The Pulse - April 2016 by ACOEP

APRIL 2016

IN THIS ISSUE: MACRA Update - Pg Palliative Care - Pg

Nurse Practitioner Certification by Examination - Pg 12 #WhyImaDO - Pg

Literature Update, Spring 2016 - Pg When itâ&#x20AC;&#x2122;s Our Turn - Pg

Getting You Through the COLAs - Pg

Presidential Viewpoints | John C. Prestosh, DO, FACOEP

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The Pulse VOLUME XXXVII No. 2 Editorial Staff Timothy Cheslock, DO, FACOEP, Editor Wayne Jones, DO, FACOEP-D, Assistant Editor Tanner Gronowski, DO, Associate Editor Drew A. Koch, DO, MBA, FACOEP-D, Board Liaison John C. Prestosh, DO, FACOEP Christine F. Giesa, DO, FACOEP-D Erin Sernoffsky, Editor Janice Wachtler, Executive Director Thomas Baxter, Graphic Design Manager

TABLE OF CONTENTS Presidential Viewpoints..............................................................................................................................3 John C. Prestosh, DO, FACOEP The Editor's Desk............................................................................................................................................4 Timothy Cheslock, DO, FACOEP Executive Director's Desk........................................................................................................................5 Janice Wachtler, BAE, CBA

Editorial Committee Timothy Cheslock, DO, FACOEP, Chair Wayne Jones, DO, FACOEP-D, Vice Chair Drew A. Koch, DO, MBA, FACOEP-D, Board Liaison John C. Prestosh, DO, FACOEP Stephen Vetrano, DO, FACOEP John Ashurst, DO John Downing, DO Tanner Gronowski, DO Erin Sernoffsky, Editor Thomas Baxter, Graphic Design Manager

The On-Deck Circle......................................................................................................................................6 Christine Giesa, DO, FACOEP-D

The Pulse is a copyrighted quarterly publication distributed at no cost by the ACOEP to its Members, Colleges of Osteopathic Medicine, sponsors, exhibitors and liaison associations recognized by the national offices of the ACOEP.

Nurse Practitioner Certification by Examination: A Major Step in Validating Practice......................................................................................................................................12 Margaret J. Carman DNP, RN, ACNP-BC, ENP-BC, FAEN and Karen Sue Hoyt PhD, RN, FNP-BC, CEN, FAEN, FAANP, FAAN

The Pulse and ACOEP accept 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.

#WhyImaDO.....................................................................................................................................................15

Display and print advertisements are accepted by the publication through ACOEP, 142 East Ontario Street, Chicago, IL 60611, (312) 587-3709 or electronically at marketing@acoep.org. Please contact ACOEP for the specific rates, due dates, and print specifications. Deadlines for the submission of articles are as follows: January issue due date is November 15; April issue due date is February 15; July issue due date is May 15; October issue due date is August 15. Advertisements due dates can be found by downloading ACOEP's media kit at www.acoep. org/advertising. The ACOEP and the Editorial Board of The Pulse reserve the right to decline advertising and articles for any issue. ©ACOEP 2016 – All rights reserved. Articles may not be reproduced without the expressed, written approval of the ACOEP and the author.

MACRA Update...............................................................................................................................................8 Jeremy Tucker, DO, FACOEP Palliative Care.................................................................................................................................................10 Mark Rosenberg, DO, MBA, FACOEP-D What Would You Do?..................................................................................................................................11 Bernard Heilicser, DO, MS, FACEP, FACOEP-D

Literature Update Spring 2016............................................................................................................ 17 Amanda Ellis DO and John Ashurst DO, MSc When it’s Our Turn.......................................................................................................................................20 Frank D. Gabrin, DO What is a COLA? What the New Physician Needs to Know....................................23 Megan Koenig , DO, FACOEP Foundation Focus........................................................................................................................................27 Sherry D. Turner, DO, MPH, FACOEP

EDITOR'S NOTE I hope you enjoy this current issue of The Pulse! We have some great articles and information to share with you. After reviewing this quarters publication, the theme seems to center around the patient experience. As Osteopathic physicians we see the bigger picture and recognize there is so much more to an encounter than the examination, work-up and disposition. I chose to discuss pain management this time around, as it is a predominant force in our daily practice. It is intertwined in almost every patient encounter. There are great articles on palliative care, end of life care and DNR issues as well. Being able to have a frank yet compassionate discussion with patients and families is crucial to providing the holistic care we are known for. Finally, an article from one of our own, not about a case he handled, but about his encounter as a patient. It is a very powerful reminder about how we should approach our patients and how sometimes when, stressed or burned out we tend to give less than our best efforts. This is something we need to recognize, correct and work on daily in order to be the provider our patients are seeking. We have added some new sections, including our #WhyImaDO highlights and news about our members. This is your publication and we want to be there to celebrate with you on your achievements. Please share your news with us for publication on our website and in future issues! - Timothy Cheslock, DO, FACOEP

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Our Time Begins Now veryone here has the sense that right now is one of E those moments when we are influencing the future. — Steve Jobs

Presidential Viewpoints John C. Prestosh, DO, FACOEP

he American College of Osteopathic Emergency Physicians Board of Directors recently concluded our Strategic Planning Session for 2016-2018. We worked diligently over a three day period with a sense of urgency but also exhibited patience, knowing the future relevance of our college was at stake. I believe the quotation of Steve Jobs is very appropriate, for the decisions that emanated from that meeting could undeniably shape our future.

The purpose of this particular strategic planning meeting was twofold. The first objective was to recognize the strengths of our college and to build upon them. The second objective was to understand our weaknesses and to establish a bridge to overcome them. I believe this meeting met both those challenges, and we have formulated a plan for ACOEP to face the future with success and relevance. I further believe this planning session was the moment that will influence our future. I know our Board of Directors share this belief. ACOEP has a proud Osteopathic heritage; we must never forget the tenets that make us different from nonosteopathic physicians. At times, it is

difficult to even describe how we are different, especially when we practice our specialty in the emergency department. However, there is a “sense” of our physician-patient relationship that sets us apart. After years of observing many emergency medicine physicians, it has become apparent to me that there are other physicians who are practicing the Osteopathic philosophy while not being osteopathically trained. Our college needs to reach out to these like-minded practitioners and have them become a part of us. Our Board of Directors has also noted this, and it is with this observation that we are redefining our mission statement and goals. The Board of Directors firmly believes there are many practicing emergency medicine physicians who would join us when they realize they care for patients as we do.

we are continuing to refine strategies to meet them. 1. Member engagement and value ACOEP will develop an inclusive approach to building the emergency medicine profession by increasing value and engagement. Some examples would be: • Exploring means to construct a dashboard to track membership involvement Continued on Page 7

Our revised mission statement states that the American College of Osteopathic Emergency Physicians “promotes patient-centric holistic emergency care consistent with Osteopathic philosophy by all emergency medical professionals.” This mission statement acknowledges that other emergency medicine professionals are practicing our specialty similarly to us, and yet it maintains loyalty to our Osteopathic training and heritage. By utilizing this language in our mission statement, we are further opening the door for non-osteopathic physicians to join our organization. We are also restating the goals of our college. While the goals are established,

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Dealing with the Opioid Epidemic However you choose to treat pain, try to maintain a regimented approach rather than go for the big guns every time.

The Editor's Desk Timothy Cheslock, DO, FACOEP

here is a huge problem with opioid addiction in the United States. I’m sure that is not news to anyone. For years now the problem has been spiraling out of control. Many factors contributed to this, from the overuse of illegal substances like heroin, to well-meaning providers that want to help their patients treat their pain, to the demands of the health care system that we address pain at every visit and respond to patient’s complaints of pain effectively. We are expected to do whatever we can to control pain or fear the dreaded post visit survey that will give us a poor rating and will soon if not already have some effect on our compensation for providing patient care. Patients have learned the system and use it against us daily. Is this really a patient problem or one created by a warped bureaucracy that rewards irresponsible behavior? A recent interview published in the Portland Press Herald, highlighted the efforts of a group of 26 Senators to look into this issue and try to help alleviate part of the problem. A letter to the HHS Secretary questioned the use of pain control surveys as part of the process to determine Medicare payments in the future. The letter goes on to state that

rewarding quality is important, but it is important to measure quality correctly. Objective measurements to determine true pain scores have not been reliable and more ongoing research is needed to help determine objectively what real pain is. Physicians often feel pressure to prescribe narcotic medications due to fear of bad survey results even though they know the medications are not indicated. Discussions with physicians will highlight these challenges and many others in dealing with pain-related issues. I think it is great that the government is finally listening, or realizing that they are part of the problem. This is an area where our advocacy groups need to be vocal and contribute to a solution. If you would like to access the letter I am referencing you can find it at: https://assets.documentcloud. org/documents/2708217/Letter-toSecretary-Burwell-2-9-16.pdf

Determining what is really acute pain is challenging. Many will state their pain is “20 out of 10” but yet show no signs of distress and have normal vital signs and demand Dilaudid, because it’s the only thing that works. I have huge issue with these patients. I will properly evaluate them but in a lot of cases what they are complaining of does not justify what they are seeking. When I confront them with that fact and they realize they are not getting what they want usually one of a few things happen. They will either complain and ask to speak to another provider, which if you are unified in your process will not be an issue, they will bargain for something else which just Continued on Page 11

Since the wheels of government move slowly, we are left to deal with the current problem at hand. Having a strong departmental or hospital-wide pain management policy is key. A unified front on how your institution deals with pain can save a lot of frustration later. This way you cannot pit one provider or service against another as long as you stick to the established guidelines. I am not saying that we stop treating pain but doing so in a manner that is consistent with good medical practice will serve us well and allow us to feel justified in our actions.

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DNR - Is it Really the End? I found that basically the whole area regarding DNR, living wills, and POLST was written on shifting sands that change as the tide comes in and washes old findings away with new opinions.

Executive Director's Desk Janice Wachtler, BAE, CBA

kay, I’ll say it right out loud, I’m a medical show junkie; I’ve been one since the early years of my youth from Ben Casey, a neurosurgeon who could fix everything to shows today, like Chicago Med. And that’s what brings me to this question of Do Not Resuscitate and how physicians in the emergency department treat patients with DNR’s.

The scenario is this . . . a woman in the throes of stage 4 lymphoma appears at the door of the ED, husband and child in tow. She has passed out at a coffee shop and was brought in by paramedics. The husband tearfully tells the emergency physician his wife is terminally ill and has a DNR. Upon waking, the emergency physician sits down with the patient and questions if she truly wants not to be resuscitated should she conk out again. She vehemently says that she’s been there done that and for the sake of her family she doesn’t want them to be stressed anymore by her illness, she’s tired of not feeling well and would rather be dead. The physician states that there is a new pharma drug being tested just exactly for her type of lymphoma and he can get her in the trial. With fire in her eyes, she tells him to get lost. But, of course,

he seeks out the pharma rep and gets the woman in the trial. When she goes into respiratory or heart failure again in the ED, the emergency physician, despite the husband’s and another colleague’s warning, resuscitates the woman and transfers her to the cancer floor of the hospital. The woman wakes up, talks to the husband and a lawyer, and sues the hospital and physician for 10 mil. The hour is up and we wait for next week. Now my question and comments during this show were that this guy was basically a moron and was setting himself up for a lawsuit. Of course, to others he may seem to be someone who is doing a great thing. But this type of order is nothing to play with and many times people in chronic need of healthcare make this decision with their families after long and painful discussions. So do you as a physician have the right to say; sorry, I think I can change the outcome of your disease pathway and make you all better? This is where I began my quest to find the answers. In reading through several legal articles, the authors all define a DNR order as the

patient’s ability to refuse cardiopulmonary resuscitation (CPR) to save their lives, but does not prevent the physician from doing anything else to keep the patient from dying. Constitution and the National Health Act provide the no one can be refused emergency medical treatment. Talk about mixed messages. And this is not just an issue here in America but worldwide.1 Most literature has pointed out that if, as in the scenario above, the family and patient have stated to the attending physician that the patient has a DNR, the physician should suggest to the patient and his or her family that other things can be done to sustain life and keep the patient comfortable as they pass from life to death. They may even suggest, as the physician in the scenario did, that they are new methods for treating their illness; however, it always remains the patient’s right to refuse treatment or to consider new treatment. Another item in the patient’s portfolio is a living will, this surpasses a DNR order and may address the other items that physicians can legally use to sustain Continued on Page 9

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The Changing PatientPhysician Relationship How many patients did you see who presented with a “self-diagnosis” or a list of expected diagnostic studies all gleaned from the internet?

The On-Deck Circle Christine Giesa, DO, FACOEP-D, President-Elect

n the United States, a physician’s care of his patients was historically characterized as paternalistic. The patient visited the physician for an illness or a routine physical. The physician, with all of his education, wisdom, and experience, evaluated the patient, provided a diagnosis, and outlined a detailed treatment plan for the patient to follow. The patient accepted the physician’s diagnosis and treatment plan as “gospel” and did what was recommended. This paternalistic approach appeared to work well. Or did it? It was found that an overwhelming number of patients in this model were noncompliant with their physician’s recommendations for treatment, medication or lifestyle change, and did not see their physician on a regular basis despite having chronic medical conditions.

in their care. Think back to your last few shifts. How many patients did you see who presented with a “self-diagnosis” or a list of expected diagnostic studies all gleaned from the internet? These patients can certainly be challenging, especially when we need to explain why a certain diagnostic study is not indicated. Instead of rolling my eyes and groaning, I embrace these patients. Particularly when the alternative is the non-compliant patient. I find their interest refreshing. I acknowledge their preconceived expectations, and I politely explain why I will or will not be following their recommendations. In the past decade, there has been a major shift in the physician-patient paradigm. Patients are now encouraged and even expected to take an active role in their medical care. Physicians are now expected not only to render a medical opinion, but they are expected to be versed in evidence-based medicine and to take an active role in teaching their patients about

their medical conditions. The physician and patient are considered to be co-decision makers about patient care. This new physician-patient relationship is an integral part of the Patient-Centered Medical Home (PCMH). The PCMH has nothing to do with a building. The PCMH is a patient-centric care model led by the personal physician who provides continuous and coordinated care for the patient across the healthcare team. It is a coordinated, efficient and personal approach to primary care. The physician’s office schedules routine patient visits, visits with specialists, and diagnostic studies. It also collects and stores all of the patients’ results and records of office visits in one location. PCMH health care professionals can schedule appointments before the patient leaves the office. They can also offer extended hours and open scheduling so patients do not have to wait as long to get an appointment. Preventative medicine is one of the key Continued on Page 13

Why would patients be noncompliant with their doctor’s orders? I personally cannot understand how patients could be so naïve. As physicians, do we expect too much from our patients? Is it unrealistic for us to expect our patients to be knowledgeable of their medical conditions and medications? I do not think so. I think our patients are smart. I think that they want to be engaged

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"Our Time" continued from page 3 • S eek to offer state-mandated CME, such as Stroke and Trauma • Review membership fees and consider member bonuses • Continuation of Student Chapter visits by Board members • Initiation of visits to Residency Programs by Board members 2. Advocacy and Influence ACOEP will be an advocate for the profession and the College with positions of influence where decisions are made impacting emergency medicine. We are entertaining the following: • Empower the Government Affairs Committee to have a more active role with governmental leaders • Collaborate with organizations with mutual interests such as • EDPMA (Emergency Department Practice Management Association), EMAF (Emergency Medicine Action Fund) 3. Improve Awareness ACOEP will improve awareness and understanding of the Osteopathic influence and philosophy in emergency medicine. Considerations include: • Continue promoting WestJem, The Pulse, and The Fast Track • Capitalize on the AOA campaign of “Doctors that DO” • Marketing our conferences to ACGME programs 4. Education and Knowledge COEP will provide high-quality A educational opportunities to meet the needs of members for continued professional development and practice. Examples are: • Expand the Digital Classroom Add pre-structured social events • to Spring Seminar as a registration process • Increase attendance at the Scientific Assembly by attracting nurse practitioners and physician assistants

5. College Strength and Sustainability ACOEP will be positioned as an effective national College to advance and protect Osteopathic emergency practice through governance and management excellence. • excellent financial M aintain stewardship • Implement a new nominations format and improve the voting process • Maintain investment in technology to support College function • Expand methods to identify and mentor future leaders

4. Holistic, patient-centered care Emergency medicine is best practiced by board certified emergency physician led teams providing holistic, patient care consistent with Osteopathic philosophy.

The Board of Directors has discussed multiple strategies on how to strengthen our goals, and the staff is presently working on what strategies will best support these goals. I have listed a few strategies and they too will in all likelihood be refined. I would like to place our mission statement on our web page, in The Pulse, FastTrack, and at all our conferences. All members need to see and know our mission statement as it represents who we are and why we exist as a college.

This is the direction that the American College of Osteopathic Physicians Board of Directors has chosen to propel us into the future. We have made no decisions that would jeopardize our Osteopathic heritage and hope to expand our membership by enlarging our outreach to non-osteopathic professionals and spreading the word of who and what we are. Prior to our strategic planning session, our hope was to have goals not only to meet the next two years but well beyond that time frame.

We also decided to update our values. Values are important as they serve as principles that guide the volunteer leaders and the professional staff of our organization. We have decided upon five values that will guide us into the future: 1. Accessibility Quality emergency care accessible by all is best provided in environments that support the interests of emergency care professionals. 2. Community Professional excellence and wellness is promoted by creating a sense of community that includes family, friends, and colleagues. 3. Diversity Diversity strengthens the emergency care team. We must represent all emergency medical professionals and not exclude members based on ethnicity, race, or gender.

5. Advocacy Advocacy is a critical duty of all emergency medicine professionals. We must all advocate on behalf of emergency medicine at the governmental level when it concerns our profession and especially our patients.

That is the reason we have listed the goals of the meeting as reaching 20162018. I believe we have accomplished our objective and look forward to promoting our mission, goals, and values at every meeting I attend. I am committed to this task as are all the board members. We will spread the word about one of the best-kept secrets in emergency medicine, the American College of Osteopathic Emergency Physicians. How about you? We are but fifteen voices. If every member of our College told one person every week about ACOEP, we would no longer be a secret. We would be the most-talked about “house” in the world of emergency medicine. Please join me and the Board of Directors to make this a reality. This is truly a moment in time that will make a difference in our future!

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MACRA Update Jeremy Tucker, DO, FACOEP

o, MACRA is not a new dance craze sweeping the nation. For background, the H.R. 2 Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was passed in April 2015 and is commonly known as the “doc fix” or “permanent SGR repeal.” While this was a welcome change from the periodic threats of Medicare payment reductions under the Sustainable Growth Rate (SGR) formula, there are other components of this law that are important to be knowledgeable about. First, the law did eliminate the automatic Medicare payment cuts based the old SGR formula, and additionally provides a yearly positive update of 0.5% through 2018. The second goal of this legislation is to accelerate the transition from fee-forservice to a quality based, value-driven model for providing care. In addition, it will

streamline their current quality reporting structure into one system. H.R. 2 also continues to fund Children’s Health Insurance Program which helps to cover low and middle income children who do not qualify for Medicaid but cannot obtain affordable insurance through parent’s employers or exchanges. There are two pathways to MACRA that phase in over the next decade. First is the Merit-based Incentive Payment System (MIPS). It combines the current Physician Quality Reporting System (PQRS), the Value Modifier, and the Medicare EHR incentive program into one single program based on quality, resource use, clinical practice improvement and meaningful use of certified EHR technology. Based on a composite score, the provider may receive an upward

adjustment, a downward adjustment, or no adjustment in Medicare rates. The maximum payment adjustment starts at 4% in 2019 and increases to 9% in 2022 and beyond. The other pathway is Alternative Payment Models (APM’s) which include Accountable Care Organizations (ACO’s), Patient Centered Medical Home’s (PCMH’s) and bundled payment models. APM’s also require certified EHR technology and quality measures and requires the entity to accept financial risk for monetary losses under the APM. We encourage all physicians to continue to research MACRA as well as check ACOEP’s website and social media outlets for updates and announcements. At Spring Seminar in Scottsdale, Arizona this March, Ray Quintero from the AOA will be giving an update lecture on MACRA.

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"DNR” continued from page 5 a patient’s life. Yet in some states, practitioners and healthcare organizations are recognizing a newer document called, Physicians Orders for Life Sustaining Treatment (POLST) in which seriously ill patients document their choices for end of life care, which is then signed by the patient and physician and placed in the patient’s permanent health record.2 As I dug for more answers, I found that basically the whole area regarding DNR, living wills, and POLST was written on shifting sands that change as the tide comes in and washes old findings away with new opinions. I think dealing with patients who wish no further treatment, who wish to just pass from this life to death without tubes and machines keeping them alive; a physician must honor the patient’s requests, ensure that the patient’s family understands the patient has made his or her stance understood and then maintain

the patient in a comfortable and safe environment until such time as their life ends.

paramedics

commonly

misinterpret

documents for end-of-life care choices, study finds.” ScienceDaily. ScienceDaily, 26 February 2015. www.sciencedaily.

I think the most moving information I found was written by a physician in a blog, called the Daily Beast. He stated, “In the event that I suffer from a terminal disease, once the point has been passed where a return to health or meaningful quality of life is no longer a realistic possibility, when further treatment will do nothing but fill my days with more of itself, then I want that treatment to end.3 (Endnotes) 1. D J McQuoid-Mason, Emergency medical treatment and ‘do not resuscitate’ orders: When can they be used? The South African Medical Journal. Vol 103, No 4, 2013. www.samj.org.za/index.php.samj/ article/view/6672/4490. 2. Wolters Kluwer Health: Lippincott Williams and Wilkins. “Emergency doctors and

com/releases/2015/02/15022611032.html. 3. Russell Saunders, When Doctors Ignore ‘Do Not Resuscitate’ Orders. www.

rescusitate-orders.htm.

References: • U nderstanding Living Wills and DNR Orders, Pa Patient Safety Advisory 2008 Dec”5(4): 111-7. Abstract. • http://patientsafetyauthority.org/ ADVISORIES/AdvisoryLibrary/2009/ Dec5(4)/Pages/111/aspx • Jessica Nutik Zitter, MD, A ‘Code Death’ for Dying Patients. New York Times, 2014, April 10. http://mobile. nytimes.com/blogs/well/2014/04/10/ a-better-way-to-help-dyingpatients/?referer

Bernard Heilicser DO, MS, FACEP, FACOEP-D

This is rather misleading, dangerous and portrays a ridiculous scenario. A patient with decision-making capacity has the autonomous right to make medical decisions for themselves. We can offer treatments, but it is their decision. The

Designating a POAHC allows you to have someone you trust to be “you” with all medical decisions (your soulmate). This cannot be contested, A Living Will kicks in when your physician determines you are terminal. Obviously, the POAHC is more applicable to your desires. The POLST is more comprehensive, but can be tedious.

a moron. He is violating the patient’s right to self-determination. Although, the legal action would probably be for battery and perhaps, wrongful life, he is ethically contradicting the do no harm principle. A discussion with the patient and family regarding palliative care would be a kind and meaningful alternative. Additionally, to suggest an ED doc and a drug representative can get a patient into a protocol without patient consent is absurd. Television, the internet and social media are very powerful influences in our society. Unfortunately, accuracy and responsibility are often secondary to sponsors and people’s fears and ignorance. We have an obligation to protect our patients with the truth and honesty.

So, our ED doc is acting in an inappropriate manner, and is, as suggested,

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when-doctors-ignore-do-not-

A Response to the Executive Director presence of an advance directive is in play when the patient cannot speak for themselves. A DNR essentially says “no CPR or extraordinary measures”. A Living Will is nice, but not as effective as a Power of Attorney for Health Care (POAHC). The relatively new, Physician’s Order for Life Sustaining Treatment (POLST), is gaining popularity.

thedailybeast.com/articles/2014/06/03/

Ethics Response to DNR In this issue of The Pulse, our outstanding Executive Director, Jan Wachtler, addresses the dilemma recently presented on Chicago Med. An ED doc decides to enroll a terminal lymphoma patient in a clinical trial. The problem is she is a Do Not Resuscitate (DNR) status, and wants to remain a DNR and does not want treatment. Somehow, the doc gets her in the protocol by contacting the drug representative. The patient regains decision-making capacity and sues the doc for his actions.

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a w c a p t r i d

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Palliative Care When a Patient’s Health Collides with Family Wishes. Mark Rosenberg, DO, MBA, FACOEP-D

imilar to the case described in the Executive Director’s article and commented in the Ethic section, I recently had a case that led to much debate and discussion on end-of-life issues and whose wishes should be followed. This case involved a 62 year-old female with advanced stage ovarian cancer. The patient had a seizure and was very difficult to arouse. A CT scan, following the seizure, revealed a large bleeding metastatic lesion in her brain. If we did nothing, she would be dead in a few hours. Her two daughters told us that their Mom was aware of her disease and did not want anything done that would prolong her suffering. At that point, it would have been relatively easy to make Mom a DNR with comfort care. But, in speaking with the family and listening to a recent conversation, it soon became more complex. Her daughters mentioned that at Christmas time, their Mom said if the cancer spread to her brain, she would only want comfort care measures. The only thing that was important to her was to say goodbye to her family, her grandchildren, which she did not get to do yet. An important part to all End-of-Life care is a family meeting. This can be done in the Emergency Department with a dedicated ED team member, while stabilizing care is provided to the patient. As we prepared for a family meeting to discuss next steps, our team was well aware of the dilemma we faced. This patient’s goals were inconsistent in terms of wanting to say goodbye while not doing anything if the cancer metastasized to her brain. In minutes we realized we needed more information.

he risk was tremendous as she may not even wake T up and we may prolong her suffering. We decided to get a neurosurgical consult to see if indeed Mom could survive the surgery. The neurosurgeon came down to the bedside, and agreed with the grave prognosis, but also felt there was a good chance Mom would wake from the surgery. So, do we keep Mom comfortable and symptom-free, knowing that she will never wake to say goodbye? Do we operate knowing that we may prolong her suffering? A family meeting was quickly assembled with five close members of the family. The facts, prognosis, and options were clear. The decision making was complex. Surgery or Comfort Care…. choosing either option would not prevent her impending

death. The answer came from our meeting with her family: Operate and pray. Three days after surgery, Mom went home with hospice care. She sent the hospital staff flowers when she went home. We sent her flowers two weeks later. She had spent the last two weeks of her life at home with her family saying goodbye, pain, and symptom free. The lesson we learn time and time again is we should not make this more difficult than it has to be. The tough decisions are the patients and their families to make. Not ours. We are there to listen, advise, and support the patient and family in meeting their End-of-Life goals.

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What Would You Do? Ethics in Emergency Medicine

Bernard Heilicser, DO, MS, FACEP, FACOEP-D

contentious. Who has jurisdiction? Although, the police paramedic has a profound concern for his team member, the ambulance in another town is not his jurisdictional authority for providing medical care. He may be initiating care in the hot zone, but is delivering the patient to the deployed ambulance in the town of the event. If advanced care beyond the scope of the EMS crew is being provided, he would have greater standing to maintain that level of treatment, and would be appropriate to assume responsibility. Otherwise, it is the EMS crew’s authority.

In this issue of The Pulse we will review the dilemma presented in the January, 2016 issue provided by a municipal EMS coordinator.

In considering the liability of this situation, it remains the EMS crew’s responsibility, and the SWAT Team medic would be assuming a precarious liability that would be difficult to defend.

A municipal EMS ambulance responded as a standby for SWAT Team activity. One of the SWAT team members was also a police paramedic from a neighboring community. He informed the EMS crew that if one of his members was shot he would be performing care in their ambulance, as it was “his show.”

Nevertheless, the optimal response would be to work together, with the EMS crew’s authority, through their medical control, and respect for the SWAT medic’s feelings. However, it should be observed if the SWAT medic’s emotional response to a colleague’s injury is preventing him from an objective approach to the situation.

How should the ambulance crew respond? This situation is challenging to all involved and can obviously be rather

If you have any cases that you would like to present or be reviewed in The Pulse, please email them to us ThePulse@acoep.org. Thank you.

"Opioid Epidemic” continued from page 4 goes to show they are fishing, or they will get up and leave since they know they are exposed. Other strategies for dealing with pain can include administering pain medication diluted in small fluid bolus rather than IV push. This still addresses pain but blunts the euphoric effects. However you choose to treat pain, try to maintain a regimented approach rather than go for the big guns every time. In many instances oral pain medication will suffice in cases where a patient is not vomiting and can tolerate oral therapy. They may be dismayed because they have an IV and want the good stuff but efficacious pain control can be obtained with oral medication in many instances. The last point is the use of available information to help screen out narcotic seeking patients. Many states, including mine, have state databases that are easily accessible that can give you a much broader picture of the patient’s recent medication fills outside your institution. Many problems can be headed off by taking a few extra minutes to query that database. Many EMR systems also integrate with local pharmacies and other network hospitals to pull in a patient’s medication profile. This is useful in reviewing what else they may be taking and also to help reconcile medication records of those who forgot to bring a current list. In closing, let me say that I am not an advocate of ignoring complaints of pain or dismissing a patient’s complaints. An astute provider has no problem recognizing and dealing with acute painful conditions in their department. What I am a strong believer in is providing safe, reasonable and compassionate care and stemming the tide of chronic medication abuse and addiction that is continuing to affects the lives of so many in the communities that we serve.

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Nurse Practitioner Certification by Examination: A Major Step in Validating Practice Margaret J. Carman DNP, RN, ACNP-BC, ENP-BC, FAEN and Karen Sue Hoyt PhD, RN, FNP-BC, CEN, FAEN, FAANP, FAAN

urses and emergency physicians have a great deal in common; both disciplines place first priority on managing each patient not as a condition, but as an individual who is also an integral part of the medical team, with their own personal treatment preferences. Many emergency physicians have had experience working with nurse practitioners (NPs) in emergency settings, but the various credentials of NPs it can make it confusing as to the level of competency and complexity which falls within their scope of practice. A recent partnership between the American Academy of Emergency Nurse Practitioners (AAENP) and the American Association of Nurse Practitioners Certification Program (AANPCP) has resulted in plans for the development of the first board certification by examination for nurse practitioners working in the emergency care setting. This is a major advancement in assisting emergency physicians to understand the role Emergency Nurse Practitioners (ENPs) and to also build on this essential physician-NP relationship. Nurse practitioners are board certified primarily according to their educational population of focus. Family nurse practitioners (FNPs) are trained in assessment and management of patient across the lifespan, with a focus on primary care. AAENP has

taken the position that, moving forward, FNP certification with specialty training for practice in the emergency department setting is the most appropriate preparation for ENP practice. The consensus model for Advanced Practice Registered Nurse (APRN) Regulation (AACN, 2008) guides certification by patient population; NPs who received their Masters education and

certification prior to implementation of the model may have received education and demonstrated competencies which extend beyond one specific population. Due to the lifespan scope of the ENP examination, only certified FNPs who meet eligibility criteria will be able to take the AANPCP Emergency NP examination. ENPs obtain graduate education from an accredited Master degree program. Curricula are designed to provide a solid foundation of pathophysiology, advanced physical assessment, pharmacology, and

role identification upon which the NP can build in coursework focused on clinical management for their specific population. ENPs then obtain additional training in acute care skills appropriate to ED practice, through continuing medical education or by attending one of the eight Emergency Nurse Practitioner academic programs currently available in the United States. The first ENP validation option has been available through the American Nurses Credentialing Center (ANCC) since 2013. The ANCC specialty certification is obtained by submission and review of a portfolio. Individuals with a minimum of 2000 hours ENP practice within the past three years and primary NP certification, as well as a minimum of 30 hour in continuing medical education focused in emergency care can apply for the credential of ENP-BC through provision of an exemplar of their expertise and peer evaluations. The Emergency Nurse Practitioner Certification (ENP-C) examination will soon provide another method of NP validation. The AANPCP (www.aanpcert.org) and AAENP (www.aaenp-natl.org) collaboration will provide a certification program that aligns with the APRN Consensus Model (Fig.1) for specialty nursing practice and meets national accreditation standards. Individuals practicing in the emergency care Continued on Page 13

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"Nurse Practitioner” continued from page 12

"Patient-Physician ” continued from page 6

setting who seek certification are eligible to take the examination, provided that they have completed an appropriate graduate degree and have primary certification as a family, adult-gerontology or pediatric acute care, adult-gerontology or pediatric primary care nurse practitioner. It is anticipated that in the future, all nurse practitioners seeking initial certification will be educated in a formal Emergency Nurse Practitioner program.

concepts behind the PCMH. The primary care physician schedules regular checkups to identify potential health issues before they become a problem. He or she also discusses preventative steps that patients can take to protect their health, such as better glucose control, weight reduction, or smoking cessation. By taking a proactive approach to one’s health, the patient can potentially decrease the likelihood of a health crisis that requires a trip to the emergency room.

Details regarding the ENP-C launch date, eligibility criteria, and application process will be posted on the organizations’ websites when this information is available. The anticipated “go live’ date at this time is January 1, 2017. This collaboration between professional nursing and medical organizations, as well as a recognized accreditation body is an exciting achievement and one which presents the opportunity for a long and highly regarded relationship between emergency nurse practitioners and their emergency physician colleagues. American Association of Colleges of Nursing APRN Consensus Work Group and National Council of State Boards of Nursing APRN Advisory Committee (2008). Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education. Washington DC. :

Figure 1. Building an APRN Curriculum within the Consensus APRN Regulatory Model, AACN 2012. (http://www.aacn.nche. edu/geriatric-nursing/Adult-Gero-ACNPCompetencies.pdf)

Because the emphasis is on preventative medicine, the PCMH saves patients money and makes it less likely that a patient will need expensive emergency care. Since a personal physician helps coordinate care, patients should not receive unnecessary or redundant tests, prescriptions, or treatments from professionals who are not familiar with the patient’s health care. The PCMH is rooted in the idea of a holistic approach to health care. Since a personal physician is the patient’s constant provider and liaison for health concerns, he or she forms a true relationship with the patient on both a medical and a personal level. Having a strong relationship with a primary care physician empowers the patient to make good health choices. Also, if specialists are involved in a patient’s care, they have easy access to the patient’s personal care physician and medical records that will assist them in their evaluations. With emphasis on a patient-centered, holistic approach to medical care, the PCMH truly fits the model of osteopathic medicine. It was not surprising to find that the Joint Principles for the PatientCentered Medical Home were developed by four primary care societies: the American Osteopathic Association (AOA), American Academy of Family Physicians, American Academy of Pediatrics, and American College of Physicians. The AOA is also a proud member of the PatientCentered Primary Care Collaborative Board of Directors and Executive Council.

The above description of the PCMH is meant to provide emergency physicians with an overview of this healthcare model. Patient-centered medical homes are specially accredited facilities, and they are appearing in the communities that are served by our hospitals. An emergency physician might ask, “How does the PCMH impact care in the emergency department?” We need to be aware of the PCMH and use its wealth of information to provide the best care for our patients. Also, there is a future plan to possibly extend the PCMH to include a specific hospital to provide emergency or in-patient care for patients. References • American Osteopathic Association http://www.osteopathic.org • Joint Principles of the PatientCentered Medical Home Published on Patient-Centered Primary Care Collaborative (http://www.pcpcc.net)

Explore ACOEP’s New Online Home!

Take a moment to look at ACOEP’s new, interactive website. Find the answers to your CME FAQs, peruse the member benefits, check out upcoming meetings, find a committee that fits your interests, and see the latest updates in the new blog.

www.acoep.org

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#WhyImaDO We asked you why you’re a DO and got great responses from members at every level. Here is a sampling of just some of the responses we got! I shadowed DOs while in high school. I immediately recognized there was a difference in their approach to their patient, their interaction with staff, and their overall happiness with their careers. I don’t think I completely understood at the time but I knew I was only going one route and that was to be a DO. Since then I have stayed committed to my profession. I love being a DO. And I love that I have patients who appreciate my compassionate approach. - Stephanie Davis, DO

I had decided to pursue a career in medicine my junior year of college. I was committed to finish my degree in languages and then start my premed studies. My family doctor was a graduate of PCOM. When we talked about my desire to go to med school I was concerned about finishing my training at an older age. He told that in 10 years I could either be a doctor and 10 years older or I could just be 10 years older. My family doctor and PCOM administration were all down to earth. They were very personable and were interested in me as a person. I was not just a number on a price of paper.

I became a DO because I believed in the Osteopathic approach to patient care- the holistic approach to patient, treat the patient not the disease; the emphasis on primary care; and, structure and structure influences function. My decision to only pursue osteopathic medicine was based upon the exemplary qualities of osteopathic physicians that I met as I was growing up, during my college years and as mentors when I was an osteopathic medical student and resident. -Drew Koch, DO, FACOEP, ACOEP Board Member

I was a welterweight in New Hampshire back in ‘71-’72. Dr. Paul Sharky was an old middleweight from NYC and he was our “Family Doc”. He mentored me in his office above the old “5 & 10” store. He shared Osteopathic thought, technique, and practice while I attended the University of NH. He was in my corner while I applied to the COM and after graduation. I still respect the 1950 vintage books he handed down to me, the memories, and teachings he shared with me. Mentors shape our lives. - William Bograkos, MA, DO, FACOEP, FACOFP, COL, MC, FS

- Chris Giesa, DO, FACOEP, ACOEP President Elect

I was first exposed to DOs in St.Louis by Terry Weis, DO an orthopedic surgeon there. He is loved by his patients and always seems to care for more than the diagnosis. It was an inspiring reason to join the DO community.

Get in on the conversation! Next issue we invite you to share the best advice you were ever given. Was it from a mentor? Patient? Nurse? Family member? What did they say? Email ThePulse@acoep.org or share it on social media using #AdviceintheED

-John Downing, DO, ACOEP RC President

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Austin San Antonio Northeast Texas Dallas/Fort Worth Texas Hill Country Bryan/College Station

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Literature Update Spring 2016 Amanda Ellis DO and John Ashurst DO, MSc

A New Trick for Nausea Management

nausea relief as compared to a placebo.

Reference: Beadle KL, Helbling AR, Love SL, April MD, and Hunter CJ. Isopropyl alcohol nasal inhalation for nausea in the Emergency Department: A Randomized Controlled Trial. Ann of Emergency Med. 2015 Nov 21 epub ahead of print.

Commentary: This study suggests that the use of nasally inhaled isopropyl alcohol could benefit adult patients who present to the ED with a chief complaint of nausea and vomiting. Although this study is limited in size, it does show promise due to the participants reporting reduction of nausea in the isopropyl group as well as improved satisfaction over the placebo group. Nasally inhaled isopropyl alcohol offers ease of use by its very nature of delivery, is inexpensive and readily accessible. Therefore in the undifferentiated adult patient that presents to the ED for nausea and vomiting, having the patient inhale isopropyl alcohol nasally from an alcohol pad may provide shortterm benefit until further treatment can be started.

What we know: Nausea is one of the most common complaints addressed in the Emergency Department with antiemetics being used as a first line treatment option. However, multiple randomized control trials have not been able to show superiority over placebo. Alternatively, studies have demonstrated that inhaled isopropyl alcohol has been shown to be more effective than saline solution in treating postoperative nausea and vomiting. Article Review: In this randomized double-blind, placebo controlled trail, adults with a chief complaint of nausea or vomiting were enrolled. Patients were randomized into groups that either received nasally inhaled isopropyl alcohol or nasally inhaled normal saline. The primary outcome was reduction in nausea 10 minutes post treatment while secondary outcomes were patient satisfaction and pain reduction. A total of 80 patients completed the study protocol. The median nausea verbal numeric response scale score was 3 in the isopropyl treated group and 6 in the saline treated group. The median satisfaction score in the isopropyl treated group was 4 versus 2 in the saline treated group. There was no noted difference in pain amongst the two groups. The authors concluded that inhaled isopropyl alcohol has increased

Oral Dexamethasone Asthma Management

for

Pediatric

Reference: Cronin JJ, McCoy S, Kennedy U et al. A Randomized Trial of Single-Dose Oral Dexamethasone Versus Multidose Prednisolone for Acute Exacerbation of Asthma in Children who attend the Emergency Department. Ann Emergency Med. 2015 Oct. 10 What We Know: Prednisolone is the most commonly used corticosteroid in the pediatric population. However, compliance can be reduced due to the prolonged treatment, bitter taste and vomiting that is associated with its use. Article Review: This was a randomized, open-label, non-inferiority study comparing the use of oral dexamethasone

(0.3 mg/kg) with prednisolone (1 mg/kg) in known asthmatic patients between the ages of 2 and 16. Primary outcome measure was Pediatric Respiratory Assessment Measure (PRAM) score at day 4. Secondary outcome measures included further steroid use, vomiting of study medication, hospital admission, and unscheduled return visits to a health care provider within 14 days. When comparing mean PRAM score at 4 days, there was no difference between the two groups (dexamethasone group 0.91 versus prednisolone group 0.91, absolute difference 0.005, and 95% CI -0.35 to 0.34). As for secondary outcome measures; no patients in the dexamethasone groups experienced vomiting while 14 patients prednisolone group vomited at least 1 dose, 13.1% of the dexamethasone group needed additional systemic steroids at 14 days as compared to 4.2% in the prednisolone group but there was no difference between hospital admission rates and unscheduled return visits amongst the two groups. Commentary: The bitter taste and vomiting associated with oral preparations of prednisolone in conjunction with frequent dosing, makes compliance an issue. This study attempted to demonstrate noninferiority when comparing dexamethasone to prednisolone in the pediatric population. Results show that PRAM score on day 4 was not significantly different between the two groups. There was also no difference found in hospitalization rates or unscheduled return visits between the two groups. Therefore, one might want to consider a single dose of dexamethasone (0.3mg/kg) in pediatric patients presenting with an asthma exacerbation.

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Risk Stratification Tools and a Single Troponin for Chest Pain Reference: Carlton EW, Khattab A, and Greaves K. Identifying Patients Suitable for Discharge after a single-presentation highsensitivity troponin result: A comparison of five established risk scores and two highsensitivity assays. Ann Emergency Med. 2015 Dec; 66 (6): 635-645. What We Know: Patients with suspected cardiac chest pain account for 6 million ED visits annually across the United States. Current guidelines recommend serial cardiac markers between 6 to 12 hours after presentation, before a patient can be safely discharged. Despite the recommendation, only 15-25% of patients receive a final diagnosis of acute coronary syndrome. Article Review: This was a prospective observational study conducted in the United Kingdom with a primary endpoint of myocardial infarction within 30 days. Patients were enrolled if they were suspected of having ACS whom would be undergoing serial high sensitivity troponin testing and were also low risk as defined by modified Goldman, TIMI, GRACE, HEART, and Vancouver Chest Pain Rule. A total of 867 patients underwent high-sensitivity troponin I analysis and subsequent risk stratification based on the five risk assessment scores. The use of TIMI score of 0 or less than or equal to 1 and a modified Goldman score less than or equal to 1 with high-sensitivity troponin T had a negative predictive value of equal to or greater than 99.5% and identified greater than 30% of patients suitable for immediate discharge. Similarly, a negative

troponin I in conjunction with a TIMI score of 0 and a HEART score of less than or equal to 3 also had the potential to achieve a negative predictive value greater than or equal to 99.5% and identified greater than 30% of patients who were suitable for immediate discharge from the ED. Commentary: This study attempted to elucidate the use of high-sensitivity troponin T or troponin I assays in conjunction with low risk assessments scores to effectively rule-out patients who present to the ED for concerns of ACS. The implication is that it is likely that a patient with a single negative high-sensitive troponin T and low risk assessment based on TIMI or modified Goldman score can be safely discharged home. Similarly, the use of high-sensitive troponin I assay that is negative, in conjunction with a TIMI score of 0 or a HEART score <3 may be used to rule out ACS. Ultimately these results demonstrated that there is likely >30% of patients who present as ACS rule-out that could be safely discharged home with appropriate negative tests and a low risk assessment score from the ED. However, caution must be employed given the variation in high troponin assays currently in use. To Use tPa or not to use TPa; that is the question Reference: Badhiwala JH, Nassiri F, Alhazzani W, et al. Endovascular Thrombectomy for Acute Ischemic Stroke: A Meta-analysis. JAMA 2015 Nov 3; 314(17):1832-43. What we know: In acute ischemic stroke, endovascular intervention

improves revascularization. Alternatively intravenous tPA can also but used to treat acute ischemic stroke. However the use of tPA has a narrow therapeutic window and subsequent complications, such as the risk of bleeding. Therefore, defining the effect of endovascular intervention on specific subgroups is important and to date has not been studied. Article Review: This study was a metaanalysis reviewing known data from randomized clinical trials that looked at endovascular therapy with mechanical thrombectomy versus standard medical treatment, including tPA. The main outcomes and measures that were analyzed included, ordinal improvement across modified Rankin scale scores at 90 days, functional independence at 90 days, angiographic revascularization at 24 hours, symptomatic intracranial hemorrhage within 90 days, and all-cause mortality at 90 days. Data was reviewed from 8 studies involving 2423 patients. One thousand one-hundred thirteen patients underwent endovascular thrombectomy and 1110 underwent standard medical care with tPA. Endovascular treatment showed a significant proportional benefit across modified Rankin scale score at 90 days (p=0.005). The group that received endovascular treatment also had significantly higher rates of angiographic revascularization at 24 hours as compared to the standard medical therapy (75.8% vs 34.1%; p<0.001). There was no significant difference in the amount of intracranial hemorrhages (5.7% vs 5.1;p= 0.53) or deaths at 90 days(15.8% vs 17.8%; p=0.27) amongst the two groups. The authors from this meta-analysis concluded that patients who underwent endovascular therapy

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for acute ischemic stroke had better outcomes when compare to patients that received tPA.

from the emergency department with a diagnosis of peripheral vertigo. Ann of Neurology. 2016; 79(1): 32 – 41.

Commentary: This meta-analysis shows that endovascular treatment for acute ischemic stroke has improved functional outcomes at 90 days with improved revascularization at 24 hours when compared to standard medical treatment, mainly tPA. Furthermore this meta-anaylsis demonstrates that endovascularization does not increase the likelihood of symptomatic intracranial hemorrhage or increase all-cause mortality at 90 days. Therefore this suggests that endovascular treatment with mechanical thrombectomy may have benefits over standard medical treatment in acute ischemic stroke with associated risks no different than standard medical treatment, i.e. tPA.

What we know: Dizziness accounts for 2.5% of all US emergency department visits each year and has increased by almost 90% over the last decade. A posterior CVA may also present with a chief complaint of dizziness and may go overlooked in the initial acute setting.

Did I Just Miss a Posterior CVA? Reference: Atzema CL, Grewal K, Lu H et al. Outcomes among patients discharged

Article Review: This was a retrospective, population based, cohort study from Ontario Canada. The purpose of the study was to assess the frequency of stroke and accidents in both the short term and long term in those diagnosed with a peripheral vestibular disorder as compared to a matched patient population (renal colic). A total of 41,794 patients qualified for enrollment between 2006 and 2011. At 7, 30, 90 and 365 days the percentage of patients hospitalized for stroke was 0.14%, 0.19%, 0.25% and 0.41% respectively. After matching to a patient population for renal

colic, a relative risk of 50 was seen at 7 days and 9.3 at 30 days for stroke. Accidental injury varied from 0.01% (falls) to 0.15% (fractures) at 30 days. When compared to the matched group of renal colic patients, there was no difference in the risk of accidental injury. Commentary: Based upon the results, the risk of stroke is relatively low in those diagnosed and discharged with a “peripheral vestibular disorder”. However, once compared to a “matched” grouping of patients there is a stark difference in the relative risk of stroke in those diagnosed with a “peripheral vestibular disorder”. The clinician should use a heightened awareness in order to not miss those patients with a CVA.

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When it’s Our Turn Frank D. Gabrin, DO

woke up alone on a stretcher feeling disoriented and drugged. I had horrible epigastric abdominal pain and felt like I was about to throw up. What was going on? I couldn’t remember anything. I had on two pairs of underwear, jeans, but no shirt. My shoes and socks were still on. I wasn’t in a hospital gown. My wallet and keys were in my pants pockets but I had no cell phone. I had an IV of NS hanging that had gone dry. The curtain in front of me was wide open and I saw all sorts of lab coat lengths and quickly realized that I must be in an Emergency Department at a teaching hospital. What city was I in? Which hospital? How did I get here? I thought backwards. I remembered working a brutal 12 hour night shift in my ER and the drive home in the morning. I’d had horrible abdominal pain most of the shift and it was even worse by the time I’d gotten home. All I wanted to do when I got home was fall asleep so that I could escape the abdominal pain I was feeling. A few years back, I developed chronic intermittent abdominal pain after an ERCP to remove a stone in my common bile duct. I was told by my gastroenterologist that I had developed chronic pancreatitis. He told me that I was going to have to learn to live with it. I figured the abdominal pain I was having that morning was just due to my chronic pancreatitis. I remembered eating a few Rolaids and taking some Zantac and Nexium with a fizzing glass of Alka Seltzer. I watched a half hour of TV news, took some Benadryl and laid down in my bed. I couldn’t fall asleep. I got up and took an Ambien and laid back down. I still couldn’t sleep. My bellyache was really bad. I got up and took a big shot of vodka and laid back down. The last thing

I remember was laying in my bed praying for sleep. Now I am on a stretcher in an ER at a teaching hospital. I tried to reach for the call button that was coiled up and hanging on the wall behind me. As I moved, something was bugging me on my lower back. I reached back there to find a bandaid in the midline over the L4-L5 area. What? I had a spinal tap? I had no recollection of that at all. Suddenly, I panicked. My mouth went dry. My heart was pounding and I became shaky. I had an urgent need for information. All those people running around in front of me I felt like I was invisible. I decided to stand up so that I could get to the call button. All

After the nurse got to my bedside and slammed the side rail back into place, I got a good talking down to. He set limits and explained what the rules were. Then he put the call button in my hand wrapped my fingers around it and stormed away from my bedside just as quickly as he had arrived, obviously very proud of himself. Everyone, and I do mean everyone, saw (and heard) what he did and what he said to me. During that interaction, I was not allowed to ask any questions. He clearly had no interest in helping me: His only goal was to publicly shame and humiliate me so that I would “behave.” So what was I supposed to do now? Press the call button? That would have just made things worse.

I t is so easy for us to objectify our patients and treat them as caricatures of their dis-ease. I wanted was to talk to someone, anybody who knew anything about me. As I stood up, my illusions of being invisible were shattered. A really young, burly male nurse bellowed from the nurses’ station, “Get back in bed before you fall down and hurt yourself!” I recognized the tone and I realized that he was talking to me as if I was a “drunk!” I told him that I was just trying to get my call button. He lurched in my direction in a very aggressive way and started running towards me. It became clear to me that he planned to “put me back in bed.” Thank god I am an ED Doc, for I knew that if I did not get back on the stretcher at that very moment, security would be called and the next thing I would be telling you is that they put me in leather restraints. I sat down and got myself back into the stretcher.

I was super shaky and adrenalin was running through every cell in my body. My mouth was so dry I wondered if I could even talk. I was even more panicked than I was before. I still did not know where I was, how I had gotten here, how long I had been here, what other tests besides the spinal tap they had done? Did they know that I was having really intense abdominal pain and nausea? With the call button in my hand, my fingers wrapped around it, I couldn’t bring myself to press the button. After that public display, I felt that there was little, if any hope, that anyone would see me as anything but that “unruly drunk guy.” It took me a little while to get myself together, for my heart rate to slow and saliva to return to my mouth, and just a little longer to summon up the courage to press my call button. The flashing light above my bed went off and I could hear the ringing at

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the nurses’ station which was right in front of me. It seemed like forever before someone answered and asked if they could help me. I asked for my nurse to come to my room. By this time, I had spotted a clock on the wall. It was 11:30, but was it AM or PM? Knowing that I’d had a spinal tap, I figured out that it must be PM. The last hour I remembered was 10:30 AM and I was in my own bed. Thirteen hours were lost. As my nurse walked up to my bedside, before I had a chance to speak, she began to tell me that I was already admitted and that she was just waiting for my bed to be ready so she could call report. I said hello and thanked her for that information and told her I had some questions. She said, “Oh? OK.” I said, “Before I ask my questions, I want you to know that I am an ED physician, I don’t usually drink and I am not an alcoholic.” I explained to her that the last thing I remembered was being in my bed trying to fall asleep at about 10:30 this morning. A little while ago I’d woken up on this stretcher and found a bandaid over my spine and realized that someone had already done a spinal tap and I had no recollection of the procedure. I told her that I didn’t even know where I was, how I’d gotten here and/ or what was happening to me. I asked her if she could please fill in the blanks for me. She said, “Oh, I’m sorry, but I can’t answer those questions. All they told me in report was that everything is done, the orders are written and all I had to do was call report when the bed was ready. I have not had time yet to look at your chart. Let me go and read your chart. I will come back and try to help you.” About an hour later she returned. She told me that I’d arrived by ambulance, that I was being worked up for confusion, that I had a 21,000 white blood cell count with bands and a left shift and that my CT and my LP were both negative. I asked if “they” knew that I have a history of chronic pancreatitis and that I was having horrible epigastric pain and nausea. She said nobody mentioned that. I asked if I could talk to the ED attending. She went to ask, and about twenty minutes later she returned

and said that the attending currently on duty hadn’t seen me, and that the attending who’d seen me earlier, had already gone home. Since I’d already been admitted, I’d have to speak with one of the doctors on my “team.” I asked her to ask the doctor on my team to come speak to me. Later she returned to let me know that doctor was tied up with an emergency on the floors and would speak to me once I was settled in my room. My inpatient bed was not ready and there was no telling when it would be.

myself to my ED at a community hospital. I was febrile, jaundiced, hypotensive and tachycardic. Labs showed that I was in full blown multi system organ failure and sepsis. CT and MRCP showed a large stone in my common bile duct causing complete obstruction along with a pancreatic phlegmon. They were unable to remove the stone at my community hospital so I had to go back to the tertiary care center where I was treated so badly. I elected to go there as an outpatient.

I said, “Well then, can you get me a paper scrub top and take out this IV?” She asked me why and I said, “Well I am not going to allow myself to be admitted to the hospital under these circumstances, especially if no one is willing to talk with me or tell me what

After an office visit with a high powered gastroenterologist I had the ERCP with ultrasonic guidance done as a same day procedure. They were able to remove the stone and place a metal stent in my common bile duct. Later that evening, after the anesthesia wore off, the pain I began to experience was really bad. I waited almost a week, as the pain got worse, before I realized that I had no choice except to go back to that same awful ER because my pain was completely unbearable. My pain was so bad I could hardly breathe. When I arrived in triage, it was clear that I was obviously in distress. They actually rushed me back to a room. I waited almost a week to go back there because I knew that as soon as they read my “old” chart, they again would not take me seriously and the label of “drunk” would again be applied.

is going on.” She said, “Let me page your doctor again and let them know how you feel.” She returned fairly quickly and told me they were still tied up and couldn’t come talk to me right now. I told her that it was clear to me that I’d been labeled as a “drunk,” and that no one here, except her, felt that I deserved even the time of day. I told her that I have never been treated with such disrespect and prejudice. She went to get the paper scrub top. She apologized to me as she took out my IV, and asked me again to stay. I said thanks, but no thanks. I walked outside, got into a cab and went home. Over the next four days my abdominal pain and nausea only got worse. I drove

Actually it did not even take that long, as soon as I said the word pancreatitis, everything changed. When I asked the ED Attending for some pain medicine I was matter of factly denied and was told that I would have to wait for all the test results to come back first. She was kind enough to start an IV and give me some Zofran for nausea. The ED doc who refused to give me pain medicine must have been embarrassed when the work up was complete because she sent the GI Fellow to tell me that the workup in the ED showed that I had developed post procedure necrotizing pancreatitis. It looked like I had already lost about 13% of my pancreas based on the CT scan. I looked at the GI fellow and said can I

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please have some pain medicine now? I was admitted and taken back to the GI lab to have a PEG-J tube placed to facilitate complete gut rest, I remained in the hospital for almost a month. That fateful night in the ED, when I was treated as if I were just a “drunk,” was about five months ago. I have not been able to work since that night. I have lost 40 pounds. I am malnourished and run down, currently battling a bad case of shingles. I still have the PEG-J and I do six tube feedings a day. I have not been allowed to have even fluids by mouth yet. The visiting nurse comes twice a week. I hope and pray that when I see GI this coming week, they will give me permission to start clear liquids. This illness has been devastating and catastrophic for me. It will be a couple more months before I will be strong enough to go back to work in the ED. Had I not been treated with such a lack of human dignity and respect, would I have signed out AMA? We all took an oath to do no harm. I don’t remember what happened in those 13 hours that I lost, but once I was awake and coherent, no doctor would even take the time to come to talk with me. I will never know how much harm may have happened to me as a result of my decision to leave AMA. Things might turned out exactly the same, but I should not have to wonder about a different outcome.

in a derogatory manner. Our perceptions of people become dehumanized. It is so easy for us to objectify our patients and treat them as caricatures of their dis-ease. This gives us the ability to depersonalize them so that we no longer see them as people, we give ourselves permission, to care less. I hope that no one reading this ever has to be on the other side of the stethoscope of a doctor, nurse or even a medic who has become so desensitized and burned out that they have lost their concern or respect for the very patient they have a duty to care for. My intention in writing all of this is to say, we can do better. I know first hand that this sort of thing happens in ED’s all across this country each and every day. I know because I could have given the same speech the male nurse gave to me demanding that I stay in bed. I have treated alcoholics this way. I have seen other ED docs tell ED nurses that they will not go to speak with a patient who has questions they would like answered before they go to their inpatient bed. “They are not my patient any more. They are admitted and they will have to talk with their doctor on the floor.” I believe that we all became physicians because we wanted to care. I also believe that caring for others should be one of the most rewarding jobs on the planet. Care is an intangible thing and care, like love,

is a transaction that occurs between two people. Care can’t happen at our computer stations. Care asks us to stand up and walk to our patient’s bedside. Make a connection with them and begin to understand their fear or their pain. Just connecting with them will naturally move us into a state of affective empathy, where we begin to feel their discomfort. If we allow our natural curiosity to carry us to the state of cognitive empathy where we ask what it would be like to be in their shoes we will automatically be transported to the state of compassion, where we honestly want to do something to make things better for both of us. This is where the transaction of care happens. It is at the bedside where real healing begins. The cure for our own dis-ease of burnout lies within our own participation in the transaction of care. When we miss the opportunity to care, to make a difference and change things for our patients and ourselves, we miss the opportunity to feel good about who we are and what we do. As a result of our omission of care, our own burnout gets a little worse. If we continue to practice this way we will never get what we really wanted in the first place, which was the opportunity to care. Our own dis-ease called burn out will surely worsen, both collectively and personally. Please, go care, make a difference and change (y)our world.

Had I stayed, maybe I would not have developed multi system organ failure and sepsis as a result of a large stone in my common bile duct. What if I could have had the ERCP before I got so sick? Would I have developed post procedure necrotizing pancreatitis? That first night, would I have stayed if a physician, any physician, had come to hear my concerns? Probably. We all know that since they started looking, burnout is on the rise among all ED physicians. Were the ED physicians involved in my care suffering from burnout? If you believe the statistics, they probably were. One of the symptoms of our burnout is that we label people or groups of people

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What is a COLA? What the New Physician Needs to Know Megan Koenig , DO, FACOEP

any of you may have heard colleagues complain about the daunting COLA requirements that loom over our heads each recertification cycle! But most of us have no clue what COLA stands for, let alone what they are, where to find them or what they mean with regards to our certification. The fact is they are really pretty simple, just another hoop to jump through for recertification. Once you are officially board certified in EM, your certificate will state an expiration date 10 years away. By this date you must complete a handful of things, but for the sake of time and space in this email I am only going to go into detail on COLA’s. You can review the rest of the details on pages 17-20 in our membership packet (www. acoep.org/npip). WHAT IS A COLA (Continuous Osteopathic Learning Assessment)? A COLA module involves reading multiple articles from the literature and then completing an online examination regarding those articles. Each COLA contains 40 questions on emergency medicine core content categories. A list of the specific references/articles are provided by the AOBEM but access to them is not. (http:// aobem.org/continuous.shtml) Each physician must take and pass a minimum of eight COLA modules within a 10-year cycle. Each candidate has a maximum of three opportunities to pass each. A new COLA module is available each year and each COLA is only available for a three year period. After that you will pay an expired fee.

If you register and pay for the COLA before it expires but don’t actually get around to completing the questions until after the three year expiration period, you should contact AOBEM to discuss. In the past they have honored this and given you access and credit, but is obviously not the desired or recommended method. Any COLA that is still downloadable online (expired or current) is available for you to complete, regardless of when you graduated from residency. For instance, if you graduated in July 2015, you can still complete a COLA from 2012 if it is still available to download on AOBEM. HOW MUCH DOES IT COST? $105/COLA Module $210/Expired COLA Module The catch is that this fee simply provides you the reference information for the articles, access to the test and the CME credits (8, 1-B credits). You then have to go out and find/obtain rights to the articles, which in some cases requires an additional payment through the specific Journals to have access to the articles. TRICKS OF THE TRADE: Those who have walked before us have some insight into ways to help decrease how much of a pain these can be: • ACOEP COLA REVIEWS: Every spring the ACOEP hosts a COLA review the Thursday evening of the conference. It is five hours long, and thoroughly presents and summarizes each article, then reviews each question and answer to ensure you pass on the first go-around. It also

includes dinner. Worth five (1-A) credits for the course in addition to the eight (1-B) credits for completing the COLA. $200/review • DIGITAL CLASSROOM: You can also access recorded versions of past COLA reviews through the ACOEP digital classroom. The question and answer portion of the live COLA review will be edited out of the online version for academic integrity purposes. You can still obtain the answers but it will be necessary to listen to the entire recorded lecture rather than just fast forwarding to the end for answers. Worth two (1-B) credits. $50/review. (www.acoep. org/classroom) • STUDY GROUPS: Some people get with a group of friends from residency or work to share in the total cost of obtaining all the articles, and they alternate years they are responsible for purchasing the articles. • GET YOUR COMPANY TO PAY FOR IT: Some physicians work for companies that either help supply them with the articles through their hospital sources and/or include this in any CME stipends/reimbursements. POWER: Some • A LULMNI residencies actually purchase these articles annually through their university or hospital resources and send them out to its past residents each year. This serves as a great way for programs to keep in touch with alumni as well as a great reminder that it is time to do another test.

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ACOEP Digital The ACOEP Digital app is your hub for conference information, course materials, and more! It’s custom tailored to fit your digital life!

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Available for all smartphones and tablets, this free app allows you to access current and past course materials, create custom schedules, explore didactic topics, and much more!

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To download, search “ACOEP” in your phone’s app store. THE PULSE | APRIL 2016

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Member News ACOEP’s members are always making headlines and exciting changes. Email ThePulse@acoep.org and share what you’ve been up to!

Along with his wife and daughter, ACOEP’s Immediate Past President Mark Mitchell, DO, FACOEP, FACEP have launched Choice Customer Care, a company that developed a bedside tablet for the most frequently reported issues. Dr. Mitchell says, “We have developed a product that will replace the age old “nurses’ call button” in hospitals. The request will be routed to the specific individual who is accountable to fulfill the request. It will track response times and re-route the request if not fulfilled in a timely manner.”

ACOEP’s William Bograkos, MA, DO, FACOEP, FACOFP, COL, MC, FS, USA presented at the first INTERPOL Bioterrorism conference. Here he is with Ron Noble, Secretary General of INTERPOL. Dr. Bograkos was recently invited to speak at the Nordic DEA conference in Copenhagen Denmark. COL Bograkos

received his MA in National Security from the Naval War College. His area of study was Irregular Warfare/Narcoterrorism and is the President Elect of AOAAM addiction medicine and is looking forward towards working with emergency medicine stakeholders as the nation addresses the opiate epidemic.

WE WANT TO HEAR FROM YOU!

Emergency Physicians do incredible things every day and we want your stories! ACOEP Executive Director Jan Wachtler has just published her second novel! Written under the name Jan Jospeh, Lost Boy, follows the frantic search for a kidnapped child. “These books run the gamut of genres, from mystery to suspense and the paranormal. We are thrilled to be the publisher,” said Robert Fletcher, CEO of Strategic Book Publishing and Rights Agency. You can find this book, as well as Jan’s first novel, Vanished: The Search for Sally Hunt on Amazon.com.

Send your story ideas to ThePulse@acoep.org, we would love to share your experience with our members. We also encourage you to email ThePulse@acoep.org to share your thoughts on specific articles that you read here. We want to keep the conversation rolling, whether you agree or disagree with a point of view represented in our articles, we want to highlight various perspectives from our diverse membership.

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Emergency Medicine Residency Program Director Hershey, PA

Emergency Medicine Physician Hershey, PA

Pediatric Emergency Medicine Physician Hershey, PA

Emergency Medicine Physician Carlisle Regional Medical Center Carlisle, PA

The Emergency Medicine Department at Penn State Milton S. Hershey Medical Center seeks energetic, highly motivated and talented physicians to join our Penn State Hershey family. Opportunities exist in both teaching and community hospital sites. This is an excellent opportunity from both an academic and a clinical perspective. As one of Pennsylvania’s busiest Emergency Departments with 26+ physicians treating over 70,000 patients annually, Penn State Hershey is a Magnet® healthcare organization and the only Level 1 Adult and Level 1 Pediatric Trauma Center in PA with state-of-the-art resuscitation/trauma bays, incorporated Pediatric Emergency Department and Observation Unit, along with our Life Lion Flight Critical Care and Ground EMS Division. We offer salaries commensurate with qualifications, relocation assistance, physician incentive program and a CME allowance. Our comprehensive benefit package includes health insurance, education assistance, retirement options, on-campus fitness center, day care, credit union and so much more! For your health, Hershey Medical Center is a smoke-free campus. Applicants must have graduated from an accredited Emergency Medicine Residency Program and be board-certified by ABEM. We seek candidates with strong interpersonal skills and the ability to work collaboratively within diverse academic and clinical environments. For additional information, please contact: Susan B. Promes, Professor and Chair, Department of Emergency Medicine, c/o Heather Peffley, Physician Recruiter, Penn State Hershey Medical Center, Mail Code A590, P.O. Box 850, 90 Hope Drive, Hershey, PA 17033-0850, Email: hpeffley@hmc.psu.edu OR apply online at www.pennstatehersheycareers.com/EDPhysicians The Penn State Milton S. Hershey Medical Center is committed to affirmative action, equal opportunity and the diversity of its workforce. Equal Opportunity Employer – Minorities/Women/Protected Veterans/Disabled.

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• A FOUNDATION DEDICATED TO RESEARCH IN OSTEOPATHIC EMERGENCY MEDICINE

budget, whether it be $5 or $250. A monthly donation of just $25 will add up to an impressive $300 per year! And, as you join with other monthly donors, your pledges accumulate to more than we could have ever raised by asking for just annual gifts. Sherry D. Turner, DO, MPH, FACOEP President

Foundation Focus MAKE IT MONTHLY

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It truly is the easiest way to make the biggest impact. Monthly donors enjoy: • A fast track to annual awards and recognition at the FOEM Legacy Gala. • The knowledge that your donation is put to work immediately. • The knowledge that your donation is combining with monthly pledges from

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other donors to make a significant impact on the organization’s mission. Hassle-free monthly donations. The ability to change or suspend your donation at any time. Automatic donation from your credit card or checking account. Complete statements provided for tax purposes. Quarterly newsletters on our progress.

So please, take just five minutes out of your day to give back to the profession that made you who you are today. Make your monthly donation quickly and easily at www.foem.org.

sifie FOEM Clas During a legendary speech in 2014, Dr. Joseph Kuchinski stood in front of the crowd at the FOEM Legacy Gala and urged attendees to not only give an annual gift, but to “make it monthly.” He collected monthly pledges from 10 other donors on the spot. Since then, he has personally given over $500 a month, making him the most successful donor in the Foundation’s history and earning him the Joseph and Florence Wachtler Spirit Award (presented to lifetime donors of over $50,000). While we do not expect everyone to be able to match Dr. Kuchinski’s enthusiasm, we do encourage everyone to give monthly at any amount that suits your

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arch g on a rese om in rk o w u Are yo benefit fr at would ct on project th your proje st o P ? ta ds more da h Classifie rc a se e R the FOEM cted with be conne to n o ti c se arch sites! other rese f the section o w e n r u o t put you Check ou and let us te si b e w cians FOEM llow physi fe h it w h c n help in tou rs that ca e h rc a se and re ! your goals you reach ifieds .org/class m e o .f w w w

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This annual competition takes place during the ACOEP Scientific Assembly and is open to residents and students that have completed a research project and would like to present it as a poster summarizing their findings.

FOEM Clinical Pathological Case Competition (CPC) WEDNESDAY, NOVEMBER 2, 2016 7:30am – 3:30pm

This exciting annual competition pits residents against faculty in diagnosing a difficult case. It takes place during the ACOEP Scientific Assembly. Residents submit the case without final diagnosis, and the faculty member is given one month to develop a diagnosis. Both residents and faculty submit PowerPoint presentations. Each program must have a resident and faculty member in order to participate.

FOEM Oral Abstract Competition WEDNESDAY, NOVEMBER 2, 2016 12:30pm – 3:30pm

FOEM Resident Research Paper Competition Sponsored by WEDNESDAY, NOVEMBER 2, 2016 11:00am – 12:30pm

This is FOEM’s most prestigious event. Participants submit their full research papers for review by a panel of physician experts. The panel identifies the top 3 papers prior to conference, and the winning resident-authors present their findings at the ACOEP Scientific Assembly annually.

The deadline to apply to the Foundation’s Fall Research Competitions is July 31, 2016. Apply now at www.foem.org FOEM BEACON | APRIL 2016 28 FOEM-2016-Comps-R2.indd Pulse-04-2016-R6.indd 28 1

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