The Pulse July 2010

July 2010 VOLUME XXXV NO. 3

Presidential Viewpoints Accountability, Emergency Medicine and Healthcare Reform Thomas A. Brabson, D.O., MBA, FACOEP, President

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The summer of 2010 is finally here after a long and harsh winter. I hope this issue of the Pulse finds you healthy, happy and enjoying the summer fun. Make sure you take some time to relax and enjoy yourself with family and friends.

The healthcare reform movement has been signed into law and now is well on its way to becoming a reality at a time when our country’s economy continues to struggle.

Healthcare costs continue to rise and for the past 30 years, these costs have increased 2.8% above the Gross Domestic Product (GDP) on an annual basis. Healthcare is the largest growing expense in the $30,000 - $80,000 income households with the average family premium being $13,000.

In order for the healthcare reform to take fully implemented in 2017 with a ‘new normal delivery system’, much work needs to be accomplished over the next few years.

There is a proposed timeline in the law but no detail of how to achieve the goals. In the first 3 years there are approximately

105 new agencies and programs that need to be implemented in order to shape the future of the system. There also must be coordination between the state and federal governments and conformity among the insurance companies. Excise taxes will be levied on insurance, medical devices, pharmaceuticals and who knows, maybe even medical practitioners. To help fund the system, Medicare cuts will amount to $439 billion and the American Hospital Association promised $155 billion. So, we may be seeing our best reimbursement from Medicare today than we ever will in the future. That is not to say however, that Medicare is the be all and end all.

Accountability is a term that is being used in many different places these days.

As emergency medicine physicians, we are accustomed to being held accountable for good patient care and favorable outcomes.

With the new health care law though, we will be held accountable for being active participants in the new model of care. This new model is proposed to be an integrated and coordinated model of patient care. It is proposed to deliver high value with overall total cost management. There will be new financial incentives that will not be based on high cost tests, equipment and procedures.

Efficiency in patient care is what will be rewarded. The efficiency will come as the result of a more integrated system for the delivery of healthcare. As we all witness in our daily practice of emergency medicine, one of the biggest contributors to the inefficiencies in our current system is a lack of care coordination. We have a system that

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allows multiple areas of episodic care but no formal mechanism to assure that all of the information about the episodes of care are gathered and assimilated in one organized place to be reviewed by a specific person.

An Accountable Care Organization (ACO) is a new concept that is proposed to be a step in the right direction to have an organized continuum of medical care. These are an expansion beyond the medical home concept. The ACOs will be responsible for the clinical care coordination and integration of medical services for patients.

They will also be responsible for capturing medical and financial data across the care continuum. They will be held accountable for measuring and monitoring costs and the quality of the medical care delivered. It is believed that clinical quality and efficiency will drive better financial performance.

Clinical results will be outcome based and income will be based on outcomes. This means that we will be subjected to many more clinical core measures than we are today. Evidence based medicine will be the driving force for the clinical quality indicators. Appropriate resource utilization will be key to the success of this initiative.

The emergency department should no longer be one of the primary entry points for access to medical care. With this integrated system, the patient should have ample opportunity to access the care that they need based upon the principle that there is healthcare provider coordination across the patient’s continuum of care. There will be continued on page 28

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Editorial Staff: Drew A. Koch, DO, FACOEP, Editor Wayne Jones, DO, FACOEP, Assist. Editor 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 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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Deadlines for the submission of articles and advertisements are the first day of the month preceding the date of publication, i.e., December 1; March 1, June 1, and September 1. The ACOEP and the Editorial Board of the PULSE reserve the right to decline advertising and articles for any issue. ©ACOEP 2009 – All rights reserved.

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

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The Pulse An Osteopathic Emergency Medicine Quarterly 142 E. Ontario St., Suite 1500 Chicago, IL 60611-5277

PULSE O s t eop a t h i c

Emergency

Me d i c i n e

Q ua r t e r ly

Table of Contents Presidential Viewpoints . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Thomas A. Brabson, D.O., MBA, FACOEP Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Drew Koch, D.O., FACOEP Our History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Executive Director's Desk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Janice Wachtler, BA, CBA Fellows and Distinguished Fellows Announced . . . . . . . . . . . . . 7 The On Deck Circle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Gregory Christiansen, D.O., M.Ed., FACOEP Guest Column . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Peter A. Bell, D.O., MBA, HPF, FACOEP-D, FACEP Guest Column . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Bermard Heilicser, D.O., FACOEP Emergency Medical Services . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Gregory Joseph Beirne, D.O., FACOEP FOEM: 2010 Research Activities . . . . . . . . . . . . . . . . . . . . . . . 14 Foundation Focus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Janice Wachtler, BA, CBA The Practice of Emergency Medicine/Special Contribution . . . . 16 2010 Student Case Competition Winning Submission . . . . . . . 23 On the Wild Side . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 James Shuler, D.O., MS, FACOEP, FAWM Ethics in Emergency Medicine . . . . . . . . . . . . . . . . . . . . . . . . . 27 Bernard Heilicser, D.O., MS, FACOEP AOBEM Update . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Members in the News . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 In My Opinion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Wayne T. Jones, D.O., FACOEP Changes in the Board Announced . . . . . . . . . . . . . . . . . . . . . . 31 Pain Management in the ED . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Steven J. Parrillo, D.O., FACOEP-D

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

Acute Exacerbation of Chronic Pain in the Emergency Department: Part II

1975

In the last edition of the Pulse, I discussed the dilemma that we as Emergency Medicine Physicians face every day in our Emergency Departments dealing with patients who present with an acute exacerbation of chronic pain. We deal with EMTALA, legal, ethical and social concerns on every patient who presents to the Emergency Department in pain.

Greg Henry, MD, wrote in a recent article in the Emergency Physicians Monthly that “we have more pain medication than you have pain.” Dr. Henry feels that as Emergency Medicine Physicians we do not treat pain as well as we can. His emphasis on adequate pain control coincides with the Joint Commission and other regulatory concerns that the Emergency Departments do no not adequately treat pain.

Oligoanalgesia in the Emergency Department was coined in 1989 by Wilson and Pendleton in their article in the American Journal of Emergency Medicine.

According to their paper, pain is the most common complaint presenting to the emergency department and that emergency physician have not established themselves as the champions in treatment of acute pain.

In the 20 years since this paper was written, it is still perceived that oligoanalgesia in the emergency department still exists despite an increased awareness of pain and the

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increased use of analgesia in the emergency department.

Opiophobia is the prejudice against the use of opioid analgesia. This is manifested in our mores; regulatory and licensing concerns; concern for drug seeking behavior; concerns for addictions or dependence; and, the lack of follow up or continuity of care. Society’s attitudes toward narcotics at times reflect a moral tone that influences health care providers and the general public. There are concerns about addiction and abuse with moral aversion for the pleasures of opioid use and the contempt for individuals with psychological addiction to their euphoric effects. These attitudes towards patients who seek pain relief result in oligoanalgesia. In the previous article of the Pulse the topics of addiction and dependence were discussed as were the concerns regarding legal and regulatory manifestations of opiophobia.

Drug seeking behaviors (DSB) are commonplace in the emergency department.

Many physicians have faced patients with multiple alleged allergies to narcotics and other medications who request a medication that the physician never would have initially thought of prescribing, whose medications were stolen, and who become angry, threatening, and agitated upon refusal to refill the stolen prescription-Emergency Medicine Reports, January 3, 2005.

Pain and the somatic manifestation of anxiety are the two most common reasons that individuals seek medical care. Since the 1990’s prescriptions for and the nonmedical use of opioids have increased. In 2005 there were more prescriptions written for hydrocodone/acetaminophen combination than any other medication. This was twice the rate of the second most prescribed generic and brand prescriptions Amoxicillin and Lipitor. In 2004 it was estimated that 2.4 million individuals 12 years old or older who initiated non-medical use of prescription pain relievers during the previous

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year. The most abused drugs during 2004 were hydrocodone, codeine, propoxyphene and oxycodone. The “non-medical use is defined as the use of a prescription pain reliever by individuals for whom it was not prescribed or use only for the experience or feeling that is produced.” Journal of Addictive Diseases, vol. 27 (1) 2008. “The Epidemiology Association between Opioid Prescribing, Non-Medical uses and ED Visits.”

The characteristics of drugs of abuse are: 1. Rapid onset of action; 2. High potency; 3. Brief duration of action; 4. High purity; 5. Water solubility (for IV use); and 6. High volatility (ability to vaporize if smoked).

The opioid that fits these characteristics is hydromorphone or as per patient request, Dilaudid. Dilaudid is the drug of choice and the most requested drug by our patients with acute exacerbation of chronic pain.

When used in higher doses and given by IV it produces euphoria that the chronic pain patients seek.

Patient characteristics of DSB suggest the following 19 behaviors: escalating use or over-use of controlled substances; manipulative, demanding behavior to obtain medication; the only possible solution to medical problem is “controlled” medication and claims non addictive medications do not work and they have an allergy to them; high tolerance to drugs; lost their prescription; ran out of prescription early before they are “allowed another refill”; selling or forging prescriptions: using family or friend’s prescription; pit one physician’s treatment opinion against another physician’s recommendation; resist non-pharmacological treatment; doctor shop use greater than 2 doctors; pressure physicians when physicians initially refuse to write prescription; history of drug and alcohol use; old records or pharmacy profiles reveal an unusual number of prescriptions and continued on page 11

Our History

Introduction: Last summer after arriving in our new headquarters as we were unpacking we found the following document, titled “Brief History.”

Typewritten on the old stationary and undated, it contained a concise overview of how the American College of Osteopathic Emergency Physicians came to be. The yellowing document is now preserved in our historical documents; it is as yellowed as our older minutes, however it was obviously written in the early 1980’s as it recaps the founding of AOBEM and the first Fellowship Ceremony. Its author is unknown, perhaps it was an early staff member or Board member who took the time to put down, the history of the College’s founding. Whoever it was did us a huge favor in preserving dates and people in our past.

convention in Las Vegas, Nevada, the first organizational meeting was held at the Sahara Hotel. During this meeting the first officers were elected including Dr. Bruce Horton, President, Dr. Anthony Gerbasi, Vice President, Dr. Richard Ballinger, Secretary and Dr. Robert Hambrick, Treasurer.

BRIEF HISTORY

The American College of Osteopathic Emergency Physicians was founded and developed by a few dedicated Osteopathic Emergency Physicians who believe the specialty of Emergency Medicine should be recognized by the American Osteopathic Association.

In July, 1978, the College was chartered in Ohio, and the American Osteopathic Association formally recognized the American College of Osteopathic Emergency Physicians.

Following this meeting, appropriate documents were developed to obtain a charter for the College.

In February, 1976, the original Board of Directors of the ACOEP was elected.

They were: Richard Ballinger, D.O., James Budzak, D.O., Donald Cucchi, D.O., Robert George, D.O., Anthony Gerbasi, D.O., James Grate, D.O., Robert Hambrick, D.O., Bruce Horton, D.O., and Scott Swope, D.O.

On October 5, 1975, the committee for the formation of the American College of Osteopathic Emergency Physicians first met in Toledo, Ohio. Present at that meeting were Bruce Horton, D.O., Richard Ballinger, D.O., Anthony Gerbasi, D.O., Robert Hambrick, D.O., and Robert George, D.O.

In November, 1978, at the American Osteopathic Association Annual Convention in Honolulu, Hawaii, the first Scientific Assembly of the American College of Osteopathic Emergency Physicians was held. This was an indication of good things to come as the program was very well received by many osteopathic physicians interested in the specialty of Emergency Medicine. As a matter of fact, a larger room was required for the presentation of the program on each of the four days involved.

In November, 1975, in conjunction with the American Osteopathic Association

Early in 1979 the Residency Standards for Training in Emergency Medicine in the

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osteopathic profession were developed, and the first residency programs were initiated at the Philadelphia College of Osteopathic Medicine and the Chicago College of Osteopathic Medicine. At the present time, there are nine A.O.A. approved Emergency Medicine residency training programs in osteopathic hospital across the United States.

In July, 1980, the American Osteopathic Association formally recognized the specialty of Emergency Medicine as a Board Certified Specialty, and approved the formation of the American Osteopathic Board of Emergency Medicine. Following this recognition the certification process was established, and there is now a mechanism for board eligibility status for certification for the osteopathic Emergency Medicine physician. Presently more than fifty osteopathic physicians are certified by the American Osteopathic Board of Emergency Medicine.

The American College of Osteopathic Emergency Physicians sponsors two educational programs annually to meet the needs of the membership. The Annual Scientific Assembly is held in conjunction with the American Osteopathic Association, and the Spring program is held each year in various areas throughout the country.

The first fellowship ceremony was conducted in Las Vegas, at the Annual Scientific Assembly of the American College of Osteopathic Emergency Physicians in November, 1984. Presently there are ten osteopathic physicians elected as Fellows in the American College of Osteopathic Emergency Physicians.

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Executive Directors Desk Janice Wachtler, BA, CBA

1975 - A Year in History

1975

As we prepared to celebrate the College’s 35th birthday on October 5th, members of the Publications Committee thought that perhaps we need to look at where the world was when the decision to establish the College was first formulated. To do this, William Kokx, D.O., FACOEP and I started to think about what the world looked like then.

As you can see from the chart below, the economics of 1975 were much different than today, but so were society and lifestyle. For instance, computers weren’t found in homes or on desktops, telephones weren’t portable and your tunes were sup-

plied via a transistor radio. Meanwhile, the US and the world were in turmoil and in the throes of the end of Vietnam War. We witnessed Pol Pot and the Khmer Rouge forces invade and take over Cambodia in early April leading to the fall of Saigon and the end of the Vietnam War on April 30th.

The US evacuated its forces from Saigon and the American public heard words like Boat People and opened its doors to many displaced people from Vietnam, Thailand, and Cambodia. We were also closing the chapter on the Watergate scandal as we saw the convictions of John Mitchell, H.R. Halderman, and John Ehrlichman sentenced to 30 months to 8 years in jail.

Also in the news were incidents involving Gerald R. Ford as he made the history books when he escaped two assassination attempts in September, once on September 5th by Lynette “Squeaky” Fromme, in Sacramento, California, and again on September 22nd in San Francisco by Sara Jane Moore. And, to help relieve our dependence on foreign oil, the U.S. approved the Alaskan Oil Pipeline.

Entertainment made history too, with the premiere of Saturday Night Live on NBC. This new fast paced live television program was aimed solely at the ‘younger generation.’ We also watched shows like Upstairs, Downstairs, Barretta and Wonder

Woman. Movies were big in 1975 too, with classics like One Flew over the Cuckoo’s Nest (which won the Academy Award for Best Picture, Best Actor and Best Actress) and Dog Day Afternoon, Nashville, and The Man Who Would Be King. Music of the day was Love Will Keep Us Together (Captain and Tennille), At Seventeen (Janis Ian), Lyin’ Eyes (Eagles), The Hustle (Van McCoy), Where is the Love (Natalie Cole), and Still Crazy After All These Years (Paul Simon).

Computers once the domain of only large corporations like Xerox and IBM, were made available to consumers for the first time. People interested in building their own could do so when Altair Innovations developed a home computer kit in 1975.

Also movies, once the sole property of cinemas were made available on home video when, Sony and Mitsubishi went head to head in this market developing the Sony Betamax System and Mitsubishi VHS. The war of home video continued for about a decade until Betamax succumbed and is now used mostly for professional recording studios.

Medicine was not immune to change in 1975. Like every other area, medicine was seeing more and more research being done to produce better patient outcomes. Three American physicians were granted the Nobel Prize in Medicine when they developed processes to follow the interaction between tumor viruses and genetic material in cells. Other physician-researchers working independently in Russia and France discovered the structure of biological molecules in antibiotics and cholesterol. And, in New York City, Interns and Doctors in 21 hospitals went on strike.

Comparing the world 35 years ago to today’s standards and norms is difficult, I mean, who today would even think of not continued on page 22

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Fellows and Distinguished Fellows Announced for 2010

The American College of Osteopathic Emergency Physicians is proud to announce the physicians named to the 2010 Class of Fellows and Distinguished Fellows of the College.

Fellowship is granted to physicianmembers of the ACOEP who meet the following minimal standards: certification in EM by AOBEM or ABEM; continuous membership in ACOEP of 5 or more years; attendance at 2 ACOEP Membership Meetings and attendance at 2 or more major ACOEP-sponsored CME meetings within 5 years of the date of application.

Candidates must also show evidence of high professional standing in two of the following areas: publication of scientific or referenced material in emergency medicine in a nationally peer-reviewed periodical with references to the publication in which the article was published; past or present membership on an ACOEP committee or Board of Directors; faculty appointment in emergency medicine at an accredited college of medicine or college of osteopathic medicine; active involvement in the leadership and education in EMS, including but not limited to EMT, First Responder, EMD and/or paramedic training; service as a medical director of a community EMS System, or participation in local disaster planning and implementation; service as an emergency medicine residency program director or faculty; advance degree or fellowship training; past or present service to the AOBEM or ABEM as an oral board examiner or a named role in test development; past or present membership on the Board of Trustees of the Foundation for Osteopathic Emergency Medicine, and/or verification of a significant contribution to the specialty of emergency medicine in the osteopathic profession. Additionally, each candidate must be recommended by a current Fellow of the ACOEP. Fellowship is maintained through continuous membership in the College.

Achieving Fellowship status in 2010 are: Paul J. Adams, D.O. (Fort Lauderdale, FL); Michael P. Applewhite,

D.O. (Temple, TX); Robert Bazuro, D.O. (Sandy Hook, CT); Todd A. Bell, D.O. (Elida, OH); Marc M. Bonin, D.O. (Greenfield Township, PA); Michele Butler, D.O. (Lake Havasu City, AZ); Nikolai Butki, D.O. (Clarkston, MI); Victoria Camba, D.O. (Wilton Manors, FL); Stephanie L. Davis, D.O. (Kansas City, MO); Elaine Diaz, D.O. (Miami, FL); Joseph J. Fosbinder, D.O. (Bakersfield, CA); Michele M. Fowler, D.O. (Bixby, OK); Richard C. Giovannini, D.O. (Shelby Township, MI); Michael L. Kelley, D.O. (Hudson, OH); Kyle Kennedy, D.O. (Joplin, MO); Judith Knoll, D.O. (Erie, PA); Cindy Yung-Fang Kuo, D.O. (Express, CA); Michael A. LoGuidice, Sr., D.O. (Trinity, FL); Daniel Lombardi, D.O. (Mahopac, NY); Tariq Noohani, D.O. (Tampa, FL); Joseph R. Peters, D.O. (Peoria, IL); Katherine J. Pitus, D.O. (West Bloomfield, MI); Fredric A. Rawlins, D.O. (Radford, VA); Brian Risavi, D.O. (Erie, PA); Martha J. Shadel, D.O. (Harrison Township, MI); Zafar Shamoon, D.O. (Rochester, NY); Kellee R. Shea, D.O. (Orlando, FL); Cynthia Shen, D.O. (Queenstown, MD); Greg Sorkin, D.O. (West Orange, NJ); Ali Taqi, D.O. (Troy, MI); Harrison Tong, D.O. (Clarkston, MI); Susan Watson, D.O. (Gunnison, CO); Amber D. Weigler, D.O. (Garden City, MI); James B. Williams, D.O. (Oklahoma City, OK), and Shelly Zimmerman, D.O. (Edmond, OK).

Distinguished Fellowship is bestowed on physicians who have reached Fellowship status in the College for a minimum of 10 years and who have been recommended by an existing Fellows or Distinguished Fellows of the ACOEP because they have been active in the practice of emergency medicine, EMS, disaster medicine, pediatric emergency medicine or medical toxicology, on boards or committees of ACOEP, AOBEM or AOA; current or prior involvement in professional organizations on an international, national, state, or local levels that concern the above

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named practice areas; involvement in past or current research and/or development medical curriculum or training programs in any of the above-named practice areas, and recognition or awards for excellence in emergency medicine (or its subspecialty areas) by a national, state, or local organization.

Achieving Distinguished Fellowship in 2010 are: Steven Aks, D.O. (Chicago, IL); Thomas A. Brabson, D.O., MBA (Media, PA); William R. Fraser, D.O. (Columbus, OH); Christine G. Giesa, D.O. (Collegeville, PA); Douglas M. Hill, D.O. (Thornton, CO); Mary J. Hughes, D.O. (Dewitt, MI); Joseph C. Hummel, D.O. (Sewell, NJ); Alan R. Janssen, D.O. (Fenton, MI)’ Drew A. Koch, D.O. (Ithaca, NY); Joseph J. Kuchinski, Jr., D.O. (Mountain Lakes, NJ); Mark S. Rosenberg, D.O., MBA (Denville, NJ); Bryan D. Staffin, D.O. (Buchanan, MI); Louis C. Steininger, D.O. (Tucson, AZ); Robert D. Suter, D.O. (Dallas, TX); David A. Wald, D.O. (Wynnewood, PA), and Douglas P. Webster, D.O. (Solvang, CA).

Applications for both types of Fellowship are available on the College’s website and are accepted throughout the year. Evaluation of any application takes place during the spring meeting of the Fellowship and Nominations Committee and are granted annually in the fall.

Please join us in congratulating the Class of 2010!

Includes the ACOEP Intense Review, COLA Essentials (2002-2008 only); Oral Board Review; New Frontiers in Toxicology, Spring Seminar or Scientific Assembly

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The On Deck Circle Gregory Christiansen, D.O., M.Ed., FACOEP President-elect

Influencing Six Degrees of Separation I was leaving the hospital and heading home one evening when I ran into a friend on my way out to the parking garage. Dr. Abatti was a resident when I first met him as he rotated through the Emergency Department. I loved working with him because he always put forth his best effort. He has long since finished and has become an accomplished cardiologist.

We have great respect for each other’s opinions after having worked through some very difficult case together over the years.

As we walked I cordially shook his hand and offered a friendly greeting. He was escorting a seasoned physician whom I had overheard speak to days when a resident meant he or she was really an apprentice who resided in the hospital. This piqued my attention because the opinion fits in well with a project I am working on related to the cultural changes in resident education that have changed the attitudes of the newly-minted physicians. Dr. Abatti introduced his friend who said he was a visiting scientist from the University of Colorado.

I welcomed him to Virginia and asked the question as only a southern hick could ask, “What were ya’ll scientisting about?” He was more then happy to tell me he was working on interleukins. This really piqued my attention because that is how I started my dabble into medicine. Tangentially I thought to myself of how important that seemingly trivial work experience has been to me. I learned self determination and ingenuity can overcome many obstacles. As the low man on the totem pole I had to take the initiative to learn as much about the subject as possible. I was not satisfied with a superficial explanation of how PCR, DNA sequencing or ELISA actually worked. I remember reading, creating ideas & then experimenting with the ideas to develop a deeper understanding of the immune response process. Eventually the company created something useful to market – IL-1 & IL-2. My experiences in immune com-

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plex interactions have since been incorporated into many of my lectures to help others understand the pathologic process.

As it turns out understanding the immune response can portend the outcome of many seemingly unrelated conditions such as heat stroke (IL-6, IL-18) or acute myocardial infarction (TNF, Platelet interactions). This chance encounter brought back so many thoughts that I had to ask more questions.

He knew the company then called Cistron – named for the biochemical term related to DNA sequencing. He also knew the cast of characters I had worked with – more then 20 years ago. They were still influential people in their fields, just a bit older. I came to the realization that this chance encounter reflected a significant impact on my experiences. My work 20 years ago is still influencing my development today. Additionally, it appears to becoming full circle with my new activities in which I am engaged. Most folks probably do not recognize at the time of an encounter how profound of an impact one can have. Simply participating and being proactive can foster the development of significant influences.

To give an illustration, one of Albert Einstein greatest contributions occurred over a chance encounter. At age four he watched the needle of a compass move without anything touching it. He realized motion did not need direct touch. Other forces were at work in moving the needle the same way every time. This was the beginning of his challenge to Sir Isaac’s Newtown’s accepted laws of motion and gravity. An interaction with patent office boss Friedrich Haller advised him in 1902 to “… think that everything an inventor says is wrong. Be critical, vigilant and question every premise, challenge everything...”

Following that advice by 1905 he had written five scientific papers which would profoundly change our world view. The Nobel Prize committee was embarrassed when they passed over Einstein in 1910

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and did not recognize him for his insightful, surreal and masterful theories until 1921.

Einstein’s theory of relativity may have an extrapolated effect in education. From a scientific perspective, ‘all movements and events are in relation to an observer’s frame of reference’. In life we are shaped by our relative frame of reference to each other – that’s how learning occurs.

We probably do not recognize the impact we have relative to each other. My coworker’s mentoring is responsible in part to my interpretation and reaction to events I experienced more then 20 years ago. Those actions back then have helped to shape my thinking today. This realization brings home the point that especially in the field of medicine, we all need mentors to help us succeed. As mentors, we have to extend ourselves to make that happen. Stepping back and acknowledging how the whole conversation got started, I thanked the visiting scientist for his influence and hoped to cross paths with him in the future… I am looking forward to the experience.

This quirk of an encounter made pause to consider the significance of our influential experiences. The theory of ‘6 degrees of separation’ regarding social networking suggests our relative experiences influence each other. I recalled my short interaction with a medical student at DO Day on Capital Hill. We were making our way to the congressional offices when we struck up a conversation. I was thrilled to see him among so many students getting involved in the political process. They recognized the changing landscape of medicine demands political involvement. In superficially conversing about some contemporary issues as we walked, I noticed he echoed the thoughts and mindset of what others wanted him to believe. He did not recognize how he was influenced in his ideas or how he shaped his decision making. The relative simplicity of his understanding of the issues made me question how we are teaching

our students. Do they learn how to think critically? What is their experience with concepts of evidence based medicine that demands inquiry? Do they question ideas which may sound good at face value but if challenged for validity, then can not with stand the scrutiny? I did not press him on his ideas - learning is relative and has to be taken from the perspective of the learner.

Once a learner recognizes that he does not know something, then it creates a conflict from within. He will have to either confirm the idea’s validity or accept the notion without challenge. Validity takes work, but it is an active process which promotes discovery of new ideas and interpretations. Mezirow called this transformation learning because the internal conflict forced a change in our perceptions. It has been said that, “the eyes can not see what the mind does not know.”

The last office visit of the day did not yield the presence of a single senator or congressman. In meeting with legislative aids a group of student mirrored the exact thoughts they were told to reflect. This pleased the legislative aid because there were no dissents, challenges or attempts to confirm the validity of the legislative

agenda. However, a spark in the group came from a student hailing from the West Virginia College of Osteopathic Medicine.

Her view allowed her to look through the mirrored thought and recognized it as simply a one-way mirror. She was being manipulated to think one way and she politely questioned the effect of the proposal. Mathematically, the espoused plan did not add up. It lacked validity and could not make sense. I was so proud of her for her willingness to be a leader and recognize truth. She used her critically thinking skills to question. She empowered herself to bring up more questions and she synthesized new coherent thoughts in her attempt to seek solutions. The legislative aid was clearly holding back information and offered no explanation to her questions.

My experience with DO Day drove home several points.

1. We as a profession need each other to do our part if we are to be successful. Our many student participants in DO day are a sign of a healthy profession, but we need more participation from our seasoned professionals. Our success as a profession now demands legislative involvement from all

of our members. Not only does our voice become a whisper when we lack participation, but we fail to model and mentor the next generation as well.

2. We need to think critically. If we don’t wrestle with the ideas then we won’t be able to establish an understanding or our position to provide effective change. The AOA offered town hall meetings to help foster dialogue to debate the ideas. We need to teach our future doctors to think critically. This is a key requirement in developing leaders for the profession. These leaders need to step forward and offer their expertise.

3. Valid arguments are truthful and therefore do not need to be hidden. The profession will not fractionate if the profession stays true to its ideals and focuses on the patients we serve.

4. We will cross paths again – Einstein’s concept of ‘spacetime’ suggests we are connected and function relative to each other. Hopefully will cordially greet each other and reflect on our influence with one another. We have much to learn from our relative positions and could do more to help each other succeed.

Wish you were here.

~EMP

Emergency Medicine Physicians has just added two new hospitals to over 60 hospitals served in the United States: Brookhaven Memorial Hospital Medical Center in Long Island and Mercy Hospital – Anderson in Cincinnati. We’re looking for emergency medicine physicians who are dedicated to delivering the best in emergency medicine to fill immediate openings. If you’re interested in joining a democratic group that offers equal equity, leadership opportunities and a schedule you make your first year, call or write back today.

800-828-0898 | careers@emp.com

Opportunities across the USA.

EMP has a number of osteopathic hospital locations including three with osteopathic EM residency training programs.

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Guest Column Peter A. Bell, D.O., MBA, HPF, FACOEP-D, FACEP Editor Emeritus

Scholarly Activity: A Road to Higher Ground In 1973 the number one hit on the U.S. Hot Soul Singles chart was ”Higher Ground” by Stevie Wonder.

It addressed the ongoing struggles and recurring challenges of man. It expressed a second chance to remake one's life and achieve something better than what was commonplace. It offered hope. It was inspirational. It focused on faith and a commitment to reaching farther, achieving more, and ascending to higher ground. It also had attitude. "Gonna keep on trying till I reach my highest ground … No one's gonna bring me down". During this same era, and with the same tenacity, the specialty of emergency medicine was established. Early goals were to codify a body of knowledge specific to the practice of emergency medicine and to that end, to train others to be specialists in the discipline.

In order to accomplish these goals, emergency medicine had to gain the respect of the other specialties within the house of medicine. The standards for training in emergency medicine were set high.

The requirements for board certification were extensive. Emergency medicine was also the first specialty to require ongoing certification. Scholarly activity and lifelong learning was a prerequisite.

Today, emergency medicine has very well defined standards for training residents in emergency medicine. These include an extensive appendix of topics, diseases, and procedures encountered in the emergency department. In addition the appendix has been weighted with both frequency and acuity so as to better direct the

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learners’ studies.

Certification through the American Osteopathic Board of Emergency Medicine requires a three-step process: the assessment of medical knowledge through a written exam, analysis of common scenarios through an oral/practical exam, and assessment of practice through a quality assurance review of charts. In addition, continuous medical education must be achieved over a three-year cycle, assuring that at least 25 hours per year are completed in the specialty of emergency medicine.

The concept of ongoing, continuing, or maintenance of certification was pioneered by emergency medicine. Both AOBEM and ABEM require a series of literature reviews annually with examination that qualifies the physician to recertify every 10 years. Most recently, the bar was raised by national authorities, to incorporate a quality improvement project into the recertification process. This requirement was inspired by the current core competency required by all AOA and ACGME training programs:”Practice-Based Learning”.

So who is a scholar? Merriam- Webster defines a scholar as a person who attends a school or studies under a teacher, or a person who has done advanced study in a special field: “a learned person". http://www. merriam-webster.com/dictionary/scholar In our pursuit of excellence, we are encouraged to develop as scholars of emergency medicine.

Today scholarly activity in emergency medicine is abundant. Like any financial portfolio, it is desirable to have diversity and balance. The ACGME defines scholarly activity for residents as:

“An opportunity for residents/fellows and faculty to participate in research, as well as organized clinical discussions, rounds, journal clubs, and conferences. In addition, some members of the faculty should also demonstrate

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scholarship through one or more of the following: peer-reviewed funding; publication of original research or review articles in peer-reviewed journals or chapters in textbooks; publication or presentation of case reports or clinical series at local, regional, or national professional and scientific society meetings; or participation in national committees or educational organizations.”http:// www.acgme.org/acWebsite/about/ab_ ACGMEglossary.pdf Specific to the emergency medicine standards, it further states that: "1. The curriculum must advance residents’ knowledge of the basic principles of research, including how research is conducted, evaluated, explained to patients, and applied to patient care.

2. Residents should participate in scholarly activity.

The curriculum should include resident experience in scholarly activity prior to completion of the program. Some examples of suitable resident scholarly activities are the preparation of a scholarly paper such as a collective review or case report, active participation in a research project, or formulation and implementation of an original research project; and,

The program must teach residents to have an understanding of basic research methodologies, statistical analysis, and critical analysis of current medical literature.

3. The sponsoring institution and program should allocate adequate educational resources to facilitate resident involvement in scholarly activities.” http://www. acgme.org/acWebsite/downloads/RRC_ progReq/110emergencymed07012007.pdf

The AOA guidelines for training in emergency medicine state similar goals for osteopathic residents. STANDARD II:

EDUCATIONAL PROGRAM GOALS AND OBJECTIVES are rather extensive.

They require faculty to be involved in research and academic pursuits such as publication in peer review journals, participation in textbook chapters, local or specialty publications, formal lectures (on a national basis), visiting professorships, or active involvement in national emergency medicine organizations within the past five (5) years. http://www.acoep.org/ uploads/2007-07-EmergencyMedicine.pdf

Scholarly activity can be demonstrated in many forms.

Research - Collaboration w/ basic scientists for

bench research - Clinical research

o case-based paper with literature

search

o comprehensive literature search

with paper i.e. collective review

o pilot studies

o abstract proposals/research pro

posals (comprehensive IRB ready)

o Survey

o Pharmaceutical or procedure/

practice comparisons: assess the effica

cy of one drug or procedure versus

another Writing - Faculty development

o train the trainer

o adult education concepts

o patient education concepts

- Peer reviewed

o online journals

o journal articles

o textbook chapter

o curriculum development

o editorials

o specialty publications

o training manuals

o grant writing Speaking - national, state, or regional presenta

tions

o papers

o abstracts

o posters

o case competition

o lecture

o literature reviews (niche)

o keynote address (inspire others to

a purpose or cause based on expertise

and mentorship)

- - -

Grant reviewer IRB member Research department o methodology o statistics/metrics o writer/reviewer

Education - Advanced degrees - Certificate programs - Honorary titles (criteria defined with

peer approval) - Accolades acknowledging scholarly

achievement

The five-year plan Research, Writing, Speaking, Serving, and Education are the elements of your portfolio. We all can add to the body of emergency medicine knowledge during the course of our careers. Start by selecting something from each of the 5 categories.

Serving Each selection must capture your interest - Editorial board and be achievable. Next, define a 5 year - Colleges, societies, associations (Board plan to accomplish each item. Once you

and committee work) begin the journey, many new opportunities

o OPTI may present themselves, adding depth and

o ACOEP often unexpected resources that expedite

o ACEP your plan. The five years will go quickly,

o AAEM and you may have to modify your origi o SAEM nal plan, but don’t lose sight of the goal.

o WADEM Remember, as an osteopathic emergency

o IFEM physician, you are a scholar. Keep reaching - Visiting professorships for higher ground.

o COMs

o International

Editorial, continued from page 4 large quantities prescribed over a short time; multiple providers writing prescriptions; symptoms that markedly deviate from objective evidence; use the ED as primary care; and, PCP is on vacation. These characteristics are suspicious for DSB but not proven behaviors.

The professional patient also exhibits DSB. These are patients who exploit chronic medical conditions; feign illness; persuade providers to diagnose by history; taint urine specimens with blood; bring own diagnostic work-up; control interview; apply psychological pressure; refuse workup; and leave before treatment is completed. How many times have we seen the

professional patient, gave into their requests and did not realize we were duped until after the patient left the ED? We all have fallen victim to these patients and do not readily recognize that we have been had.

The question arises, how do we treat patients with an acute exacerbation of chronic pain who presents to the ED? Do we concede to the patient’s request? This is the path of least resistance but now you have fed the bears and they will keep coming back for more. EMTALA requires a medical screening exam on all patients.

Once your medical screening exam is completed, do you provide the patient with analgesia or do you refer the patient to their

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PCP or the pain clinic for management of their pain. Many EDs have policies that deny patients with DSB behaviors any controlled substances after completion of their medical screening exam. Other EDs have treatment options that employ non-narcotic medications and adjunctive therapies for their chronic pain patients. These are difficult patients to manage and time and labor intensive and there is no easy solution on how to deal with them.

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Guest Column Bernard Heilicser, D.O., FACOEP

The Real Reality

We have just arrived in Port-AuPrince, 2 ½ weeks have passed since the earthquake. Words cannot describe what one sees, hears and smells. The images we have seen are bad, but this is beyond comprehension. The devastation is everywhere. This can’t be real. But, it is.

Working the ED at the large Hospital De L’Universite D’état D’ Haiti, or General Hospital, the human misery is beyond description. They come by the hundreds, many still emergently from the earthquake, others having never seen a physician before.

The ED is three tents, each with 12 mesh cots with three hundred to five hundred each day, most between 7 a.m. and 6 p.m. The injury and illness is difficult to fathom. Bones are not meant to create such angles, open wounds displaying so much anatomy is a thing for a dissection lab in medical school. Malaria, dengue fever and typhoid should only be Board questions. Tetanus is a fatal disease.

An “inpatient” ward of 360 patients is adjacent to the ED; under the trees.

Pre-Op and Post-Op are also in tents, as is the TB “isolation”. Surgery is in hallways.

ICU is in a collapsed building, mostly on the floor with occasional electricity. There is no CT, only minimal lab and simple x-ray, if you wait 2 to 4 hours. Sterility is fiction. Dunk the needle driver in Betadine and start suturing, again. The

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only sheets are the ones in the tent cities.

Irrigate the infected wounds and stumps, and welcome the next patient to the cot.

Privacy is nonexistent. Bodily functions are performed on, or squatting beside, the adjacent cot. There are no partitions. Rashes are demonstrated for all to see.

Supplies are present, at times. Today we have normal saline, yesterday we ran

out by 11 a.m. How often do we use the third indicated antibiotic for a given infection? Atrial fibrillation is a clinical (pulse) diagnosis, and treated for results and discharge in a similar manner. There may not be insulin for that patient with DKA today; hopefully normal saline is available.

How do you tell a mother to give her child the amoxicillin twice a day with water; there is no water. Apply this lotion

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for the endemic rash and then wash or bathe; with what, sewer water? Placebo medicine is the standard of care. Tylenol, Motrin and Benadryl are all wonder drugs.

Really, the arm around the patient with encouragement, reinforcement and a smile is the true medicine.

The children are the hardest. What did they do to deserve this? The 2 month old about to die who, thank God, is resuscitated with 2 intraosseous lines. The 2 week old is probably better off with her Maker. Children should grow up with all their extremities.

There is no time to cry.

The simple scalp laceration patient who decided to charge his cell phone in the tent by disconnecting the fan (it went up to 107˚in the tents). He is upset that you make him leave; so much for our Press Ganey’s.

The people of Haiti are appreciative and caring. The children are well dressed and loved. “Merci” is always voiced. They are proud and resilient.

Their emotional and physical strength is inspiring. They were most appreciative of the medical care, but we should be more appreciative of what they taught us.

There are two realities in this world.

The material reality we selfishly desire, pursue and protect; that is our reality.

And the reality that is Haiti; the REAL REALITY.

Emergency Medical Services Gregory Joseph Beirne, D.O., FACOEP

What's New, What's on the Horizon?

Greetings from St. Louis! It appears summer has arrived here with a vengeance, with temperatures this week (May 24) already in the 90’s, with that lovely humidity we are famous for. It seems like just last week that all of us were together at the Kierland Resort in Scottsdale. It was an enjoyable week for me, allowing me to catch up with friends and colleagues. As chair of the EMS committee, one of the ideas I had proposed to the other committee members was for our committee to have an article in each issue of THE PULSE. With that in mind, I would like to provide updates from our recent EMS committee meetings to the membership, as well as my own experiences as a new EMS medical director.

At our spring 2009 meeting in Orlando, we welcomed several new members and began work on an ambitious project to review position papers that are on NAEMSP (National Association of EMS Physicians). We are in the final stages of this project, and will be providing recommendations to the ACOEP Board of Directors regarding these papers, hoping to provide a link to NAEMSP on the ACOEP website. Many of our college members are actively involved in EMS and also members of NAEMSP. We also began work on the creation of an EMS section on the ACOEP website, a project that is still ongoing at this time. We hope to have this finalized within the next by spring 2011.

This section would provide the membership with resources for EMS issues, questions/answers, legal updates, and hopefully a blog for members to provide information for ideas, cases, etc. I will keep you updated on the status of this ambitious project.

At our fall 2009 meeting in Boston, we continued work on the NAEMSP papers, and also discussed the creation of

an online EMS fellowship. Many of our college members, myself included, completed an emergency medicine residency, but did not have the chance to pursue an EMS fellowship. After working as attending physicians, we became actively involved in EMS and realized that an EMS fellowship would have provided us with a tremendous educational opportunity. Currently, there are two AOA/AOBEM approved EMS fellowships, Lehigh Valley Medical Center and Albert Einstein Medical Center. Most of us, as you know, do not wish to uproot our families, or give up our current positions and responsibilities, to pursue this type of additional training. With that in mind, the EMS committee discussed the creation of a “distance-based” online learning module, similar to University of Phoenix or Kaplan University. This would allow ACOEP members who are interested in EMS fellowship certification to complete the training while enabling them to continue working as attending physicians in their current location. At the present time, we are continuing our dialogue with the AOA and AOBEM to develop a curriculum for their consideration.

At our most recent meeting in Scottsdale just a few months ago, we continued our work on the NAEMSP position papers, as well as continued discussion about the EMS fellowship project. We also welcomed new members, both students and residents, and also had a guest from WADEM (World Association of Disaster and Emergency Medicine), Jerry Overton, who is the section chief for International EMS. Jerry spoke about his mission with WADEM and international EMS, and we hope to have him speak at the scientific seminar in San Francisco this fall. Dr. Bograkos, one of our EMS committee members, spearheaded the campaign to have ACOEP become the foundation for the osteopathic section of WADEM. We hope to reach out to other osteopathic physicians who are involved in EMS and

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disaster medicine at the fall 2010 scientific seminar. All ACOEP members may join WADEM. (http://www.wadem.org)

This brings me to some final thoughts about EMS and my experiences as a medical director. I am the director of EMS Education for Missouri Baptist Medical Center in St. Louis, Director of EMS Programs for St. Louis Community College, and Medical Director for Respond Right, a privately owned EMS education company in St. Louis. In addition, I have recently become co-medical director for two fire departments in suburban St. Louis. Our emergency department is in a suburban, community-based hospital with an annual volume of approximately 40,000-45,000. We are a level 2 trauma center. We were approached in 2008 about becoming medical control by two fire departments in our area. One of these is a city-based fire department with an annual volume of 4000 calls for 2009.

Geographically, it is a unique environment, as the coverage area abuts the city of St. Louis on its eastern border, and several affluent suburbs on its western and southern borders. The call volume includes many medical emergencies, motor vehicle trauma and the “knife and gun club”. This particular department has many new paramedics and many veteran paramedics, all of whom are eager and dedicated to providing excellent patient care. I met with all of the crews last June, while the contractual process for becoming their medical control was being finalized. Many of them were colleagues I worked with during my tenure as a paramedic. During our discussions, many of the crews expressed frustration about their past experiences with other hospitals that had been their medical control over the years, as well as the lack of educational programs. I assured them that we were going to provide a unique medical control program for them and that continued on page 34

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Juan Acosta, D.O., MS, FACOEP, President, FOEM

2010 Research Activities As we move forward in our plans to expand and increase the research activities in osteopathic emergency medicine, the Foundation is pleased to announce that the Spring Case Poster Competitions were very successful and we had 19 entries into this event. The event was well attended and we were happy to see so many attendees participate in this event and give support to our presenters.

The winning case posters were: 1st Place: Marianna Karounos from St. Joseph’s Regional Medical Center for her poster titled “Dizziness and Brugada Syndrome in an Urban Setting.”

2nd Place: Alexandre Pierrot from St. Barnabas Hospital for his poster titled “Rapidly Expanding Non-Traumatic Pericardial Effusion with Tamponade.”

3rd Place: James Rodriguez from Botsford Hospital for his poster titled “Isoniazid Toxicity.”

Beginning this fall, the Foundation will host its events in conjunction with the ACOEP’s Scientific Assembly at the San Francisco Hilton Hotel, Union Square on Monday, Tuesday, and Wednesday, October 25, 26, and 27th. The session

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will lead off with the CPC on Monday, Healthcare Professionals.” beginning at 7:00 a.m. and ending at

As we continue to bring you more approximately 3:30 p.m. Research posters information on research being conducted will also be presented on Monday during by emergency physicians, we urge you to the same time period. The Oral Abstract get involved in the Foundation, not only as Competition will start the day Tuesday a donor, but a participant. We need judges at 6:00 – 7:30 a.m. and our events will to review posters, CPC presentations, and finish off with the Resident Research oral abstracts, and to serve as reviewers of Paper Luncheon on Wednesday at 11:30 resident research. If you are interested, a.m. Winners will not be announced until please contact Stephanie Whitmer, Wednesday at the end of the Luncheon.

Executive Secretary for the Foundation and

If you are interested in participating in she will gladly help you with finding the any of these programs, we urge you to visit appropriate venue for you. our website, www.foem.org, and download the application form and remember all applications must be submitted to the OHIO: OSTEOPATHIC Foundation by July 15th.

EMERGENCY MEDICINE We have also supplied RESIDENCY PROGRAM DIRECTOR copies of the Handbook to the program directors This is an exciting opportunity to lead a program and residents to keep from inception, as well as participate in the dethem informed of the date velopment process. Qualified candidates must be changes and to encourage ABOEM certified and residency trained in Osteotheir participation in these pathic Emergency Medicine with prior experience programs. as a program director or assistant director. Adena

We are also happy to Regional Medical Center is a full-service hospital announce the continuance with an annual ED volume of 41,000. Located 45 of research at all levels. miles directly south of Columbus and 90 miles This year, James Turner, northeast of Cincinnati. Chillicothe is surrounded by D.O., and his team history, recreation, and scenic beauty. at Charleston Area We offer a highly appealing package that includes Regional Medical Center, competitive remuneration, excellent benefits, and Charleston, West Virginia, equity ownership eligibility within an established, were awarded an $11,000 democratic group.

David A. Kuchinski Memorial Grant for Contact Amy Spegal, Premier Health Care Services research being done on phone: (800)726-3627, ext 3682, “Posttraumatic Stress email: aspegal@phcsday.com Disorder, Work Stress, fax: (937)312-3683 and Burnout among

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Foundation Focus Janice Wachtler, BA, CBA, Executive Director

Fickle Finances

For most of us, this past year was sort of topsy-turvy especially when it came to finances and investments. We’ve watched as banks have failed and large investment companies have had to have government help because they over extended themselves. Associations and Foundations have watched from the sidelines, just like you have and have ridden the various waves of good news and cringed as bad news was laid on your desk with each morning’s newspapers.

And like you, the Foundation has felt the pinch of diminishing returns, but while you could depend on the steady stream of patients and income, we could not.

To adjust to the fact that donations fell to an all time low in 2009, we charged for the CME provided at the various research events at the Scientific Assembly last fall and will do this again in 2010.

We also had to move the events away from anything involving a meal function just to maintain costs. We have relied heavily on the ACOEP, our regular core of donors and sponsors to continue to promote research, and we’ve had to limit the grants being funded. We’ve also relied heavily on the Board and Staff members, who in many cases waived travel and hotel reimbursement to lighten the load. Staff has been cut even though we now have two parttime staff positions, one is minimally funded and one is a volunteer position. We will continue in this leaner fashion until we can be assured that we can continue as a research entity, and that will depend on you.

Philanthropic development is individual and most people develop the tendency and frequency of donating to a cause early

in their professional career. Also, people tend to donate in causes they believe in and are personal. Generally speaking if you adopted pet from a shelter, you will support that shelter for the life of the pet and will probably return to the shelter to adopt another pet. Likewise, if you had a friend or relative with a specific disease, you will donate to that particular charity more frequently than any other. Other people feel strongly about a specific cause, wildlife, gun control, animal habitat, or whatever and they will support that cause on a long-term basis. So what we’re asking is to support the group that supports you and osteopathic emergency medicine, and that is the Foundation for Osteopathic Emergency Medicine.

Right, you say, and how can I help, I’m strapped too. Well, we know that, but . . . here’s how you can help.

Each year the ACOEP sends out its dues notices, and each year there is a “negative check off ” on it for $50 for the Foundation. Many of you have provided us with this amount and more, most have not. This $50 is 100% tax-deductible for you and each donation is acknowledged so you can claim it on your income taxes.

If all of the ACOEP members left this on their dues statement, we could raise upwards of $100,000 annually. If residents donated annually, that would add another $50,000 annually. Do you know what we could do with that? Help you in so many ways fund your residency research, help you teach research and do research at levels that we can only imagine. But it won’t happen in a year, or even in two, it will happen gradually as we gain your support and show you what we can do.

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So as you fill out that form, and write that check remember the Foundation and whether you’re a resident or attending, a student or a retiree, remember the Foundation and its mission to support osteopathic emergency physicians doing research. We’ve come a long way in 10 years and we have a long way to go, but you have to take the first step to support us and keep up the pace for us to continue to help you.

We have to work as a team, so please join us – we can’t do it without you.

RESEARCH OPPORTUNITY Opportunity exists to participate in a Multi-Center Research Project We are looking for additional Emergency Residents interested in participating in our perspective, multicenter research of MRSA skin infections.

For more information, please contact:

Judith M. Knoll, D.O. FAAEM Hamot Medical Center, Erie, PA drjmknoll@gmail.com

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Executive Directors Desk, continued from page 6 mean, who today would even think of not having a lap top or home computer at the very least? But it’s true the world then was much different than it is now.

Medicine, especially, osteopathic medicine was very different too. In 1975, doctors working the emergency department were not “specialists” in the new field of emergency medicine. Much of the work done in the ED was done by either moonlighting physicians or physicians trained in other specialty areas. Allopathic medicine, had declared Emergency Medicine a specialty in the late 1960’s and there were only a few accredited allopathic residencies in allopathic medicine by 1975.

Osteopathic physicians in any specialty area were almost all trained in a small network of osteopathic hospitals, many of which were required by their state to have the word “osteopathic” in their name. But on October 5th 1975, nine physicians joined forces to develop what became known as the American College of Osteopathic Emergency Physicians. They were: Richard Ballinger, D.O., James Budzak, D.O., Donald Cucchi, D.O., Robert George, D.O., Anthony Gerbasi, D.O., James Grate, D.O., Robert Hambrick, D.O., Bruce Horton,

D.O., and Scott Swope, D.O. (See related article, “Our History” for the exact information). From their efforts the specialty of osteopathic emergency medicine was developed and nurtured.

Many take for granted the work and sacrifice that these physicians went through developing the Articles of Incorporation in the State of Ohio; a Constitution and Bylaws by which to operate under; appearing before the AOA Board to inform them of the need for this specialty and then to be recognized, as not only a specialty affiliate, but a medical specialty within its organization. The actual recognition did not occur for three more years.

During the three-year period between the founding of the College and the recognition as an affiliate and specialty area, the Board had to recruit interested physicians to make a specific number of interested parties in this new specialty. The “founders” had to market this new area. The AOA required that a specific number of physicians show interest in any area under consideration as a “new specialty.” Additionally, they had to be ready to have training programs set up to train physicians interested in emergency medicine, and to do that they needed to recruit physicians working in the ED who were interested in teaching. And, even more important they had to develop basic

training standards for the specialty. The group of nine increased exponentially to recruit physicians who could fit the bill and medical students and interns who would be interested in the specialty.

In summer of 1978, the specialty of emergency medicine and its specialty college were officially recognized by the American Osteopathic Association; in the fall, the residency training standards were approved as were two residency programs at CCOM and Hospital of PCOM were approved and training began in the fall of 1979. The first osteopathic emergency medicine resident was Gerald E. Reynolds, D.O. at HPCOM. Today, osteopathic emergency medicine programs train about 1,000 residents each year in 44 residency programs; there are currently 504 fellows and distinguished fellows of the ACOEP and more than 3,000 members of our association.

Looking back, it’s amazing to see what 9 determined people can set in motion. And, even more amazing is seeing the fruits of their labor and the support of the dedicated members of ACOEP can take the College in the next 35 years.

We can always look back to see where we’ve been but we must never lose sight of where we want to go, so we continue to encourage your participation and support.

OFFICIAL CALL To the Officers and Members of the American College of Osteopathic Emergency Physicians: You are hereby notified of the ACOEP's Fall Membership Meeting on Monday, October 25, 2010, at the Hilton San Francisco Union Square Hotel in San Francisco, 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.

Voting for new Board Members will occur at this meeting. All classes of Active Members, Life Members and Retired Members will be provided with ballots at the time they sign into the meeting. New Board Members will be sworn into office at the Fellowship and Awards Ceremony immediately following the meeting. Candidate information will be included in your dues notice in August and will be made available on www.acoep.org after August 15th.

Janice A. Wachtler, CBA, Executive Director

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2010 Student Case Competition Winning Submission

Joshua Craig Poles, OMS III Kansas City University of Medicine and Biosciences - Class 2011 I. Case Report A. Chief Complaint: Persistent ventricular fibrillation after induction of therapeutic hypothermia and high dose vasopressor therapy.

B. History of present illness: A previously healthy 36-year-old man was brought to the emergency department (ED) by ambulance after coworkers witnessed him suddenly collapse and stop breathing.

Coworkers called 9-1-1 and initiated CPR. An on-site automated external defibrillator utilized by the man’s coworkers delivered one shock. EMS arrived approximately 4 minutes later and found the patient in asystole. Paramedics performed minimally interrupted cardiac resuscitation. The patient received a total of 2 mg intravenous epinephrine and 2 mg intravenous atropine and had return of spontaneous circulation 11 minutes into the field resuscitation without further defibrillation.

He remained unconscious and was orally intubated with a standard 8.0 endotracheal tube. Paramedics administered a 100 mg i.v. lidocaine bolus followed by a 2 mg/min lidocaine drip. Upon arrival in the ED, the patient was unconscious with stable vital signs and the EKG demonstrated normal sinus rhythm (NSR).

Therapeutic hypothermia (TH) was induced while the patient was in the ED through a closed-loop i.v. catheter and a Coolgard 3000™ fluid circulator (Alsius, Irvine, CA) 2 hours after the initial collapse. Intravascular temperature was maintained at 33.5°C. Propofol was administered for sedation and 10mg of vecuronium was administered to prevent shivering.

The patient was transferred to the intensive care unit with a core temperature of 33.5°C. Three hours after collapse the patient began experiencing recurrent epi-

sodes of ventricular fibrillation (VF). The following i.v. medications were initiated: 5 µg/min of epinephrine, 8 µg/kg/min of dobutamine, and 8 µg/kg/min of dopamine. Bedside delivery of extracorporeal membrane oxygenation (ECMO) support and the placement of an intraaortic balloon pump were required. A left heart catheterization was performed and demonstrated normal coronary anatomy without evidence of an obstructive lesion. A bedside 2-D echocardiogram demonstrated septal and ventricular akinesis with an ejection fraction of 15%. Over the course of 9 hours in the ICU, ventricular fibrillation recurred persistently with just brief intervals of NSR. He received 122 defibrillations at settings between 200 and 300 J of biphasic energy. During the ongoing 9-hour resuscitation, totals for the following i.v. medications were administered: 4.4 mg of epinephrine, 164 mg of dobutamine, 120 mg of dopamine, 795 mg of amiodarone, and 64 mg of procainamide.

Twelve hours after arrival, the patient was transferred to another facility to be evaluated for potential heart transplantation. He arrived at the receiving hospital in persistent VF with a core temperature of 33.5°C. It was proposed by the receiving physicians that either the considerable dosages of cardiac medications or TH was causing refractory VF. All vasoactive and beta adrenergic agents were abruptly discontinued and TH was withdrawn. The patient was again defibrillated with 200 J of biphasic energy and he converted to and remained in NSR. C. Past medical and surgical history: Patient has seasonal allergies. No other past medical or surgical history.

D. Medications and allergies: Claritin-D as needed for seasonal allergies. No known drug allergies.

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E. Review of systems: Per the patent’s wife: 1. General/Constitutional- No recent illness. There had been no weight changes.

The patient had been in excellent general state of health with good strength, ability to conduct usual activities, and strong exercise tolerance. He played tennis 3 days per week. No fatigue. No chills. No night sweats.

2. Skin- No rashes, changes in pigmentation, bruising or petichiae.

3. Head/Eyes/Ears/Nose/Mouth/ThroatPositive for recent mild seasonal allergy symptoms. No recent headaches. No vertigo or lightheadedenss. No change in vision. No history of head injury. No epistaxis or ginigival bleeding. No neck stiffness.

4. Cardiovascular- No precordial pain. No substernal distress. No palpitations. No syncope. No dyspnea on exertion, orthopnea, or nocturnal paroxysmal dyspnea.

No edema. No cyanosis. No known heart murmurs.

5. Respiratory- No shortness of breath, wheezing, stridor, or cough. No hemoptysis, respiratory infections, tuberculosis (or known exposure to tuberculosis).

6. Gastrointestinal- Normal Appetite. No dysphagia, indigestion, abdominal pain, heartburn, nausea, vomiting, hematemesis, jaundice, constipation, or diarrhea. No abnormal stools or recent changes in bowel habits.

7. Genitourinary- No urgency, frequency, dysuria, nocturia, hematuria, polyuria, oliguria, stones, infections, genital sores, discharge, or venereal disease.

8. Musculoskeletal- No Pain, swelling, muscular weakness, atrophy, or cramps.

9. Neurologic/Psychiatric- Denies seizures, tremor, incoordination, parathesias, difficulties with memory or speech, sensory/ motor disturbances, or muscular coordination. Also denies emotional problems, anxiety, depression, previous psychiatric care,

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or hallucinations.

10. Endocrine- Denies heat/cold intolerance, excessive sweating, polyphagia, thyroid problems, or diabetes.

F. Physical exam: This was 36 year old, well-developed, caucasian male. No cephalic deformities, lacerations, or evidence of trauma was noted. The pupils were equal and reactive to light. There was no hemorrhage from the auditory canal. There was no jugular venous distention. There was no evidence of tongue laceration. The chest was clear to auscultation; examination of the heart revealed clear heart sounds without rubs, gallops, or murmurs. Rigid posturing of the extremities was noted on neurological examination.

G. Vital signs: On arrival in the ED, the patient’s vital signs were blood pressure of 115/60 mm Hg, heart rate of 127 beats/ min, core temperature of 37.0°C (98.6°F), and oxygen saturation of 100% while being bag-valve-mask ventilated.

H. Emergency department head-to-toe format by system: 1. HEENT- Normocephalic and atraumatic. Pupils equal, round, and reactive to light. No jugular venous distension.

1. Neurological- Bilateral upper extremities were in slight decorticate (flexion) rigidity. Patient was unresponsive. Glasgow coma scale score of 4.

2. Pulmonary- 8.0 endotracheal tube in place. Mechanical ventilator programmed in assist control. Lungs were clear to auscultation bilaterally without wheezes, rhales, or rhonchi.

3. Cardiovascular- S1S2, were audible, regular rate and rhythm. No murmurs, rubs, or gallops appreciated. Capillary refill < 2 seconds in upper extremities. No jugular venous distension appreciated. No pedal edema. Radial and dorsalis pedis pulses +2/4 bilaterally.

4. Gastrointestinal- Abdomen soft, nondistended. No masses. No organomegally.

Normal bowel sounds in all 4 quadrants.

Nasogastric tube in place. No bright red blood per rectum. Stool in vault.

5. Genitourinary- Foley in place with yellow urine draining.

6. Extremities- no clubbing, cyanosis, or edema. Positive abrasion on right hand and

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knuckles.

I. Laboratory and ancillary data: EKG- Sinus tachycardia at 120 beats/min.

No ST wave changes.

Chest radiograph- Portable chest radiograph showed clear lung fields with normal heart and mediastinal silhouettes.

Labs: Arterial blood gas- pH: 7.38 pCO2: 37 pO2: 346 HCO3: 21.5.

CBC- WBC: 9.6 Hgb: 16.1 Hct: 45.7 Platelets: 319 Chem-7: Na+: 140 K+: 3.5 Cl-: 110 HCO3: 16 BUN: 11 Cr: 1.4 Glucose: 202 Creatine Phosphokinase- 155 CPK-MB- 3.8 Troponin I- 0.10 ng/mL Urine drug screen- negative.

Urinalysis- normal J. Diagnostic impression: 1. Out-of-hospital cardiac arrest with return of spontaneous circulation.

2. Persistent ventricular fibrillation secondary to excessive dopamine and dobutamine during therapeutic hypothermia.

K. Plan of disposition: On hospital day 2, his ejection fraction had increased to 75%.

On day 3, after ECMO support and the intraaortic balloon pump were removed, sedation was discontinued and he was successfully extubated. He remained in NSR. Upon regaining consciousness the patient had impaired short-term memory which gradually resolved over the next 7 days.

On hospital day 10, an automatic implantable cardioverter defibrillator (AICD) (Medtronic, Minneapolis, MN) was placed and the patient had a full neurological recovery and was discharged home.

This patient underwent cardiac magnetic resonance imaging, myocardial biopsy, channelopathy genetic screening, and evaluation for dysrhythmogenic right ventricular dysplasia, all of which were normal. Several months after discharge he is back at work full-time. The AICD has not fired and the patient has had not subsequent episodes of ventricular fibrillation.

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2. Discussion: Etiology of Persistent VF in This Patient Based on published evidence, I believe that the cause of persistent VF in our patient was excessive dopamine and dobutamine.

At intermediate doses (2–5 μg/kg/min), dopamine stimulates β-receptors, producing positive inotropic effects (1). The adverse effects are associated with excessive sympathomimetic activity and include dysrhythmia, tachycardia, hypertension, anginal pain, nausea, vomiting, and headache (2). Dobutamine stimulates myocardial β1-adrenergic receptors at doses with a positive inotropic effect (2.5–10 µg/kg/min) (1). The major side effects of dobutamine are dysrhythmia and excessive tachycardia (1). The Heart Failure Society of America guidelines recommend that if worsening tachydysrhythmias develop during administration of dobutamine, discontinuation or dose reduction should be considered (3).

Dopamine is contraindicated in patients with uncorrected cardiac dysrhythmias, including ventricular fibrillation or ventricular tachycardia (4). Dopamine and dobutamine are primarily metabolized by catechol-o-methyl transferase and monoamine oxidase, which are in highest concentration in the liver and kidneys (1).

The effect of TH on the clearance of exogenous catecholamines and cardiac life support medications has not been specifically evaluated, however, studies have demonstrated diminished liver metabolism by enzymes such as cytochrome P-450 during TH (5-7). Tortorici et al. described four medications found in higher-than-expected concentrations in patients cooled within the therapeutic range (6). Additionally, animal studies have demonstrated reduced glomerular filtration, leading to reduced excretion of parent drugs or their metabolites during TH (8).

Therapeutic Hypothermia Therapeutic hypothermia is a relatively new treatment modality for many practitioners (9). In 2005, it received the status of guideline therapy by the American Heart Association; however, details regarding its potential complications and interactions with other therapies need further delineation (10). To date, the literature demonstrates that a core body temperature <32°C is associated with refractory VF,

whereas mild TH at 32–34°C is not (1112). Several studies have demonstrated no evidence that TH poses a higher risk for dysrhythmias than normothermic therapy (11,13-14). The Hypothermia after Cardiac Arrest group performed a blinded assessment of 275 patients who were either maintained at a normothermic temperature or treated for 24 hours with mild TH at 32–34°C. There was no statistically significant difference between the two groups in the rate of dysrhythmias: 32% (44/138) in the normothermic group compared to 36% (49/135) in the group treated with mild TH. In this study, TH was discontinued to mitigate dysrhythmias in 3/137 cases (15). Bernard et al. studied 77 patients who were assigned to treatment with TH at 33°C for 12 hours vs. normothermia.

Although numerical data were not published, the authors assert that clinically significant dysrhythmias did not develop as a result of TH (11).

Idiopathic Ventricular Fibrillation Idiopathic ventricular fibrillation (IVF) is defined as cardiac arrest in the absence of structural heart disease or identifiable causes of VF (11).

It occurs in 1–9% of out-of-hospital cardiac arrest survivors (16).

The mean age is 35–40 years, and 70–75% of the patients are male (16). IVF is a diagnosis of exclusion, making it necessary to rule out all possible causes of VF (17). AICDs are currently the treatment of choice, and ongoing annual evaluations for cardiomyopathy are recommended (9,16).

Persistent Ventricular Fibrillation One of the major challenges in persistent VF is that patients resuscitated from a VF arrest are at risk of refibrillation by a variety of mechanisms (18). Initially, focal ionic and metabolic

changes create electrical myocardial heterogeneity, leading to slow conduction and micro-reentry circuits (19). These conditions can be further complicated by hyperkalemia, increased cyclic adenosine monophosphate, disturbed calcium metabolism, and disrupted electrical coupling between cells (19). Myocardial stunning as a result of numerous defibrillations, as occurred with our patient, also makes termination of the ventricular dysrhythmia progressively more difficult (20). Ventricular fibrillation in this patient eventually terminated after the simultaneous cessation of both TH and cardiac life-support medications, making it difficult to determine which factor was the primary cause.

This patient benefited from an integrated system of care encompassing all links in the AHA chain of survival, includ-

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ing the newest link, therapeutic hypothermia.

As therapeutic hypothermia becomes more commonly accepted and utilized in clinical practice its interactions with other therapies and substantial benefits will become better understood.

Figures: 1. Rhythm strip from the AED used by the patient’s co-workers demonstrating ventricular fibrillation and one shock.

2. 12-lead EKG upon arrival in the emergency department demonstrating normal sinus rhythm.

3. 12-lead EKG from ICU show one episode of recurrent ventricular fibrillation. continued on page 34

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On the Wild Side James Shuler, D.O.,MS, FACOEP, FAWM

Medical Support of Endurance Events: Part 2 So you’ve decided to medically support an “endurance event.”

Excellent! Now, comes the big question: What medical supplies do you need to bring? That’s a tough question.

Taking the time to consider the full range of situations you might encounter may well make the difference for your participants. With this in mind, give thought to the following considerations: What challenges will the participants face during the event? Where will the event take place and will “altitude” be a factor? What sorts of weather might you expect? How many participants will there be? Does the very terrain pose any consideration?

Start by putting yourself in your potential patient’s situation. For example, imagine you stepped through your bike and cut your leg on the gear-sprocket.

You’re bleeding and need help. Would you prefer to receive an appropriate “wound treatment” there on the road-side so that you can get back on your bike and moveon? Or do you want a trip to the emergency department with a $200 co-pay and a 2-6 hour wait for the same treatment?

As an emergency physician you have the opportunity to make someone’s day.

What you bring with you will of course depend on the location and type of event you’re supporting. What type of weather, temperatures, incidents/accidents, numbers of participants, etc. are all considerations to keep in mind, so be sure to get specific details about the type of event you will be supporting.

Let’s imagine some other scenarios.

Should you anticipate a female urinary tract infection on the second day? YOU BET! Are you prepared? What about altitude illness on the arrival at the reg-

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istration booth of the 2-day walk in the mountains of Colorado? Are you prepared? What if there is a cycle crash during a 2-day event, leaving one participant with a simple laceration and the other with a suspected clavicle fracture? How about a fall with a “cracked” helmet? In the emergency department, you are prepared for all of the scenarios, but what about when you’re “out there” supporting the participants and you don’t have an entire hospital full of “stuff ” and staff to support you?

Are you prepared?

What a tall order. In these situations you have two choices: 1) hope like heck your cell phone has enough bars to call 911, or 2) “fix” the problem. True, not every injury can be fixed at the scene, but a bunch can. Again, put yourself in the shoes of the event participants and think through every scenario you can imagine.

That’s the single best way to prepare.

Most events like these share the common theme of endurance. That carries with it many predictable occurrences.

Initially, “wear-and-tear” injuries like the expected blisters will occur along with the unexpected accidents. Later in the event, “over-use” injuries will ensue, like strains, bursitis and tendonitis. Be forewarned!

There will be more injuries than you expect, as not all participants will come to the event with the proper equipment, experience, and knowledge. You will need to overcompensate by preparing, yourself, for those who are woefully underprepared.

The larger the event, the more unprepared participants there will be. (Be afraid. Be very afraid…)

Next you get to deal with the complications of the climate. Do you anticipate heat, cold, wet, dry, and what about “terrain” conditions? One year I asked if we had enough blankets for riders during a July two-day ride in Colorado. The committee looked at me as if I were from another planet. However, they acquiesced and added a bunch with the thought they’d give me an “I told you so.” Guess

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what? A flash storm soaked 1500 riders who were dressed for the 90ºF sunny weather with a drop in temperature to the upper 50’s… Of all the supplies, the riders were most thankful for the truckload of blankets I had requested.

Be afraid again? Nope, be prepared for the unexpected. Any event like this is truly a “controlled” disaster, so you must truly think in the mind-set of disaster preparedness.

That said; ensure there are adequate stations appropriately spaced. There is little research on this, but walking events usually have a minimal hydration stop every 1.5 miles with a “full” rest area at every 3rd mile. That will include individuals to prepare/serve hydration and nutrition with a medical specialist there.

The medical individual may be an EMT or paramedic or nurse who needs to be in contact with you via phone or HAM radio (which is a favorite of ours on the long bike-rides).

During these events you will encounter a wide-range of problems. I’ll address specific problems later. First, you may encounter an individual that is light-headed, nauseated and tachycardic, an overall “I don’t feel well.” Is this dehydration, an electrolyte imbalance or altitude illness (which can occur at altitudes as low as 4,000 feet)? To separate this, a few questions can sort this out. First, if they are regularly urinating clear urine at each stop it is not dehydration. It is either altituderelated or an electrolyte disorder, most commonly hyponatremia. Research has shown that the body knows what it wants.

Subsequently, every “full station” should include fruit, fat (like peanut butter), carbohydrates and salt, like potato chips or pretzels. Additionally, hydration stations must include both water and an electrolyte replacement solution like Gatorade®. If it’s hot and dry and pretzels look good, eat them. If they are urinating infrequently and the urine is dark, it’s likely a hydration issue. If you are at “altitude” and every-

thing seems appropriate then you must consider altitude illness, generally accompanied by a headache. Although vital signs are important you must consider the context, these people are working hard, look at your patient’s “whole picture.”

As far as what to bring medically, every full station should have sun block and general wound-care items such as bandaging, Adaptic®, irrigation and cleaning materials like SureCleans®. Additionally, IV capabilities with normal saline and an individual capable of starting an IV should be present along with shade and a cot for the individual to lie in comfort. With respect to medications I always bring oral and injectible medications like epinephrine, diphenhydramine, Ondansetron, IV Solumedrol®, and a host of antibiotics to cover the unexpected like UTI’s and bronchitis (insure this isn’t exercise-induced asthma, for which I carry albuterol). I also

carry a couple suture sets with a variety of suture materials. I can’t tell you how often I’ve done a repair at the road-side allowing an individual to complete their objective without having to go to the ED.

Regarding blisters, there is a great medical “myth” out there that says “never ‘pop’ a ‘blood-blister’” Phooey! There is no evidence to support this and it should be treated like a blister/abrasion. Drain and cover as you would any other blister/injury.

When it comes to the standard blister, drain and cover with felt-padding or other padded adhesive materials available. There are also blister-prevention materials available through many organizations; SAM Medical Products produces Blist-O-Ban® which is available at www.blistoban.com.

Additionally they have many other medical solutions for “out there” situations.

The bottom-line is that I carry situation-specific medications with me on these

events and rely on the fact that each “aidstation” is well equipped. HAM operators are excited to help you if you call them early enough, if unavailable the cell-phone can keep you in touch with the event control.

Finally, educate participants as to the problems that can occur. Over the years I’ve done these events it has incredibly paid-off. We get minor complaints earlier before a real problem exists. If a “hotspot” starts, pad it early.

I only hope you take part in events like this locally for whatever the cause. It pays nothing but you or your organization may get a sponsorship logo. Most importantly, it’s the most rewarding work you can do. Should you have any questions, please reach me at shulers@aol.com.

Ethics in Emergency Medicine Bernard Heilicser, D.O., MS, FACOEP

What Would You Do?

In this issue of The Pulse we will review the hypothetical case of the three victims trapped in the rubble of a collapse.

The first victim is blocking the access to the other two victims. Victim 1 will not be able to be extracted without an above the knee amputation. Unfortunately, Victims 2 and 3 cannot be accessed without extraction of Victim 1. Victim 1 understands the need for the amputation, and that it will be his only hope of survival. He states he would rather die intact, and refuses the amputation. However, this refusal will prevent probable successful extraction of Victims 2 and 3, resulting in their deaths.

This has been a lengthy, difficult and dangerous rescue mission, putting you and your task force at risk.

Does Victim 1 have the right to refuse his own life saving procedure, and does he have the right to have this decision result in the death of others?

What would you do?

I raised this question at a FEMA Medical Specialist Class on January 12. Ironically,

the devastating earthquake in Haiti occurred later that afternoon. The relevance of this question was only intensified.

The first question presents a very difficult dilemma for the rescue personnel. After all your heroic effort, can the patient refuse the amputation? One could say the patient has the autonomous right to make his own medical decision and refuse the amputation. Of course absolute medical decision-making capacity with full informed refusal would be needed. In the scenario described, can decision-making capacity truly be present? The presence of possible dehydration, hypothermia, hypoglycemia, and electrolyte imbalance could certainly be invoked. This might equivocate the patient’s decision-making capacity.

In of itself, the dilemma may allow for the principle of beneficence to trump the patient’s autonomy. Our intellectual honesty may be called into question, but to error on the side of life in such a drastic situation may have credibility.

Now, with two other victims condemned to death by Victim 1, would you

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accept his refusal? Again, at the risk of questionable ethical consideration, what would/should we do?

Individuals have a right to make informed decision for themselves. This may include a refusal of standard life saving treatment or procedures (i.e. on religious grounds). However, when others will die because of these decisions, how much standing do we give autonomy?

I respectfully understand that others may disagree, but I would find it extremely difficult to accept the presence of Victim 1’s decision-making capacity. Therefore, appropriate sedation and pain control, following by life-saving procedures would be initiated.

We would welcome any additional comments on this presentation.

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 1-708-915-2743. Thank you for your participation.

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AOBEM Update Mark J. Stone, DO, FACOEP, Secretary

AOBEM would like to announce new improvements to the certification/recertification processes. Beginning in 2012, those diplomats entering the recertification process will be required to pass 8 COLA exams in order to be eligible for the Formal Recertification Examination. If a diplomat fails a COLA exam three times, he/she will be given the opportunity to re-register and pay the fee for that COLA exam. At that point, the diplomat has another three attempts to pass the COLA exam.

Secondly, all oral examinations (certi-

fication and re-certification) will be video recorded for security and quality control measures.

The AOA Bureau of Osteopathic Specialists has approved the Practice Performance Improvement component of our recertification process which will be formalized in 2012. The Practice Performance component involves the diplomat identifying a target area for growth of Emergency Medicine skills. The diplomat will review the care given to patients with that particular issue. The diplomat then

develops and implements a practice performance plan to improve care, based on evidence based guidelines or expert consensus data. He/she will review the care given to patients after the program is implemented for clinical improvement.

In conclusion, AOBEM is seeking diplomats who would like to become item writers for the examination process. Please contact Ms. Josette Fleming at aobem@ aol.com for further information.

Presidential Viewpoints, continued from page 1

our issues with our respective members of the House and Senate. I personally enjoyed speaking with Congressman Joe Sestak as he was walking back to his office from the Capitol building. I encourage every member of the ACOEP to consider participating next year. More importantly though, I strongly encourage you to stay actively involved in the many State and Federal issues that effect our practice of medicine and ability to deliver care to our patients. All it takes is a phone call or email for you to be heard by your elected officials. The more voices speaking in unison, the stronger the message will be received. Silence or a low voice signifies lack of interest and importance.

In this issue of The Pulse, we have been given permission from ACEP to print a copy of a manuscript that will also be published in the August Annals of Emergency Medicine.

We appreciate ACEP allowing us to do this because it is important for you as a member of the ACOEP to witness the fruits of your Collegeâ&#x20AC;&#x2122;s labor and see that we are actively

working with the other organized bodies in emergency medicine to help shape the future of our profession.

In closing, I want to thank Tony Jennings for all of his support and assistance as we worked very closely together over the past few years. His unfortunate illness came at a very inopportune time for him personally and professionally. Becoming ill is a personally devastating and humbling experience, especially if you are a physician.

I have continuously been inspired by the strength, maturity and resilience that Tony has demonstrated throughout his diagnostic dilemma and subsequent treatment.

Although he has chosen to step down from our Board, you should rest assured that I shall continue to use him as a valued advisor as I continue to lead our College and now work with Greg Christiansen as Presidentelect.

a very significant emphasis on primary care and the role of the primary care provider will change dramatically over the next several years. The benefit to the emergency physician should be that we are no longer the primary entry point into the healthcare system and we have efficient ways to make patient dispositions that are effective and efficient and not dependant on unnecessary testing or admission to the hospital because there is not a better alternative.

On a different note, your College has remained very active since the spring conference. We sent a letter to the CMS expressing our concerns about the adverse impact their new rule concerning Propofol and procedural sedation will have on emergency physicians and emergency medicine residency training. We also had a strong showing at DO Day on the Hill. The weather was perfect and everyone enjoyed the camaraderie and opportunity to discuss

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Member News

Joseph W. Stella, D.O., FACOEP long time member of the American College of Osteopathic Emergency Physicians, Past President of the American Osteopathic Association and the Pennsylvania Osteopathic Medical Association passed away on Saturday, May 22, 2010 at his home in Allentown, Pennsylvania surrounded by his family. Dr. Stella was the Founder of the emergency medicine residency program at St. Lukeâ&#x20AC;&#x2122;s Hospital, formerly Allentown Osteopathic Hospital, in Bethlehem, Pennsylvania. He practiced both emergency medicine and family medicine from 1963 to 1985. Dr.

Stella was a graduate of the Kirksville College of Osteopathic Medicine, Class of 1943. He served in the Navy following graduation and then entered postdoctoral training at Allentown Osteopathic Hospital in 1946. He was actively involved in the Pennsylvania Osteopathic Medical Association and served on many AOA Committees, Bureaus and its Board of Trustees and served as President of the American Osteopathic Association in 1986. Dr. Stella was a mentor to many osteopathic physicians in emergency medicine and family medicine and will be sorely missed for his gentle ways, smart gover-

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nance and infinite patience.

Congratulations go out to Victor Almeida, D.O., FACOEP; Peter Alamia, D.O.; Mark Rosenberg, D.O., MBA, FACOEP; Lauren Trattner, D.O., and Jennifer Waxler, D.O., FACOEP who have been elected to the Board of Directors of NJ-ACEP. Dr. Almeida will assume the Presidency of the Board in 2011.

Congratulations also go out to Joe Heck, D.O. who secured the Republican nomination for Nevadaâ&#x20AC;&#x2122;s Third Congressional District race by garnering 68.8% of the vote.

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In My Opinion Wayne T. Jones, D.O., FACOEP

The Next Generation's ED

1975 So, what year was it that: Saturday Night Live debuted with host George Carlin, One Flew Over the Cuckoo’s Nest swept the Oscar’s VCR’s were introduced by Sony New York City avoided bankruptcy by obtaining a $2 billion federal loan The Vietnam War ended The US saw its first “Doctors Strike” by NYC residents and interns Jimmy Hoffa disappeared Elton John sings “Lucy in the Sky With Diamonds” The FTC sues the AMA for restricting physician advertising And the ACOEP was founded

Yes, it was 1975. Unemployment was above 9%, gas was 44cents a gallon, and Foster Grants cost $5.00. We didn’t have AIDS, we had herpes. We soon discovered the difference between love and herpes (herpes is forever).

We drove Gremlins, Pacers and Firebirds. We wore bell-bottoms with halter-tops while standing on platform shoes.

Our hair was Shag, Mullet and Afro with sideburns. We were cool!

We became the first “generation” to make debt a lifestyle. During this time, we began seeing ourselves as individuals;

30

we learned that “I’m OK, You’re OK”; we became more self-indulgent and questioned everything. We were out to change the world. And we did.

I began my career as a medic, serving the rural lake coast of northwest Pennsylvania, first as a volunteer and then paid. ACLS was a new science allowing a panacea of medications and interventions.

The science of medicine was defined as medicine itself. What we did was what was supposed to be done. We never questioned if a therapy would benefit a person; if it was available, then there must be some proven benefit.

How many of you remember rotating tourniquets? We used them for CHF, to reduce preload. You would place a cuff on each of the proximal extremities and inflate the cuff to reduce venous return in three of the four limbs. On a scheduled basis you would “rotate” to another extremity. Did it work? Damn right it worked! (Really . . . I don’t know.)

Can you recall the first three drugs given in a patient with ventricular fibrillation? Edison-Medicine of course. Three stacked shocks. If a little was good, more was better. Back then there were no attachable pads, just jelly. We burned a lot of flesh (and one or two medics).

Ok, can you recall the next three drugs? Epinephrine, bicarb and calcium.

You had better flush the line well between meds though. Did it work? You bet!

Being way ahead of our time, we used a device called the Thumper. It was a piston compression device hooked up to a compressed air cylinder, which delivered cyclic cardiac compressions. This made cardiac arrests easy. Oh, and it also worked.

Remember MAST trousers. Sure you do. They were cumbersome, expensive and had exact instructions in application and use. I never really saw the utility in them, but I was told they worked.

The esophageal obturator airway was a blind insertion device used by paramedics and EMTs. You shoved it into the apnic

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patient’s mouth and ventilated through one of two holes. Which one you ask?

The one that worked, of course. It fell out of favor a few years later due to concerns it was dangerous (really?). Of course, it returned with a new name and sales pitch.

Now there are a couple devices with the same old (new) technology (really?).

The demand valve ventilator rounded out the pack. Push the trigger and you got air filling those lungs. How much should you give? Sort of like the last question… enough. Ok, you held the trigger until the chest started to rise. But, you know, you do need to blow off the CO2 that the IV bicarb created, so… more was better right? Yeah!

As a medic we always ended up in the same place... the ED. The emergency department was a place, not a career. Any physician could be an emergency physician. It was a training ground; a place to make some money; a way to support your real career. Almost daily we would meet the “new” ED Doc. They were cool, but not always very good. It was exciting and uncontrolled. Did it work? Not very well.

Emergency medicine grew and changed with the needs of patients. We looked at ourselves as a safety net. We were much like the community clinics, serving those with nowhere else to go and those who needed care without an appointment. We did not see ourselves as a service industry, but as an industry that serves.

Withstanding these arguments, we were different enough to become a specialty.

We initially focused on technique, skills and broad based medical knowledge. What we missed was service design.

Waiting was a given. Triage (through careful design) became an art form rationalizing why patients had to wait. We struggled to break free from the grip of triage as it became not just an evaluation, but a place we called “triage” (Ok, key in continued on page 31

Changes in the Board Announced

At the College’s Spring Membership Meeting, the Board of Directors announced that due to an unexpected illness, Dr. Anthony Jennings removed himself from the position of President-elect to take a general position on the Board. Dr. Jennings stated that a recent diagnosis prevented him from assuming the all duties related to the governance duties required of this office and thus would not be able to assume the Presidency as anticipated in October 2010.

At a special meeting of the Board, a recommendation was made and duly acted upon that will allow Dr. Brabson to remain in the Presidency of the College for an additional year (October 2011) and the Board voted to elect Gregory M. Christiansen, D.O., M.Ed, FACOEP to the position of President-elect. Mark A. Mitchell, D.O., FACOEP the current Treasurer of the College will maintain his position as Treasurer and in accordance with the Bylaws Ms. Wachtler who will assume the temporary duties of Secretary under Dr. Mitchell’s supervision until the October meeting of the Board when elections will be held for the positions of Treasurer and Secretary.

Normally, terms of office for Officers are two years in length, during which physicians undergo intensive orientation into the processes of governance not only of the ACOEP but the AOA. Officers in the positions of President and Presidentelect participate in executive functions of the College as well as act as representatives of the College at AOA functions. During this process, Dr. Christiansen, who has served the College in the role of Treasurer and Secretary, will be in the Office of President-elect for eighteen months during which he will play a pivotal role in representing the ACOEP at the AOA’s House of Delegates and at its various Board of Trustees meetings.

When Dr. Jennings feels that his health will allow him to participate, he will again be eligible to run for an open position on the Board. Whatever he chooses, we are all pulling for him to make a full recovery and expect to see him in the fall.

In My Opinion continued from page 30

Get well soon, Tony, we miss you.

Open Letter to the Membership

from Anthony W. Jennings, D.O., FACOEP It is with regret that I am announcing that I will not seek re-election to the Board of Directors. My current state of health prohibits me from being able to continue at a level I feel necessary to meet the obligations required for performance of the duties of a board member. I will continue to improve my health and will hopefully return in the future to serve the ACOEP once again. My time with ACOEP and its members, staff and the affiliated organizations has been very valued and cherished.

I wish you all the best!

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the singing angels and bright lights). Did it work?

We allowed other service industries to define our process. Lab and x-ray made us call, request, page and almost grovel for service. We were ranked behind the ICU, OR, morning floor STAT labs and smoke breaks. We could wait… because our patients could wait (see a trend here?).

Consultants made us conform to their practice style. We would hold patients for OR, endoscopy and admissions. If the ED was not full, then we could wait. They could wait.

Well, it’s time we changed the world again. The ED is not an office or a lab waiting area… it’s the ED. It’s our ED. It’s the next generations’ ED.

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Pain Management in the ED Steven J. Parrillo, FACOEP-D So what is "pain?"

Fishman says, “Pain is what a patient says it is.” The International Association for the Study of Pain (IASP) defines it as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage.”

We see patients every day in the ED. Study after study has made it clear that we don’t do a good job managing that pain – for a variety of reasons. One of the most common is the fear that we will either contribute to a drug problem or create one. Patients present with a history of “chronic pain” and we wonder whether that is actually true. We wonder if we are being scammed.

But there is a difference between “addiction” and “physical dependence.”

Addiction implies that use of an agent has an effect – usually adverse – in a patient’s ability to function. That may mean that he argues more often with his wife than he did before. It may mean that she does not do as well at work as before. These patients have a problem that needs to be addressed, but you may be surprised at some of the statistics below.

On the other hand, physical dependence is the physiologic requirement for the agent and that absence of that agent would induce withdrawal. The true chronic pain sufferer worries that he will not be taken seriously – largely because that is exactly what happens.

Pain management has made major strides in the last decade. Clinicians now attempt to deal with the cause of the pain whenever possible. Migraine, for example, is usually treated first with triptans or other serotonergic medications and narcotics are held in reserve for rescue.

So why do patients come to the ED for management of pain? If a patient

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presents with a headache, she is coming for one of two reasons: pain relief or diagnosis (or both). But Trainor and Minor showed that 25-50% of such patients receive no medication and only 1/3 of those who do receive medication obtain adequate pain relief. Yes, I know that headache is one of the complaints drug seekers use, but read on.

One of the gurus of ED pain management, James Ducharme, showed that pain is the presenting symptom approximately 80% of the time. Yet many receive nothing to relieve that pain during the visit.

When asked, 42% said that would have liked to receive something. The point is that no one asked until after the disposition had been determined!

So what about that ubiquitous “pain score” we are mandated to record? Many suggest that we do what must do, but treat the patient rather than the score. In a fascinating 2008 Annals study, nearly half the group with an average score of 7.8 out of 10) did not want an analgesic.

Once again, we need to ask.

So you might be asking, “Why is everyone in such ‘severe’ pain?” Many authorities point out that those with mild pain stay home. (I can hear you snickering…) Many patients know from experience that we don’t believe them, so they change their behavior to convince us that they need analgesia. They know we often do not believe them if they just say they are in pain or give a low pain score.

So think back to the last patient in pain who was watching TV, eating, playing Nintendo. Surely those behaviors prove that the pain is exaggerated, right?

Actually, studies have shown that these are all ways patients try to distract themselves from their pain. It does not mean they are not really in pain.

How about that patient who has a normal BP and heart rate? Several have documented that vital signs are not a good way to determine if pain is truly present.

What to do, what to do.

Start by questioning all of your painrelated management. Then work together with your staff to standardize your

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approach to pain. Question every step of the process. If something you do (or order done) hurts a patient, you have chosen to let it hurt. Sometimes there is no choice.

Most times you can minimize or eliminate pain.

Starting IVs in children (or adults for that matter) is a good example. There are ways to prevent or minimize the pain including needle-free jet injection or intradermal injection of lidocaine, nitrous oxide inhalation, topical EMLA® etc.

What’s the worst thing (in terms of pain) we often do to our patients?

Hands down – it is NG tube insertion. (“Can’t you put me to sleep for this, doc?”

“No, I never do that. You’ll be fine. Just swallow this hose and don’t choke or inhale it or I will have to start over.”) This is a very painful procedure, with many studies recording VASs between 80 and 100.

Take 5 minutes for local anesthesia.

Do a neb with lidocaine. Apply lidocaine gel. Atomize some lido or tetracaine. You might even consider a small dose of IV midazolam.

Initiate pain management at arrival, possibly in triage. Splint the sprain or fracture. Apply topical tetracaine for eye pain. Paramedics give IV fentanyl for fractures and burns. Surely we could do the same in triage or shortly after coming into the treatment area. And do it before getting the films!

But is it safe to do this? A 1999 Australian study looked at the safety of a nurse-managed, titrated analgesia protocol for the management of severe pain in the emergency department. The authors showed that nurses could initiate IV opioids for pain control without attracting drug seekers. Additionally, there were no patients who left the triage area after receiving analgesia.

How long do you think it takes you to address a patient’s pain?

Another Australian study that allowed nurses to titrate intravenous opioid analgesia showed that doing so reduces time to analgesia for selected painful conditions.

The range was ½ to one hour. The aver-

age time to administration of analgesia in the US is 2 hours. (That figure is 6 hours in the UK). There were no adverse events.

ED nurses are now allowed to do this by protocol down under.

Be honest. Have you ever given analgesia without first seeing a patient? Of course you have!

Suppose you are the only doctor, you are treating someone critical and the nurse says, “There’s a patient in 3 writhing from a kidney stone.” Maybe it’s time to consider a titrated opiate policy.

“Wait!” you say, “how about my sickle cell patients? I see them every day. Surely there is a problem here. They abuse the ED.” Not so fast…

A 2008 Annals study found that only 35.5% of SSC patients were found to be high ED utilizers. That subset had lower hematocrit levels, required more transfusions, had more “pain” days, more pain crises, higher mean pain and distress, and worse quality of life. After controlling for severity and frequency of pain, high ED utilizers did not use opioids more frequently than other sickle cell disease patients.

Others have shown that sickle cell patients reported at least some pain on more than 50% of days. They reported

pain > 5/10 on 16% of days. They did not see any provider on 79% of those painful days. A staggering 30% reported experiencing pain on at least 95% of days. Only 14% reported that they experience pain <5% of days.

The message . . . we see them when the pain flares.

Have you ever heard a nurse say this?

“Can I give that patient Dilaudid? The morphine just isn’t working.” The correct starting dose of IV morphine is 0.1mg/kg.

Only half of all patients will get pain relief with that dose. Repeat doses can be given every 5-10 minutes. An average dose for pain control will be about 0.16mg/kg. In order to control pain for 4 hours, many patients will require 0.4mg/kg.

If you don’t want to start an IV, consider an oral regimen. (Yes, IM opiates do work, but those injections hurt). A 2008 AEM study compared 0.1mg/kg morphine with 0.125mg/kg oxycodone in suspension. Oxycodone was given faster – 8.5 vs. 20.5 minutes for the IV group. While there was a larger VAS change at 10 and 20 minutes for IV group, there was no difference at 30 and 40 minutes. Satisfaction was higher with IV medication

Yes, it is difficult to change attitudes.

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Don’t believe that? Think back to when you first started ordering morphine in doses of 6-10mg IV. Didn’t your nurse say something like, “Okay, but I’m going to give it 2mg at a time so I don’t kill your patient, you stupid cowboy.”

Why are we so reluctant to believe patients are in pain? What would you want? Do you question dyspneic patients? Basic pain management relies on our beliefs and our attitudes, less on our knowledge. Here are more facts born out in the literature. Eighty percent of our patients are in moderate to severe pain. Yes, up to 12% of our patients have addiction or dependency issues, but the majority (88%) is actually in pain.

So here is the proverbial bottom line.

Pain is a common complaint in the ED. Only a small number of patients are drug seekers. We should do as much to relieve pain as we do to relieve dyspnea. You are not going to make someone an addict by giving him a narcotic in the ED. You are not going to cure addiction by denying analgesia in the ED.

I extend my personal thanks to James Ducharme MD for sharing his knowledge and literature base for this brief discussion.

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Emergency Medical Services, continued from page 13 this would be a tremendous opportunity for both sides. Over the last year, I have found the process of being a medical director quite challenging, but exciting. During any given ED shift, I typically see at least three or four of the crews, and am able to stay current with their practice patterns, answer their questions, give them feedback on patients they have transported to our ED, provide them with educational updates, or sometimes just “shoot the breeze” with them. It is enjoyable working with EMS providers who are so devoted

and passionate about their job. Currently, I am visiting the firehouses to ride with all of the crews so I get to know each one of them. I am also trying to recruit our ED nurses to ride with the crews as well, since the fire department has extended the opportunity to them. We also invite the paramedics to come to the ED for “shadowing” opportunities if they wish.

Lastly, what’s on the horizon in EMS? We hope to bring the EMS fellowship to fruition in the future, as this really is an exciting educational opportunity for all of

the ACOEP members. I have some EMS research and educational projects coming up with our two fire departments, including use of video laryngoscopy for field intubation, and use of Cardizem for prehospital rate control of atrial fibrillation.

I hope to have updates for all of you on these projects in future issues of The Pulse.

Thanks for allowing me to share this with you. If you are interested in joining the EMS committee, please feel free to contact me (gregbeirne@pol.net).

7. Iida Y, Nishi S, Asada A. Effect of mild therapeutic hypothermia on phenytoin pharmacokinetics. Ther Drug Monit 2001;23:192–7.

8. Sabharwal R, Johns EJ, Egginton S. The influence of acute hypothermia on renal function of anaesthetized euthermic and acclimatized rats. Exp Physiol 2004;89:455– 63.9.

10. 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care, part 2: ethical issues. Circulation 2005;112(Suppl 4):IV6 11. Bernard SA, Gary TW, Buist MD, et al.

Treatment of comatose survivors of out-of-hostpital cardiac arrest with induced hypothermia. N Engl J Med 2002;346:557– 63.

12. Danzl DF, Pozos RS. Accidental hypothermia. N Engl J Med 1994;331:1756–60.

13. Felberg RA, Krieger DW, Chuang R, et al.

Hypothermia after cardiac arrest feasibility and safety of an external cooling protocol. Circulation 2001;104:1799–804.

14. Holzer M. Devices for rapid induction of hypothermia. Eur J Anasthesiol Suppl 2008;42:31-8.

15. Arich J; European Resuscitation Council

Hypothermia After Cardiac Arrest Registry Study Group. Clinical application of mild therapeutic hypothermia after cardiac arrest. Crit Care Med 2007; 35:1041–7.

16. Marcus FI. Idiopathic ventricular fibrillation. J Cardiovasc Electrophysiol 2007;8:1075– 83.

17. Chevalier P, Touboul P. Idiopathic ventricular fibrillation. Arch Mal Coeur Vaiss 1999;92:29- 36.

18. Boddicker KA, Zhang Y, Zimmerman MB, et al. Hypothermiaimproves defibrillation success and resuscitation outcomes fromventricular fibrillation.

Circulation 2005;111:3195–201.

19 Opie LH. Electricity out of control: arrhythmias. In: Heart physiology. Philadelphia: Lippincott Williams & Wilkins; 2004:607–10.

20 Sandroni C, Sanna T, Cavallaro F. Myocardial stunning after successful defibrillation. Resuscitation 2008;76:3– 4.

21. Poles JC, Vadenboncouer TF, Bobrow BJ, et al.

Persistent ventricular fibrillation during therapeutic hypothermia and prolonged high-dose vasopressor therapy: case report. Jour Emerg Med 2009;05.027.

2010 Student Case Competition, continued from page 25 References: 1. Brunton LL, Parker K, Blumenthal D, et al.

Goodman & Gilman’s manual of pharmacology and therapeutics. New York: McGraw-Hill, Inc; 2008.

2. Shin DD, Brandimarte F, Luca L, et al. Review of current and investigational pharmacologic agents for acute heart failure syndromes. Am J Cardiol 2007;99:4A–23A. 3. Adams KF, Lindenfeld J, Arnold JM, et al. HFSA 2006 comprehensive heart failure practice guideline. J Card Fail 2006;12:32.

4. Clinical Pharmacology Online. Dopamine.

Available at: http:// www.clinicalpharmacology-ip. com/Forms/Monograph/monograph. aspx?cpnum_206&sec_moncontr. Accessed December 8, 2008.

5. Carmona MF, Malbouisson LM, Pereira VA, et al.

Cardiopulmonary bypass alters the pharmacokinetics of propanolol in patients undergoing cardiac surgery.

Braz J Med Biol Res 2005;38:713–21.

6. Tortorici MA, Kochanek PM, Poloyac SM. Effects of hypothermia on drug disposition, metabolism, and response: a focus of hypothermiamediated alterations on the cytochrome P450 enzyme system. Crit Care Med 2007;35:2196–204.

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Emergency Medicine Opportunities

Physician owned and operated, 4M Emergency Systems has over 15 years of experience management and staffing emergency departments and urgent care centers. We are nowlooking for qualified physicians at the following locations.

Warren, Ohio

Austintown, Ohio

St. Joseph Health Center in Warren, Ohio, conveniently located between Cleveland and Pittsburgh, seeks a confident and dedicated emergency medicine physician. Annual volume 34,000; level III trauma center; 12-hour shifts; EM residency program; flexible schedule; physician/physician assistant double coverage! Extremely competitive compensation and benefit package including partner plan, health plan, 401K, malpractice, life and long-term disability.

For more information about this position, contact Erin Waggoner, 4M Emergency Systems, telephone 888-758-3999; or email ewaggoner@4mdocs.com.

Brand new free-standing ED located just outside Youngstown is seeking a dedicated and confident emergency medicine physician.

Annual volume 28,000; physician assistant double coverage; 9 beds; flexible 12 hour shifts. e outstanding partner plan includes a generous stipend, health, paid malpractice with tail, 401K retirement plan, paid long term disability and life, an additional incentive plan, business spending account, sign on bonus & referral bonus program!

For more information about this position, contact Erin Waggoner, 4M Emergency Systems, telephone 888-758-3999; or email ewaggoner@4mdocs.com.

Youngstown, Ohio

Andover, Ohio

4M Emergency Systems is seeking a board certified emergency physician to join our well-established stable group at St. Elizabeth Health Center. Conveniently located between Cleveland and Pittsburgh, this Level I Trauma Center has a volume of 41,000 with 36 hours/day of physician coverage. With full specialty back-up, this facility has an excellent clinical mix as well as strong support from the attending medical staff, administration and nursing staff. Extremely competitive compensation and benefit package including partner plan, health plan, 401K, malpractice, life and long-term disability. Sign on bonus! Call us for more information about this exciting opportunity and others.

For more information about this position, contact Erin Waggoner, 4M Emergency Systems, telephone 888-758-3999; or email ewaggoner@4mdocs.com.

If balance is what you’re looking for in life, Andover has it! Located in the Pymatuning Valley Region, which is situated in Northeastern Ohio only a few miles from the Pennsylvania state line and sixty miles north of Cleveland, Andover is a nature lover’s paradise! Beautiful settings, fishing, boating, swimming and wonderful park facilities can be part of your life! Andover is a free-standing emergency department with an annual volume of 6,500. e outstanding compensation/benefit package includes partnership opportunity, a generous stipend, paid malpractice with tail, health, 401K retirement plan, paid long term disability and life, and an additional incentive plan. Candidates should be board-certified in emergency medicine or primary care with solid EM experience.

For more information about this position, contact Erin Waggoner, 4M Emergency Systems, telephone 888-758-3999; or email ewaggoner@4mdocs.com.

Boardman, Ohio Brand new, full service emergency department with full service hospital! e ED sees 38,500K patients annually with 36 hrs of physician coverage & 12 hr of physician extender coverage daily.

Nice patient mix with attentive nursing and medical staff. Boardman is an upscale, affluent community in a growing demographic area that is ideal for beginning and/or raising a family. e outstanding partner plan includes a generous stipend, health, paid malpractice with tail, 401K retirement plan, paid long term disability and life, and an additional incentive plan. Candidates should be board-certified in emergency medicine or other primary care specialty with solid EM experience.

For more information about this position, contact Erin Waggoner, 4M Emergency Systems, telephone 888-758-3999; or email ewaggoner@4mdocs.com.

To learn more about joining our practice, please contact Erin Waggoner at 1-(888) 758-3999 or via email at EWaggoner@4Mdocs.com

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GREAT CAREER. GREAT LIFE.

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