The Pulse (October 2012)

OCTOBER 2012 VOLUME XXXVII NO. 4

Presidential Viewpoints Gregory M. Christiansen, D.O., M.Ed., FACOEP

The Season of Change

This is the season of change. Summer’s heat is finally acquiescing to the blowing winds of the fall season. It reminiscently captures the excitement of a new, but familiar experience like the start of a new school year or training with the team for a run at the title. It is a great time of year. Cool mornings and warm days bring dazzling fall colors to the landscape. It’s a time for enjoying the aromatic flavor of pumpkin pancakes and turning crisp apples into irresistible pies. Using the metaphor of the harvest season, this is the time when we reap the fruits of our labor. After almost a year’s worth of work, the changing season is the time when we gear up for the impending transition.

Against the backdrop of the cacophony of migrating birds echoing in the distance, the coming change portends the need to listen up and prepare for difficult times ahead.

2013 will soon be upon us and with it will be significant change.

If you are a seasoned veteran this cycle may be predictable. If you haven’t

experienced the possibilities, then the piqued season may be deceiving. This serene season is a great time to reflect and review. With so much uncertainty, the wisdom of an experienced mentor can provide solace and alleviate anxiety.

Mentors can use their wisdom during this time to guide their mentees on the winds of change. Their experience can offer sound advice because despite the beauty, the vibrant colors and apparent bounty of the season, it could all change.

The ACOEP is mindful of its presence and is thankful for all of its members who have made the ACOEP a success.

It is the team approach which defines our organization and is an acronym for ‘Together Everyone Accomplishes More’.

While we embrace these values we also need to consider repositioning ourselves in this uncertain environment to meet our strategic planning goals. Standing on its principle, the ACOEP remains committed to excellence in emergency care and serves as the cornerstone for osteopathic emergency physicians.

What changes can be expected in 2013?

We can count on at least two actions to occur which will affect our membership.

On the political front there will be the election affecting the power structure of the country and the future of health care policy. On the fiscal side, your financial outlook must consider the fact that your taxes will not go down. In case you were not aware, 2013 will usher in new rules which will result in higher income tax, The PULSE OCTOBER 2012

payroll tax and estate tax rates. Tax credits will be scaled down and the tax code will be expanded as a result the Affordable Care Act. Yes, there are 5 major new taxes under the Affordable Care Act including the surtax on investment income and increased Medicare payroll taxes. The other major revenue source for the government will come from fines levied against those deemed as perpetrators of fraud and abuse.

The expanded powers of the Recovery Audit Contractors (RAC) have already produced a windfall for the effort. All in all, the average American will pay… not hundreds… but thousands of dollars more to the government in 2013 than in 2012.

There is little if any chance of stopping these taxes before they go into effect based on the current political party differences.

As a result of the stalemate, the economic outlook is not optimistic. Wall Street has a persistent 1.2 billion share decrease in trading volume reflecting the 30% decline in household wealth. There is stubbornly high unemployment with the threat of a second credit bureau downgrade if the national debt is not curtailed. To top it off the Congressional Budget Office (CBO) recently predicted a worsening economy.

Since political power directly affects the health care delivery system, what can we do in this political season of change? First of all, we need to recognize how significant this election will be to our profession.

Simply, we need to prepare for this political continued on page 6

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E R E H T T E G O T S L O O T IGHT R E H T H IT W U O Y IT F T U EMA WILL O

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Editorial Committee: Drew A. Koch, DO, FACOEP-D, Chair Wayne Jones, DO, FACOEP, Vice Chair Julia Alpin, DO David Bohorquez, DO Gregory M. Christiansen, DO, M.Ed., FACOEP Joseph Dougherty, DO, FACOEP Anthony Jennings, DO, FACOEP William Kokx, DO, FACOEP Annette Mann, DO, FACOEP Mark A. Mitchell, DO, FACOEP Erin Sernoffsky Brian Thommen 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.

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The Pulse Editorial Staff: Drew A. Koch, DO, FACOEP-D, Editor Wayne Jones, DO, FACOEP, Assist. Editor Gregory M. Christiansen, DO, M.Ed., FACOEP Mark A. Mitchell, DO, FACOEP Erin Sernoffsky, Communication Manager Janice Wachtler, Executive Director

O S T E O PAT H I C

EMERGENCY MEDICINE

Q U A RT E R LY

Table of Contents

Presidential Viewpoints . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Gregory M. Christiansen, D.O., M.Ed., FACOEP The Editors's Desk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Drew A. Koch, DO, FACEOP-D Executive Director's Desk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Janice Wachtler, BA, CBA The Next Generation of Emergency Physicians . . . . . . . . . . . . 10 Mark A. Mitchell, D.O., FACOEP The Policy of Healthcare Reform . . . . . . . . . . . . . . . . . . . . . . . 11 Frederick Davis, D.O. What Would You Do? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

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.

Bernard Heilicser, D.O., MS, FACEP, FACOEP

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Simplex Encephalitis in the Emergency Setting . . . . . . . . . . . . 21

FOEM: Foundation Focus . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 FOEM: 2012 Donors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 ACOEP Residency Schedule . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Jessica Smolar, MS III ACOEP Resident Chapter Governing Board Elections . . . . . . 26 Emerge Spring Seminar Program Agenda . . . . . . . . . . . . . . . . 28 The Pulse Spotlight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

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 2012 – All rights reserved.

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

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The Editors's Desk Drew A. Koch, DO, FACEOP-D

The Reason for Emergency Department Evaluation Do you ever scroll through the ED tracker and check out the menu of chief complaints and wonder what the special is today?

Different days bring different specials: chest pain, abdominal pain, weakness, dizziness, headaches, back pain, extremity pain, cough, shortness of breath, mental health evaluation, ETOH, medication refill, neurological deficit, fever, trauma, nausea and vomiting, nausea vomiting and diarrhea, altered mental status, cold symptoms, lacerations and difficulty urinating. The menu is not inclusive, but each day seems to have a common theme: chest pain, abdominal pain, weakness, etc. The complexity of the emergency medicine case varies from day to day and from patient to patient. There are days that the disposition of the patient is straight-forward: discharge, admission or transfer. Other days the disposition of the patient is not readily apparent and it is extremely difficult to admit, discharge or transfer the patient. The patients are not sick enough for admission, not well enough to go home, or the patient or the family does not want to take the patient home.

Every patient encounter after the brief introduction starts with a theme of “how may we help you, what brings you to the ED or why are you here today?” The above symptoms, with the exception of weakness and dizziness, present a road map of why the patient is in the emergency department and provides us with a starting point in gathering a history; performing a physical exam; ordering and interpreting laboratory and radiological studies; treatment; assessment and disposition.

The prudent layperson standard provides a definition for who needs to visit an emergency department. It defines an emergency as a condition that a prudent layperson who possesses an

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average knowledge of health and medicine might anticipate serious impairment to his or her health in an emergency situation.

(McGraw-Hill Concise Dictionary of Modern Medicine. © 2002 by The McGraw-Hill Companies, Inc.).

This answers the question why are you here?

I thought I was having a heart attack.

This provides the EM physician with the starting point of the emergency department encounter.

The patient who states “I don’t feel well,” or “I’m tired” presents a serious challenge and frustration if these terms cannot be defined. In others words, if the patient or family cannot quantify the meaning of “I don’t feel well,” or “I’m tired” and you cannot elicit what these symptoms mean, it provides a diagnostic nightmare for the emergency medicine physician. Where do you start your work up and what are what are you attempting to accomplish? Are you looking for the etiology of their symptoms, criteria for admission, or the start of a work up that can be completed as an outpatient with their primary care physician? Are these symptoms acute or chronic? If chronic, what makes the patient different today than any other day? Is the patient or family looking for respite from these symptoms, if so what type of relief can you offer-admission, social service consult, referral back to their PCP, or nursing home placement or symptomatic relief.

The chronic pain patient who presents to the emergency department has their own diagnostic and treatment challenges that were discussed in previous Pulse articles.

Are these patients truly having an acute exacerbation of their chronic pain, are they scamming the emergency medicine providers for controlled substances, or are they there for some other reason?

EMTALA requires that all patients who present to the emergency department have a medical screening exam. This is difficult to perform when the emergency medicine provider is unsure why the patient is in the emergency department. When further questioned, the answer is often illusive. I am here because someone else brought me in; there were issues in the community, school,

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or family; someone called an ambulance or the police. The other individuals who either brought the patient to the emergency department or called 911 may provide you with a reason for the emergency visit- the patient threatened to kill himself or others, was not him or herself; was not feeling well; used or abused alcohol or other drugs or just wanted the patient checked out. The patient may state I had nowhere to go so I came to the emergency department. These patients may be looking for a meal and a place to stay, or they may need the services of drug and alcohol and mental health services.

The final category of patients who present to the emergency department through the courtesy of our law enforcement agencies that present a diagnostic challenge are the patients who are transported to the emergency department for a mental health evaluation; and the impaired patients who need to sober up. The former category patients can be intoxicated and require sobering up or hospital admission before the mental health evaluation can occur.

The latter category of patients mostly need time to sober but could be a disposition problem because they have nowhere to go.

The question of why patients present to the emergency department is complex and not always easy to answer. There are non-medical, non-traumatic and nonpsychiatric reasons that patients present to the emergency department. The decision making of admission, discharge or transfer is not readily apparent with these emergency department visits. As more and more people access the emergency departments it is incumbent that there are resources available to enable us to deal with these patients. Emergency departments should at minimum have case managers, social workers and mental health evaluators in the emergency department 24/7. We should have the ability to refer patients directly to community resources like home health nursing, physical therapy, direct admission to nursing home and rehab hospitals, and provide patients to appropriate drug and alcohol and mental health services.

Executive Director's Desk Janice Wachtler, BA, CBA

Help Wanted As we prepare for our new fiscal year and work on things like budget-year-end adjustments and clarifications, we also take time to look at the operational documents of the College, including the Bylaws, administrative policies, committee policies and appointments. A few years ago we decided that it was better to have committee members serve terms that began at the start of the calendar year, so now all committee members serve threeyear staggered terms that run from January 1 through December 31st annually. We also made sweeping reforms to include policies that termed out members to bring fresh views to all of our committees after three consecutive terms on a committee.

The other universally adopted policy was one of attendance, requiring members to participate at least 66% of the time over their appointed term.

The policies and appointment processes overhaul have provided us with the ability to make our College and its committees function at a higher level and with more focused sets of objectives and purpose. Now what we need is YOUR PARTICIPATION to make them even stronger.

Last September, members who have expiring terms on all the committees were contacted to inform them that their term will expire on December 31st, they were also given the opportunity to seek reappointment to the same committee or be considered for appointment to another committee. Likewise, members who have failed to meet the attendance requirement were notified that they had to attend the next meeting of their committee or risk

being removed from their current position and having that position filled by another person to complete their term.

If you are interested in filling any of the vacant positions on any committee, now is your chance to apply. Applications are taken all year round and appointments are generally made during the last quarter of the year so that the new member can be oriented to the committee and have sufficient time to read the minutes and make arrangement to attend the committee’s next scheduled meeting. Be aware that some committees meet monthly by phone, while others meet quarterly or semi-annually. Some committees work only off-site and do all their work away from meeting sites, some meet only at the semi-annual meetings of the College.

Chairmanships are always at-large positions, meaning that unless otherwise specified, the chair serves at the wish of the President; if he should decide to change a chair during the year, the President has that right to do so. Other member positions may require certain criteria, like core faculty status or involvement in a certain aspect of emergency medicine practice.

So please read the following descriptions carefully. Your application/interest form should be submitted to the ACOEP Office

by November 1st annually to be considered for an appointment on a committee. You may send them to me or my Executive Assistant, Geri Phifer for inclusion into the consideration process.

There are currently fifteen committees and three special interest groups that will have opening in their members for the next term, beginning in January 1, 2013. Terms are generally three-years in length. Some appointments may be made for partial terms for members who had resigned from their positions or did not attend sufficient number of meetings and their appointment was terminated.

Similarly, if you are interested in serving

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on the Board of Directors of the ACOEP or the Board of Trustees of the Foundation, you need to contact us now. Interviews for the ACOEP Board take place at the Convention and throughout the last quarter of 2012 and the first quarter of 2013 for positions on the Board for 2013.

The Foundation Board, will interview interested candidates at its fall meeting in Denver for a term that will begin in January 2013.

The following is a synopsis of the ACOEP Committees and the number of members needed for the upcoming term. Please remember members currently serving on the Committees have the option of asking for reappointment, so if you are interested in being a member of any committee the position availability may be less than shown below.

Bylaws – The Bylaws Committee develops and reviews policies of the College, its Chapters and Committees prior to presentation to the Board and Membership. The Committee works with other College committees and the Board to keep the operational documents of the College up-to-date and meeting the needs of the membership. Committee Meetings are generally annually on an as needed basis; meetings may be in person or by conference calls or both. The Committee currently has openings for two members.

Continuing Medical Education - The CME Committee creates innovative continued medical education programs that incorporate current emergency medicine topics that meet the needs of the current emergency physician. Members are tasked with recruiting quality speakers, creating cost-effective strategies for educational conferences, developing CME activities continued on page 8

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continued from page 1 season. The results of this election will strategically plot the course for our patients and profession for many years, if not decades to come. We are in the transition period of the most sweeping reforms to the health system since the implementation of the Medicare/Medicaid system over 40 years ago. Professional advocacy is an area ACOEP wants to improve upon. Our efforts and engagement in the political process will be at the forefront during this season.

In all of our decisions to chart the course of health policy, we continue to adhere to the foundation of advocating for our patients and you the member. In reflecting on what we have done to support change, it is clear we have made significant strides.

We supported the National Osteopathic Advocacy Center to create a professional physical presence to meet with the national policy makers in Washington.

We partnered with other Emergency Medicine stakeholders in the developing a bold and successful effort to influence the regulatory reform process through the Emergency Medicine Action Fund. We also enabled our members to support our national advocates and highlighted their achievements with partnerships in Town Hall events. Yet there is still much more to do and so much opportunity to seize upon. We are challenged in many areas including member participation in our Patient Advocacy and Professional Affairs committee which needs our members to engage in the political process to promote policy. Ironically, if you think about it, the governmental policies are the rules you must work under. So it should not be such a stretch for members to want to help shape those rules. The membership is going to have to follow those rules under penalty of law anyway. Why not make a difference and proactively get involved. Likewise, we need your participation in DO day and support of the political action committee. As part of our reflective review we may find synergy on the political front with organizations like ACEP where our combined effort can advocate for a better health policy. We need a large number of members participating in the political process if we are to make a lasting impression.

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In moving forward, it is worthwhile reviewing how we got here. Believe it or not the issue of government health reform can be traced back to 1910. The tenant arguments have two sides. One side believes that the U.S. should follow other industrialized countries and support a government centered health system while the other side contended centralized health care is a socialist vehicle and subjugates freedom. Critics argue it would result in unsustainable expenses and impose an impersonal bureaucracy which would undermine the doctor patient relationship.

It would also abrogate the family’s responsibility to maintain their own health care. After decades of debate Harry Truman boldly tried to pass the National Health Act in 1945 and failed.

However, the defeat led to an improved marketing strategy which was utilized by key officials of a welfare expansion plan in the Social Security Administration.

They politically marketed to the elderly population where the private markets in 1965 failed to insure nearly one half of the population over 65 years of age. This was at a time when the life expectancy was 66 years for men and 73 years for women.

The end result was the Social Security Amendments of 1965 which established the Medicare program for senior citizens and the Medicaid program for the ‘medically indigent’ as it was termed. Medicaid was federally supported, but administered by the States. By 2001 Medicaid had paid for the care of nearly 1/3 of all births and 2/3 of all nursing home patients. It was termed the safety net for the medical system.

The emergency department became the De facto service provider in many areas of the country. Medicaid did not penetrate well into the free market system as many physicians refused participation in the program. Medicare was different in that it was federally administered social insurance to all Americans 65 years of age or older. To gain support it initially had no cost control mechanism to combat the arguments against socialized medicine.

Part A was funded by payroll taxes and reimbursed for hospital care while part B was supplemental insurance which paid for mainly doctor visits. To meet mounting pressures on solvency, increasing payroll

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taxes, deductibles and copays were imposed on the program while reimbursement declined. In 1983 Medicare instituted a policy of reimbursement for certain Diagnostic Related Groups (DRG). It reimbursed care to hospitals at a fixed amount. The impact resulted in more than 1000 fewer hospitals over the following 20 years. The Harvard economist, William Hsiao had his price control system, the Resource-Based Relative Value Scale of 1988 implemented by Congress to control physician costs. This system reimbursed physicians based on the ‘difficulty of service’ and not on the effectiveness. It failed to control health care costs. In 1997 Congress enacted a new price control system called the Sustainable Growth Rate (SGR) which tied physician fees to the country’s Gross Domestic Product. 13 times the SGR has required a ‘doctor fix’ to make up for the short fall in cost to physicians in order to keep physicians in the Medicare program.

This year the Medicare system may result in a 27% decrease in reimbursement to the physician if it is not ‘fixed’ again this year by Congress. Each passing year brings the reality that there isn’t enough tax payer money to keep ‘fixing’ the program and change is ultimately necessary. In the 1990’s Medicare encouraged enrollment in the new Health Maintenance Organization (HMO) to control costs. It also redirected academic institutions which already provided charity care, to shift faculty time away from teaching and research and instead focus on a more lucrative clinical mission. Actuary tables forecasted a declining ratio of earners paying into the system versus those who would be retiring thus producing our current financial crisis in the entitlement program.

We find ourselves in this political season still debating the future under the Affordable Care Act which has been found constitutional as the largest tax program in history. It will enact many of the fiscal changes beginning in late 2012 when Medicare Advantage programs reduce the benefits of 20% of seniors which is estimated to result in $156 million in savings to the government. 2013 marks the beginning of significant and new categories of tax increases that will partially fund the Affordable Care Act. While nearing

the ‘fiscal cliff ’, the national debt will top 16 trillion dollars during the Democratic national convention prompting the CBO to issue a warning of another recession early next year. As a result, the center of the debate is the solvency of the Medicare program. Both political parties agree that the program will run out of money in as little as 4 years. The Affordable Care Act will cut $716 billion from the Medicare program over 10 years. Combined with another $53 million dollar cut from Social Security, all that money will go to help fund the $1.9 trillion in new health care spending. $453 billion of the Medicare cuts will come from reduced reimbursement rates to doctors and hospitals. This has ominous consequences for emergency medicine. Medicare reimbursements are already too low to absorb these patients into the primary care physicians’ practices.

Compliance mandates and operational cost are not covered with the low fee schedules making incorporation of these patients into primary care offices economically impossible. These patients will be left to seek access via the safety net and the result is exactly what has happened in Spain. There is no ability for the government to fund the safety net when the system is bankrupt. The Obama administrations own Medicare Actuary, Richard Foster predicts 15% of hospitals serving Medicare patients will be unprofitable in the early years of the Affordable Care Act. Many of these institutions at risk already carry a disproportionate load of Medicare and indigent care patients. In 2011 the Health and Human Service Department attempted to conduct a study into why physicians were opting out of the Medicare program but stopped the project and only stated that they did not have sufficient data.

A memorandum from Medicare Chief, Marilyn Tavenner stated the ‘opting out issue is worsening and more physicians are expected to follow suit’. Last year a news media investigation reported that while posing as a Medicare patient half of the 200 physicians contacted had already opted out of the system. So it is inevitable that these patients will come through the emergency department doors as frustrated patients who harbor more advanced disease. This

unintended consequence will in turn result in hospital overcrowding and further delays in access to care. The Joint Commission (TJC), formally called JCAHO, has already recognized the inevitable and made emergency department length of stay under 4 hours a quality standard subject to accreditation review in 2014. CMS now routinely follows TJC inspections and failure to meet this quality standard could result in denial of participation in the Medicare program. Interestingly, the new standard is the same as the National Health Service standard used in the United Kingdom and studies show their rules initiated in 2001 made no impact on quality of care metrics. In fact, hospitals and physicians manipulated the reported data while making a significant number of treatment decisions in the last 20 minutes of the 4 hour window to avoid penalties or denial of payment.

The bottom line is the new law has imposed a system many patients and the physicians alike will find more frustrating than ever. It has been said, the smart man learns from his mistakes but the wise man learns from the mistakes of others (Anonymous). Since the Affordable Care Act was modeled after a European style health system, we only need to look across the pond to see the future results. If we stay our current course with the Affordable

Care Act, then meaningful change to improve the health care system will be difficult and slow. History tells us that we still need to change the system if we want to improve the service to our patients at an efficient cost. However, the effort to make meaning change will be labor intensive and demand more resources.

Failure to make meaningful change will result in health providers following the path of least resistance. Inevitably a two tiered system will develop just like in Europe. If we were wise then we would have never copied a system that has already failed elsewhere. A perfect contemporary example is the safety net failure in Spain.

The joke in Madrid portrays a group of elderly patients waiting in the waiting room. One says, “Where’s Juan?” Another says, “He can’t make it today. He’s ill.”

Madrid blames administrative problems and ‘foreigners’ for the system failure. We don’t need to make the same mistakes, but we need you to advocate for prudent change. Take the time to learn how you can participate to shape health policy so your patients will have the best in health care. h t t p : / / w w w. f o r b e s . c o m / s i t e s / aroy/2012/08/20/how-obamacares-716billion-in-cuts-will-drive-doctors-out-ofmedicare/

ACOEP A Look Back: Embracing Our History In the last issue of The Pulse we published a story exploring the genesis of ACOEP—the brain child and passion of a group of tireless visionaries, who saw the need for an association supporting the growth of osteopathic emergency physicians. The ACOEP archives hold pictures, stories, articles, meeting minutes, and more, painting a picture of this time of growth and challenge. However, documents do not have the same power as the stories of those who have actually been there.

The narrative of our College not only tells the story of where we have been, but it informs the direction we are moving. I would like to invite anyone involved in ACOEP through our formative years to get in touch with me so that I can record your stories and get first-hand accounts of our growth throughout the years.

If you would like to participate, please call me at 312.445.5709, or send me an email at ESernoffsky@acoep.org. I would love to ask questions and hear your stories.

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Help Wanted (continued from page 5) that reinforce the use of osteopathic principles and practices as it relates to emergency medicine, encouraging resident and student participation in College events, and providing periodic reports on its activities to the College Members.

Committee Meetings are generally twice annually at the Spring Seminar and Scientific Assembly; however, much of the activity takes place outside of these meetings and may involve off-site by conference call and email. The Committee currently has openings for four potential members.

Emergency Medical Services - The EMS Committee evaluates and develops policies and programs related to emergency medical services. The ideal member would be a physician involved in local or national EMS networks and have a sincere interest in this subspecialty area. The Committee is also charged with nominating candidates for the Aranosian Award for Excellence in EMS. Committee Meetings are twice annual at the major meetings and periodically by conference call. The Committee currently has openings for three potential members.

Fellowship and Awards - The Fellowship and Awards Committee assesses applications for the honorary titles of Fellow and Distinguished Fellow of the ACOEP. The Committee is also charged with identifying physicians for the College’s special annual physician recognition for the Field Mentor of the Year; Aranosian Excellence in EMS and Horton Lifetime Achievement awards or non-emergency medicine practitioners for several different awards such as honorary membership or honorary fellowship.

Committee Meetings are generally conducted at the Spring Seminar, with nomination review off-site and reports sent to the chair prior to the spring meeting. The Committee currently has openings for up to seven members.

Graduate Medical Education - The Committee on GME develops; initiates and evaluates educational programs and policies pertaining to residency training programs

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in emergency medicine, EMS, Pediatric Emergency Medicine and Toxicology, as well as the combined specialty areas of EM/Family Medicine and EM/Internal Medicine. Members must have a sincere interest in education as they may be asked to participate in on-site evaluations of the various programs. Committee Meetings are a combination of face-to-face and conference calls. The Committee meets a minimum of two times annually and up to 6 times by conference call annually.

The Committee currently has 1 potential opening.

Member Services – The Member Service Committee reviews and implements policies related to membership in the College.

Activities may involve identifying benefits of interest to members, to evaluating applications for membership. It is tasked with identifying Lifetime Achievement annually and evaluating any individual not meeting membership criteria who may qualify or be nominated for honorary membership in the College. Committee Meetings are generally a combination of on-site meetings and some deliberations may be done by email or conference call. The Committee has four potential openings.

Nominations – The Nominations Committee is responsible for developing the ballot for candidates interested in serving the College as a Board Member.

Members will participate in the interview process for potential Board members and developing and evaluating voting policies and mechanisms. The Committee Meets by conference call and in person at the Spring Meeting. Members will be expected to interview potential candidates at the Scientific Assembly and in subcommittees by phone outside of the regular meetings.

The Committee has a set membership of 7 members of the college, 2 past presidents, a past resident chapter president, presidentelect and immediate past president of the college. There are currently one, oneyear appointment available for a general member of the College.

Patient / Physician Advocacy - Formerly the Government Affairs Committee,

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the PPAC’s purpose is to advocate for healthcare issues that will benefit either the emergency medicine patient or physician or both.

Members are expected to participate in local and national advocacy activities including DO Day on the Hill and governmental meetings of the various bodies of the AOA. Members should have sincere interest in healthcare reform and advocacy. Committee Meetings are generally three-times annually as well as off-site meetings with governmental officials or other officials by email, internet contact, telephone, or mail activities. There are a minimum of three potential openings.

Practice Management - The Practice Management Committee is responsible for developing policies for the practice of emergency medicine. The Committee interfaces with the Practice Management Committee of ACEP. Members may be required to conduct or participate in feasibility studies on proposed policies. The Committee meets monthly by conference call and twice annually at the College’s meetings. There are currently two, oneyear positions and one, three-year position available.

Publications and Communications – The Publications and Communications Committee is responsible for the development communications vehicles of the College, including print media publications, The Pulse and The Beat; input into web-based publications like Twitter, Facebook and the ACOEP Website.

Members are expected to participate in editing and may be required to write articles pertinent to emergency medicine for any of the media outlets.

Committee Meetings are twice annually, however, members will be contacted at least quarterly to edit publications or to write articles for the publications.

There are two, three-year positions available, as well as 2 positions for student members and 2 positions for resident members.

Research - This Committee combines the best of both the College and the continued on page 9

Foundation for Osteopathic Emergency Medicine; as it is representative of both groups. Members will develop research policies as well as evaluate and provide feedback to residents on their required research projects. Membership is twotiered, one will provide final approval of research awards and policies, the other involved in off-site evaluation and feedback to the residents and committee. Members are also asked to act as judges in research committees twice annually and as mentors for young physicians on research. Formal Committee Meetings are at the two major meetings of the ACOEP; however, much of the review work is done on the physician’s time outside of the general meetings. There are openings for two physician faculty who hold faculty appointments at a medical college; two members at large of the College and 1 core faculty member of an approved EM residency.

large; 2 student and 2 resident members.

Special Interest Groups: Medical Toxicology Special Interest Group – The Med Tox SIG is a new special interest group that will launch during the 2012-2013 fiscal year and member interest and committee size has not been determined. We are asking anyone who is currently working in this subspecialty of emergency medicine come to the group meeting to help set the direction and develop a core of physicians to become the advisory committee for this SIG.

to become the advisory committee for this SIG. Young Physicians Group - The ACOEP Young Physicians Committee is currently being organized as a Special Interest Group and will ultimately develop into a Committee under the Department of Member Services. This group will consist of physicians out of residency training for five years or less and will assist the College to develop policies and procedure to assist these physicians to succeed in the practice of emergency medicine. It is anticipated that the Steering Committee of this SIG will meet several times via conference call to develop working principles and policies for the Committee and that the Committee and SIG will meet at the two regular meetings of the College.

Pediatric Emergency Medicine Special Interest Group – The PEM SIG is a new special interest group that will launch during the 2012-2013 fiscal year and member interest and committee size has not been determined. We are asking anyone who is currently working in pediatric emergency Resident In-Service Examination medicine or with a sincere interest in PEM Development - The RISE Committee is come to the group meeting to help set the tasked with developing the annual Resident4M_SmallPulseAd_Layout direction and develop1 a9/11/12 core of12:46 physicians PM Page 1 In-Service Examination. Committee members are tasked with working with specific hospitals to develop specifically assigned questions and much of the work is done on the individual’s own time. Committee Meetings are held over two-days in Chicago in August and a second meeting may be held in conjunction with the fall meeting of the ACOEP. There are currently one Physician owned and operated, 4M Emergency Systems has over 15 years potential position for a core faculty of experience management and staffing emergency departments and urgent care member of an approved program. centers. We are now looking for qualified physicians at the following locations.

Undergraduate Medical Education – Geneva, Ohio: If balance is what you’re looking for in life, Geneva has it! Located on the shores of The Undergraduate Medical Education Lake Erie in Ohio’s wine country region, Geneva is situated 55 miles from the Pennsylvania state line Committee is responsible for developing and 45 minutes north of Cleveland! Beautiful settings, fishing, boating, swimming and wonderful park facilities can be part of your life! Annual volume 15,000. 12-hour shifts. Outstanding compensation/ academic information on emergency benefit package includes partnership opportunity, a generous stipend, paid malpractice with tail, medicine on the pre-doctoral level. health, 401K retirement plan, paid long/short term disability, life, and an additional incentive plan.

Members produce student-level lectures Candidates should be board-certified emergency medicine or primary care with solid EM experience. and programs for distribution to the Austintown, Ohio: Brand new free-standing ED located just outside Youngstown is seeking a Colleges of Osteopathic Medicine and dedicated and confident emergency medicine physician. Annual volume 28,000; physician assistant to Student Chapters on pertinent topics double coverage; 15 beds; flexible 12-hour shifts. The outstanding partner plan includes a generous in emergency medicine.

Members stipend, health, paid malpractice with tail, 401K retirement plan, paid long-term disability and life, an additional incentive plan, business spending accounts, sign-on bonus & referral bonus program! should have a sincere interest in working with students in a mentoring role. The Call us for more information about Committee Meets in person twice this exciting opportunity and others.

Erin Waggoner, (888)758-3999; annually and may conduct some visits or e-mail ewaggoner@4mdocs.com.

GREAT CAREER. GREAT LIFE. to College sites, if invited. There are openings for three college members at

Emergency Medicine Opportunities

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Norcom Inc. 847-948-7762 theteam@norcomdesign.com

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The Next Generation of Emergency Physicians Mark A. Mitchell, D.O., FACOEP

The next generation of emergency physicians is currently enrolled in our medical schools, internships, and residency programs. There are many who see emergency medicine as their calling and are eager to join our ranks. Thank goodness, for those of us in the trenches need their help, energy, and the innovative solutions they will help us develop. Our EM Residency programs are ever growing and in high demand as reflected by the fact that essentially every slot is filled.

The current class consists of approximately 1,050 Osteopathic EM residents in one of our 46 Osteopathic EM programs.

While the patients who present to the ED are relatively constant with their complaints, injuries, and medical issues, the practice of emergency medicine continues to change and present more challenges.

First of all, the volume of patients who seek care in the ED continues to go up. With the closing of many hospitals over the past two decades those EDs that remain are seeing higher volumes. With the shortage of primary care and access issues many patient’s only solution to obtaining the care they need is the Emergency Department.

While we didn’t cause this problem, we are tasked with being the solution to it. This increased volume has placed more stress on already stressed system. Therefore, the current and next generation of Emergency Physicians is faced with taking care of more patients with fewer resources.

While each of us has always focused on delivering high quality care, we now have quantifiable measures for us and holding us and the hospital to these standards.

Core Measures have been with us for many years now and the number of metrics we will be held accountable for is ever growing. Many ED physicians also report data related to Physician Quality Reporting System (PQRS). “Value Based Purchasing” is here to stay and reimbursement to our

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facilities will be based upon value and quality, and not simply the volume of patients seen. Some of the new metrics are based upon time elements and it will be incumbent on the hospital to place the focus and resources on the ED and the patients we serve to meet these metrics. It will no longer be acceptable for the hospital to have admitted patients boarded in the ED for hour, and will result in financial penalties.

Meaningful Use has placed additional stresses on the ED providers as we are forced to utilize electronic documentation systems.

While there are many positive implications to an EMR, the data also shows the impact it has on the ED. These are especially obvious during the implementation phase if not done properly. Additional staffing and resources are required in order the ED and the patients we serve not to be adversely affected during this time. For without them we see significant effects such as: • Increased door to provider times • Increased length of stay • Increased numbers of “Left without treatment” (LWOTs) • Decrease in patient satisfaction • Decrease in provider and staff satisfaction • Initial decrease in quality of documentation in many instances

While over time many of these metrics come back to baseline, the price paid is often significant. It is with the marked increase in transition to EMRs that there is an ever growing demand for scribe services.

Despite the growing number of physicians obtaining training in Emergency Medicine, we still face a significant shortage.

This is a great situation for the physician looking for their first job out of their EM training. However, it is a situation that

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those “in the trenches” have to deal with on a daily basis. Many physicians are faced with working longer shifts and more shifts they wish in order to deliver the care the patients deserve. Also, getting physicians to work in rural America is an ongoing problem. The financial resources available in these areas are often not competitive with the larger facilities. It is these remote facilities that don’t have the surgical and medical backup that is often present in the metropolitan areas and therefore needs the most qualified emergency physicians to provide intensive stabilizing care prior to transferring.

Emergency medicine will continue to have demands placed upon it and will therefore continue to cultivate creative solutions and dedicated individuals. We welcome the newest members of our profession as well as those that are training to join our ranks. We challenge you to not accept the current state of emergency medicine, but to put forth innovative thinking to assist us in continuing to move forward. We need your energy, your observations, your solutions, and yes, if you want to pick up a few extra shifts, that would be great to.

The Policy of Healthcare Reform Frederick Davis, D.O.

In today’s current climate we are facing new economic restraints and political guidelines to how medicine will be practiced. Much of this will be laid out in the new policies that come from the Affordable Care Act (previously the Patient Protection and Affordable Care Act) that was signed by President Barack Obama on March 23, 2010. Yet as a physician, much of our education lies in the science of anatomy and physiology and the art of treatment of disease. Our training, however, does not encompass much of the political nature of the practice of medicine.

While we practice on how to best treat the patient, much of what resources we do have available lies in the politics of policy. The way healthcare is practiced is tied to the policies of healthcare reform.

Now more than previous years the policy of healthcare reform has gained center stage and there is much debate to how that will play out. As physicans we need to have a voice in these discussions and be able to say what will be best for our patients and how medicine will come to be practiced.

To do this we need to develop the background necessary to fully explore the policies and understand their implementations. This is not the typical education we receive in medical school or in practice. This is a different training that is just as vital to fully practice and care for our patients.

There are programs available that provide physicians the education our training has not afforded. Two of these programs are specifically designed to train Osteopathic Physicians and those involved with osteopathic medicine and training.

One such program is the Training in Policy Studies Program (TIPS) offered by the New York College of Osteopathic Medicine (NYCOM) in collaboration with the American Association of Colleges of Osteopathic Medicine (AACOM), the

American Osteopathic Association (AOA), as well as the government affairs offices of the AACOM, AOA, and the American Osteopathic Healthcare Association (AOHA). The TIPS program focuses on training osteopathic residents to become familiar with healthcare issues as they relate to federal and state policies. Participants attend four intensive three-day seminars that include presentations and direct interaction with health policy experts that have served on committees and task forces at the federal and state levels.

The TIPS program provides participants with the skills to participate in policy discussions and committee work.

The time spent during these seminars focus on issues relevant to osteopathic medicine and education and participants will work through current health care policies and learn to research, present, and develop policy position. For more information on the TIPS program please visit http://iris. nyit.edu/nycom/tips/ The Health Policy Fellowship, developed through the collaboration of the New York College of Osteopathic Medicine and the Ohio University College of Osteopathic Medicine, focuses on individuals who are preparing for leadership roles in the osteopathic profession and positions of influence in health policy. This is a more intensive program in policy studies aimed at those working in professional positions of health care and medical education interests.

This program also utilizes resources from the American Association of Colleges of Osteopathic Medicine (AACOM), the American Osteopathic Association (AOA), as well as the government affairs offices of the AACOM, AOA, and the American Osteopathic Healthcare Association (AOHA). Participants in this program attend three-day intensive seminars once a month for nine months. These include

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presentations from policy experts on various health care policy and development.

The HPF provides participants with a broad range of analytical and communication tools that can be applied to health policy.

The time spent during these seminars allows participants to develop a foundation of health policy information systems as well as interpretation of policy. They have opportunity to address various areas of health policy, including the economics of health policy, federal and state health programs, health professions workforce, special populations, manages care, medical education, telecommunications, and telemedicine. For more information on the HPF please go to http://iris.nyit.edu/ nycom/hpf/ Both the TIPS and HPF program offer the opportunity for members of our profession to gain the necessary background and tools to become not just subjects of policy. It is here that our profession as Osteopathic Physicians can voice the unique perspective we have to health care, be an advocate for our patients, and be an active part of the reform.

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What Would You Do? Ethics in Emergency Medicine Bernarnd Heilicser, D.O., M.S., FACEP, FACOEP

Our patient is a 50 year old male with a history of metastatic cancer. It appears he called his son asking him to come home. The patient’s wife was out shopping.

On arrival, the son found the patient unresponsive in a car in the garage with the motor running. A suicide note was present. The son called 911. In the ED, it was determined that the CO level was only 3. Further investigation revealed a Halcion overdose.

The patient was intubated and resuscitated. The patient’s wife wanted life

support removed to allow her husband to die peacefully. His son wanted everything done to save his life. The attending ED physician was going to honor the wife’s request. However, the ED Medical Director countermanded him and supported the son.

The patient had an uncomplicated hospital course and was subsequently discharged home. Two days later the patient sustained a fatal self-inflicted GSW to the head.

The ED Medical Director is doubting his decision.

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.

Members in the News!

Congratulations to Dr. Elise Zahn who completed her MBA at Columbia Southern University in April 2012! Well done on all of your hard work Dr. Zahn!

In July, ACOEP participated in a week of meetings with the AOA. Dr. Chrstiansen represented our College by presenting a speech on the state of ACOEP to the AOA on July 18. On July 20 the following emergency physicians attended the AOA House of Delegates meeting: Charles Finch, Joseph Kuchinski, Mark Foppe, Gerald McClallen, Ben Huang, John Casey, Mark Mitchell, Tressa Gardner, Chad Kovala, Sonbol SHahid-Salles, Gary Willyerd, Darryl Beehler, James Turner, Anthony Jennings, James Jempsa, Otto Sabando, Frederick Davis, Mitchell Fischer, David Levy, Freda Lozanoff, Peter Bell, Bret Langerman, Michael Ogle, Margaret A. Orcutt Tuddenham, John W. Becher, Tomothy J. Cheslock, Margaret Orcutt Tuddenham, John. W Becher, Timothy J. Cheslock, Thomas E. Marchiondo, and George Wolters, Jr.

Do you have news to share? An interesting idea for an article?

E-mail esernoffsky@acoep.or to be included in The Pulse!

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

Foundation Focus Our 2012 Honorees are:

Research Competition Winners:

President’s Circle Awards Presented to Donors achieving a lifetime level of $10,000 or more • • •

2012 FOEM Legacy Gala Presented by TeamHealth® Friends: Premier Physician Services® and Schumacher Group® The Foundation for Osteopathic Emergency Medicine is pleased to officially announce its 2012 Legacy Gala. This formal evening of dinner and dancing will occur on Tuesday, October 16, 2012 at the Sheraton Denver Downtown Hotel in conjunction with the ACOEP Scientific Assembly. Invitations are being sent out now, so be sure to RSVP promptly to save your seat at this exciting event!

The Gala, established in 2011, is to celebrate and thank our supporters for their generous contributions to making the Foundation what is has become during its nearly 15 years in existence. We also use this opportunity to thank and recognize those who have been our most ardent supporters and have achieved specific levels. Awards are also presented to the winners of the annual FOEM Resident Research Competitions.

Pillar Awards – Presented to Donors achieving a lifetime donation level of $5,000 or more • Mark Foppe, D.O., FAAEM, FACOEP • Victor J. Scali, D.O., FACOEP-D • Douglas Webster, D.O., FACOEP-D • Bruce Whitman, D.O., FACOEP 100% Program Challenge Winner: Presented to the ACOEP Residency Program that has raised the most funds per resident in 2012.

To qualify, 100% of the residents must contribute at least $5.00.

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•

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1st Place: Good Samaritan Hospital Medical Center - $25.00/resident 2nd Place: Ohio Valley Medical Center - $20.00/resident 3rd Place: UMDNJ-SOM @ Kennedy - $14.00/resident

Research Flame Award: Presented to the ACOEP Residency Program that has achieved the highest average score for Senior Research Papers in 2012. Scores are determined by the ACOEP Research Committee.

•

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Juan Acosta, D.O., MS, FACOEP Beth Longenecker, D.O., FACOEP Sherry Turner, D.O., and James Turner, D.O., FACOEP

Henry Ford Macomb Clinton Township, MI

Hospital,

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Research Paper Competition sponsored by EMP •

1st Place: Jill Donofrio, D.O., MPH from Kent Hospital for her research paper titled, Carotid Ultrasound and the Emergency Department Physician: A Validation Study

•

2nd Place: Amanda Miller, D.O. from Edward W. Sparrow Hospital for her research paper titled, CT Scan Detection of Injuries Without Signs or Symptoms of Injury in Stable Blunt Trauma Patients

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3rd Place: Michael Mesisca from Arrowhead Regional Medical Center for his research paper titled, Clinical Research Pilot Study: Thiamine Deficiency Among Adult Patients with Diabetic Ketoacidosis Presenting to the Emergency Department Oral Abstract Competition sponsored by EmCare

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To be determined

Clinical Pathological Case Competition sponsored by Schumacher Group •

To be determined Research Poster Competition sponsored by MedExcel

•

To be determined

FOEM 2012 Case Study Poster Competition Wednesday, April 11, 2012 Scottsdale, AZ 1st Place: Sarah Whyte, D.O. of Kent Hospital in Warwick, RI. Lisinopril Induced Angioedema Requiring Emergent Cricothyrotomy 2nd Place: Blessit George, D.O. of St. Joseph’s Regional Medical Center in Paterson, NJ An Atypical Presentation of Alcoholic Ketoacidosis in the Alcohol Naïve Patient 3rd Place: Svetlana Zakharchenko, D.O. of St. Barnabas Hospital in Bronx, NY A Case of New York City Heat Wave Induced Hyperthermia in a 44 Year-old Female with Substance Abuse History Winning Abstracts 1st Place: Sarah Whyte, D.O. of Kent Hospital in Warwick, RI. Lisinopril Induced Angioedema Requiring Emergent Cricothyrotomy Sarah C. Whyte, D.O. and Christopher P. Zabbo, D.O, FACEP Department of Emergency Medicine Kent Hospital, Warwick, RI ABSTRACT: A 49-year-old Caucasian male presented to Kent Hospital Emergency Department with a chief complaint of shortness of breath. The patient described a sensation of “something stuck” in his throat.

He had this symptom for approximately three hours and denied any recent meals.

The patient denied any trauma to the area, and is very specific as to the location of the sensation – the right anterior side of his neck at the approximate level of the C4 vertebrae. The sensation was worsened by attempts to swallow, and it was not relieved

by any actions the patient attempted. The patient had never encountered symptoms such as these in the past. The patient is an obese male with a past medical history of hypertension, anxiety and depression, and obstructive sleep apnea. He is currently prescribed captopril/HCTZ and Lisinopril.

The patient had Lisinopril added to his medication regime three months prior to presentation. The patient also has a prior substance abuse problem and is currently prescribed Suboxone. His allergies to medications include penicillin and sulfa medications. The patient uses both alcohol and tobacco on a daily basis.

The patient denied any other symptoms besides shortness of breath and a feeling of something stuck in his throat. On physical exam, the patient’s vital signs are within normal limits with the exception of mild tachycardia of 115bpm, an elevated blood pressure of 181/92mmHg, and an oxygen saturation level of 95% on room air. The patient appeared anxious, diaphoretic and in moderate distress, but exam of his oral pharynx showed no lip, tongue, posterior pharynx or uvula swelling. Although the patient initially did not show any signs of airway compromise, the patient was suspected of experiencing angioedema, likely from his ACE inhibitor. A portable chest X-ray, laboratory studies, and EKG were ordered. Intravenous (IV) access was established, and the patient was given IV famotidine, diphenhydramine, and dexamethasone. The patient was also given aspirin p.o. and IV clindamycin to cover the patient for possible cardiogenic and infectious causes of his presentation. His laboratory findings were essentially normal, as was his chest x-ray. The patient was sent for CT scan of the soft tissues of the neck – at the time, the patient was not exhibiting any form of notable airway compromise.

The patient’s CT of his neck showed diffuse soft tissue swelling with narrowing of the supraglottic airway consistent with angioedema. Upon return from the CT scan, the patient’s condition quickly deteriorated. He appeared increasing

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anxious and had worsening dyspnea. He was given inhaled racemic epinephrine and IV lorazepam to control his symptoms and placed on an oxygen non-rebreather mask. He now had increased oral swelling, including his tongue and uvula. The patient’s Mallampati score changed from Type I to Type IV in a course of less than twenty minutes. Given the patient’s worsening condition the decision was made to emergently intubate the patient.

However, multiple attempts to intubate the patient using a traditional Macintosh blade and with the GlideScope® failed.

The patient’s oxygen saturation declined to 40% and an emergent Cricothyrotomy was preformed in the emergency department.

Within seconds of completion, the patient’s oxygen saturation returned to normal. The patient was stabilized and brought to the operating room for definitive treatment – a tracheostomy. ACE inhibitors are the most common cause of medicationinduced angioedema. Numerous studies have shown that Lisinopril, in particular, is a frequent cause of angioedema.

While medication-induced angioedema generally resolves within 24-48 hours of stopping the medication, it can have life-threatening consequences as in this patient’s case. Treatment for medicationinduced angioedema includes immediately stopping the offending agent, IV steroid treatment, diphenhydramine (H1 blocker), famotidine (H2 blocker), and continuous SpO2 monitoring – all of which were done in the case. An emergency room clinician should always be weary of this and have means of protecting the patient’s airway readily available – including preparing for an emergent cricothyrotomy.

REFERENCES

• Bramante, R. and Rand, M. “Angioedema.” The New England

Journal of Medicine. July 2011.

• Hamilton. Emergency Medicine –An Approach to Clinical Problem-

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Solving. 2nd Ed. • Pub MED Health. Dugdale, D. “Angioedema.” ADAM Medical Encyclopedia. May 2010.

• Roberts and Hedges. Clinical Procedures in Emergency Medicine.

3rd Ed. • Tintinalli. Emergency Medicine – A Comprehensive Study Guide.

6th ed.

2nd Place: Blessit George, D.O. of St. Joseph’s Regional Medical Center in Paterson, NJ An Atypical Presentation of Alcoholic Ketoacidosis in the Alcohol Naïve Patient B. George. St. Josephs Regional Medical Center, Paterson, New Jersey; New York College of Osteopathic Medicine, Westbury, New York O. Sabando. St. Joseph’s Regional Medical Center, Paterson, New Jersey A. Flaxman. St. Joseph’s Regional Medical Center, Paterson, New Jersey Case Report: A 29 year old male with no past medical history presents to the emergency department with multiple episodes of vomiting and altered mental status since the night prior. As per his mother, the patient had been drinking the night before and his symptoms began once he returned home.

Review of systems: Pertinent for nausea,vomiting, altered mental status and lower abdominal pain. Negative for headache, fever, nuchal rigidity, chest pain, SOB or focal neurologic deficits History of Present Illness: This is a young alcohol naïve male who had recently had multiple cups of hard liquor the previous night without having eaten any food before or after drinking alcohol. Once he came

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home, over the course of the night he developed intractable non-bloody, nonbilious vomiting and became progressively lethargic as per his mother. The initial ED accucheck was found to be 50. After that was corrected with dextrose, he became more alert but remained slow to respond and not at his baseline mental status. Pt. denied any recreational drug use or substance overdose. His physical examination was pertinent for dry mucous membranes,heart and lung exam were within normal limits, mild RLQ abdominal pain and normal neurological exam aside from being slow to respond and drowsy appearing. His lab findings indicated metabolic acidosis with bicarbonate of 18, ketonuria, leukocytosis, an anion gap of 23, lactic acidosis and a mild osmolar gap of 11. The alcohol level was only 39, salicylates and tylenol levels negative and urine tox + for cannabinoids.

CT head and CT abdomen/pelvis were normal and carbon monoxide levels also within normal range. By assessing each of the causes of anion gap metabolic acidosis and this patients’ presentation, it was determined that this patient was in alcoholic ketoacidosis. The patient was began immediately on D5NS and admitted to the hospital with gradual improvement of his mental status coinciding with resolution of the alcoholic ketoacidosis.

Introduction: Most cases of alcoholic ketoacidosis (AKA) occur in the chronic alcoholic who has a recent alcoholic binge and subsequently decreases his nutritional status further secondary to abdominal pain, vomiting or nausea. This can occur in adults of any age who are chronic alcohol users, and rarely can occur in the alcohol naïve patient after an acute alcohol binge concomitant with poor oral intake and/ or vomiting. Physiologically, with AKA, decreased carbohydrate intake increases glucagon production and decreases insulin, along with alcohol induced inhibition of gluconeogenesis and stimulation of lipolysis which causes an increase in ketoacid production. Extracellular volume depletion also occurs secondary to poor

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PO intake and vomiting which can become profound enough to cause lactic acidosis. Diagnosis of AKA requires anion gap metabolic acidosis and ketonuria or ketonemia without hyperglycemia or other cause for the acidosis. The serum glucose level is usually normal or low, and serum ethanol levels are usually also low reflecting alcohol use over the preceding one to three days. Although mortality is rare, sudden death has been proposed to occur due to untreated metabolic derangements – including fatal hypoglycemia- among severe alcoholics. Treatment consists of reversing these metabolic derangements.

The cornerstone of therapy consists of administering carbohydrates along with normal saline in the form of D5NS which would stimulate insulin production and inhibit the glycolysis pathway as well as replace the extracellular fluid deficit and correct the anion gap. Potassium should also be replaced as needed. Additionally, in the chronic alcohol it is crucial to administer thiamine before the correction of the glucose to prevent the precipitation of Wernicke encephalopathy or Korsakoff syndrome.

Citations: Manini AF, Hoffman RS, Nelson LS. Alcoholic ketoacidosis in an 11-yearold boy. Pediatr Emerg Care. Mar 2008;24(3):170-1.

McGuire LC, Cruickshank AM, Munro PT. Alcoholic ketoacidosis. Emerg Med J. Jun 2006;23(6):417-20.

Wrenn KD, Slovis CM, Minion GE, Rutkowski R. The syndrome of alcoholic ketoacidosis. Am J Med 1991; 91:119 Rose, Burton D. "Alcoholic and Fasting Ketoacidosis." UpToDate Inc., 2 Aug. 2011. Web. 28 Jan. 2012. http://www. uptodate.com/contents/alcoholic-andfasting-ketoacidosis?source=search_result Anstass, George. "Alcoholic Ketoacidosis Treatment and Management." Emedicine.

Medscape, 19 May 2011. Web. <http:// emedicine.medscape.com/article/116820> 3rd Place: Svetlana Zakharchenko, D.O. of St. Barnabas Hospital in Bronx, NY A Case of New York City Heat Wave Induced Hyperthermia in a 44 Year-old Female with Substance Abuse History Authors: Dean Olsen, DO; Svetlana Zakharchenko, DO Introduction: Emergency department treatment of severe life threatening hyperthermia has long been debated. Most texts recommend mist and fan technique however these methods are effected by the dew point of the environment and are not rapid enough for patients with temperatures over 105F. If not corrected quickly, a patient with severe life threatening hyperthermia will rapidly decompensate and die. We present here a case of a patient who was successfully cooled, resuscitated and treated for drug induced hyperthermia using an aggressive ice emersion and internal ice water lavage combination method.

Case Description: A 44 year old female presented with a change in mental status to the emergency department during the month of July in the midst of a major heat wave – “rule out sepsis” per EMS. It was unknown when symptoms started. She was sent from a “Halfway Substance Abuse” home where she was discovered to have an altered mental status. There was a questionable history of cocaine use, and patient also reported that she missed her Methadone dose. EMS reported that she was residing in a dwelling without air conditioning. The patient was hot to touch, was mumbling words, appeared lethargic, and was not appropriately responding to questions. Per limited documentation, the patient had a past medical history of substance abuse and HIV/AIDS and she was taking Bactrim and Clonazepam. The patient was in good

health prior to the incident. Vital signs on presentation were: T of 101.2F Orally, P119 bpm, R 20 BP 160/90 and O2 sat 92%.

Rectal temperature was measured to be 106.5F. On physical exam she was lethargic with incoherent speech and appeared toxic, skin was hot to the touch, dry with tenting with a diffusely grayish appearance; there was no petechiae or rash over trunk or extremities.

Mucous membranes were dry and dentition was poor. Abdomen was soft without rigidity or masses. Chest was clear to auscultation, cardiovascular exam revealed tachycardia, with S1/S2 present and no murmurs appreciated. The patient was intubated and a central line access was established; a nasogastric tube and a urinary catheter were placed. Cooling was started via manually tying a linen sheet over patient’s head and feet in order for it to serve as a basin. Patient was covered with ice from head to toe with the basin holding ice in place. Ice water irrigation of stomach and bladder were initiated and a rectal temperature probe was placed and used to measure core temperature changes.

The patient’s core temperature was cooled to 98F within in a ten minute time frame.

The patient was transferred to the Intensive Care Unit where further supportive care was provided. After a 48 hour hospital stay the patient was discharged with no sequelae from the event.

but it is often difficult in a patient who is intubated and ventilated. It likewise causes difficulty in medication administration and execution of an ACLS protocol if resuscitation was to become necessary.

Cooling blankets and icepacks on neck, axillae and groin have a well-documented limited effectiveness. They are, in fact, currently not recommended when other methods are readily available.

Lastly, cardiopulmonary bypass is invasive, and not readily available in every emergency department. The combination of ice emersion and ice water lavage method that our team used has shown a successful rapid cooling of patient’s core temperature, with a favorable outcome and is easily achieved using simple equipment available in every emergency department. In our case, the patient was discharged with no neurologic sequelie or any other morbidity.

When faced with severe life threatening hyperthermia over 105 degrees, it should be understood that the most important goal is rapid cooling and the ED physician should consider ice immersion to achieve this goal.

Conclusion: In this case the combination of ice emersion with ice water lavage was safe, effective, inexpensive, and practical.

It can be considered for use in every emergency department.

Discussion: There are a variety of cooling techniques that have been proposed for a rapid temperature reduction in a patient with severe hyperthermia. These methods include but are not limited to evaporative methods (mist an fan), cooling blankets ice packs to major vessels, bathtub ice water immersion and cardiopulmonary bypass. Evaporative methods such as use of high flow fans and spray bottles to skin has been widely accepted; however, this method continues to still be questioned in regard to its uniform effectiveness, and is operator and equipment dependant.

Bathtub ice water emersion has been proven to be a highly effective method,

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FOEM 2012 Donors *In order to save space, designations are limited to D.O.

FOEM would like to express deep thanks to the individuals who have so generously donated to continue our mission of advancing patient care through research and education in osteopathic emergency medicine. Join us as we honor our loyal donors at the 2012 FOEM Legacy Gala on Tuesday, October 16 in Denver, Colorado.

Juan Acosta, D.O. - $4,127.50 Joseph Kuchinski, D.O. - $2,000.00 Douglas P. Webster, D.O. - $1,681.70 David Levy, D.O. - $1,169.00 William Lynch - $1,000.00 Mark A. Foppe, D.O. - $919.94 Victor J. Scali, D.O. - $825.00 Donald Beyer, D.O. - $800.00 Beth Longnecker, D.O. - $675.00 Donald Findlay, D.O. - $510.00 Stephanie Whitmer - $500.00 Janice Wachtler - $495.00 Robert E. Suter, D.O. - $450.00 Sherry Turner, D.O. - $450.00 Gary Bonfante, D.O. - $400.00 Christine Giesa, D.O. - $300.00 Mark A. Mithcell, D.O. - $300.00 Fahim Shan Ahmed, D.O. - $250.00 John C. Prestosh, D.O. - $225.00 Bruce Whitman, D.O. - $225.00 Gregory Christiansen, D.O. - $200.00 Gary LaPolla, D.O. - $200.00 John W. Graneto, D.O. - $194.30 Thomas Brabson, D.O. - $150.00 Daniel Lombardi, D.O. - $150.00 Peter J. Kaplan - $132.06 Donald Sefcik, D.O. - $115.00 James Turner, D.O. - $115.00 Justin Arnold, D.O. - $100.00 Glenn DeLong, D.O. - $100.00 Kenneth Doroski, D.O. - $100.00

18

(as of 8/30/12)

Greg Gray, D.O. - $100.00 Steven Parrillo, D.O. - $100.00 Joseph Sorber, D.O. - $100.00 Jon-Pierre Pazevic, D.O. - $56.89 Anthony Affatato, D.O. - $50.00 Rohit Agrawal, D.O. - $50.00 Kevin J. Aister, D.O. - $50.00 Victor Almeida, D.O. - $50.00 Leonardo Altamirano, D.O. - $50.00 Gaiti Bakhsh, D.O. - $50.00 John Benson, D.O. - $50.00 James Botti, D.O. - $50.00 Jeffrey Butler, D.O. - $50.00 Christina Cabott, D.O. - $50.00 Terry K. Carstensen, D.O. - $50.00 Thomas E. Carter, D.O. - $50.00 Kevin Clark, D.O. - $50.00 Jeffrey Couturier, D.O. - $50.00 Kimberly Davis, D.O. - $50.00 David Didur, D.O. - $50.00 John C. Dunlop, D.O. - $50.00 Anita W. Eisenhart, D.O. - $50.00 Andrew Flanagan, D.O. - $50.00 C.H. Fowlkes, D.O. - $50.00 Kevin Franks, D.O. - $50.00 William R. Fraser, D.O. - $50.00 Nathan Fredrick, D.O. - $50.00 Joseph Galkowski, D.O. - $50.00 Richard C. Giovannini, D.O. - $50.00 Karl Harnish, D.O. - $50.00 Laura Harvey, D.O. - $50.00 Debby Hudson, D.O. - $50.00 Michael Kelley, D.O. - $50.00 Sara Kelly, D.O. - $50.00 Gregg Kling, D.O. - $50.00 Sheera Lall, D.O. - $50.00 Paula Lange, D.O. - $50.00 Joseph Leahy, D.O. - $50.00 Francis L. Levin, D.O. - $50.00 Wesley Lockhart, D.O. - $50.00 Kevin Loeb, D.O. - $50.00 Rose Mack, D.O. - $50.00 Melissa J. Marker, D.O. - $50.00

The PULSE OCTOBER 2012

David McKelway, D.O. - $50.00 James McMullen, D.O. - $50.00 Michael Mendola, D.O. - $50.00 Brian Miller, D.O. - $50.00 Anna Milman, D.O. - $50.00 Kevin P. Neenan, D.O. - $50.00 Robert Ormanoski, D.O. - $50.00 Dana Parsons, D.O. - $50.00 Ernest Patti, D.O. - $50.00 Stuart Pyatt, D.O. - $50.00 Carol Rahter, D.O. - $50.00 Gregory Reinhold, D.O. - $50.00 Craig Reynolds, D.O. - $50.00 Jay Reynolds, D.O. - $50.00 Ellen B. Rodman, D.O. - $50.00 Charles S. Ross, D.O. - $50.00 Brain Roy, D.O. - $50.00 Fred E. Sabol, D.O. - $50.00 Sandra Schwemmer, D.O. - $50.00 Jeffrey Shipman, D.O. - $50.00 Stacia Shipman, D.O. - $50.00 Chad Shuff, D.O. - $50.00 Brandon Thomas, D.O. - $50.00 Charles W. Tolan, D.O. - $50.00 Dong Trang, D.O. - $50.00 John A. Tyrell, D.O. - $50.00 Sazanne Vass, D.O. - $50.00 Franklin Veer, D.O. - $50.00 Brianne Waggoner, D.O. - $50.00 Anthony D. Wilko, D.O. - $50.00 Thomas Wills, D.O. - $50.00 Timothy Scott Wilson, D.O. - $50.00 Christina Zhang, D.O. - $50.00 Manjushree Matadial, D.O. - $40.00 Elizabeth Berry, D.O. - $25.00 Florence Wachtler - $25.00 Cynthia Stephenson, D.O. - $5.00

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Simplex Encephalitis in the Emergency Setting: Presentation, Identification, and Treatment Jessica Smolar, MS III University of Medicine and Dentistry of New Jersey - School of Osteopathic Medicine A. Chief Complaint Confusion B. History of Present Illness A 69 year old single caucasian male is brought in by emergency medical services (EMS) to the emergency department (ED) after he was found wandering around the parking lot of a local business confused and disoriented. The owner of the business called 911 after he witnessed this erratic behavior and the danger posed by automobile traffic on the adjacent highway.

EMS relayed that they were unable to obtain any history from the patient on the scene. EMS administered no diagnostic tests or treatments prior to arrival at the ED. History was unable to be obtained at the time of presentation to the ED secondary to the patientâ&#x20AC;&#x2122;s illness. After contacting his family, history was obtained as follows: C. Medical and Surgical History Medical history is significant for diabetes mellitus type 2 and coronary artery disease.

Surgical history is significant for coronary artery bypass graft.

D. Social History Lives at home alone and works as a contractor for a construction company.

He is a current every day smoker with a history of 50 pack years. He denies alcohol or drug use.

E. Medications Metformin 1000mg daily F. Allergies No known drug, food, or environmental allergies.

G. Review of Systems On presentation to the emergency department review of systems are unable to obtain from the patient secondary to his change in mental status.

H. Physical Exam Vital Signs: Temp (max) - 101.5, Pulse - 102, BP - 119/67, RR - 18, Pulse Ox 97% room air General: The patient is a 69 year old well developed male. He is awake and alert, but disoriented to person, place, and time.

Head: Normocephalic and atraumatic.

Eyes: Pupils are equal, round, and reactive to light. Extra-ocular muscles are intact.

Sclera and conjunctiva are normal.

ENT: External ears are normal, tympanic membranes are intact bilaterally and there is no drainage from the ears. There are no nasal polyps, septal deviation, epistaxis or rhinorrhea. Mucus membranes are moist.

There is no pharyngeal exudate or edema.

Neck: Supple with normal range of motion.

No meningeal signs are appreciated.

Cervical spine is non-tender to palpation.

No thyromegaly, jugular venous distention, carotid bruits, tracheal deviation or cervical lymphadenopathy.

Respiratory: Lung sounds are clear to auscultation bilaterally. No abnormal lung sounds appreciated. No chest wall deformity or tenderness is noted. No respiratory distress or accessory muscle usage.

Cardiovascular: Tachycardic at 102bpm, regular rhythm. Normal S1 and S2, no murmurs, no rubs, no S3 or S4 present.

Abdomen: Soft, non-distended and nontender to palpation. Normal bowel sounds auscultated in 4 quadrants. No masses, no peritoneal signs.

Back: No costovertebral angle tenderness, no tenderness to palpation.

Extremities: Normal range of motion, no cyanosis, clubbing or edema.

Neurologic: GCS 14 [verbal response = 4].

No focal motor or sensory deficits. Cranial nerves are intact. No cerebellar deficits, nystagmus, clonus or asterixis. Normal deep tendon reflexes, absent Babinski sign.

Speech normal, gait normal.

Skin: Warm, dry, and intact. Normal color.

Lymphatic: No cervical, axillary, or inguinal adenopathy.

Psychiatric: Normal affect, disoriented to time, place, person, purpose. Poor insight, and poor concentration. No suicidal or homicidal ideation.

I. Ancillary Labs and Imaging The following labs and imaging were obtained in the ED CBC: WBCs

9.5 x 103

Hgb

12.4 g/dL

Hct

36%

Platelets

294 x 103

BMP: Glucose +

455 mg/dL

Na

129 mmol/L

K+

4.4 mmol/L

Cl-

92 mmol/L

CO2

24 mmol/L

Creatinine

1.58 mg/dL

BUN

63 mg/dL

Anion Gap

17.4

eGFR

44

Acetone: Small

continued on page 22

LFT: Within normal limits.

ABG: Within normal limits.

The PULSE OCTOBER 2012

Urine Drug Screen: Negative Serum alcohol: Negative

21

Cl-

92 mmol/L

CO2

24 mmol/L

Creatinine

1.58 mg/dL

BUN

63 mg/dL

Anion Gap

17.4

eGFR

44

continued from page 21

Acetone: Small LFT: Within normal limits.

ABG: Within normal limits.

Urine Drug Screen: Negative Serum alcohol: Negative Urinalysis: Appearance

Clear

Specific gravity

1.030

pH

6

Leukocyte esterase

negative

Nitrites

negative

Protein

100 mg/dL

Glucose

>1000 mg/dL

Ketones

Trace

Urobilinogen

Negative

Bilirubin

Negative

Blood

Moderate

RBC

20-30/HPF

WBC

None

Bacteria

Few

Crystals

Moderate

Casts

5-10/LPF

Epithelial cells

Few

PA/lateral chest X-Ray showed right middle lobe and lower lobe infiltrate without consolidation or effusion, not suggestive of pneumonia.

infarction, infectious disease was consulted for continued confusion with fever, and a lumbar puncture was ordered for continued mental status change.

12 lead EKG showed sinus tachycardia with evidence of old inferior wall infarct.

Considering the cardiac stability of the patient at the given time, the cardiologist ordered beta-blockers, nitrates, and a statin.

Secondary to the patient’s acute confusional state and febrile illness, the cardiologist elected to delay further ischemic work-up with pharmacologic stress test and cardiac catheterization.

CT scan of the Head without contrast was preformed secondary to the acute presentation of altered mentation and confusion. There was no acute intracranial abnormality found.

CT scan of the chest without contrast was preformed showing bronchiolitis secondary to asthma or infection.

J. Diagnostic Impression: The patient’s hyperglycemia, hyponatremia, and acute kidney injury, along with his history of diabetes mellitus type 2, suggested a diagnosis of diabetic ketoacidosis versus hyperosmolar hyperglycemic state. The absence of large ketonuria or ketonemia, and a normal anion gap suggested the latter, which was the preliminary diagnosis given in the ED. The patient was started on normal saline solution and IV Humulin bolus. A second basic metabolic profile was ordered. Though blood sugar and kidney function improved with treatment in the ED, the underlying altered mental status did not improve over the course of 6 hours. Other notable findings in the ED included tachycardia, hematuria, and fever, for which empiric treatment with IV ceftriaxone and IV azithromycin was initiated. The patient was admitted to the hospital with continued IV Humulin therapy, fasting blood glucose checks three times daily, 2 more sets of cardiac enzymes, and ultrasound of the kidneys.

K. Plan of disposition: The following morning the patient’s temperature further elevated to 104.8°F, Cardiac Enzymes: One set obtained in the ED and a second and third set of cardiac Troponin I 0.04 enzymes were positive with a Troponin I of 0.41, and 2.15 respectively. Renal Creatine Kinase 85 U/L work-up was found to be negative for anatomic abnormality as a cause of the PA/lateral chest X-Ray showed right middle lobe and lower lobe infiltrate without consolidation patient’s hematuria or infection. At or effusion, not suggestive of pneumonia. this time, cardiology was consulted for suspected non-ST elevation myocardial Coagulation profile: Within normal limits.

12 lead EKG showed sinus tachycardia with evidence of old inferior wall infarct.

CT scan of the Head without contrast was preformed secondary to the acute presentation of altered mentation and confusion. There was no acute intracranial abnormality found.

22

The PULSE OCTOBER 2012

CT scan of the chest without contrast was preformed showing bronchiolitis secondary to asthma

The lumbar puncture was preformed at 32 hours after presentation to the ED. Results are as follows:

Protein - 56, Glucose - 97

Tube #1 - colorless, clear, 25 WBCs, 3 RBCs, 75% lymphocytes, 25% monocytes

Tube #2 - colorless, clear, 23 WBCs, 4 RBCs, 83% lymphocytes, 17% monocytes This profile suggests a viral etiology with elevated WBCs (mainly lymphocytic), and high protein. Further work-up for viral central nervous system disease was ordered by infectious disease, which included brain MRI and cerebrospinal fluid (CSF) analysis by polymerase chain reaction (PCR) for West Nile virus, herpes simplex virus, Epstein Barr virus, and cytomegalovirus.

IV acyclovir was started at this time.

Further work-up showed a positive PCR for herpes simplex virus type 1. The T2 weighted MRI of the brain showed symmetrical abnormal increased intensity in both of the temporal lobes and the insular cortex. See Image 1 a, b, and c to the right.

The patient was given the working diagnosis of herpes simplex encephalitis and continued on IV acyclovir. Unfortunately, the patient’s status declined over the course of his 8 day hospital stay. When he developed respiratory distress, he was intubated and upgraded to ICU. On hospital day 7, an electroencephalogram confirmed nonconvulsive status epilepticus.

Further work-up showed a positive PCR for herpes simplex virus type 1. The T2 weighted MRI of the brain showed symmetrical abnormal increased intensity in both of the temporal lobes and the insular cortex. See Image 1 a, b, and c below.

After discussion with his family, he was made comfort care, and expired after extubation on hospital day 8.

L. Discussion: Herpes simplex encephalitis (HSE) is the most common sporadic necrotizing encephalitis in the Western world. 90% of HSE cases are caused by herpes simplex virus type 1 (HSV-1). It is estimated that about 2000 cases of HSE occur annually in the United States (approximately 1/250,000500,000 individuals per year) (1). The prevalence is equal in men and women and it has a bimodal age distribution, with onethird of cases occurring in patients under age 20, and one-half occurring in patients over age 50 (3). If untreated, HSE has an extremely high mortality rate at 70%, and only 3% of those surviving regain normal function (1).

Image 1a - T2 Weighted MRI, axial plane

Nearly 90% of the general population are seropositive for HSV-1, indicating past exposure to the virus. Latent HSV-1 can be reactivated at any time following various triggering events such as trauma, sunlight exposure, or immunosuppression. This results in the common presentation of blisters around the mouth and lips, also known as cold sores. However, despite the widespread incidence of HSV-1 latency in humans, there is a disproportionately low incidence of HSE. Furthermore, there is no connection between incidence of cutaneous presentation of HSV-1 and development of HSE. In fact, only 25% of patients with HSE have reported previous history of cold sores (1,2).

Image 1b - T2 weighted MRI, axial plane

Pathogenesis of HSE HSE has a unique neuropathological picture characterized initially by acute inflammation and hemorrhage resulting ultimately in frank necrosis and liquefaction localizing primarily to the temporal lobes with involvement of the cingulate and insular cortex. In one-third of cases, it is caused by a primary infection, with the remaining two-thirds of cases resulting from reactivation of latent virus, however the clinical course is not affected by the

continued on page 24

Image 1c - FLAIR MRI, coronal plain

The PULSE OCTOBER 2012

23

continued from page 23 difference in etiology (3). This presentation questions the pathway of viral spread, which is not completely understood.

Immunocytochemical evidence of the virus in the olfactory tract suggests that the virus enters via the olfactory pathway and spreads along the base of the brain to the temporal lobes. Other research suggests direct spread to the temporal lobes via the latent virus in the trigeminal ganglia (1,3).

Clinical Presentation & Work-Up The presenting symptoms of HSE can mimic many other intracranial, infectious, and metabolic processes, therefore it is crucial to do a thorough work-up. Studies show that in patients with HSE confirmed

by CSF PCR, the most common clinical findings were altered mental status (97%), CSF pleocytosis (97%), fever (90%), headache (81%), dysphagia (76%), personality change (71%), ataxia (40%), and seizures (38%) (3).

CSF analysis via lumbar puncture will show a viral etiology, with normal glucose, mild to moderate elevation in protein, and elevated white blood cell count (lymphocytic predominance initially but monocytosis predominates as the disease process advances). This presentation is non-specific for HSE, but consideration of a viral process warrants PCR analysis of the CSF to include testing for HSV-1/2, West Nile Virus, Epstein Barr virus, and Cytomegalovirus. PCR analysis in HSE has a sensitivity of approximately 95%, making it a very powerful diagnostic tool. Its other advantage is that it can be completed quickly, with results available within 24 hours (1,3).

MRI is the imaging study of choice in HSE and provides the most sensitive method of detecting early lesions, whereas CT may be negative in the initial assessment (1). In a study of the outcome of 93 patients ultimately diagnosed with HSE, CT showed no abnormalities in 21% of patients at primary evaluation, but bitemporal involvement was seen on follow up CT 2-7 days after presentation in 100% of the cases (4).

24

The work up of a patient presenting to the emergency department with altered mental status and a fever of unknown origin should include exploration of an acute infectious process, acute intracranial bleed, and metabolic disturbances. In the case of the patient described in this case study, other pathology discovered in the emergency department and early in the patientâ&#x20AC;&#x2122;s hospital stay may have served to potentially mask the infectious process that was ultimately discovered. For example, the presentation of altered mentation may have been falsely attributed to diabetic ketoacidosis initially. Additionally, the patient was found to have a non-ST elevation myocardial infarction early in his hospital course, which has been shown to be potentiated by acute inflammation caused by infectious etiology (5,6).

Though this patient had an extensive work up in the ED, lumbar puncture was not performed and therefore viral CNS disease was not discovered until later in the course of hospital treatment.

There is research to suggest that in a patient with acute altered mental status in the presence of fever of unknown origin, lumbar puncture is indicated in the emergency setting (7). As in this case, failure to perform a timely lumbar puncture may have led to a delay in appropriate treatment and contributed to his poor outcome.

Differential Diagnosis As mentioned in the above discussion, the presentation of fever with an acute confusional state creates a vast differential diagnosis. All patients that present with a fever should have a work-up to assess a source of infection. When including HSE in a differential in the ED, it is important to identify all of the other CNS processes that may require immediate medical intervention, such as brain abscess, subdural empyema, intracranial hemorrhage, tumors and meningitis. Other considerations could include seizure disorders including non-convulsive status epilepticus, other viral encephalopathies, vascular disease, toxic encephalopathy, neurosyphilis, and migraines (1,3).

Treatment of HSE

The PULSE OCTOBER 2012

Intravenous acyclovir is administered at a dosage of 10mg/kg every 8 hours for a duration of 14-21 days. In older studies following patient outcomes after treatment for HSE with acyclovir, age of onset less than 30, lesser severity of disease, and lesser change in level of consciousness were found to be the chief determinants of a better outcome (3). When looking at factors that contribute to poor outcome, more recent studies identified increased severity of disease (as measured by the Simplified Acute Physiology Score II) and delay of greater than 2 days between admission and initiation of acyclovir. This data signifies that the only parameter that can be modified to improve prognosis in patients with HSE is early administration of antiviral therapy (4).

A 2006 study from the Keck School of Medicine of the University of Southern California (8) looking at timing of empiric acyclovir therapy in patients presenting to the emergency department with clinical presentation consistent with encephalitis showed that the majority of patients did not receive timely therapy. In the study, 24 patients who were ultimately diagnosed with HSE met the criteria in the emergency department of having fever, neuropsychiatric symptoms, CSF pleocytosis and negative Gramâ&#x20AC;&#x2122;s stain while in the ED. Of these 24 patients, less than a third received empiric acyclovir in the ED (8).

Research suggests that timing of antiviral therapy is the only proven parameter at this time that can improve outcome. Therefore it is crucial for us as emergency physicians to recognize the signs and symptoms of encephalitis in order to treat it empirically with antiviral therapy in a timely manner.

Furthermore, it is important to note that acyclovir has been proven to be one of the safest antiviral therapies (9). While there are no studies at this time that look at side effect profile of IV acyclovir for treatment in HSE, toxic side effects of parenteral administration of the drug are rare in other settings (10,11).

There are a few limitations in applying the above discussion to the patient reviewed in

this case study. First, as mentioned above, the patient had multiple other pathology concurrent with the diagnosis of HSE, some of which were severe and requiring urgent attention (i.e. non-ST elevation myocardial infarction). The clinical discovery of these pathologies may have contributed to the delay in diagnosis and treatment of the underlying viral CNS infection. Second, though the patient did meet two of the four criteria of clinical suspicion as stated

by Benson Et Al. (8), he did not have a lumbar puncture preformed in the ED, which ultimately confirmed a viral profile.

Both of these factors may have led to a delay in administration of antiviral therapy in this patient. Furthermore, though the patient did have a delay in treatment from the time of presentation to the ED, he had a number of other comorbidities that may have also contributed to his poor outcome.

Although recognized as the number one cause of sporadic fatal encephalitis in the United States, there still remains much more to discover about HSE. The diseaseâ&#x20AC;&#x2122;s rarity contributes to the fact that it remains a difficult topic to study. More research is needed to examine how patients with HSE present initially in the ED in order to better identify and treat these patients within an appropriate time frame.

References (1) Kennedy, PG E., and A. Chaudhuri.

"Herpes Simplex Encephalitis."

Journal of Neurology, Neurosurgery, and Psychiatry 73 (2002): 237-38. Print.

(2) Gorbach, Sherwood L., Neil R. Blacklow, and John G. Bartlett, eds.

Infectious Diseases. 3rd ed. Lippincott Williams & Wilkins, 2004. Print.

(3) Whitley, Richard J. "Herpes Simplex Encephalitis: Adolescents and Adults." Antiviral Research 71 (2006): 141-48. Print.

(4) Raschilas, Franck, Michel Wolff, Frederique Delatour, Cendrine Chaffaut, Thomas De Broucker, Sylvie Chevret, Pierre Lebon, Phillipe Canton, and Flore Rozenberg.

"Outcome of and Prognostic Factors for Herpes Simplex Encephalitis in Adult Patients: Results of a Multicenter Study." Clinical Infectious Disease 35

(2002): 254-60. Print.

(5) Anderson, Jeffrey L., John F. Carlquist, Joseph B. Muhlestein, Benjamin D. Horne, and Sidney P. Elmer. "Evaluation of C-Reactive Protein, an Inflammatory Marker, and Infectious Serology as Risk Factors for Coronary Artery Disease and Myocardial Infarction." Journal of the American College of Cardiology 32.1 (1998): 35-41. Web. (6) Mattila, K. J. "Viral and Bacterial Infections in Patients with Acute Myocardial Infarction." Journal of Internal Medicine 225.5 (1989): 293-96. Web. (7) Shah, Kaushal, Kathleen Richard, and Johnathan A. Edlow. "Utility of Lumbar Puncture in the Afebrile Vs. Febrile Elderly Patient with Altered Mental Status: A Pilot Study." The Journal of Emergency Medicine 32.1 (2007): 15-18. Print.

(8) Benson, Peter C., and Stuart P. Swadron.

"Empiric Acyclovir Is Infrequently Initiated in the Emergency Department to Patients Ultimately Diagnosed with Encephalitis."

Annals of Emergency Medicine 47.1 (2006): 100-05. Print.

(9) Keeney, Ronald E., Edward Kirk, and David Bridgen. "Acyclovir Tolerance in Humans." The American Journal of Medicine 73.1 (1982): 176-81.

(10) Trevor, Anthony J., Bertram G. Katzung, and Susan B. Masters. Katzung & Trevor's Pharmacology: Examination & Board Review. 8th ed. New York: Lange Medical /McGraw Hill, Medical Pub. Division, 2008. Print.

(11) Mindel, Adrian, Michael W. Adler, Sheena Sutherland, and Paul Fiddian.

"Intravenous Acyclovir Treatment for Primary Genital Herpes." The Lancet 319.8274 (1982): 697-700. Print.

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AMERICAN COLLEGE OF OSTEOPATHIC EMERGENCY PHYSICIANS

EMERGE SPRING SEMINAR APRIL 2 – 6, 2013

MARRIOT HARBOR BEACH FORT LAUDERDALE, FLORIDA Program Agenda Monday, April 1

3:00 – 5:00 p.m.

5:00 – 6:00 p.m.

6:00 – 8:00 p.m.

Executive Committee Meeting Break for Dinner Board of Directors Executive Session

-

Tuesday, April 2

6:00 – 7:00 a.m.

Breakfast in Exhibit Area

6:00 a.m. – 12:00 p.m. Registration Open

6:00 a.m. – 12:00 Noon Exhibits Open

7:00 a.m. – 12:00 Noon FOEM Case Study Poster

Competition (posters on display)

7:00 a.m. – 12:00 Noon ACOEP Lectures 7:00 a.m.

Keynote Speaker – Peter Bell, DO, FACOEP

8:00 a.m.

Update in Evaluation and Management of Concussions in Athletes- Jace Provo, MD

9:00 a.m.

Broken not Fractured- Ken Butler, DO

10:00 a.m.

Musculoskeletal Ultrasound- Jace Provo, MD

11:00 a.m. High Risk Orthopedic Injuries Ken Butler, DO

1:00– 3:00 p.m. Continuing Medical Education

(CME) Committee Meeting

1:00– 3:00 p.m.

Finance Committee Meeting

1:00 – 3:00 p.m.

Member Services

Committee Meeting

3:00 – 5:00 p.m.

Research Committee Meeting

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3:00 – 5:00 p.m. Undergraduate Medical Education

(UGME) Committee Meeting

3:00 – 5:00 p.m. Communications Committee Meeting

5:00 – 6:30 p.m.

Welcome Reception

Wednesday, April 3

5:30 a.m.

5K Run for Research (Check In & Warm Up)

6:00 a.m.

5K Run Commences

6:30 – 7:30 a.m. Breakfast in Exhibit Area

6:30 a.m. – 12:00 p.m. Registration Open

6:30 a.m. – 12:00 Noon Exhibits Open

7:00 a.m. – 12:00 Noon ACOEP Lectures 7:00 a.m.

The Aging Physician- Steven Parrillo, DO, FACOEP-D

8:00 a.m.

Physiology of Aging- Anita Chopra, MD

9:00 a.m.

Cardiovascular Emergencies in the Elderly- James Espinosa, MD

10:00 a.m.

Altered Mental Status- Anita Chopra, MD

11:00 a.m.

Drug Therapy in the Elderly and Adverse Drug Reactions- James Espinosa, MD

8:00 a.m. – 10:00 a.m. EMS Committee Meeting

8:00 a.m. – 12:00 p.m. FOEM Board Meeting

10:00 a.m. – 12:00 p.m. WADEM Meeting

12:30 – 5:00 p.m. FOEM Case Study Poster Competition

**Posters to be removed by the end of the day** 12:00 – 2:00 p.m.

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Nominations Committee Meeting

1:00 – 5:00 p.m.

EMS Session

9:00 a.m.

Patient Satisfaction- Robert Strauss, MD

2:00 – 4:00 p.m.

Fellowship Committee

3:30 – 5:00 p.m.

Student Chapter Board Meeting

10:00 a.m.

Turning Your Abstract Into a Paper: Academic Writing Made Simpler – Mark Langdorf, MD

11:00 a.m.

Administrative Challenges- A Case Base Approach- Robert Strauss, MD

Thursday, April 4

6:30 – 7:30 a.m.

Breakfast in Exhibit Area

6:30 a.m. – 12:00 p.m. Registration Open

6:30 a.m. – 12:00 Noon Exhibits Open

7:00 a.m. – 12:00 Noon ACOEP Lectures

8:00 a.m. – 5:30 p.m.

Student Chapter Events

12:30 – 2:00 p.m.

ACOEP Membership Meeting

Saturday, April 6

7:00 a.m.

When Your Senses Fail You- Acute Loss of Smell, Taste, and HearingBeth Longenecker, DO, FACOEP

8:00 a.m.

Less Common EENT Infections- Joseph Kuchinski, DO, FACOEP

6:30 – 7:30 a.m.

Breakfast in Exhibit Area

6:30 a.m. – 12:00 p.m. Registration Open

6:30 a.m. – 12:00 Noon Exhibits Open

7:00 a.m. – 12:00 Noon ACOEP Lectures

9:00 a.m.

Acute vision changes- Beth Longenecker, DO, FACOEP

7:00 a.m.

Acute Hematologic Emergencies- Jonathan Davis, MD

10:00 a.m.

11:00 a.m.

Scan or Not Scan: Update on the Evaluation of Mild to Moderate Head Trauma- TBA TBA

8:00 a.m.

Update in Management of Pediatric and Adult Sickle Cell AnemiaJoseph Kuchinski, DO, FACOEP

8:00 a.m. – 12:00 Noon ACOEP Board Meeting

8:30 – 5:30 p.m.

Student Chapter Events

9:00 – 4:00 p.m.

Resident Chapter Events

5:00 – 10:00 p.m.

2013 COLA Review

(Optional/Fee Required)

Christine Giesa, DO, FACOEP &

Julie Johns, DO, FACOEP

9:00 a.m.

Emergencies in the Jonathan Davis, MD

10:00 a.m.

Doctor That Medication is on Back Order! - Steven Parrillo, DO, FACOEP-D

11:00 a.m.

Town Meeting- Christine F. Giesa, DO, FACOEP

Friday, April 5

6:30 – 7:30 a.m.

Breakfast in Exhibit Area

6:30 a.m. – 12:00 p.m. Registration Open

6:30 a.m. – 12:00 Noon Exhibits Open

7:00 a.m. – 12:00 Noon ACOEP Lectures

7:00 a.m.

Evaluation of Postsurgical Bariatric Patient-

Anita Eisenhart, DO, FACOEP 8:00 a.m.

Oncology

8:00 a.m. – 5:00 p.m.

CECBEMS Meeting

8:00 a.m. – 1:00 p.m.

Student Chapter Events

Patient-

Pediatric Literature Review- Anita Eisenhart, DO, FACOEP

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The Pulse Spotlight Garden City Hospital 6245 Inkster Rd. Garden City, MI 48135 Hospital Information: Type: Trauma Level: NA Number of Hospital Beds: 323 Number of ED Beds: 30 in Emergency Room; 6 in Observation Unit EM Program Information: Phone: (734) 4584486 Website: www.gchmeded.org Total Number of EM Residents: 17 Residents to Attending Ratio Working Clinically: 1:1 unless working with a EM Intern then 1:2 Accepts Medical Student Rotations? Yes; must be 4th year student- 4 week rotations only EM Program Curriculum: PGY 1: 13 Block Schedule: EM, IM, Intensive Care, Peds,

Orthopedic Surgery, OBGYN, Night House PGY 2: 12 Month Schedule: EM, Peds EM, Cardiology, Orthopedic Surgery, Infectious Disease Opthomology, Neurology PGY 3: 12 Month Schedule: EM, Peds EM, Hand/Plastics,

Intensive Care, EMS, Trauma EM PGY 4: 12 Month Schedule: EM, Peds Anesthesia, Electie, PICU, Administration/Research, Toxicology EM Program Application Information: Dates applications are accepted: Opening of ERAS through mid-December Prefers COMLEX Scores: Required to have passed COMLEX 2 CE and PE; no threshold determined Interview Dates: October-December Letters of Recommendations: Recommended 3-4 Letters

UPMC Hamot 201 State Street Erie, PA 16550 Hospital Information: Type: Community Trauma Level: II Number of Hospital Beds: 412 Number of ED Beds: 36 EM Program Information: Phone: (814) 877-6257 Website: www.upmchamot.org Total Number of EM Residents: 16 Residents to Attending Ratio Working Clinically: 1:1 Accepts Medical Student Rotations?

Yes, please contact program for more information

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EM Program Curriculum: PGY 1: 4 months EM, Urology, Neurology, OBGYN, Anesthesia, General Surgery, Radiology.Ultrasouns, Peds, Internal Medicine PGY 2: 6 months EM, PICU, Trauma, Orthopedics, Cardiology,

2 months of ICU PGY 3: 6 months EM, ICU, Critical Care Selective, Neurosurgery,

Elective, Level I Trauma, EMS PGY 4: 7 months of EM, Administration/Research, Trauma,

2 months of Elective, Community ED EM Program Application Information: Dates applications are accepted: 8/1/2012-11/1/2012 Prefers COMLEX Interview Dates: 10/12-12/12 Letters of Recommendations: 3

Grandview Hospital and Medical Center 405 W. Grand Ave Dayton, OH 45405 Hospital Information: Type: Urban Trauma Level: NA (Level III Pending) Number of Hospital Beds: 411 Number of ED Beds: 28 EM Program Information: Phone: (937) 723-3248 Website: https://www.khnetwork.org/med-ed/grandview/ Total Number of EM Residents: 11 Residents to Attending Ratio Working Clinically: Depending on the time of day: 1:1, 2:1, 1:2, 2:2 Accepts Medical Student Rotations?

Yes, please contact program for more details EM Program Curriculum: PGY 1: EM (4), IM (2), Nights, Surgical Selectiv, OBGYN, General Surgery, Peds, EM, Ophtho/ENT

(2 weeks each) PGY 2: EM (5), Peds EM, Cardiology, PICU, Surgical (Trauma)

ICU, Trauma, Ultrasound, Research/Administration PGY 3: EM (6), Peds EM, Peds EM/Peds Anesthesia

(split month), Trauma, Orthopedics, Selective (2) PGY 4: EM (7), Research/Administration, Peds EM, EMS, Elective (2) EM Program Application Information: Dates applications are accepted: August through September Prefers COMLEX Interview Dates: October 23, October 31, November 7 Letters of Recommendations: EM preferred

Oklahoma State University Medical Center

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744 West 9th Street Tulsa, OK 74127 Hospital Information: Type: Urban Teaching Hospital Trauma Level: III Number of Hospital Beds: 249 Number of ED Beds: 21 EM Program Information: Phone: (918) 599-5922 Website: https://www.osumc.net Total Number of EM Residents: 17 Residents to Attending Ratio Working Clinically: 1:1 Accepts Medical Student Rotations?

Yes, please contact program for more details EM Program Curriculum: PGY 1: 6 months ED, OBGYN, Peds, ICU, 2 months IM, Surgery PGY 2: 6 months ED, Radiology, Trauma, ICU, Orthopedics, Research, Anesthesia PGY 3: 6 months ED, PICU, Cardiology, EMS, ENT/

Ophthomology, Toxicology, Infectious Disease PGY 4: 6 months ED, Legal, Peds ED, Neurology, Elective,

Medical Examiner, Administration EM Program Application Information: Dates applications are accepted: Deadline is October 1st Prefers Comlex: Pass steps 1 and 2 before match list Interview Dates: TBA Letters of Recommendations: 2 requested, preferably from EM Faculty

Will you be our Partner?

Join the largest democratic, physician-owned practice in the U.S. and be a part of a team that truly believes in democracy, transparency, and ownership for its physician Partners.

All CEP America physicians are Partners and have a voice in our democratic group from day 1. You can be confident that CEP America is committed to long-term, satisfying careers for emergency medicine DOs.

Visit us at the 2012 ACOEP Scientific Assembly in Denver at booth #21.

To learn more, visit info.cep.com/booth21 The PULSE OCTOBER 2012 or call 800-842-2619

31

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Make your own schedule.

After years of crazy hours and jumping through hoops, you’ve earned some flexibility. It’s time to enjoy life.

Join us and make your own schedule for a full year. Why? We remember what starting out feels like.

We’re a close-knit group who’s camaraderie and support for one another is legendary.

You’ll love your schedule.

For us, there’s no better way to welcome you.

Celebrate your freedom.

Visit us at booth 1309.

Call Ann Benson at 800-828-0898 or visit emp.com. Opportunities in 60 locations across the USA. AZ, CA, CT, HI, IL, MI, NV, NY, NC, OH, OK, PA, WV

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The PULSE OCTOBER 2012

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