The Pulse July 2006 by ACOEP

The PULSE

Osteopathic Emergency Medicine Quarterly VOLUME XXXI NO. 3

JULY 2006

Presidential Viewpoints

Paula Willoughby DeJesus, D.O., FACOEP

Setting the Table for Health Reform Does Mass-achusetts have it right? A huge question! The legislature recently set another milestone in moving forward with real health care reform. In 1988, the State enacted a controversial “universal care” law that they did not implement and eventually repealed. Massachusetts is back at the table and is once again setting a precedent by its latest actions. This new health care reform plan is based on shared responsibility in health care coverage. Individuals, private industry and the government are called upon to create the foundation of the plan. It requires all Massachusetts residents, 18 years of age and older, to carry a basic health insurance plan. It will be verified and enforced through the individual’s state tax return. Parents and guardians will be responsible for all dependents. Young adults will be able to stay on their parents’ plan two years after they have lost their dependent status or until they are 25 (whichever comes first). Specifically designed products will be created for this young adult group that has limited coverage. A database will be established and those that are not compliant will be penalized by fines that will be 50% of what an “affordable” insurance premium would cost. The plan also requires businesses with 11 or more, fulltime employees to offer “cafeteria plans” which allow employees coverage choices. Small group and individual insurance will

ultimately be merged into a single market, thus eliminating added fees to non-group payers. They would be allowed to purchase insurance on a pre-taxed basis. Employers will be charged $295 per employee annually when they do not provide health care insurance or contribute to it. They will be charged a surcharge when their employee exceeds a certain threshold amount of care. The State will administer many of the parameters and establish the sliding scale definitions of “affordable.” They will establish an “approved” provider list. They will make “approved” insurance products available to small businesses. People who are self-employed, unemployed or not eligible for coverage by other mechanisms will be able to purchase coverage from these providers. Policies will be retained even if the insured changes their job. Premium assistance will be provided on a sliding scale based on income. Households earning less than 300% of the federal poverty level and who have no other mechanism to obtain insurance will be eligible for these plans. A portion of the funds that are directed to institutions that provide care to the uninsured will be used to subsidize insurance for low-income individuals. Medicaid will be expanded to include all children in these families. Medicaid providers will receive rate increases. Households who earn less than 100% of Federal poverty levels will have no premiums. None of the plans will have deductibles. Those that are ineligible for these subsidized plans may have deductibles, user networks and outof-pocket costs.

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All of theses measures will be tied to performance measures. Cost, utilization, specific procedures, ethnic health disparities and quality physician/hospital data will be public information. Hospitals will be required to report data and reimbursement will be tied to performance thresholds. A detailed discussion of this ambitious legislation appears in the May 18, 2006 Perspective Section of the New England Journal of Medicine (Volume 354, Number 20). The two articles are worth a close look. The first, “Can Massachusetts Lead the Way in Health Care Reform by Stuart Altman, PhD and Michael Doonan, PhD, applauds Massachusetts for demonstrating health care to the uninsured is possible. It projects this will challenge and “embolden leaders in other states.” There is victory for institutions providing care for Medicaid patients in that the reimbursement for care will be more in line with that of private insurance payments. This is good news for the insurance industry as well as they too are indirectly subsidizing the uninsured through increased costs for services to make up for uncovered care. The authors also realistically point out that, “The devil, as always, is in the details.” The details of this new plan have some definitions and specifics to be deviled out. What will the regulations and implementation details be? Will the current funding structure be enough to sustain the program long term? Will the “affordable” premiums be too expensive for the average individual and family? What will these “new” insurance products look Presidential Viewpoints, continued on page 4

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2006 Fellows Named At its meeting of April 20th the Board of Directors of the ACOEP on the recommendation of the Fellowship Committee approved the granting of the Honorary Title of Fellow of the American College of Osteopathic Emergency Physicians to 23 physicians. The 2006 Class of Fellows are: John Agee, D.O., Valparaiso, Indiana, Victor Almeida, D.O., Colts Neck, New Jersey, Fred Bailor, D.O., Easton, Maryland, Paul DiModica, D.O., Santa Maria, California, Thomas E. Green, D.O., Orland Park, Illinois, Douglass Harmon, Jr., D.O., Sewickley, Pennsylvania, Anwer Hussain, D.O., Naperville, Illinois, Bobby Johnson, Jr., D.O., Benbrook, Texas, Rajesh S. Kothari, D.O., Berkeley Heights, New Jersey, David Lawrence Levy, D.O., Northport, New York, Majushree Matadial, D.O., Perth Amboy, New Jersey, Jennifer Matzner-Abrams, D.O., Blythewood, South Carolina, Scott T. Miekley, D.O., Erial, New Jersey, David E. Miller, D.O., Rockford, Illinois, William E. Reisinger, III, D.O., North Canton, Ohio, Otto F. Sabando, D.O., West Orange, New Jersey, Scott P. Shisler, D.O., Port Austin, Michigan, James B. Shuler, D.O., M.S., Fort Collins, Colorado, Glenn Saucillo, D.O., Wheaton, Illinois, Nicole Wadsworth, D.O., Athens, Ohio, Brian D. Wiley, D.O., Providence, Rhode Island, Thomas M. Wills, D.O., Glendale,

Arizona, and Maury Witkoff, D.O., Gahanna, Ohio. We would also like to thank the following Fellows for participating in the nomination process for Fellowship: Paul Allegretti, D.O., FACOEP, Harris Baderak, D.O., FACOEP, Levente Batizy, D.O., FACOEP, Brad Blaker, D.O., FACOEP, David Brown, D.O., FACOEP, Joseph Calabro, D.O., FACOEP, Ben Chlapek, D.O., FACOEP, Michael Q. Doyle, D.O., FACOEP, Anita Eisenhart, D.O., FACOEP, Tressa Gardner, D.O., FACOEP, Anthony Jennings, D.O., FACOEP, Joseph J. Kuchinski, D.O., FACOEP, Mary-Lynn Magarelli, D.O., FACOEP, Charles McIntosh, D.O., FACOEP, E. Scott Morrison, D.O., FACOEP, Thomas Mucci, D.O., FACOEP, Donald Phillips, D.O., FACOEP, Catherine Polera, D.O., FACOEP, Victor J. Scali, D.O., FACOEP, Henry Schuitema, D.O., FACOEP, Juan Sinisterra, D.O., FACOEP, Bryan Staffin, D.O., FACOEP, and Jennifer Waxler, D.O., FACOEP. To become a Fellow in the ACOEP, the criteria are simple. You must be a member in good standing of the ACOEP for a minimum of 5 years; you must be certified in emergency medicine by either AOBEM/AOA or ABEM; you must attend 3 ACOEP Membership Meetings in the last 4 years; you must have attained two of the

following items: publication in a national, peer-reviewed journal; past or present membership on an ACOEP Committee; faculty appointment in emergency medicine at an accredited college of osteopathic medicine or college of medicine; active involvement in the leadership of EMS including but not limited to: EMT or paramedic training, working as a Medical Director of a Community EMS System, participation in local disaster planning and implementation, direct supervision of training of physicians and residents in online command; Director or faculty of an Emergency Medicine Residency Training Program accredited by AOA or ACGME; past or present involvement in the process of administering board certification examinations or verification of another significant contribution to the field of emergency medicine. Applications are reviewed once each year and can be downloaded from the ACOEP website or requested from the ACOEP office. The deadline for applications is always March 1. Fellows will be hooded at the Fellowship Ceremony on Tuesday, October 22, 2006 at the Las Vegas Hilton Hotel. The ceremony will begin at 6:00 p.m. and guests are welcome to help celebrate this solemn occasion.

Table of Contents Presidential Viewpoints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Money Talk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

2006 Fellows Named . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Guest Column, Mark A. Mitchell, D.O., FACOEP . . . . . . . . . . 27

Executive Directorâ&#x20AC;&#x2122;s Desk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Guest Column, Wayne Jones, D.O., FACOEP . . . . . . . . . . . . . 29

Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Guest Column, Annette Mann Brunetti, D.O., FACOEP . . . . . 31

Research Corner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Guest Editorial, Anthony Jennings . . . . . . . . . . . . . . . . . . . . . . 33

CME Calendar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Official Call to Meeting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Reports of the Membership . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Member News . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Guest Column, Gregory Christiansen, D.O., FACOEP . . . . . . . 13

Ethics in Emergency Medicine . . . . . . . . . . . . . . . . . . . . . . . . . 34

Domestic Preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Candidates Identified for Board Positions . . . . . . . . . . . . . . . . . 35

Article on Implementation of Part D . . . . . . . . . . . . . . . . . . . . 17

Guest Column, Gretchen Farinosi, R.N. . . . . . . . . . . . . . . . . . . 37

Guest Column, Douglass Hill, D.O., FACOEP . . . . . . . . . . . . . 23

Research Corner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

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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 Paula Willoughby DeJesus, 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. 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.

Presidential Viewpoints, continued from page 1 uninsured people in Massachusetts is lower when compared to the nation (11.2% vs. like? The authors aptly point out that 15.9%). The population of Massachusetts realistic ways to control health care costs is residents covered by Medicaid (12.7% vs. still an imperative. They recommend that 12.8%), Medicare (11.6% vs. 11.8%) and part of the group leading the refinement individual insurance (4.3% vs. 4.8%) does of the language needs to include patients, not significantly differ from the nation. I hospitals, physicians and other health care on the contrary find this small difference providers as the devil is drilled out of the encouraging that it is not so very differdetails. Finally, they very insightfully note ent that it might just work outside of that this plan will not be perfect straight Massachusetts too. out of the shoot but that holding out for This may be our first real opportunity the perfect plan will paralyze us to achieve to make reform real. The shared responsiany gain at all. bility approach is a pivotal premise for the Robert Steinbrook, MD provides success of any derivation of this plan to a detailed analysis of the Massachusetts succeed. Multidisciplinary groups includapproach with referenced facts and fig- ing patients, insurers, hospitals, physicians ures in his article, “Health Care Reform and other health care providers must be in Massachusetts – A Work in Progress.” formed to define the details to keep the Dr. Steinbrook provides an excellent over- devil at bay. This development of new view of the state of the state as to where insurance products could be our chance to we are fiscally funding the health care define what minimum is, closing the gap machine. He has distilled the presump- in perspective between insured and insurtions Massachusetts is banking on to drive er. By including key health prevention this change. He too expresses concerns requirements in the standards for the insurof sustainment and true affordability. He ance providers to get the bid to play we will presents a concern that the percent of peo- have the opportunity to shift their mind set ple covered by employer insurance is higher on what they must cover. Massachusetts, in Massachusetts relative to the nation as a we are all watching and waiting. whole (59.5% vs. 53.7%). The percent of

ACOEP Reincorporates in State of Illinois At its meeting of April 21, 2006 the Membership of the ACOEP approved a resolution to reincorporate the College in the State of Illinois. With this action, the ACOEP has filed documents with the State of Illinois to move its original incorporation from Ohio to where the College office has resided since 1980. It will also remove the necessity to file documents in both states to register the College as a business entity. With this change, a new set of Bylaws will be enacted, upon approval by both the ACOEP Membership and the American Osteopathic Association, the organization that ACOEP is chartered through and recognized by. The new Bylaws will be submitted to Active, Active-Exempt, Life and Retired members and will be voted on at the October 2006 Membership Meeting. The draft Bylaws will also be available on-line at www.acoep.org after August 1. Once approved, the new Bylaws will allow mail or electronic voting for the ACOEP Board, or changes in the Bylaws of the College, a benefit that is not currently available. Members will have the opportunity to begin this voting in 2007.

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Executive Director’s Desk Janice Wachtler

In the Depths of Depression Several years ago, I wrote a column on depression, identifying it and dealing with the consequences. The column, published in 2002 was based on the diagnosis of clinical depression of a very close friend of mine and someone who played a large role in my adult life. It began quietly enough, a few days where he was down in the dumps, not acting like himself. Then it began to be the majority of weekdays he went to work, carried a large role in the ED that he worked in, did his research projects, and acted normal when he was out in public. Then he would come home and dive into the depths of his unhappiness. He was enormously unhappy in his personal life. When we went out it was like being sucked into the eddy of his unhappiness, nothing you could do or say, made him smile anymore. No amount of activity got him out of the dumps and friends began to desert him. In 2000, both of us had illnesses in our immediate family that affected us profoundly. When he was diagnosed with the potential for a life-threatening illness; he became more depressed. And, although he was there for me, when we spoke on the phone or saw each other, it was evident that he was sinking fast. Why, I’d ask and he would just not answer. In mid-2001 we both went for counseling. I went for a few sessions, got my head together and went on with my life. He began to circle the drain. Nothing was simple anymore. He was delving deeper and deeper into perceived problems in his childhood that had set him up for adult depression, or so his therapist said. He began losing his grip on the world of today. Finally, in late 2001 he met someone and he buoyed up. I was happy for him. He finally had something to live for and he began to feel, act and be himself again.

Then in 2002 his soul mate developed liver cancer and he again fell into the depths of depression. Now he began being medicated and he began relying on pharmaceuticals to help him sleep and wake up, aid his appetite, and in general help him cope with day-to-day events. He became a shadow of his former self. Unable to cope with anything that happened in the world. Events in the news became personal affronts to him; he quit work and stayed at home to go to therapy, individual and group, to help him exist in the world. He drifted farther and farther away and when we did communicate, it was always with the fear that what if I said the wrong thing, would I drive him further away, or increase the size of his problems. I no longer knew if the problems and events he described were real or not, but I let him talk because I knew he had to voice them to concur with them. I tried tough love, that didn’t work. I tried tenderness and understanding and that was just as frustrating. Finally, he began to drive me away, forcefully at times. The last time I saw him was in 2004, at that time, we spent a great deal of time together. His soul mate had passed away the previous June and even though we talked every few days, I knew little of what was going on in his mind. This time, he called me at midnight; he couldn’t sleep and was afraid to stay alone in the room at the hotel. He dragged his blanket through the hotel hallway and we sat on the sofa in my room, I held him as he cried for hours. Finally, he fell asleep, his head in my lap. The same scenario played out three nights in a row. When he went home, I knew I wouldn’t see him again. That fall, a lawyer called to inform me that he passed away in the summer; letters that I had sent him, unopened on his kitchen table, phone messages from me, unanswered, on his message machine. It took me a long time to get over his death. Like, Kubler-Ross stated, I think I went through the stages of grief. I was mad at him for a long time for playing out this scenario without going to see other therapists, or trusting me when I said he needed

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to reach outward instead of peering inward that he did so often. It will be two years this summer that he is gone, and although I still I think about him and I know that he is in a better place and I miss him enormously. I write this column for him and for anyone reading this that has ever been depressed or is dealing with someone who is depressed. If you or someone you know is dealing with this dangerous illness, I urge you to get help now before it is too late. The signs of depression are many and we often mask our feelings so that others don’t know how we are feeling. But some of the signs identified by many psychologists are: • Changes in thinking, including problems with concentration and decision-making • Changes in feelings • Changes in behavior, including acting more apathetic or withdrawn, acting out, changes in appetite, excessive crying. • Complaining about everything and acting out in anger. Sexual desire may also change. • Changes in physical well-being, including chronic fatigue, changes in sleep patterns (either sleeping more or less); restlessness; pain. It can be major things that send us into a tailspin or just something minor that knocks us off our stride, but whatever it is do something to help or direct that person to help. There are numerous groups that do outreach in your local areas. If drugs are involved, know that they can be helpful or they can be dangerous and don’t self-medicate. We are there for you, remember your friends and family play a big part in your well-being and will be there for you when you need them. Sources you may use are the websites for: National Institute of Mental Health (www.nimh.nih.gov) Psychology Information (www.psychologyinfo.com)

STUDENT CHAPTER & RESIDENT CHAPTER EVENTS Resident Chapter & Student Chapter Schedule Sunday, October 15 3:00 p.m.-5:00 p.m.

Resident Chapter Meeting Student Chapter Meeting

5:00 p.m. – 7:00 p.m.

Student and Resident ECI Wine & Cheese Reception

Monday, October 16 8:00 am – 10:00 am

Resident Chapter Jeopardy Tournament

9:00 a.m. – 12:00 p.m.

Student Chapter EM Residency Exposition

10:00 am – 4:00 p.m. (break for lunch)

Resident Case Presentation Competition Residents present cases involving a typical presentation of an unusual disease or an atypical presentation of a common disease. Faculty discussants present review and suspected final diagnosis.

10:00 a.m. – 5:00 p.m.

Research Posters on Display in Convention Center

12:00 – 3:00 p.m.

Student Chapter Lecture Series

8:00-10:00 p.m.

Resident Chapter Resident Dinner

Tuesday, October 17 10:00 a.m. – 1:00 p.m.

Resident Lecture Series – Job Panel

2:00-5:00 p.m.

Wednesday, October 18 11:30 a.m.-1 p.m. Thursday, October 19 11:30 a.m. – 1 p.m.

Resident Poster Competition Judging Residents present an interesting case relevant to emergency medicine in a 4’x6’ poster format. The Resident Posters will be on display all day Monday through the end of the day Tuesday. FOEM Research Awards Luncheon Student Case Competition Winner Presentation, presentation of CPC and Poster presentation winners. Winner of the Student Case Compe-tition will also present. Research Oral Abstract Presentations & Luncheon Residents present interesting cases relevant to emergency medicine in an oral presentation.

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Editorial

Drew Koch, D.O., FACOEP, Editor

A Glimpse of ACOEP's First 30 Years It was refreshing to hear Dr. John Becher’s keynote lecture at the 2006 ACOEP Spring Conference at the Wigwam Resort in Litchfield, Arizona. The topic was “Emergency Medicine: Then and Now.” I was suddenly in a time warp-1982! I felt I was sitting in PCOM’ s Evans Hall listening to my Emergency Medicine lectures that in the most part were presented by Drs. Becher, Sarama and Parrillo. I have enjoyed listening to both Drs. Becher and Parrillo speak over the past 24 years. Dr. Parrillo lectures regularly at the ACOEP’s conferences and might I say, ever so eloquently. However, it has been years since I have had the pleasure of listening to Dr. Becher and his delivery has not changed!! Dr. Becher traced the origin of ACOEP in 1975 (however, there was mention in his presentation and documentation that ACOEP origin might have been as early as 1973) through the present. On June 22, 1975 at Parkview Hospital in Toledo, Ohio six physicians: Richard Ballinger, DO, James Budzak, DO, Robert George, DO, Anthony Gerbasi, DO, Robert Hambrick, DO, and Bruce Horton, DO met as a committee to formulate ACOEP. A letter was sent to the then AOA executive director, Edward Crowell, DO expressing their intent to form ACOEP. Membership criteria were established as was membership categories. The first Board of Directors of ACOEP consisted of the following nine physicians: Richard Ballinger, DO, James Budzak, DO, Donald Cucchi, DO, Robert George, DO, Anthony Gerbasi, DO, James Grate, DO, Robert Hambrick, DO, Bruce Horton, DO, and Scott Swope, DO. The first officers of ACOEP Board of Directors were: Chairman Bruce Horton, DO; Vice-Chairman Anthony Gerbasi, DO; Secretary Richard Ballinger, DO; and

Treasurer Robert Hambrick, DO. The first Board of Directors Meeting was held at the home of Bruce Horton, DO in Toledo, Ohio, on October 26, 1975. On November 10, 1975, during the AOA Convention at the Las Vegas Flamingo Hilton Hotel, a meeting to determine “interest” for the plan to create ACOEP was held. The first EM CME lectures were held with approximately 50 physicians attending. The meeting was chaired by Robert George, DO. Nine Board of Directors were nominated and elected. A support petition was sent to the AOA. Membership criteria and application and dues were proposed. And, the office was to be located in Toledo, Ohio. The first official Board meeting was held on February 15, 1976 in Toledo, Ohio. Board members attendance and term lengths were defined. The office was set up, equipment was purchased and banking procedures were established. Also, active membership was decreased from 5 years to 3 years full-time experience. March, 1976 brought the development of a membership survey, planned educational program and documents sent to the AOA formally requesting recognition as new affiliate “American College of Osteopathic Emergency Physicians.” At the Board Meeting on June 13, 1976 the College and membership brochures were proposed and the first CME program was planned. Membership was at 76. On October 2, 1976 the first CME was held in Cleveland, Ohio. Dr. Budzak was the program chairman and 156 physicians attended. The April 14, 1977-CME program in Tampa, Florida had 150 physicians in attendance with 76 members. The membership voted to hold the annual membership meeting with the AOA convention and the Constitution and Bylaws were approved by the membership. Committee Chairs were appointed and Residency Standards proposed and sent to AOA-COPT for consideration. At the Board Meeting on June 24,

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1978, there were 101 active members and it was recommended that all Colleges of Osteopathic Medicine require Basic Life Support prior to graduation. In July 1978, the AOA House of Delegates granted a Charter of Affiliation with the AOA to the American College of Osteopathic Emergency Physicians and Residency Standards were approved. The fall of 1978 ACOEP recommended each osteopathic hospital establish a department of emergency medicine separate from any other hospital department. Each ED must have 24 hour physician coverage and all ED physicians have BLS and ACLS and have CME in emergency medicine. June 1979, ACOEP recommends the establishment of the American Osteopathic Board of Emergency Medicine to develop certification process for osteopathic emergency physicians. At the same time the AOA placed a moratorium on approval of any specialty colleges and certification boards. November 1979 had ABOEM draft their constitution and bylaws and 14 residency programs were approved. January of 1980 ACOEP relocated its office to Chicago. With the help of AOA dignitary, Archie Feinstein, DO, the Bureau of Osteopathic Specialists approves ABOEM Rules and Regulations in June 1980. The first residency exam was administered in June 1981 and in July of 1981, ACOEP sends its first representative to the AOA Board of Trustees meeting. The bylaws were first approved in 1978 and amended 11 times, most recently in 2005. 1983 had ACOEP’s first Fellowship awards. 1984 had the first executive committee conference call meeting and the establishment of 2 face to face board meetings a year. And in 1993, the first committee on Strategic Planning was formulated. Dr. Becher was not one of the original founding fathers but he and Dr Aranosian were instrumental in the formation and Editorial, continued on page 28

Christine Perry, D.O. Vice President, ACOEP-Resident Chapter, Member, Research Committee

Wanted: Talented Research Faculty As a young investigator, one of the most frustrating things to have happen is to have your research come to a screeching halt. As a resident representative, one of the most troubling features of our graduation requirement is that some training sites do not have staff either trained or interested in mentoring residents in scientific research or conducting it. Even training facilities with strong academic research capabilities run into trouble in this area. The ACOEP Research Committee is committed to helping residents fulfill and exceed the research requirements for graduation. More than just "getting the resident by," the Committee hopes to inspire young investigators to produce quality research worthy of publication in a well-recognized peer-reviewed journal.

To reach this goal, the Committee would like to establish a group of attending physicians, from teaching and non-teaching institutions who are willing to provide assistance in research. There are no criteria set for the amount of involvement you can or need to provide. Any participation by a faculty member in a resident-driven research project is like putting high octane gas in your engine, it goes faster and runs a little smoother. The Committee and I, its Resident Representative, urge you to consider lending a hand to your future colleagues and future osteopathic principal investigators. A secondary goal of this Committee is to provide monetary compensation by grants to residents and new attending physicians with excellent, well-planned propos-

als who may need financial assistance. This can be further facilitated by any attending physician with a research background willing to lend their knowledge and patience to a project. In return you will have made contact with a future job applicant, a friend, as well as the potential for co-authorship or acknowledgement in a nationally published peer-reviewed journal. I sincerely hope that you will consider any and all levels of expertise and background in research. Please contact me if you are interested and I will assist you in answering questions or providing your name to the Chair of the Research Committee. We hope to have our list compiled no later than August 1st. You may contact me at cperry@atsu.edu, or at 734-626-0252.

Continuing Medical Education Calendar 2006-2007 September 5–11 NAEMSE 11th Annual Education & Trade Show Westin Convention Center, Pittsburgh, PA Cost and CME Varies For information call 412-920-4775 15–16 Oral Board Review Four Points Sheraton, Chicago, IL 10 hrs 1A Credit October 15 ACOEP Committee Meetings Las Vegas Hilton Hotel, Las Vegas, NV 16 ACOEP Membership Meeting Las Vegas Hilton Hotel, Las Vegas, NV 17–20 ACOEP Scientific Seminar Las Vegas Convention Center, Las Vegas, NV 25 hrs Category 1A Credit

January 2007 3–8 Emergency Medicine: An Intense Review Westin Hotel River North, Chicago, IL 40-41 hrs Category 1/1A Credit February 11–13 Program Directors Workshop The Siena Casino Spa Resort. Reno, NV 10–12 hrs Category 1A Credit 13-17 COLA Essentials The Siena Casino Spa Resort, Reno, NV 25 hrs Category 1/1A Credit April 10–14 ACOEP Spring Seminar Sheraton Wild Horse Pass Resort & Spa Chandler, AZ 25 hrs Category 1 / 1A Credit May 4–5 Oral Board Review Four Points Sheraton, Chicago, IL 10 hrs Category 1A

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Reports to the Membership The following is a summary of the Committee reports presented at the ACOEP Membership Meeting on Friday, April 21, 2006 at the Wigwam Resort and Spa in Litchfield Park, Arizona. President - Paula Willoughby DeJesus, DO, FACOEP The American College of Osteopathic Emergency Physicians is thriving. Two years ago under the leadership of Immediate Past-President Victor Scali, we had our first strategic planning Board retreat. Through a professional facilitator, we were able to introspectively look at our College. We discovered what we felt intuitively, that the American College of Emergency Physicians is a highly cohesive organization. As a medium sized national organization, we enjoy personal interactions with other College members. We remember our history of small beginnings and can relate to the maturation of its growth. We can identify with other members that are new to us because of their professional relationship with members with which we have common links. Our College has a responsive flexibility because of that connectivity that larger organizations envy. We see challenges that have such farreaching implications that outstrip our own surge capacity. We see the vision of who we are and what are members expect. Strategic planning has come out of the Board Room. It is no longer an episodic exercise but an ongoing vital process for our performance as an organization. This is the face of our College. We have begun to shape our strengths and position of leadership in the national arena. With this introspective review, we have turned to our future. At this meeting, the Board will vote to approve the organizational chart, the job descriptions for Board members, Board Officers, and Committee leaders. The next iteration of our strategic plan will be assembled with the Committee goals and objectives. The Committees will roll out their new process of leadership accountability with the development of their Project Progress Reports. The new process of convening regular meetings with the Committee Chairs and Vice-Chairs continues. This assures

real time connections for the Committees to the Board in addition to the assigned Board Liaison. It also allows a forum for Committee leaders to meet with each other to share common ground. The sleeping giant will begin to awaken. The building blocks of this College, the members, are moving into position to become the driving force of the College. Over the past year, your Board and fellow members have represented you to the AOA, other national organizations and internally on our own Committees. At the AOA, we were successful in stopping a resolution to allow general session CME to be counted for Emergency Medicine specialty CME credit and diluting our competency requirements. The agendas for the Membership Meeting and the Board’s deliberations have been retooled. Shifting focused interest reports to the appropriate Committees. Last year’s town hall meeting of six small groups generated important directives for the College. I have funneled these directives into discussion points for the Board and Presidential Initiatives. We have now awarded the contract to a new vendor to reformat and improve the website to provide better service to our members after encountering unexpected problems with previous service providers. As you are aware three ad hoc Committees, OMM, Geriatric Emergency Medicine and International Emergency Medicine, were organized. The OMM and Geriatric Committees will become educational initiatives under the Continuing Education Committee. We will consider the next step for the International Committee based on the Chair’s report to the Board. The Board is committed to providing committee venues to the members of this College to promote the advancement of our specialty. Face to face, interaction of Committee members as well as other mechanisms of communication is vital to the ability of the Committee to succeed. The productivity of our Committees not only at meetings but also throughout the entire year is crucial in fueling and revitalizing our College. Fiscally we are on solid ground. Dr. Kuchinski will present our financial data in

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more detail. We will pursue relationships that serve the members and strengthen the College. We have also focused on our external environment. We have maintained our relationships with the AOA, AOBEM, and our liaison organizations and continue to serve on two other national Boards. You will have the opportunity to hear their reports shortly. We have continued to represent the College at the working group of national emergency medicine organizations. This group consists of other national bodies such as NAEMSP, ACEP, AAEM, CORD, and SAEM. This group met at AAEM’s yearly meetings in February and will next meet in May at SAEM. It also includes the resident organizations and we will have our resident leader attend as well. The current representatives to this working group are Duane Siberski, ACEP Liaison, Peter Bell, and myself. Alex Rosenau will explore recommendations for a relationship between the Program Directors and CORD. The next leadership cabinet will start to take shape with our President-elect, Peter Bell. He will look to you to accept leadership roles as liaisons, in committees and process participation. I encourage you to welcome these challenges and join your colleagues in shaping your professional future. Thank you for your commitment and support to the College. Executive Director – Janice Wachtler This report covers the period of November 1, 2005 through March, 2006 and relates directly to the activities of the administrative operation of the ACOEP. Staffing The office of the Association has been functioning at full strength for more than a year, however, we have now had one staff person, our Administrative Assistant, leave abruptly in mid-March. Although her departure has caused some shifting in some mail response patterns, we have been able to pick up the slack, temporarily. Due to the short time between her departure and the staff ’s departure for Arizona, it was felt that Reports to Membership, continued on page 11

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Reports to Membership, from on page 9 it would be best to postpone interviewing for the position until after May 1, when staff can be added and trained. Membership The current total membership of the ACOEP is 2292, consisting of 1568 (68.4%) Active, Active/Charter and Active/Exempt Members; 15 (.7%)

Committee Assignments As we begin the appointment process for committees, the Office has developed a new tool for recruiting members to complete to inform us of their interests in working on committees. We have also developed a recruitment letter for those completing this form to confirm their interests and to obtain a CV to assist the President in his appointments. Each current committee member has been con-

Upcoming Projects Procedure Manual At this time, the Office is beginning to create a Policy and Procedures Manual that will allow us to move some of the policies stated in the current Constitution and Bylaws to this manual. This is being done in conjunction with the creation of a Bylaws document. Each Committee will have policies and procedures to act upon as this year progresses. Once approved, they will be incorporated into the manual. We anticipate that this will take approximately 18 months to accomplish. Member Materials Last year, the Office began compiling information to accompany the membership card. We changed our mechanism for distributing information regarding meetings and member benefits, and this is now being done following the receipt of payment. This year, we are continuing to develop material and are working on a folder of information that will be sent to members. Similar material will be developed to submit to prospective members. Chapter Reports

Life Members; 9 (.4%) Retired Members; 5 (.2%) Associate Members; 502 (22%) Resident Members and 180 (8%) Intern Members and 4 (.2%) Honorary Members. At this time we have gained a total of new growth (including newly graduated residents) of 131; as well as recapturing 13 members who have allowed their membership to lapse for a minimum of one year. However, as of March 31st we still have a total of 171 members who have failed to pay dues for the 2005-2006 fiscal year. The names of these members are being distributed to the Board. Donna Verga, Membership Coordinator, has been in contact with many of these members, to no end. During the past year, Ms. Verga has overhauled the membership area and we are now including blast emails to our arsenal of communication tools, however, some members have not furnished us with good addresses (electronic or street addresses) and we therefore have purchased addresses from the AOA for them. We will make one final attempt to contact them prior to June 1 at which time they will be removed from membership.

tacted to obtain their interest in remaining on a committee or to learn of new or different interests. Each Chair has also been contacted and a personal meeting with the President-elect has been arranged. A procedure is also being developed as part of the creation of a Policy and Procedures Manual that will establish a mechanism for committees to select members for terms of service, beginning in 2007, and once established 1/3 of each committee will be appointed annually to create continuity in the committee membership and procedures. Website Revival At this time, we have begun the rejuvenation of the site in December with several meetings to develop navigation and graphic design for the general web pages. However, we did hit a snag in the development of member pages when we learned that we would need to obtain a different web-based database. We are currently investigating the database purchase, however, the redesign has been restarted and the new look should premiere sometime in early summer.

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Student Chapter â&#x20AC;&#x201C; Joshua Linebaugh, President Student Dr. Linebaugh emphasized how important it was to have the website up and running to support COMNET which is very important to the students. He also presented a brief summary of the studentâ&#x20AC;&#x2122;s educational plans for the spring and fall meetings. A brief discussion was held as to the development of a national mentor program that will link mentors with both the membership and GME or program director committees. Resident Chapter Brandon Lewis, D.O., President Dr. Lewis reported that the resident committees have been reactivated and that they are very anxious to work with the ACOEP to redevelop the resident pages. He reported that the Resident Chapter is planning two workshops at the fall conference. He reported that the two resolutions submitted to the CGME were returned, however, the Chapter has submitted a request for support by the ACOEP to submit to the AOBEM. He also reported that the

Chapter has submitted a resolution that was approved by the Board, to endorse the early entry of residents into the certification process. This resolution will now be submitted to the AOBEM for consideration Affiliated Organization Reports Foundation for Osteopathic Emergency Medicine – Victor J. Scali, D.O., President I am happy to report that the Foundation is alive, well, and making progress toward the financial growth and security necessary to increase the number of research grants awarded in all categories. Through the general support of our ACOEP members, nearly $20,000 was donated during the third and fourth quarters of 2005. These donations will form a solid base for our Capitol Campaign to be initiated in 2008. The Board is currently seeking three RFPs for companies specializing in corporate notfor-profit fundraising. Corporate sponsorship will also play a key in achieving our goal of a financial self-sustaining research and education based foundation. In a recent meeting with corporate leadership

at Schering-Plough Corporation, there was a strong interest in establishing a grant for cardiovascular research. The Board of Trustees during its October 2005 meeting approved moving FOEM assets to The Vanguard Group which should result in significant savings in transaction and fund management fees. Cost-effective administration will continue to be the charge of the treasurer and officers of the Foundation, maximizing the research dollar. Work continues and progress is being made on completing the databases of the Consortium by ACOEP Emergency Medicine Residency Programs under the leadership of Mark Foppe, D.O., FACOEP, Research Consortium Director. Pharmaceutical companies continue to show interest in this complimentary FOEM research tool for choosing sites for national multi-center trials. Again, let me express the deep appreciation of the Board of Trustees for your past, present and future generosity in supporting the research and educational initiatives of the Foundation.

AOBEM Report - Bryan Staffin, D.O., FACOEP., Secretary, AOBEM On behalf of the American Osteopathic Board of Emergency Medicine, I would like to thank you for providing AOBEM with the opportunity to update you on its activities. With the closing of 2005, AOBEM completed the second year of the new process of Continuous Certification in Emergency Medicine (CCEM). As is expected with change, questions are being forwarded to AOBEM by its diplomats in regards to CCEM. AOBEM is appreciative of the constructive feedback it has received from ACOEP’s membership. The future will bring up additional questions as our diplomats continue towards recertification via CCEM. AOBEM looks forward to assisting its diplomats in the process of CCEM. AOBEM wishes to thank the ACOEP Board of Directors for allowing AOBEM the opportunity to address these issues via ACOEP publications and ACOEP general membership meetings. The body of our report is as follows. Membership Reports, continued on page 14

Don't miss these deadlines! For the 2006 Annual Resident Oral Abstract & Poster Competition and Student Case Competition Deadlines for All Applications is July 31, 2006 Notification for acceptance will be September 1 For more information or to request an application along with the guidelines, email donnaverga@acoep.org or call 312-587-3709.

2nd Annual Residency Exposition Hosted by ACOEP-Student Chapter Students are invited to attend and network with representatives from AOA-Approved Emergency Medicine Residency Programs Monday, October 16th 8:00 a.m. to Noon Las Vegas Convention Center Las Vegas, NV

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Guest Column

Gregory Christiansen, D.O., FACOEP

Warning: Physician Shortage Ahead Have you ever commented on how busy your shift had been? I, personally, have never had the opportunity to ‘sleep in’ during a night shift. It seems every corner of the country has stories of an Emergency Department with long waiting times, high patient volumes, issues with institutional diversions resulting in work stress and fatigue. Staffing shortages and job satisfaction are only a small contribution to the negative practice environmental index reported by the Massachusetts Medical Society. Did you know an index of ‘negative practice indicators’ existed? We fight with our bosses, curse the administration, blame the legal system and despise the government for the maelstrom we call our work environment. It all seems overwhelming and out of our control. My neighbors call me crazy for making a career out of the chaos. But in an almost blinded fashion, we push on day after day to provide the best care available for the sake of our patients. Who will follow us in this endeavor? According to the Graduate Medical Education Advisory Committee in 1981, we should have a physician surplus. The Council on Graduate Medical Education (COGME) summation reports for the period between 1992 -1999 reiterated the point; there are plenty of physicians to serve the needs of the nation. They told us the target number is 145-185 physicians per 100,000 populations. Then, why do we have the ‘need’ for physician extenders who lack the depth of training a physician possess, if we have enough physicians? And, why do we have long waits for our patients and trouble finding a specialist on call to do the specialty work? There shouldn’t be any need for diversion with adequately staffed emergency departments yet the country is plagued with overcrowding and a lack of capacity. The Government tells us we have the capacity and ability to meet disasters and calamities as they occur, just read the recent response report for the planning of a pandemic event. Well, COGME reversed it position in

2004. We in the trenches knew the reality that the available physician supply differed from the official position. The older guys are getting out because of the ‘negative work index.’ There are not enough specialty residency-trained doctors to do the job. The population is aging and utilizing more services. Government and financial pressures limit access causing more severe disease states. Additionally, physician extenders cannot meet the need, simply based on the fact that they are not adequately trained to meet the level of expertise acquired and required in physician training. Conclusion, we need more residency-trained specialty doctors in our ranks! COGME noted a future 15 year physician shortage and recommended a 15% increase in physician supply translating to roughly 3,000 additional medical students. In 2005, the Association of American Medical Colleges (AAMC) agreed the increase was necessary. The problem is the Graduate Medical Education (GME) committees have not reacted. They are bound by the Balanced Budget Act of 1997 capping training positions at 1996 levels. As a result, all of these new medical students will have to compete for a limited number of available residency training positions. Some of the residency training positions may go preferentially to U.S. trained students, thereby displacing foreign trainees from these opportunities. Others may benefit from the 2005 redistribution of residency training sites. However, there are not enough funded positions to meet training needs of the influx of students and therefore cannot meet the physician supply needs. Additionally, redistribution and affiliation training rules are so cumbersome, that they effectively restrict our best facilities from doing what they do best; provide top-notch physician training. The notion of only allowing opportunities to expand new training facilities in rural venues is fatally flawed. Most rural health facilities and systems lack the requirements to pass training inspection standards and cannot

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adequately provide the training exposure of urban centers where the expertise resides. Additionally, COGME also misstepped by failing to include emergency medicine as a specialty in need of additional work force. They believe emergency medicine transition levels are adequate. The flaw lies in the fact that the specialty has made the transition from certification ‘based on experience’ to a more appropriate certification ‘based on training.’ There needs to be more certified ‘based on training’ physicians. Using my car as an analogy to the medical system, at 10 years old and 150,000 miles later, my car gets the same gas mileage as most new cars. With the lack of efficiency and willingness to adapt, it’s no wonder we have fuel problems. Congress did not preplan this expected outcome in supply and demand. It is no surprise that there are physician shortages. Since Congress traditionally reacts to catastrophic problems, we need to let Congress know we have a catastrophic problem. We do not have the ability to meet to public need for adequately trained physicians. We cannot support the care necessary for a pandemic, disaster, or catastrophe. We are not meeting the current demand now, otherwise we would not be over-capacity and on diversion. I would not have to have the ICU patient receive all of his or her ICU care in my emergency department. It is a national problem and Congress will have to face the fact that the 1996 budget and training support levels are inadequate for the needs of our contemporary work force problems. I suggest training opportunities be increased in facilities where accreditation requirements can be met or exceeded and where the service shortage exists.

Membership Reports, continued from page 12 AOBEM Examinations 1. Primary Certification in Emergency Medicine 2. Certification of Added Qualifications 3. Continuous Certification in Emergency Medicine Primary Certification in Emergency Medicine Part I The written portion of the primary certification process was offered this past February. 166 candidates participated in the exam. 140 candidates passed the exam for a pass / failure rate of 84.3 %. A separate report has been forwarded to the ACOEP’s Executive Director indicating the pass / fail rate by osteopathic emergency medicine program with the intent that this information will be shared with the ACOEP’s Graduate Medical Education Committee. Part II The oral component of the primary certification process was offered this past November 2005. 68 candidates participated in the exam. 63 candidates passed the exam for a pass / failure rate of 92.7 %. A separate report has been forwarded to the ACOEP’s Executive Director indicating the pass / failure rate by osteopathic emergency medicine program. Part III The clinical component of the primary certification process is currently ongoing. The 2005 Part III was completed in October. 63 candidates submitted cases for review. 54 candidates passed (1 failure, 8 incompletes) for a pass rate of 95%. The candidates that successfully complete the final component of the primary certification process will be recommended for certification by AOBEM to the Bureau of Osteopathic Specialists (BOS) this coming June 2006. With the approval of the Bureau of Osteopathic Specialists, the candidates will then be presented to the AOA’s Board of Trustees (BOT) in July 2006 for certification in emergency medicine. Upon the approval of the BOT, the candidates will be granted certification in emergency medicine by the AOA.

Certification of Added Qualifications The next offering of a CAQ in Medical Toxicology will be in 2007. The deadline for application is December 1, 2006. The next offering of the CAQ in Emergency Medical Services will be this June 2006. A conjoint examination committee under the direction of the BOS administers the CAQ in Sports Medicine. AOBEM has participated in the conjoint examination process since its inception in 1996. The examination is given yearly at the AOA convention.

Continuous Certification in Emergency Medicine COLA 1 came online in January 2004. As of April 10, 2006, 452 diplomats have registered for the COLA. The diplomats that have successfully passed a COLA will receive CME via the ACOEP. COLA 1 will no longer be available as of January 1, 2007. COLA 2 came online in January 2005. As of April 10, 2006, 288 diplomats have registered for COLA 2. COLA 2 will expire on January 1, 2008. COLA 3 came online January 1, 2006. 58 diplomats have registered. COLA 3 will expire on January 1, 2009. Membership Reports, continued on page 16

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Domestic Preparedness

William Bograkos, D.O., FACOEP Member Police Physician Section, IACP

Homecoming “The Way is in training” “also by training, you will be able to freely control your own body”- Miyamoto Mushashi (1584- 1645) Go Rin No Sho, A Book of Five Rings. Japan’s Kensei or “sword saint” wrote “a guide for men who want to learn strategy” and listed nine broad principles in the “Way” of strategy. 1. 2. 3. 4. 5. 6. 7. 8. 9.

Do not think dishonestly. The Way is in training. Become acquainted with every art. Know the ways of all professions. Distinguish between gain and loss in worldly matters. Develop intuitive judgment and understanding for everything. Perceive those things that cannot be seen. Pay attention even to trifles. Do nothing that is of no use.

Miyamoto Musashi was one of Japan’s most renowned warriors. Three hundred sixty years after the “Classic Guide to Strategy” was written a strategic question confronts today’s leadership - “how do we greet our returning warriors?” Many of these soldiers, sailors, airmen, coasties and Marines deployed from a Law Enforcement culture with “code” and principles, changed into a different uniform and carried a shield made from past “lessons learned”. Codes and principles are “wired” in the higher neocortex of the brain. Past lessons learned are carried throughout the nervous system of all people. Today’s Reserve Component attracts personalities from the First Responder Community. These men and women believe in the mission to “serve and protect.” Many deploy and many return to their careers in civilian Law Enforcement. The question for management is how do we reintegrate them? And the question for leadership is how do we greet them?

I have deployed as a Peacekeeper and as a Division Surgeon post 9-11. The Division is an appropriate Command of a Major General and the strength of a Light Infantry Division is about 10,000 soldiers. Ultimately, the Major General (Leadership) is responsible for the health and welfare of his troops, but the Division Surgeon is responsible to the Command for the soldiers who serve the command. The Police Chief is the Commanding Officer of his or her Force. The medical department or medical advisor is often contracted or absent especially in smaller Police Departments. However, the Police Physicians and Police Psychologists Sections of the IACP can and should serve as a source of information on “Homecoming” and “Operational Stress Reaction.” The Civil-Military Section can also serve as a source for “lessons learned.” The historical “lessons learned” from military Emergency Medical Systems / Tactical Emergency Medical Support and civilian EMS/TEMS are constantly reviewed in Training Sections. Our current US Surgeon General, Dr Richard Carmona, was an advocate and pioneer of Tactical Emergency Medical Support in the 1970’s. Today with recent deployments and “Homecoming,” the time is right to develop a stronger Psychological Emergency System (PES). This is especially important as we coordinate and collaborate in All Hazard Disaster Preparedness efforts. Both TEMS and PES have a place within NIMS (National Incident Management System) under Operations. Let’s return to the essential piece of the “system” - the officer/service member. Welcome your officer back home and listen to him or her, the U.S. has changed, as has your town or city during the time of deployment. As you know, many have been deployed for a year to extreme conditions. Stressors of extreme climate, sleep adjustments, and other basic needs continue after 12-hour shifts and

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specific missions in country. The changes seen in the physiology of Police Trauma Syndrome1 should be reviewed and compared to Operational Stress Reaction, during mandatory training of every officer who is asked to serve and protect his or her community. Every student of Police Science is familiar with some basis of the Autonomic Nervous System. Every human being has experienced the “fight or flight” mechanism. However, First Responders run in when everyone else runs out. With situational awareness, the neocortex is still “on.” We are now discussing the neurology and psychology of behavior. Hard “wiring” separates First Responders from those we serve. Deployments: “Peacekeeping,” “Peace Enforcing” or “Direct Action” affects our neurophysiology in a way that should be discussed in training pre- and post- deployment. This “brain & behavior” should also be discussed with those we trust. Homecoming for service members may include a formal welcoming back to the Police Department, may include pairing the officer who has been away from home with a mature partner to facilitate “reintegration,” and may include specific training and education on post traumatic stress disorder (PTSD) and/or Police Trauma Syndrome. Returning home from mass graves, military operations in urban terrain (MOUT) or any deployment means the service member survived the deployment. Be aware that survival guilt may be carried home in the service members “ruck” or duffle bag. There needs to be an opportunity where they can put that “ruck” down and try to let go. When we “repress” we often “depress.” Leaders need to focus on attentive, active listening skills. Every deployment changes those who deploy as well as those left behind. They don’t need to be labeled Homecoming, continued on page 30

Membership Reports, continued from page 14 Recertification In September 2005, 67 diplomats participated in the formal recertification exam in emergency medicine (FRCE). 66 passed the oral component and 64 passed the written component. The next FRCE will be offered in September of 2006 in Chicago. The deadline for application is May 27, 2006 for those diplomats that wish to recertify. Diplomats with certificates that expire in 2005 and 2006 have been notified by AOBEM of the FRCE’s availability. In 2006, diplomats with certificates that expire in 2006 and 2007 will receive notification of the FRCE’s availability As of April 10, 2006 there are 1,471 diplomats certified in emergency medicine by the AOA. The Future It is expected that in 2007, AOBEM will see the implementation of a computerized Part I examination that will be offered across the country at multiple computer centers. AOBEM is currently discussing the implementation of this new process with NBOME. In addition, AOBEM is expecting to digitalize a portion of the Part II examination beginning June 2006. In closing, AOBEM is appreciative of the support it receives from the ACOEP. The mutual cooperation and support the two organizations provide to osteopathic emergency medicine will ensure a future of excellence. What is . . . Continuous Certification in Emergency Medicine As of January 1, 2004, the episodic recertification process in emergency medicine converted to a 10-year, continuous format. A diplomat receiving a certificate in year 2004 immediately became eligible to participate in CCEM. In the year 2014, this diplomat can than elect to complete their recertification by participating in the Formal Recertification Examination (FRCE), the fourth component of CCEM. Diplomats with certificates that expire prior to 2014 are being phased into the CCEM process (see table 1) if they desire to recertify. CCEM consists of four components over the 10-year period of continuous certi-

fication. The components are as follows: 1. Evidence of Professional Status 2. Evidence of Practice Status 3. Evidence of Participation in Lifelong Learning 4. Demonstration of Practice Performance and Cognitive Knowledge The professional status component is fulfilled by providing evidence of an unrestricted, unqualified license to practice medicine. The practice status component is fulfilled by providing evidence of the active practice of emergency medicine or its related activities. The third component is fulfilled by the participation in and successful completion of the required number of Continuous Osteopathic Learning Assessments (COLA). The fourth component is fulfilled by the successful completion of the FRCE. Upon the successful completion of the fourth component of CCEM, the diplomat is issued a new 10-year certification in emergency medicine by the AOA. COLA’s Each COLA is a 40 item web-based exam covering a portion of the core content of emergency medicine (see attachment). References and suggested readings for each COLA are available at AOBEM’s website www.aobem.org. In addition; these references and suggested readings are shared with the ACOEP CME committee the year prior to the COLA’s offering. The exam is an untimed, unproctered exam. The exam is intended to be taken at the convenience of the physician at his or her own computer. The COLA will assist

Table 1 Certificate Expiration Date

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

# COLA’s attempted

0 0 1 2 3 4 5 6 7 8 8 8

# COLA’s passed

0 0 1 2 3 3 4 5 6 6 6 6

the physician in their review of a specified area of the core content. Each COLA will be online for three years. The diplomat has three opportunities to pass an individual COLA though, given the fact that the exam is untimed and unproctered, it would be unlikely that the three attempts would be required. FRCE The fourth component of CCEM is the one-day FRCE. The FRCE consists of an abbreviated written exam and an abbreviated oral exam. These written and oral components are different then the Part I and Part II components of the primary certification process. They are designed to assess a recertifying diplomat’s cognitive knowledge and practice performance. Committee Reports

Membership Reports, continued from page 18

Table 2 YEAR

Core Content Areas Covered

2004

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

2005 2006 2007 2008 2009 2010 2011

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IMPLEMENTATION OF PART D: THE PHYSICIAN’S PERSPECTIVE Well it happened; we launched the biggest federal healthcare program since the original Medicare program was began in 1966. A 720 Billion dollar program, open to the 41 million people who currently qualify for benefits under the Medicare program. As required by the statute that created the benefit we started to fill prescriptions before the sun rose on January 1st. In fact Part D beneficiaries filled 6.5 million prescriptions in the first 10 days of January. Was it easy? No. Did it work smoothly in every case? No. But even in those first few chaotic days of beneficiaries without paperwork, flawed databases

to 14 percent per year. We hope that the PDPs will be able to moderate this growth. They can only achieve this by altering physician prescribing practices, and tiers and prior approvals are the only effective tools they have to modify what happens when the tip of the pen comes into contact with the prescription pad. For this reason prior approvals and tiers are not going to disappear but we have discovered that a large percentage of them were imposed because of plan concerns about inadvertently paying for a drug that should have been paid for by part B. We have taken

the task of obtaining the appropriate form when a prior approval or exception must be requested. We are working to expand the use of a standard form we have developed for the majority of requests but some drugs require a drug specific, disease specific form to collect clinical information necessary to justify the prescription. We have instructed all plans that by March 28th they must have all of their forms accessible on one webpage. As soon as that work has been completed we will list the URLs for those pages on the CMS website. Office staff will be able to go to the website, download and print the form

and overworked pharmacists the vast majority of patients got their medicines. Let’s start by thanking the pharmacists, physicians and other providers, the patient patients, the computer technicians and all the people who rolled up their sleeves and persevered. Now we are a month and a half into the benefit and we can start to work on the parts of the program that doctors and other prescribers find burdensome. Our weekly national provider conference calls and our work with the AMA and the specialty societies have given us a short list of issues. 1) Prior approvals and exceptions are burdensome, the number of drugs affected must be minimized and the process streamlined. 2) Multiple formularies are hard to keep straight 3) Multiple forms, plan specific and drug specific add to the complexity. Let’s look at each of these issues and some solutions. Drug spending has been increasing at 13

steps to make these prior approvals go away. The prior approval for a three dollar prescription for prednisone should soon be a thing of the past. Physicians and other prescribers, particularly those practicing in urban areas must contend with multiple formularies. These formularies are accessible through the CMS website but the simplest way to make sure your prescribing patterns comply as much as possible with the patient’s formulary is by using the free software from epocrates (www. epocartes.com). This software can be loaded into a PDA or used on an internet connected desktop. Not only will it give you the formulary information for a drug you select but it will recommend other drugs which are more favored on the formulary in question. We are working with epocrates to make this tool even more useful in the near future. The final issue to discuss in this article is

and place it on the patient chart so that the doctor can complete the form during the patient encounter. Once completed the form can be faxed to the plan thereby avoiding a time consuming phone call. There are many other ways that CMS can reduce the administrative burden part D has imposed on doctor’s offices. We are interested in hearing from you. You are welcome to join our provider’s conference call next Tuesday at 2:00 PM Eastern time. The number is 1-800-619-2457 and the pass code is RBDML. Provider issues can also be communicated with us by email, our address is PRIT@cms.hhs.gov. We are grateful to the provider community for their patience and hard work and we promise to work just as hard to minimize the impact Part D has on the efficient operation of your practice.

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Membership Reports, continued from page 16 Continuing Medical Education – Anita Eisenhart, D.O., FACOEP, Chair The Committee met on Tuesday, April 18 to discuss the continuing education programs of the College. The Committee discussed offering the COLA Modules test after the COLA Essentials in February. A wireless venue would be required. A vicechair is also needed for the COLA Essentials. An editorial subcommittee was formed for the Intense Review, and speaker suggestions were also asked for. The Committee also discussed site locations for the Spring Seminar 2008. A recommendation was made to the ACOEP to keep the course in the Phoenix/Scottsdale area. The Committee also discussed changing the course format from Tuesday – Friday, instead of Tuesday – Saturday. The Committee recommended that the Spring Seminar be taken to 4 days instead of 5, but still remain at 25 credit 06-EM-471 5/2/06also5:21 PM going Page hours. The Committee discussed back to the paper format instead of the CD-

ROM. The Committee agreed to recommend to the Finance Committee to return to the paper format, and offer the CD-ROM as an option. The Committee voted and decided to partner with the New Hampshire Osteopathic Association for a joint conference in the New England area. Communications – Drew A. Koch, D.O., FACOEP, Chair The Committee met on Tuesday, April 18, 2006 in joint session with the Membership and Credentials Committee to discuss several issues related to the website development and database. The members received updates on the timeline for the new website design which will premiere on the new public spaces over the summer (Phase 1) and will be implemented during the first quarter 2007 in the Members Only pages (Phase 2) and completed with the ability to update database material in the Members Only Sections as the final portion of the 1 rebuild in the summer of 2007. Members learned of the need to

purchase a new database on which the member’s only sections of the web will be built and reviewed the dynamics of the four systems that were reviewed by staff. It was the decision of the members of both committees to recommend the purchase of the MAP program as the first choice providers and the Re-Members system as the second choice. At this time the committees split into two groups and the Communications committee began their review of the Presidential Initiatives, many of which they felt had been addressed numerous times in the past. The issue of the format of the front page is now handled by rotating articles with the most noteworthy taking the front-page spot. Article development was also discussed and the Committee will be inaugurating a “hot button” topic area for issues of high interest. Student and Resident sections are already prevalent in the publications and resident program information was solicited in the Membership Reports, continued on page 24

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AstraZeneca

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American College of Osteopathic Emergency Physicians AstraZeneca is one of the worldâ&#x20AC;&#x2122;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. Our track record of innovation includes leading treatments for gastrointestinal disorders, heart disease, cancer, central nervous system (CNS) disorders, respiratory diseases and pain and infection. 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 ÂŠ 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.

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Guest Column

Douglas Hill, D.O., FACOEP

Simplified Antibiotic Regimens in Emergency Medicine Bacterial and other infections are commonly encountered in the emergency department and other urgent care settings. Because precise identification of the etiologic agent is usually impractical and unnecessary in the outpatient environment, antibiotic selection is almost always empiric. This presentation will discuss recent advances, concepts, indications and resistance, and will outline a rational and systematic approach to antimicrobial selection for the emergency medicine physician in the outpatient setting. The emergency practitioner will also be able to determine the “Drug of Choice” for specific conditions that do require antibiotic therapy. The duration of antibiotic therapy for common outpatient infections has been debated for years. Recently, there has been a trend toward simplified and shorter course therapies. Many of the newer antimicrobial agents lend themselves toward this end, as they are broad spectrum, efficacious, and well absorbed, thus resulting in increased convenience and improved compliance. When a prescription is written and given to the patient, there is no guarantee that it will be filled or if obtained, taken as directed until completion. Patient acceptance involves many factors including the cost of the prescription, frequency and duration of the regimen, side-effect profile, taste, need for refrigeration, and timing regarding food intake. Widespread resistance to antibiotics among common pathogens is caused by many factors including indiscriminate and inappropriate use of these agents. It is likely that shorter courses of therapy would result in less total antibiotic use, and thus could decrease the development of resistance in certain circumstances. Following are discussed several simplified antibiotic regimens including single dose regimens, once daily dosing, and short course therapies. Upper Respiratory Infections Acute Otitis Media (AOM) is a common illness, especially in the pediatric

population. It is often viral in etiology and in many other countries, notably in Europe, antibiotics are not even initially prescribed for this condition. However, AOM remains the most common pediatric condition for which antimicrobials are provided. The most common bacterial causes of AOM are Streptococcus pneumoniae, Hemophilius influenzae, and Moraxella catarrhalis, the typical upper respiratory pathogens. The pros of prescribing antibiotics for AOM are proposed to include promoting a potentially short term cure, rapid pain resolution, prevention of mastoiditis and meningitis, and of course expectations of the parents. The cons include the risk to benefit ratio, emergence of drug resistant organisms, side effect profile, cost, and the knowledge that analgesics are usually effective. Traditional therapy for AOM has dictated a 10-day course of antibiotics usually with multiple doses daily. Short course or even single therapy would therefore be a beneficial alternative to improve compliance and satisfaction. • Ceftriaxone 50 mg/kg (max dose 1 gm) single injection IM • Azithromycin PO single dose 30 mg/kg • Azithromycin PO both 3 & 5 day courses Pharyngitis. The complaint of a sore throat is a common cause of patients presenting to the emergency department and other ambulatory settings. Pharyngitis is usually caused by a viral etiology. Group A beta hemolytic strep (GABHS) is the most common bacterial organism to cause sore throats. Differentiation between these causes of sore throat is important, and with the development of rapid antigen testing and the use of clinical scoring rules, costeffective and evidenced-based therapy can now be provided to the patient. A typical scoring system would treat empirically any patient with 3 out of 4 of the following criteria: Fever > 38o C, tonsillar exudates, tender cervical nodes, and the absence of cough. Those patients not meeting these criteria should be screened with rapid antigen testing with subsequent culture in the

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event of a negative test. • Benzathine Penicillin 1.2 million Units single dose IM (or 25 Units/kg) • Cefuroxime PO 250-500 mg BID 5 day course • Amoxicillin/clavulanate PO 5 day course • Azithromycin PO (Z-pac) 5-day course or 500 mg BID for 3 days • Clarithromycin or Telithromycin also in a 5-day course *Note: These shorter courses have been shown to eradicate GABHS but the prevention of Rheumatic Fever has not been well studied. Sinusitis. Rhinosinusitis usually has a viral cause, and most symptoms will resolve in 1-2 weeks without antibiotic therapy. Overuse of antimicrobial agents is very common with this disease complex and symptomatic therapy should be the mainstay of treatment. However, a small percentage of patients will develop a secondary bacterial infection and the etiology of these infections is again the typical upper respiratory organisms. • Azithromycin 500 mg daily for 3 days • Telithromycin 800 mg daily for 5 days • Levofloxacin 500 mg or Gatifloxacin 400 mg daily for 5 days • Trimethoprim/Sulfa (TMP/SMX) DS BID for 3 days Lower Respiratory Infections Bronchitis is a common diagnosis made in the emergency department. Frequently patients present with cough, congestion, or wheezing. Most of these infections are again viral, and there is little science to support the routine prescribing of antibiotics for this condition, especially in the non-smoker. There is a subset of bronchitis called acute bacterial exacerbation of chronic bronchitis (ABECB) with the patient exhibiting increasing breathlessness and purulent sputum production. Strict criteria define this condition and due to lack of space will not be discussed here. However, if antibiotics are felt to be Simplified Antibiotics, continued on page 32

Membership Reports, continued from page 18 past and will continue to be solicited in the future. A section on evidence-based medicine is also being solicited, as well as a quarterly governmental column written by Shawn Martin. The Committee decided to conduct a reader’s survey to determine what articles are being read most often and this type of survey would require the ACOEP to obtain a return postage permit that will be investigated by the executive director. The Committee was pleased to learn that Astra-Zeneca has again decided to fund a $10,000 grant for advertising to the College and will be furnishing the College with new center-spread information in the next few months. Advertising revenue has been increased and now matches or exceeds this grant. The Committee presented two resolutions to the Board of Directors based on the items mentioned above and the Board approved both resolutions. Emergency Medical Services – Wayne Jones, D.O., FACOEP, Chair The Committee met on April 18th and reviewed issues concerning the Committee. One of these concerns was the start of the 2006 Hurricane Season in June. The Committee asked that if any members have questions regarding preparedness or which organizations may best accommodate them, please see an EMS Committee member. More information will be presented at the AOA convention this fall in Las Vegas, Nevada. Topics in clued grant organizations, urban search and rescue and lessons learned from Hurricane Katrina. ACOEP is working toward a liaison relationship with the Department of Defense to provide education and training for disaster response. ACOEP board members and EMS Committee members met with a representative from FEMA at the Spring Conference. Bill Bograkos, D.O. will facilitate this relationship. Joe Nelson, D.O., FACOEP reported the state of Florida is investigating 5 cases in which ambulances were required to wait in the hallway of an emergency department for a prolonged time prior to the staff allowing turnover of the patient. The state is pursuing this as an EMTALA violation.

Several projects are ongoing and will be presented in the fall. A database for EMS policies is being formatted with prehospital RSI one of the first to be presented on completion. These will be available to members who are in need of standardized policy for their EMS system. Joe Nelson reported that RSI was a topic of discussion at the Florida Medical Directors Meeting and he would like to take comments on the topic back to that group. It was felt a position statement might be appropriate. The National EMS Scope of Practice document was released in September and sent on to NHTSA. The document changed significantly from the first draft and now mirrors most EMS systems. The document can be found at emsscopeofpractice.org. The Domestic Preparedness Subcommittee will compile a list of federal and state agencies that are available for participation in disaster preparedness. One of the problems seen during the past hurricane season was too many volunteers without training, insurance or equipment attempting to find an agency to deploy with. Residents in emergency medicine residencies have requested some structured learning objective so an EMS core curriculum recommendation will be considered in the spring. If approved, it will be sent to the GME committee for consideration. Finally, the education subcommittee discussed restructuring the Scientific Assembly lectures for 2006 and agreed on focusing on EMS events surrounding Hurricane Katrina. It will cover preparation, education, planning, implementation, search and rescue, and recovery. Graduate Medical Education – Douglas Hill, D.O., Board Liaison The Committee on Graduate Medical Education met in San Diego, California on February 10, 2006 to conduct its annual mid-winter meeting. The Committee considered two resolutions submitted by the ACOEP Resident Chapter dealing with resident attendance at national conferences. The first asked the CGME to consider the creation of a standard to require programs to provide 5 days of funding and protected time for each resident to attend a national CME meeting, and the provision of this time would be a factor on

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accreditation of the program. The second resolution sought to require programs to allow residents to seek CME opportunities during their senior year. The Committee reviewed each of these resolutions but could not endorse the creation on standards as they evaluate the educational quality of the programs and could not mandate internal funding issues. Additionally, the issue of CME could not be mandated because CME gathered during the time that a resident is in training is not counted by the AOA towards the amount of pro-rated CME required following the completion of residency. The Committee has suggested that the issue of funding and protected time be passed onto the Program Directors Committee for discussion at the program level. The Committee reviewed 8 currently approved programs for continuing accreditation; 4 reports on the correction of deficiencies in recently evaluated programs; increase requests from 7 programs and the approval of two new program directors. The Committee also evaluated requests from two hospitals for the establishment of new residency programs; both requests were deferred for further correction of deficiencies sited during the inspection process. The CGME is also responsible for evaluating requests for the acceptance of allopathic residency training, at this meeting, they evaluated two such requests, approving one and denying the other. It also evaluated two requests for training credit that can be accepted toward the completion of an emergency medicine residency; this is referred to as advanced standing. One request was returned to the program for the completion of the appropriate forms and the other was not accepted. The Committee constantly evaluates its documents and procedures for mechanisms to keep its evaluation process current. Items currently under discussion for possible inclusion in future editions of the educational standards are: the requirement for core faculty to be certified within the initial eligibility period as determined by the certifying board; the requirement for programs to have an assistant program director if the program number reaches a certain resident class size; clarification of “scholarly activities” for core faculty to include question Membership Reports, continued on page 26

MoneyTalk

Monica H. Masters and C. Brooks Farley, CIMA Financial Advisors, Smith Barney

Strategies to Help Cope with Higher Oil Prices June 2006 With oil prices up sharply during the past few years, many investors are worried about the effects of higher fuel prices on the value of their investments. Some have even asked if now is a good time to avoid stocks due to the surge in oil prices. High prices at the pump—and the headlines that often accompany them—shouldn’t prompt you to make big changes to your long-term investment strategy. It’s true that rising oil prices can contribute to a slowdown in the economy that sends stock prices lower. But those negative results may not be inevitable. Examining the 10 largest average monthly oil price increases from 1970 through July 2005, the Consulting Group found that the relationship between oil prices and stock prices is somewhat unpredictable from year to year. For example, in January 1974—the first year of the Arab oil embargo—oil prices soared nearly 135%. However, the S&P 500 fell a mere 1%. Then, in 1986, oil and stock prices moved in lockstep, rising 30.4% and 7.1%, respectively. In fact, stocks gained ground during 60% of the time oil prices rose. (Source: Standard & Poor’s, Federal Reserve Bank of St. Louis). The upshot: If you cash out of stocks during periods when oil prices rise, you could miss out on opportunities to help grow your wealth faster and achieve your most important financial goals. The Real Price of Gas It’s very likely that high gas prices during the past year or two have left you with less money to spend elsewhere—and that goes double for you SUV owners. What’s more, because consumer spending accounts for two-thirds of U.S. Gross Domestic Product (GDP) growth, a weak consumer can go a long way toward dampening corporate profits and pulling the economy toward recession.

But gas prices in the recent environment have not been prohibitively high. True, it might seem that way when you fill up your tank. However, gas prices are reported in nominal dollars—which can make current prices seem steeper and scarier than they really are. Example: The average price of gas in nominal dollars in 2004 was $1.92. But when factoring inflation into the equation, the price was $1.78. That’s 51 cents less than the $2.29 consumers paid for gas in real, inflation-adjusted terms back in 1981. Likewise, the real price of a barrel of oil back in July 2005 was $11.75, even though the nominal price was more than $60. (Source: Bureau of Labor Statistics, Federal Reserve Bank of St. Louis). In fact, when taking inflation into account, oil prices would have to hit approximately $90 per barrel—well above the current price—to match their previous highs back in 1980. Not the ’70s All Over Again If you lived through the 1970s, you no doubt remember sky-high oil prices, gas rationing and the resulting recession. The good news: The current environment is significantly different than it was back then. For one thing, the U.S. has actually reduced its oil consumption thanks to new technologies and conservation efforts. Oil consumption as a percentage of GDP recently stood at 4.1%, down from 8.5% in the early 1980s, according to the Department of Energy. Another key difference: Inflation today is extremely low by historical standards and nowhere near the double-digit levels that we experienced during the 1970s. That’s helped the economy weather the recent surge in energy prices with relatively little negative impact—which, in turn, has benefited the financial markets. In other words, we’re not reliving the ’70s. Given the current environment for oil and gas prices, you may want to consider these ideas: Stay fully invested. While there most

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likely is a relationship between oil prices and stock prices, it’s not always clear how they’ll interact. Fleeing stocks because oil prices are high and/or rising is essentially a dangerous game of market timing—and it may cost you in the long run. Stay diversified. Because it’s not always certain which types of investments will perform best during periods when oil prices rise, it’s prudent to build and maintain a well-diversified portfolio that offers exposure to the full range of asset classes—including largeand small-company stocks, fixed-income securities and cash. Such a portfolio may help position you to ride out oil price fluctuations and the financial market’s ups and downs. Stay focused. Don’t let media headlines or any short-term event—such as a spike in oil prices during a particular week or month—cause you to abandon your longterm investment strategy. Be opportunistic. Continuing focusing on sectors that provide opportunities that are in line with your investment objective. That said, you might want to limit the percentage of your total assets that you allocate to any one segment of the market in order to remain diversified and potentially reduce risk. 1 Past performance is not a guarantee of future results.

Standard & Poor’s 500 Composite Index is an unmanaged by commonly used measure of common stock total return performance. Small company stocks are subject to greater volatility than large company stocks. Diversification does not ensure a profit and does not protect against loss. This article is based, in whole or in part, on information provided by “the Portfolio Management Group of Smith Barney.’ Smith Barney and Consulting Group are divisions of Citi-

Membership Reports, continued from page 24 writing for the various examinations of the ACOEP and AOBEM; program evaluation and oral board examiner. Additionally, they are considering a policy for dually accredited programs that would require osteopathic physicians to participate in the osteopathic certification process, but prior to the development of such, legal issues would need to be clarified by the AOA. Also under consideration are the development of a segregated total form for programs and the revision of the basic standards to update them in several areas. Their next meeting is tentative scheduled for June 2006. Membership and Credentials – Murry Sturkie, D.O., FACOEP, Chair The Committee on Membership and Credentials joined the Communications Committee to review a research document put together by the ACOEP staff pertaining to the need for a new database. Jointly, the Committees supported the purchase of the MAP database and this resolution was presented and approved by the ACOEP Board. The Committee reviewed several policies for incorporation into the ACOEP Policy Manual and approved these items. The Committee also reviewed the current status of the membership and brainstormed new ideas to improve retention especially of the student and resident members. A suggestion for the development of Marketing Opportunities was presented and approved. The Committee also considered two members for Life Membership and deferred action on one request and approved the second. Pediatric Emergency Medicine – Anita Eisenhart, D.O., FACOEP, Chair The Committee met on Wednesday, April 19, 2006 and reviewed items related to this area of emergency medicine. The Committee received notice from the AOBEM that a survey was being conducted to determine interest in the establishment of a Certificate of Added Qualifications in Pediatric Emergency Medicine, as requested by the ACOEP after its meeting in October 2005. Response rates to this survey appeared to be good and the certifying board was scheduled to review the results of this survey at its meeting in June. To that end

the Committee developed draft eligibility criteria to provide to the AOBEM in the event that the Board seeks jurisdiction or joint-jurisdiction over this area of emergency medicine. Additionally, the Committee reviewed draft basic standards for an educational fellowship in the area of pediatric emergency medicine that it will be reviewing over the next few months and finalizing prior to the fall meeting of the GME Committee. The Committee also reviewed the draft criteria for the revision of the pediatric section of the core content and hoped to have this revision approved prior to its next meeting for potential submission to the Committee on GME and the AOBEM late this year or early next. This item was approved by the ACOEP Board of Directors and sent to the AOBEM for consideration at its next meeting. The Committee heard a report from the representative of EMSC and learned of the availability of grants and funding available

through this body for research in the area of pediatric emergency medicine. Practice Management – William McConnell, D.O., FACOEP, Chair The Practice Management Committee reviewed the goals and purpose of the committee as well as the Presidential Initiatives. Development of several policies, including making criteria recommendations concerning pay-for-performance plans, was discussed. Research will be done by several of the committee members to find what policies already exist by similar associations. A follow-up conference call was scheduled for Tuesday, June 13. Research – Juan Acosta, D.O., FACOEP, Chair The Committee met on Wednesday, April 19, 2006 to review items related to the area of research in emergency medicine. Membership Reports, continued on page 28

ACOEP has recognized Monica H. Masters

Financial Advisor Financial Planning Specialist (800) 621-2842, ext. 3338

and

C. Brooks Farley, CIMA Financial Advisor

(800) 621-2842, ext. 3285 As Financial Advisors for: Investments, Lending, Insurance and Financial Planning. Three First National Plaza, Suite 5100, Chicago, IL 60602

© 2006 Citigroup Global Markets Inc. Member SIPC. Smith Barney is a division and service mark of Citigroup Global Markets Inc. and its affiliates and is used and registered throughout the world. CITIGROUP and the Umbrella Device are trademarks and service marks of Citigroup Inc. or its affiliates and are used and registered throughout the world.

4.25 x 5.5

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Guest Column

Mark A. Mitchell, D.O., FACOEP

Keeping Up with Technology It is amazing to look back over recent history and see all the new innovations and technology that we now take for granted on a daily basis. We find ourselves so “connected” that regardless of where we are we can always be found. For many years I lived with a pager on one hip and a cell phone on the other. It was just recently that I retired the pager and just utilize my cell phone. Email is so accessible that I even have my email downloaded on my phone and receive it almost anywhere I am located. It is hard to travel these days without seeing many travelers with Bluetooth in hand. Likewise, there are numerous advances in medicine, many of which have a direct impact on emergency medicine. In many Emergency Departments the use of bedside ultrasonography is an accepted standard. The current machines are so compact that they are handheld. It was not so long ago that these smaller and more efficient machines did not exist and in order to obtain an ultrasound the patient had to be taken to a special area located in radiology. The design of many new high volume Emergency Departments includes a designated CT scanner. We are now seeing the availability of the 64 slice CT scanners with the ability to perform a CT coronary angiogram. This has the potential of revolutionizing the evaluation of patients who present with chest pain. Prior to disposition we can quickly eliminate the potential of significant coronary artery disease, pulmonary embolism, or thoracic aortic dissection. Thus we will be able to eliminate many unnecessary hospitals admissions and practice cost-effective medicine. Another area of radiology that is a relatively new development is digital radiology. This allows for the rapid acquisition of images by multiple providers simultaneously. It also allows for the manipulation of the image in order to improve the interpretation of the study. The film archiving ability also provides the ability to rapidly obtain old images for comparison. Off site physicians can also review the images to assist in the determination of appropriate treatment.

We find ourselves continuing to monitor and improve our processes in order to practice medicine as effectively and efficiently as possible. What is your turnaround time for obtaining lab results? Can you obtain results of cardiac biomarkers within 30 minutes? If the answer is “no” then you may want to evaluate your process and see what needs to be done in order to meet this standard. I am Medical Director at St. Joseph Regional Medicine Center in Milwaukee with an annual volume of about 60,000. After much evaluation and discussion we determined that the only way we could meet this standard was to put a “stat lab” in the Emergency Department. This is a joint effort with the Laboratory Department and we now are able to have lab results in a rapid manner. We utilize the Dade Behring Stratus CS which is a desktop machine that is able to perform cardiac biomarkers (CK and Troponin I), d-dimer, and quantitative beta HCG in less than 15 minutes. We also perform the following test in the Emergency Department: - - - - - -

Hemogram Chemistry panel BNP Urinalysis Urine Pregnancy Rapid Strept

We have a work group of Emergency Medicine providers in the greater Milwaukee area that are also working with the State to put into place a mechanism to streamline communication on patients. When the project is completed all the participating facilities will be able to have patient information stored in a central database. Therefore, when a patient presents to an emergency department the provider will instantly have computer access to their medical information from all sources within the metropolitan area. It will also be linked to the state Medicaid pharmacy database to show what prescriptions the patient has filled. The emergency provider will also know who the patient’s primary care provider is in order to arrange appropriate follow up. Most of the cost savings will come from not duplicating test and examinations that the patient has already had performed. It is exciting to see where we have come in the area of technology, but it is also exciting to imagine where we will be in the future. We are moving forward at a very rapid pace and it is hard sometimes to keep up. We have to be the leaders in our institutions to make sure that our share of the capital improvement dollars is designated to the Emergency Department to make the process of taking care of patients more effective.

Avis, Always Providing New Ways To Save You Time and Money. Your membership in the Avis Association Program entitles you to a host of special Avis services and discounts that can save you lots of time and money. What’s more, you’re eligible for savings up to 10% off Avis Association Select rates and 5% off promotional rates at all participating locations. Shop around. You’ll find Avis has very competitive rates. And with the Avis Wizard System, you can receive our best available rate when you mention your ACOEP / Avis Worldwide Discount (AWD) number: T024500 Isn’t it a relief to know that Avis moves just as fast as you do? For more information and reservations, call 1-800-331-1212. And remember to mention your ACOEP / Avis Worldwide Discount (AWD) number: T024500

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Membership Reports, continued from page 26 The Committee received the report of the representative of the EMSC and learned of research opportunities through the PECARN network as well as EMSC. These opportunities included development grants, partnership grants and targeted issue grants. The EMSC also provides grants on funding sources which are short term (1 year) grants of under $100,000 total, however all grants in this area are limited to research activities related to emergency medicine for children. The Committee reviewed the Research Curriculum available through the Kirksville School and recommended that the chair contact the appropriate on-site personnel to determine if problems noted in the online program were corrected to our satisfaction. If these were not corrected, the chair was instructed to seek reimbursement from the Kirksville School for monies paid by FOEM for the procurement of 300 passwords. The Committee reviewed the potential for the creation of a research module curriculum to supply to osteopathic residency programs, if the Kirksville project does not move forward. Members of the committee were asked to solicit program models from alternate sources to use as templates for the development of such curriculum. The Committee is seeking to establish a Research Mentors Network. The network would work with current existing solicitation for educational mentors for students and would allow such mentors to be noted on the ACOEP website in the event that students, residents, or practicing physicians sought advice on projects or methodology. The research mentor solicitation would appear in issues of the Pulse along with the solicitation of educational mentors planned for future issues. The Committee reviewed and refined the methods of reviewing abstracts and cases for activities at the Fall Conference and asked that each program director and assistant director be provided with a reminder notice of the competitions, deadlines and paper format. The Committee also sought to reformat its evaluation sheet for the paper competition and recommended that this be done prior to the receipt of papers for the student case competition and the resident paper competition.

The Committee asked that a statement on conducting appropriate journal club activities be developed to assist programs in making this type of activity more beneficial to residents and attending. Undergraduate Medical Education Howard Friedland, D.O., FACOEP, Chair The Undergraduate Committee received the report given by Josh Linebaugh, Student Chapter President. Donna Verga, Membership Coordinator, presented an update on the Mentor Program along with the Mentor/Mentee guidelines, designed to help the program along. The Student Case Competition was also reviewed and the announcement was revised to include a suggested format to assist students with the preparation of better quality case presentations. Advances for the next version of the Student Lecture Series CD-ROM were also discussed and follow-up will be presented at the next meeting. The Goals and Objectives were reviewed and revised to fit with the new goals founded in this meeting.

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Editorial, continued from page 7

growth of the College. This keynote lecture was important for the members to gain insight into the College’s history and appreciate the struggles it faced in its earlier years and how it has grown to the second largest specialty college in the AOA. Dr. Becher not only lived and practiced emergency medicine in ACOEP’s infancy but he is still actively involved in the practice of emergency medicine today. He shared with the members during his lecture many documents i.e. programs, letters, tickets, brochures, and pictures etc. that were an integral part of ACOEP’s history. Hopefully, ACOEP’s future will be guided by individuals like Drs. Ballinger, Budzak, George, Gerbasi, Hambrick, Horton, Becher, Aranosian and Field who had the vision and foresight to lead ACOEP where it is today.

Guest Column

Wayne Jones, D.O., FACOEP

To What Point I received an e-mail regarding my last article The Dwindles, The Pulse, April 2006, from a medical student that I felt begged a response. Here is an excerpt of his letter: “I've volunteered in nursing homes and of course worked in hospitals...and my father has focused on the aged population and palliative care in his practice...so my experience with the patient population you wrote about is reasonably extensive (at least for a second year med student!). My question to you then is, by describing the patient's condition as "the dwindles" do you think that results in physicians conceding the patient's care? In other words, if the doctor assesses an elderly patient as, in the doctor's mind, entering the 'final stage', do you think they risk a little complacency with the remainder of that patient's treatment? I only ask because I'm embarrassed to admit that I probably fell into that trap over the years and want to do whatever possible to avoid repeating the same...any recommendations?” My response back was that the condition “is what it is.” I was not recommending care. I thought I was highlighting a ribbon of common knowledge. I must admit it does bring up many ethical questions. A couple of years ago I gave a lectureexamining end of life issues. I followed a popular generational categorization of Americans including WWII children (the greatest generation), post war children, baby boomers, Generation X, and the “me” generation (as in my 24 year old daughter). I gave a tongue-in-cheek quiz asking which “generation” of Americans is described in each of these statements: • Owns 79% of America’s financial assets • Owns 62% of Wall Street • Visits malls more often than other “generation” • Dine out 4-5 times a week • Spent 2 trillion on goods last year • Over 40% of consumer demand • 74% use internet to find health information

• Spends $29 billion on grandchildren last year The answer to all the above was the baby boomers. So, who do you think drives healthcare? Who fears disability and dependency? Who dominates ethical decision-making? And who read my article? Well, thankfully, at least one reader was from generation X (which, by the way, may be our next great generation). We need to understand that what we expect from any situation depends on our life experience. The economy, healthcare, and technology have grown exponentially since the 1920’s creating several generational divides. The “pre-boomer” generations are very accepting and optimistic. They were defined by WWII, experienced delayed gratification, and benefited from good economic growth. They have been labeled the greatest generation. Baby boomers want fast professional second opinions. They were the TV generation; marked by Vietnam, the Kennedy assassination and Watergate. They value individualism and question everything. Remember the term “I’m OK, you’re OK”? They had iron curtains, Mickey Mouse, bell-bottoms, disco, calculators, and men on the moon. Generation X wants fast technology based third opinions. They are the “latch key kids” where both parents left for work each day. They enjoyed Daisy Duke, Boy George, AIDS, Reaganomics, and HBO. They were children of divorce. The “ME” generation will seek webbased solutions. Born after 1980 they experienced a more caustic environment. The first schoolteacher died on board the Space Shuttle Challenger as all the “ME” generation watched from their school desks. Jim Baker got 45 years for defrauding God, Rock Hudson died of AIDS, MTV and Rap was “invented,” ET phoned home and mankind became humankind. So back to the original question, the disease is what it is. When we discuss end of life issues and disease processes, they are

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just that, end of life. There was, in earlier generations, a dignity with dying. It was a family based experience. The patient remained within their warm family setting; they could hear conversation and laughter from familiar voices; experience a caring hand; be comforted by smells from the kitchen; feel secure in knowing who would come if a need arose; and know their loved ones would be there at the final moments to say good bye. And yet, we now feel we must decide their end. They should not, cannot, die. I must remind everyone that it is our loss we are feeling, not theirs. We all want a “good death.” One where we suffer no pain, we are able to accept our illness, where family understands and embraces our frailty, and where medical understanding allows our will and not theirs. That is why end of life is just that. A right we are all allowed. An experience we must face and pass through. One moment in time, we want acceptance from others. One that is our decision based on our generation and none other. It is said most eloquently in Latin; decido adeo exanimus, to fall to that point lifeless. We all begin the fall as soon as we are born. But to what point?

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Homecoming, continued from page 15

or diagnosed they do need an opportunity to unpack that “ruck,” yet keep useful survival items. Continue to develop your Civil-Military support network. I recommend that your Training/Ops Officer have a “reach-back” of “subject matter experts” in Operational Stress Reaction just like the list of experts and agencies that provide guidance in other crisis (man-made or natural). We need this system in place for both natural and manmade disasters. Lots of efforts have been made in training WMD/CBRNE Awareness in the LE / First Responder community but more is needed in terms of the psychology of fear (terrorism) and the psychological response to critical incidents. Officers may end up at Employee Assistance (EA) after a deployment or critical incident. They may be Command referred for alcohol misuse or abuse. From EA they head towards AA where someone recommends they find “the God of their childhood.” Best to find that God before and during the deployment, then maintain that relationship post-deployment. It has been recommended in other Police literature that training should always be available in anger management and alcohol use and misuse. The flame of anger leads to the fire of domestic violence, community misconduct, and self-medication with alcohol only leads to flames that become unmanageable. The fire inside needs to be controlled. There are positive techniques that can be practiced pre-deployment, difficult, but possible to practice during deployment, and certainly revisited post-deployment. We started the article with a reference to a great swordsman. He would have never survived to write his teachings had he not studied and taught techniques to stay “centered.” Another post-deployment suggestion is to distribute self-care resources or develop a web based self-management/educational site that is anonymous. Perhaps this could be done at the state or national/ international level (IACP) that is based on “combat stress” reduction. This concept has been piloted in the DoD (Project DeStress) and will be rolled out next with an Active Duty battalion next. 2

Faces, places, and voices will be remembered from deployments. These are memories not “hallucinations.” This point is critical for the Police and Medical “Crisis Negotiator.” “This is my shield. I bear it before me into battle, but it is not mine alone. It protects my brother on my left. It protects my city. I will never let my brother out of its shadow or my city out of its shelter. I will die with my shield before me facing the enemy.” 3 If you welcome a veteran home with a handshake, remember that someone stood beside them. The veteran will maintain memories of those they served with and they will carry “lessons learned” like a shield in order to protect themselves. When thinking of how “the line” was held at Thermopylae (480 BC) and since then, we need to respect the fact that the shield was held with body, mind, and spirit. When we deny this trinity, we find the shields drop and we lose the health and safety of “the line.”

1The Echoes of Violence in the Police Family, Beverly J. Anderson, PhD., BCETS,Clinical Director, Metropolitan Police Employee Assistance Program, Washington, DC, www. giftfromwithin.org/html/echoes.html 2www.PDHealth.mil 3 quote from Gates of Fire (Thermopylae) by Steven Pressfield Other Helpful Resources for You/Family http://www.pdhealth.com http://hooah4health.com http://traumaprevention.com http://lifelines.navy.mil http://ncptsd.va.gov http://brothersboundbyhonor.com http://www.learningplaceonline.com http://wwwmagisgroup.com http://www.nlm.nih.gov/medlineplau/ veteransandmilitaryhealth.html#coping

The American Osteopathic Board of Emergency Medicine Announces

The NEW APPLICATION DEADLINE FOR PART I (WRITTEN) CERTIFICATION EXAMINATION SEPTEMBER 1 The new application deadline is September 1st of each year. This date is effective for 2006 registration (February 2007 examination date). Continuous Osteopathic Learning Assessment (COLA) Each COLA module will be on line for 3 years instead of 2 years, effective immediately. Formal Re-Certification Examination (FRCE) The 2006 FRCE will be administered on September 18, 2006 in Chicago, Illinois. The application deadline is May 27, 2006. If there are any questions, please contact the Board office. AOBEM 142 E. Ontario Street Chicago, IL • (312) 335-1065 aobem@aol.com • www.aobem.org

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Guest Column

Annette Mann Brunetti, D.O., FACOEP

OVERCROWING IN THE ED WHAT CAN WE DO? It’s Monday in the ED, you know what that means: patients, patients, and patients. I am surrounded by telemetry holds, the walking wounded, the sick, the not sick and the ridiculous. Once again I find myself thinking there has to be a better way. There must be a solution to the problems of ED overcrowding. What is it? The federal government would at this point form a task force, spend lots of money evaluating the problem, and make recommendations that won’t or can’t be followed because the legislative process is so cumbersome. It is a rarity for any legislation to get passed in a timely fashion. Yet, here I sit another year having gone by and little hope of relief in sight. The issues surrounding overcrowding are many and intertwined. At the top of the list is medical malpractice and lawsuits gone amok. Physicians are forced to practice defensive medicine now. We all do. We can’t ignore the society in which we live. We dread the day when it’s our turn. We order more tests in the ED when clinically our judgment says everything is okay. But in the back of our minds—what if we’re wrong? Simply relying on the patient to follow up for further evaluation with the primary care physician is not good enough. If they don’t go it’s our fault. Physicians find themselves referring patients to the ED for evaluation. They don’t want to miss anything either. Both of these issues increase the number of patients in the ED. Increase the number of tests and you increase patient wait times as the department goes into stasis pending results. This also adds to the rising cost of healthcare in the U.S. There are an increased number of patients in the department through referral. Remember the decision making tree ends with one branch that reads—go to the ED. The uninsured and underinsured add to overcrowding. These patients don’t have a

primary care physician or there is no available space at the free clinic. Some areas of the country don’t even offer any kind of free or reduced rate clinic. Now the ED becomes the clinic. The federal government estimates there are 11 million illegal immigrants in the U.S. Add to this figure the number of Americans who are uninsured. It is easy to see what kind of a burden this places on our emergency services. It is very difficult to find these patients follow up care. Sometimes they end up admitted to the hospital for an evaluation that could have been done as an outpatient but the EM physician cannot find anyone with whom the patient has follow-up. Federal legislation also adds to the burden of overcrowding. EMTALA, which came into existence to prevent the uninsured from being denied emergency healthcare, is an excellent law. However, it makes it almost impossible to refer outpatients with non-emergent conditions to other healthcare providers. The EM physician is forced to see every patient - even those with toe pain for six months. Currently, there is a shortage of nurses in the healthcare field. The “bed shortage” is not actually a bed shortage. There are rooms there just aren’t enough nurses to take care of the patients. These patients end up as holds in the ED. At times these patients can take up to 50% or more of the functioning patient beds in the ED. Yet, the ED is still required to see every patient that comes through the door. The census for the ED does not go down on these days. Patients have increased wait times. Delays in care occur because it is impossible to see the same number of patients in half the space in a timely fashion. What are the solutions to these issues? Again, it is multifaceted. First and foremost is Tort reform. The excessive litigation has got to stop. There should be a review panel

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to determine validity of claim. The review panel should be made up of physicians and non-physicians. Several-blinded standard of care determinations should be performed. Limits on judgment amounts are a must. There needs to be a clear distinction between malpractice and cases where everything is done right and still bad things happen. There needs to be reeducation of the public on what constitutes an emergency. Community clinics need to be set up for the uninsured and underinsured for nonemergent treatments. Medicare reimbursement needs to be increased. It’s getting harder and harder to find specialists willing to take MA. (That’s another article for another issue.) The ED should not have to live in fear of sanctions from the government if it refers non-urgent cases to primary care physicians. Clearly there is no single solution to solve this crisis. The solutions are many. My ideas may not be the best ideas. The burden of responsibility for good health must be shared between patient and physician. There should be a physician’s bill of rights as well as a patient’s bill of rights. I sit here and wonder why is it that the politicians don’t ask us how to fix the problems? At least I’ve never been asked. Maybe the problem is that we, as physicians have not been proactive enough. The answer may be that we need to unite and come up with a plan and present it to all that will listen. This is my opinion. Tell us at The Pulse what you think.

Simplified Antibiotics, continued from page 23

indicated, the following are potential short courses, which may be considered. • Azithromycin 500 mg daily for 3 days • Levofloxacin 750 mg daily for 5 days • Cefuroxime 250-500 mg BID for 5 days Community Acquired Pneumonia (CAP). Streptococcus pneumoniae remains the most common bacterial agent, with 5 other organisms including H. influenza, M. catarrhalis, Mycoplasma pneumoniae, Legionella pneumophilus, and Chlamydia pneumoniae rounding out the group. It is useful to score pneumonia patients into something like the PORT/Fine Criteria, also known as the Pneumonia Severity Index (PSI). This score puts patients into 5 risk classes, and helps to determine appropriate antibiotics and disposition, outpatient vs. inpatient and even ICU admission. The score actually gives a 30day mortality prognostication, and thus helps the clinician with these decisions, especially outpatient treatment as we are discussing in this article. In the past, the duration of therapy was somewhat nebulous, and often ranged from treating until the patient was afebrile for at least 3 days to a prolonged 2-week or more courses total. The following agents are especially useful for CAP as they cover both typical and atypical organisms with monotherapy. Azithromycin 500 mg BID for 3 days or Z-pac for 5 days Levofloxacin 750 mg for 5 days Genitourinary Infections Cystitis. To be considered an uncomplicated lower urinary tract infection (UTI) the patient must not have signs of fever, flank tenderness, or systemic illness. They must have normal urologic anatomy, not be a pregnant or pediatric patient, not have an indwelling catheter, or have recently had instrumentation. The most common etiology of these uncomplicated UTI’s remains Escherichia coli, which accounts for 85-90%. Short course therapy is now a well-established treatment option for these cases. Acute Urethral Syndrome can be treated the same as the uncomplicated UTI. • Fosfomycin 3 gm PO single dose (less effective cure rate about 75-80%)

• • • •

TMP/SMX DS BID for 3 days Ciprofloxacin 250 mg PO BID for 3 days Levofloxacin 250 mg PO daily for 3 days Norfloxacin 400 mg PO BID for 3 days

Other Vaginoses and Sexually Transmitted Diseases Candida Vaginitis • Fluconazole 150 mg PO single dose • Butoconazole 2% Cream Sustained Release 5 gm single dose Intravaginally • Ticonazole 6.5% Ointment 5 gm single dose Intravaginally • Clotrimazole 500 mg vaginal suppository single dose Trichomonas Vaginalis • Metronidazole 2 gm single dose PO Bacterial Vaginosis • Metronidazole 2 gm single dose PO Gonorrhea. Caused by Neisseria gonorrhea, this condition continues to play an important role in sexually transmitted diseases (STDs) in the United States and throughout the world as well. In the past few decades, penicillinase-producing strains have changed the treatment regimens for gonorrhea. Recently the emergence of strains resistant to fluoroquinolones has changed treatment strategies once again. Short course therapy is only indicated for the uncomplicated case found in certain geographical areas. Parts of the world with significant resistance include the Far East, Middle East, Pacific Islands, and even some regions of the US such as Honolulu, Hawaii; Long Beach, California; Seattle, Washington; and New Orleans, Louisiana. Also, isolates from men who have had sex with men have a high prevalence of resistance and are excluded from short course therapy. The CDC recommends taking into consideration all these issues before initiating therapy. • Ceftriaxone 125 mg IM single dose • Cefixime 400 mg PO single dose (this product is scarce in the US) • Ciprofloxacin 500 mg PO single dose • Ofloxacin 400 mg PO single dose • Levofloxacin 250 mg PO single dose • Spectinomycin 2 gm IM single dose Chlamydia • Azithromycin 1 gm PO single dose Chancroid • Azithromycin 1 gm PO single dose • Ceftriaxone 250 mg IM single dose • Ciprofloxacin 500 mg PO BID for 3 days

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Syphilis is caused by the spirochete Treponema pallidum and single dose therapy is only indicated for early syphilis found in its primary stage of a chancre at its original inoculation site. Uncomplicated early syphilis excludes the pregnant patient or those with HIV. • Benzathine Penicillin G 2.4 million Units IM single dose (1/2 each at 2 sites) • Azithromycin 2 gm PO single dose Gastrointestinal Infections Traveler’s Diarrhea (TD) is defined as a condition acquired while traveling that manifests itself as passage of at least 3 unformed stools in a 24 hour period, associated with nausea, vomiting, cramps, abdominal pain, fecal urgency, and bloody or mucoid stools. Patients are usually affected for 3-5 days and may suffer symptoms for a week or longer even after returning home. Contaminated water is the usual source for contracting this condition; recommendations to avoid this problem are legion and won’t be discussed here. Organisms that are responsible for causing TD include viruses, parasites, and bacterial pathogens. Most common bacterial causes include enterotoxigenic E. Coli, Campylobacter, shigella, and salmonella. Prophylaxis includes agents such as Ciprofloxacin 500 mg PO daily, Norfloxacin 400 mg PO daily, Ofloxacin 300 mg PO daily, Doxycycline 100 mg PO daily, and TMP/SMX DS PO daily. Bismuth subsalicylate is a low cost alternative, but the frequent dosing and large volumes make it somewhat inconvenient. If prophylaxis was not begun, the following are low dose, short course regimens. • Azithromycin 1 gm PO single dose • Rifaximin 200 mg PO TID for 3 days • Levofloxacin 500 mg PO single dose Single-dose and short course therapy for a number of frequently encountered infections in the emergency department can be safe, convenient, lower-cost, and efficacious for the patient with certain identified clinical parameters. References for this article can be obtained from the author by contacting him at the ACOEP Office, 142 E. Ontario Street, Suite 1250, Chicago, IL 60611

Guest Editorial

Anthony Jennings, D.O., FACOEP

It Really Is The Standard of Care As emergency physicians continue to debate thrombolytic use in stroke, stroke patients continue presenting to our departments. Since 1996, the medical profession has been debating the use of thrombolytics in nonhemorrhagic stroke. The question of standard of care has been decided for us. In many ways, stroke care is similar to the use of steroids in spinal cord injury that became “the standard of care” in the early 1990’s (and for years now has only been a legal standard of care for our spinal cord injured patient and not a medical standard of care). Whether or not you conform to the notion that thrombolytics are the standard of care is irrelevant. The American Heart Association has made it a class 1 standard and made the decision for you. The 2 to 3 percent of stroke patients who arrive within the 3-hour window from onset of symptoms have been deemed candidates for possible thrombolysis. Most of our physicians practice in nonteaching institutions where we do not have a stroke team with neurology readily available to assess and treat our stroke patients. We are the front line. We are the stroke team. We make the decision to use thrombolytics in our eligible patients. The stroke care we provide is scrutinized-right or wrong- after the fact. Emergency medicine physicians may be Monday morning quarterbacked more than any other specialty in medicine. We are simply expected to make the right

decision all of the time. We are expected to provide good care and ensure the best outcome possible for our patients. How do we do this? Emergency physicians, irrespective of the institution in which they practice need to have a firm understanding of indications and contraindications for thrombolytic use. This is a given. Whether the drug is given or not may be indivualized, too frequently – for a standard does exist. Physicians need to be aware that many lawsuits now are being brought forward for failure to treat with thrombolytic. A prominent Boston neurologist declared at the Spring International Stroke Association meeting that he has many expert witness cases where he is involved where the patient had a bad outcome, no lytics given, and no cases where the patient received thrombolysis and had a bad outcome. It seems that we have a potential legal albatross dangling from our necks. The small percentage of patients eligible to receive thrombolytic treatment may be one of the true “modern medical miracles” when treated and a good outcome results. The long-term deficits faced by stroke survivors are very significant. We can look at statistics and know that 1 in 3 stroke survivors will not be able to continue their lives without assistance on a daily basis. The opportunity to potentially reverse some or all of those deficits and restore the greatest degree of function sounds very appealing. I

think that we all need to step back and think about the patient as if it were you. Is there not a small part of your scientific brain that when placed in the place of the stroke patient would not want to be given the best chance at return to the highest functional level as possible. Or would you rather not receive the thrombolytic and take your chances with rehabilitation. I know the option that I would choose. Irrespective of whether you will conform to the standard of care as set by the American Heart Association, informed consent on behalf of the patient and their families is necessary. The medicolegal implications necessitate this. A chart that has some indication of the medical decision making process is a defendable chart. Charts that lack a decision process are open for contention. Enlisting the patient, the family, and the family physician when possible are very necessary components when treating the stroke patient. Talk to them; present the potential risk vs benefit and document. We have debated the thrombolysis in stroke question for 10 years and will continue debating this issue. Other treatment modalities are emerging and hopefully we will find better options for care of these patients. Hopefully a better study will come in the future to prove or disprove the issue. Our patients have benefited by the overall improvement in stroke care that has come about as a result of the debate.

OFFICIAL CALL To the Officers and Members of the American College of Osteopathic Emergency Physicians: You are hereby notified of the ACOEP’s Fall Membership Meeting on Monday, October 16, 2006 at the Las Vegas Hilton Hotel in Las Vegas, Nevada. The meeting will begin at 5:00 p.m. A “Meet and Greet” Session to introduce members to Board Candidates will begin at 4:00 p.m. Active, Active-Exempt, Life and Retired Members will be allowed to vote for members of the Board of Directors and new Board Members will be announced at this meeting. The Presidential Inauguration and swearing in of newly elected Board Members will occur at this meeting at 6:30 p.m. The location of this meeting will be announced in the October issue of The Pulse and will be placed on the website when identified. Thomas A. Brabson, D.O., FACOEP, Secretary

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Member News Nancy West

Bringing Help and Hope After Hurricane Katrina When Greg Christiansen, DO (PCOM ’92), arrived in New Orleans shortly after Hurricane Katrina struck, he was confronted with a city nearly devoid of its population, packs of feral dogs and other animals roaming the streets and a host of unknown dangers lurking in the flood waters. He was deployed to the city with a Georgia Disaster Medical Assistance Team (DMAT), one of many DMATs throughout the country established by the Department of Homeland Security’s National Disaster Medical System (NDMS) to provided medical care during a disaster. The 38-member team set up camp in a parking garage outside of the Touro Infirmary and worked with hospital personnel to get the facility’s emergency department up and running. With much of the population evacuated, they were primarily providing medical services to rescue personnel, which included the National Guard, the military and local emergency response services. “We treated a lot of animal and insect bites, as well as lacerations from falling tree limbs and many conditions resulting from exposure to toxins in and out of the water,” says Dr. Christiansen. “We even treated a group of military personnel for nerve agent toxicity after they were exposed to

Malathion, a chemical that was being sprayed via helicopters to control the mosquitoes.” Once the Touro Infirmary was reopened, Dr. Christiansen returned home to his family in Virginia and his job as educational director for Virginia Commonwealth University’s department of emergency medicine. After a brief respite, he was called to serve in early October and returned to the region with the Virginia-One (VA-1) DMAT. “I ‘m actually a member of VA-1 DMAT,” explains Dr. Christiansen. “I served as medical director of the Georgia team on my first deployment because they were experiencing a shortage of physicians.” During his second deployment, Dr. Christiansen helped augment medical services as West Jefferson Medical Center in New Orleans. As residents were allowed back in to the city, the team began treating the general population for conditions ranging from respiratory problems and drug and alcohol withdrawal to heart attacks. “We also had several people with broken bones who would have been operated on under different circumstances,” says Dr. Christiansen. “We had to set their bones as best we could. Unfortunately, there was no way to treat them more expeditiously because every hospital was operational, and transportation

services were very limited.” Many of the 180 patients the team treated each day had a positive attitude despite all the difficulties they’d endured. “I was amazed by their sense of community and how they went out of their way to help others even when they did not have any resources themselves,” says Dr. Christiansen. “It wasn’t just local people either; people from all over the country were helping. I met a physician from California who was there even though his own home was being threatened by wildfires.” Everyone was grateful for the care they received, and Dr. Christiansen was grateful for the opportunity to provide it. “DMATs are an excellent way to provide services to people in need,” he says. “We had the resources to help people immediately and ensure the team’s safety while doing so, and we didn’t have to worry about regulations or malpractice issues. It was medicine in its purest form.” This article was reprinted with permission from the editorial staff of the PCOM Friends and Alumni DIGEST. We also thank and acknowledge the article’s writer, Nancy West, for her well written profile of Greg Christiansen, DO.

Ethics In Emergency Medicine

Bernard Heilicser, D.O., M.S., FACEP, FACOEP

What Would You Do? Suicide Ideations Our patient is a 30 year-old female who presented to the Emergency Department for evaluation of suicide ideations. She revealed that 18 years ago her cousin was pregnant, had concealed this pregnancy, and subsequently delivered the baby. They placed the baby in a plastic bag and buried it. It was unknown if the baby was alive. The patient stated she had struggled with

depression ever since. The dilemma posed was what was the Emergency Department’s responsibility regarding notification of the police? Do we have an affirmative responsibility to contact the police regarding this stated incident? What would you do?

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

CANDIDATES IDENTIFIED FOR BOARD POSITIONS At its meeting in April 2006, the Board approved the Nominating Committee’s recommendation for the ballot for positions on the Board of Directors of the ACOEP. Candidates elected to the Board will begin three-year terms that will expire with the Fall Membership in 2009. Board terms are limited to three consecutive terms or a maximum of twelve years if the Board Member holds the position of Presidentelect, which is a protected position on the Board and not up for re-election. In 2006, the Nominations Committee began a new process of identifying potential candidates and contacted Active Members who were active in College Committees or other College venues. Twenty-six physicians were contacted by the Nominations Committee Chair, Victor J. Scali, D.O., FACOEP to determine their interest in being considered for possible nomination to the Board. Each Candidate was asked to submit a biographical sketch, photo, current curriculum vitae and a letter of intent expressing their interest and abilities that they could provide to the Board. Twelve physicians answered the solicitation and the potential candidates were evaluated in April with eight candidates were selected. Individual members may always solicit positions on the Board by following the same mechanism identified above. The Nominations Committee accepts applications throughout the year for interested candidates and meets each spring. The Nominations Committee is comprised of five Active Members, two of which are ACOEP Board Members and three are members chosen at large each January by the Nominations Committee Chair. There are currently four positions open on the Board. Only one candidate is a current member of the ACOEP Board who is running for re-election. Dr. Thomas Brabson is currently the Secretary of the ACOEP and, if elected, will move into the President-elect position on the Board in October.

The Candidates for ACOEP Board positions are described below. William Bograkos, D.O., FACOEP joined the ACOEP in 1992 and was granted the Honorary Title of Fellow of the ACOEP in 1999. Dr. Bograkos has served as Chair of the Emergency Medical Services Committee for two terms after serving on the Committee since its inception in 1993. He currently continues to serve as a member of the EMS Committee and the Chair of the Domestic Preparedness Subcommittee. Dr. Bograkos currently serves as a Medical Consultant / Bioterrorism Expert Consultant for the Institute for Defense Analyses and an Instructor for the Academy of Counter-Terrorism Education at the Louisiana State University through the Department of Justice Office of Domestic Preparedness. He also serves as an Adjust Instructor at the National center for Biomedical Research and Training and an Instructor of the Healthcare Leadership Course at FEMA’s Nobel Training Center in Anniston, Alabama. Dr. Bograkos is a regular contributor to The Pulse providing information on Domestic Preparedness to the ACOEP Membership and has been a frequent speaker on EMS and bio-terrorism. Gary Bonfante, D.O., FACOEP is a 1993 graduate of the Philadelphia College of Osteopathic Medicine, who completed an Emergency Medicine residency program at St. Luke’s Hospital and Lehigh Valley Hospital in Allentown, Pennsylvania. During his senior year at this residency, he served as Chief Resident. Dr. Bonfante has been certified in the specialty of emergency medicine since 1998 and has been a member of the ACOEP and the ACEP since 1994.

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In addition to being a staff physician for the Emergency Medicine Department of Lehigh Valley Hospital and Health Network, Dr. Bonfante is actively involved in resident and intern education. He serves as a member of the educational committee for the Osteopathic Internship and serves as core faculty for the Emergency Medical Services Fellowship. He has completed the ACEP Teaching Fellowship Program and actively serves on national committees for the ACOEP. These committees include the Continuing Medical Education Committee, the Subcommittee for the Scientific Seminar (Chair), the Program Directors Committee and the Resident In-Service Examination Committee (Vice Chair). He also serves as an Inspector of Residency Programs for the Committee on Graduate Medical Education. Dr. Bonfante has lectured extensively on both the local and national level. He is currently medical director of Northern Valley Emergency Medical Services, Northern Whitehall Emergency Service Organization, Slatington Fire Department, and the emergency response tem of the United States Postal Service Lehigh County Branch Office. Dr. Bonfante is also an instructor at the George E. Moekirk Emergency Medicine Institute – a training center for a variety of standard and internally developed courses. Thomas A. Brabson, D.O., MBA, FACOEP is a 1989 graduate of the Philadelphia College of Osteopathic Medicine who completed an Emergency Medicine residency program and an EMS Fellowship at the Albert Einstein Medical Center in Philadelphia, Pennsylvania. Dr. Brabson has also completed a Masters of Business of Administration

program at St. Joseph’s University in Philadelphia. Dr. Brabson has been certified in the specialty of emergency medicine since 1994 and re-certified in 2003; he has also received a Certificate of Added Qualifications (CAQ) in EMS in 1996. Dr. Brabson is currently the Medical Director of the Department of Emergency Medicine and Mobile Intensive Care Program at the AtlantiCare Regional Medical Center in Atlantic City, New Jersey, an Associate Professor in the Department of Emergency Medicine at PCOM, and an Assistant Professor in the Department of Surgery at the Thomas Jefferson University, School of Medicine in Philadelphia. Dr. Brabson is currently the Secretary of the Board of Directors of the ACOEP and was previously the College’s Treasurer (2001-2004). He has served on the ACOEP Board of Directors since 2000. Since 1996, he has been an active member of both the CME Committee and EMS Committee, where he currently serves as the Board Liaison. He has been a featured speaker on EMS topics at several national meetings and has been chair of the ACOEP’s Scientific Seminars in 1999 through 2004. Dr. Brabson is involved in research in emergency medicine and has been a frequent contributor to emergency medicine texts and magazines. Donald J. Brock, D.O., FACOEP is a 1991 graduate of the Chicago College of Osteopathic Medicine, who completed an Emergency Medicine residency program at Pontiac Osteopathic Hospital in Pontiac, Michigan. Dr. Brock is certified in the specialty of emergency medicine (1997) and a Fellow of the American College of Osteopathic Emergency Physicians (1998) and the American College of Emergency Physicians (2001). Currently, Dr. Brock serves as staff physician for a private Emergency Physi-

cian group, Independent Emergency Physicians, based in southeast Lower Michigan. Previously, Dr. Brock was the President of ER-ONE, a private professional emergency physician group and held the position of Chief of Emergency Medicine at the Oakwood Hospital, where he was instrumental in establishing a new emergency medicine residency program. Dr. Brock has also served as Medical Director of Health Emergency Medical Services (Medical Control Authority) of Wayne County, where he was very active in the local and state disaster committees. As the President of ER-ONE, Dr. Brock was able to learn and engage in many aspects of the business of emergency medicine, including physician recruitment, credentialing contract negotiations, billing and coding, Emergency Department design and flow, and information and data systems in respect to emergency medicine and emergency command. The Michigan College of Emergency Physicians, a subchapter of ACEP, named Dr. Brock Emergency Physician of the Year in 2005. John C. Prestosh, D.O., FACOEP is a 1976 graduate of the Philadelphia College of Osteopathic Medicine and has been certified in Emergency Medicine since 1988 and recertified in 2001. He has been an active member of the ACOEP since 1988. Dr. Prestosh is currently the Program Director of the Emergency Medicine Residency of the Lehigh Valley in Bethlehem, Pennsylvania. Prior to this position he served as a site coordinator since the inception of that program. Dr. Prestosh has been involved in medical education throughout his career and was a clinical instructor of Emergency Medicine at PCOM during the years of 1978 through 1988. He has served in an administrative capacity as the Site Director of the ED at Allentown Osteopathic Medical Center and again in the same capacity when the hospital became St.. Luke's Allentown Campus. He has twenty-eight years of clinical experience in emergency medicine and also been involved in various committees of the ACOEP over the past ten years. Presently, Dr. Prestosh is the Chair of the Residency In-Service Examination Committee and in charge of overseeing and creating the an-

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nual evaluation examination for all osteopathic emergency medicine residents. Duane D. Siberski, D.O., FACOEP is a full-time practitioner of emergency medicine at the Reading Hospital and Medical Center / Trauma Center for ten years. He completed his emergency medicine residency program at the Chicago Osteopathic Hospital after the completion of his rotating internship at Springfield Hospital in Pennsylvania. He was a 1992 graduate of the University of New England College of Osteopathic Medicine. Activity in the College began as a student. As the national vice-president of student chapters, he worked closely with the Board of Directors. Currently, he is a member of the Practice Management Committee, serves as the ACOEP Liaison to the American College of Emergency Physicians, and is the National Advisor to the ACOEP Student Chapter and its Officers. Together with the ACOEP President and President-elect, Dr. Siberski is a member of the EM Working Group, a panel of national emergency medicine groups that convene to discuss and address issues pertinent to emergency medicine. Involvement in pre-hospital medicine is a special area of interest for Dr. Siberski. He is a medical director for the six county Eastern Pennsylvania Region and the region’s emergency dispatch centers. In this position, he represents the region on the state medical advisory committee for EMS. Dr. Siberski is the medical director for the Reading Hospital and Medical Center’s Paramedic Training Institute and Western Berks Ambulance Association. He is an instructor of ACLS, PALS, BTLS, and an active speaker locally, statewide and nationally.

Candidates for Board, continued on page 38

Guest Column

Gretchen Farinosi, R.N.

Just Connect - A Spouse’s Viewpoint In 2001, I was approached to provide a Women’s Health Program as an adjunct to the Spring Seminar in Arizona. The following year I co-facilitated a writing activity open to physicians, their spouses, and the ACOEP staff at the same seminar. I have to tell you that, looking back at the experience, I realize how my eyes were pleasantly opened to the depth of the people who attended this conference, one of them being my husband. Years later, I can fully appreciate the value of this collective, sharing downtime. The setting was near perfect . . . a clear, blue-sky Arizona day, where the sun was out in all its glory. We gathered together on a shaded patio as people rather than physicians and spouses and conference staff. Coming in from Michigan, where we still had a foot of snow on the porch, I remember thinking that we all deserved this break from the winter and the many inspiring topics being presented each day. We also deserved the opportunity to get a glimpse of each other on a personal level. We shared topics with each other that were of value to us. Sometimes conferences can feel distancing if your schedule does not include being reacquainted with your peers and extra activities. Most of all, it was so interesting to see the collection of folks that were attracted to this offering. Not surprisingly, they were people of great faith, intelligence, and empathy. One year, I facilitated a small group presentation on The Four Agreements by Miguel Ruiz. Naively thinking that this was going to be new news, it was exciting to hear about how people used the agreements in the residency programs, patient interactions, peer interactions and in the personal lives. Other topics, such as The Power of Now, sharing of losses of family members and friends with ties to 9-11 were added to make the discussion more personal. It was extremely meaningful to me. I still keep these families in my prayers to this day. I remember feeling that something had definitely changed for me at that conference.

Instead of just passing people with a quick, “hello,” I remembered that we shared ideas that linked us to each other and thus made new friendships. The very concepts that continue to be helpful in all facets of our lives to this day! I wonder what the people who attended these activities think today? I would love to hear from them. Each year as the field of medicine grows more demanding, it is an overwhelming and sometimes, daunting challenge to keep up with the physical, emotional, spiritual, and ethical demands that come with the territory. Even if the conference cannot actively designate a time for sharing like this, I would sincerely encourage you to make the effort to CONNECT. Put a message on the board at the ACOEP Conference Desk and get together. It doesn’t mean you have to miss the activity of the day or lose valuable time sightseeing. Make it a dinner or lunch, or an informal gathering by the pool. There is a lot of sunshine, good weather, and good energy at that conference if you look past the excellent clinical topics being presented to you. At the time I attended those conferences I was an R. N. who was taking care of her

Mother, steadily declining with Alzheimer’s Disease. Talk about a dis–ease. It was one of the most precious, stressful, physically, emotionally, and spiritually demanding parts of my life. Though I now sit on the Ethics Committee, I was never so aware of medical ethical issues until it was my loved one. That ten-year period was an experience I wouldn’t wish on anyone else, it was one I sadly accepted. So, I benefitted greatly connecting with my peers. Back in those days when I attended conferences, I was not an Infection Control Practitioner who was juggling kids high school sports schedules, teaching a Fundamentals Program for new ICP’s for the State organization, or running a small medical education company, but I was, and still am, a spouse of an emergency physician. I still believe it is invaluable and necessary to connect with others on a truly personal level when you meet with your peers. Connect with your peers and make new friends - Start now by planning to attend the Spring Conference in Arizona

ATTENTION RESIDENTS & STUDENTS

Going to Vegas?

ACOEP has blocked rooms for both Resident and Student chapters to stay in Las Vegas if you plan to travel to the AOA Convention/ ACOEP Scientific Seminar.

Rooms are $140 each (plus tax) at Ballys Las Vegas on the strip. All rooms must be reserved through ACOEP, contacting the hotel directly will not provide you with a discount! If you are interested or have questions, contact Katie Cavarretta at katiecavarretta@acoep. org or (800) 521-3709. Rooms are limited and are available on a first come, first serve basis. You will be responsible for all room charges. If you are eligible for reimbursement from ACOEP, please submit your voucher with appropriate room receipts

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Research Corner

Rebecca Kirsch, D.O., 3rd Place Resident Research Award

Cost Analysis of Etomidate and Morphine vs. Versed and Morphine as a Conscious Sedation in the Emergency Room Abstract Etomidate is a fast-acting sedating agent with few, if any, effects on the cardiac stability of human patients. This agent has been used successfully in a wide range of age groups, from neonates to elderly patients, and has been shown to offer safe sedation and rapid recovery. Hypothesis: Etomidate is more costeffective than Versed in procedural conscious sedation in the emergency medicine setting. The cost includes cost of the Emergency Room (ER) taking up nursing and monitoring resources. Methods: This retrospective-based study utilized medical records from Cuyahoga Falls General Hospital, dating from July 1, 2002 through December 31, 2003, of patients who were either given a combinaCandidates for Board, continued from page 36

Bruce Whitman, D.O., FACOEP is a 1983 graduate University of Osteopathic Medicine and Health Sciences in Des Moines, Iowa, who completed a rotating internship at the University of Medicine and Dentistry of New Jersey, School of Osteopathic Medicine and an emergency medicine residency program at the Philadelphia College of Osteopathic Medicine in Pennsylvania. He is certified in the specialty of emergency medicine since 1999 and a member of the ACOEP since 1982. Since his residency, Dr. Whitman has practiced emergency medicine and serving in leadership roles as an Emergency Department Medical Director. He has been involved in EMS, Disaster Management and Trauma Management and has served

tion of Versed and Morphine or Demerol, or were given Etomidate and Morphine for procedures requiring conscious sedation, such as dislocated shoulder reductions and fracture reductions. Approximately 200 charts were reviewed, with 71 charts yielding usable data, 6 of which were Demerol and Versed, 49 Morphine and Versed, 16 Etomidate and Morphine. Statistical analysis includes both descriptive as well as inferential tests. Descriptive statistics were used to summarize selected procedures; inferential statistics used to compare costs between drug choice. Results: The time difference between Etomidate with Morphine, and Versed with Morphine sedation times, is one half an hour. The time difference between Etomidate with Morphine and Versed with Demerol is one-hour. The cost to the on the ACOEPâ&#x20AC;&#x2122;s EMS Committee since its inception. Dr. Whitman currently serves as Emergency Department Medical Director of a 45 bed emergency department at the Southeastern Regional Medical Center in Lumberton, North Carolina. Dr. Whitman also serves as the County EMS Medical Director. In December 205, Dr. Whitman completed a four-year Executive Masters Program culminating in a Masters Degree in Healthcare Administration from the University of North Carolina â&#x20AC;&#x201C; Chapel Hill. He has used his business knowledge to develop and implement a Cardiac Decision Unit as part of the Emergency Department at Southeastern Regional Medical Center. Michael H. Yangouyian, D.O., FACOEP is currently practicing emergency medicine at Garden City Hospital in Michigan where he has served as a staff physician since 1994. In 1996, he was promoted to the position of Program Director of its emergency medicine residency program. He remains active as

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hospital per average dose is $7.23 difference between Versed and Etomidate. The average total stay is 18-minutes shorter with Etomidate. That additional 18 minutes gained per stay can yield the hospital a complete patient turnover per day. Conclusions: The use of Etomidate with Morphine or alone is cheaper than Versed with Morphine or Demerol for conscious sedation. Dr. Kirsch is a 2005 graduate of the Emergency Medicine Residency Program at Meridia South Pointe Hospital in Cleveland, Ohio. Copies of this entire article can be obtained from the author. Requests for copies should be addressed to Dr. Kirsch at the ACOEP, 142 E. Ontario Street, Suite 1250, Chicago, IL 60611

an emergency physician as well as residency director. Teaching and being responsible for his residents and interns has been challenging but also very rewarding. Dr. Yangouyian is a 1989 graduate of the University of Health Sciences, College of Osteopathic Medicine. He completed a rotating internship and residency program in emergency medicine at the Pontiac Osteopathic Hospital in Michigan. Dr. Yangouyian has been an active member of the ACOEP since 1991. He is board certified in emergency medicine by the American Osteopathic Board of Emergency Medicine, where he has served as an oral board examiner since 2002.

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Physician Owned and Managed Since 1987 Dayton, Ohio z (800) 406-8118 z www.premierhcs.net The PULSE JULY 2006

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