The Pulse July 2011 by ACOEP

JULY 2011 VOLUME XXXVI NO. 3

Presidential Viewpoints Thomas A. Brabson, D.O., MBA, FACOEP-D, President

We Are Uniting to Effect Positive Change in Uncertain Times

We will be well into the summer of 2011 by the time you are reading this edition of the Pulse. This has been quite a time with much turbulence in the weather, economy, politics, and certainly, in healthcare. The good news, however, are these challenges usually work out for the best. In times of uncertainty, people tend to unite and do the right thing to effect positive change and outcomes. Our healthcare environment continues to experience much uncertainty and change. We, as emergency physicians, must remain united in order to effectively advocate for our patients and profession. We must have a voice in every discussion that concerns the access and delivery of medical care in our country. We all have a responsibility to ourselves, our patients and our profession to stay actively engaged in the issues that will be shaping our future. Staying engaged is no small task. It takes time, effort, work and often times, money. The costs, whether financial or not, are far

outweighed by the benefits that we will experience for many years in the future. The American College of Emergency Physicians (ACEP) has formed the Emergency Medicine Action Fund (EMAF). The fund will be directed by an 18-member Board of Governors which will be comprised of six key stakeholders and 10 of the largest donors to the fund. The ACEP president, Sandra Schneider M.D., spoke with us at the Future for Emergency Medicine Summit in January. As a result of our discussion, we invited her to meet with the ACOEP Board at our meeting. She graciously accepted and came to discuss the EMAF with our Board at the spring conference in Ft. Lauderdale. We had a very collegial discussion with her and she emphasized the fact that the ACOEP is considered one of the key stakeholders in emergency medicine and in the EMAF. The EMAF will be used to fund projects and programs that will advocate on behalf of emergency medicine. The majority of the spending (75 to 80 percent) is for new initiatives, such as: retaining renowned consulting and law firms Alston & Bird LLP, Hart Health Strategies, and Health Policy Alternatives hiring additional staff to focus on regulatory issues; commissioning studies, like quantifying the value of emergency medicine, to support our position with regulators; coordinating high-level meetings

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with regulatory agencies and developing additional public relations campaigns. The EMAF is much more than a political action group that lobbies legislators on behalf of emergency physicians. It will impact federal regulatory issues in ways that the political action committees cannot. As a result of our meeting, the ACOEP Board has accepted the invitation for a seat on the EMAF Board and we have committed to contribute $50,000 per year for two years. You can also personally contribute to the fund. If you chose to do so, we encourage you to identify yourself as an ACOEP member so that the EMAF Board will be able to appreciate the total impact that the ACOEP has on their mission. The goal is to raise $1 million in the EMAFâ&#x20AC;&#x2122;s first year and they hope to grow to $2 million in year two. Another significant opportunity will become effective this Fall. As a result of the Bylaws change that was approved by the membership at the recent meeting, we will begin to have electronic voting for the election of the ACOEP Board. The process by which this will take place will be revealed later in the year, however, the simple fact is that as a dues paying member of the ACOEP, we believe that you should have an opportunity to participate in the election of the people who will be leading our organization. This change has been a continued on page 20

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Editorial Staff: Drew A. Koch, DO, FACOEP-D, Editor Wayne Jones, DO, FACOEP, Assist. Editor Thomas Brabson, DO, MBA, FACOEP-D Gregory M. Christiansen, DO, M.Ed., FACOEP Janice Wachtler, Executive Director Erin Sernoffsky, Communications Manager Editorial Committee: Drew A. Koch, DO, FACOEP-D, Chair Wayne Jones, D.O., FACOEP, Vice Chair David Bohorquez, DO Thomas Brabson, DO, FACOEP-D Joseph Dougherty, DO, FACOEP Anthony Jennings, DO, FACOEP William Kokx, DO, FACOEP Annette Mann, DO, FACOEP Brian Wiboon, DO Janice Wachtler, CBA Gregory M. Christiansen, DO, M.Ed., FACOEP Erin Sernoffsky 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. Display and print advertisements are accepted by the publication through Norcom, Inc., Advertising/Production Department, PO Box 2566 Northbrook, IL 60065 ∙ 847-948-7762 or electronically at theteam@norcomdesign.com. Please contact Norcom for the specific rates and print specifications for both color and black and white print ads.

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Table of Contents Presidential Viewpoints . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Thomas A. Brabson, DO, MBA, FACOEP-D Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Drew Koch, DO, FACOEP-D Executive Director's Desk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Janice Wachtler, BA, CBA ACOEP's Show-Stopping Speaker Line-Up . . . . . . . . . . . . . . . 6 Erin Sernoffsky ACOEP Affiliates with WestJEM . . . . . . . . . . . . . . . . . . . . . . . . 8 Gregory Christiansen, D.O., M.Ed., FACOEP Membership Approves Revised Bylaws . . . . . . . . . . . . . . . . . . . . 8 2011 ACOEP Fellows and Distinguished Fellows . . . . . . . . . . . 9 In My Opinion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Wayne T. Jones, D.O., FACOEP FOEM: Foundation Focus . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 FOEM: 2011 Case Study Poster Cometition . . . . . . . . . . . . . . 13 FOEM: Fall Competitions . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 TIPS, A Change of Focus . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Sherry Turner, D.O. The Committee on Graduate Medical Education . . . . . . . . . . 19 Ethics in Emergency Medicine . . . . . . . . . . . . . . . . . . . . . . . . . 20 Bernard Heilicser, D.O., M.S., FACEP, FACOEP

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 2011 – All rights reserved. Articles may not be reproduced without the expressed, written approval of the ACOEP and the author.

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

Several years ago, I had written an editorial discussing dissatisfaction with change in how Emergency Medicine was evolving away from the practice of one patient at a time, and the Emergency Medicine physician was the only person who could order diagnostic modalities and treatments or therapies for patients. Nurse triage protocols and fast tracking minor illness and injuries away from the main Emergency Department to their own area, staffed by mid-level providers, were fraught with disdain and resentment by physicians and nurses. The authority, responsibility and accountability appeared to be removed from the physician and the physician felt loss of empowerment. During our medical education and training it was stressed that the physicians were in charge and were the only professionals who knew what was best for the patient. Doctors were considered individualists and not part of any team. Doctors worked alone, in their own silos, and did not integrate well with other members of the health-care profession. Doctors wrote orders and expected orders to be carried out without any discussion, challenge or comments. We were educated incorrectly that nurses were subservient and would carry out orders without questioning. Fast forward to the 21st century where patient safety and the Nursing Practice Act have placed nurses as valuable members of the health-care team whose opinions, input and comments are invaluable. Nurse triage protocols, trauma protocols, stroke protocols, cardiac protocols, ACLS, ATLS and PALS are examples of when and how patient care can be initiated

without the physician present on initial presentation in the ED. The days of the nurses waiting for the physician to write orders to initiate care should be a memory. Emergency Medicine is a team approach to patient care and requires that each member of the team works together to ensure that patient is properly assessed and managed. Egos and past relationships and behaviors should not be acceptable or tolerable in the ED. We are still the team leaders but we should not be authoritarian or dictator. Our role is still team leader but we should be mentoring, educating and making sure everyone member of the team is accountable for their role in the patient’s care. There will be instances where a protocol is not appropriate for a particular patient, or after you evaluate the patient the wrong protocol was applied. This is a great opportunity for education and mentoring instead of criticizing and condemning the individual nurse. Patients are unique and many times present atypically, so a particular protocol may not apply. In these instances it is imperative that the physicians “greet” the patient upon arrival and initiate the workup. CMS indicators for pneumonia and myocardial infarcts (STEMI) have changed the landscape for how patients are managed. It is imperative that there are protocols in place to insure these indicators are met so there are no financial repercussions to the hospital and the EM providers. Without having protocols for pneumonia and MI, patients would still be seen one at a time and the protocols would not be met and both the hospital and physicians would be losing out financially. On busy days in the ED where the patients are not always seen upon arrival by the physicians or mid levels, it is expected that a patient’s work up is initiated by the nurse upon arrival. Then when the physician or mid level sees the patient, the

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work up is complete and the disposition can be done after evaluation. This improves patient flow and decreases ED throughput times. CMS’s new indicators involve median length of ED from arrival to admission of admitted ED patients and admit decision time to ED departure time for admitted ED patients. Nurse triage protocols will assist the ED in meeting these new CMS indicators. EM physicians do not embrace change. The practice of placing a patient in an empty bed upon arrival with bedside triage and registration and then waiting in the ED to be seen by a provider was not well received by EM physicians. The arguments against placing a patient in an ED bed were: the patient will not be seen any faster; the definition of the waiting room is a place to wait; I can only see one patient at a time and when a patient is placed in a room their expectation is that they should be seen once they are placed in a room. The mantra of seeing the sickest patient first and then seeing the patient in the order of presentation is being replaced. Fast tracks, or areas in the ED that sees patients with minor illnesses and injury, have refuted the doctrine of one patient at a time in order of presentation with the sickest patients being seen first. The patients who are the most vertical are also the most vocal in their complaints about the long waits and prolonged length of stays. Patient satisfaction scores are an integral part of health care reflecting provider, ED and hospital scores. A reduction in patient wait times and length of stay has shown to not only improve patient satisfaction scores but has decreased the number of both patient complaints and malpractice suits. It is postulated that patients who are satisfied with their care are less likely to complain or sue. continued on page 20

Executive Directors Desk Janice Wachtler, BA, CBA

The Empty Stocking At the end of the movie, The Bishop’s Wife, one of the main character writes a sermon about the forgotten person at the holiday season, and tells how everyone gets remembered during the holidays, except of course, the person whose birth we celebrate. Lately, this seems to be true when we talk about osteopathic medicine; it appears everyone forgets about A. T. Still and the method of treatment he developed. I wondered why Dr. Still doesn’t appear to get much consideration from the osteopathic community. Is it because we think of him as just the old man holding the bone as he is depicted in so many pictures? When I began working at the AOA in 1978 the staff was introduced to Dr. Still by the Executive Director, Edward Crowell, D.O. Dr. Crowell met periodically with new staff and told us all about osteopathic medicine and the philosophy behind it. We watched an old movie about osteopathic medicine and OMT and were given a treatment by George Northrup, D.O., JAOA Editor at that time. I, too, thought he was ‘the old man with the bone’ and then I saw that osteopathic medicine wasn’t just dealing with the musculoskeletal system or the manipulation, but the method of patient approach that makes the osteopathic physician. So as I thought about leadership, I thought about A.T. and began to look at the physician who defines this profession. I embarked on a journey of discovery. I read The Autobiography of A. T. Still, and although it wasn’t an engrossing, or easilyread tome, it was interesting, but not a page-turner. I then read, DO’s in America,

by Norman Gevitz, Ph.D. and found that more easily read and much more easily understood. Both these books showed a special side of this man. Dr. Still was someone never ‘schooled’ in medicine, he spent most of his youth hanging around not really sure of what he wanted to do. He was a pioneer in areas west of Ohio. He went on to study medicine for 6 months and then moved to Missouri. He was a soldier in the Civil War, and like most innovations many of his ideas came in the post-war era; typically an era of innovation and invention. Osteopathy evolved in an era that saw many new theories of medicine coming forward and medicine as a field becoming more formalized. It was an era that medicine was limited to bleeding a patient and hoping for the best. Mesmer touted hypnosis and magnetic healing, others in Europe promoted manual medicine— healing done by the laying on of hands and praying. Others pushed potions and oils to have the body heal itself; so it wasn’t an easy sell. Most felt that Dr. Still was a quack, a snake oil salesman, convincing the public with unfounded claims. His technique then was solely manipulation, releasing muscle gas through the ‘laying on of hands’ and using a type of massage to relieve the pressure on these osteopathic lesions. Dr. Still had revolutionary ideas not only in medicine but in life too. He began teaching women to be osteopathic physicians. Their teaching was not segregated but they learned their craft and practiced side-by-side with male counterparts. He believed that all people held the potential of health within their own bodies. He also believed that to be successful in life one had to be involved, so he became a statesman, representing his fellow citizens at the state level in Congress. So as we look for leadership, we need look no further than to the founder of

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osteopathic medicine to see what he was and how much of a leader he was. This man, trained only in the basics of medicine, with skills we would consider rudimentary at best, was able to invent, promote and advocate for his new form of medicine, teach scores of interested parties and give a face to what would become a holistic form of medicine. He held fast to his conclusions, he worked diligently for their acceptance, he developed a core of knowledgeable contemporaries and trainees to support his theories and trusted them to go forward with his word and teachings to develop colleges of osteopathic medicine and to ‘spread the word’ to the world about osteopathic medicine. He had the courage to follow his beliefs in a world that was full of non-believers. His followers have taken his dream farther than he could ever imagine and will take it even further in the coming. His leadership, under recognized and often unsung, has built a system of medicine unknown before. He was an innovator, a dreamer, and a leader in medicine to be recognized with all those innovators we all pay homage to as the “Fathers of Medicine.” (A.T. Still, M.D., D.O. – August 6, 1828 – December 12, 1917)

ACOEP's Show-stopping Speaker Line-Up Erin Sernoffsky

Las Vegas is a city of lights, constant entertainment, culinary moguls and roundthe-clock fun. But more than anything, Las Vegas is a city of headliners! From Frank Sinatra and Dean Martin, to Celine Dion and Rod Stewart, this town knows how to draw a crowd. To host a conference in a city like Las Vegas, ACOEP’s Scientific Assembly needed a line-up of world-class speakers presenting cutting edge research, showstopping literature reviews, and mindbending education! Here are just some of the all-stars slated to take to the podium October 2011: Keynote speaker, Rita Cydulka, MD, MS will create a buzz with her presentation, Emergency Medicine: Where We’ve Been and Where We’re Going. Dr. Cydulka comes to the conference from MetroHealth Systems in Cleveland, Ohio, where she has won innumerable accolades for her work as a physician, researcher, and professor. She is currently a professor and the Vice-Chair of the Department of Emergency Medicine and Director of Quality and process at Case Western Reserve University Medical School/ MetroHealth Medical Center. John Kashani, DO will continue the excitement with his lectures, Suits and Cases in Toxicology as well as The Other Metabolic Acidosis. Currently, Dr. Kashani is the Director of the Toxicology Program at St. Joseph Regional Medical Center and a Staff Toxicologist at the New Jersey Poison Information and Education System. Dr. Kashani has lectured for the Executive Office of the President of the United States Office of National Drug Control Policy, Harvard

Medical School and the North American Congress of Clinical Toxicology. Kevin Klauer, DO is the Director of Center for Emergency Medical Education (CEME) and the Chief Medical Officer for Emergency Medicine Physicians. Dr. Klauer will share his expertise with his presentations High Risk Cardiovascular Cases, and Career Ending Mistakes in Medicine. Dr. Klauer has received the ACEP National Faculty Teaching Award and the EMRA Robert J. Dougherty Teaching Fellowship Award. Italo Subbarro, DO is the Director of Public Health Readiness Office at the American Medical Association Center for Public Health Preparedness and Disaster Response; Deputy Editor of the Journal of Disaster Medicine and Public Health Preparedness; and Medical Director for the National Disaster Life Support Program Office. He has served as a speaker at many domestic and international conferences and symposiums. ACOEP is looking forward to Dr. Subbarro’s presentations, Global Challenges in Disaster Response and Revisiting Disaster Preparedness 10 Years after 9/11. Hailing from Provident Hospital in Cook County, and fresh off of a tour in Kosovo as a Major in the United States Army, Christopher Colbert, DO, will address the issues of emergency medicine on the frontline in his presentation, EMS in Iraq. He will also end the conference with

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Hypothermia in the ED. You may recognize Dr. Colbert from his work with the Oral Board Review Course held in Chicago. Pawan Suri, MD, is an Assistant Professor in the Departments of Emergency Medicine & Internal Medicine at Virginia Commonwealth University in Richmond, VA. Dr. Suri is also the Chair, Division of Observation Medicine, which is a part of the Emergency Department. Attendees won’t want to overlook Dr. Suri’s lecture, The Observational Medical Unit in the ED: What it Can Do for You. Rich Cantor, MD, is a nationally recognized leader and educator in emergency medicine pediatric issues and will share the latest research on the topic during his lectures, Pediatric Literature Review and Common Problems in the First 30 Days of Life. Dr. Cantor has also served on the editorial and development boards of national curricula including APLS: The Pediatric Emergency Medicine Resource. Dr. Cantor is the recipient of ACEP Outstanding Speaker of the Year Award and the ACEP National Education Award in Emergency Medicine. Associate Professor of Medicine at the UCLA School of Medicine, Fred Abrahamian, DO, has been published in journals such as The New England Journal of Medicine, Clinical Infectious Diseases, and Annals of Emergency Medicine and now shares his knowledge in Las Vegas with Skin/Soft Tissue Infections and Infections in

Immunocompromised Patients. He has also been honored with a variety of national teaching awards, including the prestigious American College of Emergency Physicians Faculty Teaching Award. Every trade has its tricks, and Michelle Lin, MD is an expert in using them successfully. She will share her valuable tools, as well as hazards to avoid, in her lectures, Tricks of the Trade in Emergency Medicine and Pitfalls in Orthopedic Radiology. Dr. Lin is an Associate Professor of Emergency Medicine at UC San Francisco and practices full time at San Francisco General Hospital. Ken Deitch DO, FACEP returns to the ACOEP podium to kick off our final day of lectures with Procedural Sedation & Analgesia: What’s New and Challenging Cases in PSA . Dr. Deitch is the Research Director, Department of Emergency Medicine at Albert Einstein Medical Center in Philadelphia, and a Clinical Adjunct Professor of Emergency Medicine at the Jefferson Medical College. Dr. Deitch has published extensively and is currently researching pre-apneic respiratory patterns during propofol sedation and respiratory depression during hydromorphone analgesia in a geriatric population. Scott Weingart, DO completed both his degree and residency at the Mount Sinai School of Medicine where he currently serves as the Director of ED Critical Care. He then went on to a fellowship in Trauma and Surgical Critical Care at the Shock Trauma Center in Baltimore, Maryland. He is also an attending in the Department of Emergency Medicine at the Elmhurst Hospital Center. His biweekly podcast on ED Critical Care, EMCrit Podcast, is

available at emcrit.org and itunes. His presentations, Dominating the Ventilator, and the Laryngoscope as a Murder Weapon: Preoxygenation, Reoxygenation, and Delayed Sequence Intubation are must-see speeches.

Brian Kane, MD and Kevin Weaver, DO bring their popular double act back to Scientific Assembly with the twopart series, Adult Literature Review. Dr. Kane is a graduate of Yale University and the University of Pennsylvania School of Medicine. He is currently the Assistant Program Director: Research for the Emergency Medicine Residency at Leigh Valley Health Network and has won numerous awards for his work developing resident researchers and the use of evidence-based medicine. Dr. Weaver is the Program Director for the Lehigh Valley Health Network Emergency Medicine Residency Program and is also an expert on the application of evidencebased medicine in clinical practice and therapeutic hypothermia.

ACOEP President-Elect Gregory Christensen, DO, M.Ed., remains one of ACOEP’s most popular speakers. He is Department Director of Simulation and Department Director of Medical Education, at the Medical College of Virginia/Virginia Commonwealth University, Richmond, Virginia as well as a Medical Officer, VA-1 Disaster Management Assistance Team; Norfolk, Virginia. His presentation, PE or not PE: The Risky Business of VTE is not to be missed at this conference! In a hands-on profession, it’s important to have hands-on education. Nader Boulous, MD will fill the bill with his Ultrasound Course. Dr. Boulos attended Robert Wood Johnson UMDNJ Medical School and completed his Residency at NY Methodist Hospital, Brooklyn, NY. His is currently the Director of Emergency Ultrasound and Fellowship Director at St. Joseph's Regional Medical Center in Paterson, NJ, where he is an attending.

Members in the News! Congratulations are due to ACOEP Fellow John Graneto! The American Association of Colleges of Osteopathic Medicine has named Dr. Graneto a 2011 Fellow for its National Academy of Osteopathic Medical Educators. In addition to his work as an Associate Professor of Emergency Medicine and Family Medicine at the Chicago College of Osteopathic Medicine at Midwestern University, Dr. Graneto’s new Fellowship title will allow him to continue to serve as a leader and mentor to new physicians. Congratulations Dr. Graneto!

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ACOEP Affiliates with WestJEM! Gregory M. Christiansen, D.O., MEd, FACOEP

ACOEP is pleased to announce that it has finalized an agreement to partner with the highly regarded Western Journal of Emergency Medicine (WestJEM). This affiliation will provide all ACOEP members with an official scientific journal publication. The historic occasion advances ACOEP’s Strategic Plan to bring the highest quality emergency medicine literature to our members. In order to establish an understanding of each organization’s needs, ACOEP accepted WestJEM’s invitation to participate in the Editorial Board and Section Editors meeting in Boston, Massachusetts. The goal was to clarify and solidify the agreement in services between both organizations. Acting in a liaison capacity, I was afforded the distinct pleasure of meeting some of the finest academicians in the country. The Editorial Board and Section Editors hail from prestigious institutions across the nation. The physicians are of the highest caliber and represent a wide diversity of disciplines. They have taken this fledgling publication in three short years to command a research presence with 450,000 internet hits from 198 countries. They have also successful

courted an international sponsorship to meet the demand for translation into the Spanish language for distribution in South America. This affiliation between WestJEMs and ACOEP offers an unprecedented opportunity for osteopathic physicians to enhance the academic credentials for the profession. Osteopathic Emergency Physicians now have a place to showcase their work in an open access journal format which is indexed internationally for the widest possible distribution. Residents will have a unique opportunity to participate in a national competition to have their abstracts judged with the top three being offered free publication upon completion of the paper. The journal is focused on original research but is does accept a limited number of clinical reviews, case reports, and clinically relevant photography. As a sponsor for the journal, ACOEP will have 2 board positions to help direct the business and professional standing of the journal. In addition, ACOEP will offer 2 academicians the opportunity to become Section Editors in the area of musculoskeletal disorders which will include expertise in osteopathic principles. Since the journal does rotate

some Section Editors, there may also be opportunities in the areas of Behavioral Health, Disaster Medicine, and Geriatrics. Interested candidates in either an Editorial Board position or Section Editor Position should submit their intention electronically to Jan Wachtler at janwachtler@acoep.org. Ideal candidates will have demonstrated research expertise in the subject matter. For example, qualifications for a Section Editor in Musculoskeletal Disorders might include demonstrated experience in research, publications, and clinical training in either Sports Medicine or Osteopathic Manipulative Medicine. Regardless of area of expertise all candidates should submit his or her C.V. as part of the process. It will be beneficial if candidates have an understanding of research principles and understand the publication process. There are also opportunities for content reviewers in all of the journal’s subject matter. If you are interested in any of these coveted positions, then electronically submit your preference by August 15, 2011. Qualified candidates will be notified electronically on their selection.

Membership Approves Revised Bylaws To Initiate Online Voting In an exciting vote during April’s Membership Meeting, the membership unanimously approved a revision in the ACOEP Bylaws to open the door for on-line voting for new Board Members. ACOEP values the opinion and wishes of the membership and hope that this change will allow more members to participate in this important decision. Previously, only members present at the fall Membership Meeting were able to vote for members of the Board. Beginning in August 2011, all paid Active, Active-

Exempt, Retired, Life, Fellows and Distinguished Fellows will be granted access to the ballot. Profiles of Board candidates will appear on the “What’s New” section of the website (www. acoep.org) so that members will have an opportunity to familiarize themselves with the experience and qualifications of each candidate. Voters will only be able to cast a vote for the number of positions available, and each member will only be able to vote once. Once your vote is registered, you will not be able to change it.

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Voting will begin in August and remain open through October 5, 2011, at which time voting will be tallied. The Executive Director will present the decision at the Membership Meeting on Tuesday, October 11. More details and instructions on the process of voting will be forthcoming this summer. Should you have any questions, please call ACOEP during normal business hours.

2011 ACOEP Fellows and Distinguished Fellows Congratulations to our 2011 ACOEP Fellows! The title of Fellowship is granted upon recommendation of an Active, Associate, Honorary or Life Member of the College who is a current Fellow. The ACOEP Board of Directors and ACOEP Fellowship Committee granted the following members the honorary title of Fellowship for 2011: Arash Armin, D.O., FACOEP, Troy, MI Rudolph D. Bescherer, Jr., D.O., FACOEP, Voorhees, NJ Craig Black, D.O., FACOEP, Aventura, FL Dennis Blankenship, D.O., FACOEP, Bixby, OK Charles Bloom, D.O., FACOEP, Henderson, NV Carla Cameron, D.O., FACOEP, Springboro, OH Cesar Carralero, D.O., FACOEP,

Miramar, FL Steven Conroy, D.O., FACOEP, Bethlehem, PA Philippe de Kerillis, D.O., FACOEP, Erdenheim, PA Trace Dotson, D.O., FACOEP, Utica, MI Andrew H. Erlich, D.O., FACOEP, Franklin, MI Calixto G. Garica, D.O., FACOEP, Bridgewater, NJ Bradley F. Gutierrez, D.O., FACOEP, Beverly Hills, MI Heidi Jenney, D.O., FACOEP, Pontiac, MI Jitendranath Lakshmipathy, D.O., FACOEP, Glastonbury, CT Michael Passafaro, D.O., FACOEP, Saddle Brook, NJ Jehangir Pirzada, D.O., FACOEP, Pontiac, MI Keri Robertson, D.O., FACOEP, Chicago, IL Timothy Vayder, D.O., FACOEP,

The right fit

Houghton, MI Stephen Vetrano, D.O., FACOEP, Hamilton, NJ Congratulations to our 2011 ACOEP Distinguished Fellows! The title of Distinguished Fellowship exemplifies true leadership and dedication to the College. To qualify for this award, applicants must be nominated by other Fellows or Distinguished Fellows. The ACOEP Board of Directors and ACOEP Fellowship Committee granted the following members the honorary title of Distinguished Fellowship for 2011: Joseph J. Calabro, D.O., FACOEP, Dist, Red Bank, NJ A. Dale Chisum, D.O., FACOEP, Dist, Olethe, KS John William Graneto, D.O., FACOEP, Dist., Chicago, IL

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

The Prudent Layperson Not long ago, I had quite a lengthy discussion with representatives of our state Medicaid payor (DPW). As you well know, state Medicaids pay two levels of emergency service depending whether the patient presents with an “emergency medical condition” or whether the patient could receive treatment in an office setting. The DPW uses the Prudent Layperson Standard (PLS) in determining “emergency medical condition”. Since no case law defines the prudent layperson standard (and emergency medical condition), we are left with a brief descriptor contained in the Patient’s Healthcare Bill of Rights. The PLS defines a prudent layperson as someone who “possesses an average knowledge of health and medicine.” Our DPW felt that a prudent layperson would be a well-educated person able to discern true life-threatening illness from uncomplicated health issues. Well… not exactly the same, but their definition is not excluded by the published definition. What appeared to confuse our DPW (or was a contortion of the law by DPW) was their use of the exam, diagnosis and disposition to determine if each case represented a medical emergency. While they stated the PLS was taken into consideration, the acuity should be reflected in the discharge diagnosis and not the arrival complaint. So a medical emergency was based upon outcome. I am not sure even a well-educated triage nurse can predict outcome, based on arrival, with uncertainty. In a study by Tintinalli, Annals in Emergency Medicine, March 2000, up to 80% of denied charts deemed “not a medi-

cal emergency” met the standard for the prudent layperson definition of an emergency when reviewed by a third party. But are we missing something when we, as educated healthcare practitioners, review these records and attempt to apply a standard meant for laypersons? There are many patient oriented issues not easily defined in this law. These are literacy, health literacy, and what is now called numericy (numerical literacy). All of these terms relate to hurdles patients must overcome to receive appropriate healthcare. The Institute of Medicine tells us nearly half the adult population has difficulty understanding health information. Reading ability is typically 3-5 years below the last grade level completed, so high school graduates often read at the 7-8th grade level. Even the Veterans Administration, in understanding these literacy issues, have further clarified the law to match these levels of understanding; follow-up visits, subsequent transfers and multiple visits on one day may not be covered. Let me tell you a story about my son. A few years ago, I bought my son a new video game for Christmas. After playing the game for some time, he asked why the Cold War was called the Cold War. I told him about Sputnik and the Soviet’s ability to create a long range missile that could threaten the U.S. We discussed how the Bay of Pigs intensified tensions between the Soviets and US and how the Cuban Missile Crisis brought the Soviet Nation to our doorstep.

He said the game included capturing Castro and launching an active war in Russia. Although he now understands, he still refers to the game. How many of you have seen the movie Inception? My son’s perception of reality was changed using a game. How many of our patients have altered perceptions of healthcare based on available mass media broadcasts such as House, Scrubs and ER? Academics such as Blascovich and LeBlanc tell us that stress (whether disease, threat or decision-making) raises our heart rate, cortisol levels and impedes our attention, memory and decision-making. This limits our ability to evaluate threat and success. It creates a cognitive disconnect that is well known in law enforcement, fire and, most recently, medicine. It blunts our effectiveness for good decision-making. In medicine, we have created training courses that bridges this cognitive disconnect. We repeatedly practice algorithms to make our critical decision-making easier and less prone to errors. Courses such as ACLS, ATLS, and PALS are shining examples of these cognitive pathways. The patient, in a time of illness, may not be able to determine an appropriate course of action. They have a cognitive disconnect. They come to the ED. I do not dispute that we, as a nation, use emergency services as an outpatient clinic. I recognize that access, education and impaired decision-making make for what has been termed abuse. My question is: what is a prudent layperson?

Win $1,000 with ACOEP’s Visual Stimulus Competition! Have an interesting case? Send in your photographs, EKGs, radiographic studies or other visual stimuli demonstrating classic or unique findings for a chance to win! Contact Victor Almieda at almeidavic@aol.com for rules, requirements and more information!

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S A V E T H E D AT E !

Please Join Us for a sPecial evening Honoring Donors anD sUPPorters of tHe foUnDation

Inaugural Honors DInner & awarDs Ceremony THursDay, oCTober 13, 2011 enCore wynn las Vegas速 enTerTaInmenT & DInner blaCk-TIe enCourageD Presenting CorPorate sPonsor:

www.schumachergroup.com for reservations and complete information please contact: stephanie Whitmer, event chair 312.587.1765 or swhitmer@acoep.org The PULSE JULY 2011

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

Foundation Focus The Foundation for Osteopathic Emergency Medicine is so pleased to officially announce our 2011 Inaugural Honors Dinner and Awards Ceremony, generously presented to you by Schumacher Group. This formal evening will take place on Thursday, October 13, 2011 at the Encore in Las Vegas in conjunction with the ACOEP Scientific Assembly. Invitations are being sent out now, so be sure to RSVP promptly to save your seat at this exciting event! The purpose of this occasion is to celebrate and thank our most generous supporters and competition winners. These individuals have stood behind the Foundation through thick and thin and truly deserve to be acknowledged. Without further ado, we present to you our 2011 honorees: The FOEM Pinnacle Award: This most prestigious award is presented to a donor achieving a lifetime donation level of $25,000 or more. Only one individual has reached this level and we are so very thankful for his support. • Joseph Kuchinski, D.O., FACOEP-D The FOEM President’s Circle Awards: These awards are presented to donors achieving a lifetime donation level of $10,000 or more. • Paula DeJesus, D.O., MHPE, FACOEP-D • Anita Eisenhart, D.O., FACOEP

The FOEM Foundation Pillar Awards: These awards are presented to donors achieving a lifetime donation level of $5,000 or more. • Juan Acosta, D.O., MS, FACOEP • John Becher, D.O., FACOEP-D • Peter Kaplan, NORCOM, Inc • Robert Suter, D.O., MHA, FACOEP, FACEP, FIFEM • Jim Turner, D.O., FACOEP and Sherry Turner, D.O. • Janice Wachtler, BA, CBA The FOEM Corporate Champion Awards: These awards are presented to corporate sponsors that have been supporters for a minimum of 5 years. • • • •

Schumacher Group EmCare EMP MedExcel

The FOEM 2011 Competition winners: These awards are presented to the winners of the five FOEM Competitions that occur in 2011. • FOEM Case Study Poster Competition: Alexis Davison, D.O., Schakia Eze, D.O., Therese Mead, D.O. • FOEM/Schumacher

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Group CPC Competition: TBD • FOEM/EMP Resident Research Paper Competition: TBD • FOEM/MedExcel Research Poster Competition: TBD • FOEM/EmCare Oral Abstract Competition: TBD Please save the date and purchase your tickets to the 2011 FOEM Inaugural Honors Dinner and Awards Ceremony!

2011 Case Study Poster Competition The Foundation’s 2011 Case Study Poster Competition was, by all measures, an incredible success. With 59 participants, the competition more than tripled in size from last year and the quality was of the highest standard. Thank you to the Program Directors that helped to involve so many talented young doctors, as well as the residents and students who participated. We are looking forward to the competitions in the Fall! And the winners of the 2011 Case Study Poster Competition are: First Place: Alexis Davison, D.O. of St. Joseph’s Regional Medical Center Second Place: Schakia Eze, D.O. of St. Joseph’s Regional Medical Center Third Place: Therese Mead, D.O. of Genesys Regional Medical Center Congratulations! Abstracts A. Davison. St. Joseph’s Regional Medical Center, Paterson, NJ; and The University of New England College of Osteopathic Medicine, Biddeford, Maine. S. Hochman. St. Joseph’s Regional Medical Center, Paterson, NJ. J. Kashani. St. Joseph’s Regional Medical Center, Paterson, NJ. Title: Spontaneous Subdural Hematoma in a Patient Taking Fondaparinux

Case Report: A 67 year old male presented to Emergency Department (ED) with chief complaint of right hand weakness and slurred speech. His past medical history was significant for insulin dependent diabetes, hypertension, congestive heart failure, right internal jugular deep vein thrombosis, and Whipple procedure for pancreatic carcinoma. His current medications included fondaparinux (ArixtraTM) doxazosin, triazolam, alprazolam, insulin, furosemide, oxycodone/acetaminophen, potassium chloride, and finasteride. His social history is positive for tobacco use in the past, occasional alcohol use, and negative for drug use. Review of patient’s family history non-contributory. The history of present illness was significant for a brief episode of right hand weakness and numbness occurring at rest, followed by transient expressive aphasia lasting one minute. The episode occurred one hour prior to arrival with complete resolution of symptoms by the time of presentation. The patient had been taking fondaparinux for deep vein thrombosis of right internal jugular vein. On arrival patient was afebrile, with blood pressure 182/89, pulse 89, respirations 18, and oxygen saturation of 98% on room air. He was in no acute distress and was awake, alert and oriented. Pertinent physical exam findings revealed 2+ pitting edema of right forearm, wrist, and hand as well as 2 + pitting edema of bilateral lower extremities extending to mid-calf. The neurological exam including cranial nerves, strength, sensation, cerebellar function and speech were within normal limits. Laboratory results were significant for: Hemoglobin 10.2 hematocrit 29.7

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WBC 7.3 platelets 148 aPTT 42.8 PT 16.1 INR 1.3 A computerized tomography (CT) scan of the head without contrast revealed acute subdural hematoma adjacent to left parietal and frontal lobes at convexity measuring fourteen millimeter, with midline shift to right of three millimeters. There was no evidence of acute territorial infarct. Neurology, Toxicology, and Neurosurgery consults were obtained and it was agreed that fondaparinux should be discontinued. After discussions with pharmacy and toxicology it was determined that there was no clinically proven reversal agent for fondaparinux. The patient was admitted to Medical Intensive Care Unit (MICU) with repeat CT scan of the head twelve hours later, revealing no change in the subdural hematoma. He subsequently developed a change in mental status and was sent for repeat CT scan of the head. The repeat scan revealed a one millimeter increase in left parietal and frontal subdural hematoma. He returned to baseline and had a repeat CT scan the following day revealing a stable and unchanged left subdural hematoma. The remainder of the patient’s hospital course was unremarkable and patient was discharged to sub-acute rehabilitation after a five-day hospitalization. Introduction: Fondaparinux is FDA approved for the treatment of deep vein thrombosis and pulmonary embolus, unlike traditional anticoagulants fondaparinux works by inhibiting Factor Xa, and has no clinically proven reversal agent.

Therefore, in the setting of major bleeding with fondaparinux use, management is problematic. Discussion: To our knowledge, spontaneous intracranial hemorrhage associated with the use of Fondaparinux has not been reported in the medical literature. Our patient did well with supportive care, close monitoring, and discontinuation of fondaparinux. Fondaparinux has been marketed as an agent with decreased risk of spontaneous bleeding, compared with anticoagulants such as, heparin and enoxaparin. However, fondaparinux is unique in this group of agents in that it does not have a clinically proven reversal agent. Therefore, patients presenting with acute bleeding while on fondaparinux pose a management dilemma. Clinicians should consider the risks of bleeding in the individual patient and the potential difficulty of managing clinically significant bleeding episodes when prescribing this agent. Alexis Davison, DO, Emergency Medicine Resident, SJRMC/UNECOM Steven Hochman, MD, Medicine Faculty, SJRMC

Emergency

John Kashani, DO, Emergency Medicine Faculty, SJRMC No Conflicts of Interest. References: 1. Eikelboom J, et al. Major bleeding, mortality, and efficacy of fondaparinux in venous thromboembolism prevention trials. Circulation 2009; 120: 2006-2011. 2. Bordes Y, et al. Recombinant activated factor VII for acute subdural haematoma in an elderly patient taking fondaparinux. 2008; 101(4): 575-576. 3. Huisman M. et al. Treating patients with venous thromboembolism: initial strategies and long term secondary prevention. Seminars in Vascular Medicine.

2005; 5(3): 276-284. 4. Picciolo A. et al. Approach to venous thromboembolism in cancer patients. Current Treatment Options in Cardiovascular Medicine. 2011 Jan 19 [Epub ahead of print]. S. Eze. St. Joseph’s Regional Medical Center, Paterson, NJ. M. Gorn. St. Joseph’s Regional Medical Center, Paterson, NJ Title: Streptococcus Pneumoniae Pericarditis with Purulent Pericardial Effusion in a Neonate: A Cause for Concern Case Report: A previously healthy, full term 6-day-old male presented to an urban pediatric emergency department with severe shortness of breath. The patient was sent to the hospital from his pediatrician’s office due to fever, worsening respiratory distress, and hypoxia. In the office, the patient was noted to have an oxygen saturation of 69% on room air and was placed on oxygen with a non-rebreather mask by EMS. Oxygen saturation increased to 99% and patient was transported to the emergency department. Social History the patient lived with his mother, father, and older siblings. There was no history of recent travel, however both parents had immigrated to the United States from Peru. Review of systems is significant for lethargy with decreased PO intake, as per the family. Upon arrival, the patient was in severe respiratory distress and had a temperature of 101F (38.3C), heart rate of 190 bpm, respiratory rate of 36, and blood pressure of 86/51. On exam, the patient appeared pale, lethargic, and tachycardic with a 4/6 murmur was heard loudest at the lower left sternal border. An S3 gallop was also appreciated. Breath sounds were clear,

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however respirations were severely labored, with grunting and intercostal retractions apparent. Abdomen was soft with no obvious organomegaly. The neonate had warm extremities, was listless and not responding to painful stimuli (i.e. IV placement). The patient was intubated according to rapid sequence protocol. The patient was treated with IV ampicillin and Cefotaxime and further workup was obtained. CBC revealed a WBC count of 26.5 with 24 bands and 16 lymphocytes. Chemistry revealed a sodium of 122, potassium 5.6, chloride 88, bicarbonate of 21, and glucose of 182. BUN and creatinine were within normal limits. Urinalysis was notable for >300 protein in the urine. CSF analysis was unremarkable. ABG revealed respiratory acidosis with a pH 6.88. EKG demonstrated sinus tachycardia at 188 bpm and was otherwise normal . Chest X-ray demonstrated an enlarged cardiac silhouette. 2D-Echocardiogram was performed which revealed a significant pericardial effusion. In the PICU, a pericardiocentesis was performed by the pediatric cardiologist and a large amount of purulent material was drained. The patient required aggressive pressure support, IV antibiotics and a pericardial stripping procedure. The pericardial fluid culture grew Streptococcus Pneumoniae that was pan-sensitive. The patient ultimately had full recovery and was discharged home with outpatient follow-up. Introduction: Pericarditis with a purulent pericardial effusion is a rare occurrence, particularly in neonates. It carries a very high mortality rate if not treated early. The most common causes of bacterial pericarditis in the children are Staphylococcus Aureus, Haemophilus Influenzae, and Streptococcus Pneumoniae. Discussion: Pericarditis with purulent pericardial effusion is a rare occurrence, particularly in neonates, and carries a significant morbidity and mortality. The initial presentation is generally similar to sepsis. Signs and symptoms

of cardiovascular compromise including tachycardia, hypotension, lethargy, and respiratory distress should incite physicians to consider a cardiac cause of shock in the pediatric population. Cardiomegaly present on chest x-ray should raise suspicion for the possibility if a pericardial effusion. Diagnosis is ultimately made by 2D-Echo which may confirm the presence of fluid surrounding the pericardium. Pericardiocentesis should be performed for any symptomatic or lifethreatening pericardial effusion. Cultures of the pericardial fluid obtained should reveal the causative organism. EKG changes consistent with cardiac tamponade such as electrical alternans may be present in cases with significant pericardial fluid collection. There may also be diffuse ST elevations or PR depressions on EKG associated with pericarditis. The medical course may be insidious or present with rapid onset and decline therefore, clinical suspicion is key. An enlarged cardiac silhouette may or may not be present on chest X-ray, however a pericardial friction rub is often heard on physical exam. Heart sounds are usually be muffled, but may be normal in children (5). Based on review of current literature, this patient is the youngest reported case with this condition. The most common cause of bacterial pericarditis in children is Staphylococcus Aureus, closely followed by Haemophilus Influenzae and Streptococcus Pneumoniae (3). The age range of reported pediatric cases in the English literature thus far are about 9 months to adolescence, with the youngest patient being only 4 weeks old. Reported cases where diagnosed based on clinical suspicion. Mortality rate approach 100% without immediate intervention (4). Aggressive treatment includes early treatment of shock, drainage of the purulent pericardial fluid, and the use empiric systemic antibiotics covering the typical organisms. A more tailored, culturespecific antibiotic may be selected once the

causative organism has been identified. Definitive surgical intervention may be necessary to prevent future complications, such as constrictive pericarditis (2). With timely treatment, mortality may be reduced to less 20% (4). While purulent pericarditis is reported in the pediatric population, it is an extremely rare finding among neonates. Most cases of pericarditis in children are viral or of unknown etiology. Pericarditis due to tuberculosis has been reported in third world countries and is seen in children of all ages. The importance of this case is based on both the age of the child and the unusual causative agent (i.e. Streptococcus Pneumoniae). Cardiac etiologies in children who present in septic shock should be considered and prompt recognition and treatment of conditions such as purulent pericarditis may be lifesaving. Schakia Eze, DO, Emergency Medicine Resident, SJRMC Michael Gorn, MD, Pediatric Emergency Medicine, SJRMC No Conflicts of Interest References 1. Feinstein Y, Falup-Pecurariu O, Mitrica M, et al. Acute pericarditis caused by Streptococcus pneumoniae in young infants and children: Three case reports and literature review. International Journal of Infectious Diseases 2009; 14: 175-178. 2. Parikh S, Memon N, Echols M, et al. Purulent pericarditis: Report of 2 cases and review of the literature. Medicine 2009; 88: 52-65. 3. El Hassan N, Dbiabo G, Diab K, et al. Pseudomonas Pericarditis in an Immunocompetent Newborn: Unusual presentation with review of the Literature. Journal of infectious Diseases 2007. 49-51. 4. Bhaduri-McIntosh S, Prasad M, Moltedo J, et al. Purulent pericarditis

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caused by Group A Streptococcus. Texas Heart Institute Journal 2006: 33: 519-22. 5. Onyeama CO, Okomo U, Garba D, et al. Staphylococcal purulent pericarditis in a malnourished Gambian child: a case report. International Journal of cardiology 2007; 119(3): 392-394. Therese G. Mead, D.O., Virginia Labond, M.D., M.S., FACEP, Brandon Peters D.O., and SharneĂ¨ Maresh Title: Evolution of meningoencephalitis in a post-neurosurgical patient with back pain Introduction: Meningitis and encephalitis are uncommon complications of lumbar microdiscectomy with a high morbidity and mortality. The presence of a postoperative cerebrospinal fluid leak increases the likelihood of developing a central nervous system infection. This is a case discussion of a patient who initially presented to the emergency department (ED) with postoperative back pain. During evaluation for her back pain, she developed acute delirium and agitation which led to a final diagnosis of meningoencephalitis. Case Presentation: A 35 year old female with a past history of lumbar microdiscectomy and durotomy repair 12 days prior, presented to the ED with severe back pain radiating into her bilateral buttocks. Her first neurosurgical procedure was a bilateral L4-L5 and L5-S1 microdiscectomy performed three months before. She had attempted to discontinue her oxycodone, but then experienced increased pain prompting her visit to the ED. She was afebrile on arrival to the ED. Physical examination was significant for slight incisional erythema and local edema with moderate incisional tenderness. Neurologic exam revealed an alert, oriented, anxious female with cranial nerves II-XII, motor and sensation

intact. She was hyporeflexive at L4 on the right. Her initial work-up included a complete blood count, chemistry panel and magnetic resonance imaging (MRI) of the lumbar spine ordered in consultation with her neurosurgeon. Significant laboratory results included a leukocytosis of 16.3 k/ cm2 with 83% segmented neutrophils. Empiric antibiotics were initiated for possible spinal epidural abscess. While awaiting MRI, the patient became disoriented and agitated with new complaints of fever and severe headache described “like my head is going to explode.” This acute change in her mental status increased suspicion for meningitis. Definitive diagnosis of meningitis was challenging in this case. Lumbar puncture

was unable to be performed in the ED due to the cellulitic area over L3-L4 and L4-L5. Anesthesia was consulted, but also unable to perform the lumbar puncture. Additional empiric antibiotics were ordered in consultation with neurosurgery and the patient was admitted to the Neurotrauma Intensive Care Unit for acute bacterial meningitis. On admission day number one, neurosurgery performed an intraoperative lumbar puncture followed by wound exploration. Tube number one of her cerebrospinal fluid (csf ) yielded 13,300 wbc’s, 849 mg/dl protein and glucose <3 mg/dl. The csf culture showed numerous wbc’s but no growth. Blood cultures were positive for coagulase negative Staphylococcus. The initial

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CT of the brain ordered in the ED was negative but limited from motion artifact and the second CT was suggestive of acute meningitis. The patient was admitted for 11 days with a discharge diagnosis of meningoencephalitis, dural leak, cellulitis and hematoma. Conclusion: This case demonstrates the challenges faced by the ED physician in establishing a definitive diagnosis of postoperative meningoencephalitis when lumbar puncture is unable to be performed in the ED. This case also emphasizes that attention to subtle changes in personality and consciousness can expedite the diagnosis of serious central nervous system infections when evaluating postoperative neurosurgical patients.

Get Ready for FOEM's Fall Competitions The FOEM Research Study Poster Competition Sponsored by MedExcel Tuesday, October 11, 2011 7:00 a.m. – 3:30 p.m Deadline for application and abstract: July 31, 2011 Deadline for PowerPoint: September 30, 2011 This popular competition features residents or students that have completed research in the field of osteopathic emergency medicine that have created a poster of their research and wish to present their findings to an audience of physicians. The posters are put on display two days before the competition and one day after to allow judges to thoroughly read and evaluate them. During the competition, participants are given seven minutes to present their research and two minutes for questions from the audience while their poster is projected on a large screen behind them. For more information about this exciting annual competition, please go to www.foem.org. FOEM Clinical Pathological Case (CPC) Competition Sponsored by Schumacher Group Tuesday, October 11, 2011 7:00 a.m. – 3:30 p.m Deadline for application and case report: July 31, 2011 Deadline for PowerPoint: September 30, 2011 This fun and competitive competition

always draws a large crowd by pitting residents against faculty in diagnosing a difficult case. FOEM encourages every ACOEP program to participate in this exciting event. To participate, each program must pay a fee of $100 and provide both a resident and faculty member. Each resident is in charge of submitting an unusual or interesting case report with the final diagnosis on a separate sheet of paper. The undiagnosed cases are distributed to participating faculty members from other programs who are given one month to come up with a PowerPoint presentation of their case discussion, possible diagnosis, and the reasoning behind their conclusions. At the time of the competition, residents present the undiagnosed case, followed by the faculty’s discussion and differential diagnosis. The resident then returns to the podium to reveal the actual diagnosis. Both residents and faculty are evaluated on their performance by a panel of judges. FOEM Oral Abstract Competition & Breakfast Sponsored by EmCare Wednesday, October 12, 2011 6:00 a.m. – 7:30 a.m. Deadline for application and abstract: July 31, 2011 Deadline for PowerPoint: September 30, 2011 This competition features residents that have performed research in osteopathic emergency medicine and created a PowerPoint presentation of their work. Each resident is allotted seven minutes to present their research and two minutes to

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take questions from the crowd. FOEM Resident Research Paper Competition Sponsored by EMP Thursday, October 13, 2011 11:30 a.m. – 1:30 p.m. Deadline for application: July 31, 2011 Deadline for paper submission: July 31, 2011 The FOEM Resident Research Paper Competition is the Foundation’s most prestigious event, which culminates at the ACOEP Scientific Assembly in the fall. A panel of judges, made up of qualified members of the FOEM Board and the ACOEP Research Committee, is enlisted to evaluate research papers that are submitted as part of the required residency training. Up to three papers may be chosen as winners, but FOEM reserves the right to withhold these annual awards if quality is lacking.

Official FOEM Competition Handbooks are being mailed out to all Program Directors and are also available online at www.foem.org. Applications and more information on all upcoming competitions are available at www.foem.org or by contacting Stephanie Whitmer at swhitmer@foem.org.

TIPS, A Change of Focus Sherry D. Turner, D.O. As I moved through my medical education, I have discovered it is much like life—your interests and experiences change from general circles of knowledge to the specific knowledge needed for specific tasks and then widen to see the whole picture. For example, when I started residency I was very focused with a straight forward direction, which included not killing any patients, while trying to learn as much as possible. As the four years progressed I moved past that focus and looked at other aspects of Emergency Medicine, working with the Resident Chapter of the ACOEP. When the healthcare debates hit the news and began to have the focus of the Nation, I needed to learn more. These changes where going to impact my patients, their families and my income. I had heard of a program sponsored by New York College of Osteopathic Medicine called Training in Policy Studies, (TIPS), which was open

to residents in all specialties. It required four weekend meetings with lecture and development of a health policy brief by the end of the year and cost approximately $1,000.00 per weekend. This was exciting and depressing because I felt the expense was too great, and the four weekend events over the year seemed impossible to schedule. After discussion with my director and fellow residents, Steve Hollosi, DO and I applied for the program together. ACOEP sponsors Emergency Medicine residents with monetary support and we were awarded a grant for our travel and tuition. We also traveled together to save money on many of our shared expenses. The education and learning offered to us during our year was outstanding. We attended lectures with the leaders of the AOA as well as visited with governmental officials who represented our voting areas.

We were assigned topics of interest and developed our skills at writing health policy briefs. We learned to view the profession from 50,000 feet above the gut reactions. When this occurred, we could visualize the unintended consequences of the legislation taking place. The experience widened my “circle” once more to include the public, profession and the current debates in heath care with new understanding and skills to participate and shape the decisions made by legislators. I have been approached at the state level to write health policy briefs which is a great honor and also a chance to impact our future. I would not have had this opportunity if not for the support of the ACOEP. I encourage anyone interested to commit the time and energy, the return is well worth the effort. We are responsible for the profession that trains us. Step up and get involved.

PROGRAM DIRECTOR Department of Emergency Medicine Opportunity Charleston Area Medical Center (CAMC) in Charleston, West Virginia is seeking candidates for the position of Program Director within the Department of Emergency Medicine. Candidates must be residency trained in Emergency Medicine and AOBEM certified or eligible for AOBEM certification and have a minimum of three (3) years clinical experience. Providing an excellent experience for residents, CAMC is an 838-bed teaching hospital consisting of three hospital facilities, including a Level I trauma center and a Women and Children’s Hospital. The three Emergency Departments see more than 100,000 patients per year. The Emergency Medicine residency program is a fully accredited four-year program by the American Osteopathic Association (AOA) and approved for a complement of 16 residents. The program is well established and achieved a maximum accreditation status at its most recent review cycle. CAMC is the largest teaching hospital in West Virginia and serves as the sponsoring institution for 11 graduate medical education programs approved by the ACGME/AOA and other graduate level programs including pharmacy residencies, a psychology internship and a School of Nurse Anesthesia. Affiliated with the West Virginia School of Osteopathic Medicine and West Virginia University School of Medicine,

CAMC is the regional campus for more than 100 medical students completing their 3rd and 4th year of clinical training. CAMC has received numerous awards and recognitions for its patient care quality and many services to the community. As West Virginia’s largest city, picturesque Charleston offers both urban amenities and abundant outdoor activities. The Program Director position offers an opportunity to serve as a member of a dynamic team of professionals and faculty serving Southern West Virginia and the region. A highly appealing package is offered which includes excellent remuneration and benefits including equity ownership eligibility within an established democratic group. For additional information please contact: Rachel Klockow Premier Health Care Services (800) 406-8118 | rklockow@phcsday.com Fax: (954) 986-8820

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The Committee on Graduate Medical Education: Working for You John W. Graneto, D.O., FACOEP-D, Chair The Committee on Graduate Medical Education is hard at work this Spring. We currently have 45 programs and more applicants for new programs in the process of being considered. The Committee is made up of 11 members chosen from your peers by the presidents of the ACOEP. • • • • • • • • • • •

John W. Graneto, D.O., FACOEP-D (Illinois) Alan R. Janssen, D.O., FACOEP-D (Michigan) James M. Turner, D.O., FACOEP (Mississippi) Douglas Hill, D.O., FACOEP-D (Colorado) Gregory Bloxdorf, D.O., FACOEP (Ohio) John DeSalvo, D.O. (Indiana) Clifford Fields, D.O., FACOEP (Rhode Island) David Malicke, D.O., FACOEP (Michigan) Manjushree Matadial, D.O., FACOEP (New Jersey) Bryan D. Staffin, D.O., FACOEP-D (Michigan) Christopher Zabbo, D.O. (Rhode Island)

The AOA's Postdoctoral Training

and Review Comittee (PRTC) approved the 2011 basic standards revisions we are expecting to be in place this year. We have presented these for discussion to the program directors twice over the past two years. The major changes from the 2009 standards include: Standard 5 Curriculum; Previously an internship plus three years of EM was the structure of most programs, this is no longer our structure. Standard 5, Sections B and C outline the curriculum, and required rotations for the four-year continuum of education. Required procedures in Section D lists a minimal number of procedures in 20 areas that should be completed by residents in emergency medicine. The procedures should be done on patients, in simulation laboratory settings or cadaver labs. A new section in Standard 5, addresses Advanced Standing and Program Transfers. The mechanism and paperwork required for both transfers between programs (or specialty areas) and the granting of advance standing is now a standard. A new Advanced Standing Request form is available from the Executive Director. Standard 6 Program Director and Faculty the standards now further address the issues of both resident and faculty attendance and participation in didactic activities.

Defined and explained examples of Scholarly Activities are placed in Standard 6. As discussed with the program directors in January, scholarly activities have been broken into "Major" and "Minor" activities as was outlined in January at the Program Director Committee meeting. Standard 7 Residents the most significant change in the Resident Requirement is final project suitable for publication submitted to the ACOEP a minimum of six months prior to the end of the final year of training. The review of the paper will be conducted by the Research Committee of the ACOEP and reported to the CGME for a part of the requirement the declaration of program complete status. No resident will be declared program complete without a paper, papers can be submitted jointly by two residents working as a team on a project. I would suggest that P.D.’s print a copy of the standards for each of their core faculty or proposed core faculty so they are aware of the requirements for the program. One suggestion even asks that they sign off on receipt of the standards as a requirement for reimbursement for their core faculty protected time. I look forward to working with established and newly proposed program to continue to improve the educational process of the EM trainees

UMDNJ-SOM Student Wins 2011 Student Case Competition Congratulations to Farook Taha, OMS IV, for placing 1st in the 2011 Student Case Competition. Taha’s case, Recognizing Infective Endocarditis in the Emergency Department, will be presented during the general session at the 2011 Scientific Assembly in Las Vegas, NV! For a sneak-peak at Taha’s case, please visit the Research Competition section of our website located on the Student Chapter page. ACOEP would like to thank the 24 individuals who submitted compelling cases to this year’s competition and to the Undergraduate Medical Education Committee for taking the time to judge each case. It is with your continued efforts and support that the ACOEP Student Chapter keeps thriving to its greatest potential.

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

What Would You Do? In this issue of The Pulse we will review the case of an elderly male amputee who appears to be abusing the EMS system. This was presented in the April 2011. The patient weights 375 pounds, and cannot support himself on his good leg, and lives at home with his frail 98 pound wife. He frequently uses a lifeline device to call 911 for fire department assistance to adjust him in bed or to go to the bathroom. He also sold the hospital bed that was provided for free. The patient invariably refuses transport to the hospital. EMS is asking for guidance. What would you do? Unfortunately, there are many patients who use the EMS system for nonemergency needs, often for daily living assistance. This becomes rather frustrating for EMS, as they perceive this as abuse. Obviously, the danger in limiting the EMS response lies in the possibility that one of

Presidential Viewpoints, continued from page 1 long time coming and I believe it is the fairest way to allow active members of the ACOEP's learn about the candidates and then to voice their opinion on whom they believe would best serve the College as a member of the Board. I strongly encourage each of you to renew your membership early and cast your votes for the future leadership of the College. I have been invited to go to Washington to participate with a group that will have the mission of the development and promotion of a National EMS “Culture of Safety” Strategy. The product of this three-year project will be the development and dissemination of a document that

the calls may be for a real emergency (every turkey has a terminal event). Consequently, as professionals, we should respond to every EMS call in the same manner; with objectivity and compassion. However, how can we correct this inappropriate use of the EMS system? First, attempt to involve other agencies in the solution. Attempt to get the patient to the hospital, where social services can evaluate needs and possible placement. If the patient refuses transport, his decisionmaking capacity may be impaired, thereby necessitating transport to the ED (this may be stretching things, but is not unreasonable). Additionally, clergy may help. If these measures are unsuccessful, legal options become appropriate. Involvement of the municipality’s attorney should be utilized. The patient may be considered abusive and the cautious threat of legal action may be effective. Additionally, the

identifies the current state of EMS safety issues and to make recommendations for the improvement of future EMS safety practices. Jan, Greg and I will be attending the July AOA Board of Trustees meetings and the House of Delegates meetings. I anticipate that the ‘hot’ topics will be the resolutions concerning AOA approval of internships and residencies completed at ACGME sites and the update to the report of the EPPRC III committee. I shall report back after the meetings. I hope that everyone has a safe and enjoyable rest of the summer and early Fall. I look forward to seeing many of you at our October Scientific Assembly in Las Vegas. Thank You

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local board of health may be needed to help remedy the situation. What happened? The patient was subsequently transported to the hospital and finally consented to nursing home placement. These patients are difficult, but we still must be their advocate. Reasoning and education are the best answer. But, when this fails, we do need to address the situation directly and with a resolution. The greater good of society (and our patience) call for it. If you have any cases in your practice that you would like to present or be reviewed in The Pulse, please fax them to 708-915-2743. Thank you.

Editorial, continued from page 4

It is a given that Emergency Medicine physicians and mid levels provide quality care. It is also expected that not only do we provide great medical care but that the care is provided expeditiously and with excellent customer satisfaction.

Financial Report of the American College of Osteopathic Emergency Physicians October 1, 2009 – September 30, 2010

At the Board of Directors Meeting of April 2011, a resolution of the Finance Committee was approved to accept the audit conducted of the College’s finances conducted at the end of the last fiscal year. The audit conducted by the auditing division of Dugan and Lopatka, found that the College was fiscally sound according to the accepted accounting guidelines of the FASB Accounting Standards Codification. The following is a summary statements for Assets and Liabilities and Revenues and Expenses for the fiscal year ending September 30, 2010.

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OFFICIAL CALL To the Officers and Members of the American College of Osteopathic Emergency Physicians: You are hereby notified of the ACOEP’s Membership Meeting on Tuesday, October 11, 2011 at the Encore in Las Vegas, Nevada. The meeting will begin at 5:00 p.m. The meeting will report on the outcome of the College’s election for the Board of Directors as well as updates from the Board, FOEM, AOBEM, ACOEP Committees, Board and Administration will also present brief reports to the membership. This meeting will count towards Fellowship requirements for Active and Resident Members but no CME credit is awarded for participation in the Membership Meeting. Mark A. Mitchell, D.O., FACOEP, Secretary

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Do You Have the Urge to Serve? If you do, then you may be among the new nominees for the Board of Directors of the American College of Osteopathic Emergency Medicine for 2012. The Nominations Committee of the College will be conducting interviews with interested physicians who are Fellows and are current or past members of any College committees on Tuesday afternoon and Wednesday morning, October 11 and 12 at the Encore in Las Vegas. Interested parties should send their current CV and a letter outlining their interest in serving the College to: Peter A. Bell, D.O., MBA, FACOEP-D Chair, Nominating Committee ACOEP 142 E. Ontario Street, Suite 1500 Chicago, IL 60611 (fax to 312-587-9951) Or send via email to janwachtler@acoep.org, please mark â&#x20AC;&#x153;Nominations Committeeâ&#x20AC;? on the subject line

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