The Pulse - July 2015 by ACOEP

the

Pulse

July 2015

Osteopathic Emergency Medicine Quarterly

Introducing:

ACOEP's Digital Classroom See page 23 for details

Presidential Viewpoints

| Mark A. Mitchell, DO, FACOEP-D

Our Other Team Members: Hospitalist Pulse-07-2015-R4.indd 1

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VOLUME XXXVI No. 3 Editorial Staff Timothy Cheslock, DO, FACOEP, Editor Drew A. Koch, DO, FACOEP-D, Assistant Editor Mark A. Mitchell, DO, FACOEP-D John C. Prestosh, DO, FACOEP Erin Sernoffsky, Association Editor Janice Wachtler, Executive Director Thomas Baxter, Media & Technology Specialist Editorial Committee Timothy Cheslock, DO, FACOEP, Chair Drew A. Koch, DO, FACOEP-D, Vice Chair John C. Prestosh, DO, FACOEP Board Liaison/Associate Editor Stephen Vetrano, DO, FACOEP Andrew Little, DO Erin Sernoffsky, Association Editor Thomas Baxter, Media & Technology Specialist 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. 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. 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 2015 – All rights reserved. Articles may not be reproduced without the expressed, written approval of the ACOEP and the author.

Pulse

the

The Pulse

Osteopathic Emergency Medicine Quarterly

Table of Contents Presidential Viewpoints...................................................................................................................3 Mark A. Mitchell, DO, FACOEP-D The Editor's Desk..........................................................................................................................4 Timothy Cheslock, DO, FACOEP Executive Director's Desk...............................................................................................................5 Janice Wachtler, BAE, CBA The On-Deck Circle........................................................................................................................6 John C. Prestosh, DO, FACOEP The Edge: Spring Seminar Recap....................................................................................................7 Eight Critical Security Measures You Need In Place NOW With Mobile Computing...................9 Joanna Sobran What Would You Do?..................................................................................................................11 Bernard Heilicser, DO, MS, FACEP, FACOEP-D Would You Do It Again?.............................................................................................................12 Duane Siberski, DO, FACOEP Emergency Care: Expanding Our Scope of Practice.....................................................................13 Frank Gabin, DO A Rare Cause of Facial Edema: The Sodium Hypochlorite Accident..........................................17 John Ashurst DO, MSc and Shawn Quinn DO 2015 ACOEP Board of Directors Election................................................................................19 Janice Wachtler, BAE, CBA The Vital Role of ENPs.............................................................................................................22 Jennifer Wilbeck, DNP, APRN-BC, CEN Welcome to ACOEP's Digital Classroom....................................................................................23 Foundation Focus..........................................................................................................................25 Sherry D. Turner, DO, FACOEP ACOEP-RC President’s Report...................................................................................................34 Andrew Little, DO

Editor's Note I hope you all enjoy this issue of The Pulse, it is chock full of great information from the College that should help keep you up to date on current events and happenings at ACOEP. Some of the highlights you will find include several articles on the healthcare team, from Dr. Mitchell’s discussion of the EM physicians role in interacting with hospitalist physicians, to an introductory article on Emergency Nurse Practitioners from one of our new partner affiliates. I discuss the osteopathic moment, which is a concept I hope you will all enjoy on keeping us true to our roots and making a conscience effort to remind yourself and others on a daily basis, why being an osteopathic physician is truly something special. Don’t miss the overview of the ACOEP’s new digital classroom. This will be an excellent resource for all our members. Helping to keep them abreast of current topics to help meet their educational needs. You will find articles from our regular contributors on ethics and physician wellness and also a piece from Dr. Siberski, one of our current board members, on an interesting discussion that took place at the Spring Seminar about his career choice. Finally, a recap of the Spring Seminar, information on the upcoming Scientific Assembly and board elections for 2015 round things out. Please share your feedback with me or the ACOEP staff about our publications. We want to keep you informed, entertained and interested in our publication. I welcome your comments. - Timothy Cheslock, DO, FACOEP

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Our Other Team Members: Hospitalist that we are continually focused on the everincreasing list of metrics. Most hospitals now have Hospitalists who are admitting a large percentage of patients who are hospitalized. This is a rapidly growing sector of healthcare, like emergency medicine is faced with a supply and demand issue. As emergency medicine and hospital medicine are both “hospital based” physician groups, we have many things in common. Between the two groups we are accountable for the majority of admitted patients from “door to door,” which is the from the time the patient arrives until they are discharged.

Presidential Viewpoints Mark A. Mitchell, DO, FACOEP-D

s healthcare continues to go through transitions, we in emergency medicine find ourselves in the midst of this change. We have to deal with many issues other healthcare providers don't have to think about, including issues surrounding patient discharge and safety. This situation only leads to more questions and decisions.

In order to maximize efficiency for those patients, we must have a good working relationship with hospitalists. It is a lot of pressure, but we are directly responsible for the care of many patients and the financial stability of the hospital. Therefore it is imperative that we have good lines of communication between us. I would like to pose some questions: • Do you have regular meetings between the medical directors of emergency medicine and hospital medicine? • Do you have regular scheduled meetings between the departments of emergency medicine and hospital medicine?

• H ow are disagreements between the two groups handled? • Do you have shared accountability metrics for issues such as boarding times and total length of stay? • How do you recognize and evaluate potential “readmissions?” • Do you have consultations being done in the emergency department by your hospitalist? As emergency physicians and hospitalists we are both faced with many challenges in today’s healthcare environment. However, if we work collaboratively we can assist each other. For example, if the hospitalist will make sure to round early on patients who will probably be discharged, this will free up beds for admissions from the ED and thus decrease boarding. There are occasions that we can order special exams such as CT, MRI, and US that will lead to a decreased length of stay for the admitted patients. This is because test we order are done as “stat” versus ones that are routinely scheduled. If you haven’t formed the working relationship with your hospitalist group, now is the time to take that first step. Call and set up a meeting between the two groups so you can begin a working relationship in which the patients are the winners.

Many emergency departments do not have the resources to assist emergency physicians to determine if the patient should be admitted or placed in an observation status. Many times this is not an obvious decision as the criteria seem to be ever-changing and we don’t know what the actual treatment will be once the patient leaves our department. We also have the added stress of not making the right decision. Patients who are admitted and have a “short stay” put the hospital at risk for audits. Also, patients placed in observation that actually meets criteria for admission means a significant loss of revenue for the hospital. Another major issue we face is making sure that all the quality metrics are met. This includes the historical “Core Measures” as well as the new measures under “Value Based Purchasing.” More and more of the reimbursement to the hospital is at risk and is contingent upon meeting many metrics. We have to make sure

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The Osteopathic Moment

The Editor's Desk

Timothy Cheslock, DO, FACOEP

here has been an enormous amount of change happening within our profession over the last year or so the movement towards a new single accreditation system for GME, the continued expansion of osteopathic schools, and the constant chatter about where the profession is headed. Most of the momentum has been in the positive direction, but I’m sure I'm not be the first to say that there are also some naysayers out there. The rumor mill is rampant that this is “the beginning of the end” for the osteopathic profession. I’ll admit, that I was skeptical at first of the motivation and reasoning behind some of the events that transpired leading up to our present situation. I can also say that I have had my fears allayed after discussion with many members of the AOA board and AOA leadership as well as recent updates from the AOA as to the forward momentum that has been made. I think that there is a long way to go but the time is here to take a moment and let the profession shine.

Embracing the Osteopathic Moment is something that I encourage each of you to do. It will not be the same for everyone and whether or not you choose to share it publicly is completely up to you. What are some examples of the osteopathic moment that I am talking about? Pause for a minute and think about what you do on a daily basis as you interact with your patients. How do you examine them? Consciously or not, the basis of an osteopathic exam has been ingrained in each of us. While I am not performing OMT on every patient I see, the subtle tissue changes that I palpate as I examine someone’s back or extremities or evaluate their headache trigger reminders and help focus a differential on many occasions. Other examples may be in your treatment and follow up plans. How often do you encourage patients that have an osteopathic primary care provider to ask about OMT treatments at their follow up? How many times a day can you say that you have fulfilled the core competency of osteopathic principles in your daily routine? That is what I am talking about. As I said, it doesn’t need to be overt or public. It can be a personal reflection, but why not share that with your patients and colleagues? It is amazing to me in general conversation how many patients I see in my department that say, “Oh you are an Osteopath, that’s great! All my doctors have been DOs.”

On a grand scale, Osteopathic Medicine has been thrown into the limelight with all that has taken place over the last year. At every opportunity we need to showcase what makes osteopathic medicine unique and special for us, our patients and healthcare. What is it that we are doing right, that many want to emulate, and how have we been able to do it for so many years with the masses not knowing what it is that we really do? It is often said that osteopathic medicine has been the best kept secret in healthcare. The time has come where we are no longer a secret and everyone wants to know our story. How we are ultimately defined is up to each of us, from those serving on the RRC committees, to our board members, faculty, residents, students, and each of us that practice in emergency departments throughout the country. We will define what osteopathic medicine will be for years to come. We can and should rise to the challenge that we have been issued—to spread the word and keep osteopathic medicine at the forefront of healthcare and make sure that everyone that we encounter understands why the care they are receiving is special and unique based on our osteopathic training, principles and practice.

So what is the Osteopathic Moment you may ask? It is a phrase that has come up in conversation recently with some other members while discussing what makes osteopaths and their training unique. It is taking a brief moment to define what makes you special, and a method of communicating this to others.

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Advocating for a Stronger Position was. Sometimes it’s not pleasant if you find yourself face-to-face with someone with an opposite point of view, but it feels oh so good when you see something you fought for become reality. You pull up your shoulders and say, “I did that!” How cool is that? You can only achieve that feeling by getting involved.

Executive Director's Desk Janice Wachtler, BAE, CBA

" We choose to go to the moon in this decade and do the other things, not because they are easy, but because they are hard, because that goal will serve to organize and measure the best of our energies and skills, because that challenge is one that we are willing to accept, one we are unwilling to postpone, and one which we intend to win." — John F. Kennedy, September 12, 1962

his quote inspired a generation to shoot for things beyond its reach; to do things once thought impossible and to achieve its goals. That generation, my generation, fought in Viet Nam, marched for Civil Rights and advocated for Equal Rights for all. We still are active in voicing our opinions to our congressmen and fighting for things that many now take for granted. So I ask, why?

I have always been someone who has had a big mouth, maybe it was because I was the youngest in a family of outspoken people and if you didn’t speak your mind you got trampled by those who would gladly speak your mind for you. So I guess it was pretty natural for me to be a teensy bit opinionated and outspoken. Over my lifetime, I’ve written more letters to officials about issues than I can name, but I know that in my collection of letters, I have responses from J. Edgar Hoover, FBI Director (who was pretty rude); Bowie Kuhn, the Commissioner of Baseball in the 1970’s, who addressed his letter to Mr. Jan Wachtler, to the head of ABC –TV, Roone Arledge, and the former Mayor of Chicago, Richard M. Daley. For the most part they acknowledge your opinion and say go away, don’t bother me, but sometimes, the things you speak about are the same things others speak about and your collective voice is heard. Your voice is an important feature in Washington, DC. They don’t always read your letters, or emails, usually they are read by someone in the office who doesn’t get paid very much, and they put your letter on a pile of for and against. These are then weighed or

measured and the outcome of this forwarded to your member of congress or senator. If you want to really be heard, though, make an appointment to visit them at home. Your cute little face in the home office raises all kinds of bells. Now they have a face to go with a name. They have time to see and hear you. But if you do visit, make sure that you are knowledgeable about whatever you’re speaking to them about – don’t waste their time or yours. With the SGR legislation pending, physicians as a whole sat and did little to urge their senators to stay in DC an extra day to take action before going on spring break. Somehow I think when they got to their home districts they were visited or contacted by physicians who are constituents because they voted on the bill fairly quickly. But this issue didn’t have to wait until the last minute, physicians could have driven the fact home far more quickly by writing, calling, or emailing their senators. All it takes is a little effort. Remember this, you don’t have to advocate for something in person; you don’t have to scream and yell, but you have to be knowledgeable and involved. Being a citizen is not only casting your vote, it’s providing input to the people you put in office. So get out there and be heard – fight for issues you believe in and always be true to the issues you support. Don’t do it because you have to – advocate for issues because you believe in them and want to. If everyone did this, we would rock the world!

Nothing comes easy in life, we know that. If you want to have a career and be successful, you choose to do so because you realize it will take work to attain your goal. If you weren’t interested in being successful you’d be sitting on a corner with a cup and asking for support from people passing by. But you chose to be physicians or healthcare professionals and you worked hard and still work hard, so why don’t you advocate for yourself ? Advocacy isn’t easy – nobody ever said it

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ACOEP: Do You Know What It Represents? What caused this change? I believe the demands of medicine and patients were both responsible for this beneficial change in the delivery of emergent medical care. As the complexity of patient problems presenting to the emergency departments increased, it became evident that the training of those physicians working in emergency departments had to increase both in knowledge and procedural skills. The specialty of emergency medicine found its roots, and both physicians in the allopathic and osteopathic realms began rigorous training programs.

Today, the use of emergency departments is reaching critical mass levels. It is now an everyday fact that most departments are holding inpatient admissions, and waiting times for patients to be seen is directly increasing with the holding of patients. Patients are being sent directly to the emergency department after speaking with their primary care physician. The reasons are multifactorial: the family physician cannot find time to see them, a patient’s complaint may seem urgent, or a patient does

e are what we repeatedly " W do. Excellence, then, is not an act, but a habit." – Aristotle

The On-Deck Circle

John C. Prestosh, DO, FACOEP, President-Elect

believe most, if not all, readers of this article know what the initials ACOEP represent. Of course, it stands for the American College of Osteopathic Emergency Physicians. However, I also believe it reflects another interested group: Americans Count on Emergency Physicians! This is not so difficult to understand. In my thinking, emergency physicians are not just the “safety net” of healthcare, but in reality are the “house” of medical care. I recognize that emergency physicians form a partnership with other medical specialties to provide healthcare to Americans and all global citizens. However, I feel that emergency physicians are now looked upon both as a group of specialists and “primary care” physicians. We are being thrust into situations of not only caring for the acute illnesses and injuries, but also the daily tasks of filling prescriptions and assuring patients that their illness can be followed by their family doctor. Emergency physicians occupy the front line of medical care. We are available 24 hours a day, every day of the year. It does not seem so long ago that any licensed physician could cover emergency room shifts, and this seemed to be the norm. Times have certainly changed and most emergency departments now employ only board certified emergency medicine physicians.

Emergency medicine physicians are a part of a large team that delivers healthcare to Americans, and really to any patient that presents for care and treatment. Yes, I understand that questions regarding “what kind of insurance do you have?” are asked of every individual seeking care, but when have you seen an answer of “no insurance” be the reason a person seeking care did not receive it? Yes, I understand we get frustrated when we see individuals seeking care that truly do not need to be in our department, but we do see those patients and render them the care that is needed. Yes, we are specialists in our healthcare system. However, what kind of specialist are we? Consider the fact that we will treat a 13 day old male who is fussy and has a fever of 102.1 degrees F. Our next patient may well be a 23 year old male who overdosed on heroin and presents in respiratory arrest. While we are treating him, a 68 year old female presents with a one hour time frame of suddenly dropping her cup of coffee and having aphasia. The next patient is a 48 year old female who is suddenly short of breath and extremely tachycardic, does not speak English, and the only history is that she just arrived in the United States after a 12 hour plane flight from the Middle East. You then hear EMS calling via the medical command box to inform you that a 55 year old male is en route to the hospital with crushing chest pain, EKG changes, and EMS is asking for an MI alert. So what kind of specialist is the physician caring for these patients? A pediatrician, a critical care physician, a neurologist, a pulmonologist, a cardiologist? Not really! This physician is a specialist that Americans count on: an emergency medicine specialist!

not want to wait for an appointment the next day. Add to these patients the uninsured (no the Affordable Health Care Act did not fix this problem) who present for care, and then also add those patients who truly have urgent or emergent care issues, and this helps to explain why waiting rooms are so crowded. I cannot think of any other medical specialty that has to address the issues of seeing more patients in shorter time frames, being careful not to order too little or too many tests and then have to immediately make the correct diagnosis and if not, be a future participant in our judicial system. However, emergency physicians, due to their peculiar make-up actually thrive in the above situations. We enjoy being challenged with the unknown next patient. While we never boast about knowing everything, we are confident that whatever presents next to the emergency department, we will promptly enact a care plan that fits the need of that particular patient. You may ask why certain physicians would place themselves in such stressful situations. I firmly believe that there are many reasons, however, I suspect that there would be two very compelling answers. The first is that emergency medicine physicians enjoy the satisfaction of immediately making a difference in the lives of their patients. The second reason is that we who work in emergency departments understand that Americans Count On Emergency Physicians!

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Thank you to everyone who attended The Edge: Spring Seminar! » 594 attending physicians, students, and residents » 9,727 hours of category 1A CME Credit awarded » 97% of attendees would attend this course again » “ Excellent conference. Great speakers. Well organized. Will definitely attend again!” » “Cardiac lecture was the best I’ve ever seen.” » “ [ACOEP staff is] friendly and professional. I feel like a valued customer when dealing with the staff.” »W hat did you enjoy the most about Spring Seminar? “The approachability of ACOEP leadership and the ability to connect and meet up with other osteopathic emergency medicine specialists, residents, and students.”

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ACOEP Staff Contact List

Below is an updated list of ACOEP staff along with their contact information. Feel free to call or email our staff with any questions, concerns, or needs that you may have. EXECUTIVE

EVENTS (continued)

Executive Director Janice Wachtler, BAE, CBA Direct Line: (312) 445-5705 Email: janwachtler@acoep.org

Education & Events Assistant Andrea Jerabek Direct Line: (312) 445-5703 Email: ajerabek@acoep.org MEMBER SERVICES

Director, Affiliate Management Stephanie Whitmer Direct Line: (312) 445-5712 Email: swhitmer@acoep.org

Director Sonya Stephens Direct Line: (312) 445-5704 Email: sstephens@acoep.org

Executive Assistant Geri Phifer Direct Line: (312) 445-5700 Email: gphifer@acoep.org

Senior Coordinator, Member Services Jaclyn McMillin Direct Line: (312) 445-5702 Email: jmcmillin@acoep.org

EDUCATION

Director Kristen Kennedy, M.Ed. Direct Line: (312) 445-5708 Email: kkennedy@acoep.org

FOEM & Membership Database Coordinator Gina Schmidt Direct Line: (312) 445-5701 Email: gschmidt@acoep.org

EVENTS

MEDIA AND TECHNOLOGY

Director Adam Levy Direct Line: (312) 445-5710 Email: alevy@acoep.org

Association Editor Erin Sernoffsky Direct Line: (312) 445-5709 Email: esernoffsky@acoep.org

Senior Meetings Coordinator Lorelei N. Crabb Direct Line: (312) 445-5707 Email: lcrabb@acoep.org

Media and Technology Specialist Tom Baxter Direct Line: (312) 445-5713 Email: tbaxter@acoep.org

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Eight Critical Security Measures You Need In Place NOW With Mobile Computing Joanna Sobran President of MXOtech

hysicians, nurses, medical students, and many other types of healthcare employees all need the ability to access information using mobile devices. According to a report from Jackson & Coker, four out of five doctors use smartphones, tablets, and other mobile devices for their work. The utilization of mobile and cloud computing is a great benefit to the healthcare industry – increasing efficiencies and enhancing the continuity of care. From an emergency standpoint, in particular, the use of mobile technologies can help physicians to better communicate with EMT’s on the way to the hospital, reduce wait times, and aid in faster treatments. There’s no doubt about it – mobile and cloud computing have made our lives easier and our businesses more productive, cost-effective and competitive. But make no mistake about it, the Internet is also a breeding ground for thieves and predators, not to mention an enormous distraction and liability if not used properly. It is causing people to be casual, careless and flatout stupid about their privacy in an increasingly litigious society where heavy fines and severe reputational damage can occur with one slipup – which is why you cannot be casual or careless about introducing security policies to your organization. You can’t turn on the TV or read a newspaper without learning about the latest online data breach. And mobile devices are easily misplaced and stolen. Given this reality, if you or your employees use mobile devices to access your internal network or system, then it’s critical to have these 8 security measures in place. 1. I mplement a mobile device policy. This is particularly important if your care team is using their own personal devices to access office e-mail and data. If an employee leaves, are you allowed to erase company

he Internet is a breeding ground for " Tthieves and predators" data from their phone? If their phone is lost or stolen, are you permitted to remotely wipe the device (which would delete all of that employee’s photos, videos, texts, etc.) to ensure your information, and more importantly, confidential and private health information isn’t compromised? Particularly in healthcare, where the data is highly sensitive and regulated, you may not be legally permitted to allow employees to access your network on devices that are not secured, but that doesn’t mean an employee might not innocently “take work home.” If it’s a company-owned device, you need to detail what an employee can and cannot do with that device, including “rooting” or “jailbreaking” the device to circumvent security mechanisms you put in place.

key or password that unlocks (decrypts) the data. 4. I mplement remote wipe software for lost or stolen devices. If you find a laptop was taken or a cell phone lost, “kill” or wipe software will allow you to disable the device and erase any and all sensitive data remotely. 5. B ackup remote devices. If you implement Step 4, you’ll need to have a backup of Continued on Page 11

2. Require STRONG passwords and passcodes to lock mobile devices. On a cell phone, requiring a passcode be entered will go a long way in preventing a stolen device from being compromised. 3. R equire all mobile devices be encrypted. Encryption is the most effective way to achieve data security. To read an encrypted file, you must have access to a secret

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OCTOBER 18-22, 2015 Loews Portofino Bay Hotel Universal, Orlando, FL • Engaging, rapid-fire lectures • NEW specialized breakout sessions • Hands-on skills labs • The largest meeting of osteopathic emergency physicians in the world!

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Introducing ACOEP Digital! A Custom App tailored for your digital life! ACOEP is proud to launch ACOEP Digital, your hub for conference information, course materials, and more! 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!

To download, search “ACOEP” in your phone’s app store.

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What Would You Do? Ethics in Emergency Medicine

he following case was offered by the president of a private ambulance service. A home hospice nurse contacted a private ambulance service to transport a 79 year-old female with metastatic ovarian cancer Bernard Heilicser, to Hospital A, DO, MS, FACEP, where the patient’s FACOEP-D physician is on staff. ETA is 20 minutes. The patient is found to be in moderate respiratory distress, oxygen saturation 76% on room air. They provide 15 L oxygen and the oxygen saturation improves to 90%. A DNR order is presented to the crew (actually legitimately filled out!). Medical Control is contacted and orders transport to Hospital B, the closest hospital, with an ETA of 3-5 minutes.

"Critical" continued from page 9 everything you’re erasing. To that end, make sure you are backing up all MOBILE devices, including laptops, so you can quickly restore the data. 6. D on’t allow employees to download unauthorized software or files. One of the fastest ways cybercriminals access networks is by duping unsuspecting users to willfully download malicious software by embedding it within downloadable files, games or other “innocent”-looking apps. 7. K eep your security software up-to-date. Thousands of new threats are created daily, so it’s critical that you’re updating your mobile device’s security settings frequently. As an employer, it’s best to remotely monitor and manage your employees’ devices to ensure they are being updated, backed up, and secured. 8. A ssign a Privacy Officer and/or a Security Officer to your organization. It is important to know what to do and who to contact when a mobile device is lost or stolen or when you suspect that health information has been compromised. The HIPAA Privacy Rule standard for Personnel

The patient is oriented x3, and requests Hospital A. The crew appears comfortable with the longer transport to the requested hospital. This situation would have been fairly simple, except for the fact that the Medical Control is the Resource Hospital, is ordering closest hospital, and there is no immediate capability to override this order. If you were the paramedic, what would you do? Please send your thoughts and ideas to WhatWouldYouDo@acoep. org. Every attempt will be made to publish them when we review this dilemma in the next issue of The Pulse. If you have any cases that you would like to present or be reviewed in The Pulse, please email them to us at WhatWouldYouDo@acoep.org Thank you.

Designations requires a Privacy Officer. A Security Officer develops and implements policies and procedures required under the HIPAA Security Rule. (These could be the same person.) For discounts on HIPAA Training and Education visit www.mxotech. com/resources/hipaa-training/ and enter code MXOT20 at checkout. If you are concerned about the dangers inherent in mobile and cloud computing, then contact me and mention “The Pulse” for a free, no obligation Mobile and Cloud Security Assessment. We can help you document all the mobile devices accessing your network, what cloud applications your organization uses, and determine an appropriate backup for the data stored on third-party platforms. We’ll also help you implement a mobile device policy, educate your staff on how to “stay safe” online, and put critical security and backup services in place so you don’t have to worry about data loss or unauthorized access to your internal network or system. Learn more about MXO’s healthcare IT support at www.mxotech.com/healthcare.

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COMPREHENSIVE. RELEVANT. ESSENTIAL. A bout Joanna Joanna Sobran is the President and Founder of MXOtech, an IT consulting company with a focus on Managed IT Services and Custom Healthcare Applications. She started her career in the healthcare industry and moved into IT, combining healthcare and technology expertise. Joanna’s extensive knowledge of the IT and healthcare industry became a solid foundation to build her own successful business. She has a passion for taking ideas and turning them into applications and solutions that fuel growth. Joanna is focused on delivering high-level customer experience with innovation. She is passionate about helping her clients grow their businesses. Whether it’s through using better technology solutions, improving operations or education, she treasures her clients and truly cares about their success. For more information about Joanna and the MXOtech team, visit the company website at www.mxotech.com. Joanna Sobran President of MXOtech 312.554.5699 jsobran@mxotech.com

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Would You Do It Again? Duane Siberski, DO, FACOEP

s I walked around the vendors’ tables at The Edge: Spring Seminar, it all felt common. “Where do you work?” “Are you getting enough time?” “Do you want to move?” “Can you believe this weather?” were the expected conversations at the booths. The one question I did not expect was, “Would you do it again?” Not the usual question from a staffing company representative, it raised my interest. Do what again? Leave the cold and rainy climate of Pennsylvania to attend a conference in South Florida? Too easy of an answer. Eat those five pieces of bacon instead of the three I originally chose? No brainer, it’s bacon, and why would anyone care about my breakfast? What…medicine in general or is this targeted at that hobby we do called Emergency Medicine? Bingo! That’s what the question was going after, would I choose EM again? The staffing company representative who asked me this question would be starting medical school in the fall and was beginning to explore specialization options. Realizing the opportunity to practice my extemporaneous speaking techniques, the caffeine-juiced wheels in my head started rolling. The obvious response of “yes!” would be too curt for providing background to my choice. A bubbly, pink ponies and cotton candy wonderful life in the emergency department would be a horrible lie. Truth in advertising seemed to be a reasonable approach. Although dentistry was my goal starting in kindergarten, my choice was swayed after becoming a paramedic. Medicine, specifically Osteopathic Medicine, was the new goal. Who knew you could have so much fun in an ED? Hanging around EDs with great mentors and role models opened young eyes. Thanks go to Fritz Gallagher, D.O. (who is now deceased) Vic Scali, D.O., and Bob Sing, D.O. for that work. However, this fellow is already in the pipeline. His commitment to a decade of training starts this fall. The first point he realized: get a mentor. Personality traits play a role in specialty choice. I recognized the specialties developing in my classmate at UNECOM. Emergency medicine was evident in those of us who

ealizing the opportunity to practice my " Rextemporaneous speaking techniques, the caffeine-juiced wheels in my head started rolling.

fought for seats in the back of the room and had a 20 minute attention span. Orthopedic surgery was just in front of us and squeezing a hand exerciser. Backpacks with teddy-bears identified Pediatrics. Arguments regarding test question validity and why their answer was obviously correct indicated the budding Surgery candidates. Staring intently, all day, at the images projected on the screen was surely a future Radiologist. And the ones who would spring up from their seats to adjust the focus on the slide projector had the Type A+ attributes to nit-pick as a Neurologist. Self-evaluation to choose a specialty fitting of a personality was the next point to consider. I fit the model and knew Emergency medicine was the choice for me…ooo, squirrel! Training equates to hazing. The fraternity of medicine has dues required. The forty hour work week is for cubicle farmers. Hard work, eighty of the one-hundred and sixty eight hours a week for several years, and sacrifices, missed family functions, soccer games, holidays and sleep deprivation, should derive benefits. Logical reimbursement may become a reality. However, income should not drive a career choice. Sure, that Interventional Radiologist can pull the big bucks, but, wearing jammies and staying awake in a dark room staring at a computer screen…boring. If your job feels like your hobby, it won’t feel like work. Another point made: do what you like and like what you do. The discussion would have to include the dark side to be fair. Strains on family life, relationships, health stresses, and risks all need attention. Although training has moved from an indentured servant model, a working balance still needs constant attention. Loss of focus on family has occurred with a waxing and waning pattern. Strong support and occasional applied psychology, usually a backhand from Linda, keeps this issue on my front burner. Point: we don’t marry medicine.

Risks of litigation kept the discussion on the dark side. Who is at risk, who has a higher risk, and partial agreement with Shakespeare’s commentary on lawyers rounded out the negative side. Words cannot describe the effect a lawsuit has on one’s soul, family and outlook. Necessary evil was a relatively good point made. The tone swung back away from darkness with the topic of mentoring. Each level of mentee has specific goals and objectives. The high school freshman works to be accepted to a college to prepare them. The EMT questions entering paramedic school. The medical student wants the good residency. The resident wants the job to start paying back the loans. The new doc in the pit is trying to move meat and figure out the politics of the job. The satisfaction of mentoring, and seeing success, and attaining goals fills the hole in the soul the lawsuit carved out. The final point: provide mentorship to build others. As we ended our discussion and I prepared to head back into the lecture hall, I realized several things. I chose the right profession: medicine over dentistry. I chose the right specialty: Emergency Medicine over everything else. Life is a balance of good and bad: the perfect emergency department does not even exist in my dreams. And, I feel that everyone entering the medical profession can find their specialty as long as they go in with open eyes. I would do it again. As dysfunctional as the medical field can be, Emergency Medicine puts the fun in dysfunctional. I think he is going to look into Interventional Radiology. Clinical correlation is advised.

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Emergency Care: Expanding Our Scope of Practice Frank Gabin, DO

aring for patients and their families in the emergency department is one of the most challenging tasks in all of medicine today. We’re the front door for most hospitals and where much of society accesses our medical system. Most of us on the front lines have suffered some degree of compassion fatigue as a result of our practice of emergency medicine and many of us have come to accept the idea that this emotional dysfunction is an unavoidable occupational hazard. Let that idea go. Science says it isn’t so. Modern neuroscience shows us that there’s a lot happening physiologically, in our daily exposure to pain and suffering, that lies far underneath our level of conscious awareness. This process, called automatic affective empathy, goes on automatically and there’s no way for us to stop it. It happens almost at the level of our brainstem and is why we can’t help but feel what our patients are feeling. It causes us to inherently feel pain whenever we see pain on the faces of our patients, their family members, and even of our colleagues and co-workers. When we try to ignore what we’re feeling, or distance ourselves from the source of our pain, our neurological system freezes these centers. This causes the circuits that register pain to remain activated and we experience empathetic overload, emotional exhaustion, pain and suffering. Because we’re repeatedly confronted with more and more people who are in physical or emotional pain, these same centers are continually reactivated with each encounter and, as a result, our brains become drained and depleted of the neurotransmitters that allow us to feel good. Cortisol levels rise, our autonomic nervous system is hyper-activated, our pulse quickens, our blood pressure rises and our breathing becomes shallow. Without doing anything to deactivate these centers in our brains that register pain, we can’t help but to just plain feel awful. Fortunately, modern neuroscience has also shown us that the cure for this problem is in

racticing medicine compassionately feels " Pmuch different than keeping our professional distance, and is much more rewarding." the process itself. When we’re in the experience of automatic affective empathy, if, instead of trying to stop the pain, we allow our natural curiosity to lead us to wonder what’s going on within our patient and what it’d be like if we were in their situation, we begin to experience their pain as if it were our own. It’s this part of the process, where we consciously feel the pain, that we rise above the level of the brainstem and begin to use the pre-frontal and frontal cortex where we can gain conscious control. Being curious, stepping closer to our patient and into their pain, is the beginning of the process called cognitive empathy. By choosing to feel and explore the pain, the process naturally moves us away from the painful place of affective empathy and into the next phase: compassion. Compassion is activated by our desire for things to be better for the suffering human in front of us. When we experience compassion, all of the negative centers in our brain that register pain and suffering begin to down-regulate and the positive centers begin to light up. A whole new set of neurotransmitters are elaborated, including oxytocin and dopamine, and the centers that register pleasure in our frontal cortex are activated. Physiologically, things change dramatically for us. Our heart rate slows and variability returns. Our autonomic nervous system is taken off alert. Vagal tone is augmented. Spatial perception is improved. Creativity is activated and we automatically become more resilient. Math and higher cognitive functions improve. Integration and diagnostic abilities improve and we become physically stronger. We almost instantly feel, and do, better. Practicing medicine compassionately feels much different than keeping our professional

distance, and is much more rewarding. Not only does it relieve us from the effects of compassion fatigue, it gives us what we need to be emotionally available, emotionally competent, and to feel whole and fully alive. Expressing our compassion makes our patients and their family members feel better too. Although recent modern neuroscience has shown us that compassion itself is the antidote for compassion fatigue, many physicians haven’t been made aware of this information, or haven’t yet incorporated it into their practice. Too many of us are still suffering needlessly, as Carol Peckham showed us in the Medscape report Physician Burnout: It just keeps getting worse. The levels of burnout in physicians have actually gone up between 2013 and 2015. I was once extremely burned out too, but today, after having incorporated the process of compassionate care into my practice of emergency medicine, I feel much better. While I now enjoy my job as an emergency physician and love caring for patients and their families, I can’t say that my shifts are stress free or that I don’t experience frustrations. But, what I noticed lately is that some of my most challenging and difficult encounters are not with my patients, they’ve been with the consultant physicians I need to involve in their care. It seemed to me as if the very first word out of their mouth after I asked for their help was, “NO.” This almost always caught me off guard. Just as society holds physicians to a higher standard, I believe that we hold ourselves and our colleagues to even higher standards, which is why it’s so frustrating for me when other physicians do not, in my opinion, behave like I believe they should. Recently, after a series of challenging shifts and a series of difficult and unpleasant

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experiences with a few consultants, I was feeling angry and extremely frustrated. I found that it was affecting me after work as well. I began to wonder how and why this was happening every day that I worked as an attending physician in the emergency department. Then I remembered how I used to feel when I was burnt out. I hated going to work. I’m sure I was difficult too. I realized that I needed to do something so I began to look more deeply at the symptoms of burnout in physicians. Burnt out physicians feel deep physical and emotional exhaustion, are irritable and quick to anger, and are extremely cynical, especially at work. They experience a profoundly decreased ability to feel empathy for their patients, lose the ability to make decisions, and their care for their patients is impaired. Their perceptions of people are dehumanized. They lose concern or respect for others and label people or groups of people in a derogatory manner. They’ve lost the ability to enjoy their careers. They’ve lost interest in life itself. They have very low selfesteem, trouble sleeping and are hypersensitive or insensitive to emotional material both at work and at home. They lose the ability to maintain close personal friendships, develop problems with both emotional and physical intimacy within their relationships, and are more likely to divorce. They’re clinically depressed. They gain or lose weight. They’re more susceptible to physical illness. They’re more likely to turn to addictions like drugs, alcohol or gambling for temporary relief and more likely than the general population to commit suicide. Too many of our colleagues are wounded, suffering and hurting just like I used to be. No wonder they’re not behaving like I expect them to. In their current state of burn out, their ability to cope is impaired. While they are not presenting to us as patients, our colleagues need our care now more than ever. I tried to imagine what it was like to be in my consultant physicians’ situation. Especially the hospitalists and intensivists. Quite often these doctors are taking calls for admission from three or four different emergency physicians. They’re also getting calls from other hospitals trying to effect a transfer. These doctors don’t know the patients they’re being asked to care for. Each patient is complicated and will require

a lot of medical work. There is no end to the number of patients they may be asked to care for in their 12 or 24 hour shift. Putting myself in their shoes, I couldn’t help but feel compassion for them. This changed the way that I began to interact with them. I started by making an effort to get to know these physicians. One of them is in his mid sixties. He is boarded and trained in family practice. Early in his career he worked in the emergency department and spent decades there until he decided that he wanted to go back to an office practice. He found that he did not enjoy that either. Now he has taken on the role of hospitalist and he is not so sure this is what he wants to do either. It seems as if he’s never been able to enjoy his practice of medicine.

It is stories like his that make it easier for me to understand why these consultants are so unhappy and stressed out. It became clear to me that it’s time for me to expand my scope of practice of emergency care to include to the consultants I ask to care for my patients. Instead of being frustrated by them, I need to feel their pain and activate my compassion. When I am full of compassion it is much easier for me to say something that will make a difference for them and make it easier for them to care for my patients. As opposed to demanding, I now start the calls to my consultants by telling them I am sorry to bother them but I really need their help. Then I attempt to paint a full picture of the person that I am asking them to care for

before I jump right into the medical situation that requires admission. I go out of my way to make it as easy as possible for them by making sure I have everything they might need done, including a magnesium level and the patient’s home medicines clearly documented. I also thank them more than once for their help and let them know they are important and appreciated. Approaching these calls this way not only helps the consultant, it’s also made my days much better. It’s been good for my patients and better for my staff, as when the consultant arrives, they are usually much less stressed since we anticipated most of their needs. I have learned from this experience that being a caregiver is not just about caring for patients.

I’ve also learned that expanding my practice to my colleagues does not feel natural at first. Especially when it comes to interacting with physicians. We were trained in a culture of bullying, or at the very least, a culture of disrespect. In training, we were pressured, by others and ourselves, to be right 100% of the time. Morning rounds and case presentations, as an intern or resident, were always stressful situations. We were taught to be competitive and confrontational. I’ve learned that because it doesn’t feel natural, I need to apply a more conscious effort to stay engaged with my own emotions so that I can stay emotionally healthy and competent. Being consciously aware of what Continued on Page 15

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"Compassion" continued from page 14 is going on within and around us emotionally is not necessarily our human nature. This is why consciousness is something that I make an effort to continually invest in. It is what makes the difference between a good shift, where I generally feel happy, engaged and capable, and a bad shift where I feel frustrated, drained, and exhausted. I continually have to remind myself to pay attention to these intangibles if I really want to make a difference for others and myself. Most importantly, I’ve learned that activating compassion for all others is key in our work as caregivers. If we really want to upgrade our experience while working in the ED, we need to expand our scope of practice to include all the men and women who work alongside of us: consulting physicians, mid-level providers, nurses, techs, phlebotomists, security and registration, etc. These are all hard working, intelligent, and highly motivated people who, like us, are swimming in the same toxic emotions that lead to compassion fatigue and burnout. When we look closely, we will see that many are struggling too.

Recently, there was a study done involving feeling of affection, compassion, caring, and tenderness among co-workers at long-term care facilities by researchers at the Wharton School (University of Pennsylvania) and the George Mason University School of Business. They examined what they call a “culture of compassionate love.” The study was published in Administrative Science Quarterly. They found that a strong culture of compassionate love predicted benefits all around. For staff there was less burnout, fewer unplanned absences, more teamwork, and higher work satisfaction. For patients there were fewer emergency room trips, higher mood, elevated satisfaction and quality of life for patients. Overall, there was more satisfaction with the facility and willingness to recommend it for other families. It’s evident that expanding our scope of practice, as it relates to compassionate care, is a process that yields many positive and sweet intangible rewards. But when it comes to extending care to the people we work alongside, it can be challenging. One of the easiest ways to do this is to remember that no one gets up in the morning, looks in the mirror and says to themselves, “I am going to hold back today. I am not going to do my best.” Everyone is doing the best they can.

CONEMAUGH HEALTH SYSTEM

Conemaugh Memorial Medical Center, Johnstown, PA, is seeking an

Emergency Medicine Physician to expand its faculty.

Practice Highlights • Level 1 Regional Resource Trauma Center • Low incidence of penetrating trauma (<10%) • Over 65,000 ER visits • Comprehensive specialty support • 24 hour emergency medicine resident support • Opportunity to teach highly motivated EM residents • Competitive hourly rate • Paid malpractice with tail coverage • Full benefit package To join this dynamic, fast-growing healthcare organization, contact Mary Lynn Mahla, Director, Physician Recruitment at 814-534-3221 or email mmahla@conemaugh.org. www.conemaugh.org

Each and every one of us is going through something that may make it difficult for us to do better. Extending our care to include those we work with can have exponential effects on the entire work force in the emergency department and throughout the hospital. This is how we improve the lives of patients, their family members, and the very staff that cares for them. Compassion is the corner of happy and healthy, where medicine and healing intersect. Science has proven compassion works to heal compassion fatigue. Someday there may even be a pill we can prescribe to make us more compassionate people. A study at UC Berkley and UC San Francisco finds that giving the drug tolcapone changes the neurochemical balance in the prefrontal cortex of the brain and causes a greater willingness to engage in prosocial behaviors. Until then, we can do the work of generating these positive emotions for ourselves by consciously choosing to engage our compassion for others. In my humble opinion, there’s no greater work in all of medicine today! Until next time: Go care, make a difference and change (y)our world!

We Want to Hear from You! Emergency Physicians do incredible things every day and we want your stories! 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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2015-FOE

Core Faculty Academic and Research Skills Development Course

the PULSE | JULY 2015

Sponsored by a David E. Kuchinski Memorial Grant from the Foundation for Osteopathic Emergency Medicine

WHEN: CME:

Part II - October 20, 2015 Part III - October 21, 2015 Up to 14 hours of Category 1A

Approval Pending

FOEM invites core faculty members and program directors to the Faculty Development Track at The Edge: Scientific Assembly in Orlando, FL! This course will explore: • Insight into the ACGME Application process and Milestones through lectures by ACGME staff • Improve research and academic teaching skills • FOEM’s new Research Quality Improvement Initiative • Implementation of new common core standards • Ways to enrich and encourage research among physicians, residents, and students • Networking with other institutions and organizations to promote osteopathic research across a broader spectrum • Improvement of grant writing to successfully fund vital research • Effectively securing publication and recognition for your work

Only $50 per session for faculty, and FREE to residents.

Sign up for one or both phases! Participants can take both classes for the first time, or those who have already taken Phase II are welcome to return for a refresher course.

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A Rare Cause of Facial Edema: The Sodium Hypochlorite Accident John Ashurst DO, MSc1 and Shawn Quinn DO2

1 Department of Emergency Medicine, Lehigh Valley Health Network, Bethlehem, Pennsylvania, USA Correspondence should be addressed to: John Ashurst DO; ashurst.john.32.research@gmail.com

bstract

Sodium hypochlorite (NaOCl) is the most widely used endodontonic irrigant but complications can result when it is accidentally extruded under pressure into the periapical tissues. This may cause edema, discomfort, paresthesia, bleeding and secondary infections. Treatment requires pain control, decreasing inflammation with steroids and prophylactic antibiotics for 7 to 10 days. The authors report a case of a NaOCl accident and its management. Keywords: Sodium Hypochlorite, root canal Introduction Root canal treatment is a common procedure performed in dental practice across the globe but few emergency medicine physicians are aware of its complications.1-3 Sodium Hypochlorite (NaOCl) used at a concentration of 0.5 â&#x20AC;&#x201C; 6.15 % is a common irrigant used for preparation during root canal procedures but can cause injury to the surrounding skin, oral mucosa, eyes, air emphysema, allergic reactions and necrosis if local infiltration into the surrounding tissue occurs. 1-3 The authors report a case of a NaOCl accident following a root canal procedure. Case A 64-year old female was referred to the emergency department from her dentistâ&#x20AC;&#x2122;s office with acute onset of left sided facial pain and swelling. The patient noted that she had a crown placed on tooth #10 one week prior and presented back to her dentist to have a root canal completed. In preparation for the procedure, the patient received NaOCl to rinse the canal and immediately complained of intense left sided facial pain, shortness of breath and pain with movement of her left

eye. Past medical history was significant for hypothyroidism and bladder cancer, which had been in remission since 2009. Physical exam revealed a blood pressure of 179/87, pulse 68, respiratory rate 18, temperature 97 degrees Fahrenheit and oxygen saturation of 98% on room air. The patient had left sided facial swelling with infra-orbital ecchymosis extending to the inner sublabial fold. Upon palpation, crepitus was noted over the left face extending through the neck anteriorly. Intra-orally, there was tenderness to palpation over the maxillary left molars with buccal mucosal ecchymosis. Basic laboratory tests were within normal limits. An upright chest radiograph revealed subcutaneous emphysema extending from the left face to the left chest wall (Image 1) Computer tomography of the face and neck depicted extensive maxillofacial subcutaneous emphysema with minimal orbital emphysema on the left (Image 2 and 3). The patient was diagnosed with a NaOCl accident and started on clindamycin and methylprednisolone. She was subsequently admitted for monitoring and discharged two days later with no complications.

Discussion The success of root canal cleaning and shaping lies in the elimination of tissue remnants, bacteria and toxins from the root canal system. Prior research has shown that mechanical procedures alone are insufficient for total canal cleaning. 1-3 However, in 1920 Crane used Dankins solution (NaOCl buffered with sodium bicarbonate) for the first successful debridement and sterilization of the root canal system using an irrigant and has since become the standard of care.4 In 1974 the first episode of NaOCl accident was described by Becker and research has shown that only 26% of dentists who have practiced for ten years or more have encountered this complication.5,6

Image 1: Upright chest radiograph depicting subcutaneous emphysema

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NaOCl acts as an oxidizing agent not only against pulpal and dentinal tissue but also as a strong anti-microbial agent effective against gram-positive and gram negative bacteria, fungi, spores and viruses including the human immunodeficiency virus. 2 However, the inherent properties of NaOCl that allow for proper disinfection also cause it to be cytotoxic which can cause hemolysis, ulceration, inhibition of neutrophil migration and damage to endothelial and fibroblast cells.1,2 The severity of the reaction is directly related to the concentration of the solution, the pH and the duration that the irrigant is in contact with tissue. 1,2 If a NaOCl accident occurs, severe pain at the area of infiltration will present in 2 – 6 minutes followed by immediate edema of the adjacent soft tissue. Profuse bleeding and ecchymosis will then follow and is directly related to the increased vascular permeability in the tissue as a result of the release of chemical mediators and histamine. 1,2 Examination may also reveal the loss of the nasal labial fold as distortion of the maxillofacial architecture occurs with swelling.7 The patient may also complain of a “chlorine” taste in their mouth or a smell, which can be related to the injection of the NaOCl into the maxillary sinus. 1,2 Neurological manifestations include paresthesia to the infraorbital, inferior alveolar and mental branches of the trigeminal nerve. 2 Lastly, life threatening airway obstruction has been rarely reported in the literature. 2 Following assessment of the patient’s airway, immediate treatment by the emergency

physician should be aimed at diluting the irrigant with normal saline in order to minimize its spread. Pain should be controlled with a narcotic analgesic and NSAID therapy should be avoided due to the possibility of bleeding in the soft tissue. 1,2,4 Warm mouthwashes should be used to stimulate intra-oral blood flow, steroid therapy should be initiated for 3 – 5 days in order to minimize the inflammatory response and prophylactic antibiotics aimed at the coverage of the intra-oral pathogens should be prescribed for 7 – 10 days. 1,2,4,7 Depending on the degree of injury, surgical intervention aimed at increasing the drainage of surrounding tissue and debridement of necrotic tissue maybe warranted. 2 Typically, two thirds of patients will have complete recovery of symptoms within two weeks of onset but literature has shown persistent symptoms up to one year.7 Conclusion Although NaOCl is an effective antibacterial agent used routinely for root canal treatment, it is necessary for the emergency physician to be aware of its potential for complications and its treatment in the acute setting.

3. E hrich D, Brain D and Walker W. (1999) “Sodium hypochlorite accident: Inadvertent injection into the maxillary sinus,” J Endod, 19 (4) 180 -183. 4. T egginmani V, Chawla V, Kahate M and Jain V. (2011) “Hypochlorite accident: A case report,” Endodontology, 23 (2) 89 – 93. 5. B ecker G, Cohen S and Borer R. (1974) “The sequelae of accidentally injecting sodium hypochlorite beyond the root apex,” Oral Surg, Oral Med, Oral Pathol, 38 633 – 638. 6. D onald J, Robert E, and Omid M. (2008) “The sodium hypochlorite accident: Experience of diplomats of American board of endodontics.” J Endod, 34 (11) 1346 – 1350. 7. B huva, B and Williams, S (2011), Sodium hypochlorite accident, Pitt-Ford’s Problem Based Learning in Endodontology, Patel S and Duncan H (ed), Wiley-Blackwell, USA.

References 1. S ingh P. (2010) “Root canal complications: The hypochlorite accident,” SADJ , 65 (9) 416 – 419. 2. M ehdipour O, Kleier D and Averbach R. (2000) “Anatomy of sodium hypochlorite accidents,” Int Endod J, 33 (3) 186 – 193.

Image 2: Computer aided tomography depicting subcutaneous emphysema

Image 3: Computer aided tomography depicting subcutaneous emphysema in the head and neck

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2015 ACOEP Board of Directors Election Janice Wachtler, BAE, CBA Executive Director

t’s that time again—time to prepare to vote in the 2015 ACOEP Board Elections. This year’s slate of candidates boasts five of ACOEP’s most involved, dedicated members as candidates. Elections will take place later in the summer and ACOEP’s staff will send voting instructions. The winners will be announced at the Membership Meeting at The Edge: Scientific Assembly. Take a moment to review the excellent credentials of each candidate in preparation for voting.

F. Shan Ahmed, DO is a board certified emergency medicine physician who would be an asset to the college as an established leader, active member, and well respected colleague in the field. He first became involved with ACOEP by becoming a leader within the Resident Chapter. He established the annual Emergency Medicine Jeopardy Tournaments for the residents, as well as routine hands-on workshops for the students. Dr. Ahmed has not only performed numerous workshops, but also helped organize the resident and student Suture Lab, Ultrasound Workshop, and the multifaceted Procedure Labs which are still currently run by both chapters. In addition, he continues to give lectures and assist in numerous activities for both the residents and students. During his membership with ACOEP, he has been a part of several committees including the Undergraduate Medical Education Committee,

2015

which he now serves as the Chairperson. Dr. Ahmed is a proud graduate of the New York College of Osteopathic Medicine. He remains an active member of his medical college where he serves as an assistant professor, and lectures at the regional osteopathic conventions. He completed his training in osteopathic emergency medicine at Good Samaritan Hospital Medical Center in New York where he was chief resident. After graduation from residency, he became a part of the core faculty and subsequently Assistant Residency Director of the Emergency Medicine program. Dr. Ahmed then became the Assistant Medical Director at St. Charles Hospital and was promoted to Medical Director at St. Joseph Hospital, both of which were are in New York. At St. Joseph Hospital, he was involved in many aspects of hospital functions such as spearheading the sepsis initiative and creating the first Emergency Department Concussion Program in New York. Dr. Ahmed is also passionate about EMS. He volunteers his time as the Medical Director for multiple agencies in his catchment area, and serves on the physician advisory committee for Nassau County EMS. Currently, Dr. Ahmed works as the Regional Medical Director for Island Medical Physicians P.C. on Long Island New York and in addition to clinical shifts, oversees operations at 3 emergency departments on Long Island and several others in the North East. “I believe it is my time to give back as a Board Member of the ACOEP. As a member of the college since my residency, I’ve had the privilege of many great mentors contributing to my academic and personal growth and thus enabling me to develop into a confident and competent emergency medicine physician. I am truly honored to be nominated to the board and have the opportunity to serve the college that has helped me become the person I am today.”

Gary Bonfante, DO, FACOEP, FACEP has actively served this College’s membership since joining the organization over twenty years ago. He is a 1993 graduate of the Philadelphia College of Osteopathic Medicine who went on to complete his Emergency Medicine residency in 1997. That program was then a combined one with St. Luke’s Hospital and Lehigh Valley Health Network in Allentown, PA. During his final year, he served as a Chief Resident. Since graduation he has been involved in education, EMS, research and national issues related to the ACOEP. Over the years, Dr. Bonfante has worked for the College on several levels. Notably, from 2004 to 2009, he served as the Chair of the Scientific Assembly and revamped the structure of that now very successful program. He has also served on the Program Director’s Committee where he was Vice-Chair of the Resident In-Service Exam from 2005-2007. Dr. Bonfante was a member of the Continuing Education Committee for seven years and since 2011 has been Chair of the Fellowship Committee where he has served as a member since 2006. He has served on the Nominations and Awards Committee since 2010 and as a senior inspector of residency programs for the Graduate Medical Education Committee until 2009. Dr. Bonfante was an elected ACOEP Board Member from 2006-2009.

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During his tenure at Lehigh Valley Health Network, Dr. Bonfante has worked to enhance education and improve patient care. He was the Associate Program Director and then Program Director for the Emergency Medicine Residency. Under his direction, that program expanded greatly and participated actively in multiple ACOEP settings. He also filled the role of Director of Osteopathic Medical Education for Lehigh Valley. Dr. Bonfante was also core faculty for the Emergency Medical Services Fellowship and oversaw several prehospital agencies as their Medical Director. Currently Dr. Bonfante works as a staff physician in Emergency Medicine and is now the Trauma Program Medical Director at Lehigh Valley’s Hazleton campus. In seeking a relatively new designation as a Level IV Trauma Center, he has collaboratively participated in several processes aimed at providing improved and consistent care to trauma patients. It is his passion for clinical medicine that serves to drive his involvement as he appreciates that ultimately all that we do eventually reaches the patient’s bedside. Dr. Bonfante is also published in journals and textbooks. He mostly recently coauthored the “Rashes in Infants and Children” for the last two editions of Tintinalli Comprehensive Study Guide. His community involvement includes the Appalachia Service Project, several mission trips to Jamaica, participation in a local soup kitchen and currently as Medical Director for the Greater Hazleton Health Clinic. This free clinic works to provide acute, episodic care to the uninsured and underserved of that area. In speaking about accepting his nomination, Dr. Bonfante said, “It is an honor to be considered for a position on the Board. I believe that it is so very important to approach these activities with an attitude of service. I think I must always ask, ‘How can I participate and how can I be useful?’ - If elected, I look forward to engaging with my fellow Board members to continue to move the College forward. I look to serve for the good of our members and our patients. I believe my years of involvement have given me the experience and perspectives to fill that role and I welcome the challenges that come with it.”

Dr. Cheslock has been fortunate to serve one year on the ACOEP board as the Resident Chapter President. Leading the resident chapter for a year was a humbling and very rewarding experience. Taking part in the Strategic Planning Retreat was one of the highlights of his year as it provided a tremendous amount of insight into the college, the current board and how the future of the college.

Timothy Cheslock, DO, FACOEP has been very active with ACOEP for the last 10 years. As the chair of the publications committee, a member of the EMS committee, and consultant with the CME committee, Dr. Cheslock has his finger on the pulse of ACOEP. He also serves as a member of the AOA’s Committee on Continuing Medical Education. Dr. Cheslock is eager to continue and grow this service to the college. In addition to his current involvement in the ACOEP he currently takes part in a Physician Leadership Development Course in conjunction with Florida Hospital here in Orlando. This program has been an exciting way to increase Dr. Cheslock’s leadership exposure and training.

“If given the opportunity to sit as a member of the board, I hope to continue my active engagement in the various committees of the organization and help to lead the ACOEP into new territory as we move forward with the ACGME merger,” Dr. Cheslock says. “Keeping the uniqueness of Osteopathic Medicine engrained in our organization is of great importance to me personally and a key to the future success of the college. I wish to continue to engage the student and resident members and guide them with the same energy that was provided to me by so many members of the college. I look forward to the vetting process and hope to be included on the slate of candidates. Thank you for all of your support in the past and moving forward in the future.”

Dr. Cheslock has been a member of the Army National Guard for the last eighteen years. During this time he completed a tour to Afghanistan and completed the Army Command and General Staff College, and he continues to serve in a medical support battalion for the FL Army National Guard in the grade of Major. “The experiences and training I have attained through my military career have been beneficial in my civilian practice and enhances the skills set I can bring to the board,” says Dr. Cheslock. He has served on the board of a non-profit association in the past as the treasurer and a board member at large. It was a small503b association called the Spaatz Association, made up of current and former Civil Air Patrol Members that achieved the Cadet Programs highest achievement, the General Carl A. Spaatz Award. During his tenure Dr. Cheslock maintained the books for the organization and filed the annual tax reports. The primary mission was to foster comradery and provide scholarships and mentoring to current CAP cadets. The size of the organization was small in comparison to ACOEP, but the experience gained was invaluable.

Drew A. Koch, DO, MBA, FACOEP-D, graduated from the Philadelphia College of Osteopathic Medicine. He completed both his internship and residency in Emergency Medicine at Memorial Hospital in York, PA. Dr. Koch is board certified in Emergency Medicine. He is a Distinguished Fellow in the American College of Osteopathic Emergency Physicians (ACOEP). He received the Meritorious Service Award in 2003 and the Excellence in Emergency Medical Service Award in 2010 from ACOEP. Dr. Koch has been a member of ACOEP Continued on Page 21

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"Election" continued from page 20 since 1987. He has served on the following ACOEP committees beginning in 1996: EMS; Fellowship; Members Service; Nominations and Publications. He has served as the Chair of Fellowship and Publications Committees, the Editor of the Pulse from 2004 to 2014 and has been the Vice Chair of Nominations Committee from 2011-2014. Dr. Koch was elected to the Board of Directors of ACOEP in 2012 through 2015. While serving on the Board he was the liaison to the EMS, Publications, Fellowship and Finance Committees. He practiced Emergency Medicine at the Pinnacle Health System from in Harrisburg, PA prior to relocating to Ithaca, New York in 2007. He is an attending physician in Emergency Medicine and is the Chairman of the Department of Emergency Medicine at Cayuga Medical Center at Ithaca. He has been the Medical Director of Emergency Services at Cayuga Medical Center since 2007. He is the medical director of Tompkins County EMS and serves on the Central New York Regional Emergency Medical Advisory Committee. Dr. Koch served as the First and Second VP of the Medical Staff during 2012 and 2013. He was the President of the CMC’s Medical Staff and served as a member of CMC’s Board of Directors during 2014. He is currently serving as the Past President of CMC’s Medical Staff in 2015. His wife, Sandy, is the Lansing School District Coordinator of Health Service and the Elementary School Nurse. Dr. Koch has four sons: Drews, Joe, Mikey and John.

the early 90’s. He is an attending Physician at the Reading Hospital in West Reading, Pennsylvania, currently as a PGY 23. As the hospital’s EMS medical director, he has worked with the Reading Hospital’s School of Health Sciences Paramedic Education Program for over a decade. Involved in EMS since the early 1980’s, he currently serves as a Pennsylvania State Regional Medical Director in Pennsylvania’s Eastern Region. Dr. Siberski is an active member of Regional and State Medical Advisory Committees. As the EMD Medical Director, he works with the Regional Communications Committee to over-see the nine dispatch centers in the Eastern Region’s six county area. His activities as a Medical Director for the Region 2 Tactical Emergency Medical Services team include involvement with multiple SWAT teams and the Pennsylvania State Police Special Response Team. Locally, he is the Medical Director for Western Berks Ambulance Association and occasionally rides the trucks as a pre-hospital Physician. As an educator, Dr. Siberski frequently lectures in various venues. Whether presenting a Grand Rounds at The Reading Hospital or a First Aid lecture to Boy Scout Troop 237, he brings excitement and entertainment to the audience while speaking. At the University of New England College of Osteopathic Medicine, he founded the Emergency Medicine Club and has developed an Airway Workshop in conjunction with the Anatomy Department to train future physician on fresh tissue in their lab. All of his

lectures are presented with the same promise; there will be “No Netter Drawings”. He currently serves the College as Board Liaison to the By-Laws and EMS Committees. As the previous Chair of this Member Services committee, he continues to attend as a memberat-large working to improve the benefits to the College members. He has served as Board Liaison to the Resident Chapter of the ACOEP. Prior to his election to the Board of Directors, he served as the National Advisor to the Student Chapters of the ACOEP. He has represented the College as Liaison to the American College of Emergency Physicians and has promoted dialogue between our organizations allowing open lines of communication. He has served as a member on multiple other committees throughout his membership in the College. As a College member who has seen the growth of the specialty in numbers and respect, Dr. Siberski mentors prospective students as they try to decide their career path. Lessons learned from his mentors and the pioneers of the ACOEP are passed along to residents, students and prospective students. He gives them the philosophical task to support the College in its role to promote Osteopathic Emergency Medicine by bringing in at least two excellent physician candidates through the Osteopathic training system. He sees the future health of the College through this propagation of young physicians and development of future College leaders.

Board Election FAQs Each fall ACOEP holds elections for available positions on Board of Directors. Here are some frequently asked questions to remind you how the process works: Who’s eligible to vote? All categories of Active, Retired, and Life members of ACOEP are eligible to participate in the election process for the Board of Directors. The following membership categories are considered Active members categories: Active First Year Active Member Life Member

Retired Member Fellow Member Distinguished Fellow Member

When does voting begin? Voting will open on August 10, 2015 and will close one hour before the Membership Meeting at the 2015 Scientific Assembly at 33:30 pm EST on Sunday, October 18, 2015 Can I vote on that day? Voting can be done only when eligible members pay their dues. The earlier you pay your dues, the earlier you can vote. Voting remains open until 3:30 pm EST on Sunday, October 18, 2015.

Duane D. Siberski, D.O. FACOEP, FACEP has been an American College of Osteopathic Emergency Physicians Board of Directors member since 2008. He has maintained continuous activity and membership in the College since his initial involvement as Vice President of the Student Chapter of ACOEP in

How will I know when I’m eligible to vote? As dues payments are received and entered, Sonya Stephens, Member Service Director, will send paid members an email with the link and instructions. Can I vote at the Scientific Assembly? Yes, Voting will remain open until 1 hour prior to the General Membership Meeting at the 2015 Scientific Assembly in Orlando (on Sunday, October 18, 2015, 4:30-6 pm), so voting will close at 3:30 pm. A link will be available on the conference app. Eligible members, who have not already done so, may vote on-site using their own laptop or tablet.

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The Vital Role of ENPs Jennifer Wilbeck, DNP, APRN-BC, CEN Associate Professor & ENP Specialty Director Vanderbilt University School of Nursing

he American Academy of Emergency Nurse Practitioners (AAENP) is pleased to announce their increased collaboration with the American College of Osteopathic Emergency Physicians (ACOEP). With leadership from nationally and internationally recognized experts, AAENP promotes high quality, evidence-based practice for nurse practitioners providing emergency care for patients of all ages and acuities in collaboration with an interdisciplinary team. While there is currently no definitive measure, data from the American Association of Nurse Practitioners (2014) indicates 12,000 nurse practitioners (NPs) are practicing in emergency care settings providing care to the more than 5.1 million patients seen annually in emergency departments across the United States. These settings include, but are not limited to, emergency departments (EDs), urgent/fast track units, observational units, ambulatory urgent care settings, and correctional care facilities. Nurse practitioners have staffed emergency care settings since the 1980’s yet formal educational programs to prepare NPs for ED practice were not available until the 1990’s. The ENP role is unique in that it spans population and acuity continuums reflective of the care provided in EDs across the country. Emergency care focuses on potentially lifethreatening conditions irrespective of the patient’s initial chief complaint or reason for seeking care. In order to promote safe practice, the ENP role must be clearly understood by the inter-professional team in which we practice, by those in positions of hiring for ENP positions, and by regulatory agencies.

AENP aims to establish high quality " Acontinuing education and formal academic curricula for emergency nurse practitioner preparation.

care settings, where care ranges from primary care to acute resuscitation and stabilization of life threatening conditions, remains unclear to many. Although FNPs are prepared to care for primary care conditions, their education does not include management of complex medically unstable conditions. Similarly, while acute care NPs are prepared to care for either medically unstable adults or children, their education does not prepare them to care for patients with primary care problems or to care for patients across the lifespan. These educational gaps have led to the development of innovative FNP curricula incorporating additional didactic and clinical content in the care of urgent and lifethreatening emergencies. Currently there are six programs offering emergency concentrations based upon the entry-level competencies for NPs in emergency care which were jointly established and endorsed by the American

Nurses Association (ANA) and by the National Organization of Nurse Practitioner Faculties (NONPF). These include University of Texas-Houston, Emory University, Vanderbilt University, Rutgers University, Jacksonville University and Loyola-Chicago. The educationally prepared FNP/ENP is therefore the most wellprepared to provide safe, high quality care in emergency care settings. For currently practicing providers who are certified as FNPs, additional training in emergency care may be obtained by completing an accredited emergency medicine fellowship program or other educational programs, obtaining continuing education, and by demonstrating competencies through certification. AAENP aims to establish high quality continuing education and formal academic curricula for emergency nurse practitioner Continued on Page 24

Nurse practitioner educational preparation further differentiates population focused competencies based on primary (e.g., Family Nurse Practitioner) or acute care (Pediatric or Adult-Gero Acute Care Nurse Practitioner) needs. Although patient care is not setting specific, NPs who are prepared as primary care providers have different competencies than those prepared for acute care roles. These unique educational differences govern an NP’s scope of practice. Determination of what constitutes an appropriately trained and competent NP to work in emergency

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Welcome to ACOEP’s

DIGITAL CLASSROOM The ACOEP Advantage: Specialized. Personalized.

ver the years, ACOEP has become synonymous with excellence in education. Through national conferences, ACOEP members have access to world renowned speakers, the latest in technology and best practices, and leading physicians.

emergency medicine topics. Live webinars will be available, allowing physicians to earn category 1A CME credits from the comfort of home. The ACOEP Digital Classroom is an ever expanding CME resource at your fingertips.”

Now, ACOEP is proud to introduce the new Digital Classroom, an online initiative bringing all of the energy and insight of ACOEP’s conferences to the internet.

ACOEP Executive Director Jan Wachtler shares Dr. Stanton’s enthusiasm. “The digital classroom will launch ACOEP into the future of emergency medical education. The platform we’re using is the best in the business, and our members will have one hub to view lectures, take pre and post-tests, earn CME credit, and, most importantly, grow as physicians.”

“Online CME is a rapidly expanding arena in medical education. We all have busy schedules and cannot always take time away from family and work to attend in-person CME events,” said Audrey Stanton, DO, the chair of ACOEP’s Digital Learning Subcommittee. “The ACOEP Digital Classroom is a collection of high quality, up-to-date online emergency medicine CME that is available entirely at your convenience.” In addition to a review of the 2015 COLA exam, the initial launch of ACOEP’s Digital Classroom includes lecture videos from the 2014 Scientific Assembly, and 2015 Intense Review and Spring Seminar. Attendees of these conferences have full, free access to view the videos. Those who were unable to attend can purchase each individual lecture. “It is the only online site where you can access lectures from prior ACOEP Scientific Assemblies, Spring Seminars, and COLA Reviews,” says Dr. Stanton. “It will also include non-conference lectures and lecture series designed to cover a variety of current

the AOA for Category 1B Credit for those who were not at the conferences, and who view the videos and lecture materials.”

According to Kristen Kennedy, ACOEP’s Director of Educational Services, some CME credit will be available for the conference videos. “We are applying to

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Access to conference lectures and COLA reviews are just the tip of the iceberg. As the Digital Classroom expands it will include demonstrations, live events, and rapidfire lectures. Topics such as osteopathic manipulation techniques in the ED, advocacy, best practices, and EMS will soon be available. Students and Residents are also invited to take advantage of the Digital Classroom. The Resident Chapter has already begun a series of podcasts, and the Student Chapter will add to their cache of podcasts on tricks of the trade. How to Access the Digital Classroom ACOEP has worked hard to ensure that access to the Digital Classroom is simple. The classroom can be found on ACOEPâ&#x20AC;&#x2122;s website (www.acoep.org/classroom) and it synchs seamlessly with ACOEPâ&#x20AC;&#x2122;s Member Center. The same username and password used to register for events or to renew membership dues also works for accessing the Classroom. Those visiting the first time it is easy to register in a few short steps.

"ENPs" continued from page 22 preparation. AAENP further promotes research efforts in emergency care to inform emergency care practice guidelines, and facilitates representation of the emergency nurse practitioner within professional health organizations and academic institutions. Current initiatives are focused on expanding national educational standards for ENPs, supporting the practice and board certification of NPs practicing in emergency care settings and updating ENP core competencies and exploring potential partnerships with nursing and medical organizations. AAENP Board Members and State Representatives are available to work with any ACOEP initiatives or needs related to Nurse Practitioner practice in the ED.

More information is available at: www.aaenp-natl.org, including an overview of the ENP role.

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• A FOUNDATION DEDICATED TO RESEARCH IN OSTEOPATHIC EMERGENCY MEDICINE

Foundation Focus Sherry D. Turner, DO, FACOEP President The Foundation for Osteopathic Emergency Medicine put on several terrific events at the The Edge: Spring Seminar in Fort Lauderdale. The week started off with the FOEM Case Study Poster Competition which had 32 participants, all willing to share the particular details of their unique and exciting cases. It was difficult as always for our judges to decide the top three cases, but thanks to a highly sophisticated scoring rubric, the winners were identified. In first place, from Aria Health, was Michaeleena “Micki” Carr, D.O. with her case, “Isolated Leg Pain and Paralysis: Following a Course of Aortic Dissection.” The second place winners tied, meaning that no third place award was given. The second place winners, from St. Barnabas Hospital and Midwestern University respectively, were Atif Farooqi, D.O. for his case, “Loosing Her Son Broke Her Heart” and Ryan Misek, D.O. for his case “Central Venous Sinus Thrombosis and the Post Partum Headache.” The winning abstracts are featured at www.FOEM.org for your reference. Congratulations to our winners! Directly following the Case Competition was the 4th annual FOEM 5K Run for Research. Rather than ask our runners to wake up at the crack of dawn, we opted to move the race to a more comfortable hour of 6 p.m. The runners gathered on the sidewalk alongside the ocean, and prepared for what ultimately was a fun and energizing event for a great cause. Several physicians brought their kids and spouses, and everyone sported the dry-fit race t-shirts that were provided by FOEM in their welcome bags. Some runners were more competitive than others, resulting in some pretty impressive winning times.

Congratulations to our winners: For the Men: 1 st Place: John Sillery, D.O. 18 minutes and 48 seconds. 2 nd Place: Serge Wenzel, D.O 19 minutes and 55 seconds 3 rd Place: Corey Lindberg, D.O. 20 minutes and 15 seconds The female runners were equally as impressive. The first place female runner is actually our very own FOEM staff member! 1st Place: Regina Schmidt 20 minutes and 39 seconds. 2 nd Place: Jenny Boscovich, D.O. 28 minutes and 0 seconds 3 rd Place: Ashley Redinger, D.O. 29 minutes and 52 seconds. Congratulations to these amazing athletes! The race was not just about running, however. This year, we set a fundraising goal of $2,000.00, and challenged our members to stand by our mission by supporting us with a 5K pledge. Although the bar was set high, our members came through with flying colors and we more than exceeded our fundraising goal for this event! The first place fundraiser was FOEM Board Member Aimee Blagovich, D.O. who donated $501.00 to the cause. In second place was a tie – Shawn Ahmed, D.O. and Robert Suter, D.O., who both donated

$500.00! In third place was Michael Allswede, D.O. who donated $250.00 to the cause. Thank you to all of our generous supporters for backing our mission to improve patient care through quality research and education in osteopathic emergency medicine! Next on the FOEM agenda was Part I and Part II of the Faculty Development Track. The purpose of this track is to prepare Program Directors and Core Faculty members for the changes arising from the Single Pathway Program. With a more faculty-heavy research component, this track is a step-by-step tutorial on how to meet these new requirements and prepare for any changes that may come in the future. The track was well received, and Part II will encore in the fall along with the debut of Part III. Make sure to encourage your Faculty and academic-minded residents to attend in October, as topics such as the ACGME application and Milestones will be presented by ACGME experts. The final FOEM event was brand new this year – the Build-a-Bike workshop. This charitable assembly brought together socially-conscious individuals that were willing to donate their time and energy to a very heartwarming cause. Local children that are either poverty-stricken or otherwise disadvantaged were presented with bikes that were built by our very own ACOEP members. The looks on their faces were absolutely priceless as they received bikes they would have never otherwise been able to afford. A wonderful time was had by all, and we thank our kindhearted bike-builders for stepping up to the plate!

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Winning Abstracts Michaeleena Carr, DO Case Study Poster Competition – Abstract FP/EM PGY-4 ACOEP Spring Seminar 2015 Aria Health Title: Isolated Leg Pain and Paralysis: Following the Course of Aortic Dissection Authors: Michaeleena Carr, DO, PGY-4 Family Medicine/Emergency Medicine Resident, Aria Health, Philadelphia, PA and Spencer Penn, DO Core Faculty Emergency Medicine, Aria Health, Philadelphia, PA Introduction This case describes a patient who presented to the ED as a stroke alert due to right lower extremity paralysis described as painful. She was found to have an extensive aortic dissection from the aortic valve to the right common iliac artery. What is remarkable about her presentation is that she did not report any “classic” symptoms or have classic signs of aortic dissection, reminding that this illness can present without typical signs.

, .

Case Description 71 year old African American female presented to the ED via EMS as haste call of stroke alert. For 30 minutes PTA, she had numbness in her right leg from the knee down that was painful, as well an inability to move her right leg at the knee, ankle or toes. She also had a mild right sided facial droop and left tongue deviation. Distal pulses were intact and equal bilaterally. Blood pressure, checked in both arms, showed no variance. CT Brain and CXR showed no acute pathology. The pain accompanying the patient’s persistent numbness and loss of motor function were not typical of stroke and raised suspicion for a noncerebral vascular lesion. CTA studies revealed a Type A aortic dissection originating at the level of the aortic valve. It involved the right carotid, bilateral subclavian, celiac, superior mesenteric and right renal arteries. It extended down to the right common iliac artery, causing of the patient’s symptoms. Due to the aortic valve involvement, the patient was transferred to a facility capable of open heart surgery. She had a modest return of RLE motor and sensory at time of transfer. The patient’s BP and HR remained stable during her ED course until the time of transfer when a nitroprusside drip was started by the transfer team. The accepting hospital was contacted a few days

s e

Thank you all for coming out to support the Foundation this spring! Make sure to join us in Orlando this October as we present the Research Poster, CPC, Oral Abstracts, and Research Paper competitions, as well as the 2015 FOEM Legacy Gala: Dinner & Awards Ceremony!

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"Foundation" continued from page 26 later for follow up who relayed that the patient had expired. Discussion: Aortic dissection is a process of serious consequence that emergency physicians must always remember to consider. It is a relatively uncommon illness, with an incidence estimated from 2.6 to 3.5 per 100,000 person-years. Classically, patients describe severe, “tearing” chest pain with radiation to the back, abdomen or other locations depending on site of dissection. This patient was a noteworthy case as she lacked any of the typical features of aortic dissection. She did not have sudden onset of severe, tearing chest pain. Her mediastinum was not widened on chest X-ray. There was no variance in pulses or blood pressure. Upon literature review, this presentation is indeed a known phenomenon, but rather

extraordinary, only occurring in 4% of aortic dissections. Elderly patients are more likely to have such atypical presentation. One research study has attempted to assist recall and improve identification of this anomalous presentation with the acronym: ILEAD (Ischemia of the Lower Extremities due to Aortic Dissection). The crucial point from this case is to never forget that initial presentation can be misleading and if not recognized, can lead to catastrophic consequences.

Michaeleena Carr, DO Case Study Poster Competition – Abstract FP/EM PGY-4 ACOEP Spring Seminar 2015 Aria Health References: 1. v on Kodolitsch Y, Schwartz AG, Nienaber CA. Clinical prediction of

acute aortic dissection. Arch Intern Med. 2000;160(19):2977 2. M ehta RH, O’Gara PT, Bossone E, Nienaber CA, Myrmel T, Cooper JV, Smith DE, Armstrong WF, Isselbacher EM, Pape LA, Eagle KA, Gilon D, International Registry of Acute Aortic Dissection (IRAD) Investigators. Acute type A aortic dissection in the elderly: clinical characteristics, management, and outcomes in the current era. J Am Coll Cardiol. 2002;40(4):685. 3. M arcantonio, D, Suri, P, Coleman,K, Taruna, A. Aortic Dissection presenting as isolated lower limb ischemia. Journal of Emergency Medicine. 2012 April; 42(4): 406-8. 4. C hih-Hsien, Lee, Cheng-His, chang, Yi-Ting Tsai, Ching-Wen-Wu. Isolated lower limb ischaemia as an unusual presenting symptom of aortic dissection.

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Cardiovascular Journal of Africa. 2012 August; 23(7): e13-14. 5. P acifico, L, Spodik, D. ILEAD—ischemia of the lower extremities due to aortic dissection: the isolated presentation. Clinical Cardiology. 1999 May;22(5):353-6. 6. M észáros I, Mórocz J, Szlávi J, Schmidt J, Tornóci L, Nagy L, Szép L. Epidemiology and clinicopathology of aortic dissection. Chest. 2000;117(5):1271. 7. C louse WD, Hallett JW Jr, Schaff HV, Spittell PC, Rowland CM, Ilstrup DM, Melton LJ 3rd. Acute aortic dissection: population-based incidence compared with degenerative aortic aneurysm rupture. Mayo Clin Proc. 2004;79(2):176. 8. H agan PG, Nienaber CA, Isselbacher EM, Bruckman D, Karavite DJ, Russman PL, Evangelista A, Fattori R, Suzuki T, Oh

JK, Moore AG, Malouf JF, Pape LA, Gaca C, Sechtem U, Lenferink S, Deutsch HJ, Diedrichs H, Marcos y Robles J, Llovet A, Gilon D, Das SK, Armstrong WF, Deeb GM, Eagle KA. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. 2000;283(7):897 9. J ohnson, Gary A, Prince, Louise A. Aortic Dissection and Related Aortic Syndromes. In Tintinalli JE, Stapczynski J, Ma O, Cline DM, Cydulka RK, Meckler GD, T. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. New York, NY: McGraw-Hill; 2011. The False Identity of a False Lumen Atif Farooqi, DO Mehrdad Alaie, MS, DO

Department of Emergency Medicine St Barnabas Hospital, 4422 Third Ave Bronx, NY 10457 Acute aortic dissection is a pathologic process by which shear forces create a tear between the intimal and muscular layers of the ascending or descending aorta. Though classically described with a ripping chest pain, the reality of the disease is that the clinical manifestations range wide, and a high suspicion must always be maintained to avoid missing a potentially morbid outcome. Our case presents a 53 year old African American male with a history of hyperlipidemia, hypertension, who began having nausea with non-bloody, non-bilious vomiting multiple time for the past three hours prior to arrival, and has since been unable to take anything by mouth. As time passed at home, he began to also develop intermittent right lower quadrant abdominal pain radiating to the right lower

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back diffusely. On exam, the patientâ&#x20AC;&#x2122;s vital signs were stable, and the patient was afebrile. The physical exam revealed a patient reluctant to move, as it would worsened the pain, and right lower quadrant tenderness with rebound, along with right costo-vertebral angle tenderness, and after the exam, the patient had another bout of severe pain and vomiting, and was unable to find a comfortable position. An EKG showed sinus bradycardia at 58 beats per minute with evidence of left ventricular hypertrophy, and a blood count, metabolic panel, and urinalysis were sent; significant values were a white blood cell count of 14.8, a serum creatinine of 1.5, and trace blood in the urine without evidence of infection. Our main differential included an acute appendicitis and ureterolithiasis and a CT scan of the abdomen and pelvis was performed. Since a ureteral stone is diagnosed without contrast, while the appendix would need contrast in our institution, we decided to use contrast since the appendicitis posed a greater potential

morbidity. In addition, though ureterolithiasis was a strong possibility, ketorolac and other non-steroidal anti-inflammatory drugs were avoided since the pathology was still obscure, and so fentanyl was given for pain control. The CT scan was performed and showed neither evidence of ureteral stone nor of appendicitis, but it did show a Type A aortic dissection from the aortic root continuing through the thoracic and abdominal aorta and finally into the right iliac artery, with no aneurysms. The patient was immediately placed on an esmolol drip and systolic blood pressure was well maintained below 110, and the patient was transferred to the nearest medical center with cardiovascular surgical capabilities, and the dissection was successfully repaired, and the patient was subsequently discharged from the accepting facility after a number of days. Acute Aortic Dissection is a disease process associated with very high morbidity and mortality rates; as high as 38% of acute aortic

dissections are missed on evaluation. It is a disease that has severe consequences despite advancements in diagnostic tools, and although the classic presentation is ripping chest pain into the back, no one sign or symptom can positively identify a dissection. The clinical manifestations are very diverse, and a high index of suspicion is necessary to prevent the less-than-obvious cases from being missed. Central Venous Sinus Thrombosis and Postpartum Headache Ryan Misek, DO Anthony Wilko, DO Department of Emergency Medicine Franciscan St. Margaret Mercy Health; Hammond, IN Abstract

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FOEM Beacon | JULY 2015

Introduction Cerebral venous sinus thrombosis (CVST) is a rare but significant cause of cerebral infarction. CVST occurs when thrombus occludes one of the dural venous sinuses that drains blood from the brain. Symptoms include headache (70-88%), vision changes, papilledema, neurological deficits, seizures and coma.1 As the paripartum state is recognized as a risk factor in the development of CVST, the emergency physician should consider the diagnosis in the paripartum patient with headache. Case Description An 18 year old female presented to the emergency department with complaint of headache seven days status post normal spontaneous vaginal delivery. The headache began shortly after the patient had an epidural placed during labor. Since that time, the patient experienced a progressively worsening headache that was exacerbated when laying supine and improved when upright. Associated symptoms included photophobia with occasional blurred vision in the right eye. The pain radiated down the back of her neck. Physical exam revealed normal vital signs. Neurological exam findings included +5 equal bilateral upper and lower extremity strength, normal gait, negative Romberg sign, +2 patellar and Achilles reflexes bilaterally with normal finger to nose, heel to shin and rapid fast alternating hand movements. Cranial nerves 2-12 were intact. There were no carotid bruits noted or papilledema. The remainder of the physical exam was unremarkable. A CBC, CMP, PT/INR and PTT were obtained and were grossly unremarkable. CT head revealed abnormal high attenuation in the superior sagittal and left transverse sinuses suspicious of deep sinus thrombosis. A subsequent MRI with and without contrast confirmed a deep venous thrombosis with partial occlusion of the left transverse sinus and posterior aspect of the superior sagittal sinus. A tertiary care center with neuro-interventional capabilities was contacted and transfer of patient was arranged. The patient was started on Enoxaparin sodium 1mg/kg subcutaneous twice daily. Follow up at one month revealed no residual neurological deficits. Discussion Postpartum headaches are common and attributed to the rearrangement of maternal circulation, sleep deprivation, dehydration and fluctuations in estrogen level.1 39% of women experienced headache in the first postpartum

week in one cohort study.2 Primary postpartum headaches include tension, migraine, clustertype headaches. Secondary headaches can also occur and are often due to procedural complications (e.g. postdural puncture headache [PDPH]), obstetrical disease (e.g. preeclampsia), or intracranial pathology (e.g. CVST).1 In the United States, 60% of women receive epidural anesthesia for pain relief during labor and up to 70% of these women develop PDPH afterwards.1,3,4 PDPH typically occurs within 3 days of the procedure, is typically exacerbated by head movement and an upright posture, improved by lying down.1,4 CVST is extremely rare, occurring in 10-20 cases per 100,000 deliveries in the US and Western Europe.5 Mortality is low (5.6% acutely and 9.4% at 12 months), and most patients recover completely.5 MRI imaging and magnetic resonance venography are used to diagnose the condition as computerized cranial tomography can be normal in 26% of patients.1 Anticoagulation is the treatment of choice, however surgical thrombectomy and endovascular thrombolysis are considered in

severe cases. 1. Wittmann M, et al. Sinus venous thrombosis: a differential diagnosis of postpartum headache. Arch Gynecol Obstet. 2012 Jan;285(1):93-7. 2. Goldszmidt E, et al. The incidence and etiology of postpartum headaches: a prospective cohort study. Can J Anaesth 2005 52(9):971–977. 3. Bucklin BA, et al. Obstetric anesthesia workforce survey: twenty-year update. Anesthesiology. 2005: 103(3):645–653. 4. Turnbull DK, Shepherd DB. Post-dural puncture headache: Pathogenesis, prevention and treatment. Br J Anaesth. 2003:91(5):718– 729 5. Wasay M, et al. Cerebral venous thrombosis: Analysis of a multicenter cohort from the United States. J Stroke Cerebrovasc Dis. 2008:17(2):49–54.

~ Introducing ~

ACOEP invites all members in the New Jersey area to attend the first-ever ACOEP Social! Join ACOEP Board, staff, and your fellow physicians for an evening of hors d’oeuvres, sangria, and camaraderie. RSVP is required to attend. Simply contact: Lorelei Crabb P: (312) 445-5707 E: lcrabb@acoep.org or Andrea Jerabek P: (312) 445-5703 E: ajerabek@acoep.org

Just Grapes Lounge | Elmwood Park, NJ September 11, 2015 | 6:00 pm - 8:00 pm This Event is FREE!

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2015-FOE

FOEM Beacon | JULY 2015

Miss out on the Case Competition this year? Apply for the FOEM Fall Competitions by July 31! FOEM CPC Competition Sponsored by:

Sunday, October 18 7:30 am – 3:30 pm

FOEM Research Poster Competition Sunday October 18 7:30 am – 11:00 am

FOEM Oral Abstract Competition Sunday, October 18 12:30 pm – 3:30 pm

FOEM Research Paper Presentations Sponsored by:

Sunday, October 18 11:00 am – 12:30 pm 32

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the PULSE | JULY 2015

The Fast Track is a quarterly publication written by and for ACOEP's active student and resident chapters. With content designed to assist students and residents through this challenging time, The Fast Track provides information on professional development, residency training, case study information and more! This dynamic publication is an excellent representation of our growing and energetic Student and Resident Chapters.

You can view The Fast Track online by go

ing to:

www.acoep.org/fasttrack 33

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the PULSE | JULY 2015

ACOEP-RC President’s Report

Andrew Little, DO ACOEP Resident Chapter President

etween graduations and new intern classes, the ACOEP RC has been hard at work. We are excited for what the new academic year has to offer and hope we can continued to serve our members well.

the ACOEP RC.

One of the major projects we have been working on is our newly revamped offerings at ACOEP’s Scientific Assembly in Orlando. This year we will offer our core activities on one fun-filled, jam-packed day. These activities will include our Resident Chapter Game Show, Advanced Airway Shootout, and Resident Rapid Fire Madness. Each of these represent opportunities for residents and residencies to go head to head and compete for prizes and bragging rights. More information for these will be seen in summer edition of The Fast Track and in blast emails.

Thank you,

As always we appreciate the continued and growing support from the college members and our leaders.

Andy Little, DO ACOEP National Resident Chapter President ACOEP Board of Directors

We are also excited to have our ACOEP RC leadership descend on the office this coming summer to hold a strategic planning meeting to discuss our long term plans and goals for

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