The Pulse October 2008

The PULSE

Osteopathic Emergency Medicine Quarterly VOLUME XXXIII NO. 4

october 2008

Presidential Viewpoints Peter A. Bell, D.O., FACOEP

"Charting the Course by Consensus" In 1994 the ACOEP met in Boston. At the general membership meeting, the slate of candidates for the Board of Directors offered more names than open positions.

This was a major shift in practice. For the previous two decades the same cohort of physicians had assumed the various roles (elected and appointed) within the College and had assured our growth. Now change was occurring. The members had called for more new blood. That year three newcomers were elected: Joe Calabro, Tim Coleridge, and me. The members had spoken and the practice continues to this day.

During the mid-90s the College established its first annual budget. It was the membership that called for financial responsibility, accountability, and transparency. The College owes much to the attentiveness of John Becher who conducted the first budget meeting. Since then his protégé Joe Kuchinski has been the watchdog of all College funds. The membership also questioned the financial continuity of the College in the event of economic or political disaster. This reoccurring concern was raised over several presidents’ terms, and addressed by establishing a reserve fund sufficient to cover one year’s operations.

In 1996, then President Ben Field introduced the concept of continuous certification to our membership. While there were many sound arguments in favor of the process, none was stronger than the rationale offered by the rank and file. Emergency medicine was still a young specialty and was often discriminated against by other specialties. We needed to affirm our credibility through an ongoing process. The membership endorsed raising the bar by becoming the first specialty to establish continuous certification. It was also the membership that expressed the need for re-certification as an expectation for all our members. It was and has remained the high ground; especially in light of the struggle other specialties are still facing with this concept.

Many asked, “Why can’t we have a non-for-profit education Foundation?”, and then in 1998 FOEM was born. While the concept was excellent, and the gifts made by the members at inception were generous, the Foundation needs your support.

Unlike the ACOEP that derives revenue by dues, CME programming, and reserve fund investments, FOEM can only thrive by higher levels of endowment. It was an idea conceived by the membership and implemented by the Board. Help us to make your vision come true. Make a contribution to FOEM. Changes in the Spring CME venue have been a topic of frequent discussion by the membership. For years the ACOEP had met in Palm Springs for the conference. Moving

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to Phoenix in the early 90’s re-established the conference at the now extinct Red Lion La Pasada. It was the membership that asked for changes in resorts, but still desired to stay in the Phoenix area. The CME Committee and the Board honored the request, and continues to explore the membership’s preferences. In fact, this spring we will meet in Orlando. While this is a marked departure from our usual locale, it was a request by the membership. In 2010 we will return to Phoenix where (per your request) we will stay at the Wigwam Resort and Spa for two years and then move to the Westin Kierland in North Scottsdale.

So how does the College grow and meet the needs of its constituents? While I’ve offered only a few examples, I hope my point is clear. We listen, gather information, set goals, and plan according to your wishes. Our Bylaws are our operational framework, but it is your desires that drive our process. Operating by consensus has become the norm.

At the Fall ACOEP convention in Las Vegas, I will review our list of Presidential Objectives for ’06-‘08. It has been an excellent two years, but to make this organization even better we need your ongoing support. The ACOEP will be conducting a large membership survey at the end of the year. While much information is gathered routinely, we have (at the request of the membership) established an in-depth survey of all members to be conducted continued on page 20

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Editorial Drew Koch, D.O., FACOEP, Editor The summer of 2008 has officially passed. The summer vacations are over along with summer scheduling nightmares.

The kids are back at school and we are back to our routine of meetings and providing patient care in our emergency departments. Tropical storms and hurricanes indicate the end of the summer and the beginning of fall. There have been two significant hurricanes, Faye and Gustav, which delivered their devastation with flooding and wind damage but not of the magnitude of Katrina in 2005. We learned from our failures with Katrina and had early evacuation and deployment to the Gulf of Mexico before hurricane Gustav hit land.

History was made this summer that will change the face of politics. Both political parties altered the landscape of the presidential election. The Democratic Party at the Democratic National Convention held in Denver, Colorado selected Senator Barack Obama, an African American, as the presidential nominee. The Republican Party met in St. Paul, Minnesota and Senator John McCain selected as his running mate, Governor Sarah Palin of Alaska, the first GOP woman vice presidential candidate.

Whoever wins the presidential election will be a first. The Country will either have its first African American President or its first

woman Vice President. This change will be welcomed and hopefully convey fundamental reform to the delivery and payment of health care in this country without a significant increase in taxes.

When ACOEP meets in Las Vegas, Nevada from October 26th through October 30th another historical milestone will be achieved. This will be the first time in ACOEP’s history that it is not meeting in conjunction with the AOA Fall convention.

ACOEP has met in conjunction with the AOA since 1978. We will be meeting in the same city and at the same time as the AOA but will be meeting at a different hotel and convention center. One of the concerns of members of ACOEP was the cost of the Fall AOA convention. The CME registration and hotel accommodations for ACOEP’s fall seminar are between 14 and 15 percent less than the AOA’s. Scheduling of events and location will be under the jurisdiction of ACOEP and not the AOA. There will be no conflicts with the alumni events and the presidential banquet when the Fellowship Ceremony and ACOEP membership reception are held. We will not be paying for activities that we do not attend. It is a win-win situation for ACOEP. The next milestone that ACOEP should attempt to alter is how we obtain our AOA approved CME credits. The AOA requires that DO obtain 120 credits during each cycle. The current cycle runs from 20072009. Thirty CME hours must be category

1-A, AOA approved, and physicians who are board certified must earn a minimum of 50 credit hours either Category 1 or 2 in their primary specialty. If ACOEP was able to offer, in addition to their current venue for CME, category 1-A AOA approved credits on-line then the members would meet their CME requirements without significant travel costs. Through my employer I am able to obtain my CME credits for the current AOA cycle; however, to obtain AOA approved category 1-A AOA approved category credits I must travel.

I have been fortunate over the years that I have been able to attend both the spring and fall ACOEP conferences. The first conference I attended was the spring of 1991 and was held in Orlando, Florida.

The remaining spring conferences have been held in the Phoenix area at various hotels. One constant has been the quality of the CME programs. I have found that the spring conferences have been very educational and informative. The 2009 ACOEP conference will be returning to Orlando.

This marks a change and the opportunity to bring your family to the conference and enjoy the attractions of the Orlando area.

This summer marked the passing of one of ACOEP’s past presidents, Ben H. Chlapek, DO, FACOEP. Ben served as ACOEP’s president from 1991-1993. He was a familiar and friendly face at the spring and fall continued on page 20

Table of Contents Presidential Viewpoints, Peter A. Bell, D.O., FACOEP . . 1 Editorial, Drew Koch, D.O., FACOEP . . . . . . . . . . . . . . 3 Executive Director’s Desk . . . . . . . . . . . . . . . . . . . . . . . . 5 Ben Chlapek Obituary . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Members in the News. . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Member Update . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Hospital Response to Terror . . . . . . . . . . . . . . . . . . . . . 10

From the Pediatric Case Files . . . . . . . . . . . . . . . . . . . . 13 Mortgage Real Estate Crisis . . . . . . . . . . . . . . . . . . . . . 15 COLA Notification Letter . . . . . . . . . . . . . . . . . . . . . . . 18 CME Calendar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Emergency Department Ethics . . . . . . . . . . . . . . . . . . . 21 EMR Notification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Did You Know? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

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The Pulse – An Osteopathic Emergency Medicine Quarterly 142 E. Ontario St., Suite 1250 Chicago, IL 60611 312-587-3709 / 800-521-3709 Editorial Staff Drew A. Koch, D.O., FACOEP, Editor Wayne Jones, D.O., FACOEP, Asst. Editor Peter A. Bell, D.O., FACOEP Gary Bonfante, D.O., FACOEP Duane Siberski, D.O., FACOEP Janice Wachtler, Executive Director Communications Subcommittee Drew A. Koch, D.O., FACOEP, Chair Wayne Jones, D.O., FACOEP, Vice Chair Gary Bonfante, D.O., FACOEP, Advisor James Bonner, D.O., FACOEP, Advertising Bobby Johnson, Jr., D.O., FACOEP William Kokx, D.O., FACOEP Annette Mann, D.O., FACOEP

Thank you to all of our exhibitors and sponsors for supporting ACOEP at the Scientific Assembly Oct 26-30, 2008

The PULSE is a copyrighted quarterly publication distributed at no cost by the ACOEP to its Members, libraries of Colleges of Osteopathic Emergency, sponsors, and liaison agencies by the National Office of ACOEP. The Pulse and ACOEP accept no responsibility for statements made by contributors or advertisers.

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

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Subscriptions to The PULSE are available to non-ACOEP members or other organizations at a rate of $50 per year. Š ACOEP 2007 - All Rights Reserved. Articles may not be reproduced without the expressed written approval of the ACOEP and the author.

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Executive Directors Desk Janice Wachtler

How I Spent My Summer Vacation...

Like most of us, I thought my summer vacation would be spent doing something that was relaxing. This year my vacation was going to consist of working in my backyard and doing some work around the house; instead I spent eight days on jury duty for a medical malpractice case.

When I walked into the Daley Center in Downtown Chicago, I knew that this was not criminal court and the trials here were mainly white collar in nature, so when the judge announced that this was a medical malpractice case, I breathed a sigh of relief and planned how I would spend the rest of the afternoon at Macy’s shopping. There were 36 people in the jury panel and after they released the first 20, and I wasn’t among them, I thought that I surely would be released after the second cut; boy was I wrong! After lunch, I was questioned in the Judge’s Chambers to answer several questions from the lawyers who were unsure just exactly what I did and who I worked with. I answered honestly that I ran a medical association for osteopathic emergency physicians that worked as an advocate for its members and, when questioned about training standards and practice policies, I said I sometimes wrote and interpreted them as part of my job. And, before I knew it my hopes for shopping went out the window and I was a member of the jury.

The case revolved around a seven-year-old case in which a patient died after corrective surgery for a heart valve defect. The plaintiff’s case was built on the perception that if the heart surgeon had utilized a trans-esophageal echocardiogram (TEE) he would have detected that the mitral valve implant was not functioning correctly,

indicating that a mitral valve replacement was the appropriate surgery that should have been done and after the surgery the patient’s cardiac output was insufficient and he developed endocarditis from a postoperative infection. The defendant stated that the mitral valve replacement was a surgery that was no longer done and the mitral valve implant was the less invasive surgery and that the patient’s heart was functioning fine and he had no bacterial infection. His cause of death was from BOOP – Bronchial Obstructive Obliterans Pneumonia.

This is what I learned from this experience in the order that I learned them over the period of eight days.

The Jury plays a big part in the success or failure of the case. Our jury consisted of 12 individuals from varied backgrounds.

First, there were 7 women and 5 men. The women were a retired homemaker, a special education teacher, a Comcast order taker, a claims adjuster for the railroader workers union; a secretary; a phlebotomist, and me. The men were a container designer, a construction foreman, a Best-Buy clerk, a produce manager from a larger grocery store, and a school custodian. Although the jury came from diverse backgrounds, we all had had some experience with medical injuries, surgeries in our lives or the lives of close friends and relatives. Most had watched medical shows on television and were familiar with many of the medical terms being used and had numerous personal encounters with different types of physicians and surgeons.

Attorneys have to treat the jury and witnesses as intelligent people. The Plaintiff’s Attorney did not do this and treated witnesses and members of the jury like they were totally stupid. In her opening statement she drew a picture of a heart that consisted of four boxes (the four chambers of the heart) with the mitral valve coming out the bottom of the heart;

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then she explained the difference between a TEE and a trans-thoracic echocardiogram (TTE) and to “simplify it for us” told us she would be referring to them as an “Inside Echo” (the TEE) and an “Outside Echo” (the TTE). The Jury as a whole moaned at this inference but she used this terminology with the entire panel of witnesses for the entire 8 day trial.

Preparation is the key. The Plaintiff’s Lawyer was constantly unprepared, she flipped through things, repeated questions because she didn’t listen to the response of witnesses and just in general, wasted time.

The Defendant’s Lawyer was very organized.

His exhibits numbered and referenced to a large binder. Each question was also referenced to this binder.

Don’t waste anyone’s time with information that does not make sense. The Plaintiff led off with a Financial Expert who testified on the potential income that the patient could have earned in his lifetime if he had not died. The fact that the patient would have died within a few weeks without the surgery did not enter into his calculations, nor did the fact that he had had two other heart surgeries and probably would not have lived the estimated 14 years that a normal, healthy 71-year-old person would have potentially lived. The expert witness hired by the Plaintiff had been a thoracic-cardiovascular surgeon who had retired 10 years earlier. He had never done a mitral valve implant and he had not done any heart surgery since 1985. The overall feeling of the Jury was that this witness was not credible or worth our time.

The case presented by the Defendant was well planned and timely. The case presented consisted of other physicians on the case, the cardiologist, nephrologist and infectious disease physician, two expert witnesses, an infectious disease specialist Executive Director, continued on page 20

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ACOEP Past President, Ben Chlapek, D.O., FACOEP Passes Away

Monday mornings are never great for the ACOEP, but when we opened our e-mail on Monday, July 28, Monday became even harder to deal with. The first email had arrived on Sunday afternoon from ACOEP Member, Don Phillips, informing us of Dr. Chlapek’s passing, followed closely by e-mails from the Chlapek family and other physicians in and around Temple, Texas. It was true, that our Past President, Ben H. Chlapek, D.O., FACOEP had passed away at his Temple, Texas home on Sunday, July 27, 2008 at the age of 69.

Dr. Chlapek began his emergency medicine career in the late 1970’s working first at Liberty Hospital in Liberty, Missouri and then moved back to his home in Temple, Texas and Scott & White Hospital in the Emergency Department. He lived in Temple all his life. He played football as a student at Temple High School and earned a degree in Pharmacy and worked as a pharmacist for ten years in Austin and Temple, Texas. He moved to Kansas City to pursue a degree in osteopathic medicine from the Kansas City College of Osteopathic Medicine where he graduated in the mid-1970’s.

Dr. Chlapek was an early member of the American College of Osteopathic Emergency Physicians joining the College in 1982 and was elected to the Board in 1985 and was granted the honorary title of Fellow of the ACOEP in April 1986.

Dr. Chlapek served the College in the roles of Scientific Seminar Chair (19901991); Secretary (1987 – 1989); Presidentelect (1989 – 1991) and President (1991 – 1993). As Past President, Dr. Chlapek

chaired the College’s Ethics Committee and was active on the Undergraduate Medical Education Committee.

Many of our younger members may not remember when Dr. Chlapek was the President in the early 1990’s but he set the College on its current course, making subtle changes in reporting mechanisms and using the College’s publications for conveying the President’s Viewpoint on issues to the membership on a quarterly basis. He then served as an advisor to Presidents and served as the voice of ‘common sense’ to the Board for many years. Most often Dr. Chlapek opened the Membership Meetings with a prayer blessing the College and its members, and this always a memorable moment of reflection that was appreciated by our members.

Dr. Chlapek was a familiar sight at the meetings of ACOEP and missed his first Spring Seminar in 2008 in over 20 years!

He was a staunch supporter of the College and will be recognized for his contributions to the College with the 2008 Bruce D. Horton Lifetime Achievement Award scheduled to be presented at this fall’s Scientific Assembly. Additionally, Dr. Chlapek was recognized for his continuing mentoring of his colleagues with the 2004 Benjamin A. Field Mentor of the Year Award.

ailments. He cared about his patients, his fellow physicians, the hospital staff and just people in general. The Staff of the ACOEP remembers him for his song welcoming them every morning of conferences, his instance that we take breaks and his assistance in manning the booth or registration tables at our meetings and conventions.

His care and dedication will always remain with us all.

In her message to all of Dr. Chlapek’s many friends, Mrs. Chlapek explained her loss saying that he went to sleep at home and woke up in the arms of Jesus. It was true to kind that this peaceful man died peacefully at the home he lovingly shared with his beautiful wife of over 50 years. While we will all miss Dr. C, we know that he is in a better place without pain and suffering.

To honor Dr. Chlapek the Scott & White Hospital has announced that it will be dedicating its Emergency Medicine Education Suite in the Center for Advanced Medicine in his memory. The new educational suite will benefit our current and future Emergency Medicine students. A goal of $400,000 has been set to renovate and equip the room. If you are interested in contributing to this endeavor, you can send your gift to Glen W. Cosper, ACFRE, 3832 Canyon Heights Road, Belton, Texas 76513.

Dr. Chlapek encompassed the heart and soul of our College. He was a regular guy, an attending physician who cared about his patients, often singing “Jesus Loves Me” to crying children as his tended to their care.

Also he would sit, his head cocked to the side, listening as patients told him of their

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Member Update

Thomas Brabson, D.O., FACOEP President-elect, ACOEP The summer of 2008 has come and gone and we are all the better for it. We achieved a few significant victories. One was the avoidance of the 10.6% Medicare cut.

Thank you to everyone that called or wrote to your senator or congressperson. Our patients benefited, we benefited and our EMS colleagues did too. Although this was a significant victory, we still have more work to do. The Sustainable Growth Rate (SGR) still needs to be revised. We have dodged the cuts for the past few years, but we can’t afford to continue to test fate. We need to rally with our other emergency medical services colleagues and reiterate to the federal and state governments how vital our services are to people (their constituents).

Each one of us has multiple stories to tell of how we were able to make a difference in someone’s life when no one else could do anything. A single phone call, email, or letter from an emergency physician or other emergency services worker carries much

weight with our elected officials.

We also need to educate our patients about the state of medical affairs in our country.

The same is true about any other explanation we provide our patients; we need to educate them and solicit their help while providing the pros, cons, risks and benefits.

We need to help keep the politicians’ constituents healthy so they can go out and vote for what is right.

The ACOEP was again well represented at the mid year AOA Board of Directors meeting and the House of Delegates. We provided input on many of the referenda but there were none specific to emergency medicine.

As we move into the fall, you and I have much to do. We will have an exciting Scientific Assembly that will be our own.

We will have dynamic speakers and a great

line-up of vendors, all to share their expertise for the benefit our members. We hope you can all attend!

I also had the opportunity to attend a lecture by James C. Hunter, the author of “The Servant and The Servant Leader.” He was a dynamic speaker with many great points. The simple message I heard was that everyone in an organization should realize and be recognized for their importance in the organization. The pyramid is reversed, just like with PALS. As the ACOEP Board, Staff and I prepare for the coming term, we need each of our members to step up and tell us what we can do together to advance the mission of the ACOEP. As an organization, we will be green and growing, not ripe and rotting.

Thank you in advance for your input!

Members in the News Levente Batizy, D.O., FACOEP was honored by the Ohio College of Osteopathic Medicine (OUCOM) on August 16th when

many years. Last year Dr. Batizy retired from the position of program director of the emergency medicine residency at that hospital; it was a position that he held since the inception of that program in the mid-1980s.

profession, community, patients, and student and resident education.

Juan Acosta, D.O., FACOEP was recently deployed as part of the New York DMAT Team to handle the potential threat

Peter A. Bell, D.O., FACOEP was honored by the Columbus Osteopathic Association

he was the recipient of the Phillips Medal of Public Service. This award is presented to individuals who have made outstanding contributions to healthcare, education and/ or public service. Dr. Batizy is the director of medical education at Cleveland ClinicSouth Pointe Hospital in Warrensville Heights, Ohio, a position he has held for

on April 22nd when he received the COA’s Advocacy Award. This award is given for long-term advocacy for the osteopathic

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of Hurricane Gustav. Stationed in Tyler, Texas Dr. Acosta had the opportunity to meet with Michael Leavitt, Secretary of the U.S. Department of Health and Human Services.

Hospital Response to Terror Implementing the Incident Command System and NIMS in US Hospitals Steven J. Parrillo, DO

Are they “weapons of mass destruction or weapons of mass distraction?”

A respected colleague raised this question several years ago. His concern was that we are spending money, time and energy preparing for something that may never happen and neglecting areas that concern us every day. Granted, the US mainland has not faced another “terror” event since 2001, but the emphasis on WMD has allowed this nation to focus on an “all-hazards” approach to a variety of disasters. (I put “terror” in quotes because the US has faced many “small” events that qualify as MCIs or even disasters, but were not perpetrated by the typical terrorist).

Disaster preparedness has been a priority for American hospitals for many years. Until recently, however, there has been no “standard” for the development and deployment of Emergency Operations Plans. Some plans are much more comprehensive than others. All must be “cleared” by the Joint Commission (formerly the Joint Commission for Accreditation of Healthcare Facilities) during the survey process.

Following the events of September 11, 2001 there has been renewed interest in hospital preparedness. Emphasis has switched from “disasters” to “emergencies” with the recognition that an all-hazards approach makes sense for all involved.

The Incident Command System began as a way to coordinate response to fires in California. It is now standard operating procedure for almost all fire, law enforcement and emergency medical services in the United States. A hospital version – the Hospital Incident Command System – was first released as HEICS many years ago.

Although acceptance by hospital administrative, medical and safety personnel had been slow, ICS is now an expectation of the Joint Commission.

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NIMS – the National Incident Management System – was developed by the US federal government in an effort to further standardize the approach to all types of disasters in the US. NIMS is largely an expanded ICS. It is considered so important that, in 2008 all US hospitals must be “NIMS-complaint” or face financial consequences.

Let me review a few items of interest.

Following the events of 9-11, President Bush issued Homeland Security Presidential Directive 5 - a directive mandating development and use of a system to be used throughout the US. FEMA and other federal agencies are now tasked with getting the word out to the masses that NIMS is the system to use. NIMS builds on the foundation developed by the Incident Command System. Once again, HICS is the hospital version of NIMS/ICS. The system has other advantages including a reproducible structure using a common nomenclature. An Incident Commander has overall responsibility. His Command Staff includes a PIO, Liaison, Security / Safety Officer and Technical Specialists as needed. General Staff include Section Chiefs in Operations, Logistics, Planning Finance / Administration. In turn, each Chief has a staff. Unity of Command is a major piece within ICS and mandates that each person reports to only one superior. There is no confusion. Job Action Sheets are available for all major roles within ICS. Once again, that eliminates any confusion during the stress of a MCI or other emergency. The system can be expanded or contracted as needed. The process is clearly defined and outlined. A full discussion of the process is far beyond the scope of this brief article.

The National Response Framework is

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the overall outline that explains how this nation will answer the need in any type of disaster.

As an example of how hospitals have stepped up since 9-11, it would be helpful to use Pennsylvania Task Forces. Formerly called Counterterrorism Task Forces, these entities were established to bolster regional response to terror events and are supported heavily by federal funds. In summary, several of these task forces (all are sovereign) have accomplished a great deal in terms of the hospital response component.

• Emphasis on all-hazards approach • Hospital decontamination strike teams • Exercises (TTX and FSE) involving potential terror scenarios • MOUs among the 16 hospitals in the region

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• Regional Hospital Response Plan • Uniform hazmat training curriculum for all regional hospitals • Use of federal funds to increase surge capacity • Pharmaceutical cache for emergency response personnel Hospitals have looked for ways to meet the “NIMS-compliant” mandate. Most staff can meet the need by completing courses such as ICS 100, 200, 700 and 800 online through www.nimsonline.com. ICS 300 and 400 are advanced courses for upper level management (including Chairs of the hospital Emergency management Committee) and are face-to-face programs.

CDP and DHS also offer a 3-day Hospital Emergency Response Training at the Noble Training Facility in Anniston, Alabama. The program is federally funded. Information is available at https://cdp.dhs.gov.

Within the city of Philadelphia, emergency management representatives of all healthcare entities meet regularly within geographic zones. The objectives for the NE Zone include: • Develop memoranda of understanding • Develop and use joint tabletop exercises • Identify collaborative opportunities among healthcare partners and regional emergency management contacts • Assist zone member agencies in meeting regulatory mandates.

• Provide continuing education opportunities on topics relevant to emergency management.

• Identify common hazards and vulnerabilities (HVA) specific to the Northeast and identify preparedness, response, mitigation and recovery strategies.

• Establish and maintain an open pathway of communication with local,

county, and state emergency management partners.

CHEMPACK is a cache of agents supplied by and controlled by the US government.

Several hospitals – including my own – have agreed to serve as repositories for these supplies. The idea is to have these caches in areas that are strategically located so that distribution of critical supplies can be done effectively and efficiently. The cache includes atropine, 2-PAM, diazepam and other key supplies to be deployed quickly in the event of a terrorist attack. Only the CDC can give permission for release of the supplies.

The Strategic National Stockpile is similar in that it is a huge cache of supplies – including vaccines, antibiotics etc - that can be delivered to key areas within a short time (days) to regions in need. Locations of the caches are kept secret.

It is worth noting that the CDC recommended civilian hospitals have a cadre of smallpox-immunized staff. Many hospitals and clinicians objected and the plan was dropped. The US military does immunize against smallpox and anthrax.

As I mentioned above, to my mind the biggest “advantage” to spending time and money on WMD preparation is that doing so has fostered the all-hazards mindset in this country. Currently, the biggest (in terms of size and impact) threat we face is the possibility that pandemic flu will reach our shores. Virtually every US health agency from Health and Human Services (HHS) to county and local health departments have made or are currently making plans to deal with this contingency.

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The City of Philadelphia is the 6th largest in the US with a population of approximately 5 million. Representatives from all area hospitals were invited to join clinicians from the Philadelphia Department of Public Health in the development of a regional plan. After numerous meetings in a variety of subcommittees, a document was produced and distributed within the five-county region. The document is based on the one produced by Centers for Disease Control and Prevention (CDC) and HHS. Once again, a thorough discussion of this planning is beyond the scope of this article, but here is a summary of all-hazards issues that pan flu planning has addressed in Philadelphia. Each bullet represents a chapter produced by a subcommittee or working group.

• • • •

Hospital Surveillance Hospital Communications Education and Training Triage, Clinical Evaluation, Admissions and Inpatient Care • Altered Standards of care • Facility Access Planning

• Infection Control Guidelines • Occupational Health Issues • Use and Administration of Vaccines and Antiviral Drugs • Surge Capacity • Mortuary Issues I would be remiss if I did not mention efforts to train disaster managers and planners. Many large hospitals have already recognized that emergency management is a large responsibility that requires a full time, thoroughly trained professional. I am even convinced that it won’t be long before the Joint Commission will require this of all accredited hospitals, at least large ones.

Philadelphia University and other institutions of higher learning are preparing professionals to assume the role of disaster planners – not just for hospitals, but also for health departments, local and regional government, industry and law enforcement.

Students come from medicine (physicians, nurses, physician assistants), pre-hospital care, law enforcement and a variety of other backgrounds. Several such Masters programs are online and include courses in

principles of disaster management, planning for disasters, natural and man-made disasters (including terrorism), research, hazmat, psychological aspects and exercises and drills.

So they are clearly not “weapons of mass distraction.” Events like 9-11, Oklahoma City and others have served to remind officials in this country that we can’t take preparation for MCIs and disasters lightly.

Preparing ourselves for a terrorism attack with anthrax prepares us for pandemic flu. Preparing for dirty bombs and other nuclear attacks prepares us for events inside our radiology departments. Preparing for chemical attack prepares us for the everyday hazmat events. We must be proactive if we expect to respond appropriately. We must train to be as ready as we can be for any and all emergencies.

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career paths including academic, clinical, administrative, and much more. At EPMG you’ll enjoy flexible scheduling, allowing you to choose a work and lifestyle balance that suits your personal situation. We value your time. In fact, we even provide access to our retirement, health, dental, vision, and Rx plans for as little as 20 hours per week.

Emergency medicine positions are available at 6,000 - 92,000 visit emergency departments in Michigan, Illinois, Indiana, Ohio, Virginia, West Virginia, Pennsylvania, and Delaware. Three locations are host to DO EM residency programs. EPMG offers paid family benefits, Rx, dental, vision, life, LTD, 401(k), paid malpractice, CME, relocation, incentive bonus system, referral bonuses, and much more.

Contact Tynia Arnold at 800-466-3764, x335 or tarnold@epmgpc.com to learn more about your career opportunities in emergency medicine at EPMG or visit us on the web at www.epmgpc.com.

12

The PULSE October 2008

From the Pediatric Case Files…

Back Pain & Constipation in a 12 Year Old Girl Mary Young, DO1 Martina Mookadam, MD, MS2 Anita Eisenhart, DO, FACOEP, FACEP1 1Pediatric

Emergency Department Arizona Children’s Center at Maricopa Medical Center Phoenix, Arizona 2Department

of Family Medicine, Mayo Clinic Scottsdale, Arizona Introduction Imperforate hymen is a rare, and often missed, diagnosis in young, “premenarchal” females presenting with abdominal pain, back pain, urinary retention or constipation.

Case A twelve-year-old girl presented to a tertiary care pediatric emergency department (ED) complaining of a 17-day history of constipation and intermittent low back pain. She had previously been evaluated at another facility where an abdominal radiograph showed a preponderance of stool. She was diagnosed with constipation, given an enema and discharged with polyethylene glycol. Despite good compliance with the recommendations she experienced no relief of her pain.

Further questioning revealed she had been experiencing similar bouts of intermittent pain for several months with multiple medical evaluations. Each evaluation resulted in a diagnosis of constipation. She denied fever, vomiting and dysuria. Her past medical history was otherwise unremarkable with no hospitalizations or surgeries and she was noted to be premenarchal.

Physical exam revealed a lightly perspiring, uncomfortable-appearing girl, unable to sit secondary to low back pain. Her vital signs were normal. She had minimal abdominal tenderness in her bilateral lower quadrants without rebound or guarding. She did have mild midline lumbar-spine tenderness to palpation without palpable step-offs or deformity. Rectal exam showed good tone

and was guaiac negative for occult hemoglobin. The remainder of her documented exam, including limb neurologic examination, was unremarkable.

The presumptive ED diagnosis was persistent constipation resistant to outpatient therapy.

Plans for admission for a colonic “clean out” were initiated. She was evaluated with abdominal and lumbar spine radiographs (figures 1, 2 & 3) as well as baseline

Figure 1: KUB showing a paucity of stool

Two days later, the girl presented to the clinic as scheduled and was seen by the same resident who had evaluated her in the ED. On this visit an external genital exam was performed (after much convincing), which revealed a bulging tissue mass completely obstructing the vaginal introitus. A clinic diagnosis of imperforate hymen was made and the child was sent back to the ED for an ultrasound which revealed hematometrocolpos. Figure 4

Figure 2: Lumbar radiograph AP

laboratory studies. She also received 2 mg intravenous morphine sulfate. Abdominal films were negative, showing no evidence of constipation or obstruction. Lumbar spine radiographs showed no evidence of fracture, tumor or mass. Urinalysis, basic metabolic panel and complete blood count were unremarkable. Upon re-examination the girl stated that she was feeling much better and was discharged home to follow up in the clinic in two days.

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Figure 3: Lumbar radiograph lateral

She was taken to the operating room for a hymenectomy and evacuation of 500 cc of blood from the vagina. Figures 5 & 6 She was observed in the hospital overnight and discharged the next day without any complications.

Discussion The hymen is a remnant of mesodermal tissue that normally perforates during embryologic development.3 When the perforation does not occur it leaves a layer of epithelial-

13

ized connective tissue that obstructs the vagina at the introitus.9 As a result; menstral blood and cellular products build up within the vagina (hematocolpos), or both the vagina and uterus (hematocolpometra), causing pain and multiple other symptoms.

The most common symptom of imperforate hymen is urinary retention, which occurs in 58% of patients.5 Other symptoms include vague intermittent abdominal pain, dysuria, constipation, back pain, neurologic disturbances and pelvic mass.3,5,9 Back pain and neurologic disturbances are caused by compression of the sacral plexus and constipation is secondary to compression of the rectum and colon.

Figure 5: Pre-operative image of the imperforate hymen

Figure 6: Post-hymenectomy image

Posner and Spandorfer7 performed a retrospective review of 23 girls with imperforate hymen and found that almost half of girls over ten years of age at the time of diagnosis had different preliminary diagnoses.7 This delay can lead to multiple unnecessary diagnostic tests and further complications from hematocolpos and hematocolpometra. Girls with delayed

14

Bladder Uterus with hematometros

Vaginal vault with hematocolpos

h

The incidence of imperforate hymen is 0.014%-0.024%.3 There is a bimodal age distribution at time of diagnosis: younger than four years old and older than ten years old.7 The majority of younger females are asymptomatic with incidental findings on thorough physical exam. The older children are symptomatic with dysuria, abdominal pain, back pain, and constipation7.

Figure 4: Trans-abdominal ultrasound showing hematometrocolpos

Cervix

diagnosis are at a higher risk for salpingitis, infertility and endometriosis.5 The key to diagnosis and prevention of long term sequelae is a thorough physical exam, including the external genitalia at birth and then at subsequent well-child exams.

As a girl matures towards adolescence, this exam becomes more delicate and challenging, especially in a non-sexually active, non-menstruating child. It is common for the parents and/or the child to refuse a vaginal exam. If the physician is considering this diagnosis, great care should be taken to convince the child and her family to allow a simple observational examination.

Even suggesting the child hold her own labia open to avoid being touched may help improve child-physician trust.

Conclusions The diagnosis of imperforate hymen should be considered in any premenarchal female with a history of back pain, constipation, abdominal pain or urinary retention in order to decrease unnecessary diagnostic testing as well as sequelae of hematocolpometra.

References 1. Acar A, Balci O, et.al. The Treatment of 65 Women with Imperforate Hymen by a

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Central Incision and Application of Foley Catheter. BJOG 2007;114;1376-1379.

2. Botash A, Florence J. Imperforate Hymen: congential or acquired from sexual abuse? Pediatrics 2001;108;e53.

3. Dickson C, Saad S, Tesar J. Imperforate hymen with hematocolpos. Ann Emerg Med. 1985; 142/467-144/469 4. Isenhour J, Hanley M, Marx J. Hematocolpometra manifesting as constipation in the young female. Academic Emerg Med. 1999; 6;752-753.

5. Kitapci F, Avsar A, Senses D. A girl with constipation and acute urinary retention.

Em J Pediatr. 1999; 158; 337-338.

6. Letts M, Haasbeek J. Hematocolpos as a cause of back pain in premenarchal adolescents. J Pediatr Orthop. 1990; 10; 731-732 7. Posner JC, Spandorfer PR. Early Detection of Imperforate Hymen Prevents Morbidity From Delays in Diagnosis.

Pediatrics 2005;115;1008-1012.

8. Stone SM, Alexander JL. Imperforate Hymen with Hematocolpometra. N Engl J Med 2004; 351;7.

9. Wang W, Chen M, et.al. Imperforate Hymen Presenting with Chronic Constipation and Lumbago: Report of One Case. Acta Paediatr Tw 2004; 45; 340-42.

No one is immune from the mortgage and real estate crises Educating yourself and taking action now is key to avoiding struggles

By Dave Muti and Paul Haarman If you haven’t already experienced the affects of the subprime meltdown, liquidity crisis and credit crunch, you soon will.

Everyone needs to get informed and act now. Don’t think for a minute that this will not affect you, because it will.

Many of the news reports about these issues focus on families who are facing foreclosures because their fixed rate periods have ended and they no longer qualify to refinance at a lower rate. On Jan. 7, Treasurer Secretary Henry Paulson said he was concerned about a market failure and that is why he “brokered a deal” with the mortgage industry. He was referring to people who can no longer afford their mortgage payments and most Americans are sitting back and thinking, “That’s not me.”

Unfortunately, it is — and it’s critical to understand the implications of the current real estate and economic trends and, more importantly, how you can safeguard yourself.

Loans will soon be tricky to come by due to tighter lending standards, market changes and pending legislation that, if passed, will substantially change who will be able to qualify for a mortgage and how that process will work.

Even if you don’t foresee yourself needing a mortgage or loan in the near future, what happens if you suddenly become ill and can no longer work? Or what if you lose your job as we head into a possible recession? You will find yourself unable to

ACOEP has recognized William Mencke, Jr.

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

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

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

The PULSE October 2008

make your mortgage payments and, at that point, you may need a loan. But because of declining housing values, the equity you once perceived as a safety net may no longer be there to bail you out. Even if you do have some equity left to borrow, your chances of getting that loan are slim because you no longer have proof of income.

To make matters worse, you may no longer qualify for a loan on account of your current credit score, as lenders are tightening their credit standards.

Between tighter lending standards, declining housing values and pending legislation that could make it more difficult to obtain loans, you are sure to be affected in one way or another in 2008 and beyond. No matter your situation, everyone should consider speaking with a qualified mortgage planner to discuss their options. Those who are in an adjustable rate mortgage that is due to recast within the next 24 months should explore their options now because those choices may be nonexistent at a later date.

Tighter Lending Standards Today It is becoming more difficult for people to qualify for loans — regardless of whether or not they are attempting to consolidate debts, borrow equity or simply buy a home.

Even for those who make a lot of money and have great credit scores, the programs are changing daily, making it tougher to qualify.

Last year many lenders went out of business. Those who remain have been tightening lending standards by raising the credit score bar, lowering the loan to value and doing away with programs to make it even more difficult for borrowers. In fact, several lenders recently closed their “second mortgage” divisions, thereby ending several stated income Home Equity Line of Credit (HELOC) programs. Members of the mortgage community who helped thousands of clients obtain a stated income HELOC

15

within the last few weeks can no longer offer that same help today.

Some of these actions have been by individual lenders and some have been incited by the industry as a whole. For instance, if you have less than 20 percent of equity in your home and you plan on having that home financed with only one mortgage, you need to have Private Mortgage Insurance on your loan. You used to need a minimum credit score of 575 to qualify, but now you may need to have a score as high as 620 or better. This higher standard is making it very difficult, and sometimes impossible, for some people to refinance or even buy a home.

You might think that this does not apply to your situation because you have 30 percent or more of equity in your home. But what if your house declines in value and you find yourself thrown into this pool of borrowers?

You also may be thinking that you’ll simply take out two mortgages and avoid the PMI altogether. This, of course, is a popular and well known strategy, but the problem now is that most of the lenders that offered these programs are now out of business or have simply done away with the option.

Those few still offering the program require you to fully document your income. So for those who have less than 20 percent equity in their property, the stated income or no income documentation programs that were once available are no longer an option.

Premiums (YSP), which are the mortgage brokers’ compensation/commissions paid by the lenders. Due to a stronger lobby, banks earn these same YSP but they are not required to disclose them to the borrower.

Furthermore, if the proposed legislation passes as currently drafted, all borrowers will have to fully document their income.

This is a provision that the Federal Reserve Board of Governors wants added. This would mean no more stated income or no document programs for the self employed or active real estate investor.

Declining Real Estate Value — What Does It Mean To You? Housing values are on the decline and equity is disappearing from properties at an alarming rate. According to an Associated Press article on Dec. 28, new home sales plunged 19.3 percent in the Northeast and they are at their lowest level since 1991, down 34.4 percent nationally.

In addition, in order to protect their interests in the event of foreclosure, Freddie Mac and Fannie Mae have designated many areas as “declining markets” and their automated systems have already placed this limitation

One might think they need not worry about this because they are not planning on selling or refinancing anytime soon. Even if that were true, one needs to be fully informed of all the working components in today’s market and should consider re-thinking that entire thought process to protect their assets and grow their wealth.

Create An Emergency Fund Now It goes against the grain of everything we have been taught, and appears to be extremely counter-intuitive, but one should seriously consider borrowing against their existing equity to avoid new regulations and market conditions that will make it extremely difficult — if not impossible — to do so later on. We have entered an

Feeling Squeezed by CME Fees . . .

Consider ACOEP

ACOEP offers top rated CMECourses that are accredited by the AOA and ACEP at competitive prices so you can work CME activities into your schedule and pocketbook.

If you have an investment property, things are even tougher. Most lenders no longer offer interest-only programs which, of course, make the best use of your cash flow. The lenders who do have tightened their standards and that, compounded by declining real estate values, makes it very tough to accomplish the goals of the individual homeowner or investor.

Proposed Legislation Now we have politicians who are stepping in to try to fix this problem. Although they have good intensions, if the proposed legislation passes borrowers will have to deal with banks that have limited programs.

Likewise, brokers will have to charge a consulting fee or points up front because the pending legislation outlaws Yield Spread

16

on much of the country. As such, lenders are reducing the LTV limits within their guidelines, creating further depreciation of real estate values. Pouring salt into the wound, appraisers in response to pressure from lenders are getting more conservative with their appraisals before the lender even gets it. This in turn makes it harder to get the loan you need in order to buy your new house, consolidate your debts or simply refinance your existing loan.

For information on CME Programs check out our website www.acoep.org

The PULSE October 2008

era where the old rules of money no longer apply. It is now more advisable to reposition equity into a safe, interest-earning account that will act as an emergency fund if needed. Think of it as a life preserver or an insurance policy — one you hope you will never need, but if you find yourself in a situation where you do, you sure will be glad you have it.

One needs to take action now. It is paramount that you work with a qualified mortgage planner, one that is an expert in equity management strategies, to best optimize your plan. Apply to borrow against your equity while you are still gainfully employed and before you risk your house further declining in value. Take that equity and move it to a conservative, compound interest-earning account and do not touch it.

Many people fall victim to the traditional thought process in which they are apprehensive about taking out a loan because of the simple interest one must pay. However, that cost is a drop in the bucket compared

to the compounding interest you could earn in the new account. With your home equity now safely set aside and available in the event of an emergency, you are prepared to move forward in these times of economic uncertainty.

While your repositioned equity is earning you money, you can begin paying off your mortgage on a balance sheet by making additional payments to your newly created side account that will earn interest, rather than the bank holding your mortgage.

Thanks to the miracle of compounding interest, your repositioned equity will grow quickly and you will soon be able to pay off your house at a time of your choosing.

If you leave the equity in your home, you will watch your net worth evaporate as the markets continue to decline.

Obviously, the concepts discussed above are a method to invest money and grow wealth, but it is also a great way to create an emergency and liquidity fund at a time when homeowners and banks are feeling the credit and liquidity pinches as a

The PULSE October 2008

result of the sub-prime meltdown. This is a powerful way to protect your home and credit while the real estate market and economy is wavering. Home equity should be not be used as a vehicle for consumption, as many Americans have done so during the past decade to buy “things.” Home equity, when properly managed, can be utilized as a very powerful financial tool to enhance your liquidity, protect your family from the dangers of unemployment and disability, and ultimately build your net worth.

Dave Muti, JD, RMA is the author of Mortgages: What You Need To Know (www. pocketguidepress.com) and is a founding member and president of Forgotten Equity, Inc (www. forgottenequity.com). Paul Haarman, RMA, CMPS, is vice president and co-founder of Renaissance Mortgage Corp. (www.rmcmortgage. com), a mortgage planning firm with offices in Salem, NH, and Reading, Mass. Both Muti and Haarman are dedicated to helping homeowners create greater wealth by integrating their homes into their overall financial goals.

17

VITAL INFORMATION CONCERNING YOUR RECERTIFICATION The COLA modules are an important part of the recertification process. In order to be eligible to sit for the Formal Recertification Exam (FRCE), you must have taken the required number of COLA modules. There are NO EXCEPTIONS.

FRCE Year 2009 2010 2011 2012 2013

# completed COLA modules 4 5 6 7 8

There are only 3 COLA modules available on-line during any year. Each COLA module is retired after three years on-line. It is impossible to take a COLA module after it has been removed. If you have not taken at least 3 COLA modules by December 2008, you will NEVER achieve the number required to sit for the Formal Recertification Examination for the years 2009 to 2013. The ramifications are severe: your board certification will expire; and, in order to regain your certification in Emergency Medicine, you will repeat the entire certification process (Part I—written exam, Part II—oral exam, Part III—chart review).

Now is the time to check your certification expiration date and ensure that you are completing the necessary number of COLA modules

October 26 – 30 Scientific Seminar

Caesar’s Palace

Las Vegas, NV

23 – 25 Category 1A Credits 2009 January 7 – 11 Emergency Medicine: An Intense Review

Westin River North

Chicago, IL

42 Category 1A Credits February 1-3 Program Directors Workshop

Hilton Marco Island Resort

Marco Island, FL April 14 – 18 Spring Seminar

Hyatt Regency Grand Cypress

Orlando, FL

18

Important Dates for Board Certification / Recertification The AOBEM has supplied us with these dates in 2008 for anyone involved in the certification / recertification process during the calendar year of 2008. Please mark your calendars.

November 1 Application deadline for CAQ Medical Toxicology November 9 & 10 Part II Oral Examinations in Emergency Medicine, Chicago, Illinois December 1 Submission of Part III (clinical) examination in emergency medicine December 31 COLA 3 expires

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Presidential Viewpoints, cont'd from page 1

every 5 years. (The last was 2003) This survey serves to establish a direction for the College, while the smaller on-site surveys (for CME activities and town hall meetings) serve to reaffirm our progress. Dr Brabson and the Board will use this information in our strategic planning meetings and to define objectives for ’08-‘10. Help us to chart our course for the next five years.

It has been my pleasure to serve you as President. I hope to see you at future ACOEP functions.

Editorial, continued from page 3

conferences who routinely asked how you and your family were. He was a man of conviction who was extremely compassionate about the Osteopathic profession and ACOEP. He was always there to help and offer advice and he routinely lead invocation before the ACOEP annual meetings.

Ben was one of the finest individuals that I have ever known. He will be deeply missed by everyone.

Executive Director, continued from page 5

a heart surgeon, and lastly, the physician himself. All physicians were in active practice, each had spent time reviewing the case and it was obvious the Defendant’s Lawyer had personally prepared the witnesses. The Defendant’s Lawyer was also familiar with terms and procedures used by his client.

Your Attorney must know what you do and why you do it. The last two days of the trial, the Defendant’s testimony consisted of re-enacting the hospital course of the patient. The Defense Attorney asked questions that were cogent to the patient’s course in the hospital and the physician’s care. He described the patient’s condition prior to surgery, post-operatively and the course of treatment. He illus-

20

trated the bacterial counts, described the tests done and showed the progress of the BOOP obstructing the patient’s lungs and ultimately suffocating the patient and causing death. At one point, the Plaintiff’s Attorney questioned the physician as to why he didn’t prescribe an antibiotic for a 99º temperature, because “everyone knows you prescribe an antibiotic for a fever” she said as she leaned into the jury box and winked. She appeared shocked when the physician said 99º wasn’t a considered a fever and he had prescribed Tylenol®.

Shocked, she returned to the table ending her cross. On redirect the Defense Attorney emphasized what a fever was considered and why antibiotics are not prescribed, thus, nullifying her “big point.”

Finally, people still think that all physicians are rich and use their education to cover themselves in the event an error in judgement may result in the death of their patient. I know that as physicians you earn more than grocery store clerks and construction workers, but for the most part few people know get to know their physicians on a personal basis. Somehow the average person, unless they have a physician in their family, have few non-medical encounters with physicians. They don’t know them as “people,” and they think of them as superior people, and when deliberating this became a factor for one person’s vote. As we deliberated, it was clear to many of us that there was a vast difference in the representation between the patient’s family and the physician. The Plaintiff was suing for over 5 million dollars, most to offset the ‘loss of society’ for the spouse.

We discussed the case and the main points of the case. Did the heart surgeon make a judgemental error that caused the patient’s death? Did using a Swans-Ganz catheter to evaluate cardiac output indicate cardiac pressure and output accurately? Did the fact that the physician chose not to do the invasive tests (TEE) ineffectively diagnose a malfunction of the implant, if there was one? And finally, did the patient die of endocarditis? We took a vote and 9 found for the doctor, 2 were undecided, and 1 found for the patient’s family. We discussed things further, who proved their case and who did not? Another vote was

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taken and it was 11 for the physician and 1 for the patient’s family. We asked her why she felt this way and she stated that “all doctors have money and it was unfair that this woman lost her husband.” She stated her lack of faith with doctors and how she didn’t always trust them, but after another hour of discussion, we took another vote and she said that in her heart of hearts, the doctor didn’t do anything incorrectly and we ultimately found for the physician, much to the dismay to the Plaintiff.

At the end of the trial, the Judge met with us to thank us for our time. The trial had been in his court for the entire seven years.

The Plaintiff had sued not only this doctor, but also all the other physician witnesses and the hospital; one by one, the physicians were dropped because they weren’t considered the main physician on the case.

The hospital had settled out of court. He also stated that of all the cases that he has heard in more than 20 years on the Bench, this one was one of the weakest and should probably never been in court.

I understand that all people have their right to sue, but the expense involved in this case was extreme not only in the cost in money, but emotion. It prevented both the Defendant and the Plaintiff from moving on with their professional and personal lives; it basically prolonged the family’s mourning. The physician relocated and restarted his practice far away from Chicago; he still is considered one of the top heart surgeons in the U.S. It also involved twelve ordinary people to make a decision that was difficult and emotional; to take eight days in May to end the process and end a lawsuit that may not have been of merit but was of import to both parties involved.

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

What Would You Do? The following case was submitted by Atul Joshi, D.O. Dr. Joshi is an emergency department physician at Ingalls Memorial Hospital in Harvey, Illinois.

lived with her stepfather and her three daughters. The son lives with a paternal grandparent and had minimal contact with his mother and siblings. The only adult blood relative is an aunt of the patient.

The patient is a 34 year old female who presented to the ED with end-stage HIV. Sadly, she died in the ED. Her family was unaware of the HIV. She had three daughters and one son, all minors. The patient

The dilemma: 1. How do you inform the children of their mother’s death?

2. Would you tell them the diagnosis?

What would you do?

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

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.

Important Information for EMR Users January 1st CMS Regulatory Changes Could Impact the Way You Prescribe As of January 1, 2009, CMS will require that any Medicare Part D computer-generated prescription comply with the National Council for Prescription Drug Programs Script Standard, and be transmitted electronically and not via fax.

If you use an Electronic Medical Record (EMR) system to prepare and submit prescriptions to pharmacies, it is very possible that your EMR is automatically routing prescriptions to the pharmacy’s fax machine.

This will not be in compliance with the

upcoming shift in requirements. That’s why the American Osteopathic Association is participating in a national program to help practices prepare for this change.

Visit www.GetRxConnected.com/AOA to complete a quick e-prescribing readiness assessment and instantly get a free, personalized practice capability report. The report also contains a feature that will allow you to instantly send your vendor a request for connectivity.

Act now! There are only six months left until the new regulations go into affect and your vendor will need time to upgrade your system and familiarize your practice with any changes that are made.

Don’t have an EMR? Visit www.

GetRxConnected.com/AOA for guidance on how to evaluate and acquire e-prescribing technology.

Did You Know?

Recently, the Chicago Tribune reported two new abbreviations being used by police and medical professionals; they were DWT and IWT. It appears that more drivers were being ticketed for Driving While Texting (DWT) and even more people where being brought into emergency departments with injuries cause by falls down curbs and on sidewalks, as well as walking into people and things and were Injured While Texting (IWT). Go figure!

The PULSE October 2008

21

ACOEP/ThePulse_Location

4/9/07

11:30 AM

Page 1

Where you

practice medicine is almost as important as

why you do.

The best practice begins at EmCare.

You became an emergency physician because you wanted to help save lives. But you also need to have one. Which is why we work diligently to help physicians find a hospital that’s

the right fit professionally,

geographically and emotionally. Practice medicine where both your future and your family can thrive. EmCare – providing the power to improve healthcare and the lives of those who deliver it.

800-EmCare1 (800-362-2731) recruiting@emcare.com www.emcare.com

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23

r u o Y k ars Mar d n e l a C 2009

2010

Emergency Medicine: An Intense Review Westin Chicago River North Chicago, Illinois January 7 – 12, 2009

Emergency Medicine: An Intense Review Westin Chicago River North Chicago, Illinois January 6 – 11, 2010

Program Directors Workshop Hilton Marco Island Resort Marco Island, Florida February 1 – 3, 2009

Program Directors Workshop Hilton Marco Island Resort Marco Island, Florida January 31 – February 2, 2010

Spring Seminar Hyatt Grand Cypress Resort Orlando, Florida April 14 – 18, 2009

Spring Seminar Wigwam Golf Resort & Spa Litchfield Park, Arizona April 6 – 60, 2010

Scientific Assembly Westin Copley Plaza Boston, Massachusetts September 29 – October 3, 2009

Scientific Assembly Hilton Hotel – San Francisco San Francisco, California October 25 – 27, 2010

ACOEP NEWSLETTER

Presorted Standard U.S. Postage

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The PULSE October 2008