The Pulse October 2011

OCTOBER 2011 VOLUME XXXVII NO. 4

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

A Journey in Progress

I am ending my presidency with three very powerful words: Thank you and Please.

I thank each of the members of the ACOEP for having the trust and confidence in me to allow me to serve as your president for an extended threeyear term, 2008-2010. It was an exciting personal challenge filled with opportunity to advance the mission of the ACOEP. Please help support our incoming president, Gregory Christiansen, D.O. and ACOEP to continue the momentum that we have built to make this a premier organization.

When I reflect on what my presidency of ACOEP has meant to me, I have countless fond memories. As I stated in my initial publication, the letters ACOEP have meant much more than the title of Specialty College in the AOA. The A stands for Accomplishment – ACOEP has accomplished much over the past three years. Just to name a few: we moved into a beautiful new space in the AOA building, we conduct independent fall

Scientific Assemblies that have nationally acclaimed speakers and an attendance that grows each year, the Resident and Student Chapters have grown exponentially, we have strengthened our alliances with the other leading emergency medicine organizations, we have a stronger affiliation with the AOA and other specialty colleges, and we have a group of extremely talented ACOEP staff members. We have also implemented an online system that now enables all active dues paying ACOEP members to vote for the Board of Directors. We have tried to make your membership in ACOEP a valuable and rewarding experience for all members. We continue to encourage everyone to be an active participant in your College so that the momentum to becoming a stronger national leader in emergency medicine can continually be increased.

The C stands for Camaraderie – I have gained many new friends and colleagues throughout the country during my presidency. Aside from many laughs and good times, these friendships have enabled me to develop personally and professionally. We have further developed our relationships with the other emergency medicine physician organizations with our involvement in the emergency medicine workforce group and the Emergency Medicine Action Fund. We have also been invited to participate in some of the federal EMS initiatives. Although we are expanding our presence in the world of emergency medicine, I want everyone to

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realize that serving our members is our first priority. Your participation and input is what makes us such a vibrant organization.

The O is still Osteopathic – we have also further developed our relationship with the AOA. We have had a very close relationship with each of the AOA presidents and the AOA Board over the past three years. Our decision to relocate to our new office in the AOA building has proven to be a wise one. Our network of osteopathic physicians in emergency medicine continues to grow as our residencies expand. We are also very proud of all the efforts and accomplishments of our resident and student chapters. They are both continuing to grow and contributing much to ACOEP. They truly are showing us that we have a solid future. We are also very proud of the respect that our Executive Director Jan Wachtler has in the osteopathic community. Jan received the distinguished Bob E. Jones Award at the AOA House of Delegates in July. This is a well-deserved honor for Jan and we all congratulate her on receiving this award.

The E is for Education – Our CME programs have continually improved over the recent years. Our CME Committee and ACOEP staff have worked diligently to find great locations and have recruited some excellent lecturers. A testimonial to their success is the fact that we have had a significant increase in attendance at each of our CME offerings. Although it was a difficult one, our decision to conduct continued on page 16

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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, Communication 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.

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E m e r g e n c y Me d i c i n e

Q u a rt e r ly

Table of Contents Presidential Viewpoints . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Thomas A. Brabson, DO, MBA, FACOEP Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Drew Koch, DO, FACOEP-D Executive Director's Desk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Janice Wachtler, BA, CBA The On Deck Circle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Gregory M. Christiansen, D.O., M.Ed., FACOEP Pediatric Case Files . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Julie Johns, D.O., FACOEP Greg Henry, MD to Headline in Las Vegas . . . . . . . . . . . . . . . . 9 FOEM: Growing the Board . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Juan Acosta, D.O., MS, FACOEP In My Opinion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Wayne T. Jones, D.O., FACOEP Critical Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Jennifer Axelband, D.O. Medical Mission Trips of a Lifetime . . . . . . . . . . . . . . . . . . . . . 14 Janet E. Lapp, RN, PhD Ethics in Emergency Medicine . . . . . . . . . . . . . . . . . . . . . . . . . 16 Bernard Heilicser, D.O., MS, FACEP, FACOEP At First Look . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

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

Mid-Level Providers:

Are They a Blessing or a Curse in the Emergency Department?

As an emergency m e d i c i n e resident in the late 1980’s my exposure to mid-level providers (MLP) was limited to “out rotations” at tertiary care centers where nurse practitioners were hired on the surgical services to keep the surgical residents “in line” and clean up after them. It was not until my second year of practice when I moonlighted in an Emergency Department (ED) that had 24/7 physician assistants working next to the attending physicians that I understood the role and necessity of having MLPs in the ED. The three MLPs were seasoned providers whose job was to assist the physicians and to invariably make the docs look good. The docs and the MLPs worked side-by-side and you were aware of what they were doing and they were available to help you with procedures (suturing, incision and drainage, splinting, etc.); they saw most of the minor illnesses and when it was busy they would start working up sicker patients. The downside of working with MLP at that time was that the rest of the medical staff (specialists and sub-specialists) would not discuss a case with an MLP. This meant that the docs would have to call the on-call docs and present the cases for the MLPs. This symbiotic relationship between the docs and MLPs created a team of emergency medicine providers.

Like all great teams, there comes a time for change. This change occurred with the implementation of fast-track. Fast-track is where and how patients of lower acuity are seen. The fast-track does not have to be an actual separate physical space away from the main ED but could be designated space within it. The fast-track could also be the process in which lower acuity patients are

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separated from ED patients and seen by a non-EM physician or an MLP. The old system of the sickest patients being seen first (highest acuity) and the next patient to be seen was based upon time of arrival (length of time waiting) has changed with the fast-tracking of patients. The reasons for this change in how emergency patients are evaluated revolves around several things: the decrease in ED turnaround time (TAT), the increase in provider productivity (patients per hour), fewer complaints from ambulatory patients who are less ill, but complain the most about the long waits, and the decrease in cost when the fast-track is staffed by MLPs as opposed to physicians. This paradigm has decreased the length of stay, increased patients per hour, increased customer satisfaction and decreased personnel costs.

However, given this paradigm shift, the model of having mid-level providers care for lower acuity patients has created its own set of problems and concerns.

Mid-level providers are not created equal.

There are two groups: nurse practitioners (NP) and physician assistants (PA). They both do the same job but their training, focus, and licensing are different. NPs are independent practitioners and do not require physician oversight; however, many facilities require that NPs to practice under the physician license and many facilities and physician groups require co-signatures of the “supervising” physicians. Recent NP graduates that present to our facility for credentialing present a challenge. These individuals usually lack experience in procedures like suturing, splinting, and abscess management which requires direct observation and an additional layer of paperwork by the physician to ensure competence in these skills.

Physician Assistants are physician extenders. In my opinion, their training is more akin to physician training albeit not as intense and not as detailed as EM physician

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education and training. PAs work under a physician’s license and are not independent practitioners. When credentialing a new PA graduate they appear to have the requisite number of procedures necessary to credential them without contingencies.

When we hire an “experienced” MLP the expectation is that after a short orientation and some shadowing that the MLP providers are able to hit the bricks running. MLP providers are expected to diagnose and manage minor illnesses and trauma and perform simple procedures like wound management, splinting and abscess management. It is also expected that the MLP start the work-up of more complex patients when there are no “fast-track” patients and to assist the physicians.

The “experienced” MLP in EM varies from person to person.

Emergency departments throughout the country may have training or orientation programs for MLPs in emergency medicine but are not uniform. There are also emergency nurse practitioner programs and PA emergency medicine residency programs.

There are only a handful of emergency residency programs for NP and PA. In reality, there are not enough MLPs who have completed postdoctoral training in emergency medicine. In addition, there are not enough residency-trained and boardcertified EM physicians to cover every EM position/vacancy in the U.S. The proposed solutions have been to “grandfather” in physicians in EM through ABEM and AOBEM. These practice tracks have been closed for years and did not provide enough EM boarded physicians to fill the shortage.

Residencies in EM have not produced enough graduates to fill the number of EM vacancies. EM physicians are leaving the profession for alternative careers in administration, academics, urgent care, etc. continued on page 16

Executive Directors Desk Janice Wachtler, BA, CBA

Leadership and Me Throughout this last year I have addressed various leaders and their leadership styles and this last column of the year will summarize the series and how I feel about now being a

‘recognized’ leader.

In my experience, I’ve never had anyone respond to the question ‘where do you want to be in 5 years’ with a statement that he or she wants to be a leader. Likewise, few children will respond to the question, ‘what do you want to be when you grow up’ that they want to be a leader, scion in business, or an executive director of a medical society; that is unless you are my cousin who responded to that question as a kid, that she wanted to be a teacher so she could “write on the board and yell at the kids.”

Generally, people who ascend to the level of being a leader have not ever thought of being a leader in any chosen field.

Perhaps they have seen their parents as business owners and have been groomed to take over their parents’ business, perhaps they followed their mentors into business, medicine or law; but the majority of people don’t strive to be what they become in life.

I think that leadership roles are filled by a very select few who have the personality and hunger (a word I truly hate) to lead in a specific field. You do have those personalities who yearn to be a star, either on the stage or leading a company. These personalities hunger for recognition, they tout themselves above those they lead; they use words like “I did this or that” totally forgetting that the people under them have made many of their achievements possible. They seek that proverbial “15 minutes of fame” to be recognized above

their company; to be the ‘one’ and they will sacrifice all to get that recognition.

Another personality type is the one that was forced out of the crowd to take the lead. This is the person who is there when the rubber hits the road, the person who steps forward to take control of a situation when it seems like the whole world is falling apart around them. This type of person has always had leadership capabilities and may be happy to serve in a subservient position but doesn’t necessarily have the self-sacrificing nature that leaders usually have.

Then there is the person who backs into a situation, the person who may be the ideal person and then suddenly the idea takes off and boom, you’re in charge; you’re the go to guy; you’re the leader.

And finally, there is the person who leads as part of the team. They believe that the team is always stronger than an individual and it’s their job to ensure that whatever happens, the enterprise that they are in charge of continues on long after they leave. They don’t ‘own’ everything but they are part of everything in their company.

They use words like “we” and “our” and phrases like, ‘there’s no I in TEAM.” Whatever personality type a leader may be, there is always one singular component and that is the success quotient of what you put in is what you get out, so if you don’t commit, you may as well quit. They will sacrifice things for the companies that they lead and in the end they all hope that they will be recognized by someone as having made a mark.

I think most of the members who know me, know that I’m not a person that toots my own horn; sure I have opinions and often state them, but I’m more the person to stand in the background and be part of the team than the guy grabbing the spotlight. I, personally, like being in the background, the proverbial power behind the throne.

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On July 15th, I went from being the one standing behind my president to the one being recognized for my contributions to the success of two associations, ACOEP and the Society of Osteopathic Specialty Organizations, when I was presented the Bob E. Jones award by the AOA. This honor was a shared honor with Sam Jones, the Executive Director of the Texas Osteopathic Medical Association. I think I surprised everyone by not having much to say, but I was totally un-prepared, in fact I was sitting and talking when my name was announced.

I was recognized for the work I’ve done as part of Team ACOEP, as I couldn’t have achieved what I have without the support of many great physicians who have served on the Boards and Committee of the College, great members, and a wonderful staff. Without their support we would not have had the tremendous growth that we have experienced in the past 19 years. We have been fortunate to have an incredibly creative and intelligent set of physicians and staff members who have allowed us to create the CME programs, member benefits, and develop side organizations like the Student and Resident Chapters and FOEM, to bolster and better serve the emergency medicine community.

The other organization that I’ve been involved in during the last seven years has been the Society of Osteopathic Specialty Executives. Working with physicians and other executive directors who were involved in developing a specialty federation in the 1980, we developed an organization specifically designed to assist, support and mentor specialty executives to ensure that the osteopathic specialty organizations endure and grow long into the future.

Working with other executive directors we put together the foundation of this organization and with their help and continued on page 9

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

The Value of Change‌ The Lessons of Mentorship.

Everyone loves a sale. Businesses require the selling of goods and services to support the business. The marketplace responds by deciding whether or not to makes purchases, and thus reflecting the complex relationship between consumer spending and revenue generation. When business data indicates too much inventory or too little sales volume, businesses attempt to change the attitude of the consumer into a buying mood by marketing discounts.

The public temper is enticed to buy because they believe they are obtaining value. Everywhere you go some form of marketing is shouting to you 'now is the time to buy'. For the uninitiated it may be irresistible to keep the credit card from cashing in on the opportunity to buy at the "lowest prices of the year". Others will bite on the "30% off" pitch and who can resist the unbeatable offer to "buy one get one free"?

The relationship of consumer spending and the sale is the basis for the economics 101 concept called elastic economics.

Higher prices increase profits but may decrease consumer spending. Lower prices decrease profit margins but increase overall sales because the consumer can better afford the product. The market is expanded and more accessible to more consumers.

A full explanation on elasticity can be found on Wikipedia (http://en.wikipedia. org/wiki/Elasticity_(economics)), and the formula is as follows :

The concept seems so easy, so why rack your brain on how to use this formula?

Well, unfortunately understanding market forces and common sense are not always so obvious. The basis for changes in the marketplace, otherwise known as the drivers of purchasing, is not so simple.

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My headache prevention advice would be to forego attempting to understand healthcare economics, but these issues are here to stay and will surely get worse unless we tackle them head-on. Here are the health care economic facts our nation has to reconcile. We have over 17 % of the population without insurance which translates to over 51 million of Americans.

Over 9% of Americans are unemployed with real unemployment levels closer to 17%. Minority unemployment is 40% in some localities. Without a job, healthcare is out of reach to many Americans. To complicate the issue of cost and access, healthcare costs had been rising at 6.3% annually before the implementation of the Patient Protection and Affordable Care Act (PPACA). After passage of the legislation, costs are still rising at 5.7% annually and are expected to continue in that direction.

The U.S. spends more on healthcare per capita then the rest of the western world.

Social Security and Medicare expenditures are climbing to unsustainable rates. They will be over 50% of federal expenditure by year 2030 and over 100% by year 2070.

The Centers for Medicare and Medicaid Services (CMS) has a plan to fix some of the problems with the system. Some of their plans are not likely to succeed in my estimation while others are within our own power to improve upon. Two areas particularly important to ACOEP are CMS's initiative to realign physician education and develop institutionalized evidence based medicine and national standards of care. ACOEP, through its CME programs, is already working on these opportunities to improve the quality of emergency care.

In the healthcare industry the demand for services is strong. However, the costs are not following the typical elastic economic design because third parties are responsible for the payment of the service.

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The purchaser is both the patient who lacks responsibility for cost containment, to some extent the physician who wants to limit liability, and in some cases may have an incentive to continue to purchase services. Liability issues typically do not arise because of the test the doctor ordered, but rather is often in incurred because of a failure to order a test or procedure.

When is the last time a patient went to the operating room based on physical examination findings? Appendicitis is no longer a clinical diagnosis but rather requires a CT scan of the abdomen and pelvis before a surgeon will take a patient to the operating room.

This consumer concept may be the most fundamental driver of costs that has yet to be 'fixed'. The solution to fixing the problem would seem obvious but the same could be said about paying your fair share of taxes. Why isn't there a flat tax for all Americans to pay equally? There is one big factor keeping a flat tax from being initiated. What would we do with all the accountants whose livelihood is made by figuring out the complex tax code? So the concept of individual responsibility related to health expenditures is not universally applied and the government is seeking to take control of healthcare as the means to control that driver. The rationale is that the government already controls one in four American's healthcare expenditures now, so it is not a stretch to control more of the system. As an example, the Resource Based Relative Value Scale (RBRVS) which determines physician payment expects a 29.5% decrease in payment to physicians in 2012. By controlling the value of the service the government can control an aspect of the total cost.

As you can see the economy will be dominating nearly every decision for the next several years. This environment is the back drop for a challenging future for

emergency medicine. To move forward on these challenges we will need our membership to step forward, engage the issues and use their wisdom to guide our organization through these times that are only beginning to reveal the austerity ahead. Understanding economic drivers is an immense issue. It is important to emergency medicine because it enables us to continue our profession. To be successful within this economy we have to break it down to the things we can do better. Osteopathic Medicine has distinguished itself through this difficult era by sticking to its core values beyond what is listed in the Core Values statement.

Our membership has been mindful of our purpose which has placed the patient first in the debate on health reform. I hold this observation supremely important as it uniquely demonstrates the integrity of the osteopathic profession. I believe this is keeping in step with the values A.T. Still demonstrated so long ago when he confronted immense obstacles in his day in order to advance patient care. Our care has purpose and validity. These two seemingly simple principles are precisely what CMS is currently trying to tackle. It speaks to our value in the scheme of the system as a whole. Lastly, our college members offers compassion and empathy. These are the very same values that we need to instill in our future osteopaths.

Mark McCormack wrote an interesting book, Staying Street Smart in the Age of the Internet in which he reports on the behaviors people take as they utilize technologies in new, beneficial ways. His point of reference is not unlike what we have experienced in medicine. Technologies can be beneficial and improve outcomes.

The CT scan is a perfect example of how technology can improve care; it has been the single most revolutionary advancement in my practice career. But technologies can also be used inappropriately and add to problem—in this case, cost. The CT scan has been vilified as an over-used and expensive technology that may have some risk of harm, and emergency medicine is in the forefront of this growing debate.

Mr. McCormack makes an important observation, what hasn't changed is the way we do business and this has everything to

do with human behavior. If we understand human behavior, then we will understand how to foster change. If we want to effect change then we need to be grounded in sound values. Change is rooted in integrity. It has validity and reproducibility.

Change is best done when led by example which requires sound vision, compassion and empathy. In the budget battles that lie ahead we can look at the CT scan example as a template to improve our decision making in utilizing technology appropriately to improve efficiency and diagnostic accuracy. If you put a physician in a busy setting and place parameters with punitive consequences for an incorrect diagnostic decision subject to a review and malpractice, then a manager can expect over utilization to deal with those stressors.

If the physician is appropriately educated on the many facets of a potential diagnosis, then utilization and risk are better managed as well. This level of proficiency is now cost-driven and outcomes-driven to levels never seen become. Doing well will require a complex understanding of the melded relationship of cost and benefit to the outcome of patient care.

Mr. McCormack suggests we should not follow those that continue to repeat the same plan and expect a different result as this is a sign of poor leadership. Rather, we should look for other opportunities.

We can go back to a contemporary issue and see how mentoring in financial policy offers opportunity. Let’s take the instance of the falling stock market that I mentioned earlier. Panic has brought the market to amusement park levels of activity; it’s a roller coaster of a ride. The market has been up and down again and again but is mostly trending down. The roller coaster will have an end and right now as I put this article to pen, there is a 30% off sale going on. We typically don't look at a drop in the stock market in terms of elastic economics but that is essentially what is happening.

People are selling low and buying high and the stock market reflects the declining value. If you look objectively then you might have a different view. Human behavior will change the course of these events and this is where leadership emerges.

From the discontent of weak leadership, a new leader will surface to fill the void.

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Such leaders have vision and experience.

They can objectively view the market as having strong value at discounted prices.

If you change your perspective you might consider this as a great buying opportunity and ride the market. But how would you know that this is the time to buy and a gift horse is here to support your long term portfolio? Who is teaching the lessons on what works and what doesn't?

This brings me to a viable solution to help our organization assist the membership in navigating these changing times while staying true to its values.

It goes back to understanding human behavior and knowing what is of value.

We all want to learn and improve. We need to communicate how we can manage our desired outcomes and foster professional development. The most effect means to achieve this aspiration is through mentorship. This goes beyond the concept of networking which many trade organizations typically support. Mentoring is much more involved, interactive and rewarding. It stops the hemorrhaging these economic conditions create. Networking is analogous to platelets which clump together but are not very stable. Platelets break off with pressure and do not form strong bonds. The hemorrhage then continues. In contrast mentorship takes the network and stabilizes it like a fibrin clot. It can handle stress, repair and foster new growth. Mentorship is unlike any other opportunity to educate and develop sound decision making. It intrinsic worth is its ability to provide leadership and demonstrate integrity. It requires feedback and adjustment but the goal is attained. Mentor leaders can teach by example the values of good decision making. This ultimately translates into good patient care. A sound investment in our future requires our leaders to step up and use their knowledge and experience to compassionately teach and mentor the lessons of life. Only then will effective change occur.

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Pediatric Case Files Tracy Pawlows, MSN, FNP-C Julie Johns, DO, FACOEP, Associate Pediatric Medical Director

When Diaper Rash Goes to the OR Case:

A nine-month-old female is brought to the pediatric emergency department by her mother with a diaper rash. The baby is afebrile with normal vital signs and is triaged to the fast track area.

Further history reveals an ongoing diaper rash for one month. The mother has tried changing brand of diapers, wipes and laundry detergent without any improvement. The child has not been seen by a primary care physician in several months and immunizations are delayed.

The child is happy, playful, smiling, non-toxic appearing, with a noted left eye lid lag and intermittent strabismus. Pupils are equal, round and reactive to light. The baby tracks objects well, but the left eye is exotropic and only follows intermittently.

Fundoscopic exam reveals a normal red reflex in the right eye, and the left eye has no red reflex detected.

Heart, lung, abdominal and extremity exams are all normal. The perineum is angry red, excoriated with satellite lesions up the groin consistent with candidal diaper dermatitis.

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Further questioning regarding the strabismus reveals that it has been present since birth and no providers have been concerned about it. The child has not seen an ophthalmologist.

To further evaluate this strabismus, a CT scan was obtained which revealed a 2 cm densely calcified mass in the posterior aspect of the left globe, suspicious for retinoblastoma.

The baby was transferred to a pediatric tertiary care hospital and was given nystatin for her diaper dermatitis.

Hospital Course

The baby had surgery, enucleation, which confirmed the diagnosis of retinoblastoma. Her disease had not progressed beyond the globe and her discharge plan included following up with Pediatric Neuro-oncologist.

Discussion

Strabismus (also called squint, crosseyes, lazy eye, or wandering eye) is an intermittent or constant misalignment of an eye so that its line of vision is not pointed at the same object as the other eye. It can be seen in up to 5% of children, affecting boys

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and girls equally. If untreated, strabismus can cause amblyopia (a decrease in vision) and permanent loss of vision. Strabismus is treated with correction of any refractive error, an eye patch to equalize vision and, in some cases, surgery (1).

Retinoblastoma is a relatively uncommon tumor of childhood arising from the retina. It accounts for approximately 3% of cancers occurring in children under age 15. The annual incidence in the US is approximately 10-14 per 1 million children age 0-4 years. Ninety-five percent of cases are diagnosed before age 5 with two thirds being diagnosed before age 2. Older age is usually associated with more advanced disease and poorer prognosis. (3)

One or both eyes may be affected.

Other symptoms can include: crossed eyes, double vision, eyes that do not align, eye pain and redness, poor vision, differing iris colors in each eye. Retinoblastoma is caused by a mutation in a gene controlling cell division, causing cells to grow out of control and become cancerous. Unilateral retinoblastoma in children younger than 1 year should raise concern for the hereditary disease, whereas older children with a unilateral tumor are more likely to have the nonhereditary form of the disease. (2,4)

In a little over half of the cases, this mutation develops in a child whose family has never had eye cancer. Other times the mutation is present in several family members. If the mutation runs in the family, there is a 50% chance that an affected person's children will also have the mutation. They will therefore have a high risk of developing retinoblastoma themselves. Patients with hereditary retinoblastoma have a markedly increased frequency of secondary malignant neoplasms such as osteosarcoma, soft tissue sarcomas or melanoma. It is also noted that patients with hereditary retinoblastoma have an increased risk of developing

epithelial cancers in late adulthood such as lung and bladder.(2,5,6).

Treatment options depend upon the size and location of the tumor. Small tumors may be treated by laser surgery or cryotherapy. Radiation is used for both local tumor and for larger tumors.

Chemotherapy may be needed if the tumor has spread beyond the eye. The eye may need to be enucleated if the tumor does not respond to other treatments. In some cases, it may be the first treatment. (1).

If the cancer has not spread beyond the eye, almost all patients can be cured. A cure, however, may require aggressive treatment and even removal of the eye in order to be successful. If the cancer has spread beyond the eye, the likelihood of a cure is lower and depends on how the tumor has spread. (1).

Conclusion:

This case clearly illustrates the importance of a good physical exam, regardless of the chief complaint.

Emergency Departments are often the safety net for many of our patients who may or may not have adequate access to primary care. In this case, metastatic disease was prevented by an astute physical examination.

References 1. National Institutes of Health Web Page.

2011. http://www.nih.gov 2. National Institues of Health Web Page.

Genetics Home Reference. http://ghr.nlm. nih.gov/condition/retinoblastoma July 11, 2011 3. de Aguirre Neto JC, Antoneli CB, Ribeiro KB, et al.: Retinoblastoma in

children older than 5 years of age. Pediatr Blood Cancer 48 (3): 292-5, 2007 4. Murphree L, Singh A: Heritable retinoblastoma: the RBI cancer predisposition syndrome. In: Singh A, Damato B: Clinical Ophthalmic Oncology.

Philadelphia, Pa: Saunders Elsevier, 2007, pp 428-33.

5. Gallie BL, Dunn JM, Chan HS, et al.: The genetics of retinoblastoma. Relevance to the patient. Pediatr Clin North Am 38 (2): 299-315, 1991 6. Fletcher O, Easton D, Anderson K, et al.: Lifetime risks of common cancers among retinoblastoma survivors. J Natl Cancer Inst 96 (5): 357-63, 2004

Greg Henry, MD to Headline in Las Vegas In Las Vegas, amid the lights and flash, it can be difficult to rise above the din. This is why ACOEP is so pleased to welcome Greg Henry, MD, FACEP, as the keynote speaker for the 2011 Scientific Assembly. Dr. Henry’s presentation, Call It Sabbatical, Light Duty or Whatever: Just Don’t Call It “RETIREMENT” will kick off a week

of incredible speakers, topics and competitions.

It is important to take genuine care for your career as it progresses, viewing its development as a marathon, not a sprint.

Forward planning is a vital tool for all physicians and this keynote presentation provides essential information for physicians at every level of their practice.

Dr. Henry will highlight career strategies for those immediately out of their residency, as well as adjustments experienced physicians can make to their existing positions. Dr. Henry pulls no punches in his honest, yet humorous approach to managing careers in

emergency medicine.

Dr. Henry is an expert in risk management and neurological diseases, about which he has written numerous books, articles and text book chapters. He is a renowned speaker and winner of ACEP's Outstanding Speaker of the Year Award. He is also a past president of ACEP, where he served on the Board of Directors for eight years. Dr. Henry is the former Chief of Emergency Medicine at Oakwood Hospital-Beyer Center and is currently a professor at the University of Michigan, School of Medicine in Ann Arbor.

Executive Directors Desk, continued from page 5

-11) after it was chartered by the AOA. Indeed I’ve been very fortunate to be in both these roles and surrounded with wonderful role models and peers. I would like to thank not only my fellow executive directors, but John B. Crosby, JD for honoring me with this award; Diana Ewert, CAE, for her support and assistance with SOSE; Linda Mascheri, Mike Malle and Karen Nichols, D.O., FACOI for their friendship and support over the years; the AOA Board of Trustees; Tom Brabson, D.O., for his counsel, support, and

patience over the past three years and many years before; Joe Kuchinski, D.O. for keeping me on my toes and my eversupportive Board of Directors who have always been there to do the work, come up with ideas and put in the time it takes to make it work; my ever present, hardworking staff, who are the heart and soul of the organization, the staff of the AOA, and of course, you, the members who are the best physicians in the world. Thanks to all of you, I am deeply honored and humbled to be part of this team.

guidance of my fellow Board Members, Peter Schmelzer, CAE (ACOFP), Jeffrey LeBoeuf, CAE (AOCPM); Brian Donadio (ACOI), Nina Vidmer (AOAAM), and Angela Wilkins (ACOPath) we developed an organization that will serve the specialty executives for many years to come. I was fortunate enough to be the President during the founding years of 2004-07 and to serve two terms as the President (2007

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

Growing the Board Over the past year, the Foundation has made momentous progress. We have improved operations by cultivating our Board, advanced research by refining our competition entries, and we have honored our donors by hosting the 2011 Inaugural Honors Dinner and Awards Ceremony. We are working very hard to be the Foundation that osteopathic emergency physicians need and deserve, and now we turn to you to join our mission.

FOEM is currently recruiting new Board members that are dedicated to our purpose of providing funds for research and education for osteopathic emergency medicine. We are seeking physicians who want to grow into leadership positions in the field that the ability, time, drive and to

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truly bring us to the next level.

Currently, the FOEM Board consists of nine people – five osteopathic emergency physicians, and four non-physicians. We want to increase this number to fifteen by the end of the year 2013. However, a seat on the Board means giving ample time and talent to the cause. We would love to see FOEM continue on its current path of success so that eventually osteopathic emergency physicians will have one place to turn for all their research needs.

To become one of the Foundation’s next leaders, you must be willing to donate $300 or more annually, attend two meetings per year, participate in the majority of the Board’s monthly conference calls, and contribute time to participate in the various committees, activities and responsibilities of the Foundation. This participation can count as scholarly activity for a committed core faculty member and will count toward fellowship credit. As the Foundation grows

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and progresses, we will need your dedication to the cause to cross the chasm between where we are now and where we want to be Can you help us reach our goals?

If you are interested or have questions about other volunteer opportunities, please do not hesitate to contact me. As members of the American College of Osteopathic Emergency Physicians, it is your duty to advance research in your field. This is your chance to really make a difference and to stand behind something you believe in. I hope you will take this chance to mature with us at the Foundation for Osteopathic Emergency Medicine.

With warmest regards, Juan Acosta, D.O., MS, FACOEP President The Foundation for Osteopathic Emergency Medicine

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

How is Triage Similar to MAST Trousers?

Usually when I write an “In My Opinion” article, my opinion is woven into the article. Well, this time, here it is: I hate triage. Not the people that triage, and not to be disrespectful of nursing, but I hate triage. At one time, I loved triage, but not anymore. Let me explain.

The theory behind triage goes something like this. Triage is a process that determines the priority in which patients are treated based their condition and the resources available. Many of us remember the movie and TV show M*A*S*H. Some injured soldiers would be sent straight to surgery while others would wait. It made perfect sense.

When I started in EMS, we triaged everyone. In fact, we placed them into catagories and told hospitals what class of patient they were receiving. Class I was the really sick patient, Class II were kind of sick, Class III were not really sick and Class IV were able to walk to the ED but we gave them a ride anyway. There was a Class V but usually we called the coroner for those.

We thought it was a valuable service that the hospitals were receiving. Our notification gave them time to prepare for our patient, select the appropriate room and mentally stage their response. Sometimes our patient would be sent to their triage for triaging. I never felt insulted since their triage was probably better than ours.

By the time I began my residency training, triage felt completely normal. I

may not have been busy when the patient walked in, but by keeping the patient in the triage room (yes, it has now become a location) the triage nurse gave me valuable information neatly scribbled on the record.

Just because a patient complained of having a fever doesn’t mean they really have one. Triage would dutifully send them back to the waiting room until we were ready to see another patient. Back then we knew that if you were sick enough to be seen, you were sick enough to wait. If a patient left the waiting room, then they probably were not that sick (probably a Class III).

When I became an attending this was the norm; I never considered any other alternative to patient flow. I didn’t push the nurse and they didn’t push me. It also gave registration time to register the patient and ask for any copays. We had an understanding.

Triage matured into a “science” of nursing. It started as a three-tier category and evolved to the Canadian five-tier, then the five-tier two-step. Now it has been changed to the “Emergency Severity Index (ESI)” with five levels. Nurses are now required to take courses and become certified in ESI application. Triage is no longer an evaluation, and more than a place, it is hallowed ground.

Triage is no longer about sorting patients and placing them in order of illness, it is all about documentation and workload. The ESI level tells a nurse how

much nursing time is needed. As a physician, do you limit yourself to one ESI level, one patient, and two ESI level two patients? No, you see the next patient. It is a useless tool for physicians and patients.

It is a nursing-centric tool. Triage is no longer about hospital resources and seeing the sickest patients but about nursing workload.

The idea of triage is almost counterintuitive. It is the intentional delaying patient care to collect information that is already a part of patient care. Patients are not coming to the Emergency Department to receive a quality triage by a well-educated nurse; they are there to see you, the Emergency Medicine physician.

Now try to change patient flow using ESI triage. It is almost impossible. Nurses do not want to give it up, electronic documentation systems require it, and physicians expect it. In modern emergency medicine, traditional triage is almost useless. In lean quality terms, triage creates waste in an already over burdened system.

New systems of patient flow including, direct-to-room, bedside registration, team triage (where the physician and nurse see the patient together) and pivot triage are the future of patient migration. Triage is an interaction that must be patient-centric, not nurse or physician-centric. Triage is not a place and it should not be used to delay care. Triage needs to go the way of MAST trousers and rotating tourniquets.

Members in the News!

AOA Appointments: ACOEP would like to congratulate all of our members for their appointment to Bureaus and Boards of the American Osteopathic Association. ACOEP will be represented by the following physician members: John W. Becher, D.O., FACOEP-D (PA); Darrell A. Beehler, D.O., FACOEP-D (MN); Peter A. Bell, D.O., MBA, FACOEP-D (OH); William Bograkos, D.O., FACOEP(MD); Thomas A. Brabson, D.O., MBA, FACOEP-D (PA); Joseph J. Calabro, D.O., FACOEP(NJ); John Casey, D.O., MA ( ); Timothy Cheslock, D.O.(PA); John Dery, D.O. (MI); Robert J. George, D.O., FACOEP (FL); Joseph J. Kuchinski, D.O., FACOEP-D (NJ); Paul La Casse, D.O., FACOEP (MI); Gary Moorman, D.O., FACOEP-D (OH); Christopher Perry ( ); J.D. Polk, D.O., FACOEP(TX); Donald Sefcik, D.O., MBA, FACOEP (MI); Lindsay Tijattas-Saleski, D.O. (PA); Sonbol Shahid-Salles, D.O., MPH (MI); and Gary L. Willyerd, D.O., FACOEP-D (MI). Congratulations also to our Honorary Members: Peter Ajluni, D.O. and Eugene A. Oliveri, D.O., on their appointments.

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Critical Care Jennifer Axelband, D.O.

Is it Time for Osteopathic Recognition?

As we near the 40th year as an osteopathic specialty, perhaps it’s time to expand our horizons to embrace one additional areas of emergency medicine that we all do, but is often forgotten about – critical care. Critical care should be recognized as CAQ (Certificate of Added Qualifications) like toxicology, sports medicine, emergency medical services and, most recently, pediatrics for osteopathic emergency physicians with appropriate training in these subspecialty fields.

Currently, the medical community is embracing critical care and it is crucial for the osteopathic world, with our focus on treating the whole patient and respect for the larger picture, to stay at the forefront of developing a fellowship.

One year.

Your own schedule.

Critical care is a recognized fellowship and Certificate of Added Qualifications by the AOA through its certifying boards in anesthesiology, internal medicine and surgical fields, each offering some fellowship training pathways for this credentialing.

Emergency medicine has not entered into this arena at this time.

In order to best serve the membership of ACOEP, which is now over 2,000, we must follow certain designated methods to ascertain interest in pursuing a CAQ in critical care from AOBEM and AOA. This method includes several steps: • Assessing interest of emergency medicine physicians who are currently certified in emergency medicine by AOA/AOBEM • Locating a minimum of 25 physicians

(MD or DO) who would be declared ‘experts’ in the field of Emergency Medicine Critical Care, and would be willing to sit out the first round of testing to develop the examinations

In order to gather this information, as well as gauge the level of interest, we will be collecting contact information and AOA numbers at the upcoming Scientific Assembly. Materials will be available at the ACOEP booth, or contact Jan Wachtler, ACOEP Executive Director, for further information

Once these initial steps are taken, if you are interested in working with the Committee on GME in developing a fellowship in emergency medicine critical care, please let ACOEP know.

Visit us at booth # 1

2011 ACOEP

SCIENTIFIC ASSEMBLY

Go.

When you join Emergency Medicine Physicians, you make your own schedule your entire first year. After putting in crazy hours to get through the past seven years, you’ve earned it. At EMP, we’re owned and managed by emergency medicine residency trained physicians just like you. We understand that when you make your own schedule, you not only get time to enjoy the things you love, you get the time you need to adjust to your career. So what will you do your first year? Relax? Vacation? Thrive? The choice is yours. Go.

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Opportunities from New York to Hawaii.

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Medical Mission Trips of a Lifetime Janet E Lapp, RN, PhD “I didn’t know what to expect. We flew down Friday in a small plane, stayed in a superbly interesting Mexican hotel, had a fabulous dinner with amazing people and great food, did about seven surgeries on Saturday and flew back home Sunday morning. Such a short time, but it was a trip of a lifetime.

I will never forget it.” Jim Yahr, MD

Each Friday, October through June, scores of dentists, doctors, nurses, and translators pour themselves into small aircraft at airports throughout California and Arizona for their flights to El Fuerte in the State of Sinaloa, Mexico, a beautiful, safe and secure part of Mexico. There, they will spend their precious off-duty weekend hours improving the conditions of the poor and under-served in this historic town.

They will travel deep into the heart of the Copper Canyon to treat the Tarahumara Indians, the amazing “ultra-marathoners”.

Since 1934, the Flying Doctors of Mercy (Liga Internaçional) have been creating miracles deep in the heart of Mexico, where only the employed can afford medical and dental care. For the rest of the people, there is no care at all. Our volunteer physicians, audiologists, dentists and

others, work with modern donated equipment and tools, and know the satisfaction of literally changing the lives of those they treat.

Why do volunteers do this? San Francisco dentist Steve Cavaganolo, DDS says, “Look, it just makes sense to do this.

We get caught up with all our issues here and forget what this business is all about. It is brought home immediately once I get to the clinic.”

Alex Myers, D.O. has been working with Liga since her med student days.

She says, “It’s an unbeatable experience.

Beautiful flights, grateful patients, and a tremendous feeling that you’re doing some good doing what you love to do.”

Like many other volunteers, pilot Gary Burdick has given his teenage son the trip of a lifetime to experience the third world first-hand. Liga has an active Liga Youth program, whereby US-based teenagers gain valuable, supervised volunteer experience, both for their resumes and the rest of their lives, as well as contributing to a worthy cause. What a gift of perspective to a young person!

Burbank-based Len Carlson, DDS, an enthusiastic supporter, finds that the expe-

rience provides a perspective that is impossible to get at his practice in California. Rex Baumgartner, DDS from Newhall, CA has been active in updating our equipment and tools. Baumgartner says, “We often take things for granted back home. To feel the gratitude of the people here, who otherwise would have no care at all, is huge. I think every student should make at least one trip to our clinics.”

“Do not wait for leaders; do it alone, person to person”. Mother Teresa

Physicians, pilots, dentist, nurses, interpreters and others who spend just one life-changing weekend with us find that they expand their skills, confront challenges they would never encounter at home, practice their Spanish, (but no Spanish needed!) and return home with just a little bit more gratitude in their hearts.

Come and join us! To find out more, visit www.ligainternational.org, email Dr. Janet Lapp at drjanet@lapp.com or call Liga’s Secretary Pat Savage at (714) 2579952.

Members in the News!

Congratulations!

Many congratulations to Colonial, MS, FS, US (Ret) William L. Bograkos, D.O., FACOEP on the awarding of a Masters Degree in National Security and Strategic Studies from the United States Naval War College on June 10, 2011 and a Non-Tenured Affiliate Clinical Faculty Track position at the University of New England, College of Osteopathic Medicine, Biddeford, Maine in August.

Our heartfelt congratulations are in order for Charles A. (Chip) Finch, D.O., FACOEP on being named the

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Alumni of the Year at the Des Moines University College of Osteopathic Medicine. Dr. Finch who is a partner of the Scottsdale Emergency Associates also serves on the board of Stones of Hope, a nonprofit organization dedicated to providing comprehensive to support-based programs to grieving children, families, adults and communities. He is also the founder and director of Camp Paz, a program in which grieving adults and children come together. Dr. Finch is a past president of the DMU-COM Alumni Association Board of Directors and is the chair of the integrative medicine department at MWU-AZCOM.

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New WCU Medical Students Enjoy Welcome Reception

Medical student Robert Greer of Natchez (left); Dr. Jim Turner, Associate Dean For Clinical Sciences and Associate Professor of Medicine, and student Matthew Dishuck (right) of Tuscaloosa, pose for a picture at the reception held to welcome new students to William Carey University, College of Osteopathic Medicine

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

What Would You Do? The following case was presented by an EMS provider agency: A patient was being transported to the hospital by a municipal fire department.

This patient had non-life threatening psychiatric issues, and was well-known to EMS. The ambulance crew observed a vehicle driving erratically, and decided to deviate from their transport route and follow the vehicle, while attempting to

Presidential Viewpoints, continued from page 1 our fall Scientific Assembly separate from the AOA has proven to be very beneficial for the ACOEP. We have been able to meet in some great places that provided a comfortable learning environment, that are also conducive to relaxing and socializing with family and friends. We plan to continue to meet conjointly with the AOA during the unity conventions.

The P is for Pride and Perseverance – Our College was formed by a group of visionary osteopathic emergency physicians. We have grown and matured with much perseverance despite some significant challenges. ACOEP staff has

Editorial, continued from page 4 Also, EM physicians are getting older and leaving the workforce for retirement. This leaves MLPs to fill the void of the vacant emergency medicine positions in the U.S. Whether we are for or against MLPs providing emergency care in our emergency departments, emergency departments throughout the country are being staffed with these professionals.

Are these emergency departments using MLPs as an alternative to EM residency trained and board certified EM physicians? The

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notify the appropriate law enforcement agency. Their journey took them to a police roadblock where the vehicle being pursued was stopped. They then continued to deliver their patient to the intended emergency department without incident.

Did this action save the civilian population from potential harm, or was this inappropriate?

You are the medical director for this fire department. What would you do?

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

worked tirelessly to help us expand our offerings and services for our members.

Our committees have also worked extremely hard to help us to further evolve as an organization. I am very proud of the way that all of our members and staff have worked together to strengthen our position in the ‘houses’ of emergency medicine and osteopathic medicine. Everyone should feel very proud to be affiliated with ACOEP. At the beginning of my term, some of my presidential goals evolved around ACOEP’s mission statement. The American College of Osteopathic Emergency Physicians advocates quality emergency medical care and promotes the advancement of the osteopathic profession. I want to thank all of ACOEP members and staff that have

enabled me to meet those goals. Without all of the support from all of you, we would never have been able to achieve as much as we have over the past three years. I look forward to your continued support as I transition into my role as past-president.

In closing, I want to again thank all of you for allowing me to be the President of ACOEP for the past three years. It has been a truly exciting, fun and humbling experience. I sincerely hope that my personal contributions to ACOEP have been beneficial for all of our members. I anticipate working very closely with our incoming president, Dr. Christiansen and the ACOEP Board of Directors. It’s a great feeling to be a player on this winning team!

answer appears to be yes. Why; because it is cheaper to staff ED with more readily available MLPs. MLPs should not be replacing EM residency-trained and board-certified physicians but should supplement the EM physicians. The biggest challenges now facing EDs nationwide is the lack of uniform training standards for emergency medicine training of these professionals and their overall lack of experience in emergency medicine. Additionally, many “experienced” MLPs do not have the necessary emergency medicine experience

and training to function in the emergency department and require intense orientation and oversight until they can function in the emergency department.

After 20 years of working with MLPs, I am still a proponent of MLPs working in the ED. The challenge is hiring and retaining the right MLP for the job. Not all MLP are created equal and each brings a different skill set to the ED. It is our job to orient, train and supervise the MLP. But how?

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At First Look Patient Presentation: A 12 y/o African American male presents to the emergency department complaining of right 5th digit pain after falling on his right hand while playing basketball. Patient has no significant previous medical or surgical history. On exam, there is a visible deformity of the right 5th digit which is radially displaced. Exam is positive for swelling and tenderness at the proximal phalanx. The digit is neurovascularly intact.

Question: Can you describe the image shown and do you know what is going on with the patient?

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At First Look Answer: The image is a PA view of the right hand. There is a Salter-Harris II fracture of the fifth proximal phalanx with radial and volar displacement. In addition, the distal fracture fragment shows marked ulnar and dorsal angulation. While in the emergency department, the dislocation was reduced following a digital nerve block and the hand was splinted. The patient followed up the next day with a hand specialist who informed the patient that it was a non-operative fracture. The patient was told to continue using the splint for stability.

A Salter-Harris II fracture is the most common of the Salter-Harris fractures. The fracture involves the physis and metaphysis, but the epiphysis is not affected. Luckily, this injury rarely has long-term effects on growth.

This case was submitted by Mary Tran OMS IV, who attends the Lake Erie College of Osteopathic Medicine

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