The Pulse July 2007

The PULSE

Osteopathic Emergency Medicine Quarterly VOLUME XXXII NO. 3

July 2007

Presidential Viewpoints Peter A. Bell, D.O., FACOEP This quarter requires much reflection.

Following reorganization of our office staff, and committees, we had our most successful Spring Conference to date. It was great to see so many members with their families in Phoenix. The Wild Horse Pass was a great venue for the conference, and our speakers received excellent reviews. Kudos to Drs Christine Giesa and Julie Johns for chairing the Spring Conference Committee!

At the Tuesday evening reception, I had the pleasure of announcing the achievement of one of our 2006-2008 Objectives. The ACOEP is now the second largest specialty college in the AOA, and we are still growing. Will we ever catch up with Family Medicine? With 40 Emergency Medicine residencies and inquiries for new programs every month, it is possible. Realistically it will take another 30 years. I will leave that objective to a future president.

Another highlight was our presence at DO Day on the Hill. The Government Affairs Committee held its first official Washington meeting and charted a new course for our college. The Committee lead

by Dr. Raul Garcia has planned an aggressive agenda for the year, and submitted a hefty budget to fuel projects to add value to our membership. Our ongoing discussions with the AOA-Washington office and the ACEP-government affairs office have lead to a strategic alliance for mutual support and the exchange of information. It further

reinforces the importance of maintaining collaborative relationships while allowing independence.

Speaking of collaboration, Drs. Joe Kuchinski, Christine Perry, and Brandon Lewis recently represented the college at a newly formed consortium of emergency medicine organizations. A similar attempt

by SAEM to bring all the emergency medicine organizations together in dialogue last year failed. Fortunately, AAEM was able to resurrect talks, which our delegation reported as most productive. While the house of emergency medicine was present, ACEP choose not to attend this year.

The College has also expanded its liaison relationships. SAEM has requested a formal relationship with ACOEP, and Dr Beth Longenecker will be representing us at a special meeting. Our relationships with military and government agencies have also advanced over the past few years. Drs. Vic Scali and Paula DeJesus are representing the college to government agencies while Dr. Bograkos is serving as our military liaison.

New this spring is Dr. Terry Mulligan as our International Emergency Medicine Liaison, and Dr. Joe Heck as liaison to NORTHCOM. Liaison relationships extend the ACOEP circle of influence. This places us at the table when important matters are discussed and final decisions are made. It is another way we can add value for our members.

Finally, the most significant decision was the change in our Fall 2008 meeting.

For more than ten years we have actively sought the input of the membership in regards to our biannually meetings. For the past seven years we have diligently pursued your concerns regarding venue, timing, accommodations, services, and content. In

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March each member was notified of the Board of Directors decision to meet concurrently with the AOA convention, but to segregate our financial and managerial resources. Our hope is to provide you with the highest level of service, accommodation, and value for your dollar, while maintaining the osteopathic camaraderie we all find through a convention. It is through your suggestions that we are tailoring our new plan. In 2009 the AOA has planned to return to New Orleans. Based on our surveys, the overwhelming majority of our college members have stated that they do not want to return to New Orleans. We are sensitive to the opinion of our members and are looking at other venues. This also gives us an opportunity to avoid a scheduling conflict with the ACEP Scientific Assembly. (As many of you have expressed, when the ACOEP and ACEP fall dates coincide, scheduling physicians can be a nightmare.) In 2010, we anticipate to be present concurrently with the AOA at the second unified convention in San Francisco.

As we move forward as an organization, we continue to depend on the strength of our members, our committees, our elected leaders, and our staff to grow. We are listening, and we are also asking for your help. While every decision we make may not be exactly tailored to your situation, each decision has not been without due diligence, strategic planning, and a predetermined purpose. This board and my presidency are about identifying the issues pertinent to the college, gathering the necessary information, discussing options, and taking action. In the end, creating value is what it is all about.

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

Is the grass greener on the other side?

What was considered a variable in life has become a constant and that is change. It is inevitable that change is present in everything we do. It is at home, in our communities, workplace, and schools, and evident in just about everything we do.

Is change desirable or is it important that life is constant and consistent?

I envied individuals who started their employment with one company and remained with the company until retirement. I admired those individuals who remained within an organization from the beginning of their employment until their retirement. They might have changed jobs and assumed more responsibility within the organization but they remained loyal to the organization until their retirement.

One individual who embodies the concept of consistency and sameness is the Class of 2007’s Baseball Hall of Fame inductee is Cal Ripken. Not only did Cal only play for one baseball team, the Baltimore Orioles, but he also played in 2,632 straight baseball games. Thus eclipsing the 56-year-old record set by “iron horse” Lou Gehring of 2,131 straight baseball games. Cal accomplished this feat over sixteen years and spent his entire career the Orioles from 1981 through 2001.

After completing my Emergency Medicine residency 18 years ago I knew my first job would not be my last job! I did not embellish that thought, but 3 ½ years later I changed jobs. I have been at my second place of employment for the past 15 years.

It always seemed to amaze me that moving 3 miles away to my current job would have such a positive affect on my well-being.

The change did wonders for me! I found a utopia if such a place existed! Many of the same patients frequented both hospitals and many of the physicians practiced at both hospitals. The directors at both hospitals were great bosses and I enjoyed my colleagues at both institutions, but I felt a sense of accomplishment and really enjoyed my work at my new job. However, the inevitable change occurred 11 years ago and these two hospitals merged and created a new health system. As with any merger there is downsizing and cost cutting and a newer, leaner health system emerged.

Throughout all this change the physicians from both sites have formed a cohesive group that has consistently provided excellent emergency care despite all the alterations in the health care environment.

Not only has the landscape of emergency medicine changed but the focus of emergency medicine has changed as well. We not only provide emergency care to those who need emergency care, but we provide primary care to patients who have nowhere else to obtain their care but

to those individuals who chose to utilize the emergency department in lieu of their primary care physicians. People do not want to wait to see their primary care physicians, they want immediate assurances and gratification and are not happy when they are told we do not know exactly what is wrong with them and they need to follow up with their primary care physicians or another sub specialist.

It is my contention that the health care delivery system in emergency medicine has shifted from a patient driven focus to a process driven and monetary emphasis.

Productivity is measured by patients per hour and/or by RVU’s that are constantly measured and reported. The process of moving patients through the emergency department quickly does not always insure quality patient care and could lead to omissions and mistakes. Patient satisfaction is measured (not always objectively and scientifically) and monitored with emphasis on improving scores. It appears that the bottom line is the most important aspect of the delivery of health care. It is all about money!!

As we all know, we as emergency physicians, for the most part, cannot control whom we see in our emergency departments and are open to all patients regardless of whom they are or their ability to pay. The back up services and medical specialties and sub specialties are determined by the hospital administration and the composition of the medical staff. Not all

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

2007 Fellows Named . . . . . . . . . . . . . . . . . . . . . . . . . . 20

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

Members in the News . . . . . . . . . . . . . . . . . . . . . . . . . 20

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

Letters to the Editor . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

For Membership Review . . . . . . . . . . . . . . . . . . . . . . . . . 7

Guest Article, Wayne Jones, D.O., FACOEP . . . . . . . . 23

Legislative Update . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Life Lessons, Christine Perry D.O., M.S. . . . . . . . . . . . . 25

ACOEP Names Special Honorees . . . . . . . . . . . . . . . . . 10

Emergency Department Ethics . . . . . . . . . . . . . . . . . . . 26

Clinical Opinion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 The PULSE JULY 2007

Editorial Staff Drew A. Koch, D.O., FACOEP, Editor Wayne Jones, D.O., FACOEP, Asst. Editor Peter A. Bell, D.O., FACOEP Gary Bonfante, D.O., FACOEP Duane Siberski, D.O., FACOEP Janice Wachtler, Executive Director Communications Subcommittee Drew A. Koch, D.O., FACOEP, Chair Wayne Jones, D.O., FACOEP, Vice Chair Gary Bonfante, D.O., FACOEP, Advisor James Bonner, D.O., FACOEP, Advertising Bobby Johnson, Jr., D.O., FACOEP William Kokx, D.O., FACOEP Annette Mann, D.O., FACOEP The PULSE is a copyrighted quarterly publication distributed at no cost by the ACOEP to its Members, libraries of Colleges of Osteopathic Emergency, sponsors, and liaison agencies by the National Office of ACOEP. The Pulse and ACOEP accept no responsibility for statements made by contributors or advertisers.

Display and classified advertising are accepted. Display advertisements should be submitted as camera-ready, pdf, or jpg formats in black and white art only. Classified advertising must be submitted as typed copy, specifying the size, and number of issues in which the copy should be displayed. The name, address, telephone numbers and email address of the submitting party must accompany advertising copy. Advertisers will be billed for ads prior to the publication of their advertisements and payments will be due within 30 days of the issuance of the invoice.

The deadline for submission of articles and advertising is the first day of the month preceding publication, i.e., December 1, March 1, June 1, and September 1. ACOEP and its Editorial Board reserve the right to decline advertising and articles for any issue.

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. © ACOEP 2007 - All Rights Reserved. Articles may not be reproduced without the expressed written approval of the ACOEP and the author.

services and specialties are available at every hospital. The population in each community varies as does the patients who utilize the emergency department. The payer mix also varies from community to community.

Patient perception of what is an emergency also varies from patient to patient. On a day-to-day basis we are constantly dealing with these variables and have little to no impact on controlling them.

We can control patient productivity and influence patient satisfaction scores and help to enhance revenues and decrease expenses.

This can be accomplished by working harder, being more courteous to patients and to be more diligent in our billing and not ordering tests that are unnecessary.

My utopia at work has eroded. The patient appears to have lost his importance in the delivery of health care. At times I feel frustrated and caught up in the throughput process and overwhelmed with the sheer volume of patients. Rarely, do I feel that we have kept up with the patient volume and provided patient care that was patient driven and not process driven. I have started to look at emergency medicine opportunities for employment in my community (I commute 30 miles to work) and other

Employment Opportunity

The Pulse – An Osteopathic Emergency Medicine Quarterly 142 E. Ontario St., Suite 1250 Chicago, IL 60611 312-587-3709 / 800-521-3709

communities. Are these other opportunities any better than the current job I have or is it the same issues just at a different location.

Do I really need a change or am I experiencing a mid-life crisis? Generally, I am not a proponent of change unless it adds to the quality of life or it makes mundane tasks easier and simplified. I still enjoy practicing emergency medicine but am constantly searching for that inner peace and sense of self-fulfillment that I found 15 years ago.

With all the change that is going on in the delivery of emergency medicine care is it possible to find that utopia that I found 15 years ago or will I find it within myself to accept the inherent changes and realize that many of the issues with emergency medicine I have no control over and I just have to deal with them!!

I am jealous and envious of Cal Ripken because he was able to start and finish his career with one team. I am already with my second team and contemplating if it is worth going to a third team or staying put.

I am concerned that the grass might not be greener on the other side!!

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For more information, contact Sharon Doggett, CPC, PRC, at 1-800-346-0747, Ext. 3086 or email CV to sdoggett@psrinc.net or fax to 972-739-2632.

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Executive Directors Desk Janice Wachtler

Where Do We Go From Here?

As I write this column I am reflecting on my job interview for the position of Executive Secretary of the ACOEP in August 1992. At that time, I sat nervously in Dr. Hambrick’s small, windowless office on South Ellis Avenue in Chicago, with smells from the Pizza Hut counter wafting in from outside the glassed-in “Executive Suite” across the hall from the entrance to the Emergency Room. We spent time talking about the position and where he saw the College in 15 years. He smiled and leaned back in his chair, propping up his feet on the corner of the desk in a pensive mood, and said, he would like us to be the voice of the osteopathic emergency physician.

When I asked if we weren’t that now, he shook his head and said that emergency medicine was the newest specialty and was growing fast, so fast that it could be as large as family practice some day, but probably not in his lifetime. Basically, he said, “I want us to have a seat at the table.”

Having been with the AOA since 1978, I knew that politically, the emergency physicians were considered the new kids on the block and with only a few programs, and had little, if any voice in the hierarchy of politics within the body of osteopathic medicine. I remember remarking, that it would take a lot of work to get there, but it was do-able. We then spoke about what the goals and objectives of the position of Executive Secretary would be, and he said that we needed to be organized otherwise we couldn’t get anywhere and even though the College had had good direction from its Board, they needed to have a hands-on direction on a day-to-day basis. He asked me if I was up to a challenge, and I said I was looking for something that I could use all my skills and talents and to learn more.

I wanted involvement and to have ownership in the process, which I felt that I didn’t have with my position at the AOA. He smiled and asked when I could start.

Since that day in August 1992, we’ve come a long way, but I can see that we have a long way to go. Over time, we’ve made subsequent changes in our educational programs, adding dimension and focus to some of the existing programs and adding completely new programs. We’ve changed our publication from a quarterly, four page periodical, to a publication in which we discuss cutting edge facets of healthcare, political issues (both within osteopathic medicine and outside of it), and maintain the interests of our members by focusing on issues they feel are pertinent. We have “seats at the table” on the AOA’s Board of Trustees in the countenance of Dr. Joseph Stella, Dr. Darryl Beehler, and Dr. John Becher. We also have representatives on several committees of the AOA in Dr. Raul Garcia-Rodriguez, Dr. Joseph Kuchinski, Dr. James Mitchell and others I am sure I am forgetting and to whom I apologize for their omission.

We have had strong and dedicated leaders as President, Officers, and Board Members, who lead and are leading with courage and determination. We have had good Student and Resident leadership that have taken the Chapters from their inception in the early 1990’s to now. And, we have had the good fortune of dedicated and loyal members who have traveled this road with us, enduring the bumps we encountered, and enjoyed our successes.

I thank them all and for their loyalty and contributions.

Now we are embarking on new paths and are becoming more independent and stronger in our representation of our members. Now, more than ever, we need to bring our physicians together to reach the next level of our organization.

Recently, in response to members’ input at countless scientific seminars, we informed the AOA that we would take control of our

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own convention and will meet over the same dates and in the same city, but at a different hotel venue. We will no longer meet on dates that conflict with other organizations that are important to our members and we will ensure that our vendors represent the needs of our members with vendors who are emergency medicine oriented and not simply the normal general medicine physician. We will work within the osteopathic family to present combined programs to strengthen our physician skills and interests, and we hope to do this while providing the most cost-effective way we can.

To accomplish this we ask our members to do several things. First, we need established physicians to seek out and reach out to younger physicians who may not be members and encourage their participation in our organization. We need Resident Members to encourage their peers to become involved in the extracurricular activities at conventions, like the research venues and competitions to build education and interest to their peers.

We asked physicians to provide us with contacts from pharmaceutical, equipment and hiring professionals who they would like to see participate in all of our conferences as either exhibitors or sponsors. And finally, we need our members to take an active interest in the political needs of the profession of Osteopathic Emergency Medicine.

We need you to become involved at your state level and sit on AOA Committees and the House of Delegates to bring the interests of the emergency medicine physicians to the forefront.

We are a dynamic profession and we need our members to reflect this aspect of their professional life. We need you to be active. Attend our meetings and take us for a test drive, if we have what you need, join, and encourage your peers to join.

As I sit and reflect on where we were in 1992 and where we are now I smile; all those physicians who have taken time out continued on page 26

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For Membership Review

At its Midyear Meeting in February 2007, the American Osteopathic Association (AOA) approved the Bylaws of the ACOEP in its new format, however, questions were raised as to some of the wording in this document and a request was made to review some items of concern. To this end the Bylaws Committee met in March to review the questionable wording and presented the following revisions of the Bylaws to the Board of Directors in April 2007.

The Board of Directors has requested that the membership be notified of the suggested changes in our Bylaws (listed below) and has requested that these be placed in the July 2007 issue of The Pulse for review.

A vote on these changes will be taken at the Membership Meeting on Sunday, September 30th in San Diego, California. If you have any questions or comments concerning these suggested amendments, please contact Dr. Michael Yangouyian, Chair of the Bylaws Committee at the ACOEP. You may fax your questions or comments to 312-5879951 prior to September 1, 2007. All such comments and questions will be reviewed by the Bylaws Committee in September.

(2) The physician must engage in appropriate educational activities, as defined in one of the following: (i) participating in continuing medical education activities to satisfy ACOEP CME requirements for emergency medicine specialists (this activity must occur during the three years prior to the date of application); or (ii) successful completion of an emergency medicine residency program approved by the AOA AND/or ACGME. The remainder of Section 1 and Sections 2, 3, and 4 are unchanged.

SECTION 5.

AUTOMATIC TERMINATION: THE MEMBERSHIP OF ANY MEMBER WHO IS IN DEFAULT OF PAYMENT OF DUES OR ASSESSMENTS FOR MORE THAN SIXTY (60) DAYS, OR OTHERWISE BECOMES INELIGIBLE FOR MEMBERSHIP, SHALL BE TERMINATED AUTOMATICALLY, UNLESS THE BOARD OF DIRECTORS DELAYS SUCH TERMINATION. ARTICLE IV - Ethics

Proposed deletion of wording appears as strikeouts; New wording appears as capital letters or underscored capital letters ARTICLE III – Members Section 1 – Membership (b) Active Member. Active membership may be granted to any individual who is a duly licensed Doctor of Osteopathic Medicine (the “physician”) who meets the criteria set forth below: (1) The physician must engage primarily in the practice or administration of emergency, who is defined as the (i) practice or administration of emergency medicine in an emergency care facility for three years prior to the date of application; or (ii) successful completion of an emergency medicine residency program approved by the AOA AND/or ACGME.

Sections 1, 2 and 3 are unchanged.

Section 5. Automatic Termination: The membership of any member who is in default of payment of dues or assessments for more than sixty (60) days or otherwise becomes ineligible for membership, shall be terminated automatically, unless the Board of Directors delays such termination.

ARTICLE VII – Board of Directors Section 1 is unchanged.

Section 2. Composition.

The Board of Directors shall be composed of fifteen (15) Board members to include 10 at large Board members, the President of the ACOEP Student Chapter, and the President of ACOEP Resident Chapter, and the President, President-elect and Immediate Past President of the College.

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The Executive Director shall be invited AS A NON-VOTING GUEST to attend and participate in all meetings of the Board of Directors.

Sections 3 through 14 – Nominations, subsection 1 are unchanged (2) The Board of Directors shall in accordance with the Constitution and Bylaws (or the equivalent thereof) of the American Osteopathic Board of Emergency Medicine (“AOBEM”) and in compliance with the AOA requirements nominate College members to serve on the AOBEM. THE AOBEM SHALL SUBMIT THE NAMES OF QUALIFIED EMERGENCY PHYSICIANS TO THE ACOEP’s EXECUTIVE COMMITTEE OF ITS BOARD OF DIRECTORS AND THE ACOEP WILL SELECT MEMBERS FROM THIS LIST OF CANDIDATES TO THE AOBEM FOR SELECTED TERMS. THE AOBEM SHALL THEN SUBMIT THE NOMINEES TO THE AMERICAN OSTEOPATHIC ASSOCIATION FOR FINAL APPROVAL. The College shall submit such nominations to the Bureau of Osteopathic Specialists. Members of the College Board of Directors are not eligible for nominations to the AOBEM AND the Board shall take into consideration the slate of qualified candidates presented to the Board by the College’s Nomination / Election EXECUTIVE Committee in determining such nominations.

IN THE EVENT THAT ANY CANDIDATE’S NOMINATION IS DISPUTED, THE AOBEM WILL SUBMIT SUBSEQUENT NAMES FOR NOMINATION. IF, AFTER THREE SUCH SUBMISSIONS, THE ACOEP AND THE AOBEM FAIL TO REACH AGREEMENT ON A CANIDATE, THE ISSUE WILL BE FORWARDED TO THE AOA BOARD OF TRUSTEES FOR RESOLUTION, IN ACCORDANCE WITH THE NOMINATION AND ARBITRATION PROCESSES DESCRIBED IN THE HANDBOOK OF THE BUREAU OF OSTEOPATHIC SPECIALISTS.

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Legislative Update Raul J. Garcia, D.O., FACOEP Chair, Governmental Affairs Committee

Get Involved Now For A Better Future

Our Emergency Departments are getting more crowded. More physicians are retiring because they cannot afford to work in today’s Healthcare. How can this go on?

Honestly, it may very well get worse before getting better some day. We hope that someday it will get better, but how bad does it have to be before improving? Everyone knows that our Healthcare system is a ticking bomb waiting to explode, but when?

Will it be when emergency physicians see most of the patients in every city because there is no one else to take care of them?

We must get involved in our profession now and avoid a harsh future. ACOEP is privileged to represent DO’s all over our country. Our college has been growing at an exponential rate and we thank you for your continued support. We are now the second largest college within the AOA and certainly one of the most active. As we grow, we want to make sure that we give our members the best benefits possible and represent your interests at all times. One of the most important aspects that may affect us everyday are the laws that are passed that directly affect the way we practice medicine.

We need your input, however, to make sure that we do the work necessary at the right time. We need to hear from you if you hear of any bill or law that has been passed or is being worked on that will affect your practice. We need you to go to DO-online.org and sign up for our grass roots government updates and stay informed. We need you to be our ambassador by sending letters to your Congressmen.

These letters are available to you on the advocacy section of DO-online and soon to be in our ACOEP website. We need you to visit your senators and representatives at their home office

Today we enjoy a freeze on Medicare cuts largely in part to the effort of our AOA Bureau on Federal Health Programs and the support of many DO's that fought to keep our Medicare reimbursement from

being cut last January. Today we have tough challenges ahead such as resolving the formula for physician reimbursement in the future, professional liability reform, volunteer faculty, student loans, graduate medical education and more.

Whether you are a student, a resident, a physician that just started practice, or one that has practiced for many years, you are welcomed to get involved. Make a difference now and we will have a better future than the one that is showing its face in a very ugly way.

Here is a quick view into the current events in legislative affairs.

Medicare Physician Payments

Reform of the Medicare physician payment formula, specifically, the repeal of the sustainable growth rate formula, is one of the AOA’s top legislative priorities. The formula is unpredictable, inequitable, and fails to account for physician practice costs.

Physicians are the only Medicare providers that are subjected to the flawed SGR formula. We must stop any further cuts and replace the SGR formula with one that lets Medicare beneficiaries’ access to physician services.

This is a difficult thing to do since it carries a high price tag along with it

(Billions). It is, however, something that must be done and both parties are aware and agree to some extend.

Graduate Medical Education

Resident Physician Shortage Reduction Act of 2007 (HR. 1093) and (S. 588) will increase postgraduate slots in those hospitals that have a need within designated physician shortage states. This bill will certainly help those hospitals that have been unfortunately capped at a number that is not realistic in their present need to provide access to healthcare in their population.

Medical Liability Reform

After trying to pass Medical Liability Reform for so many years, this will take a back seat with the new Congress. Most of the Democratic leaders strongly oppose reforms set forth on previous years and highly supported by the AOA and ACOEP such as capitation on non economic damages. If there is any bill introduced on this issue will be to reform medical liability through reviewing and changing current laws involving medical liability insurance companies but not touching upon any restrictions on lawyers or law suits vs. physicians.

Visit our Website for the latest legislative update.

Call 800-249-5770 or go to EMPractice.com to order today!

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ACOEP Names Special Honorees

At its meeting in April, the ACOEP announced the recipients of the special awards granted annually to physicians and supporters of the College who have provided services to the ACOEP, its constituents and the field of emergency medicine and EMS. These annual awards include the Bruce D. Horton, D.O., FACOEP, Lifetime Achievement Award; Benjamin A. Field, D.O., FACOEP Mentor of the Year Award, and the Robert D. Aranosian, D.O., FACOEP Excellence in Emergency Medical Services Award which are presented to members of the College who have gone above and beyond service to their peers and the medical community.

The Bruce D. Horton, D.O., FACOEP Lifetime Achievement Award was established in the late 1970’s to honor the ACOEP’s first President. It recognizes one ACOEP member who has made significant contributions to the specialty of osteopathic emergency medicine during his or her lifetime. For 2007, the Bruce D. Horton, D.O., FACOEP Lifetime Achievement Award will

be presented to Anthony Gerbasi, D.O., FACOEP of Bath, New York. Dr. Gerbasi was a founding member of the ACOEP and has actively practiced emergency medicine for over 31 years.

The Benjamin A. Field, D.O., FACOEP Mentor of the Year Award was established in 2003 in recognition of the teaching and mentoring skills of Benjamin A. Field, D.O., FACOEP (1952-2003). The award recognizes and honors osteopathic emergency physicians known for their teaching skills and unwavering support of students, residents and their fellow physicians. This year the Benjamin A. Field, D.O. FACOEP Mentor of the Year award will be presented to Victor A. Scali, D.O., FACOEP of Springfield, Pennsylvania.

Anyone who has been involved with the ACOEP since the early 1990’s will recognize Dr. Scali as a moving force in both pre and postdoctoral education at Kennedy Memorial Hospital in New Jersey and through the ACOEP.

The Robert D. Aranosian, D.O.,

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 Sunday, September 30, 2007 at the San Diego Marriott Hotel in San Diego, California. 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 material sent out in August / September with paid dues information and will be placed on the website when identified.

Anthony Jennings, D.O., FACOEP Secretary

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FACOEP Excellence in EMS was established in 2004 in recognition of the contributions made by Robert D. Aranosian, D.O., FACOEP (1942 – 2003). The award recognizes and honors osteopathic emergency physicians who have made significant contributions to the field of emergency medical services. This year, the recipient of the Robert D. Aranosian, D.O., FACOEP Excellence in EMS will be presented to Wayne Jones, D.O., FACOEP of Erie, Pennsylvania. Dr. Jones has been involved in EMS at St. Vincent Health Center in Erie and has acted as the Chair of the ACOEP’s EMS Committee and an author of many EMS articles in The Pulse.

The Awards will be presented at the Membership Meeting of the College at its Scientific Seminar at the Marriott Hotel and Marina in San Diego, California on Sunday, September 30, 2008. The exact location for the meeting will be announced on the ACOEP’s website beginning August.

Attention ACOEP Members Interested in Pediatric Research Opportunities Emergency Medical Services for Children National Resource Center Executive Director Tasmeen Singh MPH, NREMT-P has presented an excellent opportunity for first time researchers to obtain funding for research in pediatric emergency medicine. ACOEP members with an interest in developing a project, or participating in a project involving pediatric emergency medicine pre-hospital should contact: Mark Foppe D.O. FACOEP Coordinator of the Research Consortium ACOEP at DocFop@aol.com.

The purpose of the consortium is to offer assistance in getting a multi-centered project started, however, this source of funding is specifically seeking first time researchers.

Any one who is interested in participating in research is encouraged to contact the ACOEP to hear about available projects.

Any questions about the EMSCNRC can be sent to tsingh@emscnrc.com or faxed to 202-884-6845.

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Clinical Opinion Anita W. Eisenhart, D.O., FACOEP, FACEP

Balancing Pediatric Emergency Medicine Practice: Evidence Based Emergency Medicine with Community Hospital Systems Introduction

Evaluation and management decisions on many common pediatric presentations may be effected by several factors. The most academically responsible factor is evidence-based emergency medicine (EBEM).

There are evaluation and treatment guidelines based on good and voluminous EBEM in the literature and by academic bodies such as the American Academy of Pediatrics (AAP) and the American College of Emergency Physicians (ACEP) on many clinical scenarios. However, not all of us practice in a pure academic Emergency Department (ED). Factors influencing our daily decisions include:

o EBEM o Pediatricians’ / primary care providers’ requests o Consultants’ requests o Parents’ requests / expectations g satisfaction surveys o Nursing buy-in o ED patient volume / flow o ED physician experience & comfort level o That hair that sometimes stands up on the back of your neck

In this article, we will address integrating all these factors into safe pediatric emergency medicine practice decisions.

We will describe several ‘bread & butter’ pediatric presentations with expectations, EBEM, and practical solutions that won’t compromise your integrity and, more importantly, shouldn’t harm the child.

Case 1

An 18-month-old boy was toddling around with his big brother around 8 pm when he tripped and hit his head on the coffee table. He cried, loudly, and then returned to his normal state of mind. No vomiting, no seizure, no ataxia, no complaints of headache after the initial crying episode. The mother called the pediatrician

and got an on-call after-hours nurse who told the mother she should take him to the “ER” for evaluation (or maybe she was told to go to the ER for a CAT scan – you’ll never know what was really said during that phone conversation!).

Little Roger presents to your department with normal vital signs … and a goose egg on his forehead. Otherwise, he looks fine. Roger is eating the obligatory bag of chips, wrestling with his brother, and catching the myriad of viruses floating around the department. You introduce yourself to his mother, and her first words are, “My son needs a CAT scan”, or “My doctor sent me in for a CAT scan”.

Discussion

The decision to order a head CT may be considered ‘the easy way out’ of a potentially lengthy conversation with Mom. Certainly, a negative non-contrast head CT is a completely defensible discharge that makes both the mother and the practitioner comfortable. It’s the ‘peace of mind’ test.

Additionally, if your hospital employs any type of satisfaction survey and Mom comes in requesting a CT, she will certainly be satisfied with an unopposed ordering of said CT. Unless, of course, there is a long wait for the scan and / or the radiologist’s interpretation.

There are, however, several disadvantages to ordering a CT on this particular child. Many active children require sedation for a quality set of images. This has its own set of implied risks and use of nursing and practitioner time away from the ED. This also ties in to issues of ED flow, ED length of stay (LOS), and ED overcrowding. All of which are ultimately your responsibility.

Other issues that come up (often in department meetings if indiscriminate ancillary testing is employed) involve cost containment and radiology over-utilization.

There is, additionally, the concept of encouraging our community parents to

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dictate how we practice our craft. Should a mother, who may or may not have any medical training, dictate our evaluation and management? The answer is, “sometimes – yes.” When a mother insists, “this is not my child,” or “my child is not acting / looking right,” then, YES, we do allow them to help us with decisions. But should they generally be empowered to order whatever tests they want?

What if you order a CT, and find something? A cyst, for example, should be disclosed. And now the parent will worry without medical cause. What if a “possible right frontal punctuate hemorrhage on image # 14” is interpreted by the radiologist? This is likely not clinically relevant, nor likely to be seen on a repeat scan. However, you now have a child with blunt head trauma and a radiologist who thinks there might be blood on the brain. You are committed to act upon this information and a community hospital pediatrician may not want to admit this “trauma patient” to their floor. Now you are looking at a potential transfer to a tertiary care facility for a goose egg.

Radiation exposure. This is growing into a hot topic in the literature with statements from the government and academic bodies and reactionary commentaries in journals and list-serves. The American College of Radiology has said, “Because they have more rapidly dividing cells than adults and have a longer life expectancy, the odds that children will develop cancers from x-ray radiation may be significantly higher than adults.”1

The National Research Council's Committee on the Biological Effects of Ionizing Radiation additionally estimated that children less than 10 years of age are several times more sensitive to radiation than middle-aged adults.2

The U.S. Food and Drug Administration (FDA) developed a website for clinicians that offers information and links regarding radiation exposure from CT’s. On this site,

11

a non-contrast CT of the brain is said to be ~100 times the radiation exposure as that of a single-view chest radiograph.3

The FDA additionally has made recommendations for reducing the radiation exposure of children and small adults if a CT must be obtained. These settings are described on the referenced FDA Public Health Notification.4

Many guidelines with large and small sample-sized studies address the question, “Which well-appearing child should get a non-contrast head CT in the face of minor blunt head trauma?” The most recent large-scale study is the pediatric population of the National Emergency X-Radiography Utilization Study II (NEXUS II) data.5

The NEXUS II trial was a prospective multi-centered observational study with 21 participating hospitals. Patients presenting to the ED with blunt head trauma had CT results described and analyzed.6, 7 1,666 patients of the total NEXUS II cohort (13,728) were children 0 – 18 years of age.

In identifying risk for significant intracranial head injury, the overall cohort analysis identified eight criteria as predictive if any one was found: 1. Significant skull fracture 2. Altered level of alertness 3. Neurologic deficit 4. Persistent vomiting 5. Scalp hematoma 6. Abnormal behavior 7. Coagulopathy 8. Age > 65 years Sensitivity 98.3% Specificity 13.7%

When the first seven criteria were applied to the pediatric population of the study, the results were similar. There was a sensitivity of 98.6% (identified 136 of the 138 with intracranial injuries) and a specificity of 15.1% (classified 230 children as “low risk”). Regarding the two children that were not identified with one of the seven criteria, neither required surgical intervention.5

When these authors applied the criteria to the 309 children in the cohort under three years of age, they found 25 with significant intracranial injury. The sensitivity was 100% (no child would have been missed if any one of the seven criteria

12

were found) and a specificity of 5.3% (15 children would have been classified as “low risk”). Of note, the two most common findings in children < 3 years of age was altered level of alertness and scalp hematoma.5

All of these arguments being said, this author would try to convince Mom that little Roger would be fine to go home without any imaging; using phrases like, “I wouldn’t want to expose him to unnecessary radiation,” or “There are good data to show Roger is categorized as ‘low risk’ for any serious brain injury.” Ultimately, a casual, but often effective, argument would be, “We hit our heads all the time when we were kids. I never got a CT, and I turned out OK.”

I would discuss the possibility of clinically irrelevant findings and the potential risks of chemical sedation, if that would apply. If Mom was still insistent, I would offer her an observation period (either in the ED or at home and give her my direct phone line in the ED). In the final analysis, this is still her son, and if I have failed at any of my arguments and have clearly explained the risks, a CT may be ordered.

Case 2

An 8-year-old boy is sent from the pediatrician’s office with a note, “Abdo pain X 2 days with N/V & fever. WBC in office was 13.9. Please obtain CT to r/o appendicitis.” It’s 5 pm and this child is now in your ED.

You notice little Michael walks to his stretcher a little crooked, leaning a bit to the right, and he looks pale and poopy.

Vitals are Temp = 100.8oF, Pulse = 138, Respiratory Rate = 22, and Blood Pressure = 98/74 with a pain scale of “10”. His abdomen is soft with RLQ tenderness and RLQ rebound. He also winces when you touch his LLQ and grabs his right. Testicles are unremarkable.

You order intravenous fluids, basic labs and call the surgeon in hopes of catching him / her before they leave the building. The call comes back from a cell phone and you hear the clinking of restaurant glasses in the background. “What’s the white count? Get a CT and call me if it’s positive.”

Discussion

In this scenario, the child has a clear clinical picture for an acute non-ruptured

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appendicitis. Unfortunately, your primary care physician and the key consultant have suggested testing other than the diagnostic gold standard of laparotomy or laparoscopy.

There are several cons to this approach.

First, in a child with whom you are near certain has an acute non-ruptured appendicitis; a CT would delay the surgical cure by several hours. This carries a significant risk of rupture (which markedly increases the morbidity of the disease) and would be shouldered by you, the ED physician.

Many hospital protocols require intra-luminal contrast for CT evaluation of the appendix. If the contrast is administered by mouth to a child with anorexia, nausea, vomiting, and abdominal pain, this process could take several hours in addition to the two hours one must wait for the contrast to reach the appendix. It is, by definition, uncomfortable for the child with any of the aforementioned symptoms.

By ordering this CT, you increase the LOS in your ED, you may be contributing to an “already behind” scanner with ED flow also a consideration. As in case #1 above, your radiology utilization and ED cost increases. And the longer the child and their family wait in your ED, the less likely they are to be ‘satisfied’ on follow-up surveys.

As described in case #1, there are certain risks with pediatric radiation exposure. According to the FDA, an abdominal CT is ~500 times the radiation dose as that for a single-view chest radiograph.3 Add to that the very small, but potential, risks of intravenous contrast (such as anaphylaxis or renal failure).

After all the time, discomfort, radiation, and medication it takes to perform a contrast abdominal CT, many are interpreted by the radiologist as “inconclusive for appendicitis – recommend clinical correlation.”

A reasonable alternative to oral contrast is rectal enema contrast. Acosta, et al, described its safety and efficacy in reducing hospitalizations when the appendix was visualized.8

There are several exceptions to these arguments. An adolescent (or pre-adolescent) girl, for example, must always have gynecologic considerations and often are not evaluated for pregnancy or pelvic pathology by their pediatricians. continued on page 17

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Another child may not have such a straightforward history and physical.

In that case, imaging or extended observation with an overnight admission may be recommended.

Some facilities have shown reasonable proficiency with abdominal ultrasound evaluation of the appendix. This is a non-invasive tool that has not proven globally useful.

While a non-ruptured acute appendicitis is a surgical emergency, a ruptured appendicitis is not. If a child has ruptured his / her appendix, the rush to prevent rupture is mute. At this point, the child needs supportive care such as fluids, bowel rest, analgesia, anti-emetics and antibiotics. An interval appendectomy may be warranted.

Interval appendectomy in children with ruptured appendicitis was described in the surgical literature in the 1970’s and 80’s as a safe alternative to open laparotomies yielding decreased hospital days.9 If a child was diagnosed with a ruptured appendicitis, they could be “cooled off ” with antibiotics, fluids, and bowel rest for two days, discharged home, then brought back for an interval appendectomy in six weeks. Overall, the number of days in the hospital is markedly decreased, as is morbidity of the disease.

Several studies were published in the 1990’s on interval appendectomies including this study showing histopathologic evidence of the safety and efficacy of this practice.10

In the scenario described above, the surgeon should be actively convinced to come in without the scan. The conversation should be documented in non-confrontational language with the time the phone call was first made. If the surgeon continues to resist, a discussion with the pediatrician describing the “clinical diagnosis in evolution” should occur.

In the scenario where the diagnosis was not as straightforward as above, one could consider admission for observation, serial abdominal examinations and white blood cell counts.

If a CT of the abdomen is warranted, one may consider using rectal contrast (which has essentially no preparation time and is well-tolerated by children) or an unenhanced CT. Hoecker, et al, showed

unenhanced CT in their facility to be as diagnostically accurate as contrast-enhanced CT and compression-graded ultrasound.11

Given all these variables, a clear clinical picture of acute appendicitis should go for definitive care. Others may require imaging, however, the time to diagnosis may be minimized utilizing some of the techniques mentioned above. In a low-suspicion scenario, observation without imaging may be warranted.

Case 3

A 6 1/2 month old girl is brought to your ED by her mother at 6 pm on a Friday with a complaint of “fever.” Her mother goes on to tell you, “I think she has an ear infection – again – because she pulled her ear. That one … or was it the other? Anyway, her fever just started and we’re going on vacation tomorrow morning – Disney. We ran out of the pink stuff last time she had an ear infection and we need some more. Our flight is 9 am, so could we please have a sample bottle?”

Little Sophie is playful, active, and well hydrated. You notice her copious free-flowing rhinorrhea while she’s actively drinking her bottle of juice. Her vitals are the following: Temperature = 102.8oF, Pulse = 138, Respiratory Rate = 22, Blood Pressure = 96/66, and O2 saturation = 99%. Both tympanic membranes are a bit injected, but there’s no effusion, and they move freely

CORE FACULTY POSITION

Clinical Opinion, continued from page 12

with insufflation. There is no potential bacterial source for the fever on your physical exam. What do you do next? What do you tell Mom?

Discussion

Not too long ago, a child this age with a fever that high was aggressively evaluated for occult bacteremia with blood cultures and parenteral antibiotics if the white blood cell count was too high. Now, with vaccinations updated, most academicians would not draw blood on this short duration fever in a well-appearing child over six months of age.

Urine, however, may still be a consideration and a sterile procurement of urine for urinalysis and culture should be considered. Several authors have described risk factors13 for pediatric urinary tract infections (UTI’s) and commonly include: o o o o o o o

Younger age Duration of fever Height of fever Female sex Caucasian female Uncircumcised male History of previous UTI’s or vesico-ureter reflux o Fever without a source

Recently, Zorc, et al, in a large multicentered study found uncircumcised male

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children < 60 days of age to be of particularly high risk for UTI’s. Uncircumcised boys had a rate of 21.3% UTI compared with female (5%) and circumcised male (2.3%). Higher fevers were also a major predictor in their cohort.12

Many ED practitioners would agree, giving the requested amoxicillin is quick, easy, and almost guarantees high marks on a survey. It is generally a safe drug that this child has had in the past without adverse reaction. However, many would argue it is not the most appropriate management in this child with no middle ear effusions and about an hour of fever.

The “wait and see” concept in prescribing antibiotics in children with acute otitis media is well described in the literature as a successful way to decrease antibiotic usage (and minimize the development of resistance).14,15,16,17 The concept is simple (and somewhat Osteopathic)18; otitis media is generally a self-limiting disease and 06-EM-471 5/2/06antibiotic 5:21 usage.

PM Page should recover without

The practitioner diagnoses acute otitis media, writes a prescription for first-line antibiotics, and instructs the caretaker to delay filling the prescription for three days. If the child still has a fever or ear pain after three days, the prescription should then be filled.

Assuming the urinalysis is negative and a sterile culture has been sent, this “wait and see” approach to antibiotics may be a reasonable compromise between EBEM and Mom’s request.

Even though the child does not have acute bacterial otitis media at this time, the caretaker gets to take home a prescription (that may not be filled) and the physician gets to maintain some academic integrity. One could use a phrase such as, “Unnecessary antibiotics may be dangerous for your baby as it will decrease the ability to use them in the future when she really needs them.”

Case 4 1 A 6-year-old girl is brought in by Mom

with one episode of vomiting during gastroenteritis season. Mother states, “She has a VP shunt and I’m worried it’s not working.”

Little Delmonica looks great. Her vital signs are normal. She’s active and playful with a normal gaze. Her shunt bubble compresses and refills easily. She’s eating an apple in the ED. What do you do?

Discussion

This case is completely different from the previous ones. A child with special needs (in this case, a ventriculo-peritoneal shunt for hydrocephalus) is best evaluated by the primary care taker. “Mother knows best!” If the child was anything but well appearing, any ED practitioner would order a work-up and discuss the case with her neurosurgeon, neurologist, or primary care pediatrician.

In this case, the phone call to a physician that knows her best should be done, at minimum. One may order some testing such as a shunt series or a CT (if old ones

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are available for comparison). The child may get admitted overnight for observation.

If not, arrangements for early follow-up should be made between the ED practitioner and her physician with instructions to return immediately if symptoms worsen or if Mom has any concerns.

intervention. Parental reassurance, anticipatory guidance, consultations, and primary care follow-up are the mainstay of our practice. Controversies, however, exist quite frequently with these evaluations. EBEM may not always be adhered to and compromise is the norm.

Case 5

A 5-month-old female presents to your ED with fever of two days duration. Her vitals are; Temperature =101.8oF, Pulse = 148, Respiratory Rate = 32, and O2 saturation = 98%. Per triage protocols, she is given an appropriate dose of antipyretic.

The nurse takes the extra step and places a “U-bag” on her vagina.

Several web sites may help the ED physician during these controversies: o www.aap.org (policies & guidelines) o http://www.ncbi.nlm.nih.gov/entrez/ query.fcgi (literature search) o http://www.pemdatabase.org (list of current relevant papers / new concepts, etc) o http://listserv.brown.edu/archives/cgi-bin/ wa?A0=PED-EM-L (PEM discussion group)

Discussion

There are two issues here. The first involves the vital signs. Blood pressure is a vital sign no matter how old the child is. Premature babies in the neonatal intensive care unit have their blood pressures obtained regularly. There is a nursing folklore that exists in many hospital ED’s that children under 3 or 4 years of age do not require routine blood pressure testing.

And yet, most of the pediatric cases ‘under review’ are missing a blood pressure on the medical record. And the question arises, “Doctor, how do you know the baby was hemodynamically stable? No blood pressure was ever documented on the chart.” This is your responsibility.

The second issue is the placement of a bag for non-sterile procurement of urine.

This only serves one legitimate purpose to determine hydration status by interpreting the specific gravity and presence of ketones.

A 5-month-old female with a fever of two days duration should be evaluated for UTI and pyelonephritis, as described above.

Several prospective studies have addressed this concept of urine procurement.19, 20 Most papers conclude sterile procurement is best to decrease false positives cultures, ambiguous cultures, inappropriate antibiotics, and delay to appropriate management. This author agrees and finds very little use for the non-sterile urine specimen.

Discussion

Fortunately, the vast majority of children that present to a community hospital or urban ED’s are stable and require little

Ultimately, the child’s safety, the physician’s integrity and the physician’s level of comfort are key factors in these decisions.

Other factors, such as satisfaction surveys, consultants, cost-containment, ED flow and volume, etcetera must all be considered and balanced with every decision.

This is why we practice the art of Emergency Medicine and not as much the science. This is why we train so diligently and how experience earns confidence and respect. And why ED patients, our patients, cannot be evaluated and managed by technicians and flow charts.

This topic was presented at the American College of Osteopathic Emergency Physician’s (ACOEP) Spring Seminar in Chandler, Arizona, April 2007.

References

1. American College of Radiology. One Size Does Not Fit All: Reducing Risks from Pediatric CT. ACR Bulletin Vol. 57, Issue 2, pp.20-23, Feb 2001 2. National Research Council, Committee on the Biological Effects of Ionizing Radiations. Health Effects of Exposure to Low Levels of Ionizing Radiation (BEIR V). Washington, D.C.; National Academy Press. 1990 3. U.S. Food and Drug Administration: Center for Devices and Radiologic Health. What Are the Radiation Risks from CT? www.fda.gov/cdrh/ct/ risks.html May, 2005 4. U.S. Food and Drug Administration: Center for Devices and Radiologic Health. FDA Public Health Notification: Reducing Radiation Risk from CT for Pediatric and Small Adult Patients. www. fda.gov/cdrh/safety/110201-ct.html Nov, 2001 5. Oman JA, Cooper RJ, Holmes JF, et al.

Performance of a Decision Rule to Predict Need

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for Computed Tomography Among Children With Blunt Head Trauma. Pediatrics.117(2) February 2006, pp. e238-e246 6. Mower WR, Hoffman JR, Herbert M, et al, for the Nexus II Investigators. National Emergency X-Radiography Utilization Study. Developing a clinical decision instrument to rule out intracranial injuries in patients with minor head trauma: methodology of the NEXUS II investigation. Ann Emerg Med. 2002;40 :505 –514 7. Mower WR, Hoffman JR, Herbert M, et al, for the NEXUS II Investigators. Identification of high yield criteria for use in assessing blunt head injury patients for intracranial injuries. J Trauma.

59(4):954-959, October 2005 8. Acosta R, Crain EF, Goldman HS. CT can reduce hospitalization for observation in children with suspected appendicitis. Pediatr Radiol. 2005 Jan 9. Powers RJ, Andrassy RJ, Brannan LP, et al.

Alternate approach to the management of acute perforating appendicitis in children. Surg Gynecol Obstet. 1981 Apr;152(4):473-5 10. Mazzioti MV, Marley EF, Winthrop AL, et al.

Histopathologic analysis of interval appendectomy specimens: support for the role of interval appendectomy. J Pediatr Surg. 1997 Jun;32(6):806-9 11. Hoecker CC, Billman GF. The utility of unenhanced computed tomography in appendicitis in children. J Emerg Med. 2005 May;28(4):415-21 12. Zorc JJ, Levine DA, Platt SL, et al. Clinical and demographic factors associated with urinary tract infection in young febrile infants. Pediatrics.

2005 Sep;116(3):644-8 13. Gorelick MH, Hoberman A, Kearney D, et al. Validation of a decision rule identifying febrile young girls at high risk for urinary tract infection.

Pediatr Emerg Care. 2003 Jun;19(3):162-4 14. Marchetti F, Ronfoni L, Nebali SC, et al.

Delayed prescription may reduce the use of antibiotics for acute otitis media: a prospective observational study in primary care. Arch Pediatr Adolesc Med. 2005 Jul;159(7):679-84 15. Spiro DM, Tay KY, Arnold DH, et al. Waitand-see prescription for the treatment of acute otitis media: a randomized controlled trial. JAMA. 2006 Sep 13;296(10):1235-41 16. AAP: Subcommittee on Management of Acute Otitis Media. Diagnosis and Management of Acute Otitis Media: Clinical Practice Guidelines.

Pediatrics. 113(5) May 2004, pp. 1451-1465 17. Siegel RM, Kiely M, Bien JP, et al. Treatment of Otitis Media With Observation and a Safety-net Antibiotic Prescription. Pediatrics. 2003;112:52731 18. Webster GV. Sage Sayings of Still. Wetzel Publishing CO., Inc. Los Angeles. Reprinted 1991 by the American Academy of Osteopathy. p 52 19. Zorc JJ, Kiddoo DA, Shaw KN. Diagnosis and management of pediatric urinary tract infections. Clin Microbiol Rev. 2005 Apr;18(2):417-22 20. Shroeder AR, Newman TB, Wasserman RC, et al. Choice of urine collection methods for the diagnosis of urinary tract infection in young, febrile infants. Arch Pediatr Adolesc Med. 2005 Oct;159(10):915-22

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2007 Fellows Named At it’s meeting in April 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 2007 Class of Fellows are: Jamil Alarafi, D.O., Chagrin Falls, OH; Harry Arters, D.O., Brooklyn, Connecticut; Gaiti Bakhsh, D.O., Bloomfield Hills, Michigan; Raj Baman, D.O., Lincoln City, Oregon; Paul C. DePonte, D.O., Winter Springs, Florida; Craig Dues, D.O., Troy, Ohio; Kevin Durell, D.O., Rockwood, Michigan; Todd Duthaler, D.O., Ballston Spa, New York; James Frontino, D.O., Stratford, New Jersey; Brent Gear, D.O., Mesa, Arizona; Jon R. Gildea, D.O., Fenton, Michigan; Robert Hunter, D.O., Shelby Township, Michigan; Teddy Lee, D.O., Roselyn Heights, New York; Robert Mathews, D.O., South Lyon, Michigan; Robert D. May, D.O., Waterford, Michigan; Brian F. Miller, D.O., Manchester, Massachusetts; Kristyna D. Paradis, D.O., Fort Pierce, Florida; Brian S. Saracino, D.O., Shaver Town, Pennsylvania; Ashwin Shetty, D.O., New Hyde Park, New York; Kevin J. Sirchio, D.O., Wall, New York; James M. Turner, D.O., Charleston, West Virginia, and Christian Willingham, D.O., Platte

City, Missouri.

We would also like to thank the following Fellows for participating in the nomination process for Fellowship: Juan Acosta, D.O., FACOEP; Levente Batizy, D.O., FACOEP; Duane Corsi, D.O., FACOEP; Anthony DiPasquale, D.O., FACOEP; Mitchell Garfield, D.O., FACOEP; Tressa Gardner, D.O., FACOEP; Alan Goodrich, D.O, FACOEP; E. Rodrigo Guzman, D.O., FACOEP; William Halacoglu, D.O., FACOEP; Alan Janssen, D.O., FACOEP; Eric Mann, D.O., FACOEP; Charles K. McIntosh, D.O., FACOEP; Scott T. Miekley, D.O., FACOEP; Mark Mitchell, D.O., FACOEP; Thomas Mucci, D.O., FACOEP; Erling Oksenholt, D.O., FACOEP; Diane M. Paratore, D.O., FACOEP; Ernest Patti, D.O., FACOEP; Narasinga Rao, D.O., FACOEP; Victor J. Scali, D.O., FACOEP; William R. Siegart, D.O., FACOEP; Jennifer Waxler, D.O., FACOEP, and Michael Yangouyian, 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 on-line 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 Monday, October 1, 2007 at the San Diego Marriott Hotel. The ceremony will begin at 6:00 p.m. and guests are welcome to help celebrate this solemn occasion.

Members In The News

Paula Willoughby DeJesus, D.O., FACOEP has been named the 2007 recipient of the CECBEMS Janet Head Founder’s Award. The award recognizes extraordinary and enduring contributions to the success of the CECBEMS. Dr. DeJesus has served as the National Association EMS Physicians’ appointee to the CECBEMS Board of Directors from 1998 to 2004 and played a key role in the naming of ACOEP as a CECBEMS sponsoring organization.

As a board member, she has provided principled, practical input and a willingness to do the tough work of shaping policy and thinking through strategic initiatives.

Her colleagues found Dr. DeJesus’ participation indispensable as the organization strengthened its criteria, learning programs,

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implemented organizational accreditation, developed a comprehensive database of course completion records, implemented an organizational accreditation process, and relocated and hired professional staff.

“As a new board member in 2000, I quickly realized that Paula had a comprehensive grasp of EMS issues and a passion for making continuing education meaningful to the EMS profession,” says CECMEMS Chair, Nancy Steiner. “I still recall her strong rational opinions and her ability to argue through the tough issues agreeably.

Even though she left the board in 2004, Paula continues to support CECBEMS and its mission.”

The award will be presented to Dr. DeJesus during the National Association of EMS Educators Symposium 2007 in Los

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Angeles, California in September 2007.

Anthony Guarracino, D.O., FACOEP has been elected Medical Staff President of Carlisle Regional Medical Center in Pennsylvania. Dr. Guarracino has been an ACOEP Member since 1992 and has been involved in the ACOEP’s Academic Awards Committee.

Gerald Maloney, D.O. received the 2006-07 Teacher of the Year award from Doctors Hospital in Columbus, Ohio. Dr. Maloney was presented with this award by the resident class at Doctors on June 7, 2007 at a special ceremony in his honor.

Dr. Maloney has been deployed to Iraq and is scheduled to leave in late June.

Letters to the Editor This letter was received in response to an Executive Director’s Desk article, When Rights Collide, published in our April 2007 issue and is addressed to the author of the article. The response follows.

Ms. Wachtler, I was astonished by many of the questions in your article, When Rights Collide,” in the April 2007 edition of THE PULSE. It is unfortunate you have not been able to find the answers, but I am delighted to have the opportunity to enlighten you on the topic. I am sure there are others who share your uncertainties.

First, it is a common misconception that the phrase, “First, do no harm” comes from the Hippocratic Oath. Interestingly, the Hippocratic Oath does not and never did contain those words. It expresses a similar idea, but never states the words “First, do no harm.” The same holds true for the Osteopathic Oath. The dictum “First do no harm” translates to “Primum non nocere” in Latin. Some sources attribute “Primum non nocere” to Galen, an early Roman physician.

Coincidentally, it is a familiar misconception that the scenario you describe in the first paragraph of your article could be construed as “unfair” treatment of a patient.

Most of the physicians in ACOEP have taken the Osteopathic Oath so let’s examine some pertinent excerpts as they apply to your questions. “I will be ever vigilant in aiding in the general welfare of the community, sustaining its laws and institutions, not engaging in those practices which will in any way bring shame or discredit upon myself or my profession.”

Therefore, when you ask, “Is it the physician’s right not to choose to administer a birth control method to a woman who was the victim of rape or incest because he or she believes that all life, no matter how it was conceived, is precious and sacred?” The answer is unquestionably, yes. We do not have to bring discredit upon ourselves or our profession either by practicing contrary to our religious believes (a right granted to us by Amendment 1 of the Bill or Rights) or by breaking our oath.

Any reasonable person would agree rape is tragic and hurtful to women, but children born of rape are entitled to the

same rights as children who are not. It seems inherently obvious that all children are born innocent and therefore deserving of love regardless of their heritage.

It is beyond the ability of physicians to determine who is born into a loving environment and who is born into a non-loving environment regardless of religious beliefs.

Neither do we have the right to choose what happens to those children born of rape or incest, nor do we have any responsibility regarding children’s well being in terms of upbringing. However, we do have a moral, social, and professional obligation to contribute to children’s welfare by giving them the same fair and equal opportunity at life that children not born of rape are entitled to.

“So,” you ask, “when is it appropriate to interfere with a patient’s right to choose?”

Let’s refer again to our Osteopathic Oath. “I will give no drugs for deadly purposes to any person, though it may be asked of me.” Page 1076 of the 2007 PDR states, “Plan B is believed to act as an emergency contraceptive principally by preventing ovulation or fertilization (by altering tubal transport of sperm and/or ova). In addition, it may inhibit implantation (by altering the endometrium).” The birth control pill has the same warning by the way. If we pharmacologically inhibit implantation we are causing death, which is clearly prohibited by the Oath as well as certain religions. Fortunately a marvelous solution to unwanted pregnancies exists.

Plan A. Adoption. Everyone wins.

“What happens when legislation restricts patient rights? Is it a State’s right to deny the patient all the options available?” In this situation, of course it is. It is vitally important to realize there are actually two patients to consider. If parents are not willing to stand up for their children’s rights then it is up to the physicians, with the support of the State, as has already been established in other forms of child abuse.

For illustrative purposes, liken this instance to a suicidal patient. We have an obligation to do what is right, with the support of the State, in spite of the patient’s wishes.

“Will states allow health care workers to opt out of caring for patients based on ethnicity, sexuality, religion, and appearance?”

Unlikely as this does not seem reasonable.

“Does any of this belong in medicine?” Yes, because most of us want to do what is ethical.

You also mention, “... it’s not a

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personal choice not to treat someone in need of health care.” It is crucially important to comprehend that pregnancy is not a disease. Nor is fertility, and these conditions, in and of themselves, do not require treatment. Therefore, the decision to not prescribe or dispense contraception in any form is not denying anyone health care by any means.

I thank you for allowing me to answer your questions. I hope you will contemplate the information provided and share if you encounter others with the same misunderstandings. Please feel free to contact me if you have any other questions.

Sincerely, Christian Willingham, D.O. Response: EDITOR: The ACOEP notes Dr. Willingham’s concern about the contents of the Executive Director’s article, When Rights Collide. While the ACOEP does review every article appearing in its publication for content it does not necessarily restrict viewpoints expressed within it. This particular article did go through extensive review as well as medical ethical review prior to publication. As stated by Ms. Wachtler, this was her own opinion and she was not speaking for the ACOEP, however, the Editorial Board found the topic a medically important item to our members and thus published the article.

We have also published Ms. Wachtler’s response to Dr. Willingham for the benefit of our readers.

We specifically express our thanks to Dr. Willingham and encourage our readers to take an active role in our publication.

If any reader wishes to submit medically cogent topics for discussion in the publication or issues that they feel need to be addressed we encourage them to do so.

DK Dear Dr. Willingham,

Thank you for writing to us concerning the Executive Director’s Desk article, When

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Rights Collide, appearing in the April 2007 issue of The Pulse. I appreciated your comments and thank you for your answers.

This article was based upon an issue publicized in the Washington Post last year and basically stated that States were considering legislating physician care based on the beliefs of the physician. While, I personally believe that a physician should treat every patient regardless of their lifestyle or the reason that they appear in a one’s office or emergency department, I don’t believe issues of morals and spiritual beliefs of any kind should be legislated by the government.

I personally believe, that in the case scenarios, described in my article, a physician, regardless of his or her own personal belief system, should care for the total patient. In the case of rape or incest of a child or adolescent, they should be treated to prevent pregnancy. A child should not have a child, especially when they are unable to care for it or understand the ramifications of being a mother at an early age.

However, the parent or guardian should also be counseled on the options available, if they chose to rear a child and follow your Plan A, but they need to know the available treatments and the option of a Plan B.

In the case of a mature woman, she should be treated appropriately and counseled of all available options and the choice is hers to make. Your suggestion of Plan A is great, but doesn’t happen often; the choice of Plan B should be explained, with all its physical and mental side effects, and the patient given the choice whether to take that path. Physicians have no idea of the ramifications these treatments will have on a particular patient when they leave their care, but the patient should be informed, counseled and allowed to choose the course that best suits their life.

The questions raised by such legislation are endless and only individual physicians and patients can ever know how one encounter may change their lives, but if they cannot receive the counseling and physical care they need because a physician is opposed to or restricted by law to discuss a specific treatment; that would truly be an injustice.

All people in America have rights outlined in the Bill of Rights and the Constitution, and that’s why we live in America. We all have the right to a belief system and whether it is through an

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organized religion or a self-regulated belief system, but we all must look at ourselves every day and know that today we did no harm to ourselves, our family, or society. It is this internal belief system that regulates our behavior does not need governmental intervention.

While you have expressed your opinion on this issue very eloquently this article has achieved what it’s purpose was to bring discussion to the forefront. As you have stated your opinion other ACOEP members have expressed theirs. This issue has brought both criticism and support. I have received thanks from members for bringing it up and been chastised for the same reason.

But overall, it has generated controversy and discussion. It is a powerful issue and one that is going to invoke comments and feelings on both sides, whether they were expressed in writing or just discussed in your doctor’s lounge, at least it will be

discussed. I truly appreciate your feedback and would like to use your letter in the next issue of The Pulse if you would allow us to.

Again, thank you for expressing your opinions. I have forwarded your letters to the Editorial Board and Dr. Bell for their information.

Best wishes, and please keep reading our publication and writing to us when you find it necessary. We truly appreciate your input.

Sincerely, Janice Wachtler Executive Director

ACOEP has recognized William Mencke, Jr.

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

Three First National Plaza, Suite 5100, Chicago, IL 60602

© 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.

The PULSE JULY 2007

continued on page 25

© 2006 Citigroup Global Markets Inc. Member SIPC. Smith Barney is a division and service

Guest Article Wayne Jones, D.O., FACOEP

Red Flags

Being the victim of a patient sign-out is always a stressful event for any ED physician. Drive by sign-outs are even worse. I was a victim. Here is my story.

A colleague was preparing to leave and “just wanted to let me know” about a patient still being treated, but was already written up for discharge. “She is having a panic attack and diarrhea” was the diagnosis. “OK”, I thought, “that goes together”.

The first red flag went up.

The patient was a female in her 30’s complaining of the feeling she that could not rest and was experiencing diarrhea for the last 24 hours. She was tachycardic in the 130’s with a normal blood pressure and no temperature. The attending ED physician had given one liter of saline, two milligrams of lorazepam and left an order for 25 milligrams of benadryl if the patient was not calm enough for discharge. Soon after my colleague’s departure the nurse notified me the patient was no better. The second red flag went up.

It is known that from about 1300, Norman ships would fly red streamers to indicate that they would "give no quarter" (take no prisoners) in battle. This usage persisted into the 17th century, when the flag was adopted by Buccaneers, who were pirates of French origin operating in the West Indies. Buccaneers would initially hoist the Jolly Roger to intimidate their foes. If the victims chose to fight rather than submit to being boarded, the pirates would then raise the red flag to indicate that once the ship had been captured, no man would be spared. I could feel the cannons pointed directly at me.

“When all else fails, examine the patient”, I thought to myself. I entered the room and sat down beside the patient.

Sometimes just centering yourself with the patient helps. She was ill kept and snoring. I shook her shoulder. “Mrs. Smith, Mrs. Smith, wake up, it’s Dr. Jones.” Immediately she rolled over, and over and continued moving. She mumbled incomprehensible words

and slid off the end of the bed yelling, “I’m having diarrhea!” It was too early for this.

I retreated back to the nursing station.

Red flag number three. If I were a ship, I’d be sinking.

My colleague had been a victim of a condition known as “bending the map”.

The phenomenon was coined by wilderness rescuers where people lost in the wilderness ignore sign after sign of their real whereabouts, preferring instead to replace map oriented trail signs with anything which makes the map look as they feel it should.

She made the patient fit the “map” or

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symptom complex which made sense to her at the time.

I returned to the chart. CBC normal; BMP normal; meds: paxil. The skies parted.

The cannons lifted. I called the hospitalist for the admission.

Our patient suffered from an indolent and probably under diagnosed illness. She was suffering from serotonin syndrome.

Serotonin syndrome is a potentially serious drug-related condition characterized by a number of mental, autonomic and neuromuscular changes. In the 1950’s it continued on page 26

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Life Lessons Christine Perry, D.O., M.S.

Lessons Learned from Labrador Retrievers about Relationships: Why You Should Treat People Like Dogs!

As I am preparing to graduate from residency, I looked back at “the journey.”

Some of the most important lessons I learned in residency were given by my dogs. If you are a medical student or are preparing to start residency, reading this article may save friendships, your marriage and your bank account.

1. The Tail Wag Well, last time that I looked, I did not have a tail. But, for those with dogs, when is the last time that you returned home from a long shift to find your dog(s) greeting you eagerly at the door? Yesterday? For those of you without dogs, when their tails wag from excitement, their entire backside wiggles. No matter what type of day you have had, you smile on the inside or laugh.

From now on, when you return home from a shift, no matter how tired you are, appear enthusiastic about your homecoming. If you todder off to your office or retreat to bed without giving your significant other attention, then you are missing an opportunity to preserve your relationship.

2. Eat With Gusto Now, I can make a great bowl of Cheerios.

I will admit, I am challenged in the kitchen to say the least. Give me a chest tube; I can re-expand a lung. Give me a cookbook… and you may find yourself at a restaurant, or at least wishing you had gone. Either way, if your spouse prepares you a meal, eat and enjoy the meal with them. Or, make regularly scheduled opportunities to dine out together. You have to eat so enjoy the meal, the break and the company.

3. Run, Romp and Play Daily My dogs love when I take them mountain biking. They get such delight from avoiding my crashes and I enjoy the exercise (especially if I have not impaled myself on a stick). You work hard. You have earned the right to have fun from time to time. We are so meticulous about our work schedules

that some of us don't allow time for fun, or yet … feel guilty about it. Your significant other needs to see the playful side of you too. Dedicate time together. Do something you both enjoy. The time that you spend together will rejuvenate both of you.

4. Take Naps When my dogs are tired, I find them in the yard, sleeping in the sunlight or cuddled on their favorite blanket. When they wake, they are ready to go again. Why didn’t I take more naps? I get crabby when I am overtired, which at some points during my training seemed all the time! Most arguments and poor decision-making were made right after a yawn. Do not make decisions while exhausted, sleep on it.

5. Do Not Stay Angry I have scolded my dogs for running out of the yard to chase a squirrel or for eating my running shoes when I did not take them with me. Five minutes later, they are in my face with a rope or a ball, ready to play. They seemingly forgot that I was mad at them. They do not hold a grudge.

Enough said.

6. Time Out When my dogs are playing a little rough together or fighting over the same toy, I take the toy away and give them a time out.

For them, it is all fun and games until someone gets hurt. And someone always does.

After a few minutes of distraction, they are off doing their own thing… chasing birds or digging more holes in my yard. So, next time you are in disagreement with your significant other, agree to disagree and take a time out. Go for a walk, or do whatever it takes to be alone. Revisit your problems again … later.

7. Do Not Sleep Where You Potty In training my dogs, the veterinarian said the best way to potty train your puppy is to put them in a kennel while you are away.

The dog will never urinate or defecate in the cage, because that is where they have

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to sleep. Therefore, do not consider dating anyone in your program. Eventually, it will go bad. And when it does, your dirty laundry will be scattered around the department like a room after a trauma code. Save yourself embarrassment and frustration; date someone from a different medical facility. Better yet, date someone not associated with medicine all together. Diversify!

8. Play In Your Own Yard When my dogs are in my yard, I know they are safe. There are some rules, but for the most part, I give them the run of the house and yard. I did have my dogs neutered, but don't think for a moment that they will not jump at the opportunity to sniff another dog’s “business-end.” What happens when a female dog is in heat? All the neighborhood dogs go crazy. At the end of the season, it always ends up with 6-8 bastard puppies. Then, neither owner is happy with the outcome, not so different from humans!

So, play in your own yard!

9. Be Patient I can put a dog biscuit on my dogs’ noses and they drool and wait to eat it. However, I had to learn to be patient as well. Being in Emergency Medicine, I found that I want immediate fixes in all areas of my life, however, that's not always feasible. If I learn to become more patient, things will go much smoother and less frustration will arise.

Early on in residency, I broke most of these rules. If I acted like my Labradors, I might have two-legged children in addition to furry four-legged children. Hopefully this has changed your perspective on “treating people like dogs.”

Cat person? Bad role model for relationships. They do what they want and when they want all the time. That is a sure fire way to that shiny “For Sale” sign in front of your home… and your heart.

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

What Whould You Do?

In this issue of The Pulse we will review the case of the 48 year-old female patient who came to the ED after an apparent seizure, and was subsequently intubated.

This case was presented in April 2007.

Our patient arrived obtunded and unresponsive to painful stimuli, with dysconjugate gaze, flaccid, and hypertensive. With an absent gag reflex, she was intubated prior to CAT scan. The CAT scan revealed chronic changes and no acute findings.

Initially present was one of her sons, who was unaware of the patient’s HIV status. He requested removal of life support, stating the patient “did not want to be on a machine”. There was no written advance directive. Soon after, the entire family (two more sons, a sister, and a grandfather) arrived. They all requested removal of life support; they knew of the HIV. What would you do?

Executive Director, continued from page 5 of their schedules to make a commitment to the ACOEP should be very proud of our achievements – their achievements. Where we go from here is undetermined at this time, but if I can project where I would like to see ACOEP in 15 years, I would hope our goals are these: (1) to have 85% (or more) of all osteopathic emergency physicians as our members; (2) to secure 100% of osteopathic emergency medicine residents

Guest Article, continued from page 23 was referred to as serotonin behavioral syndrome or hyperactivity syndrome which best describes its presentation.

Serotonin syndrome is often seen in patients taking two or more medications that increase CNS serotonin levels. L-tryptophan will increase serotonin synthesis while drugs like amphetamines and cocaine will

26

This case presents a dilemma for the emergency physician. We have a patient with a grim prognosis experiencing an acute event requiring intubation for airway protection. The family does not want life support continued, and indicated this had been discussed with the patient; and this was the patient’s wishes.

Certainly, had there been a formal DNR or designated power of attorney for health care this would have been no problem. In the absence of this documentation, what are our obligations? One could rely on a health care surrogate act to determine a decision-maker for the patient. Although, each State proscribes a surrogacy order and conditions, would this patient be considered terminal, irreversible or in a persistent vegetative state? Her acute condition remains undiagnosed, and is potentially reversible.

It was unknown if her HIV was full blown AIDS. Consequentially, the intubation was

protective, not for a respiratory arrest, and also potentially reversible.

as resident members and have them remain active, involved members as they leave residency and become active members; (3) to have a successful and strong philanthropic arm that provides funding for research in our profession and does not have unused funding because research is not being done; (4) to have a strong cadre of supporters of pharmaceutical, equipment and employment companies that will seek out the ACOEP to provide for our foundation and

educational sponsorships, and finally, to have a dynamic membership that will fully entrench osteopathic emergency medicine as the second largest specialty in osteopathic medicine.

Thank you all for your continued support – you are by far the most wonderful, and dedicated people I have ever encountered and I am extremely proud to say I am the Executive Director of the American College of Osteopathic Emergency Physicians.

increase serotonin release. The more typical antidepressants including amitryptyline, fluoxetine (Prozac), sertraline (Zoloft) and paroxetine (paxil) inhibit serotonin uptake.

Symptoms associated with serotonin syndrome can be varied but may include confusion, agitation, anxiety, coma, tachycardia, nausea, diarrhea, myoclonis, restlessness, diaphoresis and hyperpyrexia. Please

understand that this list is not inclusive.

Mild cases will resolve in 24-72 hours.

More severe cases may require hospitalization. Regardless, the medications suspected of inducing the illness must be discontinued.

No specific therapeutic approach to treatment has been fully evaluated. Treatment relies on symptomatic relief and monitoring.

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What happened?

The ED physician appropriately had an intense discussion with the family.

He explained the intended temporizing measure of the intubation and the need for observation. Also, it was learned the patient was under the care of physicians at a tertiary medical center and the plan would be to subsequently obtain more information. The majority of the family accepted this, although some remained upset and still wanted to remove life support.

If you have any cases in your practice that you would like to present or have reviewed in The Pulse, please fax them to us at 708-915-2743.

Coming Soon

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

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