SAEM September-October 2013 Newsletter by Society for Academic Emergency Medicine

Celebrating Our 25th Anniversary

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2340 S. River Road, Suite 208 | Des Plaines, IL 60018 | 847-813-9823 | www.saem.org SEPTEMBER-OCTOBER 2013

VOLUME XXVIII NUMBER 5

SPOTLIGHT: K12 Program at Mount Sinai School of Medicine

ETHICS IN ACTION: Refusal of Emergency Care

RISING STAR Hendry R. Sawe, MD Muhimbili University, Tanzania

CHAMPIONS FOR PUBLIC HEALTH Antibiotic Use in the Emergency Department LYNNE D. RICHARDSON, MD, AND JEFFREY A. GLASSBERG, MD K12 MENTOR AND SCHOLAR

To lead the advancement of emergency care through education and research, advocacy, and professional development in academic emergency medicine.

SAEM STAFF Executive Director Ronald S. Moen Ext. 212, rmoen@saem.org Director of Information Services & Administration James Pearson Ext. 225, jpearson@saem.org Accountant Mai Luu, MSA Ext. 208, mluu@saem.org Accounting Assistant Dipesh Patel Ext. 207, dpatel@saem.org Communications Manager/Newsletter Editor Karen Freund Ext. 202, kfreund@saem.org Assistant to the Executive Director Michelle Iniguez Ext. 206, miniguez@saem.org Education Coordinator Tricia Fry Ext. 213, tfry@saem.org Grants & Foundation Manager Melissa McMillian, CNP Ext. 203, mmcmillian@saem.org Marketing & Membership Manager Holly Gouin, MBA Ext. 210, hgouin@saem.org

2013-2014 BOARD OF DIRECTORS Alan E. Jones, MD President University of Mississippi Medical Center Robert S. Hockberger, MD President-Elect Harbor-UCLA Medical Center Andra L. Blomkalns, MD Secretary-Treasurer University of Cincinnati College of Medicine Cherri D. Hobgood, MD Past President Indiana University School of Medicine Kathleen J. Clem, MD, FACEP Loma Linda University School of Medicine D. Mark Courtney, MD Northwestern University Feinberg School of Medicine Deborah B. Diercks, MD, MSc University of California, Davis, Medical Center

Meeting Planner Maryanne Greketis, CMP Ext. 209, mgreketis@saem.org

James F. Holmes, Jr., MD, MPH University of California, Davis, Health System

Membership Coordinator George Greaves Ext. 211, ggreaves@saem.org

Amy H. Kaji, MD, PhD Harbor-UCLA Medical Center

Systems Administrator/Data Analyst Michael Reed Ext. 205, mreed@saem.org Project Manager Mel Raymond Ext. 201, mraymond@saem.org

AEM STAFF Editor in Chief David C. Cone, MD david.cone@yale.edu Journal Editor Kathleen Seal kseal@saem.org Journal Manager Sandi Arjona sandrak.arjona@gmail.com

Brett A. Rosen, MD, Resident Member WellSpan York Hospital Sarah A. Stahmer, MD University of North Carolina School of Medicine The SAEM Newsletter is published bimonthly by the Society for Academic Emergency Medicine. The opinions expressed in this publication are those of the authors and do not necessarily reflect those of SAEM. For Newsletter archives and e-Newsletters Click on Publications at www.saem.org ÂŠ 2013 Society for Academic Emergency Medicine. All rights reserved. No part of this publication may be reproduced, stored, or transmitted in any form or by any means without prior permission in writing from the copyright holder.

HIGHLIGHTS NEWSLETTER HIGHLIGHTS GUIDELINES N EWSLETTER G UIDELINES SAEM invites submissions to the Newsletter, published bimonthly six times a year in identical online and paper editions, pertaining to academic emergency medicine in President’s Message areas including:

    

Clinical practice Education of EM residents, off-service residents, medical students, and fellows Faculty development, CME Executive Director’s Message Politics and economics as they pertain to the academic environment General announcements and notices

President’s Message

Executive Director’s Message

Submit materials for consideration for publication at newsletter@saem.org. Please include the names and Ethics in Action affiliations of authors and a means of contact.



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S U B M I S S I O N D E Academic ADLINES January/February issue December 1 Announcements March/April issue February 1 May/June issue April 1 July/August issue June 1 September/October issue August 1 November/December issue October 1

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PRESIDENT’S M ESSAGE ATTRIBUTES, ABILITY, AND ACHIEVEMENT Alan E. Jones, MD

University of Mississippi Medical Center

In her 1992 book A Return to Love, the writer Marianne Williamson gives us the following:

Alan E. Jones, MD

Our deepest fear is not that we are inadequate. Our deepest fear is that we are powerful beyond measure. It is our light, not our darkness that most frightens us. We ask ourselves, Who am I to be brilliant, gorgeous, talented, fabulous? Actually, who are you not to be? You are a child of God. Your playing small does not serve the world. There is nothing enlightened about shrinking so that other people won’t feel insecure around you. We are all meant to shine, as children do. We were born to make manifest the glory of God that is within us. It’s not just in some of us; it’s in everyone. And as we let our own light shine, we unconsciously give other people permission to do the same. As we are liberated from our own fear, our presence automatically liberates others.

This quote started me thinking about the unique attributes and abilities that we all possess. It is these attributes and abilities that lead to our achievements. And it is our achievements that lead to advancement of the organizations or communities in which we invest our time and energy. Without these efforts, there would never be advancement in society or the world. All of us have unique abilities: some are more intellectual, some more artistic, some more athletic, some a balance of the three, some have abilities more honed than others – but we all have abilities. I think that one of the major factors that separate “good” from “great” in any area of life is positive personal attributes. By that I mean those attributes that make an individual really desire to be better, and willing to tolerate the discomfort that often goes along with achieving “better.” One of the most crippling attributes is mediocrity, or, stated another way, the refusal to admit that you could be better and thus settling for “good enough.” The opposite of settling for mediocrity is taking action. Without making action an attribute, there can be no improvement, and often a lack of action is due to the fear of failure. Action requires taking initiative, being curious, communicating, networking, and troubleshooting. Action requires fearlessness, and leads to achievement.

After 15 years of membership, networking, and attending annual meetings, I view SAEM as an organization made up of individuals called to action. It’s a society whose members all want to be better and want to prosper, and will not settle for just existing. And that is the challenge we all have as members of SAEM: to ask ourselves, “Are we merely existing in this organization, or are we growing, thriving, prospering, blossoming?” If the answer is the former, we must see it as a call to action. For altruistic reasons as well as (some) selfish ones, we must press the start button and begin investing our abilities and intellects in SAEM, always moving the organization forward. The opportunities at SAEM are abundant. We have interest groups, task forces, committees, academies, representatives, nominees, and elected officials. We need and want you, the individuals who are called to action. You build the community, you make the brand, you forge change, you impart knowledge. SAEM is the sum of its parts. Ask yourself, What part am I? And before you answer, know that you have the attributes and the ability to make great achievements. Now go and make yourself a crucial part of our organization. I promise, you will be glad you did. ◗

EXECUTIVE DIRECTOR’S M ESSAGE LOOKING FORWARD SAEM has a variety of “years” with which it deals. Our financial operations are on a calendar-year basis, and soon the audited financial reports for 2012 will be posted on saem.org for the membership to view. Financial reports are often considered boring by members, but they are an accurate reflection of how and where priorities have been established. The financial health and priorities of SAEM Ronald S. Moen are detailed by your elected secretarytreasurer during the business meeting held during the Annual Meeting. However, as is often the case, those meetings are less well attended than would be desirable. This often occurs when associations are doing well, members are satisfied, and progress is being made on the issues and problems identified by members, leaders, and staff. I encourage you to look at the audited financial reports when they are published on the web. As an organization that has been granted tax exemption under the 501(c)(3) provisions of the tax code, we are required to provide our audited financial reports not only to members, but upon request to the general public as well. Our program of work at SAEM revolves around what many of us term a “program year,” which runs from one Annual Meeting to the next Annual Meeting. Our officers and members of the Board change at the end of each Annual Meeting, as do the chairs of committees, task forces and often academies as well. Membership on committees and other groups within SAEM undergo some changes during the program year as well. In our current program year, we are looking forward to celebrating SAEM’s 25th Annual Meeting in Dallas May 13-17, 2014. SAEM was officially formed at its inaugural Annual Meeting in San Diego in 1989, the result of two years of work towards a merger by the University Association for Emergency Medicine (UAEM) and the Society of Teachers of Emergency Medicine (STEM). Attendance at that first Annual Meeting was noted as “over 650 registrants” in the fledgling SAEM Newsletter. In Atlanta this past May, by comparison, we had an all-time record registration of over 2,400 individuals, and we hope to exceed that next year in Dallas. The Annual Meeting Program Committee, under the direction of chair Chris Ross, is working hard to create the best ever Annual Meeting to help SAEM celebrate its 25th Anniversary. Watch future issues of the Newsletter and saem.org for further information. You have also probably noticed that our “dues year” for residents has a completely different cycle from that of our active/ faculty members. Since residents typically start their training in July of any given year, our dues billing cycle is geared to get the new residents on board with their membership in SAEM as soon as they begin their program year. One residual benefit to our residents is that when they graduate, they basically get six months of free membership, as we don’t bill them as a new active

member or member of a faculty group until the end of that year for the following calendar year. Thanks to all of the coordinators at the medical schools for their help in processing membership in SAEM for their residents as early as possible. We know that it is important for them to start getting Academic Emergency Medicine and access to saem.org, as well as this Newsletter and other important communications. They are also able to join academies and interest groups as soon as their SAEM dues are paid. As we look forward to our 25th Anniversary Annual Meeting, you will see a variety of articles in the coming issues of the Newsletter dealing with some of the early struggles of emergency medicine as a specialty. There are many individuals that paved the way for the development of this specialty. One characteristic that all these early leaders shared was their ability to look forward. They saw opportunity where others saw roadblocks and challenges. They were always looking forward to the next opportunity to advance the training, education, and experience of their colleagues in emergency medicine. They recognized that they had and needed allies in other fields of medicine if emergency medicine was to become a specialty in its own right. That is still true today. As you look at some of the most successful emergency medicine training programs, you will see that these programs usually enjoy an outstanding reputation and an equally outstanding relationship with their colleagues in other branches of medicine. Thus, as you look forward to the changes that will come in the delivery of health care in the United States as a result of changes in health policy and reimbursement, the challenge to all practitioners and leaders in emergency medicine is to be looking forward and seeing these changes as opportunities to improve the effectiveness of the services you provide. Emergency medicine is destined to play an even greater central role in service delivery in the future, but it may occur in a variety of ways that have yet to be developed or tested. So, too, at SAEM our leaders and staff must be constantly looking forward in order to seize the opportunities that will exist for this association. One of SAEM’s strengths has been the willingness of members to become and remain involved in so many different ways in the association. Whether it is in the leadership of an academy, the development of specific projects in a committee, or cooperative work to represent emergency medicine in working groups with other associations or agencies of the federal government, SAEM members are leaders by virtue of their knowledge, skills, and the ability to always be looking forward. So, a recommendation: take a moment out of your busy day, and think of how looking forward might change the way you deal with work, with family, and with the challenges that you face. Your mentors have done that, and you can do it too. As you do, SAEM will be able to look backwards as well, and recognize that the first 25 years were only a prelude to the next great 25 years, as all of us look forward together. ◗

SPOTLIGHT Reflections on the NHLBI K12 Program at Mount Sinai: A conversation with Lynne D. Richardson, MD and Jeffrey A. Glassberg, MD Karen L. Freund SAEM Newsletter editor It is now over two years since the National Heart, Lung, and Blood Institute (NHLBI) invested approximately $22 million in the future of EM research by funding six institutional K12 Research Career Development Programs in Emergency Medicine. Implementing what was viewed as a key advancement for emergency care research, the development of future emergency care investigators, and public health, the NHLBI awarded K12 funding to Oregon Health & Science University; the University of California, Davis; the University of Pennsylvania; the University of Pittsburgh at Pittsburgh; Vanderbilt University; and Mount Sinai School of Medicine. The September-October 2012 issue of the Newsletter (http://www.saem.org/publications/newsletters, p. 15) reported on the successes and challenges of the K12 programs’ first year at all six institutions. A year later, we spoke with the director of the K12 program at Mount Sinai School of Medicine, Lynne D. Richardson, MD, and one of Mount Sinai’s K12 scholars, Jeffrey A. Glassberg, MD, MA, to revisit one of the six and let the doctors share their own experiences with and thoughts on the K12 program at their institution. The transcript below has been edited for space; for the full interview, please visit http://www.saem.org/publications. SAEM: Let’s begin with some background. Dr. Richardson, were you involved in the development of the K12 programs? LR:

The funding announcement from NHLBI to fund institutional training programs in emergency medicine research was really the culmination of work by a lot of people within SAEM and the other EM organizations. It really started with the Institute of Medicine report [Hospital-Based Emergency Care: At the Breaking Point], which talked about the need to build the research enterprise within EM and to invest in training EM investigators. The NIH response to the IOM report was a series of roundtables where experts in EM research of various kinds, including myself, went to NIH and talked with people from the institutes and centers about the research agenda for EM, how it fit into their research priorities and their research portfolios at their institutes and centers, and what some of the scientific issues were and the training issues were.

The funding announcement that NHLBI put out was the first tangible result of that effort by the academic emergency medicine community - it was the first time any NIH institute had earmarked training dollars for EM research. NHLBI said that they would fund five programs, although they made it clear in the informal talks that they wouldn’t necessarily fund five if there weren’t good applications, and I think there was some skepticism within NIH about EM’s ability to write highquality grant applications for training programs. The specialty really stepped up. There was an outpouring of extraordinarily good applications. In fact, there were so many good applications that, after they were scored and before the funding decision was made, and through the important efforts of Jane Scott, who’s the program officer for the NHLBI K12 programs, they decided to fund six. SAEM: How has the program been beneficial to Mount Sinai? How is it being integrated, and do you think it’s going to serve as a model for other programs in the future? LR:

I think it is; I think that it’s really brought tremendous resources to our department here at Mount Sinai, and really accelerated our ability to train young investigators. We were doing research training before we got the K12 program, and that is true of all of the places that actually got funded. Many of us had research fellowships as we did here. But we were basically doing it on internal money. So, the fellows would have to work enough clinical hours to earn their keep, and maybe the department would subsidize it a little bit, but no one was giving the department money to allow us to train investigators. With the funding from NHLBI, I now have salary support for each one of the K12 scholars, so that it’s easy to buy down their time and protect them so that they really can do 75 percent research. I have money to pay tuition for them to get a master’s in clinical research degree. I have money for research expenses, to hire them a research coordinator, to send them to conferences. So that basically what we were doing with no resources, we now have very robust resources to do. We’ve been very fortunate here at Mount Sinai, we’ve had a lot of support from our institutional CTSA and the centralized research training Continued on Page 7

Continued from Page 6 core within that, they’ve been very collaborative and very supportive of our really launching the best program we can. So it’s very well integrated into the research training enterprise institutionally.

JG:

Exactly. One of the biggest issues in sickle cell disease is that 30 years ago we didn’t have adults with sickle cell disease because the life expectancy was around 18 years, and now people with sickle cell disease are living to 50 on average. We have 80-year-olds in our clinic, and the problem that has been created by this wonderful increase in lifespan is that sickle cell disease used to be taken care of only by pediatricians: there weren’t any adult physicians who took care of people with sickle cell disease. And as the adult population has grown and grown, their needs have not been met by the system. There aren’t enough doctors who take care of adult patients with sickle cell disease. There aren’t enough clinics, and so when these individuals graduate from their pediatric sickle cell clinics, a lot of them do just get scattered to the wind and have no real anchor for their care, and they wind up in the ED constantly. And that’s why 18- to 30-year-olds have the highest rate of ED utilization, and mortality is rising for 18- to 30-year-olds with sickle cell disease.

LR:

I would say that I think Jeff is a good example: built into the training curriculum for our K12 scholars are a number of competencies, including being able to network with investigators across the scientific span. Most of our K12 scholars are clinical or health services researchers, but we make sure that all of them have what’s called a “T1 mentor,” meaning someone who’s doing basic science research, because we want to build those ties, so the discoveries that Jeff was talking about don’t take 17 years to get into common usage, because there’s a cadre of clinical investigators who are working already with these basic science investigators, so as soon as there’s a new discovery that’s ready for a first in-human use or an early Phase 1 trial, they already have those network connections, so it’s really breaking down the scientific silos that I think are responsible for the very slow dissemination.

SAEM: Dr. Glassberg, how did you find out about the K12 program and how did you go about applying for it? JG:

Well, I was a research fellow at Mount Sinai when the funding announcement came out, so I knew that we were applying as an institution and that we were hoping to get this award, and I also knew what a K12 program was, because at Sinai we have a CTSA, which is a similar concept. So I was there when Lynne was putting together the application, and so I was waiting to find out if we got it. I wrote a letter of support which described the research infrastructure that we had in our department already, which was substantial, much more robust than any other institution that I had been at, but still, there was so much potential from what we would get from a K12 award. Then we got our score back, which was a very good score, and I was trying to get my career off the ground, and once we got the award I knew this would be an absolute excellent opportunity if I was accepted into the program, and thankfully I was.

SAEM: One of the goals of the program is “implementation of science techniques to facilitate the dissemination of research findings to providers and the public.” How is this accomplished in terms of dealing with the public and providing information to them? JG:

I can speak specifically about my own research. I’ve been told that the time it takes from the publication of study results in a subspecialty journal to the time that that actually gets integrated into clinical practice is approximately 17 years. So we do have a major dissemination problem in medicine. My research has to do with sickle cell disease. We have two community organizations in New York, which has more people with sickle cell disease than any other city in America, and I’m on the boards of both of them. I’ve been trying in many ways to raise awareness about sickle cell disease and interact. We’re just starting a program to go into public schools and teach, integrate ourselves into the public middle school curriculum and teach seventhgraders about sickle cell disease, both in their science class and also in their health class. It’s is a complex disease, it has issues around paternity and genetics and also in terms of science and biology. We’ve also worked with the Sickle Cell Advisory Council, where we’re trying continually to improve state and local funding for centers and resources, because it is a very resource-intensive disease. Those are just some of the things that I’ve been trying to do in terms of interaction with the community just to raise awareness about sickle cell disease, to increase participation in clinical trials, to encourage people living with the disease to come to the top-quality medical centers so they can get the best care.

SAEM: And I imagine this would include an effort to get them to have constant care rather than show up in the ED because of a crisis.

SAEM: Dr. Richardson, what has been your day-to-day role as a mentor to Dr. Glassberg? LR:

Well, being a mentor is a little bit like being a parent. I do think in many ways the young investigators I mentor are my professional progeny. So you have to protect them, and you have to give them every opportunity to learn while protecting them from fatal mistakes as their judgment is developing, so my role really is to create the environment in which they can flourish, to get them everything that they need to succeed, to give them help and advice and support and maybe an occasional kick in the butt (metaphorically, of course). It varies over time. I think for the early scholar there’s a lot of contact. My new scholars I meet with weekly, helping them get their research set up, helping them develop a career development plan, helping them establish their mentorship team. I would say that Jeff is very much further along on that trajectory, moving into a much more autonomous, independent role. And I just love to see that progression, the investigator progress to independence. Jeff is about to take that first major step. I expect that he will shortly be coming off my K12 Continued on Page 8

Continued from Page 7 program because he’ll be getting an individual career development award from NIH. Mostly it’s great fun, it’s talking about research ideas, it’s helping design studies, it’s helping navigate academic politics, it’s helping to find funding or resources, to make connections. It’s a tremendously rewarding activity to mentor a young scientist.

this is. We hope to see the number of applications to the programs increase every year as word gets out, because this is really a golden opportunity for a fellow or junior faculty member. They can come into a program where they have protected time and they have tuition money and they have mentoring, they have administrative support and research infrastructure. And that’s often the difference between success and failure for a young investigator.

SAEM: Dr. Glassberg, what are your plans, as far as you know, for your future career? JG:

I do research exclusively in sickle cell disease right now. And coming back to what I said about EM’s unique perspective, that our practice has to integrate everybody else’s science, everybody else’s research in our practice, and that gives us a wonderful bird’s-eye view about how different people conduct research. And because of that, I think that as emergency medicine we have a wonderful ability to contribute to how research is done. I want to do research in sickle cell disease, and sickle cell disease has been around for a long time. It was discovered 103 years ago, and there’s only one drug to treat it, and there have been many, many failures of clinical trials in sickle cell disease. In fact, it’s not just sickle cell disease; there was just an article in the New York Times called “Do Clinical Trials Work?” which covered how there have been many failures in many diseases, a lot of the way we do science right now, we don’t seem to learn very much from the research that we do. And so what I would like to do in the future, what I’m hoping to build my career as, is to learn how to do research where you move from a concept to exploring that concept, and then ultimately taking that concept to an interventional clinical trial, where you try to develop a therapy. That’s where I hope to go, to improve the way that we conduct clinical trials and learn about treatments and things like that.

SAEM: One more question: how do you think that SAEM can contribute in the future to the further development of the K12 programs? LR:

Well, I’m glad you asked that question, because the six K12 programs that were funded by NHLBI are really a little bit of an experiment. And I think a lot of people at NIH are waiting to see how these programs do before they consider committing research-training dollars from their institutes or centers to EM research. So, the success of these programs, I think, has important implications for the specialty as a whole going at least into the next decade. SAEM has already been very supportive, they’ve allowed us time on every Annual Meeting program since the K12s were funded to get information to interested people, to talk about the programs, to explain what they are. I think that we really need for the membership of SAEM to get more involved, that they need to understand what the K12 programs have to offer, and every residency director or research fellowship director who has a young emergency physician who’s interested in a career in research should be talking to them about the K12 programs and helping them understand what a wonderful resource

JG:

I really feel like, if people knew how rewarding and exciting a research career can be, that we would have more people pursuing it. I only get exposed to a handful of medical students and residents that I take on to mentor through research, and an organization like SAEM can really help us get the word out about what the K12 program is and what a wonderful opportunity it is, because right now the environment for NIH funding is very hard, and the K12 really puts you at a huge advantage, to get your foot in the door, to become an NIH-funded researcher. The more people know about it, the better. ◗

For more information on the six funded K12 Research Career Development Programs in Emergency Medicine, please visit

www.nhlbi.nih.gov/funding/training/redbook/k12-emmed.htm.

Page 6 SAEM AND Continued THEfromCREATION OF THE K12 PROGRAMS

Judd E. Hollander, MD University of Pennsylvania The K12 came about through years of work of a combined ACEP-SAEM NIH task force. This opened a very successful line of communication between EM organizations and the NIH. Jeff Kline decided to create the SAEM Fellowship Approval Task Force and appointed me to chair it. As we developed the approval process, we engaged the NIH and were fortunate to have Jane Scott appointed as the NIH rep. Jane understood emergency medicine and was head of NIH training grants. Unbeknownst to her colleagues on the task force, she was working within the NIH to help create the K12, while SAEM was working to develop a process to approve training programs. We were fortunate to have her on the task force, and she was able to see our unmet needs at the time she was creating the K12. In one swoop, emergency medicine received more training grant dollars than it had in all of its history. The K12 effectively provided funding to catapult training in our specialty. We now have opportunities for emergency physicians to get outstanding research training at the K12 sites. We also have opportunities to help train other emergency care researchers who may not have had emergency medicine training. More important than the impact to our members and specialty will be the long term benefit to our patients.

MILESTONE ASSESSMENT TOOLS WITH A SIMULATION FOCUS Danielle Hart, MD and Ivette Motola, MD With emergency medicine’s first reporting requirement for the ACGME’s Milestones project occurring in December 2013, resident assessment has come to the forefront of many of our minds and agendas. There are many groups within emergency medicine that are currently working on assessment tools related to, or linked to, the Milestones. These groups include the SAEM Simulation Academy’s Milestones Task Force, the Society for Simulation in Healthcare EM Special Interest Group’s Procedural Milestones Task Force, and the Council of Residency Directors in EM Joint Milestones Task Force. The SAEM Simulation Academy Milestones Task Force is developing 4-5 high-fidelity simulation scenarios with paired assessment tools to assess EM residents on 10 of the 23 Milestones. These 10 Milestones are: Emergency Stabilization (PC1); Performance of Focused History and Physical Exam (PC2); Diagnostic Studies (PC3); Pharmacotherapy (PC5); Observation and Reassessment (PC6); Airway Management (PC10); Professional Values (PROF1); Patient-Centered Communication (ICS1); Team Management (ICS2); and Patient Safety (SBP1). The assessment tools will review critical actions that should occur in the simulation scenarios, which will be linked on the back end to the Milestones, in addition to global rating scales. Results will be milestones-based, for easy interpretation and translation by the Clinical Competency Committee and the program director to Milestones reporting to the ACGME. Assessing the reliability and validity of these scenarios and paired assessment tools will involve a multi-institutional study; we currently have over 30 EM faculty participating. This effort is

led by Dr. Danielle Hart, associate program director and director of Simulation at Hennepin County Medical Center. The EM Special Interest Group of the Society for Simulation in Healthcare is developing procedural competency assessments linked to the EM Milestones. The group is comprised of EM faculty from over 20 academic institutions. The goal is to develop validated cognitive and psychomotor assessment tools for the Milestones that focus on procedural competency. The group is working on wound management as its first endeavor, and the effort is led by Dr. Steven Vance, assistant dean of Academic and Clinical Technology at Central Michigan University College of Medicine, and outgoing president of the EM SIG. The CORD Joint Milestones Task Force, led by Dr. Felix Ankel, currently has over 80 members. Three subgroups have been created: each is working on an aspect of the Milestones. The ED-Care-Based Subgroup is led by Dr. Moshe Weizberg; the Procedure-Based Subgroup is led by Dr. Jenna Fredette; and the Systems-Based Subgroup is led by Dr. Mary Jo Wagner. Dr. Weizberg’s group is working on a study to discover whether incoming PGY-1 residents have achieved level-1 milestones for the Patient Care Milestones 1-8 at the start of their residency. Dr. Fredette’s group is working on formulating and compiling procedural assessment tools based around the procedural milestones that can be used in a variety of contexts (ED direct observation, simulation, etc.). Dr. Wagner’s group is examining the milestones related to the other core competencies, such as communication, professionalism, problem-based learning and improvement, and systems-based practice. ◗

ETHICS IN ACTION Arvind Venkat, MD

Vice Chair for Research and Faculty Academic Affairs, Department of Emergency Medicine, West Penn Allegheny Health System, and Ethics Consultant, Allegheny General Hospital, Pittsburgh, Pennsylvania Associate Professor of Emergency Medicine, Drexel University College of Medicine and Temple University School of Medicine

CASE PRESENTATION

A 23-year-old male patient presents to the emergency department grossly intoxicated, with somewhat incoherent statements of being depressed and suicidal. He was found lying in a park and brought in by emergency medical services. Based on protocols at this center, the patient was examined for any signs of medical instability and allowed to sober up prior to psychiatric evaluation. In evaluating the patient, the emergency physician obtains a history that this patient drinks quite heavily on a regular basis and has a history of depression, with previous hospitalizations for suicidal ideation. The patient is found to have stable vital signs with no evidence of additional medical complications, and a breathalyzer alcohol reading of 0.305. He is allowed to sleep after initial examination, with a plan for the oncoming emergency medicine team to evaluate him again after six to seven hours of metabolism to allow his alcohol level to fall below the legal limit of 0.08. Three hours into the patient’s clinical course, the patient states that he wishes to go home so that he can resume drinking. He denies that he is suicidal or depressed and states that “this is as sober as I get.” He is still slurring his words, suggestive that he still has a significant amount of alcohol in his system, but appears to have gross insight into his condition and medical background. The patient also states that he is feeling “shaky” and is noted by the emergency physician to be mildly tachycardic (heart rate of 110) and diaphoretic. When the emergency physician presents his concern that the patient is in the initial stages of alcohol withdrawal, the patient becomes more belligerent, stating clearly that he will take care of himself by drinking more at home and does not want further emergency department care.

DISCUSSION

This case presents a number of ethical and medical issues of interest to emergency physicians. The primary ethical and concomitant medical issue is whether an inebriated patient can refuse medical therapy in an informed manner. Under the principle of autonomy, if this patient were not intoxicated and had insight into his medical condition, he would be able to refuse care over the recommendations of his physician. The issue here is that the patient appeared to still be impaired based on his likely having a

significant amount of alcohol in his system. On the other hand, for a patient like this one who consumes significant amounts of alcohol regularly, it may be completely normal for him to have intact decision-making capacity with a level of alcohol above the legal limit. The statement by the patient that he can treat himself for alcohol withdrawal may indicate either a lack of insight into the danger of this condition or, ironically, an acute insight into his personal physiology and the ability to self-treat! For emergency physicians, the necessity to come to a conclusion on decision-making capacity is of fundamental importance in determining whether the patient can refuse care in an informed manner. Unfortunately, the time pressures of emergency medicine make an in-depth exploration of the judgment of patients a difficult task. For a patient to be considered to have decision-making capacity, he should be able to articulate an appropriate moral or values-based framework for his decision, state how his refusal or consent fits within this framework, and relay his comprehension of the consequences of his decision in the context of the moral or values-based framework.1 Authors on this subject have also concluded that a “sliding scale” is appropriate in assessing decision-making capacity in acute care settings – the higher the consequences of refusal of care, the more stringent the evidence should be for acceptance that such refusal is being chosen in an informed manner.2 In this case, it is a professional judgment of whether or not the patient meets these criteria for informed refusal of care. It appears that he might be motivated by a wish to be left alone, but at the same time, that motivation seems most clearly coupled with a value of wanting to drink again to excess. This hardly seems to qualify as an appropriate moral or values-based framework. But the danger clearly exists that physicians may be imprudent in judging the appropriateness of the values used by patients in refusing care, lapsing into paternalism. It is only through professional training, awareness, and humility that emergency physicians can appropriately assess the value structure by which a patient expresses informed refusal.

Continued on Page 11

Continued from Page 10 The next question to consider is how far it is ethically appropriate to go in putting into effect a treatment plan in a patient who is refusing care. Here the principle of proportionality has appropriate application. Proportionality, at its essence, calls for a response to a situation to be comparable to the consequences of failure to act.3 For example, it would be lacking in proportion to physically restrain an alert patient who refuses a lumbar puncture in the evaluation of a headache. Instead, discussion and gentle persuasion on the evidence supporting this intervention, documentation of the patient’s refusal to consent, and alternative evaluation and treatment plans would be ethically preferable. In this case of an intoxicated patient refusing care, there may be a need to use more forceful persuasion or even restraint to avoid the significant and potential life-threatening consequences of alcohol withdrawal and delirium tremens. Treatment provided should ideally be kept proportionate by tempering withdrawal symptoms but still allowing the patient to communicate with medical providers on his psychological state.

CASE OUTCOME AND LESSON LEARNED

To convey the seriousness of the situation, the emergency physician asked security to stand outside the room, but did not ask for restraints, and told the patient that he felt compelled to treat him with benzodiazepines both for withdrawal symptoms

and to allow future assessment of his psychological state. The emergency physician also asked the patient if he wanted something to eat and a room in a quieter part of the emergency department, and offered to walk outside with the patient and security so that the patient could smoke a cigarette before starting treatment. The patient accepted this plan, was given multiple doses of benzodiazepines, and was admitted to the hospital for further medical and psychiatric evaluation. The main lesson of this case is that emergency physicians need to be prepared to rapidly assess decision-making capacity, likely with a sliding-scale expectation of evidence for informed refusal, and show creative flexibility in devising a proportionate response when necessary. As with much in emergency medicine, practical solutions are necessary to solve a theoretical conundrum. ◗

BIBLIOGRAPHY 1. President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. The Ethical and Legal Implications of Informed Consent in the Patient-Practitioner Relationship. In: Views of Informed Consent and Decisionmaking: Parallel Surveys of Physicians and the Public: Government Printing Office; 1982:17-316. 2. Geiderman J. Ethics Seminars: Consent and Refusal in an Urban Emergency Department: Two Case Studies. Acad Emerg Med. 2001;8:278-81. 3. Hermeren G. The principle of proportionality: interpretations and applications. Med Health Care Philos. 2012;15:373-82.

ADIEM UPDATE Sheryl L. Heron, MD, MPH Emory University ADIEM President We are well into the new academic year for the Academy for Diversity & Inclusion in Emergency Medicine, and we are looking forward to great things. Since SAEM’s Annual Meeting in May in Atlanta, many of the ADIEM leadership had the pleasure of participating in the National Medical Association’s Scientific Assembly in Toronto, Canada. Ugo Ezenkwele, ADIEM’s vice chair, is NMA’s EM chair, and Tyson Pillow, ADIEM’s secretary/treasurer is also NMA’s secretary/ treasurer. The theme of the conference was obesity as From left: Andrew Sama, MD, president of ACEP; Ugo related to emergency department patients. It was Sheryl Heron, MD, MPH, ADIEM president (left), and Gina Porter, MD, ADIEM resident Ezenkwele, MD, ADIEM vice president; and William Durkin, apropos given the increasing attention to the obesity member MD, MBA, president of AAEM epidemic in the United States. As in years past, there were presentations by the presidents of the American College of Emergency Physicians (ACEP) and the American Academy of Emergency Medicine (AAEM), Dr. Andrew Sama and Dr. William Durkin. The conference was four days in duration, with a rich array of diverse evidence-based topics, ranging from the management of complications from bariatric surgery to dealing with obese patients in trauma. In addition, residents showcased their research on health disparities and scientific interventions for their reduction. The success of our work on issues concerning LGBT persons in EM has resulted in an accepted submission spearheaded by Dr. Joel Moel to the ACGME conference in March 2014. Congratulations to Joel Moll and Paul Krieger on this effort. Our goals for the year continue to be: 1) to boost our membership; 2) to emphasize the value of ADIEM to our members; and 3) to serve as advisors and mentors for students, residents, and faculty across the spectrum of EM. We encourage everyone to get involved and share thoughts on the ADIEM community website. ◗

RESIDENT AND STUDENT ADVISORY COM M ITTEE THE KEY TO UNLOCKING THE EM DOOR: AUDITION ROTATIONS Joel Brooks, PGY1

Resident and Student Advisory Committee As you enter the emergency department, a flurry of activity surrounds you. You walk up to the front desk, but do not recognize anyone there from yesterdayâ&#x20AC;&#x2122;s orientation. Everyone is extremely busy, and you are unsure whom to report to. Welcome to your first emergency medicine rotationâ&#x20AC;Ś Emergency Medicine is a field that offers a unique perspective. Whereas the goal in many medical fields is to manage the health care needs of your patient and promote wellness, the primary goal in emergency medicine is to recognize if the patient is truly sick (presenting with a medical emergency). One must always be concerned about the worst-case scenario. Understanding these points is crucial for being successful in EM, as this influences the diagnostic workup and treatment of the patient. There are many resources available to assist students interested in emergency medicine. Organizations such as the Society for Academic Emergency Medicine (www.saem.org) the American Academy of Emergency Medicine (www.aaem.org), and the Emergency Medicine Resident Association (www.emra.org) have published guidebooks for students interested in EM and their websites contain additional information for students, such as residency application tips and links, news on upcoming conferences, and discounted pocket manuals that can be extremely useful on rotations. In addition to providing a wealth of resources for medical students, SAEM has a unique virtual mentorship program (www.saem.org/e-advising). This program provides students with a outside resources for advice and honest feedback.

As a medical student interested in emergency medicine, it is important to experience a rotation to determine if this is the right field for you. If your medical institution offers a core or elective EM rotation, it is best to take advantage of it at the end of 3rd year or beginning of 4th year. This allows you to become accustomed to the ED environment in a familiar setting, and to refine your skills to distinguish yourself on later rotations. If you are unable to arrange a rotation at your institution, try to arrange audition rotations at sites with residency programs where you would be interested in training. The first rotation is always the most challenging, but the difficulties can be overcome with the correct attitude and a willingness to learn. It is expected that you will make mistakes, but you can learn from those mistakes and strive to improve. At the start of every rotation, you should try to identify a faculty member who will provide you with guidance and feedback about your performance. Ask for a letter of recommendation early on during the rotation. This will let the physicians know you are interested in the field and want to be professionally evaluated. is The chief residents at the program where you are rotating are another helpful source of information. They are available to help address any of your concerns. Initially, if you find the faculty intimidating, you might feel that the chief residents are more approachable, and they too have a wealth of knowledge to share. There are many areas in which interested students can distinguish themselves from their peers. It is crucial to be courteous and polite to both staff members and patients. This should be obvious to everyone, but, unfortunately, it is often overlooked. Continued on Page 13

DR. HENDRY SAWE: RISING STAR IN GLOBAL EMERGENCY MEDICINE Michael S. Runyon, MD, FAAEM, FACEP

Director of Research, Department of Emergency Medicine, Carolinas Medical Center

Attendees at the 2013 SAEM Annual Meeting in Atlanta this past May might not have been familiar with the winner of the event’s award for Best Resident Presentation. Dr. Hendry Sawe is a chief resident in the emergency medicine program in Dar es Salaam, Tanzania. He is also a founding member, and president, of the Emergency Medicine Association of Tanzania, and recently joined SAEM and the Society’s Global Emergency Medicine Academy (GEMA). The residency program in Dar is a three-year Master’s of Medicine in EM program at Muhimbili University of Health Allied Sciences (MUHAS), with clinical work at the ED of the adjacent Muhimbili National Hospital (MNH). It is the first EM residency program in Tanzania. The ED and EM program are supported by visiting EM faculty from a consortium of academic programs in South Africa, Canada, and the US, made possible by the financial backing of Abbott Fund Tanzania. The plan for long-term sustainability of the project is that reliance on the international faculty support will decrease as Hendry and his colleagues graduate and take over program leadership. Indeed, he and his classmates are on track to be the first graduates from the program later this year. All too often, global EM meetings seem to consist largely of faculty and residents from the US (and other countries with an established EM infrastructure) presenting the work they are doing abroad. I really like the idea of rethinking our approach to global EM and am most proud that the MNH/MUHAS program has consistently mentored and supported the Tanzanian doctors and made them, rather than us (the consortium faculty), the face of the program. Because of this, Hendry has already had the opportunity to present at EM conferences in South Africa, Canada, and the US.

Continued from Page 12 Physicians, residents, and staff will want to work with you if you have a positive attitude and are friendly. Your professional conduct is one of the factors taken into consideration in evaluating your efforts, and may translate into a higher ranking at match time. Always arrive early for your shift. An ED physician once told me that the shift begins 10 minutes before the scheduled time. Be willing to stay late and help out if the opportunity arises. It shows that you are invested and care about what you are doing, and that you are a team player. Be proactive and sign up for a patient before being asked to by the resident or attending. The caveat to that is not to sign up for too many. Frequently, students try to sign up for more patients than they can properly manage. It is better to thoroughly manage fewer cases at the beginning of your rotation and progress as your abilities improve. Part of proper patient management includes

Hendry is incredibly intelligent and ambitious, and the project that won the award at the SAEM meeting in Atlanta is just one of several projects that he has completed during his residency. It is a study of the accuracy of doctors’ gestalt estimates of anemia among patients presenting to the MNH ED. The idea behind the project is that the ED sees a lot of patients with severe anemia, and even at the national hospital there is a limited blood supply, and lab turnaround of hemoglobin measurements frequently exceeds one hour. Furthermore, we know that aggressive crystalloid resuscitation increases morbidity and mortality among severely anemic patients presenting to the ED in shock. Hendry managed to enroll 210 patients over two months, median age 30 years, 57% male, and 40% with severe anemia, defined as a hemoglobin value of less than 7g/dL measured by the MNH Central Pathology Laboratory. He found that, while the sensitivity of the doctors’ estimates was relatively low (64%, 95% CI: 5374%), the specificity was high enough (91%, 95% CI: 85-96%) to result in a clinically important likelihood ratio positive (7.4, 95% CI: 4.2-13.3) sufficient to justify empiric transfusion therapy and avoidance of vigorous crystalloid infusion among the subset of patients deemed severely anemic by the doctors’ bedside gestalt assessment. The weighted Cohen’s kappa for inter-observer agreement between physicians on the gestalt estimate of the degree of anemia was 0.87 (95% CI 0.76 to 0.98), representing “almost perfect” agreement according to the classification of Landis and Koch. As the faculty mentor on this study, I can attest that Hendry was the driving force behind this project at every step. In addition to this project, Hendry’s additional work has focused on the effect of IVF loading on US-measured IVC indices and the trend in overall hospital mortality at MNH associated with the opening of the MNH ED. He currently has several other projects in development. I am confident that he will continue to be a star in academic EM in Tanzania and throughout the world. ◗

frequently re-evaluating them. After the initial screening, you still need to follow up with them throughout their stay, find out if there is anything they need, and assist in making them comfortable. Good grades and intelligence are important, but common sense, thoughtful caring, and hard work make you truly stand out. A strong audition rotation can help overcome weaknesses in your residency application. Many residencies will offer interviews as a courtesy to all students who auditioned with them. While some medical students may feel these interviews are a formality, your interviewers will not know why you were chosen for an interview, and will independently assess your presentation and performance. Your evaluation and success is largely based on whether or not they will want to work with you for the next 3-4 years. Whether you are on an interview or working a routine shift in the ED, attitude is everything. A positive disposition combined with a consistently solid work ethic will demonstrate your dedication and your desire to become an exceptional EM physician. ◗

THE TENTH ANNIVERSARY OF TELEMERGENCY Richard L. Summers, MD

Professor and Chairman, Department of Emergency Medicine, University of Mississippi Medical Center

Kristi Henderson, DNP, NP-BC, FAEN

Director of Telehealth, University of Mississippi Medical Center

Kristen C. Isom, Stroke & STEMI

Coordinator, Telemedicine Liaison, Anderson Regional Hospital

Robert L. Galli, MD

Professor and Director of TelEmergency, Department of Emergency Medicine, University of Mississippi Medical Center

October 2013 marks the 10-year anniversary of the TelEmergency program at the University of Mississippi Medical Center.1 The program was initially started with the assistance of private foundation funding I had acquired, but the concept and most of the original organization of the system was the work of Robert L. Galli, MD and Kristi Henderson, DNP, NP-BC, with technical expertise from Greg Hall. The program was born from a consensus within our group that there was a serious need to improve emergency care in our state. At that time we frequently received badly managed critical patients in transfer to our emergency department, particularly from critical access hospitals in small communities where there were no physicians with emergency expertise available. Often these EDs were serviced by local physicians who were also covering their clinics or by nurse practitioners with a family medicine orientation. The prospect of retaining true emergency physicians to cover these departments was financially and logistically unfeasible. On the other hand, closure of these hospitals would leave large gaps in the availability of medical care for an already underserved population. In many of these communities it might require hours of travel to find the first available hospital for emergency services. However, poor emergency medical care is often worse than no care at all. Many other states are facing similar issues. Recent workforce studies for emergency medicine indicate that residencyâ&#x20AC;&#x201C;trained/ board-certified emergency physicians will not be able to satisfy the workforce demands for many years to come.2 This problem is even more severe in rural areas where the percentages of true emergency physicians typically comprise only a small fraction of the needed workforce, with most of the emergency departments being serviced by family medicine physicians and nurse practitioners.3 A strategy which uses a telemedicine connection to provide some emergency medicine expertise to these struggling medical communities is one possible solution. Our TelEmergency system operates like an ED on a 24/7 basis, with a board certified emergency physician in our telemedicine console room ready to answer all calls. This room is contiguous with our own ED, which allows for the utilization of many additional resources if needed. Emergency consultations are available for any patient that arrives at one of our distance sites, as determined by the provider at that location. We encourage engagement with the service for any patients of ESI acuity of 3 or greater. Telemedicine equipment mounted on a mobile cart allows for two-way audio and visual communication between the patient or distant provider and the physician at our console. The telemedicine audiovisual equipment uses a secure T-1 network as

its framework for communication. There are also mechanisms in place for the electronic downloading and surveillance of images, laboratory data, and electrocardiograms from the distant site. With this system, we have assisted in running codes, delivering babies, and many other forms of acute care management in real time. If necessary, we can easily launch the helicopter from the telemedicine room for quick transports, and in the past have sent a doctor to the distant site in a time of disaster. We also have some telemedicine sites on oil rigs in the Gulf of Mexico. Preventing the unnecessary transport of these patients can save thousands of dollars. The current TelEmergency program now serves 17 rural hospital emergency departments in Mississippi, at multiple geographically distant sites, through interactions with nurse practitioners, family medicine physicians, and emergency physicians. There are another nine hospitals slated to join the program over the next Continued on Page 15

Continued from Page 14 six months. The vast majority of these small EDs are covered by nurse practitioners who see approximately 2,000 patients per month. To qualify for our program, these nurse practitioners undergo a rigorous course of special training beyond their traditional license. The 10-year volume of patients served by our program is estimated at 422,000. TelEmergency consultation is requested for 40.5% of the patients seen, and they are evaluated collaboratively by the nurse practitioner and our TelEmergency physician via an audiovisual connection. Down time due to technical issues has been estimated to be 0.00025% of the total coverage time. One of the goals of the program is to prevent unnecessary transfers. The majority of patients (57.32%) are discharged from the ED at the rural site, while 21.82% are transferred to other hospitals for a higher level of care (see dispositions chart). To our knowledge, no patient has been transferred due to the TelEmergency physician’s inability to deliver care or formulate a working diagnosis, but rather only for a higher level of care (OR, ICU, burn center). Satisfaction surveys reveal 93.6% of patients are comfortable or very comfortable with the system, 98.7% had no difficulty seeing or hearing the TelEmergency physician, 91.2% of patients are more likely to come back to the given ED because of the TelEmergency program, and 85.6% rated the overall care as good or excellent. Among hospital administrators, 100% feel that the level of care in their ED has increased or remained the same because of the TelEmergency program, 87.5% feel that it costs less or about the same to cover their ED with the TelEmergency program than with a dedicated emergency physician, 85.7% feel that their overall ED volume has increased since the implementation of the TelEmergency Program, 85.7% feel their number of admissions have increased since implementation of the TelEmergency program, 87.5% are not concerned at all about a technical failure of the system, and 87.5% have an overall good or excellent opinion of the TelEmergency program. There are some unique issues associated with the development of a viable financial and business plan for telemedicine. Trying to bill individual patients for the service is complicated and difficult to administer. Reimbursement for telehealth services is insurancedependent and may differ from state to state. It is also complicated by rules for medical licensure and hospital credentialing and by Department of Health regulations. Only recently have we had legislation passed to mandate that both public and private health insurance companies reimburse for telehealth services at the same rates as in-person services are reimbursed. Billing for services rendered at a remote site is a challenge. Collecting the required patient information and maintaining documentation for these processes can be problematic, so we sustain our program with a different business model. We currently bill the distantsite hospital a set fee for the hours we are available to provide telemedicine consults, and allow the client hospital and provider to submit all patient-directed and insurance bills. The fee is based on the usual volume and scope of service for the site. As we reflect on the successes and challenges we have faced with the development of this program, we also want to discuss the evolution of the technology and the future directions for telemedicine in the management of emergency conditions. Unlike the conditions of ten years ago at the inception of our TelEmergency program, telecommunication and Internet connectivity is almost

ubiquitous throughout the United States. Even in those areas where adequate bandwidth is not available, satellite access is almost always possible. The speed of image and information transmission has also increased dramatically. Anyone who uses Skype or FaceTime is well aware of the potential to see and communicate with almost anyone, anywhere. Recently, one of our faculty connected to our University of Mississippi TelEmergency home site by satellite phone from an international medical outreach location in Kigali, Rwanda as a proof-of-concept test. The challenge in sharing medical information in telemedicine is to make this transfer of data secure and HIPAA-compliant without dramatically changing the utility of the interaction. Additionally, higher levels of image quality are required for viewing advanced radiologic testing. Cloud technology is already overcoming many of these limitations. At the current pace of growth for these technologies, I feel sure that all these issues will become solvable in the near future. So what is the future of emergency telemedicine? The complexity of modern health care has resulted in a situation in which there is an increasing need for and expectation of specialist involvement in many acute management decisions. Unlike many other common medical consultations for chronic conditions that can be done by referral to a specialist’s clinic, emergency consultations must be done in real time. This problem is most evident in the currently evolving approach to acute stroke care and the use of thrombolytics. Most emergency physicians prefer to manage these cases in consultation with a stroke neurologist. Even hospitals with neurologists on staff often have difficulty responding to acute events in the ED around the clock while still maintaining their clinical practice. Telestroke can be considered a variation of emergency telemedicine in which a stroke specialist is engaged from a remote location to advise about management decisions during an acute presentation.4 We have used facilitated consultations in our TelEmergency system with representatives of a number of specialties, including neurologists, psychiatrists, and obstetricians, to bring the expertise of those specialties to the small community hospital emergency department in a way that was never before possible. Mobile videoconferencing technologies will be important to allow ready access to such specialists. It does not matter if you need an emergency infectious disease consultation in remote Rwanda or a stroke neurologist’s advice in the rural Delta of Mississippi: all of it is now possible. ◗

REFERENCES 1. Galli R, Keith JC, McKenzie K, Hall GS, Henderson K. TelEmergency: a novel system for delivering emergency care to rural hospitals. Ann Emerg Med. 2008;51(3):275-84. 2. Schneider SM, Gardner AF, Weiss LD, Wood JP, Ybarra M, Beck DM, Stauffer AR, Wilkerson D, Brabson T, Jennings A, Mitchell M, McGrath RB, Christopher TA, King B, Muelleman RL, Wagner MJ, Char DM, McGee DL, Pilgrim RL, Moskovitz JB, Zinkel AR, Byers M, Briggs WT, Hobgood CD, Kupas DF, Kruger J, Stratford CJ, Jouriles N. The future of emergency medicine. Acad Emerg Med. 2010;17(9):998-1003. 3. Groth H, House H, Overton R, Deroo E. Board-certified emergency physicians comprise a minority of the emergency department workforce in iowa. West J Emerg Med. 2013;14(2):186-90. 4. Albright KC, Schott TC, Boland DF, George L, Boland KP, Wohlford-Wessels MP, Finnerty EP, Jacoby MR. Acute stroke care in a neurologically underserved state: lessons learned from the Iowa Stroke Survey. J Stroke Cerebrovasc Dis. 2009;18(3):203-7.

EMERGENCY PHYSICIANS AS CHAMPIONS FOR PUBLIC HEALTH: OPTIMIZING ANTIBIOTIC USE IN ED SETTINGS Larissa S. May, MD; Michael S. Pulia, MD; Stephen Liang, MD Background: The burden of increasingly resistant bacterial infections strains our health care system and is a major public health challenge, with half of all inpatient prescriptions deemed inappropriate. As a frequent site of antibiotic use, the emergency department provides a unique opportunity for antimicrobial stewardship, or reducing unnecessary and inappropriate use, given that antibiotics are the second-most commonly prescribed medication in the ED. Avoidance of inappropriate therapy is a laudable goal in order to reduce adverse events to patients such as C.difficile colitis, and to improve public health. While some argue that policies such as reducing antibiotics in animal feed and providing incentives for development of new antibiotics will have a greater impact, a recent study by Sun et al. suggests that winter prescribing patterns lead to seasonal changes in pathogen resistance. The ED, however, is a unique care setting, where physicians must make quick treatment decisions about prescribing antibiotics, often with incomplete information and limited opportunity for follow-up. Therefore, ED-tailored strategies that include both providers and patients will likely be necessary to lead to practice change.

CDC Get Smart Campaign and Partnership with SAEM In order to address the major threat to public health posed by increasing rates of antibiotic resistance, in 1995 the Centers for Disease Control and Prevention (CDC) launched the National Campaign for Appropriate Antibiotic Use in the Community. In

addition, the Division of Healthcare Quality Promotion conducts research to identify new strategies to prevent antimicrobial resistance and collaborates with academic and public health partners to implement and improve stewardship efforts in the inpatient setting through its Get Smart for Healthcare campaign. The national campaign program, renamed Get Smart: Know When Antibiotics Work in 2003, involves media outreach, development of guidelines and educational materials, and support for local appropriate antibiotic use programs. According to CDC, the program is designed to curb rising rates of antibiotic resistance by: 1. Promoting adherence to appropriate prescribing guidelines among providers, 2. Decreasing demand for antibiotics for viral upper respiratory infections among healthy adults and parents of young children, and 3. Increasing adherence to prescribed antibiotics for upper respiratory infections In 2008, the campaign organized its first national observance, Get Smart About Antibiotics Week. The goal of this annual effort is to raise awareness about antibiotic resistance and the appropriate use of antibiotics. Each year, CDC has made an effort to focus on a different group of health care providers during this week. This year, CDC is focusing on emergency care providers as Continued on Page 17

Continued from Page 16 an important group for optimizing antimicrobial use. To facilitate reaching out to the target audience, CDC has partnered with the Society for Academic Emergency Medicine (SAEM) to promote Get Smart About Antibiotics Week 2013, which will take place November 18-24. During this week SAEM will post this article and links to CDC’s Get Smart activities on its webpage.

Strategies to Improve Antibiotic Use in the ED As part of the Get Smart for Healthcare campaign, CDC and the Institute for Healthcare Improvement (IHI) have partnered to develop educational and implementation tools to promote timely and appropriate antibiotic utilization in acute care settings. Knowledge translation and dissemination are key first steps to advancing ED antimicrobial stewardship. Enhancing clinician awareness of appropriate indications for prescribing antibiotics, adherence to evidence-based guidelines for treating infections, and incorporation of institutional antibiograms into decisionmaking can all serve to better inform selection and duration of antibiotic therapy. Improved collection of culture specimens prior to initiating antibiotics in the ED can facilitate de-escalation of empiric broad spectrum, thereby reducing the selection of resistant organisms in the hospital as well as in the community. Efforts to improve patient education and satisfaction, including follow-up phone calls after an ED visit, also provide invaluable opportunities for reassessing patients with infections (e.g., rhinosinusitis, otitis media) that could in many instances be managed with a “watch and wait” approach. At many institutions, ED clinicians may be able to engage and collaborate with existing inpatient antimicrobial stewardship programs to further promote such initiatives. Clinical decision support systems, rapid point-ofcare diagnostics, and dedicated pharmacists in emergency care and quality assurance also hold great promise for optimizing ED antimicrobial use in the not-so-distant future.

can play an important role in disseminating evidence-based interventions, identifying local barriers to changing practice, and advocating for legislation. On a day-to-day basis, ED clinicians have an important role in following guidelines for appropriate antibiotic use, such as avoiding unnecessary antibiotics for upper respiratory infection and educating patients about appropriate antibiotic use. For more information on how to reduce inappropriate antibiotic use, visit http://www.cdc.gov/getsmart/. ◗

References 1. Lieberman JM. Appropriate antibiotic use and why it is important: the challenges of bacterial resistance. Pediatr Infect Dis J 2003; 22:1143-51. 2. Dellit TH, Owens RC, McGowan JE Jr, Gerding DN, Weinstein RA, Burke JP, Huskins WC, Paterson DL, Fishman NO, Carpenter CF, Brennan PJ, Billeter M, Hooton TM; Infectious Diseases Society of America; Society for Healthcare Epidemiology of America. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship.Clin Infect Dis. 2007;44(2):159-77 3. Sun L, Klein EY, Laxminarayan R Seasonality and temporal correlation between community antibiotic use and resistance in the United States.Clin Infect Dis. 2012;55(5):687-94. . 4. http://www.cdc.gov/getsmart/healthcare/improve-efforts/ 5. May L, Cosgrove S, L’archeveque M, Talan DA, Payne P, Jordan J, Rothman RE. A call to action for antimicrobial stewardship in the emergency department: approaches and strategies. Ann Emerg Med. 2013;62(1):69-77.

Future Directions ED clinicians play an important role in addressing the growing problem of antimicrobial resistance. There remains a gap in the literature on how to improve antimicrobial stewardship outcomes in the ED. Research is needed to define appropriate metrics for measuring outcomes of interventions aimed at reducing antibiotic use, as well as to determine which strategies are most appropriate and feasible in the ED. Furthermore, researchers and advocates

SAVE THE DATE 2014 SAEM Annual Meeting Marking our 25th Anniversary

May 13-17, 2014 The Sheraton Dallas Hotel, Dallas, TX

Program Committee Chair Christopher Ross, MD Watch for meeting updates and submission deadlines on the website! www.saem.org

A WORD TO RESIDENTS: GET INVOLVED! Rebecca M. Caton, MD

McGaw Medical Center of Northwestern

Get involved. Be an advocate for change. Be a leader in emergency medicine. Most medical students and residents have pondered how to do this in a meaningful way. Opportunities abound. Time is limited. The question is: which opportunities are of high impact and will add value to your specialty? The national SAEM conference held in Atlanta in May this year was heavily attended by medical students and residents. In fact, 33% of total attendees were resident members of SAEM. Many residents presented research, but there are also other opportunities to have an impact on emergency medicine at the national level. Dr. Doug Char, cochair of the Resident and Student Advisory Committee, noted: “It’s not common knowledge, but the number of residents who attend SAEM is huge – I think trainees often figure that they are the minority and thus don’t have much say in the organization, but truth is that residents have a huge impact on SAEM.” What are these other opportunities? Perhaps less widely known are the appointed positions available on SAEM committees for an entire academic year. Each committee appointment begins in May at the Annual Meeting, which will be held in Dallas, Texas in 2014. Interested residents submit an application with a brief essay on the SAEM website (www.saem.org) from late October through December. Application to more than one committee is common and helps increase the odds in favor of appointment. Unlike faculty, the number of residents that have applied in the past has been very small, and assignment was almost guaranteed. All of the committees are available for resident participation. The committees are: Awards, Constitution and Bylaws, Consultation Services, Development, Ethics, External Collaboration, Faculty Development, Finance, Graduate Medical Education, Grants, Membership, Nominating, Program, Research, Research Fellowship, Resident and Student Advisory, Social Media, and Web Evolution. The committee objectives from the previous year are listed on the website. Once appointed, it is helpful to contact

the resident member of the SAEM Board of Directors and let him know your interest if you are unable to attend the national meeting in Dallas. This way, when projects are started and the committee is looking for resident participation, your name will be at the top of the list. Jordan Kaylor, a PGY-2 at Northwestern, was appointed to the Research Committee and attended the first meeting in Atlanta. “I didn’t know who anyone was, so I read the name tags around me and realized I was sitting next to Jeff Kline, the PE expert… after the meeting I ended up networking.” Overall, Jordan found it to be a great introduction to the leaders in research in emergency medicine and it presented opportunities for collaborative research that otherwise would not have been possible. Next year there is even more to look forward to as a resident member attending SAEM. The first-ever residents-only reception will be held in Dallas, hosted by the Resident and Student Advisory Committee. The event will be a mid-to-late-conference happy hour, where the winners of a technologically savvy scavenger hunt will be announced. Teams of residents will search for information on seminal posters and presentations at the conference. The team with the most correct answers will win free registration for SAEM 2015. Of course, all residents are encouraged to attend the reception. Clearly, hard work and a spirit of volunteerism will get you far in residency. There are many opportunities to stand out and contribute to patient care and the field of emergency medicine as a whole. Dr. Alan Jones, president of SAEM, kindly offered some words of wisdom on this matter. “I think the most important message is to show up, be involved and say yes, volunteer. That is how you go places. Be interested, pleasant, and productive. Make all deadlines. Do what you say you are going to do. That is what makes a successful person. That and good mentoring.” Hopefully, resident volunteerism at the national level will continue to increase and bring innovative ideas to the table. Looking forward to SAEM 2014! ◗

THE SEMANTICS OF LIMITED EMERGENCY ECHO Chris Moore, MD

Academy of Emergency Ultrasound

Looking back on some of the more dramatic cases I’ve encountered in emergency medicine, bedside echo has played a role more often than not, sometimes clarifying and substantially altering the approach to a given patient in an acute situation: a large pulmonary embolism masquerading as sepsis, bronchitis that was actually myocarditis, chest pain not due to an acute coronary syndrome but rather a dissection with tamponade. I’ve spent a large part of my career training emergency clinicians to use this amazing tool safely and effectively in the acute setting. Recently I had the opportunity to participate in a session entitled Point of Care, at the American Society of Echocardiography (ASE) 24th Annual Scientific Sessions in Minneapolis in June. This article will share my experience at this conference in context of the history and current issues with echo in the emergency setting. First and perhaps most importantly, there was consensus at the ASE session that echo is important in the emergency setting and can be effectively performed by emergency physicians with appropriate training. This aligns with a consensus statement from ASE and the American College of Emergency Physicians (ACEP) published in 2010 that recognized the “important role of focused cardiac ultrasound (FOCUS) in patient care and treatment”.1 This publication represented a substantial step forward in collaboration between specialties about the use of echo in the acute setting. However, speakers from the ASE worked in concert to define “point-of-care ultrasound,” “FOCUS,” “focused,” “hand-held,” and “pocket-carried” ultrasound as separate and distinct from “limited echo.” They are attempting to define the latter as echo performed by cardiologists to answer limited questions. While on the surface this may seem merely semantic, it has potentially far-reaching implications for the availability and quality of echo in the emergency setting. The terminology and message from the ASE speakers at this session adhered closely to a position statement published in the Journal of the American Society of Echocardiography in early 2013.2 Only three years after the 2010 piece, this statement (written by several of the same ASE members from 2010, but without input from any emergency physicians) departs sharply from the collaborative approach of the 2010 piece. Like the ASE speakers at the session, the 2013 manuscript attempts to distance echo performed by clinicians at the bedside from “limited echo” performed by cardiologists. While there are many eloquent rationalizations within the manuscript, the main point of the position statement can be summed up in its Table 2: that “limited echo” should be reimbursed using CPT code 93308, but billing for “FOCUS” should be “none.” The reason for this is clear: cardiologists are concerned that as technology evolves, if anyone who obtains a pocket-carried ultrasound and takes a look at the heart - in the office, the hospital, or the emergency department - can bill a “limited” code, then the code will be diluted to the point of being irrelevant (and non-reimbursed). More than 20 years ago, David Plummer published a paper entitled “Emergency department echocardiography improves outcome in penetrating cardiac injury.” As the title suggests, this manuscript demonstrated something not often shown in medical studies – a mortality benefit. The ability to identify the presence (or absence) of a pericardial effusion in the presence of penetrating chest trauma both decreased time to definitive intervention and made a significant difference in survival.3 Since that time, echo by

emergency physicians has been shown to be able to quickly and accurately categorize left ventricular function, identify significant right ventricular strain, help determine preload and fluid status, and reveal pathology of the thoracic aortic root, among other things. Emergency echo has become an integral part of emergency ultrasound, and is central to protocols for potentially life-threatening situations such as hypotension and dyspnea, where it has been shown to improve and expedite diagnosis. I started using ultrasound, particularly echo, as a resident, when the intricacies and effects of reimbursement were far from my mind. I know that I, and many of my colleagues, with appropriate training and ready access to good equipment, would effectively perform a potentially life-saving echo regardless of reimbursement considerations. However, there is little doubt that reimbursement has played an important role in the spread of emergency ultrasound, as well as the quality of equipment and training now available in many departments. Similarly, should reimbursement for bedside ultrasound performed by emergency physicians be eliminated, quality and availability of this tool, and ultimately our patients, would suffer. As ultrasound equipment has become more compact and affordable it has sometimes been referred to as the “stethoscope of the future.” Parallels may be tempting, but ultrasound is a much more powerful and versatile tool than the stethoscope, and requires far more investment in training and equipment to do well. In a sense, all imaging could be considered an extension of the physical examination - using technology to augment our powers of observation for anatomy and pathology. However, classifying all ultrasound performed by emergency physicians as an “extension of the physical exam” would eliminate reimbursement for it - reimbursement that provides the infrastructure (equipment, training, image archival processes, QA, and structured reporting) essential for accountability and quality. What exactly is the “right” level of reimbursement for the performance of emergency ultrasound could be debated, and likely will be as discussions about how we pay for health care continue. However, we should not sell ourselves short: if we are performing limited echo (and other ultrasound) well in acute situations and making critical decisions based on it, we are no less deserving of reimbursement than any other specialist. With reimbursement comes responsibility – to request it in appropriate situations and to invest it in improving quality. When we do it right, though, in situations where time and accuracy of diagnosis are key, paying attention to the semantics of reimbursement will allow us to provide the best care for our patients when they most need it. ◗

References 1. Labovitz, A. J. et al. Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians. Journal of the American Society of Echocardiography 23, 1225–30 (2010). 2. Spencer, K. T. et al. Focused cardiac ultrasound: recommendations from the american society of echocardiography. Journal of the American Society of Echocardiography 26, 567–81 (2013). 3. Plummer, D., Brunette, D., Asinger, R. & Ruiz, E. Emergency department echocardiography improves outcome in penetrating cardiac injury. Annals of Emergency Medicine 21, 709–12 (1992).

THE AMERICAN BOARD OF EMERGENCY MEDICINE ANESTHESIOLOGY CRITICAL CARE MEDICINE CERTIFICATION APPROVED FOR EMERGENCY PHYSICIANS

East Lansing, MI, and Raleigh, NC (July 12, 2013) — On June 26, 2013, the Board of Directors of the American Board of Medical Specialties (ABMS) unanimously approved certification in Anesthesiology Critical Care Medicine (ACCM) through a joint sponsorship of the American Board of Anesthesiology (ABA) and the American Board of Emergency Medicine (ABEM). This cosponsorship arrangement provides an opportunity for Emergency Medicine residency graduates to pursue a unique two-year ACCM fellowship training pathway. Upon successful completion of that training, qualified physicians will be able to seek ACCM subspecialty certification. Any Accreditation Council for Graduate Medical Education (ACGME)-accredited ACCM fellowship program that wishes to offer a two-year fellowship must first apply to the ABA for approval. The eligibility criteria, timeline, and administrative process for emergency physicians to access the ABA Critical Care Medicine Certification Examination, as well as the application process for

ACCM fellowship programs are available on the ABA and ABEM websites (www.theABA.org and www.ABEM.org). ABA President, Douglas B. Coursin, M.D., stated that “ABA is pleased to see the culmination of the many efforts of members of the Anesthesiology and Emergency Medicine communities in helping to create this new CCM pathway founded on an interdisciplinary and multi-professional approach to the care of critically ill surgical and medical patients.” ABEM President, John C. Moorhead, M.D., stated that, “ABEM appreciates the collaboration with the American Board of Anesthesiology to develop this opportunity, which further recognizes the significant interest in critical care medicine within the Emergency Medicine education community.” ACCM becomes the eighth subspecialty available to ABEMcertified physicians along with Emergency Medical Services, Hospice and Palliative Medicine, Internal Medicine-Critical Care Medicine, Medical Toxicology, Pediatric Emergency Medicine, Sports Medicine, and Undersea and Hyperbaric Medicine.

ABOUT ABA

The American Board of Anesthesiology (ABA) examines and certifies physicians who complete an ACGME accredited anesthesiology training program in the United States and voluntarily apply to the Board for certification or maintenance of certification. The ABA also offers subspecialty certification in Critical Care Medicine, Pain Medicine, Hospice and Palliative Care Medicine, Sleep Medicine and Pediatric Anesthesiology. Its mission is to advance the highest standards of the practice of anesthesiology. Formed in 1937, the ABA is one of the 24 medical specialty boards that comprise the American Board of Medical Specialties (ABMS). Through ABMS, the Boards work together to set and sustain common standards of expertise and professionalism that each uses to evaluate candidates for Board certification and specialists to maintain their certification. For more information, please visit the ABA website at www.theABA.org or contact the ABA Communications Center at (866) 999-7501.

ABOUT ABEM

Founded in 1976, the American Board of Emergency Medicine (ABEM) develops and administers the Emergency Medicine certification examination for physicians who have met the ABEM credentialing requirements. ABEM has nearly 30,000 emergency physicians currently certified. ABEM is not a membership organization, but a non-profit, independent evaluation organization. ABEM is one of 24 Member Boards of the American Board of Medical Specialties.

ACADEM IC ANNOUNCEM ENTS James Adams, MD, has been named to the newly created position of Chief Medical Officer for Northwestern Medicine. He will continue to serve as Chair of the Emergency Medicine Department.

Catherine Lynch, MD, received a grant from the

National Institute of Alcohol Abuse and Alcoholism and World Health Organization Collaboration for “Alcohol and Injuries in the Emergency Department.” The goal of this project is to determine the prevalence of alcohol use among injury patients presenting for acute care to Kilimanjaro Christian Medical Center (2012-13).

Catherine Lynch, MD, and Mark Mvungi, MD,

received the Mentored Research Training Program Medical Education Partnership Award from Kilimanjaro Christian Medical Center in Moshi, Tanzania for “Creating a Clinical Practice Guideline for Acute Traumatic Brain Injury in a Low Resource Setting” (2012-13).

Catherine Lynch, MD, received a grant from Fudan

University/ Duke Global Health Institute for “Evaluating Data Sources for Analyzing Hotspots of Road Traffic Crashes for Vulnerable Road Users.” They are collaborating with a team that includes Steven Rulisa, MD, (Rwanda), Pinnaduwage Vijitha De Silva, MD, Badra Chandanie Mallawaarachchi, MD, Luciano de Andrade RN, PhDc (Brazil/Duke), and Kezhi Jin, PhD (Fudan University, China) (2012-13).

Elizabeth Krebs, MD, received the Fogarty Global

Health Fellowship from Fogarty International Center (FIC) at NIH. The purpose of the program is to support a one-year mentored research fellowship for clinical investigators studying diseases and conditions in developing countries. Dr. Krebs will be working to improve emergency medical care in Rwanda through the study and improvement of traumatic brain injury management and the facilitation of a locally developed, contextually relevant clinical practice guideline for nurses and physicians at the University Central Hospital of Kigali (CHUK) Accident and Emergency Department.

Arthur L. Kellermann, MD, MPH, Paul O’Neill-Alcoa

Chair in Policy Analysis at the RAND Corporation in Washington, DC, has been named as the new dean of the F. Edward Hébert School of Medicine at the Uniformed Services University of the Health Sciences (USU), following a year-long search. Kellermann will be responsible for the undergraduate medical education of more than 640 uniformed medical students and more than 240 military and civilian graduate students each year.

Four emergency medicine physicians are among the 28 physician leaders selected as 2014 Robert Wood Johnson Foundation Clinical Scholars and will begin fellowships in Fall 2014 providing training in conducting innovative research and working with communities, organizations, practitioners, and policy-makers in order to take a leadership role in improving health and health care in the U.S. They are: Dr. Whitney Cabey, a medical school alumna of the University of Michigan and resident at Carolinas Medical Center (fellowship at the University of Pennsylvania supported in part through the U.S. Department of Veterans Affairs); Dr. Laura Medford-Davis, a medical school alumna of Harvard University and resident at Baylor University (fellowship at the University of Pennsylvania); Dr. William Fleischman, a medical school alumnus of the State University of New York – Buffalo, and resident at Mt. Sinai Medical Center (fellowship at Yale University); and Dr. Nir Harish, a medical school alumnus of Harvard University and resident at Denver Health Medical Center (fellowship at Yale University).

Stephen Thom, MD, PhD, has been appointed

Professor of Emergency Medicine and Research Director at the University of Maryland. Dr. Thom has a long-standing track record of federal funding supporting his investigations into the mechanisms and physiological responses associated with intravascular and perivascular oxidative stress triggered by a variety of stimuli. Previously, Dr. Thom was Chief of Hyperbaric Medicine and Medical Director of PennSTAR at the University of Pennsylvania. The University of Texas Board of Regents has formally approved the emergency medicine program at the UT Health Sciences Center San Antonio for full academic department recognition effective June 2013. The chair of the Department of Emergency Medicine, Bruce D. Adams, MD, reports that the department launched a new emergency medicine residency on July 1, 2013, with a class of ten residents, and has plans to move into a new 80-bed facility in under a year.

Alan E. Jones, MD, has been appointed chair of the

Department of Emergency Medicine at the University of Mississippi Medical Center. He succeeds Richard Summers, MD, who will assume the responsibilities of associate vice chancellor for research.

Roger Lewis, MD, PhD, has been appointed chair of

the Department of Emergency Medicine at Harbor-UCLA Medical Center. He formerly served as the department’s Vice Chair for Academic Affairs and holds appointment as a Professor of Medicine at the David Geffen School of Medicine at UCLA. Dr. Lewis is a past president of SAEM and a member of the Institute of Medicine, and is well known for his contributions to the advancement of research in emergency medicine.

Chad

Miller, MD, of the Wake Forest University Health Sciences Department of Emergency Medicine has been funded as principle investigator for a 5-year, $3.5 million RO1 grant from NHLBI entitled “CMR-IMPACT: Cardiac Magnetic Resonance Imaging Strategy for the Management of Patients with Acute Chest Pain and Detectable to Elevated Troponin.”

CLASSIFIEDS THE DEPARTMENT OF EMERGENCY MEDICINE AT HARBOR-UCLA is offering a 2-year research fellowship, with a July 2014 start date. Leading to a master’s degree in epidemiology from the UCLA School of Public Health, the fellowship requires completion of a substantive research project and submission of one or more first-authored manuscripts to peer-reviewed journals. The fellowship is co-directed by Roger Lewis, who has expertise in adaptive and Bayesian clinical trial design, health services research, and the protection of human subjects; and Amy Kaji, who has experience in disaster research and epidemiology. Contact Amy Kaji: (310) 222-3503; email akaji@emedharbor.edu.

CALLS AND M EETING ANNOUNCEM ENTS THE 35TH ANNUAL MEETING OF THE SOCIETY FOR MEDICAL DECISION MAKING October 19 - 23, 2013 — Hilton Baltimore, Baltimore, MD Theme: Bench, Bedside and Beyond: Medical Decision Making and Public Policy Capitalizing on our proximity to Washington, DC, the ongoing debate about health care reform in the US, and efforts to achieve high-value health care systems around the globe, the theme of the 2013 meeting is Bench, Bedside and Beyond: Medical Decision Making and Public Policy. In addition to oral abstract and poster sessions for the presentation of original research, special thematic sessions will address research agendas and the dissemination of findings to patients and providers in the community; strategies for influencing clinical policy and guideline development; and effective communication in policy and advocacy arenas. Through these sessions, symposia and short courses, attendees will gain an understanding of a wide range of contemporary issues and research methods at the interface of medical decision making and public policy. For more information go to: http://smdm.org/2013meeting/index.shtml

CALL FOR PAPERS 2014 Academic Emergency Medicine Consensus Conference: Gender-Specific Research in Emergency Care: Investigate, Understand, and Translate How Gender Affects Patient Outcomes The 2014 Academic Emergency Medicine (AEM) Consensus Conference, Gender-Specific Research in Emergency Care, will be held on Tuesday, May 13, 2014, the first day of the SAEM Annual Meeting in Dallas, TX. Original papers on this topic, if accepted, will be published together with the conference proceedings in the December 2014 issue of AEM. Gender-specific medicine is the “science of how normal human biology differs between men and women and how the manifestations, mechanisms, and treatment of disease vary as a function of gender.” While gender-specific medicine incorporates advances in reproductive health issues, the AEM Consensus Conference will focus on broad disease-specific EM issues that are relevant to both women and men. The key domains of the conference are cardiovascular/resuscitation, cerebrovascular, pain, trauma/injury/ violence, diagnostic imaging, mental health, and substance abuse. Consensus Goal: The goal of the 2014 AEM Consensus Conference is to stimulate EM researchers to methodically recognize, investigate, and translate the impact of gender on their clinical research outcomes. The conference proposes to build a foundation upon which researchers can build interdisciplinary scholarship, networks of expertise, discussion forums, multicenter collaborations, evidencebased publications, and improved education. The overarching

themes of the conference have been guided and informed by NIH research priorities on gender medicine, and include study of lifespan, sex/gender distinctions, health disparities/differences, and diversity and interdisciplinary research. Consensus Objectives: 1) Summarize and consolidate existing data and create a blueprint that furthers gender-specific research in the prevention, diagnosis, and management of acute diseases. 2) Discuss the conceptual models for designing studies and analysis that incorporate gender as an independent variable. 3) Build a multinational interdisciplinary consortium to study gender medicine for acute conditions. Accepted manuscripts will describe relevant research concepts in gender-specific areas, with priority placed on differential disease risk, vulnerability, progression, and outcomes. They may include work in clinical/translational, health systems, policy, or basic sciences research. Descriptions of specific research, projects, or collaborations may be used for illustrative purposes but should not comprise the core of the submission. Original contributions describing relevant research or concepts on these or similar topics will be considered, and original highquality research may also be submitted alone or in conjunction with concept papers. Papers will be considered for publication in the December 2014 issue of AEM if received by Monday, March 11, 2014. All submissions will undergo peer review, and publication cannot be guaranteed. For queries, please contact Marna Rayl Greenberg, DO, MPH (Marna.Greenberg@lvh.com) or Basmah Safdar, MD (basmah. safdar@yale.edu), 2014 Consensus Conference co-chairs. Information and updates will be posted regularly in AEM, the SAEM Newsletter, and on both the AEM and the SAEM websites.

SAEM SEEKS AWARD NOMINATIONS FOR 2014 The Awards Committee would like to consider as many exceptional candidates as possible. For submission information, please visit the SAEM awards webpage at http://www.saem.org/meetings/saem-awards Young Investigator Awards Deadline: December 13, 2013 SAEM chooses as many as three (3) awardees for the Young Investigator Award each year. This award recognizes those SAEM members who have demonstrated commitment to and achievement in research during the early stage of their academic careers. The Society’s core mission includes the creation of knowledge, and this award recognizes those who have achieved early success in this sphere. Master Clinician Bedside Teaching Award Deadline: December 13, 2013 SAEM seeks nominations for the Master Clinician Bedside Teaching Award. This award recognizes emergency physicians whose primary responsibility is clinical teaching in an emergency

CALLS AND M EETING ANNOUNCEM ENTS - CONT. medicine residency program setting, and who are regarded by current residents and residency graduates as master clinician educators who have profoundly influenced their clinical practice. This individual must not be a core faculty member in an EM residency program. Hal Jayne Educational Excellence Award Deadline: January 10, 2014 SAEM seeks nominations for the Hal Jayne Educational Excellence Award. Complimentary to the Research Award, this award is presented to a member of SAEM who has made outstanding contributions to emergency medicine through the teaching of others and by improving our knowledge base regarding the teaching of learners. Excellence in Research Award Deadline: January 10, 2014 SAEM seeks nominations for the Excellence in Research Award. Complimentary to the Hal Jayne Education Award, this award is presented to a member of SAEM who has made outstanding contributions to emergency medicine through the creation and sharing of new knowledge. Advancement of Women in Academic Emergency Medicine Award Deadline: January 10, 2014 SAEM is soliciting nominees for the Advancement of Women in Academic Emergency Medicine Award. This award recognizes an SAEM member who has made significant contributions to the advancement of women in academic emergency medicine. John Marx Leadership Award Deadline: January 10, 2014 SAEM seeks nominations for the Leadership Award. This award honors a SAEM member who has made exceptional contributions to emergency medicine through leadership – locally, regionally, nationally or internationally – with priority given to those with demonstrated leadership within SAEM. The Academy for Diversity and Inclusion and Emergency Medicine (ADIEM) launched the Lesbian, Gay, Bisexual and Transgender (LGBT) subcommittee at the 2013 Annual Meeting in Atlanta. The group will focus on health concerns of LGBT patients, development of curriculum and scholarly activity, and mentoring of LGBT professionals and students in EM. The group is chaired by Joel Moll, MD, and is open to participation by all regardless of sexual orientation or identity. Please email molljoel@med.umich.edu for more information.

INTERACTIVE CME TRAINING: ABDOMINAL PAIN IN THE OLDER ADULT How often do you encounter older patients in the emergency department with abdominal pain? Do you find it difficult to communicate with them? Is treatment challenging? Learn how to interact, diagnose, and treat older adults more effectively through this interactive online training tool titled “Abdominal Pain in the Older Adult” FREE for non-CME participants; or $95 for 6 AMA PRA Category 1 Credits™. This program is brought to you by AGEM (an academy of SAEM) and is funded through the generous support of the Retirement Research Foundation. Accreditation Statement This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of the University of California, Irvine School of Medicine and the Society for Academic Emergency Medicine. The University of California, Irvine School of Medicine is accredited by the ACCME to provide continuing medical education for physicians. Designation Statement The University of California, Irvine School of Medicine designates this enduring material for a maximum of 6 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. California Assembly Bill 1195 This activity is in compliance with California Assembly Bill 1195, which requires continuing medical education activities with patient care components to include curriculum in the subjects of cultural and linguistic competency. For specific information regarding Bill 1195 and definitions of cultural and linguistic competency, please visit the CME website at http://www.cme.uci.edu. Disclosure Policy It is the policy of the University of California, Irvine School of Medicine and the University of California CME Consortium to ensure balance, independence, objectivity, and scientific rigor in all CME activities. Full disclosure of conflicts and conflict resolutions will be made prior to the activity.

THE NIH LOAN REPAYMENT PROGRAMS (LRPS) encourage promising researchers and scientists to pursue research careers by repaying up to $35,000 of their qualified student loan debt each year. Your research goals need to be within the mission of NIH and scope of the LRPs to qualify. You do not need an NIH grant to participate in the NIH Loan Repayment Programs. Cycle opens September 1, 2013. Visit http://www.lrp.nih.gov/index.aspx for more information.

CALLS AND M EETING ANNOUNCEM ENTS - CONT. Call for Papers

2015 Academic Emergency Medicine Consensus Conference Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization The 2015 Academic Emergency Medicine (AEM) consensus conference, Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization, will be held on May 12, 2015, immediately preceding the SAEM Annual Meeting in San Diego, CA. Original papers on this topic, if accepted, will be published together with the conference proceedings in the December 2015 issue of AEM. Diagnostic imaging is integral and beneficial to the practice of emergency medicine. Over the last several decades, emergency department (ED) diagnostic imaging has increased without a commensurate rise in identified pathology or improvement in patient-centered outcomes. Unnecessary imaging results in increased resource use and significant exposure risks. ED diagnostic imaging has become the focus of many stakeholders, including patients and various regulatory agencies. This multidisciplinary consensus conference represents the first coordinated effort to further our evidence-based knowledge of ED diagnostic imaging. This consensus conference will formulate the research priorities for emergency diagnostic imaging, initiate a collaborative dialogue between stakeholders, and align this research agenda with that of federal funding agencies. Consensus Goal: The overall mission of the 2015 AEM consensus conference will be to create a prioritized research agenda in emergency diagnostic imaging for the next decade and beyond. The consensus conference will feature expert keynote speakers, panel discussions including nationally recognized experts, and facilitated breakout group sessions to develop consensus on research agendas by topic. Optimizing diagnostic imaging in the ED is a timely topic that is relevant to all who practice emergency medicine. Furthermore, the conference content spans many other specialties (e.g. radiology, pediatrics, cardiology, surgery, internal medicine), all of which will be invited to participate in the conference to optimize the agenda and for future collaboration in order to improve emergency diagnostic imaging use. Consensus Objectives: 1. Understand the current state of evidence regarding diagnostic imaging utilization in the ED and identify opportunities, limitations, and gaps in knowledge of previous study designs and methodology 2. Develop a consensus statement that emphasizes the priorities and opportunities for research in emergency diagnostic imaging that will result in practice changes, and the most effective methodologic approaches to emergency diagnostic imaging research 3. D evelop a multidisciplinary network to perform emergency diagnostic imaging research

4. Explore and improve knowledge of specific funding mechanisms available to perform research in emergency diagnostic imaging Accepted manuscripts will present original, high-quality research in emergency diagnostic imaging in areas such as clinical decision rules, shared decision making, knowledge translation, comparative effectiveness research, and multidisciplinary collaboration. They may include work in clinical/translational, health systems, policy, or basic sciences research. Papers will be considered for publication in the December 2015 issue of AEM if received by April 17, 2015. All submissions will undergo peer review, and publication cannot be guaranteed. For queries, please contact Jennifer R. Marin, MD, MSc (jennifer.marin@chp.edu) or Angela M. Mills, MD (millsa@uphs.upenn.edu), the 2015 consensus conference co-chairs. Information and updates will be regularly posted in AEM, the SAEM Newsletter, and on the journal and SAEM websites.

Call for Innovations 2014 SAEM Annual Meeting May 13â&#x20AC;&#x201C; 17, 2014 Dallas, TX Abstract submission site opens: Monday, November 4, 2013 Deadline: Wednesday, December 4, 2013, 5:00 PM (CST) The SAEM Program Committee is proud to offer educators a venue to present their educational advances. For the 2014 Annual Meeting in Dallas, Innovations will be presented either as a poster (with hands-on tabletop demonstrations as needed) or as an oral PowerPoint session, thus bringing diverse thoughts together in the same room in order to cultivate new ideas and approaches to undergraduate, graduate, and continuing medical education. In addition, we will have three theme-based sessions on technology, global medicine, and assessment. We invite educators to submit their state-of-the-art innovations, not just on these themes, but on any new teaching strategy or tool. The Innovations submission site will be available on the SAEM website at www.saem.org beginning Monday, November 4, 2013. For further information or questions, contact SAEM at tfry@saem.org or 847-813-9823. The deadline for submissions is Wednesday, December 4, 2013 at 5:00 pm (CST). Corresponding authors will be notified on February 11, 2014 regarding the status of their submission. Sincerely, JoAnna Leuck, MD (JoAnna.Leuck@carolinashealthcare.org) â&#x20AC;&#x17D;and Laurie Thibodeau, MD (thibodl@mail.amc.edu) Co-Chairs â&#x20AC;&#x201C; Innovations, Program Committee Christopher Ross, MD (cross@cookcountyhhs.org) Chair, Program Committee

ANNOUNCEM ENTS - CONT.

CALL FOR DIDACTIC PROPOSALS

CALL FOR EXPERT ABSTRACT REVIEWERS

2014 SAEM Annual Meeting May 13 – 17, 2014 — Dallas, Texas Submission Deadline: Wednesday, September 25, 2013, 5:00 PM (CST)

The Program Committee is currently accepting applications from SAEM members wishing to serve as expert reviewers of scientific abstracts submitted for presentation at the 2014 Annual Meeting, which will be held May 13-17 in Dallas, Texas. The minimum requirement for new abstract reviewers is at least two first-author peer-reviewed original research manuscripts in the topic area for which you are applying. Residents are invited to apply but must meet the same criteria. If you have been an abstract reviewer in the past five years, you do not need to reapply.

The Program Committee of the Society for Academic Emergency Medicine invites proposals for didactic sessions for the 2014 SAEM Annual Meeting. Didactics may be targeted at specific audiences, including medical students, residents, junior faculty, and senior faculty. Didactic formats include lectures, panel discussions, and workshops. The Program Committee will also consider proposals for workshops on days immediately preceding or following the main Meeting days, as well as for multiple sessions during the Meeting focusing on in-depth instruction in a specific discipline. Didactic proposals must support the mission of SAEM: “To lead the advancement of emergency care through education and research, advocacy, and professional development in academic emergency medicine,” and should fall into one of the following categories:

Career development - sessions should be targeted towards junior or senior emergency physicians and/or the skillsets needed to advance within academic emergency medicine.

Education - sessions should focus on enhancing teaching skills, improving the quality of education, educational methodology, or resident and medical student educational innovations.

Research - sessions should focus on research methodology, improving the quality of research, or providing critical tools, resources, and discussions to researchers.

State of the Art- sessions should present cutting-edge research with important implications for either further investigation or the practice of emergency medicine. These sessions are not literature reviews or summaries of clinical practice. For example, a session on how to use cardiac markers to assess patients with chest pain would not be an acceptable state-of-the-art didactic. However, a presentation on how cardiac markers are developed, trials that are being conducted for their validation, and what this research holds in store for subsequent investigation or the future practice of emergency medicine would appropriately fit this category. Reviewers will be asked to consider the content, course outline, and the appropriateness of speakers. Proposals should be edited by the lead organizer and free of spelling errors and typos. The link to submit proposals will be available via saem.org between August 1, 2013 and September 25, 2013 at 5:00 pm (CST). Lead organizers and speakers will be notified of the status of their proposals during the last week in November. For additional questions or information, contact Tricia Fry, tfry@saem.org or call 847-813-9823.

Interested members should electronically submit the following to saem@saem.org by October 9, 2013: an abbreviated CV (full CVs will not be considered) with a detailed listing of peerreviewed original research publications, review articles, textbook chapters, and prior scientific abstract presentations published in the specific area(s) of expertise selected from the list below: Abdominal/Gastrointestinal/ Genitourinary

Ethics

AEM Consensus Conference - Global Health and Emergency Care: A Research Agenda

Health Policy Research

Airway/Anesthesia/Analgesia Cardiovascular – Basic Sciences Cardiovascular – Clinical Research Clinical Decision Guidelines Clinical Operations – Personnel Clinical Operations – Processes Computer Technology Critical Care/Resuscitation Diagnostic Technologies/ Radiology Disaster Medicine Disease/Injury Prevention Education EMS/Out-of-Hospital – Cardiac Arrest

Geriatrics Health Services Research Infectious Diseases International Emergency Medicine Neurology Obstetrics/Gynecology Orthopedics Pediatrics – Infectious Diseases Pediatrics – General Professional Development Psychiatry/Social Issues Pulmonary Research Design/Methodology/ Statistics Simulation Toxicology/Environmental Trauma Ultrasound

EMS/Out-of-Hospital – Non-Cardiac Arrest

Each year, the Program Committee selects approximately six reviewers for each topic area, including both expert reviewers and members of the Program Committee. Therefore, not every appropriate reviewer will be invited to review each year. Reviewers should expect to review up to 75 abstracts, must adhere to the SAEM abstract scoring system, and must submit their abstract scores by the deadline. The deadline for authors to submit abstracts is December 13, 2013. Abstracts will be available for review by January 2, 2014 and abstract scores will be due by 5:00 pm CST on January 15, 2014. All scores will be submitted using the online system.

CALL F OR ABSTRACTS 2014 SAEM ANNUAL MEETING MAY 13 – 17, 2014 — DALLAS, TEXAS

ABSTRACT SUBMISSION SITE OPENS: MONDAY, NOVEMBER 4, 2013 DEADLINE: FRIDAY, DECEMBER 13, 2013, 5:00 PM (CST) The Program Committee is accepting abstracts for review for presentation at the 2014 SAEM Annual Meeting. Authors are invited to submit original emergency medicine research in the following categories:

Abdominal/Gastrointestinal/Genitourinary AEM Consensus Conference - Global Health and Emergency Care: A Research Agenda Airway/Anesthesia/Analgesia Cardiovascular – Basic Sciences Cardiovascular – Clinical Research Clinical Decision Guidelines Clinical Operations – Personnel Clinical Operations – Processes Computer Technology Critical Care/Resuscitation Diagnostic Technologies/Radiology

Disaster Medicine Disease/Injury Prevention Education EMS/Out-of-Hospital – Cardiac Arrest EMS/Out-of-Hospital – Non-Cardiac Arrest Ethics Geriatrics Health Policy Research Health Services Research Infectious Diseases International Emergency Medicine Neurology

Obstetrics/Gynecology Orthopedics Pediatrics – Infectious Diseases Pediatrics – General Professional Development Psychiatry/Social Issues Pulmonary Research Design/Methodology/Statistics Simulation Toxicology/Environmental Trauma Ultrasound

SAEM has an extensive peer-review process for abstract submission at the Annual Meeting. Each submission is scored by several reviewers based upon: • Hypothesis and objectives • Study design • Methods: measures of validity based upon the type of study (controlled clinical trial, prospective cohort, retrospective chart review, systematic review, survey, basic science, etc.) • Methods: sample size and reliability based upon the type of study (controlled clinical trial, prospective cohort, retrospective chart review, systematic review, survey, basic science, etc.) • Statistics • Conclusions/Results • Presentation , including style and grammar • Impact The abstract submission site will be available on the SAEM website at www.saem.org beginning Monday, November 4, 2013. For further information or questions, contact SAEM at tfry@saem.org or 847-813-9823. The deadline for submissions is Friday, December 13, 2013 at 5:00 pm (CST). Corresponding authors will be notified on February 11, 2014 regarding the status of their submission. As the reach of emergency medicine expands, SAEM recognizes that many abstracts traditionally submitted to the Annual Meeting are also pertinent to other national societies, and may be presented at their respective conferences. In an effort to provide a forum for SAEM Annual Meeting attendees to hear and experience the vast breadth of emergency medicine research, abstracts submitted to or presented at other, non-emergency-medicine, national meetings within the preceding calendar year (June 2013 to May 2014) will be considered for presentation at the SAEM Annual Meeting. Original abstracts presented at SAEM 2013-2014 Regional Meetings or the 2014 CORD Academic Assembly will be considered. Only reports of original research may be submitted. The data must not be published in a manuscript or e-publication prior to the first day of the Annual Meeting, except in abstract form when associated with a presentation at a non-emergency-medicine national conference. Abstracts accepted for publication at the Annual Meeting will be published in the Academic Emergency Medicine online supplement. SAEM strongly encourages authors to submit their manuscripts to AEM. AEM will notify authors of a decision regarding publication within 60 days of receipt of a manuscript. Proposals for Innovations will be solicited at the same time, with a submission deadline of Monday, December 3, 2013, and can also be submitted via the same submission site.

SAEM ON SOCIAL MEDIA EARLY VIEW for ACADEMIC EMERGENCY MEDICINE Academic Emergency Medicine has been loading articles on "Early View" as soon as they are processed now - so be sure to check this feature regularly on the journal's Wiley Online Library (WOL) homepage, regularly. http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)15532712/earlyview Academic Emergency Medicine on the Wiley Online Library Platform Make sure you keep checking the journal’s home page on the recently implemented platform, Wiley Online Library (WOL) http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)15532712. Many new features appear in the form of “modules” and will be updated on a regular basis. The new platform is more robust and easier to navigate, with enhanced online functionality. Visit often and stay tuned for updates! VIRTUAL ISSUES "Virtual Issues" are now a key feature of the journal's home page. A virtual issue is basically just a collection of articles on a given topic. The idea is that a reader will go there to look for a particular issue, but then will see our other offerings on that topic, as well, increasing our full-text download numbers and helping insure the broadest dissemination of our authors' work. We now have four "virtual issues" online. Go to to the journal's home page on the Wiley Online Library (WOL) platform "Find Issues" on the left-hand side and click on the feature. Three additional virtual issues, in addition to the initial geriatrics one, are up and running on: ultrasound, toxicology and injury prevention. Again, consult the "Find Issues" area and click on the desired issue. http:/onlinelibrary.wiley.com/journal/10.1111(ISSN)1553-2712.

Abstracts en Español! Beginning with the September issue, Academic Emergency Medicine will be publishing the abstracts of the various articles in Spanish. They will be presented alongside the English abstracts in the online versions of each paper (pdf, html, and mobile apps). The Spanish abstracts will also be included in the print edition of the journal for any papers that originate in Spanish-speaking countries, or are likely to be of particular interest to emergency physicians in Spanish-speaking countries. This project would not be possible without technical assistance and generous funding from our publisher, John Wiley and Sons, Inc., and the language assistance of Emergencias, the journal of the Sociedad Española de Medicina de Urgencias y Emergencias (SEMES).

Are you looking for more from SAEM? More news, reminders, updates, and insight? Then become a fan of SAEM’s Facebook page, or follow us on Twitter! Just follow the links on the SAEM homepage to join. On our Facebook page, you’ll learn about upcoming events, reconnect with colleagues, browse photos and more! By following SAEM on Twitter, you can join in the conversation on current EM topics, follow links to important resources, and get updated on the latest SAEM news. SAEM has always been a social group – now you can participate through social media!

JOIN TODAY.

The Department of Emergency Medicine at the University of Texas Health Science Center in San Antonio is recruiting for highly qualified full-time or parttime residency trained academic Emergency Medicine Physicians. Optimal candidates will have an established track record of peer-reviewed research, excellence in education and outstanding clinical service. University Hospital, the primary affiliated teaching hospital of the University of Texas Health Science Center at San Antonio, is a 498 bed, Level 1 trauma center which treats 70,000 emergency patients annually. The University Hospital Emergency Department serves as the primary source for uncompensated and indigent care as well as the major regional tertiary referral center with a focus on transplant, neurologic, cardiac, diabetes and cancer care. A new, state of the art Emergency Department with 80 beds will open in early 2014. The successful candidate will join a diverse, enthusiastic group of academic Emergency Physicians committed to creating the premiere Emergency Medicine residency program and academic department in Texas. Our initial class of Emergency Medicine residents started July 2013. Academic Emergency Physicians with expertise in EMS, Ultrasound, Toxicology, and multiple dualboard certified EM / IM physicians currently round out the faculty. The University of Texas Health Science Center at San Antonio offers a highly competitive salary, comprehensive insurance package, and generous retirement plan. Academic appointment and salary will be commensurate with experience. Candidates are invited to send their curriculum vitae to: Bruce Adams, M.D., FACEP, Professor and Chair, Department of Emergency Medicine, 7703 Floyd Curl Drive, MC 7840, San Antonio, TX 78229-3900. Email: adamsb@uthscsa.edu. All faculty appointments are designated as security sensitive positions. The University of Texas Health Science Center at San Antonio is an Equal Employment Opportunity / Affirmative Action Employer. http://emergencymedicine.uthscsa.edu/

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Assistant Clinical Director / Director of Quality Improvement The Department of Emergency Medicine at the University of California, Davis School of Medicine, is conducting a faculty search for an academic Emergency Medicine physician to serve in a leadership role as Assistant Clinical Director and Director of Quality Improvement. For the qualified individual, there are opportunities for leadership and growth within the Department and the School of Medicine. Candidates must be residency trained and board certified in Emergency Medicine, eligible for licensure in California, and have clinical operations experience. Expertise in performance improvement and quality is required, and experience in patient safety desired. It is expected that the successful candidate will be facile with the electronic health record and its use for quality improvement purposes. Candidates will be considered as faculty candidates at the Assistant, Associate or Professor level, commensurate with experience and credentials. The University of California, Davis Medical Center is one of the nationâ&#x20AC;&#x2122;s â&#x20AC;&#x153;Top 50 Hospitals.â&#x20AC;? It is a 576 bed academic medical center with approximately 65,000 annual Emergency Department visits. In 2010, we moved to a state-of-the-art ED which provides comprehensive emergency services to a large urban and referral population as a level 1 trauma center, paramedic base station and training center. The Department serves as the primary teaching site for a fullyaccredited Emergency Medicine residency training program that began more than two decades ago and currently has 42 residents. In addition, we provide advanced training in five emergency medicine fellowships including research, ultrasound, toxicology, medical simulation and advocacy/ policy. The Department is a national leader in emergency medicine research, especially federally-funded, multicenter research. Our department is also a recipient of an NHLBI K12 programmatic award to train the next generation of Emergency Medicine researchers. Salary and benefits are competitive and commensurate with training and experience. Sacramento is located near the northern end of California's Central Valley with close proximity to Lake Tahoe, San Francisco, and the "wine country" of the Napa and Sonoma Valleys. Sports enthusiasts will find Sacramento's climate and opportunities ideal. Interested candidates should submit a letter outlining interests and experience, and curriculum vitae to: Nathan Kuppermann, MD, MPH Chair, UC Davis Department of Emergency Medicine 2315 Stockton Blvd., PSSB 2100 Sacramento, CA 95817 Phone: 916.734.1535 | E-mail: nkuppermann@ucdavis.edu The University of California is an affirmative action/equal opportunity employer.

The George Washington University Department of Emergency Medicine Fellowship Program

The George Washington University Department of Emergency Medicine The Department of Emergency Medicine of the George Washington University is seeking physicians for our academic practice. Physicians are employed by Medical Faculty Associates, a University-affiliated, not-for-profit multispecialty physician group and receive regular faculty appointments at the University. The Department provides staffing for the Emergency Units of George Washington University Hospital, the Walter Reed National Military Medical Center and the DC Veterans' Administration Medical Center. The Department sponsors a Residency, 9 Fellowships and a variety of student programs.

The Department of Emergency Medicine at the George Washington University is offering Fellowship positions beginning in July 2014: Emergency Management International Emergency Medicine ED Operations & Leadership Medical Toxicology Emergency Ultrasonography Operations Research Health Policy Extreme Environmental Telemedicine/Digital Health

We are seeking physicians who will participate in our clinical and educational programs and contribute to the Department's research and consulting agenda. Rank and salary are commensurate with experience.

Fellows receive an academic appointment at the George Washington University School of Medicine and work clinically at a site staffed by the Department. The Department offers fellows a common interdisciplinary curriculum, focusing on research methodologies and grant writing. Tuition support for an MPH or equivalent degree is also provided.

Basic Qualifications: Physicians should be residency trained in Emergency Medicine. Application Procedure: Please complete an online faculty application at http://www.gwu.jobs/postings/15715 and upload a CV and cover letter. Review of applications will begin on August 1, 2013 and continue until all positions are filled. Only complete applications will be considered. Any inquiries about the position should be sent to Robert Shesser M.D., Professor and Chair: rshesser@mfa.gwu.edu.

Complete descriptions of all programs, application instructions, and Fellowship Director contacts can be found at http://www.gwemed.edu/fellowships/.

The George Washington University is an Equal Opportunity/ Affirmative Action employer. www.gwemed.edu

Emergency Physician Exceptional opportunity for highly motivated Emergency Physician (BE/BC) to join the faculty of Emergency Medicine at the University of Wisconsin School of Medicine & Public Health in Madison, Wisconsin. We are seeking applicants who are interested in furthering a professional career in academic emergency medicine. Specific leadership and/or program development opportunities exist in student & residency education, ultrasound, and research. EM faculty provides clinical services in the Emergency Department (ED) of the University of Wisconsin Hospital & Clinics (UWHC). Compensation and benefits are extremely competitive. To inquire, send your curriculum vitae and cover letter (E-mail preferred), to:

UWHC is a busy, university-based, referral hospital; one of only two academic medical centers in the state, and a Level I Trauma and Burn center for both adult and pediatric patients. EM faculty supervises EM and off-service residents, as well as medical students. The successful candidate will join a faculty of over 25 emergency physicians and pediatric emergency physicians. Madison is the capital of Wisconsin and a vibrant city boasting many recreational resources, cultural, and athletic events. Madison consistently ranks as a top community in which to live, work, play, and raise a family.

agh@medicine.wisc.edu Azita G. Hamedani, MD MPH F2/217 Clinical Science Center, MC 3280 600 Highland Avenue, Madison, WI 53792 The UW Madison is an EEO/AA Employer, Minorities and women are encouraged to apply. Wisconsin caregiver and open records laws apply. A background check will be conducted prior to employment.

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Chief of Clinical Operations | University of Colorado School of Medicine The Department of Emergency Medicine at the University of Colorado School of Medicine is seeking candidates for the position of Chief of Clinical Operations. The position will be responsible for all clinical operations of the Emergency Department at the University of Colorado Hospital. The Emergency Department at the University of Colorado Hospital is a brand new, 55,000 square foot state of the art facility with 74 treatment areas including a 16 bed observation unit and is a major teaching site for the Denver Health Residency in Emergency Medicine. The University of Colorado Hospital is a 551 bed tertiary care referral center, level II trauma center, ABA verified burn center, and joint commission certified comprehensive stroke center and is part of the newly formed University of Colorado Health System. Current patient volumes are in excess of 75,000 visits per year with anticipated growth of 10-20% annually. Interested candidates should submit a CV, cover letter and list of references to: http://www.jobsatcu.com/postings/67191 Candidates should have extensive experience in clinical operations and be eligible for appointment to the rank of associate professor or professor. Academic rank and salary will be commensurate with skills and experience. The University of Colorado offers a full benefits package. For more information, please contact: Dr. Richard Zane Professor and Chair, Department of Emergency Medicine 720-848-7630 | Richard.Zane@ucdenver.edu

Rutgers Robert Wood Johnson Medical School has an immediate need for staff physicians for their Level I Trauma Center in New Brunswick which has a residency program and a fellowship program. This busy department with 70,000 annual patient visits has a separate Pediatric Emergency Care Department, toxicology service and active clinical research. Responsibilities will include delivery of clinical services, research and teaching residents/PAs/medical students. This is an excellent opportunity with an Affirmative Action/Equal Opportunity employer offering great benefits and a very competitive compensation package.

For full details, please contact Daniel Stern at Daniel Stern & Associates 800-438-2476 or sternd@danielstern.com.

DISASTER MEDICINE FELLOWSHIP The University of California, Irvine, Department of Emergency Medicine is seeking applicants for the fellowship in EMS and Disaster Medical Sciences for July 1, 2014. UCI Medical Center is a Level I Trauma center with 2,800 runs/year and a 40,000 ED census. Fellows serve as HS Clinical Instructors. The program combines the disciplines of emergency management/disaster medicine and public health with traditional emphasis on services systems research, including mass casualty management and triage. Completion of an American Council of Graduate Medical Education (ACGME) accredited emergency medicine residency required prior to start. The two-year combined program, with an integrated masterâ&#x20AC;&#x2122;s of public health, will be jointly administered by the director, Emergency Medical Services and Disaster Medicine. Salary is commensurate with level of clinical work. RECRUIT system located at: https://recruit.ap.uci.edu/apply/JPF02026 Send CV, statement of interest, and three letters of recommendation to: Carl Schultz, MD at schultzc@uci.edu Department of Emergency Medicine, UC Irvine Medical Center, Rt 128 101 The City Drive South Orange, CA 92868 The University of California, Irvine is an equal opportunity employer committed to excellence through diversity.

IU Department of Emergency Medicine Seeks Emergency Medicine IU Department of Emergency Medicine Seeks Academic Pediatric Academic Pediatric Emergency Medicine Division Chief Division Chief Exceptional opportunity for highly motivated board-certified Pediatric Emergency Medicine Physician to join the faculty of the Exceptional opportunity for Indiana highlyUniversity motivated board-certified Pediatric Emergency Medicine Physician Department of Emergency Medicine, School of Medicine as Academic Pediatric Emergency Medicine Division Chief.

toseek joinanthe faculty of the Department of Emergency Indiana University School of Medicine as We academic leader at any rank who is interested in leading Medicine, the development of an expanded academic emergency medicine Academic Pediatric Emergency Chief. program at Indiana University. Excellence inMedicine all academicDivision missions and a demonstrated commitment to scholarly work are requirements. The successful candidate will be involved in all components of the academic enterprise. Specifically, we seek an energetic leader to develop our Pediatric Emergency Medicine Fellowship as well as create institutional opportunities for our faculty across the research We seek an academic leader at any rank who is interested in leading the development of an expanded spectrum. Ideally, this person will lead an independent research program. This faculty will also teach residents from one of the longest academic emergency program Indianaand University. Excellence all academic missions and running EM training programsmedicine in the nation, as well asatEM/Peds pediatric residents. Clinicalin services and educational oversight occur in the nationally recognized Riley Hospital for Children. a demonstrated commitment to scholarly work are requirements. The successful candidate will be Riley is located IU Medical Center campus in downtown Indianapolis and has an annual volume 30,000 patient visits, involved inon allthe components of the academic enterprise. Specifically, we seek an of energetic leader towith andevelop admissionour ratePediatric near 25%. Emergency The hospital is Medicine undergoing aFellowship $300m expansion that will include a new state of the art ED slated as well as create institutional opportunitiestoforbe completed in 2013. Riley is a Level 1 children’s trauma center and burn unit, and a tertiary care facility.

our faculty across the research spectrum. Ideally, this person will lead an independent research

Certification in Pediatric Emergency Medicine or combined certification in Emergency Medicine and Pediatrics are required. Rank and program. This faculty will also teach residents from one of the longest running EM training programs in tenure status are dependent upon qualifications of candidate. Please contact Cherri Hobgood, MD (chobgood@iupui.edu), the nation, well as EM/Peds and pediatric residents. and educational Celeste Kichefski as (ckichefski@iuhealth.org) or FAX (317) 656-4216 to learnClinical more. IU services is an EEO/AA Employer, M/F/D. oversight

occur in the nationally recognized Riley Hospital for Children.

Riley is located on the IU Medical Center campus in downtown Indianapolis and has an annual volume of 30,000 patient visits, with an admission rate near 25%. The hospital is undergoing a $300m expansion that will include a new state of the art ED slated to be completed in 2013. Riley is a Level 1 children’s trauma center and burn unit, and a tertiary care facility. EM FACULTY DEVELOPMENT/ EDUCATION FELLOWSHIP UNIVERSITY OF CALIFORNIA, IRVINE SCHOOL OF MEDICINE The UC Irvine Department of Emergency Medicine is seeking a HS Clinical Instructor- Faculty Development and Education Fellow for July 2014. UC Irvine Medical Center is a Level I Trauma center with 2,800 runs/year, 40,000 ED census with a nationally recognized three-year residency program since 1989. Fellowship concentrations could include residency and /or medical school curriculum design and education, use of instructional technology, Western Journal of EM editing and publishing. This two-year fellowship requires completion of a master’s degree in education, translational science, or public health. One-year fellowship is available for those holding a master’s degree or starting one during the fellowship. Completion of an ACGME-accredited EM residency required. Salary is commensurate with qualifications and proportion of clinical effort. RECRUIT system located at: https://recruit.ap.uci.edu/apply/JPF02025

Certification in Pediatric Emergency Medicine or combined certification in Emergency Medicine and HEALTH SCIENCES CLINICAL PROFESSOR SERIES OPEN RANKS Pediatrics are required. Rank and tenure status are dependent upon qualifications of candidate. DEPARTMENT OF EMERGENCY MEDICINE Please contact Cherri Hobgood, MD (chobgood@iupui.edu), Celeste Kichefski (ckichefski@iuhealth.org) or FAX (317)656-4216 learn more.of Emergency IU is an EEO/AA Employer, M/F/D. The University of California, Irvine School ofto Medicine, Department Medicine anticipates openings in the HS Clinical Professor Series.

Requirements: The HS Clinical Series includes substantial patient care, medical student and resident teaching, and optional clinical research. Board preparation or certification in EM required. Fellowship or advanced degree, or both, strongly desired. The University of California, Irvine Medical Center is a 472-bed tertiary care hospital with all residencies. The ED is a progressive 35-bed Level I Trauma Center with 40,000 patients, in urban Orange County. Collegial relationships with all services. Excellent salary and benefits with incentive plan. Salary and rank will be commensurate with qualifications and experience. Application Procedure: Interested candidates should apply through UC Irvine’s RECRUIT system located at: https://recruit.ap.uci.edu/apply/JPF02022 Applicants should complete an online application profile and upload the following application materials electronically to be considered for the position: 1. 2.

Curriculum Vitae Names and addresses of four references

The University of California, Irvine is an equal opportunity employer committed to excellence through diversity.

Send CV and statement of interest to Fellowship co-directors: Shahram Lotfipour, MD, MPH at shahram.lotfipour@uci.edu, 714-456-2326 Bharath Chakravarthy, MD, MPH at bchakrav@uci.edu, 714-456-6986 University of California, Irvine Medical Center Department of Emergency Medicine 101 The City Drive, Route 128-01 Orange, CA 92868 Visit http://www.emergencymed.uci.edu/Education/faculty_development.asp for more details. The University of California, Irvine is an equal opportunity employer committed to excellence through diversity.

Massachusetts General Hospital / Harvard Medical School The Massachusetts General Hospital (MGH) Department of Emergency Medicine is recruiting candidates for its fellowships in Emergency Medicine. The goal of the fellowships is to provide EM residency graduates with a formal opportunity to develop those skills required for a successful career in academic medicine. At the completion of the fellowship, it is expected that graduates will be prepared to conduct independent work in their chosen field. Fellows will be given academic appointments at Harvard Medical School. Fellowships offered include: Clinical Research, Emergency Medicine Network Research, Emergency Ultrasound, Global Health, Medical Simulation, Neurologic Emergencies, Vascular Emergencies, and Wilderness Medicine. The MGH Department of Emergency Medicine supports teaching and research in all of these fellowship areas. To obtain more specific information including deadlines and requirements, please visit http://www.massgeneral.org/ emergencymedicine/education. In addition, the MGH Department of Emergency Medicine is home to the Emergency Medicine Network, a consortium of emergency departments which focuses on public health research, with a particular emphasis on pulmonary/allergic diseases (www.emnet-usa.org). Clinical experience will be provided at a 100,000 annual visit level I trauma center with a PGY1-4 EM residency. Candidates must have completed residency training in EM and be eligible for board certification by ABEM. Interested candidates should submit a letter of interest and CV to: Shawn Paulding, phone: (617) 726-7622; email: spaulding1@partners.org. For additional information, please visit the SAEM fellowship website at: www.saem.org. MGH is an equal opportunity/ affirmative action employer.

EMERGENCY MEDICINE SIMULATION FELLOWSHIP UNIVERSITY OF CALIFORNIA, IRVINE SCHOOL OF MEDICINE The UC Irvine Department of Emergency Medicine is seeking a HS Clinical Instructor- Medical Simulation Fellow for July 2014. University of California, Irvine Medical Center is a Level I Trauma center with 2,800 runs/year, 40,000 ED census with a nationally recognized three-year residency program since 1989. The UC Irvine Medical Education Simulation Center is a new $40 million, 65,000-square-foot facility that provides telemedicine and simulation-based educational programs and CME courses for thousands of health care providers each year. The four-story medical education center includes a full-scale operating room, emergency room, trauma bay, obstetrics suite and critical care unit. The Medical Simulation Fellowship is a one-year mentored fellowship that offers advanced training in simulation teaching, curriculum design, educational program implementation, study design, and research for a graduate of an ACGME- accredited emergency medicine residency program. Salary is commensurate with qualifications and proportion of clinical effort. For more information, visit our website at: http://www.emergencymed.uci.edu/Education/simulation.asp RECRUIT system located at: https://recruit.ap.uci.edu/apply/JPF02023 Send CV and statement of interest to Fellowship Director: C. Eric McCoy, MD, MPH at cmccoy@uci.edu University of California, Irvine Medical Center Department of Emergency Medicine 101 The City Drive, Route 128-01 Orange, CA 92868 The University of California, Irvine is an equal opportunity employer committed to excellence through diversity.

POST-DOCTORAL SCHOLAR The University of California, Irvine School of Medicine's Center for Trauma and Injury Prevention Research (CTIPR), based in the Department of Emergency Medicine, has strong working relationship with Trauma Surgery and the Trauma Registry. The Post-Doctoral Scholar will carry out injury research in close collaboration with mentors and colleagues in the Department of Emergency Medicine, Program in Public Health, and School of Social Ecology. The scholar will analyze data from current research projects and existing traffic injury data sets, develop skills as an independent researcher, and develop new projects. Minimum qualifications: Required doctoral degree in epidemiology, public health, or safety research, with a focus on injury, alcohol, or mental health research. Other considerations: 1) Strong analytic skills and outstanding individual initiative; 2) Strong skills in data management and analysis, including experience using standard statistical packages; 3) Excellent scientific writing and spoken English skills; 4) Preference is given to applicants whose training and research interests align with the CTIPR. Anticipated salary range: http://www.som.uci.edu/academic-affairs/docs/postdoc.pdf Applications are accepted until the position is filled. RECRUIT system located at: https://recruit.ap.uci.edu/apply/JPF02024 Submit letter of interest, resume, research interests, and three references to: Shahram Lotfipour, MD MPH (SHL@uci.edu, 714-456-2326) and Bharath Chakravarthy MD MPH (bchakrav@uci.edu, 714-456-6986). The University of California, Irvine is an equal opportunity employer committed to excellence through diversity.

Join a PASSIONATE group of physicians and partner with a practice PERFECTLY ALIGNED with your long-term career goals. EMA provides INCOMPARABLE practice support, technology, equitable scheduling, training, benefits and compensation. Everyone is a true OWNER and has an EQUAL vote and voice.

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EMP clinicians from Saint Francis Hospital rock a charity dodgeball tournament. Having a career you love is about more than signing bonuses and hourly wages. It’s knowing you’re all in with a group of people you love working and playing with. At EMP, we’re passionate EM physicians who love owning and managing our own business because it empowers us to be successful in healthcare. It gives us the ability to create a culture we love and a career we’re excited about. Go for extraordinary. Contact us to learn more about EM positions in over 60 locations across the country.

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Opportunities from New York to Hawaii. AZ, CA, CT, HI, IL, MI, NH, NV, NY, NC, OH, OK, PA, RI, WV

The Crozer Keystone Health System (CKHS) is a four-hospital community-focused health care system that delivers patient-centered, quality care in an efficient, cost-effective, and caring manner, meeting the health needs demonstrated by our community. CKHS is seeking a Program Director (PD) and Associate Program Director (AD) for its Emergency Residency Program, which is designed to begin in July of 2015. The PD will play the central role in designing and developing the Program, including the hiring of an Associate Program Director. CKHS currently sponsors several other GME training programs, including residencies and fellowships. The ideal candidate will be an experienced residency-trained emergency medicine physician and have significant teaching experience, or will have worked as an associate director in the academic emergency department environment. Must be able to demonstrate ethical conduct, professionalism, and interpersonal skills, leadership and management abilities sufficient to effectively direct and mentor resident physicians, students, and support staff. This is a unique opportunity for those with imagination and energy to develop and build a residency program. Additionally, experience in writing a PIF is preferred. Crozerâ&#x20AC;&#x2122;s Emergency Department is one of the busiest in Southeastern Pennsylvania. At our state-of-the-art facility, we treat more than 55,000 patients each year. This is a community hospital with academic affiliations and a level II trauma center. This is an employed position with competitive salary, excellent benefits to include malpractice coverage and paid tail. Interested candidates are encouraged to apply with CV and references for immediate consideration to Bruce Nisbet, MD, FACEP â&#x20AC;&#x201C; Chairman, Department of Emergency Medicine at bruce.nisbet@crozer.org

ASSISTANT ULTRASOUND DIRECTOR (AUD) Department of Emergency Medicine The Department of Emergency Medicine at the University of Virginia seeks applicants for a tenure-ineligible position to serve as the Assistant Ultrasound Director (AUD). This individual will assist the Ultrasound Director in implementation of all aspects of the ultrasound program. The AUD's primary focus will be the education of faculty, fellow(s), residents, and medical students. The AUD will be responsible for quality assurance, image archiving, development of clinical protocols involving ultrasound, and collaboration with other departments. Opportunities are available for a physician with an interest in a balanced career of clinical care and teaching. Candidates must have an MD or DO and be board-eligible or board-certified by the American Board of Emergency Medicine. Applicants should be interested in advancing their academic career by joining a diverse and highly accomplished faculty. Those interested in pursuing research opportunities and in taking on leadership roles in the department are encouraged to apply. With an annual census of 60,000, the Department includes a chest pain center, adult and pediatric departments, fast track (Express Care), active air and ground transport programs, and the Blue Ridge Poison Control Center. The UVa Health System, a 700 bed tertiary care center with a Level 1 trauma center, is located at the foot of the Blue Ridge Mountains in Charlottesville, Virginia, a city that has consistently been rated as one of the best places to live in the U.S. This position carries a faculty appointment in the School of Medicine at the University of Virginia. Substantial protected time will be made available to support scholarly pursuits. To apply for the tenure-ineligible position, visit http://jobs.virginia.edu search on Posting Number 0612194. Complete a Candidate Profile online and attach a letter of interest, curriculum vitae, and contact information for three references. Questions related to the position duties and responsibilities or the application process should be directed to Dr. Robert O'Connor, Chair, Department of Emergency Medicine, at REO4X@virginia.edu The University of Virginia is an affirmative action/equal opportunity employer committed to diversity, equity, and inclusiveness.

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EMERGENCY MEDICINE GAINESVILLE, FL The University of Florida Department of Emergency Medicine in Gainesville is seeking talented and highly motivated, residency-trained emergency physicians of all academic ranks to join our Department and the UF community. Multiple exceptional opportunities exist in the following areas:

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Full-time Academic Teaching Faculty Full-time Pediatric Emergency Medicine Academic Teaching Faculty Full-time Clinical Faculty Fellowship Program Opportunities (beginning July 2014) – Emergency Medical Services – Critical Care Medicine – Emergency Ultrasonography

Successful candidates will hold UF appointments and become part of our current group of 33 full-time faculty, five fellows, 24 residents and more than 200 staff members that make up the UF College of Medicine Department of Emergency Medicine and the UF Health Emergency Department in Gainesville. UF Health Shands Hospital is an 872-bed teaching hospital with a Level 1 Trauma Center and Burn Center, and is the major referral center for North Central Florida. Approximately 1,500 UF faculty and community physicians and more than 8,000 skilled Shands nursing and support staff provide comprehensive, high-quality patient care, ranging from primary care and family medicine to tertiary and quaternary services for patients with highly complex medical conditions in more than 100 specialty and subspecialty medical areas. The UF Health Science Center is the country’s only academic health center with six health-related colleges, six major research institutes and versatile research facilities located on a single, contiguous campus. The UF Health Science Center, including our major research centers, institutes and clinical enterprise, receives more than $300 million in NIH and other extramural funding and focuses on building collaborative statewide education, health delivery systems and specialized clinical services centered on quality and innovation. The Department of Emergency Medicine’s faculty currently provides clinical services in three facilities: a 61-bed ED and trauma/critical care center (opened in November 2009); a separate, dedicated 20-bed Pediatric Emergency Department (opened July 2011); and a free-standing emergency department located in northwest Gainesville (opened August 2013). Our three-year emergency medicine residency program supports 24 residents. Our teaching faculty, fellows and residents are significantly integrated in the college’s undergraduate medical education mission and hold key leadership positions within UF Health Shands Hospital and the UF College of Medicine. The Department of Emergency Medicine also features a growing research environment, which has been significantly enhanced through collaborative opportunities throughout the College of Medicine and institutes on the UF campus. The Department holds multiple contracts for regional EMS direction and also provides medical direction for ShandsCair, UF Health’s hospitaloperated ground-based, helicopter and fixed-wing medical transport program. Gainesville is a beautiful, dynamic and vibrant college town. Home of “the Gator Nation,” award-winning college sports and year-round outdoor activities, Gainesville repeatedly has been voted as one of the best places to live in the US. Qualified candidates must have strong clinical experience and thrive in a dynamic, fast-paced emergency department. Our negotiable salary and benefits structure is highly competitive. Positions will post until an applicant pool has been established. The review of applications begins September 15, 2013.

For more information, please visit our website at emergency.med.ufl.edu Please send CV and cover letter to:

Joseph A Tyndall, MD, MPH Chairman Department of Emergency Medicine University of Florida College of Medicine

c/o Amy M. Smith PO Box 100186 Gainesville, FL 32610-0186 amysmith@ufl.edu

Women and minorities are encouraged to apply. The University of Florida is an Equal Opportunity Employer.

Society for Academic Emergency Medicine 2340 S. River Road, Suite 208 • Des Plaines, IL 60018 • 847-813-9823 • saem@saem.org • www.saem.org

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