduce any estate taxes that could be due in the future. In any case, you want to make sure that you are gifting your financial assets in the most tax-efficient manner.

Giving away, your financial assets can be more complicated than just writing a check. If you want to engage in lifetime gifting, you should be aware of certain rules. The annual gift tax exclusion amount is $12,000 per year per person in 2006. The lifetime federal gift tax exclusion amount is currently $1 million, and it will remain at that level through 2010.

The top federal gift tax rate will be incrementally reduced from 46% in 2006 to 45% by 2007. In 2010, the top gift tax rate will equal the top individual income tax rate (currently 35%). Any portion of the gift tax exclusion used will reduce dollar-for-dollar your estate tax exclusion available at death. You should consider some creative lifetime gifts:

The Grantor Retained Annuity Trust (GRAT)

A GRAT allows you to pass assets you believe will appreciate in value to family members at discounted levels. You contribute assets to a trust and receive a fixed annuity payment stream for a specified period of years. At the end of the trust term, the remaining assets and their appreciation (if any) are distributed to your beneficiaries.

Since the value of the gift is reduced by the present value of the annuity payments, you could structure a payment schedule and amount that could result in a minimal gift tax value. However, if you die before the end of the specified term, the trust property would be included in your estate and subject to estate taxes.

Life Insurance

You could use life insurance to help replace your estate and gift tax liabilities.

Life insurance often provides a substantial benefit for relatively small premium dollars. It may be used by itself to increase the size of your estate, creating an “instant” estate. Or, it may be used for liquidity and paying estate taxes cost effectively. And, the proceeds of life insurance are typically income tax-free to the beneficiary. With careful planning, these proceeds may also be received estate tax-free.

The Limited Liability Company (LLC) or Family Limited Partnership (FLP)

An LLC or FLP may help reduce the size of your estate for transfer-tax purposes.

The LLC or FLP is made up of managing or voting interests and nonvoting interests, and you could gift the nonvoting interests to our children and grandchildren. Since the non-voting interests gifted to your children and grandchildren lack voting rights and are not readily marketable, they might be discounted for gift tax valuation purposes .

ACOEP has recognized Monica H. Masters

Financial Advisor Financial Planning Specialist (800) 621-2842, ext. 3338 As a Financial Advisor for: Investments, Lending, Insurance and Financial Planning.

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Money Talk, ontinued from page 15 The Dynasty Trust

A Dynasty Trust could allow you to establish a source of funds for multiple generations. Here’s how it generally works: You would fund the trust with an amount up to your and your spouse’s lifetime gift tax exclusions. The trust assets, including any growth, will remain free of federal transfer taxes (i.e., estate, gift and generation-skipping transfer taxes) for as long as they remain in the trust. In certain states, such as South Dakota, the trust may theoretically last forever. And the planning could be designed so that any distribution from the Dynasty Trust would be free of gift and generation-skipping transfer taxes.

Income or principal from the trust may be distributed to your children, grandchildren, and great grandchildren as specified in the trust document. The provisions could 06-EM-471 5/2/06to incentives, 5:21 PM such Page tie those distributions as maintaining gainful employment, and

permit distributions for funding businesses or purchasing homes for the use of beneficiaries or other activities. There also may be provisions in the trust document to gift a percentage of the assets directly to a charity or family foundation. Assets remaining in the trust are protected from creditors and divorce judgments.

Create Your Estate Plan

Discuss your estate planning objectives and concerns with your Financial Consultant and your tax and legal advisors.

Together, you can develop an estate plan that addresses your unique financial and family situations so that you can effectively transfer wealth to your beneficiaries.

Monica Masters is a Financial Advisor located in Chicago, IL. She may be reached at (800) 621-2842 ext.3338.

1This amount may be adjusted annually for inflation.

21You should consult with your legal or tax advi-

sor about LLC or FLP planning and the potential tax consequences. The IRS may challenge this planning and take the position that gifted LLX or FLP interests and/or underlying LLC/FLP assets are includable in the donor’s estate.

3You should consult with a qualified appraiser to determine the appropriate amount of the valuation discounts.

Citigroup Inc., its affiliates, and its employees are not in the business of providing tax or legal advice. These materials and any tax-related statements are not intended or written to be used, and cannot be used or relied upon, by any such taxpayer for the purpose of avoiding tax penalties. Tax-related statements, if any, may have been written in connection with the "promotion or marketing" of the transaction(s) or matter(s) addressed by these materials, to the extent allowed by applicable law. Any such taxpayer should seek advice based on the taxpayer's particular circumstances from an independent tax advisor. “This article is based, in whole or in part, on information provided by the Smith Barney.”

Smith Barney is a division and service mark of Citigroup Global Markets Inc. Member SIPC.

career

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If there’s one thing your job has taught you, it’s that your training never ends. At EmCare, we make professional development and continuing education a priority for physicians. Programs like the EmCare Leadership Institute and our Internet Training System enable you to open new doors and further your career. And that is one very valuable lesson.

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The PULSE january 2007

Guest Article Zafar Shamoon, D.O. Garden City Hospital, Garden City, MI Co-Chief, Senior Emergency Medicine Resident Resident Chapter Board of Directors, American College of Osteopathic Emergency Physicians

Alopecia Areata

During a busy evening shift, I picked up a chart with the chief complaint of “I have a bald spot.” Admittedly, I chuckled to myself and thought “why would anyone come to the E.R. for this?” After glancing over the normal vitals, I noticed that the patient was only 21. Suddenly this case became a lot more interesting, and the chief complaint became a little more serious.

I walked into the room to find a relatively well-groomed, healthy looking, 21 year- old African American male with no medical history. His hair was well kept and cut short so I was quickly able to identify a circular bald spot about the size of a halfdollar in his right temporal area.

He told me the spot had been there for about a month and was getting larger. He did not have a history of any new hair products or trauma to the area. He also assured me that no one was “clipping” his hair while he was asleep, as he lived alone.

There was no redness, drainage, or pruritus in the area, and he was not taking any medication.

My initial thought was a possible ringworm infection, however he had denied any symptoms that would support that diagnosis. Then I had remembered reading about a hair loss condition that was rare and benign–ALOPECIA AREATA!

Alopecia Areata is a benign hair loss condition that affects 0.1-0.2% of the general population, or about 4 million Americans causing a tremendous amount of emotional and psychosocial stress. The disease can target any part of the body that has hair.

The exact pathophysiology still remains unclear, but current hypothesis points to a T-cell autoimmune condition that occurs in genetically predisposed patients. In mild cases the area of baldness may be confined

to one spot or patch (Figure 1), or may be severe with several dispersed patches (Figure 2). The severe c a s e s report a Figure 1 positive family history in 18%, while the mild cases report a positive family history of only 7%.

The disease does not discriminate against sex, as there is a 1:1 male to female ratio. It also does not discriminate against age, however peak incidence seems to occur from ages 15-29.

Alopecia Areata typically affects the scalp in 80% of the cases, but can affect any hair bearing area. The beard is affected in 28%, eyebrows in 3.8%, and the extremities in 1.8% as depicted in Figure 3 (1).

Although rare, a patient may lose all of their hair on their scalp (termed alopecia totalis) or entire body hair (termed alopecia universalis).

Some of the physical signs of one might expect to see include: • Hair tapered near proximal ends –“Exclamation points” • One to many round or oval shaped patches • No epidermal changes seen with the hair loss • Hair loss on other hair-bearing areas also favors the diagnosis Localized alopecia will usually resolve

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spontaneously within one year, while more extensive disease may require treatment from a dermatologist. Although there is no universally accepted treatment for extensive disease, intralesional injects with steroids seems to be the most successful. Tintinalli stresses that only a health care provider who can follow the patient long term should be administering any treatment, such as a dermatologist.

Although it was clear this patient had all the symptoms of Alopecia Areata, the differential for hair loss is extensive, which can be divided into scarring and nonscarring alopecia (2): Non-Scarring Medication Secondary syphilis Traumatic alopecia Trichotillomania Contact Dermatiitis Androgenic alopecia Thyroid Disease Telogen effluvium Hair shaft abnormalities Scarring Kerion Tinea capitis Herpes Zoster Cellulitis of the scalp Folliculitis Acne Keloidalis Lupus Sarcoidosis Scleroderma Tumors (squamous cell, basal cell, melanoma)

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Wayne Jones, D.O., FACOEP

Not Exactly EMS History - The first of a series –

It would be like many other wars. Two countries battling over commerce, land, ethics, and freedom. There would be insurgents, supply line problems and the ever present dead and injured who really define the true losses. Like an afternoon movie, it would witness betrayal, secret relations, and heroes. This war would define a country and change history forever.

Joseph was fourteen when he witnessed the death of his father. It was an unfortunate accident. His father fell from a ladder while collecting apples from his orchard.

Whether this is what hardened him is not clear, but he would go on to graduate from Harvard University with a degree in medicine. He felt a strong loyalty to his native country where he became involved in town politics and eventually in leading the state government.

When war broke out in his hometown, he felt compelled to volunteer his services.

He was assigned the duties of a foot soldier.

His wife had passed away a few years earlier and he had come to know the wife of an officer now serving the opposition. She told Joseph of a plan to attack his town by her husband and his forces. Joseph was able to spread word of the attack and minimize the assault.

Recognizing his strong loyalties and ability to lead, Joseph was promoted to the rank of Major General. He would never see his commission as he would suffer a bullet wound to the head (three days prior to his commission date) as he led his brigade on a third and final assault to capture a hill of strategic importance.

Joseph would not be found immediately after the assault. It was later learned that an opposing General had “stuffed the scoundrel with another rebel into one hole, and there he and his seditious principles may remain”. He would be exhumed ten

months later and identified using his dental records.

So, who was Joseph? What nation claimed him and what was the war in which he fought?

Joseph Warren was a physician from Boston, Massachusetts who proudly served in the Continental Army. He would receive information from a British General’s wife that “the British are coming.” He would tell his good friend Paul Revere to alert the town’s people with two lanterns (by sea).

Being a prominent physician, even the British knew him and targeted him in battle. He would be the first physician killed in our countries history- at Bunker Hill. In death, none other that his personal dentist Paul Revere- who was the first to use forensic dentistry to identify remains identified him. And who helped support his children after his death? Benedict Arnold.

Alopecia Areata, continued from page 17

care physician to rule out any of the above diseases.

After reviewing the different causes of alopecia, I did go back and ask the patient more focused questions to help rule out some of the other causes. He denied any history of syphilis or any other STD, family history of hair loss, new medication, over the counter Figure 3 supplements, palpitations, weight loss, stress, rash, fever, or dry skin. We also re-examined the patient for any other patches of hair loss, however none could be identified. He was discharged home with reassurance that the

hair may grow back within a year, a referral to a dermatologist, and, most importantly, told to see his primary care physician for further work up. A couple useful sites for patient education:

From an emergency medicine perspective, even though alopecia is usually a benign condition the importance of contemplating the differential list for alopecia can not be overstated, as alopecia may be the first Figure 2 symptom manifesting itself as one of the above disease processes. Patients must be instructed to get further work-up by their primary

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www.naaf.org www.niams.nih.gov/hi/topics/alopecia/alopecia.htm References: (1) www.niams.nih.gov/hi/topics/alopecia/alopecia.htm (2) Tintinalli, “Emergency Medicine, a Comprehensive Study Guide” 2004.

Guest Article William M. Kokx, D.O., FACOEP, FACEP Chairman Emergency Medical Services Memorial Medical Center of West Michigan Ludington, Michigan

Longevity in Emergency Medicine We in Emergency Medicine are most fortunate to be in a profession that demands continual learning and delivers challenge combined with unpredictability, thus making going to work not just a job but an ever-changing experience. In my nineteenth year in Emergency Medicine I can honestly say I still enjoy my chosen profession.

Where else can you go to be intellectually and emotionally challenged, entertained, mystified, amazed, and humbled all in the same day. .

In 1985 at the beginning of my residency at Pontiac Osteopathic Hospital, I marveled at the knowledge and abilities of my trainers and mentors, Drs. Michael Doyle, David Malicke, Bob Aranosian, Jack Hayden and Rock Qabazard. I am very grateful for the opportunity I had to have studied under these dedicated leaders in Emergency Medicine. After years of my own practice I realize how much I have learned and more importantly – how much that remains to be learned.

I have no doubt if Dr. Aranosian were living today, he would still be enjoying the practice of Emergency Medicine. My trainers and mentors along with many residents who preceded me, (including the first POH-EM resident, Dr. Doug Dero), are still in practice today. It is amazing that these doctors are going strong after 20 plus years. They, as well as their tenacious esteemed colleagues in the profession, deserve supreme recognition.

At the recent October 2006 ACOEP Scientific Assembly in Las Vegas, Dr.Victor Scali served as the keynote speaker. His topic “Balance and Giving Back” was an excellent presentation regarding necessary choices in preserving our longevity in emergency medicine. All of us in attendance identified with his entertaining movie clip, “I ordered the CT scan.”, which was an important reminder for us not to lose our sense of humor in the profession. Since Dr. Scali’s presentation, I have reflected on my own journey the past 19 years and would like to share a few of the principles that have enriched my life and kept me from burnout.

An optimistic outlook on life is crucial for effective practice, especially when inundated with a deluge of patients. For me, trying not to work more than 144 hours a month keeps everything in p e r s p e c t i v e .

The night and holiday shifts are unavoidable, however manageable when I do not exceed my 12 shifts a month. I have discovered maintaining an enriched, balanced life is a key to longevity in our profession.

As Emergency Physicians most of us enjoy living on the edge, and the challenge of being able to make critical spur-of-themoment decisions. Like anyone else, we are at our best when our life is balanced. But how do we achieve and maintain balanced?

Perhaps it is by participating in our c h o sen interests, by looking within ourselves, or moreover a combination of the two.

Many of my colleagues are involved primarily in family activities while others venture out as pilots, skydivers, mountain climbers and hockey players. Personally, I enjoy running races and basic climbing /hiking. These activities allow me to be

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outside while providing challenge and the satisfaction of finishing; thus feeding my competitive spirit. Skydiving however, I only tried twice. My desire for this sport was redirected when my instructor unfortunately plunged to his death. My adventurous spirit that led me to Emergency Medicine, has also taken me to underdeveloped countries for medical missions as well as for personal travel. Some may say that these risky pursuits are nothing more than crazy, “acting out” behaviors used to escape from the stress we endure. More likely, it is being motivated to master a challenge to enrich our lives with unusual experiences, driven by the same fearless traits that attracted us to emergency medicine.

Understanding ourselves improves our ability to understand and relate to others in crisis situations day after day. For me, my faith in God is personal and important in providing me with inner strength. I also believe, that each of us has a unique gift or talent that when discovered and developed will enhance our lives and those around us. Physicians in teaching roles enjoy their work while giving back to the profession and society. Other physician’s talents, for example, may be in areas of research, negotiations, politics, writing, music or art. My unique gift, inherited from my mother, is watercolor painting. For the past thirteen years I have been motivated with enthusiasm to develop my passion as an artist. I have become friends with many artists through this pursuit. The journey has taught me to relax and think as an artist, while nurturing the right side of my brain, and offering balancing as a person and physician.

In the ED, I sometimes find myself emotionally detached from patients as a

19

Resident Chapter Update Christine Perry, D.O., President

Resident Activities in Las Vegas

If you did not make this year’s ACOEP Fall Convention, start making arrangements to attend the 2007 conference.

The conference was lead by our annual Resident Chapter Meeting with a large attendance. The ACOEP sponsors residents from each program to attend this “free conference.” Without a registration fee, residents were able to use their $500 for flight and hotel with money to spare for food and fun. This year, we reviewed the many accomplishments from Past-President Brandon Lewis, DO, and team. Elections were also held. Last years Secretary-Treasurer Michael Kubek, D.O, from Garden City Hospital, is our new President-Elect and Juleen Jandah, D.O., from Arrowhead Hospital, is our new Secretary/Treasurer. I am following Brandon Lewis, D.O as President, whose leadership, support, and professionalism will be missed at the Resident Chapter level.

Following our annual business meeting, the students and residents had time to meet or catch up with old classmates.

Emergency Consultants, Inc. (ECI), an Emergency Medicine group with Dr. Mark Mitchell, sponsored a wine and cheese reception.

On the second day into the conference, we had a full day. The morning started with a Jeopardy Tournament. We put residency programs head-to head with one another to see who could compete for the title. The questions were tough.

Recent St. Barnabas graduates spearheaded its inception and it had an amazing turn out. The winners of this year’s tournament were a conglomeration of 4 programs that had few attendees at the conference.

Congratulations to Stella Kalantzis, D.O from Hamot Medical Center in Erie, PA, Rob Vejdani, D.O. and Donny Perez, D.O. of Mt. Sinai Medical Center in Miami Beach, FL, Melody Milliron, D.O., Shanna Swanson, and Laura Thompson from St. Vincent Hospital in Erie, PA, and Ash Kasto, D.O. from Henry Ford Bi-County Hospital. The winning team won Comedy Show Tickets and bragging rights. This inspired us to have a Dual-athon next year comprised of both a Jeopardy Tournament and Skills Labs/Procedure Olympics. Start organizing your team for next year!

The second evening was capped off with tapas and cocktails at one of Vegas’ swanky establishments, Café Ba Ba Reeba. Dr. Dan Phillips of Emergency Medicine Physicians (EMP) sponsored this event. There were

approximately 60 Emergency Medicine Residents in attendance.

The third day featured our Resident Lecture Series “How to get a Great Job.” Ann Benson of EMCare gave a lecture on “Polishing Your Resume.” Dr. Mark Mitchell of ECI and Dr. Dan Phillips of EMP who lectured followed this on contract specifics, the good, the bad, and the ugly.

Following these heavy topics, they reviewed resumes and fielded questions. The reviews from these lectures were overwhelmingly positive, as many of us are never exposed to these topics. They come in perfect timing for those seniors who are preparing to secure a contract this year. Because of the success of this forum, the ACOEP-Resident Chapter Board has decided to do these types of lectures annually. We plan on having discussions about malpractice, money management, and investing in the Fall ACOEP Convention 2007.

There should not be a program not represented at the 2007 meeting. Do not be left behind. Attend the Fall 2007 ACOEP Fall Convention and see what we are doing for YOU!

Longevity in Emergency Medicine, continued from page 19

are to enrich our lives and our profession.

By doing so, we can use and develop our talents throughout our careers. Our busy lives sometimes interfere with the many fascinating opportunities that present themselves. Being cognizant of our career-related interests and in turn using them specifically to help our community and profession, in the midst of busyness, can be a tremendous gift to our communities, profession and our selves.

If not already doing so, beginning with one or two commitments is a good start. Pursuits such as writing an article

for the Pulse, being on an ACOEP committee, giving a lecture on your favorite topic, teaching ACLS or ATLS, being involved in hospital politics, or local or state EMS disaster programs are a few suggestions. When you share your knowledge and donate your time, you feel a sense of purpose and belonging to your community.

These shared commitments strengthen the core of our Emergency Medicine profession, the respect with which we are viewed, and ultimately the desire for each individual to represent an outstanding profession.

defense mechanism that allows me to maintain my composure in order for me to see the next patient. Interestingly enough my artistry has helped me better understand the ED experience, being less judgmental of the regular visitors, improving my communication skills and understanding the patient’s perspective, including those signing out against medical advice.

The “Giving Back” portion of Dr. Scali’s talk is also of vital importance if we

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The PULSE january 2007

Guest Article Beth A. Longenecker, D.O., FACOEP, FACEP

The State of Osteopathic Medical Education The members of our college have diverse interests and participate in medical education in a variety of ways. Many are involved directly in resident education. Some serve as preceptors to medical students as a part of their daily practice. All of us must participate in continuing medical education and the recertification process. Osteopathic medical education has continued to grow and there have been a significant number of changes over the past few years. This article will serve as an overview of the current trends involving our undergraduate, graduate, and post-graduate medical education.

Undergraduate Medical Education

There are 25 osteopathic medical schools in 20 states throughout the country.

The curriculum at these institutions has been evolving beyond a strict lecture and lab format. While some of these schools still adhere to this style of education, others are offering a problem or cased based learning format. Others offer an individualized study track that allows the student to cover the core medical student curriculum in their own order and at their own pace. An additional change taking place in many centers is a move toward computer based anatomy labs to complement dissection in gross anatomy lab. This is due in part to major advances in computer technology as well as a shortage of bodies being donated to medical schools for the purpose of dissection.

Graduate Medical Education

There are currently 40 residencies in emergency medicine approved by the AOA. Of these, 35 are linked to an EM track internship within their own institution.

One of the other programs is now linked to an EM tracked internship in a neighboring hospital. The remainder are OGME 2-4 programs that accept candidates upon completion of an independent osteopathic rotating internship.

The AOA has elected to revise its OGME I year as of 2008. They are

removing the requirement of an osteopathic rotating internship as part of the OGME curriculum. Instead, the first year will be incorporated into each individual specialty, as each college deems appropriate. The program directors committee of the ACOEP continues to support a 4-year EM program and will continue to require either an EM track or a rotating intern year as part of the entire curriculum needed for completion of osteopathic training in our specialty. There are still 5 states in the US that require an AOA approved internship to obtain licensure as a practicing osteopathic physician. There is no indication that this mandate will be waived in the future.

Continuing Medical Education

The ACOEP strives to provide Quality CME to its membership. Each fall offers the scientific seminar linked to the annual AOA convention and the spring offers the annual AOA spring conference. These each offer 25 hours of category 1A credit.

The Intense Review course offers 40 hours of CME directed at those studying for the written board examination. This takes place the first week of January in Chicago.

It remains one of the most highly attended courses offered by our college, attracting both physicians studying for their examination and those wishing to refresh their knowledge base.

A newly developed and reformatted Oral Board Review Course is also now offered. This takes place in the spring and the fall, immediately preceding the board examinations. This course is always held in Chicago.

The final annual course being offered to our college is the COLA Review Course that takes place each February. The 2008 course will be held in Reno, Nevada to provide an opportunity for those who would like to ski with their CME. This will be the first year where it will be possible for those in attendance to actually take the exam during the final day of the course.

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There are many topics of interest that do not attract sufficient numbers to allow for an annual course. These are offered on a rotating basis for the membership. These include a difficult airway course (offered last summer), a toxicology review and update (which will be offered the summer of 2008) and EMS and administration.

Education For Those Involved In Teaching

For those members of the college involved directly in education, there are several resources available to provide assistance in your personal growth as educators. These are offered by both ACEP and the AOA.

The first of these are the ACEP Emergency Medicine Basic Research Skills Workshop. This is offered as a 2-part seminar offered in November and April that is geared toward those interested in developing the skills needed to perform basic clinical research and to mentor residents or students through this process.

It also offers skills useful in teaching the concepts of evidence-based medicine.

There are 2 “teaching fellowships� also available to osteopathic educators in our college. The first is offered by ACEP and again is a 2-part seminar. The second is the Costin Institute for Excellence in Osteopathic Medical Education. The curriculum for both of these programs is similar. The ACEP fellowship focuses only on our specialty and is more directed to teaching residents. Information on the ACEP programs is available on the ACEP website (ACEP.org).

The Costin Institute consists of 4 three-day weekends held over a one-year period, as well as some self-study. The Chicago College of Osteopathic Medicine and Midwestern University jointly sponsor the program and the curriculum is not specific to any specialty. The inaugural class consisted of teaching faculty from EM, IM, FP and OB/GYN programs, Directors

21

What’s Happening – An ACOEP Update – Two Young Physicians Honored by the AOF Las Vegas, Nevada – The American Osteopathic Foundation honored two emergency physicians as “Emerging Leader of the Year” and “Young Physician of the Year” for 2006 both of whom are members of the ACOEP.

Raul Garcia, D.O., an attending physician at the St. Barnabas Hospital in Bronx, New York and newly elected member of the Board of Trustees of the American Osteopathic Association was honored as Emerging Leader of the Year. Dr. Garcia was recognized for his work with young osteopathic physicians throughout his career and his continuing interest in governmental affairs. Dr. Garcia has also been involved in the ACOEP as its Chair of Governmental Affairs since 2004.

Lawrence Tews, D.O. of Boonshoft School of Medicine at Wright State University, in Kettering, Ohio was recognized as Young Physician of the Year for his involvement with the American Osteopathic Association and his involvement with research. A graduate of the Michigan State University, College of Osteopathic Medicine/Sparrow Hospital in East Lansing, Michigan was recognized for his contributions to osteopathic medicine and his mentoring of medical students and residents.

We recognize and congratulate these two physicians on their achievements.

Staff Changes at the Central Office Chicago, Illinois – Times are changing at the Central Office of the American College of Osteopathic Emergency Physicians to better serve its membership.

Effective immediately, positions have been revamped to add depth and resources to the office staff. Current employees, Amanda Lundeen and Yvonne Treacy and new employees, Sandra McGrath and Kristin Wattonville had positions readjusted so that portions of their responsibilities are redundant to add depth to the services that they provide. Ms. Lundeen, Membership Coordinator and Assistant Meeting Planner will be responsible for smaller CME meetings in addition to her membership recruitment and maintenance of the member database. Ms. Treacy, Assistant to the Executive Director, will provide support to the President, as well as the Executive Director, and assist in the graduate medical education area as well as assume marketing responsibilities. She will also be involved in member advocacy.

New employees, Sandra McGrath and Kristin Wattonville, come to the ACOEP with varying experience and will assume positions as Administrative Assistant and Meeting Manager.

Ms. McGrath, comes to the ACOEP with experience as an RN and experience in support and management of medical offices. As our part-time Administrative Assistant, Ms. McGrath will provide clerical assistance to the Meeting Manager and Membership Coordinator, and will handle the reception and data base maintenance responsibilities.

Ms. Wattonville, comes to the ACOEP with eight years of meeting planning experience in both for-profit and non-profit venues. Ms. Wattonville will be the main Meetings Manager of the Association, managing major meetings and assisting Ms. Lundeen with the smaller meetings of under 100 attendance. Ms. Wattonville will maintain and develop the Speaker recruitment and development of a Speakers’ Database and will be the Secretary for the CME Committee.

We hope that you will welcome these new professionals to the ACOEP and introduce yourself to them when you call or meet them at meetings.

The State of Osteopathic Medical Education, continued from page 21 of Medical Education, department heads, an associate dean and the dean of one of the osteopathic medical schools. The curriculum deals with issues pertaining to both undergraduate and graduate medical education. The faculty was diverse and many were highly esteemed in the field of adult education. Many of them were professors at Loyola University and the University of Illinois in Chicago. More information about this program may be

22

obtained from their website at Costin. midwestern.edu. (I can also provide more information on this program, as I was a member of the inaugural class).

This about summarizes the current issues in osteopathic medical education.

Many members of the college are not at major teaching centers and do not have the opportunity to precept students on a regular basis. Some of you may want to become more actively involved with young physicians or students interested in our specialty. One of the ways that this is possible to you, no matter where you

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practice, is to participate in our studentmentoring program. The Student Chapter of the ACOEP is currently recruiting mentors to be available by email or phone to help guide physicians in training that are considering a career in emergency medicine.

Should you wish more information about this program, please contact me, Jan Wachtler or Joshua Morrison, the Student Chapter President. We all can be contacted via the ACOEP website. My other email address is (blongene@msmc.com).

Coming Soon

Oral Board Review Chicago, Illinois May 4-5, 2007 and September 15-16, 2007

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Continuing Medical Education Calendar 2006-2007

January 2007 3 – 8 Emergency Medicine: An Intense Review Westin Hotel River North, Chicago, IL 40-41 hrs Category 1/1A Credit

April 10 – 14 ACOEP Spring Seminar Sheraton Wild Horse Pass Resort and Spa, Chandler, AZ 25 hrs Category 1/1A Credit

February 11 – 13 Program Directors Workshop The Siena Casino Spa Resort, Reno, NV 10–12 hrs Category 1A Credit

May 4 – 5 Oral Board Review Four Points Sheraton, Chicago, IL 10 hrs Category 1A

13 – 17 Core Essentials The Siena Casino Spa Resort, Reno, NV 25 hrs Category 1/1A Credit

August 1 – 4 New Frontiers in Toxicology Hotel (TBA), Cleveland, OH 25 hrs of Category 1A

23–25 Additional Stiles/Laughlin Approaches to Still Functional Techniques Indianapolis, IN 20 hrs Category 1A Credit Call 800-942-0501 for info

September 14 – 15 Oral Board Review Four Points Sheraton, Chicago, IL 10 hrs Category 1A

ACOEP NEWSLETTER

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