The Pulse January 2008 by ACOEP

The PULSE

Osteopathic Emergency Medicine Quarterly VOLUME XXXIII NO. 1

JANUARY 2008

Presidential Viewpoints Peter A. Bell, D.O., FACOEP It has been a year since you inaugurated me as the 2006-2008 President of the ACOEP. In that time, much has occurred that directly concerns you as members of our organization, and much is yet to happen. Much of what I’m about to share has been communicated to you by letter, or publication. Some will be new, some will be surprising, and some will be unsettling. We are pursuing new opportunities and breaking new ground. 2008 will be a major time of change. If you read The Pulse, Presidential Viewpoints October 2007, you can more fully appreciate this statement. We have matured as an organization and are pursuing opportunities to assure proper care and duty to our college. We are not leaving the AOA, but like other large, osteopathic specialty colleges are exercising more independence. We have elected to manage our own finances separate from the AOA for the fall convention. We are looking at our current rental space in the AOA building, and considering our long term space needs. We have also asked the AOA to consider alternatives to supporting all osteopathic GME education processes. In order to better understand all that I wish to share, allow me to offer a brief historical overview of our organization. The ACOEP was established in 1975 to perpetuate the ideals and promote the vision of a new group of Osteopathic specialists. The Social Security Act of 1965

had brought new revenues to health care. The Viet Nam War had brought many innovations and technologies to medicine. A second reformation of the medical school curriculum (circa 1972) was underway, and society was ready for a major change. Weekly TV shows like “Emergency” introduced the general public to the miracle of Emergency Medical Services, where no one ever seemed to die. Public expectations were set optimistically or perhaps unrealistically, high. The ACOEP began as an organization of like practitioners interested in developing their new specialty. The first order of business was the establishment of a body of knowledge and skills they could call their own. Meetings became centered on continuing medical education with the ultimate goal of establishing a certification board for the specialty. The American Board of Osteopathic Emergency Medicine was established by the same pioneers that established ACOEP, but over time was progressively moved farther from college business. It stands today as a separate entity under the AOA certification authority. The next order of business was to establish residency training programs in osteopathic emergency medicine. The first programs were opened in 1980, and today we are training approximately 900 residents in 42 programs. Compare that to our ACGME counterparts who have 125 programs. Finally, the ACOEP was established to promote the general welfare of our patients and our members. The relationship between the patient and physician was an essential osteopathic concept that is reflected today in our Political Advocacy.

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The history of the college from Dr Bruce Horton (1975) through Dr George Miller (1994) was slow growth, with careful attention to the 3 primary orders of business: CME/Certification, Residency Training, and Advocacy. These early years established a solid foundation upon which the next generation would build. In 1995 Dr Ben Field became our President and served for 3 years. He was followed by Dr Ted Spevack (1998) and Dr Joe Kuchinski (2000). This period was marked by new standards for CME, greater Quality Assurance in the residency inspection process, and Advocacy. Dr Field was recognized for his contributions by becoming the first residency trained emergency physician to receive the AOA’s Educator of the Year Award. Dr Spevack accelerated our momentum by assuring compliance in both our CME and GME and currently represents us on the AOA’s Post-doctorate Training Review Committee. Dr Kuchinski was the first residency trained emergency physician to be appointed Vice Chair of the Bureau of Federal Health Programs, a position he holds to this day. Dr Victor Scali (2002) and Dr Paula Willoughby DeJesus (2004) emphasized relationships, and expanded our influence and importance as stakeholders in the national health care arena. Under their leadership the ACOEP was established at the national level as a consistent, reliable, and altruistic partner in the development of health care policy. With the inception of TIPS, the college offered financial support and today we boast the largest number of graduates. We were no longer the small organization with the big name. During continued on page 20

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

Physician Impairment One issue confronting Emergency Physicians is the “impaired” physician. How do we detect such individuals and what do we do when we suspect that one of our medical colleagues is impaired? This issue not only polarizes the medical staff but also places the patient in possible direct harm. Slurred speech and incoordination does not always represent an acute alcoholic or drug intoxication but may represent some other physical illness such as multiple sclerosis, seizure disorder, hypoglycemia, TIA, CVA’s, etc. Tremors could represent Parkinson’s disease, benign essential tremors, etc. Aggressive and volatile behavior, absenteeism, failure to complete tasks, etc. could represent some underlying mental illness as well as a substance or alcohol abuse. What should we do when we suspect that a physician is impaired? You can always try to talk to the physician but most likely the physician will deny that there is a problem and that they do not need help. You could refer them to a treatment program or report them to the chief of staff. Many state medical societies have treatment programs available and many hospitals have a committee that deals with the impaired physician.

As a physician we not only have a moral obligation to report an impaired physician but a legal obligation to report an impaired physician, as well. However, it is often times difficult to detect impaired physicians before they might harm a patient. Recent physician surveys indicate that physicians would report an impaired physician about sixty percent of the time but in practice it is more like thirty percent who actually report physicians. Once a patient is harmed, many physicians are more likely to report an impaired physician. Some physicians are reluctant to report a fellow physician for fear of retaliation both legally and lack of future referrals. An impaired physician is considered to be any physician who is unable to perform their duty because of underlying psychiatric illness, physical illness, alcoholism and / or drug dependency. It is estimated that approximately 15 percent of physicians will be impaired during their careers. This number is not statistically different the general population that is impaired. Physicians are human and respond to stress, anxiety or pain by consuming alcohol or abusing prescription medications or other substances that impair their ability to perform their duties as a physician. Many physicians’ self medicate with alcohol or drugs to relieve their severe anxiety or mood swings. The underlying cause of the alcoholism and drug addictions may be mental or physical illness-

es. Once the alcohol or drug dependence is treated the mental illness or physical illness that caused the dependence is hopefully identified and treated. If these conditions are not recognized and treated there is often a relapse and failure of the recovering physician. Mental illnesses’ associated with drug or alcohol dependence include: depression, mood swings and anxiety. Other traits and behaviors that could lead to drug and alcohol dependence include personality and narcissistic traits. Personality disorders are common and difficult to treat. According to the late Dr. Hobbs, former head of the Pennsylvania (PHP) Physician Health Programs two-thirds of all impaired physicians have narcissistic traits. These individuals have little insight and take no responsibility of their actions. Physical illness would include conditions that would adversely affect cognitive, motor or perceptional skills. Physician impairment is like any other disease and early detection leads to prevention and avoidance of patient harm. Physician impairment detection is difficult because denial, suppression of feelings and reluctance of physician colleagues to report a physician before a patient is harmed. Early identification is paramount to prevent patient harm. Untreated impairment may lead to license removal and declining health. Licensing boards in many states are continued on next page

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

Financial Pathways . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

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

Common Ski Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . 13

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

History of EMS, Part IV, Wayne Jones, D.O., FACOEP . . . 16

ACOEP Members in the News . . . . . . . . . . . . . . . . . . . 7

Guest Column, Steven J. Parrillo, D.O., FACOEP . . . . 17

ACOEP Recognizes Its Members. . . . . . . . . . . . . . . . . . . 9

Emergency Department Ethics . . . . . . . . . . . . . . . . . . . 25

Changes Expected in 2008 . . . . . . . . . . . . . . . . . . . . . . 10

CME Calendar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

AOBEM Update . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

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The Pulse – An Osteopathic Emergency Medicine Quarterly 142 E. Ontario St., Suite 1250 Chicago, IL 60611 312-587-3709 / 800-521-3709 Editorial Staff Drew A. Koch, D.O., FACOEP, Editor Wayne Jones, D.O., FACOEP, Asst. Editor Peter A. Bell, D.O., FACOEP Gary Bonfante, D.O., FACOEP Duane Siberski, D.O., FACOEP Janice Wachtler, Executive Director Communications Subcommittee Drew A. Koch, D.O., FACOEP, Chair Wayne Jones, D.O., FACOEP, Vice Chair Gary Bonfante, D.O., FACOEP, Advisor James Bonner, D.O., FACOEP, Advertising Bobby Johnson, Jr., D.O., FACOEP William Kokx, D.O., FACOEP Annette Mann, D.O., FACOEP The PULSE is a copyrighted quarterly publication distributed at no cost by the ACOEP to its Members, libraries of Colleges of Osteopathic Emergency, sponsors, and liaison agencies by the National Office of ACOEP. The Pulse and ACOEP accept no responsibility for statements made by contributors or advertisers.

Editorial, continued from page 3 referring impaired physicians who have not harmed any patients to treatment programs instead of issuing sanctions against them. Several states have laws allowing physicians to refer physicians to treatment programs rather than licensing boards if there has been harm to a patient. Addictions are no longer seen as a moral taboo but a treatable illness. The goal is to get these physicians into treatment and not hiding them until they injure someone. Individuals who sucACOEP/ThePulse_Location cessfully complete a program are able to resume their careers and enjoy their lives.

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.

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References: Psychiatric News October 15, 2004. Volume 39 Number 20. P.11 Christine Lehman. Mental Illness Sometimes Overlooked in Substance-Abusing Physicians. Medical Economics October 11,2002. Ken Terry. Impaired physicians: speak no evil? 4/9/07Journal 11:30 Page American MedicalAMScience. July1 2001;322(1):31-6. EV Boisaubin and RE Levine. Identifying and assisting the impaired physician.

Where you

Display and classified advertising are accepted. Display advertisements should be submitted as camera-ready, pdf, or jpg formats in black and white art only. Classified advertising must be submitted as typed copy, specifying the size, and number of issues in which the copy should be displayed. The name, address, telephone numbers and email address of the submitting party must accompany advertising copy. Advertisers will be billed for ads prior to the publication of their advertisements and payments will be due within 30 days of the issuance of the invoice. The deadline for submission of articles and advertising is the first day of the month preceding publication, i.e., December 1, March 1, June 1, and September 1. ACOEP and its Editorial Board reserve the right to decline advertising and articles for any issue.

Has anyone known an impaired physician? If yes, do you think about reporting this individual or did you actually report this individual to the hospital impaired physician committee or to the state’s treatment program?

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Executive Directors Desk Janice Wachtler

Servicing the "One" In my career I’ve learned the importance of the word “service.” As a teacher, I learned that you had to provide not only education to your students, but you had to be someone whom they could rely to teach them not only educational facts, but coping and relationship skills. You were the stable adult figure to students who perhaps did not have stability in their lives and you were the adult to whom many could confide in. As I moved to a vice principal position, I learned that your peers depended on you to provide them with advocacy they sought with the school board or the principal. When I became involved in medical associations, I found that physician members, medical students, and other staff needed the characteristics I learned as a teacher as they too needed an advocate to speak for them. Service was something that members paid for and they wanted you to provide a contact to a world that they felt even less familiar with than the medical issues they encountered on a daily basis. Likewise as an association staff member and director, I learned that I had to depend on other professional associations to provide me with the same service components that my members required of me. The ACOEP was founded on providing service to its members and this has been a building block of the association ever since. Service is a component characteristic of each and every Board and staff member involved with this organization. The College has worked to provide service to its members in its every aspect. We have developed educational programs to bolster our members’ competence in all areas of emergency medicine, medical toxicology and EMS. The postdoctoral standards produced by the College were the first to match the

allopathic standards and quality of training and our programs are moving toward a level of excellence that now is attracting the attention of not only our educational counterparts but allopathic physicians who seek us out as potential training locations. The service aspect also is imbedded into the AOBEM and they have provided certification on par with allopathic standards and we are the only specialty in the osteopathic profession that provides a mechanism for continuing learning assessment, again, we are on par with our allopathic emergency medicine counterparts. As a specialty, emergency medicine and its organizations have excelled in the area of service, but what many organizations forget is why they exist at all, and that’s where I want to focus this article. ACOEP touts that it was founded around Bruce Horton’s kitchen table, and it was. It took a forward-thinking group of physicians to think outside the box and say, “what can we do to make this happen?” Not being there, I can’t think that they knew where to go initially, but they took the first step, sort of like Neil Armstrong landing on the moon. It was one small step for physicians and one giant leap for osteopathic medicine. The objective in founding a new specialty college is service, not self-service; but service to those who come afterward,

your progeny; your children for lack of a better term. The osteopathic profession exists not to extol the greatness of any one agency or specialty but to promote the greatness of its physicians who practice the wonderful art of osteopathic medicine. The ACOEP exists to serve you, the osteopathic emergency physician, and you are the one we work for. We exist for you; we work for you, and we all need to keep that in mind. As consumers of our products, we realize that you can go anywhere to obtain educational credentialing, CME, membership and camaraderie, and many organizations will seek you out to do just this. You can opt out of belonging to the ACOEP or the AOA, but we will continue to serve your needs; we will continue to provide you with educational standards and programs, continuing medical education, educational mechanisms by which you can obtain and maintain your certification and advocacy. Whether you choose to belong is based on our track record of service and that is all that we can provide you with. The College listens to its members, as well as those physicians who attend its educational programs; whether they are enrolled in programs we develop for CME or for postdoctoral training; whether they continued on page 26

Attention ACOEP Members Interested in Pediatric Research Opportunities Emergency Medical Services for Children National Resource Center Executive Director Tasmeen Singh MPH, NREMT-P has presented an excellent opportunity for first time researchers to obtain funding for research in pediatric emergency medicine. ACOEP members with an interest in developing a project, or participating in a project involving pediatric emergency medicine pre-hospital should contact: Mark Foppe D.O. FACOEP Coordinator of the Research Consortium ACOEP at DocFop@aol.com. The purpose of the consortium is to offer assistance in getting a multi-centered project started, however, this source of funding is specifically seeking first time researchers. Any one who is interested in participating in research is encouraged to contact the ACOEP to hear about available projects. Any questions about the EMSCNRC can be sent to tsingh@emscnrc.com or faxed to 202-884-6845.

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ACOEP Members in the News During the recent Fellowship and Awards Ceremony three physicians were honored with prestigious College awards. Anthony Gerbasi, D.O., FACOEP, a founding member, was awarded the Bruce D. Horton, D.O., FACOEP Lifetime Achievement Award. Dr. Gerbasi, who was unable to attend the ceremony stated upon receiving the award that he vividly remember “dream of starting and specialty college for emergency medicine” as founding members sat around a kitchen table in Toledo, Ohio, and he thanked his peers for recognizing him for the award. Victor J. Scali, D.O., FACOEP, ACOEP P a s t Pr e s i d e n t and current Assistant Program Director at the Kennedy Memorial Hospital, Stratford, New Jersey, was awarded the Benjamin A. Field, D.O., FACOEP,

Mentor of the Year award recognizing him for his excellence in teaching and his continued promotion of research in residency training Wayne Jones, D.O., ACOEP, Assistant Program Director at St. Vincent’s Health Center, Erie, Pennsylvania was awarded the Robert D. Aranosian, D . O . , F A C O E P, Excellence in EMS Award for his role in EMS in Erie County Pennsylvania. One member who always amazes us with her adventures, is Major Lisa DeWitt, D.O., FACOEP. Dr. DeWitt, former Program Director at Mount Sinai Hospital and active Georgia Reservist, recently climbed Mount Kilimanjaro, reaching the summit in 3½ days. Mt. Kilimanjaro is the highest free-standing mountain in the world, the highest volcano, and the high-

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est peak on the African continent. It is comprised of 3 volcanoes with separate peaks: Kibo (the highest), Mawenzi, and Shira. The actual height of the summit (although advertised at 5895 meters by a 1952 measurement) is currently believed to

be 5892.55 meters, or 19,332.5 feet. There are 6 well known routes to the summit including: the Marangu, Machame, Shira Plateau, Lemosho, Rongai, and Umbwe routes. The mountain climb is known as a fairly non-technical “trek” through various different terrains and environments, including thick forest/jungle, open heath and moorlands, and dry rocky moonscape like desert of the alpine region.

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ACOEP Recognizes Members For Long-Term Membership As we move into our 33rd year, the ACOEP would like to acknowledge those members who have been with us the longest. Our thanks go out to the members listed below for the anniversaries that they will celebrate with us during this new year as we tip our hat to these members for their faith, trust, and loyalty to us.

30 â&#x20AC;&#x201C; 33 Years of Active Membership Robert D. Aranosian, D.O., FACOEP* John W. Becher, Jr., D.O., FACOEP Fred Bailor, Jr., D.O., FACOEP James A. Budzak, D.O., FACOEP* David E. Brown, D.O., FACOEP Donald Cucchi, D.O., FACOEP Michael Q. Doyle, D.O., FACOEP Barry Feingold, D.O., FACOEP Robert C. Erwin, Jr., D.O. Anthony E. Gerbasi, D.O.

Robert J. George, D.O., FACOEP Robert L. Hambrick, D.O., FACOEP* Bruce D. Horton, D.O., FACOEP Philip B. Howren, D.O., FACOEP I. Brady Husky, D.O., FACOEP Joseph T. Imbesi, D.O., FACOEP Patrick J. Karson, D.O. Anthony C. Korvas, D.O., FACOEP Thomas J. Mucci, D.O., FACOEP Paul G. Martin, D.O., FACOEP

Anthony V. Mosca, D.O. Joseph B. Nienaltowski, D.O., FACOEP Steven J. Parrillo, D.O., FACOEP Louis C. Steininger, D.O., FACOEP Larry J. Stolsonburg, D.O. Scott Swope, D.O. Robert Upton, D.O.*

25 - 29 Years of Active Membership Thomas M. Bell, D.O., FACOEP Richard A. Balbin, D.O. Levente Batizy, D.O., FACOEP Charles M. Boothby, D.O. Robert B. Breckenfeld, D.O. A. Dale Chisum, D.O., FACOEP Ben H. Chlapek, D.O., FACOEP Anthony DiPasquale, D.O., FACOEP Arthur J. Dortort, D.O. Carl M. Desiderio, D.O., FACOEP Douglas P. Dero, D.O. James C. Eutzler, D.O., FACOEP Jack D. England, D.O., FACOEP Ronald Ellis, D.O., FACOEP Benjamin A. Field, D.O., FACOEP* Bryan T. Fitzgerald, D.O., FACOEP James J. Flowers, D.O., FACOEP Joan M. Gable, D.O., FACOEP

Dennis M. Guest, D.O., FACOEP John C. Hayden, D.O., FACOEP E. Lance Hildrew, D.O., FACOEP Douglas M. Hill, D.O., FACOEP Joseph C. Hummel, D.O., FACOEP Stephen G. Jaskowiak, D.O., FACOEP Steven G. Kaiser, D.O., FACOEP Jonathan Karol, D.O., FACOEP Michael Kleinman, D.O., FACOEP Eric J. Krieg, D.O. Francis Levin, D.O. Lori Levine, D.O. Freda Lozanoff, D.O., FACOEP David T. Malicke, D.O., FACOEP Anthony Mangiaracina, III, D.O., FACOEP Donald F. Massey, D.O., FACOEP Russell Mazda, D.O. William E. McConnell, D.O., FACOEP

James W. McCorry, D.O., FACOEP George J. Miller, III, D.O., FACOEP Erling J. Oksenholt, D.O., FACOEP Michael H. Oster, D.O., FACOEP George E. Palmer, III, D.O. Steven H. Perry, D.O. Richard H. Plummer, D.O. Richard Reidy, D.O. Martina Riley, D.O. Stephen Roskam, D.O., FACOEP Gregory J. Roskosz, D.O., FACOEP Richard Saalborn, D.O., FACOEP Sandra L. Schwemmer, D.O., FACOEP Brian S. Silverman, D.O., FACOEP Michael W. Tawney, D.O., FACOEP Gary Willyerd, D.O., FACOEP Bruce S. Whitman, D.O., FACOEP

New Active Members Ali Karrar, D.O. D. Gary Batten, D.O. Eric Cook, D.O. Armand Eusanio, D.O. Jonathan Graff, D.O. Tyler Greenberg, D.O. Kirby W. Haws, D.O.

Ralph Hess, D.O. John Kasper, D.O. Ralph W. Love, D.O. Jon Mettert, D.O. Kathleen Papazian, D.O. Timothy Robinson, D.O. Kathleen Schomer, D.O.

Michael F. Stalteri, D.O. Timothy Taylor, D.O. Wendall B. Thomas, D.O. Dawn Marie Turner, D.O. Harold Wagner, D.O.

* Deceased The PULSE JANUARY 2008

Changes Expected in 2008 Throughout 2007, the ACOEP has been preparing for changes that will be implemented in 2008 as we move towards meeting member needs and expectations as well as the demands of a changing society. Members have expressed their continued support of the proposed changes, but aren’t certain of just what will be changed now and what changes are still in the planning phases. This article will keep the member informed of what changes are being made and the timeline for implementation. What’s Really New? After a delay in implementation of a Members Only Page and a newly revised database, this change will be made available to members on January 1, 2008. With this new database, members will now be able to log onto the ACOEP’s website (www.acoep. org), click on Member Center and enter their AOA number to update their records as to address and contact information. With the implementation of this new database, online payment, through a secure credit card payment service will now be allowed for payment of dues, meeting registration and makes donations to the Foundation. This feature will go live in midto-late January. Members have informed the ACOEP that they need to be able to participate in the COLA Examination on-site at ACOEP meetings. This process was piloted successfully twice during the calendar year of 2007 and will be in effect for the larger meetings beginning in 2008. On-site COLA Examinations will be incorporated into the COLA Essentials, and Spring Seminar meetings during 2008. Meeting participants will be required to pre-register with the AOBEM for appropriate pass codes, bring their laptop computers with wireless access, and the ACOEP will supply a facilitator and wireless hub for the participants, a small registration fee will be required to offset costs for participation. Beginning in 2008, the ACOEP, at the request of its members, will meet independently for its Scientific Seminar. The 2008 meeting will be held at Caesar’s Palace in Las Vegas at the same time as the AOA is

meeting across the street at the Venetian on October 26 – 30. At press time we are still working out the details for our members to attend Alumni Luncheons so that they can meet and mingle with their peers. We will hold all of our educational meetings independently at Caesar’s Palace. Members from other specialties will be able to attend our sessions if they register on our website or in person for an additional cost and may attend by the day or whole conference. Negotiations are still underway to determine if our members will be allowed to visit the Exhibit Floor at the Venetian, but we will have Emergency Medicine oriented exhibitors at our site to allow our members’ access to those products and services most applicable to their practice. If you know of any company interested in exhibiting their emergency medicineoriented products or services, please have them contact us directly. In response to member requests, we are returning to paper syllabi for meetings. After three years of providing syllabi only in CD-ROM format, the College will return to paper syllabi for most of the participants, those wishing to have their syllabi in CDROM format will have the option of requesting this at the time of registration. Any physician registering on-site or after the cut-off date will only be able to obtain the syllabus in CD-ROM format to prevent additional costs for on-site printing and shipping. For institutions applying for programs in emergency medicine, ACOEP will be formatting a ‘how to’ guide to assist the institution in preparing for the program. The guide will contain timelines, interpretation of standards that are often misunderstood, and dates for meetings so that they can plan the course of the application and know

when to expect to implement training. What Changes are Being Planned? Within the first quarter of 2008, members will be sent copies of their entire membership files for verification. This information will contain their membership date, birth date, and training information. This will be the part of your membership record that will not be visible to you but will assist the ACOEP in building a biographic record for use in verifying information for certification and recertification as well as to provide us with demographic information on the membership. At this time, members will be asked to verify if they would like their contact information available to other membership. Members will then be able to opt out of allowing peers to view their contact information or to restrict what information is visible to other members. If members elect they will be provided with electronic notices to inform them when the electronic version of The Pulse is available and then opt out of receiving the paper publication. Members will also be able to participate on on-line surveys on various topics throughout the year on the Members Center. Additionally, the regular Member Survey (a bi-annual event) will be available on the web and members will be able to participate in this event to register their anonymous responses. You will also be able to view the results of the survey a few days after the end of the survey dates. Throughout the next year, ACOEP will post its changes on the website, as well as quarterly in The Pulse. Also, if you have any questions, please feel free to call the ACOEP at any time at 1-800-521-3709.

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AOBEM Update Bryan Staffin, D.O., FACOEP. Secretary The following is an update of the activities of the American Osteopathic Board of Emergency Medicine during the second and third quarters of 2007. The AOBEM is responsible for the certification, continuing certification and the issuance of certificates of added qualification in the subspecialty areas that fall under the jurisdiction of emergency medicine in the osteopathic profession. Part 1 – The “Written Examination” is the first part of the primary certification process for emergency medicine. This examination was last offered in February 2007. 169 candidates participated in the examination with a pass rate of 86.4%. A report on the pass/fail rates for individual programs on all facets of the examination process is shared with the ACOEP’s training programs through a combined effort of the AOBEM and the AOA’s Bureau of Osteopathic Specialists with the intent that the information is shared with the Graduate Medical Education Committee and the programs. The next examination will be offered on March 26, 2008. This examination has undergone extensive changes and besides the new testing date, 2008 will issue in a new era for the “written exam.” This date will now be offered as a computerized examination that can be taken at over 300 sites across the Country. Additionally, beginning in 2008 senior residents will be able to take the test during the residency program. To participate in this new test offering, senior residents must apply for the test before September 1 annually. Information on the application information will be forwarded to the program directors in the spring and can always be obtained on line at the Board’s website, www.aobem.org. In 2008, 40 senior residents will participate in the examination process. Part II – The “Oral Examination” is the second part of the testing process for primary certification in emergency medicine. This examination was last offered in November 2007 and is traditionally offered twice

during the year in June and September. Part III – The “Clinical” Component is the third and final part of the initial certification process in emergency medicine. This portion consists of candidates submitting a specific number of cases to the AOBEM for review. This review of clinical files allows the Board to ascertain that the physician conducts a thorough examination of patients and follows a logical process of tests and diagnostic procedures to arrive at a diagnosis and treatment plan. The pass rate for this portion of the examination was 94% during the last review period. Candidates successfully completing this final component of the primary testing process are then recommended for certification by the AOBEM to the AOA’s Bureau of Osteopathic Specialists (BOS). When approved by the Bureau of Osteopathic Specialists, the Candidates are presented to the AOA for certification in emergency medicine. Upon the receipt of this final approval, Candidates are granted certification for a 10-year period by the AOA. The next processes for maintaining certification is the completion of the Continuing Osteopathic Learning Assessment or COLA Modules. Each module covers specific sections of the Emergency Medicine Core Curriculum and is presented over a period of 8 years with new topics presented each year. Each module is available to certified physicians for a period of three years after its January 1st debut date. Currently, the active COLA Modules available to emergency medicine physicians are COLA 3, 4, and 5, which debuts on January 1, 2008. COLA 2 was available to emergency medicine physicians through January 1, 2008 and then de-activated. This process provides emergency medicine physicians with a mechanism for maintaining his or her testing skills and ensures exposure to cutting edge articles and information on the various aspects of the practice of emergency medicine. To participate in this process, emergency medicine physicians should log onto the

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AOBEM’s website and click on the COLA Module section to identify articles and to enroll for the examination. ACOEP does provide an annual course for the debuting COLA Module and does have CD-ROM’s available with lectures based on the lectures for each COLA and emergency medicine physicians should check with them for rates and availability of these CD-ROM’s. The entire articles can be obtained through your hospital librarian. Emergency Medicine physicians with expiring certificates are required to participate in the Formal Recertification Certification Examination (FRCE) in emergency medicine. This can be taken anytime during the active period for certification and can be taken by those physicians who have a lifetime certificate. Emergency medicine physicians with certificates that expire in 2007 and 2008 have been notified by the AOBEM of the availability for testing. The next examination will be given in June 2008 in Philadelphia. The deadline for participation in this test is February 1, 2008. For other test dates, please check the AOBEM’s website. For those physicians who have certificates expiring in 2008 and 2009 will be contacted in early 2008 regarding testing dates and locations. For further information on certification, please contact our office at 312-335-1065 or at www. aobem.org

Financial Pathways Sheldon R. Bender, Vice President Arnold J. Bender, ChFC, CLU GCG Financial, Inc.

Make A Difference with Charitable Giving More than ever before, charities depend on people like you to support their important work. But how can most of us make a difference, especially when we’re so busy planning for other financial goals? The answer may be a life insurance policy. A life insurance policy can transform a small giver into a substantial donor, and serve as a great replacement vehicle for your heirs if you gift other assets to charity during your lifetime. There are two main options you can use to structure your charitable gift using life insurance as the funding vehicle:

the Life Insurance Endowment Option and the Asset Replacement Option. The Life Insurance Endowment Option is easy to establish: your favorite charity is simply named beneficiary of a life insurance policy on your life. Through this technique, both you and the charity can reap important benefits. You benefit because you can make a gift for a few dollars a year. When the charity is the policy owner and beneficiary of the policy, the premium payments may be income-tax-deductible for you. Finally,

your gift is self-executing and proceeds are paid promptly. The charitable institution benefits, too. They’re assured of a source of future income. The amount of the gift is certain. There may be possible access to the cash surrender values, and they have total control of the program if they own the policy. The Asset Replacement Option allows you to make a tax-deductible gift to charity (cash, stocks, bonds, real estate, or other assets). Then you purchase a life insurance policy, naming your heirs as beneficiaries, to replace the property you ”gifted.” The money you save from the income tax deductible could help fund the policy premium. You benefit, because your gift may qualify for a current income-tax deduction. You can also place the gift in a trust to provide you with income while you’re still alive. Plus, your gift may escape estate taxes following your death. And finally, after you’re gone, your heirs receive insurance benefits equal to the value of the asset you gifted. Likewise the charitable institution benefits because the amount of the gift is certain. If you opted to place a gift in a trust, the charity can control the asset during your lifetime by serving as a trustee and they are assured of a source of income. This information should not be considered tax or legal advice. You should consult your tax and legal advisors regarding your personal situation before entering into any arrangement. Sheldon R. Bender is a Vice President and Arnold J. Bender, ChFC, CLU of GCG Financial and may be contacted at GCG Financial at 847-457-3000 or a Sheldon.Bender@ gcgfinancial.com or Arnold.Bender@gcgfinancial.com. Securities and Investment Advisory Services offered through Securian Financial Services, Inc. Member NSAD/SIPC. GCG Financial, Inc. and Securian Services, Inc. operate under separate ownership. Information provided by GCG Financial, Inc. should not be considered tax or legal advice. Should you require tax or legal information please consult your tax advisor or attorney.

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Guest Column Douglas Hill, D.O., FACOEP, FACEP

Common Ski Injuires Introduction. Man has been skiing for over 4000 years, dating back to hunting and mountain warfare by the nomadic tribes in what is now Scandinavia. The popularity of the sport increased in the US shortly after World War II with the return of the military that had originally trained at Camp Hale near Leadville, Colorado. Many of these individuals went on to develop ski areas in the state, Aspen and Vail as examples. Recent improvements in ski equipment have made the sport safer for the foot and ankle, but have done less to protect the knee and upper extremities. In fact, injury to the tibia/fibula used to be the most common ski injury—now it is the knee. It is difficult to determine the exact rate of ski injuries for several reasons. Many accidents are simply not reported or may be ignored initially or treated later away from the ski slope, upon return home. Therefore, data provided by the ski patrol reflects only those who seek immediate medical attention. In spite of these variables, it is estimated that the injury rate since the 1990’s is approximately 2 per 1000 skier days. This is down considerably from the 10 per 1000 noted in the 1960’s and 70’s, and much safer than other sports such as football with an injury rate of 81/1000. Skiers at Risk. Skiing out of control is a major factor putting the skier at high risk. Inexperienced skiers who often ski above their ability are at increased risk, both to themselves and other skiers. Speed is obviously a risk factor, slow speed contributing just as much as fast speed. When skiing at a slow rate of speed and then falling, low energy may cause unusual loading configurations and the bindings may not release properly. Snow conditions are a factor in ski injuries. Heavy and wet snow is more likely to entrap skis causing twisting knee injuries. Head, facial and upper extremity injuries may occur on

icy slopes because the skis are more likely to slide out from under the skier who is not executing a good carving turn, thus causing falls. Powder is associated with the fewest injuries. Improper equipment, whether borrowed, ill fitting, or poorly maintained is a great risk factor. Other factors that can increase the risk of injury are poor physical conditioning, fatigue (where the hips flex and the knees extend—basically poor form), juvenile skiers, alcohol, and disregard of hazardous conditions such as avalanche danger, obstacles, or other skiers. Finally, a majority of skiers are injured between 1 and 4 pm, many on their “last run of the day.” It may seem obvious that the skier would not continue to ski after a significant injury, but during interviews with many injured skiers it is clear that they were trying to get in just one more run, succumbing to fatigue and the other factors mentioned above. Ski Equipment. The modern boot is made of a high, rigid, plastic outer shell and a molded softer inner lining. Because of its design, fewer foot and ankle injuries have occurred over the past 25-30 years. Seldom seen is the old ”boot-top” distal 1/3 tibia/fibula fractures. Instead, forces are now transmitted proximally up the leg, especially to the knee. The function of the binding is to rigidly attach the boot to the ski. It should release in multiple directions when appropriate force is applied (such as a fall) but not release prematurely during a hard turn. Failure of the release mechanism accounts for about 44% of downhill ski injuries and over 70% of lower leg fractures and serious knee injuries. These injuries are classified as Lower Extremity Equipment Related (LEER) Injuries. The perfect binding has not yet been developed, but the industry is getting closer. Controversy exists regarding poles, especially the handles and straps. It is felt by many that putting

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the hand through the pole strap over the wrist prevents the skier from discarding the pole during a fall, and thus contributes to injuries, specifically to the Ulnar Collateral Ligament UCL) causing the Skier’s Thumb. Better equipment would include a pole without straps, breakaway straps, or a basket type grip. Helmets are always recommended and are becoming much more popular with skiers of all ages and abilities. The use of helmets has increased considerably since the deaths of such celebrities as Sonny Bono and Michael Kennedy, both of whom died of head injuries as neither of them was wearing helmets when they were killed. Classification of Injury by Anatomy. The Medial Collateral Ligament (MCL) of the knee is the most commonly injured structure in downhill skiing. In fact, when combined with the Anterior Cruciate Ligament (ACL) and the Medial Meniscus (MM), knee injuries comprise about 29% of all reported injuries. The thumb, specifically the UCL is the second most common injured area is skiing, and the most common upper extremity injury at 20%. Tib/fib and shoulder injuries make up about 15% and 11% of ski injuries respectively. By Type. If injuries are classified by type, and with the exceptions of contusions, sprains compromise the largest number making up approximately 43%. This is closely followed by fractures at 31%, lacerations and abrasions 11%, dislocations 4%, and other miscellaneous injuries such as overuse injuries making up the remainder. By Mechanism. Ski accidents can be categorized into two main mechanisms, collisions and falls. Collisions cause varied and continued on page 23

The American College of Osteopathic Emergency Physicians is pleased to announce its

2008 Spring Seminar STUDENT CASE COMPETITION Initiated in 1997, the Competition aims to promote research among students interested in emergency medicine Eligibility:

The Competition is open to all third and fourth year osteopathic medical students. Interested students must submit two copies of a five-page presentation and a review of literature supporting the diagnosis to the ACOEP office, on CD-ROM in Microsoft Word format, by mail along with this cover sheet. The deadline for submission is February 1, 2008.

Judging:

The members of ACOEPâ&#x20AC;&#x2122;s committee on Undergraduate Medical Education will review all presentations received by the deadline. The winner will be notified by February 25, 2008.

Prizes:

The winning entrant will receive round-trip coach airfare to Scottsdale, Arizona to present his or her case to the participants, at Spring Seminar. Also, included in the prize package is a one-night stay package at the designated hotel, and a $50 per diem. The winning entry will also be printed in the July 2008 edition of the ACOEP publication, The Pulse.

Name: _________________________________________________________________________ Mailing Address: ________________________________________________________________ Telephone: __________________________________ Email: _____________________________ School: _____________________________________ Expected Graduation Date: ____________

American College of Osteopathic Emergency Physicians Student Case Competition 142 E. Ontario Street, Suite 1250 Chicago, IL 60611 312-587-3709 312-587-9951 Please submit any questions via email to mandylundeen@acoep.org.

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Guest Column Wayne Jones, D.O., FACOEP

The Aircraft Before EMS

The Fourth in a series on EMS History Motorized air flight began with the Wright Brothers in Kitty Hawk, NC on December 17th, 1903. They flew their aircraft 120 feet in 12 seconds gaining only 10 feet off the ground. They would drift into relative obscurity for the next 5 years; mostly due in part to their fear that other inventors would steal their airplane design. The brothers would only provide an exposition to the public if a contract was signed prior to flight. In 1908 the brothers successfully secured contracts with France, Italy and the US. All contracts required sustained flight demonstrations. Wilbur, the more skilled aircraft operator, cautioned his brother Orville to wait for his return from France. The US was pressuring Orville for a flight; so on September 17th, 1908, after a series of solo flights, he accompanied a young army lieutenant into the air. At an altitude of 100 feet the propeller broke sending the aircraft to the ground. Lieutenant Thomas Selfridge would be the first soldier killed in a motorized aircraft. By 1914 the airplane was in use by most major governments. WWI would be the first initial test for military use. While reconnaissance missions would allow the airplane to enter the war, combat, while in flight, would replace much of this use. Pilots, who were able to shoot five planes from the air, would be termed an “ace”. The most famous WWI Ace was Rittmeister von Richthofen. He famously painted his aircraft red and became known by the Germans as The Red Battle Flier; the French called him Red Devil; and the US called him nothing else than The Red Barron. By WWII the invention of the cantilever wing airplane (this is where the canvas covers the skeleton of the wing) would allow for faster more stable flights. Transport of injured would now be possible. True air medical transport would not be

realized until the Korean War. Who could have foreseen the rise of the helicopter as a strategic medical tool? Though helicopters had been known about since the 1930’s, their utility was highly scrutinized by the military. If it had not been for Larry Bell (founder of Bell Aircraft) it would have been years before its introduction in mainstream military operations. Larry had demonstrated his Bell-30 helicopters with not much more than a yawn from the US government- until one fall day. Bell’s factory was situated on Lake Erie in Buffalo, NY. That day news spread that two fisherman were capsized in the cooling waters of the lake. Rescue was needed more rapidly than was possible by traditional boat. Larry, along with one of his pilots, rescued both fishermen using his Bell-30. With a limited range of 70 nautical miles, and top speeds of 100 nautical miles per hour, the new Bell-47’s became standard issue in time for the Korean War. More than twenty thousand troops were transferred by helicopter during the Korean War and thousands more in Vietnam.

The 45’s were replaced with Bell-UH-1’s or “Hueys”. Nearing the end of the Vietnam War, military-civilian helicopter demonstration projects called the Military Assistance to Safety and Traffic, or MAST, were started in five major cities. The first was at Fort Sam Houston in San Antonio. The Department of Transportation was testing the feasibility of use of military helicopters to augment EMS services throughout the nation to facilitate air medical transport in underserved areas. There are still a few of these programs existing in the United States today though many services have become hospital or private service based. Since that time helicopter EMS or HEMS has grown exponentially along with air traffic accidents (refer to my article Helicopter EMS: Incidents and Accidents, The Pulse, January 2006). We in EMS have learned a lot and continue evaluating and reassessing our role and function in the care of sick and injured. And the rest they say is history

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Guest Column Steven J. Parrillo, D.O., FACOEP

Stevens Johnson Syndrome / Toxic Epidermal Necrolysis Having had occasion to do a bit of writing on the subject of SJS/TEN, our legal brethren have contacted me on several occasions to provide expert witness in cases of alleged malpractice. “Misdiagnosis” or “mismanagement” appears to be fairly common. For that reason, I thought that a quick and dirty refresher for our members might be worthwhile. By the way, I politely decline when those attorneys represent the plaintiff. Stevens Johnson Syndrome (SJS) is an immune-complex–mediated hypersensitivity complex. While some authors believe that SJS is a severe expression of erythema multiforme, others believe that they are separate diseases. Terminology is not uniform. SJS is known by some as erythema multiforme major. Others use the term erythema multiforme major to refer to “severe cases” of erythema multiforme, but differentiate them from Stevens Johnson Syndrome. Most experts now believe that toxic epidermal necrolysis (TEN) represents a severe form of SJS, though some still believe that the two are distinct entities. From our perspective as EDPs, it is best to think of them the same entity with different degrees of involvement. The diagnosis, clinical approach and treatment are the same. Primary target sites include skin and mucous membranes. Significant involvement of oral, nasal, eye, vaginal, urethral, GI, and lower respiratory tract mucous membranes may develop in the course of the illness, though minor presentations may also occur. GI and respiratory involvement may progress to necrosis. SJS/TEN is a serious systemic disorder with the potential for severe morbidity and even death, most commonly due to sepsis or respiratory complications. Misdiagnosis is common in the early stage. Pathogenesis & Etiology Most believe that the disorder occurs

through an immune-complex–mediated hypersensitivity process. It is now well recognized that drugs in various categories are responsible for the development of SJS/TEN. Offending agents fall into two broad categories – infections and drugs. The vast majority of cases are drug related. Infections that have been linked to SJS include Mycoplasma pneumoniae, Yersinia and various herpes species. Drugs from several categories have been implicated in both TEN and SJS. Some authors divide those drugs into those used on a short-term basis from those used chronically. In the former group, sulfonamides – especially trimethoprim-sulfamethoxazole – are most commonly implicated. Others include aminopenicillins, quinolones, cephalosporins and chlormezanone. Presentations of SJS/TEN typically occur within 3 weeks of drug exposure. Drugs used on a more chronic basis have also been associated with SJS. These include phenobarbital, phenytoin, carbamazepine, valproic acid, oxcarbazine, oxicam non-steroidals (piroxicam, meloxicam), allopurinol and corticosteroids. There have been reports of SJS in HIV patients treated with the antiretroviral agent nevirapine. HIV positive patients, especially those with AIDS, are at high risk. Whether the disease is an independent risk factor or a function of increased likelihood of drug exposure is still unknown. Infection-associated SJS occurs primarily in children, with cases reported in patients as young as three months. Children may also develop drug-induced SJS. Patients with other immunological observations have also been associated with TEN has been associated with graft versus host reactions in bone marrow transplantation. Leukemia, lymphoma, ulcerative colitis and Crohn’s disease have also been named as possible risk factors for TEN.

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Clinical Presentation Many SJS/TEN patients have a prodromal period lasting up to 2 weeks that may include such non-specific signs and symptoms as fever, chills, headache, sore throat and malaise. Fever is especially common, occurring in up to 85%. There is no way to establish the diagnosis at this point. The typical mucocutaneous lesions then develop abruptly, and new lesions may continue to develop for a period of 2-4 weeks. Early lesions are usually erythematous macules with purpuric centers. There is a core that may be vesicular, purpuric or necrotic. The core is surrounded by macular erythema. Some have called these two-zone “targetoid” in contrast to the three-zone “target” lesions of erythema multiforme (EM). Early macules may also evolve into papules, vesicles, bullae or urticarial plaques. The initial lesions may also appear scarlatiniform. Nikolsky’s sign is usually obvious. Areas subject to pressure may demonstrate full detachment. Skin lesions may occur almost anywhere, but are most common on the face and upper torso, with palms, soles, dorsum of hands and extensor surfaces most commonly affected. The rash may be confined to one anatomic area, most often the trunk. Rash extension usually occurs within 72 hours but may occur over just a few hours. Any mucosal surface may be affected. Lesions include erythema, edema, sloughing, blistering, ulceration and necrosis. Oropharyngeal lesions may be severe, but mucosal involvement may also occur on the genitalia, esophagus and tracheobronchial tree. Lower GI lesions may lead to profuse, protein-rich diarrhea. Erosive vulvovaginitis or balanitis may produce painful genitourinary symptoms. It is important to be aware that internal disease may occur even in the absence of extensive dermal disease. Ocular involvement may also occur with continued on page 24

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Presidential Viewpoints, continued from page 1 their tenure various federal agencies engaged our expertise. We were also actively courted by other medical organizations, most notably the American College of Emergency Physicians and the American Academy of Emergency Physicians. These relationships are being nurtured today through liaison relationships, and a sense of duty to assure that the patient-physician relationship is strengthened. Last year, I presented to you our objectives for my term. They are in fact an application of principles put into action. They represent a continuity of purpose from one President’s term to the next, and were confirmed by the ACOEP Board of Directors last year. The following is an accounting of our progress. ACOEP Presidential Objectives 2006-2008 1) Membership participation a) Membership required for each AOA EM resident. i) We have sought accurate information from each residency program to be submitted to the ACOEP office within 30 days of the start of the new academic year. Residents can then be enrolled more efficiently as members. Resident membership is free and affords the residents membership benefits. ii) We have encouraged our GME committee to consider appropriate language to facilitate this requirement. It is currently a requirement for program directors. b) Each AOA EM residency is required to send a resident representative to each biannual meeting. i) We currently subsidize the residency representatives at $500 per fall meeting, and this year increased the total resident chapter budget by 25%. ii) This is currently a requirement for each program director (or their designee) to attend the biannual program directors committee. c) Every AOA EM resident must attend one ACOEP conference and membership meeting once during their 3 years of residency. i) The ACOEP is the primary support agency for the AOA EM residency programs. Without the ACOEP, these programs would not exist. All residents are

required to pursue educational conferences outside their residency program, and have been encouraged to select the ACOEP Spring or fall conference as one of their options. The GME committee has also been encouraged to consider appropriate language to facilitate this. d) Every core faculty member must be an Active member of ACOEP. i) The GME committee has progressively added higher standards for core faculty. A resolution (from ACOS et al) addressing board certification and specialty college membership was presented to the AOA Board of Trustees in July and rejected. We will re-introduce this concept in another venue this year. e) Every AOA EM residency is required to enter the CPC/POSTER competition. i) The revised residency program standards now require scholarly activity by the core faculty, and a research project by all residents beginning in July 2008. This year we have a huge increase in participation. 14/42 programs have entered the CPC and 57 posters were submitted for review. f) Fellows are required to participate in one membership meeting per year in order to maintain fellowship. i) The concept was submitted for consideration to the Fellowship, Awards, and Nomination Committee. The result has been an advanced level of fellowship. g) Pursue BOSS initiative for required membership in a specialty college if you belong to AOA. i) The ACOS et al took the initiative and submitted the resolution to the AOA Board of Trustees. h) Establish recurrent theme in publications; “the member is our building block”. i) Various publications have repeated this theme. ACOEP materials will increase their frequency of use. In addition, the issuing of pins in conjunction with years of membership will be considered. i) Become the second largest specialty society in the AOA. i) We have achieved this goal and will continue to increase our lead. 2) Leadership a) Future leaders i) Institution of progressive committee appointments (1) Completed this past year with cycli-

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cal, renewable 3 year appointments ii) New board members developed from committee chairs (1) Completed. This concept was developed as “the farm team” approach following the Boards last Strategic Planning Retreat. b) Annual evaluation process for i) Board members ii) Committee chairs iii) Committee members (1) Standardized Excel sheet electronic evaluation to be submitted for completion this December by all board members, committee chairs, and committee members. iv) Executive director v) Office staff (1) A standardized instrument was initiated last year. c) Effective strategy for appointment of members to AOA committees. i) This has been a long-term objective of the ACOEP. Development of relationships with AOA leadership continues. Activities include hosting the AOA President-elect at the Spring Conference, hosting a cocktail reception for the AOA Board of Trustees at the July Trustees meeting, and actively seeking to assist the AOA in the pursuit of its mission. We are seeking qualified, dedicated, interested individuals who desire to serve. 3) Advocacy a) Regular political advocacy through AOA i) 100% board member participation in OPAC (1) All Board members have been asked to make an annual contribution. Some have regularly given $500 to $1000 each year. ii) Board representation at BSGA (1) Dr Bell re-appointed to 3-year term. iii) Board representation at Federal Health Council (1) Dr Kuchinski in second of 3-year term as the V-chair. iv) 50% of board members participate in annual DO Day on the Hill (1) The Board has been given the April 24th 2008 date as an expectation. b) Annual board member visits to EM Clubs and Residencies. i) A matrix defining the clubs, board members, and dates has been constructed. The President’s discretionary funds were used last year. The new budget now includes $10,000 to visit EM clubs this year.

c) AOA actively seeks the advice, collaboration, and expertise of ACOEP. i) A cadre of academic, political, and health policy leaders are assuming more prominent positions in our college. We have also funded the TIPS scholars. Subsequently, we have yielded progressively more inquiries for assistance. Emergency Preparedness, Disaster Planning, and Educational standards have been common requests. 4) Education a) Publication of an OPP curriculum for EM residents. i) Topics, practices, and data collection through a pilot project are underway. b) Two year calendar of educational offerings available on the website i) Completed. 5) Finance a) Draft budget requests are submitted to the finance committee by the spring meeting of each year. i) Still working on compliance. b) Final budget for the next fiscal year is completed by mid-July i) Completed. c) Appointment of a member-at-large on the finance committee that demonstrates superior expertise in financial management. i) Completed.

6) Benefits a) Agreement with other Emergency Medicine organization(s) to provide additional benefits i) Publications (1) We have made inquiries to NREMT, NAEMSP, AAEM, and ACEP. No agreement as of this date. b) Interactive website with searchable data base i) The new website is up and the added features will go live later this fall. c) Advanced level of fellowship i) Approved and in the process of implementation. Finally, I need to address the political dynamics we all face as emergency physicians. Despite the recent reports by ACEP, ACS, and IOM, we continue to provide a disproportionate share of the uncompensated care. Many believe this is related to the lack of primary care access, and the growing number of uninsured or underinsured. For a long time I’ve asked questions about the uninsured in order to better understand the issue. Who is uninsured?? What are their current resources? What is their job status? Where do they live? Are there additional nuances to the problem?? It is VERY difficult to get accurate information. Sometimes, by asking the ques-

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tions, someone (or group) assumes you are taking a position, when in fact a viable solution must be predicated on verifiable facts. To arrive at a solution that does not fit the problem would be a waste of time (and eventually resources). On June 29th, the CDC released their annual report on Emergency Department use (“National Hospital Ambulatory Medical Care Survey: 2005 Emergency Department Summary”, number 386, data 1995-2005). The CDC takes all ERs into account so the poor community ERs are mixed with the wealthy. I frequently hear that the uninsured go to the ER. On page 3, under “Payment”, the percentage of “no-insurance” is 16.7%. On August 28th, the U.S. Census Bureau released the latest data on the number of Americans without health insurance. The number of uninsured rose to 47 million, from 44.8 million in 2005. This represents about 15.5% of the population in 2006, and 15.4% in 2005. It appears that Emergency medicine may be accepting a disproportionate share of the problem. In looking closer at the data, a clearer picture of the uninsured is revealed. Quoting Karen Davis, PhD, Director of the Commonwealth Foundation, “Nearly all uninsured adults are employed, and are

Presidential Viewpoints, continued from page 21 increasingly likely to be in middle-class families. In 2006, an additional 1.3 million working adults were uninsured, of which 1.2 million worked full time. Both younger adults ages 25 to 34 and older adults ages 45 to 64 experienced major increases in the number of uninsured, a sign of the difficulty of obtaining health coverage in entry-level jobs and of staying covered as older adults experience serious health problems. Those particularly affected by the loss of coverage have incomes between $25,000 and $75,000. But even among those in families earning more than $75,000, the number of uninsured grew by 1.4 million...The number of uninsured children rose to 8.7 million in 2006.” Another perspective came from an analysis reported in INVESTOR'S BUSINESS DAILY on Wednesday, August 29, 2007. “The median household income, according to the data released this week, is $48,200. You might be surprised to discover that 38% of all the uninsured — that's almost 18 million people — have incomes higher than $50,000 a year. An astounding 20% of all uninsured have incomes over $75,000. These are people who can afford coverage…Drilling even deeper, one finds that fully 27% of all the uninsured in the U.S. — that's 12.6 million people — aren't even citizens…By some estimates, another 20% or so is uninsured only for a couple of months a year.” These facts alone exemplify the problem of the uninsured as much more complex. It covers various ethic groups, financial classes, and age groups. Unfortunately, we need to be cognizant of how we are viewed and the potential influence we have. According to Dennis Gilbert author of The American Class Structure (1998, Wadsworth Publishing), the upper class or “rich” constitute less than 1% of the population. Most are old money, political dynasties, business tycoons, sports and entertainment figures, and a cadre of terminal degree professionals. This later group consists of PhDs, MDs, DOs, JDs, and MBAs. In addition, this later group holds considerable public trust and quiet influence. Other sociologists, such as Leonard Beeghly place more emphasis on heritage, education, and influence, and seeks household net worth (minus the primary residence) of greater than a million dollars as primary criteria. In 2005, the US Census Bureau placed the top 5% of household incomes at greater

than $154,000. The top 1.5% made greater than $250,000 and the top 1% greater than $350,000. Now, consider your own household income. Where do you stand in the public’s eye? We have the opportunity to influence the outcome of health care in this country. We have influence based on our degree, and our income. We have an organization with a national presence, and are actively collaborating with similar organizations. This year we are funding our Government Affairs Committee much like our GME committee. This tight group of 7 individuals will be lobbying in Washington twice a year, and implementing plans between meetings. So how do we leverage the resources of our membership? Specifically, what can you do that will make a difference? There are three things: First, look at the October 2007 issue

of The Pulse. Included is an advertisement for GOAL (Grassroots Osteopathic Advocacy Link). Sign up for the e-mail alerts. In Washington, decisions are made quickly and the only way to be effective is to be connected! The e-mail alerts give you an update on the issue and allow you to sign and send (electronically) a model letter to your elected officials. Second, skip the expensive night out next week and make a donation to a PAC (I have a particular one I mind). You have the income. Invest some of it in your future. The lawyers, chiropractors, and podiatrists put physicians to shame when comparing the amount of money they contribute. Finally, take an active, constructive role in the health policy dialogue. The 2008 elections are going to be full of health care issues. Remember your position of influence, and seek the fundamentals of protecting the patient-physician relationship. For without the patient, there can be no practice of medicine.

ACOEP has recognized William Mencke, Jr.

Financial Advisor Financial Planning Specialist (800) 621-2842, ext. 3338 As a Financial Advisor for: Investments, Lending, Insurance and Financial Planning. Three First National Plaza, Suite 5100, Chicago, IL 60602

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Common Ski Injuries, cont'd from page 13 poorly predictable injuries. They account for less than 5% of all ski injuries but over 67% of hospital admissions and fatalities. In particular, collisions can cause massive blunt trauma to the head, neck, chest, abdomen and pelvis. The most common cause of skiing related fatalities involves running into a tree. In Colorado, there are approximately 12 million skier days annually, with an average of 12 deaths (thus a fatality rate of 1 per million skier days). Two-thirds of these are due to blunt trauma, again usually hitting a tree, while the other third are due to avalanches, involving both cross country skiers and those skiing and riding out of bounds. Falls conversely cause unique and predictable injury patterns, and compromise about 83% of all reported ski injuries. Mechanisms of injury include a combination of Fixation and Enhancement, with External Rotation and Abduction, Internal Rotation, or a Forward Fall. Fixation is the catching of the ski on an obstacle, and Enhancement is leverage magnified by kinetic energy, thus increasing the chance of injury. The resultant forces can be enormous and may exceed the tensile strength of the body’s musculoskeletal system. External Rotation (catching an inside edge) is the most frequent mechanism if injury. As the skier’s momentum carries him forward, weight shifts to the downhill ski, and the caught uphill ski externally rotates and abducts his uphill leg. These forces may cause such injuries as spiral fractures to the tib/fib or may cause knee sprains, most commonly to the MCL or ACL. Internal Rotation is a frequent mechanism of injury for a beginner using the “snowplow” technique, the skier catching an ”outside edge” while turning. This enables the opposite ski to cross over, causing a fall and injuries to the ankle or knee. The Forward Fall occurs when the skier digs a ski tip into the snow or other object and his momentum carries him forward over the ski boot. Injuries may include ankle fractures or ruptures to the Achilles tendon. The skier usually then falls forward onto his hands and arms, causing additional injuries to the upper extremities. Specific Injuries. Upper extremity injuries compromise about one third of all ski injuries and are increasing in percentage as

boots and bindings become more advanced. The most common shoulder injury sustained in downhill skiing is the anterior dislocation (52%), followed by rotator cuff tears (20%), Acromioclavicular (AC) separations (18%), and other injuries such as clavicular fractures. Dislocations usually occur from a direct fall onto the shoulder, or they may involve catching the ski pole causing the arm to externally rotate and forcibly abduct. Rotator cuff tears occur when the skier falls on his side with his arm elevated or abducted against resistance. AC separations usually result from a direct fall onto the shoulder. Skier’s Thumb is a tearing of the Ulnar Collateral Ligament (UCL) of the Metacarpal Phalangeal (MCP) joint of the thumb and is the most common upper extremity injury found in skiing. The mechanism involves the skier falling on his outstretched h a n d — causing abduction and extension of the joint. These forces are exaggerated when the hand is still holding the ski pole and strap, the pole acting as a fulcrum to the adductor pollicus. The clinician will note point tenderness and laxity over the UCL at the ulnar aspect of the MCP joint. Fractures will be noted in up to 30% of cases so X-rays are always prudent. When the UCL is completely torn and displaced, the torn end may be displaced outside the adductor aponeurosis causing a permanent deformity and subsequently pinch grip strength instability. This “Stener’s Lesion” must be surgically repaired. Usually however, conservative treatment is adequate, including strapping and a thumb spica splint or cast. Lower extremity injuries include such conditions as ankle sprains, Achilles tendon ruptures, tib/fib fractures, and knee injuries. 20% of all downhill ski injuries involve the knee. As mentioned previously, while overall injury rates have declined over

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the past three decades, knee injuries have been on the rise. The most common of all skiing injuries is the sprained Medial Collateral Ligament of the knee, comprising 83% of all knee ligament injuries. The mechanism of injury is catching the inside edge of the ski, causing an external rotation—valgus strain to the knee. Exam may demonstrate tenderness and laxity; treatment is conservative. If external and lateral forces are more pronounced, the ACL may also be involved. Finally. The cascade may include the Medial Meniscus as well. The most common ACL injury scenario is known as the “Phantom Foot” because it involves the tail of the ski (a lever functioning as an unnatural foot) extending in the opposite direction to the skier’s real foot, causing injury to the downhill knee. Situations that can lead to this type of injury include attempting to get up after a fall while still moving and sitting down after losing control. To avoid the Phantom Foot ACL injury, one should ski with skis together, arms forward and hands over the skis with knees bent. The knee is more likely to sustain in jury when fully flexed or extended. The ACL sprain or rupture can be a subtle injury. The skier often detects a pop in the knee joint and feels a sudden bolt of pain, but still may be able to ski down the hill with little difficulty, at least initially. A rapidly developing large effusion is expected and will show a hemarthrosis if aspirated. The anterior drawer’s sign or Lachman’s test will be positive. Treatment remains controversial but in general ACL injuries are treated with surgical repair. Early management includes immobilization, ice, analgesics, and prompt orthopedic referral. Cross Country Ski Injuries. Nordic skiers enjoy 90% fewer injuries than their Alpine counterparts. Most Cross Country injuries occur on steep downhill terrain. The Nordic skier sustains fewer falls and collisions but has a significant increase of overuse injuries. In addition, the backcountry skier is more likely to be injured or killed by hypothermia or avalanches. Snowboarding Injuries. The overall injury rate of snowboarders is comparable to downhill skiing, but there are more upper extremity and fewer lower extremcontinued on next page

SJS/TEN, cont'd from page 17 potential long-term sequelae. This is one of the more common reasons EDPs are sued in such cases. Corneal lesions and keratitis are common, and conjunctival erosions may form synechiae in severe cases. In severe cases, blindness may develop. Classification of Skin Involvement Although there are more complicated classification schemes, the one most commonly used is as follows. SJS – a “minor form of TEN” - would be diagnosed when there is less than 10% body surface area (BSA) skin detachment. Overlapping SJS/TEN cases are represented with detachment of between 10-30%; whereas detachment of more than 30% BSA represents classic TEN. Diagnosis Although the diagnosis is usually clinically apparent, the differential diagnoses of staphylococcal scalded skin syndrome and other blistering diseases must be ruled out. Biopsy of involved areas can provide the most definitive discrimination between these processes. Although no other studies help establish the diagnosis, most authors recommend routine laboratory studies to include CBC, creatinine, electrolytes and cultures as clinically indicated. Chest radiography should be done when co-existent pneumonia is suspect. Other diagnostic studies that may be indicated include bronchoscopy, EGD and colonoscopy.

Common Ski Injuries, cont'd from page 23 ity injuries when compared to downhill skiing. More riders sustain blunt injuries such as collisions to the head, trunk and upper extremities. Additionally, when lower extremities are injured, there are more foot and ankle but fewer knee injuries, similar to the downhill ski injury patterns seen 3-4 decades ago. Special mention should be made regarding a specific snowboarding injury. The Snowboarder’s Fracture is a fracture of the lateral process of the talus, sustained when the rider catches the front edge of the snowboard on a forward fall.

Treatment The primary initial concern is volume status. Fluid replacement follows standard guidelines such as the Parkland formula ordinarily used for burn patients. Estimates of body surface involvement should be done carefully. Large quantities of saline may be required, but characteristically less than would be required in a true burn patient with equivalent body surface area involvement. Most authorities strongly advocate transfer to a burn center if possible, where care has been shown to reduce mortality. Owing to the likelihood that even minor, benign initial case may evolve quickly, many advocate hospitalization for all SJS/TEN patients. Protein loss can be significant. Once hospitalized, most will need parenteral or enteral hyperalimentation. Sterile wound care is also critical. Initial saline dressings will do until admitted. Silver sulfadiazine – must be avoided because of its sulfa base. There is controversy about whether antibiotics should be used initially. That is a decision best left to the admitting service. Cultures obtained in the ED may help guide that decision. An ophthalmologist should see all patients, although not necessarily in the ED. Likewise, selected patients should be seen in consultation by pulmonology and/or gastroenterology if involvement of these organ systems is suspected. Although to date there have not been randomized controlled trials of corticosteroid use, most uncontrolled studies have shown an increased rate of sepsis-related death. At this point, the best recommenda-

tion in the ED is to withhold steroids. IVIG use is also controversial and probably should not be given in the ED.

Physical findings reveal pain and tenderness at the lateral ankle, often misinterpreted as a lateral ankle sprain. A high index of suspicion must be maintained; appropriate imaging studies should be ordered including a CT Scan if indicated. Treatment is either a non-weight bearing cast or operative intervention with pinning to avoid long-term disability.

treatment are similar to that of non-skiing injuries. Recognition of risk factors and mechanisms of injuries, along with appropriate use of proper equipment will help to further reduce the number and severity of these injuries.

Summary. Downhill skiing is associated with common as well as unique orthopedic injuries, with the knee and thumb being involved most commonly. Diagnosis and

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Mortality Generally speaking, the mortality rate is determined largely by the extent of skin sloughing. When BSA involvement is less that 10%, the mortality rate is 1-5%. When BSA is more than 30% the mortality almost 1/3 will die. SCORTEN is a severity of illness score, calculated within the first 24 hours of admission. Each feature is assigned 1 point. The total is the SCORTEN number. Points are assigned for age > 40 years, presence of malignancy, heart rate > 120, initial percentage of skin detachment > 10% BSA, BUN > 27 mg/dL, serum glucose > 252, and bicarbonate < 20 mEq/L. As you might suspect, mortality rises with each point. At 5 or higher, mortality is 90%. Summary Early diagnosis and management is key to positive outcomes. Referral to a burn center is warranted if such facilities are available. Fluids and maintenance of nutritional status represent the mainstays of early management. Steroids and IVIG should probably not be given in the ED unless ordered by the admitting team. Careful assessment of the extent of epidermal detachment and other clinical features can provide important early prognostic information. Mortality remains high with significant areas of skin involvement with death usually resulting from sepsis or airway compromise.

References for this article are available upon request of the author. You may contact the author at Douglas Hill, D.O., FACOEP, c/o ACOEP, 142 E. Ontario Street, Suite 142 E. Ontario Street, Chicago, IL 60611 or by email at dhill@acoep.org.

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

What Would You Do? In this issue of The Pulse we will review the case of the elderly female scheduled to be transported home to die. This case was presented in October 2007. Our patient was to be transported home by a private ambulance company. She was on a ventilator and lacked decision-making capacity. The family requested EMS discontinue the portable ventilator when they arrived at the home. EMS contacted the EMS Medical Director because of concerns about this scenario.

Should we as healthcare workers promote such procedures? Death is not as easy as just pulling the tube. It is not an old western movie where Festus takes a bullet and says, “Good-bye cruel, cruel world”, and slumps over his loyal dog, Stinky. There is pain, distress, anxiety and suffering, both for the patient and family. Families may not understand the process or the personal impact. The responsibility may be too much for EMS personnel without additional support and training. What would you do? Let’s assume for a moment that EMS delivers a dying patient to their home and We received the following response from removes the endotracheal tube. What if the Wayne Jones, D.O., FACEP: family perceives the patient is in pain or “Death is not the greatest of evils: it is distress? Are medics to medicate to ease and worse to want to die and not be able to.” hasten death? What if the family changes —Sophocles their minds? Is EMS to reintubate and This is a timely question for EMS and deliver the patient back to the ED (Oh yes, healthcare in general. Interestingly, our the ED) to be re-admitted? EMS system has had two such requests EMS is just beginning to discontinue in the recent past. In general, I am never resuscitation on cardiac arrest victims, let surprised at the requests that are made alone living patients. A procedure such as of EMS. this is well outside what is termed “scope The simple answer needs to be no . . . this of practice”. Remember, paramedics are not was not appropriate for EMS - at least not yet. separately licensed. They function under But what about the family and its wishes the licensure of a physician and strict state for the patient and his or her care? Unless EMS law. the idea was either suggested or reaf- In a 2005 survey of respiratory therafirmed, the option would never be open for pists, published in Respiratory Care, regarddiscussion. Patients and their families would ing terminal extubation (as compared to never realize this was an option. Someone terminal weaning) 75% felt a nurse should at the healthcare facility allowed the be in attendance during extubation. Only family to expect this type of service. 33% had received end-of-life education and

2008

CME Calendar

January 9 – 14 February 5 – 9

Emergency Medicine: An Intense Review Westin Chicago River North Hotel, Chicago, IL 40 – 42 Category 1A Credit 40 – 42 Category 1 Credit COLA Essentials Marco Island Hilton Hotel, Marco Island, FL 25 Category 1A Credit 25 Category 1 Credit (pending)

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a full 13% felt it was not ethically correct to remove a patient from a ventilator in that manner. Now, this is a population of caregivers experienced in extubation procedures. In fact, up to 90% of all ICU deaths are related to withdrawal of treatment. In our case we requested hospice be present to accept the patient at home. We also requested they ventilate the patient until EMS had departed, and then pull the tube. We were flatly refused. Even hospice would not take on such a task. No, EMS is not ready for this. Then again, are we? We thank Dr. Jones for his insightful perspective and commentary. As an EMS Medical Director I often get EMS ethical dilemmas presented to me. In this case my response to the crew was the same as that given by Dr. Jones. It is not an EMS function to discontinue life support. A prearranged hospice nurse was to be present at the home. This nurse would continue Ambu bagging the patient while the crew removed their ventilator and left the house. At that point it would no longer be an EMS issue. This was successfully arranged. We again appreciate Dr. Jones’ response to this dilemma. If you have any cases in your practice you would like to present or have reviewed in The Pulse, please Fax them to us at 708-915-2743. Thank you.

March 25 – 29 May 2 – 3

ACOEP Spring Seminar Doubletree Paradise Valley Hotel, Scottsdale, AZ 25 Category 1A Credit 25 Category 1 Credit (Pending) Oral Board Review Sheraton Four Points Hotel, Chicago, IL 10 Category 1A Credit

Executive Director, continued from page 5 are graduates of residency programs or those who have grandfathered into the profession; or whether they are medical students just entering the profession. We’ve listened and chapters have been formed, young physicians have been added to the Board of Directors, and subspecialties areas developed to meet the various needs of our members. We’ve listened to complaints, compliments, gripes and kudos, but the fact that we do listen to you and have acted on your behalf is important as we move into the next phase of our development. Over the years, you all have shown us this loyalty and support. Our membership has grown not by single or even doubledigit numbers but triple-digit percentages! In any one five year period we have continued to double member size, growing from only 450 or so members in 1992 to almost 1800 Active Members this last year. We are proud to represent and work for you. As the College ages and we move into our third decade of existence, ACOEP need to remember where our loyalty lies. If we can’t depend on other agencies to tend for our members’ needs, wants, and wishes, then we have to speak for them in a voice that is united, clear, and concise. We need to know where we are going, how we will get there and what it will take to do the job that you hired us to do. In recent articles, Dr. Bell expressed his thoughts and concerns on AOA’s perceptions that we are in some way disloyal because we have decided to host our own Scientific Seminar and asked that they review and evaluate their educational processes to bring them into parity with our allopathic brethren. We’ve done that not because we are against AOA, but because we want the best for the individual osteopathic physician; the people we serve most humbly and honorably as we can. It is truly an honor to work to help you meet your personal and professional goals and objectives and the ACOEP looks forward to making you part of the decision making process. Please get involved; stay involved and care about your future. Let’s make it work – for all of you.

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