The Pulse July 2009

The PULSE

Osteopathic Emergency Medicine Quarterly JULY/AUGUST 2009 VOLUME XXXIV NO. 3

Working Together to Help Direct Positive Changes Presidential Viewpoints Thomas A. Brabson, D.O., MBA, FACOEP, President I sincerely hope that this issue of The Pulse finds you having a happy and healthy summer.

Although this is traditionally a busy season for many of us because school is out and many people are enjoying the great outdoors, we need to make sure we too are taking time to relax with our family and friends.

Much is in the news lately about healthcare reform. Our president Obama and Congress are trying to find a comprehensive plan to provide some form of health insurance for all Americans. The greatest beneficiaries will be the 46 million Americans who currently have no health insurance. Throughout all of the plans and debates lies a common thread, money. Who will pay for the new system? The government, the employer, or the individual are the leading options. If however, you are experiencing the misfortune of not having a job and no money, then there is only one option remaining. Our current system has government sponsored insurance available through Medicare or Medicaid, but many Americans don’t qualify. Perhaps a new system would remove these limitations.

As osteopathic emergency physicians we need to anticipate and prepare for the changes that we will be experiencing. Will the number of emergency departments visits increase with a universal healthcare coverage system? The emergency physicians in Massachusetts would likely say yes.

Will the ‘medical home’ concept increase or decrease emergency department visits?

Many emergency physicians have expressed concern that the ED visits will increase.

The medical home concept has some logical benefits but some practical deficits. We live in a society of people who want convenience and immediate gratification of their wants and needs. With that said, what will the behavior be for the person that perceives a medical condition between the hours of 5 p.m. and 9 a.m.? Will the sore throat or belly pain at 3 am. wait until the next available appointment with the medical home physician? As an osteopathic emergency physician, I’m sure you have experienced many cases of patients with doctors coming to the ED for care because they either couldn’t or didn’t want to wait to see their doctor. Your ACOEP is in the process of developing a position statement on the medical home. We shall work with the AOA and other emergency medicine organizations to assure that the voice of the osteopathic emergency physician is heard. Our position is that the emergency department is an important and necessary

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component of our current and future healthcare systems. Our emergency departments stand ready to care for people with real and perceived medical emergencies. Our state of readiness and willingness to care for all who present must be factored in when the compensation for care decisions are being made by the healthcare policy makers.

You ACOEP has also been active in addressing the Institute of Medicine report on residency training hours. The focus of the report was on patient safety, resident wellness, and the training experience. We were invited to participate in a group of emergency medicine organizations to provide practical feedback on how the issues in the report would affect the emergency medicine training programs. The other organizations involved in the group were: ACEP, Association of Academic Chairs of Emergency Medicine (AACEM), American Academy of Emergency Medicine (AAEM), Council of Residency Directors (CORD), EMRA, RRC-EM, Society for Academic Emergency Medicine (SAEM). Alan Janssen, D.O., Gregory Christiansen, D.O. and I participated in the group’s response to the report. The concern for emergency medicine is that limiting the duty hours with mandatory time off would adversely impact upon the resident’s training and the operations of the emergency departments. The consensus continued on page 4

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Table of Contents Presidential Viewpoints . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Thomas A. Brabson, DO, MBA, FACOEP Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Drew Koch, DO, FACOEP American Osteopathic Chapter of WADEM . . . . . . . . . . . . . . . . 4 Executive Director's Desk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Janice Wachtler, BA, CBA Board Nominations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Training in Policy Studies Program . . . . . . . . . . . . . . . . . . . . . . . 9 Governmental Update . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Jay Kugler, D.O. In My Opinion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Gregory M. Christiansen, D.O., MEd ACOEP Visits the Netherlands . . . . . . . . . . . . . . . . . . . . . . . . . 14 Guest Columnist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Wayne Jones, D.O., FACOEP Events Calendar for September 2009 . . . . . . . . . . . . . . . . . . . . 15 Lifestyle Adventures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 James Shuler, D.O., MA, FACOEP Emergency Department Ethics . . . . . . . . . . . . . . . . . . . . . . . . . 17 Bernard Heilicser, DO, FACEP, FACOEP

The Pulse An Osteopathic Emergency Medicine Quarterly 142 E. Ontario St., Suite 1500 Chicago, IL 60611-5277 Editorial Staff: Drew A. Koch, DO, FACOEP, Editor Wayne Jones, DO, FACOEP, Assist. Editor Gary Bonfante, DO, FACOEP Thomas Brabson, DO, MBA, FACOEP Anthony Jennings, DO, FACOEP Janice Wachtler, Executive Director Editorial Committee: Drew A. Koch, DO, FACOEP, Chair Wayne Jones, D.O., FACOEP, Vice Chair Gary Bonfante, DO, FACOEP, Advisor David Bohorquez, DO Thomas Brabson, DO, FACOEP Joseph Dougherty, DO, FACOEP Anthony Jennings, DO, FACOEP William Kokx, DO, FACOEP Annette Mann, DO, FACOEP Brian Wiboon, DO Janice Wachtler, CBA The PULSE is a copyrighted quarterly publication distributed at no cost by the ACOEP to its Members, library of Colleges of Osteopathic Medicine, sponsors, exhibitors and liaison associations recognized by the national offices of the ACOEP. The PULSE and ACOEP accepts no responsibility for the statements made by authors, contributors and/ or advertisers in this publication; nor do they accept responsibility for consequences or response to an advertisement. All articles and artwork remain the property of the PULSE and will not be returned.

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Articles may not be reproduced without the expressed, written approval of the ACOEP and the author.

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

Are We Ready for Change?

President Obama addressed the AMA House of Delegate at their annual meeting On June 15, 2009 in Chicago. This was an historic moment for our country where President Obama set his blueprint for health care reform. His speech can be found in its entirety by searching, President Obama’s Remarks at the 2009 Annual Meeting of the AMA House of Delegates. Health care reform consists of 2 crucial components: cost containment and affordable coverage for everyone.

Rising health care costs affect individuals, families, small businesses and corporations and is a major threat to our economy.

As a nation we are spending over $2 trillion annually on health care. Individuals and families have seen their out of pocket expenses soar and insurance premiums increase over the past decade at a rate higher than their wages increased. One third of small businesses have decreased health care benefits and another third of small businesses have eliminated their worker’s health coverage since the 1990’s. Chrysler and General Motors have felt the high cost of providing health care to their workers which has made them less profitable and less competitive with other automakers.

If health care costs are not reined in then many individuals, small businesses and corporations will go broke.

Past comprehensive health care reform efforts by former Presidents Teddy Roosevelt, Harry Truman, Richard Nixon, Jimmy Carter and Bill Clinton over the past century have failed. This is in part because various groups: physicians, insurance companies, businesses, workers and others could not agree upon reform and opposition by special interest groups and lobbyists. This

spring the AMA, hospital association, labor unions, health insurance companies, pharmaceutical companies and medical device manufactures agreed to work together to decrease national health care spending by $2 trillion over the next decade. This is an historic moment that all the major players are willing to work together to decrease national health care costs.

President Obama’s building blocks to health care reform are: 1. Electronic medical records.

2. Emphasis on preventive care rather than managing diseases.

3. The federal government must advance health living and disease prevention through public health and wellness programs 4. Eliminating payments on things that do not make individuals healthier but rather add to the health care expenses 5. Eliminate the current system of paying for quantity of care, i.e. the more tests you order the more you get paid 6. Changing compensation to physicians and hospitals by bundling payments so the physicians are not paid for every treatment of a chronic disease but how the overall disease is managed 7. Provide physicians with bonuses and incentives for good health outcomes 8. Reward medical students who chose primary care and work in underserved areas 9. Disseminate medical information that replicates best practices and incentivizing excellence

President Obama wants to ensure that every American can get health insurance that they can afford. One tenet of his speech that is emphasized is that if you like your insurance and you like your doctor, there is no need for you to change insurance or doctor. However, if you do not have health insurance or you do not like your

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health insurance you can participate in a Health Insurance Exchange. This Exchange will consist of either a private insurance or government insurance. This Exchange will allow an individual to do one stop shopping for insurance compare benefits and prices and select the best option for a patient and its family. The days of denying coverage based upon a preexisting condition are over.

The goal of his program is to allow every individual the ability to get insurance and a system that fosters individual responsibility for owning health insurance. There will be a hardship waiver for those who cannot afford insurance. He also feels that businesses have the responsibility to provide health insurance to its workers. If the businesses cannot afford insurance then there would be an exemption and the small business and their employees would be able to purchase insurance in the Exchange.

How do we as an individual and a nation pay for these health care reforms and health insurance for every American? One would hope that Health care reform would be cost neutral but one wonders how that can occur. There are three ways to pay for this program. The first is to increase revenues.

This would be accomplished by increasing taxes and decreasing taxable deductions.

One proposal is to tax health care benefits.

A second way to pay for these health care proposals is to increase deficit spending which has already been initiated through $635 billion that was passed in the recent stimulus package which is to be used over the next decade. Third way to pay for health care reform is to decrease spending on existing inefficient Medicare and Medicaid programs and supporting programs that utilize generic drugs.

As health care providers and consumers we must be involved in helping to solve the health care crisis and ensuring that continued on page 4

American Osteopathic Chapter of WADEM The American College of Osteopathic Emergency Physicians is currently an affiliate of the World Association for Disaster and Emergency Medicine. During the recent World Congress for Disaster and Emergency Medicine, www.wcdem2009. org, I expressed my desire to develop and establish the American Osteopathic chapter of WADEM, www.wadem.org. I currently serve on the Board of Directors for both WADEM and the ACOEP. www.acoep.org

serve Emergency Medicine and both serve humanity. Coordination and collaboration will benefit both organizations. I have sent my letter of intent to Dr. Demetrios G. Pyrros, the President of WADEM, in Athens, and to Professor Frank Archer, chairman of the Board, in Australia. In order to develop the chapter, one requirement is membership in both the AOA and in the WADEM. Other requirements and objectives can be discussed when we meet in Boston, 2009.

My vision is to synchronize efforts for the next generation of holistic international physicians. Both organizations

Holistic disaster medicine will require unity of effort from all of our academies. All AOA members are welcome. If you are interested

Presidential Viewpoints, continued from page 1

ACOEP. Also, ACOEP member Douglas McGee, D.O. attended the meeting representing CORD. We have included a picture of the group taken during the meeting. The collegial group discussions evolved around the need to address the workforce issues in emergency medicine. Quite simply, we currently do not have enough residency trained and board certified emergency physicians to staff all of the emergency departments in our country. Many ideas were discussed and prioritized. Our goal as an organized body of emergency medicine experts is to shape and direct our future as we expect to experience change in the way medicine will be practiced in our country. This was a very productive and positive meeting for all of us.

Although I started by hoping you are taking time off for yourself this summer, I still want to remind you to stay active in your ACOEP and in your chosen profession. We still have many issues to combat in order to get to the ideal practice

of emergency medicine. Much of what we need to change resides in Washington, DC. On July 1, 2009, CMS released the proposed rule for the 2010 Medicare physician fee schedule. An overall reduction of 21.5% is projected with a small increase for emergency service CPT codes. The increase will however in no way compensate for the astronomical decrease in payment.

We need to remain proactive in getting Congress to address the problems with the Sustainable Growth Rate (SGR). We also need to remain proactive in supporting the Access to Emergency Medical Services Act (S469) and (HR1188). I encourage you to utilize the expertise of Shawn Martin, Leann Fox and the rest of the AOA Washington office to achieve our goals.

I thank you for all that you do everyday for your patients, the ACOEP and the practice of emergency medicine.

order less expensive tests and educate our patients. We want affordable health care that is available to all. Second, we should support our professional organizations that can help lobby for meaningful and well thought out health reform. Our involvement is important to prevent mandated

healthcare reform that is unfunded. We hope that our legislation has the intestinal fortitude to pass meaningful health care reform that is cost neutral and provides coverage to all Americans.

report was presented at the ACGME Duty Hours Congress in June. We plan to publish the response in the future once the group has it in a publishable format.

Your ACOEP has also been invited to a historic meeting in early July held at the ACEP building in Dallas. ACEP coordinated the 2 day meeting titled, Future of Emergency Medicine Summit. In attendance were: AAEM, ACEP, ACOEP, AACEM, CORD, Emergency Department Practice Management Association, EMRA, Emergency Nurses Association (ENA), Office of the Assistant Secretary for Preparedness and Response (ASPR), SAEM, and Society of Emergency Medicine Physician Assistants (SEMPA). This was truly a historic meeting in that we had all of the major emergency medicine organizations in one room to discuss issues that were important and common to all of us. Anthony Jennings, D.O., Mark Mitchell, D.O. and I represented your

Editorial, continued from page 3 everyone can have affordable health care insurance. What can we do to help? First we can contact our lawmakers in Congress and have our patients’ contact the lawmakers to ensure that our voices are heard. We can

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in joining the AO chapter of WADEM, please title the e-mail “WADEM” and send it to irisbo@comcast.net with a copy to Andrew Lavelle at ajlavelle@medicine.wisc. edu. See you in Boston in 2009 and then in Beijing for the 2011 World Congress.

Peace and Strength, William L Bograkos, DO, FACOEP

Executive Directors Desk Janice Wachtler

Welcome Home For the past looked at purchasing property in markets five years I have throughout the U.S. but found that basihad a notebook cally, all the locations we looked at were labeled, Project: basically the same, the big difference would New Home, in be a cross-country move would involve my desk drawer. training all new staff and would the investThe 5” notebook ment in the trained staff outweigh the costs contained all the of the move? The answer: No. information on We then began to look at the purproperties we’ve chase of property in and around the downlooked at since the town Chicago area. We looked at buying Board’s Executive Committee put forth the office condominiums which would provide directive to me to find a suitable home for us with the equity we needed to have. the national office. Our search began in Unfortunately, as they say, timing is every2004; our real search began in 1992. thing, and when we were ready to buy, Back in 1992, we relocated the office the market wasn’t accommodating and we from an office in the emergency depart- had to let it go. We then began looking at ment at Chicago Osteopathic Hospital to 500 square feet at the AOA Building. Within the year, we increased our space from two rooms and some hallway space to 900 square feet to accommodate our growing need for staff assistance with a growing membership. We then moved to 1200 square feet in 1997, followed by another move to 2300 square feet in 2002.

In 2004, the Executive Committee saw that we needed to have a presence within the emergency medicine community and the space that we Entrance to the ACOEP / Foundation Offices occupied in the AOA building wasn’t going to meet this need; it would rental properties; these wouldn’t provide us also limit our staff growth that was expected with equity unless we did the buildout and within the next years. So we began to look, were able to increase our credit base, but by not in earnest but to see what we would commanding the buildout responsibilities, need to achieve a move that would provide we would be able to lower rental costs, us with a presence, growth potential, and increase our space needs and establish the the ability to grow equity for the College. presence and expansion we would need for Over the years, we looked at our invest- a long period of time. ments and began to make adjustments to AOA provided us with the ability to build a base. We also looked at real estate do this by providing us with a package for markets across the country. In 2006, we growth of both equity and staff by rent-

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ing us 5,000 square feet on its 15th floor.

We now have a home that we can be proud and will provide us with space in which to grow our services to our membership; and this is why.

As you disembark from the elevators, you will see the ACOEP and FOEM logos in the elevator lobby, as well as our office doors welcoming our members. Our office now features a formal reception area and specific areas for Member Services and Meetings and Conventions. We also have a place for staff to relax and eat, instead of at their desks and room for the Foundation to operate instead of shared space in our former conference room. We also have a conference room that is able to host the full board, as well as committee meetings. As we move forward we will be outfitting this room for remote broadcasting and be able provide online, live broadcast, CME programs. Also, in the future, we hope to be able rent the room to outside groups to provide an income line for the College. Also as we move forward, we may be able to manage other groups and staff those groups with room to spare. Additionally, we will have street level signage when AOA updates its kiosk outside the 142 Building later this year.

The photos below illustrate the changes we have undergone and we hope all of our members will visit us when they are in Chicago.

We would also like to thank the following people who helped to make this real: Peter Ajluni, D.O.; Carlo DiMarco, D.O.; John Crosby, J.D.; Frank Bedford; Josh Prober (AOA); Susan Geijer and Bill Jones (John Buck Management Company); Ray Griskelis and Dana Gilberti (Griskelis,

Young Harrell Architects); John Graziano, Jim Masso and Mike Graziano (Graystar Construction); Gordon Hill, Kathleen Gale and Samantha Smith (Office Concepts); Peter Kaplan and “The Team” (Norcom, Inc); William C. Menke, II (Citigroup); Anne Hemmings (Neal, Gerber and Eisenberg Law); Members of the ACOEP Board; Brittani Eckhardt, Mandy Lundeen, Erin Moore, Brian Thommen, Yvonne Treacy and Kristin Wattonville (ACOEP); Carolyn Swallow (FOEM) as well as Linda Holman and Shirley Jenkins (Security Officers at the AOA Building). We couldn’t do it without you!

Reception Area

Staff Break Room

Interior of Conference Room General Interior Office

Hallway to the FOEM Office and Conference Room

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Board Nominations At its meeting in April 2009, the Fellowship and Nominations Committee reviewed 7 potential candidates for the three available positions on ACOEP Board of Directors. The positions are three years in length commencing on September 30, 2009 and ending with the Membership Meeting in 2012. The candidates for the available positions are listed below.

Joseph Gregory Beirne, D.O., FACOEP Dr. Beirne is a 1997 graduate of the Chicago College of Osteopathic Medicine and a 2001 graduate of Des Peres Hospital Emergency Medicine residency program. He was core faculty for the residency program at Des Peres from 2001-2003.

Since 2003, he has worked as an attending physician in the emergency department at Missouri Baptist Medical Center in St. Louis, Missouri. Dr. Beirne is the director of EMS Education there, and also co-medical director for two fire departments in the St. Louis area. He has been the medical director for St. Louis Community College-EMS Programs since 2003.

Dr. Beirne received board certification from AOBEM in 2003, ACEP fellowship in 2004 and ACOEP fellowship in 2005. He is currently the chair of the ACOEP EMS committee, and has served as a member of this committee since 2004. He has also served on the undergraduate medical education committee and contributed lectures to the “Student Lecture Series” CD. Prior to medical school, Dr. Beirne worked as a paramedic and shift supervisor for a hospital-based EMS system in suburban St. Louis. He maintains active involvement in EMS in the St. Louis area and has EMS research interests that include Prehospital Cardiocerebral Resuscitation, Prehospital Therapeutic Hypothermia and Prehospital Treatment of Atrial Fibrillation.

Gary Bonfante, D.O., FACOEP Dr. Bonfante is a 1993 graduate of the

Philadelphia College of Osteopathic Medicine and a 1997 graduate of the Emergency Medicine Residency of the Lehigh Valley/St. Luke’s Hospital in Allentown, Pennsylvania.

Since then he has served as core faculty and Program Director of the Emergency Medicine Residency Program and Director of Medical Education at Lehigh Valley Medical Center in Bethlehem, Pennsylvania.

Dr. Bonfante has been a program evaluator for the AOA and ACOEP since 2003.

Dr. Bonfante has been involved in Continuing Medical Education for the College and has been a member of the CME Committee for many years where he has coordinated the Scientific Assembly since 2004 and assisted the College in planning and executing its first independent convention last year in Las Vegas, Nevada.

Dr. Bonfante is active in ultrasound and has taught several ultrasound workshops for the College at its Spring and Scientific Seminars, thus providing low cost training to members interested in honing their bedside ultrasound skills.

Dr. Bonfante is completing his first term on the Board of Directors of the College and requests your support in continuing to serve the College and its membership.

William Bograkos, D.O., FACOEP Dr. Bograkos received his Disaster and CBRNE training during his 28 years of military service. He has served both Army and Air Force as a military Flight Surgeon, Family Practice and Emergency Medicine physician. He has also served in Naval Hospitals as an Independent Emergency Medicine contractor. COL Bograkos chaired the U.S. Special Operations Command’s Curriculum Examination Board for the Advanced Tactical Practitioner (SOF EMT-P) from 2004-2006. He served the Pentagon’s Civil Military Emergency Preparedness office as a Bioterrorism/ Medical Consultant for the Black Sea Initiative in 2005 and briefed at the First Interpol Global Conference on Preventing Bioterrorism in Lyon, France, in March 2005. He served in the Balkans as a Division Surgeon with NATO Multi-nation-

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al Peacekeepers post 9/11 (Sept.2001- Apr. 2002). Dr. Bograkos served with a Special Operations WMD Detachment prior to and during the Millennium.

Dr. Bograkos has lectured on CBRNE terrorism and Disaster Preparedness in Bosnia-Herzegovina as a Peacekeeper, in Estonia with the State Partnership Program, in the Netherlands at the Dutch Urban Warfare Seminar, for the Special Operations Medical Association, and for various Law Enforcement agencies in the United States.

He has served as the Chief Medical Officer & Chemical- Biological Expert Consultant to the Director of Operations, Bureau of Immigration and Customs Enforcement, Department of Homeland Security (20032004). He is a current member of the Civil Law Enforcement Military Cooperation Committee of the International Association for Chiefs of Police and the Police Physician’s Section of the IACP www.theiacp.org Dr Bograkos has been an Instructor with the National Center for Biomedical Research and Training since 2002. He has instructed with Michigan State University’s “WMD for the Law Enforcement Executive” (MSU School of Criminal Justice), and with FEMA’s Healthcare Leadership training at the Noble Training site in Anniston, AL. Dr. Bograkos is a member of both the American College of Osteopathic Emergency Physician’s EMS Committee and the American College of Osteopathic Family Practitioner’s Preventive Medicine and Medical Preparedness Committee.

Publications include “Examining the Military and Law Enforcement Terrorism Counteraction Model” in Emerging Technologies: Recommendations for Counter-Terrorism Institutes for Security Technology Studies, Dartmouth College (January 2001) and the Institute for Defense Analyses AAR: “Black Sea Initiative TTX TOMIS International 2005 Constanta, Romania 13-16 September 2005” IDA Document D-3240 (both approved for public release).

In September of 2005 he returned to active duty service and has focused on the “Homecoming” of returning troops from

the GWOT. His efforts have been towards bridging trauma care with physical and psychological recovery. He currently serves as the Chief “Warrior Transition Division”, Clinical Operations, for the North Atlantic Region Medical Command.

In 2006, he was awarded the “Dr. Robert Aranosian Award for Excellence in EMS” and elected to the Board of Directors for the ACOEP www.acoep.org He serves as a Reviewer for the Continuing Education Coordinating Board for the Emergency Medical Services www.cecbems.org and as an International Reviewer (Civilian-Military Collaboration) for WADEM. He has been a member of the World Association for Disaster & Emergency Medicine www. wadem.org since 1994 and a Board Member since 2007. Dr Bograkos was appointed to the American Osteopathic Association Bureau on Scientific Affairs & Public Health in 2008.

John C. Prestosh, D.O., FACOEP Dr. Prestosh is a practicing emergency medicine physician in practice since 1978, who continues in the clinical art of our specialty. Additionally, Dr. Prestosh enjoys the academic side of emergency medicine and have been an associate program director from 1992 to 2001 and a program director since 2002. Dr. Prestosh has been active in the ACOEP for many years and was awarded the honorary title of Fellow in 1998. Presently, he serves as a member of the Undergraduate Medical Education.

Nominating and Fellowship, Program Directors Committee, and serves as Chair of the Resident In-Service Exam Committee.

Dr. Prestosh is also completing his first term on the Board of Directors of the ACOEP. Dr. Prestosh values the trust placed in him when elected to the Board of Directors three years ago. These past three years have been an effective learning experience with past and present board members mentoring him in always placing the College first and foremost in all decision making. He states that “these years have given me a solid basis of understanding in what is required from a board member and the necessary experience to be a qualified and proactive member of this decision-making body.“

Dr. Prestosh would appreciate your vote to continue as a board member. He realizes that every decision the Board enacts has a significant impact on the ACOEP membership. Board members do not vote in a vacuum but are representatives of the entire American College of Osteopathic Emergency Physicians. He assures the membership that he will continue to listen and heed what you, the members, say and will strive to reflect your requests and concerns.

James Shuler, D.O., MS, FACOEP, FAWM Since I was a medical student, my mission with this organization was to improve educational quality. While in medical school I held two jobs and pursued a Master’s Degree in healthcare administration while being an active member of several clubs including being a founder of the still popular Anatomy Club actively operating today at Des Moines’ DMU. My commitment was cemented during a board-review lecture as a resident in the late 1990’s. Since then I’ve joined the meetings twice annually and voiced my opinion. I truly believe that my input has helped “raise-the-bar” and we’ve created an outstanding educational institution of which I’m proud to be the co-chairman.

Additionally I am the Chairman of the Undergraduate Committee, I’ve been keenly interested in the undergraduate’s needs as I felt communication with that group was lacking from the profession. We have now created a lecture series and a much more open and friendly stream of communication/mentoring so far unprecedented by other groups.

My dedication is greater than ever as is my devotion to the ACOEP. My committee work is not yet done, however I am sure I can be more effective at the board-level.

I am a dedicated member missing only a single meeting in 10 years. I am steadfast in both my chair and vice-chair positions and consider them an honor and use those positions to push for improvement and greatness for the organization. I have been a fellow of the ACOEP for a while and now have recently become a Fellow of the Academy of Wilderness Medicine (FAWM)

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recently helping fulfill my passion for wilderness related medical issues.

Additionally, I have given frequent lectures to many organizations including the ACOEP. I’ve worked as an ED doc between Loveland’s McKee Medical Center, Denver’s Exempla Lutheran Medical Center and our own urgent care centers called MedExpress now burgeoning nationally over the past 8 years.

I have always enjoyed being involved in the betterment of our field and organization and helping create an even better learning environment for those in the future and would appreciate the opportunity to continue doing so by becoming an active board-member.

Thank you or your time in the consideration of my candidacy.

The 2009 election of Board Members will the last election held exclusively at the Annual Fall Meeting. Beginning in 2010, electronic voting will become the norm for the election of Board Members. Right now, the mechanism is being worked on that will make all voting available to those members with voting rights through the ACOEP website. Members will be able to log onto a confidential site and vote one time for the number of available positions from the slated candidates. This voting period will be open approximately 45 days prior to the Membership Meeting. Voting will be open for 30 days, closing 15 days prior to the meeting during which time the votes will be tallied and verified by the electronic system.

Members will be notified of the outcome of the Election at the Membership Meeting.

Please watch for additional information on this voting process in the Spring issue of the PULSE and online in our What’s New section of the Website.

Tim Cheslock, D.O. ACOEP-Resident Chapter President-elect

Training in Policy Studies (TIPS) Program Provides Unique Experience to Osteopathic Residents The AOA offers a unique program Centers for Medicare and Medicaid Services, taking in how the AOA engages the many to Osteopathic residents in Health Policy Washington political think tanks such as facets related to health policy.

Studies. Nicknamed TIPS, which stands the Brookings Institute and many others Residents are mentored through the for Training in Policy Studies, this mini provide high level overviews of current process of developing a health policy brief on a piece of current legislation. The fellowship is held over four weekends presentation of the brief is a requireduring the course of the year in ment for graduation and is critiqued conjunction with the Health Policy by several experts in the health policy Fellowship program co-sponsored by arena. the AOA and NYCOM/NYIT, and Functioning as an advocate and ACCOM. In addition to the weekend resource to elected officials is also programs, independent studies, readpromoted. This portion of the training ing and preparation encompass an culminates with a visit to Capitol Hill additional 10-20 hours per month. to meet with the participants elected The Training in Policy Studies officials to establish a relationship as (TIPS) program was created to provide a potential resource for health policy a yearlong experience for osteopathic information. physicians in training (residents) to Throughout the year the major become familiar with health care issues focus is to review health policy efforts as they relate to federal and state poliAdebimpe (Bimpe) Alfolabi, DO,PGY-1 IM Heart of Lancaster from the “high ground�, in that we cies and to equip them with the skills to Regional Medical Center; Lindsay Tjiattas-Saleski, DO, PGYparticipate in policy discussions and 1 EM/FM Frankford Hospital; Tim Cheslock, DO,PGY-2 EM limit our bias as physicians and focus committee work. Graduates of the pro- and Patricia Smolter, DO,PGY-2 EM Saint Vincent Health on the overall issues of Access, Quality, gram join a cadre of health policy experts Center; and Randi Kodroff, DO members of the 2008-09 TIPS and Cost. that may serve on committees and task and Health Policy Fellowship prepare to visit legislators on In 2008-2009 there were ten participants in TIPS, four of which were EM forces at the federal and state levels, Capitol Hill. residents. Applications are now testify on issues relevant to osteopathic medicine/education, and develop policy policy and introduce the participants to the being accepted. More information can be positions. process of health policy development and found at the TIPS website http://iris.nyit. edu/nycom/tips. Applications are due by Each weekend is centered on a particular implementation. topic related to health policy. Speakers from Participants are able to observe a June 1, 2009. the AOA government affairs office, the meeting of the AOA Bureau of Federal department of Health and Human Services, Health Programs during the first weekend,

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Governmental Update Jay Kugler, D.O. Chair, Committee on Governmental Affairs

Don’t Get Caught Homeless As part of comprehensive health care reform, the Federal Government is promoting the idea of the “Patient-Centered Medical Home.” I suspect many of you have not heard of this, or are not sure what it means to us as Emergency Physicians.

The “patient-centered medical home” (PCMH) model is an idea supported by the American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), and the American Osteopathic Association (AOA). The general idea is that patients would have a personal physician

who provides comprehensive, culturally and linguistically appropriate care. This physician would coordinate all of his/her patient’s care with specialists and be the gatekeeper for his/her patients. This model is predicated on the idea that these patients would have better access to their primary care physician. He/she would use evidence-based medicine, improved quality measures and in turn receive a higher compensation for acting as the patient’s “Medical Home.”

Proponents of the model contend it will improve the health of patients, reduce costs to the healthcare system, and, among

other benefits, reduce crowding in emergency departments.1 On the surface this is a sound idea. And, in a perfect world where all patients follow the rules, schedule their appointments and get sick during business hours, it probably will work well. However, we all know this is not the reality.

As Emergency Physicians, how does it affect us? Currently, most office based practices are only open business hours. Most do not offer late night or holiday hours.

Many primary care practices are too full to continued on page 18

Anthony Jennings D.O., FACOEP

The On Deck Circle: Healthcare Reform A few years ago my brother was taking his family to Florida for vacation on the beach. His young children were very adventuresome. He was worried that they would get into the ocean and get to far away from the shore. After pondering how he might keep them out of the water, he devised a plan. He took only one movie for the 10 hour drive……….Jaws. My nephew and nieces went no where near the water!

As we look at Healthcare Reform, perhaps we need a movie which would depict how scary the current healthcare reform bill being debated actually is. Is there a Canadian Healthcare Equivalent out there?

We could show it a few times and move on. We all can agree on only one piece of this horrific puzzle. That being that healthcare needs to be changed. We as a country certainly need to get it right. However this reform bill is so bulky it becomes weightless. It is so fragmented it is schizophrenic. I think our legislature would best serve us by taking on only a few issues and making them work well. There are so many different pieces of the bill that there

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is simply no way to enforce them if enacted and simply no way to make them work. I would be happy to see just a few issues

addressed. Say we tackle the end of life issues with one bill. Get that right. Then take on the insurance company issues.Then the undocumented alien care issue could be addressed. Eat them one bite at a time. You know….the same way you eat an elephant!

This summer I have attended the Future of Emergency Health Care Summit in Dallas July 7 and July 8. Dr Brabson, Dr Mitchell, and myself represented the ACOEP. Other attendees at the meeting were ACEP, AAEM, CORD, EMRA, ABEM, and several other notable

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organizations. Many important topics were discussed including work force issues facing us, training issues, residency issues, and other additional items. I think that more than anything it was a historically positive experience that opened a dialogue between the organizations that influence emergency medicine. Hats off to Nicholas J. Jouriles, MD, FACEP, President <http://www.acep. org/aboutus.aspx?id=23008> ACEP for putting this meeting together.

In mid-July our Executive Finance Meetings were held in Chicago. We held the meeting in our new office which served us very well. In this time in which many organizations have struggled our even gone under, the ACOEP remains a healthy organization. We as a board have committed ourselves to maintaining our organization’s health. That same week Jan, Dr Brabson, and myself attended the AOA House of Delegates Meeting also in Chicago.

I look forward to our fall conference in Boston and hope to see you all there!

In My Opinion Gregory M. Christiansen, D.O., MEd

Is It Time for You to Take a Stand On Health Care Reform?

While deciding to pursue osteopathic medicine, I observe an unsettling case which has always made me uneasy about government involvement in business affairs. I was changing jobs and seeking a new career after the market crash of 1987. I wanted to learn more about medicine and more specifically, osteopathic medicine. So I met with a DO family physician who was only 6 months into his practice. He did pro-bono work at a local nursing home as a way of giving back to the community. Unfortunately for him, he did not realize the significance of having a business partner with so much power – the federal government. In his attempt to recoup the cost of the influenza vaccine he administered to the nursing home patients, he charged Medicare approximately $1.60 for which the agency would only allow $1.30 ( I forgot what the actual costs but the difference was nominal). That cost difference he charged resulted in this young physician being charged in an indictment for Medicare fraud. He was made an example for the community to take heed. He was an easy target because he did have enough money to support adequate representation.

He spent 6 months in jail and when he got out he vowed never to participate with a Medicare, Medicaid or any other government program. From that experience I learned the government will not pay for the real cost of healthcare and politics have little regard for the altruistic motivations.

The law will be applied at it's fullest when it is politically expedient. Politics will drive a particular position without regard to the consequences or paradoxical reactions. Since that time the term fraud and abuse changed from a noble consumer protection platform into a means of bullying physicians into submission by mere threats alone. So it is with a jaded perspective that I approach the altruistic ideas of the politicians who aim to form a government centered system.

Before I speak to healthcare reform efforts I need to comment on the apparent silence on the healthcare debate. Physicians have been on the sidelines reacting to statements rather then forwarding ideas or examples of improvements. Poles indicate 60% of Americans are dead set against the reform plans as too costly and are uneasy about rationing care. But where are the physician voices to help shape this debate? Are we making the effort to get involved or are we content to let someone else do the speaking for us? In this day where mega-contract groups administrate our management for us and personal time takes precedence in contract negotiations, I wonder if there is enough interest out there to take a stand or position. The Pulse, blogs, local papers, radio and indeed our own leaders should be hearing from us. Is it that we do not know where to turn to be heard? I hope we are not being complacent to accept whatever is decided for our patients and ourselves.

I also hope people are not afraid to speak up. We need the vetting of ideas in order to improve the system. Systems research notes that group think improves processes better then individuals. When I reviewed the opinion pages in major newspapers and internet sites there are only a handful of physicians expressing their opinions on the biggest issue facing the healthcare industry. I believe the physician voice has largely been unheard because of the lack of uniformity to the message, analogous to the herding cats pictorial. Additionally, many may not be knowledgeable enough to know the real issues in this debate. Of the 100 most influential people in healthcare, not a single person is a practicing physician. The result of limited information about what the future of healthcare will be coupled with a cacophony of opinions have left many physicians to be essentially silent. We have been portrayed as a confused group

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without a direction and thus marginalized in the debate. The pharmaceutical industry and some business groups have received far more attention and perceived gains in the reform process. In fact, the debate has seemingly gone on with out much physician participation which is in itself ironic since the physician core is the backbone of any healthcare reform policy. Fortunately, the AOA through the Washington office has filled in some of the knowledge gaps with its town hall forum and web based information. If physicians are to take the responsibility to be the core of the health care engine then physicians need to engage and speak up. The AOA has provided a platform for this to occur but essentially health care reform is a grass roots issue that requires your active personal participation and accountability. It begins with your active participation in your specialty college or state chapter. You are essentially helping improve the system for your patients.

I want to go in a bit further to get at the core of the problem. Healthcare pundits have all missed the point of the debate. As physicians we hold basic values. We are all ‘socially liberal’ to the extent that we want to help our patients heal and get better.

Just as the founders of this country professed basic values of life, liberty and the pursuit of happiness, the medical profession itself has basic core values. The first tenant we need to understand is the principle of the physician – patient relationship. As a resident a wise physician once told me the day the dollar is pitted against the patient then we have lost the profession. How prophetic but predictable his words were. We need to hold as the foundation of any reform the sanctity of the physician – patient relationship.

Without this cardinal principle, any reform effort is doomed. There is little reason to work such long hours in stressful conditions if the reward is so narrowly focused. Every

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student and resident applicant submits this principle as the reason for enduring years of training and cost to become a physician.

Third party payers, the legal community, government interventions and physicians themselves have gone a long way to have desecrated this relationship. Health care reform can not be about money, it needs to be much bigger then that. A point which seems to be beyond the bean counters comprehension. We are denied time with our patients and forced into uncompromising decisions. In this worsening healthcare climate some in our profession have felt cornered by the demise of this relationship often referring to patients as litigious enemies who seek the destruction of our livelihood and our very own health. The division of the doctor patient relationship needs to be a paramount principle. In my experience, the only happy physicians in contemporary medicine have managed to maintain and emphasize this tenant. No health care system will have positive lasting effects without adhering to this principle.

We have marginalized this value and we

need to get it back into our core if we are to stem the tide of a failing health system.

Now I don’t profess to know the panacea for reform, but we can look at what we think impairs the physician – patient relationship as a starting point for meaningful change. The US ranks 37th in terms of health performance and spends about $8,000.00 per year for that performance.

With those numbers we are offering poor value for the cost. As a result 46 million people lack health insurance and impaired access to health services. Healthcare is too expensive and very dependant on a flawed insurance (access) system. Employer based coverage ends with employment.

Workers who have paid tens of thousands of dollars into the system lose everything once they complete employment. Financial security is lost and the system destabilizes for everyone. The current system rewards this behavior because it incentivizes employer based insurance with tax breaks, but penalizes individuals who are denied such breaks. This in turn pushes expenses to third party payers and places a wedge

between the physician-patient relationship.

The system is simply too complicated and impairs patient access to insurance and provider care alike. Finally, the granddaddy of all the impairments to the physician – patient relationship is the runaway malpractice system. Just today a full page advertisement was proudly displayed in the morning paper proclaiming malpractice and damages entitled to anyone who received metoclopramide (Reglan). This nonsense needs to stop – the arguments not to reform medical liability are purely politically and ignore this very real problem to access and stability.

What can we agree on – well ... it is a huge complex problem. Health delivery needs to be more predictable and meet meaningful targets. We cannot have nor accept data that 98,000 people die each year from the administration of poor healthcare. Free markets can be powerful drivers of a more desirable affect. If prices and transparency of services were available with published attained benchmark then health services would be forced to compete

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and meet regional or national standards.

In this arena government eventually fails because it is neither innovative nor fast enough to keep pacing with a changing environment. Government is capable of benchmarking, but it is often inappropriate and poorly conceived so the desired effects fall short no matter what the industry.

New York State tried to benchmark cardiac catheterizations. It was done in such a way as to penalize high risk patients. As a result cardiologists refused to accept high risk patients from the emergency departments because they did not want their numbers to look bad and potentially end up on a government watch list. This type of benchmarking hurt patients and alienated physician services. Again if done correctly, these same market forces can be applied to insurance services. The Obama administration is seeking an insurance exchange so consumers can shop competitively. This has merit as it would allow for consumer shopping and create market price controls.

This in turn would force spending limits since services would have a transparent

price tag. It may also encourage healthier life styles because higher premiums would be imposed on behaviors which impaired health. Another consideration is the medical savings account touted in the past as a means of taking the financial burden off employer and public health sectors.

Currently, some employers offer pretax savings on a limited scale for some health services. The public insurance option proposed by the administration would function much like the current Medicare and Medicaid programs, only expanded.

Here the criticism is heavy and the war of words is energized on both sides of the issue. In the President’s words, “The public option would directly compete with private insurers.” The public competition against the private sector is where the counter arguments begin. The latest Senate plan consists of an employer mandate component of $750 per employee or 8% tax on payroll. It would be run by the department of Health and Human Service which itself has a controversial history related to health policy. The plan has been criticized because

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of the disparity in number of patients who would be covered under this plan. The Congressional Budget Office accounting embarrassed the Senate HELP (Health, Education, Labor & Pension committee) with its original estimate since only 1/3 of the uninsured would be covered and the price tag was over a trillion dollars or roughly $60,000.00 per patient covered.

The numbers have been reworked since the original estimates so the number of insured increased from 16 million to 21 million, less then half of what the administration wanted. Based on my practice which is heavily supported by the public sector, I cannot foresee significant improvements in the nation’s overall health with an expanded public option. Such plans lack the resources and flexibility for future improvement such as preventative care, healthy lifestyles, and access availability across the system. Most of all it doesn’t support the doctor - patient relationship. In Central Virginia where there is a public insurance system, both the patients and doctors have a distain for this type of system.

So where does this leave us? Well patients need to have access to health services. Patients need to be able to see their physician in a timely manner to address the health care needs before they become catastrophes. But at the same time rational limitations need to be developed and futility defined. Spending tens of thousands of dollars to code a terminal cancer patient with dementia who does not have a DNR is not prudent. Currently on this issue, I follow the principle that states there is an indication and contraindication to every procedure. In my practice this scenario would follow the contraindication arm of the binary decision tree.

Unfortunately, liability matters have not addressed this issue which is another argument against government mandated reform measures. Government programs are based on political decisions and not what is best for the patient and ignore the physician patient relationship. To that end the Administration has already made a serious mistake which will impair any lasting improvement in health care reform. He told the AMA in his address that liability reform was not up for discussion. He was promptly rebuffed by the continued on page 18

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ACOEP visits the Netherlands In June, Immediate Past-President, Peter A. Bell, DO, MBA, FACOEP was hosted by Terry Mulligan, DO, MPH, FACOEP for

Dr Mulligan (right) and Dr Bell enjoying dinner at Third Annual Dutch EM Conference

two speaking engagements. Dr Mulligan is currently the Director of the Emergency Medicine Residency, Co-director of the Department of Emergency Medicine at Erasmus Medical Center and an Assistant Professor at the Erasmus University in Rotterdam. Dr Mulligan has held these

posts for 3 years and has been a key player in the recognition of emergency medicine as a specialty in the Netherlands. To that end, Dr Mulligan has established a one year Fellowship for up and coming leaders in emergency medicine. Dr Bell had the privilege of presenting “Concepts of Medical Education Consortium” and “Health Policy Principles” to a cadre of these young physicians. The capstone of the trip was Dr Bell’s presentation of “Research Models and Outcomes” at the Third Annual Dutch Emergency Medicine Conference. Several hundred physicians were present and faculty included colleagues from Australia, the USA, the Netherlands, and neighboring European countries.

Under Dr Bell’s leadership the college extended its influence beyond the US borders as part of a strategic plan to make the ACOEP a player in international emergency care. In addition to time spent discussing health care systems in the

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Netherlands, Dr Bell spent a week at Oxford University, United Kingdom.

Dr Mulligan and Dr William Bograkos (ACOEP Board of Directors) have both served as highly effective agents of the college in international outreach.

Because of their efforts, ACOEP is now a member of two highly respected global organizations: The International Federation of Emergency Medicine, and the World Association of Disaster and Emergency Medicine. Opportunities for future collaboration and speaking engagements designed to assist colleagues aboard are anticipated.

Dr Mulligan intends to continue his sabbatical from the University of Maryland for at least one more year. His contributions to international emergency medicine, both on behalf of ACOEP and as Chair-elect, ACEP Section for International EM are well recognized. Recently the Dutch honored Dr Mulligan by making him a Fellow of their national organization (NVSHA).

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Guest Columnist Wayne Jones, D.O., FACOEP

Lateral Thinkers So, are you a vertical or lateral thinker?

Most likely, you do not care and are now wondering if you will finish reading this article. But, hang on, I will get you there.

Many of us are victims of vertical (linear) teaching. This is how medical school taught us to think and it is how we now teach others. We feel that a symptom must relate in some logical scientific way to an illness.

We are disabled. And, this places us at a disadvantage to becoming that ultimate great physician we want to be. How better to cure our illness than to understand it.

Damn, vertical thinking again!

OK, remember the chicken and the egg riddle? Which came first, the chicken or the egg? If you were a pure vertical thinker, you would digress to discussing the single celled theory of evolution. If you are a lateral thinker, you may begin by discussing why the egg exists in the first place. Maybe the egg exists to create more eggs, and the chicken is just an intermediate stage of egg’s life cycle. Oh God, that hurts… but there, I said it.

So, vertical thinking is the linear progression of problem solving using stepwise methodical decision making. Lateral thinking is more creative and multidirectional.

While vertical thinking requires a depth of knowledge, lateral thinking requires a breadth of knowledge. Lateral thinking approaches a problem from many different angles, not relying on proven theories. By now, you are asking… who cares. You do. I have determined this is where many of our problems as emergency physicians arise.

Let me explain.

Matilda’s family wants you to admit her. You try to explain there is no reason to admit Matilda. You are a vertical thinker.

As lateral thinkers, the family would reason that the emergency department exists to admit people to the hospital. The reason for admission is secondary to the reason the ED exists. What you think has no bearing on their reason for bringing Matilda to the ED. Get it?

Moreover, you make Matilda leave.

Matilda returns later that day in a worsening state. Your colleague says to the family, “why did we send her home?” “Exactly”, says the family, “that is why we brought her here this morning.” Sound familiar?

Ok…Ok, you say we missed something.

No kidding, we were using vertical thinking. We reasoned our way out of considering other reasons for illness and admission.

Alternatively, we can always go the route of too much vertical thinking. How many of us suffer from colleagues ordering and reordering test after test to prove or disprove a diagnosis. Our colleagues feel pressure to diagnose every complaint-based illness or appear silly asking admitting physicians to place a patient in the hospital.

Patients linger and the ED becomes backed up. The trap is deep and wide.

Patients do not see us as individual practitioners but a hospital. We are faceless and nameless. They want a reasonable decision.

Their endpoint is different from the one we scientifically calculate for them. To them medicine is a pill, not a process. We can become frustrated, not only our inability to arrive at a scientifically sound diagnosis but by the insistence of patients and families to make a decision in concert with their expectations. In addition, we may vent our frustration by saying things best left unsaid. A little lateral thinking will tell us to stop and make a decision we, and they, can live with.

I believe this is the place a seasoned physician migrates to with time. We learn to be multidirectional thinkers. We do this without even considering the difference in the theory of vertical and lateral thinking.

So, will this article change your practice?

If not, read it again. And, this time, read it from a lateral thinking perspective.

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Lifestyle Adventures James Shuler, D.O., MA, FACOEP

Ride the Wilderness—Family Style Finally, that first beautiful spring weekend is here. You’ve been looking forward to this day since the last wonderful fall family ride. Where to go? How to prepare? What to bring? Will you be biking on a camping trip, or taking the kids on their first mountain biking adventure? Or perhaps what you want most is to escape the wildness of the city for the true wilds of wilderness?

All biking adventures offer limitless opportunities for fun; however, you’ll want to plan your ride based on your specific goals. Regardless of the type of trip, preparing can make the difference between a wonderful memory filled sojourn or an invitation for Murphy to come along. For every biking expedition, the endpoint of the ride isn’t (or at least, shouldn’t be) the key element. Instead, what you want to focus on--and what you want to help your family focus on--is the journey itself. If the process of getting to the destination is unpleasant, no one will enjoy it or want to repeat the experience.

Your first step, then, is to set realistic goals. Plan your ride while keeping in mind the needs of the least capable rider in your group. What may seem like a short, almost inconsequential trip to you may be rather arduous for someone younger and less experienced. Since we all know there are but two seasons, winter and “construction,” up-to-date guidebooks and trail maps will help you avoid disappointments and unplanned detours. They can further help by listing the difficulty level, help you plan breaks and find campsites, lodging and meals. Check your community for a trail developed by the Rails-to-Trails Conservancy. (see the side bar) Even a well-planned trip can be derailed by hardware failure. Regular equipment maintenance can avert disaster during what should be an enjoyable family adventure. If you have children, chances are one or more of them may have outgrown their bicycle. There’s nothing like poorly fitted or broken equipment to make work out of what

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should be pleasure. Ensure that bicycles are properly sized, repaired and well-tuned. If you choose to purchase used equipment, have it checked by a cycle shop.

Infants and toddlers can enjoy bicycle outings with you as well. For the little ones, there are many “carrying” devices available, such as seats, totes and trailer bikes available for children depending on their age and size. Following the manufacturer instructions and guidelines for age and weight is an absolute must, NO exceptions. Of all, the tote-type carriage with two side-by-side wheels is the safest and most stable. Any of these added pieces of equipment will slow you down and change your balance and center of gravity, so adjust your riding style and route selection accordingly. Remember, none of these has shock absorbers, so passengers will feel every pebble!

For all riders, safety comes first, starting with the “right tool for the right job.” The size and type of bicycle is very important, as is the functionality of any accessories. Bike shop professionals can help you find the right bike for you and your child, and bicycle safety courses are an excellent way for you and your children to learn the operation of the cycle in various environments. These sessions can be found through local cycling shops. While riding, keep the youngest members in the middle of the group to avoid too much separation or an accident going unnoticed. Cycle gloves, knee pads, and elbow pads are great for beginners or for bike rides on rough terrain. Handlebar and frame pads are great “ouchless” features for the little ones in your family.

Helmets are a must for everyone. All helmets should be Consumer Product Safety Commission approved. Check the box for standards. There are no significant safety changes for helmet construction in 2009 that merit replacing your child’s helmet unless it is damaged. Make sure the helmet is properly sized, meets safety standards and is not damaged. A bike shop professional should fit a new helmet for anyone in the

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family. However, things change with time, and small adjustments may be necessary.

To ensure an appropriate fit, the helmet should be low and level without impinging on the ear.

The front rim should be just visible to the wearer while gazing upward. Pads should contact evenly on all surfaces. The “Y” of the chinstrap should come together just below the ear. The snug chinstrap should “tug” on the helmet when the mouth is opened widely. A poorly fitting helmet offers little to no protection and may even be more dangerous than going without!

Check out this web site from http://www.bhsi. org/helmet09.htm for more information.

Weather and exposure will be constant factors. Hope for the best, plan for the worst. Wearing appropriately weighted clothing for the weather you expect (and don’t expect) will ensure comfort and protection. Look for sun protective clothing with built in SPF’s. When possible, try to find cycle-specific clothing that contains reflective material to increase your visibility. You can purchase reflective tape and apply it to your own to clothing, bicycles and helmets.

Adequate drinking water is essential.

There’s nothing like the nausea, cramping and lightheadedness of dehydration to throw a wrench in your ride, so plan on taking a little extra. Even if your trip incorporates planned stops for dining, take along high-energy snacks to enhance performance and prevent fatigue. To avoid the dietary “crash,” bypass snacks with simple sugars and look for more complex carbohydrates like honey and grains.

Adequate bicycle lighting is not only the law in most states; it is essential to increase your visibility and help guide you should you be out later than expected.

Additionally, a cell-phone should be taken along to summon help if needed. Consider a personal locator beacon for each person in a wilderness setting or when out of cell continued on page 18

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

What Would You Do? The Case of the 15 Year Old Virgin In this issue of The Pulse we will review the case of the 15 year-old female brought to the Emergency Department by her mother because the mother wants to know if her daughter is a virgin. This case was presented in April 2009.

The mother had heard a conversation between the patient and a girlfriend about a 26 year-old man, and was concerned there was a sexual relationship. The mother stated she did not believe there was a rape, and that her daughter had denied ever engaging in sexual activity. The mother doubted this story.

an examination. Can the parent coerce an evaluation? Does the patient have the right to refuse examination? Invariably, the ED physician is in the middle.

If the patient consents to the examination, there is no issue. If the patient refuses to be examined, two possibilities are present. Is this an evaluation for a suspected sexual assault? If so, and the police have been notified, then an examination may be performed. If the presentation is for the social knowledge of the child’s sexual activity and not for a medical emergency or necessity, then forced examination is not appropriate.

What would you do?

This case is not uncommon. We have all experienced situations where a parent wants to know if their child is sexually active. The dilemma arises if the child (patient) refuses

What happened?

The ED physician interviewed the patient in private, with the mother amenable. The patient adamantly denied any sexual activity, consensual or forced,

and denied any abdominal or genitourinary symptoms. The patient was reassured of the confidentiality of her answers. Her responses remained unchanged.

Although, the patient had initially refused examination, the comfort and safety of the environment that was created led her to change her mind and she consented to be examined. Of interest, the ED physician informed the mother that the outcome of the exam would remain confidential and not disclosed to her.

The examination demonstrated the patient to not be a virgin. The patient was encouraged to confide in her mother, as she would be a source of support and caring.

If you have nay cases in your practice that you would like to present or be reviewed in The Pulse, please Fax them to 708-9152743. Thank you.

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Evidence-based.

Learn from true experts in the field as you master airway management techniques, devices and algorithms.

Visit theairwaysite.com or call (866) 924-7929 for registration and hotel information.

Atlanta, GA

Comprehensive.

Expert Faculty.

June 5 - 7, 2009, Boston, MA Hyatt Regency Cambridge

September 18 - 20, 2009 Hyatt Regency, Chicago, IL October 23 - 25, 2009 Bally’s Hotel, Las Vegas, NV November 13 - 15, 2009 Westin Buckhead, Atlanta, GA

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In My Opinion, continued from page 13 audience since he recanted on his statement that all constituent options were on the table. On the flip side the Administration changed the Medicare sustainable growth rate formula. It was recalibrated to zero and thus avoided a projected 21% cut in reimbursement. The Administration’s hope for technologic breakthroughs in medical record keeping and transfer of medical records is shared by most physicians.

However, the Administration’s hope for an Lifestyle Adventures, continued from page 16 phone range.

A lightweight wilderness first-aid kit can prevent a "turn-around" in your trip plans due to injury. The kit should have adequate supplies to treat sprains, abrasions, blisters, stings, sunburn and pain. Include liquid pain medication for the younger members. Wilderness trips require the standard wilderness medical kit. Blisters, sunburn and “road-rash” from falls are the most common cycling injuries. Be prepared to clean and protect these wounds.

Along with first-aid for the riders, don’t forget “first-aid” for the cycle itself. There’s nothing like a flat tire ten miles from the Governmental Update, continued from page 10

accommodate walk-ins or same day visits.

Who will be picking up those patients?

As usual, the Emergency Departments will.

In addition, we have a mandate under EMTALA to see all patients that present and give them, at minimum, a medical screening evaluation. Primary care does not have this obligation and can see the patients they choose to see.

Emergency Physicians need to see the urgency of Emergency Medicine being included in the discussion of the Medical Home. We want to be recognized as the safety net of the entire medical system.

ACOEP Committee on Governmental Affairs supports the “Medical Home” under these basic tenants.

The “Medical Home” must offer: 1. Improved access (primary care, technology) in a timely manner despite

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immediate impact with these technologies is overly optimistic. I am not aware of a stand alone EMR system which can efficiently process a medical record for billing and translate the record for processing between the various departments in a hospital system. The Veterans Administration has the most widely accepted system of medical record keeping. Commercial products have lacked the uniformity because a standard has not been set. The medical home is a potential means of improving the technical data distribution component through

setting that standard, but we are still waiting on the details of what the medical home will look like. Finally, one immediate impact a physician can do is to continue to advocate for his or her patients, demonstrate compassion, self determination and innovation. These values we can practice now should serve as lasting improvements to any new system which may be constructed.

Please make your voice heard – your political leaders are waiting for your direction.

middle of nowhere to ruin your day. Be sure to bring a repair kit with equipment to handle mechanical failures for all the cycles--and don't forget the pump! Excellent lightweight hand-pumps are available that will fit easily into a pack or clip onto the bike frame.

With the basics taken care of—realistic goals, appropriate attire, an abundant supply of water and snacks, and of course safety and first-aid gear—consider one last tip from an old pro. When it comes to the kids, remember that attention span increases with age, so add some “bribes for biking.” Take frequent breaks and bring along something else to do. Small games, cards and books provide nice alternative

activities. On the bike, a handlebar bell can be fun and double as a safety signal.

Tassels are also fun and increase visibility. A bright flag is excellent for the same reason, especially when attached to a rear carrier.

A cycle outing for the entire family can be a wonderful journey filled with fun, kinship and bonding that is very healthy.

Most importantly, remember that the destination is less important than the journey, preparation decreases the odds of disappointment, and safety is paramount.

Learn more about biking with children by perusing this website http://www.bhsi. org/child.htm.

the ability to pay.

2. Improved quality and safety for all patients.

3. Avoid rationing of care.

2. Please read the ACEP “PatientCentered Medical Home Model Position Statement.” You can access it at http://www.acep.org/practres. aspx?id=40804 3. Join GOAL. Call Leann Fox at (202) 414-0140 4. Write and visit your Congressmen and Senators. Urge them to include Emergency Medicine in the discussions of the “Patient-Centered Medical Home.”

ACEP has put out a “Patient-Centered Medical Home Model Position Statement.”

This statement outlines and clarifies the impact the “Medical Home” will have on Emergency Medicine. The ACOEP Governmental Affairs Committee agrees with and endorses the ACEP Position Statement. When the government decides how they will redistribute health care dollars, Emergency Medicine needs to ensure that, as the front line (and often only line) of our health care safety net, we are an integral part of any major health care reform.

What can you do to help protect your profession, our livelihood and avoid being “homeless”?

1. Get informed!

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Happy cycling!

I challenge all ACOEP members to get involved! As Winston Churchill said, “I never worry about action, but only about inaction.”

1 Grumbach

K, Bodenheimer T. A primary care home for Americans: putting the house in order. JAMA 2002;288:889-893.

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Event Calendar 2009-2010 2009 August 28-29

September 28

The Dynamics of the Fluid Body

Indiana Academy of Osteopathy Radisson Hotel Indianapolis, Indianapolis, IN 800-942-0501 or 317-926-3009

Executive & Finance Committee Mtgs

30

ACOEP Resident Chapter Meetings

1

ACOEP Student Chapter Meetings

2

FOEM/MedExcel Poster Presentations

ACOEP Board of Directors Meeting

3

FOEM/Schumaker Group – CPC Competition

Westin Copley Plaza, Boston, MA 23 hours Category 1A Credit*

8:00 a.m. – 5:00 p.m.

FOEM / Med Excel Poster Display 9:00 a.m. – 5:00 p.m.

ACOEP Committee Meetings 9:00 a.m. – 5:00 p.m.

Westin Copley Plaza, Boston, MA

7:00 a.m. – 12:00 p.m.

23 - 24

7:00 a.m. – 2:00 p.m.

7 hours Category 1/1A credit

ACOEP Student Chapter Meetings

9:00 a.m. – 4:00 p.m.

ACOEP Membership Meeting

Scientific Assembly

Westin Copley Plaza, Boston, MA

29

October 1 – 3

9:00 a.m. – 5:00 p.m.

FOEM Board Meeting 9:00 a.m. – 11:00 a.m.

9:00 a.m. – 5:00 p.m.

8 hours Category 1A Credit*

FOEM / EMP Research Paper Award Luncheon

1.5 hours Category 1A Credit*

FOEM/ EmCare Oral Abstract Luncheon

1.5 hours Category 1A Credit* Oral Board Review

Sheraton Four Points, Chicago, IL 10 hours Category 1A Credit*

* ACEP Accreditation pending

Registration: 4:00 p.m. – 5:00 p.m.

Meeting: 5:00 p.m. – 7:00 p.m.

Westin Copley Plaza, Boston, MA

Presorted Standard U.S. Postage

PAID

Chicago, IL Permit No. 2177

142 E. Ontario Street, Suite 1250 Chicago, Illinios 60611

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The PULSE JULY 2009